Feb 23, 2024 TREATMENT FOR A PATIENT WITH A COMMON CONDITION NURS 6630
TREATMENT FOR A PATIENT WITH A COMMON CONDITION NURS 6630
A Sample Answer For the Assignment: TREATMENT FOR A PATIENT WITH A COMMON CONDITION NURS 6630
Treatment for a Patient with Insomnia
Three questions for the patient
Do you have trouble falling asleep, and how often do you wake up at night after managing to sleep? Inquiring about the frequency will help determine the severity of the condition and the right intervention.
Do you snore loudly and have trouble breathing when you wake up at night? This will help determine if there could be other underlying issues causing insomnia besides grief and depression.
Are there distractions like noise, light, and noise around your place? This will help determine if the environment is contributing to insomnia.
People to speak to and why
I will speak with the people close to the patient, particularly her friends and family members. The family members will help explain her sleep habits, while the friends will help establish how insomnia affects her daily activities
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Physical exams and diagnostic tests
I would physically assess the nasal septum and the tonsils. According to Krystal et al. (2019), this examination will help determine if insomnia could be aggravated by obstructive sleep apnea. I will also use actigraphy to monitor the patient’s movement after falling asleep. Actigraphy will help determine the severity of the condition.
Most likely differential diagnosis and why
The differential diagnosis for insomnia includes mental illness, medical conditions, drug or substance use, obstructive sleep apnea, or inadequate sleep hygiene. The most likely differential diagnosis for this case is mental illness. The patient suffered a loss; thus, she is likely to be experiencing sleep disturbance due to bereavement and depression.
TREATMENT FOR A PATIENT WITH A COMMON CONDITION NURS 6630
Two pharmacologic agents and their dosing
Benzodiazepines and Agomelatine are highly suitable for treating patients with insomnia resulting from depression. The patient should take 15 to 30 mg of Benzodiazepines daily and 25 to 50 mg of Agomelatine daily (Morera-Fumero et al., 2020). The two present a combination of sedative and non-sedative antidepressants; hence, they’ll suit the patient. The combination also offers both long-term and short-term solutions.
Contradictions or alteration in the dosing drug and why
Agomelatine dosage can be increased to 50mg daily if the condition does not improve. However, Norman and Olver (2019) warn that the drug should not be used for more than 24 weeks as extended use can result in dementia in patients above 75 years. The drug also has side effects like active liver disease and liver cirrhosis. Benzodiazepines should not be used for long-term solutions as they may lead to addiction. Morera-Fumero et al. (2020) explain that the other side effects of Benzodiazepines include drowsiness, headache, and respiratory arrest.
Checkpoints and any therapeutic changes
I will monitor for improvement after three, six, twelve, and 24 weeks of treatment to determine the effectiveness of the Agomelatine drug. Norman and Olver (2019) explain that monitoring any side effects of liver disease, like dark urine, yellow skin, eyes, and fatigue, is crucial. Regarding the Benzodiazepines, I will evaluate changes after three days, one week, and four days. The treatment will not last for more than two weeks, and in each period, I will monitor headaches and breathing challenges.
References
Krystal, A. D., Prather, A. A., & Ashbrook, L. H. (2019). The assessment and management of insomnia: an update. World Psychiatry, 18(3), 337-352.
Morera-Fumero, A. L., Fernandez-Lopez, L., & Abreu-Gonzalez, P. (2020). Melatonin and melatonin agonists as treatments for benzodiazepines and hypnotics withdrawal in patients with primary insomnia. A systematic review. Drug and Alcohol Dependence, 212, 107994.
Norman, T. R., & Olver, J. S. (2019). Agomelatine for depression: expanding the horizons?. Expert opinion on pharmacotherapy, 20(6), 647-656.
List three questions you might ask the patient if she were in your office. Provide a rationale for why you might ask these questions.
Do you drink caffeinated drinks? If yes, how many do your drink a day and at what time?
Rationale: Caffeine is a stimulant. Individuals who drink caffeine during the day cause a reduction in 6-sulfatoxymelatonin (the main metabolite of melatonin) at night, which leads to sleep disturbance (O’Callaghan et al., 2018). The lack of sleep affects cognitive functioning and psychomotor response (O’Callaghan et al., 2018).
How many hours of sleep are you getting each night?
Rationale: According to Levenson et al., when a person is living with unpleasant thoughts or worrying excessively, it can lead to sleep disturbances (2015). The decreased sleep can cause the person to worry about not getting enough sleep, leading to more anxiety and insomnia (Levenson et al., 2015).
Have you had any feelings of depression, hopelessness, or feeling down in the past month?
Rationale: Individuals who have suffered a significant loss are at high risk for depression. Individuals with depression often experience insomnia. This question is one of two that can be used to assess a patient for depression and determine if further treatment is warranted (Assessment of Depression in Adults in Primary Care, 2020). The patient’s husband died ten months ago in the given scenario. If the patient responds positively to this question, it is critical to also assess for suicide risk.
Identify people in the patient’s life you would need to speak to or get feedback from to further assess the patient’s situation. Include specific questions you might ask these people and why.
It would be important to gain information from outside sources such as family, friends, and caretakers familiar with the patient’s daily life. If possible, individuals who have been around the patient from before her husband passed until now. You could ask the patient how she got to the appointment and if someone brought her, you could ask if she would be OK with you speaking with them. There are several questions you could ask.
Have you noticed a change in her interest in doing things?
Have you she seemed down or hopeless?
How has she been eating?
Do you know if she is taking her medications or noticed any side effects from her medications?
Have you noticed any anxiety or changes in memory?
Explain what, if any, physical exams and diagnostic tests would be appropriate for the patient and how the results would be used.
Upon the initial interview, it is possible to screen the patient for depression. There are several ways this can be done. Practitioners can use the Mini-Mental State Exam MMSE), Geriatric Depression Scale Short Form (SGDS), or the Cornell Scale for Depression in Dementia (CSDD) (Brown et al., 2015). It is important to note that older adults with depression can also have dementia, so screening for dementia would also be important (Brown et al., 2015).
The CSDD can detect depression in individuals with cognitive impairment. The SGDS is used because it is fairly easy and short and can detect depression in older adults (Brown et al., 2015). Laboratory testing is also important as many organic illnesses can lead to insomnia and depression. Baseline lab work should include glucose, liver function, complete blood count, Erythrocyte Sedimentation Rate, urea, creatinine, electrolytes, B-12, and Iron studies.
List a differential diagnosis for the patient. Identify the one that you think is most likely and explain why.
A differential diagnosis for depression in an elderly patient could be Vascular Depression. It is found in adults over 60 years of age and with no prior history of depression (Small, 2009). It can be found in patients with hypertension or a history of vascular disease believed to cause inflammation within the vascular system leading to the release of cytokines, especially after a stressful event (Jeon & Kim, 2018). When reviewing the patient’s medications, she is taking bother Losartan and hydrochlorothiazide to manage her hypertension, so the differential diagnosis of Vascular Depression is possible.
List two pharmacologic agents and their dosing that would be appropriate for the patient’s anti-depressant therapy based on pharmacokinetics and pharmacodynamics. From a mechanism of action perspective, provide a rationale for why you might choose one agent over the other.
The patient is currently taking Sertraline 100mg daily. If the patient takes the medication as prescribed, the patient should see improvement in depressive symptoms. The scenario does not state how long the patient has been taking Sertraline. One side effect of SSRIs is that they can cause insomnia.
At this time, it is appropriate to consider augmenting the Sertraline with a low dose TCA like trazodone. Research suggests that short-term use of a TCA can improve sleep as soon as the first dose (Wichniak et al., 2017). It is important to remember that when the patient’s depression symptoms improve, the TCA should be lowered or discontinued because it can cause oversedation (Wichniak et al., 2017).
Sertraline makes it difficult to keep blood sugar stable. It can also be recommended to switch the anti-depressant to Bupropion. Studies have shown that in patients with diabetes, burproprione successfully treats depression and controls blood sugar levels (Darwish et al., 2018). It would be necessary to monitor the patient’s blood pressure as bupropion can elevate blood pressure (Darwish et al., 2018).
For the drug therapy, you select, identify any contraindications to use or alterations in dosing that may need to be considered based on ethical prescribing or decision-making. Discuss why the contraindication/alteration you identify exists. That is, what would be problematic with the use of this drug in individuals based on ethical prescribing guidelines or decision-making?
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Sertraline is contraindicated in patients taking thioridazine, pimozide, or monoamine oxidase inhibitors, including linezolid or methylene blue, and it should not be taken with other serotonergic medications (Singh & Saadabad, 2020). Buspirone is contradicted in patients with kidney and liver disease as the drug’s effects may increase due to slow kidney or liver removal. Trazadone is contraindicated for anyone taking an MAOI or has taken an MAOI in the past 14 days (Shin & Saadabadi, 2020).
Include any “check points” (i.e., follow-up data at Week 4, 8, 12, etc.), and indicate any therapeutic changes that you might make based on possible outcomes that may happen given your treatment options chosen.
It would be necessary to follow up with the patient in four weeks to see if adding Trazadone improves the patient’s sleep. If there is no improvement in the patient’s sleep or depressive symptoms, it would be time to consider changing the patient’s medication to buspirone.
References
Assessment of depression in adults in primary care [PDF]. (2020). Best Practice Medicine Journal New Zealand. https://bpac.org.nz/magazine/2009/Adultdep/docs/bpjse_adult_dep_assess_pages8- 12.pdf
Brown, E., Raue, P. J., & Halpert, K. (2015). Evidence-based practice guideline: Depression detection in older adults with dementia. Journal of Gerontological Nursing, 41(11), 15– 21. https://doi.org/10.3928/00989134-20151015-03
Darwish, L., Beroncal, E., Sison, M., & Swardfager, W. (2018). Depression in people with type 2 diabetes: Current perspectives. Diabetes, Metabolic Syndrome and Obesity: Targets and Therapy, Volume 11, 333–343. https://doi.org/10.2147/dmso.s106797
Jeon, S., & Kim, Y.-K. (2018). The role of neuroinflammation and neurovascular dysfunction in major depressive disorder. Journal of Inflammation Research, Volume 11, 179–192. https://doi.org/10.2147/jir.s141033
Levenson, J. C., Kay, D. B., & Buysse, D. J. (2015). The pathophysiology of insomnia. Chest, 147(4), 1179–1192. https://doi.org/10.1378/chest.14-1617
O’Callaghan, F., Muurlink, O., & Reid, N. (2018). Effects of caffeine on sleep quality and daytime functioning. Risk Management and Healthcare Policy, Volume 11, 263–271. https://doi.org/10.2147/rmhp.s156404
Park, L. T., & Zarate, C. A. (2019). Depression in the primary care setting. New England Journal of Medicine, 380(6), 559–568.https://doi.org/10.1056/nejmcp1712493
Shin, J., & Saadabadi, A. (2020). Trazadone. StatPearls. https://doi.org/https://www.ncbi.nlm.nih.gov/books/NBK470560/
Singh, H. K., & Saadabad, A. (2020). Sertraline. StatPearls. https://doi.org/https://www.ncbi.nlm.nih.gov/books/NBK547689/
Small, G. W. (2009). Differential diagnoses and assessment of depression in elderly patients. The Journal of Clinical Psychiatry, 70(12), e47. https://doi.org/10.4088/jcp.8001tx20c
Wichniak, A., Wierzbicka, A., Walęcka, M., & Jernajczyk, W. (2017). Effects of antidepressants on sleep. Current Psychiatry Reports, 19(9). https://doi.org/10.1007/s11920-017-0816-4
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Week 7 Discussion
Case: An elderly widow who just lost her spouse.
Subjective: A patient presents to your primary care office today with chief complaint of insomnia. Patient is 75 YO with PMH of DM, HTN, and MDD. Her husband of 41 years passed away 10 months ago. Since then, she states her depression has gotten worse as well as her sleep habits. The patient has no previous history of depression prior to her husband’s death. She is awake, alert, and oriented x3. Patient normally sees PCP once or twice a year. Patient denies any suicidal ideations. Patient arrived at the office today by private vehicle. Patient currently takes the following medications:
Metformin 500mg BID
Januvia 100mg daily
Losartan 100mg daily
HCTZ 25mg daily
Sertraline 100mg daily
Current weight: 88 kg
Current height: 64 inches
Temp: 98.6 degrees F
BP:132/86
Post a response to each of the following:
List three questions you might ask the patient if she were in your office. Provide a rationale for why you might ask these questions.
Identify people in the patient’s life you would need to speak to or get feedback from to further assess the patient’s situation. Include specific questions you might ask these people and why.
Explain what, if any, physical exams, and diagnostic tests would be appropriate for the patient and how the results would be used.
List a differential diagnosis for the patient. Identify the one that you think is most likely and explain why.
List two pharmacologic agents and their dosing that would be appropriate for the patient’s antidepressant therapy based on pharmacokinetics and pharmacodynamics. From a mechanism of action perspective, provide a rationale for why you might choose one agent over the other.
For the drug therapy you select, identify any contraindications to use or alterations in dosing that may need to be considered based on the client’s ethnicity. Discuss why the contraindication/alteration you identify exists. That is, what would be problematic with the use of this drug in individuals of other ethnicities?
Include any “check points” (i.e., follow-up data at Week 4, 8, 12, etc.), and indicate any therapeutic changes that you might make based on possible outcomes that may happen given your treatment options chosen.
According to the American Academy of Sleep Medicine, insomnia is defined as difficulty either falling or staying asleep that is accompanied by daytime impairments related to those sleep troubles (Balter & Uhlenhuth, 2017). Insomnia can be acute or chronic. Acute insomnia is common. Common causes include stress at work, family pressures, or a traumatic event. It usually lasts for days or weeks. Chronic insomnia lasts for a month or longer. Most cases of chronic insomnia are secondary (Stern et al, 2015).
List three questions you might ask the patient if she were in your office. Provide a rationale for why you might ask these questions.
I would ask the patient how long she has been taking the medication Sertraline, if her dose has ever been adjusted, and if she felt that it has helped her depression. The reason I am asking these questions is to determine if the medication is helping her depression and if it would benefit to increase them.
I would ask about medication adherence and educate about the importance of taking her medication as prescribed and not skipping dosage. Finding out if the patient is compliant with her medications can help determine the next step in treatment (Stern et al, 2015).
I would also ask about activities before sleep. For example, I would ask about activities such drinking alcohol beverages, or coffee before bed, smoking, exercising, and watching television. Since alcohol can reduce REM sleep and cause sleep disruptions, people who drink before bed often experience insomnia symptoms and feel excessively sleepy the following day.
. This patient may need some “calming” exercises and suggestions on how to decrease her brain’s state of arousal.
Identify people in the patient’s life you would need to speak to or get feedback from to further assess the patient’s situation. Include specific questions you might ask these people and why.
I would want to speak to this patient’s adult children if they are close to their mother and involved in her care. I would ask if they have seen any changes in their mother recently and if they have any other input, concerns, or suggestions when it comes to their mother’s care. I would also want to know if any of them or other family members has a history of insomnia.
List Explain what, if any, physical exams, and diagnostic tests would be appropriate for the patient and how the results would be used.
Since the patient is in her 70’s it is important I would get a CBC and a BMP to check for any abnormal labs and for baseline values. I would also draw endocine related labs. For example, cortisol, adrenocorticotropic hormone, melatonin, noradrenaline, γ-Aminobutyric acid, and calcium (Stern et al, 2015).
I would use the results of these labs to determine if the patient has any deficiencies or abnormalities that need treated that could be the cause of the patient’s insomnia.
I would also use the Hamilton or (DSM-5) depression scale with this patient to monitor the effects of the treatment on her depression symptoms.
List a differential diagnosis for the patient. Identify the one that you think is most likely and explain why.
A differential diagnosis for this patient would be insomnia associated with situational depression. The patient stated she lost her husband less than one year ago. This patient is more than likely still grieving her husband’s death and is unable to sleep due to her current situation.
List two pharmacologic agents and their dosing that would be appropriate for the patient’s antidepressant therapy based on pharmacokinetics and pharmacodynamics. From a mechanism of action perspective, provide a rationale for why you might choose one agent over the other.
For her depression I would start her on sertraline 50 mg daily, and then increase by 25 to 50 mg/day or the evening; may increase by 25 to 50 mg/day at intervals of at least 1 week to MAX 200 mg. Sertraline works by increasing the levels of a mood-enhancing chemical called serotonin in your brain. It helps many people recover from depression and has fewer unwanted side effects than older antidepressants (Stern et al, 2015).
I would also add trazadone for the insomnia, starting her at 25 mg at bedtime. The drug trazadone has been ‘approved for the treatment of depression, but the off-label use of this medication for insomnia has surpassed its usage as an antidepressant’ (McHorney et al,. 2019). Trazadone has reported sufficient sleep and has maintained sleep without causing daytime drowsiness (Stern et al, 2015).
For the drug therapy you select, identify any contraindications to use or alterations in dosing that may need to be considered based on the client’s ethnicity. Discuss why the contraindication/alteration you identify exists. That is, what would be problematic with the use of this drug in individuals of other ethnicities?
Some ethnicities are more prone to be carriers ‘of CYP2D6/CYP2C19 (cytochromes responsible for antidepressant metabolism)’ (Simon, 2017). This can cause problems with the metabolism of antidepressants, which can cause a buildup of toxic levels in the neurological system.
Include any “check points” (i.e., follow-up data at Week 4, 8, 12, etc.), and indicate any therapeutic changes that you might make based on possible outcomes that may happen given your treatment options choices.
I would want to see this patient back in the office in about two to three weeks in the office setting, she can also call the office if she has any questions. IT will also be a good idea to ask her to keep a log of her sleep schedule activity.
References
Balter, M. B., & Uhlenhuth, E. H. (2017). New epidemiologic findings about insomnia and its treatment. The Journal of clinical psychiatry. Vol 13.28 Pg 56-89.
McHorney, C. A., Ware Jr, J. E., & Raczek, A. E. (2019). The MOS 36-Item Short-Form Health Survey (SF-36): II. Psychometric and clinical tests of validity in measuring physical and mental health constructs. Medical care, 247-263.
Simon, G. E., & VonKorff, M. (2017). Prevalence, burden, and treatment of insomnia in primary care. American journal of psychiatry, 154(10), 1417-1423.
Stern, T. A., Fava, M., Wilens, T. E., & Rosenbaum, J. F. (2015). Massachusetts General hospital psychopharmacology and Neurotherapeutics E-book. Elsevier Health Sciences.
List three questions you might ask the patient if she were in your office. Provide a rationale for why you might ask these questions.
I would ask the patient how long she has been taking the medication Sertraline, if her dose has ever been adjusted, and if she felt that it has helped her depression. The reason I am asking these questions is to determine if the medication is helping her depression and if it would benefit to increase them.I would ask about medication adherence and educate about the importance of taking her medication as prescribed and not skipping dosage. Finding out if the patient is compliant with her medications can help determine the next step in treatment (Stern et al, 2015).
I would also ask about activities before sleep. For example, I would ask about activities such drinking alcohol beverages, or coffee before bed, smoking, exercising, and watching television. Since alcohol can reduce REM sleep and cause sleep disruptions, people who drink before bed often experience insomnia symptoms and feel excessively sleepy the following day.
. This patient may need some “calming” exercises and suggestions on how to decrease her brain’s state of arousal.
Identify people in the patient’s life you would need to speak to or get feedback from to further assess the patient’s situation. Include specific questions you might ask these people and why.I would want to speak to this patient’s adult children if they are close to their mother and involved in her care. I would ask if they have seen any changes in their mother recently and if they have any other input, concerns, or suggestions when it comes to their mother’s care. I would also want to know if any of them or other family members has a history of insomnia.
List Explain what, if any, physical exams, and diagnostic tests would be appropriate for the patient and how the results would be used.
Since the patient is in her 70’s it is important I would get a CBC and a BMP to check for any abnormal labs and for baseline values. I would also draw endocine related labs. For example, cortisol, adrenocorticotropic hormone, melatonin, noradrenaline, γ-Aminobutyric acid, and calcium (Stern et al, 2015).I would use the results of these labs to determine if the patient has any deficiencies or abnormalities that need treated that could be the cause of the patient’s insomnia.I would also use the Hamilton or (DSM-5) depression scale with this patient to monitor the effects of the treatment on her depression symptoms.
List a differential diagnosis for the patient. Identify the one that you think is most likely and explain why.A differential diagnosis for this patient would be insomnia associated with situational depression. The patient stated she lost her husband less than one year ago. This patient is more than likely still grieving her husband’
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