DECISION TREE FOR NEUROLOGICAL AND MUSCULOSKELETAL DISORDERS NURS 6521
DECISION TREE FOR NEUROLOGICAL AND MUSCULOSKELETAL DISORDERS NURS 6521
A sample Answer For the Assignment: DECISION TREE FOR NEUROLOGICAL AND MUSCULOSKELETAL DISORDERS NURS 6521
Introduction
The most common trigger of dementia in senior individuals, which affects many people worldwide, is Alzheimer’s disease. It is classified as a neurodegenerative condition brought on by the harmful progression of age-dependent cognitive decline. There is accumulation of amyloid plaques made up of abnormal deposits of located in the extracellular brain parenchyma and hippocampus. In AD, neurofibril tangles can also form inside of the neuron.
Alzheimer’s disease is characterized by a progressive memory loss and cognitive abnormalities. The case study of Mr. Akkad, a 76-year-old Iranian man who was brought in by his son, will be covered in this essay. Following a clinical assessment and mini-mental state evaluation, the patient is identified as having a significant neurodegenerative illness caused by Alzheimer’s disease (DementiaCareCentral.com, 2020)
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Decision 1 Begin Exelon (rivastigmine) 1.5 mg orally BID with an increase to 3 mg orally BID in 2weeks
Rivastigmine is a drug containing a cholinesterase inhibitor with the potential benefit of being pseudo-irreversible. The reversible binding and inactivation of cholinesterase by rivastigmine results in an increase in the level of acetylcholine at cholinergic synapses by blocking acetylcholine’s breakdown. The cholinesterase inhibitor rivastigmine is licensed for use in the treatment of mild to moderate dementia associated with Parkinson’s and Alzheimer’s diseases.
Alzheimer’s disease will develop more slowly as a result of the Exelon. The non-cognitive manifestations of Alzheimer’s disease may be treated with this medication. According to published reports, this medicine improves an Alzheimer’s patient’s cognitive functioning. In the instance of Mr. Akkad, this pharmacological therapy seeks to maximize and uphold the patient’s autonomy, functional capacity, and life quality (Rosenthal & Burchum, 2021).
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In a certain period, the patient will start to show the potential effects of the medication. Exelon will slow the spread of the condition, but the patient won’t notice any effects right away. Therefore, doctors advised patients to report any potential changes in their health within three to six weeks, with or without improvement.
Following the commencement of treatment, doctors should schedule meetings with the patient and family every three to six weeks to assess any changes in cognitive and behavioral issues and to gauge how the patient is responding to the medicine. Mr. Akkad’s patient visited the clinic again after 4 weeks, however there was no improvement in his conduct or cognitive abilities (Kazmierski et al., 2020)
Decision 2 Increase Exelon to 4.5 mg orally BID
The client has returned, and according to his son, neither his father’s cognitive nor behavioral functioning had improved. Additionally, the MMSE test results showed that the drugs’ recommended dosage was not likely to have any positive effects. Mini-mental status examination is a helpful tool for gauging how well a patient is responding to treatment, and family input is crucial for determining the patient’s daily interests. The second choice is to raise the dosage of rivastigmine in order to reduce symptoms. Exelon lessens the symptoms and slows the disease’s course, although it could take 6 to 8 weeks before memory and behavior start to improve (Kazmierski et al., 2020).
To achieve the best results, the clinical studies advise titrating the Exelon dose to the highest tolerable level. The patient came back with his son after four weeks. According to his son, he is tolerating the medication, attending religious services with family, and everyone is content. One issue is that his dad still finds humor in things that he once found to be serious (Kim et al., 2021).
Decision 3 Maintain current dose of Exelon
The third option is to keep the present dosage of medicine after assessing the condition of the patient by raising the amount in the second choice. Since this patient is responding effectively to the dosage and because there are no negative side effects from this dosage. The patient’s symptoms are reportedly getting better gradually. Behavioral, cognitive, and daily living activity tests have shown that oral Exelon’s effectiveness is dose dependent (Kim et al., 2021).
The suggested course of treatment lessens symptoms while delaying the onset of the illness. It does not, however, completely reverse the disease. Healthcare professionals have a crucial role in educating patients about Alzheimer’s disease, including its signs, problems, treatment options, and positive and negative impacts. They can also help patients and their families find financial and legal resources.
However, it is vital to explain to the client and his kid that this illness is permanent and medications only help to lessen the clinical manifestations and help improve the patient’s cognitive and behavioral functionality. The patient did not report side effects of the medication during the re- visit. Additionally, you have the choice of increasing the dosage or supplementing it with an additional drug such as Namenda (Rosenthal & Burchum, 2021).
Conclusion
In conclusion, there is no therapy option that can offer a long-term solution for Alzheimer’s disease. The patient’s quality of life, ability to do everyday tasks, and cognitive and behavioral capabilities can all be enhanced by prescribed medications and suggested therapy. It is a neurogenerative condition that develops slowly and places a heavy strain on sufferers and family.
In order to reduce the negative impacts of this condition on patients and their families, it is crucial to create appropriate and effective decisions. Making sure patients with it have enough sleep and rest in between stimulating activities and providing a tranquil environment for these individuals are crucial (DementiaCareCentral.com, 2020).
References
Rosenthal, L. D., & Burchum, J. R. (2021). Lehne’s pharmacotherapeutics for advanced practice nurses and physician assistants (2nd ed.) St. Louis, MO: Elsevier.
Kim, B., Noh, G. O., & Kim, K. (2021). Behavioral and psychological symptoms of dementia in patients with Alzheimer’s disease and family caregiver burden: a path analysis. BMC Geriatrics, 21(1), 160.https://doi-org.ezp.waldenulibrary.org/10.1186/s12877-021-02109 w
DementiaCareCentral.com. (2020, October 7). Mini-mental state exam (MMSE) alzheimer’s /dementia test: Administration, accuracy and scoring. Dementia CareCentral.https://www.dementiacarecentral.com/mini-mental-state-exam/.
Kazmierski, J., Messini-Zachou, C., Gkioka, M., & Tsolaki, M. (2018). The impact of a long- term rivastigmine and donepezil treatment on all-cause mortality in patients with Alzheimer’s disease. American Journal of Alzheimer’s Disease & OtherDementias®,33(6), 385-393
The case study depicts a 43-year-old white male who presents with a complaint of pain. He uses a set of clutches when ambulating. The patient reports that he has been referred for psychiatric assessment by his family doctor since the doctor perceived that he had psychological pain (Laureate Education, 2016). The pain began seven years ago after sustaining a fall and landed on the right hip. Four years ago, it was revealed that the cartilage around the right hip joint had a 75% tear.
However, no surgeon was willing to perform a total hip replacement since they believed that there would be tissue repair over time (Laureate Education, 2016). He reports having severe cramping of the right extremity. A neurologist diagnosed him with complex regional pain syndrome (CRPS). He states that he gets low moods at times but denies being depressed. He had been prescribed with Hydrocone but used it in low doses due to drowsiness and constipation, and the drug does not manage pain effectively (Laureate Education, 2016). The mental status exam is unremarkable.
Decision Point One: Savella 12.5 mg orally once daily on Day 1, followed by 12.5 mg BD on Day 2 and 3, then 25 mg BD on days 4-7 and then 50 mg BD after that.
Reason: Savella is a serotonin-norepinephrine reuptake inhibitor that has NMDA antagonist activity, which brings analgesia at the nerve endings (Cording et al., 2015). It is indicated for fibromyalgia and thus effective for this client (Cording et al., 2015). I prescribed Savella to help in pain management and improve the overall mood.
Expected Result: I anticipated that Savella would lower the degree of pain. However, it was expected that the client would experience adverse effects such as nausea, constipation, headache, hot flushes, and insomnia.
Expected Vs. Actual Results: The client returned to the clinic after for weeks without using crutches but with a bit of limping. He states that the pain has been more manageable. The pain is severe in the morning but improves throughout the day (Laureate Education, 2016). On a scale of 1-10, the client rates the pain at four and states that he gets to a point on most days where he does not need crutches. Nevertheless, he reported having increased sweating, sleeping difficulties, nausea, and palpitations (Laureate Education, 2016). His BP was 147/92, and the pulse at 110. He denied having suicidal ideations and was still future-oriented.
Decision Point 2: Continue with Savella but lower dose to 25 mg twice a day.
Reason: I selected this decision to lower the severity of the adverse effects of Savella, which include nausea, constipation, headache, hot flushes, and insomnia (Cording et al., 2015).
Expected Result: Reduction in the dose of Savella would help control the side effects but lower the degree of pain control.
Expected Vs. Actual Results: The client returned to the clinic in four weeks using crutches and rates his current pain at 7/10. He reports that his condition has declined since the previous month (Laureate Education, 2016). He states that he sleeps at night but frequently wakes up due to pain in the right leg and foot. The BP is at 124/87 and pulse at 87. He denies having palpitations and suicidal ideations but is discouraged by the slip in pain management and seems sad.
Decision Point 3: Change Savella to 25 mg in the morning and 50 mg at Bedtime.
I reduced the dosage in the morning since the pain is mostly under control and increased the dose at Bedtime when there is less control (Resmini et al., 2015).
Expected Result: By lowering the morning dose and increasing the bedtime dose, I expected that the client’s pain symptom would improve while at the same time controlling the side effects of Savella (Resmini et al., 2015).
Expected Vs. Actual Results: The client reported an improvement in the pain with a rate of 3/10 denied having any side effects from the drug.
References
Cording, M., Derry, S., Phillips, T., Moore, R. A., & Wiffen, P. J. (2015). Milnacipran for pain in fibromyalgia in adults. Cochrane Database of Systematic Reviews, (10).
Laureate Education. (2016). Case Study: A Caucasian man with hip pain. Baltimore, MD: Author.
Resmini, G., Ratti, C., Canton, G., Murena, L., Moretti, A., & Iolascon, G. (2015). Treatment of complex regional pain syndrome. Clinical cases in mineral and bone metabolism: the official journal of the Italian Society of Osteoporosis, Mineral Metabolism, and Skeletal Diseases, 12(Suppl 1), 26–30. https://doi.org/10.11138/ccmbm/2015.12.3s.026
Alzheimer’s is one of the most common progressive neurological disorders among the elderly caused by dementia. Patients will present with mild to moderate cognitive signs and symptoms at the onset of the disorder, which will progress to severe memory loss with time, as they grow much older (Li et al., 2019).
However, several treatment options have been proven to be effective in the management of Alzheimer’s disorder among the elderly. The purpose of this discussion is to illustrate the decision process in selecting the most effective drug, based on pharmacokinetic and pharmacodynamic factors, for treating an elderly patient diagnosed with Alzheimer’s disease.
Patient Case Study Summary
The assigned case study demonstrates a 76-year-old Iranian male with symptoms of Alzheimer’s disorder. The patient displays strange behavior upon arrival at the clinic reporting symptoms of memory loss, forgetfulness, confusion, and diminished interest in religious activities for the last 2 years. Pharmacokinetic and pharmacodynamic patient factors which contributed to the selection of drugs for this patient include his advanced age, male gender, Iranian race, and presenting symptoms in addition to the mini-mental exam results of moderate dementia. the patient’s diagnosis of Alzheimer’s disorder will also be considered.
Treatment Decisions
Based on the patient history and the pharmacokinetic and pharmacodynamic factors mentioned above, the most appropriate intervention is to initiate Exelon 1.5mg twice daily. Exelon (rivastigmine) is an FFDA-approved drug for treating mild to moderate Alzheimer’s disease (Fish et al., 2019). Previous studies support great effectiveness, and safety profile for use of the drug among the elderly diagnosed with Alzheimer’s (Khoury et al., 2018).
The second decision was to increase the dose of Exelon to 4.5 mg twice daily as recommended by most clinical practice guidelines for patients who have displayed great tolerance but with minimal effectiveness. The last decision was to increase the dose further to 6mg twice daily, to promote optimal effectiveness as the patient still displayed limited remission of symptoms with the previous intervention.
Expected Outcome
Studies show that Exelon when administered appropriately takes between 8 to 12 weeks to completely manage symptoms of Alzheimer’s among elderly patients. As such, with the initial intervention of 1.5mg Exelon twice daily, the patient was expected to display approximately 50% remission of symptoms (Nguyen et al., 2021). The dose was however to be titrated to obtain the optimum outcome, not exceeding 6mg twice daily. The same results were expected with the second and third interventions with no side effects expected.
Difference Between Expected Outcome and Actual Outcome
Just like expected, the patient displayed a minimal reduction of symptoms of Alzheimer’s with no side effects reported with the first intervention. After the dose was increased in the second intervention, the patient reported further remission of symptoms, but at a slow rate, hence increasing the dose in the last intervention, which led to optimal remission of Alzheimer’s symptoms just as expected (Huang et al., 2020).
Conclusion
Alzheimer’s is a common disorder among the elderly compromising their quality of life and well-being. For the patient in the provided case study, it was necessary to administer Exelon at a starting dose of 1.5 mg which was titrated to 4.5mg then 6.5mg twice daily. The patient displayed great effectiveness with this medication in the management of his Alzheimer’s symptoms, with no side effects reported.
References
Fish, P. V., Steadman, D., Bayle, E. D., & Whiting, P. (2019). New approaches for the treatment of Alzheimer’s disease. Bioorganic & medicinal chemistry letters, 29(2), 125-133. https://doi.org/10.1016/j.bmcl.2018.11.034
Huang, L. K., Chao, S. P., & Hu, C. J. (2020). Clinical trials of new drugs for Alzheimer’s disease. Journal of biomedical science, 27(1), 1-13. https://doi.org/10.1186/s12929-019-0609-7
Khoury, R., Rajamanickam, J., & Grossberg, G. T. (2018). An update on the safety of current therapies for Alzheimer’s disease: focus on rivastigmine. Therapeutic Advances in Drug Safety, 9(3), 171-178. https://doi.org/10.1177/2042098617750555
Li, D. D., Zhang, Y. H., Zhang, W., & Zhao, P. (2019). Meta-analysis of randomized controlled trials on the efficacy and safety of donepezil, galantamine, rivastigmine, and memantine for the treatment of Alzheimer’s disease. Frontiers in neuroscience, 13, 472. https://doi.org/10.3389/fnins.2019.00472
Nguyen, K., Hoffman, H., Chakkamparambil, B., & Grossberg, G. T. (2021). Evaluation of rivastigmine in Alzheimer’s disease. Neurodegenerative Disease Management, 11(1), 35-48. https://doi.org/10.2217/nmt-2020-0052
Hi Jasmine! I agree with many of your differential diagnosis’ as the symptoms your patient has presented with along with the findings reported from your assessment could fit in many of those diagnosis. Out of your diagnosis listed I felt it difficult to pick the priority diagnosis as many symptoms subjective and objective findings are confusing such as steady gate without mention of abnormality, but foot drop is seen on physical assessment. Other studies may be helpful to make final diagnosis.
Spinal Stenosis is a diagnosis I would not have chosen to be highest on the list of probabilities from the information given. According to John Hopkins spinal stenosis does have symptoms of back pain including the burning sensation going down the leg with tingling, as your patient did. It may also cause foot drop which was mentioned on examination, however gate was also noted as steady with no mention of foot slapping.
Some ways to prevent spinal stenosis include maintaining a healthy weight, which seems to be accurate for your patient and weight lifting which the patient reports they also do 2-3 times per week. Although there are some similar symptoms, radiological studies including Xray, CT or MRI will help to diagnosis this condition (John Hopkins Medicine, 2020).
Herniated Disk and Sciatica I will lump into one thought from the American Association of Neurological Surgeons who state that dependent on where the herniated disk is, is where you will have symptoms, such as in the lower back you may have sciatica pain from the disk pressing on the sciatic nerve. This will cause the symptoms your patient is having concerning the pain shooting down one leg with what sounds like positive SLR.
Herniated disks may happen with injury or as a person age and the disks degenerate and family history. This patient does not report a family history of disk problems and is relatively young for degeneration. I would not be convinced either of these as the highest probability diagnosis either, however MRI will also help with this diagnosis (American Association of Neurological Surgeons, 2019).
Lumbosacral Muscle Strain could be ruled out by the subjective information given. Symptoms of lumbosacral muscle strain are that of a pulled muscle where the pain is usually one sided, gets worse when you move and better with rest, may have swelling, redness and warmth (Saint Luke’s Health System, 2019). This diagnosis would not indicate why the patient is experiencing tingling/burning, and shooting pain down one side of the leg or possible foot drop.
Spondylolysis is typically seen in younger persons, however, can be caused by weightlifting or repetitive stress as I would imagine could come from roofing using the same body mechanics repeatedly to lay and anil shingles. Symptoms like your patient include radiating back pain to the back of the thigh causing tight hamstrings and tingling in the leg and may have a limited range of motion as seen in your patient (American Academy of Orthopaedic Surgeons, 2020).
Because this patient has multiple confusing symptoms that may fall into different differential diagnosis, MRI studies would help with finalizing and ruling out further options.
References
American Academy of Orthopaedic Surgeons. (2020, August). Spondylolysis and Spondylolisthesis – OrthoInfo – AAOS. Www.orthoinfo.org. https://orthoinfo.aaos.org/en/diseases–conditions/spondylolysis-and-spondylolisthesis
American Association of Neurological Surgeons. (2019). Herniated Disc – Symptoms, Causes, Prevention and Treatments. Aans.org. https://www.aans.org/en/Patients/Neurosurgical-Conditions-and-Treatments/Herniated-Disc
John Hopkins Medicine. (2020). Lumbar Spinal Stenosis. John Hopkins Medicine. https://www.hopkinsmedicine.org/health/conditions-and-diseases/lumbar-spinal-stenosis
Saint Luke’s Health System. (2019). Understanding Lumbosacral Strain. Saint Luke’s Health System. https://www.saintlukeskc.org/health-library/understanding-lumbosacral-strain
The case study depicts a 43-year-old white male who presents with a complaint of pain. He uses a set of clutches when ambulating. The patient reports that he has been referred for psychiatric assessment by his family doctor since the doctor perceived that he had psychological pain (Laureate Education, 2016). The pain began seven years ago after sustaining a fall and landed on the right hip. Four years ago, it was revealed that the cartilage around the right hip joint had a 75% tear.
However, no surgeon was willing to perform a total hip replacement since they believed that there would be tissue repair over time (Laureate Education, 2016). He reports having severe cramping of the right extremity. A neurologist diagnosed him with complex regional pain syndrome (CRPS). He states that he gets low moods at times but denies being depressed. He had been prescribed with Hydrocone but used it in low doses due to drowsiness and constipation, and the drug does not manage pain effectively (Laureate Education, 2016). The mental status exam is unremarkable.
Decision Point One: Savella 12.5 mg orally once daily on Day 1, followed by 12.5 mg BD on Day 2 and 3, then 25 mg BD on days 4-7 and then 50 mg BD after that.
Reason: Savella is a serotonin-norepinephrine reuptake inhibitor that has NMDA antagonist activity, which brings analgesia at the nerve endings (Cording et al., 2015). It is indicated for fibromyalgia and thus effective for this client (Cording et al., 2015). I prescribed Savella to help in pain management and improve the overall mood.
Expected Result: I anticipated that Savella would lower the degree of pain. However, it was expected that the client would experience adverse effects such as nausea, constipation, headache, hot flushes, and insomnia.
Expected Vs. Actual Results: The client returned to the clinic after for weeks without using crutches but with a bit of limping. He states that the pain has been more manageable. The pain is severe in the morning but improves throughout the day (Laureate Education, 2016). On a scale of 1-10, the client rates the pain at four and states that he gets to a point on most days where he does not need crutches. Nevertheless, he reported having increased sweating, sleeping difficulties, nausea, and palpitations (Laureate Education, 2016). His BP was 147/92, and the pulse at 110. He denied having suicidal ideations and was still future-oriented.
Decision Point 2: Continue with Savella but lower dose to 25 mg twice a day.
Reason: I selected this decision to lower the severity of the adverse effects of Savella, which include nausea, constipation, headache, hot flushes, and insomnia (Cording et al., 2015).
Expected Result: Reduction in the dose of Savella would help control the side effects but lower the degree of pain control.
Expected Vs. Actual Results: The client returned to the clinic in four weeks using crutches and rates his current pain at 7/10. He reports that his condition has declined since the previous month (Laureate Education, 2016). He states that he sleeps at night but frequently wakes up due to pain in the right leg and foot. The BP is at 124/87 and pulse at 87. He denies having palpitations and suicidal ideations but is discouraged by the slip in pain management and seems sad.
Decision Point 3: Change Savella to 2