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College of medicine and health

department of psychiatry
Nursing intervention and assessment
For personality disorder
• Defensive Coping related to Dysfunctional
family system Evidenced by Disregard for
societal norms
 Outcome Criteria
• Client will be able to follow rules and delay
personal gratification.
 Nursing Interventions
1. client should be made aware of which
behaviors are acceptable and which are not
2.Provide positive feedback or reward for
acceptable behaviors
3.Begin to increase the length of time requirement
for acceptable behavior in order to achieve the
 Nursing diagnosis
• Impaired social interaction related to Extreme
fears of abandonment and engulfment
Evidenced by Alternating clinging and distancing
behaviors and staff splitting
Outcome Criteria
• Client will exhibit no evidence of splitting or
clinging and distancing behaviors in
relationships with staff and/or peer
Nursing Interventions
1. Encourage client to examine these behaviors
to recognize that they are occurring
2.Explore feelings that relate to fears of
abandonment and engulfment with client
Nursing diagnosis
need self care activity to achieve and maintain
optimal wellness related to Low self-esteem
evidenced by History of lack of health-seeking
• Client will verbalize understanding of
knowledge required to fulfill basic health
needs following implementation
• Client will be able to demonstrate skills
learned for fulfillment of basic health needs
by time of discharge from therapy
1. Assess client’s level of knowledge regarding
positive self care practices.
2. Include significant others in the learning
activity, if possible
3.Implement teaching plan at a time that
facilitates, and in a place that is conducive to,
optimal learning
4.Provide positive feedback for participation
Nursing diagnosis
Extreme suspiciousness related to mistrust as
evidenced by Suspects there relatives without
any reason
Desired Outcome
• Client will be able to identify appropriate
coping techniques and remains safe and free
from harm
 Nursing intervention
1.Monitor behaviors and interactions with staff
and other client
2.Talk openly with client about their beliefs and
thoughts, showing empathy and support
3.Prevents aggressive behavior and suspicions
4.Avoid startling the client, sudden movements or
touching the client unnecessarily
5.Discuss feelings and help client identify
behaviors that cause conflict or alienate others
Nursing Diagnosis
• Social isolation related to alterations in social
desire as evidenced by being withdrawn and
poor eye contact
Desired Outcome
• client will be able to Identify feelings that lead
to poor social interaction
• Verbalize willingness to be involved with
Nursing Intervention
• Establish therapeutic nurse-client relationship
• Encourage to join programs and activities
• promote socialization skills and peer contact
• interact with other persons in the area
 Nursing Diagnosis
• Risk for suicide Related to feelings of
hopelessness, rejection, and anger
 Goal/outcome
 Client will be free of self injury
 Nursing interventions
 Encourage patient to talk freely about feelings
and help patient plan alternate ways to handle
Nursing diagnosis
• Anxiety related to Extreme fear of
abandonment evidenced by Acts of self-
mutilation in an effort to find relief from
feelings of unreality
• Client will demonstrate use of relaxation
techniques to maintain anxiety at manageable
• Client will be able to recognize events that
precipitate anxiety and intervene to prevent
disabling behaviors.
Nursing Interventions
• Correct misinterpretations of the
environment as expressed by client
• Encourage the client to talk about true
• Help the client work toward achievement of
object constancy
• Observe client’s behavior frequently.