00139 Automutilation Risk

Domain 11: security/protection
Class 3: violence
Diagnostic Code: 00139
Nanda label: self -absolute risk
Diagnostic focus: automutilation
Approved 1992 • Revised 2000, 2013, 2017

NANDA Nursing Diagnosis Definition

The Nanda nursing diagnosis « self -absolute risk is defined as: susceptible to showing deliberately autolesive behavior that causes tissue damage with the intention of causing a non -lethal lesion that relieves tension.

Risk factors

  • Absence of a family confidant
  • Body image alteration
  • Dissociation
  • Deterioration of interpersonal relationships
  • Eating disorder
  • Excessive emotional alteration
  • Feeling threatened by the loss of significant relationships
  • Inability to express verbally
  • Insufficient communication between parents and adolescents
  • Ineffective coping strategies
  • Inephic impulse control
  • Irresistible urgency of self -directed violence
  • Irresistible urgency of cutting oneself
  • labile behavior
  • Loss of control over problem solving situations
  • Low self -esteem
  • Increasing tension that is intolerable
  • Negative feelings
  • Inability pattern to plan solutions
  • Inability pattern to visualize the long -term consequences
  • Perfectionism
  • Requires rapid stress reduction
  • Social isolation
  • Inappropriate use of substances
  • Use of manipulation to obtain significant relationships with others

Risk population

  • teenagers
  • Child abuse
  • Encrehensive people
  • People who experience family divorce
  • People who experience inappropriate use of substances in the family
  • People who experience loss of significant interpersonal relationships
  • People who experience sexual identity crisis
  • People who live in a non -traditional environment
  • People with colleagues who automate
  • People with family history of self -destructive behavior
  • People with a history of child abuse

Associated problems

  • Autism
  • Personality limit disorder
  • Character disorder
  • People with a history of child affection
  • People with a history of child surgery
  • People with a history of self -directed violence
  • People who presence violence between parental figures
  • Intersonalization
  • Disabilities of development
  • Psychotic disorder

Suggestions of use

Authority risk is a more specific diagnosis than Suggested alternative diagnostics

Other examples

  • It abstains to injure
  • Verbally manifests a decrease or absence of hallucinations or delusions
  • Identify the feelings that lead you to perform impulsive acts
  • Identify and avoid high -risk environments and situations

NIC Interventions

  • Support for anger control: facilitation of anger expression in an adaptive way, without violence
  • Training for impulse control: Help the patient to control their impulsive behaviors through the application of problem -solving strategies in social and interpersonal situations
  • Behavior management: Self -injury: patient assistance to reduce or eliminate self -timing or self -abuse behaviors
  • Environment management: Security: Control and manipulation of the physical environment to favor security
  • Anxiety reduction: decreased apprehension, fear, feeling or discomfort related to an anticipated danger of unknown origin

Nursing Activities

Note : Nursing activities interventions should be chosen to modify risk factors and self -lation prevention.

For all patients

Valuations

  • Verify if the patient has a history of self -harm behaviors, including the methods used, known triggers, etc.
  • (NIC) Support for anger control-, monitor the potential for inappropriate aggression and intervene before it manifests
  • (NIC) Behavior Management: Self -harm: Determine the reason or reason for behavior
Patient and family education

  • Provide support and teaching to the family on the patient’s state and treatment methods
  • (NIC) Behavior Management: Self -injuries: Teach the patient coping strategies (for example, assertiveness training, impulse control and progressive muscle relaxation, as required).
Others

  • Offer patient security by applying the least restrictive measures (for example, manipulation of the environment, assignment of a roommate, assign the patient a room near nursing, restriction of the presence of relatives and visits, patient watched in everything moment, patient, other specific interventions of the patient)
  • Accompany the patient to activities outside the unit, as required
  • (NIC) Behavior Management: Self -injury:
    • Develop expectations and behavioral consequences appropriate to the level of cognitive functioning and patient self -control capacity
    • Remove hazardous articles from the patient’s environment
    • Use a quiet and punishment attitude when handling self -colored behaviors
  • (NIC) Support for anger control:
    • Use external controls (for example, physical or manual, breaks), as necessary (as a last resort) to calm a patient who expresses his anger inappropriately
    • Identify the consequences of inadequate expression of anger
    • Establish basic trust and a good relationship with the patient

Psychotic patients

Valuations

  • Observe behavioral changes from the baseline evaluation (for example, greater isolation, agitation)
  • Evaluate whether the patient presents a morbid concern for suicide, automutilation, despair and lack of value
  • Value the patient who presents hallucinations to determine their content and origin (for example, ask the patient: “Who is that voice? What has he told him to do? Has the voice indicated to be harmed? How? Does that voice control it? ”)
  • Monitor the intensity of hallucinations and delusions, and try to do a reality test (specify the frequency)
  • Determine if religious, persecutory or somatic delusions have contributed to self -harm
  • Watch whether somatic hallucinations have contributed to self -harm (for example, to believe that a part of the body is sick, deteriorated, or is not necessary
Collaboration activities

  • Obtaining a medical authorization if the intervention implies the violation of rights
  • (NIC) Behavior Management: Self -injury: Administer medications, as required, to reduce anxiety, stabilize mood and reduce self -stimulation
Others

  • If suddenly the patient is quiet after an agitation period, increase security measures to avoid self -harm
  • Help the patient distinguish internal stimuli from those of the outside world
  • Encourage the patient to express their feelings and impulses instead of accumulating tension
  • Register the patient and the environment to look for potentially harmful articles, as required
  • Cut the nails from the patient’s hands and feet to avoid scratching
  • Promote physical activity
  • Negotiate with the patient a contract where he undertakes not to self -harm
  • If the patient is unable to negotiate a contract or follow instructions, it is necessary imprisonment
  • (NIC) Behavior Management: Self -injury:
    • Place the patient in a more protected environment (for example, physical seclusion and restriction) if impulses or self -miting behaviors are exacerbated
    • Apply, as appropriate, gloves, immobilization systems of the limbs, helmets or clamps to limit mobility and the possibility of self -harm
    • Help the patient identify situations and feelings that can cause automation

Patients with personality disorder

Valuations

  • Evaluate the degree of impulsivity and patient frustration tolerance
Patient and family education

  • Teach the patient alternative measures to relieve stress and tension (for example, relaxation techniques, physical exercise, write a newspaper, self -affirmation and distraction techniques such as music, television and talk)
  • Teach family members and guidelines to know how to handle self -disposal behaviors outside the care environment
  • (NIC) Behavioral management: Self -harm: instruct the patient and loved ones about the disease in case the self -lation behavior is due to a disorder (for example, limit personality or autism disorder) < /li>
Collaboration activities

  • Consider the possibility of administering anxiolytic or neuroleptic medications, according to medical prescription
  • Provide clear responses to the patient by collaborating closely with other health professionals. Review the treatment plan frequently to avoid problems with personnel and conflicts regarding the objectives of the treatment.
Others

  • Motivate the patient to seek the support of personnel and their peers instead of resorting to alcohol or drugs
  • Establish frequent and regular surveillance schedules with the assigned personnel
  • (NIC) Behavior Management: Self -injury:
    • Negotiate a contract of “not self -harm” with the patient, as required
    • Indicate the consequences if the patient insists on showing self -miting behaviors

Autistic delay patients

Valuations

  • Assess the patient’s response to the environment to determine if there are stressful factors that lead to self -lation
Patient and family education

  • (NIC) Behavioral management: Self -harm: instruct the patient and loved ones about the disease in case the self -lation behavior is due to a disorder (for example, limit personality or autism disorder) < /li>
Others

  • Modify environmental situations that produce stress caused by self -miting behaviors
  • Avoid reinforcements that can cause self -miting behaviors (for example, comfort the patient after hitting the head, release him from performing tasks that he considers unpleasant)
  • Prepare a behavioral plan that reduces the incidence of self -harm
  • Use protection devices to avoid self -harm (for example, gloves, helmet, strength shirt, protective clothing)