Assessment

Diagnosis

Inference

Planning

Interventions

Rationale

Evaluation

Subjective:

Post trauma
syndrome related
to overwhelming
anxiety secondary
to Personal
assault (rape)

Severe trauma

After 2 weeks of
nursing
interventions, the
patient will be
able to:

Maintain the
clients safety and
integrity during
post trauma
episode, using
appropriate
interventions
according to
facility policy

The nurses
priority is to
protect the client
and others from
injury or harm
during post
trauma episode
since client may
experience
escalating
anxiety,
depression, or
suicidal thoughts.

After 2 weeks
of nursing
interventions,
goal met.

I always recall
that event over
and over again. I
feel out of control
and terrified, as
verbalized by the
patient

Objective:
inability to fall
asleep or
remain asleep,
hypervigilance
exaggerated
startle
response
unpredictable
episodes of
explosive
anger or
aggression

Victim is exposed
to actual or
threatened death
or serious injury

hypothalamicpituitary-adrenal
(HPA) axis
becomes
disrupted
(involved in
normal stress
reactions)

dysfunction of the
HPA system
results in
hippocampal
damage in people

Inability of the

verbalize
awareness of
psychologic,
and
psychologic
symptom of
anxiety that
accompany
recollections of
a pasttraumatic
event
Identify
situation/event
/images that
trigger
recollections
and
accompanying
responses of
past traumatic

Listen actively to
the clients details
and rumination
about the
recollection
surrounding the
traumatic event

Encourage the
client to identify
and describe
specific areas

Active listening
builds trust,
allows the client
to vent, decreases
feelings of
isolation and
guides the nurse
toward significant
problem areas
(guilt, self-blame,
anger)

Patient was
able to
verbalize
awareness of
psychologic,
and
psychologic
symptom of
anxiety that
accompany
recollections of
a pasttraumatic
event; Identify
situation/event/
images that
trigger
recollections
and
accompanying
responses of
past traumatic
experiences;

mind to process
information and
feelings in a
normal way

experiences
Use learned
adaptive
cognitivebehavioral
therapeutic
strategies to
manage
symptom of
emotional and
physical
reactivity.
Verbalize
ability to
control or
manage
symptom of
emotional and
physical
reactivity that
tend to occur
during
recollections of
the traumatic
event.

surrounding the
traumatic event
that are most
troubling and that
elicit
powerlessness or
loss of control (if
part of the clients
treatment plan)

Monitor the
clients anxiety
level

Teach the client

adaptive
cognitivebehavioral
strategies to
manage symptom
of emotional and
physical reactivity
that accompany
intrusive

Talking it out
with a trusted
person helps the
client bring the
details of the
event into the
open during a
safe,
nonthreatening
time. It gives the
client an
opportunity to
gain some
influence over the
traumatic event
and decreases
apprehension
about intrusive
recollection

Establishing the
clients anxiety
level prevents
escalation of
symptom through
early
interventions

Deep

Use certain
strategies to
manage
symptom of
emotional and
physical
reactivity; and
verbalize
ability to
control or
manage
symptom of
emotional and
physical
reactivity that
tend to occur
during
recollections of
the traumatic
event.

recollection such
as deep breathing
and relaxation
exercises,
cognitive therapy
and
desensitization

breathing/relaxati
on exercise
provide slow,
rhythmic,
controlled
patterns that
decrease physical
and emotional
tension, which
reduce the effects
of anxiety and the
threat of painful
recollection.
Cognitive therapy
helps the client
substitute
irrational
thoughts, beliefs,
or images for
more realistic
ones and thus
promotes a
greater
understanding of
the clients actual
role in the
traumatic event,
which may
decrease guilt and
self-blame.

Involve the
patient in
decisions about
the clients care
and treatment

Engage the client

in group therapy
sessions with
other clients with
PTSD when the
client is ready for
the group process

Provide realistic
feedback and
praise whenever
the client

Systematic
desensitization
helps the client
gain mstery and
control over the
past traumatic
event by
progressive
exposures to
situations and
experiences that
resemble the
original event,
which eventually
desensitize the
client and reduces
painful stimuli.

This involvement
helps foster
feelings of
empowerment,
control and
confidence in the
client rather than
feelings of being a
helpless victim of
external effects

attempts to use
learned strategies
to manage
anxiety and
reduce posttraumatic stress
response

The group process

provides
additional support
and
understanding
through
involvement with
other who may
have similar
problems. Also,
seeing the
success of others
gives hope to the
client.

Positive
reinforcement
promotes selfesteem and gives
the client the
confidence to
continue working
on the treatment
plan