Introduction to the case Briefly explain and summarize the case for this Assignment. Be sure to include the specific patient factors that may impact

Question Introduction to the case 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 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 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 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.ConclusionSummarize 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.Examine Case Study: Pakistani Woman With Delusional Thought Processes. 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.BACKGROUNDThe 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 when she was 9 years old). She presents 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 says she knows this because the television is telling her so.She currently weighs 140 lbs., and she is 5′ 5.SUBJECTIVEClient reports that her mood is “good.” She denies auditory/visual hallucinations but believes that the television talks to her. She believes that Allah sends her messages through the TV. At times throughout the clinical interview, she becomes hostile towards you but then calms down.A review of her hospital records shows that she received a medical workup from 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 EXAMThe client is alert and 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 is 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.You administer the PANSS which reveals the following scores:-40 for the positive symptoms scale-20 for the negative symptom scale-60 for general psychopathology scaleDiagnosis: Schizophrenia, paranoid typeRESOURCESPANSS Scale. Available at: http://egret.psychol.cam.ac.uk/medicine/scales/PANSS§ Kay, S. R., Fiszbein, A., & Opler, L. A. (1987). The Positive and Negative Syndrome Scale (PANSS) for schizophrenia. Schizophrenia Bulletin, 13(2), 261-276. doi:10.1093/schbul/13.2.261https://www.clozapinerems.com/CpmgClozapineUI/rems/pdf/resources/Clozapine_REMS_A_Guide_for_Healthcare_Providers.pdf§ Clozapine REMS Program. (n.d.). Clozapine REMS: A guide for healthcare providers. Retrieved September 7, 2016, from https://www.clozapinerems.com/CpmgClozapineUI/rems/pdf/resources/Clozapine_REMS_A_Guide_for_Healthcare_Providers.pdfhttp://www.ima.org.il/FilesUpload/IMAJ/0/40/20149.pdf§ Paz, Z., Nalls, M., and Ziv, E. (2011). The genetics of benign neutropenia. Israel Medical Association Journal, 13(10), 625-629. Retrieved from http://www.ima.org.il/FilesUpload/IMAJ/0/40/20149.pdfDecision Point OneSelect what you should do:Decision Point OneSelect what you should do:Start Zyprexa (olanzapine) 10 mg orally at BEDTIMEStart Invega Sustenna 234 mg IM X1 followed by 156 mg IM on day 4 and monthly thereafterStart Abilify (aripiprazole) 10 mg orally at BEDTIMERESULTS OF DECISION POINT ONE Client returns to clinic in four weeks A decrease in the PANSS score of 25% (in positive symtpoms) is noted at this visit Client seems to be tolerating medication Her husband has made sure she makes her appointments for injections (one thus far) She has noted a 2-pound weight gain, but it does not seem to be an important point for her She does, however, complain of injection-site pain, telling you that she has trouble sitting for a few hours after the injections and doesn’t like having to walk around for such a long period of timeDecision Point TwoSelect what the PMHNP should do next:Continue same made but instruct administering nurse to begin injections into the deltoid at this visit and moving forwardDC Invega Sustenna and start Haldol Decanoate (haloperidol decanoate ) 50 mg IM q2weeks with oral Haldol 5 mg BID for the next 3 monthsContinue Invega Sustenna. Begin injections into the deltoid and add on Abilify Maintena 300 mg IM qmonthly with oral Abilify 10 mg in the MORNING for 2 weeksRESULTS OF DECISION POINT TWO Client returns to clinic in four weeks Her PANNS has been reduced by a total of 50% (in positive symptoms) from the initiation of Invega Sustenna When questioned about injection-site pain, she states it is much better in the arm Her weight has increased by an additional 2.5 pounds (total of 4.5 pounds in a 2-month period). She is somewhat bothered by the weight gain and is afraid that her husband does not like it. He is not present at this visit as she brought herself She likes how she feels on the Invega Sustenna but is wondering if there is another drug like it that would not cause the weight gainDecision Point ThreeSelect what you should do next:Continue with the Invega Sustenna. Counsel client on the fact that weight gain from Invega Sustenna is not as much as what other drugs with similar efficacy can cause. Make appointment with a dietician and an exercise physiologist. Follow up in one monthDC Invega Sustenna and start Abilify Maintena (aripiprazole ) 400 mg IM monthly (after a few test doses of Abilify oral have been tried and tolerated) with overlapping oral Abilify 10 mg in the MORNINGContinue Invega Sustenna and add on Qsymia (phentermine and topiramate) for weight loss=====================================================================Schizophrenia is a psychiatric disorder involving chronic or recurrent psychosis. It is commonly associated with impairments in social and occupational functioning. It is among the most disabling and economically catastrophic medical disorders, ranked by the World Health Organization as one of the top ten illnesses contributing to the global burden of disease (American Psychiatric Association, 2013).Characteristics of schizophrenia typically include positive symptoms, such as hallucinations or delusions; disorganized speech; negative symptoms, such as a flat affect or poverty of speech; and impairments in cognition, including attention, memory, and executive functions (Murry and Lopez, 2013). A diagnosis of schizophrenia is based on the presence of such symptoms, coupled with social or occupational dysfunction, for at least six months in the absence of another diagnosis that would better account for the presentation.IntroductionIn this case study, a 34-years old Pakistani female moved to the United States in her early twenty. She is in an arranged marriage which her husband was selected for her since she was 9 years old. She came to the clinic today to see the PMHNP after a 21-day hospitalization to diagnose a brief psychotic disorder. She was diagnosed as her symptoms persisted for less than one month. She also was reporting the vision of Allah, ad over a week. She believed that she was the prophet, Mohammad. Her husband’s concern about her behavior changes to the point that he was afraid of leaving their four children with her. She appears calm and insists that the entire incident was not actual. She denies all the allegations. She thinks her husband does want her anymore. She believes her husband wants an American wife instead of her. She knows for sure that this is because the television is telling her so. She weighs 140 lbs and is 5’5″. The client reports that her mood is good, and She denies auditory, visual hallucinations, but she believes that the television does talk to her. She believes that Allah sends her messages through the TV. In the client interview, her mood was up and down; once, she became hostile towards the PMHNP but then calmed down. Even though the client denies visual or auditory hallucination, she appears to be listening to something not there; delusional and paranoid thought processes as described, the interview. Insight and judgment are impaired. She denies now suicidal or homicidal ideation. The PMHNP Administers the PANSS reveals the following scores: -40 for the positive symptoms scale, -20 for the negative symptom scale, and -60 for the general psychopathology scale. The patient is diagnosed with schizophrenia, paranoid type. The purpose of this paper to aim to choose the evaluate therapy decisions at three different levels regarding the treatment of this patient’s schizophrenic symptoms. Furthermore, this case study will include ethical considerations that can impact the suggested treatment plan and interaction with the patient. Decision 1The PMHNP considers treating the three choices: start the client on Zyprexa 10 mg PO at bedtime, Invega Sustenna 234 mg IM x 1 followed by 156 mg on day 4, and monthly after that start Abilify 10 mg PO at night. The PMHNP selects the option to start Invega Sustenna 234 mg IM x1 followed b 156 mg on day four and monthly after that. Invega binds more potently the Long-acting injectable (LAI)s are similar enough to their corresponding oral formulations to be used interchangeably and have convincing evidence of improving consistency in pharmacotherapy that reduces the rates of relapse and frequency of hospitalization for individuals with psychosis (Limandri, 2019)INVEGA SUSTENNA® (paliperidone palmitate) when used to initiate patients experiencing an acute exacerbation of schizophrenia in the hospital and maintain treatment in an outpatient setting (PR Newswire, 2019, April 9).The client admitted to being noncompliant with the oral medication. Therefore, an intramuscular administration will ensure that she received the medicine she needs for the treatment. Zyprexa can utilize in the treatment of schizophrenia, but this medication will not be the first choice for this paranoid and self-conscious patient because Zyprexa concerns the risk of diabetes; and can significant weight gain due to its antihistaminic and 5HT2C antagonist properties (Stahl, 2014). Indication of diabetes cases in people utilizing the drug; Significance of the drug for the treatment of schizophrenia and bipolar mania (Eli Lilly faces claims regarding side-effects of Zyprexa, 2004). Abilify 10 mg PO did not choose for this patient because she is not compliant with PO medications. Although Ability is a promising drug on the dopamine antagonism scale, it can cause impulsive behavior and increase drowsiness during the daytime. Aripiprazole (Abilify) is in a class of medications called atypical antipsychotics. Antipsychotic medicines are used to treat symptoms of schizophrenia that may include hearing voices, seeing things (Aripiprazole, 2011, January 1).The goal of treatment is to obtain a 50% improvement and eliminate most of the patient’s negative symptoms and normalize her positive schizophrenia symptoms. The patient returns to the clinic in four weeks with a 25 % decrease in her PANSS score. She makes her appointments for injections. Also, the patient has noted a 2-pound weight gain, but it does not seem to be an essential point for her, but she complains of injection and does not like having a walk around for such a long period. The positive outcome is as expected, a patient appears to be responding positively to the medication, and injection site pain is common with the injection drug administration.Ethical ConsiderationsWithin medicine, some values have changed profoundly over the last few decades. Chief among these is truthfulness-specifically, whether physicians should tell patients the truth when they have a potentially fatal illness, ethical consensus that generally doctors should tell patients the truth even when this may cause foreseeable, additional harm to patients. Psychiatrists treating patients with schizophrenia may face ethical conflicts. These conflicts often are between helping these patients maximally and respecting their autonomy optimally. The current consensus is that the value of respecting a patient’s autonomy generally should prevail, even when a patient may potentially do worse medically. Psychiatrists, however, should always carefully consider what moral weight should be given to the values of doing good and avoiding harm, which were given more weight in the past when psychiatrists generally were more paternalistic. This should particularly be the case when they treat patients with schizophrenia since these patients’ decision-making capacities are likely to be impaired (Howe, 2008). Decision 2In the following treatment care, the PMHNP can continue to the same decision but instruct the nurse to begin the injection in the deltoid site at this visit and move forward. The second option is to discontinue the Invega Sustenna and start Haldol Decanoate 50 mg IM every two weeks with PO Haldol 5 mg twice a day for the next three months or continue to Invega sustenna but in the deltoid and add on Abilify Maintena 300 mg IM monthly with or ability 10 mg QAM for two weeks. The PMHNP decides to keep the same decision but instructs the nurse to be the injection site in the deltoid at this visit. Paliperidone injection has shown the minor occurrence of disease relapse due to the medication on compliance, and research shows that injection site pain is one of the most common side effects to observe in the control group for paliperidone injection. (Bishara. 2010). Therefore, changing the injection site will be the right action for the patient. Changing the patient to Haldol is not recommended because Haldol has been known to cause Tardive dyskinesia, which the symptoms are tongue protrusions and lip-smacking from upregulation of D2 receptors, which can be permanent in some patients (Stahl, 2013). Sometimes have irreversible side effects. Moreover, as the name suggests, psychotropic drugs are literally “mind-altering,” implicating the most fundamental of freedoms–freedom of thought. Considering the severe side effects and harms associated with these drugs, the decision of whether to medicate over a patient’s objections implicates constitutional and common law rights as well as professional judgments (American Psychiatric Association, 2013). In addition, it is always a good clinical practice to begin a patient on PO. Haldol and evaluate its effectiveness and tolerability before initiating a long-term therapy in injection form. It is not recommended to begin the patient on intramuscular Abilify by traying the patient on a PO to monitor efficacy and side effects. The literature recommends not to use two IM medications simultaneously as proposed in option three, but rather titrate to maintain one or the other (Stahl, 2013). The goal of treatment is for the patient to obtain at least 60% improvement with a significant decrease in negative symptoms and normalization of positive or cognitive symptoms with the next 4 weeks. The patient returns to the clinic, and her PANNS score was reduced by 50% from the initial of Invega Sustenna. The patient states the injection is much better in the injection arm, but she is concerned by the weight gain and bother that her husband does not like it and wonders if another drug like Invega would not cause the weight gain. The results are as expected because the efficacy of the Invega is usually seen right eight days following injection with peak plasma level is reach approximately 14 days the dose, and some weight gain is evidence in the utilization of this drug. Ethical ConsiderationsDue to the prevalence of isolation and depression in this mental health patient population, mental health professionals must join this effort to increase access to mental health services. Delivering psychotherapy in clients’ homes presents many advantages to these homebound individuals, but there is a dearth of literature addressing how therapists should handle unique ethical issues in this type of setting. This article addresses ethical considerations and guidelines for the in-home provision of mental health services. General ethical issues related to home-based psychotherapy include boundaries, confidentiality and privacy, competency, insurance coverage, and autonomy. Issues about different categories of homebound individuals, including persons with agoraphobia, chronic illnesses, and older adults, are discussed ethical code (Boland, 2019). Mental health service users’ acceptance of proposed changes is conditional, and they emphasized the importance of consent obtaining. The findings also have implications for the explain of mental health service users’ views and how they might contribute to policy, service planning, and research (Canvin, Bartlett & Pinfold, 2005). Decision 3According to the results from the previous visit, the PMHNP can continue the patient on Invega Sustenna and discussed the patient the fact that the weight gain from Invega sustenance is as much as what other drugs effects can happen. The patient may make an appointment with the dietician and exercise physiologist and follow up in one month. The second option will be to discontinue Invega Sustenna and start Abilify Maintenna 400 mg IM monthly after a test dose of PO Abilify has been tried and tolerated with overlapping oral Abilify 10 mg PO the morning. The last option will be to continue Invega Sustenna and add on Qsymia for weight loss. The PMHNP selected the first option, made an appointment with the dietician, and did the exercise with follow-up in one month. It is essential to support the patient’s concerns with weight gain but counsel her that moderate weight gain can occur with this medication. (Stahl, 2013). However, proper diet and exercise can reduce this problem. Recommending a consultation with a dietician and exercise is an excellent way to support the patient in combatting her concerns before switching to another agent to start again. Especially the medication is working. However, Abilify is approved for the treatment of patients with schizophrenia. It is not advisable to discontinue the patient Abilify does not bind to the D2 receptor for a considerable period, such as Invega, and can be less effective in certain patients (Stahl, 2013). Also, as mentioned earlier, akathisia, mild agitation, and difficulty sleeping can behave side effects of this Abilify; Qsymia is a medication utilized primarily for weight loss combined with other medicines such as topiramate (Sweting tablet, Caterson & Markovic, 2014). However, this patient’s BMI is at 28.9kg/M2 and does not fit the definition of obesity (BMI over or greater than 30 Kg/M2) as stated in the literature (Dains, Baumann & Scheibel, 2016)Weight gain is not an acceptable adverse effect the requires the need for addition on therapy. The goal of treatment is for the patient to better an 80% or more improvement with a significant decrease in negative symptoms and normalization of positive or cognitive symptoms within the next month. The best result is expected since the patient appears to be improving on the medication despite common side effects. The patient’s goal should be able to maintain a healthy weight with adequate diet and exercise while maintaining compliance with the Invega Sustenna injection. The PMHNP will continue to monitor the patient monthly or a required based on the effect and tolerability of treatment suggested.Ethical considerationsThe PMHNP provision of services to patient’s quality of life is discussed. Legal issues are considered about case law and state statutes, and ethical issues explored include codes of ethics, ethical meta principles, cultural considerations, and ethical decision-making models. Standards of careprofessional attitudes, professional associations’ statements, and acceptable actions in end-of-life situationsare outlined (Werth, 2002). An ethical consideration when treating patients with schizophrenia is to initiate treatment.Early on, when patients appear to be in the disease’s prodromal phase, such that one target. Symptoms faster and prevents delay in care. Targeting possible symptoms of schizophrenia could present as a dilemma if the patient or family is unwilling to agree to early treatment if they believe the patient is not “sick yet.” In cases as such, open, honest, and informative communication is required to understand the course of the disease and how a delay in care can result in significant detrimental effects. Also, the PMHNP needs to provide. Educational materials, resources, and routinely follow up with the patient to evaluate treatment outcomes and promote quality management of the patients’ symptoms.ConclusionSchizophrenia is a severe mental health diagnosis characterized by positive, negative, and cognitive, and affective symptoms. Positive traits of disease are delusions; negative symptoms can occur alogia or avolition, cognitive symptoms can affect memory and learning deficits; meanwhile, affective symptoms include depression (Stahl, 2013). The cause of schizophrenia is unknown, but studies have shown a correlation of this disease with high levels of dopamine and a combination of environmental/genetic influences. Schizophrenia can be challenging to treat, but several typical and atypical antipsychotics are utilized as treatment modalities for this disease. Schizophrenia is reviewed with particular emphasis on management considerations. Findings show that practical treatment components include psychoeducation, medication strategies; it is concluded that treatment for schizophrenia is best provided by integrating the various and specific psychosocial intervention strategies in addition to the optimal use of medication.ReferencesAmerican Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.Aripiprazole (generic): (brand: Abilify). (2011, January 1). The Brown University Child and Adolescent Psychopharmacology Update, 13(1).Boland, K. M. (2019). Ethical Considerations for Providing In-Home Mental Health Services for Homebound Individuals. Ethics & Behavior, 29(4), 287-304. https://doi-org.ezp.waldenulibrary.org/10.1080/10508422.2018.1518138Canvin, K., Bartlett, A., & Pinfold, V. (2005). Acceptability of compulsory powers in the community: the ethical considerations of mental health service users on Supervised Discharge and Guardianship. JOURNAL OF MEDICAL ETHICS, 31(8), 457-462.Dains, J. E., Baumann, L. C., & Scheibel, P. (2016). Advanced health assessment and clinical diagnosis in primary care (5th ed.). St. Louis, MO: Elsevier MosbyDelia Bishara. (2010). Once-monthly paliperidone injection for the treatment of schizophrenia. Neuropsychiatric Disease and Treatment, 2010(Issue 1), 561-572.Eli Lilly faces claims regarding the side effects of Zyprexa. (2004). Pharma Watch: CNS, 3(5), 15.Howe, E. (2008). Ethical considerations when treating patients with schizophrenia. Psychiatry, 5(4), 59-64.Limandri, B. J. (2019). Long-acting injectable antipsychotic medications: Why are not they used as often as oral formulations? Journal of Psychosocial Nursing and Mental Health Services, 57(3), 7-10. https://doi-org.ezp.waldenulibrary.org/10.3928/02793695-20190218-02Murray CJL, & Lopez AD (2013). The Global Burden of Disease, Harvard University Press, Cambridge, MAPR Newswire. (2019, April 9). Alkermes Announces Positive Topline Results from Innovative Study of ARISTADA® and INVEGA SUSTENNA® for the Treatment of Schizophrenia. PR Newswire US.Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (4th ed.). New York, NY: Cambridge University Press. Stahl, S. M. (2014). The prescriber’s guide (5th ed.). New York: Cambridge University Press. Sweeting AN, Tabet E, Caterson ID, & Markovic TP. (2014). Management of obesity and cardiometabolic risk – role of phentermine/extended release topiramate. Diabetes, Metabolic Syndrome and Obesity : Targets and Therapy, (default), 35. Retrieved from https://search-ebscohost-com.ezp.waldenulibrary.org/login.aspx? direct=true&db=edsdoj&AN=edsdoj.56e0dd14d9f45b49aa2b9cff1739cda&site=edslive&scope=siteWerth, J. L., Jr. (2002). Legal and Ethical Considerations for Mental Health Professionals Related to End-of-Life Care and Decision Making. American Behavioral Scientist, 46(3), 373-388. https://doi-org.ezp.waldenulibrary.org/10.1177/000276402237770 Health Science Science Nursing NURS 6630 Share QuestionEmailCopy link Comments (0)