Personality is defined as the differences in the characteristic patterns of behaving, feeling and thinking of an individual.
A personality disorder is a type of mental illness in which a person’s personality traits have become rigid, inflexible, maladaptive and can hinder the person’s perception and association to situations and people. This can cause significant problems and restriction in the family, social activities, school, employment and other functional roles.
Nursing Care Plans
The nursing care plan varies according to the kind of personality disorder, its severity, and life situation. A collaborative intervention is needed to make sure all of the clients social, medical and psychiatric needs are met.
The goals of the nurse for clients with personality disorders focus on establishing trust, providing safety and comfort, teaching basic living skills and promoting a responsible behavior.
- Ineffective Coping
May be related to
- Failure to intend to change behavior.
- Intense emotional state.
- Lack of motivation to change behaviors.
- Negative attitudes toward health behavior.
- Neurologic factors.
- Trauma early in life (physical, emotional, or sexual abuse).
Possibly evidenced by
- Anger or hostility.
- Demonstration of nonacceptance of health status.
- Extreme distrust to others.
- Failure to learn or change behavior based on past experience or punishment.
- Failure to achieve an optimal sense of control.
- Intense emotional dysregulation.
- Manipulation of others.
- Poor judgment.
- Superficial relationship with others.
- Patient will identify behaviors leading to hospitalization.
- Patient will have an increased in frequency of expressing needs directly without ulterior motives.
- Patient will learn and master skills that facilitate functional behavior.
- Patient will demonstrate an increase in impulse control.
- Patient will demonstrate a use of a newly learned coping skill to modify anxiety and frustration.
- Patient will demonstrate decreased manipulative, attention speaking behaviors.
- Patient will not act out anger toward others while hospitalized.
- Patient will remain safe while hospitalized.
- Patient will spend time with the nurse and focus on one thing he or she would like to change.
- Patient will state that he/she will continue the treatment on an outpatient basis.
- Patient will talk about feelings and perceptions and not act on them at least twice.
- Patient will focus on one problem and work through the problem-solving process with the nurse.
- Patient will practice the substitution of functional skills for times of increased anxiety with the nurse.
|General Interventions for All Personality Disorders:|
|Review intervention guidelines for each personality disorder in this chapter.||All clients are individuals, even within the same diagnostic category. However, guidelines for specific categories are helpful for planning.|
|Identify behavioral limits and behaviors that are expected.||Client needs clear structure. Expect frequent testing of limits initially. Maintaining limits can enhance feelings of safety in the client.|
|Identify what the client sees as the behaviors and circumstances that lead to the hospitalization.||Ascertain client’s understanding of behaviors and responsibility for own action.|
|Ascertain from family/friends how the person interacts with significant people. Is the client always withdrawn, distrustful, hostile, have continuous physical complaints?||Identifying baseline behaviors helps with setting goals.|
|Approach the client in a consistent manner in all interactions.||Enhances feelings of security and provides structure. Exceptions encourage a manipulative behavior.|
|Refrain from sharing personal information with the client.||Open up areas for manipulation and undermines professional boundaries.|
|Be aware of flattery as an attempt to feed into your needs to feel special.||Giving into client’s thinking that you are “the best” or “the only one” can pit you against other staff and undermine client’s need for limits.|
|Do not receive any gift from the client.||Again, clouds the boundaries and can give the client the idea that he or she is due special consideration.|
|If the client becomes seductive, reiterate the therapeutic goals and boundaries of treatment.||The client is in the hospital/clinic for a reason. Being taken in by seductive behavior undermines effectiveness of the treatment.|
|Be clear with the client as to the unit/hospital/clinic policies. Give brief concrete reasons for the rules, if asked, and then move on.||Institutional policies provide structure and safety.|
|Be very clear about the consequences if policies/limits are not adhered to.||Client needs to understand the consequences of breaking the rules.|
|When limit or policies are not followed, enforce the consequences in a matter-of-fact, nonjudgmental manner.||Enforces that the client is responsible for his or her own actions.|
|Make a clear and concrete written plan of care so other staff can follow.||Helps minimize manipulations and might help encourage cooperation.|
|If feasible, devise a care plan with the client.||If goals and interventions are agreed upon, cooperation with the plan is optimized.|
|If the client becomes hostile or projects blame onto you or staff, project a neutral, calm demeanor, and avoid power struggles. Focus on the client’s underlying feelings.||Defuses tension and opens up productive interaction.|
|When appropriate, try to understand underlying feelings prompting inappropriate behaviors.||Often acting out behaviors stem from underlying feelings of anger, fear, shame, insecurity, loneliness, etc. Talking about feeling can lead to problem solving and growth for the client.|
|Some clients might attempt to instill guilt when they do not get what they want. Remain neutral but firm.||Nurses often want to be seen as “nice” However, being professional and maintaining limits is the better therapeutic approach.|
|Keep goals very realistic and go in small steps. There are no overnight successes with people with personality disorders.||It can take a long time to positively change ingrained, life-long, maladaptive habits; however, change is always possible.|
|Work with the client on problem-solving skills using a situation that is bothering the client. Go step by step:
||Client might not know how to articulate the problem. Helping identify alternatives gives the client a sense of control. Evaluating the pros and cons of the alternatives facilitates choosing potential solutions.|
|When the client is ready and interested, teach client coping skills to help defuse tension and trouble feelings (e.g., anxiety reduction, assertiveness skills).||Increasing skills helps the client use healthier ways to defuse tensions and get needs met.|
|Guard against personal feelings of frustration and lack of progress.||Change if often very slow and may seem to take longer than it actually is. Nurture yourself outside the job. Keep your “bucket” full of laughter and high regard from family and friends.|
|Understand that many people with personality disorders do not stay with the treatment and often come to facilities because of crisis or court order.||Even short encounters with therapeutic persons can make a difference when a client is ready to learn more adaptive ways of living his or her life.|
|Give the client positive attention when behaviors are appropriate and productive. Avoid giving any attention (when possible and not dangerous to self or others) when client’s behaviors are inappropriate.||Reinforcing positive behaviors might increase the likelihood of repetition. Ignoring negative behaviors (when feasible) robs client of even negative attention.|
|Borderline Personality Disorder (BPD):|
|Assess for self-mutilating or suicide thoughts or behaviors.||Self-mutilating and suicide threats are common behaviors for clients with BPD.|
|Clients with BPD can be manipulative.||Consistent limit setting helps provide structure and decrease negative behaviors.|
|Encourage the client to explore feelings and concerns (e.g., identify fears, loneliness, self-hate).||Client is used to acting out feelings.|
|Be nonjudgmental and respectful when listening to client’s feelings, thoughts, or complaints.||Clients have an intense fear of rejection.|
|Use assertiveness when setting limits on client’s unreasonable demands for attention and time.||Firm, clear, nonjudgmental limits give client structure.|
|Interventions often call for responses to client’s intense and labile mood swings, irritability, depression, and anxiety:||Many of the dysfunctional behaviors of BPD clients (e.g., parasuicidal, anger, manipulation, substance abuse) are used as “behavioral solutions” to intense pain.|
||Clients with BPD are extremely uncomfortable and want immediate relief from painful feelings. Anger is a response to this pain. Intervening early can help avoid escalation.|
||Most clients with BPD suffer profound depression.|
||Clients experience intense anxiety and fear of abandonment. Stress reduction techniques help the client focus more clearly.|
|Provide and encourage the client to use professionals in other in other disciplines such as social services, vocational rehabilitation, social work, or the law.||Clients with BPD often have multiple social problems. Often they do not know how to obtain these services.|
|Clients with BPD benefit from coping skills training (e.g., anger management skills, emotional regulation skills, interpersonal skills). Provide referrals and/or involve professional experts.||Client learns to refine skills in changing behaviors, emotions, and thinking patterns associated with problems in living that are causing distress and misery.|
|Clients with BPD often drop out of treatment prematurely. However, when they return, they can still draw upon what they have learned from previous encounters with health care personnel.||Clients might become impatient and leave, then return in a crisis situation. It is a good thing when they are able to tolerate longer periods of learning.|
|Treatment of substance abuse is best handled by well-organized treatment systems, not by an individual nurse/clinician.||Keeping detailed records and having a team involved with each client can minimize manipulation.|
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Mental Health and Psychiatric Care Plans
Care plans about mental health and psychiatric nursing: