Pharm Test 2: Wk 5-8
How long can the non-hormonal IUD be left in place (FDA approved duration)?
10 years
chlorpromazine (thorazine) (1st gen!)
1st gen ANTIPSYCHOTICS Therapeutic Use: psychosis, N/V, preop sedation, intractable hiccups, tetanus, porphyria (overaccumulation of porphyrin which helps hemoglobin) EPA: block D2 receptor sites in mesolimbic pathway (positive sxs like halluc and delus), also block other D2 receptors (causing EPSE, muscular, and other s/e), other peripheral actions/effects (partial histamine antagonism, partial Ach blockage, antagonism of alpha-adrenergic system) Admin: PO/IM, 200-400 mg per day, indicated all the way down to 6 months old (severe behavioral disturbances) S/E: SO MANY YO. C/I and Precaut: comatose pts, CNS depression, bone marrow depression, reye syndrome, electrolyte abnormalities, congenital long QT syndrome Interactions: give antacids and antidiarrheals 2 hrs prior to admin d/t absorption issues, drugs that have potential to affect QT prolongation Nursing Interventions: monitor and tx EPSEs, monitor for neuroleptic malignant syndrome, monitor for dysrhythmias, fall precautions, reduce WBC and agranulocytosis Edu: education on movement d/o, fall precautions, report sudden fevers (neuroleptic malignant syndrome)
How long can the contraceptive implant be used?
3 years
A client just received a prescription for a CHC. What very important education should be taught to the client before taking a combined hormonal contraceptive?
ACHES A - severe abdominal pain C - chest pain H - headache E - eye problems S - severe leg pain
carbipoda-levodopa (Sinemet)
ANTIPARKINSON'S DRUG therapeutic use: parkinson's disease EPA: DOPAMINE REPLACEMENT, inhibits peripheral dopamine decarboxylation; crossess BBB and serves as dopamine precursor, LEVODOPA CONVERTS TO DOPAMINE, carbidopa (Helping Hands) prevents breakdown of LEVODOPA in bloodstream so more of it can reach the brain Admin: IR (starts working in 30 min, but wears off QUICKLY), and XR (starts working in 2 hrs but lasts 4-6 hrs), 10mmg/100mg to 200mmg/2000mg Side Effects: anticholinergic, N/V (give with food), hypoTN, dizziness and weakness, dark urine, delusions and hallucinations (treated with pimavanserin/nuplazid), TREATMENT CAN CAUSE PSYCHOSIS DUE TO INFLUX OF DOPAMINE C/I and Precaut: angle-closure glaucoma, melanoma, psychosis (makes it worse!), MVIs are c/i (may contain pyridoxine VB6) which diminishes effects of levodopa), moderate alcohol can antagonize the drugs effects, high protein diet may increase BUN and may reduce effectiveness d/t issues crossing BBB Interactions: pimozide - QT prolongation, thiridazine - QT prolongation, MAOIs Nursing Interventions: fall precautions r/t orthostasis, potential for dyskinesias Client Edu: avoid ETOH, take with food to prevent N/V, potential for orthostasis (fall precaution!)
How does raloxifene work to prevent and treat osteoporosis?
Activate estrogen receptors in some tissues and block receptors in other tissues. Activation decreases both bone resorption and bone loss
When considering menopausal hormone therapy (MHT), hormones are prescribed based on whether a client has an intact uterus or not. What hormones must be used if a client has an intact uterus?
An estrogen-progestin combination. You cannot give unopposed estrogen to a client who has an intact uterus. This causes endometrial hyperplasia & increases their risk of cancer
What is the therapeutic action of antiandrogens and estrogen in the role of MTF transgender hormone therapy?
Antiandrogens Inhibitor of androgen receptors Inhibitor of testicular steroidogenesis Estrogen Suppress endogenous androgen secretion Indirectly suppresses testosterone
A client calls the clinic and reports they forgot to apply their new patch on time during the 2nd week (the week 1 patch is still in place). How would you advise this client?
Apply new patch ASAP If patch application occurs within 48 hours, patch change day remains the same and no need for back up method/abstinence. If patch application occurs after 48 hours, use back up method/abstinence for 7 days. The day the new patch is applied becomes the new patch change day.
A client asks you about bioidentical hormones. How would you describe this type of MHT?
Are compounded preparations based on the results of saliva or blood samples
What is the difference between biphasic and triphasic COCs?
Biphasic - provide the same amt of estrogen but progestin is increased halfway through the pill pack Triphasic - have varying levels and estrogen each week. May be good for breakthrough bleeding but increase risk for wt gain and mood changes.
Alendronate falls into which category of osteoporosis medication?
Bisphosphonates
What are the 4 classifications/categories of osteoporosis medications?
Bisphosphonates SERMs Calcitonin Calcium supplements
Calcitonin-salmon should not be administered if what other class/category of osteoporosis medication has already been given to the client?
Bisphosphonates - may decrease response to calcitonin
What is the therapeutic action of mifepristone?
Blocks the effects of progesterone Stimulates uterine contractions (along with misoprostol)
What are 2 concerning side effects of depot medroxyprogesteronae acetate that may deter a client from taking this medication?
Bone loss which is reversible Weight gain
In a client taking MHT, what types of cancer are contraindications to using estrogen only therapy (Premarin)?
Breast, vaginal, cervical, and endometrial cancers
What are the 2 main calcium supplements?
Calcium citrate and calcium carbonate
What is the time frame that a client can safely take mifepristone?
Can be given up to 70 days gestation along with misoprostol
The progestin component of contraceptives also have what therapeutic action(s)?
Causes atrophy of the endometrium Thickens the cervical mucus Impairs fallopian tube motility and peristalsis
What are the side effects associated with IUDs?
Changes in menstrual patterns Cramping Expulsion Embedment Pelvic infection Uterine perforation Pregnancy complications
What are options for combined hormonal contraceptives (CHCs)?
Combined oral contraceptives Contraceptive ring Contraceptive patch
When using combination estrogen/progestin MHT (Prempro) what is a major complication that could occur if used longer than 5 years?
Conjugated estrogen + medroxyprogesterone has an increased risk of breast cancer
What is the most effective form of emergency contraception and when should it be used?
Copper IUD inserted within 5 days of unprotected intercourse
Other than pregnancy prevention, what are additional benefits of hormonal contraceptives?
Cycle regulation Decrease ovarian cysts Improve PMS and PMDD Treatment of endometriosis Prevention of ovarian and endometrial cancer
What is the therapeutic action of alendronate?
Decrease bone resorption by inhibiting activity of osteoclasts
There are several drug interactions with calcium supplements. What are those interactions?
Digoxin, glucocorticoids, thyroid hormones, tetracycline, quinolones, and thiazide diuretics
What is the therapeutic action of emergency contraception?
Disrupts the timing of ovulation and prevents fertilization of an ovulated egg. It does not interrupt an existing pregnancy
Raloxifene should not be used concurrently with which hormone?
Estrogen
What are some common side effects when using estrogen and antiandrogens in MTF transgender hormone therapy?
Estrogen: Headache, mood changes, nausea, loss of libido, Increased triglycerides Antiandrogen: Increased urinary frequency, hyperkalemia, hypotension, renal insufficiency
How often is depot medroxyprogesterone acetate (injectable contraceptive) given?
Every 3 months
Many of the side effects related to CHCs are due to the differences in the estrogen-progestin ratio. What major side effects do excess estrogen and progestin cause?
Excess estrogen - Headache, Breast tenderness, Fluid retention Excess progestin - Excess hair growth, Decreased breast size, Vaginitis
alendronate (bisphosphonate)
FIRST LINE CHOICE FOR TX and PPX of OSTEOPOROSIS ther use: ppx and tx of postmenopausal osteoporosis in female pts and in male pts, as well as those on long term glucocorticoid therapy epa: decrease bone resorption by inhibiting activity of osteoclasts admin: oral (wkly or daily), optimal duration of therapy not established (use for 5 yrs and then extend to 10 yrs or switch) complications: ulcers of the esophagus, upper GI irritation, N/V, abd pain, joint/bone/muscle pain, eye pain and vision changes c/i and precaut: hypocalcemia, renal insufficiency, abnormalities of the esophagus, inability to stand or sit upright for at least 30 min after taking med, avoid use after bariatric surgery. precaut: upper GI disorders, liver disease, heart failure interactions: calcium supplements, DAIRY PRODUCTS n/i: monitor for serious S/E involving muscle and joint pain, vision changes ,esophagitis, pain med to help with muscle and joint pain, monitor bone density edu: educate about S/E, give med 30 min before other meds/food/drink, only drink water for 30 min after taking med, take with full glass of water, remain in sitting or standing position for 30 min after taking me, encourage calcium, vit D, weight bearing exercises/activity
What signs/symptoms should the client immediately report if they are using an IUD?
Feeling part of the IUD Have pain or bleeding with intercourse Have unusually heavy bleeding Possibly exposure to STI/possible pregnancy Unusual pelvic pain Unexplained fever or chills
A client just received a prescription for a CHC. What are the 3 methods for starting a CHC?
First day method - start on first day of menstruation Sunday start method - start on Sunday after the first day of menstruation Quick start/same day method - start on same day client receives contraceptive -
How are progestin only pills (POPs) started?
First day of menses preferred If started within the first 5 days of menses then no back up method needed. If not started within the first 5 days of menses, then use back up method/abstinence for 2 additional days from onset of menses.
How does a hormonal IUD work to prevent pregnancy?
Foreign body effect - inflammatory reaction in the uterus making it a less than favorable environment for a pregnancy Thickens cervical mucus Inhibits sperm survival Thins the uterine lining
Education is very important when a client begins taking alendronate. What two main points are important to emphasize with this medication ?
Give medication 30 minutes before other meds, food, and drink. Remain in sitting or standing position for 30 minutes after taking med.
When can the hormonal and non hormonal IUDs be inserted?
Hormonal IUD à anytime during the cycle - use back up method/abstinence 1 week after insertion if IUD placed > 7 days after LMP Non- hormonal IUD à anytime during the cycle à effective immediately
What are 2 major complications of calcium supplements?
Hypercalcemia and kidney stones
for pts with GI disease and osteoporosis
IV bisphosphonates for male and female pts, zoledronic acid (reclast) and ibandronate (boniva) denosumab (prolia) : monoclonal antibody, slows bone loss, can be used for male and female, 2 injections per year
As the nurse, you know that the quick start/same day method is generally preferred for starting CHCs because there is a 25% chance that the client will not start the medication if the start date is delayed. If you are educating a client about the quick start/same day method, what additional information do you need to provide?
If CHC is started within 5 days of menstruation, no back up method/abstinence is needed. If CHC is not started within 5 days of menstruation, use back up method/abstinence for 7 days.
A client calls the clinic and states their contraceptive patch has fallen off. How would you advise this client?
If it has been <24 hours, reapply or replace the patch at the same location. If it has been > 24 hours, a new patch should be applied and this becomes the new patch change day. Back up method/abstinence for at least 7 days should also occur.
How does calcitonin-salmon work to treat osteoporosis?
Inhibits the action of osteoclasts Decreases bone resorption
What should a client do if their contraceptive ring breaks?
Insert a new ring. There is no need for back up method or abstinence.
What are contraindications to using an IUD?
Known or suspected pregnancy Undiagnosed/unexplained vaginal bleeding Uterine cavity abnormalities Active pelvic infection Uterine or cervical cancer (and breast cancer for hormonal IUDs) Wilson's disease or copper allergy (for copper IUD) Do not use copper IUD in client who already has heavy menstrual bleeding
When using estrogen only or estrogen/progestin MHT, what s/sx should a client report immediately?
Leg pain Chest pain Leg edema Sudden vision changes Severe headache Persistent or recurrent vaginal bleeding Shortness of breath
What progestin does the hormonal IUD contain?
Levonorgestrel
What is the emergency contraceptive that can be obtained OTC and how is it taken?
Levonorgestrel - Plan B One Step Taken within 72 hours of unprotected intercourse
What are the main drug interactions associated with calcitonin-salmon?
Lithium - may decrease levels Bisphosphonates - decrease response to calcitonin
Generally speaking, which contraceptive methods are more effective and are less impacted by issues with typical use?
Long acting methods such as IUDs and the implant (also permanent methods such as vasectomy and tubal ligation).
What is the name of the primary oral abortifacient agent?
Mifepristone
How long can the hormonal IUDs be left in place (FDA approved duration)?
Mirena (8 year) Liletta (8 year) Kyleena (5 year) Skyla (3 year)
A client taking calcitonin-salmon should immediately notify the provider about what s/sx?
Muscle spasms, tingling of fingers and toes - concern for hypocalcemia
A client is interested in taking a CHC (specifically a COC). As you perform a medication reconciliation, you realize the client is taking phenytoin for seizures. Would you expect the provider to prescribe a CHC for this client? Why or why not?
No, a CHC should not be prescribed. Anticonvulsants have been shown to interact with CHCs - especially oral contraceptives. The patch and ring may have less of an interaction but it would be best to discuss different forms of contraception since the medication will be used long term.
adverse effects: neuroleptic (antipsychotic) TOXICITY
OD: hypotn, CNS depression, EPS, death by OD is rare atropine psychosis: psychotic delirium caused by excess antichol effects sxs: agitation, confusion, tachycardia, dry flushed skin
Micronized progesterone (prometrium) should not be given to someone with what allergy?
Peanut allergy - it is suspended in peanut oil
You are educating a client about using a contraceptive patch. What are the general user instructions regarding the patch?
Place new patch each week for 3 weeks, then remove patch on 4th week. Rotate sites especially if there is skin irritation (see PPT for appropriate sites).
What are the options for progestin only and LARC methods of contraceptives?
Progestin only pill Injectable - Depo Hormonal and Copper IUD Implantable contraceptive
A client who is taking combined oral contraceptives (COCs) calls the clinic to report breakthrough bleeding. The client has been taking the medication less than 6 weeks. What advice would you give the client?
Provide reassurance and encourage them to continue taking the medication for at least 3 months to allow their body time to adjust to the hormones.
What is the therapeutic use/goals of MTF transgender persons?
Reduce effect of endogenous male sex hormones. Achieve balance with hormonal medications and client desired outcomes
osteoporosis drugs
SERMs bisphosphonates calcium supplements calcitonin
adverse effects: agranulocytosis
SEVERELY DECREASED WBC suspect if develops unexplained sore throat, fever, malaise during first two months of initiating meds potentially lethal - fatalities are the result of overwhelming infection
anticholinergic adverse effects
SLUD salivation lacrimation urination defecation can't see, can't spit, can't pee, can't poop dry mouth, nasal congestion, blurred vision, urinary hesitancy or retention, constipation
If a client is using a contraceptive implant, what signs and symptoms should they immediately report?
SOB, chest pain, lower leg pain, severe headache, or migrated implant
What are some other medications (not hormone related) that may be used for menopausal symptoms?
SSRIs SNRIs Methyldopa Clonidine Gabapentin
Raloxifene falls into which category of osteoporosis medication?
Selective estrogen receptor modulator (SERMs)
What are serious (black box warning) side effects associated with mifepristone?
Serious bleeding and fatal infections that present atypically
What are 3 common labs that should be monitored frequently when a client is taking MTF transgender hormone therapy?
Serum testosterone Serum estradiol Serum electrolytes (when on spironolactone)
A client who is using the contraceptive ring, calls the clinic concerned because their ring was expelled for 3 ½ hours. The client reports that this is week 1 in their cycle. How would you advise this client?
Since it has been longer than 3 hours since the ring was expelled and it is within the first 2 weeks of their cycle, the client should reinsert the ring ASAP and use back up method/abstinence for 7 days.
A client who is using the contraceptive ring calls and states they forgot to take out their ring on week 4 of their cycle. It is almost time to insert a new ring and begin a new cycle. How would you advise this client?
Since it is between 3 and 5 weeks since the client forgot to remove the ring, advise the client to remove the ring and insert a new ring after a 1-week ring free interval or insert a new ring immediately if they prefer continuous use.
A client using a progestin only pill, calls the clinic reporting they have been vomiting from the flu. They last took their progestin only pill 2 hours ago and had the most recent episode of emesis 30 minutes ago. How would you advise this client regarding their POP.
Since vomiting occurred within 4 hours of taking the POP, the client should continue taking the pills as scheduled but use back up method/abstinence for 48 hours
Who is a good candidate for progestin only and LARC methods?
Someone who cannot have estrogen and has contraindications for CHC use.
What is the therapeutic action of the contraceptive implant?
Suppresses ovulation and thickens cervical mucus
What is the main therapeutic action of estrogen and progestin (working together) in combined hormonal contraceptive products?
Suppression of folliculogenesis and suppression of ovulation.
If the same client calls back after using the combined oral contraceptives for 4 months and still reports breakthrough bleeding. The client desires to remain on pills. What action would you anticipate the provider to take?
Switch the client to an oral contraceptive with a higher dose of estrogen since low estrogen is the leading cause of breakthrough bleeding.
DO NOT USE UNOPPOSED ESTROGEN IN SOMEONE WITH AN INTACT UTERUS (MUST HAVE A PROGESTIN TO KEEP UTERINE LINING FROM THICKENING AND PREDISPOSES THEM TO ENDOMETRIAL HYPERPLASIA
TRUE.
How should a client be instructed to take calcium supplements in relation to other medications?
Take calcium supplements 1 to 2 hours before or after other medications
A client calls the clinic and reports missing 1 of their COC pills. How would you advise this client?
Take the missed pill ASAP. Continue taking the remaining pills at the usual time. No need for back up method/abstinence.
A client calls the clinic and reports missing 3 of their COC pills in a row. How would you advise this client?
Take the most recent missed pill ASAP. Any other missed pills should be discarded. Continue taking the remaining pills at the usual time. Use back up method/abstinence until pills have been taken 7 consecutive days. If pills were missed in the last week of active (hormone) pills, then finish the remainder of the active pills and immediately start a new pack. If unable to start a new pack, use back up method/abstinence until pills have been taken 7 consecutive days.
A client is interested in the contraceptive ring. They ask how often the ring needs to be changed. How would you answer?
The client will need to place 1 ring in the vagina for 3 weeks, then remove the ring on the 4th week.
What is a very important education point that must be emphasized if a client is taking the traditional/older progestin only pill that contains norethindrone?
The pill must be taken at the same time every day! If more than 3 hours late the client will need a back up method/abstinence for 48 hours. All pills in the pack must be taken since each pill contains progestin and has a short period of coverage.
EC
Ther Use: ppx preg from occurring after UPIC EPA: disrupts timing of ovulation, prevents fertilization of an ovulated egg, is NOT an abortifacient and does not interrupt an existing preg Admin: oral EC (UPA 30 mg up to 120 hrs after/ELLA, weight based), LNG 1.5 mg can be used up to 72 hrs/PLAN B, weight based), combined oral estrogen and LNG (100 mcg and 0,5 mg up to 72 hrs, less effective), COPPER IUD (within 5 days of UPIC) or levonorgestrel IUD (inserted within 5 days of UPIC) S/E: abdominal/pelvic pain, N/V, excessive bleeding, infection C/I and Precaut: pregnancy, breastfeeding (pump and dump milk for 24h) Interactions: may decrease efficacy of anticonvulsants, antiretrovirals, antimicrobials (rifampin), herbal (st. j wort) N/I: provide pt edu, provide pt with addtl resource as needed, evaluate need for f/u (infection, bleeding) pt edu: when to take med, side effects to expect, how to manage discomfort, OTC pain med
LARC: Nexplanon implant
Ther Use: prevent preg (only FDA approved use), other cycle related benefits such as decreased endometriosis pain EPA: suppresses ovulation, thickens cervical mucus --> decreases sperm penetration Admin: implanted into non-dominant arm, etonogestrel 68 mg slowly released, can be used for 3 yrs S/E: implant site reactions (erythema, hematoma, pain, swelling), unscheduled or irregular bleeding, HA, vaginitis, weight gain, breast tenderness, mood changes, migration of implant c/i and precaut: known or suspected preg, active thrombophlebitis or current or past hx of thromboembolic d/o or cerebral vascular disease, known or suspected breast cancer, undiag abnormal uterine bleeding, benign or malignant liver tumors, severe cirrhosis or active liver disease Interactions: anticonvulsants, antiretrovirals N/I: VS, hx, rule out preg, evaluate for pain and bruising/bleeding at insertion site, provide edu Edu: best time is on their period!, if not on menses or not within 5 days of your cycle, use backup method/abstinence for at least 7 days after placement, teach how to check placement, report any severe s/sx such as SOB, CP, lower leg pain, severe HA, or migrated implant
MHT: Estrogen
Ther Use: reduce menopausal sxs EPA: binds to estrogen receptors. provides a stable amt of estrogen to help prevent menopausal sxs. admin: oral - daily (premarin/conjugated estrogen), transdermal (17-beta estradiol), rings, creams, gels/lotions s/e: N, fluid retention, HTN, breast tenderness, skin irritation (transdermal), irregular uterine bleeding, endometrial hyperplasia, VTE/PE, increased lipid levels, stroke/Mi C/I and precaut: pregnancy, undiag vaginal bleeding, active or hx of or risk for thromboembolic events/d/o, suspected or confirmed estrogen r/t cancer, suspected/confirmed liver or gall bladder disease, known or suspected estrogen-dependent neoplasia, CAD, smoking. Precaut: HTN, DM, migraines, kidney dysfunctions Interactions: may decrease efficacy of anticonvulsants, antiretrovirals, antimicrobials (rifampin), herbal (st J), may increase levels of benzos and tricyclic antidepressants n/i: VS (BP checks), pt intake and hx, rule out preg, good pt edu pt edu: report leg pain, CP, leg edema, sudden vision changes, severe HA, vaginal bleeding, SOB specific ed (oral): take at same time each day, take with food to prevent N specific ed (transdermal): apply at recommended interval, apply to clean/dry/intact skin on abd or trunk, rotate sites, DO NOT PUT ON BOOBS OR WAIST ring: how and when to insert creams: use at bedtime, no UPIC gels/lotions: apply at correct locations
A 36 yo client is seen in the clinic and desires a CHC. Their history reveals smoking 1 PPD for the past 10 years and prior VTE during pregnancy 7 years ago. Additionally, their aunt has a history of CVA. Is this client a good candidate for a CHC? Why or why not?
This client is not a good candidate for anything that contains estrogen. The combination of estrogen, age > 35, smoking, and prior history of VTE put this client at high risk for having another VTE. This client may be a candidate for a progestin only contraceptive or a non-hormonal method. Personal history of CVA (not family history) would be a contraindication for CHCs.
What is the difference between typical versus perfect use when discussing contraceptive methods?
Typical use - how effective contraception is when used well but not taken exactly as prescribed (i.e. taking medication late or forgetting it) Perfect use - how effective contraception is when used perfectly and exactly as prescribed
What are two major SE/complications involving alendronate?
Ulcers of the esophagus and upper GI irritation
What are the contraindications for using hormones in MTF transgender hormone therapy?
Unstable ischemic cardiovascular disease Estrogen-dependent cancer End stage chronic liver disease Active psychosis/SI Hypersensitivity to one of the components of the formulation
How can calcitonin-salmon be administered?
Via intranasal spray, IM or SubQ injection
A client asks you if there are any COCs other than the traditional 21/7 formulation. How would you respond?
Yes, there are pills that have 24 or 26 days of active pills with only 4 or 2 inactive days. There are also 91 day pill packs (84 active and 7 inactive pills). There is also a 365 day pill pack.
mifepristone
abortifacient med ther use: preg termination (IUP through 70 days gestation, given with miso) EPA: blocks the effects of progesterone, stimulates uterine cxs along with miso Admin: oral (200 mg), could take effect in 2-24 hrs, followed by high dose miso S/E: abd cramping, uterine cramping, N, HA, HTN, angioedema black box warning: risk for serious bleeding and fatal infections, atypical presentation of infections c/i and precaut: hypersensitivity to mife, IUD in place, ectopic preg or undiag adnexal mass, unexplained vaginal bleeding interactions: concurrent use with ANY blood thinners could lead to increased risk fo severe uterine bleeding N/I: monitor BP and HR, monitor for abnormal bleeding, evaluate for N/V, evaluate pain Pt Edu: be at appropriate timing for preg termination, miso given 24-48 hr after mife, what side effects to expect, how to treat s/e with OTC pain med, heating pads, nausea med
Memantine (namenda)
alzheimers/neurodegenerative med therapeutic use: moderate to severe alzheimer dementia epa: binds NMDA receptors, may slow Ca influx and nerve damage, NMDA receptor antagonist Admin: PO, 5-20 mg PO q day, divide doses greater than 5 mg complications: dizziness, HA, confusion, constipation c/i and precaut: contraindicated in renal failure, caution in renal and liver disorders (lower dose if so), caution in seizure disorders interactions: antacids - sodium bicarb, drugs that raise pH of urine will raise levels of drug N/I: monitor for constipation (give comfort meds), dizziness, increased confusion edu: educate caregivers to monitor for increasing confusion, monitor for dizziness and HA
who is a good candidate for progestin only and LARC contraceptive methods?
any pt who cannot have estrogen!! pt who cannot take COC due to comorbidities or chronic disease active viral hepatitis or cirrhosis breastfeeding pt HTN pts pt over 35 and smoking >15 cig per day
benefits of atypical antipsych meds
are effective for BOTH positive and neg sxs, but WAY better with positive sxs like halluc and delus atypical antipsych improve negative sxs by about 25%, compared with 10-15% improvement with conventional antipsychotics cause fewer EPS less risk of developing tardive dyskinesia
risperidone (risperdal)
atypical antipsychotic (2nd gen!) Therapeutic use: schizophrenia, bipolar I, acute manic/maixed, irritability associated with ASD EPA: exact MOA unknown, antagonizes DOPAMINE PRIMARILY, 5HT SECONDARILY Admin: PO; Oral Disintegrating Tablet; long-acting IM, 1-16 mg per day for PO and ODT, 25-50 mg q2wk for long-acting IM Side Effects: So many YO! C/I and Precaut: lactating pts, dementia related psychosis (black box warning), CNS depression, fall risk r/t orthostasis Interactions: antiHTN (potentiate their effects), anti-parkinson's meds (counteract each other in relation to dopamine) N/I: monitor sedation and dizziness, fall precautions, metabolic monitoring, come in if you begin lactating (male or female) Edu: monitor metabolic sxs, fall precautions, prolactin edu, EPS edu, THIS MED MAKES US STARVING/EAT UNHEALTHILY
biphasic and triphasic
biphasic - maintains same amt of estrogen but progestin is increased halfway through pill cycle triphasic - have varying levels of estrogen and progestin every week less progestin in general than monophasics
menopause: increased risk
bone loss osteoarthritis cardiovascular disease body comp changes skin changes endometrial cancer
antipsychotic side effects
both conventional and atypical antipsych have similar adverse effect profiles, but: conventional are more likely to cause movement disorders atypical are more likely to cause metabolic disorders however, ALL antipsych can cause all of the things EPS (drug - induced movement d/o, caused by dopamine-receptor blocking agents) - dystonia, parkinsonism, akathisia, tardive dyskinesia
adverse effects: atypical antipsychotics
can have the same s/e as first gen less likely to cause EPS than first gen (but do all the time) more likely to cause weight gain and metabolic syndrome
contraceptive patch
combo of estrogen and progestin therapeutic use: ppx of pregnancy, treat other repro concerns (cycle reg, endometriosis, ovarian cysts) EPA: estrogen and progestin: suppression of ovulation by inhibition of GnRH, LH, FSH, and the mid-cycle LH estrogen: stabilizes the endometrium to help with cycle control progestin: causes atrophy on endometrium, making it less suitable for implantation. thickens cervical mucus to impair sperm travel. impairment of normal tubal mobility and peristalsis admin: transdermal (place new patch each wk for 3 wks, then patch FREE for 4th wk, can use either (EE/N or EE/LNG patch) side effects: skin reactions, HA, N, breast tenderness, breakthrough bleeding, weight changes/fluid retention, decreased libido, mood changes, gallbladder disease, VTE C/I and Precaut: same as COCs, BMI >30 and/or clients weighing >198 lbs Interactions: same as COCs N/I: VS, pt intake and hx, provide good pt edu, rule out pregnancy Pt Edu: stay at room temp, common s/e, ACHES, patch application instructions, how to start patch (first day, sunday start, quick start methods), how to manage problems with the patch
conventional (1st gen) vs. atypical (2nd gen) antipsychotics
conventional (1st gen) - classified by potency in relationship to their ability to antagonize CNS D2 receptors, HOW WELL DO THEY BLOCK DOPAMINE, are not specifically selective D2 receptor pathways that are associated with psychosis, developed around 1950 atypical (2nd gen) - developed AFTER 1990, less D2 receptor blockade, also antagonize other D receptor subtypes and 5HT2 receptor subtypes
What substance does the non hormonal IUD contain?
copper
luteal phase
days 14-28 main hormones: estrogen and progesterone
neurochemistry associated with neurocognitive disorders due to alzheimer's disease
decrease in ACH increase in glutamate (overstimulation of NMDA and increase in intracellular calcium and neuron degeneration and cell death)
MHT: estrogen and testosterone
decrease in testosterone accompanies menopause: this can lead to loss of libido ONLY indication is severe vasomotor sxs and loss of libido long term use is assoc with hepatocellular neoplasm, increased edema, elevation of cholesterol testosterone can lead to hirsutism, voice changes, decrease in HDL estratest = most common brand and is high dose not recommended for routine use
parkinson's disease pathophysiology
degeneration of dopamine neurons in the extrapyramidal motor pathway dopamine and ACh imbalance stimulation of GABA resulting sxs: rigidity, bradykinesia, tremors, masked facies, pill-rolling DECREASE IN DOPAMINE onset usually gradual (after age 50) - slow progressive mask-like and blank expression stooped posture pill rolling tremors tremor in hands and arm shuffling, propulsive gait rarely occurs in black population muscle rigidity possible mental deterioration depression bradykinesia - loss of normal arm swing while walking
Delayed contraceptive patch changes
delay in beginning the first patch in a cycle: apply patch as soon as pt remembers and use backup contraception/abstinence for 7+ days, with the day the pt applies new patch becoming the new patch change day delay in beginning the 2nd or 3rd patch in a cycle: change patch asapt remembers, if pt change occurs within 48 hrs, we good. if patch change occurs after 48 hrs, use back up/abstinence for 7 days. the day they apply new patch becomes new patch change day. delay in removing third patch in a cycle: remove asapt remembers, patch change day not altered, no backup needed detached patch: <24 hr: reapply new one in same location, >24 hr (new patch applied and this becomes new patch change day, use backup method/abstinence for 7 days +
EPS
dystonia: severe muscle spasm -develops within first few days, often within hrs -common muscles involved: tongue, neck, face (oculogyric crisis/looking up), back, laryngeal airway obstruction parkinsonism -develops within first month, tends to resolve spontaneously, commonly manifests as akinesia, muscle rigidity and posture changes, tremors, hypersalivation and drooling, mask-like facies akathisia -extremely uncomfortable profound sense of restlessness, inability to sit or stand still, internal feelings of relentless anxiety and uneasiness, develops within first 2 months of use (leads to increased risk for suicide - so painful!) tardive dyskinesia - involuntary twisting movements, begins with tongue and face, may progress to limbs and trunk, sometimes irreversible, 15-30% of those rx long-term, onset of months to years
contraceptive ring
estrogen AND progesterone therapeutic action and EPA: same as COCs admin: vaginal (place 1 ring for 3 wks, then remove on 4th wk), NuvaRing (monthly) or Annovera (yearly) s/e: HA, vaginal sxs, breakthrough bleeding, N, breast tenderness, weight changes/fluid retention, decreased libido, mood changes, gallbladder disease, VTE, toxic shock (rare) C/I and precaut: same as COC Interactions: oil based vaginal meds, same interactions as COC (but more rare due to localization of hormone release!!) N/I: VS, pt intake and hx to rule out preg, provide good pt edu Pt Edu: store at room temp or fridge, common side effects and complications, ACHES, how to insert and remove ring, how to start using ring (first day, sunday start, quick start methods), how to manage problems with the ring
menopausal hormone therapy (MHT)
estrogen therapy (ET) for use with pts who have had a hysterectomy with bilateral removal of uterus and ovaries (SURGICAL MENOPAUSE) estrogen-progestin (EPT) therapy for use with pts who have an intact uterus goal: relieve menopausal/vasomotor sxs DO NOT USE UNOPPOSED ESTROGEN IN SOMEONE WITH AN INTACT UTERUS (MUST HAVE A PROGESTIN TO KEEP UTERINE LINING FROM THICKENING AND PREDISPOSES THEM TO ENDOMETRIAL HYPERPLASIA)
MHT: Bioidentical Hormones
estrogen-like compounds derived from plants custom-made for the pt tri-est (triple estrogen) bi-est (double estrogen) straight estriol micronized progesterone
estrogen
ethinyl estradiol (EE) estradiol valerate estetrol (plant-based)
monitoring of MTF transgender people on hormone therapy
evaluate clients every 3 mo in the first year and then 1-2 times per year to monitor for appropriate signs of feminization and for development of adverse reactions measure serum testosterone and estradiol every 3 months serum testosterone levels should be <50 ng/dL serum estradiol should not exceed the peak physiologic range of 100-200 pg/mL for indvls on spironolactone, serum electrolytes (particularly K) should be monitored every 3 months in the 1st yr and annually after routine cancer screening is recommended consider BMD testing at baseline in individuals at low risk, screening for osteoporosis should be conducted at age 60 yo or in those who are not compliant with hormone therapy
managing problems with contraceptive ring
expelled or removed ring: <3 hr(nuvaring) or <2hr(annovera): reinsert and you're good. >2-3 hr: action depends on wk of cycle (first 2 wks, reinsert and use backup/abstinence) (wk 3 of cycle - omit third wk and start new ring asap, use backup method/abstinence until new ring in place for 7 days) forgotten or late ring: > 3 wks and < 5 wks, remove ring and insert a new ring after a 1 wk free interval or insert new ring asap if cont use is preferred, >5 wks (remove old ring, get preg test and EC if needed. insert new ring and use backup/abstinence for 7 days) broken ring: insert new ring and you good
instructions on how to start COCs
first day start method: initiated on first day of menstruation sunday start method: initiated on the sunday after the first day of menstruation quick start/same day start method: initiated the day the pt receives the contraceptive, if within the first 5 days of menstrual cycle, no additional contraceptive protection is needed, if NOT within first 5 days of menstrual cycle, advise backup method or abstain for 7 days
progesterone (progestin)
first gen: norethindrone acetate, ethynodiol diacetate, lynestrenol, norethyndrel second gen: norgestrel, noresthisterone, levonorgestrel third gen: desogetrel, gestodene, norgestimate fourth gen: drospirenone, segesterone
haldol/haloperidol
first line tx non-psychiatric hospitalized pts experiencing agitation and/or delirium
estrogen only therapy and combined hormone therapy
for those who seek therapy in their late 40s-50s, absolute risk of complications is very low CHD invasive breast cancer stroke pulm edema colorectal cancer hip fracture death
adverse effects with antipsych (cont)
hypoTN - blocks alpha 1, tolerance develops in 2-3 months sedation - blocks histamine, some block N/E seizures arrhythmias associated with sudden death macular papular rashes jaundice neuroendocrine: gynecomastia, galactorrhea, menstrual irregularities sexual: decrease libido, impaired ability to achieve orgasm, erectile and ejaculatory dysfunction metabolic s/e: STARVING EATING ALL THE TIME, glucose dysregulation, weight gain, lipid dysregulation
androgenic
increased male characteristics hair growth, hirsutism, oily skin, acne, etc.
metabolic syndrome assoc with atypical antipsychotics
insulin resistance HTN high serum lipids obesity coagulation abnormalities product labeling warning for hyperglycemia and diabetics
LARC
long-acting reversible contraceptives
other meds used for menopausal sxs
low dose COCs TSEC's (SERM and estrogen) SSRIs (sertraline, escitalopram, paroxetine) SNRIs (venlafaxine) methyldopa clonidine gabapentin
adverse effects: differences by potency
low potency: more antichol type s/e, sedation and hypoTN high potency: antichol less common, more EPS
estrogen therapy
lowest dose for shortest amt of time
MHT: progesterone
medroxyprogesterone acetate (most common rx'd progestin) natural micronized progesterone (prometrium) - AVOID WITH PEANUT ALLERGY, TAKE AT NIGHT norethindrone usually in combo with estrogen mirena IUD used off-label for MHT for those that can't tolerate oral progestin
donepezil (aricept)
meds for neurocognitive disorders therapeutic use: alzheimer dementia - mild, moderate, and severe EPA: reversibly binds to and inactivates acetylcholinesterase Admin: PO or ODT, 5-10 mg PO qbedtime Complications: N/V, diarrhea, loss of appetite, insomnia, dizziness, HA, syncope C/I and Precaut: GI bleed, cardiac disease, hyperthyroidism Interactions: antihistamines - reduce effectiveness, NSAIDs - increase GI bleed risk Nursing Interventions: give with food for GI sxs, monitor for weight and GI bleeds and insomnia and dizziness, fall risk r/t syncope Edu: take with food at bedtime, report severe N/V/D, educate on GI bleeds
adverse effects: neuroleptic malignant syndrome
most commonly seen with 1st gen, can still be seen with 2nd gen psychotics primary sxs (caused by dopamine blockade) severe rigidity and tremors sudden high fever severe sweating and drooling autonomic instability changing LOC with possible: progression to seizures, progression to death fatality rate: 10-20%
complementary and alternative choices for menopause
natural soy/soy derivatives red clover extract actaea racemosa or black cohosh vitamin E evening primrose oil ginseng valerian melatonin
negative sxs and atypical antipsychotics
negative sxs are a result of hypodopaminergic process in frontal lobe selective subtypes of 5HT inhibit dopamine drugs that antagonize these 5HT subtypes will increase frontal lobe dopamine
Extended Hormone Oral Contraceptive Pills
offer an extended amt of active pills with hormones 91 and 365 days
shortened hormone free interval
offer more active pills with hormones 24-26 days
ovulatory phase
ovulation occurs mid-cycle with the surge in LH
menopause
permanent cessation of menses 3 stages during transitional process: perimenopause - occurs up to 10 yrs prior to menopause (avg age of 42-55) (FSH levels continue to rise to try to reignite the ovaries) menopause - year without menses (median age is 51) postmenopause - time afterwards
estrogenic
pertaining to producing female characteristics breast tissue, etc.
osteoporosis prevention
postmenopausal pts should take 1200 mg/day calcium and 800 IU/day vitamin D premenopausal and male pt should take 1000 mg/day calcium and 600 IU/day vitamin D exercising diet cessation of smoking
benefits of hormonal contraceptives
pregnancy prevention cycle regulation r/t dysmenorrhea, menorrhagia (heavy bleed) menometrorrhagia (abnormal uterine bleed) decrease ovarian cysts improve PMS and pre-menstrual dysphoric disorder tx of endometriosis ppx of ovarian and endometrial cancer
osteoporosis
progressive, debilitating skeletal disease characterized by low bone mass and skeletal fragility diagnosed through BMD test (T score between +1 and -1 is expected/healthy, <-2.5 indicates osteoporosis) MHT is no longer recommended for tx of osteoporosis but should be considered as a preventative measure in postmenopausal clients who are at risk
tx of EPS other than tardive dyskinesia
propranolol for dyskinesia benztropine (cogentin) and trihexyphenidyl (artane) --> both block central cholinergic receptors (dopamine deficiency results in excess cholinergic effects) diphenydramine (benadryl) ---> histamine blocker, effects in treating EPSEs is related to suppression of central cholinergic activity and prolonged action of dopamine by inhibiting its reuptake and storage
monophasic
provides the same amount of hormones every day for 21 days - days 22-28 are inactive pills modified monophasic provides very low dose estrogen on days 24-28
feminizing effects in MTF transgender people
redistribution of body fat decrease in muscle mass and strength softening of skin/decreased oiliness decreased sexual desire decreased spontaneous erections male sexual dysfunction breast growth decreased testicular volume decreased sperm production decreased terminal hair growth scalp hair voice changes
treatment of tardive dyskinesia
removal of offending drugs - slow taper! ingrezza (valbenazine) or austedo (deutrabenazine): vesicular monoamine transporter 2 inhibitors (may be used for huntington's!) switch to another agent with less potential for TD (clozapine, another AAP) clonazepam vitamin E benztropine (cogentin) may make it worse
psychosis can be present in the following d/o:
schizophrenia, mania, depression, drug/med intoxication, drug/med withdrawal, general med conditions, delirium, traumatic brain injury, dementia
recommended order of menopausal therapy
short term tx of sxs at the lowest possible dose for the shortest period possible if vasomotor sxs not controlled, higher estrogen dose used for a shorter period if there is a c/i to MHT or the decision has been made to not use these methods, use a SSRI/SNRI/other med or alternative therapy
for pts with severe osteoporosis:
teriparatide (forteo) synthetic parathyroid hormone can be used with male and female pts promotes new bone growth limited to 24 months use injection
follicular phase
the first 13-14 days main hormones involved: FSH, estrogen, LH
calcium supplements: calcium citrate and calcium carbonate
ther use: improves calcium deficiency epa: in osteoporosis, they help to prevent or decrease the rate of bone loss admin: oral (daily), IV s/e: N/V,C, hypercalcemia, kidney stones contraindic/precaut: hypercalcemia, kidney stones, low phosphate levels, cardiac dysrhythmias, caution in low gastric motility pts interactions: may increase risk of dig tox, glucocorticoids decrease absorption of calcium, decreases absorption of thyroid hormones, tetracycline and quinolone antibiotics, thiazide diuretics may increase risk for hypercalcemia n/i: monitor serum calcium, decreased gastric and intestinal motility, flank pain, hematuria pt edu: signs of hypercalcemia, take supplements as rx (no addtl doses), report N/V, eat high fiber diet, report flank pain and hematuria immediately ,take med 1-2 hr before or after other meds, take calcium basead antacids 1 hr after meal and at bedtime (no more than 600 mg at one time, drink full glass of water, chewable tablet can be chewed), avoid taking calcium with cereal and spinach, encourage vit D, weight bearing exercises/activity
raloxifene (SERM) (only for ladies!)
ther use: ppx and tx of postmenopausal osteoporosis in female pts epa: activates estrogen receptors in some tissues and block receptors in other tissues, activation decreases both bone resorption and bone loss admin: oral daily s/e: hot flashes, vte, pe, stroke contraindications/precaut: active or hx of VTE, pts on estrogen therapy, caution in pts with elevated serum lipid levels interactions: do not use concurrently with estrogen!! n/i: observe for s/sx of VTE/PE and monitor bone density pt edu: educate about SE, may take with or without food, do not take estrogen replacement therapy during tx, encourage calcium, vit D, wt bearing exercises/activity
LARC: non-hormonal copper IUD
ther use: prevent preg EPA: enhances inflammatory response, interferes with sperm motility/ viability, impairs implantation admin: IU, only contains/releases copper, approved use (10-12 yrs) s/e: changes in menstrual patterns (prolonged flow, increased pain and cramping with cycles), cramping, expulsion, embedment, pelvic infection, uterine perforation, preg complicatoins c/i and precaut: known or suspected preg, undiag/unexplained vaginal bleeding, uterine cavity abnormalities, active pelvic infection, uterine or cervical cancer, Wilson's disease or copper allergy (DO NOT USE IN PTS WHO ALREADY AHVE HEAVY MENSTRUAL BLEEDING) Interactions: none N/I: VS, pt intake, hx, rule out preg, pt edu Pt edu: can be inserted anytime during cycle (immediately effective), review s/sx of s/e, check strings once per month, report feeling part of IUD, have pain or bleeding with IC, have unusually heavy bleeding, possible exposure to STI or preg, unusual pelvic pain, unexplained fever or chills
hormone therapy for MTF transgender people (MALE TO FEMALE)
ther use: reduce effect of endogenous male sex hormones, achieve balance with hormonal meds and client desired outcomes epa: antiandrogens: inhibitor of androgen receptors, inhibitor of testicular steroidogenesis estrogen: suppress endogenous androgen secretion, indirectly suppresses testosterone GnRH agonists: inhibit gonadotropin secretion, suppresses testicular testosterone production progestin: suppress gonadotropin and testosterone secretion admin: oral (antiandrogen (spironolactone), estrogen (17 beta - estradiol valerate), transdermal, IM, SQ implant s/e: estrogen (HA, mood changes, N, loss of libido, increased triglycerides, gall bladder disease, VTE/PE, CAD, HTN, diabetes) and antiandrogen (increased urinary frequency, hyperkalemia, hypoTN, renal insufficiency) C/I and precaut: unstable ischemic cardiovascular disease, estrogen-dependent cancer, end stage chronic liver disease, active psychosis/SI, hypersensitivity to one of the components of the formulation. precautions with stable cardiovascular disease/HTN, frequent/untreated migraines, hyperprolactinemia, smoking, hx of VTE interactions: same as with hormonal contraceptives n/i: vs, pt intake, hx, consent forms, monitor lab values, schedule f/u visits, pt edu pt edu: med schedule, s/e, ACHES (severe abdominal pain, CP, HA, eye problems, severe leg pain)
MHT: estrogen and progestin
ther use: reduce menopausal sxs epa: binds to estrogen receptors. provides a stable amt of estrogen to help prevent menopausal sxs. progesterone antagonizes estrogen-influenced tissue growth in the endometrium and prevents hyperplasia admin: oral daily (prempro conjugated estrogen/medroxyprogesterone acetate) or transdermal twice weekly (estradiol/norethindrone combi-patch) s/e: HA, N, abd pain, diarrhea, breast tenderness, mood changes, skin irritation with transdermal, irregular uterine bleeding, VTE/PE, increased serum lipid levels, stroke/MI black box warning: conjugated estrogen and medroxyprogesterone has an increased risk of breast cancer c/i and precaut: preg, undiag vaginal bleeding, active/hx/risk for thromboembolic events or d/o, breast cancer, liver or gall bladder disease, estrogen-dependent neoplasia, CAD, smoking. Precaut: HTN, DM, migraine, kidney dysfunction interactions: may decrease efficacy of anticonvulsants, antiretrovirals, antimicrobials (rifampin), herbal (st j wort), aminoglutethimide (prempro) n/i: VS (BP checks), pt intake and hx and rule out preg, provide good pt edu edu: same as other MHT, take oral at same time each day!!
calcitonin - salmon
ther use: tx of postmenopausal osteoporosis in female pts epa: inhibits the action of osteoclasts, decreases bone resorption admin: IN spray (daily in one nostril), IM or SQ injection daily, decreases therapeutic effects over time s/e: nasal dryness and irritation (epistaxis d/t nasal spray), HA, injection site reactions, N/V, polyuria, hypocalcemia, hypersensitivity/anaphylaxis reactions interactions: may decrease serum lithium levels, previous tx with bisphosphonates may decrease response to calcitonin contraindic/precaut: allergy to salmon, prior tx with bisphosphonates N/I: give first calcitonin injection in office to monitor for hypersensitivity reaction, monitor for hypocalcemia, assess nostrils/nasal passageway for irritation/ulceration prior to inhaled use, monitor bone density pt edu: educate about SE, encourage calcium, vit D, wt bearing exercises/activity, notify provider of muscle spasms, tingling of fingers and toes, specific edu around IN (hold nasal pump upright, only spray in one nostril, alternate nostril used daily) and IM/SQ (rotate injection sites, protect from light, refrigerate)
combined oral contraceptive products (COCs)
therapeutic use: ppx of pregnancy, treat other repro concerns (cycle reg, endometriosis, ovarian cysts) EPA: estrogen and progestin: suppression of ovulation by inhibition of GnRH, LH, FSH, and the mid-cycle LH estrogen: stabilizes the endometrium to help with cycle control progestin: causes atrophy on endometrium, making it less suitable for implantation. thickens cervical mucus to impair sperm travel. impairment of normal tubal mobility and peristalsis Admin: PO (daily) that is differentiated based on strength of estrogen component type of progestin used and whether estrogen or progesterone activity predominate, typical 21/7 formulation (BOTH ESTRO AND PROGESTRO) S/E: HA, N, breast tenderness, breakthrough bleed, oligo/amenorrhea, chloasma, weight changes/fluid retention, mood changes, changes in libido, HTN, lipid changes, gallbladder disease, VTE/MI/stroke C/I and Precaut: known or suspected preg, ages > 35 yo and smoking >15 cig per day, 2+ risk factors for CAD, HTN, undiag/abnormal uterine bleeding, venous thromboembolism/mutations, known ischemic heart disease, hx of stroke, breast cancer, cirrhosis/hepatocellular adenoma or malignant hepatoma, migraine with aura, breastfeeding (limits milk production) interactions: anticonvulsants, antiretrovirals, anticoagulants, antimicrobial (rifampin), herbal (st. j wort) use backup method for duration of tx plus 7 extra days! if med is long term, new form of contraceptive is needed if someone has a migraine with aura, DO NOT GIVE (estrogen enhances risk of stroke) nursing interventions: obtain vs, thorough hx and provide good pt edu pt edu: common s/e and complications, ACHES (severe abdominal pain, CP, HA, eye problems, severe leg pain), how to start pills what to do about missed pills
injectable contraceptive: depot shot
therapeutic use: ppx pregnancy, tx pain from endometriosis and sickle cell crisis, reduces menstrual sxs EPA: suppresses levels of FSH and LH and eliminates the LH surge to prevent ovulation, thickens and decreases cervical mucus (preventing sperm penetration), causes some endometrial atrophy Admin: IM injection (150 mg every 3 months) in VG or delt, SubQ (104 mg monthly), should be given every 13 wks S/E: menstrual changes (unscheduled bleeding/spotting, amenorrhea), bone mineral density loss (reversible), weight gain, HA, mood changes, decreased libido, decreased return to fertility, injection site reaction C/I and Precaut: preg, active thrombophlebitis, current or past hx of thromboembolic d/o or cerebral vascular disease, known or suspected breast cancer, undiag abnormal uterine bleeding, benign or malignant liver tumors, severe cirrhosis, acute liver disease, severe/uncontrolled HTN Interactions: aminoglutethimide, anticonvulsants, antimicrobials (rifampin), herbal (st. j wort), use backup method for duration of tx plus seven extra days, if med is long term, new form of contraceptive is needed n/i: VS (document wt and BP at each visit, pt intake/obtain hx and rule out preg, provide good pt edu edu: starting DMPA (ideally within 7 days of onset of menses, quick start/same day, return on time for repeat injection, if more than 2 wks late form last injection, use backup/abstinence until getting injection + 1 wk after
POPs
therapeutic use: prevent preg, relieve pain assoc with endometriosis EPA: cervical mucus is thickened preventing sperm penetration, activity of the cilia in the fallopian tube is reduced preventing sperm and ovum from meeting, endometrium is altered which inhibits implantation admin: oral (daily), norethindrone (0.35 mg/28 day active pills), drospirenone (4 mg/24 active with 4 inactive pills) s/e: unpredictable bleeding (shorter cycles, intermenstrual bleeding and spotting, amenorrhea, prolonged bleeding), increase in follicular cysts, changes in weight, mood changes, fatigue, decreased libido, androgenic sxs of hirsutism and acne c/i and precaut: preg, breast cancer, undiag abnormal uterine bleeding, current VTE or PE, benign or malignant liver tumors, severe cirrhosis, or acute liver disease, bariatric surgery, use drospirenone cautiously in clients with potassium issues interactions: anticonvulsants, barbiturates, antimicrobial (rifampin) use backup method for duration of tx PLUS 7 extra days. if med is long term, new form of contraceptive is needed! in r/t any interaction drogas N/I: VS, pt intake and rule out preg, hx, provide edu edu: when to start POPs (first day of menses preferred, if started within first 5 days of menses then no backup method needed, if not backup method/abstinence for 2 addtl days from onset of menses, norethindrone pills - must be taken at exact same time daily (within 30 min) if more than 3 hrs late need backup method/abstinence, drospirenone (take at same time every day, less narrow window so you good for 24 hr), delayed or missed pills (take pills ASAP even if double up on one day, use backup/abstinence for 48 hr until POPs back on track, on time for 2 consecutive days, if severe V/D within 4 hrs of taking pill, continue taking pills on time but use backup method/abstinence until 48 hr after V/D over
LARC: hormonal (levonorgestrel) IUD
therapeutic use: prevent pregnancy, treat other reproductive concerns (ex. cycle regulation, endometriosis) --> mirenna, liletta, kyleena, skyla EPA: inflammatory reaction - foreign body effect, thickens cervical mucus, inhibits sperm survival, thins the uterine lining Admin: intrauterine, levonorgestrel (mirenna 8/52 mg, liletta 8/52 mg, kyleena 5/19.5, skyla 3/13.5) side effects: changes in menstrual patterns, cramping, expulsion, embedment, pelvic infection, uterine perforation, pregnancy complications c/i and precaut: known or suspected preg, undiag/unexplained vaginal bleeding, uterine cavity abnormalities, active pelvic infection, uterine or cervical or breast cancer interactions: unlikely! n/i: VS, pt intake (obtain hx and intake, rule out preg), STI testing, provide education pt edu: can be inserted anytime during cycle (use backup method/abstinence 1 wk after insertion if placed > 7 days after LMP), review s/sx of s/e, check strings once per month, report feeling part of IUD, pain/bleeding with IC, unusually heavy bleeding, possible exposure to STI, possible preg, unusual pelvic pain, unexplained fever or chills
anabolic effects
third and fourth gen progestins build body mass, etc.
categories of 1st gen antipsychotics
two groups: phenothiazines and nonphenothiazines (and then further broken up to side effect profiles) phenothiazines and thioxanthenes block N/E, causing sedative and hypoTN effects early in tx butyrophenones block only neurotransmitter dopamine (ex. haldol)
menstruation
typically occurs on days 1-7, averaging about 5 days
