WU Nursing Treating Mental Health Issues Discussion Response – Description
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Melissa Bruno
Insomnia
Questions that I might ask the patient
What is the approximate time or period you have been experiencing Insomnia?
What are your sleeping patterns/routines, including what time do you go bed every night?
Have you recently used medication that may impact your sleeping quantity and quality?
Reasons for Asking the Questions
Understanding this client’s sleeping patterns, allows me to assess if any routines or habits she is doing started before or after the passing of her husband. Knowing this will let me to determine if her sleep disturbance is associated to remembrance of her late husband. Knowing what time, she goes to bed, lets me know if there has a been a change in her sleep routine that is causing disruption. It’s important to know if she is taking medications such as diuretics or if she has always been a diabetic. I might ask these questions since they are essential in ruling out other health issues the patients may suffer from. For instance, ruling out caffeine products associated with irregular sleeping patterns may mean the patient has insomnia (Wickwire et al., 2020). The questions are also important since they help identify possible causes, consequences, and treatment of specific Insomnia.
People in the patient’s life that I would talk to regarding the patient’s condition
Some people in the patient’s life I would need to speak to and get feedback from to further asses the patient’s condition include the patient’s primary care provider, core workers and employers, and the patient’s friends and family. I will ask the primary provider have patient ever complained about trouble sleeping and if so what treatment they have tried on the patient and the duration of time the patient has been suffering from the condition. I would ask the employer how Insomnia impacts the patient’s productivity. I will ask friends and family how the patient spends leisure time, including how the patient manages anxiety and depression. According to Dopheide (2020), these questions are essential in identifying triggers, potential causes, and consequences of Insomnia.
Physical exams, diagnostic tests, and results
Physical exams and diagnostic tests would be appropriate to examine the patient. For instance, the patient gets to answer a questionnaire regarding sleeping habits. Similarly, Kitamura et al. (2020) describe the patient getting exposed to diagnostic tests comprising sleep study, Actigraphy, and blood tests. Actigraphy tests will diagnose sleep apnea, insomnia, and cardiac rhythm sleep disorder. Some blood test that would be important to monitor are thyroid function tests, simple blood test that measures average blood sugar levels over the past 3 months, CBC, liver function test, kidney function test and erythrocyte sedimentation rates.
Differential Diagnosis
Depression
Anxiety
Late-life spousal bereavement: bereavement is known to cause depression and complicated grief ( Holm etal., 2019).
Medicated-related insomnia Sleep apnea. Sleep apnea seen more in patient with diabetes ( Khandelwal et al., 2017).
Late life depression (LLD) Prompting considerations involve prior factors with ongoing sleep disturbance, proven depression, female gender, being widowed or divorced ( Blackburn etal., 2017).
I chose late-life spousal bereavement. Reason being that since the patient was diagnosed with major depressive disorder, she is still grieving the loss of her husband ten months later which is triggering her depression and insomnia. Being widowed causes impairments in sleep. The patient’s possible diagnosis is Insomnia since, apart from having irregular sleep patterns, the patient has additional symptoms, including major depressive disorder, hypertension, and perinatal mental health, all possible signs of Insomnia (Kwon et al., 2021).
Pharmacologic Agents
Foremost, I would have discontinued the patient’s current regimen of Sertraline 100 mg daily. A side effect of Sertraline is insomnia. Supplementing sertraline with another medication in patients will lead to polypharmacy. For that reason, it would be ideal to substitute sertraline for a medication that will help decrease insomnia while treating the depression. Discontinuing sertraline and starting trazadone 25 mg by mouth at bedtime would be a better drug choice for the patient. Trazadone is safe when given in low doses and are given in patient groups where hypnotics are contraindicated, e.g., in the elderly and patients with sleep apnea (Wichniaketal., etal., 2017). Trazodone is an antidepressant that works by blocking serotonin carrier and serotonin type 2 receptors. When prescribed in low doses, Trazodone offers a sedative effect for sleep through antagonism of 5-HT-2A receptor, H1 receptor, and alpha-1- adrenergic receptors (Stahl,2021). Trazodone also decreases apnea and hypopnea occurrences in clients at risk or who have obstructive sleep apnea (OSA), and it do not exacerbate hypoxemic episodes.
Another option would be to start the patent on mirtazapine. I would start the patient on 15 mg of mirtazapine by mouth at bedtime. This drug works as an atypical antidepressant and used to treat major depressive disorder. Its primary therapeutic action is ?2 antagonism. It also blocks three serotonin (5HT) receptors: 5HT2A, 5HT2C, and 5HT3. Finally, it blocks histamine 1 (H1) receptors. It consists of sedative properties which is beneficial in sleep disturbance problems like insomnia and can be used in the elderly. It works by exerting antagonist effects on the central presynaptic alpha-2-adrenergic receptors, causing an elevated release of serotonin and norepinephrine. Mirtazapine is also sometimes called a noradrenergic and specific serotonergic antidepressant (Stahl,2021). I would recommend starting the patient on 15 mg of mirtazapine by mouth at bedtime. Mirtazapine is usually used MDD in patients that don’t respond well to SSRIs.
If I were to choose between the two, I would initiate the patient on trazadone instead of mirtazapine since the side effects of Mirtazapine includes weight gain. The patient is already overweight which puts her at increase risk of cardiovascular disease. Trazadone is metabolized faster and causes quicker response to sleep results.
Check Points
Pt will be educated on expected side effects and to immediately go to nearest emergency room if she cant make it to my office. She will be educated of life threatening symptoms such as chest pain, fever, chills and back pain or suicidal ideation. When following up with patient in 4- week appointment, it would be important to hear from patient on how the medications she now is taking, how it is making her feel. Based on feedback and reaction to medication, I will know if an adjustment will need to be done in dosing.
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