· Client returns to clinic in four weeks
· Mrs. Perez states that she has noticed that she has been having suicidal ideation over the past week, and it seems to be getting worse
· Clientis She is also reporting that she is having “out of control” anxiety..
Decision Point Two
RESULTS OF DECISION POINT TWO Decision Point Two
Select what the PMHNP should do next:
- Client returns to clinic in four weeks
- Mrs. Perez reports that when she first received the valium, it helped her tremendously. She states “I was like a new person- this is a miracle drug!” However, she reports that she has trouble “waiting” between drug administration times and sometimes takes her valium early. She is asking today for you to increase the valium dose or frequency
- Although she reports that her anxiety is gone, she still reports suicidal ideation, but states “with that valium stuff, who cares?”;;;;;;;;
- Decision Point Three
- Add on Wellbutrin (bupropion) XL 150 mg orally daily
- Guidance to Student
- Given her weight (less than 60 kg), Campral should have been started at 666 mg orally BID. It is possible that the higher dose may be responsible for the severity of the symptoms that Mrs. Perez is experiencing.
- Technically, the drug should have been stopped (not simply decreased) once Mrs. Perez reported suicidal ideation. Even with the decrease in dose, she is still having suicidal ideation, which indicates the need to discontinue the drug. Although controversy exists regarding how long to use pharmacologic approaches to treatment of alcohol dependence, 8 weeks is probably insufficient, therefore, the drug should not simply be discontinued without using a different agent in its place.
- Mrs. Perez should be started on Antabuse at 250 mg orally daily and referred to psychotherapy to address her gambling issue.
- In all cases, the PMHNP needs to discuss smoking cessation options with Mrs. Perez in order to address the totality of addictions and to enhance her overall health. The decision to begin Wellbutrin XL 150 mg orally daily may help achieve this goal, but this choice does not address her abstinence from alcohol.