Feb 23, 2024 NURS 6630 Discussion Treatment for a Patient With a Common Condition
NURS 6630 Discussion Treatment for a Patient With a Common Condition
A Sample Answer For the Assignment: NURS 6630 Discussion Treatment for a Patient With a Common Condition
Three Questions to Ask the Patient and the Rationale
How much caffeine/alcohol do you consume?
Insomnia complaints are sometimes due to dietary choices. Caffeine taken late in the day can interfere with sleep. This causes a person to consume more the following day, creating a vicious cycle of being addicted to caffeine.
Do you snore?
The patient is obese, with a BMI of 34.37. Hargens et al. (2013) state that persons with obesity may report insomnia. Besides, snoring is often associated with obstructive sleep apnea (OSA). OSA is also strongly associated with obesity.
Do you have leg cramps at bedtime?
The questions help screen for restless legs syndrome (RLS). RLS can lead to delayed onset of sleep, reduced sleep time, and difficulty maintaining sleep. RLS is also associated with obesity, as those with a high BMI tend to have RLS compared to those with a low BMI (Hargens et al., 2013).
People in the Patient’s life to Speak to, Questions to Ask and the Rationale
If the patient has children and other relatives, such as siblings, they can help determine insomnia’s familial or biological cause. I can ask the family members if they have a similar problem. This will help to identify if any first-degree relative has a sleep problem (Beaulieu-Bonneau et al., 2007). Another question is about which type of sleep problem the family members experience, such as sleep apnea, restless leg syndrome, or daytime sleepiness.
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Any Useful Physical Exams and Diagnostic Tests and How to Use the Results
First, the patient is taking antidepressants which can cause insomnia. The patient is also taking diabetics medications such as metformin which can lead to sleep disturbance. Losartan may also lead to sleep difficulties. Currently, the patient’s insomnia is highly likely due to medications. It is first important to treat insomnia due to medication effects.
Besides, I can assess insomnia further using sleep diaries and questionnaires that the patient can present during the follow-up visits. One tool is the insomnia rating scale which will aid in recording the symptoms and treatment response. Wrist actigraphy will also help monitor and store movement data to assist in monitoring treatment response and other circadian issues that may lead to insomnia (Patel et al., 2018).
Differential Diagnosis and the most Likely One
Insomnia due to drugs
Insomnia due to a medical condition
The most likely differential diagnosis is insomnia due to drugs. The patient is taking medications to manage moods, hypertension, and diabetes. Khandelwal et al. (2017) assert that sleep disturbances are common in people with diabetes. People with diabetes report higher rates of poor sleep quality, excessive daytime sleepiness, and insomnia.
NURS 6630 Discussion Treatment for a Patient With a Common Condition
Sleep disturbances may be due to rapid changes in blood glucose levels during the night due to medications. Insomnia may also be due to hypertension drugs. The patient is taking HCTZ to manage hypertension, and the restlessness associated with the drug may lead to sleep disturbances. Sertraline, an antidepressant, may also be contributing to insomnia.
Pharmacologic Agents, Dosing and the Most Preferred
Doxepin 3mg once a day
Eszopiclone 1mg once a day at bedtime
At low doses, doxepin blocks the wake-promoting impacts of histamine. Adults aged 65 and older report high sleep onset with 3mg/day doxepin when taken 30 minutes before bedtime (Patel, 2018). It has a peak time of 3.5 hours (Almasi & Meza, 2019). It is highly distributed to other body tissue compartments. It is excreted through urine. It also has a high plasma protein binding rate.
Eszopiclone is rapidly absorbed and binds with plasma proteins at a rate of 52% to 59% taking about one hour. It is metabolized in the liver following oral administration. Elimination occurs after 6 hours, and about 10% or less of the dose is excreted in the urine (Brielmaier, 2006). When taken with a high-fat meal, it may lead to a one-hour delay in achieving peak concentration.
The most preferred drug is Eszopiclone 1mg/day at bedtime as there are evidence-based studies on its use among the eldrly above 65 years old. It has a peak time of one hour compared to 3.5 hours of doxepin. Fundamentally, although doxepin is highly effective, it should be avoided for patients above 65 years old (Almasi & Meza, 2019).
Contraindications of the Drug
Eszopiclone has no known contraindications. However, because the patient has depression, the drug should be cautiously administered. It is important to start with the smallest dose (Brielmaier, 2006). Long-term use of the drug may lead to physical and psychological dependence.
Check Points and Therapeutic Changes
After four weeks of 1mg eszopiclone daily, I expect improvements in total sleep time, quality, and depth of sleep, including the number of awakenings without side effects (Kirkwood & Breden, 2010). I will increase the dosage to 2mg/day. In the eighth week, I expect significant improvements in total sleep time, quality and sleep depth, daytime alertness, and a higher sense of physical well-being. The patient will continue with 2 mg/day dosage for four more weeks.
After 12 weeks of 2mg treatment, I expect a significant improvement in sleep, social life, and daily responsibilities. I will also encourage the patient to practice sleep hygiene and engage in physical activity due to her weight and to improve her sleep.
References
Almasi, A., & Meza, C. E. (2019). Doxepin. NIH National Library of Medicine, National center for biotechnology information. Statpearls. January 2022.
Beaulieu-Bonneau, S., LeBlanc, M., Mérette, C., Dauvilliers, Y., & Morin, C. M. (2007). Family history of insomnia in a population-based sample. Sleep, 30(12), 1739-1745.
Brielmaier, B. D. (2006, January). Eszopiclone (Lunesta): a new nonbenzodiazepine hypnotic agent. In Baylor University Medical Center Proceedings (Vol. 19, No. 1, pp. 54-59). Taylor & Francis.
Hargens, T. A., Kaleth, A. S., Edwards, E. S., & Butner, K. L. (2013). Association between sleep disorders, obesity, and exercise: a review. Nature and Science of Sleep, 27-35.
Khandelwal, D., Dutta, D., Chittawar, S., & Kalra, S. (2017). Sleep disorders in type 2 diabetes. Indian Journal of Endocrinology and Metabolism, 21(5), 758.
Kirkwood, C., & Breden, E. (2010). Management of insomnia in elderly patients using eszopiclone. Nature and Science of Sleep, 151-158.
Patel, D., Steinberg, J., & Patel, P. (2018). Insomnia in the elderly: a review. Journal of Clinical Sleep Medicine, 14(6), 1017-1024.
List three questions you might ask the patient if she were in your office. Provide a rationale for why you might ask these questions.
How long have you been taking Zoloft and are you currently attending psychotherapy to help with grief support and experienced depression?
Rationale: Providers need an understanding of when medication was initiated and adjusted. For the initial treatment of major depression, A combination of antidepressant medication and psychotherapy. Combination treatment is more effective than either treatment on its own. Each treatment form is effective and comparable to the other Psychotherapy may help people develop new coping skills as well as more adaptive ways of thinking about life problems (Rush, 2019).
Do you take your Zoloft daily and have you forgotten to take or missed taking a dose? Rationale: Clarifying missed doses of this medication may contribute to patient increased depression symptoms. MDD is frequently comorbid with physical problems and illnesses including obesity, cardiovascular disease and diabetes mellitus, substance misuse and other mental disorders, reflecting both antecedent and consequence pathways. This may affect the efficacy of treatments for MDD as well as increasing the vulnerability of patients to adverse effects and risk of harmful drug interactions (UptoDate, 2022).
Do you take any other medications or supplements? Rationale: Concern of Serotonin syndrome. Obtaining a current medication history will confirm if a patient is taking other medications elevate serotonin such as other antidepressants, certain NSAIDS, headache medications, St. John’s Wort.
Further Assessment
When was your last visit with your PCP, Rationale: One of the most common barriers to seeking health care is out-of-pocket medical cost? In particular, among older adults with chronic conditions, the burden of out-of-pocket medical cost is a major concern (Cheruvu & Chiyaka, 2019).
What is the patient’s current mood and how does the patient rate her current mood?
Who is and where is your PCP located? As a provider you will want to retrieve medical records from current PCP and need to send release to appropriate correspondence.
MDD is frequently associated with physical problems and illnesses such as obesity, cardiovascular disease, and type 2 diabetes. This may impair the efficacy of MDD treatments while also increasing patients’ susceptibility to adverse effects and the risk of harmful drug interactions. Collateral information from a patient’s family and friends is an essential component of psychiatric evaluation. A thorough physical examination, including a neurological examination, should be carried out. Any underlying medical/organic causes of a depressive disorder must be ruled out. A complete medical history, as well as the medical and psychiatric histories of the patient’s family, should be obtained. The mental status examination is critical in the diagnosis and evaluation of MDD.
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Appropriate Physical Tests and Diagnostic Examinations
The GDS (Geriatric Depression Scale) would be useful in assessing the level of depression in patients. Screening should also be considered in cases where bereavement effects persist 3 to 6 months after the loss, social isolation, persistent complaints of memory difficulties, chronic disabling illness, recent major physical illness, persistent sleep difficulties, significant somatic concerns or recent onset of anxiety, refusal to eat or neglect of personal care, recurrent or prolonged hospitalization, and dementia diagnosis. Even if the patient denies suicidal ideation, this should be done as a baseline during the office visit. The degree of depression and whether the patient is at risk will be determined by an assessment of the patient’s overall mood. To rule out organic or medical causes of depression, laboratory testing should include a complete blood count with differential, a comprehensive metabolic panel, thyroid-stimulating hormone, free T4, vitamin D, urinalysis, and toxicology screening. CMP testing will check kidney function and electrolytes; this medication may affect these levels. CMP sodium levels should be checked one month after starting Zoloft. Nausea, dry mouth, insomnia, somnolence, agitation, diarrhea, excessive sweating, and, less commonly, sexual dysfunction are common side effects of SSRIs. There is an increased risk of elderly patients due to declining renal function associated with aging. developing hyponatremia as a result of an antidiuretic hormone secretion syndrome (Wiese, 2011).
Differential Diagnosis
MDD is frequently comorbid with physical problems and illnesses including obesity, cardiovascular disease and diabetes mellitus. This may affect the efficacy of treatments for MDD as well as increasing the vulnerability of patients to adverse effects and risk of harmful drug interactions. Laboratory screenings during visits should consist of CBC, TSH, CMP, Vitamin D3. Neurological causes such as cerebrovascular accident, multiple sclerosis, subdural hematoma, epilepsy, Parkinson disease, Alzheimer disease should be considered during evaluation. Consideration of endocrine, metabolic disorders and nutritional deficits should be considered when obtaining labs that could be the primary cause for Major Depressive Disorder.
Appropriate Treatment
The patient is currently taking an SSRI, sertraline 100mg daily for MDD treatment. The provider should consider increasing patient sertraline to 150 mg. Selective serotonin reuptake inhibitors (SSRIs) are regarded as the treatments of choice for first line management of elderly depressed patients. The selective serotonin reuptake inhibitors (SSRIs) and the newer antidepressants bupropion, mirtazapine, moclobemide, and venlafaxine (a selective norepinephrine reuptake inhibitor or SNRI) are all relatively safe in the elderly. They have lower anticholinergic effects than older antidepressants and are thus well tolerated by patients with cardiovascular disease (Weise, 2011). This medication is safe for this patient’s depression treatment and dosage can be increased for patients up to 200mg daily. It would be appropriate for the provider to augment the sertraline with a low dose TCA, such as Trazodone, to be taken at bedtime. Patients should be educated on feelings of over sedation and discontinuation of TCA taken at HS could be lowered or discontinued.
Contraindications
The BEERS Criteria should be utilized prior to prescribing psychotropic medication treatment since the patient is older than 65 years of age.
Sertraline use requires caution in patients 65 years and older. It is identified in the Beers Criteria as a high-risk medication in geriatric patients, as it may induce a syndrome of inappropriate antidiuretic hormone or hyponatremia.
Check Points
Patients should be scheduled for in office follow-up in 2-3 weeks to follow up on medication changes as well as their depression. The provider should repeat their GDS as well as evaluate any further mood changes or concerns.
References
Cheruvu, V. & Chiyaka, E. (2019). Prevalence of depressive symptoms among older adults who
reported medical cost as a barrier to seeking health care: findings from a nationally representative sample. BMJ Geriatrics. https://bmcgeriatr.biomedcentral.com/articles/10.1186/s12877-019-1203-2
Rush, J. (2022). Patient education: Depression treatment options for adults (Beyond
the Basics). UpToDate.
Weise, B. (2011). Geriatric depression: The use of antidepressants in the elderly. The British
Medical Journal, 53(47). Geriatric depression: The use of antidepressants in the elderly | British Columbia Medical Journal (bcmj.org)
As a PNP, insomnia will be one of the most common medical issues you encounter. Insomnia is a prevalent symptom of numerous mental disorders, including anxiety, depression, schizophrenia, and attention deficit hyperactivity disorder (ADHD) (Abbott, 2016). Multiple research have proven the two-way connection between sleeplessness and mental disorders. In reality, over 50% of persons with insomnia have a mental health condition, and up to 90% of adults with depression have sleep problems (Abbott, 2016).
Due to the interrelated nature of psychopathology, it is crucial that you, as a PNP, comprehend the significance of the effects that certain psychopharmacologic treatments may have on a patient’s mental health condition and sleep patterns. For optimal health and well-being, it is crucial that you comprehend and reflect on the evidence-based research when formulating treatment plans to prescribe correct sleep practices to your patients and appropriate psychopharmacologic treatments.
Reference:
Abbott, J. (2016). What’s the link between insomnia and mental illness? Health. https://www.sciencealert.com/what-exactly-is-the-link-between-insomnia-and-mental-illness#:~:text=Sleep%20problems%20such%20as%20insomnia%20are%20a%20common,bipolar%20disorder%2C%20and%20attention%20deficit%20hyperactivity%20disorder%20%28ADHD%29
Review the case Learning Resources and the case study excerpt offered for this Discussion. Consider the therapeutic approaches you might use to analyze, diagnose, and treat the patient’s health requirements in light of the case study extract.
By the third day of Week 7,
Respond to each of the following:
Make a list of three questions you would ask the patient if she came into your clinic. Give an explanation for why you might ask these questions.Determine who in the patient’s life you need to speak with or acquire feedback from in order to further assess the patient’s situation. Include precise questions and reasons for asking them.Explain whether physical exams and diagnostic tests, if any, would be suitable for the patient, as well as how the results would be used.Make a list of possible diagnoses for the patient. Choose the one you believe is most likely and explain why.
Based on pharmacokinetics and pharmacodynamics, list two pharmacologic agents and their dosing that would be appropriate for the patient’s antidepressant therapy. Provide an explanation for why you might prefer one agent over the other in terms of mechanism of action.
Identify any contraindications to usage or dosing changes that may need to be considered based on ethical prescription or decision-making for the pharmacological therapy you choose. Discuss why the contraindication or modification you’ve identified exists. That is, depending on ethical prescribing guidelines or decision-making, what would be problematic with using this drug in individuals?Include any “check points” (e.g., follow-up data at Week 4, 8, 12, etc.) and any therapeutic changes you would make based on likely results given your treatment options.
NURS 6630 Discussion Treatment for a Patient With a Common Condition
Read some of your coworkers’ responses.
By the sixth day of Week 7,
Respond to at least two of your coworkers in one of the following ways on two different days:
Share how and why your colleagues’ posts influenced your knowledge of these issues. Include any other information you learned.If you believe your colleagues have misconstrued these notions, express your alternate viewpoint and be sure to explain why. Include resources to back up your point of view. Read a sample of your colleagues’ replies and respond to at least two of them on two separate days.
Please keep in mind that you must complete your initial post before you may access and comment to your colleagues’ postings in this Discussion. Begin by clicking on the “Post to Discussion Question” option, then “Create Thread” to finish your first post. Remember that after you hit the Submit button, you can’t delete or change your own posts, and you can’t publish anonymously. Please double-check your post before clicking the Submit button!
NURS 6630 Discussion Treatment for a Patient With a Common Condition
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NURS 6630 Discussion Treatment for a Patient With a Common Condition
SAMPLE 1
Questions and Rationale
The first question that I might ask the Patient is, “what brings you in today?”. By this question, you are forming a rapport with the Patient and making it for her to share his/her feelings openly. By asking an open-ended question, the Patient is more willing to share information with the provider (Stern, 2016). The second question that would be of beneficial knowledge during the interview is, “do you consume caffeine?” If so, how much caffeine do you consume in a day? Since caffeine consumption close to bedtime contributes significantly to insomnia.
Lastly, “do you suffer from Gastro-Esophageal Reflux Disease (GERD)?”. GERD is a contributing factor to insomnia in elderly patients. The provider can rule out environmental factors by asking the above questions while assessing the Patient’s concerns with open-ended questions. (Farazdaq et al., 2018).
People in the Patient’s life, Questions, and feedback
The People in the Patient’s life that could help and give further information are her children or caretakers. Since they are in close contact with the Patient before admission to your office, questions that would be appropriate to ask the Patient’s children or caretaker would be, “Is there a recent decrease in her appetite, energy, mood, or interests?” By asking about these questions, external information will be provided, and further assessment that the Patient might be withholding or unaware of.
Appropriate Physical Examinations and Diagnostic Tests
A physical exam could be performed with the order of blood testing to rule out thyroid problems. Hyperthyroidism results in nervousness from the overactivity of this hormone, and insomnia is often a symptom. Administering the Hamilton Anxiety Rating Scale would assess the severity of the Patient’s anxiety. The HAM-A results would aid with further treatment of the Patient’s insomnia if related to anxiety.
Also, insomnia relies heavily on self-report for a diagnosis (Levenson et al., 2015). Another appropriate scale to administer to this Patient is the Hamilton Depression Rating Scale. HDRS is an assessment that focuses on feelings of guilt, mood, suicidal ideation, activities, weight, various stages of insomnia, and many more critical areas (Hamilton, 1960) appropriate to the Patient’s condition.
Differential and Likely Diagnosis
The Patient has a previous diagnosis of depression. The differential diagnosis for this Patient is Generalized Anxiety Disorder (GAD), secondary to the husband’s death. There are many possible changes within the dynamics of life, such as financial stress, fear of being alone, fear of death, and sudden sleep alone. Generalized Anxiety Disorder (GAD) is characterized by persistent and excessive worry about several things.
People with GAD may anticipate disaster and be overly concerned about money, health, family, work, or other issues. Individuals with GAD find it difficult to control their worries. They may worry more than seems warranted about actual events. This differential diagnosis fits the Patient given in the scenario. Changes within this Patient’s routine may be a cause of reported insomnia.
Appropriate Pharmacologic Agents
The two pharmacological agents appropriate for the Patient’s antidepressant therapy are Trazodone and Temazepam.
Trazodone is widely used for insomnia. It Is FDA approved for the treatment of major depression and used off-label for insomnia and anxiety. Trazodone inhibits serotonin reuptake, alpha-1 adrenergic receptor antagonist, and serotonin 5-HT2A and 5-HT2C receptor antagonist and is metabolized primarily through CYP3A4 to active metabolite mCPP, that is metabolized by 2D6, inducing P-glycoprotein. Trazodone, however, carries the side effect of daytime somnolence and dizziness (Cook et al., 2018).
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