NSG 502 APA Paper Assignment
NSG 502 APA Paper
The case study depicts a 62-year-old female patient with a history of Major Depressive disorder (MDD). The patient reports that her medication is ineffective. She presents with low mood symptoms, sleeping difficulties, lack of motivation, and thoughts of death but denies suicidal intent or plan. She had a suicide attempt history five years ago. Her current medication is Lexapro, and she has previously taken Prozac, Zoloft, and Paxil, which were not effective. In addition, she had a history of nerve pain secondary to sciatica. This paper seeks to discuss the class of drugs that may be used for this patient, specific medications that would be prescribed, drug monitoring and patient education, and the expected outcomes and prognosis.
Classes of Medications That May Be Used for the Client’s Diagnosis
The classes of antidepressant medications that may be prescribed for a patient’s treatment-resistant depression include SSRIs, Serotonin/norepinephrine reuptake inhibitors (SNRIs), Tricyclic antidepressants (TCAs), Atypical Antidepressants, and Monoamine oxidase inhibitors. This section will discuss the pharmacodynamics and pharmacokinetics of these drug classes and whether they are appropriate for the patient.
Selective Serotonin Reuptake Inhibitors (SSRIs)
SSRIs are the recommended first-line antidepressants for uncomplicated depression due to their minimal anticholinergic side effects. Drugs in the class of SSRIs include fluoxetine, fluvoxamine, paroxetine, sertraline, and escitalopram. SSRIs selectively inhibit serotonin transporters and have modest effects on other neurotransmitters (Gautam et al., 2021). SSRIs are preferred due to their advantage of the ease of dosing and minimal toxicity in overdose. They have greater tolerability and a relatively more benign safety profile than other antidepressants. The common side effects of SSRIs include cognitive dysfunction, gastrointestinal upset, sexual dysfunction, emotional blunting, fatigue, and restlessness. The patient in the case study has been on SSRIs, the recommended first-line medications for MDD (Gautam et al., 2021). Based on the patient’s history, she seems to have treatment-resistant depression. SSRIs may not be an appropriate drug choice for this patient since she did not achieve an adequate positive response on various SSRIs, including fluoxetine, sertraline, and paroxetine.
SNRIs
SNRIs block norepinephrine and serotonin transporters. However, they lack alpha-blocking anticholinergic and antihistaminic actions. SNRIs are recommended as first-line agents, mainly in patients with fatigue or pain syndromes associated with the depressive episode (Gautam et al., 2021). SNRIs play a vital role as second-line agents in persons with no adequate response to SSRIs (Voineskos et al., 2020). SNRIs have tolerability, safety, and side-effect profiles similar to SSRIs and noradrenergic adverse effects, such as hypertension. SNRIs inhibit Cytochrome P450, enhancing the action of drugs like clozapine, carbamazepine, HMG-CoA reductase inhibitors, and TCAs (Gautam et al., 2021). SNRIs are an appropriate choice for this patient based on her history of sciatica nerve pain. SNRIs can help to alleviate the sciatica pain which is associated with MDD.
Tricyclic Antidepressants
TCAs block the reuptake transporters of both norepinephrine and serotonin. They block serotonin reuptake more than norepinephrine reuptake (Gautam et al., 2021). TCAs are incompletely absorbed per oral. They undergo a significant first-pass effect, are highly bound to tissue proteins, and are highly lipid-soluble. They have a wide volume of distribution, are not readily removed by dialysis, and have plasma half-lives of 8–36 hours, which permit once-daily dosing. The side effects of TCAs are due to their pharmacodynamic actions. They include excessive sedation, fatigue, and confusion (Gautam et al., 2021). TCAs have been established to be efficacious in the treatment of depression. However, they are rarely prescribed due to their side-effect profile and their significant toxicity in overdose. Consequently, TCAs may not be appropriate for this patient due to their high potential of adverse effects that may reduce compliance.
Atypical Antidepressants
Atypical antidepressants are serotonin and norepinephrine reuptake inhibitors. Atypical antidepressants have been found effective in monotherapy in MDD and may be prescribed in combination therapy for difficult to treat depression (Gautam et al., 2021). Their half-lives are short and usually require administration two or three times daily. They have the advantage of low toxicity in overdose. Bupropion has the advantage over the SSRIs of having less sexual dysfunction and GI disturbance (Gautam et al., 2021). However, it is associated with adverse effects, such as agitation, anxiety, dizziness, dry mouth, aggravation of psychosis, and seizures at high doses. Mirtazapine is associated with weight gain and is markedly sedating. Atypical antidepressants are suitable for this patient since they are effective in treating treatment-resistant depression.
Monoamine Oxidase Inhibitors (MAOIs)
MAOIs inhibit monoamine oxidase, the enzyme that metabolizes norepinephrine and serotonin, and dopamine. They increase norepinephrine in the sympathetic nerve terminals. MAOIs are readily absorbed orally and have a prolonged duration of action of 2–3 weeks (Gautam et al., 2021). MAOIs inhibit hepatic enzymes, which cause drug interactions. They have a high risk of hypertensive crisis in response to indirectly acting sympathomimetics, and thus patients on MAOIs must follow a low-tyramine diet. Other common side effects of MAOIs include insomnia, orthostasis, anxiety, weight gain, and sexual dysfunction (Gautam et al., 2021). MAOIs may not be the most appropriate for this patient due to their side effects and dietary restrictions.
Specific Medication or Medications I Would Prescribe for the Client
The antidepressant medications I would prescribe for the patient in the case study include Venlafaxine, an SNRI, and Bupropion, an atypical antidepressant. Venlafaxine and Bupropion are antidepressant drugs with distinctive pharmacologic profiles. This section will discuss the rationale for these medications, including their indications, mechanism of action, side effects, and adverse reactions.
The rationale for the Choice of Medications
Venlafaxine has been established as an effective treatment for MDD, which inhibits the reuptake of serotonin-norepinephrine. It is co-administered chiefly with other antidepressants to enhance the efficacy of the antidepressant action (Voineskos et al., 2020). I would prescribe Venlafaxine because it is recommended as a second-line agent in individuals who do not respond to SSRIs. The patient demonstrates no response to previously administered SSRIs. It is also a suitable drug since it will help alleviate nerve pain secondary to sciatica. I would prescribe Bupropion because it does not impact serotonin transport and thus does not have the serotonergic adverse effects such as sexual dysfunction common with other antidepressants.
FDA And Off-Label Indications Associated With the Medications
The FDA indications for Venlafaxine include major depressive disorder, generalized anxiety disorder, panic disorder, social anxiety, and cataplexy. Venlafaxine is often indicated for non–FDA-approved conditions, including obsessive-compulsive disorder (OCD), neuropathic pain, hot flashes secondary to hormonal chemotherapy, attention-deficit hyperactivity disorder (ADHD), prevention of migraine, posttraumatic stress disorder (PTSD), and premenstrual dysphoric disorder (Naseeruddin et al., 2020). The FDA indications for Bupropion include major depressive disorder, seasonal affective disorder, and smoking cessation (Huecker et al., 2020). Off-label indications for Bupropion include ADHD and neuropathic pain.
Mechanism of Action, Side Effects, and Possible Adverse Reactions
Venlafaxine and its active metabolite block the reuptake of neuronal serotonin and norepinephrine and weakly inhibits dopamine reuptake. Its action results in increased serotonin, norepinephrine, and dopamine levels in the brain (Naseeruddin et al., 2020). It is a more potent blocker of serotonin reuptake than norepinephrine reuptake. Its common side effects include headache, nausea, insomnia, dizziness, ejaculation disorder, somnolence, dry mouth, diaphoresis, anorexia, and nervousness (Naseeruddin et al., 2020). Potential adverse reactions include altered platelet function, abnormal bleeding, anaphylaxis reaction, and fatal skin conditions such as toxic epidermal necrolysis, Stevens-Johnson syndrome, and erythema multiforme. Bupropion acts by inhibiting the reuptake of neuronal dopamine and reduced the rate of norepinephrine activity. Its impact on norepinephrine and dopamine contributes to its clinical effect. Common side effects of Bupropion include headache, weight loss, dry mouth, nausea, insomnia, agitation, and dizziness. The most severe adverse effects are potential deterioration of suicidal ideation and reduced seizure threshold.
Monitoring For the Medications
Patients should have a baseline blood pressure check before being initiated on Venlafaxine and be monitored while on the drug. Additionally, the renal function and lipid profiles should be monitored. A patient on Venlafaxine should be closely monitored for psychiatric disorders, including clinical features of depression, suicidality, anxiety, mania, or unusual behavior changes (Lyndon et al., 2019). Serum testing is not indicated to monitor patients on Bupropion because it has no strong, established therapeutic concentrations. However, due to the adverse effect of a lowered seizure threshold, the patient’s mental health status should be assessed at each visit (Mohamed et al., 2017). Besides, the patient should be educated on the actions to take if a seizure occurs.
Patient Education That Is Important To Discuss
Patients on Venlafaxine should be educated on the indications of the drug, such as treating depression, panic attacks, and anxiety. They should also be informed of the common potential side effects and pharmacological and non-pharmacological ways to alleviate the symptoms. Besides, patients on Venlafaxine should be informed of the harmful side effects associated with the drug, such as chest pain, coughing blood, high BP, dyspnea, bone pain, allergic reaction, and suicidal thoughts (Lyndon et al., 2019). Patients should be cautioned against taking Venlafaxine with alcohol since it can cause increased sedation. The FDA has a black box warning against Venlafaxine because it can exacerbate depression, serotonin syndrome, hypomania, or mania and increase suicidality.
Patient education about Bupropion should include the drug’s indications such as treating depression, seasonal affective disorder, and smoking cessation. Patients should be informed of the drug’s minor side effects and lethal side effects such as confusion, behavioral changes, severe headache, severe dizziness, and seizures (Mohamed et al., 2017). In addition, patients should be educated on the signs of allergic reaction with Bupropion such as hives, itching, erythematous skin, wheezing, chest tightness, and difficulties breathing. The FDA has a black box warning against the use of Bupropion in bipolar depression.
Expected Outcomes and Prognosis
The expected outcomes from the treatment plan include improving the patient’s depressive symptoms by at least 25% within the first four weeks of treatment and 50% in the subsequent four weeks. The patient is expected to demonstrate a full remission of depressive symptoms within 12 weeks of treatment. Venlafaxine and Bupropion are associated with improved sleep, energy, and appetite within the first 1-2 weeks (Lyndon et al., 2019). Consequently, the patient’s symptoms of sleeping difficulties and lack of motivation may improve within 1-2 weeks after initiating treatment. The depressed mood may require up to 6-8 weeks to abate fully when the drug combination is used.
Conclusion
The antidepressants that may be used for the patient’s MDD diagnosis include SSRIs, SNRIs, Atypical antidepressants, TCAs, and MAOIs. SNRIs are recommended in patients who do not respond to SSRIs and those with neuropathic pain related to MDD. They are appropriate for this patient since she has not responded to SSRIs and has sciatica pain. Atypical antidepressants are also appropriate because they are effective in treating treatment-resistant depression. Medications that would be prescribed for this patient include Venlafaxine and Bupropion, which fall under the class of SNRIs and Atypical antidepressants, respectively. The patient’s parameters that should be monitored when on these drugs include blood pressure, renal function, lipid profile, and mental health status.
References
Gautam, S., Jain, A., Gautam, M., Vahia, V. N., & Grover, S. (2017). Clinical Practice Guidelines for the management of Depression. Indian journal of psychiatry, 59(Suppl 1), S34–S50. https://doi.org/10.4103/0019-5545.196973
Huecker, M. R., Smiley, A., & Saadabadi, A. (2020). Bupropion. In StatPearls [Internet]. StatPearls Publishing.
Lyndon, G. J., Prieto, R., Wajsbrot, D. B., Allgulander, C., & Bandelow, B. (2019). Efficacy of venlafaxine extended-release in major depressive disorder patients: effect of baseline anxiety symptom severity. International clinical psychopharmacology, 34(3), 110. https://doi.org/10.1097/YIC.0000000000000256
Mohamed, S., Johnson, G. R., Chen, P., Hicks, P. B., Davis, L. L., Yoon, J., … & VAST-D Investigators. (2017). Effect of antidepressant switching vs. augmentation on remission among patients with major depressive disorder unresponsive to antidepressant treatment: the VAST-D randomized clinical trial. Jama, 318(2), 132-145. https://doi.org/10.1001/jama.2017.8036
Naseeruddin, R., Rosani, A., & Marwaha, R. (2020). Desvenlafaxine. StatPearls [Internet].
Voineskos, D., Daskalakis, Z. J., & Blumberger, D. M. (2020). Management of Treatment-Resistant Depression: Challenges and Strategies. Neuropsychiatric disease and treatment, 16, 221–234. https://doi.org/10.2147/NDT.S198774
NSG 502 APA Paper Assignment
This paper should be approximately 6 pages long, not including title page and reference list. You must adhere to APA guidelines. There should be a title page, introduction, body of the paper, and conclusion. An abstract is not necessary for this paper. Should you have any difficulties the Writing Center is an excellent resource. Here is a helpful link for APA guidelines: http://www.rivier.edu/academics.aspx?menu=115&id=1252 (Links to an external site.)
This paper will be submitted through Tunritin to ensure academic honesty. Please note if there is any plagiarism you will receive a 0 and will meet with the Director of the Program per policy (see handbook).
Please See APA Guidelines/ Rubric and Resources module for document with specific guidelines and rubric: Link to get to document
Rubric
APA Paper for NSG 502
APA Paper for NSG 502
Criteria
Ratings
Pts
This criterion is linked to a Learning Outcome References
10 pts
Excellent Performance
Provided at least 5 references appropriate to the topic and professional quality 10 points
9 pts
Competent
Provided less than 5 References. Or Some are not appropriate to the Topic. Or some are not professional quality 5-9 points
4 pts
Needs Improvement
Fewer than 3 references or all references were from nonprofessional sources 0-4 points
10 pts
This criterion is linked to a Learning Outcome Discussion of possible classes of medications
25 pts
Excellent Performance
-Includes detailed discussion on different class that would or would not be appropriate for your client -Include detailed discussion pharmacodynamics and pharmacokinetics of the drug classes 25 points
24 pts
Competent
-Includes most information in discussion on different class that would or would not be appropriate for your client -Include most information in discussion pharmacodynamics and pharmacokinetics of the drug classes 15-24 points
14 pts
Needs Improvement
-Includes minimal information in discussion on different class that would or would not be appropriate for your client -Include minimal information in discussion pharmacodynamics and pharmacokinetics of the drug classes 0-14 points
25 pts
This criterion is linked to a Learning Outcome Identification of specific medications
25 pts
Excellent Performance
-Correctly identify 1 or 2 specific medications you would prescribe for your client. – Uses evidenced based practice, explain the rationale for the choice of medication or medications – Correctly discuss FDA and off label indications associated with the medications/ medications you have chosen to prescribe -Includes detailed explanation of receptors sites in discussion of mechanism of action, side effects, and possible adverse reactions 25 points
24 pts
Competent
-Correctly identify 1 or 2 specific medications you would prescribe for your client. – Does not use evidenced based practice, explain the rationale for the choice of medication or medications – Has a limited discussion FDA and off label indications associated with the medications/ medications you have chosen to prescribe -Includes minimal explanation of receptors sites in discussion of mechanism of action, side effects, and possible adverse reactions 15-24 points
14 pts
Needs Improvement
-Does not correctly identify 1 or 2 specific medications you would prescribe for your client. – Does not use evidenced based practice, explain the rationale for the choice of medication or medications – Has a limited or no discussion of FDA and off label indications associated with the medications/ medications you have chosen to prescribe -Includes minimal or no explanation of receptors sites in discussion of mechanism of action, side effects, and possible adverse reactions 0-14 points
25 pts
This criterion is linked to a Learning Outcome Discussion of Monitoring and Education
15 pts
Excellent Performance
Uses current research from reliable professional source to discuss any monitoring suggested for the medication/medications you have chose -Includes detailed patient education that is important to discuss. – Includes black box warnings 15 points
14 pts
Competent
-Research is not from professional, reliable source to discuss any monitoring suggested for the medication/medications you have chose -Includes minimal patient education that is important to discuss. – Includes black box warnings 9-14 points.
8 pts
Needs Improvement
-Research is not from professional, reliable source to discuss any monitoring suggested for the medication/medications you have chose or does not discuss monitoring in detail -Includes minimal to no patient education that is important to discuss. – Does not ncludes black box warnings 0-8 points
15 pts
This criterion is linked to a Learning Outcome Description of prognosis and expected outcomes
15 pts
Excellent Perfromance
Detailed discussion of prognosis and expected outcome of specific medications, utilizing current research form profession and reliable source
14 pts
Competent
Minimal discussion of prognosis and expected outcome of specific medications but does utilizing current research from profession and reliable source or Detailed discussion but not utilizing reliable sources 5-14 points
5 pts
Needs Improvement
Minimal to no discussion of prognosis and expected outcome of specific medications, Does not uses a profession and reliable source or detailed 0-5 points
15 pts
This criterion is linked to a Learning Outcome APA style and Composition
10 pts
Excellent Performance
Correct APA format, grammar, punctuation, and word usage; Includes a title page, introduction, body of paper, conclusion and reference page. 10 points
9 pts
Competent
Majority of the paper demonstrates correct APA format, grammar, punctuation, and word usage; Includes a title page, introduction, body of paper, conclusion and reference page. 5-9 points
5 pts
Needs Improvement
Poor use of APA format, grammar, punctuation, and word usage; Does not includes a title page, introduction, body of paper, conclusion or reference page. 0-5 points
10 pts
Total Points: 100
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