Post Traumatic Stress Disorder, Nursing Diagnoses

NURSING DIAGNOSES

Case = Patient has got post traumatic disorder, that causes, she’s got violent, and sexual abuse. The vital sign check are Blood pressure 130/80 mmHg, Heart beat 90/minutes , freq of breath 20 (depend on time), body temperature 36^oC . And this is the diagnoses :

1. Disturbing the physical condition of the patient related to the process of disease.

a. Subjective data.

· Feeling dizziness.

· Hard to breath.

· Can’t sleep well/nightmare.

· Lost appetite.

b. Objective data.

· Vital sign :

ü Blood pressure 130/80 mmHg,

ü Heart beat 110/minutes , Tachicardi.

ü freq of breath 26 (depend on time), tachipnea.

ü body temperature 36^oC.

· Hard to sleep.

· Her face show, she was mortified the pain.

2. Disturbing the cognitive condition of the patient related to the process of disease.

a. Subjective data.

· Confused.

· Forgetful.

· Imagination a memory thats she’s hate, over and over.

b. Objective data.

· Out of focus, she didn’t concentration.

· Can’t analysis and planning a simple things.

· Dazed.

· Unabillty to take a decision.

· Deny the reality.

3. Disturbing emotional condition of the patient related to the process of disease.

a. Subjective data.

· Shy

· Hallucination and depressed.

· Angry.

· Nightmare.

b. Objective data.

· She seems, she was Feel guilty.

· Anxiety and frightened.

· Repetetive behavior.

4. Disturbing social condition of the patient related to the process of disease.

a. Subjective data.

· Agressive

· Bad preconception.

· Become disolate.

· Feel refused.

b. Objective data.

· Devided her self to another people.

· Conflict with the enviroment.

The theory of Etiology.

PhysicoDynamics

Ego clients have experienced severe trauma, often perceived as a threat to physical integrity or self-concept. This causes severe anxiety which can not be controlled by the ego and manifested in the form of symptomatic behavior. Because the ego becomes vulnerable, the superego can punish and cause individuals to feel guilty about the traumatic event. Id can be domianan, causing uncontrollable impulsive behavior.

Biologic

From the results of the research, abnormalities in the storage, disposal, and elimination of catecholamines that affect brain function in the locus ceruleus, amygdala and hippocampus. Hypersensitivity in the locus ceruleus can cause a person can not learn. Amygdala as memory storage. Hippocampus generate coherent narrative, as well as the location of time and space. Can inhibit the hyperactivity in the amygdala of the brain make sense of relationships in his memory so that a memory is stored in the form of nightmares, flashbacks, and other physical symptoms.

Family dynamic.

Type of formal education, family life, and lifestyle are estimates of significant occurrence of PTSD. Success in education below average, parents' negative behavior, and poverty of parents is a predictor for development of PTSD.

NURSING PRIORITY.

1. Give the safety to the client.

2. Help client to increase the self concept and get back the control feeling about her behaviors.

3. Help the asertif behavior progress, doesn’t the agressive behavior.

4. Increase the comprehension about what happen right now is causes by herself.

5. Help client or her family to learn how the way to keep their health to face or adapt in realistic on changed or past event.

P.S = maaf berantakan,... buatnya cepet" sih, tp lumayan kan buat acuan...? ^^