NAME OF STUDENT: __________________________ NURSING CARE PLAN NAME OF PATIENT: ________________________________
GROUP NO. ___________ MEDICAL DIAGNOSIS: _____________________________
DATE: _______________ AGE: _____ NCP NO.: _________ RATING: ____
ASSESSMENT NURSING DIAGNOSIS
SCIENTIFIC EXPLANATION
OBJECTIVES NURSING INTERVENTIONS
RATIONALE EXPECTED OUTCOME
Disturbed personal identity related to absence and rejection of parental role model
Short Term:After 5 hours of nursing interventions, the client will acknowledge threat to personality
Assess client’s perception of the extent of the threat and how client is handling the situation
To assess causative and contributing factors
Short Term:The client shall have acknowledged threat to personality
Have client define own body image
To identify basis of client’s personal identity
Determine presence of delusions and distortions of reality
To identify extent of causation of causative and contributing factors
O> Client manifests: Uncertainties
about long-term goals or career choice
Vague self-image
Long termAfter 5 days of nursing interventions, the client will state ability to identify and accept self
Make time to listen to client, encouraging appropriate expression of feelings
To help the client in dealing with the situation
Long termThe client shall have stated ability to identify and accept self
Excessive use of projection
Client may manifests: Self mutilation Uncertainties
regarding gender
Help client recognize separateness from nurse by clarifying which behaviors and feelings belong to whom. If deemed
Touch and physical presence provide reality for client and serve to strengthen weak ego boundaries.
NAME OF STUDENT: __________________________ NURSING CARE PLAN NAME OF PATIENT: ________________________________
GROUP NO. ___________ MEDICAL DIAGNOSIS: _____________________________
DATE: _______________ AGE: _____ NCP NO.: _________ RATING: ____
identity appropriate, allow client to touch your hand or armDiscuss client’s commitment to an identity
To reinforce client’s integrity
Provide calm environment
To assist the client in discussing the issues
Allow the client to deal with situation in small steps
To help the client progress towards wellness
Confront statements that project client’s feelings onto others
To avoid untoward incidents
Always call client by his or her name. If client experiences feelings of depersonalization or derealization, orientation to the environment and correction of misperceptions may be helpful
These interventions help to preserve client’s feelings of dignity and self-worth.
Help client understand that there are more adaptive ways of validating his or her existence than self-mutilation. Contract with client to seek out
A contract gets the subject out in the open and places some of the responsibility for his or her safety with client. Client safety is a nursing
NAME OF STUDENT: __________________________ NURSING CARE PLAN NAME OF PATIENT: ________________________________
GROUP NO. ___________ MEDICAL DIAGNOSIS: _____________________________
DATE: _______________ AGE: _____ NCP NO.: _________ RATING: ____
staff member when these feelings occur
priority.
Work with client to clarify values. Discuss beliefs, attitudes, and feelings underlying his or her behaviors. Help client identify those values that have been (or are intended to be) incorporated as his or her own. Care must be taken by the nurse to avoid imposing his or her own value system on the client
Because of underdeveloped ego and fixation in early developmental level, client may not have established own value system. In order to accomplish this, ownership of beliefs and attitudes must be identified and clarified.
Use of photographs of client may help establish or clarify ego boundaries
Photographs may help to increase client’s awareness of self as separate from others.
Alleviate anxiety by assuring client that he or she will not be left alone
Early childhood traumas may predispose borderline clients to extreme fears of abandonment.
Provide accurate information about the threat to and potential consequences for individual
Helps client to make positive decisions in the future
NAME OF STUDENT: __________________________ NURSING CARE PLAN NAME OF PATIENT: ________________________________
GROUP NO. ___________ MEDICAL DIAGNOSIS: _____________________________
DATE: _______________ AGE: _____ NCP NO.: _________ RATING: ____
Refer to appropriate support group
To promote wellness