Nursing Assignment: Assessing and Treating Psychosis and Schizophrenia
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. 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. 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 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 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 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 Document: Midterm Exam Study Guide (PDF) Kay, S. R., Fiszbein, A., & Opler, L. A. (1987). The Positive and Negative Syndrome Scale (PANSS) for schizophrenia. Schizophrenia Bulletin, 13(2), 261-276. Clozapine REMS. (2015). Clozapine REMS: The single shared system for clozapine. Retrieved from Walden University. (2016). ASC success strategies: Studying for and taking a test. Retrieved from 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 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? 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 requiremen Delusional Disorders Pakistani Female With Delusional Thought Processes Hispanic male BACKGROUND The client is a 34-year-old Pakistani female who moved to the United States in her late teens/early 20s. She is currently in an “arranged” marriage (her husband was selected for her since she was 9 years old). She presents to your office today following a 21 day hospitalization for what was diagnosed as “brief psychotic disorder.” She was given this diagnosis as her symptoms have persisted for less than 1 month. Prior to admission, she was reporting visions of Allah, and over the course of a week, she believed that she was the prophet Mohammad. She believed that she would deliver the world from sin. Her husband became concerned about her behavior to the point that he was afraid of leaving their 4 children with her. One evening, she was “out of control” which resulted in his calling the police and her subsequent admission to an inpatient psych unit. During today’s assessment, she appears quite calm, and insists that the entire incident was “blown out of proportion.” She denies that she believed herself to be the prophet Mohammad and states that her husband was just out to get her because he never loved her and wanted an “American wife” instead of her. She tells you that she knows this because the television is telling her so. She currently weighs 140 lbs, and is 5’ 5” SUBJECTIVE Client reports that her mood is “good.” She denies auditory/visual hallucinations, but believes that the television does talk to her. She believes that Allah sends her messages through the TV. At times throughout the clinical interview, she becomes hostile towards the PMHNP, but then calms down. You reviewed her hospital records and find that she has been medically worked up by a physician who reported her to be in overall good health. Lab studies were all within normal limits. Client admits that she stopped taking her Risperdal about a week after she got out of the hospital because she thinks her husband is going to poison her so that he can marry an American woman. MENTAL STATUS EXAM The client is alert, oriented to person, place, time, and event. She is dressed appropriately for the weather and time of year. She demonstrates no noteworthy mannerisms, gestures, or tics. Her speech is slow and at times, interrupted by periods of silence. Self-reported mood is euthymic. Affect constricted. Although the client denies visual or auditory hallucinations, she appears to be “listening” to something. Delusional and paranoid thought processes as described, above. Insight and judgment are impaired. She is currently denying suicidal or homicidal ideation. The PMHNP administers the PANSS which reveals the following scores: -40 for the positive symptoms scale -20 for the negative symptom scale -60 for general psychopathology scale Diagnosis: Schizophrenia, paranoid type RESOURCES § Kay, S. R., Fiszbein, A., & Opler, L. A. (1987). The Positive and Negative Syndrome Scale (PANSS) for schizophrenia. Schizophrenia Bulletin, 13(2), 261-276. § Clozapine REMS. (2015). Clozapine REMS: The single shared system for clozapine. Retrieved from § Paz, Z., Nalls, M. & Ziv, E. (2011). The genetics of benign neutropenia. Israel Medical Association Journal. 13. 625-629. ------------ --free essay sample Assessing and Treating Psychosis and Schizophrenia Student’s Name Institutional Affiliation Course Professor’s Name Date Assessing and Treating Psychosis and Schizophrenia Introduction Treatment of psychosis and schizophrenia requires a series of decisions to manage a condition and minimize side effects. One of the best medications is Invega Sustenna 234mg IM XI, followed by 156mg after four days and monthly injections (Johnston et al., 2019). It has minimal side effects compared to other available drugs. Different decisions should consider the condition of a patient to address urgent issues. PMHNP should make the right decisions by selecting the best medication to increase the improvement of patients. Decision#1 The condition of the patient requires PMHNP to make critical decisions to stabilize the condition of the patient. In the first decision, there are three options available, including Zyprexa 10mg PO bedtime and Abilify 10mg PO bedtime. Another option is Invega Sustenna 234mg IM XI, which will be followed by 156mg after four days (Johnston et al., 2019). A monthly injection will also be necessary after the initial treatment. The best choice for decision#1 is to administer Invega Sustenna 234mg IM XI, followed by 156mg after four days and monthly injections. One of the reasons for selecting the decision is because the patient has a history of not taking medication consistently (Hsia et al., 2017). Subjective data shows that the patient stopped taking Risperdal, and thus prescribing an oral medication may not be effective. The patient also believes that her husband is out to poison her, and thus an oral medication is not preferable. According to Hsia et al. (2017), an injection is effective in ensuring the patient gets the necessary medication to promote recovery and reduce the risk of readmission with similar symptoms. Prescribing Abilify 10mg and Zyprexa 10mg to the patient is also not effective due to compliance issues. Zyprexa 10mg is also not a preferred choice since it can trigger significant side effects such as weight gain (Lin et al., 2019). For example, Zyprexa 10mg contains antihistaminic as well as 5HT2C antagonist components. The drug properties can put a patient at risk of diabetes mellitus (Stahl, 2013). Additionally, Abilify 10mg is not a first choice medicine since it can cause side effects such as drowsiness and impulsive behavior. Invega Sustenna 234mg IM XI and its subsequent dosage is the preferred medication. The reason is that the goal of treatment is to eliminate negative symptoms and normalize paranoid schizophrenia (Salvatore et al., 2018). Another reason for prescribing the medication is because Invega binds potently to 5HT2A receptors compared to D2. The ability leads to less extrapyramidal symptoms compared to other antipsychotics. The expectation of treatment is also to eliminate the symptoms that affect the quality of life of a patient, such as delusions while watching television. Treatment also focuses on improving symptoms such as quality of speech, eliminate hallucinations, and getting ‘out of control’ or agitated (Grover et al., 2017). Another expectation is that the PANSS score will reduce by 50 percent of the negative symptoms. The patient reports back to the clinic after four weeks for another monthly injection. The results of decision#1 show the patient has a 25 percent PANSS score. She is complying with the medication, one injection so far, with encouragement from the husband. The progress is commendable since it is the first month of treatment. She also noted a 2-pound weight gain, which was normal. The patient also complains of pain at the injection site, and she is unable to sit for long after the injection (Carlsson et al., 2017). However, the pain is expected, especially with the drug. She is, however, responding positively to the treatment. Decision#2 The best decision in the second step is to continue with the current medication. One of the reasons is that the patient is already responding positively to the drug with minimal side effects (Johnston et al., 2019). For example, the only side effect is adding weight and mild pain at the injection site. It is essential to explain to the client that other drugs responsible for treating paranoid schizophrenia can trigger worse side effects. Therefore, she should cope with the current conditions, although the PMHNP will make all attempts to manage the side effects. It is also not advisable to keep changing the medication, especially while treating mental disorders (Johnston et al., 2019). Patients may take several weeks before exhibiting full recovery. There is an option of adding another drug to the treatment to improve patient outcomes and improve the symptoms. However, the medications are not necessary since polypharmacy can trigger adverse results. Hsia et al. (2017) note that other drugs should only be introduced if the situation is severe, but the current condition shows the patient is responding positively. Evidence-based practice also shows that clinicians should not introduce two drugs through intramuscular injection at the same time (Stahl, 2013). In some cases, drugs should be administered orally in small portions to check the effects before introducing a high dose through an injection. The only change that will be made to the current dosage is the injection site (Salvatore et al., 2018). The client's complaint is pain and the inability to sit or walk for long. Therefore, the nurse should inject the deltoid site in the current injection and the subsequent clinic visits. The expected outcome of the treatment is to realize a 60 percent improvement. Another goal is to suppress the symptoms significantly and restore the client to normalization with the next four weeks (Salvatore et al., 2018). For example, I expect the patient will be positive about her marriage and that nobody wants to poison her. I also expect the patient to watch television normally without any delusions that Prophet Mohammed or God is speaking to her to save the world from sin. I also look forward to improved confidence of the husband to an extent he can peacefully leave children with her. The patient reports back to the clinic after four weeks, accompanied by her husband. The husband is fully supportive of realizing a complete recovery. According to the assessment, the client records a 50 percent reduction of negative symptoms based on the PANSS score. The client appreciates that the medication is preferable in the arm since it has less pain. The patient states she is positive about her marriage, and she does not receive any strange message while listening to television. She is, however, concerned about weight gain and wonders if her husband would still love her. She questions if there is any medication that can reduce weight. Weight gain is normal with the Invega Sustenna injection. Notably, the weight gain is at the peak in the second week since it is time the drug is also altering body processes to bring back a client to normalcy. The expectations and results have major similarities. The similarities include the positivity in her marriage, no more delusions, and a 50 percent improvement in the PANSS score. Different similarities indicate the patient is responding positively to the medication. Decision#3 Decision$3 has few options since the client is already responding positively to Invega Sustenna. However, there are other options available such as Abilify 10mg or Qsymia. One of the reasons for making such a move to change the drug or add another medication is to control the weight (Salvatore et al., 2018). A clinician can avoid such a decision since it can trigger adverse side effects. It is thus recommendable to send the client to an exercise physiologist or nutritionist to help manage weight (Grover et al., 2017). The reason is that weight gain is the only issue the patient raises. Therefore, the best decision is to continue with the medication for another four weeks. A nurse should thus help the client to take another injection. However, an issue was raised in decision$2 during the assessment. According to the patient, the weight issue is affecting her since she is worried her husband may dislike her body shape. One of the best decisions is to refer the client to a dietician, exercise physiologist, or nutritionist (Grover et al., 2017). The purpose of scheduling an appointment with the nutritionist, exercise physiologist, and dietician is to help the patient to manage her diet and weight. Recommending a consultation with a specialist will be effective in addressing the fear of the client. According to Stahl (2013), it is still essential to remind the patient that moderate weight gain is expected with the medication. For example, a nutritionist or physiologist will be essential to tackle the issue and boost the patient’s confidence to continue with the medication (Johnston et al., 2019). A nutritionist will also encourage the client to continue taking the medication since her weight is not at risk. The assessment shows the BMI is 28.9kg/m2, which shows she is below the obesity cutline, which starts at 30kg/m2. The goal of treatment is to realize 80 percent of the decrease in negative symptoms. A significant improvement will help the woman to resume participation in daily activities (Johnston et al., 2019). For example, I expect that the woman will be responsible for her children without any overreaction. She should also be positive about her marriage and believe her husband has no intention to poison her. The woman should also be free of any delusions while watching television, which makes her believe she can be the savior of the world. However, it is not a priority of the treatment goals to reduce the weight of the patient by adding extra medication. Hsia et al. (2017) argue that polypharmacy is not recommended in the treatment of mental disorders since it can cause adverse effects. PMHNP will continue to monitor the patient every month to facilitate a full recovery. The client reports back to the clinic after four weeks. According to the assessment, she has a PANSS score of 80 recovery. The results are similar to the expectations of decision#3. She also reports positive expectations with her marriage and no longer hearing any voice about saving the world. Her husband confirms that she is happy and at peace to leave the children with her. The significant progress was achieved due to the best selection of the medication, follow up clinics, and making the right decisions to address different outcomes. Ethical Issues in Treatment Early treatment of paranoid schizophrenia is one of the effective strategies of overcoming the negative effects of the condition. However, a PMHNP should seek the consent of a patient or family member to begin treatment (Stahl, 2013). In some cases, family members and the patient denies there is a problem. In such a case, open, honest, and evidence-based communication will be essential. Additionally, quality management of care is necessary to ensure successful treatment (Salvatore et al., 2018). The management will require the effective education of the patient. A clinician can use various channels such as talking to a patient, recommending an appointment with a nutritionist, or providing educational materials. Treatment should involve friendly medications based on a client’s condition (Salvatore et al., 2018). A PMHNP should explain to a client about the safest medication available in the market. According to Stahl (2013), the decision is per the ethical guidelines to ‘do no harm.’ Treatment of paranoid schizophrenia requires ethical considerations to improve the welfare and well-being of a patient. Conclusion Treatment of psychosis and schizophrenia is a process that requires a series of decisions. PMHNP makes decisions based on medical history and a patient’s condition. Invega Sustenna 234mg IM XI, followed by 156mg after four days and monthly injections, is the best decision. It is effective since the patient has a history of non-compliance with oral medication. Treatment should also consider ethical issues to improve the well-being of a patient. PMHNP should make accurate decisions by selecting the best medication and managing the condition effectively, including side effects. References Carlsson, I. M., Blomqvist, M., & Jormfeldt, H. (2017). Ethical and methodological issues in qualitative studies involving people with severe and persistent mental illness such as schizophrenia and other psychotic conditions: a critical review. International Journal of Qualitative Studies on Health and Well-Being, 12(sup2), 1368323. Grover, S., Chakrabarti, S., Hazari, N., & Avasthi, A. (2017). Effectiveness of electroconvulsive therapy in patients with treatment-resistant schizophrenia: a retrospective study. Psychiatry Research, 249, 349-353. Hsia, S. L., Leckband, S. G., Rao, S., Jackson, E., & Lacro, J. P. (2017). Dosing strategies for switching from oral risperidone to paliperidone palmitate: Effects on clinical outcomes. Mental Health Clinician, 7(3), 95-100. Johnston, K., Sliwa, J. K., Bossie, C. A., & Kim, E. (2019). Long-Acting Injectable Antipsychotics. Journal of Psychosocial Nursing and Mental Health Services, 57(11), 5-5. Lin, C., Strauss, R., Hong, J., Hamper, J. G., Hoy, E. S., Lazar, A. A., & Kroon, L. (2019). Impact of a pharmacist‐administered long‐acting injectable antipsychotic service in a supermarket‐based community pharmacy on medication adherence. Journal of the American College of Clinical Pharmacy, 2(4), 343-348. Salvatore, G., Buonocore, L., Ottavi, P., Popolo, R., & Dimaggio, G. (2018). Metacognitive interpersonal therapy for treating persecutory delusions in schizophrenia. American Journal of Psychotherapy, 71(4), 164-174. Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (4th ed.). New York, NY: Cambridge University Press.