Feb 23, 2024 Assignment 2: Assessing and Treating Patients With Sleep/Wake Disorders NURS 6630
A Sample Answer For the Assignment: Assignment 2: Assessing and Treating Patients With Sleep/Wake Disorders NURS 6630
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.
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.
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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-
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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
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Introduction to the Case
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 reports enjoying restful sleep although for the past 6months he has experienced both difficulties in falling and staying asleep. He even associates the onset of these sleep problems with the loss of 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 where 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 the loss of his fiancé 6months ago. The sudden loss of a dear one triggers a myriad of 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 the depression through medications or psychotherapy would help to relieve the patient’s symptoms such as insomnia that is suspected to arise from depression. The objective of this paper is 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 to 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 but antagonizing the alpha-1-adrenergic and histamine receptors in the brain (Cuomo et al., 2019). By so doing, the serotonin levels in the brain are increased as well as the intensity of their action.
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 therefore 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 the 10mg zolpidem taken daily at bedtime or 50mg hydroxyzine taken daily at bedtime. Although zolpidem is effective in the management of insomnia by promoting the action of gamma-aminobutyric acid (GABA) in the brain, its side effect profile which includes drowsiness, complex sleep-related behavior and volition usually limit 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 do 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 as well as increase the incidence of poor drug compliance (Bipeta, 2019).
The ethical principle of non-maleficence would therefore require for prescription of a single agent that could manage both depressive illness and insomnia (Seiler et al., 2020). As such, trazodone is the preferred medication to the other provided options.
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 have negative effects on 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.
To prepare for this Assignment:
Examine this week’s Learning Resources, including the Medication Resources listed.
Consider the psychopharmacologic treatments you might suggest for the evaluation and treatment of people with sleep/wake disturbances.
Assignment 2: Assessing and Treating Patients With Sleep/Wake Disorders NURS 4430
The assignment is 5 pages long.
Take a look at Case Study: Pharmacologic Approaches to the Treatment of Insomnia in a Younger Adult.
You will be required to make three decisions on the medication to be prescribed to this patient. Take into account any circumstances that may have an impact on the patient’s pharmacokinetic and pharmacodynamic processes.
At each decision point, consider all choices before making your choice and continuing on with the activity. Choose certain that you have thoroughly examined each alternative and that you have evaluated the decision that you will make. Make careful to conduct primary literature study on each option.
The Case’s Introduction (1 page)
Explain and summarize the case for this Assignment in a few sentences. When recommending medication for this patient, make sure to note any specific patient variables that may influence your decision.
First decision (1 page)
Which option did you choose?
Why did you make this choice? Be detailed in your response and back it up with clinically relevant and patient-specific resources, such as original literature.
Why didn’t you choose the other two options presented in the exercise? Be detailed in your response and back it up with clinically relevant and patient-specific resources, such as original literature.
What were your intentions in making this decision? Provide evidence and references to the Learning Resources to back up your response (including the primary literature).
Explain how ethical issues may affect your treatment approach and patient communication. Provide specifics and instances.
Assignment 2: Assessing and Treating Patients With Sleep/Wake Disorders NURS 4430
Decision No. 2 (1 page)
Why did you make this choice? Be detailed in your response and back it up with clinically relevant and patient-specific resources, such as original literature.
Why didn’t you choose the other two options presented in the exercise? Be detailed, and back up your statement with clinically relevant data. as well as patient-specific resources, such as primary literature
What were your intentions in making this decision? Provide evidence and references to the Learning Resources to back up your response (including the primary literature).
Explain how ethical issues may affect your treatment approach and patient communication. Provide specifics and instances.
Third decision (1 page)
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Why did you make this choice? Be detailed in your response and back it up with clinically relevant and patient-specific resources, such as original literature.
Why didn’t you choose the other two options presented in the exercise? Be detailed in your response and back it up with clinically relevant and patient-specific resources, such as original literature.
What were your intentions in making this decision? Provide evidence and references to the Learning Resources to back up your response (including the primary literature).
Explain how ethical issues may affect your treatment approach and patient communication. Provide specifics and instances.
Conclusion (1 page)
Summarize your thoughts on the therapy options you chose for this patient. Make sure to substantiate your recommendations and back them up with clinically relevant and patient-specific resources, such as primary literature.
Please include at least five academic resources to back up your reasoning. While you may utilize the course content to support your reasoning, it will not count as a resource. You should use both primary and secondary literature.
Assignment 2: Assessing and Treating Patients With Sleep/Wake Disorders NURS 4430
Assignment 2: Assessing and Treating Patients With Sleep/Wake Disorders NURS 6630
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Reminder : The College of Nursing requires that all papers submitted include a title page, introduction, summary, and references. The Sample Paper provided 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.
Psychopharmacological Approaches to Treat Psychopathology
Mental health problems such as insomnia affect the patient’s health and wellbeing. Patients experience reduced quality of life due to the alteration in their daily routines and lifestyles. The adoption of effective interventions to manage sleep disorders is important in nursing practice. Psychiatric mental health nurse practitioners explore the existing best practice interventions that have minimal harm and optimum benefits in ensuring patient’s recovery from their disorders
The purpose of this paper is to examine insomnia case study involving a 31-year-old man. The patient came to the unit with complaints that his insomnia has been worsening over the last six months. The patient has problems with falling asleep. He also finds hard to maintain sleep. He reports that the problems started following the loss of his fiancé. His health problem has affected his functioning significantly.
A further history obtained from him shows that he has used diphenhydramine in the past and he did not like it because of the experiences he has in the morning after its use. He also has an opiate abuse history, which has made him not being prescribed opiates over the last four years. He also reports that he uses alcohol to enhance his quality of sleep. He takes about four beers to enable his sleep. The mental status examination showed results within the normal range. The patient factors that will influence the decisions made in treating this patient include a history of opiate and alcohol abuse and experience with diphenhydramine.
Decision 1
Selected Decision
Administer Trazodone 50 mg PO at bedtime
Reason for the Selection
Trazodone is the recommended drug of choice in patients suffering from insomnia and depression. It works by antagonizing serotonin receptors, which blocks serotonin reuptake transporter. Trazodone also influences cortisol suppression to enhance sleep quality and quantity.
It also has moderate low cholinergic activity and acts as an antihistamine to improve insomnia symptoms. Trazodone also enhances slow-wave sleep to reduce insomnia symptoms (Rios et al., 2019; Yi et al., 2018). It has minimal side effects such as hangovers, hence, its appropriateness for the patient.
Why others were not selected
I did not select Zolpidem 10 mg daily at bedtime for the client due to its associated risks such as hangover symptoms. Patients often experience symptoms such as feeling drugged and dizzy following Zolpidem use. The patient may not adhere to the treatment due to the above side effects, as he stopped using diphenhydramine in the past due to similar experiences (Xiang et al., 2021).
Hydroxyzine 50 mg daily at bedtime was also not selected due to its associated anxiolytic side effects such as confusion, drowsiness, and fatigue that may affect treatment adherence and the overall functioning of the patient (Terada et al., 2022).
Expected Outcomes
I selected the above decision intending to improve insomnia symptoms due to the effects of Trazodone. The therapeutic effectiveness of Trazodone such as inhibiting serotonin reuptake improves the quantity and quality of sleep (Wang et al., 2020). I was also expecting minimal side effects that would enhance treatment adherence.
Ethical Considerations
Treating psychiatric conditions should entail weighing the benefits and risks of the available alternatives. The therapeutic efficacy of Trazodone is higher than that of Hydroxyzine and Zolpidem. As a result, as a psychiatric mental health nurse practitioner, a focus should be on ensuring treatments that have minimal harm and optimum benefits to the patient (Rios et al., 2019). Through it, non-maleficence and benevolence were promoted in the treatment process.
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Assignment 2: Assessing and Treating Patients With Sleep/Wake Disorders NURS 4430
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