Trauma, Stress, Dissociative
CHAPTER 16
Trauma- war, interpersonal trauma (sexual/physical abuse, abandonment, neglect), witnessing
something.
Trauma Informed care: framework for tx, recognizing and responding to all traumas. (realize + recognize
+ respond + resist)
Trauma Disorders: PTSD, Acute stress, Adjustment
Attachment Disorders: Reactive, disinhibited social engagement
Dissociative Disorders: Dissociative amnesia, Depersonalized/derealization, Dissociative identity disoder
TABLE 16.1 Trauma and Resilience Competencies for Undergraduate Nursing
Domain and Competency Content 16.1 pg 294
Self-Resilience: Demonstrate participation in and maintenance of self-care, managing stress, and supportive
relationships with others. Self-care, work/life balance, bullying, workplace incivility, lateral violence,
vicarious trauma
Resilience: Incorporate a strength-based approach in working with patients,
families, and communities affected by trauma. Components of resilience, somatic mindfulness, resilience narratives
ABCs (active coping, building strength, cognitive awareness and social support)
Knowledge: Explain the effects of adverse childhood experiences on risk-related
morbidity and mortality. Neurobiological changes that occur as a result of trauma, HPA dysregulation
Assessment: Ask patients if they have experienced neglect, substance use by a caregiver, physical or sexual abuse,
and how that has affected their health. Stigma, self -stigma, patient narrative
Diagnosis : Identify nursing diagnoses for those who have experienced trauma. Powerlessness Hopelessness
Impaired coping
Interventions : Apply best practices in providing holistic care to individuals and families with a history of trauma.
Individual and community resources, barriers to access resources, trauma-informed care
Evaluation: Involve the patient with a history of trauma in evaluating progress toward measurable individualized
goals. Specific, measurable, achievable, realistic, and timely (SMART) objectives
Ethics/Culture/Policy: Advocate for the patient/family/community with a history of trauma.#MeToo movement,
organizational culture, institutional betrayal, sociocultural trauma, gun violence, gender,
Attachment Disorders
Reactive: (unreactive)- emotionally withdrawn, rarely seeks comfort, or respond to
caregiver distress
Disinhibited Social Engagement: no normal fear of strangers, unfased by separation,
overly friendly, willing to go with anyone.
,Trauma Disorders
PTSD:
Exposure: direct, witnessing or learning of event (children blame themselves)
Intrusion: (flashbacks are dissociative) (children will have reduction in play,
nightmares)
Avoidance
Negative alterations in cognition/mood: (children get somatic sx-HA, stomach
issues, ect.)
Alterations in arousal and activity: (hypervigilant)
Psychological factors: attachment theory (R brain hemisphere, connection/attachment, develops
first).
Environmental Factors: external (substance abuse, violence, poor), parental modeling, cultural
expectations, stable/nurturing VS Chaotic/Non nurturing, adverse childhood experiences
*Resilience-regain mental health despite adversity, social support is crucial*
ASSESSMENT
-Interview, observe, screen (mental status exam), interact
-Hx from multiple sources
-Assess Sx: night-mare/-terror, hallucinations, intrusive thoughts, appearance, flashbacks,
play, self-injurious, behavior, dramatic mood swing, rage, numb, avoidance, somatic sx
(HA, stomachache)
-Developmental assessment- Denver II Developmental Screening (substance abuse can
slow development)
INTERVENTIONS
Stage 1: Provide Safety and stabilization, safe predictable environment
Stage 2: Reduce arousal, regulate emotion through sx reduction/memory work, accept
ambivalence, overcome avoidance, improve attention, transform memories
Stage 3: Development catches up, enhance problem solving, nurture self-awareness,
develop social skills and values, healthy support systems.
Window of tolerance: balance between sympathetic/parasympathetic arousal. Best time to
create healing environment. Increase self-regulation w/ safe support, environment,
meditate, get to know them, relaxation prior to trauma exploration.
, Meds: SSRI- taken in conjunction with therapy
EMDR: First line, helps process memories while focusing on other stimulation
Cognitive Behavioral therapy: psychoeducation, behavior modification, cognitive
therapy, exposure therapy, stress management
EVALUATION
Safety maintained
Anxiety reduced
Emotions appropriate for situation
Normal development
Child seeks adult for nurturance
ADULT GOALS
1. Able to manage anxiety by use of relaxation techniques, adequate sleep, and the ability
to maintain a role or work requirements.
2. Experiences enhanced self-esteem by maintenance of grooming/hygiene, maintenance
of eye contact, positive statements about self, and acceptance of self-limitations.
3. The patient exhibits an enhanced ability to cope by a decrease in physical symptoms, an
ability to ask for help, and seeking information.
OUTCOMES: Manage anxiety, increased Self-esteem
Meds: SSRIs (paroxetine, sertraline, fluoxetine, venlafaxine)
NO ANTIPSYCHOTICS (citalopram, amitriptyline, topiramate, and lamotrigine )
Acute Stress Disorder:
Sx right after occurrence and persist for 3 days (must be within month of trauma), either
improve or become PTSD.
Sx (must have 8 out of the following): sense numbing, derealization, inability to remember one
important aspect of event, intrusive memories, nightmares, feel as if event is recurring,
CHAPTER 16
Trauma- war, interpersonal trauma (sexual/physical abuse, abandonment, neglect), witnessing
something.
Trauma Informed care: framework for tx, recognizing and responding to all traumas. (realize + recognize
+ respond + resist)
Trauma Disorders: PTSD, Acute stress, Adjustment
Attachment Disorders: Reactive, disinhibited social engagement
Dissociative Disorders: Dissociative amnesia, Depersonalized/derealization, Dissociative identity disoder
TABLE 16.1 Trauma and Resilience Competencies for Undergraduate Nursing
Domain and Competency Content 16.1 pg 294
Self-Resilience: Demonstrate participation in and maintenance of self-care, managing stress, and supportive
relationships with others. Self-care, work/life balance, bullying, workplace incivility, lateral violence,
vicarious trauma
Resilience: Incorporate a strength-based approach in working with patients,
families, and communities affected by trauma. Components of resilience, somatic mindfulness, resilience narratives
ABCs (active coping, building strength, cognitive awareness and social support)
Knowledge: Explain the effects of adverse childhood experiences on risk-related
morbidity and mortality. Neurobiological changes that occur as a result of trauma, HPA dysregulation
Assessment: Ask patients if they have experienced neglect, substance use by a caregiver, physical or sexual abuse,
and how that has affected their health. Stigma, self -stigma, patient narrative
Diagnosis : Identify nursing diagnoses for those who have experienced trauma. Powerlessness Hopelessness
Impaired coping
Interventions : Apply best practices in providing holistic care to individuals and families with a history of trauma.
Individual and community resources, barriers to access resources, trauma-informed care
Evaluation: Involve the patient with a history of trauma in evaluating progress toward measurable individualized
goals. Specific, measurable, achievable, realistic, and timely (SMART) objectives
Ethics/Culture/Policy: Advocate for the patient/family/community with a history of trauma.#MeToo movement,
organizational culture, institutional betrayal, sociocultural trauma, gun violence, gender,
Attachment Disorders
Reactive: (unreactive)- emotionally withdrawn, rarely seeks comfort, or respond to
caregiver distress
Disinhibited Social Engagement: no normal fear of strangers, unfased by separation,
overly friendly, willing to go with anyone.
,Trauma Disorders
PTSD:
Exposure: direct, witnessing or learning of event (children blame themselves)
Intrusion: (flashbacks are dissociative) (children will have reduction in play,
nightmares)
Avoidance
Negative alterations in cognition/mood: (children get somatic sx-HA, stomach
issues, ect.)
Alterations in arousal and activity: (hypervigilant)
Psychological factors: attachment theory (R brain hemisphere, connection/attachment, develops
first).
Environmental Factors: external (substance abuse, violence, poor), parental modeling, cultural
expectations, stable/nurturing VS Chaotic/Non nurturing, adverse childhood experiences
*Resilience-regain mental health despite adversity, social support is crucial*
ASSESSMENT
-Interview, observe, screen (mental status exam), interact
-Hx from multiple sources
-Assess Sx: night-mare/-terror, hallucinations, intrusive thoughts, appearance, flashbacks,
play, self-injurious, behavior, dramatic mood swing, rage, numb, avoidance, somatic sx
(HA, stomachache)
-Developmental assessment- Denver II Developmental Screening (substance abuse can
slow development)
INTERVENTIONS
Stage 1: Provide Safety and stabilization, safe predictable environment
Stage 2: Reduce arousal, regulate emotion through sx reduction/memory work, accept
ambivalence, overcome avoidance, improve attention, transform memories
Stage 3: Development catches up, enhance problem solving, nurture self-awareness,
develop social skills and values, healthy support systems.
Window of tolerance: balance between sympathetic/parasympathetic arousal. Best time to
create healing environment. Increase self-regulation w/ safe support, environment,
meditate, get to know them, relaxation prior to trauma exploration.
, Meds: SSRI- taken in conjunction with therapy
EMDR: First line, helps process memories while focusing on other stimulation
Cognitive Behavioral therapy: psychoeducation, behavior modification, cognitive
therapy, exposure therapy, stress management
EVALUATION
Safety maintained
Anxiety reduced
Emotions appropriate for situation
Normal development
Child seeks adult for nurturance
ADULT GOALS
1. Able to manage anxiety by use of relaxation techniques, adequate sleep, and the ability
to maintain a role or work requirements.
2. Experiences enhanced self-esteem by maintenance of grooming/hygiene, maintenance
of eye contact, positive statements about self, and acceptance of self-limitations.
3. The patient exhibits an enhanced ability to cope by a decrease in physical symptoms, an
ability to ask for help, and seeking information.
OUTCOMES: Manage anxiety, increased Self-esteem
Meds: SSRIs (paroxetine, sertraline, fluoxetine, venlafaxine)
NO ANTIPSYCHOTICS (citalopram, amitriptyline, topiramate, and lamotrigine )
Acute Stress Disorder:
Sx right after occurrence and persist for 3 days (must be within month of trauma), either
improve or become PTSD.
Sx (must have 8 out of the following): sense numbing, derealization, inability to remember one
important aspect of event, intrusive memories, nightmares, feel as if event is recurring,
