I'm In Trouble B/c Of Borderline

  1. 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 to be "medically stable". One of these required round-the-clock nursing because he was dying with endstage COPD and emphysema and none of the medical floors wanted him. I sent him to ICU on Friday with a p02 of 38 and less than 24 hrs later the doc declared him medically stable because he was bothering those ICU nurses. I was terrified he would drop dead at any moment. We only have two nurses with 18-20 pts. The rest are psych techs or floated CNA personnel. On top of the two very serious med pts, we had 3 borderlines causing all kinds of ruckus, one a 19 year old girl I'll call "B". Whenever we come into report and see B's name on the census, we all groan because we can't stand her. Her picture should be next the the definition of a borderline in the textbook. She wears on our last nerve and we all find it hard to be helpful and therapeutic. She walks about the unit like she owns it, cursing and making fun of older patients. She invites males to her room for blow jobs or other sexual favors and delights when we find her. She has the bluest eyes with large pupils and she slits them and looks up at us and stares. I swear, it looks like the devil himself. After her behavior gets her in so much trouble, she cries and has her little pity party. When she first came to us, she was a minor and we had to really look out for her. Now, she's considered an adult and still doing the same crap. She and I had it out yesterday and there was some major staff splitting being attempted. When she had visitors, she cried and cried about the situation that brought her into the hospital this time and I heard several times "and now my nurse hates me" and she'd shoot me a glance and glare. I ignored her. I'm off today and get a call from my nurse manager. We have to have a talk about B so she can get my side of the story. My side of the story is I would have knocked her into next year yesterday if I could have. Instead, I set limits with her and restricted her smoking privilege after supper for some horrendous behaviours at lunchtime. This freaked her out. I must be sadistic, because this gave me pleasure. She is the only patient that is a frequent flyer that causes me to feel this way. She signed a 72-hr hold after the restriction of her smoke break and told everyone that we'd be glad after she left. No one replied and she kept on and on. We know she doesn't want to leave. It's like a cruise ship on our unit and she knows she has it made. However, I did make the remark that I'd call the doctor and see if she could leave tonight if she wanted to leave so bad. Of course, this caused the waterworks and she wanted to know why we all hated her.

    I have a feeling that I'm getting ready to be suspended or written up and I'd be upset about it if it had been any other situation. For this girl, I'll gladly sit on the sidelines without pay just so I don't have to lay eyes on her again before she leaves. And the next time we get a referral on her, I'm going to (as well as all other staff) try to sway the doctor to send her to the state psychiatric unit where they're not as comforting and loving as we are!

    What do you think? I know this borderline has succeeded in her quests to drive us insane. Any suggestions on what to do in a case like this. Setting limits with her is for the birds. You set one and she breaks it just to see what you will do.

    I've spent 2 years doing psych nursing and I think I must be getting burned out.

    Any info or support (or constructive criticism) would be greatly appreciated.

  2. Visit kittykash profile page

    About kittykash

    Joined: Dec '99; Posts: 34
    graduate nurse waiting on boards at the moment


  3. by   RN2007
    Do you have an extra Quiet Room with padded walls and video monitoring so you can keep a watch of her from the nurses station? Sometimes, if all else fails, if you give her a week or so of the quiet room by herself without minimal priviledges beside bathroom, ADL, and food & water, they tend to learn what happens when they keep pushing the envelope. When I used to work in psych units, this proved helpful many times. Of course, you continue to give them their meds, etc., she just is not able to walk the halls and harrass everyone else. Although, normally the first few days when you put her in there, it can be hel* listening to her screaming and calling you names, but tell her ahead of time what is expected of her, and what behaviors will cause her to stay in there longer. After awhile, she should get it or maybe she needs the state psychiatric ward. These patients are soooo hard to help.
  4. by   Murt
    Shes obviously the wrong patient for your ward. Its one thing upsetting staff but the way she integarates with other patients is appaling. For the other patients sake she should be moved asap, youse cant give her the care she needs.
    As for yourself id just ignore her, work on different patients, tell your boss either she goes or i go.
    I have similar problems with patients demanding drugs (drug rehab clinic), the can get to you and they can ruin your day but in my branch they allways seem to settle down aftewr a while, ie the smuggle in something theres.elves
  5. by   Liddle Noodnik
    Originally posted by kittykash
    I had a very challenging weekend.
    Yes, that is probably all it is, a BAAAAAD weekend! Get rest and follow the advice you give all your "lovely" patients, LOL! If you feel this way for a prolonged period of time tho' it MIGHT be burnout, or maybe you need to find a different way to deal with it.

    I did 1 1/2 years of Chem dependency and after a while it turned into psych and adolescent psych and I tell you, I hear ya. Plus my ex husband is supposedly a borderline and they are trickkkky!!

    Be well, glad you had a place to vent! (feel better now?)
  6. by   lucianne
    RN2007, I don't know how long it's been since you worked psych, but you can no longer seclude a patient (this is considered a restraint) for just being a royal pain and you certainly can't keep them secluded for days. They have to be aggressive or self-harming in some way and they have to released as soon as possible.

    Patients with borderline personality disorder can be so frustrating (the only ones more difficult, in my opinion, are children with attachment disorder). I've seen veteran psych nurses and doctors fall for the manipulations and make all kinds of exceptions to the rules for these patients. If at all possible, the best thing to do is stay rigidly consistent with the rules when you have one of these patients. No extra 5 minutes before room time, no extended visitation, etc. Whenever there is someone on the unit who needs extra attention, you can bet on having a patient with BPD acting out. If you can, anticipate the problem and give them some attention before they act out to get it. When we have staff splitting, we require the splitter to deal only with their assigned staff. They have to go to that person for everything. I've found confronting the patient in a calm, unemotional way is often helpful. "I'm sorry that you think I hate you." or "I don't like your behavior when you curse at other patients. Everyone here has the right to feel safe and cursing at people makes them feel unsafe." When you set the limits, do you state the consequences? "If you curse at staff or other patients, you will lose one smoking break for every time you do it." Put it in writing and make sure it is followed up (this is easier if she has to go through her own staff person for everything). Having a behavioral contract also help keep the staff from getting pissed off and being punitive in their reactions (and CYA). Of course she's going to push and push the limits to see what will happen, but consistency and lack of reaction on the part of the staff should take some of the fun out of the game.

    I don't think you're really in big trouble unless you made the remark about calling the doctor for discharge orders in a really sarcastic manner. What do you mean about "having it out" with her? Were you inappropriate or unprofessional?

    There have been times when I've had to ask for other assignments because I knew I could not be at my best with certain patients or their families. Do that if necessary.

    Your medically unstable patients are why I stated on another thread that I felt it would be good to have some med/surg experience before working in psych. Actually, I think it would be ideal to have a week or so on a medical unit every year. I would absolutely hate it, but I think it would be good for keeping our other skills at a minimum acceptable limit. We tend to get patients who've attempted suicide or have other psych issues as soon as the ICU or medical floor can possibly get rid of them and often they really aren't medically stable.

    I hope your patient gets discharged soon and you get a DNR (Do Not Readmit) order on her.
  7. by   esselmulen
    I've come up with a way to deal with those kind of borderlines, I, and only I interact with them. The staff on other shifts refer them to me with complaints and problems. Instead of trying to manipulate everybody, they try and manipulate me. I listen to them and seriously attempt to help them out if I can. They seem to accept limits better from me because they see me as an ally, little do they know, that they're being manipulated by me! It doesn't work all the time, but it sure helps to relieve my coworker of the burden of interacting with someone that they find disagreeable and manipulative.
  8. by   sanakruz
    esselmullen you must be a gift from god!
  9. by   Rapheal

    Let us know how the discussion with your nurse manager went. I do not understand why you would get written up or suspended for setting limits and boundries. This is part of your job. Is it the whole "patient satisfaction" attitude gone rampant? I hope all goes well. If you do get suspended or written up- then the management of your facility is not doing the nurses or patients any favors. Good luck and keep us posted.
  10. by   WorkingnPajamas
    Textbok typical of borderlines...true how painfully unlikable they are across the board. True about the "quiet room" being a restraint as well. THe staff splitting can be helped by frequent reminders (like in report to staff, especially CNA's) about what to expect from the patient..that can ward off some of it. Of course when the shi* hits the fan and theres an emergency, they turn it up a few notches, true to borderline form! One person (short stick gets her) can be her"contact" person each shift and she can be redirected to that person.

    If your nurse manager (director) is as lame as mine, you'll have to work extra hard to keep the milleau even marginaly therapeutic. Remarkably, most of the other psych patients arent too fazed by the antics of the borderlines....I had one floor with 41 patients, at least 15 were borderline women!!! They rewrote the book on "NASTY" seven days a week.....Ha! What a reprieve vacation time was!!!
  11. by   Nurse Ratched
    You set limits. Doesn't sound like you did anything wrong. I guess I'm confused at what "B's" side of the story is that is causing you to be bothered by your NM on your day off. Is she accusing you of abuse? Threats? Being a good psych nurse and actually setting limits? I think I'd be having a talk with the NM about appropriate admission criteria for your psych unit. The dying fellow and his probable inapproriate placement there sounds like the bigger issue, but I suppose the NM has been too sucked into the borderliine nonsense to address that.

    When I have a borderline pt with those types of behaviors, I make it known to other staff that any and all questions from that patient are to be directed to me by the patient. This eliminates staff splitting because no one else is involved in the process but the patient and me.

    What do you so when someone breaks the rules there? Is there a more restrictive unit where she can be sent?

    Any day that a borderline pt signs a request for disharge form is a huge victory in my book. They *want* to stay. In your situation, offering the patient the opportunity to initiate the process of signing herself out was perfectly appropriate, IMHO. I usually just give the standard line: "I'm sorry you feel your needs are not being met here. Since that is the case, I will get you a form to sign that tells the doctor you wish to be discharged. I don't want you to stay somewhere you aren't comfortable." No arguing, no drama, repeat as necessary. Naturally, they will either not sign it, or later tell the doc they have no desire to leave. But repeat until they realize that the situation is what it is, and they will follow the rules or they can leave.

    Please update us on the situation!
  12. by   Heidi
    Do you recieve clinical supervision???? Not negating the complex needs of these clients and the frustrations they can create but accessing clinical supervision can prevent "burnout".
  13. by   Orca
    Unless you exploded in front of a group of people, you should have nothing to worry about. What has most likely happened is that B has complained to your nurse manager, who is investigating the complaint. Nothing more.

    You don't sound burned out to me, just at your limit with one particular patient. It happens, and most of the ones who put me on the edge have been borderlines.

    Keep the faith.
  14. by   Wendy Psych RN
    I have no helpful ideas or criticism. I just want to say


    Good luck. Get yourself some Ativan.