NRNP 6635 Assessing/Diagnosing Patients With Anxiety Disorders, PTSD and OCD
Generalized anxiety disorder is one of the mental health problems that psychiatric mental health nurse practitioners encounter in their practice. Generalized anxiety disorder is characterized by excessive stress and concern about unknown anticipations in most of the days. Patients with generalized anxiety disorder also experience symptoms that include tension, worry and physical changes such as raised blood pressure. Patients are diagnosed with generalized anxiety disorder in cases where the symptoms are experienced for at least 24 weeks, with the patient experiencing challenges in undertaking activities of daily living. The prevalence of generalized anxiety disorders differs in populations. However, the rate of generalized anxiety disorder in adults is estimated to range between 1.5% and 3% (Alkhader, 2018). Therefore, this paper is an analysis of a case study involving a 46-year-old white male who has been diagnosed with generalized anxiety disorder. The analysis focuses on the decisions that will be made relating to the management of the condition of the patient and ethical considerations influencing the treatment decisions and communication with the client. The pertinent information that will influence the treatment decisions made for the client include his history of anxiety disorder, medical and surgical history. The other patient factor that will influence the selection of the treatment options is the patient’s history of medication alongside alcohol and drug use. The assessment showed that the patient has a history of using ETOH to combat his worries and consumes 3-4 beers every night. The use of other medications and alcohol might affect the effectiveness of the adopted interventions. The last patient factor to consider is his HAM-A score which will determine the effectiveness of the adopted interventions in symptom management.
Decision Point One
The first decision that I will select for treating the patient in this case study is the use of Zoloft 50 mg per oral daily. Zoloft is a drug that the FDA has approved for use as the first line of treatment of generalized anxiety disorders in adults (Strawn et al., 2018). Zoloft belongs to the class of selective serotonin reuptake inhibitors. The drug works by inhibiting the reuptake of serotonin neurotransmitters in the brain, resulting in its build up. Zoloft also has some weak inhibition of norepinephrine and dopamine reuptake mechanisms. The inhibition of the above neurotransmitters raises their concentration in the synapse and extra-synapse diffusion. The raised level of serotonin in the synapses results in the effective management of the generalized anxiety in patients with generalized anxiety disorders (Salimi Kordasiabi et al., 2020). Evidence shows that Zoloft is an effective intervention for generalized anxiety disorder due to its broad spectrum efficacy in short and long-term phases and enhanced tolerability. The efficacy of Zoloft or sertraline in generalized anxiety disorder can also be seen in the improvement in HAM-A score in patients affected by the disorder (Kassis, 2020).
However, Imipramine was not chosen for the treatment of the patient in the case study. Accordingly, Imipramine is a tricyclic antidepressant that may be effective in treating the symptoms of generalized anxiety disorder. However, it is considered a second line of treatment for patients suffering from generalized anxiety disorders. Imipramine is also associated with side effects such as weight gain, loss of appetite and constipation, which might affect the adherence to the treatment by the patient (Fayez & Gupta, 2020). Buspirone 10 mg per oral BID was not selected for the patient because this medication is used to augment the first line medications utilized in the treatment of generalized anxiety disorder (Lee et al., 2017).
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I made the above decision with the anticipation to achieve a number of outcomes. One of the outcomes that I expected to achieve is the reduction in the HAM-A score by at least 25%. This expectation is attributed to the fact that the therapeutic effect of Zoloft would have been achieved within two to four weeks of treatment. The other anticipated outcome is the improvement in the symptoms of anxiety being experienced by the patient. The use of Zoloft restores the balance of serotonin, dopamine and norepinephrine, hence, improving the mood of the patient (Lewis et al., 2019).
The client came to the clinic after four weeks. The client informed the psychiatric mental health nurse practitioner that he no longer experiences chest tightness or shortness of breath. The client also stated that his worries had decreased over the past 4 or 5 days. The HAM-A score also decreased to 18. The results showed that the above expectations were partially achieved. The selected treatment was effective in managing the symptoms of generalized anxiety disorder. The selection of the above decision took into consideration the ethical principle of benevolence and non-maleficence. The psychiatric mental health nurse practitioner selected the treatment option that had optimum benefits and minimal harm. The nurse was aware about the fact that selecting the use of Imipramine would increase the risk of adverse outcomes and poor adherence to treatment by the patient (Fayez & Gupta, 2020).
Decision Point Two
The decision that I will select for the patient in this case study is increasing the dosage of Zoloft to 50 mg orally daily. According to literature, the recommended dosage for sertraline in adults ranges between 50 mg to 200 mg daily. This implies that raising the dosage of Zoloft to 75 mg will be within the normal daily range of dosage to be used in treating generalized anxiety disorder in adults. Increasing the dosage of Zoloft to 75 mg will also increase its therapeutic effect in treating the disorder (Salimi et al., 2020). The selection of the decision also implies that the increase in dosage will be gradual. The consequence of the gradual increase in the dosage of Zoloft will minimize the risk of side and adverse effects of the drug. Some of the side and adverse effects that will be minimized with the gradual increase in the dosage of Zoloft include severe nausea, vomiting, constipation and sexual dysfunction. Therefore, the ethical consideration in making this decision is the promotion of patient safety in the treatment process. The psychiatric mental health nurse practitioner is aware that a drastic increase in the dosage of the drug will increase the risk of side and adverse effects to the patient (Lewis et al., 2019). Consequently, the outcomes of treatment that include safety, quality and efficiency will not be achieved.
The decision to increase the dosage of Zoloft was not selected due to the increased risk of side effects such as sexual dysfunction and severe gastrointestinal effects. The decision not to change the drug dosage at this time was not selected because the current dosage led to the minimal improvement in the symptoms of the patient (Kassis, 2020). The minimal or partial improvement in symptoms of generalized anxiety disorder implied the need for dose adjustment to achieve moderate to optimum therapeutic effect.
I selected the above decision with the aim of achieving moderate to optimum improvement in symptoms of the disorder. I expected to see a further decline in the HAM-A score by at least 50%. I also expected that the patient will experience no or mild side effects of the increased dosage of the medication.
The client came to the clinic after four weeks. The client reported a further reduction in symptoms. The assessment also showed that the HAM-A score had decreased to 10. At this point, the current dosage of the drug was to be maintained due to 61% reduction in the symptoms of generalized anxiety disorder. Therefore, the expectations set in the above section were optimally achieved (Alkhader, 2018).
Decision Point Three
The decision that I will select at this stage is maintaining the current dosage of Zoloft. The decision to maintain the current dose of Zoloft is because there has been significant improvement in the symptoms of generalized anxiety disorder. The patient has tolerated the gradual increase in the dosage of Zoloft to 75 mg. The HAM-A score has also reduced from 26 to 10, which implies significant improvement in symptoms. Therefore, increasing the dose of Zoloft to 100 mg is not appropriate since the anticipated optimum goals of treatment have been achieved. The decision to increase the dosage of Zoloft to 100 mg would have been considered if the patient had demonstrated further deterioration in the symptoms of the disorder. The decision to augment the treatment was also not selected because the desired outcomes of the treatment have been achieved. The patient has tolerated the gradual increase in dosage, eliminating any need for augmentation of treatment for the patient (Alkhader, 2018). Therefore, the mild symptoms of the generalized anxiety disorder do not warrant the adoption of any new treatments for the patient.
The above decision was made with the aim of achieving a further improvement in the symptoms of the disorder. The PMHNP also aimed at ensuring that the therapeutic effects of Zoloft are achieved in the long-term. It is anticipated that the patient will report almost an absolute resolution of symptoms of the disorder at 12 months. The effect of the third decision has not been given in the case study. However, it is projected that the patient responded positively to the treatment due to the maintenance of the dosage of Zoloft. The patient should therefore be educated on the importance of medication adherence. The patient should also be educated on the importance of maintaining a healthy life such as engaging in physical activity and referring him to alcohol cessation clinic and support groups.
The above decisions on the management of the patient were made with a consideration of a number of ethical principles. The PMHNP considered the ethical principle of promoting safety in making treatment decisions for the patient in this case study. The PMHNP ensured that the treatments that were selected were associated with enhanced benefits and minimal side effects to the patient. The PMHNP also weighed the benefits versus the risks of the different treatment options that were provided in the case study (Buka, 2020). As a result, the nurse adhered to the principles of doing good to the patient and minimizing any form of harm in the treatment process. The PMHNP also took into consideration the ethical principle of protecting and promoting integrity of patient’s data in the care process. Accordingly, it is the responsibility of the nurse to ensure that the patient’s data is kept private and confidential. The data should not be shared with any third parties without seeking informed consent from the patient. Similarly, the patient should be educated about the benefits and risks of the available treatment options to ensure that he makes informed decisions on the choices of treatment to be adopted (Ellis, 2017). Therefore, the consideration of these ethical principles ensured safety and quality in the management of the patient’s health problem.
The PMHNP performed optimally in determining the treatment options for the patient. The nurse practitioner utilized critical thinking and problem solving to ensure that the selected treatment option had optimum benefits and minimal risks to the patient. The PMHNP also relied on the existing evidence on the treatment of the mental health problem. The use of evidence-based data ensured that care that promoted safety, quality and efficiency was provided to the patient. It can be seen from the decisions made in this case study that PMHNP are expected to understand ethics of mental health practice in treating mental health problems. PMHNP should take into consideration ethical principles in practice such as benevolence, non-maleficence, justice, informed consent and data privacy and confidentiality. PMHN should also be knowledgeable about the need for teamwork and creation of active referral systems for patients with mental health problems. Consequently, I believe that I made the right decisions in treating the patient in this case study.
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