OBJECTIVES

y

Describe the genetic, biologic, sociologic, and psychological factors believed to precipitate suicidal behavior.

y y y y y y y y

Identify those clients or groups of individuals considered to be at risk for suicide. State at least two examples of verbal, behavioral, and situational suicidal clues. Differentiate three cultural beliefs about suicide. Distinguish among suicidal ideation, intent, threat, gesture, and attempt. Explain primary, secondary, and tertiary suicide prevention. Articulate the importance of self-assessment when providing care for suicidal clients. Define the term postvention. Describe the purpose of suicide precautions, no-suicide contracts, and seclusion and restraints in the clinical setting.

y y

State the purpose of a psychological autopsy. Reflect on the impact of physician-assisted suicide on the nursing profession.

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INTRODUCTION
Suicide is derived from the Latin word for self-murder. Latin suicidium, from Sui caedere, "to kill oneself" is the act of a human being intentionally causing his or her own death It is a fatal act that represents the person's wish to die. There is a range, however, between thinking about suicide and acting it out. Some persons have ideas of suicide that they will never act on; some plan for days, weeks, or even years before acting; and others take their lives seemingly on impulse, without premeditation. W.H.O estimates that it is the thirteenthleading cause of death worldwide. In 2002, there were 10,982 suicides in Tamil Nadu, 11,300 in Kerala, 10,934 in Karnataka and 9,433 in Andhra Pradesh. Kerala, the country's first fully literate state, has the highest number of DSH. Some 32 people commit DSH in Kerala every day. But According to The Lancet, the respected British medical journal, the south India is the is the region account for the world¶s largest number of DSH by young people. Some 50,000 people in the four states of Kerala, Karnataka, Tamil Nadu and Andhra Pradesh and the Union Territory of Pondicherry kill themselves every year. This statistic becomes even more alarming when you consider that the total number of DSH cases recorded in the whole of India in 2002 was 154,000. The suicide rate in Kerala was about 32 per 100,000 persons in 2002, thrice the rate in India as a whole. Experts like him put forward various reasons for the dismal state of mental health among people in the South. KEY TERMS Alexithymia Altruistic suicide Anomic suicide Egoistic suicide Euthanasia Parasuicide Postvention Primary prevention Psychological autopsy Secondary prevention Tertiary prevention Trichotillomania

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SUICIDE

Definition:
Suicide is associated with thwarted or unfulfilled needs, feelings of hopelessness and helplessness, ambivalent conflicts between survival and unbearable stress, a narrowing of perceived options, and a need to escape.
SHNEIDMAN, 1996

Suicide may be the culmination of self-destructive urges that have resulted from the client's internalizing his or her anger or a desperate act by which to escape a perceived intolerable psychological state or life situation. The client may be asking for help by attempting suicide, seeking attention, or attempting to manipulate someone with suicidal behavior.
SCHULTZ & VIDEBECK, 2002

Males are four times more likely to die from suicide than females. However, females are more likely to attempt suicide than males (National Center for Health Statistics [NCHS], 2003; National Center for Injury Prevention and Control .

RISK FACTORS
Gender Differences :
Men commit suicide more than four times as often as women, a rate that is stable over all ages. (70% male; female30%). Women, however, are four times more likely to attempt suicide than men. Men's higher rate of completed suicide is related to the methods they use: firearms, hanging, or jumping from high places. Globally, the most common method of suicide is hanging.

Age :
Suicide rates increase with age and underscore the significance of the midlife crisis. Among men, suicides peak after age 45; among women, the greatest number of completed suicides occurs after age 55. Rates of 40 per 100,000 population occur in men age 65 and older. Older persons attempt suicide less often than younger persons, but are more often successful. The suicide rate, however, is rising most rapidly among young persons, particularly males 15 to 24 years of age, and the rate is still rising. The suicide rate for females in the same age group is increasing more slowly than that for males. Among men 25 to 34 years of age, the suicide

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disfigurement. Previous medical care appears to be a positively correlated risk indicator of suicide: About one third of all persons who commit suicide have had medical attention within 6 months of death and a physical illness is estimated to be an important contributing factor in about half of suicides. Suicide is the third leading cause of death in those 15 to 24 years of age. corticosteroids. Single. and attempted suicides in this age group number between 1 million and 2 million annually. never-married persons register an overall rate nearly double that of married persons. especially when physical activity is important to occupation or recreation. OCCUPATION Suicide is higher among the unemployed than among employed persons. with divorced men three times more likely to kill themselves as divorced women. 4 . Patients on hemodialysis are at high risk. Widows and widowers also have high rates. Certain drugs can produce depression. intractable pain. Suicide occurs more frequently than usual in persons who are socially isolated and have a family history of suicide (attempted or real). MARITAL STATUS Marriage lessens the risk of suicide significantly. Suicide is rare before puberty. after accidents and homicides. Among these drugs are reserpine (Serpasil).Factors associated with illness and contributing to both suicides and suicide attempts are loss of mobility. especially if there are children in the home. Most suicides now occur among those aged 15 to 44. disruption of relationships and loss of occupational status are prognostic factors. which may lead to suicide in some cases. the secondary effects for example. Persons who commit so-called anniversary suicides take their lives on the day a member of their family did.rate increased almost 30 percent over the past decade. and some anticancer agents. and chronic. PHYSICAL HEALTH The relation of physical health and illness to suicide is significant. The suicide rate increases during economic recessions and depressions and decreases during times of high unemployment and during wars. In addition to the direct effects of illness. particularly among women. antihypertensives. Divorce increases suicide risk.

schizophrenia accounts for 10 percent. particularly of the psychiatric residents. mental health professionals working in emergency services must be well trained in assessing suicidal risk and making appropriate dispositions. They must also be aware of the need to contact patients at risk who fail to keep follow-up appointments. Patients. are periods associated with inpatient suicides. persons suffering from certain mental illnesses are particularly susceptible to DSH ideation and DSH attempts. 25 percent are also alcohol dependent and have dual diagnoses. who frequent emergency services. and legal troubles. . rejection.MENTAL ILLNESS Alcohol-related illnesses. and substance abuse. unemployment. and diagnoses of mood disorders and cognitive disorders most often among suicides in those age 30 and above. Their DSH rate may be 10 or 20 times higher than for the average citizen. inpatients have the same risk as the general population. Among adults who commit suicide. For both sexes. The psychiatric diagnosis with greatest risk of suicide in both sexes is a mood disorder. Thus. it literally means having no word for emotions. CLIENTS WITH ALEXITHYMIA Alexithymia is not a psychiatric diagnosis. Almost 95 percent of all persons who commit or attempt suicide have a diagnosed mental disorder. The main risk groups are patients with depressive disorders. A history of impulsive behavior or violent acts increases the risk of suicide as does previous psychiatric hospitalization for any reason. This construct is useful for characterizing clients who seem not to understand the feelings 5 . Diagnoses of substance abuse and antisocial personality disorder occurred most often among suicides in persons less than 30 years of age. and patients who make repeated visits to the emergency room. significant differences between young and old exist for both psychiatric diagnoses and antecedent stressors. but a construct introduced in 1972 by Peter Sifneos. the suicide risk is highest in the first week of the psychiatric admission. such as cirrhosis. after 3 to 5 weeks. Stressors associated with suicide in those under 30 were separation. are associated with higher suicide rates. Among all persons with mental disorders. also have an increased suicide risk. illness stressors most often occurred among suicide victims over 30. Derived from the Greek language. Depressive disorders account for 80 percent of this figure. Persons with delusional depression are at highest risk of suicide. Times of staff rotation. especially those with panic disorder. and dementia or delirium for 5 percent. schizophrenia.

The suicide rate for persons who are heroin dependent is about 20 times the rate for the general population . aggressive. a percentage that largely reflects the sex ratio for alcohol dependence. As many as 50 percent of all alcohol-dependent suicide victims have experienced the loss of a close. middle-aged. The largest group of male alcohol-dependent patients is composed of those with an associated antisocial personality disorder. socially isolated. OTHER SUBSTANCE DEPENDENCE Studies in various countries have found an increased suicide risk among those who abuse substances. Alcohol-dependent suicide victims tend to be white. which are often present in the weeks and months before the suicide. and criminal behaviors. ALCOHOL DEPENDENCE About 80 percent of all alcohol-dependent suicide victims are male. It is a real phenomenon and identifies a deficit of self. affectionate relationship during the previous year. unmarried. and to be found among alcohol-dependent suicide victims. Such interpersonal losses and other types of undesirable life events are probably brought about by the alcohol dependence and contribute to the development of the mood disorder symptoms.they experience and who seem to lack the words to describe their feelings to others. Studies show that such patients are particularly likely to attempt suicide. 2000b). older alcohol-dependent patients are at particular risk during the postdischarge period. friendless. and currently drinking. Up to 40 percent of all suicides by persons who are alcohol dependent occur within a year of the patient's last hospitalization. Studies show that many alcohol-dependent patients who eventually commit suicide are rated depressed during hospitalization and that up to two thirds are assessed as having mood disorder symptoms during the period in which they commit suicide. to exhibit impulsive. PERSONALITY DISORDERS 6 . Up to 40 percent have made a previous suicide attempt. to abuse other substances. Individuals who experience this phenomenon have been found to be at risk for self-mutilation and suicidal behavior (Muller.

A high proportion of t hose who commit suicide have various associated personality difficulties or disorders. by impairing the ability to cope with a mental or physical disorder. The risk of a second suicide attempt is highest within 3 months of the first attempt. Studies show that about 40 percent of depressed patients who commit suicide have made a previous attempt. Having a personality disorder may be a determinant of suicidal behavior in several ways: by predisposing to major mental disorders such as depressive disorders or alcohol dependence. by leading to difficulties in relationships and social adjustment. however. by precipitating undesirable life events. ANXIETY DISORDER Uncompleted suicide attempts are made by almost 20 percent of patients with a panic disorder and social phobia. PREVIOUS SUICIDAL BEHAVIOR A past suicide attempt is perhaps the best indicator that a patient is at increased risk of suicide. 7 . If depression is an associated feature. the risk of completed suicide rises.

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2003). hastening. a French sociologist. Nurses who provide palliative care for dying clients have difficulty distinguishing among allowing. identified society as an influencing factor on suicide rates. or causing death when their only goal is to help clients die with peace and dignity (Schwartz. development of modern medical technology. defined as the imparting of information or means to enable suicide to occur. He divided suicides into three categories based on the degree of an individual's 9 . The increase in human longevity. have become controversial issues in the health care industry (Sadock & Sadock.CLINICAL DETERMINANTS OF SUICIDE EUTHANASIA AND PHYSICIAN-ASSISTED SUICIDE (PAS) Euthanasia. and use of life-support systems have created an ethical dilemma for health care providers who are often confronted with their responsibility to relieve pain and suffering as well as their obligation to preserve life. 2002). ETIOLOGY SOCIOLOGICAL FACTORS Durkheim's Theory: Emile Durkheim. and physician-assisted suicide (PAS). defined as a health care provider's deliberate act to cause a client's death.

a suicide bomber in Palestine dies while fighting for independence from Israel. conceived of suicide as inverted homicide because of a patient's anger toward another person. Such fantasies often include wishes for revenge. The suicidal patients most likely to act out suicidal fantasies may have lost a love object or received a narcissistic injury. rebirth. or punishment.loss of job. or adjusting to expected normal social behavior (eg. Freud doubted that there would be a suicide without an earlier repressed desire to kill someone else. Recent Theories believe that much can be learned about the psychodynamics of suicidal patients from their fantasies about what would happen and what the consequences would be if they commit suicide. adapting to a world of overwhelming stressors. For example. and by the Heaven's Gate cult. reunion with the dead. Group dynamics underlie mass suicides such as those at Masada.also there is fatalistic suicide in which person feels that he is excessively regulated. power. He also described a selfdirected death instinct (Freud's concept of Thanatos) plus three components of hostility in suicide: the wish to kill. escape or sleep. Freud stated his belief that suicide represents aggression turned inward against an introjected. sacrifices his life while attempting to save the lives of others during the attack on the World Trade Center. rescue. altruistic. Karl Menninger. Menninger's Theory Building on Freud's ideas. atonement. In his paper Mourning and Melancholia. a fireman who knows his life is in danger and that he could die. PSYCHOLOGICAL FACTORS Sigmund Freud offered the first important psychological insight into suicide. and anomic. sacrifice. control. but he saw many depressed patients. Egoistic suicide refers to suicide by individuals who are not strongly integrated into any social group (eg. This retroflexed murder is either turned inward or used as an excuse for punishment. or restitution. or may identify with a suicide victim. may experience overwhelming affects like rage and guilt. He described only one patient who made a suicide attempt. 10 .there is no personal freedome or hope for obtaining it(prisoner). in Man against Himself. at Jonestown. or a new life. and the wish to die. Altruistic suicide describes suicide by persons who believe sacrificing their lives will benefit society. commits suicide).close friend. the wish to be killed. ambivalently cathected love object. Anomic suicide refers to suicide that occurs when an individual has difficulty relating to others.socialization: egoistic. a divorced male.a parent). who has no children and who lives alone.

Depressed persons may attempt suicide just as they appear to be recovering from their depression. and because of his belief in life after death. A group at the Karolinska Institute in Sweden first noted that low concentrations of the serotonin metabolite 511 . who never displayed an interest in her business. y A cry for help: Some people attempt suicide hoping to draw attention to themselves to receive help. y A way to end one's feelings of hopelessness and helplessness: Hope infers a sense of the possible. successful. BIOLOGICAL FACTORS Diminished central serotonin plays a role in suicidal behaviour. giving promise for the future and an expectation of fulfilment. A study by Aaron Beck showed that hopelessness was one of the most accurate indicators of long-term suicidal risk. The suicides were an effort to save face. a 49-year-old woman in financial distress attempts suicide by taking a moderate overdose of sleeping pills. For example. especially if it fulfills a patient's need for punishment. Other Psychological Factors Additional psychosocial factors or motives believed to precipitate suicidal behavior have been identified and explained. there is nothing left to sustain hope. relieving them of the responsibility of dealing with business failures. Persons who experience hopelessness feel insecure. These people had viewed themselves as competent. Helplessness is a feeling that everything that can be done has been done. and respected before the crash. They experience a sense of the impossible. He left a note to his children stating that he did not want to live without his wife. believing that there are no solutions to problems. Of equal relevance. many suicidal patients use a preoccupation with suicide as a way of fighting off intolerable depression and a sense of hopelessness. hoping that her boyfriend. these factors may include: y A reunion wish or fantasy: A newspaper article described the death of an elderly man whose wife had just died. will come to her rescue financially as well as emotionally. Briefly summarized. A suicide attempt can cause a long-standing depression to disappear. y An attempt to save face or seek a release to a better life: Persons who were involved in the stock market crash of 1929 precipitating the Great Depression jumped from windows in suicide attempts caused by feelings of failure. he planned to join his wife.

broken glass. Self-mutilation has been viewed as localized self-destruction. and hostile than controls. relief of tension. and legs are most commonly cut. breasts. a family history of suicide increases the risk of attempted suicide and that of completed suicide in most diagnostic groups. such as anger at themselves or others. or mirror. Post-mortem neurochemical studies have reported modest decreases in serotonin itself or 5-HIAA in either the brainstem or the frontal cortex of suicide victims. Self-injury is found in about 30 percent of all abusers of oral substances and 10 percent of all intravenous users admitted to substance-treatment units. the face. In medicine. neurochemical. Alcohol abuse and other substance abuse are common. Together. The incidence of self-injury in psychiatric patients is estimated to be more than 50 times that in the general population. these CSF. the female-to-male ratio is almost 3 to 1. Most persons who cut themselves claim to experience no pain and give reasons. Recent studies also report some changes in the noradrenergic system of suicide victims. For example. and abdomen are cut infrequently. Post mortem receptor studies have reported significant changes in presynaptic and postsynaptic serotonin binding sites in suicide victims. thighs. Such studies in suicide are reviewed below. This finding has been replicated many times and in different diagnostic groups. and receptor studies support the hypothesis that reduced central serotonin is associated with suicide. but who usually do not wish to die. Most cut delicately. 12 . In psychiatric patients. and most cutters have attempted suicide. not coarsely. neurotic. arms. with mishandling of aggressive impulses caused by a person's unconscious wish to punish himself or herself or an introjected object. These patients are usually in their 20s and may be single or married. knife. GENETIC FACTORS Suicidal behaviour. as with other psychiatric disorders.. Psychiatrists note that so-called cutters have cut themselves over several years. Margaux Hemingway's 1997 suicide was the fifth suicide among four generations of Ernest Hemingway's family. Most are classified as having personality disorders and are significantly more introverted. cutting the skin). and the wish to die. Para suicidal Behavior Parasuicide is a term introduced to describe patients who injure themselves by self-mutilation (e. usually in private with a razor blade.g. the strongest evidence for involvement of genetic factors comes from twin and adoption studies and from molecular genetics. The wrists. Studies show that about 4 percent of all patients in psychiatric hospitals have cut themselves.hydroxyindoleacetic acid (5-HIAA) in the lumbar cerebrospinal fluid (CSF) were associated with suicidal behaviour. tends to run in families.

Both subtle and direct messages of suicide should be taken seriously with appropriate assessments and interventions. Some people. depressed after the suicide of a loved one.VARIABLES ENHANCING RISK OF SUICIDE AMONG VULNERABLE GROUPS Adolescence and late life Lethality of previous attempt Bisexual or homosexual gender identity Living alone Criminal behaviour Low self-esteem Cultural sanctions for suicide Male sex Delusions Physical illness or impairment Disposition of personal property Previous attempts that could have resulted Divorced. friends. PHYSICAL HARM: Psychotic people may be Suicidal people only want to hurt themselves. Some suicides are EMOTIONAL HARM: 13 . responding to inner voices that command the individual to kill others before killing the self. separated. or single marital in death status Protestant or nonreligious status Early loss or separation from parents Recent childbirth Family history of suicide Recent loss Repression as a defence Hallucinations Secondary gain Homicide Severe family pathology Hopelessness Severe psychiatric illness Hypochondriasis Sexual abuse Impulsivity Signals of intent to die Increasing agitation Suicide epidemics Increasing stress Unemployment Insomnia White race Lack of future plans Lack of sleep MYTHS People who talk about suicide never commit suicide. While the self-violence of suicide demonstrates anger turned inward. and even police involved in trying to avert a suicide or thos e who did not realize the person¶s depression and plans to commit suicide feel intense guilt and shame because of their failure to help and are ³stuck´ in a never-ending cycle of despair and grief. Often family members. A depressed person who has decided to commit suicide with a gun may impulsively shoot the person who tries to grab the gun in an effort to thwart the suicide. health care professionals. FACTS Suicidal people often send out subtle or not-sosubtle messages that convey their inner thoughts of hopelessness and self -destruction. will rationalize that suicide was a ³good way out of the pain´ and plan their own suicide to escape pain. the anger can be directed toward others in a planned or impulsive action. not others.

finding new ways to resolve the problem helps these individuals become emotionally secure and have no further need for suicide as a way to resolve a problem. gestures or cues should be taken seriously and immediate help given that focuses on the problem about which the person is suicidal. There is no way to help someone who wants to kill himself or herself Suicidal people have mixed feelings (ambivalence) about their wish to die. HIGH High. All plans. or panic state Severe Hopeless. When asked about suicide. Suicidal people have already thought of the idea of suicide and may have begun plans. the majority of people with suicidal ideation can have positive resolution to the suicidal crisis.planned to engender guilt and pain in survivors. Once a suicide risk. Intervention can help the suicidal individual get help from situational supports. With proper support. This ambivalence often prompts the cries for help evident in overt or covert cues. threats. While it is true that most people who successfully commit suicide have made attempts at least once before. for example. Ignoring verbal threats of suicide or challenging a person to carry out his or her suicide plans will reduce the individual¶s use of these behaviors. or to be killed. Asking about suicide does not cause a non -suicidal person to become suicidal. learn new ways to cope. no MODERATE Moderate Moderate Some feelings of helplessness. Threats should not be ignored or dismissed nor should a person be challenged to carry out suicidal threats. INTENSITY OF RISK Anxiety Depression Isolation. withdrawal LOW Mild Mild Some feelings of isolation. as someone who wants to punish another for rejecting or not returning l ove. and self 14 . Suicidal gestures are a potentially lethal way to act out.because this could give him or her the idea to commit suicide. wish to kill others. always a suicide risk. helpless. withdrawn. and move forward in life. it is often a relief for the client to know that his or her cries for help have been heard and that help is on the way. Do not mention the word suicide to aperson you suspect to be suicidal.. choose to live.

and withdrawal deprecating Daily functioning Fairly good in most activities Moderately good in some activities Some Some that are constructive Not good in any activities Few or none Predominantly destructive Only one or none available Negative view of help received Unstable Continual abuse Multiple attempts of high lethality Resources Coping strategies. devices being used Significant others Several Generally constructive Several who are available Few or only one available Yes. or positive attitude toward Lifestyle Alcohol or drug use Previous suicide attempts Stable Infrequently to excess None. or of low lethality Disorientation. disorganization Hostility Suicide plan None Some Marked Little or none Vague. of moderate lethality Psychiatric help in past None.withdrawal hoplessness. fleeting thoughts but no plan Some Frequent thoughts. and moderately satisfied Moderately stable Frequently to excess One or more. Psychiatric and personality disorders Life events and difficulties Poor problem-solving skills Impulsivity and aggression Hopelessness and low self-esteem Motivational problems and poor compliance with treatment 15 . occasional ideas about a plan Marked Frequent or constant thought with a specific plan CHARACTERISTICS OF SUICIDE ATTEMPTERS WHICH ARE RELEVANT TO TREATMENT NEED y y y y y y Repetition of attempts and risk of suicide.

resolution of stressors)? What things would make it more (or less) likely that you would try to kill yourself? What things in your life would lead you to want to escape from life or be dead? What things in your life make you want to go on living? 16 . treatment.. including real or imagined losses. agitation. self-harm. hopelessness. or suicide Is death something you have thought about recently? Have things ever reached the point that you have thought of harming yourself? For individuals who have thoughts of self -harm or suicide When did you first notice such thoughts? What led up to the thoughts (e. holding knife or gun to your body but stopping before acting.g. escape. rebirth.g. going to edge of bridge but not jumping)? What do you envision happening if you actually killed yourself (e. making financial arrangements.GENERAL OVERVIEW OF TREATMENTS Questions about Suicidal Feelings and Behaviors* Begin with questions that address the patient's feeling about living Have you ever felt that life was not worth living? Did you ever wish you could go to sleep and just not wake up? Follow on with specific questions that ask about thoughts of death. anhedonia. reconciliation of relationship. including frequency. reactions of others)? Have you made a specific plan to harm or kill yourself? (If so.g.. anxiety. obsessional quality. specific symptoms such as mood changes. psychosis)? How often have those thoughts occurred. interpersonal and psychosocial precipitants.g.. taking steps to avoid discovery. what does the plan include?) Do you have guns or other weapons available to you? Have you made any particular preparations (e. reunion with significant other. writing a note or a will. controllability? How close have you come to acting on those thoughts? How likely do you think it is that you will act on them in the future? Have you ever started to harm (or kill) yourself but stopped before doing something (e..g.. rehearsing the plan)? Have you spoken to anyone about your plans? How does the future look to you? What things would lead you to feel more (or less) hopeful about the future (e. purchasing specific items.

g. getting a reaction out of a particular person)? Were other people present at the time? Did you seek help afterward yourself. internal versus external.g. what would you do? For individuals who have attempted suicide or engaged in self-damaging action(s).. emergency department versus inpatient versus outpatient)? Has your view of things changed. going to sleep versus injury versus dying. relief versus regret at being alive)? Did you receive treatment afterward (e. single versus multiple. precipitants.g. recognizable versus nonrecognizable)? What do the voices say (e. or did someone get help for you? Had you planned to be discovered. parallel questions to those in the previous section can address the prior attempt(s). ask specifically about hallucinations and delusions Can you describe the voices (e. Additional questions can be asked in general terms or can refer to the specific method used and may include: Can you describe what happened (e. intent... method. use of alcohol or other substances.. circumstances. view of future. positive remarks versus negative remarks versus threats)? (If the 17 .g. or were you found accidentally? How did you feel afterward (e.. medical versus psychiatric.. and what happened afterward? For individuals with psychosis.g. or is anything different for you since the attempt? Are there other times in the past when you have tried to harm (or kill) yourself? For individuals with repeated suicidal thoughts or attempts About how often have you tried to harm (or kill) yourself? When was the most recent time? Can you describe your thoughts at the time that you were thinking most seriously about suicide? When was your most serious attempt at harming or killing yourself? What led up to it.g. male versus female. seriousness of injury)? What thoughts were you having beforehand that led up to the attempt? What did you think would happen (e.If you began to have thoughts of harming or killing yourself again.

. ask for examples.remarks are commands. persecutory ideas.g. what made it difficult?) Have there been times when the voices told you to hurt or kill yourself? (How often? What happened?) Are you worried about having a serious illness or that your body is rotting? Are you concerned about your financial situation even when others tell you there's nothing to worry about? Are there things that you've been feeling guilty about or blaming yourself for? Consider assessing the patient's potential to harm others in addition to him. determine if they are for harmless versus harmful acts.or herself Are there others who you think may be responsible for what you are experiencing (e.) How do you cope with (or respond to) the voices? Have you ever done what the voices ask you to do? (What led you to obey the voices? If you tried to resist them. passivity experiences)? Are you having any thoughts of harming them? Are there other people you would want to die with you? Are there others who you think would be unable to go on without you? PSYCHOSOCIAL TREATMENTS: Problem-solving therapy: stepwise approach to dealing with the problems and working on the patient's cognitions or beliefs when these interfere with the process 18 .

SECLUSION AND RESTRAINT The hospitalized client may require confinement to a secure room to allow staff to observe the client's behavior more readily. Intensive psychotherapy: One trial has been conducted in which an intensive form of psychological treatment known as dialectical behaviour therapy was evaluated.Intensive care plus outreach: outreach either for all patients. there was a paradoxically higher repetition rate in the former group. it is helpful if treatment for many patients can be provided by clinicians who are working in general hospital services for suicide attempters. Objects that could prove to be dangerous to the client are removed by searching the client's clothing. Female patients with borderline personality disorders who had a history of repeated self-harm were offered a year of individual and group cognitive±behavioural therapy aimed at addressing the patients' problems of motivation and strengthening their behavioural skills. However. Compared with routine care this approach seemed to result in a reduction in repetition of selfharm as well as a number of other positive outcomes during the year of therapy. The body search includes checking any part of the body in which harmful objects might be stored. Other psychosocial approaches: importance of continuity of care was emphasized in a study from Germany in which patients who were followed up by the same therapist who assessed them in hospital after their attempts were more likely to attend treatment sessions than patients who were offered treatment with a different therapist than the one they saw in hospital. The same investigators found that monthly therapy for a year did not produce any difference in outcome compared with 3 months of weekly therapy. 19 . The most useful and relevant finding is that continuity of care for suicide attempters increases compliance. such as body orifices and the hair. but this seems to have been the result of a failure of the randomization procedure to produce balanced groups in terms of risk factors. together with a relatively intense treatment programme. carry-in items. and body in a dignified and professional manner. The reduction in self-harming behaviour continued 6 months after therapy ended . although the details of the content of therapy were not provided. or for those that have not attended treatment sessions. Therefore. particularly in relation to interpersonal difficulties.

self-abusive behavior. Clothing and bed linens are removed from the room because these items have been used to attempt suicide by hanging oneself. 20 . and prevent noncompliance (such as refusal to take oral medication or the hoarding of it). Monitor the client's response to medication. or extreme agitation may require medications parenterally to facilitate rapid absorption of medication. The use of restraints. although variable compliance with long-term medication may be a limiting factor. sometimes referred to as chemical restraint. The door to the seclusion room is locked whenever the client is left alone. the client or family member may be too polite. Neuroleptics: trial in which the depot neuroleptic flupenthixol was administered monthly in a dose of 20 mg for 6 months to repeaters of self-harm and compared with placebo in similar patients appeared to show that the active drug was effective in reducing the recurrence of self-harm. CLIENT AND FAMILY EDUCATION Commonly. and the client is placed in a seclusion gown. unfortunately. selfdestructive clients. Although no immediate cure exists. or embarrassed to initiate a conversation with the psychiatric³mental health nurse or other health care providers.Street clothes are removed. educating the client and family members about intervention and prevention strategies can provide great relief PHARMACOLOGICAL TREATMENTS Antidepressants: serotonin reuptake inhibitor (SSRI) fluoxetine seemed to decrease selfreported aggression in a short-term trial. health care providers tend to believe that suicidal clients or their family members know all about the factors that place an individual at risk for suicidal behavior. periodic checks are made according to established protocol. and frequent. stabilize mood and behavior. full or belt. Clearly this is an area where much further work is required. especially if the client has a history of previous psychiatric treatment. is considered to be a last resort to immobilize agitated. including the presence of any adverse effects . withdrawn. Individuals at risk for suicide. MEDICATION MANAGEMENT The use of psychotropic medication to manage behavior is. However.

Second phase. For this reason. This last phase ends on the first anniversary of the suicide. They may feel that they caused the death by wishing Daddy dead or telling the person that I hate her. survivors are contacted immediately (within 24 hours) to assist them in coping with their feelings of shock and grief. survivors are given the opportunity to develop new coping methods to help prevent the development of maladaptive or destructive behaviours. Assist the child in developing a meaningful relationship with others. or parents of the victim. 1987). exhibit signs of depression. siblings. As a result of such feelings. that is. children. Postvention: is a therapeutic program for bereaved survivors of a suicide. may be more closely involved in the death than the spouse. develop self-destructive behaviour. and the fear of developing a close interpersonal relationship. or have difficulty working through the developmental tasks of childhood. depression. Encourage the development of positive coping skills. Teach the child assertiveness. such as coworkers or significant others. peer. children may be unable to work through the grieving process. In most cases. The survivor learns to cope with feelings of lowered self-esteem. it is extremely important for these individuals to be recognized as survivors with legitimate needs of their own.in patients who repeat self-harm frequently and are willing to receive a depot this approach might be worth trying. the nonfamily survivors should be included in the network of the family (Staudacher. often the nonfamily members. First phase. Children who are survivors require special attention because they are quite vulnerable to the death of a parent. Allow the child to develop ideas and values. or close family friend. 21 . The third phase focuses on helping the survivor view the grief experience as a growthpromoting experience. It might also be worth using one of the atypical oral neuroleptics in patients who are likely to comply with oral treatment. Emphasis needs to be placed on one unusual dynamic associated with suicide. Postvention involves three phases. relative. become preoccupied with the subject of suicide. It allows family members or other survivors to vent their feelings. The following are helpful as preventive and postventive measures with children who are survivors: y y y y y Allow to express feelings.

MANAGEMENT IN CLINICAL PRACTICE THE ASSESSMENT OF ATTEMPTED-SUICIDE PATIENTS Factors to be covered 1. organising insurance) Communicating intent to others beforehand Extensive premeditation Leaving a note Not alerting potential helpers after the act Subsequent admission of suicidal intent 22 . Domestic(living alone with others) 11. Personality traits and disorder 6. Family and personal history 8. Alcohol and drug misuse 7. Life events preceded the attempt 2. Occupation(whether employed) 12. Current circumstances 9. Problems faced by the patient 4. Psychiatric disorder 5.y Expose the child to principles on human behaviour during the preventive or postventive process. Psychiatric history including previous attempts ASSESSMENTS Risk of further attempt Risk of suicide Coping resources and supports What treatment is appropriate for patients needs Motivation of patient to engage in treatment FACTORS THAT SUGGEST HIGH SUICIDAL INTENT y y y y y y y y y Act carried out in isolation Act timed so that intervention unlikely Precaution taken to avoid discovery Preparations made in anticipation of death(making will. Social(extent of social relationship) 10. Motives for the act 3.

pharmacists. 23 .STRATEGIES FOR PREVENTION OF SUICIDE AND ATTEMPTED SUICIDE 1. PRISONERS There are relatively high suicide rates in prisoners. veterinary surgeons. in-reach programmes by befriending organizations such as the Samaritans. although each group makes a relatively small contribution to the overall national suicide rate .(66) While one aspect of prevention is through ensuring that prisons and police cells are safe in terms of absence of structures from which inmates can hang themselves.population strategies: Reducing availability of means of suicide Educating of primary care nurses Influencing media portrayal of suicide Education of the public about mental illness and treatment Educational approaches in schools Befriending agencies and telephone hiplines Addressing the economic factors associated with suicidal behaviour 2. and female nurses. These include careful assessments of new inmates using risk-assessment procedures. Clinicians involved in local suicide prevention programmes should include prisons in their considerations.High risk strategies: Patients with psychiatric disorders The elderly Suicide attempters High risk occupational groups Prisoners HIGH-RISK OCCUPATIONAL GROUPS include farmers. dental practitioners. especially young males held on remand. Prevention of suicide in such occupational groups is an important consideration. and ready access to psychiatric and psychological services. It is interesting to note that all these groups have relatively easy access to dangerous methods for suicide. training of staff with regard to both assessment skills and attitudes towards mental health problems and suicide prevention. there are a range of other potentially useful and humane strategies. medical practitioners.

does not use support systems.Advanced thoughts of a suicide: patient makes a suicidal gesture. He states that he does not want to die.(a small overdose. no risk of suicide 2. Patient rationalises religious beliefs. Describes the feeling of wanting to go to sleep and never wake up. and tells the nurse that he is suicidal. or thoughts about a concrete plan to commit suicide Suicidal threat. patient has support systems in her life and is able to identify a purpose in life.Mild thoughts of suicide: fleeting thoughts of suicide.eg:look after the children 3. patient seems more interested in dying than continue to live.NURSING MANAGEMENT Terminology used to describe the range of suicidal thoughts and behavior. cutting wrist). not necessarily lethal. or vague. and checks insurance policies.(SUICIDE LEXICON) y y y y Suicidal ideation.doesnot buy needed items. but the person does not utilise them because he feels that he is a burden to others. he has support people in his life. patient is able to write his own contract for safety. or self-destructive behaviour by which an individual responds to ambivalent feelings about living (Badger. 4. or the expression of a person's desire to end his or her life Suicidal gesture. religious belief are a deterrent to suicidal threat. Patient tells that he is not going to suicide attempt. 1995) SEVERETY INDEX FOR SUICIDAL RISK 1. No explicit plan to die.Moderate thoughts of suicide: thinks about suicide as an option for solving problems.No suicidal ideation. or intentional self-destructive behaviour that is clearly not lifethreatening but does resemble an attempted suicide y Suicidal attempt. 24 . starts to give things away.or has intrusive thoughts of suicide. fleeting thoughts about wanting to die Suicidal intent.

a plan to take a 2-week supply of a tricyclic antidepressant is. demonstrate an increase in energy after deciding on the details of suicide. Patient may not disclose any commanding auditory hallucinations because voices are demanding not to disclose the suicidal ideas. lighters. patient has begun to question relationship with god. and problems specific to the crisis such as stabilization of psychiatric illness/symptoms. 25 . but usually staff members observe clients every 10 minutes if lethality is low. matches. the next step is to determine potential lethality. Other outcomes may relate to ADLs.if any and may state that he is not worthy in gods eyes. pens. with psychoactive agents.) ‡ Has the client made preparations for death such as giving away prized possessions. such as mood disorder or psychosis. what is it?Is the plan specific? ‡ Are the means available to carry out this plan? (For example. shoelaces. Outcome Identification Suicide prevention usually involves treating the underlying disorder. including the means of death and place and time death will occur. Patient cuts off communication with others and isolates himself from others. a plan to take 10 aspirin is not lethal. Believing a method to be lethal poses a significant risk. writing a suicide note. Institutional policies for suicide precautions again vary. This assessment involves asking the following questions: ‡ Does the client have a plan? If so.Severe thoughts of suicide: patient wants to die and cannot identify any other solution but suicide. commit suicide such as sharp objects.5. The overall goals are first to keep the client safe and later to help him or her to develop new coping skills that do not involve self-harm. sleep and nourishment needs. belts. It is important to consider whether or not the client believes her or his method is lethal even if it is not. pencils. LETHALITY ASSESSMENT: When a client admits to having a ³death wish´ or suicidal thoughts. The patient may not disclose the plan to nurse because she may intervene and prevent suicide attempt. is it likely to be lethal? (For example. does he have access to a gunand ammunition?) ‡ If the client carries out the plan. For clients with high potential lethality. if the person plans to shoot himself. the patient experiences intrusive thoughts of death and suicide throughout most of his thought process. or talking to friends one last time? ‡ Where and when does the client intend to carry out the plan? ‡ Is the intended time a special date or anniversary that has meaning for the client? Specific and positive answers to these questions all increase the client¶s likelihood of committing suicide. and even clothing with drawstrings.

This may be frustrating or upsetting to clients.´ . Clients are under constant staff observation with no exceptions.´ ³Remember me.´ ³Sounds like you are planning to harm yourself.´ ³I can¶t stand the pain anymore ³What is going on that you are giving away things to remember you by?´ ³I appreciate your trust. I think there is an important message you are giving me.¶ do you mean µdie¶?´ ³What is it you do not want to think of anymore?´ ³I wonder if you are thinking of suicide.´ ³Everyone will feel bad soon.´ ³Here is my chess set that you have always admired.one-to-one supervision by a staff person is initiated. Are you thinking of ending your life?´ ³How do you plan to end the pain?´ ³Tell me about the pain.´ ³It will just be the end of the story. This means that clients are in direct sight of and no more than 2 to 3 feet away from a staff member for all activities including going to the bathroom. if you think everyone would be better off without you?´ 26 ³Everyone would be better off without me. Are you?´ ³Are you planning to commit suicide?´ ³What is it you really want me to remember about you?´ ³I want it to be all over.´ NURSE RESPONSES ³Specifically just how are you planning to sleep and not think anymore?´ ³By µsleep.´ Who is the person you want to feel bad by killing yourself?´ ³What is it you cannot bear?´ ³How do you see an end to this?´ ³ ³Who is one person you believe would be better off without you?´ ³How do you plan to eliminate yourself. However.´ ³If there is ever any need for anyone to know this. so staff members may need to explain the purpose of such supervision usually more than once. SUICIDAL IDEATION:CLIENT STATEMENTS AND NURSE RESPONSES CLIENT STATEMENT ³I just want to go to sleep and not think anymore.´ ³You have been a good friend.´ ³What is it you specifically want to be over?´ ³Are you planning to end your life?´ ³How do you plan to end your story?´ ³You sound as if you are saying good -bye. my will and insurance papers are in the top drawer of my dresser.´ ³I just can¶t bear it anymore.

CREATING A SUPPORT SYSTEM LIST Suicidal clients often lack social support systems such as relatives. Many suicidal people do not have to be admitted to a hospital and can be treated successfully in the community with the help of these support people and agencies. or religious. 1998). At no time should a nurse assume that a client is safe just because a contract is in place. or movement of the person to a new area because of school. The urge to commit suicide may return suddenly. FAMILY RESPONSE Suicide is the ultimate rejection of family and friends. irrelevant. This lack may result from social withdrawal. A list of support people who agree to be readily available should be generated. however. behavior associated with a psychiatric or medical disorder. work. The literature is divided on the effectiveness of such contracts or agreements (Potter & Dawson. anxious to relaxed. The nurse makes a list of specific names and agencies that clients can call for support. and community support groups. These contracts are not. change in family structure or financial status. The nurse assesses support systems and the type of help each person or group can give a client. depressed to smiling. Mental health clinics. hostile to benign. Most suicidal people adhere to no-suicide contracts because they appeal to the will to live. clients agree to notify their caregivers. and self-help groups are part of the community support system. the contract must identify backup people in case caregivers are unavailable). 2001. friends. ³I sense you have reached a decision. or unwelcome. Some suicides ³What is one way you perceive others would be better off without you?´ ³You seem different today. clients agree to keep themselves safe and to notify staff at the first impulse to harm themselves (at home. Jacobs & Gutheil.Nonverbal change in behaviour from agitated to calm. psychiatric emergency evaluation services. Contracts also can specify when clients will be re-evaluated. What is this about?´ 27 . occupational. a guarantee of safety. In such contracts. Implicit in the act of suicide is the message to others that their help was incompetent. so someone must always be available for support. hotlines. he or she obtains client consent to avoid breach of confidentiality. Miller. church groups. student health services. Clients make contracts with input from nurses or other health care professionals.´ to be goal-directed INITIATING A NO-SUICIDE CONTRACT The nurse can implement a no-suicide contract at home as well as in the inpatient treatment setting. Share it from being without direction to appearing with me.

Jack Kevorkian. Nevertheless nurses also must realize that no matter how competent and caring interventions are. Even with therapy. The nurse does not blame clients or act judgmentally when asking about the details of a planned suicide. Significant others may feel guilty for not knowing how desperate the suicidal person was. Trying to make clients feel guilty for thinking of or attempting suicide is not helpful. and anger. Many people 28 . Also the one death may spark ³copycat suicides´ among family members or others. Suicide is newsworthy. hopeless. they already feel incompetent. Families can disintegrate after a suicide. NURSE¶S RESPONSE When dealing with a client who has suicidal ideation or attempts. The nurse must convey the belief that the person can be helped and can grow and change.are done to place blame on a certain person²even to the point of planning how that person will be the one to discover the body. angry because the person did not seek their help or trust them. Life insurance companies may not pay survivors¶ benefits to families of those who kill themselves. the nurse¶s attitude must indicate unconditional positive regard not for the act but for the person and his or her desperation. shame. and there may be whispered gossip and even news coverage. the nurse uses a nonjudgmental tone of voice and monitors his or her body language and facial expressions to make sure not to convey disgust or blame. and sad about being rejected. Rather. who may feel they have been given permission to do the same. They must convey this belief when caring for suicidal people. A client¶s suicide can be devastating to the staff members who treated him or her especially if they have gotten to know the person and his or her family well over time. Even if a person believes love for family members prompted his or her suicide²as in the case of someone who commits suicide to avoid lengthy legal battles or to save the family the financial and emotional cost of a lingering death²relatives still grieve and may feel guilt. a physician who has participated in numerous assisted suicides. Oregon was the first state to adopt assisted suicide into law and has set up safeguards to prevent indiscriminate assisted suicide. ashamed that their loved one ended his or her life with a socially unacceptable act. Legal and Ethical Considerations Assisted suicide is a topic of national legal and ethical debate with much attention focusing on the court decisions related to the actions of Dr. a few clients will still commit suicide. The ideas or attempts are serious signals of a desperate emotional state. staff members may end up leaving the health care facility or the profession as a result. and helpless. Most suicides are efforts to escape untenable situations. Nurses believe that one person can make a difference in another¶s life.

or of cycles of euphoria. Adams (2000) describes a program called Insight that uses an educational approach designed to address the unique stressors that contribute to the increased incidence of depressive illness in women. which in turn decrease the likelihood of depression. and potential side effects so that he or she can answer questions and promote compliance with treatment (Bouchard.believe it should be legal in any state for health care professionals or family to assist those who are terminally ill and want to die. 2002). loss of inhibitions. People with bipolar disorder. People with depression can be treated successfully in the community by psychiatrists. a family member may mention distress about a client¶s withdrawal from activities. Insight has succeeded in increasing self-esteem and reducing loneliness and hopelessness. dosages. psychiatric advanced practice nurses. Contributing factors may include the stigma still associated with mental disorders. complaints of being tired all the time. desired effects. Others view suicide as against the laws of humanity and religion and believe that health care professionals should be prosecuted if they assist those trying to die. the lack of understanding about the disruption to life that mood disorders can cause. Estimates are that nearly 40% of people who have been diagnosed with a mood disorder do not receive treatment (Akiskal. these combine with the reality of limited time that health care professionals devote to any one client. eating. 1999). In some cases. and sleeping. 2000). Borowsky. MENTAL HEALTH PROMOTION Several studies have been conducted to determine how to prevent mood disorders and suicide. confusion about treatment choices. and agitation (all symptoms of depression). spending binges. COMMUNITY-BASED CARENurses in any area of practice in the community frequently are the first health care professionals to recognize behaviours consistent with mood disorders. Researchers in England have found that individualized postpartum care with home visits by nurses significantly lowered the incidence of postpartum depression (Boyles. The physician or nurse who treats a person with bipolar disorder must understand the drug treatment.Documenting and reporting these behaviours can help these people to receive treatment. or a more compelling medical diagnosis. changes in sleep and eating patterns. should be referred to a psychiatrist or psychiatric advanced practice nurse for treatment. and primary care physicians.000 adolescents in an attempt to identify factors that predicted future suicide attempts. They suggest that promotion 29 . difficulty thinking. therapeutic levels. and loud clothing styles and colors (all symptoms of the manic phase of bipolar disorder). Ireland and Resnick (2001) studied more than 13. sadness. however.

family life stability. The nurse may feel frustrated because these clients engage in the same behaviours repeatedly. 2002). parental alcoholism or mental illness. screening for early detection of risk factors.´ ³I don¶t have the time to do that. the nurse uses therapeutic techniques to encourage clients to generate their own solutions. Unless a client is suicidal or is experiencing a crisis. Likewise. Studies have shown that clients tend to act on plans or solutions they generate rather than those that others offer (Schultz & Videbeck. Working with clients who are manic can be exhausting. the nurse does not try to solve the client¶s problems. undressing. Finding and acting on their own solutions gives clients renewed competence and self-worth.´ ³It would never work. SELF-AWARENESS ISSUES Nurses working with clients who are depressed often empathize with them and begin also to feel sad or agitated. Instead. The protective factors include close parent child relationships. It takes hard work to remain patient and calm with the manic client.of protective factors (those factors associated with a reduction in suicide risk) would improve the mental health of adolescents. They feel hopeless and incompetent. They are so hyperactive that the nurse may feel spent or tired after caring for them. People with depression are usually negative.´ or ³You just don¶t understand. and connectedness with peers and others outside the family. rhyming. and access to weapons in the home. The nurse easily can become consumed with suggesting ways to fix the problems . They may unconsciously start to avoid contact with these clients to escape such feelings. pessimistic. and unable to generate new ideas easily. singing.´ Rejection of suggestions can make the nurse feel incompetent and question his or her professional skill. The nurse must monitor his or her feelings and reactions closely when dealing with clients with depression to make sure he or she fulfills the responsibility to establish a therapeutic nurse±client relationship. such as family strife. such as intrusiveness with others. but it is essential for the nurse to provide limits and redirection in a calm manner until the client can control his or her own behaviour independently. history of fighting.Most clients find some reason why the nurse¶s solutions will not work: ³I have tried that. academic achievement. can lead to referral and early intervention. and dancing. 30 .

NANDA Nursing Diagnoses: Suicide 1. Risk for Suicide related to stated desire to end it all handgun and recent purchase of a 3. Tertiary prevention: Used to reduce residual disability after an illness. Next time I won't fail. halfway house. 2. Chronic Low Self-Esteem related to feelings of failure secondary to marital discord. Risk for Violence: Self-directed related to multiple losses secondary to retirement Hopelessness related to diagnosis of terminal cancer as evidenced by the statement. a residential treatment center. 31 . 4. I'd rather be dead. y suicidal intention rating scale (SIRS) that provides a guide for managing clients considered to be self-destructive. y Constant or close monitoring of the client's behavior is important because a suicidal client's mental state often fluctuates. SUICIDE PRECAUTIONS y Clients at risk for suicide need either constant (one -to-one visual supervision) or close (visual check every 15 minutes) observation in a safe. For example. or rehabilitation center may be used to treat a recovering alcoholic client who previously attempted suicide and is recovering from severe depression. SUICIDE PREVENTION primary prevention:identify and eliminate factors that cause or contribute to the development of an illness or disorder that could lead to suicide. Impaired Social Interaction related to alienation from others secondary to depressive behaviour 6. 5. secure environment. suicidal behaviour 7. Ineffective Coping related to inadequate psychological resources as evidenced by impulsive. Secondary prevention :attempts to identify and treat physical or emotional disorders in the early stages before they become disturbing to an individual. Risk for Injury related to a recent suicide attempt and the verbalization. but needs the supervision and support of others to avoid a relapse.

Carson berner verna. and management CONCLUSION These are the aspects coming under suicide and its nursing management. Provide protective care per protocol Periodically check.15 th edition. 32 . 2.arnold nolan elizabeth. mirror. at least every 30 minutes Allow limited visits by family members Confine to unit unless accompanied by a member of staff Actively attempted suicide or Implement protective care per protocol for a hospitalized to prevent self-destructive high-risk suicidal client impulses Three plus Four plus SUMMARY So far we have discussed different aspects of suicide. Fortinash.S.2003. holoday worret psychiatric nursing care plans .w. BIBILIOGRAPHY 1. mental health nursing. or nail file.A.philadelphia. remove potentially dangerous items such as razor.the nurse patient journey .mosby elsevier.U.1996.B Saunders company.its prevention.SUICIDE INTENTION RATING SCALE (SIRS) FOR HOSPITALIZED CLIENTS RATING Zero SYMPTOMS No evidence of past or present suicidal ideation One Suicidal ideation but no attempt or plus threat Two plus Actively thinking about suicide or history INTERVENTIONS Implement interventions per nursing plan of care Observe and evaluate for evidence of development of a plan Provide routine care Protect from self-destructive impulses of previous attempt Remove potentially dangerous personal items from room Suicidal threat verbalized Search client and room.

B saunders company. Gelder g.c.6th edn. psychiatric mental health nursing . Kaplan and sadocks synopsis of psychiatry:behavioural sciences/clinical psychiatry.10 th edn.juan.concepts of care in evidence-based practice.3.W. Philadelphia 4.2007.lippincott Williams and Wilkins.lopez-ibor j.2005. 8.lippincot Williams and Wilkins. Videback Sheila. Carson berner verna.1oxford university press. Shives.Anderson nancy.vol. 5. Townsend .mary. 33 .rebraca Louis.psychiatric mental health nursing.Arnold Nolan Elizabeth mental health nursing:nurse patient journey.Basic concepts of psychiatric mental health nursing. 6.New oxford text book of psychiatry.f.michael.a davis company. 7.