A young woman with Depression<\/p>\n
SUBJECTIVE<\/p>\n
Stefanie is a 32-year-old female from Puerto Rico who presents to your office today with complaints of difficulty sleeping. You learn that Stefanie can go for a few days with minimal sleep (about 3 hours\/night) but does not seem to be fatigued the next day. Stefanie explains that after 3 days with minimal sleep, she \u201ccrashes\u201d and has a good night\u2019s sleep. She states that sleep will be \u201calright\u201d for a few days, even a few weeks, and then she will have a similar issue with sleep.<\/p>\n
You learn throughout the assessment process that Stefanie has had this problem for years. She noticed that it began in college and thought it was just because of the workload and academic demands. However, she found that it persisted after college. She also notices that she has periods where she will engage in increased amounts of goal-directed activity. She states that things will just \u201cpile up\u201d at work and she gets this burst of energy to \u201cmake everything right.\u201d She states that these bursts will last most of the day. She states that these periods show up probably every 2 to 3 weeks.<\/p>\n
Stefanie also confesses to problems with being \u201cdown in the dumps.\u201d She states that when she has her episodes in which she endeavors to \u201cmake everything right,\u201d she feels fantastic and on top of the world. However, when these periods of energy end, she reports that she feels \u201cdepressed\u201d\u2014but then states: \u201cwell, maybe not depressed, but I definitely feel sad and empty.\u201d She also endorses feelings of fatigue and a decreased ability to concentrate when she is feeling sad. She finally tells you: \u201cI have lived with this for so long, I have to admit that it is finally a relief to tell someone how I feel!\u201d<\/p>\n
OBJECTIVE<\/p>\n
Stefanie is dressed appropriately to the weather. She has no gait abnormalities. Physical assessment is unremarkable. Gross neurological assessment is within normal limits.<\/p>\n
MENTAL STATUS EXAM<\/p>\n
Stefanie is alert and oriented \u00d7 4 spheres. Her speech is clear, coherent, goal directed, and spontaneous. Self-reported mood is \u201csad.\u201d Affect does appear consistent with dysphoria. Eye contact is normal. Speech is clear, coherent, and goal directed. She denies visual or auditory hallucinations. No overt evidence of paranoid or delusional thought processes noted. She denies suicidal or homicidal ideation and is future oriented.<\/p>\n
At this point, please discuss any additional diagnostic tests you would perform on Stefanie.<\/p>\n
Decision Point One<\/p>\n
BASED ON THE INFORMATION PROVIDED IN THE SCENARIO ABOVE, WHICH OF THE FOLLOWING DIAGNOSES WOULD THE PSYCHIATRIC\/MENTAL HEALTH NURSE PRACTITIONER (PMHNP) GIVE TO STEFANIE?<\/p>\n
In your write-up of this case, be certain to link specific symptoms presented in the case to DSM\u20135 criteria to support your diagnosis.<\/p>\n
Bipolar I, current phase, depressed<\/p>\n
Bipolar II, current phase, hypomanic<\/p>\n
Cyclothymic disorder<\/p>\n
Decision Point One<\/p>\n
Bipolar I, current phase, depressed<\/p>\n
Decision Point Two<\/p>\n
Begin Latuda 40 mg orally daily<\/p>\n
RESULTS OF DECISION POINT TWO<\/p>\n
Client returns to clinic in four weeks<\/p>\n
Stefanie states that she thinks that her depression \u201cmay be a bit better.\u201d She also reports that she has only had one of her \u201cmake everything right\u201d days.<\/p>\n
She does report that she has been having a new problem: the inability to \u201csit still.\u201d She states that she notices that she must move every few minutes, otherwise, she feels uncomfortable.<\/p>\n
Decision Point Three<\/p>\n
BASED ON THE ABOVE INFORMATION, SELECT YOUR NEXT ACTION. BE CERTAIN TO DISCUSS THE RATIONALE FOR YOUR DECISION.<\/p>\n
Increase Latuda to 80 mg orally daily<\/p>\n
Remind Stefanie to take her Latuda with a meal<\/p>\n
Decrease Latuda to 20 mg orally daily<\/p>\n
Decision Point Three<\/p>\n
Increase Latuda to 80 mg orally daily<\/p>\n
Guidance to Student<\/p>\n
In order to meet the criteria for a major depressive episode, the client needs to have 5 or more symptoms (refer to DSM\u20135 major depressive episode criteria). She only demonstrates criteria # 1: depressed mood most of the day, nearly every day, as indicated by either subjective reports (e.g., feels sad, empty, or hopeless) or observation made by others (e.g., appears tearful); criteria # 6: \u201cfatigue or loss of energy nearly every day\u201d; and criteria # 8: \u201cdiminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others).\u201d Thus, Stefanie does not meet the criteria for a major depressive episode as she only has three out of the needed five criteria for the diagnosis of a major depressive episode.<\/p>\n
In order to meet criteria for a hypomanic episode, the client needs to have a period of abnormally and persistently elevated, expansive, or irritable mood, and abnormally and persistently increased activity or energy, lasting at least 4 consecutive days and present most of the day, nearly every day. Stefanie\u2019s symptoms last 3 days. Additionally, during the period of mood disturbance, the person must have three or more of the qualifying symptoms. Stefanie only has an increase in goal-directed activity and distractibility. Thus, Stefanie does not meet criteria for a hypomanic episode as she only has a decreased need for sleep and an increase in goal-directed activity.<\/p>\n
Since Stefanie has symptoms of both hypomania and depression (but does not meet the criteria for a major depressive or hypomanic episode), and since these behaviors do not occur in the context of a drug\/substance or medical condition, Stefanie meets the diagnostic criteria for cyclothymic disorder.<\/p>\n
Some providers will treat cyclothymic disorder with pharmacologic agents used to treat bipolar disorder because individuals with cyclothymic disorder have a higher risk of progression to bipolar disorder. However, there is no consensus in the literature as to the optimal treatment, or if prophylactic psychopharmacologic treatment is beneficial in consideration of the side effects associated with antipsychotics and mood stabilizers.<\/p>\n
In this case, the Latuda was clearly causing problems with akathisia. Defined as an inability to sit still, or an inner feeling of restlessness, akathisia can be quite concerning to those with the condition.<\/p>\n
In this case, increasing the Latuda is the worst thing you can do, as that will most likely intensify the akathisia. Reminding the client to take the medication with food is important because Latuda should be taken with a 350-calorie meal in order to ensure absorption of the drug. However, in this case, the side effect Stefanie is complaining about is not food related.<\/p>\n
Cogentin would not be appropriate since beta-blockers (propranolol 20\u201340 mg orally BID) are considered first-line treatment for drug-induced akathisia. Cogentin could be used, but it is not a first-line treatment.<\/p>\n
Of the available options, decreasing the dose of Latuda is the most correct answer; however, the proper course of action would be to discontinue the drug. Alternatively, decreasing the offending drug could alleviate the symptoms.<\/p>\n
Required Readings<\/p>\n
American Nurses Association. (2014). Psychiatric-mental health nursing: Scope and standards of practice (2nd ed.). Washington, DC: Author.<\/p>\n
Standard 13 \u201cCollaboration\u201d (pages 78-79)<\/p>\n
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.<\/p>\n
\u201cBipolar and Related Disorders\u201d<\/p>\n
Gabbard, G. O. (2014). Gabbard\u2019s treatment of psychiatric disorders (5th ed.). Washington, DC: American Psychiatric Publications.<\/p>\n
Chapter 13, \u201cAcute and Maintenance Treatment of Bipolar and Related Disorders\u201d<\/p>\n
Marsee, K., & Gross, A. F. (2013). Bipolar disorder or something else? Current Psychiatry, 12(2), 43\u201349. Retrieved from http:\/\/www.mdedge.com\/currentpsychiatry\/article\/66320\/bipolar-disorder\/bipolar-disorder-or-something-else<\/p>\n
Miller, L. J., Ghadiali, N. Y., Larusso, E. M., Wahlen, K. J., Avni-Barron, O., Mittal, L., & Greene, J. A. (2015). Bipolar disorder in women. Health Care for Women International, 36(4), 475\u2013498. doi:10.1080\/07399332.2014.962138<\/p>\n
Schouws, S. M., Comijs, H. C., Dols, A., Beekman, A. F., & Stek, M. L. (2016). Five-year follow-up of cognitive impairment in older adults with bipolar disorder. Bipolar Disorders, 18(2), 148\u2013154. doi:10.1111\/bdi.12374<\/p>\n
Sadock, B. J., Sadock, V. A., & Ruiz, P. (2014). Kaplan & Sadock\u2019s synopsis of psychiatry: Behavioral sciences\/clinical psychiatry (11th ed.). Philadelphia, PA: Wolters Kluwer.<\/p>\n
Chapter 8, \u201cMood Disorders\u201d (pp. 347\u2013386)
\nNote: This is review from the Learning Resource in week 2 [Essay writing service – your education, our expertise: Get any assignment done with our professional essay writers before your deadlines – Zero AI, Human experts and Fast delivery.].<\/p>\n
Stahl, S. M. (2014). Prescriber\u2019s Guide: Stahl\u2019s Essential Psychopharmacology (5th ed.). New York, NY: Cambridge University Press.<\/p>\n
Note: All Stahl resources can be accessed through the Walden Library using the link below. This link will take you to a login page for the Walden Library. Once you log in to the library, the Stahl website will appear. http:\/\/ezp.waldenulibrary.org\/login?url=http:\/\/stahlonline.cambridge.org\/<\/p>\n
To access information on specific medications, click on The Prescriber\u2019s Guide, 5th Ed. tab on the Stahl Online website and select the appropriate medication.
\n——–<\/p>\n
Assignment 2
\nWrite three possible nursing interventions for a child who is hospitalized for failure to thrive. The work must be done in APA style . 300- 400 words. References should be within last 5 years.<\/p>\n
___________________
\nBased on the information provided in the scenario, the psychiatric\/mental health nurse practitioner (PMHNP) would diagnose Stefanie with Bipolar II, current phase, depressed. This diagnosis is supported by her symptoms of decreased need for sleep, increased goal-directed activity, periods of energy followed by periods of sadness and emptiness, fatigue, and decreased ability to concentrate. These symptoms meet the criteria for a hypomanic episode and a major depressive episode, but not for a manic episode, which is required for a diagnosis of Bipolar I.<\/p>\n
Decision Point Two involves starting Stefanie on Latuda 40 mg orally daily. At Decision Point Three, Stefanie reports improvement in her depressive symptoms but new symptoms of restlessness and inability to sit still. The PMHNP decides to increase the dose of Latuda to 80 mg orally daily. This is an appropriate decision as increased restlessness and inability to sit still can be symptoms of akathisia, a common side effect of antipsychotic medication. Increasing the dose may help alleviate these symptoms while also improving her depressive symptoms.<\/p>\n","protected":false},"excerpt":{"rendered":"
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