Assessment

Nursing DX/

Clinical Problem

Client Goals/ Desired Outcomes

Nursing Interventions/Actions/Orders and Rationale

*I

Evaluation

Goals

Interventions

Subjective

∙ Client states the xxxx family lived through a hurricane and lost their home as a result

∙ Family relocated to xxxxx 6 months ago

Objective

∙ Could include sleep disturbances, vivid flashbacks, depression, etc.

Problem

Post-trauma syndrome

Long Term:

Client will return to pre-trauma level of functioning as quickly as possible (Ackley & Ladwig, 2008).

∙ Explore and enhance available support systems and resources. (Support systems and community resources can encourage communication and can reduce isolation) (Ackley & Ladwig, 2008).

∙ Help the client regain previous sleep and eating habit. (Post-trauma syndrome can impact sleeping and eating habits, working to get these areas back to pretrauma levels is key) (Ackley & Ladwig, 2008).

∙ Help the client use positive cognitive restructuring to reestablish feelings of self-worth. (Fluctuations and feelings of decreased well-being can occur due to post-trauma syndrome) (Ackley & Ladwig, 2008).

∙ A successfully met goal would be evident by the client returning to her level of functioning before the traumatic event. An unsuccessfully met goal would be if the client does not return to pretrauma functioning level.

∙ If the client can identify support systems and community resources, the intervention is successful. If the client can not, the intervention has not been successful.

∙ If the client’s sleep and eating habits return to what they were before the traumatic event the intervention is successful, if these areas to not return to normal, the intervention was not successful.

∙ The intervention would be successful if the client verbalizes increased feelings of self-worth. If the client can not do this, the intervention has not been successful.

R/T

Disaster, sudden destruction of one’s home and community

AEB

Anxiety, flashbacks, and fear (Ackley & Ladwig, 2008).

Short Term:

Client will acknowledge traumatic event and begin to work with the trauma by talking about the experience and expressing feelings of fear, anger, anxiety, guilt, and helplessness a week from the date of care, xxxxx(Ackley & Ladwig, 2008).

∙ Observe for a reaction to a traumatic event in all clients regardless of age or sex. (Post-trauma syndrome can impact anyone, at any age) (Ackley & Ladwig, 2008).

∙ Provide a safe and therapeutic environment. (A safe, therapeutic environment will allow the client to feel more at ease talking through the traumatic experience) (Ackley & Ladwig, 2008).

∙ Remain with the client and provide support during periods of overwhelming emotions. (Support will allow the client to feel at ease discussing the traumatic event) (Ackley & Ladwig, 2008).

∙ Use touch with the client's permission (e.g., a hand on the shoulder, holding a hand). (Touch can be therapeutic to a client, and can further encourage open discussion) (Ackley & Ladwig, 2008).

∙ A successfully met goal would be evident by the client using open communication to discuss feelings about the hurricane that occurred. An unsuccessfully met goal would be shown if the client does not openly communicate feelings related to the traumatic event.

∙ A successfully carried out intervention would be if the client can be identified as either having post-trauma syndrome or not having post-trauma syndrome.

∙ If the client verbalizes feeling safe in the environment the intervention has been successful. If the client does not feel safe, the intervention has not been successful.

∙ If the client verbalizes feeling supported during intense emotional periods the intervention has been successful. If the client does not feel supported the intervention has not been successful.

∙ If the client verbalizes feeling additional support as the result of physical touch the intervention has been successful. If the touch is not therapeutic to the client, the intervention has not been successful.