What Happened to Randy Adams

Opening Questions How did the simulated experience of Randy Adams’ case make you feel? I could feel the patient’s pain, he wasn’t comfortable talking about the things he’s done in his past and he described the flashbacks as very horrible. It was good that his wife was very supportive although she seemed tired too. Talk about what went well in the scenario. I checked for safety before going in and maintained a hygienic environment when during my assessment. I obtained consent from the patient and he allowed his wife to be a part of the interview. I assessed vital signs to obtain a baseline and completed the Primary Care PTSD screening assessment tool. Patient education and support went well as well and I called the provider after completing all necessary assessments. Reflecting on Randy Adams’ case, were there any actions you would do differently? If so, what were these actions and why? I completed the ACE Part B. Symptom Check List (Lovell & Collins, 1998 JHTR) assessment tool. Some of my assessment answers were incorrect. Regarding the indicator "Exertion: Do these symptoms worsen with: Cognitive Activity": I should have indicated "Yes." Scenario Analysis Questions* PCC/S What could occur if Randy Adams kept taking his sumatriptan succinate? It could cause more noise and light sensitivity and there would be there would be a danger of serotonin syndrome. PCC/I Discuss the types of support groups and resources that would be beneficial to Randy Adams and his family. Patient will benefit from desensitization, Relaxation techniques also benefit from support groups for veterans, so he learns from their experiences and growth. Examples are: Veteran Service Organizations (VSO) Private Veteran-Focused Support Groups State-Run Departments Of Veterans Affairs Also, there are some phone apps that are very beneficial like:     PTSD Coach – This app is designed to help users learn about coping with the symptoms related to PTSD that commonly occur following trauma. PTSD Family Coach – PTSD Family Coach is designed to support family members of those living with post-traumatic stress disorder. Mindfulness Coach – This app helps users manage PTSD symptoms by “grounding yourself in the present moment.” VetChange – An app to help those worried about alcohol use as it relates to PTSD. Anger and Irritability Management Skills – A mobile app to help you cope with anger problems. Built for military members, it can be used by anyone who needs to learn more about anger and how to manage angry reactions. What benefit services are available for veterans with PTSD?      Healthcare. Counseling. VA disability compensation. Group therapy for special needs, like anger or stress management, or combat support. For additional support - National Center for Post Traumatic Stress Disorder PCC What discharge teaching needs to be given to Randy Adams’ wife related to his care? I would educate them to call 911 if patient think about hurting or killing himself or someone else. Call your provider if you cannot sleep or are sleeping too much or have questions or concerns about your condition or care. Patient should watch for signs of worsening headache and increased irritability Randy's wife is at risk for caregiver strain, being the only person who is taking care of everything is a stressor. This puts a large burden on her, and as a result, they she experiences tremendous strain and stress, or caregiver burden. She should also join support groups for families with PTSD. The family will benefit from a group or more therapy sessions for veterans and families. Concluding Questions How would you apply the skills and knowledge gained in the Randy Adams case to an actual patient situation in different acute care units (emergency room, intensive care unit, obstetrics unit, etc.)? I would show empathy and not put pressure my patient into talking when they’re not ready. I will provide comfort and assurance while also validating their feelings. I would use relaxation techniques and desensitization when needed and give prescribed medications. Documentation Assignment - Randy Adams  1. Document your findings related to assessments of Mr. Adams’ cognition, symptoms of concussion, and symptoms of posttraumatic stress disorder. Symptoms of concussion: Mr. Adams has a headache, that is why he’s wearing sunglasses and did not want to take them off because his headache gets worse if he did. He was sensitive to noise and light and found it hard to concentrate at times and remembering things. The patient has experiences irritability, and less sleep. And the symptoms worsen with mental activity. Symptoms of Posttraumatic stress disorder: Mr. Adams is experiencing nervousness, he stated “I can't relax, a good soldier is always prepared to act. Mr. Adams has experienced things in the past that he does not want to think or know about, he has tried going out of his way to forget or to stop thinking about some of the experiences he had that he was not happy with. The patient walks a lot at home and likes to make sure that the doors are locked. The patient recently feels that he is not the same and feels detached from his friends because they do not understand him now.        2. Identify and document key nursing diagnoses for Mr. Adams. Fear related to physiological symptoms, mental/cognitive behaviors indicative of panic Ineffective coping Powerlessness related to fear of disapproval from others and consistent negative feedback Social isolated related to Repressed fears. And past experiences. Self-care deficit related to withdrawal Deficient knowledge related to Unfamiliarity with medications used and potential adverse effects.  3. Referring to your feedback log, document all nursing care provided and Mr. Adams’ response to this care. I asked the patient: Is it OK for your wife to be here, while we talk? It was correct to let the patient give his consent for letting his wife be a part of the interview. The patient said: I'm not sure what I would do without Joy. I answered: It sounds like your relationship with your wife is very important to you. I used the therapeutic technique of encouraging expression. I said: I would like to ask you a few questions and for you to draw a specific thing, which will help me to better assess you. May I ask you these questions? The patient said: Yes. I asked the patient: Can you tell me a little bit more about what's going on with you today? It was appropriate to ask the patient what was going on with him to get an understanding of this. The patient said: The doctors at the VA want me to talk about all the things from the past that make me uncomfortable. Talking about the past won't help. I answered: Are you uncomfortable when you talk about the past? I used the therapeutic technique of making observations. The patient said: The lights; they make my headache worse. I answered: Intolerance to light is a common symptom related to a head injury. I used the therapeutic technique of giving information. I asked the patient: Over the past year, when did you feel your best? The patient said: I felt my best when I was with my team in Afghanistan. It was appropriate to ask the patient about when he felt his best. The patient said: I'll try to lay in bed at night, but then I hear sounds and have to get back up. Joy does not hear them; she says they are in my head. I answered: Let's talk more about the sounds you hear. I used the therapeutic technique of focusing. The patient said: I have these dreams; I can't remember them, but when I wake up, my heart is racing. I answered: What seems to lead up to you having these dreams? I used the therapeutic technique of placing the event in time or sequence. The patient said: I really don't need much sleep. I answered: Are you saying that you don't sleep well? I used the therapeutic technique of verbalizing the implied. The patient said: Sometimes it's like I'm full of all this energy but I don't know what to do with it. I answered: When does this happen? I used the therapeutic technique of placing the event in time or sequence. The patient said: You'll have to ask Joy about answering the questions. I answered: I'll have to ask Joy? I used the therapeutic technique of restating. I said: I would like to ask you some questions related to your concussion that will help me to better assess you. May I ask you these questions? The patient said: This is a lot. Why are you asking so many questions? I can't answer this many questions. I answered: It's important that I ask you these questions to complete your assessment. I used the therapeutic technique of giving information. The patient said: I can't help Joy when the boys cry; the sounds are too painful. I answered: Is the pain before or after you hear loud noises? I used the therapeutic technique of placing the event in time or sequence. The patient said: Can I stand up while we talk? I answered: You seem tense. I used the therapeutic technique of making observations. I said: Is it okay if I ask a few questions related to any traumatic experiences you may have encountered? There are four questions, and they will help to better clarify what might be causing some of your symptoms. The patient said: Ok. Go ahead. The patient said: Every time I go somewhere, I immediately look for the exits. I answered: I'm not sure I understand. I used the therapeutic technique of seeking clarification.  4. Document instances of therapeutic communication and Mr. Adams’ response to this intervention. When the patient said that the lights make his headache worse, I used a therapeutic technique of giving information by stating that “intolerance to light is a common symptom related to head injury”. When asked the patient if he experienced nervousness, he stated, “I can't relax a good soldier is always prepared to act” As a therapeutic communication skill of exploring I stated “Tell me more about that” Mr. Adams then was able to successfully clarify what he meant by his statement.  5. Document the patient teaching related to posttraumatic stress disorder and concussion, as well as medications, that you provided to Mr. Adams and his wife before discharge. Topiramate and Sumatriptan were prescribed to Mr. Adams for his headache due to his head injury. He was also encouraged to go to the Veterans Affairs hospital, it may be therapeutic for him to spend time and discuss his experiences in the war with others who have gone through similar experiences  6. Document your handoff report in the SBAR format to communicate Mr. Adams’ future needs. Situation: Our patient, Randy Adams, is back today. You remember that he is a 28-year-old patient of mine who suffered a concussion as the result of a motor vehicle accident about 2 weeks ago. Randy lost consciousness during the accident and was very confused, so we kept him in the hospital for 24 hours of observation. I referred him to neurology and behavioral health afterward. His vital signs are as follows: temperature, 37°C (98.6°F); heart rate, 60 beats/min; respiratory rate, 16 breaths/min; blood oxygen saturation, 99%; and blood pressure, 115/80 mmHg. Background: Randy is a war veteran, and after the car accident, he thought that he was still in the war. I am concerned that he may be having some residual problems from his service. He mentioned he had been exposed to bomb blasts in a couple of incidents when he served. His wife, Joy, told me she would make sure he goes to his appointments. I’ve encouraged him to look into getting care at the Veterans Affairs (VA) hospital, but he has really resisted that. He has a history of migraines, which started after the deployment. Randy saw Dr. Naylor, the neurologist, in a follow-up consultation. Topiramate and sumatriptan were prescribed. Also, Randy is seeing a psychiatric nurse practitioner, who recommended mindfulness. He came in for his appointment last week, but at the incorrect time. Assessment: I think he may have PTSD and maybe some neurocognitive problems from his exposure to blasts, but we need to make sure he’s recovering from this most recent head injury before we can help him with the other problems. Recommendation: I’d like for you to reassess his symptoms using part B of the ACE form and compare his results with those from the forms that were filled out at the hospital and here last week. Please also administer the Primary Care PTSD Screen. Please do a Mini-Cog assessment on him, as well. I’d like to know the results before I see him and Joy today.