0133427269 Module31 StressandCoping LectureOutline

Module 31 Stress and Coping The Concept of Stress and Coping Stress and Homeostasis Stressor ( an external influence that threatens to disrupt the equilibrium that is needed to maintain homeostasis Homeostasis ( state of dynamic balance of the bodys internal environment Stress ( bodys reaction to any stimulus in the environment that demands change or disrupts homeostasis Hans Selye Eustress ( good stress associated with accomplishment and victory Distress ( stress associated with inadequacy, insecurity, and loss Allostasis ( necessary changes that must be made to achieve homeostasis Homeostasis is the goal allostasis is the means to reach the goal Fight-or-flight response triggered by sympathetic nervous system Stress response ( physiological changes triggered by stress Stress mediators ( hormonal reactions intended to promote adaptation Allostatic load ( the physical cost of adaptation to physiological or psychosocial stressors Coping ( the dynamic process through which an individual applies cognitive and behavioral measures to handle internal and external demands that are perceived as exceeding available resources Stressors and the coping process Types of stressors Biogenic stressors ( directly trigger the stress response without any cognitive process on the part of the individual Psychosocial stressors ( environmental events, either real or imagined, that facilitate activation of stress response Stressors ( four categories Acute and time limited Sequential events following an initial stressor Chronic intermittent Chronic permanent See Table 311 CLASSIFICATIONS AND EXAMPLES OF STRESSORS, p. 1897 Developmental stressors Challenges faced by individuals as they progress through the life span Examples transition from childhood to adolescence Internal stressors Internal environment ( physical, spiritual, cognitive, emotional, and psychological well-being of an individual Hassles ( day-to-day tension Environmental stressors External stressors ( triggers outside of the individual that demand change or disrupt homeostasis See Table 31-2 FACTORS AFFECTING AN INDIVIDUALS STRESS RESPONSE The coping process Cognitive appraisalindividuals evaluation of perceived threat Primary appraisalindividual assesses the threat Secondary appraisalindividual assesses his/her coping resources, options Coping responseapplies coping resources and options Reappraisalindividual continually reinterprets situation Maslows hierarchy of basic human needs Hierarchy to explain how human beings prioritize need What needs must be met for self-actualization ( peak capacity for fulfilling potential Basic needsphysiological Meta-needsgrowth-related See Figure 311 MASLOWS HIERARCHY OF NEEDS, p. 1899 Effective coping ( a learned process Problem-focused coping ( managing/altering stressor or event Emotion-focused coping ( regulating emotional response Avoidance-coping ( using behaviors and cognitive processes Approach-coping ( taking direct action by confrontation Meaning-focused coping ( reevaluation to reduce the appraisal See Table 313 EXAMPLES OF TYPES OF COPING, p. 1900 Reappraisal and adaptation Coping mechanisms successful ( adaptation Coping mechanisms unsuccessful ( another response to stressor Theoretical models of stress and coping Stimulus-based stress models Stress defined as a stimulus, life event, or set of circumstances that arouses physiological and/or psychological reactions Exposure to such life events leads to wear and tear Holmes-Rahe SRRS scale numerically rates stress Degree of stress varies for each individual Response-based stress models Stress is considered a response to a stressor General adaptation syndrome ( three-stage chain of events Alarm reactioninitial reaction Stage of resistancebody begins to initiate adaptive responses Stage of exhaustionstressor(s) overwhelm bodys ability to cope See Figure 312 THE THREE STAGES OF ADAPTATION TO STRESS, p. 1900 Local adaptation syndrome (stress response manifested locally Transactional model Accounts for individual differences in perceptions of/responses to stress Primary appraisal Secondary appraisal Coping Reappraisal Nursing transactional model Relationship between nurse, client, and environment See Figure 313 THE NURSING TRANSACTIONAL MODEL, p. 1902 Communication emphasized Hildegard Peplaumother of psychiatric nursing Manifestations of stress Physiological indicators of stress Result from stimulation of the sympathetic and neuroendocrine systems See Table 31-4 OVERVIEW OF PHYSIOLOGICAL MANIFESTATIONS OF THE STRESS RESPONSE, p. 1903 See MULTISYSTEM EFFECTS OF STRESS, p. 1903 Psychoemotional indicators of stress Fear ( emotion or feeling of apprehension aroused by impending perceived threat Anxiety ( state of mental uneasiness, apprehension, dread, or feeling of hopelessness Anger (emotional state with subjective feelings of strong displeasure Depression( extreme feelings of sadness, despair, lack of worth Cognitive indicators of stress Problem solving ( thinking through the threatening situation Cognitive structuring ( arranging/manipulating situation so that threatening events do not occur Self-control ( assuming a manner that conveys sense of control Suppression ( consciously putting a thought/feeling out of mind Fantasizing ( threatening situation reworked so no longer threatening Ego defense mechanisms Unconscious psychological adaptive mechanism Essential to psychological survival See Table 316 EGO DEFENSE MECHANISMS, p. 1905 Integrating the concepts ( see CONCEPTS RELATED TO STRESS AND COPING, p. 1906 Alterations from normal coping responses DSM-5 recognizes three classifications of disorders of impairments in stress and coping Anxiety disorders Obsessive-compulsive and related disorders Trauma- and stress-related disorders See ALTERATIONS AND THERAPIES Stress and Coping, p. 1908 Children and anxiety Early stages of development, some degree of anxiety is normal Toddlers become more adept at distinguishing between dangerous and nondangerous situations, and fears begin to abate Anxiety disorders are the result of anxiety and fear that persist beyond the expected age of resolution and endure for 6 months or more Prevalence Anxiety disorders are most common mental health disorders in U.S. ( affects approximately 40 million adults Generalized anxiety disorder affects 6.8 million adults, twice as many women as men OCD affects 2.2 million adults Phobias affect 19 million PTSD affects 7.7 million Genetic considerations and nonmodifiable risk factors Gender is significant risk factor Anxiety disorders more common in women Men are twice as likely to develop a phobia OCD is equally common among men and women Life experiences trigger PTSD Case Study Part 1 ( Kevin DeLarno is a 23-year-old student who is completing his second year of graduate school , p. 1910 Prevention Factors that influence development of anxiety disorders include personality-related characteristics Traumatic events increase risk of impairment Family wellness promotion is essential to enhancing physiology and psychosocial outcomes for clients of all ages Screenings Screening tests are available to identify many disorders of anxiety, stress, trauma Assessment Nursing history and assessment interview Illnesses, physical complaints, health history, stressors, coping strategies See Box 313 STRESS ASSESSMENT CHECKLIST, p. 1912 Physical examination and observation Clinical signs/symptoms may not occur when cognitive coping is effective Laboratory tests not routinely performed, may be necessary to rule out Increased adrenal function Elevated levels of glucose and lactic acid Decreased parathyroid function and oxygen and calcium levels Lifespan and cultural considerations Children ( psychosocial assessment should be age appropriate and developmentally specific Older adults ( recognizing alterations can be complicated by pre-existing physical illness or cognitive changes Different cultures ( nurses must take care not to inadvertently attribute a normal. Healthy cultural response as inappropriate or maladaptive Cultural formation interview from DMS-5 can be used to help with assessment Diagnostic tests Diagnostic criteria collected primarily through interview and reports of subjective symptoms Medical testing is used to rule out underlying causes Case Study Part 2 ( Mr. DeLarno is awaiting evaluation by the university healthcare clinics nurse practitioner, p. 1913 Interventions and therapies Independent Encourage client to maintain or achieve optimal health See Table 31-7 WELLNESS PROMOTION FOR CLIENT WITH STRESS-RELATED DISORDERS Utilize therapeutic communication Implement cognitive-behavioral interventions Advocate for clients Collaborative Psychotherapy ( preferred method of treatment for anxiety disorders Cognitive-behavioral therapy (CBT) Focuses on role of clients thoughts/attitudes, effect on feelings/behaviors Aimed at reappraisal process Additional CBT techniques ( see Box 31-4 Pharmacologic therapy ( goal is to manage symptoms and alleviate distress See MEDICATIONS Disorders of Anxiety, Stress, or Trauma, p. 1916 Review The Concept of Stress and Coping Relate Link the Concepts Ready Go to Companion Skills Manual Refer Go to Nursing Student Resources Reflect Case Study Part 3 (Following Mr. DeLarnos assertion that he cannot stay here all day and this prompting for rapid treatment, , p. 1917 Exemplar 31.1 Anxiety Disorders Overview Anxietystress response Feelings of mental uneasiness, apprehension, dread, or foreboding Feeling of helplessness Feeling of dread accompanied by physical reactions Elevated pulse Elevated respirations Elevated blood pressure Can be experienced internally or externally Pathophysiology and etiology Affects individuals of all ages Can be predominant disturbance (generalized anxiety disorder) Can be experienced as a defense mechanism Free-floating anxiety ( anxiety that is not related to a specific stimulus Anxiety disorders in this exemplar ( GAD, separation anxiety, panic disorder Etiology Neurobiological theories Dysregulation of neurotransmitters Serotonin Norepinephrine Gamma-aminobutyric acid (GABA) See Figure 314 THE LIMBIC SYSTEM, p. 1918 Neurochemical theories Communication within the brain GABA Norepinephrine See Figure 315 NEUROTRANSMISSION..., p. 1919 See Figure 316 LIGANDS, p. 1919 Psychosocial theories Anxiety occurs when ego attempts to deal with conflict/tension Behavioral theories Anxiety related to faulty or distorted thinking Learned dysfunctional response to stressors Genetic theories Genetic predisposition may play a part in development of anxiety disorders Panic disorder and OCD feature a genetic factor Humanistic theories Essential to a useful understanding of the ways in which this conditions come about Biological, psychological, behavioral, and genetic causes interact with one another Risk factors Childhood adversity Family incidence Social factors Serious or chronic illness Multiple stressors Children Reported more frequently in girls Older adults Cognitive impairment One or more chronic physical impairments Significant emotional loss See FOCUS ON DIVERSITY AND CULTURE Anxiety Disorders in Immigrant Populations, p. 1920 Prevention Dependent on an individuals knowledge of her own growing anxiety Individuals at risk should seek medical help early Clinical manifestations See CLINICAL MANIFESTATIONS AND THERAPIES Anxiety Disorders, p. 1923 See Table 318 SUMMARY OF CRITERIA FOR ANXIETY DISORDERS, p. 1921 Generalized anxiety disorder (GAD) See Box 31-5 DSM-5 DIAGNOSTIC CRITERIA FOR GAD, p. 1922 Pervasive apprehension and worry Children and GAD Restlessness Excessive fatigue Poor concentration Irritability Separation anxiety disorder Most common type of anxiety disorder manifested by children Extreme state of uneasiness when in unfamiliar surroundings Refusal to visit friends house or attend school for at least 2 weeks Diagnosis made by mental health specialist See LIFESPAN CONSIDERATIONS Separation Anxiety Disorder, p. 1922 Panic disorder Recurrent attacks of severe anxiety lasting a few moments to an hour Typically not associated with a stimulus Occur suddenly and spontaneously Nocturnal panic disorder Client awakens within 14 hours after falling asleep May be related to sleep apnea Children and panic disorder Predictive factors in adolescence history of separation anxiety disorder, history of parental panic attacks Levels of anxiety Levels range from mild to panic The level of anxiety impacts nursing care Immediate interventions ( reducing exposure to stimuli, providing comfort measures to assist in reducing symptom severity Collaboration Treatment more likely to occur in home and community Includes the individual and his/her family Diagnostic tests Diagnosis based on observation and history X-ray diffraction to visualize pocket of the transporter that binds to the neurotransmitter Diagnostic tests Complete medical history Physical examination No laboratory tests currently Client may be referred to a mental health specialist Pharmacologic therapy Antianxiety medication used cautiously and sparingly Benzodiazepines effective for periods of 48 weeks Selective serotonin reuptake inhibitors (SSRIs) medications of choice for anxiety disorders Some antipsychotic medications may trigger anxiety disorders Nonpharmacologic therapy Cognitive behavior therapy Teach client to develop internal locus of control Locus of controlextent client believes that he or she has influence over life Thought blockingstop train of thoughts that lead to increasing fear/anxiety Encourage meditation Develop goal-oriented contracts Help clients test reality Children and group therapy Allows child freedom to explore feelings and behaviors Complementary and alternative therapies Herbs Chamomile Kava Contraindicated with St. Johns wort and SSIs Lavender Massage and therapeutic touch Relaxation techniques, yoga, meditation Nursing process Assessment Health history Physical exam Diagnosis Anxiety Disturbed Sleep Pattern Impaired Social Interaction Fear Risk for Ineffective Self-Health Management Ineffective Coping Planning Client will report a decrease in level of and frequency of anxiety Client will articulate successful coping mechanisms Client will report increasing use of successful coping mechanisms Client will participate in psychotherapy Implementation Mild anxietyfocus on appraisal Critically evaluate thoughts that may be increasing clients anxiety Moderate anxietycognitive reframing Severe anxiety/panicimmediate intervention Isolate client to avoid distressing others Provide a safe, quiet environment Do not leave unattended Encourage health promotion strategies Exercise Nutrition Sleep Time management Evaluation Client anxiety diminishes Client demonstrates new or improved coping measures Client self-moderates anxiety Review Anxiety Disorders Relate Link the Concept and Exemplars Ready Go to Companion Skills Manual Refer Go to Nursing Student Resources Reflect Case Study Exemplar 31.2 Crisis Overview Crisis ( when an event or circumstance overwhelms the individuals ability to manage, resolve, or process the event Any acute incident Most critical interventions begin with question What do you need from me right now Pathophysiology and etiology Experience of crisis is an individual event See Box 316 CHARACTERISTICS OF CRISIS, p. 1928 Three possible resolutions Adapt to crisis and return to previous level of functioning Utilize the opportunity to improve as an individual Deteriorate to a lower level of functioning Crisis theory Individuals perception of the crisis, resources, support, and ego strength all affect his/her capacity to return to prior levels of functioning Two types of crisis Situationalunexpected stressor, circumstance that occurs in course of daily living Maturational crisisnormal occurrence through the life cycle Resilience Resilience ( ability to continue to grow and develop emotionally and psychologically Risk factors (nature of trauma or experience Three balancing factors important to successful resolution Perception of the event, realistic or unrealistic Situational supports, social support, meaningful relationships Coping mechanisms, obvious, or subtle Bandura ( self-efficacy is shaped by Mastery experiences Vicarious experiences Social persuasion Somatic and emotional states Clinical manifestations Individuals in crisis need immediate assistance and support See CLINICAL MANIFESTATIONS AND THERAPIES Crisis, p. 1929 Nurse is active participant in intervention process Lifespan and cultural considerations Response to trauma varies across life span and among cultures Very young children ( unable to identify specific emotions changes in behavior signify a crisis response Children of all ages should be encouraged to verbalize their feelings and thoughts Older clients ( may be resistant to expressing feelings and emotions Cultural factors can present barriers to expression of emotions Collaboration Diagnostic tests Client interview and physical assessment provide most valuable data Tools are available for use in evaluating impact of crisis event Horowitz Impact of Events Scale (IES) Crisis counseling focused on brief solution, focused interventions, and supportive care Pharmacologic therapy Addresses immediate medical needs Pain following injury Threat of infection following injury or exposure to a bacterial infection Sleep disturbances Anxiety or depression Nonpharmacologic therapy Therapeutic communication Frequent, brief, simple communication Remember primary appraisal Continual observation of communication patterns Cognizant of nonverbal communication Establish a therapeutic relationship See Box 317 COMMUNICATING PAINFUL INFORMATION, p. 1930 Crisis counseling Focused on brief solutions, focused interventions, and supportive care See ABCs OF CRISIS COUNSELING, p. 1931 Crisis intervention Short-term helping process of assisting clients to work through a crisis to its resolution and restore their pre-crisis level of functioning Includes various members of the clients support network Nursing process steps correspond closely to steps of crisis intervention Crisis counseling focuses on solving immediate problems See Box 319 CRISIS CONNECTION, p. 1931 Temporary relocation Clients in crisis, particularly the homeless and those being abused, may require assistance with finding shelter Alternative therapy Meditation and prayer evoke relaxation response Nursing process Assessment Individual assessment Clients resilience Clients coping style Precipitating event Situational supports Clients perception of the crisis Any guilt a disaster survivor may feel Clients ability to handle the problem Scaling assessment questions Rate the severity of symptoms or problems Family assessment Trauma reverberates through an entire family Meet with as many family members as possible Community assessment Nurses may be among first civilians called on to offer assistance in disasters After triage and treatment of clients in need, top priorities include assessment of living conditions and availability of basic resources Diagnosis Risk for Injury Ineffective Coping Risk for Self-Harm Anxiety Impaired Social Interaction Social Isolation Post-trauma Syndrome Social Isolation Planning Client will remain free from injury or self-harm Client will be able to identify effective and ineffective coping patterns Client will be able to employ effective coping strategies Client will ask for help when necessary Client will use available social support Client will report an increase in psychological comfort and a decrease in negative feelings Implementation Communication strategies Use silence Use nonverbal communication Paraphrase Reflect feelings Allow the expression of emotions See Box 3110 SOME DOS AND DONTS OF CRISIS COMMUNICATION, p. 1933 Assist with environmental changes See Box 318 ABCs OF CRISIS COUNSELING, p. 1931 Anticipatory guidanceproviding assistance in anticipation of the potential for crisis Helping to develop social supports Immediate and tangible social support is crucial Evaluation Client remains free from injury or self-harm Client will verbalize awareness of effective coping strategies Client will identify and utilize his social support network Client will report a reduction in perceived anxiety Review Crisis Relate Link the Concepts and Exemplars Ready Go to Companion Skills Manual Refer Go to Nursing Student Resources Reflect Case Study Exemplar 31.3 Obsessive-Compulsive Disorder (OCD) Overview Obsessive-compulsive disorder (OCD) ( disabling anxiety disorder obsessive thoughts and compulsive, repetitive behaviors that dominate ones life Obsessionrecurrent, unwanted, often distressing thought or image that leads to feelings of fear and anxiety Compulsionrepetitive behavior or mental ability used in response to obsessive thoughts to decrease anxiety Must lose more than 1 hour/day to compulsions to have diagnosis of OCD Pathophysiology and etiology Etiology Genetic linkage strongly supported Dysregulation of serotonin Streptococcal infection may be a cause 2.2 million Americans have OCD Typically begins in adolescence/early adulthood Men develop disorder earlier Risk factors Family history Major life stressor See LIFESPAN CONSIDERATIONS OCD in Childhood and Adolescence, p. 1935 Clinical manifestations OCD not to be confused with obsessive-compulsive personality disorder Personality disorder more preoccupied with perfection characterized by inflexibility Most frequently reported obsessions Repeated thoughts about contamination Repeated doubts with fear of having hurt someone or leaving door unlocked Need to have things in a certain order See Table 31-9 EXAMPLES OF COMMONLY OCCURRING OBESSIONS AND COMPULSIONS, p. 1936 Most frequently reported compulsions Hand washing Order, checking, and locking Mental activity such as praying, counting, and repeating words silently Requesting or demanding assurances 90 of women with OCD are compulsive cleaners Ritualistic behaviorrepeating activities Hoarding compulsionsacquisition of/inability to discard worthless items Occurs in 1020 of individuals with OCD See CLINICAL MANIFESTATIONS AND THERAPIES Obsessive-Compulsive Disorder, p. 1936 Collaboration Important to coordinate care with health providers, clinical, community/social agencies Diagnostic tests No definitive laboratory findings for diagnosis Pharmacologic therapy First-line pharmacological agents SSRIs TCAs may also be administered Nonpharmacologic therapy Psychotherapy therapy effective May include family members or significant others See Box 3111 GUIDELINE SUMMARY FOR THE TREATMENT OF INDIVIDUALS WITH OCD, p. 1937 Nursing process Assessment Thorough physical assessment See ASSESSMENT INTERVIEW Obsessive-Compulsive Disorder, p. 1938 Diagnosis Anxiety Fear Ineffective Coping Stress Overload Disturbed Sleep Pattern Insomnia Fatigue Deficient Knowledge Risk for Caregiver Role Strain Planning Assist client in identifying triggers for obsessive-compulsive behaviors Promote quiet, restful environment Encourage client to identify strengths Reassure client that continued behaviors not indication of treatment failure Implementation Supportive/nonjudgmental demeanor See CLIENT TEACHING Adaptive Coping, p. 1938 Evaluation Client reports reduction in performance of ritualistic compulsive behaviors Client demonstrates adequate coping skills to control anxiety Review OCD Relate Link the Concepts and Exemplars Ready Go to Companion Skills Manual Refer Go to Nursing Student Resources Reflect Case Study Exemplar 31.4 Phobias Overview Phobia ( intense, persistent, irrational fear of a simple thing or social situation Client with phobic disorder will experience severe panic upon contact with stressor Defensive mechanismdisplacement Pathophysiology and etiology Complex neurochemical/neuroendocrine systems linked with dysregulation of Norepinephrine Serotonin (5-HT) Gamma-aminobutyric acid (GABA) Etiology Twice as common in women Onset usually in childhood or adolescence Risk factors Age Typically develops between 11 and 15 Almost never develops after age 25 Gender ( female Family ( more likely if immediate family members has phobia External locus of control Locus of control ( extent one believes one has control over life events Internal locus of control ( ones actions, choices, behaviors affect life events External locus of control ( powers outside of ones self determine life events Predisposing factors Traumatic events Unexpected panic attacks in the feared situation Observing other in the feared situation Seeing others demonstrate fear in the situation Informational transmission Clinical manifestations Three general categories of phobias Agoraphobia Social anxiety disorder Specific phobias See CLINICAL MANIFESTATIONS AND THERAPIES Phobias, p. 1941 Agoraphobia Anxiety about being in places/situations where escape may be difficult or embarrassing Typically include situations that involve being alone away from home, in a crowd Commonly associated with panic disorder Social anxiety disorder Marked/persistent fear of social or performance situations in which embarrassment may occur Diagnosed only if fear or anxiety significantly interferes with daily life Physical symptoms may occur Blushing Excessive sweating Nausea GI distress Specific phobias Excessive fear of a specific object or situation Collaboration May include advanced practice mental health nurses, counselors, therapists, psychologists, exercise physiologists, dietitians, yoga instructors, massage therapists, and support groups Pharmacologic therapy Benzodiazepines Short-term use only SSRIs Some antipsychotics Pharmacologic therapies not as effective if not used with cognitive-behavioral therapy Nonpharmacologic therapy Cognitive-behavioral therapy ( high degree of success See Table 3111 APPLICATION OF COGNITIVE-BEHAVIORAL TECHNIQUES IN THE TREATMENT OF CLIENTS WITH PHOBIAS, p. 1942 Nursing process Assessment Health history Attempts client has made to moderate anxiety Explore possibility of comorbidity of depression and/or substance abuse See ASSESSMENT INTERVIEW Phobias, p. 1942 Physical examination Include assessment for symptoms related to substance abuse Diagnosis Anxiety Fear Ineffective Health Maintenance Deficient Knowledge Ineffective Coping Planning Client will report a decrease in the frequency and severity of phobic episodes Client will verbalize healthy ways of responding to fear Client will demonstrate relaxation techniques Client will participate in the therapeutic regimen Implementation Panic phobias and severe anxiety must be treated immediately Ensure safety Validate concerns and fears One-to-one supervision Provides assurance to the client that s/he is in no danger Structure and direction for the client Informing the client about the next step in the treatment process Antianxiety medications as prescribed Assist client to rethink/reframe the ability to manage the anxiety Assist client to reappraise the level of the threat as less damaging Teaching client relaxation techniques See CLIENT TEACHING Deep Breathing and Progressive Relaxation, p. 1943 Assist client to gain insight into his or her reactions Evaluation Largely based on clients desire to overcome phobia and willingness to follow treatment regimen Review Phobias Relate Link the Concepts and Exemplars Ready Go to Companion Skills Manual Refer Go to Nursing Student Resources Reflect Case Study Exemplar 31.5 Posttraumatic Stress Disorder Overview Posttraumatic stress disorder (PTSD) ( trauma- or stressor-related disorder that evolves after exposure to traumatic/overwhelming event in which ones physical health endangered This class of disorders also includes Reactive attachment disorder Disinhibited social engagement disorder Acute stress disorder ( see Box 31-12 OVERVIEW OF ACUTE STRESS DISORDER, p. 1946 Adjustment disorders Pathophysiology and etiology PTSD more likely to occur, be longer lasting when stressor is of intentional human action Flashbacksrecurrence of images, sounds, smells, or feelings Often triggered by daily events Diagnosed PTSD if symptoms last longer than a month Usually occurs within 3 months of the traumatic event Etiology Exposure to overwhelming stressors can occur at any time or any age Childhood trauma, abuse, or molestation can create enduring effects 3.5 million have PTSD in U.S. Approximately half of affected individuals experience complete resolution of symptoms within 3 months Risk factors Severity of event itself Includes whether or not individual harmed/watched others be harmed Little or no social or psychological support following trauma Additional stressors immediately following event Presence of preexisting mental illness Clinical manifestations May lose touch with reality during flashbacks Depersonalizationemotional numbing, loss of sense of reality Depression may occur Hyperarousal and hypervigilance are common, keeping individuals on high alert at all times PTSD in children Children with PTDS ( manifestations are different from those of adults Children under age 6 may re-experience trauma through play or drawing Children may behave recklessly or aggressively or they may withdraw from interacting with others See CLINICAL MANIFESTATIONS AND THERAPIES Posttraumatic Stress Disorder, p. 1947 Collaboration Holistic approach may be most effective Pharmacologic therapy Used as adjunct to psychological treatment Desire for immediate, total relief may foster chemical abuse/dependency Benzodiazepines, tricyclic antidepressants, SSRIs, lithium, beta blockers, alpha antagonists, neuroleptics Sedatives discouraged Nonpharmacologic therapy Eye movement desensitization and reprocessing (EMDR) Psychotherapy Contains elements of a number of types of therapy Effective in treating clients with PTSD Dual stimulation Allows client to reprocess or reappraise the trauma by focusing internally on trauma/stressor while also focusing on a different external stimulus Acupuncture May be effective in treatment PTSD Used regularly for 3 months or more Used as adjunctive therapy Nursing process Assessment Clients in hyperarousal state may exhibit unpredictable, aggressive, bizarre behavior Also assess impact on the family Assess physical, psychological, social, risk factors See ASSESSMENT INTERVIEW Posttraumatic Stress Disorder, p. 1948 Diagnosis Risk for Self-Directed Violence Risk for Other-Directed Violence Post-trauma Syndrome Anxiety Fear Ineffective Coping Compromised Family Coping Disturbed Sleep Patterns Planning Remain free from injury or harm Report a decreased perception of anxiety Report a reduction or cessation of nightmares Discuss emotions related to traumatic experiences Verbalize awareness of nonpharmacologic stress reduction techniques Implementation Presence of PTSD not an inevitable outcome of trauma Some clients may require only limited intervention Severity of symptoms will dictate level of care Clients may benefit from community resources that can facilitate long-term care See CLIENT TEACHING Typical Human Responses to Traumatic Events, p. 1949 Evaluation Client utilizes self-calming techniques Client experiences less cognitive distortion and decreased ruminations or obsessions Client will decrease time spent ruminating over worries Review PTSD Relate Link the Concepts and Exemplars Ready Go to Companion Skills Manual Refer Go to Nursing Student Resources Reflect Case Study 2015 by Education, Inc. 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