Tag: Clinical-Nursing

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.”

BUY A PLAGIARISM-FREE PAPER HERE

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.”

BUY A PLAGIARISM-FREE PAPER HERE

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.

BUY A PLAGIARISM-FREE PAPER HERE

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

BUY A PLAGIARISM-FREE PAPER HERE

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.

Assessing and Treating Clients with With Bipolar Disorder Essay

Bipolar Therapy

Client of Korean Descent/Ancestry

BACKGROUND INFORMATION

The client is a 26-year-old woman of Korean descent who presents to her first appointment following a 21-day hospitalization for onset of acute mania. She was diagnosed with bipolar I disorder.

Upon arrival in your office, she is quite “busy,” playing with things on your desk and shifting from side to side in her chair. She informs you that “they said I was bipolar, I don’t believe that, do you? I just like to talk, and dance, and sing. Did I tell you that I liked to cook?”

She weights 110 lbs. and is 5’ 5”

ORDER A PLAGIARISM-FREE PAPER HERE

SUBJECTIVE

Patient reports “fantastic” mood. Reports that she sleeps about 5 hours/night to which she adds “I hate sleep, it’s no fun.”

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 With Bipolar Disorder Essay. Lab studies were all within normal limits. You find that the patient had genetic testing in the hospital (specifically GeneSight testing) as none of the medications that they were treating her with seemed to work.

Genetic testing reveals that she is positive for CYP2D6*10 allele.

Patient confesses that she stopped taking her lithium (which was prescribed in the hospital) since she was discharged two weeks ago.

MENTAL STATUS EXAM

The patient is alert, oriented to person, place, time, and event. She is dressed quite oddly- wearing what appears to be an evening gown to her appointment. Speech is rapid, pressured, tangential. Self-reported mood is euthymic. Affect broad. Patient denies visual or auditory hallucinations, no overt delusional or paranoid thought processes readily apparent. Judgment is grossly intact, but insight is clearly impaired. She is currently denying suicidal or homicidal ideation.

The Young Mania Rating Scale (YMRS) score is 22

RESOURCES

§ Chen, R., Wang, H., Shi, J., Shen, K., & Hu, P. (2015). Cytochrome P450 2D6 genotype affects the pharmacokinetics of controlled-release paroxetine in healthy Chinese subjects: comparison of traditional phenotype and activity score systems. European Journal of Clinical Pharmacology, 71(7), 835-841. doi:10.1007/s00228-015-1855-6 Assessing and Treating Clients with With Bipolar Disorder Essay.

Decision Point One

Select what the PMHNP should do:

Begin Lithium 300 mg orally BID

Begin Risperdal 1 mg orally BID

Begin Seroquel XR 100 mg orally at HS

To prepare for this Assignment:

• Review this week’s Learning Resources. Consider how to assess and treat clients requiring bipolar therapy.

The Assignment

Examine Case Study: An Asian American Woman With Bipolar Disorder. 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. Assessing and Treating Clients with With Bipolar Disorder Essay.

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?

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

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. Similarly, Seroquel XR could be a good alternative. However, its side effects of 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. Assessing and Treating Clients with With Bipolar Disorder Essay.

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 With Bipolar Disorder 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). Assessing and Treating Clients with With Bipolar Disorder Essay.

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). Assessing and Treating Clients with With Bipolar Disorder Essay. 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). Assessing and Treating Clients with With Bipolar Disorder Essay. 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 Assessing and Treating Clients with With Bipolar Disorder Essay.

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.  Besides, changing to Latuda is not recommendable in this case since Latuda is FDA approved for bipolar I depression which differs from the patient’s presentation that we are trying to manage. Besides, Latuda is costly and most health insurance companies would decline to pay for it until other drugs have been attempted and proven to fail (John & Antai-Otong, 2016). Assessing and Treating Clients with With Bipolar Disorder Essay.

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. 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 places the treatment goals laid by the mental healthcare provider in conflict with the patient’s autonomy to make decisions. Assessing and Treating Clients with With Bipolar Disorder Essay.

References

Chen, R., Wang, H., Shi, J., Shen, K., & Hu, P. (2015). Cytochrome P450 2D6 genotype affects the pharmacokinetics of controlled-release paroxetine in healthy Chinese subjects: comparison of traditional phenotype and activity score systems.
European Journal of Clinical Pharmacology
, 71(7), 835-841.

Culpepper, L. (2014). The diagnosis and treatment of bipolar disorder: decision-making in primary care. 
The primary care companion for CNS disorders
, 
16
(3).

Fang, F., Wang, Z., Wu, R., Calabrese, J. R., & Gao, K. (2017). Is there a ‘weight neutral’second-generation antipsychotic for bipolar disorder?. 
Expert review of Neurotherapeutics
, 
17
(4), 407-418.

John, R. L., & Antai-Otong, D. (2016). Contemporary Treatment Approaches to Major Depression and Bipolar Disorders. 
Nursing Clinics
, 
51
(2), 335-351.

Ratheesh, A., Cotton, S. M., Davey, C. G., Adams, S., Bechdolf, A., Macneil, C., & McGorry, P. D. (2017). Ethical considerations in preventive interventions for bipolar disorder. 
Early intervention in psychiatry
, 
11
(2), 104-112. Assessing and Treating Clients with With Bipolar Disorder Essay.

Asthma pathophysiology nursing sample essay

Asthma

Asthma is a disease that affects over 30 million Americans, and is mostly diagnosed during childhood to (Huether & McCance, 2017). When Asthma is not properly diagnosed or diagnosed late, it could lead to chronic changes in the airways. Asthma is a chronic disease and can show up at any age and is not gender specific (National Asthma Education, 2007). According to Huether and McCance (2017), asthma can present itself in children when exposed to high level of allergens. Smoking, exposure to allergens, air pollution and re-occurring respiratory infection all put an individual at risk for asthma. When an individual inhales irritants, it could create some permanent changes in the airways. Asthma pathophysiology nursing sample essay.

BUY A PLAGIARISM-FREE PAPER HERE

Pathophysiology

When the bronchial mucosa is exposed to allergens, it stimulates the dendritic cells, and this pushes antigen to the T-helper cells. The T-helper cells release both cytokines and interleukins that stimulates plasma cells and eosinophils. Thus, leading to obstruction of the airways (Huether & McCance, 2017). The plasma cells create IgE, and it connects to the mast cells, and it causes degranulation due to the discharge of inflammatory mediators like histamine and bradykinins. Inflammatory mediators lead to mucosal edema, bronchospasm, and vasodilations which contribute to narrowing the airways. Asthma pathophysiology nursing sample essay.

Asthma manifest differently in people, and they can range from an acute exacerbation to a severe attack (Hammer & McPhee, 2014). Asthma pathophysiology nursing sample essay. Wheezing is a classic sign of asthma, and this is caused by the contraction of smooth muscles in the airways (Hammer & McPhee, 2014). Dyspnea, tachypnea, cough (non-productive), tachycardia and prolonged expiration are manifestations of asthma. When the usual treatment is no longer effective for bronchospasm which is an inflammatory response, then the patient is believed to have status asthmaticus (Huether & McCance, 2017).

Diagnosis and Treatment

The first step in diagnosing asthma is by looking at the patients’ history of allergies and check for classic signs such as wheezing, non-productive cough, shortness of breath and chest tightness or intolerance of exercise. According to Huether and McCance (2017), arterial blood gases (ABG) is one way to diagnose asthma. Expiratory flow rates which measure the speed at which someone exhales is another method diagnose asthma and how severe it is. Administration of oxygen and short-acting bronchodilator is used for the treatment of acute asthma. Asthma pathophysiology nursing sample essay. The nurse practitioner should also administer oral corticosteroids; closely monitor airflow and how the patient reacts to the treatment (Lawlor, 2015).

Ethnicity

Asthma is not raced specific, but it has been discovered that people of black descent are more likely to suffer from asthma than white people and black children are twice likely to develop asthma than their white peers (CDC, 2016). According to the CDC (2016), blacks and people of mixed race are unlikely to seek medical assistance such as going to the emergency room and most times these are associated with the cost of care Asthma pathophysiology nursing sample essay.

Conclusion

Asthma is not gender or age specific and is mostly like to occur in black and people of mixed races than whites (CDC, 2016). If re-occurring respiratory infections are not well treated, it could lead to permanent changes known as airway remodeling in the airways obstructing airflow to the lungs such as asthma (Huether & McCance, 2017).  It is germane for people to seek early treatments for respiratory infections to avoid airway remodeling consequently worsening the situation. It is imperative for nurse practitioners to recognize the signs of asthma and differentiate between an acute exacerbation and chronic asthma attack because that will help the nurse practitioner tailor their treatment and management correctly. Asthma pathophysiology nursing sample essay.

 

 

References

Center for Disease Control and Prevention (CDC). (2016).
Asthma’s Impact on the Nation
; Data from the CDC National Asthma Control Program. Retrieved from: https://www.cdc.gov/asthma/impacts-nation/asthmafactsheet.pdf

Hammer, G. D., & McPhee, S. J. (2014).
Pathophysiology of disease: An introduction to clinical medicine
(7th ed.). New York, NY: McGraw-Hill Medical. Asthma pathophysiology nursing sample essay.

Huether, S. E., & McCance, K. L. (2017).
Understanding pathophysiology
(6th ed.). St. Louis, MO: Mosby.

Lawlor, R. (2015). Management of asthma in children.
Practice Nursing, 26
(7),326-330. Asthma pathophysiology nursing sample essay.

Assessing and Treating Pediatric Clients With Mood Disorders Essay Example

Therapy for Pediatric Clients with Mood Disorders

An African American Child Suffering From Depression

BACKGROUND INFORMATION

The client is an 8-year-old African American male who arrives at the ER with his mother. He is exhibiting signs of depression.

• Client complained of feeling “sad”

• Mother reports that teacher said child is withdrawn from peers in class

• Mother notes decreased appetite and occasional periods of irritation

• Client reached all developmental landmarks at appropriate ages

• Physical exam unremarkable

• Laboratory studies WNL

• Child referred to psychiatry for evaluation

• Client seen by Psychiatric Nurse Practitioner

ORDER A PLAGIARISM-FREE PAPER HERE

MENTAL STATUS EXAM

Alert & oriented X 3, speech clear, coherent, goal directed, spontaneous. Self-reported mood is “sad”. Affect somewhat blunted, but child smiled appropriately at various points throughout the clinical interview. He denies visual or auditory hallucinations. No delusional or paranoid thought processes noted. Judgment and insight appear to be age-appropriate. He is not endorsing active suicidal ideation but does admit that he often thinks about himself being dead and what it would be like to be dead. Assessing and Treating Pediatric Clients With Mood Disorders Essay Example.

The PMHNP administers the Children’s Depression Rating Scale, obtaining a score of 30 (indicating significant depression)

RESOURCES

§ Poznanski, E., & Mokros, H. (1996). Child Depression Rating Scale–Revised. Los Angeles, CA: Western Psychological Services.

Decision Point One

Select what the PMHNP should do:

Begin Zoloft 25 mg orally daily Begin Zoloft 25 mg orally daily

Begin P

Begin Paxil 10 mg orally daily

axil 10 mg orally daily

Begin Wellbutrin 75 mg orally BID Begin Wellbutrin 75 mg orally BID

Examine Case Study: An African American Child Suffering From Depression. 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:

o Decision #1

 Which decision did you select? Assessing and Treating Pediatric Clients With Mood Disorders Essay Example.

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

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

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

o Decision #2

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

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

 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 Pediatric Clients With Mood Disorders Essay Example.

o Decision #3

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

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

 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 references should be within 5 years.

Clinical Scenario

This assignment involves a client who is 8 years old who is an African American male who presents at the Emergency Room with his mother. The client was exhibiting signs of depression and had complaints of feeling sad. The mother reportedly informed that the teacher had examined that the child was withdrawn from peers in class. Assessing and Treating Pediatric Clients With Mood Disorders Essay Example The mother had also noted that the child had a decreased appetite with occasional irritation periods despite reports that he had reached all landmarks of development at the appropriate ages. The physical examination was unremarkable while the laboratory studies WNL.

The mental status exam revealed that the client was alert and oriented X3, his speech was clear, coherent spontaneous and goal oriented. The client self-reported a sad mood and had an affect which was somewhat blunted. The client denied visual and auditory hallucinations and no delusional or paranoid processes of thought were noted Assessing and Treating Pediatric Clients With Mood Disorders Essay Example. The client also appeared to have an appropriate, did not endorse active suicidal ideation but admitted that he often thought about being dead and what it would feel like to be dead. In administering the Children’s Depression Rating Scale, a score of 30 was obtained, indicating the client had significant depression

Decision Point One

           
The primary mental nurse practitioner should begin Zoloft 25 mg orally daily. Zoloft is a selective serotonin reuptake inhibitor that is used as a first line drug for the management of major depressive disorder and other mental health disorders. It works by increasing the amount of serotonin in the brain to improve symptoms of anxiety and depression (Cummings, Caporino & Kendall, 2014).  Similarly, the client, in this case, had been diagnosed with major depression which required relevant medications.

With this medication, I was hopeful that the symptoms the client experienced a sad mood, a blunted affect and irritations would be done away with. Instead, he would have a happy mood, an increased appetite, a fluent affect and no thoughts about being dead. Zoloft helps to improve sleep, mood, appetite and the level of energy such that, the overall interest of an individual in daily life is restored (Cox, et al., 2014). It also influences a significant reduction in anxiety and thoughts that are unwanted.

Instead, the client returned to the clinic in four weeks, stating that, although he improved in terms of mood, appetite and other life’s aspects, he had frequent suicidal thoughts that negatively influenced his life in general. Despite being the first line of treatment for depression in children, Zoloft is known to increase suicidal behavior and thoughts in children, adolescents and even young adults (Cooper, et al., 2014).  This risk increases within the first few months of treatment or in case of dosage changes Assessing and Treating Pediatric Clients With Mood Disorders Essay Example. It is for this reason that it has a black box warning from the Food and Drug Administration to alert healthcare providers and patients on how dangerous some of the side effects of drugs may change. For patients already having suicidal behavior and thoughts, administering Zoloft is likely to worsen the situation as it is in this case (Cooper, et al., 2014). This means that to reduce these side effects, the dosage can be reduced. However, the effects of suicidal thoughts and behavior would still be existent. Therefore, the best option would be to stop the Zoloft 25 mg orally daily.

Decision 2

The second decision would be to begin praxis 10mg orally daily. Praxil is a selective serotonin reuptake inhibitor that is indicated for the management of depression. It functions by influencing chemical balance in the brain which is associated with anxiety and depression disorders (Walkup, 2017). Similarly, the client, in this case, had been diagnosed with depression and had experienced intense symptoms of mood changes, reduced appetite, and feelings similar to suicidal thoughts and behavior. Praxil has the ability of increased appetite, mood, level of energy and sleep and helps to reduce unwanted thoughts Assessing and Treating Pediatric Clients With Mood Disorders Essay Example. With this decision, it was certain that by administering praxil 10mg orally daily, the client would have no more negative symptoms of behavior, mood or emotions. Besides, it was expected that he would not experience any suicidal thoughts.

After two weeks, the client returned to the clinic accompanied by his mother with complaints of losing weight for the last two weeks when therapy was started. Praxil inhibits growth among pediatric patients such that, periodic monitoring of weight and height is needed and clients are urged to take medications with food (Bachmann et al., 2016).  An alternative option would be to reduce the dosage to 5mg orally daily. However, with this dosage therapeutic outcomes cannot be achieved. Similarly, the dosage for the client, in this case, cannot be increased. Increasing the dosage will influence clinical worsening and unusual behavioral changes. Assessing and Treating Pediatric Clients With Mood Disorders Essay Example.

The Food and Drug Administration warns that high doses of praxil beyond the recommended guidelines increases the risk of suicidal behavior and thoughts in children especially during the first weeks of treatment. It is even worse among children with depressive symptoms who present with a history of suicidal ideation before treatment requiring that, children are closely monitored during the course of treatment for strange behaviors and worsening of depression (Cooper, et al., 2014). The best decision would, therefore, be to discontinue the medication by rapidly tapering the dosage since abrupt discontinuation of praxil has also proven to cause adverse symptoms.

Decision 3

At this point, the best decision would be to start Wellbutrin 75 mg orally BID. Wellbutrin has been noted to be a better antidepressant among children as compared to tricyclic’s as it also has a totally different mechanism of action as compared to selective serotonin reuptake inhibitors. It has also been approved by the Food and Drug Administration for managing depression. Assessing and Treating Pediatric Clients With Mood Disorders Essay Example. It works as a norepinephrine-dopamine reuptake inhibitor, increasing the amount of norepinephrine produced by the body (Bachmann, et al., 2016).  This helps to balance inactive and dull moods which are as a result of depression. Therefore, by administering this drug, it was expected that the client’s symptoms of a sad mood, irritation and appetite loss will gradually reduce and eventually resolve.  Similarly, it was certain that the client’s symptoms of suicidal thoughts will gradually resolve and that he will fully regain his health status after treatment (Bachmann, et al., 2016).

After two weeks, the client returned with complaints of weight loss and a suppressed appetite but no reports of seizures. Wellbutrin is known to cause loss of appetite as well as low blood sugars. This increased risk for seizures is associated with hypoglycemia. The dosage cannot be increased or reduced in this case. Increasing the dosage will result in more advanced adverse side effects and reducing the dosage will hinder the achievement of therapeutic outcomes (Walkup, 2017).  The best option would be maintaining the dosage at 75mg orally daily and adhering to dietary recommendations of eating mid-morning, midafternoon and bedtime snacks. Similarly, the child’s weight will have to be monitored closely. These effects are only expected to be more intense during the first few weeks of treatment, after which they will gradually decline Assessing and Treating Pediatric Clients With Mood Disorders Essay Example.

How Ethical Considerations Might Impact Treatment Plan and Communication with Clients

           
Working which children and adolescents can pose significant challenges for mental health providers. Major ethical considerations for this population are confidentiality and patient autonomy and require varied approaches that are highly dependent on a child’s and family’s characteristics to address (Coyne et al., 2014). Irrespective of age, children have the right to confidentiality and mental health providers are required to disclose information to parents or other people with the child’s informed consent. Similarly, children have a right to be part of decision making regarding their treatment. By observing these ethical considerations, it is certain that the therapeutic relationship between the client and mental health practitioner will be long term and promote the development of trust (Coyne et al., 2014).  This increases the chances of treatment success and reduces the likelihood of resistance. With regards to communication, a therapeutic relationship that is built on trust promotes a safe and conducive environment where the client and mental health provider can openly and freely communicate to achieve more specific and targeted health outcomes(Coyne et al., 2014). Assessing and Treating Pediatric Clients With Mood Disorders Essay Example.

References

Bachmann, C. J., Aagaard, L., Burcu, M., Glaeske, G., Kalverdijk, L. J., Petersen, I., & Hoffmann, F. (2016). Trends and patterns of antidepressant use in children and adolescents from five western countries, 2005–2012. 
European Neuropsychopharmacology
, 
26
(3), 411-419.

Cummings, C. M., Caporino, N. E., & Kendall, P. C. (2014). Comorbidity of anxiety and depression in children and adolescents: 20 years after. 
Psychological Bulletin
, 
140
(3), 816.

Cox, G. R., Callahan, P., Churchill, R., Hunot, V., Merry, S. N., Parker, A., & Hetrick, S. E. (2014). Psychological therapies versus antidepressant medication, alone and in combination for depression in children and adolescents. 
Cochrane database of systematic reviews
, (11).

Cooper, W. O., Callahan, S. T., Shintani, A., Fuchs, D. C., Shelton, R. C., Dudley, J. A.,  & Ray, W. A. (2014). Antidepressants and suicide attempts in children. 
Pediatrics
, peds-2013. Assessing and Treating Pediatric Clients With Mood Disorders Essay Example.

Coyne, I., Amory, A., Kiernan, G., & Gibson, F. (2014). Children’s participation in shared decision-making: Children, adolescents, parents and healthcare professionals’ perspectives and experiences. 
European Journal of Oncology Nursing
, 
18
(3), 273-280.

Walkup, J. T. (2017). Antidepressant efficacy for depression in children and adolescents: industry-and NIMH-funded studies. 
American Journal of Psychiatry
, 
174
(5), 430-437. Assessing and Treating Pediatric Clients With Mood Disorders Essay Example.

Critique of Systematic Research Review (SRR): Nursing Handoffs Essay

Nursing handoffs is a type of report between two clinicians that are responsible for patients care and is an important part of transferring patient information (what, how, who and where) from one healthcare provider to another in clinical practice (Smith and Schub, 2014). Ineffective, inconsistent and incongruent communication during these handoffs continues to be a problem and a threat to patient safety. Effective handoffs are instrumental in providing for the successful quality of care that the patient is to receive (Holly and Poletick 2014). Medical errors, treatment delays, inappropriate treatment and/or care omissions can happen as a result of miscommunication during handoffs which could potentially lead to patient harm, longer stays, readmissions and/or increased costs. Critique of Systematic Research Review (SRR): Nursing Handoffs Essay.

ORDER A PLAGIARISM-FREE PAPER HERE

Search Process

The authors of this article performed a search looking for only qualitative research articles that were based on the nurse’s experiences at the time of shift change/nursing handoffs. One hundred and twenty-five qualitative articles between 1988 and 2012 met the initial inclusion criteria and 50 articles were evaluated and a final sample of 29 qualitative articles was analyzed and utilized for this study and included (Holly and Poletick 2014). Only articles that described nurse to nurse shift reporting was used.

Articles

The articles chosen are as follows (Holly and Poletick 2014):

21 ethnographic studies – study of people and cultures

2 qualitative descriptive studies – subjective research that studies the characteristics of a population. Critique of Systematic Research Review (SRR): Nursing Handoffs Essay.

3 case studies – a detailed, up close and in depth research method of a subject

1 phenomenological study – study of experiences

1 appreciative enquiry study – involves bringing large, diverse groups of people together to study

1 action research study – research initiated to solve a problem

 

The data collection methods in the research articles included observations, interviews, document reviews and questionnaires.

Search Terms

The terms that were used for their search included (Holly and Poletick 2014):

Communication

Nurse’s report(s)

Intershift report(s)

Shift report

Nursing shift report

Handoff(s)

Sign-off

Signoff

Handoff report

Handoff communication

Information transfer

Handover

Handover communication

Handover report

Qualitative research

 

Databases

 

The following databases were used for their search (Holly and Poletick 2014):

CINAHL

Pre-CINAHL

Healthstar

ScienceDirect

Dissertation Abstracts International

Theses Canada

DARE

PyschINFO

BioMed Central

TRIP

SI Current Contents

Web of Science/Web of Knowledge

Scirus

gov

 

Findings

The articles were retrieved using the Qualitative Assessment Review Instrument (QARI) (www.joannabriggs.edu.au) which allows the authors to aggregate their findings with relation to their study (Holly and Poletick 2014). One hundred and seventeen findings were identified and these were then grouped into sixteen categories that were based on commonality and relevance to the nursing handoff report (Holly and Poletick 2014) and these findings were further subjected to a metasynthesis that produced these two findings that can thus be used as a basis for future evidenced-based practice:

‘Individual nurses influence patient care nurse as the gatekeeper if information handed off that is used for subsequent care decisions’ (Holly and Poletick 2014)

‘There is an embedded hierarchy in relation to the handy over of information that serves as a method of enculturation to the nursing unit’ (Holly and Poletick 2014) Critique of Systematic Research Review (SRR): Nursing Handoffs Essay.

In reference to item number one: the authors found evidence to suggest incongruence among the nurses reports (written, oral and patient observation) with an overall congruence rate of 70% and the most common deficit was omission (Holly and Poletick 2014). It was also discovered that relevant information was omitted and irrelevant information as often conveyed.

In reference to number two: shift report is when information and responsibility is passed on to the next shift. It is a great time to facilitate staff cohesion and for support. It can also be a forum for team building. The authors noticed that the quality of information exchanged during shift report was unpredictable – few questions asked and dialogue between staff was often vague and lacked precision (Holly and Poletick 2014).

On a positive note, shift reporting provides a place where new nurses can be oriented to the culture, language and rituals of the unit being worked on. This time helps to increase the cohesiveness of the teams with increased consistency. As a result this can help to increase information being given during report time. Little approval is given verbally and often nonverbal cues or gestures (i.e. head nods, eye contact) are used.

Recommendations

           
The final results of this study showed the need for a more improved handoff technique. The authors state that the nurse is the gatekeeper for clinicians versus patients and the research showed that nurses are very ineffective in this area. Critique of Systematic Research Review (SRR): Nursing Handoffs Essay. The key recommendation for improving nursing handoffs would be the improvement of communication which would include a reduction of omission, improved written report and a better communication between nurses and physicians. Other options of improving nursing shift reports would be to institute a written report to go along with a verbal report that can be passed down from shift to shift. A reliable handoff should include 3 important elements: (1) face to face, 2-way communication, (2) a universal structured written form or template and (3) the handoff needs to share the problem of the patient’s clinical situation (Halm, 2013). As sated previously a simple suggestion to improving shift change handoffs is to institute a universal structured from. One could use mnemonic devices to help in making sure that important information is transferred from one clinician to the next. A few examples are SBAR (situation, background, assessment, recommendation) or I PASS the BATON (Introduction, patient, assessment, situation, safety concerns, background, actions, timing, ownership, next) (Halm, 2013). Halm (2013) states that ‘consistently discussing information in a standardized sequence can also aid pattern recognition for clinicians’. In other words, if we all consistently use the same methods for shift change reports then, ideally, information should not be missed. Holly and Poletick (2014) states that ‘the role of a nurse as decision-make of what information is chosen to be acted up and/or handed off’ is a major finding of their research article. Critique of Systematic Research Review (SRR): Nursing Handoffs Essay. Technology allows customized reports to be created and it would be a benefit for institutions to take advantage of this ability to create a standardized form to use during nursing handoffs.

Conclusion

Effective communication among healthcare clinicians is critical for an effective handoff to provide safe high quality care. The result of a better shift change report would include improved patient satisfaction, better patient outcomes and improved financial outcomes. The author’s goal in this research article was to improve our understanding of the shift change handoff report process. It was discovered that it is very important for standardization to be implemented in order for improvement to be made. It is the responsibility of nurses to provide proper care to their patients and it is of utmost importance to relay information to the following shifts in order for proper care to be given. Holly and Poletick (2014) states that ‘handoffs allow nurses the opportunity to exchange information that will be used to make subsequent care decisions about their patients’. This results in improved satisfaction, shorter inpatient stays and reduced cost to all.

References

Halm, M.A. (2013). Nursing handoffs: ensuring safe passage for patients.
American Journal Of Critical Care 22
(2), 158-162. doi:10.4037/ajcc2013454

Holly, C., & Poletick, E. B. (2014). A systematic review on the transfer of information during nurse transitions in care.
Journal Of Clinical Nursing
, (17-18), 2387.

Smith, N., & Schub, E. (2014). Nursing report: patient hand-off.
CINAHL Nursing Guide. Critique of Systematic Research Review (SRR): Nursing Handoffs Essay.

Assessing the Genitalia and Rectum Essay Assignment Example

Assessing the Genitalia and Rectum

Patients are frequently uncomfortable discussing with health care professional’s issues that involve the genitalia and rectum; however, gathering an adequate history and properly conducting a physical exam are vital. Examining case studies of genital and rectal abnormalities can help prepare advanced practice nurses to accurately assess patients with problems in these areas.

In this assignment, you will consider case studies that describe abnormal findings in patients seen in a clinical setting.

In this assignment, you will analyze a SOAP note case study that describes abnormal findings in patients seen in a clinical setting. You will consider what history should be collected from the patients, as well as which physical exams and diagnostic tests should be conducted. You will also formulate a differential diagnosis with several possible conditions.

ORDER A PLAGIARISM-FREE PAPER HERE

GENITALIA ASSESSMENT

Subjective:

• CC: “I have bumps on my bottom that I want to have checked out.”

• HPI: AB, a 21-year-old WF college student reports to your clinic with external bumps on her genital area. She states the bumps are painless and feel rough. She states she is sexually active and has had more than one partner over the past year. Her initial sexual contact occurred at age 18. She reports no abnormal vaginal discharge. She is unsure how long the bumps have been there but noticed them about a week ago. Her last Pap smear exam was 3 years ago, and no dysplasia was found; the exam results were normal. She reports one sexually transmitted infection (chlamydia) about 2 years ago. She completed the treatment for chlamydia as prescribed. Assessing the Genitalia and Rectum Essay Assignment Example.

• PMH: Asthma

• Medications: Symbicort 160/4.5mcg

• Allergies: NKDA

• FH: No hx of breast or cervical cancer, Father hx HTN, Mother hx HTN, GERD

• Social: Denies tobacco use; occasional etoh, married, 3 children (1 girl, 2 boys)

Objective:

• VS: Temp 98.6; BP 120/86; RR 16; P 92; HT 5’10”; WT 169lbs

• Heart: RRR, no murmurs

• Lungs: CTA, chest wall symmetrical

• Genital: Normal female hair pattern distribution; no masses or swelling. Urethral meatus intact without erythema or discharge. Perineum intact with a healed episiotomy scar present. Vaginal mucosa pink and moist with rugae present, pos for firm, round, small, painless ulcer noted on external labia

• Abd: soft, normoactive bowel sounds, neg rebound, neg murphy’s, neg McBurney

• Diagnostics: HSV specimen obtained

Assessment:

• Chancre

• PLAN: This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.

To prepare:

With regard to the SOAP note case study provided:

• Review this week’s Learning Resources, and consider the insights they provide about the case study.

• Consider what history would be necessary to collect from the patient in the case study.

• Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?

• Identify at least five possible conditions that may be considered in a differential diagnosis for the patient. Assessing the Genitalia and Rectum Essay Assignment Example.

To complete:

Refer to Chapter 5 of the Sullivan text. Analyze the SOAP note case study. Using evidence based resources, answer the following questions and support your answers using current evidence from the literature.

• Analyze the subjective portion of the note. List additional information that should be included in the documentation.

• Analyze the objective portion of the note. List additional information that should be included in the documentation.

• Is the assessment supported by the subjective and objective information? Why or Why not?

• Would diagnostics be appropriate for this case and how would the results be used to make a diagnosis?

• Would you reject/accept the current diagnosis? Why or why not? Identify three possible conditions that may be considered as a differential diagnosis for this patient. Explain your reasoning using at least 3 different references from current evidence based literature. Assessing the Genitalia and Rectum Essay Assignment Example.

Introduction

For clients who present with genitourinary symptoms, it is necessary that a focused and comprehensive history is taken followed by a thorough examination.  Genitourinary problems are likely to trigger issues in other systems of the body. Similarly, difficulties that may arise in the various systems are likely to affect the quality of life and overall well-being of a client. Clinical nursing skills should possibly result in a list of the potential differential diagnoses and the definite diagnosis. With this approach, it is certain that a clinician will focus on the most appropriate tests that can confirm the diagnosis. This paper is an extensive discussion of the additional subjective and objective data that should be included in the assessment of clients presenting with genitourinary problems. A description of the use of diagnostics in making a diagnosis and possible differential diagnoses will also be provided. Assessing the Genitalia and Rectum Essay Assignment Example.

Additional Subjective Data to Include in the documentation.

The client will be asked to provide more information about additional symptoms associated with the bumps as I examine them to determine the color, pattern, size, and shape. The client will also be asked whether the bumps have appeared for the first time or they have also been there in the past, exact period and any previous medications used to manage them. It would also be necessary to ascertain and document if the client has noticed the bumps somewhere else in the body other than the genitals. According to Dains, Baumann & Scheibel (2016), general symptoms of a patient may relate to other systems within the body and produced by pathologies in the genitourinary tract. Information on associated symptoms such as a skin rash, recent weight loss, loss of hair, a fever, sores on the anus, dysuria, fatigue, and muscle aches should be documented alongside their relieving and aggravating factors is vital. The client will also be asked about the use of douches, fragrant and soaps and to rate the extent at which they are a bother to her general life on a scale of 0-10. Assessing the Genitalia and Rectum Essay Assignment Example.

Under the past medical and surgical history, past histories of genital herpes and other STIs apart from chlamydia should be documented. She will also be asked about the medications that were prescribed for chlamydia and by whom. The client should reveal if she has any skin conditions, psoriasis or eczema. The client’s full course of immunization, the age of asthma diagnosis and progress with its management should also be documented (Dains, Baumann & Scheibel, 2016). Previous female surgeries are also a vital part of the documentation.

It is also necessary that the client’s gynecological history is taken. Gynecological history includes the menstrual history where frequency, duration, volume, date of last menstrual period, contraception use and HIV is documented. The menstrual history will help to eliminate any possibilities of a pregnancy before further assessments and management (Jensen, 2018).  Still, on gynecological history, information about post-coital-bleeding, dyspareunia, and vulval itching should also be included. Post-coital bleeding and dyspareunia are symptoms of sexually transmitted illnesses. Assessing the Genitalia and Rectum Essay Assignment Example.

The client should also be asked if she performs self-breast exams. On the sexual history, it would be necessary to document the client’s preferences of her sexual practices and if she has unprotected sex, anal sex, the specific number of sexual partners, how often she has sex and if she knows the status of her sexual partners.  Her last sexual episode/encounter should be documented as this will help to approximate the duration it took for symptoms to present and possibly the definitive diagnosis.

The client is evidently married and a mother to 1 girl and 2 boys. Therefore, it would be essential to take her obstetric history. An obstetrics history provides a clinician with vital clues to the client’s health risks.  Previous congenital malformations which may result from STIs may indicate a predisposition to other STIs (Jensen, 2018). The client’s occupational history is very significant. An occupation that predisposes one to sexual encounters increases their risk for sexually transmitted illnesses which should be comprehensively addressed in the management to prevent STI risks in the future. Assessing the Genitalia and Rectum Essay Assignment Example.

Additional Objective Data to Include In the documentation.

It would be necessary to document the overall cleanliness, grooming, affect and stature of the client. On the HEENT exam, the throat should be assessed for redness, drainage, edema, enlarged tonsils, cold sores, lesions, and oral thrush to check for the systemic infection with HSV or other viruses. The documentation of the neck exam should include nodal tenderness, enlarged cervical nodes, jugular venous distension and goiters (Seidel, et al., 2015).  In the Chest exam, the client should be assessed for non-labored breathing, enlargement of axillary nodes, discharge, and tenderness over the nipples. Chest retractions and nasal flaring should be assessed and documented. Assessing the Genitalia and Rectum Essay Assignment Example.

In the CVS assessment, documentation about any pedal or general body edema and peripheral pulses should be included. In the genito-urinary exam, it would be mandatory to inspect the cervix and do a pap smear. The cervix will also be assessed for motion tenderness and general cervical tenderness. During this exam, signs of vaginal bleeding and foul-smelling vaginal discharge will be noted and documented. Palpation and documentation for inguinal tenderness and lymphadenopathy, whether the ulcer is the only one, indurated and its color should also be included (Seidel, et al., 2015). A rectal exam to ascertain any lesions, hemorrhoids, masses, and trauma will be necessary. A detailed skin exam to assess for pink color, warmth, and dryness will be included. Other areas with redness, lesions, and scarring, discoloration and patches will be examined and documented. Assessing the Genitalia and Rectum Essay Assignment Example.

Whether the Assessment Is Supported By Subjective and Objective Data

The assessment concluded that the client had a Chancre. A chancre often presents in veneral disease and it usually develops over the genital area.  More specifically, in females, chancres can also present over the vagina, anus or the vulva and take between 3 weeks to 3 months to present after infection. The chancre is often a painless ulcer, highly infectious and forms in the primary stage of syphilis which is a sexually transmitted illness (Dains, Baumann & Scheibel, 2016). Similarly, according to the subjective data, the client reportedly noticed a painless and rough lump over her genital area and reported no vaginal discharge. The client also agreed that she was sexually active and had had more than one partner in a year which increases her risk of a sexually transmitted infection. Based on the objective data, it was ascertained that the client had a round, small painless ulcer on the external labia. However, the abdominal examination and other examinations were normal. It is also due to the painless ulcer that an HSV specimen was taken for diagnostics. Therefore, the assessment of a chancre is correctly supported by both the objective and subjective data. Assessing the Genitalia and Rectum Essay Assignment Example.

The relevance of Diagnostics and Its Use to Make a Diagnosis

The diagnostics, in this case, was a HSV specimen which was taken for viral culture. In most cases, the results of a culture take between 1 to 7 days. Polymerase Chain Reaction can also be done to test for herpes simplex antibodies to confirm the diagnosis of herpes simplex (Dains, Baumann & Scheibel, 2016). Possibly, a tzanck smear can be done using the base of the vesicle which is also definitive for herpes simplex. In the findings, multinucleated giant cells may be found in case the samples would be taken from a herpes lesion that is intact. According to Dains, Baumann & Scheibel (2016), a serology test in the forms of VDRL, RPR or a non-treponemal pallidum test would be done to rule out syphilis. To rule out Chlamydia and Gonorrhea, rapid Nucleic Acid Amplification tests would be the most recommended (Tao, et al., 2017).

View on the Current Diagnosis

Primary syphilis often presents with a chancre which is a form of ulcer lesion that develops at the inoculation site.  It often starts off a papule and gradually develops into a painless, firm, indurated ulcer (Wolujewicz & Bates, 2016). Most clients cannot be aware as it presents no symptoms and the ulcer often heals on itself within 3-6 weeks. The ulcerative lesions usually appear exactly 2 weeks following exposure. Syphilis can be confirmed through serology as it is also supported by the subjective and objective data. Assessing the Genitalia and Rectum Essay Assignment Example.

Possible Differential Diagnoses

The most potential differential diagnoses, in this case, include syphilis, herpes simplex II and acute contact dermatitis. Basing on the fact that the client had multiple sexual partners within a year, she is at a potential risk of syphilis whose diagnosis can be confirmed with a serological test. To add on, by the lesion being located on the labia, it allows for contact directly with a syphilis sore (Wolujewicz & Bates, 2016). Besides, the patient reported that the ulcer was painless with no itchiness or burning prior to the eruption, this is an indication of syphilis. The client’s subjective and objective data also supports syphilis as a potential differential diagnosis but not without further history taking and diagnostics. To ascertain the possibilities of syphilis, extensive data & information on the lesion borders, clarity of its base and how central it is would be vital.

The likelihood of Herpes progenitalis also referred to as Herpes Simplex II is high.  However, the presence of a single ulcer limits this possibility since superficial vesicles can either be eroded or not. Depending on the client’s description of the ulcer, it was firm. In herpes simplex II, while primary infections are extensive, recurrent infections are often localized yet patchy with several lesions (Dains, Baumann & Scheibel, 2016). Besides, the lesions are not only painful but can result in a burning sensation with urination. Assessing the Genitalia and Rectum Essay Assignment Example.

Although the differential diagnosis of acute contact dermatitis is unlikely since the client presents with no history of topical allergens, it is possible. The history of the client’s recent activities in terms of contact with caustic chemicals and garden work may support this differential. However, if the sore could be contact related the erythema regions would be large. Assessing the Genitalia and Rectum Essay Assignment Example.

References

Dains, J. E., Baumann, L. C., & Scheibel, P., (2016).  Advanced health assessment and clinical diagnosis in primary care (5th ed.).
St. Louis, MO: Elsevier Mosby.

Jensen, S. (2018). Nursing health assessment: A best practice approach.
Lippincott Williams & Wilkins.

Seidel, H.M., Ball, J. S., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidels’s guide to physical examination (8th ed.). 
St. Louis, MO: Elsevier Mosby.

Tao, G., Hoover, K. W., Nye, M. B., Peters, P. J., Gift, T. L., & Body, B. A. (2017). Infrequent testing of women for rectal chlamydia and gonorrhea in the United States. 
Clinical Infectious Diseases
, 66(4), 570-575.

Wolujewicz, A., & Bates, C. (2016). Syphilis on the face in primary care: a rare sign of an increasingly common problem. 
The British Journal of General Practice, 66(648), e528–e530
. Assessing the Genitalia and Rectum Essay Assignment Example.