APPLICATION OF THE NURSING PROCESSASSESSMENT

By Khimber Mae Lujares Relles in BSN III-B Edit doc APPLICATION OF THE NURSING PROCESS ASSESSMENT 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 and require 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.

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.

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 with dissociation or PTSD. Early treatment, client may report little idea about the relationship of past trauma 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.