Case study - Depression and suicidal ideation: Nursing

Nurse Iris works on an inpatient psychiatric unit and is caring for Dee, a 30-year-old patient with a history of depression and previous suicide attempts, who was admitted for suicidal ideation. In collaboration with the registered nurse, RN Amrita, Nurse Iris goes through the steps of the Clinical Judgment Measurement Model to make clinical decisions about Dee’s care by recognizing and analyzing cues, prioritizing hypotheses, generating solutions, taking action, and evaluating outcomes.

First, Nurse Iris recognizes important cues, including Dee’s vital signs, which are temperature 98.9 F or 37.1 C, heart rate 65 beats per minute, respirations 16 breaths per minute, and blood pressure 116/70 mmHg. She also notices Dee does not make eye contact and has a flat affect.

Nurse Iris: Hi Dee, I’ll be your nurse today. How are you feeling?

Dee: I’m upset. My friend brought me to the hospital because I told him I wish I was dead. I don’t want to be here anymore.

Nurse Iris: I’m sorry to hear that. I want you to know that I and the rest of your medical team care about you. We're here to support you and keep you safe.

Next, Nurse Iris analyzes these cues. She reviews the electronic health record, or EHR, and notes that Dee is prescribed fluoxetine for depression and has been hospitalized in the past year for suicidal ideation. She also notes that Dee scored a 19 out of 27 on his PHQ-9 assessment, which is a nine-question, self-reporting depression survey, indicating a moderately severe level of depression. Nurse Iris recognizes that Dee needs a safe environment while he receives treatment for his depression and suicidal ideation.

Now, using the information she’s gathered, along with Dee’s medical history, Nurse Iris reports her findings to RN Amrita, and together they choose a priority hypothesis of risk for suicide.

Then, they generate solutions to address Dee’s suicidal ideation that will include pharmacologic and nonpharmacologic interventions; and they establish the expected outcome that after intervening, Dee will take part in a safety contract and will remain safe from self-harm.

Nurse Iris then takes action to implement these solutions. First, she confirms that items Dee could use to harm himself, like belts, shoelaces, and drawstring pants, have been removed from his room. An unlicensed assistive personal, or UAP, is assigned to sit with Dee to prevent self-harming behaviors. Next, she checks the EHR, and notes Dee is prescribed an antidepressant.

She gathers the supplies and enters Dee’s room.

Nurse Iris: Dee, I have your antidepressant medication for you, called sertraline. I noticed in the progress notes that you stopped taking your fluoxetine at home.