COLLEGE OF ALLIED HEALTH SCIENCES

A.Y. 2020-2021

A CASE STUDY

IN

POST TRAUMATIC STRESS DISORDER (PTSD)

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,

he has nightmares. He endorses experiencing several traumatic events during his

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

post-traumatic stress disorder. He was prescribed with Venlafaxine 25 mg BID. He was

also scheduled for Cognitive behavioral therapy.

INTRODUCTION

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.

He was diagnosed of having a posttraumatic stress disorder. Posttraumatic stress

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

incidence rate of women to have PTSD is twice as likely as men.

Maercker et al. found a substantially higher prevalence of PTSD among participants in

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

of PTSD than non-Latino whites.

PATIENT PROFILE AND HISTORY

I. BIOGRAPHIC DATA

Name: Tony Sales Serapion

Address: Pasig City, Metro Manila

Birthdate: April 1, 1989

Birthplace: Pasig City

Age: 32 years old

Gender: Male

Civil Status: Engaged

Occupation: Infantryman

Nationality: Filipino

Religion: Roman Catholic

Date of Admission: June 12, 2021

Diagnosis: PTSD

II. CHIEF COMPLAINT

Patient presented at a psychiatric clinic with a complaint of physiological and psychological

changes observed by his fiancé. Main complaints included social isolation and loss of interest,

irritability, difficulty sleeping, nightmares when falling deeply asleep, hypervigilance and

heightened startle reaction, and intrusive memories.

III. MEDICAL HISTORY

Patient Personal History

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

reported by his fiancé.

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.

Family Health History

The patient’s family members did not have any history of illnesses and other conditions

associated with the patient’s diagnosis.

IV. PHYSICAL EXAMINATION:

General Appearance:
Upon admission, the patient appeared to be hyperalert, passive, ambulatory, well-hydrated,

uncooperative, with signs of distress

Vital Signs:

Patient’s vital signs were obtained and recorded as follows: temperature: 36.9, pulse rate: 110

bpm, respiratory rate: 25 rpm, and blood pressure: 130/70 mmHg.

Head and Facial Structures:

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

hyperpigmentations seen. No lesions, cyanosis, and rash noted.

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

circles under the eyes.

Ears:

Patient’s ears are symmetrical to the face, the pinna recoils after folding, no palpable masses and

abnormal discharges noted. Lastly, no hearing aid requirement was noted.

Nose:

The nasal septum is not deviated, no lesions, no abnormal discharges, no sinus inflammation and

nasal congestion was observed and noted.

Mouth:
The lips and oral cavity is symmetrical, and the presence of normal gag reflex was noted. Patient

has no oral thrush and cavity, dentures, and prostheses.

Neck:

No tenderness, stiffness, or swollen nodes were palpated and noted.

Chest and Respiratory:

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

pattern was tachypneic, and breath sounds equal bilaterally.

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

sound was auscultated and noted.

Upper Extremities:

Patient’s arms are proportion to body structures, with no lesions, and masses inspected and noted.

Good muscular tone and arterial pulses were 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

General Appearance and Behavior:

 The patient’s grooming and characteristics of grooming is all normal, he is fairly

groomed. Puffy eyes and dark under eyes are evident because of having difficulty in

sleeping.

 He endorses in several traumatic events, but is unwilling to provide specific details.

 He is trying to avoid talking about the traumatic event and is easily annoyed.

 He gets startled by noise and motion during the interview.

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

experiences as an infantry man. Hostility can also be observed whenever he is in an unfamiliar

environment with unfamiliar people.

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

saying that he is okay.

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

hallucinations or delusions but experiences intrusive memories on a daily basis as well as

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

and long term memories.

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

to the course of his treatments.

PSYCHOPATHOLOGY

Traumatic
Events

Increased non-adrenergic
activity Difficulty sleeping due to nightmares
of past traumatic event
(Low cortisol levels due to HPA
dysregulation)

Enhanced consolidation of Outburst Behavior

traumatic memories

Increased in Fear Easily Startled

Conditioning

(Amygdala activation results Intense Distress

in exaggerated fear response
to traumatic memories)

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)

DESCRIPTION OF THE PATIENT

 The patient was a well-groomed male of tall stature, sturdy build, and average height.

 He was restless and appeared agitated and tensed.

 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

DESCRIPTION OF THE ENVIRONMENT

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,

and comfortable room wherein privacy was put into consideration.

 NURSE
(Verbal and Nonverbal)
“ Good morning sir”
“ I am Chuck Molano, I will
be your student nurse for the
whole week and I am from
University of Pangasinan “
“How about you sir? What
is your name and how old
are you? “
“How about your work sir,
how was it? “
“Oh, your job sir is
amazing, can you tell me
more about it sir? “
“Could you describe it more
fully sir? “
“You seem distracted sir,
what are you looking at? “
Therapeutic PATIENT ANALYSIS
Communication (Verbal and Nonverbal)
Techniques
Giving Recognition “ Morning “ THERAPEUTIC. I have
recognized the patient but the
patients seem to be bore
Giving Information “Ahhh “ THERAPEUTIC. Informed the
client with facts.
Exploring “ I am Tony, 32 “ THERAPEUTIC. Identify
patient’s identity.
Exploring “ I am an infantry man at THERAPEUTIC. Examine the
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 “
Exploring “It is hard to be a security THERAPEUTIC. Examining the
guard, it is boring “ patient’s issue.
Exploring “I feel like time it was THERAPEUTIC. Examining
giving me more time to the patient’s job more fully.
think and I see more more,
more ..
( looks for threats around
the room )
Making observations “ Oh none, nothing “ THERAPEUTIC. He seems
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, “

“And how was your sleep General leads “ I, I, I am … having THERAPEUTIC.

sir? Go on “ dreams about my job
before, it is no nevermind,
change topic “
Encouraged the patient to
continue expressing himself but
he seems to be uncomfortable
with the topic.

“ 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

ASSESSMENT EXPLANATION OF THE PROBLEM PLANNING INTERVENTIONS RATIONALE EVALUATION

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:
“ Nahihirapan ako
matulog, ang sasama ng
mga panaginip ko din
pag nakatulog ako “ as
verbalized by the
patient
Objective:
Dark under eyes
restless
NURSING DIAGNOSIS
Insomnia related to Anxiety
as evidenced by difficulty
sleeping
People with PTSD suffer from
insomnia. This is largely due to
hyperarousal, in which the individual is
unable to relax. It may also be a
lingering effect of having been in a
situation that required constant
alertness at night. Insomnia in PTSD
may also be selfperpetuating, as the
stress of not being able to fall asleep
eventually leads to maladaptive sleep
behaviors such as daytime napping or
substance abuse.
Short Term
Goals:
After 1 week of nursing
interventions, the patient
will be able to establish an
effective sleep pattern.
Long Term Goals:
After months of nursing
interventions, the patient
will obtain optimal amounts
of sleep as evidenced by
verbalization of feeling
rested and improvement
insleep pattern
Independent: Independent: After 1 week of nursing
interventions, the goal was met.
1. Encourage daytime physical activities but 1) In insomnia, stress may be reduced The patient
instruct the patient to avoid strenuous by therapeutic activities and may established an effective
activities before bedtime. promote sleep. However, strenuous sleep pattern and obtained
activities may lead to fatigue and
optimal amounts of sleep
may cause insomnia. as evidenced by
2) This provides baseline
verbalization of feeling
2. Take note observations of data for the evaluation of rested and improvement in sleep
sleep-wake behaviours. Take insomnia. pattern
down notes on the number of hours the patient 3) L-tryptophan is a
is asleep. component of milk which
3. Encourage patient to take milk. promotes sleep.
4. Instruct the patient to follow a consistent 4) Consistent schedules
daily schedule for rest and sleep. facilitate regulation of the
5. Introduce relaxing circadian rhythm and
activities such as warm bath, calm music, decrease the energy
reading a book, and relaxation exercises before needed for adaptation to
bedtime. changes.
5) These activities provide relaxation
and distraction to prepare mind and
body for sleep.
Dependent: Dependent:

1. Its main job in the body

1) Melatonin
is to regulate night and
2) Antihistamines
day cycles or sleep -wake
3) Prescription sedative-hypnotics, Anti -
cycles. Older adults seem
anxiety drugs
to tolerate melatonin with minimal side
effects
2. Many over-the -counter
drugs contain antihistamines that can
cause drowsiness, which might help the
patient fall
asleep for a few nights.
3. These act through
general central nervous
system depression and
disrupt the normal stages
of non -rapid eye
movement (NREM) and REM sleep. Long -
term use may cause daytime drowsiness,
rebound insomnia, and increased
dreaming when
discontinued.
 PHINMA University of Pangasinan
College of Health Sciences

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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