Psychiatric Mental Health Nursing by Videbeck

226 Unit 3 CURRENTSOCIAL ANDEMOTIONALCONCERNS

he or she appears terrified and may cry, scream, or at-
tempt to hide or run away. When the client is dissoci-
ating, he or she may speak in a different tone of voice
or appear numb with a vacant stare. The client 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
content. Clients who have been abused or trauma-
tized report reliving the trauma, often through night-
mares or flashbacks. 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 hallucinations or buzzing voices
in their head. Self-destructive thoughts and impulses
as well as intermittent suicidal ideation are also com-
mon. Some clients report fantasies in which they take
revenge on their abuser.

SENSORIUM AND

INTELLECTUAL PROCESSES

During assessment of sensorium and intellectual pro-
cesses, the nurse usually will find that the client is
oriented to reality except if the client is experiencing
a flashback or dissociative episode. During those ex-
periences, the client may not respond to the nurse
or may be unable to communicate 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 treatment, the client may report little idea about
the relationship 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 that these clients will have
low self-esteem. They may believe they are bad people
who somehow deserve or provoke the abuse. Many
clients think they are unworthy or damaged by their
abusive experiences to the point that they will never

be worthwhile or valued. Clients may think they are

going crazy and are out of control with no hope of re-

gaining control. Clients may see themselves as help-

less, 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 directions from another or have an-

other person monitor his or her performance. Close

relationships are difficult or impossible because the

client’s ability to trust others is severely compromised.

Often the client has quit work or been fired, and he or

she may be estranged from family members. Intru-

sive 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. Over-

eating or lack of appetite is also common. Frequently

these clients 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

setting when working with clients who dissociate or

have PTSD related to trauma or abuse include the

following:

• Risk for Self-Mutilation


• Ineffective Coping


• Post-Trauma Response


• Chronic Low Self-Esteem


• Powerlessness
  In addition, the following nursing diagnoses may
  be pertinent for clients over longer periods, although
  not all diagnoses will 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:

1. The client will be physically safe.


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