NURS 6521 Adult/Geriatric Depression Hispanic Male With MDD

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NURS 6521 Adult/Geriatric Depression Hispanic Male With MDD

NURS 6521 Adult/Geriatric Depression Hispanic Male With MDD

BACKGROUND INFORMATION
The client is a 70 year-old Hispanic American male who came to the United States when he was in high school with his father. His mother died back in Mexico when he was in school. He presents today to your office for an initial appointment for complaints of depression. The client was referred by his PCP after “routine” medical work-up to rule out an organic basis for his depression. He has no other health issues with the exception of some occasional back pain and “stiff” shoulders which he attributes to his current work as a laborer in a warehouse.

SUBJECTIVE
During today’s clinical interview, client reports that he always felt like an outsider as he was “teased” a lot for being “black” in high school. States that he had few friends, and basically kept to himself. He describes his home life as “good.” Stating “Dad did what he could for us, there were 8 of us.” He also reports a remarkably diminished interest in engaging in usual activities, states that he has gained 15 pounds in the last 2 months. He is also troubled with insomnia which began about 6 months ago, but have been progressively getting worse. He does report poor concentration which he reports is getting in “trouble” at work.

MENTAL STATUS EXAM
The client is alert, oriented to person, place, time, and event. He is casually dressed. Speech is clear, but soft. He does not readily make eye contact, but when he does, it is only for a few moments. He is endorsing feelings of depression. Affect is somewhat constricted, but improves as the clinical interview progresses. He denies visual or auditory hallucinations, no overt delusional or paranoid thought processes readily apparent. Judgment and insight appear grossly intact. He is currently denying suicidal or homicidal ideation. You administer the “Montgomery- Asberg Depression Rating Scale (MADRS)” and obtained a score of 51 (indicating severe depression).
RESOURCES
§ Montgomery, S. A., & Asberg, M. (1979). A new depression scale designed to be sensitive to change. British Journal of Psychiatry, 134, 382-389.

Decision Point One
Select what you should do:

Begin zoloft 25 mg orally daily

Begin Effexor XR 37.5 mg orally daily

Begin Phenelzine 15 mg orally TID

Decision Point One

Begin zoloft 25 mg orally daily
RESULTS OF DECISION POINT ONE
• Client returns to clinic in four weeks
• Reports a 25% decrease in symptoms
• Client is concerned over the new onset of erectile dysfunction
Decision Point Two

 

Decrease dose to 12.5 mg orally daily

RESULTS OF DECISION POINT TWO
• Client returns to clinic in four weeks
• Erectile dysfunction has subsided
• Depressive symptoms have worsened
Decision Point Three

 

Increase dose back to 25 mg orally daily

Guidance to Student
Increasing dose back to 25 mg orally daily may be appropriate as there is no guarantee that the side effect will return. If it does return at 25 mg orally daily, then you should consider changing to another drug. Changing to Paxil 20 mg may also be appropriate at this point, as not all SSRIs have the same side effect profile. Changing to an SNRI would not be appropriate at this point as the issue is not that the client has not responded to SSRI therapy, rather, he has had a negative side effect to one drug in the class.
Decision Point One

Begin Effexor XR 37.5 mg orally daily
RESULTS OF DECISION POINT ONE
• Client returns to clinic in four weeks
• Client reports that there is no change in depressive symptoms at all
Decision Point Two

 

Increase dose to 75 mg of Effexor XR orally daily

RESULTS OF DECISION POINT TWO
• Client returns to clinic in four weeks
• Client reports an improvement in depressive symptoms
• Montgomery- Asberg Depression Rating Scale (MADRS) decreased from 51 to 38 (25% reduction)
Decision Point Three

 

Increase dose to 112.5 mg orally daily

Guidance to Student
At this point, you would have two choices to discuss with the client- the current dose of drug can be maintained if the client is feeling better and is not offering any complaints of side effects. The dose can also be increased at this point, but you must counsel client regarding the possibility of side effects. The use of an augmenting agent is not appropriate at this time as we have not reached a maximum dose with Effexor (in fact, 75 mg is still a relatively small dose), displaying primarily SSRI properties only (recall that at lower doses, Effexor exerts a greater effect on serotonergic receptors than norepinephrine at low doses).
Decision Point One

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NURS 6521 Adult/Geriatric Depression Hispanic Male With MDD

NURS 6521 Adult/Geriatric Depression Hispanic Male With MDD

Begin Phenelzine 15 mg orally TID
RESULTS OF DECISION POINT ONE
• Client returns to clinic in four weeks
• Client reports that he was rushed to the Emergency Room 2 weeks ago after collapsing at the warehouse where he works. He was taken by ambulance to the local community hospital. He was diagnosed with postural hypotension
• Client was treated with fluid bolus and told to stop taking his phenelzine and to follow up with his primary care provider within one week, and you within that same time frame
Decision Point Two

 

Restart Phenelzine and counsel client on dietary choices and importance of hydration

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 also reports that at various times throughout the day when he goes from a sitting to a standing position, he feels light-headed
Decision Point Three

 

Discontinue Phenelzine and start an SSRI

Guidance to Student
The best choice at this point would be to discontinue Phenelzine and begin SSRI therapy. While MAOIs can be powerful drugs used to treat depression, they are generally considered last-line therapy due to unfavorable side effect profiles as well as drug/food interactions. Client’s on MAOIs must be on the MAOI diet and avoid certain aged foods which contain Tyramine. Adding Midodrine would not be appropriate as you should never add a medication to treat the side effects of a medication unless there are no other alternatives. In this case, changing from an MAOI to another drug class would be reasonable and appropriate. Reduction of the Phenelizine dose could be appropriate, but decreased dosage would result in decreased likelihood of efficacy.
Discussion: Decision Making When Treating Psychological Disorders
Psychological disorders, such as depression, bipolar, and anxiety disorders can present several complications for patients of all ages. These disorders affect patients physically and emotionally, potentially impacting judgment, school and/or job performance, and relationships with family and friends. Since these disorders have many drastic effects on patients’ lives, it is important for advanced practice nurses to effectively manage patient care. With patient factors and medical history in mind, it is the advanced practice nurse’s responsibility to ensure the safe and effective diagnosis, treatment, and education of patients with psychological disorders.

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For this Discussion, you will select an interactive media piece to practice decision making when treating patients with psychological disorders. You will recommend the most effective pharmacotherapeutic to treat the psychological disorder presented and examine potential impacts of pharmacotherapeutics on a patient’s pathophysiology.
To Prepare
• Review this week’s interactive media pieces and select one to focus on for this Discussion.
• Reflect on the decision steps in the interactive media pieces, and consider the potential impacts from the administration of the associated pharmacotherapeutics on the patient’s pathophysiology.
By Day 3 of Week 8
Post a brief explanation of the psychological disorder presented and the decision steps you applied in completing the interactive media piece for the psychological disorder you selected. Then, explain how the administration of the associated pharmacotherapeutics you recommended may impact the patient’s pathophysiology. How might these potential impacts inform how you would suggest treatment plans for this patient? Be specific and provide examples.
By Day 6 of Week 8
Read a selection of your colleagues’ responses and respond to at least two of your colleagues on two different days who selected a different interactive media piece on a psychological disorder, and provide recommendations for alternative drug treatments to address the patient’s pathophysiology.
Note: For this Discussion, you are required to complete your initial post before you will be able to view and respond to your colleagues’ postings. Begin by clicking on the “Post to Discussion Question” link, and then select “Create Thread” to complete your initial post. Remember, once you click on Submit, you cannot delete or edit your own posts, and you cannot post anonymously. Please check your post carefully before clicking on Submit!
Submission and Grading Information
Grading Criteria

To access your rubric:
Week 8 Discussion Rubric

Post by Day 3 of Week 8 and Respond by Day 6 of Week 8

To Participate in this Discussion:
Week 8 Discussion

 

 

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