NURS 6630 Assessing and Treating Patients With Sleep/Wake Disorders

NURS 6630 Assessing and Treating Patients With Sleep/Wake Disorders

Walden University NURS 6630 Assessing and Treating Patients With Sleep/Wake Disorders-Step-By-Step Guide

This guide will demonstrate how to complete the Walden University  NURS 6630 Assessing and Treating Patients With Sleep/Wake Disorders  assignment based on general principles of academic writing. Here, we will show you the A, B, Cs of completing an academic paper, irrespective of the instructions. After guiding you through what to do, the guide will leave one or two sample essays at the end to highlight the various sections discussed below.

How to Research and Prepare for  NURS 6630 Assessing and Treating Patients With Sleep/Wake Disorders

Whether one passes or fails an academic assignment such as the Walden University   NURS 6630 Assessing and Treating Patients With Sleep/Wake Disorders depends on the preparation done beforehand. The first thing to do once you receive an assignment is to quickly skim through the requirements. Once that is done, start going through the instructions one by one to clearly understand what the instructor wants. The most important thing here is to understand the required format—whether it is APA, MLA, Chicago, etc.

After understanding the requirements of the paper, the next phase is to gather relevant materials. The first place to start the research process is the weekly resources. Go through the resources provided in the instructions to determine which ones fit the assignment. After reviewing the provided resources, use the university library to search for additional resources. After gathering sufficient and necessary resources, you are now ready to start drafting your paper.

How to Write the Introduction for  NURS 6630 Assessing and Treating Patients With Sleep/Wake Disorders

The introduction for the Walden University   NURS 6630 Assessing and Treating Patients With Sleep/Wake Disorders is where you tell the instructor what your paper will encompass. In three to four statements, highlight the important points that will form the basis of your paper. Here, you can include statistics to show the importance of the topic you will be discussing. At the end of the introduction, write a clear purpose statement outlining what exactly will be contained in the paper. This statement will start with “The purpose of this paper…” and then proceed to outline the various sections of the instructions.

How to Write the Body for  NURS 6630 Assessing and Treating Patients With Sleep/Wake Disorders 

After the introduction, move into the main part of the  NURS 6630 Assessing and Treating Patients With Sleep/Wake Disorders assignment, which is the body. Given that the paper you will be writing is not experimental, the way you organize the headings and subheadings of your paper is critically important. In some cases, you might have to use more subheadings to properly organize the assignment. The organization will depend on the rubric provided. Carefully examine the rubric, as it will contain all the detailed requirements of the assignment. Sometimes, the rubric will have information that the normal instructions lack.

Another important factor to consider at this point is how to do citations. In-text citations are fundamental as they support the arguments and points you make in the paper. At this point, the resources gathered at the beginning will come in handy. Integrating the ideas of the authors with your own will ensure that you produce a comprehensive paper. Also, follow the given citation format. In most cases, APA 7 is the preferred format for nursing assignments.

How to Write the Conclusion for  NURS 6630 Assessing and Treating Patients With Sleep/Wake Disorders

After completing the main sections, write the conclusion of your paper. The conclusion is a summary of the main points you made in your paper. However, you need to rewrite the points and not simply copy and paste them. By restating the points from each subheading, you will provide a nuanced overview of the assignment to the reader.

How to Format the References List for  NURS 6630 Assessing and Treating Patients With Sleep/Wake Disorders

The very last part of your paper involves listing the sources used in your paper. These sources should be listed in alphabetical order and double-spaced. Additionally, use a hanging indent for each source that appears in this list. Lastly, only the sources cited within the body of the paper should appear here.

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Sample Answer for NURS 6630 Assessing and Treating Patients With Sleep/Wake Disorders

To promote a comprehensive understanding of the treatment of a patient with insomnia, this discussion examines the case of a 31-year-old male patient diagnosed with insomnia. The patient reports being used to getting inadequate sleep most of his life. However, ever since he lost his fiancé about 6 months ago, he has been finding it hard to fall and stay asleep. Previously, the patient was using diphenhydramine to manage his insomnia but stopped due to the side effects experienced upon waking up. His work requires very high concentration levels which are greatly impacted by his inability to get enough sleep at night. The patient even reports that he has been falling asleep at work recently. As reported by the patient’s previous physician, he has a history of opiate abuse, which was developed when he was prescribed hydrocodone/APAP (acetaminophen) for managing pain associated with his broken ankle from skiing. The patient however denies use of opioid analgesics for the past 4 years. He however reports drinking alcohol every night to help him sleep. Mental status examination reveals no possibilities of comorbidities.

Several medications have been proven to be effective in the management of insomnia among adults. However, the choice of which medication to prescribe depends on several patient factors. For the patient in this discussion, such factors include his age, gender, and insomnia diagnosis. His previous use of diphenhydramine but with undesirable side effects will also be considered. His social history of losing his fiancé, history of opiate abuse, and use of alcohol will also play a significant role in determining the most effective drug choice. The purpose of this paper is to illustrate the decisions made in prescribing medication for the treatment of young adult patients with insomnia, in addition to the ethical consideration at each decision point.

Decision #1

Selected Decision and Rationale

            Out of the provided alternatives, starting the patient on trazodone 50mg once daily at bedtime seems to be the most appropriate decision. Trazodone is an antidepressant with a complex mode of action primarily associated with the inhibition of the serotonin pathway (Martsenkovskyi & Napryeyenko, 2019). The drug is frequently prescribed off-label for the management of chronic insomnia high tolerance levels and effectiveness in initiating and maintaining sleep (Winkelman, 2015; Grandner & Perlis, 2019). The initial dose of the drug for adults with insomnia usually ranges from 25 to 50mg once daily, but the dose may range to up to 150mg once daily depending on the treatment outcome (Sateia et al., 2017). The drug is administered orally with a rapid absorption rate that promotes a short onset of action with peak plasma concentration being attained within 30 minutes to 1 hour. It is metabolized primarily via the CYP2D6 and CYP3A4 pathways with reduced risks of toxicity and adverse events.

Zolpidem can be used in the management of insomnia but is associated with increased risks of life-threatening sleep behaviors hence should only be recommended in case there is no other safer alternative (Sateia et al., 2017). On the other hand, it was not appropriate to prescribe hydroxyzine, given it belongs to a similar class of drugs to diphenhydramine (antihistamines) which already displayed undesirable side effects which made the patient discontinue using the drug (Martsenkovskyi & Napryeyenko, 2019; Yi et al., 2018).

Expected Outcome

            In about four weeks, the patient is expected to report to the hospital with significantly improved sleeping patterns (Sateia et al., 2017). He should be able to sleep adequately through the night, and exhibit improved concentration and energy levels the following morning (Grandner & Perlis, 2019).

Ethical Considerations

            When treating adult patients, the PMHNP needs to uphold the patient’s privacy and confidentiality. Consequently, the patient’s decision must be respected to uphold his autonomy.

Decision #2

Selected Decision and Rationale

            Looking at the reported treatment outcome after four weeks, it was necessary to reduce the trazodone dose to 25 mg orally at bedtime. The decision was mainly based on the reported side effect of prolonged erection the following morning (Madari et al., 2021). The patient displayed a positive outcome of the drug in managing his insomnia which is an indication of potential effectiveness (Sateia et al., 2017; Akinnusi & El Solh, 2019). Studies show that when used at low doses, the risks of potential side effects of trazodone such as priapism are normally reduced (Winkelman, 2015; Martsenkovskyi & Napryeyenko, 2019). Additionally, it has been reported that in case of self-limiting side effects like prolonged erection, reducing the dose will promote the side effect disappearing within a shorter time, hence promoting the patient’s tolerance to the medication (Yi et al., 2018).

Explaining to the patient that the reported side effect is not priapism and will resolve with time, without altering the dose was not necessary as this would promote worsening of the side effect (Grandner & Perlis, 2019; Yi et al., 2018). Consequently, stopping trazodone and starting suvorexant was also inappropriate given that the patient’s response within the two weeks displayed great adherence to the medication with only one self-limiting side effect, which does not qualify termination of the treatment therapy (Martsenkovskyi & Napryeyenko, 2019).

Expected Outcome

            The reported side effects of prolonged erection in the morning are expected to diminish within the next 4 weeks upon reducing the dose to 25mg once daily (Sateia et al., 2017). The patient’s sleeping pattern is also expected to improve even further within this time (Yi et al., 2018).

Ethical Considerations

            With the obligation of preventing harm to the patient and respecting their autonomy, the PMHNP needed to consider the patient’s discomfort with the reported side effects of the drug (Grandner & Perlis, 2019). As such, it was necessary to observe ethical principles such as justice and nonmaleficence in promoting clinical decision which promotes using a lower dose of the drug, which is still effective to elicit desired effects (Madari et al., 2021).

Decision #3

Selected Decision and Rationale

            Looking at the available options in line with the reported outcome from the initial intervention, the last decision was to continue using the same drug, at the same frequency and dose and encourage sleep hygiene. The patient has displayed great adherence and tolerance to trazodone, as the previously reported side effect diminished (Winkelman, 2015). However, the dose was quite low, hence sometimes failing to help the patient sleep through the night. Studies show that at low doses, trazodone can take up to 8 to 12 weeks to completely help patients sleep through the night (Grandner & Perlis, 2019). Consequently, to avoid side effects associated with the use of several pharmacological agents, evidence supports the use of nonpharmacological interventions such as appropriate sleep hygiene to promote treatment outcomes (Sateia et al., 2017; Yi et al., 2018).

Replacing trazodone with ramelteon, which is a hypnotic was not necessary as the already displayed great tolerance and adherence to trazodone, and the latter is also associated with undesired cardiovascular side effects which might compromise the patient’s health (Martsenkovskyi & Napryeyenko, 2019). As stated earlier, replacing trazodone with hydroxyzine was also inappropriate as hydroxyzine being an antihistamine would only lead to undesired side effects which might affect the patient’s compliance with the medication (Grandner & Perlis, 2019).

Expected Outcome

At this point, the patient is expected to attain an adequate amount of sleep every night with the adoption of appropriate sleep hygiene (Winkelman, 2015). No side effects are expected. Patient productivity at work is expected to improve due to improved quality of sleep (Yi et al., 2018).

Ethical Considerations

            Adult patients have the legal right of making sound decisions concerning their health. As such, the PMHNP must ensure that the patient is adequately acknowledged of the available treatment options, and the benefits and limitations of each choice (Grandner & Perlis, 2019). Respecting patient autonomy is also crucial in promoting trust and a positive care outcome (Martsenkovskyi & Napryeyenko, 2019).

Conclusion

Several drugs have been recommended for the management of insomnia among adults. However, the decision on which medication to prescribe greatly depends on several patient-specific factors. The provided case demonstrates a young adult male patient with worsening insomnia. The patient was initially taking phenylhydrazine for the management of his insomnia but did not like the way it made him feel the following morning. Out of the available options, the first decision was to start the patient on trazodone 50mg orally every night. The drug has been approved by the FDA for the management of depression, but due to its tolerance and great effectiveness in the management of chronic insomnia, it is frequently prescribed doff label (Winkelman, 2015). Zolpidem and hydroxyzine were thus neglected due to their increased risks of toxicity (Martsenkovskyi & Napryeyenko, 2019). After two weeks, the patient came back to the hospital complaining of prolonged erection the following morning, but with well-managed insomnia (Akinnusi & El Solh, 2019). This outcome led to the second decision which was to reduce the dose of the drug to 25 mg every night (Yi et al., 2018). Discontinuing the drug and initiating suvorexant instead was not appropriate due to associated safety risks (Madari et al., 2021).

The patient reported that the side effect diminished after 2 weeks, but the dose was quite low to keep him asleep through the night. As such, the final decision was to continue using the same drug at the same dose and consider sleep hygiene to promote the treatment outcome (Sateia et al., 2017). In each decision process, the PMHNP was forced to observe several ethical principles including justice, autonomy, nonmaleficence, and observing the patient’s privacy and confidentiality (Grandner & Perlis, 2019). The patient was also adequately informed about each decision process, in terms of all the available options with their benefits and limitations.

References

Akinnusi, M., & El Solh, A. A. (2019). Drug treatment strategies for insomnia in patients with post-traumatic stress disorder. Expert Opinion on Pharmacotherapy, 20(6), 691–699. https://doi.org/10.1080/14656566.2019.1574745

Grandner, M. A., & Perlis, M. L. (2019). Pharmacotherapy for Insomnia Disorder in Older Adults. JAMA Network Open, 2(12), e1918214. https://doi.org/10.1001/jamanetworkopen.2019.18214

Madari, S., Golebiowski, R., Mansukhani, M. P., & Kolla, B. P. (2021). Pharmacological Management of Insomnia. Neurotherapeutics. https://doi.org/10.1007/s13311-021-01010-z

Martsenkovskyi, D., & Napryeyenko, O. (2019). P.818 Adjunctive therapy with trazodone for insomnia in adolescents with post-traumatic stress disorder and depression. European Neuropsychopharmacology, 29, S543–S544. https://doi.org/10.1016/j.euroneuro.2019.09.682

Sateia, M. J., Buysse, D. J., Krystal, A. D., Neubauer, D. N., & Heald, J. L. (2017). Clinical Practice Guideline for the Pharmacologic Treatment of Chronic Insomnia in Adults: An American Academy of Sleep Medicine Clinical Practice Guideline. Journal of Clinical Sleep Medicine, 13(02), 307–349. https://doi.org/10.5664/jcsm.6470

Winkelman, J. W. (2015). Insomnia Disorder. New England Journal of Medicine, 373(15), 1437–1444. https://doi.org/10.1056/nejmcp1412740

Yi, X., Ni, S., Ghadami, M. R., Meng, H., Chen, M., Kuang, L., Zhang, Y., Zhang, L., & Zhou, X. (2018). Trazodone for the treatment of insomnia: a meta-analysis of randomized placebo-controlled trials. Sleep Medicine, 45, 25–32. https://doi.org/10.1016/j.sleep.2018.01.010

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Sample Answer 2 for NURS 6630 Assessing and Treating Patients With Sleep/Wake Disorders

Insomnia is the most prevalent sleep disorder affecting a substantive amount of the population. It is characterized by the inability to initiate, and maintain sleep or simply a poor sleep quality. Insomnia affects 10-15% of the population (Kaur et al., 2020). Insomnia can be graded based on the duration and the frequency of symptoms. This week’s case study focuses on a 31-year-old male who presented with a chief complaint of insomnia which has progressively gotten worse over the past six months. The symptomatology includes difficulty in falling asleep and staying asleep at night. The problem began after the loss of his fiancé. The problem affects his work. He has used diphenhydramine in the past to sleep but stopped due to the side effect of marked morning drowsiness. He has a history of opiate abuse which started with the prescription medication hydrocodone when he broke his ankle. He has not had any other prescription for the opiate for four years. The patient currently uses alcohol to help him fall asleep. The Mental Status Exam is normal. He denies any auditory or visual hallucinations. His judgment and insight are intact. The patient denies any suicidal ideations and is future-oriented. There are no features of depression or any other mental or physical illness.

The symptomatology of increased sleep latency, difficulty maintaining sleep, and daytime symptoms confirm the diagnosis of insomnia. The co-morbidities like alcohol use disorder, history of opiate abuse, previous pharmacotherapy for insomnia using diphenhydramine, and the maladaptive disorder of alcohol abuse to induce sleep will all greatly influence medication decisions. The selected drug must confer low toxicity, high efficacy for reduction of sleep latency and maintaining sleep, tolerability to minimize drug non-compliance, and minimal side effects especially drowsiness that may affect the subsequent day’s work. Cognitive Behavioral Therapy in conjunction with drug therapy is highly efficacious in insomnia management. The treatment is aimed at providing the best-indicated medication to the patient to provide remission of symptomatology. The treatment also aims at preventing the development of complications like depression, diabetes, and other cardiovascular diseases. Standard individualized care is indicated for a full recovery. The purpose of this paper is to describe the decision points taken to treat this patient regarding medication choice, the expectation with each decision, and ethical considerations

Decision 1

Trazodone 50mg at bedtime.

Reason for Selection

For this particular case, trazodone is the drug for use in the management. From Randomized Clinical Trials on Trazodone use in the treatment of Insomnia, it was highly efficacious in maintaining sleep by reducing the number of awakenings during sleep, it remarkably improved the quality of sleep, and was well tolerated by a majority of patients in short-term treatment (Wichniak et al., 2021). In primary Insomnia, a combination of CBT and Trazodone was found to have the highest efficacy in reducing sleep latency. Trazodone has a half-life of 12 hours with a peak plasma concentration of four hours. When trazodone is taken 1-2 hours before bedtime, it can reduce sleep latency. Trazodone reduces the risk of relapse in alcohol-dependent patients. Hypnotics like Zolpidem reduce the quality and depth of sleep and has a higher risk of drug dependence. As a result, Zolpidem is not effective in the treatment of patients with poor quality sleep insomnia (Wichniak et al., 2021). Zolpidem is also associated with adverse effects such as anterograde amnesia and an increased risk of falls. Concerning Hydroxyzine, it is only indicated for the treatment of accidental insomnia (Krysta, 2020). It is also associated with marked sedation and increased morning drowsiness. The use of hydroxyzine in the management of insomnia is highly unpopular due to hyperacute tolerance and increased daytime somnolence (Albrecht et al., 2019).  There is no further literature that justifies its use.

Sleep disorders are conditions that result in changes in an individual’s pattern of sleep (Mayo Clinic, 2020). Not surprisingly, a sleep disorder can affect an individual’s overall health, safety, and quality of life. Psychiatric nurse practitioners can treat sleep disorders with psychopharmacologic treatments, however, many of these drugs can have negative effects on other aspects of a patient’s health and well-being. Additionally, while psychopharmacologic treatments may be able to address issues with sleep, they can also exert potential challenges with waking patterns. Thus, it is important for the psychiatric nurse practitioner to carefully evaluate the best psychopharmacologic treatments for patients that present with sleep/wake disorders.

Reference:

Mayo Clinic. (2020). Sleep disorders. https://www.mayoclinic.org/diseases-conditions/sleep-disorders/symptoms-causes/syc-20354018

Sample Answer 3 for NURS 6630 Assessing and Treating Patients With Sleep/Wake Disorders

Insomnia is a mental disorder that affects significantly the health, wellbeing, and functioning of the patients. Therefore, this paper examines a case study of a 31-year-old male that presents with chief complaint of insomnia. The patient reported that the insomnia has worsened progressively over the last six months. The problem started about six months ago after his fiancé passed on. Insomnia has affected his ability to perform at his job as a forklift operator. The patient has a history of using diphenhydramine to enhance sleep but did not like what he felt the morning after, as he fallen asleep because of lack of sleep the night before. The patient’s history also shows that he has opiate abuse after breaking his ankle where he was prescribed acetaminophen for pain management. However, he has not received an opiate prescription for the last four years.

The patient also has a history of alcohol use to induce sleep. He drinks about four beers before bed. Mental status exam performed on the patient showed that he was oriented to place, time, person, and event. He made eye contact, dressed appropriately for the occasion, denied hallucinations, with judgement, insight, and reality being intact. He also denied suicidal ideation and future oriented. Therefore, the patient factors that will affect the selected treatment include his age, experience with diphenhydramine, opiate abuse, and alcohol use. The selected treatments should not predispose him to unwanted outcomes such as poor performance at workplace, dependence, or increased use of alcohol to manage insomnia symptoms.

Decision 1

Selected Decision

Zolpidem: 10 mg daily at bedtime

Why I Selected the Decision

I selected Zolpidem for the patient because of its high level of tolerance and efficacy in managing insomnia and minimal residual effects. According to Xiang et al., (2021), Zolpidem is highly effective in increasing the total sleep time, reducing sleep latency, and enhancing sleep quality in patients suffering from insomnia disorder. Clinical trials have also demonstrated that Zolpidem has a high efficacy level in improving wake after sleep onset, which enhances the performance and productivity of the patients affected by insomnia disorder (Inoue et al., 2022). In another study, zolpidem was found to increase patients’ ability to sleep within 30 minutes, eliminate troubles they experience staying awake during daytime, and remaining motivated to get things done (Asok et al., 2019). The effectiveness was high as compared to placebo and use of other agents to enhance sleep.

Why the Other Two were not Selected?

I did not select the decision to initiate the patient on Trazodone 50 mg PO at bedtime because it is not the first-line drug of choice for insomnia. Instead, it is recommended for patients treated with selective serotonin reuptake inhibitors (SSRIs) to manage their associated insomnia (Cuomo et al., 2019). I did not select the decision to start the patient with Hydroxyzine 50 mg daily at bedtime. This is because it is a histamine H1 blocker, which the patient reported having a negative experience with it (Sharma et al., 2019). Its administration is likely to affect treatment adherence, hence, the lack of realization of the desired outcomes.

What I was Hoping to Achieve

I was hoping to achieve improvements in sleep quality, latency, after night performance, and functioning in the patient. This is largely attributed to the effects of zolpidem on sleep. I was also hoping to see the patient tolerating the selected treatment (Xiang et al., 2021).

Ethical Considerations

The ethical consideration that informed the adopted decision is the principle of beneficence and non-maleficence. Psychiatric mental health nurses should adopt treatments associated with minimal harm and optimum patient benefits. As a result, zolpidem has more benefits than harm as compared to the given options (Xiang et al., 2021).

Decision 2

Selected Decision

Discontinue zolpidem and initiate therapy with Trazodone 50-100 mg daily at bedtime.

Why I Selected the Decision

The decision to discontinue zolpidem and initiate therapy with trazodone 50-100 mg daily at bedtime was adopted. This is because the patient returned to the clinic with complains that suggested that he developed adverse effects associated with zolpidem. Accordingly, he reports that he felt knocked out, waking up in the middle of the night and cooking breakfast and having no recollection of the occurrence, and taking the medication with beer right before bedtime to get sleep. As shown by Asok et al., (2019), these are some of the unwanted side effects of zolpidem. Trazodone would be the best drug of choice at this time. According to Pochiero et al., (2022), Trazodone is an off-label drug that is used in treating acute cases of insomnia because of its high affinity for alpha 1 and serotonin 2A receptors that regulate sleep. The long-term use of trazodone is associated with improved sleep complaints and enhanced cognitive and functional scores among patients suffering from insomnia (La et al., 2019). Therefore, it makes it an effective drug to manage insomnia symptoms for the patient.

Why the Other Two were not Selected?

I did not select the decision to decrease zolpidem to 5 mg daily at bedtime because the client demonstrated symptoms of adverse reaction to the drug. Its continued administration is associated with the increased risk of worsening symptoms and poor treatment adherence. I did not select the decision to discontinue zolpidem and initiate eszopiclone 1 mg daily at bedtime because it has a high risk of symptom relapse as well as studies demonstrating high efficacy when used in elderly patients (Liang et al., 2019).

What I was Hoping to Achieve

I was hoping to eliminate the adverse effects the patient developed towards zolpidem. I was also hoping to improve his sleep quality, eliminate night awakening, and improve his daily functioning. I was also hoping to improve his overall tolerance to the treatment (Cuomo et al., 2019).

Ethical Considerations

The ethical consideration that informed the above decision is utilizing evidence-based data to ensure safety and efficiency in treating mental health disorders. Psychiatric mental health nurses should adopt evidence-based decisions to minimize potentials of patient harm. As a result, the decision to change the treatment aimed at eliminating further risks associated with zolpidem in insomnia treatment (Xiang et al., 2021).

Decision 3

Selected Decision

Continue dose. Explain to patient he may split the 50 mg table in half. The decreased dose should minimize next day drowsiness. Follow up in 4 weeks.

Why I Selected the Decision

The client returned to the clinic in 2 weeks. He reported that trazodone is effective at 50 mg dose. However, he wakes up sometimes the following day with next-day drowsiness. He denies any auditory or visual hallucinations and is future oriented. These findings demonstrate the Trazodone has been effective in managing symptoms associated with insomnia. The patient denies night awakening and failing to recollect his experiences. He also does not take the drug with beer to enhance sleep quality. The next-day drowsiness is an expected finding because of the effect of the current dosage of trazodone (Cuomo et al., 2019). As a result, an effective solution would be to split the 50 mg tablet in half to minimize the next day drowsiness.

Why the Other Two were not Selected?

The decision to discontinue trazodone, initiate therapy with sonata 10 mg nightly at bedtime and following up in 4 weeks was not selected because trazodone had demonstrated the desired treatment outcomes. There was improvement in symptoms translating into no need to initiate the patient on a new drug. Similarly, the decision to discontinue trazodone and initiate therapy with hydroxyzine 50 mg at bedtime and following up in 4 weeks was not selected since trazodone had shown its effectiveness and efficacy. In addition, the patient has negative experience with diphenhydramine, which translate into a similar effect with hydroxyzine (Inoue et al., 2022).

What I was Hoping to Achieve

I was hoping to see sustained improvement in insomnia symptoms. I was also hoping that the patient will report minimal side effects associated with trazodone. Splitting the tablet into half was also expected to address the issue of next-day sleepiness (Cuomo et al., 2019).

Ethical Considerations

Ethical considerations such as justice, beneficence, and non-maleficence could have affected the adopted treatments. Accordingly, psychiatric mental health nurses demonstrate justice in their practice by ensuring confidentiality and privacy of the patient’s data. In addition, they ensure the adopted treatments are not harmful and aim at doing for their patients. Therefore, a violation of any of these principles would affect treatment outcomes.

Conclusion

In conclusion, the initially adopted treatment to begin the patient with zolpidem was ineffective. The patient demonstrated signs and symptoms of adverse reactions to zolpidem. This increased the need for the adoption trazodone to minimize the adverse and side effects while improving the symptoms of insomnia. The decision to begin the patient with zolpidem and not trazodone is that trazodone is largely used in patients with insomnia associated with other disorders. The selection of trazodone proved effective for the patient. There was the elimination of night awakening, feeling knocked out, and having to add beer to enhance his sleep quality. The patient reported feeling sleepy the following day, which necessitated the splitting of the Trazodone 50 mg table into half to address it (Cuomo et al., 2019). This decision led to further improvement in insomnia symptoms and drug tolerance, hence, the effectiveness of the decision.

Ethical considerations informed the patient’s treatment. Accordingly, the decisions made aimed at ensuring the promotion of safety, efficiency, and quality in the treatment process. The psychiatric mental health nurse practitioner made the decisions with the aim of optimizing benefits while minimizing the potential harm the selected drugs had on the patient. In addition, the principles of justice, autonomy, and beneficence, and non-maleficence informed the decisions made in the case study. For example, by minimizing harm, the nurse ensured the principle of non-maleficence. The use of evidence-based interventions in decision-making aimed at doing good for the patients (Xiang et al., 2021). Therefore, ethics guided the selected decisions in the patient’s treatment.

References

Asok, A., Sreekumar, S., TK, R., CC, A., P, U. D., & K, P. (2019). Effectiveness of zolpidem and sleep hygiene counseling in the treatment of insomnia in solid tumor patients. Journal of Oncology Pharmacy Practice, 25(7), 1608–1612. https://doi.org/10.1177/1078155218801062

Cuomo, A., Ballerini, A., Bruni, A. C., Decina, P., Sciascio, G. D., Fiorentini, A., Scaglione, F., Vampini, C., & Fagiolini, A. (2019). Clinical guidance for the use of trazodone in major depressive disorder and concomitant conditions: Pharmacology and clinical practice. Rivista di Psichiatria, 54(4), 137–149.

Inoue, Y., Nishida, M., Kubota, N., Koebis, M., Taninaga, T., Muramoto, K., Ishikawa, K., & Moline, M. (2022). Comparison of the treatment effectiveness between lemborexant and zolpidem tartrate extended release for insomnia disorder subtypes defined based on polysomnographic findings. Journal of Clinical Sleep Medicine. https://doi.org/10.5664/jcsm.10378

La, A. L., Walsh, C. M., Neylan, T. C., Vossel, K. A., Yaffe, K., Krystal, A. D., Miller, B. L., & Karageorgiou, E. (2019). Long-Term Trazodone Use and Cognition: A Potential Therapeutic Role for Slow-Wave Sleep Enhancers. Journal of Alzheimer’s Disease, 67(3), 911–921. https://doi.org/10.3233/JAD-181145

Liang, L., Huang, Y., Xu, R., Wei, Y., Xiao, L., & Wang, G. (2019). Eszopiclone for the treatment of primary insomnia: A systematic review and meta-analysis of double-blind, randomized, placebo-controlled trials. Sleep Medicine, 62, 6–13. https://doi.org/10.1016/j.sleep.2019.03.016

Pochiero, I., Gorini, M., Comandini, A., Calisti, F., Loreto, G. D., Cattaneo, A., Knight, T., Anastassopoulos, K. P., Patel, R., Baik, R., & Bruni, O. (2022). Real-World Characteristics and Treatment Patterns of Patients With Insomnia Prescribed Trazodone in the United States. Clinical Therapeutics, 44(8), 1093–1105. https://doi.org/10.1016/j.clinthera.2022.07.004

Sharma, M. K., Kainth, S., Kumar, S., Bhardwaj, A., Agarwal, H. K., Maiwall, R., Jamwal, K. D., Shasthry, S. M., Jindal, A., Choudhary, A., Anand, L., Dhamija, R. M., Kumar, G., Sharma, B. C., & Sarin, S. K. (2019). Effects of zolpidem on sleep parameters in patients with cirrhosis and sleep disturbances: A randomized, placebo-controlled trial. Clinical and Molecular Hepatology, 25(2), 199–209. https://doi.org/10.3350/cmh.2018.0084

Xiang, T., Cai, Y., Hong, Z., & Pan, J. (2021). Efficacy and safety of Zolpidem in the treatment of insomnia disorder for one month: A meta-analysis of a randomized controlled trial. Sleep Medicine, 87, 250–256. https://doi.org/10.1016/j.sleep.2021.09.005

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 with sleep/wake disorders.
The Assignment: 5 pages
Examine Case Study: Pharmacologic Approaches to the Treatment of Insomnia in a Younger Adult. 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.
NURS 6630 Assessing and Treating Patients With Sleep/Wake DisordersDecision #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.

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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. The Sample Paper provided at the Walden Writing Center provides an example of those required elements (available at https://academicguides.waldenu.edu/writingcenter/templates/general#s-lg-box-20293632). All papers submitted must use this formatting.

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________________________________________
What’s Coming Up in Week 9?

Photo Credit: [BrianAJackson]/[iStock / Getty Images Plus]/Getty Images
Next week, you will continue to build on your assessment and treatment skills as you examine patients presenting with signs and symptoms consistent with ADHD/ODD.
Next Week

To go to the next week:
Week 9

Week 8: Therapy for Patients With Sleep/Wake Disorders
From negative changes in mood to problems concentrating, sleep/wake disorders can have a tremendous impact on patients’ lives. When patients suffer from these disorders, they often seek medical care with the intent of receiving medications to manage symptoms. However, many of the medications used to treat sleep/wake disorders may be addictive, making thorough patient assessments and close follow-up care essential. To prescribe appropriate therapies with patient safety in mind, you must understand not only the pathophysiology of these disorders but also the pharmacologic agents used to treat them.
This week, as you study therapies for individuals with sleep/wake disorders, you examine the assessment and treatment of patients with these disorders. You also explore ethical and legal implications of these therapies.
Learning Objectives
Students will:
• Synthesize concepts related to the psychopharmacologic treatment of patients
• Assess patient factors and history to develop personalized therapy plans for patients with sleep/wake disorders
• Analyze factors that influence pharmacokinetic and pharmacodynamic processes in patients requiring therapy for sleep/wake disorders
• Synthesize knowledge of providing care to patients presenting for sleep/wake disorders
• Analyze ethical and legal implications related to prescribing therapy for patients with sleep/wake disorders
________________________________________

Also Read:

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NURS 6630 Case Study 53-year-old Puerto Rican Female with Comorbid Addiction

Learning Resources

Required Readings (click to expand/reduce)

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596

Fernandez-Mendoza, J., & Vgontzas, A. N. (2013). Insomnia and its impact on physical and mental health. Current Psychiatry Reports, 15(12), 418. https://doi.org/10.1007/s11920-012-0418-8

Levenson, J. C., Kay, D. B., & Buysse, D. J. (2015). The pathophysiology of insomnia. Chest, 147(4), 1179–1192. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4388122/

Morgenthaler, T. I., Kapur, V. K., Brown, T. M., Swick, T. J., Alessi, C., Aurora, R. N., Boehlecke, B., Chesson, A. L., Friedman, L., Maganti, R., Owens, J., Pancer, J., & Zak, R. (2007). Practice parameters for the treatment of narcolepsy and other hypersomnias of central origin. SLEEP, 30(12), 1705–1711. https://j2vjt3dnbra3ps7ll1clb4q2-wpengine.netdna-ssl.com/wp-content/uploads/2017/07/PP_Narcolepsy.pdf

Morgenthaler, T. I., Owens, J., Alessi, C., Boehlecke, B, Brown, T. M., Coleman, J., Friedman, L., Kapur, V. K., Lee-Chiong, T., Pancer, J., & Swick, T. J. (2006). Practice parameters for behavioral treatment of bedtime problems and night wakings in infants and young children. SLEEP, 29(1), 1277–1281. https://j2vjt3dnbra3ps7ll1clb4q2-wpengine.netdna-ssl.com/wp-content/uploads/2017/07/PP_NightWakingsChildren.pdf

Sateia, M. J., Buysse, D. J., Krystal, A. D., Neubauer, D. N., & Heald, J. L. (2017). Clinical practice guideline for the pharmacologic treatment of chronic insomnia in adults: An American Academy of Sleep Medicine clinical practice guideline. Journal of Clinical Sleep Medicine, 13(2), 307–349. https://jcsm.aasm.org/doi/pdf/10.5664/jcsm.6470

Winkleman, J. W. (2015). Insomnia disorder. The New England Journal of Medicine, 373(15), 1437–1444. https://doi.org/10.1056/NEJMcp1412740

Medication Resources (click to expand/reduce)

U.S. Food & Drug Administration. (n.d.). Drugs@FDA: FDA-approved drugs. https://www.accessdata.fda.gov/scripts/cder/daf/index.cfm

Note: To access the following medications, use the Drugs@FDA resource. Type the name of each medication in the keyword search bar. Select the hyperlink related to the medication name you searched. Review the supplements provided and select the package label resource file associated with the medication you searched. If a label is not available, you may need to conduct a general search outside of this resource provided. Be sure to review the label information for each medication as this information will be helpful for your review in preparation for your Assignments.
• alprazolam
• amitriptyline
• amoxapine
• amphetamine
• desipramine
• diazepam
• doxepin
• eszopiclone
• flunitrazepam
• flurazepam
• hydroxyzine
• imipramine
• lemborexant
• lorazepam
• melatonin
• methylphenedate
• modafinil • armodafinil
• carnitine
• clomipramine
• clonazepam
• nortriptyline
• pitolisant
• ramelteon
• sodium oxybate
• solriamfetol
• SSRI’s
• temazepam
• trazodone
• triazolam
• trimipramine
• wellbutrin
• zaleplon
• zolpidem

Sample Answer 3 for NURS 6630 Assessing and Treating Patients With Sleep/Wake Disorders

The patient, in this case, is a 31-year-old man with insomnia. The condition began six months ago after the sudden death of his wife. He is employed as a forklift operator at a local chemical company, but his health condition has affected his ability to perform his work. The patient claims that he has utilized diphenhydramine for sleeping in the past, but he does not like how he feels the next morning after using the medication. According to the patient’s prior physician’s medical record, he was abusing opiates after injuring his ankle in a skiing accident. The patient’s previous physician prescribed him hydrocodone/APAP (acetaminophen) for acute pain management after the accident. For four years, the individual has not received a prescription for an opiate analgesic. He points out that he has recently consumed approximately four beers to help him fall asleep. The patient is attentive and aware of the person talking to him, location, time, and incident. He maintains eye contact and is dressed appropriately for the season. All aspects of judgment, insight, and reality contact remain intact. The man also denies any suicidal ideas and is focused on the future.

Decision One

The treatment should start with Trazodone 10 mg daily at bedtime. Trazodone has been approved as an effective treatment for insomnia. The medicine is effective in lower doses in treating primary and secondary insomnia. Due to its generic availability, the medication is less expensive than newer insomnia medications. Trazodone can also be an effective sleep aid when taken in lower doses. The other reason for selecting the medication is that it is not addictive compared to other insomnia medications such as benzodiazepine class medication such as Valium and Xanax (Yi et al, 2018). The medication can also help the patient improve slow wave sleep, and the medication also has fewer side effects than most of the other medications used in treating insomnia.

There are various reasons why Zolpidem was not selected. The medication can result in severe allergic reactions in some patients. The various signs of allergic reaction due to the medication include swelling of the face and difficulty in breathing. The other reason is that the sedative effect of the medication is stronger than the other available options. The medication can also make a patient experience severe dizziness and drowsiness, resulting in falls, accidents, and severe injuries. Considering the nature of the patient’s work, the medication is not a good option because it can result in daytime drowsiness and dizziness, making the patient not conduct his job effectively. The medication can also result in a high level of aggressiveness and extroversion that is abnormal compared to the patient’s usual behavior (Jung, 2018). Considering that the patient has confirmed that he takes alcohol, Zolpidem cannot be used in the treatment process because the patient can experience auditory and visual hallucinations associated with strange behavior due to alcohol toxicity. Hydroxyzine 50mg was also not selected due to various. One of the main reasons is that the medication has a high side effects profile compared to Trazodone. The medication can also lead to daytime sedation, affecting how the patient will perform at work. Hydroxyzine can also result in various side effects such as skin rash, fast heartbeat, difficulty in swallowing, and chest discomfort (Silvestro, 2021).

From the treatment process, I expect that Trazodone will effectively treat the patient’s condition, and he will be able to sleep well. The patient experience an erection, which will last for approximately 15 minutes as a side effect of the medication. Ethical consideration will positively impact the treatment plan and when communicating with the patient. For instance, every decision and action that I will take will be for the fulfillment of the obligation to provide optimal care to the patient.

Decision Two

Explaining to the patient that an erection that lasts for approximately 15 minutes that he is experiencing is not priapism and should end over time, and he should continue taking the current dose. I choose this decision because the medication effectively treats insomnia, and the patient has enough sleep at night. Continuing with the current dose is also important because the patient is not experiencing any severe side effects apart from the prolonged erections and priapism due to its adrenergic blocking activity.

I did not select the decision to discontinue Trazodone and initiate treatment with suvorexant 1o mg at bedtime daily because of various reasons. Trazodone effectively treated the patient’s condition, and the patient did not experience any side effects; hence, changing the medication will negatively impact the treatment process. Initiating treatment with suvorexant is not a good decision. The medication is associated with various side effects such as next-day drowsiness and agitation. There is also limited evidence supporting the safety of using suvorexant in treating insomnia. The medication can cause the patient to become less alert during the day and feel drowsiness, headache, and dizziness. The medication can also result in memory problems or confusion. The patient can experience disturbed sleep as a side effect and have various experiences such as abnormal dreams, nightmares, and hallucinations. The medication can also cause the patient to experience sleep paralysis or even walk in their sleep.

Decreasing the current trazodone dose to 25 mg daily at bedtime is also not a good decision because the current dose of the medication was effective in treating the patient’s condition. Dose reduction can only be implemented when the patient is experiencing severe side effects due to the medication or it is too expensive for the patient to purchase the current dose of the medication (Yi et al, 2018). Considering the effectiveness of the current dose of Trazodone, reducing the dose can reduce the medication’s efficiency in treating insomnia or slow down the treatment process. I expect the patient to experience a further decrease in priapism from the treatment approach, and insomnia will also decrease. In this case, ethical consideration will ensure that I avoid causing harm to the patient.

Decision Three

The patient should continue with the current dose, and he may split the 50mg tablet into two. Decreasing the dose will help in reducing next-day drowsiness. In order to reduce the side effects of the medication, it is crucial to reduce the current dose to a lower dose considering that the medication is effective and the patient is getting better. Taking a lower dose of Trazodone is proven to be similarly effective than a higher dose, with appreciably fewer adverse effects such as decreased drowsiness and potentially improved quality of life.

The decision to discontinue Trazodone and initiate treatment with sonata 10 mg administered during bedtime is not good. This is because Trazadone has been effective in managing the patient’s condition. Initiating therapy with sonata 10 mg will is not a good decision considering the patient operates a vehicle in the chemical industry. This is because one of the major side effects of the sonata is lack of coordination which can lead to an accident, especially when an individual is driving. Other side effects of the medication that can reduce the patient’s quality of life include dizziness, drowsiness, and short-term memory loss. Another reason why treatment with sonata should not be initiated is that the medication is habit forming and can lead to dependency and can also be abused (Reeve & Bailes, 2010). Due to its habit-forming characteristics, it is not advisable to use the medication in long-term treatment, and it has not been proven to be effective in treating patients with long-term insomnia. Considering the patient has a history of alcohol consumption, the medication is not the best option and can result in various withdrawal symptoms if the patient suddenly stops using it.

The decision to discontinue Trazadone and start treatment with hydroxyzine 50 mg at bedtime is also not advisable. Hydroxyzine cannot be clinically significant to the patient considering the medication has a comparatively long half-life of approximately 20 hours (Schiffman et al, 2011). This will result in daytime sedation after sleeping at night. The medication also has a high side effect profile compared to the low side effect profile of Trazodone. Introducing hydroxyzine can also result in other adverse side effects such as Xerostomia and Xerophthalmia.

From the treatment approach, I expect the patient condition to become better after another four weeks of using the medication. Priapism will also diminish completely, and the level of drowsiness will decrease because the patient will be using a lower dose than the initial dose. Ethical consideration will be crucial in the treatment process and communication with the patient because it will allow me to minimize the medication’s harm to the patient and focus on promoting good health (Haddad, 2018).

References

Haddad, L. M., & Geiger, R. A. (2018). Nursing ethical considerations.

Jaffer, K. Y., Chang, T., Vanle, B., Dang, J., Steiner, A. J., Loera, N., … & Ishak, W. W. (2017). Trazodone for insomnia: a systematic review. Innovations in clinical neuroscience, 14(7-8), 24.

Jung, M. (2018). Zolpidem overdose: a dilemma in mental health. The Health Care Manager, 37(1), 86-89.

Reeve, K., & Bailes, B. (2010). Insomnia in adults: Etiology and management. The journal for nurse practitioners, 6(1), 53-60.

Schiffman, J., Davis, M., Pierre, J., & Saunders, C. S. (2011). Hydroxyzine: rational choice for inpatients with insomnia. Current Psychiatry, 10(3), 88-89.

Silvestro, S. (2021). Hydroxyzine (Vistaril): dosage, uses, side effects. Drugs.

Sample Answer 3 for NURS 6630 Assessing and Treating Patients With Sleep/Wake Disorders

To promote a comprehensive understanding of the treatment of a patient with insomnia, this discussion examines the case of a 31-year-old male patient diagnosed with insomnia. The patient reports being used to getting inadequate sleep most of his life. However, ever since he lost his fiancé about 6 months ago, he has been finding it hard to fall and stay asleep. Previously, the patient was using diphenhydramine to manage his insomnia but stopped due to the side effects experienced upon waking up. His work requires very high concentration levels which are greatly impacted by his inability to get enough sleep at night. The patient even reports that he has been falling asleep at work recently. As reported by the patient’s previous physician, he has a history of opiate abuse, which was developed when he was prescribed hydrocodone/APAP (acetaminophen) for managing pain associated with his broken ankle from skiing. The patient however denies use of opioid analgesics for the past 4 years. He however reports drinking alcohol every night to help him sleep. Mental status examination reveals no possibilities of comorbidities.

Several medications have been proven to be effective in the management of insomnia among adults. However, the choice of which medication to prescribe depends on several patient factors. For the patient in this discussion, such factors include his age, gender, and insomnia diagnosis. His previous use of diphenhydramine but with undesirable side effects will also be considered. His social history of losing his fiancé, history of opiate abuse, and use of alcohol will also play a significant role in determining the most effective drug choice. The purpose of this paper is to illustrate the decisions made in prescribing medication for the treatment of young adult patients with insomnia, in addition to the ethical consideration at each decision point.

 Decision #1

Selected Decision and Rationale

            Out of the provided alternatives, starting the patient on trazodone 50mg once daily at bedtime seems to be the most appropriate decision. Trazodone is an antidepressant with a complex mode of action primarily associated with the inhibition of the serotonin pathway (Martsenkovskyi & Napryeyenko, 2019). The drug is frequently prescribed off-label for the management of chronic insomnia high tolerance levels and effectiveness in initiating and maintaining sleep (Winkelman, 2015; Grandner & Perlis, 2019). The initial dose of the drug for adults with insomnia usually ranges from 25 to 50mg once daily, but the dose may range to up to 150mg once daily depending on the treatment outcome (Sateia et al., 2017). The drug is administered orally with a rapid absorption rate that promotes a short onset of action with peak plasma concentration being attained within 30 minutes to 1 hour. It is metabolized primarily via the CYP2D6 and CYP3A4 pathways with reduced risks of toxicity and adverse events.

Zolpidem can be used in the management of insomnia but is associated with increased risks of life-threatening sleep behaviors hence should only be recommended in case there is no other safer alternative (Sateia et al., 2017). On the other hand, it was not appropriate to prescribe hydroxyzine, given it belongs to a similar class of drugs to diphenhydramine (antihistamines) which already displayed undesirable side effects which made the patient discontinue using the drug (Martsenkovskyi & Napryeyenko, 2019; Yi et al., 2018).

Expected Outcome

            In about four weeks, the patient is expected to report to the hospital with significantly improved sleeping patterns (Sateia et al., 2017). He should be able to sleep adequately through the night, and exhibit improved concentration and energy levels the following morning (Grandner & Perlis, 2019).

Ethical Considerations

            When treating adult patients, the PMHNP needs to uphold the patient’s privacy and confidentiality. Consequently, the patient’s decision must be respected to uphold his autonomy.

Decision #2

Selected Decision and Rationale

            Looking at the reported treatment outcome after four weeks, it was necessary to reduce the trazodone dose to 25 mg orally at bedtime. The decision was mainly based on the reported side effect of prolonged erection the following morning (Madari et al., 2021). The patient displayed a positive outcome of the drug in managing his insomnia which is an indication of potential effectiveness (Sateia et al., 2017; Akinnusi & El Solh, 2019). Studies show that when used at low doses, the risks of potential side effects of trazodone such as priapism are normally reduced (Winkelman, 2015; Martsenkovskyi & Napryeyenko, 2019). Additionally, it has been reported that in case of self-limiting side effects like prolonged erection, reducing the dose will promote the side effect disappearing within a shorter time, hence promoting the patient’s tolerance to the medication (Yi et al., 2018).

Explaining to the patient that the reported side effect is not priapism and will resolve with time, without altering the dose was not necessary as this would promote worsening of the side effect (Grandner & Perlis, 2019; Yi et al., 2018). Consequently, stopping trazodone and starting suvorexant was also inappropriate given that the patient’s response within the two weeks displayed great adherence to the medication with only one self-limiting side effect, which does not qualify termination of the treatment therapy (Martsenkovskyi & Napryeyenko, 2019).

Expected Outcome

            The reported side effects of prolonged erection in the morning are expected to diminish within the next 4 weeks upon reducing the dose to 25mg once daily (Sateia et al., 2017). The patient’s sleeping pattern is also expected to improve even further within this time (Yi et al., 2018).

Ethical Considerations

            With the obligation of preventing harm to the patient and respecting their autonomy, the PMHNP needed to consider the patient’s discomfort with the reported side effects of the drug (Grandner & Perlis, 2019). As such, it was necessary to observe ethical principles such as justice and nonmaleficence in promoting clinical decision which promotes using a lower dose of the drug, which is still effective to elicit desired effects (Madari et al., 2021).

Decision #3

Selected Decision and Rationale

            Looking at the available options in line with the reported outcome from the initial intervention, the last decision was to continue using the same drug, at the same frequency and dose and encourage sleep hygiene. The patient has displayed great adherence and tolerance to trazodone, as the previously reported side effect diminished (Winkelman, 2015). However, the dose was quite low, hence sometimes failing to help the patient sleep through the night. Studies show that at low doses, trazodone can take up to 8 to 12 weeks to completely help patients sleep through the night (Grandner & Perlis, 2019). Consequently, to avoid side effects associated with the use of several pharmacological agents, evidence supports the use of nonpharmacological interventions such as appropriate sleep hygiene to promote treatment outcomes (Sateia et al., 2017; Yi et al., 2018).

Replacing trazodone with ramelteon, which is a hypnotic was not necessary as the already displayed great tolerance and adherence to trazodone, and the latter is also associated with undesired cardiovascular side effects which might compromise the patient’s health (Martsenkovskyi & Napryeyenko, 2019). As stated earlier, replacing trazodone with hydroxyzine was also inappropriate as hydroxyzine being an antihistamine would only lead to undesired side effects which might affect the patient’s compliance with the medication (Grandner & Perlis, 2019).

Expected Outcome

At this point, the patient is expected to attain an adequate amount of sleep every night with the adoption of appropriate sleep hygiene (Winkelman, 2015). No side effects are expected. Patient productivity at work is expected to improve due to improved quality of sleep (Yi et al., 2018).

Ethical Considerations

            Adult patients have the legal right of making sound decisions concerning their health. As such, the PMHNP must ensure that the patient is adequately acknowledged of the available treatment options, and the benefits and limitations of each choice (Grandner & Perlis, 2019). Respecting patient autonomy is also crucial in promoting trust and a positive care outcome (Martsenkovskyi & Napryeyenko, 2019).

Conclusion

Several drugs have been recommended for the management of insomnia among adults. However, the decision on which medication to prescribe greatly depends on several patient-specific factors. The provided case demonstrates a young adult male patient with worsening insomnia. The patient was initially taking phenylhydrazine for the management of his insomnia but did not like the way it made him feel the following morning. Out of the available options, the first decision was to start the patient on trazodone 50mg orally every night. The drug has been approved by the FDA for the management of depression, but due to its tolerance and great effectiveness in the management of chronic insomnia, it is frequently prescribed doff label (Winkelman, 2015). Zolpidem and hydroxyzine were thus neglected due to their increased risks of toxicity (Martsenkovskyi & Napryeyenko, 2019). After two weeks, the patient came back to the hospital complaining of prolonged erection the following morning, but with well-managed insomnia (Akinnusi & El Solh, 2019). This outcome led to the second decision which was to reduce the dose of the drug to 25 mg every night (Yi et al., 2018). Discontinuing the drug and initiating suvorexant instead was not appropriate due to associated safety risks (Madari et al., 2021).

The patient reported that the side effect diminished after 2 weeks, but the dose was quite low to keep him asleep through the night. As such, the final decision was to continue using the same drug at the same dose and consider sleep hygiene to promote the treatment outcome (Sateia et al., 2017). In each decision process, the PMHNP was forced to observe several ethical principles including justice, autonomy, nonmaleficence, and observing the patient’s privacy and confidentiality (Grandner & Perlis, 2019). The patient was also adequately informed about each decision process, in terms of all the available options with their benefits and limitations.

References

Akinnusi, M., & El Solh, A. A. (2019). Drug treatment strategies for insomnia in patients with post-traumatic stress disorder. Expert Opinion on Pharmacotherapy, 20(6), 691–699. https://doi.org/10.1080/14656566.2019.1574745

Grandner, M. A., & Perlis, M. L. (2019). Pharmacotherapy for Insomnia Disorder in Older Adults. JAMA Network Open, 2(12), e1918214. https://doi.org/10.1001/jamanetworkopen.2019.18214

Madari, S., Golebiowski, R., Mansukhani, M. P., & Kolla, B. P. (2021). Pharmacological Management of Insomnia. Neurotherapeutics. https://doi.org/10.1007/s13311-021-01010-z

Martsenkovskyi, D., & Napryeyenko, O. (2019). P.818 Adjunctive therapy with trazodone for insomnia in adolescents with post-traumatic stress disorder and depression. European Neuropsychopharmacology, 29, S543–S544. https://doi.org/10.1016/j.euroneuro.2019.09.682

Sateia, M. J., Buysse, D. J., Krystal, A. D., Neubauer, D. N., & Heald, J. L. (2017). Clinical Practice Guideline for the Pharmacologic Treatment of Chronic Insomnia in Adults: An American Academy of Sleep Medicine Clinical Practice Guideline. Journal of Clinical Sleep Medicine, 13(02), 307–349. https://doi.org/10.5664/jcsm.6470

Winkelman, J. W. (2015). Insomnia Disorder. New England Journal of Medicine, 373(15), 1437–1444. https://doi.org/10.1056/nejmcp1412740

Yi, X., Ni, S., Ghadami, M. R., Meng, H., Chen, M., Kuang, L., Zhang, Y., Zhang, L., & Zhou, X. (2018). Trazodone for the treatment of insomnia: a meta-analysis of randomized placebo-controlled trials. Sleep Medicine, 45, 25–32. https://doi.org/10.1016/j.sleep.2018.01.010