NURS 6630 Week 8 Assignment 2: Assessing and Treating Patients With Sleep/Wake Disorders
BACKGROUND
This week, we examine a 31-year-old male who presents to the office with a chief complaint of insomnia.
SUBJECTIVE
NURS 6630 Week 8.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.NURS 6630 Week 8
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
Trazodone: 50–100 mg daily 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 a prolonged erection of the penis, 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 priapism is a side effect of trazodone that should diminish over time. Continue 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
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.
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 lite. NURS 6630 Week 8
NURS 6630 Week 8 Answer
Introduction to the Case
Insomnia is a recognized sleep disorder characterized by difficulties in falling asleep, maintaining regular and quality sleep, sleep disruption, and often accompanied by significant anxiety. To qualify as insomnia, these issues must persist for a duration of 3 to 4 months or more. It’s important to differentiate insomnia from other conditions such as sleep apnea, narcolepsy, substance abuse, or drug side effects, as per DSM-IV criteria (Olufsen, Sørensen, & Bjorvatn, 2020). Diagnosing insomnia can be challenging, particularly when it co-occurs with anxiety or depression. When insomnia is confirmed, pharmacological therapy is often recommended to alleviate symptoms and achieve remission (Rios et al., 2019).
The case at hand involves a 31-year-old male patient who has been struggling with initiating sleep and maintaining it. Although the patient had a history of difficulty falling asleep, the condition significantly worsened following the loss of his fiancée six months ago. The problem extends to the workplace, where the patient reports falling asleep during the day. His medical history indicates past opiate addiction, which began after an accidental knee injury. The patient also admits to frequently using alcohol before bedtime as a sleep aid. Previous attempts to manage his sleep issues with various medications were unsuccessful, leading to unwanted side effects. Notably, the patient does not report any visual or auditory hallucinations, nor does he express suicidal or homicidal ideation. During a mental examination, he is alert, appropriately dressed, and oriented to person, place, time, and event.NURS 6630 Week 8
Decision #1
The decision is to initiate treatment with Trazodone, administered at 50 mg before bedtime. This choice is based on the drug’s efficacy in treating insomnia and addressing symptoms associated with depression. Trazodone is known for its high effectiveness and has a reduced potential for abuse (Jaffer et al., 2017). Given the patient’s recent loss, which might increase his anxiety and eventually lead to depression, Trazodone is a suitable option. Although he has not received a formal depression diagnosis, the emotional impact of his fiancée’s death is a significant concern (Oh, Kim, Na, Cho, & Chu, 2019). Additionally, Trazodone is commonly prescribed off-label for insomnia, making it a well-recognized option.
Alternative choices, such as Zolpidem and Hydroxyzine, were not selected. Zolpidem is associated with notorious adverse drug events, including dose-dependent sedation and an increased risk of psychomotor impairments (Wong et al., 2017). These effects can be debilitating, interfering with the patient’s daily functioning and overall quality of life. Zolpidem also carries an elevated risk of abuse, which is particularly concerning for individuals who have previously been dependent on substances such as opiates (Wong et al., 2017). Hydroxyzine was deemed less desirable due to its sedative properties, which can lead to increased daytime drowsiness and somnolence (Dirani, Nasreddine, Melhem, Arabi, & Beydoun, 2017). This daytime sleepiness could adversely affect the patient’s work performance and overall daily life.NURS 6630 Week 8
The expected outcome of using Trazodone is to alleviate the patient’s difficulties in achieving and maintaining quality sleep. Additionally, it should help him fall asleep more easily and improve his ability to remain asleep. It is anticipated that the treatment will reduce daytime sleepiness, enhancing his ability to concentrate at work. Trazodone’s mechanism of action involves blocking chemicals that interact with serotonin and various neurotransmitter receptors in the brain, such as alpha1 adrenergic receptors, 5-HT2A receptors, and H1 histamine receptors, thus promoting improved sleep quality (Jaffer et al., 2017).NURS 6630 Week 8
Ethical considerations are essential in ensuring that the selected treatment benefits the patient without causing harm. It is important to closely monitor the patient’s response to the prescribed medication and make necessary adjustments to the treatment plan to ensure the best possible outcome and minimal side effects.
References: (Include the references for Olufsen, Sørensen, & Bjorvatn, 2020; Rios et al., 2019; Jaffer et al., 2017; Oh, Kim, Na, Cho, & Chu, 2019; Wong et al., 2017; Dirani, Nasreddine, Melhem, Arabi, & Beydoun, 2017, and any other relevant sources as needed).
