Assessing and Treating Clients With Psychosis and Schizophrenia Sample Essay

Assessing and Treating Clients With Psychosis and Schizophrenia Sample Essay

Delusional Disorders
Pakistani Female With Delusional Thought Processes

BACKGROUND
The client is a 34-year-old Pakistani female who moved to the United States in her late teens/early 20s. She is currently in an “arranged” marriage (her husband was selected for her since she was 9 years old). She presents to your office today following a 21 day hospitalization for what was diagnosed as “brief psychotic disorder.” She was given this diagnosis as her symptoms have persisted for less than 1 month.
Prior to admission, she was reporting visions of Allah, and over the course of a week, she believed that she was the prophet Mohammad. She believed that she would deliver the world from sin. Her husband became concerned about her behavior to the point that he was afraid of leaving their 4 children with her. One evening, she was “out of control” which resulted in his calling the police and her subsequent admission to an inpatient psych unit. Assessing and Treating Clients With Psychosis and Schizophrenia Sample Essay.

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During today’s assessment, she appears quite calm, and insists that the entire incident was “blown out of proportion.” She denies that she believed herself to be the prophet Mohammad and states that her husband was just out to get her because he never loved her and wanted an “American wife” instead of her. She tells you that she knows this because the television is telling her so.
She currently weighs 140 lbs, and is 5’ 5”

SUBJECTIVE
Client reports that her mood is “good.” She denies auditory/visual hallucinations, but believes that the television does talk to her. She believes that Allah sends her messages through the TV. At times throughout the clinical interview, she becomes hostile towards the PMHNP, but then calms down.
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 Assessing and Treating Clients With Psychosis and Schizophrenia Sample Essay. Lab studies were all within normal limits.
Client admits that she stopped taking her Risperdal about a week after she got out of the hospital because she thinks her husband is going to poison her so that he can marry an American woman.

MENTAL STATUS EXAM
The client is alert, oriented to person, place, time, and event. She is dressed appropriately for the weather and time of year. She demonstrates no noteworthy mannerisms, gestures, or tics. Her speech is slow and at times, interrupted by periods of silence. Self-reported mood is euthymic. Affect constricted. Although the client denies visual or auditory hallucinations, she appears to be “listening” to something. Delusional and paranoid thought processes as described, above. Insight and judgment are impaired. She is currently denying suicidal or homicidal ideation. Assessing and Treating Clients With Psychosis and Schizophrenia Sample Essay.
The PMHNP administers the PANSS which reveals the following scores:
-40 for the positive symptoms scale
-20 for the negative symptom scale
-60 for general psychopathology scale
Diagnosis: Schizophrenia, paranoid type

RESOURCES
§ Kay, S. R., Fiszbein, A., & Opler, L. A. (1987). The Positive and Negative Syndrome Scale (PANSS) for schizophrenia. Schizophrenia Bulletin, 13(2), 261-276.
§ Clozapine REMS. (2015). Clozapine REMS: The single shared system for clozapine. Retrieved from https://www.clozapinerems.com/CpmgClozapineUI/rems/pdf/resources/Clozapine_REMS_A_Guide_for_Healthcare_Providers.pdf
§ Paz, Z., Nalls, M. & Ziv, E. (2011). The genetics of benign neutropenia. Israel Medical Association Journal. 13. 625-629.

Decision Point One
Select what the PMHNP should do:

Start Zyprexa 10 mg orally at BEDTIME

Start Zyprexa 10 mg orally at BEDTIME

Start Invega Sustenna 234 mg intramuscular X1 followed by 156 mg intramuscular on day 4 and monthly thereafter

Start Invega Sustenna 234 mg intramuscular X1 followed by 156 mg intramuscular on day 4 and monthly thereafter

Start Abilify 10 mg orally at BEDTIME

Start Abilify 10 mg orally at BEDTIME

Examine Case Study: Pakistani Woman with Delusional Thought Processes. You will be asked to make three decisions concerning the medication to prescribe to this client. Assessing and Treating Clients With Psychosis and Schizophrenia Sample Essay. Be sure to consider factors that might impact the client’s pharmacokinetic and pharmacodynamic processes.
At each decision point stop to complete the following:
• Decision #1
o Which decision did you select?
o Why did you select this decision? Support your response with evidence and references to the Learning Resources.
o What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
o Explain any difference between what you expected to achieve with Decision #1 and the results of the decision. Why were they different?
• Decision #2
o Why did you select this decision? Support your response with evidence and references to the Learning Resources.
o What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
o Explain any difference between what you expected to achieve with Decision #2 and the results of the decision. Why were they different? Assessing and Treating Clients With Psychosis and Schizophrenia Sample Essay.
• Decision #3
o Why did you select this decision? Support your response with evidence and references to the Learning Resources.
o What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
o Explain any difference between what you expected to achieve with Decision #3 and the results of the decision. Why were they different?
Also include how ethical considerations might impact your treatment plan and communication with clients.
Note: Support your rationale with a minimum of three academic resources. While you may use the course text to support your rationale, it will not count toward the resource requirement.

Below is a simple paper for reference.

“Bipolar” refers to a mental condition characterized by a sudden shift in the energy and the moods of the patient. The condition may also result in the occurrence of manic phases along with slight depression. The condition is quite difficult to diagnose being that one may exhibit depression-like symptoms and/or manic phases. Symptoms associated with bipolar disorder are common, often symptoms of other disorders Assessing and Treating Clients With Psychosis and Schizophrenia Sample Essay. Cases of misdiagnosis for this condition is also common. This, in turn, results in wrong medication prescribed to the patient. Under such circumstance, the condition of the patient might become more complicated, and worst-case scenario, some might lose their lives (Stahl, 2013). It is therefore important to thoroughly assess the symptoms exhibited by a client before making a diagnosis. This is in a bid to eliminate any case of misdiagnosis. This paper will provide three medical decisions that can be taken in the treatment of a patient diagnosed with Bipolar disorder.
Background
The client that I assessed this week is a 26-year-old Korean female. The client has been hospitalized for 21 days as a result of manic phases that she experienced. During the assessment process, the client would fiddle with things. She weighed 110lbs while standing 5’5”. She explains how she only sleeps for five hours since “sleeping is not fun.” Her medical history indicated that she is of good health and the results from the lab evaluation indicated that her vital signs are within normal limits. A gene test of the client indicated that she is positive for CYP2D6*10 allele, which means any medication offered to her would not yield the desired results. She reports that she stopped taking the medications that she was prescribed within hospital (Laureate Education, 2016f). The client is alert and oriented to the events taking place around her. However, she is dressed inappropriately and her speaking rapidly. Assessing and Treating Clients With Psychosis and Schizophrenia Sample Essay. She reports her mood as unbothered and affects as broad. She denies any form of hallucination or paranoia. Her judgment is intact while her insight is slightly affected. Nonetheless, she denies suicidal ideations.
Decision #1
Selected Decision
The first decision is to start Risperdal 1mg orally BID
Reason For Selecting This Decision
Risperdal, originally referred to as risperidone, is a typical antipsychotic that has proven to be highly effective in the management of bipolar disorders. It does so by trying to influence a rebalance in serotonin and dopamine thus resulting in good conduct. Since the patient was having bipolar confusion, Risperdal happens to be the best alternative also considering that it is readily accessible (Culpepper, 2014). In the past treatment therapy, the patient happened to default lithium. Therefore, it wouldn’t be a smart option to start lithium 300mg since the chances of the patient not adhering to treatment are high. Assessing and Treating Clients With Psychosis and Schizophrenia Sample Essay. Also, Lithium has a lot of side effects and the patient will be subjected to monitoring therapeutic range periodical to avoid toxic range, which means the patient have to go to a lab and have her blood drawn periodical. Similarly, Seroquel XR could be a good alternative, but it’s mostly used for acute Schizophrenia and Schizophrenia maintenance. However, its side effects of increase diabetes, dyslipidemia, constipation and weight addition might contribute to non-compliance thus not achieving the therapeutic goals (John & Antai-Otong, 2016). This leaves Risperdal as the best option in this case.
Expected Outcomes
Within four weeks on treatment, the patient is expected to show immense progress. The current manifestations of bipolar disorder that she experiences are also expected to diminish to an extent that the patient has a peaceful state of mind. The patient should be restful and be able to conduct her activities of daily life with little or no difficulty (John & Antai-Otong, 2016) Risperdal is the best choice to influence mental action and improve the patient’s capacity to be of rational sound mind in the way she addresses issues. It is also expected that the patient’s self-destructive practices and tension would diminish and will respond to her environment and social interactions positively (Fang, et al., 2017).

Difference between Expected Outcomes and Actual Outcomes
After four weeks, the client returned to the clinic accompanied by her mother looking very lethargic and sedated. They, however, agreed that the patient\’s self-destructive practices had significantly diminished. The client’s mother explained that the client had been lethargic for about a week after the last visit. Assessing and Treating Clients With Psychosis and Schizophrenia Sample Essay. It should be noted that one of the side effects of Risperdal is sedation (John & Antai-Otong, 2016) Similarly, based on the fact that the client is reportedly positive for CYP2D6*10 allele, it is probable that she might be having a slow rate of clearance of Risperdal from her systems leading to higher levels than normal of Risperdal in blood (Chen et al., 2015).
Decision #2
Selected Decision
Based on the client\’s presentation and the initial decision, the second-best decision, in this case, would be reducing Risperdal to 1mg HS.
Reason for Selecting This Decision
Based on the patient\’s progress during the second visit, it was evident that Risperdal was effective in attaining therapeutic goals of treatment. However, the unwanted side effects were the major concerns. It is therefore wise to decrease the dosing to deal with the side effects rather than change to another drug. Decreasing the dosage to one mg HS would be the best alternative that will help to reduce the significant impact of the side effects (Culpepper, 2014). Changing the drug to lithium will possibly result in non-compliance since the client has already developed some demeanor towards it. Besides, the patient may turn out to generally have a negative attitude towards all medicines which may be prescribed by the mental health practitioner. Giving the patient support to adapt to an alternate dosage of the same medication will also improve their dedication, trust, and understanding to collaborate in achieving the treatment goals (John & Antai-Otong, 2016).
Expected Outcomes
As earlier stated, Risperdal has proven to be effective in managing the symptoms of bipolar disorder by influencing a balance in serotonin and dopamine to help address a patient’s self-destructive behaviors. Based on the fact that the client is positive for CYP2D6*10 allele, the initial dosage could have resulted in an accumulation of Risperdal which is slowly being cleared (John & Antai-Otong, 2016). Reducing the dosage to one mg HS will definitely reduce the amount of Risperdal accumulated in the body and subsequent side effects of lethargy and sedation. By adjusting this dosage, it is expected that the patient will record some positive progress in terms of reduced self-destructive behaviors, ease in performing activities of daily life and thinking patterns (Fang, et al., 2017). It is also expected that the client will have minimal episodes of lethargy and sedation.
Difference between Expected Outcomes and Actual Outcomes
After four weeks, the client returned to the clinic accompanied by her mother. She was less sedated, less lethargic and showed a lot of improvement in symptoms. The young mania rating scale had also reduced from 22 to 16, an illustration that there was more than a 25% reduction in symptoms. These outcomes were actually foreseen and were the reason the dosage of Risperdal was reduced to one mg HS (John & Antai-Otong, 2016) Risperdal is a powerful choice for bipolar disorder; its side effects are easily manageable and help in the achievement of therapeutic goals for bipolar patients more easily.
Decision #3
Selected Decision
My third decision would be to continue at the same dosage of 1 mg HS.
Reason for Selecting This Decision
From the initial visit, it was evident that the client has good progress in terms of reducing self-destructive behaviors and management of the drugs side effects. Maintaining this dosage and reassessing the client after four weeks will contribute to the achievement of the treatment goals for both the client and the attending mental health practitioner. The initial dosage of 1 mg BID had turned out to be detrimental to the patient’s health (Fang, et al., 2017). Therefore, going back to it would prompt similar side effects. Assessing and Treating Clients With Psychosis and Schizophrenia Sample Essay. Besides, changing to Seroquel is not recommendable in this case since Seroquel is FDA approved for bipolar II depression and schizophrenia which differs from the patient\’s presentation that we are trying to manage.
Expected Outcomes
It is expected that, within four weeks, the patient will record immense progress by reducing self-destructive behaviors. Besides, she will report very minimal or no side effects from Risperdal. She will have a good state of mind, conduct, and good thinking patterns. Risperdal is FDA approved for managing bipolar symptoms and has proven to be highly effective with manageable side effects (John & Antai-Otong, 2016)
Difference between Expected Outcomes and Actual Outcomes
As initially expected, the patient has some significant progress and very minimal side effects of lethargy and sedation. The reassessment proved that Risperdal had adequately helped to achieve the necessary treatment goals in the entire course of treatment. Given the pharmacodynamics and pharmacokinetics of Risperdal, these are certainly the outcomes that ought to be expected. Since the client is for positive for CYP2D6*10 allele, Risperdal could be clearing at a slower rate resulting to higher than normal levels in the blood (Fang, et al., 2017).
However, the effect, in this case, may not be significant as compared to the initial point.
How Ethical Considerations Might Impact the Treatment Plan and Communication with Clients
The major ethical considerations that ought to be considered in managing clients with bipolar disorder are beneficence, nonmaleficence, and autonomy. Despite the fact that clients need treatment to live near-normal lives, the risks of the choice of medications used should balance with the corresponding benefits. Alternatively, a mental healthcare provider should consider giving the patient some of the best available options for management to maximize the benefits of treatment (Ratheesh et al., 2017). The impairment or insight and judgment that is always characterized by mania and mood episodes may render a patient as not able to provide informed consent nor incapable of making rational decisions regarding their treatment. Assessing and Treating Clients With Psychosis and Schizophrenia Sample Essay. Besides, a number of clinical presentations such as delusional thinking and irritability could probably be a threat in damaging the therapeutic alliance that exists between a client and a mental healthcare provider. It should also be noted that, due to the relapsing-remitting nature of bipolar disorder, there are instances where a patient might feel well and question the need to continue with treatment (Ratheesh et al., 2017). This place the treatment goals laid by the mental healthcare provider is in conflict with the patient’s autonomy to make decisions.

Background Information

For this assignment, the patient was a 34-year old Pakistani female who relocated to the United States while in her early 20s. Currently, she was in an organized marriage with a husband who was selected for her since she was 9 years old.  Today, she presents at the clinic following hospitalization for 21 days for a ‘brief psychotic disorder’ since her symptoms had lasted for less than a month.

Prior admission, the client reported of visions of Allah and in an entire week, she strongly believed that she was Prophet Mohammad and would deliver the entire world from sin. Her husband became more concerned about her behavior to the extent that he was afraid of leaving their children with her. One evening, the client was described to be out of control. As a result, the husband called the police which was followed by a subsequent admission to an inpatient psychiatric unit. Assessing and Treating Clients With Psychosis and Schizophrenia Sample Essay.

In today’s assessment, the patient appeared to be calm and emphasizes that the whole incident was just blown out of proportion. She also denies having believed that she was Prophet Mohammad and stated that her husband was out to get her since he never loved her and wanted a wife who was American instead of her. She informs that she knows this since the television told her so. Currently, she was 140 lbs. and 5’5’’.

Based on this case study, this paper discusses three major decisions regarding the medication to be prescribed to this client suffering from Schizophrenia, paranoid type. A description of the expected outcomes and actual outcomes will be provided for every decision with an explanation for any differences likely to be witnessed. Major ethical considerations that are likely to impact the client’s treatment plan and communication with clients will also be provided Assessing and Treating Clients With Psychosis and Schizophrenia Sample Essay.

Decision Pont 1

Decision Selected

Start Zyprexa 10 mg orally at bedtime

Reason for Selecting this Decision

Zyprexa, also known as olanzapine is an antipsychotic drug which affects brain chemicals. It is approved to treat symptoms of mental health disorders such as bipolar disorder and schizophrenia in both children and adults who are 13 years or older. Zyprexa is an atypical antipsychotic, which functions by helping to restore the balance of neurotransmitters in the brain. In terms of dosing, it is administered once daily (Wei Xin, 2016). Assessing and Treating Clients With Psychosis and Schizophrenia Sample Essay. Zyprexa is used to treat dysfunctional behaviors, malfunctions, speeches and distorted interpretations of the issues and events surrounding them.

Abilify could be a good option but only for a patient who has a good response to oral abilify. It should also be remembered that, Abilify does not bind to D2 receptor for quite a long time. Therefore, it can be less effective for some patients. Another possible side effect of Abilify is akathisia which is an extrapyramidal side effect that may lead to medication non-adherence. On the other hand, Invega Sustenna could also be a good option. However, it increases the risk of  memory loss  and  its side effects of pain, redness, swelling at the site of injection increases the chances of the patient failing to turn up for appointments. Invega Sustenna also leads to muscle spasms, high cholesterol and weight gain, which may generally impair the client’s physical wellbeing based on her current weight.

Expected Outcomes

By administering Zyprexa, it was expected that the client will have no hallucinations or delusional thoughts and she would be able to think more positively and clearly about herself. It was also expected that she would feel less agitated and actively participate in activities of daily life (Drug, 2015).

Difference between Expected Outcomes and Actual Outcomes

After four weeks, the client returned to the clinic accompanied by her husband. The client’s PANSS had decreased to a partial response of 25%.  The client also reported a weight gain of 5 pounds. When questioned further, the client stated that she could never seem to get satisfied with her meals. Assessing and Treating Clients With Psychosis and Schizophrenia Sample Essay. As a result, she constantly snacked in an entire day. One of the major side effects of Zyprexa is increased appetite which influences an increase in the frequency of taking meals hence weight gain.  Among all atypical antipsychotics, Zyprexa causes the most significant weight gain. Zyprexa has also been associated with increasing the risk of hyperglycemia hence newly diagnosed diabetes mellitus in clients (Takeuchi et al., 2015).

Decision Point 2

Decision Selected

Reduce Zyprexa to 7.5 mg orally at bedtime

Reason for Selecting this Decision

Based on the client’s visit, it was evident that she was concerned about the weight gain and increased appetite which was caused by the medication Zyprexa at dosing of 10mg Assessing and Treating Clients With Psychosis and Schizophrenia Sample Essay. Therefore, reducing the dosage to 7.5mg orally at bedtime is an effort to purposely counter the side effect of weight gain and increased appetite while treating the psychotic symptoms of delusions, hallucinations, dysfunctional thoughts, mood and behaviors (Drug, 2015).

Expected Outcomes

            It was expected that, by reducing the dosage of Zyprexa from 10 mg orally at bedtime to 7.5mg orally at bedtime, the patient would not gain additional weight. Additionally, the currently revised dosage of 7.5mg orally at bedtime is within the patient’s weight. Apart from being advised to stop snacking an entire day, the client will be advised to observe normal meal schedules and actively engage in regular physical exercise to lose the excess weight that she had initially added(Wei Xin, 2016).

Difference between Expected Outcomes and Actual Outcomes

The client returned to the clinic after four weeks accompanied by her husband. She had worsened. Her PANNS had increased by 10%, an indicator that all her negative symptoms were gradually worsening. However, her weight had stabilized and excess hunger episodes had abated. According to the husband’s explanation, the client was gradually becoming less manageable at home, which forced him to take time off work as he was fearful to leave her alone. This was clear that the therapeutic goals were not being achieved with the current dosing of 7.5 mg of Zyprexa orally at bedtime (Takeuchi et al., 2015). Assessing and Treating Clients With Psychosis and Schizophrenia Sample Essay.

Decision Point 3

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Decision Selected

Increase the dosage of Zyprexa to 10mg orally at bedtime and

Reason for Selecting this Decision

            From the client’s previous visit, it was notable that the dosage of 7.5 mg failed to help achieve the desired therapeutic levels. Despite the fact that having no complaints of weight gain and a manageable appetite, the client was reportedly unmanageable which also inconvenienced the husband. This also means that 7.5mg was an under dosage for the patient hence was insufficient to achieve the desired therapeutic goals for treatment. However, by returning to a dosage of 10 mg orally at bedtime, the client will receive similar side effects as that of the initial point of weight gain and increased appetite. Assessing and Treating Clients With Psychosis and Schizophrenia Sample Essay. Besides, she will also be at risk of Diabetes mellitus (Drug, 2015). Therefore, Risperdal could be considered a perfect option. Nonetheless, since Risperdal is dosed twice daily, compliance for this patient could be a problem. Evidence exists to support the efficacy of administering Risperdal once which is a good option in case compliance for this patient becomes an issue. Despite the fact that weight gain is also a side effect of Risperdal, it is not as serious as Zyprexa (Takeuchi et al., 2015).

Expected Outcomes

With Risperdal as an alternative, it is expected that the client will be more manageable and display less severe psychotic symptoms. She will report little or no delusions, hallucinations and significantly improve in terms of being more manageable (Takeuchi et al., 2015). Besides, the client will be able to execute her activities of daily life with little or no assistance and associated symptoms will have very minimal effect/impact on her overall life. Assessing and Treating Clients With Psychosis and Schizophrenia Sample Essay.

Difference between Expected Outcomes and Actual Outcomes

            Although the patient reported minor on and off delusional symptoms, there was no significant difference between the expected outcome and the actual outcome. The client demonstrated to be alert and oriented with a stable mood and fluent affect. She also reported no side effects of increased appetite or weight gain, an indicator that therapeutic goals were gradually being achieved (Takeuchi et al., 2015).

How Ethical Considerations Might Impact the Treatment Plan and Communication with Clients

A major ethical consideration in counseling this client and making the treatment plan is that of informed consent. Patients with schizophrenia tend to have neurological deficits such that, they are not mentally/psychologically fit to make decisions for themselves regarding treatment. The same way, it is difficult to tell whether by consenting to a treatment plan, they fully understand what they are consenting to. As supported by Young, Taylor & Lawrie (2015), while attempting to get an informed and voluntary consent from the patient, caution should be taken to ensure that any decisions made do not harm the patient. This means that a mental health practitioner ought to strive to strike a balance between the principle of autonomy and non-maleficence. Assessing and Treating Clients With Psychosis and Schizophrenia Sample Essay.

References

The drug, A. A. (2015). 8 Olanzapine (Zyprexa). Top Drugs: Their History, Pharmacology, and Syntheses, 138.

Takeuchi, H., Fervaha, G., Lee, J., Agid, O., & Remington, G. (2015). The effectiveness of different dosing regimens of risperidone and olanzapine in schizophrenia. European Neuropsychopharmacology25(3), 295-302.

Wei Xin Chong, J., Hsien-Jie Tan, E., Chong, C. E., Ng, Y., & Wijesinghe, R. (2016). Atypical antipsychotics: A review on the prevalence, monitoring, and management of their metabolic and cardiovascular side effects. Mental Health Clinician6(4), 178-184.

Young, S. L., Taylor, M., & Lawrie, S. M. (2015). “First do no harm.” A systematic review of the prevalence and management of antipsychotic adverse effects. Journal of Psychopharmacology29(4), 353-362. Assessing and Treating Clients With Psychosis and Schizophrenia Sample Essay.

 

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