Self harm wounds - assessment and management

The UK has one of the highest rates of self-harm in Europe (Stallard et al, 2021). The prevalence of self-harm is higher in women than men (although some of behaviours are not classified as self-harm for example, punching walls) and people who self-harm are more likely to die by suicide (National Institute for Health and Care Excellence (NICE), 2020). The act of self-harm tends to be followed by a sense of relief and relaxation. It can be a coping mechanism, often as a result of:

• trauma
• psychological illness
• abuse
• a deep-seated sense of powerlessness
• negative feelings, such as anger, guilt, frustration, hopelessness and self-hatred (Mind, 2020).

These overwhelming emotional feelings are converted into a visible, physical wound, which the individual can find easier to deal with (Sutton, 2007).

A range of methods can be used to cause self-harm, for example, needles, shards of glass, fingernails or boiling water (Mitchell, 2021)

• Ask the patient’s age – the highest rate of self-harm is reported in women aged 16–24 years (Mental Health Foundation, 2016)
• Assess risk – individuals who self-harm should be assessed for risk of further harmful behaviour as well as potential suicide (Ousey and Ousey, 2012). The nurse should focus the assessment on the person’s needs and how to support their immediate and long-term psychological and physical safety (NICE, 2022)
• Ask the individual about alcohol or substance misuse – it may be appropriate to refer them to local alcohol and drug services with the individual’s consent.
• Past medical history including any previous wounds – this is particularly relevant for recurrent self-harm wounds (Mitchell, 2021).
• Medical and family background – include questions about any potential stressors in the patient’s family dynamics or personal relationships. This may warrant referral to the psychological therapy team (Mitchell, 2021).
• Ask the patient about any allergies, previous

Management of the wound

• Confirm the patient’s identify, explain and discuss the full procedure and seek consent and check for any allergies
• Wash hands and put on aprons and gloves
• If the patient presents shortly after initial wounding immediate action may be required to control the bleeding and to address shock from hypovolaemia (Hill and Mitchell, 2020). Blood perfusion may be restored by removing any ligatures or stabilising a puncture wound (Ousey and Ousey, 2012).
• Review the history and duration of the wound. This should include how the wound was caused including any instruments used and type of wound. A repeated injury and inflammation can result in elevated, thick, or nodular hypertrophic scars (Benbow, 2011)
• Review the level of tissue injury – does the wound involve the epidermis, dermis, fat, fascia, muscle, tendon and/or bone? The nurse should document any findings. (Mitchell, 2021).
• Wound depth – if the wound is

Risk factors for self-harm include socioeconomic disadvantages, and psychiatric illness for example, depression, alcohol and/or drug misuse and stressful life events (NICE, 2020). The risk of repetition of self-harm and later suicide is high (Skegg, 2005). The prevalence of suicide following self-harm is relatively higher within secure institutions such as prisons and secure hospitals (Sarkar, 2018). Deliberate self-harm and injury to the skin can leave permanent scarring in anatomically conspicuous areas (Todd et al, 2012) and scar treatment can be lengthy and invasive. Management after self-harm should include treating the psychiatric illness, forming trusting relationships with the patient and ensuring support is available.

Self-harm wounds should be managed with the patient as part of their holistic and psychological care. It is important to encourage ownership and support individuals in their own self-care pathways.

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Mitchell A. Assessment of wounds in adults. Br J Nurs. 2020;29(20):S18–S24. https://doi.org/10.12968/bjon.2020.29.20.S18

Mitchell A. Self-harm wounds: assessment and management. Br J Nurs. 2021;30(12):S16–S20

Mind. Self-harm. 2020. https://www.mind.org.uk/information-support/types-of-mental-health-problems/self-harm/about-self-harm/ (accessed 15 March 2023)

Monstrey S, Middelkoop E, Vranckx JJ et al. Updated scar management practical guidelines: non-invasive and invasive measures. J Plast Reconstr Aesthet Surg. 2014;67(8):1017–1025. https://doi.org/10.1016/j.bjps.2014.04.011

National institute for Health and Care Excellence. Self-harm. 2020. https://cks.nice.org.uk/topics/self-harm/background-information/prevalence/ (accessed 15 March 2023)

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