PIA MAE D.
BUAYA N-31
NURSING CARE PLAN
Borderline PD (Client A) NCP #1
Assessment Diagnosis Planning Interventions Rationale Evaluation
Subjective cue: “I would get Risk for suicide Short term goal: Independent Nursing 1. This study Short term goal:
really suicidal because I related to unresolved Interventions demonstrated the Goal met.
would feel like I already got grief Within 2-4 hours of 1. Establish a importance of this After 4 hours of nursing
tried to get help and nothing’s nursing interventions therapeutic relationship in interventions the patient
s working.” the patient will talk relationship with identifying and was able to talk about her
about her feelings and client. preventing suicide feelings and disclose
disclose suicidal 2. Keep accurate (Rudd et al, 2000). suicidal ideations
ideations if present and thorough 2. These might throughout her stay in the
“I tried to kill myself more throughout her stay in records of client’s become court hospital.
than like two or three times... the hospital. behaviors (verbal documents. If client
I would try to commit suicide and physical) and checks and
because I felt I would by Long term goal: all attention to client’s Long term goal:
killing myself I would kill her nursing/physician needs or request Goal met.
too (referring to other self)... I Within 3-4 weeks of actions. are not After 4 weeks of nursing
would like to take an nursing interventions 3. Follow unit documented, they interventions the patient
extension cord and make a the patient will be able protocol for do not exist in a was able to identify at
noose and like wrapped to identify at least one suicide regarding court of law. least one goal for the
around my neck and hang it goal for the future. creating a safe 3. Provide safe future.
on something and like choke environment environment during
myself out for a couple (taking away time client is
seconds until I felt I was potential actively suicidal
gonna go.” weapons– belts, and impulsive;
sharp objects, self-destructive
items, and so on). acts are perceived
4. Put on either as ties, the only
Objective cues: suicide precaution way out of an
(one-on-one intolerable
monitoring at one situation.
arm’s length 4. Protection and
History of cutting wrist or away) or suicide preservation of the
observation client’s life at all
(15-minute visual costs during crisis
arms check of mood, is part of medical
behavior, and and nursing staff
verbatim responsibility.
statements), Follow unit
Suicide behavior; 2-3 suicide depending on protocol.
attempts level of suicide 5. Talking about
potential. feelings and
5. Encourage the looking at
client to talk about alternatives can
Suicide ideation their feelings and minimize suicidal
problem solve acting out.
alternatives. 6. Because of “tunnel
6. During the crisis vision“, clients do
Suicide plan period, health not have
care workers will perspective on their
continue to lives. These
emphasize the statements give
following four perspective to the
Statements of despair,
points: client and help offer
helplessness and
1. The crisis hope for the future.
hopelessness
is 7. During crisis
temporary. situations, people
2. Unbearabl are unable to think
e pain can clearly or evaluate
be their options
survived. readily.
3. Help is 8. Gives client other
available. ways of dealing
4. You are with strong
not alone. emotions and
7. Encourage the gaining a sense of
client to avoid control over their
decisions during lives.
the time of crisis 9. It is helpful for the
until alternatives patient to talk about
can be suicidal thoughts
considered. and intentions to
8. Encourage the harm themselves.
client to talk freely Expressing their
about feelings thoughts and
and help plan feelings may
alternative ways lessen their
of handling intensity. Also, they
disappointment, need to see that
anger, and staff are open to
frustration. discussion.
9. Present 10. Patients can get to
opportunities for identify situational,
the patient to interpersonal, or
express thoughts, emotional triggers
and feelings in a and learn to assess
nonjudgmental a problem and
environment. implement
10. Help the patient problem-solving
with measures before
problem-solving reacting.
in a constructive 11. Patient learns to
manner. identify negative
11. Educate the thoughts and
patient develops positive
cognitive-behavio approaches and
ral positive thinking.
self-management 12. Patients are better
responses to to acknowledge
suicidal thoughts. and safely handle
12. Introduce the use suicidal feelings by
of self-expression programs such as
methods to keeping journals
manage suicidal and calling
feelings. hotlines.
13. Borderline
Dependent Nursing personality disorder
Intervention is mainly treated
using
13. Administer psychotherapy, but
medication as medication may be
prescribed. added. Your doctor
also may
recommend
Collaborative Nursing hospitalization if
Intervention your safety is at
14. Collaborate with risk. Treatment can
the healthcare help you learn skills
team to monitor to manage and
prescribed cope with your
medical and condition.
psychotherapy 14. Collaborative Care
treatment plans originated in
for the patient. somatic health care
to increase shared
decision making
and to enhance self
management skills
of chronic patients.
Narcissistic PD (CLIENT B) NCP#2
Assessment Diagnosis Planning Interventions Rationale Evaluation
Subjective: “ I feel cut off Impaired social Short term goal Independent Nursing 1. Establishing Short term goal:
from the rest of the world” “I interaction related to Interventions rapport is very Goal met.
tried so hard to be like one of biological changes in Within 4-8 hours of 1. Introduce self and important as this After 4 hours of nursing
those girls with money. It was the brain and nursing interventions explain to the client facilitates trust and interventions the patient
so unfair they were so rich, I unacceptable social the patient will be able reason of visit/interview. participation of the was able to verbalize
wasn’t, and they didn’t want behavior or values to verbalize client. awareness of factors
me. All that mattered were secondary to awareness of factors 2. Use a calm tone when 2. A calm tone will causing or promoting
clothes and cars, they Narcissistic causing or promoting speaking to the client. help the client feel impaired social
screwed up, no brains, no Personality Disorder impaired social Avoid jargons. that she is secure interactions and identify
style.” interactions and and that no one and express feelings to
identify and express 3. Use the client’s name. intends to harm the nurse.
feelings to the nurse. her. Some medical
4. Maintain a peaceful terms may be Long term:
Objective: and clean environment. misinterpreted by Goal met.
Long term goal: clients thus it is After 3 weeks of nursing
5. Develop a trusting better that one interventions the patient
Within 3-4 weeks of relationship with the client avoids them. was able to state that she
Nips nails with fingers nursing interventions by being honest, 3. Stating client’s is willing to continue in
the patient will be able conveying acceptance name will enable follow up therapy and will
to state that she is separate from them to recognize work with the
willing to continue in unacceptable behaviors. self, real-time and nurse/clinician on
Tends to look down after follow up therapy and avoid confusions. substituting positive
answering questions and will work with the 6. Assess the client’s 4. A peaceful and behaviors for those
often spaces or remembering nurse/clinician on behavior, attitudes, clean environment unacceptable behaviors
past memories substituting positive problems, and needs. will enable the identified earlier on an
behaviors for those client to feel secure ongoing basis.
unacceptable and allow thought
behaviors identified 7. Obtain the client’s to flow since there
Asserts that she is right and earlier on an ongoing perception of his or her are no distractions.
is a priority all the time basis. problems and what the 5. Acceptance of
client expects to gain from client increases his
the relationship or or her feelings of
hospitalization. self-worth.
Grandiose sense of self 6. Baseline data are
importance and specialness 8. Show the client you essential for
accept her as a person by developing a plan
initiating interactions, of nursing care.
remaining with the client 7. The client’s actions
Arrogant and haughty in silence, using active are based on his or
attitude listening, and etc her perceptions,
which may or may
9. . Set and maintain not be the same as
limits on the client’s other people’s
Rejects any feedback or “negative” or perceptions or
criticism unacceptable behavior; objective reality.
withdraw your attention 8. Conveying
from the client if acceptance can
necessary when it is safe help the client feel
to do so. worthwhile.
9. t is possible to
10. Problem solve and accept the client
role play with client yet not accept
acceptable social skills “negative” or
that will help obtain needs undesirable
effectively and behaviors. Lack of
appropriately. attention can help
extinguish
11. Do not allow the client unacceptable
to bargain to obtain behavior. The
special favors, avoid client’s safety and
responsibilities, gain the safety of others
privileges, or otherwise are priorities
subvert limits. 10. Over time,
alternative ways of
12. Teach the client social experiencing
skills. Describe and interpersonal
demonstrate specific relationships might
skills, such as eye emerge. Take one
contact, attentive small skill that
listening, nodding. client is willing to
work on, break it
13. In a respectful, neutral down into small
manner, explain expected parts, and work on
client behaviors, limits, it with the client.
and responsibilities during 11. Allowing bargaining
sessions with nurse permits the client to
clinician. be manipulative
and undermines
14. Help the client identify limits and trust.
and implement ways of 12. The client may
expressing emotions and never have learned
communicating with basic social skills
others. and how to use
them appropriately
15. Assist the client in 13. From the
identifying beginning, clients
personal need to have
behaviors or explicit guidelines
problem areas in and boundaries for
his or her life expected behaviors
situation that on their part, as
interfere with well as what client
relationships or can expect from
interactions with the nurse.
others and 14. The client’s ability
identifying more to identify and
effective methods express feelings
of dealing with and to
stress. communicate with
others is impaired.
Dependent Nursing Thus, nurses ought
Intervention to help client
16. Administer to the identify so.
patient prescribed 15. The client must
medication. identify what
behaviors or
Collaborative Nursing problems need
Interventions modification before
change can occur.
17. Refer or assist The client may be
the client in dealing with stress
identifying in the most
sources of effective way he or
support outside she can and may
the hospital, need to learn new
including skills and
agencies or behaviors.
individuals in the 16. . Medications are to
community and be given at the
on the Internet, if right time and
appropriate, as frequency as to
well as significant avoid complications
others in his or and stagnation of
her personal life. improvement.
18. Provide group 17. Community support
interactions for may help the client
client. deal with future
19. Collaborate with stress and avoid
family by hospitalization.
educating them 18. It is through these
about the disorder group interactions
and the do’s and that client will learn
don’ts when socially acceptable
dealing with the behavior, with
individual. positive and
negative feedback
from her peers.
19. Family is the
foundation and
support system of
an individual. It is
vital to collaborate
with them as to
broaden their
understanding and
awareness about
the disorder and
how they can help
the client improve.
