To implement suicidal precautions or not to implement suicidal precautions

[RNdiva505]

I am a working new nurse since May 2011. I did my 3 month orientation on med/surg and now I am on my own!! I am so excited until last night. My patient fired me Ok from the beginning to catch you up to speed....I was doing my initial assessment (i.e. history, allergies, contact information, etc...) As I came to the question about previous suicide attempts the patient stated no. Next question, do you have any suicidal thoughts patient answered yes due to loss of job, living pay check to pay check, no health insurance, multiple hospital bills, etc... I stated due to acknowledgement of suicidal thoughts suicidal precautions would have to be implemented and a sitter would have to sit with them until the physican can come in the morning hours for further evaluation. Patient became irrate stated they wanted to retract their statement, they need their privacy, and refused sitter. Charge nurse, house supervisor, and hospitalist informed. Hospitalist reienforced suicidal precaution implementation. Security was called to control patient ourburst. Patient stated he had no plan of harming themself and it was my word against theirs, we were violating their patient rights, and they wanted to leave. Patient could not leave due to protocol, so patient had to be upgraded to invol. committed until a psych doc could come evaluate. Well, his surgeon came in the early AM and dc'd the sitter and stated the patient was not suicidal and we blew everything out of portion and the patient is very unhappy. I tried to explain that it was protocol, but fell on the drs deaf ears.

Question: 1) Protocol is protocol, right?

2) If patient has no plan should I have implemented suicide precautions?

3) What could I have done differently?

4) Why do I feel so guilty of the whole thing spiraling out of control?

Thnx, Stress out Newbie:confused:

[bloodlikefire]

question: 1) protocol is protocol, right?

2) if patient has no plan should i have implemented suicide precautions?

3) what could i have done differently?

4) why do i feel so guilty of the whole thing spiraling out of control?

thnx, stress out newbie:confused:

a. 1) yes. always follow protocol. ask yourself how you would feel if your patient killed themselves???

2) as soon as they stated any suicidal ideation, if they acted on it in any way you license is gone. your charge nurse and nurse manger agreed.

3) you did nothing wrong and you very well may have saved the patient's life!

4) do not feel guilty, you took the necessary and reasonable steps after a patient expresses these thoughts.

when i was working in a prison, i had a patient come to me one day saying he was thinking about killing himself. i immediately stopped what i was doing, told another patient to shut up, as he was only complaining about some knee pain, and escorted this patent inside and had him searched for weapons. i have never seen psych move faster, as he was in with a psych doc within 15 minutes.

if the guy complains to the board remember that you followed protocol and acted as any reasonable nurse would. tell the doctor you would do it again. you don't answer to the doctor.

please remember you just could have saved his life that night.

[Rob72, ASN, RN]

From an old (ish) ED monkey- you may not have saved a life, but he'll sure think twice before he lets something stupid dribble off his lips again!

6 of 1, 1/2 dozen of the other. A good interview/assessment is very manipulative. Once the statement of intent is made, ideally, you should pursue it in a very sympathetic, non-threatening manner. I.e., as you note, do they have means, motivation and opportunity. If the answer is, "yes", absolutely initiate the SP. If not, I would discuss your findings with your charge and the doc(as you did), and document. Legally, you're always better safe than sorry, but...

A psych admit does have (sometimes significant) social, professional, and economic consequences for the patient.

First and foremost, remember, your call was not in any way, "wrong". Look at the event in a couple of months, and re-examine it. What's done is done, what you learn and carry forward is important.

[RNdiva505]

Thank you for your positive posts. Definitely will make this incident an educational moment. Next time, because I know there will always be a next time, I can take a slightly different approach to the question....Lesson learned!

[MrChicagoRN, RN]

Question: 1) Protocol is protocol, right?

2) If patient has no plan should I have implemented suicide precautions?

3) What could I have done differently?

4) Why do I feel so guilty of the whole thing spiraling out of control?

I'd have explored more before acting. Most people have had these thoughts at some point in their lives. Were these fleeting thoughts, or active ideation? Does he have a plan? Does the patient feel they may harm himself while here? Did you continue with the interview, or immediately announce the restrictions?

What you could have done is complete the interview and then, if there was no imminent risk, call the hospitalist and discuss the case; ask them to come see the patient first. Is it custom, protocol, or policy? While you need to be sure the patient is safe, you don't want to over-react and create an unnecessary adversarial relationship with a patient who's takeaway is "I'll never be honest with a doctor or nurse again."

We weren't there, we didn't see the patient, or witness the interactions, so it's difficult to say exactly what could have been done differently. It's great that you are asking these questions in order to avoid this type of messy situation in the future. The patient was upset, you were upset, the doctor was upset.

Is there a behavioral health unit there, psych liaison nurse, anyone else that you can process this with.

Sorry this event happened to you. Keep asking the hard questions!