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Assignment: Assessing and Treating Patients With Impulsivity, Compulsivity, and

Assignment: Assessing and Treating Patients With Impulsivity Compulsivity and Addiction Impulsivity compulsivity and addiction are challenging disorders for patients across the life span. Impulsivity is the inclination to act upon sudden urges or desires without considering potential consequences; patients often describe impulsivity as living in the present moment without regard to the future (MentalHelp.net n.d.). Thus these disorders often manifest as negative behaviors resulting in adverse outcomes for patients. For example compulsivity represents a behavior that an individual feels driven to perform to relieve anxiety (MentalHelp.net n.d.). The presence of these behaviors often results in addiction which represents the process of the transition from impulsive to compulsive behavior. In your role as the psychiatric nurse practitioner (PNP) you have the opportunity to help patients address underlying causes of the disorders and overcome these behaviors. For this Assignment as you examine the client case study in this weeks Learning Resources consider how you might assess and treat clients presenting with impulsivity compulsivity and addiction. Reference:MentalHelp.net. (n.d.). Impaired decision-making impulsivity and compulsivity: Addictions effect on the cerebral cortex. https://www.mentalhelp.net/addiction/impulsivity-and-compulsivity-addictions-effect-on-the-cerebral-cortex/ To prepare for this Assignment: Review this weeks 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 requiring therapy for impulsivity compulsivity and addiction. The Assignment: 5 pages ExamineCase 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 clientspharmacokinetic 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. Week 10: Therapy for Patients With Impulsive/Substance Use Disorders (SUD) Impulsivity and compulsivity have a wide range of clinical presentations and often overlap with many other psychiatric disorders. Some individuals act without forethought and have difficulty saying no to certain things such as using illicit drugs or spending money whereas other individuals engage in compulsive behaviors with undesirable consequences. In some cases these impulsive and compulsive behaviors also fuel issues with addiction. To effectively assess and treat patients you must understand how these disorders differ as well as how their symptoms impact patients and their families. This week as you examine therapies for individuals with impulsivity compulsivity and addiction you explore the assessment and treatment of patients with these disorders. You also consider ethical and legal implications of these therapies. Learning Objectives Students will: Assess patient factors and history to develop personalized therapy plans for patients with impulsivity compulsivity and addiction Analyze factors that influence pharmacokinetic and pharmacodynamic processes in patients requiring therapy for impulsivity compulsivity and addiction Synthesize knowledge of providing care to patients presenting for impulsivity compulsivity and addiction Analyze ethical and legal implications related to prescribing therapy for patients with impulsivity compulsivity and addiction Learning Resources Required Readings (click to expand/reduce) Kelly J. E. & Renner J. A. (2016). Alcohol-Related disorders. In T. A. Stern M. Favo T. E. Wilens & J. F. Rosenbaum. (Eds.) Massachusetts General Hospital psychopharmacology and neurotherapeutics(pp. 163“182). Elsevier. Renner J. A. & Ward N. (2016). Drug addiction. In T. A. Stern M. Favo T. E. Wilens & J. F. Rosenbaum. (Eds.) Massachusetts General Hospital psychopharmacology and neurotherapeutics(pp. 163“182). Elsevier. Substance Abuse and Mental Health Services Administration. (1999). Treatment of adolescents with substance use disorders: Treatment improvement protocol series no. 32. http://www.ncbi.nlm.nih.gov/books/NBK64350/ Chapter 1 Substance Use Among Adolescents Chapter 2 Tailoring Treatment to the Adolescents Problem Chapter 7 Youths with Distinctive Treatment Needs University of Michigan Health System. (2016). Childhood trauma linked to worse impulse control. Journal of Psychosocial Nursing & Mental Health Services 54(4) 15. Grant J. E. Odlaug B. L. & Schreiber L. N. (2014). Pharmacological treatments in pathological gambling. British Journal of Clinical Pharmacology 77(2) 375“381. https://doi.org/10.1111/j.1365-2125.2012.04457.x Hulvershorn L. A. Schroeder K. M. Wink L. K. Erickson C. A. & McDougle C. J. (2015). Psychopharmacologic treatment of children prenatally exposed to drugs of abuse. Human Psychopharmacology 30(3) 164“172. https://doi.org/10.1002/hup.2467 Loreck D. Brandt N. J. & DiPaula B. (2016). Managing opioid abuse in older adults: Clinical considerations and challenges. Journal of Gerontological Nursing 42(4) 10“15. https://doi.org/10.3928/00989134-20160314-04 Salmon J. M. & Forester B. (2012). Substance abuse and co-occurring psychiatric disorders in older adults: A clinical case and review of the relevant literature. Journal of Dual Diagnosis 8(1) 74“84. https://doi.org/10.1080/15504263.2012.648439 Sanches M. Scott-Gurnell K. Patel A. Caetano S. C. Zunta-Soares G. B. Hatch J. P. Olvera R. Swann A. C. & Soares J. C. (2014). Impulsivity in children and adolescents with mood disorders and unaffected offspring of bipolar parents. Comprehensive Psychiatry 55(6) 1337“1341. https://doi.org/10.1016/j.comppsych.2014.04.018 Medication Resources (click to expand/reduce) IBM Corporation. (2020). IBM Micromedex. https://www.micromedexsolutions.com/micromedex2/librarian/deeplinkaccess?source=deepLink&institution=SZMC%5ESZMC%5ET43537 Note: To access the following medications use the IBM Micromedex resource. Type the name of each medication in the keyword search bar. Be sure to read all sections on the left navigation bar related to each medications result page as this information will be helpful for your review in preparation for your Assignments. naltrexone (revia/vivitrol) naloxone acamprosate disulfiram Required Media (click to expand/reduce) Case Study: A Puerto Rican Woman with Comorbid Addiction Note:This case study will serve as the foundation for this weeks Assignment. Optional Resources (click to expand/reduce) Lupi M. Martinotti G. Acciavatti T. Pettorruso M. Brunetti M. Santacroce R. Cinose E. Di Iorio G. Di Nicola M. & Di Giannantonio M. (2014). Pharmacological treatments in gambling disorder: A qualitative review. Biomed Research International 2014. https://doi.org/10.1155/2014/537306 Comorbid Addiction (ETOH and Gambling) 53-year-old Puerto Rican Female BACKGROUND Mrs. Maria Perez is a 53 year old Puerto Rican female who presents 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 20s and has been involved with Alcoholics Anonymous on and off for the past 25 years. She states that for the past 2 years she has been having more and more difficulty maintaining her sobriety since the opening of the new Rising Sun casino near her home. Mrs. Perez states that she and a friend went to visit the new casino during its 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 2 years and she is concerned about the negative effects of the cigarette smoking on her health. She states that she attempts to abstain from drinking but 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 doesnt smoke as much  but she 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 borrowed over $50 000 from her retirement account to pay off her gambling debts and her husband does not know. MENTAL STATUS EXAM The client is a 53 year old Puerto Rican female who is alert and 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. When 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 and self-reported mood. She denies visual or auditory hallucinations and 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 Select what you should do: Vivitrol (naltrexone) injection 380 mg intramuscularly in the gluteal region every 4 weeksAntabuse (disulfiram) 250 mg orally dailyCampral (acamprosate) 666 mg orally three times/day Comorbid Addiction (ETOH and Gambling) 53-year-old Puerto Rican Female Decision Point One Vivitrol (naltrexone) injection 380 mg intramuscularly in the gluteal region every 4 weeks RESULTS OF DECISION POINT ONE Client returns to clinic in four weeks Mrs. Perez says she feels wonderful as she has not touched a drop of alcohol since receiving the injection Client reports that she has not been going to the casino as frequently but when she does go she drops a bundle (meaning spends a lot of money gambling) Client She is also still smoking which has her concerned. She is also reporting some problems with anxiety which also has her concerned Decision Point Two Add on Valium (diazepam) 5 mg orally TID/PRN/anxiety RESULTS OF DECISION POINT TWO 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 an increase the Valium dose or frequency Decision Point Three Continue current dose of Vivitrol increase Valium to 10 mg orally TID/PRN/anxiety. Refer to counseling for her ongoing gambling issue Guidance to Student Anxiety is a common side effect of Vivitrol. Mrs. Perez reports that she is doing well with this medication and like other side effects the anxiety associated with this medication may be transient. The psychiatric mental health nurse practitioner should never initiate benzodiazepines in a client who already has issues with alcohol or other substance dependencies. Additionally benzodiazepines are not to be used long-term. Problems associated with long-term benzodiazepine use include the need to increase the dose in order to achieve the same therapeutic effect. This is what we are seeing in Mrs. Perezs case. The most appropriate course of action in this case would be to continue the current dose of Vivitrol while decreasing the Valium with the goal of discontinuation of the drug within the next two weeks. At that point you would need to evaluate whether or not the side effect of anxiety associated with Vivitrol persists. Increasing the dose of Valium would not be appropriate neither would maintaining her on the current dose of Valium. Additionally the client should be referred for counseling to help with her gambling addiction as there are no FDA approved medications gambling disorder. Medication should never be added treat side effect of another medication unless that side effect is known to be transient (for instance benzodiazepines are sometimes prescribed to overcome the initial problem of activation associated with initiation of SSRI or SNRI therapy). However in a client with multiple addictive disorders benzodiazepines should never be used (unless they are only being used for a limited duration of therapy such as acute alcohol detoxification to prevent seizures). Additionally it should be noted that Mrs. Perez continues to engage in problematic gambling at considerable personal financial cost. Mrs. Perez needs to be referred to a counselor who specializes in the treatment of gambling disorder and should also be encouraged to establish herself with a local chapter of gamblers anonymous. You need to discuss smoking cessation options with Mrs. Perez in order to address the totality of addictions and to enhance her overall health.]

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