TREATMENT FOR A PATIENT WITH A COMMON CONDITION NURS 6630

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TREATMENT FOR A PATIENT WITH A COMMON CONDITION NURS 6630

 

A Sample Answer For the Assignment: TREATMENT FOR A PATIENT WITH A COMMON CONDITION NURS 6630

Title: TREATMENT FOR A PATIENT WITH A COMMON CONDITION NURS 6630

Discussion: Treatment for a Patient With a Common Condition 

Insomnia is one of the most common medical conditions you will encounter as a PMHNP. Insomnia is a common symptom of many mental illnesses, including anxiety, depression, schizophrenia, and ADHD (Abbott, 2016). Various studies have demonstrated the bidirectional relationship between insomnia and mental illness. In fact, about 50% of adults with insomnia have a mental health problem, while up to 90% of adults with depression experience sleep problems (Abbott, 2016). Due to the interconnected psychopathology, it is important that you, as the PMHNP, understand the importance of the effects some psychopharmacologic treatments may have on a patient’s mental health illness and their sleep patterns. Therefore, it is important that you understand and reflect on the evidence-based research in developing treatment plans to recommend proper sleep practices to your patients as well as recommend appropriate psychopharmacologic treatments for optimal health and well-being. 

Reference: Abbott, J. (2016). What’s the link between insomnia and mental illness? Health. https://www.sciencealert.com/what-exactly-is-the-link-between-insomnia-and-mental-illness#:~:text=Sleep%20problems%20such%20as%20insomnia%20are%20a%20common,bipolar%20disorder%2C%20and%20attention%20deficit%20hyperactivity%20disorder%20%28ADHD%29 

For this Discussion, review the case Learning Resources and the case study excerpt presented. Reflect on the case study excerpt and consider the therapy approaches you might take to assess, diagnose, and treat the patient’s health needs.   

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  

By Day 3 of Week 7 

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 ethical prescribing or decision-making. Discuss why the contraindication/alteration you identify exists. That is, what would be problematic with the use of this drug in individuals based on ethical prescribing guidelines or decision-making?  
  • 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.  

Read a selection of your colleagues’ responses. 

By Day 6 of Week 7 

Respond to at least two of your colleagues on two different days in one of the following ways: 

  • If your colleagues’ posts influenced your understanding of these concepts, be sure to share how and why. Include additional insights you gained. 
  • If you think your colleagues might have misunderstood these concepts, offer your alternative perspective and be sure to provide an explanation for them. Include resources to support your perspective.Read a selection of your colleagues’ responses and respond to at least two of your colleagues on two different days and 

Note: For this Discussion, you are required to complete your initial post before you will be able to view and respond to your colleagues’ postings. Begin by clicking on the “Post to Discussion Question” link and then select “Create Thread” to complete your initial post. Remember, once you click on Submit, you cannot delete or edit your own posts, and you cannot post anonymously. Please check your post carefully before clicking on Submit! 

MEREDITH 

Wk7 Discussion-Initial Post  

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Insomnia is defined as the inability to fall asleep or stay asleep. Aging as well as acute stressors are contributing to risk factors for insomnia. It is important to assess primary and secondary causes of insomnia to provide the most appropriate interventions.   

Three questions to ask include; 

  1. Prior sleep quality, quantity prior to death of her husband? This will provide a framework to evaluate the progression of sleep disturbances.   
  1. How many hours do you sleep on average per night? There are normative sleep changes that occur across lifespan such as shifts in circadian rhythms that occur in elderly which is important to differential from insomnia (Lavoie et al., 2018).   
  1. Compliance with medication and the time of day each are taken. The root cause of sleep disturbances can be impacted by the side effects of medications, medical comorbidities, and lifestyle habits such as daytime napping.   

To assess the patient’s situation further, it would be important to include other individuals who have an ongoing relationship with the patient. This may or may not include immediate relatives. It may be the neighbor who accompanied the patient to the appointment or religious members or paid or unpaid caregivers. It would be useful to ask the patient who she spends time with or is supportive to her.   

Additional questions to ask include; 

  • Any noticeable change in mood or attitude, such as sad, withdrawn?   
  • Any avoidance of interactions or socialization?  
  • Any observance of excessive daytime sleepiness?  

Subtle changes in mood and interaction may not be noticeable or significant for the patient to be aware of or report but may be observed by independent parties. It is important to establish which factor, whether depression or insomnia is responsible for the worsening symptoms which have a bi-directional relationship (Stone & Xiao, 2018).   

 

Physical and Diagnostic Examination 

Physical examination would be necessary to rule out pathological causes such as sleep disordered breathing (SDB), obstructive sleep apnea (OSA) nocturia, polyuria resulting in interrupted sleep. Non-pathological changes should also be assessed including sleep habits and physiological changes in sleep (Lavoie et al., 2018). Laboratory testing such as CBC, CMP, hormone levels (e.g., TSH (Thyroid Stimulating Hormone), Estrogen, cortisol, adrenocorticotropic, melatonin) which can detect imbalances that may lead to depression and insomnia.   

Other diagnostic evaluations would include depression assessment using tools such as Geriatric Depression Short Form (SGDS), Pittsburgh sleep quality index (PSQI)  

 or HAM-D which can evaluate both depression and anxiety and can serve as a baseline to evaluate effectiveness of treatment.   

Differential Diagnosis  

A differential diagnosis could be complicated grief which resulted in impairment of psychological functioning. Grieving is a normal following death and typically the indicators such as yearning, anger and depression peaks in six months after the death of a loved one, however in CG the symptoms are prolonged and mimic features of major depressive disorder (Nakajima, 2018). Losing a partner after 40 years of marriage can be challenging.   

Pharmacological Agents  

Different classes of drugs used to treat insomnia include orexin agonists, histamine receptor antagonists, non-benzodiazepine gamma aminobutyric acid receptor agonists, and benzodiazepines. Elderly patients are very sensitive to hypnotics and most drugs will lead to an increased risk of confusion, falls and sedation.   

Since the patient is taking a first-line antidepressant Sertraline 100mg, it would be crucial to determine the length of use and efficacy. Two pharmacological agents appropriate for the adjunct management of depression and insomnia would be zolpidem and melatonin.  

The first decision would be to add a hypnotic such as Zolpidem 5mg po at bedtime and re-evaluate the patient in 7-10 days (about 1 and a half weeks) for improvement in sleep quality. Patients will be educated on correct use and precautions to take since the medication leads to impairment in alertness and motor coordination.   

Non-FDA-approved hypnotic such as Melatonin shown to improve sleep onset and duration (Abad & Guilleminault, 2018). Melatonin 3mg po at bedtime is another option which provides safe and alternative therapy without comparable side effect profile. According to Pierce et al., (2019), in older adults a dose between 1mg-6mg of Melatonin appears to be effective.   

Ethical Prescribing and Follow-Up 

Elderly or debilitated patients may be especially sensitive to the effects of zolpidem tartrate and other hypnotics. It is important not to exceed the recommended dose or take several doses during the night. The use of Zolpidem is contraindicated in patients with severe hepatic impairment and may lead to encephalopathy.   

Initial follow up for sleep improvement following initiation of Zolpidem is within 10 days. If symptoms improve then the dose can be continued as short-term adjunct while antidepressant effectiveness is achieved. After 4 weeks of insomnia treatment, the dose of Sertraline can be reevaluated and potentially increased if necessary.   

  
 

 

References  

 

Abad, V. C., & Guilleminault, C. (2018). Insomnia in Elderly Patients: Recommendations for Pharmacological Management. Drugs & Aging, 35(9), 791–817. https://doi.org/10.1007/s40266-018-0569-8 

Lavoie, C. J., Zeidler, M. R., & Martin, J. L. (2018). Sleep and aging. Sleep Science and Practice, 2(1). https://doi.org/10.1186/s41606-018-0021-3 

Nakajima, S. (2018). Complicated grief: recent developments in diagnostic criteria and treatment. Philosophical Transactions of the Royal Society B: Biological Sciences, 373(1754), 20170273. https://doi.org/10.1098/rstb.2017.0273 

Pierce, M., Linnebur, S. A., Pearson, S. M., & Fixen, D. R. (2019). Optimal Melatonin Dose in Older Adults: A Clinical Review of the Literature. The Senior Care Pharmacist, 34(7), 419–431. https://doi.org/10.4140/TCP.n.2019.419 

Stone, K. L., & Xiao, Q. (2018). Impact of Poor Sleep on Physical and Mental Health in Older Women. Sleep Medicine Clinics, 13(3), 457–465. https://doi.org/10.1016/j.jsmc.2018.04.012 

HIGHLIGHTS OF PRESCRIBING INFORMATION. (n.d.). Retrieved July 14, 2022, from https://www.accessdata.fda.gov/drugsatfda_docs/label/2017/019908s038lbl.pdf 

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ANDREW 

Andrew Wargo – Main Post  

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Questions for Patient 

If I were the nurse practitioner dealing with the case study of the 75-year old widowed woman, this is how I would approach her treatment plan. Based upon the information provided, I assume the patient is suffering from insomnia due to depression. I would ask questions in the assessment like, are you having any thoughts of suicide or ever attempted suicide in the past? The main risk factors for suicidal death are becoming a widow/widower, having other mental disorders, physical illness, and bereavement (Conjero et al., 2018). Screening for suicide is one of the most important things during a psychiatric evaluation, even if they have previously denied suicidal thoughts or ideations. 

Have you changed your diet patterns, exercise, or taken any drugs/alcohol since your partner’s passing? This question is important in determining if the patient’s sleep patterns are being affected by something other than her mental health. The patient is on a plethora of medications for medical conditions and one/some of these medications could possibly be causing insomnia. Also, there are sometimes foods/drinks that people don’t know contain caffeine that they are consuming before bed, and it is interfering with their sleep.  The patient’s sleeping patterns, daily activities, and compliance with the current medication can have a significant impact on a patient’s mental health (Lechtzin et al., 2017). 

Do you have someone that you can talk to and socialize with on a consistent basis? This question is imperative to ensure the patient is safe and has someone else they can talk to and checks up on them. According to Kleiman & Liu (2013), having social support is associated with a decreased likelihood of a lifetime suicide attempt. 

Family and Friends 

As an older woman, who has a combination of comorbid conditions it is your responsibility to ensure the patient is safe. Getting feedback from close family or friends about the patient’s status can determine if the patient is capable of living alone or need assistance. There are a few questions I would ensure to ask her friends or family. Has the patient been keeping up with her hygiene? Have you noticed any significant weight gain or loss? Have you noticed any changes in the patient since her husband passed away? Can the patient independently perform all her daily activities of living? Asking these questions gets honest feedback from a third party because sometimes patients will not tell the truth in order to protect their liberties. Older people especially do not want to admit they need help, so having trusted friends and family’s opinions can prove worthwhile. Also, you do want to make sure the lady has someone who is checking up on her and noticing her health changes. 

Diagnostic Tests 

Diagnostic tests in this case study I would include would be a sleep study, including polysomnography. This monitors brain wave activity, heart and breathing rates, oxygen levels, and muscle movements that occur prior to, during, and after sleep. Another important test to run is a sleep apnea test. This is a study to measure your vitals during your sleep, specifically checking for a drop in oxygen levels during sleep. Other diagnostic tests to run would be blood tests like TSH, CBC, and CMP. These tests can help determine if there are other underlying medical conditions that may be inhibiting her sleep. I also would have the patient fill out the HAM-D. Also called the Hamilton Depression Rating Scale, this is a multiple-item questionnaire used to provide an indication of depression, and as a guide to evaluate recovery. 

Differential Diagnoses  

A possible differential diagnosis is sleep apnea. Sleep apnea is a sleep disorder where breathing is interrupted repeatedly during sleep, causing the person to constantly awaken. Sleep apnea can also be caused a drug, the patient is on a plethora of medications. If the insomnia is not caused by depression and anxiety then I would say that sleep apnea is the most likely differential diagnosis. Another differential diagnosis is restless legs syndrome. Although, restless legs syndrome is a common cause of insomnia, most patients will report that their legs are uncomfortable and the urge to move them does not stop during nighttime. Restless legs syndrome can be the side effect of medications and an effect from conditions like high blood pressure or diabetes. 

Possible Medications 

I would recommend the patient begin on 50 mg Trazodone PO at bedtime. I would choose the medication because it is an effective antidepressant that is also used for insomnia. Trazodone acts by binding at the 5-HT2 receptor and acts as a serotonin agonist at high doses. At low doses, it acts as a serotonin antagonist. The activity is likely to result from reuptake by inhibiting the serotonin reuptake pump at the presynaptic neuronal membrane. The prolonged usage of trazodone may affect postsynaptic neuronal receptor binding sites and cause a sedative effect resulting from modest histamine blockade and adrenergic blocking action at the H1 receptor (Yi et al., 2018). The initial dosage is 150 mg daily in divided doses and increased after four days to 200 mg daily. 

Another medication therapy that could be used is Eszopiclone 3 mg PO at bedtime. Sold under the brand name Lunesta, the medication is used to treat insomnia. The medication interacts with GABA receptor complexes at the binding domains allosterically coupled close to benzodiazepine receptors (Brielmaier, 2006). I would prefer starting this patient on Trazodone 50 mg PO at bedtime, over the Lunesta because trazodone’s mechanism of action is aimed at increasing serotonin, which aids in depression and insomnia. 

Ethics and Contraindications 

With any medication comes contraindications. Contraindications of trazodone include glaucoma because the drug has the potential to increase intraocular pressure leading to the deterioration of vision. Trazodone is also contraindicated in people with liver disease because the drug is mainly metabolized in the liver. If the liver function is compromised, then the pharmacokinetics of the drug on the body could be slowed down. This leads to the slower metabolism of the drug resulting in the diminished therapeutic effects of the medication. Another contraindication is renal disease because trazodone is significantly eliminated by the kidneys, in urine. Individuals with renal disease and diminished renal function cannot eliminate trazodone normally, which allows the medication to be in the bloodstream longer, thus increasing the risk for side effects and toxicity with medication. Because the patient is elderly the drug may be eliminated slower, so it is ethical to prescribe the smallest possible dose first to see how the patient reacts. The elderly are at increased risk of side effects of medications due to 

Follow-Ups 

Follow-up appointments are very important to see how the patient is tolerating the medication along with its effectiveness in treating the patient’s symptoms. Things to screen for include side effects including hypertension/hypotension, dizziness, weight gain, and confusion. The patient is also prescribed sertraline 100 mg, which combined with trazodone can increase the chance of serotonin syndrome. Recognizing signs of serotonin syndrome like restlessness, insomnia, confusion, and increased HR and BP is important. It is a possibility that I would have to make therapeutic changes based on the patient’s response. Increasing the medication to 100 mg daily is a possibility if the medication does not seem to be strong enough for her depression or insomnia. The 50 mg is a good starting dose to test for any possible side effects the patient might exhibit. I would include all these “check points” at week 4, 8, 12, etc.). 

References 

Brielmaier, B. (2006). Eszopiclone (Lunesta): a new nonbenzodiazepine hypnotic agent. Proc (Bayl Univ Med Cent). 2006 Jan;19(1):54-9. doi: 10.1080/08998280.2006.11928127. PMID: 16424933; PMCID: PMC1325284. 

Conejero I, Olié E, Courtet P, & Calati R. (2018). Suicide in older adults: current perspectives. Clin Interv Aging. 2018 Apr 20;13:691-699. doi: 10.2147/CIA.S130670. PMID: 29719381; PMCID: PMC5916258. 

Kleiman EM, Liu RT. Social support as a protective factor in suicide: findings from two nationally representative samples. J Affect Disord. 2013 Sep 5;150(2):540-5. doi: 10.1016/j.jad.2013.01.033. Epub 2013 Mar 5. PMID: 23466401; PMCID: PMC3683363. 

Lechtzin, N., Mayer-Hamblett, N., West, N. E., Allgood, S., Wilhelm, E., Khan, U., & Aitken, M. L. (2017). Home monitoring of patients with cystic fibrosis to identify and treat acute pulmonary exacerbations eICE study results. American Journal of Respiratory and Critical Care Medicine, 196(9), 1144-1151. https://doi.org/10.1164/rccm.201610-2172OC 

Levenson, J. C., Kay, D., & Buysse, D. (2015). The pathophysiology of insomnia. Chest, 147(4), 1179-1192. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4388122/ 

Yi, X., Ni, S., Ghadami, M., & Meng, H. (2018). Trazodone for the treatment of insomnia: a meta-analysis of randomized placebo-controlled trials. Sleep Medicine, 45, 25-32. https://doi.org/10.1016/j.sleep.2018.01.01 

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

Do you drink caffeinated drinks? If yes, how many do your drink a day and at what time?

Rationale: Caffeine is a stimulant. Individuals who drink caffeine during the day cause a reduction in 6-sulfatoxymelatonin (the main metabolite of melatonin) at night, which leads to sleep disturbance (O’Callaghan et al., 2018). The lack of sleep affects cognitive functioning and psychomotor response (O’Callaghan et al., 2018).

How many hours of sleep are you getting each night?

Rationale: According to Levenson et al., when a person is living with unpleasant thoughts or worrying excessively, it can lead to sleep disturbances (2015). The decreased sleep can cause the person to worry about not getting enough sleep, leading to more anxiety and insomnia (Levenson et al., 2015).

Have you had any feelings of depression, hopelessness, or feeling down in the past month?

Rationale: Individuals who have suffered a significant loss are at high risk for depression. Individuals with depression often experience insomnia. This question is one of two that can be used to assess a patient for depression and determine if further treatment is warranted (Assessment of Depression in Adults in Primary Care, 2020). The patient’s husband died ten months ago in the given scenario. If the patient responds positively to this question, it is critical to also assess for suicide risk.

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.

It would be important to gain information from outside sources such as family, friends, and caretakers familiar with the patient’s daily life. If possible, individuals who have been around the patient from before her husband passed until now. You could ask the patient how she got to the appointment and if someone brought her, you could ask if she would be OK with you speaking with them. There are several questions you could ask.

Have you noticed a change in her interest in doing things?

Have you she seemed down or hopeless?

How has she been eating?

Do you know if she is taking her medications or noticed any side effects from her medications?

Have you noticed any anxiety or changes in memory?

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

Upon the initial interview, it is possible to screen the patient for depression. There are several ways this can be done. Practitioners can

TREATMENT FOR A PATIENT WITH A COMMON CONDITION NURS 6630
TREATMENT FOR A PATIENT WITH A COMMON CONDITION NURS 6630

use the Mini-Mental State Exam MMSE), Geriatric Depression Scale Short Form (SGDS), or the Cornell Scale for Depression in Dementia (CSDD) (Brown et al., 2015). It is important to note that older adults with depression can also have dementia, so screening for dementia would also be important (Brown et al., 2015). The CSDD can detect depression in individuals with cognitive impairment. The SGDS is used because it is fairly easy and short and can detect depression in older adults (Brown et al., 2015). Laboratory testing is also important as many organic illnesses can lead to insomnia and depression. Baseline lab work should include glucose, liver function, complete blood count, Erythrocyte Sedimentation Rate, urea, creatinine, electrolytes, B-12, and Iron studies.

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List a differential diagnosis for the patient. Identify the one that you think is most likely and explain why.

A differential diagnosis for depression in an elderly patient could be Vascular Depression. It is found in adults over 60 years of age and with no prior history of depression (Small, 2009). It can be found in patients with hypertension or a history of vascular disease believed to cause inflammation within the vascular system leading to the release of cytokines, especially after a stressful event (Jeon & Kim, 2018). When reviewing the patient’s medications, she is taking bother Losartan and hydrochlorothiazide to manage her hypertension, so the differential diagnosis of Vascular Depression is possible.

List two pharmacologic agents and their dosing that would be appropriate for the patient’s anti-depressant 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.

The patient is currently taking Sertraline 100mg daily. If the patient takes the medication as prescribed, the patient should see improvement in depressive symptoms. The scenario does not state how long the patient has been taking Sertraline. One side effect of SSRIs is that they can cause insomnia. At this time, it is appropriate to consider augmenting the Sertraline with a low dose TCA like trazodone. Research suggests that short-term use of a TCA can improve sleep as soon as the first dose (Wichniak et al., 2017). It is important to remember that when the patient’s depression symptoms improve, the TCA should be lowered or discontinued because it can cause oversedation (Wichniak et al., 2017).

Sertraline makes it difficult to keep blood sugar stable. It can also be recommended to switch the anti-depressant to Bupropion. Studies have shown that in patients with diabetes, burproprione successfully treats depression and controls blood sugar levels (Darwish et al., 2018). It would be necessary to monitor the patient’s blood pressure as bupropion can elevate blood pressure (Darwish et al., 2018).

For the drug therapy, you select, identify any contraindications to use or alterations in dosing that may need to be considered based on ethical prescribing or decision-making. Discuss why the contraindication/alteration you identify exists. That is, what would be problematic with the use of this drug in individuals based on ethical prescribing guidelines or decision-making?

Sertraline is contraindicated in patients taking thioridazine, pimozide, or monoamine oxidase inhibitors, including linezolid or methylene blue, and it should not be taken with other serotonergic medications (Singh & Saadabad, 2020). Buspirone is contradicted in patients with kidney and liver disease as the drug’s effects may increase due to slow kidney or liver removal. Trazadone is contraindicated for anyone taking an MAOI or has taken an MAOI in the past 14 days (Shin & Saadabadi, 2020).

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.

It would be necessary to follow up with the patient in four weeks to see if adding Trazadone improves the patient’s sleep. If there is no improvement in the patient’s sleep or depressive symptoms, it would be time to consider changing the patient’s medication to buspirone.

TREATMENT FOR A PATIENT WITH A COMMON CONDITION NURS 6630 References

Assessment of depression in adults in primary care [PDF]. (2020). Best Practice Medicine Journal New Zealand. https://bpac.org.nz/magazine/2009/Adultdep/docs/bpjse_adult_dep_assess_pages8- 12.pdf

Brown, E., Raue, P. J., & Halpert, K. (2015). Evidence-based practice guideline: Depression detection in older adults with dementia. Journal of Gerontological Nursing, 41(11), 15– 21. https://doi.org/10.3928/00989134-20151015-03

Darwish, L., Beroncal, E., Sison, M., & Swardfager, W. (2018). Depression in people with type 2 diabetes: Current perspectives. Diabetes, Metabolic Syndrome and Obesity: Targets and Therapy, Volume 11, 333–343. https://doi.org/10.2147/dmso.s106797

Jeon, S., & Kim, Y.-K. (2018). The role of neuroinflammation and neurovascular dysfunction in major depressive disorder. Journal of Inflammation Research, Volume 11, 179–192. https://doi.org/10.2147/jir.s141033

Levenson, J. C., Kay, D. B., & Buysse, D. J. (2015). The pathophysiology of insomnia. Chest, 147(4), 1179–1192. https://doi.org/10.1378/chest.14-1617

O’Callaghan, F., Muurlink, O., & Reid, N. (2018). Effects of caffeine on sleep quality and daytime functioning. Risk Management and Healthcare Policy, Volume 11, 263–271. https://doi.org/10.2147/rmhp.s156404

Park, L. T., & Zarate, C. A. (2019). Depression in the primary care setting. New England Journal of Medicine, 380(6), 559–568.https://doi.org/10.1056/nejmcp1712493

Shin, J., & Saadabadi, A. (2020). Trazadone. StatPearls. https://doi.org/https://www.ncbi.nlm.nih.gov/books/NBK470560/

Singh, H. K., & Saadabad, A. (2020). Sertraline. StatPearls. https://doi.org/https://www.ncbi.nlm.nih.gov/books/NBK547689/

Small, G. W. (2009). Differential diagnoses and assessment of depression in elderly patients. The Journal of Clinical Psychiatry, 70(12), e47. https://doi.org/10.4088/jcp.8001tx20c

Wichniak, A., Wierzbicka, A., Walęcka, M., & Jernajczyk, W. (2017). Effects of antidepressants on sleep. Current Psychiatry Reports, 19(9). https://doi.org/10.1007/s11920-017-0816-4

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).

TREATMENT FOR A PATIENT WITH A COMMON CONDITION NURS 6630 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 research10(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 metabolism16 Suppl 1(Suppl1), S63–S64. https://doi.org/10.4103/2230-8210.94262

 

TREATMENT FOR A PATIENT WITH A COMMON CONDITION NURS 6630 Grading Rubric

Performance Category 100% or highest level of performance

100%

16 points

Very good or high level of performance

88%

14 points

Acceptable level of performance

81%

13 points

Inadequate demonstration of expectations

68%

11 points

Deficient level of performance

56%

9 points

 

Failing level

of performance

55% or less

0 points

 Total Points Possible= 50           16 Points    14 Points 13 Points        11 Points           9 Points          0 Points
Scholarliness

Demonstrates achievement of scholarly inquiry for professional and academic topics.

Presentation of information was exceptional and included all of the following elements:

  • Provides evidence of scholarly inquiry relevant to required TD topic(s).
  • Presents specific information from scholarly sources to develop a comprehensive presentation of facts.
  • Uses at least one outside scholarly reference that is relevant, less than 5 years old (use of older references requires instructor permission) and reliable for the required topic.*
  • Uses in-text citation and full reference at end of posting when presenting another person’s thoughts as quotes or paraphrase of information.
Presentation of information was good, but was superficial in places and included all of the following elements:

  • Provides evidence of scholarly inquiry relevant to required TD topic(s).
  • Presents specific information from scholarly sources to develop a comprehensive presentation of facts.
  • Uses at least one outside scholarly reference that is relevant, less than 5 years old (use of older references requires instructor permission) and reliable for the required topic.*
  • Uses in-text citation and full reference at end of posting when presenting another person’s thoughts as quotes or paraphrase of information.
Presentation of information was minimally demonstrated in all of the following elements:

  • Provides evidence of scholarly inquiry relevant to required TD topic(s).
  • Presents specific information from scholarly sources to develop a comprehensive presentation of facts.
  • Uses at least one outside scholarly reference that is relevant, less than 5 years old (use of older references requires instructor permission) and reliable for the required topic.*
  • Uses in-text citation and full reference at end of posting when presenting another person’s thoughts as quotes or paraphrase of information.
 

Presentation of information is unsatisfactory in one of the following elements:

  • Provides evidence of scholarly inquiry relevant to required TD topic(s).
  • Presents specific information from scholarly sources to develop a comprehensive presentation of facts.
  • Uses at least one outside scholarly reference that is relevant, less than 5 years old (use of older references requires instructor permission) and reliable for the required topic.*
  • Uses in-text citation and full reference at end of posting when presenting another person’s thoughts as quotes or paraphrase of information.
 

Presentation of information is unsatisfactory in two of the following elements:

  • Provides evidence of scholarly inquiry relevant to required TD topic(s).
  • Presents specific information from scholarly sources to develop a comprehensive presentation of facts.
  • Uses at least one outside scholarly reference that is relevant, less than 5 years old (use of older references requires instructor permission) and reliable for the required topic.*
  • Uses in-text citation and full reference at end of posting when presenting another person’s thoughts as quotes or paraphrase of information.
Presentation of information is unsatisfactory in three or more of the following elements

  • Provides evidence of scholarly inquiry relevant to required TD topic(s).
  • Presents specific information from scholarly sources to develop a comprehensive presentation of facts.
  • Uses at least one outside scholarly reference that is relevant, less than 5 years old (use of older references requires instructor permission) and reliable for the required topic.*
  • Uses in-text citation and full reference at end of posting when presenting another person’s thoughts as quotes or paraphrase of information
 16 Points  14 Points  13 Points 11 Points 9 Points  0 Points
Application of Course Knowledge

Demonstrate the ability to analyze and apply principles, knowledge and information learned in the outside readings and relate them to real-life professional situations

Presentation of information was exceptional and included all of the following elements:

  • Applies principles, knowledge and information from scholarly resources to the required topic.
  • Applies facts, principles or concepts learned from scholarly resources to a professional experience.
  • Application of information is comprehensive and specific to the required topic.
Presentation of information was good, but was superficial in places and included all of the following elements:

  • Applies principles, knowledge and information from scholarly resources to the required topic.
  • Applies facts, principles or concepts learned from scholarly resources to a professional experience.
  • Application of information is comprehensive and specific to the required topic.
Presentation of information was minimally demonstrated in the all of the following elements:

  • Applies principles, knowledge and information from scholarly resources to the required topic.
  • Applies facts, principles or concepts learned from scholarly resources to a professional experience.
  • Application of information is comprehensive and specific to the required topic.
Presentation of information is unsatisfactory in one of the following elements:

  • Applies principles, knowledge and information from scholarly resources to the required topic.
  • Applies facts, principles or concepts learned from and scholarly resources to a professional experience.
  • Application of information is comprehensive and specific to the required topic.
Presentation of information is unsatisfactory in two of the following elements:

  • Applies principles, knowledge and information from scholarly resources to the required topic.
  • Applies facts, principles or concepts learned from scholarly resources to a professional experience.
  • Application of information is comprehensive and specific to the required topic.
Presentation of information is unsatisfactory in three of the following elements

  • Applies principles, knowledge and information and scholarly resources to the required topic.
  • Applies facts, principles or concepts learned scholarly resources to a professional experience.
  • Application of information is comprehensive and specific to the required topic.
   10 Points 9 Points  6 Points  0 Points
Interactive Dialogue

Initial post should be a minimum of 300 words (references do not count toward word count)

The peer and instructor responses must be a minimum of 150 words each (references do not count toward word count)

Responses are substantive and relate to the topic.

Demonstrated all of the following:

  • Initial post must be a minimum of 300 words.
  • The peer and instructor responses must be a minimum of 150 words each.
  • Responses are substantive
  • Responses are related to the topic of discussion.
Demonstrated 3 of the following:

  • Initial post must be a minimum of 300 words.
  • The peer and instructor responses must be a minimum of 150 words each.
  • Responses are substantive
  • Responses are related to the topic of discussion.
Demonstrated 2 of the following:

  • Initial post must be a minimum of 300 words.
  • The peer and instructor responses must be a minimum of 150 words each.
  • Responses are substantive
  • Responses are related to the topic of discussion.
Demonstrated 1 or less of the following:

  • Initial post must be a minimum of 300 words.
  • The peer and instructor responses must be a minimum of 150 words each.
  • Responses are substantive
  • Responses are related to the topic of discussion.
  8 Points 7 Points  6 Points         5 Points          4 Points  0 Points
Grammar, Syntax, APA

Points deducted for improper grammar, syntax and APA style of writing.

The source of information is the APA Manual 6th Edition

Error is defined to be a unique APA error. Same type of error is only counted as one error.

The following was present:

  • 0-3 errors in APA format

AND

  • Responses have 0-3 grammatical, spelling or punctuation errors

AND

  • Writing style is generally clear, focused on topic,and facilitates communication.
The following was present:

  • 4-6 errors in APA format.

AND/OR

  • Responses have 4-5 grammatical, spelling or punctuation errors

AND/OR

  • Writing style is somewhat focused on topic.
The following was present:

  • 7-9 errors in APA format.

AND/OR

  • Responses have 6-7 grammatical, spelling or punctuation errors

AND/OR

  • Writing style is slightly focused on topic making discussion difficult to understand.
 

The following was present:

  • 10- 12 errors in APA format

AND/OR

  • Responses have 8-9 grammatical, spelling and punctuation errors

AND/OR

  • Writing style is not focused on topic, making discussion difficult to understand.
 

The following was present:

  • 13 – 15 errors in APA format

AND/OR

  • Responses have 8-10 grammatical, spelling or punctuation errors

AND/OR

  • Writing style is not focused on topic, making discussion difficult to understand.

AND/OR

  • The student continues to make repeated mistakes in any of the above areas after written correction by the instructor.
The following was present:

  • 16 to greater errors in APA format.

AND/OR

  • Responses have more than 10 grammatical, spelling or punctuation errors.

AND/OR

  • Writing style does not facilitate communication
  0 Points Deducted 5 Points Lost
Participation

Requirements

Demonstrated the following:

  • Initial, peer, and faculty postings were made on 3 separate days
Failed to demonstrate the following:

  • Initial, peer, and faculty postings were made on 3 separate days
  0 Points Lost 5 Points Lost
Due Date Requirements Demonstrated all of the following:

  • The initial posting to the graded threaded discussion topic is posted within the course no later than Wednesday, 11:59 pm MT.

A minimum of one peer and one instructor responses are to be posted within the course no later than Sunday, 11:59 pm MT.

Demonstrates one or less of the following.

  • The initial posting to the graded threaded discussion topic is posted within the course no later than Wednesday, 11:59 pm MT.

A minimum of one peer and one instructor responses are to be posted within the course no later than Sunday, 11:59 pm MT.