[Solved]: Nurses Progress Note:Patient Name: Nicole DiazAge:…

Nurses Progress Note:Patient Name: Nicole DiazAge: 48 yearsDate/Time: [Insert Date/Time]Diagnosis: Chronic sleep disorder related to PTSDSubjective:Patient reports obtaining 4 to 5 hours of sleep per night on average, with difficulty falling asleep that often takes over an hour. She states she does not fall asleep until 2 or 3 in the morning and frequently wakes to check doors and windows multiple times throughout the night. The patient also reports nightmares, flashbacks of the rape, and hypervigilance. She describes heightened alertness, being easily startled, and insecurity in the presence of men, which exacerbates her fear of vulnerability. The patient also reports difficulty forming or maintaining relationships, citing a lack of trust and emotional safety as contributing factors.Objective:Patient appears fatigued but alert during the assessment.Demonstrates anxious behaviors, including fidgeting and avoiding prolonged eye contact.Service dog remains attentive and calm, offering visible emotional support.Interventions Implemented:1.Sleep Hygiene Education: Educated the patient on the importance of establishing a consistent bedtime routine, reducing screen use before bed, and engaging in relaxation techniques such as deep breathing or progressive muscle relaxation.2.Safety Measures: Discussed strategies for reducing the frequency of door and window checks, such as completing a single, thorough security check before bedtime and considering a symbolic lockout routine to reinforce feelings of safety.3.Emotional Support: Validated the patients experiences and acknowledged the challenges of living with PTSD. Reassured her that her feelings are a normal response to trauma and that the care team is here to support her.4.Collaboration with Mental Health Team: Notified the interdisciplinary care team about the patients concerns, including hypervigilance, nightmares, and fear of vulnerability, to tailor a trauma-informed care plan.5.Encouraged Open Communication: Invited the patient to share additional triggers or concerns that may impact her recovery and treatment goals.Plan:Collaborate with the mental health team to explore trauma-focused therapies such as EMDR or cognitive-behavioral therapy to address flashbacks, nightmares, and fear of vulnerability.Assess the need for a sleep specialist consultation to evaluate the chronic sleep disorder and consider adjunctive therapies or medications.Continue monitoring the patients sleep patterns and emotional well-being during her stay.Provide ongoing support and education tailored to her evolving needs.Next Steps:Follow up with the patient and the mental health team to evaluate progress and reassess interventions. Maintain a compassionate, patient-centered approach to care.