Post-Traumatic Stress

Disorder
Katherine Casey
NURS 360 PMH
Professor Chat

Patient Data
44 year old female
58, 196 lbs, BMI 29.8, Overweight
Legal status MH4
Income: Cashier and receives SSI
Food & fluid intake: 100% of meals, 100% of liquids
Bladder & bowel status: Continent
Sleep pattern:
Avg 5 hours total/night
Difficulty falling asleep and has been waking up more frequently
lately d/t increased nightmares
Avg 30 min-1 hour disruption
0-2 naps/day, avg 10-30 min, afternoon

Reason for Hospitalization

Patient told her psychiatrist she had an
increased desire to slit her property managers
throat and wanted the police to shoot her
afterwards so she could go to heaven.
Arrangements were made to have patient MH4
to QMC for admission.

Patients description of
illness/issues
Patient has felt increasingly depressed over the
last month after being sexually harassed and
threatened by her property manager.
Reports hypervigillance, increased nightmares,
anxiety, and depressed mood.
Became significantly intoxicated one night and
accidentally called her property manager instead
of another man to come to her place to have
intercourse with her.
The next day, the patient realized what had
occurred and felt sexually violated.

Patients description of
illness/issues continued
Since the incident, the patient reported her
property manager has been sexually harassing
her and continuing to inappropriately touch
her.
She informed other people in their complex
about the situation, which eventually got back
to him.
He then threatened her to keep quiet and she
reported being afraid he will break into her
home and hurt her.
She wants to move out, but is unable to do so
due to financial problems.

Patients description of
illness/issues continued
Patient also suffers from multiple incidents of
sexual abuse starting at age 10.
Attempted to overdose on cocaine, but failed
at age 20.
Older sister recently passed away a year ago,
which is adding to her worsening depression.

Axis
Axis 1: PTSD, MDD, Polysubstance Abuse,
Anxiety Disorder
Axis 2: No diagnoses or conditions
Axis 3: DM Type 1, HTN, legally blind
Axis 4: Strained relationship with family,
financial problems, drug-filled
neighborhood/complex, sister passed away a
year ago
Axis 5: 50-41: Suicidal and homicidal ideation

DSM V for PTSD

A. Exposure to actual or threatened
death, serious injury, or sexual
violence in one (or more) of the
following ways:
1. Directly experiencing the
traumatic event(s).
2. Witnessing, in person, the
event(s) as it occurred to others.
3. Learning that the traumatic
event(s) occurred to a close
family member or close friend. In
cases of actual or threatened
death of a family member or
friend, the event(s) must have
been violent or accidental.
4. Experiencing repeated or extreme
exposure to aversive details of
the traumatic event(s) (e.g., first
responders collecting human
remains; police officers

Patients S+S
1. Patient has
experienced
multiple traumatic
events first hand
(sexual abuse, rape,
recent threat by her
property manager).

DSM V for PTSD Continued

B. Presence of one (or more) of the
following intrusion symptoms associated
with the traumatic event(s), beginning
after the traumatic event(s) occurred:
1. Recurrent, involuntary, and intrusive
distressing memories of the traumatic
event(s).
2. Recurrent distressing dreams in which the
content and/or affect of the dream are
related to the traumatic event(s).
3. Dissociative reactions (e.g., flashbacks) in
which the individual feels or acts as if the
traumatic event(s) were recurring.
4. Intense or prolonged psychological
distress at exposure to internal or external
cues that symbolize or resemble an aspect
of the traumatic event(s).
5. Marked physiological reactions to internal
or external cues that symbolize or
resemble an aspect of the traumatic
event(s).

Patients S+S
1. Patient has
recurrent,
involuntary, and
intrusive memories
of multiple traumatic
events.
2. Patient c/o worsening
nightmares r/t
multiple traumatic
events, including her
home being broken
into by her property
manager most
recently.
3. Patient has
experienced several

DSM V for PTSD Continued

C. Persistent avoidance of stimuli
associated with the traumatic
event(s), beginning after the
traumatic event(s) occurred, as
evidenced by one or both of the
following:
1. Avoidance of or efforts to avoid
distressing memories, thoughts,
or feelings about or closely
associated with the traumatic
event(s).
2. Avoidance of or efforts to avoid
external reminders (people,
places, conversations, activities,
objects, situations) that arouse
distressing memories, thoughts,
or feelings about or closely
associated with the traumatic
event(s).

Patients S+S
2. Patient avoids/tries
to avoid all of her
previous sexual
abusers as well as the
places her traumatic
events took place.

DSM V for PTSD Continued

D. Negative alterations in cognitions and
mood association with the traumatic event(s),
beginning or worsening after the traumatic
event(s) occurred, as evidenced by two (or
more) of the following:
1. Inability to remember an important aspect of
the traumatic event(s) (typically due to
dissociative amnesia).
2. Persistent and exaggerated negative beliefs or
expectations about oneself, others, or the
world (e.g., I am bad, No one can be
trusted, The world is completely
dangerous).
3. Persistent, distorted cognitions about the
cause or consequences of the traumatic
event(s) that lead the individual to blame
himself/herself or others.
4. Persistent negative emotional state (e.g., fear,
horror, anger, guilt, or shame).
5. Markedly diminished interest or participation
in significant activities.
6. Feelings of detachment or estrangement from
others.
7. Persistent inability to experience positive
emotions (e.g., inability to experience
happiness, satisfaction, or loving feeling(s).

Patients S+S (5)

1. Patient exhibits some
dissociative amnesia r/t rape
incident.
3. Patient used to blame herself
for some incidents and used to
feel it was her fault for allowing
the sexual abuse to
happen/remaining quiet when the
sexual abuse took place.
4. Patient has experienced a
persistent negative emotional
state of fear, guilt, and shame
from the sexual abuse.
5. Patient is currently c/o of
anhedonia and has experienced it
in the past as well.
7. Patient has had periods where
she was unable to experience
positive emotions as a result of
the multiple incidents of sexual

DSM V for PTSD Continued

E. Marked alterations in arousal and reactivity
associated with the traumatic event(s),
beginning or worsening after the traumatic
event(s) occurred, as evidenced by two (or more)
of the following:
1. Irritable behavior and angry outbursts (with
little or no provocation) typically expressed
as verbal or physical aggression toward
people or others.
2. Reckless or self-destructive behavior.
3. Hypervigilance.
4. Exaggerated startle response.
5. Problems with concentration.
6. Sleep disturbances (e.g., difficulty falling or
staying asleep or restless sleep).
F. Duration of the disturbance (Criteria B, C, D,
and E) is more than 1 month.
G. The disturbance causes clinically significant
distress or impairment in social, occupational,
or other important areas of functioning.
H. The disturbance is not attributable to the
physiological effects of a substance (e.g.,
medication, alcohol) or another medical
condition.

Patients S+S (4)

1. Patient acknowledged having
multiple angry outbursts that
occurred after her traumatic events
took place.
3. Patient is currently c/o of
hypervigilance.
5. Patient is currently c/o problems
with concentration.
6. Patient has expressed having
difficulty falling asleep and waking
up during the sleep r/t increased
nightmares.
F. Duration of all criteria has been
more than 1 month.
G. Patient reported having difficulty
in school growing up and recently
has been having difficulty at her
workplace r/t to her most recent
incident.
H. The disturbance is not r/t to a
substance or another medical

DSM V for MDD

A. Five or more of the following symptoms have
been presented during the same 2-week period
and represented a change from previous
functioning: at least one of the symptoms is
either (1) depressed mood or (2) loss of interest
or pleasure.
1. Depressed mood most of the day, nearly
every day, as indicated by either subjective
report or observations made by others.
2. Markedly diminished interest or pleasure in
all, or almost all, activities most of the day,
nearly every day.
3. Significant weight loss when not dieting or
weight gain or decrease or increase in
appetite nearly every day.
4. Insomnia or hypersomnia nearly every day.
5. Psychomotor agitation or retardation nearly
every day
6. Fatigue or loss of energy nearly every day
7. Feelings of worthlessness or excessive or
inappropriate guilt, nearly every day
8. Diminished ability to think or concentrate or
indecisiveness, nearly every day.
9. Recurrent thoughts of death, recurrent
suicidal ideation without a specific plan, or a

Patients S+S (5)

1. Patient reports
increasingly depressed
mood x1 month.
2. Patient reports
anhedonia.
6. Patient reports
fatigue and loss of
energy.
7. Patient reports
difficulty concentrating.
8. Patient is at risk for
suicide.

DSM V for MDD Continued

B. The symptoms cause clinically
significant distress or impairment
in social, occupational, or other
impairment areas of function.
C. The episode is not attribute to
the physiological effects of a
substance or to another medical
condition.
D. The occurrence of the major
depression episode is not better
explained by schizoaffective
disorder, schizophrenia,
schizopheniform disorder,
delusional disorder, or other
specified and unspecified
schizophrenia spectrum and other
psychotic disorders.

Patients S+S
B. Patient has
expressed difficulty in
functioning at work.
C. Patients
symptoms are not r/t
to a substance or
medication condition.
D. Patient has never
had a manic episode
or hypomanic
episode.

Axis III Conditions

1. DM Type 1
Exercise 30 min a day 4 days out of the week
Refer to MyPlate as food reference and reduce intake of fatty foods, fried
foods, fast food, soda, juice, and other products high in sugar and fat
Instruct patient to check blood sugar levels daily
Provide patient teaching on S+S of hyper and hypoglycemia, inspecting feet
daily, wearing closed-toe shoes, and that it will take longer for the patients
cuts/infections to heal
2. Hypertension
Exercise 30 min a day 4 days out of the week
Monitor sodium intake and avoid foods high in sodium
Instruct patient to check their blood pressure daily
Provide patient teaching on orthostatic and postural hypotension

3. Legally Blind
Maintain a safe environment
Orient patient to their surroundings
Describe location of patients food on plate using clock method
Educate patients to available resources in the community

Medications
1. Clonazepam (Klonopin) 1.5 mg once daily

Benzodiazepines, Target Sx: Anxiety

Recommended range: 1 mg/day (may require up to 4 mg/day)
High
Current SE: Drowsiness, sedation

2. Duloxetine (Cymbalta) 60 mg once daily

SNRI, Target Sx: Depression

Recommended range: 40-60 mg/daily
Max
Current SE: Occasional nausea

3. Levothyroxine 150 mcg once daily

Thyroid Preparations, Target: Hypothyroidism
Recommended range: 75-125 mcg/day (1.5 mcg/kg/day)
Over maximum dose (133.36 mg), but is okay to administer to
pt due to her age and weight
Current SE: None

4. Lisinopril 20 mg once daily

ACE Inhibitors, Target Sx: HTN

Recommended range: 20-40 mg/day
Medium
Current SE: Occasional dizziness/orthostatic hypotension

5. Prazosin 1 mg once daily

Peripherally Acting Antiadrenergics/Antihypertensives

Recommended range: 1 mg once daily
Medium
Current SE: Occasional dizziness/orthostatic hypotension

Medications Continued
6) Triamterene/Hydrochlorothiazide 75/50 mg once daily
Diuretics, Target Sx: HTN
Recommended range:
Triamterene: 100 mg twice daily, lower doses in combo products
Hydrochlorothiazide: 12.5-100 mg/day in 1-2 divided doses (not to exceed
50 mg/day)
Max
Current SE: None
7) Insulin NPH/Regular Human Rec (NovoLIN 70/30) Inj 55 units before breakfast
Antidiabetic Hormones, Target Sx: Hyperglycemia
Recommended range:0.5-1 unit/kg/day in divided doses (98-196
units/day)
Low, appropriate to administer b/c patient is receiving other types of Insulin
Current SE: None
8) Insulin Regular Human (HumuLIN R) 100 unit/mL
Antidiabetic Hormones, Target Sx: Hyperglycemia
Sliding Scale
Current SE: None

Labs
BMP, CBC w/ differential, and urine screening
Abnormal Labs:
WBC Count (3.80-10.80x10(3)/uL) 12.54 High
Abs Neutrophils (1.56-6.20x10(3)/uL) 8.06 High

Drug Screening Findings:

Negative for ALL drugs (ethanol, amphetamines,
barbiturates, benzodiazepines, cocaine,
methadone, opiates, oxycodone/oxymorphone,
PCP/Phencyclidine, and THC)

Glucose Readings (NR = 70-99 mg/dL):

61 Low (1/29/16 3:37 PM)
37 Low (1/29/16 4:12 PM)
209 High (1/29/16 5:14 PM)

Mental Status Exam

Behavior:
Dressed: Patient dressed in clean hospital top and pants and is
wearing own slippers. Hair is neatly tied in a braid.
Motor Behavior: Patient exhibits no unusual physical movements.
Sleep Pattern: Patient gets approximately 5 hours sleep total per
night and reports waking up more frequently due to increased
nightmares lately.
Appetite: Patient has excellent appetite and finished 100% of her
meals.
Suicidal/Homicidal Actions: Patient reports having no thoughts of
self-harm while in the hospital on my shift, but continues to have
homicidal thoughts.
Affect: Full/wide range affect aeb patient being mainly pleasant
during conversation, but crying when she talked about her sisters
passing away and becoming angry when she talked about her
property manager. Affect appropriate to all situations.

MSE Continued
Sensorium:
Recent Memory: Intact aeb patient being able to recall what she ate for
breakfast.
Remote Memory: Intact aeb patient being able to recall her last phone
conversation with her sister before she passed away a year ago.
Insight: Fair insight aeb patient being able to verbalize the reason for her
hospitalization.
Judgment: Poor judgment aeb patient having desire to slit her property
managers throat and wanting the police to shoot her afterwards so she can
go to heaven. Patient also demonstrates poor judgment aeb patient stating
she uses alcohol to cope at times even though it worsens her depression.
Imagery: Patient denies any delusions or hallucinations.
Cognition: A+Ox4. Patient displays clear, organized, and fluent speech
without any evidence of pressured speech, poverty of speech, thought
blocking, flight of ideas, loosening of association, echolalia, clanging,
preservation, or ideas of reference.

More About the Patient

Spirituality:Catholic

Considerations r/t ethnicity or religion: No considerations

Strengths: Smart, outspoken, opinionated, generous, caring
Limitations: Short-tempered, stubborn, emotional, has
trouble letting go of the past, legally blind
Interpersonal Relationships:
Rocky relationship with mother
Good relationship with father and older sister, but both have
passed away
Avoids older brother d/t his current drug use
Few close friends at work
Not involved in a serious romantic relationship

Developmental Level
(Erikson)
According to patients age, she should be in the
Generativity vs. Stagnation stage. Adults achieve
generativity by creating/nurturing things that will outlast
them, giving back to society, and doing things that
benefit future generations. This is done through raising
their children, being productive at work, and becoming
involved in community activities and organizations.
My patient is in this stage due to mastering the previous
stage, Intimacy vs. Isolation, aeb her having some close
friendships. She has no children nor is planning on
having any and is not involved in the community. Patient
has not mastered this stage of development.

Problems in Hospital Tx
Plan
1. Harm prevention
2. Mood stabilization
3. Medical optimization

Nursing Interventions Performed

1:1 to assess mental status
TM33 9, Moderate Risk Precautions
Burns Depression Checklist 28, Moderate Depression

Discharge Plan
Initiate follow up assessment after discharge
Continue to have patient see social worker

Prioritized Patient Needs

1. P: Risk for suicide
E: Patient has verbalized an increased desire to slit her property managers
throat and wants the police to shoot her afterwards so she can go to heaven.
S: Encourage patient to talk about her feelings, continue to monitor patients
suicidal ideation daily, ask the patient to agree to sign a no-suicide contract or
verbal no-suicide contract, initiate one-to-one supervision around the clock,
provide a safe environment, ensure patient swallows all of her oral medications,
and continue hospitalization of patient until her suicidal ideation improves.
2. P: Risk for homicide
E: Patient has verbalized an increased desire to slit her property managers
throat and wants the police to shoot her afterwards so she can go to heaven.
S: Encourage patient to talk about her feelings, continue to monitor
patients homicidal ideation daily, provide referral to social worker to help
patient try to move out of her current place of residency, and continue
hospitalization of patient until homicidal ideation improves.

Prioritized Patient Needs

Continued
3. P: Mood stabilization
E: Patient reported increasingly worsening symptoms of PTSD and MDD over the
past month as evidenced by hypervigilance, increased nightmares, anxiety, and
depressed mood.
S: Encourage patient to talk about her feelings, administer scheduled
antidepressant and antianxiety medications, provide patient teaching on the
different relaxation techniques and how to perform them (deep breathing,
meditation, progressive muscle relaxation), instruct patient to engage in 30
minutes of exercise/day for 3-5 days/week to assist with mood improvement,
educate patient on the importance of getting adequate sleep, and encourage
patient to explore other types of therapies, such as group and family therapy, to
help improve her symptoms of PTSD.
4. P: Ineffective coping
E: Patient expressed she uses alcohol to cope with her feelings of stress and
depression at times.
S: Encourage patient to talk about her feelings when she develops feelings of
stress and depression, assess previously used coping mechanisms by the patient in
the past, provide patient teaching on the different relaxation techniques and how

harassment aeb pt verbalizing she

wants to slit her property
managers throat and have the
cops shoot her afterwards.
ST goal: Patient will report a decrease in her suicidal ideation in
comparison to when she was first admitted during my shift.
LT goal: Patient will exhibit no suicidal ideation upon discharge.
Interventions:
1) Provide a safe environment.
Rationale: Suicide precautions are used to prevent the patient from
acting on sudden self-destructive impulses. These measures include
removing potentially harmful objects, such as electrical appliances,
sharp instruments, belts and ties, glass items, and medications
(Gulanick & Myers, 2014, 187).
Evaluation: Safe environment was provided and potentially harmful
objects remained out of patients reach.

Nursing Care Plan

Continued
2) Provide close patient supervision by maintaining observation or awareness of the
patient at all times.
Rationale: The degree of supervision is defined by the degree of risk. Suicide may be an
impulsive act with little or no warning (Gulanick & Myers, 2014, 187).
Evaluation: One-to-one supervision was provided and patients location was known at all
times during my shift.

3) Provide opportunities for the patient to express concerns, fears, feelings, and
expectations in a nonjudgmental environment.
Rationale: The patient benefits from talking about suicide thoughts with trusted staff.
Patients need the opportunity to discuss suicidal thoughts and intentions to harm
themselves. Verbalization of these feelings may lessen their intensity. Patients also need
to see that staff members are open to discussion of suicidal thoughts (Gulanick & Myers,
2014, 187).
Evaluation: Patient was encouraged to discuss her feelings of suicide openly. Patient
verbalized she wants to slit her managers throat and have the cops shoot her afterwards
so she can go to heaven already. Patient verbalized she currently did not have thoughts
of committing suicide or self-harm while in the hospital during my shift.

Nursing Care Plan

Continued
4) Instruct the patient in the appropriate use of medications
to facilitate his or her ability to cope.
Rationale: Drug therapy may help the patient manage underlying
health problems such as depression (Gulanick & Myers, 2014,
188).
Evaluation: Patient teaching was provided on her current
scheduled medication Duloxetine (Cymbalta) in regards to this
medication being used for the treatment of depression, the
importance of being med compliant, and that it may take several
weeks or more for the medications full effects to kick in.

Journal Article
The Prevalence of Mental Health Disorders in a Community Sample of
Female Victims of Intimate Partner Violence
Study examined prevalence of PTSD, depression, and substance abuse
disorders in female victims of intimate partner violence (IPV).
Results showed 57.4% of the overall sample met criteria for PTSD, 56.4%
met criteria for depression, the rate of alcohol dependence was 18.1%,
alcohol abuse was 3.2%, substance dependence was 6.4%, and substance
abuse was 6.4%.
The more severe the physical, sexual, or psychological intimate partner
violence was, the more severe and intense those womens symptoms were.
Research also shows that victims of IPV are more likely to engage in
substance use in an attempt to cope with their depression and traumarelated symptoms.