Full Practice Authority (FPA) Assignment

Management of a 56 Year-Old Hispanic Male with Schizophrenia by a Psychiatric-Mental Health Nurse Practitioner (PMHNP) with Full Practice Authority (FPA)

In the latest (fifth edition) of the Diagnostic and Statistical Manual of Mental Disorders or DSM-5, the psychiatric disorder known as schizophrenia is placed in a diagnostic category referred to as ‘Schizophrenia Spectrum and Other Psychotic Disorders’ (APA, 2013). Increasingly, empirical evidence has continued to suggest that schizophrenia is actually not a single homogeneous condition but a group of interrelated mental disease states presenting as one. The condition itself has been shown to be caused by a multiplicity of factors that include genetic and environmental components. Moreover, its etiology also has an organic component as seen on imaging studies, such as a smaller than usual hippocampus in the brain. The diagnosis of schizophrenia is exclusively arrived at only through a proper history and mental status examination. Additionally, the symptoms must satisfy the criteria in the DSM-5 for a diagnosis of schizophrenia to be made (Sadock et al., 2015). In states that give PMHNPs full practice authority, the PMHNP is solely and independently responsible for the assessment, diagnosis, treatment, and follow up of such patients with schizophrenia. The PMHNP is thus the ‘Captain of the ship’ in the management of the condition. She is the team leader in the patient management team that includes the PMHNP, the therapist, the pharmacist, and the social worker. This paper looks at how a PMHNP with FPA typically manages a 56 year-old Hispanic male with schizophrenia.

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History of Presenting Illness and Clinical Impression

This 56 year-old Hispanic client (who shall thereafter be referred to as patient RR) was brought by his daughter in the PMHNP’s consultation office with complaints of bizarre behavior, withdrawal, and hallucinations. In the last six months patient RR had been having episodes in which he would talk to himself and gesture to no one in particular. He would also smile or laugh loudly when alone, but also at times withdraw himself completely and refuse to talk or eat. Recently, these symptoms had become worse and he started to accuse his two daughters of plotting to kill him because he is no longer strong enough to work. At night, he sometimes screams from his room that there are insects that are eating his toes. On examination, patient RR is disheveled and bearded. He displays flat affect and does not make eye contact or answer any questions. Occasionally, he mumbles incomprehensibly to himself as though the PMHNP and the daughter who brought him are not there. He lives with his daughter after he became homeless a year ago upon losing his job. Patient RR has no obvious physical illness and history of substance abuse is negative. In line with the DSM-5 criteria for schizophrenia, a clinical impression of schizophrenia is made (APA, 2013; Sadock et al., 2015). Full Practice Authority (FPA) Assignment

Psychopharmacologic Recommendations

Management of schizophrenia has been shown to be effective when medication is combined with psychosocial therapies (Sadock et al., 2015). Medication for schizophrenia that the PMHNP can prescribe for this client include either first-generation antipsychotics or second-generation antipsychotics. For instance, he can be given the second-generation drug olanzapine (Zyprexa) 20 mg orally daily or the first generation antipsychotic chlorpromazine 400 mg orally daily (Stahl, 2017; Katzung, 2018). Either of these would be prescribed for one month at first before reviewing the client again. To manage serious Parkinson-like (extrapyramidal) side effects, the chlorpromazine is prescribed together with the benzodiazepine lorazepam (Sadock et al., 2015; Katzung, 2018; Stahl, 2017). If the symptoms were severe and incapacitating, patient RR would have been given the olanzapine as an injection for immediate effect. However, since he is not violent, the PMHNP can just prescribe the oral formulation of the medications. The specific therapeutic endpoints for both the first generation and second-generation antipsychotics are that remission is achieved beginning after the first month of continuous therapy. For the chlorpromazine, however, residual troubling side effects are expected.

Psychotherapeutic Recommendations

Patient RR will need psychosocial therapy to complement the pharmacologic treatment described above. As stated earlier, evidence suggests that a combination of psychotherapy and psychopharmacology is most effective in managing schizophrenia. This client will, therefore, need behavioral skills therapy or cognitive-behavioral therapy (CBT) sessions with the therapist. This will be twice weekly for the next twelve weeks. This will assist him to cope socially and manage practical tasks that help him be self-reliant. He may also benefit from dialectical behavior therapy (DBT) which helps in restoring interpersonal skills (Sadock et al., 2015; Corey, 2013). The family will also need therapy which will be in the form of intensive psychoeducation. This will be daily for a period of two weeks. This way the family is prepared to cope with their relative’s illness and help him comply with therapy and medication (Corey, 2013). The client can also be enrolled in group psychotherapy in which he will benefit from group therapeutic factors like catharsis (Corey, 2013). Full Practice Authority (FPA) Assignment

Medical Management Needs and Community Support Resources

This client and his family will also need medical management and community support. Because the antipsychotic medications impact on the metabolism of insulin, it is crucial that this client’s blood sugar levels, body mass index, and lipid profile be monitored for at least six months. This way, abnormalities brought by the medications can be identified and dealt with early (Sadock et al., 2015). Also, the community support services that this client and his family will need may come from not-for-profit organizations and religious organizations. This may help him with food, housing, and counseling. This is because the client no longer has employment. This client will also benefit from agencies like the Schizophrenia and Related Disorders Alliance of America (SARDAA) for coping resources.

References

American Psychiatric Association [APA] (2013). Diagnostic and Statistical Manual of Mental Disorders (DSM-5), 5^th ed. Arlington, VA: Author.

Corey, G. (2013). Theory and practice of counseling and psychotherapy, 9th ed. Belmont, CA: Cengage Learning.

Katzung, B.G. (Ed) (2018). Basic and clinical pharmacology, 14^th ed. New York, NY: McGraw-Hill Education.

Sadock, B.J., Sadock,V.A., & Ruiz, P. (2015). Synopsis of psychiatry: Behavioral sciences/ clinical psychiatry, 11th ed. New York, NY: Wolters Kluwer.

Stahl, S.M. (2017). Stahl’s essential psychopharmacology: Prescriber’s guide, 6th ed. New York, NY: Cambridge University Press.Full Practice Authority (FPA) Assignment