​Assignment 1: Assessing and Treating Patients With Impulsivity, Compulsivity, and Addiction

Impulsivity, compulsivity, and addiction are challenging disorders for patients across the life span. Impulsivity is the inclination to act upon sudden urges or desires without considering potential consequences; patients often describe impulsivity as living in the present moment without regard to the future (MentalHelp.net, n.d.). Thus, these disorders often manifest as negative behaviors, resulting in adverse outcomes for patients. For example, compulsivity represents a behavior that an individual feels driven to perform to relieve anxiety (MentalHelp.net, n.d.). The presence of these behaviors often results in addiction, which represents the process of the transition from impulsive to compulsive behavior.

In your role as the psychiatric nurse practitioner (PNP), you have the opportunity to help patients address underlying causes of the disorders and overcome these behaviors. For this Assignment, as you examine the client case study in this week’s Learning Resources, consider how you might assess and treat clients presenting with impulsivity, compulsivity, and addiction.

Reference: MentalHelp.net. (n.d.). Impaired decision-making, impulsivity, and compulsivity: Addictions’ effect on the cerebral cortex. https://www.mentalhelp.net/addiction/impulsivity-and-compulsivity-addictions-effect-on-the-cerebral-cortex/

​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 requiring therapy for impulsivity, compulsivity, and addiction.

​The Assignment: 5 pages

Examine Case Study: A Puerto Rican Woman With Comorbid Addiction. You will be asked to make three decisions concerning the medication to prescribe to this client. Be sure to consider factors that might impact the client’s pharmacokinetic and pharmacodynamic processes.

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.

 

 

Comorbid Addiction (ETOH and Gambling)

53-year-old Puerto Rican Female

 

BACKGROUND

 

Mrs. Maria Perez is a 53 year old Puerto Rican female who presents today due to a rather “embarrassing problem.”

 

 

SUBJECTIVE

 

Mrs. Perez admits that she has had “problems” with alcohol since her father died in her late teens. She reports that she has struggled with alcohol since her 20’s and has been involved with Alcoholics Anonymous “on and off” for the past 25 years. She states that for the past 2 years, she has been having more and more difficulty maintaining her sobriety since the opening of the new “Rising Sun” casino near her home. Mrs. Perez states that she and a friend went to visit the new casino during its grand opening at which point she was “hooked.” She states that she gets “such a high” when she is gambling. While gambling, she “enjoys a drink or two” to help calm her during high-stakes games. She states that this often gives way to more drinking and more reckless gambling. She also reports that her cigarette smoking has increased over the past 2 years and she is concerned about the negative effects of the cigarette smoking on her health.

 

She states that she attempts to abstain from drinking but she gets such a “high” from the act of gambling that she needs a few drinks to “even out.” She also notices that when she drinks, she doesn’t smoke “as much,” but she enjoys smoking when she is playing at the slot machines. She also reports that she has gained weight from drinking so much. She currently weights 122 lbs., which represents a 7 lb. weight gain from her usual 115 lb. weight.

 

Mrs. Perez is quite concerned today because she borrowed over $50,000 from her retirement account to pay off her gambling debts, and her husband does not know.

 

 

MENTAL STATUS EXAM

 

The client is a 53 year old Puerto Rican female who is alert and oriented to person, place, time, and event. She is dressed appropriately for the weather and time of year. Her speech is clear, coherent, and goal directed. Her eye contact is somewhat avoidant during the clinical interview. When you make eye contact with her, she looks away or looks down. She demonstrates no noteworthy mannerisms, gestures, or tics. Her self-reported mood is “sad.” Affect is appropriate to content of conversation and self-reported mood. She denies visual or auditory hallucinations, and no delusional or paranoid thought processes are readily appreciated. Insight and judgment are grossly intact; however, impulse control is impaired. She is currently denying suicidal or homicidal ideation.

 

Diagnosis: Gambling disorder, alcohol use disorder

 

Decision Point One

Select what you should do:

 

Vivitrol (naltrexone) injection, 380 mg intramuscularly in the gluteal region every 4 weeks

Antabuse (disulfiram) 250 mg orally daily

Campral (acamprosate) 666 mg orally three times/day

 

Decision Point One

 

 

Vivitrol (naltrexone) injection, 380 mg intramuscularly in the gluteal region every 4 weeks

RESULTS OF DECISION POINT ONE

 

Client returns to clinic in four weeks

Mrs. Perez says she feels “wonderful” as she has not “touched a drop” of alcohol since receiving the injection

Client reports that she has not been going to the casino, as frequently, but when she does go she “drops a bundle” (meaning, spends a lot of money gambling)

Client She is also still smoking, which has her concerned. She is also reporting some problems with anxiety, which also has her concerned

Decision Point Two

 

 

Add on Valium (diazepam) 5 mg orally TID/PRN/anxiety

RESULTS OF DECISION POINT TWO

 

Client returns to clinic in four weeks

Mrs. Perez reports that when she first received the Valium, it helped her tremendously. She states “I was like a new person. This is a miracle drug!” However, she reports that she has trouble “waiting” between drug administration times and sometimes takes her Valium early

She is asking today for an increase the Valium dose or frequency

Decision Point Three

 

 

Continue current dose of Vivitrol, increase Valium to 10 mg orally TID/PRN/anxiety. Refer to counseling for her ongoing gambling issue

Guidance to Student

Anxiety is a common side effect of Vivitrol. Mrs. Perez reports that she is doing well with this medication, and like other side effects, the anxiety associated with this medication may be transient. The psychiatric mental health nurse practitioner should never initiate benzodiazepines in a client who already has issues with alcohol, or other substance dependencies. Additionally, benzodiazepines are not to be used long-term. Problems associated with long-term benzodiazepine use include the need to increase the dose in order to achieve the same therapeutic effect. This is what we are seeing in Mrs. Perez’s case.

 

The most appropriate course of action in this case would be to continue the current dose of Vivitrol, while decreasing the Valium with the goal of discontinuation of the drug within the next two weeks. At that point, you would need to evaluate whether or not the side effect of anxiety associated with Vivitrol persists.

 

Increasing the dose of Valium would not be appropriate, neither would maintaining her on the current dose of Valium. Additionally, the client should be referred for counseling to help with her gambling addiction, as there are no FDA approved medications gambling disorder.

 

Medication should never be added treat side effect of another medication, unless that side effect is known to be transient (for instance, benzodiazepines are sometimes prescribed to overcome the initial problem of “activation” associated with initiation of SSRI, or SNRI therapy). However, in a client with multiple addictive disorders, benzodiazepines should never be used (unless they are only being used for a limited duration of therapy such as acute alcohol detoxification to prevent seizures).

 

Additionally, it should be noted that Mrs. Perez continues to engage in problematic gambling, at considerable personal financial cost. Mrs. Perez needs to be referred to a counselor who specializes in the treatment of gambling disorder, and should also be encouraged to establish herself with a local chapter of gamblers anonymous.

 

You need to discuss smoking cessation options with Mrs. Perez in order to address the totality of addictions, and to enhance her overall health.

 

Decision Point One

 

 

Vivitrol (naltrexone) injection, 380 mg intramuscularly in the gluteal region every 4 weeks

RESULTS OF DECISION POINT ONE

 

Client returns to clinic in four weeks

Mrs. Perez says she feels “wonderful” as she has not “touched a drop” of alcohol since receiving the injection

Client reports that she has not been going to the casino, as frequently, but when she does go she “drops a bundle” (meaning, spends a lot of money gambling)

Client She is also still smoking, which has her concerned. She is also reporting some problems with anxiety, which also has her concerned

Decision Point Two

 

 

Refer to a counselor to address gambling issues

RESULTS OF DECISION POINT TWO

 

Mrs. Perez returns in 4 weeks and reports that the anxiety that she had been experiencing is gone.

She reports that she has met with the counselor, but she did not really like her.

She also started going to a local meeting of Gamblers Anonymous. She states that last week, for the first time, she spoke during the meeting. She reports feeling supported in this group.

Decision Point Three

 

 

Encourage Mrs. Perez to continue seeing her current counselor as well as continuing with the Gamblers Anonymous group

Guidance to Student

Although controversy exists in the literature regarding how long to maintain a client on Vivitrol, 8 weeks is probably too soon to consider discontinuation. The psychiatric mental health nurse practitioner should explore the issues that Mrs. Perez is having with her counselor. As will be covered in more depth in future courses, ruptures in the therapeutic alliance can result in clients stopping therapy. Clearly, if the client does not continue with therapy, the likelihood of the gambling problem spontaneously remitting is lower (than had the client continued to receive therapy). Recall that there are no FDA-approved treatments for gambling addiction. The mainstay of treatment for this disorder is counseling. Since Mrs. Perez reports good perceived support from the Gamblers Anonymous meetings, she should be encouraged to continue her participation with this group.

 

You need to discuss smoking cessation options with Mrs. Perez in order to address the totality of addictions, and to enhance her overall health.

 

 

Decision Point One

 

 

Vivitrol (naltrexone) injection, 380 mg intramuscularly in the gluteal region every 4 weeks

RESULTS OF DECISION POINT ONE

 

Client returns to clinic in four weeks

Mrs. Perez says she feels “wonderful” as she has not “touched a drop” of alcohol since receiving the injection

Client reports that she has not been going to the casino, as frequently, but when she does go she “drops a bundle” (meaning, spends a lot of money gambling)

Client She is also still smoking, which has her concerned. She is also reporting some problems with anxiety, which also has her concerned

Decision Point Two

 

 

Add on Chantix (varenicline) 1 mg orally BID

RESULTS OF DECISION POINT TWO

 

Client returns to clinic in four weeks

Client reports that she had to stop taking Chantix secondary to abnormal dreams and agitation

She also reports that she felt nauseous and vomited several times after she began taking the drug

Decision Point Three

 

 

Restart Varenicline at 1 mg orally BID and educate Mrs. Perez regarding side effects

Guidance to Student

Mrs. Perez was experiencing normal side effects associated with Chantix. She should be counseled regarding the potential side effects associated with Chantix and reassured that they will most likely abate. It should be noted that the problem Mrs. Perez is experiencing from the Chantix is most likely related to the starting dose. Recall that this drug should be initiated at 0.5 mg/day; after 3 days, increase to 1 mg/day in two divided doses; after 4 days, the dose can be increased to 2 mg/day in two divided doses. Side effects would most likely have been minimized or completely avoided had she been started at the appropriate starting dose. Therefore, it may be prudent to restart this drug at 0.5 mg orally daily and uptitrate consistent with the manufacturer’s suggested titration schedule. It would not be appropriate to restart Mrs. Perez at 1 mg orally BID, as it would most likely result in a return of the unpleasant symptoms she experienced.

 

If Mrs. Perez is adverse to the idea of restarting Chantix, you could begin Wellbutrin XL, 150 mg orally daily.

 

Additionally, it should be noted that Mrs. Perez continues to engage in problematic gambling, at considerable personal financial cost. Mrs. Perez needs to be referred to a counselor who specializes in the treatment of gambling disorder and should also be encouraged to establish herself with a local chapter of Gamblers Anonymous.

 

Decision Point One

 

 

Antabuse (disulfiram) 250 mg orally every morning

RESULTS OF DECISION POINT ONE

 

Client returns to clinic in four weeks

Mrs. Perez reports to the office complaining of sedation, fatigue, and a “metallic taste” in her mouth, which “seems to be going away.” She also reports that she had just one drink about 5 days after starting the drug and thought that she would “die.” She reports that her face was red, and she felt that her heart would “pound right out of my chest.”

Mrs. Perez also reports that she continues to visit the casino but has not been spending as much money there. She has noticed that her cigarette smoking is increasing

Decision Point Two

 

 

Continue current dose of Antabuse and begin Campral (acamprosate) 666 mg orally BID

RESULTS OF DECISION POINT TWO

 

Client returns to clinic in four weeks

Mrs. Perez reports that the metallic taste is “still there” but that it doesn’t bother her anymore

She reports that she has managed to avoid alcohol as she is afraid of the side effects of the medications when she does drink

She reports that over the course of the past 2 weeks, her cigarette consumption is “almost double—I’m up to almost 2 packs a day!”

Decision Point Three

 

 

Continue current doses of medications and discuss smoking cessation options

Guidance to Student

Sedation/fatigue is a common complaint of people who take Antabuse. The best approach would be to change the administration time to the evening. The “metallic” taste in Mrs. Perez’s mouth is also another side effect that should lessen and may fully go away with the passage of time. When a person taking Antabuse ingests alcohol, they will most likely experience “flushing,” tachycardia, nausea, and vomiting.

 

There is no reason to add Campral to her current medication regimen. Although the two drugs do not interact, it is simply a waste of money and increases the pill burden on the patient. There is no reason to discontinue both medications—only one should be discontinued to help support sobriety. The remaining medication could be stopped in several weeks after the client as demonstrated a pattern of abstinence

 

At this point, you should maintain the Antabuse, discontinue Campral, and discuss smoking cessation options with the client in order to address the totality of addictions and to enhance her overall health.

 

Additionally, it should be noted that Mrs. Perez continues to engage in problematic gambling, at considerable personal financial cost. Mrs. Perez needs to be referred to a counselor who specializes in the treatment of gambling.

 

 

Antabuse (disulfiram) 250 mg orally every morning

RESULTS OF DECISION POINT ONE

 

Client returns to clinic in four weeks

Mrs. Perez reports to the office complaining of sedation, fatigue, and a “metallic taste” in her mouth, which “seems to be going away.” She also reports that she had just one drink about 5 days after starting the drug and thought that she would “die.” She reports that her face was red, and she felt that her heart would “pound right out of my chest.”

Mrs. Perez also reports that she continues to visit the casino but has not been spending as much money there. She has noticed that her cigarette smoking is increasing

Decision Point Two

 

 

Continue current dose of Antabuse and refer to counseling for ongoing gambling issues

RESULTS OF DECISION POINT TWO

 

Client returns to clinic in four weeks

Mrs. Perez in 4 weeks and reports that she has met with the counselor, but she did not really like her. She also started going to a local meeting of Gamblers Anonymous

She states that last week, for the first time, she spoke during the meeting. She reports feeling supported in this group. She also reports that she is still smoking quite a bit

Decision Point Three

 

 

Encourage Mrs. Perez to continue seeing her current counselor as well as continuing with the Gamblers Anonymous group. Discuss smoking cessation options

Guidance to Student

Sedation/fatigue is a common complaint of people who take Antabuse; the best approach would be to change the administration time to the evening. The “metallic” taste in Mrs. Perez’s mouth is also another side effect that lessens and may fully go away with the passage of time. When a person taking disulfiram ingests alcohol, they will most likely experience “flushing,” tachycardia, nausea, and vomiting.

 

Although controversy exists in the literature regarding how long to maintain a client on disulfiram, 8 weeks is probably too soon to consider discontinuation. The psychiatric mental health nurse practitioner should explore the issues that Mrs. Perez is having with her counselor. As will be covered in more depth in future courses, ruptures in the therapeutic alliance can result in the client stopping therapy. Clearly, if the client does not continue with therapy, the likelihood of the gambling problem spontaneously remitting is lower (as opposed to the client who receives therapy). Recall that there are no FDA-approved treatments for gambling addiction, and the mainstay of treatment for this disorder is counseling. Since Mrs. Perez reports good perceived support from the Gamblers Anonymous meetings, she should be encouraged to continue her participation with this group.

 

Decision Point One

 

 

Antabuse (disulfiram) 250 mg orally every morning

RESULTS OF DECISION POINT ONE

 

Client returns to clinic in four weeks

Mrs. Perez reports to the office complaining of sedation, fatigue, and a “metallic taste” in her mouth, which “seems to be going away.” She also reports that she had just one drink about 5 days after starting the drug and thought that she would “die.” She reports that her face was red, and she felt that her heart would “pound right out of my chest.”

Mrs. Perez also reports that she continues to visit the casino but has not been spending as much money there. She has noticed that her cigarette smoking is increasing

Decision Point Two

 

 

Continue current dose of Antabuse and begin Wellbutrin (bupropion) XL 150 mg orally daily

RESULTS OF DECISION POINT TWO

 

Client returns to clinic in four weeks

Mrs. Perez reports that the side effects of the Antabuse are “gone” and that she is feeling much better

She reports that she is still smoking but that “it has dropped to only a couple of cigarettes a day.”

She still reports that she is visiting the casino but is not spending “as much money” as she had been in the past

Decision Point Three

 

 

Continue Wellbutrin XL at 150 mg orally daily, but discontinue Antabuse

Guidance to Student

Sedation/fatigue is a common complaint of people who take Antabuse, the best approach would be to change the administration time to the evening. The “metallic” taste in Mrs. Perez’s mouth is also another side effect that lessens and may fully go away with the passage of time. When a person taking disulfiram ingests alcohol, they will probably experience “flushing,” tachycardia, nausea, and vomiting.

 

At this point, you should maintain the current dose of each medication and refer the client to a counselor. Recall that there are no FDA-approved medications for the treatment of gambling addiction, and counseling is the mainstay of treatment for this particular disorder.

 

Nothing indicates an increase the Wellbutrin. Recall that it could take as long as 12 weeks for this medication to exert its full therapeutic effect. Cognitive behavioral principles can also be employed to help Mrs. Perez stop smoking, in addition to the Wellbutrin.

 

Although controversy exists in the literature regarding how long to maintain a client on Antabuse, 8 weeks is probably too soon to consider discontinuation.

Decision Point One

 

 

Campral (acamprosate) 666 mg orally TID

RESULTS OF DECISION POINT ONE

 

Client returns to clinic in four weeks

Upon return Mrs. Perez states that she has noticed that she has been having suicidal ideation over the past week, and it seems to be getting worse

She is also reporting that she is having “out of control” anxiety

Decision Point Two

 

 

Educate Mrs. Perez on the side effects of Campral and add Valium (diazepam) 5 mg orally TID to address anxiety symptoms

RESULTS OF DECISION POINT TWO

 

Client returns to clinic in four weeks

Mrs. Perez reports that when she first received the Valium, it helped her tremendously. She states, “I was like a new person. This is a miracle drug!” However, she reports that she has trouble “waiting” between drug administration times and sometimes takes her Valium early. She is asking today for an increase in the Valium dose or frequency

Although she reports that her anxiety is gone. She still reports suicidal ideation, but she states, “With that Valium stuff, who cares?”

Decision Point Three

 

 

Continue current dose of Campral, and increase Valium to 10 mg orally TID/PRN/anxiety. Refer to counseling for her ongoing gambling issue

Guidance to Student

Given her weight (less than 60 kg), Campral should have been started at 666 mg orally BID. Her side effects were most likely related to the high starting dose.

 

Although the anxiety is a problematic side effect, it is not as serious as her suicidal ideation. The suicidal ideation is a side effect that should have signaled the need to discontinue the drug and consider a different agent such as Antabuse.

 

Medication should never be added to treat the side effect of another medication unless that side effect is known to be transient (for instance, benzodiazepines are sometimes prescribed to overcome the initial problem of “activation” associated with initiation of SSRI, or SNRI therapy). However, in a patient with multiple addictive disorders, benzodiazepines should never be used (unless they are only being used for a limited duration of therapy such as acute alcohol detoxification to prevent seizures). Additionally, benzodiazepines are not to be used long term. Problems associated with long-term benzodiazepine use include the need to increase the dose in order to achieve the same therapeutic effect. This is what is being seen in Mrs. Perez’s case.

 

Additionally, it should be noted that Mrs. Perez continues to engage in problematic gambling, at considerable personal financial cost. Mrs. Perez needs to be referred to a counselor who specializes in the treatment of gambling disorder, and should also be encouraged to establish herself with a local chapter of Gamblers Anonymous.

 

You need to discuss smoking cessation options with Mrs. Perez in order to address the totality of addictions and to enhance her overall health.

 

Decision Point One

 

 

Campral (acamprosate) 666 mg orally TID

RESULTS OF DECISION POINT ONE

 

Client returns to clinic in four weeks

Upon return Mrs. Perez states that she has noticed that she has been having suicidal ideation over the past week, and it seems to be getting worse

She is also reporting that she is having “out of control” anxiety

Decision Point Two

 

 

Discontinue Campral and begin Antabuse (disulfiram) 250 mg orally daily

RESULTS OF DECISION POINT TWO

 

Client returns to clinic in four weeks

Mrs. Perez states that the suicidal thoughts have abated but reports that she has been feeling tired for several hours after taking the drug

She reports that she has not been going to the casino because she is afraid that she may be tempted to drink, and she noticed that the last time she drank, she felt nauseous and began to vomit. She also reported that it felt like her heart would “pound right out” of her chest.” She does report that she is smoking more, however

Decision Point Three

 

 

Continue Antabuse in the morning and discuss smoking cessation options

Guidance to Student

Sedation occurs in many people taking Antabuse. Mrs. Perez is experiencing adverse effects when she consumes alcohol with this drug, which is the expected/intended therapeutic effect. As a “side effect” she is avoiding the casino, which is also helping. At this point, it is not appropriate to discontinue Antabuse. Despite the fact that controversy exists regarding how long someone should remain on this medication, the client has only been on this drug for 4 weeks. Additional time on the medication would be prudent.

 

To minimize the side effect of sedation, the administration of the drug should be changed to bedtime. In all cases, you need to discuss smoking cessation options with Mrs. Perez in order to address the totality of addictions and to enhance her overall health.

 

Additionally, it should be noted that although Mrs. Perez reports that she has been avoiding the casino secondary to her fear that she will drink, this “fear” has not actually treated her gambling addiction. This particular addiction has resulted in considerable personal financial cost to Ms. Perez. Mrs. Perez needs to be referred to a counselor who specializes in the treatment of gambling disorder, and she should also be encouraged to establish herself with a local chapter of Gamblers Anonymous.

 

Decision Point One

 

 

Campral (acamprosate) 666 mg orally TID

RESULTS OF DECISION POINT ONE

 

Client returns to clinic in four weeks

Upon return Mrs. Perez states that she has noticed that she has been having suicidal ideation over the past week, and it seems to be getting worse

She is also reporting that she is having “out of control” anxiety

Decision Point Two

 

 

Decrease Campral to 666 mg orally BID

RESULTS OF DECISION POINT TWO

 

Client returns to clinic in four weeks

Mrs. Perez reports that the suicidal ideation is “still there” but not as bad. She reports that she is still afraid to go to the casino for fear that she may drink, which may cause those “horrible” side effects to come back

Her anxiety has also decreased quite a bit since decreasing the dose to twice a day. She reports that she is still smoking cigarettes

Decision Point Three

 

 

Add on Wellbutrin (bupropion) XL 150 mg orally daily

Guidance to Student

Given her weight (less than 60 kg), Campral should have been started at 666 mg orally BID. It is possible that the higher dose may be responsible for the severity of the symptoms that Mrs. Perez is experiencing.

 

Technically, the drug should have been stopped (not simply decreased) once Mrs. Perez reported suicidal ideation. Even with the decrease in dose, she is still having suicidal ideation, which indicates the need to discontinue the drug. Although controversy exists regarding how long to use pharmacologic approaches to treatment of alcohol dependence, 8 weeks is probably insufficient, therefore, the drug should not simply be discontinued without using a different agent in its place.

 

Mrs. Perez should be started on Antabuse at 250 mg orally daily and referred to psychotherapy to address her gambling issue.

 

In all cases, you need to discuss smoking cessation options with Mrs. Perez in order to address the totality of addictions and to enhance her overall health. The decision to begin Wellbutrin XL 150 mg orally daily may help achieve this goal, but this choice does not address her abstinence from alcohol.

 

Additionally, it should be noted that although Mrs. Perez reports that she has been avoiding the casino secondary to her fear that she will drink, this “fear” has not actually treated her gambling addiction. This particular addiction has resulted in considerable personal financial cost to Ms. Perez. Mrs. Perez needs to be referred to a counselor who specializes in the treatment of gambling disorder, and she should also be encouraged to establish herself with a local chapter of Gamblers Anonymous.

 

 

 

Decision Point One

 

 

Campral (acamprosate) 666 mg orally TID

RESULTS OF DECISION POINT ONE

 

Client returns to clinic in four weeks

Upon return Mrs. Perez states that she has noticed that she has been having suicidal ideation over the past week, and it seems to be getting worse

She is also reporting that she is having “out of control” anxiety

Decision Point Two

 

 

Discontinue Campral and begin Antabuse (disulfiram) 250 mg orally daily

RESULTS OF DECISION POINT TWO

 

Client returns to clinic in four weeks

Mrs. Perez states that the suicidal thoughts have abated but reports that she has been feeling tired for several hours after taking the drug

She reports that she has not been going to the casino because she is afraid that she may be tempted to drink, and she noticed that the last time she drank, she felt nauseous and began to vomit. She also reported that it felt like her heart would “pound right out” of her chest.” She does report that she is smoking more, however

Decision Point Three

 

 

Continue Antabuse in the morning and discuss smoking cessation options

Guidance to Student

Sedation occurs in many people taking Antabuse. Mrs. Perez is experiencing adverse effects when she consumes alcohol with this drug, which is the expected/intended therapeutic effect. As a “side effect” she is avoiding the casino, which is also helping. At this point, it is not appropriate to discontinue Antabuse. Despite the fact that controversy exists regarding how long someone should remain on this medication, the client has only been on this drug for 4 weeks. Additional time on the medication would be prudent.

 

To minimize the side effect of sedation, the administration of the drug should be changed to bedtime. In all cases, you need to discuss smoking cessation options with Mrs. Perez in order to address the totality of addictions and to enhance her overall health.

 

Additionally, it should be noted that although Mrs. Perez reports that she has been avoiding the casino secondary to her fear that she will drink, this “fear” has not actually treated her gambling addiction. This particular addiction has resulted in considerable personal financial cost to Ms. Perez. Mrs. Perez needs to be referred to a counselor who specializes in the treatment of gambling disorder, and she should also be encouraged to establish herself with a local chapter of Gamblers Anonymous.

 

Decision Point One

 

 

Vivitrol (naltrexone) injection, 380 mg intramuscularly in the gluteal region every 4 weeks

RESULTS OF DECISION POINT ONE

 

Client returns to clinic in four weeks

Mrs. Perez says she feels “wonderful” as she has not “touched a drop” of alcohol since receiving the injection

Client reports that she has not been going to the casino, as frequently, but when she does go she “drops a bundle” (meaning, spends a lot of money gambling)

Client She is also still smoking, which has her concerned. She is also reporting some problems with anxiety, which also has her concerned

Decision Point Two

 

 

Refer to a counselor to address gambling issues

RESULTS OF DECISION POINT TWO

 

Mrs. Perez returns in 4 weeks and reports that the anxiety that she had been experiencing is gone.

She reports that she has met with the counselor, but she did not really like her.

She also started going to a local meeting of Gamblers Anonymous. She states that last week, for the first time, she spoke during the meeting. She reports feeling supported in this group.

Decision Point Three

 

 

Encourage Mrs. Perez to continue seeing her current counselor as well as continuing with the Gamblers Anonymous group

Guidance to Student

Although controversy exists in the literature regarding how long to maintain a client on Vivitrol, 8 weeks is probably too soon to consider discontinuation. The psychiatric mental health nurse practitioner should explore the issues that Mrs. Perez is having with her counselor. As will be covered in more depth in future courses, ruptures in the therapeutic alliance can result in clients stopping therapy. Clearly, if the client does not continue with therapy, the likelihood of the gambling problem spontaneously remitting is lower (than had the client continued to receive therapy). Recall that there are no FDA-approved treatments for gambling addiction. The mainstay of treatment for this disorder is counseling. Since Mrs. Perez reports good perceived support from the Gamblers Anonymous meetings, she should be encouraged to continue her participation with this group.

 

You need to discuss smoking cessation options with Mrs. Perez in order to address the totality of addictions, and to enhance her overall health.

Decision Point One

 

 

Campral (acamprosate) 666 mg orally TID

RESULTS OF DECISION POINT ONE

 

Client returns to clinic in four weeks

Upon return Mrs. Perez states that she has noticed that she has been having suicidal ideation over the past week, and it seems to be getting worse

She is also reporting that she is having “out of control” anxiety

Decision Point Two

 

 

Educate Mrs. Perez on the side effects of Campral and add Valium (diazepam) 5 mg orally TID to address anxiety symptoms

RESULTS OF DECISION POINT TWO

 

Client returns to clinic in four weeks

Mrs. Perez reports that when she first received the Valium, it helped her tremendously. She states, “I was like a new person. This is a miracle drug!” However, she reports that she has trouble “waiting” between drug administration times and sometimes takes her Valium early. She is asking today for an increase in the Valium dose or frequency

Although she reports that her anxiety is gone. She still reports suicidal ideation, but she states, “With that Valium stuff, who cares?”

Decision Point Three

 

 

Decrease Campral to 666 mg orally BID, and maintain current dose of Valium. Refer to counseling for her ongoing gambling issue

Guidance to Student

Given her weight (less than 60 kg), Campral should have been started at 666 mg orally BID. Her side effects were most likely related to the high starting dose.

 

Although the anxiety is a problematic side effect, it is not as serious as her suicidal ideation. The suicidal ideation is a side effect that should have signaled the need to discontinue the drug and consider a different agent such as Antabuse.

 

Medication should never be added to treat the side effect of another medication unless that side effect is known to be transient (for instance, benzodiazepines are sometimes prescribed to overcome the initial problem of “activation” associated with initiation of SSRI, or SNRI therapy). However, in a patient with multiple addictive disorders, benzodiazepines should never be used (unless they are only being used for a limited duration of therapy such as acute alcohol detoxification to prevent seizures). Additionally, benzodiazepines are not to be used long term. Problems associated with long-term benzodiazepine use include the need to increase the dose in order to achieve the same therapeutic effect. This is what is being seen in Mrs. Perez’s case.

 

Additionally, it should be noted that Mrs. Perez continues to engage in problematic gambling, at considerable personal financial cost. Mrs. Perez needs to be referred to a counselor who specializes in the treatment of gambling disorder, and should also be encouraged to establish herself with a local chapter of Gamblers Anonymous.

 

You need to discuss smoking cessation options with Mrs. Perez in order to address the totality of addictions and to enhance her overall health.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

​Rubric Detail

 

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

 

​Name: NURS_6630_Week10_Assignment1_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_Week10_Assignment1_Rubric

 

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