NURS 6630 Assessing and Treating Patients With Sleep/Wake Disorders
Assessing and Treating Patients with Sleep/Wake Disorders
Getting enough sleep is crucial for overall well-being, like maintaining a regular exercise routine and eating a balanced diet. According to Madari et al. (2021), adults are generally advised to aim for six to eight hours of sleep per night, but individual needs may vary. Insomnia can adversely affect a person’s overall physical and mental health, regardless of the reasons behind it. Insomnia is characterized by the inability to sleep, frequent awakenings, and trouble falling asleep. As a result, individuals may experience symptoms including but not limited to anxiety, fatigue, drowsiness, mood disturbances, and compromised cognitive abilities.
This case study focuses on a 31-year-old male patient who is experiencing insomnia. The patient has sleeplessness, with worsening symptoms over time. The symptoms were a direct consequence of the emotional distress experienced due to the loss of his fiancée. Symptoms have significantly impacted the patient’s forklift operation. In his medical records, diphenhydramine was given as a remedy for insomnia. Four years ago, the patient started using opiates after being prescribed hydrocodone for pain relief. The individual also uses four alcoholic beverages before going to bed to promote sleep. The patient reported no hallucinations or violent thoughts.
Various patient-related factors influence the selection of medication for prescription. The patient’s age, gender, and insomnia diagnosis are all critical considerations. Previous diphenhydramine usage by the person and any adverse effects will be considered. The social background of the person—including the death of his fiancé, opiate addiction, and alcoholism—will have a significant influence on whether medicinal intervention is best. This paper explores the decision-making process and legal and ethical considerations involved in prescribing medication for the management of insomnia in the above patient.
Decision Point One
Selected Decision and Rationale
The first intervention was giving a 50 mg dosage of trazodone just before bed. Trazodone was selected for its strong effectiveness in promoting and maintaining sleep. Trazodone has received FDA approval for the medical management of insomnia, as stated by Pelayo et al. (2023). Trazodone inhibits the production of neurotransmitters linked to arousal, including histamine, serotonin, noradrenaline, dopamine, and acetylcholine (Madari et al., 2021). Trazodone is often given to people with primary and secondary sleeplessness to help them sleep. Furthermore, studies indicate that low doses of trazodone to treat and manage insomnia are linked to a positive safety record (Vgontzas et al., 2020). Trazodone allows patients to manage sleep disturbances while remaining focused on their work.
Numerous adverse effects, including decreased inhibitory control, hallucinations, sleeplessness, and gastrointestinal discomfort, including nausea and abdominal pain, have been related to zolpidem (Madari et al., 2021). In addition, Hydroxyzine was not selected because it closely resembles the client’s diphenhydramine. In addition, the medication has sedative effects and may lead to urination retention (Wang et al., 2020).
Expected Outcome
After starting trazodone, the patient is anticipated to get more and better quality sleep over the following four weeks. It is projected that there is going to be an improvement in his general well-being and work-related focus throughout this period (Hassinger et al., 2020).
Ethical Considerations
Beneficence and nonmaleficence are ethical concepts that govern treatment options and patient-provider communication. Considering the moral concept of beneficence, it was essential to dedicate sufficient efforts to provide aid and safeguard the patient’s welfare, reducing the likelihood of potential harm (Hassinger et al., 2020). The pharmacological drug with the lowest occurrence of adverse effects was administered in the scenario without any malicious intentions.
Decision Point Two
Selected Decision and Rationale
The trazodone dose was later decreased to 25 mg to be consumed before going to sleep. The intervention is undertaken due to the patient’s claim of significant side effects related to Trazodone, namely an abnormally extended penile erection, which has been ongoing for two weeks. It is recommended to begin using trazodone with a lower dose of 25 mg and then incrementally raise it to 100 mg while carefully observing the patient’s reaction (Vgontzas et al., 2020). With a half-life of six to seven hours, trazodone helps sustain sleep while minimizing side effects, especially at lower dosages (Pelayo et al., 2023). Frequently seen transient adverse effects include a reduction in both the quality and length of sleep. Hence, it was concluded that the optimal course of action was reducing the Trazodone dose to 25mg and closely observing the patient’s condition for two weeks (Pochiero et al., 2022).
The patient’s favorable reaction to Trazodone eliminates the possibility of substituting it with Suvorexant or Hydroxyzine. Reducing the dose may help alleviate unwanted consequences. Treatment for insomnia with suvorexant and hydroxyzine carries a risk of addiction as well as possible physical or mental decline (Madari et al., 2021). There may be a decrease in the patient’s psychological and physical abilities, which might be dangerous for their health. Hallucinations and drowsiness are potential adverse effects of Suvorexant or Hydroxyzine therapy initiation (Pochiero et al., 2022).
Expected Outcome
With a lower dose of trazodone, the side effects of priapism should be resolved, and the patient’s sleep quality should improve. According to Wang et al. (2020), trazodone is as effective in treating insomnia when given at lower doses while also reducing adverse side effects. The patient is expected to demonstrate improved concentration and less drowsiness throughout the day, resulting in higher productivity at work.
Ethical Considerations
Beneficence entails that healthcare personnel consistently prioritize the patient’s well-being, actively advocating for and protecting them from potential damage. As a result, the dose was decreased to minimize the chance of priapism and assure the safety of the patient. Furthermore, they ensure that informed permission is obtained before treatment, highlighting the significance of autonomy. It is of utmost importance to assist patients in comprehending the consequences of decreasing their medication dose (Hassinger et al., 2020). The patient exhibited confidence in the given information and was granted informed consent.
Decision Point Three
Selected Decision and Rationale
The ultimate resolution was to continue delivering a 25mg dosage of trazodone before bed and employ techniques to enhance sleep hygiene. Due to the patient’s satisfactory sleep quality and priapism side effects, the dose had to be reduced. According to research conducted by Wang et al. (2020), to improve general well-being and regulate sleep patterns, it is essential to include psychotherapy treatments and implement good sleep hygiene practices. Furthermore, patients should enforce modifications in their lifestyle, such as reducing their intake of caffeine and alcoholic beverages (Pochiero et al., 2022). According to Pelayo et al. (2023), psychotherapy and other tailored therapies are crucial for addressing these demands. Combining pharmaceutical treatment with non-pharmacological approaches may enhance patient results and safety profiles.
When Trazodone was administered at a lower dosage, the patient’s sleep quality improved, and priapism decreased. The medicine cessation was considered thus unnecessary in this particular context (Madari et al., 2021). It is advised against using Ramelteon and Hydroxyzine together owing to their possible adverse effects, such as exhaustion and withdrawal symptoms, which might impair everyday functioning (Pochiero et al., 2022).
Expected Outcome
Although the patient is still getting treatment and following strict sleep hygiene rules, it is expected that their sleep habits and general sleep quality will get better. To ensure the effectiveness of Trazodone and establish a healthy sleep routine, a subsequent consultation may include assessing the individual’s sleeping hygiene (Wang et al., 2020).
Ethical Consideration
The ethical principle of autonomy is crucial in therapy since it requires obtaining informed consent before commencing any treatment. To improve adherence to the recommended treatment plan, it is essential to assess and provide support regarding the patient’s sleep patterns (Hassinger et al., 2020). The importance of pushing for alcohol abstinence as a method for improving an individual’s overall well-being is emphasized.
Conclusion
The individual seeking medical attention is a 31-year-old man experiencing insomnia. Insomnia is characterized by a lack of sleep, frequent interruptions during sleep, and trouble falling asleep. It is advised to start therapy by taking a daily dosage of 50 mg of Trazodone before going to bed. According to Layo et al. (2023), the FDA has authorized Trazodone as a therapy for insomnia. This SARI treats insomnia by inhibiting the serotonin 5-HT2A receptor. The second intervention consisted of lowering the dosage of trazodone from 50 mg to 25 mg before bed. Although Trazodone was beneficial, the patient experienced priapism as a side effect, which had a substantial negative influence on their overall quality lifestyle (Vgontzas et al., 2020). The third intervention involves maintaining the patient’s trazodone dose and offering sleep hygiene advice (Pochiero et al., 2022).
Zolpidem and hydroxyzine were excluded as treatment options for insomnia owing to their known correlation with sleep-related eating problems and their antihistamine qualities (Wang et al., 2020). Furthermore, studies have shown that the usage of zolpidem leads to detrimental side effects like amnesia, hallucinations, impaired self-restraint, dizziness, vertigo, and abdominal discomfort. The sedative properties of hydroxyzine have been associated with urine retention (Madari et al., 2021). Beneficence, autonomy, and non-maleficence are three ethical principles that impact the treatment plan and the communication between the patient and the healthcare provider. Adhering to the beneficence principle, it was crucial to engage in behaviors that enhanced well-being and protected the patient from harm (Hassinger et al., 2020). Preceding the initiation of treatment, autonomy is an essential notion within the framework of informed consent. The concept of nonmaleficence was adhered to by choosing the drug with the least amount of harmful side effects.
References
Hassinger, A., Bletnisky, N., Dudekula, R., & El-Solh, A. (2020). Selecting a pharmacotherapy regimen for patients with chronic insomnia. Expert Opinion on Pharmacotherapy, 21(9), 1035–1043. https://doi.org/10.1080/14656566.2020.1743265
Madari, S., Golebiowski, R., Mansukhani, M. P., & Kolla, B. P. (2021). Pharmacological management of insomnia. Neurotherapeutics, 18(1), 44–52. https://doi.org/10.1007/s13311-021-01010-z
Pelayo, R., Bertisch, S. M., Morin, C. M., Winkelman, J. W., Zee, P. C., & Krystal, A. D. (2023). Should Trazodone be First-Line therapy for insomnia? A Clinical Suitability Appraisal. Journal of Clinical Medicine, 12(8), 2933. https://doi.org/10.3390/jcm12082933
Pochiero, I., Gorini, M., Comandini, A., Calisti, F., Di Loreto, G., Cattaneo, A., Knight, T., Anastassopoulos, K., Patel, R., Baik, R., & Bruni, O. (2022). Real-world characteristics and treatment patterns of patients with insomnia prescribed trazodone in the United States. Clinical Therapeutics, 44(8), 1093–1105. https://doi.org/10.1016/j.clinthera.2022.07.004
Vgontzas, A. N., Puzino, K., Fernández-Mendoza, J., Krishnamurthy, V., Basta, M., & Bixler, E. O. (2020). Effects of trazodone versus cognitive behavioral therapy in insomnia with short sleep duration phenotype: a preliminary study. Journal of Clinical Sleep Medicine, 16(12), 2009–2019. https://doi.org/10.5664/jcsm.8740
Wang, J., Liu, S., Zhao, C., Han, H., Chen, X., Tao, J., & Lu, Z. (2020). Effects of trazodone on sleep quality and cognitive function in arteriosclerotic cerebral small vessel disease comorbid with chronic insomnia. Frontiers in Psychiatry, 11. https://doi.org/10.3389/fpsyt.2020.00620
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Assessing and Treating Patients With Sleep/Wake Disorders
Sleep disorders are conditions that result in changes in an individual’s pattern of sleep (Mayo Clinic, 2020). Not surprisingly, a sleep disorder can affect an individual’s overall health, safety, and quality of life. Psychiatric nurse practitioners can treat sleep disorders with psychopharmacologic treatments, however, many of these drugs can have negative effects on other aspects of a patient’s health and well-being. Additionally, while psychopharmacologic treatments may be able to address issues with sleep, they can also exert potential challenges with waking patterns. Thus, it is important for the psychiatric nurse practitioner to carefully evaluate the best psychopharmacologic treatments for patients that present with sleep/wake disorders.
Reference: Mayo Clinic. (2020). Sleep disorders. https://www.mayoclinic.org/diseases-conditions/sleep-disorders/symptoms-causes/syc-20354018
Resources
Be sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources.
Learning Resources
Required Readings
- Stahl, S. M. (2021). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (5th Ed.) Cambridge University Press.
- Chapter 10, “Disorders of Sleep and Wakefulness and Their Treatment: Neurotransmitter Networks for Histamine and Orexin” (pp. 401-448)
- American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders
- Links to an external site. (5th ed., text rev.). https://go.openathens.net/redirector/waldenu.edu?url=https://dsm.psychiatryonline.org/doi/book/10.1176/appi.books.9780890425787
- Fernandez-Mendoza, J., & Vgontzas, A. N. (2013). Insomnia and its impact on physical and mental health.
- Links to an external site., 15(12), 418. https://doi.org/10.1007/s11920-012-0418-8
- Levenson, J. C., Kay, D. B., & Buysse, D. J. (2015). The pathophysiology of insomnia. Chest
- Links to an external site., 147(4), 1179–1192. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4388122/
- Morgenthaler, T. I., Kapur, V. K., Brown, T. M., Swick, T. J., Alessi, C., Aurora, R. N., Boehlecke, B., Chesson, A. L., Friedman, L., Maganti, R., Owens, J., Pancer, J., & Zak, R. (2007). Practice parameters for the treatment of narcolepsy and other hypersomnias of central origin. SLEEP
- Links to an external site., 30(12), 1705–1711. https://j2vjt3dnbra3ps7ll1clb4q2-wpengine.netdna-ssl.com/wp-content/uploads/2017/07/PP_Narcolepsy.pdf
- Morgenthaler, T. I., Owens, J., Alessi, C., Boehlecke, B, Brown, T. M., Coleman, J., Friedman, L., Kapur, V. K., Lee-Chiong, T., Pancer, J., & Swick, T. J. (2006). Practice parameters for behavioral treatment of bedtime problems and night wakings in infants and young children. SLEEP
- Links to an external site., 29(1), 1277–1281. https://j2vjt3dnbra3ps7ll1clb4q2-wpengine.netdna-ssl.com/wp-content/uploads/2017/07/PP_NightWakingsChildren.pdf
- Sateia, M. J., Buysse, D. J., Krystal, A. D., Neubauer, D. N., & Heald, J. L. (2017). Clinical practice guideline for the pharmacologic treatment of chronic insomnia in adults: An American Academy of Sleep Medicine clinical practice guideline. Journal of Clinical Sleep Medicine
- Links to an external site., 13(2), 307–349. https://jcsm.aasm.org/doi/pdf/10.5664/jcsm.6470
- Winkleman, J. W. (2015). Insomnia disorder. The New England Journal of Medicine
- Links to an external site., 373(15), 1437–1444. https://doi.org/10.1056/NEJMcp1412740
Medication Resources
- U.S. Food & Drug Administration. (n.d.). Drugs@FDA: FDA-approved drugs
- Links to an external site.. https://www.accessdata.fda.gov/scripts/cder/daf/index.cfm
Links to an external site.
Note: To access the following medications, use the Drugs@FDA resource. Type the name of each medication in the keyword search bar. Select the hyperlink related to the medication name you searched. Review the supplements provided and select the package label resource file associated with the medication you searched. If a label is not available, you may need to conduct a general search outside of this resource provided. Be sure to review the label information for each medication as this information will be helpful for your review in preparation for your Assignments.
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Required Media
- Links to an external site.
Note: This case study will serve as the foundation for this week’s Assignment.
To prepare for this Assignment:
- Review this week’s Learning Resources, including the Medication Resources indicated for this week.
- Reflect on the psychopharmacologic treatments you might recommend for the assessment and treatment of patients with sleep/wake disorders.
The Assignment: 5 pages
Examine Case Study: Pharmacologic Approaches to the Treatment of Insomnia in a Younger Adult. You will be asked to make three decisions concerning the medication to prescribe to this patient. Be sure to consider factors that might impact the patient’s pharmacokinetic and pharmacodynamic processes.
At each decision point, you should evaluate all options before selecting your decision and moving throughout the exercise. Before you make your decision, make sure that you have researched each option and that you evaluate the decision that you will select. Be sure to research each option using the primary literature.
Introduction to the case (1 page)
- Briefly explain and summarize the case for this Assignment. Be sure to include the specific patient factors that may impact your decision making when prescribing medication for this patient.
Decision #1 (1 page)
- Which decision did you select?
- Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
- Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
- What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
- Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.
Decision #2 (1 page)
- Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
- Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
- What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
- Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.
Decision #3 (1 page)
- Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
- Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
- What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
- Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.
Conclusion (1 page)
- Summarize your recommendations on the treatment options you selected for this patient. Be sure to justify your recommendations and support your response with clinically relevant and patient-specific resources, including the primary literature.
Note: Support your rationale with a minimum of five academic resources. While you may use the course text to support your rationale, it will not count toward the resource requirement. You should be utilizing the primary and secondary literature.
Reminder : The College of Nursing requires that all papers submitted include a title page, introduction, summary, and references. The Sample Paper provided at the Walden Writing Center provides an example of those required elements (available at https://academicguides.waldenu.edu/writingcenter/templates/general#s-lg-box-20293632). All papers submitted must use this formatting
By Day 7
Submit your Assignment.
submission information
Before submitting your final assignment, you can check your draft for authenticity. To check your draft, access the Turnitin Drafts from the Start Here area.
- To submit your completed assignment, save your Assignment as WK8Assgn2_LastName_Firstinitial
- Then, click on Start Assignment near the top of the page.
- Next, click on Upload File and select Submit Assignment for review.
Rubric
NURS_6630_Week8_Assignment2_Rubric
| Criteria | Ratings | Pts | ||||
|---|---|---|---|---|---|---|
| This criterion is linked to a Learning Outcome Introduction to the case (1 page)Briefly explain and summarize the case for this Assignment. Be sure to include the specific patient factors that may impact your decision making when prescribing medication for this patient. |
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10 pts | ||||
| This criterion is linked to a Learning Outcome Decision #1 (1–2 pages)• Which decision did you select?• Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.• Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.• What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).• Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples. |
|
20 pts | ||||
| This criterion is linked to a Learning Outcome Decision #2 (1–2 pages)• Which decision did you select?• Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.• Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.• What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).• Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples. |
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20 pts | ||||
| This criterion is linked to a Learning Outcome Decision #3 (1–2 pages)• Which decision did you select?• Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.• Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.• What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).• Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples. |
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20 pts | ||||
| This criterion is linked to a Learning Outcome Conclusion (1 page)• Summarize your recommendations on the treatment options you selected for this patient. Be sure to justify your recommendations and support your response with clinically relevant and patient-specific resources, including the primary literature. |
|
15 pts | ||||
| This criterion is linked to a Learning Outcome Written Expression and Formatting – Paragraph Development and Organization: Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused—neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria. |
|
5 pts | ||||
| This criterion is linked to a Learning Outcome Written Expression and Formatting – English writing standards: Correct grammar, mechanics, and proper punctuation |
|
5 pts | ||||
| This criterion is linked to a Learning Outcome Written Expression and Formatting – The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, parenthetical/in-text citations, and reference list. |
|
5 pts | ||||
| Total Points: 100 | ||||||