Case Study For Assessing And Treating Patients With Sleeping Disorder

Case Study For Assessing And Treating Patients With Sleeping Disorder

The prevalence of insomnia has increased dramatically in the United States, becoming the most common sleep disorder (Garland et al., 2018). Insomnia is primarily characterized by poor sleep or “trouble sleeping.” People diagnosed with insomnia report difficulty initiating or maintaining sleep, even if one has an adequate opportunity to sleep, resulting in daytime impairment (Garland et al., 2018). A person meets diagnostic criteria for insomnia disorder if sleep disturbances occur over 3 times weekly for a minimum of 3 months. Insomnia increases the risk of other physical health conditions such as obesity, diabetes mellitus, and cardiovascular diseases, including hypertension, stroke, and heart attack). Additionally, poor sleep affects one’s mental health adversely. According to Garland et al. (2018)Case Study For Assessing And Treating Patients With Sleeping Disorder, insufficient duration or quality sleep increases the risk of anxiety and mood disorders. Inadequate sleep also impairs cognitive functioning, resulting in adverse economic effects. For this reason, mental healthcare providers have embarked on using pharmacological interventions to treat insomnia in various patient populations, including adults. In the presented scenario, the client is a 31yo who presents a chief complaint of insomnia. The client revealed that he has been experiencing insomnia for the past six months and the condition has gotten progressively worse over time. Although he denies being a “great sleeper,” the difficulty to fall and stay asleep at night has worsened. He added that this condition started when he lost his fiancé six months ago. The client reports that this problem is compromising his job perform his job. He added falling asleep at work due to inadequate sleep at night. The client has been using diphenhydramine to initiate and remain asleep although he does not like the morning after feeling. His medical records indicated an opiate abuse history that started when he has prescribed this medication to manage pain after breaking his ankle. This paper presents pharmacological interventions for treating insomnia in this client, including three treatment decisions.

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Decision One

The first treatment decision involves starting Trazodone 50 mg PO at bedtime. This option was preferred following the effectiveness and safety of Trazodone 50 mg in treating insomnia in adults. According to Jaffer et al. (2017), the off-label use of Trazodone 50 mg in treating insomnia in adults has exceeded its use as an antidepressant due to superior results reported by insomnia patients treated using this drug. Hence, starting the client’s treatment with Trazodone 50 mg PO at bedtime was the best decision.

Other decisions, including zolpidem 10mg daily at bedtime and hydroxyzine 50mg daily at bedtime were rejected. First, Zolpidem 10mg daily at bedtime was rejected due to drug-related side effects, including hallucinations, nocturnal behaviors, including eating and sleepwalking, and amnesia (Neubauer, 2021). Additionally, hydroxyzine 50mg daily at bedtime was rejected since it is associated with abuse and dependence liability (Atkin et al., 2018)Case Study For Assessing And Treating Patients With Sleeping Disorder. This drug is unsafe for this client since he has a history of opiate abuse; hence he is likely to develop dependence or abuse it.

It was expected that the client would report improvement in insomnia symptoms upon returning to the clinic after two weeks due to the effectiveness of Trazodone 50 mg in treating insomnia in adults (Jaffer et al., 2017). The client reported that the drug was working well although it was giving him an erection that lasted for about 15 every morning, making him late for work.

In developing this treatment plan, the PMHNP adhered to the ethical principles of patient autonomy and informed consent. The PMHNP disclosed the benefits and potential consequences of all treatment options to the client and allowed him to select his preferred treatment intervention without influencing him.

Decision Two

The second treatment decision involves explaining to the client that a 15-minute erection is priapism and would diminish after some time and advising him to continue with the current medication and dosage, Trazodone 50 mg PO at bedtime. This decision was preferred since the client reported that the current medication was working well when he returned to the clinic after two weeks. Reported improvement indicated the efficacy of the current dosage in treating insomnia in this client; hence should be continued to achieve further improvement. Other potential options were rejected since the client was responding well to Trazodone 50 mg PO at bedtime; hence no need for alternative treatment intervention.

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The client was expected to report further improvement in initial symptoms after continuing with the current dosage for two weeks due to the effectiveness of Trazodone 50 mg in treating insomnia in adults (Jaffer et al., 2017)Case Study For Assessing And Treating Patients With Sleeping Disorder. Additionally, further, improvement was expected since the client responded well to this medication in the first two weeks. Upon returning to the clinic after two weeks, the client reported a diminishing of previously reported priapism. Additionally, he denied visual or audio hallucinations, and he seems to be future-oriented. However, he reported waking up with drowsiness the following morning after, which was associated with Trazodone 50 mg.

In developing this treatment plan, the mental healthcare provider adhered to the ethical principle of beneficence. According to Varkey (2021), the ethical guideline of beneficence holds that healthcare providers should focus on benefiting their patients through provided treatment. In this case, the PMHNP benefited the client by advising him to continue with the current medication, Trazodone 50 mg, which has a success history in treating insomnia symptoms.

Decision Three

The third treatment intervention involves continuing with the current dose and advising the patient to split the 50 mg tablet in half. Taking 25 mg twice daily is expected to reduce next-day drowsiness. Being a selective serotonin reuptake inhibitor, Trazodone is associated with minimal and less severe side effects. Therefore, continuing with the current medication and dividing the tablet into two halves is the best treatment that would improve insomnia symptoms with minimal or zero drug-related side effects.

Other potential options, including sonata and Hydroxyzine, were dismissed. Sonata was rejected since it increases the risk of complex sleep behaviors when used in treating insomnia in adult patients. Additionally, hydroxyzine was dismissed since it is histamine, which is associated with sedative properties, including drowsiness and impaired performance (Kawauchi et al., 2019)Case Study For Assessing And Treating Patients With Sleeping Disorder.

It was expected that the client would report further improvement with minimal or zero side effects upon returning to the clinic after four weeks. The results would be achieved due to the effectiveness of Trazodone in treating insomnia in adults. Additionally, the client was responding well to Trazodone, indicating its effectiveness in treating insomnia symptoms in this client. Lastly, the client would report that drowsiness had decreased or reduced upon dividing the 50mg tablet into 2 halves.

In developing this treatment plan, the PMHNP adhered to the ethical principle of non-beneficence, which holds that healthcare providers should not harm their patients knowingly. In this case, the PMHNP protected the patient from potential harm associated with other potential treatment interventions, including sonata and Hydroxyzine.

Conclusion

Three treatment interventions have been applied in treating insomnia in this client. The first treatment decision involves starting Trazodone 50 mg PO at bedtime. This option was preferred following the effectiveness and safety of Trazodone 50 mg in treating insomnia in adults. Other decisions, including zolpidem 10mg daily at bedtime and hydroxyzine 50mg daily at bedtime were rejected. First, Zolpidem 10mg daily at bedtime was rejected due to drug-related side effects, including hallucinations, nocturnal behaviors, including eating and sleepwalking, and amnesia. Additionally, hydroxyzine 50mg daily at bedtime was rejected since it is associated with abuse and dependence liability. Therefore, this drug is unsafe for this client since he has a history of opiate abuse. It was expected that the client would report improvement in insomnia symptoms upon returning to the clinic after two weeks due to the effectiveness of Trazodone 50 mg in treating insomnia in adults. The second treatment decision involves explaining to the client that a 15-minute erection is priapism and would diminish after some time and advising him to continue with the current medication and dosage, Trazodone 50 mg PO at bedtime. This decision was preferred since the client reported that the current medication was working well when he returned to the clinic after two weeks. Other potential options were rejected since the client was responding well to the current medication. The client was expected to report further improvement in initial symptoms after continuing with the current dosage for two weeks. The third treatment intervention involves continuing with the current dose and advising the patient to split the 50 mg tablet in half. Taking 25 mg twice daily is expected to reduce next-day drowsiness. This treatment option was preferred since Trazodone is a selective serotonin reuptake inhibitor, which has minimal and less severe side effects. Other potential options, including sonata and Hydroxyzine, were dismissed. Sonata was rejected since it increases the risk of complex sleep behaviors when used in treating insomnia in adult patients. Additionally, hydroxyzine was dismissed since it is histamine, which is associated with sedative properties.

References

Atkin, T., Comai, S., & Gobbi, G. (2018). Drugs for insomnia beyond benzodiazepines: pharmacology, clinical applications, and discovery. Pharmacological reviews, 70(2), 197-245. DOI:10.1124/pr.117.014381

Garland, S. N., Rowe, H., Repa, L. M., Fowler, K., Zhou, E. S., & Grandner, M. A. (2018). A decade’s difference: 10-year change in insomnia symptom prevalence in Canada depends on sociodemographics and health status. Sleep Health, 4(2), 160-165. Doi: 10.1016/j.sleh.2018.01.003

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. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5842888/Case Study For Assessing And Treating Patients With Sleeping Disorder

Kawauchi, H., Yanai, K., Wang, D. Y., Itahashi, K., & Okubo, K. (2019). Antihistamines for allergic rhinitis treatment from the viewpoint of nonsedative properties. International journal of molecular sciences, 20(1), 213. Doi: 10.3390/ijms20010213

Neubauer, D. N., Elmore, J. G., & Benca, R. (2021). Pharmacotherapy for insomnia in adults. UpToDate. https://www.uptodate.com/contents/pharmacotherapy-for-insomnia-in-adults.

Varkey, B. (2021). Principles of clinical ethics and their application to practice. Medical Principles and Practice, 30(1), 17-28. https://doi.org/10.1159/000509119 Case Study For Assessing And Treating Patients With Sleeping Disorder

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. 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)Case Study For Assessing And Treating Patients With Sleeping Disorder

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).
Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples Case Study For Assessing And Treating Patients With Sleeping Disorder
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)Case Study For Assessing And Treating Patients With Sleeping Disorder.
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.
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.

By Day 7
Submit your Assignment.

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Click the Week 8 Assignment 2 Rubric to review the Grading Criteria for the Assignment.
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Click on the Submit button to complete your submission.
From negative changes in mood to problems concentrating, sleep/wake disorders can have a tremendous impact on patients’ lives. When patients suffer from these disorders, they often seek medical care with the intent of receiving medications to manage symptoms. However, many of the medications used to treat sleep/wake disorders may be addictive, making thorough patient assessments and close follow-up care essential. To prescribe appropriate therapies with patient safety in mind, you must understand not only the pathophysiology of these disorders but also the pharmacologic agents used to treat them.

This week, as you study therapies for individuals with sleep/wake disorders, you examine the assessment and treatment of patients with these disorders. You also explore ethical and legal implications of these therapies Case Study For Assessing And Treating Patients With Sleeping Disorder.

Learning Objectives

Students will:

Synthesize concepts related to the psychopharmacologic treatment of patients
Assess patient factors and history to develop personalized therapy plans for patients with sleep/wake disorders
Analyze factors that influence pharmacokinetic and pharmacodynamic processes in patients requiring therapy for sleep/wake disorders
Synthesize knowledge of providing care to patients presenting for sleep/wake disorders
Analyze ethical and legal implications related to prescribing therapy for patients with sleep/wake disorders
Insomnia
31-year-old Male

BACKGROUND

This week, we examine a 31-year-old male who presents to the office with a chief complaint of insomnia.
Patient is a 31-year-old male. He states that his insomnia has gotten progressively worse over the past 6 months. Per the patient, he has never been a “great sleeper” but is now having difficulty both falling asleep and staying asleep at night. The problem began approximately 6 months ago after the sudden loss of his fiancé. The patient states this is affecting his ability to perform his job, which is a forklift operator at a local chemical company. The patient states he has used diphenhydramine in the past to sleep but does not like the way it makes him feel the morning after. He states he has fallen asleep on the job due to lack of sleep from the night before. The patient’s medical record from his previous physician states that he has a history of opiate abuse, which began after he broke his ankle in a skiing accident and was prescribed hydrocodone/apap (acetaminophen) for acute pain management. The patient has not received a prescription for an opiate analgesic in 4 years. The patient states recently he has been using alcohol to help him fall asleep, approximately four beers prior to bed Case Study For Assessing And Treating Patients With Sleeping Disorder

MENTAL STATUS EXAM

The patient is alert and oriented to person, place, time, event. He makes good eye contact and is dressed appropriately for time of year. He denies auditory/visual hallucinations. Judgement, insight, and reality contact are all intact. Patient denies suicidal/homicidal ideation, and is future oriented.

Decision Point One
Please Pay Special attention to the answers of the responses AND INCLUDE THEM IN THE ASSIGNMENT.

DECISION 1 IS TO START 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
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

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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 Case Study For Assessing And Treating Patients With Sleeping Disorder