NURS 6630 Self Assessment Assessing and Treating Patients With Psychopharmacology

Sample Answer for NURS 6630 Self Assessment Assessing and Treating Patients With Psychopharmacology Included After Question

NURS 6630 Self Assessment Assessing and Treating Patients With Psychopharmacology

 

 

Assessing and Treating Patients with Bipolar Disorder 

The DSM V describes Bipolar disorder as a group of mental disorders that result in extreme fluctuation in an individual’s mood, energy, and functioning. Bipolar disorder presents with intervals of deep, prolonged, and profound depression that alternate with intervals of mania characterized by an excessively elevated or irritable mood (APA, 2013). A manic episode represents a significant change from usual behavior. It manifests with at least three of the following symptoms: Inflated self-esteem or grandiosity, increased talkativeness, decreased need for sleep, racing thoughts, easy distraction, increase in goal-directed activity, and engaging in activities that have negative consequences (APA, 2013). This paper seeks to review a client with Bipolar disorder and outline the client’s treatment plan using a decision tree.  

Case Study Overview 

The case scenario depicts a 26-year-old woman of Korean descent on her first appointment after a 21-day hospitalization for acute mania. The client has been diagnosed with bipolar I disorder. Her current weight is 110 pounds, and her height is 5’ 5. She describes her mood as fantastic and mentions that she sleeps roughly 5 hours/night, but she hates sleep because it is not fun (Laureate Education, 2016). The client’s patient records show that she is in overall good health and her lab results are within normal limits. However, genetic testing shows that she is positive for the CYP2D6*10 allele. The client admits that she stopped taking Lithium after being discharged two weeks ago. On MSE, the client is alert and oriented to person, place, time, and event. Her dressing is odd, and her speech is rapid, pressured, and tangential. Her self-reported mood is euthymic, and her affect is broad. She denies visual or auditory hallucinations, and she has no overt delusional or paranoid thought processes readily apparent (Laureate Education, 2016). Her insight is impaired, but she denies suicidal or homicidal ideation. She scores 22 on the Young Mania Rating Scale (YMRS). 

Decision Point One 

Begin Lithium 300 mg orally BID. 

Why I Selected This Decision 

Lithium is a mood stabilizer recommended for treating Mania in Bipolar disorder and maintenance therapy of bipolar disorder in persons with a history of mania. I selected Lithium because it targets unstable mood, which is the major symptom of mania (Won & Kim, 2017). Besides, mania is recommended as first-line therapy for long-term prevention of Bipolar disorder, particularly for euphoric mania.  

I did not select Seroquel because it has documented side effects of dry mouth, fatigue, constipation, and dizziness, contributing to decreased medication compliance. Seroquel is also associated with increased appetite and weight and elevated triglycerides and total cholesterol levels (Shah et al., 2017). The side effects make it an inappropriate drug since the client is overweight.  I did not select Risperdal since the patient was positive for the CYP2D6*10 allele. According to Puangpetch et al. (2016), the CYP2D6*10 allele slows the drug’s clearance resulting in high levels of Risperdal in the blood, causing sedation.  

What I Was Hoping To Achieve By Making This Decision 

I hoped that prescribing Lithium would stabilize the patient’s mood and reduce the severity of manic symptoms by at least 50% in the first four weeks of treatment. According to Won and Kim (2017), Lithium exerts mood-stabilizing effects by acting on cellular targets and exerting neuroprotective effects.  

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

Ethical principles of nonmaleficence and beneficence may impact the treatment plan as the PMHNP has a duty to prevent harm and promote better patient outcomes. The PMHNP is obliged to assess a drug for its impact and potential side effects before prescribing it to ensure it will promote better outcomes and have no adverse consequences to the patient (Bipeta, 2019). In this case, the PMHNP assessed each drug’s potential side effects and selected the one associated with better outcomes and fewer adverse effects. 

Decision Point Two 

Assess rationale for non-compliance to elicit reason for non-compliance and educate the client on drug effects and pharmacology. 

Why I Selected This Decision 

I selected this decision because the client reported taking the medication “off and on” when she feels that she needs it. The decision aimed at understanding the primary cause for the patient not complying with the medication (Won & Kim, 2017). Besides, educating the patient on the possible side effects and pharmacology of Lithium would enlighten her on the drug’s impact in improving her health outcomes. 

I did not increase Lithium to 450 mg because the non-compliance behavior would persist if the reasons for the behavior were not identified and addressed. Besides, it is crucial that the PMHNP assess a patient’s response to Lithium and associated side effects before increasing the dose (Won & Kim, 2017).  I did not switch treatment to Depakote because the patient’s response to Lithium had not been established. According to Shah et al. (2017), the evidence for Depakote efficacy in acute depression is not as robust as that for Lithium.  

What I Was Hoping To Achieve By Making This Decision 

I was hoping that assessing and eliciting reason for non-compliance would help in identifying a practical solution to increasing compliance and eventually improve the manic symptoms. I was hoping that educating the patient on Lithium’s drug effects and pharmacology would enable her to understand the importance of adhering to treatment and increase her medication compliance.  

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

The ethical principle of autonomy, which means that patients have a right to make decisions about their lives without interference from others, may impact the treatment plan. The PMHNP must respect the patient’s decision regarding her care which may impact the treatment interventions (Bipeta, 2019). In this case, the PMHNP had to elicit the rationale for the patient not complying with treatment, which determined the next intervention. 

Decision Point Three 

Change Lithium to sustained release, preparation at the same dose and frequency. 

Why I Selected This Decision 

I changed Lithium to sustained release because the formulation is documented to prevent Lithium’s side effects, such as nausea and diarrhea, which were reported. The sustained release formulation suppresses the side effects while at the same time effecting its mood-stabilizing properties (Girardi et al., 2016).  I did not change therapy to Depakote because it is also associated with similar side effects as Lithium (Shah et al., 2017). Besides, the sustained Lithium formulation is a better option than Depakote. I did not select Trileptal because it is only recommended as a second-line agent in treating Bipolar disorder (Shah et al., 2017). It was not ideal at this step because there had been no adequate trials with Lithium. 

What I Was Hoping To Achieve By Making This Decision 

I hope that the sustained release formulation would alleviate the severity of side effects and that the patient would report fewer side effects. I also hoped that the patient’s treatment compliance would increase, and there would be improved manic symptoms. According to Girardi et al. (2016), Lithium’s sustained formulation has several advantages, including fewer adverse events, consistent serum lithium concentrations, and improved adherence to therapy. 

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 may be forced to change treatment based on associated adverse effects to avoid harming the client (Bipeta, 2019).  In this case, the PMHNP changed Lithium from immediate to sustained formulation to reduce the drug’s side effects and improve the patient’s quality of life.  

Conclusion 

The client in the case study was diagnosed with Bipolar 1 Disorder, a manic-depressive disorder that can occur both with and without psychotic episodes.  She presented with manic symptoms, including excessive talking, reduced need for sleep, and distractibility. In the first decision step, I began treatment with Lithium 300 mg BD to target the manic symptoms and stabilize the patient’s mood. However, the drug did not have any impact since the patient was not compliant with treatment. I assessed the rationale for non-compliance to elicit the reason for non-compliance and educate the patient on Lithium effects and pharmacology. This aimed at establishing the causes of non-compliance and increasing the compliance to promote better outcomes.  

The patient was still not compliant with the medication because of its associated side effects of nausea and diarrhea. I changed the Lithium from immediate to sustained-release preparation but at the same dose and frequency to reduce the side effects and increase compliance. Ethical principles that may impact the treatment plan include beneficence, nonmaleficence, and autonomy. In this case, the PMHNP upheld beneficence by selecting the medication associated with the best possible outcomes for patients with Bipolar disorder. Nonmaleficence was upheld by evaluating the medication’s side effects and changing the Lithium formulation due to the associated side effects. Besides, autonomy was promoted by addressing the patient’s concerns on treatment and identifying solutions to address these concerns. 

 

References 

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub. 

Bipeta, R. (2019). Legal and Ethical Aspects of Mental Health Care. Indian journal of psychological medicine, 41(2), 108–112. https://doi.org/10.4103/IJPSYM.IJPSYM_59_19 

Girardi, P., Brugnoli, R., Manfredi, G., & Sani, G. (2016). Lithium in Bipolar Disorder: Optimizing Therapy Using Prolonged-Release Formulations. Drugs in R&D, 16(4), 293–302. https://doi.org/10.1007/s40268-016-0139-7 

Laureate Education. (2016f). Case study: An Asian American woman with bipolar disorder [Interactive media file]. Baltimore, MD: Author 

Puangpetch, A., Vanwong, N., Nuntamool, N., Hongkaew, Y., Chamnanphon, M., & Sukasem, C. (2016). CYP2D6 polymorphisms and their influence on risperidone treatment. Pharmacogenomics and personalized medicine, 9, 131–147. https://doi.org/10.2147/PGPM.S107772 

Shah, N., Grover, S., & Rao, G. P. (2017). Clinical Practice Guidelines for Management of Bipolar Disorder. Indian journal of psychiatry, 59(Suppl 1), S51–S66. https://doi.org/10.4103/0019-5545.196974 

Won, E., & Kim, Y. K. (2017). An Oldie but Goodie: Lithium in the Treatment of Bipolar Disorder through Neuroprotective and Neurotrophic Mechanisms. International journal of molecular sciences, 18(12), 2679. https://doi.org/10.3390/ijms18122679 

 

 

 

Assessing and Treating Patients with Bipolar Disorder 

 

Name 

Institution 

Course 

Date 

 

Assessing and Treating Patients with Bipolar Disorder 

The DSM V describes Bipolar disorder as a group of mental disorders that result in extreme fluctuation in an individual’s mood, energy, and functioning. Bipolar disorder presents with intervals of deep, prolonged, and profound depression that alternate with intervals of mania characterized by an excessively elevated or irritable mood (APA, 2013). A manic episode represents a significant change from usual behavior. It manifests with at least three of the following symptoms: Inflated self-esteem or grandiosity, increased talkativeness, decreased need for sleep, racing thoughts, easy distraction, increase in goal-directed activity, and engaging in activities that have negative consequences (APA, 2013). This paper seeks to review a client with Bipolar disorder and outline the client’s treatment plan using a decision tree.  

Case Study Overview 

The case scenario depicts a 26-year-old woman of Korean descent on her first appointment after a 21-day hospitalization for acute mania. The client has been diagnosed with bipolar I disorder. Her current weight is 110 pounds, and her height is 5’ 5. She describes her mood as fantastic and mentions that she sleeps roughly 5 hours/night, but she hates sleep because it is not fun (Laureate Education, 2016). The client’s patient records show that she is in overall good health and her lab results are within normal limits. However, genetic testing shows that she is positive for the CYP2D6*10 allele. The client admits that she stopped taking Lithium after being discharged two weeks ago. On MSE, the client is alert and oriented to person, place, time, and event. Her dressing is odd, and her speech is rapid, pressured, and tangential. Her self-reported mood is euthymic, and her affect is broad. She denies visual or auditory hallucinations, and she has no overt delusional or paranoid thought processes readily apparent (Laureate Education, 2016). Her insight is impaired, but she denies suicidal or homicidal ideation. She scores 22 on the Young Mania Rating Scale (YMRS). 

Decision Point One 

Begin Lithium 300 mg orally BID. 

Why I Selected This Decision 

Lithium is a mood stabilizer recommended for treating Mania in Bipolar disorder and maintenance therapy of bipolar disorder in persons with a history of mania. I selected Lithium because it targets unstable mood, which is the major symptom of mania (Won & Kim, 2017). Besides, mania is recommended as first-line therapy for long-term prevention of Bipolar disorder, particularly for euphoric mania.  

I did not select Seroquel because it has documented side effects of dry mouth, fatigue, constipation, and dizziness, contributing to decreased medication compliance. Seroquel is also associated with increased appetite and weight and elevated triglycerides and total cholesterol levels (Shah et al., 2017). The side effects make it an inappropriate drug since the client is overweight.  I did not select Risperdal since the patient was positive for the CYP2D6*10 allele. According to Puangpetch et al. (2016), the CYP2D6*10 allele slows the drug’s clearance resulting in high levels of Risperdal in the blood, causing sedation.  

What I Was Hoping To Achieve By Making This Decision 

I hoped that prescribing Lithium would stabilize the patient’s mood and reduce the severity of manic symptoms by at least 50% in the first four weeks of treatment. According to Won and Kim (2017), Lithium exerts mood-stabilizing effects by acting on cellular targets and exerting neuroprotective effects.  

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

Ethical principles of nonmaleficence and beneficence may impact the treatment plan as the PMHNP has a duty to prevent harm and promote better patient outcomes. The PMHNP is obliged to assess a drug for its impact and potential side effects before prescribing it to ensure it will promote better outcomes and have no adverse consequences to the patient (Bipeta, 2019). In this case, the PMHNP assessed each drug’s potential side effects and selected the one associated with better outcomes and fewer adverse effects. 

Decision Point Two 

Assess rationale for non-compliance to elicit reason for non-compliance and educate the client on drug effects and pharmacology. 

Why I Selected This Decision 

I selected this decision because the client reported taking the medication “off and on” when she feels that she needs it. The decision aimed at understanding the primary cause for the patient not complying with the medication (Won & Kim, 2017). Besides, educating the patient on the possible side effects and pharmacology of Lithium would enlighten her on the drug’s impact in improving her health outcomes. 

I did not increase Lithium to 450 mg because the non-compliance behavior would persist if the reasons for the behavior were not identified and addressed. Besides, it is crucial that the PMHNP assess a patient’s response to Lithium and associated side effects before increasing the dose (Won & Kim, 2017).  I did not switch treatment to Depakote because the patient’s response to Lithium had not been established. According to Shah et al. (2017), the evidence for Depakote efficacy in acute depression is not as robust as that for Lithium.  

What I Was Hoping To Achieve By Making This Decision 

I was hoping that assessing and eliciting reason for non-compliance would help in identifying a practical solution to increasing compliance and eventually improve the manic symptoms. I was hoping that educating the patient on Lithium’s drug effects and pharmacology would enable her to understand the importance of adhering to treatment and increase her medication compliance.  

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

The ethical principle of autonomy, which means that patients have a right to make decisions about their lives without interference from others, may impact the treatment plan. The PMHNP must respect the patient’s decision regarding her care which may impact the treatment interventions (Bipeta, 2019). In this case, the PMHNP had to elicit the rationale for the patient not complying with treatment, which determined the next intervention. 

Decision Point Three 

Change Lithium to sustained release, preparation at the same dose and frequency. 

Why I Selected This Decision 

I changed Lithium to sustained release because the formulation is documented to prevent Lithium’s side effects, such as nausea and diarrhea, which were reported. The sustained release formulation suppresses the side effects while at the same time effecting its mood-stabilizing properties (Girardi et al., 2016).  I did not change therapy to Depakote because it is also associated with similar side effects as Lithium (Shah et al., 2017). Besides, the sustained Lithium formulation is a better option than Depakote. I did not select Trileptal because it is only recommended as a second-line agent in treating Bipolar disorder (Shah et al., 2017). It was not ideal at this step because there had been no adequate trials with Lithium. 

What I Was Hoping To Achieve By Making This Decision 

I hope that the sustained release formulation would alleviate the severity of side effects and that the patient would report fewer side effects. I also hoped that the patient’s treatment compliance would increase, and there would be improved manic symptoms. According to Girardi et al. (2016), Lithium’s sustained formulation has several advantages, including fewer adverse events, consistent serum lithium concentrations, and improved adherence to therapy. 

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 may be forced to change treatment based on associated adverse effects to avoid harming the client (Bipeta, 2019).  In this case, the PMHNP changed Lithium from immediate to sustained formulation to reduce the drug’s side effects and improve the patient’s quality of life.  

Conclusion 

The client in the case study was diagnosed with Bipolar 1 Disorder, a manic-depressive disorder that can occur both with and without psychotic episodes.  She presented with manic symptoms, including excessive talking, reduced need for sleep, and distractibility. In the first decision step, I began treatment with Lithium 300 mg BD to target the manic symptoms and stabilize the patient’s mood. However, the drug did not have any impact since the patient was not compliant with treatment. I assessed the rationale for non-compliance to elicit the reason for non-compliance and educate the patient on Lithium effects and pharmacology. This aimed at establishing the causes of non-compliance and increasing the compliance to promote better outcomes.  

The patient was still not compliant with the medication because of its associated side effects of nausea and diarrhea. I changed the Lithium from immediate to sustained-release preparation but at the same dose and frequency to reduce the side effects and increase compliance. Ethical principles that may impact the treatment plan include beneficence, nonmaleficence, and autonomy. In this case, the PMHNP upheld beneficence by selecting the medication associated with the best possible outcomes for patients with Bipolar disorder. Nonmaleficence was upheld by evaluating the medication’s side effects and changing the Lithium formulation due to the associated side effects. Besides, autonomy was promoted by addressing the patient’s concerns on treatment and identifying solutions to address these concerns. 

 

References 

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub. 

Bipeta, R. (2019). Legal and Ethical Aspects of Mental Health Care. Indian journal of psychological medicine, 41(2), 108–112. https://doi.org/10.4103/IJPSYM.IJPSYM_59_19 

Girardi, P., Brugnoli, R., Manfredi, G., & Sani, G. (2016). Lithium in Bipolar Disorder: Optimizing Therapy Using Prolonged-Release Formulations. Drugs in R&D, 16(4), 293–302. https://doi.org/10.1007/s40268-016-0139-7 

Laureate Education. (2016f). Case study: An Asian American woman with bipolar disorder [Interactive media file]. Baltimore, MD: Author 

Puangpetch, A., Vanwong, N., Nuntamool, N., Hongkaew, Y., Chamnanphon, M., & Sukasem, C. (2016). CYP2D6 polymorphisms and their influence on risperidone treatment. Pharmacogenomics and personalized medicine, 9, 131–147. https://doi.org/10.2147/PGPM.S107772 

Shah, N., Grover, S., & Rao, G. P. (2017). Clinical Practice Guidelines for Management of Bipolar Disorder. Indian journal of psychiatry, 59(Suppl 1), S51–S66. https://doi.org/10.4103/0019-5545.196974 

Won, E., & Kim, Y. K. (2017). An Oldie but Goodie: Lithium in the Treatment of Bipolar Disorder through Neuroprotective and Neurotrophic Mechanisms. International journal of molecular sciences, 18(12), 2679. https://doi.org/10.3390/ijms18122679 

A Sample Answer For the Assignment: NURS 6630 Self Assessment Assessing and Treating Patients With Psychopharmacology

Title: NURS 6630 Self Assessment Assessing and Treating Patients With Psychopharmacology

 

Question 1

  1. Martin is a 92-year-old male who presents to the clinic with signs/symptoms consistent with MDD. The patient suffers from glaucoma and just recently underwent surgery for a cataract. Which of the following is the LEAST appropriate course of therapy when treating the MDD?
a. sertraline
b. amitriptyline
c. duloxetine
d. vilazodone

0 points

Question 2

  1. Mark is a 46-year-old male with treatment-resistant depression. He has tried various medications, including SSRIs, SNRI, and TCAs. You have decided to initiate therapy with phenelzine. Which of the following must the PMHNP take into consideration when initiating therapy with phenelzine?
a. There is a minimum 7-day washout period when switching from another antidepressant to phenelzine.
b. Patient must be counseled on dietary restrictions.
c. MAOIs may be given as an adjunctive therapy with SSRIs.
d. A & B
e. All of the above

0 points

Question 3

  1. Earle is an 86-year-old patient who presents to the hospital with a Community Acquired Pneumonia. During stay, you notice that the patient often seems agitated. He suffers from cognitive decline and currently takes no mental health medications. Treatment for the CAP include ceftriaxone and azithromycin. The LEAST appropriate medication to treat Earle’s anxiety is:
a. sertraline
b. duloxetine
c. citalopram
d. venlafaxine

0 points

Question 4

  1. Richard is a 54-year-old male who suffers from schizophrenia. After exhausting various medication options, you have decided to start him on Clozapine. Which of the statements below is true regarding Clozapine?
a. Regular blood monitoring must be performed to monitor for neutropenia.
b. Clozapine can only be filled by a pharmacy that participates in the REMS program.
c. Bradycardia is a common side effect of Clozapine.
d. A & B
e. All of the above

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NURS 6630 Self Assessment Assessing and Treating Patients With Psychopharmacology
NURS 6630 Self Assessment Assessing and Treating Patients With Psychopharmacology

Question 5

  1. Sam is a 48-year-old male who presents to the clinic with signs and symptoms consistent with GAD & MDD. Which of the following medications would be the LEAST appropriate choice when initiating pharmacotherapy?
a. duloxetine
b. sertraline
c. mirtazapine
d. buproprion

0 points

Question 6

  1. Which of the following medications, when given intramuscularly, is most likely to cause severe postural hypotension?
a. haloperidol
b. lorazepam
c. benztropine
d. chlorpromazine

0 points

Question 7

  1. Jane is a 17-year-old patient who presents to the office with signs consistent with schizophrenia. She states multiple times that she is concerned about gaining weight, as she has the perfect prom dress picked out and she finally got a date. Which of the following is the least appropriate choice to prescribe Jane?
a. Aripiprazole
b. Olanzapine
c. Haloperidol
d. Brexpiprazole

0 points

Question 8

  1. Jordyn is a 27-year-old patient who presents to the clinic with GAD. She is 30 weeks pregnant and has been well controlled on a regimen of sertraline 50mg daily. Jordyn says that “about once or twice a week my husband really gets on my nerves and I can’t take it.” She is opposed to having the sertraline dose increased due to the risk of further weight gain. You have decided to prescribe the patient a short-term course of benzodiazepines for breakthrough anxiety. Which of the following is the LEAST appropriate benzodiazepines to prescribe to this patient?
a. diazepam
b. alprazolam
c. clonazepam
d. lorazepam

0 points

Question 9

  1. Stephanie is a 36-year-old female who presents to the clinic with a history of anxiety. Social history is unremarkable. For the last 4 years, she has been well controlled on paroxetine, however she feels “it just doesn’t work anymore.” You have decided to change her medication regimen to vortioxetine 5mg, titrating up to a max dose of 20mg per day based on tolerability. The patient states, “I can’t even last 1 more day without feeling like my insides are going to explode with anxiety.” The most appropriate course of action would be:
a. Inform the patient to try yoga or other natural remedies until the vortioxetine takes effect.
b. Prescribe a short-term course of low dose benzodiazepine, such as alprazolam.
c. Prescribe an SNRI, such as venlafaxine, in addition to the vortioxetine.
d. Recommend in-patient mental health for the foreseeable future.

0 points

Question 10

  1. Stephanie is a 36-year-old female who presents to the clinic with a history of anxiety. Social history is unremarkable. For the last 4 years, she has been well controlled on paroxetine, however she feels “it just doesn’t work anymore.” You have decided to change her medication regimen to vortioxetine 5mg, titrating up to a max dose of 20mg per day based on tolerability. The patient asks, “When can I expect this to start kicking in?” The best response is:
a. 3 or 4 days
b. 1 or 2 weeks
c. 3 or 4 weeks
d. 10 weeks

0 points

Question 11

  1. Thomas is a 28-year-old male who presents to the clinic with signs and symptoms consistent with MDD. He is concerned about starting antidepressant therapy, however, because one of his friends recently experienced erectile dysfunction when he was put on an antidepressant. Which of the following would be the most appropriate antidepressant to start Thomas on?
a. Vilazodone
b. Sertraline
c. Paroxetine
d. Citalopram

0 points

Question 12

  1. Rebecca is a 32-year-old female who was recently prescribed escitalopram for MDD. She presents to the clinic today complaining of diaphoresis, tachycardia, and confusion. The differential diagnosis for this patient, based on the symptoms presenting, is:
a. Panic disorder
b. Gastroenteritis
c. Abnormal gait
d. Serotonin syndrome

0 points

Question 13

  1. Mirza is a 75-year-old patient with a long history of schizophrenia. During the past 5 years, she has shown significant cognitive decline consistent with dementia. The patient has been well controlled on a regimen of risperidone 1mg BID. As the PMHNP, the most appropriate course of action for this patient is:
a. Increase the risperidone to 1mg QAM, 2mg QPM
b. Discontinue risperidone and prescribe a long-acting injectable such as Invega Sustenna.
c. Discontinue risperidone and initiate therapy with clozapine.
d. Augment the patient’s risperidone with brexpiprazole.

0 points

Question 14

  1. John is a 41-year old-patient who presents to the clinic with diarrhea, fatigue, and recently has been having tremors. He was diagnosed 19 years ago with bipolar disorder and is currently managed on Lithium 300mg BID. As the PMHNP, you decide to order a lithium level that comes back at 2.3mmol/l. What is the most appropriate course of action?
a. Investigate other differential diagnoses for his symptoms.
b. Tell John to skip his next four Lithium doses and resume therapy.
c. Tell John he needs to go to the hospital and call an ambulance to bring him.
d. Prescribe loperamide to treat the diarrhea and ropinirole to treat the tremors

0 points

Question 15

  1. Amber is a 26-year-old female who presents to the clinic 6 weeks postpartum. The patient states that she has been “feeling down” since the birth of her son. She is currently breastfeeding her infant. You diagnose the patient with Postpartum depression. Which of the following is the LEAST appropriate option in treating her PPD?
a. paroxetine
b. escitalopram
c. citalopram
d. sertraline

0 points

Question 16

  1. Which of the following statements are true?
a. First-generation (typical) antipsychotics are associated with a higher incidence of EPS.
b. Second-generation (atypical) antipsychotics are associated with a higher risk of metabolic side effects.
c. There is evidence that atypical antipsychotics are significantly more effective than typical antipsychotics in the treatment of cognitive symptoms associated with schizophrenia.
d. A & B
e. A, B, and C

0 points

Question 17

  1. Cindy is a 55-year-old patient who presents with symptoms consistent with Generalized anxiety disorder. The patient has an unremarkable social history other than she consumes two or three glasses of wine per night. Which of the following would be an appropriate therapy to start this patient on?
a. Xanax 0.25mg BID PRN Anxiety
b. Escitalopram 10mg daily
c. Buspirone 10mg BID
d. Aripiprazole 10mg daily

0 points

Question 18

  1. Jason is a 6-year-old child whose mother presents to the clinic with him. The mother says that “he’s not himself lately.” After a thorough workup, you diagnose the patient as having GAD. Which of the following medications would be the LEAST appropriate to prescribe to this child?
a. Sertraline
b. Paroxetine
c. Venlafaxine
d. Buspirone

0 points

Question 19

  1. Steve is a 35-year-old male who presents to the primary care office complaining of anxiety secondary to quitting smoking cold turkey 2 weeks ago. The patient has a 14-year history of smoking two packs per day. The patient has an unremarkable social history other than a recent divorce from his wife, Brittany. Which of the following would be the LEAST effective medication to treat Steve’s anxiety?
a. Buproprion
b. Sertraline
c. Varenicline
d. Alprazolam

0 points

Question 20

  1. Melvin is an 89-year-old male who presents to the clinic with signs/symptoms consistent with MDD. Which of the following would be the LEAST appropriate medication to prescribe to this elderly patient?
a. nortriptyline
b. amitriptyline
c. desipramine
d. trazodone

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

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.

 

 

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).

 

List three questions you might ask the patient if she were in your office. Provide a rationale for why you might ask these questions.

 

 

I would ask the patient how long she has been taking the medication Sertraline, if her dose has ever been adjusted, and if she felt that it has helped her depression. The reason I am asking these questions is to determine if the medication is helping her depression and if it would benefit to increase them.

I would ask about medication adherence and educate about the importance of taking her medication as prescribed and not skipping dosage. Finding out if the patient is compliant with her medications can help determine the next step in treatment (Stern et al, 2015).

 

I would also ask about activities before sleep. For example, I would ask about activities such drinking alcohol beverages, or coffee before bed, smoking, exercising, and watching television. Since alcohol can reduce REM sleep and cause sleep disruptions, people who drink before bed often experience insomnia symptoms and feel excessively sleepy the following day.

 

. This patient may need some “calming” exercises and suggestions on how to decrease her brain’s state of arousal.

 

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.

            I would want to speak to this patient’s adult children if they are close to their mother and involved in her care.  I would ask if they have seen any changes in their mother recently and if they have any other input, concerns, or suggestions when it comes to their mother’s care.  I would also want to know if any of them or other family members has a history of insomnia.

 

List Explain what, if any, physical exams, and diagnostic tests would be appropriate for the patient and how the results would be used.

           

Since the patient is in her 70’s it is important I would get a CBC and a BMP to check for any abnormal labs and for baseline values. I would also draw endocine related labs. For example, cortisol, adrenocorticotropic hormone, melatonin, noradrenaline, γ-Aminobutyric acid, and calcium (Stern et al, 2015).

I would use the results of these labs to determine if the patient has any deficiencies or abnormalities that need treated that could be the cause of the patient’s insomnia.

I would also use the Hamilton or (DSM-5) depression scale with this patient to monitor the effects of the treatment on her depression symptoms.

 

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 would be insomnia associated with situational depression. The patient stated she lost her husband less than one year ago.  This patient is more than likely still grieving her husband’s death and is unable to sleep due to her current situation.

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 her depression I would start her on sertraline 50 mg daily, and then increase by 25 to 50 mg/day or the evening; may increase by 25 to 50 mg/day at intervals of at least 1 week to MAX 200 mg. Sertraline works by increasing the levels of a mood-enhancing chemical called serotonin in your brain. It helps many people recover from depression and has fewer unwanted side effects than older antidepressants (Stern et al, 2015).

 

I would also add trazadone for the insomnia, starting her at 25 mg at bedtime. The drug trazadone has been ‘approved for the treatment of depression, but the off-label use of this medication for insomnia has surpassed its usage as an antidepressant’ (McHorney et al,. 2019). Trazadone has reported sufficient sleep and has maintained sleep without causing daytime drowsiness (Stern et al, 2015).

 

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?

            some ethnicities are more prone to be carriers ‘of CYP2D6/CYP2C19 (cytochromes responsible for antidepressant metabolism)’ (Simon, 2017).  This can cause problems with the metabolism of antidepressants, which can cause a buildup of toxic levels in the neurological system.

 

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 choices.

I would want to see this patient back in the office in about two to three weeks in the office setting, she can also call the office if she has any questions. IT will also be a good idea to ask her to keep a log of her sleep schedule activity.

 

 

References

 

Balter, M. B., & Uhlenhuth, E. H. (2017). New epidemiologic findings about insomnia and its treatment. The Journal of clinical psychiatry. Vol 13.28 Pg 56-89.

 

McHorney, C. A., Ware Jr, J. E., & Raczek, A. E. (2019). The MOS 36-Item Short-Form Health Survey (SF-36): II. Psychometric and clinical tests of validity in measuring physical and mental health constructs. Medical care, 247-263.

Simon, G. E., & VonKorff, M. (2017). Prevalence, burden, and treatment of insomnia in primary care. American journal of psychiatry154(10), 1417-1423.

Stern, T. A., Fava, M., Wilens, T. E., & Rosenbaum, J. F. (2015). Massachusetts General hospital psychopharmacology and Neurotherapeutics E-book. Elsevier Health Sciences.

As we begin this session, I would like to take this opportunity to clarify my expectations for this course:

Please note that GCU Online weeks run from Thursday (Day 1) through Wednesday (Day 7).

 

Course Room Etiquette:

  • It is my expectation that all learners will respect the thoughts and ideas presented in the discussions.
  • All postings should be presented in a respectful, professional manner. Remember – different points of view add richness and depth to the course!

 

Office Hours:

  • My office hours vary so feel free to shoot me an email at Kelly.[email protected] or my office phone is 602.639.6517 and I will get back to you within one business day or as soon as possible.
  • Phone appointments can be scheduled as well. Send me an email and the best time to call you, along with your phone number to make an appointment.
  • I welcome all inquiries and questions as we spend this term together. My preference is that everyone utilizes the Questions to Instructor forum. In the event your question is of a personal nature, please feel free to post in the Individual Questions for Instructor forum I will respond to all posts or emails within 24 or sooner.

 

Late Policy and Grading Policy

Discussion questions:

  • I do not mark off for late DQ’s.
  •  I would rather you take the time to read the materials and respond to the DQ’s in a scholarly way, demonstrating your understanding of the materials.
  • I will not accept any DQ submissions after day 7, 11:59 PM (AZ Time) of the week.
  • Individual written assignments – due by 11:59 PM AZ Time Zone on the due dates indicated for each class deliverable.

Assignments:

  • Assignments turned in after their specified due dates are subject to a late penalty of -10%, each day late, of the available credit. Please refer to the student academic handbook and GCU policy.
  • Any activity or assignment submitted after the due date will be subject to GCU’s late policy
  • Extenuating circumstances may justify exceptions, which are at my sole discretion. If an extenuating circumstance should arise, please contact me privately as soon as possible.
  • No assignments can be accepted for grading after midnight on the final day of class.
  • All assignments will be graded in accordance with the Assignment Grading Rubrics

Participation

  • Participation in each week’s Discussion Board forum accounts for a large percentage of your final grade in this course.
  • Please review the Course Syllabus for a comprehensive overview of course deliverables and the value associated with each.
  • It is my expectation that each of you will substantially contribute to the course discussion forums and respond to the posts of at least three other learners.
  • substantive post should be at least 200 words. Responses such as “great posts” or “I agree” do not meet the active engagement expectation.
  • Please feel free to draw on personal examples as you develop your responses to the Discussion Questions but you do need to demonstrate your understanding of the materials.
  • I do expect outside sources as well as class materials to formulate your post.
  • APA format is not necessary for DQ responses, but I do expect a proper citation for references.
  • Please use peer-related journals found through the GCU library and/or class materials to formulate your answers. Do not try to “Google” DQ’s as I am looking for class materials and examples from the weekly materials.
  • will not accept responses that are from Wikipedia, Business dictionary.com, or other popular business websites. You will not receive credit for generic web searches – this does not demonstrate graduate-level research.
  • Stay away from the use of personal pronouns when writing. As a graduate student, you are expected to write based on research and gathering of facts. Demonstrating your understanding of the materials is what you will be graded on. You will be marked down for lack of evidence to support your ideas.

Plagiarism

  • Plagiarism is the act of claiming credit for another’s work, accomplishments, or ideas without appropriate acknowledgment of the source of the information by including in-text citations and references.
  • This course requires the utilization of APA format for all course deliverables as noted in the course syllabus.
  • Whether this happens deliberately or inadvertently, whenever plagiarism has occurred, you have committed a Code of Conduct violation.
  • Please review your LopesWrite report prior to final submission.
  • Every act of plagiarism, no matter the severity, must be reported to the GCU administration (this includes your DQ’s, posts to your peers, and your papers).

Plagiarism includes:

  • Representing the ideas, expressions, or materials of another without due credit.
  • Paraphrasing or condensing ideas from another person’s work without proper citation and referencing.
  • Failing to document direct quotations without proper citation and referencing.
  • Depending upon the amount, severity, and frequency of the plagiarism that is committed, students may receive in-class penalties that range from coaching (for a minor omission), -20% grade penalties for resubmission, or zero credit for a specific assignment. University-level penalties may also occur, including suspension or even expulsion from the University.
  • If you are at all uncertain about what constitutes plagiarism, you should review the resources available in the Student Success Center. Also, please review the University’s policies about plagiarism which are covered in more detail in the GCU Catalog and the Student Handbook.
  • We will be utilizing the GCU APA Style Guide 7th edition located in the Student Success Center > The Writing Center for all course deliverables.

LopesWrite

  • All course assignments must be uploaded to the specific Module Assignment Drop Box, and also submitted to LopesWrite every week.
  • Please ensure that your assignment is uploaded to both locations under the Assignments DropBox. Detailed instructions for using LopesWrite are located in the Student Success Center.

Assignment Submissions

  • Please note that Microsoft Office is the software requirement at GCU.
  • I can open Word files or any file that is saved with a .rtf (Rich Text Format) extension. I am unable to open .wps files.
  • If you are using a “.wps” word processor, please save your files using the .rtf extension that is available from the drop-down box before uploading your files to the Assignment Drop Box.

Grade of Incomplete

  • The final grade of Incomplete is granted at the discretion of the instructor; however, students must meet certain specific criteria before this grade accommodation is even possible to consider.
  • The grade of Incomplete is reserved for times when students experience a serious extenuating circumstance or a crisis during the last week of class which prevents the completion of course requirements before the close of the grading period. Students also must pass the course at the time the request is made.
  • Please contact me personally if you are having difficulties in meeting course requirements or class deadlines during our time together. In addition, if you are experiencing personal challenges or difficulties, it is best to contact the Academic Counselor so that you can discuss the options that might be available to you, as well as each option’s academic and financial repercussions.

Grade Disputes

  • If you have any questions about a grade you have earned on an individual assignment or activity, please get in touch with me personally for further clarification.
  • While I have made every attempt to grade you fairly, on occasion a misunderstanding may occur, so please allow me the opportunity to learn your perspective if you believe this has occurred. Together, we should be able to resolve grading issues on individual assignments.
  • However, after we have discussed individual assignments’ point scores, if you still believe that the final grade you have earned at the end of the course is not commensurate with the quality of work you produced for this class, there is a formal Grade Grievance procedure which is outlined in the GCU Catalog and Student Handbook.