Moleno, April Marie BSN III F

Nursing Care Plan

Case: AntiSocial Personality Disorder
Patient: Initials

Assessment Nursing Scientific Reference Planning Interventions Rationale Evaluation

Diagnosis (Research Articles) (Short / Long Term (Independent, Collaborative,
(Actual or Goals) Dependent)
Potential
Problem)
Subjective: Impaired Antisocial personality Long Term: INDEPENDENT
Social disorder (ASPD) is a After 1 week of  Expand limits by  When time is taken in Goals met as evidenced
“I don't get along with anyone, Interaction mental health condition. nursing clarifying expectations for initial meetings to clarify by the patient identify
including my family” as related to People with ASPD intervention the clients in a number of expectations, two personal behaviors
verbalized by the patient Disruptive or show a lack of respect patient will be able settings. confrontations, and that are responsible for
abusive early toward others. They to identify and power struggles with relationship difficulties
family don’t follow socially express feelings as clients can be minimized and demonstrate
background as accepted norms or rules. they occur with and even avoided. acceptable social skills
Objective: evidenced by People with ASPD may nurse and interacting with friend
Dysfunctional break the law or cause demonstrate an  In a respectful, neutral  From the beginning, and family and was able
Patient is incapable of interaction physical or emotional increase in manner, explain expected clients need to have to express feelings as
maintaining intimate and with peers, harm to the people nonviolent client behaviors, limits, explicit guidelines and they occur with nurse.
sexual connections. family, and/or around them. They may behaviors as and responsibilities during boundaries for expected
She separates herself from others. disregard consequences evidenced by a sessions with nurse behaviors on their part,
others. or refuse to take reduction in clinician. Clearly state the as well as what client can
responsibility for their reported outbursts. rules and regulations of expect from the nurse.
actions. the institution, and the Clients need to be fully
consequences when these aware that they will be
Reference: rules are not adhered to. held responsible for their
https://my.clevelandcli Short Term: behaviors.
nic.org/health/diseases After 3 days of
/9657-antisocial- nursing  Monitor own thoughts and  Strong and intense
personality-disorder intervention the feelings constantly countertransference
patient will be able regarding your response reactions to clients are
Moleno, April Marie BSN III F

to identify two to the client. Supervision bound to occur. When

personal behaviors is strongly recommended the nurse is enmeshed in
that are responsible for new and seasoned his or her own strong
for relationship clinicians alike when reactions toward the
difficulties and working with PD clients. client (either positive or
demonstrate negative), nurse
acceptable social effectives suffer, and the
skills interacting therapeutic alliance
with friend and might be threatened.
family.
 Collaborate with the  Tangible reinforcement
client, as well as the for meeting expectations
multidisciplinary team, to can strengthen the
establish a reward system client’s positive
for compliance with behaviors.
clearly defined
expectations.

 Understand that clients in  Responding to client’s

particular will be resistant resistance and seeming
to change and that this is lack of change in a
symptomatic of PDs. This neutral manner is part of
is particularly true in the the foundation for trust.
beginning phases of In other words, the nurse
therapy. does not have a vested
interest in the client
“getting better.”. The
nurse remains focused on
the client’s needs and
issues in any event.

COLLABORATIVE: Cognitive behavioral therapy

Moleno, April Marie BSN III F

Encourage patient to seek focuses on changing a person's

therapy. thinking and behavior. People
with ASPD may benefit from
therapy that encourages them to
consider how their actions affect
others. Individual, group, or
family therapy may be beneficial
to someone with ASPD.

DEPENDENT:
The following medications were
given by the physician that may
help treat these related disorders
include:  help relieve depression
 Antidepressants and anxiety in people
with personality
disorders.

 Can control aggressive or

 Antipsychotics violent behavior.
Risperidone and
quetiapine are two
examples.

Case: SOMATISATION DISORDER

 Moleno, April Marie BSN III F

Patient: Initials

Assessment Nursing Scientific Reference Planning Interventions Rationale Evaluation

Diagnosis (Actual (Research Articles) (Short / Long Term Goals) (Independent, Collaborative,
or Potential Dependent)
Problem)
Subjective: Somatic symptom Long Term:  Perform complete  Get baseline Goals met, as
“I have an uncomfortable Chronic disorder (SSD) occurs After 5 days of nursing nursing assessment information and evidenced by the
feeling in my pain related to when a person feels intervention, the patient with vital signs determine if there is a patient demonstrate
stomach, which could be severe level of extreme, exaggerated will be able to demonstrate physical or explained alternative ways to
cramping or stabbing” as anxiety, repressed anxiety about physical alternative ways to deal cause of symptoms. deal with stress,
verbalized by the patient as evidenced by symptoms. The person with stress, anxiety, and anxiety, and other
verbalization of has such intense other feelings.  Pain is subjective and feelings and patient
Objective: pain in the thoughts, feelings, and  Assess pain per must be managed able to managed
 Patient is restless stomach, behaviors related to the Short Term: appropriate scale according to what the her pain.
and fearful about restlessness. symptoms, that they feel After 3 days of nursing client feels and reports.
her feelings they cannot do some of intervention the patient
 Their primary the activities of daily life. will be able to manage her  Recognizing the
concern is They may believe routine pain interconnectedness of
typically medical problems are life  Discuss with the client physical and emotional
exaggerated threatening. This anxiety directly regarding a health improves the
bodily worries, as may not improve despite correlation between client's chances for
well as denial of normal test results and emotions, stress, and good health.
just thinking reassurance from the physical symptoms.
about all of the health care provider.  It will be easier to
symptoms. manage or control
Reference:  Encourage the patient illness if you are
https://medlineplus.gov/e to improve his or her physically fit.
ncy/article/000955.htm physical fitness. (For
example, regular
exercise and proper
nutrition).
 Helps patient
Moleno, April Marie BSN III F

 Provide education understand the

about feared or actual condition in a more
medical condition realistic light and helps
alleviate fear and
anxiety about a
particular health
concern
COLLABORATIVE:
Cognitive Behavior Therapy It helps the patient understand
what factors (usually stress)
that prompt the onset of
symptoms. It can also help the
client determine a pattern of
emotions surrounding the
symptoms.

DEPENDENT:
The following medications
were given by the physician
that may help treat these
related disorders include:  Perceived pain and
 Pain relievers / symptoms are to be
analgesics treated appropriately,
but as circumstance
allows, decrease
medication and
continue offering praise
for improvement of
symptoms to encourage
continuing positivity.
 Moleno, April Marie BSN III F

Case: PARANOID SCHIZOPHRENIA

Patient: Initials

Assessment Nursing Scientific Reference Planning Interventions Rationale Evaluation

Diagnosis (Research Articles) (Short / Long Term (Independent, Collaborative,
(Actual or Goals) Dependent)
Potential
Problem)

SUBJECTIVE: Impaired Social  Paranoid schizophrenia Long Term: INDEPENDENT: Goals met, as

“I don't want to go Interaction considered the most severe After 5 days of nursing  Assess if the medication  Many of the positive symptoms evidenced by
out, and my related to type. It is characterized by intervention the patient has reached therapeutic of schizophrenia (hallucinations, the patient able
colleagues seem to be dysfunctional strange delusions, such as will be able to levels. delusions, racing thoughts) will to
distracted” as interaction with believing that one’s improve social subside with medications, which improve social
verbalized by the others or peers thoughts are being interaction with family, will facilitate interactions. interaction
patient secondary to broadcast over the radio. friends, and neighbors. with family,
Paranoid Hallucinations, especially  Identify with client  Increased anxiety can intensify friends, and
OBJECTIVE: Schizophrenia bizarre ones, are also symptoms he agitation, aggressiveness, and neighbors and
 The patient has common to the condition. Short Term: experiences when he or suspiciousness. use appropriate
a A person with paranoid After 3 days of nursing she begins to feel social skills in
dysfunctional i schizophrenia often finds intervention the patient anxious around others. interactions
nteraction the world confusing and will be able to use
with peers, fa functions poorly without appropriate social skills  Keep client in an  Client might respond to noises
mily, and other treatment. in interactions and use environment as free of and crowding with agitation,
people appropriate skills to stimuli (loud noises, anxiety, and increased inability
 Have major Reference: initiate and maintain an crowding) as possible. to concentrate on outside events.
break down https://www.betterhealth.v interaction.
 Observed ic.gov.au/health/conditions  Avoid touching the  Touch by an unknown person
social andtreatments/paranoia client. can be misinterpreted as a sexual
discomfort or threatening gesture. This
particularly true for
a paranoid client.
Moleno, April Marie BSN III F

 Avoids pressure on
 Ensure that the goals set the client and sense of failure on
are realistic; whether in part of nurse/family.  This sense
the hospital or of failure can lead to mutual
community. withdrawal

COLLABORATIVE:  Will help the patient for social

 Cognitive behavioral skills training to improve
therapy communication and social
interactions.

DEPENDENT:  It works by blocking dopamine

in the brain.
 Antipsychotic drugs
 Moleno, April Marie BSN III F

Case: DEPRESSIVE DISORDER

Patient: Initials

Assessment Nursing Diagnosis Scientific Reference Planning Interventions Rationale Evaluation

(Actual or Potential (Research Articles) (Short / Long Term Goals) (Independent,
Problem) Collaborative, Dependent)
SUBJECTIVE: Risk for self- Depression (major depressive Long Term: INDEPENDENT: Goals met, as
directed violence disorder) is a common and After 1 week of nursing  Create a safe  Client safety is a evidenced by the
“I attempted related to depression serious medical illness that intervention the patient will be able environment for nursing priority. patient
suicide” as as evidenced by negatively affects how you to demonstrate alternative ways of the client. Remove demonstrate
verbalized by the family dysfunction, feel, the way you think and dealing with negative feelings and all potentially alternative ways of
patient exhibits suicidal and how you act. Fortunately, it is emotional stress harmful objects dealing with
take 100 pills to kill also treatable. Depression from client’s negative feelings
OBJECTIVE: herself causes feelings of sadness Short Term: access.  Clients can learn and emotional
 Family and/or a loss of interest in After 4 days of nursing intervention  Encourage clients alternative ways of stress and not
dysfunction activities you once enjoyed. It the patient will be able to not inflict to express feelings dealing with inflict any harm to
 Patient can lead to a variety of any harm to self or others and state (anger, sadness, overwhelming emotions self or others and
exhibits emotional and physical that he/she wants to live. guilt) and come up and gain a sense of state that he/she
suicidal problems and can decrease with alternative control over his/her life. wants to live.
tendencies. your ability to function at ways to handle
 She work and at home. feelings of anger
constantly and frustration.
took 100 Reference:  Contact the family,  Clients need a network
tablets to kill https://psychiatry.org/patients- arrange for crisis of resources to help
herself. families/depression/what-is- counseling. diminish personal
depression Activate links to feelings of helplessness,
self-help groups. worthlessness, and
isolation.

COLLABORATIVE:
Cognitive Behavioral This will helps assess and
Therapy change negative thinking
patterns associated with
Moleno, April Marie BSN III F

depression.

It encourages the patient to

Psychodynamic Therapy look at negative behaviors and
try to recognize and then
change them.

DEPENDENT:
If clients require continued
Teach the client's family or treatment, they must be given
significant others about the clear instructions on self-care
therapy options and drugs and medication safety.
available for the client's
physical symptoms, if the
doctor has prescribed
them.
 Moleno, April Marie BSN III F

Case: MANIC DISORDER

Patient: Initials
Assessment Nursing Scientific Reference (Research Planning Interventions Rationale Evaluation
Diagnosis Articles) (Short / Long Term (Independent, Collaborative,
(Actual or Goals) Dependent)
Potential
Problem)
SUBJECTIVE: Impaired Bipolar disorder, also known Long Term: INDEPENDENT: Goals met, as
“I’m fantastic” as Social as manic depression, is a mental After 7 days of  Maintain a firm but  Your presence and evidenced by the
verbalized by the Interaction illness that brings severe high nursing intervention calm and relaxed demeanor will aid in patient demonstrate
patient related to and low moods and changes the patient will be able demeanor. communicating your an ability to remove
disturbed in sleep, energy, thinking, and to demonstrate interest, expectations, and self from
OBJECTIVE: thought behavior. People who an ability to remove boundaries, as well as your a stimulating
 The patient process as have bipolar disorder can have self from a stimulating self-control. environment in order
is sociable evidenced by periods in which they feel overly environment in order  When less manic, the  As mania subsides, to “cool down” by
and active. the patient is happy and energized and other to “cool down” by client might join one involvement in activities discharge and initiate
 When the sociable and periods of feeling very sad, discharge. or two other clients in that provide a focus and and maintains goal-
client is in a active, pressure hopeless, and sluggish. In quiet, no stimulating social contact becomes directed and
highly of speech between those periods, they Short Term: activities (e.g., more appropriate. mutually satisfying
stimulating usually feel normal. You can After 5 days of drawing, board Competitive games can activities/verbal
situation, his think of the highs and the lows nursing intervention games, cards). stimulate aggression and exchanges with
manic as two "poles" of mood, which is the patient will be able can increase psychomotor others.
conduct why it's called "bipolar" to initiate and activity.
increases. disorder. The word "manic" maintains goal-  When possible,  Reduction in stimuli lessens
 Pressure of describes the times when directed and mutually provide an distractibility.
speech someone with bipolar disorder satisfying environment with
feels overly excited and activities/verbal minimum stimuli
confident. These feelings can exchanges with others. (e.g., quiet, soft
also involve irritability and music, dim lighting).
impulsive or reckless decision-  Solitary activities  Solitary activities minimize
making. About half of people requiring short stimuli; mild physical
during mania can also have attention spans with activities release tension
Moleno, April Marie BSN III F

delusions (believing things that mild physical exertion constructively.

aren't true and that they can't be are best initially (e.g.,
talked out of) writing, taking photos,
or hallucinations (seeing or painting, or walks
hearing things that aren't there). with staff).

Reference: COLLABORATIVE:
https://www.webmd.com/ Cognitive-behavioral therapy A type of psychotherapy that
bipolar-disorder/mental-health- focuses on looking at the
bipolar-disorder#:~:text=The relationship between thoughts,
%20word%20%22manic feelings, and behaviors.
%22%20describes
%20the,impulsive%20or DEPENDENT:
%20reckless%20decision Antipsychotics and mood These drugs help to control mood
%2Dmaking. stabilizers. swings and prevent the symptoms
of psychosis that often occur in
mania, such as delusions and
hallucinations.