29 YEAR OLD FEMALE ARRIVED VIA AMBULANCE FOR SUICIDE ATTEMPT. HX OF
MAJOR DEPRESSION, BIPOLAR, AND BORDERLINE PERSONALITY DISORDER. AFTER
FINDING OUT THAT HER CASE WORKER WAS “LEAVING HER”, PATIENT ATTEMPTED
TO OVERDOSE BY CONSUMING 10 200MG TABLETS OF SEROQUEL. PATIENT
REPORTED FEELING DIZZY, HEAVY, NAUSEATED, AND CONFUSED AFTER TAKING
PILLS, THEN CALLED 911.
VOLUNTARY COMMITMENT (MH-5)
PATIENT COMMITTED HERSELF ON HER OWN FREE WILL AND PHYSICIAN
DETERMINED THAT SHE NEEDED IN-PATIENT TREATMENT. ADMITTED ON 01/25/2016.
Axis I : Major Depression, Bipolar
Axis II: Borderline Personality Disorder/Cluster B, Borderline traits
Axis III: None
Axis IV: Unstable living conditions, Unemployed, Strained
Axis V: GAF is 40
(Some impairment in reality testing or communication
(speech at times illogical, obscure, or irrelevant) OR major
impairment in several areas such as work or school, family
relations, judgment, thinking or mood.)
A pervasive pattern of instability of interpersonal relationships,
self-image, and affects, and marked impulsivity beginning by
early adulthood and present in a variety of contexts, as
indicated by five (or more) of the following:
(1) frantic efforts to avoid real or imagined abandonment.
(2) a pattern of unstable and intense interpersonal
relationships characterized by alternating between extremes
of idealization and devaluation
(3) identity disturbance: markedly and persistently unstable
self-image or sense of self
DSM : DIAGNOSTIC CRITERIA CONTINUED….
(4) impulsivity in at least two areas that are potentially selfdamaging (e.g., spending, sex, Substance Abuse, reckless
driving, binge eating).
(5) recurrent suicidal behavior, gestures, or threats, or selfmutilating behavior
(6) affective instability due to a marked reactivity
of mood (e.g., intense episodic dysphoria, irritability,
or anxiety usually lasting a few hours and only rarely more than
a few days)
• (8) inappropriate, intense anger or difficulty controlling anger (e.g.,
frequent displays of temper, constant anger, recurrent physical fights)
• (9) transient, stress-related paranoid ideation or severe dissociative
•Patient meets all 9 diagnostic criteria
• Medicare Insurance
• Monthly income: $1,120 per
• Rent is $350 per month for a room
in a 4 bedroom group home with
three other individuals.
• Patient also receives $350 food
• Patient claims to have adequate
income to meet her needs.
PATIENT’S DESCRIPTION OF PROBLEM:
Admits having constant suicidal thoughts and multiple
attempts. Patient states that she has difficulty getting along
with others and disagrees with having a personality disorder,
but agrees to being depressed and bipolar. She complains of
feeling hopeless and helpless. She states that her mother is also
bipolar, so that’s the reason they don’t get along. She said she
tries to make everyone happy but then they abuse her and
take advantage of her by using her for money and sex and
then leave her. She tried to overdose because she said there’s
no sense staying alive to continue to get abused by everyone
in her life including her case manager. She claims that she is
forced to use meth and only uses it once or twice a month. She
also stated that she uses meth to stop the racing thoughts and
it gives her a break.
PART HAWAIIAN/ GERMAN
NO DECLARATION OF RELIGIOUS BELIEFS. BELIEVES IN GOD, BUT
DOES NOT PRAY OFTEN. CHANGES RELIGION FREQUENTLY.
STRENGTHS: ARTICULATE, CAN BE COOPERATIVE, WILLING TO SEEK HELP
- Self-destructive impulses, self-mutilating behavior, suicidal threats or gestures,
especially when an attachment relationship is disrupted or threatened.
-Lack a stable sense of self: Attitudes, values, goals, and feelings about
themselves are unstable or ever-changing.
-Fear rejection and abandonment, fear being alone, become attached quickly
-Play the role of "victim", often elicit intense emotions in other people who they
-Feel misunderstood, mistreated, or victimized.
-Relationships tend to be unstable, chaotic, and rapidly changing
-Splitting: When upset, trouble perceiving positive and negative qualities in the
same person at the same time. Idealization to devaluation. Love you.. hate you
Antidepressants, anxiolytics, antipsychotics, or mood stabilizers
may be prescribed.
escitalopram oxalate Lexapro 5mg PO daily.
(Anti-depressant SSRI ) (Dose: 10-20mg/day PO)
hydroxyzine Atarax 10mg tab PO Q8h PRN (Mild-moderate anxiety,
offer before Ativan) (Antihistamine)
lorazepam Ativan 0.5mg tab PO Q8hrs PRN (Agitation, moderate to
severe anxiety) If hydroxyzine ineffective after 1 hour
(Benzodiazepine) (Dose: 1-4mg/day PO)
Melatonin 3 mg tab PO at bedtime may repeat PRN
diphenhydramine Benadryl 25mg tab PO BID PRN Anxiety
Appearance: Poor hygiene aeb greasy uncombed hair and disheveled appearance.
Clothes age and environmentally appropriate
Behavior: Cooperative, attentive and friendly. Speech: Articulate, clear and
spontaneous, occasional rapid speech, able to hold a conversation. Agitated motor
activity AEB pacing back and forth from room to nursing station. Distracted with periods
of irritability, anger, and sadness AEB yelling at case worker on the phone when
informed of need to reschedule appointment and crying when talking about changing
case workers. Attention seeking behavior and self- injury AEB self-inflicted pencil
puncture to left hand and giving writer sharpened pencil while smiling.
Affect: Labile affect, incongruent with mood AEB smiling and laughing while talking
about suicidal thoughts and self harm.
Mood: Depressed mood with feelings of hopelessness, helplessness with ambivalent.
Major depression AEB 35 on Burn’s Depression check list. Very low self-esteem AEB 9 on
Coopersmith self-esteem tool.
Thought process: Linear, easy to follow.
Thought content: Positive suicidal ideation, suicidal threat, gestures, attempts and with
plans to overdose with pills or use neighbor’s gun if discharged early.TM33=17. High risk
precautions. Positive threat to hurt self. Agreed to contact Nursing staff and writer for
Cognitive exam: Alert and oriented x3, able to express oneself. Long term and short term
memory intact. Able to recall events.
Insight and judgment: Poor insight and judgement related to negative consequences of
behaviors and the impact that it has on her life, relationships, housing situation, and
HOSPITAL TREATMENT PLAN
• Eliminate suicidal ideation and intent to harm self.
• Medication management to stabilize depression, mood and anxiety.
• Limit aggressive behavior; promote socially acceptable responses.
• Implement CBT to decrease negative and inaccurate perceptions and increase
positive coping statement and skills.
• Individual therapy to recognize internal and external cues of emotions and how
to cope with unpleasant emotions.
• Group therapy for improving patient’s use of effective, assertive, and respectful
communication to appropriately express her thoughts, needs, and feelings to
• Educate patient regarding the need for follow-up care in an outpatient setting,
• the psychiatric symptoms that indicate a need for emergent treatment and
• an understanding of any medications that the patient is receiving.
DISCHARGE PLAN/COMMUNITY RESOURCES
• No suicidal ideation or intent to hurt self. An agreement by the patient to use a
suicide hotline (e.g., 1-800-273-TALK) or to call a supportive friend, family
member, or case worker if suicidal ideation happens again to prevent
readmission, harm, or death.
• CBT, Group therapy, individual therapy, Clubhouses, psychosocial rehabilitation
programs, and vocational rehabilitation
(SRSP) Specialized Residential Services Population at Care Hawaii
• Individual and group programming and activities are provided to facilitate
recovery and assist the consumer to live successfully in the community, maintain
an abstinent lifestyle, regain employment, develop and maintain social
relationships, or to independently participate in social, interpersonal, community
and peer support activities to increase community stability.
• Therapeutic Living Program (TLP) at Care Hawaii
The primary goal of the program is to assist consumers in meeting their basic
needs until they are able to transition in to a more independent living option of
their choice. Support is flexible, focused, and based on recovery. restorative
therapy, CBT therapy, recreational therapy, individual and group skill building and
other activities which support healthy living.
STANDARDIZED ASSESSMENT TOOLS
• High suicide risk precautions AEB 33 on TM33
• Major depression AEB 35 on Burn’s Depression check list.
Very low self-esteem AEB 9 on Coopersmith self-esteem tool.
3 HIGHEST PRIORITIES & PROBLEMS W/ RATIONALES
• Risk for suicide and risk for self-directed violence
• Evaluate the client’s risk for suicide through careful observation of behaviors and
direct questioning (asking for suicidal intent & plan).
• The nurse’s first priority is to provide for the clients safety and protect the client from
self-inflicted life-threatening injury or death.
• Protect the client and others from harm or injury when client loses control as
a result of impulsive, aggressive behaviors.
• Staff members who use appropriate safety methods for clients with
impulsive/threatening or aggressive behaviors are the best source of protection
against harm or injury to the client and others in the milieu. Use methods according
to facility policies/procedures and standards of care.
• Impaired coping and chronic low self esteem
• Engage the client in appropriate group, cognitive and behavioral therapies such as
role-play, cognitive-behavioral therapy, assertiveness training, and process groups.
• Participation in a variety of therapeutic activities and groups tends to increase self
esteem and foster independent functioning and behaviors resulting from support,
acceptance, and the universality of group dynamics.
NURSING CARE PLAN
• Nursing Diagnosis: Risk for suicide related to ineffective coping and
ineffective support system as evidenced by multiple suicide attempts and
current suicidal ideations.
• P: Risk for suicide
• E: Verbalize intent to die, dysfunctional family relationships, ineffective
coping style, low self- esteem, effects of sexual abuse, history of previous
suicide attempts, lethal suicide plan, depressed mood.
• S: Suicide prevention; Mood management; Behavior management: selfharm; Impulse control training; Environmental management: safety; Anger
control assistance; Support group; Therapy group; Self-esteem enhancement
• ST goal: Client will reduce frequency of suicidal ideation and inform staff if SI
occur throughout the day.
• LT goal: Client will not have any recurrent suicidal ideation or intent to harm
self at time of discharge.
INTERVENTIONS W/ SCIENTIFIC RATIONALE
Intervention & Frequency
Evaluate the client’s risk for suicide every 15 minutes through
careful observation, of behaviors, and direct questioning.
There is always a chance that clients at risk for suicide will act out
on their thoughts, and studies show that the more detailed the
plan, the greater risk for suicide. (Fortinash, p.96)
Tell the patient to come to staff whenever the client experiences
such thoughts or feelings.
(Contract for safety) every shift (8 hours)
Constant staff support and protection reduce the client’s fear of
suicidal impulses and offer hope for survival.
Monitor the client for behaviors every 15 minutes that are
precursors to suicide: threats, gestures, giving away possessions,
making a will, leaving a suicide note, obsessing or fantasizing about
death, self-deprecating or command hallucinations, delusions of
persecution, insomnia, with recurring thoughts of suicide,
These behaviors are strong indicators of a client’s suicidal ideation
and cue the staff to take steps to prevent the client from acting on
suicidal thoughts and feelings and to secure the therapeutic
Check the client and room daily for potentially destructive
implements: sharp objects, belts, shoe laces, socks, chemicals,
hoarded medications; and take steps to protect client through
appropriate therapeutic interventions.
The nurse’s first priority is to provide for the client’s safety and
protect the client from self-inflicted life threatening injury or/and
death. (Fortinash, p.96)
NURSING CARE PLAN
• Nursing Diagnosis: Ineffective coping r/t negative thinking patterns, self
defeating behaviors, multiple stressors, and ineffective support system as
evidenced by self-destructive behaviors, lack of assertive communication,
impaired judgement and insight, misdirected anger, and social isolation.
• P: Ineffective coping
E: Self-destructive behaviors, lack of assertive communication, impaired
judgement and insight, misdirected anger, and social isolation.
S: Coping enhancement; Anger control assistance; Anxiety reduction; Mood
management; Emotional support; Support group; Support system
enhancement; Teaching: individual; Therapy group
ST Goal: Client will begin to gain insight on positive outcomes of utilizing
therapeutic coping skills today.
LT Goal: Client will demonstrate effective coping skills prior discharge.
INTERVENTIONS WITH SCIENTIFIC RATIONALE
Intervention & Frequency
Assist the client to redirect angry or ambivalent feelings
through constructive activities; physical exercise, art/music
therapy, and relaxation techniques daily.
Therapeutic activities help the client release negative
energy and reduce stress and frustration in a socially
accepted way (Fortinash, 261).
Engage the client in therapeutic groups, including roleplay/ sociodrama, behavioral cognitive therapy,
assertiveness training, and process/focus groups daily.
Therapeutic groups help the client explore splitting
behaviors and their effects on self and others through the
dynamics of the group process and feedback from other
clients and group leaders(Fortinash, 263).
Offer feedback to the client in a tactful manner when
observing client perceptions that individuals or groups are
either “all good” or “all bad” daily.
The nurse’s tactful feedback of the client’s splitting
behaviors will challenge the client’s perception and help
her correct the distorted views and reduce splitting
behaviors. (Fortinash, 261)
Teach the client therapeutic strategies to increase the time
span between the stimulus and the client’s response;
practice slow deep breathing, relaxation techniques, count
to 5 slowly, engage in physical exercise daily.
These therapeutic strategies give the client time and
opportunity to choose an alternative, less volatile response
and thus reduce the incidence of sudden intense
emotional expressions by the client(Fortinash,268).
NURSING CARE PLAN
• Nursing Diagnosis: Chronic low self esteem related to disturbance of self-perception
powerlessness, ineffective problem solving, perceived abandonment or rejection as
evidenced by poor self concept and body image, dependency, abandonment fears,
attention seeking, hysteria, and jealousy.
• P: Chronic low self-esteem
• E: Poor self concept, dependency, abandonment fears, attention seeking, hysteria,
• S: Self-esteem enhancement, body image enhancement, emotional support, coping
enhancement, cognitive restructuring, role enhancement and support groups.
• ST goal: Client will begin to demonstrate improved self confidence in self and abilities.
• LT goal: Client will demonstrate confidence in abilities and have a positive selfperception prior to discharge.
NURSING CARE PLAN
Interventions and Frequency
Reinforce the client’s independent behavior in a positive
Reinforcing the client’s behaviors increases confidence
and self-esteem and encourages continuity of appropriate
Help the client set realistic, attainable goals daily.
Setting realistic, achievable goals helps to avoid or
minimize failure, provides hope for behavioral change, and
increases the client’s feelings of independence and control
over life(Fortinash, 240).
Engage the client in appropriate group, cognitive, and
behavioral therapies; role play, cognitive behavioral
therapy, assertiveness training, process groups at least
twice a day.
Participation in a variety of therapeutic activities and
groups tends to increase self-esteem and foster
independent functioning and behaviors resulting from
support, acceptance, and the universality of group
Teach the client to challenge unrealistic beliefs (e.g. failure,
unattractiveness, lack of initiative) by pointing out factual
Pointing out realistic facts that challenge the client’s
negative self perception helps decrease the client’s
negative self-concept and promote selfworth(Fortinash,241).
•Evidenced based article
• randomized controlled trial of cognitive behavioral therapy (CBT) for 106
people with borderline personality disorder attending community-based
• Used instrumental variable regression modelling to estimate the impact of
• quantity and quality of therapy received.
• A total of 101 participants provided full outcome data at 2 years post
• randomization. The previously reported intention-to-treat (ITT) results showed
• average a reduction of 0.91 (95% confidence interval 0.15)
• 1.67) suicidal acts over 2 years for those randomized to CBT. By incorporating
the influence of quantity of therapy and therapist competence, we show that
this estimate of the effect of CBT pd could be approximately two to three
times greater for those receiving the right amount of therapy
EVIDENCE BASED JOURNAL ARTICLE
• Norrie, J., Davidson, K., Tata, P., & Gumley, A. (2013). Influence of therapist
competence and quantity of cognitive behavioural therapy on suicidal
behaviour and inpatient hospitalisation in a randomised controlled trial in
borderline personality disorder: Further analyses of treatment effects in the..
Psychology & Psychotherapy: Theory, Research & Practice, 86(3), 280-293.
• Patient’s treatment plan is relevant
• More aggressive and frequent inpatient-therapy
• More support and referrals to community outpatient
programs. (Decrease helplessness)
IMPROVE MENTAL HEALTH STATUS
Actively participate in aggressive treatment therapy: Inpatient/outpatient
Dialectical behavioral therapy (DBT)
Cognitive therapy (CBT)
NA 12 step program
Increase support systems- Case worker, church, Mother
Stable living situation
• American Psychiatric Association: Diagnostic and statistical manual of
mental disorders. 5th Edition, Arlington, VA. American Psychiatric
• Fortinash, Katherine, Patricia Worret. Psychiatric Mental Health Nursing,
5th Edition. Mosby, 2012. VitalBook file.
• Fortinash, Katherine, Patricia Worret. Psychiatric Nursing Care Plans 5th
Edition. Mosby, 2012, St.Louis.