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    This case study outlines the nursing diagnoses, goals, interventions, and evaluations for a patient with psychiatric conditions including risk for violence, anxiety, ineffective coping, sleep disturbance, dysfunctional grieving, and impaired social interaction resulting from trauma experienced during war. The nursing care plan aims to help the patient improve safety, coping skills, sleep, grieving process, and social interactions through interventions such as contracting for safety, relaxation techniques, counseling, medication management, and socialization opportunities. Evaluations indicate the patient is progressing in identifying triggers, using positive coping strategies, sleeping better, moving through grief, and increasing interactions, though still experiences anxiety and needs continued support.

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    PTSD care plan

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    This case study outlines the nursing diagnoses, goals, interventions, and evaluations for a patient with psychiatric conditions including risk for violence, anxiety, ineffective coping, sleep disturbance, dysfunctional grieving, and impaired social interaction resulting from trauma experienced during war. The nursing care plan aims to help the patient improve safety, coping skills, sleep, grieving process, and social interactions through interventions such as contracting for safety, relaxation techniques, counseling, medication management, and socialization opportunities. Evaluations indicate the patient is progressing in identifying triggers, using positive coping strategies, sleeping better, moving through grief, and increasing interactions, though still experiences anxiety and needs continued support.

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    69K views2 pages

    PTSD Care Plan

    Uploaded by

    leen2767
    This case study outlines the nursing diagnoses, goals, interventions, and evaluations for a patient with psychiatric conditions including risk for violence, anxiety, ineffective coping, sleep disturbance, dysfunctional grieving, and impaired social interaction resulting from trauma experienced during war. The nursing care plan aims to help the patient improve safety, coping skills, sleep, grieving process, and social interactions through interventions such as contracting for safety, relaxation techniques, counseling, medication management, and socialization opportunities. Evaluations indicate the patient is progressing in identifying triggers, using positive coping strategies, sleeping better, moving through grief, and increasing interactions, though still experiences anxiety and needs continued support.

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    of 2

    UNIVERSITY OF RHODE ISLAND COLLEGE OF NURSING

    NUR 334: PRACTICUM IN PSYCHIATRIC MENTAL HEALTH NURSING


    PT. INITIALS: CASE STUDY

    NURSING DIAGNOSIS PATIENT OUTCOME / GOALS NURSING INTERVENTIONS EVALUATION & REVISION

    Risk for violence directed towards self Distinguish between present and Evaluate s/s SI/suicidal/homicidal Pt remains safe, effectively contracts
    or others r/t intrusive memory, rage memories behavior for safety, and remains A&Ox3. Able
    reactions Recognize triggers Contract for safety to ID triggers and use positive coping
    Demonstrate relaxation techniques Encourage identification of triggers skills to deescalate self when
    Demonstrate control Reorient pt when necessary necessary. Compliant with
    Utilize deescalation techniques interventions.
    PRN meds as prescribed if necessary

    Anxiety r/t traumatic war experience, Identify anxious feelings and report Assess anxiety level, perceived threat
    environment change, preoccupation feeling control over factors Develop trusting therapeutic Pt presents with severe anxiety at
    with experience AEB fear, withdrawal contributing to fear relationship times causing feelings of depression,
    from support system Use appropriate coping strategies Determine other psychological effects, fear, and guilt. Identifies causes of
    Reduction in highest phase of anxiety change in mood/affect emotions and uses positive coping
    reached Assess for non threatening items that skills appropriately and effectively.
    yield phobic reactions Compliant with interventions and
    Remain c pt, decrease stimuli, create treatment.
    calming environment
    Assess for distortions and help correct
    Determine perception of cause,
    encourage use coping skills
    Encourage gradual participation in
    groups, activities, c peers
    Administer meds as ordered

    Ineffective coping r/t stress AEB Recognize ineffective coping Encourage identification ineffective
    disinterest in present and distancing strategies and correlate to negative coping mechanisms and
    from supports outcomes consequences Pt. able to ID negative ways of coping
    Express feelings adequately and Provide adequate time for pt to and verbalize appropriate positive
    utilize positive coping mechanisms discuss and explore feelings coping skills to replace. Verbalizes
    Encourage acceptance of emotions understanding of behavior
    Develop appropriate support consequences. More readily discusses
    systems/referrals for further therapies feelings. Plans to utilize resources as
    Administer meds as ordered part of support system.
    NURSING DIAGNOSIS PATIENT OUTCOME / GOALS NURSING INTERVENTIONS EVALUATION & REVISION
    Sleep disturbance r/t psychological Decrease frequency awakening during Obtain pt sleep hx, keep sleep diary, Pt. IDs and displays positive sleeping
    stress, AEB nightmares, flashbacks night and flashbacks and observe habits, develops appropriate bedtime
    insomnia Increase feelings of being rested, Check anxiety level a bed, routine. Decrease in
    experience limited fatigue during day teach/utilize relaxation techniques if nightmares/flashbacks/waking, and
    Fall asleep s difficulty, acceptable necessary increased feelings of being rested
    number hours of sleep Determine disturbance cause/trigger
    Form bedtime routine plan Provide environment conducive to
    sleep
    Teach good sleep hygiene habits
    Encourage development bedtime
    routine plan
    Meds as ordered
    Dysfunctional Grieving r/t loss of Demonstrate advancement through Provide education to wife Pt able to appropriately discuss
    comrades, pre-war identity, and stages of grief feelings and utilize coping skills when
    psychological health AEB verbal Express emotions associated c Encourage expression of feelings and necessary. Actively moving through
    expression guilt, hopelessness, grieving appropriately use of appropriate coping skills, teach grieving process.
    flashbacks, anger, and changes in Express hope/make appropriate plans new if necessary
    behavior patterns for future Assess for “survivor’s guilt”,
    Return to previous LOF avoidance behaviors
    Determine stage of grief
    Provide pt education about grief
    stages, what feelings/thoughts to
    expect
    Impaired social interaction r/t Recognize alterations in relationships, Make appropriate referrals to support Pt showing decreased desire to
    preoccupation c trauma, change in determine causes groups, counseling, therapy isolate, increased interactions with
    environment, survivor’s guilt, phobic Display willingness to increase social family, peers, and staff. Increased
    reactions to nonthreatening stimuli involvement Assess level of isolation participation in therapies.
    AEB withdrawal from family support, Increase participation in groups and Assess pt’s feelings associated with
    generalized loss of interest, guilt activities isolation
    Assess current support system and
    identify ways to improve if necessary
    Encourage interactions in groups,
    activities and with peers
    Make appropriate referrals
    Education and referrals for wife

    Resources
    Varcarolis, E.M., & Halter, M.J. (2010). Foundations of psychiatric mental health nursing. St. Louis, Missouri: Evolve Elsevier
    Varcarolis, E. M. (2011). Manual of psychiatric nursing care planning: Assessment guides, diagnoses, psychopharmacology (4th ed.). New York, NY: Saunders.

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