00141 Post -Traumatic Syndrome

Domain 9: coping/stress tolerance
Class 1: posttraumatic responses
Diagnostic Code: 00141
Nanda label: posttraumatic syndrome
Diagnostic focus: posttraumatic syndrome
Approved 1986 • Revised 1998, 2010, 2017 • Level of evidence 2.1

NANDA Nursing Diagnosis Definition

Nanda’s nursing diagnosis « posttraumatic syndrome ” is defined as: persistence of an unbalanced response to a traumatic and overwhelming event.

Definite characteristics

  • Aggressive behaviors
  • ATTACTION OF ATTENTION
  • alteration of the mood
  • Anxiety (00146)
  • Avitation behaviors
  • Compulsive behavior
  • denial
  • Depressive symptoms
  • Dissociative amnesia
  • enuresis
  • Exaggerated alarm response
  • Express alienation
  • Express anger
  • Express numbness
  • Express dishonor
  • Fear (00148)
  • Flashbacks
  • Gastrointestinal irritation
  • Cepaleas
  • Cardiac palpitations
  • Desperateness (00124)
  • Horror
  • Hypervigilance
  • During dreams
  • Distinguishing thoughts
  • Irritable mood
  • Neurosensorial irritability
  • Nightmares
  • Panic attacks
  • Rabia
  • Report feel guilty
  • Repression
  • Inappropriate use of substances

Related factors

  • Decrease in the force of the ego
  • The environment does not meet the needs
  • Exaggerated sense of responsibility
  • Inadequate social support
  • Perceive the event as traumatic
  • Autolesive behavior
  • Survivor role

Risk population

  • Persons displaced from home
  • People who experience a prolonged duration of a traumatic event
  • People exposed to disaster
  • People exposed to epidemics
  • People exposed to events that involve multiple deaths
  • People exposed to events outside the range of usual human experiences
  • People exposed to serious accidents
  • People exposed to war
  • People with humanitarian service professions
  • People who suffer serious threats
  • People who presence mutilation
  • People who witness violent death
  • People with significant people who have suffered serious injuries
  • People with significant people who have suffered serious threats
  • People with the destroyed home
  • People with a history of having been prisoners of war
  • People with a history of abuse
  • People with a history of having been victims of crime
  • People with a history of detachment
  • People with a history of torture

Associated problems

  • Depression

Suggestions of use

(a) If the related factor is the violation, use the diagnosis of traumatic violation syndrome, (b) as it is about the diagnosis of a syndrome, its approach does not require related factors and the second part of the approach must be omitted (Etiology), (c) It is likely that other nursing diagnoses are required (for example, suicide risk) in addition to traumatic violation syndrome, to focus more specifically nursing activities.

Suggested alternative diagnostics

  • Family coping committed or disabling
  • Ineffective coping
  • Automutilation, risk of
  • Traumatic violation syndrome
  • suicide, risk of
  • Self -directed violence, risk of

NOC Results

  • coping: personal actions aimed at handling the stressful factors that test the resources of an individual
  • Impulses self -control: Self -limitation of compulsive or impulsive behaviors
  • Sothing containment: Personal actions to avoid self -inflicted (non -lethal) intentional lesions
  • Anxiety level: severity of the manifestation of apprehension, tension or discomfort, from an unknown source
  • Depression level: severity of the melancholic mood and the loss of interest in life
  • Fear level: severity of the manifestation of apprehension, tension or discomfort, from an unknown source
  • Fear Level: Child: Gravity of the manifestation of apprehension, tension or discomfort, from an unknown source, in a child between one and 17 years of age
  • Abuse recovery: economic: scope of control of economic and legal aspects after an economic exploitation
  • Abuse recovery: emotional: scope of the healing of psychological injuries due to abuse
  • Abuse recovery: sexual: scope of healing of physical and psychological injuries due to sexual abuse or exploitation

Evaluation objectives and criteria

  • • Demonstrates abuse recovery: sexual, as manifested by the following indicators (specify from 1 to 5: none, limited, moderate, substantial or broad):
    • Expressions of the right to have had protection against abuse
    • Healing of physical injuries
    • Relief of wrath of non -destructive forms
    • Evidence of relationships without abuse with people of the opposite (or the same sex)
  • • Demonstrates abuse recovery: sexual, as manifested by the following indicators (specify 1 to 5: broad, substantial, moderate, limited or none):
    • Verbal expression of feelings regarding abuse
    • Sleep problems
    • Depression
    • Automutilation
    • Suicide attempts
  • Other examples

    • • Recognizes the importance of psychological advice
    • • Shows hope and empowerment
    • • It shows no eating disorders
    • • Identify the feelings and situations that lead to impulsive acts
    • • Control the destructive and harmful impulses without supervision
    • • Request help when it is unable to control your impulses
    • • Reports relief of physical symptoms (for example, headache, gastrointestinal discomfort)

    NIC Interventions

    • Economic resources support: Help the individual and family to maintain and manage the economic resources with which to cover health needs
    • Psychological advice: Application of an interactive process of help focused on the needs, problems or feelings of the patient and their loved ones, to improve or strengthen the coping, solution of problems and interpersonal relationships
    • Training for impulse control: Help the patient to control their impulsive behaviors through the application of problem -solving strategies in social and interpersonal situations
    • Behavior management: Self -injury: patient assistance to reduce or eliminate self -timing or self -abuse behaviors
    • mood management: provision of security, stability, recovery and maintenance, to a patient who abnormally experiences a depressed or elevated mood
    • Security improvement: increased sensation of physical and psychological security of the patient
    • Improvement of coping: Help the patient to adapt to stressful factors, changes or perceived threats, which interfere with the satisfaction of the demands and the roles of life
    • Improvement of the Support System: Patient facilitation of support by family, friends and community
    • Suicide prevention: Reduction of the risk of self -inflicted damage with the intention of ending life
    • Anxiety reduction: minimization of apprehension, fear, omen or discomfort, related to the feeling of an unknown danger of origin
    • Group therapy: application of psychotherapeutic techniques to a group, including the use of interaction between its members
    • Therapy for traumatic situations: Child: application of an interactive help process to solve the traumatic experience of a child

    Nursing Activities

    • See also nursing activities for diagnosis Post -traumatic syndrome, risk of.

    Collaboration activities

    • • Follow hospital or institutional norms, regarding the legal responsibility of informing the authorities

    Others

    • • Improve the patient’s sensation in the following ways:
      • Monitor and limit telephone calls at the patient’s request
      • Monitor and limit visits
      • Contemplate the possibility of assigning a private or semi -relieved room and the selection of the roommate
      • Establish security measures to avoid physical damage to the patient or other people
    • • (NIC) Psychological advice:
      • Establish a therapeutic relationship based on trust and respect
      • Demonstrate empathy, warmth and authenticity
      • Use reflex and clarification techniques to facilitate the expression of concerns
      • Motivate the expression of feelings
      • Reveal some aspects of one’s experience or personality, to promote authenticity and trust, as required
      • Consequently do decision making when the patient is subject to high levels of stress, whenever possible