Introduction
Assessing and treating patients who have been diagnosed with psychosis and schizophrenia often creates a challenge to the PMHNP, as one has to choose the most appropriate treatment approach that would not cause any harm to the patient. This study involves managing a 34-year-old Pakistani female who had earlier been diagnosed with psychotic disorder, based on her symptoms, but was later discovered that she had paranoid schizophrenia. Patients with schizophrenia usually experience debilitating social, as well as occupational challenges, but with proper treatment, most patients are able to function effectively. Antipsychotic therapy is considered as the cornerstone of managing patients with schizophrenia (Mustafa et al., 2019). The following is an explanation of three decisions that seemed to be the most appropriate for managing the client with paranoid schizophrenia.
The most effective way of managing the patient with paranoid schizophrenia was to begin with an injection of Invega Sustenna 234 mg, which was followed by another injection of 156 mg on the fourth day. Additionally, the injection of 156 mg should be done after every month. According to Stahl (2014), Invega Sustenna (paliperidone) belongs to a category of atypical antipsychotic drugs, which are normally prescribed for patient with schizophrenia and other psychotic disorders. However, I had an option of choosing Zyprexa 10 mg, which would be administered orally at bedtime, but Zyprexa is known for causing weight gain, which the patient was trying to avoid. Additionally, Abilify (aripiprazole) is also known to cause weight gain among some patients (Mustafa et al., 2019). My decision was guided by the idea that paliperidone has a few side effects, and offers instant relief to some symptoms of schizophrenia.
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My expectations were that choosing Invega Sustenna would assist in eliminating positive symptoms, in addition to improving negative symptoms. Invega Sustenna is likely to demonstrate positive response to about 15% of patients with schizophrenia, who can experience a reduction of up to 60% of symptoms (Stahl, 2014). However, the results did not meet my expectations, as the client only experienced a decline of about 25% in PANSS score after four weeks and also gained 2 pounds in terms of weight. Some of the positive gains were that the client was tolerating to medication and was able to return for the monthly injection.
The second decision was to continue with the same medication at the same dosage, but I requested the administering nurse to shift the injection site to the deltoid during the second visit and subsequent visits. This decision was reached after the client’s complaint of pain when siting after the injection. Basically, Invega Sustenna starts to react after 4 to 6 weeks, thus, one can determine the efficacy of the drug after this period (Stahl, 2014). Besides, long-acting injectable antipsychotic therapy offers therapeutic plasma concentrations for weeks to months, which eliminates the need to have daily oral treatment administration (Bossie et al., 2017).
The expectations at this stage were that symptoms would reduce to about 50% and that the client would not complain of weight gain. The reasons why first-line antipsychotic drugs are preferred to the second-generation antipsychotics is because the latter causes weight gain and lipid abnormalities while their effects cannot be controlled through dosage (Holder, 2014). The results at this stage met my expectations, as the client reported 50% reduction of symptoms since he began taking Invega sustenna. Although most patients do not experience a total remission in terms of symptoms, they usually record a reduction of about a third of the symptoms (Stahl, 2014). The only challenge the client was facing after the second decision was gaining of weight, which could be dealt with through exercise and diet.
A major issue with the first and the second decisions is that the client has been gaining weight, which was affecting him psychologically. Hence, the third decision was to continue with the injection of Invega sustenna, in addition to convincing the client that gaining weight through using Invega sustenna was insignificant as compared to other antipsychotic medications. To ease the pressure of explaining on the use of Invega sustenna, I made an appointment with a dietician, as well as an exercise physiologist. According to Stanton et al. (2015), physical exercise may assist patients with psychosis and schizophrenia to reduce cardiometabolic symptoms while having proper diet helps in maintaining acceptable weight.
The expectations after making a connection with a physiologist and a dietician was to ensure that the client does not gain too much weight, which could lead to cardiovascular disorders. Understanding the client’s personal and family history is essential before administering atypical antipsychotics to avoid making him worse, as individuals with hypertension, obesity, dyslipidemia, and cardiovascular disease should be evaluated first before they receive such medication (Stahl, 2014).
The results meet my expectations because the client was able to respond effectively to Invega sustenna before the recommended 6 months were over, thus, there was no need for augmenting or switching to other antipsychotic drugs. While Abilify Maintena (aripiprazole) is a suitable option for individuals who respond well to abilify oral, it does not bind well to D2 receptor as Invega sustenna does; hence, it can only benefit certain individuals. Additionally, akathisia and weight gain are some of the adverse effects of Abilify Maintena (Lenze et al., 2015). Although Qsymia is known for managing weight, it is only appropriate for individuals with obesity.
Ethical Considerations on Treatment Plans and Communication with the Client
Treating clients with schizophrenia should be guided by ethics to avoid harming them through ineffective medications. Consequently, understanding the patient’s family and medical history is the first step towards effective diagnosis and treatment of clients with psychosis and schizophrenia. PMHNPs should ensure that they have chosen appropriate antipsychotic medications, based on their clients’ preferences. Most patients are unable to tolerate antipsychotic drugs, thus, the PMHNP should strive to convince patients to take the medications in order to improve their lives (Morrison, Meehan & Stomski, 2015). The PMHNP should demonstrate communicate with the client whenever there is a need to switch to a new medication. Additionally, any adverse effect coming from the new medication should be considered while patients should be informed of the risk of relapse in case medical therapy is discontinued after one or two years (Holder, 2014). Morrison, Meehan and Stomski (2015) encourage PMHNPs to understand how patients experience medication side effects so that they can assist them to manage adverse effects.
Conclusion
Although schizophrenia does not have a cure for now, it can be managed effectively using appropriate atypical antipsychotic medications. Patients who undergo both medical and psychosocial therapies tend to have better outcomes than those who receive medical therapy alone. However, ethics should be considered when developing treatment plans for schizophrenia, since adverse effects resulting from antipsychotic medications may be costly and painful to the patients, as well as family members.
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