00145 Post -Traumatic Syndrome Risk

Domain 9: coping/stress tolerance
Class 1: posttraumatic responses
Diagnostic Code: 00145
NANDA Tag: Postraumatic Syndrome Risk
Diagnostic focus: posttraumatic syndrome
Approved 1998 • Revised 2013, 2017 • Evidence level 2.1

NANDA Nursing Diagnosis Definition

Nanda nursing diagnosis « risk of post -traumatic syndrome ” is defined as: susceptible to experiencing persistence of an unbridled response to a traumatic and overwhelming event, which can compromise health.

Risk 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) In general, syndromes diagnoses constitute a part of the diagnostic statement, omitting related factors.
  • However, as a diagnosis of “risk of” (potential), it would be useful inadequate social support to face the aftermath of surviving a fire in which friends died). (b) If there are defining characteristics for any of the suggested alternative diagnoses, the nursing professional must decide whether it is more useful to propose a real diagnosis (for example, social isolation
  • Related to unacceptable social values) or use alternative diagnosis as etiology (for example, risk of posttraumatic syndrome related to social isolation).

Suggested alternative diagnostics

  • Inefficient community coping
  • Committed family coping
  • Incapacitating family coping
  • Ineffective coping
  • Social isolation
  • Low situational self -esteem
  • Family processes, interruption of the
  • Spiritual suffering
  • Personal identity disorder

NOC Results

  • coping: personal actions aimed at handling the stressful factors that test the resources of an individual
  • Social support: other people’s reliable help
  • Self -esteem: Personal judgment of one’s worth
  • Risk control: Personal actions to prevent, eliminate or reduce threats to health that can be modified
  • Beliefs on health: perceived threat: conviction that a possible personal health problem is serious and has potential negative consequences for lifestyle
  • Risk detection: Personal actions carried out to identify threats to your own health
  • Comfort status: psycho -spiritual: psycho -spiritual tranquility related to self -concept, emotional well -being, the source of inspiration, and the meaning and purpose in life
  • Anxiety level: severity of the manifestation of apprehension, tension or discomfort, from an unknown source
  • Stress level: severity of manifested physical or mental tensions, secondary to factors that alter the previous balance
  • Abuse recovery: degree of recovery after physical or psychological abuse, which can include sexual or economic exploitation
  • Personal resilience: adaptation and positive functioning of an individual after an important adversity or a crisis

Evaluation objectives and criteria

  • • Recovery of posttraumatic syndrome indicated by abuse recovery (if applicable); anxiety level; Psycho -spyritual state of comfort; coping; personal resilience; Self -esteem, and stress level
  • Other examples

    Risk factors are identified and controlled or eliminated, so that post -traumatic syndrome is not presented.

    • • shows a force of the right self
    • • It has adequate social support
    • • Demonstrates an appropriate affection to the situation
    • • Demonstrates an adequate social interaction
    • • Identify and use effective coping strategies

    NIC Interventions

    • Spiritual support: Help the patient to feel in balance and connected with a superior power
    • 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
    • Facilitation of guilt management: helps another person to face the painful feelings caused by a real or perceived responsibility
    • Safety promotion: Intensification of the sensation of physical and psychological security of the patient
    • Support Group: Use of a group environment to provide its members emotional support and health -related information
    • Risk identification: Analysis of possible risk factors, determination of health risks and prioritization of risk reduction strategies for a person or group
    • Inspiration of hope: Facilitation of the development of a positive perspective in a given situation
    • Improvement of self -esteem: Help a patient to improve the way of judging his own worth
    • 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
    • Family mobilization: use of family strength to positively influence patient health
    • Resilience promotion: Help people, families and communities, to develop, use and strengthen protective factors that must be used to face environmental and social stressful factors
    • Anxiety reduction: minimization of apprehension, fear, feeling or discomfort, related to the anticipation of an unknown danger of origin
    • Surveillance: Collection, interpretation and synthesis of patient data, continuously and with an end, to make clinical decisions

    Nursing Activities

    Valuations

    • • Assess the psychological response to trauma
    • • Assess the adequacy and availability of the support system and community resources
    • • Evaluate the family situation

    Patient and family education

    • • Explain to loved ones how to provide support

    Collaboration activities

    • • Offer information, or channel, to the patient to community resources (for example, psychological advice for violation, priests, crisis care centers, support groups, mental health professionals, social services, victims’ associations , survivors of traumatic situations)

    Others

    • • Provide social support opportunities and problem solving (such as participation in social and community activities)
    • • Motivate the patient to talk about the event
    • • Support the patient who needs an invasive medical procedure which could trigger memories:
      • Explain the need for the procedure
      • Pre -Anesthetic medication, if necessary, to reduce discomfort and discomfort
      • Stay with the patient during the procedure
      • Encourage the patient to talk about their feelings after the procedure

    At home

    • • above interventions can adapt to home care
    • • Encourage the family to continue with daily activities as they used to do it before the traumatic situation
    • • If only a family member experienced the traumatic situation, ensure to assess its impact on the rest of the family
    • • Offer support to loved ones, as well as the traumatized person

    Babies and Children

    • • Use game therapy (for example, draw, play with dolls) to help the child express feelings of fear, anger, guilt, etc.
    • • Adapt the explanations to the child’s development stage
    • • Help parents understand the child’s needs
    • • Collaborate with schools to establish psychological advice and other types programs to face posttraumatic stress caused by a disaster or other traumatic event
    • • Channel to a psychological advice and evaluation to a child who has had a traumatic experience, who suffers an injury that produced a deformation, which suffers from cancer or other serious illness

    Older people

    • • Evaluate the existence of multiple losses or crises that could affect coping skills
    • • Help the patient to resort to the skills he used previously to successfully face past crises
    • • Assess the presence of depression; channel a specialist in case necessary
    • • In patients living alone, encourage social interaction and help them develop a support system