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- QUESTION
Examine Case Study: Pakistani Woman with Delusional Thought Processes. You will be asked to make three decisions concerning the medication to prescribe to this client. Be sure to consider factors that might impact the client’s pharmacokinetic and pharmacodynamic processes.
Decision #1
Which decision did you select?
Why did you select this decision? Support your response with evidence and references to the Learning Resources.
What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
Explain any difference between what you expected to achieve with Decision #1 and the results of the decision. Why were they different?
Decision #2
Why did you select this decision? Support your response with evidence and references to the Learning Resources.
What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
Explain any difference between what you expected to achieve with Decision #2 and the results of the decision. Why were they different?
Decision #3
Why did you select this decision? Support your response with evidence and references to the Learning Resources.
What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
Explain any difference between what you expected to achieve with Decision #3 and the results of the decision. Why were they different?
Also include how ethical considerations might impact your treatment plan and communication with clients.
Finally: 1. Complete the decision tree (keep track of what you selected. come up with a rational reason why you chose it. Come up with patient specific rational reason behind not choosing the other two options not chosen).2. Write paper addressing all section listed based on the decision tree.
Case Study: Pakistani Woman with Delusional Thought Processes:
BACKGROUND
The client is a 34-year-old Pakistani female who moved to the United States in her late teens/early 20s. She is currently in an “arranged” marriage (her husband was selected for her since she was 9 years old). She presents to your office today following a 21 day hospitalization for what was diagnosed as “brief psychotic disorder.” She was given this diagnosis as her symptoms have persisted for less than 1 month.
Prior to admission, she was reporting visions of Allah, and over the course of a week, she believed that she was the prophet Mohammad. She believed that she would deliver the world from sin. Her husband became concerned about her behavior to the point that he was afraid of leaving their 4 children with her. One evening, she was “out of control” which resulted in his calling the police and her subsequent admission to an inpatient psych unit.
During today’s assessment, she appears quite calm, and insists that the entire incident was “blown out of proportion.” She denies that she believed herself to be the prophet Mohammad and states that her husband was just out to get her because he never loved her and wanted an “American wife” instead of her. She tells you that she knows this because the television is telling her so.
She currently weighs 140 lbs, and is 5’ 5”SUBJECTIVE
Client reports that her mood is “good.” She denies auditory/visual hallucinations, but believes that the television does talk to her. She believes that Allah sends her messages through the TV. At times throughout the clinical interview, she becomes hostile towards the PMHNP, but then calms down.
You reviewed her hospital records and find that she has been medically worked up by a physician who reported her to be in overall good health. Lab studies were all within normal limits.
Client admits that she stopped taking her Risperdal about a week after she got out of the hospital because she thinks her husband is going to poison her so that he can marry an American woman.MENTAL STATUS EXAM
The client is alert, oriented to person, place, time, and event. She is dressed appropriately for the weather and time of year. She demonstrates no noteworthy mannerisms, gestures, or tics. Her speech is slow and at times, interrupted by periods of silence. Self-reported mood is euthymic. Affect constricted. Although the client denies visual or auditory hallucinations, she appears to be “listening” to something. Delusional and paranoid thought processes as described, above. Insight and judgment are impaired. She is currently denying suicidal or homicidal ideation.
The PMHNP administers the PANSS which reveals the following scores:
-40 for the positive symptoms scale
-20 for the negative symptom scale
-60 for general psychopathology scaleDiagnosis:
Schizophrenia, paranoid typeDecisions Made and Outcomes (Needed to formulate the paper)
Choices for Decision 1: Select what the PMHNP should do:
1. Start Zyprexa 10 mg orally at BEDTIME
2. Start Invega Sustenna 234 mg intramuscular X1 followed by 156 mg intramuscular on day 4 and monthly thereafter
3. Start Abilify 10 mg orally at BEDTIME
4.My decision 1
Outcome: RESULTS OF DECISION POINT ONE:
• Client returns to clinic in four weeks
• A decrease in PANSS score of 25% is noted at this visit
• Client seems to be tolerating medication
• Client's husband has made sure she makes her appointments for injections (one thus far)
• Client has noted a 2 pound weight gain but it does not seem to be an important point for her
• Client complains of injection site pain telling the PMHNP that she has trouble siting for a few hours after the injections and doesn’t like having to walk around for such a long period of timeChoices for Decision 2: Select what the PMHNP should do:
1. Continue same decision made but instruct administering nurse to begin injections into the deltoid at this visit and moving forward
2. Discontinue Invega Sustenna and start Haldol Decanoate (haloperidol decanoate ) 50 mg IM q2weeks with oral Haldol 5 mg BID for the next 3 months
3. Continue Invega Sustenna. Begin injections into the deltoid and add on Abilify Maintena 300 mg intramuscular monthly with oral Abilify 10 mg in the MORNING for 2 weeks
4.My decision 2
Outcome: RESULTS OF DECISION POINT TWO:
• Client returns to clinic in four weeks
• Client's PANNS has reduced by a total of 50% from the initiation of Invega sustenna
• When questioned about injection site pain, client states it is much better in the arm
• Client's weight has increased by an additional 2.5 pounds (total of 4.5 pounds in a 2 month period). She is somewhat bothered by the weight gain and is afraid that her husband does not like it. He is not present at this visit as she brought herself
• Client likes how she feels on the Invega Sustenna but is wondering if there is another drug like it that would not cause the weight gainChoices for Decision 3: Decision Point Three Select what the PMHNP should do next:
1. Continue with the Invega Sustenna. Counsel client on the fact that weight gain from Invega Sustenna is not as much as what other drugs with similar efficacy can cause. Make appointment with a dietician and an exercise physiologist. Follow up in one month
2. Discontinue Invega Sustenna and start Abilify Maintenna 400 mg IM monthly (after a few test doses of Abilify oral have been tried and tolerated) with overlapping oral abilify 10 mg orally in the MORNING
3. Continue Invega sustenna and add-on Qsymia for weight lossDecision 3
Outcome: Guidance to Student
RESULT FROM CHOOSING TO CONTINUE INVEGA AND INCLUDE DIETICIAN AND AN EXERCISE PHYSIOLOGIST:
Guidance to Student
Weight gain can occur with Invega Sustenna. It is modest in nature and can be controlled with proper nutrition and exercise. It is always a good idea to try and control a client’s weight through consultation with a dietician and exercise physiologist (life coach) before switching to another agent when a product is showing efficacy for at least 6 months.Abilify Maintena is a good option for someone who has good response to abilify oral. Remember that Abilify does not bind to the D2 receptor for a great period of time (such as Invega) and can be less affective in certain individuals. Also, remember that akathisia can be a possible side effect. Once an IM long acting medication is given, the effects of the drug (both efficacious and untoward effects) can be maintained for a long duration (up to a month or longer). Tolerability and efficacy should be established with oral medication first before administering the first injection. Also a disadvantage to Abilify Maintena is a 2-week overlap of oral therapy is required due to effective blood levels lagging behind the induction dose.
Qsymia is a weight loss medication that is a combination of Phenteramine and Topiramate. It is only indicated to treat obesity. This client’s BMI (28.9 kg/M2) does not fit the definition of obesity (BMI >30 Kg/M2- Following from CDC website: Class 1: BMI of 30 to < 35, Class 2: BMI of 35 to < 40, Class 3: BMI of 40 or higher. Class 3 obesity is sometimes categorized as “extreme” or “severe” obesity). There are two things wrong with this therapy option. First, there are only a few occasions where add-on therapy to treat a side effect is acceptable and weight gain is not one of those scenarios. Secondly, Phenteramine has a lot of cardiovascular toxicities (such as elevated BP, HR, increased workload on the heart).
RUBICS
Quality of Work Submitted:
The extent of which work meets the assigned criteria and work reflects graduate level critical and analytic thinking. 27 (27%) - 30 (30%)
Assignment exceedsexpectations. All topics are addressed with a minimum of 75% containing exceptional breadth and depth about each of the assignment topics.
Quality of Work Submitted:
The purpose of the paper is clear. 5 (5%) - 5 (5%)
A clear and comprehensive purpose statement is provided which delineates all required criteria.
Assimilation and Synthesis of Ideas:
The extent to which the work reflects the student's ability to:Understand and interpret the assignment's key concepts. 9 (9%) - 10 (10%)
Demonstrates the ability to critically appraise and intellectually explore key concepts.
Assimilation and Synthesis of Ideas:
The extent to which the work reflects the student's ability to:Apply and integrate material in course resources (i.e. video, required readings, and textbook) and credible outside resources. 18 (18%) - 20 (20%)
Demonstrates and applies exceptional support of major points and integrates 2 or more credible outside sources, in addition to 2-3 course resources to suppport point of view.
Assimilation and Synthesis of Ideas:
The extent to which the work reflects the student's ability to:Synthesize (combines various components or different ideas into a new whole) material in course resources (i.e. video, required readings, textbook) and outside, credible resources by comparing different points of view and highlighting similarities, differences, and connections. 18 (18%) - 20 (20%)
Synthesizes and justifies (defends, explains, validates, confirms) information gleaned from sources to support major points presented. Applies meaning to the field of advanced nursing practice.
Written Expression and FormattingParagraph and Sentence Structure: Paragraphs make clear points that support well developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are clearly structured and carefully focused--neither long and rambling nor short and lacking substance. 5 (5%) - 5 (5%)
Paragraphs and sentences follow writing standards for structure, flow, continuity and clarity
Written Expression and FormattingEnglish writing standards: Correct grammar, mechanics, and proper punctuation 5 (5%) - 5 (5%)
Uses correct grammar, spelling, and punctuation with no errors.
Written Expression and FormattingThe paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, running head, parenthetical/in-text citations, and reference list. 5 (5%) - 5 (5%)
Uses correct APA format with no errors.
| Subject | Nursing | Pages | 7 | Style | APA |
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Answer
Pakistani Woman with Delusional Thought Processes
Decision 1 was to start Zyprexa 10mg orally at bedtime. Zyprexa was selected for treatment of schizophrenia and/or mixed or manic episodes of bipolar disorder. It is atypical antipsychotic that is similar to clozapine, but it is associated with less incidences of hyperprolactinemia, extrapyramidal symptoms, or neutropenia (Prescribers’ Digital Reference (PDR), 2019). The agent was also aimed at treating refractory depression (PDR, 2019). The route of drug administration is through intramuscular injection (PDR, 2019). Hence, informed consent following proper patient education is necessary before the patient is treated (Shahriari et al., 2013). This is particularly important especially in this case whereby the patient believes that the husband is planning to poison her. Despite treatment with Zyprexa, the patient returned to the clinic in four weeks. The Positive and Negative Syndrome Scale (PANSS) score decreased by 25%. The patient seemed to be tolerating medication. She has made one injection appointment so far and a 2 pound weight gain. She complains of injection site pain. There is no significant difference between what was expected following the decision and the actual outcome of the decision. The agent had decreased the severity scale of schizophrenia. In next injection, Zyprexa should be injected deeply into the muscle to avoid muscle irritation and perhaps muscle pain (PDR, 2019).
Decision 2 was to discontinue Invega Sustenna and begin Haldol Decanoate (haloperidol decanoate) 50gm IM q2 weeks with oral Haldol 5mg BID for the next 3 months. Invega Sustenna was discontinued since it had the potential to impair motor and cognitive skills. In addition, Invega Sustenna was discontinued since it may have contributed to the patient’s weight gain (PDR, 2019). Instead, Haldol decanoate was administered so as to help manage schizophrenia (PDR, 2019). The patient should be asked on whether she is breastfeeding since Haldol decanoate can be passed in breast milk (PDR, 2019). This decision resulted in the client returning to clinic in four weeks, reduction of PANNS by 50% after the initiation of Invega Sustanna, injection site pain, and weight gain by 2.5 pounds. Invega Sustenna is causing weight gain; hence, the Haldol decanoate substitutes Invega Sustenna. It was expected that Invega Sustenna causes weight gain injection site pain as side effects (PDR, 2019).
Decision 3 was to continue with the Invega Sustenna. The patient was counseled that the Invega Sustenna does not cause weight gain as much as other drugs (PDR, 2019). An appointed with a dietician was made as well as with an exercise physiologist. In addition, a follow up of one month was included in the therapeutic plan. The patient’s weight was well managed with exercise and nutrition (Wiklund, 2016). The outcome was expected since physical exercise and proper nutrition is effective is effective for weight management and for treatment of obesity (Wiklund, 2016).
In conclusion, decision 3 is the best decision so far since it matches both life style changes and pharmacotherapy. Lifestyle changes including proper nutrition and physical is important for managing weight gain caused by use of Invega Sustenna. On the other hand, pharmacotherapy (use of Invega Sustenna) helps in proper management of schizophrenia.
References
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PDR. (2019). Drug search. References on Apr. 06, 2019 from, https://www.pdr.net/ Shahriari, M., Mohammadi, E., Abbaszadeh, A., & Bahrami, M. (2013). Nursing ethical values and definitions: A literature review. Iran J Nurs Midwifery Res., 18(1), 1-8. Wiklund, P. (2016). The role of the physical activity and exercise in obesity and weight management: Time for critical appraisal. Journal of Sport and Health Science, 5(2), 151-154. https://doi.org/10.1016/j.jshs.2016.04.001
Appendix
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