NURS 6630 Assessing and Treating Patients With Sleep Wake Disorders 

Sample Answer for NURS 6630 Assessing and Treating Patients With Sleep Wake Disorders  Included After Question

The Assignment: 5 pages

Examine Case Study: Pharmacologic Approaches to the Treatment of Insomnia in a Younger Adult. You will be asked to make three decisions concerning the medication to prescribe to this patient. Be sure to consider factors that might impact the patient’s pharmacokinetic and pharmacodynamic processes.

At each decision point, you should evaluate all options before selecting your decision and moving throughout the exercise. Before you make your decision, make sure that you have researched each option and that you evaluate the decision that you will select. Be sure to research each option using the primary literature.

Introduction to the case (1 page)

  • Briefly explain and summarize the case for this Assignment. Be sure to include the specific patient factors that may impact your decision making when prescribing medication for this patient.

Decision #1 (1 page)

  • Which decision did you select?
  • Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
  • Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
  • What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
  • Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.

Decision #2 (1 page)

  • Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
  • Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
  • What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
  • Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.

Decision #3 (1 page)

  • Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
  • Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
  • What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
  • Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.

Conclusion (1 page)

  • Summarize your recommendations on the treatment options you selected for this patient. Be sure to justify your recommendations and support your response with clinically relevant and patient-specific resources, including the primary literature.

Note: Support your rationale with a minimum of five academic resources. While you may use the course text to support your rationale, it will not count toward the resource requirement. You should be utilizing the primary and secondary literature.

A Sample Answer For the Assignment: NURS 6630 Assessing and Treating Patients With Sleep Wake Disorders 

Title: NURS 6630 Assessing and Treating Patients With Sleep Wake Disorders 

Introduction to the Case

The case scenario provided is of a 31year old male whose chief complaint is insomnia that has been worse in the past 6 months. Previously, he reports enjoying restful sleep although for the past 6months he has experienced both difficulties in falling and staying asleep. He even associates the onset of these sleep problems with the loss of his fiancé consequently leading to the loss. During the interview with the clinic, he explains that the problem is a bother because it has interfered with his job where because he experiences sleepiness during the day thus affecting his concentration and productivity at the workplace. He reports recent dependence on alcohol to help him fall asleep. The mental status examination performed on him revealed no abnormality in the orientation appearance, insight, and judgment.

A comprehensive assessment of this case study shows that the patient’s insomnia might be related to his psychological dysfunction resulting from the loss of his fiancé 6months ago. The sudden loss of a dear one triggers a myriad of psychiatric conditions even if the individual has no prior history of psychiatric conditions (Seiler et al., 2020). One of these psychiatric conditions is depression which is especially triggered by complicated grief.

The affected individual would therefore present with low mood, intense sadness, low energy, and loss of interest in activities of pleasure. They may also report sleep disturbances with insomnia being more common than hypersomnolence (Hasin et al., 2018). Managing the depression through medications or psychotherapy would help to relieve the patient’s symptoms such as insomnia that is suspected to arise from depression. The objective of this paper is to discuss how the patient in the case study was managed by describing the therapeutic options at Decision points 1, point 2, and point 3.

Decision Point One

For the initial management of the patient, I would prescribe 50mg of trazodone to be taken orally at bedtime daily. Trazodone is a drug that acts in the brain by reducing the reuptake of different neurochemicals in the brain such as serotonin but antagonizing the alpha-1-adrenergic and histamine receptors in the brain (Cuomo et al., 2019). By so doing, the serotonin levels in the brain are increased as well as the intensity of their action. Given depression results from an imbalance of brain neurochemicals such as serotonin and norepinephrine, increased serotonin levels resulting from trazodone use can lead to improved serotonergic actions thus treating depression and its symptoms (Hasin et al., 2018). When trazodone is therefore prescribed, the symptoms of depression including insomnia, appetite changes, and mood changes are corrected (Wang et al., 2020). It would therefore be the first-line medication for this patient.

At decision point one, the foregone options are the 10mg zolpidem taken daily at bedtime or 50mg hydroxyzine taken daily at bedtime. Although zolpidem is effective in the management of insomnia by promoting the action of gamma-aminobutyric acid (GABA) in the brain, its side effect profile which includes drowsiness, complex sleep-related behavior and volition usually limit its use as a first-line medication for insomnia (Edinoff et al., 2021). Hydroxyzine has also been foregone because of its anticholinergic effects such as xerophthalmia and xerostomia (Hasin et al., 2018). Further, neither of these drugs is effective for the management of depression that has been linked with the patient’s insomnia.

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The ethical principles require that the health care providers do not harm the patient. At point one, increasing the pill burden by prescribing the antidepressants separately from the drugs addressing insomnia would pose the risk of adverse drug reactions as well as increase the incidence of poor drug compliance (Bipeta, 2019). The ethical principle of non-maleficence would therefore require for prescription of a single agent that could manage both depressive illness and insomnia (Seiler et al., 2020). As such, trazodone is the preferred medication to the other provided options.

Decision Point Two

After 2 weeks of therapy with 50mg of trazodone at bedtime daily, the patient reports experiencing a prolonged erection in the morning that lasts 15 minutes but is undesired and affects his morning preparation for work although his sleeping has improved. At this point, the choice is to be made on how to address the prolonged erection. My decision at this step would be to explain to the patient that this prolonged erection is not priapism and would resolve over time. Thereafter, the current drug dose could be continued for patient care.

One of the undesired side effects of trazodone use is the prolonged erection caused. Through its α-adrenergic antagonism, the drug can lead to dilatation of vessels in the penis thus resulting in prolonged erection (Cuomo et al., 2019). The patient in the case study reports such prolonged undesired erection that lasts for approximately 15 minutes and thus cannot be considered priapism which usually lasts for up to 4hours (Hasin et al., 2018). However, the patient requires reassurance about the side effect profile of the drug, especially with the emphasis that the symptoms would dissipate with time (Cuomo et al., 2019). This would enhance adherence to therapy despite the drug’s side effects.

The other options at decision point 2 were either to discontinue trazodone and initiate 10mg suvorexant daily therapy or to decrease the dose of trazodone to 25mg daily at bedtime. The negative side effect of suvorexant includes daytime drowsiness thus its contraindication for this patient who operates a forklift. On the other hand, decreasing the dose of trazodone to 25mg daily may not be adequate to correct insomnia (Seiler et al., 2020). Patient education on the drug’s side effects, as well as reassurance, would therefore be opted for at this step.

At this decision point 2 where the patient reports the drug’s side effects, it would be ethical to truthfully educate him on the drug’s side effects to anticipate. Medications may be discontinued if necessary to prevent more harm to the patient (Bipeta, 2019). These honor ethical principles of beneficence and non-maleficence.

Decision Point Three

2 weeks after reassuring and educating the patient on the side effects of trazodone, he now reports that the priapism has resolved although he now experiences increased drowsiness during the next day. His insomnia has also resolved at 50mg of trazodone. At this step, I would continue the patient therapy at 50mg although the dose is split in half, and the patient is reassessed after a month.

As had been alluded to, trazodone is associated with increased drowsiness that may limit its use although the occurrence of such side effects is either rare or mild. However, when such drowsiness occurs, a reduction of the drug dose by 50% may be necessary as this may result in a reduction in drowsiness (Cuomo et al., 2019). The patient should however be adequately educated on how to split the drug dose so that the required drug dose is maintained. Further, patient follow-up within 4weeks would also be indicated to help in reassessing the effectiveness of the drug as well as the persistence of the drowsiness at 50% of the dose (Wang et al., 2020).

The other options provided at decision point 3 included either discontinuing trazodone and initiating sonata at 10mg nightly or replacing trazodone with 50mg of hydroxyzine at bedtime. Both of these options are not appropriate as they involved replacing trazodone that the patient has shown partial response to. Further, both sonata and hydroxyzine have worse side effect profile that limits their administration in this patient (Hasin et al., 2018).

At this decision point, the ethical principle of patient autonomy may affect further care. For instance, the patient may prefer either sonata or hydroxyzine to the in-use trazodone thus they can be prescribed despite their side effect profile (Bipeta, 2019). Such prescription seeks to promote the role of patients in their treatment.

Conclusion

Individuals presenting with any signs and symptoms at the clinic should be suspected and examined for any underlying conditions responsible for such presentation. For instance, a patient with insomnia may have underlying anxiety or depression. In managing these patients, the drugs prescribed should aim at correcting the underlying psychological disorder instead of addressing the signs and symptoms such as insomnia. specifically for this patient whose insomnia was thought to result from depression due to complicated grief, trazodone which is an antidepressant was prescribed at decision point one because of its effectiveness in managing insomnia (Cuomo et al., 2019).

When he returns to the clinic with complaints of prolonged erection, the patient would be reassured with the emphasis that the symptoms would disappear with time. The patient would also be adequately educated on the adverse effects of the drugs to encourage drug compliance as they would be anticipating these side effects (Hasin et al., 2018). Thereafter, when he comes complaining of drowsiness, the drug dose would be reduced by 50% to resolve the symptoms. At either of the steps, the drugs’ side effects profile, as well as effectiveness, are compared before an effective drug with the least side effects is prescribed.

References

Bipeta, R. (2019). Legal and ethical aspects of mental health care. Indian Journal of Psychological Medicine41(2), 108–112. https://doi.org/10.4103/IJPSYM.IJPSYM_59_19

Cuomo, A., Ballerini, A., Bruni, A. C., Decina, P., Di Sciascio, G., Fiorentini, A., Scaglione, F., Vampini, C., & Fagiolini, A. (2019). Clinical guidance for the use of trazodone in major depressive disorder and concomitant conditions: pharmacology and clinical practice. Rivista Di Psichiatria54(4), 137–149. https://doi.org/10.1708/3202.31796

Edinoff, A. N., Wu, N., Ghaffar, Y. T., Prejean, R., Gremillion, R., Cogburn, M., Chami, A. A., Kaye, A. M., & Kaye, A. D. (2021). Zolpidem: Efficacy and side effects for insomnia. Health Psychology Research9(1), 24927. https://doi.org/10.52965/001c.24927

Hasin, D. S., Sarvet, A. L., Meyers, J. L., Saha, T. D., Ruan, W. J., Stohl, M., & Grant, B. F. (2018). Epidemiology of adult DSM-5 major depressive disorder and its specifiers in the United States. JAMA Psychiatry (Chicago, Ill.)75(4), 336. https://doi.org/10.1001/jamapsychiatry.2017.4602

Seiler, A., von Känel, R., & Slavich, G. M. (2020). The psychobiology of bereavement and health: A conceptual review from the perspective of Social Signal Transduction Theory of Depression. Frontiers in Psychiatry11, 565239. https://doi.org/10.3389/fpsyt.2020.565239

Wang, J., Liu, S., Zhao, C., Han, H., Chen, X., Tao, J., & Lu, Z. (2020). Effects of trazodone on sleep quality and cognitive function in arteriosclerotic cerebral small vessel disease comorbid with chronic insomnia. Frontiers in Psychiatry11, 620. https://doi.org/10.3389/fpsyt.2020.00620

A Sample Answer For the Assignment: NURS 6630 Assessing and Treating Patients With Sleep Wake Disorders 

Title: NURS 6630 Assessing and Treating Patients With Sleep Wake Disorders 

Insomnia is a mental disorder that affects significantly the health, wellbeing, and functioning of the patients. Therefore, this paper examines a case study of a 31-year-old male that presents with chief complaint of insomnia. The patient reported that the insomnia has worsened progressively over the last six months. The problem started about six months ago after his fiancé passed on. Insomnia has affected his ability to perform at his job as a forklift operator. The patient has a history of using diphenhydramine to enhance sleep but did not like what he felt the morning after, as he fallen asleep because of lack of sleep the night before. The patient’s history also shows that he has opiate abuse after breaking his ankle where he was prescribed acetaminophen for pain management. However, he has not received an opiate prescription for the last four years.  

The patient also has a history of alcohol use to induce sleep. He drinks about four beers before bed. Mental status exam performed on the patient showed that he was oriented to place, time, person, and event. He made eye contact, dressed appropriately for the occasion, denied hallucinations, with judgement, insight, and reality being intact. He also denied suicidal ideation and future oriented. Therefore, the patient factors that will affect the selected treatment include his age, experience with diphenhydramine, opiate abuse, and alcohol use. The selected treatments should not predispose him to unwanted outcomes such as poor performance at workplace, dependence, or increased use of alcohol to manage insomnia symptoms.

Decision 1

Selected Decision

Zolpidem: 10 mg daily at bedtime

Why I Selected the Decision

I selected Zolpidem for the patient because of its high level of tolerance and efficacy in managing insomnia and minimal residual effects. According to Xiang et al., (2021), Zolpidem is highly effective in increasing the total sleep time, reducing sleep latency, and enhancing sleep quality in patients suffering from insomnia disorder. Clinical trials have also demonstrated that Zolpidem has a high efficacy level in improving wake after sleep onset, which enhances the performance and productivity of the patients affected by insomnia disorder (Inoue et al., 2022). In another study, zolpidem was found to increase patients’ ability to sleep within 30 minutes, eliminate troubles they experience staying awake during daytime, and remaining motivated to get things done (Asok et al., 2019). The effectiveness was high as compared to placebo and use of other agents to enhance sleep.

Why the Other Two were not Selected?

I did not select the decision to initiate the patient on Trazodone 50 mg PO at bedtime because it is not the first-line drug of choice for insomnia. Instead, it is recommended for patients treated with selective serotonin reuptake inhibitors (SSRIs) to manage their associated insomnia (Cuomo et al., 2019). I did not select the decision to start the patient with Hydroxyzine 50 mg daily at bedtime. This is because it is a histamine H1 blocker, which the patient reported having a negative experience with it (Sharma et al., 2019). Its administration is likely to affect treatment adherence, hence, the lack of realization of the desired outcomes.

What I was Hoping to Achieve

I was hoping to achieve improvements in sleep quality, latency, after night performance, and functioning in the patient. This is largely attributed to the effects of zolpidem on sleep. I was also hoping to see the patient tolerating the selected treatment (Xiang et al., 2021).  

Ethical Considerations

The ethical consideration that informed the adopted decision is the principle of beneficence and non-maleficence. Psychiatric mental health nurses should adopt treatments associated with minimal harm and optimum patient benefits. As a result, zolpidem has more benefits than harm as compared to the given options (Xiang et al., 2021).

Decision 2

Selected Decision

Discontinue zolpidem and initiate therapy with Trazodone 50-100 mg daily at bedtime.

Why I Selected the Decision

The decision to discontinue zolpidem and initiate therapy with trazodone 50-100 mg daily at bedtime was adopted. This is because the patient returned to the clinic with complains that suggested that he developed adverse effects associated with zolpidem. Accordingly, he reports that he felt knocked out, waking up in the middle of the night and cooking breakfast and having no recollection of the occurrence, and taking the medication with beer right before bedtime to get sleep. As shown by Asok et al., (2019), these are some of the unwanted side effects of zolpidem. Trazodone would be the best drug of choice at this time. According to Pochiero et al., (2022), Trazodone is an off-label drug that is used in treating acute cases of insomnia because of its high affinity for alpha 1 and serotonin 2A receptors that regulate sleep. The long-term use of trazodone is associated with improved sleep complaints and enhanced cognitive and functional scores among patients suffering from insomnia (La et al., 2019). Therefore, it makes it an effective drug to manage insomnia symptoms for the patient.

Why the Other Two were not Selected?

I did not select the decision to decrease zolpidem to 5 mg daily at bedtime because the client demonstrated symptoms of adverse reaction to the drug. Its continued administration is associated with the increased risk of worsening symptoms and poor treatment adherence. I did not select the decision to discontinue zolpidem and initiate eszopiclone 1 mg daily at bedtime because it has a high risk of symptom relapse as well as studies demonstrating high efficacy when used in elderly patients (Liang et al., 2019).

What I was Hoping to Achieve

I was hoping to eliminate the adverse effects the patient developed towards zolpidem. I was also hoping to improve his sleep quality, eliminate night awakening, and improve his daily functioning. I was also hoping to improve his overall tolerance to the treatment (Cuomo et al., 2019).

Ethical Considerations

The ethical consideration that informed the above decision is utilizing evidence-based data to ensure safety and efficiency in treating mental health disorders. Psychiatric mental health nurses should adopt evidence-based decisions to minimize potentials of patient harm. As a result, the decision to change the treatment aimed at eliminating further risks associated with zolpidem in insomnia treatment (Xiang et al., 2021).

Decision 3

Selected Decision

Continue dose. Explain to patient he may split the 50 mg table in half. The decreased dose should minimize next day drowsiness. Follow up in 4 weeks.

Why I Selected the Decision

The client returned to the clinic in 2 weeks. He reported that trazodone is effective at 50 mg dose. However, he wakes up sometimes the following day with next-day drowsiness. He denies any auditory or visual hallucinations and is future oriented. These findings demonstrate the Trazodone has been effective in managing symptoms associated with insomnia. The patient denies night awakening and failing to recollect his experiences. He also does not take the drug with beer to enhance sleep quality. The next-day drowsiness is an expected finding because of the effect of the current dosage of trazodone (Cuomo et al., 2019). As a result, an effective solution would be to split the 50 mg tablet in half to minimize the next day drowsiness.

Why the Other Two were not Selected?

The decision to discontinue trazodone, initiate therapy with sonata 10 mg nightly at bedtime and following up in 4 weeks was not selected because trazodone had demonstrated the desired treatment outcomes. There was improvement in symptoms translating into no need to initiate the patient on a new drug. Similarly, the decision to discontinue trazodone and initiate therapy with hydroxyzine 50 mg at bedtime and following up in 4 weeks was not selected since trazodone had shown its effectiveness and efficacy. In addition, the patient has negative experience with diphenhydramine, which translate into a similar effect with hydroxyzine (Inoue et al., 2022).

What I was Hoping to Achieve

I was hoping to see sustained improvement in insomnia symptoms. I was also hoping that the patient will report minimal side effects associated with trazodone. Splitting the tablet into half was also expected to address the issue of next-day sleepiness (Cuomo et al., 2019).

Ethical Considerations

Ethical considerations such as justice, beneficence, and non-maleficence could have affected the adopted treatments. Accordingly, psychiatric mental health nurses demonstrate justice in their practice by ensuring confidentiality and privacy of the patient’s data. In addition, they ensure the adopted treatments are not harmful and aim at doing for their patients. Therefore, a violation of any of these principles would affect treatment outcomes.

Conclusion

 In conclusion, the initially adopted treatment to begin the patient with zolpidem was ineffective. The patient demonstrated signs and symptoms of adverse reactions to zolpidem. This increased the need for the adoption trazodone to minimize the adverse and side effects while improving the symptoms of insomnia. The decision to begin the patient with zolpidem and not trazodone is that trazodone is largely used in patients with insomnia associated with other disorders. The selection of trazodone proved effective for the patient. There was the elimination of night awakening, feeling knocked out, and having to add beer to enhance his sleep quality. The patient reported feeling sleepy the following day, which necessitated the splitting of the Trazodone 50 mg table into half to address it (Cuomo et al., 2019). This decision led to further improvement in insomnia symptoms and drug tolerance, hence, the effectiveness of the decision.

Ethical considerations informed the patient’s treatment. Accordingly, the decisions made aimed at ensuring the promotion of safety, efficiency, and quality in the treatment process. The psychiatric mental health nurse practitioner made the decisions with the aim of optimizing benefits while minimizing the potential harm the selected drugs had on the patient. In addition, the principles of justice, autonomy, and beneficence, and non-maleficence informed the decisions made in the case study. For example, by minimizing harm, the nurse ensured the principle of non-maleficence. The use of evidence-based interventions in decision-making aimed at doing good for the patients (Xiang et al., 2021). Therefore, ethics guided the selected decisions in the patient’s treatment.

References

Asok, A., Sreekumar, S., TK, R., CC, A., P, U. D., & K, P. (2019). Effectiveness of zolpidem and sleep hygiene counseling in the treatment of insomnia in solid tumor patients. Journal of Oncology Pharmacy Practice, 25(7), 1608–1612. https://doi.org/10.1177/1078155218801062

Cuomo, A., Ballerini, A., Bruni, A. C., Decina, P., Sciascio, G. D., Fiorentini, A., Scaglione, F., Vampini, C., & Fagiolini, A. (2019). Clinical guidance for the use of trazodone in major depressive disorder and concomitant conditions: Pharmacology and clinical practice. Rivista di Psichiatria, 54(4), 137–149.

Inoue, Y., Nishida, M., Kubota, N., Koebis, M., Taninaga, T., Muramoto, K., Ishikawa, K., & Moline, M. (2022). Comparison of the treatment effectiveness between lemborexant and zolpidem tartrate extended release for insomnia disorder subtypes defined based on polysomnographic findings. Journal of Clinical Sleep Medicine. https://doi.org/10.5664/jcsm.10378

La, A. L., Walsh, C. M., Neylan, T. C., Vossel, K. A., Yaffe, K., Krystal, A. D., Miller, B. L., & Karageorgiou, E. (2019). Long-Term Trazodone Use and Cognition: A Potential Therapeutic Role for Slow-Wave Sleep Enhancers. Journal of Alzheimer’s Disease, 67(3), 911–921. https://doi.org/10.3233/JAD-181145

Liang, L., Huang, Y., Xu, R., Wei, Y., Xiao, L., & Wang, G. (2019). Eszopiclone for the treatment of primary insomnia: A systematic review and meta-analysis of double-blind, randomized, placebo-controlled trials. Sleep Medicine, 62, 6–13. https://doi.org/10.1016/j.sleep.2019.03.016

Pochiero, I., Gorini, M., Comandini, A., Calisti, F., Loreto, G. D., Cattaneo, A., Knight, T., Anastassopoulos, K. P., Patel, R., Baik, R., & Bruni, O. (2022). Real-World Characteristics and Treatment Patterns of Patients With Insomnia Prescribed Trazodone in the United States. Clinical Therapeutics, 44(8), 1093–1105. https://doi.org/10.1016/j.clinthera.2022.07.004

Sharma, M. K., Kainth, S., Kumar, S., Bhardwaj, A., Agarwal, H. K., Maiwall, R., Jamwal, K. D., Shasthry, S. M., Jindal, A., Choudhary, A., Anand, L., Dhamija, R. M., Kumar, G., Sharma, B. C., & Sarin, S. K. (2019). Effects of zolpidem on sleep parameters in patients with cirrhosis and sleep disturbances: A randomized, placebo-controlled trial. Clinical and Molecular Hepatology, 25(2), 199–209. https://doi.org/10.3350/cmh.2018.0084

Xiang, T., Cai, Y., Hong, Z., & Pan, J. (2021). Efficacy and safety of Zolpidem in the treatment of insomnia disorder for one month: A meta-analysis of a randomized controlled trial. Sleep Medicine, 87, 250–256. https://doi.org/10.1016/j.sleep.2021.09.005