Nurse's Pocket Guide

often is an attempt to establish individuality, addressing
issues of separation and belonging, it is not considered as
self-injury behavior.
• Determine relationship of previous self-mutilative behavior
to stressful events. Self-injury is considered to be an attempt
to alter a mood state.
• Note use/abuse of addicting substances.
• Review laboratory findings (e.g., blood alcohol, polydrug
screen, glucose, and electrolyte levels). Drug use may affect
self-injury behavior.
NURSING PRIORITY NO. 2.To structure environment to maintain
client safety:
• Assist client to identify feelings leading up to desire for selfmutilation.
Early recognition of recurring feelings provides
opportunity to seek and learn other ways of coping.
• Provide external controls/limit setting. May decrease the
opportunity to self-mutilate.
• Include client in development of plan of care. Commitment
to plan increases likelihood of adherence.
• Encourage appropriate expression of feelings. Identifies feelings
and promotes understanding of what leads to development
of tension.
• Note feelings of healthcare providers/family, such as frustration,
anger, defensiveness, need to rescue. Client may be
manipulative, evoking defensiveness and conflict. These
feelings need to be identified, recognized, and dealt with
openly with staff/family and client.
• Provide care for client’s wounds, when self-mutilation occurs,
in a matter-of-fact manner that conveys empathy/concern.
Refrain from offering sympathy or additional attention that
could provide reinforcement for maladaptive behavior and
may encourage its repetition.
NURSING PRIORITY NO.3.To promote movement toward positive
changes:
• Involve client in developing goals for stopping behavior.
Enhances commitment, optimizing outcomes.
• Develop a contract between client and counselor to enable
the client to stay physically safe, such as “I will not cut or
harm myself for the next 24 hours.” Renew contract on a
regular basis and have both parties sign and date each
contract.
• Provide avenues of communication for times when client
needs to talk to avoid cutting or damaging self.
Information in brackets added by the authors to clarify and enhance
the use of nursing diagnoses.
Diagnostic Studies Pediatric/Geriatric/Lifespan Medications 599
SELF-MUTILATION