[ANSWERED] Pakistani Woman with Delusional Thought Processes

Decision #2 (1–2 pages)

• 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.—

>excellent point range

Excellent Point range: 90–100 18 (18%) – 20 (20%)

Good Point range: 80–89 16 (16%) – 17 (17%)

>fair point range

Fair Point range: 70–79 14 (14%) – 15 (15%)

Poor Point range: 0–69 0 (0%) – 13 (13%)

Decision #3 (1–2 pages)

• 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.—

>excellent point range

Excellent Point range: 90–100 18 (18%) – 20 (20%)

>good point range

Good Point range: 80–89 16 (16%) – 17 (17%)

>fair point range

Fair Point range: 70–79 14 (14%) – 15 (15%)

Poor Point range: 0–69 0 (0%) – 13 (13%)

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.—

Excellent Point range: 90–100 14 (14%) – 15 (15%)

Good Point range: 80–89 12 (12%) – 13 (13%)

Fair Point range: 70–79 11 (11%) – 11 (11%)

Poor Point range: 0–69 0 (0%) – 10 (10%)

Written Expression and Formatting – Paragraph Development and Organization:
Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused—neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria.—

>excellent point range

Excellent Point range: 90–100 5 (5%) – 5 (5%)

Good Point range: 80–89 4 (4%) – 4 (4%)

Fair Point range: 70–79 3.5 (3.5%) – 3.5 (3.5%)

Poor Point range: 0–69 0 (0%) – 3 (3%)

Written Expression and Formatting – English writing standards:
Correct grammar, mechanics, and proper punctuation—

>excellent point range

Excellent Point range: 90–100 5 (5%) – 5 (5%)

Good Point range: 80–89 4 (4%) – 4 (4%)

Fair Point range: 70–79 3.5 (3.5%) – 3.5 (3.5%)

Poor Point range: 0–69 0 (0%) – 3 (3%)

Written Expression and Formatting – The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, parenthetical/in-text citations, and reference list.—

>excellent point range

Excellent Point range: 90–100 5 (5%) – 5 (5%)

Good Point range: 80–89 4 (4%) – 4 (4%)

Fair Point range: 70–79 3.5 (3.5%) – 3.5 (3.5%)

Poor Point range: 0–69 0 (0%) – 3 (3%)

Name: NURS_6630_Week7_Assignment_Rubric

Expert Answer and Explanation

Decision Tree for Patients with Psychosis and Schizophrenia

Introduction to the Case

The client is a 34-year-old Pakistani female who presents to my office today following a 21day hospitalization for what was diagnosed as “brief psychotic disorder.” The diagnosis was reached after suffering the symptoms for less than a month. The patient reported visions of Allah and for a week, she believed to be prophet Mohammad and that she will deliver people from sin.

She went out of control one evening and her husband was forced to call the police who admitted her to an inpatient psych unit. During physical exam, the patient looks calm and insists that the incident was “blown out of proportion.” She notes that her husband is saying these things about her because he wants to get her because she does not love him and that he wants an “American wife”.

She says that she knows this because the television is telling her so. The client denies hallucinations but seems to be listening to something.

She notes that she is in a good mood and believes that Allah is speaking to her through the TV. She became hostile to the PMHNP but calmed down. Her medical records show that she is in an overall good health. She says that she stopped taking Risperdal because she believes that her husband wants to kill her. Mental exam shows that she is oriented and alert but has slow speech that often get interrupted by periods of silence. She has impaired judgment and memory and denies suicidal or homicidal thoughts. Currently, she weights 140 lbs, and is 5’ 5.” PANSS scores show 40 for the positive, 20 for the negative, and 60 for general psychopathology symptoms scales. Based on the objective and subjective data, the patient has schizophrenia, paranoid type. The factors that will influence my decision making when prescribing drugs for the patient include her context and the cost of medication.

Decision Point 1

The first decision I selected is starting Invega Sustenna 234 mg intramuscular X1 followed by 156 mg intramuscular on day 4 and monthly thereafter. I selected this decision because Invega Sustenna was manufactured solely for treatment of patients with schizoaffective disorder and schizophrenia. Pesa et al.

(2017) argue that Invega Sustenna is a second-generation antipsychotic drug that works by rebalancing serotonin and dopamine to improve mood, thinking, judgment, and behavior (Fellner, 2017). Some of the symptoms the drug can reduce include delusions, hallucinations, disorganized thinking, and lack of motivation.

The symptoms are experienced by the patient. I also selected this decision because the drug can be taken for a long time without grave side effects. American Psychiatric Association (2019) note that schizophrenia needs a long-term care, hence patients should take medications that cannot affect them after long-term use.

Lastly, I also selected the medication because it is a second-generation drug, and thus has lower risk of serious side effects.

I did not select the other two provided options in the exercise due to the following reasons. First, I avoided Abilify because according to Mustafa et al. (2019), long-term use of the medication may lead to a condition known as tardive dyskinesia (involuntary movement of lips, jaws, and tongue). Schizophrenia is a long-term disorder, hence prescribing Abilify would be a bad choice.

Second, I did not select Zyprexa because high doses or long-term use of the medication can lead to irreversible disorder, especially if the patient is a woman (Freudenreich et al., 2016). I was hoping to reduce PANSS score by 20% after two weeks of drug usage. When the patient returned to the clinic after four weeks, her PANSS score had reduced by 25% but she complained of injection site pain and 2pounds weight gain.

Ethical consideration might affect the treatment plan in that the patient or her husband must be consulted first before recommending the therapy.

Decision Point 2

In the second decision, I selected is to continue same decision made but instruct administering nurse to begin injections into the deltoid at this visit and moving forward. I selected this decision because her PANSS score had reduced by 25% meaning that she was responding well to the medication. I also selected the decision because the patient seemed to be tolerating medication and that the site of was changed to suit the patient’s request.

Earlier, the client has reported that she was feeling pain in the injection site and had trouble sitting for few hours. So, changing the infection site would help improve the situation.

I did not select the second decision because it involved discontinuation of Invega and starting of Haldol Decanoate. Haldol Decanoate is a first-generation drug. According to Funk et al. (2018), first generation medications have potentially and frequent neurological side effects, such as the possibility of developing irreversible movement disorder, and hence should be used as the last resort.

I did not select the third decision because like Haldol Decanoate, its long-term use can lead to involuntary movement of the lips, tongue, and jaws (Yeager et al., 2020). When making the decision I was hoping that the patient’s PANSS score would reduce by 50%. I was also hoping that the patient would not experience injection site pain.

The patient’s PANSS score reduced by 50%, injection site pain reduced, and the patient added 2.5 pounds. One of the ethical considerations that can impact treatment plan is accountability. I decided the therapy, and hence I must be accountable for my actions.

Decision Point 3

In the third decision, I selected to continue with the Invega Sustenna. Counsel client on the fact that weight gain from Invega Sustenna is not as much as what other drugs with similar efficacy can cause. Make appointment with a dietician and an exercise physiologist. Follow up in one month. I selected this decision because diet and physical exercise can help the client maintain healthy weight.

Rose et al. (2017) argue that if a person exercises for 30 minutes three days a week, the individual will maintain a healthy weight. Hence, advising the patient to see a dietician and an exercise physiologist will help her with weight problem. Counseling the client will also help improve her attitude towards the medication.

I did not select the second decision because Abilify does not react well with D2 receptor, such Invega because their reaction can lead to akathisia. Akathisia is a mental condition that can lead to feelings of anxiety, worry, or fear (Zhi et al., 2018). I did not select the third decision because Qsymia is used to treat obesity.

However, the patient has BMI of 28.9 kg/M2, which does not fit any of the classes of obesity. I also avoided the decision because Qsymia can cause addiction, seizures, kidney stones, and insomnia. Instead of prescribing Qsymia, the patient should be advised to observe her diet and engage in frequent physical exercise (Food and Drug Administration, 2017).

I was hoping to reduce the patient’s PANSS score by 80% and to help the patient lose two pounds in one month. An ethical consideration that will affect the treatment plan in this situation is informed consent. If the patient refuses to be counseled or meet dietician and an exercise physiologist, then the plan will not work.

Conclusion

The 34-year-old Pakistani female was diagnosed with schizophrenia, paranoid type. The assignment required that I make three decisions with the aim of treating the client and improve her mental health. The first decision I recommended as treatment plan was starting Invega Sustenna 234 mg intramuscular X1 followed by 156 mg intramuscular on day 4 and monthly thereafter.

I selected the therapy because the medication can improve the patient’s mood, thinking, judgement, and reduce hallucinations. I did not select the other two medications because their long-term use can lead to development of permanent movement disorder (Pesa et al., 2017). The second decision was to continue same decision made but instruct administering nurse to begin injections into the deltoid at this visit and moving forward.

The patient was responding well to the first decision.

Her PANSS score dropped by 25% and she was tolerant to the medication. I decided to change the injection site to reduce the pain felt by the patient during the first injection. I did not select Haldol Decanoate because of its adverse effects after long-term use (Yeager et al., 2020). The third decision was to continue with the Invega Sustenna.

Counsel client on the fact that weight gain from Invega Sustenna is not as much as what other drugs with similar efficacy can cause. Make appointment with a dietician and an exercise physiologist. Follow up in one month. I selected the decision because diet and physical activity and help the patient lose weight.

Qsymia is a weight loss medication that should be prescribed to obese patients (Food and Drug Administration, 2017). However, the patient is not obese, and that is why I avoided the third decision.

References

American Psychiatric Association. (2019). Practice guideline for the treatment of patients with schizophrenia. https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/Clinical%20Practice%20Guidelines/APA-Draft-Schizophrenia-Treatment-Guideline.pdf

Fellner, C. (2017). New schizophrenia treatments address unmet clinical needs. Pharmacy and Therapeutics, 42(2), 130. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5265239/

Food and Drug Administration. (2017). FDA news release: FDA approves weight-management drug Qsymia.

Freudenreich, O., Goff, D. C., & Henderson, D. C. (2016). Antipsychotic drugs. In T. A. Stern, M. Favo, T. E. Wilens, & J. F. Rosenbaum. (Eds.), Massachusetts General Hospital psychopharmacology and neurotherapeutics (pp. 72–85). Elsevier.

Funk, M. C., Beach, S. R., Bostwick, J. R., Celano, C. M., Hasnain, M., Pandurangi, A., Khandai, A., Taylor, A., Levenson, J. L., Riba, M., & Kovacs, R. J. (2018). Resource document on QTc prolongation and psychotropic medications. American Psychiatric Association. https://www.psychiatry.org/File%20Library/Psychiatrists/Directories/Library-and-Archive/resource_documents/Resource-Document-2018-QTc-Prolongation-and-Psychotropic-Med.pdf

Mustafa, S., Bougie, J., Miguelez, M., Clerzius, G., Rampakakis, E., Proulx, J., & Malla, A. (2019). Real-life assessment of aripiprazole monthly (Abilify Maintena) in schizophrenia: a Canadian naturalistic non-interventional prospective cohort study. BMC psychiatry, 19(1), 114. https://link.springer.com/article/10.1186/s12888-019-2103-x

Pesa, J. A., Doshi, D., Wang, L., Yuce, H., & Baser, O. (2017). Health care resource utilization and costs of California Medicaid patients with schizophrenia treated with paliperidone palmitate once monthly or atypical oral antipsychotic treatment. Current Medical Research and Opinion, 33(4), 723-731. https://doi.org/10.1080/03007995.2016.1278202

Rose, T., Barker, M., Jacob, C. M., Morrison, L., Lawrence, W., Strömmer, S., … & Baird, J. (2017). A systematic review of digital interventions for improving the diet and physical activity behaviors of adolescents. Journal of Adolescent Health, 61(6), 669-677. https://doi.org/10.1016/j.jadohealth.2017.05.024

Yeager, V., Bogoyas, M., Goubran, B., Gonzalez, L., & Ferrer, G. F. (2020). Olanzapine as an Adjunct in the Management of Refractory Psychogenic Excoriation With Comorbid Schizophrenia: A Case Report. Cureus, 12(6). doi: 10.7759/cureus.8772

Zhi, P., Wang, Y., Quan, W., Su, Y., & Zhang, H. (2018). Aripiprazole combination for reversal of paliperidone-induced increase in prolactin level. Neuropsychiatric disease and treatment, 14, 2175. doi: 10.2147/NDT.S167129

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