Hofstra Northwell School of Nursing and Physician Assistant Studies Psychiatric Mental Health Nurse Practitioner Program
Nurs 281 Chief Complaint
“I can’t sleep.”
HPI
Jenny Moore is a 62-year-old woman who is referred by her family medicine physician to a Pharmacotherapy Clinic for medication therapy management for insomnia. She receives help paying for her medications from medication
assistance programs. She reports that she is unable to sleep at all during the week and then sleeps all day on Sunday. Ms Moore is currently taking temazepam 30 mg daily at bedtime that was recently increased from 15 mg. She is also
experiencing depression due to an abusive relationship with her boyfriend as well as lack of current employment. Her most recent Patient Heath Questionnaire-9 (PHQ-9) result was 20. She admits to being nonadherent to her medication
regimen. She reports that she is no longer able to see her psychiatrist due to cost of the visits.
PMH
Insomnia for many years
COPD
Depression
Migraine headaches
GERD
Allergic rhinitis FH
Mother died 2 years ago from complications of diabetes. Father died of an MI at age 65.
SH
Single, lives with her abusive boyfriend. Unemployed, but receives some money from her mother. She smokes approximately five cigarettes per day, but has smoked up to two ppd in the past. She denies alcohol use. She sees a deacon at her church for counseling. She receives medication assistance for several of her medications from a local agency.
Medications
Temazepam 30 mg PO QHS PRN sleep
Fluticasone/salmeterol DPI 250/50, one inhalation BID
Albuterol MDI, two puffs Q 6 H PRN SOB
Tiotropium Handihaler, one inhalation daily
Citalopram 20 mg PO Q AM
Olanzapine 3 mg/fluoxetine 25 mg PO Q PM
Sumatriptan 100 mg PO PRN migraine
Atenololl 25 mg PO Q AM for migraine prophylaxis
Dexlansoprazole 60 mg PO Q AM
Ibuprofen 200–400 mg PO Q 6 H PRN pain
Tramadol 50 mg PO Q 6 H PRN pain
Pseudoephedrine 30 mg PO Q 6 H PRN allergies Allergies
NKDA ROS
Patient reports that she does not sleep during the week and only sleeps on
Sunday. She reports poor sleep hygiene, because she reads and watches television in bed. She drinks six to eight cups of coffee throughout the day and really does not pay attention to how late she eats or exercises. Patient reports difficulty going to sleep and staying asleep, and reports having had this problem for several years.
Additionally, the temazepam does not seem to help much. She has a long history
of depression but has never been hospitalized. She currently denies a “blue mood” or any thoughts of suicide, and her PHQ-9 score today is 20. She is
prescribed citalopram and the combination olanzapine/fluoxetine to help with her depressive symptoms. Her COPD is secondary to a long history of smoking but is currently controlled on tiotropium, fluticasone/salmeterol, and albuterol PRN. She has experienced migraine headaches for several years and
uses sumatriptan and ibuprofen PRN and atenolol daily for prophylaxis. Her GERD, which she experiences when she is supine, is currently controlled
on dexlansoprazole. She has runny nose, congestion, and itchy eyes in the spring.
Physical Examination (From the Last Visit With Her PCP) Gen
Obese woman in NAD who looks her stated age VS
BP 125/80 mm Hg, P 76 BPM, RR 16, T 37°C; Wt 105 kg; Ht 5 6″′ Skin
Normal skin color and turgor, no lesions noted HEENT
Normocephalic, PERRLA, EOMI Neck/Lymph Nodes
Supple with normal size thyroid, (–) adenopathy Lungs
CTA bilaterally CV
Normal S1, S2; no MRG Abd
NTND, no HSM Genit/Rect
Deferred. Last PAP smear was WNL 6 months ago.
Ext
No C/C/E; normal muscle bulk and tone; muscle strength 5/5 and equal in all extremities; normal pulses
Neuro
Oriented to person, place, and time; CN II–XII intact; Mini-Mental State Examination results: 30/30
Labs
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Na 140 mEq/L Hgb 14 g/dL AST 34 IU/L Lipid panel
K 4.2 mEq/L Hct 43% ALT 32 IU/L TC 212 mg/dL
Cl 105 mEq/L RBC 4.7 × 106/mm3 LDH 112 IU/L LDL 135 mg/dL CO2 28 mEq/L Plt 262 × 103/mm3 GGT 47 IU/L HDL 45 mg/dL BUN 11 mg/dL WBC 6.2 × 103/mm3 T. bili 0.3 mg/dL TG 160 mg/dL SCr 0.8 mg/dL TSH 3.9 mIU/L T. prot 7.1 g/dL
Glu 82 mg/dL Free T4 4.1 ng/dL Alb 4.0 g/dL Assessment
1. Insomnia uncontrolled with temazepam, poor sleep hygiene 2. Depression
3. Migraine headaches
4. COPD, currently controlled 5. GERD, currently controlled 6. Nonadherence
7. Allergic rhinitis 1. Obesity
2. Health maintenance QUESTIONS
Listen
Problem Identification
1.a. Create a drug-related problem list for the patient.
1.b. Which information (signs, symptoms, laboratory values) indicates the presence or severity of insomnia?
1.c. Could any of the patient’s problems have been caused by drug therapy?
1.d. What additional information is needed to satisfactorily assess this patient’s insomnia?
Desired Outcome
2. What are the goals of pharmacotherapy in this case?
Therapeutic Alternatives
3.a. What nonpharmacologic therapies might be useful for this patient’s insomnia?
3.b. What feasible pharmacotherapeutic alternatives are available for treatment of insomnia?
3.c. What economic, psychosocial, cultural, and ethical considerations are applicable to this patient?
Optimal Plan
4.a. What drug, dosage form, dose, schedule, and duration of therapy are best for this patient’s insomnia?
4.b. What alternatives would be appropriate if the initial therapy fails or cannot be used?
Outcome Evaluation
5. Which clinical and laboratory parameters are necessary to evaluate the therapy for achievement of the desired therapeutic outcome and to detect or prevent adverse effects?
6. Discuss clinical pharmacy interventions that can improve medication adherence.
Patient Education
7. What information should be provided to the patient to enhance adherence, ensure successful therapy, and minimize adverse effects?
Plan
7. What other medication adjustments should be made at this time?