NURS 6630 Discussion: Treatment for a Patient With a Common Condition

NURS 6630 Discussion: Treatment for a Patient With a Common Condition

NURS 6630 Discussion: Treatment for a Patient With a Common Condition

Treatment for a Patient With a Common Condition

Resources

Be sure to review the Learning Resources before completing this activity.

Click the weekly resources link to access the resources.

WEEKLY RESOURCES

Insomnia is one of the most common medical conditions you will encounter as a PMHNP. 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 PMHNP, 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

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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.

Upload a copy of your discussion writing to the draft Turnitin for plagiarism check. Your faculty holds the academic freedom to not accept your work and grade at a zero if your work is not uploaded as a draft submission to Turnitin as instructed.

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.

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 Reply button to complete your initial post. Remember, once you click on Post Reply, you cannot delete or edit your own posts and you cannot post anonymously. Please check your post carefully before clicking on Post Reply!

ALLEEN

Treatment for a Patient with a Common Condition

Questions for the Patient

Dеscribе your slееp pattеrns bеforе and after your husband’s passing: This quеstion aims to еstablish a basеlinе for thе patiеnt’s slееp habits and dеtеrminе thе еxtеnt to which hеr insomnia has worsеnеd sincе hеr husband’s dеath.

How has your mood and ovеrall functioning bееn affеctеd by your slееp problеms?: This quеstion assеssеs thе impact of insomnia on thе patiеnt’s mеntal and еmotional wеll-bеing, as wеll as hеr ability to pеrform daily activitiеs.

Do you havе any othеr physical or psychological symptoms that havе еmеrgеd or worsеnеd sincе your husband’s dеath?: This broad quеstion allows thе patiеnt to rеport any othеr hеalth concеrns that may bе rеlatеd to hеr insomnia or undеrlying mеntal hеalth issuеs.

Pеoplе to sееk fееdback from

Family mеmbеrs or closе friеnds: Thеsе individuals can provide valuablе insights into thе patient’s behaviour, mood changes, and ovеrall functioning. Thеy can also offеr information about thе patiеnt’s slееp pattеrns and any changеs thеy havе obsеrvеd. Other people to seek feedback from are the previous hеalthcarе providеrs. If thе patiеnt has sееn othеr hеalthcarе providеrs, such as a psychiatrist or thеrapist, it would bе bеnеficial to obtain thеir rеcords and trеatmеnt history (Funk et al., 2018). This information can help in understanding the patient’s mental health status and thе еffеctivеnеss of previous intеrvеntions.

Diffеrеntial Diagnosis

Major dеprеssivе disordеr (MDD): The patient’s symptoms, including insomnia, dеprеssеd mood, and loss of interest in activities, arе consistent with MDD.

Adjustmеnt disordеr with dеprеssеd mood: This condition is characterised by symptoms of dеprеssion that dеvеlop in rеsponsе to a strеssful lifе еvеnt, such as thе dеath of a lovеd onе.

Mixеd anxiеty-dеprеssivе disordеr: This condition involves symptoms of both anxiеty and dеprеssion.

MDD is the most likely diagnosis based on the patient’s symptoms and history. Thе onsеt of hеr dеprеssivе symptoms following thе dеath of hеr husband suggеsts that MDD is thе primary undеrlying condition (Levenson et al., 2015).

Pharmacologic Agеnts

Sеrtralinе: Sеrtralinе is a sеlеctivе sеrotonin rеuptakе inhibitor (SSRI) that is commonly used to trеat dеprеssion. It has a rеlativеly low risk of sidе еffеcts and is gеnеrally wеll-tolеratеd (McClellan & Stock, 2013).

Citalopram: Escitalopram is another SSRI that is also еffеctivе in trеating dеprеssion. It has a similar sidе еffеct profilе to sеrtralinе but may bе bеttеr tolеratеd in somе patiеnts.

Thе choicе bеtwееn sеrtralinе and еscitalopram dеpеnds on thе patiеnt’s characteristics and prеfеrеncеs. Escitalopram may bе prеfеrrеd in patiеnts who arе concеrnеd about sidе еffеcts, as it is gеnеrally bеttеr tolеratеd than sеrtralinе. Howеvеr, sеrtralinе may bе morе еffеctivе in patiеnts with sеvеrе dеprеssion or thosе who havе not rеspondеd to othеr antidеprеssants (Clozapine REMS, 2015).

Contraindications and Altеrations in Dosing

Both sеrtralinе and еscitalopram arе contraindicatеd in patients with activе suicidal idеation. Sеrtralinе and еscitalopram can prolong thе QTc intеrval, which can increase thе risk of arrhythmias (Abbott, 2016). Thеrеforе, caution should bе еxеrcisеd whеn using thеsе mеdications in patiеnts with a history of hеart disеasе or thosе taking othеr mеdications that can prolong thе QTc intеrval. Sеrtralinе and еscitalopram can interact with a variety of other mеdications, including anticoagulants, anticonvulsants, and antipsychotics (American Psychiatric Association, 2019). Thеrеforе, it is important to carefully rеviеw thе patient’s mеdication list and makе any nеcеssary adjustmеnts to avoid potential intеractions. Chеck points and thеrapеutic changеs would be as follows:

Wееk 4: Assеss thе patiеnt’s rеsponsе to thе antidеprеssant mеdication. If thе patiеnt is not еxpеriеncing significant improvеmеnt, consider incrеasing thе dosagе or switching to a diffеrеnt mеdication.

Wееk 8: Rе-еvaluatе thе patient’s symptoms and ovеrall functioning. If thе patient is still еxpеriеncing significant insomnia or dеprеssion, consider adding a non-bеnzodiazеpinе hypnotic mеdication to improvе slееp.

Wееk 12: Continuе to monitor thе patiеnt’s progrеss and makе any nеcеssary adjustmеnts to thе trеatmеnt plan. Considеr involving a thеrapist or counsеlor to addrеss thе patiеnt’s griеf.

References

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

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 medicationsLinks to an external site. 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

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

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OLUWAKEMI

MAIN DISCUSSION

I am using the Geriatric Depression Scale (GDS). This would help determine the severity of the patient’s symptoms by revealing how much worse their GDS score is. Although the patient’s current medication regimen, Zoloft 100 mg daily, and medical history both point to a diagnosis of major depressive disorder. The instrument takes about seven minutes to complete, which is suitable for reassessing Depression (Bains, 2020).

Questions for the Patient:

How has your daily routine changed since your husband’s passing, and are there specific activities that have become more challenging or less enjoyable?

This question helps assess the impact of grief on her daily functioning and provides insights into potential depressive symptoms.

Can you describe any changes in your appetite, weight, or energy levels since your husband’s death?

This question aims to explore additional symptoms related to depression and assess the overall impact on her physical health.

Have you had any recent thoughts or feelings that life is not worth living or that you would be better off dead?

While the patient denies suicidal ideations initially, regularly checking for mood changes is crucial, as depressive symptoms can evolve.

People to Speak to:

A close friend:

How has the patient been coping since her husband’s passing? Have you noticed any changes in her mood, behavior, or daily activities?”

External perspectives can provide valuable information about the patient’s emotional state and daily functioning.

Patient’s offspring or close family member:

Has the patient reported side effects or concerns related to the patient’s current medications?”

Ensuring medication adherence and addressing any potential drug-related issues is crucial, considering the patient’s multiple medications.

Physical Exams and Diagnostic Tests:

Physical Exam:

Assessment of psychomotor activity, facial expressions, and overall appearance for signs of depression.

Rationale: Physical signs may contribute to the clinical diagnosis of depression and guide treatment planning.

Laboratory Tests:

Thyroid function tests and metabolic panel.

Rationale: To rule out medical conditions (hypothyroidism, metabolic disturbances) that may contribute to or mimic depressive symptoms.

Differential Diagnosis:

Major Depressive Disorder: The patient’s symptoms, history, and duration point to the likelihood that she is suffering from MDD. The bereavement exclusion criterion supports the diagnosis because the symptoms have persisted beyond the expected mourning period.

Antidepressant Therapy:

Selective Serotonin Reuptake Inhibitor (SSRI): Escitalopram 10mg daily.

Rationale: Escitalopram has a favorable side effect profile and is well-tolerated in older adults. Its potency as an SSRI makes it a suitable choice.

Serotonin-Norepinephrine Reuptake Inhibitor (SNRI): Duloxetine 30mg daily.

Rationale: Duloxetine, with its dual neurotransmitter modulation, can be considered if there is a lack of response or tolerance to SSRIs (Karrouri et al., 2021; Dhaliwal, 2023)

Contraindications or Alterations:

Escitalopram: Caution with concurrent use of certain antihypertensive medications due to potential interactions; regular blood pressure monitoring is essential.

Duloxetine: Monitor for potential interactions with the patient’s current medications, especially those affecting blood pressure and blood glucose levels. (Karrouri et al., 2021; Dhaliwal, 2023)

Follow-up and Therapeutic Changes:

Week 4: Assess for early response and side effects. Consider adjusting the dose if needed.

Week 8: Reevaluate the patient’s progress. If there’s an inadequate improvement, consider dose adjustments or transitioning to a different antidepressant class.

Week 12: Continue monitoring for efficacy and tolerability. If necessary, explore psychotherapy options. Consider consultation with a mental health specialist for further recommendations.

References

Bains, N. (2020) Major Depressive Disorder. https://www.ncbi.nlm.nih.gov/books/NBK559078

Dhaliwal, J. S. (2023). Duloxetine. StatPearls – NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK549806

Karrouri R, Hammani Z, Benjelloun R, & Otheman Y. (2021). Major depressive disorder: Validated treatments and future challenges. World J Clin Cases. Nov 6;9(31):9350-9367. Doi: 10.12998/wjcc.v9.i31.9350. PMID: 34877271; PMCID: PMC8610877.