ASSESSMENT
Subjective:
“Matagal nang patay ang asawa
ko. Sobrang hirap. Minsan naiisip
ko na sumunod na lang sa
kanya.” As verbalized by the
client.
“Sa dami ng mga pinagdaanan ko
sa buhay, naiisip ko na
masmabuti pa sigurong mawala
na lang ako sa mundong ito.” As
verbalized by the client
Objective:
- weak in appearance
-decreased wt.
-unkempt appearance(untidy
hair, clothes, dirty and long nails)
-defeated-looking/slouched
-withdrawn
NURSING DIAGNOSIS:
Risk for self-directed violence r/t
post-traumatic experience as
manifested by verbalization of
suicidal ideation
PLANNING
After 6 to 7 days of nursing
intervention, the client’s suicidal
ideation will be lessened or will
be absent
INTERVENTION
-determine whether client has
specific suicide plan identified
-identify degree of risk/potential
for suicide through direct
questions
-reevaluate potential for suicide
periodically at key times
-implement suicide precautions
by explaining to the client that
you are concerned for his/her
safety
-create a time-specific contract
with the client on what client
and nurse will do to provide for
client’s safety
-monitor client’s weight
RATIONALE EVALUATION
-to further assess the After 7 days of nursing
interventions specifically needed intervention, the client’s suicidal
for the client ideation is lessened
-degree of hopelessness
expressed by the client is an
important indicator of severity of
depression and suicide risk
-suicide risk is the greatest
during the first few weeks
following admission to treatment
-communicates caring and sense
of protection
-short-term contracts encourage
the client to deal with the here-
and-now and provide
opportunity to reassess situation
-dramatic and extreme changes
in the client’s weight helps
identify the degree of depression
the client
-monitor environment for -to prevent client from access of
potential safety hazards possible tools for self harm

-remove dangerous items from -to prevent client for further

the client’s environment ideation of inflicting self-harm

-provide appropriate level of -to monitor patient and to allow

supervision/surveillance by therapeutic actions as needed
placing patient in a least
restrictive environment

-refer to psychiatrist as needed -for further effective

management, a specialty
physician is needed