Assessment of Suicidal and Homicidal Thoughts (Nursing)

by Brenda Marshall, EdD, MSN, RN

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    00:01 Now, we're going to be talking about a very serious assessment.

    00:09 We're going to be looking at the patient who has some ideas about killing themselves or killing someone else.

    00:20 These thoughts are thoughts that we consider suicide thoughts, suicidal ideations, and homicidal thoughts or ideations.

    00:34 So, we're going to start with suicide.

    00:38 Suicide is when a person is threatening to kill themself.

    00:46 It's important when we are considering suicide that we do not use the word commit.

    00:54 This is a very recent change in the lexicon of talking about suicidality.

    01:02 We don't want a person to commit to, make a commitment for.

    01:10 We also think about commitment within psychiatric nursing as being committed to institutions.

    01:20 So, that word commit, and commitment has a lot of different meanings.

    01:27 Therefore, when we're thinking about suicidality, we say it is the threat of killing self.

    01:35 And we want to ask very direct questions.

    01:39 We want to ask the person, "Are you thinking about killing yourself by suicide?" Or "Do you want to kill yourself?" You are not going to be putting this idea in your patient's mind.

    01:56 If you ask someone, "Are you considering suicide?" If they say yes, it means they've been thinking about it for a while.

    02:07 If they say no, well, you've asked the question.

    02:11 They're not going to start thinking about it because you've asked a question.

    02:16 You're going to be able to say to that person, "Are you thinking about killing yourself?" Because if that person has been thinking about killing themselves, it will give them the opportunity to talk about their thoughts.

    02:34 They don't have to be afraid to speak to a psychiatric nurse about these kinds of thoughts.

    02:42 If a person says no, that's fine.

    02:47 You say, "Thank you. Thank you for giving me an honest answer." But if you say to someone, "Are you considering suicide? Have you been thinking about killing yourself?" And they say, "Yes. Yes, I have," you must follow up that question with, "Well, do you have a plan? Do you know how you might accomplish that?" Why do you think that's important? It's important because a person who is thinking about suicide might be amassing those things that he or she needs in order to do that deed.

    03:30 They might be not taking medications that are prescribed so that they can take all of the medications at the same time.

    03:39 I have had patients who have said, "I just want to go out, get in my car, and drive into a wall." If I know that person has a car, I'm not letting them get into the car.

    03:54 I'm going to say, "I'm going to stay here with you." That's offering self.

    03:59 "I'm going to stay here with you and I'm going to help you get the help you need." We say that suicide is a permanent solution.

    04:09 The first time you may have to ask that of a patient, it might feel very uncomfortable.

    04:18 Consider the fact this is not about you, it's not about your discomfort, it's about giving the other person the chance to be able to express a thought that has been in their mind that they haven't been able to tell anyone.

    04:37 Oftentimes, the person who has thoughts of suicide and has a plan will start giving things away.

    04:45 Will start taking things that are very important to him or her and making sure that someone else has them. They might start talking about, "When I'm not here anymore, I want to make sure that you are okay." People who love someone who have thoughts of killing themselves may not see or hear the warning signs. They may be very subtle.

    05:17 In some circumstances, if the person has been having these thoughts for a long period of time, right before they go ahead and kill themselves, they will be happy.

    05:32 It will be as though they have found the solution that they were looking for, and now they have the courage to go ahead and do it.

    05:40 That switch, that change in personality, from being very depressed to suddenly feeling free and okay is in itself a warning sign.

    06:12 Suicide is the second leading cause of death for people between the ages of 10 and 24.

    06:23 It's very important to be forthcoming and to ask these questions in order to get help for the people who have these thoughts.

    06:35 What about people who are thinking about hurting others or killing others? As we're listening and assessing a patient and the patient starts saying, "I really hate that principal," or "I hate that teacher," boy oh boy, when I get out of here, they're going to feel it.

    06:56 You need to be able to say to that person, "Are you thinking about hurting that principal?" "Is there someone you are thinking about specifically that you are going to injure, hurt, kill?" You want to be able to listen and make sure that when you're asking these questions, you are not asking it in such a way that will make them say no.

    07:25 Oftentimes, we'll say, "You're not thinking about hurting someone, are you?" Of course, that's going to give you a, "Well, no, of course not." We want the person to be able to talk to us.

    07:43 To let us know what they are thinking.

    07:46 To give air to their thoughts, because those thoughts, the thoughts of hurting or of killing someone, the thought of killing themselves are symptoms of other illnesses, other psychiatric illnesses.

    08:06 So, just like when we ask about suicidality, we might ask the question, "So, do you have a desire to hurt others?" How would you do this? We need to know this for another reason.

    08:26 We need to know this because we have a duty to warn.

    08:29 If a person comes in and says, "I hate my ex-husband, and as soon as I am out of here, I'm going to kill him," we have a duty to warn the ex-husband.

    08:43 If that person has a plan, we have a duty to let that person know.

    08:49 This is our legal duty. The other piece is, one time, when I was working with students, one of the patients really liked the student nurse that she was working with and right before we were leaving the unit, she confided in the student nurse and told her that a friend of hers was coming to get her.

    09:14 She was being discharged that day. She was very happy.

    09:17 She had not been happy for the past two weeks whenever we saw her, but she was being discharged and she was very happy.

    09:25 And in our post-conference, the student said, "Yeah, she's really happy her girlfriend's coming to pick her up and bring her home.

    09:33 But she told me something a little crazy." So, I said, "Well, what did she tell you?" "She asked me not to share it with anyone." I said, "This is a patient. You are the nurse. You are part of a team.

    09:49 Our team is not to keep a secret that a patient may want to keep.

    09:55 Our team is to share information to keep that patient safe.

    10:00 What did she say?" And she told us, "This patient has a friend coming and both of them were in very abusive marriages and they were both going to drive to a bridge, and they were going to videotape themselves on their phone, livestream, as they jump off the bridge." We had to go back onto the unit, we had to call the physician, we had to call a meeting, we sat down with the woman who, in fact, said, "Yes, that is my intention, but I've already got all the papers that say I'm out of here, and this is what we're going to do." And we had to stop her from being discharged on that day.

    10:44 Because that is one thing you never, ever want.

    10:49 You never want to be the last person the patient speaks to before they hurt themselves or before they hurt someone else.

    About the Lecture

    The lecture Assessment of Suicidal and Homicidal Thoughts (Nursing) by Brenda Marshall, EdD, MSN, RN is from the course Psychiatric Assessment (Nursing).

    Included Quiz Questions

    1. “Are you thinking about hurting or killing yourself?"
    2. “How are you feeling today?”
    3. “Are you looking forward to anything in the next couple of weeks?”
    4. “Is something bothering you today?”
    1. “Do you have a plan?”
    2. “Why are you feeling suicidal?”
    3. “Is this the first time you’ve had these thoughts?”
    4. “Do you want some medication to help with the thoughts?”
    1. Antidepressants
    2. Benzodiazepines
    3. Antipsychotics
    4. Antihypertensives
    1. A client who began taking an antidepressant two weeks ago who suddenly exhibits increased energy and a significantly improved mood
    2. A client who has a recent history of depression who currently presents with an increased mood and offers the nurse a car as a gift
    3. A client who began taking an antidepressant five weeks ago who has a mood scale of 4/10 before taking the medications and is now increased to 5/10
    4. A client who presents for follow-up who states to the nurse, "I'm planning to bake some cookies for everyone next week, to thank them for their hard work."
    5. A client who has a history of mania who presents with decreased need for sleep, and pressured speech
    1. “Are you thinking of hurting that doctor?”
    2. “We don’t say things like that.”
    3. “Do you want me to see if we can switch you to another doctor?”
    4. “You’ll like your doctor once you get to know him better.”
    1. “We have a responsibility to warn the client’s father. Disclosing threats of harm to the involved parties does not violate client confidentiality.”
    2. “Although these statements are worrisome, we have a duty to protect client confidentiality.”
    3. “We are only allowed to disclose threats of violence if the client consents to this, but we are allowed to document this in their chart.”
    4. “Does the client have a history of violence? We are only allowed to disclose threats of harm if the client has behaved violently towards this person in the past.”

    Author of lecture Assessment of Suicidal and Homicidal Thoughts (Nursing)

     Brenda Marshall, EdD, MSN, RN

    Brenda Marshall, EdD, MSN, RN

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