Nursing Process for Client with PTSD.Vinicha

NURSING PROCESS FOR CLIENT WITH PTSD

Focus:

For the client who develops fear, terror, dread, or helplessness following exposure to a traumatic event (rape, war, natural disaster, abuse, experiencing or witnessing serious trauma or violence). Symptoms range from emotional “numbness” to vivid nightmares in which the traumatic even is recalled.

NOC:

Suicide self-restraint, Anxiety level, Fear level, Abuse recovery, Emotional, Physical or Sexual, Coping, Depression level, Impulse self-control.

NIC:

Suicide prevention, Anxiety reduction, Anger control assistance, Simple relaxation therapy, Coping enhancement, Mood management, Support system enhancement.

ASSESMENT DATA

1. Related factors (Etiology)

· Overwhelming anxiety secondary to:

a. War experiences/military combat

b. Natural disaster (earthquake, hurricane, tornado, flood)

c. Personal assault (rape, incest, molestation, beatings, abuse)

d. Kidnap of self or significant others

e. Catastrophic illness or accident

f. Prisoner of war death camp hostage experiences

g. Learning of a loved one’s serious accident, injury, or maiming

h. Destruction of home or valued resources

i. Witnessing a serious accident or act(s) of violence (car crash, building collapse, mother being beaten, killing of family member)

j. Viewing a scene in which there are dead and/or maimed bodies (aftermath of war, plane or train crash, earthquake)

k. Threat to physical and emotional integrity (all of the above)

2. Defining Characteristics

· Client relates frequent intrusive recollection of past traumatic experience.

· States that recollections are accompanied by feelings of dread, terror, helplessness, powerlessness, cardiac palpitations, shortness of breath, and other symptoms of emotional physical reactivity.

a. “I feel out of control and terrified when I recall the event”

b. “I get out of breath and my heart beats faster and faster”

c. “I have a sense of doom, as if something terrible is going to happen”

· Describes recurrent dreams or nightmares in which vivid details of traumatic event are relived or reenacted.

a. “I had another horrible nightmare last night and went through the same trauma and anxiety all over again”

· Express feelings of “numbness” detachment, or loss of interest toward people and the environment (generally occurs immediately after the traumatic event)

· Demonstrates avoidance or lack of responsiveness toward stimuli associated with the traumatic event (in rare instances, may experience psychogenic amnesia)

a. A war veteran avoids hospitals, injured persons, bandages, and blood.

b. An accident victim demonstrates a flat affect while listening to a news report describing a traumatic event.

· Demonstrates symptom of psychogenic reactivity (anxiety symptom) when exposed to events that resemble or symbolize the original trauma.

a. A young woman develops fear, dread, or terror when she attempt sexual intimacy with her partner because it reminds her of when she was raped.

b. A prison camp victim experiences sympathetic nervous system stimulation (rapid heart rate, shortness of breath, nausea, diarrhea) while sitting in a cell-sized room.

c. A war veteran who fought in a hot, humid climate experiences dread or terror when exposed to similar weather many years later.

· Demonstrates symptom of increased arousal (inability to fall asleep or remain asleep, hypervigilance, exaggregated startle response).

· Manifest unpredictable episodes of explosive anger or aggression.

· Verbalize inability to concentrate or complete task.

a. “I’m too distracted to make my bed or go to an activity”

b. “I can’t concentrate on my craft”

c. “I can barely shower and groom myself”

· Relates inability to express angry feelings.

a. “I feel as if I might explode, but I can’t let it out”

b. “I can’t begin to express my anger”

· Expresses thoughts of self-blame and guilt regarding a traumatic event.

a. “If only I had locked the door, it wouldn’t have happened”

b. “If I had been there on time, it wouldn’t have occurred”

· Verbalizes anger at others for perceived role in traumatic event.

a. “If they had helped more, he wouldn’t have lived”

b. “If they have called for help right away, I wouldn’t be so badly injured”

3. Outcome Criteria

· Clients verbalizes awareness of psychologic, and psychologic symptom of anxiety that accompany recollections of a past-traumatic event.

· Identifies situation/event/images that trigger recollections and accompanying responses of past traumatic experiences (small or enclosed spaces, hot or cold climate, argument or fight, sexual intimacy)

· Communicates and interacts within the milieu to control and manage anger and relieve thoughts of self-blame and guilt.

a. Communicates thoughts/feelings to a trusted person.

b. Problem solves source of thoughts/feelings.

c. Participates in group activities.

d. Engages in physical activities/exercise.

· Use learned adaptive cognitive-behavioral therapeutic strategies to manage symptom of emotional and physical reactivity.

a. Attending process groups for group therapy.

b. Slow, deep-breathing technique.

c. Progressive relaxation exercise.

d. Thought, image, and memory substitution.

e. Cognitive restructuring.

f. Systematic desensitization.

g. Behavior modification.

h. Assertive behaviors.

· Relates understanding that anger, self-blame, and guilt are common in person who have experienced or witnessed traumatic events in which others were injured, assaulted, or threatened.

a. “I realize others who gone through this have had similar reaction”

· Verbalizes ability to control or manage symptom of emotional and physical reactivity that tend to occur during recollections of the traumatic event.

a. “I can deal with my anxiety much better now”

b. “My symptoms are much less troubling now”

c. “I feel more in control of my reactions”

· Demonstrates ability to remain significantly calmer when exposed to situations or events that symbolize or are similar to the original traumatic event (displays relaxed affect and facial expression; smooth, nonagitated psychomotor movements).

· Expresses relief from anger, self-blame, or guilt related to the traumatic event.

a. “I’m not so hard on myself anymore; I realize things happen that we can’t control or change”

b. “I’m not overcome with anger anymore ”

· Verbalized realistic hopes and plans for the future with absence of suicidal thoughts.

a. “I’m going back to my old job; I have a lot of reasons to live; my family needs me”

· Identifies significant support systems (family, friends, community group).

· Identifies the normal progression of grief symptoms that may be a part of the traumatic event (shock, denial, awareness, anger, restitution, acceptance).

· Verbalizes self-forgiveness and forgiveness of others for reactions or non actions perceived by the client to have influenced the traumatic event.

b. “I can finally forgive myself for being human”

c. “they did what they could to help at time”

d. “it’s time to forgive and get on with my life”

NURSING DIAGNOSIS

With the symptoms themselves, an assessor of PSTD must pay attention to the qualifying adjectives: “persistent,” “recurrent,” and “distressing.” The assessor must also decide whether or not numbed responsiveness and hyper arousal occurred subsequent to the trauma. In cases of chronic PSTD and in cases of early traumatization, arriving at such judgments is not easy; indeed, the validity of such a construct can be questioned when traumatic events like incest and childhood abuse were the causes of PSTD. Unless proper attentions is given to those points, PSTD may be over diagnosed.

At least one of five possible intrusive symptoms is quired for B criteria, which represent the essential and distinctive set of symptoms by which represent the essential and distinctive set of symptoms by which represent the essential and distinctive set of symptoms by which PSTD is distinguished from all other forms of anxiety and depression.

At least three of seven possible avoidance (C criteria) symptoms are required. The first three criteria – (1) avoiding thoughts or feelings associated with the trauma; (2) avoiding activities, situations, or play associated with the trauma; and (3) inability to recall an important aspect of trauma- specifically relate to the trauma. The remaining four criteria are not specific to PSTD and may be found in other disorders, such as depression. Both avoidance and numbing are required for the diagnosis.

At least two of five possible hyper arousal symptoms (D criteria) are require. Those symptoms may also be seen in other disorder, such as generalized anxiety disorder.

On the basis of literature surveys, no compelling reason lead one to believe that the symptoms picture differs substantially according to the age, sex, or ethnicity of the patient or the type of trauma. However, somatic expressions of PSTD may be seen more commonly in populations from others cultures, as well as in children. A number of associated symptoms can occur and may prove important in the treatment of individual patients. Those symptoms include survival and the behavioral guilt, somatic distress, paranoia, interpersonal alienation alienation, and the vegetative changes of depression. Victims of prolonged interpersonal abuse can inhibited impaired modulation of affect, impulsive behavior, and feelings of indeed on studies of combat veterans. effectiveness and hopelessness.

Psychometric testing may reveal elevated neuroticism scores on the Eysenck Personality Inventory and elevated Sc, D, F, and Ps scores on the Minnesota Multiphasic personality Inventory (MMPI). Rorschach testing may reveal the presence of aggressive and violent thoughts. For the most part, however, those psychometric studies are bas

GENERALIZED ANXIETY DISORDER. The hyper arousal symptoms described in the D criteria set are similar to those present in generalized anxiety disorder bull than disorder lack a traumatic origin and the intrusive symptom found in criteria B. Nonetheless, if any anxious patient presents with ready startle, remain on guard, and does not respond to the usual measures for generalized anxiety disorder, the clinician should consider a diagnosis of PTSD.

DEPRESSION. Depressive features of reduced interest, estrangement, numbing poor concentration, and insomnia occur in PSTD. Intrusive trauma-bound symptom are not a feature of depression. However, after exposure to trauma , post traumatic reactions are seen, and the clinician needs to address the traumatic component. Polysonographs and neuroendocrine studies may help in differential diagnosis of PSTD and major depressive disorder.

PANIC DISORDER. Panic attacks resembles the autonomic hyperactivity in PSTD (criteria D). O distinguish the two, the interviewer should establish whether the panic attacks are related to the trauma or to reminders of it.

OBSESSIVE-COMPULSIVE DISORDER . PSTD and obsessive-compulsive disorder both share the occurrence of repetitive, distressing recollections, images, or thoughts. To distinguish between the two disorder, the clinical must obtain a careful history, asking about the occurrence of the trauma and establishing whether the intrusive phenomena are thematically linked to the event.

DISSOCIATIVE DISORDERS. Flashbacks, numbing, and amnesia may suggest dissociative disorder. When those symptoms are prominent or presenting features, the clinical must elicit a clear history of the additional intrusive, avoid, and hyper arousal features that occur in PSTD but not in dissociative

BORDERLINE PRERSONALITY DISORDER. The diagnosis of borderline personality disorder is often made when PSTD is a more appropriate diagnosis or, at least, a necessary concomitant diagnosis. A clinical who makes the diagnosis of borderline personality disorder must inquire further into possible early trauma and ensuing symptom.

MEDICAL DISORDER. After a patient sustains a head injury, the clinical must evaluated the degree of any brain damage and its possible contribution to some of the symptoms. Close collaboration with a neurologist in advisable.

The clinical should also clarify the role of alcohol or psychoactive substance intoxication and withdrawal, since those disorder can aggravate PTSD symptoms.

FACTITIOUS DISORDER. PSTD must sometimes be distinguished from fastinguished from factitious disorder. Helpful clues are corroborative evidence that trauma did occur and that the patient is usually distressed about the trauma and often reluctant at first to discuss its details. Factitious symptoms often vary in response to the immediate environment.

PLANNING AND IMPLEMENTATION

Nursing Intervention	Rationale
Involve the client in decisions about the client’s care and treatment. · “What are some of the behaviors and coping methods you use to decrease anxiety and control intrusive memories?” · “I notice the methods you’ve been using seem to reduce your symptoms effectively. What do you think?”	This involvement helps foster feelings of empowerment, control, and confidence in the client rather than feelings of being a helpless victim of external effects.
Engage the client in group therapy sessions with other clients with posttraumatic stress disorder when the client is ready for the group process (see Appendix G).	The group process provides additional support and understanding through involvement with others who may have similar problems. Also, seeing the success of other gives hope to the client.
Promote the client’s awareness of his or her own avoidance of experiences similar to the traumatic event.	Awareness gives the client the opportunity to integrate the past traumatic event into present and future life experiences without fear or apprehension.
Provide realistic feedback and praise whenever the client attempts to use learned strategies to manage anxiety and reduce posttraumatic stress response. · “The staff has noticed you practicing the relaxation exercises.” · “You handled your anger well in the assertiveness training class today.” · “Your thoughts about your self have become more realistic.”	Positive reinforcement promotes self-esteem and gives the client the confidence to continue working on the treatment plan.
Assist the client and family to develop realistic life goals (school, work, community, and leisure activities).	The client and family will be better prepared for a hopeful future that will absorb and alleviate the posttraumatic stress response.

EVALUATION

· Evaluation of outcome criteria is a critical method that determines:

a. Client (individual, family, community) progress and response to treatment

b. Effective use of the nursing process

c. Accountability for the nurse’s standards of care

· Evaluation is dynamic and may be used at any stage of the nursing process.

REFERENCES

· Yosep, Iyus. 2009. Keperawatan Jiwa Edisi Revisi. Bandung: Refika Aditama.

· Fortinash, Haladay. 2007. Psychiatric Nursing Care Plans. 5th ed. Philadelphia: Mosby Elsevier.

· Varcarolis, M.Elizabeth. 1994. Foundations of Psychiatric: Mental Health Nursing. Philadelphia: W.B Sounders Company.

· Kaplan, Sadock, B. 1995. Comprehensive Text Book of Psychiatry. 6th ed,vol 1. Maryland: William & Wilkins.

· Kozier, Barbara. 1979. Fundamental of Nursing. California: Wesley Publishing Company.

· http://www.medterms.com/script/main/art.asp?articlekey=22491 downloaded on Desember 15^th 2009.

· http://en.wikipedia.org/wiki/PTSD downloaded on Desember 15th 2009.