NURS 6630N PSYCHOPHARMACOLOGIC APPROACHES TO TREATMENT OF PSYCHOLOGY.

Posted: December 26th, 2022

NURS 6630N PSYCHOPHARMACOLOGIC APPROACHES TO TREATMENT OF PSYCHOLOGY.

 

 

Complex Regional Pain Disorder
White Male With Hip Pain

BACKGROUND
This week, a 43-year-old white male presents at the office with a chief complaint of pain. He is assisted in his ambulation with a set of crutches. At the beginning of the clinical interview, the client reports that his family doctor sent him for psychiatric assessment because the doctor felt that the pain was “all in his head.” He further reports that his physician believes he is just making stuff up to get “narcotics to get high.”NURS 6630N PSYCHOPHARMACOLOGIC APPROACHES TO TREATMENT OF PSYCHOLOGY.

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SUBJECTIVE
The client reports that his pain began about 7 years ago when he sustained a fall at work. He states that he landed on his right hip. Over the years, he has had numerous diagnostic tests done (x-rays, CT scans, and MRIs). He reports that about 4 years ago, it was discovered that the cartilage surrounding his right hip joint was 75% torn (from the 3 o’clock to 12 o’clock position). He reports that none of the surgeons he saw would operate because they felt him too young for a total hip replacement and believed that the tissue would repair with the passage of time. Since then, he reported development of a strange constellation of symptoms including cooling of the extremity (measured by electromyogram). He also reports that he experiences severe cramping of the extremity. He reports that one of the neurologists diagnosed him with complex regional pain syndrome (CRPS), also known as reflex sympathetic dystrophy (RSD). However, the neurologist referred him back to his family doctor for treatment of this condition. He reports that his family doctor said “there is no such thing as RSD, it comes from depression” and this was what prompted the referral to psychiatry. He reports that one specialist he saw a few years ago suggested that he use a wheelchair, to which the client states “I said ‘no,’ there is no need for a wheelchair, I can beat this!”
The client reports that he used to be a machinist where he made “pretty good money.” He was engaged to be married, but his fiancé got “sick and tired of putting up with me and my pain, she thought I was just turning into a junkie.”NURS 6630N PSYCHOPHARMACOLOGIC APPROACHES TO TREATMENT OF PSYCHOLOGY.
He reports that he does get “down in the dumps” from time to time when he sees how his life has turned out, but emphatically denies depression. He states “you can’t let yourself get depressed… you can drive yourself crazy if you do. I’m not really sure what’s wrong with me, but I know I can beat it.”
During the client interview, the client states “oh! It’s happening, let me show you!” this prompts him to stand with the assistance of the corner of your desk, he pulls off his shoe and shows you his right leg. His leg is turning purple from the knee down, and his foot is clearly in a visible cramp as the toes are curled inward and his foot looks like it is folding in on itself. “It will last about a minute or two, then it will let up” he reports. Sure enough, after about two minutes, the color begins to return and the cramping in the foot/toes appears to be releasing. The client states “if there is anything you can do to help me with this pain, I would really appreciate it.” He does report that his family doctor has been giving him hydrocodone, but he states that he uses is “sparingly” because he does not like the side effects of feeling “sleepy” and constipation. He also reports that the medication makes him “loopy” and doesn’t really do anything for the pain.NURS 6630N PSYCHOPHARMACOLOGIC APPROACHES TO TREATMENT OF PSYCHOLOGY.

MENTAL STATUS EXAM
The client is alert, oriented to person, place, time, and event. He is dressed appropriately for the weather and time of year. He makes good eye contact. Speech is clear, coherent, goal directed, and spontaneous. His self-reported mood is euthymic. Affect consistent to self-reported mood and content of conversation. He denies visual/auditory hallucinations. No overt delusional or paranoid thought processes appreciated. Judgment, insight, and reality contact are all intact. He denies suicidal/homicidal ideation, and is future oriented.
Diagnosis: Complex regional pain disorder (reflex sympathetic dystrophy)
Decision Point One
Select what the PMHNP should do:

Savella 12.5 mg orally once daily on day 1; followed by 12.5 mg BID on day 2 and 3; followed by 25 mg BID on days 4-7; followed by 50 mg BID thereafter
Amitriptyline 25 mg po QHS and titrate upward weekly by 25 mg to a max dose of 200 mg per day
Neurontin 300 mg po BEDTIME with weekly increases of 300 mg per day to a max of 2400 mg if needed

NURS 6630N PSYCHOPHARMACOLOGIC APPROACHES TO TREATMENT OF PSYCHOLOGY.

 

Psychopharmacologic Approaches to Treatment of Psychology

Introduction

Complex regional pain disorder is the chronic pain condition where in most cases one limb is affected. The condition normally occurs after an injury. Complex regional pain disorder is also characterized by a general deterioration of physical function, anxiety, sleep problems, depression, and parenthesis (Zanotti et al., 2017). The client in this case study reported persistent hip pain. The client further reported that the pain began 7 years back after he sustained a fall while working. The fall led to a 75% tear on the cartilage close to the right hip joint. During the mental status examination, the client reported a euthymic mood. The client was thus diagnosed with Complex regional pain disorder (reflex sympathetic dystrophy). This essay will make decisions about three treatment options for this client and factors impacting the pharmacodynamic and pharmacokinetic processes of the treatment options. The paper will also discuss the ethical factors that could affect the treatment plan for this client.NURS 6630N PSYCHOPHARMACOLOGIC APPROACHES TO TREATMENT OF PSYCHOLOGY.

Decision Point 1

The first decision chosen for this client is Savella 12.5 mg orally once per day with increasing dose as appropriate. Savella was selected because the medication has been demonstrated to be effective in the treatment of fibromyalgia. Fibromyalgia is a condition that affects cartilages, muscles, along with other connective tissues. Savella is an SNRI with an NMDA antagonist activity and thus the medication works by increasing the level of norepinephrine and serotonin within the brain. Availing of these two neurotransmitters generates an analgesic effect at the nerve endings and this leads to pain relief (Abida et al, 2016). The other reason for selecting Savella is that the medication does not have any affinity for histaminergic, adrenergic, and cholinergic receptors and this means the medication does not have significant side effects. therefore, it is expected that the client will tolerate the drug and experience minimal side effects (Masuda et al., 2014).NURS 6630N PSYCHOPHARMACOLOGIC APPROACHES TO TREATMENT OF PSYCHOLOGY.

Selecting Savella hoped that the pain score for the client would decrease significantly as indicated by self-report and the client stopping using the crutches while walking. The second expectation is that the client’s mood would improve and that he would experience no/minimal adverse effects. This is because Savella has been demonstrated to be an effective analgesic in fibromyalgia and the medication has minimal side effects (Abida et al, 2016).

As was anticipated, the client reported reduced pain score after taking the mediation for four weeks. However, the client wished for further pain reduction as the current pain score was still uncomfortable. Also, he also reported sweating bouts, nausea, sleep problems, increased heart rate, increased blood pressure, and a feeling of butterflies in his chest. These effects are attributable to the side effects of Savella (Abida et al, 2016).NURS 6630N PSYCHOPHARMACOLOGIC APPROACHES TO TREATMENT OF PSYCHOLOGY.

Decision Point 2

The second decision that was chosen is to have the client continue with Savella but have the dose reduced to 25 mg twice daily. This decision was chosen since Savella seems to be effective in lowering the pain score for this client and also the eurythmic mood improved. This is because of the mediation’s efficacy in treating fibromyalgia. Nonetheless, the client reported significant side effects after starting the medication and thus it was appropriate to reduce the current dose. Lyrica was not selected since it has more adverse effects than Savella and also Lyrica can increase mood problems and cause suicidal ideation for this client (Goodman & Brett, 2017). Sertraline was not selected since it is not approved for the treatment of fibromyalgia. Moreover, the sudden withdrawal of Savella is associated with withdrawal symptoms and thus the client shouldn’t stop taking Savella suddenly (Mease et al, 2014).

Selecting this decision hoped that the pain would continue reducing to an acceptable level. This is due to the efficacy of Savella in relieving pain caused by fibromyalgia (Abida et al, 2016). Secondly, it was expected that the side effects would reduce due to the reduced dose. Lower doses of medications have been shown to have an effective clinical response while minimizing side effects (Stroup & Gray, 2018).

However, the actual outcome of the decision significantly differed with the expected outcome. Even though the client reported a reduction of the side effects, he reported increased pain score and this adversely affected his mood. The higher pain score is due to decreased dose resulting in reduced efficacy of the mediation in decreasing the pain. According to Mease et al, (2014) the suggested dose for Savella is first day 2.5 mg/day; 2^nd day and 3^rd day 25 mg/day; 4^th-4^th day 50 mg/day; while after the 7^th day the dose can be increased to 100 mg/day. The dose is increased progressively to ensure efficacy and this the reduced dose for the client may explain the reduced efficacy in lowering pain score for the client (Mease et al., 2014).NURS 6630N PSYCHOPHARMACOLOGIC APPROACHES TO TREATMENT OF PSYCHOLOGY.

Decision Point 3

The third decision is changing the Savella to 25 mg orally in the MORNING and 50 mg at BEDTIME. The reason for choosing this decision is because an increased dose of Savella is associated with increased efficacy (Hayashi et al., 2017). As per Hayashi et al, (2017) when the response of the standard dose of Savella is ineffective, it is appropriate to increase the dose while assessing the patient’s response to the increased dose. Moreover, the increased dose was done at bedtime to minimize side effects during the daytime.

With this decision, the expectation was that the pain score for the client would significantly decrease and that the client would experience minimal or no side effects. This is because the efficacy of Savella is dose-dependent and thus higher doses are expected to be more effective (Hayashi et al., 2017). The side effects would be minimal because the increased dose is administered at bedtime while the minimal dose is administered during the daytime.

Ethical Considerations

Ethical issues associated with the treatment of the client include nonmaleficence and informed consent. Nonmaleficence involves doing no harm and thus the PMHNP should ensure that the prescribed medications do not cause unnecessary harm to the client. On the other hand, regarding informed consent, the PMHNP should provide all the necessary information about the treatment options, including the side effects so that he can make an informed treatment choice (Lin et al., 2019).NURS 6630N PSYCHOPHARMACOLOGIC APPROACHES TO TREATMENT OF PSYCHOLOGY.

Conclusion

The first decision that was chosen is for the client to begin Savella 12.5 mg, with the suitable dose increment. Savella was selected due to its efficacy in the treatment of fibromyalgia and relieving pain. Even though the client reported pain reduction, he experienced significant side effects. Therefore, the second decision was to reduce the dose of Savella to 25 mg twice daily. With this decision, the client reported increased pain score even though the side effects decreased. The third decision was thus to change Savella to 25 mg orally in the MORNING and 50 mg at BEDTIME. The rationale for choosing this decision is to increase the efficacy of Savella and thus decrease the pain score while reducing the likelihood of the client experiencing major side effects during daytime since the client took the higher dose (50 mg) at bedtime. The relevant ethical considerations for this client entail nonmaleficence and informed consent.NURS 6630N PSYCHOPHARMACOLOGIC APPROACHES TO TREATMENT OF PSYCHOLOGY.

 

BACKGROUND

This week, a 43-year-old white male presents at the office with a chief complaint of pain. He is assisted in his ambulation with a set of crutches. At the beginning of the clinical interview, the client reports that his family doctor sent him for psychiatric assessment because the doctor felt that the pain was “all in his head.” He further reports that his physician believes he is just making stuff up to get “narcotics to get high.”

 

SUBJECTIVE

The client reports that his pain began about 7 years ago when he sustained a fall at work. He states that he landed on his right hip. Over the years, he has had numerous diagnostic tests done (x-rays, CT scans, and MRIs). He reports that about 4 years ago, it was discovered that the cartilage surrounding his right hip joint was 75% torn (from the 3 o’clock to 12 o’clock position). He reports that none of the surgeons he saw would operate because they felt him too young for a total hip replacement and believed that the tissue would repair with the passage of time. Since then, he reported development of a strange constellation of symptoms including cooling of the extremity (measured by electromyogram). He also reports that he experiences severe cramping of the extremity. He reports that one of the neurologists diagnosed him with complex regional pain syndrome (CRPS), also known as reflex sympathetic dystrophy (RSD). However, the neurologist referred him back to his family doctor for treatment of this condition. He reports that his family doctor said “there is no such thing as RSD, it comes from depression” and this was what prompted the referral to psychiatry. He reports that one specialist he saw a few years ago suggested that he use a wheelchair, to which the client states “I said ‘no,’ there is no need for a wheelchair, I can beat this!”

The client reports that he used to be a machinist where he made “pretty good money.” He was engaged to be married, but his fiancé got “sick and tired of putting up with me and my pain, she thought I was just turning into a junkie.”NURS 6630N PSYCHOPHARMACOLOGIC APPROACHES TO TREATMENT OF PSYCHOLOGY.

He reports that he does get “down in the dumps” from time to time when he sees how his life has turned out, but emphatically denies depression. He states “you can’t let yourself get depressed… you can drive yourself crazy if you do. I’m not really sure what’s wrong with me, but I know I can beat it.”

During the client interview, the client states “oh! It’s happening, let me show you!” this prompts him to stand with the assistance of the corner of your desk, he pulls off his shoe and shows you his right leg. His leg is turning purple from the knee down, and his foot is clearly in a visible cramp as the toes are curled inward and his foot looks like it is folding in on itself. “It will last about a minute or two, then it will let up” he reports. Sure enough, after about two minutes, the color begins to return and the cramping in the foot/toes appears to be releasing. The client states “if there is anything you can do to help me with this pain, I would really appreciate it.” He does report that his family doctor has been giving him hydrocodone, but he states that he uses is “sparingly” because he does not like the side effects of feeling “sleepy” and constipation. He also reports that the medication makes him “loopy” and doesn’t really do anything for the pain.NURS 6630N PSYCHOPHARMACOLOGIC APPROACHES TO TREATMENT OF PSYCHOLOGY.

 

MENTAL STATUS EXAM

The client is alert, oriented to person, place, time, and event. He is dressed appropriately for the weather and time of year. He makes good eye contact. Speech is clear, coherent, goal directed, and spontaneous. His self-reported mood is euthymic. Affect consistent to self-reported mood and content of conversation. He denies visual/auditory hallucinations. No overt delusional or paranoid thought processes appreciated. Judgment, insight, and reality contact are all intact. He denies suicidal/homicidal ideation, and is future oriented.NURS 6630N PSYCHOPHARMACOLOGIC APPROACHES TO TREATMENT OF PSYCHOLOGY.

Diagnosis: Complex regional pain disorder (reflex sympathetic dystrophy)

Decision Point One

Select what the PMHNP should

SaSsvellaT 12.5s mg orally once daily on day 1; followed by 12.5 mg BID on day 2 and 3; followed by 25 mg BID on days 4-7; followed by 50 mg BID thereafter

Amitriptyline 25 mg po QHS and titrate upward weekly by 25 mg to a max dose of 200 mg per day

Nweurontin 300 mg po BEDTIME with weekly increases of 300 mg per day to a max of 2400 mg if needed

(2)   Amitriptyline 25 mg po QHS and titrate upward weekly by 25 mg to a max dose of

200mg per day

 

NURS 6630N PSYCHOPHARMACOLOGIC APPROACHES TO TREATMENT OF PSYCHOLOGY.

(3)     Neurontin 300 mg po BEDTIME with weekly increases of 300 mg per day to a max of 2400mg if needed

 

• Savella 12.5 mg orally once daily on day 1; followed by 12.5 mg BID on day 2 and

3: followed by 25 mg BID on days 4-7; followed by 50 mg BID thereafter

 

Review this week’s Learning Resources. Consider how to assess and treat clients requiring therapy for pain and sleep/wake disorders.

The Assignment

Examine Case Study: A Caucasian Man With Hip Pain. You will be asked to make three decisions concerning the medication to prescribe to this client. Be sure to consider factors that might impact the client’s pharmacokinetic and pharmacodynamic processes.NURS 6630N PSYCHOPHARMACOLOGIC APPROACHES TO TREATMENT OF PSYCHOLOGY.

At each decision point stop to complete the following:

• Decision #1
  • Which decision did you select?
  • Why did you select this decision? Support your response with evidence and references to the Learning Resources.
  • What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
  • Explain any difference between what you expected to achieve with Decision #1 and the results of the decision. Why were they different?
• Decision #2
  • Why did you select this decision? Support your response with evidence and references to the Learning Resources.
  • What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
  • Explain any difference between what you expected to achieve with Decision #2 and the results of the decision. Why were they different?
• Decision #3
  • Why did you select this decision? Support your response with evidence and references to the Learning Resources.
  • What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
  • Explain any difference between what you expected to achieve with Decision #3 and the results of the decision. Why were they different?

Also include how ethical considerations might impact your treatment plan and communication with clients.

NURS 6630N PSYCHOPHARMACOLOGIC APPROACHES TO TREATMENT OF PSYCHOLOGY.