Assignment: NURS 6630 Patient With Psychosis and Schizophrenia
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Psychosis and Schizophrenia are both mental health conditions. Schizophrenia is one of the causes of psychosis with other additional causes being bipolar disorder, depression, and dementia. Notably, the two conditions tend to alter the normal state of the brain. Consequently, those who suffer from the condition are not capable of maintaining a good relationship or interaction with colleagues at a workplace, school, and even friends in a social gathering. Some of the additional symptoms that are often evident amongst those suffering from the two conditions include delusions and hallucinations. Despite their prevalence amongst the aged, especially those above 60 years, the symptoms of the two conditions can be effectively controlled (Remington et al., 2017).
Positive and Negative Syndrome Scale (PANSS) is a diagnostic procedure that clinical psychologists can utilize in the management of symptoms related to the condition. Stahl (2013) advances that the effectiveness of the medicine issued to the patient and their tolerance levels impact the medication therapy after the diagnostic tests and procedures have been established. This paper examines a Pakistani female adult suffering from psychosis and schizophrenia who has been taken through the diagnostic tests. The scores of the patient, according to PANSS are, 40, 20 and 60 for positive symptoms, negative symptoms, and general psychopathology respectively. The options for medication are also discussed in this paper as well as the ethical considerations for the nurse.
First Decision Point
Start Abilify (aripiprazole) 10 mg orally at BEDTIME
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Justification
The Positive and Negative Syndrome Scale score of the patient affirms that she suffers from Schizophrenia, which is then responsible for the paranoid feelings that she develops. According to Stahl (2014b), Abilify is the first medication that needs to be granted to a patient who has schizophrenia. The chemical compound of the drug, known as Aripiprazole, works by balancing serotonin and dopamine within the brain in order to enhance behavior, mood, and thinking. The choice of the drug is premised on the minimal adverse effects that it may present to a patient.
Also, aripiprazole has a favorable tolerability compared to other atypical antipsychotics that have been approved for schizophrenia. The medication is also highly effective in achieving the required therapeutic concentration within a duration of five to seven days. Studies have also revealed that Abilify contains a lower risk of increased prolactin as well as prolongation concerning the interval of the QTc, hence making it preferable to the given options. Lastly, a monotherapy comprised of Aripiprazole has the capacity to manage the symptoms of cognitive, negative, and positive symptomatology of schizoaffective disorder and schizophrenia.
On the other hand, Abilify is preferable over Zyprexa since the latter has low efficacy despite its tolerance levels being similar to that of Abilify. In fact, Zyprexa has been shown to have adverse events such as weight gain within the first four weeks of administration, which disqualified it from consideration (Harvey, James, & Shields, 2016). Further, the usage of Zyprexa raises the risk of metabolic syndrome in schizophrenic patients such as the Pakistani woman in this case.
Invega Sustenna has also been left out of the existent options since it is relatively inconvenient to administer compared to Abilify, and its tolerance levels are relatively lower. Further, Invega Sustena also increases the risk of weight gain in patients suffering from schizophrenia. Whereas it is more effective compared to Abilify, the inconvenient mode of administration and associated adverse effects such as head ache, tarchycardia, sexual dysfunction, and other extrapyramidal side effects makes it difficult to prescribe to the Pakistani woman (Leucht et al., 2013). Such leaves Abilify as the ideal medication to utilize for the patient.
Expected Results
For a patient taking Abilify medication, her condition needs to indicate an improvement within the second week of taking the drug. Therefore, in the third week, schizophrenia symptoms need to be less severe compared to their current state. Some of the expected results at the end of the fourth week include a reduction in hallucination and being paranoid and an improvement in judgment and insights that the patient exudes (Leucht et al., 2013). Thus, by the fourth week, the PMHNP expects the Pakistani woman to show improvements in her symptoms.
Difference between Expected and Actual Results
Hallucinations and delusions are still existent at the fourth week of the treatment. The incidences of the patient dozing off often are an indication that her concentration levels have become even lower. Therefore, it can deduce that there are no positive or expected results that are got out of taking the Abilify medication. The reason that this has happened to the patient could be attributed to a lack of response to Abilify or existence of concentrations of the drug beyond the therapeutic levels. All of these may be related to the genetic make-up of the patient.
Second Decision Point
Decision
Discontinue Abilify and start Geodon (ziprasidone ) 40 mg orally BID with meals
Justification
The medics have the discretion of discontinuing a given medication where it is affirmed that it is not useful in the treatment of a patient. Such is the basis upon which Abilify has been abandoned in the treatment process. Indeed, the discontinuation of Abilify from its supposed therapeutic dosage of 40mg of Geodon follows the standard protocol for the management of schizophrenia. The usage of Geodon 40 mg with meals is important since its absorption increases to optimal levels (Peng & Deng, 2017). Further, the steady-state plasma concentration of the drug occurs 1-3 days after oral administration, which hastens its activity. Studies have demonstrated efficacy in the usage of Geodon within the dose range of 20-100 mg.
The drug undergoes extensive metabolism to its active compound while its bioavailability is also high, making it effective for schizophrenia management. Further, the drug does not have anticholinergic side effects owing to its insignificant affinity to the mACh receptor (Su, Lu, Shi, & Xu, 2018). Reducing the dosage of Abilify to 75 mg is not advisable as the symptoms of schizophrenia will persist even as the side-effects reduce. Further, the nurse cannot change the administration to AM as the some of the side-effects will remain while only slight improvements will be noted. Therefore, the correct decision at this point is to introduce ziprasidone while discontinuing Abilify.
Expected Results
The introduction of Gedeon would lead to the lessening of schizophrenic symptoms that the patient exudes in addition to minimizing or eliminating the adverse effects. The hallucinations that the patient experiences are also expected to reduce (Stahl, 2013).The patent improvement will be monitored after eight weeks of being under medication. Importantly, the scores in the Positive and Negative Syndrome Scale are expected to be lower compared to the time upon which the first scores were taken. The next appointment will be four weeks after commencement of the Geodon medication.
Differences between Expected and Actual Results
Based on the client account, there is a general improvement that she realizes when the Geodon medication is introduced. When taking the PANSS score as the 4th week, there was a reduction of 40% compared to the earlier scores that had been recorded as at the commencement of the medication. This is consistent with the expectations of the PMHNP when they changed the first antipsychotic therapy. However, unseen by the PMNHP, a critical issue that has been noted based on the 4th-week visit is the struggle that the patient has in complying with the drug. Therefore, headed to the remaining duration of taking the Geodon medication, it will be ideal to address the issue of compliance.
Decision Point Three
Selected Decision
Give her a few test doses of Risperdal 1 mg orally BID for 3 days to see if she tolerates the medication. If tolerated, start Invega Sustenna at an appropriate starting and maintenance dose
Justification
The oral therapy is proving to be effective, yet the patient is struggling with finding compliance for the Geodon medication. Such justifies the reason for shifting the patient from the Geodon medication to Invega Sustenna (Remingotn et al., 2017). However, in the event where the patient shows negative results with regards to tolerance of 1g Risperdal medication, it would be ideal to maintain Geodon medicines and increasing the dosage that is issued by the patient.
Expected Results
The two critical expectations of the decision include adherence to the Invega Sustenna and the reduction in the schizophrenic symptoms that the patient exudes (Alphs et al., 2015). Unlike with Gedeon, the Pakistani woman is expected to adhere to the Invega Sustenna as she tolerated the Risperdal 1 mg dose. Therefore, the choice would be ideal in improving the quality of life of the patient under medication as her PANSS scale rating is expected to demonstrate further improvements in the symptoms of Schizophrenia.
Differences between Expected and Actual Results
The decision to introduce Invega Sustenna is consistent with the manufacturer’s advice and even standard procedure for the treatment of schizophrenia. The essence of the third decision is influenced by the extent to which the patient tolerates the Invega Sustenna medication and compliance. Importantly, the decision premises on the tolerance levels to the Invega Sustenna and since that determination was made, it became ideal to choose the decision.
Ethical Consideration
The third decision is premised on the tolerance of the patient to the Invega Sustenna. Invega Sustenna will only replace Geodon based on its positive tolerance by the patient. Importantly, the nurse will need to discuss with the patient the side effects that are likely to take place owing to the change in treatment then enable the patient to make an informed decision on the choice of medication to continue with (Stahl, 2014b). In other words, the PMNHP will have to collaborate with the patient as they change from one therapy to another by giving them reasons for doing so. Moreover, the nurse is expected to share with the patient these decisions in order to ensure compliance out of the patient as they will feel part of the decision
Conclusion
Schizophrenia is a mental health condition that impacts both the patient and the people close to the patient. Of critical importance is the accurate diagnosis of the situation and making decisions that would lead to the overall improvement in the quality of life of the patient. Conducting regular Positive and Negative Syndrome Scale tests is essential in ascertaining the response of the patient. Importantly, before commencement of therapy, there is a need to adhere to ethical codes of medical practice, including the determination of the side effects of a given medication and discussing such with the patient.
References
Alphs, L., Benson, C., Cheshire-Kinney, K., Lindenmayer, J. P., Mao, L., Rodriguez, S. C., & Starr, H. L. (2015). Real-world outcomes of paliperidone palmitate compared to daily oral antipsychotic therapy in schizophrenia: a randomized, open-label, review board-blinded 15-month study. J Clin Psychiatry, 76(5), 554-561.
Harvey, R.C., James, A.C., Shields, G.E. (2016). A Systematic Review and Network Meta-Analysis to Assess the Relative Efficacy of Antipsychotics for the Treatment of Positive and Negative Symptoms in Early-Onset Schizophrenia. CNS Drugs, 30(1): 27–39
Leucht, S., Cipriani, A., Spineli, L., Mavridis, D., Orey, D., Richter, F., Samara, M., Barbui, C., Engel, R.R., Geddes, J.R., Kissling, W., Stapf, M.P., Lässig, B., Salanti, G., Davis, J.M. (2013). Comparative efficacy and tolerability of 15 antipsychotic drugs in schizophrenia: a multiple-treatments meta-analysis. Lancet, 382(9896), 951–62. doi:10.1016/S0140-6736(13)60733-3. PMID 23810019.
Peng, A., & Deng, H. (2017). Curative effect of ziprasidone in the treatment of agitation in acute phase of schizophrenia. Chinese Journal of Primary Medicine and Pharmacy, 24(2), 283-286.
Remington, G., Addington, D., Honer, W., Ismail, Z., Raedler, T., & Teehan, M. (2017). Guidelines for the pharmacotherapy of schizophrenia in adults. The Canadian Journal of Psychiatry, 62(9), 604-616.
Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (4th ed.). New York, NY: Cambridge University Press.
Stahl, S. M. (2014b). The prescriber’s guide (5th ed.). New York, NY: Cambridge University Press.
Su, L., Lu, Z., Shi, S., & Xu, Y. (2018). Ziprasidone, haloperidol and clonazepam intramuscular administration in the treatment of agitation symptoms in Chinese patients with schizophrenia: A network meta-analysis. General psychiatry, 31(2).
Assignment: Assessing and Treating Clients With Psychosis and Schizophrenia
Psychosis and schizophrenia greatly impact the brain’s normal processes, which interferes with the ability to think clearly. When symptoms of these disorders are uncontrolled, clients may struggle to function in daily life. However, clients often thrive when properly diagnosed and treated under the close supervision of a psychiatric mental health practitioner. For this Assignment, as you examine the client case study in this week’s Learning Resources, consider how you might assess and treat clients presenting with psychosis and schizophrenia.
Learning Objectives
Students will:
Assess client factors and history to develop personalized plans of antipsychotic therapy for clients
Analyze factors that influence pharmacokinetic and pharmacodynamic processes in clients requiring antipsychotic therapy
Evaluate efficacy of treatment plans
Analyze ethical and legal implications related to prescribing antipsychotic therapy to clients across the lifespan
Learning Resources
Note: To access this week’s required library resources, please click on the link to the Course Readings List, found in the Course Materials section of your Syllabus.
Required Readings
Note: All Stahl resources can be accessed through this link provided.
Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (4th ed.). New York, NY: Cambridge University Press.
To access the following chapters, click on the Essential Psychopharmacology, 4th ed tab on the Stahl Online website and select the appropriate chapter. Be sure to read all sections on the left navigation bar for each chapter.
Chapter 4, “Psychosis and Schizophrenia”
Chapter 5, “Antipsychotic Agents”
Stahl, S. M. (2014b). The prescriber’s guide (5th ed.). New York, NY: Cambridge University Press.
To access information on the following medications, click on The Prescriber’s Guide, 5th ed tab on the Stahl Online website and select the appropriate medication.
Review the following medications:
amisulpride
aripiprazole
asenapine
chlorpromazine
clozapine
flupenthixol
fluphenazine
haloperidol
iloperidone
loxapine
lurasidone
olanzapine
paliperidone
perphenazine
quetiapine
risperidone
sulpiride
thioridazine
thiothixene
trifluoperazine
ziprasidone
Naber, D., & Lambert, M. (2009). The CATIE and CUtLASS studies in schizophrenia: Results and implications for clinicians. CNS Drugs, 23(8), 649-659. doi:10.2165/00023210-200923080-00002
Document: Midterm Exam Study Guide (PDF)
Kay, S. R., Fiszbein, A., & Opler, L. A. (1987). The Positive and Negative Syndrome Scale (PANSS) for schizophrenia. Schizophrenia Bulletin, 13(2), 261-276.
Clozapine REMS. (2015). Clozapine REMS: The single shared system for clozapine. Retrieved from https://www.clozapinerems.com/CpmgClozapineUI/rems/pdf/resources/Clozapine_REMS_A_Guide_for_Healthcare_Providers.pdf
Walden University. (2016). ASC success strategies: Studying for and taking a test. Retrieved from https://academicguides.waldenu.edu/academic-skills-center/skills/study
Required Media
Laureate Education. (2016j). Case study: Pakistani woman with delusional thought processes [Interactive media file]. Baltimore, MD: Author
Note: This case study will serve as the foundation for this week’s Assignment.
Optional Resources
Chakos, M., Patel, J. K., Rosenheck, R., Glick, I. D., Hammer, M. B., Tapp, A., & … Miller, D. (2011). Concomitant psychotropic medication use during treatment of schizophrenia patients: Longitudinal results from the CATIE study. Clinical Schizophrenia & Related Psychoses, 5(3), 124-134. doi:10.3371/CSRP.5.3.2
Fangfang, S., Stock, E. M., Copeland, L. A., Zeber, J. E., Ahmedani, B. K., & Morissette, S. B. (2014). Polypharmacy with antipsychotic drugs in patients with schizophrenia: Trends in multiple health care systems. American Journal of Health-System Pharmacy, 71(9), 728-738. doi:10.2146/ajhp130471
Lin, L. A., Rosenheck, R., Sugar, C., & Zbrozek, A. (2015). Comparing antipsychotic treatments for schizophrenia: A health state approach. The Psychiatric Quarterly, 86(1), 107-121. doi:10.1007/s11126-014-9326-2
To prepare for this Assignment:
Review this week’s Learning Resources. Consider how to assess and treat clients requiring anxiolytic therapy.
The Assignment
Examine Case Study: Pakistani Woman with Delusional Thought Processes. You will be asked to make three decisions concerning the medication to prescribe to this client. Be sure to consider factors that might impact the client’s pharmacokinetic and pharmacodynamic processes.
At each decision point stop to complete the following:
Decision #1
Which decision did you select?
Why did you select this decision? Support your response with evidence and references to the Learning Resources.
What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
Explain any difference between what you expected to achieve with Decision #1 and the results of the decision. Why were they different?
Decision #2
Why did you select this decision? Support your response with evidence and references to the Learning Resources.
What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
Explain any difference between what you expected to achieve with Decision #2 and the results of the decision. Why were they different?
Decision #3
Why did you select this decision? Support your response with evidence and references to the Learning Resources.
What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
Explain any difference between what you expected to achieve with Decision #3 and the results of the decision. Why were they different?
Also include how ethical considerations might impact your treatment plan and communication with clients.
Note: Support your rationale with a minimum of three academic resources. While you may use the course text to support your rationale, it will not count toward the resource requirement.
Submission and Grading Information
To submit your completed Assignment for review and grading, do the following:
Save your Assignment using the naming convention “WK6Assgn+last name+first initial.(extension)” as the name.
Click on the Assignment Rubric to review the Grading Criteria for the Assignment.
Click on the Week 6 Assignment link. Next, from the Attach File area, click on the Browse My Computer button. Find the document you saved as “WK6Assgn+last name+first initial.(extension)” and click on Open.
If applicable: From the Plagiarism Tools area, click in the checkbox for I agree to submit my paper(s) to the Global Reference Database.
Grading Criteria
To access your rubric:
Week 6 Assignment Rubric
Check Your Assignment Draft for Authenticity
To check your Assignment draft for authenticity:
Submit your Week 6 Assignment draft and review the originality report.
Submit Your Assignment by Day 7
To submit your Assignment:
Week 6 Assignment
Midterm Exam
Learning Objectives
Students will:
Assess psychopharmacologic approaches to treatment for clients across the lifespan
This exam will cover the following topics, which relate to psychopharmacologic approaches to treatment for clients across the lifespan:
Introduction to neuroscience
Therapy for pediatric patients with mood disorders
Adult and geriatric antidepressant therapy
Bipolar therapy
Anxiolytic therapy
Antipsychotic therapy
By Day 7
Complete the Midterm Exam. Prior to starting the exam, you should review all of your materials. There is a 2-hour time limit to complete this 76-question exam. You may only attempt this exam once.
This exam is a test of your knowledge in preparation for your certification exam. No outside resources including books, notes, websites, or any other type of resource are to be used to complete this exam. You are expected to comply with Walden University’s Code of Conduct.
Submission and Grading Information
Submit Your Midterm Exam by Day 7
To submit your Midterm Exam:
Week 6 Midterm Exam
Making Connections
Now that you have:
Assessed clients presenting with psychosis and schizophrenia
Developed personalized plans of antipsychotic therapy for clients
Examined factors that influence pharmacokinetic and pharmacodynamic processes in clients requiring antipsychotic therapy
Explored ethical and legal implications of prescribing antipsychotic therapy to clients
Next week, you will build on your assessment and treatment skills as you examine clients presenting for therapy for pain and sleep/wake disorders.
To go to the next week:
Week 7
Week 7: Therapy for Clients With Pain and Sleep/Wake Disorders
From negative changes in mood to problems concentrating, pain and sleep/wake disorders can have a tremendous impact on clients’ lives. When clients 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 pain and sleep/wake disorders may be addictive, making thorough client assessments and close follow-up care essential. To prescribe appropriate therapies with client 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 pain and sleep/wake disorders, you examine the assessment and treatment of clients with these disorders. You also explore ethical and legal implications of these therapies.
Mental health problems that include schizophrenia affect negatively the patient’s health. Schizophrenia affects the patient’s quality of life by increasing dependence on medications, lowering productivity, and predisposing them to premature mortality. Psychiatric mental health nurse practitioners play essential roles in providing appropriate treatments that minimize the worsening and progression of schizophrenia symptoms. In doing this, they consider the legal and ethical principles of their practice in the process of patient care. Therefore, this paper is a case analysis of a patient diagnosed with schizophrenia, paranoid type.
The patient in the case study is a 34-year-old Pakistani female who has been brought to the unit for psychiatric assessment. She is currently in an arranged marriage. She has a history of 21-day hospitalization due to a brief psychotic disorder since the symptoms persisted for less than a month. The client also has a history of seeing Allah, and false belief of herself, as she considers that she is Prophet Mohammad. She also beliefs that her husband wants to marry an American wife since the television tells her so.
Subjective data shows that she stopped taking Risperdal a week ago because she thinks her husband will poison her so that he can marry an American woman. PANSS was administered, which showed that the client scored 40 for the positive symptoms scale, 20 for the negative symptoms scale, and 60 for the general psychopathology scale. As a result, she was diagnosed with schizophrenia, paranoid type. The patient information that would be crucial for use in decision making includes her PANSS score, history of Risperdal use, obesity, illusions, and family social support systems available to her, as they influence the care outcomes.
Decision 1
Start Invega Sustenna 234 mg intramuscular X1 followed by 156 mg intramuscular on day 4 and monthly thereafter.
Reason for Selection
Studies have demonstrated that Invega Sustenna is highly effective in managing schizophrenia symptoms. The effectiveness can be seen in Patel et al. (2020) study where Invega Sustenna reduced patient claims for psychoses diagnoses, hypertension, depression, substance-related and addictive disorders, bipolar disorder, anxiety, and sleep-wake disorders. The authors also found a significant reduction in the need for hospital visits, hospitalizations, and costs when patients were initiated on Invega Sustenna rather than Risperidone (Patel et al., 2020).
Early treatment of schizophrenia with Invega Sustenna also results in enhanced treatment adherence and social functioning (Cassidy & Miles, 2021). According to Emsley and Kilian (2018), Invega Sustenna provides benefits that include its availability in long-acting injectable formulations and dose initiation, which causes rapid onset of action compared to other antipsychotics.
Why The Other Options Were Not Selected
Zyprexa 10 mg orally at bedtime was not selected because of the increased risk of poor adherence by the patient due to side effects that include memory loss, metabolic deregulation, and changes in the menstrual cycle. The safety risks associated with Zyprexa have made it a second choice of drug in schizophrenia (Citrome et al., 2019). Starting the patient on Abilify 10 mg orally at bedtime was not selected because studies have shown that psychotic symptoms worsen in the patient when switched from other antipsychotics to Abilify. In addition, case studies report the increased risk of adverse events and lack of efficacy with the use of Abilify in schizophrenia patients (Takeuchi et al., 2018).
Expected Outcomes
Invega Sustenna improves schizophrenia symptoms. As a result, I was expecting to witness symptom improvement, as evidenced by improvement in PANSS score, social functioning, and treatment adherence. I also expected minimal side effects associated with Invega Sustenna (Cassidy & Miles, 2021).
Ethical Considerations
Psychiatric mental health nurse practitioners should weigh the benefits and risks associated with the available treatments for mental health disorders. While the given antipsychotics have comparable effectiveness in schizophrenia, prio
