A client with post-traumatic stress disorder (PTSD) is sitting in the communal dining area when a heavy supply cart loudly rolls by. The client suddenly dives under a table, covers their head, and yells, 'Take cover!' Arrange the following nursing interventions in the most appropriate chronological order from first to last to manage this acute dissociative flashback.
- 1Maintain a safe physical distance and strictly refrain from touching the client.
- 2Instruct other individuals to clear the immediate area to reduce noise and stimuli.
- 3Address the client by name and provide verbal reassurance that they are safe in the hospital.
- 4Encourage the client to focus on their current surroundings by describing what they see.
- 5Stay continuously with the client until the dissociative episode completely subsides.
Answer
The correct sequence prioritizes safety and trauma-informed care: maintain distance/avoid touch, clear the milieu, verbally reorient, utilize grounding techniques, and remain with the client.
The sequence for managing an acute dissociative flashback follows the principles of trauma-informed care and milieu safety. First, the nurse must ensure personal safety by maintaining distance and avoiding touch, as touch can trigger a combative response. Second, the nurse secures the milieu by clearing bystanders, which also reduces environmental stimuli. Third, verbal reorientation is initiated using a calm voice and the client's name. Fourth, once the client can hear the nurse, active grounding techniques are used to solidify reality testing. Finally, the nurse remains with the client to provide ongoing support until the episode concludes.
Step-by-Step Solution
Key Concept
Trauma-Informed Crisis Intervention and Flashback Management