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