Question

SKINNY Reasoning Part I: Recognizing RELEVANT Clinical Data 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. PersonalVSocial 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

Answer 1

4. What psychosocial or holistic care priorities need to be addressed for this patient?

Priority Nursing Interventions	Rationale	Expected outcome
Physical comfort measures: Here the patient is unable to sleep and he suffers with night flashes, nightmares and excessive anxiety regarding a blast. As a nurse, we have to promote the physical comfort of the patient by providing a calm and quiet environment that promotes comfort. *Pause all voices during the night *If needed put light music in the bedroom *Provide the books that promote the positive thoughts of the patient before going to sleep	Promote comfort and reduce anxiety.	*Promotes relaxation *Promotes good sleep *Improves positive thoughts
Emotional Support: *Talk with the patient in a calm and quiet manner *Can use gentle soft touch over the shoulder while speaking *Can build a good rapport with the patient. *Communicate the with an understandable manner. *Shake the head while he talks with you and hear whatever he wants to say *Show positive emotions while speaking with him	*By this way we can create a positive emotion within the patient	*Shows positive emotions towards the future life.
Spiritual care/support: *Improves his own spiritual being *Plan a schedule to meet his spiritual needs mainly in the morning and before going to sleep *Encourage to participate in spiritual programmes	*Shows a positive attitude towards the life.	*Improves the spiritual well being of the patient

5.

*Educate the patient and family members regarding the measures that improve the self-efficacy of the patient, thus can improve the self-esteem of the patient.

* Educate them regarding the managing of the medical components of illness, thus can manage their behaviours as well as the emotional sequelae

*  Educate them and help with the creation of action plans, developed by patients through the use of problem-solving skills

* Educate and coaching them regarding the measures enhancing self-management especially during times of transition.

* Enhance them and coping with day-to-day personal health issues gained through trial and error of the lived experience

*Educate the measures to improve the decision-making process

*Educate him to recognize the benefits of self-management.