Examine Case Study: Pakistani Woman with Delusional Thought Processes

Week 6: Antipsychotic Therapy

According to the National Alliance on Mental Illness, approximately 100,000 people experience psychosis in the United States each year (NAMI, 2016). In practice, clients may present with delusions, hallucinations, disorganized thinking, disorganized or abnormal motor behavior, as well as other negative symptoms that can be disabling for these individuals. Not only are these symptoms one of the most challenging symptom clusters you will encounter, many are associated with other disorders such as depression, bipolar disorder, and disorders on the schizophrenia spectrum. As a psychiatric mental health nurse practitioner, you must understand the underlying neurobiology of these symptoms to select appropriate therapies and improve outcomes for clients.

This week, as you examine antipsychotic therapies, you explore the assessment and treatment of clients with psychosis and schizophrenia. You also consider ethical and legal implications of these therapies.

Photo Credit: Ingram Publishing/Getty Images

Assignment: Assessing and Treating Clients With Psychosis and Schizophrenia

Psychosis and schizophrenia greatly impact the brain’s normal processes, which interferes with the ability to think clearly. When symptoms of these disorders are uncontrolled, clients may struggle to function in daily life. However, clients often thrive when properly diagnosed and treated under the close supervision of a psychiatric mental health practitioner. For this Assignment, as you examine the client case study in this week’s Learning Resources, consider how you might assess and treat clients presenting with psychosis and schizophrenia.

Learning Objectives

Students will:

·         Assess client factors and history to develop personalized plans of antipsychotic therapy for clients

·         Analyze factors that influence pharmacokinetic and pharmacodynamic processes in clients requiring antipsychotic therapy

·         Evaluate efficacy of treatment plans

·         Analyze ethical and legal implications related to prescribing antipsychotic therapy to clients across the lifespan

Learning Resources

Note: To access this week’s required library resources, please click on the link to the Course Readings List, found in the Course Materials section of your Syllabus.

Required Readings

Note: All Stahl resources can be accessed through the Walden Library using this link. This link will take you to a log-in page for the Walden Library. Once you log into the library, the Stahl website will appear.

Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (4th ed.). New York, NY: Cambridge University Press.

To access the following chapters, click on the Essential Psychopharmacology, 4th ed tab on the Stahl Online website and select the appropriate chapter. Be sure to read all sections on the left navigation bar for each chapter.

·         Chapter 4, “Psychosis and Schizophrenia”

·         Chapter 5, “Antipsychotic Agents”

Stahl, S. M. (2014b). The prescriber’s guide (5th ed.). New York, NY: Cambridge University Press.

To access information on the following medications, click on The Prescriber’s Guide, 5th ed tab on the Stahl Online website and select the appropriate medication.

Review the following medications:

• amisulpride
• aripiprazole
• asenapine
• chlorpromazine
• clozapine
• flupenthixol
• fluphenazine
• haloperidol
• iloperidone
• loxapine
• lurasidone

• olanzapine
• paliperidone
• perphenazine
• quetiapine
• risperidone
• sulpiride
• thioridazine
• thiothixene
• trifluoperazine
• ziprasidone

Naber, D., & Lambert, M. (2009). The CATIE and CUtLASS studies in schizophrenia: Results and implications for clinicians. CNS Drugs, 23(8), 649-659. doi:10.2165/00023210-200923080-00002

Note: Retrieved from Walden Library databases.

Kay, S. R., Fiszbein, A., & Opler, L. A. (1987). The Positive and Negative Syndrome Scale (PANSS) for schizophrenia. Schizophrenia Bulletin, 13(2), 261-276.

Note: Retrieved from Walden Library databases.

Clozapine REMS. (2015). Clozapine REMS: The single shared system for clozapine. Retrieved from /orders/www.clozapinerems.com/CpmgClozapineUI/rems/pdf/resources/Clozapine_REMS_A_Guide_for_Healthcare_Providers.pdf

Walden University. (2016). ASC success strategies: Studying for and taking a test. Retrieved from http://academicguides.waldenu.edu/ASCsuccess/ASCtesting

Required Media

Laureate Education. (2016j). Case study: Pakistani woman with delusional thought processes [Interactive media file]. Baltimore, MD: Author

Note: This case study will serve as the foundation for this week’s Assignment.

Optional Resources

Chakos, M., Patel, J. K., Rosenheck, R., Glick, I. D., Hammer, M. B., Tapp, A., & … Miller, D. (2011). Concomitant psychotropic medication use during treatment of schizophrenia patients: Longitudinal results from the CATIE study. Clinical Schizophrenia & Related Psychoses, 5(3), 124-134. doi:10.3371/CSRP.5.3.2

Fangfang, S., Stock, E. M., Copeland, L. A., Zeber, J. E., Ahmedani, B. K., & Morissette, S. B. (2014). Polypharmacy with antipsychotic drugs in patients with schizophrenia: Trends in multiple health care systems. American Journal of Health-System Pharmacy, 71(9), 728-738. doi:10.2146/ajhp130471

Lin, L. A., Rosenheck, R., Sugar, C., & Zbrozek, A. (2015). Comparing antipsychotic treatments for schizophrenia: A health state approach. The Psychiatric Quarterly, 86(1), 107-121. doi:10.1007/s11126-014-9326-2

To prepare for this Assignment:

·         Review this week’s Learning Resources. Consider how to assess and treat clients requiring anxiolytic therapy.

The Assignment

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.

At each decision point stop to complete the following:

·         Decision #1

o    Which decision did you select?

o    Why did you select this decision? Support your response with evidence and references to the Learning Resources.

o    What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.

o    Explain any difference between what you expected to achieve with Decision #1 and the results of the decision. Why were they different?

·         Decision #2

o    Why did you select this decision? Support your response with evidence and references to the Learning Resources.

o    What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.

o    Explain any difference between what you expected to achieve with Decision #2 and the results of the decision. Why were they different?

·         Decision #3

o    Why did you select this decision? Support your response with evidence and references to the Learning Resources.

o    What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.

o    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.

Note: Support your rationale with a minimum of three academic resources. While you may use the course text to support your rationale, it will not count toward the resource requirement.

Delusional Disorders Pakistani Female With Delusional Thought Processes

Decision Point One

Start Invega Sustenna 234 mg intramuscular X1 followed by 156 mg intramuscular on day 4 and monthly thereafter

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 time

Decision Point Two

Continue same decision made but instruct administering nurse to begin injections into the deltoid at this visit and moving forward

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 gain

Decision Point Three

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

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).

ADDITIONAL INSTRUCTIONS FOR THE CLASS

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• Discussion Questions (DQ)

Initial responses to the DQ should address all components of the questions asked, including a minimum of one scholarly source, and be at least 250 words. Successful responses are substantive (i.e., add something new to the discussion, engage others in the discussion, well-developed idea) and include at least one scholarly source. One or two-sentence responses, simple statements of agreement or “good post,” and responses that are off-topic will not count as substantive. Substantive responses should be at least 150 words. I encourage you to incorporate the readings from the week (as applicable) into your responses.

• Weekly Participation

Your initial responses to the mandatory DQ do not count toward participation and are graded separately. In addition to the DQ responses, you must post at least one reply to peers (or me) on three separate days, for a total of three replies. Participation posts do not require a scholarly source/citation (unless you cite someone else’s work). Part of your weekly participation includes viewing the weekly announcement and attesting to watching it in the comments. These announcements are made to ensure you understand everything that is due during the week. Examine Case Study: Pakistani Woman with Delusional Thought Processes

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Familiarize yourself with the APA format and practice using it correctly. It is used for most writing assignments for your degree. Visit the Writing Center in the Student Success Center, under the Resources tab in Loud-cloud for APA paper templates, citation examples, tips, etc. Points will be deducted for poor use of APA format or absence of APA format (if required). Cite all sources of information! When in doubt, cite the source. Paraphrasing also requires a citation. I highly recommend using the APA Publication Manual, 6th edition.

• Use of Direct Quotes

I discourage over-utilization of direct quotes in DQs and assignments at the Master’s level and deduct points accordingly. As Masters’ level students, it is important that you be able to critically analyze and interpret information from journal articles and other resources. Simply restating someone else’s words does not demonstrate an understanding of the content or critical analysis of the content. It is best to paraphrase content and cite your source. Examine Case Study: Pakistani Woman with Delusional Thought Processes

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For assignments that need to be submitted to Lopes Write, please be sure you have received your report and Similarity Index (SI) percentage BEFORE you do a “final submit” to me. Once you have received your report, please review it. This report will show you grammatical, punctuation, and spelling errors that can easily be fixed. Take the extra few minutes to review instead of getting counted off for these mistakes. Review your similarities. Did you forget to cite something? Did you not paraphrase well enough? Is your paper made up of someone else’s thoughts more than your own? Visit the Writing Center in the Student Success Center, under the Resources tab in Loud-cloud for tips on improving your paper and SI score.

• Late Policy

The university’s policy on late assignments is a 10% penalty PER DAY LATE. This also applies to late DQ replies. Please communicate with me if you anticipate having to submit an assignment late. I am happy to be flexible, with advance notice. We may be able to work out an extension based on extenuating circumstances. If you do not communicate with me before submitting an assignment late, the GCU late policy will be in effect. I do not accept assignments that are two or more weeks late unless we have worked out an extension. As per policy, no assignments are accepted after the last day of class. Any assignment submitted after midnight on the last day of class will not be accepted for grading.

• Communication

Communication is so very important. There are multiple ways to communicate with me: Questions to Instructor Forum: This is a great place to ask course content or assignment questions. If you have a question, there is a good chance one of your peers does as well. This is a public forum for the class. Individual Forum: This is a private forum to ask me questions or send me messages. This will be checked at least once every 24 hours.

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