Nurs 360 Capstone Presentation

8/18/2019 Nurs 360 Capstone Presentation

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NURS 360 PMHKAPI’OLANI COMMUNITY COLLEGE

CAPSTONE PRESENTATION:

BORDERLINE PERSONALITY DISO

By: Christine Rombawa


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DATA:29 YEAR OLD FEMALE ARRIVED VIA AMBULANCE FOR SUICIDE ATTEMPT. HMAJOR DEPRESSION, BIPOLAR, AND BORDERLINE PERSONALITY DISORDERFINDING OUT THAT HER CASE WORKER WAS “LEAVING HER”, PATIENT ATTETO OVERDOSE BY CONSUMING 10 200MG TABLETS OF SEROQUEL. PATIENREPORTED FEELING DIZZY, HEAVY, NAUSEATED, AND CONFUSED AFTER TAPILLS, THEN CALLED 911.

LEGAL STATUS:VOLUNTARY COMMITMENT (MH-5)PATIENT COMMITTED HERSELF ON HER OWN FREE WILL AND PHYSICIANDETERMINED THAT SHE NEEDED IN-PATIENT TREATMENT. ADMITTED ON 01/2


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DSM DIAGNOSISAxis I : Major Depression, Bipolar

Axis II: Borderline Personality Disorder/Cluster B, Borderline traitsAxis III: None

Axis IV: Unstable living conditions, Unemployed, Strainedrelationships

Axis V: GAF is 40

(Some impairment in reality testing or communication(speech at times illogical, obscure, or irrelevant) OR majorimpairment in several areas such as work or school, familyrelations, judgment, thinking or mood.)


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BORDERLINE PERSONALITY DIAGNOSTIC CRITERIA 301.83

A pervasive pattern of instability of interpersonal relationshi

self-image, and affects, and marked impulsivity beginning early adulthood and present in a variety of contexts, asindicated by five (or more) of the following:

(1) frantic efforts to avoid real or imagined abandonment.

(2) a pattern of unstable and intense interpersonalrelationships characterized by alternating between extremof idealization and devaluation

(3) identity disturbance: markedly and persistently unstableself-image or sense of self


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DSM : DIAGNOSTIC CRITERIA CONTINUED…

(4) impulsivity in at least two areas that are potentially sedamaging (e.g., spending, sex, Substance Abuse, reckledriving, binge eating).

(5) recurrent suicidal behavior, gestures, or threats, or selmutilating behavior

(6) affective instability due to a marked reactivityof mood (e.g., intense episodic dysphoria, irritability,or anxiety usually lasting a few hours and only rarely mora few days)


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DSM : DIAGNOSTIC CRITERIA CONTINUED

• (7) chronic feelings of emptiness

• (8) inappropriate, intense anger or difficulty controlling angfrequent displays of temper, constant anger, recurrent phys

• (9) transient, stress-related paranoid ideation or severe dissosymptoms

•Patient meets all 9 diagnostic cri


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FINANCIAL DATA

• Medicare Insurance

• Monthly income: $1,120 pmonth.

• Rent is $350 per month forin a 4 bedroom group hothree other individuals.

• Patient also receives $350stamps monthly.

• Patient claims to have adincome to meet her need


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PATIENT’S DESCRIPTION OF PROBLEMAdmits having constant suicidal thoughts and multipleattempts. Patient states that she has difficulty getting alonwith others and disagrees with having a personality disorbut agrees to being depressed and bipolar. She complaifeeling hopeless and helpless. She states that her motherbipolar, so that’s the reason they don’t get along. She saitries to make everyone happy but then they abuse her atake advantage of her by using her for money and sex a

then leave her. She tried to overdose because she said tno sense staying alive to continue to get abused by everin her life including her case manager. She claims that shforced to use meth and only uses it once or twice a montalso stated that she uses meth to stop the racing thoughtit gives her a break.


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PART HAWAIIAN/ GERMANNO DECLARATION OF RELIGIOUS BELIEFS. BELIEVES IN GO

DOES NOT PRAY OFTEN. CHANGES RELIGION FREQUENT


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STRENGTHS: ARTICULATE, CAN BE COOPERATIVE, WILLING TO SEEK HELP

Limitations:

- Self-destructive impulses, self-mutilating behavior, suicidal threatsespecially when an attachment relationship is disrupted or threate

-Lack a stable sense of self: Attitudes, values, goals, and feelings athemselves are unstable or ever-changing.

-Fear rejection and abandonment, fear being alone, become attaand intensely.

-Play the role of "victim", often elicit intense emotions in other peopmanipulate.

-Feel misunderstood, mistreated, or victimized.

-Relationships tend to be unstable, chaotic, and rapidly changing

-Splitting: When upset, trouble perceiving positive and negative qusame person at the same time. Idealization to devaluation. Love y


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MEDICATIONSAntidepressants, 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 anxietyoffer before Ativan) (Antihistamine)

lorazepam Ativan 0.5mg tab PO Q8hrs PRN (Agitation, moderate tsevere 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(Antihistamine)


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MEDICAL ISSUES/LABSUrine toxicology screen: Positive formethamphetamine

CBC w/diff, CMP, BMP lab values WNL excelevated K+ 5.3 (H) (3.3-5.1mEq/l)


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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 positive coping statement and skills.

• Individual therapy to recognize internal and external cues of emotions to cope with unpleasant emotions.

• Group therapy for improving patient’s use of effective, assertive, and re

communication to appropriately express her thoughts, needs, and feeliothers.

• Educate patient regarding the need for follow-up care in an outpatient

• the psychiatric symptoms that indicate a need for emergent treatment

• an understanding of any medications that the patient is receiving.


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DISCHARGE PLAN/COMMUNITY RESO• No suicidal ideation or intent to hurt self. An agreement by the patien

suicide hotline (e.g., 1-800-273-TALK) or to call a supportive friend, famember, or case worker if suicidal ideation happens again to prevenreadmission, harm, or death.

• CBT, Group therapy, individual therapy, Clubhouses, psychosocial rehprograms, and vocational rehabilitation

(SRSP) Specialized Residential Services Population at Care Hawaii

• Individual and group programming and activities are provided to facrecovery and assist the consumer to live successfully in the communitan abstinent lifestyle, regain employment, develop and maintain soc

relationships, or to independently participate in social, interpersonal, and peer support activities to increase community stability.

• Therapeutic Living Program (TLP) at Care HawaiiThe primary goal of the program is to assist consumers in meeting theneeds until they are able to transition in to a more independent livingtheir choice. Support is flexible, focused, and based on recovery. resttherapy, CBT therapy, recreational therapy, individual and group skillother activities which support healthy living.


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STANDARDIZED ASSESSMENT TOOLS

• High suicide risk precautions AEB 33 on TM33

• Major depression AEB 35 on Burn’s Depression chec

Very low self-esteem AEB 9 on Coopersmith self-este

3 HIGHEST PRIORITIES PROBLEMS W/ RATIO


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3 HIGHEST PRIORITIES & PROBLEMS W/ RATIO

• Risk for suicide and risk for self-directed violence

• Evaluate the client’s risk for suicide through careful observation of behadirect questioning (asking for suicidal intent & plan).

•

The nurse’s first priority is to provide for the clients safety and protect the self-inflicted life-threatening injury or death.

• Protect the client and others from harm or injury when client losea result of impulsive, aggressive behaviors.

• Staff members who use appropriate safety methods for clients withimpulsive/threatening or aggressive behaviors are the best source of pragainst harm or injury to the client and others in the milieu. Use method

to facility policies/procedures and standards of care.• Impaired coping and chronic low self esteem

• Engage the client in appropriate group, cognitive and behavioral thera role-play, cognitive-behavioral therapy, assertiveness training, and pro

• Participation in a variety of therapeutic activities and groups tends to inesteem and foster independent functioning and behaviors resulting from

acceptance, and the universality of group dynamics.


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INTERVENTIONS W/ SCIENTIFIC RATION


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INTERVENTIONS W/ SCIENTIFIC RATION

Fortinash, Katherine, Patricia Worret. Psychiatric Nursing Care Plans 5th Edition. Mosby,

Intervention & Frequency Scientific Rationale

Evaluate the client’s risk for suicide every 15 minutes throughcareful observation, of behaviors, and direct questioning.

There is always a chance that clients at rion their thoughts, and studies show that tplan, the greater risk for suicide. (Fortinas

Tell the patient to come to staff whenever the client experiencessuch thoughts or feelings.(Contract for safety) every shift (8 hours)

Constant staff support and protection resuicidal impulses and offer hope for surviv(Fortinash, p.97)

Monitor the client for behaviors every 15 minutes that areprecursors 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 ofpersecution, insomnia, with recurring thoughts of suicide,hopelessness.

These behaviors are strong indicators of and cue the staff to take steps to prevensuicidal thoughts and feelings and to sec

environment.(Fortinash, p.97)

Check the client and room daily for potentially destructiveimplements: sharp objects, belts, shoe laces, socks, chemicals,hoarded medications; and take steps to protect client throughappropriate therapeutic interventions.

The nurse’s first priority is to provide for theprotect the client from self-inflicted life thdeath. (Fortinash, p.96)


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NURSING CARE PLAN• Nursing Diagnosis: Ineffective coping r/t negative thinking pattern

defeating behaviors, multiple stressors, and ineffective support syevidenced by self-destructive behaviors, lack of assertive comm

impaired judgement and insight, misdirected anger, and social is• P: Ineffective coping

E: Self-destructive behaviors, lack of assertive communication, im judgement and insight, misdirected anger, and social isolation.

S: Coping enhancement; Anger control assistance; Anxiety reducmanagement; Emotional support; Support group; Support system

enhancement; Teaching: individual; Therapy group

ST Goal: Client will begin to gain insight on positive outcomes of utitherapeutic coping skills today.

LT Goal: Client will demonstrate effective coping skills prior dischar

INTERVENTIONS WITH SCIENTIFIC RATIONALE


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INTERVENTIONS WITH SCIENTIFIC RATIONALE

Intervention & Frequency Scientific Rationale

Assist the client to redirect angry or ambivalent feelingsthrough constructive activities; physical exercise, art/music

therapy, and relaxation techniques daily.

Therapeutic activities help the clientenergy and reduce stress and frustra

accepted way (Fortinash, 261).

Engage the client in therapeutic groups, including role-play/ sociodrama, behavioral cognitive therapy,assertiveness training, and process/focus groups daily.

Therapeutic groups help the client ebehaviors and their effects on self adynamics of the group process and clients and group leaders(Fortinash,

Offer feedback to the client in a tactful manner whenobserving client perceptions that individuals or groups are

either “all good” or “all bad” daily.

The nurse’s tactful feedback of the c

behaviors will challenge the client’s

her correct the distorted views and rbehaviors. (Fortinash, 261)

Teach the client therapeutic strategies to increase the timespan between the stimulus and the client’s response;

practice slow deep breathing, relaxation techniques, countto 5 slowly, engage in physical exercise daily.

These therapeutic strategies give theopportunity to choose an alternativeand thus reduce the incidence of suemotional expressions by the client(F

Fortinash, Katherine, Patricia Worret. Psychiatric Nursing Care Plans 5th Edition. Mo


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NURSING CARE PLAN

• Nursing Diagnosis: Chronic low self esteem related to disturbance of powerlessness, ineffective problem solving, perceived abandonmen

evidenced by poor self concept and body image, dependency, abaattention seeking, hysteria, and jealousy.

• P: Chronic low self-esteem

• E: Poor self concept, dependency, abandonment fears, attention seeand jealousy.

• S: Self-esteem enhancement, body image enhancement, emotional

enhancement, cognitive restructuring, role enhancement and suppo• ST goal: Client will begin to demonstrate improved self confidence in

• LT goal: Client will demonstrate confidence in abilities and have a pperception prior to discharge.

NURSING CARE PLAN


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NURSING CARE PLANInterventions and Frequency Scientific Rationale

Reinforce the client’s independent behavior in a positiveway daily.

Reinforcing the client’s behaviors inc

and self-esteem and encourages coindependent behavior(Fortinash,238

Help the client set realistic, attainable goals daily. Setting realistic, achievable goals hminimize failure, provides hope for bincreases the client’s feelings of inde

over life(Fortinash, 240).

Engage the client in appropriate group, cognitive, andbehavioral therapies; role play, cognitive behavioral

therapy, assertiveness training, process groups at leasttwice a day.

Participation in a variety of therapegroups tends to increase self-esteem

independent functioning and behasupport, acceptance, and the univedynamics(Fortinash,242).

Teach the client to challenge unrealistic beliefs (e.g. failure,unattractiveness, lack of initiative) by pointing out factualinformation daily.

Pointing out realistic facts that challe

negative self perception helps decr

negative self-concept and promoteworth(Fortinash,241).

Fortinash, Katherine, Patricia Worret. Psychiatric Nursing Care Plans 5th Edition. Mosby,

•Evidenced based article


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•Evidenced based article

• randomized controlled trial of cognitive behavioral therapy (CBT)people with borderline personality disorder attending community

clinics• Used instrumental variable regression modelling to estimate the im

• quantity and quality of therapy received.

• A total of 101 participants provided full outcome data at 2 years

• randomization. The previously reported intention-to-treat (ITT) resuon

• average a reduction of 0.91 (95% confidence interval 0.15)

• 1.67) suicidal acts over 2 years for those randomized to CBT. By inthe influence of quantity of therapy and therapist competence, wthis estimate of the effect of CBT pd could be approximately two times greater for those receiving the right amount of therapy


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EVIDENCE BASED JOURNAL ARTIC

• Norrie, J., Davidson, K., Tata, P., & Gumley, A. (2013). Influence ofcompetence and quantity of cognitive behavioural therapy on sbehaviour and inpatient hospitalisation in a randomised controlleborderline personality disorder: Further analyses of treatment effePsychology & Psychotherapy: Theory, Research & Practice, 86(3)doi:10.1111/papt.12004

• LINK

• http://web.a.ebscohost.com.ezproxy.library.kapiolani.hawaii.ed/pdfviewer/pdfviewer?vid=4&sid=45567287-d549-4306-b078-a633d854a502%40sessionmgr4004&hid=4107

http://web.a.ebscohost.com.ezproxy.library.kapiolani.hawaii.edu:8080/ehost/pdfviewer/pdfviewer?vid=4&sid=45567287-d549-4306-b078-a633d854a502@sessionmgr4004&hid=4107http://web.a.ebscohost.com.ezproxy.library.kapiolani.hawaii.edu:8080/ehost/pdfviewer/pdfviewer?vid=4&sid=45567287-d549-4306-b078-a633d854a502@sessionmgr4004&hid=4107http://web.a.ebscohost.com.ezproxy.library.kapiolani.hawaii.edu:8080/ehost/pdfviewer/pdfviewer?vid=4&sid=45567287-d549-4306-b078-a633d854a502@sessionmgr4004&hid=4107http://web.a.ebscohost.com.ezproxy.library.kapiolani.hawaii.edu:8080/ehost/pdfviewer/pdfviewer?vid=4&sid=45567287-d549-4306-b078-a633d854a502@sessionmgr4004&hid=4107http://web.a.ebscohost.com.ezproxy.library.kapiolani.hawaii.edu:8080/ehost/pdfviewer/pdfviewer?vid=4&sid=45567287-d549-4306-b078-a633d854a502@sessionmgr4004&hid=4107


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• Patient’s treatment plan is relevant

• Changes?

• More aggressive and frequent inpatient-therapy(Beneficial)

•

More support and referrals to community outpatprograms. (Decrease helplessness)


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REFERENCES

•

American Psychiatric Association: Diagnostic and statisticalmental disorders. 5th Edition, Arlington, VA. American PAssociation, 2013

• Fortinash, Katherine, Patricia Worret. Psychiatric Mental Hea 5th Edition. Mosby, 2012. VitalBook file.

• Fortinash, Katherine, Patricia Worret. Psychiatric Nursing CarEdition. Mosby, 2012, St.Louis.


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BORDERLINE PERSONALITY DISORDE

• https://www.youtube.com/watch?v=VhFI9O0ogYk

https://www.youtube.com/watch?v=VhFI9O0ogYkhttps://www.youtube.com/watch?v=VhFI9O0ogYkhttps://www.youtube.com/watch?v=VhFI9O0ogYk


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Documents

Nurs 360 Capstone Presentation