00289 Suicidal Behavior Risk

Domain 11: security/protection
Class 3: violence
Diagnostic Code: 00289
Nanda label: suicidal behavior risk
Diagnostic focus: suicidal behavior
approved 2020 • Evidence level 3.2

NANDA Nursing Diagnosis Definition

Nanda nursing diagnosis « suicidal behavior risk ” is defined as: susceptible to self -colored acts associated with the intention of dying.

Risk factors

Behavioral factors

  • Apathy
  • Difficulty requesting help
  • Difficulty to face unsatisfactory execution
  • Difficulty expressing feelings
  • INEFICIAL SELFGESTION OF CHRONIC PAIN
  • Inephic impulse control
  • Autolesive behavior
  • Personal negligence
  • Drug accumulation
  • Inappropriate use of substances

psychological

  • Anxiety
  • Depressive symptoms
  • Express deep sadness
  • Express frustration
  • Express loneliness
  • Hostility
  • Low self -esteem
  • Imported duel
  • Dimonra perception
  • Failure perception
  • Informs excessive guilt
  • Informs defenselessness
  • Informs despair
  • Informs sadness
  • Suicide ideas

Situational

  • Easy access to weapons
  • Loss of independence
  • Loss of personal autonomy

Social factors

  • Dysfunctional family processes
  • Inadequate social support
  • Inappropriate pressure of colleagues
  • Legal difficulties
  • Social deprivation
  • Social devaluation
  • Social isolation
  • Violence not attended by others

Risk population

  • teenagers
  • Teenagers living in orphanages
  • People at economic disadvantage
  • People who change a testament
  • People who experience situational crises
  • People who face discrimination
  • People who donate possessions
  • People who live alone
  • People who obtain potentially lethal materials
  • People who prepare testament
  • People seeking frequently care because of vague symptomatology
  • People with discipline problems
  • People with family history of suicide
  • People with a history of suicide attempt
  • People with a history of violence
  • People with sudden euphoric recovery of severe depression
  • Institutionalized people
  • Men
  • American native people
  • Older adults

Associated problems

  • Depression
  • Mental disorders
  • Physical condition
  • Terminal condition

Suggestions of use

When there is a risk of suicide (for example, suicidal ideas, suicide plan), suicide risk should be used instead of self -directed violence risk, which is less specific.

Suggested alternative diagnostics

  • Automutilation, risk of
  • Self -directed violence, risk of

NOC Results

Note : The following result can be used to measure the occurrence of the diagnosis:

  • Suicide self -convenience: personal actions to suppress gestures or attempts to take your life

Note : The following results are associated with some of the suicide risk factors:

  • Impulses self -control: Self -limitation of compulsive or impulsive behaviors
  • Emotional balance: appropriate adjustment of the predominant emotional tone in response to circumstances
  • Family operation: Family system capacity to meet the needs of its members during development transitions
  • Depression level: severity of the melancholic mood and the loss of interest in life

Evaluation objectives and criteria

  • • Suicide risk decreases, as evidenced by emotional balance, suicide self -consent and impulse control.
  • • Demonstrates suicide self -containment, manifested by the following indicators (specify from 1 to 5: never, sometimes, sometimes, often or usually):
    • Get help when you need it
    • Verbally express your suicidal ideas
    • It refrains from looking for means to commit suicide
    • It refrains from giving goods
    • It refrains from trying to commit suicide
    • Get treatment for depression or substance abuse
  • Other examples

    • • Verbally express the desire to live
    • • Verbally expresses feelings of anger
    • • Contact adequate people if suicidal thoughts occur

    NIC Interventions

    • Psychological advice: Application of an interactive process of help focused on the needs, problems or feelings of the patient and their loved ones, to improve or strengthen the coping, solution of problems and interpersonal relationships
    • Inspiration of hope: Facilitation of the development of a positive perspective in a given situation
    • Behavior management: Self -harm: Patient helps to reduce or eliminate self -confidence or self -conflict behaviors
    • mood management: provision of security, stability, recovery and maintenance, to a patient who normally experiences a depressed or elevated mood
    • Improvement of the Support System: Facilitation to the patient of support by family, friends and the community
    • Suicide prevention: Reduction of the risk of self -inflicted damage with the intention of ending life

    Nursing Activities

    • Nursing activities focus on preventing suicide and modifying risk factors.

    Valuations

    • • As often as indicated, but at least daily, value and document the patient’s suicide potential (specify the intervals)
    • • Evaluate behaviors that indicate suicidal thoughts or plans (for example, give away and get rid of goods)
    • • (NIC) suicide prevention:
      • Monitor the side effects of medicines and the desired results
      • During the admission procedure, register the newly hospitalized patient and their personal belongings to find potential weapons or weapons, as required
      • Record the environment routinely and withdraw hazardous articles to release it from dangers
      • Watch the patient during the use of potential weapons (for example, razor)
      • Observe, record and inform any change in the state of
      • mood or behavior that could imply an increase in suicidal risk, and document the results of the usual surveillance controls
      • Review the patient’s mouth after managing medications, to make sure that he is not “keeping” and then try to ingest an overdose

    Patient and family education

    • • Indicate visitors what are the prohibited items (for example, razors, scissors, plastic bags)
    • • (NIC) suicide prevention:
      • Explain to the patient, relatives and closest people, suicide precautions, as well as relevant security aspects (for example, purpose, duration, expectations and behavioral consequences)
      • Involve the family in the plans for hospital discharge (for example, instruction on disease and medicines, the recognition of an increase in suicidal risk, the patient’s plan to handle thoughts of damaging himself, resources resources community)

    Collaboration activities

    • • Organize a multidisciplined meeting to develop a patient care plan, or to determine modifications to suicide precautions
    • • (NIC) suicide prevention:
      • Channel to the patient with a mental health specialist (for example, psychiatrist or a specialized nursing professional) to evaluate and treat suicidal ideas and behavior, if necessary
      • Administer medications to reduce anxiety, restlessness or psychosis, and stabilize mood, if necessary
      • Help the patient identify a support network of people and resources (for example, priest, relatives, caregivers)
      • Communicate the risk and other relevant security issues to other care suppliers

    Others

    • • Establish precautions for suicide, as required (for example, 24 -hour assistance)
    • • Ensure the patient to be protected against suicidal impulses until he is able to control, through the patient’s constant observation (even if privacy is lost); (b) Frequent verification of the patient, and (c) take suicidal ideas seriously
    • • Encourage the patient to express anger
    • • Talk to the patient and family about the role of anger in self -harm
    • • Require the patient to use the hospital robe instead of their own clothes, since there is a risk of getting out of the facilities
    • • Apply restrictions and insulation, as required, but place the patient in the less restrictive environment that allows the basic level of observation
    • • Perform searches in the room according to institutional policy
    • • (NIC) suicide prevention:
      • Make a contract (verbal or written) with the patient, if necessary, of “not self -harm” for a certain period, and endorse the contract at specific intervals
      • Relate to the patient at regular intervals to convey interest and openness, and give him the opportunity to talk about his feelings
      • Avoid repeated discussions about suicidal history and keep the talks oriented towards the present and the future
      • Limit access to windows, unless they are closed or that are unbreakable, as required
      • Consider strategies to reduce isolation and the opportunity to act based on harmful thoughts (for example, use a vigilant)

    At home

    • • Some of the previous activities can be adapted to be used at home
    • • Teach the family techniques to establish limits
    • • Teach the family and the closest people to recognize behaviors that indicate an increase in risk (as verbal expressions of “I’m going to kill” or “I would like to be dead”, and withdrawal)
    • • (NIC) suicide prevention: consider the hospitalization of the patient if it has serious suicidal behavior risks

    Babies and Children

    • • Evaluate the presence of automation and eating disorders
    • • Encourage schools to establish programs for suicide prevention

    Older people

    • • Be especially attentive to suicidal ideas in the elderly
    • • Evaluate the causes of depression (financial problems, medicines) and intervene properly
    • • Evaluate the existence of multiple or accumulated recent losses
    • • Evaluate the support system
    • • Promote physical activity