Assessing and Treating Patients With Sleep/Wake Disorders -Pharmacologic Approaches to the Treatment of Insomnia in a Younger Adult
Assessing and Treating Patients With Sleep/Wake Disorders -Pharmacologic Approaches to the Treatment of Insomnia in a Younger Adult
Introduction
The patient, in this case, is a 31-year-old man with insomnia. The condition began six months ago after the sudden death of his wife. He is employed as a forklift operator at a local chemical company, but his health condition has affected his ability to perform his work. The patient claims that he has utilized diphenhydramine for sleeping in the past, but he does not like how he feels the next morning after using the medication. According to the patient’s prior physician’s medical record, he was abusing opiates after injuring his ankle in a skiing accident. The patient’s previous physician prescribed him hydrocodone/APAP (acetaminophen) for acute pain management after the accident. For four years, the individual has not received a prescription for an opiate analgesic. He points out that he has recently consumed approximately four beers to help him fall asleep. The patient is attentive and aware of the person talking to him, location, time, and incident. He maintains eye contact and is dressed appropriately for the season. All aspects of judgment, insight, and reality contact remain intact. The man also denies any suicidal ideas and is focused on the future.
Decision One
The treatment should start with Trazodone 10 mg daily at bedtime. Trazodone has been approved as an effective treatment for insomnia. The medicine is effective in lower doses in treating primary and secondary insomnia. Due to its generic availability, the medication is less expensive than newer insomnia medications. Trazodone can also be an effective sleep aid when taken in lower doses. The other reason for selecting the medication is that it is not addictive compared to other insomnia medications such as benzodiazepine class medication such as Valium and Xanax (Yi et al, 2018). The medication can also help the patient improve slow wave sleep, and the medication also has fewer side effects than most of the other medications used in treating insomnia Assessing and Treating Patients With Sleep/Wake Disorders -Pharmacologic Approaches to the Treatment of Insomnia in a Younger Adult.
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There are various reasons why Zolpidem was not selected. The medication can result in severe allergic reactions in some patients. The various signs of allergic reaction due to the medication include swelling of the face and difficulty in breathing. The other reason is that the sedative effect of the medication is stronger than the other available options. The medication can also make a patient experience severe dizziness and drowsiness, resulting in falls, accidents, and severe injuries. Considering the nature of the patient’s work, the medication is not a good option because it can result in daytime drowsiness and dizziness, making the patient not conduct his job effectively. The medication can also result in a high level of aggressiveness and extroversion that is abnormal compared to the patient’s usual behavior (Jung, 2018). Considering that the patient has confirmed that he takes alcohol, Zolpidem cannot be used in the treatment process because the patient can experience auditory and visual hallucinations associated with strange behavior due to alcohol toxicity. Hydroxyzine 50mg was also not selected due to various. Assessing and Treating Patients With Sleep/Wake Disorders -Pharmacologic Approaches to the Treatment of Insomnia in a Younger Adult. One of the main reasons is that the medication has a high side effects profile compared to Trazodone. The medication can also lead to daytime sedation, affecting how the patient will perform at work. Hydroxyzine can also result in various side effects such as skin rash, fast heartbeat, difficulty in swallowing, and chest discomfort (Silvestro, 2021).
From the treatment process, I expect that Trazodone will effectively treat the patient’s condition, and he will be able to sleep well. The patient experience an erection, which will last for approximately 15 minutes as a side effect of the medication. Ethical consideration will positively impact the treatment plan and when communicating with the patient. For instance, every decision and action that I will take will be for the fulfillment of the obligation to provide optimal care to the patient.
Decision Two
Explaining to the patient that an erection that lasts for approximately 15 minutes that he is experiencing is not priapism and should end over time, and he should continue taking the current dose. I choose this decision because the medication effectively treats insomnia, and the patient has enough sleep at night. Continuing with the current dose is also important because the patient is not experiencing any severe side effects apart from the prolonged erections and priapism due to its adrenergic blocking activity.
I did not select the decision to discontinue Trazodone and initiate treatment with suvorexant 1o mg at bedtime daily because of various reasons. Trazodone effectively treated the patient’s condition, and the patient did not experience any side effects; hence, changing the medication will negatively impact the treatment process. Initiating treatment with suvorexant is not a good decision. The medication is associated with various side effects such as next-day drowsiness and agitation. There is also limited evidence supporting the safety of using suvorexant in treating insomnia. The medication can cause the patient to become less alert during the day and feel drowsiness, headache, and dizziness. The medication can also result in memory problems or confusion. The patient can experience disturbed sleep as a side effect and have various experiences such as abnormal dreams, nightmares, and hallucinations. The medication can also cause the patient to experience sleep paralysis or even walk in their sleep.
Decreasing the current trazodone dose to 25 mg daily at bedtime is also not a good decision because the current dose of the medication was effective in treating the patient’s condition. Dose reduction can only be implemented when the patient is experiencing severe side effects due to the medication or it is too expensive for the patient to purchase the current dose of the medication (Yi et al, 2018). Considering the effectiveness of the current dose of Trazodone, reducing the dose can reduce the medication’s efficiency in treating insomnia or slow down the treatment process. I expect the patient to experience a further decrease in priapism from the treatment approach, and insomnia will also decrease. In this case, ethical consideration will ensure that I avoid causing harm to the patient.
Decision Three
The patient should continue with the current dose, and he may split the 50mg tablet into two. Decreasing the dose will help in reducing next-day drowsiness. In order to reduce the side effects of the medication, it is crucial to reduce the current dose to a lower dose considering that the medication is effective and the patient is getting better. Taking a lower dose of Trazodone is proven to be similarly effective than a higher dose, with appreciably fewer adverse effects such as decreased drowsiness and potentially improved quality of life.
The decision to discontinue Trazodone and initiate treatment with sonata 10 mg administered during bedtime is not good. This is because Trazadone has been effective in managing the patient’s condition. Initiating therapy with sonata 10 mg will is not a good decision considering the patient operates a vehicle in the chemical industry. This is because one of the major side effects of the sonata is lack of coordination which can lead to an accident, especially when an individual is driving. Other side effects of the medication that can reduce the patient’s quality of life include dizziness, drowsiness, and short-term memory loss. Another reason why treatment with sonata should not be initiated is that the medication is habit forming and can lead to dependency and can also be abused (Reeve & Bailes, 2010). Due to its habit-forming characteristics, it is not advisable to use the medication in long-term treatment, and it has not been proven to be effective in treating patients with long-term insomnia. Considering the patient has a history of alcohol consumption, the medication is not the best option and can result in various withdrawal symptoms if the patient suddenly stops using it.
The decision to discontinue Trazadone and start treatment with hydroxyzine 50 mg at bedtime is also not advisable. Hydroxyzine cannot be clinically significant to the patient considering the medication has a comparatively long half-life of approximately 20 hours (Schiffman et al, 2011). This will result in daytime sedation after sleeping at night. The medication also has a high side effect profile compared to the low side effect profile of Trazodone. Introducing hydroxyzine can also result in other adverse side effects such as Xerostomia and Xerophthalmia. Assessing and Treating Patients With Sleep/Wake Disorders -Pharmacologic Approaches to the Treatment of Insomnia in a Younger Adult.
From the treatment approach, I expect the patient condition to become better after another four weeks of using the medication. Priapism will also diminish completely, and the level of drowsiness will decrease because the patient will be using a lower dose than the initial dose. Ethical consideration will be crucial in the treatment process and communication with the patient because it will allow me to minimize the medication’s harm to the patient and focus on promoting good health (Haddad, 2018).
References
Haddad, L. M., & Geiger, R. A. (2018). Nursing ethical considerations.
Jaffer, K. Y., Chang, T., Vanle, B., Dang, J., Steiner, A. J., Loera, N., … & Ishak, W. W. (2017). Trazodone for insomnia: a systematic review. Innovations in clinical neuroscience, 14(7-8), 24.
Jung, M. (2018). Zolpidem overdose: a dilemma in mental health. The Health Care Manager, 37(1), 86-89.
Reeve, K., & Bailes, B. (2010). Insomnia in adults: Etiology and management. The journal for nurse practitioners, 6(1), 53-60.
Schiffman, J., Davis, M., Pierre, J., & Saunders, C. S. (2011). Hydroxyzine: rational choice for inpatients with insomnia. Current Psychiatry, 10(3), 88-89.
Silvestro, S. (2021). Hydroxyzine (Vistaril): dosage, uses, side effects. Drugs.
Assignment 2: Assessing and Treating Patients With Sleep/Wake Disorders
Sleep disorders are conditions that result in changes in an individual’s pattern of sleep (Mayo Clinic, 2020). Not surprisingly, a sleep disorder can affect an individual’s overall health, safety, and quality of life. Psychiatric nurse practitioners can treat sleep disorders with psychopharmacologic treatments, however, many of these drugs can have negative effects on other aspects of a patient’s health and well-being. Assessing and Treating Patients With Sleep/Wake Disorders -Pharmacologic Approaches to the Treatment of Insomnia in a Younger Adult . Additionally, while psychopharmacologic treatments may be able to address issues with sleep, they can also exert potential challenges with waking patterns. Thus, it is important for the psychiatric nurse practitioner to carefully evaluate the best psychopharmacologic treatments for patients that present with sleep/wake disorders.
Reference: Mayo Clinic. (2020). Sleep disorders. https://www.mayoclinic.org/diseases-conditions/sleep-disorders/symptoms-causes/syc-20354018
To prepare for this Assignment:
Review this week’s Learning Resources, including the Medication Resources indicated for this week.
Reflect on the psychopharmacologic treatments you might recommend for the assessment and treatment of patients with sleep/wake disorders.
The Assignment: 5 pages
Examine Case Study: Pharmacologic Approaches to the Treatment of Insomnia in a Younger Adult. You will be asked to make three decisions concerning the medication to prescribe to this patient. Be sure to consider factors that might impact the patient’s pharmacokinetic and pharmacodynamic processes.
At each decision point, you should evaluate all options before selecting your decision and moving throughout the exercise. Before you make your decision, make sure that you have researched each option and that you evaluate the decision that you will select. Be sure to research each option using the primary literature.
Introduction to the case (1 page)
Briefly explain and summarize the case for this Assignment. Be sure to include the specific patient factors that may impact your decision making when prescribing medication for this patient.
Decision #1 (1 page)
Which decision did you select?
Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
Assessing and Treating Patients With Sleep/Wake Disorders -Pharmacologic Approaches to the Treatment of Insomnia in a Younger Adult
Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.
Decision #2 (1 page)
Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.
Decision #3 (1 page)
Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.
Conclusion (1 page)
Summarize your recommendations on the treatment options you selected for this patient. Be sure to justify your recommendations and support your response with clinically relevant and patient-specific resources, including the primary literature. Assessing and Treating Patients With Sleep/Wake Disorders -Pharmacologic Approaches to the Treatment of Insomnia in a Younger Adult
ORDER PAGE
Note: Support your rationale with a minimum of five academic resources. While you may use the course text to support your rationale, it will not count toward the resource requirement. You should be utilizing the primary and secondary literature.
Reminder : The College of Nursing requires that all papers submitted include a title page, introduction, summary, and references. The Sample Paper provided at the Walden Writing Center provides an example of those required elements (available at https://academicguides.waldenu.edu/writingcenter/templates/general#s-lg-box-20293632). All papers submitted must use this formatting.
NURS_6630_Week8_Assignment2_Rubric
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Show Descriptions
Introduction to the case (1 page)
Briefly explain and summarize the case for this Assignment. Be sure to include the specific patient factors that may impact your decision making when prescribing medication for this patient.—
Excellent
Point range: 90–100 9 (9%) – 10 (10%)
Good
Point range: 80–89 8 (8%) – 8 (8%)
Fair
Point range: 70–79 7 (7%) – 7 (7%)
Poor
Point range: 0–69 0 (0%) – 6 (6%)
Decision #1 (1–2 pages)
• Which decision did you select?
• Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
• Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
Assessing and Treating Patients With Sleep/Wake Disorders -Pharmacologic Approaches to the Treatment of Insomnia in a Younger Adult
• What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
• Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.—
Excellent
Point range: 90–100 18 (18%) – 20 (20%)
Good
Point range: 80–89 16 (16%) – 17 (17%)
Fair
Point range: 70–79 14 (14%) – 15 (15%)
Poor
Point range: 0–69 0 (0%) – 13 (13%)
Decision #2 (1–2 pages)
• Which decision did you select?
• Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
• Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
• What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
• Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.—
Excellent
Point range: 90–100 18 (18%) – 20 (20%)
Good
Point range: 80–89 16 (16%) – 17 (17%)
Fair
Point range: 70–79 14 (14%) – 15 (15%)
Poor
Point range: 0–69 0 (0%) – 13 (13%)
Decision #3 (1–2 pages)
• Which decision did you select?
• Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
• Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
• What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
Assessing and Treating Patients With Sleep/Wake Disorders -Pharmacologic Approaches to the Treatment of Insomnia in a Younger Adult
• Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.—
Excellent
Point range: 90–100 18 (18%) – 20 (20%)
Good
Point range: 80–89 16 (16%) – 17 (17%)
Fair
Point range: 70–79 14 (14%) – 15 (15%)
Poor
Point range: 0–69 0 (0%) – 13 (13%)
Conclusion (1 page)
• Summarize your recommendations on the treatment options you selected for this patient. Be sure to justify your recommendations and support your response with clinically relevant and patient-specific resources, including the primary literature.—
Excellent
Point range: 90–100 14 (14%) – 15 (15%)
Good
Point range: 80–89 12 (12%) – 13 (13%)
Fair
Point range: 70–79 11 (11%) – 11 (11%)
Poor
Point range: 0–69 0 (0%) – 10 (10%)
Written Expression and Formatting – Paragraph Development and Organization:
Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused—neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria.—
Excellent
Point range: 90–100 5 (5%) – 5 (5%)
Good
Point range: 80–89 4 (4%) – 4 (4%)
Fair
Point range: 70–79 3.5 (3.5%) – 3.5 (3.5%)
Poor
Point range: 0–69 0 (0%) – 3 (3%)
Written Expression and Formatting – English writing standards:
Correct grammar, mechanics, and proper punctuation—
Excellent
Point range: 90–100 5 (5%) – 5 (5%)
Good
Point range: 80–89 4 (4%) – 4 (4%)
Fair
Point range: 70–79 3.5 (3.5%) – 3.5 (3.5%)
Poor
Point range: 0–69 0 (0%) – 3 (3%)
Written Expression and Formatting – The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, parenthetical/in-text citations, and reference list.—
Excellent
Point range: 90–100 5 (5%) – 5 (5%)
Good
Point range: 80–89 4 (4%) – 4 (4%)
Fair
Point range: 70–79 3.5 (3.5%) – 3.5 (3.5%)
Poor
Point range: 0–69 0 (0%) – 3 (3%)
Total Points: 100
Name: NURS_6630_Week8_Assignment2_Rubric
Insomnia
31-year-old Male
Decision Point One
Trazodone 50 mg po at bedtime
RESULTS OF DECISION POINT ONE
Patient returns to clinic in 2 weeks
Patient states medication works well but gives him an unpleasant side effect of an erection lasting approximately 15 minutes after waking
Patient states this makes it difficult to get ready for work or go downstairs and have coffee with his girlfriend and daughter in the morning
Patient denies auditory/visual hallucinations and is future oriented
Decision Point Two
Explain that an erection lasting 15 minutes is not considered a priapism and should diminish over time, continue with current dose
RESULTS OF DECISION POINT TWO
Patient returns to clinic in 2 weeks
Patient states priapism has diminished over time
Patient denies auditory/visual hallucinations and is future oriented
Patient states trazodone is effective at 50 mg dose but sometimes wakes up following day with next-day drowsiness
Assessing and Treating Patients With Sleep/Wake Disorders -Pharmacologic Approaches to the Treatment of Insomnia in a Younger Adult
Patient denies auditory/visual hallucinations and is future oriented
Decision Point Three
Continue dose. Explain to patient he may split the 50 mg tablet in half. The decreased dose should minimize next-day drowsiness. Follow up in 4 weeks
Guidance to Student
Trazodone is a selective serotonin reuptake inhibitor that has a low side effect profile. It would not be prudent to prescribe sonata as it carries with it the risk of complex sleep behaviors. Hydroxyzine is an antihistamine with strong sedative properties. However, many patients complain of anticholinergic adverse effects the following morning, such as Xerostomia and Xerophthalmia.
The patient is presenting with excessive somnolence. It would be prudent to reduce the dose of trazodone by 50% and reassess in 4 weeks. Assessing and Treating Patients With Sleep/Wake Disorders -Pharmacologic Approaches to the Treatment of Insomnia in a Younger Adult
