COLLEGE OF NURSING SILLIMAN UNIVERSITY DUMAGUETE CITY

RESOURCE UNIT ON THE CARE OF DEPRESSED, WITHDRAWN AND SUICIDAL PATIENTS

Submitted by: Sarah Charlina Abanto Micca Borja NCM 105 A1 (Psychiatric-Mental Health Nursing Rotation) Submitted to: Asst. Prof. Lorelei M. Bacay

COLLEGE OF NURSING SILLIMAN UNIVERSITY

Vision:

As a leading Christian Institution in Asia, Silliman University is committed to total human development for societal and environmental wellbeing.

Mission:

In this regard, the University: o Provides opportunities for all members of the academic community to seek justice, truth, and love. o Pursues excellence in every dimension of inquiry, learning and teaching. o Instills in all members of the university community-including all its integral units-an enlightened social consciousness, a profound sense of involvement, and a genuine compassion for every person. o Enhances national development and unity by making its life and programs relevant to the total environment.

COLLEGE OF NURSING SILLIMAN UNIVERSITY DUMAGUETE CITY

RESOURCE UNIT ON THE CARE OF DEPRESSED, WITHDRAWN AND SUICIDAL PATIENTS PLACEMENT: Level IV First Semester TIME ALLOTMENT: 2 hours TOPIC DESCRIPTION: This topic deals with the Care OF depressed, withdrawn & suicidal patients. It also includes the risk factors, signs & symptoms, the types & the nursing responsibilities. CENTRAL OBJECTIVE: At the end of 2 hours, the learner shall have gained more knowledge, developed beginning skills and manifested positive attitudes and values toward the care of depressed, withdrawn & suicidal patients.

Specific Objectives I. Prayer

Content

T/A 2 min.

T/L Activities

Evaluation Oral Evaluation through Question and Answer

Almighty Father, we worship You & we give You thanks for all the graces & blessings that you have given to us. Thank you for giving us another opportunity to live & be with our family, friends & loved ones. We humbly ask for Your forgiveness for our wrong doings. Today Lord, we ask for Your guidance as we present our assigned topics. May You continue to bless us each day & send forth Your Holy Spirit to be with us always. May You also continue to protect us all from any form of harm & danger. We just lift to You Lord, all our personal intentions. Amen. II. Introduction Everyone experiences the highs & lows of life. Mood disorders are characterized by exaggerations of that variability in mood. Being too high or too low or 3 min.

experiencing both extremes causes intrapersonal & interpersonal anguish. However, because experiencing lifes ups & downs is normal, & indeed it would be unnatural not to do so, it is not always clear where the line between normal & abnormal, or between healthy & unhealthy, should be drawn. The depressed person & others in that persons life recognize the normalness of the response & the person eventually is able to get on with life. In contrast, if the sadness or guilt Given the resources, goes on too long, an imaginary line is crossed at some point & a clinically the learner shall: significant mood disorder exists. Mood disorders are the most common psychiatric diagnoses associated with suicide; Depression is one of the most important risk 1. Correctly define the factors. related terms in their own words. III. Definition of Related Terms 5 min. Depression mood disturbance characterized by feelings of sadness, despair, apathy & discouragement caused by loss in the persons life or by neurobiological imbalance Depressive Personality a lifestyle or character disorder in which the person is chronically down, is pessimistic, is a complainer, is unhappy with job, family, life position Suicide self-inflicted death; the intentional act of killing oneself Suicide Gesture suicide attempt directed toward the goal of receiving attention rather than actual destruction of the self Suicide Threat usually occurs before overt suicidal activity takes place Suicide Attempt include any self-directed actions taken by the person that will lead to death if not interrupted 10 min. Socialized Discussion Group Discussion

IV. Depression Everyone feels sad or guilty from time to time in response to the events of life. If the sadness or guilt persists for too long, a diagnosable cognition exists. Examples include, loss of loved one through death, a sense of shame or guilt for an unacceptable behavior or a feeling of failure (failing the

2. Enumerate 5 signs & symptoms, (respectively) of Depression

board exam, divorce, etc.) A. Symptoms of Depression: Common Symptoms Apathy (inability to be motivated & interested) Sadness Sleep Disturbances (Insomnia or Hypersomnia) Hopelessness Helplessness Worthlessness Guilt Other Symptoms Fatigue Thoughts of Death Decreased Libido Ruminations of inadequacy Psychomotor agitation Private verbal beratings of self Spontaneous crying without apparent cause Dependency Passiveness

Anger (Covert or overt) 3. Discuss the different signs (objective or subjective) of depression briefly. B. Signs of Depression Objective:

20 min.

Socialized Discussion

Aggressiveness (these patients become irritable when disturbed; they may seek to be alone not wanting anyone to talk to or distract them from their obsessions in the inner world)

Irritability Alterations of activity - Patients may exhibit psychomotor agitation. They may be unable to sit still & may pace & engage in hand-wringing & pulling or rubbing their hair, skin or other objects. Tying & retying shoes, & buttoning & unbuttoning a shirt are typical behaviors. Psychomotor retardation is marked by slowing of speech, increased pauses before answering, soft or monotonous speech, poverty of speech & muteness. Slowing of body movements also occurs. Patients may feel tired all the time. The smallest task may seem impossible. Activities of daily living suffer also. Poor personal hygiene may be caused by the lack of energy (depressed adults lie in bed & become incontinent or constipated because of the inability to muster the energy & motivation to walk to the bathroom. Change in eating behaviors results in either a loss or gain of weight. Sleeping behaviors also change. Depressed persons may often deny being depressed, but are brought to the attention of the psychiatric community by the complaint of always being tired, or taking too many naps, daytime sleepiness, etc. Many patients want to lie down but do not sleep.)

Altered social interactions Patients are distracted easily & are not interested in other people, or other ideas or problems. The self-absorbing nature of depression leaves depressed persons with little to offer to others. Conversations are difficult to maintain & only with great effort can depressed persons sustain a facial expression of interest & concern.

Depressed persons are also withdrawn; they may withdraw form family & friends & seek social isolation. Saddened expression & a drooping posture serve as a social barrier. Subjective: Alterations of affect symptoms primarily associated with depression which dominate the internal world of depressed persons. (anger, anxiety, bitterness, dejection, denial of feelings, despondency, guilt, helplessness, hopelessness, uselessness, loneliness, low-self esteem, sadness, & a sense of worthlessness) Alterations of cognition (ambivalence & indecision, inability to concentrate, confusion, loss of interests & motivation, pessimism, self-blame, selfdepreciation, self-destructive thoughts, thoughts of death & dying & uncertainty) Alteration of physical nature these subjective symptoms come to the attention of the nurse because of the numerous complaints of depressed patients. Some people become so preoccupied with their bodies that every twinge, every body change is greeted with great alarm & dread. (abdominal pain, anorexia, chest pain, constipation, dizziness, fatigue, headache, indigestion, insomnia, menstrual changes, nausea & vomiting, sexual dysfunction)

Alteration of perception Typically delusions (delusion of persecution because of a moral mistake, somatic & nihilistic delusions, are common in depressed patients) & hallucinations (tend to be less elaborate than those of schizophrenics & tend to focus on personal faults) D. Psychodynamic Treatments for Depression

1. Supportive Psychotherapy this approach attempts to guide patients in reference to their environment. 2. Psychoanalysis this approach conceptualizes depression as arising from early life, deprivations of love & affection, or from conflicts resulting from an overly severe conscience 3. Interpersonal theory attempt to explore losses related to interpersonal relationships & deficits in social skills in order to understand the relationship of the losses to the depression 4. Cognitive Behavioral therapy the goal of the therapy is to reverse these beliefs & attitudes 5. Marital & Family Therapy life at home is considered a major contributor to depression. Therapy goals include resolving family conflicts & establishing the family as a base of support 4. Discuss at least 5 Nursing Interventions (with rationale) for Depressed & Withdrawn clients E. Nursing Interventions Depressed Patients: Provide a safe environment for the client. Rationale: Physical safety of the client is a priority. Many common items may be used in a self-destructive manner. Continually assess the clients potential for suicide. Remain aware of this suicide potential at all times. Rationale: Depressed clients may have a potential for suicide that may or may not be expressed & that may change in time. Reorient client to person, place & time as indicated (ex. Call the client by name, tell the client your name, tell the client where she is) Rationale: Repeated presentation to reality is concrete reinforcement. When approaching the client, use moderate, level tone of voice.

20 min.

Group Discussion

Avoid being overly cheerful. Rationale: Being overly cheerful may indicate to the client that being cheerful is the goal & that other feelings are not acceptable. Avoid asking the client many questions, especially questions that require only brief answers. Rationale: Asking questions & requiring only brief answers may discourage the client from expressing feelings. Accept patients where they are & focus on their strengths Rationale: Depressed persons have low self-esteem & this is the best approach to recapturing some sense of value Reinforce decision-making by patients. Rationale: Depressed patients struggle to make even simple decisions. Decisions may be symbolic & represent moving in a wrong direction. By reinforcing patients efforts to make simple decisions, the nurse helps patients move toward health. Never reinforce hallucinations or delusions Rationale: Confronting these psychotic symptoms tends to reinforce them. The best approach is for the nurse to state his or her view of reality & to begin discussing real people & events. Allow (& encourage) the client to cry. Stay with & support the client if he or she desires. Provide privacy if the client desires & if it is safe to do so. Rationale: Crying is a healthy way of expressing feelings of sadness, hopelessness, & despair. The client may not feel comfortable crying & may need encouragement or privacy. Respond to anger therapeutically. Rationale: Depressed persons are typically angry. By understanding that anger, is a

symptom of depression, the nurse can focus on the issue at hand & help patients to move toward a more acceptable style of interaction. It is not therapeutic to badger patients into making a decision, but it is therapeutic to provide decision-making opportunities as patients are able to comply. Rationale: Some patients cannot make a decision. Initially. The nurse may need to make decisions for patients (it is time for your bath). When possible, the nurse helps to guide patients to appropriate problem-solving techniques; that is, identifying options, the advantages & disadvantages of each option, the potential consequences of each decision. Involve patients in activities in which they can experience success Rationale: People feel good about themselves in several ways. One way to develop self-worth is through accomplishment. It may be necessary to teach the client effective social skills such as eye contact, attentive listening, & topics appropriate for initial social conversation (ex. The weather, current events, local news) Rationale: Even if the client knows these skills, practicing them is important first with the nurse & then with others. Practicing with the nurse is less threatening. Help the client practice giving others compliments. Rationale: This requires the client to identify something positive rather than negative in others. Giving compliments also promotes receiving compliments, which further enhances positive feelings. Giving factual feedback rather than general praise. Rationale: Reinforces attempts to interact with others & gives specific positive information about improved behaviors. Manage medications.

Rationale: The increase activity & improved mood that antidepressants produce can provide the energy for suicidal patients to carry out the act. Thus, the nurse must assess suicide risk even when clients are receiving these drugs. It is also important to ensure that clients ingest the medication & are not saving it in attempt to commit suicide. Withdrawn Patients: Keep contracts with withdrawn patients brief but frequent. Rationale: Depressed patients often do not want anyone around or, at least, anyone to talk to them. Unfortunately, their wishes are not a good indicator of what should be done. Spend time with withdrawn patients. Rationale: Withdrawn patients are aware of their surroundings. By spending time (frequent but brief contact) with these patients, the nurse communicates patients worth &, consequently, may be available during a time when patients feel comfortable with initiating dialogue. To spend time with patients is constructive; allowing patients to isolate themselves is not. Rationale: Patients may need to increase physical activity before they are able to verbalize issues. Locking a patients room during the day may be required to keep the withdrawn or isolative patient from disappearing for hours at a time. Rationale: Many patients are insistent about going to their rooms to lie down. They may stay there all day if the nurse does not intervene. Sitting in silence during an activity is better than ruminating in isolation.

V. Suicide Suicide is a complex phenomenon influenced by religious, cultural, & psychological factors. Men are far more prone to it than women. The psychiatric nurse continually must assess for suicide potential among all patients, but especially among schizophrenic, depressed & alcoholic patients. Hendin (1986) points out that suicide is most often the result of depression, diagnosed or not. Suicidal patients view & utilize death differently from other people. There is a tendency for suicidal patients to use their own death to control others & to maintain control over their own lives. A. Risk Factors Hopelessness General medical illness Family History of Substance abuse Depression Substance abuse Male gender Caucasian race Psychotic symptoms Living alone Prior suicide attempts AIDS B. Factors in the Assessment of the Self-Destructive Patient: Assessing Circumstances of an Attempt: Precipitating humiliating life event Preparatory actions: acquiring a method, putting affairs in order, suicide talk, giving away prized possessions, suicide noted Use of violent method or more lethal drugs/poisons

15 min.

Socialized Discussion

5. Discuss briefly the factors in the assessment of the Selfdestructive patient

 Understanding of lethality of chosen method Precautions taken against discovery Presenting Symptoms: Hopelessness Self-approach, feelings of failure & unworthiness Depressed mood Agitation & restlessness Persistent insomnia Weight loss Slowed speech, fatigue, social withdrawal Suicidal thoughts & plans Psychiatric Illness: Previous suicide attempt Mood disorders Alcoholism or other substance abuse Conduct disorders & depression in adolescents Early dementia & confusional states in the elderly Combinations of the above Psychosocial history: Recently separated, divorced or bereaved Lives alone Unemployed, recent job change or loss Multiple life stresses (move, early loss, break-up of important relationships, school problems, threat of disciplinary crisis) Chronic medical illness Excessive drinking or substance abuse Personality factors: Impulsivity, aggressivity, hostility

 Cognitive rigidity & negativity Hopelessness Low self-esteem Borderline or anti-social personality disorder Family History: Family History of Suicidal behavior Family history of mood disorder, alcoholism or both

C. Format for evaluating Suicidal Lethality Plan The more developed the plan, the greater the risk for suicide. Persons who have developed a suicidal plan generally are more serious about suicide & present a greater risk. Method Some methods of attempting suicide are more lethal than others. Accessibility of the means to commit suicide is also important. Rescue the person who deliberately attempts to deceive would-be rescuers has a high lethality potential. 30 min. Group Discussion

6. Briefly discuss the risky behaviors of suicidal patients.

-In summary, the more detailed the plan, the more lethal & accessible the method & the more effort that is exerted to block rescue, the greater the likehood of the suicidal effort being successful. D. Warnings of Suicide Intent & Risky Behaviors Most people with suicidal ideation send either direct or indirect signals to others about their intent to harm themselves. The nurse never ignores any

hint of suicidal ideation regardless of how trivial or subtle it seems & the clients intent or emotional status. Often, people contemplating suicide have ambivalent & conflicting feelings about their desire to die; they frequently reach out to others for help. Asking clients directly about thoughts of suicide is important. A few people who commit suicide give no warning signs. Some artfully hide their distress & suicide plans. Others act impulsively by taking advantage of a situation to carry out the desire to die. Some suicidal people in treatment describe placing themselves in risky or dangerous situations such as speeding in a blinding rainstorm or when intoxicated. This Russian roulette approach carries a high risk of harm o clients & innocent bystanders alike. It allows clients to feel brave by repeatedly confronting death & surviving.

7. Enumerate at least 5 Nursing Responsibilities (with rationale) for Suicidal patients

E. Nursing Interventions: Provide a safe environment Rationale: For suicidal patients, staff members remove any item they can use to commit suicide, such as sharp objects, shoelaces, belts, lighters, matches, pencils, pens, & even clothing with drawstrings. Evaluate patients for suicide risk. Rationale: Risk is based on plan, method & rescue prevention. By knowing the risk, the nurse can establish a reasonable plan of care. Suspect suicidal ideation in most depressed patients. Rationale: Suspecting suicidal ideation prevents the nurse from overlooking a potentially suicidal patient. Inquire directly about frequency & content of suicidal ideation. Rationale: the nurse will not provoke suicide by asking patients about it. In fact, the

nurse will convey concern, the worth of the patient, & a sense of understanding. Furthermore, the nurse needs this information to plan care. Ask patients about the advantages & disadvantages of suicide. Rationale: This information enables the nurse to understand how patients see their situations. Evaluate patients access to a means of suicide. Rationale: If the patient has a means of suicide, the nurse should arrange to have that means blocked. For some patients, if the method of choice is blocked, they will not use another method. Develop a formal no suicide contract with patients. Rationale: Many patients will honor the contract; hence, the nurse has one more tool to prevent patients from self-injury. However, this contract is not a guarantee of safety. At no time should the nurse assume that a client is safe just because a contract is in place. Advice patients to discontinue drugs &/or alcohol. Rationale: Drugs & alcohol significantly increase the risk of suicidal behavior. Support patients reason to live. Rationale: As the nurse is able to align with the healthy part of each patients personality, the nurse gains a therapeutic ally. Create a support system list

Rationale: the nurse makes a list of specific names & agencies that the client can call for support; he or she obtains client consent to avoid breach of confidentiality. Face to face in working face to face with suicidal patents, several general guidelines are useful to the nurse:

Ask patients if they plan to hurt themselves. It is important to for the nurse to understand the ff: Talking to patients about their suicidal intentions will not drive them to suicide. Asking patients directly provides useful information & often provides patients with a sense of relief. The nurse must take all suicidal threats seriously.

If the patient is considering suicide, the nurse should ask about the plan (when & where), method, & how the patient intends to accomplish the suicide. Ask about previous suicide attempts (when & how) Evaluate patients for depression, recent loss or threat of loss, selfdestructive hallucinations, & alcohol or drug-use, all of which place persons at higher risk for suicide. Once patients are hospitalized, most units protect them by using one of the 2 levels of suicide prevention: a. Level 1 is used for patients who are not considered to be at immediate risk for suicide. b. Level 2 is used for patients who present an immediate & serious threat of suicidal behavior. VI. Open Forum 15 min.

References:
Johnson, B.S. (2000). Adaptation and growth psychiatric-mental health nursing. 3rd ed. J.B. Lippincott: Philadelphia Keltner, N.L., Schwecke, L.H., & Bostrom, C.E. (2007). Psychiatric nursing. 5th ed. Mosby: St. Louis Stuart, G.W. Laraia, M.T. (2001). Principles and practice of psychiatric nursing. 7th ed. Mosby: St. Louis Videbeck, S.L. (2006). Psychiatric mental health nursing. 3rd ed. Lippincott: William & Wilkins, Philadelphia