NURS 6630 Treatment for a Patient With a Common Condition

NURS 6630 Treatment for a Patient With a Common Condition

List three questions you might ask the patient if she were in your office. Provide a rationale for why you might ask these questions.

1. Do you drink caffeinated drinks? If yes, how many do your drink a day and at what time?

Rationale: Caffeine is a substance that makes you more alert. When people have caffeine during the day, it lowers the amount of a substance called 6-sulfatoxymelatonin at night. This can mess up your sleep (O’Callaghan et al., 2018). When you don’t get enough sleep, it can make it hard for your brain to work well and affect how your body responds (O’Callaghan et al., 2018).

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1. How many hours of sleep are you getting each night?

Rationale: As per Levenson and colleagues, if someone is dealing with bothersome thoughts or worrying too much, it can mess up their sleep (2015). When you don’t get enough sleep, it can make you even more anxious and can cause trouble sleeping, like insomnia (Levenson et al., 2015).

1. Have you had any feelings of depression, hopelessness, or feeling down in the past month?

Rationale: People who have been through a big loss are more likely to get depressed. When someone has depression, they often have trouble sleeping. This question is one of two that can help figure out if a person might be depressed and if they need more help (Assessment of Depression in Adults in Primary Care, 2020). In the situation you mentioned, the patient’s husband passed away ten months ago. If the patient says yes to this question, it’s really important to also check if they might be thinking about hurting themselves.

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.

Getting information from people who know the patient well, like family, friends, or caregivers, is crucial. It would be great if these people have known the patient both before and after her husband passed away. You can start by asking the patient how she got to the appointment. If someone brought her, you can check if it’s okay to talk to them. You can ask them various questions to get a better understanding of the situation.

Have you noticed a change in her interest in doing things?

Have you she seemed down or hopeless?

How has she been eating?

Do you know if she is taking her medications or noticed any side effects from her medications?

Have you noticed any anxiety or changes in memory?

Explain what, if any, physical exams and diagnostic tests would be appropriate for the patient and how the results would be used.

In the first meeting, it’s possible to check if the patient is experiencing depression. There are various ways to do this. Healthcare providers can use tools like the Mini-Mental State Exam (MMSE), the Geriatric Depression Scale Short Form (SGDS), or the Cornell Scale for Depression in Dementia (CSDD) (Brown et al., 2015). It’s crucial to consider that older adults with depression might also have dementia, so checking for dementia is important (Brown et al., 2015). The CSDD can identify depression in individuals with cognitive issues. The SGDS is used because it’s relatively simple and short and can detect depression in older adults (Brown et al., 2015).

Additionally, it’s essential to perform laboratory tests because certain medical conditions can lead to insomnia and depression. Initial lab work should include checking glucose levels, liver function, complete blood count, Erythrocyte Sedimentation Rate, urea, creatinine, electrolytes, B-12, and Iron studies.

List a differential diagnosis for the patient. Identify the one that you think is most likely and explain why.

A potential alternative diagnosis for depression in an older patient could be Vascular Depression. This condition is typically observed in individuals aged 60 and above who haven’t had a history of depression before (Small, 2009). It can occur in patients with high blood pressure or a previous history of vascular diseases, which are believed to trigger inflammation in the vascular system and the release of certain chemicals called cytokines, especially after a stressful event (Jeon & Kim, 2018). Considering the patient’s medications, she is taking both Losartan and hydrochlorothiazide to manage her hypertension, making the possibility of Vascular Depression as a differential diagnosis worth considering.

List two pharmacologic agents and their dosing that would be appropriate for the patient’s anti-depressant 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.

The patient is presently taking Sertraline 100mg daily. If the patient adheres to this prescribed medication, they should experience an improvement in their depressive symptoms. It’s important to note that the scenario doesn’t specify how long the patient has been on Sertraline. It’s worth considering that one of the potential side effects of SSRIs (like Sertraline) is insomnia. Given this, it may be appropriate to think about enhancing the Sertraline treatment with a low dose of a tricyclic antidepressant (TCA) such as trazodone. Research indicates that TCAs can have a positive impact on sleep, potentially providing relief as early as the first dose (Wichniak et al., 2017). However, it’s crucial to keep in mind that once the patient’s depression symptoms improve, the TCA dosage should be reduced or discontinued as it can lead to excessive sedation (Wichniak et al., 2017).

Additionally, Sertraline can make it challenging to maintain stable blood sugar levels. In such cases, it might be advisable to switch the antidepressant to Bupropion. Studies have demonstrated that Bupropion can effectively treat depression and help control blood sugar levels, particularly in patients with diabetes (Darwish et al., 2018). It’s important to monitor the patient’s blood pressure when using Bupropion since it can potentially raise blood pressure (Darwish et al., 2018).

For the drug therapy, you select, identify any contraindications to use or alterations in dosing that may need to be considered based on ethical prescribing or decision-making. Discuss why the contraindication/alteration you identify exists. That is, what would be problematic with the use of this drug in individuals based on ethical prescribing guidelines or decision-making?

Sertraline should not be used by patients who are taking certain medications such as thioridazine, pimozide, or monoamine oxidase inhibitors, including linezolid or methylene blue. It’s also important not to combine Sertraline with other serotonergic medications (Singh & Saadabad, 2020).

As for Buspirone, it’s not recommended for patients with kidney and liver disease. This is because the effects of the drug may become more pronounced due to the slower removal of the drug by the kidneys or liver (Singh & Saadabad, 2020).

Trazodone, on the other hand, should not be taken by anyone who is currently taking a monoamine oxidase inhibitor (MAOI) or has used an MAOI within the past 14 days (Shin & Saadabadi, 2020).

Include any “check points” (i.e., follow-up data at Week 4, 8, 12, etc.), and indicate any therapeutic changes that you might make based on possible outcomes that may happen given your treatment options chosen.

It would be necessary to follow up with the patient in four weeks to see if adding Trazadone improves the patient’s sleep. If there is no improvement in the patient’s sleep or depressive symptoms, it would be time to consider changing the patient’s medication to buspirone.

References

Assessment of depression in adults in primary care [PDF]. (2020). Best Practice Medicine Journal New Zealand. https://bpac.org.nz/magazine/2009/Adultdep/docs/bpjse_adult_dep_assess_pages8- 12.pdf

Brown, E., Raue, P. J., & Halpert, K. (2015). Evidence-based practice guideline: Depression detection in older adults with dementia. Journal of Gerontological Nursing, 41(11), 15– 21. https://doi.org/10.3928/00989134-20151015-03

Darwish, L., Beroncal, E., Sison, M., & Swardfager, W. (2018). Depression in people with type 2 diabetes: Current perspectives. Diabetes, Metabolic Syndrome and Obesity: Targets and Therapy, Volume 11, 333–343. https://doi.org/10.2147/dmso.s106797

Jeon, S., & Kim, Y.-K. (2018). The role of neuroinflammation and neurovascular dysfunction in major depressive disorder. Journal of Inflammation Research, Volume 11, 179–192. https://doi.org/10.2147/jir.s141033

Levenson, J. C., Kay, D. B., & Buysse, D. J. (2015). The pathophysiology of insomnia. Chest, 147(4), 1179–1192. https://doi.org/10.1378/chest.14-1617

O’Callaghan, F., Muurlink, O., & Reid, N. (2018). Effects of caffeine on sleep quality and daytime functioning. Risk Management and Healthcare Policy, Volume 11, 263–271. https://doi.org/10.2147/rmhp.s156404

Park, L. T., & Zarate, C. A. (2019). Depression in the primary care setting. New England Journal of Medicine, 380(6), 559–568.https://doi.org/10.1056/nejmcp1712493

Shin, J., & Saadabadi, A. (2020). Trazadone. StatPearls. https://doi.org/https://www.ncbi.nlm.nih.gov/books/NBK470560/

Singh, H. K., & Saadabad, A. (2020). Sertraline. StatPearls. https://doi.org/https://www.ncbi.nlm.nih.gov/books/NBK547689/

Small, G. W. (2009). Differential diagnoses and assessment of depression in elderly patients. The Journal of Clinical Psychiatry, 70(12), e47. https://doi.org/10.4088/jcp.8001tx20c

Wichniak, A., Wierzbicka, A., Walęcka, M., & Jernajczyk, W. (2017). Effects of antidepressants on sleep. Current Psychiatry Reports, 19(9). https://doi.org/10.1007/s11920-017-0816-4

NURS 6630 – Treating a Patient With a Common Condition

1. Questions for the Patient

Question 1: “Do you consume drinks with caffeine? If so, how many and at what times?”

Rationale: Caffeine is a stimulant and can disrupt sleep patterns by reducing melatonin metabolites at night (O’Callaghan et al., 2018). Sleep disturbances can affect cognitive function and psychomotor responses.

Question 2: “How many hours of sleep are you getting each night?”

Rationale: Excessive worry and persistent negative thoughts can lead to sleep disruptions (Levenson et al., 2015). Lack of sleep can exacerbate anxiety and insomnia.

Question 3: “Have you experienced feelings of depression, hopelessness, or sadness in the past month?”

Rationale: Individuals who have suffered significant losses, like the patient, are at higher risk for depression. Depression often co-occurs with insomnia. This question helps assess the patient for depression, and if she responds positively, further evaluation for depression and suicide risk is essential.

2. Gathering Information from Others

Collecting information from the patient’s family, friends, and caretakers who are familiar with her daily life is crucial. Specific questions for these individuals could include:

Question 1: “Have you noticed any changes in her interest in doing things?”

Question 2: “Has she appeared down or hopeless?”

Question 3: “How has her appetite been?”

Question 4: “Do you know if she is taking her medications or if she has experienced any side effects?”

Question 5: “Have you observed any signs of anxiety or changes in her memory?”

3. Physical Exams and Diagnostic Tests

In the initial evaluation, screening for depression is essential. Screening tools such as the Mini-Mental State Exam (MMSE), Geriatric Depression Scale Short Form (SGDS), or Cornell Scale for Depression in Dementia (CSDD) can be used (Brown et al., 2015). As older adults with depression may also have dementia, screening for dementia is important. The CSDD can detect depression in individuals with cognitive impairment, while the SGDS is suitable for older adults due to its brevity. Baseline laboratory tests, including glucose, liver function, complete blood count, Erythrocyte Sedimentation Rate, urea, creatinine, electrolytes, B-12, and Iron studies, should be conducted as organic illnesses can lead to insomnia and depression.

4. Differential Diagnosis

A potential differential diagnosis for depression in the elderly patient is Vascular Depression, which occurs in adults over 60 years of age with no prior history of depression. This diagnosis is considered due to the patient’s history of hypertension and the use of Losartan and hydrochlorothiazide, which could potentially lead to inflammation within the vascular system and the release of cytokines, especially after a stressful event (Jeon & Kim, 2018).

5. Pharmacologic Agents and Dosing

The patient is currently taking Sertraline 100mg daily. If her symptoms improve, it may be necessary to consider adding a low-dose tricyclic antidepressant (TCA) like trazodone to address any insomnia caused by the Sertraline. Short-term TCA use can improve sleep and should be adjusted or discontinued as the patient’s depression symptoms improve to avoid oversedation.

Switching to Bupropion is also an option, especially if the patient has diabetes, as studies suggest it can effectively treat depression and control blood sugar levels. However, blood pressure should be closely monitored, as Bupropion may increase it.

6. Contraindications and Dosing Alterations

Sertraline should not be used with certain medications, including thioridazine, pimozide, monoamine oxidase inhibitors, and other serotonergic medications. Buspirone is contraindicated in patients with kidney and liver disease due to potential drug effects due to impaired kidney or liver function. Trazodone should not be taken with a monoamine oxidase inhibitor (Shin & Saadabadi, 2020).

7. Follow-up and Therapeutic Changes

A follow-up in four weeks is necessary to evaluate the effects of adding Trazodone on the patient’s sleep. If there is no improvement in sleep or depressive symptoms, it might be time to consider switching the patient’s medication to Bupropion or exploring other treatment options.