NANDA-NursingPlan Area 11 Safety/Defense

NANDA-Nursing Plan 00138 Risk for other-directed violence

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

00138 Risk for other-directed violence


Nursing Diagnosis: Risk for other-directed violence
Definition: The state of being prone to behavior that can physically, emotionally or sexually affect others.

1. Indications for the Nursing Diagnosis `Risk for other-directed violence”


・antisocial forces
・Substance abuse (illegal drugs, alcohol, thinner, etc.)
・ Threatening behavior (loud, threatening remarks or actions, violent behavior, hitting objects)
・Nervous system disorders (abnormal brain waves, head injuries, convulsive disorders)
Hyperactivity (irritability and restlessness)
・History of arson
・Has been child abused or has a history of child abuse
・Domestic violence, elder abuse
Attempted rape or history of rape
・ Carrying a weapon
・Mental instability (perinatal period, psychosis)

2. setting a goal


Goal setting by linkage (listed in the second half of the NOC)
* “Linkage” has the role of connecting “NANDA”, “NIC” and “NOC” (link means “connection”).


1) Linkage achievements

・Aggression restraint (1401)
(Definition: behavior of an individual to restrain aggressive, belligerent, or destructive behavior towards others)
・Abusive self-restraint (1400)
(Definition: Individual behavior that inhibits abusive behavior and neglect towards others)
・Level of delirium (0916)
(Definition: severity of short-term, reversible impairment of consciousness and cognition)
・Risk Control: Drug Use (1904)
(Definition: Individual behavior to understand, prevent, eliminate or reduce health threats associated with drug use)
・Risk Control: Drinking (1903)
(Definition: Individual behavior to understand, prevent, eliminate or reduce health threats associated with alcohol consumption)

2) Goal

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

・Describe and implement methods to control aggression.

・You can participate in the addiction improvement program.

• Caregivers and caregivers can make statements about abuse. Describe self-control to avoid abuse.

*Nurse goals include:

• Control aggression and prevent violent behavior.

・Addiction utilizes social resources and leads to actions to overcome addiction.

・Understand the background of abuse, eliminate the cause and solve the problem, and encourage behavioral change to prevent abuse.

3. nursing plan


1) Observation Plan 《OP》

We will plan according to the results of the linkage


Aggression restraint〉
・Are you able to recognize situations in which you feel angry, and are you able to control your impulses in those situations?
・Are you aware of situations in which you feel frustrated, and are you able to control your impulses in those situations?
Awareness of hostile situations and ability to control impulses in those situations
Are you aware of your responsibility to exercise self-control?
・Have you found effective conflict resolution skills?
・Whether animals are harmed
・Do you have a weapon?
Factors that contribute to abusive behavior
・Can you describe how to deal with stress other than abuse?
・ Do you understand appropriate role behavior?
Do you understand how to provide proper care?
Are you trying to restrain yourself from emotionally abusive behavior?
If you are on treatment, are you continuing treatment?
・Do you recognize effective local resources (nursery school, family support, etc.)?
・Unrest
·excitement
・hallucination
・Delusion
・Changes in consciousness level
・cannot maintain concentration
・Own drinking pattern and amount
A history of loss of consciousness known as a blackout
・History of violent incidents while drinking alcohol
・Are there any intentions to adjust the drinking control method, and are there any measures in place?
・Participation in support groups
・Frequency of drug use
・Use history, drugs used
・Experience of loss of consciousness or clouding of consciousness due to drug use
・History of violent incidents during drug use
・Monetary trouble
・Are there any intentions to adjust the drinking control method, and are there any measures in place?
・Participation in support groups

2) Action plan 《TP》

・Helping you find effective conflict skills.
・If care for childcare is insufficient, go together and aim to acquire skills.
・Environmental improvements should be made to create a quiet and calm environment in which delirium is unlikely to occur.
・During delirium, do not place weapons within reach so as not to lead to dangerous behavior.

3) Education plan 《EP》

・Explain that intimidation and violence against others are subject to punishment under the Penal Code, and think together about what to do to prevent the same thing from happening again.
* Criminal law: assault crimes, injury crimes, coercion crimes
・Have a counselor intervene and explain programs and treatments for behavior improvement.
・Think together about how to avoid infringing on the personal space of others.
・Think together about what effective ways to release anger and stress.
・Take a look at the background of elder abuse and think together about ways to eliminate the causes of stress.
・Explain that child abuse is a crime under the Abuse Prevention Law, Child Welfare Law, and Penal Code, and think together about what can be done to prevent recurrence.
* Criminal law: assault crimes, injury crimes, coercion crimes, guardian obscenity and guardian sexual intercourse crimes, guardian abandonment crimes, etc.
*Child Welfare Law: Acts that involve or cause a child to commit adultery are punishable by imprisonment with work for up to 10 years or a fine of up to 3 million yen.
is a joint course (both)
* Abuse Prevention Law: There are penalties for disobeying a restraining order. No other penalties.
• Look at the causes of parental stress behind the abuse and get involved to alleviate the stress.
For example, in the case of childcare stress, you can try to reduce your burden by enlisting the cooperation of other family members and family support, and by making good use of retort packs of baby food. If the child has insomnia at night, consider increasing the child’s daytime activity so that he/she can sleep at night. If the child cries and has no time to rest if he/she is not always present, create a safe environment where the child can play alone so that he or she does not have to be present or does other things while the child is watching from a distance. As a result, you can make time for yourself to rest.
・Seek the understanding of the people around the person who is abusive or violent, and think together about what kind of coping method is appropriate.
・Introduce abuse clinics and recidivism prevention programs run by counselors, and work to prevent recurrence.
・Propose that social resources can be used when violence is caused due to alcohol dependence.
・Encourage consultation at specialized medical institutions, such as hospitals and clinics that advocate alcohol dependence treatment.
• Encourage participation in dependent party meetings called “self-help groups”.
(Danshukai and AA are representative groups for alcohol dependence.)
・Promote the use of private counseling rooms.
・Promote the use of private dependency recovery support facilities.

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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