Assignment- Assessing and Treating Clients With Psychosis and Schizophrenia-WK6-63N

Assessing and Treating Clients With Psychosis and Schizophrenia. Psychosis and 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 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 the Assessing and Treating Clients With Psychosis and Schizophrenia Assignment:

Review this week’s Learning Resources. Consider how to assess and treat clients requiring anxiolytic therapy.

The Assessing and Treating Clients With Psychosis and Schizophrenia Assignment

The Assignment: 5 pages

Case Study: Pakistani Woman With Delusional Thought Processes. You will be asked to make three decisions concerning the medication to prescribe to this patient. Be sure to consider factors that might impact the patient’s pharmacokinetic and pharmacodynamic processes.

At each decision point, you should evaluate all options before selecting your decision and moving throughout the exercise. Before you make your decision, make sure that you have researched each option and that you evaluate the decision that you will select. Be sure to research each option using the primary literature.

Introduction to the case (1 page)

Briefly explain and summarize the case for this Assignment. Be sure to include the specific patient factors that may impact your decision making when prescribing medication for this patient.

Decision #1 (1 page)

Which decision did you select?
Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.

Decision #2 (1 page)

Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.

Decision #3 (1 page)

Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.

Conclusion (1 page)

Summarize your recommendations on the treatment options you selected for this patient. Be sure to justify your recommendations and support your response with clinically relevant and patient-specific resources, including the primary literature.

Note: Support your rationale with a minimum of five academic resources. While you may use the course text to support your rationale, it will not count toward the resource requirement. You should be utilizing the primary and secondary literature.

Reminder : The College of Nursing requires that all papers submitted include a title page, introduction, summary, and references. The Sample Paper provided at the Walden Writing Center provides an example of those required elements (available at https://academicguides.waldenu.edu/writingcenter/templates/general#s-lg-box-20293632). All papers submitted must use this formatting.

By Day 7

Submit your Assignment.

Submission and Grading Information

To submit your completed Assignment for review and grading, do the following:

Please save your Assignment using the naming convention “WK7Assgn+last name+first initial.(extension)” as the name.
Click the Week 7 Assignment Rubric to review the Grading Criteria for the Assignment.
Click the Week 7 Assignment link. You will also be able to “View Rubric” for grading criteria from this area.
Next, from the Attach File area, click on the Browse My Computer button. Find the document you saved as “WK7Assgn+last name+first initial.(extension)” and click Open.
If applicable: From the Plagiarism Tools area, click the checkbox for I agree to submit my paper(s) to the Global Reference Database.
Click on the Submit button to complete your submission.

Also include how ethical considerations might impact your treatment plan and communication with clients.

Note: Support your rationale with a minimum of three academic resources. While you may use the course text to support your rationale, it will not count toward the resource requirement.

CASE STUDY: Assessing and Treating Clients With Psychosis and Schizophrenia

Examine Case Study: Pakistani Woman 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 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

Assessing and Treating Clients With Psychosis and Schizophrenia Diagnosis: Schizophrenia, paranoid type

Assessing and Treating Clients With Psychosis and Schizophrenia 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.

OPTION 1: Assessing and Treating Clients With Psychosis and Schizophrenia

Decision Point One

Select what the PMHNP should do:

Start Zyprexa 10 mg orally at BEDTIME

Start Invega Sustenna 234 mg intramuscular X1 followed by 156 mg intramuscular on day 4 and monthly thereafter

Start Abilify 10 mg orally at BEDTIME

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 from her meals so she is snacking constantly throughout the day.

Decision Point Two

Change medication to Geodon 40 mg orally BID with meals

RESULTS OF DECISION POINT TWO

Client returns to clinic in four weeks
Client has a significant reduction in her PANSS (reduction of 40%)
Client notices her weight is down slightly from the previous visit (lost 2 pounds) and that her hunger has been curbed since starting this med
Client does complain that it is difficult to remember the second dose and admits to missing afternoon doses on several occasions over the past month

Decision Point Three

Give her a few test doses of Risperdal 1 mg orally BID for 3 days to see if she tolerates the medication. If tolerated, start Invega Sustenna at an appropriate starting and maintenance dose.

Assessing and Treating Clients With Psychosis and Schizophrenia Guidance to Student

Changing to Risperdal oral therapy to test for side effects and then switching to Invega Sustenna is a good option in a patient who has problems with compliance and who shows good effect from oral therapy. The manufacturer advertises that patients can be switched from an entirely different medication to Invega Sustenna if tolerability can be shown through oral therapy. From a clinical standpoint, the patient may or may not respond to the medication and therefore this could be a waste of time. Remember, manufacturers have a product to sell and there information should always be verified before implementing into clinical practice.

Although Geodon is recommended twice daily with meals, some providers will choose to give the dose once a day and monitor for efficacy in patients who have compliance issues with BID dosing regimens.

Latuda is a medication that behaves much like Geodon but is taken only once daily. This makes it a good option for someone who responds to Geodon but has compliance problems with the twice daily dosing. Tolerability can be an issue as doses are escalated. Particularly, nausea, vomiting and extrapyramidal side effects can be problematic and therefore good counseling is recommended for clients. Patients usually tolerate lower doses (40 mg) but significant GI distress and movement disorders can occur when doses are pushed upward toward the daily max of 160 mg.

OPTION 1-: Assessing and Treating Clients With Psychosis and Schizophrenia

Delusional Disorders: Pakistani Female With Delusional Thought Processes

Decision Point One

Start Abilify (aripiprazole) 10 mg orally at BEDTIME

RESULTS OF DECISION POINT ONE

Client returns to clinic in four weeks
Client returns and looks disheveled. Upon questioning, her husband states that she has not been sleeping at night. He states she is up and down all night and has also been disrupting his sleep
Client is unable to participate in the PANSS rating tool because she continually is nodding off (sleeping) during the appointment
The appointment is not productive for assessing how she is responding to the Abilify started 4-weeks ago

Decision Point Two

Discontinue Abilify and start Geodon (ziprasidone ) 40 mg orally BID with meals

RESULTS OF DECISION POINT TWO

Client returns to clinic in four weeks
Client has a significant reduction in her PANSS (make her a responder w/ score reduction of 40%)
Client notices her weight is down slightly from the previous visit (lost 2 pounds) and that her hunger has been curbed since starting this medication
Client does complain that it is difficult to remember the second dose and admits to missing afternoon doses on several occasions over the past month

Decision Point Three

Give her a few test doses of Risperdal 1 mg orally BID for 3 days to see if she tolerates the medication. If tolerated, start Invega Sustenna at an appropriate starting and maintenance dos.

Assessing and Treating Clients With Psychosis and Schizophrenia Guidance to Student

Changing to Risperdal oral therapy to test for side effects and then switching to Invega Sustenna is a good option in a client who has problems with compliance and who shows good effect from oral therapy. The manufacturer advertises that clients can be switched from an entirely different medication to Invega Sustenna if tolerability can be shown through oral therapy. From a clinical standpoint, the client may or may not respond to the medication and therefore this could be a waste of time. Remember, manufacturers have a product to sell, and their information should always be verified before implementing into clinical practice.

Although Geodon is recommended twice daily with meals, some providers will choose to give the dose once a day and monitor for efficacy in clients who have compliance issues with BID dosing regimens.

Latuda is a medication that behaves much like Geodon and is therefore a good option for someone who responds to Geodon but has compliance problems due to its once daily dosing schedule. Tolerability can be an issue as doses are escalated. Particularly, nausea, vomiting, and extrapyramidal side effects can be problematic and therefore good counseling points to clients. Clients usually tolerate lower doses (40 mg), but significant GI distress and movement disorders can occur when doses are pushed upward toward the daily max of 160 mg.

DECISION OPTION 2: Assessing and Treating Clients With Psychosis and Schizophrenia

Decision Point One

Start Abilify (aripiprazole) 10 mg orally at BEDTIME

RESULTS OF DECISION POINT ONE

Client returns to clinic in four weeks
Client returns and looks disheveled. Upon questioning, her husband states that she has not been sleeping at night. He states she is up and down all night and has also been disrupting his sleep
Clientis unable to participate in the PANSS rating tool because she continually is nodding off (sleeping) during the appointment
The appointment is not productive for assessing how she is responding to the Abilify started 4-weeks ago

Decision Point Two

Discontinue Abilify and start Geodon (ziprasidone ) 40 mg orally BID with meals

RESULTS OF DECISION POINT TWO

Client returns to clinic in four weeks
Client has a significant reduction in her PANSS (make her a responder w/ score reduction of 40%)
Client notices her weight is down slightly from the previous visit (lost 2 pounds) and that her hunger has been curbed since starting this medication
Client does complain that it is difficult to remember the second dose and admits to missing afternoon doses on several occasions over the past month

Decision Point Three

Give her a few test doses of Risperdal 1 mg orally BID for 3 days to see if she tolerates the medication. If tolerated, start Invega Sustenna at an appropriate starting and maintenance dose

Guidance to Student: Assessing and Treating Clients With Psychosis and Schizophrenia

Although Geodon is recommended twice daily with meals, some providers will choose to give the dose once a day and monitor for efficacy in clients who have compliance issues with BID dosing regimens.

DECISION OPTION 3: Assessing and Treating Clients With Psychosis and Schizophrenia

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 from 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

Change to Risperdal 1 mg orally BID

Guidance to Student: Assessing and Treating Clients With Psychosis and Schizophrenia

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).

Learning Resources-WK663N: Assessing and Treating Clients With Psychosis and Schizophrenia

Note: To access this week’s required library resources, please click on the link to the Course Readings List, found in the Course Materials section of your Syllabus.

Required Readings

Note: All Stahl resources can be accessed through the Walden Library using this link. This link will take you to a log-in page for the Walden Library. Once you log into the library, the Stahl website will appear.

Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (4th ed.). New York, NY: Cambridge University Press.

To access the following chapters, click on the Essential Psychopharmacology, 4th ed tab on the Stahl Online website and select the appropriate chapter. Be sure to read all sections on the left navigation bar for each chapter.

Chapter 4, “Psychosis and Schizophrenia”
Chapter 5, “Antipsychotic Agents”

Stahl, S. M. (2014b). The prescriber’s guide (5th ed.). New York, NY: Cambridge University Press.

To access information on the following medications, click on The Prescriber’s Guide, 5th ed tab on the Stahl Online website and select the appropriate medication.

Review the following medications for Assessing and Treating Clients With Psychosis and Schizophrenia:

amisulpride
aripiprazole
asenapine
chlorpromazine
clozapine
flupenthixol
fluphenazine
haloperidol
iloperidone
loxapine
lurasidone
olanzapine
paliperidone
perphenazine
quetiapine
risperidone
sulpiride
thioridazine
thiothixene
trifluoperazine
ziprasidone

Naber, D., & Lambert, M. (2009). The CATIE and CUtLASS studies in schizophrenia: Results and implications for clinicians. CNS Drugs, 23(8), 649-659. doi:10.2165/00023210-200923080-00002

Note: Retrieved from Walden Library databases.

Document: Midterm Exam Study Guide (PDF)

Kay, S. R., Fiszbein, A., & Opler, L. A. (1987). The Positive and Negative Syndrome Scale (PANSS) for schizophrenia. Schizophrenia Bulletin, 13(2), 261-276.

Note: Retrieved from Walden Library databases.

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

Walden University. (2016). ASC success strategies: Studying for and taking a test. Retrieved from http://academicguides.waldenu.edu/ASCsuccess/ASCtesting

Required Media for Assessing and Treating Clients With Psychosis and Schizophrenia

Laureate Education. (2016j). Case study: Pakistani woman with delusional thought processes [Interactive media file]. Baltimore, MD: Author

Note: This case study will serve as the foundation for this week’s Assignment.

Optional Resources for Assessing and Treating Clients With Psychosis and Schizophrenia

Chakos, M., Patel, J. K., Rosenheck, R., Glick, I. D., Hammer, M. B., Tapp, A., & … Miller, D. (2011). Concomitant psychotropic medication use during treatment of schizophrenia patients: Longitudinal results from the CATIE study. Clinical Schizophrenia & Related Psychoses, 5(3), 124-134. doi:10.3371/CSRP.5.3.2

Fangfang, S., Stock, E. M., Copeland, L. A., Zeber, J. E., Ahmedani, B. K., & Morissette, S. B. (2014). Polypharmacy with antipsychotic drugs in patients with schizophrenia: Trends in multiple health care systems. American Journal of Health-System Pharmacy, 71(9), 728-738. doi:10.2146/ajhp130471

Lin, L. A., Rosenheck, R., Sugar, C., & Zbrozek, A. (2015). Comparing antipsychotic treatments for schizophrenia: A health state approach. The Psychiatric Quarterly, 86(1), 107-121. doi:10.1007/s11126-014-9326-2

Rubric Detail

Select Grid View or List View to change the rubric’s layout.

Name: NURS_6630_Week7_Assignment_Rubric

Introduction to the case (1 page)

Briefly explain and summarize the case for this Assignment. Be sure to include the specific patient factors that may impact your decision making when prescribing medication for this patient.

9 (9%) – 10 (10%)
The response accurately, clearly, and fully summarizes in detail the case for the Assignment.

The response accurately and clearly explains in detail the specific patient factors that impact decision making when prescribing medication for this patient.

8 (8%) – 8 (8%)
The response accurately summarizes the case for the Assignment.

The response accurately explains the specific patient factors that impact decision making with prescribing medication for this patient.

7 (7%) – 7 (7%)
The response inaccurately or vaguely summarizes the case for the Assignment.

The response inaccurately or vaguely explains the specific patient factors that impact decision making with prescribing medication for this patient.

0 (0%) – 6 (6%)
The response inaccurately and vaguely summarizes the case for the Assignment, or is missing.

The response inaccurately and vaguely explains the specific patient factors that impact decision making with prescribing medication for this patient.
Decision #1 (1–2 pages)

• Which decision did you select?
• Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
• Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
• What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
• Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.

18 (18%) – 20 (20%)
The response accurately and clearly explains in detail the decision selected.

The response accurately and clearly explains in detail why the decision was selected, with specific clinically relevant resources that fully support the decision selected.

The response accurately and clearly explains in detail why the other two responses were not selected, with specific clinically relevant resources that fully support the response.

The response accurately and clearly explains in detail the outcome the student was hoping to achieve with the selected decision, with specific clinically relevant resources that fully support the response.

The response accurately and clearly explains in detail how ethical considerations impact the treatment plan and communication with patients.

Examples provided fully support the decisions and responses provided.

16 (16%) – 17 (17%)
The response accurately explains the decision selected.

The response explains why the decision was selected, with specific clinically relevant resources that support the decision selected.

The response accurately explains why the other two responses were not selected, with specific clinically relevant resources that support the response.

The response accurately explains the outcome the student was hoping to achieve with the selected decision, with specific clinically relevant resources that support the response.

The response accurately explains how ethical considerations impact the treatment plan and communication with patients.

Examples provided support the decisions and responses provided.

14 (14%) – 15 (15%)
The response inaccurately or vaguely explains the decision selected.

The response inaccurately or vaguely explains why the decision was selected, with specific clinically relevant resources that inaccurately or vaguely support the decision selected.

The response inaccurately or vaguely explains why the other two responses were not selected, with specific clinically relevant resources that inaccurately or vaguely support the response.

The response inaccurately or vaguely explains the outcome the student was hoping to achieve with the selected decision, with specific clinically relevant resources that inaccurately or vaguely support the response.

The response inaccurately or vaguely explains how ethical considerations impact the treatment plan and communication with patients.

Examples provided may support the decisions and responses provided.

0 (0%) – 13 (13%)
The response inaccurately and vaguely explains the decision selected.

The response inaccurately and vaguely explains why the decision was selected, with specific clinically relevant resources that do not support the decision selected, or is missing.

The response inaccurately and vaguely explains why the other two responses were not selected, with specific clinically relevant resources that do not support the decision selected, or is missing.

The response inaccurately and vaguely explains the outcome the student was hoping to achieve with the selected decision, with specific clinically relevant resources that do not support the response, or is missing.

The response inaccurately and vaguely explains how ethical considerations impact the treatment plan and communication with patients, or is missing.

Examples provided do not support the decisions and responses provided, or is missing.
Decision #2 (1–2 pages)