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A 22-year-old woman who presents to the emergency department with multiple superficial cuts on her wrists and forearms. She reports making the cuts after her husband told her he wanted a separation. The patient has a history of self-injurious behavior during periods of intense emotional distress.

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Borderline personality disorder (BPD) is a mental health condition characterized by a pervasive pattern of instability in interpersonal relationships, self-image, and mood.

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The exact causes of BPD are not fully understood, but it is believed to be a complex interaction of genetic, environmental, and developmental factors

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Heart rate: 93 bpm

Blood pressure: 137/78 mmHg

Respiratory rate: 18 breaths/minute

Temperature: 37.5°C (99.5°F)

Oxygen saturation: 99% on room air

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Upon assessment, the patient is visibly upset and tearful. She reports feeling overwhelmed and helpless and expresses frustration with her spouse for “letting her down.”  The nurse notes multiple superficial lacerations across the forearms and one deep laceration on the inner thigh needing 6 sutures.

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A 22-year-old woman who presents to the emergency department with multiple superficial cuts on her wrists and forearms. She reports that she made the cuts after her husband told her he wanted a separation.

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Patient has a history of self-harm during periods of emotional distress. She reports feeling overwhelmed and helpless in response to the recent marital issue, expressing frustration with her spouse.

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Patient is visibly disturbed, upset and tearful. Multiple superficial cuts present across both right and left forearms. One large deep cut on left inner thigh with six sutures present. Patient reports feeling overwhelmed and helpless and expresses frustration with her spouse for “letting her down.” Latest vital signs are as follows: HR 93 BPM, BP 137/88 mmHg, RR 18 breaths/minute, Temp 37.5 C, SpO2 99% on room air.

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Immediate wound care including proper cleaning, suturing of the deep laceration (if not already complete), and monitoring for any signs of further self-harm ideation. Psychiatric evaluation is recommended to assess the patient’s mental health and suicidal risk due to her history of self-injurious behavior. Safety planning measures should be implemented, and the patient should be put on a one-to-one. Additionally, this patient should be referred to a social worker, a counselor, and to the crisis intervention team for additional support. Lastly this patient should be in transition to a higher level of care.

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The highest-level complication is the risk of further self-harm or suicide. We would anticipate the provider to immediately order a one-to-one sitter, in addition to implementing a safety plan to reduce the risk of the patient having the capabilities to perform additional self-harm.

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1. Further self-harm or suicidal behavior 

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1. Further self-harm or suicidal behavior 

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Request a sitter for the patient to create a one-to-one ratio

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Perform a suicide/self-harm assessment to determine if the patient is considering harming herself further

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Remove potential means of self-harm from the patient’s room

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2. Wound complications (Hemorrhage, infection, scarring, delayed healing) 

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2. Wound complications (Hemorrhage, infection, scarring, delayed healing) 

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Clean and dress her wounds

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Request an order for a broad-spectrum antibiotic as prophylaxis for infection

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Monitor vital signs and wound sites for signs of infection or bleeding

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3. Heightened Psychiatric Complications (anxiety, depression, PTSD) 

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3. Heightened Psychiatric Complications (anxiety, depression, PTSD) 

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Use therapeutic communication techniques to build trust and rapport and provide emotional validation and support.

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3B: Request a psychiatrist referral to complete a full psych evaluation and risk assessment

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Connect the patient with a social worker and case manager to help in the effective treatment of the patient's psychological and emotional needs.

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Intense, rapidly shifting emotions, including intense anger, anxiety, and depression.

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Reckless behaviors, such as self-harm, substance abuse, or risky sexual behavior.

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Unstable sense of identity and self-worth.

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Difficulty maintaining stable relationships due to intense emotions and fear of abandonment.

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A persistent sense of boredom, dissatisfaction, and lack of purpose.

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Recurrent thoughts of suicide or self-harm.

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Thoroughly assess and document the declination of the patient’s mental/physical/emotional status and communicate it to the provider in order to initiate the transition of this patient to a unit that can better address her health needs at this time.

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Requesting a sedative or anti-anxiety medication to reduce the patient’s agitation and anxiety.

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Implementation of physical restraints in order to prevent the patient from harming herself or others.