Discussion: Treatment for a Patient With a Common Condition NURS 4430

NURS 6630 Week 7: Therapy for Patients With Schizophrenia
Discussion: Treatment for a Patient With a Common Condition NURS 4430
Discussion: Treatment for a Patient With a Common Condition NURS 4430
Insomnia is one of the most common medical conditions you will encounter as a PNP. Insomnia is a common symptom of many mental illnesses, including anxiety, depression, schizophrenia, and ADHD (Abbott, 2016). Various studies have demonstrated the bidirectional relationship between insomnia and mental illness. In fact, about 50% of adults with insomnia have a mental health problem, while up to 90% of adults with depression experience sleep problems (Abbott, 2016). Due to the interconnected psychopathology, it is important that you, as the PNP, understand the importance of the effects some psychopharmacologic treatments may have on a patient’s mental health illness and their sleep patterns. Therefore, it is important that you understand and reflect on the evidence-based research in developing treatment plans to recommend proper sleep practices to your patients as well as recommend appropriate psychopharmacologic treatments for optimal health and well-being.
Reference: Abbott, J. (2016). What’s the link between insomnia and mental illness? Health. https://www.sciencealert.com/what-exactly-is-the-link-between-insomnia-and-mental-illness#:~:text=Sleep%20problems%20such%20as%20insomnia%20are%20a%20common,bipolar%20disorder%2C%20and%20attention%20deficit%20hyperactivity%20disorder%20%28ADHD%29
For this Discussion, review the case Learning Resources and the case study excerpt presented. Reflect on the case study excerpt and consider the therapy approaches you might take to assess, diagnose, and treat the patient’s health needs.
According to the Schizophrenia and Related Disorders Alliance of America, approximately 3.5 million people in the United States are diagnosed with schizophrenia (n.d.), and it is one of the leading causes of disability. In practice, patients may present with delusions, hallucinations, disorganized thinking, disorganized or abnormal motor behavior, as well as other negative symptoms that can be disabling for these individuals. Not only are these symptoms one of the most challenging symptom clusters you will encounter, many are associated with other disorders, such as depression, bipolar disorder, and disorders on the schizophrenia spectrum. As a psychiatric nurse practitioner, you must understand the underlying neurobiology of these symptoms to select appropriate therapies and improve outcomes for patients.
This week, as you examine antipsychotic therapies, you explore the assessment and treatment of patients with psychosis and schizophrenia. You also consider ethical and legal implications of these therapies.
Reference:
Schizophrenia and Related Disorders Alliance of America. (n.d.). About schizophrenia.https://sardaa.org/resources/about-schizophrenia/#:~:text=Quick%20Facts%20About%20Schizophrenia.%20Schizophrenia%20can%20be%20found,is%20one%20of%20the%20leading%20causes%20of%20disability
Learning Objectives
Students will:
Assess client factors and history to develop personalized therapy plans for patients with insomnia
Analyze factors that influence pharmacokinetic and pharmacodynamic processes in patients requiring therapy for insomnia
Assess patient factors and history to develop personalized plans of antipsychotic therapy for patients
Analyze factors that influence pharmacokinetic and pharmacodynamic processes in patients requiring antipsychotic therapy
Synthesize knowledge of providing care to patients presenting for antipsychotic therapy
Analyze ethical and legal implications related to prescribing antipsychotic therapy to patients across the lifespan
Learning Resources
Required Readings (click to expand/reduce)
Freudenreich, O., Goff, D. C., & Henderson, D. C. (2016). Antipsychotic drugs. In T. A. Stern, M. Favo, T. E. Wilens, & J. F. Rosenbaum. (Eds.), Massachusetts General Hospital psychopharmacology and neurotherapeutics (pp. 72–85). Elsevier.
American Psychiatric Association. (2019). Practice guideline for the treatment of patients with schizophrenia. https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/Clinical%20Practice%20Guidelines/APA-Draft-Schizophrenia-Treatment-Guideline.pdf
Clozapine REMS. (2015). Clozapine REMS: The single shared system for clozapine. https://www.clozapinerems.com/CpmgClozapineUI/rems/pdf/resources/Clozapine_REMS_A_Guide_for_Healthcare_Providers.pdf
Funk, M. C., Beach, S. R., Bostwick, J. R., Celano, C. M., Hasnain, M., Pandurangi, A., Khandai, A., Taylor, A., Levenson, J. L., Riba, M., & Kovacs, R. J. (2018). Resource document on QTc prolongation and psychotropic medications. American Psychiatric Association. https://www.psychiatry.org/File%20Library/Psychiatrists/Directories/Library-and-Archive/resource_documents/Resource-Document-2018-QTc-Prolongation-and-Psychotropic-Med.pdf
Kay, S. R., Fiszbein, A., & Opler, L. A. (1987). The Positive and Negative Syndrome Scale (PANSS) for schizophrenia. Schizophrenia Bulletin, 13(2), 261–276. https://doi.org/10.1093/schbul/13.2.261
Levenson, J. C., Kay, D. B., & Buysse, D. J. (2015). The pathophysiology of insomnia. Chest, 147(4), 1179–1192. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4388122/
McClellan, J. & Stock. S. (2013). Practice parameter for the assessment and treatment of children and adolescents with schizophrenia. Journal of the American Academy of Child and Adolescent Psychiatry, 52(9), 976–990. https://www.jaacap.org/article/S0890-8567(09)62600-9/pdf
Naber, D., & Lambert, M. (2009). The CATIE and CUtLASS studies in schizophrenia: Results and implications for clinicians. CNS Drugs, 23(8), 649–659. https://doi.org/10.2165/00023210-200923080-00002
Medication Resources (click to expand/reduce)
IBM Corporation. (2020). IBM Micromedex. https://www.micromedexsolutions.com/micromedex2/librarian/deeplinkaccess?source=deepLink&institution=SZMC%5ESZMC%5ET43537
Note: To access the following medications, use the IBM Micromedex resource. Type the name of each medication in the keyword search bar. Be sure to read all sections on the left navigation bar related to each medication’s result page, as this information will be helpful for your review in preparation for your Assignments.
amisulpride
aripiprazole
asenapine
brexpiprazole
cariprazine
chlorpromazine
clozapine
flupenthixol
fluphenazine
haloperidol
iloperidone
loxapine
lumateperone
lurasidone
olanzapine
paliperidone
perphenazine
pimavanserin
quetiapine
risperidone
sulpiride
thioridazine
thiothixene
trifluoperazine
ziprasidone
Required Media (click to expand/reduce)
Case study: Pakistani woman with delusional thought processes
Note: This case study will serve as the foundation for this week’s Assignment.
Optional Resources (click to expand/reduce)
Chakos, M., Patel, J. K., Rosenheck, R., Glick, I. D., Hammer, M. B., Tapp, A., Miller, A. L., & Miller, D. D. (2011). Concomitant psychotropic medication use during treatment of schizophrenia patients: Longitudinal results from the CATIE study. Clinical Schizophrenia & Related Psychoses, 5(3), 124–134. https://doi.org/10.3371/CSRP.5.3.2
Fangfang, S., Stock, E. M., Copeland, L. A., Zeber, J. E., Ahmedani, B. K., & Morissette, S. B. (2014). Polypharmacy with antipsychotic drugs in patients with schizophrenia: Trends in multiple health care systems. American Journal of Health-System Pharmacy, 71(9), 728–738. https://doi.org/10.2146/ajhp130471
Lin, L. A., Rosenheck, R., Sugar, C., & Zbrozek, A. (2015). Comparing antipsychotic treatments for schizophrenia: A health state approach. The Psychiatric Quarterly, 86(1), 107–121. https://doi.org/10.1007/s11126-014-9326-2
https://nursingpaperslayers.com/discussion-treatment-for-a-patient-with-a-common-condition-nurs-4430/
Discussion: Treatment for a Patient With a Common Condition
Insomnia is one of the most common medical conditions you will encounter as a PNP. Insomnia is a common symptom of many mental illnesses, including anxiety, depression, schizophrenia, and ADHD (Abbott, 2016). Various studies have demonstrated the bidirectional relationship between insomnia and mental illness. In fact, about 50% of adults with insomnia have a mental health problem, while up to 90% of adults with depression experience sleep problems (Abbott, 2016). Due to the interconnected psychopathology, it is important that you, as the PNP, understand the importance of the effects some psychopharmacologic treatments may have on a patient’s mental health illness and their sleep patterns. Therefore, it is important that you understand and reflect on the evidence-based research in developing treatment plans to recommend proper sleep practices to your patients as well as recommend appropriate psychopharmacologic treatments for optimal health and well-being.
Reference: Abbott, J. (2016). What’s the link between insomnia and mental illness? Health. https://www.sciencealert.com/what-exactly-is-the-link-between-insomnia-and-mental-illness#:~:text=Sleep%20problems%20such%20as%20insomnia%20are%20a%20common,bipolar%20disorder%2C%20and%20attention%20deficit%20hyperactivity%20disorder%20%28ADHD%29
For this Discussion, review the case Learning Resources and the case study excerpt presented. Reflect on the case study excerpt and consider the therapy approaches you might take to assess, diagnose, and treat the patient’s health needs.
Case: An elderly widow who just lost her spouse.
Subjective: A patient presents to your primary care office today with chief complaint of insomnia. Patient is 75 YO with PMH of DM, HTN, and MDD. Her husband of 41 years passed away 10 months ago. Since then, she states her depression has gotten worse as well as her sleep habits. The patient has no previous history of depression prior to her husband’s death. She is awake, alert, and oriented x3. Patient normally sees PCP once or twice a year. Patient denies any suicidal ideations. Patient arrived at the office today by private vehicle. Patient currently takes the following medications:
Metformin 500mg BID
Januvia 100mg daily
Losartan 100mg daily
HCTZ 25mg daily
Sertraline 100mg daily
Current weight: 88 kg
Current height: 64 inches
Temp: 98.6 degrees F
BP: 132/86
By Day 3 of Week 7
Post a response to each of the following:
List three questions you might ask the patient if she were in your office. Provide a rationale for why you might ask these questions.
Identify people in the patient’s life you would need to speak to or get feedback from to further assess the patient’s situation. Include specific questions you might ask these people and why.
Explain what, if any, physical exams, and diagnostic tests would be appropriate for the patient and how the results would be used.
List a differential diagnosis for the patient. Identify the one that you think is most likely and explain why.
List two pharmacologic agents and their dosing that would be appropriate for the patient’s antidepressant therapy based on pharmacokinetics and pharmacodynamics. From a mechanism of action perspective, provide a rationale for why you might choose one agent over the other.
For the drug therapy you select, identify any contraindications to use or alterations in dosing that may need to be considered based on ethical prescribing or decision-making. Discuss why the contraindication/alteration you identify exists. That is, what would be problematic with the use of this drug in individuals based on ethical prescribing guidelines or decision-making?
Include any “check points” (i.e., follow-up data at Week 4, 8, 12, etc.), and indicate any therapeutic changes that you might make based on possible outcomes that may happen given your treatment options chosen.
Read a selection of your colleagues’ responses.
By Day 6 of Week 7
Respond to at least two of your colleagues on two different days in one of the following ways:
If your colleagues’ posts influenced your understanding of these concepts, be sure to share how and why. Include additional insights you gained.
If you think your colleagues might have misunderstood these concepts, offer your alternative perspective and be sure to provide an explanation for them. Include resources to support your perspective.Read a selection of your colleagues’ responses and respond to at least two of your colleagues on two different days and
Note: For this Discussion, you are required to complete your initial post before you will be able to view and respond to your colleagues’ postings. Begin by clicking on the “Post to Discussion Question” link and then select “Create Thread” to complete your initial post. Remember, once you click on Submit, you cannot delete or edit your own posts, and you cannot post anonymously. Please check your post carefully before clicking on Submit!
Submission and Grading Information
Grading Criteria
To access your rubric:
Week 7 Discussion Rubric
Post by Day 3 of Week 7 and Respond by Day 6 of Week 7
To Participate in this Discussion:
Week 7 Discussion
Case: An elderly widow who just lost her spouse.
Subjective: A patient presents to your primary care office today with chief complaint of insomnia. Patient is 75 YO with PMH of DM, HTN, and MDD. Her husband of 41 years passed away 10 months ago. Since then, she states her depression has gotten worse as well as her sleep habits. The patient has no previous history of depression prior to her husband’s death. She is awake, alert, and oriented x3. Patient normally sees PCP once or twice a year. Patient denies any suicidal ideations. Patient arrived at the office today by private vehicle. Patient currently takes the following medications:
Metformin 500mg BID
Januvia 100mg daily
Losartan 100mg daily
HCTZ 25mg daily
Sertraline 100mg daily
Current weight: 88 kg
Current height: 64 inches
Temp: 98.6 degrees F
BP: 132/86
By Day 3 of Week 7
Post a response to each of the following:
List three questions you might ask the patient if she were in your office. Provide a rationale for why you might ask these questions.
Identify people in the patient’s life you would need to speak to or get feedback from to further assess the patient’s situation. Include specific questions you might ask these people and why.
Explain what, if any, physical exams, and diagnostic tests would be appropriate for the patient and how the results would be used.
List a differential diagnosis for the patient. Identify the one that you think is most likely and explain why.
List two pharmacologic agents and their dosing that would be appropriate for the patient’s antidepressant therapy based on pharmacokinetics and pharmacodynamics. From a mechanism of action perspective, provide a rationale for why you might choose one agent over the other.
For the drug therapy you select, identify any contraindications to use or alterations in dosing that may need to be considered based on the client’s ethnicity. Discuss why the contraindication/alteration you identify exists. That is, what would be problematic with the use of this drug in individuals of other ethnicities?
Include any “check points” (i.e., follow-up data at Week 4, 8, 12, etc.), and indicate any therapeutic changes that you might make based on possible outcomes that may happen given your treatment options chosen.
Read a selection of your colleagues’ responses.
By Day 6 of Week 7
Respond to at least two of your colleagues on two different days in one of the following ways:
If your colleagues’ posts influenced your understanding of these concepts, be sure to share how and why. Include additional insights you gained.
If you think your colleagues might have misunderstood these concepts, offer your alternative perspective and be sure to provide an explanation for them. Include resources to support your perspective.Read a selection of your colleagues’ responses and respond to at least two of your colleagues on two different days and
Note: For this Discussion, you are required to complete your initial post before you will be able to view and respond to your colleagues’ postings. Begin by clicking on the “Post to Discussion Question” link and then select “Create Thread” to complete your initial post. Remember, once you click on Submit, you cannot delete or edit your own posts, and you cannot post anonymously. Please check your post carefully before clicking on Submit!
Submission and Grading Information
Grading Criteria
To access your rubric:
Week 7 Discussion Rubric
Post by Day 3 of Week 7 and Respond by Day 6 of Week 7
To Participate in this Discussion:
Week 7 Discussion
RE: Discussion – Week 7
Questions that will be asked to the patient who presents to the clinic with complaints of insomnia include
How many hours of sleep did you get prior to your spouse passing away? (Obtaining a baseline data will help the PNP understand the root cause of the patients insomnia, whether the problem is psychosomatic or caused by a psychiatric illness such as depression or anxiety.)
What activities do you find soothing that could encourage sleep? (Identifying methods by which the patients finds relaxing, will give the PNP perspective on how to tailor treatment and potential medication therapy.)
What recurrent thoughts do you have at night? (The PNP should understand the cause of the patient’s insomnia; obtaining a clear understanding of how the patient feels and things will bring the PNP closer to identifying how to treat the problem).
As a PNP, I would discuss with the patients primary care physician in order to create a narrative of how the patient presents herself outside of seeking psychiatric evaluation and treatment. The PCP will be able to provide his or her professional observation of the patients, compliance with medical treatments and adherence to a healthy lifestyle. The second person or people I would discuss with is the neighbor or close friend of the patient. These individuals would know the patient behaves in private and public settings, organization of her living space, or potential alarming behaviors such as irritability or withdraw from her normal routine.
The mini mental status examination will be given to assess the patients orientation, registration, attention/calculation, recall and language to determine the patients overall baseline functionality within her current stage of insomnia. Secondly, the patients’ health questionnaire will be given to the patient to assess depression (Hughes et al., 2018). The results of the examinations will give the PNP a starting point for dosages of sleep inducing medication based on the severity of lack of functionality or severity of depression and anxiety.
Differential Diagnosis:
Acute stress disorder: a transient reaction that is expected to subside within one week, and encompasses a broad range of mood, anxiety, and behavioral responses that reflect the sudden impact of trauma
Poor sleep hygiene : sleep disturbances that cause clinical stress or behavioral impairment in several important areas of functioning (Becker et al., 2016). I think that the patients active depression episode is caused her to have poor sleep hygiene. Once the patient is able to restart a tolerable routine to induce sleep, her symptoms will resolve.
Treatments
Bupropion (Wellbutrin) 100mg PO daily
Clonazepam 2.5mg PO qhs
Clonazepam would be added as a therapy for this patient because of its anxiolytic affects for patients. Clonazepam is in the benzodiazepine class that has been found to have prophylactic effects against recurrence of depression. Starting the patient at a 2.5mg per day at night dosage will encourage the patients sleep cycle as well as decrease the patient’s depressive symptoms over time (Morishita, 2009).
Contraindications: Patients who have comorbidities including liver disease or narrow angle glaucoma are contraindicated for Clonazepam usage. Clonazepam is metabolized by the liver, therefore without the metabolism of the medication by the liver, there will be an accumulation of the medication causing excess sedation and respiratory distress to the patient. Elderly patients >65 years of age are require lower initial dosages due to increased sensitivity. (Basit and Kahwaji, 2017). Issues that would be problematic with prescribing medication to this patient could include be client dependence on the medication for sleep; the patient does not have any liver problems therefore the patient is a minimal risk for adverse effects.
Therapeutic changes
10. Based on the patients tolerance of the medication based on a two to four week follow up clinic visit, the patient can either be increased on the medication dosage, maintained at the same rate, or change medication regimen. I hope for the patient to report improved sleep, and improved mood from the Clonazepam treatment, based on the side effects that the patient reports, I will adjust the dosage of the medications as tolerated.
References
Basit H and Kahwaji CI. (2017). Clonazepam. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK556010/
Becker, N. et al. (2017). Depression and sleep quality in older adults: a meta-analysis, Psychology, Health & Medicine, 22(8), 889-895, DOI:
Bryant, R. (2017). Acute stress disorder. Current Opinion in Psychology,
14: 127-131. https://doi.org/10.1016/j.copsyc.2017.01.005.
Hughes, J. et al. (2018). Measuring sleep in vulnerable older adults: A comparison of subjective and objective sleep measures. Clinical gerontologist, 41(2), 145–157. https://doi.org/10.1080/07317115.2017.1408734
Morishita, S. (2009). Clonazepam as a therapeutic adjunct to improve the management of depression: a brief review. Hum Psychopharmacology. 24(3):191-8. doi: 10.1002/hup.1015. PMID: 19330803.
NURS_6630_Week7_Discussion_Rubric
Excellent
Point range: 90–100
Good
Point range: 80–89
Fair
Point range: 70–79
Poor
Point range: 0–69
Main Posting:
Response to the Discussion question is reflective with critical analysis and synthesis representative of knowledge gained from the course readings for the module and current credible sources.
40 (40%) – 44 (44%)
Thoroughly responds to the Discussion question(s).
Is reflective with critical analysis and synthesis representative of knowledge gained from the course readings for the module and current credible sources.
No less than 75% of post has exceptional depth and breadth.
Supported by at least three current credible sources.
35 (35%) – 39 (39%)
Responds to most of the Discussion question(s).
Is somewhat reflective with critical analysis and synthesis representative of knowledge gained from the course readings for the module.
50% of the post has exceptional depth and breadth.
Supported by at least three credible references.
31 (31%) – 34 (34%)
Responds to some of the Discussion question(s).
One to two criteria are not addressed or are superficially addressed.
Is somewhat lacking reflection and critical analysis and synthesis.
Somewhat represents knowledge gained from the course readings for the module.
Post is cited with fewer than two credible references.
0 (0%) – 30 (30%)
Does not respond to the Discussion question(s).
Lacks depth or superficially addresses criteria.
Lacks reflection and critical analysis and synthesis.
Does not represent knowledge gained from the course readings for the module.
Contains only one or no credible references.
Main Posting:
Writing
6 (6%) – 6 (6%)
Written clearly and concisely.
Contains no grammatical or spelling errors.
Adheres to current APA manual writing rules and style.
5 (5%) – 5 (5%)
Written concisely.
May contain one to two grammatical or spelling errors.
Adheres to current APA manual writing rules and style.
4 (4%) – 4 (4%)
Written somewhat concisely.
May contain more than two spelling or grammatical errors.
Contains some APA formatting errors.
0 (0%) – 3 (3%)
Not written clearly or concisely.
Contains more than two spelling or grammatical errors.
Does not adhere to current APA manual writing rules and style.
Main Posting:
Timely and full participation
9 (9%) – 10 (10%)
Meets requirements for timely, full, and active participation.
Posts main Discussion by due date.
8 (8%) – 8 (8%)
Posts main Discussion by due date.
Meets requirements for full participation.
7 (7%) – 7 (7%)
Posts main Discussion by due date.
0 (0%) – 6 (6%)
Does not meet requirements for full participation.
Does not post main Discussion by due date.
First Response:
Post to colleague’s main post that is reflective and justified with credible sources.
9 (9%) – 9 (9%)
Response exhibits critical thinking and application to practice settings.
Responds to questions posed by faculty.
The use of scholarly sources to support ideas demonstrates synthesis and understanding of learning objectives.
8 (8%) – 8 (8%)
Response has some depth and may exhibit critical thinking or application to practice setting.
7 (7%) – 7 (7%)
Response is on topic, may have some depth.
0 (0%) – 6 (6%)
Response may not be on topic, lacks depth.
First Response:
Writing
6 (6%) – 6 (6%)
Communication is professional and respectful to colleagues.
Response to faculty questions are fully answered, if posed.
Provides clear, concise opinions and ideas that are supported by two or more credible sources.
Response is effectively written in Standard, Edited English.
5 (5%) – 5 (5%)
Communication is mostly professional and respectful to colleagues.
Response to faculty questions are mostly answered, if posed.
Provides opinions and ideas that are supported by few credible sources.
Response is written in Standard, Edited English.
4 (4%) – 4 (4%)
Response posed in the Discussion may lack effective professional communication.
Response to faculty questions are somewhat answered, if posed.
Few or no credible sources are cited.
0 (0%) – 3 (3%)
Responses posted in the Discussion lack effective communication.
Response to faculty questions are missing.
No credible sources are cited.
First Response:
Timely and full participation
5 (5%) – 5 (5%)
Meets requirements for timely, full, and active participation.
Posts by due date.
4 (4%) – 4 (4%)
Meets requirements for full participation.
Posts by due date.
3 (3%) – 3 (3%)
Posts by due date.
0 (0%) – 2 (2%)
Does not meet requirements for full participation.
Does not post by due date.
Second Response:
Post to colleague’s main post that is reflective and justified with credible sources.
9 (9%) – 9 (9%)
Response exhibits critical thinking and application to practice settings.
Responds to questions posed by faculty.
The use of scholarly sources to support ideas demonstrates synthesis and understanding of learning objectives.
8 (8%) – 8 (8%)
Response has some depth and may exhibit critical thinking or application to practice setting.
7 (7%) – 7 (7%)
Response is on topic, may have some depth.
0 (0%) – 6 (6%)
Response may not be on topic, lacks depth.
Second Response:
Writing
6 (6%) – 6 (6%)
Communication is professional and respectful to colleagues.
Response to faculty questions are fully answered, if posed.
Provides clear, concise opinions and ideas that are supported by two or more credible sources.
Response is effectively written in Standard, Edited English.
5 (5%) – 5 (5%)
Communication is mostly professional and respectful to colleagues.
Response to faculty questions are mostly answered, if posed.
Provides opinions and ideas that are supported by few credible sources.
Response is written in Standard, Edited English.
4 (4%) – 4 (4%)
Response posed in the Discussion may lack effective professional communication.
Response to faculty questions are somewhat answered, if posed.
Few or no credible sources are cited.
0 (0%) – 3 (3%)
Responses posted in the Discussion lack effective communication.
Response to faculty questions are missing.
No credible sources are cited.
Second Response:
Timely and full participation
5 (5%) – 5 (5%)
Meets requirements for timely, full, and active participation.
Posts by due date.
4 (4%) – 4 (4%)
Meets requirements for full participation.
Posts by due date.
3 (3%) – 3 (3%)
Posts by due date.
0 (0%) – 2 (2%)
Does not meet requirements for full participation.
Does not post by due date.
Total Points: 100
Name: NURS_6630_Week7_Discussion_Rubric