Assignment: Assessing and Treating Patients With Psychosis and Schizophrenia

Psychosis and schizophrenia greatly impact the brain’s normal processes, which interfere with the ability to think clearly. When symptoms of these disorders are uncontrolled, patients may struggle to function in daily life. However, patients often thrive when properly diagnosed and treated under the close supervision of a psychiatric mental health practitioner. For this Assignment, as you examine the patient case study in this week’s Learning Resources, consider how you might assess and treat patients presenting with psychosis and schizophrenia.

 

To prepare for this Assignment:

Review this week’s Learning Resources, including the Medication Resources indicated for this week.

Reflect on the psychopharmacologic treatments you might recommend for the assessment and treatment of patients with schizophrenia-related psychoses.

The Assignment: 5 pages

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.

 

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.

 

 

 

 

 

Delusional Disorders

Pakistani Female With Delusional Thought 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 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.

 

 

SUBJECTIVE

 

Client 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 EXAM

 

The 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 scale

 

Diagnosis: Schizophrenia, paranoid type

 

Decision Point One

Select what you should do among these medications and the consequencies

 

Start Zyprexa (olanzapine) 10 mg orally at BEDTIME

Start Invega Sustenna 234 mg IM X1 followed by 156 mg IM on day 4 and monthly thereafter

Start Abilify (aripiprazole) 10 mg orally at BEDTIME

 

Decision Point One

 

 

Start Abilify (aripiprazole) 10 mg orally at BEDTIME

RESULTS OF DECISION POINT ONE

 

Client returns to clinic in four weeks

Client returns and looks disheveled. Upon questioning, her husband states that she has not been sleeping at night. He states she is up and down all night. It has been disrupting his sleep too

The client is unable to participate in the PANSS rating tool because she is continually nodding off (sleeping) during the appointment

The appointment is not productive for assessing how she is responding to the Abilify started 4 weeks ago

Decision Point Two

 

 

Change Abilify administration time to AM dosing

RESULTS OF DECISION POINT TWO

 

Client arrives at office appearing to have slept better. Her husband tells you that she is still up and down at night, but it is much less frequently

He notices that it is better when she takes her medication as soon as she awakens, but some days she forgets and takes it when she remembers (in the afternoon)

Her PANNS has decreased by 5% since her initial visit

Decision Point Three

 

 

Increase dose to 20 mg at bedtime and counsel client on the importance of taking this medication first thing in the morning due to akathisia and insomnia that can be problematic in some clients. Counsel the husband on setting up reminders for her at home to help avoid these symptoms at night. Submit an e-prescription to the client’s pharmacy for Ambien 10 mg orally at BEDTIME to help with sleep

Guidance to Student

This is week 8 since therapy was initiated. Although the client’s side effects seem to be better managed, her PNSS is not changing by much. An acceptable time frame for treatment is defined as 4–6 weeks at an acceptable dose. Increasing Abilify to 20 mg in the morning certainly is an option, but she seems to be forgetful of taking this medication first thing in the morning on occasion and is still experiencing side effects when it is taken later in the day. It might be a good time to explore other options.

 

Latuda is a medication that behaves much like Geodon (ziprasidone). It offers a once-daily dosing option and weight gain is minimal. She would not be expected to experience the insomnia and akathisia that has been experienced on the Abilify. Tolerability can be an issue as doses are escalated. Particularly, nausea, vomiting, and extrapyramidal side effects can be problematic and therefore good counseling points to clients. Clients usually tolerate lower doses (40 mg) but significant GI distress and movement disorders can occur when doses are pushed upward toward the daily max of 160 mg.

 

Invega oral therapy is a good option as it has a once daily dosing option, and it has a greater effect at the D2 receptor than Abilify and may offer more efficacy and less insomnia and akathisia than seen in Abilify. It has a long-acting option that can be given monthly (to start). With good efficacy maintained over a 4-month period, it can be changed to once every 3 months. This is a good option in someone where compliance can be problematic.

Decision Point One

 

 

Start Zyprexa (olanzapine) 10 mg orally at BEDTIME

RESULTS OF DECISION POINT ONE

 

Client returns to clinic in four weeks

Her PANSS decreases to a partial response (decrease in positive symptoms by 25%)

She comes in today with a reported weight gain of 5 pounds. When questioned further on this point, she states that she can never seem to get full from her meals, so she is snacking constantly throughout the day

Decision Point Two

 

 

Decrease Zyprexa to 7.5 mg orally at BEDTIME

RESULTS OF DECISION POINT TWO

 

Client returns to clinic in four weeks

Result of next decision (what happened): Client worsens (her positive symtpoms scale increased by 25% and her negative symptom scale score decreased by 10% indicating improved negative symptoms), but her weight becomes stabilized and excessive hunger abates

Husband explains that she is becoming less manageable at home, and he has to take time off from work because he is fearful of leaving her alone

Decision Point Three

 

 

Change to Risperdal (risperidone) 1 mg orally BID

Guidance to Student

Weight gain is a significant problem with Zyprexa. Next to Clozaril (clozapine), Zyprexa causes the most weight gain of all the atypical antipsychotics. This is a side effect that a significant number of clients will experience. There also appears to be an increased association of newly diagnosed diabetes mellitus in clients treated with Zyprexa. Although this can be disease related in this population, Zyprexa is above what would be considered coincidental.

 

Risperdal is a good option, although it is dosed twice daily and compliance in this population can be problematic. There is evidence that shows giving Risperdal all at once can be efficacious and therefore could be an option down the road should compliance become an issue. Weight gain is also possible with Risperdal, but it is not as great as that seen with Zyprexa. If compliance does become an issue with this client, Risperdal has a long-acting injectable formulation, Risperdal Consta, that could be used. Remember, Risperdal Consta has to be given every 2 weeks at the provider’s office, and therapeutic blood levels take time to achieve (on average 3–6 weeks or 2–3 injections). Oral overlapping therapy is required to bridge this period of time. Another option in someone who responds to Risperdal would be Invega Sustenna (paliperidone palmitate), which is the first metabolite of Risperdal and has greater activity at the D2 receptor than Risperdal. An advantage of Invega Sustenna over Risperdal Consta is that therapeutic blood levels are attained within the first 4–7 days, and overlapping oral therapy is usually not necessary. A disadvantage is that during the initiating phase of medication, the first two doses need to be given within 4–7 days of one another. This is followed by monthly injections. There is another product on the market called Invega Trinza, which is given once every 3 months. This product is for clients who have been stabilized on Invega Sustenna for at least 4 months where the last two doses were the same strength (two months of 156 mg injections).

 

Increasing Zyprexa to 15 mg at bedtime will only worsen the weight gain side effect. While additional benefits from increasing the dose may be possible from an efficacy standpoint, side effects always need to be taken into consideration. “First, do no harm.” Qsymia is a weight loss medication that is a combination of phentermine and topiramate. It is only indicated to treat obesity. This client’s BMI (28.9 kg/M2) does not fit the definition of obesity (BMI >30 Kg/M2- Following from CDC website: Class 1: BMI of 30 to < 35, Class 2: BMI of 35 to < 40, Class 3: BMI of 40 or higher. Class 3 obesity is sometimes categorized as “extreme” or “severe” obesity). There are two things wrong with this therapy option. First, there are only a few occasions where add-on therapy to treat a side effect is acceptable, and weight gain is not one of those scenarios. Secondly, phentermine has a lot of cardiovascular toxicities (such as elevated BP, HR, and increased workload on the heart).

 

Decision Point One

 

 

Start Zyprexa (olanzapine) 10 mg orally at BEDTIME

RESULTS OF DECISION POINT ONE

 

Client returns to clinic in four weeks

Her PANSS decreases to a partial response (decrease in positive symptoms by 25%)

She comes in today with a reported weight gain of 5 pounds. When questioned further on this point, she states that she can never seem to get full from her meals, so she is snacking constantly throughout the day

Decision Point Two

 

 

Change medication to Geodon (ziprasidone) 40 mg orally BID with meals

RESULTS OF DECISION POINT TWO

 

Client returns to clinic in four weeks

Client has a significant reduction in her PANSS (reduction of 40% in positive symptoms)

She notices her weight is down slightly from the previous visit (2 pounds) and that her hunger has been curbed since starting this med

She does complain that it is difficult to remember the second dose and admits to missing afternoon doses on several occasions over the past month

Decision Point Three

 

 

Give the client a few test doses of Risperdal 1 mg orally BID for 3 days to see if she tolerates the medication. If tolerated, start Invega Sustenna at an appropriate starting and maintenance dose

Guidance to Student

Changing to Risperdal oral therapy to test for side effects and then switching to Invega Sustenna is a good option in a client who has problems with compliance and who shows good effect from oral therapy. The manufacturer advertises that clients can be switched from an entirely different medication to Invega Sustenna if tolerability can be shown through oral therapy. From a clinical standpoint, the client may or may not respond to the medication and therefore could be wasted time. Remember, manufacturers have a product to sell, and their information should always be verified before implementing in clinical practice.

 

Although Geodon is recommended twice daily with meals, some providers will choose to give the dose once a day and monitor for efficacy in clients who have compliance issues with BID dosing regimens.

 

Latuda is a medication that behaves much like Geodon and is therefore a good option for someone who responds to Geodon but has compliance problems due to its once daily dosing schedule. Tolerability can be an issue as doses are escalated. Particularly, nausea, vomiting, and extrapyramidal side effects can be problematic and therefore good counseling points for clients. Clients usually tolerate lower doses (40 mg), but significant GI distress and movement disorders can occur when doses are pushed upward toward the daily max of 160 mg.

 

Decision Point One

 

 

Start Invega Sustenna 234 mg IM X1 followed by 156 mg IM on day 4 and monthly thereafter

RESULTS 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 time

Decision Point Two

 

 

DC Invega Sustenna and start Haldol Decanoate (haloperidol decanoate ) 50 mg IM q2weeks with oral Haldol 5 mg BID for the next 3 months

RESULTS OF DECISION POINT TWO

 

Client returns to clinic in four weeks

Client’s PANNS reveals a 10% increase in positive symptoms (representing an overall 15% reduction in positive symptoms from the first visit)

When she walks into the office, you notice an unusual movement in the trunk area of the client

When the client sits down, her head is turned to the left and she is unable to move it. She continually smacks her lips and repeatedly sticks her tongue out during this interview session

Decision Point Three

 

 

Decrease Haldol Decanoate 25 mg IM q2weeks. Submit e-prescription to client’s pharmacy for Cogentin (benztropine )2 mg orally BID

Guidance to Student

Unusual trunk movements, torticollis, and lip smacking/tongue thrusting are all cardinal signs of extra pyramidal effects and tardive dyskinesia [TD] (tongue thrusting). With continued treatment, TD can become persistent for years to decades and needs to be treated immediately. Since typical and atypical antipsychotics block D2 receptors in the substantia nigra, cholinergic effects “take over” and present with movement disorders. Treatment consists of anticholinergic therapy with or without benzodiazepine to control the movements. Since the client has been on long-acting Haldol Decanoate, it will take 4–5 half-lives to see complete removal of Haldol from her body. This translates into roughly 9–15 weeks (a half-life of Haldol Decanoate is around 3 weeks). It is always good clinical practice to start a client on oral therapy of Haldol and evaluate for efficacy and side effects (tolerability) before initiating long-acting therapy such as in this case.

 

A reduction in the Haldol dose will not do anything for the immediate effects of the Haldol that are being seen at today’s visit. It is a long-acting medication, and it is going to take time to reduce the overall steady concentration. This time frame is 9–15 weeks, or 4–5 half-lives (half-life is roughly 3 weeks).

 

Discontinuation of Haldol is the most prudent option in this case due to the client’s side effects and their effect on her quality of life. The decision to start at 2 mg of Abilify or 5 mg of Abilify is left to provider choice. This client, in any event, should be prescribed anticholinergic therapy with eight Cogentin, Artane (trihexyphenidyl), or Benadryl to control the EPS symptoms until the Haldol has been safely eliminated from her body. A follow-up phone call in 3–5 days is also in the best interest of the client to see if the EPS is lessening with the addition of anticholinergic therapy. Continued monitoring for these side effects should be considered at each follow-up visit until such time as they can be deemed eliminated.

Decision Point One

 

 

Start Invega Sustenna 234 mg IM X1 followed by 156 mg IM on day 4 and monthly thereafter

RESULTS 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 time

Decision Point Two

 

 

Continue same made but instruct administering nurse to begin injections into the deltoid at this visit and moving forward

RESULTS 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 gain

Decision Point Three

 

 

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 month

Guidance to Student

Weight gain can occur with Invega Sustenna. It is modest in nature and can be controlled with proper nutrition and exercise. It is always a good idea to try and control a client’s weight through consultation with a dietician and exercise physiologist (life coach) before switching to another agent when a product is showing efficacy for at least 6 months.

 

Abilify Maintena is a good option for someone who has good response to Abilify oral. Remember that Abilify does not bind to the D2 receptor for a great period of time (such as Invega) and can be less effective in certain individuals. Also, remember that akathisia can be a possible side effect. Once an IM long-acting medication is given, the effects of the drug (both efficacious and untoward effects) can be maintained for a long duration (up to a month or longer). Tolerability and efficacy should be established with oral medication before administering the first injection. Also a disadvantage to Abilify Maintena is that a 2-week overlap of oral therapy is required due to effective blood levels lagging behind the induction dose.

 

Qsymia is a weight loss medication that is a combination of phentermine and topiramate. It is only indicated to treat obesity. This client’s BMI (28.9 kg/M2) does not fit the definition of obesity (BMI >30 Kg/M2- Following from CDC website: Class 1: BMI of 30 to < 35, Class 2: BMI of 35 to < 40, Class 3: BMI of 40 or higher. Class 3 obesity is sometimes categorized as “extreme” or “severe” obesity). There are two things wrong with this therapy option. First, there are only a few occasions where add-on therapy to treat a side effect is acceptable, and weight gain is not one of those scenarios. Secondly, phentermine has a lot of cardiovascular toxicities (such as elevated BP, HR, and increased workload on the heart).

Decision Point One

 

 

Start Invega Sustenna 234 mg IM X1 followed by 156 mg IM on day 4 and monthly thereafter

RESULTS 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 time

Decision Point Two

 

 

DC Invega Sustenna and start Haldol Decanoate (haloperidol decanoate ) 50 mg IM q2weeks with oral Haldol 5 mg BID for the next 3 months

RESULTS OF DECISION POINT TWO

 

Client returns to clinic in four weeks

Client’s PANNS reveals a 10% increase in positive symptoms (representing an overall 15% reduction in positive symptoms from the first visit)

When she walks into the office, you notice an unusual movement in the trunk area of the client

When the client sits down, her head is turned to the left and she is unable to move it. She continually smacks her lips and repeatedly sticks her tongue out during this interview session

Decision Point Three

 

 

Discontinue Haldol. Start Abilify 2 mg orally daily and schedule a follow-up phone call 4 days from today’s appointment to check on client’s current symptoms. Also e-prescribe Cogentin 2 mg orally BID to treat the EPS

Guidance to Student

Unusual trunk movements, torticollis, and lip smacking/tongue thrusting are all cardinal signs of extra pyramidal effects and tardive dyskinesia [TD] (tongue thrusting). With continued treatment, TD can become persistent for years to decades and needs to be treated immediately. Since typical and atypical antipsychotics block D2 receptors in the substantia nigra, cholinergic effects “take over” and present with movement disorders. Treatment consists of anticholinergic therapy with or without benzodiazepine to control the movements. Since the client has been on long-acting Haldol Decanoate, it will take 4–5 half-lives to see complete removal of Haldol from her body. This translates into roughly 9–15 weeks (a half-life of Haldol Decanoate is around 3 weeks). It is always good clinical practice to start a client on oral therapy of Haldol and evaluate for efficacy and side effects (tolerability) before initiating long-acting therapy such as in this case.

 

A reduction in the Haldol dose will not do anything for the immediate effects of the Haldol that are being seen at today’s visit. It is a long-acting medication, and it is going to take time to reduce the overall steady concentration. This time frame is 9–15 weeks, or 4–5 half-lives (half-life is roughly 3 weeks).

 

Discontinuation of Haldol is the most prudent option in this case due to the client’s side effects and their effect on her quality of life. The decision to start at 2 mg of Abilify or 5 mg of Abilify is left to provider choice. This client, in any event, should be prescribed anticholinergic therapy with eight Cogentin, Artane (trihexyphenidyl), or Benadryl to control the EPS symptoms until the Haldol has been safely eliminated from her body. A follow-up phone call in 3–5 days is also in the best interest of the client to see if the EPS is lessening with the addition of anticholinergic therapy. Continued monitoring for these side effects should be considered at each follow-up visit until such time as they can be deemed eliminated.

Decision Point One

 

 

Start Abilify (aripiprazole) 10 mg orally at BEDTIME

RESULTS OF DECISION POINT ONE

 

Client returns to clinic in four weeks

Client returns and looks disheveled. Upon questioning, her husband states that she has not been sleeping at night. He states she is up and down all night. It has been disrupting his sleep too

The client is unable to participate in the PANSS rating tool because she is continually nodding off (sleeping) during the appointment

The appointment is not productive for assessing how she is responding to the Abilify started 4 weeks ago

Decision Point Two

 

 

Change Abilify administration time to AM dosing

RESULTS OF DECISION POINT TWO

 

Client arrives at office appearing to have slept better. Her husband tells you that she is still up and down at night, but it is much less frequently

He notices that it is better when she takes her medication as soon as she awakens, but some days she forgets and takes it when she remembers (in the afternoon)

Her PANNS has decreased by 5% since her initial visit

Decision Point Three

 

 

Increase dose to 20 mg at bedtime and counsel client on the importance of taking this medication first thing in the morning due to akathisia and insomnia that can be problematic in some clients. Counsel the husband on setting up reminders for her at home to help avoid these symptoms at night. Submit an e-prescription to the client’s pharmacy for Ambien 10 mg orally at BEDTIME to help with sleep

Guidance to Student

This is week 8 since therapy was initiated. Although the client’s side effects seem to be better managed, her PNSS is not changing by much. An acceptable time frame for treatment is defined as 4–6 weeks at an acceptable dose. Increasing Abilify to 20 mg in the morning certainly is an option, but she seems to be forgetful of taking this medication first thing in the morning on occasion and is still experiencing side effects when it is taken later in the day. It might be a good time to explore other options.

 

Latuda is a medication that behaves much like Geodon (ziprasidone). It offers a once-daily dosing option and weight gain is minimal. She would not be expected to experience the insomnia and akathisia that has been experienced on the Abilify. Tolerability can be an issue as doses are escalated. Particularly, nausea, vomiting, and extrapyramidal side effects can be problematic and therefore good counseling points to clients. Clients usually tolerate lower doses (40 mg) but significant GI distress and movement disorders can occur when doses are pushed upward toward the daily max of 160 mg.

 

Invega oral therapy is a good option as it has a once daily dosing option, and it has a greater effect at the D2 receptor than Abilify and may offer more efficacy and less insomnia and akathisia than seen in Abilify. It has a long-acting option that can be given monthly (to start). With good efficacy maintained over a 4-month period, it can be changed to once every 3 months. This is a good option in someone where compliance can be problematic.

Decision Point One

 

 

Start Abilify (aripiprazole) 10 mg orally at BEDTIME

RESULTS OF DECISION POINT ONE

 

Client returns to clinic in four weeks

Client returns and looks disheveled. Upon questioning, her husband states that she has not been sleeping at night. He states she is up and down all night. It has been disrupting his sleep too

The client is unable to participate in the PANSS rating tool because she is continually nodding off (sleeping) during the appointment

The appointment is not productive for assessing how she is responding to the Abilify started 4 weeks ago

Decision Point Two

 

 

Change Abilify administration time to AM dosing

RESULTS OF DECISION POINT TWO

 

Client arrives at office appearing to have slept better. Her husband tells you that she is still up and down at night, but it is much less frequently

He notices that it is better when she takes her medication as soon as she awakens, but some days she forgets and takes it when she remembers (in the afternoon)

Her PANNS has decreased by 5% since her initial visit

Decision Point Three

 

 

DC Abilify and start Latuda (lurasidone) 40 mg orally daily

Guidance to Student

This is week 8 since therapy was initiated. Although the client’s side effects seem to be better managed, her PNSS is not changing by much. An acceptable time frame for treatment is defined as 4–6 weeks at an acceptable dose. Increasing Abilify to 20 mg in the morning certainly is an option, but she seems to be forgetful of taking this medication first thing in the morning on occasion and is still experiencing side effects when it is taken later in the day. It might be a good time to explore other options.

 

Latuda is a medication that behaves much like Geodon (ziprasidone). It offers a once-daily dosing option and weight gain is minimal. She would not be expected to experience the insomnia and akathisia that has been experienced on the Abilify. Tolerability can be an issue as doses are escalated. Particularly, nausea, vomiting, and extrapyramidal side effects can be problematic and therefore good counseling points to clients. Clients usually tolerate lower doses (40 mg) but significant GI distress and movement disorders can occur when doses are pushed upward toward the daily max of 160 mg.

 

Invega oral therapy is a good option as it has a once daily dosing option, and it has a greater effect at the D2 receptor than Abilify and may offer more efficacy and less insomnia and akathisia than seen in Abilify. It has a long-acting option that can be given monthly (to start). With good efficacy maintained over a 4-month period, it can be changed to once every 3 months. This is a good option in someone where compliance can be problematic.

Decision Point One

 

 

Start Abilify (aripiprazole) 10 mg orally at BEDTIME

RESULTS OF DECISION POINT ONE

 

Client returns to clinic in four weeks

Client returns and looks disheveled. Upon questioning, her husband states that she has not been sleeping at night. He states she is up and down all night. It has been disrupting his sleep too

The client is unable to participate in the PANSS rating tool because she is continually nodding off (sleeping) during the appointment

The appointment is not productive for assessing how she is responding to the Abilify started 4 weeks ago

Decision Point Two

 

 

DC Abilify and start Geodon (ziprasidone ) 40 mg orally BID with meals

RESULTS OF DECISION POINT TWO

 

Client has a significant reduction in her PANSS (with a 40% reduction in positive symptoms)

She notices her weight is down slightly from the previous visit ( 2-pound loss) and that her hunger has been curbed since starting this med

She does complain that it is difficult to remember the second dose and admits to missing afternoon doses on several occasions over the past month

Decision Point Three

 

 

Give her a few test doses of Risperdal 1 mg orally BID for 3 days to see if she tolerates the medication. If tolerated, start Invega Sustenna at an appropriate starting and maintenance dose

Guidance to Student

Changing to Risperdal oral therapy to test for side effects and then switching to Invega Sustenna is a good option in a client who has problems with compliance and who shows good effect from oral therapy. The manufacturer advertises that clients can be switched from an entirely different medication to Invega Sustenna if tolerability can be shown through oral therapy. From a clinical standpoint, the client may or may not respond to the medication and therefore this could be a waste of time. Remember, manufacturers have a product to sell, and their information should always be verified before implementing into clinical practice.

 

Although Geodon is recommended twice daily with meals, some providers will choose to give the dose once a day and monitor for efficacy in clients who have compliance issues with BID dosing regimens.

 

Latuda is a medication that behaves much like Geodon and is therefore a good option for someone who responds to Geodon but has compliance problems due to its once daily dosing schedule. Tolerability can be an issue as doses are escalated. Particularly, nausea, vomiting, and extrapyramidal side effects can be problematic and therefore good counseling points to clients. Clients usually tolerate lower doses (40 mg), but significant GI distress and movement disorders can occur when doses are pushed upward toward the daily max of 160 mg.

Decision Point One

 

 

Start Abilify (aripiprazole) 10 mg orally at BEDTIME

RESULTS OF DECISION POINT ONE

 

Client returns to clinic in four weeks

Client returns and looks disheveled. Upon questioning, her husband states that she has not been sleeping at night. He states she is up and down all night. It has been disrupting his sleep too

The client is unable to participate in the PANSS rating tool because she is continually nodding off (sleeping) during the appointment

The appointment is not productive for assessing how she is responding to the Abilify started 4 weeks ago

Decision Point Two

 

 

Reduce Abilify dose to 7.5 MG orally at BEDTIME

RESULTS OF DECISION POINT TWO

 

Client returns to clinic in four weeks

Client arrives at appointment a little less sedate but still exhausted. Husband states that it is a little better at home, but she is still up and down all night long

Her PANNS has not changed from her initial visit (reduction of 25%)

Decision Point Three

 

 

DC Abilify and start Fanapt (iloperidone ) 1 mg orally BID and titrate slowly to response. Max dose out at 12 mg orally BID if required

Guidance to Student

It seems obvious at this point that this client is always going to react to Abilify in this manner and therefore it should be discontinued and deemed as a treatment failure due to intolerable side effects. (The insurance companies are going to want to see this documentation. It is a good idea to get in the habit of documenting why medications are discontinued in an effort to save yourself time in the future and prevent re-challenges to medications like this.) A change to either Risperdal, Fanapt, or Prolixin are all suitable options and are up to you and client tolerability/efficacy. Risperdal is a nice option because it has a long-acting injectable option. This also applies to Prolixin. Disadvantages to Prolixin long- acting injectable to Risperdal/Invega long acting injectable are side effects (EPS) and injection site pain (typical antipsychotic long-acting injectables are in an oleaginous base compared to nanoparticles in an aqueous base for the atypical options). Fanapt has to be slowly titrated upward to help avoid side effects that can lead to noncompliance.

 

RUBRICS

 

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​Rubric Detail

 

Select Grid View or List View to change the rubric’s layout.

 

​Name: NURS_6630_Week7_Assignment_Rubric

 

Excellent Point range: 90–100

Good Point range: 80–89

Fair Point range: 70–79

Poor Point range: 0–69

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.

9 (9%) – 10 (10%)

The response accurately, clearly, and fully summarizes in detail the case for the Assignment. The response accurately and clearly explains in detail the specific patient factors that impact decision making when prescribing medication for this patient.

8 (8%) – 8 (8%)

The response accurately summarizes the case for the Assignment. The response accurately explains the specific patient factors that impact decision making with prescribing medication for this patient.

7 (7%) – 7 (7%)

The response inaccurately or vaguely summarizes the case for the Assignment. The response inaccurately or vaguely explains the specific patient factors that impact decision making with prescribing medication for this patient.

0 (0%) – 6 (6%)

The response inaccurately and vaguely summarizes the case for the Assignment, or is missing. The response inaccurately and vaguely explains the specific patient factors that impact decision making with prescribing medication for this patient.

Decision #1 (1–2 pages) • 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.

18 (18%) – 20 (20%)

The response accurately and clearly explains in detail the decision selected. The response accurately and clearly explains in detail why the decision was selected, with specific clinically relevant resources that fully support the decision selected. The response accurately and clearly explains in detail why the other two responses were not selected, with specific clinically relevant resources that fully support the response. The response accurately and clearly explains in detail the outcome the student was hoping to achieve with the selected decision, with specific clinically relevant resources that fully support the response. The response accurately and clearly explains in detail how ethical considerations impact the treatment plan and communication with patients. Examples provided fully support the decisions and responses provided.

16 (16%) – 17 (17%)

The response accurately explains the decision selected. The response explains why the decision was selected, with specific clinically relevant resources that support the decision selected. The response accurately explains why the other two responses were not selected, with specific clinically relevant resources that support the response. The response accurately explains the outcome the student was hoping to achieve with the selected decision, with specific clinically relevant resources that support the response. The response accurately explains how ethical considerations impact the treatment plan and communication with patients. Examples provided support the decisions and responses provided.

14 (14%) – 15 (15%)

The response inaccurately or vaguely explains the decision selected. The response inaccurately or vaguely explains why the decision was selected, with specific clinically relevant resources that inaccurately or vaguely support the decision selected. The response inaccurately or vaguely explains why the other two responses were not selected, with specific clinically relevant resources that inaccurately or vaguely support the response. The response inaccurately or vaguely explains the outcome the student was hoping to achieve with the selected decision, with specific clinically relevant resources that inaccurately or vaguely support the response. The response inaccurately or vaguely explains how ethical considerations impact the treatment plan and communication with patients. Examples provided may support the decisions and responses provided.

0 (0%) – 13 (13%)

The response inaccurately and vaguely explains the decision selected. The response inaccurately and vaguely explains why the decision was selected, with specific clinically relevant resources that do not support the decision selected, or is missing. The response inaccurately and vaguely explains why the other two responses were not selected, with specific clinically relevant resources that do not support the decision selected, or is missing. The response inaccurately and vaguely explains the outcome the student was hoping to achieve with the selected decision, with specific clinically relevant resources that do not support the response, or is missing. The response inaccurately and vaguely explains how ethical considerations impact the treatment plan and communication with patients, or is missing. Examples provided do not support the decisions and responses provided, or is missing.

Decision #2 (1–2 pages) • 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.

18 (18%) – 20 (20%)

The response accurately and clearly explains in detail the decision selected. The response accurately and clearly explains in detail why the decision was selected, with specific clinically relevant resources that fully support the decision selected. The response accurately and clearly explains in detail why the other two responses were not selected, with specific clinically relevant resources that fully support the response. The response accurately and clearly explains in detail the outcome the student was hoping to achieve with the selected decision, with specific clinically relevant resources that fully support the response. The response accurately and clearly explains in detail how ethical considerations impact the treatment plan and communication with patients. Examples provided fully support the decisions and responses provided.

16 (16%) – 17 (17%)

The response accurately explains the decision selected. The response explains why the decision was selected, with specific clinically relevant resources that support the decision selected. The response accurately explains why the other two responses were not selected, with specific clinically relevant resources that support the response. The response accurately explains the outcome the student was hoping to achieve with the selected decision, with specific clinically relevant resources that support the response. The response accurately explains how ethical considerations impact the treatment plan and communication with patients. Examples provided support the decisions and responses provided.

14 (14%) – 15 (15%)

The response inaccurately or vaguely explains the decision selected. The response inaccurately or vaguely explains why the decision was selected, with specific clinically relevant resources that inaccurately or vaguely support the decision selected. The response inaccurately or vaguely explains why the other two responses were not selected, with specific clinically relevant resources that inaccurately or vaguely support the response. The response inaccurately or vaguely explains the outcome the student was hoping to achieve with the selected decision, with specific clinically relevant resources that inaccurately or vaguely support the response. The response inaccurately or vaguely explains how ethical considerations impact the treatment plan and communication with patients. Examples provided may support the decisions and responses provided.

0 (0%) – 13 (13%)

The response inaccurately and vaguely explains in detail the decision selected. The response inaccurately and vaguely explains why the decision was selected, with specific clinically relevant resources that do not support the decision selected, or is missing. The response inaccurately and vaguely explains why the other two responses were not selected, with specific clinically relevant resources that do not support the decision selected, or is missing. The response inaccurately and vaguely explains the outcome the student was hoping to achieve with the selected decision, with specific clinically relevant resources that do not support the response, or is missing. The response inaccurately and vaguely explains how ethical considerations impact the treatment plan and communication with patients, or is missing. Examples provided do not support the decisions and responses provided, or is missing.

Decision #3 (1–2 pages) • 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.

18 (18%) – 20 (20%)

The response accurately and clearly explains in detail the decision selected. The response accurately and clearly explains in detail why the decision was selected, with specific clinically relevant resources that fully support the decision selected. The response accurately and clearly explains in detail why the other two responses were not selected, with specific clinically relevant resources that fully support the response. The response accurately and clearly explains in detail the outcome the student was hoping to achieve with the selected decision, with specific clinically relevant resources that fully support the response. The response accurately and clearly explains in detail how ethical considerations impact the treatment plan and communication with patients. Examples provided fully support the decisions and responses provided.

16 (16%) – 17 (17%)

The response accurately explains the decision selected. The response explains why the decision was selected, with specific clinically relevant resources that support the decision selected. The response accurately explains why the other two responses were not selected, with specific clinically relevant resources that support the response. The response accurately explains the outcome the student was hoping to achieve with the selected decision, with specific clinically relevant resources that support the response. The response accurately explains how ethical considerations impact the treatment plan and communication with patients. Examples provided support the decisions and responses provided.

14 (14%) – 15 (15%)

The response inaccurately or vaguely explains the decision selected. The response inaccurately or vaguely explains why the decision was selected, with specific clinically relevant resources that inaccurately or vaguely support the decision selected. The response inaccurately or vaguely explains why the other two responses were not selected, with specific clinically relevant resources that inaccurately or vaguely support the response. The response inaccurately or vaguely explains the outcome the student was hoping to achieve with the selected decision, with specific clinically relevant resources that inaccurately or vaguely support the response. The response inaccurately or vaguely explains how ethical considerations impact the treatment plan and communication with patients. Examples provided may support the decisions and responses provided.

0 (0%) – 13 (13%)

The response inaccurately and vaguely explains in detail the decision selected. The response inaccurately and vaguely explains why the decision was selected, with specific clinically relevant resources that do not support the decision selected, or is missing. The response inaccurately and vaguely explains why the other two responses were not selected, with specific clinically relevant resources that do not support the decision selected, or is missing. The response inaccurately and vaguely explains the outcome the student was hoping to achieve with the selected decision, with specific clinically relevant resources that do not support the response, or is missing. The response inaccurately and vaguely explains how ethical considerations impact the treatment plan and communication with patients, or is missing. Examples provided do not support the decisions and responses provided, or is missing.

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.

14 (14%) – 15 (15%)

The response accurately and clearly summarizes in detail the recommendations on the treatment options selected for this patient. The response accurately and clearly explains a justification for the recommendations provided, including clinically relevant resources that fully support the recommendations provided.

12 (12%) – 13 (13%)

The response accurately summarizes the recommendations on the treatment options selected for this patient. The response accurately explains a justification for the recommendation provided, including clinically relevant resources that support the recommendations provided.

11 (11%) – 11 (11%)

The response inaccurately or vaguely summarizes the recommendations on the treatment options selected for this patient. The response inaccurately or vaguely explains a justification for the recommendations provided, including clinically relevant resources that inaccurately or vaguely support the recommendations provided.

0 (0%) – 10 (10%)

The response inaccurately and vaguely summarizes the recommendations on the treatment options selected for this patient, or is missing. The response inaccurately and vaguely explains a justification for the recommendations provided, including clinically relevant resources that do not support the recommendations provided, or is missing.

Written Expression and Formatting – Paragraph Development and Organization: Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused—neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria.

5 (5%) – 5 (5%)

Paragraphs and sentences follow writing standards for flow, continuity, and clarity. A clear and comprehensive purpose statement, introduction, and conclusion are provided that delineate all required criteria.

4 (4%) – 4 (4%)

Paragraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time. Purpose, introduction, and conclusion of the assignment are stated, yet they are brief and not descriptive.

3.5 (3.5%) – 3.5 (3.5%)

Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60%–79% of the time. Purpose, introduction, and conclusion of the assignment is vague or off topic.

0 (0%) – 3 (3%)

Paragraphs and sentences follow writing standards for flow, continuity, and clarity < 60% of the time. No purpose statement, introduction, or conclusion were provided.

Written Expression and Formatting – English writing standards: Correct grammar, mechanics, and proper punctuation

5 (5%) – 5 (5%)

Uses correct grammar, spelling, and punctuation with no errors.

4 (4%) – 4 (4%)

Contains a few (1 or 2) grammar, spelling, and punctuation errors.

3.5 (3.5%) – 3.5 (3.5%)

Contains several (3 or 4) grammar, spelling, and punctuation errors.

0 (0%) – 3 (3%)

Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding.

Written Expression and Formatting – The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, parenthetical/in-text citations, and reference list.

5 (5%) – 5 (5%)

Uses correct APA format with no errors.

4 (4%) – 4 (4%)

Contains a few (1 or 2) APA format errors.

3.5 (3.5%) – 3.5 (3.5%)

Contains several (3 or 4) APA format errors.

0 (0%) – 3 (3%)

Contains many (≥ 5) APA format errors.

 

Total Points: 100

​Name: NURS_6630_Week7_Assignment_Rubric

 

 

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