Category: Nursing

Practicum Week 10 Journal Entry

Week 10 Journal Entry

Reflect on your overall practicum experience in this course. Then, address the following in your Practicum Journal:

• Explain whether your therapeutic theory has changed as a result of your practicum experiences. Recall the theories you selected in Week 1.

• Explain how you integrated the therapeutic approaches from this course in your clinical practice. Include how this helped you achieve the goals and objectives you developed in Week 1.

• Explain how you might impact social change through your work with clients who have mental health issues. Practicum Week 10 Journal Entry.

• Support your approach with evidence-based literature.

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Week 10 journal entry

Explain whether your therapeutic theory has changed as a result of your practicum experiences. Recall the theories you selected in Week 1.

My therapeutic theory prior to the practicum experience was Peplau’s Theory, and this has not changed although. I feel that the theory stresses on the identity of nurses as carers, sentiments I concur with since I understand that nursing is concerned with caring as a central function when considering that patients receiving palliative care and who have had their medical intervention for a cure withdrawn would still require nursing care in the form of comfort. Still, the theory has some shortcomings that should be addressed to improve its functionality, especially in today’s nursing practice environment. Peplau’s theory was first developed by Hildegard Peplau in 1952 and has been revised twice in 1991 and 1997. Practicum Week 10 Journal Entry. It is a middle-range theory that acknowledges that nursing care can be improved through incorporating concepts from patient’s experiences. It notes that the relationship between nurses and patients has an influence on the overall experience of patients, holding to the notion that nursing care should be focused on patients’ perceptions and needs (Hagerty et al., 2017).

The central tenet of Peplau’s theory is that nurses’ core function is to aid patients who are facing difficulty and require care. The implication is that nursing personnel are therapeutic agents who have a contract with patients that allows them to have close interactions. As such, it is prudent to have a good interpersonal relationship between patients and nurses. The theory does not mention implications for interaction time, however, longer interactions are encouraged since they allow the relationship to mature at a faster rate while shorter interactions would cause the relationship to mature at a slower rate. To be more precise, the current form of the theory presents a concern about limited contact time between nursing personnel and patients. Another concern is that theory does not make allowances for information technology solutions. In fact, there is a need to revise the theory to allow for adoption of information technology solution, especially the self-guiding applications that use routine processes to improve the quality of interaction between patients and nursing personnel. Practicum Week 10 Journal Entry. Addressing the two concerns ensures that the theory keeps abreast with the reality of social transformations as it pertains to the 21
st
century, particularly in the face of social changes that include social media and the internet. These information technologies (such as online resource centers and smartphone applications) are acting as automated substitutes for routine nursing activities. The proposed revision should assign a supervisory role to nursing personnel, allowing them to intervene when clarification is needed (Peterson & Bredow, 2017). As such, my therapeutic theory remains the same although I would recommend that it be revised. Practicum Week 10 Journal Entry.

Explain how you integrated the therapeutic approaches from this course in your clinical practice. Include how this helped you achieve the goals and objectives you developed in Week 1.

The therapeutic approaches presented in my eclectic education were integrated into my clinical practice. In this case, my initial objective was to provide care through taking on a passive connotation of supporting or maintaining the patients’ current health position. However, I reviewed my objective during actual practice and realized that I need to be more proactive to make meaningful change. My new objective changed to not only achieving comfort (from support and maintenance) for my patients as a major nursing function, but also looking at comfort as simply the beginning in a structured process and not the end in itself. Currently, I view nursing as being concerned with providing care, a dynamic process whose main objective is the patients’ health. This is reflected in my ability as a nurse to improve the patients’ capacity for self-determination, self-esteem and self-care. Through reviewing the therapeutic approaches, I now understand that nursing is a dynamic process that is not simply concerned with supporting other medical interventions (such as the efforts of physicians), but has the potential for influencing the achievement of health for patients. This is particularly so when it is considered that nurses have traditional been concerned with caring functions while physicians have traditionally been concerned with curative functions (Finkelman, 2016).

In addition, I understand that therapeutic approaches applied in nursing should be ‘non-purist’. For this approaches to be effective, they must focus on highlighting the need for an effective helping relationship that is independent of theoretical orientation. The fundamental form of the helping relationship between nursing personnel and patients should be focused on integrating different theoretical orientations. This new mentality (‘non-purist’ approach) allows me to adopt appropriate patient-need-driven intervention that are not constrained by theoretical dogma. Besides that, the approach allows me to be an empowered, collaborative and perceptive nurse, allowing me to interactively work with the patients to teach, assess and understand the changes to the patient’s body that constitutes the illness. This should occur in both the inpatient and outpatient care settings, offering advice, help and professional support (Catalano, 2015) Practicum Week 10 Journal Entry.

During the process of integrating therapeutic approaches, I noticed that my interactions and relationship with the patients presented a tough challenge with regards to emotional stability and physical boundaries of the relationship. Still, my priorities should be guided by the understanding that therapeutic nursing is targeted at ill health and its meaning as perceived by patients and interpreted through medical literature, while encouraging a nurse-patient relationship that is creative rather than passive. Overall, every professional action that I undertake as a nurse should be reflective and intuitive, while encompassing therapeutic dimensions in nursing (Catalano, 2015).

Explain how you might impact social change through your work with clients who have mental health issues.

As a nurse, my work with patients who have mental health issues could impact social change. In fact, I have been actively engaged in eliminating health inequalities and achieving equity. This occurred through focusing on the importance of humility in acknowledging that cultural diversity exists and no single culture should smoother another culture. In addition, I consider trust as a foundation of my relationship with other stakeholders in the care environment (such as patients, family members and other medical personnel). Also, I have an awareness of myself and others in my professional environment. Practicum Week 10 Journal Entry. These qualities have allowed me to recognize and understand the effect of social health determinants on population outcomes, to include the physical and social environments, socio-economic status, behavioral and biologic response, and access to care. I understand that social determinants of health, inequality and poverty adversely affect health outcomes, mortality and morbidity. As a nurse, I am well positioned to assess patients and communities, advocate for care equality and justice, and partner with other stakeholders to address mental health issues as social change issues (Finkelman, 2016).

 

 

References

Catalano, J. (2015).
Nursing now! today’s issues, tomorrow’s trends
. (7
th
ed.). Philadelphia, PA: FA Davis Company.

Finkelman, A. (2016).
Leadership and management for nurses: core competencies for quality care
(3
rd
ed.). London: Pearson Education. Practicum Week 10 Journal Entry.

Hagerty, T., Samuels, W., Norcini-Pala, A. & Gigliotti, E. (2017). Peplau’s theory of interpersonal relations: an alternate factor structure for patient experience data?
Nurs Sci Q
., 30(2), 160-167. doi: 10.1177/0894318417693286

Peterson, S. J. & Bredow, T. S. (2017).
Middle range theories: application to nursing research
(4
th
ed.). Philadelphia, PA: Lippincott Williams & Wilkins. Practicum Week 10 Journal Entry.

Practicum Week 9 Journal Entry Essay assignment

Practicum – Week 9 Journal Entry

Learning Objectives

Students will:

• Develop diagnoses for clients receiving psychotherapy*

• Analyze legal and ethical implications of counseling clients with psychiatric disorders*

* The Assignment related to this Learning Objective is introduced this week and submitted in Week 10.

Select a child or adolescent client whom you observed or counseled this week. Then, address the following in your Practicum Journal:

• Describe the client (without violating HIPAA regulations) and identify any pertinent history or medical information, including prescribed medications. practicum Week 9 Journal Entry Essay assignment.

• Using the DSM-5, explain and justify your diagnosis for this client.

• Explain any legal and/or ethical implications related to counseling this client.

• Support your position with evidence-based literature.

Week 9 Journal Entry

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Introduction

This journal entry presents a description of a 16-year-old Caucasian female who presented with her mother with complaints on symptoms such as sadness, loss of appetite, feeling of worthlessness, social withdrawal, irritability, poor academic performance, among other symptoms. In addition, the diagnosis of the client will be made and justified according to the DSM-5 criteria. Finally, the legal or ethical implications related to providing psychotherapy to the client will be discussed.

Client Description

The client was a 16-year-old Caucasian female staying with both parents and her two siblings. The client presented with her mother. The mother reported that the client had become relatively difficult to handle unlike before. Her parents were experiencing significant marital issues and were currently separated and planning to officially divorce. The mother reported that the father has bipolar disorders and he has been hospitalized numerous times for psychiatric symptoms. practicum Week 9 Journal Entry Essay assignment.

The client’s academic performance had significantly dropped, she was skipping classed and she was having problems at school and hence the family was looking for a transfer because she was not even getting along with her classmates.

The client presented with these symptoms as reported by the mother and self: sadness for the most part of the day, crying spells, loss of appetite and weight loss, nicety, anger tantrums, irritability, low self-esteem, social withdraw, loss of interest in former activities such as watching television, sleeping problems, feelings of worthlessness and hopelessness, and concentration problems. Additionally, the client also reported difficulties in interpersonal relationships especially with her parents, friends and her classmates as well. practicum Week 9 Journal Entry Essay assignment. She also reported persistent negative thoughts regarding her physical appearances and academic abilities, in addition to guilt and remorse over her parents’ impending divorce.

The medical history of the client indicated that she has asthma, and has always been overweight. The mother further reported that the client was diagnosed with major depressive disorder 3 years ago and was provided treatment intermittently with supportive psychotherapy and pharmacological treatments that included sertraline and fluoxetine. This depressive episode was triggered by the death of her maternal grandmother whom she was very attached to. The most recent psychiatrist episode seemed to be related to the marital problems her parents were experiencing, as well as the academic problems and social difficulties.

Diagnosis of the Client

The diagnosis of the client is major depressive disorder, According to the DSM-5 diagnostic criteria, the clinical features of major depressive disorder include the following symptoms: depressed mood and sadness; reduced interest in nearly all activities; significant appetite and weight changes; sleep problems; psychomotor agitation; sleep problems, feeling of hopeless and worthlessness; fatigue; concentration problems; and suicidal thoughts (American Psychiatric Association, 2013). These symptoms significantly impair social, academic, occupation or any other vital functioning area. The client manifested symptoms such as sadness, loss of appetite, weight loss, irritability, social withdrawal, loss of interest in former interesting activities, sleep problems, concentration problems, and feelings of worthlessness and hopelessness. These symptoms have impaired the client’s academic and social functioning as indicated by declining academic performance and problems in relating to her classmates. Therefore, the client fits the diagnostic criteria of Major Depressive Disorder (American Psychiatric Association, 2013) practicum Week 9 Journal Entry Essay assignment.

Legal and/or Ethical Implications Related to Counseling the Client

The legal and ethical issues implicated to counseling this client include the clinical competence of the therapist, the issue of autonomy and informed consent, as well as the issue of confidentiality. The psychotherapist is ethically obligated to obey the law and protect the client’s best interests. However, working with the adolescent client presents a role conflict situation because children and adolescents are mostly brought to seek mental health services by their parents and sometimes the parents’ or guardians’ interests may not be congruent with the adolescents’ interests (Parsapoor et al, 2014). practicum Week 9 Journal Entry Essay assignment.  Therefore, the psychotherapist is legally obligated to conduct her/his independent assessment of the needs of the client while recognizing that the parent or guardian may have different “best interests” from the client’s best interests (Parsapoor et al, 2014). Therefore, the therapist should focus on the adolescents “best interest” clinically.

The issue of autonomy and decision making capacity may also affect the clients’ counseling. Parents normally give permission and informed consent while children and adolescents assent; this is an active process where all patients are engaged including children. While dealing with pediatrics, therapists encounter various cognitive difficulties regarding the parental participation in the decision-making process; this along with the parents who have the right and duty to care for their children (Grootens-Wiegers et al, 2017). For example, sometimes the adolescent may not be willing to participate in some treatment yet the parent consents to the treatment option due to the evidence health benefits.

Another aspect when counseling this client is the issue of confidentiality. According to Bista et al (2016) confidentiality of mental health records for pediatric clients receiving psychotherapy is not an absolute right. This is because parents or their legal guardians have the right to access the health records for their children who are still minors. The Health Insurance Portability and Accountability Act (HIPAA) stipulate that psychotherapists should normally cede to parents of minors the rights that the minor may exercise in regard to their health information (Colorafi & Bailey, 2016). Therefore, this client presents the issue of confidentiality and privacy because she is a minor and any information shared during treatment may be accessed by the parents. practicum Week 9 Journal Entry Essay assignment.

Conclusion

The client was a 16-year-old Caucasian female who presented with her mother. The client was manifesting symptoms such as sadness, loss of appetite, feeling of worthlessness, social withdrawal, irritability, poor academic performance, among other symptoms. The client’s symptoms fit the DSM-diagnostic criteria of major depressive disorder. The legal and ethical issues involved in counseling this client include informed consent, decision-making capacity, clinical competence of the psychotherapist, and the issue of confidentiality. practicum Week 9 Journal Entry Essay assignment.

References

American Psychiatric Association. (2013).
Diagnostic and statistical manual of mental disorders
  (5th ed.). Washington, DC: Author.

Bista B, Thapa P, Diksha S, Suman S & Paras P. (2016). Psychosocial Problems among Adolescent Students: An Exploratory Study in the Central Region of Nepal.
Front Public Health
. 4(158).

Colorafi K & Bailey B. (2016). It’s Time for Innovation in the Health Insurance Portability and Accountability Act (HIPAA).
JMIR Med Inform
. 4(4): e34.

Grootens-Wiegers P, Hein I, Broek  & Vries M. (2017). Medical decision-making in children and adolescents: developmental and neuroscientific aspects.
BMC Pediatr
. 17(120).

Parsapoor A, Parsapoor M, Nima R & Fariba A. (2014). The autonomy of Children and Adolescents in Consent to Treatment: Ethical, Jurisprudential and Legal Considerations.
Iran J Pediatr.
24(3), 241–248. practicum Week 9 Journal Entry Essay assignment.

Practicum – Week 8 Journal Entry Essay Assignment

Practicum – Week 8 Journal Entry

This week, you complete a two-part journal entry.

Learning Objectives

Students will:

• Develop diagnoses for clients receiving psychotherapy*

• Evaluate efficacy of existential-humanistic therapy for clients*

• Analyze legal and ethical implications of counseling clients with psychiatric disorders*

• Analyze clinical supervision experiences*

* The Assignment related to this Learning Objective is introduced this week and submitted in Week 10.

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For Part 1, select a client whom you observed or counseled this week (other than the client used for this week’s Discussion). Then, address the following in your Practicum Journal:

• Describe the client and identify any pertinent history or medical information, including prescribed medications Practicum – Week 8 Journal Entry Essay Assignment.

• Using the DSM-5, explain and justify your diagnosis for this client.

• Explain whether existential-humanistic therapy would be beneficial with this client. Include expected outcomes based on this therapeutic approach.

• Explain any legal and/or ethical implications related to counseling this client.

• Support your approach with evidence-based literature.

For Part 2, reflect on your clinical supervision experiences. Then, address the following in your Practicum Journal:

• How often are you receiving clinical supervision from your preceptor?

• What are the sessions like?

• What is the preceptor bringing to your attention?

• How are you translating these sessions to your clinical practice? Practicum – Week 8 Journal Entry Essay Assignment.

Journal entry

Part 1

Describe the client.

James is a 62-year-old Caucasian male. He has been admitted into the emergency room unconscious having been brought in by the personnel at the elderly home facility where he stays. He gained consciousness 30 minutes after admission. An interview with medical personnel reveals that he uses un-prescribed heroin as a pain reliever to address chronic back pain that he has experienced over the last five years. The back pain began after a bad fall while at home. He reports that he has been using heroin for the last two years but is very careful on how much he uses since he occasionally supplements the heroin with ice packs as a pain reliever. He further adds that he purchases the heroin from local dealers and has been careful not to expose his stash of drugs to the personnel at the elderly home facility. In addition, he has been careful to prevent his children from knowing that he uses heroin. In fact, he puts on a strong public face to show that everything is ok and he is not in pain. Practicum – Week 8 Journal Entry Essay Assignment. He admits that there are times when the back pain is unbearable and he ends up writhing in pain without the ability to engage in any other activity.

Identify any pertinent history or medical information, including prescribed medications.

James had an accident five years ago at home. He fell and hurt his back. Since then he has occasionally experienced chronic back pain that sometimes becomes debilitating. His initial case worker determined that he was at risk of developing an addiction and dependence on opioid pain medication. That was because he was demanding increasingly larger quantities of the medication at a faster rate Practicum – Week 8 Journal Entry Essay Assignment. The case worker recommended that he use alternative pain management therapies. Rather than explore alternative pain management therapies, James decided to look for other opioid sources since prescription opioid was closed to him. This led him to acquire heroin from dealers in his locality. Currently, he barely function without the heroin to manage his pain. He does not use any other prescription medication.

Using the DSM-5, explain and justify your diagnosis for this client.

Using DSM-5, James would be diagnosed with opioid use disorder. He initially used prescription opioids to manage his back pain and has since turned to using heroin to manage the pain since the prescriptions stopped. He has been acquiring the heroin from local dealers. He knows that purchasing and using heroin is a criminal activity since heroin is a controlled medication. He is aware that he will definitely be arrested by the police if found purchasing or using heroine. Besides that, he is aware that using heroin [resents a danger to his life owing to its addictive and dependence properties. Also, the drug has interfered with his personal responsibilities and safety. Overall, James exhibits excessive and compulsive heroin use, thus meeting the conditions for opioid use disorder based on DSM-5 criteria (Levounis, Zerbo & Aggarwal, 2016). Practicum – Week 8 Journal Entry Essay Assignment.

Explain whether existential-humanistic therapy would be effective with this client. Include expected outcomes based on this therapeutic approach.

Existential-humanistic therapy would be effective for this client. That is because the approach considers opioid use disorder is resultant from existential struggles, a true statement for the present client who developed the disorder from a need to address his chronic back pain. Using this approach would allow the client to focus on human potential, life meaning and objective reality, allowing him to create a life that does not revolve around managing his back pain. In addition, it would allow him to accept that pain is an inevitable part of life and that he is yet to reach his full potential, something that would only occur if he can live with the pain (Brooks, 2015). Although he is free to freely make the decisions that shape his life, he should make a decision that has meaning to his life since using heroin is a way of escaping his pain since it only removes him from his physical reality of the pain. Also, taking heroin is only temporarily pleasurable in eliminating the pain by introduces unfavorable negative consequences (Wheeler, 2014).

Explain any legal and/or ethical implications related to counseling this client.

Counseling James has an ethical implication. There is a confidentiality concern when it is considered that heroin is an illegal substance and the therapist could identify information about the dealers. How to handle such information is a challenge since reporting it to law enforcement officers violates confidentiality expectations while protecting other heroin users through blocking their supply. Practicum – Week 8 Journal Entry Essay Assignment. On the other hand, failing to report the information implies that other heroin users would still have their supply, turning them into addicts (Gunn & Taylor, 2014).

Part 2

How often are you receiving clinical supervision from your preceptor?

I receive clinical supervision from my preceptor once weekly.

What are the sessions like?

The sessions are typically tense but informative. The sessions are tense because I am supposed to ignore the presence of the preceptor and yet I can see him observing me and making notes. I typically feel that I am making mistakes when he takes notes. Also, the sessions are informative since the preceptor objectively evaluates my approach to care, guiding me on how to improve care delivery. Besides that, the presence of the preceptor makes it difficult to communicate with the client, especially with regards to disclosing confidential or embarrassing information since there is a third party (preceptor) that the client feels would disclose the information outside the session.

What is the preceptor bringing to your attention?

The preceptor brings to my attention the things issues that I should change or improve in my practice, as well as commending me on the things that I did well. The clinical supervision is objective with a view to improving my practice.

How are you translating these sessions to your clinical practice?

I am translating the supervised clinical session to clinical practice through incorporating the comments from the preceptor. Supervision is intended to improve my practice while confirming that I apply correct conventional approaches. Practicum – Week 8 Journal Entry Essay Assignment.

References

Brooks, T. (2015).
Alcohol and public health
. New York, NY: Routledge.

Gunn, J. & Taylor, P. (2014).
Forensic psychiatry: clinical, legal and ethical issues
(2
nd
ed.). Boca Raton, FL: CRC Press.

Levounis, P., Zerbo, E. & Aggarwal, R. (2016).
Pocket guide to addiction assessment and treatment
. Arlington, VA: American Psychiatry Association Publishing.

Wheeler, K. (Eds.) (2014).
Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice
(2
nd
ed.). New York, NY: Springer Publishing Company. Practicum – Week 8 Journal Entry Essay Assignment.

Assessing and Treating Clients With Dementia – 76-year-old Iranian Male

Alzheimer’s Disease

76-year-old Iranian Male

BACKGROUND

Mr. Akkad is a 76 year old Iranian male who is brought to your office by his eldest son for “strange behavior.” Mr. Akkad was seen by his family physician who ruled out any organic basis for Mr. Akkad’s behavior. All laboratory and diagnostic imaging tests (including CT-scan of the head) were normal.

According to his son, he has been demonstrating some strange thoughts and behaviors for the past two years, but things seem to be getting worse. Per the client’s son, the family noticed that Mr. Akkad’s personality began to change a few years ago. He began to lose interest in religious activities with the family and became more “critical” of everyone. They also noticed that things he used to take seriously had become a source of “amusement” and “ridicule.”

Over the course of the past two years, the family has noticed that Mr. Akkad has been forgetting things. His son also reports that sometimes he has difficult “finding the right words” in a conversation and then will shift to an entirely different line of conversation.

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SUBJECTIVE

During the clinical interview, Mr. Akkad is pleasant, cooperative and seems to enjoy speaking with you. You notice some confabulation during various aspects of memory testing, so the PMHNP performs a Mini-Mental State Exam. Mr. Akkad scores 18 out of 30 with primary deficits in orientation, registration, attention & calculation, and recall. The score suggests moderate dementia.

MENTAL STATUS EXAM

Mr. Akkad is 76 year old Iranian male who is cooperative with today’s clinical interview. His eye contact is poor. Speech is clear, coherent, but tangential at times. He makes no unusual motor movements and demonstrates no tic. Self-reported mood is euthymic. Affect however is restricted. He denies visual or auditory hallucinations. No delusional or paranoid thought processes noted. He is alert and oriented to person, partially oriented to place, but is disoriented to time and event [he reports that he thought he was coming to lunch but “wound up here”- referring to your office, at which point he begins to laugh]. Insight and judgment are impaired. Impulse control is also impaired as evidenced by Mr. Akkad’s standing up during the clinical interview and walking towards the door. When the PMHNP asked where he was going, he stated that he did not know. Mr. Akkad denies suicidal or homicidal ideation.

Diagnosis: Major neurocognitive disorder due to Alzheimer’s disease (presumptive)

RESOURCES

§ Folstein, M. F., Folstein, S. E., & McHugh, P. R. (2002). Mini-Mental State Examination (MMSE). Lutz, FL: Psychological Assessment Resources. Assessing and Treating Clients With Dementia – 76-year-old Iranian Male.

Decision Point One

Select what the PMHNP should do:

Begin Exelon (rivastigmine) 1.5 mg orally BID with an increase to 3 mg orally BID in 2 weeks

Begin Exelon (rivastigmine) 1.5 mg orally BID with an increase to 3 mg orally BID in 2 weeks

: Begin Aricept (donepezil) 5 mg orally at BEDTIME

: Begin Aricept (donepezil) 5 mg orally at BEDTIME

Begin Razadyne (galantamine) 4 mg orally BID

ca Begin Razadyne (galantamine) 4 mg orally BID

Below is a simple of how the paper will look, the needs an introduction, background of the case study, and a conclusion. All 3 medication is discussed in all 3 decisions, the reason why a medication is selected and a reason why they are not selected.

Assessing and Treating Clients with Dementia

Introduction

The focus of this assignment is on a client whose diagnosis is major neurocognitive disorder due to Alzheimer’s disease (presumptive). Major Neurocognitive disorder due to Alzheimer’s disease is diagnosed to a person manifesting cognitive deficits linked to the onset and progression of Alzheimer’s Dementia. In major neurocognitive disorder due to Alzheimer’s disease, a person has progressive cognitive dysfunction. Symptoms associated with major neurocognitive disorder due to Alzheimer’s disease, include cognitive decline manifested by complex attention where an individual is inattentive and take longer time in processing information; impaired of executive function manifested by inability to plan, impaired decision-making and inability to hold information; memory and learning problems; language problems manifested by loss of the speaking ability or aphasia; impaired perceptual-motor; social cognition exhibited by inability to identify emotions of other people; social withdrawal; as well as emotional distress (Apostolova, 2016). Therefore, this assignment will involve making three decisions about the client’s medication.

Background of the Case Study

This case study is on Mr. Akkad, a 76-year-old Iranian male who presented to the office accompanied by the son. The son reported that the client was exhibiting “strange behavior” manifested by changed personality and behavior. The client has lost interest in religious activities and was overly critical with everyone.  Other symptoms included forgetfulness, language problems, among other impaired cognitive functions. The client’s MMSE score was 18 out of 30 with major deficits in attention, calculation, memory, orientation, and registration indicating moderate dementia. On assessment, the client’s eye contact was poor, confused, restricted affect, euthymic mood, and impaired impulse control. His insight and judgment are also impaired, and he is also disoriented to event and time.

Decision Point One

The selected decision point one is to have the client begin Exelon (rivastigmine) 1.5 mg orally BID. The reason for selecting this medication is because rivastigmine is effective in treating Alzheimer’s disease and dementia. Symptoms in major neurocognitive disorder due to Alzheimer’s disease are as a result of pathological changes in cholinergic neuronal pathways. Therefore, rivastigmine is an appropriate choice because the medical works by improving cholinergic function; rivastigmine halts the process of acetylcholine breakdown and therefore increases the availability of acetylcholine in the brain improving, synaptic transmissions; this is what improves memory and other cognitive functions in individuals with major neurocognitive disorder and Alzheimer’s disease (Khoury et al, 2018). In addition, rivastigmine reduces the progress of the disease when the brain has fewer cells to make acetylcholine (Yoon-Sang et al, 2015). Assessing and Treating Clients With Dementia – 76-year-old Iranian Male.

The decision to start Aricept (donepezil) 5 mg orally at BEDTIME was not chosen because donepezil is associated with several side effects such as vomiting, loss of appetite, dizziness, diarrhea, shakiness as well as muscle cramps (Chen et al, 2017). In addition, administrating Aricept (donepezil) at bedtime is allied to sleep disturbances another reason the medication was not selected for the client (Carmen et al, 2014). Assessing and Treating Clients With Dementia – 76-year-old Iranian Male.

Selection of this decision hoped to improve the client’s symptoms which will be manifested by improved cognitive function. This is because the selected medication is effective in improving cognitive functions and other symptoms associated with the major neurocognitive disorder and Alzheimer’s disease (Yoon-Sang et al, 2015).

The actual outcome and the expected outcome were different because the son reported that the client’s symptoms did not improve and his MMSE score was still at 18 out of 30 with orientation, attention and memory deficits.

Decision Point Two

The selected decision point two is for the client’s rivastigmine dose to be increased to 4.5 mg orally BID. The reason for increasing the current dose of rivastigmine is because evidence indicates that higher dose of rivastigmine have higher efficacy because the medication’s efficacy is dose-dependent (Yoon-Sang et al, 2015). Assessing and Treating Clients With Dementia – 76-year-old Iranian Male. Therefore, a higher dose of rivastigmine for the client is expected to be more effective in improving cognitive functions and other behavioral symptoms for the client. This is because the increased dose of rivastigmine increases concentration acetylcholine within the brain and therefore increasing the medication’s efficacy (Yoon-Sang et al, 2015).

The reason for not selecting the decision to increase Exelon to 6 mg is because increasing the dose from 1.5 mg to 6 mg suddenly would result to a sudden increase of the drug levels within the bloodstream which may increase the possibility of the client having adverse and side effects. According to Nour et al (2016), a dosage increase for rivastigmine should be steady in order to ensure tolerability of the medication. The reason for not selecting the decision to discontinue Exelon and start Namenda is because there is no need to discontinue Exelon because the medication normally takes some time to stabilize symptoms in people with presumptive Alzheimer’s disease and therefore given time the client might start manifesting symptom improvement (Mahoney et al, 2014). Assessing and Treating Clients With Dementia – 76-year-old Iranian Male.

The decision to increase rivastigmine dose to 4.5 mg hoped to stabilize and improve the client’s symptoms of presumptive Alzheimer’s disease which will be manifested by improved cognitive function and the client’s ability to perform activities of daily living. It was also hoped that the client will tolerate the dose and therefore experience minimal side effects from the increased dose. This is because evidence shows that the efficacy of Exelon is dose-dependent and therefore increased dose is likely to be more effective for the client (Khoury et al, 2018). In addition, the steady increase in medication dose ensures a steady increase of the medication within the bloodstream and therefore minimal side effects for the individuals.

Generally, there was no difference between what was expected and the outcome of the selected decision. Assessing and Treating Clients With Dementia – 76-year-old Iranian Male. The outcome of the decision was that the client’s symptoms started improving as manifested by the client starting to take part in religious services with the family. The client also tolerated the medication well because he did not manifest any side effect with the increased dose.

Decision Point Three

The selected third decision is to increase the Exelon dose to 6 mg. The reason for selecting this decision is because the efficacy of Exelon is dose-dependent because an increased dose increases the level of acetylcholine in the brain and hence increasing the medication efficacy (Mahoney et al, 2014). Therefore, it is expected that with the increased level of acetylcholine, cognitive function and other behavioral symptoms for the client will improve.

The decision to maintain the current Exelon dose was not selected because the efficacy of Exelon is dose dependent and therefore it is important to increase the dose in order to increase the efficacy and hence improve the client’s symptoms (Mahoney et al, 2014). Assessing and Treating Clients With Dementia – 76-year-old Iranian Male. The decision to add Namenda 5 mg was not selected because it is recommended to maximize the dose of Exelon as a cholinesterase inhibitor prior to augmenting the Exelon medication.

Selection of the decision to increase Exelon dose to 6 mg was expected to have symptoms continue improving for the client; this would be manifested by improved cognitive functioning as well as the improved ability of the client to perform activities of daily living. According to Nour et al (2016), higher dosages of Exelon are effective in improving cognitive function and behavioral symptoms. It was also expected that the client would tolerate the increased dose and this will be manifested by no or minimal side effects Assessing and Treating Clients With Dementia – 76-year-old Iranian Male.

Ethical Considerations

Capacity determination, informed consent, and decision-making ability are the ethical aspects that may affect the client’s treatment plan. This is because the client is manifesting cognitive impairment as a symptom of             Alzheimer’s disease and this may interfere with his ability to understand the treatment options (Dunn et al, 2015).

Conclusion

The selected first decision is to have the client start Exelon 1.5 mg. The reason for choosing this decision is because Exelon has been shown to be effective in treating cognitive function for people with Alzheimer’s disease due to the improved cholinergic function. The results of the selected decision indicated no improvement which can be attributed to the fact that cholinesterase inhibitors take time to improve symptoms. The second decision was to increase the dose to 4.5 mg while the third decision was to increase the dose to 6mg orally. The reason for selecting decisions to increase Exelon dose was because the medication is dose-dependent where higher doses are more effective in treating symptoms for people with Alzheimer’s disease. The results of increased dose in the second and third decisions were that the client manifested improved disease symptoms since he was able to take part in religious activities with the family. Lastly, ethical issues that may affect the treatment plan for the client include informed consent, capacity determination, and decision-making ability because the client’s cognitive function is impaired. Assessing and Treating Clients With Dementia – 76-year-old Iranian Male.

References

Apostolova L. (2016). Alzheimer Disease.
Continuum (Minneap Minn
). 22(2): 419–434.

Carmen A, Soheyla, Angela S, Patty G, Angela H & Ragan S. (
2014
) Impact of nighttime donepezil administration on sleep in the older adult population: A retrospective study.
Mental Health Clinician
. 4(5), 257-259.

Chen R, Chan P, Chu H, Lin Y, Chang P, Chen C & Chou K. (2017). Treatment effects between monotherapy of donepezil versus combination with memantine for Alzheimer disease: A meta-analysis.
PLoS One
. 12(8), e0183586.

Dunn L, Alici Y & Wiss L. (2015). Ethical Challenges in the Treatment of Cognitive Impairment in Aging.
Current Behavioral Neuroscience Reports
. 2(4), 226-233.

Khoury R, Jayashree R & Grossberg G. (2018). An update on the safety of current therapies for Alzheimer’s disease: focus on rivastigmine.
Ther Adv Drug Saf
. 9(3), 171–178. Assessing and Treating Clients With Dementia – 76-year-old Iranian Male.

Mahoney J, Ari K, Verrico C, Arnoudse N, Shapiro B & Garza R. (2014). Preliminary findings of the effects of rivastigmine, an acetylcholinesterase inhibitor, on working memory in cocaine-dependent volunteers.
Prog Neuropsychopharmacol Biol Psychiatry
. 3(50): 137–142.

Nour J, Chouliaras L & Hickey L. (2016). High dose rivastigmine in the symptom management of Lewy body dementia Case Reports. 2016(2016):bcr2016217240.

Yoon-Sang O, Kim J & Lee P. (2015). Effect of Rivastigmine on Behavioral and Psychiatric Symptoms of Parkinson’s Disease Dementia.
J Mov Disord
. 8(2), 98–102. Assessing and Treating Clients With Dementia – 76-year-old Iranian Male.

Assessing and Treating Clients With Attention Deficit Hyperactivity Disorder – Young Girl With ADHD

Attention Deficit Hyperactivity Disorder

A Young Girl With ADHD

BACKGROUND

Katie is an 8 year old Caucasian female who is brought to your office today by her mother & father. They report that they were referred to you by their primary care provider after seeking her advice because Katie’s teacher suggested that she may have ADHD. Katie’s parents reported that their PCP felt that she should be evaluated by psychiatry to determine whether or not she has this condition.

The parents give the PMHNP a copy of a form titled “Conner’s Teacher Rating Scale-Revised”. This scale was filled out by Katie’s teacher and sent home to the parents so that they could share it with their family primary care provider. According to the scoring provided by her teacher, Katie is inattentive, easily distracted, forgets things she already learned, is poor in spelling, reading, and arithmetic. Her attention span is short, and she is noted to only pay attention to things she is interested in. Assessing and Treating Clients With Attention Deficit Hyperactivity Disorder – Young Girl With ADHD. The teacher opined that she lacks interest in school work and is easily distracted. Katie is also noted to start things but never finish them, and seldom follows through on instructions and fails to finish her school work.

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Katie’s parents actively deny that Katie has ADHD. “She would be running around like a wild person if she had ADHD” reports her mother. “She is never defiant or has temper outburst” adds her father.

SUBJECTIVE

Katie reports that she doesn’t know what the “big deal” is. She states that school is “OK”- her favorite subjects are “art” and “recess.” She states that she finds her other subjects boring, and sometimes hard because she feels “lost”. She admits that her mind does wander during class to things that she thinks of as more fun. “Sometimes” Katie reports “I will just be thinking about nothing and the teacher will call my name and I don’t know what they were talking about.”

Katie reports that her home life is just fine. She reports that she loves her parents and that they are very good and kind to her. Denies any abuse, denies bullying at school. Offers no other concerns at this time. Assessing and Treating Clients With Attention Deficit Hyperactivity Disorder – Young Girl With ADHD.

MENTAL STATUS EXAM

The client is an 8 year old Caucasian female who appears appropriately developed for her age. Her speech is clear, coherent, and logical. She is appropriately 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. Self-reported mood is euthymic. Affect is bright. Katie denies visual or auditory hallucinations, no delusional or paranoid thought processes readily appreciated. Attention and concentration are grossly intact based on Katie’s attending to the clinical interview and her ability to count backwards from 100 by serial 2’s and 5’s. Insight and judgment appear age appropriate. Assessing and Treating Clients With Attention Deficit Hyperactivity Disorder – Young Girl With ADHD. Katie denies any suicidal or homicidal ideation.

Diagnosis: Attention deficit hyperactivity disorder, predominantly inattentive presentation

RESOURCES

§ Conners, C. K., Sitarenios, G., Parker, J. D. A., & Epstein, J. N. (1998). Revision and restandardization of the Conners’ Teacher Rating Scale (CTRS-R): Factors, structure, reliability, and criterion validity. Journal of Abnormal Child Psychology, 26, 279-291.

Decision Point One

Select what the PMHNP should do:

Begin Wellbutrin (bupropion) XL 150 mg orally daily

Begin Wellbutrin (bupropion) XL 150 mg orally daily

Begin Intuniv extended release 1 mg orally at BEDTIME

Begin Intuniv extended release 1 mg orally at BEDTIME

Begin Ritalin (methylphenidate) chewable tablets 10 mg orally in the MORNING

Begin Ritalin (methylphenidate) chewable tablets 10 mg orally in the MORNING

Examine Case Study: A Young Caucasian Girl With ADHD You will be asked to make three decisions concerning the medication to prescribe to this client. Be sure to consider factors that might impact the client’s pharmacokinetic and pharmacodynamic processes. Assessing and Treating Clients With Attention Deficit Hyperactivity Disorder – Young Girl With ADHD.

At each decision point stop to complete the following:

• Decision #1

o Which decision did you select?

o Why did you select this decision? Support your response with evidence and references to the Learning Resources.

o What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.

o Explain any difference between what you expected to achieve with Decision #1 and the results of the decision. Why were they different?

• Decision #2

o Why did you select this decision? Support your response with evidence and references to the Learning Resources.

o What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources. Assessing and Treating Clients With Attention Deficit Hyperactivity Disorder – Young Girl With ADHD.

o Explain any difference between what you expected to achieve with Decision #2 and the results of the decision. Why were they different?

• Decision #3

o Why did you select this decision? Support your response with evidence and references to the Learning Resources.

o What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.

o Explain any difference between what you expected to achieve with Decision #3 and the results of the decision. Why were they different?

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.

The below is a simple paper, the three medication have to be discussed in all three decision, the reasons for selecting the one selected and the reason for not the other two that were not selected.

Week 2 Assignment: Assessing and Treating Pediatric Clients with Mood Disorders

Depression is considered an affective disorder due to its effect on the internal emotions and external mood seen by others (Stahl, 2013). Symptoms of depression include generalized sadness which can lead to feelings of guilt, fatigue, anxiety, poor concentration, changes in sleep pattern, increased or poor appetite and social isolation among many others. It is theorized that the cause of depression is due to a deficiency of monoamine neurotransmitters which are responsible for the amount of norepinephrine, serotonin and dopamine in the brain (Stahl, 2013). When treating a patient with depression, medications generally target this deficiency in hopes to provide relief from the symptoms the client is experiencing. Assessing and Treating Clients With Attention Deficit Hyperactivity Disorder – Young Girl With ADHD.

Case Study Information

The case study presented this week consists of an 8-year-old African American male presenting to the emergency department with mom due to increased feelings of sadness, withdrawn behavior in school, decreased appetite and occasional agitated behaviors (Laureate Education, 2016e). While the physical examination and laboratory studies were within normal limits, the mental status exam proved to be normal with reported “sad” mood, blunted affect but appropriately smiled at times and endorses thoughts of passive suicidal ideation (Laureate Education, 2016e). The client scored a 30 on the Children’s Depression Rating Scale, indicating significant depression (Laureate Education, 2016e).

The purpose of this assignment is to consider the 8-year-old client and information and make three decisions concerning medications to prescribe to the client. Each decision offers multiple options to choose from. Assessing and Treating Clients With Attention Deficit Hyperactivity Disorder – Young Girl With ADHD. The decision will be chosen based on evidence consisting of recent academic resources and research studies along with a rational for why the other two options were not chosen. Each outcome will be discussed based on if it was expected or not and what the next step will be. Lastly, ethical considerations will be discussed and how they may impact the treatment plan for the client and the communication with the client and his family.

Decision One

The first decision point the Psychiatric Mental Health Nurse Practitioner (PMHNP) must choose which medication the client will start. The medications to choose from include Zoloft (sertraline) 25 mg by mouth daily, Paxil (paroxetine) 10 mg by mouth daily, and Wellbutrin (bupropion) 75 mg by mouth twice daily (Laureate Education, 2016e). As the PMHNP caring for this client, Zoloft 25 mg daily would be the first choice of therapy for this patient. Selective serotonin reuptake inhibitors (SSRIs) are known to be the first line of treatment for children with depression (DeFilippis & Wagner, 2014). While sertraline and paroxetine are both SSRIs, sertraline is FDA approved when treating children whereas paroxetine has been found to be affective when treating children with depression, it is not specifically approved by the FDA at this point in time (Stahl, 2014b). Sertraline is approved by the FDA for use in children with depression beginning at the age of six (Stahl, 2013). Additionally, paroxetine is not recommended in use for children due to its short half-life which can lead to withdrawal when the medication is stopped abruptly (Nathan & Gorman, 2015).

The safety and efficacy of bupropion have not been established thus far but it some research that has been done suggests that this medication is effective for treatment of a client with both attention deficit disorder and depression, something that the client in this case study does not exhibit (Stahl, 2014b). Assessing and Treating Clients With Attention Deficit Hyperactivity Disorder – Young Girl With ADHD. Research has also shown that often the placebo effect alone on prescription medications can play a part in reduction of depressive symptoms in both children and adults (DeFilippis & Wagner, 2014).

As a new prescriber, I would most likely make a cautious decision when treating a child for the first time. Due to the fact that sertraline is FDA approved in the treatment of depression in children, I would most likely go with that medication as a primary action for prescribing for this client. The goal of this treatment is to alleviate depressive symptoms in the client while minimizing the risk for side effects of the medication.

When the client returned to the clinic four weeks after starting on Zoloft 25 mg daily, there was no change in the depressive symptoms at all (Laureate Education, 2016e). I am surprised that there was absolutely no change given the fact that the effects can be either medicinal or placebo, with changes seen as early as a week into the medication trial (Nathan & Gorman, 2015). As with all medications, there is always the chance that the client does not see an improvement in symptoms.

Decision Two

After the initial trial of Zoloft 25 mg yielded no change in the client’s symptoms, the treatment options are to increase the dose to 37.5 mg daily, increase the dose to 50 mg daily or to change the medication completely to Prozac 10 mg daily (Laureate Education, 2016e). Because the patient has not exhibited any adverse reactions to the medication, there is no need to change the medication at this time. As for titrating the sertraline, it can be titrated in increments of 25 mg with the maximum dosage not to exceed 200 mg daily (Southammakosane & Schmitz, 2015). Once the medication is started and tolerated, research supports titrating the medication up to minimize depressive symptoms (Cheung et al., 2018). Paroxetine, in general, was not recommended for treatment of pediatric depression based on research by Nathan & Gorman (2015) and this will not be considered for this client. Assessing and Treating Clients With Attention Deficit Hyperactivity Disorder – Young Girl With ADHD.

Based on this research, the decision was made to increase the Zoloft dose to 50 mg daily for the client. Again, the goals of treatment are to find a medication that reduces depressive symptoms in this pediatric patient while minimizing adverse effects. Once that goal is accomplished, long term goals for the client would be medication compliance and absence of relapse in depressive symptoms and suicidality.

The client returned to the clinic in four weeks with a decrease in depressive symptoms by 50% and is tolerating the medication well (Laureate Education, 2016e). While I anticipated the patient to have a reduction in depressive symptoms with the increase in dose, I had hoped the low dose would be effective for this patient. Assessing and Treating Clients With Attention Deficit Hyperactivity Disorder – Young Girl With ADHD. I am pleasantly surprised that the patient is not exhibiting any side effects from the medication.

Decision Three

The increase in the Zoloft dose to 50 mg yielded decreased depressive symptoms and no side effects (Laureate Education, 2016e). The next decision for the client involves maintaining the current dose, increasing the dose by 25 mg again to achieve a total dose of 75 mg daily or changing the medication to a SNRI (Laureate Education, 2016e). When discussing the medication with the client and parent, it would be important to discuss medication adherence to assure the client is taking the medication as directed. If this is the case, I would likely recommend increasing the dose to 75 mg due to the fact that the medication can be titrated up in 25 mg increments with the maximum prescribed dose of Zoloft being no more than 200 mg by mouth each day (Southammakosane & Schmitz, 2015). If the patient had seen no response and had reached the upper limit of Zoloft already, I would consider changing the medication, but it appears as though there is some desired effect from the medication without adverse reactions, which is the goal of treatment. Assessing and Treating Clients With Attention Deficit Hyperactivity Disorder – Young Girl With ADHD.

Serotonin-norepinephrine reuptake inhibitors (SNRI’s) such as duloxetine, venlafaxine and desvenlafaxine are considered second-line or third-line treatments for children with depression (Koechlin et al., 2018). Additionally, some research shows that there is significant cost benefit as well as safety in using SSRI’s over SNRI’s (Locher et al., 2107). In this case, I would continue with the SSRI medication I have been utilizing for this patient, which is a first line medication until I have exhausted my dosage options.

With increasing the dose of the Zoloft to 75 mg daily, I am hopeful that the medication will have an increased effect, perhaps 75-100% effective with little to no side effects. The response to the decision was that the client had a sufficient response to the medication with associated symptom reduction (Laureate Education, 2016e). It was recommended to either continue the Zoloft at 50 mg daily considering there was a response to the medication and evaluate again in four weeks to see if the medication continues to work or to increase it to 75 mg daily considering it was not complete remission of depressive symptoms (Laureate Education, 2016e).

While an increased dose may yield potential adverse effects, it can also give the necessary response of decreased depressive symptoms. This could be an opportunity to discuss the medication and symptoms with both the client and his parents to make them apart of the decision making. Although the client is only 8-years-old, he is capable of discussing his feelings as well as his response to the medication. Family can offer additional feedback from an external source about the client’s symptoms (Stahl, 2013). Should the patient not be able to tolerate the medication increase, the dose can be decreased as well Assessing and Treating Clients With Attention Deficit Hyperactivity Disorder – Young Girl With ADHD. As I anticipated with the third decision, there is no reason to change the medication to an SNRI at this time considering the client is tolerating the Zoloft dose and exhibiting a response to it.

Conclusion

While there is not one correct answer when treating a child with depression, beginning drug therapy with a SSRI and titrating up slowly and as indicated has proved to be effective for my 8-year-old client with depression. When combined with therapy, such as cognitive behavioral therapy (CBT) treatment is enhanced and side effects of medications are diminished (Giles & Martini, 2016). Along with follow up for medication management, this client and his mom should also be educated on potential side effects including potential increase in suicidality. Should this happen, the client should be encouraged to reach out to a parent or adult he trusts and seek an appointment immediately. Assessing and Treating Clients With Attention Deficit Hyperactivity Disorder – Young Girl With ADHD.

Ethically, when treating clients with medications, benefit of treatment must outweigh potential harm (Merry et al., 2017). When discussing the treatment plan with the client and family, we must remain transparent and educate them on the pros and cons of the medications and also the potential for a placebo effect from taking an antidepressant medication. Information should be provided based on educational level and should be basic enough for an 8-year-old to understand and also complex enough for the parent to gauge an understanding of the medication their child is taking Assessing and Treating Clients With Attention Deficit Hyperactivity Disorder – Young Girl With ADHD.

This assignment was an opportunity to examine different medication therapy for a child with depression and make changes as needed to help alleviate the client’s symptoms. Although there is not one clear answer when diagnosing and treating patients, it is important we treat each patient individually and based upon their needs and responses to medications prescribed.

References

Cheung, A. H., Zuckerbrot, R. A., Jensen, P. S., Laraque, D., Stein, R. E., & GLAD-PC

STEERING GROUP. (2018). Guidelines for adolescent depression in primary care (GLAD-PC): Part II. Treatment and ongoing management. Pediatrics, 141(3), e20174082.

DeFilippis, M., & Wagner, K. D. (2014). Management of treatment-resistant depression in

children and adolescents. Pediatric Drugs, 16(5), 353-361

Giles, L. L., & Martini, D. R. (2016). Challenges and promises of pediatric

psychopharmacology. Academic pediatrics, 16(6), 508-518. Assessing and Treating Clients With Attention Deficit Hyperactivity Disorder – Young Girl With ADHD.

Koechlin, H., Kossowsky, J., Gaab, J., & Locher, C. (2018). How to address the placebo

response in the prescription SSRIs and SNRIs in children and adolescents.

Laureate Education (2016e). Case study: An African American child suffering from depression

[Interactive media file]. Baltimore, MD: Author.

Locher, C., Koechlin, H., Zion, S. R., Werner, C., Pine, D. S., Kirsch, I. & Kossowsky, J. (2017).

Efficacy and Safety of Selective Serotonin Reuptake Inhibitors, Serotonin-Norepinephrine Reuptake Inhibitors, and Placebo for Common Psychiatric Disorders Among Children and Adolescents: A Systematic Review and Meta-analysis. JAMA Psychiatry, 74(10), 1011–1020. http://doi.org/10.1001/ jamapsychiatry.2017.2432

Merry, S. N., Hetrick, S. E., & Stasiak, K. (2017). Effectiveness and Safety of Antidepressants

for Children and Adolescents: Implications for Clinical Practice. JAMA psychiatry, 74(10), 985-986.

Nathan, P. E., & Gorman, J. M. (Eds.). (2015). A guide to treatments that work. Oxford

University Press Assessing and Treating Clients With Attention Deficit Hyperactivity Disorder – Young Girl With ADHD.

Introduction

Attention Deficit Hyperactive Disorder is a mental health disorder in which children present with symptoms of being impulsive, inattentive or hyperactive. Impulsivity refers to a child acting in a way which is overly rash, impatient, inconsiderate and careless for his/her age. Inattentiveness refers to a child who has a lot of difficulties to focus and gets distracted easily. Hyperactivity refers to a child who constantly keeps fidgeting and is generally restless. For instance, during lessons at school, one is not able to remain still.  ADHD can result in major problems in the life of a child and activities of daily life. Since they behave differently than expected, children with ADHD cause a lot of trouble. Assessing and Treating Clients With Attention Deficit Hyperactivity Disorder – Young Girl With ADHD.

Case Study Overview

In this week, the client is an 8-year-old Caucasian female named Katie who was accompanied by her mother and father as a referral from their primary care provider with reports from her teacher that she could be having ADHD. The PCP was certain that Katie needed to be evaluated by a psychiatrist to establish whether or not she had ADHD. Upon conducting a thorough evaluation, a diagnosis of Attention Deficit Hyperactivity Disorder, predominantly inattentive presentation was made. Based on the client’s presentation, the purpose of this paper is to determine the best psychopharmacologic drugs to use in the management of the client based on three decisions. The reasons for selecting each decision will have a rationale from currently existing academic resources. The expected and actual outcomes for each decision will be discussed alongside the ethical considerations and how they are likely to impact the client’s treatment plan and communication with the family and client.

Decision #1

Decision Selected

Begin Ritalin (methylphenidate) chewable tablets 10 mg orally in the morning.

Reason for Selecting This Decision

According to Thomas et al., (2015), Ritalin is a stimulant medication that has been used for decades in the management of ADHD since it is a cognitive enhancer. It functions by promoting the presence of neurotransmitters dopamine and norepinephrine in the CNS which speeds up the activity of the brain. Ritalin is fast acting and gets to the peak performance faster than other stimulant medications (Tarrant et al., 2018).  Besides, it is also affordable and readily available in the market, and therefore the best choice in this case. Wellbutrin could be a good choice since it is also used off label for managing ADHD but in adults. It works by increasing the availability of norepinephrine and dopamine in the frontal cortex, which explains its effectiveness in managing symptoms of ADHD. However, it has suicidal ideation as a major side-effect in adolescents and children thus not a good choice for this patient who is 8 years old (Briars & Todd, 2016). Assessing and Treating Clients With Attention Deficit Hyperactivity Disorder – Young Girl With ADHD.

Intuniv could also be a good choice since it a non-stimulant drug used in the management of oppositional behaviors in children with ADHD. It, however, has a major side effect of sedation which can make a patient be very sluggish in a whole day (Briars & Todd, 2016). It also has very minimal or no effect on improving a child’s attention. Therefore, for Katie in this case, it wouldn’t be a good choice since sedation will negatively impact her quality of life, social functioning, and academic performance.

Expected Outcome

           
By starting Katie on Ritalin (methylphenidate) chewable tablets 10 mg orally in the morning, it was expected that Katie would have some improvement in terms of paying attention at school and that her academic performance will also improve. Ritalin has been approved by the FDA for treatment of ADHD in patients aged 6 years and older, although it can also be used for managing children who are younger than 6 years of age and diagnosed with ADHD. It targets norepinephrine and dopamine in the brain to reduce common symptoms of attention, concentration, fidgeting and enhancing listening skills (Huss, et al, 2017). Assessing and Treating Clients With Attention Deficit Hyperactivity Disorder – Young Girl With ADHD.

Difference between Expected Outcome and Actual Outcome

The client returned to the clinic after four weeks accompanied by her parents who reported that according to Katie’s teacher reports,  her symptoms were much better in the morning, the progress that has resulted to her overall improvement in her academic performance. However, her teacher noted that, in the afternoon, Katie often stared into space and started to daydream again. Katie’s parents were also concerned about Katie’s reports that her heart felt funny. Upon taking a pulse rate, I found that Katie’s heart was regular and beating at about 130 beats per minute. The fast heartbeat that the patient reported was a side effect of Ritalin. The immediate release form of Ritalin has tachycardia as a common side effect (Huss, et al, 2017).   Besides, the immediate release form cannot help Katie maintain her attention throughout the day.

It also worth noting that, since the heartbeat was regular with no other signs of cardiac abnormality, the best way to address this issue is by switching to a long-acting preparation (Huss, et al, 2017).

Decision # 2

Decision Selected

Change to Ritalin LA 20mg orally in the morning

Reason for Selecting This Decision

Ritalin LA is the long-acting formulation of Ritalin. The decision for this choice was attributed to initial reports that although Katie had shown some improvement in her academic performance and could remain focused in the morning hours, she had a lot of difficulties maintaining her attention in the remainder of the day. Therefore, Ritalin LA would her to remain focused the whole day (Briars & Todd, 2016).  Besides, Ritalin LA would help to reduce the severity of the side effect of tachycardia. Assessing and Treating Clients With Attention Deficit Hyperactivity Disorder – Young Girl With ADHD.

Expected Outcome

By starting the client on Ritalin LA 20mg orally in the morning, it was expected that she will be able to pay attention for an entire day in school as compared to previous reports. As a result, her academic performance will also improve significantly. It was also expected that the client will no longer report about ‘hear heart feeling funny’. Therefore, the symptoms of tachycardia will completely disappear and her heartbeat will return to normal for her age (Tarrant et al., 2018).

Difference between Expected Outcome and Actual Outcome

The patient returned to the clinic after four weeks with reports that her academic performance has really improved and that the switch to LA lasted her in the entire school day. Katie also informed that reports of her heart feeling funny had gone away and when taking her pulse during that visit, it was 92 which was good treatment progress (Briars & Todd, 2016).

Decision #3

Decision Selected

Maintain the current dose of Ritalin and re-evaluate the patient again in 4 weeks.

Reason for Selecting This Decision

Based on the client’s previous visit, it was evident that all her symptoms were well contained and her attention could be sustained during the entire school day. Besides, by changing to a long-acting preparation, the side effects that the client experienced went away. It should also be noted that there is no indication to increase the dosage and as recommended by the FDA, maintaining low effective dosages of stimulant medications is the most preferred approach of managing ADHD (Tarrant et al., 2018). Thus, maintaining the current dosage of Ritalin and re-evaluating the client after 4 weeks is the best decision. Ritalin remains the best medication choice for the symptoms of inattentiveness and deficits in concentration. Assessing and Treating Clients With Attention Deficit Hyperactivity Disorder – Young Girl With ADHD.

Expected Outcome

                       
It was expected that the patient will show more improvement as compared to the previous visit. Her symptoms of forgetfulness, inattentiveness, generally lacking interest in school work and poor spelling will totally be diminished and will no longer have tachycardia or other side effects caused by Ritalin(Huss, et al, 2017).

Difference between Expected Outcome and Actual Outcome

There was no significant difference between the expected outcome and the actual outcome. The client returned to the clinic after four weeks accompanied by her parents. She reported that her academic performance had continued to improve and was able to focus throughout the day. There were also no reports about tachycardia and the pulse rate was notably 90 during this visit (Thomas et al., 2015)

How Ethical Considerations Might Impact Treatment Plan and Communication with Families and the Client

           
From an ethical perspective, in managing pediatric clients with ADHD, the benefits of  treatment should outweigh the potential harm that can be caused by the same treatment.  This, therefore, requires that mental health practitioners strictly observe the ethical principles of non-maleficence and beneficence (Gardner, Ruest & Cummings, 2016).   During discussions regarding the treatment plan with the client and her family, it is mandatory that a mental health practitioner provides true information and remains transparent. He/she should not forget to provide additional information about the benefits, risks and available options for every treatment for a client to choose from (Gardner, Ruest & Cummings, 2016).

Conclusion

ADHD is a complex mental health disorder that develops in preschool years and whose symptoms can manifest either partially or fully entirely to adulthood. Drugs to treat ADHD in adolescents and children exist in long and short-acting formulations. However, formulations that are short-acting of Ritalin which is generally given 2-3 times daily have proven to be very efficacious in reducing the symptoms of ADHD are flexible in terms of flexibility of the dosages. Assessing and Treating Clients With Attention Deficit Hyperactivity Disorder – Young Girl With ADHD.

References

Briars, L., & Todd, T. (2016). A review of pharmacological management of attention-deficit/hyperactivity disorder. 
The Journal of Pediatric Pharmacology and Therapeutics
, 
21
(3), 192-206.

Gardner, K., Ruest, S., & Cummings, B. (2016). Diagnostic Uncertainty and Ethical Dilemmas in Medically Complex Pediatric Patients and Psychiatric Boarders. 
Hospital pediatrics
, 
6
(11), 689-692.

Huss, M., Duhan, P., Gandhi, P., Chen, C. W., Spannhuth, C., & Kumar, V. (2017). Methylphenidate does optimization for ADHD treatment: a review of safety, efficacy, and clinical necessity.
Neuropsychiatric disease and treatment
, 
13
, 1741.

Thomas, R., Sanders, S., Doust, J., Beller, E., & Glasziou, P. (2015). Prevalence of attention-deficit/hyperactivity disorder: a systematic review and meta-analysis. 
Pediatrics
, 
135
(4), e994-e1001. Assessing and Treating Clients With Attention Deficit Hyperactivity Disorder – Young Girl With ADHD.

Tarrant, N., Roy, M., Deb, S., Odedra, S., Retzer, A., & Roy, A. (2018). The effectiveness of methylphenidate in the management of Attention Deficit Hyperactivity Disorder (ADHD) in people with intellectual disabilities: A systematic review. 
Research in developmental disabilities
, 
83
, 217-232. Assessing and Treating Clients With Attention Deficit Hyperactivity Disorder – Young Girl With ADHD.

Assessing and Treating Clients With Impulsivity, Compulsivity, and Addiction Essay

Co-morbid Addiction (ETOH and Gambling)

53-year-old Puerto Rican Female

BACKGROUND

Mrs. Maria Perez is a 53-year-old Puerto Rican female who presents to your office today due to a rather “embarrassing problem.”

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SUBJECTIVE

Mrs. Perez admits that she has had “problems” with alcohol since her father died in her late teens. She reports that she has struggled with alcohol since her 20’s and has been involved with Alcoholics Anonymous “on and off” for the past 25 years. She states that for the past two years, she has been having more and more difficulty maintaining her sobriety since they opened the new “Rising Sun” casino near her home. Mrs. Perez states that she and a friend went to visit the new casino during their grand opening at which point she was “hooked.” She states that she gets “such a high” when she is gambling. While gambling, she “enjoys a drink or two” to help calm her during high-stakes games. She states that this often gives way to more drinking and more reckless gambling. She also reports that her cigarette smoking has increased over the past two years and she is concerned about the negative effects of the cigarette smoking on her health. Assessing and Treating Clients With Impulsivity, Compulsivity, and Addiction Essay.

She states that she attempts to abstain from drinking but that she gets such a “high” from the act of gambling that she needs a few drinks to “even out.” She also notices that when she drinks, she doesn’t smoke “as much” but enjoys smoking when she is playing at the slot machines. She also reports that she has gained weight from drinking so much- she currently weights 122 lbs., which represents a 7 lb. weight gain from her usual 115 lb. weight.

Mrs. Perez is quite concerned today because she has borrowed over $50,000 from her retirement account to pay off her gambling debts. Assessing and Treating Clients With Impulsivity, Compulsivity, and Addiction Essay. She is very concerned because her husband does not know that she has spent this much money.

MENTAL STATUS EXAM

The client is a 53-year-old Puerto Rican female who is alert, oriented to person, place, time, and event. She is dressed appropriately for the weather and time of year. Her speech is clear, coherent, and goal directed. Her eye contact is somewhat avoidant during the clinical interview. As you make eye contact with her, she looks away or looks down. She demonstrates no noteworthy mannerisms, gestures, or tics. Her self-reported mood is “sad.” Affect is appropriate to content of conversation & self-reported mood. She visual or auditory hallucinations, no delusional or paranoid thought processes are readily appreciated. Insight and judgment are grossly intact, however, impulse control is impaired. She is currently denying suicidal or homicidal ideation. Assessing and Treating Clients With Impulsivity, Compulsivity, and Addiction Essay.

Diagnosis: Gambling disorder, alcohol use disorder

Decision Point One

Select what the PMHNP should do:

Naltrexone (Vivitrol) injection, 380 mg intramuscularly in the

Naltrexone (Vivitrol) injection, 380 mg intramuscularly in the gluteal region every 4 weeks

gluteal region every 4 weeks

Antabuse (Disulfiram) 250 mg orally daily

Antabuse (Disulfiram) 250 mg orally daily

Campral (Acamprosate) 666 mg orally three times/day

Campral (Acamprosate) 666 mg orally three times/day

To prepare for this Assignment:

• Review this week’s Learning Resources. Consider how to assess and treat adolescent clients requiring therapy for impulsivity, compulsivity, and addiction.

The Assignment

Examine Case Study: A Puerto Rican Woman With Comorbid Addiction. You will be asked to make three decisions concerning the medication to prescribe to this client. Be sure to consider factors that might impact the client’s pharmacokinetic and pharmacodynamic processes.

At each decision point stop to complete the following:

• Decision #1

o Which decision did you select?

o Why did you select this decision? Support your response with evidence and references to the Learning Resources.

o What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.

o Explain any difference between what you expected to achieve with Decision #1 and the results of the decision. Why were they different? Assessing and Treating Clients With Impulsivity, Compulsivity, and Addiction Essay.

• Decision #2

o Why did you select this decision? Support your response with evidence and references to the Learning Resources.

o What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.

o Explain any difference between what you expected to achieve with Decision #2 and the results of the decision. Why were they different?

• Decision #3

o Why did you select this decision? Support your response with evidence and references to the Learning Resources.

o What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.

o Explain any difference between what you expected to achieve with Decision #3 and the results of the decision. Assessing and Treating Clients With Impulsivity, Compulsivity, and Addiction Essay. Why were they different?

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.

In each decision please discuss reason why the other 2 medication were not used, there should be an introduction and a conclusion.

Assessing and Treating Clients with Impulsivity, Compulsivity, and Addiction

Introduction

The focus of this assignment is on Mrs. Maria Perez is a 53-year-old Puerto Rican female who was diagnosed with a gambling disorder, alcohol use disorder. Gambling disorder refers to the repetitive and persistent maladaptive gambling behavior as manifested by preoccupation with gambling; has to gamble with larger sums of money to attain the anticipated excitement; constant unsuccessful efforts to stop or control gambling; irritability when trying to stop gambling; goes back to gambling even after losing money; lies to family and endangers relationships, work, education etc. to gamble, among other symptoms (Calado & Griffiths, 2016). On the other hand, alcohol use disorder is the inability of a person to manage or control their alcohol-intake behaviors in spite of the desire to stop or the alcohol intake jeopardizing their relationships, work, education etc. (Yau & Marc, 2015). The client reported of alcohol and gambling addiction and is also worried about her increased tobacco smoking. MSE for the client indicates that the client is avoiding direct eye contact and is sad as well. Accordingly, in this paper, three decisions will be made on the client’s treatment while considering the pharmacokinetic and pharmacodynamics effects on the client. Assessing and Treating Clients With Impulsivity, Compulsivity, and Addiction Essay.

Decision Point One

The first decision that was selected is to administer the client with Naltrexone (Vivitrol) injection, 380 mg intramuscularly in the gluteal region every 4 weeks. The rationale for selecting this decision is based on the fact that naltrexone is a competitive antagonist at addiction/alcohol receptors and therefore inhibits alcohol agonist-induced effects, including the effects the alcohol abusers desire. The medication also represses the desire for alcohol intake (Sullivan et al, 2014). Therefore, Naltrexone (Vivitrol) is an appropriate choice to treat alcohol addiction for the client. Additionally, clinical trials demonstrate the efficacy of Naltrexone in treating alcoholism (Alanis-Hirsch et al, 2016). Assessing and Treating Clients With Impulsivity, Compulsivity, and Addiction Essay. Moreover, the medication has minimal side effects and therefore the client is likely to tolerate the administered dose with the targeted efficacy.

The option of Antabuse (Disulfiram) 250 mg orally daily was not selected because the medication is associated with numerous serious side effects such as a headache, dyspnea, sympathetic over-activity, palpitations, vomiting, seizure, coma, and even death. Moreover, there is a high risk of toxicity with the medication in addition to the high rate of non-adherence with Disulfiram (Crowley, 2015). On the other hand, the option of Campral (Acamprosate) was not selected because evidence recommends Campral to be used in combination with psychological and social treatment as a component of a full alcohol addiction treatment (Crowley, 2015). In addition, guidelines recommend the medication to be started 5-7 days after the last drink yet the client has not withdrawn from the alcohol. In addition, the 3-times daily dosing regimen with Campral can reduce its adherence (Crowley, 2015). Assessing and Treating Clients With Impulsivity, Compulsivity, and Addiction Essay.

With this decision, the expectation was that the client will gradually reduce her alcohol abuse, and stop craving for alcohol and desire to gamble as well. This is because studies demonstrate the efficacy of Naltrexone (Vivitrol) in lowering the desire to take alcohol as well as in reducing gambling cravings in individuals with gambling disorder. The other expectation was that the client would tolerate the medication and therefore she would not experience any adverse event.

The outcome that was hoped for and the results of the decision were almost similar. This is because after starting Naltrexone (Vivitrol) injection, the client did stop alcohol intake and also there was a reduction in gambling. The only difference is that the client reported complaints about anxiety. The anxiety is a common side effect of Naltrexone (Vivitrol) medication.

Decision Point Two

For decision 2, the decision that was chosen is to add valium (diazepam) 5 mg. This reason for choosing this decision is to treat the anxiety for the client. The medication was selected because valium influences GABA receptors within the brain; the receptors regulate anxiety. Valium influences GABA receptors by slowing the central nervous system which reduced the feelings of anxiety and produces a calming effect and therefore reduced anxiety symptoms (Calcaterra & Barrow, 2014). A study conducted by Warren et al (2016) indicated the efficacy of valium in the treatment of anxiety symptoms. Assessing and Treating Clients With Impulsivity, Compulsivity, and Addiction Essay.

The choice to have the client attend counseling for gambling issue was not chosen because this option would not address the anxiety the client is currently manifesting and also the client is already manifesting improvement in regard to gambling. The option of adding Chantix (varenicline) was not chosen due to the many adverse and side effects associated with varenicline, for example, suicide, sleep disturbance, cardiovascular events etc. (Davies et al, 2015).

Selection of this decision aimed to ensure that the symptoms of anxiety that the client is manifesting would improve. This is because the evidence demonstrates the efficacy of valium in improving anxiety symptoms (Warren et al, 2016). Another expectation was that the client would not have a dependency on the medication.

There were no notable differences between the expected results and the actual outcome of the decision. Assessing and Treating Clients With Impulsivity, Compulsivity, and Addiction Essay. The actual outcome was that the symptoms of anxiety considerably improved. The only difference is that the client was asking for higher and frequent doses of the medication indicating a dependency on the medication. The dependency the client is manifesting on valium is because of the addictive effect of valium as a benzodiazepine (Tvete et al, 2016).

Decision Point Three

The chosen decision point three is for the client to continue with Vivitrol dose; taper Valium with the aim to discontinue the medication within the next two weeks and to have the client to counseling for the gambling issue. The reason for selecting the decision to taper valium is to gradually withdraw the medication and discontinue it in two weeks because the client is showing symptoms of dependency on the medication. According to Tvete et al (2016) benzodiazepines such as valium are not supposed to be taken for more than two-four weeks of continuous use since individuals can develop dependency and tolerance even after a short period. The decision to not discontinue valium immediately is because sudden withdraw might have led to the client developing withdrawal symptoms. Evidence and guidelines recommend gradual withdrawal of benzodiazepines in order to avoid patients from experiencing withdrawal symptoms (Fluyau et al, 2018). In addition, this option also involved the client being referred to counseling to help in her gambling addiction. Assessing and Treating Clients With Impulsivity, Compulsivity, and Addiction Essay. Evidence shows that counseling is effective in managing gambling addiction and therefore counseling would have addressed gambling addiction for the client (Choliz, 2018).

Options to continue with the existing Vivitrol dose and maintain or increase the current valium dose were not chosen because the client needs to be tapered off the valium medication because she is already showing dependency on the medication and therefore there is need to gradually withdraw the medication (Warren et al, 2016).

Selecting the decision to continue with Vivitrol dose and taper Valium medication hoped to gradually withdrawal valium for the patient and ensure the client does not develop any valium dependency. Another expectation was that the counseling would address the gambling issue for the client and help reduce the gambling addiction. Assessing and Treating Clients With Impulsivity, Compulsivity, and Addiction Essay.

Conclusion

The first decision point for the client was to administer Naltrexone (Vivitrol) injection every four weeks. This decision was selected because Vivitrol has been shown to be effective in the treatment of alcohol addiction. Just like it was expected, the client stopped drinking alcohol and also she stop gambling as frequently as before. Nonetheless, the client manifested anxiety and this was attributable to the side effects of Vivitrol. The second decision was the addition of valium (diazepam) for the treatment of the client’s anxiety symptoms. Just as expected, the anxiety levels for the client reduced. However, the client exhibited a dependency on valium as indicated by her request to increase the valium dose. Assessing and Treating Clients With Impulsivity, Compulsivity, and Addiction Essay. Due to the evidence dependency on valium, the third decision that was selected was to have the current dose of naltrexone maintained while gradually tapering valium dose. This decision was chosen because even though the client is showing dependency on the medication, sudden withdrawal would result in withdrawal symptoms for the client. The third decision also involved referring the client to a counselor to have her gambling addiction issue addressed. Finally, the therapist should maintain the confidentiality of all information that the client disclosed and not divulge the information to any other party without the client’s consent. Assessing and Treating Clients With Impulsivity, Compulsivity, and Addiction Essay.

References

Alanis-Hirsch K, Coff R, Ford J, Johnson K, Mady C, Laura S & Dennis M. (2016). Extended-release naltrexone: A qualitative analysis of barriers to routine use.
J Subst Abuse Treat
. 1(62), 68–73

Calado F & Griffiths M. (2016). Problem gambling worldwide: An update and systematic review of empirical research (2000–2015).
J Behav Addict
.  1; 5(4), 592–613.

Calcaterra N & Barrow J. (2014). Classics in Chemical Neuroscience: Diazepam (Valium).
ACS Chem Neurosci
. 5(4), 253–260. Assessing and Treating Clients With Impulsivity, Compulsivity, and Addiction Essay.

Choliz M. (2018). Ethical Gambling: A Necessary New Point of View of Gambling in Public Health Policies.
Front Public Health
. 6(12).

Crowley P. (2015). Long-term drug treatment of patients with alcohol dependence.
Aust Prescr
. 38(2), 41–43.

Davies N, Taylor G, Taylor A, Thomas K, Frank W, Martin R & Munafo M. (2015). What are the effects of varenicline compared with nicotine replacement therapy on long-term smoking cessation and clinically important outcomes? Protocol for a prospective cohort study.
BMJ Open
. 5(11): e009665. Assessing and Treating Clients With Impulsivity, Compulsivity, and Addiction Essay.

Fluyau D, Revadigar N & Brittany M. (2018). Challenges of the pharmacological management of benzodiazepine withdrawal, dependence, and discontinuation.
Ther Adv Psychopharmacology
. 8(5), 147–168.

Sullivan M, Adam B, Mariani J, Glass A, Levin F, Comer S & Nunes E. (2014). Naltrexone treatment for opioid dependence: Does its effectiveness depend on testing the blockade?
Drug Alcohol Depend.
133(1), 80–85.

Tvete I, Trine B & Tor S. (2016). A 5-year follow-up study of users of benzodiazepine: starting with diazepam versus oxazepam.
Br J Gen Pract
. 66(645), e241–e247.

Warren A, Cowen G & Harmer C. (2016). Cognitive mechanisms of diazepam administration: a healthy volunteer model of emotional processing.
Psychopharmacology (Berl).
1(233), 2221–2228.

Yau Y & Marc P. (2015). Gambling Disorder and Other Behavioral Addictions: Recognition and Treatment.
Harv Rev Psychiatry
. 23(2), 134–146. Assessing and Treating Clients With Impulsivity, Compulsivity, and Addiction Essay.

BUY A PLAGIARISM-FREE PAPER HERE

The purpose of this Iowa Model for Evidence Based Practice assignment is to incorporate research evidence into a clinical model for a practice change. Using the Iowa Model for Evidence Based Practice as a guide, develop a concept map that shows the pathways necessary for a clinical change of your choice that you would like to see implemented in your current practice setting. I have no preference as to what you choose to write about. Iowa Model for Evidence Based Practice

Assessing and Treating Clients With Pain Essay – Complex Regional Pain Disorder

Complex Regional Pain Disorder

White Male With Hip Pain

BACKGROUND

This week, a 43-year-old white male presents at the office with a chief complaint of pain. He is assisted in his ambulation with a set of crutches. At the beginning of the clinical interview, the client reports that his family doctor sent him for psychiatric assessment because the doctor felt that the pain was “all in his head.” He further reports that his physician believes he is just making stuff up to get “narcotics to get high.”

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SUBJECTIVE

The client reports that his pain began about 7 years ago when he sustained a fall at work. He states that he landed on his right hip. Over the years, he has had numerous diagnostic tests done (x-rays, CT scans, and MRIs). He reports that about 4 years ago, it was discovered that the cartilage surrounding his right hip joint was 75% torn (from the 3 o’clock to 12 o’clock position). He reports that none of the surgeons he saw would operate because they felt him too young for a total hip replacement and believed that the tissue would repair with the passage of time. Since then, he reported development of a strange constellation of symptoms including cooling of the extremity (measured by electromyogram). He also reports that he experiences severe cramping of the extremity. Assessing and Treating Clients With Pain Essay – Complex Regional Pain Disorder. He reports that one of the neurologists diagnosed him with complex regional pain syndrome (CRPS), also known as reflex sympathetic dystrophy (RSD). However, the neurologist referred him back to his family doctor for treatment of this condition. He reports that his family doctor said “there is no such thing as RSD, it comes from depression” and this was what prompted the referral to psychiatry. He reports that one specialist he saw a few years ago suggested that he use a wheelchair, to which the client states “I said ‘no,’ there is no need for a wheelchair, I can beat this!”

The client reports that he used to be a machinist where he made “pretty good money.” He was engaged to be married, but his fiancé got “sick and tired of putting up with me and my pain, she thought I was just turning into a junkie.”

He reports that he does get “down in the dumps” from time to time when he sees how his life has turned out, but emphatically denies depression. He states “you can’t let yourself get depressed… you can drive yourself crazy if you do. I’m not really sure what’s wrong with me, but I know I can beat it.”

During the client interview, the client states “oh! It’s happening, let me show you!” this prompts him to stand with the assistance of the corner of your desk, he pulls off his shoe and shows you his right leg. His leg is turning purple from the knee down, and his foot is clearly in a visible cramp as the toes are curled inward and his foot looks like it is folding in on itself. “It will last about a minute or two, then it will let up” he reports. Sure enough, after about two minutes, the color begins to return and the cramping in the foot/toes appears to be releasing. Assessing and Treating Clients With Pain Essay – Complex Regional Pain Disorder. The client states “if there is anything you can do to help me with this pain, I would really appreciate it.” He does report that his family doctor has been giving him hydrocodone, but he states that he uses is “sparingly” because he does not like the side effects of feeling “sleepy” and constipation. He also reports that the medication makes him “loopy” and doesn’t really do anything for the pain.

MENTAL STATUS EXAM

The client is alert, oriented to person, place, time, and event. He is dressed appropriately for the weather and time of year. He makes good eye contact. Speech is clear, coherent, goal directed, and spontaneous. His self-reported mood is euthymic. Affect consistent to self-reported mood and content of conversation. He denies visual/auditory hallucinations. No overt delusional or paranoid thought processes appreciated. Judgment, insight, and reality contact are all intact. He denies suicidal/homicidal ideation, and is future oriented. Assessing and Treating Clients With Pain Essay – Complex Regional Pain Disorder.

Diagnosis: Complex regional pain disorder (reflex sympathetic dystrophy)

Decision Point One

Select what the PMHNP should do:

Savella 12.5 mg orally once daily on day 1; followed by 12.5 mg BID on day 2 and 3; followed by 25 mg BID on days 4-7; followed by

Savella 12.5 mg orally once daily on day 1; followed by 12.5 mg BID on day 2 and 3; followed by 25 mg BID on days 4-7; followed by 50 mg BID thereafter

50 mg BID thereafter

Amitriptyline 25 mg po QHS and titrate upward weekly by 25

Amitriptyline 25 mg po QHS and titrate upward weekly by 25 mg to a max dose of 200 mg per day

mg to a max dose of 200 mg per day

Neurontin 300 mg po BEDTIME with weekly increases of 300

Neurontin 300 mg po BEDTIME with weekly increases of 300 mg per day to a max of 2400 mg if needed

mg per day to a max of 2400 mg if needed

The Assignment

Examine Case Study: A Caucasian Man With Hip Pain. You will be asked to make three decisions concerning the medication to prescribe to this client. Be sure to consider factors that might impact the client’s pharmacokinetic and pharmacodynamic processes. Assessing and Treating Clients With Pain Essay – Complex Regional Pain Disorder.

At each decision point stop to complete the following:

• Decision #1

o Which decision did you select?

o Why did you select this decision? Support your response with evidence and references to the Learning Resources.

o What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.

o Explain any difference between what you expected to achieve with Decision #1 and the results of the decision. Why were they different?

• Decision #2

o Why did you select this decision? Support your response with evidence and references to the Learning Resources.

o What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.

o Explain any difference between what you expected to achieve with Decision #2 and the results of the decision. Why were they different? Assessing and Treating Clients With Pain Essay – Complex Regional Pain Disorder.

• Decision #3

o Why did you select this decision? Support your response with evidence and references to the Learning Resources.

o What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.

o Explain any difference between what you expected to achieve with Decision #3 and the results of the decision. Why were they different?

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.

Below is a simple paper for reference, the needs an introduction and a conclusion.

Assessing and Treating Clients with Anxiety Disorder

Introduction

Anxiety disorders refer to a syndrome of mental disorders typified by substantial feelings of fear and anxiety. The anxiety and fears may cause physical symptoms like shakiness and rapid heart rate. Various forms of anxiety disorders include panic disorder, social anxiety disorder, agoraphobia, generalized anxiety disorder, among other disorders (Locke et al, 2015). The focus of this assignment is on a 46-year-old male who presented with symptoms of anxiety disorder that included shortness of breath, chest tightness as well as a feeling of impending doom. Lab results and EKG in the ER were normal which ruled out myocardial infarction. (HAM-A) scale yielded a score of 26 and a diagnosis of generalized anxiety disorder (GAD) was made. Following the diagnosis, three decisions will be made about the treatment regimen for the client. After making each decision, a rationale supported by clinical evidence and patient data will be provided. Moreover, after making each decision, factors likely to impact the pharmacokinetic and pharmacodynamic processes for the client will be considered when making decisions. Finally, ethical considerations likely to impact the client’s treatment plan will be discussed. Assessing and Treating Clients With Pain Essay – Complex Regional Pain Disorder.

Decision # 1

The first decision for this client would be to start Zoloft 50 mg orally daily. This decision was made because Zoloft is selective serotonin reuptake inhibitors (SSRIs) and SSRIs are the recommended first-line treatments for anxiety disorders. SSRIs work by increasing the amount of serotonin within the brain; serotonin is a brain chemical that is very important for mood regulation (Locher et al, 2017). Accordingly, SSRIs such as Zoloft work by hindering serotonin reuptake in the brain and therefore increases the level of serotonin in the brain; availability of serotonin thus helps in regulating moods and hence improves anxiety symptoms. In addition, evidence shows that Zoloft is effective in improving anxiety symptoms manifest in GAD; this is because anxiety depletes serotonin in the brain and this is addressed by an SSRI such as Zoloft which replaces the depleted serotonin in the brain (Patel et al, 2018).

Imipramine (Tofranil) at 25 mg BID and Buspirone (Buspar) 10 mg orally twice daily choices were not selected because evidence shows that SSRIs as the first-line medications in the treatment of anxiety disorders. Both Imipramine and Buspirone takes about 2 – 4 weeks before making any improvement on the symptoms. Assessing and Treating Clients With Pain Essay – Complex Regional Pain Disorder. Moreover, these two medications are not well tolerated as Zoloft and also have numerous side effects when compared to Zoloft.

By selecting the decision to begin Zoloft 50 mg orally daily, it was expected that symptoms of generalized anxiety disorder manifested by the client would gradually clear away. It was also expected that the HAM-A score for the client would significantly reduce indicating an improvement of the anxiety symptoms. This is because evidence shows that Zoloft as an SSRI is effective in the treatment of GAD symptoms (Patel et al, 2018). In addition, it was hoped that the client would have minimal side effects and tolerate the medication because evidence shows that SSRIs have minimal side effects are well tolerated (Clevenger et al, 2018)

There was no significant difference between the actual outcome of the decision and the expected results because when the client came for review the anxiety symptoms had significantly reduced and manifested by the client not having symptoms such as shortness of breath or chest tightness. Assessing and Treating Clients With Pain Essay – Complex Regional Pain Disorder. Moreover, the client reported that he had stopped worrying about his job and also the HAM-A score dropped from 28 to 18 which shows that the client was responding to treatment, although partially.

Decision # 2

The chosen second decision is to increase the client’s Zoloft dose to 75 mg orally daily. This decision was selected because the client’s HAM-A score dropped from 28 to 18 which indicated a partial response to treatment which shows that the client is responding to the treatment. Therefore, the increase of the dose from 50 mg to 75mg will further increase the availability of serotonin within the brain and thus further improve the anxiety symptoms for the client. Evidence supports the gradual increase of the SSRIs dosage if the clients are not satisfactorily responsive to the treatment (Jakubovski et al, 2016). This decision was also based on the fact that the client seems to be tolerating Zoloft medication well and without any side effect.

The option to increase Zoloft to 100mg was not chosen because dosage increase and titration are supposed to be gradual to ensure the client continues to tolerate the medication well with minimal side effects. On the other hand, the option to have the client continue with the same dose and have him reassessed after four weeks was not selected because the client’s response is partial and therefore it is essential to increase the dosage to ensure complete response to the medication (Jakubovski et al, 2016).

By choosing this decision, the expectation was that the anxiety symptoms would continue reducing and this would be indicated by a significantly reduced HAM-A score. There was no noticeable difference between the actual decision and the expected decision because on coming to the clinic the client’s anxiety symptoms had further reduced as indicated by the further reduction of the HAM-A score. Assessing and Treating Clients With Pain Essay – Complex Regional Pain Disorder.

Decision # 3

For the third decision, the decision will be to maintain the client on the current dose of Zoloft 75 mg orally daily. This decision was made because with the current regime the client is showing improvement of the anxiety symptoms as such as tightness in the chest, difficulty breathing or the feeling that something terrible is about to happen and also the HAM-A score indicated significant reduction with the current dose. This means that the client is responding to the current medication and dose adequately. In addition, with the current dose, the client is not experiencing any side effects and he is tolerating the medication very well. Evidence and clinical guidelines recommend titration of medications according to the response of the client; in this case, the client is responding very well and hence there is no need to titrate medication any further (Jakobsen et al, 2017).

The option to either augment the current treatment with Buspar or the option of increasing the current dose of Zoloft to 100mg was not chosen since the client is showing a satisfactory response to the current dose of Zoloft 75 mg.

By selecting this decision, the expectation is that the client will show a complete response to the treatment where the client will report complete clearance of the symptoms and the HAM-A score will significantly reduce.

Impact of Ethical Considerations on the Treatment Plan

For this client, the ethical considerations will encompass informed consent, confidentiality, and autonomy. Assessing and Treating Clients With Pain Essay – Complex Regional Pain Disorder. First, it is essential to seek informed consent from the client to ensure that the client has full information about the recommended treatment before he consents to the treatment (Millum, 2013). Secondly, the confidentiality of the client should be respected. This means that any information and the client’s treatment regimen should not be disclosed to any other party without the consent of the client. Lastly, the client’s autonomy should be respected where the client should not be forced or coerced to have any treatment; he should decide to accept or refuse the treatment. Any decision the client makes about the treatment should be respected (Millum, 2013).

Conclusion

The selected first decision is to begin Zoloft 50 mg orally daily. The rationale for selecting this decision is because SSRIs such as Zoloft are the first treatment choice for anxiety disorders and evidence shows that the medication is effective in treating anxiety symptoms. There was significant improvement with this decision. The second decision was to increase the dose to the Zoloft dose to 75 mg orally daily. This decision was made because the client was showing partial response as indicated by the HAM-A score and hence increasing the dose would facilitate a satisfactory response. Assessing and Treating Clients With Pain Essay – Complex Regional Pain Disorder. The third decision is to maintain the current dose because the client is showing a satisfactory response to the treatment as indicated by the reduced HAM-A score and reduced symptoms as per the subjective data. Finally, the ethical considerations that should be considered include autonomy, confidentiality, and informed consent.

References

Clevenger S, Devvrat M, Dang J, Vanle B & William I. (2018). The role of selective serotonin reuptake inhibitors in preventing relapse of major depressive disorder. Ther Adv Psychopharmacology. 8(1): 49–58.

Jakubovski E, Anjali V, Freemantle N, Taylr M & Bloch M. (2016). Systematic Review and Meta-Analysis: Dose-Response Relationship of Selective-Serotonin Reuptake Inhibitors in Major Depressive Disorder. Am J Psychiatry. 173(2): 174–183.

Jakobsen J, Kumar K, Timm A, Gluud C, Ebert E et al. (2017). Selective serotonin reuptake inhibitors versus placebo in patients with major depressive disorder. A systematic review with meta-analysis and Trial Sequential Analysis. BMC Psychiatry. 17(58).

Locke A, Faafp M, Krist N & Shultz C. (2015). Diagnosis and Management of Generalized Anxiety Disorder and Panic Disorder in Adults. Am Fam Physician. 1;91(9),617-624. Assessing and Treating Clients With Pain Essay – Complex Regional Pain Disorder.

Locher, C., Koechlin, H., Zion, S. R., Werner, C., Pine, D. S., Kirsch, I. & Kossowsky, J. (2017).

Efficacy and Safety of Selective Serotonin Reuptake Inhibitors, Serotonin-Norepinephrine Reuptake Inhibitors, and Placebo for Common Psychiatric Disorders Among Children and Adolescents: A Systematic Review and Meta-analysis. JAMA Psychiatry. 74(10), 1011–1020.

Millum J. (2013). Introduction: Case Studies in the Ethics of Mental Health Research. J Nerv Ment Dis. 200(3), 230–235.

Patel D, Feucht C, Brown K & Ramsay J. (2018). Pharmacological treatment of anxiety disorders in children and adolescents: a review for practitioners. Transl Pediatr. 7(1): 23–35. Assessing and Treating Clients With Pain Essay – Complex Regional Pain Disorder.

Introduction

Complex regional pain syndrome is a debilitating condition that affects the limbs and is likely to be induced by trauma or surgery.  Apart from complicating the entire recovery process, it tends to impair the psychosocial and functional well-being of an individual. It’s characterized by vasomotor abnormalities, hyperalgesia, , and allodynia. The pain that a patient experiences is often disproportionate to the degree of tissue injury that occurs and may persist beyond the anticipated period required for tissue healing (Stanton-Hicks, 2018). Assessing and Treating Clients With Pain Essay – Complex Regional Pain Disorder. The major goals of therapy are: to ensure pain relief, to restore functioning and psychologically stabilize a patient.

Many drugs are often used in pain management to improve functional status. However, mental health practitioners should ensure that the choice of drugs promotes compliance and have fewer side effects. This paper discusses the management of a 43-year-old who presented with complex regional pain disorder. In his management, three decisions are to be made regarding the most effective medications, expected outcomes, , and actual outcomes. A description of the ethical issues when engaging clients with complex regional pain disorder and their families will also be provided.

Decision #1

Decision Selected

Start Savella 12.5 mg orally once daily on day 1; followed by 12.5 mg BID on day 2 and 3; followed by 25 mg BID on days 4-7; followed by 50 mg BID thereafter

Reasons for Selecting This Decision

           
Patients with regional pain disorder have a low pain threshold which may be caused by changes in the central nervous system. These changes cause a patient to be more sensitive to pain due to wrong neurotransmitter levels in the brain. As selective norepinephrine and serotonin reuptake inhibitor (SNRI) that has an equal effect on both neurotransmitters, Savella is an NMDA antagonist that works on nerve endings to produce analgesic effects (Stanton-Hicks, 2018).  It promotes the reuptake of the neurotransmitters in the brain thus easing the pain, reducing fatigue and promoting memory. Assessing and Treating Clients With Pain Essay – Complex Regional Pain Disorder.

Amitriptyline, a tricyclic antidepressant that has proven to be effective in the management of neuropathic pain off label could also be a good option (Benzon, Liu & Buvanendran, 2016).  However, it has a side effect of drowsiness and dizziness that the client initially stated clearly that he didn’t like. Therefore, prescribing this medication for a start might only trigger non-compliance.

Neurontin, also referred to as gabapentin, is an anti-epileptic / anticonvulsant, is used in for nerve pain relief. Therefore, it could also be a good option for the management of this patient. However, it also has the side effects of drowsiness and in high doses, results in extreme somnolence and drowsiness (Finnerup, et al., 2015).  Since the patient expressed his dislike for the side effect of feeling sleepy from the start, prescribing it would only lead to non-compliance. Assessing and Treating Clients With Pain Essay – Complex Regional Pain Disorder.

Expected Outcome

By starting the patient on Savella, it was expected that his pain will significantly reduce to 3 on a scale of 1-10 and be able to walk without support. It was also expected that he would resume to a normal work routine and be able to perform activities of daily life will very minimal or no assistance (Stanton-Hicks, 2018).  His mood would be happy or joyous and he would have a stable effect.

Difference between Expected outcome and Actual Outcome

           
The client returned to the clinic after four weeks walking without crutches but minimally limping.  He reported that the main was more manageable and he was able to walk around with no assistance. However, he noted that the pain was worse during the morning hours and got better as the day progressed.  On a scale of 1-10, his pain was reportedly 4 but admitted that he could be able to live and tolerate a level of 3. The client also noted that he occasionally experienced bouts of sweating that he couldn’t explain with some sleep disturbance. An assessment revealed that he had a blood pressure of 147/92mmhg and a pulse of 110 beats/ min. He was still future-oriented and denied homicidal/suicidal ideation. One of the major side effects of Savella is heart palpitations (Finnerup, et al., 2015).  It is for this reason that the patient experienced bouts of sweating, sleep disturbance and had a high blood pressure. Reducing the dosage can help to minimize this side effect.

Decision #2

Decision Selected

Continue With the Current medication but reduce the dosage to 25 mg twice daily

Reasons for Selecting This Decision

During the first visit, the client reported that he experienced unexplained symptoms of bouts of sweats, sleep disturbance and he had a high blood pressure. These symptoms were the resultant side effects of Savella. According to Stanton-Hicks (2018), by reducing the dosage of Savella, its side effects are also minimized resulting in more improved health outcomes. Assessing and Treating Clients With Pain Essay – Complex Regional Pain Disorder.

Expected Outcome

By reducing the dosage of Savella, it was expected that the patient’spatient’s pain level will also be minimized, he will still be able to perform most activities of daily life with very minimal support and that his social, professional and physical functioning will also improve (Benzon, Liu & Buvanendran, 2016). Above all, the dosage reduction aimed to ensure that the side effects weren’t adverse and that he would live a near normal life.

Difference between Expected outcome and Actual Outcome

           
After four weeks, the patient returned to the clinic walking with crutches. He stated that the pain was 7 out of 10 and admitted that he didn’t feel good as compared to the previous month. He frequently woke up at night due to pain on his right leg and foot. He, however,, however, denied homicidal and suicidal ideation. Assessing and Treating Clients With Pain Essay – Complex Regional Pain Disorder. His blood pressure was 124/85 and pulse rate was 87 beats/ min. He looked sad and discouraged by the slip in the management of his pain. The decision to lower the dosage of Savella in managing the client’s initial side effects to the dug inspired this difference at the cost of uncontrolled pain (Murnion, 2018).

Decision #3

Decision Selected

Change Savella to 25 mg orally in the morning and 50 mg orally at bedtime

Reasons for Selecting This Decision

           
During the client’s first visit to the clinic, he clearly stated that the medication Savella was effective for his pain management but the pain worsened early morning and improved as the day progressed. As supported by Finnerup, et al., (2015), starting with dose reductions during parts of the day when pain is mostly under control is a good idea that can still contribute to the achievement of therapeutic goals.

Expected Outcome

It was expected that the patient’s pain will effectively be managed to a level of 3 on a scale of 1-10. He will also be able to walk and perform most of his activities of daily life with minimal or no support. As supported by Stanton-Hicks (2018), the patient would no longer experience sleep disturbance and that his affect and mood will gradually be stable. With regards to the drugs side effects, it was expected that the patient’s blood pressure and pulse rate will gradually normalize and that he will no longer experience palpitations or unexplained bouts of sweating.

Difference between Expected outcome and Actual Outcome

The client returned to the clinic after four weeks walking without crutches. He reported his pain level to be 4 on a scale of 1-10 and expressed how he was grateful but would love it to reduce to 3 since it’s the best level that he could easily manage. His blood pressure was 120/84mmhg and pulse rate 86beats/min. He denied suicidal/homicidal ideation and was still future-oriented. At this point, it will be necessary to explain to the client that he has a neuropathic pain syndrome which probably may never respond to pain medications. Therefore, it would be practical to collaboratively set realistic expectations and make the patient understand that he will frequently experience some pain level daily (Benzon, Liu & Buvanendran, 2016). What matters most is to manage it in such a manner that permits him to effectively perform activities of daily life.  The patient should also be educated that medications are not a final solution but a part of a complex regimen of chiropractic care, physical therapy, massage and heat therapy (Murnion, 2018).

How Ethical Considerations Might Impact Treatment plan and Communication With Clients

The most significant ethical consideration for this client is that of informed consent, autonomy, beneficence, and non-maleficence. Before changing any treatments, it is important to seek informed consent just to ensure that he is fully aware of what he is consenting to, possible dangers and outcomes involved (Millum, 2013).  Secondly, any treatment options considered should only be for the patient’s best interest/benefit and have fewer side effects. This will guarantee that all treatment options cause no harm. Lastly, the client’s autonomy should also be respected such that, he shouldn’t be forced or coerced to agree to a treatment modality that his conscience is against (Millum, 2013). Assessing and Treating Clients With Pain Essay – Complex Regional Pain Disorder.

Conclusion

The management of regional pain disorder in adults requires a careful and thorough assessment of a patients needs which will help to decide the best medications to use as part of a broader regimen of heat and massage therapy, chiropractic care and physical therapy. Savella, an SNRI was the best medication choice for the management of this patient’s pain. It has minimal side effects with the major side effect being heart palpitations which can be managed with dosage reduction. Although in patients with regional pain disorder dose reduction comes with the cost of uncontrolled pain, string reductions during the parts of a day when pain is mostly under control helphelp to achieve the desired therapeutic goals as it was in this case.

References

Benzon, H. T., Liu, S. S., & Buvanendran, A. (2016). Evolving definitions and pharmacologic management of complex regional pain syndrome.

Finnerup, N. B., Attal, N., Haroutounian, S., McNicol, E., Baron, R., Dworkin, R. H., .& Kamerman, P. R. (2015). Pharmacotherapy for neuropathic pain in adults: a systematic review and meta-analysis. 
The Lancet Neurology
, 
14
(2), 162-173. Assessing and Treating Clients With Pain Essay – Complex Regional Pain Disorder.

Millum J. (2013). Introduction: Case Studies in the Ethics of Mental Health Research. J Nerv Ment Dis. 200(3), 230–235.

Murnion, B. P. (2018). Neuropathic pain: current definition and review of drug treatment. 
Australian Prescriber
, 
41
(3), 60.

Stanton-Hicks, M. (2018). Complex regional pain syndrome. In 
Fundamentals of Pain Medicine
(pp. 211-220). Springer, Cham. Assessing and Treating Clients With Pain Essay – Complex Regional Pain Disorder.

Assessing and Treating Clients With Psychosis and Schizophrenia Sample Essay

Delusional Disorders

Pakistani Female 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. Assessing and Treating Clients With Psychosis and Schizophrenia Sample Essay.

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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 Assessing and Treating Clients With Psychosis and Schizophrenia Sample Essay. 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. Assessing and Treating Clients With Psychosis and Schizophrenia Sample Essay.

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

Diagnosis: Schizophrenia, paranoid type

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.

Decision Point One

Select what the PMHNP should do:

Start Zyprexa 10 mg orally at BEDTIME

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 Invega Sustenna 234 mg intramuscular X1 followed by 156 mg intramuscular on day 4 and monthly thereafter

Start Abilify 10 mg orally at BEDTIME

Start Abilify 10 mg orally at BEDTIME

Examine Case Study: Pakistani Woman with Delusional Thought Processes. You will be asked to make three decisions concerning the medication to prescribe to this client. Assessing and Treating Clients With Psychosis and Schizophrenia Sample Essay. Be sure to consider factors that might impact the client’s pharmacokinetic and pharmacodynamic processes.

At each decision point stop to complete the following:

• Decision #1

o Which decision did you select?

o Why did you select this decision? Support your response with evidence and references to the Learning Resources.

o What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.

o Explain any difference between what you expected to achieve with Decision #1 and the results of the decision. Why were they different?

• Decision #2

o Why did you select this decision? Support your response with evidence and references to the Learning Resources.

o What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.

o Explain any difference between what you expected to achieve with Decision #2 and the results of the decision. Why were they different? Assessing and Treating Clients With Psychosis and Schizophrenia Sample Essay.

• Decision #3

o Why did you select this decision? Support your response with evidence and references to the Learning Resources.

o What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.

o Explain any difference between what you expected to achieve with Decision #3 and the results of the decision. Why were they different?

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.

Below is a simple paper for reference.

“Bipolar” refers to a mental condition characterized by a sudden shift in the energy and the moods of the patient. The condition may also result in the occurrence of manic phases along with slight depression. The condition is quite difficult to diagnose being that one may exhibit depression-like symptoms and/or manic phases. Symptoms associated with bipolar disorder are common, often symptoms of other disorders Assessing and Treating Clients With Psychosis and Schizophrenia Sample Essay. Cases of misdiagnosis for this condition is also common. This, in turn, results in wrong medication prescribed to the patient. Under such circumstance, the condition of the patient might become more complicated, and worst-case scenario, some might lose their lives (Stahl, 2013). It is therefore important to thoroughly assess the symptoms exhibited by a client before making a diagnosis. This is in a bid to eliminate any case of misdiagnosis. This paper will provide three medical decisions that can be taken in the treatment of a patient diagnosed with Bipolar disorder.

Background

The client that I assessed this week is a 26-year-old Korean female. The client has been hospitalized for 21 days as a result of manic phases that she experienced. During the assessment process, the client would fiddle with things. She weighed 110lbs while standing 5’5”. She explains how she only sleeps for five hours since “sleeping is not fun.” Her medical history indicated that she is of good health and the results from the lab evaluation indicated that her vital signs are within normal limits. A gene test of the client indicated that she is positive for CYP2D6*10 allele, which means any medication offered to her would not yield the desired results. She reports that she stopped taking the medications that she was prescribed within hospital (Laureate Education, 2016f). The client is alert and oriented to the events taking place around her. However, she is dressed inappropriately and her speaking rapidly. Assessing and Treating Clients With Psychosis and Schizophrenia Sample Essay. She reports her mood as unbothered and affects as broad. She denies any form of hallucination or paranoia. Her judgment is intact while her insight is slightly affected. Nonetheless, she denies suicidal ideations.

Decision #1

Selected Decision

The first decision is to start Risperdal 1mg orally BID

Reason For Selecting This Decision

Risperdal, originally referred to as risperidone, is a typical antipsychotic that has proven to be highly effective in the management of bipolar disorders. It does so by trying to influence a rebalance in serotonin and dopamine thus resulting in good conduct. Since the patient was having bipolar confusion, Risperdal happens to be the best alternative also considering that it is readily accessible (Culpepper, 2014). In the past treatment therapy, the patient happened to default lithium. Therefore, it wouldn’t be a smart option to start lithium 300mg since the chances of the patient not adhering to treatment are high. Assessing and Treating Clients With Psychosis and Schizophrenia Sample Essay. Also, Lithium has a lot of side effects and the patient will be subjected to monitoring therapeutic range periodical to avoid toxic range, which means the patient have to go to a lab and have her blood drawn periodical. Similarly, Seroquel XR could be a good alternative, but it’s mostly used for acute Schizophrenia and Schizophrenia maintenance. However, its side effects of increase diabetes, dyslipidemia, constipation and weight addition might contribute to non-compliance thus not achieving the therapeutic goals (John & Antai-Otong, 2016). This leaves Risperdal as the best option in this case.

Expected Outcomes

Within four weeks on treatment, the patient is expected to show immense progress. The current manifestations of bipolar disorder that she experiences are also expected to diminish to an extent that the patient has a peaceful state of mind. The patient should be restful and be able to conduct her activities of daily life with little or no difficulty (John & Antai-Otong, 2016) Risperdal is the best choice to influence mental action and improve the patient’s capacity to be of rational sound mind in the way she addresses issues. It is also expected that the patient’s self-destructive practices and tension would diminish and will respond to her environment and social interactions positively (Fang, et al., 2017).

Difference between Expected Outcomes and Actual Outcomes

After four weeks, the client returned to the clinic accompanied by her mother looking very lethargic and sedated. They, however, agreed that the patient’s self-destructive practices had significantly diminished. The client’s mother explained that the client had been lethargic for about a week after the last visit. Assessing and Treating Clients With Psychosis and Schizophrenia Sample Essay. It should be noted that one of the side effects of Risperdal is sedation (John & Antai-Otong, 2016) Similarly, based on the fact that the client is reportedly positive for CYP2D6*10 allele, it is probable that she might be having a slow rate of clearance of Risperdal from her systems leading to higher levels than normal of Risperdal in blood (Chen et al., 2015).

Decision #2

Selected Decision

Based on the client’s presentation and the initial decision, the second-best decision, in this case, would be reducing Risperdal to 1mg HS.

Reason for Selecting This Decision

Based on the patient’s progress during the second visit, it was evident that Risperdal was effective in attaining therapeutic goals of treatment. However, the unwanted side effects were the major concerns. It is therefore wise to decrease the dosing to deal with the side effects rather than change to another drug. Decreasing the dosage to one mg HS would be the best alternative that will help to reduce the significant impact of the side effects (Culpepper, 2014). Changing the drug to lithium will possibly result in non-compliance since the client has already developed some demeanor towards it. Besides, the patient may turn out to generally have a negative attitude towards all medicines which may be prescribed by the mental health practitioner. Giving the patient support to adapt to an alternate dosage of the same medication will also improve their dedication, trust, and understanding to collaborate in achieving the treatment goals (John & Antai-Otong, 2016).

Expected Outcomes

As earlier stated, Risperdal has proven to be effective in managing the symptoms of bipolar disorder by influencing a balance in serotonin and dopamine to help address a patient’s self-destructive behaviors. Based on the fact that the client is positive for CYP2D6*10 allele, the initial dosage could have resulted in an accumulation of Risperdal which is slowly being cleared (John & Antai-Otong, 2016). Reducing the dosage to one mg HS will definitely reduce the amount of Risperdal accumulated in the body and subsequent side effects of lethargy and sedation. By adjusting this dosage, it is expected that the patient will record some positive progress in terms of reduced self-destructive behaviors, ease in performing activities of daily life and thinking patterns (Fang, et al., 2017). It is also expected that the client will have minimal episodes of lethargy and sedation.

Difference between Expected Outcomes and Actual Outcomes

After four weeks, the client returned to the clinic accompanied by her mother. She was less sedated, less lethargic and showed a lot of improvement in symptoms. The young mania rating scale had also reduced from 22 to 16, an illustration that there was more than a 25% reduction in symptoms. These outcomes were actually foreseen and were the reason the dosage of Risperdal was reduced to one mg HS (John & Antai-Otong, 2016) Risperdal is a powerful choice for bipolar disorder; its side effects are easily manageable and help in the achievement of therapeutic goals for bipolar patients more easily.

Decision #3

Selected Decision

My third decision would be to continue at the same dosage of 1 mg HS.

Reason for Selecting This Decision

From the initial visit, it was evident that the client has good progress in terms of reducing self-destructive behaviors and management of the drugs side effects. Maintaining this dosage and reassessing the client after four weeks will contribute to the achievement of the treatment goals for both the client and the attending mental health practitioner. The initial dosage of 1 mg BID had turned out to be detrimental to the patient’s health (Fang, et al., 2017). Therefore, going back to it would prompt similar side effects. Assessing and Treating Clients With Psychosis and Schizophrenia Sample Essay. Besides, changing to Seroquel is not recommendable in this case since Seroquel is FDA approved for bipolar II depression and schizophrenia which differs from the patient’s presentation that we are trying to manage.

Expected Outcomes

It is expected that, within four weeks, the patient will record immense progress by reducing self-destructive behaviors. Besides, she will report very minimal or no side effects from Risperdal. She will have a good state of mind, conduct, and good thinking patterns. Risperdal is FDA approved for managing bipolar symptoms and has proven to be highly effective with manageable side effects (John & Antai-Otong, 2016)

Difference between Expected Outcomes and Actual Outcomes

As initially expected, the patient has some significant progress and very minimal side effects of lethargy and sedation. The reassessment proved that Risperdal had adequately helped to achieve the necessary treatment goals in the entire course of treatment. Given the pharmacodynamics and pharmacokinetics of Risperdal, these are certainly the outcomes that ought to be expected. Since the client is for positive for CYP2D6*10 allele, Risperdal could be clearing at a slower rate resulting to higher than normal levels in the blood (Fang, et al., 2017).

However, the effect, in this case, may not be significant as compared to the initial point.

How Ethical Considerations Might Impact the Treatment Plan and Communication with Clients

The major ethical considerations that ought to be considered in managing clients with bipolar disorder are beneficence, nonmaleficence, and autonomy. Despite the fact that clients need treatment to live near-normal lives, the risks of the choice of medications used should balance with the corresponding benefits. Alternatively, a mental healthcare provider should consider giving the patient some of the best available options for management to maximize the benefits of treatment (Ratheesh et al., 2017). The impairment or insight and judgment that is always characterized by mania and mood episodes may render a patient as not able to provide informed consent nor incapable of making rational decisions regarding their treatment. Assessing and Treating Clients With Psychosis and Schizophrenia Sample Essay. Besides, a number of clinical presentations such as delusional thinking and irritability could probably be a threat in damaging the therapeutic alliance that exists between a client and a mental healthcare provider. It should also be noted that, due to the relapsing-remitting nature of bipolar disorder, there are instances where a patient might feel well and question the need to continue with treatment (Ratheesh et al., 2017). This place the treatment goals laid by the mental healthcare provider is in conflict with the patient’s autonomy to make decisions.

Background Information

For this assignment, the patient was a 34-year old Pakistani female who relocated to the United States while in her early 20s. Currently, she was in an organized marriage with a husband who was selected for her since she was 9 years old.  Today, she presents at the clinic following hospitalization for 21 days for a ‘brief psychotic disorder’ since her symptoms had lasted for less than a month.

Prior admission, the client reported of visions of Allah and in an entire week, she strongly believed that she was Prophet Mohammad and would deliver the entire world from sin. Her husband became more concerned about her behavior to the extent that he was afraid of leaving their children with her. One evening, the client was described to be out of control. As a result, the husband called the police which was followed by a subsequent admission to an inpatient psychiatric unit. Assessing and Treating Clients With Psychosis and Schizophrenia Sample Essay.

In today’s assessment, the patient appeared to be calm and emphasizes that the whole incident was just blown out of proportion. She also denies having believed that she was Prophet Mohammad and stated that her husband was out to get her since he never loved her and wanted a wife who was American instead of her. She informs that she knows this since the television told her so. Currently, she was 140 lbs. and 5’5’’.

Based on this case study, this paper discusses three major decisions regarding the medication to be prescribed to this client suffering from Schizophrenia, paranoid type. A description of the expected outcomes and actual outcomes will be provided for every decision with an explanation for any differences likely to be witnessed. Major ethical considerations that are likely to impact the client’s treatment plan and communication with clients will also be provided Assessing and Treating Clients With Psychosis and Schizophrenia Sample Essay.

Decision Pont 1

Decision Selected

Start Zyprexa 10 mg orally at bedtime

Reason for Selecting this Decision

Zyprexa, also known as olanzapine is an antipsychotic drug which affects brain chemicals. It is approved to treat symptoms of mental health disorders such as bipolar disorder and schizophrenia in both children and adults who are 13 years or older. Zyprexa is an atypical antipsychotic, which functions by helping to restore the balance of neurotransmitters in the brain. In terms of dosing, it is administered once daily (Wei Xin, 2016). Assessing and Treating Clients With Psychosis and Schizophrenia Sample Essay. Zyprexa is used to treat dysfunctional behaviors, malfunctions, speeches and distorted interpretations of the issues and events surrounding them.

Abilify could be a good option but only for a patient who has a good response to oral abilify. It should also be remembered that, Abilify does not bind to D2 receptor for quite a long time. Therefore, it can be less effective for some patients. Another possible side effect of Abilify is akathisia which is an extrapyramidal side effect that may lead to medication non-adherence. On the other hand, Invega Sustenna could also be a good option. However, it increases the risk of  memory loss  and  its side effects of pain, redness, swelling at the site of injection increases the chances of the patient failing to turn up for appointments. Invega Sustenna also leads to muscle spasms, high cholesterol and weight gain, which may generally impair the client’s physical wellbeing based on her current weight.

Expected Outcomes

By administering Zyprexa, it was expected that the client will have no hallucinations or delusional thoughts and she would be able to think more positively and clearly about herself. It was also expected that she would feel less agitated and actively participate in activities of daily life (Drug, 2015).

Difference between Expected Outcomes and Actual Outcomes

After four weeks, the client returned to the clinic accompanied by her husband. The client’s PANSS had decreased to a partial response of 25%.  The client also reported a weight gain of 5 pounds. When questioned further, the client stated that she could never seem to get satisfied with her meals. Assessing and Treating Clients With Psychosis and Schizophrenia Sample Essay. As a result, she constantly snacked in an entire day. One of the major side effects of Zyprexa is increased appetite which influences an increase in the frequency of taking meals hence weight gain.  Among all atypical antipsychotics, Zyprexa causes the most significant weight gain. Zyprexa has also been associated with increasing the risk of hyperglycemia hence newly diagnosed diabetes mellitus in clients (Takeuchi et al., 2015).

Decision Point 2

Decision Selected

Reduce Zyprexa to 7.5 mg orally at bedtime

Reason for Selecting this Decision

Based on the client’s visit, it was evident that she was concerned about the weight gain and increased appetite which was caused by the medication Zyprexa at dosing of 10mg Assessing and Treating Clients With Psychosis and Schizophrenia Sample Essay. Therefore, reducing the dosage to 7.5mg orally at bedtime is an effort to purposely counter the side effect of weight gain and increased appetite while treating the psychotic symptoms of delusions, hallucinations, dysfunctional thoughts, mood and behaviors (Drug, 2015).

Expected Outcomes

           
It was expected that, by reducing the dosage of Zyprexa from 10 mg orally at bedtime to 7.5mg orally at bedtime, the patient would not gain additional weight. Additionally, the currently revised dosage of 7.5mg orally at bedtime is within the patient’s weight. Apart from being advised to stop snacking an entire day, the client will be advised to observe normal meal schedules and actively engage in regular physical exercise to lose the excess weight that she had initially added(Wei Xin, 2016).

Difference between Expected Outcomes and Actual Outcomes

The client returned to the clinic after four weeks accompanied by her husband. She had worsened. Her PANNS had increased by 10%, an indicator that all her negative symptoms were gradually worsening. However, her weight had stabilized and excess hunger episodes had abated. According to the husband’s explanation, the client was gradually becoming less manageable at home, which forced him to take time off work as he was fearful to leave her alone. This was clear that the therapeutic goals were not being achieved with the current dosing of 7.5 mg of Zyprexa orally at bedtime (Takeuchi et al., 2015). Assessing and Treating Clients With Psychosis and Schizophrenia Sample Essay.

Decision Point 3

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Decision Selected

Increase the dosage of Zyprexa to 10mg orally at bedtime and

Reason for Selecting this Decision

           
From the client’s previous visit, it was notable that the dosage of 7.5 mg failed to help achieve the desired therapeutic levels. Despite the fact that having no complaints of weight gain and a manageable appetite, the client was reportedly unmanageable which also inconvenienced the husband. This also means that 7.5mg was an under dosage for the patient hence was insufficient to achieve the desired therapeutic goals for treatment. However, by returning to a dosage of 10 mg orally at bedtime, the client will receive similar side effects as that of the initial point of weight gain and increased appetite. Assessing and Treating Clients With Psychosis and Schizophrenia Sample Essay. Besides, she will also be at risk of Diabetes mellitus (Drug, 2015). Therefore, Risperdal could be considered a perfect option. Nonetheless, since Risperdal is dosed twice daily, compliance for this patient could be a problem. Evidence exists to support the efficacy of administering Risperdal once which is a good option in case compliance for this patient becomes an issue. Despite the fact that weight gain is also a side effect of Risperdal, it is not as serious as Zyprexa (Takeuchi et al., 2015).

Expected Outcomes

With Risperdal as an alternative, it is expected that the client will be more manageable and display less severe psychotic symptoms. She will report little or no delusions, hallucinations and significantly improve in terms of being more manageable (Takeuchi et al., 2015). Besides, the client will be able to execute her activities of daily life with little or no assistance and associated symptoms will have very minimal effect/impact on her overall life. Assessing and Treating Clients With Psychosis and Schizophrenia Sample Essay.

Difference between Expected Outcomes and Actual Outcomes

           
Although the patient reported minor on and off delusional symptoms, there was no significant difference between the expected outcome and the actual outcome. The client demonstrated to be alert and oriented with a stable mood and fluent affect. She also reported no side effects of increased appetite or weight gain, an indicator that therapeutic goals were gradually being achieved (Takeuchi et al., 2015).

How Ethical Considerations Might Impact the Treatment Plan and Communication with Clients

A major ethical consideration in counseling this client and making the treatment plan is that of informed consent. Patients with schizophrenia tend to have neurological deficits such that, they are not mentally/psychologically fit to make decisions for themselves regarding treatment. The same way, it is difficult to tell whether by consenting to a treatment plan, they fully understand what they are consenting to. As supported by Young, Taylor & Lawrie (2015), while attempting to get an informed and voluntary consent from the patient, caution should be taken to ensure that any decisions made do not harm the patient. This means that a mental health practitioner ought to strive to strike a balance between the principle of autonomy and non-maleficence. Assessing and Treating Clients With Psychosis and Schizophrenia Sample Essay.

References

The drug, A. A. (2015). 8 Olanzapine (Zyprexa).
Top Drugs: Their History, Pharmacology, and Syntheses
, 138.

Takeuchi, H., Fervaha, G., Lee, J., Agid, O., & Remington, G. (2015). The effectiveness of different dosing regimens of risperidone and olanzapine in schizophrenia.
European Neuropsychopharmacology
, 
25
(3), 295-302.

Wei Xin Chong, J., Hsien-Jie Tan, E., Chong, C. E., Ng, Y., & Wijesinghe, R. (2016). Atypical antipsychotics: A review on the prevalence, monitoring, and management of their metabolic and cardiovascular side effects. 
Mental Health Clinician
, 
6
(4), 178-184.

Young, S. L., Taylor, M., & Lawrie, S. M. (2015). “First do no harm.” A systematic review of the prevalence and management of antipsychotic adverse effects. 
Journal of Psychopharmacology
, 
29
(4), 353-362. Assessing and Treating Clients With Psychosis and Schizophrenia Sample Essay.

Assessing and Treating Clients With Anxiety Disorders Sample Essay

Generalized Anxiety Disorder

Middle-Aged White Male With Anxiety

BACKGROUND INFORMATION

The client is a 46-year-old white male who works as a welder at a local steel fabrication factory. He presents today after being referred by his PCP after a trip to the emergency room in which he felt he was having a heart attack. He stated that he felt chest tightness, shortness of breath, and feeling of impending doom. He does have some mild hypertension (which is treated with low sodium diet) and is about 15 lbs. overweight. He had his tonsils removed when he was 8 years old, but his medical history since that time has been unremarkable. Myocardial infarction was ruled out in the ER and his EKG was normal. Remainder of physical exam was WNL.

He admits that he still has problems with tightness in the chest and episodes of shortness of breath- he now terms these “anxiety attacks.” He will also report occasional feelings of impending doom, and the need to “run” or “escape” from wherever he is at.

In your office, he confesses to occasional use of ETOH to combat worries about work. He admits to consuming about 3-4 beers/night. Although he is single, he is attempting to care for aging parents in his home. He reports that the management at his place of employment is harsh, and he fears for his job. You administer the HAM-A, which yields a score of 26.

Client has never been on any type of psychotropic medication.

ORDER A PLAGIARISM-FREE PAPER HERE

MENTAL STATUS EXAM

The client is alert, oriented to person, place, time, and event. He is appropriately dressed. Speech is clear, coherent, and goal-directed. Client’s self-reported mood is “bleh” and he does endorse feeling “nervous”. Affect is somewhat blunted, but does brighten several times throughout the clinical interview. Affect broad. Client denies visual or auditory hallucinations, no overt delusional or paranoid thought processes readily apparent. Judgment is grossly intact, as is insight. He denies suicidal or homicidal ideation.

The PMHNP administers the Hamilton Anxiety Rating Scale (HAM-A) which yields a score of 26.

Diagnosis: Generalized anxiety disorder. Assessing and Treating Clients With Anxiety Disorders Sample Essay.

RESOURCES

§ Hamilton, M. (1959). Hamilton Anxiety Rating Scale. Psyctests, doi:10.1037/t02824-0

Decision Point One

Select what the PMHNP should do:

Begin Zoloft 50 mg po daily

Begin Zoloft 50 mg po daily

Begin Imipramine 25 mg po BID

Begin Imipramine 25 mg po BID

Begin Buspirone 10 mg po BID

Begin Buspirone 10 mg po BID

The Assignment

Examine Case Study: A Middle-Aged Caucasian Man With Anxiety. You will be asked to make three decisions concerning the medication to prescribe to this client. Be sure to consider factors that might impact the client’s pharmacokinetic and pharmacodynamic processes.

At each decision point stop to complete the following:

• Decision #1

o Which decision did you select?

o Why did you select this decision? Support your response with evidence and references to the Learning Resources.

o What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.

o Explain any difference between what you expected to achieve with Decision #1 and the results of the decision. Why were they different?

• Decision #2

o Why did you select this decision? Support your response with evidence and references to the Learning Resources.

o What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.

o Explain any difference between what you expected to achieve with Decision #2 and the results of the decision. Why were they different?

• Decision #3

o Why did you select this decision? Support your response with evidence and references to the Learning Resources.

o What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.

o Explain any difference between what you expected to achieve with Decision #3 and the results of the decision. Why were they different? Assessing and Treating Clients With Anxiety Disorders Sample Essay.

Also include how ethical considerations might impact your treatment plan and communication with clients.

Below is a simple paper for reference.

Week 2 Assignment: Assessing and Treating Pediatric Clients with Mood Disorders

Depression is considered an affective disorder due to its effect on the internal emotions and external mood seen by others (Stahl, 2013). Symptoms of depression include generalized sadness which can lead to feelings of guilt, fatigue, anxiety, poor concentration, changes in sleep pattern, increased or poor appetite and social isolation among many others. It is theorized that the cause of depression is due to a deficiency of monoamine neurotransmitters which are responsible for the amount of norepinephrine, serotonin and dopamine in the brain (Stahl, 2013). When treating a patient with depression, medications generally target this deficiency in hopes to provide relief from the symptoms the client is experiencing.

Case Study Information

The case study presented this week consists of an 8-year-old African American male presenting to the emergency department with mom due to increased feelings of sadness, withdrawn behavior in school, decreased appetite and occasional agitated behaviors (Laureate Education, 2016e). While the physical examination and laboratory studies were within normal limits, the mental status exam proved to be normal with reported “sad” mood, blunted affect but appropriately smiled at times and endorses thoughts of passive suicidal ideation (Laureate Education, 2016e). The client scored a 30 on the Children’s Depression Rating Scale, indicating significant depression (Laureate Education, 2016e).

The purpose of this assignment is to consider the 8-year-old client and information and make three decisions concerning medications to prescribe to the client. Each decision offers multiple options to choose from. The decision will be chosen based on evidence consisting of recent academic resources and research studies along with a rational for why the other two options were not chosen. Assessing and Treating Clients With Anxiety Disorders Sample Essay. Each outcome will be discussed based on if it was expected or not and what the next step will be. Lastly, ethical considerations will be discussed and how they may impact the treatment plan for the client and the communication with the client and his family.

Decision One

The first decision point the Psychiatric Mental Health Nurse Practitioner (PMHNP) must choose which medication the client will start. The medications to choose from include Zoloft (sertraline) 25 mg by mouth daily, Paxil (paroxetine) 10 mg by mouth daily, and Wellbutrin (bupropion) 75 mg by mouth twice daily (Laureate Education, 2016e). As the PMHNP caring for this client, Zoloft 25 mg daily would be the first choice of therapy for this patient. Selective serotonin reuptake inhibitors (SSRIs) are known to be the first line of treatment for children with depression (DeFilippis & Wagner, 2014). While sertraline and paroxetine are both SSRIs, sertraline is FDA approved when treating children whereas paroxetine has been found to be affective when treating children with depression, it is not specifically approved by the FDA at this point in time (Stahl, 2014b). Sertraline is approved by the FDA for use in children with depression beginning at the age of six (Stahl, 2013). Additionally, paroxetine is not recommended in use for children due to its short half-life which can lead to withdrawal when the medication is stopped abruptly (Nathan & Gorman, 2015).

The safety and efficacy of bupropion have not been established thus far but it some research that has been done suggests that this medication is effective for treatment of a client with both attention deficit disorder and depression, something that the client in this case study does not exhibit (Stahl, 2014b). Research has also shown that often the placebo effect alone on prescription medications can play a part in reduction of depressive symptoms in both children and adults (DeFilippis & Wagner, 2014). Assessing and Treating Clients With Anxiety Disorders Sample Essay.

As a new prescriber, I would most likely make a cautious decision when treating a child for the first time. Due to the fact that sertraline is FDA approved in the treatment of depression in children, I would most likely go with that medication as a primary action for prescribing for this client. The goal of this treatment is to alleviate depressive symptoms in the client while minimizing the risk for side effects of the medication.

When the client returned to the clinic four weeks after starting on Zoloft 25 mg daily, there was no change in the depressive symptoms at all (Laureate Education, 2016e). I am surprised that there was absolutely no change given the fact that the effects can be either medicinal or placebo, with changes seen as early as a week into the medication trial (Nathan & Gorman, 2015). As with all medications, there is always the chance that the client does not see an improvement in symptoms.

Decision Two

After the initial trial of Zoloft 25 mg yielded no change in the client’s symptoms, the treatment options are to increase the dose to 37.5 mg daily, increase the dose to 50 mg daily or to change the medication completely to Prozac 10 mg daily (Laureate Education, 2016e). Because the patient has not exhibited any adverse reactions to the medication, there is no need to change the medication at this time. As for titrating the sertraline, it can be titrated in increments of 25 mg with the maximum dosage not to exceed 200 mg daily (Southammakosane & Schmitz, 2015). Once the medication is started and tolerated, research supports titrating the medication up to minimize depressive symptoms (Cheung et al., 2018). Paroxetine, in general, was not recommended for treatment of pediatric depression based on research by Nathan & Gorman (2015) and this will not be considered for this client.

Based on this research, the decision was made to increase the Zoloft dose to 50 mg daily for the client. Again, the goals of treatment are to find a medication that reduces depressive symptoms in this pediatric patient while minimizing adverse effects. Once that goal is accomplished, long term goals for the client would be medication compliance and absence of relapse in depressive symptoms and suicidality.

The client returned to the clinic in four weeks with a decrease in depressive symptoms by 50% and is tolerating the medication well (Laureate Education, 2016e). While I anticipated the patient to have a reduction in depressive symptoms with the increase in dose, I had hoped the low dose would be effective for this patient. Assessing and Treating Clients With Anxiety Disorders Sample Essay. I am pleasantly surprised that the patient is not exhibiting any side effects from the medication.

Decision Three

The increase in the Zoloft dose to 50 mg yielded decreased depressive symptoms and no side effects (Laureate Education, 2016e). The next decision for the client involves maintaining the current dose, increasing the dose by 25 mg again to achieve a total dose of 75 mg daily or changing the medication to a SNRI (Laureate Education, 2016e). When discussing the medication with the client and parent, it would be important to discuss medication adherence to assure the client is taking the medication as directed. If this is the case, I would likely recommend increasing the dose to 75 mg due to the fact that the medication can be titrated up in 25 mg increments with the maximum prescribed dose of Zoloft being no more than 200 mg by mouth each day (Southammakosane & Schmitz, 2015). If the patient had seen no response and had reached the upper limit of Zoloft already, I would consider changing the medication, but it appears as though there is some desired effect from the medication without adverse reactions, which is the goal of treatment.

Serotonin-norepinephrine reuptake inhibitors (SNRI’s) such as duloxetine, venlafaxine and desvenlafaxine are considered second-line or third-line treatments for children with depression (Koechlin et al., 2018). Additionally, some research shows that there is significant cost benefit as well as safety in using SSRI’s over SNRI’s (Locher et al., 2107). In this case, I would continue with the SSRI medication I have been utilizing for this patient, which is a first line medication until I have exhausted my dosage options.

With increasing the dose of the Zoloft to 75 mg daily, I am hopeful that the medication will have an increased effect, perhaps 75-100% effective with little to no side effects. The response to the decision was that the client had a sufficient response to the medication with associated symptom reduction (Laureate Education, 2016e). It was recommended to either continue the Zoloft at 50 mg daily considering there was a response to the medication and evaluate again in four weeks to see if the medication continues to work or to increase it to 75 mg daily considering it was not complete remission of depressive symptoms (Laureate Education, 2016e).

While an increased dose may yield potential adverse effects, it can also give the necessary response of decreased depressive symptoms. This could be an opportunity to discuss the medication and symptoms with both the client and his parents to make them apart of the decision making. Although the client is only 8-years-old, he is capable of discussing his feelings as well as his response to the medication. Family can offer additional feedback from an external source about the client’s symptoms (Stahl, 2013). Should the patient not be able to tolerate the medication increase, the dose can be decreased as well. As I anticipated with the third decision, there is no reason to change the medication to an SNRI at this time considering the client is tolerating the Zoloft dose and exhibiting a response to it.

Conclusion

While there is not one correct answer when treating a child with depression, beginning drug therapy with a SSRI and titrating up slowly and as indicated has proved to be effective for my 8-year-old client with depression. When combined with therapy, such as cognitive behavioral therapy (CBT) treatment is enhanced and side effects of medications are diminished (Giles & Martini, 2016). Along with follow up for medication management, this client and his mom should also be educated on potential side effects including potential increase in suicidality. Should this happen, the client should be encouraged to reach out to a parent or adult he trusts and seek an appointment immediately.

Ethically, when treating clients with medications, benefit of treatment must outweigh potential harm (Merry et al., 2017). When discussing the treatment plan with the client and family, we must remain transparent and educate them on the pros and cons of the medications and also the potential for a placebo effect from taking an antidepressant medication. Information should be provided based on educational level and should be basic enough for an 8-year-old to understand and also complex enough for the parent to gauge an understanding of the medication their child is taking.

This assignment was an opportunity to examine different medication therapy for a child with depression and make changes as needed to help alleviate the client’s symptoms. Although there is not one clear answer when diagnosing and treating patients, it is important we treat each patient individually and based upon their needs and responses to medications prescribed.

References

Cheung, A. H., Zuckerbrot, R. A., Jensen, P. S., Laraque, D., Stein, R. E., & GLAD-PC

STEERING GROUP. (2018). Guidelines for adolescent depression in primary care (GLAD-PC): Part II. Treatment and ongoing management. Pediatrics, 141(3), e20174082.

DeFilippis, M., & Wagner, K. D. (2014). Management of treatment-resistant depression in

children and adolescents. Pediatric Drugs, 16(5), 353-361

Giles, L. L., & Martini, D. R. (2016). Challenges and promises of pediatric

psychopharmacology. Academic pediatrics, 16(6), 508-518.

Koechlin, H., Kossowsky, J., Gaab, J., & Locher, C. (2018). How to address the placebo

response in the prescription SSRIs and SNRIs in children and adolescents.

Laureate Education (2016e). Case study: An African American child suffering from depression

[Interactive media file]. Baltimore, MD: Author. Assessing and Treating Clients With Anxiety Disorders Sample Essay.

Locher, C., Koechlin, H., Zion, S. R., Werner, C., Pine, D. S., Kirsch, I. & Kossowsky, J. (2017).

Efficacy and Safety of Selective Serotonin Reuptake Inhibitors, Serotonin-Norepinephrine Reuptake Inhibitors, and Placebo for Common Psychiatric Disorders Among Children and Adolescents: A Systematic Review and Meta-analysis. JAMA Psychiatry, 74(10), 1011–1020. http://doi.org/10.1001/ jamapsychiatry.2017.2432

Merry, S. N., Hetrick, S. E., & Stasiak, K. (2017). Effectiveness and Safety of Antidepressants

for Children and Adolescents: Implications for Clinical Practice. JAMA psychiatry, 74(10), 985-986.

Nathan, P. E., & Gorman, J. M. (Eds.). (2015). A guide to treatments that work. Oxford

University Press.

—————————— ————–

Assessing and Treating Clients with Anxiety Disorder

Introduction

Anxiety disorders refer to a syndrome of mental disorders typified by substantial feelings of fear and anxiety.  The anxiety and fears may cause physical symptoms like shakiness and rapid heart rate. Various forms of anxiety disorders include panic disorder, social anxiety disorder, agoraphobia, generalized anxiety disorder, among other disorders (Locke et al, 2015).  The focus of this assignment is on a 46-year-old male who presented with symptoms of anxiety disorder that included breath shortness, chest tightness as well as a feeling of impending doom. Results of ER and ECK were normal which ruled out myocardial infarction. (HAM-A) scale yielded a score of 26 and a diagnosis of generalized anxiety disorder (GAD) was made. Following the diagnosis, three decisions will be made about the treatment regimen for the client. After making each decision, a rationale supported by clinical evidence and patient data will be provided. Moreover, after making each decision, factors likely to impact the pharmacokinetic and pharmacodynamic processes for the client will be considered when making decisions. Finally, ethical considerations likely to impact the client’s treatment plan will be discussed.

Decision Point One

The first choice for the client would be to begin Zoloft 50 mg orally daily. This decision was selected because Zoloft is selective serotonin reuptake inhibitors (SSRIs) and SSRIs are the recommended first-line treatments for anxiety disorders. SSRIs work by increasing the amount of serotonin within the brain; serotonin is a brain chemical that is very important for mood regulation (Locher et al, 2017). Accordingly, SSRIs such as Zoloft work by hindering serotonin reuptake in the brain and therefore increases the level of serotonin in the brain; availability of serotonin thus helps in regulating moods and hence improves anxiety symptoms. In addition, evidence shows that Zoloft is effective in improving anxiety symptoms manifest in GAD; this is because anxiety depletes serotonin in the brain and this is addressed by an SSRI such as Zoloft which replaces the depleted serotonin in the brain (Patel et al, 2018).

Imipramine (Tofranil) at 25 mg BID and Buspirone (Buspar) 10 mg orally twice daily choices were not selected because as aforementioned evidence recommends SSRIs as the first-line medications in the treatment of anxiety disorders Assessing and Treating Clients With Anxiety Disorders Sample Essay. Moreover, these two medications are not well tolerated as Zoloft and also have numerous side effects when compared to Zoloft.

By selecting the decision to begin Zoloft 50 mg orally daily, it was expected that symptoms of generalized anxiety disorder manifested by the client would gradually clear away. It was also expected that the HAM-A score for the client would significantly reduce indicating an improvement of the anxiety symptoms. This is because evidence shows that Zoloft as an SSRI is effective in the treatment of GAD symptoms (Patel et al, 2018). In addition, it was hoped that the client would have minimal side effects and tolerate the medication because evidence shows that SSRIs have minimal side effects are well tolerated (Clevenger et al, 2018)

There was no significant difference between the actual outcome of the decision and the expected results because when the client came for review the anxiety symptoms had significantly reduced and manifested by the client not having symptoms such as shortness of breath or chest tightness. Moreover, the client reported that he had stopped worrying about his job and also the HAM-A score dropped from 28 to 18 which shows that the client was responding to treatment, although partially.

Decision Point Two

The chosen second decision is to increase the client’s Zoloft dose to 75 mg orally daily. This decision was selected because the client’s HAM-A score dropped from 28 to 18 which indicated a partial response to treatment which shows that the client is responding to the treatment. Therefore, the increase of the dose from 50 mg to 75mg will further increase the availability of serotonin within the brain and thus further improve the anxiety symptoms for the client.  Evidence supports the gradual increase of the SSRIs dosage if the clients are not satisfactorily responsive to the treatment (Jakubovski et al, 2016). This decision was also based on the fact that the client seems to be tolerating Zoloft medication well and without any side effect.

The option to increase Zoloft to 100mg was not chosen because dosage increase and titration are supposed to be gradual to ensure the client continues to tolerate the medication well with minimal side effects.  On the other hand, the option to have the client continue with the same dose and have him reassessed after four weeks was not selected because the client’s response is partial and therefore it is essential to increase the dosage to ensure complete response to the medication (Jakubovski et al, 2016). Assessing and Treating Clients With Anxiety Disorders Sample Essay.

By choosing this decision, the expectation was that the anxiety symptoms would continue reducing and this would be indicated by a significantly reduced HAM-A score. There was no noticeable difference between the actual decision and the expected decision because on coming to the clinic the client’s anxiety symptoms had further reduced as indicated by the further reduction of the HAM-A score.

Decision Point Three

For the third decision, the chosen decision is to have the client maintain the current dose of Zoloft 75 mg orally daily. This decision was chosen because with the current decision the client is showing improvement of the anxiety symptoms as indicated by the subjective data and the HAM-A score; the client reported that he was no longer experiencing the symptoms and also the HAM-A score indicated significant reduction with the current dose. This means that the client is responding to the current medication and dose adequately. Assessing and Treating Clients With Anxiety Disorders Sample Essay. In addition, with the current dose, the client is not experiencing any side effects and he is tolerating the medication very well. Evidence and clinical guidelines recommend titration of medications according to the response of the client; in this case, the client is responding very well and hence there is no need to titrate medication any further (Jakobsen et al, 2017).

The option to either augment the current treatment with Buspar or the option of increasing the current dose of Zoloft to 100mg was not chosen since the client is showing a satisfactory response to the current dose of Zoloft 75 mg.

By selecting this decision, the expectation is that the client will show a complete response to the treatment where the client will report complete clearance of the symptoms and the HAM-A score will significantly reduce.

Impact of Ethical Considerations on the Treatment Plan

For this client, the ethical considerations will encompass informed consent, confidentiality, and autonomy. First, it is essential to seek informed consent from the client to ensure that the client has full information about the recommended treatment before he consents to the treatment (Millum, 2013). Secondly, the confidentiality of the client should be respected. This means that any information and the client’s treatment regimen should not be disclosed to any other party without the consent of the client. Lastly, the client’s autonomy should be respected where the client should not be forced or coerced to have any treatment; he should decide to accept or refuse the treatment. Any decision the client makes about the treatment should be respected (Millum, 2013).

 

Conclusion

The selected first decision is to begin Zoloft 50 mg orally daily. The rationale for selecting this decision is because SSRIs such as Zoloft are the first treatment choice for anxiety disorders and evidence shows that the medication is effective in treating anxiety symptoms. There was significant improvement with this decision. The second decision was to increase the dose to the Zoloft dose to 75 mg orally daily. This decision was made because the client was showing partial response as indicated by the HAM-A score and hence increasing the dose would facilitate a satisfactory response. The third decision is to maintain the current dose because the client is showing a satisfactory response to the treatment as indicated by the reduced HAM-A score and reduced symptoms as per the subjective data. Finally, the ethical considerations that should be considered include autonomy, confidentiality, and informed consent.

 

 

References

Clevenger S, Devvrat M, Dang J, Vanle B & William I. (2018). The role of selective serotonin reuptake inhibitors in preventing relapse of major depressive disorder.
Ther Adv Psychopharmacology
. 8(1): 49–58. Assessing and Treating Clients With Anxiety Disorders Sample Essay.

Jakubovski E, Anjali V, Freemantle N, Taylr M & Bloch M. (2016). Systematic Review and Meta-Analysis: Dose-Response Relationship of Selective-Serotonin Reuptake Inhibitors in Major Depressive Disorder.
Am J Psychiatry
. 173(2): 174–183.

Jakobsen J, Kumar K, Timm A, Gluud C, Ebert E et al. (2017). Selective serotonin reuptake inhibitors versus placebo in patients with major depressive disorder. A systematic review with meta-analysis and Trial Sequential Analysis.
BMC Psychiatry
. 17(58).

Locke A, Faafp M, Krist N & Shultz C. (2015). Diagnosis and Management of Generalized Anxiety Disorder and Panic Disorder in Adults.
Am Fam Physician.
  1;91(9),617-624.

Locher, C., Koechlin, H., Zion, S. R., Werner, C., Pine, D. S., Kirsch, I. & Kossowsky, J. (2017).

Efficacy and Safety of Selective Serotonin Reuptake Inhibitors, Serotonin-Norepinephrine Reuptake Inhibitors, and Placebo for Common Psychiatric Disorders Among Children and Adolescents: A Systematic Review and Meta-analysis.
JAMA Psychiatry
. 74(10), 1011–1020.

Millum J. (2013). Introduction: Case Studies in the Ethics of Mental Health Research.
J Nerv Ment Dis
. 200(3), 230–235.

Patel D, Feucht C, Brown K & Ramsay J. (2018). Pharmacological treatment of anxiety disorders in children and adolescents: a review for practitioners.
Transl Pediatr
. 7(1): 23–35. Assessing and Treating Clients With Anxiety Disorders Sample Essay.