Should I have implemented Suicide Precautions?

[RNdiva505]

I have posted this also on another forum....Just looking for advice

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, Stressed out Newbie:confused:

[VivaLasViejas, ASN, RN]

Sometimes, wording is everything.

I wasn't there, so I have no idea if you overreacted or not. However, I wonder how the patient verbalized his/her suicidal thoughts, e.g., something along the lines of, "Yes, I want to kill myself because my life sucks and it's never going to get better ". Or was it more like, "My life sucks and I can think of worse things than dying right now"? There is a world of difference between these expressions of "suicidal ideation"; both clearly proclaim a desire to be out of whatever pain the patient is experiencing, but the first statement is indicative of intent and thus more alarming, while the second is something almost everyone has said or thought at some point in their lives.

You are a brand-new nurse; like with everything else in nursing, it takes time and repeated experiences with these situations to learn how to gauge their seriousness. And even then, we all make mistakes and either blow something completely out of proportion, or we don't take it seriously enough (and that's apt to bite us in the butt later on......better to be safe than sorry!).

But until you've dealt with these things a few more times, you may want to rely on a colleague or a charge nurse to assist you in deciding whether a given patient is actually suicidal, if they're just on a down-trip and need some extra TLC, or if there is an active disease process (like a UTI) that's prompting the crazy-talk.

Sorry your patient 'fired' you......happens to all of us. :hug: But if s/he were in the correct frame of mind, I can imagine s/he would be very grateful to know you cared enough about him/her to be proactive in calling in reinforcements in case something did go sideways.

JMHO....

[loriangel14, RN]

If you had skipped over this statement and the patient harmed themselves they would have been all over you for not implementing suicide precautions. At my facility that would have been immediate grounds for a "form 1", meaning a 72 hour hold on the patient and a security guard on the patient 24/7. I think you did the right thing.

[LaughingRN]

I'm on the same page as Viva

It depends on the context.

If the patient said "my life sucks because ..."

and you asked them "have you ever thought of killing yourself?" and they replied yes............

This does not necessarily make them currently suicidal.

If you clarified do you have those feelings right now? and the answer was still "yes" then you have something carry on and ask about a plan :)

[gonzo1, ASN, RN]

Always know what your hospital policy and procedure is and follow it. I once had a psyche pt and my charge nurse said I didn't need to follow the policy, and 2 days later I ended up getting written up because I didn't follow policy.

Needless to say I prefer to follow policy now and rather have a couple of people ****** off at me rather than go against policy and get in trouble.

If you always follow p and p and maintain the standard of nursing care than you don't risk your license

[SeeTheMoon]

I'm just a student, but I'm with viva too. Sometimes we say things for impact, with out using the actual meaning. Example, how many times have you heard a parent say, " son, I'm gonna kill you if you don't turn down that music, take out that trash,..etc" out of frustration. Of course they don't mean it literally (usually lol).

Then again, you did ask him out right and he gave an affirmative. Maybe he just wanted/needed sympathy but didn't realize that by saying that, he would rock a major boat. Either way, you did what you thought was best for your patient. Certainly, many a nurse has done worse. :)

[Old.Timer]

Assuming he was admitted by surgeon to surgical floor (vs inpatient psych) and next thing he knows he ends up as an involuntary admission , I can see why he was extremely upset.

As pp said, there is a difference between general ideation and ideation with a concrete plan.

In this instance, I probably would have alerted the MD that pt had ideation, no plan, offer my assessment and together determine if suicide precautions and involuntary status are indicated.

Assessment of suicidal ideation comes with experience. You did what you thought was the right thing in this instance. No shame in that whatsoever. Consider this experience as part of your learning curve.

[wooh, BSN, RN]

We had a similar case recently. He was suicidal in the ER, but when we said we couldn't take him to the floor yet because we were still working on getting a sitter, all of the sudden he was "just mad at his mother." We held our ground, didn't take him until we had a sitter. Half the staff was saying, "He's just mad at his mother, teenagers say stuff like that." Well great. Yes they do. And I'm pretty sure that was all it was. But he said he was going to kill himself. I'd rather have the precautions in place and not need them than the other way around.

Also agree with the previous posters. There is a huge difference between "I wish I was dead" and "I'm going to kill myself."

[LongislandRN23]

I would have documented what the pt stated word for word and reviewed the hospital policy. I would have double checked with the charge nurse and perhaps called the dr. about the precautions. If I thought it was immediately life threatening than that's a different story.

[workingspaz]

good for you- it's a hard thing to assess for suicidal ideation and abuse; awkward. keep up the good work! chalk this one up to learning, and see previous post LaughingRN mentioned about plan. i wasn't there, i don't know your situation but before initiating precautions here's an idea of what I ask: Are you here because you tried to hurt yourself? Have you though about it? (if yes) Have you thought about a plan, or how would you take action on your thoughts? Let the md or anyone else say whatever they like; it's YOUR license if rounding 2 hours later you find them hurt or worse, DEAD and could have prevented it. It's one of the National Patient Safety Goals, outreach to suicidal patients. listen to your gut.

[jpeters84]

If a patient says they have suicidal thoughts then you must follow protocol I don't care how they said or intended it. If this person did try to commit suicide you would be getting commended for doing the right thing. If you didn't follow protocol and they attempted you would be getting fired. But because this person didn't attempt suicide after making that statement people are questioning you. Please! You did the right thing. If the person got upset too bad. Its not their license on the line. This person and their safety is your responsibility plain and simple. Don't ever second guess following protocol when it comes to suicide precautions. The surgeon was just saving face with the patient. You did the right thing. I can't believe other nurses would even insinuate that you overreacted. People love to question new grads. Don't second guess yourself. You followed protocol and kept this patient safe. Too bad if they were inconveinenced or didn't mean it that way. There is no grey area when it comes to answering questions about taking ones life.

[jadelpn, LPN, EMT-B]

You did the absolute correct thing. Often someone who is suicidal will in fact retract the statements when faced with a nurse reacting to it by implementing precautions. Especially when the patient is serious about them. But because you are not a mental health professional, you have to go on what a patient says and follow protocol. My blanket statement to a patient who identifies SI and then gets mad when nurse reacts is "in this facility we take statements pertaining to suicide very seriously". Do not get into a debate about intent. I would also tell any nurse who says you "over-reacted" that "I was under the assumption that this facility takes suicidal statements very seriously". Again, remember, people who are serious about suicide who let their walls down and in a vulnerable moment and confess it will most often retract the statement. Use your charge nurse and chart that you did so, have her help you. If the MD decides to stop the protocol, make sure you have an order to do so, and DOCUMENT. Hope this helps.