Question

Im having trouble making nursing diagnosis for PTSd , anyone can give idea. My pt is 26 yo had car accident since then shes distressed by the accident, social interaction changed, unable to handle work , she experienced flashback and have phobia against car. She experienced self destructive behavior and experienced sleep dosturbances

Answer 1

Nursing diagnosis :

1.) Intrusion or Re-experiencing - recurrent memories, traumatic nightmares, flashbacks, prolonged distress following traumatic reminders, significant physical symptoms after exposure to stressors

2.) Avoidance distressing trauma-related stressors after the event in at least one way

3.) Persistent negative alterations in cognitions and mood - Inability to recall key features of the event, persistent or negative beliefs, persistent distorted blame, persistent negative emotions, significant lack of interest, feeling of alienation, inability to experience positive emotions

4.) Alterations in arousal and activity - .aggressiveness, self-destructive behavior, hypervigilance, exaggerated startle response, difficulty concentrating, sleep problems

Subjective Data:

Irritability, easily agitated

Difficulty sleeping, nightmares

Lack of interest or pleasure in activities

Feeling emotionally numb

Easily startled or frightened

Mood swings, outbursts of anger

Difficulty communicating with others

Impaired relationships

Loss of memory

Objective Data:

Alcohol or drug use since event

Suicidal or homicidal ideations

Self-mutilation or self-destructive behavior

Nursing Interventions and Rationales

1. Assess vitals and perform nursing assessment.

Rationale : Determine baseline for vitals and assess for underlying or accompanying medical conditions

2. Assess client for suicidal or homicidal ideations

Rationale : To ensure safety of the client and others.

3. Assess anxiety level

Rationale : Determine severity of condition and course of treatment or therapy

4. Establish trust with the client

Rationale : Listen to what the client is saying

5. Behave in a calm manner

Rationale : Especially when a client has a high level of anxiety, establishing trust can help the client calm down and make treatment more effective

6. Provide extra time for care and allow client extra time to respond to questions

Rationale : Clients often have difficulty communicating due to racing thoughts or inability to concentrate. Avoid rushing the client and allow them more time to answer or respond to promote security and instill a sense of value.

7. Encourage client to express emotions in a safe environment

Rationale : Allows the client the freedom to acknowledge their feelings and release any repressed emotions that may be exacerbating their distress. A safe environment should be free from actual or perceived judgement and physical or perceived danger.

8. Encourage client to verbally identify current ineffective coping techniques

Rationale : Helps the client understand their current behaviors that may be preventing effective healing or treatment.

9. Encourage client to write about the traumatic event

Rationale : Allows provider to better understand the nature of the client’s condition and anticipate triggers that may cause symptoms. Also allows client and provider to periodically review evolution of emotions toward the traumatic event

10. Encourage client to keep a journal of stressors and emotional reactions to those stressors

Rationale : Helps client identify triggers that prompt anxiety or symptoms and evaluate the outcomes of those reactions.

11. Teach visualization and relaxation techniques such as deep breathing and imagery

Rationale : Helps client learn to manage anxiety that accompanies flashbacks or environmental stressors and triggers

12. Administer medications appropriately and monitor for side effects or dependance

Rationale : Selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) are antidepressants that have proven to be effective for chronic management of symptoms.

13. Provide calming and reassuring environment safety

Rationale : Clients with PTSD are often fearful. Providing a calm, relaxing environment can help lessen or relieve anxiety and promote a feeling of safety.

14. Facilitate access to community resources using Case Manager or Social Worker

Rationale : Support groups and other community resources such as service animals, etc., can provide support that the client needs to function in their daily lives.