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Sample Answer for NURS 6630 Discussion Treatment for a Patient With a Common Condition Included After Question
NURS 6630 Discussion Treatment for a Patient With a Common Condition
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
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 the client’s ethnicity. Discuss why the contraindication/alteration you identify exists. That is, what would be problematic with the use of this drug in individuals of other ethnicities?
- 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.
A Sample Answer For the Assignment: NURS 6630 Discussion Treatment for a Patient With a Common Condition
Title: NURS 6630 Discussion Treatment for a Patient With a Common Condition
According to the American Academy of Sleep Medicine, insomnia is defined as difficulty either falling or staying asleep that is accompanied by daytime impairments related to those sleep troubles (Balter & Uhlenhuth, 2017). Insomnia can be acute or chronic. Acute insomnia is common. Common causes include stress at work, family pressures, or a traumatic event. It usually lasts for days or weeks. Chronic insomnia lasts for a month or longer. Most cases of chronic insomnia are secondary (Stern et al, 2015).
You provided a comprehensive assessment of the patients’ condition, possible differential diagnosis, and treatment options. I agree with many of your recommendations and have been able to obtain a deeper understanding of a comprehensive assessment after reading your post. I would like to offer some things that I researched after reading your post below.
Insomnia has a significant impact on the quality of life of many adults. Prolonged depression can affect sleep patterns, while lack of sleep can exacerbate depression. This can lead to a cycle of problematic issues, warranting assessment, diagnosis, and treatment of the primary condition. Criteria for diagnosis of insomnia includes difficulty falling or maintaining sleep and impairment in daily functioning (Krystal et al., 2019). I agree that it is important to assess the specific factors that the patient is experiencing and for how long she has been experiencing them. I also agree that speaking to those that regularly interact with the patient may be able to provide important information regarding changes or impacts on daily functioning that the patient herself may not notice.
Performing a thorough physical assessment will contribute important information regarding overall health. I agree that assessment of current hemoglobin A1c is essential because uncontrolled hyperglycemia can contribute to many serious illnesses and can exacerbate symptoms of insomnia. I would examine diet to determine whether the patient is compliant with recommendations and that she demonstrates understanding of her specific diet. Metformin and Januvia are both associated with insomnia, so if they are not providing effective treatment for her diabetes, I would consider use of insulin. (Wiwanitkit & Wiwanitkit, 2012). Lack of sleep contributes to poor glycemic control and poor glycemic control contributes to insomnia, so it is necessary to treat both conditions concurrently. Along with obtaining a sleep log or diary I would also recommend starting a glucose log.
Considering the age of this patient and the fact that she has a history of depression, I would assess her ability to care for herself. It may be necessary to obtain a home care nurse for the management of diabetes, and blood pressure. Assessing the level of understanding in diabetes management may reveal the need of a diabetes educator (Ernawati et al., 2021). Evaluation of ability to complete ADLs would also be helpful, as the patient recently lost her husband and may not have sufficient help. Use of HCTZ can also increase blood sugar levels, I would consider changing the medication to Chlorthalidone, which is effective at lowering blood pressure, lowering cholesterol (commonly a problem in diabetics), providing cardioprotective effects, and less likely to increase blood sugar. If labs show a decrease in kidney function, use of an ACE inhibitor may also be warranted (Khalil & Zeltser, 2022).
NURS 6630 Discussion Treatment for a Patient With a Common Condition References
Ernawati, U., Wihastuti, T. A., & Utami, Y. W. (2021). Effectiveness of diabetes self-management education (DSME) in type 2 diabetes mellitus (T2DM) patients: Systematic literature review. Journal of public health research, 10(2), 2240. https://doi.org/10.4081/jphr.2021.2240
Khalil H, Zeltser R. Antihypertensive Medications. [Updated 2022 May 15]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK554579/
Krystal, A. D., Prather, A. A., & Ashbrook, L. H. (2019). The assessment and management of insomnia: an update. World psychiatry : official journal of the World Psychiatric Association (WPA), 18(3), 337–352. https://doi.org/10.1002/wps.20674
Wiwanitkit, S., & Wiwanitkit, V. (2012). Metformin and sleep disorders. Indian journal of endocrinology and metabolism, 16 Suppl 1(Suppl1), S63–S64. https://doi.org/10.4103/2230-8210.94262
Additional questions that I will ask the patient if they were in my office
The additional questions that I would ask the patient to gather more information concerning her problem would include the following:
The first would be, “How have your sleep patterns been affected by your husband’s passing on?”. By asking this question, I would be gathering information to understand more about how her sleeping habits have changed and assess the relationship of the problem to her spouse’s death. It aids in determining her sleep length, quality, and timing, as well as any specific sleep disorders she may be having.
The second question would be, “Have you experienced any other changes in mood, appetite, or energy levels?” By asking this question, I would be able to examine the patient’s general emotional well-being and spot any signs of depression or other mental health issues. It is useful in understanding the scope and significance of her symptoms beyond insomnia.
The third question would be,” How are you coping with the loss of your spouse?” By asking this question, I would be able to assess the patient’s coping methods and emotional resilience in the aftermath of a major life catastrophe. Understanding her methods of coping with the loss would aid in identifying potential areas of support or intervention to help her deal with her grief and maintain her emotional health.
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.
The first people would be people within her family and especially those who are very close to her. I’d question the patient’s behavior, mood, and sleeping habits since her husband’s death. I’d ask whether they’ve noticed any changes in her daily functioning, or if they’re concerned about her mental health. This can provide other perspectives on her mental well-being as well as any changes seen by those close to her that the patient is unable to disclose.
I would also question her friends especially those who are very close to her or her family friends concerning any recent changes in her health. I’d ask whether they’ve observed any changes in her sleep patterns, mood, social participation, appetite, activity levels, or expressions of despair or hopelessness after her spouse’s death. Insights from her close circle can help provide a more complete picture of her emotional well-being and any depression symptoms.
The other person to question concerning any recent changes on her health would be her primary care physician. I’d ask them about the patient’s medical history, current medications, and any previous mental health issues. This collaboration would help guarantee a thorough grasp of the patient’s health status, including any potential interactions or contraindications connected to her medical conditions and drugs.
Explain what, if any, physical exams, and diagnostic tests would be appropriate for the patient and how the results would be used.
In this scenario, I would perform a physical assessment to check the patient’s overall health and possibly find any underlying physical causes of her insomnia. The evaluation would include taking vital signs, performing a neurological exam, and examining her overall physical well-being. This would help rule out any medical illnesses or causes that might be causing her sleep problems. If the physical examination reveals any abnormalities, such as neurological deficiencies or evidence of an underlying medical illness, I would do additional tests or refer the patient to a specialist if I couldn’t manage it (Santarnecchi et al., 2018).
I would perform diagnostic testing such as a complete blood count, thyroid function tests, or a sleep study for further investigations. These tests can help uncover any underlying medical diseases that may be contributing to her symptoms, such as anemia or thyroid disorders. If anomalies are discovered, I will start the necessary interventions or therapies.
List a differential diagnosis for the patient. Identify the one that you think is most likely and explain why.
A differential diagnosis for this patient is major depressive disorder with insomnia. Major depressive disorder is a form of mental illness characterized by persistent grief, a lack of interest or happiness, poor appetite or loss of weight, difficulties sleeping, fatigue, trouble paying attention, feelings of lack of worth or guilt, and, in severe cases, suicidal ideation. In this case, the patient’s symptoms of increased depression and disrupted sleep patterns after the death of her spouse corresponds to the diagnostic criteria for major depressive disorder. The absence of a history of depression in the patient before her husband’s death shows that the depressive symptoms are a direct effect of the stressful life event (Gutiérrez-Rojas et al., 2020).
Pharmacological agents that would be appropriate for the patient’s antidepressant therapy
Pharmacological agents that could be used as antidepressants for this patient include sertraline and mirtazapine. Sertraline is a serotonin reuptake inhibitor (SSRI) that is often used to treat depression. Sertraline’s beginning dose for adults is normally 50 mg once daily, which can be gradually elevated to a therapeutic dosage of 50-200 mg every day, based on how well the patient responds (Kishi et al., 2022). Mirtazapine is an atypical antidepressant that regulates the brain’s serotonin and noradrenaline levels. Mirtazapine’s recommended starting dose is 15 mg once daily at bedtime, which can be escalated to a maximum dosage of 45 mg per day based on the patient’s reaction and tolerance (Xiao et al., 2020).
Sertraline is frequently recommended as the initial therapy for depression due to its efficacy, safety profile, and long history of use. Because the patient is already taking 100 mg of sertraline every day and her response to the medicine is just minimal, keeping the present medication and possibly changing the amount if necessary could be a sensible option. Sertraline works by selectively decreasing serotonin reuptake in the brain, consequently boosting its availability and improving mood regulation. If the patient continues to have considerable sleep disruptions, mirtazapine may be investigated as an alternative. It has sedative qualities that can aid in the improvement of sleep patterns. However, given that the patient is already on sertraline and showing signs of improvement, improving the current treatment regimen before considering a switch or the addition of another medication might be a logical strategy (Kishi et al., 2022).
Contraindications to use or alterations in dosing that may need to be considered based on ethical prescribing or decision-making
When it comes to antidepressant drug therapy, it is critical to assess any contraindications that require changes in dosing from an ethical standpoint in order to promote patient safety. In this case, concurrent usage of sertraline with monoamine oxidase inhibitors (MAOIs) such as Phenelzine is a serious contraindication. Combining the two can result in serotonin syndrome, a potentially fatal illness. This illness is distinguished by an upsurge of symptoms such as agitation, increased blood pressure, tremors, and even seizures. To avoid such hazardous consequences, it is critical to establish that the patient is not currently taking any MAOIs before beginning or maintaining sertraline medication. In order to detect any bad effects, the patient’s response to the medicine must be monitored on a frequent basis (Suchting et al., 2021).
I would consider following up on the progress of the patient after 4 weeks after the treatment date and then after 8 weeks. At 4 weeks, I would evaluate the patient’s reaction to the present treatment, such as changes in sleep patterns, mood, and overall well-being. If there is insufficient improvement, I would consider raising the Sertraline dosage to a higher but similar to the existing one. If there are bothersome side effects, I would consider switching from sertraline to mirtazapine.
At 8 weeks, I would reassess the patient’s development, including the influence of medications continued or change or adjusted at week 4 on her sleep and depressive symptoms. I would suggest prolonging the dosage while waiting for the symptoms to decrease and referring the patient to therapy groups based on the therapeutic response. I would then reevaluate the patient in two weeks and advise them to progressively reduce the amount until she is no longer using drugs and only participating in support groups.