WK7Example.pdf

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    Delusional Thought Processes

    Julie Thibeaux

    NURS6630-13

    Walden University

    July 19, 2021

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    Looking into the case this week, we are visited by a thirty-four-year-old woman of

    Pakistani descent. This woman just moved here from Pakistan in her teen years or early twenties.

    The patient expresses being married, one of which was arranged for her when she was only nine

    years old. She has recently been hospitalized for twenty-one days and was diagnosed with

    “brief” psychotic disorder. The patient explains she was given this diagnosis because her

    symptoms have persisted for less than a month. The patient’s husband has reported he was afraid

    to leave their children alone with the her because she was expressing visions of Allah while

    believing she was the prophet Mohammad who could heal the world from sin. When the patient

    showed signs of uncontrollable behavior the husband was forced to call the police on his wife

    which resulted in her admission to the psychiatric unit. During the assessment of the patient, she

    is quiet and calm, explaining that her husband has blown everything out of proportion. The

    patient strongly believes that her husband does not truly love her and wishes she were American.

    The reason she feels this way is because what she sees on television tells her so. She does report

    today she is in a good mood, denying hallucinations, but does believe Allah is sending messages

    through the television. There appears to be some hostility at times, but the patient manages to

    calm down. Previous lab work and assessment from previous physicians prove to be normal. She

    is alert, dressed appropriately and does not show any signs of hallucinations yet does appear to

    be listening to something. The patient does deny thoughts of harm to self or others. Lim et al.

    (2021) inform the positive and negative syndrome scale (PANSS) is a widely used 30-item

    clinician-rated instrument developed to provide comprehensive assessment of schizophrenia

    psychopathology. The goal for this patient is to achieve a pharmacotherapy level that is less than

    fifty percent in symptoms as demonstrated with the PANSS score within two months.

    Decision One

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    My first decision for this patient is to start her on Abilify 10mg orally at bedtime.

    Lertxundi et al. (2021) explains Abilify was the first dopamine 2 receptor partial agonist among

    antipsychotics and was approved by the food and drug administration (FDA) for the treatment of

    schizophrenia in 2002 and later approved for bipolar disorder. I chose this route first because I

    felt the patient would see results in symptoms as she suffers from psychotic episodes and the

    medication is only once at bedtime. The patient has expressed noncompliance before with

    medication as she was prescribed Risperdal in the past. The other two options were Zyprexa

    10mg orally at bedtime and Invega Sustenna 234mg intramuscular (IM) once then 156mg

    intramuscular on the fourth day and monthly thereafter. The reason I did not choose these two

    different options was because Zyprexa has been known to cause weight gain and this patient is a

    thirty-four-year-old woman, so weight is still a concern for her. Gautam et al. (2016) note of

    patients receiving Zyprexa, 66% had a weight gain of one to five pounds over a four-week

    period. For this reason, I would not recommend this first for my young female patient. The

    reason I did not choose the intramuscular injection was I would try all oral medications before

    giving a patient an IM injection. Injections should always be thought to give as a last resort only

    because patients do not usually want to stick themselves every day and with the dosing of

    Sustenna changing, for a patient who has already shown medication noncompliance, I would not

    start her on this first. I was hoping to achieve a 50% decrease in symptoms as well as an

    improved PANNS score. Ethical considerations would be to teach the patient and the husband

    about all medication options and possible side effects as well as the frequency of them to see

    what works for them allowing them autonomy.

    Decision Two

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    The client has returned for her four-week visit looking disheveled. When questioned the

    patient’s husband explains that she is not sleeping and is up and down all night, disrupting his

    sleep too. The patients PANSS score could not be completed as the patient continues to doze off

    asleep at her appointment and the appointment is not a productive one to assess the patient. My

    next decision is to discontinue the Abilify and start the patient on Geodon 40mg orally twice a

    day with meals. I chose to do this because when the patients husband expresses how the sleep

    habits have been, this is a side effect that is common with this medication and rather than

    continue the stress on the patient and her spouse, it is still early enough to try another medication

    without major effects from this medication will occur. The U.S. Food & Drug Administration

    (n.d.) inform to call a healthcare provider right away when there are symptoms of insomnia. The

    other two decisions included Abilify which is why I did not choose either due to the symptoms

    expressed by the spouse and the patient’s inability to complete her four-week assessment. By

    making this decision I was hoping to see actual improvement, even if in the slightest to know the

    patient is experiencing improved symptoms with her medication. Ethical considerations would

    be to continue to explain all medication options to the patient and inform the husband it is what

    the patient is comfortable with as she is the one whose autonomy is of concern, not his. While I

    want to help him with the patient, their marriage is separate from the patients individualized

    treatment and the patient comes first. With switching to Geodon, the patient has returned with a

    40% decrease in her PANSS score and improved symptoms. Her weight is also down but does

    complain that it is hard to remember her second dose and at times she is missing her second

    dose.

    Decision Three

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    I thought it best to change her Geodon dose to 80mg orally at bedtime while monitoring

    for breakthrough symptoms throughout the day. American Psychiatric Association (2019)

    informs the FDA has required that a warning about QT prolongation be included with product

    labeling for Geodon. With this, I would constantly monitor this with the patient, and I chose to

    continue the same medication and increasing the dose in order for the patient to take it once a

    day so that she would not forget to take a second dose. The patient has also shown signs of

    improvement so it would not be wise to just discontinue the medication when there can be

    adjustments made and monitor for more improvement for the patient. The other two selections

    were to discontinue Geodon and start Latuda and to give Risperdal. I would not choose to begin

    the patient on a medication where she has history of non-compliance so I would try other routes

    before going back to Risperdal, a medication she has not had compliance with. Miller et al.

    (2020) informs accumulating evidence has implicated insulin resistance and inflammation in the

    pathophysiology of cognitive impairments associated with neuropsychiatric disorders while on

    certain medications including Latuda. For this reason, I did not choose to switch a medication

    that is already showing improvement for the patient to another medication such as Latuda that

    could cause different side effects for the patient. I was hoping to achieve more improvement of

    symptoms while continuing Geodon, while also motivating the patient that continuing her

    medication and taking all doses, now especially that there is just one dose so that she can also see

    improvement in her treatment plan. Ethical considerations for this patient are to inform her of all

    the options, while encouraging her to remain on her treatment plan.

    Conclusion

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    When continuing to check on this patient at her four-week visits, the goal is to see a 50%

    decrease in her symptom shown by the PANSS score and her symptoms. I am confident in the

    decision to continue the Geodon once at bedtime as this can encourage the patient to continue to

    take her medication and not miss doses or not be compliant completely. I would continue to

    monitor this patient, especially since there are risks of non-compliance, side effects such as

    extrapyramidal, and GI issues. I would also continue speaking with the patient and evaluating her

    PANSS score while also speaking with her family who attends her appointments with her. It is

    important to note that while her spouse attends with her and appears supportive, the patient has

    expressed negative feelings toward him and their marriage so taking this into considerations is

    important. Switching the patients’ medications early in her treatment plan are ok, but when the

    patient has been on the medication for longer than two months that is when we could possibly

    see more negative side effects in this patient. Barnsteiner (2021) informs medication

    reconciliation is a formal process for creating the most complete an accurate list possible of a

    patient’s current medications and comparing the list to those in the patient record or medication

    orders. For this reason, it is important to speak with the patient about current medications,

    complete medication compliance, and what to look for once the medication Geodon is started.

    Ethical considerations are important to consider these patients beliefs, thought process, religion,

    and ethical background in order to find the best treatment plan for them. Speaking with the

    family is also important to understand the patients support system and teach them what to look

    for when they are home with the patient and when to call the physician.

    References

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    American Psychiatric Association. (2019). Practice guideline for the treatment of patients with

    schizophrenia. https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/Clinical

    %20Practice%20Guidelines/APA-Draft-Schizophrenia-Treatment-Guideline.pdf

    Barnsteiner, J. (2021). Medication reconciliation. Patient Safety and Quality: An Evidence-Based

    Handbook for Nurses.

    Gautam, S., Jain, S., & Bhargava, M. (2016). Weight gain with olanzapine: Drug, gender or age?

    Indian Journal of Psychiatry, 48(1), 39. https://doi.org/10.4103/0019-5545.31617

    Lertxundi, U., Hernandez, R., Medrano, J. (2021). Aripiprazole: Features and use in the aged.

    Assessments, Treatments and Modeling in Aging and Neurological Disease, 355-365.

    https://doi.org/10.1016/B978-0-12-818000-6.00032-9

    Lim, K., Peh, O.-H., Yang, Z., Rekhi, G., Rapisarda, A., See, Y.-M., Rashid, N. A., Ang, M.-S.,

    Lee, S.-A., Sim, K., Huang, H., Lencz, T., Lee, J., & Lam, M. (2020). Large-scale

    evaluation of the positive and negative syndrome scale (PANSS) symptom architecture in

    schizophrenia. https://doi.org/10.1101/2020.08.10.20170662

    Miller, B. J., Pikalov, A., Siu, C. O., Tocco, M., Tsai, J., Harvey, P. D., Newcomer, J. W., &

    Loebel, A. (2020). Association of C-reactive protein and metabolic risk with cognitive

    effects of lurasidone in patients with schizophrenia. Comprehensive Psychiatry, 102,

    152195. https://doi.org/10.1016/j.comppsych.2020.152195

    U.S. Food & Drug Administration. (n.d.). Drugs@FDA: FDA-approved drugs.

    https://www.accessdata.fda.gov/scripts/cder/daf/index.cfm

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