Page 14 nursing.elitecme.com Complete Your CE Test Online - Click Here Prolonged Exposure Therapy (PE). PE is based in emotional processing theory, which proposes that PTSD symptoms occur as a result of cognitive and behavioral avoidance of trauma-related thoughts, reminders, activities, and situations. PE is designed to help veterans interrupt and reverse these factors by stopping (referred to as blocking) cognitive and behavioral avoidance and introducing corrective actions (Center for Deployment Psychology. (2016b). PE has four components (National Center for PTSD, 2016): 1. Teaching veterans how to identify symptoms and how treatment can help them. 2. Teaching veterans the technique of breathing retraining to slow breathing and heart rate and facilitate relaxation. 3. Facilitating in vivo exposure (real-world practice). Veterans with PTSD avoid situations, activities, or behaviors that, although not actually dangerous, remind them of the traumatic event(s) that triggered PTSD. Real-world practice involves having veterans engage in activities and behaviors and face situations that they have been avoiding. Over time, in vivo exposure reduces excessive fear and other distressing symptoms. It also helps veterans recognize that the situations, activities, and behaviors that they have been avoiding are not excessively dangerous and that they can deal with them effectively, even when under stress. 4. Helping veterans to talk through their trauma using imaginal exposure. Imaginal exposure involves repeatedly revisiting the traumatic event(s) in memory while describing the event(s) aloud in specific detail. Using this technique to revisit the traumatic event(s) helps veterans process the memories of the trauma by activating the thoughts and emotions linked to the trauma in a safe environment. Imaginal exposure helps veterans understand that they can cope with the distress associated with memories of the traumatic event(s). In addition to meeting with their therapists, veterans receive practice assignments to help use new skills outside of the therapy setting (National Center for PTSD, 2016). Eye Movement Desensitization and Reprocessing (EMDR). EMDR is a fairly new clinical treatment that has been evaluated primarily as a technique used to help trauma survivors. In EMDR, a qualified therapist guides the veterans to vividly recall distressing past experiences (desensitization) in a safe setting while gaining new insight (reprocessing) into the events and how they respond physically and emotionally to these distressing events. The eye movement component of EMDR involves the veterans moving their eyes in a back and forth manner while recalling the traumatic event(s) (Psychcentral.com, 2016). EMDR has four main components (National Center for PTSD, 2016): 1. Identification of a specific target memory, belief, and image of the traumatic event(s). 2. Desensitization and reprocessing is done to focus on mental images while performing eye movements taught by the therapists. 3. Initiating positive thoughts and images once the negative images are no longer distressing to the veterans. 4. Focusing on tension or unusual sensations in the body (referred to as body scan). This helps identify any additional issues the veterans may need to address in later therapy sessions. Nursing consideration: A course of four to 12 sessions of EMDR is common (National Center for PTSD, 2016). Nurses must be sure that clients be provided with information about the length of treatment. Selective Serotonin Reuptake Inhibitors (SSRIs). SSRIs are antidepressant medications that have been used to treat PTSD symptoms. SSRIs prescribed for the treatment of PTSD symptoms act upon neurotransmitters linked to the fear and anxiety circuitry of the brain that include serotonin, norepinephrine, GABA, and dopamine (National Center for PTSD, 2017). These drugs can increase the level of serotonin in the brain, which can help decrease symptoms (Comerford, 2018). As of this writing, only two SSRIs have been approved by the U.S. Food and Drug Administration (FDA) for the treatment of PTSD (National Center for PTSD, 2016; National Center for PTSD, 2017): ● ● Sertraline (Zoloft®). ● ● Paroxetine (Paxil®). Side effects associated with these medications include (Comerford, 2018): ● ● Decreased sexual desire and/or erectile dysfunction in males. ● ● Dizziness. ● ● Drowsiness. ● ● Dry mouth. ● ● Insomnia. ● ● Nausea, vomiting, and diarrhea. ● ● Nervousness, agitation, and restlessness. ● ● Weight gain or loss. The FDA requires that all antidepressants carry black box warnings for increase in suicidal ideation, especially in children, teenagers, and young adults under 25 (Comerford, 2018). Nursing consideration: At times, some physicians may prescribe other antidepressants for use in veterans with PTSD. However, only Zoloft and Paxil are FDA-approved for PTSD treatment. Other antidepressants and anti-anxiety agents may help initially but have not been found to treat core PTSD symptoms. Treatment can be complicated when other mental illnesses require treatment and medications that are not approved or shown to help treatment of PTSD. (National Center for PTSD, 2017). Nursing consideration: It is essential that nurses provide detailed client/family education regarding medications. Nurses must assess whether or not clients and family members have acquired the necessary knowledge to safely administer their medications. For example, avoid asking “yes” or “no” questions such as “Do you know what side effects your medication may cause?” Instead, say, “Please tell me what side effects your medication might cause and what you should do if they happen.” Asking clients and families to actually explain what side effects might occur and what they should do if they occur allows the nurse to assess the extent of their knowledge. Stress inoculation training. Stress inoculation training (SIT) provides information and facilitates acquiring skills to handle stressful situations that can help with the management of PTSD symptoms. During SIT the therapist helps veterans to learn and practice how to solve problems and deal with stress (National Center for PTSD, 2016). Additional nursing interventions. Promoting client safety is a priority. Nurses must assess veterans for suicidal ideation or any type of self- injury and initiate appropriate interventions. Nurses can help veterans learn to go to a safe place at home, work, etc., where they can calm down, stop self-destructive thoughts, and regain control of themselves (Videbeck, 2017). Other interventions to help clients cope with stress include (Videdbeck, 2017): ● ● Validate the veterans’ feelings of fear but promote contact with reality. ● ● During flashbacks, help veterans change body position as needed but do not grab or attempt to force them to stand up or move. ● ● Encourage the use of deep breathing and relaxation techniques. ● ● Facilitate the use of distraction techniques such as physical exercise, listening to music, talking to others, or participating in hobbies or activities that are positive. Recommend strategies to cope with substance abuse such as joining Alcoholics Anonymous or other appropriate support groups and therapies. Nurses must be aware that long-term identified goals may take years to achieve. Veterans can learn to manage their thoughts, feelings, and behaviors, but the effects of the traumatic event(s) can last a lifetime. Participation in ongoing community support groups may be helpful (Videbeck, 2017). No matter how long it has been since the traumatic event(s) occurred, there is considerable reason to believe that symptoms can be reduced and quality of life improved. Veterans who have lived with PTSD for many years may believe that there is nothing that can help them. It is important to teach veterans and their families that therapy can work even after considerable time has passed (National Center for PTSD, 2016).