Post Trauma Syndrome Nursing Diagnosis and Nursing Care Plan

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Post Trauma Syndrome Nursing Care Plans Diagnosis and Interventions

Post Trauma Syndrome NCLEX Review and Nursing Care Plans

Post-trauma syndrome is a NANDA nursing diagnosis that can be used by nurses to described a mental health condition brought on by watching or experiencing a horrific incident.

A traumatic incident must be experienced in order to be diagnosed with post-trauma syndrome. However, rather than experiencing the incident firsthand, the exposure might also be indirect.

For example, someone who learns of the brutal death of a close relative or friend may get post-trauma syndrome.

It can also happen as a result of recurrent exposure to gruesome details of the trauma, such as police personnel who are exposed to child abuse cases.

People with post-trauma syndrome have powerful, unsettling thoughts and sensations about the traumatic incident that continue long after it has occurred.

They may have flashbacks or dreams about the occurrence, experience despair, dread, or fury, and feel disconnected or estranged from others.

Persons with post-trauma syndrome may avoid circumstances or people that remind them of the traumatic experience, and they may have intense unpleasant reactions to seemingly innocuous things like loud noises or unintentional touches.

Most people who experience traumatic situations have temporary difficulties adjusting and coping, but they normally get better with time and adequate self-care.  It’s crucial to get therapy as soon as post-trauma syndrome symptoms appear in order to lessen symptoms and enhance function.

Symptoms of Post-Trauma Syndrome

Post-Trauma Syndrome symptoms are generally grouped into four categories: intrusive memories, avoidance, negative changes in thinking and mood, and changes in physical and emotional reactions. Symptoms can vary over a period of time or differ from person to person.

  1. Intrusive Memories
    • Unwanted, uncomfortable recollections of the tragic event
    • Re-enacting the terrible incident as if it were happening for the first time or flashbacks.
    • Recurrent nightmares or disturbing dreams regarding the terrible incident
    • Physical reactions to something that reminds of the traumatic experience or severe emotional discomfort
  2. Avoidance
    • Attempting to avoid recalling or discussing the painful incident.
    • Keeping away from locations, events, or people who remind of the horrific event.
  3. Negative Changes in Thinking and Mood
    • Negative feelings against oneself, others, or the world.
    • Uncertainty about the future.
    • Memory issues, such as forgetting critical details about the traumatic incident.
    • Difficulty in maintaining tight relationships.
    • Distancing self from family and friends
    • Lack of enthusiasm for activities.
    • Difficulty in experiencing positive emotions.
  4. Changes in Physical and Emotional Reactions
    • Being easily frightened or startled.
    • Always on the lookout for danger.
    • Self-destructive conduct, such as binge drinking or speeding.
    • Sleeping problems
    • Concentration issues
    • Angry outbursts, irritability, or aggressive behavior
    • Overwhelming guilt or humiliation.

Causes of Post-Trauma Syndrome

Post-trauma syndrome is likely caused by a complicated mix of factors, like most mental health issues:

  • Stressful events, particularly the amount and degree of trauma experienced
  • Family History. Mental health concerns are passed down through the generations, such as anxiety and depression.
  • Temperament. This refers to a personality trait that is inherited.
  • Stress response. This refers to the way the brain controls the chemicals and hormones released by the body in reaction to stress.

Related Factors to Post-Trauma Syndrome

  • Incidents outside the range of common human experiences
  • Physical violence and psychosocial abuse
  • A tragic event involving deaths
  • Epidemics
  • Sudden destruction of a home or community
  •  Having been a prisoner of war or a victim of torture.
  • Wars
  • Rape
  • Natural disasters or man-made
  • Serious accidents.
  • Witnessing mutilations, violent deaths, or other horrors.
  • Serious injury to oneself or loved ones or a threat
  • Industrial or motor vehicles accident
  • Military combat

Complications of Post-Trauma Syndrome

Post-trauma syndrome can affect every aspect of the patient’s life, including employment, relationships, health, and enjoyment of regular activities. It can also increase the risk of developing other mental health issues, such as:

  • Anxiety and depression
  • Drug or alcohol abuse
  • Eating disorders
  • Suicidal ideas and behaviors

Prevention of Post-Trauma Syndrome

Getting help and support as soon as possible might help avoid typical stress reactions from becoming worse and leading to post-trauma syndrome. This may entail reaching out to family and friends for support and advice. It could mean seeing a mental health expert for a short period of therapy. Some people may find it beneficial to seek help from their faith community. Support from other people may also help in preventing unhealthy coping mechanisms, such as misuse of alcohol or drug abuse.

Treatment for Post-Trauma Syndrome

The treatment for post-traumatic stress disorder can help in regaining the patient’s control over life. Psychotherapy is the primary treatment; however, medicines may also be used. Combining these therapies can help in getting better results by:

  • Teaching the patient how to deal with the symptoms.
  • Assisting the patient in thinking more positively about self, others, and the world.
  • Learning coping mechanisms in case symptoms reappear.
  • Treating additional issues that are frequently associated with traumatic events, such as depression, anxiety, or alcohol or drug abuse.
  1. Psychotherapy. Often known as talk therapy, can be utilized to treat post-trauma syndrome in both children and adults. Some of the psychotherapies used to treat post-trauma syndrome include:
    • Cognitive Therapy. This sort of talk therapy assists in recognizing the ways of thinking (cognitive patterns) that are holding the patient locked, such as poor self-perceptions and the possibility of traumatic events reoccurring. Cognitive therapy is frequently used in conjunction with exposure therapy.
    • Exposure Therapy. This behavioral therapy assists the patient in safely confronting both terrifying circumstances and memories so that they can learn to cope properly. Flashbacks and nightmares might both benefit from exposure therapy. Virtual reality programs allow the patient to re-enter the setting in one method.
    • Eye movement desensitization and reprocessing (EMDR). Exposure therapy is combined with a sequence of guided eye movements in EMDR to help the patient process painful memories and modify how the patient reacts to them.
  2. Medications. Post-trauma syndrome can be treated with a variety of drugs, including:
    • Antidepressants. These drugs can help with depression and anxiety symptoms. They can also aid with sleep and attention issues. The selective serotonin reuptake inhibitor (SSRI) drugs have been licensed by the FDA for the treatment of post-trauma syndrome.
    • Anti-anxiety drugs. These medications can help with extreme anxiety and other issues. Because some anti-anxiety drugs have the potential to be abused, they are usually only used for a short period of time.

Nursing Considerations for patients with Post-trauma Syndrome

  • Establish trust with the patient and pay attention to the thoughts and emotions of the patient especially when the patient has a high level of anxiety, as it can assist the patient to relax and make treatment more effective.
  • Allow extra time for care and for the patient to answer queries to build security and instill a sense of value, avoid rushing the patient and give more time to answer or respond.
  • Encourage the patient to communicate feelings in a secure environment as this allows the patient to express their feelings and let go of any repressed emotions that are increasing their distress. Ensure that actual or perceived judgment, as well as real or imagined threats, are absent in a safe environment.
  • Encourage the patient to identify inadequate coping strategies verbally.
  • Educate the patient about relaxation and visualization techniques that includes deep breathing exercises and imagery.
  • Administer the patient’s drugs as directed and monitor the patient for side effects or addiction.
  • Provide the patient with a relaxing and soothing environment as fear is usual among post-trauma syndrome patients. Creating a peaceful, calm environment will help lessen or eliminate anxiety while also providing a sense of security.
  • Provide materials that the patient can manipulate or destroy, such as clay, to assist the patient in employing displacement whenever furious.
  • Discuss with the patient how anger rises after each outburst.
  • Desensitize the patient to traumatic event recollections.
  • Remind the patient that setbacks in the treatment process are not failures, but rather a normal part of the process.
  • Encourage the patient to forgive himself as well as others.
  • Stress to the patient the significance of sticking to the medication regimen.

Post Trauma Syndrome Nursing Diagnosis

Post Trauma Syndrome Nursing Care Plan 1

Anxiety Disorder

Nursing Diagnosis: Post-Trauma Syndrome related to a lack of understanding of symptoms, disease progression, and treatment options secondary to anxiety disorder, as evidenced by the inability to focus, restlessness, discomfort, apprehension, delusions, and unorganized thought process.

Desired Outcomes:

  • The patient will be able to express and discuss dread, worry, and other negative emotions.
  • The patient will be able to learn relaxation techniques that will result in a reduction in anxiety.
  • The patient will exhibit reduced level of anxiety.
  • The patient will get rid of the anxiety episodes.
Post Trauma Syndrome Nursing InterventionsRationale
Maintain a calm, non-threatening behavior while working with the patient.  Anxiety is contagious, and it can be passed from one health care worker to another. In the presence of a calm staff member, the patient develops a sense of security.
Establish and sustain a trusting relationship with the patient by listening to the patient, demonstrating warmth, immediately answering questions, expressing unconditional acceptance, being available, and respecting the patient’s usage of personal spaceBecause the nurse, who is a stranger, may constitute a threat to the very anxious patient, therapeutic skills must be aimed toward putting the patient at ease.  
Stay with the patient at all times and reassure the patient of safety and security when the patient’s anxiety is strong.The safety of the patient is the priority. A patient who is really anxious should not be left alone since the anxiety may worsen.
Place the patient in a calm, low-stimulation place, such as a tiny room or a seclusion area with dim lighting and few people.  External stimuli exacerbate anxious behavior. In comparison to a vast area, which might make the patient feel disoriented and terrified, a smaller or secluded environment improves a sense of security.
Maintain a calm behavior when dealing with the patient.If the nurse is cool and confident in their control or management of the issue, the patient will feel more secure.
Assist the patient with reassurance and comfort.Assists with anxiety relief.  
Assist the patient and/or the SO in understanding that anxiety disorders can be managed.Anxiety disorders can be effectively treated with pharmacological therapy, which may include antidepressants and anxiolytics.
Support the patient’s defense mechanisms initially.    The patient employs defenses in an attempt to resolve an unconscious conflict, and hastily abandoning these defenses may result in heightened anxiety.
Advise the caregiver or the family of the patient to manage their own emotions and level of discomfort.  Anxiety is expressed through interpersonal communication. Being around an anxious patient can make someone feel even more uneasy. Discussion of these emotions might serve as a role model for the patient, demonstrating a different approach to dealing with them.

Post Trauma Syndrome Nursing Care Plan 2

Burn Injury

Nursing Diagnosis: Post-Trauma Syndrome related to the memory of the trauma experienced and fear of physical disfigurement secondary to burn injury as evidenced by verbalization of concern regarding changes in appearance, apprehension, expressions of helplessness, decreased self-assurance, and difficulty sleeping.

Desired Outcomes:

  • The patient will be able to make a conscious effort to express feelings and good coping mechanisms.
  • The patient will show signs of decreased anxiety levels.
  • The patient will be able to demonstrate problem-solving abilities and resource efficiency.
Post Trauma Syndrome Nursing InterventionsRationale
Assess the patient’s mental health status, including mood and emotion, event comprehension, and thought content.    Initially, the patient may utilize denial and repression to restrict and filter potentially overwhelming information. Some individuals have a calm demeanor and alert mental state, indicating a dissociation from reality that serves as a protective mechanism.
Educate the patient about the current situation and the treatment plan, and make sure that explanations and information about care procedures are given frequently.Knowing what to expect minimizes worry and dread, resolve misunderstandings, and encourages cooperation. Many people do not recall information given during that time due to the shock of the original trauma.
Demonstrate a willingness to listen and converse to the patient.  Aids the patient and family in understanding that help is accessible and that the healthcare provider is interested in them.
Include the patient and family in the decision-making process. Allow the patient to express concerns and questions regarding the treatment plan.Reduces feelings of helplessness or hopelessness by increasing a sense of control and cooperation.  
Assess the patient for mentation alterations and the presence of hypervigilance, hallucinations, sleep difficulties, nightmares, agitation, apathy, disorientation, and labile affect, which can all shift from moment to moment.Indices of intense anxiety and delirium in which the patient is fighting for life. Although psychological factors are possible, pathological life-threatening causes must be monitored.  
Maintain a stable and continuous orientation about the patient’s current condition and surroundings.Allows the patient to maintain contact with their surroundings and reality.
Encourage the patient to discuss the burn situation when the patient is ready.  To make sense of a terrible incident, the patient may need to repeat the story over and over again. Clinical depression, psychosis, and post-trauma syndrome can readily result from adjusting to the trauma’s impact, sadness over losses, and disfigurement.
Explain to the patient what happened and allow for questioning and provide truthful responses.  Compassionate words that reflect the truth of the situation can assist the patient and family in accepting that reality and dealing with what has occurred.

Post Trauma Syndrome Nursing Care Plan 3

Perinatal Loss

Nursing Diagnosis: Post-Trauma Syndrome related to the death of the infant secondary to perinatal loss, as evidenced by crying, expression of loneliness, anger, loss, guilt and alteration in sleeping pattern.

Desired Outcomes:

  • The patient will be able to engage in self-care activities of daily living.
  • The patient will be able to understand the impact or effect of the grieving process and seek appropriate assistance.
  • The patient will freely recognize and expresses emotions such as sadness, guilt, and fear.
  • The patient will be able to consider and plan for the future.
Post Trauma Syndrome Nursing InterventionsRationale
Label the patient’s chart, room door, and/or head of the bed.Staff and volunteers at the hospital are notified of the patient’s infant death.
Provide the patient with a private room with regular care provider interaction. Encourage unrestricted visits from family and friends.Comfort comes from a location where family and friends can open up and share their sentiments freely.  
Encourage the patient to express emotions freely. Restrict activities that are harmful to the patient’s or couple’s health such as pulling out IV, or using fists to pound on the abdomen.    Cultural/religious beliefs and expectations influence mourning expression, which can range from stoic quiet to yelling and banging one’s chest/throwing objects, among other things. While expressing grief is beneficial, prolonged stoicism can stifle the grieving process.
Include the patient’s partner in the care planning. Allow time for each partner to be seen separately, and encourage both the patient and the partner to express their concerns.Partnering in planning and decision-making recognizes that the spouse has also lost a child and may require time to express feelings of grief and receive support without having to support the patient or others.
Determine the patient’s level of activity, sleep habits, appetite, and personal hygiene.Because of the grieving process and associated melancholy, these areas may be overlooked. Disrupted sleep habits can lead to exhaustion and an inability to cope with stress. The patient may require assistance in completing physical activities and assurance that it is safe to resume normal activities.
Provide physical care such as bath, back rub, and nourishment, allowing the patient to participate at their own pace.Demonstrates compassion and care, as well as assisting the patient in conserving energy to meet the demands of the grieving process. Self-care participation helps to retain self-esteem and competence.
Review with the patient the role shifts and plans to deal with loss. Note the presence of siblings if necessary.    Most families expect a healthy pregnancy and a favorable outcome and are unprepared to think about funeral arrangements, what to do with the nursery, how to go on with their lives, and how to care for the other children.
Assist the patient with getting requests and signatures for autopsy procedures, if the patient requires them.Families may demand or require a cause of death explanation, which may or may not be attainable.
Refer the patient for counseling or psychiatric treatment if necessary.      Older women and those who have had longer-term pregnancies may experience a severe mourning response. Carrying the fetus for 1 or more days after death also raises the risk. In cases of pathological mourning, continuing counseling may be required to assist the individual in identifying potential causes of the abnormal reaction and resolving the grieving process.

Post Trauma Syndrome Nursing Care Plan 4

Sexual Assault

Nursing Diagnosis: Post-Trauma Syndrome related to forceful and non-consensual intercourse secondary to sexual assault, as evidenced by feelings of revenge, humiliation, embarrassment, loss of self-esteem, sleep disturbances, and phobia.

Desired Outcomes:

  • The patient will feel positive and confident in the ability to carry out life ambitions.
  • The patient will be able to resolve negative feelings such as anger, guilt, fear, depression, and low self-esteem.
  • The patient will begin to articulate their reactions and feelings regarding the incident, before leaving the emergency room or crisis center.
  • The patient will understand the need for follow-up crisis counseling and other services.
Post Trauma Syndrome Nursing InterventionsRationale
Establish rapport and trust with the patient.      The nurse should refrain from asking inquiries until the therapeutic nature has been established, since the victim may take any words unrelated to the immediate circumstances as blaming or rejecting.
Maintain the patient’s privacy.  Unless the patient consents, the patient’s circumstances will not be discussed with anybody other than the medical personnel involved.
Approach the patient without being judgmental.  The attitudes of nurses can have a significant therapeutic impact. Shock, horror, contempt, or disbelief are not appropriate reactions.
Advice the family to stay with the patient while the patient is waiting to be treated.  People with high levels of anxiety require physical safety, which can be provided by having someone by their side until their anxiety levels are reduced to a moderate level.
Reduce the patient’s guilt and maintain self-esteem by reinforcing that what has been done to stay alive is meant to be done.Victims of rape may experience feelings of remorse and shame. Reminding them that they did what they needed to keep alive can help them feel less guilty and maintain their self-esteem.
Encourage the patient to share thoughts.People feel more in control of their situations when they are understood.

Post Trauma Syndrome Nursing Care Plan 5

            Child Abuse

Nursing Diagnosis: Post-Trauma Syndrome related to physical injury secondary to child abuse, as evidenced by bruises, social isolation, low self-esteem, and violence towards other people.

Desired Outcome: The patient will not experience abuse or maltreatment from parents and caregiver.

Post Trauma Syndrome Nursing InterventionsRationale
Assess the parent’s conduct toward their children, including how to respond to the child’s behavior, the ability to soothe the child, the sentiments and perceptions about the child, the expectations for the child, and whether they are overprotective or concerned about the child.Characteristics that may suggest a danger of abuse are revealed.
Provide written instructions for care and the kid’s requirements to people on the abuse team or to new caretakers if the child is being placed with a foster parent or someone other than his or her parents.  Provides a care plan for the child based on the court’s ruling to caretakers working with the family for the patient’s care. Teach parents how to recognize the events that lead to child abuse and how to cope with the situation without damaging the child.  
Assess parents’ behavior toward their children, including how they respond to the child’s behavior, the ability to soothe the child, and their sentiments and perceptions about the child.Proper nursing assessment and interview of the parents or guardian may provide strong evidence or signs of child abuse.  
Provide written instructions for care and the kid’s requirements to people on the abuse team or to new caretakers if the child is being placed with a foster parent or someone other than the parents.Provides a care plan for the child based on the court’s ruling to caretakers working with the family for the child’s care.  
Educate the parents on how to recognize the events that lead to child abuse and how to cope with the situation without damaging the child.Prevents the patient from being subjected to additional abuse.

Nursing References

Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier.  Buy on Amazon

Nursing Stat Facts
Nursing Stat Facts

Gulanick, M., & Myers, J. L. (2022). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon

Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2020). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier.  Buy on Amazon

Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier.  Buy on Amazon

Disclaimer:

Please follow your facilities guidelines, policies, and procedures.

The medical information on this site is provided as an information resource only and is not to be used or relied on for any diagnostic or treatment purposes.

This information is intended to be nursing education and should not be used as a substitute for professional diagnosis and treatment.

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