Application of the Nursing Process
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7/28/2019 Application of the Nursing Process
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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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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.