NURS 6630 Week 8: Assessing and Treating Patients with Sleep/Wake Disorders Assignment 2 Paper

NURS 6630 Week 8: Assessing and Treating Patients with Sleep/Wake Disorders Assignment 2 Paper

NURS 6630 Week 8: Assessing and Treating Patients with Sleep/Wake Disorders Assignment 2 Paper

Assessing and Treating Patients with Sleep/Wake Disorders
Sleep disorders can potentially affect an individual’s life. Sleep disorders often result from other underlying health conditions, such as depression or medications like dopamine agonists, and present as difficulty initiating or maintaining sleep (APA, 2013). Sleep disorders can interfere with the quality of life, social interactions, productivity, and patient safety. Problems sleeping at night can also result from other factors, such as activities and sleep during the day. Psychiatric/mental health practitioners evaluate and manage patients individually based on their presenting problems. This paper analyzes the case of a patient with a sleep/wake disorder and addresses the initial and subsequent management till symptom resolution.

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The 31-year-old client in this case study complains that his insomnia symptoms have worsened progressively over the last six months, and he has trouble falling and staying asleep at night. The problem worsened six months ago when he lost his fiancé, negatively affecting He reports safety concerns after falling asleep at the job due to a lack of sleep at night. He reports using diphenhydramine to fall asleep, but the side effects made him stop the medication. He used alcohol to help him fall asleep, about four beers before bedtime. The medical records show that he had a skiing accident for which she has prescribed opiates for pain and which led to opiate dependence, but he has been free for four years now. The patient’s mental state exams show that he is well-oriented. There are various areas of concern for this patient. The first concern is to ensure adequate sleep and eliminate daytime sleepiness for safety purposes. Social relationships are also a problem, and there is a need to eliminate the client’s alcohol use problem. Given the patient’s current concerns about keeping his job and being safe, the medications used should have a short onset of action. The primary focus is the management decisions, their outcomes, and the influence of the outcomes on other decisions.
Decision Point 1
There are several treatment options, and the first choice is to initiate therapy with Trazodone 50mg. The choices made are based on evidence from research on the choices’ efficacy in insomnia management and FDA approval. The goals of the therapy session are to improve night-time sleep, reduce daytime sleepiness, improve productivity, eliminate the need for alcohol intake, and improve workplace safety. The ethical considerations include adherence because the history of the patients shows poor adherence to intervention based on side effects and perceived efficacy of the interventions. The goal is to use an effective medication with minimal side effects. Trazodone balances serotonin levels in the brain, which is significant to the patient’s insomnia management. According to Pochiero et al. (2020), trazodone improves daytime functioning and sleep quality in insomnia patients. Wichniak et al. (2022) note that trazodone helps manage primary insomnia symptoms by reducing the time falling asleep and helps patients maintain sleep.
Mittal et al. (2021) note that Zolpidem side effects include complex sleep behaviors, especially when taking high doses, but the medication is more effective than other interventions, such as benzodiazepines. It has hypnotic properties, and it is FDA-approved. However, the medication is given to patients when other interventions, such as cognitive behavioral therapy, sleep hygiene, and other medical interventions. Mittal et al. (2021) note that the medication is avoided due to its side effects, such as cognitive impairment, dependence, and recurring insomnia symptoms.
The third option is hydroxyzine, an off-label drug for short-term primary insomnia management. It is an antihistamine approved for anxiety and not FDA-approved for insomnia. Hydroxyzine is a Hi-receptor antagonist with serotonergic activity hence its anxiolytic, antiemetic, and sedative-hypnotic properties (Burgazli et al., 2023). Available evidence shows that the medication is moderately effective, and studies show mixed efficacy of the drug (Burgazli et al., 2023). Krzystaniek et al. (2020) note that hydroxyzine has undesirable side effects such as headache, drowsiness, dry mouth, somnambulism, fatigue, and undesirable headaches that can affect individual adherence to the medication. The patient is a forklift operator, and recent incidences of sleeping while on the job can worsen due to the drowsiness and fatigue effects of the drug. These factors, from side effects to efficacy issues, eliminate the choice of therapy change to hydroxyzine.
Decision Point Two
The patient returned to the facility two weeks after initiating Trazodone 50mg, reporting that the medication effectively managed his insomnia symptoms. However, he experienced an erection after waking up for about 15 minutes. The erection was undesirable for him because his work preparation schedule was delayed. He could not join his girlfriend or daughter for breakfast affecting his social life. The goals of the decisions at this point are to ensure patient remission and elimination of the side effects/. Side effects are concurrent with the dosages of drugs, and increasing the drug above the minimum licensed dosage may have little to no clinical efficacy but increases the risk for side effects (Babaei et al., 2023). Trazodone 50mg is a high dose prone to other side effects. A prolonged erection of 15 minutes is not priapism because priapism is an erection that lasts for more than 4 hours with no sexual stimulation. While prolonged erection can disappear independently, trazodone worsens the patients’ social life and preparation for work, eliminating the first decision (Shah et al., 2021).
The ethics involved included respect for autonomy and beneficence. It is crucial to explain the cause of the prolonged erection and the options at hand, considering that the patient can select an intervention guided by the care provider. The third option is discontinuing trazodone and initiating therapy with suvorexant 10mg at bedtime. The medication is FDA-approved for insomnia, but at this pout, the patient does not present with any factors requiring changes in therapy. He is already responding to the initial therapy hence no need for change. The patient has been on trazodone for two weeks only, and the medication is effective and has a manageable side effect. At this point, the patient should be given a four weeks appointment for evaluation and further decisions.
Decision 3
The patient came to the clinic a third time after four weeks. After reducing the trazodone dose from 50 to 25 mg at bedtime, the patient has remission from the prolonged erection symptom. The patient reports that the complex sleep behaviors have disappeared, but the dose is insufficient for adequate sleep. The patient has achieved partial remission, and the symptoms have been managed (prolonged erection has subsided). The decision chosen is to initiate sleep hygiene, a clinic in four weeks, and continue the dose of 25mg trazodone. Manzar et al. (2020) note that sleep hygiene practices are the frontline management interventions in primary insomnia and help improve the efficacy of other interventions. Sleep hygiene practices help patients initiate sleep and eliminate activities that may prevent falling or staying asleep. These practices include avoiding TV or phones in the bedroom, avoiding sleeping during the day, ensuring a quiet bedroom environment, and taking meals at least 2 hours before bedtime (Manzar et al., 2020). This decision aims to retain the efficacy of care interventions while ensuring patients do not develop undesirable side effects. Another essential goal in this decision point is to reduce the risk of medication dependence and symptom relapse.
The therapy has achieved the desired remission; thus, starting another medication is unnecessary. Ramelteon and hydroxyzine are effective against insomnia, but no reason or indication could lead to changes in therapy. Other issues, such as drug interactions, could also arise in this patient. The indications for therapy changes include reactions to a medication, non-remission of symptoms, or disabling side effects of the medication. The ethical considerations here are non-maleficence and beneficence, where the decision is to eliminate the risk of side effects in the patients while ensuring total remission of the symptoms. Medication adherence at this point is essential because patients do not perceive interventions as practical or necessary. They tend to reduce medication adherence, precipitating poor patient outcomes and worsening symptoms.
Summary
The client’s mental health issue threatens their quality of life and the safety of themselves and others. The first choice was trazodone 50mg, a potent medication for insomnia. The other options are avoided due to their side effects. After four weeks, the patient presents with drug side effects such as complex sleep problems and a prolonged erection affecting their preparation time. The intervention of choice is to reduce the dose of trazodone to 25mg to eliminate the side effects. The patient has no reason to change therapy to another medication at this point. The third decision is to continue trazodone 25mg, initiate sleep hygiene, and review after four weeks. Sleep therapy is an adjunct to medications and other interventions and can be used only in patients with primary insomnia. At four weeks, the TCA will help reevaluate the patient to determine remission, development of side effects, or eliminate symptom relapse. Payment went management should consider various factors, such as the efficacy of medications and their side effects, to ensure they achieve the desired outcomes among their patients.
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disordersLinks to an external site. (5th ed.). https://doi.org/10.1176/appi.books.9780890425596
Babaei, M., Evers, T. M., Shokri, F., Altucci, L., de Lange, E. C., & Mashaghi, A. (2023). Biochemical reaction network topology defines dose-dependent Drug–Drug interactions. Computers in Biology and Medicine, 155, 106584. https://doi.org/10.1016/j.compbiomed.2023.106584
Burgazli, C. R., Rana, K. B., Brown, J. N., & Tillman III, F. (2023). Efficacy and safety of hydroxyzine for sleep in adults: Systematic review. Human Psychopharmacology: Clinical and Experimental, 38(2), e2864. https://doi.org/10.1002/hup.2864
Manzar, M. D., Noohu, M. M., Salahuddin, M., Nureye, D., Albougami, A., Spence, D. W., Pandi-PerumL, S. R., & Bahammam, A. S. (2020). Insomnia symptoms and their association with anxiety and poor sleep hygiene practices among Ethiopian university students. Nature and Science of Sleep, 575-582. https://doi.org/10.2147/NSS.S246994
Mittal, N., Mittal, R., & Gupta, M. C. (2021). Zolpidem for insomnia: a double-edged sword. A systematic literature review on Zolpidem-induced complex sleep behaviors. Indian Journal of Psychological Medicine, 43(5), 373–381. https://doi.org/10.1177/0253717621992372
Pochiero, I., Gorini, M., Comandini, A., Calisti, F., Di Loreto, G., 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
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. https://doi.org/10.4111/icu.20200195
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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WEEK 8 ASSIGNMENT 2: 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
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 formattingLinks to an external site..Insomnia
31-year-old Male
BACKGROUND
This week, we examine a 31-year-old male who presents to the office with a chief complaint of insomnia.
SUBJECTIVE
Patient is a 31-year-old male. He states that his insomnia has gotten progressively worse over the past 6 months. Per the patient, he has never been a “great sleeper” but is now having difficulty both falling asleep and staying asleep at night. The problem began approximately 6 months ago after the sudden loss of his fiancé. The patient states this is affecting his ability to perform his job, which is a forklift operator at a local chemical company. The patient states he has used diphenhydramine in the past to sleep but does not like the way it makes him feel the morning after. He states he has fallen asleep on the job due to lack of sleep from the night before. The patient’s medical record from his previous physician states that he has a history of opiate abuse, which began after he broke his ankle in a skiing accident and was prescribed hydrocodone/apap (acetaminophen) for acute pain management. The patient has not received a prescription for an opiate analgesic in 4 years. The patient states recently he has been using alcohol to help him fall asleep, approximately four beers prior to bed.
MENTAL STATUS EXAM
The patient is alert and oriented to person, place, time, event. He makes good eye contact and is dressed appropriately for time of year. He denies auditory/visual hallucinations. Judgement, insight, and reality contact are all intact. Patient denies suicidal/homicidal ideation, and is future oriented.
Decision Point One
Select what you should do:

Zolpidem: 10 mg daily at bedtime

Trazodone 50 mg po at bedtime

Hydroxyzine: 50 mg daily at bedtime
Trazodone 50 mg po at bedtime
Decision Point 1: Trazodone 50 mg po at bedtime
RESULTS OF DECISION POINT ONE
• Patient returns to clinic in 2 weeks
• Patient states medication works well but gives him an unpleasant side effect of an erection lasting approximately 15 minutes after waking
• Patient states this makes it difficult to get ready for work or go downstairs and have coffee with his girlfriend and daughter in the morning
• Patient denies auditory/visual hallucinations and is future oriented

Decision Point Two
Select what you should do next:

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

Discontinue trazodone. Initiate therapy with suvorexant 10 mg daily at bedtime

Decrease trazodone to 25 mg daily at bedtime

Decision Point Two
Decrease trazodone to 25 mg daily at bedtime

RESULTS OF DECISION POINT TWO
• Patient returns to clinic in 2 weeks
• Patient states trazodone is very effective for sleep
• Patient states sometimes the 25 mg dosage isn’t quite enough to help him sleep through the night
• Patient denies auditory/visual hallucinations and is future oriented

Decision Point Three
Select what you should do next:

Discontinue trazodone. Initiate therapy with ramelteon 8 mg nightly at bedtime. Follow up in 4 weeks
Continue dose. Encourage sleep hygiene. Follow up in 4 weeks
Discontinue trazodone. Initiate therapy with hydroxyzine 50 mg nightly at bedtime. Follow up in 4 weeks

Decision Point Three
Continue dose. Encourage sleep hygiene. Follow up in 4 weeks
Guidance to Student
Since the patient is already showing a partial response from trazodone, it may not be prudent to switch therapy. A thorough sleep hygiene analysis should always be performed prior to initiation of pharmacotherapy as well as at reassessments. If you find the patient isn’t practicing proper sleep hygiene, you may continue the dose and encourage sleep hygiene. If the patient is practicing good sleep hygiene, you may consider discontinuing trazodone and initiating hydroxyzine. Although there are some negative side effects associated with hydroxyzine such as Xerostomia and Xerophthalmia, it is still a safer medication to prescribe than ramelteon.

LEARNING RESOURCES
Required Readings
• American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disordersLinks to an external site. (5th ed.). https://doi.org/10.1176/appi.books.9780890425596
• Fernandez-Mendoza, J., & Vgontzas, A. N. (2013). Insomnia and its impact on physical and mental health. Current Psychiatry ReportsLinks 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. ChestLinks 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. SLEEPLinks 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. SLEEPLinks 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 MedicineLinks 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 MedicineLinks 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 drugsLinks 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 adultLinks to an external site.
Note: This case study will serve as the foundation for this week’s Assignment.