Assignment: Assessing and Treating Patients With Impulsivity NURS 4430

The 53-year-old female appears with an alcohol use disorder that she was diagnosed with in her twenties. She maintains that her issues, which include alcoholism, cigarette smoking, and gambling, are embarrassing. The patient reports that a casino was established in the neighborhood around 2 years ago, which caused her to start drinking again after being sober for several years, as she enjoys consuming cigarettes and alcohol when gaming. This resulted in her gaining roughly 7 pounds. Her gambling has gotten worse since then, as she recalls borrowing $50,000 from her workplace pension and using the money to cover gambling bills. She is worried that her spouse will be furious when he finds out. The results of the mental state evaluation show that the patient is depressed, and her emotion regulation is also compromised. With really no psychiatric symptoms, the patient was initially diagnosed with gambling and alcohol use disorder (AUD)

Several factors will be taken into account when selecting the most effective and safest drug to prescribe in the treatment of the patient’s medical needs (Yang et al., 2022). For example, a patient’s history of persistent addiction to alcohol and gambling will influence the choice of the most beneficial drug. Her age and Puerto Rican race will also aid in medicine selection, as well as identifying the optimum dosage and frequency. Her recent weight increase will also have an impact on the prescription she chooses, as most psychiatric medications cause weight gain. The goal of this discussion is to choose the best treatments for this patient’s care, with an explanation of the predicted outcome and ethical issues at each decision point.

Decision #1

Selected Decision and Rationale

The initial intervention was a 380mg IM injection of naltrexone into the gluteal region. Naltrexone is the most effective and safest medicine for treating alcohol consumption disorder, according to the FDA and most clinical standards, including the National Institute for Health and Care Excellence (NICE) (Renner & Ward, 2016). Naltrexone has an antagonistic action on opioid receptors, inhibiting endogenous opioid binding (Pettorruso et al., 2023). According to studies, naltrexone may be useful in lowering the desire to gamble in patients with comorbid alcohol addiction and gambling (Yang et al., 2022). Naltrexone has been shown to primarily target the Asp40 allele, which is prevalent among Puerto Ricans, enhancing its efficacy in this community (Trick & Le Foll, 2020). Because it is administered once a month, the LA formulation was chosen because it is more pleasant for the patient (Taubin et al., 2022).

The prescribed disulfiram formulation is short-acting, which might affect the patient’s degree of compliance, in conjunction with the elevated risks of side effects like palpitations (Mistarz et al., 2021). Acamprosate is likewise short-acting, with a greater frequency of administering, which may make it difficult for the patient to adhere to the prescription (Antonelli et al., 2022).

Expected Outcome

The patient’s desire to consume alcohol or gamble should be greatly reduced after one month of using naltrexone (Renner & Ward, 2016). Her smoking habit is linked to gambling; thus, it is predicted to decrease during this period (Yang et al., 2022).

Ethical Consideration

Clinicians are recommended to be nonjudgmental and not discriminate against individuals with substance use disorders based on their gender, color, or any other criteria (Mistarz et al., 2021). In caring for this patient, the PMHNP followed the ethical ideal of justice (Pettorruso et al., 2023).

Decision #2

Selected Decision and Rationale

The second approach was to refer the patient to a psychotherapist for assistance with her gambling tendencies. From the reported outcome, the patient demonstrated outstanding efficacy with naltrexone, as she asserts to have never drunk alcohol after the initial injection (Taubin et al., 2022). The sole negative effect reported was anxiousness, which is frequent among naltrexone patients but fades with time (Mistarz et al., 2021). The patient’s desire to gamble was also lessened, although she was still upset about the handful of times she gambled because she wasted a lot of money, necessitating the requirement of a specialist (Renner & Ward, 2016). Although there is no particular medication for gambling, most individuals have reported favorable outcomes when using cognitive behavioral treatment (Yang et al., 2022). The counselor is anticipated to resolve the client’s gambling, which will aid in her smoking cessation (Ray et al., 2020).

Because diazepam is addicting, using it as an adjuvant to naltrexone was improper (Mistarz et al., 2021). Chantix is an excellent smoking cessation medication, but it can only be used in conjunction with naltrexone in modest dosages once a day for a limited time (Pettorruso et al., 2023).

Expected Outcome

The patient will remain sober with a reduced desire to gamble if the counselor implements proper intervention and continues to utilize naltrexone (Antonelli et al., 2022). She will be able to quit smoking as well (Renner & Ward, 2016). The previously observed anxiety symptoms are also likely to entirely resolve over this time.

Ethical Consideration

Ethically, nurses must treat all patients equally and without discrimination. Promoting patient-centered treatment is also critical, with a greater emphasis on meeting the patient’s requirements (Trick & Le Foll, 2020). For example, in this judgment, the patient was primarily concerned regarding her gambling, which a counselor can effectively address (Pettorruso et al., 2023). In making its decision, the PMHNP followed the ethical concept of non-maleficence.

Decision #3

Selected Decision and Rationale

The patient’s challenges with her psychotherapist were discussed in the final decision, and she was advised to continue attending gamblers’ anonymous groups. Because the patient confessed to disliking her counselor, the decision was largely based on the stated outcome (Taubin et al., 2022). Positive counseling outcomes require a solid therapeutic relationship between the client and the counselor (Mistarz et al., 2021). As a result, research suggests that patients who have a hostile perception toward their psychiatrist are more likely to discontinue therapy (Trick & Le Foll, 2020). Participating in alcohol anonymous meetings can also help to promote continued recovery from alcohol (Antonelli et al., 2022). Previous research indicates that naltrexone can take 8 to 12 weeks for the majority of patients to achieve complete control over not drinking alcohol (Ray et al., 2020).

Encouraging the patient to keep seeing the counselor while ignoring their differences will result in her discontinuing therapy sessions (Pettorruso et al., 2023). It is also not acceptable to discontinue naltrexone therapy because the medicine is more beneficial for long-term use, particularly in patients with chronic addiction to substances (Taubin et al., 2022).

Expected Outcome

With the client and her counselor’s disagreement addressed, she is expected to cease gambling and continue refraining from alcohol (Renner & Ward, 2016). She ought to be able to work with her counselor to improve her smoking behaviors (Ray et al., 2020).

Ethical Considerations

To enhance excellent outcomes, psychiatrists are recommended to invest in creating a healthy therapeutic interaction with their patients (Trick & Le Foll, 2020). When settling disagreements between the client and her psychiatrist, it is important to remain neutral and assist the patient in understanding the importance of concentrating on this connection (Ray et al., 2020). This decision was also guided by ethical concepts like respect for autonomy and non-maleficence.

Conclusion

The 53-year-old patient arrived at the clinic with the primary complaint of embarrassment due to alcohol addiction and gambling. Several characteristics, including the patient’s age, gender, and race, were examined when deciding on the best solution for her disease. The initial step was to provide naltrexone, which is FDA-authorized and recommended as the first line of treatment for substance use disorder by most clinical recommendations, including NICE (Renner & Ward, 2016). Disulfiram and Campral have a short half-life and a high risk of side effects, making them unsuitable for the patient (Mistarz et al., 2021). After four weeks, the patient indicated that she had not used alcohol since the first injection, although she still gambled and smoked (Yang et al., 2022). As a result, it was necessary to recommend the client to a psychotherapist for assistance with her gambling. Adding diazepam or varenicline to the patient’s therapy regimen was not acceptable because the former is addictive, whereas the latter is only recommended in low dosages for smoking cessation (Trick & Le Foll, 2020).

During the subsequent visit, the client reported enhanced symptoms but was mostly concerned with her contempt for her counselor (Pettorruso et al., 2023). As a result, it was determined that the conflicts between the client and her therapist be investigated and that the patient be motivated to keep participating in gambling anonymous sessions as the overall solution (Antonelli et al., 2022). Discontinuing naltrexone and dismissing the patient’s distaste for her psychotherapist were not appropriate actions (Taubin et al., 2022). At each decision point, the PMHNP was confronted with various ethical considerations, such as not prejudice against the client and respecting the right to self – determination (Ray et al., 2020). Other ethical principles observed include fairness and non-maleficence.

References

Antonelli, M., Sestito, L., Tarli, C., & Addolorato, G. (2022). Perspectives on the pharmacological management of alcohol use disorder: Are the approved medications effective? European Journal of Internal Medicine, 103, 13–22. https://doi.org/10.1016/j.ejim.2022.05.016

Mistarz, N., Nielsen, A. S., Andersen, K., Goudriaan, A. E., Skøt, L., Mathiasen, K., Michel, T. M., & Mellentin, A. I. (2021). Brain+ AlcoRecover: A Randomized Controlled Pilot-Study and Feasibility Study of Multiple-Domain Cognitive Training Using a Serious Gaming App for Treating Alcohol Use Disorders. Frontiers in Psychiatry, 12. https://doi.org/10.3389/fpsyt.2021.727001

Pettorruso, M., Di Carlo, F., Romeo, V. M., Jimenez-Murcia, S., Grant, J. E., Martinotti, G., & di Giannantonio, M. (2023). The pharmacological management of gambling disorder: if, when and how. Expert Opinion on Pharmacotherapy. https://doi.org/10.1080/14656566.2023.2172329

Ray, L. A., Meredith, L. R., Kiluk, B. D., Walthers, J., Carroll, K. M., & Magill, M. (2020). Combined Pharmacotherapy and Cognitive Behavioral Therapy for Adults With Alcohol or Substance Use Disorders. JAMA Network Open, 3(6), e208279. https://doi.org/10.1001/jamanetworkopen.2020.8279

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.

Taubin, D., Wilson, J. C., & Wilens, T. E. (2022). ADHD and Substance Use Disorders in Young People. Child and Adolescent Psychiatric Clinics of North America. https://doi.org/10.1016/j.chc.2022.01.005

Trick, L., & Le Foll, B. (2020). Pharmacological Treatment of Alcohol Use Disorder. Textbook of Addiction Treatment, 123–139. https://doi.org/10.1007/978-3-030-36391-8_10

Yang, W., Singla, R., Maheshwari, O., Fontaine, C. J., & Gil-Mohapel, J. (2022). Alcohol Use Disorder: Neurobiology and Therapeutics. Biomedicines, 10(5), 1192. https://doi.org/10.3390/biomedicines10051192

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 week’s 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/

Click here to ORDER an A++ paper from our Verified MASTERS and DOCTORATE WRITERS: Assignment: Assessing and Treating Patients With Impulsivity NURS 4430

To prepare for this Assignment:
Review this week’s 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
Examine Case 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 client’s pharmacokinetic 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)

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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)

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.

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What’s Coming Up in Week 11?

Photo Credit: [BrianAJackson]/[iStock / Getty Images Plus]/Getty Images

Next week, you will synthesize and apply your knowledge and skills of assessing and treating patients with various psychopharmacologic treatments as you prepare for your Final Exam.

Next Week

To go to the next week:

Week 11

Week 11: Therapy for Patients With Dementia/Alzheimer’s and Comorbid States

As a psychiatric nurse practitioner, you will frequently work with patients across the life span who may also have comorbid conditions. For instance, you may treat a 16-year-old female with Down syndrome and increasing violent behaviors; a middle-aged male with schizophrenia, diabetes, and poor lung function; or an older adult with a mental disorder, Stage 1 Alzheimer’s disease, and chronic heart disease (CHD). In cases like these, you must draw from foundational knowledge of pathophysiology and collaborate with other healthcare providers to ensure optimal safety and efficacy of psychopharmacologic therapies for patients.

This week, as you examine therapy for patients with dementia/Alzheimer’s and comorbid states, you review psychopharmacologic approaches to treatment for these patients across the life span. You will also complete your Final Exam.

Learning Objectives

Students will:

Assess psychopharmacologic approaches to treatment for patients across the life span

Learning Resources

Required Readings (click to expand/reduce)

Gatchel, J. R., Wright, C. L., Falk, W. E., & Trinh, N. (2016). Dementia. In T. A. Stern, M. Favo, T. E. Wilens, & J. F. Rosenbaum. (Eds.), Massachusetts General Hospital psychopharmacology and neurotherapeutics (pp. 149–162). Elsevier.

Angermeyer, M. C., Matschinger, H., & Schomerus, G. (2013). Attitudes towards psychiatric treatment and people with mental illness: Changes over two decades. The British Journal of Psychiatry, 203(2), 146–151. https://doi.org/10.1192/bjp.bp.112.122978

Bui, Q. (2012). Antidepressants for agitation and psychosis in patients with dementia. American Family Physician, 85(1), 20–22

Crocker, A. G., Prokić, A., Morin, D., & Reyes, A. (2014). Intellectual disability and co-occurring mental health and physical disorders in aggressive behaviour. Journal of Intellectual Disability Research, 58(11), 1032–1044. https://doi.org/10.1111/jir.12080

Dingfelder, S. F. (2009). Stigma: Alive and well. Monitor on Psychology, 40(6), 56-59. https://doi.org/10.1037/e542802009-028

Erickson, S. C., Le, L., Zakharyan, A., Stockl, K. M., Harada, A. M., Borson, S., Ramsey, S. D., & Curtis, B. (2012). New-onset treatment-dependent diabetes mellitus and hyperlipidemia associated with atypical antipsychotic use in older adults without schizophrenia or bipolar disorder. Journal of the American Geriatrics Society, 60(3), 474–479. https://doi.org/10.1111/j.1532-5415.2011.03842.x

Jenkins, J. H. (2012). The anthropology of psychopharmacology: Commentary on contributions to the analysis of pharmaceutical self and imaginary. Culture, Medicine and Psychiatry, 36(1), 78–79. https://doi.org/10.1007/s11013-012-9248-0

Malhotra, A. K., Zhang, J., & Lencz, T. (2012). Pharmacogenetics in psychiatry: Translating research into clinical practice. Molecular Psychiatry, 17(8), 760–769. https://doi.org/10.1038/mp.2011.146

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 medication’s result page, as this information will be helpful for your review in preparation for your Assignments.

donepezil
galantamine
memantine
rivastigmine

Optional Resources (click to expand/reduce)

Bennett, T. (2015). Changing the way society understands mental health. National Alliance on Mental Illness. http://www.nami.org/Blogs/NAMI-Blog/April-2015/Changing-The-Way-Society-Understands-Mental-Health

Mechanic, D. (2007). Mental health services then and now. Health Affairs, 26(6), 1548–1550. https://web.archive.org/web/20170605094514/http://content.healthaffairs.org/content/26/6/1548.full

Rothman, D. J. (1994). Shiny, happy people: The problem with “cosmetic psychopharmacology.” New Republic, 210(7), 34–38.

Final Exam

This exam will cover the following topics, which relate to psychopharmacologic approaches to treatment for patients across the life span:

Therapy for Patients With Substance Dependence
Therapy for Patients With Impulsivity, Compulsivity, and Substance Use Disorder
Therapy for Patients With ADHD
Therapy for Patients With Dementia/Alzheimer’s
Therapy for Patients With Pathophysiology and Psychiatric Comorbidities

Photo Credit: [Vergeles_Andrey]/[iStock / Getty Images Plus]/Getty Images

Prior to starting the exam, you should review all of your materials. There is a 2.5-hour time limit to complete this 50-question exam. You may only attempt this exam once.

This exam is a test of your knowledge in preparation for your certification exam. No outside resources including books, notes, websites, or any other type of resource are to be used to complete this exam. You are expected to comply with Walden University’s Code of Conduct.

By Day 7

Submit your Final Exam by Day 7.

Submission Information

Submit Your Exam by Day 7

To submit your Final Exam:

Week 11 Final Exam

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