16 PERSONALITYDISORDERS 391
JUDGMENT AND INSIGHT
Clients frequently report behaviors consistent with
impaired judgment and lack of care and concern for
safety such as gambling, shoplifting, and reckless
driving. They make decisions impulsively based on
emotions rather than facts.
Clients have difficulty accepting responsibility
for meeting needs outside a relationship. They see
life’s problems and failures as a result of others’
shortcomings. Because others are always to blame,
insight is limited. A typical reaction to a problem is,
“I wouldn’t have gotten into this mess if so-and-so
had been there.”
SELF-CONCEPT
Clients have an unstable view of themselves that
shifts dramatically and suddenly. They may appear
needy and dependent one moment and angry, hostile,
and rejecting the next. Sudden changes in opinions
and plans about career, sexual identity, values, and
types of friends are common. Clients view themselves
as inherently bad or evil and often report feeling as if
they don’t really exist at all.
Suicidal threats, gestures, and attempts are
common. Self-harm and mutilation such as cutting,
punching, or burning, are common. These behaviors
must be taken very seriously because these clients
are at increased risk for completed suicide, even
if numerous previous attempts have not been life-
threatening. These self-inflicted injuries cause much
pain and often require extensive treatment; some re-
sult in massive scarring or permanent disability such
as paralysis or loss of mobility from injury to nerves,
tendons, and other essential structures.
ROLES AND RELATIONSHIPS
Clients hate being alone, but their erratic, labile, and
sometimes dangerous behaviors often isolate them.
Relationships are unstable, stormy, and intense; the
cycle repeats itself continually. These clients have
extreme fears of abandonment and difficulty believ-
ing a relationship still exists once the person is away
from them. They engage in many desperate behaviors,
even suicide attempts, to gain or to maintain relation-
ships. Feelings for others are often distorted, erratic,
and inappropriate. For example, they may view some-
one they have only met once or twice as their best and
only friend or the “love of my life.” If another person
does not immediately reciprocate their feelings, they
may feel rejected, become hostile, and declare them
to be their enemy. These erratic emotional changes
can occur in the space of 1 hour. Often these situa-
tions precipitate self-mutilating behavior; occasion-
ally clients may attempt to harm others physically.
Clients usually have a history of poor school and
work performance because of constantly changing ca-
reer goals and shifts in identity or aspirations, pre-
occupation with maintaining relationships, and fear
of real or perceived abandonment. Clients lack the
concentration and self-discipline to follow through on
sometimes mundane tasks associated with work or
school.PHYSIOLOGIC AND SELF-CARE
CONSIDERATIONS
In addition to suicidal and self-harm behavior, clients
also may engage in binging (excessive overeating)
and purging (self-induced vomiting), substance
abuse, unprotected sex, or reckless behavior such as
driving while intoxicated. They usually have diffi-
culty sleeping.Data Analysis
Nursing diagnoses for clients with borderline per-
sonality disorder may include the following:- Risk for Suicide
- Risk for Self-Mutilation
- Risk for Other-Directed Violence
- Ineffective Coping
- Social Isolation
Outcome Identification
Treatment outcomes may include the following:- The client will be safe and free of significant
injury. - The client will not harm others or destroy
property. - The client will demonstrate increased control
of impulsive behavior. - The client will take appropriate steps to
meet his or her own needs. - The client will demonstrate problem-solving
shills. - The client will verbalize greater satisfaction
with relationships.
Interventions
Clients with borderline personality disorder often
are involved in long-term psychotherapy to address
issues of family dysfunction and abuse. The nurse is
most likely to have contact with these clients during
crises, when they are exhibiting self-harm behaviors
or transient psychotic symptoms. Brief hospitaliza-