Delusional Disorders Pakistani Female With Delusional Thought Processes

Hispanic male

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

RESULTS OF DECISION POINT ONE

Client returns to clinic in four weeks
A decrease in PANSS score of 25% is noted at this visit
Client seems to be tolerating medication
Client’s husband has made sure she makes her appointments for injections (one thus far)
Client has noted a 2 pound weight gain but it does not seem to be an important point for her
Client complains of injection site pain telling the PMHNP that she has trouble siting for a few hours after the injections and doesn’t like having to walk around for such a long period of time

Decision Point Two

Select what the PMHNP should do next:

Continue same decision made but instruct administering nurse to begin injections into the deltoid at this visit and moving forward

RESULTS OF DECISION POINT TWO

Client returns to clinic in four weeks
Client’s PANNS has reduced by a total of 50% from the initiation of Invega sustenna
When questioned about injection site pain, client states it is much better in the arm
Client’s weight has increased by an additional 2.5 pounds (total of 4.5 pounds in a 2 month period). She is somewhat bothered by the weight gain and is afraid that her husband does not like it. He is not present at this visit as she brought herself
Client likes how she feels on the Invega Sustenna but is wondering if there is another drug like it that would not cause the weight gain

Decision Point Three

Select what the PMHNP should do next:

Continue with the Invega Sustenna. Counsel client on the fact that weight gain from Invega Sustenna is not as much as what other drugs with similar efficacy can cause. Make appointment with a dietician and an exercise physiologist. Follow up in one month

Guidance to StudentWeight gain can occur with Invega Sustenna. It is modest in nature and can be controlled with proper nutrition and exercise. It is always a good idea to try and control a client’s weight through consultation with a dietician and exercise physiologist (life coach) before switching to another agent when a product is showing efficacy for at least 6 months.

Abilify Maintena is a good option for someone who has good response to abilify oral. Remember that Abilify does not bind to the D2 receptor for a great period of time (such as Invega) and can be less affective in certain individuals. Also, remember that akathisia can be a possible side effect. Once an IM long acting medication is given, the effects of the drug (both efficacious and untoward effects) can be maintained for a long duration (up to a month or longer). Tolerability and efficacy should be established with oral medication first before administering the first injection. Also a disadvantage to Abilify Maintena is a 2-week overlap of oral therapy is required due to effective blood levels lagging behind the induction dose.

Qsymia is a weight loss medication that is a combination of Phenteramine and Topiramate. It is only indicated to treat obesity. This client’s BMI (28.9 kg/M2) does not fit the definition of obesity (BMI >30 Kg/M2- Following from CDC website: Class 1: BMI of 30 to < 35, Class 2: BMI of 35 to < 40, Class 3: BMI of 40 or higher. Class 3 obesity is sometimes categorized as “extreme” or “severe” obesity). There are two things wrong with this therapy option. First, there are only a few occasions where add-on therapy to treat a side effect is acceptable and weight gain is not one of those scenarios. Secondly, Phenteramine has a lot of cardiovascular toxicities (such as elevated BP, HR, increased workload on the heart).

Start Over

Discontinue Invega Sustenna and start Abilify Maintenna 400 mg IM monthly (after a few test doses of Abilify oral have been tried and tolerated) with overlapping oral abilify 10 mg orally in the MORNING

Guidance to StudentWeight gain can occur with Invega Sustenna. It is modest in nature and can be controlled with proper nutrition and exercise. It is always a good idea to try and control a client’s weight through consultation with a dietician and exercise physiologist (life coach) before switching to another agent when a product is showing efficacy for at least 6 months.

Abilify Maintena is a good option for someone who has good response to abilify oral. Remember that Abilify does not bind to the D2 receptor for a great period of time (such as Invega) and can be less affective in certain individuals. Also, remember that akathisia can be a possible side effect. Once an IM long acting medication is given, the effects of the drug (both efficacious and untoward effects) can be maintained for a long duration (up to a month or longer). Tolerability and efficacy should be established with oral medication first before administering the first injection. Also a disadvantage to Abilify Maintena is a 2-week overlap of oral therapy is required due to effective blood levels lagging behind the induction dose.

Qsymia is a weight loss medication that is a combination of Phenteramine and Topiramate. It is only indicated to treat obesity. This client’s BMI (28.9 kg/M2) does not fit the definition of obesity (BMI >30 Kg/M2- Following from CDC website: Class 1: BMI of 30 to < 35, Class 2: BMI of 35 to < 40, Class 3: BMI of 40 or higher. Class 3 obesity is sometimes categorized as “extreme” or “severe” obesity). There are two things wrong with this therapy option. First, there are only a few occasions where add-on therapy to treat a side effect is acceptable and weight gain is not one of those scenarios. Secondly, Phenteramine has a lot of cardiovascular toxicities (such as elevated BP, HR, increased workload on the heart).

Start Over

Continue Invega sustenna and add-on Qsymia for weight loss

Guidance to StudentWeight gain can occur with Invega Sustenna. It is modest in nature and can be controlled with proper nutrition and exercise. It is always a good idea to try and control a client’s weight through consultation with a dietician and exercise physiologist (life coach) before switching to another agent when a product is showing efficacy for at least 6 months.

Abilify Maintena is a good option for someone who has good response to abilify oral. Remember that Abilify does not bind to the D2 receptor for a great period of time (such as Invega) and can be less affective in certain individuals. Also, remember that akathisia can be a possible side effect. Once an IM long acting medication is given, the effects of the drug (both efficacious and untoward effects) can be maintained for a long duration (up to a month or longer). Tolerability and efficacy should be established with oral medication first before administering the first injection. Also a disadvantage to Abilify Maintena is a 2-week overlap of oral therapy is required due to effective blood levels lagging behind the induction dose.

Qsymia is a weight loss medication that is a combination of Phenteramine and Topiramate. It is only indicated to treat obesity. This client’s BMI (28.9 kg/M2) does not fit the definition of obesity (BMI >30 Kg/M2- Following from CDC website: Class 1: BMI of 30 to < 35, Class 2: BMI of 35 to < 40, Class 3: BMI of 40 or higher. Class 3 obesity is sometimes categorized as “extreme” or “severe” obesity). There are two things wrong with this therapy option. First, there are only a few occasions where add-on therapy to treat a side effect is acceptable and weight gain is not one of those scenarios. Secondly, Phenteramine has a lot of cardiovascular toxicities (such as elevated BP, HR, increased workload on the heart).

Start Over

Discontinue Invega Sustenna and start Haldol Decanoate (haloperidol decanoate ) 50 mg IM q2weeks with oral Haldol 5 mg BID for the next 3 months

RESULTS OF DECISION POINT TWO

Client returns to clinic in four weeks
Client’s PANNS decreases by 10% since last visit (15% overall reduction from first visit)
When she walks into the office, the PMHNP notices an unusual movement in the trunk area of the client
When the client sits down, you note that her head is turned to the left and she is unable to move it. She continually smacks her lips and sticks her tongue out repeatedly during this interview session

Decision Point Three

Select what the PMHNP should do next:

Instruct nurse give the client 50 mg intramuscular injection of Benadryl (diphenhydramine) and 1 mg IM Ativan (lorazepam). Discontinue Haldol and make a follow-up appointment for 2 weeks from today. Starts the client on a short course of Ativan 1 mg orally TID with Benadryl 25 mg orally TID for 1 week. Start oral Abilify 5 mg in the MORNING. Make a follow-up phone call to the home 4 days after this appointment

Guidance to StudentUnusual Trunk movements, torticollis, and lip smacking/tongue thrusting are all cardinal signs of extra pyramidal effects and Tardive Dyskinesia [TD] (tongue thrusting). With continued treatment, TD can become persistent for years to decades and needs to be treated immediately. Since typical and atypical antipsychotics block D2 receptors in the substantia nigra, cholinergic effects “take over” and present with movement disorders. Treatment consists of anticholinergic therapy with or without benzodiazepine to control the movements. Since the client has been on long acting Haldol decanoate, it will take 4-5 half-lives to see complete removal of Haldol from her body. This translates into roughly 9 to 15 weeks (half-life of Haldol decanoate is around 3-weeks). It is always good clinical practice to start a client on oral therapy of Haldol and evaluate for efficacy and side effects (tolerability) before initiating long acting therapy such as in this case.

A reduction in the Haldol dose will not do anything for the immediate effects of the Haldol that being seen at today’s visit. It is a long acting medication and is going to take time to reduce the overall steady-concentration. This time frame is 9-15 weeks or 4-5 half-lives (half-life is roughly 3 weeks).

Discontinuation of Haldol is the most prudent option in this case due to her side effects and their effect on her quality of life. The decision to start at 2 mg of abilify or 5 mg of abilify is left to provider choice. This client, in any event, should be prescribed anticholinergic therapy with eight Cogentin, Artane, or Benadryl to control the EPS symptoms until which time the Haldol has been safely eliminated from her body. A follow-up phone call in 3-5 days is also in the best interest of the client to see if the EPS is lessening with the addition of anticholinergic therapy. Continued monitoring for these side effects should be considered at each follow-up visit until such time they can be deemed eliminated.

Start Over

Decrease Haldol Decanoate 25 mg IM q2weeks. Submit e-prescription to client’s pharmacy for Cogentin (benztropine )2 mg orally BID

Guidance to StudentUnusual Trunk movements, torticollis, and lip smacking/tongue thrusting are all cardinal signs of extra pyramidal effects and Tardive Dyskinesia [TD] (tongue thrusting). With continued treatment, TD can become persistent for years to decades and needs to be treated immediately. Since typical and atypical antipsychotics block D2 receptors in the substantia nigra, cholinergic effects “take over” and present with movement disorders. Treatment consists of anticholinergic therapy with or without benzodiazepine to control the movements. Since the client has been on long acting Haldol decanoate, it will take 4-5 half-lives to see complete removal of Haldol from her body. This translates into roughly 9 to 15 weeks (half-life of Haldol decanoate is around 3-weeks). It is always good clinical practice to start a client on oral therapy of Haldol and evaluate for efficacy and side effects (tolerability) before initiating long acting therapy such as in this case.

A reduction in the Haldol dose will not do anything for the immediate effects of the Haldol that being seen at today’s visit. It is a long acting medication and is going to take time to reduce the overall steady-concentration. This time frame is 9-15 weeks or 4-5 half-lives (half-life is roughly 3 weeks).

Discontinuation of Haldol is the most prudent option in this case due to her side effects and their effect on her quality of life. The decision to start at 2 mg of abilify or 5 mg of abilify is left to provider choice. This client, in any event, should be prescribed anticholinergic therapy with eight Cogentin, Artane, or Benadryl to control the EPS symptoms until which time the Haldol has been safely eliminated from her body. A follow-up phone call in 3-5 days is also in the best interest of the client to see if the EPS is lessening with the addition of anticholinergic therapy. Continued monitoring for these side effects should be considered at each follow-up visit until such time they can be deemed eliminated.

Start Over

Discontinue Haldol. Start Abilify 2 mg orally daily and schedule a follow-up phone call 4 days from today’s appointment to check on client’s current symptoms. Also e-prescribe Cogentin 2 mg orally BID to treat the EPS

Guidance to StudentUnusual Trunk movements, torticollis, and lip smacking/tongue thrusting are all cardinal signs of extra pyramidal effects and Tardive Dyskinesia [TD] (tongue thrusting). With continued treatment, TD can become persistent for years to decades and needs to be treated immediately. Since typical and atypical antipsychotics block D2 receptors in the substantia nigra, cholinergic effects “take over” and present with movement disorders. Treatment consists of anticholinergic therapy with or without benzodiazepine to control the movements. Since the client has been on long acting Haldol decanoate, it will take 4-5 half-lives to see complete removal of Haldol from her body. This translates into roughly 9 to 15 weeks (half-life of Haldol decanoate is around 3-weeks). It is always good clinical practice to start a client on oral therapy of Haldol and evaluate for efficacy and side effects (tolerability) before initiating long acting therapy such as in this case.

A reduction in the Haldol dose will not do anything for the immediate effects of the Haldol that being seen at today’s visit. It is a long acting medication and is going to take time to reduce the overall steady-concentration. This time frame is 9-15 weeks or 4-5 half-lives (half-life is roughly 3 weeks).

Discontinuation of Haldol is the most prudent option in this case due to her side effects and their effect on her quality of life. The decision to start at 2 mg of abilify or 5 mg of abilify is left to provider choice. This client, in any event, should be prescribed anticholinergic therapy with eight Cogentin, Artane, or Benadryl to control the EPS symptoms until which time the Haldol has been safely eliminated from her body. A follow-up phone call in 3-5 days is also in the best interest of the client to see if the EPS is lessening with the addition of anticholinergic therapy. Continued monitoring for these side effects should be considered at each follow-up visit until such time they can be deemed eliminated.

Start Over

Continue Invega Sustenna. Begin injections into the deltoid and add on Abilify Maintena 300 mg intramuscular monthly with oral Abilify 10 mg in the MORNING for 2 weeks

RESULTS OF DECISION POINT TWO

Client returns to clinic in four weeks
Client returns today with no change in her PANNS of 10% reduction (35% overall reduction from first visit)
Client has not been sleeping as well as she was prior to the last visit. Her husband says that she has been unable to sit still. At night, she is constantly up and down. It has been effecting his sleeping patterns as well

Decision Point Three

Select what the PMHNP should do next:

Discontinue Abilify. Continue with the Invega Sustenna

Guidance to StudentDiscontinuation of Abilify is the most logical option in this scenario. There is no backing in the literature to have a client on dual long-acting injectable antipsychotic therapy and should not be considered. There is information regarding dual antipsychotic therapy, but either both are given orally or one is given orally and the other by long-acting injection. The client has definitely responded to therapy as evidenced by her current PANNS.

Ambien add-on therapy is an option but most likely is not warranted. The client may have been experiencing akathisia from the Abilify; this would be expected to abate with time and with the discontinuation of therapy. A short course of Ambien can be considered as long as there is no drug abuse history. The dose in women is started at 5 mg and may be titrated upward to 10 mg should the 5 mg dose be ineffective. Another option would be low-dose trazodone 25 to 50 mg at bedtime. Trazodone at low doses has anithistaminergic activity only and works well in most clients to help with sleep. Whichever sleeping agent is chosen, it should be explained to the client that this is a short course of therapy with no intention of continuing long term as long as sleeping patterns should return to baseline once Abilify Maintena is eliminated.

Lithium carbonate is a medication used to treat mania in bipolar disorder. This client is not displaying any symptoms that are indicative of mania; therefore, this is not a good option.

Start Over

Add on Ambien (zolpidem) 10 mg orally at BEDTIME

Guidance to StudentDiscontinuation of Abilify is the most logical option in this scenario. There is no backing in the literature to have a client on dual long-acting injectable antipsychotic therapy and should not be considered. There is information regarding dual antipsychotic therapy, but either both are given orally or one is given orally and the other by long-acting injection. The client has definitely responded to therapy as evidenced by her current PANNS.

Ambien add-on therapy is an option but most likely is not warranted. The client may have been experiencing akathisia from the Abilify; this would be expected to abate with time and with the discontinuation of therapy. A short course of Ambien can be considered as long as there is no drug abuse history. The dose in women is started at 5 mg and may be titrated upward to 10 mg should the 5 mg dose be ineffective. Another option would be low-dose trazodone 25 to 50 mg at bedtime. Trazodone at low doses has anithistaminergic activity only and works well in most clients to help with sleep. Whichever sleeping agent is chosen, it should be explained to the client that this is a short course of therapy with no intention of continuing long term as long as sleeping patterns should return to baseline once Abilify Maintena is eliminated.

Lithium carbonate is a medication used to treat mania in bipolar disorder. This client is not displaying any symptoms that are indicative of mania; therefore, this is not a good option.

Start Over

Start client on lithium carbonate immediate release 300 mg orally BID

Guidance to StudentDiscontinuation of Abilify is the most logical option in this scenario. There is no backing in the literature to have a client on dual long-acting injectable antipsychotic therapy and should not be considered. There is information regarding dual antipsychotic therapy, but either both are given orally or one is given orally and the other by long-acting injection. The client has definitely responded to therapy as evidenced by her current PANNS.

Ambien add-on therapy is an option but most likely is not warranted. The client may have been experiencing akathisia from the Abilify; this would be expected to abate with time and with the discontinuation of therapy. A short course of Ambien can be considered as long as there is no drug abuse history. The dose in women is started at 5 mg and may be titrated upward to 10 mg should the 5 mg dose be ineffective. Another option would be low-dose trazodone 25 to 50 mg at bedtime. Trazodone at low doses has anithistaminergic activity only and works well in most clients to help with sleep. Whichever sleeping agent is chosen, it should be explained to the client that this is a short course of therapy with no intention of continuing long term as long as sleeping patterns should return to baseline once Abilify Maintena is eliminated.

Lithium carbonate is a medication used to treat mania in bipolar disorder. This client is not displaying any symptoms that are indicative of mania; therefore, this is not a good option.

Start Over

The post Decision Point One Start Invega Sustenna 234 mg intramuscular X1 followed by 156 mg intramuscular on day 4 and monthly thereafter appeared first on Infinite Essays.

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