Post-traumatic stress disorder (PTSD) is a psychiatric condition that can occur after someone experiences or witnesses a traumatic or terrifying event. PTSD can be a lasting consequence of the traumatic event, even years later. Examples of traumatic events include war, terrorism, natural disasters, motor vehicle accidents, the unexpected death of a loved one, a life-threatening medical diagnosis, and assault.
In this article:
- Overview
- Nursing Process
- Nursing Care Plans
- Fear
- Ineffective Coping
- Post-Trauma Syndrome
- Risk for Suicide
Overview
Traumatic events cause feelings of intense terror, fear, and helplessness. These feelings can be experienced by victims, families of victims, and medical personnel. Symptoms can include nightmares, severe anxiety, and flashbacks. Symptoms are generally grouped into four types: physical and emotional reactions, intrusive memories, avoidance, and negative changes in thinking and mood. Symptoms, and severity, can vary over time and for each individual.
PTSD is generally diagnosed with a physical exam, psychological evaluation, and criteria in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Treatment includes psychotherapy and/or medication.
Nursing Process
Nurses will be involved in caring for patients with PTSD in various settings. Patients directly involved in a traumatizing event will be seen in the trauma center or emergency department and once stabilized, may require psychiatric evaluation with further inpatient or outpatient treatment. Nurses can also care for patients with PTSD in a behavioral health center. Nurses should remain sensitive to patients with a history of PTSD so as not to trigger a negative response when providing invasive care or when communicating personal information.
Nursing Care Plans
Once the nurse identifies nursing diagnoses for PTSD, nursing care plans help prioritize assessments and interventions for both short and long-term goals of care. In the following section, you will find nursing care plan examples for PTSD.
Anxiety
Patients with PTSD can experience varying degrees of anxiety.
Nursing Diagnosis: Anxiety
Related to:
- Threat of harm or death
- Loss of a loved one
- Situational crisis
As evidenced by:
- Tachycardia
- Increased blood pressure
- Verbalization of feeling anxious
- Panic attacks
- Restlessness
- Apprehension
- Feelings of worry
- Fidgeting
- Difficulty concentrating
- Urinary urgency/frequency
Expected outcomes:
- Patient will exercise control over their anxiety as evidenced by reports of feeling relaxed.
- Patient will implement two strategies to reduce anxiety.
- Patient will demonstrate reduced anxiety as evidenced by heart rate and blood pressure within normal limits.
Assessment:
1. Identify the source of anxiety.
Encourage the patient to discuss what causes their anxiety. Ask if they notice a pattern or triggers for their anxious thoughts. Make sure the patient knows they will not be judged or dismissed if they are open about how they feel.
2. Assess the severity of anxiety.
Mild anxiety may include restlessness and insomnia, while severe anxiety interferes with daily functioning. Panic distorts reality. Interventions can be based on the level of anxiety the patient experiences.
3. Assess the use of stimulants.
Review medications and the use of stimulants such as caffeine which can also cause a sense of anxiety. These may worsen the patient’s physical and emotional symptoms.
Interventions:
1. Encourage therapeutic communication.
Display empathy and positivity allowing the patient to express their anxiety. Encourage the patient to openly express their emotions. Use silence and active listening to portray a patient attitude. Do not deny or minimize their anxiety.
2. Encourage relaxation techniques.
Relaxation techniques include deep breathing, yoga, and meditation. Encourage the patient to try implementing different methods when they are feeling anxious. In the hospital setting, the nurse can promote a calm environment through dim lighting and soft music.
3. Evaluate the patient’s support systems.
Patients with PTSD need to know they aren’t alone. Determine what kind of personal support the patient has at home. Encourage support groups along with their home support system.
4. Administer medications as ordered.
The patient’s anxiety may be at a level where they are experiencing panic. Benzodiazepines are the most common class of medications administered to reduce anxiety.
Fear
Patients with PTSD can experience fear in response to the traumatic event.
Nursing Diagnosis: Fear
Related to:
- Perceived danger
- Perceived threat
As evidenced by:
- Agitation
- Tachycardia and heart palpitations
- Tachypnea
- Verbalization of feeling fear
- Muscle tension
- Reports of apprehension
- Increased alertness or avoidance
- Jitteriness
- Nausea or vomiting
- Increased perspiration
- Dilated pupils
Expected outcomes:
- Patient will openly discuss fear and what is invoking the sense of fear.
- Patient will be able to use effective coping behaviors to resume normal life activities.
- Patient will acknowledge that they are safe and cannot be harmed.
Assessment:
1. Assess the degree of fear.
Assess the patient’s degree of fear or perceived threat. Use open-ended questions to actively listen, as this reassures the patient and shows them that their concerns are being heard.
2. Observe for signs of fear.
Nonverbal expressions can indicate they are experiencing fear. Physical signs such as an increased heart rate, tachypnea, dyspnea, sweating, and agitation are signs of fear.
3. Assess coping strategies.
Find out how the patient has coped in the past with their fear. The nurse can also get an idea of how the patient is coping by their actions during the assessment. Discuss coping strategies and implement if applicable.
Interventions:
1. Reassure safety.
This may likely be the first step, especially if the patient is in a state of panic. Ensure the patient is in a calm and safe environment, and reassure them repeatedly that they are safe. Allow time for them to become accustomed to the environment, giving them periods of rest.
2. Discuss the reality of the situation.
Inquire about what the patient’s fear is. Acknowledging what can and can’t be changed can help the patient feel in control.
3. Encourage healthy coping strategies.
After evaluating whether the patient’s coping strategies are healthy or not, encourage implementing positive strategies. Some healthy ways to cope during a fearful situation include positive self-talk, listening to music, and relaxation techniques. Encourage them to try various methods and see which is most helpful.
4. Be sensitive to the patient’s feelings.
Reassure the patient that feelings of fear after a traumatic event are normal and valid. Empathize with their feelings instead of giving them false reassurances. Showing compassion promotes trust.
Ineffective Coping
Patients with PTSD may attempt to cope in ways that are ineffective and even harmful.
Nursing Diagnosis: Ineffective Coping
Related to:
- Situational crises
- Fear
- Uncertainty
- Lack of confidence in the ability to cope
- Inadequate resources or support system
As evidenced by:
- Inability to perform daily tasks
- Sleep disturbances
- Self-destructive habits (drugs, alcohol, smoking)
- Reoccurrence of intrusive thoughts
- Inappropriate defense mechanisms
- Inability to partake in self-care
- Somatic symptoms (diarrhea, headaches, ulcers)
- Changes in behavior and/or communication
Expected outcomes:
- Patient will identify maladaptive coping behaviors.
- Patient will participate in self-care activities: cooking healthy meals, exercising, proper sleep, etc.
- Patient will display a desire for effective coping as evidenced by asking for help and reaching out to a support person/group.
Assessment:
1. Assess for self-destructive habits.
Patients with PTSD may turn to unhealthy habits as a way of dealing with their trauma. They may self-medicate with alcohol and/or drugs. Assess for substance abuse by asking the patient directly about their substance use and looking for physical indications.
2. Assess the effect on everyday activities.
Even if a patient isn’t coping with substances they may be in denial about other ways they cope and how this affects their life. Assess their job, family and other relationships, and how they take care of themselves.
3. Observe speech and behavior.
Observe for impatience, frustration, a lack of confidence in their self-talk, or defense mechanisms that signal ineffective coping.
Interventions:
1. Empathetic listening.
Acknowledge the patient’s feelings and show understanding. This creates a supportive environment in which the patient will be more willing to open up about how they’re feeling and how they cope.
2. Arrange for professional support.
Referring the patient to a therapist or counselor may be warranted. Ask the patient how they feel about this and reiterate that it’s not a negative, but a positive step. A mental health professional trained in PTSD can offer different treatments for effective coping.
3. Encourage positive self-talk and self-care.
A traumatic event may harm the patient’s confidence. Encourage positive statements and mantras. Institute self-care opportunities by allowing the patient to make decisions and do things for themselves. Show the patient they are capable of taking control.
4. Recommend a support group.
Speaking with other individuals who understand the trauma the patient has experienced can be beneficial in coping and recovering.
Post-Trauma Syndrome
Someone who has experienced a traumatic event may develop negative physical and emotional responses.
Nursing Diagnosis: Post-Trauma Syndrome
Related to:
- Post-traumatic event or experience
- Inadequate social support
- Exaggerated sense of responsibility
- Self-injurious behavior
As evidenced by:
- Aggressive behavior
- Poor concentration
- Altered mood
- Avoidance
- Compulsive behaviors
- Denial
- Exaggerated startle response
- Flashbacks
- Guilt
- Anxiety
- Depressive symptoms
- Fear
- Headache
- Heart palpitations
- Hopelessness
- Hypervigilance
- Intrusive thoughts
- Nightmares
- Gastrointestinal irritation
- Panic attacks
- Rage
- Substance misuse
Expected outcomes:
- Patient will return to their pre-trauma level of functioning.
- Patient will acknowledge traumatic events and demonstrate interventions to cope effectively.
Assessment:
1. Assess for intrusive memories, numbing, avoidance, and hyperarousal.
Assess for the development of unwanted and disruptive recollections of the event, unhealthy coping behaviors, negative alterations in mood and cognition, and abnormal emotional reactions.
2. Conduct a physical and psychological examination.
Post-trauma syndrome may include physiological responses to chronic stress, such as GI issues, pain, headaches, and heart palpitations, along with psychological symptoms.
Interventions:
1. Refer the patient to psychotherapy.
Cognitive-behavioral therapy, exposure therapy, and eye movement desensitization and reprocessing (EMDR) are beneficial in helping the patient cope with distressing symptoms.
2. Remain with the patient if experiencing symptoms.
If the patient feels overwhelmed, fearful, or anxious, provide reassurance and do not leave them alone. Use physical touch if the patient gives consent.
3. Encourage the expression of feelings through creative outlets.
Patients may be reluctant to verbally share details or feelings surrounding a traumatic event, but expressing emotions is vital to recovery. The nurse can offer opportunities to draw, paint, or write as another means of expression.
4. Support a return to normal habits.
It is important for the patient to return to their usual routines as soon as possible. Interruptions in sleep can increase the development of PTSD.
5. Encourage stress reduction methods.
Assist the patient with visualization techniques, deep breathing exercises, and guided imagery, especially when intrusive thoughts or flashbacks occur.
Risk for Suicide
Patients with PTSD are at an increased risk for suicidal behavior.
Nursing Diagnosis: Risk for Suicide
Related to:
- Trauma
- Anxiety
- Depressive symptoms
- Risky, reckless, and destructive behaviors
- Guilt
- Grief
- Helplessness
- Hopelessness
- Intrusive thoughts or images
- Substance misuse
- Access to a weapon
- Chronic pain
- Lack of support
- History of abuse
As evidenced by:
A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred yet, and nursing interventions are directed at prevention.
Expected outcomes:
- Patient will not harm self.
- Patient will verbalize suicidal ideations.
- Patient will demonstrate effective coping mechanisms to control suicidal ideation and impulses.
- Patient will not abuse mood-altering substances.
Assessment:
1. Assess the patient’s history of suicidal ideations and attempts.
Patients with a history of PTSD are significantly more likely to attempt suicide. Assess for a history of attempts and suicidal thoughts.
2. Note a history of comorbid mental health disorders.
PTSD frequently occurs with major depressive disorder, and this enhances the risk for suicidal behavior. Assess for other mental health conditions, such as personality disorders, that increase the risk of suicide.
3. Assess for significant changes in the patient’s behavior and attitude.
Reckless behavior, reduced motivation, withdrawal, or giving away possessions can alert the nurse to an increased risk of suicide. On the other hand, if the patient suddenly has a euphoric recovery from a previous depressive state, this is also a warning sign that the patient has decided to end their life.
Interventions:
1. Monitor for substance abuse.
Patients who have experienced a traumatic event are more likely to cope with their distress by abusing drugs and alcohol and are at risk for drug addiction. Substance abuse increases the risk of suicidal ideation or attempts.
2. Refer the patient to psychotherapy.
Prolonged exposure therapy and cognitive processing therapy are types of cognitive behavioral therapy that help the patient cope with traumatic memories and challenge negative beliefs related to trauma.
3. Remove potentially dangerous objects from the patient’s environment.
Inquire if the patient has access to weapons, which is common in patients with a military background. Weapons may need to be removed, and other items, such as medications, may need to be locked away.
4. Refer the patient to community support groups.
Experiencing a traumatic event can feel isolating. Refer the patient to support groups for rape or assault survivors, VA support groups, or other peer support groups to connect with survivors who have navigated similar situations.
References
- Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2019). Nurse’s pocket guide: Diagnoses, interventions, and rationales (15th ed.). F A Davis Company.
- Posttraumatic Stress Disorder. (n.d.). NAMI. Retrieved May 10, 2022, from https://www.nami.org/About-Mental-Illness/Mental-Health-Conditions/Posttraumatic-Stress-Disorder
- Posttraumatic stress disorder. (n.d.). American Psychological Association. Retrieved May 10, 2022, from https://www.apa.org/topics/ptsd
- Post-traumatic stress disorder (PTSD) – Diagnosis and treatment. (n.d.). Mayo Clinic. Retrieved May 12, 2022, from https://www.mayoclinic.org/diseases-conditions/post-traumatic-stress-disorder/diagnosis-treatment/drc-20355973
- Post-traumatic Stress Disorder (PTSD) – PTSD Therapy | familydoctor.org. (2022, April 18). FamilyDoctor.org. Retrieved May 12, 2022, from https://familydoctor.org/condition/post-traumatic-stress-disorder/
- Post-Traumatic Stress Disorder: PTSD: Symptoms, Treatment & Definition. (2021, January 20). Cleveland Clinic. Retrieved May 11, 2022, from https://my.clevelandclinic.org/health/diseases/9545-post-traumatic-stress-disorder-ptsd
- Torres, F. (n.d.). Psychiatry.org – What is Posttraumatic Stress Disorder (PTSD)? American Psychiatric Association. Retrieved May 10, 2022, from https://psychiatry.org/patients-families/ptsd/what-is-ptsd
