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I’m working on a nursing discussion question and need a sample draft to help me learn.

Instructions:

It is anticipated that the initial discussion post should be in the range of 250-300 words. Response posts to peers have no minimum word requirement but must demonstrate topic knowledge and scholarly engagement with peers. Substantive content is imperative for all posts. All discussion prompt elements for the topic must be addressed. Please proofread your response carefully for grammar and spelling. Do not upload any attachments unless specified in the instructions. All posts should be supported by a minimum of one scholarly resource, ideally within the last 5 years. Journals and websites must be cited appropriately. Citations and references must adhere to APA format.

DISCUSSION QUESTION/PROMPT

Consider the following questions in your initial discussion post:

Review the partial SOAP note on the attached file.

Initial Post

Post a discussion constructed as the ‘P’ (treatment plan) that completes the partial SOAP note accessed through the attached file.

Include in the discussion:

3.For each article, you cited in support of an element of the plan, provide your thoughts about the strength of the evidence presented in the article(s)

Examples:

1. Ron

1) Insomnia: ICD-10 – F51.01

Plan:

• Patient to complete Sleep wake Diary, Sleep problems Questionnaire, Alcohol use Disorder Identification test (AUDIT), General Anxiety Disorder seven- Item (GAD-7) and Depression Screening (PHQ-9).

Rule out RLS by simply asking the patient if there is a irresistible urge to move the legs, usually accompanied by uncomfortable sensations and if the symptoms are temporarily relieved by activity such as walking or stretching and symptoms are worse at night.

Diagnostic:

Polysomnography to rule out sleep apnea. Patient with BMI of 41.34 , waking up several times at night and waking up fatigue in the morning. Patient with substance abuse disorders are at risk for sleep related breathing disorder , which may relate to sleep disturbance and may require independent treatment.

Therapeutic:

CBT is the preferred initial therapy endorsed by the American Academy of Sleep Medicine, the British Association of Psychopharmacology, the American College of Physicians and the European Sleep Research Society ( Winkelman, 2021).

Education:

Sleep hygiene which includes avoidance of substances that interfere with sleep, avoidance of nap to maximize sleep drive and enhance the comfort of sleep environment. Try to sleep only when sleepy, get out of bed if unable to sleep and encourage the use of bed only for sleep.

Consultation/Collaboration:

Consider referral to a sleep medicine physician when insomnia does not respond to therapy ; Patients with insomnia report profound daytime sleepiness or symptoms of other sleep disorders, including sleep apnea, periodic limb movements, narcolepsy, parasomnias, or circadian rhythm sleep-wake disorders (Bonnet 2021).

2.Alcoholuse: ICD-10 – F10.99

Plan:

DSM-5 diagnostic criteria for alcohol use disorder.

Diagnostic tests:

LFTs an AST:ALT ratio of 2:1 is suggestive of alcohol-induced liver disease. GGT an indicator of excessive alcohol use when elevated (normal reference range for male 9-50 units/L and for female 8-40 units/L)

Therapeutic:

• Motivational interviewing is an evidence-based counseling technique for eliciting behavior change by helping the patient explore and resolve ambivalence about change;
• CBT is a structured goal-directed form of psychotherapy in which patients learn how their thought processes contribute to their behavior. Increased cognitive awareness is combined with techniques to help patients develop new and adaptive ways of behaving and alter their social environment, which in turn leads to change in thoughts and emotions.

Pharmacological- Naltrexone can be initiated while the patient is still drinking without the need for abstinence. Starting dose is 50 mg/day and can increase the dose up to 100 mg/day (Saitz, 2021)

Education:

• Alcohol Cessation

Educate on the consequences of alcohol consumption which includes risk of accidents, suicide, drowning, alcohol-related liver disease, risk of certain cancers of mouth, throat, esophagus, dementia and heart failure

Consultation/Collaboration:

Refer to mutual help group Alcoholics Anonymous for alcohol use disorder which is based on social fellowship, peer support and belief in spiritual basis for recovery. Thus program is free and available without appointment

2.Anxiety: ICD-10- F41.9

Plan:

Assessment GAD-7

Therapeutic:

Start Sertraline 25 mg PO daily. After a week, sertraline can be increased to a therapeutic dose of 50 mg/day and continued for a total of four to six weeks. If the patient does not experience a robust clinical response, sertraline can be titrated up in weekly or bi-weekly increments of 50 mg to a maximum of 200 mg/day, CBT or both (Craske, Bystritsky, 2021)

Education:

• Encourage aerobic exercise if able.

Mindfulness-based stress reduction and Yoga

Consultation/Collaboration:

CBT

References:

Bonnet, M. H. (2021, June 18). UpToDate. https://www.uptodate.com/contents/evaluation-and-diagnosis-of-insomnia-in-adults?search=alcohol+insomnia&source=search_result&selectedTitle=3~150&usage_type=default&display_rank=3.

Winkelman, J. W. (2021, May 26). UpToDate. https://www.uptodate.com/contents/overview-of-the-treatment-of-insomnia-in-adults?search=alcohol+insomnia&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1.

Saitz, R. (2021, January 22). UpToDate. https://www.uptodate.com/contents/approach-to-treating-alcohol-use-disorder?search=alcohol+use+disorder+treatment&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1.

Craske, M., & Bystritsky, A. (2021, January 26). UpToDate. https://www.uptodate.com/contents/approach-to-treating-generalized-anxiety-disorder-in-adults?search=anxiety+treatment+adult&topicRef=14631&source=see_link.

2) Kaur

1.Insomnia (ICD-10 F51.01).

• Diagnostics: based upon chief complaint “I’m having trouble sleeping, I need something to help me sleep” and patient’s subjective assessment. Objective assessment, BMI=41.3, the patient is morbidly obese along with other presenting symptoms, highly suspicious for obstructive sleep apnea. A comprehensive approach to therapy involves assessing both OSA and insomnia in order to provide comprehensive care. Insomnia symptoms can predict OSA and also have an adverse impact on treatment (Ong & Crawford, 2013).
• Therapeutics – Cognitive behavioral therapy is the leading nonpharmacologic treatment for insomnia (Ong & Crawford, 2013). Trial of Melatonin, and educate the patient that Melatonin is a naturally occurring hormone that is involved in circadian rhythms which chemically signals the brain to become sleepy. Also, it is available as an over-the-counter supplement and with a lack of major side effects (Heldt, 2017).
• Education – Educate the patient that even though alcohol makes you feel sleepy, it actually causes a loss of sleep due to disrupted sleep cycles, fragmented sleep, and nonrestorative sleep (Suni, 2020). Educate the importance of behavioral therapy. It is important to teach patients sleep hygiene. Also, educate the patient that maintaining a regular sleep schedule may be beneficial, refraining from drinking alcohol, avoiding naps during the day, avoiding caffeine near bedtime, and getting plenty of exercises may also be beneficial.

Consultation/Collaboration – referrals to cognitive behavioral therapy and sleep study

2 Alcohol use ( ICD-10 – F10.99).

• Diagnostics – CAGE Questionnaire Assessment and based upon the subjective assessment.
• Therapeutics – Start Gabapentin. The initial dose of Gabapentin is 300 mg a day in the evening for 5 days then 300 mg twice a day and then increases to 300 mg three times a day in a few weeks. Gabapentin is a safe, readily available, and effective drug for alcohol-use disorder. Moreover, in addition to its use in treating alcohol dependence, gabapentin also has specific benefits for alcohol-induced insomnia (Mason et al., 2018). Also, there is some evidence that gabapentin is a moderately effective anti-anxiety medication without the risk of tolerance and abuse that can occur with benzodiazepines (Heldt, 2017).
• Education – Explain how alcohol can contribute to insomnia and encourage patients to refrain from drinking. Provide information about the symptoms of alcohol dependence and withdrawal. Educate on the side effects of Gabapentin.

Consultation/Collaboration – referral for cognitive behavioral therapy.

3.Anxiety ( ICD- 10-F41.9)

• Diagnostics – Subjective assessment “ frequent feelings of anxiety”. Further assessment with PHQ-2 to assess depression.

Therapeutics – Start Lexapro 5 mg a day for 2 weeks then increase to Lexapro 10 mg a day. Side effects discussed in detail. Also, the patient was counsel to refrain from alcohol.

Labs to check for CBC, CMP, TSH

• Education – Non-pharmacological techniques such as regular aerobic exercise and yoga discussed. The patient will be educated that he can benefit from regular yoga practice by staying relaxed in daily life and also by maintaining the strength to face events without getting frustrated (Shah, 2020).

Consultation/Collaboration – referral for talk therapy, Cognitive behavioral therapy.

The articles ‘Insomnia and obstructive sleep apnea’ and ‘Gabapening for alcohol use disorder’ are peer-reviewed articles and provide evidence-based guidelines. I believe in this scenario patient is having secondary insomnia due to experiencing sleep apnea symptoms. Gabapentin is generally well-tolerated, and it does not have the risk of abuse or dependency as compared to benzodiazepines. In the third article, ‘The Top 10 Tips to Deal With Stress and Panic’ yoga has been shown to improve anxiety and depression along with medical management.

References

Heldt, J. (2017). Memorable Psychopharmacology. CreateSpace Independent Publishing Platform.

Mason, B. J., Quello, s., & Shadan, F. (2018). Gabapentin for the treatment of alcohol use disorder. US National Library of Medicine, 27(1), 113-124. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC59575…

Ong, J. C., & Crawford, M. R. (2013). Insomnia and Obstructive Sleep Apnea. Sleep Medicine Clinic, 8(3), 389-398. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC37639…

Shah, S. (2020). Yoga for Anxiety: The Top 10 Tips to Deal With Stress and Panic. Yoga. https://www.artofliving.org/us-en/yoga-for-anxiety…

Suni, E. (2020). What Causes Insomnia?Sleep Foundation. https://www.sleepfoundation.org/insomnia/what-caus…