Delusional Disorders

Week 6: Antipsychotic Therapy

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. Delusional Disorders

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

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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 to develop personalized plans of antipsychotic therapy for clients

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

·         Evaluate 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 https://www.clozapinerems.com/CpmgClozapineUI/rems/pdf/resources/Clozapine_REMS_A_Guide_for_Healthcare_Providers.pdf Delusional Disorders

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.

The Assignment

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.

At each decision point stop to complete the following:

·         Decision #1

o    Which decision did you select?

o    Why did you select this decision? Support your response with evidence and references to the Learning Resources.

o    What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.

o    Explain any difference between what you expected to achieve with Decision #1 and the results of the decision. Why were they different?

·         Decision #2

o    Why did you select this decision? Support your response with evidence and references to the Learning Resources.

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o    What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.

o    Explain any difference between what you expected to achieve with Decision #2 and the results of the decision. Why were they different?

·         Decision #3

o    Why did you select this decision? Support your response with evidence and references to the Learning Resources.

o    What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.

o    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.

Note: Support your rationale with a minimum of three academic resources. While you may use the course text to support your rationale, it will not count toward the resource requirement.

Delusional Disorders Pakistani Female With Delusional Thought Processes

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

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

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). Delusional Disorders

Professional Identity And Stewardship – Part II: Leadership Interview

DUE ON FRODAY (9/29/2017) AT 10AM SHARP

BE SURE TO FOLLOW ALL INSTRUCTIONS OR A DESPITE WILL BE MADE!!! 

Details:

Interview a person in a formal position of leadership within your organization (e.g., a supervisor, a manager, a director). Begin your interview with the following questions:

1. What is your role as a health care team member?
2. How do you define professionalism and how does professional responsibility influence your work?
3. Do you consider yourself a steward of health care? Why or Why not?
4. Is it important to you that leaders exercise professional advocacy and authenticity as well as power and influence when working with colleagues? Why or why not? Professional Identity And Stewardship – Part II: Leadership Interview

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In 500-750 words, summarize your interview and share your impressions of the leader’s responses. STAY WITHIN WORD COUNT

Compare and contrast responses provided by your peer (in Professional Identity and Stewardship – Part I: Peer Interview assignment) with those provided by the leader. Share your impressions of their differences and similarities.

Prepare this assignment according to the APA guidelines found in the APA Style Guide.

This assignment uses a grading rubric. SEE RUBRIC ATTACHMENT. Instructors will be using the rubric to grade the assignment; therefore, students should review the rubric prior to beginning the assignment to become familiar with the assignment criteria and expectations for successful completion of the assignment.

You are required to submit this assignment to Turnitin. SIMILARITY INDEX SHOULD NOT EXCEED 15% Professional Identity And Stewardship – Part II: Leadership Interview

significance of the subjective and objective data

The case scenario provided will be used to answer the discussion questions that follow.

Case Scenario

Ms. G., a 23-year-old diabetic, is admitted to the hospital with a cellulitis of her left lower leg. She has been applying heating pads to the leg for the last 48 hours, but the leg has become more painful and she has developed chilling.

Subjective Data

• Complains of pain and heaviness in her leg.
• States she cannot bear weight on her leg and has been in bed for 3 days.
• Lives alone and has not had anyone to help her with meals. significance of the subjective and objective data
•  

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Objective Data

• Round, yellow-red, 2 cm diameter, 1 cm deep, open wound above medial malleolus with moderate amount of thick yellow drainage
• Left leg red from knee to ankle
• Calf measurement on left 3 in > than right
• Temperature: 38.9 degrees C
• Height: 160 cm; Weight: 83.7 kg

Laboratory Results

• WBC 18.3 x 10¹² / L; 80% neutrophils, 12% bands
• Wound culture: Staphylococcus aureus

Critical Thinking Questions

1. What clinical manifestations are present in Ms. G and what recommendations would you make for continued treatment? Provide rationale for your recommendations.
2. Identify the muscle groups likely to be affected by Ms. G’s condition by referring to “ARC: Anatomy Resource Center.” significance of the subjective and objective data 
3. What is the significance of the subjective and objective data provided with regard to follow-up diagnostic/laboratory testing, education, and future preventative care? Provide rationale for your answer.
4. What factors are present in this situation that could delay wound healing, and what precautions are required to prevent delayed wound healing? Explain. significance of the subjective and objective data 

Workflow analysis

Workflow analysis aims to determine workflow patterns that maximize the effective use of resources and minimize activities that do not add value. There are a variety of tools that can be used to analyze the workflow of processes and clarify potential avenues for eliminating waste. Flowcharts are a basic and commonly used workflow analysis method that can help highlight areas in need of streamlining. Workflow analysis

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In this Assignment, you select a common event that occurs regularly in your organization and create a flowchart representing the workflow. You analyze the process you have diagrammed and propose changes for improvement.

To prepare:

• Identify a common, simple event that frequently occurs in your organization that you would like to evaluate.
• Consider how you would design a flowchart to represent the current workflow.
• Consider what metrics you would use to determine the effectiveness of the current workflow and identify areas of waste.

To complete:

Write a 3- to 5-page paper which includes the following:

• Create a simple flowchart of the activity you selected. (Review the Sample Workflow of Answering a Telephone in an Office document found in this week’s Learning Resources for an example.) Workflow analysis
• Next, in your paper:
  • Explain the process you have diagrammed.
  • For each step or decision point in the process, identify the following:
    • Who does this step? (It can be several people.)
    • What technology is used?
    • What policies and rules are involved in determining how, when, why, or where the step is executed?
    • What information is needed for the execution of this step?
  • Describe the metric that is currently used to measure the soundness of the workflow. Is it effective?
  • Describe any areas where improvements could occur and propose changes that could bring about these improvements in the workflow.
  • Summarize why it is important to be aware of the flow of an activity.
• Remember to include a cover page, introduction, and summary for your paper. Workflow analysis