Respond  of your colleagues who were assigned to a  different case than you. Explain how you might apply knowledge gained  from your colleagues’ case studies to you own practice in clinical  settings.

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The three questions this writer would as the patient are: 
Did your depressive symptoms worsen after the death of your husband? 
How many hours per night do you sleep on average? 
Do you sleep throughout those hours of sleep or do you wake constantly? 
Do you ingest any stimulants like coffee or chocolate before bed? 
Do you sleep during the daytime? 

The rationale behind question one is to gauge the timeline of the patient’s depression. She appears to have been suffering with untreated depression for a long time, however the additional symptoms of insomnia and tearfulness seemed to worsen after his death. With this information the nurse practitioner will know if her depression is in an acute state and the severity of her illness.The patient is reporting sleeplessness; however the nurse practitioner needs to gauge if the patient is participating in restful sleep. Sleep of two hours or less may only consist of REM sleep (Boland et al., 2020). If the patient is not getting restful sleep, she is not benefiting from the bodily repair that takes place during sleep (Fitzgerald et al., 2017).  This can place her at an increased risk for other illnesses and heighten depressive symptoms (Uchmanowicz et al., 2019).Knowing if the patient sleeps consistently throughout those hours of sleep will provide information to the nurse about the kind and amount of sleep the patient is getting. Ingesting certain stimulants like caffeinated drinks, coffee or chocolate can affects the client’s sleep by providing wakefulness (Ulke et al., 2017).  If the patient is sleeping during the daytime, her circadian rhythm could have been reversed where she will need less sleep during the night time hours (Fitzgerald et al., 2017).

The people this writer would interview are:
The patient’s aide 
The patient’s son 

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The patient aide may be able to provide more information about observed sleepiness during the daytime. In addition, she will be able to provide information on the patient’s dietary patterns and physical activity. The questions to the aide would be:    
Does she easily nod off during the daytime? 
Does she easily become fatigued? 
Does she consume a well-balanced diet? 
Question one would illicit answers about her getting sleep. 
It appears that she in fact getting sleep but because of a revered circadian rhythm she is not able to get the sleep at the night which is the desired time.  Question two will help the nurse practitioner gauge the extent of the effects that non sleep has taken on the patient’s life. The patient, if constantly fatigued throughout the day has a life that has been highly impacted by the lack of sleep. The aide would be able to provide a clear, picture of the patient’s diet. The aide would be able to reveal if the patient consumes a vast amount of sugar or caffeine which could interrupt sleep.
Questions to the son would surround the family’s psychiatric history.  These questions will help the nurse practitioner construct the family history of the patient and rule out or consider familial history as a cause for her symptoms.
Can you recall any maternal family members with psychiatric disorders including depression and insomnia? 
Did the symptoms start after the death of the client’s husband?  
This would help the nurse practitioner rule out depressive symptoms as the cause of her insomnia.

Physical Examinations and Tests
Sleep Study:
Polysomnogram – The sleep study or polysomnogram measures the brain waves, blood oxygen, leg movements and breathing during sleep (Meghdadi et al., 2019). The Nurse Practitioner would be able to rule out physiological reason’s ad the cause for the patient’s insomnia.
Actigraphy: This is where a small device is worn on the wrist and it measures the person’s sleep wake cycle for a specified period (Meghdadi et al., 2019). This is convenient for this client and the Nurse Practitioner would be able to monitor the client’s sleep health and gauge the severity of the disruption of her sleep.The nurse practitioner could also physically examine the patient’s nares for septal occlusion.
Septal occlusion or deviation could lead to problems with sleeping even during sleep, this would be important for the nurse practitioner to evaluate as this could be interfering with the patient’s sleep.
Epworth sleepiness scale – assesses the patient’s tendency to nod off in various situations (Meghdadi et al., 2019).  For this client it would be necessary for the nurse practitioner to assess the severity of her nodding off during the day time especially at unexpected times like during eating and other activities that would put her safety at risk. 
Differential Diagnosis
G47.00 Unspecified Insomnia Disorder- The patient is experiencing insomnia at nighttime that could be related to several factors. She reports staying up late to watch T.V., depressive symptoms, restless leg syndrome, sleep apnea and sleeping during the daytime. Some of these factors have not been ruled out yet as the cause of her anxiety. 
G47.23 Persistent Irregular Sleep Wake type severe 
F32.9 Unspecified Depressive Disorder 
G25.81 Restless legs syndrome 

Trazodone 50 mg – This medication would be the first choice as it offers antidepressant properties as well as promotes sleep in those diagnoses with insomnia. It is generally safe for the elderly population at low doses (Pagel et al., 2018). The Nurse Practitioner should monitor the patient and evaluate the needs to slowly increase or in some cases decrease the dose. 
Rozerem 8 mg- Is a nonbenzodiazepine hypnotic that promotes sleep. The patient would benefit from his, but an added benefit would be that she would be at a diminished risk of falls as this is a concern following the use of hypnotics in the elderly. This drug is reported as one that would prevent less falls from over sedation (Pagel et al., 2018).
Lessons Learned            
This writer has learned that it is important to conduct a complete evaluation of the patient and not just focus on the presenting symptoms. There are additional environmental and physiological symptoms that could be attributed to the patient’s insomnia. In this case the patient had several factors that could be contributing her insomnia and they needed to be ruled out. The cause of her insomnia could have been physiological from the sleep apnea or from her habits of staying up tool late at nights and sleeping during the daytime. It is also important to evaluate medications, social and economic factors before the resorting to pharmacological interventions. 

Boland, E. M., Vittengl, J. R., Clark, L. A., Thase, M. E., & Jarrett, R. B. (2020). Is sleep disturbance linked to short- and long-term outcomes following treatments for recurrent depression? Journal of Affective Disorders, 262, 323–332. 
FitzGerald, J. M., O’Regan, N., Adamis, D., Timmons, S., Dunne, C. P., Trzepacz, P. T., & 
Meagher, D. J. (2017). Sleep-wake cycle disturbances in elderly acute general medical inpatients: Longitudinal relationship to delirium and dementia. Alzheimer’s & Dementia: Diagnosis, Assessment & Disease Monitoring, 7, 61–68. 
Meghdadi, A. H., Popovic, D., Rupp, G., Smith, S., Berka, C., & Verma, A. (2019). Transcranial Impedance Changes during Sleep: A Rheoencephalography Study. IEEE Journal of Translational Engineering in Health and Medicine, Translational Engineering in Health and Medicine, IEEE Journal of, IEEE J. Transl. Eng. Health Med, 7, 1–7.  
Pagel, T., Seithikurippu R. Pandi-Perumal, & Jaime M. Monti. (2018). Treating insomnia with medications. Sleep Science and Practice, (1), 1. Uchmanowicz I, Markiewicz K, 
Uchmanowicz B, Kołtuniuk A, & Rosińczuk J. (2019). The relationship between sleep disturbances and quality of life in elderly patients with hypertension. Clinical Interventions in Aging, 155. 
Ulke, C., Sander, C., Jawinski, P., Mauche, N., Huang, J., Spada, J., Hegerl, U. (2017). Sleep disturbances and upregulation of brain arousal during daytime in depressed versus non-depressed elderly subjects. World Journal of Biological Psychiatry, 18(8), 633–640.    

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