NUR 3105-002 MSE / Suicide Part 1-4

Reference Evolve Lesson: Prevention of Suicide (Chapter 25)

What is a mental illness?

Psychiatric disorders with definable diagnoses. Definitions are based on a cultural norms, social expectations, polituacl climates, and even reimbursments critieria by third-party payers. Current diagnoses are defined in the DSM-G-TR

What is the Diathesis-Stress Theory

That most psychiatric disorders result from a combinatiom of genetic vulnerability and negative environmental stressors

Mental health

Defined as state of well-being in which individuals reach their own potential, cope with the normal stresses of life, engage in meaningful activities, and relate to others

Resilience: ability to regulate one’s emotions and secure resources that are needed to support ones well-being. Essential for recovery

What is the difference between a medical dx and a nursing dx: Medical Dx

Psychiatric Medical Dx is the identification of a disease proccess.

Dx of an illness that causes significant changes in thinking, emotion, and or behavior

Based on the Diagnostic and Statistical Manual. DSM-5-TR

What is the difference between a medical dx and a nursing dx: Nursing Dx

Identification of clients response to an actual or potential health problem

Dx of the human response to mental illness

Based on the Nursing Diagnosis Handbook

Mental Status Examination

Looking to identify signs of potential mental illness

• Client’s general appearance, psychomotor activity, and gait

• Client’s expressions, thoughts, and ability to think

• Client’s reports of suicidality, homicidality, hallucinations, and/or delusions

• Client’s cognition: speech, concentration, orientation, memory. and abstraction

  • Situational Judgement: thinking through a hypothetical situation

  • Insight: awareness and understanding of illness

Safety Assessment portion of MSE

Assess everyone fo suicidal ideation

“ I want to check in about your safety, it is not uncommon for people to experience thoughts of wanting to end one’s life, is that something you have ever experienced?

Always thank the client for engaging in the conversation openly.

Assess for lacerations, scratches, and scars. These could indicate previous attempts at self-harm.

• Ask the client about suicide if uou see these marking when conducting a physical assesment

Non suicidal self-harm vs. Passive SI vs. Active SI

Right now do you have thoughts of harming yourself?

Do you wish you were dead?

Are you thinking aboutt killing yourself?

Safety Planning / Managing Risk

Follow through with taking one’s life is often impulsive

• SI may be very intense for a period of time and then become manageable

  • You can give hope that suicidal ideation is not a forever state of mind

How do we keep the client safe while they are experience suicidall ideation?

Contacting professionals for help (& national hotlines)

Questions to ask regarding social support?

“Who are your most important connections right now?

“With whom can you shre your experiences of feelings with?

Who can you trsut to give you advice to help with your recovery?

Who is available to help you with practical task like errands?

Who might benefit from your help or support right now?

Perceptual Disturbances

Assess everyone for hallucinations - more common thank you think

• Perceptual disturbances risk of hard to self and or others

  • Major risk: Command hallucinations telling client to harm self or others

Most common type of hallucinations

Auditory (e.g voices or other sounds that do not exist

Second most common type of hallucinations

Visual (e.g. seeing images that do not exist)

Cognitive Function

Assess everyone for cognitive functioning

• Memory, concentration, judgment, orientation is needed for everyday functioning

• Do not know this status unless you ask the questions

Orientation of Cognitive Functioning

Person - What is your full name

Place - Where are you right now?

Time: What is todays date/ day of week/ month/ season?

Situation - Do you know who I am? Can you tell me why we are taking right now?

Memory in Cognitive Function

Immediate, recent, and remote recall

• Immediate: repeat these three words now (church, banana, and hand)

• Recent: Remember these three words, and I will ask you to repeat them in a few minutes

• Remote: What is your date of birth/

Abstract vs Concrete Thinking

What does it mean: Rome wasn’t built in a day?

How are a ruler and a watch the same?

Concentration in Cognitive Function

Can the client concentrate long enough to engage in serial 7s?

E.g: What is 100-7, 93-7, What is 86-7, with is 79-7? What is 72-7?

OR “ Spell WORLD forward, now spell it backwards

Say the months of the year in reverse, starting with December

Situational Judgement in Cognitive Functioning

Decision-making skills: ask questions like:

What would you do if the fire alarm went off in the hospital?

What would you do if you went home and felt suicidal again?

What would you do if you saw an urresponsive person laying on the sidewalk?

Insight in Cognitive Function

An understanding of self and one’s health: Ask questions like:

What do you think about what is going on in your life?

Do you think your symptoms, thoughts, feelings, perceptions are normal or abnormal?

What troubles you the most? How have you been handling this?

How do you plan to get help for this problem?

Closing out your MSE

At the end of your MSE assessment the SP is expecting you to briefly orient them to the unit.

Try to establish a mutual goal: How willing are you to stay for your care in the hospital?

• In the hospital staff will be checking on you often (every 15mins)

• You can come to staff if you have ny questions or concerns

• Members of the treatment team will be talking with you everyday

• You are invited to participate in group activities like group therapy sessions