Geriatric Depression Hispanic Male With MDD
Order ID 53563633773 Type Essay Writer Level Masters Style APA Sources/References 4 Perfect Number of Pages to Order 5-10 Pages Description/Paper Instructions
Geriatric Depression Hispanic Male With MDD
Adult/Geriatric Depression Hispanic Male With MDD
BACKGROUND INFORMATION
The client is a 32-year-old Hispanic American male who came to the United States when he was in high school with his father. His mother died back in Mexico when he was in school. He presents today to the PMHNPs office for an initial appointment for complaints of depression. The client was referred by his PCP after “routine” medical work-up to rule out an organic basis for his depression. He has no other health issues with the exception of some occasional back pain and “stiff” shoulders which he attributes to his current work as a laborer in a warehouse.
SUBJECTIVE
During today’s clinical interview, client reports that he always felt like an outsider as he was “teased” a lot for being “black” in high school. States that he had few friends, and basically kept to himself. He describes his home life as “good.” Stating “Dad did what he could for us, there were 8 of us.” He also reports a remarkably diminished interest in engaging in usual activities, states that he has gained 15 pounds in the last 2 months. He is also troubled with insomnia which began about 6 months ago, but have been progressively getting worse. He does report poor concentration which he reports is getting in “trouble” at work.
MENTAL STATUS EXAM
The client is alert, oriented to person, place, time, and event. He is casually dressed. Speech is clear, but soft. He does not readily make eye contact, but when he does, it is only for a few moments. He is endorsing feelings of depression. Affect is somewhat constricted, but improves as the clinical interview progresses. He denies visual or auditory hallucinations, no overt delusional or paranoid thought processes readily apparent. Judgment and insight appear grossly intact. He is currently denying suicidal or homicidal ideation. The PMHNP administers the “Montgomery- Asberg Depression Rating Scale (MADRS)” and obtained a score of 51 (indicating severe depression).
RESOURCES
- Montgomery, S. A., & Asberg, M. (1979). A new depression scale designed to be sensitive to change. British Journal of Psychiatry, 134, 382-389.
Part#1 Decision Point One
Select what the PMHNP should do:
- Begin zoloft 25 mg orally daily Reports a 25% decrease in symptoms
- Client is concerned over the new onset of erectile dysfunction
Begin Effexor XR 37.5 mg orally daily Client returns to clinic in four weeks
- Client informed the PMHNP that he stopped taking the drug because his inability to perform sexually was worsening his self-esteem
- Begin Phenelzine 15 mg orally TID Client returns to clinic in four weeks
- Client reports that he was rushed to the Emergency Room 2 weeks ago after collapsing at the warehouse where he works. He was taken by ambulance to the local community hospital. He was diagnosed with postural hypotension
- Client was treated with fluid bolus and told to stop taking his phenelzine and to follow up with his primary care provider within one week, and his PMHNP within that same time frame
Decision Point Two
Select what the PMHNP should do next:
Decrease dose to 12.5 mg orally daily Client returns to clinic in four weeks
- Erectile dysfunction has subsided
- Depressive symptoms have worsened
- Continue same dose and counsel client: Client returns to clinic in four weeks
- Client informed the PMHNP that he stopped taking the drug because his inability to perform sexually was worsening his self-esteem
- Add augmenting agent such as Wellbutrin IR 150 mg in morning Client returns to clinic in four weeks
- Client stated that depressive symptoms have decreased even more and his erectile dysfunction has abated
- Client reports that he has been feeling “jittery” and sometimes “nervous”
Decision Point Three
Select what the PMHNP should do next:
Increase dose back to 25 mg orally daily
Change to Paxil 20 mg orally daily
Change to Cymbalta 40 mg orally daily
Decision Point Three
- Increase dose back to 25 mg orally daily: Client returns to clinic in four weeks
- Client reports an improvement in depressive symptoms
- Montgomery- Asberg Depression Rating Scale (MADRS) decreased from 51 to 38 (25% reduction)
Guidance to Student Increasing dose back to 25 mg orally daily may be appropriate as there is no guarantee that the side effect will return. If it does return at 25 mg orally daily, then the PMHNP should consider changing to another drug. Changing to Paxil 20 mg may also be appropriate at this point, as not all SSRIs have the same side effect profile. Changing to an SNRI would not be appropriate at this point as the issue is not that the client has not responded to SSRI therapy, rather, he has had a negative side effect to one drug in the class.
Decision Point Three
Change to Paxil 20 mg orally daily
Guidance to Student Increasing dose back to 25 mg orally daily may be appropriate as there is no guarantee that the side effect will return. If it does return at 25 mg orally daily, then the PMHNP should consider changing to another drug. Changing to Paxil 20 mg may also be appropriate at this point, as not all SSRIs have the same side effect profile. Changing to an SNRI would not be appropriate at this point as the issue is not that the client has not responded to SSRI therapy, rather, he has had a negative side effect to one drug in the class.
Decision Point Three
Change to Cymbalta 40 mg orally daily
Guidance to Student Increasing dose back to 25 mg orally daily may be appropriate as there is no guarantee that the side effect will return. If it does return at 25 mg orally daily, then the PMHNP should consider changing to another drug. Changing to Paxil 20 mg may also be appropriate at this point, as not all SSRIs have the same side effect profile. Changing to an SNRI would not be appropriate at this point as the issue is not that the client has not responded to SSRI therapy, rather, he has had a negative side effect to one drug in the class.
Decision Point Three
Encourage client to re-start drug at previous dose
Guidance to Student Encouraging client to restart at previous dose would not be appropriate. Obviously, the side effect did not abate- so there is no reason to assume that it would abate at the previous dose. Re-starting the drug at 50% of starting dose may be appropriate to determine whether or not side effect is dose dependent. If the side effect of erectile dysfunction returns once the drug is returned to full dose, the PMHNP would need to change the drug. Changing to Wellbutrin XL may be appropriate at this point, but may worsen his insomnia. Additionally, guidelines tell us that another SSRI should be attempted for an adequate trial before switching drug classes.
Decision Point Three
Re-start drug at 50% initial dose
Guidance to Student Encouraging client to restart at previous dose would not be appropriate. Obviously, the side effect did not abate- so there is no reason to assume that it would abate at the previous dose. Re-starting the drug at 50% of starting dose may be appropriate to determine whether or not side effect is dose dependent. If the side effect of erectile dysfunction returns once the drug is returned to full dose, the PMHNP would need to change the drug. Changing to Wellbutrin XL may be appropriate at this point, but may worsen his insomnia. Additionally, guidelines tell us that another SSRI should be attempted for an adequate trial before switching drug classes.
Decision Point Three
Change to Wellbutrin XL
Guidance to Student Encouraging client to restart at previous dose would not be appropriate. Obviously, the side effect did not abate- so there is no reason to assume that it would abate at the previous dose. Re-starting the drug at 50% of starting dose may be appropriate to determine whether or not side effect is dose dependent. If the side effect of erectile dysfunction returns once the drug is returned to full dose, the PMHNP would need to change the drug. Changing to Wellbutrin XL may be appropriate at this point, but may worsen his insomnia. Additionally, guidelines tell us that another SSRI should be attempted for an adequate trial before switching drug classes.
Decision Point Two
Add augmenting agent such as Wellbutrin IR 150 mg in morning
RESULTS OF DECISION POINT TWO
- Client returns to clinic in four weeks
- Client stated that depressive symptoms have decreased even more and his erectile dysfunction has abated
- Client reports that he has been feeling “jittery” and sometimes “nervous”
Decision Point Three
Select what the PMHNP should do next:
Discontinue Zoloft altogether and continue with Wellbutrin
Change Wellbutrin to XL 150 mg orally daily in AM
Add Ativan 0.5 mg orally TID/PRN for anxiety
Decision Point Three
Discontinue Zoloft altogether and continue with Wellbutrin
Guidance to Student The PMHNP should be aware that Zoloft or Wellbutrin could be responsible for the client complaints of Jitteriness. This feeling is usually temporary with SSRIs, however. The cause of the client’s complaint of “jitteriness” is most likely related to the Wellbutrin immediate release. As a result, the most appropriate answer would be to change the Wellbutrin to an extended release formulation. It would not be appropriate to add Ativan as the PMHNP should never add an additional medication to treat the side effect of another medication without first attempting to modify/change the medication causing the side effect.
Decision Point Three
Change Wellbutrin to XL 150 mg orally daily in AM
Guidance to Student The PMHNP should be aware that Zoloft or Wellbutrin could be responsible for the client complaints of Jitteriness. This feeling is usually temporary with SSRIs, however. The cause of the client’s complaint of “jitteriness” is most likely related to the Wellbutrin immediate release. As a result, the most appropriate answer would be to change the Wellbutrin to an extended release formulation. It would not be appropriate to add Ativan as the PMHNP should never add an additional medication to treat the side effect of another medication without first attempting to modify/change the medication causing the side effect.
Decision Point Three
Add Ativan 0.5 mg orally TID/PRN for anxiety
Guidance to Student The PMHNP should be aware that Zoloft or Wellbutrin could be responsible for the client complaints of Jitteriness. This feeling is usually temporary with SSRIs, however. The cause of the client’s complaint of “jitteriness” is most likely related to the Wellbutrin immediate release. As a result, the most appropriate answer would be to change the Wellbutrin to an extended release formulation. It would not be appropriate to add Ativan as the PMHNP should never add an additional medication to treat the side effect of another medication without first attempting to modify/change the medication causing the side effect.
Part#2Decision Point One
Begin Effexor XR 37.5 mg orally daily
RESULTS OF DECISION POINT ONE
- Client returns to clinic in four weeks
- Client reports that there is no change in depressive symptoms at all
Decision Point Two
Select what the PMHNP should do next:
Increase dose to 75 mg of Effexor XR orally daily
Change to Cymbalta 30 mg orally daily
Augment with an atypical antipsychotic
Decision Point Two
Increase dose to 75 mg of Effexor XR orally daily
RESULTS OF DECISION POINT TWO
- Client returns to clinic in four weeks
- Client reports an improvement in depressive symptoms
- Montgomery- Asberg Depression Rating Scale (MADRS) decreased from 51 to 38 (25% reduction)
Decision Point Three
Select what the PMHNP should do next:
Increase dose to 112.5 mg orally daily
Continue same dose of medication
Augment with Wellbutrin XL 150 mg orally daily
Decision Point Three
Increase dose to 112.5 mg orally daily
Guidance to Student At this point, the PMHNP would have two choices to discuss with the client- the current dose of drug can be maintained if the client is feeling better and is not offering any complaints of side effects. The dose can also be increased at this point, but the PMHNP must counsel client regarding the possibility of side effects. The use of an augmenting agent is not appropriate at this time as we have not reached a maximum dose with Effexor (in fact, 75 mg is still a relatively small dose), displaying primarily SSRI properties only (recall that at lower doses, Effexor exerts a greater effect on serotonergic receptors than norepinephrine at low doses).
Decision Point Three
Continue same dose of medication
Guidance to Student At this point, the PMHNP would have two choices to discuss with the client- the current dose of drug can be maintained if the client is feeling better and is not offering any complaints of side effects. The dose can also be increased at this point, but the PMHNP must counsel client regarding the possibility of side effects. The use of an augmenting agent is not appropriate at this time as we have not reached a maximum dose with Effexor (in fact, 75 mg is still a relatively small dose), displaying primarily SSRI properties only (recall that at lower doses, Effexor exerts a greater effect on serotonergic receptors than norepinephrine at low doses).
Decision Point Three
Augment with Wellbutrin XL 150 mg orally daily
Guidance to Student At this point, the PMHNP would have two choices to discuss with the client- the current dose of drug can be maintained if the client is feeling better and is not offering any complaints of side effects. The dose can also be increased at this point, but the PMHNP must counsel client regarding the possibility of side effects. The use of an augmenting agent is not appropriate at this time as we have not reached a maximum dose with Effexor (in fact, 75 mg is still a relatively small dose), displaying primarily SSRI properties only (recall that at lower doses, Effexor exerts a greater effect on serotonergic receptors than norepinephrine at low doses).
Decision Point Two
Change to Cymbalta 30 mg orally daily
RESULTS OF DECISION POINT TWO
- Client returns to clinic in four weeks
- Client reports that his depressive symptoms are “not really any better”
- Client has noticed that his back pain and shoulder stiffness have improved, which he was not expecting
- Client is asking if he could be kept on the current medication due to its favorable effect on his pain
Decision Point Three
Select what the PMHNP should do next:
Continue current dose of Cymbalta
Increase Cymbalta to 60 mg orally daily
Discontinue Cymbalta and begin Elavil 25 mg orally daily
Decision Point Three
Continue current dose of Cymbalta
Guidance to Student Maintaining the current dose would be appropriate if the client were showing an improvement in depressive symptoms, but since he is not showing improvement, something needs to be done. Increasing Cymbalta to 60 mg orally daily would be the most appropriate choice as 30 mg is a small dose, and with an effective dose range of 60 to 120 mg orally daily, it would be prudent to increase the client’s dose to a therapeutic dose. Changing to Elavil, a tricyclic antidepressant is not the best choice as it can be associated with increased side effects and although it can treat pain symptoms as well, there is no indication that changing drug therapy at this point would be appropriate as we have not trialed the client with an adequate duration or dose of Cymbalta. It is always beneficial when we can select medications that will treat co-morbid conditions. So Cymbalta should be trialed at an appropriate dose for an appropriate duration to treat the clients pain and depression.
Decision Point Three
Increase Cymbalta to 60 mg orally daily
Guidance to Student Maintaining the current dose would be appropriate if the client were showing an improvement in depressive symptoms, but since he is not showing improvement, something needs to be done. Increasing Cymbalta to 60 mg orally daily would be the most appropriate choice as 30 mg is a small dose, and with an effective dose range of 60 to 120 mg orally daily, it would be prudent to increase the client’s dose to a therapeutic dose. Changing to Elavil, a tricyclic antidepressant is not the best choice as it can be associated with increased side effects and although it can treat pain symptoms as well, there is no indication that changing drug therapy at this point would be appropriate as we have not trialed the client with an adequate duration or dose of Cymbalta. It is always beneficial when we can select medications that will treat co-morbid conditions. So Cymbalta should be trialed at an appropriate dose for an appropriate duration to treat the clients pain and depression.
Decision Point Three
Discontinue Cymbalta and begin Elavil 25 mg orally daily
Guidance to Student Maintaining the current dose would be appropriate if the client were showing an improvement in depressive symptoms, but since he is not showing improvement, something needs to be done. Increasing Cymbalta to 60 mg orally daily would be the most appropriate choice as 30 mg is a small dose, and with an effective dose range of 60 to 120 mg orally daily, it would be prudent to increase the client’s dose to a therapeutic dose. Changing to Elavil, a tricyclic antidepressant is not the best choice as it can be associated with increased side effects and although it can treat pain symptoms as well, there is no indication that changing drug therapy at this point would be appropriate as we have not trialed the client with an adequate duration or dose of Cymbalta. It is always beneficial when we can select medications that will treat co-morbid conditions. So Cymbalta should be trialed at an appropriate dose for an appropriate duration to treat the clients pain and depression.
Decision Point Two
Augment with an atypical antipsychotic
RESULTS OF DECISION POINT TWO
- Client returns to clinic in four weeks
- Client reports that he has gained about 9 pounds in the past month
- Client states that his depression was a little better but his self-esteem is worsening as he is gaining weight
Decision Point Three
Select what the PMHNP should do next:
Discontinue atypical antipsychotic
Increase dose of atypical antipsychotic
Counsel client about diet and exercise
Decision Point Three
Discontinue atypical antipsychotic
Guidance to Student At this point, discontinuation of the atypical antipsychotic would be appropriate. It has contributed minimally to the client’s depressive symptoms, but has instead, decreased self-esteem due to weight gain. Weight gain associated with atypical antipsychotics can also represent a health issue due to its contribution to dyslipidemia, and hyperglycemia. Increasing the dose would most likely worsen these symptoms. If an atypical antipsychotic were needed to augment the antidepressant medication, it would be appropriate to counsel client about diet and exercise to decrease weight gain associated with atypical antipsychotic usage. However, antipsychotics should be discontinued and the PMHNP should counsel client to help with weight loss caused by the atypical antipsychotic.
Decision Point Three
Increase dose of atypical antipsychotic
Guidance to Student At this point, discontinuation of the atypical antipsychotic would be appropriate. It has contributed minimally to the client’s depressive symptoms, but has instead, decreased self-esteem due to weight gain. Weight gain associated with atypical antipsychotics can also represent a health issue due to its contribution to dyslipidemia, and hyperglycemia. Increasing the dose would most likely worsen these symptoms. If an atypical antipsychotic were needed to augment the antidepressant medication, it would be appropriate to counsel client about diet and exercise to decrease weight gain associated with atypical antipsychotic usage. However, antipsychotics should be discontinued and the PMHNP should counsel client to help with weight loss caused by the atypical antipsychotic.
Decision Point Three
Counsel client about diet and exercise
Guidance to Student At this point, discontinuation of the atypical antipsychotic would be appropriate. It has contributed minimally to the client’s depressive symptoms, but has instead, decreased self-esteem due to weight gain. Weight gain associated with atypical antipsychotics can also represent a health issue due to its contribution to dyslipidemia, and hyperglycemia. Increasing the dose would most likely worsen these symptoms. If an atypical antipsychotic were needed to augment the antidepressant medication, it would be appropriate to counsel client about diet and exercise to decrease weight gain associated with atypical antipsychotic usage. However, antipsychotics should be discontinued and the PMHNP should counsel client to help with weight loss caused by the atypical antipsychotic.
Part#3 Point One
Begin Phenelzine 15 mg orally TID
RESULTS OF DECISION POINT ONE
- Client returns to clinic in four weeks
- Client reports that he was rushed to the Emergency Room 2 weeks ago after collapsing at the warehouse where he works. He was taken by ambulance to the local community hospital. He was diagnosed with postural hypotension
- Client was treated with fluid bolus and told to stop taking his phenelzine and to follow up with his primary care provider within one week, and his PMHNP within that same time frame
Decision Point Two
Select what the PMHNP should do next:
Restart Phenelzine and counsel client on dietary choices and importance of hydration
Phenelzine is not reinitiated. Instead, we began therapy with Lexapro 20 mg orally daily after an appropriate “wash out” period (5 half-lives).
Re-start Phenelzine 7.5 mg orally TID
Decision Point Two
Restart Phenelzine and counsel client on dietary choices and importance of hydration
RESULTS OF DECISION POINT TWO
- Client reports that although he had no more episodes of passing out, he has been dizzy when he gets up at night to use the bathroom
- Client also reports that at various times throughout the day when he goes from a sitting to a standing position, he feels light-headed
Decision Point Three
Select what the PMHNP should do next:
Discontinue Phenelzine and start an SSRI
Reduce dose of phenelzine to 7.5 mg orally BID
Start Midodrine 10 mg TID during the daytime only
Decision Point Three
Discontinue Phenelzine and start an SSRI
Guidance to Student The best choice at this point would be to discontinue Phenelzine and begin SSRI therapy. While MAOIs can be powerful drugs used to treat depression, they are generally considered last-line therapy due to unfavorable side effect profiles as well as drug/food interactions. Client’s on MAOIs must be on the MAOI diet and avoid certain aged foods which contain Tyramine. Adding Midodrine would not be appropriate as the PMHNP should never add a medication to treat the side effects of a medication unless there are no other alternatives. In this case, changing from an MAOI to another drug class would be reasonable and appropriate. Reduction of the Phenelizine dose could be appropriate, but decreased dosage would result in decreased likelihood of efficacy.
Decision Point Three
Reduce dose of phenelzine to 7.5 mg orally BID
Guidance to Student The best choice at this point would be to discontinue Phenelzine and begin SSRI therapy. While MAOIs can be powerful drugs used to treat depression, they are generally considered last-line therapy due to unfavorable side effect profiles as well as drug/food interactions. Client’s on MAOIs must be on the MAOI diet and avoid certain aged foods which contain Tyramine. Adding Midodrine would not be appropriate as the PMHNP should never add a medication to treat the side effects of a medication unless there are no other alternatives. In this case, changing from an MAOI to another drug class would be reasonable and appropriate. Reduction of the Phenelizine dose could be appropriate, but decreased dosage would result in decreased likelihood of efficacy.
Decision Point Three
Start Midodrine 10 mg TID during the daytime only
Guidance to Student The best choice at this point would be to discontinue Phenelzine and begin SSRI therapy. While MAOIs can be powerful drugs used to treat depression, they are generally considered last-line therapy due to unfavorable side effect profiles as well as drug/food interactions. Client’s on MAOIs must be on the MAOI diet and avoid certain aged foods which contain Tyramine. Adding Midodrine would not be appropriate as the PMHNP should never add a medication to treat the side effects of a medication unless there are no other alternatives. In this case, changing from an MAOI to another drug class would be reasonable and appropriate. Reduction of the Phenelizine dose could be appropriate, but decreased dosage would result in decreased likelihood of efficacy.
Decision Point Two
Phenelzine is not reinitiated. Instead, we began therapy with Lexapro 20 mg orally daily after an appropriate “wash out” period (5 half-lives).
RESULTS OF DECISION POINT TWO
- Client returns to clinic in four weeks
- Client had no more syncopal episodes or episodes of orthostatic hypotension
- Client reports a decrease in depressive symptoms by approximately 25 percent on the MADR scale
Decision Point Three
Select what the PMHNP should do next:
Continue current dose
Increase Lexapro to 30 mg orally daily
Increase Lexapro to 25 mg orally daily
Decision Point Three
Continue current dose
Guidance to Student At this point, the PMHPM is seeing evidence of response to therapy without negative side effects. The PMHNP could hold at the current dose for another 4 weeks to see if any more gains in efficacy are achieved. The PMHNP should discuss these options with the client so that the client is aware of risks/benefits of maintaining current dose of medication vs. increasing dose. If the decision to increase is made, the increase should be to 25 mg orally daily. Increasing to 30 mg orally daily (a 50% increase from 20 mg) increases the risk of side effects. NOTE: The initiation of an SSRI or SNRI should not begin until an adequate “wash out” period of MAOI- this is generally defined as the time it takes for 5 half-lives of the drug to be metabolized.
Decision Point Three
Increase Lexapro to 30 mg orally daily
Guidance to Student At this point, the PMHPM is seeing evidence of response to therapy without negative side effects. The PMHNP could hold at the current dose for another 4 weeks to see if any more gains in efficacy are achieved. The PMHNP should discuss these options with the client so that the client is aware of risks/benefits of maintaining current dose of medication vs. increasing dose. If the decision to increase is made, the increase should be to 25 mg orally daily. Increasing to 30 mg orally daily (a 50% increase from 20 mg) increases the risk of side effects. NOTE: The initiation of an SSRI or SNRI should not begin until an adequate “wash out” period of MAOI- this is generally defined as the time it takes for 5 half-lives of the drug to be metabolized.
Decision Point Three
Increase Lexapro to 25 mg orally daily
Guidance to Student At this point, the PMHPM is seeing evidence of response to therapy without negative side effects. The PMHNP could hold at the current dose for another 4 weeks to see if any more gains in efficacy are achieved. The PMHNP should discuss these options with the client so that the client is aware of risks/benefits of maintaining current dose of medication vs. increasing dose. If the decision to increase is made, the increase should be to 25 mg orally daily. Increasing to 30 mg orally daily (a 50% increase from 20 mg) increases the risk of side effects. NOTE: The initiation of an SSRI or SNRI should not begin until an adequate “wash out” period of MAOI- this is generally defined as the time it takes for 5 half-lives of the drug to be metabolized.
Decision Point Two
Re-start Phenelzine 7.5 mg orally TID
RESULTS OF DECISION POINT TWO
- Client returns to clinic in four weeks
- Client reported that he still has a little dizziness
- Client also reports that that his depression has improved greatly (a 35% decrease in MADR scale from 51 to 33)
Decision Point Three
Select what the PMHNP should do next:
Continue current drug dose and counsel client on dietary modifications and orthostatic hypotension safety
Augment with Lexapro 10 mg orally daily
Increase dose of Phenelzine back to 15 mg orally TID now that the client is tolerating lower dose
Decision Point Three
Continue current drug dose and counsel client on dietary modifications and orthostatic hypotension safety
Guidance to Student The initiation of an SSRI or SNRI should not begin until an adequate “wash out” period of MAOI- this is generally defined as the time it takes for 5 half-lives of the drug to be metabolized. Co-administration of SSRI, SNRI, or TCA with MAOI is contraindicated as it can cause serotonin syndrome and can actually be fatal. The PMHNP can continue the current dose and counsel client as to dietary modifications as well as orthostatic hypotension safety, however, it should be remembered that he works in a warehouse and may be at risk for falls/injury due to orthostatic hypotension. A “watch and wait” approach may be appropriate if the client has failed all other antidepressants. Increasing the dose back to 15 mg orally TID is not indicated as his orthostatic hypotension will likely worsen.
Decision Point Three
Augment with Lexapro 10 mg orally daily
Guidance to Student The initiation of an SSRI or SNRI should not begin until an adequate “wash out” period of MAOI- this is generally defined as the time it takes for 5 half-lives of the drug to be metabolized. Co-administration of SSRI, SNRI, or TCA with MAOI is contraindicated as it can cause serotonin syndrome and can actually be fatal. The PMHNP can continue the current dose and counsel client as to dietary modifications as well as orthostatic hypotension safety, however, it should be remembered that he works in a warehouse and may be at risk for falls/injury due to orthostatic hypotension. A “watch and wait” approach may be appropriate if the client has failed all other antidepressants. Increasing the dose back to 15 mg orally TID is not indicated as his orthostatic hypotension will likely worsen.
Decision Point Three
Increase dose of Phenelzine back to 15 mg orally TID now that the client is tolerating lower dose
Guidance to Student The initiation of an SSRI or SNRI should not begin until an adequate “wash out” period of MAOI- this is generally defined as the time it takes for 5 half-lives of the drug to be metabolized. Co-administration of SSRI, SNRI, or TCA with MAOI is contraindicated as it can cause serotonin syndrome and can actually be fatal. The PMHNP can continue the current dose and counsel client as to dietary modifications as well as orthostatic hypotension safety, however, it should be remembered that he works in a warehouse and may be at risk for falls/injury due to orthostatic hypotension. A “watch and wait” approach may be appropriate if the client has failed all other antidepressants. Increasing the dose back to 15 mg orally TID is not indicated as his orthostatic hypotension will likely worsen.
RUBRIC
QUALITY OF RESPONSE NO RESPONSE POOR / UNSATISFACTORY SATISFACTORY GOOD EXCELLENT Content (worth a maximum of 50% of the total points) Zero points: Student failed to submit the final paper. 20 points out of 50: The essay illustrates poor understanding of the relevant material by failing to address or incorrectly addressing the relevant content; failing to identify or inaccurately explaining/defining key concepts/ideas; ignoring or incorrectly explaining key points/claims and the reasoning behind them; and/or incorrectly or inappropriately using terminology; and elements of the response are lacking. 30 points out of 50: The essay illustrates a rudimentary understanding of the relevant material by mentioning but not full explaining the relevant content; identifying some of the key concepts/ideas though failing to fully or accurately explain many of them; using terminology, though sometimes inaccurately or inappropriately; and/or incorporating some key claims/points but failing to explain the reasoning behind them or doing so inaccurately. Elements of the required response may also be lacking. 40 points out of 50: The essay illustrates solid understanding of the relevant material by correctly addressing most of the relevant content; identifying and explaining most of the key concepts/ideas; using correct terminology; explaining the reasoning behind most of the key points/claims; and/or where necessary or useful, substantiating some points with accurate examples. The answer is complete. 50 points: The essay illustrates exemplary understanding of the relevant material by thoroughly and correctly addressing the relevant content; identifying and explaining all of the key concepts/ideas; using correct terminology explaining the reasoning behind key points/claims and substantiating, as necessary/useful, points with several accurate and illuminating examples. No aspects of the required answer are missing. Use of Sources (worth a maximum of 20% of the total points). Zero points: Student failed to include citations and/or references. Or the student failed to submit a final paper. 5 out 20 points: Sources are seldom cited to support statements and/or format of citations are not recognizable as APA 6th Edition format. There are major errors in the formation of the references and citations. And/or there is a major reliance on highly questionable. The Student fails to provide an adequate synthesis of research collected for the paper. 10 out 20 points: References to scholarly sources are occasionally given; many statements seem unsubstantiated. Frequent errors in APA 6th Edition format, leaving the reader confused about the source of the information. There are significant errors of the formation in the references and citations. And/or there is a significant use of highly questionable sources. 15 out 20 points: Credible Scholarly sources are used effectively support claims and are, for the most part, clear and fairly represented. APA 6th Edition is used with only a few minor errors. There are minor errors in reference and/or citations. And/or there is some use of questionable sources. 20 points: Credible scholarly sources are used to give compelling evidence to support claims and are clearly and fairly represented. APA 6th Edition format is used accurately and consistently. The student uses above the maximum required references in the development of the assignment. Grammar (worth maximum of 20% of total points) Zero points: Student failed to submit the final paper. 5 points out of 20: The paper does not communicate ideas/points clearly due to inappropriate use of terminology and vague language; thoughts and sentences are disjointed or incomprehensible; organization lacking; and/or numerous grammatical, spelling/punctuation errors 10 points out 20: The paper is often unclear and difficult to follow due to some inappropriate terminology and/or vague language; ideas may be fragmented, wandering and/or repetitive; poor organization; and/or some grammatical, spelling, punctuation errors 15 points out of 20: The paper is mostly clear as a result of appropriate use of terminology and minimal vagueness; no tangents and no repetition; fairly good organization; almost perfect grammar, spelling, punctuation, and word usage. 20 points: The paper is clear, concise, and a pleasure to read as a result of appropriate and precise use of terminology; total coherence of thoughts and presentation and logical organization; and the essay is error free. Structure of the Paper (worth 10% of total points) Zero points: Student failed to submit the final paper. 3 points out of 10: Student needs to develop better formatting skills. The paper omits significant structural elements required for and APA 6th edition paper. Formatting of the paper has major flaws. The paper does not conform to APA 6th edition requirements whatsoever. 5 points out of 10: Appearance of final paper demonstrates the student’s limited ability to format the paper. There are significant errors in formatting and/or the total omission of major components of an APA 6th edition paper. They can include the omission of the cover page, abstract, and page numbers. Additionally the page has major formatting issues with spacing or paragraph formation. Font size might not conform to size requirements. The student also significantly writes too large or too short of and paper 7 points out of 10: Research paper presents an above-average use of formatting skills. The paper has slight errors within the paper. This can include small errors or omissions with the cover page, abstract, page number, and headers. There could be also slight formatting issues with the document spacing or the font Additionally the paper might slightly exceed or undershoot the specific number of required written pages for the assignment. 10 points: Student provides a high-caliber, formatted paper. This includes an APA 6th edition cover page, abstract, page number, headers and is double spaced in 12’ Times Roman Font. Additionally, the paper conforms to the specific number of required written pages and neither goes over or under the specified length of the paper. GET THIS PROJECT NOW BY CLICKING ON THIS LINK TO PLACE THE ORDER
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