Psychiatric Mental Health, part 11: Sexual Assault and Suicidal Patients
July 30, 2021 Updated: December 29, 2021 11 min read
Content warning: This nursing education video covers sexual assault and suicide.
In this article, we discuss how to care for patients who have been sexually assaulted and patients who are at risk of suicide.
This series follows along with our Psychiatric Mental Health Nursing Flashcards which are intended to help RN and PN nursing students study for nursing school exams, including the ATI, HESI, and NCLEX.
Sexual assault is defined as a crime of violence where a person makes sexual contact with another person without their freely given consent. Rape is a type of sexual assault.
Labs and diagnostics needed after sexual assault and/or rape may include collection of hair samples, blood, genital swabs, rectal cultures, scrapings of material underneath the client's nails. A patient may need pregnancy testing and STI screening.
You may have heard the term "rape kit" before, this refers to the actual container that includes a checklist, diagnostic materials, and instructions, and containers
Treatment for patients who have been sexually assaulted
If a patient has been sexually assaulted, they may need an emergency contraceptive (e.g., Plan B), HIV post-exposure prophylaxis, or STI prophylaxis.
Nursing care for patients who have been sexually assaulted
When you are caring for a patient who has been sexually assaulted, allow them to be accompanied by a friend or trusted person for exams. Bringing someone along may help increase their feelings of safety.
Oftentimes the diagnostic exams described above involve having to touch areas of the patient's body that were recently subjected to violence. It is incredibly important to ensure that informed consent is obtained prior to forensic examinations and treatment.
For a patient that has been sexually assaulted, you can make referrals to sexual assault crisis centers.
If your facility employs any Sexual Assault Nurse Examiners (SANEs), you may need to use their services during this time. You can assess for signs of PTSD and rape-trauma syndrome, described below. Facilitate referrals to mental health specialists as indicated.
Rape-trauma syndrome is a pyschological, physical, and behavioral reaction following a sexual assault. Remember that the word syndrome comes from syn- (together) and -drom (run) which means "runs together," in reference to a group of signs and symptoms that occur together. The trauma experienced after a sexual assault is not a disorder nor a pathology; it is a normal human reaction of trauma to experienced violence. Rape-trauma syndrome has an acute phase, an outward adjustment phase, and a resolution phase.
During the acute phase of rape-trauma syndrome, a wide range of emotions are possible. Expressed emotion like crying or yelling, controlled emotion with a flat affect and outward calmness, or shocked disbelief including disorientation and difficulty concentrating.
Outward adjustment phase
During the outward adjustment phase of rape-trauma syndrome, a person who has been sexually assaulted may resume normal daily activities, but suffer from symptoms that include sleeping and eating disturbances, physical pain, phobias and fears, flashbacks, sexual dysfunction, or depression.
During the resolution phase of rape-trauma syndrome, a person who has been sexually assaulted may no longer have the assault as the central focus of their life, and their physical pain and other symptoms may decrease over time.
This information on sexual assault is for your nursing exams and practice. If you (or someone you know) have been sexually assaulted, you can call the free RAINN (external link) hotline 24 hours a day at 1-800-656-HOPE (4673) to talk to a trained support specialist.
Patients at risk of suicide
Suicide is the act of taking one's own life on purpose. If a patient "is suicidal," it means they are at risk of dying by suicide. It would in fact be more humanizing and equally accurate to say that someone is at risk of suicide, facing suicide, thinking of suicide, has expressed intent to die by suicide, or is experiencing suicidal thoughts.
Did you know that the terminology surround suicide has changed? You've probably heard the term, "commit suicide," but did you know that the word commit is in there because suicide was a crime? Thus, "committing" suicide was likened by its terminology to committing murder or committing a crime.
That's why mental health advocates use the term "die by suicide." In addition, instead of "failed/unsuccessful suicide attempt" the appropriate terminology "nonfatal suicide attempt," "suicide attempt," or "survived a suicide attempt," can be used.
Risk factors for suicide include a family history of suicide, age greater than 50 years old, being unmarried, white race, previous sucide attempts, chronic illness, mental health disorder(s), substance abuse, isolation, lack of access to mental health services, job loss, financial difficulties, and access to a firearm.
It's important to note that these risk factors are statistically correlated with suicide, and they do not predetermine someone to die by suicide! For example, unmarried (single) status being correlated with suicide obviously does not mean that someone who is unmarried will die by suicide. It just means that out of all the people who die by suicide, more of them are unmarried than married.
Protective factors, which are the opposite of risk factors, for suicide include access to mental health services, family and community support, effective coping skills, and cultural or religious beliefs that discourage suicide.
Signs of impending suicide
Warning signs for an impending suicide is if a patient is talking about death or suicide, if they make statements about hopelessness, if they are "getting their affairs in order" (e.g., making a will), writing a suicide note, giving away their posessions, if they have an increase in substance use, substance withdrawal, or a sudden improvement of mood (e.g., "everything will be alright soon").
Treatment of patients at risk for suicide
Treatment options for patients at risk of suicide include talk therapy, pharmacological therapy (e.g, anti-depressive medications). Routine screening to check for patients' suicide ideation and intent to die by suicide is also common.
It is very important to note that as a patient at risk for suicide begins pharmacological therapy, it may result in their depression lifting enough that they are more "energized" to carry out a plan of suicide, so it is important to closely monitor patients as they begin pharmacological therapy.
Nursing care for patients at risk of suicide
If you have a patient at risk of suicide, it is your priority to ask them directly, "Have you thought about harming or killing yourself?" As a nursing student or new nurse, this can feel like an uncomfortable or hard question to ask, but as Cathy shares in the video, you will get used to being very direct with your patients in asking them these questions. This is part of providing care.
If a patient says yes, that they have thought about harming or killing themselves, then you need to ask them directly about their plan. You will need to assess for their means to carry out that plan. For example, do they have access to a firearm? Remember, that's one of the risk factors for dying by suicide.
If a patient is at risk for suicide, you will implement one-on-one observation. They should not be assigned to a private room. They should be close to the nurse's station. Remove any potentially harmful objects, including belts, shoelaces, necklaces, or sharp objects. Perform room searches as needed to remove potentially harmful items that have been acquired. Search all objects brought in by visitors.
If you have a patient at risk for suicide, make rounds frequently at irregular intervals so that they do not know when to expect you next. Patients should not be left in isolation.
This information on nursing care for patients at risk of suicide is for your nursing exams and nursing practice. If you (or someone you know) are thinking of harming yourself or attempting suicide, tell someone who can help right away. Call the toll-free, 24-hour hotline of the National Suicide Prevention Lifeline (external link) at 1-800-273-TALK (8255) to be connected to a trained counselor.
Hi, I'm Cathy with Level Up RN. In this video, we are going to talk about the nursing care of victims of sexual assault. We're also going to talk about the nursing care of suicidal patients. If you are new to our channel, be sure to subscribe. We have hundreds of free videos to help you along your journey to becoming a nurse. At the end of this video, I'll be providing a quick little knowledge check to see how well you've picked up on some of the key concepts that I will be covering in this video, so stay tuned for that.
All right. Sexual assault is a crime of violence, not of passion, where sexual contact happens without consent. When we are caring for a patient who's a victim of a sexual assault, there are a number of labs that we're going to want to collect and some of this forensic evidence will require informed consent from the patient before we can collect that evidence. So some of those things include blood, hair samples, genital swabs, anal cultures, as well as scrapings of material from underneath the victim's fingernails. We're also going to want to do STI screening and pregnancy testing as well. In terms of medications that we can provide the patient, we can give them emergency contraceptives. We can give them post-exposure HIV prophylaxis, as well as STI prophylaxis. So we always want to allow the patient to be accompanied by a friend or a trusted person during the exam. Again, we want to make sure informed consent has been obtained before we do that collection of forensic evidence. We want to utilize the services of a sexual assault nurse examiner, if possible, because they are specially trained in these situations. And then afterwards, we're going to want to really follow up with the patient, assess for signs of PTSD, and something called rape trauma syndrome, which we'll be talking about next. And then we want to facilitate referrals to mental health specialists as indicated for the patient.
All right. Now let's talk about rape trauma syndrome. This syndrome describes the psychological, physical, and behavioral reaction of the victim following a sexual assault, and it can be broken down into three phases, which is the acute phase, the outward adjustment phase, and the resolution phase. During the acute phase, there are a wide range of emotions that are possible from the victim. They may include an expressed reaction, like crying and yelling. It may be a controlled reaction, such as the victim may present with a flat affect and be outwardly calm, or they may exhibit shocked disbelief. So they may be disoriented and have difficulty concentrating. After the acute phase, we move into the outward adjustment phase. This is where the individual kind of resumes their normal daily activities but may suffer from a number of symptoms that can include sleeping and eating disturbances, physical pain, phobias, flashbacks, sexual dysfunction, and/or depression. And then, finally, we move into the resolution phase. This is where the sexual assault is no longer the central focus of the victim's life, and then their pain and symptoms decrease over time.
All right. Now let's transition to talking about nursing care of suicidal patients. Let's first talk about some of the risk factors that place an individual at high risk for suicide. I'm not going to go over all the ones on our card here, but I will hit some of the highlights. So having a family history does place an individual at higher risk. If the person is unmarried and single, they're at higher risk. Previous suicide attempts, chronic illness, mental health disorders, substance abuse, and isolation are all risk factors. Job loss, financial difficulties, and access to a firearm are also risk factors. So what are protective factors? What factors exist that help decrease the risk for suicide? This includes access to mental health services as well as family and community support. If the patient has effective coping skills, that's obviously going to decrease their risk of suicide. And then if the patient has religious beliefs that discourage suicide, that is also protective.
In terms of the signs of impending suicide, some of the things I'm going to talk about here are kind of straightforward, more obvious, but some may not be. So if the individual is talking more about death and suicide, that's obviously a red flag. Statements about hopelessness are also suspect. If the individual starts getting their affairs in order, like making a will, that is a clear warning sign that suicide may be impending. Also, if they start giving away their prized possessions to others, that is a warning sign. If their substance use increases, if they become more withdrawn, and if there's a sudden improvement in their mood, and they say things like, "Everything's going to be all right soon," then that red flag should come way up there, and you definitely should suspect that suicide may be on their mind.
Treatment options for a patient who is suicidal can include talk therapy as well as pharmacological interventions such as anti-depressive medications. We also want to do routine screening for our patients to check for suicide ideation and intent to commit suicide. One thing to note, as a patient who is suicidal begins pharmacological therapy, it may result in their depression lifting enough that they are more energized to carry out their suicidal plans, so we're definitely going to want to closely monitor our suicidal patients as they begin pharmacological therapy because of this increased risk as their depression lifts. In terms of nursing care, it is a priority that you ask the patient directly, "Have you thought about harming yourself or killing yourself?" And as a nursing student or a new nurse, it can be a little bit uncomfortable or hard to do this, but you will get used to being very direct with your patients and asking them these things. You'll just get used to it as you get more experience as a nurse.
And then if they say yes, they have thought about harming themselves or killing themselves, then you need to ask them directly about their plan and see if a means to carry out that plan. For example, do they have access to a firearm? If the patient is at risk for suicide, you want to implement one-on-one observation. Someone needs to be watching that patient at all times, and you do not want to assign them to a private room. In addition, you want to place them in a room close to the nurse's station. You want to remove any potentially harmful objects. So this could include belts, shoelaces, and anything sharp. You want to make rounds frequently on your suicidal patient, and you want to do so at irregular intervals. So you don't want the patient to think, "Oh, well, he or she is only going to come by every hour on the hour." You want to kind of change things up so that you are coming by on irregular intervals. And then you want to perform room searches as needed, and you definitely want to search all items brought in from visitors.
Okay. It's time for a quiz. I have three questions, and they are all true, false. First question, collection of forensic evidence following a sexual assault requires informed consent, true or false? The answer is true.
Second question, it is best to assign a patient who is at risk for suicide to a private room to keep things quiet and calm, true or false? False. The patient who is at risk for suicide should not be assigned to a private room.
Question number three, giving away prized possessions is a sign of impending suicide, true or false? The answer is true, in addition, getting your affairs in order, like making a will, is also a potential sign of impending suicide. All right. That's it for this video. I don't know about you guys, but I'm happy to be done with these topics. They're really important topics, so we definitely have to talk about them and cover them in nursing, but I'm anxious to move on to some other material. Take care.
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