Caring for a client in an acute care mental health unit

A nurse is caring for a client in an acute care mental health unit. The nurse is planning care for a client who has borderline personality disorder. Exhibit 1 Exhibit 2 For each potential nursing intervention, click to specify if the potential intervention is anticipated, nonessential, or contraindicated for the Nurses’ Notes client. Day 1 0700:

Potential Intervention Anticipated Nonessential Contraindicated Encourage the client to O O O A client who has a history of borderline personality disorder is written in a journal. admitted with manifestations of anxiety and accompanied by Hold weekly staff their partner. The client is alert and oriented to person, place, O O O meeting to allow staff and time.

The client presents with evidence of self-mutilation on time to express their upper extremities. Perspiration was noted on the face, chest, and feelings. back. The client reports a feeling of "emptiness" when asked how they are feeling at the current time. The client displays anger or Communicate O O O sarcasm when responding to staff. The client’s partner states behavioral expectations the injuries are self-inflicted and often occur after an argument.

with the client’s family. Partner also reports the client has a history of substance use Limit consequences for O O O and excessive gambling. undesirable behavior while receiving treatment. Day 2 1000: Encourage the client to O O O self-reward for positive Client is participating in a milieu therapy session. Client states that outcomes. they are planning to open their own business as soon as they Bargain with the client are discharged from the hospital. The client exhibits O O O to establish behavioral manipulative behavior when interacting with staff and other expectations. clients.

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