Feb 23, 2024 NURS 6630 Assessing and Treating Patients With Sleep Disorders
A Sample Answer For the Assignment: NURS 6630 Assessing and Treating Patients With Sleep Disorders
The patient is a male patient who is 31 years old and has insomnia. Since he lost his fiancé, the sleeplessness has been worse over the past six months. The patient claimed that although he hasn’t always been a “great sleeper,” he now has trouble going to sleep or staying asleep at night.
The patient claims that his inability to sleep is now impairing his performance at work as a forklift operator at a chemical plant, where he is dozing off in the course of his duties. He usually takes diphenhydramine to fall asleep, but the morning after is unpleasant.
Review of the patient’s medical file reveals that he has a history of opiate usage dating back more than 4 years, when he was prescribed hydrocodone for an ankle fracture sustained in a skiing accident. Prior to going to bed, the patient has been consuming about 4 beers and using diphenhydramine to put him to sleep.
The patient is awake, alert, and aware of place, time, people, and events. The patient denies experiencing auditory or visual hallucinations and is adequately dressed. He is future-focused, denies SI or HI, and has sound insight and judgment.
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Decision one
The patient was first given 50 mg of trazodone PO at bedtime. Trazodone is a drug that belongs to the category of a serotonin reuptake inhibitor and antagonist. Trazodone is an off-label treatment for insomnia and has FDA approval as an antidepressant. For those with chronic alcohol use like the patient in question, trazodone is a secure pharmaceutical option. Alcohol consumption may not interact with hydroxyzine or zolpidem to provide an additional sedative effect.
Since the patient has been taking diphenhydramine as a supplement, hydroxyzine may not be as beneficial because it works on comparable receptors. Zolpidem may cause sleepwalking and other unusual sleep habits, which are undesirable side effects. The option with less negative effects was trazodone. Trazodone may be able to address two issues since the patient also sounds like he may be having difficulties adjusting to the death of his fiancé.
Alcohol and substance abuse can be a bad coping mechanism for depressive disorders, and depression and sleeplessness are frequently co-occurring disorders. As the other two do not have antidepressant characteristics and can cause further sedations when combined with alcohol, trazodone would be the better option. Zolpidem in combination with alcohol can lead to further respiratory depression and death (Jaffer et al., 2017).
Decision two
When the patient comes back two weeks later, he says the drug works great but gives him a 15-minute erection when he wakes up. The patient additionally claims that this makes it challenging to prepare for work. He rejects auditory and visual hallucinations and is future oriented. The decision was made to reduce the dosage of trazodone to 25 mg once a day at bedtime.
An erection that lasts longer than four hours is known as priapism and is a side effect of the drug trazodone. Since the patient is still developing, lowering the dose may reduce that side effect and be a safer alternative than using the other two drugs (Settimo et al., 2018).
When the patient comes back two weeks later, he says the drug works great but gives him a 15-minute erection when he wakes up. The patient additionally claims that this makes it challenging to prepare for work. He rejects auditory and visual hallucinations and is future oriented. The decision was made to reduce the dosage of trazodone to 25 mg once a day at bedtime.
An erection that lasts longer than four hours is known as priapism and is a side effect of the drug trazodone. Since the patient is still developing, lowering the dose may reduce that side effect and be a safer alternative than using the other two drugs (Schifano et al., 2022).
Decision three
The patient returns to the clinic two weeks after the trazodone dosage is reduced and notes that while the trazodone is good for promoting sleep, the 25mg dose is occasionally insufficient for a full night’s rest. He rejects auditory or visual hallucinations and is future oriented. The choices were to keep taking the medication, encourage good sleeping habits, or return in four weeks. Stop taking trazodone and replace it with remolten 8 mg at bedtime.
Follow up in four weeks. Trazodone should be stopped, and hydroxyzine 50 mg should be prescribed at bedtime, with a follow-up after 4 weeks. The decision was made to advocate good sleeping habits and then reevaluate in four weeks. Because the trazodone was effective and he had only sometimes complained of not being able to sleep through the night, it was decided to continue using it.
If the medicine is changed, the patient may become irritated and less likely to follow instructions because it may be necessary to try several different medications and doses and run into options that don’t work (Krzystanek et al., 2020).
Because hydroxyzine has CNS depressive and sedative effects that may intensify with alcohol, causing dizziness and stumbling and a hangover effect the next morning, it is not a viable alternative to diphenhydramine. Ramelteon is a highly selective melatonin receptor agonist for MTI and MT2.This medicine may help with insomnia and enhance several aspects of sleep.
Alcohol and ramalteon both intensify each other’s effects. Ramelteon was not chosen due to the increased side effects of the drug and alcohol as well as the fact that trazodone is effective and only rarely causes interrupted sleep, making it unwise to start a new treatment (Uchiyama et al., 2019).
Conclusion
Insomnia can accompany depression or cause it, as well as result in poor work performance, anxiety, and substance abuse. The guy has been grieving the loss of his fiancé for six months and has trouble sleeping. Trazodone is an effective sedative antidepressant that affects serotonin neurotransmitters and can help with depression and sleep-related issues. The histamine class of drugs includes hydroxyzine, and the patient has been using diphenhydramine with minimal effects and lingering effects of lethargy the next day.
Since trazodone had some negative effects, reducing the dose could lessen them while maintaining the medication’s current level of effectiveness. Poor sleep hygiene can reduce most people’s capacity to sleep, making it a crucial factor to consider. Changing a patient’s drug regimen on a regular basis can result in noncompliance and frustration if the patient continues to experience unwanted side effects (Riemann et al., 2017).
References
Jaffer, K. Y., Chang, T., Vanle, B., Dang, J., Steiner, A. J., Loera, N., … & Ishak, W. W. (2017). Trazodone for insomnia: a systematic review. Innovations in Clinical Neuroscience, 14(7-8), 24. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5842888/
Krzystanek, M., Krysta, K., & Pałasz, A. (2020). First generation antihistaminic drugs used in the treatment of insomnia–superstitions and evidence. Pharmacotherapy in Psychiatry and Neurology/Farmakoterapia w Psychiatrii i Neurologii, 36(1), 33- 40. Doi:10.33450/fpn.2020.04.003
Riemann, D., Baglioni, C., Bassetti, C., Bjorvatn, B., Dolenc Groselj, L., Ellis, J. G., … & Spiegelhalder, K. (2017). European guideline for the diagnosis and treatment of insomnia. Journal of Sleep Research, 26(6), 675-700. Doi: 10.1111/jsr.12594.
Schifano, N., Capogrosso, P., Boeri, L., Fallara, G., Cakir, O. O., Castiglione, F., … & Salonia, A. (2022). Medications mostly associated with priapism events: Assessment of the 2015–2020 Food and Drug Administration (FDA) pharmacovigilance database entries. International Journal of Impotence Research, 1-5. Doi: 10.1038/s41443-022- 00583-3
Settimo, L., & Taylor, D. (2018). Evaluating the dose-dependent mechanism of action of trazodone by estimation of occupancies for different brain neurotransmitter targets. Journal of Psychopharmacology, 32(1), 96-104. Doi: 10.1177/0269881117742101
Uchiyama, M., Sakamoto, S., & Miyata, K. (2019). Effect of ramelteon on insomnia severity: evaluation of patient characteristics affecting treatment response. Sleep and Biological Rhythms, 17(4), 379-388. https://link.springer.com/article/10.1007/s41105-019-00224-1
The case scenario provided is of a 31year old male whose chief complaint is insomnia that has been worse in the past 6 months. Previously, he reported enjoying restful sleep, although, for the past 6 months, he has experienced difficulties falling and staying asleep.
He even associates the onset of these sleep problems with losing his fiancé, consequently leading to the loss. During the interview with the clinic, he explains that the problem is a bother because it has interfered with his job because he experiences sleepiness during the day, thus affecting his concentration and productivity at the workplace.
He reports recent dependence on alcohol to help him fall asleep. The mental status examination performed on him revealed no abnormality in the orientation appearance, insight, and judgment. A comprehensive assessment of this case study shows that the patient’s insomnia might be related to his psychological dysfunction resulting from losing his fiancé 6months ago.
The sudden loss of a dear one triggers many psychiatric conditions, even if the individual has no prior history of psychiatric conditions (Seiler et al., 2020). One of these psychiatric conditions is depression which is especially triggered by complicated grief. The affected individual would therefore present with low mood, intense sadness, low energy, and loss of interest in activities of pleasure.
They may also report sleep disturbances, with insomnia being more common than hypersomnolence (Hasin et al., 2018). Managing depression through medications or psychotherapy would help to relieve the patient’s symptoms, such as insomnia, that are suspected to arise from depression.
This paper aims to discuss how the patient in the case study was managed by describing the therapeutic options at Decision points 1, point 2, and point 3.
Decision Point One
For the initial management of the patient, I would prescribe 50mg of trazodone be taken orally at bedtime daily. Trazodone is a drug that acts in the brain by reducing the reuptake of different neurochemicals in the brain, such as serotonin. Still, it antagonizes the alpha-1-adrenergic and histamine receptors in the brain (Cuomo et al., 2019).
By so doing, the serotonin levels in the brain and the intensity of their action are increased. Given depression results from an imbalance of brain neurochemicals such as serotonin and norepinephrine, increased serotonin levels resulting from trazodone use can lead to improved serotonergic actions, thus treating depression and its symptoms (Hasin et al., 2018).
When trazodone is prescribed, the symptoms of depression, including insomnia, appetite changes, and mood changes, are corrected (Wang et al., 2020). It would therefore be the first-line medication for this patient.
At decision point one, the foregone options are 10mg zolpidem taken daily or 50mg hydroxyzine taken daily at bedtime. Although zolpidem is effective in managing insomnia by promoting the action of gamma-aminobutyric acid (GABA) in the brain, its side effect profile includes drowsiness, complex sleep-related behavior, and volition, usually limiting its use as a first-line medication for insomnia (Edinoff et al., 2021).
Hydroxyzine has also been foregone because of its anticholinergic effects, such as xerophthalmia and xerostomia (Hasin et al., 2018). Further, neither of these drugs is effective for the management of depression that has been linked with the patient’s insomnia.
The ethical principles require that the health care providers not harm the patient. At point one, increasing the pill burden by prescribing the antidepressants separately from the drugs addressing insomnia would pose the risk of adverse drug reactions and increase poor drug compliance (Bipeta, 2019).
Therefore, the ethical principle of non-maleficence would require the prescription of a single agent that could manage both depressive illness and insomnia (Seiler et al., 2020). As such, trazodone is the preferred medication over the other provided options.
Decision Point Two
After 2 weeks of therapy with 50mg of trazodone at bedtime daily, the patient reports experiencing a prolonged erection in the morning that lasts 15 minutes but is undesired and affects his morning preparation for work, although his sleeping has improved.
At this point, the choice is to be made on addressing the prolonged erection. My decision at this step would be to explain to the patient that this prolonged erection is not priapism and would resolve over time. After that, the current drug dose could be continued for patient care.
One of the undesired side effects of trazodone use is the prolonged erection caused. Through its α-adrenergic antagonism, the drug can dilate vessels in the penis, thus resulting in prolonged erection (Cuomo et al., 2019). The patient in the case study reports such prolonged undesired erection that lasts approximately 15 minutes and thus cannot be considered priapism which usually lasts up to 4 hours (Hasin et al., 2018).
However, the patient requires reassurance about the drug’s side effect profile, especially with the emphasis that the symptoms would dissipate with time (Cuomo et al., 2019). This would enhance adherence to therapy despite the drug’s side effects.
The other options at decision point 2 were either to discontinue trazodone and initiate 10mg suvorexant daily therapy or decrease the trazodone dose to 25mg daily at bedtime. The negative side effect of suvorexant includes daytime drowsiness, thus its contraindication for this patient who operates a forklift.
On the other hand, decreasing the dose of trazodone to 25mg daily may not be adequate to correct insomnia (Seiler et al., 2020). Therefore, patient education on the drug’s side effects and reassurance would be opted for at this step.
At this decision point 2, where the patient reports the drug’s side effects, it would be ethical to truthfully educate him on the drug’s side effects to anticipate. Medications may be discontinued if necessary to prevent more harm to the patient (Bipeta, 2019). These honor the ethical principles of beneficence and non-maleficence.
Decision Point Three
Two weeks after reassuring and educating the patient on the side effects of trazodone, he now reports that the priapism has resolved. However, he now experiences increased drowsiness the next day. His insomnia has also resolved at 50mg of trazodone. At this step, I would continue the patient therapy at 50mg, although the dose is split in half, and the patient is reassessed after a month.
Trazodone is associated with increased drowsiness, which may limit its use, although such side effects are rare or mild. However, when such drowsiness occurs, a reduction of the drug dose by 50% may be necessary, as this may result in a reduction in drowsiness (Cuomo et al., 2019).
The patient should, however, be adequately educated on how to split the drug dose so that the required drug dose is maintained. Further, patient follow-up within 4 weeks would also be indicated to help reassess the effectiveness of the drug and the persistence of the drowsiness at 50% of the dose (Wang et al., 2020).
The other options at decision point 3 included discontinuing trazodone and initiating sonata at 10mg nightly or replacing trazodone with 50mg of hydroxyzine at bedtime. Both options are inappropriate as they involve replacing trazodone, which the patient has shown partial response to. Further, sonata and hydroxyzine have worse side effect profiles that limit their administration in this patient (Hasin et al., 2018).
At this decision point, the ethical principle of patient autonomy may affect further care. For instance, the patient may prefer either sonata or hydroxyzine to the in-use trazodone. They can be prescribed despite their side effect profile (Bipeta, 2019). Such prescription seeks to promote the role of patients in their treatment.
Conclusion
Individuals presenting with any signs and symptoms at the clinic should be suspected and examined for any underlying conditions responsible for such presentation. For instance, a patient with insomnia may have underlying anxiety or depression.
In managing these patients, the drugs prescribed should aim at correcting the underlying psychological disorder instead of addressing the signs and symptoms, such as insomnia. Specifically for this patient, whose insomnia was thought to result from depression due to complicated grief, trazodone, an antidepressant, was prescribed at decision point one because of its effectiveness in managing insomnia (Cuomo et al., 2019).
NURS 6630 Assessing and Treating Patients With Sleep Disorders
When he returns to the clinic with complaints of prolonged erection, the patient would be reassured with the emphasis that the symptoms would disappear with time. The patient would also be adequately educated on the adverse effects of the drugs to encourage drug compliance as they would be anticipating these side effects (Hasin et al., 2018).
After that, when he complains of drowsiness, the drug dose would be reduced by 50% to resolve the symptoms. At either of the steps, the drugs’ side effects profile and effectiveness are compared before an effective drug with the least side effects is prescribed.
References
Bipeta, R. (2019). Legal and ethical aspects of mental health care. Indian Journal of Psychological Medicine, 41(2), 108–112. https://doi.org/10.4103/IJPSYM.IJPSYM_59_19
Cuomo, A., Ballerini, A., Bruni, A. C., Decina, P., Di Sciascio, G., Fiorentini, A., Scaglione, F., Vampini, C., & Fagiolini, A. (2019). Clinical guidance for the use of trazodone in major depressive disorder and concomitant conditions: pharmacology and clinical practice. Rivista Di Psichiatria, 54(4), 137–149. https://doi.org/10.1708/3202.31796
Edinoff, A. N., Wu, N., Ghaffar, Y. T., Prejean, R., Gremillion, R., Cogburn, M., Chami, A. A., Kaye, A. M., & Kaye, A. D. (2021). Zolpidem: Efficacy and side effects for insomnia. Health Psychology Research, 9(1), 24927. https://doi.org/10.52965/001c.24927
Hasin, D. S., Sarvet, A. L., Meyers, J. L., Saha, T. D., Ruan, W. J., Stohl, M., & Grant, B. F. (2018). Epidemiology of adult DSM-5 major depressive disorder and its specifiers in the United States. JAMA Psychiatry (Chicago, Ill.), 75(4), 336. https://doi.org/10.1001/jamapsychiatry.2017.4602
Seiler, A., von Känel, R., & Slavich, G. M. (2020). The psychobiology of bereavement and health: A conceptual review from the perspective of Social Signal Transduction Theory of Depression. Frontiers in Psychiatry, 11, 565239. https://doi.org/10.3389/fpsyt.2020.565239
Wang, J., Liu, S., Zhao, C., Han, H., Chen, X., Tao, J., & Lu, Z. (2020). Effects of trazodone on sleep quality and cognitive function in arteriosclerotic cerebral small vessel disease comorbid with chronic insomnia. Frontiers in Psychiatry, 11, 620. https://doi.org/10.3389/fpsyt.2020.00620
NURS 6630 Assessing and Treating Patients With Sleep Disorders
Sleep disorders are conditions that result in changes in an individual’s pattern of sleep (Mayo Clinic, 2020). Not surprisingly, a sleep disorder can affect an individual’s overall health, safety, and quality of life. Psychiatric nurse practitioners can treat sleep disorders with psychopharmacologic treatments. However, many of these drugs can negatively affect other aspects of a patient’s health and well-being.
Additionally, while psychopharmacologic treatments may be able to address issues with sleep, they can also exert potential challenges with waking patterns. Thus, it is important for the psychiatric nurse practitioner to carefully evaluate the best psychopharmacologic treatments for patients that present with sleep/wake disorders.
Reference:
Mayo Clinic. (2020). Sleep disorders. https://www.mayoclinic.org/diseases-conditions/sleep-disorders/symptoms-causes/syc-20354018
To prepare for this Assignment:
Review this week’s Learning Resources, including the Medication Resources indicated for this week.
Reflect on the psychopharmacologic treatments you might recommend for assessing and treating patients with sleep/wake disorders.
The Assignment: 5 pages
Examine Case Study: Pharmacologic Approaches to the Treatment of Insomnia in a Younger Adult.
You will be asked to make three decisions concerning the medication to prescribe to this patient. Consider factors that might impact the patient’s pharmacokinetic and pharmacodynamic processes.
You should evaluate all options at each decision point before deciding and moving throughout the exercise. Before making your decision, ensure that you have researched each option and evaluated the decision you will select. Be sure to research each option using the primary literature.
Introduction to the case (1 page)
Briefly explain and summarize the case for this Assignment. Be sure to include the specific patient factors that may impact your decision-making when prescribing medication for this patient.
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Decision #1 (1 page)
Which decision did you select?
Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.
Decision #2 (1 page)
Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.
Decision #3 (1 page)
Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.
Conclusion (1 page)
Summarize your recommendations on the treatment options you selected for this patient. Be sure to justify your recommendations and support your response with clinically relevant and patient-specific resources, including the primary literature.
Note: Support your rationale with a minimum of five academic resources. While you may use the course text to support your rationale, it will not count toward the resource requirement. You should be utilizing the primary and secondary literature.
Reminder: The College of Nursing requires that all papers submitted include a title page, introduction, summary, and references. The Sample Paper at the Walden Writing Center provides an example of those required elements (available at https://academicguides.waldenu.edu/writingcenter/templates/general#s-lg-box-20293632). All papers submitted must use this formatting.
For this discussion, the case of a young adult male patient with a history of insomnia has been used. The patient is 31 years old and presents with insomnia as the chief complaint. He reports that the lack of sleep has been getting worse over the past 6 months. According to him, sleeping problems have never created a great concern as he is used to them. However, it has b
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