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S: The 17 year old patient suspected of being human trafficked has attempted suicide and has lashed out at staff members who attempt to perform assessments.

B:The patient is a 17 year old hispanic gender fluid person who came into the emergency room last night. The patient has not provided an address or identification documents and has said little to no words. The aunt is answering all the questions for them and does not leave their side.

A:The patient came in with a fractured right humeral head that is consistent with blunt force trauma. Upon assessing the patient further, it was revealed that they had multiple bruises on their torso that were all in different healing stages. On their neck they had 3 scars from cigarette burns. The patient’s vital signs are a heart rate of 92 bpm, blood pressure 134/84, respiration 18, temperature of 37.5 C, and oxygen saturation is 99% on room air.

R: Place the patient on 1:1 for close monitoring for signs of self harm and continue to build trust and rapport with the patient. Encourage the patient to open up and talk about the trauma. Keep the patient calm and incorporate trauma informed care.

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While the nurses attempted to stabilize the patient's right leg with bandages, the patient suddenly reached for the bandage scissors and attempted to cut their wrist yelling that they wanted to die. The patient frantically started yelling and screaming at the top of their lungs. Due to the patient's actions, they are at risk for suicide.

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The nurse attempts to interview the patient. However, the aunt is the one answering all the questions. When the nurse asks the aunt if she can step outside for a few minutes so the patient can have some privacy she responds, “No, that will not be necessary.”

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While doing routine vital signs today at 0800, a male PCT came into the patient’s room where the patient was sitting up in bed. The PCT introduced himself and greeted the patient to which he got no response. When attempting to take the patient's blood pressure, he touched their arm and the patient began to scream hysterically saying “get away from me” and “do not hurt me”. Additional staff entered the room to tend to the patient and de-escalate the situation.

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I: Patient unstable on 1:1.

P: Patient is a 17-year-old gender fluid individual who is suspected to be a victim of human trafficking. Patient has suicidal ideations and has attempted suicide once while in our care. We were able to get a heartbeat back, however she is still unresponsive. Her vital signs were as follows: heart rate of 48 bpm, blood pressure 82/58, respiration 8, temperature of 37.5 C, and oxygen saturation is 83% on room air. The patient came in with a fractured right humeral head that is consistent with blunt force trauma. Upon assessing the patient further, it was revealed that they had multiple bruises on their torso that were all in different healing stages. On their neck they had 3 scars from cigarette burns. Patient became violent when a male staff member attempted to take vital signs.

A: Monitor vital signs periodically for improvement or deterioration. Please keep the patient on 1:1 for suicidal ideations. Have a female staff member attempt vital signs and go slow to avoid re-traumatization. Contact the provider for care of the patient’s right humeral head fracture. Assess pain and provide comfort measures and pain medication as ordered. Obtain a psychiatric evaluation consult and work alongside health care providers to establish a plan of care.

S: If the patient’s suicidal ideations worsen, please provide comfort measures to ensure the patient feels safe.

S: The patient’s priority intervention is to stabilize their vital signs and monitor for suicide. The patient's safety and pain is also of great importance. You want to attempt vital signs and proceed slowly to avoid re-traumatization. I will contact the provider regarding the humeral fracture and methods for pain management.

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The anticipatory order for the patient due to her suicide attempt is to have a psych evaluation done and put on 1:1 SI risk watch.

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The nurse was able to quickly and safely retrieve the bandage scissors from the patient before true damage was done. The nurse administered alprazolam (Xanax) as a last resort to calm the patient down after she kept attempting to hit staff members. The patient had a minor cut on her left arm that the nurse was able to bandage up and stop the bleeding.

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The nurse asks the aunt if she can go to the front desk to fill out her niece’s paperwork as it needs to be completed before the patient can be discharged. The aunt agrees and steps out of the room. This allows the nurse to have some time to have a confidential discussion with the patient and begin to build rapport while setting the stage for developing a trusting nurse-patient relationship.

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Nursing Intervention 3 After Patient Deteriorates

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Nursing Intervention 3 After Patient Deteriorates

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For this particular patient, it is important to provide trauma informed care. Trauma informed care is key in preventing re-traumatization and creating a safe environment. Once a safe and trusting relationship is developed, the patient should be educated on coping techniques. Some effective coping techniques include identifying immediate safety concerns, seeking support from family or the community, and providing quality self-care. These coping skills will help the patient develop a stronger sense of autonomy, safety, and empowerment.

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During the shift change between the nurses in charge of the 1:1 watch, the patient’s aunt stepped outside briefly to go to the restroom. The new nurse enters the room and finds the patient has hung themselves with the bed sheets while they were alone for one moment.

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Nursing intervention 1 After Patient Deteriorates 

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Nursing intervention 1 After Patient Deteriorates 

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Emergency rescue from suicide attempt:

After noticing the patient has hung herself, the nurse immediately gets the patient down and calls a code team. She assesses the patient airway, breathing, and circulation. The nurse began CPR while the team set up the AED and they shocked the patient which successfully brought her heart rate back. Due to the patient's condition she is being transferred to the ICU for further monitoring, assessment, and intervention.

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Nursing Intervention 2 After Patient Deteriorates

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Nursing Intervention 2 After Patient Deteriorates

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Establish trust and rapport with patient:

The patient refused to talk to any staff in the room and avoided eye contact. The patient started to scream when anyone walked too close. The nurse went into the room to speak privately with the patient, reintroducing herself and calmly discussing the care plan. The nurse was transparent with the patient and made sure not to pressure them to speak, and allowed enough time for the patient to respond. Patient kept on looking for items to harm herself with in the room even after initial suicide attempt. She was found looking frantically through cabinets for anything to use while muttering words under her breath. Any items from the room that the patient could use to hang herself, cut herself, or swallow were removed from the room. Nurse reassured the patient that she was in a safe place and stayed with her in the room.

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The LEAP method is an effective way for the nurse to de-escalate a situation by showing respect, validation, and interest in what the patient is saying. The nurse asked all of the male staff members to leave the room to avoid further upsetting the patient. The nurse then used the first component of this method which is listening to allow the patient to express how they were feeling about the situation. By actively and reflectively listening to the patient’s concerns and feelings, the nurse can build a stronger relationship with the patient. The second component of the LEAP method is empathizing. Having a deep understanding of the patient’s feelings and identifying with those feelings helps the patient feel validated. The patient told the nurse that she did not want any males around her for the fear that they would hurt her. The third component is agreeing. It is important to find common ground and acknowledge the patient’s perspective of the situation. Finally, partnering with the patient establishes trust and allows the patient to collaborate with the nurse to have a role in their treatment. Once learning this information the nurse stated “I understand that it can be scary to have males around you, we will make sure that you only have female nurses attending to you”.

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Maria Roman: complication 1, intervention 1, anticipatory order, created the concept map, and made final review and corrections

Denise Hernandez: SBAR, complication #3, decompensation scenario, created the concept map, and made final review and corrections

Karen Diaz: intervention 1 and 2 after decompensation

Heidi Cabrera: complication 2 and intervention 2

Rachel Hayman: intervention 3 and IPASS

Colin Toro: intervention 3 after decompensation