NCP Post Traumatic Stress Disorder

DSM-IV

309.81 Posttraumatic stress disorder (specify acute, chronic, or delayed onset)

308.3 Acute stress disorder

An anxiety disorder resulting from exposure to a traumatic event in which the individual has experienced, witnessed, or been confronted with an event or events that involve actual or threatened death/serious injury or a threat to the physical integrity of the self or others. The individual’s response involved intense fear, helplessness, or horror. (A thorough physical examination should be done to rule out neurological organic problems.) Additionally, a newly recognized phenomenon is the development of PTSD-like symptoms in some individuals who have been involved over a long period of time in the treatment of (or living with) clients with PTSD.

ETIOLOGICAL THEORIES

Psychodynamics

The client’s ego has experienced a severe trauma, often perceived as a threat to physical integrity or self-concept. This results in severe anxiety, which is not controlled adequately by the ego and is manifested in symptomatic behavior. Because the ego is vulnerable, the superego may become punitive and cause the individual to assume guilt for traumatic occurrence; the id may assume dominance, resulting in impulsive, uncontrollable behavior.

Biological

(Refer to CP: Generalized Anxiety Disorder.)

Some studies have revealed abnormalities in the storage, release, and elimination of catecholamines affecting function of the brain in the region of the locus coeruleus, amygdala, and hippocampus. Hypersensitivity in the locus coeruleus may lead to “learned helplessness.” The amygdala appears to be the storehouse for memories, while the hippocampus provides narrative coherence and a location in time and space. Hyperactivation in the amygdala may prevent the brain from making coherent sense of its memories resulting in the memories being stored as nightmares, flashbacks, and physical symptoms.

Research is exploring the possibility of a genetic vulnerability including the belief that neurological disturbances in the womb or during childhood may influence the development of PTSD.

Family Dynamics

(Refer to CP: Generalized Anxiety Disorder.)

Types of formal education, family life, and lifestyle are significant forecasters of PTSD. Below average or lack of success in education, negative parenting behaviors, and parental poverty have been identified as predictors for development of PTSD, as well as for peritraumatic dissociation.

Current research also suggests that the effects of severe trauma may last for generations, meaning someone else’s traumatic experience can be internalized by another, intruding into the second individual’s own mental life.

CLIENT ASSESSMENT DATA BASE

Activity/Rest

Sleep disturbances, recurrent intrusive dreams of the event, nightmares, difficulty in falling or staying asleep; hypersomnia (intrusive thoughts, flashbacks, and/or nightmares are the triad symptomatic of PTSD)

Easy fatigability, chronic fatigue

Circulation

Increased heart rate, palpitations; increased blood pressure

Hot/cold spells, excessive perspiration

Ego Integrity

Various degrees of anxiety with symptoms lasting days, weeks, or months (2 days to maximum of 4 weeks occurring within 4 weeks of traumatic event [acute stress disorder]; duration of symptoms less than 3 months [acute PTSD], more than 3 months [chronic PTSD], or onset at least 6 months after traumatic event [delayed])

Difficulty seeking assistance (e.g., medical, legal) or mobilizing personal resources (e.g., telling family members/friends of experience)

Feelings of guilt, helplessness, powerlessness, isolation

Feeling shame for own helplessness; demoralization

Sense of a bleak or foreshortened future (e.g., expects failing relationships, early death)

Neurosensory

Cognitive disruptions, difficulty concentrating and/or completing usual life tasks

Hypervigilence (result of inability to assimilate and integrate experiences)

Excessive fearfulness of objects and/or situations in the environment triggered by reminders or internal cues that resemble or symbolize the events; e.g., startle response to loud noises (someone who experienced combat trauma/bombing), breaking out in a sweat when riding an elevator (for someone who was raped in an elevator)

Persistent recollection (illusions, dissociative flashbacks, hallucinations) or talk of the event, despite attempts to forget; impaired/no recall of an important aspect of the trauma

Poor impulse control with unpredictable explosions of aggressive behavior or acting-out of feelings such as anger, resentment, malice, and ill will (in high dudgeon)

Mental Status: Change in usual behavior (moody, pessimistic, brooding, irritable); loss of self-confidence, depressed affect; feelings seem unreal, business of life no longer matters

Muscular tension, tremulousness, motor restlessness

Pain/Discomfort

Pain/physical discomfort of the injury may be exaggerated beyond expectation in relation to severity of injury

Respiratory

Increased respiratory rate, dyspnea

Safety

Angry outbursts, violent behavior toward environment/other individuals

Suicidal ideation, previous attempts

Sexuality

Loss of desire; avoidance of/dissatisfaction with relationships

Inability to achieve sexual satisfaction/orgasm; impotence

Social Interactions

Avoidance of people/places/activities that arouse recollections of the trauma, decreased responsiveness, psychic numbing, emotional detachment/estrangement from others; inability to trust

Markedly diminished interest/participation in significant activities, including work

Restricted range of affect, absence of emotional responsiveness (e.g., absence of loving feelings)

Teaching/Learning

Occurrence of PTSD often preceded or accompanied by physical illness/harm

Use/abuse of alcohol or other drugs

DIAGNOSTIC STUDIES

(Refer to CPs: Generalized Anxiety Disorder; Pain Disorders/Phobias.)

NURSING PRIORITIES

1. Provide safety for client/others.

2. Assist client to enhance self-esteem and regain sense of control over feelings/actions.

3. Encourage development of assertive, not aggressive, behaviors.

4. Promote understanding that the outcome of the present situation can be significantly affected by own actions.

5. Assist client/family to learn healthy ways to deal with/realistically adapt to changes and events that have occurred.

DISCHARGE GOALS

1. Self-image improved/enhanced.

2. Individual’s feelings/reactions are acknowledged, expressed, and dealt with appropriately.

3. Physical complications treated/minimized.

4. Appropriate changes in lifestyle planned/made.

5. Plan in place to meet needs after discharge.