Posttraumatic Stress Disorder (PTSD)
UNFOLDING Reasoning
STUDENT
Marcus Jackson, 34 years old
Primary Concept
Mood and Affect
Interrelated Concepts (In order of emphasis)
1. Stress
2. Coping
3. Anxiety
4. Clinical Judgment
5. Patient Education
6. Communication
7. Collaboration
© 2016 Keith Rischer/www.KeithRN.com
, 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 ½ 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:
Served four combat tours The patient suffers from severe PTSD, he is sleep deprived due to the
Not slept more than 2 hours a night nightmare that he has from his time in the service. The patient has
Inability to sleep, nightmare, increased anxiety which has caused him to isolate and feel alone. He
increasing anxiety, isolation relives his trauma based on familiar noises in the community. It is
Relives bombing and flashbacks important to evaluate his surrounding environment for any triggers. The
combat & more aware of noises ex: medication has not controlled his symptoms therefore, a provider
firework would need to add a new prescription. The patient is isolating himself
Extreme anxiety and avoids his family. The patient is at risk for suicide; therefore, family
PTSD Medication has not controlled should keep close eye on Marcus and his behavior.
anxiety
Avoid time with family
RELEVANT Data from Social History: Clinical Significance:
The patient can be experiencing guilt that may trigger depression. The
Bestfriend was killed in combat patient may be experiencing low self-esteem which causes depression
Marcus was seriously injured; lost to worsen. The patients has increased agitation which increases
sight in left eye; multiple surgeries depression and suicidal thoughts. The patient however has a very
More agitated and trouble sleeping supportive family, this can be a very big advantage for the patient.
Walks with a limp and continuous to
complain of pain
Married for 14 years with 3 children
Denies drug use and any no drinking
for the past 1.5.
© 2016 Keith Rischer/www.KeithRN.com
UNFOLDING Reasoning
STUDENT
Marcus Jackson, 34 years old
Primary Concept
Mood and Affect
Interrelated Concepts (In order of emphasis)
1. Stress
2. Coping
3. Anxiety
4. Clinical Judgment
5. Patient Education
6. Communication
7. Collaboration
© 2016 Keith Rischer/www.KeithRN.com
, 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 ½ 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:
Served four combat tours The patient suffers from severe PTSD, he is sleep deprived due to the
Not slept more than 2 hours a night nightmare that he has from his time in the service. The patient has
Inability to sleep, nightmare, increased anxiety which has caused him to isolate and feel alone. He
increasing anxiety, isolation relives his trauma based on familiar noises in the community. It is
Relives bombing and flashbacks important to evaluate his surrounding environment for any triggers. The
combat & more aware of noises ex: medication has not controlled his symptoms therefore, a provider
firework would need to add a new prescription. The patient is isolating himself
Extreme anxiety and avoids his family. The patient is at risk for suicide; therefore, family
PTSD Medication has not controlled should keep close eye on Marcus and his behavior.
anxiety
Avoid time with family
RELEVANT Data from Social History: Clinical Significance:
The patient can be experiencing guilt that may trigger depression. The
Bestfriend was killed in combat patient may be experiencing low self-esteem which causes depression
Marcus was seriously injured; lost to worsen. The patients has increased agitation which increases
sight in left eye; multiple surgeries depression and suicidal thoughts. The patient however has a very
More agitated and trouble sleeping supportive family, this can be a very big advantage for the patient.
Walks with a limp and continuous to
complain of pain
Married for 14 years with 3 children
Denies drug use and any no drinking
for the past 1.5.
© 2016 Keith Rischer/www.KeithRN.com
