response with 2 references

According to McCance & Huether (2019), Generalized anxiety disorder (GAD) is a psychological condition wherein the norepinephrine and serotonin systems are abnormal such as α2-adrenergic receptor binding, decreased serotonin levels in the cerebrospinal fluid, decreased platelet binding of paroxetine, an SSRI. McCance et al. (2019) also noted that there is decease Benzodiazepine binding in the left temporal hemisphere in GAD. According to Rosenthal & Burchum (2021), situational anxiety responds to everyday stressful situations, but symptoms resolve sooner.

McCance et al. (2019) noted that GAD is diagnosed when someone worries excessively for at least six months, exhibiting at least three main symptoms: vigilance, tension, apprehension, poor concentration, difficulty falling, or staying asleep.  According to Rosenthal et al. (2021), some physiological symptoms include restlessness, trembling, muscle tension, palpitation, tachycardia, sweating, cold and clammy hands.

Goal to Manage Patient’s Condition, Decision to Administer Effective Treatment and Supporting Evidence

With this patient’s condition, the goal of treatment will be to manage the condition with the least number of drugs and minimize the side effects of medication while maximizing the patient’s health outcomes. McCance et al. (2019) also noted that 5- HT/norepinephrine reuptake inhibitors like Venlafaxine or SSRIs like paroxetine and escitalopram and more are the first line of medications to manage GAD with which relief of symptoms are felt within one week of starting treatment, but optimal effect requires many weeks. In addition, the SSRIs and Norepinephrine reuptake inhibitors have also been effective in the treatment of comorbidities such as depression. Rosenthal et al. (2021) noted that the U.S Food and Drug Administration (FDA) approved the SSRIs, SNRIs, and buspirone as the first line of medications for treating GAD for long-term treatment and comorbidities depression and Benzodiazepines as second-line choices. However, because of delayed relief of symptoms with these medications, they cannot be used on a PRN basis. SSRIs and NE reuptake inhibitors can also be used in decreasing cognitive and psychic symptoms of anxiety, but they are not the best options to treat somatic symptoms. These classes of medications have no potential for abuse, although sudden discontinuation may cause withdrawal symptoms. Cardiotoxicity or death by overdose from SSRIs are rare. It is also essential to take precautions when using Venlafaxine with monoamine Oxidase inhibitors due to toxicity.

Buspirone has an affinity for serotonin receptors (5-HT1A), but it may take up to two weeks to notice the improvement in condition.  SSRIs side effects include dizziness, headache, nausea, and mild nervousness.

Furthermore, McCance et al. (2019) noted benzodiazepines are used to treat GAD in people who do not respond to 5-HT/NE reuptake inhibitors or buspirone and uncomplicated GAD. Also, benzodiazepines can be used as immediate relief when severe anxiety (Rosenthal et al., 2021). Moreover, behavioral and cognitive therapy for relaxation, supportive therapy, and biofeedback may be used to manage GAD to manage anxiety-provoking situations and improve the patient’s coping skills.

 From my job, working with patients in a correctional facility like a jail, the protocol to manage patients’ anxiety, including anxiety from the withdrawal of substance use, is Benadryl 50mg by mouth at bedtime or Hydroxyzine 25 to 50mg by mouth two times a day for three days. This regimen can be repeated by the nurse once. If it is not effective, the nurse has to notify the provider and or place the patient on the provider’s list to be seen during clinic by the Family practice provider or Mental health provider. However, for patients who come in with a diagnosis of GAD and are actively taking antianxiety medications, the order will be verified and continued if the order is current. Patients on Benzodiazepines such as Ativan who come into the jail with their medications will continue to take and gradually tapered by the provider. Where I work, Librium is used for alcohol withdrawal with a high CIWA score.

According to the Laureate interactive video (2019g), in the case scenario where a 46years old patient presented with a complaint of “anxiety attacks” and a history of chest tightness, shortness of breath, and feeling of impending doom that led him to pass out at work and was taken to the ER where myocardial infarction was ruled out, with normal EKG and other physical assessments that appeared to be within normal limit.

The patient admitted to stressful situations going on in his life, using alcohol to help him, which is non-effective. The Hamilton Anxiety (Ham-A) Rating scale score of 26 led to a diagnosis of a generalized anxiety disorder (Laureate interactive video file, 2019g).

As a practitioner, I will initiate Zoloft 50mg by mouth daily and inform the patient to return in four weeks for reassessment or seek immediate help if he feels like hurting himself. I will use Zoloft because it is an SSRI which are among the FDA’s approved first-line medication for the treatment of GAD. Upon reassessing this patient in the clinic after four weeks, his HAM-A score reduced from 26 to 18, indicating the patient is responding well to the treatment regimen as evidenced by a self-report of no chest tightness nor shortness of breath and decreased worrying over the past four or five days.

Based on the evidence that the patient’s symptoms have partially improved and there is still room to increase the dose of his Zoloft without any risk of abuse, given that patient has not experienced any side effect or interaction from taking this medication. I will up the dose to Zoloft 75mg by mouth daily and reassess the patient after 4weeks. When the patient returned in four weeks for a follow-up, he reported that his symptoms got even better. On assessment, his HAM-A score is 10, indicative of effective treatment. The patient denies any side effects from taking Zoloft at this time.

Conclusion

I will maintain the patient on Zoloft 75mg by mouth daily ongoing and continue to monitor since the patient has experienced significant improvement in symptoms with no side effects. Also, I will encourage the patient to follow up about his weight concern with a dietitian and to seek supportive help for anxiety coping mechanisms, and encourage the patient to have trusted people that he can vent to. Another recommendation I will give to this patient is to provide community resources such as respite care for his elderly parents, and other social services that may be of help with taking care of his parents such as meals on wheels, volunteer organizations that may provide help with his parents’ care and needs.

 

 

References

Laureate Education (Producer). (2019g). Generalized anxiety disorder [interactive media file]. Baltimore, MD: Author.

McCance, K. L. & Huether, S. E. (2019). Pathophysiology: the biologic basis of disease in adults and children (8th ed.). St Louis, MO: Mosby/Elsevier

Rosenthal, L. D. & Burchum, J. R. (2021). Lehne’s pharmacotherapeutics for advanced practice nurses and physician assistants (2nd ed.) St Louis, MO: Elsevier

 

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response with 2 references

Bilar disorder, formerly called manic depression, is a mental health condition that causes extreme mood swings that include emotional highs (mania or hypomania) and lows (depression) (Mayo Clinic, 2021). I have worked with many bipolar people. I also have a couple people in my family who are bipolar. From my experience, many I work with are non-compliant with their medications and that’s what leads to them becoming a patient on my unit.

Bipolar disorder is chronic and requires lifelong treatment. Treatment may include medication, psychotherapy, and/or cognitive behavioral therapy. Cognitive therapy helps change patients negative thinking or behaviors. It also teaches coping mechanisms. Psychotherapy helps patients deal with self-care and stress management. Many of their setbacks come from depression and stress. Many are unable to cope or use their coping skills to get through a crisis.

Medication therapy plays a big part in stabilizing bipolar patients. According to Help Guide, the main medications used for bipolar patients are Zyprexa, Seroquel, Risperdal, Abilify, Geodon, Clozaril. I have seen all of these used amongst my patients. From experience, I noticed Geodon is usually used as a prn or on patients requiring a stronger medication. The patient listed in the scenario I chose, is taking Lithium, Risperdal, and Seroquel XR.

Medication Therapy

Lithium as a mood stabilizer has been used as the standard pharmacological treatment for bipolar disorder for more than 60 years. Recent studies have also shown that it has the potential for the treatment of many other neurodegenerative disorders, including Alzheimer’s, Parkinson’s, and Huntington’s disease, through its neurotrophic, neuroprotective, antioxidant and anti-inflammatory actions (Wen, J., et al, 2019). Lithium is a very popular drug used to treat bipolar disorder. Lithium is taken orally and absorbed quickly from the GI tract. At first the level his high then redistributed to the body. Lithium is not metabolized and most of it is excreted unchanged through the kidney. Two enzymatic chains or pathways emerge as targets for lithium: inositol monophosphates within the phosphatidylinositol signaling pathway and the protein kinase glycogen synthase kinase. Lithium inhibits these enzymes through displacing the normal cofactor magnesium, a vital regulator of numerous signaling pathways (Brown, K., and Tracy, D. K., 2012). It has a narrow therapeutic window and patients should be getting labs weekly. Prior to starting Lithium, patients should have baseline labs (CBC with diff, UA) on file.

According to Rx List (2020), Risperdal is indicated for the treatment of acute manic or mixed episodes associated with bipolar I disorder. Risperdal adjunctive therapy with lithium or valproate is indicated for the treatment of acute manic or mixed episodes associated with bipolar I disorder. Risperidone is rapidly and completely absorbed after oral administration; less than 1% is excreted unchanged in the feces. Risperidone acts through antagonism at the serotonin 2A receptor and dopamine D2 receptors. It also is a moderate antagonist at histaminergic H1 and adrenergic alpha1 and alpha2 receptors (PharmGKB, n.d.).

Seroquel is a psychotropic agent. It is metabolized and excreted by the kidneys. Seroquel is an antagonist at multiple neurotransmitter receptors in the brain as with other drugs having efficacy in the treatment of schizophrenia and acute manic episodes associated with bipolar disorder, is unknown. However, it has been proposed that this drug=s efficacy in schizophrenia is mediated through a combination of dopamine type 2 (D2) and serotonin type 2 (5HT2) antagonism. Antagonism at receptors other than dopamine and 5HT2 with similar receptor affinities may explain some of the other effects of Seroquel (Food and Drug Administration, 2004)

Psychotherapy

            According to National Alliance of Mental Illness (2019), bipolar disorder is a condition that is strongly affected by stress. Episodes of mania and depression can be triggered by significant life events, severe family conflicts, turbulent relationships and situations that disrupt sleep/wake rhythms. Patients with bipolar are unable to handle daily life stresses without treatment. Psychotherapy teaches them coping mechanisms and ways to handle or get through stressful situations. Some psychotherapy involves family therapy. It allows families to get an understanding and help the patient to cope.

According to National Alliance of Mental Illness (2019), cognitive behavioral therapy (CBT) is an individual therapy focused on the relationship between a person’s thoughts, feelings, and behaviors. CBT teaches people to identify negative assumptions and thinking patterns and challenge themselves to rehearse more adaptive ways of thinking. It also teaches them to monitor their activity levels to make sure they are engaged with rewarding aspects of their environment when depressed and are not overly stretched when manic.

For a patient to stabilize and maintain stability, their treatment plan should include medication and at least one form of therapy. All patients need to learn coping skills. Medication alone won’t fix them. They need to learn skills to deal with stress, stressful situations and focus on having positive thoughts, feelings, and behaviors. My dad was bipolar (he passed away last year) and I have a daughter who is bipolar. She has been pretty much stable the last couple of years but there are times she gets overwhelmed and needs to be reminded about her using her coping skills. Sometimes the things that seem so simple to us can be so overwhelming to others.

References

Brown, K. M., and Tracy, D. K. (2012). Lithium: The pharmacodynamic actions of the amazing ion. https://www.researchgate.net/publication/318820427_Lithium_the_pharmacodynamic_actions_of_the_amazing_ion

Mayo Clinic. (2021). Bipolar disorder. https://www.mayoclinic.org/diseases-conditions/bipolar-disorder/symptoms-causes/syc-20355955

National Alliance of Mental Illness. (2019). Different types of therapy for bipolar disorder. https://www.nami.org/Blogs/NAMI-Blog/April-2019/Different-Types-of-Therapy-for-Bipolar-Disorder

PharmGKB. (n.d.). Risperidone. https://www.pharmgkb.org/chemical/PA451257

Food and Drug Administration. (2004). Seroquel. https://www.accessdata.fda.gov/drugsatfda_docs/label/2004/20639se1-017,016_seroquel_lbl.pdf

Ware, K., Tillery, E., and Linder, L. (2016). General pharmacokinetic/pharmacodynamic concepts of mood stabilizers in the treatment of bipolar disorder. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6009247/

Wen, J., Sawmiller, D., Wheeldon, B., and Tan, J. (2019). A review for lithium: Pharmacokinetics, drug design, and toxicity. https://pubmed.ncbi.nlm.nih.gov/31724518/

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