NURS 6630 Case Elderly Widow Who Just Lost her Spouse Discussion Essay
NURS 6630 Case Elderly Widow Who Just Lost her Spouse Discussion Essay
NURS 6630 Case Elderly Widow Who Just Lost her Spouse Discussion Essay
Treatment for a Patient with a Common Condition
Treatment for a Patient with a Common Condition
Health assessment is essential in the diagnosis and patient management. For this 75-year-old patient with insomnia, there are various questions to ask that will aid in the diagnosis and management of her problem. The goal is to establish the cause of her problem and derive a cause-effect relationship. The questions to ask her include:”
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- Do you take her medications as prescribed? Failing to take the antidepressant sertraline might aggravate the symptoms of insomnia and depression.
- Do you have trouble initiating sleeping, night awakening, or waking up early? The question helps identify the type of insomnia and inform their management.
- Do you sleep during the day? How many hours do you sleep each day? The questions will help confirm the diagnosis. Sleep during the day can affect sleep at night, and the number of hours is significant in insomnia diagnosis (Dolpheide, 2020).
- Describe your day-to-day relationship with friends and family. Grief can escalate the patient’s MDD, causing them to self-isolate and worsening their depressive state.
Several individuals in the patient’s life can provide critical information for the patient’s management. Her children are essential resource persons. Questions include; Have you noticed any physical/mental changes with your mother? These questions help to ascertain her claims and the doctor’s suspicions, such as suicide ideations. Another important person is the caregiver. Essential questions include; Does the patient take her medication as instructed? It will help rule out depression caused by neglecting medication.
Physical Exam and Diagnostic Tests
A physical exam and health history help determine underlying problems, while diagnosis tests help confirm diagnosis accurately. One of the diagnostic tools to use is the Patient Health Questionnaire- (PHQ-9). This tool is used to estimate the severity of depression (Sun et al., 2020). It is governed by the DSM 5 guideline that aids in correctly diagnosing mental disorders. Additional testing will include Neuropsychological testing. It will help diagnose any underlying psycho-cognitive issues and differentiate them from those caused by aging.
Differential Diagnosis
The differential diagnosis includes major depressive disorder, post-traumatic stress disorder, PTSD, and adjustment disorder. It compounds symptoms similar to those the patient manifests, such as anxiety, depression, and insomnia. The patient’s history with grief (loss of a loved one) and the onset of these symptoms function as triggers of PTSD. However, he lacks the recurrent memories associated with PTSD. The most appropriate diagnosis is Chronic Adjustment Disorder with Depression. The patient was unable to cope with the death of her husband, and the depression and insomnia worsened ever since (within three months of the occurrence) and persisted for more than six months hence meeting the criteria (O’Donnell et al., 2019)
Pharmacologic Interventions, Rationale for Selecting One, and Contraindications
The selected intervention is Paroxetine 5-10ml once a day. Paroxetine is an antidepressant, particularly a selective serotonin reuptake inhibitor (SSRI). It is used in the treatment of anxiety and depression. It functions by increasing the production of serotonin in the synapse. Amoxapine 50mg, twice or thrice daily, is the second option. The antidepressant falls under tricyclic antidepressants (TCA), which work by inhibiting the reuptake of serotonin and antagonizing receptor activity (Davidson, 2015). Of the two, Paroxetine is preferable because Amoxapine elicits more devastating side effects, such as arrhythmia and mood changes. Paroxetine is contraindicated with the concurrent use of MAOIs causing serotonin syndrome characterized by severe hypertension. It is contraindicated with TCA medications since it inhibits TCA metabolism while affecting hepatic metabolism. It is essential to monitor any weight gain, heart rate, and blood pressure every four weeks, and significant changes in any of these factors could warrant therapy changes. Insomnia is often a characteristic of an underlying condition, and thorough patient assessment is vital for accurate diagnosis and effective management.
References
Davidson, J. (2015). Vintage treatments for PTSD: A reconsideration of Tricyclic Drugs. Journal of Psychopharmacology, 29(3), 264–269. https://doi.org/10.1177/0269881114565143
Dopheide, J. A. (2020). Insomnia overview: epidemiology, pathophysiology, diagnosis and monitoring, and nonpharmacologic therapy. The American journal of managed care, 26(4 Suppl), S76-S84. https://doi.org/10.37765/ajmc.2020.42769
O’Donnell, M. L., Agathos, J. A., Metcalf, O., Gibson, K., & Lau, W. (2019). Adjustment disorder: Current developments and future directions. International journal of environmental research and public health, 16(14), 2537. https://doi.org/10.3390/ijerph16142537
Sun, Y., Fu, Z., Bo, Q., Mao, Z., Ma, X., & Wang, C. (2020). The reliability and validity of PHQ-9 in patients with major depressive disorder in a psychiatric hospital. BMC Psychiatry, 20(1), 474. https://doi.org/10.1186/s12888-020-02885-6
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Case: An elderly widow who just lost her spouse.
Subjective: A patient presents to your primary care office today with chief complaint of insomnia. Patient is 75 YO with PMH of DM, HTN, and MDD. Her husband of 41 years passed away 10 months ago. Since then, she states her depression has gotten worse as well as her sleep habits. The patient has no previous history of depression prior to her husband’s death. She is awake, alert, and oriented x3. Patient normally sees PCP once or twice a year. Patient denies any suicidal ideations. Patient arrived at the office today by private vehicle. Patient currently takes the following medications:
Metformin 500mg BID
Januvia 100mg daily
Losartan 100mg daily
HCTZ 25mg daily
Sertraline 100mg daily
Current weight: 88 kg
Current height: 64 inches
Temp: 98.6 degrees F
BP: 132/86
List three questions you might ask the patient if she were in your office. Provide a rationale for why you might ask these questions.
Identify people in the patient’s life you would need to speak to or get feedback from to further assess the patient’s situation. Include specific questions you might ask these people and why.
Explain what, if any, physical exams, and diagnostic tests would be appropriate for the patient and how the results would be used.
List a differential diagnosis for the patient. Identify the one that you think is most likely and explain why.
List two pharmacologic agents and their dosing that would be appropriate for the patient’s antidepressant therapy based on pharmacokinetics and pharmacodynamics. From a mechanism of action perspective, provide a rationale for why you might choose one agent over the other.
For the drug therapy you select, identify any contraindications to use or alterations in dosing that may need to be considered based on ethical prescribing or decision-making. Discuss why the contraindication/alteration you identify exists. That is, what would be problematic with the use of this drug in individuals based on ethical prescribing guidelines or decision-making?
Include any “check points” (i.e., follow-up data at Week 4, 8, 12, etc.), and indicate any therapeutic changes that you might make based on possible outcomes that may happen given your treatment options chosen.
Respond to at least two of your colleagues on two different days in one of the following ways:
If your colleagues’ posts influenced your understanding of these concepts, be sure to share how and why. Include additional insights you gained.
If you think your colleagues might have misunderstood these concepts, offer your alternative perspective and be sure to provide an explanation for them. Include resources to support your perspective. Read a selection of your colleagues’ responses and respond to at least two of your colleagues on two different days.
