Psychiatric Mental Health Nursing by Videbeck

15 MOODDISORDERS ANDSUICIDE 349

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Stabilization

The client will

• Express feelings directly with congru-
  ent verbal and nonverbal messages


• Be free from psychotic symptoms


• Demonstrate functional level of
  psychomotor activity
  Community
  The client will


• Demonstrate compliance with and
  knowledge of medications, if any


• Demonstrate an increased ability to
  cope with anxiety, stress, or frustration


• Verbalize or demonstrate acceptance
  of loss or change, if any


• Identify a support system in the
  community


• Sleep disturbances: early awakening,
  insomnia, or excessive sleeping


• Anger or hostility (may not be overt)


• Rumination


• Delusions, hallucinations, or other psy-
  chotic symptoms


• Sexual dysfunction: diminished inter-
  est in sexual activity, inability to expe-
  rience pleasure


• Fear of intensity of feelings


• Anxiety

IMPLEMENTATION

Nursing Interventions *denotes collaborative interventions Rationale

Provide a safe environment for the client.

Continually assess the client’s potential for suicide.

Observe the client closely, especially under the
following circumstances:

After antidepressant medication begins to raise
the client’s mood

After any sudden dramatic behavioral change
(sudden cheerfulness, relief, freedom from guilt,
or giving away personal belongings)

Unstructured time on the unit

Times when the number of staff on the unit is
limited

Physical safety of the client is a priority. Many

common items and environmental situations may

be used by the client in a self-destructive manner.

Depressed clients may have a potential for suicide

that may or may not be expressed and that may

change with time. You must remain aware of this

suicide potential at all times.

You must be aware of the client’s activities at all

times when there is a potential for suicide or

self-injury:

Risk of suicide increases as the client’s energy

level is increased by medication.

These changes may indicate that the client has

come to a decision to commit suicide.

Risk of suicide increases when the client’s time is

unstructured.

Risk of suicide increases when observation of the

client decreases.

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