I'm In Trouble B/c Of Borderline - page 3

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

  1. by   docpsychrn
    i too use to work with the borderline females! 7 years of pure exhaustion! not only did they drain me emotionally on some days but they drained all of us physically on most days. my borderlines were maxium security forensic females that if they didn't get what they wanted, they just hurt themselves. i had 2 of the most notorious borderlines in the whole state (according to the forensic community in the state). one would cut on herself (over 2500 scars) and the other would insert items in her urethra. between the two they would fight over being able to be the center of attention with me everyday. so, i started a routine which involved talking to each of them for 5 minutes only at the beginning of the day unless they were on suicide watch (which was all the time) and then i would go about my daily routine. if they were on sucide watch, i would then only ask them the required questions as to them remaining on suicide watch. if either of them did self harm while on my shift, i never panicked nor did i feed into their crying or complaints of pain. (this really pissed them off!). and after they returned from the hospital and things were removed or stitched up, they would want to apologize to me or talk etc and i would not feed into them at all. of course they would esculate with my consistentcy and firmness and blame me for not caring but they eventually would end up in 4 point restraints after i exhausted every step leading up to that last resort consequence. documentation is so very important with this individuals as well. they will turn things around that you might have said or not said and make things ugly. i think the main thing that i learned with the borderline females was to be firm, fair and consistent at all times. if you give them one inch they will take a dozen miles! even when they are doing half way good one day, i still never went over the boundaries and led them to believe that we were pals or anything close to that. i thought that one suggestion about having the borderlines only talk to the one nurse was an excellent idea as well. but with 3 shifts, you can't control what the other staff are doing. but i always made it clear that i didn't care what the other staff did or said, i was on duty that day and it was what i said or did that went for that shift. good luck to you, i left forensic nursing and went into correctional nursing as the mental health rn and i love it. now i am dealing with antisocial personalities and some serious mental cases. so much easier than the borderline females. hang in there.
  2. by   CharlieRN
    The 3 most important things to remember with borderlines are: boundries, boundries, and boundries.

    The rule is to keep your back against the institutions policy book. Never move into grey territory.

    In much of the civilized world a borderline dx is considered a contra-indication for hospitalization, so just why is the client on your unit? Many of these clients are chronicly self destructive so merely wanting to hurt herself is not a reason to be inpatient. At my institution we are working toward a standard plan of response that involves not preventing a patient from doing acts that are not lethal or severly self destructive. You want to scratch your wrist, we will put a watch on you, keep talking to you, distract you, deny you the privacy to self injure according to your personal ritual, but we will not lay hands on you. If you want to impliment such a plan everyone on staff, from the director to the mental health workers need to be on the same page. It has to be the documented treatmentplan signed by the MD. The nurse can't do it alone.

    It is also helpful to try to identify the healthy need that your problem client is trying to get met. Humans do not seek evil. She is trying to fulfill a legitimate healthy need, what is it? BD pts generate chaos on our units, but they don't want chaos. Chaos is dangerous to them, as it is to anyone. But they often want the power to create chaos. Wanting to be empowered is a legitimate need. Wanting attention is a legitimate need. Wanting to be loved is a legitimate need. Wanting to be respected is legitimate.
  3. by   Thunderwolf
    Most excellent post, Charlie.
  4. by   Thunderwolf
    And may I echo your thoughts again?....boundaries, boundaries, boundaries...are everyone's friend.

    Structure is the very thing these folks need but quite often internally lack. We, as nurses, role model that boundaries do exist, do work, and are self empowering.
  5. by   epg_pei
    Hypothetical scenario: if a pt follows a psychiatrist from Iowa to New York to maintain their relationship, is that healthy?

    Follow-up: if that dr admits the same pt to an acute care psych unit and retains the admission for weeks/months (on a regular basis) is that therapeutic?
    Last edit by epg_pei on Dec 18, '07 : Reason: Carefully wording
  6. by   Thunderwolf
    Quote from epg_pei
    hypothetical scenario: if a pt follows a psychiatrist from iowa to new york to maintain their relationship, is that healthy?

    i guess one way to answer this is: is it reasonable for a patient to follow a cardiologist or neurologist from iowa to new york to ensure continuity of care? if the case is severe and the risk of treatment failure is great without it (especially if the patient is rurally islolated), this may (in some circles) be seen as reasonable. however, "most" patients are able to receive comparable care if a provider should need to relocate. but, since this thread is devoted to bordline pd...which has inherent clinging and dramatic smothering of relationships....it may hint more of a pathological process....therefore, it may not be therapeutic.

    follow-up: if that dr admits the same pt to an acute care psych unit and retains the admission for weeks/months (on a regular basis) is that therapeutic?

    if i leap frog from my previous answer, it may again suggest the severity of the borderline pathology. however, a relationship is a two way street....even a doctor/patient relationship. if the psychiatrist is psychodynamically trained in psychotherapy (which many are)...he/she may actually do very little to actively thwart the pathologic process...hoping that one day that the patient will eventually "see it for what it is" on his/her own terms and as a result, desiring one day to end one's own therapy from gaining this new personal insight (or "ah hah" experience). in psychodynamic theory, it is believed that once insight is achieved, behavior will then change accordingly...but not until then...for the psychodynamic process and therapist are but to reflect back, like a mirror, the patient's own distorted self projections...with the eventual hope that the patient will "get it one day" by seeing him/herself more clearly then. so in this theory, behavioral change is believed to occur first with the patient-psychiatrist relationship (patient transference)...then working outward towards other relations in a more healthy way. many other psychotherapies do not prescribe to this slow process of change or viewpoint as a primary modality and neither do many insurance companies....because we are talking, quite often, years here. this is one reason why cognitive therapy had made such an impact in the treatment community. it doesn't necessarily have to take years....but, it does require change...not passively, but actively so. this reminds me of a joke from my ole therapist days (i used to be a licensed counselor). how many therapists/psychiatrists does it take to change a light bulb? the answer: one...but the light bulb has got to really want to change first (psychodynamic humor).
    good questions. thank you.
    Last edit by Thunderwolf on Dec 21, '07
  7. by   Amazed*bythe*Mind
    Your unit sounds alot like mine. Lately we have been up to our eyeballs with geri's that have major med problems and borderlines. For the borderline we put it in the treatment plan that patient is only to talk to assigned staff for their needs, etc. This can be horrible for the assign staff but then you just have to set clear boundaries and stick to them and keep a vigilant eye out because from my experience when they can't disrupt or get the attention they want they act out. It does take alot of patience. As for the medical, I've recently pick up a PRN position on a med/oncology unit and I try to get the staff educators to come and do as many inservices on med/surg skills as they can. Every one seems to appreciate it.
  8. by   2bnursenikki82
    I work at a 80-something bed psych hospital...we have a kids unit, acute unit generally reserved for psychotic and actively hallucinating patients, a general adult unit we use for major depression and drug abuse and a geriatric unit. We have a few borderlines that are in and out CONSTANTLY. CONSTANTLY. CONSTANTLY. We've had some get discharged, state that were NOT suicidal at discharge, and walk directly across the parking lot to the main hospital ER and request readmission because they are feeling suicidal. What I've noticed works sometimes, at least to delay readmission and put a halt on some of the more flamboyant borderline behavior, is to stick them on the acute unit when we have the beds. Then they see the patients who are TRULY sick and who are truly having serious mental issues. Usually only takes a day on the unit with a few of our favorite schizophrenics, whom I love, to scare them back out of the hospital for a few weeks. A bit evil...but I like it!
  9. by   Thunderwolf
    The issues you describe here, the immediate revolving door of BPD, is a counseling/therapy issue ...not an inpatient psych issue. The system, as is, as you just described just fosters even more the BPD pathology. It needs addressed in therapy....actively so.
  10. by   Weeping Willow
    Quote from TitaniaSidhe
    First 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.
    OOH, Girl, you're terrible! Just kidding. You actually took the patient literally is all you did. How did he respond? Did you ever have to do that again? Did you get in any trouble? Was the patient violent or cooperative about going into the leathers? What did your manager say?

    I have a hard time saying no to clients, also the nursing assistants. I guess I need to toughen up and stop worrying so much about avoiding conflict. I've been burned, though, and am probably overly cautious as a result. Any advice for me? I mention this because I am probably likely to be manipulated by the Borderlines.
  11. by   island40
    BPD clients are like 2 year olds that have never been told no. The only way to deal with them is tell them the rules and enforce them, over and over and over and over. They either get with the program or they get out. Either way my day goes better. Good luck. Too bad your NM is the type to call you on the carpet insead of having a relaxing discussion between professionals.