Decision Tree for Neurological and Musculoskeletal Disorders – Assignment 1 Solution

Decision Tree for Neurological and Musculoskeletal Disorders

To Prepare

• Review the interactive media piece assigned by your Instructor.
• Reflect on the patient’s symptoms and aspects of the disorder presented in the interactive media piece.
• Consider how you might assess and treat patients presenting with the symptoms of the patient case study you were assigned.
• You will be asked to make three decisions concerning the diagnosis and treatment for this patient. Reflect on potential co-morbid physical as well as patient factors that might impact the patient’s diagnosis and treatment.

By Day 7 of Week 8

Write a 1- to 2-page summary paper that addresses the following:

• Briefly summarize the patient case study you were assigned, including each of the three decisions you took for the patient presented.
• Based on the decisions you recommended for the patient case study, explain whether you believe the decisions provided were supported by the evidence-based literature. Be specific and provide examples. Be sure to support your response with evidence and references from outside resources.
• What were you hoping to achieve with the decisions you recommended for the patient case study you were assigned? Support your response with evidence and references from outside resources.
• Explain any difference between what you expected to achieve with each of the decisions and the results of the decision in the exercise. Describe whether they were different. Be specific and provide examples.

You will submit this Assignment in Week 8.

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Solution

Decision Tree for Neurological and Musculoskeletal Disorders

Summary of Case Study

The case study depicts Sabrina, a 26-year-old female patient. She presents to the clinic for a scheduled appointment with her physician as a follow-up on the patient’s recent diagnosis of multiple sclerosis. Sabrina has several questions concerning her diagnosis and reached out to the Nurse Helpline for the hospital network, whereby she has also learned that her diagnosis impacts her neurologic and musculoskeletal systems. Suffice it to say that MS is a chronic, autoimmune-mediated characterized by a degenerative central nervous disorder. In most cases, it triggers myelin and axons injury leading to different neurologic clinical manifestations. According to Ford (2020), MS onset is anywhere between 15 and 60 years, with a peak age at onset being 20-40 years and females having a predominance of 3:1 compared to their male counterparts.

Most importantly, a healthcare provider should appreciate that MS is a disorder accompanied by broad-ranging effects on physical functioning. Medication interventions play a crucial role in managing MS symptoms. The symptoms of MS are generalized weakness, optic neuritis, tremor, vertigo, and dizziness. Additional symptoms include sexual dysfunction, psychiatric disorders like depression, and pain, to mention a few. Because of these symptoms, optimal management of MS demands that the provider adopts a multidisciplinary approach to the treatment plan that integrates pharmacological interventions, rehabilitation, and patient education. Consequently, this paper addresses the potential neurologic and musculoskeletal symptoms Sabrina might experience and outlines the clinical decision-making structure and rationale for treatment.

Decision Point 1

Siponimod prescription and initiate a five-day titration. Starting dose 0.25 mg orally once daily on Day 1 and Day 2 followed 0.25 mg twice daily on Day 3, and increase dosage by 0.25 mg daily so that by Day 6 the dose is 2 mg PO qday.

Reason:

As noted in the introductory section, MS is an immune-mediated disorder that progressively causes the patient’s body to mistakenly attack the CNS like the brain, spinal cord, and optic nerve. The individual becomes acutely inflamed, leading to nerve damage as the nerve’s protective layer of myelin, whose function is to insulate the nerve fibers and facilitate the transmission of CNS signals, wears away (Ghasemi et al., 2017). Once the myelin and nerve fibers are damaged, signal transmission is interrupted and can even be stopped completely. The resulting degeneration triggers various debilitating symptoms: nerve pain and musculoskeletal pain, both of which contribute to aching joints and body pains. Therefore prescribing Siponimod would help treat and manage the pain.

Expected Result 

It is expected that Siponimod would lower the degree of pain in the patient. However, the patient would experience adverse effects like nausea, vomiting, stomach pain, and dark urine, indicative of liver pro problems. From the outset, the treatment goals would be to shorten acute exacerbations, relieve the symptoms and delay disability, particularly maintaining the patient’s ability to work.

Expected versus Actual Results

The patient may return to the clinic after four weeks for a follow-up visit. The patient may probably rate her pain at five on a scale of 1-10 and report that she can function almost normally. However, she might report increased loss of appetite, tiredness, and her skin or whites of the eyes turning yellow.

Decision point 2

Continue with Siponimod but a lower dose to 1 mg PO daily. At the same time, I would consider initiating disease-modifying therapies using an immunosuppressant Nitoxantrone 12 mg/m2 IV every three months for 24months.

Reason

This decision would be selected to lower the severity of the adverse effects of Siponimod, which include liver problems (Gajofatto et al., 2017). The use of an immunosuppressant would help in progressive MS that is refractory to other treatments.

Expected Result 

Reducing the Siponimod dose would help control the side effects and lower the degree of pain control (Song et al., 2019). The Siponimod would help symptom control, while the Nitoxantrone would help treat any relapsing forms of MS.

Expected versus Actual Results

The patient would report on whether the current pain has either increased or decreased after four weeks. She might rate the pain at s7/10 and say the pain is causing her to wake up at night frequently due to the body pain.

Decision Point 3

Change the Siponimod dosage to 0.5 m in the morning and 1.5 mg at bedtime. At this point, patient education would also be incorporated so that highly skilled MS Navigators link the patient to information, resources, and support needed to improve their quality of life. Non-pharmacological interventions like light exercise, stretching/yoga, and positive lifestyle changes would also be used to improve symptoms of joint and muscle pain.

Reason:

I would reduce the dosage in the morning if the patient reports that the pain is mostly under control in the morning and increase the dose at bedtime when the pain worsens. The MS navigators would help the patient to navigate the challenges of MS.

Expected Result 

Lowering the morning dose and increasing the bedtime dose would help alleviate the patient’s pain symptoms while also controlling the dose-dependent side effects. The support network would offer information and education on the patient’s needs, when, and how the individual needs them.

Expected versus Actual Results

The client would then report an improvement in the pain with a rate of 3/10 or less and not report any side effects from the drug. Cessation of smoking and weight management would help to improve muscle and joint pains.

Decision Tree

Types of drugs prescribed to patients with psychological disorders.

The types of drugs prescribed for patients with psychological disorders are grouped as:

• Antidepressants: Norepinephrine Reuptake Inhibitors (SNRIs), Selective Serotonin Reuptake Inhibitors (SSRIs), Serotonin and Bupropion.
• Anti-anxiety medications: benzodiazepines, including clonazepam, alprazolam, and lorazepam
• Mood stabilizers: Lithium, Carbamazepine, Depakote, and Lamotrigine
• Antipsychotic medications: Serentil, Haldol, Trilafon,Loxitane, Prolixin, Navane, Moban, Stelazine, Mellaril, and Thorazine
• Long-acting injectable antipsychotics: Aripiprazole, Aripiprazole lauroxil, Fluphenazine, Olanzapine pamoate, Paliperidone, and Risperidone.

You also examine the potential impacts of pharmacotherapeutics used to treat psychological disorders on a patient’s pathophysiology

Pharmacological interventions have both positive and negative impacts on a patient’s pathophysiology.  Typically, pharmacological interventions are prescribed to mitigate adverse and antisocial behaviors, i.e., symptoms of diagnosed psychological disorder. However, different patients react differently to medication leading to unwanted effects on their pathophysiology. Besides, the drugs have inherent side effects that, when not appropriately monitored, can lead to significantly unwanted outcomes. For instance, lithium is approved for bipolar disorder and helps manage associated symptoms such as hyperactivity, delusions, intense moods, and unreasonable euphoria (Volkmann, Bschor & Köhler, 2020). However, long-term use of lithium affects the parathyroid glands involved in regulating calcium levels, leading to hyperparathyroidism and, consequently, hypercalcemia and associated pathophysiological conditions such as osteoporosis and cardiovascular disease issues.

How does an advanced practice nurse determine the best treatment option or pharmacotherapeutic to recommend for patients with psychological disorders?

The nurses’ primary role is to ensure a safe and definitive diagnosis, evidence-based treatment, and patient education. Usually, the best treatment option for psychological disorders is preceded with a definitive diagnosis, supported by the patient’s medical history and data. Appropriate diagnosis allows a registered nurse to match the best interventions with a given psychological disorder. Equally, a nurse must understand the guiding principles of treating psychological illnesses and the adverse effects of a given drug and patient’s condition.

Conclusion

To sum up, conventional MS treatment concentrates on speeding recovery from attacks, slowing the MS progression, and managing its symptoms. For some patients, the symptoms are mild and therefore require no treatment. Pharmacological interventions for MS attacks are recommended in other individuals, as do treatments modifying primary –progressive type. Physical therapy is also prescribed as a non-pharmacological intervention. The physical therapist would evaluate and address the patient’s body’s ability to move and function, emphasizing walking and mobility, strength, balance, posture, fatigue, and pain.

References

Ford, H. (2020). Clinical presentation and diagnosis of multiple sclerosis. Clinical Medicine, 20(4), 380.

Gajofatto, A. (2017). Spotlight on siponimod and its potential in treating secondary progressive multiple sclerosis: the evidence to date. Drug design, development, and therapy, 11, 3153.

Ghasemi, N., Razavi, S., & Nikzad, E. (2017). Multiple sclerosis: pathogenesis, symptoms, diagnoses and cell-based therapy. Cell Journal (Yakhteh), 19(1), 1.

Song, Y., Lao, Y., Liang, F., Li, J., Jia, B., Wang, Z., … & Song, B. (2019). Efficacy and safety of siponimod for multiple sclerosis: Protocol for a systematic review and meta-analysis. Medicine, 98(34).

Volkmann, C., Bschor, T., & Köhler, S. (2020). Lithium treatment over the lifespan in bipolar disorders. Frontiers in Psychiatry, 11, 377. https://doi.org/10.3389/fpsyt.2020.00377