Wk 8 clinical decision tree

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I have attached a previous clinical decision tree for you to use as guidance

Please see the decision tree case study attached

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4-5 scholarly references with in the last 5 years

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Sleep disorders are conditions that result in changes in an individual’s pattern of sleep (Mayo Clinic, 2020). Not surprisingly, a sleep disorder can affect an individual’s overall health, safety, and quality of life. Psychiatric nurse practitioners can treat sleep disorders with psychopharmacologic treatments, however, many of these drugs can have negative effects on other aspects of a patient’s health and well-being. Additionally, while psychopharmacologic treatments may be able to address issues with sleep, they can also exert potential challenges with waking patterns. Thus, it is important for the psychiatric nurse practitioner to carefully evaluate the best psychopharmacologic treatments for patients that present with sleep/wake disorders.


 Case Study: Pharmacologic Approaches to the Treatment of Insomnia in a Younger Adult. You will be asked to make three decisions concerning the medication to prescribe to this patient. Be sure to consider factors that might impact the patient’s pharmacokinetic and pharmacodynamic processes.

At each decision point, you should evaluate all options before selecting your decision and moving throughout the exercise. Before you make your decision, make sure that you have researched each option and that you evaluate the decision that you will select. Be sure to research each option using the primary literature.

Introduction to the case (1 page)

· Briefly explain and summarize the case for this Assignment. Be sure to include the specific patient factors that may impact your decision making when prescribing medication for this patient.


31-year-old male who presents to the office with a chief complaint of insomnia.


Patient is a 31-year-old male. He states that his insomnia has gotten progressively worse over the past 6 months. Per the patient, he has never been a “great sleeper” but is now having difficulty both falling asleep and staying asleep at night. The problem began approximately 6 months ago after the sudden loss of his fiancé. The patient states this is affecting his ability to perform his job, which is a forklift operator at a local chemical company. The patient states he has used diphenhydramine in the past to sleep but does not like the way it makes him feel the morning after. He states he has fallen asleep on the job due to lack of sleep from the night before. The patient’s medical record from his previous physician states that he has a history of opiate abuse, which began after he broke his ankle in a skiing accident and was prescribed hydrocodone/apap (acetaminophen) for acute pain management. The patient has not received a prescription for an opiate analgesic in 4 years. The patient states recently he has been using alcohol to help him fall asleep, approximately four beers prior to bed.


The patient is alert and oriented to person, place, time, event. He makes good eye contact and is dressed appropriately for time of year. He denies auditory/visual hallucinations. Judgement, insight, and reality contact are all intact. Patient denies suicidal/homicidal ideation, and is future oriented.

Decision Point One

Trazodone 50 mg po at bedtime


Patient returns to clinic in 2 weeks

Patient states medication works well but gives him an unpleasant side effect of an erection lasting approximately 15 minutes after waking

Patient states this makes it difficult to get ready for work or go downstairs and have coffee with his girlfriend and daughter in the morning

Patient denies auditory/visual hallucinations and is future orient

Decision Point Two

Explain that an erection lasting 15 minutes is not considered a priapism and should diminish over time, continue with current dose


Patient returns to clinic in 2 weeks

Patient states priapism has diminished over time

Patient denies auditory/visual hallucinations and is future oriented

Patient states trazodone is effective at 50 mg dose but sometimes wakes up following day with next-day drowsiness

Patient denies auditory/visual hallucinations and is future oriented

Decision Point Three

Continue dose. Explain to patient he may split the 50 mg tablet in half. The decreased dose should minimize next- day drowsiness. Follow up in 4 weeks

Guidance to Student
Trazodone is a selective serotonin reuptake inhibitor that has a low side effect profile. It would not be prudent to prescribe sonata as it carries with it the risk of complex sleep behaviors. Hydroxyzine is an antihistamine with strong sedative properties. However, many patients complain of anticholinergic adverse effects the following morning, such as Xerostomia and Xerophthalmia.

The patient is presenting with excessive somnolence. It would be prudent to reduce the dose of trazodone by 50% and reassess in 4 weeks.


Anxiety is considered a mental health disorder that is characterized by fear and an increase in emotions. Individuals also report worries and increased fear of failure in the future, and they tend to be more concerned about current events. According to the DSM-5 diagnosis, for an individual to be diagnosed with anxiety disorder, there must be an excess of worries or anxiety for at least six months (Strawn et al., 2018). This case is focused on a case scenario about a 46-year-old client suffering from anxiety.

These case scenarios focus on offering the appropriate treatment for the patient. The treatment process is guided by the three decisions to be made. On a brief history of the case scenario, the client presented to the emergency room following the referral process. He had previously experienced chest tightness, SOB, and myocardia infection was r/o; however, he remains concerned about the future. In addition to daily stress, he is also caring for his aging parent. He struggles with constant worries about his job and has resorted to alcohol as a coping mechanism for his present problems. He has been consuming 3 to 4 beers daily. His current Hamilton Anxiety Rating Scale results are 26, indicating that he has a generalized anxiety disorder (GAD). Therefore, the case scenario offers a practical treatment approach for the patient based on three decisions.

Decision #1: Start Paxil (Paroxetine)10 mg PO daily

Reasons for the decision: this is an FDA-approved medication for anxiety conditions such as GAD, major depressive disorder, panic disorder, and PTSD, among others. The drug helps effectively treat GAD symptoms by decreasing these un-wanting symptoms and allowing an individual to gain control of his life.

           The expected outcomes: Based on the treatment decision above, the patient will report reduced anxiety symptoms. He is expected to register a decrease in chest tightness as well as a decrease in shortness of breath. There will also likely be a decrease in the HAM-A scale rate readings.

Decision #2: increasing the dosage to 20 mg PO daily

Reasons for the decision: Secondary to the patient’s improvement in the symptoms from the previous decision, there is a need to increase the dosage from 10 mg to 20 mg PO daily while monitoring his outcome. Increasing the dosage to 40 mg is not advisable due to potential adverse reactions, which might affect the treatment process. Increasing the dosage to 40 mg is likely to cause poor treatment adherence since the patient is likely to be slightly evasive about the symptoms (Mennin et al., 2018). The treatment adherence is also expected to be affected as the patient can report erection difficulty when the dosage is increased to 40 mg. it is also not advisable to start him on Imipramine 25 mg BID since he is likely to report a slight drop in the symptoms. Prescribing Imipramine 25 mg also implies occasional shortness of breath with a minimal reduction in the HAM-A score from 26 to 22 compared to Paxil 10 mg, which significantly decreased the HAM-A score from 26 to 10.

The expected outcomes from the intervention are further improvement in symptoms and HAM-A score. The patient is expected to report fewer worries about his job and daily life concerns (DeMartini et al., 2019). The patient is expected to report no side effects associated with the prescribed medication and dosage. This will be an indication of adequate adherence to the prescribed medications. The compliance level is necessary for this patient’s successful treatment outcomes.

The differences between the anticipated and actual outcomes: the client returns to the facility after four weeks with a report on further reduction in the symptoms. His HAM-A score has now been reduced to 10. At this point, there is a 61 percent reduction in his symptoms. Based on the outcomes, no associated side effects have occurred with the increase in the dosage.

Decision #3: Maintain the Present Dosage

Reasons for this decision: from the previous decision, there is a 61 percent reduction in the patient’s symptoms previously presented by the patient. Therefore, continuing with the current medication dosage is advisable seems it has a positive and expected outcome. Furthermore, maintaining the current treatment will help to avoid potential side effects, such as sexual dysfunction issues. Such side effects might occur due to the change in the drugs or increase in the dosage, compromising treatment adherence. Therefore, starting the patient on Burispone 10 mg BID is not a suitable option since he is likely to report a slight drop in symptoms and severe anxiety persistence. Additionally, the decrease in the HAM-A score might not be significant compared to Paxil 10 mg (26 to 23 compared to Paxil 20 mg, which reduces it from 26 to 10).

The expected outcome: the patient would report further improvement in the symptoms, and the HAM-A score would drop by 90 percent.

The differences between the expected and the actual outcomes: No significant variations are expected between the desired and the actual results. Nevertheless, the anticipation is that at the end of 12 weeks, the patient would return to the facility with a drop in the HAM-A score of about 90 percent.


This is a case of a middle-aged Caucasian male who presents to the clinic with complains of severe anxiety symptoms. The treatment of the symptoms presented by the patient is based on three decisions. Both legal and ethical principles guide the decisions made on the treatment approach. Treating a patient with a mental disorder is faced with numerous challenges. In this case, providers are expected to be more careful concerning the potential benefits and harms of the prescribed drugs. In this case, preventing possible damage implies collecting relevant information to help avoid potential injury. For example, containing information about the drug use history in the case scenario is essential—the patient’s ETOH abuse might tamper with the effectiveness of the prescribed treatment. The patient must be educated about adverse drug-medication interactions that might affect his health. It is also essential to inform the patient about the available different types of medicines to prescribe. The patient is informed about each medication treatment’s benefits and harms or side effects. Such information is essential in the promotion of the adherence process. As a provider, it is also necessary to consider other alternative medications that can be combined with the prescribed medicines to help improve the patient’s condition. In this case, finding out the causes and triggers of the anxiety for this patient can be extremely helpful. Psychotherapy approaches such as cognitive behavior therapy can be different therapeutic approaches that can be adopted to help improve the patient’s mental status. Based on the overall outcomes of the treatment decisions, it is evident that Paxil is effective in managing the symptoms presented. Therefore, the observation of the dosage and ensuring that close monitoring of the patient while increasing the dosage is essential. It helps prevent possible side effects that can tamper with the adherence process.


DeMartini, J., Patel, G., & Fancher, T. L. (2019). Generalized anxiety disorder. Annals of Internal Medicine, 170 (7), ITC49.

Mennin, D. S., Fresco, D., O’Toole, M., & Heimberg, R. G. (2018). A randomized controlled trial of emotion regulation therapy for generalized anxiety disorder with and without co-occurring depression. Journal of consulting and clinical psychology, 86(3), 268.

Strawn, J. R., Geracioti, L., Rajdev, N., Clemenza, K., & Lavine, A. (2018). Pharmacotherapy

for generalized anxiety disorder in adult and pediatric patients: an evidence-based treatment review. Expert opinion on pharmacotherapy, 19(10), 1057-1070. https://doi.org/10.1080/14656566.2018.1491966

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