In paragraph form- Reply to Kiara provide additional information, alternative points of view, resear

In paragraph form- Reply to Kiara provide additional information, alternative points of view, research to support treatment, or patient education strategies you might use with the relevant patient Other than that mentioned in presentation. Week (9): Case Presentation Kiara Robinson College of Nursing-PMHNP, Walden University PRAC 6675: PMHNP Care Across the Lifespan I Dr. Connole-Pond April 23, 2025 Subjective: CC (chief complaint): “The whole weekend was a hallucination” HPI: The patient is a 58 y.o female presenting with a history of Anxiety, Depression, and PTSD. The patient is currently residing at NF for long-term care. The patient was originally admitted to the facility last fall. Patient denies any significant past psychiatric history, IP/OP psychiatric services or SA. The patient reports the presenting problem began when she moved to her new apartment. The patient states that she is feeling a lot of pain right now, she did sleep last night and the pain medication is helpful. Patient reports pain as chronic, not new or worsening. Reports no issues with appetite. Patient reports signs and symptoms of depression and anxiety as not good, continue to be significant. She starts to talk about hearing voices, that she started dating Scott first and people tell her she is full of it. She reports she feels like the whole weekend was a hallucination. She reports this morning she saw her granddaughter, she is 19 and pregnant. She then goes on to explain that birds are in her room and are communicating about her. Reports seeing and hearing things that are not there. She reports this morning she saw spiders jumping off her head. The patient states that there were worms on the ceiling last night that startled her awake. She believes this is a church and the nuns are working here. Per staff: The patient continues to have ongoing psychosis that can distressing and disruptive to the patient. She can be redirected at times, reports the weekend was difficult for her. She has been worked up for medical causes but everything was WNL. Reports of depression and anxiety are increased and worsening. No reports of agitation, aggression, or psychosis. No issues reported with appetite. Substance Current Use:No substance use/history Medical History: Depression Rheumatoid Arthritis Anxiety Hypokalemia Hypotension Osteoporosis Esophageal Reflux A-Fib COPD Current Psychiatric Medications: Abilify 2 mg PO QHS Trazodone 100 mg PO QHS Duloxetine 40 mg PO BID Buspirone 15 mg PO BID Allergies:Penicillins, Ibuprofen Reproductive Hx: Not sexually active. Post-Menopause, Two Daughters ROS: GENERAL: No weight loss, fever, chills, weakness, or fatigue HEENT: No visual loss, blurred vision, double vision, or yellow sclerae. No hearing loss, sneezing, congestion, runny nose, or sore throat SKIN: No rash or itching. CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No palpitations. RESPIRATORY: No shortness of breath, cough, or sputum. GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood. GENITOURINARY: No burning on urination, urgency, hesitancy, odor, or odd color NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in extremities. No change in bowel or bladder control. MUSCULOSKELETAL: Reports some stiffness in joints related to arthritis. HEMATOLOGIC: No anemia, bleeding, or bruising. LYMPHATICS: No enlarged nodes. No history of splenectomy. ENDOCRINOLOGIC: No reports of sweating, cold, or heat intolerance. No polyuria or polydipsia. Objective: Diagnostic results: Urine analysis with culture negative. CBC, CMP, Ammonia level all unremarkable. Assessment: Mental Status Examination: The patient is well-groomed with appropriate attire. She is calm, cooperative, and her speech is normal rate/rhythm. Her mood is depressed and affect is full range, The patients thought process is linear, goal-directed, and her thought content is normal. She is experiencing both auditory and visual hallucinations. She is alert and oriented to self, place, and time. Her memory is intact while her insight, judgement, impulse control are fair. Diagnostic Impression: Depression with psychotic features: The DSM-5 characterizes depression with psychotic features as depression with loss of touch with reality (psychosis). The criteria of depression is met such as agitation, restlessness, withdrawn, fatigue or lack of energy, feeling hopeless, loss of interest, change in appetite, difficulty with concentration, and trouble sleeping or sleeping too much. However, it is accompanied by psychotic features such as delusions (false beliefs about surroundings or people) and hallucinations (seeing or hearing things that are not there) (American Psychiatric Association, 2022). This patient is likely experiencing depression with psychotic features due to her stating that she is having increased symptoms associated with depression, while she is also experiencing hallucinations such as spiders, birds, and worms being on the ceiling. Delusional Disorder: The DSM-5 classifies delusional disorder as the presence of one or more delusions for one month or longer. These patients struggle with differentiating between real and fictional beliefs. This results in a fixation on false religion and an incorrect perception of realities (American Psychiatric Association, 2022). There are seven different subtypes of delusions. The first is the Erotomanic type, which applies when the theme of the delusion is an individual is in love with the patient. Secondly, a Grandiose type applies when the theme of the delusion is having some great (unrecognized) talent, insight, or having made an important discovery. Thirdly, there is a Jealous type that applies when the theme of the patient’s delusion involves a spouse or lover who is unfaithful. Fourthly, there is the Persecutory type, when the theme consists of the individual’s belief that the patient is being conspired against, cheated, spied on, followed, poisoned/drugged, harassed, or obstructed from goals. Fifthly, there is the Somatic type, in which the theme of the delusion involves bodily functions or sensations. Sixthly, a mixed type applies when no one’s delusions dominate. Lastly, there is the Unspecified type that applies when the delusion cannot be determined or not described (American Psychiatric Association, 2022). Though the patient is experiencing some persecutory type delusions (the birds talking about her) her symptoms of increased depression better align with depression with psychotic features. Schizophreniform Disorder: The DSM-5 characterizes schizophreniform disorder, symptoms as identical to schizophrenia; however, it is different due to its duration. The illness lasts at least one month, but less than a six-month duration???another feature of schizophreniform is that it does not impair social and occupational function (American Psychiatric Association, 2022).The patient’s delusions and hallucinations could possibly be caused by schizophreniform. However, her hallucinations and delusions have only been recently discovered and a cause of distress for the patient. This could be diagnosed if it last longer than one month and less than six months. Reflections: This psychiatric evaluation also does not explore her current support system or how her relationship with her family is currently. I recommend including the patient’s children in her next session with her consent to explore possible causes of her visual and auditory hallucinations. Also, it is essential to acknowledge cultural stigmas, as well as public stigma against mental health, such as negative perceptions toward mental health treatment (Ran et al., 2021). When starting any new therapy, it is crucial to discuss legal and ethical issues, such as educating the patient on medication adherence, the advantages and disadvantages of different treatment options, alternative treatment options, and whether the patient is ready for treatment. Maintaining patient confidentiality during treatment is essential to ensure that information is only released when required by law or approved by the patient (Mandl & Perakslis, 2021). For future advanced providers, one health promotion activity is daily exercise. The patient has been declining rehab services with physical therapy. It is essential to explain that exercise has been influential in reducing tension and stress, boosting physical and mental energy, and enhancing overall health (Marconcin et al., 2022). For this client, explaining the importance of medication adherence is essential. As the practitioner, I want to explain the importance of taking her medication. Engaging in physical activity can aid this patient in focusing on a task to minimize hallucinations. I want to increase his knowledge of new drugs and what they are prescribed for and clarify any misconceptions he may have about medications or medical conditions. (Boutemen & Miller, 2023). One social determinant of health, according to HealthyPeople 2023, that is applied to this case is Healthcare Access and Quality. The patient was living in unhealthy conditions that caused her to develop Sepsis which required prolonged hospitalization. After her hospitalization she developed further health complications and is now having increased symptoms associated with mental distress. One health promotion would be the recommendation of cognitive behavioral therapy. Cognitive behavioral therapy (CBT) is a “goal-oriented” version of talk therapy that combines mental and behavioral components. It is commonly utilized in treating mental health disorders such as depression, anxiety, and emotional disorders (Demir & Ercan, 2022). However, CBT has also been helpful in the treatment of visual and auditory hallucinations by focusing on their ability to become aware of inappropriate or harmful thinking, enabling them to effectively see and react to challenging situations. Case Formulation and Treatment Plan: Plan review and education provided to Caregiver: [x] Nursing Staff [ ] Family [x] Patient [ ] Other ______ The patient continues to experience hallucinations and delusions, she is tolerating Abilify well without side effects, will maximize to 5 mg, she continues to endorse worsening depression, anxiety and psychosis. She is tolerating Trazodone well with improved sleep. Medications have been thoroughly reviewed. Plan to continue current medications as prescribed. Will continue to develop rapport and evaluate symptoms. Staff is instructed to notify MindCare with any increase in behaviors or worsening Order to be: D/C Abilify 2mg Start Abilify 5 mg PO QHS dx depression with psychotic features, psychosis. Current Medications: – TraZODone HCl Tablet 100 MG, Give 1 tablet by mouth at bedtime for DEPRESSION started 4/14/25 – DULoxetine HCl Oral Capsule Delayed Release Particles 40 MG, Give 40 mg by mouth two times a day for anitdepressant related to DEPRESSION, – busPIRone HCl Oral Tablet 15 MG, Give 15 mg by mouth two times a day for ANXIETY Continue to monitor for side effects from medications Continue to monitor for mood/behavioral changes. Encourage participation in groups and activities. Follow Up: Follow up within 2-8 weeks or sooner if clinically indicated. Medication risks and benefits reviewed and discussed. Lowest effective dose used for all psychotropics. Questions and concerns addressed. Requested that notes be placed in chart for referring clinicians review as well as notification of medication changes. Antipsychotic Treatment Plan: Antipsychotic Treatment Plan: Patient medical history, current conditions, and previous treatment have been reviewed. The patient has a history of hallucinations and delusions impacting the patients quality of life. Consideration of alternative treatment options has been reviewed and discussed with the interdisciplinary team. Due to the severity and distress of the patients psychosis, treatment with an antipsychotic is warranted to reduce symptoms and improve quality of life. Antipsychotic medications work by blocking dopamine receptors in the brain, which helps to regulate and restore the balance of dopamine activity. By reducing excessive dopamine signaling, antipsychotics can effectively alleviate the positive symptoms of psychosis, such as hallucinations and delusions. Medication Education: Aripiprazole (Abilify): Common, possible, and serious side effects discussed: sedation, insomnia, tremor, HA; nausea; dizziness, orthostatic hypotension, tachycardia; constipation, dry mouth; weight gain, diabetes, hyperlipidemia, hyperprolactinemia, neuroleptic malignant syndrome, EPS, QTC increase, sudden death. Black Box warning. Weight gain has been minimal in short and long-term trials. The drug has a lower risk of extrapyramidal symptoms, increases in lipid prolactin levels, and sedation, compared to other atypicals. RATES OF AKATHESIA are substantially higher for patients receiving aripiprazole for major depressive disorder and bipolar disorder compared to patients receiving aripiprazole for schizophrenia. Rationale: for mood stabilization; target thought disorder symptoms. Expected outcome: Improve mood, reduce irritability, help organize thinking, and therefore improve functioning and safety. Other classes of medications, such as antidepressants or mood stabilizers, primarily target different neurotransmitters and are not specifically designed to address the unique neurochemical imbalances associated with psychosis. While these medications may be beneficial in managing co-occurring symptoms or underlying conditions, they are not as effective in directly addressing the core symptoms of psychosis Non-pharmacological interventions including, but not limited to; redirection, reorientation, relaxation techniques, and distraction methods have minimal to no effect on patient behaviors. Risk-benefit analysis completed. Black box warning for antipsychotic use reviewed. Potential side effects and adverse events reviewed. Potential benefits of medication outweigh the risks associated with medication use.

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