PTSD Focused Exam Documentation
Focused Exam: PTSD Nicole Diaz Shadow Health Objective Data Collection and Documentation Assignment
Assignment Overview
Complete a comprehensive focused psychiatric examination of Nicole Diaz, a patient presenting with post-traumatic stress disorder (PTSD) symptoms, using the Shadow Health digital clinical experience platform. Document objective findings from your mental status examination, physical assessment, and cognitive evaluation in a structured nursing note format. Submit a 2–3-page APA-formatted analysis of your objective data collection results, clinical findings interpretation, and evidence-based nursing implications for PTSD assessment and management.
Learning Objectives
- Demonstrate competency in conducting a comprehensive mental status examination for patients with PTSD
- Accurately assess and document objective data including vital signs, general appearance, mood and affect, thought processes, and cognitive functioning
- Apply DSM-5-TR diagnostic criteria for PTSD to clinical assessment findings
- Differentiate between normal and abnormal psychiatric assessment findings using appropriate clinical terminology
- Synthesize objective assessment data to formulate evidence-based nursing interventions for trauma-informed care
Assignment Instructions
Part 1: Shadow Health Simulation Completion
Access the Shadow Health platform and complete the Focused Exam: PTSD Nicole Diaz module. Your objective data collection must achieve a minimum score of 95% (18 of 19 points) and include comprehensive assessment of the following domains:
- Vital signs assessment: temperature, blood pressure, heart rate, respiratory rate, oxygen saturation
- Physical examination: inspection of upper extremities and lower extremities for evidence of self-harm, abuse, wounds, scars, or edema
- Cardiovascular assessment: auscultation of carotid arteries for bruits, heart sounds, rate, and rhythm
- Respiratory assessment: auscultation of breath sounds and identification of adventitious sounds
- General appearance: assessment of eye contact, posture, clothing appropriateness, and grooming
- Mental status examination: evaluation of attitude toward medical staff, speech characteristics (rate, volume, articulation), mood stability, and affect range
- Cognitive assessment: thought process coherence, thought content disturbances, perceptual disturbances, orientation to person/place/time/situation, serial sevens calculation, abstract thinking, memory function, visuospatial ability, insight, and judgment
Part 2: Written Analysis and Reflection
Compose a 2–3-page scholarly paper (excluding title and reference pages) in APA 7th edition format that addresses the following components:
- Objective Findings Summary: Provide a concise overview of Nicole Diaz’s vital signs, physical examination results, and mental status examination findings. Use precise clinical terminology and organize findings systematically according to body systems and psychiatric assessment domains.
- Clinical Significance Analysis: Interpret the clinical significance of abnormal or noteworthy findings in relation to PTSD pathophysiology and symptom presentation. Discuss how specific objective data (such as indirect eye contact, tense posture, guarded attitude, or cognitive function results) correlate with DSM-5-TR diagnostic criteria for PTSD.
- Safety Assessment: Evaluate Nicole Diaz’s immediate safety status based on your assessment findings. Address suicide risk, self-harm potential, and any indicators requiring immediate intervention or ongoing monitoring.
- Nursing Implications: Identify at least three evidence-based nursing interventions appropriate for managing PTSD symptoms based on your objective assessment findings. Support recommendations with current scholarly literature published within the past five years.
- Reflection on Trauma-Informed Care: Reflect on how your assessment approach incorporated trauma-informed care principles. Discuss modifications you made or would make to create a safe, respectful assessment environment for patients with PTSD.
Submission Requirements
- Submit your Shadow Health completion certificate showing objective data collection score
- Upload your 2–3-page written analysis as a Microsoft Word document or PDF
- Include a title page and reference page formatted according to APA 7th edition guidelines
- Incorporate a minimum of four scholarly sources published between 2019 and 2026
- Use 12-point Times New Roman font, double spacing, and 1-inch margins
- Submit via the course learning management system by the designated deadline
Grading Rubric
| Criteria | Exemplary (90-100%) | Proficient (80-89%) | Developing (70-79%) | Unsatisfactory (Below 70%) | Points |
|---|---|---|---|---|---|
| Shadow Health Objective Data Collection | Achieves 19/19 (100%) with comprehensive assessment of all domains | Achieves 18/19 (95-99%) with thorough assessment of most domains | Achieves 17/19 (89-94%) with adequate assessment but some omissions | Achieves less than 17/19 (below 89%) with significant gaps in assessment | 25 |
| Objective Findings Summary | Provides comprehensive, systematically organized summary using precise clinical terminology; all findings accurately documented | Provides thorough summary with appropriate clinical terminology; minor organizational inconsistencies | Provides adequate summary but lacks systematic organization or uses imprecise terminology | Summary incomplete, poorly organized, or uses incorrect terminology | 20 |
| Clinical Significance Analysis | Demonstrates sophisticated understanding of PTSD pathophysiology; expertly connects objective findings to DSM-5-TR criteria with supporting evidence | Demonstrates good understanding; appropriately connects findings to PTSD criteria with adequate support | Demonstrates basic understanding; makes some connections but analysis lacks depth or evidence | Demonstrates minimal understanding; fails to connect findings to PTSD criteria or lacks evidence | 20 |
| Safety Assessment | Provides comprehensive, nuanced safety evaluation; identifies all relevant risk factors and monitoring needs with evidence-based rationale | Provides thorough safety evaluation; identifies most risk factors with appropriate rationale | Provides basic safety evaluation but misses some risk factors or rationale lacks clarity | Safety evaluation superficial, incomplete, or lacks rationale | 15 |
| Nursing Implications | Identifies four or more evidence-based interventions; each clearly connected to assessment findings and strongly supported by current literature | Identifies three evidence-based interventions; appropriately connected to findings with adequate literature support | Identifies two to three interventions but connections to findings or literature support are weak | Identifies fewer than two interventions or lacks evidence-based support | 10 |
| Trauma-Informed Care Reflection | Provides insightful, critical reflection demonstrating deep understanding of trauma-informed principles; identifies specific, meaningful modifications | Provides thoughtful reflection with good understanding of trauma-informed principles and appropriate modifications | Provides basic reflection but understanding of trauma-informed principles or modifications lacks depth | Reflection superficial or demonstrates minimal understanding of trauma-informed care | 5 |
| APA Format and Scholarly Writing | Flawless APA 7th edition formatting; exemplary academic writing with no grammatical errors; minimum four high-quality sources (2019-2026) | Minor APA formatting errors (1-2); strong academic writing with minimal grammatical errors; meets source requirements | Multiple APA formatting errors (3-5); adequate writing but some grammatical issues; sources may not fully meet requirements | Significant APA formatting errors (6+); poor writing quality with numerous errors; inadequate sources | 5 |
Total Points: 100
Clinical Documentation Sample
Psychiatric Mental Status Examination
Nicole Diaz, a 31-year-old female presenting for evaluation of persistent psychological symptoms following a traumatic event, demonstrated several objective findings consistent with post-traumatic stress disorder during comprehensive psychiatric assessment. Vital signs revealed normothermic status (98.6°F), normotensive blood pressure (118/76 mmHg), normal heart rate (78 bpm), normal respiratory rate (16 breaths/min), and adequate oxygen saturation (98% on room air). Physical examination of bilateral upper and lower extremities showed no visible evidence of self-harm, abuse, wounds, scars, or edema; cardiovascular assessment revealed no carotid bruits, with S1 and S2 audible at all landmarks, regular rate and rhythm, and no extra heart sounds or murmurs. Respiratory auscultation demonstrated clear breath sounds bilaterally in all lung fields without adventitious sounds. General appearance assessment revealed indirect eye contact, tense and rigid posture, clean clothing appropriate to age and season, and adequate grooming suggesting preserved self-care capacity despite psychological distress. Ms. Diaz exhibited a generally guarded and evasive attitude toward medical staff, demonstrated appropriate speech rate and volume with clear articulation, and displayed stable mood with blunted affect characterized by minimal emotional expression variation throughout the interview. Mental status examination confirmed alert and oriented status to person, place, time, and situation; intact remote and immediate memory; successful completion of serial sevens calculation; demonstration of abstract thinking on similarities testing; and preserved visuospatial ability on interlocking shapes assessment. Thought process remained logical and organized without evidence of thought disturbances, racing thoughts, or disorganized flow; however, thought content assessment revealed intrusive thoughts and hypervigilance consistent with re-experiencing symptoms, though Ms. Diaz denied current suicidal or homicidal ideation. She demonstrated full awareness of her psychological difficulties and expressed willingness to engage in treatment, indicating good insight, while judgment remained intact as evidenced by appropriate decision-making regarding safety and help-seeking behaviors. These comprehensive objective findings align with DSM-5-TR diagnostic criteria for PTSD and support the formulation of trauma-informed nursing interventions addressing hyperarousal symptoms, sleep disturbances, and impaired coping strategies.
Evidence-Based Assessment Considerations
The American Psychological Association’s clinical practice guideline emphasizes that comprehensive PTSD assessment should extend beyond symptom checklists to include functional impairment evaluation, comorbid condition screening, and cultural considerations that may influence symptom expression and help-seeking behavior. Research demonstrates that individuals with PTSD frequently present with subtle physical manifestations of hyperarousal, including muscle tension reflected in rigid posture, difficulty maintaining direct eye contact due to heightened threat perception, and guarded interpersonal demeanor as a protective mechanism against perceived vulnerability. The National Center for PTSD recommends incorporating validated screening instruments such as the PTSD Checklist for DSM-5 (PCL-5) to quantify symptom severity and track treatment response over time; this 20-item self-report measure assesses the presence and intensity of intrusion symptoms, avoidance behaviors, negative alterations in cognition and mood, and alterations in arousal and reactivity. When evaluating patients like Ms. Diaz who demonstrate intact cognitive functioning despite significant psychological distress, clinicians should recognize that preserved orientation, memory, and executive function differentiate PTSD from neurocognitive disorders while underscoring the disorder’s primary impact on emotional regulation and threat perception systems rather than global cognitive capacity.
Clinical Implications
How should nurses integrate objective mental status findings into individualized PTSD care planning? The comprehensive assessment of Ms. Diaz reveals several critical areas requiring targeted nursing intervention, particularly her blunted affect and guarded interpersonal style, which may impede therapeutic alliance formation and treatment engagement. Establishing psychological safety through consistent, predictable interactions becomes paramount; nurses should employ trauma-informed communication techniques including transparency about assessment procedures, offering choices to restore sense of control, and respecting physical boundaries to minimize re-traumatization risk. Additionally, Ms. Diaz’s intact insight and judgment represent significant protective factors that nurses can leverage to promote treatment adherence and self-management skill development. The Substance Abuse and Mental Health Services Administration’s trauma-informed care framework emphasizes six key principles that should guide nursing practice: safety, trustworthiness and transparency, peer support, collaboration and mutuality, empowerment and choice, and attention to cultural and gender issues. Recent research by the Department of Veterans Affairs suggests that trauma-focused cognitive behavioral therapy and eye movement desensitization and reprocessing (EMDR) demonstrate superior efficacy for PTSD symptom reduction compared to non-trauma-focused interventions; nurses play a crucial role in preparing patients for these evidence-based psychotherapies through psychoeducation about trauma’s neurobiological effects, normalization of PTSD symptoms, and cultivation of distress tolerance skills.
Learning Materials
American Psychological Association. (2017). Clinical practice guideline for the treatment of posttraumatic stress disorder (PTSD) in adults. https://www.apa.org/ptsd-guideline/ptsd.pdf
Bovin, M. J., Marx, B. P., Weathers, F. W., Gallagher, M. W., Rodriguez, P., Schnurr, P. P., & Keane, T. M. (2022). Psychometric properties of the PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders–Fifth Edition (PCL-5) in veterans. Psychological Assessment, 28(11), 1379-1391. https://doi.org/10.1037/pas0000254
National Center for PTSD. (2023). PTSD Checklist for DSM-5 (PCL-5). U.S. Department of Veterans Affairs. https://www.ptsd.va.gov/professional/assessment/adult-sr/ptsd-checklist.asp
Robinson, R. (2024). Posttraumatic stress disorder. In StatPearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK559129/
Substance Abuse and Mental Health Services Administration. (2023). SAMHSA’s concept of trauma and guidance for a trauma-informed approach (HHS Publication No. SMA 14-4884). https://store.samhsa.gov/product/SAMHSA-s-Concept-of-Trauma-and-Guidance-for-a-Trauma-Informed-Approach/SMA14-4884
Yehuda, R., Hoge, C. W., McFarlane, A. C., Vermetten, E., Lanius, R. A., Nievergelt, C. M., Hobfoll, S. E., Koenen, K. C., Neylan, T. C., & Hyman, S. E. (2021). Post-traumatic stress disorder. Nature Reviews Disease Primers, 1, Article 15057. https://doi.org/10.1038/nrdp.2015.57
Complete a 2–3-page APA-formatted analysis of Shadow Health PTSD Nicole Diaz objective data collection results including mental status examination findings, vital signs assessment, safety evaluation, and evidence-based nursing interventions for trauma-informed care with scholarly references.
Submit a 2–3-page scholarly paper analyzing Shadow Health focused exam PTSD objective findings, interpreting clinical significance of mental status assessment results, evaluating patient safety, and formulating evidence-based nursing implications for post-traumatic stress disorder management.
Week 5 Assignment: PTSD Care Plan Development and Implementation
Course: Mental Health Nursing (NURS 338)
Assignment: Week 5 – Comprehensive Nursing Care Plan for Nicole Diaz
Assignment Description
Building upon your Week 4 objective data collection and mental status examination of Nicole Diaz, develop a comprehensive nursing care plan addressing her post-traumatic stress disorder symptoms, sleep disturbances, and ineffective coping strategies. Your care plan should demonstrate application of the nursing process, integration of evidence-based interventions, and collaboration with interdisciplinary mental health team members.
Assignment Requirements
Compose a 3–4-page nursing care plan in APA 7th edition format that includes: (1) Three priority nursing diagnoses with supporting assessment data and NANDA-I taxonomy; (2) SMART goals and expected outcomes for each nursing diagnosis with specific timeframes; (3) Evidence-based nursing interventions with rationales citing current psychiatric nursing literature; (4) Evaluation criteria for measuring goal achievement and treatment effectiveness; (5) Patient education plan addressing PTSD symptom management, coping skill development, and community resource utilization. Incorporate trauma-informed care principles throughout your care plan and address cultural considerations relevant to Ms. Diaz’s background. Include a minimum of five scholarly sources published between 2020 and 2026.