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NRSG 437 - Psychiatric Nursing
Transcript of NRSG 437 - Psychiatric Nursing
Axis I: Major depressive disorder
Axis II: none
Axis III: tardive dyskinesia, elevated liver enzymes, no reported allergies
Axis IV: social isolation due to social stigma of tremors, concerns of money as depression leads to lost work days.
Axis V: GAF - 61 Subjective Data Key significant positives of case: the exact mechanism remains largely uncertain but...the most compelling evidence suggests: Diagnostic tests/labs: references A Case Study: Tardive Dyskinesia
by: Brian Cey
NRSG 437 - Psychiatric Nursing
Spring, 2013 Case Study: Anita, a 53 year old Native American woman reports a "lifelong" problem with depression and has been treated with Zoloft, Prozac, and effexor with little effect, but started to get some resolution of symptoms when on Celexa 60 mg/day. In 2007, Anita was still depressed so ariprazole was started and added to Celexa 60 mg. She was started on 5 mg/day. She developed akasthisia and clonazepam 1mg was added which resolved the akasthisia. Since then, her depression has significantly improved. She had been an IV heroin user in her 20's, and had hepatitis C, but HIV negative. She is on no other medication, and has no other medical problems. Her CBC is WNL, and her comp panel shows elevated liver enzymes. Thyroid profile and lipid profile are WNL. She denied use of other drugs or alcohol in the past 5 years. On your next visit in 2010, you note some involuntary movement. You note she has involuntary truncal spasms, mostly flexing of her trunk, with occasional extension of her pelvis. These occured when Anita was sitting or standing, but resolved when lying down. She had mild facial masking and mild bradykinesia and walked without arm-swing. She displayed no chloreiform movements. Ariprozole treatment was stopped, and Anita continued to have these symptoms 2 months after stopping treatment, and her depression is returning. Probable Axis III: Tardive Dyskinesia due to long term usage of ariprazole. Defintions akasthisia - sensation of inner restlessness manifested by inability remain calm or sit still.
facial masking - facial muscle paralysis.
bradykinesia - abnormal slowness of movement.
chloreiform movements - involuntary, forcible, rapid, jerky movements.
tardive dyskinesia - involuntary bodily movements with delayed onset (tardive) most commonly the result of long term or high dose use of antipsychotic drugs "lifelong" problem of depression
Celexa, and ariprozole yielded "some resolution of depression symptoms" Key significant negatives of case: denies any drug or alcohol use for 5+ years Objective Data Key significant positives of case: second generation anti psychotic drug use - ariprozole 5mg/day since 2007
involuntary movements: truncal spasms, mild facial masking, mild bradykinesia without arm swing
clonazepam resolved akasthisia R/O Parkinson's Disease or Parkinson's syndrome
older female Key significant negatives of case: Relevant to Tardive Dyskinesia Relevant to Tardive Dyskinesia no chloreiform movements other medical hx drug abuser - IV heroin, diagnosis of hepatitis C, long history of depression and antidepressant use, elevated liver enzymes negative hx positive hx HIV negative, thyroid, lipids, CBC WNL, no documented medical problems GAF 61-70: Some mild symptoms (e.g. depressed mood and mild insomnia) OR some difficulty in social, occupational or school functioning. (wickipedia, 2013). Rule outs: mania with depression, single episode depression for Axis I, any personality disorders for Axis II, Parkinson's disease and syndrome for Axis III. Tardive Dyskinesia (TD) may result from neuroleptic-induced (anytipsychotic drugs) dopamine supersensitivity in the nigrostriatal pathway, the primary effected receptor being the D2 receptor that neuroleptics act on. Increasing age and alcohol usage may also have a relationship. (pubmed 2013).
Dopamine is a catecholomine along with epinepherine and norepinepherine. Dopamine regulates movement, mood, memory recall, alertness and others - when a person becomes supersensitive to dopamine he or she can lose control of bodily movements - TD. (pubmed 2013) In English please Current set of vitals
CBC for general medical health
Pregnancy to rule out/precautionary (age 53 not impossible)
Toxicity screen to rule out use/abuse - drugs or ETOH
Liver function test - antipsychotics are metabolized by the cytochrome P450 system Pharmacological treatment: the goal of treatment is to treat the symptoms of depression to allow patient to engage in life's activities, while decreasing or eliminating the symptoms of TD. Medications: continue Celexa, but reduce to 40 mg/day (max recommended dose), because it works.
continue clonazepam or another benzodiazepine as they have been shown to reduce symptoms of TD.
Discontinue ariprozole a partial agonist at D2 receptors ASAP as there are cases reported of it leading to tardive dysinesia, and start clozapine as it has been shown to have the lowest risk of TD (Abassian & Power, 2008). Start clozapine 25 mg/1-2 times daily and increase by 25 - 50 mg per day until reach target of 300 -450 mg by two weeks. (Vallerand, Sanoski, & Deglin, 2013). author's note: information for pharmacological treatment and medication usage and protocol is compiled from Davis Drug Guide, Becky White lectures, Wickipedia, cited sources above, The Principles of Psychiatric Nursing textbook, Medical-Surgical Nursing textbook; the sources are believed to be credible and reliable for this use. education, therapy and rationale: goals: patient goals are always patient centered with the whole patient's well being in mind - an approach of wellness incorporating biological, psychological, and sociocultural concepts (The Stuart Stress Model). This patient will endure the fewest, least severe symptoms of depression and TD and function at the highest possible level. patient evaluation: patient will need to be seen monthly by provider
to address symptoms of TD and depression
and medication adjustments and/or changes
can be recommended or changed on the
patient's request or provider discretion. Case management: make sure ADL's are being met, medications being taken, no absences at work, help with co-pay/insurance questions, liaison to provider patient may need notes at work explaining TD, depression, perhaps absences. May need help advocating for decreased payment plan from drug companies, referrals to therapist, and case manager, and perhaps for disability coverage. -------------------------------------------- White, Rebecca (2013) MSU lectures/slides from D2L website.
Pubmed, (2013) for definitions. Retrieved from http://www.pubmed/gov
Wickipedia, (2013) for definitions. Retrieved from http://en.wickipedia.org
Stuart, Gail W. (2013). Principles and practice of psychiatric nursing: tenth edition. St.
Louis, MO: Elsevier Mosby.
Vallerand, Sanoski, & Deglin (2013). Davis's drug guide for nurses: thirteenth edition. Philadelphia, PA: F.A. Davis Company.
Doenges, Moorhouse, & Murr (2010). Nursing care plans: guidelines for individualizing client care across the lifespan. Philadelphia, PA: F.A. Davis Company.
Lewis, Dirksen, Heitkemper, Bucher, & Camera (2011). Medical-surgical nursing: assessment and management of clinical problems. St. Louis, MO: Elsevier Mosby.
Abbasian, & Power (2008). A case fo ariprazole and tardive dyskinesia. Journal of Psychopharmacology 23 (2): 214-215. doi: 10.1177/0269881108089591 retrieved from http://www.ncbi.nlm.nih.gov/pubmed/18515468 (wickipedia, 2013). be vigilant for new evidence, be ready to adjust dosages and/or make changes most common symptoms: repetitive, involuntary, purposeless movements of face, limbs, torso, and fingers including: grimacing, lip smacking, puckering and pursing of lips, rapid eye blinking, trunk spasms, pelvic extension