Regina Ricardo Ihuman Case Analysis: Comprehensive Evaluation

REGINA RICARDO IHUMAN CASE ANALYSIS: COMPREHENSIVE EVALUATION AND EVIDENCE-BASED MANAGEMENT OF CHRONIC INSOMNIA IN A 65-YEAR-OLD FEMALEWeek 3, NURS 6512 Patient: Regina Ricardo Age/Sex: 65-year-old Female Chief Complaint: "I just cant seem to sleep through the night anymore." Abstract Insomnia is one of the most prevalent sleep disorders among older adults and is associated with significant physical, cognitive, and psychological consequences. This case study examines Regina Ricardo, a 65-year-old female presenting with difficulty initiating and maintaining sleep for three months. The patient reports averaging four to five hours of sleep per night with associated daytime fatigue and irritability. A comprehensive history using the OLDCARTS framework was conducted to evaluate symptom onset, duration, aggravating and relieving factors, and functional impact. Contributing factors identified include poor sleep hygiene practices, caffeine and alcohol use, intermittent nocturia, and mild nighttime anxiety. Screening for red flag conditions such as obstructive sleep apnea, major depressive disorder, medication-induced insomnia, and chronic pain was performed. Findings were most consistent with chronic primary insomnia. Evidence-based management prioritizes non-pharmacologic interventions, particularly Cognitive Behavioral Therapy for Insomnia (CBT-I), as recommended by the American Academy of Sleep Medicine. Pharmacologic therapy is considered secondary due to increased adverse effect risk in geriatric patients,