NURS 6630 Week 8 Therapy for Patients With Sleep/Wake Disorders
A Sample Answer For the Assignment: NURS 6630 Week 8 Therapy for Patients With Sleep/Wake Disorders
For this discussion, the case of a young adult male patient with a history of insomnia has been used. The patient is 31 years old and presents with insomnia as the chief complaint. He reports that the lack of sleep has been getting worse over the past 6 months. According to him, sleeping problems have never created a great concern as he is used to them. However, it has been worse ever since the death of his fiancé, as he struggles to fall and stay asleep. This has greatly compromised his quality of life as his job performance has reduced.
He also claims that due to poor sleep at night, he sometimes falls asleep at the workplace. He confirms that he has been taking diphenhydramine to help him sleep in the past, but is unhappy with the way it makes him feel the next morning. His previous physician reports that the patient has a history of opiate abuse following his ankle fracture in a skiing accident that led to the use of hydrocodone/APAP (acetaminophen) for the management of pain. He has however not used analgesics for the past 4 years. The patient however confirms to be taking alcohol to help with his sleeping. Mental status examination results reveal that the patient current healthcare need is only insomnia.
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Several patient factors affect their pharmacokinetic and pharmacodynamic processes hence must be considered when making decisions concerning which drug to prescribe to the patient. For this patient, some of such factors include his male gender, adult age, diagnosis of insomnia, previous use of diphenhydramine, substance use history of opiate abuse, and use of alcohol. The purpose of this paper is thus to consider the above patient factors and determine the most effective choice of drugs for the management of the patient’s insomnia, and necessary medication adjustments based on the treatment outcomes.
Decision Point One
Selected Decision and Rationale
Based on the patient-specific factors, the initial decision was to administer trazodone 50mg orally at bedtime. Despite trazodone being approved by the FDA for the management of depression, evidence demonstrates that its off-label use in the management of insomnia has surpassed its antidepressant indications (Bollu & Kaur, 2019). Trazodone mode of action is associated with the inhibition of serotonin reuptake, antagonizing serotonin, antagonizing alpha1 (α1) adrenergic receptors, and inhibitor of serotonin reuptake transporter (Levenson et al., 2015; Medalie & Cifu, 2017).
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It is effective for patients with diphenhydramine withdrawal (Krystal et al., 2019: Bollu & Kaur, 2019). The drug is also rapidly absorbed from the GI when administered orally with a short onset of action of between 1 to 2 hours, hence appropriate in helping the patient fall asleep easily (Sateia et al., 2017). Its half-life is also short promoting its safety profile as a result of reduced toxicity risks (Zhand & Milin, 2018).
It was not necessary to consider zolpidem as the medication can only be prescribed in case there is no other better option for the management of the patient’s insomnia, as the drug has increased risks of adverse events such as hallucination and amnesia (Krystal et al., 2019; Palagini et al., 2020).Hydroxyzine on the other hand could also not be selected given that it is an antihistamine just like diphenhydramine (Levenson et al., 2015). As such, it will lead to similar side effects to the ones that made the patient stop using the drug, to begin with (Sateia et al., 2017).
Expected Outcome
The patient’s insomnia should be getting better with the use of trazodone for the following four weeks. He should be able to easily fall asleep and stay asleep (Bollu & Kaur, 2019). Achievement of 50% remission of symptoms within the first four weeks, is demonstrated as a positive response to the medication (Levenson et al., 2015).
Ethical Considerations
When deciding on which medication to prescribe to the patient, the PMHNP must demonstrate a high level of critical thinking with the patient’s interest at hand (Krystal et al., 2019). Ethical guidelines recommend all healthcare professionals uphold the patient’s autonomy and promote their health while preventing harm (Sateia et al., 2017; Medalie & Cifu, 2017).
The patient is a male patient who is 31 years old and has insomnia. Since he lost his fiancé, the sleeplessness has been worse over the past six months. The patient claimed that although he hasn’t always been a “great sleeper,” he now has trouble going to sleep or staying asleep at night. The patient claims that his inability to sleep is now impairing his performance at work as a forklift operator at a chemical plant, where he is dozing off in the course of his duties. He usually takes diphenhydramine to fall asleep, but the morning after is unpleasant.
Review of the patient’s medical file reveals that he has a history of opiate usage dating back more than 4 years, when he was prescribed hydrocodone for an ankle fracture sustained in a skiing accident. Prior to going to bed, the patient has been consuming about 4 beers and using diphenhydramine to put him to sleep. The patient is awake, alert, and aware of place, time, people, and events. The patient denies experiencing auditory or visual hallucinations and is adequately dressed. He is future-focused, denies SI or HI, and has sound insight and judgment.
Decision one
The patient was first given 50 mg of trazodone PO at bedtime. Trazodone is a drug that belongs to the category of a serotonin reuptake inhibitor and antagonist. Trazodone is an off-label treatment for insomnia and has FDA approval as an antidepressant. For those with chronic alcohol use like the patient in question, trazodone is a secure pharmaceutical option. Alcohol consumption may not interact with hydroxyzine or zolpidem to provide an additional sedative effect. Since the patient has been taking diphenhydramine as a supplement, hydroxyzine may not be as beneficial because it works on comparable receptors.
Zolpidem may cause sleepwalking and other unusual sleep habits, which are undesirable side effects. The option with less negative effects was trazodone. Trazodone may be able to address two issues since the patient also sounds like he may be having difficulties adjusting to the death of his fiancé.
Alcohol and substance abuse can be a bad coping mechanism for depressive disorders, and depression and sleeplessness are frequently co-occurring disorders. As the other two do not have antidepressant characteristics and can cause further sedations when combined with alcohol, trazodone would be the better option. Zolpidem in combination with alcohol can lead to further respiratory depression and death (Jaffer et al., 2017).
Decision two
When the patient comes back two weeks later, he says the drug works great but gives him a 15-minute erection when he wakes up. The patient additionally claims that this makes it challenging to prepare for work. He rejects auditory and visual hallucinations and is future oriented. The decision was made to reduce the dosage of trazodone to 25 mg once a day at bedtime.
An erection that lasts longer than four hours is known as priapism and is a side effect of the drug trazodone. Since the patient is still developing, lowering the dose may reduce that side effect and be a safer alternative than using the other two drugs (Settimo et al., 2018).
When the patient comes back two weeks later, he says the drug works great but gives him a 15-minute erection when he wakes up. The patient additionally claims that this makes it challenging to prepare for work. He rejects auditory and visual hallucinations and is future oriented.
The decision was made to reduce the dosage of trazodone to 25 mg once a day at bedtime. An erection that lasts longer than four hours is known as priapism and is a side effect of the drug trazodone. Since the patient is still developing, lowering the dose may reduce that side effect and be a safer alternative than using the other two drugs (Schifano et al., 2022).
Decision three
The patient returns to the clinic two weeks after the trazodone dosage is reduced and notes that while the trazodone is good for promoting sleep, the 25mg dose is occasionally insufficient for a full night’s rest. He rejects auditory or visual hallucinations and is future oriented. The choices were to keep taking the medication, encourage good sleeping habits, or return in four weeks. Stop taking trazodone and replace it with remolten 8 mg at bedtime. Follow up in four weeks.
Trazodone should be stopped, and hydroxyzine 50 mg should be prescribed at bedtime, with a follow-up after 4 weeks. The decision was made to advocate good sleeping habits and then reevaluate in four weeks. Because the trazodone was effective and he had only sometimes complained of not being able to sleep through the night, it was decided to continue using it.
If the medicine is changed, the patient may become irritated and less likely to follow instructions because it may be necessary to try several different medications and doses and run into options that don’t work (Krzystanek et al., 2020).
Because hydroxyzine has CNS depressive and sedative effects that may intensify with alcohol, causing dizziness and stumbling and a hangover effect the next morning, it is not a viable alternative to diphenhydramine. Ramelteon is a highly selective melatonin receptor agonist for MTI and MT2.This medicine may help with insomnia and enhance several aspects of sleep.
Alcohol and ramalteon both intensify each other’s effects. Ramelteon was not chosen due to the increased side effects of the drug and alcohol as well as the fact that trazodone is effective and only rarely causes interrupted sleep, making it unwise to start a new treatment (Uchiyama et al., 2019).
Conclusion
Insomnia can accompany depression or cause it, as well as result in poor work performance, anxiety, and substance abuse. The guy has been grieving the loss of his fiancé for six months and has trouble sleeping. Trazodone is an effective sedative antidepressant that affects serotonin neurotransmitters and can help with depression and sleep-related issues. The histamine class of drugs includes hydroxyzine, and the patient has been using diphenhydramine with minimal effects and lingering effects of lethargy the next day.
Since trazodone had some negative effects, reducing the dose could lessen them while maintaining the medication’s current level of effectiveness. Poor sleep hygiene can reduce most people’s capacity to sleep, making it a crucial factor to consider. Changing a patient’s drug regimen on a regular basis can result in noncompliance and frustration if the patient continues to experience unwanted side effects (Riemann et al., 2017).
References
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. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5842888/
Krzystanek, M., Krysta, K., & Pałasz, A. (2020). First generation antihistaminic drugs used in the treatment of insomnia–superstitions and evidence. Pharmacotherapy in Psychiatry and Neurology/Farmakoterapia w Psychiatrii i Neurologii, 36(1), 33- 40. Doi:10.33450/fpn.2020.04.003
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. Doi: 10.1111/jsr.12594.
Schifano, N., Capogrosso, P., Boeri, L., Fallara, G., Cakir, O. O., Castiglione, F., … & Salonia, A. (2022). Medications mostly associated with priapism events: Assessment of the 2015–2020 Food and Drug Administration (FDA) pharmacovigilance database entries. International Journal of Impotence Research, 1-5. Doi: 10.1038/s41443-022- 00583-3
Settimo, L., & Taylor, D. (2018). Evaluating the dose-dependent mechanism of action of trazodone by estimation of occupancies for different brain neurotransmitter targets. Journal of Psychopharmacology, 32(1), 96-104. Doi: 10.1177/0269881117742101
Uchiyama, M., Sakamoto, S., & Miyata, K. (2019). Effect of ramelteon on insomnia severity: evaluation of patient characteristics affecting treatment response. Sleep and Biological Rhythms, 17(4), 379-388. https://link.springer.com/article/10.1007/s41105-019-00224-1
From negative changes in mood to problems concentrating, sleep/wake disorders can have a tremendous impact on patients’ lives. When patients suffer from these disorders, they often seek medical care with the intent of receiving medications to manage symptoms.
However, many of the medications used to treat sleep/wake disorders may be addictive, making thorough patient assessments and close follow-up care essential. To prescribe appropriate therapies with patient safety in mind, you must understand not only the pathophysiology of these disorders but also the pharmacologic agents used to treat them.
This week, as you study therapies for individuals with sleep/wake disorders, you examine the assessment and treatment of patients with these disorders. You also explore ethical and legal implications of these therapies.
Learning Objectives
Students will:
- Synthesize concepts related to the psychopharmacologic treatment of patients
- Assess patient factors and history to develop personalized therapy plans for patients with sleep/wake disorders
- Analyze factors that influence pharmacokinetic and pharmacodynamic processes in patients requiring therapy for sleep/wake disorders
- Synthesize knowledge of providing care to patients presenting for sleep/wake disorders
- Analyze ethical and legal implications related to prescribing therapy for patients with sleep/wake disorders
Learning Resources
Required Readings (click to expand/reduce)
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Medication Resources (click to expand/reduce)
Note: To access the following medications, use the Drugs@FDA resource. Type the name of each medication in the keyword search bar. Select the hyperlink related to the medication name you searched. Review the supplements provided and select the package label resource file associated with the medication you searched. If a label is not available, you may need to conduct a general search outside of this resource provided. Be sure to review the label information for each medication as this information will be helpful for your review in preparation for your Assignments.
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Required Media (click to expand/reduce)
Assignment 1: Short Answer Assessment
As a psychiatric nurse practitioner, you will likely encounter patients who suffer from various mental health disorders. Not surprisingly, ensuring that your patients have the appropriate psychopharmacologic treatments will be essential for their overall health and well-being.
The psychopharmacologic treatments you might recommend for patients may have potential impacts on other mental health conditions and, therefore, require additional consideration for positive patient outcomes. For this Assignment, you will review and apply your understanding of psychopharmacologic treatments for patients with multiple mental health disorders.
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To Prepare
- Review the Learning Resources for this week.
- Reflect on the psychopharmacologic treatments that you have covered up to this point that may be available to treat patients with mental health disorders.
- Consider the potential effects these psychopharmacologic treatments may have on co-existing mental health conditions and/or their potential effects on your patient’s overall health.
To complete:
Address the following Short Answer prompts for your Assignment. Be sure to include references to the Learning Resources for this week.
- In 3 or 4 sentences, explain the appropriate drug therapy for a patient who presents with MDD and a history of alcohol abuse. Which drugs are contraindicated, if any, and why? Be specific. What is the timeframe that the patient should see resolution of symptoms?
- List 4 predictors of late onset generalized anxiety disorder.
- List 4 potential neurobiology causes of psychotic major depression.
- An episode of major depression is defined as a period of time lasting at least 2 weeks. List at least 5 symptoms required for the episode to occur. Be specific.
- List 3 classes of drugs, with a corresponding example for each class, that precipitate insomnia. Be specific.
By Day 7
This Assignment is due.
Submission and Grading Information
To submit your completed Assignment for review and grading, do the following:
- Please save your Assignment using the naming convention “WK8Assgn1+last name+first initial.(extension)” as the name.
- Click the Week 8 Assignment 1 Rubric to review the Grading Criteria for the Assignment.
- Click the Week 8 Assignment 1 link. You will also be able to “View Rubric” for grading criteria from this area.
- Next, from the Attach File area, click on the Browse My Computer button. Find the document you saved as “WK8Assgn1+last name+first initial.(extension)” and click Open.
- If applicable: From the Plagiarism Tools area, click the checkbox for I agree to submit my paper(s) to the Global Reference Database.
- Click on the Submit button to complete your submission.
Grading Criteria
To access your rubric:
Week 8 Assignment 1 Rubric
Check Your Assignment Draft for Authenticity
To check your Assignment draft for authenticity:
Submit your Week 8 Assignment 1 draft and review the originality report.
Submit Your Assignment by Day 7 of Week 8
To participate in this Assignment:
Week 8 Assignment 1
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