15.7 Applying the Nursing Process to Clients Experiencing Trauma, Abuse, or Violence

This section will provide an overview of applying the nursing process to clients experiencing trauma, abuse, or violence using trauma-informed care principles. Review specific focused assessments and nursing interventions in the preceding sections.

Assessment (Recognizing Cues)

Assessment focuses on recognizing physical, psychological, and behavioral indicators of trauma, abuse, or violence. Key actions include the following:

• Recognize injuries inconsistent with explanations (e.g., bruises, fractures, burns).
• Recognize nonverbal cues (e.g., flinching, hypervigilance, avoidance).
• Ensure assessment occurs in a safe, private space, free from potential abusers.
• Screen for anxiety, depression, PTSD, dissociation, or suicidal ideation.

Diagnosis (Analyzing Cues)

Nurses create nursing diagnoses based on assessment data obtained. Potential nursing diagnoses for clients experiencing trauma, abuse, or violence include the following:

• Risk for Post-Trauma Syndrome
• Ineffective Coping
• Powerlessness
• Impaired Social Interaction
• Sleep Pattern Disturbance
• Chronic Low Self-Esteem

Outcome Identification (Generate Solutions)

SMART outcomes are identified in relation to the established nursing diagnoses for each client. SMART is an acronym for Specific, Measurable, Attainable/Actionable, Relevant, and Timely. Read more about outcomes identification in the “Application of the Nursing Process in Mental Health Care” chapter.

Examples of SMART outcomes for clients experiencing trauma, abuse, or violence include the following:

• The client will verbalize how to contact a safe person or environment if in crisis by the end of the teaching session.
• The client will identify at least one positive coping strategy by the end of the teaching session.

Planning (Generate Solutions)

Safety receives top priority when planning and implementing interventions for clients experiencing trauma, abuse, or violence. Nurses help ensure a safety plan is created in collaboration with the client by integrating information about community resources, legal advocacy, and counseling resources. Nurses also help ensure the client’s physical care needs are addressed (e.g., food, housing, pain control, and wound care).

Implementation (Take Action)

Nursing implement nursing interventions that are therapeutic, respectful, and empowering. Examples of nursing interventions for clients experiencing trauma, abuse, or violence include the following:

• Use grounding techniques to manage dissociation and anxiety.
• Educate client about normal trauma responses and coping tools.
• Offer emotional support and validate their experiences without pressuring for disclosure.
• Facilitate referrals to mental health, social work, domestic violence shelters, or trauma-specific therapy.
• Monitor for suicidal ideation and psychosis.

Evaluation (Evaluate Outcomes)

Nurses assess the effectiveness of nursing interventions and revise the nursing care plan as needed. They evaluate client’s verbal and nonverbal indicators of emotional safety, determine if the expected outcomes were met, and support continuation of trauma-specific therapy.