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