Nursing Care Plan: Risk for Injury (Risk for Self Mutilation)

Risk for Self MutilatiionThis nursing care plan for risk for injury is specific to situation where there is a risk for self mutilation in children. A risk for self mutilation nursing diagnosis is used when a patient/client is at risk for deliberate self-injurious behavior causing tissue damage with the intent of causing nonfatal injury to attain relief of tension

Risk for Self- Mutilation Related To (Etiology)

  • Impaired neurologic development or dysfunction
  • Need for painful stimuli to increase opiate levels and reduce tension
  • Rage reactions and aggression turned toward self
  • Lack of impulse control and the ability to tolerate frustration

As Evidenced By (Assessment Findings/Diagnostic Cues)

  • History of self-injuries (head banging, biting, scratching, hair pulling)when frustrated or angry
  • Old scars or new areas of tissue damage
  • Self-injurious tantrums when changes are made in routines, rituals, or the environment, or when asked to end a pleasurable activity

Risk for injury nursing care plan (Risk for self mutilation) Outcome Criteria

  • Demonstrate new behaviors and skills to cope with anxiety and feelings

Long-Term Goals

  • Be free of self-inflicted injury

Short-Term Goals
Client will:

  • Respond to a parent or surrogate’s limits on self-injurious behaviors within 1 to 6 months
  • Seek help when anxiety and tension rise within 1 to 6 months
  • Express feelings and describe tensions verbally and/or with non-injurious body language within 6 months to 1 year
  • Use appropriate play activities for the release of anxiety and tension within 1 to 6 months

Risk for Self Mutilation Interventions and Rationales

1. Monitor the client’s behavior for cues of rising anxiety. R: Behavioral cues signal increasing anxiety.
2. Determine emotional and situational triggers. R: Knowledge of triggers is used in planning ways to prevent or manage outbursts.
3. Intervene early with verbal comments or limits and/or removal from the situation. R: Potential outbursts can be defused through early recognition, verbal intervention, or removal.
4. Give plenty of notice when having to change routines or rituals or end pleasurable activities. R: Children often react to change with catastrophic reactions and need time to adjust.
5. Provide support for the recognition of feelings, reality testing, impulse control. R: These competencies are often underdeveloped in these children.
6. If the client does not respond to verbal interventions, use therapeutic holding.Some might need special restraints  (helmets, mittens, special padding) R: Therapeutic holding reassures the client that the adult is in control; feelings of security can become feelings of comfort and affection.
7. Help the client connect feelings and anxiety to self-injurious behaviors. R: Self-control is enhanced through understanding the relationship between feelings and behaviors.
8. Help the client develop ways to express feelings and reduce anxiety verbally and through play activities. Use various types of motor and imaginative play (e.g., swinging, tumbling, role playing, drawing, singing). R: Methods for modulating and directing the expression of emotions and anxiety must be learned to control destructive impulses.

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A Nursing Care Plan example for : Risk for Injury (Risk for Self Mutilation)

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