College of Nursing

Graduate Studies

NURSING CARE PLAN

NAME OF PATIENT: VICKI ATTENDING PHYSICIAN: Dr. Edwards DIAGNOSIS: Borderline Personality Disorder HOSPITAL/ROOM: _________

ASSESSMENT DIAGNO PLANING INTERVENTION EVALUATION

SIS
SUBJECTIVE Risk for SHORT TERM GOALS INDEPENDENT SHORT TERM GOALS
: ‘There’s nothing injury After 24 hours of nursing 1. Observe client’s behavior frequently. Do this through routine activities and After 24 hours of nursing
about me or my related intervention the patient will interactions; avoid appearing watchful and suspicious. intervention the patient was
personality you can to be able to: a. Rationale: Close observation is required so that intervention can occur if able to:
tell me that I do not Extreme  Client will no longer exhibit required to ensure client’s (and others’) safety.  No longer exhibit potentially
already know. And hyperac potentially injurious 2. Reduce environmental stimuli. Assign a private room, if possible, with soft lighting, injurious movements after
what you don’t hear tivity/ph movements after 24 hours low noise level, and simple room decor. 24 hours with administration
from me, you’ll ysical with administration with a. Rationale: In the hyperactive state, the client is extremely distractible, and with administration of
make up anyway. agitatio administration of responses to even the slightest stimuli are exaggerated. tranquilizing medications.
You, Dr. Hernandez n tranquilizing medications. 3. Assign to a quiet unit, if possible.  Experience no physical
(the consultant who  Client will experience no a. Rationale: Milieu unit may be too distracting. injury.
contacted the Dean) physical injury. 4. Limit group activities. Help client try to establish one or two close relationships.  Client’s agitation was
and Professor  Client’s agitation will be a. Rationale: Client’s ability to interact with others is impaired. He or she feels maintained at manageable
Borromeo (the maintained at manageable more secure in a one-to-one relationship that is consistent over time. level with the administration
Dean) are three level with the administration 5. Remove hazardous objects and substances from client’s environment (including of tranquilizing medications
sides of the same of tranquilizing medications smoking materials). during first week of
coin. Just greedy during first week of a. Rationale: Client’s rationality is impaired, and he or she may harm self treatment.
stenocrats. That is treatment. inadvertently. Client safety is a nursing priority.  Client did not harm self or
it, the end.’ As  Client will not harm self or 6. Stay with the client others.
verbalized by the others. a. Rationale: to offer support and provide a feeling of security as agitation  Client has consume
patient  Client will consume grows and hyperactivity increases. sufficient finger foods and
sufficient finger foods and 7. Provide structured schedule of activities that includes established rest periods between-meal snacks to
between-meal snacks to throughout the day. meet recommended daily
meet recommended daily a. Rationale: A structured schedule provides a feeling of security for the client. allowances of nutrients..
allowances of nutrients. 8. Provide physical activities as a substitution for purposeless hyperactivity (examples:
brisk walks, housekeeping chores, dance therapy, aerobics).
a. Rationale: Physical exercise provides a safe and effective means of relieving
pent-up tension.
9. Encourage the client to talk about feelings he or she was having just before this

OBJECTIVE LONG TERM GOALS
Constant After 2 weeks of nursing
movement, seem intervention the patient will
restless and fidgety be able to:
Cannot maintain  Client will not harm self or
eye contact for others.
long, eye wander  Patient will respond to
around external limits.
Presents agitation  Patient will participate in
and high risk the therapeutic regimen.
behavior (buying of  Within one week, client will
property without be able to recognize and
appropriate verbalize when thinking is
funding) non-reality based.
Thinks the dean and  Client will be able to
GP are all making is recognize and verbalize
condition up when he or she is
interpreting the
environment inaccurately.
College of Nursing
Graduate Studies
behavior occurred.
a. Rationale: To problem-solve the situation with the client, knowledge of the
precipitating factors is important.
10. Try to redirect violent behavior with physical outlets for the client’s anxiety (e.g.,
punching bag, jogging).
a. Rationale: Physical exercise is a safe and effective way of relieving pent-up
tension.
11. Act as a role model for appropriate expression of angry feelings, and give positive
reinforcement to the client when attempts to conform are made.
a. Rationale: It is vital that the client expresses angry feelings, because suicide
and other self-destructive behaviors are often viewed as a result of anger
turned inward on the self.
DEPENDENT LONG TERM GOALS
 Have sufficient staff available to indicate a show of strength to the client if necessary. After 2 weeks of nursing
Rationale: This conveys to the client evidence of control over the situation and intervention the patient was
provides some physical security for staff. able to:
 Administer tranquilizing medication, as ordered by physician. Antipsychotic drugs are  Client did not harm self or
commonly prescribed for rapid relief of agitation and hyperactivity. Atypical forms others.
commonly used include olanzapine, ziprasidone, and aripiprazole. Examples of the  Respond to external limits.
typical forms include haloperidol and chlorpromazine. Observe for effectiveness and  Participated in the
evidence of adverse side effects therapeutic regimen.
 Was able to recognize and
verbalize when thinking is
non-reality based.
 Was able to recognize and
verbalize when he or she is
interpreting the
environment inaccurately.