PTSD

32 talks about trauma, trauma response, stress response. There's a lot of good information in there. Specifically for today, we're going to focus on PTSD.

So before you're expecting with a lot of good concepts, some of this cottage-based learning, we're going to translate some of this to what does this mean for patients we care for in the hospitals?

Hello, so we're just going to talk about caring for a patient with PTSD. What does that mean? And then we'll apply a lot of this to a case study.

Okay. Trauma's another word that's like we go through different buzzwords and you could see things. Trauma, trauma's another one. Trauma in and of itself.

A traumatic event is defined in the DSM 5 as an event or a series of events in which an individual has been personally or indirectly exposed to actual or threatened death serious injury or sexual violence.

That's a very broad definition. You can think of a lot of things that this could encompass, but the patient has to have been exposed to or indirectly exposed to, so perhaps they witnessed something happening.

But an actual or threatened to death, serious injury or sexual violence. Patients with trauma in their history can have a very wide range of psychological responses, which is a key thing to be aware of if you're caring for a patient that comes from a traumatic situation or experience trauma.

You can see some people that are completely fine or minimizing, and you can see people that have very profound psychological and physiological responses.

So do be aware there's a wide range within this. Trauma can affect anyone from any background across the lifespan. And there are a lot of similar clinical manifestations with PTSD specific that overlap with other mental health disorders.

We'll talk through some of those. So when we do talk about some of these, we have post-traumatic stress disorder or PTSD, that's probably the more common one people have heard of.

There's another one called acute stress disorder or ASD. I kind of like to equate these two when we talk about depression, we had major depressive disorder and then adjustment disorder with depressive symptoms, that it was a shorter lived experience with a lot of the safe symptoms.

ASD or acute stress disorder is a short-term disorder related to experience of a major trauma. So usually within a month of the trauma for at least three days and causes just stress versus PTSD is a long-term disorder related to the experience, and the symptoms persist beyond a month.

So a patient is still having these. So it's not you know three days to a couple weeks. This is beyond a month, still having these symptoms that are occurring and causing an impact on day-to-day life.

So some of the events that can cause PTSD. There's a long list here, hyphen or ethanol. The key point here is it can be just about anything. Okay, so car crashes, natural disasters, wars, threats, threats of violence or injury.

We have had an increase in school shootings, increased incidence of mashing nationwide, really, just across different situations, not just schools, but lots of different ways people can experience trauma in different events that can cause PTSD.

So biology behind this. So we do have a stress response. Put a little picture in there as a reminder of what's going on, but big point with this is this cortisol, the adrenaline is getting released into the bloodstream and affecting, having a physiological response.

Okay, so we're getting this hyperarousal, this hypervigilance. Okay, so uh, and this was referenced in that video at the beginning. So the patient's hyper aware of what's going on in their body, but also hypervigilant with their surroundings.

What's going on with the surrounding? What's going on over there? You know, what are they doing over there? And looking for danger. You may see an overreaction to things in poor sleep.

And you can also see what's called intrusion, where people start to relive the trauma. So the trauma will intrude into their thoughts, that they'll have flashbacks, or they'll have similar feelings to how they felt when that thing was happening.

So you can see this intrusion that can occur. Um, and then you can also see what are called dissociative symptoms within that. So the patient's reliving that experience of what happened to that, and so a defense mechanism that is the piece that will disassociate that they might seem like they checked out, but their brain is protecting them from that, that they're not going to experience those symptoms.

Um, so it's a detachment from reality. So, this is an important note here that with psychosis in the psychotic presentation, patients have an altered reality or a loss of reality, versus this, the patient is detached from reality.

So they might disassociate or be detached from what's going on versus psychosis having a distorted or a loss of reality. So the epidemiology of this, PTSD does affect about 6% of the general population.

Rates vary a lot across different gender in different populations, particularly that's some military veterans. Um PTSD does affect females more commonly than males.

About 13% of military vets who are female experience this versus male veterans about six. So about double the number of female veterans of PTSD compared with men.

Symptoms can fluctuate, but will increase during periods of high stress. So if your patient has a history of PTSD and they're going through a stressful point, perhaps getting a new diagnosis or going through a stressful procedure, you might see a fluctuation, an increase in those symptoms that can occur.

So anyone of any age or any cultural group can develop PTSD. I mentioned before higher incidence among among military veterans. You also can see a higher incidence among people who see more traumatic events.

So law enforcement officers, fire predators, emergency medical personnel. You also can have what's called secondary trauma, where that this it didn't happen to you, but you saw it happen to someone else.

Um for a lot of you know paramedics, especially EMTs responding to situations and police officers responding to situations can then develop PTSD where they're reliving that.

General risk factors for this, um, severity of the event, um, so the more traumatic the event, the higher the risk of developing PTSD. Um social support and psychological support.

So if the patient already didn't have great coping skills or didn't have support and they experience this trauma, and they're not able to process that in a healthy way, you have a higher risk of developing PTSD, pre-existing mental illness, and then any additional stressors.

So perhaps after the trauma happened, continued on with work. Did it take any time off and had another stressor happened, or something's going on with my family?

Um that that high stress state increases the likelihood of developing PTSD. Most effective prevention method is a support system. So if you are caring for someone or working with someone or know someone who works in one of those high-risk groups, encouraging them, what's your support system?

What do you do to cope with the stress of your job? What do you do if you experience or witness a traumatic event? Um who helps to support you? What are the ways that you process this?

Because if they don't take time to process it in a healthy way, it will they can continue to relive that experience. You want to encourage avoiding ineffective coping skills.

Um the VA especially does a lot with this. They may provide specific group therapies for veterans, individual counseling, um, and job training to help manage some of these symptoms.

Perhaps they, if someone has PTSD, they shouldn't continue in a setting that's going to continue to relive that or bring that out. So some of that clinical manifestations for a patient with PTSD.

I mentioned this intrusion already, where they get these distressing memories of the event that intrude into their daily life. So they have these flashbacks, or perhaps at night they're having recurring dreams, or keep having memories of the event that come back into their head.

They may avoid stimuli or external reminders. So they might avoid a place. So perhaps there was a motor vehicle accident that happened on the stretch of the highway, and I can't go over there because I will relive that.

Or objects that bring up that or movies, or going to see avoidance of anything that's going to remind them of that event. You may see aggression occur.

So you can see more physical aggression, angry outbursts, irritable behavior, exaggerated startle response. That is the body has this physiological arousal that's occurring.

And then alterations in mood. So you might see more negativity that occurs, distorted cognitive processes, feelings of fear, guilt, shame, might see some detachment from others, or they're not able to process emotions in a healthy way.

Individuals with PTSD are also at risk for developing depression and alcohol or substance abuse. If you think about some of these things here, if we're not sleeping well, if I'm avoiding people, avoiding going out, having more negative thoughts going to increase the risk of developing depression.

And also possibly have some increased use of substance as a means, a maladaptive means of coping and handling that stress. So we as nurses, as the patient advocate, need to connect them with the needed resources.

So this might be going to psychotherapy, this might be pharmacological therapy. SSRIs can be used in conjunction with psychotherapy to help with general symptoms of PTSD.

I'm thinking about similar to anxiety. Um that's used to reduce nightmares associated with PTSD. So if the patient is having these nightmares at night, they were waking them up, sitting in the Crossin or sometimes to help reduce person.

Who's part of this? Where did you do your gut? I've actually done it, and one of my friends is in a master's program for counseling and talks about it a lot.

Oh yes. I've done it and all science is just a therapist. Therapy connections. But then I was worried about it. So it's positive talk. It is almost a ticket.

Yeah, so what have you guys heard or seen or screens? They're talking to people who are in counseling side of things. Um highly high reward type thing almost.

A lot of therapy is a lot of the high reward therapy is high risk because you have to revisit it to then change. I think EMDR I find fascinating, just that it is reliving it, but then by very purposeful movement of the eyes during this therapy session.

This is something that licensed there with Zoom who is bedside nurses, they're not trained to do this. Um, but in counseling and therapy programs, they teach people how to do this because it's going to rewire how the brain is processing that information through eye movement.

So really interesting area someone came up with, and again, another non-pharmacological approach to change how the brain is processing information.

So you go online and look it up. Um what did you see on the TikTok? I it was just talking about like how the movement works, like people were discussing whether it was beneficial or not, but how like it provokes the memories to come out, kind of like these patients get into like disassociative states and like kind of warp is behind themselves, so it's like bringing it back to surface.

Yeah. Just fascinating. They do this. Um I have a friend who took a child to a trauma therapist, and they did it with kids even, of just like bringing a toy across the kids' eyes, especially if the kids are following the toy while go out talking about the trauma, and even then, like that's something they can implement and just the way the eye movement is going and activating brain circuits, affecting how the brain is processing that trauma.

So fascinating area. Um to look up. Exposure therapy, so slowly exposing patients. Again, in a controlled setting, that we as bedside nurses, but this might be something they're doing.

Exposure therapy, so slowly bringing in things to talk about what happened, and then acupuncture is another thing. There is some research about acupuncture, can also help with processing some of those symptoms that can occur.

Typically, that is done for more than three months. Regular acupuncture, it's not a one-time thing, but again, resetting the nervous system and how they're processing trauma.

Um lifespan considerations. Um do know that the older adults with PTSD tend to have more somatic complaints that can occur. Um also should include cognitive screening.

If you're caring for an older adult, perhaps an older vet, also screening for any cognitive changes, perhaps some dementia that might be occurring.

Um, and a full history of trauma, symptomatology should be done routinely if you know your patients at a high risk for PTSD. Um knowing they may have some of those somatic symptoms over emotional, um, and also knowing that the patient who has PTSD is also in an increased risk for suicide.

Um, so nursing process, a lot of the same for talking about anxiety disorders, ensuring safety, lowering anxiety levels if they're in that extreme anxiety, providing reassurance that they are safe.

We are here to help you, maintaining a quiet and calm environment and an immediate pharmacological intervention to help reduce that severe level of anxiety.

And after the anxiety level is brought down, talking about how can we cope with these feelings that you're feeling, what can we do to help with this?

Um, do note in national national disasters, you know, large hurricane or large tornado or large scales of things, you may see an entire community that's involved with trauma.

So if you're in a community type of setting, that might be something that a whole group of people or a neighborhood, or if there's a shootings that occur, sometimes it is a whole community that needs talked with and helped with that.

So assessment, thinking about risk and protective factors, safety. Um, specific interview questions, so some of the unique components here. Um, if your patient's having flashbacks, you know, are you able to identify what triggers those flashbacks?

Those startle responses and sleep disturbances are huge. Uh I was driving around the county somewhere, and there I saw very specific sign that said, vet in this area, please do not rev your engine.

Um street corner. But my assumption is that someone probably read out just that rubbing of the engine was enough of a trigger for that person. This is what you just had that outside their house on both sides of the road.

That in this neighborhood, please don't rev your engine. Um they had a very specific thing they were able to identify that was triggering for them.

I should never pressure the patient to reveal information the patient's not ready to share. That seems obvious, but we as humans tend to be curious.

Maybe we hear our patient is a vet, and wow, that's so cool, you served this war. I want to hear more information, but you should never pressure your patient to reveal information they're not ready to share.

I have talked to the best, and some of them are very open to talking about their experience, and some are like absolutely not. I'm not sharing anything ever my whole life about what I did in my time in the military.

So you ask your interview questions, and if patients say I don't want to talk about that, and you're non-judgmental tone, we're not going to pressure that.

We're not going to probe and offer those open-ended questions to let people share what they're willing to share and demonstrate respect for their own personal boundaries.

So priority concerns, potential for violence against still for others, particularly if they're having flashbacks and reliving those traumatic experiences, especially with military, uh, there is that potential for violence there with that.

Anxiety, fear, inadequate coping skills, and sleep disturbances. Again, the priority with all this is safety. So assessing, and this may be a collateral with family assessing what happens when they're having those flashbacks.

What did they do? Um, what happened, uh, and what can we do to promote safety for that patient? Um, so goals, we want our patients to be safe and free from injury or firm, decreased anxiety, reduction or cessation of nightmares, be able to discuss the emotions related to the traumatic experience, um, take the medications ascribed if they are prescribed something.

So some patients may only require limited intervention. Um some may require more. So that's where that nursing assessment is so important. Looking at the big picture, how long they've been doing with this, um, and then see do they need long-term assistance with this?

And then it we should be reinforcing their understanding of effective coping strategies. Um, all the things we just talked about for anxiety carry over to this.

So relaxation techniques, limiting caffeine, limiting alcohol, um, because those can amplify the anxiety response within the body. Okay. So, as a result of our care, what we should expect to see happen, the patient should be able to use self-combing technique.

Uh, they should have less cognitive distortion, less repetitive thoughts, less time spent on their thing that's causing worry. Uh and if that isn't able to happen, we'll need to encourage, you know, do we need to talk to the doctor if they need a different dose of a medication, uh, a different treatment, or something else to help avoid triggers while they're running coping strategies.

Okay. Questions on PTSDs? I'm sorry, it's not on PDSC. It's kind of you saw the word collateral information. Yes. I'm a little bit confused about when it's okay when during a test question to get collateral information from family versus when it's hypo violated with this within the psych.

So, what does it mean you get to talk to a family member about what the patient's what they've been acting like and feeling and supporting collateral obtaining, not giving.

You're obtaining. Is my obtaining information and hypovolation? No. No, okay. Yeah. So if I call you and say.