NURS 6630 Assessing and Treating Patients With Sleep/Wake Disorders Essay

NURS 6630 Assessing and Treating Patients With Sleep/Wake Disorders Essay

NURS 6630 Assessing and Treating Patients With Sleep/Wake Disorders Essay

Assessing and Treating Patients with Sleep/Wake Disorders

Sleep is a crucial part of human existence, much like regular exercise and a healthy diet. Adults need between 6 and 8 hours of sleep per night on average, although individual needs may vary. No matter what the underlying cause of sleep loss is, insomnia may have negative effects on both a person’s physical and mental health. Insomnia is characterized by sleeplessness, frequent awakenings, and trouble falling asleep. As a result, patients may experience anxiety, fatigue, sleepiness, mood disturbances, and reduced cognitive performance.

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The patient in the provided case study is a 31-year-old male who suffers from insomnia. The patient has trouble falling asleep, and the symptoms progressively worsen. The symptoms were brought on by the emotional pain due to the death of his fiancée. The patient’s symptoms have significantly impacted his capacity to do his duties as a forklift operator. Insomnia was treated with diphenhydramine in his medical history. The patient began taking opiates four years ago after using hydrocodone for pain treatment. The patient consumes four beers before bed to help him sleep. The patient refuted any claims of experiencing hallucinations or harboring violent ideations.

The selection of the appropriate medication for prescription is contingent upon various patient-related factors. The patient under consideration is influenced by various factors, including his age, gender, and diagnosis of insomnia. The individual’s prior utilization of diphenhydramine, which resulted in unfavorable adverse reactions, will also be taken into account. The individual’s social history, which includes the experience of losing his fiancé, a history of opiate abuse, and the consumption of alcohol, will also exert a substantial influence on the selection of the most appropriate pharmaceutical intervention. The purpose of this paper is to elucidate the decision-making process involved in prescribing medication for the management of insomnia in young adult individuals, while also exploring the ethical considerations associated with each decision juncture.

Decision Point One

Selected Decision

 Administration of Trazodone 50 mg before bedtime.

Rationale

Trazodone was selected as the treatment since it is one of the most effective drugs for inducing and maintaining sleep. The FDA has approved the use of trazodone to treat insomnia (Pan et al., 2023). Trazodone inhibits the serotonin 5-HT2A receptor as a SARI (Muehlan et al., 2020). Trazodone has traditionally been used to treat the patient’s potential primary and secondary insomnia. Furthermore, studies indicate that utilizing low doses of trazodone to treat and manage insomnia has a high safety profile (Bragg et al., 2019; Zheng et al., 2020). Trazodone would thus allow the patient to manage sleep interruptions while focusing on his work.

The decision to not select zolpidem was influenced by its association with a sleep-related eating disorder (Pan et al., 2023). Zolpidem is associated with various adverse effects, including cognitive decline, hallucinations, diminished inhibitory control, somnolence, as well as gastrointestinal discomfort such as nausea and abdominal pain. Moreover, due to the resemblance of Hydroxyzine to the client’s diphenhydramine, it was not selected (Muehlan et al., 2020). In addition, the medication possesses sedative characteristics and induces urinary retention.

Expected Outcome

Within the next four weeks, the patient’s sleep quality and quantity are anticipated to improve with the administration of trazodone (Yue et al., 2023). Within this period, his ability to focus at work and his general quality of life should both increase (Begum et al., 2021).

Ethical Considerations

The moral considerations of beneficence and nonmaleficence have had an impact on the treatment approach and communication with the patient (Pan et al., 2023). Due to the ethical principle of beneficence, it was imperative to exert sufficient endeavors to assist, safeguard, and safeguard the patient from any potential harm. The prescription of the drug with the least number of adverse effects was made in a situation where malice was not present (Bragg et al., 2019).

Decision Point Two

Selected Decision

The trazodone dosage was decreased to 25 mg administered before sleep.

Rationale

The intervention is prompted by the patient’s claim over a period of two weeks that Trazodone, while effective, has notable negative effects, specifically in terms of prolonged penile erection. Based on the findings of Lancee et al. (2019), it is recommended that the administration of trazodone commence at lower dosages of 25 mg, followed by a gradual increase to 100 mg while observing patient outcomes. In addition, the pharmacokinetic property of trazodone, characterized by a half-life of approximately six to seven hours, contributes to its efficacy in promoting and sustaining sleep while minimizing adverse reactions, even at lower dosages. According to Zheng et al. (2020), there are commonly observed self-limiting side effects such as a reduction in both the quality and duration of sleep. Consequently, the optimal course of action involved reducing the dosage of Trazodone to 25mg and closely observing the patient’s progress over a period of two weeks.

Because the patient responded well to Trazodone, replacing it with Hydroxyzine or Suvorexant would not have been suitable (Muehlan et al., 2020). It has unintended repercussions, which may be reduced by a lower dosage (Yue et al., 2023). Suvorexant and Hydroxyzine are used to treat insomnia, however, they may lead to addiction and mental or physical degeneration. The patient may be in danger due to diminished cognitive and physical activities (Pan et al., 2023). As a result, commencing therapy with Suvorexant or Hydroxyzine may have negative consequences.

Expected Outcome

With a reduced dose of trazodone, the patient’s sleep is expected to improve with resolved side effects of priapism. Lowering doses of trazodone have proven to be equally effective in treating insomnia, with reduced incidences of side effects(Begum et al., 2021). The patient is expected to concentrate more at work with reduced sleepiness during the day.

Ethical Considerations

 According to Bragg et al. (2019), the concept of beneficence guarantees that medical personnel behave in the best interests of the patient, advocate for him, and protect him from harm. As a result, the dosage was lowered to safeguard patient safety by lowering priapism. Furthermore, since informed consent is required before initiating therapy, autonomy was critical. It is critical to assist the patient in comprehending the consequences of a dose reduction. The patient had faith in the information supplied and gave informed consent (McCall et al., 2019).

Decision Point Three

Selected Decision

 Maintain the current dosage of 25mg of trazodone at bedtime, while concurrently implementing strategies to enhance sleep hygiene.

Rationale

The patient reported receiving sufficient sleep; however, he also presented with priapism as an adverse reaction, thus necessitating a reduction in dosage. According to Pan et al. (2023), empirical evidence indicates that the implementation of psychotherapy interventions and the adoption of effective sleep hygiene practices are essential for enhancing both the overall well-being and the regulation of sleep patterns. Moreover, the patient must initiate specific modifications in their lifestyle, such as the reduction of alcohol and caffeine intake. Consequently, tailored interventions, such as psychotherapy, become indispensable in addressing these requirements (Muehlan et al., 2020). Therefore, the integration of non-pharmacological interventions alongside pharmaceutical therapy has the potential to enhance patient outcomes and safety profiles (Zheng et al., 2020).

The administration of a reduced dosage of Trazodone resulted in an amelioration of the patient’s sleep quality, concurrently mitigating the occurrence of priapism as an adverse effect. The discontinuation of the drug was deemed unnecessary in this particular situation (Yue et al., 2023). According to Pan et al. (2023), the use of Ramelteon and Hydroxyzine is not advised due to their potential side effects, including fatigue and withdrawal symptoms, which may negatively impact daily functioning.

Expected Outcome

It is expected that the patient’s sleep habits and quality will improve with the implementation of therapy and adherence to sleep hygiene practices (Yue et al., 2023). To ensure the continued effectiveness of Trazodone and the maintenance of a healthy sleep routine, a subsequent consultation may entail an assessment of the patient’s sleep hygiene, as outlined by Pan et al. (2023). 

Ethical Consideration

The ethical principle of autonomy plays a crucial role in therapy as it necessitates obtaining informed consent before commencing any treatment (Bragg et al., 2019). To promote adherence to the treatment regimen, it is imperative to assess and provide guidance regarding the patient’s sleep patterns. Yue et al. (2023) emphasized the importance of recommending abstinence from alcohol as a means to improve an individual’s overall well-being.

Conclusion

The client in this case is a 31-year-old male suffering from insomnia. Insomnia is characterized by sleep deprivation, awakenings frequently, and difficulty falling asleep. According to Yue et al. (2023), it was suggested to begin treatment by prescribing daily doses of 50 mg of Trazodone before bed. The FDA has approved Trazodone for insomnia. According to Bragg et al. (2019), it is a SSRI that inhibits the serotonin 5-HT2A receptor in managing insomnia. The second intervention was to reduce the dose of trazodone from 50mg to 25 mg at bedtime. Although Trazodone is effective, the patient claims that it caused priapism affecting the patient’s quality of life. The third intervention was to continue the same dose of trazodone and advise the patient on sleep hygiene.

The administration of zolpidem and hydroxyzine for the management of insomnia was refrained from due to their correlation with sleep-related eating disorders and their possession of antihistamine properties, respectively. Furthermore, the administration of zolpidem has been found to induce adverse effects such as memory impairment, hallucinations, reduced inhibitory control, dizziness, vertigo, and gastrointestinal discomfort. According to Pan et al. (2023), the sedative properties of hydroxyzine have been associated with the occurrence of urinary retention.

The ethical principles of beneficence, autonomy, and non-maleficence affected the treatment plan and the patient’s communication. Aware of the beneficence principle, it was necessary to act in a way that assisted, defended, and protected the patient from damage (Muehlan et al., 2020). Since informed consent is required before beginning treatment, the concept of autonomy was crucial. Finally, the principle of nonmaleficence was applied when choosing the medication with the fewest adverse effects.

References

Begum, M., Gonzalez-Chica, D., Bernardo, C., Woods, A., & Stocks, N. (2021). Trends in the prescription of drugs used for insomnia: an open-cohort study in Australian general practice, 2011–2018. British Journal of General Practice, 71(712), e877–e886. https://doi.org/10.3399/BJGP.2021.0054

Bragg, S., Benich, J., Christian, N., Visserman, J., & Freedy, J. (2019). Updates in insomnia diagnosis and treatment. The International Journal of Psychiatry in Medicine, 54(4-5), 275–289. https://doi.org/10.1177/0091217419860716

Lancee, J., Effting, M., van der Zweerde, T., van Daal, L., van Straten, A., & Kamphuis, J. H. (2019). Cognitive processes mediate the effects of insomnia treatment: evidence from a randomized wait-list controlled trial. Sleep Medicine, 54, 86–93. https://doi.org/10.1016/j.sleep.2018.09.029

McCall, W. V., Benca, R. M., Rosenquist, P. B., Youssef, N. A., McCloud, L., Newman, J. C., Case, D., Rumble, M. E., Szabo, S. T., Phillips, M., & Krystal, A. D. (2019). Reducing Suicidal Ideation Through Insomnia Treatment (REST-IT): A Randomized Clinical Trial. American Journal of Psychiatry, app. app.2019.1. https://doi.org/10.1176/appi.ajp.2019.19030267

‌Muehlan, C., Vaillant, C., Zenklusen, I., Kraehenbuehl, S., & Dingemanse, J. (2020). Clinical pharmacology, efficacy, and safety of orexin receptor antagonists for the treatment of insomnia disorders. Expert Opinion on Drug Metabolism & Toxicology, 16(11), 1063–1078. https://doi.org/10.1080/17425255.2020.1817380

Pan, B., Ge, L., Lai, H., Hou, L., Tian, C., Wang, Q., Yang, K., Lu, Y., Zhu, H., Li, M., Wang, D., Li, X., Zhang, Y., Gao, Y., Liu, M., Ding, G., Tian, J., & Yang, K. (2023). The Comparative Effectiveness and Safety of Insomnia Drugs: A Systematic Review and Network Meta-Analysis of 153 Randomized Trials. 83(7), 587–619. https://doi.org/10.1007/s40265-023-01859-8

Yue, J.-L., Chang, X.-W., Zheng, J.-W., Shi, L., Xiang, Y.-J., Que, J.-Y., Yuan, K., Deng, J.-H., Teng, T., Li, Y.-Y., Sun, W., Sun, H.-Q., Vitiello, M. V., Tang, X.-D., Zhou, X.-Y., Bao, Y.-P., Shi, J., & Lu, L. (2023). Efficacy and tolerability of pharmacological treatments for insomnia in adults: A systematic review and network meta-analysis. Sleep Medicine Reviews, 68, 101746. https://doi.org/10.1016/j.smrv.2023.101746

Zheng, X., He, Y., Yin, F., Liu, H., Li, Y., Zheng, Q., & Li, L. (2020). Pharmacological interventions for the treatment of insomnia: Quantitative comparison of drug efficacy. Sleep Medicine. https://doi.org/10.1016/j.sleep.2020.03.022

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Assessing and Treating Patients With Sleep/Wake Disorders

Sleep disorders are conditions that result in changes in an individual’s pattern of sleep (Mayo Clinic, 2020). Not surprisingly, a sleep disorder can affect an individual’s overall health, safety, and quality of life. Psychiatric nurse practitioners can treat sleep disorders with psychopharmacologic treatments, however, many of these drugs can have negative effects on other aspects of a patient’s health and well-being. Additionally, while psychopharmacologic treatments may be able to address issues with sleep, they can also exert potential challenges with waking patterns. Thus, it is important for the psychiatric nurse practitioner to carefully evaluate the best psychopharmacologic treatments for patients that present with sleep/wake disorders.

Reference: Mayo Clinic. (2020). Sleep disorders. https://www.mayoclinic.org/diseases-conditions/sleep-disorders/symptoms-causes/syc-20354018

Resources

Be sure to review the Learning Resources before completing this activity.

Click the weekly resources link to access the resources.

WEEKLY RESOURCES

Learning Resources

Required Readings

Stahl, S. M. (2021). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (5th Ed.) Cambridge University Press.

Chapter 10, “Disorders of Sleep and Wakefulness and Their Treatment: Neurotransmitter Networks for Histamine and Orexin” (pp. 401-448)

American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders

Links to an external site. (5th ed., text rev.). https://go.openathens.net/redirector/waldenu.edu?url=https://dsm.psychiatryonline.org/doi/book/10.1176/appi.books.9780890425787

Fernandez-Mendoza, J., & Vgontzas, A. N. (2013). Insomnia and its impact on physical and mental health.

Current Psychiatry Reports

Links to an external site., 15(12), 418. https://doi.org/10.1007/s11920-012-0418-8

Levenson, J. C., Kay, D. B., & Buysse, D. J. (2015). The pathophysiology of insomnia. Chest

Links to an external site., 147(4), 1179–1192. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4388122/

Morgenthaler, T. I., Kapur, V. K., Brown, T. M., Swick, T. J., Alessi, C., Aurora, R. N., Boehlecke, B., Chesson, A. L., Friedman, L., Maganti, R., Owens, J., Pancer, J., & Zak, R. (2007). Practice parameters for the treatment of narcolepsy and other hypersomnias of central origin. SLEEP

Links to an external site., 30(12), 1705–1711. https://j2vjt3dnbra3ps7ll1clb4q2-wpengine.netdna-ssl.com/wp-content/uploads/2017/07/PP_Narcolepsy.pdf

Morgenthaler, T. I., Owens, J., Alessi, C., Boehlecke, B, Brown, T. M., Coleman, J., Friedman, L., Kapur, V. K., Lee-Chiong, T., Pancer, J., & Swick, T. J. (2006). Practice parameters for behavioral treatment of bedtime problems and night wakings in infants and young children. SLEEP

Links to an external site., 29(1), 1277–1281. https://j2vjt3dnbra3ps7ll1clb4q2-wpengine.netdna-ssl.com/wp-content/uploads/2017/07/PP_NightWakingsChildren.pdf

Sateia, M. J., Buysse, D. J., Krystal, A. D., Neubauer, D. N., & Heald, J. L. (2017). Clinical practice guideline for the pharmacologic treatment of chronic insomnia in adults: An American Academy of Sleep Medicine clinical practice guideline. Journal of Clinical Sleep Medicine

Links to an external site., 13(2), 307–349. https://jcsm.aasm.org/doi/pdf/10.5664/jcsm.6470

Winkleman, J. W. (2015). Insomnia disorder. The New England Journal of Medicine

Links to an external site., 373(15), 1437–1444. https://doi.org/10.1056/NEJMcp1412740

Medication Resources

U.S. Food & Drug Administration. (n.d.). Drugs@FDA: FDA-approved drugs

Links to an external site.. https://www.accessdata.fda.gov/scripts/cder/daf/index.cfm

Links to an external site.

Note: To access the following medications, use the Drugs@FDA resource. Type the name of each medication in the keyword search bar. Select the hyperlink related to the medication name you searched. Review the supplements provided and select the package label resource file associated with the medication you searched. If a label is not available, you may need to conduct a general search outside of this resource provided. Be sure to review the label information for each medication as this information will be helpful for your review in preparation for your Assignments.

alprazolam

amitriptyline

amoxapine

amphetamine

desipramine

diazepam

doxepin

eszopiclone

flunitrazepam

flurazepam

hydroxyzine

imipramine

lemborexant

lorazepam

melatonin

methylphenedate

modafinil

armodafinil

carnitine

clomipramine

clonazepam

nortriptyline

pitolisant

ramelteon

sodium oxybate

solriamfetol

SSRI’s

temazepam

trazodone

triazolam

trimipramine

wellbutrin

zaleplon

zolpidem

Required Media

Case study: Pharmacologic approaches to the treatment of insomnia in a younger adult

Links to an external site.

Note: This case study will serve as the foundation for this week’s Assignment.

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 sleep/wake disorders.

The Assignment: 5 pages

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

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

Introduction to the case (1 page)

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

Decision #1 (1 page)

Which decision did you select?

Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.

Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.

What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).

Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.

Decision #2 (1 page)

Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.

Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.

What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).

Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.

Decision #3 (1 page)

Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.

Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.

What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).

Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.

Conclusion (1 page)

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

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

Reminder : The College of Nursing requires that all papers submitted include a title page, introduction, summary, and references. The Sample Paper provided at the Walden Writing Center provides an example of those required elements (available at https://academicguides.waldenu.edu/writingcenter/templates/general#s-lg-box-20293632). All papers submitted must use this formatting

Links to an external site..

By Day 7

Submit your Assignment.

submission information

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To submit your completed assignment, save your Assignment as WK8Assgn2_LastName_Firstinitial

Then, click on Start Assignment near the top of the page.

Next, click on Upload File and select Submit Assignment for review.

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