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PTSDPosttraumatic Stress Disorder (PTSD).pdf
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Cassandra BraithwaitePosttraumatic Stress Disorder (PTSD)
RAPID Reasoning
STUDENT
Marcus Jackson, 34 years old
Primary Concept
Mood and Affect
Interrelated Concepts (In order of emphasis)
1. Stress
2. Coping
3. Anxiety
4. Clinical Judgment
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 that 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 to his abdomen, and six reconstruction surgeries to 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 was making everything worse. Reports he has not had a drink for the past 1 ½ years. Denies other drug use.
, Cassandra Braithwaite
What data from the histories are RELEVANT and have clinical significance to the nurse?
RELEVANT Data from Present Problem: Clinical Significance:
• Served 4 combat tours in Iraq and • Significant past trauma causes PTSD
Afghanistan • Exhaustion and sleep deprivation only increase PTSD symptoms
• Has not slept more than 2 hrs a night for the • His current plan of care it manage his sleep issues is not working. Will
past week need to be reevaluated and a new plan implemented
• 4th clinic visit in the past yar for the same • Marcus experienced significant trauma. This is a symptom of PTSD
symptoms: insomnia, nightmares, increasing • This is good information to know, as Marcus will benefit from a less
instances of anxiety stimulation environment. Need to educate him on avoiding loud
• Relives bombing and has flashbacks of environments
bloody body parts • He would need medications to help reduce his anxiety
• Loud noises cause him extreme anxiety • Social isolation and feeling guilty for living will only make his
• Avoids spending time with wife and kids depression worse and contribute to suicidal ideations
• Tells his wife that he should have died and
not is friends
RELEVANT Data from Social History: Clinical Significance:
• Married with 3 kids • Has a good support system, kids may cause added stress and be
• Lost his best friend in an IED explosion exhausting which can increase his agitation
• Has had extensive reconstructive surgeries • Significant loss/grief or guilt may be the cause of depression or make
and is now blind in one eye and walks with a it worse
limp • Low self-esteem or not being able to do things he once used to can
• No hx of aggression, but has increased increase suicidal thoughts.
agitation • Increasing agitation without a proper outlet for relieving symptoms
• Was medically dc’d from the Marines can cause increasing depression/suicidal thoughts
• Denies drinking or drug use • Having to leave the Marines against his will can be a significant and
unexpected life change that can have negative effects on his mental
health.
• Significant because “self-medicating” by abusing alcohol and other
drugs can complicate his treatment and any pharmacological
therapies he may need
Patient Care Begins:
Current VS: P-Q-R-S-T Pain Assessment:
T: 98.2 F/37.3 C (oral) Provoking/Palliative: Movement provokes, always present. Goal is 5/10
P: 92 (regular) Quality: Ache
R: 18 (regular) Region/Radiation: Left leg
BP: 118/70 Severity: 5/10
O2 sat: 98% RA Timing: Continuous
What VS data are RELEVANT that must be recognized as clinically significant to the nurse?
RELEVANT VS Data: Clinical Significance:
• Pain (Movement • Chronic 5/10 pain means he may need help controlling it. May also help him control some
provokes and is of the symptoms he’s having if it’s causing him problems with his abilities to relax and
always present, 5/10; sleep.
continuous ache in his • v/s are all relevant and important to help assist in guiding his treatment
L leg)
• All other v/s
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