NUSING CARE PLAN:

ANXIETY
(POST-STRESS TRAUMA SYNDROME)

PREPARED BY: BSN-II

OCUBILLO,FRANCISE ELYN B.

ASSESSMENT DIAGNOSIS SCIENTIFIC BASE PLANNING IMPLEMENTATION RATIONALE EVALUATIO

N
SUBJECTIVE : Post-Trauma Rape and other forms of After 8 hours 1. Assess degree of - Identifies needs for After 8 hours
“ PERMENTE KO syndrome r/t sexual assault have of nurse- anxiety/fear developing plan of of nurse-client
MAKAHINUMDOM overwhelming broad-reaching effects on client present, behaviour’s interaction the
ATO NA anxiety many levels, including interaction associated care/interventions. patient is able
PANGHITABOA, NYA secondary to basic needs, functional the patient behaviour’s, and Clearly to Use learned
DLI NKO sexual assault . impairment, physical will be able reality of threat understanding adaptive
MAPUGNAGN NA health, and mental health. to Use perceived by client’s cognitive
MAHADLOK UG Although chronic learned client. perception is pivotal behavIoral
MANGUROG.” psychopathology does not adaptive to providing therapeutic
As verbalized by the develop in most rape or cognitive appropriate strategies to
client. sexual assault victims, behavIoral assistance in manage
these forms of traumatic therapeutic overcoming the fear. symptoms of
victimization are strategies to - Retelling the physical and
OBJECTIVE: associated with a higher manage 2. Encourage the experience can help emotional
- inability to fall prevalence of PTSD than symptoms of client to talk the client to identify reactivity.
asleep or remain are other types of physical and about his or her the reality of what
asleep traumatic events. emotional experience(s); be has happened and
 reactivity. accepting and help to identify and
- hypervigilance (www.psychiatrictimes non-judgemental work through related
 .com/ptsd/rape-related- of the client’s feelings.
- exaggerated startle ptsd-issues-and- accounts and
response interventions) perception.
 3. Teach the client - deep breathing
- unpredictable adaptive /relaxation exercise
episodes of explosive cognitive provide slow"
anger behavioral rhythmic" controlled
strategies to patterns that decrease
manage physical and
symptoms of emotional tension"
emotional and which reduce the
physical effects of anxiety and
reactivity that the threat of painful
accompany recollection.
intrusive
recollection such
as deep
breathing and
relaxation
exercises
cognitive
therapy and
desensitization.
- active listening
4. listen actively to builds trust allows
the client’s the client to vent
 details and decreases feelings of
rumiination isolation and guides
about the the nurse toward
recollection significant problem
sorrounding the areas (guilt, self-
traumaatic event. blame and anger).
- This involvement
helps foster feelings
5. involve the of empowerment
patient in control and
decisions about confidence in the
the client’s care client rather than
and treatment. feelings of being a
helpless victim of
external effects.

- Positive
6. Provide realistic reinforcement
feedback and promotes self-esteem
praise whenever and gives the client
the client the confidence to
attempts to use continue working on
learned the treatment plan.
strategies to
manage anxiety
and reduce post-
traumatic stress
response.

7. Engage the - The group process

client in group provides additional
therapy sessions support and
with other understanding
clients with through involvement
PTSD when the with other who may
client Is ready have similar
for the group problems. Also,
process. seeing the success of
others gives hope to
the client.