Disorder: PTSD

Factors: PREDISPOSING

 Stressful experiences, including the amount and severity of trauma you've gone through in your life
 Inherited mental health risks, such as a family history of anxiety and depression
 Inherited features of your personality — often called your temperament
 The way your brain regulates the chemicals and hormones your body releases in response to stress
Neurochemical/biological alternation:
The prefrontal cortex (PFC) is an area of the brain found in the frontal lobe. This region of the brain plays an important part in PTSD. Some of the
key functions of the prefrontal cortex include: Emotional regulation. PTSD causes your brain to get stuck in danger mode. Even after you're no
longer in danger, it stays on high alert. Your body continues to send out stress signals, which lead to PTSD symptoms. Studies show that the part
of the brain that handles fear and emotion (the amygdala) is more active in people with PTSD.

PRECIPITATING:

 Experiencing intense or long-lasting trauma

 Having experienced other trauma earlier in life, such as childhood abuse
 Having a job that increases your risk of being exposed to traumatic events, such as military personnel and first responders
 Having other mental health problems, such as anxiety or depression
 Having problems with substance misuse, such as excess drinking or drug use
 Lacking a good support system of family and friends
 Having blood relatives with mental health problems, including anxiety or depression

Assessment:

Mental Status Assessment Adaptive Functioning Theories

General Appearance Conceptual Psychosexual/ Freud
Facial Expression: Sad or Depressed, Communication - Speech, language, Oral - tension and gratification
Pale/Reddened vocabulary and listening Anal - Control
Posture: Upright Functional Academics - academic skills in Phallic - Genital (Elektra & Oedipus complex)
Gait: Normal basic reading, writing, Latency - Social activities
Dressed: Appropriately dress/Wrinkled mathematics Genital - True intimacy
Grooming/hygiene: Unkempt/tidy Self-Direction - independence and Psychosocial/ Erickson
Odor: No presence/ Alcohol/ Cigarette smoke completing task Trust vs Mistrust - Drive and hope
Eye contact: Poor eye contact (lacks) Social Autonomy vs Shame/Doubt - Self-control &
Motor Behavior Social Skills - Interact socially and get along will power
None with others Initiative vs Guilt - Direction & Purpose
Speech Leisure - planning leisure and recreational Industry vs Inferiority - Methods &
Rate: Slow activities Competence
Volume: Soft/ mumbled Practical Life Skills Identity vs Role Confusion - Devotion &
Quantity: Paucity/ Muteness Self-care - dressing, bathing, toileting, Fidelity
Quality: Pressured speech/ monotonous grooming, hygiene Intimacy vs Isolation - Affiliation & Love
Emotional State Home/School Living - basic care of a home or Generativity vs Stagnation - Productivity &
Unpleasurable living setting Care
Inappropriate Community Use - functioning in the Ego Integrity vs Despair - Wisdom
Flat/Blunted affect community, including use Cognitive/ Piaget
Anxiety/ Panic attack of community resources Sensorimotor (0-2) - Use language
Depression Health and Safety - Skills needed for Pre-operational (2-7) - Understand
Fear protection of health relationships
Anger Work - holding a part-time or full-time job in Concrete operation (7-11) - Socialized and
Perception a work setting logical
None Formal Operation (11-above) - Think
Thinking scientifically and solve complex problems
None Moral/Kohlberg
Attitudes PRECONVENTIONAL LEVEL
Cooperative Stage 1: Punishment and Obedience
Withdrawal Orientation
Fearful Stage 2: Instrumental Relativist Orientation
Defense Mechanisms
Dissociation CONVENTIONAL LEVEL
Denial Stage 3: Good-Boy-Nice-Girl Orientation
Repression Stage 4: Society-Maintaining Orientation
Suppression
 POST CONVENTIONAL LEVEL
Stage 5: Social Contract Reorientation
Stage 6: Universal Ethical Principle
Orientation
Hierarchy of needs/Maslow
SELF ACTUALIZATION - Fulfillment of unique
potential
SELF ESTEEM - Self-esteem and respect;
prestige
LOVE AND BELONGING - Giving and receiving
affection; companionship; group
identification
SAFETY - Avoiding harm; security; and
physical safety
PHYSIOLOGIC NEEDS - Biological needs for
oxygen, water, food, sleep, sex

Nursing Diagnosis:

1. Risk for other-directed violence r/t experienced traumatic life event AEB reexperiencing the event
2. Ineffective coping r/t multiple stressors repeated over a period of time AEB inability to cope
3. Complicated grieving r/t loss of physio psychosocial well-being AEB verbal expression of distress at loss

Planning: Priority

 Reduce severity of psychotic symptoms

 Prevent recurrence of acute episodes
 Meet patient’s’ physical and psychosocial needs
 Help patient gain optimum level of functioning
  Increase client’s compliance to treatment and nursing plan

Psychopharma:

 Benzodiazepine therapy (may be prescribed to manage uncontrollable anxiety)

 Clonidine and Propranolol (decrease peripheral autonomic response to fear)
 Lithium carbonate (for explosive response and intense feeling being out of control, decrease hyper-arousal and startle response

Nursing Considerations

- Do not leave the patient until the drug is swallowed.

- Do not permit the patient to go to the bathroom to take the medication.
- Do not allow one patient to carry medicine to another.
- Always address the patient by name and make certain identification.
- Give fresh water after all medications. – If it is necessary to leave the patient to get water or assistance, do not leave the tray within the
reach of the patient or unsupervised. Do not take the tray within reach of disturbed or delirious patients.
- Do not force oral medication because of the danger of aspiration.

Therapy

 Cognitive Behavioral Therapy - Exposure to the trauma narrative, as well as reminders of the trauma or emotions associated with the
trauma, are often used to help the patient reduce avoidance and maladaptive associations with the trauma

Adaptive disclosure - is specialized CBT approach in which the participant says whatever he or she needs to say to anyone, alive or
dead.

 Exposure Therapy - Is a treatment approach designed to combat the avoidance behavior that occurs with PTSD. The exposure therapy
may confront the event in reality by returning to the place where one was assaulted, or may use imagined confrontation that is mentally
placing oneself in the traumatic situation.
 Cognitive processing therapy - has been used successfully with rape survivors as well as combat veterans. It involves structured sessions
that occurs on examining beliefs that are erroneous or interfere with daily life.
 PNCP

Cues/Clues Psychiatric Psychodynamics Planning Therapeutic Rationale Evaluation

Nursing Diagnosis (Rationale) Approach
Subjective Risk for suicide Schematic Patient will In the community: Relieve isolation Patient will
Objective r/t History of Diagram refrain from Arrange for the and provide refrain from
prior suicide attempting client to stay with safety and attempting
attempt/ suicide. family or friends. A comfort. suicide.
Helplessness/ hospitalization is
Alcohol and Patient will make considered if there Patient will make
Substance a no-suicide is no one is a no-suicide
abuse/use contract with the available especially contract with the
AEB statement of nurse covering if the person is nurse covering
despair/ suicide the next 24 highly suicidal. the next 24
behavior hours, then hours, then
renegotiate the renegotiate the
terms at that Encourage the During crisis terms at that
time (If in client to avoid situations, people time (If in
hospital and decisions during are unable to hospital and
accepted at your the time of crisis think clearly or accepted at your
institution). until alternatives evaluate their institution).
can be considered. options readily.
Patient will stay Patient will stay
with a friend or with a friend or
family if the family if the
person still has Encourage the Gives client other person still has
the potential for client to talk freely ways of dealing the potential for
suicide (if in the about feelings and with strong suicide (if in the
community). help plan emotions and community).
alternative ways of gaining a sense of
handling control over their
disappointment, lives.
anger, and
frustration.

Weapons and pills To provide a safe

are removed by environment,
friends, relatives, free from things
or the nurse. that may harm
the client.

If anxiety is If anxiety is
extremely high, or extremely high,
client has not slept or client has not
in days, a slept in days, a
tranquilizer might tranquilizer might
be prescribed. Only be prescribed.
a 1-to-3-day supply Only a 1-to-3-day
of medication supply of
should be given. medication
Family member or should be given.
significant other Family member
should monitor or significant
pills for safety. other should
monitor pills for
safety.

Contact family Reestablishes

members, arrange social ties.
for individual and/ Diminishes sense
or family crisis of isolation, and
counseling. provides contact
Activate links to from individuals
self-help groups. who care about
the suicidal
person.
In the hospital: Because of
During the crisis “tunnel vision “,
period, health care clients do not
workers will have perspective
continue to on their lives.
emphasize the These statements
following four give perspective
points: to the client and
- The crisis is help offer hope
temporary. for the future.
- Unbearabl
e pain can
be
survived.
- Help is
available.
- You are not
alone.
The no-suicide
Construct a no- contract helps
suicide contract client know what
between the to do when they
suicidal client and begin to feel
nurse. Use clear, overwhelmed by
simple language. pain
When the contract
is up, it is
renegotiated (If
this is accepted
procedure at your
institution).