St.

Paul College of Ilocos Sur

(Member: St. Paul University System)
St. Paul Avenue, 2727 Bantay, Ilocos Sur

DEPARTMENT OF NURSING
NAME: RICA MACHELLS C. DAYDA DATE: 05/24/21

BOARDERLINE DIRORDER

Disturbed Personality Identity

Assessment Diagnosis Planning Intervention Rationale Evaluation
Subjective: “ Laging Disturbed Short Term Goal : Independent: Short term goal: (Goal Met)
nag babago yung Personality Identity
mood ko” as secondary to  Promoted patient’s Suicidal thoughts, as well as the
verbalized by the Borderline Within 8 hours of existence of a plan, availability of Within 8 hours of effective nursing
safety all the time.
patient. Personality effective nursing intervention, the patient was safe,
means for carrying out the plan,
Disorder as intervention, the injury-free, and demonstrate
and self-harm acts, must all be
evidenced by patient will be safe, satisfaction with personal
injury-free, and taken seriously by the nurse, and relationships.
impulsive behavior, necessary interventions must be
unstable personal demonstrate
satisfaction with provided.
relationships,
tendency of self- personal
inflicted injury, and relationships.
intense feelings of  Established the
Objective therapeutic The nurse must give structure
emptiness
● Poor eye relationship with the and boundary setting in the
contact patient by setting therapeutic relationship
 ● Facial tension
boundaries. regardless of the clinical context.
Vital signs: In a medical environment, this
Temperature: would involve seeing the patient
36.4 °C for pre-scheduled appointments
RR: 24bpm rather than whenever the patient
PR: 115bpm shows up and requires prompt
BP: 160/110 mmHg treatment from the nurse. The
SPO2: 97% nurse can also set the tone by
attending appointments on
schedule and setting clear,
realistic treatment goals.
Boundaries are often essential for
patients with Borderline
Personality Disorder (BPD) to
help them see their surroundings
as more constant and
predictable.

 Demonstrated This communicates to the patient

attention and empathy that the nurse is engaged with
to the patient’s him or her and ready to offer
concerns. assistance. Despite the patient’s
conduct and obstacles it
presents, maintain a warm
demeanor while staying
unbiased.
 Answered questions of
the BPD patient in a Since patients with BPD may
clear, non-technical have altered communication
 manner. styles, it is indeed important to
speak clearly, simply, and without
the complexity that can alienate
the patient even more. Maintain a
neutral stance and encourage the
patient to communicate his or her
thoughts and queries.
 Teach the BPD patient
Basic communication techniques,
about using effective
including eye contact, listening
communication
skills, taking turns speaking,
techniques.
confirming the context of
another’s message, and using “I”
statements, should be taught to
BPD patients.
 Assisted the BPD
The nurse can assist BPD
patient in coping and
patients to recognize their
controlling his
feelings and practice enduring
emotions.
them without having extreme
responses such as destroying
property or self-harm; journaling
can also assist these patients in
being more conscious of their
emotions.
 Planned the patient’s
da-to-day tasks.
Patients ca handle time alone by
reducing downtime by planning
activities. Patients may develop a
written plan that involves
meetings, buying groceries,
 reading a book, and getting some
exercise.

 Worked with ither

mental health
providers. Psychotropic medicines and
psychotherapy may be required
for BPD patients. When a nurse
collaborates with other mental
health practitioners, he or she
takes part in a more holistic
approach to therapy and has the
resources required to better
communicate with patients.

 Ensured that a Since many BPD patients had

member of staff is been abused as children, their
around to act as a imagination borders may be quite
witness throughout the hazy. As a result, any procedure
physical examination that the patient perceives as
of the BPD patient. intrusive, such as a physical
examination, may trigger sexual
or abusive thoughts.
 Risk Personality Identity

Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective Self-directed Short term: Independent Short term:
“nurse bakit ba ako violence At the end of 4 hours Function At the end of 4 hours of nursing intervention,
nabubuhay? Gusto ko secondary to of nursing  Determined To prevent the client..
nalang talagang boarder line intervention, the whether client occurrence of
mamatay ” as disorder as client will: shows signs harming oneself/ - did not hurt/harm himself
verbalized by the manifested by that will lead planned suicide
patient feeling of hopeless - not harm self to harming and was able to:
and scratches on self/suicide
Objective his wrist. - verbalize - verbalize feelings; express decreased
- Scratched on wrist feelings; express  Determined To know if there is a anxiety and anger appropriately
decreased history of pattern of
Vital signs: anxiety and suicide/ self occurrence to - Verbalize understanding of why behavior
Temperature: anger harming anticipate and occurs.
36.4 °C appropriately attempts intervene
RR: 24bpm immediately - Identify precipitating factors in individual
PR: 115bpm - Verbalize situation.
BP: 160/110 mmHg understanding of
SPO2: 97% why behavior  Refrain from - Express realistic self-evaluation and
occurs. negatively To avoid further increased sense of self-esteem.
criticizing depression
- Identify - Participate in care and meet own needs
precipitating  Demonstrate in an assertive manner.
factors in concern about Showing concern
 individual client’s can help establish - perform relaxation techniques
situation. welfare trust from client
making her Long term
- Express realistic cooperate in At the end of the shift, the client was able to:
self-evaluation interventions
and increased - Demonstrate self-control as evidenced by
sense of self- relaxed posture, nonviolent
esteem.  Facilitate behavior/verbalizations.
discussion of
- Participate in factors or
care and meet events that Aids in discovering
own needs in an precipitated the root and cause of
assertive the suicidal behavior to give
manner. thoughts optimal care and
intervention
- perform
relaxation to prevent
techniques provocation and
 Remove implementation of
dangerous suicide tendencies
Long term: items from the
At the end of the client’s A calm external
shift, the client will: environment environment often
helped to promote a
- Demonstrate relaxed internal state
self-control as within the client and
evidenced by and may lessen
relaxed posture,  Reduce milieu agitation and prevent
nonviolent noise and violence
behavior/verbaliz stimulation or
ations. accompany To prevent
client to a tendencies of
calmer, injuring self
 quieter
environment
at early signs
of anger,

 Place client in
room with
protective To equip client and
window significant other with
coverings, as knowledge on what
appropriate is it and how will it be
mangaged.
 Instruct client
and
significant Helps client relax
other in signs, and divert client’s
symptoms, attention
and basic
physiology of
depression

 Encourage to
do deep Staff and family can
breathing help the client
exercises, prevent negative
activity feelings from
therapies reaching destructive
such as music levels if they know
therapy, the clients state in
dance advance. Staff can
 therapy, also engage client in
recreational therapeutic
therapy. activities/exercises
and can offer
medications when
necessary.

 Encourage
client to To empower the
continue client to feel the
seeking staff support to have a
or family faster recovery
when
experiencing
frustration,
stress,
anxiety rather
than waiting
until the
negative
thoughts and
feelings are
out of control,
which can
lead to
impulse
tendencies of
hurting self.
Dependent
Function
 Administer Medications help
medications control client’s
on time as condition. Adherence
orderedand can help client to be
promote mentally stable.
compliance.

Collaborative
Function: For manifestations
 Refer client to that cannot be
psychiatrist, managed/ done
as needed. independently by the
nurse.

 Instruct family To help the family

that suicidal know what are the
risk increases things that can
for severely happen
depressed
clients as they
begin to feel
better
 Anxiety
Assessment Nursing Planning Intervention Rationalization Evaluation
Diagnosis
Subjective: Anxiety related to Short Term Goal : Independent Fucntion: Short Term Goal :
“natatakot akong borderline disorder  Encourage patient to Provides opportunity to examine
ganto nalang ako as evidenced by share thoughts and realistic fears and misconception
palagi" as verbalized Within 8 hours of feelings. Within 8 hours of effective nursing
feeling of
of the pt. effective nursing Provides assurance that patient is intervention, client will be able to
hopelessness and  Maintain frequent
intervention, client not alone and fostering trust. display appropriate range of feeling
fear contact with patient.
will be able to and lessened fear
Talk and touch patient
display appropriate
appropriate.
range of feeling and Helps patient feel accepted in
 Provide open
lessen fear present condition without feeling Long Term Goal:
environment in which
patient feels safe to judged Within 1-2 days patient will be
discuss feelings. able to demonstrate use of
Objective
 Assist patient in Support and counseling are often effective coping mechanism and
● Poor eye Long Term Goal:
recognizing and necessary to enable individual to active participation in reducing
contact fear.
clarifying fears to recognize and deal with fear
● Facial tension
Within 1-2 days begin developing
● Increase .
patient will be able coping strategies.
perspiration
to demonstrate use
of effective coping Dependent Function:
Vital signs: mechanism and ● Administered To help relax the patient.
Temperature: active participation medications for anxiety
36.4 °C in reducing fear. such selective
RR: 24bpm serotonin reuptake
PR: 115bpm inhibitors
BP: 160/110 mmHg
SPO2: 97%
 SEXUAL DIRORDER
Sexual dysfunction

Assessment Nursing Planning Intervention Rationalization Evaluation

Diagnosis
Subjective: He Sexual dysfunction Short term Goal: Independent Function: Short term goal: (Goal Met)
reports significant related to low After 8 hours of
erectile dysfunction testosterone level effective nursing  Obtained the patient's Gradual problems with sexual After 8 hours of effective nursing
(ED) that has secondary to interventions the medical, surgical, and function may occur with interventions, the patient has
progressed over the hypertension and patient will identify sexual history, noting advancing age or as the result of identify stressors in lifestyle that
past 8 months. diabetes as stressors in lifestyle normal and disease problems. Sexual contribute to his erectile
manifested of that contribute to his problematic patterns of problems can result from dysfunction
functioning. neurological, hormonal, arterial,
reporting significant erectile dysfunction.
Objective: cavernosal, and psychological
erectile dysfunction
factors, and/or surgical
over for the past 8 procedures.
Vital signs: Long term Goal:(Goal Met)
months.
Temperature: 36.4 After 3 days hours of effective
°C Long term Goal:  If in a specialty area, nursing interventions the patient
RR: 24bpm consider administering Comparing before-and- after
PR: 115bpm After 3 days hours the International Index treatment response may provide verbalized understanding of
BP: 160/110 mmHg of effective nursing of Erectile Function an objective measurable individual reasons for erectile
SPO2: 97% interventions the tool before and after indication of improvement. dysfunction and he is able to follow
patient will verbalize treatment. some treatments for his erectile
Laboratory understanding of dysfunction.
Findings: individual reasons  Determined the
patient's and Men are often embarrassed or
for erectile
significant other's hesitant to discuss sexual
 Low dysfunction and
current knowledge, problems. A lack of information or
Testosterone able to follow some understanding, and having misinformation may add to
level: 1.35 treatments for his expectations. the patient's problem.
ng/dL erectile dysfunction.
 Explore physical
causes (e.g., diabetes, ED often occurs as a result of a
hormonal insufficiency, disease process or drug side
heart disease, and effects.
drug side effects).

 Provided a privacy and

be nonjudgmental Privacy facilitates development of
during interactions with a trusting relationship. Men may
the patient and not feel comfortable discussing
significant other. their sexuality with others,
especially a female nurse. A
confident, matter-of- fact, and
knowledgeable approach by the
nurse will instill confidence in
working with patients. Respecting
the individual and treating his
concerns as normal may foster
greater acceptance of the
problem and reduce anxiety.
 Explaind the need to
 share concerns with Men with ED commonly isolate
the significant other. themselves from others because
Correct misinformation of shame, embarrassment, and
about sexuality and stress.
ED.

 Correct misinformation
about sexuality and Misinformation about ED may
ED prevent the patient from seeking
help for treatable problems. Many
men may accept ED as a natural
result of aging. Providing
accurate information about ED
may decrease the patient's
unrealistic expectations.
 Encouraged the
patient to include his Both partners have a vested
significant other in interest in working toward an
discussions of acceptable and successful
treatment and teaching treatment plan. Patience and
sessions. cooperation are needed from
each person.

 Teach the importance

of rest before sexual Patients may have a more
activity. meaningful experience if not
excessively tired.

 Encouraged use of a
nonnarcotic pain Pain inhibits sexual activity;
medication before however, narcotic use may cause
sexual activity. dysfunction.
 Teach the possible
side effects of drug Some drugs may impair sexual
therapies (e.g., function; these need to be
antidepressants, reported to the primary care
cardiac drugs, provider.
narcotics, some H₂-
receptor antagonists,
some nonsteroidal
antiinflammatory
drugs, and alcohol).

 Teach diabetics the

importance of diabetic
control. Explain use of Altered glucose levels may
5PDE treatment of ED. change sexual function due to
associated neuropathies and
 Explained accelerated peripheral vascular
contraindications of its disease.
use with patients
receiving nitrates (e.g., This drug enhances the effects of
nitroglycerin, nitric oxide released during
isosorbides). sexual stimulation, promoting
blood flow and subsequent
erection.
 Instructed the patient
to take the 5PDE from
30 minutes to 4 hours
before sexual activity, The combination of PDE
and not more than inhibitors and nitrates can cause
once daily. a sudden drop in blood pressure
that may result in sudden death,
myocardial infarction, or
 cardiovascular collapse. Sildenafil
is not effective in the absence of
 Advised the patient sexual stimulation.
that 5PDE is not
indicated for use in
women. Research has not proven this
drug to be effective in women.
 Instructed the patient
to notify his health
care professional if Priapism is a serious side effect
erection lasts longer and needs to be alleviated before
than 4 to 6 hours. permanent damage occurs.
 Informed the patient
that these medications
do not protect against Proper use of condoms is needed
sexually transmitted to prevent STIs.
infections (STIS).
Teach regarding
androgen replacement
therapy with
testosterone:

Collaborative Function:
 Refered the patient to Changes in sexual function may
appropriate resources have adverse effects on the
such as primary care couple's relationship. Specialists
provider, urologist, are needed for complex
clinical specialist, situations.
sexual counselor, or
family counselor.
 Anxiety

Assessment Nursing Planning Intervention Rationalization Evaluation

Diagnosis
Subjective: He fears Anxiety related to Short Term Goal : Independent Function Short term goal: (Goal Met)
he is “impotent” and threat to current
will never be able to condition as ● Assessed level of This will helps determine the kind
have a normal sex Within 8 hours of of interventions required. After 8 hours of effective nursing
evidenced by patient anxiety.
life again. effective nursing interventions, the patient
Glancing about, intervention, the appeared relaxed and reported
Poor eye contact, patient will appear Patient and SO are hearing and reduced anxiety.
Facial tension, relax and report ● Evaluated patient level assimilating new information that
increase reduced anxiety. of understanding of includes changes in self-image Long term Goal:(Goal Met)
perspiration and diagnosis. and lifestyle
verbalization of After 1-2 days of effective nursing
uneasiness Long Term Goal: intervention, Patient was able to
● Identified patients Distorted perception of the demonstrate healthy ways to deal
Objective current perception to situation will magnify feelings
● Poor eye Within 1-2 days with and express anxiety.
the current threat.
contact patient will be able
● Facial tension demonstrate healthy Anxiety causes palpitation and
● Monitor vital signs.
ways to deal with rapid pulse
 ● Increase and express anxiety
perspiration

Vital signs: ● Established To be able to gain the trust of the

Temperature: therapeutic patient
36.4 °C relationship, conveying
RR: 24bpm empathy and
PR: 115bpm unconditional positive
BP: 160/110 mmHg regard.
SPO2: 97%
This helps the patient identify
● Provided accurate what is reality based
information about the
situation.

To reduce additional anxiety.

● Avoid False
reassurance.

This helps promote expression of

● Be available to the feeling
patient for listening
and talking
To help calm and relax the
● Provided quiet patient
environment

● Encouraged patient to Provide chance of expressing

verbalize feelings as fear and feeling of sadness
much as he can.
● Assisted client in
developing anxiety Utilizing anxiety reducing
 reducing activities like activities enhances patients’
deep breathing sense of personal mastery and
exercise and positive confidence.
visualization.

Dependent Function

● Administered
medications for anxiety This is to help the client to be
such selective calm and relax
serotonin reuptake
inhibitors
 Disturbed Personality Identity
Assessment Diagnosis Planning Intervention Rationale Evaluation
Subjective: “ Laging Disturbed Short Term Goal : Independent: Short term goal: (Goal Met)
nag babago Yung Personality Identity  Constantly ensure  Considering dissociative
mood ko” as secondary to patient’s safety by behaviors can be
verbalized by the Sexual Within 8 hours of Within 8 hours of effective nursing
raising the side rails, disturbing for patients,
patient. Dysfunction. effective nursing intervention, The patient displayed
intervention, The and close supervision reassuring them of their appropriate and culturally
patient will display among others. safety and security with acceptable acts for the given
appropriate and the nurse’s presence is gender and exhibit pleasure with
culturally acceptable  Determine the vital. his or her sexuality pattern.
acts for the given patient’s causes of  Assist the patient in
gender and exhibit stress. determining the dimension
pleasure with his or of time linked with the
her sexuality commencement of the
Objective pattern. problem and talking about
● Poor eye what was going on his or
contact her life at the time.
● Facial tension  Encourage the patient  Encouraging the patient to
to talk about his or her talk about any disease
Vital signs: condition. processes that may be
Temperature: influencing the sexual
36.4 °C dysfunction. This will make
RR: 24bpm the patient aware that
PR: 115bpm there are other ways to
BP: 160/110 mmHg achieve sexual fulfillment
SPO2: 97% through sex counseling if
the patient and partner so
choose.
 Determine what  Consider the cultural,
influences the patient’s social, and religious
 sexuality. aspects that may play a
role in disagreements over
different sexual behaviors.
 Ensure privacy and  Sexuality is a very private
accept the patient’s and sensitive matter; if the
sexual concerns patient does not fear being
without being judged by the nurse, he or
judgmental. she is more willing to
disclose this information.
Privacy also promotes the
development of trust in a
patient-nurse relationship.
 Assist the patient to  The act of verbalizing
express his feelings perceived or actual
about the changes in changes might help to
his image and bodily lessen anxiety and
function. facilitate continuous
conversation. Encourage
the patient to distinguish
between feelings about
physical changes and
feelings about self-worth.
 As needed, provide  Examine the patient’s
positive actions and the reactions
encouragement to the he or she elicits from
patient. others’ desirable
behaviors, such as social
attention (e.g., smiling or
nodding).

 Make a referral to
 support and self-help  Participating in support
organizations. groups can help patients
realize that they are not
alone in their concerns,
and they can utilize this
information to find
alternatives or solutions for
 Examine and validate specific treatment options.
the patient’s feelings  The severity of the
about a change in problem is determined by
sexual function. the patient’s value or
emphasis placed on
sexual performance rather
 Explore the root of any than by basic thoughts of
self-negating sexuality.
statements made by  There are variety of
the patient with sexual reasons for sexual
dysfunction. dysfunction, which could
be the source of this
coping issue. Other
factors, such as job
transfer or poor family
connections, might
exacerbate the problem
and result in poor self-
esteem, needing additional
interventions that cannot
 Evaluate the patient’s be addressed only through
past coping techniques the ability to execute
to see if they were intercourse.
effective.  Previous coping success
influences successful
adjustment; although past
coping skills may or may
not be effective in the
current situation.