4. The psychiatric nurse collects accurate assessment information and communicates the risk to the treatment team and appropriate persons
Performs an independent risk assessment for self-directed violence upon admission and on an ongoing basis throughout the patient’s hospitalization even in the absence of expressed suicidality.
- Risk factors (distinguish between modifiable and non-modifiable).
- Full suicidal inquiry.
- Mental Status Exam.
- History of physical and/or psychological trauma.
- Current triggers that activate feeling of distress.
- Patient’s minimization or exaggeration of symptoms.
- Collateral personal sources as appropriate.
- History of self-directed violence (SDV) and interventions.
- Communicates the assessment of risk to the treatment team and appropriate persons (i.e. nursing supervisor, on duty M.D., etc.).
5. The psychiatric nurse formulates a risk assessment.
- Makes a clinical judgment of the risk that a patient will attempt suicide or die as a result of suicide in the short and long term.
- Participates as a member of the interprofessional team in ongoing formulation of risk based on changing assessment data.
- Continues to integrate and prioritize all the information on an ongoing basis.
- Applies constructs, theories, studies and systematic reviews to understand changes in risk.
- Determines level of risk of suicide as acute or chronic.
- Assesses the patient’s motivation to minimize risk and to exaggerate risk, including psychological, environmental and contextual influences.
- Distinguishes between acute and chronic suicidal ideation and behavior.
- Distinguishes between self-directed violence with the intent to die vs. without the intent to die.
- Considers developmental, cultural, and gender related issues related to suicide.