NURS 6630 Week 6 Assignment: Assessing and Treating Clients With Psychosis and Schizophrenia

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NURS 6630 Week 6 Assignment: Assessing and Treating Clients With Psychosis and Schizophrenia

NURS 6630 Week 6 Assignment

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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 of developing personalized plans of antipsychotic therapy for clients

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

·         Evaluate the 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.

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 scale

 

Diagnosis:

 Schizophrenia, paranoid type

 

Decisions 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

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

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 time

 

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

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 gain

 

Choices 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 loss

 

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).

***Write on each decision. Make sure that in each decision choice that you explain why the other two decisions were not good choices. Use cited sources to validate points. Make sure that this paper has at least 7 References. Please use in-text citations for each section of each decision. Don’t forget the ethical considerations for this assignment. Make it a section by itself.***

 

***Also please make sure when looking at the ethical consideration for this assignment that you look at how Invega Sustenna and the Pakistani culture/ethnicity. What considerations does the drugs have with this ethnicity.***

 

DECISION CHOSEN 

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

/orders/mym.cdn.laureate-media.com/2dett4d/Walden/NURS/6630/06/mm/delusional_disorders/img/pill-red.pngContinue 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).

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