Shadow Health Nicole Diaz - PTSD : NURS /NURS 479 PTSD CARE PLAN . Established chief complaint {{Ans - Reports sleep problems Asked about onset and frequency of sleep problems {{Ans - Reports sleep problems for the past 10+ years Reports having problems sleeping most nights of the week Asked about sleep quality and characteristics {{Ans - Reports recent sleep problems include nightmares. Reports falling asleep often takes more than an hour. Reports waking up two or three times during the night for "at least ten minutes" Reports waking i n the morning feeling "out of it" and not rested. Reports frequent snoring. Asked about sleep habits {{Ans - Reports going to be "around midnight", but feeling "too nervous" to sleep. Reports actually falling asleep around 2 or 3am Reports checking her w indows and doors twice before going to bed. Reports no screen use (tv or computer) before bed. Reports average wake up time of 7am. Reports sleeping an average of 4 or 5 hours a night. Reports sleeping alone in a quiet room. Asked about patterns for s leep problems. {{Ans - Reports that stress and anxiety exacerbate sleep problems. Asked about existing health conditions {{Ans - Reports hypertension diagnosis Followed up on hypertension diagnosis {{Ans - Diagnosed at age 45 Asked about history of mental health {{Ans - Reports PTSD diagnosis Followed up about symptoms of PTSD diagnosis {{Ans - Reports depression accompanies PTSD diagnosis. Reports anxiety as a symptom of PTSD. Reports sleep problems are a symptom of PTSD diagnosis. Followed up on onset o f PTSD {{Ans - Reports diagnosed at age 35. Reports PTSD cause is military sexual assault. Reports MST was at age 23. Reports even involved commanding officer and ostracization from unit. Reports left military at 28, but did not seek immediate care. Followed up on aggravating factors for PTSD. {{Ans - Reports stress triggers PTSD symptoms. Reports avoiding crowds or most social situations. Reports fear of "losing control" of a situation. Reports discussing event is triggering. Reports difficulties with relationships and emotional/physical intimacy.
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