NANDA-NursingPlan Area 11 Safety/Defense

NANDA-Nursing Plan 00151 “Self-mutilation” “Risk for self-mutilation”

Note: This article was translated from Japanese using translation software. Please use at your own risk, as there may be unnatural points in the content or differences in content due to cultural differences.

Area 11 “Safety/Defense”
Category 3 Violence Use of excessive force or ability that results in injury or abuse

Nursing Diagnosis “Self-mutilation” “Risk for self-mutilation”

Nursing Diagnosis: Self-mutilation
Definition: The state of intentionally harming oneself and causing tissue damage without being fatal in order to relieve tension.


Nursing Diagnosis: Risk for self-mutilation
Definition: The state of being prone to intentionally harming oneself and causing tissue damage without being fatal in order to relieve tension.

1. Consider “Self-mutilation”

This is how Wikipedia introduces self-harm.
https://ja.wikipedia.org/wiki/%E8%87%AA%E5%82%B7%E8%A1%8C%E7%82%BA

1) self-harm

Self-harm (formerly self-mutilation) is the intentional act of injuring one’s own body or ingesting poison , and is considered suicide due to its low lethality. different from There are acts such as wrist cutting, burning the skin with a lighter or cigarette (guts burning), pulling out hair, and punching walls until injured. It is believed to be positively correlated with abusive trauma, psychological abuse and eating disorders, low self-esteem and perfectionism. Antidepressants and other drugs are also known to cause self-harm.

2) Distinction between self-harm and suicide

Self-harm and suicide are strictly different. Misinterpreting self-harm as suicidal has been shown to hinder treatment (Lineham, 1993a [bibliographic specific details required]).
Suicide is motivated by the desire to end consciousness, to be forever away from pain. Only 1.4% of people commit suicide using the method of cutting, which is common in self-harm.
Self-injury, as many self-injured individuals self-report, is for the purpose of relieving and changing psychological distress, while a minority finds the robotic emotional emptiness to be painful and an escape. report . In self-harm, except for extreme cases such as cutting, burning, punching, hitting the head, tattooing, piercing, hair pulling, etc., the probability of death is low.. Instead, more intense wounding suggests a loss of control over behavior, which is more self-mutilation than self-mutilation.

3) causes self-harm

① Mental illness
Borderline Personality Disorder and Dissociative Identity Disorder are the most suspected forms of self-harm. The DSM-IV-TR includes “repeated suicidal acts, gestures, threats, or self-harm” as the fifth diagnostic criterion for borderline personality disorder. Other possible causes include depression, bipolar disorder, histrionic personality disorder, narcissistic personality disorder, and obsessive-compulsive disorder. It may also be diagnosed as schizophrenia.
Psychiatrically, self-harm is considered to be a secondary symptom of mental disorders such as personality disorders and dissociative disorders, and it is not considered to occur alone. However, in reality, it is known that the seriousness of symptoms does not necessarily match the severity of self-harm. This seems to depend on whether or not the person establishes an “identity as a self-harming person (wrist cutter).” This was once pointed out by sociologists in the relationship between many mental patients and hospitals, and it is said that friendships in hospitals become regular and people lose the awareness that they are healthy. be done.
②Drugs and alcohol
Associated with alcohol and drug abuse. Among 10-24 year olds, SSRI antidepressants were found to increase self-harm, with self-harm occurring twice as often, especially when starting at a higher dose.

③Genetic and biochemical factors

Serotonin deactivation in the brain has also been implicated as a cause of self-harm. However, it is said that the biochemical factor is also formed by trauma in childhood, so at present there is no conclusion as to whether it is the same as the genetic factor.
Genetic factors such as alcoholism are thought to be factors that make self-harm more severe.
④ Lack of self-ownership of the body
In some cases, the sense of ownership of one’s own body is weak, and the problem of underlying pathology can be pointed out, but the direct causal relationship with self-harm is unclear. The view that a vague perception that one’s own body is not one’s own due to socio-cultural institutions such as patriarchy is an inciting factor is not correct. There are no credible reports that self-harm is more common in countries where patriarchy is as strong as Islamic societies, and where it is still very strong today, compared to developed countries such as Japan.
⑤Relationship with abuse
Abused people do not necessarily self-harm.
In January 2006, Kagoshima University announced a survey of 1,626 first- and second-year students attending five universities in Kyushu. Of the 1,592 respondents (831 males and 761 females), 120 (7.5%) had experienced self-harm. The risk of hurting behavior is 8.7 times higher than those who do not, 5.8 times higher for “experienced sexual violence by a third party,” 5.5 times higher for “experienced neglect by teachers or friends,” and 5.5 times higher for “experienced by parents.” 4.2 times that they have never been petted

Treatment: In Europe and the United States, cognitive behavioral therapy is the main treatment. This is accomplished by learning less risky alternatives to self-harm.

2. Nursing Diagnosis Self-mutilation Indications

・Psychiatric disorders
・Personality disorder (see ✩1) #parson
・Dissociative disorders (see ✩2)
・depression
・Bipolar disorder
・ Histrionic Personality Disorder (See ✩3)
・ Narcissistic personality disorder (see ✩4)
・Obsessive-compulsive disorder
・Alcohol abuse, drug abuse
・In the age group of 10 to 24 years old, oral SSRI antidepressants
・Patriarchy society
・Acts that hurt yourself: wrist cuts, biting, intentional burns,
・Home environment (inappropriate parent-child communication, weak relationship)
・Living environment (foster parents, groups, facilities)
・domestic violence
・Puberty, changes in body image

✩ 1 personality disorder

Since 2003, the diagnosis of personality disorder has been changed from the diagnosis of “personality disorder” to “personality disorder”. (“DSM-IV-TR Diagnostic and Statistical Manual of Mental Disorders,” revised 2003)
Diagnostic classifications include the World Health Organization’s “ICD-10” and the American Psychiatric Association’s “Diagnostic and Statistical Manual of Mental Disorders (DSM).”
Personality is defined by the World Health Organization as “various states and patterns of behavior in an individual’s lifestyle and manner of relating to others [1].”
The WHO also defines personality disorders as “deep-rooted and persistent patterns of behavior that are culturally biased from those of the average human being [1]. Personality disorders manifest during childhood and adolescence and persist. [1] Therefore, if it occurs in adulthood, there may be other causes associated with stress or brain disease [1][8].”
To put it bluntly,
・Personality can be said to be personal life ability and adaptability to society including the following two.
・Personal lifestyle: way of thinking, habits, way of perceiving things, education
・Behavioral patterns in relation to others: behavior, how to relate to people, reactions,
Disorders that lead to uncommon behavior in these cases are “personality disorders”.
It means that you cannot adapt to society due to personality problems.
According to WHO, this “personality disorder” develops and persists during childhood and adolescence. “Onset in adulthood suggests a different disease.”
From the point of view of its onset from childhood to adolescence, it can be seen as an obstacle in the formation of personality. The environment and elements necessary for character formation are not in place, such as being in an environment where general ways of thinking, customs, and manners are not taught, or being unable to acquire them due to impaired comprehension. It can also be said that it is a failure that occurs because

✩ 2 Dissociative disorders

Excerpt from the Ministry of Health, Labor and Welfare’s “Let’s start with what we know: everyone’s mental health”
https://www.mhlw.go.jp/kokoro/know/disease_dissociation.html
Dissociative disorder is a state in which a person loses a sense of who they are. Our memories, our consciousness, our perceptions and our identities (self-identity) are inherently united. Dissociation is the temporary loss of the ability to bring these sensations together. For example, some memories of the past may be lost, some perceptions may be lost, and emotions may be numbed. There are various symptoms, such as a memory loss of a certain event, feeling as if you are in a capsule without a sense of reality, and being in a place you do not know before you know it.
In a dissociated state, in addition to the loss of some memories and the lack of some perceptions that cause emotional paralysis, new perceptions and actions that are not normally experienced may appear. Abnormal behavior (fugue, etc.) and the formation of new personalities (multiple personality disorder, shamanism, etc.) are typical examples. In multiple personality disorder (dissociative identity disorder), in which multiple personalities appear within oneself, when one personality is manifesting, it is often the case that there is no memory of the other personality, leading to various difficulties in daily life. come out.
If these dissociation phenomena are mild and temporary, they may appear in healthy people. When these symptoms are severe and interfere with daily life, they are called dissociative disorders.
The cause is said to be related to stress and trauma. There are many different types of this trauma. Some are transient, such as disasters, accidents, and assaults, while others are chronic, recurring, such as sexual abuse, long-term confinement, and combat experiences. For example, there are various symptoms such as completely missing memory of a certain event, feeling as if you are in a capsule without a sense of reality, and being in a place you do not know before you know it.

“So… it’s complicated.”
In summary, dissociative disorders have two patterns of symptoms. One is a pattern in which the ability to integrate various perceptions weakens, causing partial memory loss, lack of perception, and emotional numbness. The other is the opposite of the former, which is lacking. pattern that emerges.

✩ 3 Histrionic Personality Disorder

Wikipedia defines it as follows.
https://ja.wikipedia.org/wiki/%E6%BC%94%E6%8A%80%E6%80%A7%E3%83%91%E3%83%BC%E3%82%BD%E3 %83%8A%E3%83%AA%E3%83%86%E3%82%A3%E9%9A%9C%E5%AE%B3
Histrionic personality disorder is characterized by demanding excessive attention from friends, excessively playing the role of a victim without being aware of it, switching between roles too quickly so that others feel that they are pretending, He keeps away from interpersonal relationships because his provocative style does not suit those around him. He craves new and exciting things and tends to find everyday life boring.
This is often attributed to abuse, growing up without the love and affection of their parents, or still not being recognized by those around them.
Feature:
① Extraversion
Characterized by strong extroversion. At the same time, the inner world is thin and the establishment of identity is weak. Therefore, it is highly suggestible and easily influenced by others. The attention of others is the standard of self, and it uses superficial means such as appearance to do so.
② Lies
A psychiatric disorder associated with histrionic personality disorder is pseudologia fantastica, the so-called lyrical disorder.
In lyrism, people sometimes lie based on a desire to appear more than they really are. It speaks of delusions of desire as if they were facts. We wear makeup to look better, and in the same way we lie to look better. Name-drop during conversations as if you were acquainted with a celebrity or powerful person. With high intelligence, they may fall within the category of power-oriented people who like to stand and play, but many are unable to coordinate their interests with those around them, and may commit crimes such as fraud.

✩ 4 Narcissistic personality disorder

Narcissism is the state of loving oneself or seeing oneself as a sexual object. The name comes from the Greek myth of Narcissus. A pattern of thought that excludes others from self-infatuation and attachment.
Wikipedia introduces it as follows.
https://ja.wikipedia.org/wiki/%E8%87%AA%E5%B7%B1%E6%84%9B%E6%80%A7%E3%83%91%E3%83%BC%E3 %82%BD%E3%83%8A%E3%83%AA%E3%83%86%E3%82%A3%E9%9A%9C%E5%AE%B3
According to the Mayo Clinic, Narcissistic Personality Disorder is characterized by dramatic and emotional behavior and includes the following main symptoms:
Symptoms of Narcissistic Personality Disorder
• Believe that you are better than others
• Daydream about power, success, and self-attraction
• Exaggerate achievements and talents
• Expect constant praise and admiration
• Believe that you are special and act accordingly
• Failure to recognize other people’s emotions and feelings
• Expect people to follow your ideas and plans
• take advantage of people
• Be haughty of people you feel are inferior
• Thinking you’re jealous
• be jealous of others
• troubled in many relationships
• Set unrealistic goals
• Easily hurt and feel rejected
• Has a fragile and fragile self-esteem
• appear unsentimental and callous
Individuals with Narcissistic Personality Disorder tend to display arrogance, display superiority, and continue to seek power. They crave admiration, but lack empathy for others. These qualities are generally attributed to defenses against powerful inferiority complexes and feelings of never being loved. People with Narcissistic Personality Disorder have an inherently high sense of self-worth that they are better than others, but in reality they have a fragile and fragile self-esteem. Unable to handle criticism, often seeks to compensate for internal vulnerability by scorning and disrespecting others in an attempt to justify self-worth. This is precisely what characterizes the narcissistic personality in contrast to other psychological conditions with painful levels of self-worth. Narcissism is narcissism, the state of loving oneself or seeing oneself as a sexual object.

2. Indications for Nursing Diagnosis “Self-mutilation” (Repeated)

・Psychiatric disorders
・Personality disorder (see ✩1)
・Dissociative disorders (see ✩2)
・depression[
・Bipolar disorder
・ Histrionic Personality Disorder (See ✩3)
・ Narcissistic personality disorder (see ✩4)
・Obsessive-compulsive disorder
・Alcohol abuse, drug abuse
・In the age group of 10 to 24 years old, oral SSRI antidepressants
・Patriarchy society
・Acts that hurt yourself: wrist cuts, biting, intentional burns,
・Home environment (inappropriate parent-child communication, weak relationship)
・Living environment (foster parents, groups, facilities)
·domestic violence
・Puberty, changes in body image

3. setting a goal

Goal setting by linkage (listed in the second half of the NOC)

1) Linkage achievements

Self-harm restraint (1406)
(Definition: Behavior of an individual to refrain from intentional self-harm (non-fatal))
・Tissue integrity: skin and mucosa (1101)
(Definition: normal skin and mucosal tissues and normal physiological function)
・Identity -: self-identity (1202)
(Definition: Distinguishing between self and others and understanding self’s essence)
・Family climate (2601)
(definition: family capacity to provide a supportive environment, characterized by family relationships and goals)

2) Goal

The goal is to make the patient the subject.
Instead of saying “Nurses can do ○○”,
For example, “The patient will be able to do ○○.”

・Continuous treatment and counseling

・ You can talk to someone you trust without worrying about it alone.

・You can state what you need for your own growth.

*Nurse goals include:

・Provide a safe environment (physical and personal) and support so that they can lead a calm life both mentally and physically.

・Collaborate with relevant organizations and provide support so that interpersonal and family relationships are sound.

・Continue treatment, counseling, and support group efforts to help overcome mental instability.

4. nursing plan

1) Observation plan <OP> Plans will be made according to the outcome of the linkage

<Self-harm self-restraint 1406>

・Do not collect tools (tools) for self-harm or keep them within reach
・Are you aware of the risks in the surrounding environment?
・Are you avoiding dangerous environments (physical environment, human environment)?
・Recognizing emotions that trigger impulsive behavior (anger, sadness, helplessness, etc.)
・Are you aware of the consequences of impulsive behavior?
・Are you controlling your impulses?
・Are you actually self-harming?
・Is there anyone to talk to?
・Are you in a support group?
・Whether you are continuing treatment such as psychosomatic medicine, and whether you are continuing oral medicine
・Are you able to control yourself without supervision?


<Tissue integrity: mucosal skin 1101>
→ Observe whether or not there is damage to the skin due to self-injury, and if so, the degree of damage.
・ Skin sensation ・ Scar tissue ・ Bleeding ・ Scabs ・ Skin lesions ・ Mucous membrane lesions ・ Erythema ・ Pale ・ Necrosis

<Identity: Identity 1202>
・Is the identity established?
・Are you able to express your values in words?
・Whether you have excessive delusions about your own worth or whether you are lying
・Are you fulfilling your social role?
・Are you aware of the disharmony that arises between interpersonal relationships and the mind of the individual?

<Family social climate 2601>
・Is your home kept clean?
・Does the family feel that they care for each other?
Do family members share problems with each other?
Are families solving problems together?
・Is privacy between family members secured?
・Are you participating in local events? (Are you isolated?)

2) Action plan 《TP》

・Environmental maintenance to create a safe and calm environment.
・Confirm the distribution of medicines and oral medicines for the continuation of treatment.
・ Provide ADL assistance, including necessary hygiene care.
・Occasionally call out and watch.
・In order to establish a good family relationship, collect information not only about the patient but also about the functions of the family, and if necessary, cooperate with related organizations.
・ Accompany the patient to the counseling room or examination room (go with them to reassure them).

3) Education plan 《EP》

・Speak in a way that is easy to understand.
・There is no need to worry too much about the evaluation of others, and think together about what makes you unique (approach to establish identity).
・In order to build a good family relationship, collect information not only about the patient but also about the functions of the family, and extract the causes of self-harm. Think about each problem together so that everyone in the family can share their problems and solve them. Cooperate with related organizations if necessary.
For each of the causes of self-harm (e.g., family relationships, other relationships, lack of adaptive capacity, psychiatric disorders, which may be complicated by the intervention of others) , intellectual disabilities, etc.) will be approached in collaboration with experts. We will share information so that we can unify our response to patients.
• If abuse is in the background, focus on both the abuser and the abused and respond accordingly. Abusers may have experience of being abused themselves and may not know how to raise their children themselves. The same applies to the abuse of the elderly, so we will consider together why they abuse them and provide the necessary knowledge each time.

References

T. Heather Hardman Shigemi Kamitsuru. (2016). NANDA-I Nursing Diagnosis Definition and Classification 2015-2017. Igaku Shoin.
Okaniwa, Yutaka. (2012). Review book for nurses and nursing students. Medic Media Co., Ltd.
Yutaka Okaniwa. (2019.3). Year Note 2020. Medic Media Co., Ltd.
Yuko Kuroda (Translation). (2015). Nursing Outcome Classification (NOC) Original 5th Edition Indicators and Measurement Scales for Measuring Outcomes. Elsevier Japan K.K.
Yamaguchi Toru, Kitahara Mitsuo, Fukui Tsuguya. (2012). Today’s treatment guidelines.
Yumiko Ohashi, Hajime Yoshino, Naoki Aikawa, Sumi Sugawara. (2008). Nursing Learning Dictionary (3rd Edition). Gakken Co., Ltd. (Gakken).

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