NUR 6630 Assessing and Treating Patients with Sleep/Wake Disorders

NUR 6630 Assessing and Treating Patients with Sleep/Wake Disorders

NUR 6630 Assessing and Treating Patients with Sleep/Wake Disorders

Sleep disorders are crucial concerns that psychiatric mental health nurse practitioners (PMHNP) experience in their practice. Disorders such as insomnia affect the quality of life of the patients. PMHNP collaborate with their patients and other healthcare providers to develop patient-centered interventions that facilitate optimum symptom management and improved functioning. The development of the treatment plan considers patient factors and ethics of psychiatric practice. Therefore, the purpose of this paper is to explore a case study of a patient who has been diagnosed with insomnia. The essay develops treatment plan based on the given options, explores the ethical considerations that may affect the treatment, and patient factors that should guide the treatment.

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The patient in the case study is a 31-year-old male that comes to the office with complaints of insomnia. The patient reports that insomnia has progressively worsen over the past six months. He has never been a great sleeper and is now having trouble in falling asleep and staying asleep at night. The problem started six months ago after he lost his fiancé. Insomnia has affected his ability to perform optimally at his job as a forklift operator at a local company. He has a history of diphenhydramine to sleep, which he did not like the way it made him feel. He reports that he has fallen asleep on the job because of the lack of sleep the night before. The patient’s medical record shows that he has a history of opiate abuse. He also reports recent use of alcohol to help him fall asleep. He takes about four beers before bed. Therefore, the patient’s experience with diphenhydramine, opiate abuse, and alcohol use will inform the treatment decisions that would be made in this case study.

Decision 1

Selected Decision

Trazodone 50 mg PO at bedtime.

Why the Decision was Selected

I selected the decision to start the patient on Trazodone 50 mg PO at bedtime because it is the most recommended drug for insomnia among those in the option list. Trazodone is an antidepressant that is largely used for insomnia than it is for depression. At a dosage of 50 mg, Trazodone antagonizes histamine and alpha-1 adrenergic receptors to produce hypnotic effect. The hypnosis induces and maintains sleep without causing any complaints of daytime drowsiness or tolerance because of its short half-life (Wang et al., 2020). Evidence-based data consistently support the use of Trazodone in the treatment of insomnia. For example, Trazodone has been found to prolong sleep time among the affected populations. It also increases sleeping efficiency and eliminates daytime drowsiness seen in the use of benzodiazepines. Trazodone also has low response and remission rates of insomnia, which make it the most desirable drug for insomnia(Sys et al., 2020). Trazodone has also demonstrates its effectiveness in the treatment of primary and secondary insomnia.

Why the Other Two Options Were not Selected

Zolpidem 10 mg daily at bedtime was not selected as the first option of treating the patient’s insomnia despite being approved by the Food and Drug Administration. Zolpidem is a benzodiazepine. Evidence has associated the use of benzodiazepines with side and adverse effects such as next day drowsiness and sleepiness. Benzodiazepines also have a high risk of abuse, psychomotor impairment, and dizziness. These side effects are likely to affect the patient’s work functioning as a forklift operator, hence, not selecting its use(Sys et al., 2020). Hydroxyzine 50 mg daily at bedtime was not selected because the client has a negative experience with it. Its administration is likely to affect treatment compliance and outcomes.

What I was Hoping to Achieve

I was hoping that the client would report prolonged sleep duration, quality, and quantity because of the effects of Trazodone. I was also hoping Trazodone would eliminate next day sleepiness being experienced by the patient. I also intended to improve his social and occupational functioning with the above decision(Shah et al., 2021).

Impact of Ethical Considerations

PMHNPs should promote autonomy in their practice. They should prioritize patients’ needs, values, and preferences when developing treatment plans. They should also seek informed consent before initiating them on treatments. The patient in the case study reported a negative experience with diphenhydramine. As a result, it was considered in treatment selection to promote autonomous care(Hughes, 2023). His decision to reject the selected treatment would affect his care trajectory.

Decision 2

Selected Decision

Explain that an erection lasting 15 minutes is not considered a priapism and should diminish over time, continue with current dose.

Why the Decision was Selected

I made the above decision because the patient’s complain is a common side effect associated with Trazodone. Trazodone is associated with an increased risk of prolonged erections as well as priapism. However, the client’s complaint is a prolonged erection and not priapism. Prolonged erection with the use of Trazodone diminishes over time, as the patient tolerates the treatment(Pelayo et al., 2023). Therefore, Shah et al., (2021) recommend the need for healthcare providers to educate patients about the anticipated side and adverse effects associated with Trazodone and the need to seek healthcare should they experience worrying signs such as priapism.

Why the Other Two Options Were not Selected

The decisions to discontinue Trazodone and initiate therapy with suvorexant 10 mg daily at bedtime and decrease Trazodone to 25 mg daily at bedtime were not selected. This is because the patient returned to the clinic after two weeks with reports of improved sleep problem. The patient reported that the medication works well besides the side effect of giving him an erection lasting about 15 minutes after waking. The patient also denied auditory or visual hallucinations and his thought process was future oriented. This implies that he has not developed adverse effects of Trazodone. Discontinuing Trazodone at this time would increase the risk of symptom relapse and adverse reaction to suvorexant. There is also no indication for discontinuing the treatment. The optimum therapeutic effectiveness of Trazodone has not been achieved. As a result, decreasing Trazodone to 25 mg daily at bedtime is not indicated, as it will lead to relapse of symptoms of insomnia(Wang et al., 2020).

What I was Hoping to Achieve

I was hoping that the client’s complaint of prolonged erection would diminish with time as he tolerates the drug. I was also hoping that he would report further improvements in sleep quality, quantity, and social and occupational functioning(Sys et al., 2020).

Impact of Ethical Considerations

PMHNPs should promote quality and safety in the treatment of their patients. They should make decisions that do not predispose patients to unintended harm. They should rely on practice and clinical guidelines to make informed decisions. Through it, PMHNPs would ensure non-maleficence and beneficence in their practice. The treatment decisions in this step aimed at preventing any case of symptom relapse or adverse reactions for the patients(Hughes, 2023). Therefore, safety and quality in insomnia management were promoted.

Decision 3

Selected Decision

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

Why the Decision was Selected

I made the above decision because the patient returned to the office after two weeks reporting further improvement in his symptoms of insomnia. The patient reports that priapism has diminished over time. He also denies any visual or auditory hallucinations. His thought process is future oriented. The patient reports that Trazodone is effect at 50 mg dose but sometimes wakes up following day with next-day drowsiness. The patient’s report shows that Trazodone has led to moderate improvement in his symptoms. The occasional experience of following day drowsiness indicates that the optimum therapeutic level of Trazodone has been reached. As a result, it would be appropriate for him to split the 50 mg tablet of Trazodone to minimize this side effect(Wang et al., 2020).

Why the Other Two Options Were not Selected

I did not select the decision to discontinue Trazodone, initiate therapy with sonata 10 mg nightly at bedtime, and follow up in 4 weeks. The patient reports optimum improvement in insomnia symptoms. The improvement rules out any need for a change in the treatment plan. Trazodone should also not be discontinued abruptly but tapered off to minimize the risk of harm and symptom relapse(Pochiero et al., 2022). Similarly, I did not select the decision to discontinue Trazodone, initiate therapy with hydroxyzine 50 mg at bedtime, and follow up in four weeks because of the above symptoms.

What I was Hoping to Achieve

I was hoping to sustain the improvement in insomnia symptoms. I was also hoping that the patient’s experience of priapism would diminish completely as the patient tolerates Trazodone. I was also expecting that splitting the 50 mg tablet into two would eliminate the next day drowsiness the patient experiences occasionally.

Impact of Ethical Considerations

PMHNPs must consider the benefits and risks of the different treatments for insomnia. The focus should be on selecting a treatment that is associated with maximum benefits and minimal risk of harm to the patients. PMHNPs must also protect the confidentiality of the patient’s data. This can be achieved by ensuring privacy and confidentiality of the information(Hughes, 2023). A breach of confidentiality and privacy requirements would result in legal and ethical issues in nurses’ practice.

Conclusion

The use of Trazodone was effective in managing the symptoms of insomnia. Trazodone is largely used for insomnia despite it being an antidepressant. Trazodone has been shown to improve sleep quality, quantity, duration, and functioning. It is not associated with next day drowsiness. These benefits informed the decision to initiate the patient on Trazodone. The given options were not selected in step one because of the known side and adverse effects of Zolpidem and the patient’s experience with diphenhydramine. Trazodone continued to demonstrate improved symptoms in the second step. This led to the decision to reject the other options that aimed at discontinuing the therapy and starting the patient on a new treatment. Prolonged erection is an expected side effect of Trazodone(Rios et al., 2019; Wichniak et al., 2021). However, the treatment could have been changed should the patient have experienced priapism. In the third stage, the decision to split Trazodone 50 mg tablet into two resulted in the desired treatment outcomes.

Ethical considerations informed the treatment decisions. One of them is the need for the promotion of data integrity. PMHNPs should protect privacy and confidentiality of data of their patients. They should ensure unauthorized parties do not access the patient’s data without seeking their informed consent. The need for the promotion of beneficence and non-maleficence also informed the decisions made. The PMHNP aimed at selecting treatments that are associated with maximum benefits and minimal potential of harm(Hughes, 2023). The PMHNP also relied on best practice guidelines and sources of evidence-based data to select the treatments for the patient in the case study.

References

Hughes, J. (2023). Ebook: Dementia and Ethics Reconsidered. McGraw-Hill Education (UK).

Pelayo, R., Bertisch, S. M., Morin, C. M., Winkelman, J. W., Zee, P. C., & Krystal, A. D. (2023). Should Trazodone Be First-Line Therapy for Insomnia? A Clinical Suitability Appraisal. Journal of Clinical Medicine, 12(8), Article 8. https://doi.org/10.3390/jcm12082933

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

Rios, P., Cardoso, R., Morra, D., Nincic, V., Goodarzi, Z., Farah, B., Harricharan, S., Morin, C. M., Leech, J., Straus, S. E., & Tricco, A. C. (2019). Comparative effectiveness and safety of pharmacological and non-pharmacological interventions for insomnia: An overview of reviews. Systematic Reviews, 8(1), 281. https://doi.org/10.1186/s13643-019-1163-9

Shah, T., Deolanker, J., Luu, T., & Sadeghi-Nejad, H. (2021). Pretreatment screening and counseling on prolonged erections for patients prescribed trazodone. Investigative and Clinical Urology, 62(1), 85–89. https://doi.org/10.4111/icu.20200195

Sys, J., Van Cleynenbreugel, S., Deschodt, M., Van der Linden, L., & Tournoy, J. (2020). Efficacy and safety of non-benzodiazepine and non-Z-drug hypnotic medication for insomnia in older people: A systematic literature review. European Journal of Clinical Pharmacology, 76(3), 363–381. https://doi.org/10.1007/s00228-019-02812-z

Wang, J., Liu, S., Zhao, C., Han, H., Chen, X., Tao, J., & Lu, Z. (2020). Effects of Trazodone on Sleep Quality and Cognitive Function in Arteriosclerotic Cerebral Small Vessel Disease Comorbid With Chronic Insomnia. Frontiers in Psychiatry, 11. https://www.frontiersin.org/articles/10.3389/fpsyt.2020.00620

Wichniak, A., Wierzbicka, A. E., & Jarema, M. (2021). Treatment of insomnia—Effect of trazodone and hypnotics on sleep. Psychiatria Polska, 55(4), 743–755. https://doi.org/10.12740/pp/125650

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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

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. 

Resources:

• 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 (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, 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, 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, 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, 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, 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, 373(15), 1437–1444. https://doi.org/10.1056/NEJMcp1412740