Respond to at least two of your colleagues who were assigned to a different case than you. Explain how you might apply knowledge gained from your colleagues’ case studies to you own practice in clinical settings.
If your colleagues’ posts influenced your understanding of these concepts, be sure to share how and why. Include additional insights you gained.
If you think your colleagues might have misunderstood these concepts, offer your alternative perspective and be sure to provide an explanation for them. Include resources to support your perspective.
Case #7
The Case: The case of physician do not heal thyself
The Question: Does the patient have a complex mood disorder, a personality disorder or both?
The Dilemma: How do you treat a complex and long-term unstable disorder of mood in a difficult patient?
*List three questions you might ask the patient if he or she were in your office:
1. Has there ever been a period of time when you were not your usual self and thoughts raced through your head or you couldn’t slow your mind down (Hirschfeld, 2002)?
Rationale: This question specifically inquires about whether the client feels they have been their usual self and specifically references their energy levels (Hirschfeld, 2002). These symptoms are important to identify and rule out if a manic episode related to a mood disorder (such as Bipolar I) is occurring. By narrowing down correct symptomologies, the correct and appropriate psychiatric diagnosis can be made, along with the appropriate treatment.
2. Has your mood or behaviors caused major problems in your life like being unable to work; having a family, money or legal troubles; getting into arguments (Hirschfeld, 2002)?
Rationale: This question specifically focuses on how much of a problem the symptoms have been in a client’s everyday life. Mood disorders such as Bipolar I and Bipolar II can significantly impact a client’s life. Patients suffering from a mood disorder, such as Bipolar I, are at a significantly higher risk for suicide, harm to self, or harm to others (Hirschfeld, 2002).
3. How frequently would you estimate that you have experienced racing thoughts or elevated energy in relationship to your mood or fights and have any of these issues occurred during the same period of time (Hirschfeld, 2002)?
Rationale: This particular question addresses if the symptoms that are being experienced, occurred during the same time period, which would be indicative of the diagnosis of Bipolar I mood disorder. This question is important when assessing a client for a mood disorder in those patients who are misdiagnosed may experience rapid cycling or mania (Hirschfeld, 2002).
*Identify people in the patient’s life you would need to speak to or get feedback from to further assess the patient’s situation. Include specific questions you might ask these people and why.
According to Stahl (2013), it is essential for healthcare providers to obtain information from not only the client but also from outside sources. Outside sources for a client may include their spouse, parents, or siblings. Information obtained from outside sources may be significantly different than what the client describes and can assist in accurately diagnosing the client (Stahl,2013). Clients that are accurately diagnosed, can then be appropriately treated with pharmacological agents.
-Were there any significant triggering factors related to the client’s first major depression episode at age 23?
These questions can assist in distinguishing between Bipolar Mood Disorders and Borderline Personality Disorder. Bipolar Mood Disorders typically manifest in the early to mid-’20s ( It must be determined if the depression was an initial onset of a hypomanic episode or if it was due to an existing personality disorder.
-What other moods did the client exhibit when they were not in a depressive episode? How long did these moods last?
According to Stahl (2013), individuals often downplay their manic symptomologies and their duration. These episodes and their duration are essential in order to accurately diagnosing a client.
-Does the client have any significant psychiatric history, such as Bipolar I, Bipolar II, or other mood disorders?
According to Stahl (2013), first-degree relatives who also have bipolar disorder can indicate the likelihood that the client also suffers from a bipolar disorder. If the client does have a significant family history of bipolar disorder, any effective treatments, the severity of the condition, and any hospitalizations that occurred should be documented in the client record.
Explain what physical exams and diagnostic tests would be appropriate for the patient and how the results would be used.
Certain diagnostic tests such as a Complete Metabolic Panel (CMP), Liver Function Tests (LFT’s), Hemoglobin A1c, and a urine specific gravity can be ordered to evaluate the functionality of the client’s kidneys, liver, and the presence/risk of diabetes mellitus. A mood stabilizer such as Lithium may be used to manage the client’s severe fluctuation in moods. Lithium, however, can be severely nephrotoxic. Kidney function tests should be drawn prior to initiating therapy and throughout the course of therapy to assess for kidney dysfunction (Tolliver & Anton, 2015). A urine specific gravity can also indicate the functionality of the kidneys. Antipsychotic medications may be used to treat long-term unstable mood disorders. Antipsychotic medications, both first and second generations, can cause metabolic syndrome. The development of metabolic syndrome can be monitored by obtaining a CMP, LFTs, & Hemoglobin A1C prior to starting medication therapy and then throughout the medication therapy course. According to Stahl (2013), clients taking antipsychotic medications should have lab diagnostic studies done every 3-6 months. A urine drug screen (UDS) should also be done to rule out the illicit substances as the causation of the mood disorder.
It is essential to assess all clients if they have any suicidal ideations. The Columbia-suicide severity rating scale can be used to assess the severity of suicide risk. COLUMBIA-SUICIDE SEVERITY RATING SCALE (C-SSRS): This screening tool is used to detect suicidal ideations and their severity. It is scored from 0-5. A score greater than 0 may indicate a need for mental health intervention. A score of 4-5 indicates active suicidal ideation with some intent to act (“Columbia-Suicide Severity,” 2019).
This client should have a full head-to-toe physical assessment completed including a mental status exam, and vital signs. These initial findings can be used as a baseline for the patient and any future assessment changes can be compared to the initial findings (Tolliver & Anton, 2015).
**List three differential diagnoses for the patient. Identify the one that you think is most likely and explain why.
1. Recurrent major depression with an anxious/dysphoric temperament Most likely diagnosis
According to the DSM V (2013), the client’s symptoms most likely indicate a mood disorder. Due to the limited amount of time with the patient and limited past mania history, a Bipolar mood disorder could be ruled out. The client’s main symptoms present as depressive in nature, with one suicide attempt 40 years ago (Stahl Online, 2018). Recurrent major depression with an anxious/dysphoric temperament, which is also a complex mixed mood disorder, is the most likely diagnosis given the patient’s current symptoms. According to the scenario provided by Stahl Online (2018), the client has been experiencing a mixed dysphoric state with the depression occurring the majority of the time.
2. Bipolar II mixed episode:
Per the client’s history, he has been experiencing symptoms that are consistent with hypomania since the age of 23, such as inflated self-esteem, irritability, and decreased need for sleep (Stahl Online. 2018). Per the DSM 5, Bipolar II is defined as an abnormally elevated or irritable mood with an increased activity that lasts at least 4 uninterrupted days along with at least three behaviors such as inflated self-esteem, decreased need for sleep, increased talking, flight of ideas, racing thoughts, goal-driven activity, and participating in high-risk behaviors (American Psychiatric Association, 2013). Hypomanic episodes should also be noted by those close to the client per the DSM 5. Further interviewing with the client’s family needs to be completed in order to determine if the client exhibited hypomanic episodes.
3. Primarily a cluster B personality disorder (antisocial/histrionic/narcissistic/borderline)
The client’s irritability, anxiety, and past failed relationships may be explained by a cluster B personality disorder, per the DSM 5.
1. ** 2 Pharmacological Agents: The medications of choice for this client would be those that aim at stabilizing the client’s mood, such as lithium or Lamictal. According to Stahl (2013), Lamictal is a second-line medication therapy that can be used to treat mixed state depression symptoms. The goal dosage of Lamictal would be 200 mg PO Daily. Lamictal dosages need to be titrated up slowly because of the serious side effect known as Steven Johnson’s Syndrome. Dosing Schedule: 25 mg PO daily for 2 weeks-50 mg PO Daily for 2 weeks- 100 mg PO Daily for 1 week-Double dose every week to maintenance at 200 mg Daily PO. Lithium is used for the maintenance treatment for manic-depressive conditions and major depressive disorder (Stahl, 2017). The main goal of treatment with lithium therapy is complete remission of symptoms (Stahl, 2017). The client should have initial kidney function tests done prior to starting therapy and 1 to 2 times a year during therapy. Serum lithium levels should be drawn every 1-2. weeks until the desired serum concentration is achieved, then every 2-3 months for 6 months (Stahl, 2017). After the first 6 months of lithium therapy, stable serum lithium levels should be drawn 1-2 times per year. I would choose Lamictal therapy over lithium therapy due to the lack of lab work needed to maintain and dose Lamictal, compared to lithium.
**Dosing Considerations in Regard to Ethnicity
This particular client’s race was not identified in the case study. According to Prescribing Information (2005), Lamictal had an oral clearance that was 25% lower in non-Caucasians than Caucasians. If this patient were not Caucasian, he would most likely require a lower dose of Lamictal due to the 25% decrease in oral clearance.
**Check Points
12 Week Follow Up:
– The client discontinued his methylphenidate per PMHNP recommendation due to the increased risk of causing the client to have cycling unstable mood states.
-The client started lamotrigine by his local psychiatrist, 400mg PO Daily. I would decrease this dose to 200mg PO Daily per current lamotrigine initiation recommendations (Stahl, 2013).
16 Week Follow Up:
– The client decided to discontinue his lamotrigine because it was making him more depressed and inhibiting his sex life. I would review the patient’s renal function and urinalysis and initiate lithium therapy in order to stabilize his mood. I would prescribe the patient 400mg PO QHS
20, 24, 28 Week Follow Up:
-The client’s lithium levels are 0.4, his dose finally increased to 1800 mg daily. The client unhappy with his lithium therapy due to it negatively affecting his Chron’s disease. The dose is titrated down to 1500mg of lithium and Lamictal therapy is restarted at 25mg and titrated to a max dose of 200mg, which was half of his initial dosage. The hope is that using two mood stabilizers will work together and produce therapeutic effects
– The client restarted methylphenidate therapy against medical advice. The client attested to restarting it because of his low energy and dysphoric mood.
32, 34, & 36 Week Follow Up:
-The client is non-compliant with prescribed medications and therapy and continues to disregard PMHNP recommendations
**Lessons Learned and Ethical Considerations
This case study has taught me to always remember that difficult clients will inevitably be difficult to treat. There will be times when I will need to ask those who have more experience than me for help in deciding the appropriate course of treatment in certain challenging clients. I also learned that treating challenging clients will take time and results may not be observed for a while. It is important to give the specific choice of treatment time to work. One ethical consideration that I took away from this case study is that this patient is a physician, who has taken the liberty of making his own therapeutic decisions in the past. As a provider, I need to monitor and observe this client closely in case he chooses to self prescribe his own medications and disregard his care plan.
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author
Columbia-Suicide Severity Rating Scale. (2016). Retrieved December 9, 2019, from http://cssrs.columbia.edu/scoring_cssrs.html
Hirschfeld, R. M. (2002). The Mood Disorder Questionnaire (MDQ). Retrieved December 9, 2019, from
SAMHSA website: https://www.integration.samhsa.gov/images/res/MDQ.pdf
Perscribing Information for Lamictal. (2005). Retrieved December 11, 2019, from FDA website:
https://www.accessdata.fda.gov/drugsatfda_docs/label/2006/
020241s10s21s25s26s27,020764s3s14s18s19s20lbl.pdf
Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (4th ed.). New York, NY: Cambridge University Press
Stahl, S. M. (2017). The prescriber’s guide (6th ed.). New York, NY: Cambridge University Press
Tolliver, B. K., & Anton, R. F. (2015). Assessment and treatment of mood disorders in the context of
substance abuse. Dialogues in clinical neuroscience, 17(2), 181-190.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4518701/
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Post Bibli Gill
/in Uncategorized /by developerHello everyone, my name is Rajwinder Gill, I go by Raj. I’m originally from India. I moved to the states with my parents when I was 21 years old. Currently, I live in California. I moved to US in Dec 1999, and got my RN degree in 2003. I joined Sutter Hospital as a new grad in 2004, and have been working there since then. I work in telemetry department as a night shift charge nurse. I like the hospital, my coworkers and the management team. It feels like home while I’m at work, that’s the main reason I haven’t changed my job in 15 years.
I’m married to a very loving and supportive husband, and we have two beautiful girls. They are 11 and 13. We love traveling as a family and try to spend as much time together as possible. That’s one of the main reasons I work night shift so I can attend to all their needs and wants during the day. One of my daughter is type 1 diabetic since she was 3 years old. I have been trying my best to manage all of that while working and supporting my other daughter. Now, since she is 11 and getting independent in taking care of her diabetes, I have more time for myself. I always wanted to go into management or teaching in nursing. This is my first step towards my future goals. I chose GCU so I can have the independence of studying from home. Nothing can beat not having to go the classroom and still be able to finish school.
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Post Brandy Ni 19180349
/in Uncategorized /by developerRespond to the post bellow offering additional/alternative ideas regarding opportunities and risks related to the observations shared.
Main Post
I am currently a home telehealth nurse for a large VA hospital. I worked bedside for 17 years prior my current position. Unlike the inpatient setting, the technology and advancement made for the telehealth programs within the VA are impressive and evolving rapidly.
Technology Trends and Risk
An obvious trend within the VA system is the expansion of technology within the telehealth program. A large percentage of the veterans live in rural areas. At the time, home telehealth technology is limited to monitoring patients with chronic diseases through platforms via PC, a device to manually enter readings daily, mobile apps, and manually entering readings through a phone number. The VA is now trending toward video assisted monitoring with home telehealth. There are physician’s offices and community-based clinics are already using this technology. The primary challenge with this technology is the accessibility of reliable signal strength to patients in rural areas. An additional struggle is difficulty with these veterans working with this technology.
Data Safety
The VA medical system has an adequate privacy and security protection as it relates to data safety and information sent through telemedicine modalities. The VA has a dedicated department that strictly monitors all data activity. Despite the security in place there are risk, specifically with telehealth transmission of personal health information. These risks include accidental transmission of household information and activities including personal interactions with family members or indicators when the patient may not be home (Hall & McGraw, 2014).
Patient Care
Patient care benefits of telemedicine are endless. These benefits include less travel time, real time monitoring of medication changes, monitors patients with chronic condition like COPD and CHF closely to prevent or address acute episode (McGonigle & Mastrian, 2018). This cuts down on office visits and travel time. More importantly, healthcare management is achieved sooner improving overall patient outcomes. Patient’s rely heavily on monitoring from home creating a potential risk. Often these patients with chronic care management are not compliant with transmitting information or information is sent inconsistently making it difficult to assist with achieving overall goals.
Legislation
Telehealth technology allows providers to treat remotely defined by state-by-state licensure (Milstead & Short, 2019). The benefit of state regulation is the ability to closely monitor practice and outcomes on a state level. The federal government is considering nationalizing the regulations for telehealth. This presents a dilemma as physicians practicing telehealth will require multi state licenses.
I believe the most promising healthcare trends impacting healthcare technology and nursing practice is the advancement of telemedicine. The ability to remotely monitor patients and maintain a consistent record provide information for time sensitive diagnosis and treatment. The impact this has on nursing is profound. Nurses will be responsible not only for monitoring but for teaching these patients how to manage these problems themselves. The nurse’s consistent communication allows for education not only with medication but with diet, exercise, weight loss and overall prevention. Telehealth is a promising tool to the new culture of preventative healthcare. While patients are in the program, they can interact and learn about their disease process and exacerbation prevention. Telehealth is a win win.
References
Hall, J. L., & McGraw, D. (2014). For Telehealth to Succeed, Privacy and Security risks must be Identified and Addressed []. Health Affairs, 33(2). https://doi.org/https://doi.org/10.1377/hlthaff.2013.0997
McGonigle, D., & Mastrian, K. G. (2018). Nursing Informatics and the Foundation of Knowledge (4 ed.). Burlington, MA: Jones & Bartlett Learning.
Milstead, J. A., & Short, N. M. (2019). Health Policy & Politics A Nurse’s Guide. Burlington, MA: Jones & Bartlett Learning Books.
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Post Britan Policy
/in Uncategorized /by developerRespond to this post with a positive response :
Ask a probing question, substantiated with additional background information, evidence or research.
Share an insight from having read your colleagues’ postings, synthesizing the information to provide new perspectives.
Offer and support an alternative perspective using readings from the classroom or from your own research in the Walden Library.
Validate an idea with your own experience and additional research.
Make a suggestion based on additional evidence drawn from readings or after synthesizing multiple postings.
Expand on your colleagues’ postings by providing additional insights or contrasting perspectives based on readings and evidence.
Use references
EXAMPLE OF A REFERENCE:
If you cannot locate a doi number, this is how the reference should look:
Quelly, S. B. (2017). Characteristics Associated with School Nurse Childhood Obesity Prevention Practices. Pediatric Nursing, 43(4). Retrieved from https://www.pediatricnursing.net/issues/17julaug/abstr5.html
Main Post
In order to reform the healthcare system, strong leadership is needed to make that transformation and that leadership needed comes from all levels within an organization. Nurses need leadership skills and to be full partners with other health professionals in the efforts to redesign the health care system. It is crucial for nursing research and practice to develop improvements in care based on best evidence-based practices. Nurse leaders must be able to interpret new research findings and incorporate those into practice and education in order to advocate for policy change. Nurses are vital in identifying problems in the work environment, executing a plan for improvement, tracking it over time, and adjusting as needed to establish the best possible outcomes.
From the information in box 7.3, “Research Priorities for Transforming Nursing Leadership,” one of the topics is the identification of skills and knowledge most critical to leaders of healthcare organizations. This is important to me as I further my education to pursue a career in advanced nurse practitioner. The unique position that advanced nurse practitioners are in is they still posses the qualities of a nurse such as communication skills, attention to detail, empathy, emotional stability, problem-solving skills, and respect but are specialized to diagnose illnesses and conditions, interpret diagnostic tests, provide counseling, and prescribe medication as needed. According to the article in the Journal of Professional Nursing, Reforming health care means fixing escalating costs, providing accessibility and quality care to patients, and addressing personnel shortages in various health disciplines. Nurse practitioners are in a position to utilize their skills and knowledge to increase those shortcomings in various health disciplines and to provide high-quality more cost-effective care.
It is essential for nurses to possess leadership skills to be able to contribute to patient safety and quality of care effectively. These skill sets include being able to work in a team, knowledge of the healthcare delivery system, and holding themselves and others accountable. Collaboration amongst all levels within an organization has been proven to demonstrate more significant results with patient outcomes, cost, and job satisfaction. Education and self-confidence are essential attributions in a leader to advocate for needed changes in health care.
References
Archibald, M. M., & Fraser, K. (2013). The Potential for Nurse Practitioners in Health Care Reform. ScienceDirect, 29(5), 270-275. Retrieved from https://www-sciencedirect-com.ezp.waldenulibrary.org/science/article/pii/S8755722312001883?
Barnes, H., Maier, C. B., Sarik, D. A., Germack, H. D., Aiken, L. H., & McHugh, M. D. (2016, May 13). Effects of Regulation and Payment Policies on Nurse Practitioners’ Clinical Practices. Medical Care Research and Review, 74(4). Retrieved from https://journals-sagepub-com.ezp.waldenulibrary.org/doi/full/10.1177/1077558716649109?
Shaughnessy, M., Griffin, M. Q., Bhattacharya, A., & Fitzpatrick, J. J. (2018, November). Transformational leadership practices and work engagement among nurse leaders. The Journal of Nursing Administration, 48(11), 574-579. https://doi.org/10.1097/NNA.0000000000000682
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Post Britta
/in Uncategorized /by developerRespond to this post with a positive response :
Ask a probing question, substantiated with additional background information, evidence or research.
Share an insight from having read your colleagues’ postings, synthesizing the information to provide new perspectives.
Offer and support an alternative perspective using readings from the classroom or from your own research in the Walden Library.
Validate an idea with your own experience and additional research.
Make a suggestion based on additional evidence drawn from readings or after synthesizing multiple postings.
Expand on your colleagues’ postings by providing additional insights or contrasting perspectives based on readings and evidence.
Use at least 3 references
Main Post
The projected demands from an increasing elderly population on the nation’s healthcare system along with the accessibility and advancement of life-extending technology, has society begging the question of how we will meet the future demands of healthcare. According to Garza (2016), as reported by the World Health Organization (WHO) “the number of people aged 65 or older is projected to grow from an estimated 524 million in 2010 to nearly 1.5 billion in 2050,” (Garza, 2016, para. 1). This leaves society confronted with the issue of determining how to properly allocate the nations already limited healthcare resources to this future elderly population and still uphold appropriate ethical standards.
Craig (2010), states that from an ethical standpoint, society must incorporate rights, merit, need, and priority of healthcare when assisting the geriatric population and appropriately allocating healthcare resources. Every person should have the right to equal access to healthcare, but in a system with already limited resources success rate of a necessary treatment should be evaluated and utilized based on what will produce the most effective outcomes, this is known as merit. Take for instance end-of-life dilemmas, as nurses we are bound by our ANA Code of Ethics and must respect our patient’s personal beliefs and values, but it is also the nurse’s responsibility to maintain educated and informed choices for both the patient and patient’s family. Ultimately, when planning for this growing population and determining such dilemmas as end-of-life care, it is imperative to ensure we are not only adding years to life, but life to years. Although, according to Crippen & Barnato (2011), healthcare costs are driven by the increases in managing chronic disease in this population and not necessarily with end-of-life spending. According to Garza (2016), by 2030, 60% of the generation will be managing more than one chronic condition. As frontline healthcare providers it is imperative to teach and promote preventative measures to chronic and costly diseases to help drive down the financial burden on healthcare systems in the long run.
There will be a plethora of ethical challenges related to the preparation for the establishment of such a health care. One challenge will in determining the value of health. Who measures what is deemed healthy; the individual, the family, or the doctor? Will this determination of health discriminate against the elderly or those individuals with disabilities? Will the healthcare system discriminate against those who made bad lifestyle choices (i.e., smoking, drinking, obesity) to those with a certain genetic predisposition for a disorder? When we are sorting out all these ethical challenges, it is important to consider the economic impact on future generations of taxpayers if the policy is not changed. According to Crippen (2011), increased government spending on the elderly population is taking away from educational programs for the youth population and could also lead to an increase in chronic health issues at younger ages because there are no funds to provide them healthcare.
References
Barnett, J. E., & Quenzel, A. P. (2017). Innovating to meet the needs of our aging population. Practice Innovations, 2(3), 136-149. http://dx.doi.org/10.1037/pri0000049
Craig, H. D. (2010). Caring enough to provide healthcare: An organizational framework for the ethical delivery of healthcare among aging patients. International Journal for Human Caring, 14(4), 27–30. Retrieved from https://eds-a-ebscohost com.ezp.waldenulibrary.org/eds/pdfviewer/pdfviewer?vid=2&sid=0d6ab6aa-739e-4f50ab6c-4b5245f91690%40sdc-v-sessmgr01
Crippen, D., & Barnato, A. E. (2011). The ethical implications of health spending: Death and other expensive conditions. Journal of Law, Medicine & Ethics, 39(2), 121–129. https://doi.org/10.1111/j.1748-720X.2011.00582.x
Garza, A. (2016, January 19). The aging population: The increasing effects on health care. Pharmacy Times. Retrieved from https://www.pharmacytimes.com/publications/issue/2016/january2016/the-aging-population-the-increasing-effects-on-health-care
Hayutin, A.M., Dietz, M., Mitchell, L. (2010). New realities of an older America. Retrieved fromhttp://www.nasuad.org/sites/nasuad/files/hcbs/files/199/9941/New_Realities_of_an_Oldr_America.pdf
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Post Brittan
/in Uncategorized /by developerRespond to this post with a positive response :
Ask a probing question, substantiated with additional background information, evidence or research.
Share an insight from having read your colleagues’ postings, synthesizing the information to provide new perspectives.
Offer and support an alternative perspective using readings from the classroom or from your own research in the Walden Library.
Validate an idea with your own experience and additional research.
Make a suggestion based on additional evidence drawn from readings or after synthesizing multiple postings.
Expand on your colleagues’ postings by providing additional insights or contrasting perspectives based on readings and evidence.
Use references
Main Post
The burden of mental illness in the United States is among the highest of all diseases, and mental disorders are among the most common causes of disability (HealthyPeople.gov, 2014). Many people with a variety of mental disorders are disadvantaged because of poor access to health care. Poor access to care can be due to several reasons, and those reasons range from lack of employment and insurance to knowledge deficiencies surrounding mental conditions and the need to get help. Several factors can play into this, such as the behavior of an individual. Individual determinants include stress, coping mechanisms, risk-taking behaviors, and openness. Another factor is social environment determinants. These determinants include access to good education and a supportive network of people, access to employment for income, and community dynamics. A third factor is physical environment. Physical environment determinants include access to parks and safe sidewalks for physical activity to relieve stress, supportive house environment with no violence, residential crowding, home conditions, and exposure to toxins at certain developmental stages. Lastly, genetic factors play a significant role in a person’s susceptibility to mental health issues. Disorders such as depression, schizophrenia, and autism are known to run in families through DNA transmission.
In overlooking the five population determinants, the ones that most standout when it comes to mental health are access to healthcare and social environment determinants. According to an article in Social Solutions, more than half of Americans living with a mental health condition receive no treatment. These barriers to health access are due to financial burdens, lack of mental health providers, mental health education and awareness, the social stigma that surrounds mental health conditions, and racial barriers. Early screenings, accurate diagnoses, and appropriate treatment for mental illnesses can help to alleviate suffering from both patients and those close to the individual.
The social determinants of health, defined as those conditions in which people are born, grow, live, work, and age that impact health and well-being are known to have major influences on diverse health outcomes (Shim et al., 2014, p. 23). Prevention at a population level will have the most significant impact. Providing health equity across a populational level regardless of economic or social status will play a crucial role when considering all five determinants of health.
According to the Centers for Disease Control and Prevention (2012), epidemiologic data provides enough evidence to direct swift and effective public health control and prevention measures. Mental health effects people of all ages. Data in HealthPeople.gov (2014), states that approximately 20% of children are affected within their lifetime and about 83% of adults have some type of mental illness. Epidemiologic data is gathered to analyze the health status of a population living in an environment and then utilize that information to outline potential health impacts and quantify them. This information is then used as a direct link to policy-making decisions.
References
Centers for Disease Control and Prevention. (2012). Lesson 1: Introduction to epidemiology.
Retrieved December 17, 2018, from https://www.cdc.gov/ophss/csels/dsepd/ss1978/lesson1/section1.html
Gulis, G., & Fujino, Y. (2015). Epidemiology, population health, and health impact assessment. Journal of Epidemiology, 25(3), 179-180. https://doi.org/
HealthyPeople.gov. (2014). Mental health. Retrieved December 17, 2018, from https://www.healthypeople.gov/2020/leading-health-indicators/2020-lhi-topics/Mental-Health/determinants
Kindig, D., Asada, Y., & Booske, B. (2008). A population health framework for setting national and state health goals. JAMA, 299(17), 2081–2083. Retrieved from https://jamanetwork-com.ezp.waldenulibrary.org/journals/jama/fullarticle/181830
Laureate Education (Producer). (2012). Population health. Baltimore, MD: Author.
Shim, R., Koplan, C., Langheim, F. J., Manseau, M. W., Powers, R. A., & Compton, M. T. (2014). The social determinants of mental health: An overview and call to action. Psychiatric Annals, 44(1), 22-26. Retrieved from http://m3.wyanokecdn.com/94bb6a43efb278e9eb152cdaf4e17b9a.pdf
Social Solutions. (n.d.). Top 5 barriers to mental healthcare access. Retrieved December 17, 2018, from https://www.socialsolutions.com/blog/barriers-to-mental-healthcare-access/
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Post Brittany 19102007
/in Uncategorized /by developerRespond to this post with a positive response :
Ask a probing question, substantiated with additional background information, evidence or research.
Share an insight from having read your colleagues’ postings, synthesizing the information to provide new perspectives.
Offer and support an alternative perspective using readings from the classroom or from your own research in the Walden Library.
Validate an idea with your own experience and additional research.
Make a suggestion based on additional evidence drawn from readings or after synthesizing multiple postings.
Expand on your colleagues’ postings by providing additional insights or contrasting perspectives based on readings and evidence.
Use at least 3 references
Main post
Professional nursing is defined as “the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations” (Epstein & Turner, 2015, para. 2). This definition comes from the American Nurses Association (ANA). The ANA has been responsible for supporting nursing practice through developing and applying policies, establishing the standards and scope with which nurses can practice, and the implementation of the Code of Ethics for Nurses. Nurses have responsibilities to advocate for their patients regardless of their own beliefs and values. This can result in conflicting and ethical challenges for the nurse; such is the case in this scenario with the community health nurse, Lena.
In this scenario, it is imperative to observe what ethical responsibilities Lena has as a professional nurse, as defined by the ANA. Provision 3 of the Code of Ethics for Nurses states, “the nurse promotes, advocates for, and strives to protect the health, safety, and rights of the patient,” (Fowler, 2015, p. 42). Her responsibilities include ensuring patient autonomy which gives the patient the right to self-determination. Beneficence refers to the actions that promote the well-being of others and ties into non-malfeasance meaning to ‘do no harm.’ Lastly, Lena’s ethical responsibilities boil down to justice, which I feel plays the largest role in this scenario and it means to uphold and follow the laws in place that govern how a nurse practices. Lena must decide in this situation if she is going to inform her sister of her boyfriend’s HIV status or maintain the integrity of the patient which is her ethical duty as a nurse. There are statutes in place in the state of Florida that would help Lena to uphold her ethical responsibilities but also her moral duties to her sister. Florida statute 384.24 (2) states that it is unlawful for an individual who knowingly has HIV and has been informed that the disease is transmissible and can be passed on to another individual through sexual intercourse unless the other person has been informed and consents to the interaction.
If I were in Lena’s place, I would first verify the patient’s identity and all pertaining results. Once I have all accurate information in hand, I would contact the patient (sister’s boyfriend) and have him come into the clinic where he would be informed of all results, treatment options, and the importance of informing all partners of HIV status. I would impress upon the patient the consequences of not abiding by the Florida law and how the patient can be required to pay fines of up to $5,000 and face up to five years of prison time (The Center for HIV Law & Policy, n.d.). I would reiterate the fact that I would abide by his rights to privacy and confidentiality but that it is unlawful not fully to disclose HIV/AIDS status to all sexual partners.
References
Epstein, B., & Turner, M. (2015). The nursing code of ethics: Its value, its history. The Online Journal of Issues in Nursing, 20 (2). https://doi.org/10.3912/OJIN.Vol20No02Man04
Fowler, M. D. (2015). Guide to the code of ethics for nurses with interpretive statements: Development, interpretation, and application (2nd ed.). Silver Spring, MD: Nursebooks.
Official Internet Site of the Florida Legislature. (2018). The 2018 Florida statutes: Sexually transmissible diseases. Retrieved January 22, 2019, from http://www.leg.state.fl.us/statutes/index.cfm?App_mode=Display_Statute&URL=0300-0399/0384/0384.html
Schroeder-Back, P., Duncan, P., Sherlow, W., Brall, C., & Czabanowska, K. (2014). Teaching seven principles for public health ethics: Towards a curriculum for a short course on ethics in public health programmes. BMC Medical Ethics, 15, 73. https://doi.org/10.1186/1472-6939-15-73
The Center for HIV Law and Policy. (n.d.). Florida: HIV-specific criminal laws. Retrieved January 22, 2019, from https://www.hivlawandpolicy.org/states/florida
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Post Brittany
/in Uncategorized /by developerRespond to this post with a positive response :
Ask a probing question, substantiated with additional background information, evidence or research.
Share an insight from having read your colleagues’ postings, synthesizing the information to provide new perspectives.
Offer and support an alternative perspective using readings from the classroom or from your own research in the Walden Library.
Validate an idea with your own experience and additional research.
Make a suggestion based on additional evidence drawn from readings or after synthesizing multiple postings.
Expand on your colleagues’ postings by providing additional insights or contrasting perspectives based on readings and evidence.
Use at least 3 references
Main Post
United States veterans are a multifaceted population with a distinct culture that includes, but is not limited to, values, customs, ethos, selfless duty, codes of conduct, implicit patterns of communication, and obedience to command (Olenick, Flowers, & Diaz, 2015, para. 1). Veterans have experiences that no civilian could begin to fathom. Mental health and substance abuse disorders, post-traumatic stress (PTSD), suicide, pain management, homelessness, and traumatic brain injuries can be a common occurrence for veterans returning from war. The advancement of medical technology has allowed servicemen to survive injuries that can be linked with mental scarring, such as a limb amputation. Although, this can lead to certain health disparities making it difficult for the individual to settle back into ‘normal’ civilian life, not only putting stressors on them but also their families. According to Weber & Clark (2016), there are currently 22 million veterans that live in the United States but nearly 60% of veterans are not enrolled in the Veteran Administration (VA) Health Care System and are relying on other resources or not receiving the care they need at all. The two main health care needs of veterans are mental health needs and helping those veterans and their families understand their healthcare benefits and how they can better access those benefits.
Nurses today are often at the front lines of providing services to the veteran population. The most crucial way that nurses can advocate for this population and their family is to be highly trained and competent when it comes to the military culture and to help veterans understand how to navigate the VA system to increase their access to healthcare. According to Begley (2010), successfully advocating for clients requires compassion, courage, empowerment, and commitment. As a nurse, understanding this concept can help to “ensure high quality, veteran-specific patient care, and potentially decrease the health disparities within the veteran population,” (Weber & Clark, 2016, para. 3).
Nurses need to understand what specific requirements are necessary to ensure veterans are eligible for health benefits. Determining the veteran’s minimum lengths of service, type of discharge, environmental exposures, and psychosocial characteristics of the time period in which the individual served are important first steps. When determining mental health status of a serviceman it is vital to develop a good rapport with both the individual themselves as well as the family. The most important step for nurses when advocating for veterans is to educate themselves on the primary issues. Immersing one’s self in veteran and military specific organizations, pushing for faculty development opportunities that provide trainings on veteran issues, and attending seminars and courses specific to the military population are all examples of how to advocate for these servicemen and their families.
References
Begley, A. M. (2010). On being a good nurse: Reflections on the past and preparing for the future. International Journal of Nursing Practice, 16, 525-532. https://doi.org/10.1111/j.1440-172X.2010.01878.
Olenick, M., Flowers, M., & Diaz, V. J. (2015). US veterans and their unique issues: Enhancing health care professional awareness. Advances in Medical Education and Practice, 6, 635-639. https://doi.org/10.2147/AMEP.S89479
Weber, J., & Clark, A. (2016, May 18). Legislative: Providing veteran-specific healthcare. The Online Journal of Issues in Nursing, 21(2). https://doi.org/10.3912/OJIN.Vol21No02LegCol01
Westphal, R. J., & Convoy, S. P. (2015). Military culture implications for mental health and nursing care. The Online Journal of Issues in Nursing, 20. Retrieved from http://ojin.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol-20-2015/No1-Jan-2015/Military-Culture-Implications.html
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Post Camille
/in Uncategorized /by developerRead a selection of your colleagues’ responses and respond on two different days who selected a different type of diabetes than you did. Provide recommendations for alternative drug treatments and patient education strategies for treatment and management.
Main Post
Type 1 diabetes which is sometimes called juvenile or insulin-independent is when the pancreas produces little to no insulin. It can be seen as an autoimmune disease because the immune system mistakenly attacks the insulin-producing beta cells of the pancreas (Diabetes UK The Global Diabetes Community, 2019). Since these patients are not producing enough insulin, they are insulin-dependent for the rest of their lives, and most patients wear an insulin pump (Mayo Clinic, 2018). Type 1 is normally diagnosed during pediatric years or people younger than the age of 30 (Diabetes UK The Global Diabetes Community, 2019).
Type 2 diabetes which is also called adult-onset or non–insulin-dependent diabetes, is different from type 1 because in type 2 the body loses the ability to respond to insulin (Thompson & Romito, 2018). This causes the body to become insulin resistant because the body is not using insulin in the right way (Thompson & Romito, 2018). The pancreas soon becomes overworked and makes less insulin leading to insulin deficiency. Type 2 diabetes can be treated with insulin and medications, it can also be prevented if caught early and by lifestyle modifications such as in food, diet, and behaviors. Type 1 diabetes is not preventable (Diabetes UK The Global Diabetes Community, 2019).
Gestational diabetes (GDM) occurs during pregnancy. A hormone made by the placenta in the womb keeps the body from using insulin the way it should (Cedars-Sinai, 2019). Glucose builds up in the body and is not absorbed by cells leading to this disorder. GDM normally goes away after the birth of a baby. Women who are overweight are more prone to developing this disorder, and their children are at an increased risk of developing type 2 diabetes (Cedars-Sinai, 2019). Making sure to get blood work done routinely, sticking to proper diet, exercise, medications, and insulin injections can control and prevent developing GDM (Cedars-Sinai, 2019).
I selected Aspart (Novolog) insulin pen as the drug of choice for GDM. To prepare this drug I would show the pregnant patient how to administer this drug. First, I would instruct the patient to check their blood sugar pre-meals. If the blood sugar is above 150, right before their meal then the patient should follow the range dose of insulin to give that is prescribed to the patient. If the patient plans of eating all of their food then the patient will be told to give the required dose 15 minutes before or after the meal (University of Iowa Hospitals & Clinics [UIHC], 2019). If the patient only eats half then wait till after the meal to administer insulin.
The patient will be told that in pregnancy the best place to administer insulin is in the abdomen because this is where insulin gets absorbed the fastest in the bloodstream (UIHC, 2019). It should be injected at least 2 inches away from the belly button. To use the pen I would instruct the patient to remove the cap of pen and clean with alcohol, apply needle, prime the pen by selecting 2 units making sure to see drops so you know its working right. After this, select the appropriate dose needed for the patient, point the pen towards the abdomen site and push down to inject (UIHC, 2019). The dietary considerations would consist of a balance of legumes, sweet potatoes, salmon, eggs, fruits, broccoli, green leafy vegetables, fish liver oil. Berries, whole wheat products, and lean cooked meats (Cedars-Sinai, 2019). The patient would be told to stay away from processed, sugary, and fried foods.
A short term effect that may not be talked about with GDM is the cost. On average women living with GDM spend up to two-thousand dollars more than women living without GDM (Xu et al., 2015). This is related to the cost of medications, frequent doctor visits, and symptoms of hyperglycemia that the patient experiences. This is why making sure to take insulin, following a proper diet, and exercise program can help decrease these cost and prevent developing type 2 diabetes in the long-term for patient and child. If the patient develops type 2 diabetes after pregnancy this can lead to obesity, stroke, and heart attack if not properly controlled (Diabetes UK The Global Diabetes Community, 2019). It is clear that following and living a balanced diet regardless of the type of diabetes diagnosed with can help control, and prevent detrimental effects on the body and allow to live a satisfying life.
References
Cedars-Sinai. (2019). Gestational Diabetes. Retrieved from https://www.cedars-sinai.org/health-library/diseases-and-conditions/g/gestational-diabetes.html
Diabetes UK The Global Diabetes Community. (2019). Differences Between Type 1 and Type 2. Retrieved from https://www.diabetes.co.uk/difference-between-type1-and-type2-diabetes.html
Mayo Clinic. (2018). Type 1 Diabetes. Retrieved from https://www.mayoclinic.org/diseases-conditions/type-1-diabetes/symptoms-causes/syc-20353011
Thompson, E., & Romito, K. (2018). Diabetes: Differences Between Type 1 and 2. Retrieved from https://www.mottchildren.org/health-library/uq1217abc
University of Iowa Hospitals & Clinics. (2019). Insulin use during pregnancy. Retrieved from https://uihc.org/health-topics/insulin-use-during-pregnancy
Xu, T., Danielli, L., Yu, K., Ma, L., Silva Zolezzi, I., Detzel, P., & Fang, H. (2015). The short-term health and economic burden of gestational diabetes mellitus in China: a modelling study []. BMJ Open, 7(12). Retrieved from https://bmjopen.bmj.com/content/7/12/e018893
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Post Casey 19465791
/in Uncategorized /by developerRespond to at least two of your colleagues who were assigned to a different case than you. Explain how you might apply knowledge gained from your colleagues’ case studies to you own practice in clinical settings.
If your colleagues’ posts influenced your understanding of these concepts, be sure to share how and why. Include additional insights you gained.
If you think your colleagues might have misunderstood these concepts, offer your alternative perspective and be sure to provide an explanation for them. Include resources to support your perspective.
Case #7
The Case: The case of physician do not heal thyself
The Question: Does the patient have a complex mood disorder, a personality disorder or both?
The Dilemma: How do you treat a complex and long-term unstable disorder of mood in a difficult patient?
*List three questions you might ask the patient if he or she were in your office:
1. Has there ever been a period of time when you were not your usual self and thoughts raced through your head or you couldn’t slow your mind down (Hirschfeld, 2002)?
Rationale: This question specifically inquires about whether the client feels they have been their usual self and specifically references their energy levels (Hirschfeld, 2002). These symptoms are important to identify and rule out if a manic episode related to a mood disorder (such as Bipolar I) is occurring. By narrowing down correct symptomologies, the correct and appropriate psychiatric diagnosis can be made, along with the appropriate treatment.
2. Has your mood or behaviors caused major problems in your life like being unable to work; having a family, money or legal troubles; getting into arguments (Hirschfeld, 2002)?
Rationale: This question specifically focuses on how much of a problem the symptoms have been in a client’s everyday life. Mood disorders such as Bipolar I and Bipolar II can significantly impact a client’s life. Patients suffering from a mood disorder, such as Bipolar I, are at a significantly higher risk for suicide, harm to self, or harm to others (Hirschfeld, 2002).
3. How frequently would you estimate that you have experienced racing thoughts or elevated energy in relationship to your mood or fights and have any of these issues occurred during the same period of time (Hirschfeld, 2002)?
Rationale: This particular question addresses if the symptoms that are being experienced, occurred during the same time period, which would be indicative of the diagnosis of Bipolar I mood disorder. This question is important when assessing a client for a mood disorder in those patients who are misdiagnosed may experience rapid cycling or mania (Hirschfeld, 2002).
*Identify people in the patient’s life you would need to speak to or get feedback from to further assess the patient’s situation. Include specific questions you might ask these people and why.
According to Stahl (2013), it is essential for healthcare providers to obtain information from not only the client but also from outside sources. Outside sources for a client may include their spouse, parents, or siblings. Information obtained from outside sources may be significantly different than what the client describes and can assist in accurately diagnosing the client (Stahl,2013). Clients that are accurately diagnosed, can then be appropriately treated with pharmacological agents.
-Were there any significant triggering factors related to the client’s first major depression episode at age 23?
These questions can assist in distinguishing between Bipolar Mood Disorders and Borderline Personality Disorder. Bipolar Mood Disorders typically manifest in the early to mid-’20s ( It must be determined if the depression was an initial onset of a hypomanic episode or if it was due to an existing personality disorder.
-What other moods did the client exhibit when they were not in a depressive episode? How long did these moods last?
According to Stahl (2013), individuals often downplay their manic symptomologies and their duration. These episodes and their duration are essential in order to accurately diagnosing a client.
-Does the client have any significant psychiatric history, such as Bipolar I, Bipolar II, or other mood disorders?
According to Stahl (2013), first-degree relatives who also have bipolar disorder can indicate the likelihood that the client also suffers from a bipolar disorder. If the client does have a significant family history of bipolar disorder, any effective treatments, the severity of the condition, and any hospitalizations that occurred should be documented in the client record.
Explain what physical exams and diagnostic tests would be appropriate for the patient and how the results would be used.
Certain diagnostic tests such as a Complete Metabolic Panel (CMP), Liver Function Tests (LFT’s), Hemoglobin A1c, and a urine specific gravity can be ordered to evaluate the functionality of the client’s kidneys, liver, and the presence/risk of diabetes mellitus. A mood stabilizer such as Lithium may be used to manage the client’s severe fluctuation in moods. Lithium, however, can be severely nephrotoxic. Kidney function tests should be drawn prior to initiating therapy and throughout the course of therapy to assess for kidney dysfunction (Tolliver & Anton, 2015). A urine specific gravity can also indicate the functionality of the kidneys. Antipsychotic medications may be used to treat long-term unstable mood disorders. Antipsychotic medications, both first and second generations, can cause metabolic syndrome. The development of metabolic syndrome can be monitored by obtaining a CMP, LFTs, & Hemoglobin A1C prior to starting medication therapy and then throughout the medication therapy course. According to Stahl (2013), clients taking antipsychotic medications should have lab diagnostic studies done every 3-6 months. A urine drug screen (UDS) should also be done to rule out the illicit substances as the causation of the mood disorder.
It is essential to assess all clients if they have any suicidal ideations. The Columbia-suicide severity rating scale can be used to assess the severity of suicide risk. COLUMBIA-SUICIDE SEVERITY RATING SCALE (C-SSRS): This screening tool is used to detect suicidal ideations and their severity. It is scored from 0-5. A score greater than 0 may indicate a need for mental health intervention. A score of 4-5 indicates active suicidal ideation with some intent to act (“Columbia-Suicide Severity,” 2019).
This client should have a full head-to-toe physical assessment completed including a mental status exam, and vital signs. These initial findings can be used as a baseline for the patient and any future assessment changes can be compared to the initial findings (Tolliver & Anton, 2015).
**List three differential diagnoses for the patient. Identify the one that you think is most likely and explain why.
1. Recurrent major depression with an anxious/dysphoric temperament Most likely diagnosis
According to the DSM V (2013), the client’s symptoms most likely indicate a mood disorder. Due to the limited amount of time with the patient and limited past mania history, a Bipolar mood disorder could be ruled out. The client’s main symptoms present as depressive in nature, with one suicide attempt 40 years ago (Stahl Online, 2018). Recurrent major depression with an anxious/dysphoric temperament, which is also a complex mixed mood disorder, is the most likely diagnosis given the patient’s current symptoms. According to the scenario provided by Stahl Online (2018), the client has been experiencing a mixed dysphoric state with the depression occurring the majority of the time.
2. Bipolar II mixed episode:
Per the client’s history, he has been experiencing symptoms that are consistent with hypomania since the age of 23, such as inflated self-esteem, irritability, and decreased need for sleep (Stahl Online. 2018). Per the DSM 5, Bipolar II is defined as an abnormally elevated or irritable mood with an increased activity that lasts at least 4 uninterrupted days along with at least three behaviors such as inflated self-esteem, decreased need for sleep, increased talking, flight of ideas, racing thoughts, goal-driven activity, and participating in high-risk behaviors (American Psychiatric Association, 2013). Hypomanic episodes should also be noted by those close to the client per the DSM 5. Further interviewing with the client’s family needs to be completed in order to determine if the client exhibited hypomanic episodes.
3. Primarily a cluster B personality disorder (antisocial/histrionic/narcissistic/borderline)
The client’s irritability, anxiety, and past failed relationships may be explained by a cluster B personality disorder, per the DSM 5.
1. ** 2 Pharmacological Agents: The medications of choice for this client would be those that aim at stabilizing the client’s mood, such as lithium or Lamictal. According to Stahl (2013), Lamictal is a second-line medication therapy that can be used to treat mixed state depression symptoms. The goal dosage of Lamictal would be 200 mg PO Daily. Lamictal dosages need to be titrated up slowly because of the serious side effect known as Steven Johnson’s Syndrome. Dosing Schedule: 25 mg PO daily for 2 weeks-50 mg PO Daily for 2 weeks- 100 mg PO Daily for 1 week-Double dose every week to maintenance at 200 mg Daily PO. Lithium is used for the maintenance treatment for manic-depressive conditions and major depressive disorder (Stahl, 2017). The main goal of treatment with lithium therapy is complete remission of symptoms (Stahl, 2017). The client should have initial kidney function tests done prior to starting therapy and 1 to 2 times a year during therapy. Serum lithium levels should be drawn every 1-2. weeks until the desired serum concentration is achieved, then every 2-3 months for 6 months (Stahl, 2017). After the first 6 months of lithium therapy, stable serum lithium levels should be drawn 1-2 times per year. I would choose Lamictal therapy over lithium therapy due to the lack of lab work needed to maintain and dose Lamictal, compared to lithium.
**Dosing Considerations in Regard to Ethnicity
This particular client’s race was not identified in the case study. According to Prescribing Information (2005), Lamictal had an oral clearance that was 25% lower in non-Caucasians than Caucasians. If this patient were not Caucasian, he would most likely require a lower dose of Lamictal due to the 25% decrease in oral clearance.
**Check Points
12 Week Follow Up:
– The client discontinued his methylphenidate per PMHNP recommendation due to the increased risk of causing the client to have cycling unstable mood states.
-The client started lamotrigine by his local psychiatrist, 400mg PO Daily. I would decrease this dose to 200mg PO Daily per current lamotrigine initiation recommendations (Stahl, 2013).
16 Week Follow Up:
– The client decided to discontinue his lamotrigine because it was making him more depressed and inhibiting his sex life. I would review the patient’s renal function and urinalysis and initiate lithium therapy in order to stabilize his mood. I would prescribe the patient 400mg PO QHS
20, 24, 28 Week Follow Up:
-The client’s lithium levels are 0.4, his dose finally increased to 1800 mg daily. The client unhappy with his lithium therapy due to it negatively affecting his Chron’s disease. The dose is titrated down to 1500mg of lithium and Lamictal therapy is restarted at 25mg and titrated to a max dose of 200mg, which was half of his initial dosage. The hope is that using two mood stabilizers will work together and produce therapeutic effects
– The client restarted methylphenidate therapy against medical advice. The client attested to restarting it because of his low energy and dysphoric mood.
32, 34, & 36 Week Follow Up:
-The client is non-compliant with prescribed medications and therapy and continues to disregard PMHNP recommendations
**Lessons Learned and Ethical Considerations
This case study has taught me to always remember that difficult clients will inevitably be difficult to treat. There will be times when I will need to ask those who have more experience than me for help in deciding the appropriate course of treatment in certain challenging clients. I also learned that treating challenging clients will take time and results may not be observed for a while. It is important to give the specific choice of treatment time to work. One ethical consideration that I took away from this case study is that this patient is a physician, who has taken the liberty of making his own therapeutic decisions in the past. As a provider, I need to monitor and observe this client closely in case he chooses to self prescribe his own medications and disregard his care plan.
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author
Columbia-Suicide Severity Rating Scale. (2016). Retrieved December 9, 2019, from http://cssrs.columbia.edu/scoring_cssrs.html
Hirschfeld, R. M. (2002). The Mood Disorder Questionnaire (MDQ). Retrieved December 9, 2019, from
SAMHSA website: https://www.integration.samhsa.gov/images/res/MDQ.pdf
Perscribing Information for Lamictal. (2005). Retrieved December 11, 2019, from FDA website:
https://www.accessdata.fda.gov/drugsatfda_docs/label/2006/
020241s10s21s25s26s27,020764s3s14s18s19s20lbl.pdf
Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (4th ed.). New York, NY: Cambridge University Press
Stahl, S. M. (2017). The prescriber’s guide (6th ed.). New York, NY: Cambridge University Press
Tolliver, B. K., & Anton, R. F. (2015). Assessment and treatment of mood disorders in the context of
substance abuse. Dialogues in clinical neuroscience, 17(2), 181-190.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4518701/
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Post Casey 19490227
/in Uncategorized /by developerRespond to at least two of your colleagues who were assigned to a different case than you. Explain how you might apply knowledge gained from your colleagues’ case studies to you own practice in clinical settings.
NOTE: Positive Comment
Main Post
Case #13 the 8-year-old girl who was naughty
This case study will examine an 8-year-old girl who initially presents to the pediatrician’s office with complaints of a fever and sore throat. After further examination, the client is diagnosed with attention deficit hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD). According to Ghosh, Ray, & Basu (2017), characteristics of ODD include persistent anger or irritable mood, argumentativeness, defiance, and vindictiveness for at least 6 months. ADHD is characterized by a pattern of inattention, hyperactivity, and impulsivity that interferes with daily functioning or development (American Psychiatric Association, 2013).
3 Additional Assessment Questions for the Client:
1. I would ask the client and her mother how often her daughter displays symptoms that are congruent with ODD and? According to the authors Ghosh, Ray, & Basu (2017), the occurrence of ODD symptoms must be disproportionate to the child’s developmental stage and age.
2. I would ask the client if she had trouble learning in class when she was younger. The onset of ADHD symptoms usually occurs before a child reaches age 12, and in some children, these symptoms are noticeable at age 3 (Sibley, Rohde, & Swanson, 2017).
3. A final question that I would ask the client is if she interrupts her classmates when they are speaking. Children suffering from ADHD feel the need to be constantly active and struggle with controlling impulsive behaviors (American Psychiatric Association, 2013).
Feedback From the Client’s Loved Ones
The first person in this client’s life that I would like to further interview is the client’s mother. According to Stahl (2019), the client’s mother is 26 years old and is a single parent of two children, ages 8 and 6. I would want to ask the client’s mother more about her daughter’s academic performance in earlier grades. Identifying the precise onset of the client’s ADHD symptoms will assist the provider in creating the most appropriate treatment for the client (Stahl, 2014). I would also like to interview the client’s teacher in order to gain another perspective on the client’s behavior in the classroom. The client’s teacher did use an ADHD rating scale, but scales of that nature are very broad and do not elaborate on the child’s specific classroom behaviors. A third person that I would interview is the client’s 6-year-old sister. According to Stahl (2019), the client began displaying signs of anger and resentfulness when her sister was born. I would ask the client’s sister if she felt safe at home and if she and her sister fought often, in order to determine if the home environment is safe for both children.
Physical Exams and Diagnostic Tests
The physical assessment of the client is essential for developing an appropriate diagnosis and treatment plan. Visual assessment of the client’s behaviors during the physical assessment will be extremely useful to the provider. The provider would also want to obtain and review the client’s report cards along with any behavior reports, and attendance records from the client’s school (Adesman, 2011). The healthcare provider should also review the client’s pediatric health records to see if her symptoms are congruent with a learning disability, auditory processing disorder, signs of language delay, spacial orientation confusion, and complete a more thorough family history involving learning disabilities (Adesman, 2011). A complete blood count should be down to rule out physical illness as a causetive factor for the client’s ODD symptoms. The client is currently suffering from a fever and sore throat, which could be an indicator of PANDAS (pediatric autoimmune neuropsychiatric disorder associated with streptococcal infections). Since the client does have a current sore throat, a rapid strep test should be ordered. If the client does test positive for strep, it could explain the client’s symptomologies impulsivity, temper tantrums, and aggressiveness.
Differential Diagnoses
Autism Spectrum Disorder: there are deficits in social-emotional reciprocity, ranging from an abnormal social approach and failure to communicate in a standard back-and-forth conversation (American Psychiatric Association, 2013). There is also a reduced sharing of interests, emotions, or affect, along with a failure of the patient to initiate or respond during social interactions (American Psychiatric Association, 2013). The client’s history does not show any indication of impaired communication.
Conduct Disorder: characterized by behavior that violates either the rights of others or major societal norms, the symptoms must be present for at least 3 months with one symptom having been present in the past 6 months. The symptoms of conduct disorder must cause significant impairment in social, academic or occupational functioning (American Psychiatric Association, 2013). Per the client’s medical record, her symptoms fit the time frame for conduct disorder, however, her behavior is not this severe in nature.
ADHD with Co-occurring ODD: The authors Ghosh, Ray, & Basu (2017), describe the characteristics of ODD as persistent anger or irritable mood, argumentativeness, defiance, and vindictiveness for at least 6 months. ADHD is characterized by a pattern of inattention, hyperactivity, and impulsivity that interferes with daily functioning or development (American Psychiatric Association, 2013). The client’s behavior is congruent with ADHD with co-occurring ODD.
Pharmacological Agents for ADHD/ODD Therapy:
Risperdal is the first pharmacological agent that I would choose for this client. This medication is not listed on the suggested medication list of the case study, however, the medication list does list “other” as a possible choice. According to Stahl (2014), Risperidone is also used to treat behavior problems such as aggression, self-injury, and sudden mood changes in teenagers and children 5 to 16 years of age. Risperidone is in a class of medications called atypical antipsychotics. It works by changing the activity of certain natural substances in the brain. The second medication that was chosen for this client is Vyvanse. Vyvanse increases norepinephrine and dopamine actions by blocking their reuptake and creating an environment that allows their release (Stahl, 2013). Vyvanse also causes an enhancement of dopamine and norepinephrine in specific areas of the brain that may improve attention, concentration, executive dysfunction, and wakefulness (Stahl, 2013). According to Stahl (2014), it is thought that the increased dopamine action caused by Vyvanse, may help with hyperactivity. I would initially start this client on Vyvanse due to its efficacy in treating symptoms of ADHD. If the child’s academic performance and classroom behavior improve, perhaps ODD symptoms will improve.
CheckPoints:
According to Stahl (2019), the closest child psychotherapist is an hour away, therefore the client did not receive therapy. I would refer the client and her mother to case management in order to connect the client with resources that are closer to her home. I would also ask the client’s school what type of resources are available in terms of psychotherapy.
Lessons Learned:
Through this case study I have learned that co-occurring childhood disorders can be difficult to treat. Pediatric clients can respond differently to medication dosages than adults, so careful dose titration is essential. Pediatric clients also rely on their parents or caregivers to provide them with their prescribed medications and transportation to medical appointments. It is essential that the healthcare provider conveys how important treatment regime compliance is to both the client and their caregiver.
Adesman, A. R. (2011). The Diagnosis and Management of Attention-Deficit/Hyperactivity Disorder in
Pediatric Patients. Primary care companion to the Journal of clinical psychiatry, 3(2), 66-77.
https://doi.org/10.4088/pcc.v03n0204
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders
(5th ed.). Washington, DC: Author.
Ghosh, A., Ray, A., & Basu, A. (2017). Oppositional defiant disorder: current insight. Psychology
research and behavior management, 10, 353-367. https://doi.org/10.2147/PRBM.S120582
Sibley, M. H., Rohde, L. A., & Swanson, J. M. (2017). Late-Onset ADHD Reconsidered with
Comprehensive Repeated Assessments between Ages 10 and 25. American journal of psychiatry,
175(2), 140-149. https://doi.org/10.1176/appi.ajp.2017.17030298
Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (fourth ed.). New York, NY: Cambridge University Press.
Stahl, S. M. (2014). The prescriber’s guide (5th ed.). New York, NY: Cambridge University Press.
Stahl Online. (2019). Volume 1 case #5: The sleepy woman with anxiety. (PDF file).
Retrievedfrom http://stahlonline.cambridge.org.ezp.waldenulibrary.org/viewPdf?p
age=csEP_05.pdf
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