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PTSD Nursing Admin - Lecture notes 3-6

exam help practice
Course

Mental Health Nurs (NURS 4163)

54 Documents
Students shared 54 documents in this course
Academic year: 2020/2021
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Prairie View A&M University

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2/16/2020 Focused Exam: PTSD | In Progress Attempt | Shadow Health

app.shadowhealth/assignment_attempts/6136778 1/

Focused Exam: PTSD (Part 2 of 2)

Mental Health Nursing Theory/Practicum - Spring 2020, NURS 4163/

Return to Assignment (/assignments/291252/)

Reflections

Activity Description: Reflective writing develops your clinical reasoning skills as you grow and improve as a clinician and gives your instructor insight into your learning proces This reflection activity will help you think more deeply about your performance in the assignment. Use your documentation as you respond to the prompts at the bottom of the page.

Documentation Review

Nursing Admitting Note

Student Response Model Documentation

Chief Complaint Patient reports "I haven't been able to get a good night of sleep in weeks. I am having trouble falling asleep, and I only get a few hours of sleep at a time ... I wake up several times during the night, and I can't seem to let myself relax. My nightmares are getting worse, and I am starting to feel really frayed around the edges. I need help."

Ms. Diaz presented at the clinic with severe sleep issues she said were impacting her life. She claimed she was un to rest and was suffering from insomnia, nightmares, and frequent waking.

History of Present Illness

Sleep habits: Pt reports not actually falling asleep until 2/3 am and gets in bed around midnight. Pt reports refraining from using screens before bed and it hasn't made a difference. Pt reports checking doors and windows a few times before going to bed and still feels anxious to go to sleep nonetheless. Pt reports getting between 4-5 hrs of sleep a night.

Nicole is a 48 year-old Cuban American woman with a his of hypertension and post-traumatic stress disorder.

Allergies NKA NKA

Nursing Admitting...

Mental Status Note

SBAR

2/16/2020 Focused Exam: PTSD | In Progress Attempt | Shadow Health

app.shadowhealth/assignment_attempts/6136778 2/

Student Response Model Documentation

Past Medical History Health hx: - HTN (diagnosed at 45) - PTSD: diagnosed at 35 yrs ("it felt like I was screaming and no one could listen. It felt like i carried around this wound that had changed me, that was slowly killing me, and no one else knew." PTSD s/s & aggrivating factors: - nightmares - flashbacks -easy to startle - afraid of sexual assault - hypervigilant -doesn't like to be alone with men - hard to trust others and enjoy self Onset of PTSD: - sexual assult that occured about 20 yrs while serving in Air Force (pt was 23 yrs old) Poor coping (stays home, avoids going out // has a service dog) Reports no suicidal ideation/self harm but does wonder about self worth No homicidal ideation No previous psych. hospitalizations

HTN diagnosed age 45 PTSD diagnosed age 35 stemming from a sexual assault during her military service

Home Medication Losartan - HTN (last took in the evening) Buspirone - Anxiety (last took in the AM) Bupropion - Depression (last took in the AM)

Buspirone HCL 15 mg b.i. for anxiety, last dose this morning Bupropion HCL (12H) 150 mg b.i. for depression, last d this morning Losartan 100 mg daily for blood pressure, last dose this morning

Family History Mother: Cervical Cancer (survived) Father: died of Coronary Heart Disease, had neck lump (unsure of what it was), suffered from a stroke before passing away

Cervical cancer in mother at 36; father had neck lump - ty unknown age 50's; no family history of diabetes, MI, strok Father deceased of coronary heart disease; mother still liv

Social History Relationships declined due to PTSD and inability to trust others and have fun Occupation: grant writer Denies illicit drug use Consumes alcohol less than once a month // social drinker Smokes 4 cigarettes a day (sometimes less/more) Lives alone with service dog (Boomer) Decline in activity (lack of energy) Takes dog for walks a few times a day Diet: Mostly eats carry out food (Breakfast: yogurt/ Lunch: sandwich or leftovers/ Dinner: take out) Appetite: less than normal as of late. (stress) LMP: two weeks ago (irregular) No sexual activity in more than a year

Education and work: Currently retired (military disability); served 10 years in the US Air Force as an airplane mecha sexual assault by a commanding officer; service connecte for PTSD related to military sexual trauma (MST); bachelo degree in English.

Religion: Actively involved in a Catholic church in Shadowville.

Living situation and family: Nicole lives alone with her ser dog. Her family does not live in the area but she remains contact with her family members. She has close friends through her church. She dated a man from her church bu broke it off when they became too close.

Diet: Nicole does not like to cook for herself so she eats o great deal. She eats sometimes to calm her nerves

Substance use: Morning coffee only, rare alcohol, 3- cigarettes a day

Exercise: Nicole walks her dog daily; she used to ride her bicycle on local bike trails until she became uneasy about being on the trails alone. Since she got her service dog, s does not ride her bicycle.

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PTSD Nursing Admin - Lecture notes 3-6

Course: Mental Health Nurs (NURS 4163)

54 Documents
Students shared 54 documents in this course

University: Prairie View A&M University

Was this document helpful?
2/16/2020 Focused Exam: PTSD | In Progress Attempt | Shadow Health
https://app.shadowhealth.com/assignment_attempts/6136778 1/3
Focused Exam: PTSD (Part 2 of 2)
Mental Health Nursing Theory/Practicum - Spring 2020, NURS 4163/4262
Return to Assignment (/assignments/291252/)
Reflections
Activity Description: Reflective writing develops your clinical reasoning skills as you grow and improve as a clinician and gives your instructor insight into your learning proces
This reflection activity will help you think more deeply about your performance in the assignment. Use your documentation as you respond to the prompts at the bottom of the
page.
Documentation Review
Nursing Admitting Note
Student Response Model Documentation
Chief Complaint Patient reports "I haven't been able to get a good night of
sleep in weeks. I am having trouble falling asleep, and I only
get a few hours of sleep at a time ... I wake up several times
during the night, and I can't seem to let myself relax. My
nightmares are getting worse, and I am starting to feel really
frayed around the edges. I need help."
Ms. Diaz presented at the clinic with severe sleep issues
she said were impacting her life. She claimed she was un
to rest and was suffering from insomnia, nightmares, and
frequent waking.
History of Present
Illness
Sleep habits: Pt reports not actually falling asleep until 2/3 am
and gets in bed around midnight. Pt reports refraining from
using screens before bed and it hasn't made a difference. Pt
reports checking doors and windows a few times before
going to bed and still feels anxious to go to sleep
nonetheless. Pt reports getting between 4-5 hrs of sleep a
night.
Nicole is a 48 year-old Cuban American woman with a his
of hypertension and post-traumatic stress disorder.
Allergies NKA NKA
Nursing Admitting...
Mental Status Note
SBAR

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