University:
American Career College
Course:
NURS-113 | Beginning Medical/Surgical Nursing
Academic year:

2022
Views:

361

Pages:

1
Author:

Leilani Contreras

Nursing Intervention/Rationale: 1. Assess client for suicidal or homicidal ideations Nursing Diagnosis: 2. Assess anxiety level Post Trauma Syndrome 3. Encourage client to verbally identify current ineffective coping techniques Ineffective coping Goals/Outcomes 4. Encourage client to keep a journal of stressors and emotional reactions to those stressors Risk Prone Health Behavior - improve symptoms of PTSD - Restore self esteem 5. Teach visualization and relaxation techniques such as deep breathing and imagery - Patient will develop skills to deal with PTSD episodes - Patient will not harm self-and/or others Risk Factors: -living through dangerous events Disorder: Signs/Symptoms PTSD Flashbacks, avoidance of memories or feelings, fear, guilt that are distorted of event, anger, self-destructive behaviors, and exaggerated startle response. PTSD Screening, Behavior Assessment Scale, Anxiety, Depression Assessment, and Suicide Screening. -Feeling horror, helplessness, or extreme fear of getting hurt History of abuse Ongoing stress Complications & Actions to Prevent: Diagnostics: (Lab/X-ray) Lab Values for Cortisol and Corticotropi Releasing Hormone (Patients with PTSD appear to have lower than normal circulating cortisol. Lower cortisol levels are associated with more severe PTSD symptoms.) -Death of a loved one Pathophysiology: Pathophysiology for PTSD is still unclear but when a traumatic event occurs, it activates the hypothalamic/pituitary/adrenal systems. Aﬀects the sympathetic nervous system. Genetics may play a role in an individual’s susceptibility to PTSD. Previous exposure to trauma appears to increase the development of PTSD At risk for self-harm and to others, impaired thought process, poor self-esteem, and self-worth -continuous contact with and support from important people in patient’s lives -Disclosing trauma to loved ones -Identify as a survivor rather than the victim -Use positive emotion and laughter -Help others with the same disorder