ptsd capstone
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Post Traumatic
Stress DisorderCristine SasanoN360-Mental Health
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Identifying data & Legal
status51 year old femaleHeight 63!
"eight 1#3 l$s % MI 30 '($ese)
*dmitted 5+,1+15
Legal Status 06
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.SM .iagnosis
I/ 30/1 2ost-traumati Stress .isorder4 hroni30/0 2oly-su$stane a$use deendene 'alohol4
anna$is4 oioids4 and amhetamines)
,,/1, Su$stane indued syhosis $y history rule outSS7I indued mania
II/ 2ersonality disorder4 mi8ed 9ith $oth $orderline andnarissisti features
III/ Status ost neumonia4 hyerliidemia4 asthma4 hroni
ain4 status ost hysteretomy4 $ilateral salingooohoretomy4 history of melanoma4 history of $reastaner4 o:arian yst4 osteoorosis4 multile re:iousa$dominal surgeries inluding $reast imlant
I;/ 2syhosoial and en:ironmental ro$lems
Chroni Mental and medial illnesses and limited suort
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7eason for *dmission
2atient 9as $eing disruti:e at grou home/=>ore aart room! and 9al?ing around na?ed
2atient stated she 9as =leaning u!
"ent to HSH '6thhositali@ation) for
reommended hositali@ation due toreommendations to sta$ili@e inreasedsyhoti+$i@arre $eha:iors/ Not omliant 9ithC7
>ransferred to Aahi Mohala on 5+,1+15 on alegal status '13) suggesting susension of C7
(riginal harges are of one ount of theft in thethdegree and one ount of rohi$itions in u$liareas in the 1stdegree
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Binanial data+Insurane
Soial Seurity .isa$ility Insurane 'SS.I)
nder age 66
na$le to erform su$stantial 9or? $eause
of disa$ility
Non-emloyed
Homeless
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2atientDs desrition ofro$lem
=*t a young age4 I 9as raed $y my unle!
=*t 16 I got married to my no9 e8-hus$and 9hom I 9asmarried to for ,0 years/ He $eat me all the time andthreatened to ?ill me/ He istol 9hied me/ I tried tolea:e $ut he 9ould threaten to End me and ?ill me/!
=>ill this day I 9a?e u 9ith my Ests lenhed4 sared formy life/ I ha:e nightmares 9ith him trying to hase meand ?ill me and my daughter/ It is ne:er ending $eause I
feel li?e I an ne:er get a9ay from him/!
=Fears ago I 9as diagnosed 9ith $reast aner4 I 9asderessed then started doing ie/ >his aused a loss inmy onnetion 9ith my daughter 9ho I am no9 trying toma?e amends 9ith!/
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Gthniity+7eligion+Sirit
ualCatholi.oesnDt attend hurh
Cauasian
.oesnDt ha:e any rituals
sed to go to N* and ** and $elie:ed it heled at thetime $efore her relase
elie:ed in the Higher 2o9er
elie:es in
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2atientDs StrengthDs &
LimitationsStrengths Comlies 9ith mediations
*$le to identify goals
Cooerati:e and artiiates in ati:ities4 leads ommunitymeetings
Some higher eduation 'ollege)
*dmits to su$stane a$use
*$le to maintain le:el 3-
Can identify triggers to 2>S.
7eogni@es oing mehanisms
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2atientDs StrengthDs &
LimitationsLimitations Limited suort
Homeless4 non-emloyed
Limited family relationshi
Chroni ain4 siatia 'holds her $a? from
ati:ities)
La?s slee due to reurrent dreams+nightmares
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Mediations7anitidine '*N>*C) 300mg one daily
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Mediations
*d:air 'BL>IC*S(NG+S*LMG>G7(L) 1 inh ,8 daily
*sthma
Cyrohetadine '2G7I*C>IN) 16mg one daily
*llergies
;entolin '*L>G7(L) , uKs 27N*sthma '27N)
Lidoaine
a? ain '27N)
Magnesium+simethione 'MFL*N>*) 30mL 27N
.ysesia '27N)
.ousate Sodium 'C(L*CG) 1 asule 27N
Constiation '27N)
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Medial IssuesChroni ain - Siatia
*sthma
Hyerliidemia
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La$sCM2 'Comrehensi:e meta$oli anel) on +,1+15
G:aluate organ funtion and he? for onditionssuh as dia$etes4 li:er disease and ?idney disease
Monitor H>N
>C(, ',,-3,) % ,1 Lo9
* 'rinalysis) on 10++15
>o detet ?idney and urinary trat disorders4hroni ?idney disease4 dia$etes4 and $ladderinfetions
CC 9ith .iKerential on 1+1+16
sed to detet o:eral health
2atient on Alonoin
7." '0-1/5) % 15/, High
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La$s
>ests that should ha:e $een omleted
.rug sreening
Should ha:e $een done on admission
2atient 9ith history of alohol and oly-su$stane a$use
Li:er Buntion >est
2atient on Alonoin and yre8a
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en a a us*ssessment
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Mental Status
*ssessment>hought ContentIntat4 denies suiidal and homiidal ideations
.enies any auditory and :isual halluinations4 $ut9itnessed t tal?ing to self/ Stated that it 9as her
9ay of =relie:ing her ain and oing!
Insight
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Hosital >reatment 2lan
1* 2atient 9ill rioriti@e syhosoial issues andidentify at Aahi Mohala
,* 2atient 9ill identify at least 3 rela8ationtehniues+attend 3 grous er shift
.* 2atient 9ill reort ain $efore it interferes 9itha$ility to artiiate in unit ati:ities
/*2atient 9ill attend 1,-ste meetings t9o times
a 9ee?
+* 2atient 9ill de:elo a su$stane a$usereo:ery lan that inludes suort system4identifying relase ues and rosoial $eha:ior
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.isharge lan &
Community 7esoures2atient 9ent to ourt4 9as granted Conditional7elease 'C7)
"ill $e disharged to a rogram
Need to End an oen $ed for laement
Community 7esoures
N* and **>heray for 2>S.
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Standardi@ed
*ssessment >oolsurns .eressionSore 1, 'orderline to Mild .eression)
Coersmith Self-Gsteem >ool
Sore 5 'Moderately lo9 Self-Gsteem)
Stress Inde8
Sore 1 '*roahing danger @one4
suKering stress related symtoms)
>M33
Sore , 'No reautions)
2 ti tD t
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2atientDs symtomsomared to .SM ;
Criteria*/ G8osure to atual or threateneddeath4 serious inury4 or se8ual :iolenein one 'or more)of the follo9ing 9ays
1/ .iretly e8eriening the traumati
e:ent's)/
,/ "itnessing4 in erson4 the e:ent's)as it ourred to others/
3/ Learning that the traumati e:ent's)ourred to a lose family mem$eror lose friend/ In ases of atual orthreatened death of a family
mem$er or friend4 the e:ent's) mustha:e $een :iolent or aidental/
/ G8eriening reeated or e8tremee8osure to a:ersi:e details of thetraumati e:ent's) 'e/g/4 Erstresonders olleting human
remains olie oers reeatedlye8osed to details of hild a$use)/
2atients Signs andSymtoms
1/ 2atient has e8eriened
multile traumati e:ents'se8ual a$use4 rae4 anddomesti a$use)
2atientDs s mtoms
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2atientDs symtomsomared to .SM ;
Criteria/ 2resene of one 'or more) of the follo9ingintrusion symtoms assoiated 9ith thetraumati e:ent's)4 $eginning after thetraumati e:ent's) ourred
1/ 7eurrent4 in:oluntary4 and intrusi:edistressing memories of the traumati
e:ent's)/,/ 7eurrent distressing dreams in 9hih the
ontent and+or aKet of the dream arerelated to the traumati e:ent's)/
3/ .issoiati:e reations 'e/g/4 Oash$a?s) in9hih the indi:idual feels or ats as if thetraumati e:ent's) 9ere reurring/
/ Intense or rolonged syhologialdistress at e8osure to internal or e8ternalues that sym$oli@e or resem$le anaset of the traumati e:ent's)/
5/ Mar?ed hysiologial reations to internalor e8ternal ues that sym$oli@e orresem$le an aset of the traumati
e:ent's)/
2atients Signs andSymtoms
1/ 2atient has
reurrent4in:oluntary4 andintrusi:e memoriesof the multiletraumati e:ents
,/ 2atient omlains of9orseningnightmares relatedto multiletraumati e:ents
3/ 2atient e8erienes
2atientDs symtoms
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2atientDs symtomsomared to .SM ;
CriteriaC/ 2ersistent a:oidane of stimuliassoiated 9ith the traumatie:ent's)4 $eginning after thetraumati e:ent's) ourred4 ase:idened $y one or $othof thefollo9ing
1/ *:oidane of or eKorts to a:oiddistressing memories4 thoughts4or feelings a$out or loselyassoiated 9ith the traumatie:ent's)/
,/ *:oidane of or eKorts to a:oid
e8ternal reminders 'eole4laes4 on:ersations4 ati:ities4o$ets4 situations) that arousedistressing memories4 thoughts4or feelings a$out or loselyassoiated 9ith the traumatie:ent's)/
2atients Signs and
Symtoms
1/ 2atient a:oids+tries toa:oid her memoriesand thoughts that areassoiated 9ith the
traumati e:ents
,/ 2atient a:oids+tries toa:oid her e8-hus$and'a$user) as 9ell as thelaes her traumati
e:ents too? lae
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2atientDs symtoms omaredto
.SM-; Criteria./ Negati:e alterations in ognitions and moodassoiation 9ith the traumati e:ent's)4 $eginning or9orsening after the traumati e:ent's) ourred4 ase:idened $y t9o 'or more) of the follo9ing
1/Ina$ility to remem$er an imortant aset of thetraumati e:ent's) 'tyially due to dissoiati:eamnesia)/
,/2ersistent and e8aggerated negati:e $eliefs ore8etations a$out oneself4 others4 or the 9orld 'e/g/4=I am $ad4! =No one an $e trusted4! =>he 9orld isomletely dangerous!)/
3/2ersistent4 distorted ognitions a$out the ause oronseuenes of the traumati e:ent's) that lead theindi:idual to $lame himself+herself or others/
/2ersistent negati:e emotional state 'e/g/4 fear4 horror4
anger4 guilt4 or shame)/5/Mar?edly diminished interest or artiiation insigniEant ati:ities/
6/Beelings of detahment or estrangement from others/
#/2ersistent ina$ility to e8eriene ositi:e emotions'e/g/4 ina$ility to e8eriene hainess4 satisfation4 orlo:ing feeling's)/
2atients Signs andSymtoms
,/ 2atient $elie:es that noone an $e trusted
/ 2atient has e8erieneda ersistent negati:eemotional state of fear4guilt4 and shame from these8ual+domesti a$use
5/ 2atient has e8erienedanhedonia in the ast
#/ 2atient desri$esha:ing eriods 9here she9as una$le to e8eriene
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2atientDs symtoms omaredto
.SM ; CriteriaG/ Mar?ed alterations in arousal and reati:ity assoiated9ith the traumati e:ent's)4 $eginning or 9orsening afterthe traumati e:ent's) ourred4 as e:idened $y t9o 'ormore) of the follo9ing
1/Irrita$le $eha:ior and angry out$ursts '9ith little or noro:oation) tyially e8ressed as :er$al or hysialaggression to9ard eole or others/
,/7e?less or self-destruti:e $eha:ior/
3/Hyer:igilane/
/G8aggerated startle resonse/
5/2ro$lems 9ith onentration/
6/Slee distur$anes 'e/g/4 diulty falling or stayingaslee or restless slee)/
B/ .uration of the distur$ane 'Criteria 4 C4 .4 and G)is more than 1 month/
he distur$ane auses linially signiEant distressor imairment in soial4 ouational4 or otherimortant areas of funtioning/
H/ >he distur$ane is not attri$uta$le to thehysiologial eKets of a su$stane 'e/g/4 mediation4
alohol) or another medial ondition/
2atientDs Signs andSymtoms
/ 2atient stated that shegets easily startled $ysreaming or loud noise
5/ 2atient omlains ofro$lems 9ithonentration at times
6/ 2atient e8resses ha:ing
diulty sleeing andstaying aslee due toreurrent nightmares
B/ .uration of all riteria has$een more than a month
H/ >he distur$ane is notrelated to the h siolo ial
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3 Highest 2riorities
1/ Slee
,/ *n8iety
3/ IneKeti:e oing
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7ationale
1/ Slee
2atient omlains of la? of slee and ina$ility to stayaslee due to reurrent nightmares+Oash$a?s of traumatie:ents and dreams of her hus$and trying to =?ill her!/
"a?es u 9ith Ests lenhed and sared for her life
,/ *n8iety
2atient reorts feeling restless and o:er9helmed+stressedat times4 9a?es u feeling an8ious and fearing for her life
3/ IneKeti:e oing
2atient has a history of alohol a$use and oly-su$stane
a$use/ 2atient stated that it heled her to oe 9ith herstress and 2>S./ Stated that it heled her =forget! andmade her feel $etter
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Nursing .iagnosisPriorit! 1
ursin Dianosis2 Slee distur$ane r+t 2>S. *Gatient stated she hasa hard time staying aslee due to reurrent nightmares+Oash$a?s of herhus$and oming after her to =?ill her!/ 2t states she has la? of slee andgets a$out 5-6 hours of slee/ "a?es u 9ith Ests lenhed and saredfor her life/
P2 Slee
E2 2atient stated she has a hard time staying aslee due to reurrentnightmares+Oash$a?s of her hus$and oming after her to =?ill her!/ 2tstates she has la? of slee and gets a$out 5-6 hours of slee/ "a?es u9ith Ests lenhed and sared for her life/
S2>eah atient rela8ation tehniues in the ase of a nightmare4 teahatient to reogni@e and a:oid triggers4 monitor slee and ati:ity
atterns4 ad:oate for atient $y tal?ing 9ith staK a$out atientssymtoms and inuire a$out 2ra@osin/
'T oal y the end of one month4 the atient 9ill ha:e gotten #- hours ofundistur$ed slee at night4 e:eryday/
ST oal y ne8t shift4 atient 9ill get 6-# hours of undistur$ed slee at
night4 $eing a$le to stay aslee
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nter3ention 45re6uenc!
Scienti7c Rationale E3aluation
>eah atient
rela8ation tehniuesin the ase of anightmare4 daily
>hese ati:ities assist
in lessening an8ietyand its relati:eomonents/Ano9ledge and use ofthem inreases theatientDs ontrol o:er
the disorder 'eah atient toreogni@e and a:oidtriggers4 daily
(rdinary o$ets orsituations may ausethe erson to
e8eriene feelingsfrom the originaltraumati e:ent/ >heatient may startleeasily or resondaggressi:ely in
resonse to these
2atient 9as a$le to:er$ali@e triggers suhas sreaming and loud
noises/ 2atient statedshe 9ill learn to as? forassistane 9hen shefeels that her 2>S. istriggered/
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nter3ention 45re6uenc!
Scienti7c Rationale E3aluation
Monitor slee andati:ity atterns
e:ery night
Slee distur$ane is aommon
manifestation of2>S./ >he atientmay e8erienee8essi:e fatigue thatlimits artiiation inati:ities '
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Nursing .iagnosisPriorit! ,
ursin Dianosis2 *n8iety r+t 2>S. *G2atient states that she feelsrestless and o:er9helmed at times4 9a?es u feeling an8ious4 9ith =Estslenhed! and fearing for her life after a nightmare+Oash$a?/ 2atientstates that she is stressed 9hen she thin?s a$out the ast situations/
2atient is on Alonoin for *n8iety/
P2*n8iety
E2 2atient states that she feels restless and o:er9helmed at times4 9a?es ufeeling an8ious4 9ith =Ests lenhed! and fearing for her life after anightmare+Oash$a?/ 2atient states that she is stressed 9hen she thin?sa$out the ast situations/ 2atient is on Alonoin for *n8iety/
S2*ssess for the degree of an8iety/ >eah atient rela8ation tehniues4 dee$reathing4 and 9ays to suress fears/ Stay 9ith atient during
an8iety+ani atta?s/ >eah atient mindfulness4 :isual imagery/ *ssessmediation omliane for an8iety
'T oal y the end of one month4 atient 9ill ha:e no symtoms ofan8iety/
ST oal y ne8t shift4 atient 9ill :er$ali@e a derease in an8iety/
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nter3ention 45re6uenc!
Scienti7c Rationale E3aluation
*ssess for the degreeof an8iety daily
* thoroughassessment results in
early identiEationand inter:ention tore:ent esalation ofsymtoms 'eah atientrela8ation tehniues4dee $reathing4 and9ays to suressfears/ >eah atientmindfulness4 :isual
imagery daily
>hese ati:ities assistin lessening an8ietyand its relati:eomonents/Ano9ledge and use ofthem inreases the
atientDs ontrol o:erthe disorder '
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nter3ention 45re6uenc!
Scienti7c Rationale E3aluation
Stay 9ith atientduring an8iety+aniatta?s 9hen itours
* atientDs an8ietyan esalate to ani4and she may $eomesuiidal or out9ardly:iolent '
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Nursing .iagnosis
Priorit! .
ursin Dianosis2 IneKeti:e Coing r+t 2>S. *G2atient has history ofoly-su$stane a$use and alohol a$use/ 2atient stated that it heled her
to oe 9ith her stress and 2>S./ Stated that it heled her to =forget!
those moments and made her feel $etter
P2IneKeti:e Coing
E22atient has history of oly-su$stane a$use and alohol a$use/ 2atientstated that it heled her to oe 9ith her stress and 2>S./ Stated that it
heled her to =forget! those moments and made her feel $etter
S27efer+teah atient a$out N* and **/ *ssess for ati:e su$stane a$use/Gnourage adating oing $eha:ior 'mindfulness4 and other ositi:e
9ays to oe)4 refer to rofessional ounseling/ Ha:e atient :er$ali@eositi:e oing s?ills/ Gnourage the atient to see? suort eole+grousto assist 9ith oing
'T oal In three months4 the atient 9ill $e su$stane and alohol free/
ST oal y ne8t shift4 the atient 9ill :er$ali@e and demonstrate alternati:e9ays of oing/
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nter3ention 45re6uenc!
Scienti7c Rationale E3aluation
7efer+teah atient
a$out N* and ** thisshift
>hese ati:ities assist
in lessening an8ietyand its relati:eomonents/Ano9ledge and useof them inreases theatientDs ontrol o:er
the disorder'
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nter3ention 45re6uenc!
Scienti7c Rationale E3aluation
Gnourage adatingoing $eha:ior'mindfulness4 andother ositi:e 9ays tooe) daily
2atients may $e usingmaladati:e ordysfuntional oingto a:oid dealing 9ithfeelings and issues'
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G:idened asedournal *rtile
2>S. Symtom 7edution "ith Mindfulness-ased Strething and .eereathing G8erise 7andomi@ed Controlled Clinial >rial of Gay
($eti:e determine 9hether mindfulness-$ased strething anddee $reathing normali@es ortisol le:els and redues 2>S.symtom se:erity
7andomi@ed ontrolled trial onduted at ni:ersity of Ne9 Me8ioHeath Sienes Center
, nurses ', females) ages 5-66 years artiiated
60 minute MJ sessions 9ere onduted semi9ee?ly for 9ee?s
7esults , omleted studies4 ,, 9ith 2>S. symtoms and #9ithout 2>S.
Conlusions MJ aears to redue the re:alene of 2>S.symtoms in indi:iduals e8hi$iting features of 2>S.
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2ertinent StandardG:aluations
2>S. Che?list
urns .eression
Coersmith Self-Gsteem
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7ele:ane & Critial>hin?ing.uring our on:ersation4 my atient tal?ed a$out 9hen she 9as a hild4 she 9as raed $y her
unle/ "hen she 9as 16 years old4 she got married to her no9 e8-hus$and and 9as married for,0 years/ He 9ould often $eat her and threaten to ?ill her/ >here 9ere times she 9ould run a9ay$ut the hus$and 9ould End her and threaten to ?ill her if she ran a9ay again/ She also stated he9ould istol 9hi her/ She 9as $oth emotionally and hysially a$used $y her hus$and/ "henthe atient 9as diagnosed 9ith $reast aner4 she started to do meth4 amongst othersu$stanes/ >his led to her addition4 and aused her to disonnet from her daughter/ No94 theatient is trying to ma?e amends 9ith her daughter $eause she 9ants to $e a =goodgrandmother!/ *ll this emotion and distress that my atient 9as ut through aused her to feel
un9anted and unlo:ed/ "hat added to the deression 9as that she 9as diagnosed 9ith $reastaner/ "hen she started to do drugs4 this aused her to searate from her daughter/ >his alsoaused her deression and added to her su$stane a$use/ Mt atient stated that she 9a?es u inthe middle of the night 9ith her Ests lenhed/ She had nightmares+Oash$a?s of her e8-hus$andhasing after her and her daughter4 trying to ?ill them/ She e8lained this as a dou$le loss$eause she =lost! her daughter and doesnDt ha:e a onnetion 9ith her anymore4 and she also9as out through the a$use/ >he atient la?s on slee and has an8iety $eause of her traumatie:ents4 and uses ineKeti:e oing mehanisms to deal 9ith her Oash$a?s+nightmares/
C> Model =I ?ee re-li:ing these nightmares4 I ant seem to get them out of my head/! feelsshameful and fearful/ Beels hoeless that she ?ees relaying these dreams 7esorts tonegati:e oing mehanisms to hel 9ith ast and hels her to forget/ She is afraid to reli:ethose moments $eause it uts her in a :ulnera$le situation/ Has no means of soial suort49hih is 9hy she also resorts to su$stane a$use and alohol/ She is a9are of her ro$lems4 $utis also in need of suort to hel her suress her Oash$a?s4 so she resorts to negati:e oings?ills/
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7ele:ane & Critial>hin?ing
"hat is ne8tQ2atient needs to attend a grou home 9here shean get the suort she needs and to hel her 9ithmediation omliane and manage her disorder
>he atient needs hel 9ith her slee distur$anes4su$stane a$use+alohol a$use4 and needs suort
Needs to End eKeti:e oing mehanisms fortriggers
Changes to atient are that 9ill $eneEt the lient
Court order to attend N*+** meetings
*dding 2ro@osin to mediation regimen for nightmares
Court order for theray
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"hat must our forthis lientQ
Comly 9ith mediations 9hen disharged
7eogni@e and a:oid triggers to 2>S.
se rela8ation tehniues in ase of Oash$a?s
See? hel from theraist+ounselor 9hendisharged
See? suort
se eKeti:e oing mehanisms
*:oid negati:e su$stanes
*ttend N*+**
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7eferenes
S. symtom redution9ith mindfulness-$ased strething anddee $reathing e8erise randomi@edontrolled linial trial eay/ CGM4 4 #-
/ doi htt++d8/doi/org+10/1,10+/,01,-3#,
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