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Suicide (Implementation (Ensure that restraints are frequently assessed…
Suicide
Implementation
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Administer Zoloft, Risperdal, and Depakote as ordered for depression and bipolar disorder.
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Assess foley catheter, intravenous line, and nasogastric tube frequently for complications.
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Diagnoses
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Risk for Fall
Use one-fourth to one-half length side rails only, and maintain bed in a low position.
Orient the client to environment. Place the call light within reach and show how to call for assistance.
Refer to physical therapy or other programs for exercise programs that target strength, balance,flexibility, or endurance.
Risk for Suicide
Be alert for warning signs of suicide: making statements such as, "I can't go on," "Nothing matters anymore"
Assess for suicidal ideation when the history reveals the depression, bipolar, substance abuse.
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Risk for Aspiration
Monitor respiratory rate, depth, and effort.
Note presence of nausea, vomiting, or diarrhea.
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Acute Pain
Assess pain characteristics (Quality, Intensity, Location, Onset, Duration, and Precipitating factors)
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Evaluation
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Zoloft, Depakote, and Risperdal
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Assessment
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pain in both ankles and in back, fractured ankle
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previous self-harm: attempted to cut wrists, jumped from 2nd story of building
depression assessment: risk factors - female, predisposition suicidal ideations, depressed mood, feelings of worthlessness & hopelessness
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Behavior & though process: decreased need for sleep, euphoric mood, racing thoughts, restless, agitated
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soft speech, circumstantial thought process, poor impulse control, maladaptive
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appearance: poor hygiene, disheveled
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foley catheter, IV line, NG tube to suctioning
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