PTSD Capstone

7/26/2019 PTSD Capstone

1/41

Post Traumatic

Stress DisorderCristine SasanoN360-Mental Health


2/41

Identifying data & Legal

status51 year old femaleHeight 63!

"eight 1#3 l$s % MI 30 '($ese)

*dmitted 5+,1+15

Legal Status 06


3/41

.SM .iagnosis

I/ 30/1 2ost-traumati Stress .isorder4 hroni30/0 2oly-su$stane a$use deendene 'alohol4

anna$is4 oioids4 and amhetamines)

,,/1, Su$stane indued syhosis $y history rule outSS7I indued mania

II/ 2ersonality disorder4 mi8ed 9ith $oth $orderline andnarissisti features

III/ Status ost neumonia4 hyerliidemia4 asthma4 hroni

ain4 status ost hysteretomy4 $ilateral salingooohoretomy4 history of melanoma4 history of $reastaner4 o:arian yst4 osteoorosis4 multile re:iousa$dominal surgeries inluding $reast imlant

I;/ 2syhosoial and en:ironmental ro$lems

Chroni Mental and medial illnesses and limited suort


4/41

7eason for *dmission

2atient 9as $eing disruti:e at grou home/=>ore aart room! and 9al?ing around na?ed

2atient stated she 9as =leaning u!

"ent to HSH '6thhositali@ation) for

reommended hositali@ation due toreommendations to sta$ili@e inreasedsyhoti+$i@arre $eha:iors/ Not omliant 9ithC7

>ransferred to Aahi Mohala on 5+,1+15 on alegal status '13) suggesting susension of C7

(riginal harges are of one ount of theft in thethdegree and one ount of rohi$itions in u$liareas in the 1stdegree


5/41

Binanial data+Insurane

Soial Seurity .isa$ility Insurane 'SS.I)

nder age 66

na$le to erform su$stantial 9or? $eause

of disa$ility

Non-emloyed

Homeless


6/41

2atientDs desrition ofro$lem

=*t a young age4 I 9as raed $y my unle!

=*t 16 I got married to my no9 e8-hus$and 9hom I 9asmarried to for ,0 years/ He $eat me all the time andthreatened to ?ill me/ He istol 9hied me/ I tried tolea:e $ut he 9ould threaten to End me and ?ill me/!

=>ill this day I 9a?e u 9ith my Ests lenhed4 sared formy life/ I ha:e nightmares 9ith him trying to hase meand ?ill me and my daughter/ It is ne:er ending $eause I

feel li?e I an ne:er get a9ay from him/!

=Fears ago I 9as diagnosed 9ith $reast aner4 I 9asderessed then started doing ie/ >his aused a loss inmy onnetion 9ith my daughter 9ho I am no9 trying toma?e amends 9ith!/


7/41

Gthniity+7eligion+Sirit

ualCatholi.oesnDt attend hurh

Cauasian

.oesnDt ha:e any rituals

sed to go to N* and ** and $elie:ed it heled at thetime $efore her relase

elie:ed in the Higher 2o9er

elie:es in


8/41

2atientDs StrengthDs &

LimitationsStrengths Comlies 9ith mediations

*$le to identify goals

Cooerati:e and artiiates in ati:ities4 leads ommunitymeetings

Some higher eduation 'ollege)

*dmits to su$stane a$use

*$le to maintain le:el 3-

Can identify triggers to 2>S.

7eogni@es oing mehanisms


9/41

2atientDs StrengthDs &

LimitationsLimitations Limited suort

Homeless4 non-emloyed

Limited family relationshi

Chroni ain4 siatia 'holds her $a? from

ati:ities)

La?s slee due to reurrent dreams+nightmares


10/41

Mediations7anitidine '*N>*C) 300mg one daily


11/41

Mediations

*d:air 'BL>IC*S(NG+S*LMG>G7(L) 1 inh ,8 daily

*sthma

Cyrohetadine '2G7I*C>IN) 16mg one daily

*llergies

;entolin '*L>G7(L) , uKs 27N*sthma '27N)

Lidoaine

a? ain '27N)

Magnesium+simethione 'MFL*N>*) 30mL 27N

.ysesia '27N)

.ousate Sodium 'C(L*CG) 1 asule 27N

Constiation '27N)


12/41

Medial IssuesChroni ain - Siatia

*sthma

Hyerliidemia


13/41

La$sCM2 'Comrehensi:e meta$oli anel) on +,1+15

G:aluate organ funtion and he? for onditionssuh as dia$etes4 li:er disease and ?idney disease

Monitor H>N

>C(, ',,-3,) % ,1 Lo9

* 'rinalysis) on 10++15

>o detet ?idney and urinary trat disorders4hroni ?idney disease4 dia$etes4 and $ladderinfetions

CC 9ith .iKerential on 1+1+16

sed to detet o:eral health

2atient on Alonoin

7." '0-1/5) % 15/, High


14/41

La$s

>ests that should ha:e $een omleted

.rug sreening

Should ha:e $een done on admission

2atient 9ith history of alohol and oly-su$stane a$use

Li:er Buntion >est

2atient on Alonoin and yre8a


15/41

en a a us*ssessment


16/41

Mental Status

*ssessment>hought ContentIntat4 denies suiidal and homiidal ideations

.enies any auditory and :isual halluinations4 $ut9itnessed t tal?ing to self/ Stated that it 9as her

9ay of =relie:ing her ain and oing!

Insight


17/41

Hosital >reatment 2lan

1* 2atient 9ill rioriti@e syhosoial issues andidentify at Aahi Mohala

,* 2atient 9ill identify at least 3 rela8ationtehniues+attend 3 grous er shift

.* 2atient 9ill reort ain $efore it interferes 9itha$ility to artiiate in unit ati:ities

/*2atient 9ill attend 1,-ste meetings t9o times

a 9ee?

+* 2atient 9ill de:elo a su$stane a$usereo:ery lan that inludes suort system4identifying relase ues and rosoial $eha:ior


18/41

.isharge lan &

Community 7esoures2atient 9ent to ourt4 9as granted Conditional7elease 'C7)

"ill $e disharged to a rogram

Need to End an oen $ed for laement

Community 7esoures

N* and **>heray for 2>S.


19/41

Standardi@ed

*ssessment >oolsurns .eressionSore 1, 'orderline to Mild .eression)

Coersmith Self-Gsteem >ool

Sore 5 'Moderately lo9 Self-Gsteem)

Stress Inde8

Sore 1 '*roahing danger @one4

suKering stress related symtoms)

>M33

Sore , 'No reautions)

2 ti tD t


20/41

2atientDs symtomsomared to .SM ;

Criteria*/ G8osure to atual or threateneddeath4 serious inury4 or se8ual :iolenein one 'or more)of the follo9ing 9ays

1/ .iretly e8eriening the traumati

e:ent's)/

,/ "itnessing4 in erson4 the e:ent's)as it ourred to others/

3/ Learning that the traumati e:ent's)ourred to a lose family mem$eror lose friend/ In ases of atual orthreatened death of a family

mem$er or friend4 the e:ent's) mustha:e $een :iolent or aidental/

/ G8eriening reeated or e8tremee8osure to a:ersi:e details of thetraumati e:ent's) 'e/g/4 Erstresonders olleting human

remains olie oers reeatedlye8osed to details of hild a$use)/

2atients Signs andSymtoms

1/ 2atient has e8eriened

multile traumati e:ents'se8ual a$use4 rae4 anddomesti a$use)

2atientDs s mtoms


21/41


Criteria/ 2resene of one 'or more) of the follo9ingintrusion symtoms assoiated 9ith thetraumati e:ent's)4 $eginning after thetraumati e:ent's) ourred

1/ 7eurrent4 in:oluntary4 and intrusi:edistressing memories of the traumati

e:ent's)/,/ 7eurrent distressing dreams in 9hih the

ontent and+or aKet of the dream arerelated to the traumati e:ent's)/

3/ .issoiati:e reations 'e/g/4 Oash$a?s) in9hih the indi:idual feels or ats as if thetraumati e:ent's) 9ere reurring/

/ Intense or rolonged syhologialdistress at e8osure to internal or e8ternalues that sym$oli@e or resem$le anaset of the traumati e:ent's)/

5/ Mar?ed hysiologial reations to internalor e8ternal ues that sym$oli@e orresem$le an aset of the traumati

e:ent's)/


1/ 2atient has

reurrent4in:oluntary4 andintrusi:e memoriesof the multiletraumati e:ents

,/ 2atient omlains of9orseningnightmares relatedto multiletraumati e:ents

3/ 2atient e8erienes

2atientDs symtoms


22/41


CriteriaC/ 2ersistent a:oidane of stimuliassoiated 9ith the traumatie:ent's)4 $eginning after thetraumati e:ent's) ourred4 ase:idened $y one or $othof thefollo9ing

1/ *:oidane of or eKorts to a:oiddistressing memories4 thoughts4or feelings a$out or loselyassoiated 9ith the traumatie:ent's)/

,/ *:oidane of or eKorts to a:oid

e8ternal reminders 'eole4laes4 on:ersations4 ati:ities4o$ets4 situations) that arousedistressing memories4 thoughts4or feelings a$out or loselyassoiated 9ith the traumatie:ent's)/

2atients Signs and

Symtoms

1/ 2atient a:oids+tries toa:oid her memoriesand thoughts that areassoiated 9ith the

traumati e:ents

,/ 2atient a:oids+tries toa:oid her e8-hus$and'a$user) as 9ell as thelaes her traumati

e:ents too? lae


23/41

2atientDs symtoms omaredto

.SM-; Criteria./ Negati:e alterations in ognitions and moodassoiation 9ith the traumati e:ent's)4 $eginning or9orsening after the traumati e:ent's) ourred4 ase:idened $y t9o 'or more) of the follo9ing

1/Ina$ility to remem$er an imortant aset of thetraumati e:ent's) 'tyially due to dissoiati:eamnesia)/

,/2ersistent and e8aggerated negati:e $eliefs ore8etations a$out oneself4 others4 or the 9orld 'e/g/4=I am $ad4! =No one an $e trusted4! =>he 9orld isomletely dangerous!)/

3/2ersistent4 distorted ognitions a$out the ause oronseuenes of the traumati e:ent's) that lead theindi:idual to $lame himself+herself or others/

/2ersistent negati:e emotional state 'e/g/4 fear4 horror4

anger4 guilt4 or shame)/5/Mar?edly diminished interest or artiiation insigniEant ati:ities/

6/Beelings of detahment or estrangement from others/

#/2ersistent ina$ility to e8eriene ositi:e emotions'e/g/4 ina$ility to e8eriene hainess4 satisfation4 orlo:ing feeling's)/


,/ 2atient $elie:es that noone an $e trusted

/ 2atient has e8erieneda ersistent negati:eemotional state of fear4guilt4 and shame from these8ual+domesti a$use

5/ 2atient has e8erienedanhedonia in the ast

#/ 2atient desri$esha:ing eriods 9here she9as una$le to e8eriene


24/41

2atientDs symtoms omaredto

.SM ; CriteriaG/ Mar?ed alterations in arousal and reati:ity assoiated9ith the traumati e:ent's)4 $eginning or 9orsening afterthe traumati e:ent's) ourred4 as e:idened $y t9o 'ormore) of the follo9ing

1/Irrita$le $eha:ior and angry out$ursts '9ith little or noro:oation) tyially e8ressed as :er$al or hysialaggression to9ard eole or others/

,/7e?less or self-destruti:e $eha:ior/

3/Hyer:igilane/

/G8aggerated startle resonse/

5/2ro$lems 9ith onentration/

6/Slee distur$anes 'e/g/4 diulty falling or stayingaslee or restless slee)/

B/ .uration of the distur$ane 'Criteria 4 C4 .4 and G)is more than 1 month/

he distur$ane auses linially signiEant distressor imairment in soial4 ouational4 or otherimortant areas of funtioning/

H/ >he distur$ane is not attri$uta$le to thehysiologial eKets of a su$stane 'e/g/4 mediation4

alohol) or another medial ondition/

2atientDs Signs andSymtoms

/ 2atient stated that shegets easily startled $ysreaming or loud noise

5/ 2atient omlains ofro$lems 9ithonentration at times

6/ 2atient e8resses ha:ing

diulty sleeing andstaying aslee due toreurrent nightmares

B/ .uration of all riteria has$een more than a month

H/ >he distur$ane is notrelated to the h siolo ial


25/41

3 Highest 2riorities

1/ Slee

,/ *n8iety

3/ IneKeti:e oing


26/41

7ationale

1/ Slee

2atient omlains of la? of slee and ina$ility to stayaslee due to reurrent nightmares+Oash$a?s of traumatie:ents and dreams of her hus$and trying to =?ill her!/

"a?es u 9ith Ests lenhed and sared for her life

,/ *n8iety

2atient reorts feeling restless and o:er9helmed+stressedat times4 9a?es u feeling an8ious and fearing for her life

3/ IneKeti:e oing

2atient has a history of alohol a$use and oly-su$stane

a$use/ 2atient stated that it heled her to oe 9ith herstress and 2>S./ Stated that it heled her =forget! andmade her feel $etter


27/41

Nursing .iagnosisPriorit! 1

ursin Dianosis2 Slee distur$ane r+t 2>S. *Gatient stated she hasa hard time staying aslee due to reurrent nightmares+Oash$a?s of herhus$and oming after her to =?ill her!/ 2t states she has la? of slee andgets a$out 5-6 hours of slee/ "a?es u 9ith Ests lenhed and saredfor her life/

P2 Slee

E2 2atient stated she has a hard time staying aslee due to reurrentnightmares+Oash$a?s of her hus$and oming after her to =?ill her!/ 2tstates she has la? of slee and gets a$out 5-6 hours of slee/ "a?es u9ith Ests lenhed and sared for her life/

S2>eah atient rela8ation tehniues in the ase of a nightmare4 teahatient to reogni@e and a:oid triggers4 monitor slee and ati:ity

atterns4 ad:oate for atient $y tal?ing 9ith staK a$out atientssymtoms and inuire a$out 2ra@osin/

'T oal y the end of one month4 the atient 9ill ha:e gotten #- hours ofundistur$ed slee at night4 e:eryday/

ST oal y ne8t shift4 atient 9ill get 6-# hours of undistur$ed slee at

night4 $eing a$le to stay aslee


28/41

nter3ention 45re6uenc!

Scienti7c Rationale E3aluation

>eah atient

rela8ation tehniuesin the ase of anightmare4 daily

>hese ati:ities assist

in lessening an8ietyand its relati:eomonents/Ano9ledge and use ofthem inreases theatientDs ontrol o:er

the disorder 'eah atient toreogni@e and a:oidtriggers4 daily

(rdinary o$ets orsituations may ausethe erson to

e8eriene feelingsfrom the originaltraumati e:ent/ >heatient may startleeasily or resondaggressi:ely in

resonse to these

2atient 9as a$le to:er$ali@e triggers suhas sreaming and loud

noises/ 2atient statedshe 9ill learn to as? forassistane 9hen shefeels that her 2>S. istriggered/


29/41



Monitor slee andati:ity atterns

e:ery night

Slee distur$ane is aommon

manifestation of2>S./ >he atientmay e8erienee8essi:e fatigue thatlimits artiiation inati:ities '


30/41

Nursing .iagnosisPriorit! ,

ursin Dianosis2 *n8iety r+t 2>S. *G2atient states that she feelsrestless and o:er9helmed at times4 9a?es u feeling an8ious4 9ith =Estslenhed! and fearing for her life after a nightmare+Oash$a?/ 2atientstates that she is stressed 9hen she thin?s a$out the ast situations/

2atient is on Alonoin for *n8iety/

P2*n8iety

E2 2atient states that she feels restless and o:er9helmed at times4 9a?es ufeeling an8ious4 9ith =Ests lenhed! and fearing for her life after anightmare+Oash$a?/ 2atient states that she is stressed 9hen she thin?sa$out the ast situations/ 2atient is on Alonoin for *n8iety/

S2*ssess for the degree of an8iety/ >eah atient rela8ation tehniues4 dee$reathing4 and 9ays to suress fears/ Stay 9ith atient during

an8iety+ani atta?s/ >eah atient mindfulness4 :isual imagery/ *ssessmediation omliane for an8iety

'T oal y the end of one month4 atient 9ill ha:e no symtoms ofan8iety/

ST oal y ne8t shift4 atient 9ill :er$ali@e a derease in an8iety/


31/41



*ssess for the degreeof an8iety daily

* thoroughassessment results in

early identiEationand inter:ention tore:ent esalation ofsymtoms 'eah atientrela8ation tehniues4dee $reathing4 and9ays to suressfears/ >eah atientmindfulness4 :isual

imagery daily

>hese ati:ities assistin lessening an8ietyand its relati:eomonents/Ano9ledge and use ofthem inreases the

atientDs ontrol o:erthe disorder '


32/41



Stay 9ith atientduring an8iety+aniatta?s 9hen itours

* atientDs an8ietyan esalate to ani4and she may $eomesuiidal or out9ardly:iolent '


33/41

Nursing .iagnosis

Priorit! .

ursin Dianosis2 IneKeti:e Coing r+t 2>S. *G2atient has history ofoly-su$stane a$use and alohol a$use/ 2atient stated that it heled her

to oe 9ith her stress and 2>S./ Stated that it heled her to =forget!

those moments and made her feel $etter

P2IneKeti:e Coing

E22atient has history of oly-su$stane a$use and alohol a$use/ 2atientstated that it heled her to oe 9ith her stress and 2>S./ Stated that it

heled her to =forget! those moments and made her feel $etter

S27efer+teah atient a$out N* and **/ *ssess for ati:e su$stane a$use/Gnourage adating oing $eha:ior 'mindfulness4 and other ositi:e

9ays to oe)4 refer to rofessional ounseling/ Ha:e atient :er$ali@eositi:e oing s?ills/ Gnourage the atient to see? suort eole+grousto assist 9ith oing

'T oal In three months4 the atient 9ill $e su$stane and alohol free/

ST oal y ne8t shift4 the atient 9ill :er$ali@e and demonstrate alternati:e9ays of oing/


34/41



7efer+teah atient

a$out N* and ** thisshift

>hese ati:ities assist

in lessening an8ietyand its relati:eomonents/Ano9ledge and useof them inreases theatientDs ontrol o:er

the disorder'


35/41



Gnourage adatingoing $eha:ior'mindfulness4 andother ositi:e 9ays tooe) daily

2atients may $e usingmaladati:e ordysfuntional oingto a:oid dealing 9ithfeelings and issues'


36/41

G:idened asedournal *rtile

2>S. Symtom 7edution "ith Mindfulness-ased Strething and .eereathing G8erise 7andomi@ed Controlled Clinial >rial of Gay

($eti:e determine 9hether mindfulness-$ased strething anddee $reathing normali@es ortisol le:els and redues 2>S.symtom se:erity

7andomi@ed ontrolled trial onduted at ni:ersity of Ne9 Me8ioHeath Sienes Center

, nurses ', females) ages 5-66 years artiiated

60 minute MJ sessions 9ere onduted semi9ee?ly for 9ee?s

7esults , omleted studies4 ,, 9ith 2>S. symtoms and #9ithout 2>S.

Conlusions MJ aears to redue the re:alene of 2>S.symtoms in indi:iduals e8hi$iting features of 2>S.


37/41

2ertinent StandardG:aluations

2>S. Che?list

urns .eression

Coersmith Self-Gsteem


38/41

7ele:ane & Critial>hin?ing.uring our on:ersation4 my atient tal?ed a$out 9hen she 9as a hild4 she 9as raed $y her

unle/ "hen she 9as 16 years old4 she got married to her no9 e8-hus$and and 9as married for,0 years/ He 9ould often $eat her and threaten to ?ill her/ >here 9ere times she 9ould run a9ay$ut the hus$and 9ould End her and threaten to ?ill her if she ran a9ay again/ She also stated he9ould istol 9hi her/ She 9as $oth emotionally and hysially a$used $y her hus$and/ "henthe atient 9as diagnosed 9ith $reast aner4 she started to do meth4 amongst othersu$stanes/ >his led to her addition4 and aused her to disonnet from her daughter/ No94 theatient is trying to ma?e amends 9ith her daughter $eause she 9ants to $e a =goodgrandmother!/ *ll this emotion and distress that my atient 9as ut through aused her to feel

un9anted and unlo:ed/ "hat added to the deression 9as that she 9as diagnosed 9ith $reastaner/ "hen she started to do drugs4 this aused her to searate from her daughter/ >his alsoaused her deression and added to her su$stane a$use/ Mt atient stated that she 9a?es u inthe middle of the night 9ith her Ests lenhed/ She had nightmares+Oash$a?s of her e8-hus$andhasing after her and her daughter4 trying to ?ill them/ She e8lained this as a dou$le loss$eause she =lost! her daughter and doesnDt ha:e a onnetion 9ith her anymore4 and she also9as out through the a$use/ >he atient la?s on slee and has an8iety $eause of her traumatie:ents4 and uses ineKeti:e oing mehanisms to deal 9ith her Oash$a?s+nightmares/

C> Model =I ?ee re-li:ing these nightmares4 I ant seem to get them out of my head/! feelsshameful and fearful/ Beels hoeless that she ?ees relaying these dreams 7esorts tonegati:e oing mehanisms to hel 9ith ast and hels her to forget/ She is afraid to reli:ethose moments $eause it uts her in a :ulnera$le situation/ Has no means of soial suort49hih is 9hy she also resorts to su$stane a$use and alohol/ She is a9are of her ro$lems4 $utis also in need of suort to hel her suress her Oash$a?s4 so she resorts to negati:e oings?ills/


39/41

7ele:ane & Critial>hin?ing

"hat is ne8tQ2atient needs to attend a grou home 9here shean get the suort she needs and to hel her 9ithmediation omliane and manage her disorder

>he atient needs hel 9ith her slee distur$anes4su$stane a$use+alohol a$use4 and needs suort

Needs to End eKeti:e oing mehanisms fortriggers

Changes to atient are that 9ill $eneEt the lient

Court order to attend N*+** meetings

*dding 2ro@osin to mediation regimen for nightmares

Court order for theray


40/41

"hat must our forthis lientQ

Comly 9ith mediations 9hen disharged

7eogni@e and a:oid triggers to 2>S.

se rela8ation tehniues in ase of Oash$a?s

See? hel from theraist+ounselor 9hendisharged

See? suort

se eKeti:e oing mehanisms

*:oid negati:e su$stanes

*ttend N*+**


41/41

7eferenes

S. symtom redution9ith mindfulness-$ased strething anddee $reathing e8erise randomi@edontrolled linial trial eay/ CGM4 4 #-

/ doi htt++d8/doi/org+10/1,10+/,01,-3#,

PTSD Capstone

Documents

Transcript of PTSD Capstone