Nursing Assignment Acers

Case Study: 34-Year-Old Pakistani Female With Schizophrenia

Case Study: 34-Year-Old Pakistani Female With Schizophrenia

Case Study: 34-Year-Old Pakistani Female With Schizophrenia

NURS 6630: Psychopharmacologic Approaches to Treatment of Psychopathology Walden University

The Assignment

Examine Case Study: Pakistani Woman with Delusional Thought Processes. You will be asked to make three decisions concerning the medication to prescribe to this client. Be sure to consider factors that might impact the client’s pharmacokinetic and pharmacodynamic processes.

BACKGROUND

The client is a 34-year-old Pakistani female who moved to the United States in her late teens/early 20s. She is currently in an “arranged” marriage (her husband was selected for her since she was 9 years old). She presents to your office today following a 21 day hospitalization for what was diagnosed as “brief psychotic disorder.” She was given this diagnosis as her symptoms have persisted for less than 1 month.

Prior to admission, she was reporting visions of Allah, and over the course of a week, she believed that she was the prophet Mohammad. She believed that she would deliver the world from sin. Her husband became concerned about her behavior to the point that he was afraid of leaving their 4 children with her. One evening, she was “out of control” which resulted in his calling the police and her subsequent admission to an inpatient psych unit.

During today’s assessment, she appears quite calm, and insists that the entire incident was “blown out of proportion.” She denies that she believed herself to be the prophet Mohammad and states that her husband was just out to get her because he never loved her and wanted an “American wife” instead of her. She tells you that she knows this because the television is telling her so.

ORDER NOW FOR CUSTOMIZED, PLAGIARISM-FREE PAPERS

She currently weighs 140 lbs, and is 5’ 5”

SUBJECTIVE

Client reports that her mood is “good.” She denies auditory/visual hallucinations, but believes that the television does talk to her. She believes that Allah sends her messages through the TV. At times throughout the clinical interview, she becomes hostile towards the PMHNP, but then calms down.

You reviewed her hospital records and find that she has been medically worked up by a physician who reported her to be in overall good health. Lab studies were all within normal limits.

Client admits that she stopped taking her Risperdal about a week after she got out of the hospital because she thinks her husband is going to poison her so that he can marry an American woman.

MENTAL STATUS EXAM

The client is alert, oriented to person, place, time, and event. She is dressed appropriately for the weather and time of year. She demonstrates no noteworthy mannerisms, gestures, or tics. Her speech is slow and at times, interrupted by periods of silence. Self-reported mood is euthymic. Affect constricted. Although the client denies visual or auditory hallucinations, she appears to be “listening” to something. Delusional and paranoid thought processes as described, above. Insight and judgment are impaired. She is currently denying suicidal or homicidal ideation.

The PMHNP administers the PANSS which reveals the following scores:

    • -40 for the positive symptoms scale
    • -20 for the negative symptom scale
    • -60 for general psychopathology scale

Diagnosis: Schizophrenia, paranoid type

RESOURCES
  • Kay, S. R., Fiszbein, A., & Opler, L. A. (1987). The Positive and Negative Syndrome Scale (PANSS) for schizophrenia. Schizophrenia Bulletin, 13(2), 261-276.
  • Clozapine REMS. (2015). Clozapine REMS: The single shared system for clozapine. Retrieved from https://www.clozapinerems.com/CpmgClozapineUI/rems…
  • Paz, Z., Nalls, M. & Ziv, E. (2011). The genetics of benign neutropenia. Israel Medical Association Journal. 13. 625-629.

Decision Point One

Select what the PMHNP should do:
  1. Start Zyprexa 10 mg orally at BEDTIME
  2. Start Invega Sustenna 234 mg intramuscular X1 followed by 156 mg intramuscular on day 4 and monthly thereafter
  3. Start Abilify 10 mg orally at BEDTIME

At each decision point stop to complete the following:

  • Decision #1
    • Which decision did you select?
    • Why did you select this decision? Support your response with evidence and references to the Learning Resources.
    • What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
    • Explain any difference between what you expected to achieve with Decision #1 and the results of the decision. Why were they different?
  • Decision #2
    • Why did you select this decision? Support your response with evidence and references to the Learning Resources.
    • What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
    • Explain any difference between what you expected to achieve with Decision #2 and the results of the decision. Why were they different?
  • Decision #3
    • Why did you select this decision? Support your response with evidence and references to the Learning Resources.
    • What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
    • Explain any difference between what you expected to achieve with Decision #3 and the results of the decision. Why were they different?

Also include how ethical considerations might impact your treatment plan and communication with clients.

To Prepare:

  1. Week 6 Discussion
  2. Week 6 Assignment

CLICK TO ORDER CUSTOM NURS 6630 PAPERS

SAMPLE PAPER  Assessing and Treating Clients With Psychosis and Schizophrenia

Introduction

Psychosis is typically defined as an event that has an impact on one’s mental state and causes them to lose some sense of reality (National Institute of Mental Health [NIMH], 2016). A million or more young individuals in the US experience psychosis each year because it is not regarded as a sickness but rather as a sign of illness. The symptoms that a person experiencing psychotic episodes may experience include depression, anxiety, restless sleep, social withdrawal, a lack of inspiration, and general operational difficulties (NIMH, 2016). Psychotherapy and medications can help treat psychosis, which often has one or two symptoms but sometimes several. The most common symptoms are delusion and hallucination (National Alliance on Mental Illness [NAMI], 2019). Schizophrenia is considered as a complex psychotic illness that disturbs the ability of an individual to think openly or to regulate his or her emotions and feelings, or unable to make decisions and build relationships with others, making it a severe long-term health condition by which about 1% Americans are suffering (NAMI, 2019).

The case study for this week’s assignment features a woman from Pakistan who is 34 years old. She has a “brief psychotic condition” diagnosis and has been in the hospital for 21 days. She claimed that after taking the drugs that were Risperdal prescribed by the doctor, she stopped taking them because she thought her spouse was going to poison her. She continued by saying that she was having doubtful and suspicious ideas (Laureate Education, 2016j). According to the Positive and Negative Syndrome Scale (PANSS) results, the client was identified as having paranoid type schizophrenia (Laureate Education, 2016j). The complexity of positive and negative symptoms and also the overall psychology of schizophrenic people can be classified by the help of PANSS which is a consistent or scientific interview and rates the negative and positive symptoms schizophrenia (Depp, Loughran, Vahia, & Molinari, 2010). The main objective of this week’s assignment is to evaluate and manage the client who needs the antipsychotic therapy which depends upon the decisions regarding the drugs which have been recommended for a Pakistani woman who is 34 years old and diagnosed with schizophrenia, the impact of drugs pharmacokinetic and pharmacodynamics, and also consists of the ethical considerations which influence the strategy of the treatment and also the communication with the patient.

Decision #1

My first decision would begin the client with Invega Sustenna with a dose of 234mg intramuscular (IM) X1 after that a dose of 156mg has been given on the fourth day and one in a month subsequently. Paliperidone considers as a drug that has been used to treat schizophrenia and schizoaffective disorders by showing its function in the brain. The drug has been given every month, the reason behind that is Paliperidone is long-acting injectable (LAIs), because of this characteristic it shows the slow release of drugs in the blood. It also balances the neurotransmitters, for example, serotonin and dopamine when they become imbalanced and helps to support thinking, behavior, and emotions. The function of Invega Sustenna is to block the D2 receptors, it also decreases the positive symptoms of psychosis and alleviates the affective symptoms, serotonin 2A receptors have also been blocked by the drug which in turn increases the release of DA in different areas of the brain which results in the decrease of side effects related to motor activity and probably the affective and cognitive symptoms have been enhanced (Stahl, 2014b). In order to have a significant type of treatment, the long-acting antipsychotic injections can be used, so, the patients who rejected the oral medication, it would be a beneficial type of therapy (Bishara, 2010).

There are some other antipsychotic drugs (AP) for example Zyprexa and Abilify, they are also helpful for treating the psychosis but the client is suffering from delusions and misperception so, the drug may act as useless. However, the side effects occur by the drug may obstruct the client to follow the plan of the treatment. The rates of emergency room visit and rehospitalization of schizophrenic patients and psychotic patients have been shown to expressively decrease by using LATs as compared to oral medications. Thus, it has been recommended that the patient would prefer to adhere to the injectable kind of antipsychotics which are second-generation drugs because of its effectiveness and acceptability as it helps to decrease the claim for emergency rooms and hospitalization visits of the worsened schizophrenic patient (Lafeuille et al., 2013). The main objective of this decision is that the patient would remain to this decision and within the four weeks the symptoms should be decreased, as the client would be returned to the clinic, I am also hoping that she will show a decrease in the score of PANNS.

It has been stated by Stahl (2014b), within 1 week, the symptoms of psychosis can be better but the suggestion is to take 4 to 6 weeks for the next visit in order to define the drug effectiveness. In my decision one, I am supposing that after four weeks when the client has been returned for the follow-up, she stated that she can tolerate the drug which decreases the symptoms of psychosis and enhanced the mood. After four weeks, the client returned to the clinic. She mentions that she can tolerate the drug, while testing on PANNS she scores a 25% reduction in this visit. She also stated that her weight has also been increased about 2 pounds and complains that while injecting the drug, the place where it is injected started to hurt so she feels concerned for a place for a little time after injecting the drug.

Decision #2

The next decision is to keep going with the decision one but a nurse has been provided to train her the administration of the injection in the deltoid site at her visit and after that. I have selected the same treatment as in decision one, this is because of the scores which she scored on PANNS which is a 25% decrease. Although, it is necessary to change the site of the injection because of the complaint of the client that she was unable to sit properly after administrating the injection. As a practitioner, it is necessary for me to teach the client, the side effects of the prescribed drugs prior to begin and educate her to always ask her practitioner if she wants to stop any medication which has been prescribed. I would not recommend stopping the Invega Sustenna and begin with Haldol Decanoate (haloperidol decanoate) 50mg IM q2weeks with Haldol 5mg from mouth BID for next three months (McEvoy et al., 2014). There is an older antipsychotic known as Haldol which shows the increased risk of having tardive dyskinesia (TD) for example lips twisting, lapping and spanking, different movements which are uncontrollable are the side effects, while TD has low chances to be occurred by the consumption of Paliperidone (NAMI, 2016).

Abilify Maintena 300mg IM every month with Abilify 10 mg from the mouth in the morning for 2 weeks cannot be recommended because it cannot be beginning unless the patient started to tolerate the drug by mouth (Stahl, 2013). The purpose of this decision is to observe the injection site of the patient have no pain and she can tolerate the new site in order to keep the treatment and the symptoms may decrease more and more. As there is a side effect of antipsychotics, I will ask the patient to monitor her weight timely. According to this decision, I am looking for a decrease in the symptoms of psychosis while having a low score on the PANNS. Later four weeks, on the return of the client, I have observed a 50 reduction in the PANNS score, she further mentions that her arm is not hurting anymore. Upon asking for the treatment, she stated that within two months, she has gained about 4.5 pounds of weight which are troubling her because her husband is not going to like this weight gain.

Decision #3

The previous decisions have shown improvement with the present routine excluding the weight gain by which she is being disturbed. At this point, I would decide to go with the same drug Invega Sustenna, suggesting the client over the weight gain that Invega Sustenna is not that bad as compared to other drugs with same effectiveness. The treatment should be continued for a year when the patient has shown up the first episode of the psychosis, as the patient may need about 16–20 weeks to demonstrate a better reaction and to keeping the treatment till reaching a better position or after reaching at better position (Stahl, 2014b). Weight gain can be occurring by many antipsychotics and after the starting time it will start to increase quickly by taking the antipsychotics olanzapine and clozapine, so, transferring to the substance which has a decreased efficiency to increase the weight can be a choice, but the disease can be revert back (Dayabandara, 2017). The weight can be influenced by the nonpharmacological interventions which are dietary analysis, different programs for the strategies of cognitive and behavior and also the mediation strategies that can be included (Dayabandara, 2017). I would not recommend the client with Abilify because it is not able to bind with D2 receptors and shows very little effectiveness causing akathisia which is a side effect of the drug (Stahl, 2014b). In order to manage the weight gain, the drug Qsymia which is combined with Phenteramine and Topiramate can be used for adults who are having their starting BMI of a minimum of 30 kg/m2 (Stahl, 2014b). I am expecting that the patient will show a decrease in the symptoms of generalized anxiety disorder.

Pharmacodynamics and Pharmacokinetics

The main effective metabolite of risperidone (Risperdal) is Paliperidone (Invega). Risperidone is converted into Paliperidone in the liver. Neurotransmitters are involved in order to interact with the brain cells by using different chemicals. But, somehow, the increase or decrease dose of these drugs can cause problems in different parts of the brain, thus, Paliperidone mechanism is to block the activity of serotonin and dopamine neurotransmitters in different regions of the brain (Diagnostic and statistical manual of mental disorders [DSM-5], 2013). The release of the drug started as day one and remains for 126 days because it has very low solubility of water, Paliperidone which has been designed in one-month palmitate dissolves gradually after injecting it. After a single dose IM, the concentration of Paliperidonein plasma slowly reaches to highest plasma concentration at an average of Tmax of 13 days, so, the release of the drug starts as early as day one and lasts for as long as 126 days.

Conclusion with Ethical Considerations

By emphasizing mental health, culture and ethos are interconnected. As professionals, it is important to understand different experiences and beliefs, including values and religion about the culture, to bring attention, consideration and empathy to clients (Hoop, DiPasquale, Hernandez, & Roberts, 2008). In order to have an improved outcome by the treatment plan, it is important to talk about the side effects and wellbeing, and any variations in the treatment plan, it is necessary to include the family of the client with the permission of the client for educating them on the treatment plan. This week, the case is consisting of a woman, she belongs to Pakistan where culture is considered an important part so the psychotic disorder may be secreted because the society will talk about her. The brain of the patient has been affected by the disorder like schizophrenia and different psychosis, such patients needed the support in making the decision and also the special attention is required for them. In concluding the assignment, being a practitioner, involving the client making any decision would be beneficial as the patient will feel the empowerment, by this, they make sure that their practitioner is giving the better treatment and they are around the loved ones who are helping them to come out of this situation. It is very important to admire the privacy and confidentiality of the patient.

References: Case Study: 34-Year-Old Pakistani Female With Schizophrenia
  1. Bishara, D. (2010). Once-monthly paliperidone injection for the treatment of schizophrenia. Neuropsychiatric disease and treatment, 6, 561.
  2. Dayabandara, M., Hanwella, R., Ratnatunga, S., Seneviratne, S., Suraweera, C., & de Silva, V. A. (2017). Antipsychotic-associated weight gain: management strategies and impact on treatment adherence. Neuropsychiatric disease and treatment, 13, 2231-2241.
  3. Depp, C. A., Loughran, C., Vahia, I., & Molinari, V. (2010). Assessing Psychosis in Acute and Chronic Mentally Ill Older Adults. Handbook of Assessment in Clinical Gerontology (2nd ed., pp.123-154).
  4. Diagnostic and statistical manual of mental disorders. [electronic resource] : DSM-5. (2013). Washington, D.C. : American Psychiatric Association, c2013. Retrieved from https://ezp.waldenulibrary.org
  5. Hoop, J. G., DiPasquale, T., Hernandez, J. M., & Roberts, L, W. (2008) Ethics and Culture in Mental Health Care. ETHICS & BEHAVIOR, 18(4) 353-372.
  6. Lafeuille, M. H., Laliberté-Auger, F., Lefebvre, P., Frois, C., Fastenau, J., & Duh, M. S. (2013). Impact of atypical long-acting injectable versus oral antipsychotics on rehospitalization rates and emergency room visits among relapsed schizophrenia patients: a retrospective database analysis. BMC psychiatry, 13(221).
  7. Laureate Education. (2016j). Case study: Pakistani woman with delusional thought processes [Interactive media file]. Baltimore, MD: Author
  8. McEvoy, J. P., Byerly, M., Hamer, R. M., Dominik, R., Swartz, M. S., Rosenheck, R. A., … Stroup, T. S. (2014). Effectiveness of paliperidone palmitate vs haloperidol decanoate for maintenance treatment of schizophrenia: a randomized clinical trial. JAMA, 311(19), 1978-87.
  9. National Alliance on Mental Illness. (2016). Paliperidone (Invega). Retrieved from https://www.nami.org/Learn-More/Treatment/Mental-Health-Medications/paliperidone-(Invega)
  10. National Alliance on Mental Illness. (2019). Early Psychosis And Psychosis. Retrieved from https://www.nami.org/earlypsychosis
  11. National Alliance on Mental Illness. (2019). Schizophrenia. Retrieved from https://www.nami.org/Learn-More/Mental-Health-Conditions/Schizophrenia
  12. National Institute of Mental Health. (2016). What is Psychosis? Retrieved from https://www.nimh.nih.gov/health/topics/schizophrenia/raise/what-is-psychosis.shtml
  13. Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (4th ed.). New York, NY: Cambridge University Press.
  14. Stahl, S. M. (2014b). The prescriber’s guide (5th ed.). New York, NY: Cambridge University Press.

 

 

mersin escmersin esc