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. 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 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: RELEVANT Data from Social History:Clinical Siguificance: Patient Care Begins: Current VS: P-Q.R-S.T Pain Assessment T: 982 F/37.3 C(onl Provoking Pallavokes, always preient Goal is 510 P: 92 (regular) Quality Severity: Timing Ache 5/10 Continuous Region/Radiation: Left leg BP: 11870 | 02 sat: 9896 RA What VS data are RELEVANT that must he recognized as clinically signiflcant to the nurse? RELEVANT VS Data: Clinical Significanee

Answer 1

Relevant data from present problem	Clinically significant
Sleep disturbance,	PTSD
Frequent flash backs of the past
Sitting alone at home
Not interacting with anyone
Anxiety
Suicidal thoughts	Depression
Relevant data from social history	Clinically significant
3 children and wife constitute the family	Adequate support from family but has to support 3 children
Significant disability after the blast	He lost eye sight of left eye, injury to left leg and abdomen
Alcohol use but abstinent for 1.5 years
Relevant data in vitals	Clinically significant
Vitals normal
Only pain on left leg with a severity of 5 out of 10	Pain is continues and ache type