Nursing: Scope and Standards of Practice, Essay Example

Case Study

This report describes the results of a physical and psychiatric examination conducted of a 21-year male referred to a physiotherapy clinic with a degenerative joint knee pain (Knee Osteoarthritis). Later, the patient was identified as suffering from a complex regional pain syndrome (CRPS). Upon completion of a comprehensive physical examination and interview, the physician concludes that he was suffering from complex medical conditions. It was determined that apart from suffering degenerative joint knee pain and CRPS he also had mental disorders. Following a comprehensive psychiatric test, it was established the patient suffered from schizophrenia and General anxiety disorder. The condition required urgent psychiatric and medical referral.

Chief Complainant from Patient: “I feel extreme knee pain and traumatized. I wake up every day feeling extremely nervous”

HPI: The patient was lastly treated in our facility late 2016. His PCP has been following up his condition thereafter and recently he has exhibited extreme symptoms of increased pain during temperature changes and sudomotor disturbances. In addition, his skin color has changed from reddish to bluish while exhibiting increased anxiety and trauma-related behaviors. The patient has consistently complained of nightmares and anxiety while handling any task that requires concentration. The patient lives with his parents and it is reported he exhibits violent behaviors at times to his siblings. It had been reported that the patient had a prior incidence of attempted suicide and was admitted to an emergency room in the company of his friend after consuming an overdose of Xanax, Lexapro and Zoloft pills in an attempt to commit suicide. Before the incidence, the patient fought with his girlfriend because he believed that he was not giving him enough time. After the incidence, he has been consuming a lot of alcohol on daily basis. Recently, he used synthetic marijuana and occasionally takes cigarettes in unknown amounts. However, he declined that he had never taken any intravenous drugs such as cocaine and heroin. However, the patient recalls that he speaks and thinks quickly since he had always been bright and talented. He states that he has been getting at least five hours of sleep since he was 15 and believes that he can be very influential. Furthermore, the patient reported that he gets angry quickly and gets sad often. He had been depressed and physically restless and had been considering suicide frequently. As a result, he had lost weight over the past few weeks.

Past Psychiatric History: The patient reports to have first been depressed while 15 years when he lost his younger brother. Due to their close bond, it was difficult to overcome the trauma and after the incidence, he had frequent nightmares of his brother standing beside his bed for almost a year. It is reported that during that duration the patient was violent and quick to anger and would easily resort to physical violence. However, no psychiatric hospitalization reports exist.

Past Medical History: Allergic to Lexapro and Fentanyl

Review of recent lab results shows calcium low at 6.8., BMP Wnl, with normal lipid panel. HDL results were normal with triglycerides at 178, CBC WNL and ALT WNL.

Current Medication and their Side Effect:

Social and Family History: The patient was born in 1996 in the United States and is currently a college student in Minneapolis Minnesota. He is an alcoholic and lives with his parents and three other siblings. He lost his younger brother while 15 years old. After the death of his younger brother the patient started to exhibit violent and anxiety disorders. He actively participates in sports while at school and he is a bright student.

MSE: Folstein mini mental status score 34, General anxiety scale score 12.  GAD 7- 15.

General: The patient is a well developed white male who is currently on medication supervised by his PCP. He is overly anxious when performing tasks that require a lot of concentration and exhibits violent behaviors at times. His mood is not quick to ascertain as it changes rapidly and he is not paranoid. The medical condition he is experiencing has not shown any negative effects on his school performance.

Memory: His memory status is still good as he can remember random unrelated questions when asked frequently.

Attention and Concentration: His attention is normal but gets overly anxious while concentrating on a serious issue.

General Fund of Knowledge: Based on the interview with the patient, his general knowledge can be rated excellent.

Insight and Judgement; Good

Diagnostic Criteria

Diagnostic Criteria for Knee Osteoarthritis

The clinical classification criteria for knee osteoarthritis was developed by the American College Rheumatology (ACR).

• Pain in the knee
• Must have 3 of the following traits:
• Over 50 years of age
• Less than 30 minutes of morning stiffness
• Crepitus on active motion
• Bony tenderness or enlargement
• No palpable warmth of synovian

Budapest Clinical Diagnostic Criteria for CRPS

Continuing pain, which is disproportionate to any inciting event

The patient must show one symptom in three of the four following categories:

• Sensory: reports of hyperesthesia or any symptoms of allodynia
• Vasomotor: reports of temperature asymmetry or skin color changes or skin color asymmetry
• Sudomotor/edema: reports of edema or sweating changes or sweating asymmetry
• Motor/trophic: reports of the decreased range of motion or motor dysfunction (weakness, tremor, dystonia) or trophic changes (hair, nail, skin)

The patient ought to display at least one sign at the time of evaluation in at least two of the following categories:

• Sensory: evidence of hyperalgesia or allodynia (to light touch or deep somatic pressure or joint movement)
• Vasomotor: evidence of temperature asymmetry or skin color changes
• Sudomotor/edema: evidence of edema or sweating changes
• Motor/trophic: evidence of the decreased range of motion or motor dysfunction (weakness, tremor, dystonia) and/or trophic changes (hair, nail, skin)

There is no other diagnosis that better explains the signs and symptoms

DSM-5 Diagnostic Criteria for General Anxiety Disorder

In order to make a proper diagnosis of GAD all the following features need to be present:

• Presence of excessive anxiety and worry about a variety of issues. The worry occurs often not for atleast 6 months and a person might worry even about petty issues excessively.
• The anxiety and worry is associated with atleast six of the following feature symptoms (note that only one symptom is associated with children):

1. Restlessness and the individual feels pushed up to the edge
2. Fatigued easily
3. Difficulty in concentration
4. Irritability
5. Muscle tension
6. Disturbance during sleep
7. The disturbance is not due to psychological effects of a substance or any medical condition
8. Not any other medical condition can better explain the occurrence of these disturbances.

DSM 5  Diagnostic Criteria for Schizophrenia

1. Must show at least two of the following symptoms for a period of not less than one month:
2. Delusions
3. Hallucinations
4. Disorganized speech (either frequent derailment or incoherence)
5. Grossly disorganized
6. Negative symptoms are affective flattening, alogia or avolition

Note: Only one Criterion A symptom is required if delusions are bizarre or hallucinations. Additionally,  if the voice consist keeping up a running commentary on the person’s behavior or thoughts, or both. Furthermore, more voices might be conversing with each other.

• Social/occupation dysfunction: major areas of assessment are functioning such as work, interpersonal relations or self-care.
• Duration: continuance disturbance for at least 6 months with one month of symptoms that meet criterion A.
• Schizoaffective/ Mood disorders: these two disorders with psychotic features are ruled out because of lack of major depressive or manic episodes that occur concurrently with active phase symptoms (Sadock, 2008). Subsequently, if mood episodes have occurred during active-phase symptoms, they have lasted less period to the active and residual periods.
• General medical condition exclusion: disturbance is not due to direct psychological effects of a substance.
• Relationship to a Pervasive Developmental Disorder: If there exist a history of Autistic Disorder or another Pervasive Developmental Disorder, additional diagnosis of Schizophrenia needs to be made only if prominent delusions or hallucinations are also present for at least a month.

Note: Classification of longitudinal course can be applied only after at least 1 year has elapsed since the initial onset of active-phase symptoms

• Episodic With Interepisode Residual Symptoms: if these episodes reemerge with prominent psychotic symtoms.
• Episodic With No Interepisode Residual Symptoms 
• Continuousof psychotic symptoms are present throughout the period of observation
• Single Episode in full remission 

Neurobiological and other influences

Mental disorders are highly comorbid with each other and major depressive influences. As for syndromes, schizophrenia and General anxiety disorder share various symptoms and hence can share several treatments. Various distinguishing features support continued classification of mental disorders (Shally-Jensen, 2013). Usually, anxiety disorder and schizophrenia can profoundly alter cognition. Schizophrenia and anxiety disorder strongly influence attention and concentration while inhibiting potential sources of distraction. Importantly, concentration is guided by endogenous factors as well as anxiety. This extended network comprising sensory and anxiety circuits facilitate rapid changes in cognition behavior of an individual. Most contributors to this study have concluded that Schizophrenia and anxiety disorders affect transient responses to shape emotional responses of a patient. Combination of emotional state, neuroendocrine activity, and resting-state brain activity demonstrate the alterations in amygdala-hippocampal functional connectivity (Vaivaser et al., 2013)

Therefore, it is vital to understand mechanisms that guide variation in speed recovery from anxiety disorders. For instance, personal traits such as neuroticism are widely determined by patient’s ability to recover from anxiety and stress disorders. Subsequently, these differences are sensitive to chronic stress exposure for individuals suffering from schizophrenia and anxiety disorders (Hales, 2014). More so, endogenous attention is closely tied to working memory, hence making the working memory a key determinant of cognitive behavior.

Treatment Options and Guidelines

Guidelines for treatment of Schizophrenia (Lehman, (2010). A. Practice Guideline for Treatment of Patients with Schizophrenia, 2^nd ed.)

It consists three major parts and many subdivisions, which are not useful in this study.

Part A: treatment recommendation represents varying levels of clinical confidence. First, it may be recommended with substantial clinical confidence. Second, it might be recommended with moderate clinical confidence or lastly on basis of individual confidence.

Part B: it encompasses formulation and implementation of a treatment plan.  This treatment plan has three objectives, which include reduction or elimination of symptoms, maximizing quality of life for the patient and lastly maintaining recovery from adverse effects of illness. Due to the need of new evaluation of patient’s symptoms, the diagnosis needs to be reevaluated, and treatment plan changed if need arises. Additionally, there is need for identifying targets for each treatment in order to achieve the greatest outcome (Green, 2006).

Part C: Establishment of a Therapeutic alliance enables the psychiatric gain useful information from the patient. Additionally, it helps to establish a trustful relation between the patients and the psychiatric, which is essential for the recovery plan. Equally important, is the need to establish barriers to patient’s participation in the treatment plan. Finally, is engagement of family and close persons with patient’s permission in order to strengthen the therapeutic efforts.

Guidelines for Treatment of Knee Osteoarthritis (T.E. McAlindon (2013). QARSI guidelines for non-surgical management of Knee Osteoarthritis)

Part A: Balneotherapy is recommended for patients with multiple-joint OA and other relevant comorbidities. This therapy involves bathing with thermal mineral waters (Antony, 2009).

Part B: for quality assessment, the use of biochemical interventions as requested by an appropriate specialist. This is effective in reducing pain, joint stiffness, and drug dosage.

Part C: Cane walking is appropriate in disease management, as it helps improve physical functioning and overall quality life of the patient.

Guidelines for Treatment of CRPS (Royal College of General practitioners (2012) Complex regional pain syndrome in adults: Guidelines for diagnosis, referral, and management in primary and secondary care)

To improve the outcome of treatment, the guidelines of treatment of CRPS work under the following three principles: pain intensity, limb dysfunction, and distress.

Part A: Referral.

In cases where pain treatment is unsuccessful, it is required referral of the patient to a pain specialist. This referral is vital for assessment of any related pain diseases that might have similar symptoms. This is crucial even if he is undergoing other treatment plans. Subsequently, after pain intensity has been assessed, the patient is referred to physiotherapy.

Part B: Physiotherapy

Phase 1 is for the therapist to identify any signs and symptoms of CRPS without prior diagnosis. The second phase includes confirmation of diagnosis through Budapest diagnostic criteria. Subsequently, the third phase involves management of the diagnosed CRPS by physiotherapist through assessment of severity. During the therapeutic approach to treatment, the patient is educated, supported, and desensitized. In addition, general exercise and functional activities are assigned to the patient for strengthening and finally transcutaneous electrical nerve stimulation is done to the patient (Saxena, 2012). Note that these guidelines only apply to  patients who do not require any surgical procedures.

Guidelines for Treatment of General Anxiety Disorder (International journal of psychiatry in clinical practice, 2012; 16: 77-84)

he first treatment option for GAD is SSRIs, SNRIs, and pregabalin. Other options may vary from buspirone and hydroxyzine. Benzodiazepines should only be used when other options for treatment fail to work. Subsequently, the patient should be put under cognitive behavioral therapy in order to stress out the role of worrying and avoidance behavior.

Drug-drug interaction

Since the patient is undergoing current medication that seems to reduce his knee pain and anxieties, it is appropriate not to change his medication at the moment because it could result up to complications. Therefore, the patient will continue with his prescriptions while undergoing intense assessment by his PCP. Equally important, the patient ought not to be prescribed any moamine oxidase inhibitors as they result to severe reactions that can be fatal when they interact with narcotic analgesics (Hales, 2011) which he is currently using.

Black Box Warnings for Physicians

The rationale behind black box warning for physicians is to encourage or prompt them to carefully take into account the risk of medication before prescribing them. It also enables physicians to determine whether the use of the drugs is warranted or whether there is an option (Zun 2013). The process aims at enabling discussions between physicians and patients concerning potential adverse effects. It is important to be aware of the potential risks of medication since patients may also be informed to make important decisions about their level of comfort with the medication.

 Course of Treatment

The care plan prioritized physiatrist referral, follow-ups by the physician and patient. It also involved explaining to him that the physical therapy was not suitable at the time due to the psychiatric condition. The patient was put under two different medical care plans due to various medical conditions the patient was diagnosed with.

The patient will start an 8 weekly cognitive behavioral therapy session. Subsequently, he is to be placed on a daily Celexa dose with further instructions to continue with every other week.  Also, the PCP needs to ensure that the patient is complying with the medication as advised. These sessions would also allow the physician to assess progress and discuss the same with the patient. It would be appropriate for weekly check-ups by the designated PCP. Accordingly, the patient is encouraged to undergo further assessment to determine the reason for abnormal laboratory tests.

Psychiatric Medication Management

The patient is to start taking Celexa dose  in small quantities once daily. Upon assessment, it can be recommended for increased doses weekly, which will run for 3 months. The reason for gradual doses application is due to the strong side effects, which might not work well with his current medication.

Psychotherapy and Teaching Concerns

The patient will require both individual and group therapy sessions. Group therapies will help improve interrelation problems the patient is undergoing currently while individual therapy will help the therapist to assess extensively the patient. Subsequently, family members will undergo family therapy sessions because they play a key role in the recovery process of the individual. The recommended therapy approaches are interpersonal and cognitive-behavioral therapies.  Equally important, the patient should be taught on the dangers of involving himself on physical aggression behaviors, indulgence of alcohol and other drugs other than prescribed ones while undergoing treatment.

The Scope of Practice Issues Related to the Role of FNPs vs. PMHNPs

FNPs and PMHNPs are prepared educationally to assess for mental health disorders. However, the difference lies in the breadth and depth of the assessment of the disorder (American Nurses’ Association, 2010). Most important is to ensure that patients with mental health disorders needs or disorders obtain an accurate diagnosis as well as an exploration of evidence-based treatment options when needed and as indicated. Therefore, the evidence should provide support to psychotherapy coupled with non-pharmacological approaches to the treatment of major mental disorders, such as anxiety and depression. In most cases, the PMHNP is prepared to offer psychotherapy to patients whereas the FNP should collaborate with the physicians to ensure that psychotherapy is available as indicated (Antai-Otong & Stephen, 2016). These services should be available to patients regardless of the nature of the healthcare providers. All patients need to be monitored closely based on best practice guidelines as well as the side effects and the therapeutic effects of the recommended treatment modality to ensure patient safety.

Conclusion

Clinical assessments draw information from both analytic as well as medical models. However, some individuals have psychodynamic that take up a greater portion of an interview. Among these are patients who are considered for a psychodynamic therapy or those who are not subsumed in a conventional categorical diagnosis. There are patients whose psychodynamic formulations may be of little importance. For instance, patients who are diagnosed with an obsessive-compulsive disorder of simple phobia that is considered as planned therapies that are pharmacological or psychodynamic. Apparently, even in such cases, most psychiatrists prefer to have some sense of an individual’s makeup and developmental history. The main aim is to avoid focusing on symptoms relief to the exclusion of other areas that are of potential concern and to deal with resistance to therapy. Similarly, the principles of psychoanalytic theory may provide a workable model that can be used to organize and use such steps.

References

American Nurses’ Association. (2010). Nursing: Scope and standards of practice. Silver Spring, Md: American Nurses Association.

Antai-Otong, D., & Stephen, D. K. (2016). Psychiatric Mental Health Nursing: An Update. Pennsylvania: Elsevier.

Antony, M., M, & Murray, B., S. (2009). Oxford Handbook of Anxiety and Related Disorders. Oxford: Oxford University Press.

Green, S., A, & Sidney, B. (2006). An Anthology of Psychiatric Ethics. New York: Oxford University Press.

Hales, R., E, Stuart C. Y., & Glen, O. G. (2011). Essentials of Psychiatry. Arlington, VA: American Psychiatric Pub.

Hales, R., E, Stuart C. Y., & Laura, W. R. (2014). The American Psychiatric Publishing Textbook of Psychiatry. American Psychiatric Publishing.

Sadock, B., J, Virginia A., S., & Benjamin, J., S. (2008). Kaplan & Sadock’s Concise Textbook of Clinical Psychiatry. Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins,

Saxena, S. (2012). Public Health Aspects of Diagnosis and Classification of Mental and Behavioral Disorders: Refining the Research Agenda for Dsm-5 and Icd-11. American Psychiatric Association.

Shally-Jensen, M. (2013). Mental Health Care Issues in America: An Encyclopedia. ABC-CLIO.

Vaisvaser, S. et al (2013). Neural traces of stress: cortisal related sustained enhancement of amygdala-hippocampal functional connectivity. Front. Hum. Neurosci

Zun, L., S. (2013). Behavioral Emergencies for the Emergency Physician. Cambridge University Press.