Assignment: Assessing and Treating Clients With Psychosis and Schizophrenia

  // Delusional Disorders

Delusional Disorders Pakistani Female With Delusional Thought Processes

Hispanic male

 

Decision Point One : Start Abilify (aripiprazole) 10 mg orally at BEDTIME

RESULTS OF DECISION POINT ONE

• Client returns to clinic in four weeks
• Client returns and looks disheveled. Upon questioning, her husband states that she has not been sleeping at night. He states she is up and down all night and has also been disrupting his sleep
• Clientis unable to participate in the PANSS rating tool because she continually is nodding off (sleeping) during the appointment
• The appointment is not productive for assessing how she is responding to the Abilify started 4-weeks ago

Decision Point Two

Select what the PMHNP should do next:

Change Abilify administration time to AM dosing

RESULTS OF DECISION POINT TWO

• Client reports that although he had no more episodes of passing out, he has been dizzy when he gets up at night to use the bathroom
• Client arrives at office appearing to have slept better. Her husband tells you that she is still up and down at night but it is much less frequently. He notices that it is better when she takes her medication as soon as she awakens but some days she forgets and takes it when she remembers (in the afternoon)
• Client's PANNS has decreased by 5% since her initial visit

Decision Point Three

Select what the PMHNP should do next:

Increase dose to 20 mg at bedtime and counsel client on the importance of taking this medication first thing in the morning due to akathesia and insomnia that can be problematic in some clients. Counsel the husband on setting up reminders for her at home to help avoid these symptoms at night. E-prescribe Ambien 10 mg orally QHS to her pharmacy to help with sleep

Guidance to Student

This is week 8 since therapy was initiated. Although her side effects seem to be better managed, her PNSS is not changing by much. An acceptable time frame for treatment is defined as 4-6 weeks at an acceptable dose. Increasing Abilify to 20 mg in the morning certainly is an option but she sees to be forgetful of taking this medication first thing in the morning on occasion and is still experiencing side effects when it is taken later in the day. It might be a good time to explore other options at this juncture.

Latuda is a medication that behaves much like Geodon. It offers a once daily dosing option and weight gain is minimal. She would not be expected to experience the insomnia and akathesia that has been experienced on the Abilify. Tolerability can be an issue as doses are escalated. Particularly, nausea, vomiting and extrapyramidal side effects can be problematic and therefore good counseling is recommended for clients. Clients usually tolerate lower doses (40 mg) but significant GI distress and movement disorders can occur when doses are pushed upward toward the daily max of 160 mg.

Invega oral therapy is a good option as it has a once daily dosing option and it has a greater effect at the D2 receptor than Abilify and may offer more efficacy and less insomnia and akathesia as seen in Abilify. It has a long acting option that can be given monthly (to start) and with good efficacy maintained over a 4-month period, changed to once every 3 months. This is a good option in someone where compliance can be problematic.

Start Over

Discontinue Abilify and start Latuda (lurasidone) 40 mg orally daily

Guidance to Student

This is week 8 since therapy was initiated. Although her side effects seem to be better managed, her PNSS is not changing by much. An acceptable time frame for treatment is defined as 4-6 weeks at an acceptable dose. Increasing Abilify to 20 mg in the morning certainly is an option but she sees to be forgetful of taking this medication first thing in the morning on occasion and is still experiencing side effects when it is taken later in the day. It might be a good time to explore other options at this juncture.

Latuda is a medication that behaves much like Geodon. It offers a once daily dosing option and weight gain is minimal. She would not be expected to experience the insomnia and akathesia that has been experienced on the Abilify. Tolerability can be an issue as doses are escalated. Particularly, nausea, vomiting and extrapyramidal side effects can be problematic and therefore good counseling is recommended for clients. Clients usually tolerate lower doses (40 mg) but significant GI distress and movement disorders can occur when doses are pushed upward toward the daily max of 160 mg.

Invega oral therapy is a good option as it has a once daily dosing option and it has a greater effect at the D2 receptor than Abilify and may offer more efficacy and less insomnia and akathesia as seen in Abilify. It has a long acting option that can be given monthly (to start) and with good efficacy maintained over a 4-month period, changed to once every 3 months. This is a good option in someone where compliance can be problematic.

Start Over

Discontinue Abilify. Start her on Invega oral tablets 6 mg orally qdaily and begin the conversation about long acting injectable antipsychotics in preparation of starting Invega Sustenna at her next appointment

Guidance to Student

This is week 8 since therapy was initiated. Although her side effects seem to be better managed, her PNSS is not changing by much. An acceptable time frame for treatment is defined as 4-6 weeks at an acceptable dose. Increasing Abilify to 20 mg in the morning certainly is an option but she sees to be forgetful of taking this medication first thing in the morning on occasion and is still experiencing side effects when it is taken later in the day. It might be a good time to explore other options at this juncture.

Latuda is a medication that behaves much like Geodon. It offers a once daily dosing option and weight gain is minimal. She would not be expected to experience the insomnia and akathesia that has been experienced on the Abilify. Tolerability can be an issue as doses are escalated. Particularly, nausea, vomiting and extrapyramidal side effects can be problematic and therefore good counseling is recommended for clients. Clients usually tolerate lower doses (40 mg) but significant GI distress and movement disorders can occur when doses are pushed upward toward the daily max of 160 mg.

Invega oral therapy is a good option as it has a once daily dosing option and it has a greater effect at the D2 receptor than Abilify and may offer more efficacy and less insomnia and akathesia as seen in Abilify. It has a long acting option that can be given monthly (to start) and with good efficacy maintained over a 4-month period, changed to once every 3 months. This is a good option in someone where compliance can be problematic.

Start Over

Reduce Abilify dose to 7.5 MG orally at BEDTIME

RESULTS OF DECISION POINT TWO

• Client returns to clinic in four weeks
• Client arrives at appointment a little less sedate but still exhausted. Husband states that it is a little better at home but she is still up and down all night long
• Client's PANNS has not changed from her initial visit (reduction of 25%)

Decision Point Three

Select what the PMHNP should do next:

Discontinue Abilify and start Risperdal (risperidone ) 1 mg orally BID

Guidance to Student

It seems obvious at this point that this client is always going to react to Abilify in this manner and therefore should be discontinued and deemed as a treatment failure due to intolerable side effects (the insurance companies are going to want to see this documentation. It is a good idea to get in the habit of documenting why medications are discontinued in an effort to save yourself time in the future and prevent re-challenges to medications like this). A change to either Risperdal, Fanapt, or prolixin are all suitable options and are up to PMHNP choice and client tolerability/efficacy. Risperdal is a nice option because it has a long acting injectable option. This also applies to prolixin. Disadvantages to Prolixin long acting injectable and to Risperdal/invega long acting injectable are side effects (EPS) and injection site pain (typical antipsychotic long acting injectables are in an oleaginous base compared to nanoparticles in an aqueous base for the atypical options). Fanapt has to be slowly titrated upward to help avoid side effects that can lead to noncompliance.

Start Over

Discontinue Abilify and start Fanapt (iloperidone ) 1 mg orally BID and titrate slowly to response. Max dose out at 12 mg orally BID if required

Guidance to Student

It seems obvious at this point that this client is always going to react to Abilify in this manner and therefore should be discontinued and deemed as a treatment failure due to intolerable side effects (the insurance companies are going to want to see this documentation. It is a good idea to get in the habit of documenting why medications are discontinued in an effort to save yourself time in the future and prevent re-challenges to medications like this). A change to either Risperdal, Fanapt, or prolixin are all suitable options and are up to PMHNP choice and client tolerability/efficacy. Risperdal is a nice option because it has a long acting injectable option. This also applies to prolixin. Disadvantages to Prolixin long acting injectable and to Risperdal/invega long acting injectable are side effects (EPS) and injection site pain (typical antipsychotic long acting injectables are in an oleaginous base compared to nanoparticles in an aqueous base for the atypical options). Fanapt has to be slowly titrated upward to help avoid side effects that can lead to noncompliance.

Start Over

Discontinue Abilify and start client on Prolixin (fluphenazine ) 2.5 mg orally BID

Guidance to Student

It seems obvious at this point that this client is always going to react to Abilify in this manner and therefore should be discontinued and deemed as a treatment failure due to intolerable side effects (the insurance companies are going to want to see this documentation. It is a good idea to get in the habit of documenting why medications are discontinued in an effort to save yourself time in the future and prevent re-challenges to medications like this). A change to either Risperdal, Fanapt, or prolixin are all suitable options and are up to PMHNP choice and client tolerability/efficacy. Risperdal is a nice option because it has a long acting injectable option. This also applies to prolixin. Disadvantages to Prolixin long acting injectable and to Risperdal/invega long acting injectable are side effects (EPS) and injection site pain (typical antipsychotic long acting injectables are in an oleaginous base compared to nanoparticles in an aqueous base for the atypical options). Fanapt has to be slowly titrated upward to help avoid side effects that can lead to noncompliance.

Start Over

Discontinue Abilify and start Geodon (ziprasidone ) 40 mg orally BID with meals

RESULTS OF DECISION POINT TWO

• Client returns to clinic in four weeks
• Client has a significant reduction in her PANSS (make her a responder w/ score reduction of 40%)
• Client notices her weight is down slightly from the previous visit (lost 2 pounds) and that her hunger has been curbed since starting this medication
• Client does complain that it is difficult to remember the second dose and admits to missing afternoon doses on several occasions over the past month

Decision Point Three

Select what the PMHNP should do next:

Give her a few test doses of Risperdal 1 mg orally BID for 3 days to see if she tolerates the medication. If tolerated, start Invega Sustenna at an appropriate starting and maintenance dose

Guidance to Student

Changing to Risperdal oral therapy to test for side effects and then switching to Invega Sustenna is a good option in a client who has problems with compliance and who shows good effect from oral therapy. The manufacturer advertises that clients can be switched from an entirely different medication to Invega Sustenna if tolerability can be shown through oral therapy. From a clinical standpoint, the client may or may not respond to the medication and therefore this could be a waste of time. Remember, manufacturers have a product to sell, and their information should always be verified before implementing into clinical practice.

Although Geodon is recommended twice daily with meals, some providers will choose to give the dose once a day and monitor for efficacy in clients who have compliance issues with BID dosing regimens.

Latuda is a medication that behaves much like Geodon and is therefore a good option for someone who responds to Geodon but has compliance problems due to its once daily dosing schedule. Tolerability can be an issue as doses are escalated. Particularly, nausea, vomiting, and extrapyramidal side effects can be problematic and therefore good counseling points to clients. Clients usually tolerate lower doses (40 mg), but significant GI distress and movement disorders can occur when doses are pushed upward toward the daily max of 160 mg.

Start Over

Change the Geodon to 80 MG at bedtime daily and monitor for breakthrough symptoms throughout the day

Guidance to Student

Changing to Risperdal oral therapy to test for side effects and then switching to Invega Sustenna is a good option in a client who has problems with compliance and who shows good effect from oral therapy. The manufacturer advertises that clients can be switched from an entirely different medication to Invega Sustenna if tolerability can be shown through oral therapy. From a clinical standpoint, the client may or may not respond to the medication and therefore this could be a waste of time. Remember, manufacturers have a product to sell, and their information should always be verified before implementing into clinical practice.

Although Geodon is recommended twice daily with meals, some providers will choose to give the dose once a day and monitor for efficacy in clients who have compliance issues with BID dosing regimens.

Latuda is a medication that behaves much like Geodon and is therefore a good option for someone who responds to Geodon but has compliance problems due to its once daily dosing schedule. Tolerability can be an issue as doses are escalated. Particularly, nausea, vomiting, and extrapyramidal side effects can be problematic and therefore good counseling points to clients. Clients usually tolerate lower doses (40 mg), but significant GI distress and movement disorders can occur when doses are pushed upward toward the daily max of 160 mg.

Start Over

Discontinue Geodon and start Latuda 40 mg orally Daily

Guidance to Student

Changing to Risperdal oral therapy to test for side effects and then switching to Invega Sustenna is a good option in a client who has problems with compliance and who shows good effect from oral therapy. The manufacturer advertises that clients can be switched from an entirely different medication to Invega Sustenna if tolerability can be shown through oral therapy. From a clinical standpoint, the client may or may not respond to the medication and therefore this could be a waste of time. Remember, manufacturers have a product to sell, and their information should always be verified before implementing into clinical practice.

Although Geodon is recommended twice daily with meals, some providers will choose to give the dose once a day and monitor for efficacy in clients who have compliance issues with BID dosing regimens.

Latuda is a medication that behaves much like Geodon and is therefore a good option for someone who responds to Geodon but has compliance problems due to its once daily dosing schedule. Tolerability can be an issue as doses are escalated. Particularly, nausea, vomiting, and extrapyramidal side effects can be problematic and therefore good counseling points to clients. Clients usually tolerate lower doses (40 mg), but significant GI distress and movement disorders can occur when doses are pushed upward toward the daily max of 160 mg.

Start Over