Personality Disorders Nursing Process

Question 1

Assessment

Answer 1

• Assess for suicidal or homicidal thoughts. If these are present, the patient will need immediate attention.
• Assess whether the patient experienced a recent important loss. Symptoms are often exacerbated after the loss of significant supporting people or in a disruptive social situation.
• Patient history: determine if the patient has a medical disorder or another psychiatric disorder that may be responsible for the symptoms (especially a substance use disorder).
• Legal history: assess for any past troubles with the law i.e. arrests for criminal behavior.
• Assess for past physical, sexual, or emotional abuse.
• Determine medications currently prescribed.
• Assess for alcohol abuse and illegal substances i.e. marijuana, cocaine, crack, etc.
• When performing nursing assessments, asking the patient questions may not always result in accurate responses. They often lack insight into their behaviors and therefore, have difficulty describing themselves.
• _One way to elicit objective information is to ask patients if family members and or friends perceive them in a certain wa_y.
• For example, “You said that you don’t think you’re emotionally distant. How would your wife describe you?”

Question 2

Planning

Answer 2

• It is often difficult to create a therapeutic relationship with patients who have personality disorders, particularly antisocial or borderline personality disorders, because most of them have experienced failed relationships, including therapeutic alliances.
• When patients blame and attack others, the nurse needs to understand the context of their complaints; that is, these attacks spring from the feeling of being threatened.
• Lacking the ability to trust, patients with personality disorders require a sense of control over what is happening to them.
• Giving them realistic choices (i.e. selection of a particular group activity or providing alternative ways to cope) may enhance adherence to treatment.

Question 3

Interventions for Impulsive Behavior

Answer 3

• Assist patient to identify the feelings prior to impulsive acts or identify situations that trigger impulsivity and discuss alternative behaviors.
• Assist patient to identify courses of possible action and their costs and benefits (pros vs cons).
• Teach patient to cue himself or herself to “stop and think” before acting impulsively.
• Assist patient to evaluate the outcome of the chosen course of action.
• Provide positive reinforcement (e.g. praise and rewards) for successful outcomes.
• Encourage patient to self-reward for successful outcomes.
• Provide opportunities for patient to practice problem solving (role playing) within the therapeutic environment.
• Encourage patient to practice problem solving in social and interpersonal situations outside the therapeutic environment, followed by evaluation of outcome.

Question 4

Interventions for Manipulative Behavior - Limit Setting

Answer 4

• Set clear, consistent limits on specific behavior.
• Example: “Alcohol is not allowed on the unit” NOT “I don’t want you to drink alcohol on the unit”
• Discuss with patient, when appropriate, concerns about behavior, what is desirable behavior in a given situation and the consequences of undesired behaviors.
• Guard against power struggles.
• Refrain from arguing or bargaining with patient about established behavioral expectations and consequences.
• Communicate established behavioral expectations and consequences to patient in language that is easily understood and non-punitive.
• Can use the technique of “empathetic mirroring” wherein the nurse reflects back to the patient an understanding of the patient’s distress or situation in a neutral manner that does not judge; it helps elicit a more positive response to the limit that is being set.
• For example, “I understand that you are angry and upset, but acting out is not safe.”
• Modify behavioral expectations and consequences, as needed, to accommodate reasonable changes in patient’s situation.

Question 5

Nursing Process - Interventions for Aggressive Behavior

Answer 5

• Determine appropriate behavioral expectations for expression of anger, given patient’s level of cognitive and physical functioning.
• Limit access to frustrating situations until patient is able to express anger in an adaptive manner.
• Encourage patient to seek assistance from nursing staff during periods of increasing tension.
• Monitor potential for inappropriate aggression, and intervene before its expression.
• Identify consequences of inappropriate expression of anger.
• Assist patient in identifying source/feelings of anger instead of acting on intense feelings of frustration, anger or perceived threats.
• Identify function that anger, frustration, and rage serve for patient.
• Provide physical outlets for expression of anger or tension (e.g. sports, clay, journal writing).
• Prevent physical harm if anger is directed at self or others (e.g. restraint and removal of potential weapons).
• Provide reassurance to patient that nursing staff will intervene to prevent patient from losing control.