Intervention - Application of the Nursing Process

Intervention

Promote Client’s Safety

·        Discuss self-harm thoughts.

·        Help client develop plan for going to safe place when having destructive thoughts or impulses.

Help Client Cope with Stress and Emotions

·        Use grounding techniques to help client who is dissociating or experiencing flashbacks.

·        Validate client’s feelings of fear, but try to increase contact with reality.

·        During dissociative experience or flashback, help client change body position but do not grab or force client to stand up or move.

·        Use supportive touch if client responds well to it.

·        Teach deep breathing and relaxation techniques. 

·        Use distraction techniques such as participating in physical exercise, listening to music, talking with others, or engaging in a hobby or other enjoyable activity. 

·        Help to make a list of activities and keep materials on hand to engage client when client’s feelings are intense.

Help Promote Client’s Self-Esteem

·        Refer to client as “survivor” rather than “victim.”

·        Establish social support system in community.

·        Make a list of people and activities in the community for client to contact when he or she needs help. 

The nurse and treatment team must provide safety measures when the client cannot do so. To increase the client’s sense of per-sonal control, he or she must begin to manage safety needs as soon as possible. The nurse can talk with the client about the difference between having self-harm thoughts and tak-ing action on those thoughts: having the thoughts does not mean the client must act on those thoughts. Gradually, the nurse can help the client to find ways to tolerate the thoughts until they diminish in intensity.

The nurse can help the client learn to go to a safe place during destructive thoughts and impulses so that he or she can calm down and wait until they pass. Initially, this may mean just sitting with the nurse or around others. Later, the client can find a safe place at home, often a closet or small room, where he or she feels safe. The client may want to keep a blanket or pillows there for comfort and pictures or a tape recording to serve as reminders of the present.

Promoting the Client’s Safety

The client’s safety is a priority. The nurse continually must assess the client’s potential for self-harm or suicide and take action accordingly. The nurse and treatment team must provide safety measures when the client cannot do so. To increase the client’s sense of per-sonal control, he or she must begin to manage safety needs as soon as possible. The nurse can talk with the client about the difference between having self-harm thoughts and tak-ing action on those thoughts: having the thoughts does not mean the client must act on those thoughts. Gradually, the nurse can help the client to find ways to tolerate the thoughts until they diminish in intensity.

The nurse can help the client learn to go to a safe place during destructive thoughts and impulses so that he or she can calm down and wait until they pass. Initially, this may mean just sitting with the nurse or around others. Later, the client can find a safe place at home, often a closet or small room, where he or she feels safe. The client may want to keep a blanket or pillows there for comfort and pictures or a tape recording to serve as reminders of the present.

Helping the Client Cope with Stress and Emotions

Grounding techniques are helpful to use with the client who is dissociating or experiencing a flashback. Groundingtechniques remind the client that he or she is in the pres-ent, is an adult, and is safe. Validating what the client is feeling during these experiences is important: “I know this is frightening, but you are safe now.” In addition, the nurse can increase contact with reality and diminish the dissocia-tive experience by helping the client focus on what he or she is currently experiencing through the senses:

·    “What are you feeling?”

·    “Are you hearing something?”

·    “What are you touching?”

·    “Can you see me and the room we’re in?”

·    “Do you feel your feet on the floor?”

·    “Do you feel your arm on the chair?”

·    “Do you feel the watch on your wrist?”

For the client experiencing dissociative symptoms, the nurse can use grounding techniques to focus the client on the present. For example, the nurse approaches the client and speaks in a calm reassuring tone. First, the nurse calls the cli-ent by name and then introduces himself or herself by name and role. If the area is dark, the nurse turns on the lights. He or she can reorient the client by saying the following:

“Hello, Janet, I’m here with you. My name is Sheila. I’m the nurse working with you today. Today is Thursday, February 8, 2010. You’re here in the hospital. This is your room at the hospital. Can you open your eyes andlook at me? Janet, my name is Sheila.”

The nurse repeats this reorienting information as needed. Asking the client to look around the room encour-ages the client to move his or her eyes and avoid being locked in a daze or flashback.

As soon as possible, the nurse encourages the client to change positions. Often during a flashback, the client curls up in a defensive posture. Getting the client to stand and walk around helps to dispel the dissociative or flashback experi-ence. At this time, the client can focus on his or her feet mov-ing on the floor or the swinging movements of his or her arms. The nurse must not grab the client or attempt to force him or her to stand up or move. The client experiencing a flashback may respond to such attempts aggressively or defensively, even striking out at the nurse. Ideally, the nurse asks the client how he or she responds to touch when dissociating or experi-encing a flashback before one occurs; then the nurse knows if using touch is beneficial for that client. Also, the nurse may ask the client to touch the nurse’s arm. If the client does so, then supportive touch is beneficial for this client.

Many clients have difficulty identifying or gauging the intensity of their emotions. They also may report that extreme emotions appear out of nowhere with no warning. The nurse can help clients to get in touch with their feel-ings by using a log or journal. Initially, clients may use a “feelings list” so they can select the feeling that most closely matches their experience. The nurse encourages the client to write down feelings throughout the day at specifiedintervals, for example, every 30 minutes. Once clients have identified their feelings, they can gauge the intensity of those feelings, for example, rating each feeling on a scale of 1 to 10. Using this process, clients have a greater awareness of their feelings and the different intensities; this step is important in managing and expressing those feelings.

After identifying feelings and their intensities, clients can begin to find triggers, or feelings that precede the flashbacks or dissociative episodes. Clients can then begin to use grounding techniques to diminish or avoid these episodes. They can use deep breathing and relaxation, focus on sensory information or stimuli in the environ-ment, or engage in positive distractions until the feelings subside. Such distractions may include physical exercise, listening to music, talking to others, or engaging in a hobby or activity. Clients must find which distractions work for them; they should then write them down and keep the list and the necessary materials for the activities close at hand. When clients begin to experience intense feelings, they can look at the list and pick up a book, listen to a tape, or draw a picture, for instance.

Helping to Promote the Client’s Self-Esteem

Often it is useful to view the client as a survivor of trauma or abuse rather than as a victim. For these clients, who believe they are worthless and have no power over the situation, it helps to refocus their view of themselves from being victims to being survivors. Defining themselves as survivors allows them to see themselves as strong enough to survive their ordeal. It is a more empowering image than seeing oneself as a victim.

Establishing Social Support

The client needs to find support people or activities in the community. The nurse can help the client to prepare a list of support people. Problem-solving skills are difficult for these clients when under stress, so having a prepared list eliminates confusion or stress. This list should include a local crisis hotline to call when the client experiences self-harm thoughts or urges and friends or family to call when the client is feeling lonely or depressed. The client can also identify local activi-ties or groups that provide a diversion and a chance to get out of the house. The client needs to establish community sup-ports to reduce dependency on health-care professionals.

Local support groups can be located by calling the county mental health services or the Department of Health and Human Services. A variety of support groups, both online and in person, can be found on the Internet.

Evaluation

Long-term treatment outcomes for clients who have sur-vived trauma or abuse may take years to achieve. These clients usually make gradual progress in protecting themselves, learning to manage stress and emotions, and functioning in their daily lives. Although clients learn to manage their feelings and responses, the effects of trauma and abuse can be far reaching and can last a lifetime.