Psychiatric Nurse NP

Psychiatric Nurse NP

BACKGROUND

Mrs. Maria Perez is a 53 year old Puerto Rican female who presents to your office today due to a rather “embarrassing problem.”

SUBJECTIVE

Mrs. Perez admits that she has had “problems” with alcohol since her father died in her late teens. She reports that she has struggled with alcohol since her 20’s and has been involved with Alcoholics Anonymous “on and off” for the past 25 years. She states that for the past two years, she has been having more and more difficulty maintaining her sobriety since they opened the new “Rising Sun” casino near her home. Mrs. Perez states that she and a friend went to visit the new casino during their grand opening at which point she was “hooked.” She states that she gets “such a high” when she is gambling. While gambling, she “enjoys a drink or two” to help calm her during high-stakes games. She states that this often gives way to more drinking and more reckless gambling. She also reports that her cigarette smoking has increased over the past two years and she is concerned about the negative effects of the cigarette smoking on her healthPsychiatric Nurse NP.

ORDER A PLAGIARISM – FREE PAPER NOW

She states that she attempts to abstain from drinking but that she gets such a “high” from the act of gambling that she needs a few drinks to “even out.” She also notices that when she drinks, she doesn’t smoke “as much” but enjoys smoking when she is playing at the slot machines. She also reports that she has gained weight from drinking so much- she currently weights 122 lbs., which represents a 7 lb. weight gain from her usual 115 lb. weight.

Mrs. Perez is quite concerned today because she has borrowed over $50,000 from her retirement account to pay off her gambling debts. She is very concerned because her husband does not know that she has spent this much money Psychiatric Nurse NP.

MENTAL STATUS EXAM

The client is a 53 year old Puerto Rican female who is alert, oriented to person, place, time, and event. She is dressed appropriately for the weather and time of year. Her speech is clear, coherent, and goal directed. Her eye contact is somewhat avoidant during the clinical interview. As you make eye contact with her, she looks away or looks down. She demonstrates no noteworthy mannerisms, gestures, or tics. Her self-reported mood is “sad.” Affect is appropriate to content of conversation & self-reported mood. She visual or auditory hallucinations, no delusional or paranoid thought processes are readily appreciated. Insight and judgment are grossly intact, however, impulse control is impaired. She is currently denying suicidal or homicidal ideation.

Diagnosis: Gambling disorder, alcohol use disorder

Decision Point One

Antabuse (Disulfiram) 250 mg orally every morning ON

Naltrexone (Vivitrol) injection, 380 mg intramuscularly in the gluteal region every 4 weeks

Antabuse (Disulfiram) 250 mg orally daily

Campral (Acamprosate) 666 mg orally three times/day

E

·  Client returns to clinic in four weeks

·  Mrs. Perez states that she has noticed that she has been having suicidal ideation over the past week, and it seems to be getting worse

·  Clientis She is also reporting that she is having “out of control” anxiety.. 

Decision Point Two

Educate Mrs. Perez on the side effects of Campral and add Valium (diazepam) 5 mg orally TID to address anxiety symptoms

RESULTS OF DECISION POINT TWO Decision Point Two

Select what the PMHNP should do next:

  • Client returns to clinic      in four weeks
  • Mrs. Perez reports that      when she first received the valium, it helped her tremendously. She states      “I was like a new person- this is a miracle drug!” However, she reports      that she has trouble “waiting” between drug administration times and      sometimes takes her valium early. She is asking today for you to increase      the valium dose or frequency
  • Although she reports that      her anxiety is gone, she still reports suicidal ideation, but states “with      that valium stuff, who cares?”;;;;;;;;
  • Decision Point Three
  •  Add on Wellbutrin (bupropion) XL 150 mg orally daily
  • Guidance to Student Psychiatric Nurse NP
  • Given her weight (less than 60      kg), Campral should have been started at 666 mg orally BID. It is possible      that the higher dose may be responsible for the severity of the symptoms      that Mrs. Perez is experiencing.
  • Technically, the drug should      have been stopped (not simply decreased) once Mrs. Perez reported suicidal      ideation. Even with the decrease in dose, she is still having suicidal      ideation, which indicates the need to discontinue the drug. Although      controversy exists regarding how long to use pharmacologic approaches to      treatment of alcohol dependence, 8 weeks is probably insufficient,      therefore, the drug should not simply be discontinued without using a      different agent in its place.
  • Mrs. Perez should be started on      Antabuse at 250 mg orally daily and referred to psychotherapy to address      her gambling issue.
  • In all cases, the PMHNP needs      to discuss smoking cessation options with Mrs. Perez in order to address      the totality of addictions and to enhance her overall health. The decision      to begin Wellbutrin XL 150 mg orally daily may help achieve this goal, but      this choice does not address her abstinence from alcohol.
  • Additionally, it should be      noted that although Mrs. Perez reports that she has been avoiding the      casino secondary to her fear that she will drink, this “fear” has not      actually treated her gambling addiction. This particular addiction has      resulted in considerable personal financial cost to Ms. Perez. Mrs. Perez      needs to be referred to a counselor who specializes in the treatment of      gambling disorder, and she should also be encouraged to establish herself      with a local chapter of Gamblers Anonymous.
  • Examine Case Study: A      Puerto Rican Woman With Comorbid Addiction. 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.
  • 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? Psychiatric Nurse NP

Also check: Discussion: Skin and Respiratory System Disorders