Sample Answer for NURS 6630 Pakistani Woman With Delusional Thought Processes Essay Included After Question
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 when she was 9 years old). She presents 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.
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 says she knows this because the television is telling her so.
She currently weighs 140 lbs., and she is 5’ 5.
SUBJECTIVE
Client reports that her mood is “good.” She denies auditory/visual hallucinations but believes that the television talks to her. She believes that Allah sends her messages through the TV. At times throughout the clinical interview, she becomes hostile towards you but then calms down.
A review of her hospital records shows that she received a medical workup from physician, who reported her to be in overall good health. 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 and 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 is 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.
You administer 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
PANSS Scale. Available at: http://egret.psychol.cam.ac.uk/medicine/scales/PANSS
- Kay, S. R., Fiszbein, A., & Opler, L. A. (1987). The Positive and Negative Syndrome Scale (PANSS) for schizophrenia. Schizophrenia Bulletin, 13(2), 261–276. doi:10.1093/schbul/13.2.261
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- Clozapine REMS Program. (n.d.). Clozapine REMS: A guide for healthcare providers. Retrieved September 7, 2016, from https://www.clozapinerems.com/CpmgClozapineUI/rems/pdf/resources/Clozapine_REMS_A_Guide_for_Healthcare_Providers.pdf
http://www.ima.org.il/FilesUpload/IMAJ/0/40/20149.pdf
- Paz, Z., Nalls, M., and Ziv, E. (2011). The genetics of benign neutropenia. Israel Medical Association Journal, 13(10), 625–629. Retrieved from http://www.ima.org.il/FilesUpload/IMAJ/0/40/20149.pdf
Decision Point One
Select what you should do:
Start Zyprexa (olanzapine) 10 mg orally at BEDTIME
Start Invega Sustenna 234 mg IM X1 followed by 156 mg IM on day 4 and monthly thereafter
Start Abilify (aripiprazole) 10 mg orally at BEDTIME
Decision Point One
Start Zyprexa (olanzapine) 10 mg orally at BEDTIME
RESULTS OF DECISION POINT ONE
- Client returns to clinic in four weeks
- Her PANSS decreases to a partial response (decrease in positive symptoms by 25%)
- She comes in today with a reported weight gain of 5 pounds. When questioned further on this point, she states that she can never seem to get full from her meals, so she is snacking constantly throughout the day
Decision Point Two
Decrease Zyprexa to 7.5 mg orally at BEDTIME
RESULTS OF DECISION POINT TWO
- Client returns to clinic in four weeks
- Result of next decision (what happened): Client worsens (her positive symtpoms scale increased by 25% and her negative symptom scale score decreased by 10% indicating improved negative symptoms), but her weight becomes stabilized and excessive hunger abates
- Husband explains that she is becoming less manageable at home, and he has to take time off from work because he is fearful of leaving her alone
Decision Point Three
Increase Zyprexa 10 MG orally at BEDTIME
Guidance to Student
A Sample Answer For the Assignment: NURS 6630 Pakistani Woman With Delusional Thought Processes Essay
Title: NURS 6630 Pakistani Woman With Delusional Thought Processes Essay
Weight gain is a significant problem with Zyprexa. Next to Clozaril (clozapine), Zyprexa causes the most weight gain of all the atypical antipsychotics. This is a side effect that a significant number of clients will experience. There also appears to be an increased association of newly diagnosed diabetes mellitus in clients treated with Zyprexa. Although this can be disease related in this population, Zyprexa is above what would be considered coincidental.
Risperdal is a good option, although it is dosed twice daily and compliance in this population can be problematic. There is evidence that shows giving Risperdal all at once can be efficacious and therefore could be an option down the road should compliance become an issue. Weight gain is also possible with Risperdal, but it is not as great as that seen with Zyprexa. If compliance does become an issue with this client, Risperdal has a long-acting injectable formulation, Risperdal Consta, that could be used. Remember, Risperdal Consta has to be given every 2 weeks at the provider’s office, and therapeutic blood levels take time to achieve (on average 3–6 weeks or 2–3 injections). Oral overlapping therapy is required to bridge this period of time. Another option in someone who responds to Risperdal would be Invega Sustenna (paliperidone palmitate), which is the first metabolite of Risperdal and has greater activity at the D2 receptor than Risperdal. An advantage of Invega Sustenna over Risperdal Consta is that therapeutic blood levels are attained within the first 4–7 days, and overlapping oral therapy is usually not necessary. A disadvantage is that during the initiating phase of medication, the first two doses need to be given within 4–7 days of one another. This is followed by monthly injections. There is another product on the market called Invega Trinza, which is given once every 3 months. This product is for clients who have been stabilized on Invega Sustenna for at least 4 months where the last two doses were the same strength (two months of 156 mg injections).
Increasing Zyprexa to 15 mg at bedtime will only worsen the weight gain side effect. While additional benefits from increasing the dose may be possible from an efficacy standpoint, side effects always need to be taken into consideration. “First, do no harm.” Qsymia is a weight loss medication that is a combination of phentermine and topiramate. It is only indicated to treat obesity. This client’s BMI (28.9 kg/M2) does not fit the definition of obesity (BMI >30 Kg/M2- Following from CDC website: Class 1: BMI of 30 to < 35, Class 2: BMI of 35 to < 40, Class 3: BMI of 40 or higher. Class 3 obesity is sometimes categorized as “extreme” or “severe” obesity). There are two things wrong with this therapy option. First, there are only a few occasions where add-on therapy to treat a side effect is acceptable, and weight gain is not one of those scenarios. Secondly, phentermine has a lot of cardiovascular toxicities (such as elevated BP, HR, and increased workload on the heart).
Decision Point One
Start Invega Sustenna 234 mg IM X1 followed by 156 mg IM on day 4 and monthly thereafter
RESULTS OF DECISION POINT ONE
- Client returns to clinic in four weeks
- A decrease in the PANSS score of 25% (in positive symtpoms) is noted at this visit
- Client seems to be tolerating medication
- Her husband has made sure she makes her appointments for injections (one thus far)
- She has noted a 2-pound weight gain, but it does not seem to be an important point for her
- She does, however, complain of injection-site pain, telling you that she has trouble sitting for a few hours after the injections and doesn’t like having to walk around for such a long period of time
Decision Point Two
RESULTS OF DECISION POINT TWO
- Client returns to clinic in four weeks
- Her PANNS has been reduced by a total of 50% (in positive symptoms) from the initiation of Invega Sustenna
- When questioned about injection-site pain, she states it is much better in the arm
- Her weight has increased by an additional 2.5 pounds (total of 4.5 pounds in a 2-month period). She is somewhat bothered by the weight gain and is afraid that her husband does not like it. He is not present at this visit as she brought herself
- She likes how she feels on the Invega Sustenna but is wondering if there is another drug like it that would not cause the weight gain
Decision Point Three
Guidance to Student
Weight gain can occur with Invega Sustenna. It is modest in nature and can be controlled with proper nutrition and exercise. It is always a good idea to try and control a client’s weight through consultation with a dietician and exercise physiologist (life coach) before switching to another agent when a product is showing efficacy for at least 6 months.
Abilify Maintena is a good option for someone who has good response to Abilify oral. Remember that Abilify does not bind to the D2 receptor for a great period of time (such as Invega) and can be less effective in certain individuals. Also, remember that akathisia can be a possible side effect. Once an IM long-acting medication is given, the effects of the drug (both efficacious and untoward effects) can be maintained for a long duration (up to a month or longer). Tolerability and efficacy should be established with oral medication before administering the first injection. Also a disadvantage to Abilify Maintena is that a 2-week overlap of oral therapy is required due to effective blood levels lagging behind the induction dose.
Qsymia is a weight loss medication that is a combination of phentermine and topiramate. It is only indicated to treat obesity. This client’s BMI (28.9 kg/M2) does not fit the definition of obesity (BMI >30 Kg/M2- Following from CDC website: Class 1: BMI of 30 to < 35, Class 2: BMI of 35 to < 40, Class 3: BMI of 40 or higher. Class 3 obesity is sometimes categorized as “extreme” or “severe” obesity). There are two things wrong with this therapy option. First, there are only a few occasions where add-on therapy to treat a side effect is acceptable, and weight gain is not one of those scenarios. Secondly, phentermine has a lot of cardiovascular toxicities (such as elevated BP, HR, and increased workload on the heart).
Decision Point One
Start Abilify (aripiprazole) 10 mg orally at BEDTIME
RESULTS OF DECISION POINT ONE
- Client returns to clinic in four weeks
- Client returns and looks disheveled. Upon questioning, her husband states that she has not been sleeping at night. He states she is up and down all night. It has been disrupting his sleep too
- The client is unable to participate in the PANSS rating tool because she is continually nodding off (sleeping) during the appointment
- The appointment is not productive for assessing how she is responding to the Abilify started 4 weeks ago
Decision Point Two
Change Abilify administration time to AM dosing
RESULTS OF DECISION POINT TWO
- Client arrives at office appearing to have slept better. Her husband tells you that she is still up and down at night, but it is much less frequently
- He notices that it is better when she takes her medication as soon as she awakens, but some days she forgets and takes it when she remembers (in the afternoon)
- Her PANNS has decreased by 5% since her initial visit
Decision Point Three
Guidance to Student
This is week 8 since therapy was initiated. Although the client’s side effects seem to be better managed, her PNSS is not changing by much. An acceptable time frame for treatment is defined as 4–6 weeks at an acceptable dose. Increasing Abilify to 20 mg in the morning certainly is an option, but she seems to be forgetful of taking this medication first thing in the morning on occasion and is still experiencing side effects when it is taken later in the day. It might be a good time to explore other options.
Latuda is a medication that behaves much like Geodon (ziprasidone). It offers a once-daily dosing option and weight gain is minimal. She would not be expected to experience the insomnia and akathisia that has been experienced on the Abilify. Tolerability can be an issue as doses are escalated. Particularly, nausea, vomiting, and extrapyramidal side effects can be problematic and therefore good counseling points to clients. Clients usually tolerate lower doses (40 mg) but significant GI distress and movement disorders can occur when doses are pushed upward toward the daily max of 160 mg.
Invega oral therapy is a good option as it has a once daily dosing option, and it has a greater effect at the D2 receptor than Abilify and may offer more efficacy and less insomnia and akathisia than seen in Abilify. It has a long-acting option that can be given monthly (to start). With good efficacy maintained over a 4-month period, it can be changed to once every 3 months. This is a good option in someone where compliance can be problematic.
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For assignments that need to be submitted to Lopes Write, please be sure you have received your report and Similarity Index (SI) percentage BEFORE you do a “final submit” to me.
Once you have received your report, please review it. This report will show you grammatical, punctuation, and spelling errors that can easily be fixed. Take the extra few minutes to review instead of getting counted off for these mistakes.
Review your similarities. Did you forget to cite something? Did you not paraphrase well enough? Is your paper made up of someone else’s thoughts more than your own?
Visit the Writing Center in the Student Success Center, under the Resources tab in LoudCloud for tips on improving your paper and SI score.
Late Policy
The university’s policy on late assignments is 10% penalty PER DAY LATE. This also applies to late DQ replies.
Please communicate with me if you anticipate having to submit an assignment late. I am happy to be flexible, with advance notice. We may be able to work out an extension based on extenuating circumstances.
If you do not communicate with me before submitting an assignment late, the GCU late policy will be in effect.
I do not accept assignments that are two or more weeks late unless we have worked out an extension.
As per policy, no assignments are accepted after the last day of class. Any assignment submitted after midnight on the last day of class will not be accepted for grading.
Communication
Communication is so very important. There are multiple ways to communicate with me:
Questions to Instructor Forum: This is a great place to ask course content or assignment questions. If you have a question, there is a good chance one of your peers does as well. This is a public forum for the class.
Individual Forum: This is a private forum to ask me questions or send me messages. This will be checked at least once every 24 hours.
Important information for writing discussion questions and participation
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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Please, be advised I do NOT accept any assignments by email. If you are having technical issues with uploading an assignment, contact the technical department and inform me of the issue. If you have any issues that would prevent you from getting your assignments to me by the deadline, please inform me to request a possible extension. Note that working fulltime or overtime is no excuse for late assignments. There is a 5%-point deduction for every day your assignment is late. This only applies to approved extensions. Late assignments will not be accepted.
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Plagiarism is highly prohibited. Please ensure you are citing your sources correctly using APA 7th edition. All assignments including discussion posts should be formatted in APA with the appropriate spacing, font, margin, and indents. Any papers not well formatted would be returned back to you, hence, I advise you review APA formatting style. I have attached a sample paper in APA format and will also post sample discussion responses in subsequent announcements.
Your initial discussion post should be a minimum of 200 words and response posts should be a minimum of 150 words. Be advised that I grade based on quality and not necessarily the number of words you post. A minimum of TWO references should be used for your initial post. For your response post, you do not need references as personal experiences would count as response posts. If you however cite anything from the literature for your response post, it is required that you cite your reference. You should include a minimum of THREE references for papers in this course. Please note that references should be no more than 5 years old except recommended as a resource for the class. Furthermore, for each discussion board question, you need ONE initial substantive response and TWO substantive responses to either your classmates or your instructor for a total of THREE responses. There are TWO discussion questions each week, hence, you need a total minimum of SIX discussion posts for each week. I usually post a discussion question each week. You could also respond to these as it would count towards your required SIX discussion posts for the week.
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!
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
- Your response needs to be a minimum of 150 words (not including your list of references)
- There needs to be at least TWO references with ONE being a peer reviewed professional journal article.
- Include in-text citations in your response
- Do not include quotes—instead summarize and paraphrase the information
- Follow APA-7th edition
- Points will be deducted if the above is not followed
Participation –replies to your classmates or instructor
- A minimum of 6 responses per week, on at least 3 days of the week.
- Each response needs at least ONE reference with citations—best if it is a peer reviewed journal article
- Each response needs to be at least 75 words in length (does not include your list of references)
- Responses need to be substantive by bringing information to the discussion or further enhance the discussion. Responses of “I agree” or “great post” does not count for the word count.
- Follow APA 7th edition
- Points will be deducted if the above is not followed
- Remember to use and follow APA-7th edition for all weekly assignments, discussion questions, and participation points.
- Here are some helpful links
- Student paper example
- Citing Sources
- The Writing Center is a great resource