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PTSD: Nursing Interview and Diagnoses

by Brenda Marshall, EdD, MSN, RN

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    00:01 So, how are we coming up with our nursing diagnosis? Of course, we know that the nursing diagnosis doesn't emanate from us, it emanates from...? The patient.

    00:14 What is the patient's needs? What has the patient told us? How are we going to be able to go to a mutual agreed upon goal? Well, we know that a person has Post-Traumatic Stress Disorder.

    00:31 When we know that they have these maladaptive responses, one of our nursing diagnosis might actually be post-trauma response.

    00:44 Those maladaptive responses that occurred to an event that overwhelmed the individual.

    00:52 We also might think of anxiety as a nursing diagnosis.

    00:59 We know that oftentimes, because of the sense of worthlessness, because of the feeling that there is no future, these are some of our patients who are at high risk for suicidal ideation.

    01:15 Or, perhaps if there was someone who they wanted to hurt back, they might be at high risk for homicidal or hurting someone else.

    01:28 So, a nursing diagnosis might be risk for violence to self or others.

    01:37 Another nursing diagnosis we might be considering is ineffective coping.

    01:42 Especially for those patients who have started to eat or drink, or be using any kind of substances in order to help them cope with the way that they are feeling.

    01:53 And also risk prone behaviors.

    01:55 We are seeing patients who are taking risks, especially if they are reactive to situations that aren't actually occurring within the natural present day situation.

    02:09 So what can we do as psychiatric nurses? Well, the first thing we need to do is track.

    02:16 And tracking means that we are simultaneously going to be observing the patient for what we see, what their physical experience looks like, what their emotional experiences are? The way that they are making stories or cognitive schemas about what happened to them.

    02:36 We really want to make sure as we're watching this, we're looking at, are they watching us? Are they talking to us? Are they orienting to one side or another? Are they beginning to cry? Are they beginning to have some emotional responses to their words? And then, what's the story? We are psychiatric nurses.

    03:02 We want the story because the story lets us know what happened.

    03:08 We do not pursue the story of trauma when we see a person getting dysregulated.

    03:15 If you are interviewing a patient on the unit, and they are saying to "Yes, I had a very difficult childhood.

    03:23 Yes, there was sexual abuse in my family.

    03:27 Yeah, well, in my household, it was my uncle and you see them start clamming up." And then you say, "It wasn't so much I was worried about myself, because I can always take care of myself.

    03:42 It was when he went from my three year old sister." And you see, the person starts shaking.

    03:48 And they say it was my responsibility to take care of her, even though I was only five. I knew what he was capable on.

    03:56 You want to slow it down at that moment.

    03:59 They're giving you the story, but they're also putting themselves back in that room.

    04:05 And you have the right to say, "That must have been so difficult for that little girl. Wow." And let that person reflect for a minute.

    04:18 That little girl only five years old.

    04:21 Uh, I'm so sorry. She had to be a witness to that." We're giving that person the right to know it's over.

    04:31 I'm talking about it in the past that little girl when you were five.

    04:36 "Uh, I'm so sorry that she had to witness that." When you're seeing this, these stories, these present themselves in this present moment.

    04:52 It seems like the person is with us.

    04:57 But what's happening in this present moment is that these thoughts, these memories are being recalled and put in the moment with us.

    05:09 And we might see the person totally freeze.

    05:12 At that moment, they might say he was at the door.

    05:21 And they're frozen.

    05:22 They're frozen there, or they might actually collapse in front of you.

    05:28 They might have these impulsive movements of, "I want him to go away. Just make him go away." Even though there's no one in the room.

    05:38 This is a memory that is flooding an autonomic nervous system.

    05:45 The person ends up with the dissociation, because your brain is trying to save you.

    05:52 So you don't have to be in that moment.

    05:54 You're able to dissociate, break yourself off from that moment.

    06:03 So when we're doing a psychiatric interview with somebody who we believe has Post-Traumatic Stress Disorder.

    06:13 We're going to find out their history.

    06:16 We're going to be doing the mental status exam.

    06:20 We're going to be doing our psychiatric assessment: saying what the client looks like, listening to how they sound, look for the clarity of thoughts.

    06:31 We're also going to be thinking about a nursing plan.

    06:36 Meaning that along with our patient, we're going to be coming up with a nursing diagnosis, which is going to guide us, on how we are going to move forward.

    06:51 Sometimes, with trauma, the person who has had this trauma, they think that, "Maybe if I just stand up and I go back in, it'll be better." Maybe, if I just confront that bully who's been beating me up every day after school.

    07:14 If I just take them aside, that'll cure me." PTSD is a psychological problem.

    07:23 It requires a skilled intervention, so that we can explore what the problem is, and treat the problem.

    07:32 It is not something that a person can simply get over on their own.

    07:37 They need help.

    07:40 I often say, when people are asking me, "What does a psychiatric nurse do? Are you a real nurse?" I look at them. And I say, "Well, there are nurses that are our nurses.

    07:56 And their skill set is to be able to know, what are the instruments that are needed in an operation? There are other nurses who are ICU nurses, cardiac ICU nurses.

    08:11 And their skill set is specific to all of the machines and the patients, and the needs of that patient's cardiac problem during recovery.

    08:25 As a psychiatric nurse, my words are my scalpels.

    08:30 I have to be really careful.

    08:33 My words and my behaviors are my instruments that can help someone move into recovery.

    08:43 I don't expect anyone to think I know what's going on in them.

    08:48 They are the expert on them.

    08:52 That they have a psychiatric illness does not make them less or more, or different from me, except for I have a set of skills, that if I practice my profession, I can help them to be able to move towards recovery.

    09:13 There are things that can bring up unwanted memories, activate unwanted memories.

    09:23 These things that are activators when they happen, it is almost like a tsunami or a tornado that picks this person up and hijacks them, no matter who they are.

    09:40 Whether they are a lawyer, or whether they are a person who for the moment has lost their home and their insurance.

    09:48 If they have trauma in their history, there can be an event that is going to hijack this person and take them over, and make them feel as though, what is going on in the moment is actually what happened years ago.

    10:09 And we need to know that this person is suffering from Post Traumatic Stress Disorder, not psychosis.

    10:17 That this person may be having a psychotic event related to their trauma.

    10:24 Just as a person who has severe depression may have a psychotic break related to the depression.

    10:35 And when we treat the depression, the psychosis goes away.

    10:39 And when we treat the PTSD, the psychosis goes away.


    About the Lecture

    The lecture PTSD: Nursing Interview and Diagnoses by Brenda Marshall, EdD, MSN, RN is from the course Anxiety and Anxiety Disorders: GAD, Phobias, OCD, PTSD (Nursing).


    Included Quiz Questions

    1. Ineffective coping
    2. Risk for violence to self
    3. Anxiety
    4. Risk for violence to others
    1. “It is very important to talk about traumatizing incidents in the present tense.”
    2. “Tracking a client’s verbal and non-verbal behavior during an interaction is essential.”
    3. “Orienting the client and bringing them back to the present is very important."
    4. "Clients with PTSD can be at risk for violence to themselves or others."
    1. Mental status exam
    2. History
    3. Psychiatric assessment
    4. Cognitive-behavioral therapy
    5. Medical diagnosis
    1. An activator
    2. A flashback
    3. An instigator
    4. A reagent
    1. Risk-prone behaviors
    2. Anxiety
    3. Risk of violence to others
    4. Ineffective coping

    Author of lecture PTSD: Nursing Interview and Diagnoses

     Brenda Marshall, EdD, MSN, RN

    Brenda Marshall, EdD, MSN, RN


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