Learning Objectives Students will: Assess patient factors and history to develop

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Learning Objectives
Students will:
Assess patient factors and history to develop personalized plans of anxiolytic therapy for patients
Analyze factors that influence pharmacokinetic and pharmacodynamic processes in patients requiring anxiolytic therapy
Synthesize knowledge of providing care to patients presenting with anxiolytic therapy
Analyze ethical and legal implications related to prescribing anxiolytic therapy to patients across the lifespan
Assess psychopharmacologic approaches to treatment for patients across the lifespan
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CASE STUDY
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Examine Case Study: A Middle-Aged Caucasian Man With Anxiety. 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.
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BACKGROUND INFORMATION
The client is a 46-year-old white male who works as a welder at a local steel fabrication factory. He presents today after being referred by his PCP after a trip to the emergency room in which he felt he was having a heart attack. He stated that he felt chest tightness, shortness of breath, and feeling of impending doom. He does have some mild hypertension (which is treated with low sodium diet) and is about 15 lbs. overweight. He had his tonsils removed when he was 8 years old, but his medical history since that time has been unremarkable. Myocardial infarction was ruled out in the ER and his EKG was normal. Remainder of physical exam was WNL.
He admits that he still has problems with tightness in the chest and episodes of shortness of breath- he now terms these “anxiety attacks.” He will also report occasional feelings of impending doom, and the need to “run” or “escape” from wherever he is at.
In your office, he confesses to occasional use of ETOH to combat worries about work. He admits to consuming about 3-4 beers/night. Although he is single, he is attempting to care for aging parents in his home. He reports that the management at his place of employment is harsh, and he fears for his job. You administer the HAM-A, which yields a score of 26.
Client has never been on any type of psychotropic medication.
MENTAL STATUS EXAM
The client is alert, oriented to person, place, time, and event. He is appropriately dressed. Speech is clear, coherent, and goal-directed. Client’s self-reported mood is “bleh” and he does endorse feeling “nervous”. Affect is somewhat blunted, but does brighten several times throughout the clinical interview. Affect broad. Client denies visual or auditory hallucinations, no overt delusional or paranoid thought processes readily apparent. Judgment is grossly intact, as is insight. He denies suicidal or homicidal ideation.
You administer the Hamilton Anxiety Rating Scale (HAM-A) which yields a score of 26.
Diagnosis: Generalized anxiety disorder
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Decision Point One (FIRST MEDICATION)
Begin Zoloft 50 mg orally daily
RESULTS OF DECISION POINT ONE
Client returns to clinic in four weeks
Client informs you that he has no tightness in chest, or shortness of breath
Client states that he noticed decreased worries about work over the past 4 or 5 days
HAM-A score has decreased to 18 (partial response)
Decision Point Two
Increase dose to 75 mg orally daily
RESULTS OF DECISION POINT TWO
Client returns to clinic in four weeks
Client reports an even further reduction in his symptoms
HAM-A score has now decreased to 10. At this point- continue current dose (61% reduction in symptoms)
Decision Point Three
Maintain current dose
Guidance to Student
At this point, it may be appropriate to continue client at the current dose. It is clear that the client is having a good response (as evidenced by greater than a 50% reduction in symptoms) and the client is currently not experiencing any side effects, the current dose can be maintained for 12 weeks to evaluate full effect of drug. Increasing drug at this point may yield a further decrease in symptoms, but may also increase the risk of side effects. This is a decision that you should discuss with the client. Nothing in the client’s case tells us that we should consider adding an augmentation agent at this point as the client is demonstrating response to the drug. Avoid polypharmacy unless symptoms cannot be managed by a single drug.
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Decision Point One (SECOND MEDICATION)
Begin Tofranil (imipramine) 25 mg orally BID
RESULTS OF DECISION POINT ONE
Client returns to clinic in four weeks
Client reports a “slight” decrease in symptoms
Client’s states that he no longer gets chest tightness, but still has occasional episodes of shortness of breath
HAM-A score decreased from 26 to 22
Decision Point Two
Continue current dose and reassess in 4 weeks
RESULTS OF DECISION POINT TWO
Client returns to clinic in four weeks
Client reports that he has had no change in his level of anxiety
Client reports that his anxiety may be getting a bit “worse” because he has been having the strange bouts of dizziness
Decision Point Three
Discontinue Tofranil and begin Lexapro 5 mg orally daily for 7 days, then increase to 10 mg orally daily until next appointment
Guidance to Student
Tofranil can cause orthostatic hypotension. This may be a transient side effect and you should discuss this with the client as these symptoms can be dangerous.
Increasing the Tofranil would not be ideal as the side effects can be dose dependent. Increasing the dose may increase the side effects.
While the client may acclimate to the current dose of the medication, the client is still quite anxious, and Tofranil, a second-line agent, appears to have contributed minimally to the treatment of the anxiety symptoms. At this point, waiting to provide the client with symptom relief may not be the best course of action.
Discontinuation of Tofranil and beginning Lexapro 5 mg orally daily would be the most prudent course of action. It should be noted that Lexapro is an SSRI and a first-line agent that is FDA approved to treat generalized anxiety disorder. 5 mg is lower than the recommended starting dose, but some will initiate lower doses for 7 to 10 days in order to minimize the possibility of side effects (which may include sexual dysfunction in men as well as gastrointestinal side effects like nausea, decreased appetite, constipation, dry mouth, vomiting, and diarrhea).
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Decision Point One (THIRD MEDICATION)
Begin Buspirone 10 mg orally BID
RESULTS OF DECISION POINT ONE
Client returns to clinic in four weeks
Client reports slight decrease in symptoms
Client states that he still feels very anxious
HAM-A score decreased from 26 to 23
Decision Point Two
Discontinue buspirone and begin Lexapro 10 mg orally daily
RESULTS OF DECISION POINT TWO
Client returns to clinic in four weeks
Client reports that he feels “great”
Client states that his anxiety is getting “better”
HAM-A score has decreased from 23 to 13
Client does report that he sometimes feels sleepy for a few hours after taking the medication, but “perks up” by early to midafternoon
Decision Point Three
Continue same dose of Lexapro but change administration time to bedtime
Guidance to Student
At this point, the client reports that he is feeling “great” with a decrease in symptoms from an initial HAM-A score of 26 down to 13. This represents a 50% decrease in symptoms in just 4 weeks. Recall that an adequate trail can be as long as 12 weeks, we may not need to increase the drug any more at this point as we do not know how much more the current dose will improve the client’s symptoms. You could increase the dose but this could increase the risk of side effects- especially the sleepiness that the client is complaining about in the morning after taking the medication. It is plausible that an increase in the dose would increase morning sedation.
The most prudent course of action would be to continue the same dose of medication, but change the administration time to bedtime. This way, the client will not be troubled by the sedating effects of the medication, and sleep may be enhanced which could also improve overall anxiety.
At this point, nothing in the client presentation suggests the need to augment his Lexapro with any other agents. Therefore, buspirone augmentation would not be an appropriate response.
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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 requiring anxiolytic therapy.
The Assignment: 5 pages
Examine Case Study: A Middle-Aged Caucasian Man With Anxiety. 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 ===========================================
Bui, E., Pollack, M. H., Kinrys, G., Delong, H., Vasconcelos e Sá, D., & Simon, N. M. (2016). The pharmacotherapy of anxiety disorders. In T. A. Stern, M. Favo, T. E. Wilens, & J. F. Rosenbaum. (Eds.), Massachusetts General Hospital psychopharmacology and neurotherapeutics (pp. 61–71). Elsevier.
American Psychiatric Association. (2010a). Practice guideline for the treatment of patients with acute stress disorder and posttraumatic stress disorder. https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/acutestressdisorderptsd.pdf
American Psychiatric Association. (2010c). Practice guideline for the treatment of patients with panic disorder (2nd ed.). https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/panicdisorder.pdf
Bendek, D. M., Friedman, M. J., Zatzick, D., & Ursano, R. J. (n.d.). Guideline watch (March 2009): Practice guideline for the treatment of patients with acute stress disorder and posttraumatic stress disorder. https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/acutestressdisorderptsd-watch.pdf
Cohen, J. A. (2010). Practice parameter for the assessment and treatment of children and adolescents with posttraumatic stress disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 49(4), 414–430. https://jaacap.org/action/showPdf?pii=S0890-8567%2810%2900082-1
Davidson, J. (2016). Pharmacotherapy of post-traumatic stress disorder: Going beyond the guidelines. British Journal of Psychiatry, 2(6), e16–e18. 10.1192/bjpo.bp.116.003707. http://bjpo.rcpsych.org/content/2/6/e16
Hamilton, M. (1959). Hamilton Anxiety Rating Scale (HAM-A). PsycTESTS. https://doi.org/10.1037/t02824-0
Ostacher, M. J., & Cifu, A. S. (2019). Management of posttraumatic stress disorder. JAMA, 321(2), 200–201. https://doi.org/10.1001/jama.2018.19290
Strawn, J. R., Wehry, A. M., DelBello, M. P., Rynn, M. A., & Strakowski. S. (2012). Establishing the neurobiologic basis of treatment in children and adolescents with generalized anxiety disorder. Depression and Anxiety, 29(4), 328–339. https://doi.org/10.1002/da.21913
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I am a Registered Nurse that works in mental health and substance use disorders and the Emergency Room. I am in school for my Psychiatric Nurse Practitioner. Please use original thought, as it will be checked for plagiarism. Please use sources within 5 years. Thank you

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