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NCP Borderline Personality Disorder | Nursing Care Plan

“Borderline” has been used to identify clients who seem to fall on the border between the standard categories of neuroses or psychoses. The term has been refined to indicate a client with a pervasive pattern of instability of interpersonal relationships, self-image, affect, and control over impulses beginning in early adulthood, and includes such factors as feelings of abandonment, impulsivity, reactivity of mood, chronic feelings of emptiness, and problems with anger.

DSM-IV
301.83 Borderline personality disorder

ETIOLOGICAL THEORIES
Psychodynamics
Unconscious processes that are believed to shape personality are set in motion by drives or instincts that are then influenced by conflicts among them as well as instinctual wishes and demands of reality. Defensive maneuvers are unconsciously developed to protect against anxiety arising from this conflict. This personality is seen as a painstaking but poorly constructed defense.

It is also seen as resulting from a fixation of libido at stages of psychosexual development associated with certain body parts. Although it is difficult to agree on how personality is formed, severe personality disorders are believed to begin early in childhood and milder forms are thought to be influenced by factors during later development.

Biological
Personality is believed to have a hereditary basis known as “temperament” and biological dispositions that affect mood and level of activity (e.g., cranky, placid, self-contained, outgoing, impulsive, cautious). There is little agreement about how this affects the development of personality disorders.

Family Dynamics
The child’s social environment, particularly that within the family, is assumed to be the main force that shapes personality. The theory of object relations provides a basis for personality development and an explanation of the dynamics that manifest the borderline characteristics. The individual with borderline personality may be fixed in the rapprochement phase of development (18–25 months of age). In this phase, the child is experiencing increasing autonomy, while still requiring “emotional refueling” from the mothering figure. Because the mother feels threatened by the child’s efforts at independence, she strives to keep the child dependent. Nurturing and emotional support become bargaining tools. They are withheld when the child exhibits independent behaviors and are used as rewards for clinging, dependent behaviors. This engenders a deep fear of abandonment in the child that persists into adulthood as the child continues to view objects (people) as parts—either good or bad. This is called “splitting,” which is the primary dynamic of borderline personality.

Current studies suggest that borderline personality disorders are strongly associated with a history of physical or sexual abuse by family members, and incest may be a major reason for the disproportionate ratio (2:1) of female clients.

NURSING PRIORITIES
1. Limit aggressive behavior; promote socially acceptable responses.
2. Encourage assertive behaviors to attain sense of control.
3. Assist client to learn healthy ways of controlling anxiety/developing positive self-concept.
4. Promote development of effective coping skills.
5. Help client learn alternate, constructive methods of interacting with others.

DISCHARGE GOALS
1. Impulsive behavior(s) recognized and controlled.
2. Establishes goals and asserts control over own life.
3. Problem-solving techniques used constructively to resolve conflicts.
4. Interacts with others in socially appropriate manner.
5. Client/family involved in behavioral therapy/support programs.
6. Plan in place to meet needs after discharge.

Nursing diagnosis for Borderline Personality Disorder: Risk for VIOLENCE, directed at self or others and Risk for SELF MUTILATION may be related to Use of projection as a major defense mechanism; Pervasive problem with negative transference; Feelings of guilt/need to “punish” self, distorted sense of self
Inability to cope with increased psychological/physiological tension in a healthy manner possibly evidenced by Vulnerable self-esteem; Easily agitated, angry when frustrated (may become assaultive); Provocative behavior: argumentative, dissatisfied, overreactive, hypersensitive; use of unprovoked anger, hostility toward others; Choice of maladjusted ways of getting needs met (e.g., splitting, projection, provocation, depression); Self-mutilative acts; substance abuse.

Desired Outcomes and Goal:
1. Verbalize understanding of why behavior occurs.
2. Recognize precipitating factors.
3. Demonstrate self-control, using appropriate, assertive coping skills.
4. Clarify feelings of negative transference and eliminate the use of projection.

Nursing intervention with rationale:
1. Establish therapeutic nurse/client relationship. Maintain a firm, consistent approach.
Rationale: Building rapport and trust is imperative, although

2. Determine negative transference feelings and clarify the actual source of anger, hostility.
Rationale: Heightens self-awareness of these feelings to assist with resolution.

3. Help identify how much anger is “elicited” by significant other(s) and how much results from own unresolved feelings.
Rationale: Becoming aware of the use of projection helps break this maladjusted pattern. Note: Feelings of anger and hostility, not depression, are more often the basis for destructive behaviors/suicidal acts.

4. Intervene immediately in a nondefensive manner when acting-out occurs. Set firm, consistent limits.
Rationale: Intervention is critical to prevent dangerous situation for client or others. Therapeutic milieu helps client manage self and develop self-control. Environmental safety provides external control until internal control is regained.

5. Make an agreement or “no harm” contract to discuss angry or hurt feelings when they begin, instead of “internalizing” and displacing anger/ hurt onto others and acting on the feelings.
Rationale: Agreeing not to engage in violent behaviors involving self, others, or property promotes safety and enhances feelings of self-worth by having client assume control of own behavior. Helps client learn to work through feelings as they occur, to prevent intensification and promote resolution.

6. Determine prior suicidal gestures/attempts. Evaluate seriousness of suicidal expressions/ideation. Use scale of 1–10 and prioritize according to seriousness of threat, availability of means, timing of previous attempts, current age.
Rationale: It is important to take suicidal threats seriously, listening carefully to underlying messages and providing a safe environment to prevent client from following through on plan, especially when scale is in upper range. Note: Risk of suicide completion is highest during first few years after initial presentation, declining as client ages.

7. Provide close supervision, as indicated.
Rationale: Allows for early recognition of escalating behavior and timely intervention.

8. Provide care for client’s wounds, if self-mutilation occurs, in a matter-of-fact manner. Do not offer sympathy or provide additional attention.
Rationale: Additional attention and sympathy can provide positive reinforcement for the maladaptive behavior and may encourage its repetition. A matter-of-fact attitude can convey empathy/concern.

9. Have client participate in group therapy sessions with feedback given by peers.
Rationale: Group setting aids in promoting diffusion of anger; provides insight as to how negative, aggressive behaviors affect others, making feedback easier to digest.

10. Administer medication as indicated, e.g., carbamazepine (Tegretol), tranylcypromine (Parnate).
Rationale: May reduce frequency of impulsive/self destructive acts while other therapeutic interventions are initiated.
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