A nurse is caring for a client who has a personality disorder.
Nurses' Notes
Day 1 - Admit note 0700
Talkative, well-groomed.
States she is "looking forward to divorcing partner number four" because she has "found my next partner."
Anxious if left alone - wants to remain close to nurse.
Tells the nurse, "I feel like a bomb waiting to explode."
Day 2 1000
Restless for past 2 hr. Pacing from bedroom to dayroom and mumbling to self. Argued with nurse this morning about attending group therapy session.Staring at staff members with fists clenched.
Diagnostic Results
Day 1 0730
Hematocrit 45% (female: 37% to 47%)
Hemoglobin 14.5 g/dL (female: 12 to 16 g/dL)
Fasting blood glucose 92 mg/dL (74 to 106 mg/dL)
Graphic Record
Day 1 0715
Temperature 36.2° C (97.2° F)
Heart rate 86/min
Respiratory rate 16/min
Blood pressure 112/76 mm Hg
Day 2 0900
Temperature: 36.7° C (98.2° F)
Heart rate 98/min
Respiratory rate 20/min
Blood pressure 118/78 mm Hg
History and Physical
36-year-old well-nourished female presenting with recurrence of labile behavior involving episodes of self-injury (cutting arms and legs) and hypersexualization, recent arrest for stealing money from family to cover credit card charges and instigating physical altercations with current spouse.
Axis 1: major depressive disorder; Axis 2: borderline personality disorder
Client attends a group exercise class twice a week and eats a well-balanced diet.
Employed as legal secretary for past 12 years.
Provider Prescriptions
Admit orders Day 1
Regular diet
Activity as tolerated
Observe closely for self-injury or violence toward others
Buspirone 7.5 mg PO twice a day
Haloperidol 2 mg IM every 3 hr PRN severe agitation
Bacitracin ointment ¼ to ½ inch to arm and leg wounds three times daily
Medication Administration Record
Day 1
Buspirone 7.5 mg PO at 0800 and 2000
Bacitracin ointment applied to leg and arm wounds at 0800, 1400, and 2000
For each potential nursing intervention, click to specify if the potential intervention is anticipated, nonessential, or contraindicated for the client.
1) Hold next dose of buspirone.
2) Haloperidol 2 mg IM
3) Calmly approach client and state, "You seem agitated. Let's sit quietly and talk about it."
4) Request change of diet to mechanical soft.
5) Request prescription for digoxin 1 mg IV bolus STAT.
A) Anticipated
B) Nonessential
C) Contraindicated
