Background Information https://mym.cdn.laureate-media.com/2dett4d/Walden/NURS/6660/05/mm/decision_tree/index.html The Assignment: Examine Case 2: You will be asked to make three decisions concerning the diagnosis and treatment for this client. Be sure to consider co-morbid physical as well as mental factors that might impact the client’s diagnosis and treatment. At each Decision Point, stop to complete the following: Decision #1: Differential DiagnosisWhich Decision did you select?Why did you select this Decision? Support your response with evidence and references to the Learning Resources.What were you hoping to achieve by making this Decision? Support your response with evidence and references to the Learning Resources.Explain any difference between what you expected to achieve with Decision #1 and the results of the Decision. Why were they different?Decision #2: Treatment Plan for PsychotherapyWhy did you select this Decision? Support your response with evidence and references to the Learning Resources.What were you hoping to achieve by making this Decision? Support your response with evidence and references to the Learning Resources.Explain any difference between what you expected to achieve with Decision #2 and the results of the Decision. Why were they different?Decision #3: Treatment Plan for PsychopharmacologyWhy did you select this Decision? Support your response with evidence and references to the Learning Resources.What were you hoping to achieve by making this Decision? Support your response with evidence and references to the Learning Resources.Explain any difference between what you expected to achieve with Decision #3 and the results of the decision. Why were they different?Also include how ethical considerations might impact your treatment plan and communication with clients and their families. Note: Support your rationale with a minimum of three academic resources. While you may use the course text to support your rationale, it will not count toward the resource requirement. Decision Point One BASED ON THE INFORMATION PROVIDED IN THE SCENARIO ABOVE, WHICH OF THE FOLLOWING DIAGNOSES WOULD THE PMHNP GIVE TO TYREL? In your write-up of this case, be certain to link specific symptoms presented in the case to DSM–5 criteria to support your diagnosis. Generalized Anxiety Disorder (GAD) Obsessive Compulsive Disorder Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections (“PANDAS”) My Decision: Obsessive Compulsive Disorder Decision Point Two BASED ON THE ABOVE INFORMATION, SELECT YOUR NEXT ACTION. BE CERTAIN TO DISCUSS THE RATIONALE FOR YOUR DECISION. Begin Zoloft 50 mg orally daily Begin Fluvoxamine immediate release 25 mg orally at bedtime Begin Fluvoxamine controlled release 100 mg orally in the morning My decision: Begin Fluvoxamine immediate release 25 mg orally at bedtime RESULTS OF DECISION POINT TWO Client returns to clinic in four weeks Upon return to the clinic, Tyrel’s mother reported that he has had some decrease in his symptoms. She states that the frequency of the handwashing has decreased, and Tyrel seems a bit more “relaxed” overall. She also reports that Tyrel has not fully embraced returning to school, but that his attendance has improved. She reported that over this past weekend, Tyrel went outside to play with his friend from across the street, which he has not done in a while. Decision Point Three BASED ON THE ABOVE INFORMATION, SELECT YOUR NEXT ACTION. BE CERTAIN TO DISCUSS THE RATIONALE FOR YOUR DECISION. Increase Fluvoxamine to 50 mg orally at bedtime Augment with an atypical antipsychotic such as Abilify Augment treatment with cognitive behavioral therapy My decision: Increase Fluvoxamine to 50 mg orally at bedtime Guidance to Student In terms of an actual diagnosis, the child’s main symptoms are most consistent with obsessive-compulsive disorder. There may also be an element of social phobia developing, but at this point, the PMHNP has not assessed the nature of the school avoidance—that is, why is the child avoiding school. Notice that nothing in the scenario tells us that the PMHNP has assessed this. Fluvoxamine immediate release is FDA-approved for the treatment of OCD in children aged 8 years and older. Fluvoxamine’s sigma-1 antagonist properties may cause sedation and as such, it should be dosed in the evening/bedtime. At this point, it would be appropriate to consider increasing the bedtime dose, especially since the child is responding to the medication and there are no negative side effects. Atypical antipsychotics are typically not used in the treatment of OCD. There is also nothing to tell us that an atypical antipsychotic would be necessary (e.g., no psychotic symptoms). Additionally, the child seems to be responding to the medication, so there is no rationale as to why an atypical antipsychotic would be added to the current regimen. Cognitive behavioral therapy is the psychotherapy of choice for treating OCD. The PMHNP should augment medication therapy with CBT. If further assessment determines that Tyrel has social anxiety disorder, CBT is effective in treating this condition as well.
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