1. Definition

2. Client shows personality traits that are long-lasting, inflexible and maladaptive.

3. Client may appear to function normally until stressed

4. Generally begins in childhood or adolescence

5. More common in women

Etiology

1. Impaired development of object relations; separation-individuation process is arrested

2. Issues of dependence, independence, and control are mixed with fear of abandonment, loss of love, or engulfment by mother

Findings

1. Personal relationships are unstable; lonely; emotions shallow

2. Images of self and others are primarily bad; feels inadequate

3. Anger, hostility

4. Projection of hostility onto others

5. Acts out and denies responsibility for actions

6. Poor judgment

7. Impaired problem solving

8. Very "black or white" thinking

9. Regression

10. Marked mood swings

11. Demanding

12. Sarcastic

13. Manipulative

14. Behaves self-destructively

15. Splitting

Treatment

1. Pharmacologic

   1. antianxiety agents: oxazepam (Serax)

   2. antidepressants: carbamazapine (Carbatrol)

2. Psychotherapy

5. Nursing care in borderline personality disorder

   1. Protect client and others from harm

   2. Administer medications as ordered

   3. Establish a trusting relationship

   4. Set limits, and provide a structured environment

   5. Use a calm, controlled approach; see that other staff stay consistent

   6. Do not argue with client

   7. Encourage client to evaluate consequences of actions

   8. Divert anger, or let client ventilate it in positive ways

   9. Set limits on manipulative behaviors by communicating expected behaviors

   10. Teach client

       1. medications and their side effects

       2. anger-control strategies

       3. relaxation strategies

Suicide Prevention

5. Definitions:

   1. Suicide is a self-harming act intended to produce death

   2. Degrees

      1. completed suicide: life ends

      2. attempted suicide: failed self-destructive act

      3. suicide ideation: thoughts of ending one's life

6. Epidemiology

   1. Women attempt more than men

   2. Men are more often successful

   3. Second leading cause of death in adolescence

   4. Black males have higher incidence

7. Etiology

   1. Depression

   2. Delusions/hallucinations in psychotic clients

   3. Hopelessness

   4. Environmental factors: work or school performance, loss of job, death of loved one, unsatisfying interpersonal relationships

8. Findings 

   1. Statements about suicide

   2. Anger, sadness, hopelessness, negative view of future

   3. Recent loss of job, loved one

   4. Perceived lack of support system

   5. Self-mutilation

5. Treatment for suicidal condition

   1. Objective: to treat the condition that underlies the suicidal thoughts

   2. Medications: amitriptyline (Elavil), chlorpromazine (Thorazine)

   3. Suicide precautions 

6. Nursing care

   1. Administer medications as ordered

   2. Institute suicide precautions

   3. Encourage relaxation strategies

Crisis Intervention

5. Definition - crisis: temporary personality disorganization with an acute emotional state. Crisis is a normal response to threatening environment.

6. Types and phases of crisis response

   1. Panic state: acute crisis where client temporarily loses control

      1. emotional reactions are overwhelming

      2. decision making and problem solving abilities are inoperative

      3. thinking is scattered

      4. social isolation

      5. immobilization (unable to act)

   2. Exhaustion crisis

      1. under emergency conditions

      2. person has lost effective coping

      3. cannot continue to function

   3. Shock crisis

      1. sudden external change

      2. causes release of emotions

      3. overwhelms client

   4. Four phases of crisis (average crisis four to six weeks but may vary widely)

      1. vulnerable state

      2. precipitating event

         1. developmental change (maturational crisis)

         2. a life change (situational crisis)

         3. loss of loved one or job (situational crisis)

         4. environmental disaster or war (adventitious crisis)

      3. acute crisis

      4. reorganization

7. Findings of crisis

   1. Mild to severe anxiety

   2. Anger

   3. Crying, social isolation, helplessness

   4. Impaired cognitive processes; inability to concentrate; confusion

   5. Insomnia

   6. Regression

   7. Nausea and vomiting

4. Treatment: crisis intervention

   1. Objective: to help the client through the current crisis

   2. Brief supportive interventions focused on the phase of crisis

   3. Allow free discharge of emotions

   4. Enhance client's cognitive processes

   5. Pharmacologic: trazodone (Desyrel), alprazolam (Xanax)

   6. Occupational therapy

   7. Recreational therapy

5. Nursing care in crisis

   1. Provide a quiet, restful environment

   2. Help the client solve problems

   3. Let the client ventilate

   4. Correct any misperceptions about the crisis that the client may have

   5. Help the client to identify support systems, alternative solutions

   6. Help the client to deal with long term impact of crisis

   7. Encourage relaxation strategies

   8. Assist the client in the development of new coping skills

   9. Give medications as ordered

Substance Abuse

1. Definitions

   1. Maladaptive behaviors resulting from the regular intake of large amounts of addictive chemicals

   2. Addictive chemicals include alcohol, stimulants, depressants, hallucinogens, narcotics.

   3. Levels of substance abuse

      1. abuse is pathologic use of mood-altering chemicals that continues for at least 1 month, which impairs social or occupational functioning

      2. dependence is a more severe level of abuse that involves impaired ability to control use of substance and results in withdrawal (adverse consequences) when substance is discontinued or reduced. There are three types of dependence

         1. psychologic dependence: pleasure that intensifies craving for substance; often begins in teens and twenties.

         2. physiologic dependence: after repeated use, physiology changes; and after substance is reduced or removed, withdrawal symptoms appear

         3. tolerance: drug dosage must keep increasing to achieve same effect

2. Alcohol
   Although alcohol is a legal substance, problem drinking has detrimental physiologic and social effects.

   1. Dependence

      1. daily intake of large quantities, or

      2. excessive drinking limited to weekends; or

      3. periods of abstinence with binges lasting for weeks or longer

   2. Etiology unknown

      1. stress has been implicated

      2. some research suggests a familial tendency

   3. Produces withdrawal symptoms 

   4. Findings of chronic alcohol use

      1. anemia

      2. hypertension

      3. tachycardia

      4. hepatomegaly

      5. ascites

      6. cirrhosis

      7. gastritis

      8. esophagitis

      9. malabsorption syndrome

      10. fatigue

      11. depression

      12. impaired judgment; cognitive impairment

      13. tremors

      14. wernicke-Korsakoff syndrome

   5. Treatment of alcohol dependence

      1. antianxiety agents: chlordiazepoxide (Librium)

      2. vitamin and nutritional therapy

      3. disulfiram (Antabuse) - alcohol abuse deterrent

      4. support groups (Alcoholics Anonymous)

6. Nursing care in alcohol dependence

   1. during acute withdrawal

      1. stay with client

      2. provide quiet environment

      3. administer medications as ordered

      4. protect the client from harm

      5. institute seizure precautions as indicated

      6. maintain adequate fluid intake

   2. during abstinence

      1. provide emotional support

      2. provide nutritious diet

      3. encourage the development of new coping skills

      4. provide relaxation exercises

      5. inform client about support groups and rehab programs