PTSD

PTSD: clinical therapies

-CBT -EMDR -supportive therapy -group therapy -benzos -SSRIs -antipsychotics -Prazosin -- an antihypertensive that also inhibits brain's response to norepinephrine (helps with nightmares)

Prevention

-utilize support system after exposure -obtain help ASAP

PTSD: comorbidities

-depression -substance abuse -other anxiety disorders

Acute stress disorder: clinical therapies

-ensure safety -provide basic needs -promote support by family and friends -coping mechanisms -emotional support -meds per MD -CBT

Therapies for PTSD

-exposure therapy -acupuncture -EMDR -CBT

Acute stress disorder: manifestations

-intrusive distressing memories -negative mood -dissociation -avoidance -arousal problems

Third phase of PTSD

-lasts a few months -associated with attempts to cope with the trauma -anxiety and somatic manifestations

Second phase of PTSD

-lasts about two weeks -includes the mobilization of defense mechanisms, such as denial

Initial phase of PTSD

-lasts minutes to a few hours -includes the fight or flight response

PTSD: manifestations

-persistent frightening thoughts and memories or flashbacks of the event -images, smells, sounds, feelings -emotional numbing -sleep disorders -hypervigilence and exaggerated startle response -re-experiencing the event -trouble with affection -irritability, aggressiveness -avoidance of trauma-related situations or general social situations -drug and alcohol abuse -depression -suicidal thoughts -violence

Other related disorders

-reactive attachment disorder -- associated with neglect in young children; apparent aversion to engaging in interaction with adults -disinhibited social engagement disorder -- associated with neglect in young children; abnormal propensity for child to interact with unfamiliar adults -acute stress disorder -- symptoms only last from 3 days to 1 month following exposure to traumatic events -adjustment disorders -- begins 3 months after stressor, resolves within 6

Diagnostic criteria

-recurrent nightmares -patterns of persistent efforts to avoid stimuli associated with or reminiscent of the traumatic event -negative changes in cognition or mood -marked changes in reactivity or arousal (hyper-vigilance) -these must occur for more than one month beyond the precipitating event

PTSD risk factors

-severity of the event -little or no social or psychologic support following the trauma -additional stressors immediately following the event -presence of pre-existing mental illness

Posttraumatic stress disorder (PTSD)

A trauma or stressor-related disorder that can evolve after exposure to a traumatic or overwhelming event in which an individual's physical health was endangered

Triggers

-violent person assaults -natural or human-caused disasters -MVCs -military combat -being taken hostage or tortured -imprisonment -dismemberment -incest -child abuse -sexual assault -childhood sexual trauma -threats of violence or injury -intentional infliction of harm or violence

PTSD: recovery time

1 month to several years

Acute stress disorder: recovery time

3 days to 1 month

The nurse is planning care for the older veteran with posttraumatic stress disorder​ (PTSD). Which understanding should the nurse apply to the care of this​ client? A. The older veteran with PTSD is at an increased risk of suicide. B. The older veteran with PTSD is likely to be hostile. C. The older veteran with PTSD will report emotional symptoms. D. The older veteran with PTSD will have significant depression.

A Rationale: The older veteran with PTSD is at increased risk of suicide compared to a​ middle-aged veteran. The older veteran with PTSD is less likely to be​ hostile, has less​ depression, and complains of somatic issues instead of emotional issues when compared to the younger veteran.

The nurse is discussing treatment options with a client with posttraumatic stress disorder​ (PTSD). The client asks the nurse how the PTSD will be cured. How should the nurse​ respond? A. Treatment and therapies are done with and without medication. B. We will try the therapies that your insurance company covers. C. PTSD will reoccur if you skip group counseling. D. There are medications that can cure PTSD.

A ​Rationale: The client with PTSD will be treated holistically with pharmacologic and non-pharmacologic therapies to obtain the best results. The​ nurse's response would not focus on medication​ alone, therapy​ alone, or concerns over insurance​ coverage, because it is better to avoid them as therapeutic responses.

Eye movement desensitization and reprocessing (EMDR)

A form of psychotherapy that contains elements of CBT and body-centered therapy Dual attention stimulus using eye movements, taps, or tones Allows patient to reprocess or reappraise the trauma by focusing internally on the traumatic event or another stressor while simultaneously focusing on a different external stimulus

The nurse is providing care to a client who is diagnosed with posttraumatic stress disorder​ (PTSD). Which factor could interfere with the nurse establishing trust during a therapeutic encounter with this​ client? SATA A. Aggressiveness B. Depersonalization C. Hypervigilance D. Ineffective coping E. Nightmares

A, B, C Rationale: Clients with PTSD have experienced traumatization and may be physically and emotionally isolated. They may be​ irritable, aggressive, emotionally​ numb, frightened, experiencing​ flashbacks, and on high physical and emotional alert during an appointment with the nurse. They may be reluctant to share their thoughts and feelings and should not be pressured to until they feel ready. These clinical manifestations of PTSD make establishing trust with the client a challenge for the nurse. Nightmares are a clinical manifestation of PTSD that do not take place during therapeutic encounters between the client and nurse. Ineffective coping is a problem that may be included in the nursing plan of care for a client with PTSD.

The nurse is caring for a client who is diagnosed with posttraumatic stress disorder​ (PTSD). Which outcome should the nurse include in the​ client's plan of​ care? SATA A. The client will report fewer or no nightmares. B. The client will talk about emotions that are associated with traumatic experiences with at least one counseling professional. C. The client will remain free of harm or injury to self or others. D. The client will demonstrate avoidance of situations related to the trauma or general social contacts. E. The client will demonstrate comorbidity that may include​ depression, substance​ abuse, or other anxiety disorders.

A, B, C ​Rationale: General examples of client goals and outcomes that may be appropriate for inclusion in the plan of care for the client with PTSD​ include: The client will remain free of harm or injury to self or others. The client will articulate decreased feelings of anxiety. The client will talk about emotions that are associated with traumatic experiences with at least one counseling professional or other mental health care provider. The client will report fewer or no nightmares. The client will articulate awareness of stress reduction techniques that are not pharmacologic. Demonstrating comorbidity or avoidance are clinical manifestations of the​ disorder, and not client goals and outcomes.

The nurse is teaching the client and the family about eye movement desensitization and reprocessing​ (EMDR) therapy, which has been successful in the treatment of posttraumatic stress disorder. Which teaching should the nurse​ include? SATA A. External focus on a different stimulus B. Reprocessing the trauma C. Effective nonpharmacologic therapy D. Effective pharmacologic therapy E. Telehealth strategy

A, B, C ​Rationale: The largest number of studies on psychotherapy for PTSD indicates that​ cognitive-behavioral therapy​ (CBT), as well as eye movement desensitization and reprocessing​ (EMDR), are the most effective therapies for PTSD. EMDR includes aspects of CBT and​ body-centered therapy. In this type of​ therapy, the client reprocesses the trauma by focusing internally on the traumatic event while focusing externally on a different stimulus. EMDR is a nonpharmacologic therapy that is used to treat​ PTSD, not a telehealth strategy. Telehealth is the delivery of​ health-related services and information via telecommunication technologies. Effective pharmacologic therapy is not a consideration in eye movement desensitization and reprocessing​ (EMDR) therapy.

The nurse is planning care for client families who are refugees from​ war-torn countries. Which client outcome would be the most appropriate for inclusion in a plan of care for a client with posttraumatic stress disorder​ (PTSD)? SATA A. The client will demonstrate stress reduction techniques. B. The client will remain free of harm or injury to self or others. C. The client will articulate decreased feelings of anxiety. D. The client will talk about emotions that are associated with traumatic experiences. E. The client will report no change in the occurrence of nightmares.

A, B, C, D Rationale: Client goals and outcomes should be measurable. In​ addition, client goals and outcomes should be​ client-specific and tailored to meet the​ client's needs. General examples of client goals and outcomes that may be appropriate for inclusion in the plan of care for the client with PTSD​ include: The client will remain free from harm. The client will be able to talk about emotions associated with the traumatic experiences. The client will demonstrate stress reduction techniques. The client will verbalize a decrease in anxious feelings. The goal for no change in the occurrence of nightmares is inappropriate. An appropriate goal would be for the client to report a decrease in the occurrence of nightmares.

The nurse is preparing to encounter a client who has experienced multiple violent assaults during the last month. Which priority should the nurse consider when assessing this client with possible posttraumatic stress disorder​ (PTSD)? SATA A. Ensure the safety of the client and others. B. Lower client anxiety levels. C. Establish trust. D. Assess for indirect nonprofessional exposure. E. Determine alcohol or drug use.

A, B, C, E ​Rationale: When assessing a client diagnosed with​ PTSD, the nurse will ensure the safety of the client and​ others, lower the​ client's anxiety​ levels, determine the use of alcohol or​ drugs, and establish trust. Indirect nonprofessional​ exposure, such as observing a terrorist event through electronic​ media, television,​ movies, or​ photographs, is not a factor in the development of PTSD.

A nurse is providing teaching to the parent of a child who has a new diagnosis of PTSD. Which of the following information should the nurse include? SATA A. Children who have PTSD can benefit from psychotherapy B. Phobias can be manifestations of PTSD C. Personality disorders are a complication of PTSD D. PTSD develops following a traumatic event E. There are three phases of PTSD

A, B, D, E Rationale: Children who have PTSD can experience alterations in coping mechanisms and may benefit from psychotherapy to assist in dealing with the traumatic event. Phobias related to the traumatic event can be a manifestation of PTSD. Phobias, depression, or anxiety may occur during the third phase of PTSD. PTSD develops following a traumatic event, such as assault, serious injury, or a life-threatening episode. The child may require psychotherapy to assist in healing from the event. PTSD has three phases: the initial phase, the second phase, and the third phase Personality disorders are not a complication of PTSD. Unresolved PTSd can cause behavioral changes, such as a decrease in school performance or unexplained anger.

The nurse is providing care for a client diagnosed with posttraumatic stress disorder​ (PTSD). The​ client's family has asked about nonpharmacologic therapies that may be appropriate. Which therapy should the nurse mention when responding to this​ family? SATA A. Acupuncture therapy B. Atypical antipsychotic therapy C. Cognitive-behavioral therapy D. Selective serotonin reuptake inhibitor therapy E. Eye movement desensitization and reprocessing therapy

A, C, E Rationale: Acupuncture therapy is a​ complementary, non-pharmacologic therapy that has been useful in the treatment of PTSD.​ Cognitive-behavioral therapy​ (CBT) and eye movement desensitization and reprocessing therapy​ (EMDR) are nonpharmacologic therapies used by interdisciplinary teams to treat posttraumatic stress disorder. Selective serotonin reuptake inhibitor​ (SSRI) and atypical antipsychotic therapy are both pharmacologic therapies that may be used to treat PTSD.

The nurse is planning care for the combat veteran with posttraumatic stress disorder​ (PTSD). Which nursing intervention should the nurse​ include? SATA A. Improve client coping through nonpharmacologic and pharmacologic therapies. B. Limit contact with the client to reduce the occurrence of compassion fatigue. C. Connect clients with resources for​ social, occupational, and interpersonal support. D. Remove the family from therapy so the client can focus on health. E. Reduce client​ harm, anxiety, and fear.

A, C, E Rationale: Appropriate nursing interventions for clients with PTSD aim to reduce and eliminate client​ harm, anxiety, and​ fear, and improve client​ coping, using non-pharmacologic and pharmacologic therapies. Nursing interventions also aim to connect clients and families with organizations and community resources that can provide longer term​ social, occupational, and interpersonal support. The family should be involved and included in resources for support. Compassion fatigue should be recognized but not avoided through decreasing contact with clients.

The nurse is caring for a combat veteran client with posttraumatic stress disorder​ (PTSD). Which condition can be ideal for acupuncture to be an effective​ treatment? SATA A. When used regularly B. When used as a​ short-term therapy for a period of no more than a month C. When used as an adjunct to​ cognitive-behavioral therapy​ (CBT) and other traditional therapies D. When solely used as a primary therapy E. When used for a period of 3 months or more

A, C, E ​Rationale: Preliminary research shows that acupuncture may be an effective treatment for PTSD only if the treatment is regular and lasts for at least 3​ months, and is used as an additional treatment with CBT and other more traditional​ therapies, including pharmacologic agents.

PTSD vs. acute stress disorder

Acute stress disorder: -symptoms for 3 days to 1 month immediately after exposure PTSD: -symptoms for more than 1 month -onset of symptoms occurring 3 or more months after exposure

Depersonalization

An emotional numbing and a loss of sense of reality, feelings, and sense of self in relation to others

The client with posttraumatic stress disorder​ (PTSD) states they are experiencing undesirable adverse effects from sertraline​ (Zoloft). Which is the most appropriate response by the​ nurse? A. "Divide the doses in half to decrease the side​ effects." B. "These effects are​ expected, but they should not stop you from continuing your​ medication." C. "It is OK to stop any medication that does not agree with​ you." D. "You may be overdosing on your​ medication."

B Rationale: Selective serotonin reuptake inhibitors​ (SSRIs) like sertraline have known adverse effects that should be discussed with the client to improve adherence to prescribed pharmacologic treatment. Overdosing is not the cause of adverse effects. Decreasing or stopping medication should not be done without the order from the healthcare provider.​ However, since SSRIs carry a black box warning for increased​ suicidality, the nurse should question the client about experiencing any increase in suicidal ideation and follow up appropriately.

Nurses are working with the victims of a disaster after a bombing at a school lunchroom. Which persons have the greatest risk for factors of PTSD? A. First responders arriving just after the bombing B. Cafeteria workers at the site closest to the bomb C. Children who were being dropped off for school at the entrance D. Disaster-trained health care school nurses

B Rationale: The closer the individual is to the actual site and the longer they are exposed to it, the greater the psychological distress the individual will experience, potentially leading to PTSD. The first responders undergo training for disaster situations. Children with their parents in the car did not witness the bombing. Disaster-trained school nurses are not the most likely to experience PTSD. Nurses should assess clients for psychiatric trauma and physical trauma following a disaster. PTSD symptoms include emotional numbness, sleep disturbances, anxiety, irritability, and emotional outbursts of anger or feelings of intense guilt. PTSD is typically diagnosed when the symptoms last for more than a month.

The nurse is assessing a client with PTSD. The client is currently taking clonazepam. Which of the following instructions is not appropriate for this client? A. Avoid alcohol intake B. Drink grapefruit juice C. Report jaundice if it occurs D. Report the occurrence of fever, sore throat, and bruising

B Rationale: ​Adverse reactions of klonopin include blood dyscrasia and cognitive impairment. Drinking grapefruit juice increases the blood concentration of klonopin, causing toxicity. The nurse should tell the client not to drink grapefruit juice. Concurrent use of alcohol + klonopin intensifies its action, leading to an adverse reaction Symptoms of dyscrasia include fever, sore throat, bruising, rash, and jaundice. The client should be instructed to report these symptoms.

Which statement should the nurse expect to hear from a client with posttraumatic stress disorder​ (PTSD)? SATA A. "I'm a​ high-stress person. I feel content most of the​ time." B. "I can't remember the last time I enjoyed​ myself." C. "I have trouble sleeping at night and​ don't feel rested in the​ morning." D. "There is no one I can really talk to. I​ don't feel close to​ anyone." E. "I feel very optimistic and positive about the future and what I can​ accomplish."

B, C, D Rationale: Clients with PTSD experience​ recurrent, involuntary, and intrusive​ memories, traumatic​ nightmares, and flashbacks. They have negative alterations in cognition and mood that began or worsened after the traumatic event. Examples are an inability to experience positive emotions and persistent blame of self or others for causing the trauma or its consequences. Clients may have trouble sleeping and may become emotionally numb or have trouble with​ affection, impairing their relationships. Clients with PTSD typically do not express feelings of optimism and contentment.

The nurse is preparing a presentation on posttraumatic stress disorder​ (PTSD) to a group of people whose spouses have just returned from an active war zone. Which information about PTSD should the nurse include in the​ presentation? SATA A. Incidence among veterans is low. B. Stressors can occur at any time or age of life. C. Traumatic events in childhood can create clinical symptoms that last into adulthood. D. History of psychiatric disorders is common. E. Men are more susceptible than women.

B, C, D Rationale: PTSD is more common among individuals with a history of psychiatric disorders. Exposure to a traumatic stressor can happen at any age or time of life. Traumatic stress in childhood can create effects that persist into adulthood. The incidence of PTSD among veterans is especially high. Women are more susceptible to the development of PTSD than are men

The nurse is providing care to the victim of a kidnapping that occurred over 1 year ago. Which clinical manifestation supports the diagnosis of posttraumatic stress disorder​ (PTSD) in this​ client? SATA A. Tremors B. Hypervigilance C. Depression D. Flashbacks E. Agitation

B, C, D, E Rationale: Agitation,​ flashbacks, depression, and hypervigilance are all clinical manifestations of PTSD that usually emerge within 3 months but may become evident years after the experience. Tremors are not a clinical manifestation of PTSD.

The nurse is caring for a client in law enforcement diagnosed with posttraumatic stress disorder​ (PTSD). Which finding in the​ client's health history places the client at risk for this​ disorder? SATA A. Adult-onset diabetes mellitus B. Preexisting mental illness C. Experiencing difficulty sleeping D. Losing a job after a traumatic event E. Witnessing the death of a friend

B, D, E ​Rationale: Risk factors for developing PTSD include preexisting mental​ illness, direct exposure to a traumatic event such as witnessing a​ death, and experiencing loss after a traumatic event. Difficulty sleeping is a clinical manifestation of​ PTSD, not a risk factor. A concurrent diagnosis of diabetes mellitus is not a risk factor for PTSD.

The nurse is working with a child suspected of having posttraumatic stress disorder who has been removed from the home because of neglect. Which manifestation may the nurse observe with the young child that conveys a message about the traumatic​ event? SATA A. Crying B. Drawing C. Dreaming D. Jumping E. Playing

B, E ​Rationale: Young children with posttraumatic stress disorder often recreate a traumatic event by playing and drawing.​ Jumping, dreaming, and crying do not give a coherent message.

A nurse is caring for a client with PTSD. Which nursing diagnosis is most appropriate for this client? A. At risk for histrionics r/t the events surrounding the trauma B. At risk for obsessive talking about the traumatic events C. At risk for hallucinations r/t the traumatic events D. At risk for impaired sensory and motor function r/t PTSD

C Rationale: Signs and symptoms of PTSD: -hallucinations r/t the traumatic events -nightmares -substance abuse -insomnia -flashbacks -intrusive memories -anxiety -avoidance of discussions about and participation in activities r/t the trauma -detachment -hypervigilance -anger -depression -guilt Can occur in: -pts who witness or experience physical or sexual assault -war -natural disaster -traumatic injury -unexpected death of a loved one An individual with PTSD experiences: -prolonged fear -shock -anger -anxiety -guilt

The nurse is assessing an adolescent foster child diagnosed with posttraumatic stress disorder​ (PTSD). Which question is most beneficial for the nurse to ask the adolescent with​ PTSD? A. "Are you napping during the​ day?" B. "Are you wetting the bed at​ night?" C. "Have you had thoughts of hurting​ yourself?" D. "Do you know what year it​ is?"

C Rationale: The adolescent with PTSD is at an increased risk for​ suicide, and reduction of harm is a priority for the client with PTSD. Mental orientation should be performed with the older adult client. A​ follow-up question about napping may be asked to assess​ sleep, but it does not take precedence over suicide and​ self-harm. Bedwetting should be assessed in a child with PTSD.

The nurse is teaching about how to recognize those at risk for posttraumatic stress disorder​ (PTSD) to begin early intervention. Which scenario should the nurse include as an example to look for in the general​ population? SATA A. Clients who have looked at photographs of a war zone B. Clients who watched a documentary about the terror attack of September 11 C. Clients who have engaged in military combat D. Clients who have been to prison E. Clients who have been taken hostage and tortured

C, D, E Rationale: To be at risk for​ PTSD, the client must have experienced direct exposure to the traumatic stressor and witnessed it in person. The client can also have had indirect exposure​ (for example, by learning that a close friend or relative was exposed to trauma such as a violent or accidental​ death), or have had repeated or extreme exposure to aversive details of the traumatic event​ (usually through professional​ duties, such as being a first​ responder). Nonprofessional exposure through electronic​ media, television,​ movies, or photographs does not qualify for a diagnosis of PTSD.

A nurse is facilitating a support group for veterans who were involved in combat and observed war casualties. Which of the following client statements should the nurse identify as an indication the client might be experiencing PTSD? A. "My marriage has improved since I left the military" B. "My child was born with a birth defect due to an exposure I had overseas" C. "I killed four enemy soldiers with my bare hands and saved my entire battalion" D. "In my dreams, all I can see are the wounded reaching out and trying to grab me"

D Rationale: Many clients who have PTSD repeatedly experience the ordeal in the form of flashback episodes, memories, nightmares, or frightening thoughts, especially when they are exposed to events or objects that remind them of the trauma. C. is a grandiose statement, more close to bipolar in a manic phase Manifestations: -flashbacks -increasing difficulty with interpersonal, occupational, and social relationships -reports using alcohol or meds to alleviate symptoms -easy to anger -increasingly aggressive -difficulty relating to significant other -chronic pain, vague somatic symptoms -increased risk for violence directed toward self or others -suicidal ideation Outcomes: -client's ability to use relaxation techniques to manage anxiety -fewer flashbacks -less hypervigilance -less feelings of guilt -identify and utilize community resources -support groups -identify triggers -coping strategies

A nurse is assessing a client who has PTSD following a natural disaster. Which of the following findings should the nurse expect? A. Increasingly cautious behavior B. Increasing sense of attachment to others C. Constant need to talk about the event D. Increasing feelings of anger

D Rationale: Severe manifestations: -hypervigilance -exaggerated startle response -problems with concentration and sleep -reckless or self-destructive behavior -irritability -striking out at others with little to no provocation

A client is prescribed​ prazosin, an antihypertensive​ medication, for the pharmacologic treatment of posttraumatic stress disorder​ (PTSD). The client asks how a blood pressure medication will help with symptoms. Which response by the nurse is the most​ appropriate? A. ​"I am not sure why this medication has been​ prescribed, so I will follow up with your healthcare​ provider." B. ​"Your medical record indicates elevated blood pressure during the last two​ visits." C. ​"The medication reduces your blood​ pressure, which decreases the symptoms of​ PTSD." D. ​"The medication has been found quite useful to reduce the nightmares associated with​ PTSD."

D ​Rationale: Prazosin is an antiadrenergic agent that has been used to treat hypertension for many years. Recent research has found that this medication is useful in the treatment of the nightmares associated with PTSD through its action of inhibiting the​ brain's response to norepinephrine. While the medication will reduce blood​ pressure, this is not the reason it is used for PTSD. It is inappropriate for the nurse to avoid answering the question and to instead promise to follow up with the healthcare provider.

Acute stress disorder criteria

Experiencing nine or more symptoms from any of five categories: -intrusion -negative mood -dissociation -avoidance -arousal

Flashbacks

The recurrence of images, sounds, smells, or feelings from the traumatic event

The mother of a child with posttraumatic stress disorder​ (PTSD) expresses concern that the child is now wetting the bed at night. Which response by the nurse is​ accurate? A. "The child should be tested for a urinary tract​ infection." B. "This is an expected manifestation of PTSD that will get resolved with​ treatment." C. "The traumatic event may have damaged the​ child's kidneys." D. "Drinking too much before bedtime is likely causing this​ problem."

​B Rationale: PTSD in children can lead to nocturnal​ enuresis, wetting the bed at​ night, in a​ toilet-trained child.​ Infection, kidney​ damage, and excessive fluid intake are not the primary causes of bedwetting in the child with PTSD.