Discussion: Sleep/Wake Disorders NURS6630

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Discussion: Sleep/Wake Disorders NURS6630

Discussion: Sleep/Wake Disorders NURS6630

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Pharmacologic Agents and Their Dosing

            According to the case, the patient has been diagnosed with comorbid major depressive disorder alongside obstructive sleep apnea. However, the present section will only concern itself with the antidepressant therapy based on agents’ pharmacologic and pharmacokinetic properties. Therefore, the nurse practitioner will consider prescribing Citalopram at a starting dose of 10 mg/d, which will be increased to a maintenance dose of 20mg/d due to the patient’s age (Lavresky et al., 2015). On the other hand, the nurse practitioner should also consider prescribing duloxetine at a starting dose of 30 mg/day that will be increased gradually to 60 mg/day (Stahl, 2014). These two agents are under consideration because of their shorter half-lives and ability to quickly reach maximum plasma concentration.

The former pharmacological agent (Citalopram) is a selective serotonin reuptake inhibitor while the latter (duloxetine) is a serotonin and norepinephrine selective inhibitor. Both inhibit the reuptake of neurotransmitter serotonin, making its level to be higher in the brain (Stahl, 2014). However, duloxetine additionally prevents the reuptake of norepinephrine by the nerve cells, essentially ensuring that the brain has a higher level of neurotransmitters, thus improving mood. Therefore, based on the mechanism of action alone, duloxetine is more effective and will be used by the present nurse practitioner to manage the MDD symptomatology of the present patient.

Contraindications/Alterations of Using Duloxetine

According to available information concerning duloxetine pharmacokinetics and dosage, no study has been conducted to identify the effect of ethnicity on dosage and/or contraindication. However, using other closely-linked antidepressants, Lesser et al. (2010) discovered that no noticeable differences existed in dosages and contraindications in a study sample that consisted of African-Americans and Caucasians. Perhaps the results of this study can be extrapolated to duloxetine and make us to tentatively conclude that ethnicity is not a factor regarding its dosage and contraindications.

Check-Point Data

Assuming that the follow-up data applies to the present drug, there are things that will need to be changed or introduced to the therapy. The results of the first follow-up visit indicate that while the MDD symptoms have received slight improvement, the patient is still symptomatic of OSA. Therefore, duloxetine will be titrated to 40mg/day while the patient will be given a hypnotic, most preferably Gabitril to manage the OSA symptoms.

During the interim follow-up through four months, since the symptoms of MDD still exist, the duloxetine dosage will be increased to 60 mg/day as allowed by various studies. In addition, Gabitril will be replaced with Zaleplon 5 mg at night as the latter is a more effective hypnotic.

During the interim follow-up through nine months, duloxetine should be augmented with bupropion XL (Wellbutrin-XL) to increase the therapy’s anti-depressant effect. In addition, the dosage of Zaleplon should be increased towards the maximum dosage of 10mg/day for the elderly. The interim follow-up through the ninth month will see duloxetine maintained at 60 mg/day, Zaleplon maintained at 10 mg/day as required while there will be an introduction of 300 mg of Gabapentin bi-daily to combat RLS. In addition, Modafinil will also be used 400 mg/d to manage the OSA symptoms. This is expected to provide a full remission of MDD symptoms while significantly managing OSA symptoms.

Discussion: Sleep/Wake Disorders NURS6630
It is not uncommon to experience a night or two of disrupted sleep when there is something major going on in your life. However, sleep/wake disorders are much more than an occasional night of disrupted sleep. A recent report from the Centers for Disease Control and Prevention estimated that between 50 and 70 million American have problems with sleep/wake disorders (CDC, 2015). Although the vast majority of Americans will visit their primary care provider for treatment of these disorders, many providers will refer patients for further evaluation. For this Discussion, you consider how you might assess and treat the individuals based on the provided client factors.

Learning Objectives
Students will:
Assess client factors and history to develop personalized therapy plans for clients with sleep/wake disorders
Analyze factors that influence pharmacokinetic and pharmacodynamic processes in clients requiring therapy for sleep/wake disorders
Evaluate efficacy of treatment plans for clients presenting for sleep/wake therapy
Apply knowledge of providing care to adult and geriatric clients presenting for sleep/wake disorders
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 this link provided.

 

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 11, “Disorders of Sleep and Wakefulness and Their Treatment”
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:

For insomnia

alprazolam
amitriptyline
amoxapine
clomipramine
clonazepam
desipramine
diazepam
doxepin
flunitrazepam
flurazepam
hydroxyzine
imipramine
lorazepam
nortriptyline
ramelteon
temazepam
trazodone
triazolam
trimipramine
zaleplon
zolpidem

 

 

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

 

 

Davidson, J. (2016). Pharmacotherapy of post-traumatic stress disorder: Going beyond the guidelines. British Journal of Psychiatry, 2(6), e16-e18. doi:10.1192/bjpo.bp.116.003707. Retrieved from http://bjpo.rcpsych.org/content/2/6/e16

 

To prepare for this Discussion:

Note: By Day 1 of this week, your Instructor will have assigned you to one of the following case studies to review for this Discussion. To access the following case studies, click on the Case Studies tab on the Stahl Online website and select the appropriate volume and case number.

Case 1: Volume 2, Case #16: The woman who liked late-night TV

Case 2: Volume 2, Case #11: The figment of a man who looked upon the lady

Case 3: Volume 1, Case #5: The sleepy woman with anxiety

Review this week’s Learning Resources and reflect on the insights they provide.
Go to the Stahl Online website and examine the case study you were assigned.
Take the pretest for the case study.
Review the patient intake documentation, psychiatric history, patient file, medication history, etc. As you progress through each section, formulate a list of questions that you might ask the patient if he or she were in your office.
Based on the patient’s case history, consider other people in his or her life that you would need to speak to or get feedback from (i.e., family members, teachers, nursing home aides, etc.).
Consider whether any additional physical exams or diagnostic testing may be necessary for the patient.
Develop a differential diagnoses for the patient. Refer to the DSM-5 in this week’s Learning Resources for guidance.
Review the patient’s past and current medications. Refer to Stahl’s Prescriber’s Guide and consider medications you might select for this patient.
Review the posttest for the case study.
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!

By Day 3
Post a response to the following:

Provide the case number in the subject line of the Discussion.
List three questions you might ask the patient if he or she were in your office. Provide a rationale for why you might ask these questions.
Identify people in the patient’s life you would need to speak to or get feedback from to further assess the patient’s situation. Include specific questions you might ask these people and why.
Explain what physical exams and diagnostic tests would be appropriate for the patient and how the results would be used.
List three differential diagnoses for the patient. Identify the one that you think is most likely and explain why.
List two pharmacologic agents and their dosing that would be appropriate for the patient’s sleep/wake therapy based on pharmacokinetics and pharmacodynamics. From a mechanism of action perspective, provide a rationale for why you might choose one agent over the other.
If your assigned case includes “check points” (i.e., follow-up data at week 4, 8, 12, etc.), indicate any therapeutic changes that you might make based on the data provided.
Explain “lessons learned” from this case study, including how you might apply this case to your own practice when providing care to patients with similar clinical presentations.
Read a selection of your colleagues’ responses.

By Day 6
Respond to at least two of your colleagues who were assigned to a different case than you. For example, if you were assigned to Case Study 1, respond to one colleague assigned to Case Study 2 and one colleague assigned to Case Study 3. Explain how you might apply knowledge gained from your colleagues’ case studies to you own practice in clinical settings.

Submission and Grading Information
Grading Criteria
To access your rubric:

Week 7 Discussion Rubric

 

Post by Day 3 and Respond by Day 6
To participate in this Discussion:

Week 7 Discussion

It is not uncommon to experience a night or two of disrupted sleep when there is something major going on in your life. However, sleep/wake disorders are much more than an occasional night of disrupted sleep. A recent report from the Centers for Disease Control and Prevention estimated that between 50 and 70 million American have problems with sleep/wake disorders (CDC, 2015). Although the vast majority of Americans will visit their primary care provider for treatment of these disorders, many providers will refer patients for further evaluation. For this Discussion, you consider how you might assess and treat the individuals based on the provided client factors. NURS 6630: Therapy for Clients With Pain and Sleep/Wake Disorders.

Learning Objectives

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Students will:
  • Assess client factors and history to develop personalized therapy plans for clients with sleep/wake disorders
  • Analyze factors that influence pharmacokinetic and pharmacodynamic processes in clients requiring therapy for sleep/wake disorders
  • Evaluate efficacy of treatment plans for clients presenting for sleep/wake therapy
  • Apply knowledge of providing care to adult and geriatric clients presenting for sleep/wake disorders

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. NURS 6630: Therapy for Clients With Pain and Sleep/Wake Disorders.

 

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 11, “Disorders of Sleep and Wakefulness and Their Treatment”

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:

For insomnia

  • alprazolam
  • amitriptyline
  • amoxapine
  • clomipramine
  • clonazepam
  • desipramine
  • diazepam
  • doxepin
  • flunitrazepam
  • flurazepam
  • hydroxyzine
  • imipramine
  • lorazepam
  • nortriptyline
  • ramelteon
  • temazepam
  • trazodone
  • triazolam
  • trimipramine
  • zaleplon
  • zolpidem

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

Note: Retrieved from Walden Library databases.

Davidson, J. (2016). Pharmacotherapy of post-traumatic stress disorder: Going beyond the guidelines. British Journal of Psychiatry, 2(6), e16-e18. doi:10.1192/bjpo.bp.116.003707. Retrieved from http://bjpo.rcpsych.org/content/2/6/e16. NURS 6630: Therapy for Clients With Pain and Sleep/Wake Disorders.

To prepare for this Discussion:

Note: By Day 1 of this week, your Instructor will have assigned you to one of the following case studies to review for this Discussion. To access the following case studies, click on the Case Studies tab on the Stahl Online website and select the appropriate volume and case number.

Case 1: Volume 2, Case #16: The woman who liked late-night TV

Case 2: Volume 2, Case #11: The figment of a man who looked upon the lady

Case 3: Volume 1, Case #5: The sleepy woman with anxiety

  • Review this week’s Learning Resources and reflect on the insights they provide.
  • Go to the Stahl Online website and examine the case study you were assigned.
  • Take the pretest for the case study.
  • Review the patient intake documentation, psychiatric history, patient file, medication history, etc. As you progress through each section, formulate a list of questions that you might ask the patient if he or she were in your office.
  • Based on the patient’s case history, consider other people in his or her life that you would need to speak to or get feedback from (i.e., family members, teachers, nursing home aides, etc.).
  • Consider whether any additional physical exams or diagnostic testing may be necessary for the patient.
  • Develop a differential diagnoses for the patient. Refer to the DSM-5 in this week’s Learning Resources for guidance. NURS 6630: Therapy for Clients With Pain and Sleep/Wake Disorders.
  • Review the patient’s past and current medications. Refer to Stahl’s Prescriber’s Guide and consider medications you might select for this patient.
  • Review the posttest for the case study.

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! NURS 6630: Therapy for Clients With Pain and Sleep/Wake Disorders

By Day 3

Post a response to the following:

  • Provide the case number in the subject line of the Discussion.
  • List three questions you might ask the patient if he or she were in your office. Provide a rationale for why you might ask these questions.
  • Identify people in the patient’s life you would need to speak to or get feedback from to further assess the patient’s situation. Include specific questions you might ask these people and why.
  • Explain what physical exams and diagnostic tests would be appropriate for the patient and how the results would be used.
  • List three differential diagnoses for the patient. Identify the one that you think is most likely and explain why.
  • List two pharmacologic agents and their dosing that would be appropriate for the patient’s sleep/wake therapy based on pharmacokinetics and pharmacodynamics. From a mechanism of action perspective, provide a rationale for why you might choose one agent over the other. NURS 6630: Therapy for Clients With Pain and Sleep/Wake Disorders.
  • If your assigned case includes “check points” (i.e., follow-up data at week 4, 8, 12, etc.), indicate any therapeutic changes that you might make based on the data provided.
  • Explain “lessons learned” from this case study, including how you might apply this case to your own practice when providing care to patients with similar clinical presentations. NURS 6630: Therapy for Clients With Pain and Sleep/Wake Disorders.

Read a selection of your colleagues’ responses.

By Day 6

Respond to at least two of your colleagues who were assigned to a different case than you. For example, if you were assigned to Case Study 1, respond to one colleague assigned to Case Study 2 and one colleague assigned to Case Study 3. Explain how you might apply knowledge gained from your colleagues’ case studies to you own practice in clinical settings.

Submission and Grading Information

Grading Criteria

To access your rubric:

Week 7 Discussion Rubric

Post by Day 3 and Respond by Day 6

To participate in this Discussion:

Week 7 Discussion

Pain can greatly influence an individual’s quality of life, as uncontrolled pain negatively impacts mood, concentration, and the overall physical and mental well-being of clients. Although pain can often be controlled with medications, the process of assessing and treating clients can be challenging because pain is such a subjective experience. Only the person experiencing the pain truly knows the intensity of the pain and whether there is a need for medication therapies. Sometimes, beliefs about pain and treatments for pain can have an adverse effect on the provider-client relationship. For this Assignment, as you examine the interactive case study consider how you might assess and treat clients presenting with pain. NURS 6630: Therapy for Clients With Pain and Sleep/Wake Disorders.

Learning Objectives

Students will:
  • Assess client factors and history to develop personalized therapy plans for clients with pain
  • Analyze factors that influence pharmacokinetic and pharmacodynamic processes in clients requiring therapy for pain
  • Evaluate efficacy of treatment plans for clients presenting for pain therapy
  • Analyze ethical and legal implications related to prescribing therapy for clients with pain. NURS 6630: Therapy for Clients With Pain and Sleep/Wake Disorders.

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. NURS 6630: Therapy for Clients With Pain and Sleep/Wake Disorders.

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 10, “Chronic Pain and Its Treatment”

Stahl, S. M., & Ball, S. (2009a). Stahl’s illustrated chronic pain and fibromyalgia. New York, NY: Cambridge University Press. NURS 6630: Therapy for Clients With Pain and Sleep/Wake Disorders.

To access the following chapter, click on the Illustrated Guides tab and then the Chronic Pain and Fibromyalgia tab.

  • Chapter 5, “Pain Drugs”

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. NURS 6630: Therapy for Clients With Pain and Sleep/Wake Disorders.

Review the following medications:

For insomnia

  • amitriptyline
  • amoxapine
  • carbamazepine
  • clomipramine
  • clonidine (adjunct)
  • desipramine
  • dothiepin
  • doxepin
  • duloxetine
  • gabapentin
  • imipramine
  • lamotrigine
  • levetiracetam
  • lofepramine
  • maprotiline
  • memantine
  • milnacipran
  • nortriptyline
  • pregabalin
  • tiagabine
  • topiramate
  • trimipramine
  • valproate (divalproex)
  • zonisamide

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

Note: Retrieved from Walden Library databases.

National Institute of Neurological Disorders and Stroke. (2016). Pain: Hope through research. Retrieved from http://www.ninds.nih.gov/disorders/chronic_pain/detail_chronic_pain.htm#3084_2

Required Media

Laureate Education (2016a). Case study: A Caucasian man with hip pain [Interactive media file]. Baltimore, MD: Author

Note: This case study will serve as the foundation for this week’s Assignment.

To prepare for this Assignment:

  • Review this week’s Learning Resources. Consider how to assess and treat clients requiring therapy for pain and sleep/wake disorders. NURS 6630: Therapy for Clients With Pain and Sleep/Wake Disorders.

The Assignment

Examine Case Study: A Caucasian Man With Hip Pain. 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
    • Which decision did you select?
    • Why did you select this decision? Support your response with evidence and references to the Learning Resources.
    • What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
    • Explain any difference between what you expected to achieve with Decision #1 and the results of the decision. Why were they different? NURS 6630: Therapy for Clients With Pain and Sleep/Wake Disorders.
  • Decision #2
    • Why did you select this decision? Support your response with evidence and references to the Learning Resources.
    • What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
    • Explain any difference between what you expected to achieve with Decision #2 and the results of the decision. Why were they different?
  • Decision #3
    • Why did you select this decision? Support your response with evidence and references to the Learning Resources.
    • What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
    • 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.

Submission and Grading Information

To submit your completed Assignment for review and grading, do the following:

  • Please save your Assignment using the naming convention “WK7Assgn+last name+first initial.(extension)” as the name.
  • Click the Week 7 Assignment Rubric to review the Grading Criteria for the Assignment.
  • Click the Week 7 Assignment link. You will also be able to “View Rubric” for grading criteria from this area.
  • Next, from the Attach File area, click on the Browse My Computer button. Find the document you saved as “WK7Assgn+last name+first initial.(extension)” and click Open.
  • If applicable: From the Plagiarism Tools area, click the checkbox for I agree to submit my paper(s) to the Global Reference Database.
  • Click on the Submit button to complete your submission. NURS 6630: Therapy for Clients With Pain and Sleep/Wake Disorders.
Grading Criteria

To access your rubric:

Week 7 Assignment Rubric

Check Your Assignment Draft for Authenticity

To check your Assignment draft for authenticity:

Submit your Week 7 Assignment draft and review the originality report.

Submit Your Assignment by Day 7

To submit your Assignment:

Week 7 Assignment


Making Connections

Now that you have:

  • Assessed clients presenting with pain and sleep/wake disorders
  • Developed personalized plans of therapy for clients with pain and sleep/wake disorders
  • Examined factors that influence pharmacokinetic and pharmacodynamic processes in clients requiring therapy for pain and sleep/wake disorders. NURS 6630: Therapy for Clients With Pain and Sleep/Wake Disorders.
  • Explored ethical and legal implications of prescribing therapy to clients with pain and sleep/wake disorders

Next week, you will build on your assessment and treatment skills as you examine clients presenting for therapy for impulsivity, compulsivity, and addiction.

Week 7: Therapy for Clients With Pain and Sleep/Wake Disorders

From negative changes in mood to problems concentrating, pain and sleep/wake disorders can have a tremendous impact on clients’ lives. When clients 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 pain and sleep/wake disorders may be addictive, making thorough client assessments and close follow-up care essential. To prescribe appropriate therapies with client safety in mind, you must understand not only the pathophysiology of these disorders, but also the pharmacologic agents used to treat them. NURS 6630: Therapy for Clients With Pain and Sleep/Wake Disorders.

This week, as you study therapies for individuals with pain and sleep/wake disorders, you examine the assessment and treatment of clients with these disorders. You also explore ethical and legal implications of these therapies. NURS 6630: Therapy for Clients With Pain and Sleep/Wake Disorders

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