Assessment - Application of the Nursing Process

APPLICATION OF THE NURSING PROCESS

Assessment

The health history reveals that the client has a history of trauma or abuse. It may be abuse as a child or in a current or recent relationship. It generally is not necessary or desirable for the client to detail specific events of the abuse or trauma; rather, in-depth discussion of the actual abuse is usually undertaken during individual psychotherapy sessions.

General Appearance and Motor Behavior

The nurse assesses the client’s overall appearance and motor behavior. The client often appears hyperalert and reacts to even small environmental noises with a startle response. He or she may be very uncomfortable if the nurse is too close physically and may require greater distance or personal space than most people. The client may appear anxious or agitated and may have difficulty sitting still, often needing to pace or move around the room. Sometimes the client may sit very still, seeming to curl up with arms around knees.

Mood and Affect

In assessing mood and affect, the nurse must remember that a wide range of emotions is possible, from passivity to anger. The client may look frightened or scared or agitated and hostile depending on his or her experience. When the client experiences a flashback, he or she appears terrified and may cry, scream, or attempt to hide or run away. When the client is dissociating, he or she may speak in a different tone of voice or appear numb with a vacant stare. The cli-ent may report intense rage or anger or feeling dead inside and unable to identify any feelings or emotions.

Thought Process and Content

The nurse asks questions about thought process and con-tent. Clients who have been abused or traumatized report reliving the trauma, often through nightmares or flash-backs. Intrusive, persistent thoughts about the trauma interfere with the client’s ability to think about other things or to focus on daily living. Some clients report hallucina-tions or buzzing voices in their heads. Self-destructive thoughts and impulses as well as intermittent suicidal ide-ation are also common. Some clients report fantasies in which they take revenge on their abusers.

Sensorium and Intellectual Processes

During assessment of sensorium and intellectual pro-cesses, the nurse usually finds that the client is oriented to reality except if the client is experiencing a flashback or dissociative episode. During those experiences, the client may not respond to the nurse or may be unable tocommunicate at all. The nurse also may find that clients who have been abused or traumatized have memory gaps, which are periods for which they have no clear memories. These periods may be short or extensive and are usually related to the time of the abuse or trauma. Intrusive thoughts or ideas of self-harm often impair the client’s ability to concentrate or pay attention.

Judgment and Insight

The client’s insight is often related to the duration of his or her problems with dissociation or PTSD. Early in treat-ment, the client may report little idea about the relation-ship of past trauma to his or her current symptoms and problems. Other clients may be quite knowledgeable if they have progressed further in treatment. The client’s ability to make decisions or solve problems may be impaired.

Self-Concept

The nurse is likely to find these clients have low self-esteem. They may believe they are bad people who some-how deserve or provoke the abuse. Many clients believe they are unworthy or damaged by their abusive experi-ences to the point that they will never be worthwhile or valued. Clients may believe they are going crazy and are out of control with no hope of regaining control. Clients may see themselves as helpless, hopeless, and worthless.

Roles and Relationships

Clients generally report a great deal of difficulty with all types of relationships. Problems with authority figures often lead to problems at work, such as being unable to take direc-tions from another or have another person monitor his or her performance. Close relationships are difficult or impos-sible because the client’s ability to trust others is severely compromised. Often the client has quit work or has been fired, and he or she may be estranged from family members. Intrusive thoughts, flashbacks, or dissociative episodes may interfere with the client’s ability to socialize with family or friends, and the client’s avoidant behavior may keep him or her from participating in social or family events.

Physiologic Considerations

Most clients report difficulty sleeping because of night-mares or anxiety over anticipating nightmares. Overeating or lack of appetite is also common. Frequently, these cli-ents use alcohol or other drugs to attempt to sleep or to blot out intrusive thoughts or memories.

Data Analysis

Nursing diagnoses commonly used in the acute care set-ting when working with clients who dissociate or have PTSD related to trauma or abuse include the following:

·    Risk for Self-Mutilation

·    Ineffective Coping

·    Posttrauma Response

·    Chronic Low Self-Esteem

·    Powerlessness

In addition, the following nursing diagnoses may be perti-nent for clients over longer periods, although not all diag-noses apply to each client:

·    Disturbed Sleep Pattern

·    Sexual Dysfunction

·    Rape-Trauma Syndrome

·    Spiritual Distress

·    Social Isolation

Outcome Identification

Treatment outcomes for clients who have survived trauma or abuse may include the following:

·    The client will be physically safe.

·    The client will distinguish between ideas of self-harm and taking action on those ideas.

·    The client will demonstrate healthy, effective ways of dealing with stress.

·    The client will express emotions nondestructively.

The client will establish a social support system in the community.