381 Med Quiz #1
What is the therapeutic level of lithium?
0.8-1.4 mEq/L
Why do first generation drugs cause EPS side effects to occur?
First-generation antipsychotics are dopamine (D2) antagonists in both limbic and motor centers. Blockage of D2 receptors in motor areas causes EPS side effects to occur.
With this medication although serious complications are rare, it is important to monitor liver function and platelet count periodically.
Volproate (Divalproex sodium/Depakote)
It is important to let your provider know if you are on what other type of medication if your prescribed lithium?
diuretics
People with schizophrenia have larger amounts of ___________________ in the body and more __________________________ receptor sites
dopamine
what extrapyramidal side effects are seen earlier?
dystonia, pseudoparkinson, and akathisia
You should stop taking lithium and notify your provider when you begin to experience what?
excessive diarrhea, vomiting, or sweating
What antipsychotic medications generally have more side effects but are less expensive?
first generation (FGA)
What drug group causes EPS side effects?
first generation antipsychotics
Lithium levels are _____________________________ by sodium deficiency, diarrhea, diuretics, dehydration, high fever, strenuous activity, poor renal functioning
increased
A motor restlessness that causes pacing, repetitive movements, or an inability to stay still or remain in one place. It can be severe and distressing to patients. It can be mistaken for anxiety or agitation.
akathisia
Reduced or absent peristalsis (can lead to bowel obstruction); urinary retention; mydriasis; hyperpyrexia without diaphoresis (hot dry skin); delirium with tachycardia, unstable vital signs, agitation, disorientation, hallucinations, reduced responsiveness; worsening of psychotic symptoms; seizure; repetitive motor movements
anticholinergic toxicity
• Superior for continuously cycling patients • More effective when there is no family history of bipolar disease • Effective at diminishing impulsive and aggressive behavior in some nonpsychotic patients • Helpful in cases of alcohol and benzodiazepine withdrawal • Beneficial in controlling mania (within 2 weeks) and depression (within 3 weeks or longer)
anticonvulsant (mood stabilizer) drugs
What drug class is Asenapine (Saphris)?
atypical antipsychotic (2nd gen)
What drug class is Clozapine (Clorazil)?
atypical antipsychotic (2nd gen)
What drug class is Lurasidone (Latuda)?
atypical antipsychotic (2nd gen)
What drug class is Olanzapine (Zyprexa)?
atypical antipsychotic (2nd gen)
What drug class is Paliperidone (Invega)?
atypical antipsychotic (2nd gen)
What drug class is Quetiapine (Seroquel)?
atypical antipsychotic (2nd gen)
What drug class is Risperidone (Risperdal)?
atypical antipsychotic (2nd gen)
What drug class is Aripiprazole (Abilify)?
atypical antipsychotic (3rd gen)
Because the onset of Lithium is so slow it is usually in the early phase of treatment supplemented with what other medication?
atypical antipsychotics, anticonvulsants, or antianxiety medications.
When is lithium contraindicated?
cardiovascular disease, brain damage, renal disease, thyroid disease, or myasthenia gravis, pregnant women, breast-feeding mothers and children younger than 12 years of age.
What are FGAs?
chlorpromazine, thioridazine, thiothixene, fluphenazine, haloperidol, trifluoperazine
Rare, reversible, and usually benign if caught in time; early symptoms are fever, malaise, nausea, and abdominal pain; jaundice appears 1 week later
cholestatic jaundice
Weight gain, dyslipidemia (abnormal lipid levels), increased insulin resistance, leading to increased risk of cardiovascular disease, diabetes, and other serious medical conditions
metabolic syndrome
Atypical antipsychotics have the risk of what side effects?
metabolic syndrome, prolonged QT interval, agranulocytosis, and orthostatic hypotension
The risk of a manic episode in a person who is depressed and diagnosed bipolar when you combine antidepressants with a what?
mood stabilizer
What drug class is Carbamazepine (Tegetrol)?
mood stabilizer (antiepileptic)
What drug class is Divalproex Sodium (Depokote)?
mood stabilizer (antiepileptic)
What drug class is Lamotrigine (Lamactil)?
mood stabilizer (antiepileptic)
What drug class is Lithium (Eskalith) in?
mood stabilizer (antimanic)
First generation antipsychotics (FGA's) are used less for schizophrenic patients because of their minimal impact on what?
negative symptoms
what symptoms are second generation antipsychotic drugs effective in treating?
positive and negative symptoms
what symptoms are first generation antipsychotic drugs effective in treating?
positive symptoms
A temporary group of symptoms that looks like Parkinson's disease: tremor, reduced accessory movements (e.g., arms swinging when walking), gait impairment, reduced facial expressiveness (mask facies), and slowing of motor behavior (bradykinesia).
pseudoparkinsonism
Antipsychotics are used for what?
schizophrenia, bipolar disorder, Tourette's syndrome, and nausea
Negative symptoms of schizophrenia are best managed with what type of drugs?
second generation antipsychotic's (SGA)
Metabolic syndrome is more common when using what class of drugs?
second generation antipsychotics
Ataxia, giddiness, serious electroencephalographic changes, blurred vision, clonic movements, large output of dilute urine, seizures, stupor, severe hypotension, coma. Death is usually secondary to pulmonary complications.
signs of advanced lithium toxicity (2.0-2.5 mEq/L)
Gastrointestinal upset, coarse hand tremor, confusion, hyperirritability of muscles, electroencephalographic changes, sedation, incoordination
signs of early lithium toxicity (1.5-2.0 mEq/L)
Convulsions, oliguria (producing none or small amounts of urine), and death can occur.
signs of severe lithium toxicity (2.5 mEq/L or more)
Persistent EPS side effect involving involuntary rhythmic movements. Develops in 10% or more of patients, usually after prolonged treatment, and often persists even after the medication has been discontinued. This side effect usually begins in oral and facial muscles and progresses to include the fingers, toes, neck, trunk, or pelvis. More common in women, it varies from mild to severe and can be disfiguring or incapacitating
tardive dyskinesia
what extrapyramidal side effects are seen later?
tardive dyskinesia
What drug class is Chlorpromazine (Thorazine)?
typical antipsychotic (1st gen)
What drug class is Fluphenazine (Prolixin/Permitil)?
typical antipsychotic (1st gen)
What drug class is Haloperidol (Haldol)?
typical antipsychotic (1st gen)
What drug class is Perphenazine (Trilafon)?
typical antipsychotic (1st gen)
SGAs have a greater risk of what?
weight gain, diabetes, and metabolic syndrome
What is a toxic level of lithium?
1.5 mEq/L or more
when a patient is taking lithium it is important that their fluid intake is how much?
1500ml-3000ml a day or six 12 oz glasses of fluid
How long does it take for Lithium to start being effective?
7-14 days (can take up to 21 days)
It is common for patients on Lithium to gain up to how much water weight in the first week?
5 pounds
What is a therapeutic level of Valproate (Depakote) Valproic Acid (Depakene)?
50-100 mg/l
What is a therapeutic level of Carbamazepine (Tegetrol)?
6-8 mg/l
What are some of the nursing considerations for pseudoparkinsonism?
Administer antiparkinsonian agent such as trihexyphenidyl (Artane) or benztropine (Cogentin). If intolerable, consult prescriber regarding dose reduction or medication change. Provide towel or handkerchief to wipe excess saliva. Teach how to reduce fall risk.
This medication seems to work better in patients with rapid cycling and in severely paranoid angry patients experiencing manias rather than in euphoric, overactive, overfriendly patients experiencing mania. It is also thought to be more effective in dysphoric patients experiencing manias.
Carbamazepine (Tegetrol)
What do second generation antipsychotic medications do?
Antagonize D2 receptors as do FGAs but also bind to serotonin receptors as well (stronger blockade for serotonin). Fewer EPS symptoms.
What drugs are used to help treat EPS side effects ?
Anticholinergics: Cogentin (this is used the most), Artane, Akineton, Benadryl
what are the benefits of long-acting injectable antipsychotics (depot-meds)?
By requiring less frequent medication administration, adherence is improved and conflict about taking medications is reduced.
Other than liver enzymes what other lab should be done when a patient is prescribed Carbamazepine and why?
CBC because it is known to periodically cause leukopenia and aplastic anemia
What drug specifically has the side effect risk of agranulocytosis?
Clozapine (Clozaril)
What is the most effective antipsychotic medication?
Clozapine (Clozaril)
what are some of the nursing considerations for cholestatic jaundice?
Consult prescriber regarding possible medication change. Bed rest and high-protein, high-carbohydrate diet if ordered. Liver function tests should be performed every 6 months.
what are some of the nursing considerations for a patient experiencing akathisia?
Consult prescriber regarding possible medication change. Give antiparkinsonian agent or lorazepam (Ativan) as ordered. Propranolol (Inderal), lorazepam (Ativan), or diazepam (Valium) may be used. Relaxation exercises may be helpful. Take care to distinguish akathisia (inability to sit still, generalized muscle restlessness) from simple anxious repetitive movement (which usually involve only the extremities). In severe cases, may cause great distress and contribute to suicidality. Usually subsides when antipsychotic is discontinued (exception: tardive form of akathisia).
how does sodium effect lithium levels?
High sodium intake leads to lower levels of lithium and less therapeutic effect. Low sodium intake leads to higher lithium levels, which could produce toxicity
When you suspect someone is in NMS what should you do?
Hold all antipsychotics Transfer to a critical care unit Bromocriptine (Parlodel) and dantrolene (Dantrium) can relieve muscle rigidity and reduce the heat (fever) generated by muscle contractions. Cool body to reduce fever (cooling blankets; alcohol, cool water, or ice bath as ordered). Maintain hydration with oral or IV fluids; correct electrolyte imbalance. Treat dysrhythmias. Small doses of heparin may decrease possibility of pulmonary emboli.
What interventions should be done for someone who is experiencing advanced lithium toxicity?
Hospitalization is indicated. The drug is stopped, and excretion is hastened. Whole bowel irrigation may be done to prevent further absorption of lithium
what interventions should be done for someone with severe lithium toxicity?
Hospitalization is indicated. The drug is stopped, and excretion is hastened. Whole bowel irrigation may be done to prevent further absorption of lithium. In addition, hemodialysis may be used in severe cases.
What is the downside of long-acting injectable antipsychotics (depot-meds)?
Lack of dosing flexibility and patients may feel like they have less control and are coerced
This medication is used for maintenance therapy that is usually tolerated well but there is one serious but rare dermatological reaction: a potentially life-threatening rash. Instruct patients to seek immediate medical attention if a rash appears although most are likely benign.
Lamotrigine (Lamacitl)
This medication is approved for both acute treatment and maintenance therapy of mania.
Lithium (Eskalith)
What should be monitored, how long should it be monitored and why is it monitored when a patient is prescribed Carbamazepine?
Liver enzymes should be monitored at least weekly for the first 8 weeks of treatment because the drug can increase levels of liver enzymes that can speed its own metabolism.
what interventions should be done for someone who is experiencing early signs of lithium toxicity?
Medication should be withheld, blood lithium levels measured, and dosage reevaluated.
What are some of the nursing considerations for an acute dystonic reaction?
Monitor and assure open airway. Administer antiparkinsonian agent as above (IM for faster response). Relief usually occurs in 5-15 minutes. Also consider diphenhydramine hydrochloride (Benadryl) 25-50 mg IM/IV. Prevent further dystonias with antiparkinsonian agent. Reassure patient that although frightening, dystonias are not dangerous except for rare airway complications. Stay with the patient to provide comfort and support. Assist patient to understand the event and avert mistrust of medications.
What are nursing considerations for someone with agranulocytosis?
Monitor for neutropenia weekly for 6 months, then twice monthly for 6 more months, then monthly. If neutropenia develops, hold drug and consult prescriber. Moderate neutropenia (ANC 500-999 μL) Severe neutropenia (ANC <500 μL) Both should result in treatment interruption (Clozapine REMS, 2015). In some cases clozapine may be reinstituted once the ANC returns to normal. Reverse isolation may be initiated temporarily. Teach patient to observe for signs of infection and to report these promptly to prescriber
What are some nursing considerations for a patient experiencing hypotension/orthostatic hypotension?
Monitor lying or sitting and standing blood pressure. Hold dose and consult prescriber if systolic pressure is <80 mm Hg when standing. Advise patient to arise slowly to prevent dizziness and to hold onto railings/furniture while arising to reduce falls. If lying down, patient should first move slowly to sitting position and pause until he any dizziness passes before standing. Effect usually subsides in 1-2 weeks. Ensure adequate hydration.
What are the suspected side effects of Lithium?
Nausea, vomiting, diarrhea, thirst, polyuria (producing too much urine), lethargy, sedation, and fine hand tremor Renal toxicity may occur with long-term use Goiter and hypothyroidism
What two second generation antipsychotic (SGA) drugs are commonly used in the treatment of acute mania?
Olanzapine (Zyprexa) Risperidone (Risperdal)
What are some nursing considerations for drugs that cardiac dysrhythmias are a possibility?
Patients, especially those with existing cardiac problems, should always be evaluated before antipsychotic drugs are administered. Monitor pulse for tachycardia and irregularities. Abnormal Q-T interval can be a contraindication for certain antipsychotics
what are some of the nursing considerations for someone experiencing an anticholinergic toxicity?
Potentially life-threatening medical emergency Hold all medications. Consult prescriber immediately. Implement emergency cooling measures as ordered (cooling blanket, alcohol, or ice bath). Urinary catheterization as needed. Administer a benzodiazepine or other sedation as ordered. Physostigmine, an antidote to reverse the toxicity of anticholinergic effects, may be ordered. Evaluate for anticholinergic toxicity any time psychosis appears to be worsening
What antipsychotic drugs have the risk of cardiac dysrhythmias (torsade's)?
SGA's: quetiapine, risperdone, and ziprasidone FGA's: chlorpromazine, haloperidol and thioridazine
what are some of the nursing considerations for tardive dyskinesia?
Screening for abnormal movements at least every 3 months. Purposeful muscle contraction overrides and masks involuntary tardive movements. Discontinuing the drug rarely relieves symptoms but onset may merit reconsideration of medication. Movements associated with tardive dyskinesia may contribute to stigmatizing response by others. Provide support. Teach patient ways to conceal involuntary movements such as holding one hand with the other.
What are some nursing considerations for a patient experiencing metabolic syndrome?
Teach patient how to minimize weight gain through proper nutrition and physical activity, e.g. help the patient to identify low-calorie snacks that he enjoys, engage the patient in regular physical activity, and help the patient to identify and pursue enjoyable physical activities such as walking or cycling. Teach the patient and family about the importance of regular medical evaluation and care to identify and correct possible changes that could lead to this syndrome and increase the risk of premature illness and death
What other medications can also be used in the treatment of acute mania?
The high-potency antianxiety benzodiazepines clonazepam (Klonopin) and lorazepam (Ativan)
What are important teaching points to discuss with a patient with mania that has be prescribed lithium?
What the expected/normal side effects are Expectations of follow-up Factors that influence lithium levels Inform them of how long it takes for it to start to work
Sudden, sustained contraction of one or several muscle groups, usually of the head and neck. Can be frightening and painful, but unless they involve muscles affecting the airway, which is rare, they are not dangerous. However, they cause significant anxiety and should be treated promptly
acute dystonia
What are extrapyramidal side effects?
acute dystonia, akathisia, pseudoparkinsonism, and tardive dyskinesia
Reduced neutrophil counts and increased frequency and severity of infections. Any symptoms suggesting infection (e.g., sore throat, fever, malaise, body aches) should be carefully evaluated
agranulocytosis
The second-generation antipsychotics lurasidone (Latuda) and quetiapine (Seroquel) have FDA approval for the treatment of what?
bipolar depression
If the Carbamazepine begins to increase levels of liver enzymes which in end increase the drugs own metabolism what can this cause?
bone-marrow suppression and liver inflammation
In treating a depressed client that is diagnosed bipolar we would not want to use antidepressant medications because they pose the risk of what?
bringing on a manic episode
Lithium levels are ____________________________ by high salt intake, high sodium bicarbonate intake, pregnancy, caffeine
decreased
Characterized by reduced consciousness and responsiveness, increased muscle tone (generalized muscular rigidity), and autonomic dysfunction. Caused by excessive dopamine receptor blockade One of the first symptoms you will see is a fever and then you would look to see if they are diaphoretic and often the patient will complain of muscle stiffness Later the muscle stiffness will change to cogwheel rigidity and it will lead to them eventually falling in and out of consciousness (autonomic instability)
neuroleptic malignant syndrome (NMS)
What are the life threatening side effects of antipsychotic drugs?
neuroleptic malignant syndrome (NMS), agranulocytosis, and cardiac dysrhythmias (prolonged QT aka Torsade's)
If a patient is no longer going to be taking Lithium how will it be discontinued?
the dosage will be tapered to minimize the risk of relapse
How do first generation antipsychotics work?
they are dopamine antagonists (block dopamine receptors) in both the limbic and motor centers
Dopamine stabilizer-less incidence of metabolic DO, prolactin release and hypotension (Aripiprazole and cariprazine)
third generation antipsychotics
When on lithium you should talk to your provider about having what other systems looked at periodically?
thyroid, parathyroid, and renal function
when should lithium be taken and why?
with meals to avoid stomach irritation