Nursing Diagnosis: Application to Clinical Practice
11th Edition

Risk for Self-Harm*
DEFINITION
Risk for Self-Harm: State in which a person is at risk for inflicting direct harm on himself. This may include one or more of the following: self-abuse, self-mutilation, suicide.
DEFINING CHARACTERISTICS
Major (Must Be Present, One or More)
Expresses desire or intent to harm self
Expresses desire to die or commit suicide
Past history of attempts to harm self
Minor
Reported or observed
  • Depression
  • Helplessness
  • Substance abuse
  • Hostility
  • Hopelessness
  • Hallucinations/delusions
  • Emotional pain
  • Agitation
  • Poor self-concept
  • Lack of support system
  • Poor impulse control
RELATED FACTORS
Risk for Self-Harm can occur as a response to a variety of health problems, situations, and conflicts. Some sources are listed next.
Pathophysiologic
Related to feelings of helplessness, loneliness, or hopelessness secondary to:
Disabilities
Terminal illness
Chronic illness
Chronic pain
Chemical dependency
Substance abuse
New diagnosis of positive human immunodeficiency virus (HIV) status
Mental impairment (organic or traumatic)
Psychiatric disorder
  • Schizophrenia
  • Adolescent adjustment disorder
  • Personality disorder
  • Post-trauma syndrome
  • Bipolar disorder
  • Somatoform disorders
Treatment-Related
Related to unsatisfactory outcome of treatment (medical, surgical, psychological)
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Related to prolonged dependence on
  • Dialysis
  • Ventilator
  • Chemotherapy/radiation
  • Insulin injections
Situational (Personal, Environmental)
Related to:
Incarceration
Depression
Ineffective coping skills
Parental/marital conflict
Substance abuse in family
Child abuse
Real or perceived loss secondary to:
  • Finances/job
  • Death of significant others
  • Separation/divorce
  • Threat of abandonment
  • Status/prestige
  • Someone leaving home
Related to wish for revenge on real or perceived injury (body or self-esteem)
Maturational
Adolescent
Related to feelings of abandonment
Related to peer pressure
Related to unrealistic expectations of child by parents
Related to depression
Related to relocation
Related to significant loss
Older Adult
Related to multiple losses secondary to:
  • Retirement
  • Illness
  • Social isolation
  • Significant loss
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Focus Assessment Criteria
The nurse must be able to differentiate between the diagnoses of Risk for Suicide and Risk for Self-Mutilation or Self-Abuse. Although initially they may appear (in action) or sound (in statements) the same, the distinction lies in the intent. Self-mutilation and self-abuse are pathologic attempts to relieve stress (temporary reprieve), whereas suicide is an attempt to die (to relieve stress permanently). The nurse will be able in the assessment to gather data that enable him or her to distinguish which diagnosis is appropriate for the client. It is prudent to remember that some clients may become so self-harmful that they eventually die, even though they are not intentionally suicidal.
Subjective Data
Assess for Risk Factors
Psychological status
Present concerns
Have you experienced a severe stressor recently?
How are you feeling?
Do you want to hurt yourself?
Can you tell me the reason?
Do you want to die or just have the pain (thoughts/feelings) go away?
Assess for a suicide plan.
  • Method: Is there a specific plan (eg, pills, wrist-slashing, shooting)? Plans for rescue?
  • Availability: Is the method accessible? Is access easy or difficult?
  • Specificity: How specific is the plan?
  • Lethality: How lethal is the method?
Feelings of
  • Hopelessness
  • Guilt/shame
  • Chemical dependency/substance abuse
  • Anger/hostility
  • Isolation/abandonment
  • Helplessness
  • Impulsivity
Assess if person is suffering from withdrawal or is under the influence. Chemical use lowers cognition ability and raises the level of impulsivity.
History of psychiatric problems
Previous history of self-harm
  • Methods
  • Lethality
  • How recent
  • Number of times
  • Ensures rescue will be made
Outpatient follow-up support system
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Medical status
Acute or chronic illness—how is it affecting life?
Prescribed drugs
  • What is person using?
  • Does he or she take it according to directions?
Sources of stress in past environment
Job change/loss
Failure in work/school
Threat of financial loss
Divorce/separation
Death of significant other
Illness/accident
Alcohol/drug use in family
Parental rejection
Dysfunctional family dynamics
Physical, psychological, sexual abuse
Unrealistic expectations
  • Of child by parent
  • Of parent by child
  • Of self
Severe trauma
Sources of stress in current environment
Any of the above (past environment)
Threat of criminal prosecution
Alcohol/drug use by person
Role change/responsibilities
Any threat to self-concept (real or perceived)
Assessment of person’s awareness of self-harm activities
Acknowledgment or denial—does the person admit self-harm or claim to have “accidents”?
What are the payoffs or reasons for self-harm?
  • Is nonverbal communication—gains someone’s attention and coerces others for their needs
  • Makes others believe—physical evidence of pain
  • Demonstrates the feeling of hopelessness
  • Demonstrates outside what person feels like inside (ugly, scarred, garbage)
  • Feels he or she deserves it—bad, ugly, evil, crazy
  • Releases pain and anger—use of self-harm is a safety valve to prevent suicide
  • (Re)establishes control over one’s body
  • Verifies there is still life—physical evidence of life in flow of blood
  • Is sadomasochistic pleasure
  • Is an addiction to near death
Can the person identify specifics in the process?
  • Personal triggers
    • Sensory input
    • Situations
    • Particular types of people or places
  • Flashbacks or nightmares
  • Does the person disassociate or “numb out”?
  • Can person identify levels or stages before the act of self-harm?
Motivation to cease self-harm
  • Wants to stop and is willing to work toward that end
  • Wants emotional pain to stop, sees self-harm as part of that pain and is considering change
  • Unwilling to give up self-harm behavior
Support system
Who is relied on during periods of stress?
  • Are they available?
  • What is their reaction to current situation?
  • Denial
  • Not receptive to helping
  • Anger/guilt
  • Helplessness/frustration
  • Concern and willingness to help
Personal and financial resources
  • Employment
  • Housing
  • Finances
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Objective Data
Assess for Risk Factors
General appearance
  • Facial expression
  • Apparel
  • Posture
Behavior during interview
  • Agitated
  • Cooperative
  • Hostile
  • Withdrawn
  • Restless
  • Disassociated
Communication pattern
  • Hopeless/helpless (subjective)
  • Suicidal expressions
  • Hallucinates
  • Difficulty concentrating
  • Allusive Delusional
  • Pressured speech
  • Supersensitive (subjective)
  • Denial
  • Indecisive
  • Misinterprets
Nutritional status
  • Appetite
  • Bulimic behavior
  • Weight (anorectic, obese)
Sleep–rest pattern
  • Afraid of dark
  • Sleeps too much
  • Easily awakened
  • Difficulty staying asleep
  • Difficulty falling asleep
  • Nightmares
Physical manifestations
  • Tremors
  • Tightness of chest
  • Shortness of breath
  • Aches and pains: stomach, head, muscles
  • Heart palpitations
  • Hyperalertness
  • Fists clench
  • Change in facial color
  • Agitation
  • Buzzing in head
  • Perspiration
Evidence of self-harm
Be highly suspicious if
There have been repeated accidents
Person wears long sleeves in hot weather
Person is reluctant to uncover parts of body
Look for
  • Scars
  • Reddened, irritated areas
  • Areas that do not heal as expected
  • Lumps/bumps
  • Sores
  • Clumps/patches of missing hair
  • Open cuts
  • Burn marks
Body parts often affected
  • Wrists, arms, legs, feet
  • Genitals
  • Head, face, eyes, neck
  • Chest, abdomen
Behaviors of self-mutilation
Cutting
Picking
Slashing
Gouging
Stabbing
Head smashing
Scratching
Hitting (eg, fists against walls)
Burning (cigarettes, lighters, matches, stove, clothes iron, curling iron)
Use of corrosives (eg, drain cleaner)
Behaviors of self-abuse
Head banging
Slapping
Picking
Scratching
Nonlethal use of drugs/poison
Anorectic/bulimic behaviors
Swallowing foreign objects (glass, needles, safety pins, straight pins, various hardware [eg, nails, screws])
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Hair pulling
Excessive rubbing
Noncompliance with treatment for serious physical or medical conditions (eg, diabetes)
For more information on Focus Assessment Criteria, visit http://connection.lww.com.
Goal
The person will choose alternatives that are not harmful.
Indicators
  • Acknowledge self-harm thoughts.
  • Admit to use of self-harm behavior if it occurs.
  • Be able to identify personal triggers.
  • Learn to identify and tolerate uncomfortable feelings.
General Interventions
Establish a Trusting Nurse–Client Relationship
Demonstrate acceptance of client as a worthwhile person through nonjudgmental statements and behavior.
Ask questions in a caring, concerned manner.
Encourage expression of thoughts and feelings.
Actively listen or provide support by just being there if the person is silent.
Be aware of the client’s supersensitivity.
Label the behavior, not the person.
Be honest in your interactions.
Assist client to recognize hope and alternatives.
Provide reasons for necessary procedures or interventions.
Maintain client’s dignity throughout your therapeutic relationship.
Validate Reality
Schizophrenia or Drug-Induced Psychosis
Tell the person “you are safe.”
Use quiet, calming voice.
Use “talk downs” when client has taken a hallucinogenic drug. If agitation increases, stop immediately.
Orient client as required. Point out sensory/environmental misperceptions without belittling his or her fears or indicating disapproval of verbal expressions.
Reassure client that this will pass.
Watch for signs of increased delusional thinking and/or frightening hallucinations (increased anxiety, agitation, irritability, pacing, hypervigilance).
Post-Trauma or Dysfunctional
Tell the person “you are not bad, crazy, hopeless.”
Say you believe him or her when he or she tells you personal history; many grew up in denial or minimization.
Let the person know he or she is not the only one.
Help Reframe Old Thinking/Feeling Patterns (Carscadden, 1993a)
Encourage the belief that change is possible.
Assist client to identify thought–feeling–behavior concept.
Help client assess payoffs and drawbacks to self-harm.
Rename words that have a negative connotation (eg, “setback,” not “failure”).
Encourage identification of personal triggers.
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Assist client to explore viable alternatives.
Help client to examine feelings of ambivalence about recovery.
Encourage client to become comfortable with and to use feelings.
Facilitate the Development of New Behavior
Validate good coping skills already in existence.
Serve as a role model in your own behavior and interactions.
Encourage the use of positive affirmations, meditation and relaxation techniques, and other esteem-building exercises.
Promote the concept of being helpful instead of helpless.
Encourage journaling, keeping a diary of triggers, thoughts, feelings, and alternatives that work or do not work.
Assist client to develop body awareness as a method of ascertaining triggers and determining levels of impending self-harm.
Assist with role playing to work on situations/relationships.
Promote development of healthy self-boundaries for the person.
Endorse an Environment that Demotes Self-Harm
How much control or influence a professional exerts in this area will depend on the diagnosis, the environmental setting, and the policies of that setting (eg, a person’s home, residential setting, treatment facility, or institution). If mandated by the setting’s policies to intervene in self-harm attempts, then the following interventions should take place.
Structure the Client’s Time and Activities
Provide a scheduled day that meets the person’s need for activity and rest.
Encourage assistance to and activities with others without competitiveness.
Relieve pent-up tension and purposeless hyperactivity with physical activity (eg, brisk walk, dance therapy, aerobics).
Reduce Excessive Stimuli
Provide a quiet, serene atmosphere.
Establish firm, consistent limits while giving person as much control/choice as possible within those boundaries.
Intervene at earliest stages to assist person to regain control, prevent escalation, and allow treatment in the least restrictive manner.
Keep communication simple. Agitated people cannot process complicated communication.
Provide an area where the person can retreat to decrease stimuli (eg, time-out room, quiet room; person on hallucinogens needs a darkened, quiet room with a nonintrusive observer).
Remove potentially dangerous objects from environment (if in crisis stage).
Reduce Triggers as Much as Possible
Assess problem areas and assist in problem solving with the client.
  • Is person afraid of dark? Allow a small light on at night.
  • Is person afraid of being alone? Put in a double room with roommate.
Promote the Use of Alternatives
Stress that there are always alternatives.
Stress that self-harm is a choice, not something uncontrollable.
Allow opportunities for verbal expression of thoughts and feelings.
Provide acceptable physical outlets (eg, yelling, pounding pillow, tearing up newspapers, using clay or Play-Doh, taking a brisk walk).
Provide for less physical alternatives (eg, relaxation tapes, soft music, warm bath, diversional activities).
Determine Present Level of Impending Self-Harm if Indicated
Beginning Stage (Thought Stage)
Provide soothing touch if permitted by person (predetermined).
Remind person that this is an “old tape” and to replace with new thinking and belief patterns.
Provide nonintrusive, calming alternatives.
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Climbing Stage (Feeling Stage)
Remind person to consider alternatives.
Give as much control to the person as possible to support his or her accountability.
  • Are you in control?
  • How can I help?
  • Would you like me to assist?
Provide more intense interventions at this stage.
Encourage person to turn over any potential items of self-harm.
Crisis Stage (Behavior Stage)
Give positive feedback if person chooses an alternative and does not harm himself or herself.
Ask person to put down any object of harm if he or she possesses one.
Continue to emphasize there are always alternatives.
Restrain only if person becomes out of control.
Release from restraints as soon as possible to give responsibility back to person. “Are you in control now?” “Are you feeling safe?”
Remain calm and caring throughout the crisis period.
Attend to practical issues in a nonpunitive, nonjudgmental manner.
Postcrisis Stage
Give positive reinforcements if person did not harm himself or herself.
Assist client to problem-solve on how to divert self before crisis stage.
Assess degree of injury/harm if person did not choose alternative.
Provide assistance or medical care, as necessary.
Pay as little attention as possible to the act of self-harm and focus on prior stages (eg, “Can you remember what triggered you?” “What kinds of things were going through your mind?” “What do you think you might have done instead?”).
Return person to normal activities/routine as soon as possible.
Initiate Support Systems to Community, When/Where Indicated
Teach family
  • Constructive expression of feelings
  • How to recognize levels of impending self-harm
  • How to assist with appropriate interventions
  • How to deal with self-harm behavior/results
Supply Phone Number of 24-h Emergency Hotlines
Provide referral to:
  • Individual therapist
  • Leisure/vocational counseling
  • Family counseling
  • Halfway houses
  • Peer support group
  • Other community resources
Rationales
  • Frequent contact by the caregiver indicates acceptance and may facilitate trust. The client may be hesitant to approach staff because of negative self-concept; the nurse must reach out.
  • Expressing feelings and perceptions increases the client’s self-awareness and helps the nurse plan effective interventions to address his or her needs. Validating the client’s perceptions provides reassurance and can decrease anxiety.
  • The nurse must be aware that the person may express or exhibit ambivalence about stopping the self-harm behavior. This coping mechanism probably served a useful purpose. Often, unless the payoffs cease or until the payoffs for not harming are greater or more important, the behavior will continue.
  • It is important not to reward the act of self-harm with reinforcements (negative or positive). Treatment of the injury should be done matter-of-factly, much like removing a splinter, but also provide the person with dignity. Returning to activities/schedules as quickly as possible restores responsibility to the person.
  • Control of environment is a basic, but not to be discounted, intervention. A structured schedule provides boundaries and security, enhancing the sense of safety. A quiet environment reduces reactivity, enhances calm feelings, and decreases the likelihood of confusion and fear. Gross
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    motor activity in a protected environment can lessen aggressive drives, whereas rest periods promote opportunities for relaxation, calm the emergency response, and reconnect body/mind/heart.
  • The therapeutic alliance promotes client responsibility for behavioral restraint while supplementing internal controls. Expression of feelings may assist in resolving them regardless of the discomfort involved and may decrease the need for physical action.
  • Promise contracts contain things like “promise that you won’t…” or “promise you’ll come and tell me before you.…” They should never be used, because they reinforce the notion that the person is incompetent and impulse-driven, not in control. They also multiply the potential for distortions and make others, not the self-injurer, responsible for the behavior and its control. A no-harm contract is not a logical tool to use with psychotic, mentally challenged, or chemically impaired persons, who are not competent to enter into such agreements. With a depressed person, the intent might be misinterpreted. A contract might be more useful if used as boundaries (eg, results of self-harm are attended to before a therapy session, or details or specifics of self-harm are not discussed in group therapy so that other members are not triggered; Dawson & MacMillan, 1993; Egan et al., 1997).
  • Maladaptive behaviors can be replaced with healthy ones to manage stress and anxiety (Stuart & Sundeen, 2002).
  • Social isolation perpetuates feelings of low self-esteem and self-destructive behavior (Stuart & Sundeen, 2002).
  • People who dissociate or are ungrounded or unsafe have difficulty when asked to “give up their body” or “close their eyes” in relaxation or visualization and should never be encouraged to do so until they are ready.
Footnote
*These diagnoses are not currently on the NANDA list but have been included for clarity or usefulness.