Feb 23, 2024 NURS 6630 Assessing and Treating Patients With Sleep/Wake Disorders
A Sample Answer For the Assignment: NURS 6630 Assessing and Treating Patients With Sleep/Wake 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.
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.
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NURS 6630 Assessing and Treating Patients With Sleep/Wake Disorders
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
Insomnia is the most prevalent sleep disorder affecting a substantive amount of the population. It is characterized by the inability to initiate, and maintain sleep or simply a poor sleep quality. Insomnia affects 10-15% of the population (Kaur et al., 2020). Insomnia can be graded based on the duration and the frequency of symptoms. This week’s case study focuses on a 31-year-old male who presented with a chief complaint of insomnia which has progressively gotten worse over the past six months.
The symptomatology includes difficulty in falling asleep and staying asleep at night. The problem began after the loss of his fiancé. The problem affects his work. He has used diphenhydramine in the past to sleep but stopped due to the side effect of marked morning drowsiness. He has a history of opiate abuse which started with the prescription medication hydrocodone when he broke his ankle. He has not had any other prescription for the opiate for four years.
The patient currently uses alcohol to help him fall asleep. The Mental Status Exam is normal. He denies any auditory or visual hallucinations. His judgment and insight are intact. The patient denies any suicidal ideations and is future-oriented. There are no features of depression or any other mental or physical illness.
The symptomatology of increased sleep latency, difficulty maintaining sleep, and daytime symptoms confirm the diagnosis of insomnia. The co-morbidities like alcohol use disorder, history of opiate abuse, previous pharmacotherapy for insomnia using diphenhydramine, and the maladaptive disorder of alcohol abuse to induce sleep will all greatly influence medication decisions.
The selected drug must confer low toxicity, high efficacy for reduction of sleep latency and maintaining sleep, tolerability to minimize drug non-compliance, and minimal side effects especially drowsiness that may affect the subsequent day’s work. Cognitive Behavioral Therapy in conjunction with drug therapy is highly efficacious in insomnia management. The treatment is aimed at providing the best-indicated medication to the patient to provide remission of symptomatology.
The treatment also aims at preventing the development of complications like depression, diabetes, and other cardiovascular diseases. Standard individualized care is indicated for a full recovery. The purpose of this paper is to describe the decision points taken to treat this patient regarding medication choice, the expectation with each decision, and ethical considerations.
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Decision 1
Trazodone 50mg at bedtime.
Reason for Selection
For this particular case, trazodone is the drug for use in the management. From Randomized Clinical Trials on Trazodone use in the treatment of Insomnia, it was highly efficacious in maintaining sleep by reducing the number of awakenings during sleep, it remarkably improved the quality of sleep, and was well tolerated by a majority of patients in short-term treatment (Wichniak et al., 2021). In primary Insomnia, a combination of CBT and Trazodone was found to have the highest efficacy in reducing sleep latency.
Trazodone has a half-life of 12 hours with a peak plasma concentration of four hours. When trazodone is taken 1-2 hours before bedtime, it can reduce sleep latency. Trazodone reduces the risk of relapse in alcohol-dependent patients. Hypnotics like Zolpidem reduce the quality and depth of sleep and has a higher risk of drug dependence. As a result, Zolpidem is not effective in the treatment of patients with poor quality sleep insomnia (Wichniak et al., 2021).
Zolpidem is also associated with adverse effects such as anterograde amnesia and an increased risk of falls. Concerning Hydroxyzine, it is only indicated for the treatment of accidental insomnia (Krysta, 2020). It is also associated with marked sedation and increased morning drowsiness. The use of hydroxyzine in the management of insomnia is highly unpopular due to hyperacute tolerance and increased daytime somnolence (Albrecht et al., 2019). There is no further literature that justifies its use.
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.
Reference:
Mayo Clinic. (2020). Sleep disorders. https://www.mayoclinic.org/diseases-conditions/sleep-disorders/symptoms-causes/syc-20354018
Click here to ORDER an A++ paper from our Verified MASTERS and DOCTORATE WRITERS: NURS 6630 Assessing and Treating Patients With Sleep/Wake Disorders
ASSESSING AND TREATING PATIENTS WITH SLEEP/WAKE 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 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.
Reference: Mayo Clinic. (2020). Sleep disorders. https://www.mayoclinic.org/diseases-conditions/sleep-disorders/symptoms-causes/syc-20354018
RESOURCES
Be sure to review the Learning Resources before completing this activity.Click the weekly resources link to access the resources.
WEEKLY RESOURCES
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 the assessment and treatment of 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. 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.
Assignment 2: Assessing and Treating Patients with Sleep/Wake Disorders
Introduction to the case
The case scenario depicts a 31-year-old man with a primary symptom of insomnia, which has deteriorated in the past six months since he lost his fiancé. The client admits that he is not usually a great sleeper, but he has been experiencing problems falling asleep and maintaining sleep during the night. He reports that insomnia adversely impacts his occupational functioning since he sleeps at his job due to failure to sleep at night. The client has previously taken diphenhydramine to trigger sleep, but he does not like its effects in the morning. His medical history reveals a history of opiate abuse, which started after an ankle fracture, and he was prescribed hydrocodone/apap for acute pain. However, he had not been prescribed an opiate analgesic for the last four years. The client admits to drinking about four beers to help initiate sleep. His mental status exam results reveal an alert and oriented patient who maintains good eye contact and dresses appropriately according to the weather. The client denies experiencing auditory/visual hallucinations or having suicidal/homicidal ideations. Besides, his judgment, reality contact, and insight are intact, and he is future-oriented.
The treatment plan for this patient should aim at enhancing sleep quality and improving related daytime impairments. However, interventions for attaining these goals vary based on the underlying etiology and the patient factors (Krystal, Prather & Ashbrook, 2019). For instance, if the client has an underlying neurologic, medical, or sleep disorder, the treatment should focus on it. Furthermore, the patient’s history of opiate abuse should guide the PMHNP to prescribe a drug with no risk of abuse (Krystal et al., 2019). This paper seeks to describe the treatment plan for this client and explain the ethical considerations that may impact the treatment plan and communication with the client.
Decision Point One: Prescribe Trazodone: 50–100 mg daily at bedtime.
Why did you select this decision?
I initiated the client on Trazodone because its efficacy in treating insomnia has been established. Trazodone blocks the receptors for neurotransmitters that promote wakes, such as alpha-1-adrenergic and histamine receptors (Neubauer et al., 2018). It also inhibits serotonin reuptake resulting in sleep-enhancing effects. Sateia et al. (2017) conducted a study that showed that Trazodone increases sleep duration, reduces sleep latency, reduces onset of wake after sleep, moderately improved quality of sleep, and lessens the frequency of nighttime awakenings.
Why I Did Not Select the Other Two Options Provided
The other two options provided were Zolpidem and Hydroxyzine. I did not select Zolpidem because of its associated adverse effects, including psychomotor impairment and dose‐dependent sedation, which can impair functioning and lower the quality of life (Krystal et al., 2019). Zolpidem has a documented risk of abuse and complex sleep behaviors, making it a less ideal drug due to the client’s history of opiate abuse. I did not select Hydroxyzine due to its strong sedative properties. Krystal (2019) explains that Hydroxyzine sedative properties contribute to increased daytime sleepiness following nighttime use.
What I Was Hoping To Achieve By Making This Decision
I was hoping that starting the client on Trazodone would improve sleep quality and duration and help initiate and maintain sleep. I also hoped that the client would report reduced daytime speediness and improved daytime functioning. Jaffer et al. (2017) explain that Trazodone enhances subjective and objective sleep and awakening in persons with primary insomnia. The drug also enhances subjective sleep, duration, and quality in individuals with primary insomnia.
How Ethical Considerations May Impact the Treatment Plan and Communication
Ethical considerations may influence the treatment plan since the PMHPN ensures the prescribed treatment is safe and will promote the best possible outcomes. For instance, I evaluated the treatment options and selected the drug with strong evidence supporting its efficacy and safety. I did not select drugs with adverse effects to avoid causing harm to the client and improve his quality of life. According to Milliken (2018), communication may be impacted since the PMHMNP has to obtain consent from the client before initiating treatment or sharing his information with other providers.
Decision Point Two: Explain to the client that priapism is a side effect of Trazodone that should diminish over time and continue the dose.
Why I Selected This Decision
I selected this decision because the patient expressed concerns about prolonged erection for about 15 minutes after waking within two weeks of therapy. A client has a right to information about their medication, including potential side effects (Milliken, 2018). Consequently, I explained to the patient about Trazodone’s side effect of priapism and informed him about its duration for reassurance and to promote medication adherence.
Why I Did Not Select the Other Two Options Provided
Other options provided were to discontinue Trazodone and initiate therapy with suvorexant or decrease trazodone dose to 25 mg daily. The PMHNP did not stop Trazodone and start suvorexant because the latter causes psychomotor hyperactivity, has a seda
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