Impact of Trauma, Crisis, and Disaster: Describe how these factors affect a client’s overall health.
Epidemiological and Etiological Risk Factors: Explore the factors that increase the likelihood of clients experiencing trauma, crisis, or disaster.
Clinical Presentation Differentiation: Differentiate among the clinical presentations of clients experiencing trauma, crisis, or disaster.
Nurse's Role: Explore the responsibilities of nurses in caring for clients affected by trauma, crisis, or disaster.
Application of Nursing Process: Apply the nursing process using clinical judgment functions in the context of trauma, crisis, or disaster care.
Overview
Definitions:
Trauma
Crisis
Disaster
Types of disasters:
Natural disasters
Human-caused disasters
Examples of Adverse or Traumatic Events or Experiences
Natural Disasters: Events like earthquakes, floods, hurricanes.
Human-Caused Disasters: Events such as terrorist attacks, industrial accidents.
Other Adverse Experiences:
Poverty
Racism, discrimination, and oppression (citing American Psychiatric Association, 2020a; Trauma-Informed Care: Implementation Resource Center, 2021; SAMHSA, 2021)
Trauma-Related Disorders
Effects of Trauma: Understand the various manifestations arising from exposure to trauma, including:
Intense fear
Feelings of confusion
Dissociation
Disruptive emotions (according to American Nurses Association, American Psychiatric Nurses Association, 2015; American Psychiatric Association, 2022; Trauma-Informed Care: Resource Center, 2021)
Types of Trauma
Various Types of Trauma:
Acute Trauma: Short-term trauma response.
Chronic Trauma: Prolonged exposure to traumatic events.
Complex Trauma: Exposure to varied forms of trauma, often in childhood.
System-induced Trauma: Trauma resulting from systemic issues.
Vicarious Trauma: Trauma experienced through exposure to the trauma of others.
Historical Trauma: Cumulative emotional and psychological wounds that are passed through generations (citing CT.gov, 2021; Trauma-Informed Care in Behavioral Health Services, 2014; Gone et al., 2019; Garner et al., 2021).
Theoretical Framework: Bowlby’s Attachment Theory
John Bowlby’s Perspective (1969): Highlights the significance of attachment relationships formed with caregivers (typically parents) during infancy to early childhood as essential for survival and brain development.
Early Childhood and Attachment Relationships
Key Points:
Development of a child's brain relies on healthy attachment relationships.
These relationships act as protective factors against stress and trauma.
Crucial in providing support and safety, modeling positive social-emotional skills and effective responses to needs.
Important for developing self-regulation (sources: Garner et al., 2021; Forkey, 2019; Herringa, 2017).
Bowlby’s Attachment Theory: Stages of Attachment
Stages of Attachment Development:
Birth to 3 months: Pre-attachment stage
6 weeks to 7 months: Indiscriminate attachment
7 months to 11 months: Discriminant attachment
24 months and beyond: Attachment continues to evolve (citing Esteves et al., 2020; Garner et al., 2021; Marshall & Frazier, 2019).
Polyvagal Theory: Nervous System and Trauma
Response Mechanism During Trauma: Interaction between various parts of the nervous system following a traumatic event:
Sympathetic Nervous System Activation: Triggers flight or fight response.
Dorsal Vagus Nerve Activation: Leads to fainting or freezing.
Ventral Vagal Nerve Activation: Calls for social engagement and safety (citing Porges, 2009; Huttunen & Mednick, 2018; Kolacz et al., 2019).
Trauma Response and Polyvagal Theory
Responses to Trauma:
Fight or Flight (Sympathetic Nervous System): Initial defense mechanism.
Faint or Freeze (Dorsal Vagus): Secondary defense mechanism characterized by shutdown behavior.
Fawn or Social Engagement (Ventral Vagus): Unconsciously using social skills to appease or protect oneself (citing Huttunen & Mednick, 2018; Kolacz et al., 2019).
Pathophysiology of Trauma: When the Past Becomes the Present
Types of Stress:
Chronic Exposure: Continuous stress leading to long-term adverse effects.
Toxic Stress: Prolonged activation of stress response hindering recovery of brain and body, leading to biological and genetic changes, particularly in the absence of protective factors (citing Forkey, 2019; Garner et al., 2021).
Toxic Stress
Consequences: Prolonged stress activation:
Prevents recovery of the body and brain.
Results in increased vulnerability and instability, impacting mental and physical health (Forkey, 2019; Garner et al., 2021).
Impact on Brain and Body
Hypothalamic-Pituitary Axis (HPA):
Chronic stress leads to hyperarousal.
Can be acute with temporary symptoms or chronic with ongoing perception of threat (citing Center on the Developing Child, 2021; CT.gov, 2021; Forkey, 2019).
Manifestations of Toxic Stress: Children and Adolescents
Developmental Changes:
Developmental delays as a consequence of toxic stress.
Behaviors such as engaging in risky activities.
Increased risk for autoimmune diseases and mental health concerns like suicide attempts (citing Center on the Developing Child: Harvard University, 2021; SNOHMIS Health District, 2021; Felitti et al., 1998).
Manifestations of Toxic Stress: Adults
Common Behavioral Manifestations:
Increased risk of intimate partner violence.
Social challenges such as financial stress.
Physiological effects including ischemic heart disease and increased risk of infections.
Mental health challenges demonstrated through substance use, suicidal thoughts, or depression (sources: Center on the Developing Child: Harvard University, 2021; SNOHMIS Health District, 2021; Felitti et al., 1998).
Impact of Repeated Toxic Stress
Neuroplasticity and Neurological Changes:
Trauma leads to changes in brain architecture and function.
Adverse childhood experiences (ACEs) can adversely affect brain structure, impacting both physical and mental health (citing Center on the Developing Child, 2021; Crouch et al., 2019; Luby et al., 2019; de Oliveira, 2020; Mateos-Aparicio & Rodriguez-Mareno, 2019).
Fear Learning
Significance of the Amygdala:
Functions as the brain’s fear detection system; dysfunction can lead to altered fear learning, which modifies nerve pathways, impacting emotional responses.
Mechanisms such as fear conditioning and fear extinction are important to understand traumatic re-experiencing (citing Stahl, 2021; Terranova et al., 2019; McLeod, 2021; Shalev et al., 2017).
Genetic Implications
Protective and Risk Factors:
Stress response activation and resilience can change through mechanisms such as epigenetics, affecting health and behavior across generations (citing Stahl, 2021; van Rooij et al., 2020; Estevez et al., 2019; Jiang et al., 2019).
Historic Trauma
Concept of Generational Trauma:
Trauma that manifests across generations, often seen in vulnerable populations, can lead to inherited predispositions affecting future generations (Jiang et al., 2019).
Trauma-Related Disorders in Children
Impact of Childhood Trauma:
Exposure and absence of protective factors can lead to developmental changes and difficulties in interpersonal functioning, potentially increasing chronic health issues and risk for trauma-related disorders (citing Felitti et al., 1998; Claypool et al., 2021; Crouch et al., 2019; Zhou et al., 2020).
Common Risk Factors: Mental Health and Trauma Related
Examples of Risk Factors:
Family history of mental health issues.
Current health and well-being concerns.
Individual experience of traumatic events (citing Felitti et al., 1998; Forkey, 2019; American Wellness Association, 2022; Kimberg & Wheeler, 2019).
Common Protective Factors: Mental Health and Trauma Related
Notable Protective Factors:
Social/Developmental: Secure attachment in childhood.
Behaviors/Practices: Effective emotional self-regulation (citing Felitti et al., 1998; Forkey, 2019; American Wellness Association, 2022; Kimberg & Wheeler, 2019).
PACES: Protective and Compensatory Experiences in Children
Importance of PACES:
Proves a protective factor for physical or mental issues, thereby increasing resilience and promoting well-being (citing Ratliff et al., 2020).
DSM-5-TR Categories: Trauma- and Stress-Related Disorders
Disorders Include:
Reactive attachment disorder (RAD)
Disinhibited social engagement disorder (DSED)
Post-traumatic stress disorder (PTSD)
Acute stress disorder (ASD)
Adjustment disorder
Other specified trauma- and stressor-related disorder
Unspecified trauma- and stressor-related disorder.
Disaster Management Cycle
Phases Include:
Pre-Disaster phase: Prevention/mitigation and preparedness.
Disaster phase: Impact assessment.
Post-Disaster phase: Recovery and response.
Crisis Emergency Model of Care
**Adaptation from Brennaman’s Theory of Crisis Emergencies (2021):
Framework emphasizes a structured response to crisis situations in care settings.
Impact of Disaster
Types of Disasters:
Human-caused disasters.
Natural disasters.
Effects: Emotional and physical impacts on affected populations.
Trauma Related Disorders: Prevalence
Common Disorders:
PTSD and adjustment disorder.
Population Groups at Higher Risk:
Women
Adolescents
Black Americans, Hispanic Americans, and Indigenous peoples
LGBTQ+ individuals
Military personnel and first responders.
Etiology and Risk Factors
General Risk Factors for Trauma:
Experiencing or witnessing trauma.
Childhood maltreatment.
Interpersonal violence.
Chronic exposure to adverse childhood events.
Witnessing the loss of life or limb (WHO, 2020, APA, 2022).
Adverse Childhood Experiences (ACEs)
Impact of ACEs:
Genetic vulnerabilities can arise from harmful childhood experiences leading to lifelong consequences including chronic illness and mental health issues (citing CDC, ACEs Pyramid, n.d.; Felitti et al., 1998; WHO, 2020; Shalev et al., 2017; Jiang et al., 2019).
Cultural Considerations
Generational Impact of Trauma:
Epigenetic changes experienced by vulnerable populations affected by historical trauma result in inequitable health outcomes, presenting higher rates of mental health problems and social inequity (citing Gone et al., 2019; Bhatt & Bathija, 2018).
Historical Trauma
Definition and Characteristics:
Represented as "invisible soul wounds" on the collective psyche of populations, leading to persistent inequalities and health disparities (citing Gillson & Ross, 2019; Joo-Castro & Emerson, 2020; Salerno et al., 2020).
Comorbidities: Trauma-and-Stress Related Disorders
Related Conditions:
Mental health disorders like bipolar disorder and alcohol use disorder, which may manifest as anxiety or aggression.
Physical health issues such as cardiovascular disease or type 2 diabetes may present as obesity (American Psychiatric Association, 2022).
Acute Stress Disorder and Post-Traumatic Stress Disorder: Shared Characteristics
Common Symptoms:
Intrusive manifestations and negative alterations in cognition/mood.
Distinguishing Feature:
Timeline:
Acute stress disorder: Occurs 3 days to 1 month post-trauma.
Post-traumatic stress disorder (PTSD) (citing American Psychiatric Association, 2022).
Criteria for PTSD: Individuals Younger Than 6 Years
Event Exposure: Must be exposed to, witness, or experience learning about a traumatic event.
Manifestations:
Intrusive manifestations
Avoidance manifestations or changes in thoughts/mood
Arousal or reactive manifestations (American Psychiatric Association, 2022).
Criteria for PTSD: Individuals Older Than 6 Years
Event Exposure: Definition remains similar to younger individuals.
Manifestations Include:
Intrusive behavior
Avoidance behavior or cognitive/mood alterations
Negative alteration in cognition or mood
Arousal or reactive behaviors (American Psychiatric Association, 2022).
Additional Manifestations of PTSD
Common Symptoms in Adults and Adolescents:
Depersonalization and derealization experiences.
Children's Unique Symptoms:
Time skew, omen formation, and post-traumatic reenactment (citing American Psychiatric Association, 2022; Hamblen et al., 2019).
Nursing Role in Trauma, Crisis, and Disaster
Primary Goal: Structure client care to address needs and promote positive health outcomes.
Trauma-Informed Nursing Practice: Avoid practices that could lead to re-traumatization (citing Fleishman et al., 2019).
Cultural Humility: Cultural-Ecological Model of Health
Shift in Perspective: Moving from asking, "Why are you here?" to "What has happened to you?" (citing Ranjbar et al., 2020).
Creating Equitable, Client Sensitive Care
Implementing Peplau’s Phases of Therapeutic Interventions: Focus on safety, equity, and inclusion while preventing traumatic re-experiencing and enhancing communication (citing SAMHSA, 2014; Fleishman et al., 2019; Olson, 2020).
Universal Trauma Precautions
Key Considerations for Care:
Acknowledge the impact of crisis, utilize therapeutic communication, uphold non-judgment, create a healing environment, and practice self-care (adapted from Rutgers Biomedical and Health Sciences, 2022).
Bias in Healthcare
Consequences of Bias: May result in health inequities and disparities.
Types of Bias:
Explicit bias
Implicit bias
Addressing Bias: Implementation of trauma-informed care to move beyond biases (National Center for Cultural Competence, n.d.a).
4 Cs of Trauma-Informed Care
Four Core Principles:
Calm
Contain
Care
Cope (Kimberg & Wheeler, 2019; Trauma-Informed Behavioral Care, 2014).
Crisis Interventions
Focus: Utilize therapeutic responses, de-escalation techniques, and support from team members (The National Institute for Occupational Safety and Health, 2020).
Disaster Management: Role of Mental Health Nurse
Key Responsibilities:
Provide psychological first aid and both physical and emotional support.
Identify problems and prioritize steps/actions needed (State of Indiana, n.d.).
Behaviors and Manifestations Requiring Further Assistance
When to Seek Additional Support:
Disorientation
Significant depression or anxiety
Pre-existing mental illness
Suicidal or homicidal ideations/plans.
Problems with substance use
Interpersonal violence or abuse
Prolonged disruptive behaviors/emotions related to disasters (State of Indiana, n.d.).
Post Disaster: Mental Health Risks
Possible Disorders Post-Disaster:
Adjustment disorders
Acute stress disorders
Mood disorders, including depression
PTSD
Anxiety disorders
Non-specific somatic symptoms or disorders
Substance use disorders (American Psychiatric Association, 2022).
Age-Related Manifestations After Disaster
Behavioral Symptoms:
Regression behaviors typical in children.
Isolation and withdrawal common among adolescents and adults.
Physical Symptoms:
Eating and sleep disturbances ubiquitous across age groups.
Psychological Symptoms:
Depression and anxiety prevalent in adolescents and adults, while sadness and angry outbursts may be observed more in children (State of Indiana, n.d.).
Trauma: Disease & Illness Prevention
Prevention Strategies Broken Down:
Primordial prevention
Primary prevention
Secondary prevention
Tertiary prevention.
Nursing Process and Plan of Care (1 of 3)
Initial Steps: Collect data and recognize clinical cues using a trauma-informed perspective.
Key Questions: What has happened? Assess current manifestations, evaluate life stressors, and consider functional impairments.
Recognizing Cues (Assessment)
Importance: Acknowledge the cues exhibited by clients to provide proper assessment and intervention using trauma-informed approaches (Trauma-Informed Care in Behavioral Health Services, 2014; Ranjbar et al., 2020).
Screening Tools
Purpose and Usage:
Not for diagnosis but to guide treatment and safety interventions.
Steps involve explaining the screening tool and ensuring active listening and support for client's discomfort (Trauma-Informed Care in Behavioral Health Services, 2014).
Nursing Process and Plan of Care (2 of 3)
Analyzing Cues: Assess and validate each symptom indicated, searching for evidence of hopelessness or helplessness in the client’s condition.
Prioritize Hypotheses: Focus on critical areas like risk for self-harm or harm to others, including command hallucinations (Trauma-Informed Care in Behavioral Health Services, 2014).
Nursing Process and Plan of Care (3 of 3)
Developing Solutions (Planning):
Client-Centered Care: Building effective relationships focused on safety and collaboration.
Execution Steps (Implementation): Implement strategies to enhance coping and diminish negative manifestations while collaborating with health care teams for medication and therapies.
Nursing Process and Plan of Care: Evaluation
Response to Interventions: Regularly evaluate the effectiveness of the plan of care and collect feedback from interprofessional teams to adjust resources and support accordingly.
Trauma-Informed Care: Key Principles
Core Principles:
Safety
Trustworthiness and transparency
Peer support
Collaboration and mutuality
Empowerment, voice, and choice
Attention to cultural, historical, and gender issues (SAMHSA, 2014).
Pharmacology and Therapies
Common Therapeutic Approaches:
Cognitive Behavioral Therapy (CBT)
Prolonged Exposure Therapy (PE)
Cognitive Processing Therapy (CPT)
Eye Movement Desensitization and Reprocessing (EMDR)