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					PTSD Poc A1 Blue 4/24/05 4:16 PM Page 1 Cutting Guides





                                                                                                                                                                   VA/DoD Clinical Practice Guideline for
                ASR ASSESSMENT
                                                                                                                                                                  the Management of Post Traumatic Stress
                                                                          Functional Assessment
           a) Symptoms                                                                                                                                           Acute Stress Reaction (ASR) Module - Pocket Guide
           b) Trauma                                      Work            • Any changes in productivity?
                                                                          • Have co-workers or supervisors commented on any recent                                                Update April 2005
           c) Risk factors                                                  changes in appearance, quality of work, or relationships?
           d) Medical status                                              • Tardiness, loss of motivation, loss of interest?
                                                                          • Been more forgetful, easily distracted?                                                            Core Module - Initial Evaluation and Triage
           e) Mental status
           f) Functional status                           School          • Changes in grades?                                                                     Primary                                     Symptoms                            Symptom
           g) Psychosocial status                                         • Changes in relationships with friends?                                                Prevention                                  Presentation                         Clusters
                                                                          • Recent onset or increase in acting out behaviors?
           h) Dangerousness                                               • Recent increase in disciplinary actions?                                         Education and training to                    Physical - chronic pain,         Re-experiencing:
           i) Unit disruption                                             • Increased social withdrawal?                                                      promote hardiness and                         migraines or vague               Intrusive memories,
                                                                                                                                                                    resiliency                              somatic complaints                 images or perceptions
                                                          Family        • Negative changes in relationship with significant others?                                                                       Mental - substance                 Flashbacks
            ASR IMMEDIATE NEEDS                           Relationships • Irritable or easily angered by family members?                                                                                    abuse, MDD, anxiety,             Nightmares
                                                                        • Withdrawal of interest in or time spent with family?                                                                              or depression                    Exaggerated emotion
           Survival                                                     • Any violence within the family?                                                                                                 Behavior - irritability,             and physical reactions
                                                                                                                                                                                                            avoidance, anger or            Avoidance/emotional
           Safety                                                                                                                                                                                           non-compliance, self           numbing:
                                                          Recreation      • Changes in recreational interests?
           Security                                                       • Decreased activity level?                                                                                                       risk behavior (HIV)              Avoids activity
                                                                                                                                                         1
                                                                                                                                                                                                          Evokes aversion or fear            Loss of interest
           Food
                                                                                                                                                              Person exposed to trauma
                                                                          • Poor motivation to care for self?
                                                                                                                                                                                                            in provider                      Detached
           Shelter                                                        • Sudden decrease in physical activity?                                                                                         Change in function                 Restricted emotion
                                                                          • Anhedonia?                                                                   2
                                                                                                                                                                                                                                           Increased arousal:
           Sleep
                                                                                                                                                              Screen for PTSD symptoms

                                                                                                                                                                                                                                             Difficulty sleeping
           Medical care (first aid)                       Housing         • Does the person have adequate housing?
                                                                                                                                                                                                                                             Irritability or outbursts
                                                                          • Are there appropriate utilities and services (electricity, plumbing, etc)?       3
                                                                                                                                                                                                                                               of anger
           Mental health triage                                           • Is the housing situation stable?
                                                                                                                                                                  Are trauma-related
                                                                                                                                                                                             Y
                                                                                                                                                                  symptoms present?
                                                                                                                                                                                                                                             Difficulty concentrating
           Orientation                                                                                                                                              (See sidebars)
                                                                                                                                                                                                                                             Hypervigilance
                                                          Legal           • Are there outstanding warrants, restraining orders, or                                                                                                           Exaggerated startle
           Communication with family friends                                disciplinary actions?                                                                                                                                              response
            and community                                                 • Is the person regularly engaging in, or at risk to be involved in,                                                             Acute Stress
                                                                            illegal activity?                                                                                                      4
                                                                                                                                                                                                         Reaction (ASR)/


           ASR ACUTE INTERVENTIONS
                                                                                                                                                                                                            Combat or
                                                                          • Is patient on probation or parole?                                                                         2-4 days
                                                                                                                                                                                                         ongoing military
                                                                                                                                                                                                                                 Go to Module A
                                                                                                                                                                                                                                   ASR [ A1 ]
                                                                                                                                                                                                                                                           See pocket guide
                                                                                                                                                                                                         Operation Stress
                                                                          • Is there family advocacy/ Dept. of Social Services (DSS) involvement?                       N
                                                                                                                                                                                                         Reaction (COSR)
                                                                                                                                                                                                                                  COSR [ A2 ]
                                                                                                                                                                                                                                                               for ASR


           Provide:                                       Financial       • Does the patient have the funds for current necessities                                                                5

            • Acute symptom management                                      including food, clothing, and shelter?                                                              4 days - 1 month
                                                                                                                                                                                                       Acute Stress Disorder
                                                                                                                                                                                                              (ASD)
                                                                                                                                                                                                                                 Go to Module B
                                                                                                                                                                                                                                  ASD/PTSD
                                                                                                                                                                                                                                                           See pocket guide
                                                                                                                                                                                                                                                            for ASD/PTSD
            • Education & normalization                                   • Is there a stable source of income?
            • Social & spiritual support                                  • Are there significant outstanding or past-due debts, alimony,                                          > 1 month
                                                                                                                                                                                                   6
                                                                                                                                                                                                       Acute PTSD
                                                                            child support?                                                                                        > 3 months           Chronic PTSD              Go to Module B
            • Consider medication                                                                                                                                                                       • simple                  Primary Care
                                                                          • Has the patient filed for bankruptcy?                                                                                       • PTSD with comorbid      or Module C
              (avoid use of benzodiazepines)                              • Does the patient have access to healthcare and/or insurance?
                                                                                                                                                         7
                                                                                                                                                                 Provide education and
                                                                                                                                                                                                          conditions (SUD,        Mental Health
                                                                                                                                                                                                          psychosis, bipolar,
           Avoid:                                                                                                                                                 access information
                                                                                                                                                                                                          addiction)

            • Individual debriefing                       Unit/           • Does the patient need to be put on profile, MEB, or limited duty?
                                                          Community       • Is patient functional and contributing in the unit environment?                  VA access to full guideline: http://www.oqp.med.va.gov/cpg/cpg.htm          December 2003
            • Compulsory group debriefing                 Involvement                                                                                        DoD access to full guideline: http://www.QMO.amedd.army.mil/pguide.htm
                                                                          • Is there active/satisfying involvement in a community group
                                                                            or organization?                                                                 Sponsored & produced by the VA Employee Education System in cooperation with the Offices of
                                                                                                                                                             Quality & Performance and Patient Care Services and the Department of Defense.
PTSD Poc A1 Blue 4/24/05 4:16 PM Page 2 Cutting Guides





            MANAGEMENT OF ACUTE STRESS REACTION (ASR)
                  (2-4 Days After Trauma Exposure)                                                                                           Common Symptoms After Exposure to Trauma or Loss
                  Module A1 - Acute Stress Reaction
                                                                                                                             Physical                          Cognitive/Mental                               Emotional                              Behavioral
 1       Individual or community exposed to
             trauma within the last 4 days                                                                       • Fatigue                             • Attention                                 • Anxiety                            •   Change in activity
                                                                                                                 • Muscle tremors                      • Change in alertness                       • Grief                              •   Suspiciousness
 2
          Assess briefly based on general                                                                        • Chest pain                          • Memory problems                           • Severe pain                        •   Inability to rest
            appearance and behavior                                                                              • Elevated blood pressure             • Poor problem solving                      • Fear                               •   Pacing
                                                                                                                 • Thirst                              • Poor decisions                            • Loss of emotional control          •   Emotional outbursts
     3                                                      4                                                    • Visual difficulties                 • Increased or decreased awareness          • Apprehension                       •   Hyper-alert to environment
               Is person unstable or
          dangerous to self or others, or in           Y
                                                                 Provide appropriate care or                     • Grinding teeth                        of surroundings                           • Agitation                          •   Erratic movements
                                                                      refer to stabilize
             need of urgent medical or
                                                                   Follow legal mandates                         • Dizziness                           • Difficulty identifying familiar objects   • Inappropriate emotional response   •   Somatic complaints
                 surgical attention?
                                                                                                                 • Chills                                or people                                 • Guilt                              •   Withdrawal
                                                                                                                 • Fainting                            • Intrusive images                          • Denial                             •   Alcohol consumption
                        N                                                                                        • Nausea                              • Poor abstract thinking                    • Emotional shock                    •   Antisocial acts
                                                                                                                 • Twitches                            • Nightmares                                • Uncertainty                        •   Change in speech pattern
 5
              Assess environment for                               For person during                             • Difficulty breathing                • Confusion                                 • Depression                         •   Loss of, or increased appetite
                  ongoing threats                               ongoing military operation
                                                                                                                 • Rapid heart rate                    • Poor concentration                        • Feeling overwhelmed                •   Startle reflex intensified
             Protect from further harm                           See Module A2: COSR
                                                                                                                 • Headaches                           • Hyper-vigilance                           • Irritability                       •   Change in sexual functioning
                                                                                                                 • Vomiting                            • Blaming someone                                                                •   Change in communication
     6                                                                                                           • Weakness                            • Loss of orientation to time, place,
          Excessive arousal, dissociation,              Y
                                                                                                                 • Profuse sweating                      person
            confusion/disorientation, or
                impaired function?                                                                               • Shock symptoms
                                          7    Assess medical and fuctional status
                                               Assess pre-existing psychiatric and
                                                      medical conditions
                                                                                                                                                         Primary Care PTSD Screen (PC-PTSD)
                                                                                                                 In your life, have you ever had any experience that was so frightening, horrible, or upsetting that, in the past month, you…
                                          8
                                               Ensure basic physical needs are met
                                                                                                                 1. Have had nightmares about it or thought about it when you did not want to?                                                             YES          NO
                                          9                                                                      2. Tried hard not to think about it or went out of your way to avoid situations that reminded you of it?                                  YES          NO
                                                    Initiate acute interventions
                                                                                                                 3. Were constantly on guard, watchful, or easily startled?                                                                                YES          NO
                        N
                                          10
                                                       Excessive arousal,                                        4. Felt numb or detached from others, activities, or your surroundings?                                                                   YES          NO
                                                                                               Y
                                                dissociation, impaired function, or
                                                    confusion/disorientation?
                                                                                                                                             Current research suggests that the results of the PC-PTSD should be considered
     13
                Is patient at high risk                         N                                                                               "positive" if a patient answers "yes" to any three items. Update April 2005
                                                       Y
               for developing PTSD?


                        N                                                                                                                                          2 Days                          1 Month                      3 Months
14
          Offer contact/access information                                                                                                    Trauma
         Repeat screen for traumatic stress 12        Monitor and follow up
                                                                                   11
                     frequently                                                         Refer to mental health
                                                          as indicated                                                                                  Combat                    Acute Stess                   Acute PTSD                  Chronic
           Provide secondary prevention
                   and education                                                                                                                        Stress                     Disorder                                                  PTSD

				
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