I'm In Trouble B/c Of Borderline - page 2
I had a very challenging weekend. As charge nurse of a very busy 20-bed facility, our doctor didn't do too well and admitted several psych patients with medical problems. All of ours are supposed... Read More
Jun 25, '03Don't ya just love the BPD's and all the problems they cause? What really gets to me is the staff splitting and the "rescuing" staff that fall for it. I am just about at the end of my rope with staff, ususally female, ( I am female) who are too afraid to set limits. They are too afraid of upsetting the pt. Any suggestions?
Jun 25, '03Originally posted by PsykoRN
Don't ya just love the BPD's and all the problems they cause? What really gets to me is the staff splitting and the "rescuing" staff that fall for it. I am just about at the end of my rope with staff, ususally female, ( I am female) who are too afraid to set limits. They are too afraid of upsetting the pt. Any suggestions?
Aug 1, '03It might be worth considering a plan of action at discharge as to preventing/minimizing future admissions. Being hospitalized is really not theraputic for individuals with BPD. Having a meeting with her and any staff who work with her both in and out of hospital to develop a plan can be helpful, include family and any other resources she identifies. Build on the strengths she has and try to minimize the negatives. EVERYONE must use the plan in order for it to be helpful and to work.
What about Dialectical Behavioral Therapy? Is that an available option in your area? It has been very successful with clients with personality disorders among others. Don't allow your self to get caught up in the manipulation. All staff MUST work with her the same way and if they can't, they shouldn't be assigned to her
Aug 1, '03the previous post by Elizabeth hits the nail on the head
part of frustration is knowing inpatient tx is not helpful
meds won't resolve the problems
DBT is the way
I wish for you
which supports your limit setting
Sep 14, '03Borderlines are quite difficult to deal with your right. There is one I work with who, like the one you described makes everyone shutter when they know she is on the unit. She at present has 191 admissions. The thing with BPD they are just that personality disoders. they are for the most part behavioral problems. insurance companies won't reimburse doctors if they give them BPD as an axis one. These patients are difficult to deal with. The key is to set limits and to be CONSISTENT! do not let them MANIPULATE you or others. Apparently your rosy little patient is doing exactly what it is that she likes to accomplish, she is bothering you and everyone else on the unit, it makes her feel special! thats what BPDs need. So that is what they aim for. When you have a treatment plan meeting, discuss doing shorter LOS, this is what we are doing. Along with not allowing splitting, manipulation, not giving her special privilges like a private room. making the environmet therapeutic yet not cozy, comfy.They sense fear and when people are uncomfortable around them Do not let this be known, that is how they gain control of the unit! You are the nurse they are the patient,you are in control, they are not and do not let them forget this. Good luck. PJH
Sep 16, '03Does your unit use a multidisciplinary approach and have weekly
meetings to address the plan of care? Do u have a treatment
plan and behavior plan written out with the signatures of the
team on it and then during the team meeting the pt attends
if they don't refuse their plan is reviewed with them and they
sign it along with everyone else on the team.
My experience with borderlines everyone needs to be on the same accord. they will test their limits and push staff to see
how far they can push. try assigning staff to her and then have
her nurse tell her who her contact person is for that shift and
also have this in her treatment and behavior plan and then
if she goes to someone other than her contact it will be
mapped out in her beh. and tx plan of what privileges she
losses or the consequences--- then all staff caring for her
needs to be aware of what her behavior and tx plan says
and stick to it. By going over her treatment plan and beh. plan
she already is aware of the consequences for her actions.
Sep 22, '03Sounds like you have already gotten a lot of great advice. As for me, I make sure they deal with only one staff member(usually me) on my shift. There is no bending the rules or being a "softy". If smoke time is at 3:00, we smoke at 3:00 on the dot. That is if their behavior is appropriate to do so. I find setting the tone right at the first interaction of the shift is beneficial for the rest of the shift. Do not let them get you emotional, stay firm and walk away if they want to argue about your decision, which they will. And if they get mad or cry and run to their room, well that works for me. Stay strong
Sep 23, '03First allow me to qualify myself. I have worked acute, locked admissions for15 years now at the perhaps worst of the worst a VA hospital. We are the equivalent of state but for veterans only.
The one thing I have not heard anyone mention as far as advise goes is documentation. Undoubtedly borderline patients are the most difficult to deal with. Personality disorders are always such fun as there is no medication to treat them. I agree inpatient stay if countertheraputic to BD however this will not prevent them from being admitted as each admission means more money for the hospital. Nowdays it all boils down to money, sad but true. As far as assigning one staff member this I also do, I tell all the staff to direct the problem patient to me & I handle it solo. Since I am charge nurse for my shift this eliminates her asking to see who is in charge, which they often do if you given an answer not to their liking. Better yet is the demand to see the doctor. Unfortunately many times the docs do not want to be bothered with dealing with these difficulty patients & cave in to their demands just to shut them up. I know extreemly counterproductive. Then of course you have all the many other staff members who do not fall under nursing who can be also manipulated, dietary, patient advocates, rec. therapists. Many of them are only minimally aware of the havock this BD plays on the unit & only see the charming image she presents when trying to get her way or solicite a champion to her cause of unjust treatment by nursing. *sigh* The very best defense against these sort of patients I have found to be thorough & professional documentation. My favorite is to actually quote the threats & things being said by the patient. They can find no discrepancy with the RN for quoting a patient's statements Address the fact that you have made every reasonable effort to address her needs, address her behaviors & your rational for restricting privileges also state that you explained the restrictions to her but that she was unwilling to listen or accept responsibility for her behavior. Show with you words a clear picture of her manipulations, dystructive or disruptive behavior, threats toward staff, abusive language, etc. This will actually save you aggravation in the long run as when a complaint is made, & we all know there will be at least one, your ass will be thoroughly covered with your most excellant documentation. Simply refer them to her chart for some amusing reading. If your facility is like ours then you know you are guilty of whatever you have been accused of until you can prove you are innocent. Patients can accuse you of any rediculious thing they want & you will have to answer to it.
4 leather restraints is a lovely idea & can be just the attitude adjustment needed at times. Again however make very sure you document VERY WELL if you should opt of this course. Keep in mind the BD would have to be a danger to herself or others, dystructive to property, assaultive or danger to herself. All alternatives must be tried- 1:1 intervention, recreational activity, medication, ambulation, food/drink, etc. But hey I have every confidence in you if you being to set the stage with you notes at the beginning of your shift you can perhaps work in the restraints by mid shift....LOL. We sadly do not have seclusion rooms in our facillity. It is either 4 leather restraints or nothing. Once in my past I was dealing with a manipulative & very difficult patient who was demanding some very heavy narcotic medication for "pain" (pain in my ass I could have used the medicine) He threatened that if he did not get this medication he might hurt himself. I very sweetly asked him, "do you mean to tell me that if you do not recieve this medication you will hurt yourself?" He replied yes...hehe...I further went on to ask still sweetly, "do you mean to tell me that you feel you are in danger of loosing control of your behavior?" He answered yes....hehe...I then very sweetly informed him that since he would not be recieving this medication as the doc is not giving it to him & that since he felt he would hurt himself & was incapable of maintaining control of his behavior then I would simply have to assist him with maintaining control of his behavior. Then came the 4 leather restraints...hehe I know terrible but sometimes you just have to do what you have to do to maintain your sanity & peace on the unit for the rest of the patients. My favorite statement is this, "your behavior is becoming uncontroled, if you are unable to control your behavior & you refuse to take some PRN medication then I am sorry but I shall be forced to assist you in regaining control of your behavior."
Whatever did happen in regard to your favorite BD? Myself I just got done dealing with almost the same thing you are speaking about. I know how you feel. It is frustrating that the admin even feeds in to such rediculious statements from known problem patients. It only leads these patients to keep doing it again & again.
Oct 12, '03hi
we try to NOT allow these pd's to get settled on the ward(that is to say discharge them as soon as is appropriate).This strategy is well excepted, but isnt the only one. Please be a aware at all times about what you say to them. They are manipulative and dangerous people. Primarily because their coping skills are sooooooooooo primitive not like ours which are sofisticated hahahaha. Temper ALL of your responses....caution is the word. And in many cases im certain ive seen the devil in their eyes too
Nov 11, '03Dear In Trouble,
There is great book out there about Borderlines that you might want to read in your spare time if you have any. It's called Skills Training Manual for Treating Borderline Personality Disorder by Marsha M. Lenihan. It has a few insights that might help your whole unit in dealing with Borderlines. You could be the shining star and educate everyone. It sounds like you're not really interested right now in being the shining star but instead surviving. My question is why is your boss calling you at home on your day off? I wonder if the whole unit needs a little reminder about boundaries not only with patients but starting with each other. The scenario in my mind is that you finally get to get away from blue eyes for one day and your boss calls and ruins it for you by racking your nerves. Thanks for nothing! I'm sure her nerves got racked by someone and she calls to get relief by getting answers and venting a little. It's human and hard to resist but I think needs to be especially on one of her valued employees day off. I hope to never go back on inpatient again so sorry that's all the advice I have. Good luck and I like the idea of the patient having one contact person only!