10.4 Applying the Nursing Process to Personality Disorders

This section will apply the nursing process to caring for a client diagnosed with borderline personality disorder who is hospitalized due to self-injurious behavior.

Assessment

Assessment includes interviewing the client, observing verbal and nonverbal behaviors, completing a mental status examination, and performing a psychosocial assessment. Review information about performing a mental status examination and psychosocial assessment in the “Application of the Nursing Process in Mental Health Care” chapter.

Assessment findings for clients hospitalized with borderline personality disorder may include the following^[1]:

• Feelings of emptiness
• Self-mutilation and self-harm
• Suicidal behaviors, gestures, or threats
• Extreme mood shifts that occur in a matter of hours or days
• Impulsive behavior such as reckless driving, unsafe sex, substance use, gambling, overspending, or binge eating
• Intense feelings of abandonment
• A tendency towards anger, sarcasm, and bitterness
• Intense and unstable relationships

Review how to assess for suicide risk in the “Foundational Mental Health Concepts” chapter.

Diagnostic and Lab Work

There is no specific laboratory test that diagnoses personality disorders. Laboratory or diagnostic tests may be used to rule out other possible causes for the behaviors the client is exhibiting. For example, a thyroid stimulating hormone (TSH) test may be ordered because thyroid disorders can affect mood.

Diagnoses

Mental health disorders are diagnosed by mental health providers using the diagnostic criteria in the DSM-5. Personality disorder diagnoses are typically not made until late adolescence or over the age of 18 because it is important to determine if the symptoms are traits of a developmental stage or pervasive traits of a personality disorder in multiple contexts.

Nurses create individualized nursing care plans based on the client’s response to their mental health disorder(s). Common nursing diagnoses related to the clusters of personality disorders include the following:

• Cluster A: Social Isolation, Disturbed Thought Process, Risk for Loneliness
• Cluster B: Risk for Suicide, Risk for Self-Directed Violence, Social Isolation, Chronic Low Self-Esteem, Ineffective Coping
• Cluster C: Anxiety, Risk for Loneliness, Social Isolation

Common nursing diagnoses for clients diagnosed and hospitalized with borderline personality disorder are further described in Table 10.4.

Table 10.4 Common Nursing Diagnoses for Clients With Borderline Personality Disorder^[2],[3]

Outcomes Identification

In the acute care setting, the focus for setting goals and outcomes is the reason for admission, which may include conditions such as suicidal ideation, self-injurious behavior, severe depression, or severe anxiety. Outcomes should address the acute nursing diagnoses with prioritization on safety. For example, if the client has a nursing diagnosis of Risk for Self-Mutilation, a SMART outcome could be, “The client will refrain from intentional self-inflicted injury during hospitalization.” Read more information about setting SMART outcomes in the “Application of the Nursing Process in Mental Health Care” chapter.

Examples of other SMART outcomes for clients hospitalized with borderline personality disorder may include the following^[4]:

• The client will remain safe and free of injury during their hospital stay.
• The client will seek help from staff when experiencing urges to self-mutilate during hospitalization.
• The client will identify three triggers to self-mutilation by the end of the shift.
• The client will describe two preferred healthy coping strategies by the end of the week.

Planning Interventions

Individuals diagnosed with borderline personality disorder may be suicidal, self-mutilating, impulsive, angry, manipulative, or aggressive. Nurses plan interventions according to the symptoms the client is currently exhibiting with the goal of keeping the client and others safe and free of injury. Review interventions for clients diagnosed with Risk of Suicide in the “Application of the Nursing Process in Mental Health Care” chapter.

Clear boundaries and limits should be set and consistently reinforced by the health care team. When behavioral problems emerge, the nurse should calmly review therapeutic goals, limits, and boundaries with the client.^[5]

Implementing Interventions

Promoting Safety

When implementing planned interventions, the nurse must always consider safety. Develop a crisis/safety plan with the client that includes components such as these:

• Identifying thoughts or behaviors that increase the risk of harming self or others
• Identifying people, events, or situations that trigger those thoughts or behaviors
• Implementing coping strategies
• Reaching out to other coping resources

For example, if a client performs superficial self-injurious behavior, the nurse should act based on agency policy while remaining neutral and dressing the client’s self-inflicted wounds in a matter-of-fact manner. The client may be asked to write down the sequence of events leading up to the injuries, as well as the consequences, before staff will discuss the event. This cognitive exercise encourages the client to think independently about their triggers and behaviors and facilitates discussion about alternative actions.^[6]

De-Escalating

The nurse should implement de-escalation strategies if the client exhibits early signs of increasing levels of anxiety or agitation. Strategies include the following:

• Speaking in a calm voice
• Avoiding overreacting
• Implementing active listening
• Expressing support and concern
• Avoiding continuous eye contact
• Asking how you can help
• Reducing stimuli
• Moving slowly
• Remaining patient and not rushing them
• Offering options instead of trying to take control
• Avoiding touching the client without permission
• Verbalizing actions before initiating them
• Providing space so the client doesn’t feel trapped
• Avoiding arguing and judgmental comments
• Setting limits early and enforcing them consistently across team members
• Addressing manipulative behaviors therapeutically

If the client continues to escalate, measures must be taken to keep the client and others safe. Review signs of crisis and crisis interventions in the “Stress, Coping, and Crisis Intervention” chapter. If interventions are not effective in de-escalating a client at risk to themselves or others, seclusion or restraints may be required. Review using seclusion and restraints in the “Psychosis and Schizophrenia” chapter.

Coping Strategies

Teaching self-care and coping strategies is helpful for people diagnosed with personality disorders and their loved ones.^[7] Read about stress management and coping strategies in the “Stress, Coping, and Crisis Intervention” chapter.

For clients seeking immediate relief from intense symptoms such as panic or depersonalization, nurses can teach how to stimulate the parasympathetic nervous system. Stimulation of the vagal nerve can result in an immediate, direct relief of intense emotions. This can be accomplished by doing the following^[8]:

• Applying ice or ice-cold water to the face
• Performing paced-breathing techniques in which the exhalation phase is at least two to four counts longer than the inhalation phase. For example, advise the client to inhale while counting to four and then exhale while counting to eight.

Collaborative Interventions

Psychotherapy

First-line treatment for personality disorders is psychotherapy. Examples of psychotherapy used with clients with personality disorders are cognitive behavioral therapy, dialectical behavioral therapy, interpersonal therapy, mentalization-based therapy, psychodynamic psychotherapy, and psychoeducation. Read more about these treatments in the “Treatment for Personality Disorders” section of this chapter.

Pharmacotherapy

There are no specific medications approved to treat personality disorders. However, clients may be treated for symptoms associated with personality disorders that cause them significant impairment and distress. Read more information about common medications used to treat symptoms of personality disorders in the “Treatment for Personality Disorders” section of this chapter.

Evaluation

Refer to the SMART outcomes established for each individual client to evaluate the effectiveness of the planned interventions. Modification of the established nursing care plan may be required based on the effectiveness of the interventions.