A) Subjective: (Lisa) 1. Lisa is 29 years old and has been feeling…

Question Answered step-by-step A) Subjective: (Lisa) 1. Lisa is 29 years old and has been feeling… A) Subjective: (Lisa)1. Lisa is 29 years old and has been feeling sad and hopeless for BB most days for the past 6 months. Before this she was an avid runner who liked to spend time outside, but she hasn’t been running for the past 3 months and now finds it difficult to get out of bed as she feels tired all of the time. Lisa has difficulty sleeping as she feels constantly anxious about not exercising and has guilt over the things she can’t perform anymore. She finds it difficult to go to work as she has difficulty concentrating on the tasks she needs to complete and has been calling in sick at least once per week for the past month. She has gained 15 pounds in the last 3 months and this makes her feel worse about herself. Her husband encouraged her to go to her family doctor who found no abnormal medical findings. Lisa feels that she cannot go on like this and has recurrent thoughts of dying in her sleep. She has no thoughts of suicide and no previous suicide attempts.please answer:   a. What is Lisa’s diagnosis? What might the differential diagnosis be,if there is one?2.Lisa goes to see her family physician who prescribed her Cipralex (escitalopram) and gives her a note to be off work for 1 month. She is also referred to see a psychiatric nurse to manage the medication follow up and provide supportive counseling. Please answer:   a. Why would Cipralex be prescribed for Lisa?3.You’re the psychiatric nurse that Lisa has been assigned to. She comes in for her first visit and you inquire about how she is feeling on her medication. She reports to you that she has been taking the medication for three days and she feels like her anxiety has gotten much worse. She is thinking of stopping the medication because she felt better before she took it.Please answer:a. What would you teach Lisa about Cipralex?b.How  does this medication relate to her diagnosis? c. What are the nursing implications?B) Subjective: (Walter)1. Walter’s son and daughter-in-law bring him in to the clinic to see you as they are concerned about his behavior at night time. Walter is an 80 year old man who started living with his son 2 years ago after his wife, Helen, passed away. Over the past two weeks they have noticed that Walter has become restless, getting out of bed at midnight and rummaging through the office and kitchen, seemingly looking for something. When they ask him what he needs, he cannot say and seems confused. He is also very unsteady on his feet. They are able to settle him after awhile and he returns to bed without a problem.Please answer:a. What is Walter’s likely diagnosis? What is a differential diagnosis?2.You discover that two weeks ago, Walter was feeling anxious about flying on an upcoming trip to Florida to visit his brother so his doctor gave him Ativan (lorazepam) to take on the airplane. He started taking the Ativan at night to help him sleep as well.Please answer:a.Why would Walter’s doctor prescribe this medication? b. What affect is the Ativan having on Walter?3. Walter’s son and daughter-in-law are concerned that Walter is dementing and feel that he needs assessment for assisted living.Please answer:a.What teaching would you provide Walter about the medication?b.What teaching would you provide to Walter’s son and daughter-in-law?NOTE:THE QUESTIONS ON THE 2 CASE STUDIES ABOVE WERE ALREADY ANSWERED: AND ANSWERS TO THE ABOVE QUESTIONS ARE WRITTEN BELOW. LOOKING TO PROVIDE REFERENCES THAT WERE USED ON THE ANSWERS. Thank you.A1. Diagnosis: The possible diagnosis in the given client could be Major Depressive Disorder.The above diagnosis is made because:The presenting symptoms such as feeling of sadness, hopelessness (criteria A1), weight gain (criteria A3), difficulty sleeping (criteria A4), feeling tired all of the time (criteria A6), feeling worse about herselft (criteria A7), diminished concentration (criteria A8), anxiety and recurrent thoughts of dying in sleep (criteria A9) over a period of 6 months fall under the diagnostic criteria (mentioned in parenthesis above as per Diagnostic and Stastistical manual of Mental disorders) of Major Depressive disorderThese symptoms are not attributable to any substance abuse or medical condition which concludes a diagnosis of major depressive disorder in this case.Differential diagnoses: Manic episodes with irritable mood or mixed episodes,Adjustment disorder with depressed mood,Mood disorder due to underlying medical conditionAttention deficit/hyperactivity disorderSubstance induced depressive or bipolar disorder.Explanation:2. Reason for prescribing Cipralex (escitalopram) to the given client:Cipralex (escitalopram) is a selective serotonin reuptake inhibitor (SSRI) which is used as one of the first line drug in the management of major depressive disorder due to its tolerance and safety. It can also help with the excessive anxiety as seen in this client. Escitalopram is more effective than citalopram at a lesser dose and lesser side effects.Due to this pharmacological and therapeutic benefits Cipralex could have been prescribed to the given client.3a. Patient teaching to be provided about Cipralex:Client should be instructed to take Cipralex as directedIn case of missed dose, Cipralex should be taken as soon as it is remembered and the following routine schedule of drug should be continuedClient should be advised not to discontinue the drug suddenly without the advise of health care providerAs cipralex can cause dizziness, activities requiring alertness like driving or hazardous operations should not be carried outPatient and the caregiver/ family member should be taught about the possible adverse effects that could occur with the use of Cipralex such nausea, headache, nervousness, sleep disturbances, anxiety, s_ex_ual dysfunction, dizziness, fatigue, rashes, diarrhea, loss of appetite etc.Patient should be taught that the medication should be discontinued if pregnancy occurs and inform to the health care providerSymptoms of serotonin syndrome such as diarrhea, tachycardia, myoclonus, hyper-reflexia should be taught to the client and should be advised not to use other drugs like monoamine oxidase inhibitors, tryptophan, anti-migraine drugs, St. John’s wort or other herbal supplements while taking CipralexFamily members are advised to watch for any changes in thoughts in the patient as there is a risk of suicidality with the use of this drug (especially in the beginning phases of therapy).3b. Relation of medication to the diagnosis of the client:As major depressive disorder is associated with decreased levels of serotonin or 5-Hydroxytryptamine (5-HT) in serotonergic neurones, administration of Cipralex can help in preventing uptake of 5-HT (or serotonin) and increases the levels of serotonin.As a result, serotonin levels are restored to normal and can counter the effects of depression providing a therapeutic relief to the clientAs Cipralex can also be used in the management of anxiety and post traumatic stress and both these symptoms are also present in the given client, it can provide a comprehensive benefit to the client3c. Nursing implications:Nurse should monitor for mood changes and anxiety during therapyAssess for risk of suicidal tendencies and the client should be scheduled for periodic follow up visits for evaluation of effectivenessAssess the patient for changes in libidoAssess for serotonin syndromeB1. The most likely diagnosis in this client could be Sleepwalking (Non Rapid eye movement Sleep arousal disorder) The diagnosis is made based on:Client gets out of bed and walking about (Criterion A1)Seems confused (Criteria A)Unsteady on his feet (Criteria A)Assumes recovery without a problem after a while (Criteria A)All the above findings from the given case are consistent with sleep walking disorder  according to DSM-5 criteria. Differential diagnosis: The following differentials have to be ruled out by comprehensive assessmentBreathing related sleep disorderREM (Rapid Eye movement) Sleep disorderDissociative amnesiaAlcohol induced blackout2a. Reason for doctor prescribing Ativan:As the client in the given case is anxious about the upcoming trip, ativan (lorazepam) is prescribed by the doctor.Ativan, a benzodiazepine derivative is an anxiolytic drug which relieves anxiety and can also treat sleep disturbances as seen in this caseThus, by prescribing Ativan doctor intends to offer therapeutic relief from anxiety and sleep disturbances in this client2b. Effect of Ativan on the client:Ativan being a benzodiazepine derivative increases the inhibitor activity of Gamma Aminobutyric acid (GABA) by facilitating influx of chloride ions on GABA-A receptor.This produces a inhibitory effect on various areas in nervous system such as spinal cord, brain stem, limbic system, cortical areas resulting in calmative, anxiolytic and sleep like state in the client3a.Teaching to be provided about the medication:Patient should be taught to avoid any motor activity or activity that requires alertness as ativan causes dizziness and increases risk of fallAdverse effects such as drowsiness, ataxia, blurred vision, hypotension, transient memory impairment can occur with ativanAtivan should not be taken along with opioid analgesics, cimetidine, ketoconazole, metoprolol, St. John’s wort, propranolol etc due to risk of drug interactionsCaffeine containing products should be avoided along with ativanAlcohol should be avoided while taking ativanAtivan should not be discontinued suddenly3b. Teaching to be provided to client’s son and daughter-in-law:Family members should be inquired about any change of mood or thoughts in the client to assess the risk for suicidalityAny deficient knowledge regarding anxiety disorder should be addressed to the client’s son and daughter in lawEffective coping strategies in dealing with situational crisis about current situation like need of assisted living etc should be taughtAppropriate family constructive problem solving skills, community resources, family roles in addressing the issues should be taughtBeing elderly the client is at risk of developing incontinence, risk for falls due to ativan and hence, appropriate precautionary measures to be implemented should be taughtImportance of continuing medications and periodic follow up visits should be explained to the familyThought stopping techniques, relaxation techniques etc should be taught to the client as well as family members as they can train the patient in situational crisisFamily should be reassured about the transient nature of the condition. 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