Respond to the following Response Post # 1 & 2
Explain how you might apply knowledge gained from the Response case studies to your own practice in clinical settings.
Response Post #: 1
Case 1: Volume 2, Case #16: The woman who liked late-night TV
This is a case study of a 70-year-old female who lives at home by herself. The patient struggles with depression. She is sad, has lost interest in things she used to enjoy, and is fatigued with poor focus and concentration. The patient reports trouble sleeping. The patient also likes to watch late-night TV.
Sleeping disturbances affect 1/3 of Americans. Sleep can affect an individual’s memory, health, immune system, and pain. Some questions that we may need to ask the client:
How much sleep do you usually get?
Do you feel rested when you wake up?
Do you have trouble falling asleep, or difficulty getting back to sleep when you wake up in the middle of the night?
(Siengsukon, Al-Dughmi, & Stevens, 2017)
When assessing a patient, it is nice to allow the family to be involved, with the patient’s permission, if they are supportive and want to help the patient’s health improve. Some questions that the provider may want to ask the family are:
How are the family dynamics, Does the patient’s symptoms nap during the day, and What does the family member suffering from sleep react throughout the day? These are important questions to help develop a picture of what is going on with the patient (Laff, 2016).
Physical Exam and Diagnostic Testing
When assessing the patient for a sleeping disorder you want to perform a physical examination to see if the patient has difficulty initiating sleep, maintaining sleep, and their routine before going to bed. As practitioners, we want to look to see if the patient is in pain.
Does the patient use any substances such as alcohol, caffeine, nicotine, or any illegal drugs? Laboratory diagnostic tools may include blood work such as blood count, thyroid panel, comprehensive metabolic panel, C-Reactive Protein, ferritin, and vitamin B12. We may need to have the patient have echocardiograms, CT, or EEG performed depending on the lab results.
Looking at the patient’s psychiatric history and sleep history. These are just a few tools to help diagnose and help determine the treatment (Riemann et al. 2017).
Three differential diagnoses that the patient fits the criteria for are Chronic insomnia disorder, sleep apnea syndrome, and psychological insomnia.
Chronic Insomnia disorder is when the individual has trouble sleeping three-four nights per week for three or more months. sleep apnea syndrome criteria include feeling tired throughout the day and snoring while sleeping. Psychological insomnia criteria are hyper-arousal and learned sleep- preventing associations (Suzuki, Miyamoto, & Hirata, 2017).
Doxepin is a medication recommended to help with sleep at lower dosages. The recommended dosages are 3-6 mg (Sateia, Buysse, Krystal, Neubauer, & Heald, 2017). Doxepin binds with high specificity and affinity to the histamine H1 receptor compared with other receptors.
At low doses, doxepin selectively antagonizes H1 receptors, which is believed to promote the initiation and maintenance of sleep (Weber, Siddiqui, Wagstaff, & McCormack, 2010). The next treatment option I would choose is Trazodone.
The Therapeutic dose for Trazodone in 50 mg -200 mg. Trazodone can help with sleep and depression (Sateia, Buysse, Krystal, Neubauer, & Heald, 2017). Trazodone is an antagonist/blocker for all the targets except for the serotonin receptor, where it acts as an agonist/agonist (Settimo & Taylor, 2018).
Follow-ups are used to evaluate the progression of the patient’s symptoms. Practitioners evaluate medication side effects, the effectiveness of the medication, and the patient’s symptoms. It can take 4-8 weeks to know the effectiveness of a medication. In the case study, they followed up with the patient every four weeks.
Response Post #: 2
Case Study 3
Case Study 3: Volume 1, Case 5: The sleepy woman with anxiety
Insomnia is a common household occurrence with many people. This disorder can be attributed to medication, trauma, anxiety, and pain. According to Stahls (2013), sleep is considered to be a vital psychiatric sign during treatment evaluations
Additional Evaluation Questions
The case study included a lot of information; however, additional information is needed for an accurate diagnosis.
The following questions are asked to find additional information about the patient’s sleep history. Inquiring about past medications and non-pharmacological intervention is important to know when determining the new treatment options.
Anxiety and the trauma-related event could cause an individual to lose sleep, especially if the event happens in the night hours. Many victims that experience night time trauma often has flashbacks during that time or increases anxiety.
Also, drinking high caffeinated drinks could cause insomnia. The timing of drinking caffeinated beverages could be adjusted to be more beneficial to the patient.
I would also include questions for other family members. I would ask them about the patient’s sleep pattern. Also, questions such as “have you witnessed bizarre behaviours from the patient that could affect the lack of sleep.”
How much time do you think the patient sleeps daily? Do you think the patient has stressors or anxiety that keep her from sleeping? Many times, the family members’ views on the patient’s insomnia can be different from the patient’s account.
Testing and Diagnostic
When patients are prescribed an antipsychotic, it important for the providers to start with a baseline EKG. According to Brown University Psychopharmacology (2014), Geodon is has known to cause QT prolongation for an individual with a personal or family of cardiac issues.
The patient presents with several symptoms and has an intensive mental health history. The three diagnoses that I considered a) post-traumatic syndrome (PTSD), Major Depressive Disorder (MDD), Insomnia Disorder.
I think the patient should be treated for insomnia disorder. According to Stahl (2013), insomnia disorders can be linked to other psychiatric disorders and can advance to depressive occurrences.
The two-agents that I would consider for this patient are Trazodone and Ambien. Trazodone is a serotonin receptor antagonist, that has an immediate effect on insomnia (Stahl, 2014). The recommended starting dose is 50mg PO nightly. The dose can tamper to produce the desired effect.
Ambien is non-benzodiazepine hypnotic and is used to treat short term insomnia (Stahl. 2014). Ambien recommended starting dose is 5mg PO nightly immediate release. This medication would only be prescribed for 7-10 days due to the risk of dependence and worsening symptoms of depression and suicidal ideations.
This case study includes many variables about the patient’s past and present medical history. Lagerberg et al. (2019) stated that incidents with polypharmacy increase with age and children have the highest incident with 3 or more psychotic drug classes.
As an advanced practice nurse, it’s important to assess the medication and the patient history before determining the treatment. The patient indicated that several medications did not work for her but more information was needed to determine if that was an accurate assumption of the medication.