Personality Disorders: Management and Discharge Criteria (Nursing)

by Brenda Marshall, EdD, MSN, RN

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    00:02 When we are thinking about helping this person with self-management, learning how to manage their life in this disorder, we really need to understand that there are different approaches.

    00:18 One might be that they need to be hospitalized, or in a therapeutic community, we call that Milieu Management.

    00:27 Being able to put them in a place where they feel safe.

    00:31 There are also medications that help to manage aspects and symptoms of these disorders.

    00:39 We also have to think about case management.

    00:42 Because a disorder doesn't only affect one person, it affects a family.

    00:48 A person with a personality disorder, if they are living with other people, is that living environment actually activating all of these maladaptive coping behaviors? How can we manage this case so that we can help this person develop other coping mechanisms and also allow them to have community supports.

    01:13 We want to make sure that at least while they are in the hospital, in our care, we establish clear boundaries.

    01:21 And one of the things that I think is really important, there are so many times that I speak with students who say, "I don't really need to know about this because I'm going to be working in orthopedics." I just want to make sure everyone understands that people with personality disorders, and people with psychiatric disorders, they break bones and they end up in orthopedics.

    01:47 People with personality disorders and people with psychiatric disorders, they have children.

    01:53 And they often go into the hospital to have those children.

    01:58 And they are in labor and delivery.

    02:00 So understanding your patient, even though your focus might be the delivery of a baby, understanding your patient, being a nurse, and seeing the individual in front of you comprehending that we are complex individuals each one of us.

    02:19 Understanding that if there is a personality disorder that exists in a person who's about to give birth, having some of these disorder management tools in your belt really helps you to provide that safe environment not just for this patient, but for all your patients.

    02:38 So establishing clear boundaries, what are the rules and regulations within your unit that you're working? Understanding the contract that you have with this patient, that if they feel depressed, if they feel like they want to kill themselves, they will call you or call someone before attempting to do so.

    03:01 You want to know that that can be verbal, but it can also be written if you are in a psychiatric unit, we often use written contracts.

    03:11 And we want to make sure that it's not us saying to the patient, "This is what you better do." That doesn't work.

    03:18 When we are going to arrive at a solution for someone that has to be arrived that mutually.

    03:25 There has to be buy in from both.

    03:27 It's a negotiation.

    03:30 And nurses, we are very good negotiators.

    03:33 So I'd like you to think about some of the different types of therapies that we do use.

    03:40 One of the therapies that we use is called Dialectic Behavioral Therapy.

    03:46 Now, dialectic behavioral therapy is not something that a nurse is going to do.

    03:52 Dialectic behavioral therapy is a therapeutic intervention.

    03:57 It is therapy that the patient will undergo with a therapist who is trained in DBT.

    04:05 And part of DBT is learning new coping skills and having the patient learn them and then evaluate them.

    04:14 It uses dialogue to be able to rework some of the destructive ways that the patient has learned over a lifetime to deal with crisis, even just threat without crisis.

    04:27 We also want to know that this teaches our clients that there are multiple ways that they are able to decrease some of these suicidal ideations, these thoughts that they have.

    04:39 And also to slow down some of those emotionally reactive patterns.

    04:46 We sometimes say their knee jerk responses, they happen without thinking.

    04:52 And finally, it teaches the patient how to have a new pattern of thinking and behaving.

    04:59 So one of the things I do as a nurse, when I'm working with a patient who needs to learn a new way of thinking.

    05:08 I usually say to them, "If you have two dogs, a good dog and a bad dog.

    05:13 And the good dog and bad dog get into a terrible fight, who's gonna win?" Most of the time, people say, "Oh, the bad dogs gonna win." And I say, "Why?" And they say, "Bad dogs mean, bad dogs gonna hurt the good dog, bad dogs always win." And I'm going to say to them, "The dog that's going to win is a dog you're going to feed." If you feed that bad dog, that bad dog's gonna get really strong.

    05:40 But if you feed that good dog, if you stop feeding that bad dog, that good dog is going to get strong, and the stronger the good dog gets.

    05:50 And the longer the good dog stays strong, the more the bad dog learns that it's better to be the good dog.

    06:00 So when these patients are going to go home, and that's an important thing to remember, our patients with personality disorders and psychiatric disorders do not live in an institution, they live in our neighborhoods.

    06:15 So we want to make sure that when these people are going home, our patients, that we are giving them the resources to be able to continue their recovery.

    06:28 Because just being in the hospital to get medication management or to learn some new skills, that's fine for while they're there.

    06:37 But we want them to go home and have a good life, be a good neighbor, be a good partner, be a good parent.

    06:44 So let's consider, what kind of risk factors they might have in their environments.

    06:51 And also think about their protective factors, whether they belong to a religious group that they can count on, whether they have a job that they're going back to.

    07:02 We want to make sure that they know that we are available for them, and that we've set up so that they have a follow up appointment, that if they require ongoing therapy, that they're going to be able to get their therapy.

    07:16 If they need to have medication that upon discharge, they're going to have their medication.

    07:22 I had one patient who upon discharge, I realized she didn't have her medication yet.

    07:28 We were able to postpone her discharge for one day to allow her to get the medication she needed from the hospital for at least one week.

    07:38 And to set up so that she had our medications sent and ready for her in her own neighborhood pharmacy so she'd be able to fill that when she got home.

    07:50 We also want to make sure that we are able to have the person understand their disorder, understand that it is a disorder and help them with psycho education.

    08:05 Teaching them the importance of taking their medication, the importance of being able to do their small steps towards their recovery.

    08:14 Teaching them patience with themselves, perhaps getting their family into family therapy, so that the whole family can work towards the recovery of this one individual.

    About the Lecture

    The lecture Personality Disorders: Management and Discharge Criteria (Nursing) by Brenda Marshall, EdD, MSN, RN is from the course Personality Disorders (Nursing).

    Included Quiz Questions

    1. Milieu management
    2. Case management
    3. Establishing clear boundaries
    4. Contract creation
    1. Boundary setting
    2. Making contracts collaboratively with clients
    3. Dialectic behavioral therapy
    4. Discussing protective factors with clients
    5. Assist in discharge planning
    1. How to decrease suicidal thoughts
    2. Using dialogue to rework destructive coping mechanisms
    3. Increasing emotionally reactive patterns
    4. Reinforcing old patterns of thinking
    1. Their cousin, with whom they have a good relationship, lives five minutes away.
    2. The client is a member of their local church.
    3. The client lives alone.
    4. The client is unemployed.

    Author of lecture Personality Disorders: Management and Discharge Criteria (Nursing)

     Brenda Marshall, EdD, MSN, RN

    Brenda Marshall, EdD, MSN, RN

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