Week 6: Assignment: Decision Tree for Neurological and Musculoskeletal Disorders questions and answers.
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.
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Students will:
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
Write a 1- to 2-page summary paper that addresses the following:
Sample Essay
Introduction
Complex regional pain syndrome is a debilitating condition that affects the limbs and is likely to be induced by trauma or surgery. Apart from complicating the entire recovery process, it tends to impair the psychosocial and functional well-being of an individual. It’s characterized by vasomotor abnormalities, hyperalgesia, , and allodynia. The pain that a patient experiences is often disproportionate to the degree of tissue injury that occurs and may persist beyond the anticipated period required for tissue healing (Stanton-Hicks, 2018). The major goals of therapy are: to ensure pain relief, to restore functioning and psychologically stabilize a patient.
Many drugs are often used in pain management to improve functional status. However, mental health practitioners should ensure that the choice of drugs promotes compliance and have fewer side effects. This paper discusses the management of a 43-year-old who presented with complex regional pain disorder. In his management, three decisions are to be made regarding the most effective medications, expected outcomes, , and actual outcomes. A description of the ethical issues when engaging clients with complex regional pain disorder and their families will also be provided.
Decision #1
Decision Selected
Start Savella 12.5 mg orally once daily on day 1; followed by 12.5 mg BID on day 2 and 3; followed by 25 mg BID on days 4-7; followed by 50 mg BID thereafter
Reasons for Selecting This Decision
Patients with regional pain disorder have a low pain threshold which may be caused by changes in the central nervous system. These changes cause a patient to be more sensitive to pain due to wrong neurotransmitter levels in the brain. As selective norepinephrine and serotonin reuptake inhibitor (SNRI) that has an equal effect on both neurotransmitters, Savella is an NMDA antagonist that works on nerve endings to produce analgesic effects (Stanton-Hicks, 2018). It promotes the reuptake of the neurotransmitters in the brain thus easing the pain, reducing fatigue and promoting memory.
Amitriptyline, a tricyclic antidepressant that has proven to be effective in the management of neuropathic pain off label could also be a good option (Benzon, Liu & Buvanendran, 2016). However, it has a side effect of drowsiness and dizziness that the client initially stated clearly that he didn’t like. Therefore, prescribing this medication for a start might only trigger non-compliance.
Neurontin, also referred to as gabapentin, is an anti-epileptic / anticonvulsant, is used in for nerve pain relief. Therefore, it could also be a good option for the management of this patient. However, it also has the side effects of drowsiness and in high doses, results in extreme somnolence and drowsiness (Finnerup, et al., 2015). Since the patient expressed his dislike for the side effect of feeling sleepy from the start, prescribing it would only lead to non-compliance.
Expected Outcome
By starting the patient on Savella, it was expected that his pain will significantly reduce to 3 on a scale of 1-10 and be able to walk without support. It was also expected that he would resume to a normal work routine and be able to perform activities of daily life will very minimal or no assistance (Stanton-Hicks, 2018). His mood would be happy or joyous and he would have a stable effect.
Difference between Expected outcome and Actual Outcome
The client returned to the clinic after four weeks walking without crutches but minimally limping. He reported that the main was more manageable and he was able to walk around with no assistance. However, he noted that the pain was worse during the morning hours and got better as the day progressed. On a scale of 1-10, his pain was reportedly 4 but admitted that he could be able to live and tolerate a level of 3. The client also noted that he occasionally experienced bouts of sweating that he couldn’t explain with some sleep disturbance. An assessment revealed that he had a blood pressure of 147/92mmhg and a pulse of 110 beats/ min. He was still future-oriented and denied homicidal/suicidal ideation. One of the major side effects of Savella is heart palpitations (Finnerup, et al., 2015). It is for this reason that the patient experienced bouts of sweating, sleep disturbance and had a high blood pressure. Reducing the dosage can help to minimize this side effect.
Decision #2
Decision Selected
Continue With the Current medication but reduce the dosage to 25 mg twice daily
Reasons for Selecting This Decision
During the first visit, the client reported that he experienced unexplained symptoms of bouts of sweats, sleep disturbance and he had a high blood pressure. These symptoms were the resultant side effects of Savella. According to Stanton-Hicks (2018), by reducing the dosage of Savella, its side effects are also minimized resulting in more improved health outcomes.
Expected Outcome
By reducing the dosage of Savella, it was expected that the patient’s pain level will also be minimized, he will still be able to perform most activities of daily life with very minimal support and that his social, professional and physical functioning will also improve (Benzon, Liu & Buvanendran, 2016). Above all, the dosage reduction aimed to ensure that the side effects weren’t adverse and that he would live a near normal life.
Difference between Expected outcome and Actual Outcome
After four weeks, the patient returned to the clinic walking with crutches. He stated that the pain was 7 out of 10 and admitted that he didn’t feel good as compared to the previous month. He frequently woke up at night due to pain on his right leg and foot. He, however,, however, denied homicidal and suicidal ideation. His blood pressure was 124/85 and pulse rate was 87 beats/ min. He looked sad and discouraged by the slip in the management of his pain. The decision to lower the dosage of Savella in managing the client’s initial side effects to the dug inspired this difference at the cost of uncontrolled pain (Murnion, 2018).
Decision #3
Decision Selected
Change Savella to 25 mg orally in the morning and 50 mg orally at bedtime
Reasons for Selecting This Decision
During the client’s first visit to the clinic, he clearly stated that the medication Savella was effective for his pain management but the pain worsened early morning and improved as the day progressed. As supported by Finnerup, et al., (2015), starting with dose reductions during parts of the day when pain is mostly under control is a good idea that can still contribute to the achievement of therapeutic goals.
Expected Outcome
It was expected that the patient’s pain will effectively be managed to a level of 3 on a scale of 1-10. He will also be able to walk and perform most of his activities of daily life with minimal or no support. As supported by Stanton-Hicks (2018), the patient would no longer experience sleep disturbance and that his affect and mood will gradually be stable. With regards to the drugs side effects, it was expected that the patient’s blood pressure and pulse rate will gradually normalize and that he will no longer experience palpitations or unexplained bouts of sweating.
Difference between Expected outcome and Actual Outcome
The client returned to the clinic after four weeks walking without crutches. He reported his pain level to be 4 on a scale of 1-10 and expressed how he was grateful but would love it to reduce to 3 since it’s the best level that he could easily manage. His blood pressure was 120/84mmhg and pulse rate 86beats/min. He denied suicidal/homicidal ideation and was still future-oriented. At this point, it will be necessary to explain to the client that he has a neuropathic pain syndrome which probably may never respond to pain medications. Therefore, it would be practical to collaboratively set realistic expectations and make the patient understand that he will frequently experience some pain level daily (Benzon, Liu & Buvanendran, 2016). What matters most is to manage it in such a manner that permits him to effectively perform activities of daily life. The patient should also be educated that medications are not a final solution but a part of a complex regimen of chiropractic care, physical therapy, massage and heat therapy (Murnion, 2018).
How Ethical Considerations Might Impact Treatment plan and Communication With Clients
The most significant ethical consideration for this client is that of informed consent, autonomy, beneficence, and non-maleficence. Before changing any treatments, it is important to seek informed consent just to ensure that he is fully aware of what he is consenting to, possible dangers and outcomes involved (Millum, 2013). Secondly, any treatment options considered should only be for the patient’s best interest/benefit and have fewer side effects. This will guarantee that all treatment options cause no harm. Lastly, the client’s autonomy should also be respected such that, he shouldn’t be forced or coerced to agree to a treatment modality that his conscience is against (Millum, 2013).
Conclusion
The management of regional pain disorder in adults requires a careful and thorough assessment of a patients needs which will help to decide the best medications to use as part of a broader regimen of heat and massage therapy, chiropractic care and physical therapy. Savella, an SNRI was the best medication choice for the management of this patient’s pain. It has minimal side effects with the major side effect being heart palpitations which can be managed with dosage reduction. Although in patients with regional pain disorder dose reduction comes with the cost of uncontrolled pain, string reductions during the parts of a day when pain is mostly under control helphelp to achieve the desired therapeutic goals as it was in this case.
References
Benzon, H. T., Liu, S. S., & Buvanendran, A. (2016). Evolving definitions and pharmacologic management of complex regional pain syndrome.
Finnerup, N. B., Attal, N., Haroutounian, S., McNicol, E., Baron, R., Dworkin, R. H., .& Kamerman, P. R. (2015). Pharmacotherapy for neuropathic pain in adults: a systematic review and meta-analysis. The Lancet Neurology, 14(2), 162-173.
Millum J. (2013). Introduction: Case Studies in the Ethics of Mental Health Research. J Nerv Ment Dis. 200(3), 230–235.
Murnion, B. P. (2018). Neuropathic pain: current definition and review of drug treatment. Australian Prescriber, 41(3), 60.
Stanton-Hicks, M. (2018). Complex regional pain syndrome. In Fundamentals of Pain Medicine (pp. 211-220). Springer, Cham.
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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 difficult “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 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
Decision Point One
Begin Exelon (rivastigmine) 1.5 mg orally BID with an increase to 3 mg orally BID in 2 weeks
: Begin Aricept (donepezil) 5 mg orally at BEDTIME
Begin Razadyne (galantamine) 4 mg orally BID
http://cdnfiles.laureate.net/2dett4d/Walden/NURS/6521/05/mm/decision_trees/week_10/index.html
The case study is on a 76-year-old Iranian male patient that is suspected to have Alzheimer’s disease. The conclusion is based on the reports provided by his eldest son and there were no organic disease processes that were identified during the examination. The behavioral changes started two years ago, and included personality changes, apathy, which was followed by memory loss and challenges in finding the appropriate words during conversation. Confabulation is also noticed during the clinical interview, speech, and self-reported euthymic mood. The patient also has an impairment in his judgment and insight as well as absence of impulse control. There is no suicide ideation reported and the patient is diagnosed with neurocognitive disorder as a result of Alzheimer’s disease.
The first approach that will be taken will include Donepezil 5mg at bedtime. The use of donepezil among patients that have Alzheimer’s disease has been examined for decades. The medication is an acetylcholinesterase inhibitor, which increases the acetylcholine levels in the brain and compensates the reduced function of cholinergic neurons (Birks and Harvey, 2018). An assessment of randomized clinical trials analyzed the impact that donepezil has on patients with Alzheimer’s using randomized control trials. The findings showed that there is strong evidence that donepezil is effective in three major areas in the management of this condition, which include behavior, functional ability, and cognition (Li et al., 2018). These are the major areas that were affected in the patient and the goal was to limit their impact on his quality of life. As indicated in the case, he had significant personality changes that negatively impacted his engagement in activities of interest. However, there is a need to state that the National Institute of Aging has noted that there is still a poor comparison between different agents that are used as the first line of treatment for the patient (NIH, 2020).
The outcomes from donepezil differ as there can be development of complications along with limited clinical benefits. The patient complained of side effects such as loss of weight and appetite, vomiting, nausea, and diarrhea, which have been reported among patients using this medication (Kumar and Sharma, 2019).
The second decision was the use of cognitive behavioral treatment, which has been found studies to have a positive impact among patients with early stages of Alzheimer’s disease. Evidence supporting psychosocial interventions for patients with dementia has been identified in isolated cases (Forstmeier et al., 2015). However, there is still limited empirical data on these approaches. Some scholars have labelled behavioral interventions as appropriate among patients that have neuropsychiatric symptoms. Therefore, these will be used on the patient to improve behavior, and particularly targeted at reducing apathy and improving the self-control by the patient. Improvement of mood will positively impact the quality of life and the ability for the patient to engage in activities that will improve his cognitive status.
The third decision will be to include family members in the therapeutic process as this will help reinforce behaviors that will assist the patient. Studies illustrate that there is a high lack of adherence to care among elderly patients (Smith et al., 2017). This reduces the ability to evaluate the effectiveness of the interventions, as outcomes may be due to poor drug use. The goal is to increase the support system of the patient, and daily interactions as this has been found to positively impact the cognitive and emotional well-being of patients with dementia.
References
Birks, J. S., & Harvey, R. J. (2018). Donepezil for dementia due to Alzheimer’s
disease. Cochrane Database of systematic reviews, (6).
Forstmeier, S., Maercker, A., Savaskan, E., & Roth, T. (2015). Cognitive behavioural
treatment for mild Alzheimer’s patients and their caregivers (CBTAC): study protocol for a randomized controlled trial. Trials, 16(1), 526.
How is Alzheimer’s Disease Treated? (2020). NIH
Kumar, A., & Sharma, S. (2019). Donepezil. In StatPearls [Internet]. StatPearls Publishing.
Li, Q., He, S., Chen, Y., Feng, F., Qu, W., & Sun, H. (2018). Donepezil-based multi
functional cholinesterase inhibitors for treatment of Alzheimer’s disease. European journal of medicinal chemistry, 158, 463-477.
Smith, D., Lovell, J., Weller, C., Kennedy, B., Winbolt, M., Young, C., & Ibrahim, J. (2017).
A systematic review of medication non-adherence in persons with dementia or cognitive impairment. PloS one, 12(2).
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.
Write a 1- to 2-page summary paper that addresses the following:
You will submit this Assignment in Week 8.
To submit your completed Assignment for review and grading, do the following:
| Excellent | Good | Fair | Poor | ||
| Briefly summarize the patient case study you were assigned, including each of the three decisions you took for the patient presented. Be specific. | Points Range: 18 (18%) – 20 (20%)
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. |
Points Range: 16 (16%) – 17 (17%)
The response accurately summarizes the patient case study assigned, including details on each of the three decisions made for the patient presented. |
Points Range: 14 (14%) – 15 (15%)
The response inaccurately or vaguely summarizes the patient case study assigned, including details on each of the three decisions made for the patient presented. |
Points Range: 0 (0%) – 13 (13%)
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. |
|
| 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. | Points Range: 23 (23%) – 25 (25%)
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. |
Points Range: 20 (20%) – 22 (22%)
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. |
Points Range: 18 (18%) – 19 (19%)
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. |
Points Range: 0 (0%) – 17 (17%)
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. |
|
| 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. | Points Range: 18 (18%) – 20 (20%)
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. |
Points Range: 16 (16%) – 17 (17%)
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. |
Points Range: 14 (14%) – 15 (15%)
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. |
Points Range: 0 (0%) – 13 (13%)
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. |
|
| 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. | Points Range: 18 (18%) – 20 (20%)
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. |
Points Range: 16 (16%) – 17 (17%)
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. |
Points Range: 14 (14%) – 15 (15%)
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. |
Points Range: 0 (0%) – 13 (13%)
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. |
|
| 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. |
Points Range: 5 (5%) – 5 (5%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity. |
Points Range: 4 (4%) – 4 (4%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time. |
Points Range: 3.5 (3.5%) – 3.5 (3.5%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60%–79% of the time. |
Points Range: 0 (0%) – 3 (3%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity less than 60% of the time. |
|
| Written Expression and Formatting – English writing standards: Correct grammar, mechanics, and proper punctuation |
Points Range: 5 (5%) – 5 (5%)
Uses correct grammar, spelling, and punctuation with no errors |
Points Range: 4 (4%) – 4 (4%)
Contains a few (1–2) grammar, spelling, and punctuation errors |
Points Range: 3.5 (3.5%) – 3.5 (3.5%)
Contains several (3–4) grammar, spelling, and punctuation errors |
Points Range: 0 (0%) – 3 (3%)
Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding |
|
| 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. | Points Range: 5 (5%) – 5 (5%)
Uses correct APA format with no errors |
Points Range: 4 (4%) – 4 (4%)
Contains a few (1–2) APA format errors |
Points Range: 3.5 (3.5%) – 3.5 (3.5%)
Contains several (3–4) APA format errors |
Points Range: 0 (0%) – 3 (3%)
Contains many (≥ 5) APA format errors |
|
| Total Points: 100 | |||||
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