Posted: July 17th, 2022

Assignment: Assessing and Treating Clients with Psychosis and Schizophrenia

Assignment: Assessing and Treating Clients with Psychosis and Schizophrenia
Psychosis and schizophrenia greatly impact the brain’s normal processes, which interferes with the ability to think clearly. When symptoms of these disorders are uncontrolled, clients may struggle to function in daily life. However, clients often thrive when properly diagnosed and treated under the close supervision of a psychiatric mental health practitioner. For this Assignment, as you examine the client case study in this week’s Learning Resources, consider how you might assess and treat clients presenting with psychosis and schizophrenia.
Learning Objectives
Students will:
• Assess client factors and history to develop personalized plans of antipsychotic therapy for clients
• Analyze factors that influence pharmacokinetic and pharmacodynamic processes in clients requiring antipsychotic therapy
• Evaluate efficacy of treatment plans
• Analyze ethical and legal implications related to prescribing antipsychotic therapy to clients across the lifespan

To prepare for this Assignment:
• Review this week’s Learning Resources. Consider how to assess and treat clients requiring anxiolytic therapy.
The Assignment
Examine Case Study: Pakistani Woman with Delusional Thought Processes. You will be asked to make three decisions concerning the medication to prescribe to this client. Be sure to consider factors that might impact the client’s pharmacokinetic and pharmacodynamic processes.
At each decision point stop to complete the following:
• Decision #1
o Which decision did you select?
o Why did you select this decision? Support your response with evidence and references to the Learning Resources.
o What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
o Explain any difference between what you expected to achieve with Decision #1 and the results of the decision. Why were they different?
• Decision #2
o Why did you select this decision? Support your response with evidence and references to the Learning Resources.
o What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
o Explain any difference between what you expected to achieve with Decision #2 and the results of the decision. Why were they different?
• Decision #3
o Why did you select this decision? Support your response with evidence and references to the Learning Resources.
o What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
o Explain any difference between what you expected to achieve with Decision #3 and the results of the decision. Why were they different?
Also include how ethical considerations might impact your treatment plan and communication with clients.

Delusional Disorders
Pakistani Female With Delusional Thought Processes

BACKGROUND
The client is a 34-year-old Pakistani female who moved to the United States in her late teens/early 20s. She is currently in an “arranged” marriage (her husband was selected for her since she was 9 years old). She presents to your office today following a 21-day hospitalization for what was diagnosed as “brief psychotic disorder.” She was given this diagnosis as her symptoms have persisted for less than 1 month.
Prior to admission, she was reporting visions of Allah, and over the course of a week, she believed that she was the prophet Mohammad. She believed that she would deliver the world from sin. Her husband became concerned about her behavior to the point that he was afraid of leaving their 4 children with her. One evening, she was “out of control” which resulted in his calling the police and her subsequent admission to an inpatient psych unit.
During today’s assessment, she appears quite calm, and insists that the entire incident was “blown out of proportion.” She denies that she believed herself to be the prophet Mohammad and states that her husband was just out to get her because he never loved her and wanted an “American wife” instead of her. She tells you that she knows this because the television is telling her so.
She currently weighs 140 lbs, and is 5’ 5”
SUBJECTIVE
Client reports that her mood is “good.” She denies auditory/visual hallucinations but believes that the television does talk to her. She believes that Allah sends her messages through the TV. At times throughout the clinical interview, she becomes hostile towards the PMHNP, but then calms down.
You reviewed her hospital records and find that she has been medically worked up by a physician who reported her to be in overall good health. Lab studies were all within normal limits.
Client admits that she stopped taking her Risperdal about a week after she got out of the hospital because she thinks her husband is going to poison her so that he can marry an American woman.

MENTAL STATUS EXAM
The client is alert, oriented to person, place, time, and event. She is dressed appropriately for the weather and time of year. She demonstrates no noteworthy mannerisms, gestures, or tics. Her speech is slow and at times, interrupted by periods of silence. Self-reported mood is euthymic. Affect constricted. Although the write my essay client denies visual or auditory hallucinations, she appears to be “listening” to something. Delusional and paranoid thought processes as described, above. Insight and judgment are impaired. She is currently denying suicidal or homicidal ideation.
The PMHNP administers the PANSS which reveals the following scores:
-40 for the positive symptoms scale
-20 for the negative symptom scale
-60 for general psychopathology scale
Diagnosis: Schizophrenia, paranoid type

RESOURCES
§ Kay, S. R., Fiszbein, A., & Opler, L. A. (1987). The Positive and Negative Syndrome Scale (PANSS) for schizophrenia. Schizophrenia Bulletin, 13(2), 261-276.
§ Clozapine REMS. (2015). Clozapine REMS: The single shared system for clozapine. Retrieved from https://www.clozapinerems.com/CpmgClozapineUI/rems/pdf/resources/Clozapine_REMS_A_Guide_for_Healthcare_Providers.pdf
§ Paz, Z., Nalls, M. & Ziv, E. (2011). The genetics of benign neutropenia. Israel Medical Association Journal. 13. 625-629.

Decision Point One
Select what the PMHNP should do:

Start Zyprexa 10 mg orally at BEDTIME Click to see options it will take you to decision point two and three

Start Invega Sustenna 234 mg intramuscular X1 followed by 156 mg intramuscular on day 4 and monthly thereafter Click to see options it will take you to decision point two and three

Start Abilify 10 mg orally at BEDTIME Click to see options it will take you to decision point two and three

All references require creditable sources, nothing less than 5 years. References require doi or http. Please add conclusion.
Tips:
– Always use the choices given
– Continuation of psych meds may be needed before switching as they take time.

Provided two different examples not to be used word for word. Thank you

EXAMPLE ONE NOT TO BE USED WORD FOR WORD.

Decision Point One
Start Zyprexa (olanzapine) 10 mg po orally at BEDTIME
RESULTS OF DECISION POINT ONE
• Client returns to clinic in four weeks
• Client’s PANSS decreases to a partial response (25%)
• Client comes in today with a reported weight gain of 5 pounds. When questioned further on this point, she states that she can never seem to get full of her meals, so she is snacking constantly throughout the day.
Decision Point Two
Decrease Zyprexa to 7.5 mg BEDTIME
RESULTS OF DECISION POINT TWO
• Client returns to clinic in four weeks
• Patient worsens. Her PANNS increases by 10% (negative symptoms are getting worse) but weight becomes stabilized and excessive hunger abates
• Husband explains that she is becoming less manageable at home and he is having to take time off from work because he is fearful of leaving her alone
Decision Point Three
Increase Zyprexa 10 MG orally at BEDTIME
Guidance to Student
Weight gain is a significant problem with Zyprexa. Next to Clozaril (clozapine), Zyprexa causes the most weight gain of all the atypical antipsychotics. This is a side effect that a significant number of clients will experience. There also appears to be an increased association of newly diagnosed diabetes mellitus in clients treated with Zyprexa. Although this can be disease related in this population, Zyprexa is above what would be considered coincidental. Risperdal is a good option, although it is dosed twice daily and compliance in this population can be problematic. There is evidence that shows giving Risperdal all at once can be efficacious and therefore could be an option down the road should compliance become an issue. Weight gain is also possible with Risperdal, but it is not as great as that seen with Zyprexa. If compliance does become an issue with this client, Risperdal has a long-acting injectable formulation, Risperdal Consta, that could be used. Remember, Risperdal Consta has to be given every 2 weeks at the provider’s office, and therapeutic blood levels take time to achieve (on average 3–6 weeks or 2–3 injections). Oral overlapping therapy is required to bridge this period of time. Another option in someone who responds to
Risperdal would be Invega Sustenna (paliperidone palmitate), which is the first metabolite of Risperdal and has greater activity at the D2 receptor than Risperdal. An advantage of Invega Sustenna over Risperdal Consta is that therapeutic blood levels are attained within the first 4–7 days, and overlapping oral therapy is usually not necessary. A disadvantage is that during the initiating phase of medication, the first two doses need to be given within 4–7 days of one another. This is followed by monthly injections. There is another product on the market called Invega Trinza, which is given once every 3 months. This product is for clients who have been stabilized on Invega Sustenna for at least 4 months where the last two doses were the same strength (two months of 156 mg injections).
Increasing Zyprexa to 15 mg at bedtime will only worsen the weight gain side effect. While additional benefits from increasing the dose may be possible from an efficacy standpoint, side effects always need to be taken into consideration. “First, do no harm.” Qsymia is a weight loss medication that is a combination of phentermine and topiramate. It is only indicated to treat obesity. This client’s BMI (28.9 kg/M2) does not fit the definition of obesity (BMI >30 Kg/M2- Following from CDC website: Class 1: BMI of 30 to < 35, Class 2: BMI of 35 to < 40, Class 3: BMI of 40 or higher. Class 3 obesity is sometimes categorized as “extreme” or “severe” obesity). There are two things wrong with this therapy option. First, there are only a few occasions where add-on therapy to treat a side effect is acceptable, and weight gain is not one of those scenarios. Secondly, phentermine has a lot of cardiovascular toxicities (such as elevated BP, HR, and increased workload on the heart).

EXAMPLE TWO NOT TO BE USED WORD FOR WORD.

Introduction

Schizophrenia is a severe mental syndrome with complex symptoms that occur differently in different patients. Schizophrenia occurs as early as in teenage years and is more prevalent in males than females possibly due to higher levels of prenatal estrogens in female patients (Paipa at al., n.d.). Schizophrenia is characterized by positive, negative and cognitive and affective symptoms. The positive traits of this disease are new features which do not have a normal occurring counterpart such as delusions, hallucinations, catatonic behavior, and disorganized speech or behavior. Negative symptoms are a reduction of natural processes such as; apathy, flat affect, alogia, avolition. Cognitive symptoms of schizophrenia include memory and learning deficits; meanwhile, affective symptoms include depression and anxiety which can increase the likelihood of suicidality in patients with schizophrenia (Stahl, 2013).
Although the cause of schizophrenia is unknown, research has linked this disease with an increase in dopamine as well as a combination of genetic and environmental factors. According to the DSM-5 manual (2013), a diagnosis of schizophrenia has to include two positive symptoms or negative symptoms. And at least one of them has to be delusions, hallucinations disorganized speech. Also, the signs have to have been going on for at least six months, and the patient needs to have had active symptoms of the disease for a month. A variety of typical and atypical antipsychotics are utilized as treatment modalities for schizophrenia, and although they can be useful, there are additional considerations such as medication cost and adverse reactions. Treatment of this disease can be challenging and requires a combined effort from various disciplines in the medical field.

Case Study

The client is a 34-year-old Pakistani female who moved to the United States in her late teens/ early 20s. She is currently in an “arranged” marriage (her husband was selected for her since she was 9 years old). She presents to the PMHNP today after a 21-day hospitalization for a diagnosis of “brief psychotic disorder.” She was given this diagnosis as her symptoms have persisted for less than one month. Before admission, the patient was reporting visions of Allah, and over a week, she believed that she was the prophet, Mohammad. Her husband became concerned about her behavior to the point that he was afraid of leaving their four children with her. One evening, she was “out of control” which resulted in his calling the police and her subsequent admission to an inpatient psych unit. During today’s assessment, she appears quite calm, and insists that the entire incident was “blown out of proportion.” She denies that she believed herself to be the prophet Mohammad and states that her husband was just out to get her because he never loved her and wanted an “American wife” instead of her. She tells you that she knows this because the television is telling her so. She currently weighs 140 lbs. and is 5’ 5.”
The patient reports that her mood is “good.” She denies auditory/visual hallucinations but believes that the television does talk to her. She thinks that Allah sends her messages through the TV. At times throughout the clinical interview, she becomes hostile towards the PMHNP but then calms down. The patient had a medical workup while at the hospital and the physician reported her to be in overall good health. Lab studies were all within normal limits. The patient also admits that she stopped taking her Risperdal about a week after she got out of the hospital because she thinks her husband is going to poison her so that he can marry an American woman. The client is alert, oriented to person, place, time, and event. She is dressed appropriately for the weather and time of year. She demonstrates no noteworthy mannerisms, gestures, or tics. Her speech is slow and at times, interrupted by periods of silence. The self-reported mood is euthymic. Affect constricted. Although the client denies visual or auditory hallucinations, she appears to be “listening” to something — delusional and paranoid thought processes as described, above. Insight and judgment are impaired. She currently denies suicidal or homicidal ideation. The PMHNP administers the PANSS which reveals the following scores: -40 for the positive symptoms scale, -20 for the negative symptom scale and -60 for general psychopathology scale. The patient is diagnosed with schizophrenia, paranoid type. The purpose of this paper is to choose and evaluate therapy decisions at three different levels regarding the treatment of this patient’s schizophrenic symptoms. Also, the essay will include ethical considerations that can impact the suggested treatment plan as well as communication with the patient.
Decision 1

To begin treatment, the PMHNP can start the patient on Zyprexa 10mg PO at bedtime, Invega Sustenna 234mg IM X1 followed by 156mg on day 4 and monthly after that or start Abilify 10mg PO at night. The PMHNP selects the option to start Invega Sustenna 234mg IM X1 followed by 156mg on day 4 and monthly after that. Invega binds more potently to the 5HT2A receptor than to the D2 receptor thus having less extrapyramidal symptoms (EPS) as evidenced in first-generation antipsychotics (Dieter & Martin, 2009). Also, the patient admitted to being noncompliant with the previous oral medication; thus, an intramuscular administration will ensure that she obtains the medicine she needs. Although Zyprexa is similar to Clozapine in action as utilized in the treatment of schizophrenia, this medication will not be the first choice for this remarkably paranoid and self-conscious patient because Zyprexa can cause significant weight to gain possibly due to its antihistaminic and 5HT2C antagonist properties as well as a risk for diabetes mellitus (Stahl, 2014).
Abilify 10mg PO would not be the first choice for this patient because she is not compliant with taking her medications orally, and although Abilify is shown to be a “just right” drug on the dopamine antagonism scale, it can cause impulsive behavior and increase drowsiness during the day time (Casey & Canal, 2017). The goal of treatment is to attain a 50% improvement and eliminate a majority of the patient’s negative symptoms as well as normalize her positive schizophrenic symptoms. The patient returns to the clinic in four weeks with a 25% decrease in her PANSS score. She seems to be tolerating the medication and her husband has made sure she makes her appointments for injections (one thus far). Also, the patient has noted a 2-pound weight gain, but it does not seem to be an essential point for her, but she complains of injection site pain telling the PMHNP that she has trouble sitting for a few hours after the injections and doesn’t like having to walk around for such a long period of time. The outcome is as expected as the patient appears to be responding positively to the medication and injections site pain is a common complaint with this type of drug administration.
Decision 2

In the next phase of care, the PMHNP is presented with the option to continue the same decision but instruct the nurse to begin the injection in the deltoid site at this visit and moving forward. The second option is to discontinue the Invega Sustenna and start Haldol Decanoate 50mg IM every two weeks with PO Haldol 5mg BID for the next three months or continue the Invega Sustenna but in the deltoid and add on Abilify Maintena 300mg IM monthly with oral Abilify 10mg QAM for two weeks. The PMHNP decides to keep the same decision but instruct the nurse to begin the injection in the deltoid site at this visit and moving forward. Paliperidone injection has shown less occurrence of disease relapse related to medication noncompliance and research shows that injection site pain is one of the most common side effects observed in the control group for paliperidone injection (as cited in Morris & Tarpada, 2017). Thus, changing the injection write my paper site will be a suitable action for this patient. Switching the patient to Haldol is not recommended because Haldol has been shown to cause Tardive dyskinesia (e.g., tongue protrusions and lips smacking) from upregulation of D2 receptors which can be permanent in some patients (Stahl, 2013). Plus, it is always a good clinical practice to begin a patient on PO Haldol and evaluate its effectiveness and tolerability before initiating a long-term therapy in injection form.
Similarly, it is not advisable to begin the patient on intramuscular Abilify without first trying the patient on a PO version to monitor efficacy and side effects. And, the literature recommends not to use two IM medications at the same time as proposed in option three, but rather titrate to maintain one or the other (Stahl, 2013). The goal of treatment at this time is for the patient to obtain at least a 60% improvement with a significant decrease in negative symptoms and normalization of positive/cognitive symptoms within the next month. The patient returns to the clinic in four weeks, and her PANNS score has reduced by a total of 50% from the initiation of Invega Sustenna. She states the injection is much better in the arm, but she is somewhat bothered by the weight gain and is afraid that her husband does not like it and wonders if there is another drug like Invega that would not cause the weight gain. The results are as expected because the efficacy of the Invega is usually seen roughly eight days following injection, with peak plasma level is reached approximately 13 days after the dose and some weight gain is evidenced in the utilization of this drug (Morris & Tarpada, 2017).
Decision 3

Based on the results from the previous visit, the PMHNP can continue the patient on Invega Sustenna and counsel patient on the fact that weight gain from Invega Sustenna is not as much as what other drugs with similar efficacy can cause. Still, make an appointment with the dietician and exercise physiologist and follow up in 1 month. The second option will be to discontinue the Invega Sustenna and start Abilify Maintenna 400mg IM monthly (after a few test doses of PO Abilify have been tried and tolerated) with overlapping oral Abilify 10mg PO in the morning. The third option will be to continue Invega Sustenna and add-on Qsymia for weight loss. The PMHNP chooses the first option and makes an appointment with the dietician and exercise physiologist with follow up in 1 month. It is vital to validate the patient’s concerns with weight gain but counsel her on the fact that moderate weight gain can occur with this medication (Stahl, 2013), but proper nutrition and exercise can tackle this issue. Recommending a consultation with a dietician and exercise trainer is an excellent way to support the patient combat her concerns before switching to another agent especially since the medication is showing efficacy. Although Abilify is approved for treatment of patients with schizophrenia, it is not advisable to discontinue the patient Abilify does not bind to the D2 receptor for a considerable period (such as Invega) and can be less effective in certain individuals (Stahl, 2013). Also, as previously mentioned, akathisia, mild agitation and difficulty sleeping can be possible side effects of this Abilify. Qsymia is a medication utilized primarily for weight loss in combination with other medicines such as Topiramate (Sweeting, Tabet, Caterson & Markovic, 2014). This patient’s BMI is at 28.9 kg/M2 and does not fit the definition of obesity (BMI >30 Kg/M2) as stated in the literature (Dains, Baumann & Scheibel, 2016).
Moreover, weight gain is not an acceptable adverse effect that requires the need for add-on therapy. The goal of treatment is for the patient to obtain an 80% improvement with more than a significant decrease in negative symptoms and normalization of positive/cognitive symptoms within the next month. The outcome is as expected since the patient appears to be improving on the medication despite common side effects. As part of her goal, the patient should be able to maintain a healthy weight with adequate diet and exercise while maintaining compliance with the Invega Injection. The PMHNP will continue to monitor the patient monthly or as required based on the efficacy and tolerability of treatment recommendations.

Conclusion with Ethical considerations

Schizophrenia is a severe mental health diagnosis characterized by positive, negative and cognitive and affective symptoms. Positive traits of disease are symptoms such as delusions, negative symptoms can alogia or avolition, cognitive symptoms can include memory and learning deficits; meanwhile, affective symptoms include depression (Stahl, 2013). The cause of schizophrenia is unknown, but studies have shown a correlation of this disease with high levels of dopamine as well as a combination of environmental/genetic influences. Schizophrenia can be challenging to treat, but several typical and atypical antipsychotics are utilized as treatment modalities this disease.
An ethical consideration when treating patients with schizophrenia is to initiate treatment early on when patients appear to be in the prodromal phase of the disease such that one targets symptoms faster and prevents delay in care. Targeting possible symptoms of schizophrenia could present as a dilemma if the patient or family is unwilling to agree to early treatment if they believe the patient is not “sick yet.” In cases as such, open, honest and informative communication required to enable understanding of the course of the disease and how a delay in care can result in significant detrimental effects. Also, it is vital for the PMHNP to provide educational materials, resources and routinely follow up with the patient to evaluate the outcomes of treatment and promote quality management of the patients’ symptoms.

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– free essay sample
Psychopharmacologic Approaches to Treatment of Psychopathology

Student’s Name
Institutional Affiliation
Course
Professor’s Name
Date

Psychopharmacologic Approaches to Treatment of Psychopathology
Introduction
Paranoid schizophrenia is a common trigger for significant symptoms, including delusions and hallucinations. The symptoms are evident in the case study and they require immediate treatment. The best medication is Invega Sustenna 234mg IM XI, followed by 156mg after four days and monthly injections due past non-compliance issues. Previously, the patient stopped taking the drug due to the fear her husband would poison her. During the decision-making process, educating a patient about the medication and the side effects is essential (Hirjak et al., 2016). Ethical considerations also promote the level of compliance, which boosts the rate of recovery. Patients with paranoid schizophrenia should seek immediate treatment to avoid deterioration of symptoms, which can undermine the quality of life.
Decision #1
The first decision is to introduce Invega Sustenna 234mg IM XI, 156mg after four days and monthly injections. Some of the reasons for selecting the drug is due to the previous non-compliance with oral drugs and the fear that the husband wants to poison her. It is also an approved and effective drug for the treatment of paranoid schizophrenia (Hirjak et al., 2016). According to the assessment, the patient is exhibiting various symptoms such as paranoid delusions and hallucinations. For example, she believes that the husband wants to kill her to marry another woman. Invega Sustenna is effective in the treatment of paranoid schizophrenia by rebalancing dopamine and serotonin thus improving mood, thinking, and behavior (Stahl, 2013). The drug is effective for the current patient since she is experiencing various issues, including aggressive behavior.
The decision also involved discarding other options, including Zyprexa 10mg and Abilify 10mg. One of the major reasons for not selecting Zyprexa and Abilify is due to the severity of the side effects (Al-Sayed & Soliman, 2019). The two drugs trigger adverse side effects that can undermine the quality of life of a patient. Therefore, Invega Sustenna will be effective in addressing the symptoms of paranoid schizophrenia (Kotler et al., 2016). The patient should have a monthly injection during each clinic visit. She should avoid taking alcohol or other substances that can interfere with the drug.
A clinician should educate the patient on the need to come for the injection every month to promote recovery. According to the case study, the patient was previously taking Risperdal but stopped due to fear that her husband wants to poison her. The first decision is thus considerate of the fear which can lead to non-compliance causing slow recovery (Gerasimou et al., 2018). The clinician should also highlight weight gain, as one of the expected side effects of the medication. (Gerasimou et al., 2018). However, PMHNP should highlight that Invega Sustenna.is one of the safest drugs since others such as Abilify cause severe side effects such as weight gain.
The expectation of making decision #1 is to relieve symptoms such as aggression, hallucinations, and paranoid delusions. For example, the patient should report back to the clinic with a positive mind that the husband is not targeting to kill her. I also expect that the patient will not be aggressive during treatment on her second visit to the clinic. Another expectation is that the hallucinations will subside significantly (Choy et al., 2016). For instance, the patient should stop indicating that Prophet Allah is speaking to her, or she is a prophet with a message to the nations. I also expect minimal side effects of the drug on the patient.
Additionally, I expect that her husband will note an improvement in the changes. For example, the husband should develop the trust of leaving their children with the wife. Another expectation is to improve judgment and mood (Gerasimou et al., 2018). I also expect the patient will exhibit an improved quality of speech without unnecessary silence since Invega Sustenna is effective in addressing paranoid schizophrenia symptoms (Choy, 2016). The symptoms should improve since Invega Sustenna helps in balancing brain chemicals, thus improving mood and behavior. I, however, expect one side effect which is weight gain.
The patient returns to the clinic since the initial treatment and after the second injection on the fourth day. According to the assessment, the patient has a 25 percent reduction in the PANSS score. The patient reports she has gained some weight and that the injection site is painful. Notably, it is essential to educate the patient about the need to eat healthy while taking the medication (Stahl, 2013). One of the differences between the expectations and outcomes is the period of treatment. Research shows that Invega Sustenna should take several weeks to generate expected outcomes (Noordsy, 2016). Therefore, after several weeks of treatment, the patient should have full recovery.
Decision #2
The second decision is to continue with the current medication since it is already generating expected results but change the injection site to the deltoid. It is not prudent to change the medication since the patient is already recovering with minimal side effects. Changing the drug is not a suitable decision since antipsychotic drugs can take several weeks before the realization of the full effect. It can also trigger adverse side effects, which can undermine the recovery of a patient (Hirjak et al., 2016).
Invega Sustenna is effective in decreasing negative symptoms, improving cognitive functions without increasing the chances of relapse (Noordsy, 2016). The drug is also effective in treating symptoms such as delusions, hallucinations, agitation, anxiety, and mood disorders. Currently, the patient reports an increase in weight within the four weeks of administration. Therefore, the patient may require to see a dietician or physiologist to know how to manage the weight (Hirjak et al., 2016). The response is effective since the patient states she feels extra weight will make her less favorable to her husband.
My expectation while prescribing a lower dosage of medication is to improve patient outcomes. For example, I expect the patient to report after four weeks with minimal delusions, agitation, anxiety, hallucinations, and mood disorder. Invega Sustenna is an effective medication in the treatment of paranoid schizophrenia. The FDA approved Invega Sustenna for the treatment of paranoid schizophrenia (Stahl, 2013). PMHNP has used the drug for years to treat a patient with various psychotic symptoms successfully. The drug is also effective for both adults and children.
I look forward to a patient who will not think the husband wants to terminate her life to marry another wife. I also expect that in the next clinic appointment, the patient will not express agitation compared to the first clinic. The patient should also speak clearly in the next visit since she is currently speaking slowly with episodes of silence (Al-Sayed & Soliman, 2019). Another expectation is that the patient will record significant improvement in the PANSS rating scale (Hirjak et al., 2016). Currently, she has recorded a 25 percent improvement, but I expect further improvement.
The patient reports back to the clinic after four weeks. The outcomes indicate the patient has significant improvement compared to the first visit. For example, the PANSS score shows the symptoms have improved by 60 percent. The husband explains that the wife is getting better since he does not need to take time off his work to stay with her. He narrates that he is not worried about leaving the wife alone with children. However, the assessment shows the patient’s weight has stabilized, and the excess hunger has abated after meeting with a dietician and nutritionist.
There is a significant similarity between the outcome and the expected results. However, one of the objectives of decision#2 was minimizing the symptoms and controlling the weight gain. The patient recorded an improvement in symptoms such as agitation, delusions, hallucination, anxiety, and quality of speech (Choy et al., 2016).
Decision #3
The third decision involves continuing with Invega Sustenna. The injection is one of the antipsychotic drugs that cause less weight gain compared to other drugs (Gerasimou et al., 2018). Therefore, it is important to prioritize the treatment of major symptoms such as delusions, hallucinations, agitation, anxiety, and quality of speech.
The treatment of paranoid schizophrenia has other options, including Risperdal. One of the risks of Risperdal is that it is administered twice a day, which may be hard due to past non-compliance issues. Patients with mental issues experience a problem of consistently taking the medication (Gerasimou et al., 2018). It is thus safe to continue with Invega Sustenna since it helps overcome non-compliance issues.
The patient had requested medication to address her weight issues. PMHNP is required to subscribe to the ethical health code of conduct of ‘do no harm’ (Choy et al., 2016). It is not advisable to introduce other drugs which can cause adverse effects. The side effects can undermine the quality of life of a patient. For example, it is not advisable to prescribe medication such as Qsymia to counter weight gain (Choy et al., 2016). The reason is that the medication is only effective in treating obesity. However, the patient has no obesity cases despite the high BMI score. According to Choy et al. (2016), Qsymia also contains phentermine, which can trigger cardiovascular toxicities.
The expectation while prescribing the medication is that the patient will record a better PANSS score. Prescription of Invega Sustenna demonstrates a reduction in delusions, anxiety, hallucination, mood disorders, and agitation (Noordsy, 2016). For example, I expect the patient to express the hope that her marriage will stand, and no one is planning to terminate her life. Prescribing Invega Sustenna is an effective decision in the treatment of psychotic issues (Noordsy, 2016). The medication is effective in balancing the brain chemicals in the brain. Effective coordination of brain chemicals promotes positive behavior and improved mood.
The patient reports back to the clinic after four weeks. One of the results is that the patient has over 80 percent score on the PANSS scale. According to the husband, the spouse is at peace without any agitation. She also has no cases of delusion, such as thinking a divine voice is speaking to her. During the assessment, she is not agitated and is focused without any indication she is listening to a strange voice. The patient also does not indicate any longer that her husband intends to terminate her life. The patient has, however, gained weight.
The outcomes are similar to the expectations since it shows the patient has positive significant progress. According to the assessment, the patient is almost back to normal life. She is watching television without any hallucinations and no fear about her marriage or life.
Ethical Issues in Treatment
Patients with psychotic problems should be educated about the side effects of a drug. Educating the patient helps them to make the right decision about treatment. For example, the law provides an option for a patient to decline treatment (Choy et al., 2016). Educating the patient also increases the rate of compliance. Another ethical issue is treating the patient fairly with human dignity despite their agitation. PMHNP should always treat their patient with love and patience despite their behavior during treatment. Patients should also enjoy privacy and confidentiality (Stahl, 2013). All the information shared by the patient should remain confidential. Clinicians should assure the patients that their information will be protected.
Clinicians should explain clearly to the husband or any other family member on the need for treatment. Some family members or patients may be opposed to beginning treatment. PMHNP should provide open, honest, and informative communication about the condition and the risks to a patient (Al-Sayed & Soliman, 2019). The decisions of a clinician should also be focused on improving the quality of care (Gerasimou et al., 2018). For example, it is essential to begin treatment early to avoid deterioration of symptoms. Ethical considerations improve the quality of treatment and prevent lawsuits due to unethical behavior.
Conclusion
Treatment of paranoid schizophrenia is a process that requires a series of decisions. One of the risks during decision making is to balance treatment and side effects. Invega Sustenna has a common side effect of adding weight, yet it is an effective medication. In the three decisions, it is essential to educate a patient about the side effects and engage a dietician for consultation. Promoting open and honest communication will increase the rate of compliance and speed of recovery.

References
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