NURS 3363
Lab 1
Suicide Assessment
Mental health nursing involves assessing mental
health status as we would physical health.
The mnemonic ABCTPS can help you remember the components of a
mental status exam.
Appearance ​
Behaviour & Speech​
Cognition & Mood​
Thoughts ​
Perceptions ​
Safety
An MSE gives us both objective and subjective
data. We want to know:
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What a person looks like: APPEARANCE
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What a person acts like: BEHAVIOUR & How do they talk: SPEECH
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Understanding their environment: COGNITION How do they describe
their state: MOOD
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What a person is thinking (what they say and how they say it): THOUGHTS
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How a person perceives their environment: PERCEPTIONS
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Is there a risk for Suicide or Homicide: SAFETY
Safety
This is really part of Thought Content or Perceptions, however it is important enough
to highlight on its own.
Suicidal or Homicidal
● Are they experiencing thoughts of harming self or others? If others, who?
● How frequently are these thoughts occurring?
● Is there an intent to act?
● Do they have a plan?
● The means and/or opportunity to carry out the plan?
● Are there any protective factors?
Asking About Suicide
●
Is part of your patient assessment in mental health nursing​
●
As part of your patient assessment each shift ​
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In response to patient behaviour​
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Before patient leaves on a pass and prior to discharge
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Is a skill you will get better at with practice​
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Safety is always the most important factor
Risk Factors
●
●
History of previous
suicide attempts​
Having a mental
illness or recent
serious diagnosis​
●
Recent loss
●
Male ​
●
Single
●
Older adult
●
Indigenous (2.1 x
higher)
●
Poverty
●
Addictions
●
Victim of Abuse​
Measuring Risk
SIG E CAPS
SAD PERSONS
Sleep changes
Interest
Guilt
Sad
Age
Depression
Energy
Previous attempts
Ethanol abuse
Rational thinking loss
Social supports lacking
Organized plan
No spouse
Sickness
Cognition
Appetite
Psychomotor
Suicide/death preoccupation
Protective Factors
●
Supportive family & social network​
●
Problem solving skills/coping skills​
●
Conflict resolution skills​
●
Sense of belonging/identity & self-esteem​
●
Future goals ​
●
Supportive medical & mental health care relationships
* be mindful – you will be heavily influenced by your
own experiences and perceptions of societal norms.
When we do a suicide assessment; we need to be sure
we are working from an evidence-informed practice &
be sure to not let our own experiences & beliefs cloud
what our patients are telling us.
Assessment
●
Nurses are the most numerous health care professional so it makes
sense we need to gain skill in being able to assess patients for suicide
risk. ​
●
A study published in 2018 showed 1/3 of Mental Health care
professionals did not ask every patient about suicidal ideations. Why do
you think that might be?​
●
20% of all persons who died by suicide has contact with a mental health
professional within the past month. ​
Roush et al (2018)
Assessment
●
How Frequently have they been thinking about suicide?​
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Is there Intent?​
●
Do they have a plan?​
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Are they making specific plans about when?​
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Lethality of plan? (Important part of assessment)​
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Do they have the Means to carry it out? Access to means?​
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Any Protective factors?​
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Collateral history: Any recent changes, i.e. sudden happiness, losses, giving things away​
●
Safety always on our minds: Are they safe? How much observation do they need? What is
their safety plan?
Columbia-Suicide Severity Rating Scale (C-SSRS)
https://vtspc.org/wp-content/uploads/2021/04/Adam-C-SSRS-Full-Training-3.5.21-no-videos.pptx.pdf
C-SSRS
Practice
●
Break into groups of 3​
●
Think back to your med/surg rotation. Here is your scenario for the first
practice.
●
You have a patient who was admitted with chest pain, this is your initial
round. Not doing any physical assessment or vital signs – how would you
assess the patient for chest pain? ​
●
Discuss what is important to ask about the chest pain?
Practice
●
You would ask if they were having chest pain currently.​
○ If yes – you would assess intensity, onset, frequency, duration, what they have
done to control it (especially if they have had previous angina/chest pain)​
○ If no – you would assess when the last time was they had chest pain, what
precipitated it, frequency, duration, controllability, how they managed it.
●
When to ask:
○ It depends on the context of the presentation of the patient​, but like with chest
pain, you would want to assess for thoughts of suicide early in your assessment. ​
○ Sometimes people will say they want to establish a therapeutic relationship with
the patient prior to asking about suicide. Would you do the same if you thought
the patient might be having chest pain? Suicide assessment should be a priority
just like chest pain assessment would be
Practice
Scenario #1​
●
The patient you are assessing is a 23 year old male, admitted 2 days ago
with suicidal ideation. Having no previous history of suicidal ideation or
behavior, they have a recent onset of depression related to stress when
they lost their job. The patient has a plan (to jump off a bridge over a
road in front of a large truck) but has no current intent of following
through with the plan, but thinks about it several times a day increasing
in frequency and is having a harder time controlling the urge to go do it
which is why they came into emergency.
Practice
Scenario #2
●
The patient was admitted last night after they were brought into
emergency by their best friend. The patient has had a recent history of
depression, has been having thoughts of suicide with increasing intensity
for a week. Yesterday they took an overdose of their anti-depressant
medication. After they had taken 30 pills, they called their best friend
who brought them into emergency.
Practice
​Scenario #3
●
The patient was admitted last evening following a suicide attempt. They
had attempted to hang themselves when their roommate came home
unexpectantly early and interrupted the suicide attempt. The patient has
had a previous attempt, but that time had come into emergency on their
own.​
●
Looking at the behaviour subscale – what 3 things makes this suicide
attempt higher risk?
If You’re Feeling Stuck
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*Be Direct: Are you having suicidal thoughts?
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What has been helpful that has got you through this so far?​
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How can I help?​
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What have you tried that has been helpful?​
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Have you been in this situation before?​
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What would you like to be different?
REFERENCES
Pollard, C., & Jakubec, S. (2023). Canadian psychiatric mental health nursing: A clinical approach. (3rd
CDN ed.). Elsevier
Roush, J. F., Brown, S. L., Jahn, D., R., Mitchell, S. M., Taylor, N. J., Quinnett, P., & Ries, R. (2018).
Mental health professionals' suicide risk assessment and management practices. Journal of
Psychosocial Crisis, 39(1), 55-64. https://doi.org/10.1027/0227-5910/a000478