Nursing Management For Self-HARM &

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1 Nursing Management for Selfharm & Attempted Suicide in Adolescents Lau Sau Lai, APN, P & AM Department, United Christian Hospital. 24 march 2017.

2 學童自殺 : 母路祭泣不成聲 媽媽唔鬧你呀 ( 東網 6/2/2017) 13 歲女童墮樓死亡案, 死者姓蔡, 就讀中一, 居於長康邨康祥樓, 今日是農曆新年長假期後上學首天, 今晨 6 時 49 分, 穿着校服離家的蔡女, 疑從大廈高處梯間跨越圍欄墮樓, 重傷不治 警方在現場檢獲遺書, 據了解, 女生因生活問題不開心

3 八日內四學童自殺專家促落實防自殺措施 2017/02/12, 都市日報 一名 15 歲男生今早在馬鞍山錦泰苑錦邦閣懷疑墮樓身亡, 是本港八日內第四宗學生墮樓尋死事件, 有專家呼籲教育局盡快實行防止學生自殺的 20 多個建議措施 事發在今早九時許, 一名 15 歲男童懷疑從馬鞍山錦泰苑錦邦閣高處墮下, 救護員接報到場後證實他當場死亡 ; 警方未有在現場發現遺書, 初步調查後相信死者因受學業問題困擾而不開心, 事件無可疑, 死者父母其後到場認屍 今次是上周日以來第四名尋死的學生, 除上周三在黃大仙下邨企圖自殺的中一女生獲救外, 其餘三人均告死亡

4 學生自殺響警號 : 再有中一女生學業困擾危企 8/2/2017 東網 女學生危企幸及時獲救未釀悲劇 早上 8 時 11 分, 一名就讀中一的姓周 (12 歲 ) 女學生, 身穿校服離家後, 被發現於黃大仙下邨龍吉樓七樓走廊攀出欄河, 危站簷篷上, 街坊見狀大驚報案 警方衝鋒隊警員接報首先趕至, 趁其不備將她熊抱再拖返安全位置 由於女生情緒不穩, 需要送院檢驗, 其一名女親友則在現場助查, 初步相信她受學業問題困擾不開心

5 2017 年港聞 : 青少年自殺 2 月 5 曰, 17 歲男生, 墮樓身亡. 2 月 6 曰, 13 歲女生, 墮樓身亡. 2 月 8 曰, 12 歲女生, 企跳被救回. 2 月 12 曰, 15 歲男生, 墮樓身亡. 2 月 17 曰, 15 歲男生, 墮樓身亡. 2 月 19 曰, 15 歲男生, 吊頸被母救回. 2 月 21 曰, 13 歲男生, 墮樓身亡.

6 Content The definition of Self-harm & Attempted Suicide. The statistic and trend of Self-harm & Attempted Suicide in Adolescents. The causes behind Self-harm & Attempted Suicide in Adolescents. Signs of Non-Suicidal Self-Injury. Nursing Intervention for Self-harm or Suicidal Patients. Brief of Depression. Community resources. Case sharing & discussion.

7 The definition of Self-harm & Attempted Suicide. Self-harm is the deliberate infliction of damage to your own body and includes cutting, burning, and other forms of injury (Robert T Muller, 2014). Attempted Suicide: A non-fatal, self-directed, potentially injurious behaviour with an intent to die as a result of the behaviour, might not result in injury (Centers for Disease Control & Prevention, USA).

8 Other terminologies: Suicidal Ideation: thinking about or planning suicide. Completed Suicide: death caused by self-directed injurious behaviour with an intent to die. Non-Suicidal Self-Injury (NSSI): not intended to be fatal. Injuries to the body parts that are concealed. NSW Ministry of Health 2016

9 How common is NSSI? In Hong Kong, Shek and Lu (2012) reported 32.7% of secondary school students had engaged in self harm in the past 12 months More common in females (1.3x) then males No difference in rate was seen between local youth and immigrant youth

10 How common is suicide? In Hong Kong, whilst reported rates vary between studies, Shek and Yu (2012) found in the previous 12 months amongst secondary students: 13.7% of adolescents experienced suicidal ideation 4.9% had made a plan 4.7% had attempted suicide

11 The Statistic of Suicide Death in Hong Kong (By Age Group)

12 The Statistic of Suicide Rates in Hong Kong (By Age Group)

13 The Statistic of Method Used in Completed Suicide by Age Group in Hong Kong in 2015

14 Myths & Facts about Suicide (Centre for Suicide Research & Prevention. The University of Hong Kong. ) Myths Pt who talks on suicide will not commit suicide. Pt who die by suicide is very determined. Asking pts about suicide may provoke them to carry out the plan. Only trained mental health professionals can help suicidal pts. Facts Pt who commits suicide usually shows warning signs & cues. Pt is often ambivalent. Timely intervention can save life. This will often make pt feels understood & relieved. Most suicidal pts do not seek help from mental health professionals.

15 The causes behind Self-harm & Attempted Suicide in Adolescents. Coping strategy. Reduce distress, negative feelings or emotional pain. Self- punishment. Relief from strong thoughts or numbness. Demonstrate outwardly intensity of feelings. NSW Ministry of Health 2015

16 Ten Commonalities of Suicide The common stimulus is unbearable psychological pain. The common purpose is to seek a solution. The common goal is cessation of consciousness. The common stressor is frustrated psychological needs. The common emotion is hopelessness. Adapted from Shenidman (1996).

17 Ten Commonalities of Suicide The common cognitive state is ambivalence. The common perceptual state is constriction. The common action is escape. The common interpersonal act is communication of intention. The common pattern is consistency of lifelong styles. Adapted from Shenidman (1996).

18 The Suicidal Mind (Shneidman, 1996) Dominant psychological needs Frustrated Psychological pain become unbearable Constricted thinking Death as the only solution to stop the consciousness of pain Actively sought Suicide

19 The reasons for patient s resistance to disclose suicidal thought Think nobody can help. Wants to die & not be stopped. Suicide is a sign of weakness. Suicide is immoral or a sin. People may think he/she is crazy.

20 Problem solving model of suicidal behaviour Intense negative emotion A passive problem solving style with escape & low emotion tolerance A learned in which suicidal ideation & attempt is associated with short term reduction in distress.

21 Signs of Non-Suicidal Self-Injury Changes in mood Social withdrawal Avoiding activities where body is exposed e.g. swimming Change in school performance Lack of self care Unexplained injuries Wearing unseasonal or uncharacteristic clothing that conceals body Hiding or storing objects like blades, lighters, matches

22 Factors in associated with self harm indicates high risk of suicide: A medically serious act of self harm. Precaution was taken against being found. Previous episode of self harm. Depression or Psychosis. Substance misuse. Impulsive & aggressive personality traits. Loneliness & lack of social support. ( Isacsson & Rich, 2001).

23 Nursing Intervention for Self-harm or Suicidal Patients: Attitude & approach Assessment: Initial & HEADSSS Suicidal precaution Developing Safety & Contingency Plan

24 Attitude & Approach: Stay with the patient in a sympathetic way. Calm & non-judgmental approach. Avoid anger or shock. Listen & speak with respect. Keep patient talking & allow expression of feelings. Be patient & accepting.

25 Attitude & Approach: Express empathy. Acknowledge the patient s feelings. Use reflective communication skills to clarify & don t assume. Ensure safety at this time. Manage physical & medical needs.

26 Initial assessment on admission with three questions: Patient is admitted due to attempted suicide? Patient express suicidal ideation or self-harm behaviour? Patient s relative or friend reveals that patient has suicidal risk?

27 Home Education Eating/exercise Activities Drugs & alcohol Sexuality Suicide Safety Assessment with HEADSSS:

28 Assessment with HEADSSS (Suicide) Have you ever thought about hurting yourself? Have you ever tried hurting yourself? Prior suicide attempts? Do you have a plan? 你有無想過傷害自己 / 自殺? 你之前有無試過傷害自己 / 自殺? 你有甚麼想法或計劃? 你身上有無任何協助你傷害自己 / 自殺的工具?

29 Key Indicators in Assessment Severity of psychological pain. Tolerance of emotional distress. Hopelessness. Evaluation of suicide in solving problem. Strength of survival & coping beliefs.

30 Assess predisposing factors ( Treatment-focused assessment) Thinking style Problem solving style Tolerance for negative feelings Interpersonal deficits Life stress & social support buffers ( Chiles & Strosahl, 2005).

31 Risk Assessment Mental state: depression, psychosis, impulsivity, hopelessness Suicide attempt or thoughts: intention, lethality, access to means, previous attempts Substance use: misuse of alcohol or other drugs Corroborative history: family, records, other service providers Protective factors: e.g. capacity of support persons

32

33 自殺風險評估 ( 自殺危機評估及處理訓練手冊 ) 內容中度風險高風險 1. 自殺意念間有自殺意念持續自殺意念 2. 自殺計劃有計劃, 數小時內考慮周詳, 即時 3. 自殺史曾有低致命行為曾有中度致命行為 4. 健康狀況急性, 短期疾病慢性或嚴重疾病 5. 日常活動有顯著轉變受嚴重影响 6. 性格穩定但有自殺衝動不穩定, 有自殺行為 7. 生活模式偶有使用毒品 / 酒精沉溺毒品 / 酒精 8. 精神病病症憂傷, 易怒, 寂寞, 減興趣絕望, 哀傷, 感生存沒價值 9. 社交支援家人及朋友只作短暫緩助沒有家人及朋友緩助 10 壓力, 打擊對環境變化有中度負面反應對環境變化有嚴重負面反應

34 危機介入 : 視不同自殺風險 (Centre for Suicide Research & Prevention. The University of Hong Kong. 低 - 承認人生有希望 - 持續評估抑鬱程度 / 自殺傾向 - 治療抑鬱症 / 精神病 高 - 限制接触自殺工具 - 自願 / 非自願入院 中 - 考慮全時間陪伴 - 使用熱線, 家探 - 研究應變方法 急 - 移除自殺工具 -24 小時監察 - 住院 - 联絡家人, 朋友

35

36 Suicidal Precaution:

37 Suicidal Precaution: Remove the objects that patient can use to hurt himself/herself. Advise his/her relative/ friend who trust to accompany with him/her or arrange a security staff to do so. Using the behaviour observation chart to close observe patient s emotion and behaviour. Refer psychiatrist for +/- medication or admission/f.u., clinical psychologist and MSW for counselling.

38 Developing Safety & Contingency Plan Completed in collaboration with the Adolescent Safety plans are used to identify and document: Individual warning signs and triggers Coping strategies Supportive people that can be contacted Professionals or organisations in local area that can be contacted Crisis information and after hours numbers Ways to keep self and surroundings safe A personal statement strengths, goals ( From HA Adolescent Nursing Course) 2016)

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40 Positive Action Card( 緊急應對咭 ) (Centre for Suicide Research & Prevention. The University of Hong Kong 當我有自殺意圖, 我会作以下步驟 : 1. 不要喝酒 2. 坐下並深呼吸 3. 做一些我感覺良好的事情至少 30 分鐘, 如聽音樂 4. 和一個關心我的人談談我們的共同興趣 - 如果我想自殺, 我会找 傾談, 电話 若情況沒改善, 我会电 999, 或往急症室

41 Depression

42 Depression 15% individuals diagnosed with Major Depressive Disorder die by suicide. (Clark & Fawcett, 1992).

43 Symptoms of Depression: Psychological Depressed mood most of the day Feeling of worthlessness, helplessness & hopelessness Difficulty in concentration Recurrent thought of death /suicide.

44 Symptoms of Depression: Physical Insomnia Lack of appetite Weight loss Fatique Psychomotor retardation

45 Depression: Common Masked Signs Hostile Uncommunicated Boredom Reduce personal hygiene and self care Truancy Accident prone.

46 46

47 活動尺 去歐洲旅行 1. 打電話俾中學同學 2. 睇赤壁 游水 / 打羽毛球 試想十項能夠讓自己快樂 但平時不願嘗試做的活動, 例如致電好友 做運動 看一場電影等 請將這十項活動按開心指數排列次序, 填寫上面的 活動尺 ( 第一項是最容易達成而開心指數較低的活動, 到第十項是較難達成而開心指數最高的活動 ) 47 未來兩星期內, 你會選擇完成哪一項? 請在該項活動旁的方格裡加上剔 ( 黃冨強 2004)

48 Treatment Goals of individual counseling A. help client to understand her cognitive and behavioural patterns and how these affect her emotions B. help client to learn skills to enhance her cognitive functioning C. help client to learn skills to enhance her behavioural functioning 48

49 CBT for depression: Thought Analysis Behavioural activation e.g. mood monitoring; pleasant activities, physical exercise Dealing with Automatic thoughts Dealing with Schema 49

50 Prevention of Depression Primary/Secondary prevention: teaching/ training of optimism Tertiary prevention: Mindfulness-based CBT Mindfulness deliberate awareness of experiential events as they happen in the moment in a non-judgmental way. 50

51 Community Resources: 香港大學香港賽馬会防止自殺研究中心 人間互助社聯.Tel: 生命熱線 : 自殺危機處理中心 : 社署熱線 : 撒瑪利亞防止自殺会 :

52 香港大學香港賽馬会防止自殺研究中心

53 香港大學香港賽馬会防止自殺研究中心

54 References NSW Ministry of Health (2016) Caring for Young People with Mental Health Issues in Paediatric Inpatient Settings Shek, D.L. & Yu, L. (2012) Self-Harm and Suicidal Behaviours in Hong Kong Adolescents: Prevalence and Psychosocial Correlates. Scientific World Journal, published online 2012 Apr 1 Web page of Centre for Suicide Research & Prevention. The University of Hong Kong. Isacsson, G., Rich,C.L.(2001)Management of patients who deliberately harm themselves. British Medical Journal, 322:

55 References Blumenthal, S.J. & Kupfer, D.J. ( 1988). Clinical Assessment & Treatment of Youth Suicide. Journal of Youth & Adolescence17: Clark, D.C. & Fawcett, J. (1992). Review of empirical risk factors for evaluation of the suicide patient. In B. Bongar (Ed.). Suicide: Guidelines for assessment, management & treatment (pp ). New York: Oxford University Press.

56 Case Discussion 24/3/2017

57 Case Discussion: 1.Using the Suicide Assessment of the HEADSSS to assess the following cases. 2.What is the nursing intervention for the cases?