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NURS 6630 Assignment Assessing and Treating Patients With Anxiety Disorders

NURS 6630 Assignment Assessing and Treating Patients With Anxiety Disorders

Introduction to the Case Study

The case study portrays a 46-year-old white male referred by his primary care provider after visiting the ED due to a perception of having a heart attack. The client reported symptoms of chest tightness, dyspnea, and a feeling of looming doom. He has a history of mild hypertension managed with a low sodium diet, and he is overweight with about 15 lbs (Laureate Education, 2016). Myocardial infarction was ruled out after having a normal EKG and physical exam. The patient still reports chest tightness and dyspnea episodes, which he refers to as anxiety attacks. He also experiences occasional feelings of looming doom and a need to escape from the situation.

The patient admits taking alcohol, 3-4 beers/night, to suppress worries about work. He is single but cares for his aging parents in his home. The client also mentions that the management at his workplace is harsh, and he is concerned about his job. He scores 26 on the Hamilton Anxiety Rating Scale (Laureate Education, 2016). Pertinent positive MSE findings include a “blah” mood and admit feeling nervous. His affect is a bit blunted but brightens during the interview (Laureate Education, 2016). Judgment and insight are grossly intact, and he denies suicidal or homicidal ideation. He is diagnosed with generalized anxiety disorder (GAD).

Various patient factors determine the psychopharmacologic plan for a patient, and the PMHNP must consider these factors when developing the treatment plan. Patient factors that may influence decision-making on the patient’s treatment plan include age, medical history, the severity of the illness, history with previous treatment attempts, comorbidities such as personality disorders, and suicidality (Bandelow, Michaelis & Wedekind, 2017). The patient’s age will determine the anxiolytic medication to prescribe and the dosage of medication. The patient has a history of blood pressure and overweight which will influence his medication. Medication prescribed for the patient should not have potential side effects of increasing blood pressure or weight gain to promote overall better health outcomes (Bandelow et al., 2017). The HAMA score signifies moderate to severe anxiety. Consequently, the medication selected should be documented to be effective in treating moderate and severe anxiety.  NURS 6630 Assignment: Assessing and Treating Patients With Anxiety Disorders

Decision Point One

Initiate Zoloft 50 mg orally daily.

Why I Selected This Decision

Zoloft is a Selective serotonin reuptake inhibitor antidepressant recommended as first-line therapy for treating GAD. I initiated the client on Zoloft therapy because SSRIs have been documented as the most effective treatment option for GAD (Guaiana et al., 2018). The FDA also approves Zoloft to treat GAD, which means its efficacy and safety have been established. Furthermore, I chose Zoloft because it is associated with few and mild side effects, which increases its compliance rate.

Why I Did Not Select the Other Two Options Provided

Imipramine was not an ideal drug for this client due to its high toxicity levels and its lethal potential in the event of an overdose. According to Bandelow et al. (2017), tricyclic antidepressants (TCAs) such as Imipramine are effective as 2nd generation antidepressants in treating anxiety disorders. Imipramine has antihistaminic effects, which cause an increased appetite and weight gain. Therefore, Imipramine is not ideal for this patient due to his overweight status. I did not select Buspirone due to its prolonged onset of action and weak efficacy, limiting its use as a sole agent in treating GAD (Bandelow et al., 2017). According to Strawn et al. (2018), Buspirone is recommended as a second-line agent after SSRIs when a person does not respond to or cannot tolerate SSRIs’ side effects. NURS 6630 Assignment: Assessing and Treating Patients With Anxiety Disorders

What I Was Hoping To Achieve By Making This Decision

I hoped that Zoloft would alleviate GAD symptoms’ severity to at least 16 in the HAM-A within four weeks. I also hoped that the patient would report reduced worries about his work and anxiety attacks with an improved overall mood. According to Strawn et al. (2018), SSRIs such as Zoloft have a 30-50% treatment response rate in GAD. The drug acts in the CNS by controlling serotonin levels, which regulate personality, mood, and wakefulness.

How Ethical Considerations May Impact the Treatment Plan and Communication with Patients

Ethical considerations of patient right to autonomy and beneficence may impact the patient’s treatment plan and communication.

Autonomy requires that the PMHNP gives the patient a right to choose and the ability to act on that choice (Dolan, 2017). The PMHNP can uphold this by obtaining informed consent before initiating treatment and respecting his care decisions. Beneficence requires the PMHNP to provide benefits and balance the benefits and harms of treatment (Dolan, 2017). In this case, the PMHNP weighed each drug’s benefits and harms and selected the one with the greatest benefit and least harm.

Decision Point 2

Increase Zoloft dose to 75 mg daily.

Why I Selected This Decision

I selected this decision because the patient reported improved symptoms with Zoloft treatment. After four weeks of Zoloft therapy, the patient reported that anxiety symptoms, including chest tightness and shortness of breath, had diminished and he had reduced worries regarding his work. He scored 18 in the HAM-A from 26, which is a partial response (Laureate Education, 2016). I increased the dose to improve the HAM-A score further and prevent relapse of anxiety symptoms. Furthermore, the patient did not report any side effects with the initial dose, and thus gradually increasing the dose would allow monitoring of the drug.

Why I Did Not Select the Other Two Options Provided

            The other options were to increase the Zoloft dose to 100 mg daily or maintain the drug and dose. It would have been inappropriate to increase Zoloft to 100 mg daily because it would have been impossible to monitor the drug’s side effects gradually. According to Guaiana et al. (2018), individuals with anxiety disorders are sensitive to antidepressant therapy and need slow titration for successful treatment. Besides, failing to change the dose would not have been ideal because the patient had a partial response to the initial dose. It was important to increase the dose to promote better outcomes and further decrease the HAM-A score.

I did not also select the option of not changing the dose because the client was only on the starting dose, which had demonstrated a partial response. Failing to increase the drug may result in the lack of a further decrease in anxiety symptoms. According to Mangolini et al. (2019), higher doses of SSRIs are associated with treatment response and symptomatic improvement.

What I Was Hoping To Achieve By Making This Decision

I hoped that increasing the Zoloft dose would improve the GAD symptom and reduce the HAM-A score to at least 10 within four weeks. A dose increase for SSRIs is associated with having a superior clinical response in GAD patients (Mangolini et al., 2019). Besides, Sertraline, unlike other SSRIs, is more effective at the higher end of its dose range than the recommended starting dose of 50 mg/day.

How Ethical Considerations May Impact the Treatment Plan and Communication with Patients

                        Ethical consideration that might influence treatment includes the principle of beneficence that requires the PMHPN to promote good and prevent harm when planning treatment interventions (Dolan, 2017). In this case, the PMHNP assessed the patient’s response to the initial Zoloft dose and medication tolerance. The PMHNP increased the dose to promote better patient outcomes and evaluated side effects to avoid harming the patient, thus promoting beneficence.

Decision Point 3

Maintain current Zoloft dose.

Why I Selected This Decision

I selected this decision because the 75 mg/day dose had achieved the desired outcome of a HAM-A score of 1, which is a 61% reduction in GAD symptoms. The patient had a further reduction in symptoms, and he reported no side effects after increasing the dose to 75 mg. According to Bandelow et al. (2017), SSRIs doses in the lower part of the therapeutic range, that is, 50 mg-100 mg, are sufficient in promoting the desired therapeutic effect.

Why I Did Not Select the Other Two Options Provided

Other treatment options were to increase the current dose to 100 mg daily or add an augmentation agent such as Buspirone. The option of increasing the dose to 100 mg/day was not ideal because the patient had an adequate treatment response of 75 mg/day. Increasing an SSRI dose can promote a further improvement in GAD symptoms, but it has the disadvantage of side effects, limiting medication compliance (Bandelow et al., (2017). I did not select the option of augmentation with Buspirone because the patient had a positive response to monotherapy with Zoloft. According to a study by Mangolini et al. (2019), augmentation strategy does not seem beneficial in persons with treatment-resistant anxiety disorders, such as generalized anxiety.

What I Was Hoping To Achieve By Making This Decision

I hoped that maintaining the current dose would increasingly reduce the GAD symptoms and result in complete remission, evidenced by a HAM-A score of below 5 within four weeks. According to a study by Strawn et al. (2018), flexibly dosed Zoloft was found to significantly reduce GAD symptoms and was associated with a decrease in anxiety symptoms.

How Ethical Considerations May Impact the Treatment Plan and Communication with Patients

            The ethical principle of nonmaleficence may impact the treatment plan since the PMHNP has to assess the medication for any side effects that could be lowering the quality of life or causing non-compliance (Dolan, 2017). In this case, the PMHNP did not increase the dose due to associated side effects that could harm the patient. The principle of confidentiality may impact communication since the PMHNP has to obtain consent before sharing the patient’s information with a third party, including other providers.

Conclusion

            The patient in the case study was diagnosed with GAD manifested by excessive worry, shortness of breath, chest tightness, and a feeling of incoming doom. My initial treatment recommendation was to begin Zoloft 50 mg daily to improve anxiety symptoms and reduce the HAM-A score. I selected Zoloft because it is approved for GAD treatment and is associated with fewer side effects. Imipramine was not selected because of its high toxicity and side effects of increased appetite and weight gain.  Buspirone was not also selected because of its weak efficacy in the treatment of GAD. In the second decision, I increased Zoloft to 75 mg daily because the patient demonstrated a positive response with the initial dose. Besides, I increased the dose to improve the anxiety symptoms further, lower the HAM-A score, and promote better patient outcomes. I did not increase the dose to 100 mg at this point to allow monitoring of the drug’s associated side effects.

In the third decision, I maintained the dose at 75 mg daily because the patient had an adequate response to the dose. I did not increase the dose because of the associated side effects of high doses of Zoloft. The PMHNP did not add Buspirone as an augmentation agent because Zoloft was effective when used as monotherapy and the strategy is not effective in GAD. The treatment plan was influenced by ethical principles of beneficence and nonmaleficence, which require the PMHNP to promote better patient outcomes and prevent harm. Consequently, the PMHNP evaluated the medications and selected the drug with the best possible outcomes and least adverse effects.

NURS 6630 Assignment Assessing and Treating Patients With Anxiety Disorders

NURS 6630 Assignment Assessing and Treating Patients With Anxiety Disorders

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References

Bandelow, B., Michaelis, S., & Wedekind, D. (2017). Treatment of anxiety disorders. Dialogues in clinical neuroscience19(2), 93–107. https://doi.org/10.31887/DCNS.2017.19.2/bbandelow

Dolan, C. (2017). Moral, ethical, and legal decision-making in controversial NP practice situations. The Journal for Nurse Practitioners13(2), e57-e65. https://doi.org/10.1016/j.nurpra.2016.10.017

Guaiana, G., Barbui, C., & Abouhassan, R. (2018). Antidepressants versus placebo for generalized anxiety disorder (GAD). The Cochrane Database of Systematic Reviews2018(2), CD012942. https://doi.org/10.1002/14651858.CD012942

Laureate Education. (2016b). Case study: A middle-aged Caucasian man with anxiety [Interactive media file]. Baltimore, MD: Author.

Mangolini, V. I., Andrade, L. H., Lotufo-Neto, F., & Wang, Y. P. (2019). Treatment of anxiety disorders in clinical practice: a critical overview of recent systematic evidence. Clinics (Sao Paulo, Brazil)74, e1316. https://doi.org/10.6061/clinics/2019/e1316

Strawn, J. R., Geracioti, L., Rajdev, N., Clemenza, K., & Levine, A. (2018). Pharmacotherapy for generalized anxiety disorder in adult and pediatric patients: an evidence-based treatment review. Expert opinion on pharmacotherapy19(10), 1057–1070. https://doi.org/10.1080/14656566.2018.1491966

Excellent

Point range: 90–100

Good

Point range: 80–89

Fair

Point range: 70–79

Poor

Point range: 0–69

Introduction to the case (1 page)

Briefly explain and summarize the case for this Assignment. Be sure to include the specific patient factors that may impact your decision making when prescribing medication for this patient.

(9%) – 10 (10%)

The response accurately, clearly, and fully summarizes in detail the case for the Assignment.

The response accurately and clearly explains in detail the specific patient factors that impact decision making when prescribing medication for this patient.

(8%) – 8 (8%)

The response accurately summarizes the case for the Assignment.

The response accurately explains the specific patient factors that impact decision making with prescribing medication for this patient.

(7%) – 7 (7%)

The response inaccurately or vaguely summarizes the case for the Assignment.

The response inaccurately or vaguely explains the specific patient factors that impact decision making with prescribing medication for this patient.

(0%) – 6 (6%)

The response inaccurately and vaguely summarizes the case for the Assignment, or is missing.

The response inaccurately and vaguely explains the specific patient factors that impact decision making with prescribing medication for this patient.

Decision #1 (1–2 pages)

• Which decision did you select?
• Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
• Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
• What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
• Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.

18 (18%) – 20 (20%)

The response accurately and clearly explains in detail the decision selected.

The response accurately and clearly explains in detail why the decision was selected, with specific clinically relevant resources that fully support the decision selected.

The response accurately and clearly explains in detail why the other two responses were not selected, with specific clinically relevant resources that fully support the response.

The response accurately and clearly explains in detail the outcome the student was hoping to achieve with the selected decision, with specific clinically relevant resources that fully support the response.

The response accurately and clearly explains in detail how ethical considerations impact the treatment plan and communication with patients.

Examples provided fully support the decisions and responses provided.

16 (16%) – 17 (17%)

The response accurately explains the decision selected.

The response explains why the decision was selected, with specific clinically relevant resources that support the decision selected.

The response accurately explains why the other two responses were not selected, with specific clinically relevant resources that support the response.

The response accurately explains the outcome the student was hoping to achieve with the selected decision, with specific clinically relevant resources that support the response.

The response accurately explains how ethical considerations impact the treatment plan and communication with patients.

Examples provided support the decisions and responses provided.

14 (14%) – 15 (15%)

The response inaccurately or vaguely explains the decision selected.

The response inaccurately or vaguely explains why the decision was selected, with specific clinically relevant resources that inaccurately or vaguely support the decision selected.

The response inaccurately or vaguely explains why the other two responses were not selected, with specific clinically relevant resources that inaccurately or vaguely support the response.

The response inaccurately or vaguely explains the outcome the student was hoping to achieve with the selected decision, with specific clinically relevant resources that inaccurately or vaguely support the response.

The response inaccurately or vaguely explains how ethical considerations impact the treatment plan and communication with patients.

Examples provided may support the decisions and responses provided.

(0%) – 13 (13%)

The response inaccurately and vaguely explains the decision selected.

The response inaccurately and vaguely explains why the decision was selected, with specific clinically relevant resources that do not support the decision selected, or is missing.

The response inaccurately and vaguely explains why the other two responses were not selected, with specific clinically relevant resources that do not support the decision selected, or is missing.

The response inaccurately and vaguely explains the outcome the student was hoping to achieve with the selected decision, with specific clinically relevant resources that do not support the response, or is missing.

The response inaccurately and vaguely explains how ethical considerations impact the treatment plan and communication with patients, or is missing.

Examples provided do not support the decisions and responses provided, or is missing.

Decision #2 (1–2 pages)

• Which decision did you select?
• Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
• Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
• What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
• Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.

18 (18%) – 20 (20%)

The response accurately and clearly explains in detail the decision selected.

The response accurately and clearly explains in detail why the decision was selected, with specific clinically relevant resources that fully support the decision selected.

The response accurately and clearly explains in detail why the other two responses were not selected, with specific clinically relevant resources that fully support the response.

The response accurately and clearly explains in detail the outcome the student was hoping to achieve with the selected decision, with specific clinically relevant resources that fully support the response.

The response accurately and clearly explains in detail how ethical considerations impact the treatment plan and communication with patients.

Examples provided fully support the decisions and responses provided.

16 (16%) – 17 (17%)

The response accurately explains the decision selected.

The response explains why the decision was selected, with specific clinically relevant resources that support the decision selected.

The response accurately explains why the other two responses were not selected, with specific clinically relevant resources that support the response.

The response accurately explains the outcome the student was hoping to achieve with the selected decision, with specific clinically relevant resources that support the response.

The response accurately explains how ethical considerations impact the treatment plan and communication with patients.

Examples provided support the decisions and responses provided.

14 (14%) – 15 (15%)

The response inaccurately or vaguely explains the decision selected.

The response inaccurately or vaguely explains why the decision was selected, with specific clinically relevant resources that inaccurately or vaguely support the decision selected.

The response inaccurately or vaguely explains why the other two responses were not selected, with specific clinically relevant resources that inaccurately or vaguely support the response.

The response inaccurately or vaguely explains the outcome the student was hoping to achieve with the selected decision, with specific clinically relevant resources that inaccurately or vaguely support the response.

The response inaccurately or vaguely explains how ethical considerations impact the treatment plan and communication with patients.

Examples provided may support the decisions and responses provided.

(0%) – 13 (13%)

The response inaccurately and vaguely explains in detail the decision selected.

The response inaccurately and vaguely explains why the decision was selected, with specific clinically relevant resources that do not support the decision selected, or is missing.

The response inaccurately and vaguely explains why the other two responses were not selected, with specific clinically relevant resources that do not support the decision selected, or is missing.

The response inaccurately and vaguely explains the outcome the student was hoping to achieve with the selected decision, with specific clinically relevant resources that do not support the response, or is missing.

The response inaccurately and vaguely explains how ethical considerations impact the treatment plan and communication with patients, or is missing.

Examples provided do not support the decisions and responses provided, or is missing.

Decision #3 (1–2 pages)

• Which decision did you select?
• Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
• Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
• What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
• Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.

18 (18%) – 20 (20%)

The response accurately and clearly explains in detail the decision selected.

The response accurately and clearly explains in detail why the decision was selected, with specific clinically relevant resources that fully support the decision selected.

The response accurately and clearly explains in detail why the other two responses were not selected, with specific clinically relevant resources that fully support the response.

The response accurately and clearly explains in detail the outcome the student was hoping to achieve with the selected decision, with specific clinically relevant resources that fully support the response.

The response accurately and clearly explains in detail how ethical considerations impact the treatment plan and communication with patients.

Examples provided fully support the decisions and responses provided.

16 (16%) – 17 (17%)

The response accurately explains the decision selected.

The response explains why the decision was selected, with specific clinically relevant resources that support the decision selected.

The response accurately explains why the other two responses were not selected, with specific clinically relevant resources that support the response.

The response accurately explains the outcome the student was hoping to achieve with the selected decision, with specific clinically relevant resources that support the response.

The response accurately explains how ethical considerations impact the treatment plan and communication with patients.

Examples provided support the decisions and responses provided.

14 (14%) – 15 (15%)

The response inaccurately or vaguely explains the decision selected.

The response inaccurately or vaguely explains why the decision was selected, with specific clinically relevant resources that inaccurately or vaguely support the decision selected.

The response inaccurately or vaguely explains why the other two responses were not selected, with specific clinically relevant resources that inaccurately or vaguely support the response.

The response inaccurately or vaguely explains the outcome the student was hoping to achieve with the selected decision, with specific clinically relevant resources that inaccurately or vaguely support the response.

The response inaccurately or vaguely explains how ethical considerations impact the treatment plan and communication with patients.

Examples provided may support the decisions and responses provided.

(0%) – 13 (13%)

The response inaccurately and vaguely explains in detail the decision selected.

The response inaccurately and vaguely explains why the decision was selected, with specific clinically relevant resources that do not support the decision selected, or is missing.

The response inaccurately and vaguely explains why the other two responses were not selected, with specific clinically relevant resources that do not support the decision selected, or is missing.

The response inaccurately and vaguely explains the outcome the student was hoping to achieve with the selected decision, with specific clinically relevant resources that do not support the response, or is missing.

The response inaccurately and vaguely explains how ethical considerations impact the treatment plan and communication with patients, or is missing.

Examples provided do not support the decisions and responses provided, or is missing.

Conclusion (1 page)

• Summarize your recommendations on the treatment options you selected for this patient. Be sure to justify your recommendations and support your response with clinically relevant and patient-specific resources, including the primary literature.

14 (14%) – 15 (15%)

The response accurately and clearly summarizes in detail the recommendations on the treatment options selected for this patient.

The response accurately and clearly explains a justification for the recommendations provided, including clinically relevant resources that fully support the recommendations provided.

12 (12%) – 13 (13%)

The response accurately summarizes the recommendations on the treatment options selected for this patient.

The response accurately explains a justification for the recommendation provided, including clinically relevant resources that support the recommendations provided.

11 (11%) – 11 (11%)

The response inaccurately or vaguely summarizes the recommendations on the treatment options selected for this patient.

The response inaccurately or vaguely explains a justification for the recommendations provided, including clinically relevant resources that inaccurately or vaguely support the recommendations provided.

(0%) – 10 (10%)

The response inaccurately and vaguely summarizes the recommendations on the treatment options selected for this patient, or is missing.

The response inaccurately and vaguely explains a justification for the recommendations provided, including clinically relevant resources that do not support the recommendations provided, or is missing.

Written Expression and Formatting – Paragraph Development and Organization:
Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused—neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria.
(5%) – 5 (5%)

Paragraphs and sentences follow writing standards for flow, continuity, and clarity.

A clear and comprehensive purpose statement, introduction, and conclusion are provided that delineate all required criteria.

(4%) – 4 (4%)

Paragraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time.

Purpose, introduction, and conclusion of the assignment are stated, yet they are brief and not descriptive.

3.5 (3.5%) – 3.5 (3.5%)

Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60%–79% of the time.

Purpose, introduction, and conclusion of the assignment is vague or off topic.

(0%) – 3 (3%)

Paragraphs and sentences follow writing standards for flow, continuity, and clarity < 60% of the time.

No purpose statement, introduction, or conclusion were provided.

Written Expression and Formatting – English writing standards:
Correct grammar, mechanics, and proper punctuation
(5%) – 5 (5%)
Uses correct grammar, spelling, and punctuation with no errors.
(4%) – 4 (4%)
Contains a few (1 or 2) grammar, spelling, and punctuation errors.
3.5 (3.5%) – 3.5 (3.5%)
Contains several (3 or 4) grammar, spelling, and punctuation errors.
(0%) – 3 (3%)
Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding.
Written Expression and Formatting – The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, parenthetical/in-text citations, and reference list.
(5%) – 5 (5%)
Uses correct APA format with no errors.
(4%) – 4 (4%)
Contains a few (1 or 2) APA format errors.
3.5 (3.5%) – 3.5 (3.5%)
Contains several (3 or 4) APA format errors.
(0%) – 3 (3%)
Contains many (≥ 5) APA format errors.
Total Points: 100
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