CLINICAL CASE STUDY :Posttraumatic Stress Disorder
Case
CLINICAL CASE STUDY :Posttraumatic Stress Disorder (PTSD)
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CLINICAL CASE STUDY :Posttraumatic Stress Disorder
Institution
Keiser University
CLINICAL CASE STUDY :Posttraumatic Stress Disorder (PTSD) Case Study Posttraumatic Stress Disorder (PTSD), RAPID Reasoning STUDENT, Marcus Jackson, 34 years old, Latest Questions and Answers with Explanations, All Correct Study Guide, Download to Score A
, History of Present Problem:
Marcus Jackson is a 34-year-old African American male who served four combat tours of duty in Iraq and Afghanistan. He came to the
Veterans Administration (VA) today for an outpatient appointment because he has not slept more than two hours a night for the past week.
This is his fourth clinic visit over the past year with the same symptoms: inability to sleep, nightmares, increasing anxiety, and isolation.
Every time he falls asleep, he relives the bombing and has flashbacks of bloody body parts he witnessed after the explosion. He states that he
is more aware of noises and any loud noise such as fireworks and or cars backfiring causes him extreme anxiety. His medications for PTSD
have not been helping control his anxiety. He has been spending more time in his room watching TV and avoids spending time with his wife
and children. Today he told his wife he should have died and not his friends. His primary care provider encouraged voluntary admission, and
his wife brought Marcus to the emergency department of the closest VA hospital so he can be admitted.
Personal/Social History:
During his last tour in combat, Marcus' best friend drove over an IED. The explosion killed everyone in the vehicle. During the blast, Marcus
was hit with shrapnel in his left leg, stomach, and left eye. These injuries left him blind in his left eye. He has had multiple surgeries on his
abdomen and six reconstruction surgeries on his leg. He walks with a limp and continues to complain of severe pain in his left leg. He was
given a medical discharge from the Marines because of the extensive nature of his injuries and is receiving disability.
Marcus is married with three children from six to twelve years of age. He has been married to his wife, Ariel, for fourteen years. While in the
service, his family moved six times and endured four combat tours of duty. Each time he returned home from combat, his wife noted that he
has no history of physical aggression and has been more agitated and had more trouble sleeping with frequent nightmares. Marcus reports he
used to drink "a lot" but decided two years ago that alcohol made everything worse. Reports he has not had a drink for the past 1 ½ years.
Denies other drug use.
What data from the histories are RELEVANT and have clinical significance to the nurse?
RELEVANT Data from Present Problem: Clinical Significance:
m
‣ 4 yr combat veteran ‣ Likely cause of PTSD
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‣ Insomnia/hyperarousal/social avoidance ‣ S/S of PTSD
‣ 4 visits within a year for the same symptoms ‣ Seasonal PTSD?
co
eH w
‣ Relives trauma through nightmares ‣ A lack of sleep will intensify s/s
‣ Meds not relieving symptoms ‣ Perform medication reconciliation and request a change
o.
‣ Believes he should have died instead of his friends ‣ Initiate suicide precautions
RELEVANT Data from Social History:
rs e Clinical Significance:
ou urc
‣ Witnessed his best friend die in an explosion and was hit ‣ The scars from the surgeries and severe pain are a constant reminder of
during the blast by shrapnel what happened to his best friend and other friends
‣ Blind in his left eye ‣ Make accommodations to prevent injury
‣ Limps and complains of severe pain ‣ Provide a cane if necessary
o
‣ Medically discharged from the Marines ‣ Can leave a soldier feeling like a disappointment and worthless – this was
his career
aC s
‣ Receives disability ‣ Disability, unfortunately, has its financial limitations – research resources
vi y re
to help with finances and consult case manager if deemed necessary
‣ Married with three children ‣ He is not alone and has a support system
Patient Care Begins:
Current VS: P-Q-R-S-T Pain Assessment:
ed d
T: 98.2 F/37.3 C (oral) Provoking/Palliative: Movement provokes, always present. Goal is 5/10
ar stu
P: 92 (regular) Quality: Ache
R: 18 (regular) Region/Radiation: Left leg
BP: 118/70 Severity: 5/10
O2 sat: 98% RA Timing: Continuous
is
RELEVANT VS Data: Clinical Significance:
Th
‣ Pain rating 5/10 and continuous ‣ Possibly neuropathic in nature
What VS data are RELEVANT that must be recognized as clinically significant to the nurse?
Current Assessment:
GENERAL Appears anxious, body tense, tired (dark circles under his eyes)
sh
APPEARANCE:
RESP: Breath sounds clear with equal aeration bilaterally, non-labored respiratory effort
CARDIAC: Pink, warm & dry, no edema, heart sounds regular with no abnormal beats, pulses strong,
equal with palpation at radial/pedal/post-tibial landmarks
NEURO: Alert & oriented to person, place, time, and situation (x4), flat affect, inability to fall asleep
and stay asleep– averaging only two hours a night, nightmares, flashbacks while awake
GI: Abdomen soft/non-tender, bowel sounds audible per auscultation in all four quadrants
Reports poor appetite with no weight loss.
This study source was downloaded by 100000823851721 from CourseHero.com on 04-28-2021 12:18:11 GMT -05:00
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