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Respond  of your colleagues who were assigned to a   different case than you. Explain how you might apply knowledge gained   from your colleagues’ case studies to you own practice in clinical   settings as a Psychiatric Nurse Practitioner.

NOTE: Positive comment

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The three questions this writer would as the patient are: 
Did your depressive symptoms worsen after the death of your husband? 
How many hours per night do you sleep on average? 
Do you sleep throughout those hours of sleep or do you wake constantly? 
Do you ingest any stimulants like coffee or chocolate before bed? 
Do you sleep during the daytime? 
The rationale behind question one is to gauge the timeline of the  patient’s depression. She appears to have been suffering with untreated  depression for a long time, however the additional symptoms of insomnia  and tearfulness seemed to worsen after his death. With this information  the nurse practitioner will know if her depression is in an acute state  and the severity of her illness.The patient is reporting sleeplessness;  however the nurse practitioner needs to gauge if the patient is  participating in restful sleep. Sleep of two hours or less may only  consist of REM sleep (Boland et al., 2020). If the patient is not  getting restful sleep, she is not benefiting from the bodily repair that  takes place during sleep (Fitzgerald et al., 2017).  This can place her  at an increased risk for other illnesses and heighten depressive  symptoms (Uchmanowicz et al., 2019).Knowing if the patient sleeps  consistently throughout those hours of sleep will provide information to  the nurse about the kind and amount of sleep the patient is getting.  Ingesting certain stimulants like caffeinated drinks, coffee or  chocolate can affects the client’s sleep by providing wakefulness (Ulke  et al., 2017).  If the patient is sleeping during the daytime, her  circadian rhythm could have been reversed where she will need less sleep  during the night time hours (Fitzgerald et al., 2017).
The people this writer would interview are:
The patient’s aide 
The patient’s son 
The patient aide may be able to provide more information about  observed sleepiness during the daytime. In addition, she will be able to  provide information on the patient’s dietary patterns and physical  activity. The questions to the aide would be:    
Does she easily nod off during the daytime? 
Does she easily become fatigued? 
Does she consume a well-balanced diet? 
Question one would illicit answers about her getting sleep. 
It appears that she in fact getting sleep but because of a revered  circadian rhythm she is not able to get the sleep at the night which is  the desired time.  Question two will help the nurse practitioner gauge  the extent of the effects that non sleep has taken on the patient’s  life. The patient, if constantly fatigued throughout the day has a life  that has been highly impacted by the lack of sleep. The aide would be  able to provide a clear, picture of the patient’s diet. The aide would  be able to reveal if the patient consumes a vast amount of sugar or  caffeine which could interrupt sleep.
Questions to the son would surround the family’s psychiatric history.   These questions will help the nurse practitioner construct the family  history of the patient and rule out or consider familial history as a  cause for her symptoms.
Can you recall any maternal family members with psychiatric disorders including depression and insomnia? 
Did the symptoms start after the death of the client’s husband?  
This would help the nurse practitioner rule out depressive symptoms as the cause of her insomnia.
Physical Examinations and Tests
Sleep Study:
Polysomnogram – The sleep study or polysomnogram  measures the brain waves, blood oxygen, leg movements and breathing  during sleep (Meghdadi et al., 2019). The Nurse Practitioner would be  able to rule out physiological reason’s ad the cause for the patient’s  insomnia.
Actigraphy: This is where a small device is worn on  the wrist and it measures the person’s sleep wake cycle for a specified  period (Meghdadi et al., 2019). This is convenient for this client and  the Nurse Practitioner would be able to monitor the client’s sleep  health and gauge the severity of the disruption of her sleep.The nurse  practitioner could also physically examine the patient’s nares for  septal occlusion.
Septal occlusion or deviation could lead to problems  with sleeping even during sleep, this would be important for the nurse  practitioner to evaluate as this could be interfering with the patient’s  sleep.
Epworth sleepiness scale – assesses the patient’s  tendency to nod off in various situations (Meghdadi et al., 2019).  For  this client it would be necessary for the nurse practitioner to assess  the severity of her nodding off during the day time especially at  unexpected times like during eating and other activities that would put  her safety at risk. 
Differential Diagnosis
G47.00 Unspecified Insomnia Disorder- The patient is  experiencing insomnia at nighttime that could be related to several  factors. She reports staying up late to watch T.V., depressive symptoms,  restless leg syndrome, sleep apnea and sleeping during the daytime.  Some of these factors have not been ruled out yet as the cause of her  anxiety. 
G47.23 Persistent Irregular Sleep Wake type severe 
F32.9 Unspecified Depressive Disorder 
G25.81 Restless legs syndrome 
Medications:
Trazodone 50 mg – This medication would be the first choice as it  offers antidepressant properties as well as promotes sleep in those  diagnoses with insomnia. It is generally safe for the elderly population  at low doses (Pagel et al., 2018). The Nurse Practitioner should  monitor the patient and evaluate the needs to slowly increase or in some  cases decrease the dose. 
Rozerem 8 mg- Is a nonbenzodiazepine hypnotic that promotes sleep.  The patient would benefit from his, but an added benefit would be that  she would be at a diminished risk of falls as this is a concern  following the use of hypnotics in the elderly. This drug is reported as  one that would prevent less falls from over sedation (Pagel et al.,  2018).
Lessons Learned            
This writer has learned that it is important to conduct a complete  evaluation of the patient and not just focus on the presenting symptoms.  There are additional environmental and physiological symptoms that  could be attributed to the patient’s insomnia. In this case the patient  had several factors that could be contributing her insomnia and they  needed to be ruled out. The cause of her insomnia could have been  physiological from the sleep apnea or from her habits of staying up tool  late at nights and sleeping during the daytime. It is also important to  evaluate medications, social and economic factors before the resorting  to pharmacological interventions. 
References
Boland, E. M., Vittengl, J. R., Clark, L. A., Thase, M. E., &  Jarrett, R. B. (2020). Is sleep disturbance linked to short- and  long-term outcomes following treatments for recurrent depression? Journal of Affective Disorders, 262, 323–332. 
FitzGerald, J. M., O’Regan, N., Adamis, D., Timmons, S., Dunne, C. P., Trzepacz, P. T., & 
Meagher, D. J. (2017). Sleep-wake cycle disturbances in elderly acute  general medical inpatients: Longitudinal relationship to delirium and  dementia. Alzheimer’s & Dementia: Diagnosis, Assessment & Disease Monitoring, 7, 61–68. 
Meghdadi, A. H., Popovic, D., Rupp, G., Smith, S., Berka, C., &  Verma, A. (2019). Transcranial Impedance Changes during Sleep: A  Rheoencephalography Study. IEEE Journal of Translational Engineering  in Health and Medicine, Translational Engineering in Health and  Medicine, IEEE Journal of, IEEE J. Transl. Eng. Health Med, 7, 1–7.  
Pagel, T., Seithikurippu R. Pandi-Perumal, & Jaime M. Monti. (2018). Treating insomnia with medications. Sleep Science and Practice, (1), 1. Uchmanowicz I, Markiewicz K, 
Uchmanowicz B, Kołtuniuk A, & Rosińczuk J. (2019). The  relationship between sleep disturbances and quality of life in elderly  patients with hypertension. Clinical Interventions in Aging, 155. 
Ulke, C., Sander, C., Jawinski, P., Mauche, N., Huang, J., Spada, J.,  Hegerl, U. (2017). Sleep disturbances and upregulation of brain arousal  during daytime in depressed versus non-depressed elderly subjects. World Journal of Biological Psychiatry, 18(8), 633–640.    

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