Feb 7, 2024 Assignment- Assessing and Treating Clients With Psychosis and Schizophrenia-WK6-63N
Assignment- Assessing and Treating Clients With Psychosis and Schizophrenia-WK6-63N
Assignment- Assessing and Treating Clients With Psychosis and Schizophrenia-WK6-63N
Mental health problems that include schizophrenia affect negatively the patient’s health. Schizophrenia affects the patient’s quality of life by increasing dependence on medications, lowering productivity, and predisposing them to premature mortality. Psychiatric mental health nurse practitioners play essential roles in providing appropriate treatments that minimize the worsening and progression of schizophrenia symptoms. In doing this, they consider the legal and ethical principles of their practice in the process of patient care. Therefore, this paper is a case analysis of a patient diagnosed with schizophrenia, paranoid type.
The patient in the case study is a 34-year-old Pakistani female who has been brought to the unit for psychiatric assessment. She is currently in an arranged marriage. She has a history of 21-day hospitalization due to a brief psychotic disorder since the symptoms persisted for less than a month. The client also has a history of seeing Allah, and false belief of herself, as she considers that she is Prophet Mohammad. She also beliefs that her husband wants to marry an American wife since the television tells her so.
Subjective data shows that she stopped taking Risperdal a week ago because she thinks her husband will poison her so that he can marry an American woman. PANSS was administered, which showed that the client scored 40 for the positive symptoms scale, 20 for the negative symptoms scale, and 60 for the general psychopathology scale. As a result, she was diagnosed with schizophrenia, paranoid type. The patient information that would be crucial for use in decision making includes her PANSS score, history of Risperdal use, obesity, illusions, and family social support systems available to her, as they influence the care outcomes.
Decision 1
Start Invega Sustenna 234 mg intramuscular X1 followed by 156 mg intramuscular on day 4 and monthly thereafter.
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Reason for Selection
Studies have demonstrated that Invega Sustenna is highly effective in managing schizophrenia symptoms. The effectiveness can be seen in Patel et al. (2020) study where Invega Sustenna reduced patient claims for psychoses diagnoses, hypertension, depression, substance-related and addictive disorders, bipolar disorder, anxiety, and sleep-wake disorders. The authors also found a significant reduction in the need for hospital visits, hospitalizations, and costs when patients were initiated on Invega Sustenna rather than Risperidone (Patel et al., 2020). Early treatment of schizophrenia with Invega Sustenna also results in enhanced treatment adherence and social functioning (Cassidy & Miles, 2021). According to Emsley and Kilian (2018), Invega Sustenna provides benefits that include its availability in long-acting injectable formulations and dose initiation, which causes rapid onset of action compared to other antipsychotics.
Why The Other Options Were Not Selected
Zyprexa 10 mg orally at bedtime was not selected because of the increased risk of poor adherence by the patient due to side effects that include memory loss, metabolic deregulation, and changes in the menstrual cycle. The safety risks associated with Zyprexa have made it a second choice of drug in schizophrenia (Citrome et al., 2019). Starting the patient on Abilify 10 mg orally at bedtime was not selected because studies have shown that psychotic symptoms worsen in the patient when switched from other antipsychotics to Abilify. In addition, case studies report the increased risk of adverse events and lack of efficacy with the use of Abilify in schizophrenia patients (Takeuchi et al., 2018).
Expected Outcomes
Invega Sustenna improves schizophrenia symptoms. As a result, I was expecting to witness symptom improvement, as evidenced by improvement in PANSS score, social functioning, and treatment adherence. I also expected minimal side effects associated with Invega Sustenna (Cassidy & Miles, 2021).
Ethical Considerations
Psychiatric mental health nurse practitioners should weigh the benefits and risks associated with the available treatments for mental health disorders. While the given antipsychotics have comparable effectiveness in schizophrenia, priority should be placed on treatment safety. Invega Sustenna demonstrated enhanced efficacy over Zyprexa and Abilify due to its safety in symptom management (Patel et al., 2020).
Assessing and Treating Clients With Psychosis and Schizophrenia. Psychosis and schizophrenia greatly impact the brain’s normal processes, which interferes with the ability to think clearly. When symptoms of these disorders are uncontrolled, clients may struggle to function in daily life. However, clients often thrive when properly diagnosed and treated under the close supervision of a psychiatric mental health practitioner. For this Assignment, as you examine the client case study in this week’s Learning Resources, consider how you might assess and treat clients presenting with psychosis and schizophrenia.
Learning Objectives
Students will:
Assess client factors and history to develop personalized plans of antipsychotic therapy for clients
Analyze factors that influence pharmacokinetic and pharmacodynamic processes in clients requiring antipsychotic therapy
Evaluate efficacy of treatment plans
Analyze ethical and legal implications related to prescribing antipsychotic therapy to clients across the lifespan
To prepare for the Assessing and Treating Clients With Psychosis and Schizophrenia Assignment:
Review this week’s Learning Resources. Consider how to assess and treat clients requiring anxiolytic therapy.
The Assessing and Treating Clients With Psychosis and Schizophrenia Assignment
The Assignment: 5 pages
Examine Case Study: Pakistani Woman With Delusional Thought Processes. You will be asked to make three decisions concerning the medication to prescribe to this patient. Be sure to consider factors that might impact the patient’s pharmacokinetic and pharmacodynamic processes.
At each decision point, you should evaluate all options before selecting your decision and moving throughout the exercise. Before you make your decision, make sure that you have researched each option and that you evaluate the decision that 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.
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 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.
By Day 7
Submit your Assignment.
Submission and Grading Information
To submit your completed Assignment for review and grading, do the following:
Please save your Assignment using the naming convention “WK7Assgn+last name+first initial.(extension)” as the name.
Click the Week 7 Assignment Rubric to review the Grading Criteria for the Assignment.
Click the Week 7 Assignment link. You will also be able to “View Rubric” for grading criteria from this area.
Next, from the Attach File area, click on the Browse My Computer button. Find the document you saved as “WK7Assgn+last name+first initial.(extension)” and click Open.
If applicable: From the Plagiarism Tools area, click the checkbox for I agree to submit my paper(s) to the Global Reference Database.
Click on the Submit button to complete your submission.
Also include how ethical considerations might impact your treatment plan and communication with clients.
Note: Support your rationale with a minimum of three academic resources. While you may use the course text to support your rationale, it will not count toward the resource requirement.
CASE STUDY: Assessing and Treating Clients With Psychosis and Schizophrenia
Examine Case Study: Pakistani Woman with Delusional Thought Processes.
BACKGROUND
The client is a 34-year-old Pakistani female who moved to the United States in her late teens/early 20s. She is currently in an “arranged” marriage (her husband was selected for her since she was 9 years old). She presents to your office today following a 21 day hospitalization for what was diagnosed as “brief psychotic disorder.” She was given this diagnosis as her symptoms have persisted for less than 1 month.
Prior to admission, she was reporting visions of Allah, and over the course of a week, she believed that she was the prophet Mohammad. She believed that she would deliver the world from sin. Her husband became concerned about her behavior to the point that he was afraid of leaving their 4 children with her. One evening, she was “out of control” which resulted in his calling the police and her subsequent admission to an inpatient psych unit.
During today’s assessment, she appears quite calm, and insists that the entire incident was “blown out of proportion.” She denies that she believed herself to be the prophet Mohammad and states that her husband was just out to get her because he never loved her and wanted an “American wife” instead of her. She tells you that she knows this because the television is telling her so.
She currently weighs 140 lbs, and is 5’ 5”
SUBJECTIVE
Client reports that her mood is “good.” She denies auditory/visual hallucinations, but believes that the television does talk to her. She believes that Allah sends her messages through the TV. At times throughout the clinical interview, she becomes hostile towards the PMHNP, but then calms down.
You reviewed her hospital records and find that she has been medically worked up by a physician who reported her to be in overall good health. Lab studies were all within normal limits.
Client admits that she stopped taking her Risperdal about a week after she got out of the hospital because she thinks her husband is going to poison her so that he can marry an American woman.
MENTAL STATUS EXAM
The client is alert, oriented to person, place, time, and event. She is dressed appropriately for the weather and time of year. She demonstrates no noteworthy mannerisms, gestures, or tics. Her speech is slow and at times, interrupted by periods of silence. Self-reported mood is euthymic. Affect constricted. Although the client denies visual or auditory hallucinations, she appears to be “listening” to something. Delusional and paranoid thought processes as described, above. Insight and judgment are impaired. She is currently denying suicidal or homicidal ideation.
The PMHNP administers the PANSS which reveals the following scores:
-40 for the positive symptoms scale
-20 for the negative symptom scale
-60 for general psychopathology scale
Assessing and Treating Clients With Psychosis and Schizophrenia RESOURCES
Kay, S. R., Fiszbein, A., & Opler, L. A. (1987). The Positive and Negative Syndrome Scale (PANSS) for schizophrenia. Schizophrenia Bulletin, 13(2), 261-276.
Clozapine REMS. (2015). Clozapine REMS: The single shared system for clozapine. Retrieved from https://www.clozapinerems.com/CpmgClozapineUI/rems/pdf/resources/Clozapine_REMS_A_Guide_for_Healthcare_Providers.pdf
Paz, Z., Nalls, M. & Ziv, E. (2011). The genetics of benign neutropenia. Israel Medical Association Journal. 13. 625-629.
OPTION 1: Assessing and Treating Clients With Psychosis and Schizophrenia
Decision Point One
Select what the PMHNP should do:
Start Zyprexa 10 mg orally at BEDTIME
Start Invega Sustenna 234 mg intramuscular X1 followed by 156 mg intramuscular on day 4 and monthly thereafter
Start Abilify 10 mg orally at BEDTIME
Decision Point One
Start Zyprexa (olanzapine) 10 mg po orally at BEDTIME
RESULTS OF DECISION POINT ONE
Client returns to clinic in four weeks
Client’s PANSS decreases to a partial response (25%)
Client comes in today with a reported weight gain of 5 pounds. When questioned further on this point, she states that she can never seem to get full from her meals so she is snacking constantly throughout the day.
Decision Point Two
Change medication to Geodon 40 mg orally BID with meals
RESULTS OF DECISION POINT TWO
Client returns to clinic in four weeks
Client has a significant reduction in her PANSS (reduction of 40%)
Client notices her weight is down slightly from the previous visit (lost 2 pounds) and that her hunger has been curbed since starting this med
Client does complain that it is difficult to remember the second dose and admits to missing afternoon doses on several occasions over the past month
Decision Point Three
Give her a few test doses of Risperdal 1 mg orally BID for 3 days to see if she tolerates the medication. If tolerated, start Invega Sustenna at an appropriate starting and maintenance dose.
Assessing and Treating Clients With Psychosis and Schizophrenia Guidance to Student
Changing to Risperdal oral therapy to test for side effects and then switching to Invega Sustenna is a good option in a patient who has problems with compliance and who shows good effect from oral therapy. The manufacturer advertises that patients can be switched from an entirely different medication to Invega Sustenna if tolerability can be shown through oral therapy. From a clinical standpoint, the patient may or may not respond to the medication and therefore this could be a waste of time. Remember, manufacturers have a product to sell and there information should always be verified before implementing into clinical practice.
Although Geodon is recommended twice daily with meals, some providers will choose to give the dose once a day and monitor for efficacy in patients who have compliance issues with BID dosing regimens.
Latuda is a medication that behaves much like Geodon but is taken only once daily. This makes it a good option for someone who responds to Geodon but has compliance problems with the twice daily dosing. Tolerability can be an issue as doses are escalated. Particularly, nausea, vomiting and extrapyramidal side effects can be problematic and therefore good counseling is recommended for clients. Patients usually tolerate lower doses (40 mg) but significant GI distress and movement disorders can occur when doses are pushed upward toward the daily max of 160 mg.
OPTION 1-: Assessing and Treating Clients With Psychosis and Schizophrenia
Delusional Disorders: Pakistani Female With Delusional Thought Processes
Decision Point One
Start Abilify (aripiprazole) 10 mg orally at BEDTIME
RESULTS OF DECISION POINT ONE
Client returns to clinic in four weeks
Client returns and looks disheveled. Upon questioning, her husband states that she has not been sleeping at night. He states she is up and down all night and has also been disrupting his sleep
Client is unable to participate in the PANSS rating tool because she continually is nodding off (sleeping) during the appointment
The appointment is not productive for assessing how she is responding to the Abilify started 4-weeks ago
Decision Point Two
Discontinue Abilify and start Geodon (ziprasidone ) 40 mg orally BID with meals
RESULTS OF DECISION POINT TWO
Client returns to clinic in four weeks
Client has a significant reduction in her PANSS (make her a responder w/ score reduction of 40%)
Client notices her weight is down slightly from the previous visit (lost 2 pounds) and that her hunger has been curbed since starting this medication
Client does complain that it is difficult to remember the second dose and admits to missing afternoon doses on several occasions over the past month
Decision Point Three
Give her a few test doses of Risperdal 1 mg orally BID for 3 days to see if she tolerates the medication. If tolerated, start Invega Sustenna at an appropriate starting and maintenance dos.
Assessing and Treating Clients With Psychosis and Schizophrenia Guidance to Student
Changing to Risperdal oral therapy to test for side effects and then switching to Invega Sustenna is a good option in a client who has problems with compliance and who shows good effect from oral therapy. The manufacturer advertises that clients can be switched from an entirely different medication to Invega Sustenna if tolerability can be shown through oral therapy. From a clinical standpoint, the client may or may not respond to the medication and therefore this could be a waste of time. Remember, manufacturers have a product to sell, and their information should always be verified before implementing into clinical practice.
Although Geodon is recommended twice daily with meals, some providers will choose to give the dose once a day and monitor for efficacy in clients who have compliance issues with BID dosing regimens.
Latuda is a medication that behaves much like Geodon and is therefore a good option for someone who responds to Geodon but has compliance problems due to its once daily dosing schedule. Tolerability can be an issue as doses are escalated. Particularly, nausea, vomiting, and extrapyramidal side effects can be problematic and therefore good counseling points to clients. Clients usually tolerate lower doses (40 mg), but significant GI distress and movement disorders can occur when doses are pushed upward toward the daily max of 160 mg.
DECISION OPTION 2: Assessing and Treating Clients With Psychosis and Schizophrenia
Decision Point One
Start Abilify (aripiprazole) 10 mg orally at BEDTIME
RESULTS OF DECISION POINT ONE
Client returns to clinic in four weeks
Client returns and looks disheveled. Upon questioning, her husband states that she has not been sleeping at night. He states she is up and down all night and has also been disrupting his sleep
Clientis unable to participate in the PANSS rating tool because she continually is nodding off (sleeping) during the appointment
The appointment is not productive for assessing how she is responding to the Abilify started 4-weeks ago
Decision Point Two
Discontinue Abilify and start Geodon (ziprasidone ) 40 mg orally BID with meals
RESULTS OF DECISION POINT TWO
Client returns to clinic in four weeks
Client has a significant reduction in her PANSS (make her a responder w/ score reduction of 40%)
Client notices her weight is down slightly from the previous visit (lost 2 pounds) and that her hunger has been curbed since starting this medication
Client does complain that it is difficult to remember the second dose and admits to missing afternoon doses on several occasions over the past month
Decision Point Three
Give her a few test doses of Risperdal 1 mg orally BID for 3 days to see if she tolerates the medication. If tolerated, start Invega Sustenna at an appropriate starting and maintenance dose
Guidance to Student: Assessing and Treating Clients With Psychosis and Schizophrenia
Changing to Risperdal oral therapy to test for side effects and then switching to Invega Sustenna is a good option in a client who has problems with compliance and who shows good effect from oral therapy. The manufacturer advertises that clients can be switched from an entirely different medication to Invega Sustenna if tolerability can be shown through oral therapy. From a clinical standpoint, the client may or may not respond to the medication and therefore this could be a waste of time. Remember, manufacturers have a product to sell, and their information should always be verified before implementing into clinical practice.
Although Geodon is recommended twice daily with meals, some providers will choose to give the dose once a day and monitor for efficacy in clients who have compliance issues with BID dosing regimens.
Latuda is a medication that behaves much like Geodon and is therefore a good option for someone who responds to Geodon but has compliance problems due to its once daily dosing schedule. Tolerability can be an issue as doses are escalated. Particularly, nausea, vomiting, and extrapyramidal side effects can be problematic and therefore good counseling points to clients. Clients usually tolerate lower doses (40 mg), but significant GI distress and movement disorders can occur when doses are pushed upward toward the daily max of 160 mg.
DECISION OPTION 3: Assessing and Treating Clients With Psychosis and Schizophrenia
Decision Point One
Start Zyprexa (olanzapine) 10 mg po orally at BEDTIME
RESULTS OF DECISION POINT ONE
Client returns to clinic in four weeks
Client’s PANSS decreases to a partial response (25%)
Client comes in today with a reported weight gain of 5 pounds. When questioned further on this point, she states that she can never seem to get full from her meals so she is snacking constantly throughout the day.
Decision Point Two
Decrease Zyprexa to 7.5 mg BEDTIME
RESULTS OF DECISION POINT TWO
Client returns to clinic in four weeks
Patient worsens. Her PANNS increases by 10% (negative symptoms are getting worse) but weight becomes stabilized and excessive hunger abates
Husband explains that she is becoming less manageable at home and he is having to take time off from work because he is fearful of leaving her alone
Decision Point Three
Change to Risperdal 1 mg orally BID
Guidance to Student: Assessing and Treating Clients With Psychosis and Schizophrenia
Weight gain is a significant problem with Zyprexa. Next to Clozaril (clozapine), Zyprexa causes the most weight gain of all the atypical antipsychotics. This is a side effect that a significant number of clients will experience. There also appears to be an increased association of newly diagnosed diabetes mellitus in clients treated with Zyprexa. Although this can be disease related in this population, Zyprexa is above what would be considered coincidental. Risperdal is a good option, although it is dosed twice daily and compliance in this population can be problematic. There is evidence that shows giving Risperdal all at once can be efficacious and therefore could be an option down the road should compliance become an issue.
Weight gain is also possible with Risperdal, but it is not as great as that seen with Zyprexa. If compliance does become an issue with this client, Risperdal has a long-acting injectable formulation, Risperdal Consta, that could be used. Remember, Risperdal Consta has to be given every 2 weeks at the provider’s office, and therapeutic blood levels take time to achieve (on average 3–6 weeks or 2–3 injections). Oral overlapping therapy is required to bridge this period of time. Another option in someone who responds to
Risperdal would be Invega Sustenna (paliperidone palmitate), which is the first metabolite of Risperdal and has greater activity at the D2 receptor than Risperdal. An advantage of Invega Sustenna over Risperdal Consta is that therapeutic blood levels are attained within the first 4–7 days, and overlapping oral therapy is usually not necessary. A disadvantage is that during the initiating
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