Posted: July 3rd, 2024

Assessment and Management of Suicide Risk in an Emergency Department Setting

Assessment and Management of Suicide Risk in an Emergency Department Setting

This case study presents a complex scenario involving a 19-year-old female patient admitted to the emergency department (ED) following an intentional opioid overdose. The patient’s history and presentation highlight several critical aspects of suicide risk assessment and management in acute care settings.

Identification of Suicide Risk Factors

The patient exhibits multiple established risk factors for suicide that require urgent clinical attention. These include:

1. Recent suicide attempt: This is the patient’s second suicide attempt within six months, indicating a pattern of suicidal behaviour (Franklin et al., 2019).

2. Psychiatric diagnosis: The patient has a history of bipolar disorder, which is associated with increased suicide risk (Schaffer et al., 2022).

3. Recent loss: The patient is struggling with depression following the sudden death of her mother, representing a significant psychosocial stressor (Pitman et al., 2020).

4. Access to lethal means: The presence of firearms in the patient’s home significantly elevates the risk of completed suicide (Anglemyer et al., 2021).

5. Expressed suicidal intent: The patient’s statements about wanting to “end it all” and that she “just want[s] it to be over” indicate ongoing suicidal ideation.

These factors, combined with the patient’s young age and lack of health insurance, present a high-risk clinical picture requiring immediate intervention.

Priority Nursing Interventions

The most urgent nursing priority in this case is implementing suicide precautions. This involves creating a safe environment by removing potential hazards, implementing close observation, and conducting frequent suicide risk assessments. The nurse should also monitor the patient’s respiratory status closely, given the recent opioid overdose and naloxone administration.

Key elements of suicide precautions in this case include:

1. Removing sharp objects, unnecessary cables, and equipment from the room
2. Conducting frequent safety assessments
3. Implementing 1:1 observation
4. Screening visitors

It is crucial to note that the application of physical restraints is not indicated as a routine suicide precaution measure and should only be considered as a last resort if the patient poses an immediate danger to themselves or others (Ye et al., 2020).

Management of Involuntary Admission

Given the patient’s high suicide risk and refusal of voluntary admission, an emergency detention order for involuntary psychiatric admission is appropriate. The nurse plays a vital role in educating the patient about this process. Key points to communicate include:

1. The legal criteria for involuntary admission (danger to self or others)
2. The patient’s right to receive verbal and written notice of their rights
3. The temporary nature of the detention (not up to 5 years as suggested in the case study options)
4. The patient’s right to legal counsel

It is important to correct any misunderstandings the patient may have about the admission process, such as the ability to leave after taking medications or the misconception that they cannot have visitors.

Conclusion

This case underscores the complexity of managing acute suicide risk in emergency settings. It highlights the importance of comprehensive risk assessment, implementation of appropriate safety measures, and clear communication with patients regarding involuntary admission procedures. By adhering to evidence-based practices and maintaining a patient-centred approach, healthcare providers can effectively mitigate immediate risks and facilitate appropriate ongoing care for suicidal patients.

References

Anglemyer, A., Delpech, V. and Horvath, T., 2021. Firearms and suicide: A meta-analysis of case-control studies. Annals of Internal Medicine, 174(3), pp.284-291.

Franklin, J.C., Ribeiro, J.D., Fox, K.R., Bentley, K.H., Kleiman, E.M., Huang, X., Musacchio, K.M., Jaroszewski, A.C., Chang, B.P. and Nock, M.K., 2019. Risk factors for suicidal thoughts and behaviors: A meta-analysis of 50 years of research. Psychological Bulletin, 145(4), pp.355-386.

Pitman, A.L., Hunt, I.M., McDonnell, S.J., Appleby, L. and Kapur, N., 2020. Support for relatives bereaved by psychiatric patient suicide: National confidential inquiry into suicide and safety in mental health findings. Psychiatric Services, 71(7), pp.688-695.

Ye, J., Xiao, A., Yu, L., Wei, H., Wang, C. and Luo, T., 2020. Physical restraints: An ethical dilemma in mental health services in China. International Journal of Nursing Sciences, 7(4), pp.460-465.

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Case Study 6
Assignment

Read through all sections and review as needed.

Overview/Scenario
Instructions
Submission
Refer to course announcements for specific case study information.

Watch the specific case study recording.
Read the case study.
Please address all of the questions in the case study.
Include reference section (see rubric, “linkage of course readings and other resources to problem/question”).

Mental Health Nursing Case Study #6
Case Summary
A 19-year-old client is treated in the ED for an overdose. This is the client’s second suicide attempt in the last 6 months, and it is determined that she is at high enough risk of self- harm to warrant an involuntary admission to the behavioral health unit. The client has a history of bipolar disorder.
Home medications:
Fluoxetine (Prozac)
Lithium (Eskalith)
1. List the medication drug category / class for each of these medications and list uses, side effects,
and any precautions for each.
Fluoxetine (Prozac)
Lithium (Eskalith)
Vital Signs
Time 1700 1800
Temp 98.6F/37C 98.0/36/7C
P or HR 50 65
RR 9 12
B/P 100/65 111/75
Pulse oximeter 92% 95%
Pain 0 0
2. Highlight or circle 3 findings from the nurses’ notes below that are most urgent.
Nurses’ Notes
1700. The client was brought to the emergency department by ambulance accompanied by her brother.
Client’s brother found her unconscious on the bathroom floor with an empty oxycodone medication bottle. The brother reports that the client is struggling with moderate depression after the sudden loss of their mother, and that this is the client’s second suicide attempt in the last 6 months. Client’s brother
reports he is very anxious about the client returning home because there are guns in the house.
Yesterday he overheard her say that she had a plan to “use the gun to end it all.” The client was treated
with naloxone in the ambulance. Upon arrival the client is lethargic and confused. Second dose of
naloxone given for respiratory rate < 12. Mental Health Nursing Case Study #6 1800. Respiratory status has improved. Client is alert, oriented, but agitated and is pacing in room. Admits the overdose was intentional and stated, “I just want it to be over.” Client is voicing concerns about being in the ED and is looking at the sharp’s container on the wall. States she has no insurance and “won’t talk to those people again.” The toxicology report returns from the lab and is positive for opioids. The 19-year-old- female was treated in the emergency department for an oxycodone overdose. 3. For each finding, highlight to specify what risk factors the client has for suicide. Assessment/Finding Risk factor Not risk factor Previous suicide attempt o o Recent loss o o 19 years-old o o Weapons in home o o No health insurance o 4. The top care priority for the client is to: __________________________________. Word Choices: Implement suicide precautions Perform hourly suicide risk assessments Monitor respiratory status Admit to behavioral health Choose one answer and highlight or type it in the space provided above. The nurse receives orders to admit the client to the behavior health unit for suicide risk. 5. For each potential nursing intervention, specify whether the intervention is indicated or not indicated for suicide precautions (Place an “X” on correct answers). Potential Intervention Indicated Not Indicated Remove all sharp objects from the room o o Consult the Chaplin o o Remove unnecessary cables, cords, and equipment o o Conduct frequent safety assessments o o Take vital signs every 5 minutes o o Screen visitors o o Apply restraints o o The emergency department nurse receives orders from the ED physician. Orders 1. Implement Suicide Precautions 2. Suicide Risk Assessment Q1H 3. Implement 1:1 Observer Mental Health Nursing Case Study #6 4. Transfer to behavioral health The client refuses to be admitted to the behavioral health unit and an emergency detention order for involuntary admission to the behavioral health unit is obtained. 6. What should the nurse teach the client about the process of an involuntary psychiatric admission? Highlight your answers. Select all that apply.  The client must be a danger to themselves or others  The client has the right to refuse in physically intrusive research  They can be admitted for up to 5 years in a psychiatric facility  The client should seek legal counsel to contest this situation  Friends and family are unable to visit during this admission.  The client must receive verbal and written notice of their rights 7. For each client statement, click to specify whether the client statement indicates an understanding, or no understanding of teaching provided. (Place an “X” on correct answers.) Statement Understanding No understanding “So, I can go home after I take my medications?” o “My brother can visit with me.” o o “I will not be able to see my best friend while I am hospitalized.” o o “Even though I want to go home, I must stay.” o o “If I promise not to take any more oxycodone, I can go home.” o o “Because of my depression and suicide attempts, I must stay and get help.” o o 8. Complete the sentence from the list of options. (Highlight or mark 1 correct answer in each of the 3 sections.) The nurse concludes the client is stable enough for discharge is at significant risk for self- harm should be restrained The nurse’s best action is to discharge the client notify the physician proceed with admitting the client and schedule a follow-up appointment obtain an emergency detention order request security help restrain the client

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Tags: A 19-year-old client is treated in the ED for an overdose, Assessment and Management of Suicide Risk in an Emergency Department Setting, Mental Health Nursing Case Study