Post Traumatic Stress Disorder Comprehensive Nursing Essay Example

Post Traumatic Stress Disorder Comprehensive Nursing Essay Example

Client ID:  12-year-old boy

Subjective.

Chief complaint: The client’s grandmother reports “deteriorating behavior.”

Source of reliability: Reliability of information is good. Presents with grandmother.

Present illness: The patient has a history of neglect and parental abuse. He has been under the care of his grandmother. Recently, his behavior has deteriorated since her sister was placed in the same care as him. He envies attention given to her sister. He becomes easily angered, moods shift from constricted to volatile, with frequent angry outbursts that carry over to and interfere with school. The client shows multiple signs of arousal, including insomnia, impaired concentration, edginess, and irritability.(Post Traumatic Stress Disorder Comprehensive Nursing Essay Example)

Current psych meds: None.

Past psychiatric history: No previous hospitalization and medication reported. Diagnosed with oppositional defiant disorder and ADHD

Past medical history: Allergies: None

Substance use/abuse: None.

Past family, social history:

Family psych hx: The mother had a history of stress from her abusive husband, now separated. The client’s parents had a history of drug and alcohol abuse.

Education/Employment/Disability: The client is in Middle school, 6^th grade. Classes include remedial reading, Math, 6th grade Science, Art, Social Studies, and PE.  He is at least two years behind in reading. No Individualized Education Program. The client is talkative and social with his peers when in a good mood.(Post Traumatic Stress Disorder Comprehensive Nursing Essay Example)

Primary support system: Suffered neglect, physical abuse, and parental substance abuse. The client has been in the care of his grandmother since he was18 months old.

Hobbies: Likes Art and the Remedial Reading.

Review of systems-pertinent (per GM):

Constitutional: denies: fatigue, no fever or chills

Cardiovascular: denies: chest pain, palpitations

Pulmonary: denies: shortness of breath, wheezing, or cough

GI: denies: n/v/c/d, states appetite is good, and eats three meals a day

GU: Not sexually active

Neuro: denies: n/v/c/d, report good appetite, and eats three meals a day

Musculoskeletal: denies: muscle tension or joint pains

Skin: denies: rash, hives, itching

Objective.

Vitals: BP: 130/77 P: 94 Ht: 57.5in Wt: 89 BMI: 18.9

Appearance: Well kempt and appropriately dressed. Makes good eye contact.

Attitude/interaction: Calm and interactive. Appears restricted

Activity level/behavior: In no acute distress. No psychomotor retardation or agitation.

Orientation: Alert and oriented in all spheres.(Post Traumatic Stress Disorder Comprehensive Nursing Essay Example)

Speech: clear and fluent, sounds mildly anxious

Thought content/process/perception: Thought is past-oriented and somber.

Mood/affect: Mood is reported as “impulsive,” affect appropriate for the situation.

Judgment/insight/cognitive/memory: Poor judgment and insight due to impulsivity. Cognition is below average. Difficulty with abstract. Apparent cognitive deficits.

Attention: Noted some attention and concentration problems during the exam

Testing: No test done. UDS negative.

Assessment.

(F90.9) Attention-Deficit /Hyperactivity Disorder.

(F91.3) Oppositional Defiant Disorder.

(F34.8) Disruptive mood dysregulation disorder.

(F43.10) Posttraumatic Stress Disorder

(F94.1) Reactive Attachment Disorder

Plan: Medication treatment prescribed & education provided: (Discuss treatment & patient

education, discuss follow up plan for the patient)

The plan will be to start the client on Methylphenidate 5mg twice per day. Methylphenidate is a CNS stimulant and contributes to hyperactivity and impulse control in children and adolescents with ADHD (Huss et al., 2017). Refer the client to a behavioral therapist for behavior management to improve a child’s self-esteem, control, and behavior (CDC, 2020). The caregiver should also be trained in behavior therapy to gain skills and strategies to help the client succeed in his relationships. Recommend an IEP to ensure the client thrives in school and achieves his potential by changing how and what they learn (Spiel, Evans & Langberg, 2014). Educate the grandmother of the medication’s side effects such as irritability, nervousness, diarrhea, and vomiting. The client and grandmother voice understanding and agrees with the treatment plan.(Post Traumatic Stress Disorder Comprehensive Nursing Essay Example)

Required laboratory monitoring with frequency: None required

The non-pharmacologic treatment recommended: Behavioral therapy.

Duration until next scheduled visit: 2 weeks

Billing code: 25468, Office visit, established

References

Centre for Disease Control and Prevention. (September 2020). Parent Training in Behavior Management for ADHD. Retrieved 9 September 2021, from https://www.cdc.gov/ncbddd/adhd/behavior-therapy.html(Post Traumatic Stress Disorder Comprehensive Nursing Essay Example)

Huss, M., Duhan, P., Gandhi, P., Chen, C. W., Spannhuth, C., & Kumar, V. (2017). Methylphenidate dose optimization for ADHD treatment: a review of safety, efficacy, and clinical necessity. Neuropsychiatric disease and treatment. https://dx.doi.org/10.2147%2FNDT.S130444(Post Traumatic Stress Disorder Comprehensive Nursing Essay Example)

Spiel, C. F., Evans, S. W., & Langberg, J. M. (2014). Evaluating the content of Individualized Education Programs and 504 Plans of young adolescents with attention-deficit/hyperactivity disorder. School Psychology Quarterly, 29(4), 452. https://dx.doi.org/10.1037%2Fspq0000101(Post Traumatic Stress Disorder Comprehensive Nursing Essay Example)