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Brenda Green, 28 years old, voluntarily admitted herself to the Psychiatric Unit where you work. She is accompanied by her husband. Two small children, ages 3 and 5, are at home with a friend. Brenda is tearful and frightened. She has bandages on both wrists from a suicide attempt this evening, the second in the past five months. Dressed in jeans and an oversized shirt, she cries softly as she says good-bye to her husband. You are assigned as Brenda’s nurse on the Psychiatric Unit this evening. After reviewing Brenda’s admission data, you spend time with her. Brenda speaks in a low monotone voice. Her affect is flat, although her pervasive mood is one of sadness. She is quiet, introspective, and guarded in her responses. You determine that Brenda is oriented to time, place, and person. She admits to feelings of sadness and tension, and frequent thoughts of cutting herself. She also states she feels worthless. Brenda says she hears voices that tell her, “You’re not worthy of living,” “You’re a bad mother,” “You should suffer for your sins,” and “You should kill yourself.” These voices are more frequent when she is under stress, and decrease after she hurts herself. Brenda’s risk of suicide is obvious, given her recent attempts and admitted feelings. During your time with Brenda this first evening, you encourage her to try to identify and discuss her feelings. You use active listening and validate Brenda’s feelings as she tells you about her experience of coming to the hospital. Brenda says that she doesn’t really want to take her life, even though she feels depressed and cuts herself. Instead, cutting her wrists provides a “release from the tension” she feels. Brenda says she frequently feels a need to withdraw from her family and cut her arms or burn herself with cigarettes. Brenda’s deliberate harming of herself is referred to as parasuicidal behavior, also known as self-injury. This behavior is as serious as suicidal behavior. All self-injurious behavior is potentially life threatening. Brenda says she is also concerned about the safety of her children. She worries about losing control when she becomes angry with them sometimes, and fears that she will hurt them. She says these kinds of thoughts make her feel even worse about herself. It will be useful to explore Brenda’s beliefs about her expression of anger and other emotions. Together you and other team members will work with Brenda on finding ways she can express her feelings and release anger in ways that are not self-destructive, or hurtful to others. Brenda agrees to notify a staff member if she experiences suicidal or self-mutilating thoughts, so that she may get help. This kind of agreement is called a contract. A contract is a mutually-agreed upon plan of action made between a patient and staff members. It can be verbal or written. It addresses safety within the least-restrictive environment possible. A contract is reviewed and renewed with a client as often as needed. A no-suicide/no self-harm contract is common practice when caring for a client who is suicidal. Establishing a contract enhances the client’s perception of control and autonomy. However, having a no-suicide contract does not mean that a client will not commit suicide. Ongoing assessment of suicide risk is indicated. Suicide precautions should remain in effect as needed. Agency protocols should be followed. A social worker is part of Brenda’s multidisciplinary team. During Brenda’s first day on the unit, he meets with Brenda’s husband, who provides a detailed psychosocial history. You and the other staff members have developed a dialectical behavior therapy (DBT) program for use with persons who have borderline personality disorder (BPD). The team will use this approach in helping Brenda. Dialectical behavior therapy (DBT) is designed to gradually cause changes in behavior through cognitive and behavioral methods. The four core skill concepts of DBT are emotional regulation, distress tolerance, mindfulness, and interpersonal effectiveness. DBT requires a collaborative relationship between patient and staff. DBT seeks to balance supportive acceptance and change, while validating feelings and experiences. Using dialectical behavior therapy (DBT), therapy will be long-term. Brenda will need to commit to learning about healthier problem-solving and coping methods. She will learn new coping behaviors to replace her self-destructive behaviors. While in the hospital, staff will begin the DBT process by encouraging Brenda to identify behaviors that have interrupted her quality of life. Brenda’s hospital stay is too short to realistically effect change, but it will start the process. Given the severity of Brenda’s depression and the psychotic symptoms she displays, her medication regimen includes an antidepressant and an antipsychotic. Brenda is taking a selective serotonin reuptake inhibitor (SSRI) antidepressant, paroxetine. Quetiapine is the antipsychotic drug being used with Brenda. It is an atypical antipsychotic drug. Atypical antipsychotics are less likely to cause the often disabling extrapyramidal side effects that are common with typical antipsychotic drugs, like haloperidol. Quetiapine is the antipsychotic drug prescribed for Brenda. It should decrease and eliminate the “voices” (auditory hallucinations) that Brenda hears. It should also help Brenda sleep better. Impaired Social Interaction is an important nursing diagnosis for a person with borderline personality disorder. You have assessed that this is a major problem for Brenda. To help Brenda begin to establish and maintain successful interpersonal relationships, she will be exposed to and cared for by a variety of different staff members. Interactions with some will be limited and brief, with others the interactions will be more lengthy and occur more often. Feedback regarding appropriate and inappropriate social behaviors will be consistent. One staff member will be designated to provide this feedback. Both adaptive and maladaptive behaviors will be discussed in a caring manner. After a few days, Brenda reports that auditory hallucinations have decreased. She denies any suicidal intent or plan, and has not attempted to hurt herself. Brenda has tested staff members on a few occasions, but found all staff to be cohesive in addressing any maladaptive behavior on her part. Brenda’s treatment program is implemented within the context of milieu therapy. Milieu therapy involves the use of staff members, activities, and other clients (peers) in the client’s immediate environment to promote intrapersonal and interpersonal growth. Brenda’s treatment plan includes a number of activities and groups. An activity-filled schedule will help to prevent boredom and will also allow less time for maladaptive behavior. Boredom is common in persons with borderline personality disorder (BPD). Brenda shares with her attending psychiatrist that she was sexually molested by one of her older brother’s friends when she was about eight years old. He threatened to hurt her if she ever told anyone. She felt frightened and ashamed. She was disappointed that her parents never intervened. They seemed not to notice that she was withdrawn and unhappy as a child. In later years, Brenda says she felt both ashamed and angry, but did not confide in anyone. According to Brenda, her mother was often in a stupor from prescribed medications and her father was always working. Brenda made progress in her treatment. Suicide precautions are no longer in effect, although ongoing assessment for suicide or self-harm continues. Plans are made for discharge. Brenda is discharged to rejoin her family seven days after admission. Individual outpatient therapy is approved for 20 visits. Brenda signs Consent for Release of Information so that details of her hospitalization may be shared with her primary care provider and her outpatient therapist. Need a SOAP note on Brenda Green Hesi case study

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