Exam 2-Care of clients with trauma- and stressor- related disorders and dissociative disorders Flashcards
what makes an event traumatic?
-sudden, unexpected, and extreme
-usually involve physical harm or perceived life threat
-people experience these events as out of their control
-across the lifespan people are vulnerable to the effects of trauma
-family violence, losing a family member, acts of terrorism, and natural disasters are traumatic events
-IT IS NOT OUR DEFINITION OF WHAT IS TRAUMATIC, IT IS THE PATIENT’S RESPONSE TO IT.
trauma
-physical trauma: bodily injury; from an accident, self-inflicted damage, or violence perpetrated by others
-psychological trauma: emotional injury caused by an overwhelmingly stressful event that threatens one’s survival and sense of security
resilience
the capacity to withstand stress and catastrophe. develops overtime, beginning in childhood, and is the culmination of multiple internal and external factors. reduces impact of the risk factors, and enhances an individual’s ability to bounce back or recover from stressful experiences.
-develops in association with positive self concept and self worth, a feeling of being in control of one’s life, and a feeling of power.
4 core components: connection, wellness, healthy thinking, and meaning.
-these can empower a person to withstand and learn from difficult and traumatic experiences.
epidemiology and risk factors
-6.1-9.2% life prevalence of PTSD
-risk factors: prior diagnosis of acute stress disorder, extent, duration, and intensity of trauma involved, environmental factors, high anxiety level, low self-esteem, existing personality difficulties
-women 2x greater than men; median time onset is 4 years for women, 1 year for men
-male triggers: fires, disasters, accidents, assaults, combat mission, being held captive
-female triggers: anxiety, depression, child abuse, sexual or physical abuse, trauma prior to 18
-African American individuals have higher rates of PTSD than white individuals
across the lifespan
-disorders can develop any time throughout the life
-childhood psychological and physical abuse including sexual abuse can lead to a lifelong struggle with trauma and stress related disorder
-in adults, military violence is responsible for a lifelong effects for deployed service members.
-older adults experiencing trauma will have memories of a lifetime of previous traumas and abuse which influence their current experience
three groups of adverse childhood experiences as categorized by CDC-Kaiser ACE study
-abuse: emotional, physical, sexual
-household challenges: violence, substance abuse, mental illness, parent separation or divorce, criminal household member
-neglect: emotional, physical
PTSD diagnostic criteria
-symptoms often develop 3 to 6 months after event
-about 1/3 of those diagnosed will develop chronic symptoms
-symptoms fluctuate in intensity with time, usually worse during periods of stress
-children may react differently than adults-may wet the bed, forget how or not talk, act out scary event during play time, being clingy towards adults.
4 general symptoms for PTSD diagnosis
1- intrusive symptoms: avoiding person, place, object as reminder of traumatic event
2- negative mood or negative thoughts: associated with event
3- hyperarousal: seen with aggressive, reckless, or self-destructive behavior
4- sleep disturbances or hypervigilance: present for at least one month
intrusive symptoms
intrusion: involuntary thoughts, memories, or dreams of traumatic events that cause psychological and sometimes physiological distress. associated with cues that symbolize or resemble to original event.
-terrifying flashbacks and nightmares
-many stimuli are associated with the trauma causing flashbacks and dreams
-consequently, affected individuals avoid these stimuli!!
-dissociative reactions: feeling or acting as if the event is reoccurring
-dysfunctional sleep patterns
dissociative symptoms
disruption in normally occurring linkages among subjective awareness, feelings, thoughts, behavior and memories. making yourself “disappear.”
-the feeling of leaving the body and observing what happens from a distance
-dissociation allows a person to observe the event while experiencing no pain or limited pain and to protect themselves from awareness of the full impact of the traumatic event during traumas
-derealization: feelings of unreality
-depersonalization: the experience itself or the environment as a stranger or unreal
-periods of disengagement from the immediate environment during stress, such as “spacing out”
-alterations in bodily perceptions, out of body experiences
-emotional numbing, amnesia about abuse related memory.
mood and cognition with PTSD
-moods often become more irritable, with episodes of explosive anger, fear, guilt, or shame
-may have difficulty handling experience of positive emotions like happiness or love
-thought process becomes distorted, with exaggerated negative beliefs or expectations about one’s self, others, and the world
-may believe that no one can be trusted or that they are terrible people
hyperarousal
stress system may go on permanent alert! as if the danger might return at any time.
-the traumatized person is hypervigilant for signs of danger, startles easily, reacts irritably to small annoyances, and sleeps poorly
-can be irritable and overreact to others, causing others to avoid the person
sleep disturbances
ONE OF THE MOST COMMONLY REPORTED SYMPTOMS
-typically either insomnia or nightmares
-improvement in sleep quality is associated with reduction of PTSD symptoms
-patients may be easily startled
diagnostic criteria of PTSD for child six years and under
symptoms: recurrent, involuntary, and intrusive distressing memories of the event.
for diagnosis, one of the following must be present for at least 1 month, not related to any physical change caused by mediations or illness:
-avoidance of stimuli or negative conditions/mood associated with traumatic event, irritable behavior and angry outbursts after the event with little or no provocation, clinically significant distress.
trauma informed care
a strengths based framework that is grounded in an understanding of and responsiveness to the impact of trauma… that emphasizes physical, psychological, and emotional safety for both providers and survivors…and that creates opportunities for survivors to rebuild a sense of control and empowerment.
4 E’s model of trauma-informed care
- education: provide training, make screening a common practice, responding to disclosures.
- empathize: effects of trauma on patients’ current behaviors and health, recognize potential barriers to adherence, deliver sensitive responses to abuse disclosures.
- explain: create a safe environment, honestly explain exams, and procedures, answer questions, adjust routines to
- empower: use a patient centered approach, facilitate shared decision-making, goalsetting, positive health choices. use evidence-based treatment planning, connect patients to care and resources.
recovery oriented care for persons with PTSD
-takes time, support, and patience
-early recognition of symptoms and treatment leads to more successful outcomes and less likely to have major complications
-use current guidelines for PTSD: education, brief psychotherapy sessions, acute symptom management
-during acute reaction: no debriefing
-chronic symptoms: trauma-focused therapy, stress management, and medications.
safety issues with PTSD
-INCREASED RISK OF SUICIDE, SUICIDE ATTEMPTS, AGGRESSION, AND SUBSTANCE ABUSE
-assessment includes determining risk of: self injury, aggression toward others, substance abuse, assess need for increased observation, use of safety protocols.
mental health nursing assessment
-assess for and meet initial concerns: physical needs, safety needs (suicide, aggression)
-assess for specific mental health issues: original trauma, specific physical symptoms, emotional/behavioral consequences
-may need several meetings to collect information depending on patient’s ability to discuss traumatic event and avoid traumatization
trauma mental health nursing assessment
-identify original trauma, establishing the nature of the trauma
-duration of PTSD symptoms
-do not dig for details of trauma if patient is unwilling to discuss this
-meaning of trauma is more important than details of what happened
-patient may be seeking help for consequences, not the original trauma
-physical health assessment: acute physical problems, healthy aspects like nutrition, exercise, and self-care, general healthcare practices like sleep, substance use, pain, or other somatic responses
-psychosocial assessment: impact of PTSD on daily life, presence of intrusive thoughts, irritability, negative thoughts, avoidance behaviors, arousal behaviors, depression, shame, and guilt
mental health nursing priorities
safety: risk assessment, recovery planning, addressing areas interfering with coping ability
-create therapeutic connection, trusting relationship! we are not asking why, we are asking open questions or statements allowing the person to share what they want to.
health and wellness goals: guide patient to prioritize goals, introduce small changes at a time
wellness strategies: sleep hygiene, health stress management, exercise
mental health nursing interventions
physical:
-sleep enhancement
-nutrition intervention
-smoking cessation
-daily exercise/yoga
medication interventions: sertraline, paroxetine, prazosin, substance abuse interventions
psychosocial:
-relaxation and stress reduction-daily stress may impact ability of someone to manage PTSD symptoms, and they may notice that symptoms are worse on certain days or circumstances. these should be linked to the person’s current coping skills, which may be positive or negative.
-support groups
-use of trauma informed care
-service and companion dogs
psychoeducation: individualize to patient
pharmacotherapy and prazosin for PTSD
-SSRIs and beta blockers, off label use of prazosin, a peripherally acting anti-adregnergic alpha 1 inhibitor.
indications: mild to moderate HTN, off label use of nightmares
action: blocks post synaptic alpha 1 adrenergic receptors at night, decreasing activation of traumatic memories and autonomic arousal.
SE: dizziness, HA, weakness, drowsiness, blurry vision, decreased BP with first dose, palpitations
route: PO QD, first dose at bedtime
nursing implications for prazosin
-check vitals- BLOOD PRESSURE!!! cannot give if hypotensive (decreases by 30 2 hours after 1st dose!)
-Is and Os
-weight
-similar to patients on anti-HTN medication
-avoid situations that can cause orthostatic hypotension (long standing periods, prolonged or intense exercise, heat exposure)
-assess impact on sleep
psychotherapy and PTSD
-psychodynamic psychotherapy
-CBT= cognitive behavioral therapy
-EMDR= rapid eye movement desensitization and reprocessing
-VRET= virtual reality exposure therapy
-group therapy and family therapy
patient and family teaching
-identify risk factors, specific triggers, cues for re-experiencing trauma
-create safety plan for self-care during stressful times
-create a self-care plan to include exercise, healthy food, sleep schedule, avoid or minimize substance use, reminders of personal strengths.
-community connections!!!!! outpatient follow up and other services
-educate family on altered thinking patterns, including self-defeating mindsets, distorted thoughts about shortcomings and challenges, and possible mistrust of family members.
expected clinical outcomes
-treatment of PTSD may last several years with changing goals
-evaluation will be modified as goals and interventions change
-treatment across the continuum of care: psychoeducation and short-term hospitalization if risk of injury to self or others.
adjustment disorder
-common diagnosis for hospitalized patients
-occurs within three months of the stressor
-experience distress seemingly out of proportion to the severity of the stressor, and may interfere with social functioning
-after situation is resolved, symptoms will subside
acute stress disosrder
-similar to PTSD
-resolves within one month of the traumatic event
-may develop into PTSD if symptoms last longer than one month
reactive attachment disorder
a rare but serious condition in which a child fails to form a healthy attachment to caregivers, usually their mothers, usually before the age of 5.
-challenges: establishing trust, addressing emotional dysregulation, comorbidities (PTSD, depression), behavioral changes, ensuring consistency with care!!!
-provide routine, encourage positive attachments, monitor behavior, promote emotional expression, educate caregivers, support development.
medications for RAD
therapy over meds!! meds used to manage co-occuring symptoms.
-stimulants for overlapping ADHD symptoms: ritalin, concerta, adderall
-SSRIs for anxiety, depression, mood regulation: floxetine, sertraline, escitalopram
-atypical antipsychotics for severe aggression, mood instability, or impulsivity: risperidone, aripiprazole, quetiapine
-mood stabilizers for extreme mood swings or aggression: lithium, valproic acid
dissociative identity disorder
a severe form of mental illness characterized by dysfunction in the integration of cognitive systems related to self, agency, and memory.
-criteria A: disruption of identity characterized by two or more distinct personality states involving discontinuity in sense of self and sense of agency
-criteria B: gaps in memory exceeding normal forgetting
manifestations: new alter takes over and presents itself to the public, the original identity doesn’t feel as much pain to the situation as they would if their identity was presented. dissociating allows person to protect oneself from the full impact of traumatic event.
-sudden switch in personality/affect/voice/opinions/interests
-the feeling of leaving the body
-amnesia about trauma related situations
-emotional numbing
challenging aspects of care and nursing considerations of DID
challenges:
-understanding the disorder
-trust issues
-misdiagnosing the patient
-triggers
nursing considerations:
-safety: high risk of self-harm or suicide, especially during a dissociation
-trauma: may be coping mechanism for patient.
-build trust: difficult due to multiple personalities
-relationships: with themselves and different identities, may provide good foundation and communication with other alters; supportive relationships helps prevent isolation
medications for DID
no specific medication for DID management, but manage symptoms associated with disorder.
-antidepressants: SSRIs, TCAs, MAOIs
-atypical antipsychotics: clozapine, olanzapine, quetiapine, risperidone
