TEACHING PLAN

Topic: Caring for the Client with Suicidal Ideations

Audience: 3rd year BScN Student nurses

Date: February, 2018

Time: 8:15 Am

Duration: 100 Minutes

Venue: Room – A2102

Methodology: Lecture Discussion

Number of participants: 62

Learning Theories: Ausubel: Emphasized the use of advance organizers which he said was

different from overviews and summaries. His use of an advance organizer acted as a bridge to

the chasm between learning material and existing related ideas. The advanced organizer used;

sought to bridge new knowledge with what was known (sometimes what is known is uncertain

and not concrete). Although he specified that his theory applied only to reception learning in

school, it was utilized because it introduced the topic and aid the sequence of the information to

be imparted. (Ormrod & Rice, 2003). Rogers- Dealt with adult learner, he posited that learning

is student centered and personalized and the educator’s role is that of a facilitator. Affective and

cognitive needs are central and the goal is to develop self-actualized people in a cooperative,

supportive environment. (Quinn, 2010). Bruner- who belief that learners are not blank slate but

brings past experiences to a situation, he also states that new information is linked to prior
knowledge, thus mental representations are subjective. Bruner: Discovery learning is an inquiry-

based, constructivist learning theory that takes place in problem solving situations where the

learner draws on his or her own past experience and existing knowledge to discover facts and

relationships and new truths to be learned. (Quinn, 2010). Students interact with the world by

exploring and manipulating objects, wrestling with questions and controversies, or performing

experiments. As a result, students may be more likely to remember concepts and knowledge

discovered on their own (in contrast to a transmissionist model). (Quinn, 2010). Models that are

based upon discovery learning model include: guided discovery, problem-based learning,

simulation-based learning, case-based learning, incidental learning, among others. The

advantages of this theory are encourages active engagement, promotes motivation, a tailored

learning experience, promotes autonomy, responsibility, independence, the development of

creativity and problem solving skills. (Quinn, 2010). Vygotsky: Posited that both learners and

teachers learn from each other through a socialization process, this he term social interaction.

(Ormrod et al, 2003).

Aim of activity: To educate students on the nursing management of the suicidal patient

Scientific Principle: Homeostasis: The concept of homeostasis is widely used in physiology and

psychology. This is the tendency to maintain and restore

certain steady states or conditions of the organism. (The Free

Dictionary, 2017). The theory of homeostasis is applicable to

the study at hand (suicide) since it occurs as a result of an

imbalance of neurochemicals (particularly dopamine &

Axetylcholine). Given this, the aim of the nurse will be to

care for clients so that homeostasis is maintained/restored.

Objectives: At the end of the 100 mins interactive session students will be able to:

1. Define the term suicide according to Frisch & Frisch (2010) and The Merriam-Webster’s

Dictionary

2. Explain the four (4) categories of suicide as cited by Frisch and Frisch, (2010); Klonsky,

May and Saffer, (2016); Giner, Guija, Root and Baca Garci, (2016); Nock and

Kessler (2010)

3. Outline the etiology/risk factors for suicide as indicated by Evans, Nizette and O’Brien

(2016)

4. Discuss at least seven preventative measures for the client with suicidal

ideation/Thoughts as espoused by Hagen, (2016); Frisch and Frisch (2010);

Alflague and Ferszt (2010).

5. Describe the nursing management for the client with suicidal ideations as put forth by

Schultz and Videbeck (2013); Doenges, Moorhouse and Mishler (2014); Ackley,

Ladwig and Makic (2017); Towsend (2017)

Evaluation: Formative and Summative. Questions will be asked following each objectives and a

quiz at the end of the presentation.

References:

Aflague, J. M & Ferszt, G. G. (2010). Suicide assessment by psychiatric nurses: A

phenomenographic study. Issues Ment Health Nurs. 31(4):248-56. doi:

10.3109/01612840903267612.

Ackley, B & Ladwig,, Makic. (2017). Nursing diagnosis handbook: Nursing care plans

Amsterdam: Elsevier
Birckhead, Loretta.M. (1989). Psychiatric mental health nursing. The therapeutic use of self.

Philadelphia: J.B. Lippincott Company.

Doenges, M., Moorhouse, M & Murr, A. (2014). Nursing diagnosis manual, planning,

individualizing and documenting patient care. Philadelphia: F.A. Davis

Evans, K., Nizette., D & O'brien, A. (2016) Challenging behaviours, risks and responses in

Psychiatric and mental health nursing (4th ed). Retrieved from

https://www.researchgate.net/publication/311226140_Challenging_Behaviours_Risks_an

d_Responses

Frisch, N & Frisch, L. (2010) Psychiatric Mental Health Nursing. New York: Thomson Delmar

Learning

Giner, L., Guija, J., Root, C & Baca Garcia, E. (2016). Understanding Suicide. Nomenclature

and Definition of Suicidal Behavior: pp 3-17

Hagen, N & Russell, A. P. (2016). Student Suicides: A tragic silent issue and potential solutions.

Science Insights. Doi: 10.15354/si.16.re202. Retrieved from

http://bonoi.org/basicpage/student-suicides-tragic-silent-issue-and-potential-solutions-ft

Klonsky, E. D., May, A. M & Saffer, B. Y. (2016). Suicide, suicide attempts, and suicidal

ideation. Annu Rev Clin Psychol. 12:307-30. doi: 10.1146/annurev-clinpsy-021815-

093204. Epub 2016 Jan 11.

Nock, M. K., Hwang, I., Sampson, N. A & Kessler, R.C. (2010). Mental disorders, comorbidity

and suicidal behavior: results from the National Comorbidity Survey Replication. Mol

Psychiatry: 15(8):868-76. doi: 10.1038/mp.2009.29. Epub 2009 Mar 31.

Ormro d, J & Rice, F. (2003). Lifespan development and learning. Boston MA: Pearson

Publishing.

Quinn, F. (2010). The principles and practice of nurse education. London: Stanley Thornes

The Free Dictionary (2017). Homeostasis. Retrieved on February 02, 2017 from

http://www.encyclopedia.com/topic/Homeostasis.aspx

The Merriam-Webster’s Dictionary. Suicide. Retrieved on February 2, 2017 from

http://www.merriam- webster.com/dictionary/suicide

Townsend, M. (2017). Essentials of psychiatric mental health nursing: Concepts of care in

evidence-based practice (7th ed): Philadelphia: F. A. Davis

Videbeck, S. (2018). Psychiatric mental health nursing. (7th). Philadelphia: Wolters Kluwer
 OBJECTIVES
ICE BREAKER: Ausubel:
Emphasized the use of advance mad rush and shouted, “Suicidal!” Guess
organizers which he said was
different from overviews and
summaries. The advanced
organizer used, seeks to bridge
new knowledge with what is
known
1. Define the term suicide Suicide is the intentional killing of
according to Merriam
Webster’s Dictionary;
Frisch and Frisch
(2010).
CONTENT TEACHER’S LEARNER’S EVALUATION
ACTIVITY ACTIVITY
A patient ran off the mental health bus in a Teacher will ask Students will attempt
students to read ice to read the ice breaker
what happened to him?
breaker and attempt and attempt to identify
to identify today’s topic for todays lesson
topic
He
was promptly admitted without any
questioning, for fear of the inevitable!!
Teacher will ask one One participant will Participants will be
oneself.(Merriam-Webster’s Dictionary) participant to define define suicide in own able to define suicide
suicide in own words. stating at least two
The purposeful taking of one’s own life words. specific words from
(Frisch & Frisch, 2010) the definition such as:
Teacher will define Participants will sit “purposeful taking of
the term suicide attentively and listen to one’s own life or the
according to the the definition of intentional taking of
content. suicide. one’s self…”
One participant to the
Teacher will ask a
right will define
participant to the
suicide using specific
right to define the
words according to the
term suicide
 according to the content.
content.

2. Explain the four 1. SUICIDAL IDEATION: this is Teacher will ask Two participants will Participants will be
categories of suicide as when a client tells you that voices two participants to attempt to give one
able to explain the
cited by Birckhead are telling him to kill himself. give one category category each for
four categories of
(1989); Frisch & 2. SUICIDAL ATTEMPT: this is a each of suicide. suicide.
Frisch, (2010); self-destructive act with the intent suicide by utilizing
Klonsky, May & to die by methods such as shooting, Teacher will explain Participants will look,
terms such as
Saffer, (2016); Giner, stabbing, hanging, jumping and the four categories listen and follow on
“Suicidal Ideation,
Guija, Root & Baca drug over dose and so on (Frisch & of suicide according PowerPoint as the four
Garci, (2016); Nock & Frisch, 2010; Klonsky, May & to the content using categories of suicide Suicidal Attempt,
Kessler, (2010, p. 616) Saffer, 2016) PowerPoint as an are explained.
Suicidal Threat and
3. SUICIDAL THREAT: this is aid
Suicidal Gesture…”
when the client verbally says he is
going to kill himself. Three participants will
Teacher will ask
explain any two
4. SUICIDAL GESTURE: this is a three participants to
category of suicide
explain any two
self-destructive act where lethality according to the
category of suicide
content
is low e.g. superficial wrist according to the
content.
laceration and self-inflected
cigarette burns. (Birckhead, 1989;
Frisch & Frsich, 2010; Klonsky,
 May & Saffer, 2016; Giner, Guija,
Root & Baca Garci, 2016).
 “self-injury in which there is no
intent to die, but instead an intent to
give the appearance of a suicide
attempt in order to communicate
with others”
(Nock & Kessler, 2010)
3. Outline the  There is no single cause for suicide Teacher will ask one A male participant will Participants will be
etiology/risk factors for  Depression is the condition most male participant to attempt to state at least able to correctly
suicide as indicated by associated with suicide and its state at least one one etiological and one outline the
Evans, Nizette and attempts, it is often undiagnosed etiology or one risk risk factor suicide etiology/risk factors
O’Brien (2016) and untreated factor suicide for suicide utilizing
Other conditions such as; key words such as
 Anxiety, and substance use Teacher will outline Students will look, “There is no single
especially if not addressed increase the etiology/risk listen and ask cause for suicide;
the risk for suicide factors utilizing questions as teacher Depression is the
WARNING SIGNS PowerPoint outlines the etiology condition most
 A change in behaviour or new presentation risk factors for suicide associated with
behaviours especially if it is related suicide and its
to a painful experience, loss or Teacher will ask one One student seated on attempts, it is often
change (Evans, Nizette, & O’Brien, student seated on the left will outline the undiagnosed and
 2016) the left to outline etiology or risk factor untreated…”
 Most people who take or make an one etiology or risk for suicide according
attempt on their lives exhibit factor for suicide to the content
warning signs through either talk or according to the
action content
TALK
 Killing self
 Feeling hopeless
 Having no reason to live
 Being a burden to other
 Feeling trapped
 Unbearable pain
BEHAVIOUR
 Increased use of alcohol/drugs
 Looking for ways to end their lives
(internet)
 Withdrawal from activities
 Sleeping too much or too little
 Visiting or calling people to say
goodbye
 Giving away personal possessions
 Fatigue
  Aggression
(Evans, Nizette, & O’Brien, 2016)
MOOD – one or more of the following is
displayed
 Depression
 Anxiety
 Loss of interest
 Irritability
 Humiliation
 Agitation
 Rage
RISK FACTORS
Health factors
 Mental health conditions
 Depression
 Substance use
 Bipolar disorder
 Schizophrenia
 Anxiety disorder
 Aggressive personality
traits
 Serious or chronic health
 conditions and or pain
(Evans, Nizette, & O’Brien, 2016)
Environmental factors
 Access to lethal means (guns,
knives, ropes)
 Prolonged stress (harassment or
bullying, employment or relational)
 Stressful life events (divorce, death
of job loss)
 Exposure to another person’s
suicide
Historical Factors
 Previous suicide attempt
 Family history of suicide
 Childhood neglect, abuse or trauma
(Evans, Nizette, & O’Brien, 2016)
PREVENTATIVE MEASURES
 Suicidal clients are restricted on the
unit/ward.
 The staff informed of client’s
suicidal precautionary status;
instructed in appropriate ways of
 interacting with clients.
 Suicidal clients not allowed access
to knives other sharp objects.
 Observe for and remove potentially
harmful objects in environment;
shoe lace, belt, bottles and ropes
(Hagen 2016)
 Suicidal clients monitored by staff
at least every15 minutes or if
available one to one staff coverage.
 If suicidal clients are agitated or
presenting management problem,
they may be placed in seclusion
area/room to calm them.
 Restraint is usually a last resort.
(Frisch et al, 2010; Alflague &
Ferszt. 2010).
4. Discuss at least seven PREVENTATIVE MEASURES Teacher will ask the The two tallest Participants will be
precautionary/preventat  Suicidal clients are restricted on the two tallest students students in the class able to state at least
ive measures for unit/ward. in the class to name will attempt to name five of the seven
suicide as postulated by  The staff informed of client’s two preventative two preventative precautionary
Hagen (2016); Frisch & suicidal precautionary status; measures each for measures each for measures when
Frisch (2010); Alflague instructed in appropriate ways of suicide suicide caring for the suicidal
& Ferszt. (2010). interacting with clients. clients by using terms
 Suicidal clients not allowed access Teacher will discuss Participants will listen such as “clients are
to knives other sharp objects. the precautionary attentively to the restricted on the
 Observe for and remove potentially measures for the precautionary unit/ward; clients not
harmful objects in environment; suicidal clients measures and ask allowed access to
shoe lace, belt, bottles and ropes using PowerPoint questions. knives other sharp
(Hagen 2016) presentation and objects; Observe for
 Suicidal clients monitored by staff answer questions and remove
at least every15 minutes or if asked. potentially harmful
available one to one staff coverage. Teacher will ask objects in
Three participants will
 If suicidal clients are agitated or three participants to environment; shoe
recall one
presenting management problem, recall on lace, belt, bottles and
precautionary measure
they may be placed in seclusion precautionary ropes; clients
each when caring for a
area/room to calm them. measure each monitored by staff at
suicidal client
 Restraint is usually a last resort. according to the least every15 minutes
according to the
(Frisch et al, 2010; Alflague & content or if available one to
content.
 Ferszt. 2010) . one staff coverage

5. Discuss the nursing ASSESSMENT CRITERIA (RISK Teacher will ask Participants will break Participants will be
Management for the FACTORS) - MANIFESTATIONS participants to form out into three groups of able to discuss at
suicidal client  Suicidal ideas, feelings, ideation, at least three groups at least 20 and least six of the nine
according to (Doenges, plans, gestures, or attempts of 20-and brainstorm at least nursing management
Moorhouse, Muir 2014;  Lack of impulse control brainstorm at least three possible nursing for the suicidal
Ackley & Ladwig,  Lack of future orientation three possible interventions and clients by using
2017; Schultz, J. M. &  Self-destructive tendencies nursing discuss their findings nursing diagnoses
Videbeck, S. L. 2013;  Feelings of anger or hostility interventions and with the class. such as “Risk for
Townsend, 2015).  Agitation discuss their suicide, Ineffective
 Aggressive behavior findings with the Coping, High risk for
  Feelings of worthlessness, class. violence, Risk for
hopelessness, or despair mutilation, Ineffective
 Guilt Teacher will discuss Participants will listen, family coping; Low
 Anxiety the possible nursing follow and ask self-esteem, Spiritual
 Sleep disturbance diagnoses nursing questions from distress….”
 Substance use and interventions PowerPoint and white
 Perceived or observable loss for the suicidal board as the nursing
 Social isolation clients using the diagnoses and
 Problems of depression, withdrawn white board and interventions are
behavior, eating disorders, PowerPoint as aids. presented.
psychotic behavior, personality
disorder, manipulative behavior, Teacher will ask Four participants will
post-traumatic stress, or other four participants to give two interventions
psychiatric problems give two each for the suicidal
NEED (Maslow’s Hierarchy) – Safety & interventions each clients according to the
Security for the suicidal content.
 At risk for self-inflicted, life- clients according to .
threatening injury. the content.
NURSING DIAGNOSIS

 Risk for suicide related to:

Suicidal ideas, feelings, ideation,
plans, gestures, or attempts, Lack
 of impulse control, Lack of future
orientation, Self-destructive
tendencies, Anxiety, Sleep
disturbance
EXPECTED OUTCOMES

At end of collaborative care the client will:

 Be safe and free from injury
throughout hospitalization
 Refrain from harming self
throughout hospitalization
 Identify alternative ways of dealing
with stress and emotional problems,
(for example, talking with staff or
significant others, within 48 to 72
hours)
INTERVENTIONS & RATIONALES
 Determine the appropriate level of
suicide precautions for the client.
Institute these precautions
immediately on admission by
physician order. Some suggested
levels of precautions follow:
 RATIONALE: Physical safety of
the client is a priority.
 A staff member provides one-to-
one supervision of the client at all
times, even when in the bathroom
and sleeping.
The client is restricted to the unit
and is permitted to use nothing that
may cause harm to him or her (e.g.,
sharp objects, a belt).
 RATIONALE: A client who is at
high risk for suicidal behavior
needs constant supervision and
strict limitation of opportunities to
harm himself or herself.
 A staff member provides one-to-
one supervision of the client at all
times, but the client may attend
activities off the unit (maintaining
one-to-one contact).
 RATIONALE: A client at a
somewhat lower risk of suicide may
 join in activities and use potentially
harmful objects (such as sharp
objects) but still must have close
supervision.
 Special attention—the client must
be accompanied by a staff member
while off the unit but may be in a
staff–client group on the unit,
though the client’s whereabouts
and activities on the unit should be
known at all time.
 RATIONALE: A client with a
lower level of suicide risk still
requires observation, though one-
to-one contact may not be
necessary at all times when the
client is on the unit.
 Explain suicide precautions to the
client.
 RATIONALE: The client is a
participant in his or her care.
Suicide precautions demonstrate
 your caring and concern for the
client.
 Be especially alert to sharp objects
and other potentially dangerous
items (e.g., glass containers, vases,
and matches); items like these
should not be in the client’s
possession.
 RATIONALE: The client’s
determination to commit suicide
may lead him or her to use even
common objects in self-destructive
ways. Many seemingly innocuous
items can be used, some lethally.
 The client’s room should be near
the nurses’ station and within view
of the staff, not at the end of a
hallway or near an exit, elevator,
or stairwell
 RATIONALE: The client at high
risk for suicidal behavior requires
close observation.
 Make sure that the client cannot
open windows. (The maintenance
department may have to seal or
otherwise secure the windows.)
 RATIONALE: The client may
attempt to open and jump out of a
window or throw himself or
herself through a window if it is
locked.
 If the client needs to use a sharp
object, sign out the object to the
client, and stay with the client
during its use.
 RATIONALE: The client may use
a sharp object to harm himself or
herself or may conceal it for later
use.
 Stay with the client when he or she
is meeting hygienic needs such as
bathing, shaving, and cutting nails.
 RATIONALE: Your presence and
supervision may prevent self-
 destructive activity, or you can
immediately intervene to protect
the client.
 Check the client at frequent,
irregular intervals during the night
to ascertain the client’s safety and
whereabouts.
 RATIONALE: Checking at
irregular intervals will
minimize the client’s ability to
predict when he or she will (or
will not) be observed.
 Be alert to the possibility of the
client saving up his or her
medications or obtaining
medications or dangerous objects
from other clients or visitors. You
may need to check the client’s
mouth after medication
administration
(Doenges, Moorhouse, Muir 2014; Ackley &
Ladwig, 2017; Schultz, J. M. & Videbeck, S. L.
2013; Townsend, 2015)
  RATIONALE: The client may
accumulate medication to use in a
suicide attempt. The client may
manipulate or otherwise use other
clients or visitors to obtain
medications or other dangerous
items.
 Observe, record, and report any
changes in the client’s mood
(elation, withdrawal, sudden
resignation).
 RATIONALE: Risk of suicide
increases when mood or behavior
suddenly changes. Remember: As
depression decreases, the client
may have the energy to carry out a
plan for suicide.
OTHER NURSING DIAGNOSES
 High risk for violence, self-directed
or directed at others
 Risk for self-mutilation
  Ineffective (individual) coping
 Ineffective (family) coping
 Spiritual distress
 Low self esteem
(Doenges, Moorhouse, Muir 2014; Ackley &
Ladwig, 2017; Schultz, J. M. & Videbeck, S. L.
2013; Townsend, 2015).

QUIZ

QUESTIONS

1. Define the term suicide.

Identify the differences with the following terms:

2. Suicidal ideations and suicidal threats

3. Suicidal gestures and suicidal attempts

4. State three precautionary measures for suicidal clients.

5. State three nursing management methods for the suicidal client.

ANSWERS

1. Suicide is the intentional killing of oneself (Merriam-Webster’s Dictionary) or the purposeful taking of one’s life
2. Suicidal Ideation: When the client tells you that voices are telling him to kill himself
3. Suicidal threat: when the client threatens to kill himself
4. Suicidal Gestures: when the client gets involved in self destructive/inflicting acts with low levels of lethality-
 5. Suicidal attempt: self-destructive act with the intent to die by methods such as: shooting, stabbing, hanging, jumping and drug
over dose

Management methods

1. Suicidal clients restricted to the unit/ward.

2. Staff to be informed of client’s suicidal precautionary status and instructed in appropriate ways of interacting with these
clients.
3. Suicidal clients not allowed access to razor blades, scissors or other sharp objects.
4. Observe for and remove potentially harmful objects in the environment such as shoe lace, belt.
5. Suicidal clients must be seen by staff every 15 minutes or if available one to one staff coverage.
6. If suicidal clients are agitated or presenting management problem, they may be placed in seclusion area/room to calm them.
7. Last resort is restraint.

Nursing management

1. Nurse clients close to nurse’s station.

2. Observe closely at all times for direct and indirect verbal and behavioral clues indicating suicidal potential.
3. Protect these clients against self-destruction rather than punish them.
4. Support the part of these clients that wants to live.
5. Remove environmental objects that could be used to injury self.