How to write a nursing psychotherapist soap note: Suicidality in Pediatrics and Adolescents

How to write a nursing psychotherapist soap note: Suicidality in Pediatrics and Adolescents

Prompt: Complete a SOAP Note as if you were the psychotherapist in the video from this week\’s resources. To view the video again click here.
https://www.youtube.com/watch?v=wNF1FIKHKEU

Simulation Scenario – Adolescent Risk Assessment

Then write a one-page summary highlighting the warning signs of suicidality in Pediatrics and adolescent patients and why you chose the treatment plan you choose in your SOAP Note.

Use the SOAP Note rubric to guide you.

SOLUTION TO THE SOAP NOTE

SOAP Notes

PATIENT: Heide                AGE: 14                  GENDER: FEMALE

Subjective Data

A 14 years old female patient is brought by her mother to the hospital emergency department. Her mother reported her daughter has a history of depression and self-harm. The mother is concerned her daughter wants to kill herself tonight, and her mood is scrap. Additionally, another doctor cleared Heide medically.

Heide reports she has been thinking of dying every day by jumping down the bridge near her house, precipitated by her mother’s arguments. Also, she confesses to cutting her legs regularly and has no perception disturbances. Heide reports she only takes alcohol occasionally with her friends and willing to get assistance by cooperating for further assessment.

Objective Data

Appearance: Dress well, neat appearance, good hygiene

Behavior: calm

Attitude: Cooperative

Orientation; Well oriented to time, place, and person

Affect: Depressed, flattened

Speech and language: clear and coherent

Thought content: depression

Attention span/ concentration: appropriate

Heide got support from her mother and friend; the mother is concerned about her condition, the reason she brought her to the hospital. Also, she shares her issues with her friend, whom she trusted to keep her problems secret.

Assessment

Medical diagnosis: Depression with suicidal ideations and self-harm

Nursing diagnoses: 1 Hopelessness related to signs and symptoms of depression and self-harm, as evidenced by poor judgment.

2: Disturbed thought processes related to depression, as evidenced by suicidal ideations.

Plan

Assess both positive and negative signs and symptoms.

Assess mental status and history

Assess patient’s support system

Promote social skills, for example, through group therapies (Mayo, 2022).

Establish and maintain trust and rapport

Assist the patient in managing the situation

Initiate individual psychotherapy, i.e., cognitive behavioral therapy (CBT), dialectical behavior therapy, and mindfulness-based therapy (Mayo, 2022).

Administer antidepressants, i.e., Zoloft

Warning Signs of Suicidality in Pediatrics and Adolescent Patients

The first warning sign of suicidality in pediatrics and adolescents is baseline behavior changes (Hurley, 2022). Apart from depression, the following changes in normal behavior might be a warning sign of suicidality; changes in sleeping pattens and habits, withdrawal from close associates (social isolation) and presence of psychosomatic symptoms, such as stomachaches, headaches, and other pains that can’t be described.

Secondly, changes at school can be a red flag of suicidality in children and teenagers (Hurley, 2022). It’s normal for the young to experience ups and downs in their academic fields, but the following can indicate otherwise and create the need for further assessment and help; a significant drop in academic performance/ excellence, school refusal, lack of interest in schooling, lowered interest in normal activities and decreased interaction and association with the teachers and colleagues.

The third warning sign is a preoccupation with death (Hurley, 2022). It’s normal for any human being to think about death. But preoccupation with death, talking and planning their deaths and funerals, and finding ways to die can be a warning sign, for example, a kid asking how their parents and siblings will feel when they die, often asking possible ways to die can be a red flag.

The fourth warning is feelings of hopelessness (Hurley, 2022). When kids communicate hopelessness for their endeavors or feel helpless in a given situation, that is a red flag of suicidality. Additionally, a child-sized will is a warning sign. It entails kids giving away their possessions or dictating who should get them. This can be a red flag when combined with changes in conduct.

Significant mood changes can be a great indicator of suicidality. It’s normal for children to change moods when they grow up due to life stressors. But a sudden shift of mood from extremely happy to sad or completely withdrawn it’s a red flag. Furthermore, writing about death or suicide is a warning sign (Hurley, 2022). Most kids and adolescents try to verbalize their emotions and intentions via writing or drawing. Any writing or drawing that depicts suicide or death should be evaluated. Finally, an increase in alcohol and substance abuse can be a sign of warning for suicidality. Studies indicate that most youths abuse drugs before committing suicide (Mayo, 2022).

The rationale for the above intervention

Assessing a patient’s signs of hopelessness helps focus attention on her needs.

Assessing family and patient’s mental illness history will guide to finding the source of the issue and subsequent management.

Cognitive-behavioral therapy helps caregivers identify negative behaviors and substitute them with healthy and adaptive ones (Mayo, 2022).

Dialectical behavior therapy teaches the patient to tolerate, regulate and manage emotions. It improves relationships with other people (Mayo, 2022).

Mindfulness-based therapies help individuals live in the present and perceive thoughts appropriately and actions, hence reducing stress and depression (Mayo, 2022).

Antidepressants might help the patient to feel less compelled to hurt herself (Mayo, 2022).

Assessing a supporting system is crucial in establishing if they are aggravating or alleviating the situation.

References

Hurley, K. (2022). Children and Suicide: What are The Warning Signs?. Psycom.net – Mental Health Treatment Resource Since 1996. Retrieved 4 March 2022, from https://www.psycom.net/children-and-suicide.

Mayo. (2022). Self-injury/cutting – Diagnosis and treatment – Mayo Clinic. Mayoclinic.org. Retrieved 4 March 2022, from https://www.mayoclinic.org/diseases-conditions/self-injury/diagnosis-treatment/drc-20350956.

Mayo. (2022). What parents need to know about teen suicide. Mayo Clinic. Retrieved 4 March 2022, from https://www.mayoclinic.org/healthy-lifestyle/tween-and-teen-health/in-depth/teen-suicide/art-20044308.

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