Nurse's Pocket Guide

isk for POST-TRAUMA SYNDROME
NURSING PRIORITY NO. 3. To promote wellness (Teaching/
Discharge Considerations):
• Provide a calm, safe environment in which client can deal
with disruption of life.
• Encourage client to identify and monitor feelings on an ongoing
basis. Promotes awareness of changes in ability to deal
with stressors.
• Encourage learning stress-management techniques to help
with resolution of situation.
• Recommend participation in debriefing sessions that may be
provided following major events. Dealing with the stressor
promptly may facilitate recovery from event/prevent exacerbation,
although issues about best timing of debriefing
continue to be debated.
• Explain that post-traumatic symptoms can emerge months or
sometimes years after a traumatic expeirence and that
help/support can be obtained when needed/desired if client
begins to experience intrusive memories/other symptoms.
• Identify employment, community resource groups (e.g.,
Assistance Support and Self Help in Surviving Trauma
[ASSIST], employee peer assistance programs; Red Cross/
other victim support services, Compasionate Friends). Provides
opportunity for ongoing support to deal with recurrent
stressors.
• Refer for individual/family counseling, as indicated.
Documentation Focus
ASSESSMENT/REASSESSMENT
• Identified risk factors noting internal/external concerns.
• Client’s perception of event and personal significance.
PLANNING
• Plan of care and who is involved in the planning.
• Teaching plan.
IMPLEMENTATION/EVALUATION
• Response to interventions/teaching and actions performed.
• Attainment/progress toward desired outcome(s).
DISCHARGE PLANNING
• Long-term needs and who is responsible for actions to be
taken.
• Specific referrals made.
Information in brackets added by the authors to clarify and enhance
the use of nursing diagnoses.
536 Cultural Collaborative Community/Home Care