NURS 6630: Psychopharmacologic Approaches to Treatment of Psychopathology | Week 7

From negative changes in mood to problems concentrating, pain and sleep/wake disorders can have a tremendous impact on clients’ lives. When clients 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 pain and sleep/wake disorders may be addictive, making thorough client assessments and close follow-up care essential. To prescribe appropriate therapies with client 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 pain and sleep/wake disorders, you examine the assessment and treatment of clients with these disorders. You also explore ethical and legal implications of these therapies.

Discussion: Sleep/Wake Disorders

It is not uncommon to experience a night or two of disrupted sleep when there is something major going on in your life. However, sleep/wake disorders are much more than an occasional night of disrupted sleep. A recent report from the Centers for Disease Control and Prevention estimated that between 50 and 70 million American have problems with sleep/wake disorders (CDC, 2015). Although the vast majority of Americans will visit their primary care provider for treatment of these disorders, many providers will refer patients for further evaluation. For this Discussion, you consider how you might assess and treat the individuals based on the provided client factors.

Learning Objectives – Nursing Therapy for Clients With Pain and Sleep/Wake Disorders

Students will:

• Assess client factors and history to develop personalized therapy plans for clients with sleep/wake disorders
• Analyze factors that influence pharmacokinetic and pharmacodynamic processes in clients requiring therapy for sleep/wake disorders
• Evaluate efficacy of treatment plans for clients presenting for sleep/wake therapy
• Apply knowledge of providing care to adult and geriatric clients presenting for sleep/wake disorders

Learning Resources

Note: To access this week’s required library resources, please click on the link to the Course Readings List, found in the Course Materialssection of your Syllabus.

Required Readings

Note: All Stahl resources can be accessed through the Walden Library using this link. This link will take you to a log-in page for the Walden Library. Once you log into the library, the Stahl website will appear.

Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (4th ed.). New York, NY: Cambridge University Press.

To access the following chapters, click on the Essential Psychopharmacology, 4th ed tab on the Stahl Online website and select the appropriate chapter. Be sure to read all sections on the left navigation bar for each chapter.

• Chapter 11, “Disorders of Sleep and Wakefulness and Their Treatment”

Stahl, S. M. (2014b). The prescriber’s guide (5th ed.). New York, NY: Cambridge University Press.

To access information on the following medications, click on The Prescriber’s Guide, 5th ed tab on the Stahl Online website and select the appropriate medication.

Review the following medications:

For insomnia

• alprazolam

• amitriptyline

• amoxapine

• clomipramine

• clonazepam

• desipramine

• diazepam

• doxepin

• flunitrazepam

• flurazepam

• hydroxyzine

• imipramine

• lorazepam

• nortriptyline

• ramelteon

• temazepam

• trazodone

• triazolam

• trimipramine

• zaleplon

• zolpidem

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

Davidson, J. (2016). Pharmacotherapy of post-traumatic stress disorder: Going beyond the guidelines. British Journal of Psychiatry, 2(6), e16-e18. doi:10.1192/bjpo.bp.116.003707. Retrieved from http://bjpo.rcpsych.org/content/2/6/e16

To prepare for this Discussion:

Note: By Day 1 of this week, your Instructor will have assigned you to one of the following case studies to review for this Discussion. To access the following case studies, click on the Case Studies tab on the Stahl Online website and select the appropriate volume and case number.

Case 1: Volume 2, Case #16: The woman who liked late-night TV

Case 2: Volume 2, Case #11: The figment of a man who looked upon the lady

Case 3: Volume 1, Case #5: The sleepy woman with anxiety

• Review this week’s Learning Resources and reflect on the insights they provide.
• Go to the Stahl Online website and examine the case study you were assigned.
• Take the pretest for the case study.
• Review the patient intake documentation, psychiatric history, patient file, medication history, etc. As you progress through each section, formulate a list of questions that you might ask the patient if he or she were in your office.
• Based on the patient’s case history, consider other people in his or her life that you would need to speak to or get feedback from (i.e., family members, teachers, nursing home aides, etc.).
• Consider whether any additional physical exams or diagnostic testing may be necessary for the patient.
• Develop a differential diagnoses for the patient. Refer to the DSM-5 in this week’s Learning Resources for guidance.
• Review the patient’s past and current medications. Refer to Stahl’s Prescriber’s Guide and consider medications you might select for this patient.
• Review the posttest for the case study.

Note: For this Discussion, you are required to complete your initial post before you will be able to view and respond to your colleagues’ postings. Begin by clicking on the “Post to Discussion Question” link and then select “Create Thread” to complete your initial post. Remember, once you click on Submit, you cannot delete or edit your own posts, and you cannot post anonymously. Please check your post carefully before clicking on Submit!

By Day 3 Nursing Therapy for Clients With Pain and Sleep/Wake Disorders

Post a response to the following:

• Provide the case number in the subject line of the Discussion.
• List three questions you might ask the patient if he or she were in your office. Provide a rationale for why you might ask these questions.
• Identify people in the patient’s life you would need to speak to or get feedback from to further assess the patient’s situation. Include specific questions you might ask these people and why.
• Explain what physical exams and diagnostic tests would be appropriate for the patient and how the results would be used.
• List three differential diagnoses for the patient. Identify the one that you think is most likely and explain why.
• List two pharmacologic agents and their dosing that would be appropriate for the patient’s sleep/wake therapy based on pharmacokinetics and pharmacodynamics. From a mechanism of action perspective, provide a rationale for why you might choose one agent over the other.
• If your assigned case includes “check points” (i.e., follow-up data at week 4, 8, 12, etc.), indicate any therapeutic changes that you might make based on the data provided.
• Explain “lessons learned” from this case study, including how you might apply this case to your own practice when providing care to patients with similar clinical presentations.

Read a selection of your colleagues’ responses.

By Day 6

Respond to at least two of your colleagues who were assigned to a different case than you. For example, if you were assigned to Case Study 1, respond to one colleague assigned to Case Study 2 and one colleague assigned to Case Study 3. Explain how you might apply knowledge gained from your colleagues’ case studies to you own practice in clinical settings. Nursing Therapy for Clients With Pain and Sleep/Wake Disorders.

ADDITIONAL INFO 

Nursing Therapy for Clients With Pain and Sleep/Wake Disorders

Introduction

Pain is a common experience, and it can be difficult to understand how to best respond. The nurse should assess the client’s pain level, its severity and duration, and any additional symptoms that might be associated with it. The goals of nursing care for the client with pain include:

Reduce pain intensity and/or frequency

Increase ability to cope with pain

In some cases, however, these goals may be difficult or impossible to achieve because of limitations in physical function or mobility imposed by the disease process itself. Nursing interventions for patients with pain often include measures such as reassurance support; education about safe self-care practices; reassurance about not having much control over their condition; activities such as rest breaks during work periods if possible; medications such as nonsteroidal anti-inflammatory drugs (NSAIDs) or acetaminophen (Tylenol), when needed; acupuncture treatments if available; or other forms of treatment such as heat therapy using electrical pads placed on skin areas affected by arthritis in lower legs while moving around slowly on footrests called orthoses).

Pain

Pain is a subjective experience that can be either acute or chronic. Acute pain is experienced immediately after injury, while chronic pain persists over time.

Pain can be described as nociceptive or neuropathic (which means the root cause of your pain is in your nervous system). Nociceptors are sensory receptors that detect noxious stimuli such as heat, cold or pressure; the nerve fibers carrying these signals are known as afferent neurons. Neuropathic pains develop when there’s damage to the peripheral nerve(s) due to injury or disease (like diabetes).

Sleep/wake disorders

Sleep disorders are common, but often under-diagnosed. The most common sleep disorders include:

• Insomnia (difficulty falling asleep)

• Narcolepsy (sleepiness while lying down)

• Restless leg syndrome (uncomfortable leg movements during sleep).

Types of sleep/wake disorders

There are many different types of sleep disorders, but they all have one thing in common: they make it difficult for you to get a good night’s rest.

• Insomnia: This is when you wake up several times during the night or wake up feeling unrefreshed or fatigued. You may also have nightmares that interfere with your ability to stay asleep at night.

• Narcolepsy: This condition causes uncontrollable bouts of sleepiness that last at least an hour per day, sometimes even longer than that. It can be triggered by stress and other emotions such as anger or fearfulness; however, narcolepsy can occur without these triggers as well (for example, if someone has been taking medications).

• Sleep apnea syndrome affects about 10 percent of people between ages 18 and 54 years old who suffer from chronic pain conditions like arthritis pain or fibromyalgia; this condition causes them not only wake up frequently from their sleep but also feel tired throughout the day due to lack of energy due to lack oxygen flow through their nose during REM periods (rapid eye movement) when dreaming happens most intensely before waking up again after another period goes by without enough oxygen coming into contact with tissues inside brain itself so that person starts dreaming again until he/she becomes fully awake again after some time passes since last time he/she fell asleep while experiencing dream state–this cycle continues itself until finally someone realizes he needs help getting better quality restful nights away from bedside table where monitors show constant readings indicating levels still remain normal even though person feels exhausted all over body causing muscles aches everywhere including neck vertebrae area where back attaches itself onto spine itself resulting in discomforting feeling around shoulder blades area caused by weakness due

Assessment of pain and sleep/wake disorders

As the therapist, you should be aware of any issues with pain and sleep/wake disorders. You can use your physical exam skills to help clients identify their symptoms, which may include:

• Pain that occurs in or around the body (such as back pain)

• Difficulty falling asleep at night or staying asleep during the day (insomnia)

• Daytime fatigue followed by difficulty concentrating or remembering things (drowsiness)

Nursing interventions for the client with pain and sleep/wake disorders

• Pain management

• Sleep and wake disorders

• Medications

To treat pain, the nurse may provide short-term relief through medication, or longer-term care by helping clients to manage their pain with exercises and other nonpharmacologic interventions. The nurse also evaluates for sleep disorders such as insomnia or oversleeping. If a client has both pain and sleep problems, he or she may be prescribed a sleeping medication (e.g., Ambien) that works well for both conditions.

• Lifestyle changes: Asking your patient about how much time he or she spends in bed each day may help you determine whether there’s room for improvement in this area—and if so, what kind of changes could lead toward better outcomes!

Evaluation for effectiveness of nursing care for pain and sleep/wake disorders.

The nurse should evaluate the client’s pain level, sleep patterns and ability to function. The nurse should also conduct a patient interview to determine what type of nursing care is needed at this time.

Takeaway:

Nursing interventions for clients with pain and sleep/wake disorders include:

• Education about pain, sleep, and wake disorders.

• Assessments of physical conditions that may affect sleep or wakefulness (e.g., depression).

• Identification of factors that contribute to the development of polysomnography abnormalities (e.g., medications).

Nursing interventions for clients with pain and sleep/wake disorders also include:

Conclusion

In the next section, we will give you an overview of the assessment of pain and sleep/wake disorders. The assessment can be done by a nurse, physical therapist or physician.