NURS 6630 Assignment 2: Assessing and Treating Patients With Sleep/Wake Disorders Essay

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.

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.

 

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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.

 

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.

SUBJECTIVE

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.

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

Select what you should do:

Zolpidem: 10 mg daily at bedtime

Trazodone 50 mg po at bedtime

Hydroxyzine: 50 mg daily at bedtime

 

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Solution To : Assessing and Treating Patients with Sleep/Wake Disorders Assignment

Sleep disorders are among mental health conditions that affect the normal and efficient functioning of people; they alter the sleep-wake cycle which affects a person’s mental health. Majority of patients suffering from the condition present severe episodes that impact on the overall quality. The condition not only affects the mental health of the patient but also the economic wellbeing as some of the patients cannot take part in day to day economic activities (Fernandez-Mendoza & Vgontzas, 2013). Due to the adverse effects associated with the development of the condition, it is necessary for patients to receive effective medications to help ease the symptoms and hence promote healthy mental state.

Insomnia is a common sleep disorder that is prevalent among people with mental illnesses and it affects the ability of a patient to fall asleep, maintain a sleep status or fall asleep again after a sudden awaking (Riemann et al., 2017). In the United States, insomnia affects a large population that is estimated to be around 60 million and it remains to be the most common sleep disorder. Insomnia can either acute, therefore last for one or few days; it can also be chronic and last for several weeks. The etiology of insomnia is based on several factors that include stress, working conditions, family issues, trauma or even the loss of a loved one. Apart from medications, insomnia treatment also emphasizes on sleep hygiene, avoiding some drugs such as alcohol and caffeine as well as following sleep schedules promptly. This paper aims to assess a case study of a patient suffering from insomnia and the recommendation of suitable medical interventions to manage the disorder.

 

 

Case summary

The study involves a 31 years old male who presented himself to a health facility with the main complaint of insomnia. The patient stated that his insomnia condition has vividly worsened progressively which has made it difficult for the patient to fall asleep with ease at night. The cause of the condition as confessed by the patient was due to the loss of a loved one, his fiancé which led to an emotional stress. Besides affecting his health, the patient laments that his performance at work has been immensely affected because he works in a local chemical company where alertness is essential. The patient denied any form of suicidal intentions and he remained alert and properly focused and has no incidences of visual or auditory hallucinations. To ensure that he falls asleep, the patient uses alcohol before going to bed to facilitate his ability to sleep.

Previously, the patient had used hydrocodone which was prescribed to him after an accident at work that saw him break his ankle a period where opiate abuse was evident. The patient currently uses diphenhydramine but is not satisfied with its effects. Appropriate prescription of medications for the patient is essential because it will determine among other factors his ability to concentrate effectively at his workplace and hence improve his wellbeing.

The prescription decision making for the patient will be based on the medical history obtained from the patient. Besides, the decision making will also consider some other pertinent issues such as the employment status of the patient because the medications should help him fit in the workplace effectively. Some of the factors that must be considered include the emotional trauma due to the loss of a loved one; alcohol consumption to promote sleep and the past opiate abuse.

Decision 1

The first decision entails the administration of 50-100 mg of trazodone daily at bedtime. Trazodone is an antidepressant which works by inhibiting the reuptake of serotonin and also blocks histamine and alpha-1 adrenergic receptors. Trazodone is a triazolopyridine divertive which enables it to effects the inhibition properties. Besides, it is also a reuptake inhibitor and a serotonin antagonist. Even though the drug is an off-label drug, one of the factors that contribute to its selection for treating sleep disorders is its profound and effective mode of action. Clinically, trazodone has been proven to  be effective in the treatment of depression hence, its appropriate application for the case study given that the patient is currently suffering from depression after losing his fiancé (Jaffer et al., 2017). Because the case study aligns with the condition that is treated by the drug, it will be wise to prescribe the drug to the patient to manage his case.

The administration of 10mg zolpidem orally is not appropriate for the patient because it has undesirable side effects that the patient finds unworthy his case. Some of the side effects that are associated with the use of the drug include drowsiness and hallucinations (Sateia et al., 2017). The patient was also administered an antihistamine, hydroxyzine 50mg orally at bedtime. Hydroxyzine is used to in the treatment of nausea and itchiness and anxiety which is not in line with the diagnosis of the patient which is insomnia. Trazodone 50 mg was also administered for the patient with the expectation of improvement in sleep patterns without causing adverse effects to the patient. In terms of the ethical considerations for choosing the drug, the patient autonomy should be considered when making the decision for the drug because even though it is effective. It has some side effects of priapism which interferes with his routine.

Decision 2

The second decision recommended for the patient is the reduction of the dosage for the drug, trazodone to 25 mg from 50 mg at bedtime. Decreasing the dosage from 50 to 25 is justified because the patient reported an improvement in his symptoms after the first decision with mild side effects which makes reduction in dosage an ideal decision. Yi et al. (2018), report that the reduction in drug dosage of trazodone is effective with a decrease in general dosage form associated with a reduction in the side effects associated with the condition. A general reduction in the dose of trazodone is effective against the reduction in the severity of symptoms leading to a healthy mental state.

One option that is associated with the use of the drug is to explain to the patient the side effects of trazodone because it has proved to be effective in managing the condition. For instance, one of the most common side effects of the drug is priapism which is associated with an increase in blood flow. Therefore, there is need to explain to the patient that with time, priapism will diminish with time given that the drug is effective. Another option is to discontinue trazodone and introduce suvorexant 10 mg at bed time. The drug is effective against insomnia but has several side effects that include diarrhea and upper respiratory tract infections (Sateia et al., 2017). Therefore, it is not advisable to discontinue trazodone and replace with suvorexant because the patient is able to tolerate the side effects of the first drug. One major ethical consideration for the drug is beneficence in that the aim of the decision is to increase the benefit to the patient.

 

 

Decision 3

After making the second decision, there were positive improvements noticed by the patient with no noticeable side effects indicating that the drug is effective and the patient can tolerate the effects which is fine with the patient. One of the concerns raised by the patient regarding the second decision is that the drug dosage was not effective to maintain her asleep the whole night meaning that there is need to maintain the drug dose because reducing the dosage could lead to a less effective dose and hence not appropriate for his condition. Beside another decision is to encourage sleep hygiene which includes maintaining a conducive sleeping environment and adhering to some hygienic sleep behaviors that encourage effective and sufficient sleep (Chung et al., 2018). One of the reasons for making the decision is that sleep hygiene and other related practices are essential in creating awareness to the patient and hence encourage a healthy sleeping pattern. For instance, there is need to have fixed and scheduled times for sleeping to create a conducive sleep pattern. Also, creating a conducive sleep environment is essential in ensuring that there are minimal distractions that can affect the quality and quantity of sleep for the patient. An ethical concern associated with the decision is confidentiality where the patient must be allowed free space free from distractions that may limit his sleep quality and quantity.

Conclusion

The case study involved a case of a 31 year old male presenting signs of insomnia that started after the loss of her fiancé and the symptoms have progressed for a while and increased in intensity. The patient was treated with an antidepressant which he responded to very well even though there were cases of side effects that made the patient feel like discontinuing the drug. However, reduction of the drug dose helped to reduce the side effects and increased rye efficacy of the drug. One of the aspects evident in the case study is effective communication between the healthcare provider and patients to ensure all side effects of drugs are expressed to allow a patient continue with their medications.

 

                                                              References

Chung, K. F., Lee, C. T., Yeung, W. F., Chan, M. S., Chung, E. W. Y., & Lin, W. L. (2018). Sleep hygiene education as a treatment of insomnia: a systematic review and meta-analysis. Family practice, 35(4), 365-375.

Fernandez-Mendoza, J., & Vgontzas, A. N. (2013). Insomnia and its impact on physical and mental health. Current Psychiatry Reports, 15(12), 418. https://doi.org/10.1007/s11920-012-0418-8

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.

Riemann, D., Baglioni, C., Bassetti, C., Bjorvatn, B., Dolenc Groselj, L., Ellis, J. G., … & Spiegelhalder, K. (2017). European guideline for the diagnosis and treatment of insomnia. Journal of sleep research, 26(6), 675-700.

Sateia, M. J., Buysse, D. J., Krystal, A. D., Neubauer, D. N., & Heald, J. L. (2017). Clinical practice guideline for the pharmacologic treatment of chronic insomnia in adults: An American Academy of Sleep Medicine clinical practice guideline. Journal of Clinical Sleep Medicine, 13(2), 307–349. https://jcsm.aasm.org/doi/pdf/10.5664/jcsm.6470

Yi, X. Y., Ni, S. F., Ghadami, M. R., Meng, H. Q., Chen, M. Y., Kuang, L., … & Zhou, X. Y. (2018). Trazodone for the treatment of insomnia: a meta-analysis of randomized placebo-controlled trials. Sleep medicine, 45, 25-32.

 

Learning Resources

Required Readings (click to expand/reduce)

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596

Fernandez-Mendoza, J., & Vgontzas, A. N. (2013). Insomnia and its impact on physical and mental health. Current Psychiatry Reports, 15(12), 418. https://doi.org/10.1007/s11920-012-0418-8

Levenson, J. C., Kay, D. B., & Buysse, D. J. (2015). The pathophysiology of insomnia. Chest, 147(4), 1179–1192. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4388122/

Morgenthaler, T. I., Kapur, V. K., Brown, T. M., Swick, T. J., Alessi, C., Aurora, R. N., Boehlecke, B., Chesson, A. L., Friedman, L., Maganti, R., Owens, J., Pancer, J., & Zak, R. (2007). Practice parameters for the treatment of narcolepsy and other hypersomnias of central origin. SLEEP, 30(12), 1705–1711. https://j2vjt3dnbra3ps7ll1clb4q2-wpengine.netdna-ssl.com/wp-content/uploads/2017/07/PP_Narcolepsy.pdf

Morgenthaler, T. I., Owens, J., Alessi, C., Boehlecke, B, Brown, T. M., Coleman, J., Friedman, L., Kapur, V. K., Lee-Chiong, T., Pancer, J., & Swick, T. J. (2006). Practice parameters for behavioral treatment of bedtime problems and night wakings in infants and young children. SLEEP, 29(1), 1277–1281. https://j2vjt3dnbra3ps7ll1clb4q2-wpengine.netdna-ssl.com/wp-content/uploads/2017/07/PP_NightWakingsChildren.pdf

Sateia, M. J., Buysse, D. J., Krystal, A. D., Neubauer, D. N., & Heald, J. L. (2017). Clinical practice guideline for the pharmacologic treatment of chronic insomnia in adults: An American Academy of Sleep Medicine clinical practice guideline. Journal of Clinical Sleep Medicine, 13(2), 307–349. https://jcsm.aasm.org/doi/pdf/10.5664/jcsm.6470

Winkleman, J. W. (2015). Insomnia disorder. The New England Journal of Medicine, 373(15), 1437–1444. https://doi.org/10.1056/NEJMcp1412740