Self Harm and Suicide, Risk Assessment, Safegaurding Flashcards
Suicide risk assessment: Key questions to ask about current episode of self harm - before
Was there a precipitant?
(e.g. argument with a spouse or a recent bereavement. May help establish psychological, physical or social problems)
Was the self-harm planned, or impulsive?
Did the patient carry out any final acts?
(e.g. write a suicide note/leaving a will/terminating contracts)
Were any precautions taken against discovery?
(e.g. closing curtains/locking doors/waiting until home alone/going somewhere remote)
Was alcohol used?
(amount/type, previous alcohol use)
Suicide risk assessment: Key questions to ask about current episode of self harm - during
What method of self-harm was involved?
Was the patient alone?
Where were they when they self-harmed?
What was going through their mind at the time?
Did they think their self-harm would end their life?
What did they do straight after the self-harm?
Suicide risk assessment: Key questions to ask about current episode of self harm - after?
Did the patient call anyone? How did they get to A&E? Who were they found by?
How did they feel when help arrived?
How does the patient feel about the attempt now? Do they regret it?
What is the patient’s current mood?
Does the patient still feel suicidal?
If the patient were to go home today, what would they do? (make sure you cover the next few days)
If the patient were to feel like this again, what might they do differently?
What does the patient think might prevent them from doing this again in the future?
Does the patient feel there is anything to live for? (i.e. protective factors)
Will the patient accept treatment?
When a patient takes an overdose, what specific questions must you asked them?
What medication or medications did the patient take?
Where did the patient get the medication from?
How much of the medication did the patient take?
What did the patient take the medication with?
What did the patient think that amount of medication would do?
What made the patient decide to take the medication/how long had they been thinking about taking an overdose for?
What did the patient do after taking the medication?
How did the patient get to the hospital?
Specific questions to ask about cutting when a patient presents with self harm/suicide attempt?
Where are the cuts?
How many cuts are there?
How deep are the cuts?
How did the patient feel whilst they were cutting?
How did the patient feel when they saw blood?
What was the patient hoping the cutting would do?
Suicide risk assesment: Screen for other mental health disorders which increase the risk of suicide
Depression
Ask about anhedonia/low mood/fatigue
Psychosis
Ask about thought insertion/auditory hallucinations
Anorexia
Ask about eating habits/intake/appetitie/recent weight loss/feelingd about current weight
What should be asked when inquiring about previous episodes of self harm?
Has the patient ever carried out self-harm in the past?
What methods of self-harm were involved?
Did they get any help from their support network or other agencies as a result of their self-harm?
What should be established in regard to the psychiatric past medical history when assessing for suicide equipment?
Does the patient have any psychiatric diagnoses?
Has the patient had any previous admissions to a psychiatric hospital?
Why might past medical history and drug history be relevant in cases of self harm/suicidal ideation or attempt
It is important to ask about a patient’s past medical history as this may be relevant to their current episode of self-harm (e.g. bleeding disorder/liver dysfunction).
Chronic pain and chronic illness are also risk factors for suicide.
It’s important to take a thorough drug history as this may be relevant to the current episode of self-harm (e.g. anticoagulants/overdose/interactions).
Suicide risk assesment - family history
Have any of the patient’s family members ever attempted or completed suicide?
Are there any psychiatric conditions present in close family members?
Taking a thorough social history allows identification of social risk factors for suicide. What should be asked about?
Living situation (with who/where, support network, able to do activities of daily living, any children - safegaurding)
Occupation (what is it, feelings towards job, coping, needing to take time off, debt/financial situation)
Alcohol (particularly important to ask about if used during the episode of self-harm, do they drink - if so how much, pattern of drinking (binge/daily))
Recreational drugs (are they used, what/when, how much/how frequent)
Things to include when assessing for risk of suicide?
Current episode of self harm
Specific questions about overdose or cutting if applicable
Screen for mental health disorders
Previous episodes of self harm/suicide attempts
Past psychiatric history
PMH + DHx
Family history
Social History
Plans
Precipitating factors
Protective factors
Suicide risk assessment: If the patient is not suicidal and you intend to send them home with no follow-up
Safety plan:
Seek the support of their family and friends (clarify who they have already told ).
Recognise stressors and address them where possible.
Avoid harmful alcohol use when stressed.
Ask the patient who they could tell if they felt like this again.
Suggest that if the patient feels like this again, they can seek help from a number of places (A&E, samaritans, GP, personal support nerwork)
Signpost to appropriate agencies which may be able to address stressors/risk factors:
GP
Housing services
Citizen’s Advice Bureau
Alcohol and drugs services
Domestic violence services
Counselling services
Suicide risk assessment: If the patient requires support from a mental health team
Some patients may require support from the local mental health team. Have a discussion about whether the patient could manage safely at home with the support of an intensive home treatment team or will accept voluntary admission to a psychiatric hospital.
Suicide risk assessment: If the patient is unsafe to send home
For some patients, it may be clear that they are at high risk of completing suicide or further self-harm and lack insight. In these cases, a Mental Health Act assessment will need to be carried out.
Factors that increase the risk of suicide: demographics
Male
Older
Widowed/separated/single
Living alone/social isolation
Low income/unemployed
Certain occupation (e.g. doctor, farmer)
Family history of suicide
Factors that increase the risk of suicide: diagnosis
A previous suicide attempt (risk x 40)
Severe depression (risk x 20)
Anorexia (risk x 25)
Haemodialysis (risk x 14)
Recreational opiate use/dependence (risk x 14)
Alcohol dependence (risk x 6)
Schizophrenia
Factors that increase the risk of suicide: the act itself
The patient carried out final acts (e.g. writing a will)
The patient has researched methods and prepared for the act (e.g. stockpiling tablets)
The patient perceived the act to have a high lethality
The patient took precautions against being found
The patient used a violent method of suicide (e.g. firearms, jumping from a height)
The patient’s attempt is discovered by chance
The patient resists/tries to evade medical intervention
The patient downplays the seriousness of the attempt
Common protective factors against suicide
family support
having children at home
religious belief
Clinical features of paracetomol overdose?
No symptoms
Nausea and vomiting
Loin pain
Haematuria and proteinuria
Jaundice
Abdominal pain
Coma
Severe metabolic acidosis
Pathophysiology of paracetamol overdose?
When taken as an overdose, the metabolism of paracetamol results in a buildup of a toxic substance called NAPQI (N-acetyl-p-benzoquinone-imine).
NAPQI is inactivated by glutathione.
In an overdose, glutathione stores are rapidly depleted, and NAPQI is left un-metabolised.
It can cause liver and kidney damage.
Paracetamol overdose: If ingestion less than 1 hour ago + dose >150mg/kg
If ingestion less than 1 hour ago + dose >150mg/kg: Activated charcoal
When can activated charcoal be used in paracetamol overdose?
If ingestion in the last hour
If dose >150mg/kg (aprox 10 paracetomol in a 70kg pt)
Paracetamol overdose: If staggered overdose or ingestion >15 hours ago
Start N-acetylcysteine immediately
When should N-acetylcysteine be started immediately in paracetamol overdose?
If staggered overdose or ingestion >15 hours ago
NAC can also be administered immediately if there is an increased risk of toxicity. This occurs in the following:
Patient on long-term enzyme inducers
Regular alcohol excess
Pre-existing liver disease
Glutathione-deplete states: eating disorders, malnutrition and HIV.
