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MENTAL STATUS EXAM The client is a 53 year o

MENTAL STATUS EXAM The client is a 53 year old Puerto Rican female who is alert, oriented to person, place, time, and event. She is dressed appropriately for the weather and time of year. Her speech is clear, coherent, and goal directed. Her eye contact is somewhat avoidant during the clinical interview. As you make eye contact with her, she looks away or looks down. She demonstrates no noteworthy mannerisms, gestures, or tics. Her self-reported mood is sad. Affect is appropriate to content of conversation & self-reported mood. She visual or auditory hallucinations, no delusional or paranoid thought processes are readily appreciated. Insight and judgment are grossly intact, however, impulse control is impaired. She is currently denying suicidal or homicidal ideation. Diagnosis: Gambling disorder, alcohol use disorder Decision Point One: Select what the PMHNP should do: Naltrexone (Vivitrol) injection, 380 mg intramuscularly in the gluteal region every 4 weeks RESULTS OF DECISION POINT ONE Client returns to clinic in four weeks Mrs. Perez said that she felt wonderful as she has not touched a drop to drink since receiving the injection Client reports that she has not been going to the casino, as frequently, but when she does go she drops a bundle (meaning, spends a lot of money gambling) Client She is also still smoking, which has her concerned. She is also reporting some problems with anxiety, which also have her concerned Decision Point Two: Select what the PMHNP should do next: Add on Valium(diazepam) 5 mg orally TID/PRN/anxiety RESULTS OF DECISION POINT TWO 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 Client is asking today for you to increase the valium dose or frequency Decision Point Three: Select what the PMHNP should do next: Continue current dose of Vivitrol, increase Valium to 10 mg orally TID/PRN/anxiety. Refer to counseling for her ongoing gambling issue Guidance to Student Anxiety is a common side effect of Vivitrol. Mrs. Perez reports that she is doing well with this medication, and like other side effects, the anxiety associated with this medication may be transient. The psychiatric mental health nurse practitioner should never initiate benzodiazepines in a client who already has issues with alcohol, or other substance dependencies. Additionally, benzodiazepines are not to be used long-term. Problems associated with long-term benzodiazepine use include the need to increase the dose in order to achieve the same therapeutic effect. This is what we are seeing in Mrs. Perez’s case. The most appropriate course of action in this case would be to continue the current dose of Vivitrol, while decreasing the Valium with the goal of discontinuation of the drug within the next two weeks. At this point, we need to evaluate whether or not the side effect of anxiety associated with Vivitrol persists. Increasing the dose of Valium would not be appropriate, neither would maintaining her on the current dose of Valium. Additionally, the client should be referred for counseling to help with her gambling addiction, as there are no FDA approved medications gambling disorder. Medication should never be added treat side effect of another medication, unless that side effect is known to be transient (for instance, benzodiazepines are sometimes prescribed to overcome the initial problem of activation associated with initiation of SSRI, or SNRI therapy). However, in a client with multiple addictive disorders, benzodiazepines should never be used (unless they are only being used for a limited duration of therapy such as acute alcohol detoxification to prevent seizures). Additionally, it should be noted that Mrs. Perez continues to engage in problematic gambling, at considerable personal financial cost. Mrs. Perez needs to be referred to a counselor who specializes in the treatment of gambling disorder and should also be encouraged to establish herself with a local chapter of gamblers anonymous. 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.

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