NCP 1

NURSING DIAGNOSIS

Disturbed sleep pattern related to a familiar event of incident as evidence by

experienced nightmares about the rape in which the event is replayed.

NURSING INFERENCE

PTSD disrupt sleep by increasing the duration of light sleep; decreasing the duration of
deep, restorative sleep; and interfering with rapid eye movement (REM) sleep, the stage of
sleep linked to dreaming and nightmares. This often results in insomnia, difficulty falling and
staying asleep and daytime fatigue.

NURSING GOAL

After 1 month of providing nursing interventions, the patient will be able to report
improve sleeping pattern without reoccurrence of nightmares.

NURSING INTERVENTIONS

INTERVETNTIONS RATIONALE
1. Listen to reports of sleep quality and To clarify perception of sleep quantity and
response from the lack of good sleep quality and response to inadequate sleep.
2. Observe for physical signs of fatigue To address
such as restlessness, hand tremors,
thick speech, drooping eyes,
inattention, lack of interest in
activities.
3. Provide sleep-diary for screening To evaluate the type and etiology of sleep
information. disturbance and to identify useful treatment
options.
4. Adjust an ambient lighting To maintain daytime light and nighttime dark
5. Encourage usual bedtime routines These activities provide relaxation and
such as washing face and hands, and distraction to prepare mind and body for
 brushing teeth or relaxing activities sleep.
such as warm bath, calm music,
reading a book, and relaxation
exercises before bedtime.
6. Provide bedtime care such as To promote physical comfort.
straightening bed sheets, changing
damp linens, and back massage
7. Encourage to listen into soft music, To increase relaxation
calm TV program, or provide quiet
environment
8. Minimize sleep-disturbing factors To promote readiness for sleep and improve
such as shut the room door, adjust sleep duration and quality.
room temperature, reduce talking,
turn off phones or alarms,
9. Avoid daytime napping as appropriate To help in the promotion of normal sleep-
maintain being active during day like wake patterns and stress may be reduced by
doing physical activities but avoid therapeutic activities and may promote
strenuous activities before bedtime sleep. However, strenuous activities may lead
and more passive at night. to fatigue and may cause insomnia.
10. Encourage patient to drink milk. L-tryptophan is a component of milk which
promotes sleep.
11. 1Instruct the patient to follow a Consistent schedules facilitate regulation of
consistent daily schedule for rest and the circadian rhythm and decrease the
sleep. energy needed for adaptation to changes.
12. Remind the patient to avoid taking a This will refrain the patient from going to the
large amount of fluids before bathroom in between sleep.
bedtime.

NURSING EVALUATION
 After 1 month of providing nursing interventions, the patient improved her sleeping
pattern without reoccurrence of nightmares.

NCP 2

Nursing Diagnosis

Post-trauma syndrome related to overwhelming anxiety secondary to sexual assault as

evidenced by intrusive nightmares, unpredictable episodes of explosive anger or aggression,
and inability to remain asleep.

Nursing Inference

When a person is exposed to a severe trauma (e.g. sexual assault), a disruption of the
hypothalamic-pituitary-adrenal axis which plays a major role in regulation of stress response.
Consequently, this results to hippocampal and amygdala damage which then causes the failure
of the mind to process information and feelings.

Nursing Goal

After 4 weeks of providing nursing interventions, the patient will be able to demonstrate
ability to deal with emotional reactions in an individually appropriate manner and report relief
of physical manifestations as evidenced by absence of unpredictable episodes of explosive
anger or aggression, intrusive nightmares, and ability to remain asleep.

Nursing Interventions
INTERVENTIONS RATIONALE
Maintain the patient’s safety and The priority is to protect the client and
integrity during post trauma episode, using others from injury or harm
appropriate interventions according to facility during post trauma episode since client
policy. may experience escalating anxiety,
depression, or suicidal thoughts.

Monitor the client’s anxiety level Establishing the client’s anxiety

level prevents escalation of symptom
through early interventions
Teach the client adaptive cognitivebehavioral Cognitive therapy helps the client
strategies to manage symptom of emotional substitute irrational thoughts, beliefs, or
and physical reactivity that accompany images for more realistic
intrusive recollection such as deep breathing ones and thus promotes a greater
and relaxation exercises, cognitive therapy understanding of the client’s actual role in
and desensitization the traumatic event, which may decrease
guilt and self-blame.

Systematic desensitization helps the client

gain mastery and control over the past
traumatic event by progressive exposures
to situations and experiences that
resemble the original event, which
eventually
desensitize the client and reduces
painful stimuli.

Deep breathing/relaxation exercise

provide slow, rhythmic, controlled
patterns that decrease physical and
emotional tension, which reduce the
effects of anxiety and the threat of painful
recollection.

Involve the patient in decisions about This involvement helps foster

the client’s care and treatment feelings of empowerment, control and
confidence in the client rather than
Nursing Evaluation

After 3 weeks and 5 days of providing nursing interventions, the goal was fully met since
the patient was able to demonstrate ability to deal with emotional reactions in an individually
appropriate manner and report relief of physical manifestations as evidenced by absence of
unpredictable episodes of explosive anger or aggression, intrusive nightmares, and ability to
remain asleep.

NCP 3

Nursing Diagnosis

Rape-trauma syndrome related to actual forced sexual penetration as evidenced by

presence of repetitive nightmares, alteration in sleep pattern, depressed mood, irritable, angry,
and emotionally disconnected from his spouse for no apparent reason.

Nursing Inference

Traumatic event such as rape leads to psychological trauma as a response of the victim,

Nursing Goal

After 1 month of rendering nursing intervention, the patient will be able to deal
appropriately with emotional reactions as evidenced by improvement in behavior and feelings,
controlled emotions to nightmares, lifted mood, and improved relationship with her spouse.

Nursing Interventions

INTERVENTIONS RATIONALE
Note signs of increasing anxiety. This indicates need for immediate
interventions to prevent panic reaction.
 Provide presence with the patient. In order to provide reassurance and sense of
safety.
Provide an environment where patient can To help patient feel safe and comfortable in
talk freely about feelings and fears, including opening up.
concerns about relationships.
Provide psychological support by listening To reassure the patient is not alone, and
and remaining with client. provide sense of safety.
Listen for expressions of fear to crowds, men, In order to identify developing phobias.
and being alone.
Permit free expression of feelings and refrain To facilitate resolution of feelings without
from rushing patient in opening up. diminishing self-concept.
Assist patient to identify factors that may To help patient protect self in the future
have created a vulnerable situation

Nursing Evaluation

After 1 month of rendering nursing intervention, the patient dealt appropriately with
emotional reactions as evidenced by improvement in behavior and feelings, controlled
emotions to nightmares, lifted mood, and improved relationship with her spouse.