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:

[Davey Do]

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?

1) Right

2) Yes.

3) Ask the Patient if he would make a commitment to safety, i.e. he will do nothing to harm himself, and document that statement. Perhaps, during the assessment process, you could have delved more into his statement, and been direct, stating, "I am hearing you say that you are suicidal, correct?" This way, the Patient has to directly confirm or deny his intent.

4) You are probably feeling guilty because you performed a task to the best of your ability, followed protocol, a lot of negative energy was created, and your decision was trumped by one with more power.

Listen, RNdiva, these sorts of situations are going to occur. The important thing now is that you're examining the situation and your perspective on it, while requesting the input of others. You will learn from this situation, as we all have.

Don't be so hard on yourself- you had the best of intentions in mind, and that was your Patient's safety.

And remember this: "If at first you succeed, try to hide your astonishment".

The best to you.

Dave

[Trekfan]

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 :)

thats true , lets face it ,we all at some point have had thoughts for killing ourselfs that does not make you suicidal . back when i worked a rest home a co-worker wounce showed a bluit he car red around with him sence the war (50 years) it was to kill himself if he every got bedridden so forth .

now two years ago another co-worker killed himself and no one had anyida he was thinking about it and it kiiled me i sitting next to him olney hours before and he was fine . people that are serrice in my appenon will not go around telling every one because they do not want to be stopped .

[Meriwhen, ASN, BSN, MSN, RN]

I agree with Viva: you needed to dig a little deeper in your assessment to determine if the patient was truly suicidal or just frustrated, before immediately jumping to the suicide precautions. That being said, if after the assessment you have any doubt about whether the patient is serious, IMO it's better to err on the side of caution and implement suicide precautions, or at the least up his observation level while you consult with the MD. Document what the patient said using direct quotes, so at least you have a legal record of what the patient said. Also, if after hearing your assessment the doctor stated that suicide precautions weren't necessary, document that too.

Keep the patient safe yet CYA.

[OCNRN63, RN]

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.

I agree. If he had no active plan and was willing to give a verbal contract to notify staff if he felt actively suicidal, I don't think I'd have put a sitter in the room. I would have let his attending know, though.

[Nurse SMS, MSN, RN]

Where I work if the patient states "I wish I were dead" that is enough to warrant implementation of suicidal precautions. Even if they retract it later, get mad, etc.

You were acting in the patient's best interest. In these cases, particularly as a new RN, erring on the side of caution is definitely the correct thing to do.

I think you handled the situation just fine. Now that another licensed entity discontinued the suicidal precautions, if the patient DOES attempt or accomplish self harm, it will be very clear you took the client seriously and that you did all you could to protect him - and your license will be safe.

[rnmi2004]

Do you ask about suicide attempts or suicidal ideations on every med-surg patient? That seems odd to me. We have a question about stressors, but we don't specifically ask about suicide.

IMO, if your hospital's policy is to open this can of worms with every patient (and I'm not saying it isn't an appropriate question to ask) then they need to give each nurse additional training on how you are expected to handle the various responses you are going to get. They also need to have 24/7 resources available in-house to respond promptly to even the patients with questionable responses, like yours.

[pyrazen]

I think (with the available info) you acted correctly. Better to take precautions than call the morgue.

When I was a med/surge nurse I cared for a SI pt. I was told by mgmt he was fine, not to worry, didn't need a sitter etc... Two days later I'm called into a incident debriefing, and he was dead. Caution and following the P&P is a good thing.

[Rob72, ASN, RN]

Do you ask about suicide attempts or suicidal ideations on every med-surg patient? That seems odd to me. We have a question about stressors, but we don't specifically ask about suicide.

Many places do, along with domestic violence. sexual abuse and presence of firearms in the home. The cynic in me recognizes this as the social-engineering model/referral revenue generator that it is, while it is certainly beneficial to a minority of admits.

[systoly]

Anger, frustration, unhappiness - managable

death - not so much

[whichone'spink, BSN, RN]

Do you ask about suicide attempts or suicidal ideations on every med-surg patient? That seems odd to me. We have a question about stressors, but we don't specifically ask about suicide.

Yes, many hospitals include psychosocial history and assessment in the admission paperwork. I think it's a joint commission requirement.

[leslie :-D]

i seriously don't think that specific suicide questions, is appropriate.

pt stated he wasn't suicidal at present, and admitted that he had been in the past.

past thoughts should be treated as past, and not present.

but if the pt answers 'honestly', the nurse is obligated to implement precautions.

if s/he doesn't, it's her ass on the line.

and, what will this pt learn?

to lie, should there be a next time.

those type of questions and answers, require further discussion, and NOT automatic precautions.

sev'l times in my life, i have muttered that i wish i wasn't here.

but that doesn't mean i'm suicidal!

i think op, as a new nurse, did exactly what she deemed appropriate.

i'm just saying, this type of question is tricky, and a yes or no answer, is meaningless w/o further inquiry.

get those stupid-ass questions out of there until they can be revised to encourage accurate assessment.

leslie

[Esme12, ASN, BSN, RN]

Always error on the side of caution. I think you were right to get the supervisor involved and the hospitalist involved but if you didn't react and he hurt himself, you're liable and responsible.

Food for thought....I had a patient once present to triage. Professional male mid thirties early forties, he had been drinking. He admitted to job loss, family loss, house loss. He stated he has lost everything that meant anything to him. He stated he wished he was dead. When I asked him if he would hurt himself he stated that was what mede him come to the ED........he stopped his vehicle just before driving off a bridge and he was scared.

When he realized what SI watch 1:1 entailed he decided he didn't want to stay, convinced the psych eval person that it was the alcohol talking that he would NEVER hurt himself and would follow up outpatient(he was also prominent in the community and very bright). I was chicken little and over reacting to the situation and adding too much drama.

I was dead set against it.......I was the one who spoke to him when he was SI upon arrival and I said he still was........after much debate....he was discharged.

Later that night............He hung himself in the hospital garage.......

Always be safe not sorry.:hug: