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Discussion NURS 6630 Treatment for a Patient With a Common Condition

Discussion: NURS 6630 Treatment for a Patient With a Common Condition

Insomnia is one of the most common medical conditions you will encounter as a PNP. Insomnia is a
common symptom of many mental illnesses, including anxiety, depression, schizophrenia, and ADHD
(Abbott, 2016). Various studies have demonstrated the bidirectional relationship between insomnia and
mental illness. In fact, about 50% of adults with insomnia have a mental health problem, while up to
90% of adults with depression experience sleep problems (Abbott, 2016). Due to the interconnected
psychopathology, it is important that you, as the PNP, understand the importance of the effects some
psychopharmacologic treatments may have on a patient’s mental health illness and their sleep patterns.
Therefore, it is important that you understand and reflect on the evidence-based research in developing
treatment plans to recommend proper sleep practices to your patients as well as recommend
appropriate psychopharmacologic treatments for optimal health and well-being.
Reference: Abbott, J. (2016). What’s the link between insomnia and mental illness? Health. https://www.sciencealert.com/what-exactly-is-the-link-between-insomnia-and-mental-
illness#:~:text=Sleep%20problems%20such%20as%20insomnia%20are%20a%20common,bipolar%20disorder%2C%20and%20attention%20deficit%20hyperactivity%20disorder%20%28ADHD%29

For this Discussion, review the case Learning Resources and the case study excerpt presented. Reflect on
the case study excerpt and consider the therapy approaches you might take to assess, diagnose, and
treat the patient’s health needs.
Case: An elderly widow who just lost her spouse.
Subjective: A patient presents to your primary care office today with chief complaint of insomnia. Patient
is 75 YO with PMH of DM, HTN, and MDD. Her husband of 41 years passed away 10 months ago. Since
then, she states her depression has gotten worse as well as her sleep habits. The patient has no previous
history of depression prior to her husband’s death. She is awake, alert, and oriented x3. Patient normally
sees PCP once or twice a year. Patient denies any suicidal ideations. Patient arrived at the office today by
private vehicle. Patient currently takes the following medications:
 Metformin 500mg BID
 Januvia 100mg daily
 Losartan 100mg daily
 HCTZ 25mg daily
 Sertraline 100mg daily
Current weight: 88 kg
Current height: 64 inches
Temp: 98.6 degrees F
BP: 132/86
By Day 3 of Week 7
Post a response to each of the following:
 List three questions you might ask the patient if she were in your office. Provide a rationale for
why you might ask these questions.
 Identify people in the patient’s life you would need to speak to or get feedback from to further
assess the patient’s situation. Include specific questions you might ask these people and why.
 Explain what, if any, physical exams, and diagnostic tests would be appropriate for the patient
and how the results would be used.
 List a differential diagnosis for the patient. Identify the one that you think is most likely and
explain why.
 List two pharmacologic agents and their dosing that would be appropriate for the patient’s
antidepressant therapy based on pharmacokinetics and pharmacodynamics. From a mechanism
of action perspective, provide a rationale for why you might choose one agent over the other.
 For the drug therapy you select, identify any contraindications to use or alterations in dosing
that may need to be considered based on ethical prescribing or decision-making. Discuss why

the contraindication/alteration you identify exists. That is, what would be problematic with the
use of this drug in individuals based on ethical prescribing guidelines or decision-making?
 Include any “check points” (i.e., follow-up data at Week 4, 8, 12, etc.), and indicate any
therapeutic changes that you might make based on possible outcomes that may happen given
your treatment options chosen.
Read a selection of your colleagues' responses.
By Day 6 of Week 7
Respond to at least two of your colleagues on two different days in one of the following ways:
 If your colleagues’ posts influenced your understanding of these concepts, be sure to share how
and why. Include additional insights you gained.
 If you think your colleagues might have misunderstood these concepts, offer your alternative
perspective and be sure to provide an explanation for them. Include resources to support your
perspective.Read a selection of your colleagues’ responses and respond to at least two of your
colleagues on two different days and
Note: For this Discussion, you are required to complete your initial post before you will be able to view
and respond to your colleagues’ postings. Begin by clicking on the "Post to Discussion Question" link and
then select "Create Thread" to complete your initial post. Remember, once you click on Submit, you
cannot delete or edit your own posts, and you cannot post anonymously. Please check your post carefully
before clicking on Submit!
Submission and Grading Information
Grading Criteria

To access your rubric:
Week 7 Discussion Rubric

Post by Day 3 of Week 7 and Respond by Day 6 of Week 7

To Participate in this Discussion:
Week 7 Discussion

Week 7 Initial Post

COLLAPSE

Kevin A. Smith
Questions For the Patient

1. Tell me about your experience with Sertraline including how long have you been taking it
and at what time of day do you take it?
Rationale: One of the common side effects of sertraline in patients being
treated for MDD is somnolence (Pfizer, 2022). Taking the med at bedtime
may help with insomnia. Additionally, it appears that this patient has had a
failure on Sertraline, and it will be informative to know how the patient’s
treatment has progressed. This will help determine what treatments to trial
moving forward.

1. Could you elaborate on what you mean by sleep habits?

Rationale: There may be non-pharmaceutical interventions that can be
implemented to improve the patient's sleep. Understanding the patient's sleep
routine would help in implementing this.
1. Are you waking to urinate multiple times during the night?

Rationale: Uncontrolled blood sugar can lead to polyurea which can interrupt
sleep.

Collateral Information

I would like to find out from the patient’s PCP what medications have been tried
and how long the patient has been experiencing depression. I would like to also get
collateral information from the PCP and the patient’s family so I can rule out any
diagnosis of bipolar disorder. While it is unlikely in this scenario it is important to rule out
bipolar disorder prior to using sertraline since monotherapy with SSRIs could propel a
patient into a manic episode.

Additional Tests

To accurately assess the effects of future treatments I would like to score the
patient on the Hamilton Depression Scale (HAM-D). Since SSRIs are significantly
hepatically metabolized I will get AST and ALT by way of a liver panel. I will also order
an A1C to see if the patient's blood sugar is being sufficiently controlled as this may be
contributing to some sleep disturbance due to frequent urination at nighttime.

Differential Diagnosis

1. Treatment-Resistant Depression

Discussion NURS 6630 Treatment for a Patient With a Common Condition

Discussion NURS 6630 Treatment for a Patient With a Common Condition

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2. Major Depressive Disorder
3. Adjustment Disorder
The most likely of these diagnoses is that the patient has treatment-resistant
depression. This diagnosis is contingent upon confirming the course of treatment and
ensuring that the patient has had a fair trial on the Sertraline.
Possible Prescriptions

Since it appears that this patient has failed on Sertraline, I will consider
switching the patient to another agent altogether. I could start the patient on 25mg of the
Tricyclic-Antidepressant (TCA) imipramine for one week to ensure tolerability and then
increase the dose to 50mg for the following 3 weeks.  This would be followed up at 4
weeks post-initiation. I also have the option of augmenting the sertraline with the
serotonin-norepinephrine receptor inhibitor venlafaxine. I would leave the patient’s dose
of sertraline unchanged and augment it with a 25mg tab of venlafaxine. If this dose is
tolerated, I will increase the dose to 50 within one week and follow up at 4 weeks to
evaluate the progress.

Works Cited
Baek, J.-H., Nierenberg, A., & Fava, M. (2016). Pharmacological Approaches to Treatment-
Resistant Depression. In T. Stern, M. Fava, T. Wilens, & J.
Rosenbaum, Psychopharmacology and Neurotherapeutics (pp. 44-47). Philadelphia:
Elsevier.
Pfizer. (2022, April 16). Zoloft Package Insert. Retrieved from fda.gov:
https://www.accessdata.fda.gov/drugsatfda_docs/label/2016/019839S74S86S87_20990S35S44S
45lbl.pdf
Zisook, S., Johnson, G., Hicks, P., Chen, P., Beresford, T., Michalets, J., . . . Mohamed, S.
(2019). Continuation Phase Treatment Outcomes for Switching, Combining or

Augmenting Strategies for Treatment‐Resistant Major Depressive Disorder: A
VAST‐D Report. Depression and Anxiety, 185-195.

f the more typical unwanted side effects of Lexapro is insomnia, in which individuals
think it is hard to drop or even stay in bed.
Over ten % of individuals found insomnia while on Lexapro, based on the FDA, making
it the most typical unwanted side effect of the drugs (Yocum, 2022). This client’s chief
complaint is Insomnia; therefore, this will not be a drug of choice for her.
 For the drug therapy you select, identify any contraindications to use or alterations in dosing that
may need to be considered based on ethical prescribing or decision-making. Discuss why the
contraindication/alteration you identify exists. That is, what would be problematic with the use
of this drug in individuals based on ethical prescribing guidelines or decision-making?

The client has a history of diabetes and Abilify might seldom make the blood sugar rise,
which may cause or even worsen diabetes. The client is advised to Tell the doctor
instantly in case of signs of high blood sugar like increased thirst/urination. If you
currently have diabetes, look at your blood sugar levels frequently as directed and share
the result with your doctor. The doctor of yours may have to adjust the diabetes
medication, workout program, or diet. Much older people could be much more delicate to
the unwanted side effects of this medication, swallowing problems, tardive dyskinesia,
confusion, lightheadedness, dizziness, drowsiness, especially seizures, along with other
severe (rarely fatal) side effects. Drowsiness, lightheadedness, dizziness, and confusion
can boost the risk of falling (Webmd.com)
 Include any “checkpoints” (i.e., follow-up data at Week 4, 8, 12, etc.), and indicate any
therapeutic changes that you might make based on possible outcomes that may happen given
your treatment options chosen.
The Client’s follow-up will be every four weeks in case the choice was made to alter the
medication treatment for the depression/insomnia. I will see her every four weeks for
twelve weeks with medication changes as necessary and afterward when over a fifty %
improvement occurred I'd transition the client's treatment plan to be coming for a follow-

up every twelve weeks until she noted an alteration of mood or even general overall
wellness.

References

Abilify Oral: Uses, Side Effects, Interactions, Pictures, Warnings & Dosing – WebMD.
(n.d.). Www.webmd.com. Retrieved April 15, 2022, from
https://www.webmd.com//drugs/2/drug-64439/abilify-oral/details
Berry, J. (2018, February 6). Endorphins: Effects and how to increase levels.
Medicalnewstoday.com; Medical News Today.
https://www.medicalnewstoday.com/articles/320839
Cunha, J. (2022, January 5). Abilify (Aripiprazole): Uses, Dosage, Side Effects,
Interactions, Warning. RxList. https://www.rxlist.com/abilify-drug.htm#description
Ho, S. C., Jacob, S. A., & Tangiisuran, B. (2017). Barriers and facilitators of adherence to
antidepressants among outpatients with major depressive disorder: A qualitative
study. PLOS ONE, 12(6), e0179290. https://doi.org/10.1371/journal.pone.0179290
Kroenke, K. (2010). PHQ-9 (Patient Health Questionnaire-9) – MDCalc. Mdcalc.com;
MDCalc. https://www.mdcalc.com/phq-9-patient-health-questionnaire-9
Pacheco, D. (2021, April 12). How Grief and Complicated Grief Affect Sleep. Sleep
Foundation. https://www.sleepfoundation.org/mental-health/grief-and-sleep
Stern, T. A., Fava, M., Wilens, T. E., Rosenbaum, J. F., & Massachusetts General Hospital.
(2016). Massachusetts General Hospital comprehensive clinical psychiatry.
Elsevier.
Yocum, A. (2022, March 7). Lexapro Insomnia: How To Manage. K Health.
https://khealth.com/learn/medication/lexapro-
insomnia/#:~:text=More%20than%2010%25%20of%20patients

Larry Kertner
NURS 6630N-37
Week 7
Discussion Post
Insomnia- A Patient Case Study Discussion
Patient: 70-year-old female
C.C.: Insomnia
PMH: DM, HTN, and Major Depressive Disorder (MDD)
Spouse: Diseased- 10 months ago
Subjective: patient stated her depression has become worse, as well as, her sleep habits.  She visits her
PCP once or twice a year.  She denies having suicidal ideations.
Objective: patient is AAOx3, and she appears to be alone for this visit.
Medication: Metformin 500mg twice a day
Januvia 100mg Daily
Losartan 100mg Daily
HCTZ 25mg Daily
Sertraline 100mg Daily
Weight: 88 kgs (194 lbs.), Height: 64 inches (5 ft. and 3 in.), B.P.: 132/86, and Temp: 98.6 F
Three Questions and The Rationale for Each Question
1).  When did you begin taking Sertraline, and was the medication started at 100mg?
Rationale:  Based on neuroanatomical changes that take place in the older adult, pharmacokinetics of
Sertraline, initiation of the medication, and starting dose, I can determine if this is lending
to the patient’s condition.
2). Have you noticed the following symptoms: headache, period of confusion, nausea/vomiting,
restlessness, fatigue, irritability, muscle weakness/spasms/cramps?  New or worsening?
Rationale:  The patient is taking HCTZ, along with Sertraline, this can lead to an excessive release of
antidiuretic hormone (ADH), placing the patient at risk for syndrome of antidiuretic hormone
secretion (SIADH) and hyponatremia.
3). Do you take any other medications prescribed, over the counter (OTC), vitamins or herbals?
Rationale: Polypharmacy is common among older adults, which can pose a significant risk to their health

and safety.  Medications such as Ibuprofen, a nonsteroidal anti-inflammatory (NSIDs), and
herbals such as St. Johns Wart can lead to serious adverse consequences due to their
mechanisms of action in the brain and body.
Investigational Information
The patient’s chief complaint is insomnia, which can be caused by sertraline, but also by the various
potential side effects and interaction of the medications she is taking presently and mentioned
previously.  It is imperative that I first speak with her current primary care physician (PCP) to better
understand the patient’s past and present health care issues and management.
Top Three Questions
1). How long has the patient been on her current medication regimen, and what changes, if any, have
been made recently?
Rationale: This will help me understand the reasoning behind the PCP’s decision on medications chosen,
and why changes were made.
2). Has the patient expressed to you that she has insomnia, or any other issues that she may be having
with her current medications?
Rationale: Due to the generation older adults grew up in, they may feel that there is no need to run to
doctor for every little ailment they may be experiencing.  Unfortunately, this type of think/
reasoning can lead to serious or even dangerous medical events for the patient.
3). Are you aware of any other medication the patient may be taking, and any other providers she may
be seeing?
Rationale: Older adults have various reasons for seeking health care from various providers, and this in
turn can lead to polypharmacy.  Usually, the patient is unaware that engaging in this behavior
can lead to dire consequences, and even death.
I would also need to speak to the patient’s spouse, children (if any), or closes living relative to gather
pertinent information about the patient’s current medications and use, and if the patient has expressed
any complaints with those medications.
1). Are you aware of any other medications (prescribed/OTC) that the patient may be taking that is in
addition to her current medication regimen?
Rationale: This would help me identify if the patient is engaging in polypharmacy, which may be lending
to her experience of insomnia, and possibly to other adverse health events.
2). Can you tell me if the patient is compliant with her medication regimen?
Rationale: If the patient is non-compliant, this could lead to adverse neuro, physical, and metabolic

complications that the patient may or may not be aware of, which could place the patient’s
life in danger.
3). Would you know of, or have a list of other healthcare providers that the patient is seeing?
Rational: If the patient is seeing multiple providers, it is of the upmost importance that we all connect,
to discuss the patient’s health conditions, and possible adverse issues, in order to facilitate the
most appropriate and safe plan of care.
Physical Exam and Diagnostics Tests
Heart: what is the rate and rhythm, is there any extra heart sounds (i.e., S3, S4, or gallup noted).
Lungs: are the lungs clear to auscultation, or is the decreased breath sounds, rales, crackles.
Eyes: Are there petechial hemorrhages or changes in the color in the sclera.
G.I.: Are there bowel sounds, are they normal or abnormal, and upon palpation, does the patient exhibit
discomfort or pain, and if so, in what area and region(s).
G.U.: Blatter palpation: How is her urinary patterns, and has she noticed an unusual increase or decrease
in output, and has she experience difficulty and or pain with urination?
Skin: Does the patient have petechia and bruising on torso, and or extremities.  Is the skin dry and intact,
and skin color within normal limits.
Neuro: Are there signs of ataxia or an ataxic gait.  Are there signs of cognitive impairment; forgetting
things more frequently, or important events or engagements.
Sexual: Is the patient sexually active, if so, has she noticed a significant decrease in libido?
Laboratory Tests
CBC with differential, electrolyte panel, serum Osmolality, serum uric acid, serum cortisol, serum
glucose and Hemoglobin A1c, Thyroid panel, ACTH test, complete renal panel, hepatic panel, urinalysis,
Urine osmolality with sodium concentration, PT/APTT and INR, CK-CKMB with troponin.
Diagnostic Tests
12-Lead EKG and CXR, other test would depend on laboratory results, i.e., CT and MRI.
The physical exam and diagnostic test will guide my treatment options in correcting any metabolic
disturbances, aid cardiopulmonary efficacy, and decrease the insomnia effects that these conditions
may create.
Differential Diagnosis
Sleep Apnea caused by the patient’s excessive weight (Obesity).  There are two main principles at work
with sleep apnea and sleeping disorders.  One is that obese people tend to develop fat deposits in the
upper respiratory tract that narrows the airway, decreasing muscle activity, which then leads to hypoxic
and apneic events.  Second, the patients sleeping habits my interfere with the type and quality of sleep

the patient may receive, such as evening and night time routines, and the position in which the patients
prefer to sleep.  For example, an obese person has difficulty lying flat due to the distribution of weight
being force upon the diaphragm, thus decreasing lung capacity and volume, which leads to decreased
air flow and gas exchange, thus, then leading to hypoxia and apneic events.
Antidepressant Therapy: Two Medication Choices
1). Citalopram- 20mg by mouth once daily at bedtime.  2). Escitalopram 10mg by mouth daily at
bedtime.
I would choose Citalopram over Escitalopram since it has shown in published studies not to effect
systolic or diastolic blood pressure due to it’s 5-HT effects on blood vessels, and less GI disturbances.
Ethical Prescribing or Decision-Making
I must present all possible side/adverse effects to the patient, such as the possibility for SIADH, an
increase in blood pressure (BP) and increased suicidal ideation, so she can make an informed decision
and give consent to taking the medication.  Based on various primary research studies, SSRIs have
caused SIADH, and increased the risk for suicidal ideations, thus prompting warning about their use.
Check Points: 4, 8, and 12 Weeks
Week 4: A 20-25 percent decrease in depressive symptom, a decrease in insomnia events, and no signs
or symptoms of SIADH, increase in BP, suicidal ideations.
Week 8: A 50 present decrease in depression, indicating full response to the medication, and a
decrease in insomnia events.
Week 12: Remission and very few or no insomnia events.

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Hi Class,

Please read through the following information on writing a Discussion question response and participation posts.

Contact me if you have any questions.

Important information on Writing a Discussion Question

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Welcome to class

Hello class and welcome to the class and I will be your instructor for this course. This is a -week course and requires a lot of time commitment, organization, and a high level of dedication. Please use the class syllabus to guide you through all the assignments required for the course. I have also attached the classroom policies to this announcement to know your expectations for this course. Please review this document carefully and ask me any questions if you do. You could email me at any time or send me a message via the “message” icon in halo if you need to contact me. I check my email regularly, so you should get a response within 24 hours. If you have not heard from me within 24 hours and need to contact me urgently, please send a follow up text to.

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I understand this is a lot of information to cover in 5 weeks, however, the Bible says in Philippians 4:13 that we can do all things through Christ that strengthens us. Even in times like this, we are encouraged by God’s word that we have that ability in us to succeed with His strength. I pray that each and every one of you receives strength for this course and life generally as we navigate through this pandemic that is shaking our world today. Relax and enjoy the course!

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