Video Case Study - Caring for Patients With Personality Disorder

Nurse Amirah works on an inpatient psychiatric unit and is caring for Yang, a 42-year-old with a history of borderline personality disorder, who was admitted a week ago for self-harm ideation following a breakup with his partner.

In collaboration with the registered nurse, RN Francie, Nurse Amirah goes through the steps of the Clinical Judgment Measurement Model to make clinical decisions about Yang’s care by recognizing and analyzing cues, prioritizing hypotheses, generating solutions, taking action, and evaluating outcomes.

First, Nurse Amirah recognizes important cues, including Yang’s vital signs, which are temperature 98.9 F or 37.1 C, heart rate 70 beats per minute, respirations 16 breaths per minute, and blood pressure 132/82 mmHg.

She notes that Yang’s breakfast tray is untouched on the bedside table. Nurse Amirah: Hi Yang, I noticed you haven’t eaten your breakfast.

How are you doing today? Yang: Sorry, no offense, but that food is disgusting.

I’m good, actually, and I’m happy I don’t have a sitter anymore. I’m ready to pack up my stuff and go home.

Nurse Amirah: I’m glad you feel ready for discharge. To make sure you’re safe to leave, Nurse Francie and I need to gather some information and give you your medicine.

Yang: I know, I know. I’m still sad my boyfriend broke up with me, but I’m able to talk about it now.

I have other people in my life that care about me, so I feel less alone. Nurse Amirah: That’s good to hear.

Next, Nurse Amirah analyzes these cues. She reviews the electronic health record, or EHR, and notes Yang was diagnosed with borderline personality disorder, or BPD, five years ago, and has been hospitalized for self-harm ideation in the past.

Nurse Amirah reviews the progress notes and sees that following the breakup between Yang and his partner, Yang called his sister and told her he wanted to commit suicide.

His sister then called the emergency services, and he was taken to the hospital. Nuse Amirah recognizes that BPD is a condition where individuals have unstable moods and relationships.

Those with BPD may also experience fear of abandonment, which leads to threats of self-harm to keep someone from leaving them.

Nurse Amirah recognizes that Yang needs continued mood stabilization to prevent self-harm. Now, using the information she's gathered, along with Yang’s medical history, Nurse Amirah reports her findings to RN Francie, and together they choose a priority hypothesis of risk for violence against self.

Then, Nurse Amirah collaborates with RN Francie to generate solutions to address Yang’s altered safety that will include pharmacologic and nonpharmacologic interventions; and they establish the expected outcome that after intervening, Yang will continue to use coping strategies to remain safe and free from injury.

Nurse Amirah then takes action to implement these solutions. First, she confirms Yang’s room remains free from items that he could use to harm himself.

She also notes that Yang is scheduled for his prescribed mood stabilizer. She gathers the supplies and enters Yang’s room.

Nurse Amirah: Yang, I have your medication, lithium, which will help keep your mood stabilized. Yang: Okay, I think it’s been helping me.

Nurse Amirah: Great. Nurse Amirah then administers the lithium according to the principles of safe medication administration.

Nurse Amirah: Now, I understand that your breakup has been very painful and caused you to have thoughts about hurting yourself.

Yang: Yeah, I did have those thoughts, but not anymore. Nurse Amirah: I’m happy to hear that.

Can you tell me about the strategies you’re using to keep from harming yourself after you go home? Yang: During our sessions, the counselor taught me how to write down my thoughts in a journal and it has been helping a lot.

Nurse Amirah: Journaling is a great way to express your feelings in a safe way, and I hope you can continue this after you leave.

Yang: I will. My sister already bought me a new notebook for when I get home.

Nurse Amirah updates RN Francie on Yang’s progress, who begins to compile his discharge paperwork. At the end of her shift, Nurse Amirah enters Yang’s room to evaluate the outcome of her actions.

Yang’s vital signs are temperature 98.9 F or 37.1 C, heart rate 65 beats per minute, respirations 14 breaths per minute, and blood pressure 122/80 mmHg.

Yang is sitting at a table with his notebook and appears relaxed. Nurse Amirah calls Yang’s sister who plans to pick him up once he’s discharged.

Alright, as a quick recap… Nurse Amirah recognized and analyzed cues related to Yang’s risk for self-harm, and in collaboration with RN Francie, prioritized hypotheses and generated solutions to address this problem.

Nurse Amirah and RN Francie then implemented pharmacologic and nonpharmacologic interventions and evaluated Yang’s outcomes and compared them to the expected