Reply to any one of colleague below. Abdulai abu-jajah or Ethel
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Abdulai abu-jajah
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A sleep disorder such as insomnia is usually characterized by the inability of the individual to have a satisfactorily restful sleep at night, and sometimes when they awake, it becomes difficult to return to sleep. It is characterized by inadequate and difficulty staying asleep during the night (Levenson, 2015). Problems with sleep, such as insomnia, affect about 60% to 80% of individuals with depression (Abdulrahman, 2018). This widow presenting to this clinic has had effects of insomnia and depression since the demise of her husband past ten months ago. The patient currently has Zoloft 100 mg PO daily and has some sleep problems.
Questions to ask a patient with complaints of insomnia and the rationale
- How many hours of sleep did you normally get before the passing of your husband? This question will help determine when insomnia started, the root cause, and create a baseline that will help the PNP determine whether the condition is psychosomatic or depression.
- What things soothe you to sleep? This question will assist the PNP on what medication therapy to administer the patient and what home remedies to advise the patient to use.
- Is there anyone in your family with insomnia? Family history is important because this condition can be inherited in an autosomal dominant pattern.
People in the patient’s life you would need to speak to; include specific questions.
I would like to speak to the patient’s PCP and helper. The PCP will be able to give the professional insight into the patient’s visits, medicine compliance, and how she presents herself. In addition, the helper will provide the patient’s any withdrawals from the normal routine and if she has presented any alarming signs recently (Tsai, 2017).
Appropriate physical exams and diagnostic tests.
Polysomnography, actigraphy, and give the patient a sleep diary to help diagnose insomnia. Other diagnostic tests include a thyroid function test and a lipid profile test, as reduced sleep can be associated with dyslipidemia (Zhan et al., 2014). In addition, the PNP will examine the head and neck for the physical exam for any thyroid problems, enlarged tonsils, or throat problems.
List a differential diagnosis for the patient. Identify the most likely and explain why.
The differential diagnoses would be obstructive sleep apnea, acute stress disorder, and major depressive disorder (Time of Care, 2017). The most likely diagnosis would be MDD because of her medical history, and the condition got worse after the loss of her husband.
List two pharmacologic agents and their dosing for the patient’s antidepressant therapy and explain why you might choose one agent over the other.
The drugs would be Citalopram 20mg PO QD or Amitriptyline 25mg qhs. Citalopram is an SSRI used to treat late-onset of depression (NHS, 2018). The drug also has sedative properties and improves sleeping patterns in depressed patients. Amitriptyline is a TA used to treat major depressive disorder. Citalopram is preferred because of the minimum side effects. Amitriptyline would worsen the patient’s obesity.
Identify any contraindications to use or alterations in dosing that may need to be considered based on ethical prescribing or decision-making.
The contraindication of taking Citalopram for the patient is her DM because it causes unstable blood sugar levels (EMC, n.d.). The alteration in dosing can be done to administer the patient 10mg PO QD because of her age. Higher doses in the elderly have diverse side effects.
Include any “check points” and indicate any therapeutic changes that you might make.
I would plan to see this patient back in the clinic in approximately four weeks, but with her diagnosis, it would be wise to check in on her via phone weekly. The patient would also be advised to log her sleep hours and how restful she feels (quality) daily. After every two weeks, I will review the patient for observation and monitor the treatment toleration or any side effects. I expect that the patient will have improved sleep patterns. Based on any major side effects, I will adjust the dosage to tolerable doses or change the therapy regimen. Finally, it would be prudent to monitor her for any adverse effects from the medication prescribed.
Ethel Uzoma
Ethel Uzoma wk7 discussion 1st post
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Treating a Patient with a Common Condition
Insomnia is dissatisfaction with the quantity and quality of sleep. It is characterized by difficulties initiating and maintaining sleep, frequent awakenings, and problems returning to sleep after that (Levenson et al., 2015). Insomnia is a common problem that psychiatric mental health nurse practitioners (PMHNPs) encounter because of its bidirectional relationship with mental illnesses ascribed by interconnected pathophysiology (Ogeil et al., 2020). It is crucial to understand the importance of psychopharmacological treatments on a patient’s mental illness and sleep patterns (Freudenreich et al., 2016). The following discussion reflects the best approaches taken to assess, diagnose, and treat insomnia in an elderly widow with depression.
Patient-Centered Questions listed/rationale
i)-How often do you have trouble sleeping, and how long has this problem lasted?
ii)-How long does it take you to fall asleep? How often do you wake up at night, and how long does it take to fall asleep again?
iii)-Do you feel refreshed after waking up, and how tired are you during the data? Does it interfere with your daily tasks?
- i)How often do you have trouble sleeping, and how long has this problem lasted? This is a straightforward question that will help me assess the history of the client’s insomnia and the depth of the problem.
- ii)How long does it take you to fall asleep? How often do you wake up at night, and how long does it take to fall asleep again? This open-ended question will help assess the progression of insomnia in order to develop a practical treatment approach.
iii) Do you feel refreshed after waking up, and how tired are you during the data? Does it interfere with your daily tasks? This open-ended question will help diagnose insomnia as per DSM-V criteria to develop the proper intervention.
People in the Patient’s Life
I will interview her children, other household members (relatives or housemaids), friends, close neighbors, and more importantly the caregiver with whom the client spent most of her time and most necessarily knows the client better. Client’s caregiver might be nurses, client’s children or family members who takes who cares of client’s needs at home. Relevant questions for the caregiver includes:
i)-Based on day-to-day encounters and personal experience with the client as a mother/friend/relative/neighbor, could you say the patient has changed, after your father’s/her husband’s ultimate demise?
- ii) Is the client as active during the day as she was before her husband’s death? And how can you describe her general mood?
iii) Can you state to me several changes in her character that you might have observed? These people are the closest to the patient; by asking these questions, one can get better insight into the patient’s depression and the depth of related insomnia progress.
Physical Examination and Diagnostic Tests
I will perform a head-to-toe physical examination to rule out conditions causing insomnia. I will also order laboratory tests, including complete blood count (hemoglobin and hematocrit), arterial blood gas, and thyroid functions test to assess for thyroid problems or other conditions associated with sleep disturbances such as overactive thyroid, Alzheimer’s disease, and Parkinson’s disease.
Differential Diagnosis
The differential diagnosis based on the patient’s history is depression. It is a psychiatric disorder characterized by a markedly diminished interest in pleasure (Kaltenboeck & Harmer, 2018). Having lost her husband, her depression and sleep habits got worse. Although she does not have any history of depression, it is a possible diagnosis based on the traumatic event she experienced.
Pharmacological Agents
i)-The first agent is Celexa (citalopram) at a dosing of 20 mg orally once daily. As a selective serotonin reuptake inhibitor (SSRI), that inhibits the central nervous system’s neuronal reuptake of serotonin (Sharbaf Shoar et al., 2021).
- ii) Desvenlafaxine (Pristiq) would also be appropriate for this patient taken at a dosage of 50 mg orally once daily. It is a serotonin-noradrenaline reuptake inhibitor (SNRI) that impedes neurotransmitter reuptake of serotonin, norepinephrine, and dopamine transporters (Naseeruddin et al., 2021).
I chose Celexa because it is more effective than Desvernlafaxine and its side effects occur less frequently due to the minimal dosage required to initiate maximum effect. In addition, Celexa improves appetite, sleep, and energy symptoms within 6-8 hours (Szoke-Kovacs et al., 2020). Its effectiveness and tolerability are associated with the presence of two isomers (R and S citalopram) that enhance the drug’s activity.
Contraindications to Use of Alterations
The use of monoamine oxidase inhibitors to treat depression with Celexa is contraindicated. It leads to an increased risk of occurrence of serotonin syndrome. Concomitant Celexa use in patients taking Pimozide is also contraindicated. It should also not be taken in patients with a hypersensitivity to citalopram or any active ingredients and those with low body electrolytes (sodium, chloride, and potassium) (Hieronymus et al., 2018). These contraindications exist to serve a reason not to take Celexa due to the invigorating harm that it could cause.
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Response to Abdulai abu-jajah
This was a productive and educative post based on the provided case study I agree with almost every point made in this discussion post. Indeed, insomnia is often marked by one’s inability to have a satisfactory sleep at night (McIntyre et al., 2020). Such individuals might find it hard to return to sleep when they wake up. A significant number of people with depression experience insomnia, which is why it is recognized as one of the symptoms of depression. Assessment is usually the first step both in the nursing process and medical diagnosis. Asking the patient about her sleep patterns is important to document a comprehensive history of illness (Pierce, 2018). It is also important to always assess the family background of patients to a certain whether the illness is a generational problem. This information is also used when advising the patient.
Additionally, families are very important people when developing care plans for certain types of patients. Patients who have depression and other mental illnesses may fail to make rational decisions, hence, having a family member with them is extremely important (McIntyre et al., 2020). Family members would provide reliable information about the patient. As indicated in the discussion post, indeed the patient’s PCP and helper are also important. Proper physical examination is necessary. A thyroid function test and a lipid profile test are also necessary to determine the patient’s illness. The most likely differential diagnosis is indeed depression. The patient’s medical history of depression is the most likely illness (Pierce, 2018). Abdulai Abu-Jajah posted a very insightful discussion about the patient. All the points discussed above were presented properly and accurately.
References
McIntyre, R. S., In Rong, C., In Subramaniapillai, M., & In Lee, Y. (2020). Major depressive disorder. Elsevier.
Pierce, S. (2018). Major depressive disorder. Lucent Press.