4. Homicidal or assaultive reaction - seen in acutely drug-intoxicated, delirious, paranoid, acutely excited manic, or acute anxiety-panic conditions.
1. Assessment - history of obvious antisocial behavior, paranoid psychosis, previous violence, sexual conflict, rivalry, substance abuse, recent moodiness, and withdrawal.
2. Nursing care plan/implementation:
1. Physically restrain if client has a weapon; use group of trained people to help.
2. Allow person to “save face” in giving up weapon.
3. Separate from intended victims.
4. Approach: calm, unhurried; one person to offer support and reassurance; use clear, unambiguous statements.
5. Immediate and rapid admission procedures.
6. Observe for suicidal behavior that may follow homicidal attempt.
3. Evaluation/outcome criteria: client regains impulse control.
5. Suicidal ideation - seen in anxiety attacks, substance intoxication, toxic delirium, schizophrenic auditory hallucinations, and depressive reactions.
1. Concepts and principles related to suicide:
1. Based on social theory: suicidal tendency is a result of collective social forces rather than isolated individual motives (Durkheim’s Le Suicide).
1. Common factor: increased alienation between person and social group; psychological isolation, called “anomie,” when links between groups are weakened.
2. “Egoistic” suicide: results from lack of integration of individual with others.
3. “Altruistic” suicide: results from insufficient individualization.
4. Implication: increase group cohesiveness and mutual interdependence, making group more coherent and consistent in fulfilling needs of each member.
2. Based on symbolic interaction theory:
1. Person evaluates self according to others’ assessment.
2. Thus, suicide stems from social rejection and disrupted social relations.
3. Perceived failure in relationships with others may be inaccurate but seen as real by the individual.
4. Implication: need to recognize difference in perception of alienation between own viewpoint and others’.
3. Based on psychoanalytic theory:
1. Suicide stems mainly from the individual, with external events only as precipitants.
2. There is a strong life urge in people.
3. Universal death instinct is always present (Freud).
4. Person may be balancing life wishes and death wishes. When self-preservation instincts are diminished, death instincts may find direct outlet via suicide.
5. When love instinct is frustrated, hate impulse takes over (Menninger).
1. Desire to kill —> desire to be killed —» desire to kill oneself.
2. Suicide may be an act of extreme hostility, manipulation, and revenge to elicit guilt and remorse in significant others.
3. Suicide may also be act of selfpunishment to handle own guilt or to control fate.
4. Based on synthesis of social and psychoanalytic theories:
1. Suicide is seen as running away from an intolerable situation to interrupt it rather than running to something more desirable.
2. Process defined in operational terms involves:
1. Despair over inability to cope.
2. Inability to feel hope or adequacy.
3. Frustration with others when others cannot fill needs.
4. Rage and aggression experienced toward significant other is turned inward.
5. Psychic blow acts as precipitant.
6. Life seen as harder to cope with, with no chance of improvement in life situation.
7. Implication: persons who experience suicidal impulses can gain a certain amount of control over these impulses through the support they gain from meaningfill relationships with others.
5. Based on crisis theory (Dublin): concept of emotional disequilibrium:
1. Everyone at some point in life is in a crisis, with temporary inability to solve problems or to master the crisis.
2. Usual coping mechanisms do not function.
3. Person unable to relate to others.
4. Person searches consciously and unconsciously for useful coping techniques, with suicide as one of various solutions.
5. With inadequate communication of needs and isolation, suicide is possible.
6. Based on the view that suicide is an individual’s personal reaction and decision, a final response to own situation:
1. Process of anger turned inward self-inflicted, destructive action.
2. Definition of concept in operational steps:
1. Frustration of individual needs —> anger.
2. Anger turned inward —> feelings of guilt, despair, depression, incompetence, hopelessness, and exhaustion.
3. Stress felt and perceived as unbearable and overwhelming.
4. Attempt to communicate hopelessness and defeat to others.
5. Others do not provide hope.
6. Sudden change in behavior, as noted when depression appears to lift, may indicate danger, as person has more energy to act on suicidal thoughts and feelings.
7. Decision to end life —> plan of action —» self-induced, self-destructive behavior.
3. May be pseudosuicide attempts, where there is no actual or realistic desire to achieve finality of death. Intentions or causes may be:
1. “Cry for help,” where nonlethal attempt notifies others of deeper intentions.
2. Desire to manipulate others.
3. Need for attention and pity.
4. Self-punishment.
5. Symbol of utter frustration.
6. Wish to punish others.
7. Misuse of alcohol and other drugs.
4. Other reasons for self-destruction, where the individual gives his or her life rather than takes it, include:
1. Strong parental love that can overcome fear and instinct of selfpreservation to save child’s life.
2. Sacrificial death” during war, such as kamikaze pilots in World War II.
3. Submission to death for religious beliefs (martyrdom).
2. Assessment of suicide:
1. Assessment of risk regarding statistical probability of suicide - composite picture: male, older than 45 years, unemployed, divorced, living alone, depressed (weight loss, somatic delusions, sleep disturbance, preoccupied with suicide), history of substance abuse and suicide within family.
2. Ten factors to predict potential suicide and assess risk:
1. Age, sex, and race - teenage, older age; more women make attempts; more men complete suicide act. Highest risk: older women rather than young boys; older men rather than young girls. Suicide occurs in all races and socioeconomic groups.
2. Recent   stress - family   problems:
3. death, divorce, separation, alienation; financial pressures; loss of job; loss of status; failing grades.
4. Clues to suicide: suicidal thoughts are usually time limited and do not last forever. Early assessment of behavioral and verbal clues is important.*
1. Verbal clues - direct: “I am going to shoot myself.” Indirect: “It’s more than I can bear.” Coded: This is the last time you’ll ever see me.” “I want you to have my coin collection.”
2. Behavioral clues - direct: trial run with pills or razor, for example. Indirect: sudden lifting of depression, buying a casket, giving away cherished belongings, putting affairs in order, writing a will.
3. Syndromes - dependent-dissatisfied: emotionally dependent but dislikes dependent state, irritable, helpless. Depressed: detachment from life; feels life is a burden; hopelessness, futility. Disoriented: delusions or hallucinations, confusion, delirium tremens, organic brain syndromes. Willful-defiant: active need to direct and control environment and life situation, with low frustration tolerance and rigid mind-set, rage, shame.
5. Suicidal plan - the more details about method, timing, and place, the higher the risk.
6. Previous suicidal behavior - history of prior attempt increases risk. Eight out of ten suicide attempts give verbal and behavioral warnings as listed previously.
7. Medical status - chronic ailments, terminal illness, and pain increase suicidal risk.
8. Communication - the more withdrawn and apathetic, the greater the potential for suicide, unless extreme psychomotor retardation is present.
9. Style of life - high risks include substance abusers, those with sexualidentity conflicts, unstable relationships (personal and job related). Suicidal tendencies are not inherited but learned from family and other interpersonal relationships.
10. Alcohol - can reinforce helpless and hopeless feelings; may be lethal if used with barbiturates; can decrease inhibitions, result in impulsive behavior.
11. Resources - the fewer the resources, the higher the suicide potential. Examples of resources: family, friends, colleagues, religion, pets, meaningful recreational outlets, satisfying employment.
3. Assess needs commonly communicated by individuals who are suicidal:
1. To trust.
2. To be accepted.
3. To bolster self-esteem.
4. To “fit in” with groups.
5. To experience success and interrupt the failure syndrome.
6. To expand capacity for pleasure.
7. To increase autonomy and sense of self-mastery.
8. To work out an acceptable sexual identity.
3. Analysis/nursing diagnosis: risk for selfdirected violence related to:
1. Feelings of alienation.
2. Feelings of rejection.
3. Feelings of hopelessness, despair.
4. Feelings of frustration and rage.
4. Nursing care plan/implementation:
1. Long-term goals
1. Increase client’s self-reliance.
2. Help client achieve more realistic and positive feelings of self-esteem, selfrespect, acceptance by others, and sense of belonging.
3. Help client experience success, interrupt failure pattern, and expand views about pleasure.
2. Short-term goals
1. Medical: assist as necessary with gastric lavage; provide respiratory and vascular support; assist in repair of inflicted wounds.
2. Provide protection from self-destruction until client is able to assume this responsibility.
3. Allow outward and constructive expression of hostile and aggressive feelings.
4. Provide for physical needs.
3. Suicide precautions to institute under emergency conditions:
1. One-to-one supervision at all times for maximum precautions; check whereabouts every 15 min, if on basic suicide precautions.
2. Before instituting these measures, explain to client what you will be doing and why; MD must also explain; document this explanation.
3. Do not allow client to leave the unit for tests, procedures.
4. Look through client’s belongings with the client and remove any potentially harmful objects, e.g., pills, matches, belts, razors, glass, tweezers.
5. Allow visitors and phone calls, but maintain one-to-one supervision during visits.
6. Check that visitors do not leave potentially harmful objects in the client’s room.
7. Serve meals in an isolation meal tray that contains no glass or metal silverware.
8. Do not discontinue these measures without an order.
4. General approaches
1. Observe closely at all times to assess suicide potential.
2. Be available.
1. Demonstrate concern for client as a person.
2. Be sensitive, warm, and consistent.
3. Listen with empathy.
4. Avoid imposing your own feelings of reality on client.
5. Avoid extremes in your own mood when with client (especially exaggerated cheerfulness).
3. Focus directly on client’s self-destructive ideas.
1. Reduce alienation and immobilization by discussing this “taboo” topic.
2. Acknowledge suicidal threats with calmness and without reproach—do not ignore or minimize threat.
3. Find out details about suicide plan and reduce environmental hazards.
4. Help client verbalize aggressive, hostile, and hopeless feelings.
5. Explore death fantasies -try to take “romance” out of death.
4. Acknowledge that suicide is one of several options.
5. Make a contract with the client, and structure a plan of alternatives for coping when next confronted with the need to commit suicide (e.g., the client could call someone, express feeling of anger outwardly, or ask for help).
6. Point out client’s self-responsibility for suicidal act.
1. Avoid manipulation by client who says, “You are responsible for stopping me from killing myself.”
2. Emphasize protection against self-destruction rather than punishment.
7. Support the part of the client that wants to live.
1. Focus on ambivalence.
2. Emphasize meaningfill past relationships and events.
3. Look for reasons left for wanting to live. Elicit what is meaningful to the client at the moment.
4. Point out effect of client’s death on others.
8. Remove sources of stress.
1. Decrease uncomfortable feelings of alienation by initiating one-toone interactions.
2. Make all decisions when client is in severe depression.
3. Progressively let client make simple decisions: what to eat, what to watch on TV, etc.
9. Provide hope.
1. Let client know that problems can be solved with help.
2. Bring in new resources for help.
3. Talk about likely changes in client’s life.
4. Review past effective coping behaviors.
10. Provide with opportunity to be useful. Reduce self-centeredness and brooding by planning diversional activities within the client’s capabilities.
11. Involve as many people as possible.
1. Gradually bring in others, for instance, other therapists, friends, staff, clergy, family, co-workers.
2. Prevent staff “burnout,” found when only one nurse is working with suicidal client.
12. Health teaching: teach client and staff principles of crisis intervention and resolution. Teach new coping skills.
5. Evaluation/outcome criteria: physical condition is stabilized; client able to verbalize feelings rather than acting them out.