| Course | NR 606 Diagnosis & Management in Psychiatric-Mental Health II Practicum |
|---|---|
| Week | 4 |
| Paper type | Plan revision note |
| Length | About 800 words, 3 pages |
| Format | APA 7 student paper |
| School | Chamberlain University |
| Program | MSN, Psychiatric-Mental Health Nurse Practitioner (PMHNP) |
| Updated | October 2026 |
Free sample paper for NR 606 Week 4
Plan Revision Note: D.L. After Eight Weeks of Airway Pressure, Sleep and Energy Restored but Interest Still Missing, and Sertraline Increased From 150 to 200 mg
Student Name
College of Nursing, Chamberlain University
NR 606: Diagnosis & Management in Psychiatric-Mental Health II Practicum
Instructor Name
Month Day, Year
Plan Revision Note: D.L. After Eight Weeks of Airway Pressure, Sleep and Energy Restored but Interest Still Missing, and Sertraline Increased From 150 to 200 mg
Status Against the Last Decision
The last plan was built on the premise that airway pressure might lift some depressive symptoms (Edwards et al., 2015); this note tests that premise.
Eight weeks ago, the plan held sertraline at 150 mg daily, started airway pressure for moderate sleep apnea and set a review at eight weeks to see which symptoms the airway treatment would move.
Airway pressure use: 6.4 hours a night on 92% of nights, from the machine's data. Residual apnea-hypopnea index on treatment: 3.
Sertraline adherence: no missed doses in the last four weeks by D.L.'s count; pharmacy fills on time.
PHQ-9 by item: sleep 1 (was 3), tiredness 1 (was 3), concentration 1 (was 2), interest 2 (unchanged), mood 1, others 0 to 1. Total 9, down from 12.
Epworth Sleepiness Scale: 7, down from 14.
Weight: down 2 kilograms. Blood pressure: 132/84.
The Trigger, Named
Loss of interest has not shifted. D.L. still has not returned to cycling or cooking and describes weekends as "just getting through them." This symptom did not respond to airway pressure, which points to depression rather than sleep apnea, and it has persisted through an adequate trial of sertraline at 150 mg: eight weeks of daily dosing.
Why Now and Not Later
The sleep apnea test has now done its job: it showed that sleep, tiredness and concentration were largely from the airway. What remains is depressive. Waiting another interval would mean a third month with residual anhedonia, and residual symptoms after partial response carry a raised risk of relapse. The trial at 150 mg is complete; there is nothing left to learn by holding.
The Change
Increase sertraline from 150 mg to 200 mg every morning, starting tomorrow.
What Was Passed Over
Adding a second antidepressant now: premature while the dose of the first can still rise, and it would add a second source of side effects.
Switching to another antidepressant: would abandon a partial response that has been real for mood and suicidal thinking.
Antipsychotic augmentation: it helps some patients (Mohamed et al., 2017), but the weight and blood sugar effects would undercut D.L.'s sleep apnea progress.
Holding at 150 mg: considered above; nothing further to learn.
Risks of the Change
Sexual side effects, already present as delayed orgasm, may increase at 200 mg. D.L. was told this and agreed to report it. Nausea or loose stools may return briefly.
Monitoring and Review Point
Review in four weeks, by video. Measures: PHQ-9 item by item, with the interest item as the target; sexual side effects asked directly; airway pressure use from the data card; adherence count.
Success at four weeks: interest item at 1 or below, or D.L. reporting a return to at least one activity, such as a weekend ride.
If interest has not moved by eight weeks at 200 mg, the next decision is between adding a second agent and switching, with the evidence for each weighed then.
What D.L. Said
"I'm sleeping like a person again, but I still don't want to do anything." D.L. agreed to the increase and asked whether a higher dose meant the depression was worse. I explained that the dose is being raised because one symptom has not yet improved, not because anything has worsened.
Why the Dose Increase Comes Before Augmentation
This is the simplest next step that is still a real step, and it keeps the plan to one change at a time.
In STAR*D, patients moved to a second step after an adequate first trial, and the first trial included dose increases as tolerated (Rush et al., 2006). Raising a single drug to its maximum before adding another is a simpler plan, keeps one source of side effects and allows the effect of the dose to be seen on its own.
What Would Have Changed This Decision
If airway pressure use had been poor, the first step would have been helping D.L. use it rather than increasing sertraline. If sleep and energy had not improved despite good use, the sleep apnea would have been ruled out as the main explanation and the dose increase would have been even more clearly needed. If interest had returned with the airway treatment, no change would have been made.
Coordination
Sleep clinic informed of the airway pressure success. Primary care informed of the dose change and the blood pressure.
References
Edwards, C., Mukherjee, S., Simpson, L., Palmer, L. J., Almeida, O. P., & Hillman, D. R. (2015). Depressive symptoms before and after treatment of obstructive sleep apnea in men and women. Journal of Clinical Sleep Medicine, 11(9), 1029-1038. https://doi.org/10.5664/jcsm.5020
Mohamed, S., Johnson, G. R., Chen, P., Hicks, P. B., Davis, L. L., Yoon, J., Gleason, T. C., Vertrees, J. E., Weingart, K., Tal, I., Scrymgeour, A., Lawrence, D. D., Planeta, B., Thase, M. E., Huang, G. D., & Zisook, S. (2017). Effect of antidepressant switching vs augmentation on remission among patients with major depressive disorder unresponsive to antidepressant treatment: The VAST-D randomized clinical trial. JAMA, 318(2), 132-145. https://doi.org/10.1001/jama.2017.8036
Rush, A. J., Trivedi, M. H., Wisniewski, S. R., Nierenberg, A. A., Stewart, J. W., Warden, D., Niederehe, G., Thase, M. E., Lavori, P. W., Lebowitz, B. D., McGrath, P. J., Rosenbaum, J. F., Sackeim, H. A., Kupfer, D. J., Luther, J., & Fava, M. (2006). Acute and longer-term outcomes in depressed outpatients requiring one or several treatment steps: A STAR*D report. American Journal of Psychiatry, 163(11), 1905-1917. https://doi.org/10.1176/ajp.2006.163.11.1905
Reading the NR 606 Week 4 instructions
The Week 4 note is short, and that is the difficulty: one decision, stated once, with everything around it earning its place. The trigger comes first and must be specific: a symptom that failed to shift after an adequate run, a side effect the patient is working around, a result off range. The change takes a line. Then the rejected alternatives, briefly. Argue why waiting would be worse. Set monitoring and the next review. Instructors deduct most for a change that arrives with no trigger, a trigger with no argument that waiting was worse and a note that grows into a full case paper. Report status against the last plan before naming the trigger.
How the NR 606 Week 4 example is put together
The sample reports status against the plan from eight weeks earlier: airway pressure used 6.4 hours a night, daily sertraline confirmed and PHQ-9 items showing sleep, tiredness and concentration down while interest stayed at 2. The trigger is that interest did not move with airway treatment or an adequate trial. Why now is argued from relapse risk and the completed test. The change is one line: sertraline to 200 mg. Four alternatives are set aside briefly, including antipsychotic augmentation on weight grounds. Risks, monitoring, success criteria, the patient's words, what would have changed the decision and coordination close it. Margin notes show where the trigger and the brevity earn credit.
Reading the NR 606 Week 4 grading rubric
The costliest loss is a change with no trigger, and this note names the one symptom that failed to shift. A timing gap, with no argument that waiting was worse, costs the next share; here the completed test and relapse risk are given. A note that grows into a case paper loses a row, and this one stays focused on a single change. Missing alternatives lose marks, while four are named with reasons. Monitoring tied to the target symptom and a success criterion earns the review criterion. Saying what would have changed the decision shows the trigger was tested. Recording the patient's own words about sleep and interest shows the trigger matched the patient's experience.
NR 606 Week 4 help from the desk
Weak NR 606 Week 4 notes describe a medication change without saying what made it necessary. Others give a trigger but no reason not to wait. Many become long case summaries. Alternatives are often missing. Monitoring is frequently general. Name the trigger as a specific symptom or result, argue why waiting is worse, state the change in one line, list the options passed over and set a review with a measure. Keep it short. If your revision differs, share the trigger and the change, and a brief note in this form can be drafted. Say what would have made you decide differently.
Get a NR 606 Week 4 example written to your instructions
Send the Week 4 instructions with your section's note template if one is published, and a custom example is written to that template and returned inside 24 to 48 hours. The first one is free. Include the case you were assigned, because the trigger sentence only works when it is written against a specific patient.
More NR 606 papers and PMHNP samples
- NR 606 Week 1: Inherited Patient Post
- NR 606 Week 2: Partial Response Analysis
- NR 606 Week 3: Comorbidity Case Write-Up
- NR 606 Week 5: Case Analysis
- NR 606 Week 6: Augmentation Rationale
- NR 606 Week 7: Progress Note Series
- NR 606 Week 8: Complex Case Paper
- NR 605 Week 4: Anxiety Case Analysis
- NR 548 Week 4: Suicide Risk Assessment Note
- NR 546 Week 4: Titration and Monitoring Plan
- NR 547 Week 4: Rule Out Analysis
NR 606 Week 4 questions, answered
How short is too short?
Short is rarely the failure. A note loses points for missing a required element, not for economy, and most sections publish the elements they expect. The genuine risk in a brief document is compressing the timing argument into a clause, since that is the part being marked. Keep that paragraph intact and let the background be the thing that gets cut.
What if the case does not support changing anything?
Then the note argues for holding and does it explicitly. Holding is a revision decision with the same requirements: a trigger that has not yet arrived, a stated threshold that would change the answer, and a review point. What fails is silence, where nothing is decided and the note leaves a reader unable to tell whether that was a choice.
Should the note repeat the whole history?
No. It picks up from the last decision and reports what that decision produced. This course assumes a plan already exists, so a note that reintroduces the patient from the beginning is spending its space on material the reader has. Two or three lines of status are usually enough to make the trigger legible to someone who was not present.
Where can I find a free NR 606 Week 4 sample paper?
The full plan revision note increasing sertraline after airway treatment left anhedonia unchanged is published on this page.
What is the trigger in the NR 606 Week 4 note?
Loss of interest that did not improve with airway pressure or eight weeks of daily sertraline at 150 mg.