NURSING BACKGROUND

CUES PLANNING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS KNOWLEDGE

SUBJECTIVE Risk for Self Etiology is unknown Short term: INDEPENDENT: INDEPENDENT: Short term:
DATA: Harm related to
feeling of At the end of 4 1. Determined 1. To prevent At the end of 4 hours of
“Gusto ko ng hopelessness as hours of nursing whether the client occurrence of nursing intervention, the
mamatay para intervention the shows signs that harming oneself/ clients
evidence of planned suicide.
matapos na lahat ng suicidal thought. client will: will leaad to
Contributing factors - did not hurt/harm
ito” as verbalized harming self/
by the patient. not harm self suicide. self.
2. Determined hx of - She was able to
verbalize - Verbalized
suicide self
understanding of 2. To know if there understanding of
harming attempts.
OBJECTIVE Borderline why behavior is a pattern of why behavior
DATA: Personality Disorder occurs. occurance to occur.
anticipated and - Identified
Ÿ History of cutting Identify 3. Refrained from intervene
precipitating
arms and legs precipitating immediately.
negatice factors in
Ÿ 2 suicide attempts factors in
by OD during criticizing. individual
individual 3. To avoid further
teenage years depression. situation
Ÿ 1 suicide attempts situation.
- Exrpressed
past 6 months. realistic self
Behavioral Traits Express realistic
Ÿ Chronic suide
self evaluation and evaluation and
ideation
increased sense of 4. Demonstratedcon increase sense of
4. Showing concern
self esteem. cern about client’s can help self esteem.
welfare establish trust - Participated in
Participate in care from client care and meet
and meet own making her own needs in
needs in assertive cooperate in assertive manner.
Suicidal behavior
manner interventions. - Performed
relaxation
Perform relaxation
5. Aids in
 techniques. 5. Facilitated discovering the techniques.
discussion of root and cause of
Long Term: factors or events behavior to give
optimal care and
that precipitated
At the end of the intervention.
the suicadal
shift the client will
Risk for Self Harm thoughts.
related to feeling of - demonstrate self-
hopelessness as control as 6. Removed 6. To prevent
dangerous items provocation and
evidence of suicidal evidenced by
from the client implementation
thought relaxed posture, of suicide
nonviolent environment.
endencies.
behavior/verbaliza
tion.

7. A calm external - Long Term:

7. Reduce milieu environment
noise and often helped to
stimulation or promote a
accompany client relaxed internal - at the end of the
to a calmer, state within the shift, the client
quieter client and may was able to
lessen agitation
environment at - -Demonstrate
and prevent
early signs of violence. self-control as
anger. evidence by
relaxed posture,
nonviolent
8. To prevent behavior/verbaliz
8. Place client in tendencies of
ation.
room with injuring self.
protective
window coverings
as appropriate.
 9. To equip client
9. Instruct client and and significant
significant other others with
in signs knowledge on
what is it and
symptoms and
how it will be
basic. engaged.

10. Ecouraged to do 10. Help client relax

deep breathing and divert
exercises activity. client’s attention
therapies such
asmusic, dance,
and recreational. .
11. Staff and family
11. Encouraged client
can help the
to continue client prevent
seeking staff or negative feelings
family when from any
experiencing reaching
frustration rather destructive levels
than waiting until if they know
clients state in
negative thoughts
advance.
are out of control
which leads to
imulse tendencies
of hurting self. 12. To help family
12. Instructed the to know what are
things that can
family that
happen.
suicidal isk
 increase for
severely
depressed clients
as they begin to
feel better. 13. To empower the
13. Facilitate support client to feel the
of client by support to have a
family and friends faster recovery.
14. Administer 14. Medications help
medication on control clients
condition.
time as ordered
Adhereance can
and promote helo client to be
compliance. mentally stabe.

Busspirone15 mg
STAT

Fluxetine 10 mg 1 tab
OD