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Patient decompensates and now has a raw score of 64, with the subcategories of hyper-arousal and negative alterations in cognition and mood both scoring a 21.

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45-year-old Male, came in the the Emergency Departmemnt via EMS. He is experiencing an acute episode of post-traumatic stress disorder (PTSD) and is presenting signs of distress.

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Mayo Foundation for Medical Education and Research. (2022, December 13). Post-traumatic stress disorder (PTSD). Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/post-traumatic-stress-disorder/symptoms-causes/syc-20355967

Morgan, K. I., & Townsend, M. C. (2021). Davis Advantage for Psychiatric Mental Health Nursing. (10th ed.). F. A. Davis Company. https://bookshelf.vitalsource.com/books/9781719645140

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Signs and Symptoms of Further Decompensation 

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Signs and Symptoms of Further Decompensation 

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Severe depression
Isolation
Outburst of anger
Chronic pain
Substance abuse
Life threatening conditions like : Cardiovascular diseases.

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Patient had an original overall raw Score of 32, with subcategory of hyper-arousal being the highest at 12 when first admitted.

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Post Traumatic Stress Disorder Checklist (PCL-5)

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Post Traumatic Stress Disorder Checklist (PCL-5)

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Admittance into an inpatient facility that will include a variety of psychotherapy treatments. These treatments will aim to address triggers, as well as survival guilt felt.

Resources, such as support groups and professional help, will be available for the patient while in patient as well as for after discharge.

Providing resources and support for the patient's family.

Provide spiritual support therapy.

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"Post-traumatic stress disorder (PTSD) is a mental health condition that's triggered by a terrifying event — either experiencing it or witnessing it (Mayo Clinic, 2022).

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-SSRI medications, like Zoloft and Paxil
-Antianxiety medication
-Psychotherapy

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The nurse should speak in a calm and confident manner, using short and simple sentences to redirect the patient to a more quiet and less stimulating environment. Once the patient is brought to a less stimulating environment, the nurse should discuss with the patient what perceptions are currently causing his anxiety. If the patient's thoughts are distorted from reality, it is the nurse's job to redirect the client to reality.

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Assess the patient's coping strategies and ability to perform daily tasks. Those with PTSD are at risk for self-destructive behaviors such as alcohol and drug abuse to cope with the trauma. Assessing the patient's coping mechanisms allows for conversation for additional interventions such as therapy or support groups and prevents further deterioration.

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Place the patient on 1 to 1 observation. This involves assigning a staff member to stay with the patient and closely monitor their behavior, ensuring their safety. The nurse should maintain open communication with the patient, actively listen to their concerns. This intervention helps establish a therapeutic relationship and promotes trust, which are vital in managing acute suicidal ideation in individuals with PTSD.

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Acute Anxiety

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Ineffective coping

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Acute Suicidal Ideation

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I recommend calling the provider for an order for a 1:1 sitter. Remove all contrabands and clear the room of things that could cause injury or be used for self-harm. I would also recommend the provider to have a mental health assessment to be done along with a psychiatric consult. I recommend once the patient is medically cleared to possibly try to transfer patient to an inpatient psychiatric facility.

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Upon assessment, there are signs of distress. He reports experiencing survivor guilt, he states "I should be dead instead of them". He also has suicidal ideations with a plan stating he wishes to jump of the 10th story roof of his apartment build.
He does not have current vitals to report.

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He is a veteran with a history of military service with reports of being involved in violent engagements and firefights during deployment.