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Patient NICOLE DIAZ Ms Diaz is a 48-year-old Cuban American woman who came to the VA
clinic at 10:30 AM this morning to receive treatment for her chronic sleep disorders related to
her PTSD.
You are expected to assess Ms Diaz's physiological and psychological condition in order to
engage in appropriate therapeutic communication and patient education. You will then
continue Ms. Diaz's treatment in the Care Plan activity.
CARE PLAN DX EXHIBITS INEFFECTIVE COPING r/t INSUFFICIENT SENSE OF CONTROL aeb
[nightmares, paranoia, tobacco use, fear]
Care plan Planning Short term goals the patient will identify at least 2 constructive short
term coping strategies by the end of the visit
Care plan Planning Interventions -Identify current stressors impacting patient coping
abilities and secondary concerns
-Discuss the strengths and weaknesses of the current coping strategies with the patient
-Discuss the harmful effects of smoking on physical health
-Assess readiness to learn
-Assist in determining realistic, feasible, and more efficient coping strategies
-Assist in use of diversion, recreation, and relaxation techniques
-Teach the patient how to substitute negative thoughts for positive ones
-Involve social services, psychiatric provider, and next-level support as needed
asked about sleep habits "-what is your sleep like?
what time do you fall asleep?
-what do you usually do before bed?
-do you use the computer of watch TV before you go to sleep?
, -what time do you wake up?
-how much sleep do you get a night?
-can you described where you sleep?"
patterns for sleep problems "what makes it hard for you to sleep?"
existing health conditions "do you have high blood pressure?"
f/u HTN dx "when was your high blood pressure first diagnosed?"
hx of mental health "do you have PTSD?"
f/u sx of PTSD dx -what makes you feel depressed?
-what makes you anxious?
-what are the symptoms of your PTSD?
onset PTSD -when were you diagnosed with PTSD?
-what brought on the PTSD?
-how long have you had MST?
-what happened when you were sexually assaulted?
-when did you get help for your PTSD symptoms?
aggravating factors for PTSD -how do you experience stress?
-does you anxiety prevent you from completing your usual activities?
-do you feel nervous in new situations?
-are you ok with talking about what happened?
-how does ptsd affect your relationship?