Peer Pressure

Instructions:

• Read the SOAP notes constructed by your course colleagues.
• Review the ‘P’s (Plans) posted by your peers from your Nurse Practitioner role perspective.  From your advanced practice mindset reflect on a discussion you would like to have with two of your course colleagues about their ‘P’(Plan). 
• Post a response individually to each of them that expresses your advanced practice nursing role perspective of their ‘P’.

Use scholarly resources relevant to your advanced practice nursing role to support the key elements of the peer discussions you construct. [For example – if you are a nurse practitioner did your peer develop a ‘P’ that aligns with EBP/CPG guidelines and/or the foundational basic sciences, etc.?

Please be sure to validate your opinions and ideas with citations and references in APA format. (short reply, at least 150 words each).

PEER RESPONSE #1

SOAP Note

Subjective:

CC: “I have to force myself to go to work and other than that I don’t want to leave my house.” 

A 32-year-old white female reports that last week she tried to go to a Pampered Chef party one of her coworkers was having and she only got about three blocks from her house and had to turn around and go back home. She admits that being anxious is not new for her but feels as though lately those feelings are negatively impacting her life. Her medical history is inclusive for a diagnosis of psoriasis. She is married and has a 4-year-old son. She is presently on no routine medications.  She takes an over-the-counter B-50 vitamin to help her manage stress associated with marital strife and childcare challenges secondary to her work schedule. Her last menstrual period was two weeks ago.

Objective: BP 100/58, P 66, R 18

Large raised silvery-white scaly patch noted posterior occipital region of scalp; no thyroid enlargement or tenderness with palpation; heart -regular rate and rhythm; lungs are clear to auscultation.

Assessment: Generalized Anxiety Disorder. The criteria to diagnose generalized anxiety disorder is excessive anxiety frequently occurring for at least 6 months or longer about different events impairing function (Arcangelo et al., 2017). Patient has been dealing with anxiety for a while now but lately is getting worse and impacting her life. She is anxious about several things like marital strife, childcare challenges, about leaving her house and has only been able to leave the house to go to work.

Plan

Therapeutics: Nonpharmacological therapies or CAM options are psychoeducation, counseling, meditation, behavioral or cognitive therapy, exercise, and techniques to manage stress (Arcangelo et al., 2017). The therapeutic regimen to place this patient on is an antidepressant. Antidepressants is first line treatment with patients with anxiety being SSRIs like Paxil, Zoloft, Celexa and Lexapro a good option since they improve symptoms of anxiety by inhibiting serotonin reuptake (Arcangelo et al., 2017). A good SSRI to start the patient with is Lexapro at 10mg daily which could eventually increase to a max dose of 20mg if medication is tolerated but ideal effect has not been achieved; Zoloft is great for patients with moderate to severe generalized anxiety disorder like our patient (Arcangelo et al., 2017).

Educational: Patient needs to understand her illness, what is expected with treatment regarding duration, follow-ups, time needed for pharmacological therapy to work and possible adverse effects (Arcangelo et al., 2017). Patient needs to understand that it can take a while for the medication to take effects 2-4 weeks and after 4-8 weeks patient needs to return for follow-up to assess effectiveness of medication (Arcangelo et al., 2017). Patient needs to know to report adverse effects of Zoloft like weight gain, insomnia, GI issues and agitation and an evaluation would be needed to see if patient needs to try another antidepressant (Arcangelo et al., 2017). Patient needs to know that she can’t stop the antidepressant or increase the dose without consulting first with her provider. Patient needs to be aware that the physical symptoms her anxiety causes like palpitations and muscle tension are not life threatening and provider should provide written instructions to patient will all the information so she can refer to it later (Arcangelo et al., 2017). It is pertinent to teach patient how to deal with her anxiety like getting help early, journaling (what causes her stress and what helps), proper management or time and energy and avoiding unhealthy substances (alcohol, caffeine, drugs, and nicotine can make anxiety worse) (Mayo Clinic, 2022).

Consultation/ Collaboration: Referring the patient to a psychologist is pertinent, this way she can get some counseling and help learn techniques to control her anxiety.

References

Arcangelo, V. P., Peterson, A. M., Wilbur, V., & Reinhold, J. A. (2017). Pharmacotherapeutics for advanced practice (4th ed.). Wolters Kluwer Health.

Mayo Clinic. (2022, October 13). Generalized anxiety disorder. Retrieved February 20, 2022, from https://www.mayoclinic.org/diseases-conditions/generalized-anxiety-disorder/symptoms-causes/syc-20360803

PEER RESPONSE #1

Subjective

  A 32-year-old white female comes to the office today with a chief complaint, “I have to force myself to go to work, and other than that I don’t want to leave my house.” She reports that last week she tried to go to a Pampered Chef party one of her coworkers was having and she only got about three blocks from her house and had to turn around and go back home. She admits that being anxious is not new for her but feels as though lately those feelings are negatively impacting her life. She is married and has a 4-year-old son. She is presently on no routine medications. She takes an over-the-counter B-50 vitamin to help her manage stress associated with marital strife and childcare challenges secondary to her work schedule. Her last menstrual period was two weeks ago.

Objective

  Her medical history is inclusive for a diagnosis of psoriasis. Her BP is 100/58, her pulse is 66, and her respirations are 18. A large raised silvery-white scaly patch is noted to the posterior occipital region of the scalp. There is no thyroid enlargement or tenderness with palpation. The heart rate has a regular rate and rhythm. The lungs are clear to auscultation.

Assessment

  Based on the patient’s avoidance of social situations such as work and the coworker’s party, she may be experiencing a generalized social anxiety disorder. The provider can use the DSM-5 Criteria for diagnosing social anxiety disorder (Arcangelo & Peterson, 2017). Some of the criteria for diagnosing include actively avoiding social situations or enduring the situation with intense fear or anxiety, the fear/anxiety/avoidance is persistent and typically lasting for at least 6 months, and causes clinically significant distress or impairment in social, occupational, or other important areas of functioning (Arcangelo & Peterson, 2017). The patient also has psoriasis. Patients with psoriasis commonly occurred anxiety, and this can exacerbate psoriasis and potentially impair treatment (Jing et al., 2021). She may experience anxiety unrelated to psoriasis, however, the skin condition could also cause her to feel embarrassed, causing poor self-esteem, and social anxiety (Jeremias, 2020).

Plan

Therapeutics

  For this patient, an SSRI such as paroxetine or sertraline, or the SNRI venlafaxine with or without cognitive behavioral therapy would be considered first-line therapy (Arcangelo & Peterson, 2017). Stress management, exercise, or meditation are additional interventions that can help treat her anxiety along with her drug therapy. Regular physical exercise can improve well-being, life satisfaction, and cognitive functioning, with positive effects on mood and anxiety (Zika & Becker, 2021). Monitoring for symptom improvement and compliance is important to assess effectiveness.

Education

  The patient should be aware of the amount of time it will take for the drug’s effect, and the drug’s effect will need to be monitored with possible dosage adjustments. The patient should know that a non-life-threatening discontinuation condition with flu-like symptoms may occur after the abrupt cessation of an SSRI (Arcangelo & Peterson, 2017). She should be educated on the adverse effects of SSRIs. Adverse effects include weight gain, insomnia, GI sequelae, and agitation, and paroxetine can cause more weight gain and sexual inhibition than the other drugs (Arcangelo & Peterson, 2017). She should know about the related sexual effects. The dose-related sexual effects such as decreased libido and anorgasmia are common and typically don’t resolve without intervention such as dosage reduction, and adding or switching an antidepressant such as bupropion, which is not associated with sexual dysfunction (Arcangelo & Peterson, 2017). Venlafaxine has similar side effects to the SSRIs except for a significant increase in blood pressure (Arcangelo & Peterson, 2017). The provider can provide instructions on relaxation exercises. Cognitive-behavioral therapy can involve the patient’s cognitive biases/thinking habits and teach the patient to develop new, more helpful thinking habits that will shift away from focusing on worry (Hirsch et al., 2019). The patient should understand that this will take time and repetition.

Consultation

  If there is no response to medication or relaxation therapy, the provider can refer the patient to a psychiatric specialist (Arcangelo & Peterson, 2017). The patient may need a referral to a dermatologist for further evaluation and treatment of her psoriasis.

References

Arcangelo, V. & Peterson, A. (2017). Pharmacotherapeutics for advanced practice: A practical approach. 4th Ed. Philadelphia: Wolters Kluwer

Hirsch, C. R., Beale, S., Grey, N., & Liness, S. (2019). Approaching Cognitive Behavior Therapy For Generalized Anxiety Disorder From A Cognitive Process Perspective. Frontiers in Psychiatry, 10. https://doi.org/10.3389/fpsyt.2019.00796

Jeremias, S. (2020). Certain Personality Traits in Patients With Psoriasis May Explain Social Anxiety. AJMC. https://www.ajmc.com/view/certain-personality-traits-in-patients-with-psoriasis-may-explain-social-anxiety

Jing, D., Xiao, H., Shen, M., Chen, X., Han, X., Kuang, Y., Zhu, W., & Xiao, Y. (2021). Association of Psoriasis With Anxiety and Depression: A Case–Control Study in Chinese Patients. Frontiers in Medicine, 8. https://doi.org/10.3389/fmed.2021.771645

Zika, M. A., & Becker, L. (2021). Physical Activity as a Treatment for Social Anxiety in Clinical and Non-clinical Populations: A Systematic Review and Three Meta-Analyses for Different Study Designs. Frontiers in Human Neuroscience, 15. https://doi.org/10.3389/fnhum.2021.653108