ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Risk for suicide SHORT TERM: IDEPENDENT: INDEPENDENT: SHORT TERM:
“napapagod na ko. related to history
After one week of 1. Developed 1. In order to have After one week of
Ito na lang paraan of prior suicide nursing intervention caring rapport client’s nursing intervention
para matapos lahat attempt and the client: will be
with client cooperation and the goal was met as
to.” as verbalized verbalizations of able to:
improve nurse- evidenced by
by the patient threats of killing
 Will be patient
herself  Verbalization
Objective: involved in relationship of control to
planning impulses
Temperature: 2. Approach the 2. Enhances
course of  Participated
36.5 client in a feelings of well in care
action to
BP: 120/90  Assisted in
correct consistent manner security and
mmHg identifying
RR: 20 cpm existing in all interactions. provides structure. thoughts,
PR: 113 bpm problems and 3. Provided a safe feelings, and
02: Saturation: 3. Removing behavior that
verbalize environment.
95% potentially leads up to
control of Weapons and pills her wanting
harmful objects
impulses should be removed to commit
 Participate in prevents the suicide.
• feeling of by friends,
patient from acting  Participated
hopelessness care
relatives, or the in planning
 Will assist in or sudden self- course of
nurse.
• Impulsive identifying destructive action to
thoughts, correct
impulses.
4. Presented existing
 opportunities for problems
• Suicide ideation feelings, and 4. It is helpful for
the patient to LONG TERM:
behavior that the patient to talk
• History of express thoughts,
leads up to her about suicidal
suicide attempts After 1 month of
wanting to and feelings in a
thoughts and nursing intervention
commit nonjudgmental
intentions to harm the client was able
suicide. environment.
themselves to;
5. Made a clear
LONG TERM:
and concrete 5. Helps minimize  Demonstrated
After 1 month of
written plan of care manipulations and a use of a
nursing intervention
so other staff can might help newly
the client will able
follow. encourage learned
to
6. Educated the cooperation. coping skill
• Demonstrate a use patient in the
6. Drug therapy to modify
of a newly learned
appropriate use of suicidal
coping skill to may benefit the
medications to attempts.
modify suicidal patient endure
facilitate his or her
attempts. underlying health  Made a
ability to cope. decision that
• Make a decision problems such as
that suicide is not suicide is not
7. Introduced the depression.
the answer to
the answer to the
use of self- the perceived
perceived
7. Patients are
problems.
expression
problems. better to
methods to manage GOAL WAS MET
acknowledge and
safely handle
suicidal feelings. suicidal feelings
by programs such
as keeping
journals and
calling hotlines.

8. Instructed the 8. To guarantee

patient on how and the safety of the
when to use the patient.
emergency hot-
lines when she gets
feelings of suicidal
thoughts at
discharge.

DEPENDENT:
DEPENDENT:
9. Encouraged 9.To avoid over-
dosing of the
patient with the
patient.
compliance for
drug dosing
 ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Self-Mutilation Short term: INDEPENDENT: INDEPENDENT: Short term:

“Hinahanap related to history After 3 days of 1. Developed 1. To gain After 3 days of
naming siya dahil of self-injury and nursing rapport with patients’ trust nursing
and
kakain na. at negative feelings intervention: client cooperation intervention the
nakita na lang as manifested by that will further goal was met as
- Patient will improve nurse-
namin nasa banyo marks of old scars evidence by
demonstrate patient
at madaming on wrist. relationship
alternative 2. The client is - Patient
dugo.”as 2. Placed the
ways of easier to demonstrated
verbalized by the client in a room observe and has
expressing less chance to alternative
mother of the near the
feelings, such leave the area ways of
patient nursing station undetected.
as contact with expressing
or where the
a therapist or feelings, such
client can be
significant as contact with
Objective: observed
other instead a therapist or
Vital signs taken easily, rather
of acting-out significant
as follows: than a room
behaviors other instead
near an exit
Temperature: of acting-out
or stairwell,
36.5 behaviors.
BP: 120/90 - Patient will be and so
3. The client may -
mmHg safe and free forth. use these items - Patient was
RR: 20 cpm 3. Closely for self-
of self- safe and free
PR: 113 bpm destructive
inflicted injury supervised the
02: Saturation: acts. of self-
95% throughout client’s use of
inflicted injury
 hospitalization sharp or throughout
• presence of
- Patient will other hospitalization.
slashes on wrist
participate in potentially - Patient
impulse dangerous participated in
•history of self-
control objects. 4. Identifying impulse
harm
patterns and
• Feeling Anxious training 4. Assessed control
circumstances
client’s history surrounding training
• Heavily crying Long term:
of self- self-injury can
help the nurse Long term:
After 1 month of mutilation: plan
nursing -Types of interventions After 1 month of
intervention: and teaching nursing
mutilating
strategies
behaviors. suitable to the intervention the
-Frequency client. client was able to:
- Independently
of
- Patient was
control urges
behaviors.
able to
for self-
-Stressors
independently
harming
preceding
control urges
behavior 5. Feelings are a
behavior
for self-
- Patient will guideline for
5. Recognized
future harming
participate in
feelings intervention behavior.
the therapeutic (e.g., rage at
experienced
regimen. feeling left out
before and or abandoned). - Patient
- Patient will
 seek help around the act participated in
when of self- the therapeutic
experiencing mutilation. regimen.
self- Explored with - Patient was
destructive the client what able to seek
impulses. these feelings help when
- . might mean. experiencing
- A way to self-
gain control destructive
over others. impulses.
- A way to
Goal was met.
feel alive
through
pain. 6. Patient may
-An respond with
anxious or
expression
aggressive
of self-hate behavior if
or guilt. startled or over
stimulated.
6. Provided a
pleasant and
quiet
environment
 and approached
patient with a
calm, 7. Professionalism
helps improve
respectful, the client’s
supportive and treatment and
therapy and
stable attitude.
avoid negative
behaviors.
7. Be consistent
when 8. Consistency
interacting with helps
encourage new
the client and
thought
in routine care. processes and
can establish a
sense of
8. Use a matter-
security.
of-fact
approach when
self-mutilation
9. A neutral
occurs. Avoid approach
criticizing or prevents
blaming, which
giving
increases
sympathy anxiety, giving
special
9. Discussed with attention that
 the client their encourages
plans and acting out.

goals; help
distinguish
between
10. Help the client
positive, regain control
realistic goals of reality and
become more
and unrealistic
focused. Helps
goals. the client
understand
their
10. After the
capabilities.
treatment of the
wound, discuss
what happened
right before,
the thoughts
and feelings
11. Identify
that the client dynamics for
had both client and
clinician.
immediately
Allows the
before self- identification
mutilating. of less harmful
responses to
 help relieve
11. Work out a intense
tensions.
plan
identifying 12. Plan is
periodically
alternative to
reviewed and
self-mutilating evaluated.
behaviors. Offers a chance
to deal with
feelings and
struggles that
12. Identify two or arise
three people
13. To have
whom the someone
client can guiding the
client during
contact to those times

13. discuss and

examine
intense feelings
(rage, self-hate)
when they arise