Advanced Pharmacology Nursing Assignment

Pharmacology for Psychological Disorders

How does an advanced practice nurse determine the best treatment option or pharmacotherapeutic to recommend for patients with psychological disorders?

Much like assessing or recommending pharmacotherapeutics for other conditions or disorders, as an advanced practice nurse, you may encounter a patient who presents with a psychological disorder. Understanding the guiding principles related to treating patients with psychological disorders as well as the effects of pharmacotherapeutics on a patient’s overall health and well-being is critical for the safe and effective delivery of care.

This week, you examine types of drugs prescribed to patients with psychological disorders. You also examine potential impacts of pharmacotherapeutics used to treat psychological disorders on a patient’s pathophysiology.

Discussion: Decision Making When Treating Psychological Disorders

Psychological disorders, such as depression, bipolar, and anxiety disorders can present several complications for patients of all ages. These disorders affect patients physically and emotionally, potentially impacting judgment, school and/or job performance, and relationships with family and friends. Since these disorders have many drastic effects on patients’ lives, it is important for advanced practice nurses to effectively manage patient care. With patient factors and medical history in mind, it is the advanced practice nurse’s responsibility to ensure the safe and effective diagnosis, treatment, and education of patients with psychological disorders.

For this Discussion, you will select an interactive media piece to practice decision making when treating patients with psychological disorders. You will recommend the most effective pharmacotherapeutic to treat the psychological disorder presented and examine potential impacts of pharmacotherapeutics on a patient’s pathophysiology.

To Prepare

· Review this week’s interactive media pieces and select one to focus on for this Discussion.

· Reflect on the decision steps in the interactive media pieces, and consider the potential impacts from the administration of the associated pharmacotherapeutics on the patient’s pathophysiology.

Post a brief explanation of the psychological disorder presented and the decision steps you applied in completing the interactive media piece for the psychological disorder you selected. Then, explain how the administration of the associated pharmacotherapeutics you recommended may impact the patient’s pathophysiology. How might these potential impacts inform how you would suggest treatment plans for this patient? Be specific and provide examples. Advanced Pharmacology Nursing Assignment

You are required to include at least three evidence based peer-reviewed journal articles or evidenced based guidelines which relates to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 6th edition formatting.

Week 8 Initial Discussion Post Discussion

Decision Making When Treating Psychological Disorders

The psychological disorder selected for this week’s discussion post was Bipolar Disorder in a 26-year-old Korean female. She presented to the clinic after a 21-day hospitalization for onset of acute mania. She arrives to the office dressed in evening attire, and her speech is rapid, pressured, and tangential. She is unable to sit still during the interview as she reports having a “fantastic” mood and decreased need for sleep due to sleep not being “fun”. She admits that she does not believe that she has bipolar because she just likes to “talk, dance, and cook”. She reports being prescribed Lithium while she was hospitalized, but admits that she stopped taking this medication once she was discharged.

These initial assessment behaviors represent those similar to a bipolar, manic or euphoric state. Manic episodes are characterized by heightened or irritable moods that are often associated with hyperactivity, excessive enthusiasm, flight of ideas, and a reduced need for sleep (Rosenthal & Burchum, 2018). Patients with bipolar disorder can often present with varying mood behaviors, and these situations often occur in cycles of unsafe and even risky behavior. Patients can also experience periods of comparably normal moods in-between manic or depressive episodes, which can make adherence to treatment difficult.

Pharmacotherapeutic Impact on Patient Pathophysiology

The first treatment plan decision was to begin Lithium 300 mg orally BID . Research suspects that bipolar disorder may be caused by a neurotransmitter imbalance, or by disruption of neuronal growth and survival. Mood-stabilizing drugs can prevent or reverse neuronal atrophy in patients with bipolar disorder by influencing the signaling pathways that regulate neuronal growth and survival (Rosenthal & Burchum, 2018). Lithium has been effective for approximately 70 percent of the people who take it, as it has helped stabilize or modulate the ups and downs of this illness (Gooding & Wolford, 2019). Starting this patient back on her Lithium was the first choice to address her manic behaviors.

The patient returned to the clinic four weeks later with similar presenting behaviors. She reported taking her medication “off and on” when she “feels like she needs it”. The patient may not feel that her behaviors require medication every day, and she previously reported that she does not feel that her behaviors required a diagnosis or medication. Some people who have taken lithium for bipolar disorder have complained that it robs them of their energy and creativity, and this perceived loss can be a factor in relapse associated with lithium noncompliance (Gooding & Wolford, 2019). The second decision made was to assess rationale for non-compliance to elicit reason for non-compliance and educate client re: drug effects, and pharmacology. Thorough patient education is required prior to prescribing all medications. It is equally important to re-assess the patient’s level of understanding at each follow-up encounter to determine if non-compliance is also related to a lack of patient understanding.

She returned to the clinic for another 4 week follow-up and stated that the medication made her feel nauseated and gave her diarrhea. She reported that she would stop take the medication until the symptoms subsided and that she would then only take the medication again until the symptoms returned. Although medication education was provided at the last appointment, the patient was not adhering to her prescribed medications due to the development of these unpleasant symptoms. The third decision involved a medication adjustment of switching her Lithium to a sustained release preparation while keeping the dose and frequency the same. She was reporting that her medication was causing nausea and diarrhea, which are classic side effects of lithium therapy. Switching to an extended release formulation can help prevent unpleasant side effects while it also provides the patient with the same benefit of lithium’s mood stabilizing properties (Laureate Education, 2019). The patient must be clearly informed that these side effect can subside in time, but that she should continue with use to ensure if the medication is working effectively. If the side effects do not subside after completing an adequate trial of this sustained release preparation, it may be necessary to switch her to an alternate medication. Mood-stabilizing anticonvulsant medications, such as divalproex sodium (Depakote), carbamazepine (Tegretol), and lamotrigine (Lamictal), are showing promise in helping some people who were formerly referred to as lithium nonresponders (Gooding & Wolford, 2019).

Treatment Plans Suggestions

To successfully development a treatment plan, the patient and all treatment team members must all work together to develop achievable goals. Patients may resist treatment because they fail to see anything wrong with their thinking or behavior (Rosenthal & Burchum, 2018). Being aware of possible barriers to treatment will help create guidelines for the team to follow. If the patient is resistant to therapy, or if they are afraid of unpleasant side effects, the patient must be provided clear education and steps to move forward successfully. It is important that patients are educated and informed prior to starting any medications, to avoid abrupt discontinuation of treatment along the way. Telling the patient how long symptoms may occur and ways that they can be alleviated could also lead to successful adherence to therapy. Patients may not feel that they need medication due to episodes of mania or instability. It is important to provide support and honest medication education to help reach improved patient outcomes.

Patients should also be informed of the positive ways that medication could impact their life as well. When a patient is recommended medication to treat a disorder or illness, they should be informed of the beneficial factors that this medication can have on their future health and well-being also. A study was conducted to investigate the effect that lithium therapy had on preservation of cognitive functioning. Lithium has emerged as a neuroprotective/neurotrophic drug due to its capacity to activate multiple neurotrophic signaling cascades, upregulate levels of neurotrophic, angiogenic, and anti-apoptotic factors; and to also promote neurogenesis and neuronal process growth (Bersani, Quartini, Zullo, & Iannitelli, 2016). This study was able to demonstrate a potential hippocampus neuroprotective effect of Lithium in patients with borderline disorder. Although continued research will help confirm the extent of protection that Lithium therapy can have on bipolar disorder patients, this information is helpful to add to patient education discussions. Patients should be aware of the possible side effects and positive impacts that their medications can have on their brain activity and future health outcomes. Advanced Pharmacology Nursing Assignment

References

Bersani, G., Quartini, A., Zullo, D., & Iannitelli, A. (2016). Potential neuroprotective effect of lithium in bipolar patients evaluated by neuropsychological assessment: Preliminary results. Human Psychopharmacology: Clinical and Experimental, 31(1), 19–28. https://doi-org.ezp.waldenulibrary.org/10.1002/hup.2510

Gooding, D. C., Wolford, K., & Gooding, D. C. (2019). Bipolar disorder. Salem Press Encyclopedia of Health. Retrieved from https://search-ebscohost-com.ezp.waldenulibrary.org/login.aspx?direct=true&db=ers&AN=93871807&site=eds-live&scope=site

Laureate Education (Producer). (2019d). Bipolar therapy [Interactive media file]. Baltimore, MD: Author.

Rosenthal, L. D., & Burchum, J. R. (2018). Lehne’s pharmacotherapeutics for advanced practice providers. St. Louis, MO: Elsevier.

interactive media

Bipolar Therapy Client of Korean Descent/Ancestry

BACKGROUND INFORMATION

The client is a 26-year-old woman of Korean descent who presents to her first appointment following a 21-day hospitalization for onset of acute mania. She was diagnosed with bipolar I disorder.

Upon arrival in your office, she is quite “busy,” playing with things on your desk and shifting from side to side in her chair. She informs you that “they said I was bipolar, I don’t believe that, do you? I just like to talk, and dance, and sing. Did I tell you that I liked to cook?”

She weights 110 lbs. and is 5’ 5”

SUBJECTIVE

Patient reports “fantastic” mood. Reports that she sleeps about 5 hours/night to which she adds “I hate sleep, it’s no fun.”

You reviewed her hospital records and find that she has been medically worked up by a physician who reported her to be in overall good health. Lab studies were all within normal limits. You find that the patient had genetic testing in the hospital (specifically GeneSight testing) as none of the medications that they were treating her with seemed to work.

Genetic testing reveals that she is positive for CYP2D6*10 allele.

Patient confesses that she stopped taking her lithium (which was prescribed in the hospital) since she was discharged two weeks ago.

MENTAL STATUS EXAM

The patient is alert, oriented to person, place, time, and event. She is dressed quite oddly- wearing what appears to be an evening gown to her appointment. Speech is rapid, pressured, tangential. Self-reported mood is euthymic. Affect broad. Patient denies visual or auditory hallucinations, no overt delusional or paranoid thought processes readily apparent. Judgment is grossly intact, but insight is clearly impaired. She is currently denying suicidal or homicidal ideation. Advanced Pharmacology Nursing Assignment

The Young Mania Rating Scale (YMRS) score is 22

RESOURCES

§ Chen, R., Wang, H., Shi, J., Shen, K., & Hu, P. (2015). Cytochrome P450 2D6 genotype affects the pharmacokinetics of controlled-release paroxetine in healthy Chinese subjects: comparison of traditional phenotype and activity score systems. European Journal of Clinical Pharmacology, 71(7), 835-841. doi:10.1007/s00228-015-1855-6

Bipolar Therapy Client of Korean Descent/Ancestry

Decision Point One

Begin Lithium 300 mg orally BID

RESULTS OF DECISION POINT ONE

· Client returns to clinic in four weeks

· Client informs you that she has been taking her drug “off and on” only when she “feels like she needs it”

· Today’s presentation is similar to the first day you met her

Decision Point Two

Increase Lithium to 450 mg orally BID

RESULTS OF DECISION POINT TWO

· Client returns to clinic in four weeks

· Client returns reports that she is still taking the medication when she feels that she needs it

· She remains quite manic and reports that her family is getting really upset because she likes to play her new guitar at night

Decision Point Three

Assess for rationale for non-compliance and educate client

Guidance to Student You should further assess for dangerousness to self or others. The client should be assessed for self-care, to including hygiene, eating, sleeping, etc. Hospitalization may be indicated if the client remains non-compliant and is a danger to self. If the client is not a danger to self, and hospitalization is not indicated, you needs to assess for rationale for non-compliance. Many clients enjoy mania as it is a nice feeling to be consistently happy. When clients are successfully treated for mania, they often describe themselves as feeling ‘down’ or ‘flat.’ You need to assess for depression at this point as opposed to normalization of mood. Abilify is also FDA approved as monotherapy for mania and mixed presentations, but at a dose of 15 mg. day., so although you may be tempted to begin Abilify- be certain to use correct dose. Also, because it can be “activating” you need to dose this drug in the morning. However, the client is non-compliant and therefore, eliciting reasons for non-compliance is essential to the care of this client. Advanced Pharmacology Nursing Assignment