PTSD Case Study 3bsn 6
PTSD Case Study 3bsn 6
PTSD Case Study 3bsn 6
A.Y. 2020-2021
A CASE STUDY
IN
Submitted to:
Prof. Barbie Mae Cabalo RN, MAN
Submitted by:
Mamaat, John Marc Ibao
Mendoza, Ledy Jade Alberto
Milar, Arlyn Paris
Molano, Chuck Lloyd Meredor
Sabado, Gella Soriano
Salamanca, Joshua Andrei Dolores
Sales, Carlos Angelo Reyes
Serapion, Monsour Moni Mamaradlo
Solis, Nathaniel Muñoz
Tambot, Baldric Parayno
Viray, Danielle Quemuel
Yu, Lynnette Marionne Molina
Zacarias, Thea Rossette Ann
(3BSN-6)
June 2021
CASE SCENARIO
A 32-year-old resident – Mr. Tony Sales Serapion, of Pasig City, Metro Manila
comes in the psychiatric clinic for help at the urging of his fiancé. He was an infantry
man with a local Marine Reserve unit who was honorably discharged in 2019 after
serving two tours of duty in Mindanao. His fiancé told him he has “not been the same”
since his second tour of duty and it is affecting their relationship negatively. Although
he offers few details, upon questioning, he reports that he has significant difficulty of
sleeping and that he “sleeps with one eye open”, and when he falls into a deeper sleep,
second tour, but is unwilling to provide specific details – he tells you he has never
spoken with anyone about them and he is not sure he ever will. He spends so much time
alone because he feels annoyed and doesn’t want to burst out at people. He reports that
he finds it difficult to perform his duties as a security guard because it is boring and
gives him too much time to think. At the same time, he is easily startled by noise and
motion and spends excessive time searching for threats that are never confirmed both
when on duty and at home. He describes having intrusive memories about his traumatic
experiences on a daily basis but declines to share any details. He also avoids seeing his
friends from his Reserve unit because seeing them reminds him of experiences that he
does not want to recall. He was brought to the psychiatric clinic and was diagnosed of
A 32-year-old infantryman named Tony reports that he has been experiencing difficulty
in sleeping, sleeps with one eye open, and has nightmares when he falls into a deeper sleep.
Aside from that, Tony also experienced several traumatic events in his working area making him
spend his time more of being alone and having difficulty performing his duties as well.
disorder (or PTSD) is a psychiatric disorder that may occur in people who have experienced or
witnessed a traumatic event such as a natural disaster, a serious accident, terrorist act, or rape or
who have been threatened with death, sexual violence or serious injury. People with PTSD have
intense, disturbing thoughts and feelings related to their experience that last long after the
traumatic event has ended. They may relive the event through flashbacks or nightmares; they
may feel sad, fearful or angry; and they may feel detached or estranged from other people. Just
like Tony, people with PTSD may avoid situations or people that remind them of the traumatic
event, and they may have strong negative reactions to something as ordinary as a loud noise or
an accidental touch.
PTSD can occur in all people, of any ethnicity, nationality or culture, and at any age. The
lifetime prevalence of PTSD among men was 3.6% and among women was 9.7%. The
the age range of 60 to 93 years compared to the participants below 60 years of age because of
what happened in the past. In certain population / ethnic groups – U.S. Latinos, African
Americans, and American Indians – are disproportionately affected and have higher rates
I. BIOGRAPHIC DATA
Gender: Male
Occupation: Infantryman
Nationality: Filipino
Diagnosis: PTSD
changes observed by his fiancé. Main complaints included social isolation and loss of interest,
irritability, difficulty sleeping, nightmares when falling deeply asleep, hypervigilance and
The patient was urged to consult in the psychiatric clinic with the help of his fiancé. He
was a former infantryman with a local Marine Reserve unit and was honorably discharged in
2019 after serving two tours on duty in Mindanao. His experiences on the said duty were a
contributing factor of his unusual behaviors and the negative impacts on their relationship as
Past Illness
The patient did not have any hospitalizations. Other than signs and symptoms being
reported in the psychiatric clinic on the admission, patient did not have any conditions.
Present Illness
The patient reported having disturbed sleeping patterns and nightmares associated with
past traumatic experiences. Irritability, outburst behaviors, being easily startled, intense distress,
and intrusive thoughts were also present based on the data gathered. The patient was admitted in
the psychiatric clinic and diagnosed with post traumatic distress disorder or PTSD.
The patient’s family members did not have any history of illnesses and other conditions
General Appearance:
Upon admission, the patient appeared to be hyperalert, passive, ambulatory, well-hydrated,
Vital Signs:
Patient’s vital signs were obtained and recorded as follows: temperature: 36.9, pulse rate: 110
Patient’s head and facial structures are symmetrical, with no lesions, no tenderness and masses
upon palpation, hair is evenly distributed and black in color with dry texture. Patient’s head is
assessed as normocephalic.
Skin:
Patient’s skin was warm and dry, good skin turgor and normal skin complexion with
Eyes:
Eyes are symmetrical, unicentric with black and round iris, pale palpebral conjunctiva with no
redness, lesions, and no discharges notes, and pupils constrict upon illumination. Patient has rark
Ears:
Patient’s ears are symmetrical to the face, the pinna recoils after folding, no palpable masses and
Nose:
The nasal septum is not deviated, no lesions, no abnormal discharges, no sinus inflammation and
Mouth:
The lips and oral cavity is symmetrical, and the presence of normal gag reflex was noted. Patient
Neck:
The chest and thoracic structure is symmetrical, with no lesions and masses palpated and noted.
The areola and nipples were black in color as inspected. Upon admission, patient’s respiratory
Heart/Cardiovascular:
Patient was experiencing tachypnea upon admission. No murmur and gallop were noted.
Abdomen:
No abdominal rigidity, tenderness, distention, or abnormal sounds were noted. Good bowel
Upper Extremities:
Patient’s arms are proportion to body structures, with no lesions, and masses inspected and noted.
Lower Extremities:
The lower extremities are symmetrical. No lesions and palpable masses were noted. Toe nails
were clean as inspected. No bilateral edema and deformity were observed and noted.
MENTAL STATUS EXAMINATION
groomed. Puffy eyes and dark under eyes are evident because of having difficulty in
sleeping.
He is trying to avoid talking about the traumatic event and is easily annoyed.
Affect:
Mr. Serapion showed blunted affect as he displayed lack of emotion and energy during the
interview process. Moreover, the patient appeared to be terrified when asked about his past
Mood:
Mr. Tony appeared to be in a dysphoric mood and restless all throughout the interview process.
Mood was incongruent with the content as it can be seen that the patient was anxious despite
Thought Process:
The patient had a linear, logical, and coherent thought as he never provided multiple,
unnecessary details nor he deviated from the focused questions. However, he provided very
limited answers. He was able to report his symptoms – difficulty sleeping, nightmares,
hypervigilance, lack of interest, feeling isolated, and intrusive thoughts, as well as he endorsed
experiencing traumatic events during his second tour as an infantry man but refused to disclose
specific details. On the other hand, his speech pattern and tone appeared to be dull and sparse.
Thought Content:
There were no abnormalities to the patient’s thought content noted. Mr. Tony never had
nightmares when falling into a deeper sleep. Furthermore, his thought content revealed feeling of
isolation or detachment from others but never had suicidal ideations or self-destructive thoughts.
Cognitive Evaluation:
During the interview process, the patient was alert and oriented to the reality except when the
patient was being reminded of his past experiences. As a result, the patient was unable to respond
to the nurse. His cognitive evaluation revealed that he has a reduced concentration due to the
intrusive thoughts that he experiences on a daily basis. The patient never experienced
dissociative amnesia. Hence, it can be concluded that he has intact memory and can recall short
Insight:
The patient had a poor insight as he was able to recognize the triggering factors but was unaware
of his condition until his fiancé mentioned his behavioral changes that have negatively affected
their relationship.
Judgment:
Mr. Tony showed poor judgment since he had no initiative of visiting a psychiatric clinic until
his fiancé encouraged him to seek professional and medical help. The patient was not compliant
Traumatic
Events
Increased non-adrenergic
activity Difficulty sleeping due to nightmares
of past traumatic event
(Low cortisol levels due to HPA
dysregulation)
Intrusive Thoughts
Difficult to achieve fear extinction,
habituation, desensitization
POST
TRAUMATIC
STRESS
DISORDER
Tony was a 32-year-old infantryman with a local Marine Reserve unit in Mindanao way
back 2019. His fiancée noticed a change in his behavior and it negatively affects their
relationship. He reports difficulty sleeping, sleeps with an eye open, and has nightmares when
falling into a deep sleep. According to him, he experienced traumatic events when he is still on
duty on his second tour as an infantryman. He never spoke these events to anyone and most of
the time; he spends this alone because he becomes irritable. He also finds a hard time performing
his job as a security guard because for him, this job is boring and making him too much time to
think. He avoids anything that reminds him of his traumatic experiences that he doesn’t want to
recall. With this, Tony was diagnosed to have posttraumatic stress disorder in a psychiatric clinic.
PROCESS RECORDING
(ORIENTATION PHASE)
The patient was a well-groomed male of tall stature, sturdy build, and average height.
He avoided direct eye contact and wandered his eyes around the room
Patient had a difficulty in sitting still and would fidget his hands and legs frequently
The meeting took place at the PHINMA Mock Hospital. The hygiene procedure took place in the
wash area of the said hospital while the therapeutic interview was held in a safe, well-ventilated,
“How about your work sir, Exploring “ I am an infantry man at THERAPEUTIC. Examine the
how was it? “ Marine Reserve unit, my patient’s background.
job is boring and I keep on
thinking about thing, lots of
things, keeps on thinking
and boring “
“Oh, your job sir is Exploring “It is hard to be a security THERAPEUTIC. Examining the
amazing, can you tell me guard, it is boring “ patient’s issue.
more about it sir? “
“Could you describe it more Exploring “I feel like time it was THERAPEUTIC. Examining
fully sir? “ giving me more time to the patient’s job more fully.
think and I see more more,
more ..
“You seem distracted sir, Making observations “ Oh none, nothing “ THERAPEUTIC. He seems
what are you looking at? “ distracted.
So, how was your stay here Exploring “ I find it hard to sleep, I THERAPEUTIC. Examining the
sir? can’t sleep when I sleep patient’s present situation.
urghh no, no, “
“ Okay sir, so after this we Accepting and giving “ Okay, I like that “ THERAPEUTIC.Oriented the
will go outside so you can information patient to the sequence of events.
communicate with the
others as well “
EVALUATION
The orientation phase was somehow successful since the patient engaged in the interview. Trust and rapport were
partially established as the patient was also able to share information about him but was still hesitant and seems to
lost focus at times to report some specific details. Moreover, the parameters of the nurse-patient relationship were
disclosed properly.
University of Pangasinan
PHINMA Education
Network College of Health
Sciences
Subjective: Posttraumatic stress After implementation of Independent: Independent: Goal Met. After
Patient has disorder (PTSD), once called shell nursing interventions, the implementation of nursing
shock or battle fatigue syndrome, is a client will be able to:
Encourage the client to Identification and interventions, the client
verbalized
difficulty sleeping serious condition that can develop express his or her feelings expression of feelings was able to:
and sleeping with Short term goal: through talking, writing, are central to grieving
after a person has experienced or
“one eye open” crying, or other ways in process. Short term goal:
witnessed a traumatic or terrifying Begin healthy grieving
Patient has which the client is Retelling the
event in which there was serious resolution, initiating Begin healthy
verbalized having comfortable. experience can help the
physical harm or threat. PTSD is a the process of grieving
nightmares and Encourage to talk about client to identify the
lasting consequence of traumatic psychological healing resolution,
intrusive trauma at their own pace. reality of what has
ordeals that cause intense fear, Demonstrate ability to initiating the
recollections of Non-threatening happened and help to
helplessness, or horror. deal with emotional process of
traumatic event environments, include identify and work
Objective: reactions psychological
Most people who have a significant other if patient through related feelings
Patient appears to traumatic event will have reactions appropriately. healing
desires. The nurses’ priority is to
be reserved when that may include shock, anger, Demonstrate
Maintain the client’s safety protect the client from
asked about the nervousness, fear, and even guilt. ability to deal
and integrity during post injury or harm during a
details of past These reactions are common, and for Long term goal: with emotional
trauma episode" using post traumatic episode.
events most people, they go away over reactions
Integrate the appropriate interventions Offer reassurance of
Agitated and appropriately.
time. For a person with PTSD, according to facility policy. safety and security,
annoyed traumatic experience
however, these feelings continue Stay with patient during normality of symptoms
Easily startled by into persona, renew
and even increase, becoming so flashbacks and nightmares. after trauma
noise and motion significant
strong that they keep the person Long term goal:
relationships and Discuss coping strategies. What has worked in the
NURSING DIAGNOSIS from going about their life as past, alternative
establish meaningful Integrate the
expected. People with PTSD have strategies
Post Trauma Syndrome goals for the future. traumatic
symptoms for longer than one Collaborative:
R/T distressing event Collaborative: experience into
month and can’t function as well as
outside the range one persona, renew
before the event that triggered it Assign patient same staff as
human experience To build trust significant
happened. possible, use
evidenced by intrusive relationships and
nonthreatening manner,
recollections and establish
nightmares friendly approach, and
meaningful goals
respect client’s wishes.
for the future.
ASSESSMENT EXPLANATION OF THE PROBLEM PLANNING INTERVENTIONS RATIONALE EVALUATION
Subjective: People with PTSD suffer from Short Term Independent: Independent: After 1 week of nursing
interventions, the goal was met.
“ Nahihirapan ako insomnia. This is largely due to Goals: 1. Encourage daytime physical activities but 1) In insomnia, stress may be reduced The patient
matulog, ang sasama ng hyperarousal, in which the individual is After 1 week of nursing instruct the patient to avoid strenuous by therapeutic activities and may established an effective
mga panaginip ko din unable to relax. It may also be a interventions, the patient activities before bedtime. promote sleep. However, strenuous sleep pattern and obtained
pag nakatulog ako “ as activities may lead to fatigue and
lingering effect of having been in a will be able to establish an optimal amounts of sleep
verbalized by the may cause insomnia. as evidenced by
situation that required constant effective sleep pattern. 2) This provides baseline
patient verbalization of feeling
alertness at night. Insomnia in PTSD Long Term Goals: 2. Take note observations of data for the evaluation of rested and improvement in sleep
may also be selfperpetuating, as the After months of nursing sleep-wake behaviours. Take insomnia. pattern
Objective: down notes on the number of hours the patient 3) L-tryptophan is a
stress of not being able to fall asleep interventions, the patient
Dark under eyes is asleep. component of milk which
eventually leads to maladaptive sleep will obtain optimal amounts
restless 3. Encourage patient to take milk. promotes sleep.
behaviors such as daytime napping or of sleep as evidenced by 4. Instruct the patient to follow a consistent 4) Consistent schedules
substance abuse. verbalization of feeling daily schedule for rest and sleep. facilitate regulation of the
5. Introduce relaxing circadian rhythm and
rested and improvement
activities such as warm bath, calm music, decrease the energy
insleep pattern reading a book, and relaxation exercises before needed for adaptation to
NURSING DIAGNOSIS bedtime. changes.
5) These activities provide relaxation
Insomnia related to Anxiety and distraction to prepare mind and
as evidenced by difficulty body for sleep.
sleeping Dependent: Dependent:
DRUG STUDY
NAME OF DRUG MECHANISM OF ACTION CONTRAINDICATIONS SIDE EFFECTS ADVERSE EFFECTS NURSING
RESPONSIBILITIES
GENERIC NAME The venlafaxine drug mechanism of Hypersensitivity to the Nausea Trouble breathing Assess the patient for any
Venlafaxine drug or tightness in the allergies or contraindications
action is to improve the serotonin
Hydrochloride Inappropriate Drowsiness chest regarding the drug
levels, norepinephrine and dopamine antidiuretic hormone Monitor the patient for
High cholesterol Dizziness Memory worsening conditions including
BRAND NAME by means of blocking of the transport
Low amount of depression, anxiety and suicidal
Effexor proteins then inhibiting the reuptake sodium ideation.
Dry mouth Hallucination
Increased risk of Monitor the vital signs of the
at the presynaptic terminal. This drug bleeding due to
Constipation Seizures patient and observe heart rate
have effect on conditioned fear clotting disorder and blood pressure status.
CLASSIFICATION Manic-depression Fever Monitor neurologic status and
responses of patients with PSTD Loss of appetite
Selective Serotonin and Suicidal thoughts report attack of insomnia,
which can cause chronic hyperarousal Serotonin syndrome Increased heart nervousness and anxiety.
Norepinephrine (High Serotonin
Blurred vision
rate or blood Assess safety of the patient
Reuptake Inhibitors and exhibit re-experiencing levels)
pressure because of dizziness and
(SNRIs); Closed angle Nervousness
symptoms. Conditioned fear sedation.
Antidepressant glaucoma Educate patient’s family about
responses are related to Significant Trouble Hostility
the potential adverse effects and
norepinephrine dysregulating nerves uncontrolled high sleeping report it immediately to the
INDICATION blood pressure Agitation
unusual physician.
Major Depressive from locus coerulus to the amygdala, heart attack within the
sweating or Aggression Educate the patient not to drive
Disorder (MDD), prefrontal cortex, and hippocampus last 30 days or engage in potentially
Liver problems yawning
Generalized Anxiety Suicidal thoughts hazardous activities, to avoid
and by the venlafaxine, this may Mild to moderate
Disorder (GAD), Social or behavior alcohol while taking the drug
reduce hyperarousal and re- kidney impairment and not to use herbal
Anxiety Disorder Seizures
Sudden changes medications without
(SAD), and Panic experiencing core symptoms of a Weight loss
consultations.
Disorder (PD) with or in moods or
client diagnosed with PSTD.
without agoraphobia behavior
DOSAGE & Anxiety or panic
FREQUENCY
attacks
25 mg BID
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