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 Current VS T: 98.2 F/37.3 C (oral) P-Q-R-S-T Pain Assessment: Provoking Palliative: Quality Region/Radiation Left leg Se Timin Movement provokes, always present. Goal is 5/10 Ache P: 92 (regular) R: 18 (regular) ВР: 11 8/70 02 sat: 9890 RA 5/10 Continuous Current Assessment: GENERAL APPEARANCE RESP: CARDIAC: Appears anxious, body tense, tired (dark circles under his eyes) Breath sounds clear with equal aeration bilaterally, non-labored respiratory effort Pink, warm & dry, no edema, heart sounds regular with no abnormal beats, pulses strong, equal with palpation at radial/pedal/post-tibial landmark Alert & oriented to person, place, time, and situation (x4), flat affect, inability to fall asleep NEURO: res, flashbacks while awake GI: Abdomen softnon-tender, bowel sounds audible per auscultation in all four quadrants Reports poor appetite with no weight I Voiding without difficulty, urine clear/yellow Skin integrity intact GU: SKIN: SUBSTANCE USE: | Last use of alcohol 1 ½ years ago. Denies use of other drugs Mental Status Examinations Casually dressed; facial scars noted, cooperative with interview Walks with a limp. No abnormal motor activity noted. Speech is of normal tone and cadence Anxious affect. Patient states, "I feel nothing"most of the time, but also states that he "lies off the handle" a lot, Reports he "startles easily" to environmental noises. MOTOR BEHAVIOR: SPEECH MOOD/AFFECT THOUGHT PROCESS: THOUGHT CONTENT: Denies delusions when assessed, somewhat guarded in responses, but no evidence of paranoia. Admits to intrusive thoughts about his time in combat. Expresses excessive guilt that "good men died" and "I wasn't able to help." Also states he ometimes thinks he should have died with "his patrol." States he has periods of time in which he has visions (flashbacks) of being back in Iraq during the IED blast also reports that sometimes he just sees "flashes" of body parts PERCEPTION INSIGHT/AUDGMENT: Recognized symptoms as part of PTSD diagnosis but states "There is probably nothing that can be done to help." Judgement intact Oriented x3. Has some memory problems associated with the exact events during the IEID blast. Possible TBI? Reports current difficulty concentrating at times Tends to stay to self COGNITION: INTERACTIONS SUICIDALHOMICIDAL:Stated that he thinks he should have died instead of the men in his unit. Denies current suicide ideation and has no plan. Denies homicidal ideation Collaborative Care: Medical Management 2. State the rationale and epectedtcomes for the medical plan of care. Pharm and Parenteral Therap Medical Management: Rationale: Expected Outcome: 1. Admit patient to unit under voluntary 2. Initiate milieu therapy 3. Initiate safety measures according to unit admission. protocol, including keeping environment free of dangerous items and maintain regular close observation 4. VS every shift while awake 15. Paroxetine 40 mg daily 6. Prazosin 4 mg PO HS 7. Mirtazapine 15 mg PO HS Collaborative Care: Nursing J What nursing priority fies will guide you ur plan of care? Management of Care) Nursing PRIORITY: PRIORITY Nursing Interventions: Rationale: Expected Outcome: 175

Answer 1

1.patient is in imminent danger of harming himself or others or the patient cannot properly care for his basic needs and cannot protect himself from harm.

2Initiate and support group interaction via therapeutic groups and activities.

3Presence of trusted individual provide feeling of security and assurance of personal safety.

5it helps in treating post traumatic stress disorder and anxiety.

6it helps in treating post traumatic stress disorder.

7it helps in relieving depression.

Intervention

• Stay with the patient and offer reassurance of safety and anxiety.
• Maintain a calm non-threatening matter-of -fact approach.
• Use simple words and brief messages, spoken calmly and clearly to explain hospital experience.

Rational

• Presence of trusted individual provide feelings of security and assirsnce of personal safety.
• Anxiety is contagious and maybe transferred from staff to patient.
• In and intensely anxious situation, patient is unable to comprehend anything but the most elementary communication.

Expected outcome

• The client experience a reduced level of anxiety
• The client recognizes symptoms as anxiety-related
• The client is sble yo use newly learned behavior to manage anxiety.