Student Nurses Community

NURSING CARE PLAN Post Trauma

ASSESSMENT

SUBJECTIVE:
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

DIAGNOSIS

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

INFERENCE

Severe trauma

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

PLANNING

INTERVENTIONS

RATIONALE

EVALUATION

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.

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

Listen actively to
the clients details
and rumination
about the
recollection
surrounding the
traumatic event
Encourage the
client to identify
and describe
specific areas
surrounding the
traumatic event
that are most
troubling and that
elicit powerlessness

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)
Talking it out
with a trusted
person helps the

Patient was
able to
verbalize
awareness of
psychologic,
and
psychologic
symptom of
anxiety that
accompany
recollections
of a pasttraumatic
event;
Identify
situation/eve
nt/images
that trigger
recollections
and

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aggression

hippocampal
damage in
people

Inability of the
mind to process
information and
feelings in a
normal way

responses of
past traumatic
experiences

or loss of control (if

part of the clients
treatment plan)

Use learned
adaptive
cognitivebehavioral
therapeutic
strategies to
manage
symptom of
emotional and
physical
reactivity.

Monitor the clients

anxiety level

Verbalize
ability to
control or
manage
symptom of
emotional and
physical
reactivity that
tend to occur
during
recollections
of the
traumatic
event.

Teach the client

adaptive cognitivebehavioral
strategies to
manage symptom
of emotional and
physical reactivity
that accompany
intrusive
recollection such as
deep breathing and
relaxation
exercises, cognitive
therapy and
desensitization
Involve the patient
in decisions about
the clients care and
treatment
Engage the client in
group therapy
sessions with other

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
breathing/relaxatio
n exercise provide
slow, rhythmic,
controlled patterns
that decrease
physical and

accompanyin
g responses
of past
traumatic
experiences;
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.

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clients with PTSD

when the client is
ready for the group
process.
Provide realistic
feedback and praise
whenever the client
attempts to use
learned strategies
to manage anxiety
and reduce posttraumatic stress
response.

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.
Systematic
desensitization
helps the client
gain mstery and
control over the
past traumatic
event by

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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
The group process
provides additional
support and
understanding
through
involvement with
other who may
have similar

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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.