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Puerto Rican Woman With Comorbid Addiction Case Study
Puerto Rican Woman With Comorbid Addiction Case Study
Order ID 53563633773 Type Essay Writer Level Masters Style APA Sources/References 4 Language English Pages 5-10 pages Description/Paper Instructions
Examine Case Study: A Puerto Rican Woman With Comorbid Addiction. 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?
case Study and the decisions
BACKGROUND
Mrs. Maria Perez is a 53 year old Puerto Rican female who presents to your office today due to a rather “embarrassing problem.”
SUBJECTIVE
Mrs. Perez admits that she has had “problems” with alcohol since her father died in her late teens. She reports that she has struggled with alcohol since her 20’s and has been involved with Alcoholics Anonymous “on and off” for the past 25 years. She states that for the past two years, she has been having more and more difficulty maintaining her sobriety since they opened the new “Rising Sun” casino near her home. Mrs. Perez states that she and a friend went to visit the new casino during their grand opening at which point she was “hooked.” She states that she gets “such a high” when she is gambling. While gambling, she “enjoys a drink or two” to help calm her during high-stakes games. She states that this often gives way to more drinking and more reckless gambling. She also reports that her cigarette smoking has increased over the past two years and she is concerned about the negative effects of the cigarette smoking on her health.
She states that she attempts to abstain from drinking but that she gets such a “high” from the act of gambling that she needs a few drinks to “even out.” She also notices that when she drinks, she doesn’t smoke “as much” but enjoys smoking when she is playing at the slot machines. She also reports that she has gained weight from drinking so much- she currently weights 122 lbs., which represents a 7 lb. weight gain from her usual 115 lb. weight.
Mrs. Perez is quite concerned today because she has borrowed over $50,000 from her retirement account to pay off her gambling debts. She is very concerned because her husband does not know that she has spent this much money.
MENTAL STATUS EXAM
The client is a 53 year old Puerto Rican female who is alert, oriented to person, place, time, and event. She is dressed appropriately for the weather and time of year. Her speech is clear, coherent, and goal directed. Her eye contact is somewhat avoidant during the clinical interview. As you make eye contact with her, she looks away or looks down. She demonstrates no noteworthy mannerisms, gestures, or tics. Her self-reported mood is “sad.” Affect is appropriate to content of conversation & self-reported mood. She visual or auditory hallucinations, no delusional or paranoid thought processes are readily appreciated. Insight and judgment are grossly intact, however, impulse control is impaired. She is currently denying suicidal or homicidal ideation.
Decision Point One
Select what the PMHNP should do:
Naltrexone (Vivitrol) injection, 380 mg intramuscularly in the gluteal region every 4 weeks
Antabuse (Disulfiram) 250 mg orally daily
Campral (Acamprosate) 666 mg orally three times/day
Decision Point Two
Select what the PMHNP should do next:
Add on Valium (diazepam) 5 mg orally TID/PRN/anxiety
Refer to a counselor to address gambling issues
Add on Chantix (varenicline) 1 mg orally BID
Decision Point Three
Select what the PMHNP should do next:
BACKGROUND
Mrs. Maria Perez is a 53 year old Puerto Rican female who presents to your office today due to a rather “embarrassing problem.”
SUBJECTIVE
Mrs. Perez admits that she has had “problems” with alcohol since her father died in her late teens. She reports that she has struggled with alcohol since her 20’s and has been involved with Alcoholics Anonymous “on and off” for the past 25 years. She states that for the past two years, she has been having more and more difficulty maintaining her sobriety since they opened the new “Rising Sun” casino near her home. Mrs. Perez states that she and a friend went to visit the new casino during their grand opening at which point she was “hooked.” She states that she gets “such a high” when she is gambling. While gambling, she “enjoys a drink or two” to help calm her during high-stakes games. She states that this often gives way to more drinking and more reckless gambling. She also reports that her cigarette smoking has increased over the past two years and she is concerned about the negative effects of the cigarette smoking on her health.
She states that she attempts to abstain from drinking but that she gets such a “high” from the act of gambling that she needs a few drinks to “even out.” She also notices that when she drinks, she doesn’t smoke “as much” but enjoys smoking when she is playing at the slot machines. She also reports that she has gained weight from drinking so much- she currently weights 122 lbs., which represents a 7 lb. weight gain from her usual 115 lb. weight.
Mrs. Perez is quite concerned today because she has borrowed over $50,000 from her retirement account to pay off her gambling debts. She is very concerned because her husband does not know that she has spent this much money.
MENTAL STATUS EXAM
The client is a 53 year old Puerto Rican female who is alert, oriented to person, place, time, and event. She is dressed appropriately for the weather and time of year. Her speech is clear, coherent, and goal directed. Her eye contact is somewhat avoidant during the clinical interview. As you make eye contact with her, she looks away or looks down. She demonstrates no noteworthy mannerisms, gestures, or tics. Her self-reported mood is “sad.” Affect is appropriate to content of conversation & self-reported mood. She visual or auditory hallucinations, no delusional or paranoid thought processes are readily appreciated. Insight and judgment are grossly intact, however, impulse control is impaired. She is currently denying suicidal or homicidal ideation.
Decision Point One
Select what the PMHNP should do:
Naltrexone (Vivitrol) injection, 380 mg intramuscularly in the gluteal region every 4 weeks
Antabuse (Disulfiram) 250 mg orally daily
Campral (Acamprosate) 666 mg orally three times/day
Decision Point Two
Select what the PMHNP should do next:
Add on Valium (diazepam) 5 mg orally TID/PRN/anxiety
Refer to a counselor to address gambling issues
Add on Chantix (varenicline) 1 mg orally BID
Decision Point Three
Select what the PMHNP should do next:
Explore the issue that Mrs. Perez is having with her counselor, and encourage her to continue attending the Gamblers Anonymous meetings
Encourage Mrs. Perez to continue seeing her current counselor as well as continuing with the Gamblers Anonymous group
Discontinue Vivitrol. Encourage Mrs. Perez to continue seeing her counselor and to continue participating in the Gamblers Anonymous group
My decisions
DECISION POINT ONE
Ø Naltrexone (Vivitrol) injection, 380 mg intramuscularly in the gluteal region every 4 weeks
RESULTS OF DECISION POINT ONE
Client returns to clinic in four weeks
Mrs. Perez said that she felt “wonderful” as she has not “touched a drop” to drink since receiving the injection
Client reports that she has not been going to the casino, as frequently, but when she does go she “drops a bundle” (meaning, spends a lot of money gambling)
Client She is also still smoking, which has her concerned. She is also reporting some problems with anxiety, which also have her concerned
v DECISION POINT TWO
Ø Refer to a counselor to address gambling issues
RESULTS OF DECISION POINT TWO
Client returns to clinic in four weeks
Client reports that the anxiety that she had been experiencing is gone
Client reports that she has met with the counselor, but did not really like her. She did start going to a local meeting gamblers anonymous. She stated that last week, for the first time, she spoke during the meeting. She reports feeling supported in this group
DECISION POINT THREE
Ø Explore the issue that Mrs. Perez is having with her counselor, and encourage her to continue attending the Gamblers Anonymous meetings
Guidance to Student
Although controversy exists in the literature regarding how long to maintain a client on Vivitrol, four weeks is probably too soon to consider discontinuation. The psychiatric mental health nurse practitioner should explore the issues that Mrs. Perez is having with her counselor. As you will learn in future courses, ruptures and the therapeutic alliance can result in clients stopping therapy. Clearly, if the client does not continue with therapy, the likelihood of the gambling problem spontaneously remitting is lower (than had the client continued to receive therapy). Recall that there are no FDA approved treatments for gambling addiction, and the mainstay of treatment for this disorder is counseling. Since Mrs. Perez reports good perceived support from the gamblers anonymous meetings, she should be encouraged to continue her participation with this group.
The PMHNP needs to discuss smoking cessation options with Mrs. Perez in order to address the totality of addictions, and to enhance her overall health.
Assessing and Testing Clients with Psychosis and Schizophrenia
National Alliance on Mental Illness reports that there are about 100,000 individuals that have been diagnosed with psychosis in the United State almost every year. The symptoms associated with psychosis include delusions, hallucinations, disorganized thoughts, abnormal motor behavior, and the adverse symptoms which can make the situation to be worse for the patients. Other symptoms presented by these patients can include depression, bipolar disorders, and disorders on the schizophrenia.
The case study is a patient who is thirty-four-year-old Pakistani female that moved to the United States in her early teens or early twenties. She has a pre-arranged marriage when she was nine years old. She visited to the clinic after twenty-one days hospitalization. Her symptoms persist for one month and was diagnosed with brief psychotic disorder.
Before hospitalization, she reports seeing visions of Allah, and that she believed she prophet Mohammad. Patient husband became very concerned about her behavior has she get out of control with result calling the ambulance and was taking to the hospital for psychic evaluation.
She denies what she said and instead stated that the television is speaking to her and that she is receiving messages through the television. Patient is alert and oriented x4.
There will be three decisions based on the appropriate medications to the client (Lin, Rosenheck, Sugar, & Zbrozek, 2015).
Decision #1 Prescribing Invega Sustenna 234 mg IM followed by 156 mg IM on day 4 and monthly thereafter
The reason for the decision: this drug is having reduced side effects as compared to other optional drugs that supposed to be prescribed to this patient. This implies that it can well be tolerated as well as assists in reducing the symptoms of the patient’s condition. The work of this drug is that it rebalances dopamine and the serotonin to help in the improvement of the thinking, mood, and the behavior of the patient. It also binds to the D2 receptors quicker than Abilify and Zyprexa. The Zyprexa, on the other hand, is not effective to be prescribed to the patients since the patient need immediate relief from the symptom of his condition. When Zyprexa is used, it starts to work after 1 to 2 weeks and this makes it not to help in the improvement of the patient symptoms at a faster rate. It is also possible that it can take up to six weeks for its full benefits to be realized. The action of Abilify medication does not occur at a faster rate as compared to the Invega sustenna. This is basically because it does not bid to the D2 receptors for longer thus making them less effective (Fangfang, Stock, Copeland, Zeber, Ahmedani, & Morissette, 2014).
The expected outcome: the patient is expected to report an improvement in her condition, for example, the speech and judgment. The patient is also expected to have a reduction in the PANSS score thus showing an improvement in her condition.
The differences in the actual and the expected outcome: The patient returns to the facility after four weeks. There is a reduction in the PANSS score by 25 percent and the patient is tolerating the medication. Nevertheless, the patient has noted an increase in the weight by 2 pounds, but it does not seem to bother her. She also complains of the pain at the injection site that leads to difficult sitting down.
Decision#2 continue with the same medication but instruct state the injections into the deltoid at this visit going forward
Reason for the decision: The patient appears to have tolerated the medication even though there is a slight increase in the weight. It is not possible to discontinue the Invega Sustenna and start or add Abilify Maintena 300 mg IM monthly with the oral Abilify 10 mg in the morning. This is because there will be a poor reduction in the rate of the PANNS and other complications associated with the unusual movement of the trunk. The prescription of the Zyprexa might also cause more problem specially to gain in weight. Zyprexa is increasing the glucose and cholesterol levels at a higher rate as compared to the Invega Sustenna. The use of Abilify causes a slight reduction in the PANNS scores thus indicating no improvement in the condition of the patient.
The expected outcome: the patient is expected to record further reduction in the score of the PANNS. The weight of the patient is expected to reduce to normal with no further weight gain. The patient is expected not to complain of pain from the injection site.
These differences in the expected outcome and the actual outcome: the patient return to the clinic after two weeks. There is a 50 percent reduction in the PANSS score from the previous use of the Invega Sustenna. The patient stated that she feels much better in her arm and denies no pain in the injected site. Meanwhile the patient has gain two.five pounds, making a total of four.five pound within the last two month. The patient is worried about the weight gain and is afraid that her husband might not like it. She feels that the drug should be changed so that the weight could not increase further.
Decision #3 Maintain the medication but introduce suitable counseling about the weight gain from the Invega sustenna
Reason for the decision above: it appears that there is further weight gain from the medication even though she has tolerated it and had experience improvement in the symptom. The patient can be advised to take other medication since Abilify, and Zyprexa have more adverse impacts concerning weight gain as compared to the rate of weight gain caused by the use of the Invega sustenna. Therefore, an appointment is made with the dietitian and the exercise physiologist to help in ensuring that the patient is involved in regular exercise and watch a healthy diet. Abilify is not binding to the D2 receptors for longer as compared to Invega sustenna thus making it less effective (Lin, Rosenheck, Sugar, & Zbrozek, 2015).
The expected results: the patient is expected to have fully recovered with a reduction in the score of PANSS. The patient is expected to have a reduced weight following the nutritional and exercise counseling program.
The differences in the actual and the expected outcome: there is no further difference since the patient has fully recovered. However, the weight of the patient is expected to return to normal and healthy one after the initiation of the nutritional and exercise program.
Ethical considerations
While taking care for the patients with the delusional thought process, the psychiatric mental health nurse practitioner needs to know about the neurobiology of the symptoms to help in the selection of the recommended and appropriate treatment therapies and improvement of the healthcare outcome of the patient (Fangfang, Stock, Copeland, Zeber, Ahmedani, & Morissette, 2014).
References
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.
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.
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. The 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.
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