Mrs. Leddy is a 68-year-old female patient admitted to the unit with a diagnosis of unexplained weight loss of 60 pounds over the past 3 months. Mrs. Leddy is quiet and withdrawn and difficult to engage in conversation. As a part of the routine admission assessment process, the nurse asks questions that assess suicide risk. Mrs. Leddy states that she is a widow, lives alone, and has been very sad since losing her 35-year-old son a year ago to lymphoma. He was her only child and lived with her. Mrs. Leddy states that she does not have any other family members or friends that are close to her or that she can count on for support. She tells the nurse that she attempted to kill herself 2 months ago and is upset that her attempt failed—she was hoping to be reunited with her son and husband. After completing the suicide risk assessment, the score indicates that Mrs. Leddy’s suicide risk is in the highest category for suicidal ideation.

1.

What CUES (Assessment) might the nurse identify as risk for suicide?

2.

What HYPOTHESIS (Diagnosis) will the nurse consider for making a nursing diagnosis?

3.

What ACTION (Plan and Implement) will be most effective for the nurse to take to assure the patient’s safety?

4.

How will the nurse evaluate the effectiveness of actions taken and the patient’s OUTCOME (Evaluation)?