Nursing Case Study for (PTSD) Post Traumatic Stress Disorder
Watch More! Unlock the full videos with a FREE trial
Included In This Lesson
Study Tools For Nursing Case Study for (PTSD) Post Traumatic Stress Disorder
Outline
Mr. Bryant is a 32-year-old male who presents to the emergency room brought by law enforcement for what they describe as possible public drug or alcohol intoxication along with erratic and aggressive behavior. He was outside a local bar and patrons called 911.
Law enforcement officers (LEOs) seek medical clearance before proceeding any further and present a Veteran Health Care ID card identifying Mr. Bryant. The patient is resisting officers and saying he has to, “…save my buddies. They are down range and there’s explosions and gunfire. Can’t you hear it? Let me go so I can help them!” He also points at the LEOs and whispers to the nurse, “These guys captured me. They’re not on our side.”
What assessments and initial check-in activities should the nurse perform to best assist the patient and law enforcement?
- The priority for this patient and staff is SAFETY. First, place the patient in a gown, removing all potential dangers; this step is vital for security and safety, and it also helps the nurse to begin a full head-to-toe assessment which is the first step of the nursing process. He should be screened for suicide and asked specifically if he has a plan. Signs of injury or hints to the patient’s history can guide the plan of care and next interventions. Determining his veteran status may help with obtaining medical history as well as to guide nursing interactions to help alleviate the paranoia he seems to be exhibiting. Next, asking LEOs to leave the room will afford the patient his right to privacy and protection of his personal health information to which he is entitled. LEOs may remain nearby (i.e. outside of the room)
What orders does the nurse expect the provider to give?
- Psychiatric precautions like placing in a gown, removing personal items, searching for weapons, suicide/harm screening should be expected. Diagnostics to rule out medical issues like vital signs, urine drug screen/blood alcohol level, blood work, and IV start are all orders to anticipate. The IV may be needed for urgent/STAT med orders. Further diagnostics (i.e. radiology, etc.) might be anticipated only after initial screening gives data. For example, high HR and BP may warrant an EKG. Signs of trauma may warrant an XRay or CT scan. Similarly, referrals may be necessary, but not initially.
After screening and assessing the patient, the nurse has the following data:
Patient is able to follow instructions after LEOs step out of the room. He removes his clothing with assistance to be placed in a gown and on a monitor. He voids unassisted, but supervised, for a urine sample. Offers no resistance to IV placement and blood draw.
He frequently looks around and seems hyperalert. He is unable to articulate his exact location, only saying, “I’m at a hospital.” PERRLA, moves all extremities. Multiple military-themed tattoos are visible on his arms, chest, back, and legs.
No potential weapons noted. No signs or symptoms of physical assault, skin is intact with no bruising. The patient is wearing military-issued dog tags on a long chain beneath his clothing. Personal items placed in a belongings bag and secured per protocol. He indicates he has not slept for several days due to being out of his medication and says, “I can’t do it anymore. I can’t take the nightmares, so I don’t want to sleep. I just can’t make it.” He denies a medical or psychiatric history only saying, “I go to the VA hospital. They give me meds and therapy, though.”
BAC: 0.15 percent
UDS: NO INDICATION of amphetamines, methamphetamines, benzodiazepines, barbiturates, marijuana, cocaine, PCP, methadone, opioids (narcotics)
CBC: WNL
CMP: WNL
EKG: sinus tachycardia, no ectopy noted
PRN medications ordered:
Lopressor 5 mg IV bolus given over 2 minutes, PRN
Normal Saline 0.9% 1000 mL rapid IV bolus, PRN
Naloxone 0.4-2 mg IV/IM/SC; may repeat q2-3min PRN; not to exceed 10 mg
Lorazepam 1 mg IV, may repeat PRN; not to exceed 4 mg
BP 180/90 SpO2 98% on Room Air
HR 112 bpm and regular Ht 182 cm
RR 28 bpm Wt 99.8 kg
Temp 37.9°C
Prioritize the top nursing interventions. What are some vital interventions and why are they performed in this order?
- Making sure the patient and staff stay SAFE is the priority right now. Placing him in a gown and checking for dangerous items take precedence PRIOR to obtaining labs or monitoring. Reassuring the patient and remaining calm throughout is needed at this time as well. Putting him on a monitor for continuous monitoring is important in case there are sudden changes so that happens 2nd since his initial triage vital signs are outside of parameters but not emergent. Obtaining samples to rule out medical/metabolic concerns vs intoxication is 3rd. Further examining the patient’s statements with therapeutic communication can happen concurrently with medical interventions and help foster a healthy nurse-patient relationship. Based on assessment findings, the nurse could also use a reliable and valid PTSD screening tool like the five-item Primary Care PTSD Screen for the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders. Please note: restraints are not mentioned and should be avoided if the patient is SAFE. If orders for restraints are placed, the provider MUST document as either medical or behavioral. This is not within a nurse’s scope of practice.
Should the nurse administer the PRN medications written by the provider now or question other medication orders? Why or why not?
- No. Firstly, ALL PRN orders need parameters to proceed. I.e. Answer Lopressor IV 5 mg bolus over 2 minutes FOR stated HR and/or BP. These orders do not have any parameters provided. It is beyond a nurse’s scope of practice to administer without the prescriber’s guidance. None of these PRN orders have parameters provided.
Also, for each med:
For the Lopressor, there is no indication this is a cardiac issue and no frequency/max provided either. For the IVF there is no indication that he is dehydrated, and cardiac status is not known so the nurse should be concerned for possible fluid overload. Also, there is no scientific evidence that NS can impact the alcohol intoxication this patient appears to have. For the naloxone, UDS shows the patient did not ingest an overdosage of opioids and his V/S do not indicate respiratory depression or opioid intoxication (even without labs to prove it). For the Lorazepam, there is no seizure activity and giving this medication may impair the psychiatric screening needed to further assess the situation.
Are there other orders the nurse might anticipate and/or suggest?
- Placing him on suicide precautions would be a good start as it is not harmful and can always be discontinued after further observation/assessments. Obtaining medical records to determine PTSD treatment and/or other conditions would be helpful. Also, seeking expert consultation in the form of a psychiatric consult is in the patient’s best interest.
Are there past medical history concerns specific to this patient and his background that may aid in the plan of care?
- Research indicates that many who suffer from PTSD also have a history of traumatic brain injury and/or other combat trauma. Determining his TBI status may help in obtaining consults (i.e. neurology, occupational therapy, etc.) as well as guiding further diagnostics (does he need a head CT? For example). TBI-related issues may be the root cause of his current behavior but if they are not then psychiatric concerns would be more likely. Finding out all you can about his current treatment plan will help in the present.
After determining the patient is not a harm to himself or others, LEOs release him to the medical treatment facility. A records request produces a brief patient history and treatments he is receiving from the local VA hospital. Records do not indicate any history of physical combat trauma, no traumatic brain injury (TBI). The medication list is available to review and, since some time has passed and the patient has been cooperative and calm, he is conversing appropriately. He concurs with his medications verbally.
Regarding patient medications, what process is necessary for the nurse to perform and why?
- A medication reconciliation should be completed on ALL patients per Joint Commission. From the National Patient Safety Goal literature:
“NPSG.03.06.01 Maintain and communicate accurate patient medication information. –Rationale for NPSG.03.06.01– There is evidence that medication discrepancies can affect patient outcomes. Medication reconciliation is intended to identify and resolve discrepancies—it is a process of comparing the medications a patient is taking (or should be taking) with newly ordered medications. The comparison addresses duplications, omissions, and interactions, and the need to continue current medications. The types of information that clinicians use to reconcile medications include (among others) medication name, dose, frequency, route, and purpose. Organizations should identify the information that needs to be collected in order to reconcile current and newly ordered medications and to safely prescribe medications in the future.”
What patient education topics would need to be covered? When? Is this only the nurse’s responsibility?
- Once the patient is determined to be no harm to himself and AA&O enough to participate in self-care (by assessment and provider determination) then staff can provide education with a focus on medication regimen adherence with rationales (i.e. sudden discontinuation of antidepressants may cause sleep disturbances and they should not be taken with alcohol either). Resources for him to seek out if he has suicidal ideation (this should be simple and clearly explained – avoid medical jargon) or thoughts of self-harm. Ensuring he has a support system and the resources to follow up with appropriate parties should be part of the interactive education process. Case management may need to assist in discharge/follow-up recommendations. His family/support system should be included in discharge planning as well. There may be literature or web sources to give to the patient as well so he can participate in self-care.
After sleeping for a few more hours, the patient remains appropriate, cooperative, and calm. HR, BP, RR all decreased. His spouse arrives to take him home. They both verbally acknowledge discharge plans for him to return home with particular emphasis on follow-up with the VA psychiatric team. Mr. Bryant states very clearly that he has no plans to harm himself or others. The nurse documents he is fully alert and oriented x 4 after assessing one more time.
What does oriented x 4 mean? Why is this important?
- Oriented x 4 means oriented to person (who are you? name?), place (where are you? specific), time (time/day/date), and situation (what is going on?) This is vital for this patient because initially, he presented as disoriented. In order for him to be discharged to self-care and able to follow up as directed he must be fully awake and oriented so as not to pose a threat to himself, others, or his future care. This also allows staff to accurately document the level of consciousness at discharge.
View the FULL Outline
When you start a FREE trial you gain access to the full outline as well as:
- SIMCLEX (NCLEX Simulator)
- 6,500+ Practice NCLEX Questions
- 2,000+ HD Videos
- 300+ Nursing Cheatsheets
Transcript
Hi everyone. My name is Abby, and we’re going to go through a case study for PTSD together, also known as post-traumatic stress disorder. In this scenario, Mr. Bryant is a 32-year-old male. He presents to the ED after being brought in by law enforcement for possible drug and alcohol intoxication, as well as for displaying erratic and aggressive behavior. He was outside a local bar and patrons called 911. The law enforcement officers seek medical clearance before proceeding with any further treatment. They present his veteran ID card Identifying Mr. Bryant. The patient is still resisting and says he has to save his buddies. “They are down range and there’s explosions in gunfire. Can you hear it? Let me go so I can help them.” He also points at the officers and whispers to the nurse, these guys captured me. They’re not on our side.” All of this is pretty concerning behavior. Let’s look at critical thinking checks number 1 and number 2 below.
Great job after screening and assessing the patient, the nurse has the following data. The patient is able to follow instructions after the officers step out of the room. He removes his clothing with assistance and is placed on a monitor and dressed in a gown. He voids unassisted but supervised. We need a urine sample. He offers no resistance to having an IV placed and having blood drawn. However, he frequently looks around and seems hyper alert. He is unable to articulate his exact location, only stating, “I’m at a hospital.” His pupils are equal round reactive to light, and he is able to move all of his extremities. He has multiple military themed tattoos visible on his arms, chest, back and legs. He has no weapons on him nor any signs of assault from physical contact and his skin is intact with no bruising. He is wearing military issued dog tags on a long chain beneath his clothing. Personal items were placed in a belongings bag and secured per protocol. He indicates he has not slept for several days due to being out of his medication. He says, “I can’t do it anymore. I can’t take the nightmares, so I don’t want to sleep. I just can’t take it.” He denies a medical or psychiatric history only saying, “I go to the VA hospital. They give me meds and therapy.” Now that we have all of this information, let’s take a look at the lab results and vital signs before moving on to the critical thinking checks.
All right. Let’s take a look at these vitals:
His blood pressure came back at 180/90 mmHg. His heart rate is 112 with a regular rhythm. Respiratory rate of 28 and his temperature is 37.9 degrees Celsius.
He’s saturating at 98% on room air. And his height is 182 centimeters with a weight of 99.8 kilograms. Let’s take a look at that urinary analysis:
His blood alcohol content (BAC) puts him at 0.15%. His urinary drug screening shows no indication of amphetamines, methamphetamines, benzodiazepines, barbiturates, marijuana, cocaine, PCP, methadone, or opioids, also known as narcotics. The blood work shows his CBC, everything was within normal limits, and his comprehensive metabolic panel, also within normal limits. His EKG states that he’s in sinus tachycardia with no ectopy noted. They also decided to give him some PRN medications. Our PRN medications include Metoprolol, that’s our beta blocker, and he can have five milligrams via IV bolus given over two minutes. PRN also ordered one liter of normal saline just in case, and we can also give that rapidly through IV bolus. Additionally, we have Naloxone, which you may know as Narcan. We’re given that at 0.4 to two milligrams that can be given either intravenously, intramuscularly or subcutaneously, and can be repeated every two to three minutes PRN. We don’t want to exceed 10 milligrams on the Naloxone. And he’s given something for anxiety, lorazepam, one milligram intravenous that may also be repeated PRN, but not to exceed four milligrams. Now that we have all of this info, let’s go ahead and go through our critical thinking checks. You’re going to look at numbers 3, 4, 5, and 6 before we chat again.
Excellent. After determining the patient is not a harm to himself or others, law enforcement releases him to the medical treatment facility. A records request produces a brief patient history in treatments he is receiving from the local VA hospital records and does not indicate any history of physical combat trauma nor a traumatic brain injury or TBI. The medication list is available to review and since some time has passed, and the patient has been cooperative and calm, he is conversing appropriately. He concurs with his medications verbally. Now with this in mind, let’s take a look at our critical thinking checks number 7 and number 8 below.
Great job. After finally sleeping for a few hours, the patient remains appropriate, cooperative and calm. His vital signs have even gotten better. His heart rate, his blood pressure and his respiratory rate have all come down to being closer to within normal limits. His spouse arrives to take him home. They both verbally acknowledge discharge plans for him to return home with particular emphasis on following up with the VA psychiatric team. Mr. Bryant states very clearly that he has no plans to harm himself or others. The nurse documents that he is fully alert and oriented times four after she does her final assessment. Now that we have this information, let’s take a look at our critical thinking check number nine below.
Wonderful everyone, that wraps up our case study on PTSD. Please take a look at the attached study tools and test your knowledge with a practice quiz. We love all of you, now go out and be your best self today, and as always, happy nursing!
References:
Sources: for meds throughout mixed sources pdr.net or rxlist.com along with uptodate.com, too; for condition from uptodate.com posttraumatic stress disorder in adults: Epidemiology, pathophysiology, clinical manifestations, course, assessment, and diagnosis
Author:Jitender Sareen, MD, FRCPCSection Editor:Murray B Stein, MD, MPHDeputy Editor:Michael Friedman, MD (last updated Sept, 2021)
Further info at this link:
https://www.jointcommission.org/-/media/tjc/documents/standards/national-patient-safety-goals/2020/npsg_chapter_ahc_jul2020.pdf
View the FULL Transcript
When you start a FREE trial you gain access to the full outline as well as:
- SIMCLEX (NCLEX Simulator)
- 6,500+ Practice NCLEX Questions
- 2,000+ HD Videos
- 300+ Nursing Cheatsheets
