NURS 6521 Week 6 Decision Tree for Neurologic and Musculoskeletal Disorders Example Solution Provided

Week 6: Neurologic and Musculoskeletal Disorders and Opioids

Sabrina is a 26-year-old female who has just been diagnosed with multiple sclerosis. She has scheduled an appointment for a follow-up with her physician but has several questions about her diagnosis and is calling the Nurse Helpline for her hospital network. As she talks with the advanced practice nurse, she learns that her diagnosis also impacts her neurologic and musculoskeletal systems.

Although multiple sclerosis is an autoimmune disorder, both the neurologic and musculoskeletal systems will be affected by adverse symptoms that Sabrina needs to be aware of and for which specific drug therapy plans and other treatment options need to be decided on.

As an advanced practice nurse, what types of drugs will best address potential neurologic and musculoskeletal symptoms Sabrina might experience?

This week, you will evaluate patients for the treatment of neurologic and musculoskeletal disorders by focusing on specific patient case studies through a decision tree exercise. You will analyze the decisions you will make in the decision tree exercise and reflect on your experiences in proposing the recommended actions to address the health needs in the patient case study.

Learning Objectives 

Students will:

  • Evaluate patients for treatment of neurologic and musculoskeletal disorders
  • Analyze decisions made throughout the diagnosis and treatment of patients with neurologic and musculoskeletal disorders
  • Justify decisions made throughout the diagnosis and treatment of patients with neurologic and musculoskeletal disorders

DECISION TREE FOR NEUROLOGICAL AND MUSCULOSKELETAL DISORDERS

For your Assignment, your Instructor will assign you one of the decision tree interactive media pieces provided in the Resources. As you examine the patient case studies in this module’s Resources, consider how you might assess and treat patients presenting symptoms of neurological and musculoskeletal disorders.

To Prepare:

  • Review the interactive media piece assigned by your Instructor. 
  • Reflect on the patient’s symptoms and aspects of the disorder presented in the interactive media piece.
  • Consider how you might assess and treat patients presenting with the symptoms of the patient case study you were assigned.
  • You will be asked to make three decisions concerning the diagnosis and treatment for this patient. Reflect on potential co-morbid physical as well as patient factors that might impact the patient’s diagnosis and treatment.

BY DAY 7 OF WEEK 8

Write a 1- to 2-page summary paper that addresses the following:

  • Briefly summarize the patient case study you were assigned, including each of the three decisions you took for the patient presented.
  • Based on the decisions you recommended for the patient case study, explain whether you believe the decisions provided were supported by the evidence-based literature. Be specific and provide examples. Be sure to support your response with evidence and references from outside resources.
  • What were you hoping to achieve with the decisions you recommended for the patient case study you were assigned? Support your response with evidence and references from outside resources.
  • Explain any difference between what you expected to achieve with each of the decisions and the results of the decision in the exercise. Describe whether they were different. Be specific and provide examples.
  • You will submit this Assignment in Week 8.

Learning Resources

  • Rosenthal, L. D., & Burchum, J. R. (2021). Lehne’s pharmacotherapeutics for advanced practice nurses and physician assistants (2nd ed.) St. Louis, MO: Elsevier.

o   Chapter 11, “Basic Principles of Neuropharmacology” (pp. 67–71)

o   Chapter 12, “Physiology of the Peripheral Nervous System” (pp. 72–81)

o   Chapter 12, “Muscarinic Agonists and Cholinesterase Inhibitors” (pp. 82–89)

o   Chapter 14, “Muscarinic Antagonists” (pp. 90-98)

o   Chapter 15, “Adrenergic Agonists” (pp. 99–107)

o   Chapter 16, “Adrenergic Antagonists” (pp. 108–119)

o   Chapter 17, “Indirect-Acting Antiadrenergic Agents” (pp. 120–124)

o   Chapter 18, “Introduction to Central Nervous System Pharmacology” (pp. 125–126)

o   Chapter 19, “Drugs for Parkinson Disease” (pp. 127–142)

o   Chapter 20, “Drugs for Alzheimer Disease” (pp. 159–166)

o   Chapter 21, “Drugs for Seizure Disorders” (pp. 150–170)

o   Chapter 22, “Drugs for Muscle Spasm and Spasticity” (pp. 171–178)

o   Chapter 24, “Opioid Analgesics, Opioid Antagonists, and Nonopioid Centrally Acting Analgesics” (pp. 183–194)

o   Chapter 59, “Drug Therapy of Rheumatoid Arthritis” (pp. 513–527)

o   Chapter 60, “Drug Therapy of Gout” (pp. 528–536)

o   Chapter 61, “Drugs Affecting Calcium Levels and Bone Mineralization” (pp. 537–556)

This website provides information relating to the diagnosis, treatment, and patient education of dementia. It also presents information on complications and special cases of dementia.

Required Media

In this interactive media piece, you will engage in a set of decisions for prescribing and recommending pharmacotherapeutics to treat Alzheimer’s disease.

In this interactive media piece, you will engage in a set of decisions for prescribing and recommending pharmacotherapeutics to treat complex regional pain disorders.

Disorders of The Nervous System

Note: This media program is approximately 9 minutes.

Note: This media program is approximately 7 minutes.

Alzheimer’s Disease

BACKGROUND

Mr. Akkad is a 76 year old Iranian male who is brought to your office by his eldest son for “strange behavior.” Mr. Akkad was seen by his family physician who ruled out any organic basis for Mr. Akkad’s behavior. All laboratory and diagnostic imaging tests (including CT scan of the head) were normal.

According to his son, he has been demonstrating some strange thoughts and behaviors for the past two years, but things seem to be getting worse. Per the client’s son, the family noticed that Mr. Akkad’s personality began to change a few years ago. He began to lose interest in religious activities with the family and became more “critical” of everyone. They also noticed that things he used to take seriously had become a source of “amusement” and “ridicule.”

Over the course of the past two years, the family has noticed that Mr. Akkad has been forgetting things. His son also reports that sometimes he has difficulty “finding the right words” in a conversation and then will shift to an entirely different line of conversation.

SUBJECTIVE

During the clinical interview, Mr. Akkad is pleasant, cooperative and seems to enjoy speaking with you. You notice some confabulation during various aspects of memory testing, so you perform a Mini-Mental State Exam. Mr. Akkad scores 18 out of 30 with primary deficits in orientation, registration, attention & calculation, and recall. The score suggests moderate dementia.

MENTAL STATUS EXAM

Mr. Akkad is a 76-year-old Iranian male who is cooperative with today’s clinical interview. His eye contact is poor. Speech is clear, coherent, but tangential at times. He makes no unusual motor movements and demonstrates no tic. Self-reported mood is euthymic. Affect however is restricted. He denies visual or auditory hallucinations. No delusional or paranoid thought processes noted. 

He is alert and oriented to person, partially oriented to place, but is disoriented to time and event [he reports that he thought he was coming to lunch but “wound up here”- referring to your office, at which point he begins to laugh]. Insight and judgment are impaired. Impulse control is also impaired as evidenced by Mr. Akkad’s standing up during the clinical interview and walking towards the door. When you asked where he was going, he stated that he did not know. Mr. Akkad denies suicidal or homicidal ideation.

Diagnosis: Major neurocognitive disorder due to Alzheimer’s disease (presumptive)

Resources

Folstein, M. F., Folstein, S. E., & McHugh, P. R. (2002). Mini-Mental State Examination (MMSE). Lutz, FL: Psychological Assessment Resources.

Decision Point One

Select what you should do:

Decision Point One : Begin Aricept (donepezil) 5 mg orally at BEDTIME

RESULTS OF DECISION POINT ONE

  • Client returns to clinic in four weeks
  • The client is accompanied by his son who reports that his father is “no better” from this medication
  • He reports that his father is still disinterested in attending religious services/activities, and continues to exhibit disinhibited behaviors
  • You continue to note confabulation and decide to administer the MMSE again. Mr. Akkad again scores 18 out of 30 with primary deficits in orientation, registration, attention & calculation, and recall

Decision Point Two

Select what you should do next:

Decision Point Two: Increase Aricept to 10 mg orally at BEDTIME

RESULTS OF DECISION POINT TWO

  • Client returns to clinic in four weeks
  • Client’s son reports that the client is tolerating the medication well, but is still concerned that his father is no better
  • He states that his father is attending religious services with the family, which the son and the rest of the family is happy about. He reports that his father is still easily amused by things he once found serious

Decision Point Three

Select what you should do next:

Decision Point Three: Continue Aricept 10 mg orally at BEDTIME

Guidance to Student

At this point, it would be prudent to continue Aricept at 10 mg orally at bedtime. Recall that this medication can take several months before stabilization of deterioration is noted. At this point, the client is attending religious services with the family, which has made the family happy. Disinhibition may improve in a few weeks, or it may not improve at all. This is a counseling point that you should review with the son.

There is no evidence that Aricept given at doses greater than 10 mg per day has any therapeutic benefit. It can, however, cause side effects. Increasing to 15 and 20 mg per day would not be appropriate.

There is nothing in the clinical presentation to suggest that the Aricept should be discontinued. Whereas it may be appropriate to add Namenda to the current drug profile, there is no need to discontinue Aricept. In fact, NMDA receptor antagonist therapy is often used with cholinesterase inhibitors in combination therapy to treat Alzheimer’s disease. The key to using both medications is slow titration upward toward therapeutic doses to minimize negative side effects.

Finally, it is important to note that changes in the MMSE should be evaluated over the course of months, not weeks. The absence of change in the MMSE after 4 weeks of treatment should not be a source of concern.

NURS 6521 Week 6 Decision Tree for Neurologic and Musculoskeletal Disorders Assignment Rubric

CriteriaRatingsPts
This criterion is linked to a Learning Outcome Briefly summarize the patient case study you were assigned, including each of the three decisions you took for the patient presented. Be specific.
20 to >17.8 pts Excellent
The response accurately and thoroughly summarizes in detail the patient case study assigned, including specific and complete details on each of the three decisions made for the patient presented.
17.8 to >15.8 pts Good
The response accurately summarizes the patient case study assigned, including details on each of the three decisions made for the patient presented.
15.8 to >13.8 pts Fair
The response inaccurately or vaguely summarizes the patient case study assigned, including details on each of the three decisions made for the patient presented.
13.8 to >0 pts Poor
The response inaccurately and vaguely summarizes the patient case study assigned, including details on each of the three decisions made for the patient presented, or is missing.		20 pts
This criterion is linked to a Learning Outcome Based on the decisions you recommended for the patient case study, explain whether you believe the decisions provided were supported by the evidence-based literature. Be specific and provide examples. Be sure to support your response with evidence and references from outside resources.
25 to >22.25 pts Excellent
The response accurately and thoroughly explains in detail how the decisions recommended for the patient case study are supported by the evidence-based literature. …
The response includes specific and relevant outside reference examples that fully support the explanation provided.
22.25 to >19.75 pts Good
The response accurately explains how the decisions recommended for the patient case study are supported by the evidence-based literature. …
The response includes relevant outside reference examples that lend support for the explanation provided that are accurate.
19.75 to >17.25 pts Fair
The response inaccurately or vaguely explains how the decisions recommended for the patient case study are supported by the evidence-based literature. …
The response includes inaccurate or vague outside reference examples that may or may not lend support for the explanation provided or are misaligned to the explanation provided.
17.25 to >0 pts Poor
The response inaccurately and vaguely explains how the decisions recommended for the patient case study are supported by the evidence-based literature, or is missing. …
The response includes inaccurate and vague outside reference examples that do not lend support for the explanation provided, or is missing.		25 pts
This criterion is linked to a Learning OutcomeWhat were you hoping to achieve with the decisions you recommended for the patient case study you were assigned? Support your response with evidence and references from outside resources.
20 to >17.8 pts Excellent
The response accurately and thorough explains in detail what they were hoping to achieve with the decisions recommend for the patient case study assigned. …
The response includes specific and relevant outside reference examples that fully support the explanation provided.
17.8 to >15.8 pts Good
The response accurately explains what they were hoping to achieve with the decisions recommended for the patient case study assigned. …
The response includes relevant outside reference examples that lend support for the explanation provided that are accurate.
15.8 to >13.8 pts Fair
The response inaccurately or vaguely explains what they were hoping to achieve with the decisions recommended for the patient case study assigned. …
The response includes inaccurate or vague outside reference examples that may or may not lend support for the explanation provided or are misaligned to the explanation provided.
13.8 to >0 pts Poor
The response inaccurately and vaguely explains what they were hoping to achieve with the decisions recommended for the patient case study assigned, or is missing. …
The response includes inaccurate and vague outside reference examples that do not lend support for the explanation provided, or is missing.		20 pts
This criterion is linked to a Learning Outcome Explain any difference between what you expected to achieve with each of the decisions and the results of the decisions in the exercise. Describe whether they were different. Be specific and provide examples.
20 to >17.8 pts Excellent
The response accurately and clearly explains in detail any differences between what they expected to achieve with each of the decisions and the results of the decisions in the exercise. …
The response provides specific, accurate, and relevant examples that fully support whether there were differences between the decisions made and the decisions available in the exercise.
17.8 to >15.8 pts Good
The response accurately explains any differences between what they expected to achieve with each of the decisions and the results of the decisions in the exercise. …
The response provides accurate examples that support whether there were differences between the decisions made and the decisions available in the exercise.
15.8 to >13.8 pts Fair
The response inaccurately or vaguely explains any differences between what they expected to achieve with each of the decisions and the results of the decisions in the exercise. …
The response provides inaccurate or vague examples that may or may not support whether there were differences between the decisions made and the decisions available in the exercise.
13.8 to >0 pts Poor
Vaguely explains in detail any differences between what they expected to achieve with each of the decisions and the results of the decisions in the exercise, or is missing. …
The response provides inaccurate and vague examples that do not support whether there were differences between the decisions made and the decisions available in the exercise, or is missing.		20 pts
This criterion is linked to a Learning Outcome Written Expression and Formatting – Paragraph Development and Organization: Paragraphs make clear points that support well developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused–neither long and rambling nor short and lacking substance.
5 to >4.45 pts Excellent
Paragraphs and sentences follow writing standards for flow, continuity, and clarity.
4.45 to >3.95 pts Good
Paragraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time.
3.95 to >3.45 pts Fair
Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60%–79% of the time.
3.45 to >0 pts Poor
Paragraphs and sentences follow writing standards for flow, continuity, and clarity less than 60% of the time.		5 pts
This criterion is linked to a Learning OutcomeWritten Expression and Formatting – English writing standards: Correct grammar, mechanics, and proper punctuation
5 to >4.45 pts Excellent
Uses correct grammar, spelling, and punctuation with no errors
4.45 to >3.95 pts Good
Contains a few (1–2) grammar, spelling, and punctuation errors
3.95 to >3.45 pts Fair
Contains several (3–4) grammar, spelling, and punctuation errors
3.45 to >0 pts Poor
Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding		5 pts
This criterion is linked to a Learning Outcome Written Expression and Formatting – The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, running head, parenthetical/in-text citations, and reference list.
5 to >4.45 pts Excellent
Uses correct APA format with no errors
4.45 to >3.95 pts Good
Contains a few (1–2) APA format errors
3.95 to >3.45 pts Fair
Contains several (3–4) APA format errors
3.45 to >0 pts Poor
Contains many (≥ 5) APA format errors		5 pts
Total Points: 100

NURS 6512 Week 8 Discussion – Comparing and Contrasting Pharmacologic Options for the Treatment of Generalized Anxiety Disorder

NURS 6521 Week 6 Decision Tree for Neurologic and Musculoskeletal Disorders
NURS 6521 Week 6 Decision Tree for Neurologic and Musculoskeletal 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.

Generalized Anxiety Disorder is a psychological condition that affects 6.1 million Americans, or 3.1% of the US Population. Despite several treatment options, only 43.2% of those suffering from GAD receive treatment. This week you will review several different classes of medication used in the treatment of Generalized Anxiety Disorder. You will examine the potential impacts of pharmacotherapeutics used in the treatment of GAD. Please focus your assignment on FDA-approved indications when referring to different medication classes used in the treatment of GAD.

To Prepare:

  • Review the Resources for this module and consider the principles of pharmacokinetics and pharmacodynamics.
  • Reflect on your experiences, observations, and/or clinical practices from the last 5 years and think about how pharmacokinetic and pharmacodynamic factors altered his or her anticipated response to a drug.
  • Consider factors that might have influenced the patient’s pharmacokinetic and pharmacodynamic processes, such as genetics (including pharmacogenetics), gender, ethnicity, age, behavior, and/or possible pathophysiological changes due to disease.
  • Think about a personalized plan of care based on these influencing factors and patient history with GAD.

BY DAY 3 OF WEEK 8

Post a discussion of pharmacokinetics and pharmacodynamics related to anxiolytic medications used to treat GAD. In your discussion, utilizing the discussion highlights, compare and contrast different treatment options that can be used.

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 by suggesting additional factors that might have interfered with the pharmacokinetic and pharmacodynamic processes of the patients diagnosed with GAD. In addition, suggest different treatment options you would suggest to treat a patient with the topic of discussion.

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 Reply button to complete your initial post. Remember, once you click on Post Reply, you cannot delete or edit your own posts and you cannot post anonymously. Please check your post carefully before clicking on Post Reply! 

Comparing and Contrasting Pharmacologic Options for the Treatment of Generalized Anxiety Disorder Example Solution

Generalized anxiety disorder (GAD) can be a debilitating problem as those suffering from anxiety disorders face constant worry. Symptoms of generalized anxiety disorder are related to hyperarousal effects such as insomnia, irritability, restlessness, and lack of concentration (Melaragno, 2021). GAD can affect those of all ages, and as for treatment, clinicians have to consider various factors such as age, underlying co-morbidities, and prior treatments and their effects (Strawn, Geracioti, Rajdev, Clemenza, & Levine, 2018).

Different pharmacologic options are available to treat GAD, including serotonergic reuptake inhibitors, selective serotonin reuptake inhibitors, benzodiazepines, and non-benzos (Rosenthal & Burcham, 2021). Aside from pharmacologic treatment, psychotherapy, such as outdoor activity and therapy sessions, helps to amplify pharmacotherapy (Strawn, Geracioti, Rajdev, Clemenza, & Levine, 2018).

SSRIs and SNRIs

SSRIs and SSNIs have been named the first line of treatment for GAD and include venlafaxine, duloxetine, paroxetine, and escitalopram (Rosenthal & Burcham, 2021). SSRIs are also used when there is underlying depression but are also helpful when depression is not apparent (Rosenthal & Burcham, 2021). This group of medications does not take effect immediately and should not be used as needed, instead should be used daily to help decrease the effects of anxiety; in contrast to benzodiazepines, SSRIs and SNRIs are not habit-forming (Rosenthal & Burcham, 2021). However, this group of medications must be tapered off due to unpleasant withdrawal symptoms (Rosenthal & Burcham, 2021).

Benzodiazepines and Non-benzodiazepines

The most common medications in the group of benzodiazepines are alprazolam, diazepam, and lorazepam, which are used for acute onsets of anxiety as they work relatively fast after administration in contrast to SSRIs or SNRIs (Strawn, Geracioti, Rajdev, Clemenza, & Levine, 2018). The current best practice limits the use of benzodiazepines to short-term use due to their habit-forming components (Strawn, Geracioti, Rajdev, Clemenza, & Levine, 2018). In contrast, a nonbenzodiazepine commonly used is buspirone.

Buspirone is an anxiolytic that does not affect the central nervous system and does not carry the potential for abuse. like benzodiazepines do (Strawn, Geracioti, Rajdev, Clemenza, & Levine, 2018). It is comparable to the group of SSRIs and SNRIs in terms of its onset time, as it takes a week or more for therapeutic effects to occur (Rosenthal & Burcham, 2021).

Clinical Experience

Previous experience as a mental health nurse in an outpatient clinic has helped me to have a deeper understanding of the issues faced by those who suffer from GAD. I recall a lady in her upper seventies who was dependent on lorazepam for the past ten years. She was on the highest dose, and her Psychiatrist retired, leaving her to see another clinician within the office who did not feel comfortable continuing to prescribe lorazepam to her at her age. 

After talking it over with her, she realized she was dependent on the medication, had been taking more than prescribed, and would run out of her medication before it was time, which was a problem. The plan was to send her to a geriatric behavioral unit to detox so she could be titrated off lorazepam under medical supervision. She agreed and went, and once she returned to the office for a follow-up visit, she was now only taking half of what she had previously been prescribed as they were unsuccessful in having her entirely off of lorazepam; however, it was a step in the right direction. 

Unfortunately, she reverted to her old ways and began abusing lorazepam once again and suffered a traumatic fall leaving her with a brain bleed, later passing away. According to the American Geriatric Beers Criteria, lorazepam is not an appropriate medication for the geriatrics population due to its central nervous system suppression and increased risk of instability related to falls (Ghiasi, Bhansali, & Marwaha, 2023). An alternative care plan may have made a difference in this patient’s life, such as using an SSRI combined with venlafaxine. 

Venlafaxine is commonly used for GAD and panic disorders; as I recall, she would call the office several times a day in a panic state. These medications and cognitive behavioral therapy could have produced a better outcome. In conclusion, lorazepam should have never been prescribed to this patient due to physiological factors associated with her age.

References

Ghiasi, N., Bhansali, R. K., & Marwaha, R. (2023). Lorazepam. StatPearls.

Melaragno, A. J. (2021). Pharmacotherapy for Anxiety Disorders: From First-Line Options to Treatment Resistance. Focus, 19(2), 143-263.

Rosenthal, L. D., & Burcham, J. R. (2021). Lehne’s Pharmacotherapeutics for Advanced Practice Nurses and Physician Assistants (2nd ed.). St. Louis, Missouri: Elsevier.

Strawn, J. R., Geracioti, L., Rajdev, N., Clemenza, K., & Levine, A. (2018). Pharmacotherapy for generalized anxiety disorder in adult and pediatric patients: an evidence-based treatment review. Expert Opinion on Pharmacotherapy, 19(10), 1057-1080.