4.1: 4.01-0 Spotlight Application
Let’s review how the nursing process can be applied to Sample Case A introduced in the “ Diagnosis ” section of this chapter regarding caring for a suicidal client:
Assessment
During an interview with a 32-year-old male client diagnosed with Major Depressive Disorder, the client exhibited signs of a sad affect and hopelessness. He expressed desire to die and reported difficulty sleeping and a lack of appetite. He reports he has not showered in over a week and his clothes have a strong body odor.
Diagnosis
The nurse analyzed this data and created four nursing diagnoses:
- Hopelessness related to social isolation
- Risk for Suicide as manifested by the reported desire to die
- Imbalanced Nutrition: Less than Body Requirements related to insufficient dietary intake
- Self-Neglect related to insufficient personal hygiene
The nurse established the top priority nursing diagnosis of Risk for Suicide and immediately screened for suicidal ideation and a plan using the Columbia Suicide Severity Rating Scale (C-SSRS).
Outcome Identification
The nurse identified the following SMART expected outcomes:
- The client will verbalize feelings by the end of the shift.
- The client will remain free from injury during the hospitalization stay.
- The client will progressively gain at least one pound per week toward his ideal body weight (180 pounds).
- The client will participate in daily bathing.
Planning and Implementation
The nurse implemented planned nursing interventions for Risk for Suicide as previously discussed in Table 4.6.
Evaluation
Day 1: Outcomes partially met. By the end of the shift, the client verbalized feelings related to hopelessness and did not harm himself. He did not agree to participate in taking a bath and only ate 25% of his meal tray. Interventions will be re-attempted on Day 2 and reassessed for effectiveness.
Sample Documentation
0900: 32-year-old male client diagnosed with Major Depressive Disorder admitted for active suicidal ideation with a plan to do so with a gun. He has the means to accomplish this plan at home. He has expressed the desire to die and reports difficulty sleeping and a lack of appetite for the past two weeks. He reports he has not showered in over a week, and his clothes have a strong body odor. Client was placed in a room near the nursing station and assigned a 1:1 sitter. His personal belongings were removed and placed in a secure area. An environmental scan was completed, and all hazards were removed from the room. He agreed to complete a no-harm contract. Dr. Delgado was notified at 0930. She assessed the client at 0945, and new orders for medications were received and administered. —– Zerimiah Alimi, Nursing Student