Decision Point 1
Start Invega Sustenna 234mg intramuscular X1 followed by 156mg intramuscular on day four and monthly after that. There is a positive behavioral and health progress witnessed in the client when a dose Invega Sustena is administered consistently after four weeks. The client’s Positive and Negative Syndrome Scale (PANSS) decreases to a partial response of 25 percent at week four ("Dilusional Disorders," 2020) . According to the Global Impressions (CGI), a PANSS reduction indicates the patient to be "minimally improved." It shows that incidences of positive symptoms like visual and auditory hallucinations have decreased ( Anderson n et al., 2015).
The client is also adhering to antipsychotic Invega Sustenna medication and is unlikely to stop taking the recommended dose as it happened when she was under Risperdal. Invega Sustenna is even more desirable because the side effects are mild compared to using Zyprexa or Abilify. Dilusional Disorders (2020) discusses that Abilify disrupts the sleep patterns of the patient, while Zyprexa makes the client have a weight gain of 5 pounds.
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I was expecting that Invega Sustenna will help alleviate the schizophrenia symptoms, such as delusions, disorganized thinking, and unpredictable behavior experienced by the patient from reappearing over time. Though it is common for a patient to complain of injection site pain after Invega Sustenna, I did not expect that the pain would be much worse to the point that it prevents the client from walking around comfortably for a long time. The client complains that she has trouble sitting, especially a few hours after being injected with a dose of Invega Sustenna (" Dilusional Disorders," 2020) . Fortunately, the client is experiencing only a few side effects, that is, weight gain and injection site pain. She does not experience symptoms, such as restlessness, headaches, constipation, or muscle weakness, which are common side effects of using Invega Sustenna ( Keltner, 2018). It seems like her husband’s support and encouragement played a vital role in influencing the client’s treatment efficacy. The husband has so far ensured that the client does not miss appointments for Invega Sustenna injections.
Decision Point Two
Continue the same decision made but instruct administering nurse to begin injections into deltoid at this visit and moving forward. I selected the decision because the client has been tolerating Invega Sustenna's medication so far. Additionally, the client’s behavior is improving because the PANSS has significantly reduced, a score of 25 percent. It means that the severity of symptoms in the positive, negative, and general scale have been maintained at a minimum. Even though schizophrenia has been regarded as a heterogeneous entity, continuing the treatment using Invega Sustenna has proved to reinforce desirable behavior change on the client ("Dilusional Disorders," 2020 ). Positive symptoms, such as delusional thoughts and hallucinations, seem to have subsided, as observed in the first visit .
The SGA antipsychotics have so far recorded a success because the client’s PANNS has so far reduced by a total of 50 percent since the initiation of the treatment remedy ( Dilusional Disorders, 2020) . Studies show that a 50 percent PANNS reduction response corresponds to a CGI rating of "much improved" for schizophrenia patients with acute exacerbations (Anderson et al., 2015). I was hoping that the medication would address the client’s paranoia, reduce injection site pain, limit weight gain, and improve her impaired insight and judgment. From the last visit, the patient had noted a 2 pound weight gain, and I, therefore, hoped that the client could only add a maximum of 1 pound in the second phase of treatment. It was also my expectation that feelings of paranoia experienced by the patient, especially concerning her marriage, will reduce. The client had previously intimated that her husband never loved her and instead wanted an “American wife" ("Dilusional Disorders," 2020 ). Most of my expectations regarding the efficacy of the drug were achieved. For instance, the injection site pain had since reduced after beginning injections into the patient's deltoid compared to when she was being administered with gluteus medius injections (injections in the buttocks). The injection dose administered in the arm is much better, and the client is responding positively.
The patient could now sit down comfortably after the arm injection as opposed to when she was receiving gluteus medius injections. Unfortunately, the client has continued to add more weight than expected. She has added 2.5 pounds since the last visit, thereby totaling 4.5 pounds in two months (" Dilusional Disorders," 2020) . The weight gain is affecting her moods, insight, and judgment. She is now more bothered and afraid that her husband dislikes the additional weight she has gained. Her paranoia regarding her husband’s lack of affection has heightened. The client’s fears collaborate by the fact that her husband was not present at the second visit.
Even though it is normal for married people to demand to be shown affection by their better halves, the client’s case is different because she was used to entertaining paranoia thought processes before starting the treatment regimen. The client previously claimed that the television told her that her husband wanted an "American wife" instead of her. If the weight gain is not managed promptly, it is highly likely that the client might begin experiencing the second wave of visual or auditory hallucinations. The increased weight gain is due to the client’s failure to incorporate weight management strategies to improve her quality of life. The client reported in the last first visit that she does not like having to walk around for such a long time (" Dilusional Disorders," 2020) . It would have been better if the client considered engaging in mild exercises like walking or jogging as a strategy to manage the weight.
However, the chosen option provided desirable results compared to the remaining two. For instance, continuing Invega Susstena and adding 300 mg of Abilify Maintena intramuscular monthly and oral Abilify 10 mg in the morning disrupted the patient's sleep patterns (" Dilusional Disorders," 2020) . Adding Abilify in the dose also led to symptoms of restlessness. The husband claimed that the client is unable to sit still, and she is constantly up and down. Discontinuing Invega Sustenna and starting Haldol Decanoate also causes more health problems such as muscle stiffness and drooling (Matthew, 2016) . The patient’s neck is turned on the left and is unable to move it, continually smacks her lips, and sticks her tongue out repeatedly after using Haldol Decanoate.
Decision Point Three
Continue with Invega Sustenna and counsel the client. Looking at other measures, it seems that Invega Sustenna brings out the most desirable outcomes for the patient compared to other medications like Abilify and Haldol Decanoate. The only side affects the client experiences for using Invega Sustenna is weight gain, which can be managed modestly using natural measures (" Dilusional Disorders," 2020) . It is thus crucial for the client to continue with the medication and consider observing proper nutrition and exercise to achieve and maintain a desirable weight.
I was hoping that it will be possible to consult with a dietician and exercise physiologist on some of the best ways that the client can implement to manage weight loss. The move to ask for expert opinion on weight loss was to put the client on a strict diet or exercise for a six month trial period and observe whether there will be a significant weight reduction (Dilusional Disorders, 2020 ). I will then switch to another agent if the product prescribed by the dietician and the physiologist fail to show efficacy. If the product fails to show efficacy, I will recommend Qsymia, a weight loss medication to the client, and observe the efficiency of the treatment regimen for at least six months.
Ethical Considerations
Some of the ethical considerations that might impact the treatment plan are related to informed consent and confidentiality (Jain et al., 2017) . It is sometimes difficult to get consent from the client when prescribing medication. Sometimes I might be forced to convince clients to take doses of the prescribed medicine against their will and at times without seeking their consent to help better their health (Jain et al., 2017) . Communicating with the client is sometimes difficult and thus necessary to involve the husband in the treatment process. Sharing information with the husband or the dietician or the physiologist is essential but is against the ethical principle of maintaining the confidentiality of the client's information.
References
Anderson, A., Wilcox, M., Savitz, A., Chung, H., Li, Q., Salvadore, G., ... & Bilder, R. M. (2015). Sparse factors for the positive and negative syndrome scale: Which symptoms and stage of illness?. Psychiatry Research , 225 (3), 283-290.
Dilusional Disorders. (2020). Psychopharmacologic Approaches to Treatment of Psychopathology . Mym.cdn.laureate-media.com. Retrieved 29 March 2020, from https://mym.cdn.laureate-media.com/2dett4d/Walden/NURS/6630/06/mm/delusional_disorders/index.html .
Jain, S., Kuppili, P. P., Pattanayak, R. D., & Sagar, R. (2017). Ethics in psychiatric research: Issues and recommendations. Indian journal of psychological medicine , 39 (5), 558.
Keltner, N. L. (2018). AntipsychoticAntipsychotic drugs. Psychiatric Nursing-eBook , 136.
Matthew, B. J. (2016). Haloperidol decanoate/metamfetamine. Reactions , 1583 , 549-9.
Naber, D., & Lambert, M. (2009). The CATIE and CUtLASS studies in schizophrenia. CNS drugs , 23 (8), 649-659.
