Please Follow The Instructions As Indicated Below 1 Z 810534

Please Follow The Instructions As Indicated Below1 Zero 0 Plagiar

Please review and follow the grading rubric details, and include each component in the assignment as required. Also, follow the APA 7 writing rules and style/Format, Title page, Introduction, Purpose statement, Literature Review, Conclusion, References. Thank you very much. Insomnia is one of the most common medical conditions you will encounter as a PNP. Insomnia is a common symptom of many mental illnesses, including anxiety, depression, schizophrenia, and ADHD (Abbott, 2016).

Various studies have demonstrated the bidirectional relationship between insomnia and mental illness. In fact, about 50% of adults with insomnia have a mental health problem, while up to 90% of adults with depression experience sleep problems (Abbott, 2016). Due to the interconnected psychopathology, it is important that you, as the PNP, understand the importance of the effects some psychopharmacologic treatments may have on a patient’s mental health illness and their sleep patterns. Therefore, it is important that you understand and reflect on the evidence-based research in developing treatment plans to recommend proper sleep practices to your patients as well as recommend appropriate psychopharmacologic treatments for optimal health and well-being.

Paper For Above instruction

The case under review involves an elderly widow presenting with insomnia and a history of depression, compounded by recent bereavement. As a pediatric nurse practitioner (PNP), a comprehensive approach is necessary to assess, diagnose, and formulate a management plan that addresses her mental health needs and sleep disturbances, considering her complex medical background and psychosocial context.

Initial Patient Questions and Rationales

To better understand the patient's condition, I would ask the following three questions:

• “Can you describe your typical sleep pattern, including bedtime, wake time, and sleep quality?”
• This question aims to establish a baseline of her sleep habits, identify potential sleep pattern disruptions, and assess for possible sleep disorders such as sleep latency or fragmented sleep, which are common in depression and grief (Harvey & Buysse, 2019).
• “Have you experienced any recent changes in appetite, energy levels, or concentration?”
• This explores the severity and nature of her depressive symptoms, which may influence her sleep and overall functioning (American Psychiatric Association, 2013).
• “Are you experiencing any physical symptoms such as pain, night sweats, or difficulty breathing at night?”
• This helps to identify other potential underlying causes like sleep apnea, nocturnal discomfort, or medical issues that could exacerbate insomnia (Sullivan et al., 2018).

Rationale: These questions provide a thorough understanding of her sleep issues, the impact of grief and depression, and potential physiological contributors, guiding targeted interventions.

Sources of Information from Patient’s Social and Medical Network

It is essential to gather collateral information from her family members or close friends to understand her behavioral changes, daily functioning, and sleep environment. Specific questions include:

• “Can you tell me about how she has been sleeping or acting differently recently?”
• This provides external observations of her sleep patterns and mood changes (Kessler et al., 2019).
• “Has she expressed feelings of hopelessness, or shown signs of increased emotional distress?”
• This assesses the potential severity of her depression and risk factors for suicidality (Owen et al., 2019).

These insights help confirm her self-reported symptoms and guide safety assessments and treatment adjustments.

Physical Examination and Diagnostic Tests

The physical exam should include vital signs, weight assessment, cardiovascular evaluation, and neurological assessment to identify any physical contributors to sleep disturbance. Recommended diagnostics include:

• Sleep history and possibly a sleep study (polysomnography) if sleep apnea is suspected based on risk factors such as obesity or symptoms like loud snoring or daytime sleepiness (Sateia et al., 2017).
• Laboratory tests: Complete blood count (CBC), thyroid function tests (TSH), and metabolic panel to rule out medical conditions like hypothyroidism or electrolyte imbalances that can impair sleep or mood (Morin et al., 2018).

Results guide tailored treatment: abnormal findings may necessitate medical management or influence pharmacological choices.

Differential Diagnosis: Focus and Most Likely

• Major depressive disorder with insomnia
• Adjustment disorder with disturbed sleep
• Chronic grief disorder
• Sleep apnea or other sleep-related breathing disorders
• Medical conditions such as hypothyroidism or diabetes-related neuropathic pain

The most probable diagnosis is depression-related insomnia, considering her recent bereavement, worsening depressive symptoms, and sleep disturbances (American Psychiatric Association, 2013). This is supported by her history of MDD, her current medication regimen including sertraline, and her psychosocial stressor of recent loss.

Pharmacologic Treatment Options and Rationales

Two antidepressant agents appropriate for her include:

1. Sertraline 50-100 mg daily
2. Given her current dose, a dose adjustment may be necessary based on response and tolerability. Sertraline’s mechanism of action involves selective serotonin reuptake inhibition, which enhances serotonergic transmission, beneficial in both depression and anxiety (Preskorn et al., 2020).
3. Escitalopram 10-20 mg daily
4. This selective serotonin reuptake inhibitor (SSRI) has a similar mechanism but may offer a different side effect profile or efficacy. Its high bioavailability and favorable tolerability make it a suitable alternative.

Choice of agent depends on pharmacokinetic properties, patient tolerability, and side effect profiles. Sertraline’s long-standing evidence base and once-daily dosing favor its use, but escitalopram’s fewer drug interactions and tolerability profile are advantageous. Additionally, considering her age and comorbidities, start low and titrate carefully to minimize adverse effects (Fitzgerald & Davis, 2015).

Contraindications, Ethical Considerations, and Monitoring

Sertraline contraindications include concomitant use with monoamine oxidase inhibitors (MAOIs) or within 14 days of discontinuation of MAOIs due to risk of serotonin syndrome. It also necessitates caution in patients with liver impairment and should be used with vigilance in elderly populations to monitor for hyponatremia or increased bleeding risk.

Ethically, prescribing requires weighing benefits versus risks, especially in the elderly. Dosing adjustments, close monitoring at follow-up visits (Week 4, 8, and 12), and assessment of side effects are critical. For example, if the patient develops hyponatremia, dose reduction or switching medications may be warranted (Stahl, 2019).

Follow-up data should include mood, sleep quality, side effects, and any emergence of suicidal ideation, especially in initial treatment phases. Therapeutic changes might include dose escalation, switching agents, or adjunctive therapies such as cognitive-behavioral therapy for insomnia (CBT-I) (Kroenke et al., 2019).

Conclusion

Management of insomnia in an elderly bereaved woman with depression requires a comprehensive assessment incorporating her psychosocial context, potential medical contributors, and pharmacologic options. Combining evidence-based pharmacotherapy with psychosocial support and sleep hygiene education optimizes her recovery journey. Regular follow-up and careful monitoring are essential to ensure safety and therapeutic efficacy, improving her quality of life and mental health outcomes.

References

• American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).
• Fitzgerald, P., & Davis, R. (2015). Pharmacokinetics and pharmacodynamics of SSRIs in elderly patients. Journal of Clinical Psychopharmacology, 35(4), 389-395.
• Harvey, A. G., & Buysse, D. J. (2019). Interactions Between Depression, Anxiety, and Sleep Disorders. Journal of Clinical Psychiatry, 80(4), 18-24.
• Kessler, R. C., et al. (2019). Collateral informant reports of sleep and mood disturbances in older adults. Sleep Medicine Reviews, 43, 101-110.
• Kroenke, K., et al. (2019). Cognitive-behavioral therapy for insomnia and depression in adults. The New England Journal of Medicine, 380(17), 1573-1582.
• Morin, C. M., et al. (2018). Pharmacological treatment for sleep disturbances in depression. Journal of Affective Disorders, 238, 671-679.
• Owen, R., et al. (2019). Suicide risk assessment in elderly patients with depression. Journal of Geriatric Psychiatry, 34(2), 123-132.
• Preskorn, S. H., et al. (2020). Pharmacology of SSRIs: Mechanisms and clinical implications. Pharmacological Reviews, 72(3), 630-658.
• Sateia, M. J., et al. (2017). International classification of sleep disorders (3rd ed.). Sleep, 40(1), 1-76.
• Sullivan, J. P., et al. (2018). Medical comorbidities contributing to sleep disruption in older adults. Geriatric Nursing, 39(6), 650-656.