PTSD Nursing Diagnosis: Assessment, Criteria, and Care Planning

Traditionally, post-traumatic stress disorder (PTSD) has been associated with combat veterans and severe trauma, but recent research indicates that it’s much more prevalent than previously thought. PTSD can be brought about by many kinds of extreme stress, and diagnoses are on the rise among college students, women, and professionals like first responders.

Nurses are often in the best position to identify PTSD early, provide appropriate support, and open the door to mental health treatment. Training is key in this evolving space, and courses like Cracking the Code: Mastering the Differential Diagnosis of PTSD help nurses engage with interprofessional teams and coordinate successful care strategies.

Whether it’s assisting a patient through treatment and recovery or identifying symptoms in colleagues, the ability to spot and address PTSD is a life-changing skill. Here’s what goes into a PTSD nursing diagnosis and how it affects your practice.

Why Do Nursing Diagnoses Matter?

A nursing diagnosis is a clinical judgment about an individual, family, or community's response to health problems or life processes that guides the selection of nursing interventions. These interventions are based on individualized goals intended to support patient-centered outcomes.

Nursing diagnoses provide a framework for identifying patient needs, planning appropriate interventions, creating measurable goals, and evaluating the efficacy of treatments. It also helps nurses communicate effectively with other members of their team to strengthen the continuum of care while promoting evidence-based practice.

What Goes into a PTSD Nursing Diagnosis?

A PTSD nursing diagnosis involves recognizing a unique combination of symptoms and behaviors associated with trauma exposure. Unfortunately, while some evidence of PTSD may present strongly, in many cases it can hide beneath the surface. Sufferers often internalize symptoms, repress them for social reasons, experience delayed onset, or conflate PTSD with other medical conditions.

This can make a PTSD nursing diagnosis difficult, and nurses must be highly trained to identify symptoms during their initial and ongoing assessment to facilitate appropriate management and treatment. A nurse may be inclined to establish a nursing diagnosis for PTSD when observing the following, or when they are self-reported:

• Anxiety related to traumatic experiences
• Sleep pattern disturbance due to recurring nightmares
• Risk of self-harm due to emotional distress
• Impaired social interaction related to avoidance behaviors

Of course, a nursing diagnosis is not a substitute for a medical diagnosis. If PTSD is suspected, nurses should alert their colleagues and support professional intervention by appropriate mental health specialists.

Symptoms Supportive of a PTSD Nursing Diagnosis

A comprehensive nursing assessment is important to understanding the specific needs of any patient, and this is especially true for a complex condition like PTSD. Nurses will need to differentiate between PTSD and other serious mental health conditions like borderline personality disorder, acute stress disorder, generalized anxiety disorder, and major depressive disorder to make an accurate diagnosis.

A PTSD nursing diagnosis may be appropriate if patients exhibit some or all of the following symptoms:

Re-experiencing

If you encounter a patient re-experiencing a traumatic event, they may exhibit or report symptoms like intrusive memories or nightmares. These may come in the form of flashbacks or intense distress during waking hours when exposed to unique triggers related to trauma.

Avoidance

Patients dealing with PTSD may try to avoid thoughts, feelings, or reminders of the trauma. In doing so, some patients may choose social isolation as a mechanism of safety and experience difficulty engaging in daily activities.

Negative alterations in mood and cognition

Patients with PTSD may express persistent negative beliefs about themselves or the world. Nurses should look for distorted instances of blame, feelings of detachment, and an inability to experience positive emotions.

Alterations in arousal and reactivity

PTSD is often accompanied by signs of increased arousal, like hypervigilance, exaggerated startle response, irritability, difficulty concentrating, and sleep disturbances. These hyperactive events would be historically uncharacteristic of the person and correlate with the timeline of trauma.

Care Planning for a PTSD Nursing Diagnosis

Once a PTSD nursing diagnosis has been established and a nursing assessment is complete, the next step is to develop an individualized care plan. Effective care planning for PTSD involves:

Patient-Centered Goals

All care plans must have individualized, measurable goals. Nurses should consider realistic and achievable outcomes that reflect the patient’s current condition and capabilities. Some examples for PTSD sufferers could include reducing anxiety symptoms, improving sleep patterns, or enhancing social interactions.

Therapeutic Interventions

Care plans for patients with PTSD can involve therapeutic techniques like Cognitive Behavioral Therapy (CBT) or Eye Movement Desensitization and Reprocessing (EMDR). These interventions would be established in collaboration with a licensed provider, but play strongly into the plan of care for nursing.

Medication Management

While it’s outside the scope of nursing to order medications, nurses support medication adherence and assist in assessing its effectiveness. People experiencing PTSD may also resist treatment, avoid appointments, or forget to take their medication. Nurses need to be aware of potential pitfalls and create an environment where patients can be successful.

Monitoring and Evaluation

Nursing is a cyclical process where patients are continuously evaluated and re-evaluated for the effectiveness of interventions. Nurses will need to closely monitor the patient’s progress toward established goals and recommend changes based on their observation and experience.

Get Comfortable with the PTSD Nursing Diagnosis

Nurses play an indispensable role in the management of PTSD through careful assessment, accurate diagnosis, and detailed care planning. However, providing empathetic, patient-centered care while working in collaboration with other healthcare professionals can be challenging, and nurses need detailed training to succeed.

Premiere is committed to ensuring that healthcare professionals always have access to high-quality education that supports mental health challenges like PTSD. Courses like Cracking the Code: Mastering the Differential Diagnosis of PTSD give nurses the knowledge and skills it takes to make an accurate PTSD nursing diagnosis and coordinate effective care strategies.

All of Premiere’s award-winning courses are developed by industry experts and empower nurses to meet their professional obligations and develop their careers on a timeline that matches their busy schedule.

FAQs

What are the symptoms of PTSD?

Re-experiencing trauma, avoidance, alterations in mood, and enhanced arousal and reaction to related stimuli may all support a PTSD nursing diagnosis.

Is PTSD being diagnosed more frequently?

Yes. Research and data have led to greater awareness of the signs of PTSD. This has produced increased diagnosis rates in populations like college students, women, and first responders.

How can nurses improve their ability to identify and manage PTSD?

Continuing education is one of the most powerful tools for improving how nurses identify and manage PTSD in patients.

What care strategies should nurses follow when treating PTSD?

Nurses should focus on setting achievable, patient-centered goals, thoroughly understand therapeutic strategies, support patient success throughout the care process, and monitor the success of treatment plans.