Ms. Blessing is a 68-year-old widow who has been a patient of her primary care physician (PCP), Dr. Le, for more than 10 years. She has a history of anemia, osteoarthritis, diabetes mellitus, and congestive heart failure—and is a recent victim of home invasion and rape. She was referred to the mental health acute care clinic for evaluation of complaints of not being able to sleep for days, and she reports feeling “nervous all the time.” Her daughter states that Ms. Blessing is “unable to stop thinking about the night; it has been 4 months since the home invasion and her rape,” and she has become “more and more like this.” The patient lives alone and is independent, but her daughter reports she has become more and more nervous and jumpy, cries easily, and exhibits more helpless behaviors that have become more pronounced since her assault. On interview, she is tearful, shaking, trembling, and overtly distressed. She keeps her eyes on the floor or her lap most of the time, and then wrings her hands as she answers questions about the event. “I just keep seeing him,” she says, “And I’m constantly checking my doors to make sure they’re locked.” She holds back tears discussing her challenges with sleep, specifically being able to sleep at night while fearing the rapist will return. She offers apologies for having to talk about this matter, saying, “I have the best daughter and family. I just need to get some sleep. I will be okay.”
Self-Assessment
The nurse assigned to Ms. Blessing is Angela Juarez, a new graduate who has been at the mental health clinic for the past several months. She has a calm demeanor and is known to be a good listener. Although Nurse Juarez has never worked with a patient with PTSD, after her initial meeting with Ms. Blessing, she thought that her best approach would be to offer a comfort and caring response, especially because Ms. Blessing offers apologetic pleas for help with insomnia. Nurse Juarez plans to allow Ms. Blessing to verbalize her concerns without interruption. Angela speaks to her nurse supervisor about her approach, and the supervisor recognizes that Angela’s planned approach will support a foundation for a therapeutic alliance with Ms. Blessing and allows her to continue with intervention. This includes:
Outcomes Identification
The patient will develop effective coping skills or patterns to reduce anxiety. The patient will secure a normal activity and rest schedule.
Planning
Because of the patient’s known cardiac history, she is admitted to a 23-hour bed for further assessment of physical status and for guidance related to her response to prescribed medication to treat anxiety and insomnia. The nurse plans interventions that will help reduce Ms. Blessing’s anxiety and offer information related to self-help techniques to reduce anxiety and promote sleep, as well as the education about and administration of medications to reduce anxiety and promote sleep.
Implementation
Nurse Angela makes the following nursing care plan.
Short-Term Goal
Patient will self-report a reduction in anxiety symptoms and ability to rest without interruption for at least 4 hours within 23 hours.
Intervention
Help patient recognize early signs of anxiety (eg, dyspnea, chest pain, rapid pulse).
Administer low-dose antihistamine hydroxyzine pamoate (Vistaril) as ordered.
Administer daily dose at bedtime to promote sleep.
Monitor mental status with antihistamine dosing.
Place the patient in a private or quiet room (whenever possible).
Stay with the patient and ensure the patient’s safety with the introduction of new medication.
Rationale
The sooner the patient recognizes the onset of anxiety, the more quickly she will be able to alter her response.
Antihistamines are one of the most common classes of sleep-inducing agents; they are also a commonly used medication to treat concurrent anxiety.
This may minimize adverse effects and allow more normal daytime activities to occur.
Older adults may experience delirium secondary to adverse effects.
Environmental stimuli and distractibility are minimized.
Elder response to medication could result in oversedation; monitor vital signs and fall risk.
Evaluation
GOAL MET
After receiving the first dose of antihistamine, the patient states that she feels less jittery and was noted closing eyes and resting comfortably.
Nurse noted patient asleep in bed with half rails up and daughter sitting bedside.
Short-Term Goal
Patient will sleep or rest 4 hours during the first night in the hospital with aid of medication and nursing interventions.
Intervention
Continue to direct patient to areas of minimal activity.
When possible, try to direct energy into productive and calming activities (e.g., slow, soft music; slow exercise; drawing alone; or writing in quiet area).
Encourage short rest periods throughout the day (e.g., 3 to 5 minutes every hour) when possible.
Patient should drink decaffeinated drinks only—decaffeinated coffee, tea, or colas.
Provide nursing measures at bedtime that promote sleep: warm milk, soft music.
Consider home environment consult to assess whether patient’s home is safe and whether she can stay in home alone.
Rationale
Lower levels of stimulation can decrease excitability.
Directing patient to paced, non-stimulating activities can help minimize excitability.
Patient may be unaware of feelings of fatigue. Can collapse from exhaustion if hyperactivity continues without periods of rest.
Caffeine is a central nervous system stimulant that inhibits needed rest or sleep.
Such measures promote non-stimulating and relaxing mood.
Patient may not be able to return to home while rapist is at large. Family needs to look at support options of home safety.
Evaluation
GOAL MET
Sleeps for 2 hours from 7 to 9 pm and rested again from 2 am until 6:30 am.
Patient able to report feeling rested for the “first time in weeks.” She was observed having short periods of uninterrupted calm throughout shift.
Patient agrees to stay with daughter for undetermined time while rapist is still “at large.”
Short-Term Goal
Patient’s blood pressure (BP) and pulse will be within normal limits within 24 hours with the aid of medication and nursing interventions.
Intervention
Continue to monitor BP and pulse frequently throughout the day (every 30 minutes).
Keep staff informed by verbal and written reports of baseline vital signs and patient progress.
Rationale
Anxious/panic and sleep-deprived condition could place an additional strain on patient’s heart.
Alerting all staff regarding patient’s status can increase medical intervention if a change in status occurs.
Evaluation
GOAL MET
Information from family physician states that baseline BP is 130/90 mm Hg and baseline pulse is 88 beats/min.
BP at end of first shift (8 hr) is 130/70 mm Hg and pulse is 78 beats/min.
Evaluation
At the time of her discharge from the 23-hour admission stabilization unit, the treatment team believed Ms. Blessing’s mental and physical status was more stable. Her vital signs were within normal limits, she rested, she consumed sufficient food and fluids, and her urinary output and glucose level were normal. She openly expresses some reluctance to discharge to her own home, so in the discharge family session, it was agreed that she would stay with her daughter and family for an undetermined time to receive more support for stabilization. Ms. Blessing’s insomnia and anxiety will continue to be a clinical treatment challenge; however, she seems motivated to participate in recommended aftercare outpatient therapy sessions that will include medication monitoring checks to adjusting medication as needed.
Both Ms. Blessing and her daughter were encouraged to continue with skills learned in the hospital and to keep and maintain follow-up care as directed. They were encouraged to report any untoward medication effects to the physician as soon as possible and follow up with her PCP within 2 days of release. They were further encouraged to contact a victim support group, which may offer peer support and interface efforts with police, which could serve to reduce Ms. Blessing’s fear of revictimization.
Questions
This case study skips over Ms. Blessing’s current diagnosis. Identify two key diagnoses you predict this included and why.
Ms. Blessing’s outcomes, plan, and treatment seem to have been on point. During assessment, what did Nurse Juarez most likely have identified as objective data to support this diagnosis?
Identify at least three subjective data for Ms. Blessing.
