4 Personality Disorders Nursing Care Plans

Risk For Self-Mutilation

Patients with a history of self-injury may continue to engage in self-mutilation as a maladaptive coping mechanism for emotional distress. In cases of abuse, the patient may engage in self-injury as a way to exert control over their own body, while those with mental retardation may engage in self-injury as a result of an inability to communicate emotional distress effectively. Attention-seeking behaviors may also contribute to self-injury as a means of eliciting a response from caregivers or loved ones.

Nursing Diagnosis

• Risk For Self-Mutilation

Risk factors

• Desperate need for attention
• Emotionally disturbed or battered children
• Feelings of depression, rejection, self-hatred, separation anxiety, guilt, and depersonalization
• History of self-injury
• History of physical, emotional, or sexual abuse
• High-risk populations (BPD, psychotic states)
• Impulsive behavior
• Inability to verbally express feelings
• Ineffective coping skills
• Mentally retarded and autistic children

Possibly evidenced by

• Not applicable for risk diagnosis. A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred and nursing interventions are directed at prevention.

Desired Outcomes

• The patient will be free of self-inflicted injury.
• The patient will participate in impulse control training.
• The patient will participate in coping skills training.
• The patient will seek help when experiencing self-destructive impulses.
• The patient will discuss alternative ways a client can meet the demands of the current situation.
• The patient will express feelings related to stress and tension instead of acting-out behaviors.
• The patient will sign a “no-harm” contract that identifies steps he or she will take when urges return.
• The patient will respond to external limits.
• The patient will participate in the therapeutic regimen.
• The patient will demonstrate decreased frequency and intensity of the self-inflicted injury.
• The patient will demonstrate two new coping skills that work for the client when tension mounts and impulse returns.

Nursing Assessment and Rationales

1. Assess the client’s history of self-mutilation which includes: types of mutilating behaviors, frequency behaviors, and stressors preceding behavior.
Identifying patterns and circumstances surrounding self-injury can help the nurse plan interventions and teaching strategies suitable to the client.

2. Identify feelings experienced before and around the act of self-mutilation.
Feelings are a guideline for future intervention (e.g., rage at feeling left out or abandoned).

3. Explore with the client what these feelings might mean.
Self-mutilation might also be a way to gain control over others, a way to feel alive through pain, and an expression of self-hate or guilt.

Nursing Interventions and Rationales

1. Secure a written or verbal no-harm contract with the client. Identify specific steps (e.g., persons to call upon when prompted to self-mutilate).
The client is encouraged to take responsibility for healthier behavior. Talking to others and learning alternative coping skills can reduce frequency and severity until such behavior ceases.

2. Set and maintain limits on acceptable behavior and make clear the client’s responsibilities. If the client is hospitalized at the time, be clear regarding the unit rules.
Clear and nonpunitive limit setting is essential for decreasing negative behaviors.

3. Be consistent in maintaining and enforcing the limits, using a nonpunitive approach.
Consistency can establish a sense of security.

4. Use a matter-of-fact approach when self-mutilation occurs. Avoid criticizing or giving sympathy.
A neutral approach prevents blaming, which increases anxiety, giving special attention that encourages acting out.

5. After the treatment of the wound, discuss what happened right before, and the thoughts and feelings that the client had immediately before self-mutilating.
Identifies dynamics for both client and clinician. Allows the identification of less harmful responses to help relieve intense tensions.

6. Work out a plan identifying alternatives to self-mutilating behaviors.
The plan is periodically reviewed and evaluated. Offers a chance to deal with feelings and struggles that arise.

• 6.1. Anticipate certain situations that might lead to increased stress (e.g., feeling overwhelmed, rejected, tense, or rage).
  Anticipation can help the patients be better prepared to manage those situations without resorting to self-mutilation.
  
• 6.2. Identify actions that might modify the intensity of such situations.
  Learning and practicing coping skills like deep breathing, meditation, or mindfulness can help decrease stress and manage difficult emotions.
  
• 6.3. Identify two or three people the client can contact to discuss and examine intense feelings (rage, self-hate) when they arise.
  Discussing intense emotions with others can help the client learn coping strategies for dealing with difficult emotions and avoid self-mutilation.