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S: The patient is a 45-year-old male who was brought into the Emergency Room experiencing an acute episode of post-traumatic stress disorder (PTSD) with signs of distress. The patient has expressed survivor's guilt and suicidal ideation with a plan to jump off the 10th-story roof of his apartment building.

B: The patient is a veteran with a history of military service, having previous involvement in violent engagements and firefights during deployment. The patient reports hearing voices and seeing the friends he lost during deployment telling him to "join them". The patient reports he feels intense guilt for surviving when his friends did not, expressing thoughts such as, "I should be dead be dead instead of them."

A: The patient has self-inflicted cuts on his abdomen and thighs upon examination. The patient is experiencing 9/20 of the following symptoms: intrusive thoughts/memories, flashbacks & vivid dreams, avoidance of things that remind the patient of the traumatic event, negative thinking, difficulty experiencing positive emotions, difficulty sleeping, irritability & angry outbursts, difficulty concentrating, and hypervigilant & exaggerated startle responses as evidenced by the Posttraumatic Stress Disorder Checklist (PCL-5) assessment.

The patient is at high risk for suicide and self-harm. The patient's latest vital signs are as follows: heart rate of 96 bpm, blood pressure of 150/90 mmHg, respiratory rate of 24, temperature 98.6°F (37°C), and an oxygen saturation of 95% on room air.

R: The patient should be placed in a 1:1 due to high suicide risk and potential for self-harm. The patient should remain in a low-stimulus environment.

Administer medications as ordered and provide education on potential side effects regarding medication.

Continue to monitor the patient's progress and vital signs.

Provide trauma-informed care through creating an environment in which the patient feels safe.

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Suicide precautions

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Complication 1: Suicidal Ideation & Self-Harm

Complication 2: Medication Compliance

Complication 3: Social Isolation

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Use of Restraints

Patient posed a risk of self-injury and violent behavior during flashbacks and hallucinations. After the maximum dose of medication was given, the patient is still exhibiting violent behavior and posed a further risk to self and others. Two-point restraints were prescribed by the provider and are now in use for patient safety.

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1:1 Suicide Precaution/Pt Sitter

This intervention would be implemented immediately due to the patient's impaired mental state, which prevents him from assuring the nursing staff of his safety. It addresses the risk of self-harm arising from his survivor's guilt or PTSD-related psychosis.

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Administer prescribed medications

The SSRIs Sertraline (ZOLOFT) and Paroxetine (PAXIL) are the two FDA-approved medications for PTSD and are used for first-line defense. However, other medications such as SNRIs and anti-epileptics may also be utilized. Educate patient about the importance to adhering to the medications and possible side effects of medications. Monitor patient's response to the medications.

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Provide trauma-informed care

Realizing the high prevalence of traumatic events, it is crucial to recognize the signs and symptoms of trauma in this veteran, such as social isolation.

Responding effectively involves building rapport to establish a safe environment in which the patient feels more open to sharing sensitive information about their trauma and current mental state.

Additionally, every effort should be made to actively prevent re-traumatization, emphasizing the importance of maintaining the patient's privacy and ensuring that set boundaries aren't crossed. In doing all of these, the patient will potentially feel more inclined to facilitate engagement.

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Administered Benzodiazepines: To reduce anxiety in patients under suicide precautions.

Assessed anxiety levels using clinical judgment and anxiety scales.

Assessed patient for contraindication.

Verified Physician order/dosage

Preparations: Confirmed identity using two identifiers.

Administrations: Administer medication as prescribed (e.g., "Lorazepam 5 mg orally").

Monitor the patient for effects: Watch for side effects (e.g., drowsiness, dizziness).

Document the administration and patient response.

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Short Term:

Remove harmful objects from the PT’s reach & Move PT to secluded room/area

Reassure Safety

Re-orient PT to reality

Tend to the PT’s wound by providing wound care, preventing infection

Monitor vitals

Document Findings

Long Term:

Cognitive Behavioral Therapy & Coping Mechanisms

CBT: Teaching the patient to reframe his irrational/negative thinking such as believing that the death of his friends was his fault will help illicit more positive thinking in hopes to improve mood and relief of symptoms.

Coping Mechanisms: Joining a support group with other veterans with PTSD will help build a community and relate with others who are going through the same experiences. Also teaching relaxation techniques such as deep breathing, meditation, and exercise will help improve symptoms long term.

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Despite the efforts of the patient's care team, his symptoms of PTSD persist. He says the voices are calling him and that he sees the entrails of his squad scattered across the room. The patient is starting to scream for his comrades and hits himself repeatedly. He starts scratching his face until his skin bleeds and states that he must set himself on fire.

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Morgan, K. (2023). Davis Advantage for Townsend's Psychiatric Mental Health Nursing (11th ed.). F. A. Davis Company. https://fadavisreader.vitalsource.com/books/9781719649872