NURS 7330 Module 3 Case Study

NURS 7330 Module 3 Case Study

NURS 7330 Module 3 Case Study

Module 2  Case Study

Case Study

6 y/o male

HISTORY OF PRESENT ILLNESS

NURS 7330 Module 3 Case Study

A 6 y/o boy, usually in good health, is brought in by his mother because of several recent episodes in which the child suddenly began to screaming in his sleep.  The episodes occurred approximately 90 min. after the child had gone to bed and lasted anywhere from 1 minute to 7 minutes.  The parents attempted to soothe the child but to no avail.  The child was inconsolable, and they had great difficulty comforting him.  When the child finally calmed down, he looked around the room, asked where he was, and went back to sleep.  NURS 7330 Module 3 Case Study

The parents thought he has simply suffered from a severe nightmare and were thus quite surprised in the morning when they discovered that he did not remember anything of the previous night’s events and claimed that he did not dream.  The next four nights were uneventful and the child slept well.  However, similar episodes on the fifth and sixth nights, with a single enuretic episode on the 6th night, prompted the current evaluation.  The pediatrician deemed the child physically healthy and subsequently referred him to you. NURS 7330 Module 3 Case Study

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The boy lives with his parents and 2 yr. old brother.  The family moved from the Midwest to the East Cost 3 months ago.  The boy recently started the 1st grade in public school and has been doing well academically but reportedly has difficulty making friends and is frequently picked on by some of his peers.

PAST HX:

The parents describe the boy as a colicky baby for the first 6 months of life, with subsequent frequent nighttime awakenings.  From the age of 6 months until recently he has slept well.  The child had met all developmental milestones on time.  He has been toilet trained since the age of 3 with occasional and infrequent nocturnal enuresis.  Speech is of normal volume, rate and rhythm.  The patient describes his mood as “OK”, but his affect appears mildly dysphoric.  Thought processes are logical and goal directed.  He denies any suicidal or homicidal ideation.  He also denies hallucinations, and there is no evidence of paranoid ideation.  His concentration and memory are normal.  Insight is fair and judgment is good. NURS 7330 Module 3 Case Study

DIAGNOSTIC TESTING:

The parents used a camcorder to document the episodes.  Nighttime polysomnography was not indicated at this time.  EEG was not currently indicated.

Initial Post Requirement

List Potential Differential Diagnoses based on DSM 5 Criteria

Include brief rationale to support Dx

What is Your Final Diagnosis from the Differential Dx List. Note: You may have more than one final dx

Include Management Plan for chosen diagnosis(es): Pharmacological Psychotherapy

NURS 7330 Module 3 Case Study Rubrics

Application of Course Knowledge

1.  List Potential Differential Diagnoses based on DSM 5 Criteria

2.  Include brief rationale to support Dx

3. Select Final Diagnosis from the Differential Dx List. Note: You may have more than one final dx

4. Include Management Plan for chosen diagnosis(es):

1.Pharmacological

2.Psychotherapy

 

(4 critical elements NURS 7330 Module 3 Case Study)

Support from Evidence-Based Practice (EBP)

1.     1. Case Study Answers are supported with a minimal of One (1) appropriate, scholarly source; AND. NURS 7330 Module 3 Case Study

2.     2. Sources are published within the last 5 years

3.

4.     3. Reference list is provided and in-text citations match.

5.

6.       4. Includes support from textbook(s) NURS 7330 Module 3 Case Study

 

 

(4 critical elements)

REQUIRED TEXTS

1.American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). American Psychiatric Association Publishing, Inc.

2.American Psychiatric Nurses Association, International Society of Psychiatric-Mental Health Nursing, & American Nurses Association. (2014). Psychiatric-mental health nursing: Scope and standards of practice (2nd ed.). Nursebooks.org. NURS 7330 Module 3 Case Study

3.American Psychological Association. (2019). Publication manual of the American Psychological Association (7th ed.). American Psychological Association. https://www.googleadservices.com/pagead/aclk?sa=L&ai=DChcSEwih7ua-3PH6AhWkgVsKHZp0AMIYABAjGgJ5bQ&ohost=www.google.com&cid=CAESauD21555TFkE8Xk-rz2ge1rh4tld5PPzuR82kgw0CXcJxIPp7XeHwo_SzlwrkSUsEU–4hkKxcYspkCVlbgIg0hpXALvxyVwzriHyVOzdY4s8EPwbGALmBCHbe5PBgCcdzb3mpXps50pnCo&sig=AOD64_3CtzX0tcla-LE0qAeoZUVFFZumBg&q&adurl&ved=2ahUKEwiuzNy-3PH6AhWDjIkEHQgfAfYQ0Qx6BAgLEAE

4.Perese, E. (2012). Psychiatric advance practice nursing: A biopsychosocial foundation for practice. F.A. Davis Company. NURS 7330 Module 3 Case Study

5.Taylor, D. M., Barnes, T. R. E., & Young, A. H. (2018). The Maudsley prescribing guidelines in psychiatry (13th ed.). John Wiley & Sons, Inc.

OPTIONAL MATERIALS

1.Boyd, M. A. & Lubbert, R. A. (2019). Essentials of psychiatric nursing (2nd ed.). Wolters Kluwer/Lippincott Williams & Wilkins Co. Leahy, L. G., & Kohler, C. G. (2013).

2.Clinical manual of psychopharmacology for nurses. American Psychiatric Association Publishing.

  1. Stahl, S. M. (2017). Prescriber’s guide: Stahl’s essential psychopharmacology (6th ed.). Cambridge University Press. NURS 7330 Module 3 Case Study

NURS 7330 Module 3 Case Study – Psychiatric Diagnosis and Management – Child Sample Paper

Keen patient history and analysis of the subjective and objective data is key to determining the differential and actual diagnosis and informs the management of the patient. Children’s mental health issues may differ slightly from adults and adolescents due to the various issues such as development and the maturity of thought processes. The week’s case study is a 6-year-old boy who presents with several screaming episodes for about 1-7minutes about an hour and a half after sleeping. The baby screams and cries, and it is difficult to soothe him. Finally, the child woke up and was confused and disoriented and later went back to sleep. In the morning, he does not remember anything that happened. He also had an enuresis episode which prompted the evaluation. The boy has a dysphoric mood and has a history of frequent nighttime awakening as a baby. The data provided has some gaps history of traumatic history as a baby. NURS 7330 Module 3 Case Study

Differential Diagnosis

Nightmare disorder. According to Brown et al. (2018), nightmares and other sleep disorders occur in 35-40% of children between ages two and eighteen. According to the DSM-5, A nightmare disorder is a “recurrent episodes of awakening from sleep with a recollection of terrifying episodes which usually involve fear, anxiety, sadness, anger, or other dysphoric emotions” (American Psychiatric Association, 2013). Nightmares are frightening and may alarm the family, but nightmares are quite common in developing children. The DSM-5 criteria for Nightmare disorder diagnosis and its relationship to the case study are: 1. Recurrent episodes of prolonged extremely dysphoric and vivid dreams that the patient easily recalls. These dreams usually involve fight or flight from threats to survival or security, and these episodes occur in the second half of a major sleep. 2. The individual becomes fully oriented alert on walking from the nightmare. 3. The episodes significantly affect/impair social and occupational functioning. 4. The symptoms are not associated with the effects of drug abuse or medications. 5. The symptoms cannot be attributed to an underlying mental disorder. NURS 7330 Module 3 Case Study

The boy meets some of the diagnostic criteria from DSM-5, such as difficulty forming and maintaining social relationships, episodes of uncontrollably screaming, the patient does not have an underlying mental health condition, the patient does not have vivid dreams, and there is half-arousal from sleep (American Psychiatric Association, 2013 NURS 7330 Module 3 Case Study). The boy does not remember the episodes and has time and place disorientation after awakening. Thus, the patient does not meet the DSM 5 for Nightmare disorder.

Sleep terror. It is an NREM Sleep Arousal disorder characterized by partial awakening from a deep sleep. These episodes occur in non-random eye movement, that is, after a few hours of sleep (within the first few hours). Children with sleep terrors often awaken abruptly, scream, and cry inconsolably for up to ten minutes. According to the DSM-5, sleep terrors are episodes of abrupt and partial awakening from a deep sleep in the first triad of the night, inconsolable cries and screams, and autonomic symptoms (hardly recognized at home). NURS 7330 Module 3 Case Study

These other autonomic symptoms include hyperventilation, tachycardia, pupillary dilations and tend to occur only at night, and daytime naps are not affected. There is a single episode of night terrors, but sometimes, there may be two episodes of sleep terrors. Unlike in nightmare disorders, the patient remembers nothing or only some episode fragments with sleep terrors. Sleep terrors may lead to significant distress and impairment, leading to sleep terror disorder.

Sleep terrors are different from nightmares. In terrors, patients do not recall dreams or remember screaming or crying. They do not gain full orientation after the episode. In contrast, patients vividly remember the dreams and are fully oriented after waking from nightmares (Ellington, 2018 NURS 7330 Module 3 Case Study). Sleep terrors and nightmares can cause enuresis after being scared to losing autonomic control. The patient’s symptoms and presentations coincide remarkably with the DSM-5 criteria for sleep terrors.

Post-Traumatic Stress Disorder is notorious for causing nightmares in children and adults. Memories of untold episodes may be disturbing a patient’s mind and making it difficult even to form healthy social relationships with others. PTSD criteria according to DSM-5 include: 1. Experiencing (narrated) trauma directly. 2. Witnessing a traumatic event as it occurs. 3. Learning of a traumatic event involving a family member or close friend (American Psychiatric Association, 2013 NURS 7330 Module 3 Case Study).

Other criteria are recurrent, involuntary, and intrusive memories of the traumatic events, repetitive, distressing dreams with the evet’s content, dissociation, intense or prolonged psychological distress, and persistent avoidance of associated stimuli. The patient has episodes of crying and screaming at night but does not remember. He verbalizes social withdrawal and that his friends are always picking on him. While some of these symptoms are present in PTSD, the patient does not have a history of traumatic events and does not meet the criteria for PTSD.

Possible Final Diagnosis

The possible final diagnosis is sleep terrors. Sleep terrors cause abrupt episodes of crying or screaming that last for about one to ten minutes uncontrollably, just like in the case study. In addition, sleep terrors present with partial awakening, and failure to recall these episodes, just like the boy denies dreaming or having nightmares (American Psychiatric Association, 2013 NURS 7330 Module 3 Case Study). Sleep terrors also affect social and occupational functioning, as the boy has difficulties making friends. These sleep terrors are disruptive to the family, and their management is imminent.

Management Plan

The first-line treatment for sleep terrors is behavioral interventions. However, pharmacologic interventions can temporarily relieve severe symptoms affecting waking behavior.

Psychotherapy

The first-line treatment options for sleep terrors are treating any underlying condition. A keen physical exam and history and adjuncts tests such as MRI and CT scans may help unearth underlying conditions causing the disorder. Anticipatory awakening is another intervention involving waking the person with sleep terrors about 15 minutes to the time they usually experience these terrors and letting them fall asleep again (Leung et al., 2020).

Polysomnography could help study the sleep-wake cycle and record behavior at night for better management (Drakatos, P., & Leschziner, 2019 NURS 7330 Module 3 Case Study). This intervention can be difficult to implement with irregular sleep terror patterns and could be further disruptive to the family. Stress management through cognitive behavioral therapy may be necessary if the patient is stressed. However, it may not be necessary for this patient with no stress signs or reports.

Pharmacotherapy

I would delay the pharmacotherapy intervention and begin with the behavioral intervention, as recommended by the American Psychiatric Association (2014). The drugs of choice are Imipramine and Clonazepam. Imipramine 25md/day at night, 1-2 hours before bedtime (Gigliotti et al., 2021). It is a tricyclic antidepressant that inhibits serotonin and norepinephrine reuptake at the postsynaptic junction. Imipramine treatment for eight weeks has treated the disorder. Clonazepam 0.5mg at bedtime in tapered doses depending on the response to the drug (Gigliotti et al., 2021). It is a long-acting benzodiazepine. It increases the presynaptic GABA inhibition, reducing the postsynaptic reflexes. It is used as an off-label drug to treat sleep terrors. NURS 7330 Module 3 Case Study

NURS 7330 Module 3 Case Study References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). American Psychiatric Association Publishing, Inc.

American Psychiatric Nurses Association, International Society of Psychiatric-Mental Health Nursing, & American Nurses Association. (2014). Psychiatric-mental health nursing: Scope and standards of practice (2nd ed.). Nursebooks.org. NURS 7330 Module 3 Case Study

Brown, W. J., Wilkerson, A. K., Boyd, S. J., Dewey, D., Mesa, F., & Bunnell, B. E. (2018). A review of sleep disturbance in children and adolescents with anxiety. Journal of Sleep Research, 27(3), e12635. https://doi.org/10.1111/jsr.12635

Drakatos, P., & Leschziner, G. (2019). Diagnosis and management of non-rapid eye movement-parasomnias. Current Opinion In Pulmonary Medicine, 25(6), 629-635. https://doi.org/10.2174/1573396315666191014152136

Ellington, E. (2018). It’s not a nightmare: Understanding sleep terrors. Journal of Psychosocial Nursing And Mental Health Services, 56(8), 11-14. https://doi.org/10.3928/02793695-20180723-03

Gigliotti, F., Esposito, D., Basile, C., Cesario, S., & Bruni, O. (2021). Sleep terrors—A parental nightmare. Pediatric Pulmonology. https://doi.org/10.1002/ppul.25304

Leung, A. K., Leung, A. A., Wong, A. H., & Hon, K. L. (2020). Sleep terrors: an updated review. Current Pediatric Reviews, 16(3), 176-182. https://doi.org/10.1097/MCP.0000000000000619