Patient Information

Initials: J Age: 20 Gender: Female

Psychiatric diagnosis: Borderline Personality Disorder
Description of diagnosis (Use glossary)
Patients with borderline personality disorder have unstable moods, behaviors, and interpersonal
relationships. They fear abandonment and have a poorly formed identity. Relationships begin
with intense attachments and end with the slightest conflict. Aggression is common. They are
impulsive and may have a history of repeated suicide attempts/gestures or episodes of
self-mutilation. They have higher rates of childhood physical, emotional and sexual abuse than
the general population.

Past Medical History:

Borderline Personality Disorder, self-harm, anxiety, depression, hypothyroidism, polysubstance
abuse, impulsivity

History of Present Illness:

The patient has a history of Borderline Personality Disorder (BPD), self-harm and substance
abuse. Her family states she has lost a lot of weight recently, they believe she is drinking a lot of
alcohol, and suspect the use of several substances. She has lost 32 pounds since her primary care
provider (PCP) visit a little over 3 months ago. She has been a “no show” for her last 2 monthly
appointments with her PCP. She admits she has not taken any of her medications for close to
three months. She laid in the middle of the road for more than 20 minutes in front of her home
and police had to be called.
Medication List:
Currently not taking any medications. She was supposed to be taking:
Synthroid 75 mcg PO daily
Abilify 15 mg PO Daily
Sertraline 50 mg PO BID
Current Care-Interventions/Therapy (Describe therapy and give examples)
Dialectical Behavioral Therapy (DBT): DBT is a type of talk therapy for people who experience emotions
very intensely. It's a common therapy for people with borderline personality disorder. Can be useful in treating mood
disorders and suicidal ideation as well as for changing behavioral patterns such as self-harm and substance use.
The patient had recently started DBT and attended 1 session.
Ever since then she has been a no show for appointments.

Labs/Tests/Procedures/Exams (Abnormal results and interpretation)

UA: Clear, no leukocytes, no blood, negative bili, (grossly negative).
HCG: Urine pregnancy negative
UDS: + Marijuana, + methamphetamine, + opioids Blood Alcohol: less than 0.05
CBC: normal CMP: normal other than low Na 134, low K 3.3, high TSH: 7.2
May be due to history of hypothyroidism
EKG: NSR in the 90s, no ST elevation or depression. No ectopy
Assessment findings (Also, include a drawing or a photo detailing the client)
 Current VS
VS: BP:112/60, P:92, RR:16, T:98.0, O2 Sat: 99% on RA, Wt: 112 lbs

●
● Skin assessment: Patient has superficial cuts on wrists and thighs bilaterally. (unable to add the cuts to the anatomy
body)

Assessment to Support
Nursing Diagnosis and Pt. Individualized Nursing Interventions. Evaluation of
Nursing Diagnosis:
Centered Goal: 3 Required Rationale for Each Intervention Progress
(Subjective & Objective
(NOC) (NIC) Towards Goals:
Data)

Nursing Diagnosis: Risk for

self-directed
violence/suicidal behavior 1. Close observation is
r/t: impulsiveness of 1. Assessment related: required so interventions can
suicidal behavior and Assess and observe the patient's behavior q4 be implemented to ensure
Subjective: When asked
suicidal ideation about lacerations, she states
hours. Do this through routine activities and patients safety.
AEB: History of self-harm. interactions avoiding the appearance of
“sometimes I just need to 2. Discussing feelings of
being watchful and suspicious.
Patient laid in the middle feel something.” self-harm with a trusted Patient did
of the Patient states, “Everyone
2. Independent/nurse driven intervention individual may provide some require some
road for more than 20 would probably be better off
if it did happen.” When
(A provider RX is not needed for this, what relief to the patient. Patient Lorazepam as
minutes in front of her asked about lying in the road
can the RN do autonomously): safety is a nursing priority. needed. She
home and police had to be Encourage the patient to seek out a staff
she states, “I don’t really 3. Medications may be has been
member when the urge for self-injury
called. know if I was trying to die ordered such as anxiolytics or stabilized
intensifies. Remove all dangerous objects
Patient centered outcome: but at least my neighbors
from the patients environment, antipsychotics. These have a showing more
(SMART goal – specific, and people were paying
attention and actually cared
3. Collaborative (Interprofessional calming effect on the patient participation
measurable, attainable, realistic, intervention):
time-bound) for once. That made me feel and may prevent aggressive and is planning
Administer medications as ordered by the
Patient will seek out staff alive.” behaviors. Close monitoring to discharge
physician or obtain an order if necessary.
Objective: Patient has is important due to home.
members if feelings of Monitor the patient for effectiveness of
superficial cuts to her wrists
harming themselves or medication for the appearance of adverse impulsivity being a common
and thighs bilaterally.
others emerge while being side effects to ensure the patient is not symptom of BPD and may
hoarding medication. increase risk for overdose
an inpatient. Patient will
not harm themselves or attempt.
others throughout the shift.
 Presenting Target of Intervention Nursing colleague’s role My role in the
Intervention Client Strengths
Problem #1 & Benefit to Client in the intervention Intervention

This intervention
targets the issue of
environmental
insecurity that Julia
Has previous
is experiencing. As
work
she is currently
Connecting experience
being prepared as an
Julia to that has lasted My role in this
outpatient, it will be The nurse's role is to
resources a year. intervention as a
Julia is vital to provide a refer them to
such as a Making it social worker will
concerned secure foundation assistance programs
career more likely be to seek out
that she will for her to live in. So, after evaluating their
advisor, food that the resources such as
be out of a making a secure concerns and trying
stamps, or company will food stamps, rent
job and environment and to support them
any rent let her back. relief programs, and
unable to pay decreasing outside emotionally
relief If not then a career advisor to
bills. stressors provides throughout the
resources this assist her in finding
the client with some process.
available in experience a new job.
stability. This will
her area. will benefit in
allow her to focus
future job
on improving her
searches.
mental health rather
than her trying to
keep up with her
environment.
Presenting Target of Intervention Nursing colleague’s role My role in the
Intervention Client Strengths
Problem #1 & Benefit to Client in the intervention Intervention

Providing the This intervention When in the The nurse's role in

Julia appears client with a will provide Julia hospital Juila this intervention
to struggle in mild form of with a consistent was able get would highly depend
her in-home care form of company on her on being empathetic,
My role in this
environment where the and attention that previous showing them
intervention would
where she is individual she has expressed a medications kindness, earning
be to connect Julia
alone. This will visit the desire for. Without and their trust, and being
to an in-home care
has resulted in client this engagement the participate in there for them in
program and to
the client regularly to client is more likely group and ways that others
check up on Julia to
engaging in accompany to engage in risky individual cannot. The ongoing
monitor if this
risky her to behavior that could situations. relationship that is
approach leads to
behaviors so appointments lead to serious This shows built with each
improvement.
others may or encourage injury or death. It that if patient contributes to
pay attention her to take also can help Julia encouraged whether they feel
to her. her to attend more by others alone or connected
medication. appointments and Juila is able on their health
possibly take her to improve journey and how
medication more her health. their health
consistently because progresses.
as she has stated Examples would be
before she does not taking them on a
know why she is not walk, allowing them
attending her PCP to engage in group
meetings. So, by activities, and
providing someone encourage support
to go with her and groups.
encourage her like
Julia was in the
hospital, then it may
help the client in her
treatment.