Primary Concept
Mood and Affect
Interrelated Concepts (In order of emphasis)
1. Stress
2. Coping
3. Anxiety
4. Clinical Judgment
5. Patient Education
6. Communication
7. Collaboration
History of Present Problem:
Marcus Jackson is a 34-year-old African American male who served four combat tours of duty in Iraq and Afghanistan.
He came to the Veterans Administration (VA) today for an outpatient appointment because he has not slept more than
two hours a night for the past week. This is his fourth clinic visit over the past year with the same symptoms: inability
to sleep, nightmares, increasing anxiety, and isolation.
Every time he falls asleep, he relives the bombing and has flashbacks of bloody body parts that he witnessed after the
explosion. He states that he is more aware of noises and any loud noise such as fireworks and or cars backfiring causes
him extreme anxiety. His medications for PTSD have not been helping control his anxiety. He has been spending more
time in his room watching TV and avoids spending time with his wife and children. Today he told his wife he should
have died and not his friends. His primary care provider encouraged voluntary admission and his wife brought Marcus to
the emergency department of the closest VA hospital so he can be admitted.
Personal/Social History:
During his last tour in combat, Marcus’ best friend drove over an IED. The explosion killed everyone in the vehicle.
During the blast, Marcus was hit with shrapnel in his left leg, stomach, and left eye. These injuries left him blind in his
left eye. He has had multiple surgeries to his abdomen, and six reconstruction surgeries to his leg. He walks with a limp
and continues to complain of severe pain in his left leg. He was given a medical discharge from the Marines because of
the extensive nature of his injuries and is receiving disability.
Marcus is married with three children from six to twelve years of age. He has been married to his wife, Ariel, for
fourteen years. While in the service, his family moved six times and endured four combat tours of duty. Each time he
returned home from combat, his wife noted that he has no history of physical aggression and has been more agitated
1
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and had more trouble sleeping with frequent nightmares. Marcus reports he used to drink “a lot”, but decided two years
ago that alcohol was making everything worse. Reports he has not had a drink for the past 1 ½ years. Denies other drug
use.
What data from the histories are RELEVANT and have clinical significance to the nurse?
RELEVANT Data from Present Problem: Clinical Significance:
Impaired sleep cycle Has same symptoms recurring, and his meds are not working to decrease
4 served combat tours his anxiety level. Socially isolated and has no desire to spend time with
4 visits with same symptoms
th
family. Not sleeping, could lead to exhaustion.
PTSD meds not working
Extreme anxiety
Avoids spending time with
family Has guilt
RELEVANT Data from Social History: Clinical Significance:
Injuries from the past effect his living Experiences from duty. Having guilt, he should of
Multiple surgeries died Surgeries causing the pain
Cont. pain in left
More agitated and trouble sleeping PTSD symptoms
What is the RELATIONSHIP of your patient’s past medical history (PMH) and current meds?
(Which medication treats which condition? Draw lines to connect.)
PMH: Home Meds: Pharm. Classification: Expected Outcome:
• Post Traumatic 1. Bupropion HCL SR 100 mg PO bid Antidepressant
Stress Disorder 2. Trazodone 200 mg PO at bedtime PRN
(PTSD) 3. Prazosin 4 mg PO at HS
• Depression 4. Oxycontin SR 30 mg PO BID
• Chronic pain 5. Oxycodone 5-10 mg PO every 4
hours PRN pain
Patient Care Begins:
Current VS: P-Q-R-S-T Pain Assessment:
T: 98.2 F/37.3 C (oral) Provoking/Palliative: Movement provokes, always present. Goal is 5/10
P: 92 (regular) Quality: Ache
R: 18 (regular) Region/Radiation: Left leg
BP: 118/70 Severity: 5/10
O2 sat: 98% RA Timing: Continuous
What VS data are RELEVANT that must be recognized as clinically significant to the nurse?
RELEVANT VS Data: Clinical Significance:
Movement increases pain Has chronic pain from accident
in left leg
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