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UNIT 2 ■ Psychiatric Mental Health Nursing Interventions
W ithdrawal: Expresses desire to withdraw from oth- ers or has begun withdrawing A nxiety: Expresses anxiety, agitation, and/or changes in sleep patterns R ecklessness: Engages in reckless or risky activities
(Posner et al., 2011) is an evidence-based tool that assists in this process (Figure 11–2). The Collaborative Assessment and Management of Suicidality (CAMS) model is an evidence- based approach that focuses on the importance of patient-centered, problem-focused intervention to build an alliance with patients for collaboration in reducing risk for suicidal behavior (Jobes, 2012). This model focuses on assessment, which necessarily includes asking the patient to identify what is driving the desire to take their own life so that alternatives (identifying and capitalizing on motivations to live) can be explored. For all health-care professionals, this work begins with developing skill in asking basic and direct questions such as, “Are you having thoughts of hurting or killing yourself?” Beyond the basic questions of whether or not a person has suicidal ideas, a plan, and access to
with little thought of consequences M ood: Expresses dramatic mood shifts
Mnemonic devices such as IS PATH WARM? can be helpful in remembering what types of presenting symptoms to assess for, but the overall assessment and management of suicidal behavior are far more complex and must consider available support sys- tems, the patient’s willingness to accept support, and the patient’s ability to establish a trusting therapeutic alliance with health-care professionals intervening on their behalf. Ultimately, a clinical judgment must be made about the patient’s degree of risk so that appropriate measures can be taken to prevent an attempt. The Columbia Suicide Severity Rating Scale
Columbia-Suicide Severity Rating Scale Screen Version - Recent
Past Month
Lifetime (Worst Point)
Yes No
Yes No
Ask questions that are bolded and underlined.
Ask Questions 1 and 2
1) Have you wished you were dead or wished you could go to sleep and not wake up?
2) Have you actually had any thought of killing yourself?
If YES to 2, ask questions 3, 4, 5, and 6. If NO to 2, go directly to question 6.
3) Have you been thinking about how you might do this? E.g. “I thought about taking an overdose but I never made a specific plan as to when where or how I would actually do it...and I would never go through with it.” 4) Have you had these thoughts and had some intention of acting on them? As opposed to “I have the thought but I definitely will not do anything about them.” 5) Have you started to work out or worked out the details of how to kill yourself? Do you intend to carry out this plan?
How long ago did the Worst Point Ideation occur?
6) Have you ever done anything, started to do anything, or prepared to do anything to end your life? Examples: Collected pills, obtained a gun, gave away valuables, wrote a will or suicide note, took out pills but didn’t swallow any, held a gun but changed your mind or it was grabbed from your hand, went to the roof but didn’t jump; or actually took pills, tried to shoot yourself, cut yourself, tried to hang yourself, etc... If YES, ask: Was this within the past three months?
Yes No
Low risk High risk FIGURE 11–2 Columbia Suicide Severity Rating Scale (C-SSRS). Reprinted with permission from The Columbia Lighthouse Project. Moderate risk
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