Week 8: Pharmacology for Psychological Disorders

How does an advanced practice nurse determine the best treatment option or pharmacotherapeutic to recommend for patients with psychological disorders? NURS 6521N Week 8 Assignment

Much like assessing or recommending pharmacotherapeutics for other conditions or disorders, as an advanced practice nurse, you may encounter a patient who presents with a psychological disorder. Understanding the guiding principles related to treating patients with psychological disorders as well as the effects of pharmacotherapeutics on a patient’s overall health and well-being is critical for the safe and effective delivery of care.

This week, you examine types of drugs prescribed to patients with psychological disorders. You also examine potential impacts of pharmacotherapeutics used to treat psychological disorders on a patient’s pathophysiology. NURS 6521N Week 8 Assignment

Learning Objectives

Students will:

• Evaluate patients for treatment of psychological disorders
• Analyze decisions made throughout the diagnosis and treatment of patients with psychological disorders
• Analyze impacts of pharmacotherapeutics for psychological disorders on patient pathophysiology
• Evaluate patients for treatment of neurological and musculoskeletal disorders
• Analyze decisions made throughout the diagnosis and treatment of patients with neurological and musculoskeletal disorders
• Justify decisions made throughout the diagnosis and treatment of patients with neurological and musculoskeletal disorders NURS 6521N Week 8 Assignment

Learning Resources – NURS 6521N Week 8 Assignment

Required Readings (click to expand/reduce)

Rosenthal, L. D., & Burchum, J. R. (2018). Lehne’s pharmacotherapeutics for advanced practice providers. St. Louis, MO: Elsevier.

• Chapter 24, “Antipsychotic Agents and Their Use in Schizophrenia” (pp. 231–246)
• Chapter 25, “Antidepressants” (pp. 247–265)
• Chapter 26, “Drugs for Bipolar Disorder” (pp. 267–274)
• Chapter 27, “Sedative-Hypnotic Drugs” (pp. 275–285)
• Chapter 28, “Management of Anxiety Disorders” (pp. 287–292) NURS 6521N Week 8 Assignment
• Chapter 29, “Central Nervous System Stimulants and Attention-Deficit/Hyperactivity Disorder” (pp. 293–299)

Required Media (click to expand/reduce)

Laureate Education (Producer). (2019a). Adult geriatric depression [Interactive media file]. Baltimore, MD: Author.

NURS 6521N Week 8 Assignment

In this interactive media piece, you will engage in a set of decisions for prescribing and recommending pharmacotherapeutics to treat adult geriatric depression.

Laureate Education (Producer). (2019c). Attention deficit hyperactivity disorder [Interactive media file]. Baltimore, MD: Author.

 

In this interactive media piece, you will engage in a set of decisions for prescribing and recommending pharmacotherapeutics to treat attention deficit hyperactivity disorder.

Laureate Education (Producer). (2019d). Bipolar therapy [Interactive media file]. Baltimore, MD: Author.

NURS 6521N Week 8 Assignment

In this interactive media piece, you will engage in a set of decisions for prescribing and recommending pharmacotherapeutics for bipolar therapy.

Laureate Education (Producer). (2019g). Generalized anxiety disorder [Interactive media file]. Baltimore, MD: Author.

 

In this interactive media piece, you will engage in a set of decisions for prescribing and recommending pharmacotherapeutics to treat generalized anxiety disorder.

Discussion: Decision Making When Treating Psychological Disorders

For this Discussion, you will select an interactive media piece to practice decision making when treating patients with psychological disorders. You will recommend the most effective pharmacotherapeutic to treat the psychological disorder presented and examine potential impacts of pharmacotherapeutics on a patient’s pathophysiology.

To Prepare

• Review this week’s interactive media pieces and select one to focus on for this Discussion.
• Reflect on the decision steps in the interactive media pieces, and consider the potential impacts from the administration of the associated pharmacotherapeutics on the patient’s pathophysiology. NURS 6521N Week 8 Assignment

By Day 3 of Week 8

Post a brief explanation of the psychological disorder presented and the decision steps you applied in completing the interactive media piece for the psychological disorder you selected. Then, explain how the administration of the associated pharmacotherapeutics you recommended may impact the patient’s pathophysiology. How might these potential impacts inform how you would suggest treatment plans for this patient? Be specific and provide examples. NURS 6521N Week 8 Assignment

Sample Approach to Discussion

Brief Explanation of Generalized Anxiety DisorderThe psychological disorder presented in interactive media piece is Generalized Anxiety Disorder (GAD). GAD is a chronic condition characterized by uncontrollable worrying. The hallmark of GAD is unrealistic or excessive anxiety about several events or activities that lasts 6 months or longer. Most patients with GAD also have another psychiatric disorder, usually depression (Rosenthal & Burchum, 2020). Anxiety disorders are the most common type of psychiatric illness and GAD is the most frequent anxiety disorder, affecting about 5% of adults in the primary care setting (Bandelow & Michaelis, 2015).

Scenario

The client is a 46-year-old white male who works as a welder at a local steel fabrication factory. He presents today after being referred by his PCP after a trip to the emergency room in which he felt he was having a heart attack. He stated that he felt chest tightness, shortness of breath, and feeling of impending doom. He does have some mild hypertension (which is treated with low sodium diet) and is about 15 lbs. overweight. He had his tonsils removed when he was 8 years old, but his medical history since that time has been unremarkable. Myocardial infarction was ruled out in the ER and his EKG was normal.

Remainder of physical exam was WNL. He admits that he still has problems with tightness in the chest and episodes of shortness of breath- he now terms these “anxiety attacks.” He will also report occasional feelings of impending doom, and the need to “run” or “escape” from wherever he is at. In your office, he confesses to occasional use of ETOH to combat worries about work. NURS 6521N Week 8 Assignment

He admits to consuming about 3-4 beers/night. Although he is single, he is attempting to care for aging parents in his home. He reports that the management at his place of employment is harsh, and he fears for his job. You administer the HAM-A, which yields a score of 26. Client has never been on any type of psychotropic medication.

Results of Mental Status Exam-                                                                                                                                                                                The client is alert, oriented to person, place, time, and event. He is appropriately dressed. Speech is clear, coherent, and goal directed. Client’s self-reported mood is “bleh” and he does endorse feeling “nervous”. Affect is somewhat blunted but does brighten several times throughout the clinical interview. Affect broad. Client denies visual or auditory hallucinations, no overt delusional or paranoid thought processes readily apparent. Judgment is grossly intact, as is insight. He denies suicidal or homicidal ideation. NURS 6521N Week 8 Assignment

Steps Applied in Interactive Media

Decision point one– Begin Buspirone 10 mg orally BID. Which yield a result of slight decrease in symptoms and a HAM-A score decreased from 26 to 23 which indicates a decrease from severe anxiety to moderate anxiety (Matza et al., 2010). However, the client reports that he still feels very anxious after four weeks.

Decision Point Two– Discontinue buspirone and begin Lexapro 10mg orally daily. Results after four weeks from medication change include client reports that he feels “great”, client states that his anxiety is getting “better”, and a HAM-A score has decreased from 23 to 13 which indicates mild anxiety. However, client does report that he sometimes feels sleepy for a few hours after taking the medication, but “perks up” by early to mid afternoon.  NURS 6521N Week 8 Assignment

Decision Point Three– Continue same dose of Lexapro but change administration time to bedtime. Guidance to Student after third decision: At this point, the client reports that he is feeling “great” with a decrease in symptoms from an initial HAM-A score of 26 down to 13. This represents a 50% decrease in symptoms in just 4 weeks. Recall that an adequate trail can be as long as 12 weeks, we may not need to increase the drug any more at this point as we do not know how much more the current dose will improve the client’s symptoms.

You could increase the dose, but this could increase the risk of side effects- especially the sleepiness that the client is complaining about in the morning after taking the medication. It is plausible that an increase in the dose would increase morning sedation. The most prudent course of action would be to continue the same dose of medication but change the administration time to bedtime.

This way, the client will not be troubled by the sedating effects of the medication, and sleep may be enhanced which could also improve overall anxiety. At this point, nothing in the client presentation suggests the need to augment his Lexapro with any other agents. Therefore, buspirone augmentation would not be an appropriate response. NURS 6521N Week 8 Assignment

Explanation of Treatment Plan

The client was started on Buspirone 10 mg orally BID. Buspirone is an approved anxiolytic medication and indicated for GAD and while it is therapeutic affect is not rapid, I felt this was a good medication to start with for multiple reasons. First, buspirone is not known for causing weight gain, ant with the client already 15 lbs. overweight additional weight gain may cause the client to be noncompliant.

Second, the client admits to consuming 3-4 beers a night. Buspirone has no abuse potential and does not intensify the effects of CNS depressants thus may be especially appropriate for patients known to abuse alcohol and other drugs (Rosenthal & Burchum, 2020).  NURS 6521N Week 8 Assignment

Of course, I would instruct and encourage the client not to consume any alcohol, but if he continues, I felt this would be the safest option. Third, while the client did score 26 on the HAM-A which does indicate severer anxiety, however the fact that he is under situational stresses such as the new responsibility of caring for his parents in his home and a difficult employment situation, I would augment the buspirone with some nondrug therapies such as supportive therapy, cognitive behavioral therapy (CBT), biofeedback, and relaxation training. Lastly, buspirone has minimal sexual side effects (Wilson & Tripp, 2020), which would be an important aspect for a 46-year-old male.

After four weeks of treatment on buspirone 10 mg client only has minimal improvement, so the decision is made to start the client on Escitalopram/Lexapro which is one of the four SSRI antidepressants approved for the treatment of GAD. Also, in the initial visit the client reported his mood as “bleh” and did have somewhat of a blunted affect which gave me this impression of depressive tendencies.

One of the known adverse effects with Lexapro is hyponatremia and with the client on a low sodium diet to treat his mild hypertension, this would need to be monitored. Another adverse effect of SSRI’s is nausea and vomiting which can increased hyponatremia also initially cause weight loss, however with long-term treatment may cause the weight to be regained, and then some. NURS 6521N Week 8 Assignment

So patient education will be important. Also, teaching on the importance of taking the medication in a safe and controlled place until the effects of the medication are known and the signs and symptoms of Serotonin Syndrome from increasing serotonergic transmission in the brainstem and spinal cord. There is also the possibility of extrapyramidal symptoms (EPS).

The most common EPS for patients taking SSRI’s is akathisia. Lastly, the risk for suicide. All antidepressants have the ability to cause or increase the risk of suicidal ideation, so patients taking antidepressant drugs should be observed closely for suicidality, worsening mood, and unusual changes in behavior (Rosenthal & Burchum, 2020).

The change to Lexapro 10 mg orally daily yielded overall positive effects with the exception of feeling sleepy for a few hours after taking the medication, which will be remedied by changing the administration time to bedtime. The maximal therapeutic response may take up to 12 weeks, so there is still hope for continued relief of GAD symptoms.

After symptoms are in remission, treatment should continue for at least 4 to 9 months to prevent relapse (Rosenthal & Burchum, 2020). With the use of Lexapro and the use of supportive therapy, CBT, biofeedback, and or relaxation training ideally this client can get off medication and manage his GAD solely with nondrug therapies. NURS 6521N Week 8 Assignment

References

Bandelow, B., & Michaelis, S. (2015). Epidemiology of anxiety disorders in the 21st century. Dialogues in Clinical Neuroscience, 327-335.

Matza et al. (2010). Identifying HAM-A cutoffs for mild, moderate, and severe generalized anxiety disorder. International Journal of Methods in Psychiatric Research, 223-232.

Rosenthal, L. D., & Burchum, J. R. (2020). Lehne’s pharmacotherapeutics for advanced practice providers. Philadelphia: Saunders.

Wilson, K. T., & Tripp, J. (2020, March 16). Buspirone. Retrieved from StatPearls: https://www.ncbi.nlm.nih.gov/books/

By Day 6 of Week 8

Read a selection of your colleagues’ responses and respond to at least two of your colleagues on two different days who selected a different interactive media piece on a psychological disorder, and provide recommendations for alternative drug treatments to address the patient’s pathophysiology. NURS 6521N Week 8 Assignment

Note: For this Discussion, you are required to complete your initial post before you will be able to view and respond to your colleagues’ postings. Begin by clicking on the “Post to Discussion Question” link, and then select “Create Thread” to complete your initial post. Remember, once you click on Submit, you cannot delete or edit your own posts, and you cannot post anonymously. Please check your post carefully before clicking on Submit!

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Assignment: Decision Tree for Neurological and Musculoskeletal

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