Assessing and Treating Patients with Sleep/Wake Disorders Essay

Assessing and Treating Patients with Sleep/Wake Disorders Essay

Assessing and Treating Patients with Sleep/Wake Disorders Essay

Insomnia is a sleep/wake disorder that affects the quality and quantity of sleep. As a result, people with insomnia face difficulties achieving the therapeutic levels of sleep, which results in daytime sleepiness and fatigue. Besides, the lack of adequate sleep causes anxiety, irritability, and depression, which can cause occupational and social problems (Vargas et al., 2020). Insomnia manifests in different ways. Some individuals experience difficulties falling asleep, while others have frequent nighttime awakenings and struggle to fall asleep. Acute insomnia occurs for less than a month, while chronic insomnia surpasses a month. Insomnia is a common side effect of depressants like alcohol and stimulants like caffeine, which alter the regular sleep cycle (Vargas et al., 2020). The purpose of this paper is to discuss a patient with insomnia and describe the treatment plan, including ethical considerations.

Case Overview

The case study is about a 31-year-old male patient with a primary complaint of insomnia. The patient mentions that insomnia had gradually worsened in the past six months. He reports having problems falling asleep and remaining asleep at night. The sleeping problem began about six months ago after he lost his fiancé. Insomnia affects his job performance. He previously used diphenhydramine to sleep but does not like the side effects. The client has a history of opiate abuse but has not had an opiate prescription for four years.

The specific patient factors that may influence decisions when prescribing for this patient include the pattern of symptoms, treatment goals, past treatment responses, patient preference, and cost (Hassinger et al., 2020). In addition, the clinician should consider the availability of other therapies, comorbid conditions, contraindications, concurrent medication interactions, and potential adverse effects.

Decision #1

Trazodone: 50–100 mg daily at bedtime.

Why I Selected This Decision

Trazodone was selected because it is a sedating antidepressant commonly used in managing insomnia. The drug has a short onset of action and brings about sleep. Krystal et al. (2019) explain that one of trazodone’s side effects is drowsiness which acts to benefit patients in treating sleep-maintenance insomnia and insomnia related to depression.

Zolpidem 10 mg daily was not prescribed due to the complex sleep behaviors associated with the drug. Besides, Zolpidem is associated with treatment-emergent adverse events, like nausea, drowsiness, dizziness, nightmares, and agitation, which have led to its discontinuation. Hydroxyzine was also not administered because it is an antihistamine and has a strong sedation side effect that causes drowsiness (Pagel et al., 2018). Its side effects are similar to the previously prescribed drug diphenhydramine and therefore have a high potential for non-compliance.

What I Was Hoping To Achieve

I hoped that trazodone would improve the patient’s quality and quantity of sleep. I also hoped that the patient would report reduced difficulties initiating and maintaining sleep. Trazodone enhances the quality of sleep and daytime functioning in people with insomnia. Besides, low doses of the drug (25-100 mg) stimulate and maintain sleep with no daytime drowsiness due to its short half-life of 3–6 hours (Hassinger et al., 2020).

How Ethical Considerations May Impact the Treatment Plan

The ethical principles of beneficence and nonmaleficence impacted treatment decisions. The PMHNP selected trazodone because of its strong safety profile and efficacy in alleviating insomnia, which upholds beneficence (Bipeta, 2019). Drugs associated with severe adverse effects were not selected, which promotes nonmaleficence.

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Decision #2

Explain that priapism is a side effect of trazodone that should abate over time and continue dose.

Why I Selected This Decision

The decision was selected because the patient reported experiencing a prolonged erection for roughly 15 minutes after waking. Trazodone is associated with a side effect of priapism (Wang et al., 2020). I continued the dose because the drug’s safety is established and well-tolerated.

The decision to stop trazodone and start Suvorexant was not selected because the patient reported that trazodone was effective. Suvorexant’s side effects include somnolence and abnormal dreams, which would reduce the compliance rate (Krystal et al., 2019). Besides, reducing trazodone to 25 mg was not ideal since low drug doses are ineffective in maintaining a whole night’s sleep due to a short half-life.

What I Was Hoping To Achieve

            I hoped that explaining trazodone’s side effects to the patient would increase compliance with treatment. Besides, I hoped that continuing the initial Trazodone dose would further enhance the quality and quantity of sleep and improve the patient’s daytime functioning. Wang et al. (2020) explain that trazodone helps improve nighttime sleep maintenance without a drowsiness effect. Besides, it can improve cognitive function by increasing serotonin concentration in the synaptic space.

How Ethical Considerations May Impact the Treatment Plan

Beneficence influenced the treatment plan since the PMHNP selected the decision that would promote the best outcomes. The clinician explained to the patient about priapism to improve compliance to treatment and thus promote the best health outcomes. Nonmaleficence was also upheld by selecting the treatment intervention with the least side effects to avoid harming the patient (Bipeta, 2019).

Decision #3

Continue the dose. Explain he may split the 50 mg tablet in half. Follow up in four weeks.

Why I Selected This Decision

I selected this decision because the patient complained of next-day drowsiness, a side effect of trazodone. Therefore, it was appropriate to lower the dose by splitting the tablet in half to reduce the side effect (Krystal et al., 2019). Besides, the patient would be reassessed after four weeks to evaluate if the side effect had diminished and if the drug was still effective in improving insomnia.

Discontinuing Trazodone and staring Sonata was not an ideal decision because the latter is associated with a risk of complex sleep behaviors. Besides, changing therapy to Hydroxyzine was not ideal due to its strong sedative properties that cause drowsiness and dry mouth, which may lower treatment compliance (Pagel et al., 2018).

What I Was Hoping To Achieve

I hoped that reducing the Trazodone dose by splitting the tablet into half would alleviate the side effect of drowsiness. I also hoped that the 25 mg dose would improve sleep quality and alleviate insomnia, similar to the initial 50 mg dose. Hassinger et al. (2020) explain that trazodone promotes a transient improvement in sleep quality and sleep continuity in patients with insomnia.

How Ethical Considerations May Impact the Treatment Plan

The principle of autonomy influenced the treatment plan since the PMHNP had to consider the patient’s complaints of drug side effects when making treatment decisions (Bipeta, 2019). Besides, nonmaleficence impacted the treatment plan when the dose was reduced to reduce the drug’s side effects.

Conclusion

The patient in the case study presented with insomnia, as evidenced by reports of difficulties initiating and maintaining sleep. The patient factors influencing treatment decisions include the pattern of insomnia symptoms, treatment goals, past treatment responses, patient preferences, and comorbid conditions (Hassinger et al., 2020). In the first treatment decision, the patient was initiated on Trazodone 50 mg since it is used to treat insomnia. Trazodone is used off-label and is preferred due to its efficacy and strong safety profile. Zolpidem and Hydroxyzine were not selected because of their associated adverse effects, harming the patient and lowering the treatment compliance rate (Pagel et al., 2018). However, the client complained of priapism, a common side effect of trazodone.

The PMHNP continued the dose and explained to the patient that priapism is a side effect of trazodone that diminishes over time. The aim of this decision was to promote compliance, which is significantly influenced by a drug’s associated side effects (Wang et al., 2020). Suvorexant was not initiated because of its associated somnolence and abnormal dreams. Nevertheless, the patient complained of next-day drowsiness associated with the Trazodone 50 mg dose. The PMHNP advised the patient to split the tablet in half to lower the side effect of drowsiness, which is usually dose-dependence. Ethical factors influencing treatment decisions include beneficence, nonmaleficence, and autonomy (Bipeta, 2019). The PMHNP upheld beneficence and nonmaleficence by selecting treatment options with the best efficacy and least side effects.

 References

Bipeta, R. (2019). Legal and Ethical Aspects of Mental Health Care. Indian journal of psychological medicine, 41(2), 108–112. https://doi.org/10.4103/IJPSYM.IJPSYM_59_19

Hassinger, A. B., Bletnisky, N., Dudekula, R., & El-Solh, A. A. (2020). Selecting a pharmacotherapy regimen for patients with chronic insomnia. Expert opinion on pharmacotherapy, 21(9), 1035–1043. https://doi.org/10.1080/14656566.2020.1743265

Krystal, A. D., Prather, A. A., & Ashbrook, L. H. (2019). The assessment and management of insomnia: an update. World psychiatry: official journal of the World Psychiatric Association (WPA), 18(3), 337–352. https://doi.org/10.1002/wps.20674

Pagel, J. F., Pandi-Perumal, S. R., & Monti, J. M. (2018). Treating insomnia with medications. Sleep Science and Practice, 2(1), 1-12. https://doi.org/10.1186/s41606-018-0025-z

Vargas, I., Nguyen, A. M., Muench, A., Bastien, C. H., Ellis, J. G., & Perlis, M. L. (2020). Acute and Chronic Insomnia: What Has Time and/or Hyperarousal Got to Do with It?. Brain sciences, 10(2), 71. https://doi.org/10.3390/brainsci10020071

Wang, J., Liu, S., Zhao, C., Han, H., Chen, X., Tao, J., & Lu, Z. (2020). Effects of Trazodone on Sleep Quality and Cognitive Function in Arteriosclerotic Cerebral Small Vessel Disease Comorbid With Chronic Insomnia. Frontiers in psychiatry, 11, 620. https://doi.org/10.3389/fpsyt.2020.00620

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Assignment 2: Assessing and Treating Patients With Sleep/Wake Disorders
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)

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.
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).
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.

CASE STUDY
https://cdn-media.waldenu.edu/2dett4d/Walden/NURS/6630/DT/week_11/index.html