Patient’s Initials: ________J______ Age & Gender: 21/F____ Chief Complaint: “I feel like killing myself” Name of Student

Name of Student Nurse:

Birthday: _____March 3, 2000______________________ Admitting Diagnosis:__Major Depressive Disorder__ Level/block/group:
Address: ____ ______________ ________________________________________________ Hospital/area: ________________________________
_____________________________________________________ Date of Confinement: ______ ______________ Clinical Instructor: _ ____ Date:

ASSESSMENT NURSING ANALYSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

Subjective: “I feel like
killing myself”
Objective:
 Refuses to eat
 Does not display
brightened affect as
day goes on
 Weight loss is
evident
NURSING DIAGNOSIS
Risk for suicide related to
hopelessness as
manifested by suicide
behavior
Major depressive disorder typically
involves 2 weeks or more of a sad
mood or lack of interest in life
activities, with at least four other
symptoms of depressions such as
anhedonia and changes in weight,
sleep, energy, concentration,
decision-making, self-esteem and
goals. Major depression is twice as
common in women and has a one-
and-a-half to three times greater
incidence in first-degree relatives
than in the general population.
An untreated episode of depression
can last from a few weeks to months
or even years, though most episodes
clear in about 6 months. Some
people have a single episode of
depression, while 50% to 60% will
have a recurrence of depression.
Depressive symptoms can vary from
Short term goals: Short term goals
After 48 to 72 hours of  Check the client  The nurse’s first priority After 48 to 72 hours of
nursing immediately and the is provide for the client’s nursing interventions, the
interventions, the client’s room for safety and protect the goal was met because the
patient will: potentially destructive client from self-inflicted patient is:
 Be safe and free from implements like sharp lifethreatening injury or  Safe and free from
injury throughout objects, belts, shoelaces, death. injury throughout
hospitalization socks, chemicals, hoarded hospitalization as
 Identify alternative medications; and take evidence by patient
ways of dealing with steps to protect client does not do any
stress and emotional through appropriate suicicidal ideation like
problems, for therapeutic interventions. punching her abdomen
example, talking with area and cutting her
staff or significant  Evaluate the client’s risk  There is always a chance extremities.
others, within 48 to for suicide through careful that clients at risk for  Able to identify
72 hour observation of behaviors suicide will act on their alternative ways of
Long term goals: and direct questioning like thoughts, studies show dealing with stress and
After 1-2 months of asking for suicidal intent that the more detailed emotional problems,
nursing and plans. the plans, the greater for example, talking
interventions, the the risk for suicide with staff or significant
patient will be able (Akiskal, 2017). others, within 48 to 72
to:  The client’s room should  The client at high risk for hours
 Demonstrates be near the nurses’ suicidal behavior Long term goals:
absence of suicidal station and within view of requires close After 1-2 months of
ideation the staff, not at the end of observation. nursing interventions, the
 Expresses desire to a hallway or near an exit, goal was met because the
live and lists several elevator, or stairwell. patient:
reasons for wanting  Demonstrates absence
to live. of suicidal ideation or
 Displays consistent,  Listen actively to the  Allowing the client to plans.
mild to severe. The degree of
depression is comparable with the
person’s sense of helplessness and
hopelessness. Some people with
severe depression (about 20%) have
psychotic features (Akiskal, 2017)
optimistic, hopeful client’s story regarding
attitude how the client came to
 Makes plans for the the point of suicide, using
future that include therapeutic skills such as
follow up care and reflection, clarification,
medication and validation, and
compliance. indicate acceptance of the
client’s thoughts and
feelings.
verbalize helps the
client relieve pent-up
thoughts, feelings, and
emotions related to
suicide and is in itself
therapeutic. It also gives
the nurse information
about the critical events
that influenced the
client’s current level of
hopelessness and
despair. Acceptance of  Displays consistent,
the client’s story
promotes trust and
instills hope (Lacroux,
2016).
 Makes plans for the
 Expresses desire to live
and lists several
reasons for wanting to
live as evidenced by
the statement, “Kaya
kong iovercome ‘to,
hindi lang para sa akin
kundi para sa pamilya
ko. Hindi titigil ang
mundo ko ng dahil lang
sa nangyari sa akin”
optimistic, hopeful
attitude as evidenced
by the statement,
“Darating din ang
panahon na magiging
okey din ang lahat”.
future that include
follow up care and
medication compliance
as evidenced by the
following:
- Eating full served
meals three times
a day
- Taking medications
religiously and
attending therapy
sessions as
scheduled.
- Absence of tears,
agitation and
morose
- Displays
brightened affect
as day goes on