Domain 11. Safety-protection
Class 3. Violence
Diagnostic Code: 00140
Nanda label: Risk for self-directed violence
Diagnostic focus: Self-directed violence
Nursing Diagnosis: Risk for Self-Directed Violence
Introduction
Nursing diagnosis is the process of assessing and analyzing a person's health status and developing individualized nursing interventions. Additionally, nurses use this process to identify and address risks for self-directed violence, which can include activities such as suicide, homicide, others (e.g., child or elder abuse). Practicing nurses have an important role in assessing, monitoring, evaluating, and intervening in high risk cases. This article will discuss the nursing diagnosis of risk for self-directed violence and its associated considerations.
NANDA Nursing Diagnosis: Definition and Symptoms
NANDA-International (the International Council of Nurses) defines Risk for self-directed violence as: βAt risk for practices or behaviors that directing toward oneself and which could result in harm.β Symptoms associated with this diagnosis include, but are not limited to, suicidal thoughts and behavior, extreme anxiety and depression, threatening language, violent behaviors, accessing or threatening to access dangerous materials (such as weapons), and other such risk-taking behaviors.
Risk Factors
Risk factors can range from personal to environmental in nature, though determinants may vary by age group and cultural context. Personal factors may include biological elements, such as genetics or mental illness, as well as psychological stressors, such as low self-esteem, substance use, and a history of abuse or neglect. Environmental factors can include exposure to media and internet content, religious beliefs, living environment, and the availability of resources (e.g., education, housing, employment).
At Risk Population
Certain populations may be more vulnerable to risk for self-directed violence. This can include individuals suffering from acute or chronic mental health issues, such as depression, schizophrenia, or bipolar disorder, as well as persons currently in treatment for chemical dependency or at risk for substance abuse. It also includes those who belong to certain identity groups, such as LGBTQ+, or those who have experienced traumatic events, recently incarcerated persons, veterans, and those with physical disabilities.
Associated Conditions
There may be several associated conditions or contributing factors that place a person at risk for self-directed violence. These may include conflicting beliefs and values, communication problems, lack of family support or social isolation, poverty, intense negative emotions, bullying, or difficult cultural transition. Essentially, any situation or feeling of being trapped could put one at risk.
Suggestions of Use
Nurses have an important role to recognize signs and symptoms of self-directed violence and take actions accordingly. When conducting an assessment, nurses should be aware of environmental influences and cultural expectations, as well as psychological and social elements, to determine if a person poses an immediate danger to themselves or others. A person must receive the necessary interventions and referrals as needed to ensure their safety.
Suggested Alternative NANDA Nursing Diagnoses
NANDA International provides several related diagnoses that may serve as alternatives to risk for self-directed violence. This includes:
- Noncompliance with Treatment Regimen,
- Social Isolation,
- Risk for Injury, and
- Risk for Self-Mutilation.
Each of these diagnoses is closely interconnected and should be taken into consideration when assessing and intervening for someone at risk for self-directed violence.
Usage Tips
When using the nursing diagnosis of risk for self-directed violence, it is essential to consider all available resources to determine the best course of action. This includes assessments, assistance and referrals, family or social support systems, lifestyle changes, and other treatments or interventions, as appropriate. Additionally, when working with individuals at risk, caregivers and family members should be included in decision-making to help build understanding and trust.
NOC Outcomes
The nursing diagnosing process involves setting measurable goals and objectives. The following are a few key NOC outcomes, or patient centered goals, in relation to this diagnosis:
- Health Maintenance,
- Injury Prevention,
- Cope/Adapt to Physical/Emotional Stressors, and
- Safety Awareness.
The Health Maintenance outcome will focus on promoting overall wellbeing and preventing illnesses. Injury Prevention encourages safe behaviors and avoidance of risk taking activities. The Cope/Adapt to Physical/Emotional Stressors outcome promotes emotional regulation, emotional resilience, and relaxation methods. Lastly, the Safety Awareness outcome addresses promoting healthy interpersonal relationships and providing harm reduction strategies for the individual at risk.
Evaluation Objectives and Criteria
In addition to evaluation objectives, it is also important to set criteria when assessing the effectiveness of nursing interventions. The evaluation criteria are specific knowledge and skills that will be addressed through an intervention. For example:
- Demonstrate ability to identify warning signs of self-directed violence,
- Demonstrate knowledge of risk factors and associated conditions,
- Demonstrate ability to create safe environments, and
- Demonstrate knowledge of support systems and resources.
Measuring progress using these evaluation criteria is a key element for successful implementation of care plans.
NIC Interventions
After discussing the NOC outcomes, it is important to determine which NIC interventions will be used to reach goals. The following list provides a few common interventions for those at risk for self-directed violence:
- Interpersonal therapies to improve relationships,
- Stress management techniques,
- Cognitive-behavioral therapies,
- Support group/peer counseling,
- Referral to specialists,
- Medication management,
- Reality therapy, and
- Substance abuse therapies.
Keep in mind that the number and type of interventions necessary to achieve desired results may vary depending on each case.
Nursing Activities
Nursing activities are necessary to implement interventions. They involve organizing and engaging in practices that support and promote a person's safety. These activities consist of periodic monitoring and documentation, crisis management, communication and education, family meetings, goal setting, psychological assessment and crisis prevention planning, referral to specialists, and follow-up care.
Conclusion
In conclusion, nurses have an important role in assessing and addressing risk for self-directed violence. The nursing diagnose process involves setting attainable goals and appropriate interventions, followed by input from the patient, their families, and other healthcare providers. Caregivers should establish realistic and attainable evaluation objectives and criteria to measure progress.
FAQs
What is the definition of nursing diagnosis of Risk for self-directed violence?
NANDA International defines Risk for self-directed violence as: βAt risk for practices or behaviors that directing toward oneself and which could result in harm."
What are common risk factors?
Risk factors can range from personal to environmental in nature, though determinants may vary by age group and cultural context. Personal factors may include biological elements, such as genetics or mental illness, as well as psychological stressors, such as low self-esteem, substance use, and a history of abuse or neglect. Environmental factors can include exposure to media and internet content, religious beliefs, living environment, and the availability of resources (e.g., education, housing, employment).
Who is considered to be an at-risk population?
At-risk populations may include individuals suffering from acute or chronic mental health issues, such as depression, schizophrenia, or bipolar disorder, as well as persons currently in treatment for chemical dependency or at risk for substance abuse. It also includes those who belong to certain identity groups, such as LGBTQ+, or those who have experienced traumatic events, recently incarcerated persons, veterans, and those with physical disabilities.
Are there other associated conditions of Risk for Self-Directed Violence?
Yes. There may be several associated conditions or contributing factors that place a person at risk for self-directed violence. These may include conflicting beliefs and values, communication problems, lack of family support or social isolation, poverty, intense negative emotions, bullying, or difficult cultural transition. Essentially, any situation or feeling of being trapped could put one at risk.
What are some tips for using the nursing diagnosis of Risk for Self-Directed Violence?
When using the nursing diagnosis of risk for self-directed violence, it is essential to consider all available resources to determine the best course of action. This includes assessments, assistance and referrals, family or social support systems, lifestyle changes, and other treatments or interventions, as appropriate. Additionally, when working with individuals at risk, caregivers and family members should be included in decision-making to help build understanding and trust.
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