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22 Nursing made Incredibly Easy! January/February 2014 www.NursingMadeIncrediblyEasy.com

A suicide attempt is the unsuccessful act of directing

violence at oneself with the intent to end one’s life.

When a person is contemplating ending his or her

life, it’s referred to as suicidal ideation. Although most

individuals with suicidal ideation don’t ultimately

commit suicide, the extent of suicidal ideation must

be determined, including the presence of a suicide

plan and the means to commit suicide.

If a patient has both a concrete plan to end his or

her life and the means to complete the plan, it’s a

medical/psychiatric emergency. Even when the patient voices

suicidal ideation and doesn’t have the means to complete the

task, it can still be an emergency because the patient may opt for

a more readily accessible avenue to complete the suicide.

As nurses, we spend the most time with our patients at the

bedside, so we’re the most likely candidates to notice the warning

signs of a suicidal patient. In this article, we show you how to

recognize a patient at risk for suicide and the steps you can take

to ensure his or her safety.

By the numbersSuicide is a serious problem in the United States. In 2010, an

average of 105 people committed suicide each day (38,364 deaths

per year) in the United States. In 2011, over 487,700 people were

seen by ED healthcare personnel for self-inflicted injuries. Sui-

cide attempts can cause devastating injuries that may leave the

patient physically and/or mentally disabled. Suicide and self-

inflicted injuries resulted in an estimated $41.2 billion in com-

bined medical and work loss costs in 2012.

Can you recognize the warning signs of suicidal

ideation? We show you how to keep your patients safe.

By Charlotte Davis, BSN, RN, CCRN;

Stacy Shuss, RN; and

Lisa Lockhart, MHA, MSN, RN

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Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

www.NursingMadeIncrediblyEasy.com January/February 2014 Nursing made Incredibly Easy! 23

risk



According to the CDC, suicide is the third-

leading cause of death among individuals

ages 15 to 24, the second for ages 25 to 34, the

fourth in those ages 35 to 54, and the eighth

for ages 55 to 74. Suicide is the 10th-leading

overall cause of death in the United States.

Annual suicide rates among American

adults ages 35 to 64 increased from 13.7 to

17.6 suicides per 100,000 people between

1999 and 2010.

Suicidal ideation can occur in both men

and women; however, women are more like-

ly to have suicidal thoughts than men.

According to the CDC, 8 million Americans

reported suicidal thoughts in 2012. The prev-

alence of suicidal thoughts, suicide planning,

and suicide attempts is significantly higher

among young adults ages 18 to 29 than

among adults ages 30 and older. Other

groups with higher rates of suicidal behavior

include American Indian and Alaska

Natives, rural populations, and active or

retired military personnel.

Across the generationsBaby boomers (1946-1965). The greatest

increases in suicide rates were among

people ages 50 to 54 (48%) and ages 55

to 59 (49%). However, the CDC states

that the suicide rates among Vietnam

veterans (enlisted 1959 to 1975) are

the highest of any particular generation.

The CDC cites the recent economic down-

turn, loss of peer support, and a rise in in-

tentional overdoses because of increased

availability of prescription opioids as com-

mon reasons for the increase in suicide rates

among this generation (see Recognizing de-pression in older patients).

Generation X (1966-1976). There are

approximately 41 million Generation Xers

currently residing in the United States.

According to the latest CDC research, sui-

cide is the fourth-leading cause of death for

this age group. Considering the impulsive

nature and inward focus that are said to

define this generation, it’s understandable

why depression, disappointment, or per-

ceived failure could result in a downward

spiral. In addition, this group has now

reached “middle age”—a time in an individ-

ual’s life that may be marked by a decline in

health, children leaving the home, loss of

parents and siblings, and an end to per-

ceived career alteration choices.

Generation Y (1977-1994). As previously

mentioned, suicide is the third-leading cause

of death among people ages 15 to 24 and the

second among those ages 25 to 34. Recent

CDC research states that Generation Y sui-

cide rates may be due to technology, finan-

cial distress, and family dynamic problems.

The rise of social media technology has

meant that many teenagers and young

adults are vulnerable to meeting people who

don’t have their best interests in mind. They

may be victims of cyber bullying, which has

been directly linked to major depression and

increased suicide rates. Combine this with

the normal turbulent emotions associated

with puberty and young adulthood, self-

esteem issues, career choices, young family

struggles, learning to survive successfully in

an adult world, and the failures that often

accompany life’s journey.

Generation Z (1995-2013). Suicide has

become much more common for American

children. Suicide is the fourth-leading cause of

death for children ages 10 to 14. For children

Recognizing depression in older patients

Red flags include:

• sadness

• fatigue

• abandoning or losing interest in hobbies or other pleasurable pastimes

• social withdrawal and isolation (reluctance to be with friends, engage in

activities, or leave home)

• weight loss or loss of appetite

• sleep disturbances (difficulty falling asleep or staying asleep, oversleeping,

or daytime sleepiness)

• loss of self-worth (worries about being a burden or feelings of worthless-

ness or self-loathing)

• increased use of alcohol or other drugs

• fixation on death, suicidal thoughts, or suicide attempts.



under age 15, about

1 to 2 out of every

100,000 will commit

suicide. For those

15 to 19, about 11

out of 100,000 will

commit suicide.

According to the

latest research, evi-

dence suggests that

children ages 15 to

19 are at a higher

risk for suicide that

children ages 10 to

14 because of

increased substance

abuse rates, access

to guns, and social

relationship prob-

lems. This generation has had increased

exposure to violent video games, media

coverage of ongoing wars and terrorist

attacks, and other distressing news. When

added to the naturally emotionally charged

state that accompanies puberty, the results

can be impulsive outbursts. It’s important

to remember that this age group doesn’t yet

have the benefit that comes with age and

experience; they may not readily under-

stand that situations can and do change.

A note on social mediaIn recent years, electronic technology has

greatly improved our ability to maintain

frequent contact with family and friends.

However, with the expansion of social me-

dia, cyber bullying has become an increas-

ing problem that can cause great distress to

all age groups, especially teenagers.

Cyber bullying refers to the intentional

harassment or targeting of a person via

social media or other Internet outlets or

by the sharing of unfavorable pictures,

thoughts, rumors, or negative suggestions

via electronic devices. If your patient is

suicidal, the healthcare team may remove

electronic devices until his or her mental

health has improved or stabilized.

Although most family members and

friends utilize electronic devices and

social media outlets to convey their posi-

tive support for the patient, there may be

instances in which harassment can be con-

tinuously evolving while the patient is

under the multidisciplinary team’s care.

Follow your facility’s policy regarding

removal of electronic devices, such as

computers, cell phones, or other devices

that have the capability of interacting with

others outside the healthcare team.

At riskRisk factors for suicide include:

• history of violence or previous suicide at-

tempts

• psychiatric illness

• recent loss of a relationship, family mem-

ber, or pet

• recent diagnosis of a serious medical con-

dition

• alcohol or substance abuse

• financial stress

• exposure to a perceived traumatic event

• victim of physical or sexual abuse.

These risk factors may predispose patients

to suicide; however, just because a patient

has one of the above risk factors doesn’t

mean that he or she will become suicidal. It

simply means that the patient may be pre-

disposed to thoughts of self-harm.

Heed the warning signsWarning signs of suicidal ideation include:

• observation of the patient looking for

ways to kill him or herself

• seeking access to pills, weapons, or other

means of harm

• rage, anger, or revenge-seeking behavior

• voicing hopelessness

• acting reckless or engaging in risky

activities seemingly without thinking

• feeling trapped like there’s no way out

• increasing alcohol or drug use

• withdrawal from friends, family, and

social activities

• anxiety or agitation

memory jogger

To remember the risk factors for suicide, think

SAD PERSONS.

Sex (men at higher risk)

A ge (highest-risk age groups are younger than

19 and older than 45)

Depression

Previous suicide attempt(s)

EtOH (excessive alcohol consumption)

Rational thinking (loss of)

Social support (lacking)

Organized plan

No spouse/children

Sickness (chronic) or stated intent



• sleep disturbances or sleeping all the time

• dramatic mood or personality changes

• talking or writing about death, dying, or

suicide

• making statements such as “there’s no

purpose in life” or “there’s no reason for

living”

• saying goodbye to people as if the patient

won’t be seen again.

Ask the right questionsMany nurses struggle with how to begin a

suicide risk assessment. Start with these

nine simple questions:

• How are you coping with what’s been

happening in your life?

• Do you ever feel like just giving up?

• Are you thinking about dying?

• Are you thinking about hurting yourself?

• Are you thinking about suicide?

• Have you thought about how you would

do it?

• Do you know when you would do it?

• Do you have the means to do it?

• Have you ever attempted to harm your-

self in the past?

Assess for nonverbal signs that may

potentially indicate the patient is considering

self-harm, such as avoiding eye contact, tear-

fulness, crying, or an abrupt change in

behavior. Examples of abrupt changes in

behavior include:

• A patient is typically severely depressed,

expressing no hope for the future, and he or

she suddenly becomes happy and jubilant.

This may signal that the patient’s stress is

relieved because he or she has solidified the

plan to commit suicide.

• A patient is typically very social and inter-

active with family and staff and he or she

suddenly becomes reclusive.

• A patient begins to give away cherished

mementos or possessions.

If you observe a notable change in behav-

ior, consult with the interdisciplinary team

immediately. The multidisciplinary team

may need to complete an in-depth suicide

risk assessment.

Don’t leave the patient alone if you suspect

he or she is experiencing suicidal ideation;

ensure that the patient is being adequately

monitored. This can be accomplished by

having a staff member continuously monitor

the patient on a 1:1 basis to minimize the risk

of self-harm.

Some facilities encourage staff members

to place the patient in paper scrubs to ensure

his or her safety. Unlike cloth scrubs or a

cloth gown, a set of paper scrubs can’t be

twisted to make a ligature. Follow your

healthcare facility’s policies on how to safely

manage the care of a suicidal patient.

Clinical interventionsSuicidal patients require the skills of a

multidisciplinary team to safely manage

their care. Common members of the multi-

disciplinary team include:

key points

Nursing considerations

• Observe for physical signs that the patient has attempted to harm him

or herself, such as self-inflicted cuts to wrists or hesitation cuts in other

visible areas.

• Conduct a personal belongings search for the presence of medications,

caustic liquids or powders, weapons, or items that could be modified

to cut, stab, or fashion into a ligature device if the patient has voiced

suicidal ideation.

• Notify the healthcare team immediately if the patient voices suicidal

ideation, and have one employee within arm’s length of the patient until

the team can evaluate his or her safety.

• Assess the patient each shift for suicidal ideation and/or behavior.

• Assess the patient’s environment at least every shift and remove all

potentially dangerous items.

• Observe the patient for decreased communication, disorientation,

dependency, and concealing potentially dangerous items, and notify the

healthcare team of significant changes.

• Monitor the patient daily for adequate nutrition, hydration, and elimination.

• Encourage the patient to identify positive self-aspects and determine

stressful life situations that may precipitate suicidal thoughts to develop

alternative coping techniques.

• Encourage the patient to have a balance of rest, sleep, and activity.

• Advise the patient regarding follow-up care.

• Ask yourself, have I documented expressed suicidal ideation, environ-

mental risks, nutritional status, activity level, and patient education?



• psychiatrists

• social workers

• nurses

• physicians

• psychologists

• unlicensed assistive personnel.

During the evaluation period, the mental

health expert may request that the patient

be held against his or her wishes. Each

state has specific legal guidelines that

direct this process. Typically, the physician

must complete a legal document that will

hold the patient for 72 hours. This legal

document is often called a 6404, 5150, or

Baker Act document, and it must be

recorded with the local court system. Its

primary goal is to provide an individual

with emergency medical services and

temporary detention for mental health

evaluation and treatment, either on a

voluntary or involuntary basis.

Before the 72-hour observation period

has expired, the multidisciplinary team

must complete the patient evaluation and

determine if he or she is at risk for harming

him or herself or others. If the patient is

considered to be at high risk for harming

him or herself or others, the multidisci-

plinary team must complete additional

legal documents to hold him or her beyond

the initial 72 hours.

The multidisciplinary team may need to

evaluate the patient’s social support system,

which can include spouses or partners, par-

ents, children, sib-

lings, extended fami-

ly members, friends,

or coworkers. A

strong social support

system may act as an

anchor, giving the

individual a sense

of belonging and

release. Remember,

suicide is often an

impulsive, sponta-

neous act. A strong

support system

that’s involved and present can often deflect

an impulsive response to anger, depression,

or disappointment.

A patient’s social support system is an

integral part of his or her safety plan.

Developed by the healthcare team with the

patient, the safety plan sets clear instruc-

tions, interventions, and expectations, and

the patient agrees not to harm him or herself.

Items in the safety plan include stressors to

avoid, specific people to call if the patient

needs to talk to someone, and when to call a

suicide hotline if needed.

Be aware that some social support systems

may be toxic to the immediate and long-term

mental health of the patient. In these situa-

tions, a multidisciplinary team approach

should be utilized to ensure that appropriate

support services are provided to limit,

restrict, or improve the healthiness of the

patient’s current social support system.

Immediate response neededIf a patient voices suicidal ideation, main-

tain visual sight of him or her at all times.

Notify the healthcare team by activating

a call light and requesting the presence

of another staff member or supervisor at

the bedside. Keeping the patient within

your visual field will reduce the chance

of self-harm until he or she can receive a

full psychiatric evaluation by the health-

care team.

Carefully assess the healthcare environ-

ment and the patient’s personal possessions

for items that could be used as a weapon,

such as:

• call light cord

• belt

• glass

• mirrors

• shoelaces

• syringes

• scalpels

• glass medication vials

• metal utensils

• lanyards (even the type with break-

away clasps can be used as a ligature).

On the web

• American Association of Suicidology: http://www.suicidology.org/home

• American Foundation for Suicide Prevention: http://www.afsp.org

• Mayo Clinic: http://www.mayoclinic.com/health/suicide/

DS01062

• Suicide Prevention Resource Center: http://www.sprc.org



These items should be removed from the

patient until he or she has been deemed not

at risk for self-harm.

Stay vigilant!We must continue to fine-tune our clinical

and psychosocial assessment skills to main-

tain our patients’ safety. If your patient ex-

hibits warning signs of suicidal ideation, im-

mediately consult with the multidisciplinary

team to ensure an optimal, safe outcome. ■

Learn more about itCDC. Understanding suicide. http://www.cdc.gov/ViolencePrevention/pdf/Suicide_FactSheet_2012-a.pdf.

Crosby AE, Han B, Ortega LAG, Parks SE, Gfroerer J. Suicidal thoughts and behaviors among adults aged ≥18 years—United States, 2008-2009. http://www.cdc.gov/mmwr/preview/mmwrhtml/ss6013a1.htm?s_cid=ss6013a1_e.

Gliatto MF, Rai AK. Evaluation and treatment of patients with suicidal ideation. http://www.aafp.org/afp/1999/0315/p1500.html.

Kuehn B. Preventing suicide’s ripple effects takes coordi-nated effort. JAMA. 2013;310(6):570-571.

Romer D. As the national adult suicide rate increases, news stories about suicides during the holidays grow in number. http://www.annenbergpublicpolicycenter.org/as-the-national-adult-suicide-rate-increases-news-stories-about-suicides-during-the-holidays-grow-in-number/.

World Health Organization. World report on violence and health. http://www.who.int/violence_injury_prevention/violence/world_report/wrvh1/en.

Charlotte Davis is a Clinical Nurse at Heritage Medical Center

in Shelbyville, Tenn., and a Clinical Nurse/Charge Nurse/ CCRN

Review Program Coordinator at Alvin C. York VA Medical Center in

Murfreesboro, Tenn. She is also a Nursing made Incredibly Easy!

Editorial Advisory Board Member. Stacy Shuss is a CCU Clinical

Nurse at Heritage Medical Center in Shelbyville, Tenn. Lisa Lockhart

is a Nurse Manager, Specialty Clinics, at Alvin C. York VA Medical

Center in Murfreesboro, Tenn.

The authors have disclosed that they have no financial relationships

related to this article.

DOI-10.1097/01.NME.0000438409.07755.e3

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