Nursing Case Study: Therapy for Sleep-Wake Disorders
This paper presents a nursing case study of a 31-year-old male experiencing chronic insomnia exacerbated by the loss of his fiancée, alcohol dependency, and occupational risk. The paper walks through three sequential clinical decisions — prescribing Zolpidem 5mg, transitioning to Suvorexant 10mg with behavioral therapy, and continuing Hydroxyzine 50mg — explaining the rationale for each choice, why alternative options were rejected, and the ethical principles of nonmaleficence, autonomy, and beneficence that guide each decision. Patient education and the long-term risks of alcohol-disrupted sleep are also discussed.
- Case Introduction: Patient background, insomnia history, and alcohol use
- Decision 1: Zolpidem 5mg: Rationale for reduced-dose Zolpidem prescription
- Decision 2: Suvorexant 10mg with Behavioral Therapy: Switch to Suvorexant and addition of behavioral therapy
- Decision 3: Continuing Hydroxyzine 50mg: Continuation of Hydroxyzine with patient education
- Conclusion: Synthesis of decisions and ethical obligations
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What makes this paper effective
- Each decision section follows a consistent format: rationale for the chosen option, explanation of why alternatives were rejected, expected outcomes, and applicable ethical principles — making the argument easy to follow.
- The paper integrates peer-reviewed citations to justify every clinical choice, grounding nursing decisions in evidence-based practice.
- Ethical principles (nonmaleficence, autonomy, beneficence) are applied explicitly and repeatedly, demonstrating awareness of professional obligations beyond pharmacology alone.
Key academic technique demonstrated
The paper demonstrates sequential clinical reasoning — a technique common in nursing case studies where each decision builds on the outcomes of the previous one. Rather than presenting all treatment options at once, the writer shows how patient responses shape subsequent pharmacological and behavioral choices, mirroring real-world clinical decision-making.
Structure breakdown
The paper opens with a detailed patient background that establishes the clinical and psychosocial context. Three numbered decision sections form the core, each structured identically: chosen intervention, rejected alternatives, anticipated outcomes, and ethics. A brief conclusion synthesizes all three decisions and reinforces the long-term importance of combined pharmacological and behavioral treatment. References follow APA format throughout.
Case Introduction
A 31-year-old male presents with insomnia, reporting that he has found it extremely difficult to fall asleep for the past six months. The problem has recently been aggravated by the sudden loss of his fiancée. He has a prior history of difficulty falling asleep, but the problem has now become unbearable: he cannot fall asleep at a reasonable hour and also suffers from disrupted sleep throughout the night.
His sleep patterns are affecting his work, as he has begun falling asleep on the job the following day. His previous night was again deprived of sleep, which caused further difficulties at work. He is employed as a forklift operator at a local chemical company, making daytime sleepiness a significant safety concern.
The client reported that he had been taking diphenhydramine; however, the medication caused unpleasant next-morning effects. He also experienced adverse conditions related to a prior physician's prescription of an opiate for acute pain management following a skiing accident. Specifically, hydrocodone/APAP (acetaminophen) was prescribed as an opiate analgesic, though it has not been prescribed to him in four years.
A key concern arises when the patient mentions that alcohol helps him sleep better. He consumes at least four beers before bed each night, which is problematic. Sleep initiation and maintenance must be monitored to prevent adverse patient outcomes, especially in the management of chronic disease (Plescia et al., 2021). Sleep cycles are important predictors of good mental and physical health, and when disrupted, they can cause lasting consequences.
The patient's use of alcohol as a sleep aid is a clinical concern. While mild amounts of alcohol act as a central nervous system relaxant — briefly numbing nerves and stimulating sleep for several hours — prolonged use can cause the body to become tolerant to its effects (Plescia et al., 2021). This forces the patient to consume higher quantities, which ultimately disrupts sleep quality, generates sleep latency, and negatively impacts REM (rapid eye movement) sleep, total sleep time, memory, learning, and sleep-wake stability (Plescia et al., 2021).
Decision 1: Zolpidem 5mg
The first decision is to prescribe the patient Zolpidem 5mg. Reducing the dose from 10mg to 5mg would help the patient sleep better. At the 10mg dose, despite falling asleep more easily, the patient experienced a "knock out" effect and could not recall making breakfast in the middle of the night — an incident reported by his girlfriend. This memory impairment is a recognized side effect of higher Zolpidem doses (NHS, 2019).
The other two options presented were not selected because Zolpidem had already initiated positive results regarding the patient's sleep pattern. Discontinuing the medication did not seem appropriate, as there were no significant adverse side effects at a reduced dose. Initiating therapy to address alcohol use would be a valuable addition, but discontinuing Zolpidem entirely did not seem appropriate given that the patient had confidently reported falling asleep quickly — a marked improvement from his prior experience of struggling to fall asleep and then waking repeatedly throughout the night.
It was anticipated that sleep patterns would stabilize over time with continued use of Zolpidem at the lower dose. Zolpidem is effective for insomnia patients in part because it does not induce daytime sleepiness, which had previously affected the patient's occupational performance (Edinoff et al., 2021). Zolpidem is also considered effective when combined with behavioral therapies, which this patient would benefit from given his alcohol dependency (Edinoff et al., 2021). As the first decision, the reduced dose of Zolpidem remains a suitable pharmacological intervention at this stage.
The ethical considerations relevant to prescribing Zolpidem include nonmaleficence (avoiding harm to the patient), autonomy (the patient's right to accept or refuse treatment), and beneficence (acting in the patient's best health interest) (Peters, 2014).
Conclusion
The primary goal of all three decisions is to improve the patient's sleep cycles and reduce his reliance on alcohol for sleep. Evidence consistently shows that sleep disturbances are worsened by increasing alcohol dependency, placing the patient at risk for more serious complications as he ages. As a 31-year-old, he requires thorough education regarding the side effects and potential benefits of each treatment decision.
While one decision involves lowering a medication dose and another involves continuing the same dosage, a common thread across decisions is the value of combining pharmacological treatment with cognitive behavioral therapy. Research supports CBT as more effective for long-term positive health outcomes when used alongside medication. Ethical principles — nonmaleficence, beneficence, and autonomy — guide the physician throughout this process, ensuring that each decision serves the patient's best interest and upholds professional duty.
References
Britton, A., Fat, L. N., & Neligan, A. (2020). The association between alcohol consumption and sleep disorders among older people in the general population. Scientific Reports, 10. https://doi.org/10.1038/s41598-020-62227-0
Edinoff, A. N., Wu, N., Ghaffar, Y. T., Prejean, R., Gremillion, R., Cogburn, M., Chami, A. A., Kaye, A. M., & Kaye, A. D. (2021). Zolpidem: Efficacy and side effects for insomnia. Health Psychology Research, 9(1). https://doi.org/10.52965/001c.24927
Lee-Iannotti, J. K., & Parish, J. M. (2016). Suvorexant: A promising, novel treatment for insomnia. Neuropsychiatric Disease and Treatment, 12, 491–495. https://doi.org/10.2147/NDT.S31495
NHS. (2019, November 15). Zolpidem. https://www.nhs.uk/medicines/zolpidem/
Peters, B. (2014). Ethics commentary: Ethical considerations in sleep medicine. Psychiatry Online, 12(1), 64–67.
Plescia, F., Cirrincione, L., Martorana, D., Ledda, C., Rapisarda, V., Castelli, V., Martines, F., Vinnikov, D., & Cannizzaro, E. (2021). Alcohol abuse and insomnia disorder: Focus on a group of night and day workers. International Journal of Environmental Research and Public Health, 18(24).
Tan, C. S. (2020). The need for patient education to improve medication adherence among hypertensive patients. Malaysian Journal of Pharmacy, 6(1). https://doi.org/10.52494/MOEL1486
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