ASSLSSMLn1 LAnnlnC ln1L8vLn1lCn 8A1lCnALL LvALuA1lCn

05708843

a. Subjective Data:

Not able to express opinions
and lazy speech. Often
expressed somatic
complaints. Feeling
themselves are not useful
anymore, feel insignificant,
there is no purpose in life,
feeling desperate and likely to
commit suicide.

b. Objective data:

Body movements that are
blocked, the body is curved
and when sitting in an attitude
of slump, depressed facial
expression, a slow gait with
dragging step. Sometimes it
can happen stupor. Patients
appear lazy, tired, no appetite,
difficulty sleeping and often
cry. Thought process too late,
as if the mind is empty,
disturbed concentration, has
no interest, can not think, do
not have the imagination

AfLer 68 hours of nurslng
lnLervenLlon Lhe cllenL's sulcldal
ldeaLlon wlll be lessened or wlll
be absenL

deLermlne wheLher cllenL has
speclflc sulclde plan ldenLlfled


ldenLlfy degree of rlsk/poLenLlal
for sulclde Lhrough dlrecL
quesLlons


reevaluaLe poLenLlal for sulclde
perlodlcally aL key Llmes


lmplemenL sulclde precauLlons
by explalnlng Lo Lhe cllenL LhaL
you are concerned for hls/her
safeLy

creaLe a Llmespeclflc conLracL
wlLh Lhe cllenL on whaL cllenL
and nurse wlll do Lo provlde for
cllenL's safeLy


monlLor cllenL's welghL






Lo furLher assess Lhe
lnLervenLlons speclflcally needed
for Lhe cllenL

degree of hopelessness
expressed by Lhe cllenL ls an
lmporLanL lndlcaLor of severlLy of
depresslon and sulclde rlsk

sulclde rlsk ls Lhe greaLesL
durlng Lhe flrsL few weeks
followlng admlsslon Lo LreaLmenL

communlcaLes carlng and sense
of proLecLlon



shorLLerm conLracLs encourage
Lhe cllenL Lo deal wlLh Lhe here
andnow and provlde
opporLunlLy Lo reassess slLuaLlon


dramaLlc and exLreme changes
ln Lhe cllenL's welghL helps
ldenLlfy Lhe degree of depresslon
Lhe cllenL



AfLer 68 of nurslng lnLervenLlon
Lhe cllenL's sulcldal ldeaLlon ls
lessened

depressive psychosis patients
have deep feelings of guilt, no
sense (irrational), delusions of
sin, depersonalization, and
hallucinations. Sometimes
patients prefer hostile, irritable
and does not like to be
disturbed.





weak ln appearance
decreased wL
unkempL appearance(unLldy
halr cloLhes dlrLy and long nalls)
defeaLedlooklng/slouched
wlLhdrawn


nu8SlnC ulACnCSlS
8lsk for selfdlrecLed vlolence r/L
posLLraumaLlc experlence as
manlfesLed by verballzaLlon of
sulcldal ldeaLlon




monlLor envlronmenL for
poLenLlal safeLy hazards

remove dangerous lLems from
Lhe cllenL's envlronmenL

provlde approprlaLe level of
supervlslon/survelllance by
placlng paLlenL ln a leasL
resLrlcLlve envlronmenL

refer Lo psychlaLrlsL as needed



Lo prevenL cllenL from access of
posslble Lools for self harm

Lo prevenL cllenL for furLher
ldeaLlon of lnfllcLlng selfharm

Lo monlLor paLlenL and Lo allow
LherapeuLlc acLlons as needed



for furLher effecLlve
managemenL a speclalLy
physlclan ls needed