NANDA-NursingPlan Area 11 Safety/Defense

NANDA-Nursing Plan 00140 Risk for self-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

00140 Nursing Diagnosis “Risk for self-directed violence”

Nursing Diagnosis: Risk for self-directed violence
Definition: The state of being susceptible to behavior that may harm oneself physically, emotionally, or sexually.

1. cause of suicide

Before thinking about self-harm (harming yourself), let’s think about the causes of suicide.
Below, 2019 (Reiwa 1) Ministry of Health, Labor and Welfare
“Situation of Suicide in 2019 March 17, 2020 Ministry of Health, Labor and Welfare Suicide Countermeasures Promotion Office National Police Agency Community Safety Bureau Community Safety Planning Division” https://www.npa.go.jp/safetylife/seianki/ Excerpt from jisatsu/R02/R01_jisatsuno_joukyou.pdf
・From 1998 to 2011, the number of suicides exceeded 30,000. Since 2012, it has decreased to the 20,000 level.
・Many suicides have diverse and complex causes and backgrounds.
(1) health problems, (2) family problems, (3) economic and living problems, (4) work problems, (5) school problems, and (6) gender problems.

I think that the causes differ depending on the social background, so please check the statistics in your own country.

2. Indications for the Nursing Diagnosis “Risk for self-directed violence”

・Age 45 and over
・Age 15-19
-Low self-efficacy
・Interpersonal relationships (parents and children, family, friends, workplace)
・Economic reasons (debt, single parent, gambling addiction, financial hardship)
・Employment problems (unemployment, relegation, lack of results, failure at work)
Health problems (end of life, long-term chronic illness, mental illness)
・Managers (Executives, Senior Officials, Managers, Business Owners, Professionals)
・suicidal ideation
・Actions suggestive of suicidal ideation: Posting on social media, remarks, withdrawal, writing a will, changing a will, giving up property or belongings, attempted suicide, impulsive, dejected behavior, purchasing a lethal weapon, hoard drugs,
・Acute phase and chronic phase of depression
・Domestic violence, broken family life, social isolation
・Isolation due to environmental changes (transfer, relocation)
・Change or loss of role (retirement, independence of child), helplessness
・Loss of important relationships, death of important others
・Experience of child abuse, suffering from gender identity disorder, suffering from homosexuality
・Young people living in different environments (juvenile training schools, prisons, rehabilitative training centers)

3. 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

・Abstinence from suicide attempts (1408)
(Definition: Suicidal Attempts and Personal Actions to Deter Suicide Attempts)
Self-harm restraint (1406)
(Definition: Behavior of an individual to refrain from intentional self-harm (non-fatal)
・Identity (self-identity) (1202)
(Definition: Distinguishing between self and others and understanding self’s essence)
・Personal health status (2006)
(Definition: General physical, psychological, social and spiritual health status of adults 18 years and older)
・Motivation to live (1206)
(Definition: desire, determination, effort to live)
・Family functions (2602)
(Definition: The ability of the family to meet their needs during the period of change associated with the attached rabbit)

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 ○○.”

・You can accept a change in role (retirement or independence of a child) and gain a new sense of purpose in life.

・Be able to describe the condition of the disease and its future course. You can find a way to spend the rest of your life without regrets. Similarly, family members can also describe ways to watch over the patient.

・Participate in treatment to prevent self-harm.

・You can find your place in society.

*Nurse goals include:

・Encourage the patient to accept the change in role (retirement or independence of the child) and gain a new sense of purpose in life.

・Help patients understand their disease, accept their condition and future course, and find a way to spend the rest of their lives without regrets. It also encourages the family to understand and help them acquire the means to support them.

• Patients with low self-efficacy and unidentified identity (eg, because of abuse) should be encouraged to seek counseling and assist in identity acquisition.

・According to the treatment policy of doctors and counselors for children who are underage and self-harm.

・To help prevent recurrence in the environment surrounding the patient (system and human environment) by family and social resources, and to help each related organization cooperate and acquire knowledge.

4. nursing plan

1) Observation Plan 《OP》

We will draft an observation plan (OP) for each outcome of the linkage.

・ Expression of emotion ・ Expression of hope
・Isolation (lack of human relationships)・Environment and personality in which help is sought
・Remarks about suicidal thoughts・Are you able to control yourself without supervision
・ Confess your suicide plan ・ Collect information on suicide methods ・ Give your possessions to others
・ Inflict serious injuries on your body ・ Accumulate internal medicine
・Intake status of oral medication (whether or not you are taking it as prescribed) ・Using over-the-counter medications that cause mood changes
・ Mental instability due to substance abuse (drugs, alcohol, tobacco)
・Progress of treatment for depression ・Whether or not mental health services are being used

・Can you express yourself as such a person? (Do you have an established identity?)
・ Do you show consistent verbal and non-verbal about yourself
・Are you able to express your own values in words?
・Can you confront your negative image of yourself (whether you blame yourself or drive yourself into a corner)
・ Do you distinguish yourself from others
・Have you established personal boundaries
・Are you fulfilling your social role?

・Disease name ・Painful treatment ・Disease stage and healing process ・Life expectancy ・Pain ・Symptoms
・ADL ・Awareness level ・Emotional stability ・Coping ability
・Family cooperation
・Are you expressing your determination to live?・Are you expressing hope?・Are you constantly making pessimistic statements?・Are you interested in your illness and treatment?
・ Anxiety about the future ・ Burden on family ・ Things left unfinished
・The other world of a close and important person
・ Changes in the environment (transfer/relocation)
・Loss of role (independence of child/retirement) ・Feeling of helplessness
・ Human relationships at school
・ Personality that can’t be said to be unpleasant ・ Feeling mental pain from being bullied

・Understanding of the family’s medical condition (understanding of future progress and things that will be necessary when returning home)
・ Relations with family (whether there is any discord)
・The patient’s behavior towards the family (whether the family was distressed by being violent, intimidating, being the husband’s vice president, etc.)
・Family attachment to the patient
・Does the family have knowledge about social resources
· Do you have the intention to cooperate with your family to support your recuperation life
・Whether family members have acquired nursing care skills to support recuperative life

2) Action plan 《TP》

・If your self-efficacy is low and you are pessimistic, saying, “I shouldn’t be here,” I will listen and accept it. Understand the background of such cases and act as a bridge to doctors and counselors.
・Tell them that no one is better off without them.
・For patients who are worried about the future due to illness, think together with their families about what they can do with the rest of their lives.
・If self-care is difficult due to lethargy, help with self-care. Take care of cleanliness.
・Improve the environment and do not leave weapons or chemicals within reach.
・If you have distressing symptoms such as pain, hallucinations, delirium, or dyspnea, report them to your doctor. In addition, efforts should be made to provide palliative care.
• If there is self-injury due to substance abuse (drugs, alcohol, tobacco), keep the subject substance away from the patient to avoid abuse.

3) Education plan 《EP》

Encourage participation in self-help groups if substance abuse leads to mental instability and self-harm.
List of self-help groups|NPO ASK
・Tell the patient that he or she will continue to receive medical care after being discharged from the hospital, and that he or she can consult experts such as “Ministry of Health, Labor and Welfare: Heart Dial 0570-064-556” when in trouble. Tell them that they don’t have to worry alone.
・Explain to the family the circumstances leading up to the self-injury and how they can be involved in preventing the recurrence of the self-injury, according to the doctor’s treatment plan. (Check if the doctor or counselor’s explanation is understood, and if they do not understand it correctly, encourage them to understand it correctly.)
・If you have lost your motivation to live due to an illness, etc., talk about the various options you have for the rest of your life, such as giving examples of people who are still living with purpose even after being notified, and increase their motivation to live. Involved so that you can have it.

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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