Question

 Reflection Mental health

 Three Area of Strength Explained

 1. Start your paragraph here

 2.

 3..

 Two Areas of Weakness, Steps for Improvement

 1.

 Patient Priority Care

 Start your paragraph here

 Nursing Diagnosis

 Safety Measures

 Two Learned Concepts Explained

 Patient Introduction

 Location: Provider's office

 Time: 15:00

 Report from Dr. Joe Reynolds to his office nurse:

 Situation: Our patient, Randy Adams, is back today. You remember that he is a 28-year-old patient of mine who sutfered 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. 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.

Answer 1

The ACE is intended to provide an evidence based on clinical protocol to conduct an evaluation and diagnosis of patients .

Injury- concussion on head

Amnesia- present, failure to form new memories

LOC - unconscious during accident

Risk factor - concussion and migraine

Diagnosis- Mr Randy suffer from 850.1 as par ICD 10.

Traumatic event is persistently reexperienced as flashbacks and distressing dreams .Remote memories overcome Mr Randy and he has forgotten recent memory .

Administer primary care for the PSTD :-

• Complete diagnostic workup to rule out physical illness.
• Psychotropic medications-sedatives and antianxiety agenst are used for short term when client is unable to cope or accomplish daily activities and until healthier coping emerges.
• Behaviour modification to provide controlled exposure to recall of event .
• Use of eye movement, desensitization , reprocessing techniques.
• Imagery , relaxation and meditation.
• Cognitive restructuring and reframing.