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APPLICATION OF THE NURSING PROCESS-ASSESSMENTByKhimber Mae Lujares RellesinBSN III-BEdit doc

APPLICATION OF THE NURSING PROCESSASSESSMENT

Health History reveals that the client has a history of trauma and abuse. It may

be abuse as a child or in current relationship. It generally is not necessary or

desirable for the client to detail specific events of the abuse or trauma.

Clients who present with clinical symptoms of dissociative disorder require a

thorough physical examinations to rule out organic causes such as brain tumor.

SADOCK AND SADOCK (2003) assessment focus suggestions on clinical features

such as: Clients level of orientation and ability to maintain contact with reality.

History of a precipitating emotional trauma

Clients ability to recall recent and past events or the use of confabulation to

cover up memory gaps

Clients level of anxiety and possible coexistence of depression.

History of suicidal gestures or self-mutilation

Clients degree of impaired social functioning(e.g. stormy relationships, drug

and alcohol abuse) Clients degree of occupational functioning (e.g. inability to hold a job due to

changes in personality)

Evidence of other psychiatric disorders that are difficult to differentiate from

dissociative disorder (e.g. psychosis and personality disorders)

A. General Appearance and Motor Behavior

Often appears hyper alert and reacts to even small environment noises with a

startle response.

Client may feel very uncomfortable if the nurse too close physically andrequire greater distance or personal space than most people.

Appear anxious or agitated and may have difficult sitting still, often needing

to pace or move around the room.

Sometimes client may sit very still, seeming to curl up with arms around

knees.

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7/28/2019 Application of the Nursing Process

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B. Mood and Affect

->Nurse must remember that a wide range of emotions is possible, from

passivity to anger.

Client may look frightened, scared, agitated or hostile depending on

experience.

Two common experiences

FLASHBACK

- appears terrified and may cry, scream or attempt to hide or run away.

DISSOCIATING

-may speak in a different tone of voice or appear numb with a vacant stare.

- Client may report intense rage, anger or feeling dead inside and unable to

identify any feelings or emotions.

C. Thought Process and Content

-> Clients ability to think about other things or to focus on daily living are

affected by the intrusive, persistent thoughts.

Some clients report hallucinations or buzzing voices in their heads.

Self destructive thoughts and impulses as well as intermittent suicidal

ideations are also common.

Some clients report fantasies in which they take revenge on their

abusers.

D. Sensorium and Intellectual Processes

Client is oriented to reality.-Client is oriented to reality except if the client is experiencing a flashback or

dissociative episodes.

Client may not respond to the nurse or may be unable to communicate at all. Memory gaps- periods which they have no clear memories.

-These periods may be short or extensive and are usually related to time of the

abuse or trauma.

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Client has impaired ability to concentrate or pay attention.- Intrusive thoughts or ideas of self harm often impaired the clients ability to

concentrate or pay attention.

E. Judgment and Insight

The clients insight is often related to the duration of his or her problems withdissociation or PTSD.

Early treatment, client may report little idea about the relationship of pasttrauma to current symptoms and problems.

Clients may be quite knowledgeable if they have progressed further in treatment. Client ability to make decisions or solve problems may be impaired.