BarbRPN

Thanks for your comments and you are so right about s/s of depression and other problems having potential for being overlooked due to the nature of BPD. Thanks for your insights. ------------------ Barb Registered Practical Nurse Psychiatry Ontario CANADA

I'm a registered practical nurse in Canada and I must say I was a bit surprised at the replies you've received (from the original questions). I've worked in a large provincial psych hospital for sixteen years in geriatrics, chronic care, rehab and admissions. Over the years I have seen a fair bit of change in management of disturbed behavior but none so positive as has been described here. Certainly there is much less use of passive and active restraint in our facility but restraints are still utilized frequently. Our policies have become tighter, with higher degree of monitoring by physicians. Currently we use "special observation rooms" when a client becomes dangerous to himself or others. If the person is at risk of self harm, seclusion is not permitted. They are either monitored at least every fifteen minutes OR if they are more critically suicidal, they are monitored on a constant one on one protocol. Clients with self harm/suicidal ideation are NEVER secluded (locked in a seclusion room). Agressive/threatening/hostile/abusive clients are secluded, monitored every fifteen minutes and when escorted to the washroom or shower they are on constant observation by two or more staff. Most times when a constant observation client is out of seclusion the physicians will order that they must wear three point OR wrist to waist restraints. These are applied before bringing the person out of seclusion and then ALWAYS removed before seclusion resumes. Wrist to waist to chair orders are less and less frequently used, ankle to ankle restraints are also used less frequently in recent years. The type of restraints we use are cloth and velcro wrist to waist restraints (which I personally don't care for since most clients can easily remove them) and the older version of plastic keylock cuffs with leather belt. These have an archaic appearance but when used are far superior IMHO. When a client is completely out of control and use of medications is limited or ineffective, or if the person is at serious risk of suicide even with constant observation, we have a specially designed bed that is used in combination with the leather and plastic cuffs, to prevent imminent harm of the client or others. I work in an acute admission ward so we use this means of restraint a few times a year. In any of the described cases, the expectation is to use the restraint for the least length of time as possible and encourage the client to regain control of his/her actions. Other restraints used previously were the "Posey Company" restraints. These generally were used in chronic care and geriatrics to restrain clients in bed or in a chair. They were generally used with clients suffereing from dementia where the client was unaware that they could not ambulate and would be at risk in the night of getting out of bed. The "vest" type of bed/chair restraint have been banned due to strangulation accidents that occurred in our facility and others around the world. We still use belt restraints for this type of client. It is secured to the bed/chair with a magnet and around the patient's middle with a magnet. When applied properly these restraints are quite effective in preventing falls. These again are used less and less but are effective in certain situations such as dementia clients who are post surgery and don't realize they are not to be walking. I can't comment on your question about detox and seizures, as I have not worked in this kind of situation. Our clients have to be physically cleared in a general setting before they can be admitted, so if they were in detox we would return them to a general hospital. ------------------ Barb Registered Practical Nurse Psychiatry Ontario CANADA

Hi and thanks for your input. I've been checking DBT links and it does appear that this modality is for the "outpatient" client. I still think there may be valuable therapeutic technique that can be elicited for inpatient use. Any thoughts, anyone? ------------------ Barb Registered Practical Nurse Psychiatry Ontario CANADA

Dialectical Behavior Therapy (DBT) is a compassionate psychosocial treatment for borderline personality disorder with proven effectiveness including: reduced suicidal behaviors, reduced substance abuse, reduced therapy dropout rates, and reduced hospitalization. I plan to go to a workshop soon by Patricia Verby MA LP that will give a comprehensive overview of DBT.[/b] CK, Thank you very much for responding. Ironically enough, I was just reading about Dialectical Behavior Training the night before last. I've been searching the net every night in my free time, for therapy models for this type of client. The DBT was the model that was most desirable to me and seemed the most all-encompasing for this particular client. I would love to attend such a conference but I live in a very small town and there is never any conferences within a day's trip. And despite the fact that I work in a huge facility, we are in a divestment transition between government and public governance of the facilty, so budget for such a conference is always denied. If I could afford to pay for entire conferences I would do it, but I can't. At any rate, I would be interested in learning more about this therapy, do you have any websites that you find particularly helpful? I need to present information to my team, particulary the medical part of the team. Right now we are using up nursing resources to the MAX on this one client. She is on constant observation 24/7 at an arm's length. What really gets me hot under the collar is that we are providing her with nothing more than a "paid companion". We are doing NO therapy what so ever. We are giving her no responsibility for her actions/decsisions. We aren't empowering this client AT ALL and I feel that the longer we keep her in this situation the more dependant she will become on this type of relationship. She even calls us her "body guards"! This is not therapeutic at all. The doctor is of the opinion that the nurses will be the downfall of this client because we suggest that this relationship and technique is not only NOT therapeutic but detrimental. The doctor says we are damaging the patient by suggesting this but our supervisor will not support us in any manner. (this is not unique to this situation only). I'm not even cautiously optimistic that the doctor will be ammenable to even review any info on DBT but at this point I figure there's nothing to lose. The last admission this client was on one to one, arm's length observation 24/7 for FIVE years!!!! I know this client from two other units I've worked on and aside from the obvious, I know that this current intervention DOES NOT WORK and is not therapuetic in the least. Thank you for your comment and if you have any good web resources, please post or email them directly. ------------------ Barb Registered Practical Nurse Psychiatry Ontario CANADA

Would anyone who has any insights or good resources on the internet, please respond. My facility has no policy on admission and treatment of borderline personality disordered clients who are repeatedly readmitted and self-abuse during admission/stay. Can anyone please comment or share admission and treatment protocol. Thank you, ------------------ Barb Registered Practical Nurse Psychiatry Ontario CANADA