Post

Traumatic

Stress

Disorder
INTRODUCTION

OVERVIEW
Tony, a 32-year-old man and a former
infantryman was admitted in a psychiatric
clinic with a diagnosis of Post-Traumatic Stress
Disorder (PTSD). Based on the assessment and
his reports during the admission, symptoms
like hypervigilance, intrusive thoughts,
irritability, loss of interest, sleep difficulties, and
trauma are all present. On the other hand, his
treatment plan includes, pharmacologic
interventions and Cognitive Behavioral
Therapy.

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INTRODUCTION
POST-TRAUMATIC STRESS DISORDER

may occur in people who have

experienced or witnessed a traumatic
event such as:
• natural disaster
• a serious accident
• a terrorist act
• war/combat
• rape or who have been threatened
with death, sexual violence or serious
injury
They may relive the event through:
• flashbacks or nightmares
• sadness, fear or anger
• detached or estranged from other
people

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INTRODUCTION

PREVALENCE and INCIDENCE RATE

70% of adults experience at least 1 PTSD in Adults

traumatic event in their lifetime 3.6% of American adults are affected

20% of people who experience a PTSD Among Adolescents

traumatic event will develop PTSD 5% of adolescents are affected

About 8 million people have PTSD PTSD in WOMEN vs. MEN

in a given year 1.8% (men)
5.2% (women)
1 in 13 people will develop PTSD
at some point in their life

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 PATIENT’S PROFILE Chief Complaint:
AND HISTORY
Upon admission, the
Name: TONY client reports having
difficulty in sleeping and
having nightmares.
Age: 32 y/o

History of Present Illness:

Sex: MALE
The client was a former
infantryman with a local marine
Marital reserve unit. After his 2 tours in
SINGLE Mindanao, his fiancée noticed
Status:
that he was not the same as
before which affected their
FORMER relationship.
Occupation:
INFANTRYMAN He reported to have experienced
traumatic events during their 2nd
ROMAN tour that caused his condition
RELIGION: 5
CATHOLIC
 MENTAL STATUS
EXAMINATION

General Appearance and Behavior

During the interview, cooperation is noted with the client, for the reason that he can provide

information, although he gave few details regarding to his past traumatic experiences. And passiveness

is still evident due to its unwillingness to provide specific details. Psychomotor agitation is present as

stated by feelings of annoyance, and social withdrawal to avoid triggering his emotions, and to avoid

recalling memories of traumatic events. Furthermore, the client reported that he is easily startled by

noise and motion. Restlessness is also evident due to his disturbed sleeping pattern. The client reported

that he “sleeps with one eye open” and, on the occasions when he falls into a deeper sleep, he has

nightmares.
 MENTAL STATUS
EXAMINATION

Attitude towards the Examiner

While cooperation is noted with the client’s attitude towards the examiner, the client still offers

few details and that exhibits passivity. He describes having intrusive memories about his traumatic

experiences on a daily basis but he declines to share specific details.

Affect and Mood

An appropriate affect is noted for the reason that the client can express his feelings and past

traumatic experiences verbally. The client’s mood is noted as anxious supporting its statement of being

hyper-alert to noise and motion. Moreover, restlessness is noted with the client due to disturbed

sleeping patterns.
 MENTAL STATUS
EXAMINATION

Thinking Process

The client exhibited distressing thoughts and intrusive memories regarding with his traumatic

experiences. It is apparent from his statement that he avoids seeing his friends form their Reserve Unit

because every time he remembered them it reminds him of his experiences that he does not want to

recall. The client was also anxious since he easily get startled by noise and motion and spends

excessive time searching for threats that are never confirmed both when duty and at home.
 MENTAL STATUS
EXAMINATION
Thought Content

With the given statement of the client, it was noted that he is encountering thought disturbances, and

delusion was perceived. This claim was validated with the client's given statement wherein he expressed

that he consumes excessive searching for threats that are never confirmed both on his duty and at his

home. Thus, the client's action is significant to a type of delusion called persecutory delusion. This type of

delusion, the client's central belief is that he is being threatened by someone or in a dangerous situation

which can cause him to fear ordinary situations, excessive worrying, constantly seeking safety, and or

extreme distress. Additionally, it is known that post-traumatic stress disorder (PTSD) can manifest with

secondary psychotic symptoms, for instance, flashbacks and hypervigilance, which can be associated with

persecutory delusions.
 MENTAL STATUS
EXAMINATION

Cognitive Evaluation

The level of consciousness of the client was suspicious as it was stated that he consumed most of

his time in searching for threats and easily agitated by the noise and motion. The client can fairly recall

the long term and recent memories he had as evidenced by telling few details regarding his first former

occupation. Because of the intrusive and traumatic experiences in his former occupation, the client

cannot fully express his memory of it.

 MENTAL STATUS
EXAMINATION

Insight

The reluctance of the client to provide a factual information is caused by hiding his memories as

he describes them as intrusive and traumatic. With regards to the client’s insight to his awareness in his

thoughts and feelings it is noted as moderate, as evidenced by giving few details of his thoughts and

feelings. The client recognized the changes in his daily living, including the effects of this changes on

his relationship with his fiancé who was suggested that the client really needs to seek help.
 MENTAL STATUS
EXAMINATION

Judgement

The client concurred with his fiancé’s suggestion to seek for psychiatric help. Despite the

difficulties in giving information regarding to his thoughts and feelings because of his past experiences,

the client still managed to provide details to help the psychiatric team understand him even more. The

client’s performance suggests that his judgement was noted as moderate as he comes to realize that his

situation is significantly affecting his relationship with his fiancé. And he decided to take some course

of action with the urge of his fiancée.

 PSYCHOPATHOLOGY
Frequent exposure to a
traumatic event (e.g.
war, loss of loved ones,
natural disaster or an
assault)
Intense fear activates the
Hypothalamus Pituitary
Adrenal axis (HPA axis) then
sends signal to the
autonomic nervous system.
An increased in the
levels of catecholamines,
cortisol, helplessness
and distress during the
event
Impaired social,
occupational, or/and
family functioning.
Other behavioral
consequences of the
traumatic events. (e.g.
hypervigilance, difficulty
sleeping, irritability,
excessive reaction to noise)
Chronic cascade of
catecholamines and
cortisol that may linger
for weeks to months.
Leads to avoidance behavior
of anything related to the
traumatic memories and
become anxious with his
safety.
Frequent flashbacks or
nightmares of the traumatic
event and distress when
faced to a stimulus that
triggers the event. (People,
places, or situations)
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PROCESS
RECORDING (ORIENTATION PHASE)

Description of the Patient

Tony, an infantryman with a local Marine Reserve discharged from the service last 2019, comes into
the psychiatric clinic. During the interview, he gives few details about his previous situations. Tony also
mentioned that he experienced several traumatic events but declined to give and provide more specific details.
Most of the time, Tony chooses to be alone and not to be with people as he is afraid that he might burst out at
them. He also stated that he finds it difficult to perform his duties as a security guard because it is boring and
gives him too much time to think.
During the interview, he gets easily started by noise and motion. He spends too much time
searching for threats that are not confirmed in his duty or at home. He also describes his traumatic experiences
intrusively every day, but he refuses to share any details. Tony also avoids seeing his reserve unit friends
because they remind him of previous experiences he does not want to recall
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PROCESS
RECORDING (ORIENTATION PHASE)

Description of the Environment

Tony was admitted to a psychiatric clinic, a facility where patients with psychiatric
disorders stay and receive appropriate treatments. The interview and assessment were performed
in an area that is safe, comfortable, and private for both the nurse and client.

Objectives:

• To be able to build therapeutic rapport between the nurse and client

• To be able to establish baseline data for patient’s plan of care

• The nurse and the client will build trust and respect

• The nurse will be empathetic and discover patient concerns and problems

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PROCESS
RECORDING

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PROCESS
RECORDING

Description of the Environment

In the orientation phase, the nurse was able to meet and greet the client

with a proper approach. Using these proper approaches, the nurse was able to build

trust and rapport to the client. Along with this also established a baseline data for

the patient’s plan of care. Towards the whole orientation phase, the nurse portrayed

empathy to the patient. Due to that, the nurse was capable of discovering problems

concerning the client bolstering mutual trust and respect with one another.

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NCP

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NCP

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DRUG STUDY

2
0
DRUG STUDY

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REFERENCE
Rachel Yehuda, et. al (2015)
Post Traumatic Stress
Disorder retrieved from
https://www.nature.com/articles/nrdp201557.

Felix Torres M.D., DFAPA, MBA, (2020)

What Is Posttraumatic Stress Disorder? Retrieved from
https://www.psychiatry.org/patients-families/ptsd/what-is-ptsd.

Denise-Marie Griswold, LCAS, (2021)

PTSD Facts and Statistics retrieved from
https://www.therecoveryvillage.com/mental-
health/ptsd/related/ptsd-statistics/

Nicholas L, (2000) Antidepressant efficacy of venlafaxine

retrieved from
https://go.drugbank.com/drugs/DB00285.

https://www.scribd.com/document/169059474/Venlafaxine-Xr

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THANK YOU!

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 GROUP 2
JIMENEZ, KELLY ROSE S.
MACARAEG, MICHAELLA ANGELA M.
MANGULAD, KIMBERLY S.
MUYANO, JOHNE SIGRID C.
NEMENZO, ZAIRA ALYSSA S.
PEREZ, MARIELLE S.
RABADON, RACHELLE MAE D.
RAMIREZ, KIT
REYES, ARVIE
RUIZ, MICHAEL KENNETH E.
RULLAN, GERALDYN C.
SANCHEZ, NICOLE M.
SANDOVAL, IVAN ZEV G.
SIGNO, CARLA MAE P.

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