Common Nursing Diagnoses and Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence tissue damage with the intent of causing nonfatal injury to at tain Defi 4. Extreme fascination for objects that move (e.g., fans, trains). ●health, and private practice.) 5. Unreasonable insistence on following routines in precise patient and partial hospitalization, community outpatient clinic, home (Interventions are applicable to various health care settings, such as in-^ 6. Marked distress over changes in trivial aspects of environ-Autistic Disorder 7. St e r e ot y p e d b o d y mo ve me nt s (e .g., h a nd flInterventions for the Client with relief of tension movements). RISK FOR SELF-MUTILATIONment (e.g., when a vase is moved from its usual position).followed when shopping).detail (e.g., insisting that exactly the same route always be parts of the body.Special interest in music, playing with water, buttons, or twisting, spinning, head banging, complex whole-body nition: At risk for deliberate self-injurious behavior causing icking or ●^21
2506_Ch02_014-053.indd Sec1:21 2506 Ch 02 014 - 053 .indd depend on severity and chronicity of the disorder.)Long-term GoalClient will not inflRelated/Risk Factors (“related to”)Interventions with [Obvious indifference to environment or hysterical reactions to 1. Intervene to protect child when self-mutilative behaviors, SGoals/ObjectivesShort-term GoalClient will demonstrate alternative behavior (e.g., initiating in-teraction between self and nurse) in response to anxiety within [Neurological alterations]specifi[History of self-mutilative behaviors in response to increasing ecchanges in the environment] anxiety] 1 evident. such as head banging or other hysterical behaviors, become : 21 ed time. (Length of time required for this objective will The nurse is responsible for ensuring client safety. ict harm on self. Selected Rationales 1 10/1/10 9:33:17 AM 0 / 1 / 10 9 : 33 : 17 AM
