Therapeutic Nursing Interventions Paper

Helping Veterans with Post Traumatic Stress Disorder (PTSD)

Nikole Hardy, RN
NURS403
October 16, 2022
 Post-traumatic stress disorder

Post-traumatic stress disorder, otherwise known as PTSD, is a mental health condition that is

triggered by an event that the individual either witnessed or experienced. Symptoms can include extreme

anxiety, nightmares, flashbacks, and uncontrolled thoughts about the event. It is reported that patients

have recurring unwanted memories of the event, reliving the event in their mind as flashbacks, and avoid

places, activities or people that may remind them of the event. Physical symptoms that are common are

consistently being on guard as though they are awaiting danger, self-destructive behavior such as drinking

or drugs, trouble sleeping, angry and/or aggressive outbursts, an increased irritability and even potential

guilt and shame. (Mayo Clinic) It is estimated by the Veteran Administration statistics that every day 22

soldiers die of PTSD-related suicide in the United States of America. That is one veteran succumbing to

their invisible wounds every 65 minutes. (Military Veteran Project) PTSD was not an official diagnosis

until 1980 when a group of Vietnam veterans along with the New York psychoanalysts Chaim Shatan and

Robert J. Lifton successfully lobbied the American Psychiatric Association to create the diagnosis. Prior

to this diagnosis these veterans were treated for other diagnosis’ such as alcoholism, substance abuse,

depression, mood disorders and even schizophrenia. Fortunately, since the 1980’s technology has allowed

the medical field to further examine what happens to the human brain of patients with PTSD. (Van Der

Kolk pgs.19-21) A study revealed that most patients with PTSD use mental health services and they are

also more likely to use non-mental health services. The use of outpatient nonmental health services was

91% greater in veterans’ with PTSD and they were three times more likely to be hospitalized. Another

study concluded that the cost of PTSD hospitalization in the United States from 2002 to 2011 was $34.9

billion. Interestingly and unfortunately, almost 95% of hospitals in that study also only listed PTSD as a

secondary versus a primary diagnosis which suggests that most of these providers are not trained as

mental health professionals. (Society of Hospital Medicine) A major problem in hospitals for these PTSD

patients is that attention is only given to PTSD if a related problem arises such as increased anxiety

during their hospitalization or having confrontations with the staff. There is little evidence regarding best
methods to teach the medical team how to provide quality care for these patients. (Fletcher) This paper

will focus on PTSD patients within the inpatient hospital setting and current and potentially new practices

to provide optimal care supporting their PTSD diagnosis.

Current Practice

The PTSD Toolkit for Nurses sponsored by the American Nurses Foundation was created to

teach nurses about the psychological consequences from stress and trauma in veterans to increase the

quality of care and understanding of this diagnosis. It provides videos and case summaries that highlight

essential points for nurses to assess, intervene and refer veterans with PTSD and has a simulation for

nurses to practice these skills. (Hanrahan) As a nurse it is important to recognize the signs and symptoms

of PTSD and provide a screening to determine a potential diagnosis. This is typically done with the

provider but nurses typically play a part in this screening also. The screening asks about experiences,

listens to stories, screen for suicidal ideation and a history of trauma. This can be very emotional to the

patient so this should take place in a private setting where they feel comfortable. (Wiley University)

There are some very simple interventions that could be put in place in the hospital setting to decrease the

amount of triggers these patients may have. Common things such as loud beeping from IV pumps,

frequent interrupted sleep due to labs and/or medications or even the way they are woken up. As a nurse

caring for a patient with PTSD should pay attention to timing of medication that may interfere with a

proper night of rest. It is not uncommon for Furosemide to have an evening administration time which

will lead to multiple bathroom trips throughout the night or medications such as Lovenox in the middle of

the night or the early morning hours before 0700 or antibiotic times for a medication that should be

administered twice a day but scheduled for times such as 1400 and 0200. Nurses have the ability to

contact pharmacy and schedule these medications for a more appropriate time with the approval from the

physician and should make these adjustments. Another recommended intervention that could be put in

place in hospitals for PTSD patients are bedtime routines. Many of these patients follow a routine

schedule at home and to continue this while hospitalized staff should be encouraged to turn lights and

televisions off at a designated time. Nurses and other members of the interdisciplinary team should also
assess the patient’s triggers such as a startle response when being woken up by another persons’ touch.

(Kwan) By assessing these triggers the nurses and healthcare team could prevent increased anxiety and

trigger reactions. It is also important for the nurse to develop a trusting relationship with the patient and

provide positive open communication.

The American Psychological Association currently strongly recommends four interventions for

PTSD treatment. The four that are strongly recommended are all types of cognitive behavioral therapy

(CBT). CBT focuses on relationships between thoughts and feelings, assess and targets current problems

and symptoms and focuses on changing behavior patterns and thoughts and feelings that cause difficulty

functioning. Cognitive Processing Therapy (CPT) is a type of cognitive behavioral therapy that teaches

the patient how to modify and challenge unhelpful believes related to their trauma. Cognitive therapy

consists of modifying negative evaluations and memories of trauma with a goal of disrupting the

behaviors and/or thought patterns that have been affecting the patient’s everyday life. Lastly, they

recommend Prolonged Exposure which is a specific cognitive behavioral therapy that gradually

encourages patients to approach their trauma-related memories, feelings, and situations. By facing the

triggers that they typically avoid, a personal can potentially learn that these cues are not dangerous and

don’t need to be avoided which can potentially illuminate a flashback or anxiety attack. There are four

specific medications that are recommended for PTSD treatment: sertraline, paroxetine, fluoxetine, and

venlafaxine. (American Psychological Association)

Nursing Interventions

One potential future intervention for PTSD veterans is the use of the holistic therapy Reiki, also

sometimes known as “Healing Touch” to assist with their symptoms of PTSD. Reiki originated from

Japan by a man named Mikao Usui for reducing stress, relaxation and promotes healing based on the idea

of a life force- energy that exists in all living things and the cleansing of your inner body’s chakras.

(International Center for Reiki Training) A randomized crossover waitlist-controlled trial was conducted

using Reiki at the Tibor Ruben VA Medical Center in Long Beach, California. The veterans that were

eligible to participate in the study had to be mental health outpatients with an active diagnosis of PTSD,
18 years or older and with at least one deployment in a combat zone and both mentally and physically fit

to participate. A total of 40 study candidates were enrolled in the study over a time of 5-6 weeks. The test

group would receive a weekly series of 10 1-hour reiki treatments in addition to standard care such as

medication, psychotherapy, and other interventions. The control group only received standard care.

Subjects in the study were reported to show significant decreases in their PTSD symptoms when

receiving Reiki therapy and standard care and reported a range of positive physical and psychological

effects even though some stated these effects were only temporary. Reiki has shown in multiple studies

that is a low cost, low-risk and non-invasive effective treatment for PTSD and should be utilized much

more in the healthcare system. (Reeve)

Another potentially new intervention for PTSD is a new psychotropic medication called

Methylenedioxymethamphetamine ( MDMA), With this assisted psychotherapy the medication is only

administered to the patient for a couple of doses paired with talk therapy sessions. Researchers reported

their results of the phase 3 trial consisting of 90 patients with severe PTSD. Many of the patients reported

they had a decrease in their PTSD symptoms after receiving the MDMA-assisted therapy. There were no

reports of adverse reactions such as suicidal thoughts or abuse potential with the drug. This study

included PTSD patients that suffered from dissociation, depression, a history of substance and alcohol

abuse, and childhood trauma. PTSD symptoms were measured using the clinician-administered PTSD

scale from baseline and then two months after the final dose. (Mitchell) In May of 2022 the FDA gave

expanded access to MDMA as a treatment for PTSD. Results from phase two and phase three showed the

67% of the participants no longer show PTSD symptoms. The treatment only takes between four to six

months. An FDA approval for the drug is expected in 2023. (Vaillancourt)

A third potential new intervention for PTSD patients is called Theta Burst Stimulation (TBS), a

novel form of Repetitive Transcranial Magnetic Stimulation. In 2020 a study was published in Military

Medicine that Australian researchers from the Centre for Post-traumatic Mental Health completed a pilot

study that used TBS and was shown to improve depressive symptoms in veterans with PTSD. In the study

eight Australian Defense Force veterans with PTSD received 20 bilateral TBS treatments over four
weeks. They stated that their participants did have a decrease in depressive and PTDS symptoms and had

an increase in their working memory and processing speed. They denied any serious side effects or

adverse reactions. These are great results and a step in the right direction, but this procedure is in the early

stages and because the study was such a small-scale study a lot more controlled trials will be needed

before it can be considered a mainstream treatment for PTSD. (Jain)

Conclusion

Post-traumatic stress disorder is a serious diagnosis that many veterans are faced with. As a

healthcare worker, it is important to understand this diagnosis and the importance of finding these patients

help. Mental health, in my opinion, is severely ignored and not taken as serious as a physical disorder

when it is just as serious and life-threatening. There are many available treatments currently, but the

suicide rate alone related to PTSD in veterans is horrifying. Hopefully, these new upcoming interventions

can provide results that can cure PTSD or significantly decrease their symptoms. As a nurse, it is

imperative that you advocate for your patient and take the proper steps to assess and screen patients for

PTSD and/or suicidal thoughts and take any measures to decrease potential triggers and disturbing their

established routine.
 Resources

American Psychological Association. 2022. “PTSD Treatments”

https://www.apa.org/ptsd-guideline/treatments

Fletcher, K. E., Steinbach, S., Lewis, F., Hendricks, M., & Kwan, B. (2021). Hospitalized Medical
Patients With Posttraumatic Stress Disorder (PTSD): Review of the Literature and a Roadmap for
Improved Care. Journal of hospital medicine, 16(1), 38–43. https://doi.org/10.12788/jhm.3409

Hanrahan, Nancy, PhD, RN, Judge, Kate, Olamijulo, Grace, MS, BSN, Seng, Lisa, et al. (2017). The
PTSD Toolkit for Nurses: Assessment, intervention, and referral of veterans. Nurse Practitioner, 42, 46-
55. https://doi.org/10.1097/01.NPR.0000488717.90314.62

International Training Center for Reiki Training. 2022. “What is Reiki” https://www.reiki.org/faqs/what-
reiki

Jain M.D, Shaili. July 1, 2021. “The Latest in PTSD Treatment: Emerging ideas, promising treatments
and novel innovation.” Sussex Publishers LLC. Psychology Today.
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Mayo Clinic 2022. “Post-traumatic stress disorder” https://www.mayoclinic.org/diseases-conditions/post-

traumatic-stress-disorder/symptoms-causes/syc-20355967.

Military Veteran Project. 2019. “Military Suicide Awareness”

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%20Administration%20statistics%20confirm%2022%20Veterans%20a,and%20treatments%20are%20not
%20able%20to%20be%20done.

Mitchell, J. M., Bogenschutz, M., Lilienstein, A., Harrison, C., Kleiman, S., Parker-Guilbert, K., Ot'alora
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Kwan, Brian MD; Fletcher, Kathlyn MD; Steinbach, Scott MD. Society of Hospital Medicine. 2019
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Reeve, K., Black, P., & Huang, J. (2020). Examining the Impact of a Healing Touch Intervention to
Reduce Posttraumatic Stress Disorder Symptoms in Combat Veterans. Psychological Trauma, 12(8), 897-
903.

Vaillancourt, Cory. May 11, 2022. “FDA gives expanded access to MDMA as treatment for PTSD” Blue
Ridge Public Radio. https://www.bpr.org/bpr-news/2022-05-11/fda-gives-expanded-access-to-mdma-as-
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Van Der Kolk MD, Bessel. 2015. “The Body Keeps The Score: Brain, Mind, and Body In the Healing of
Trauma.” Penguin Books. (pgs. 19-21)

Wiley University Services. 2022. “How can Nurses help treat PTSD?”
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%20Nurses%20Help%20treat%20PTSD%3F%201%20Recognizing,important%20that%20the
%20appropriate%20treatment%20is%20chosen.%20