Cluster B: Nursing Diagnoses

by Brenda Marshall, EdD, MSN, RN

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    00:01 So, let's think about what kind of nursing diagnosis we're going to use for our patients who may be suffering with Cluster B diagnoses.

    00:10 They don't have good coping skills.

    00:12 They have maladaptive coping skills that have given rise to their behaviors and their thought patterns, as adults.

    00:20 They also have a disturbed personal identity, either they think they are the best, either they think they are that and more, or they think they are totally worthless.

    00:32 We also have that chronic low self-esteem, even with our patients who suffer with narcissism, because that self-esteem says that it has to be perfect, or it's terrible.

    00:45 If you take away one little item, the whole house of cards might fall.

    00:52 Because of this lability of emotions, this changing, I'm the greatest and I am the worst, there is a chance that these persons will hurt themselves, they will harm themselves.

    01:06 There is a risk for self-mutilation, which we call non-suicidal self-injury.

    01:13 It's not that they're trying to kill themselves, it is that they are trying to hurt themselves, either to feel excited and alive, or actually to punish themselves.

    01:26 But with a non-suicidal self-injury, and with hopelessness, we always have a risk for suicide.

    01:33 And if we have any thoughts that this person might be contemplating taking their life by suicide, we must ask them, "Are you thinking about killing yourself? Are you thinking about suicide?" It is not going to put the thought in their head.

    01:51 Instead, if they are thinking about it, they will say, "Yes." I've had patients who say, "Doesn't everyone?" And my only answer can be, "Not everyone.

    02:03 Can you tell me how you might think of doing it? Do you have any ideas of how you want to kill yourself? And if they have an idea, I immediately put them on a one to one.

    02:15 If they say they want to kill themselves, I make sure they have constant observation.

    02:20 I never want to be the last person that anyone has spoken to before they have taken their own life by suicide.

    02:28 And it doesn't take a lot for us to be able to sit and listen, assess, evaluate, and find someone who can sit and watch them.

    02:38 They have very impaired social interactions.

    02:42 All of the different behaviors and characteristics we just talked about, really indicate that it is hard for them to connect with others.

    02:50 And connecting with others is a great protective factor.

    02:54 They have a high risk for other directed violence.

    03:00 Hurting someone else, especially if they had had a conduct disorder, and they became someone who is suffering with antisocial personality disorder.

    03:12 And, again, this self-directed violence, the idea that they hurt themselves, that idea they hurt each other, and the idea that they might get into relationships that actually cause pain to them, which relieves them of having to hurt themselves, because now they have someone else to inflict pain on them.

    03:34 So, if we are looking at that patient with a borderline personality disorder, we watched that this person is making steady progress.

    03:44 But one day the person's boyfriend calls and says, "It's over. I'm breaking up with you." Now, although she hasn't hurt herself in over two months.

    03:54 After that call, she makes repeated lacerations on her forearm.

    04:00 Which statement about this and most maladaptive behaviors that we can see in borderline personality disorder are accurate? So a client with personality disorder rarely achieves lasting improvements.

    04:19 Or, although dysfunctional, most behaviors are the client's best efforts to cope.

    04:26 Or clients with borderline personality disorder are at the mercy of others.

    04:33 Or sometimes what seems to be improvement is only maladaptions and manipulation.

    04:41 So let's think about this.

    04:43 If we are thinking about what we want, for working in psychiatric nursing.

    04:52 If we think about how this person has come in front of us and that they are at a crisis point in their life.

    05:01 We have to understand that they're maladaptive coping mechanisms that they have put together over their lifetime, a way of trying to help them survive, are just not working anymore.

    05:16 And so if you chose B, although dysfunctional, most behaviors are the client's best effort to cope.

    05:24 You are correct.

    05:27 So, which statement by a patient with borderline personality disorder shows that their treatment plan is working? What if they say to you, "I think you're the best nurse ever." Or maybe they say, "I hate my doctor.

    05:45 She never listens to me and gives me what I asked for." Or perhaps, "I feel empty, I want to cut myself. So I called you." Or finally, "I'm never going to get high on drugs again." Well, if you're thinking about all of these statements, you know that first one, "I think you're the best nurse ever." That's part of splitting. You're either the best or the worst.

    06:16 So it can't be that.

    06:17 "I hate my doctor.

    06:18 She never listens to me, or gives me what I asked for." Again, the doctor is the worst person in the world.

    06:24 That again, is splitting.

    06:26 And that last one, "I am never ever, ever, ever going to get high again on drugs, not ever." Well, that's magical thinking for a person who has a substance use disorder, in addition with borderline personality disorder.

    06:41 So we want to believe that the patient who says, "I feel empty, and I want to cut myself. So I called you." Demonstrates that they are developing a new coping skill.

    06:54 One of the things that I haven't said yet, that is really important is that sometimes when we have patients with personality disorders, putting together a contract really helps.

    07:05 Being able to have that therapeutic relationship with that person, and being able to say to them, "I know you.

    07:11 There are going to be days that you want to cut yourself." What I'm going to ask you to do is on those moments, when you think cutting is the answer, I want you to call me. I want you to text me.

    07:23 I want you to ring the buzzer, and come out to the front desk.

    07:27 And if we can slow down that automatic coping mechanism that's maladaptive, we've helped them to make one step towards getting a little bit better.

    About the Lecture

    The lecture Cluster B: Nursing Diagnoses by Brenda Marshall, EdD, MSN, RN is from the course Personality Disorders (Nursing).

    Included Quiz Questions

    1. “Are you thinking of killing yourself?”
    2. “I’m sorry you feel like that. Do you want to sit in the dining room?”
    3. “There’s no need to feel hopeless; everyone loves you!”
    4. “Why does no one love you?”
    1. “Do you think you can ring the call bell and tell another nurse or me if you are having thoughts of self-harm?”
    2. “I will give you an extra helping of dessert if you don’t cut yourself.”
    3. “I will tell your mother if you cut yourself.”
    4. “Can you please try not to self-harm while you are here?”
    1. Impaired social interaction
    2. Risk for other-directed violence
    3. Risk for self-mutilation
    4. Risk for suicide
    1. Risk for self-mutilation
    2. Risk for suicide
    3. Risk for self-directed violence
    4. Risk for other-directed violence

    Author of lecture Cluster B: Nursing Diagnoses

     Brenda Marshall, EdD, MSN, RN

    Brenda Marshall, EdD, MSN, RN

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