Nurse's Pocket Guide

[actual/] risk for self-directed VIOLENCE
[actual/] risk for self-directed Violence
Taxonomy II: Safety/Protection—Class 3 Violence (00140)
[Diagnostic Division: Safety]
Submitted 1994
Definition: At risk for behaviors in which an individual
demonstrates that he or she can be physically, emotionally,
and/or sexually harmful to self
Risk Factors/[Indicators]*
Ages 15 to 19/over 45
Marital status (single, widowed, divorced)
Employment problems (e.g., unemployed, recent job loss/failure);
occupation (executive, administrator/owner of business,
professional, semi-skilled worker)
Conflictual interpersonal relationships
Family background (e.g., chaotic or conflictual, history of suicide)
Sexual orientation (bisexual [active], homosexual [inactive])
Physical health problems (e.g., hypochondriac, chronic or terminal
illness)
Mental health problems (e.g., severe depression, [bipolar disorder]
psychosis, severe personality disorder, alcoholism or drug abuse)
Emotional problems (e.g., hopelessness, [lifting of depressed
mood], despair, increased anxiety, panic, anger, hostility); history
of multiple suicide attempts; suicidal ideation; suicidal plan
Lack of personal resources (e.g., poor achievement, poor
insight, affect unavailable and poorly controlled)
Lack of social resources (e.g., poor rapport, socially isolated,
unresponsive family)
Verbal clues (e.g., talking about death, “better off without me,”
asking questions about lethal dosages of drugs)
Behavioral clues (e.g., writing forlorn love notes, directing angry
messages at a significant other who has rejected the person, giving
away personal items, taking out a large life insurance policy)
Desired Outcomes/Evaluation
Criteria—[For Other-Directed/
Self-Directed] Client Will:
• Acknowledge realities of the situation.
• Verbalize understanding of why behavior occurs.
*Although a risk diagnosis does not have defining characteristics
(signs and symptoms), the factors identified here can be used to denote
an actual diagnosis or as indicators of risk for/escalation of violence.
Information in brackets added by the authors to clarify and enhance
the use of nursing diagnoses.
768 Cultural Collaborative Community/Home Care