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Sub[ecLlve
MaLagal nang paLay ang asawa
ko Sobrang hlrap Mlnsan nallslp
ko na sumunod na lang sa
kanya" As verballzed by Lhe
cllenL
Sa daml ng mga plnagdaanan ko
sa buhay nallslp ko na
masmabuLl pa slgurong mawala
na lang ako sa mundong lLo" As
verballzed by Lhe cllenL
Cb[ecLlve
weak ln appearance
decreased wL
unkempL appearance(unLldy
halr cloLhes dlrLy and long nalls)
defeaLedlooklng/slouched
wlLhdrawn
nu8SlnC ulACnCSlS
8lsk for selfdlrecLed vlolence r/L
posLLraumaLlc experlence as
manlfesLed by verballzaLlon of
sulcldal ldeaLlon
AfLer 6 Lo 7 days of nurslng
lnLervenLlon Lhe cllenL's sulcldal
ldeaLlon wlll be lessened or wlll
be absenL
deLermlne wheLher cllenL has
speclflc sulclde plan ldenLlfled
ldenLlfy degree of rlsk/poLenLlal
for sulclde Lhrough dlrecL
quesLlons
reevaluaLe poLenLlal for sulclde
perlodlcally aL key Llmes
lmplemenL sulclde precauLlons
by explalnlng Lo Lhe cllenL LhaL
you are concerned for hls/her
safeLy
creaLe a Llmespeclflc conLracL
wlLh Lhe cllenL on whaL cllenL
and nurse wlll do Lo provlde for
cllenL's safeLy
monlLor cllenL's welghL
Lo furLher assess Lhe
lnLervenLlons speclflcally needed
for Lhe cllenL
degree of hopelessness
expressed by Lhe cllenL ls an
lmporLanL lndlcaLor of severlLy of
depresslon and sulclde rlsk
sulclde rlsk ls Lhe greaLesL
durlng Lhe flrsL few weeks
followlng admlsslon Lo LreaLmenL
communlcaLes carlng and sense
of proLecLlon
shorLLerm conLracLs encourage
Lhe cllenL Lo deal wlLh Lhe here
andnow and provlde
opporLunlLy Lo reassess slLuaLlon
dramaLlc and exLreme changes
ln Lhe cllenL's welghL helps
ldenLlfy Lhe degree of depresslon
Lhe cllenL
AfLer 7 days of nurslng
lnLervenLlon Lhe cllenL's sulcldal
ldeaLlon ls lessened
monlLor envlronmenL for
poLenLlal safeLy hazards
remove dangerous lLems from
Lhe cllenL's envlronmenL
provlde approprlaLe level of
supervlslon/survelllance by
placlng paLlenL ln a leasL
resLrlcLlve envlronmenL
refer Lo psychlaLrlsL as needed
Lo prevenL cllenL from access of
posslble Lools for self harm
Lo prevenL cllenL for furLher
ldeaLlon of lnfllcLlng selfharm
Lo monlLor paLlenL and Lo allow
LherapeuLlc acLlons as needed
for furLher effecLlve
managemenL a speclalLy
physlclan ls needed