00140 Risk Of Self -Directed Violence

Domain 11: security/protection
Class 3: violence
Diagnostic Code: 00140
Nanda label: self -directed violence risk
Diagnostic focus: self -directed violence
approved 1994 • Revised 2013, 2017

NANDA Nursing Diagnosis Definition

Nanda nursing diagnosis « risk of self -directed violence ” is defined as: susceptible to having behaviors that demonstrate that a person can be physical, emotionally and/or sexually harmful to himself. P>

Risk factors

  • Behavioral signs of suicide attempt
  • Conflict over sexual orientation
  • Conflict in interpersonal relationships
  • Labor concern
  • Implication in autoerotic sexual acts
  • Inadequate personal resources
  • Social isolation
  • Suicide ideas
  • Suicide plan
  • Verbal signals of suicide attempts

Risk population

  • People 15-19 years of age
  • People> 45 years of age
  • People with occupations with high suicide risk
  • People with a history of multiple suicide attempts
  • People with a pattern of difficulties in the family environment

Associated problems

  • Mental health problems
  • Physical health problems
  • Psychological disorder

Suggestions of use

  • If specific risk factors occur for self -confidence or suicide risk, these more specific nursing diagnoses should be used instead of risk of self -directed violence.

Suggested alternative diagnostics

  • Automutilation, risk of
  • suicide, risk of

NOC Results

  • Suicide self -concentration: personal actions to avoid gestures and attempts to take your life
  • Sothing containment: Personal actions to avoid self -inflicted (non -lethal) lesions intentionally

Note : The following results are associated with the risk factors of self -directed violence:

  • Impulses self -control: Self -limitation of compulsive or impulsive behaviors
  • Control of distorted thoughts: self -limitation of perception alterations, the processes of thought and the content of thought
  • Emotional balance: appropriate adjustment of the predominant emotional tone in response to circumstances
  • Social interaction skills: personal behaviors that favor effective relationships
  • Anxiety level: severity of manifest apprehension, tension or discomfort, whose origin is not identifiable
  • Social participation: social interactions with people, groups or organizations

Evaluation objectives and criteria

  • • Demonstrates impulse self -control, which is manifested by the following indicators (specify from 1 to 5: never, sometimes, sometimes, often or usually):
    • Identify feelings or behaviors that lead to impulsive acts
    • Identify the consequences of impulsive acts towards oneself and others
    • Avoid high -risk environments and situations
    • Control your impulses
  • Other examples

    The patient will be able to:

    • • Identify alternative forms to face problems
    • • Identify community support systems
    • • Report the decrease in suicidal thoughts
    • • Avoid suicidal attempts
    • • Not hurting

    NIC Interventions

    Note : Nursing interventions focus on monitoring self -directed violence, as well as identifying and modifying risk factors.

    • Preparation of a contract with the patient: negotiation of an agreement with an individual, where a specific change of behavior is reinforced
    • 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: Help the patient reduce or eliminate self -timing or self -abuse behaviors
    • Environment management: Violence prevention: supervision and modification of the physical environment to reduce potential aggressive behaviors aimed at itself, to others, or the environment
    • mood management: provision of security, stability, recovery and maintenance, to a patient who abnormally experiences a depressed or elevated mood
    • Suicide prevention: Reduction of the risk of self -inflicted damage with the intention of ending life
    • Treatment of substance consumption: patient care and care and family members suffering from physical and psychosocial problems, related to alcohol or drug use

    Nursing Activities

    • Also see nursing activities for self -lation diagnoses; Authority risk, and suicide risk.

    Valuations

    • • Evaluate and document the patient’s suicide potential every ______
    • • Identify behaviors that indicate imminent violence against themselves; Specify behaviors
    • • (NIC) Environment Management: Violence Prevention:
      • Monitor the safety of the objects that visitors carry
      • Watch the patient during the use of potential weapons (for example, razor sheet)

    Patient and family education

    • • (NIC) Support for anger control: teach to use tranquilizer measures (such as breaks, deep breathing)

    Collaboration activities

    • • Clarify the usefulness of staying 72 hours in the psychiatric unit for evaluation and treatment, in case of attempt to self -harm
    • • Talk to the doctor about the use of appropriate restriction measures when it is necessary
    • • Organize a multidisciplinary meeting on patient care to develop a care plan

    Others

    • • Establish precautions for suicide, if necessary (for example, company 24 hours)
    • • Ensure the patient that he will be protected against their suicidal impulses until he is able to recover control by means of constant observation of the patient; (b) frequent patient surveillance, and (c) take suicidal ideas seriously
    • • Talk to the patient and the family about the function of anger in self -inflicted damage
    • • Encourage the patient to express anger with words
    • • (NIC) Support for anger control:
      • Apply a calm and safe style
      • Limit the experimentation of frustrating situations until the patient is able to express anger adaptively
      • Encourage the patient to ask for help from nursing staff or other responsible persons, during periods of great tension
      • Prevent physical damage if anger addresses itself (for example, restricting and removing potential weapons)
      • Allow the physical expression of anger or tension (for example, box bag, sports, clay work or write a newspaper)
      • Establish the expectation that the patient can control their behavior
    • • (NIC) Environment Management: Violence Prevention:
      • Place with a partner the patients who tend to self -harm, to reduce the isolation and the opportunity to act from self -harm thoughts, when required
      • Place the patient in a room located near the nursing module
      • Limit access to windows, unless they are closed or armored, if required
      • Place the patient in the less restrictive environment that allows the necessary level of observation
      • Put gloves, tablets, helmets or straps, to limit mobility and the possibility of self -harm, when required
      • Provide plastic hooks for clothing instead of metal hooks, when required
      • Provide paper dishes and plastic utensils at meals