Borderline Personality Disorder

  
CASE STUDY
S.is a 48-year-old divorced woman with one adult daughter and three grandchildren. She is currently working as an LPN part time in a nursing home and also works at a convenience store one or two days per week. She has had many jobs over the last 22 years, usually changing every one or two years. S notes that she has been called less often to work in the convenience store and worries that they don’t like her anymore. She reports being written up several times for arguing with customers. She also reports that her supervisor at the nursing home “is a bitch”; although she really liked her supervisor at first, she says “Now I hate her; she’s trying to get me fired.” S. reports that she has tried to get fulltime jobs five times in the last four years, was hired for three, but only lasted one or two weeks at each one. 
S. reports that she is currently not talking to her daughter because “she is horribly mean to me and she needs to apologize or I won’t talk to her again”. She is upset that she hasn’t seen her three small grandchildren in about a year. She sends them presents and cards frequently that say “I still love you! Grandma”, but hasn’t called them since she stopped talking to her daughter. She is considering reporting to the county that her daughter is keeping her grandchildren from her. 
S. is very unhappy that she isn’t in a relationship. She was abused by her ex-husband, and has a pattern of meeting and dating men who eventually abuse her. She states that her last relationship was very good, however; the man was not abusive and “I loved him very much”. The relationship ended for reasons that S. doesn’t understand, although she does report many arguments that ended in “scenes” such as her throwing chairs, stomping out of the house, making crank phone calls to his family, and calling the police with false reports. But S. also reports that she “couldn’t have loved him more and I showed it”. She gives examples of going to her boyfriend’s place of work with flowers, buying him expensive presents, surprising him with tickets to Mexico at the last minute – she was very upset that he wasn’t willing to drop everything and go with her. S. reports asking him why he didn’t love her and what she was doing wrong on a regular basis. When the boyfriend asked to break up, S. reports sitting outside his house for weeks, crying; she called his mother, called his boss, and called and texted him until he filed a restraining order. This occurred about 4 months ago.
S. admitted herself to the mental health unit when she felt suicidal. She reports that she had stopped her individual psychotherapy 3 months ago and stopped going to DBT. She also stopped her anti-depressant at that time, as she felt it wasn’t working, and missed her last two psychiatrist appointments.
 

How would you use therapeutic communication and principles of cognitive behavioral therapy with the client?
Describe your assessment process. What are some likely co-morbid conditions? List one nursing diagnosis and an appropriate nursing intervention.
What interdisciplinary referrals might be appropriate?

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