NURS 6630 Week 6 Assignment: Assessing and Treating Clients 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 interacting with colleagues at the workplace, school, and even friends in a social gatherings. Some of the additional symptoms that are often evident among 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 established diagnostic tests and procedures. This paper examines a Pakistani female adult suffering from psychosis and schizophrenia who has been taken through 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

Justification

The Positive and Negative Syndrome Scale score of the patient affirms that she suffers from Schizophrenia, which is responsible for her developing paranoid feelings. 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 headache, tachycardia, sexual dysfunction, and other extrapyramidal side effects makes it difficult to prescribe to 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 with 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 the 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.

 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.

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