Psychopharmacology Final

Planning/Implementation for antidepressants

-Dry mouth -Sedation give drug at bedtime -Nausea take with food -discontinuation syndrome- Fluoxetine is less likely to produce withdrawal symptoms because of its long 1/2 life With heterocyclic -Blurred vision -Constipation high fiber diet -Urinary retention - orthostatic hypotension avoid hot showers or tub baths - Reduction in seizure threshold -Tachycardia, arrhythmias -photosensitivity -weight gain With SSRIs and SNRIs -Insomnia, agitation take early in the day, avoid caffeine -Headache -weight loss -sexual dysfunction -serotonin syndrome With MAOIs -Hypertensive crisis-avoid tyramine -application site reaction -Priapism-trazadone -Hepatic failure- nafazodone

Client teaching while on antidepressants

-TCAs avoid smoking b/c smoking increases the metabolism of TCAs and requires an adjustment of dosage -Do not double up on medication if a dose of wellbutrin is missed

anti anxiety agents contraindications / precautions

-to individuals with known allergy to any of the drugs within the classification (like benzo's). -Should not be taken in combination with other CNS depressants and are contraindicated in pregnancy and lactation, narrow angle glaucoma, shock, and coma. -Caution with the elderly or people with hepatic/renal dysfunction. -Caution with individuals who have a HX of drug abuse or addiction, and those who are depressed or suicidal. in depressed clients CNS depressants can exacerbate symptoms.

Planning/implementation of anti anxiety agents

1) Drowsiness, confusion, lethargy (most common side effect) 2) Tolerance, physical and psychological dependence (not with BuSpar)- instruct client ton long-term therapy 3)Ability to potentiate the effects of other CNS depressants 4)Possibility of aggravating symptoms in depressed patients 5) Orthostatic hypotension 6)Paradoxal Excitement- withhold drug and notify physician 7)Dry mouth 8)Nausea and vomiting- take med with food or milk 9)Blood dyscrasias- symptoms are sore throat, fever, malaise, easy bruising, unusual bleeding report immediately 10)Delayed onset- BuSpar only

Nursing diagnosis for mood stabilizing agents

1) Risk for injury r/t manic hyperactivity 2) Risk for self directed or other directed violence r/t unresolved anger turned inward on self or outward to the environment 3) Risk for injury r/t lithium toxicity 4) Risk for injury r/t adverse effects 5) Risk for inactivity intolerance r/t side effects of drowsiness or dizziness

Nursing diagnosis for anti anxiety agents

1) Risk for injury r/t seizures, panic anxiety, acute agitation from alcohol withdrawal, abrupt withdrawal from medication, effects of medication intoxication 2)Anxiety related to threat to physical integrity or self concept 3) Risk for activity intolerance related to side effects of sedation, confusion, and lethargy 4) Disturbed sleep pattern r/t situational crisis, physical condition, or severe level of anxiety 5) Deficient knowledge r/t medication regimen 6) Risk for acute confusion r/t action of the medication on the CNS

Nursing diagnosis for antidepressants

1) Risk for suicide r/t depressed mood 2) Risk for injury r/t side effects of sedation, lowered seizure threshold, orthostatic hypotension, priapism, photosensitivity, arrhythmias, hypertensive crisis, or serotonin syndrome 3) Social isolation r/t depressed mood 4) Risk for constipation r/t side effects of medication 5) Insomnia r/t depressed mood and elevated level of anxiety

Antipsychotics

1st Generation (typical, traditional) more EPS symptoms- Thiothixene (Navane) blocks dopamine receptors; can cause blood dyscrasias, caution with heat exposure; indicated for treatment of psychosis delusions and hallucinations. 2nd Generation (Atypical) Fewer EPS symptoms but higher risk of metabolic syndromes like diabetes, hypercholesterolemia, and weight gain. Block both serotonin and dopamine receptors. include Thorazine- used to treat psychotic disorders- encourage sugar free everything

Strattera, Methylphenidate (Ritalin), Adderal, Concerta, Dextrine

5 Medications that are commonly prescribed for ADHD?

-Clozapine (Clozaril) -Fever, sore throat, malaise -WBC count or CBC count should be monitored And it occurs within the first 3 months of treatment.

Agranulocytosis is more common with typical than the atypical antipsychotics with the exception of which medication? What might be the first sign? What should be monitored?

Black-box warning

All anti depressants carry an FDA ____________ for increased risk of suicide in children and adolescence.

anti anxiety agents indications

Also called anxiolytics and minor tranquilizers. Used for the treatment of anxiety disorders, anxiety symptoms, acute alcohol withdrawal, skeletal muscle spasms, convulsive disorders, status epileptics, and preoperative sedation

Antipsychotic medications background

Also called major tranquilizers and neuroleptics

Tricyclics for depression

Amitriptyline Amoxapine Clomipramine (anafranil) Desipramine (Norpramin) Doxepin Imipramine (Tofranil) Nortriptyline (Aventyl;Pamelor) Protriptyline (Vivacity) Trimipramine (Surmontil)

Fluoxetine (Prozac)

An FDA approved medication for the treatment of depression in children and adolescents?

Fluoxetine (Prozac)

Antidepressant (SSRI) -side effects include headache, insomnia, nervousness, GI upset, sexual dysfunction. -Take in the morning -Full effect may take 2-4 weeks, do not discontinue abruptly - Inhibits serotonin reuptake. -is available in sustained release that should be taken 1x per week.

Contraindication of antidepressants

Antidepressant medications are contraindicated in individuals with allergies. TCAs are contraindicated in the acute recovery phase following a myocardial infarction and in individuals with angle-closure glaucoma TCAs, heterocyclics, SSRIs, and SNRIs are contraindicated with the use of MAOIs Caution when administering to the elderly or people with renal/hepatic insufficiency Caution is also required in psychotic clients, with clients who have benign prostatic hypertrophy, and with individuals who have a HX of seizures

Selegiline transdermal system (Emsam) -most common include rash, itching, erythema, redness, irritation, swelling, urticarial lesions. -Most resolve without treatment but topical steroids have been used.

Application site reactions can occur with this MAOI?

Antidepressants

As these drugs take effect, and mood begins to lift, the individual may have increased energy with which to implement a suicide plan. Suicide potential often increases as depression decreases. Be aware for sudden lifts in mood.

Tardive Dyskinesia

Bizarre facial and tounge movements, stiff neck, and difficulty swallowing; may occur with all classifications but more common with typical antipsychotics. - All clients receiving long-term (months or years) antipsychotic therapy are at risk. -The symptoms are potentially irreversible - The drug should be withdrawn at the first sign, which is usually vermiform movements of the lounge; prompt action may prevent irreversibility. -The AIMS scale is a rating scale that was developed in the 70's by the National Institute of Mental Health to measure involuntary movements associated with this disorder. The AIMS aids in early detection of movement disorders and provides a means for ongoing surveillance.

Heterocyclics for depression

Bupropion (wellbutrin) Maprotiline Mirtazapine (Remeron) Nefazodone Trazodone

-Concomitant use of St. Johns Wort. -Concomitant use of SSRI with metoclopramide, sibutramine, tramadol, triptans, or any drug that increases serotonin including antidepressants

Causes of Serotonin syndrome

Selective serotonin reuptake inhibitors for depression

Citalopram (Celexa) Escitalopram (Lexapro) Fluoxetine (Prozac; Sarafem; Selfemra) Fluvoxamine (Luvox) Paroxetine (Paxil) Sertraline (Zoloft) Vilazodone (Viibryd) Vortioxetine (Brintellix)

-1 Week -Potential for suicide by overdose

Clients who are discharges with antidepressant medication should be given only a __________ supply. Why?

Akathisia

Continuous restlessness and fidgeting. This occurs most frequently in women; symptoms may occur 50 to 60 days following initiation of therapy.

-Also called anxiolytics -Bind to BZ receptor sites on the GABA(a) receptor complex, increase receptor affinity for GABA; depress subcortical levels of the CNS, particularly in the limbic system and reticular formation. They potentiate the effects of GABA producing a calming effect. -Relief of anxiety, Sedation -The effects would increase with alcohol because it too is a CNS depressant; They would decrease with caffeine because it is a stimulant and would counteract the effects.

Describe anti anxiety drugs (How do they work?); When used in combination with anti anxiety medications would alcohol lead to increased or decreased effects?

Occurs if the individual consumes containing tyramine while receiving MAOI therapy. -Symptoms include severe occipital headache, palpitations, nauseam vomiting, nucal rigidity, fever, sweating, marked increase in blood pressure, chest pain, and coma. -Treatment includes discontinuing the drug immediately, monitoring vital signs, administering short-acting antihypertensive medication as ordered by the physician, and using external cooling measures to control hyperpyrexia. -The combination of a MAOI with amphetamines, methyldopa, levodopa, dopamine, epinephrine, norepinephrine, guanethidine, guanadrel, reserpine, or vasoconstrictors.

Describe hypertensive crisis. Which combination of classifications of psychoactive medications could lead to a hypertensive crisis?

May occur when two drugs that potentiate serotonergic neurotransmission are used concurrently. -Most frequent symptoms include changes in mental status, restlessness, myoclonus, hyperreflexia, tachycardia, labile blood pressure, diaphoresis, shivering, and tremors. -Discontinue the offending medication immediately. The physician may prescribe medications to block serotonin receptors, relieve hyperthermia, and muscle rigidity, and prevent seizures. In severe cases, artificial ventilation may be required. The histamine-1 receptor antagonist, cyproheptadine, is commonly used to treat the symptoms. -Supportive nursing measures include monitoring vital signs, providing safety measures to prevent injury when muscle rigidity and changes in mental status are present, cooling blankets and tepid baths to assist with temp regulation, and monitoring I&O -The condition will usually resolve on its own once the medication has been discontinued. If left untreated, the condition may progress to seizures, coma, hypotension, ventricular arrhythmias, disseminated intravascular coagulation, rhabdomyolysis, metabolic acidosis, and renal failure.

Describe symptoms of serotonin syndrome.

Client family education for anticonvulsants

Do not stop abruptly. Report skin rash, unusual bleeding, spontaneous bruising, sore throat, fever, malaise, dark urine, and yellow skin or eyes. Avoid alcohol

Antipsychotic

Extrapyramidal Symptoms are adverse effects from __________ medications.

-Aged Cheeses (cheddar, swiss, camembert, blue cheese, parmesan, provolone, Romano, brie) -Rasins, fava beans, flat Italian beans, Chinese pea pods. -Red wines -Smoked and processed meats; caviar, pickled herring, corned beef, chicken or beef liver. -Soy sauce, brewer's yeast, meat tenderizer.

Foods that have a high Tyramine content avoid with MAOIs

Obsessive-compulsive disorder

For which diagnosis would an SSRI such as fluvoxamine (Luvox) be prescribed in excess of the recommended dosage for depression?

Atypical Antipsychotics

Hyperglycemia and diabetes are potential side effects of which classification of medications?

Typical antipsychotics would be contraindicated in clients with known allergy to a phenothiazines because of a cross-sensitivity -Chlorpromazine (thorazine), Fluphenazine, Haloperidol, Loxapine, Perphenazine, Pimozide, Prochlorperazine, Thioridazine (Malarial), Thiothixene (Navane), and Trifluoperazine are the typical antipsychotics

If a client has allergies to prochlorperazine (compazine), which antipsychotic medication would be contraindicated and why?

Serotonin syndrome confusion, rigidity and the others discussed previously

If a patient is prescribed two different SSRI's like Zoloft and Paxil, what complication would the nurse suspect and what are the symptoms?

Orthostatic hypotension

If a patient is taking both an antipsychotic and a beta-adrenergic blocking agent such as propranolol for hypertension what could be the combined side effect?

Increase acetylcholine

In alzheimers the goal is to?

Increase GABA

In anxiety the goal is to?

Increase serotonin and norepinephrine. Dopamine, acetylcholine, and GABA may also play a role in depression.

In depression the goal is to?

Decrease dopamine

In schizophrenia the goal is to?

anti anxiety agents interactions

Increased effects when taken with alcohol, barbiturates, narcotics, antipsychotics, antidepressants, antihistamines, neuromuscular blocking agents, cimetidine, or disulfiram. Decreased effects can be noted with cigarette smoking and caffeine consumption.

Acute Dystonia

Involuntary muscular movements of face, arms, legs, and neck. Occurs most often in men and in people younger than 25 years of age.

Monoamine Oxidase Inhibitors for depression

Isocarboxazid (Marplan) Phenelzine (Nardil) Tranylcypromide (Partite) Selegiline Transdermal System (Emsam)

Serotonin-Norepinephrine reuptake inhibitors SNRIs for depression

Levomilnacipran (Fetzima) Desvenlefaxine (Pristiq) Duloxetine (Cymbalta) Venlafaxine (Effexor)

Parnate, Nardil, Marplan, Emsam

List 4 Examples of MAOIs

Librium, Ativan, Serax Seizures

List medications that are often used for substitution therapy in alcohol withdrawal. What are the priority nursing interventions on the first day of a client's alcohol depression?

Acute mania- 1.0-1.5 mEq Maintenance- 0.6-1.2 mEq At serum levels of 1.5 to 2.0 blurred vision, ataxia, tinnitus, persistent nausea and vomiting, severe diarrhea At serum levels of 2.0-3.5 excessive output of dilute urine, increasing tremors, muscular irritability, psychomotor retardation, mental confusion, giddiness At serum levels above 3.5 mEq impaired consciousness, nystagmus, seizures, coma, oliguria/anuria, arrhythmias, myocardial infarction , cardiovascular collapse

List signs of initial lithium toxicity. What are the therapeutic levels for acute mania, and maintenance? Levels over ______ would lead a person to exhibit initial signs and symptoms? Levels between ________ would produce extreme symptoms and possibly death?

Psychotropic medication

Medication that affects psychic function, behavior, or experience

Neuroleptic Malignant Syndrome (NMS)

More common with the typical rather than the atypical antipsychotics. -This is a relatively rare, but potentially fatal, complication of treatment with antipsychotic drugs. Routine assessments should include temperature and observation for parkinsonian symptoms. -Onset can occur within hours or even years after drug initiation, and progression is rapid over the following 24 to 72 hours. -Symptoms include severe parkinsonian muscle rigidity, very high fever, tachycardia, tachypnea, fluctuations in blood pressure, diaphoresis, and rapid deterioration of mental status to stupor and coma. -Discontinue antipsychotic medication immediately. - Monitor vital signs, degree of muscle rigidity, intake and output, level of consciousness. -The physician may order bromocriptine (Parlodel) or dantrolene (Dantrium) to counteract the effects of this disorder.

Akinesia

Muscular Weakness. Same as for pseudoparkinsonism.

TCAs Include- Elavil, Topranil, Remeron

Not used first line for depression because of intolerable adverse effects.

Extrapyramidal Symptoms (EPS)

Observe for symptoms and report; administer antiparkinsonian drugs as ordered

Psychotherapeutic combinations for depression

Olanzapine and Fluoxetine (Symbyax) Chlordiazepoxide and fluoxetine (Limbitrol) Perphenazine and amitriptyline (Etrafon)

MAOIs Include- Nardil (binge eating)

Only used for patients who do not respond to TCAs

Atypical antipsychotic Clozaril, Risperidone

Patients who have bipolar and are experiencing psychosis may be prescribed an _________ such as? In addition to the mood stabilizer.

Trazodone

Priapism (prolonged penile erection) can result from which medication?

Trazodone; insomnia

Priapism is a rare side effect that has occurred in some men taking which medication? This medication is also used for what condition other than depression?

Depression they include Citalopram (celexa) Fluoxetine (Prozac) Paroxetine (Paxil) Escitalopram (Lexapro)

SSRIs are the first line of treatment for?

Hyperglycemia and diabetes

Studies have suggested an increased risk of treatment-emergent, hyperglycemia-related adverse events in clients using atypical antipsychotics -Risperidone, Clozapine, Olanzapine, Quetiapine, Ziprasidone, Paliperidone, iloperidone, asenapine, lurasidone, and aripiprazole. -The FDA recommends that clients with diabetes starting on atypical antipsychotic drugs be monitored regularly for worsening of glucose control. Clients with risk factors for diabetes should undergo fasting blood glucose testing at the beginning of treatment and periodically after. All clients taking these medications should be monitored for signs of hyperglycemia (polydipsia, polyuria, polyphagia, weakness)

4 weeks

TCAs may not reach their full therapeutic effects for?

Client family education for calcium channel blockers

Take with meals if GI upset occurs. Don't stop abruptly. Report irregular heartbeat, SOB, swelling of the feet or hands, pronounced dizziness, chest pain, profound mood swings, and severe persistent headache

Anticonvulsants

The FDA requires that all anti epileptic drugs carry a black box warning for increases in suicide.

Short; High

The benzodiazepines in treatment for anxiety disorders are indicated for _______-term use? And have a _______ abuse potential?

Hypertensive crisis

The combination of an MAOI and fluvoxamine (Luvox) could result in which complication?

Thorazine

The discovery of which psychoactive medication in the book by Edward Shorter is described as being as important as the discovery of penicillin for general medicine?

Antihypertensive sometimes procardia, or nifedipine.

The treatment of hypertensive crisis begins with the administration of short-acting __________________ medications.

Lithium, Clozaril, Valproic Acid (Depakote)

Three medication that require blood level monitoring?

Benadryl, Congentin, Artane

Three medications commonly prescribed for EPS symptoms

After meals

To reduce the anorexia associated with methylphenidate (Ritalin) should be given when?

Pseudoparkinsonian Symptoms

Tremor, Shuffling gait, Drooling, Rigidity. Symptoms may appear 1 to 5 days following initiation of antipsychotic medication. Occurs most often in women, the elderly, and dehydrated clients.

Interaction of antidepressants

Tricyclics -Increased effects if used with bupropion, cimetidine, haloperidol, SSRIs, and valproic acid -Decreased effects if used with carbamazepine, barbiturates, and rifamycins -Hyperpyretic crisis, convulsions and death can occur with MAOIs -If used with clonidine may produce hypertensive crisis -decreased effects of levodopa and guanethidine MAOIs -Avoid using for 5 wks if fluoxetine was taken before -wait 14-21 days if opioids were used -Tyramine avoid -avoid caffeine SSRIs -may decrease effects of buspirone and digoxin

Action of antidepressants

Ultimately work to increase the concentration of norepinephrine, serotonin and or dopamine in the body. This is accomplished in the brain by blocking the reuptake of these neurotransmitters by the neurons. It also occurs when an enzyme MAO that inactivates these NT's is inhibited

Oculogyric Crisis

Uncontrolled rolling back of the eyes. This may appear as part of the syndrome described as dystonia. It may be mistaken for seizure activity. Dystonia and oculogyric crisis should be treated as an emergency situation. The physician should be contacted; intravenous benzotropine mesylate (Congentin) is commonly administered. Stay with the client and offer reassurance and support during this frightening time.

Client family education for lithium

Use contraception. Know what symptoms to report to the physician like persistent nausea, vomiting, severe diarrhea, ataxia, blurred vision, tinnitus, excessive urine output, increasing tremors, mental confusion

Indication for antidepressants

Used in the treatment of major depressive disorder; dysthymia; major depression with melancholia or psychotic symptoms; depression associated with organic disease; alcoholism, schizophrenia, intellectual disability, depressive phase of bipolar disorder; and depression accompanied by anxiety. These agents elevate mood and alleviate other symptoms associated with moderate to severe depression

Tranylcypromine sulfate (Parnate)

Used to treat major depressive disorder in adults after other antidepressants have been tried and failed. Will not treat bipolar or manic depression.

Lithium; Antipsychotics

Weight gain is a common side effect of which medication?

Antihistamines -Hydroxyzine (vistaril) Benzos -Alaprazolam (Xanax) -Chlordiazepoxide (Librium) -Clonazepam (Klonopin) -Clorazepate (Tranxene) -Diazepam (Valium) -Lorazepam (Ativan) -Oxazepam Carbamate Derivative -Meprobamate Azaspirodecanedione -Buspirone (BuSpar) takes 7-10 days or 1-2 weeks to control symptoms so do not take PRN

What are some examples of anti anxiety medications? Buspirone (BuSpar) takes at least _______ weeks to control anxiety symptoms.

Cancer, COPD, heart failure, dementia, Alzheimer's disease, hypothyroidism

What are some general medical conditions that would include symptoms of depression?

-Do not drive or operate heavy machinery -Do no stop taking the drug abruptly this can cause serious withdrawal symptoms -Do not consume other CNS depressants including alcohol -Do not take prescription medication without consulting your doctor -Rise slowly -Report symptoms of sore throat, fever, malaise, easy bruising, unusual bleeding, or motor restlessness, to physician immediately -Be aware of taking the drug during pregnancy -Blood work monitoring is not needed

What are some teaching points for a patient who is being discharged home with a benzodiazepine?

May produce tolerance with chronic use and have the potential for psychological or physical dependence.

What are the potential side effects of hypnotics/sedatives?

100-200mg

What is the maximum dose of Lamotrigine (Lamictal) for mood stabilization?

Prozac; BuSpar

What medications would be appropriate for a patient with generalized anxiety disorder? Which specific medication is an anxiolytic medication that does not have the dependency concerns of other anxiolytics?

Anticonvulsants -Carbamazepine (Tegretol) -Clonazepam (Klonopin) -Valproic acid (Depakene; Depakote) -Lamotrigine (Lamicital) -Topiramate (Topamax) -Oxcarbazepine (Trileptal) Calcium Channel Blocker -Verapamil (Calan, Isoptin) Antipsychotics -Olanzapine (Zyprexa) -Olanzapine and fluoxetine (Symbax) -Aripiprazole (Abilify) -Chlorpromazine -Quetiapine (Seroquel) -Risperidone (Risperdal) -Ziprasidone (Geodon) -Asenapine (Saphris)

What other medication other than Lithium would be prescribed for a patient in a manic episode?

Ramelteon (Rozerem) is not a controlled substance. Sleep-promoting properties are the result of ramelteon's agonist activity on selective melatonin receptors.

Which Sedative-Hypnotic does not produce tolerance or dependence?

Buspirone (BuSpar) does not depress the CNS. The action is unknown, but the drug is believed to produce the desired effects through interactions with serotonin, dopamine, and other NT receptors.

Which anti anxiety medication does NOT depress the CNS?

TCAs

Which classifications of medications have the risk of photosensitivity?

Zyprexa

Which medication might be prescribed with Eskalith (Lithium) for a patient who has severe manic behaviors (hyperactivity) until the lithium can take effect?

Benzo's Xanax, Librium. Klonopin, Tranxene, Valium, Ativan, Oxazepam

Which medication might be used in the treatment of panic disorder?

Caffeine decreases the effect of lithium and can increase the chance of a manic episode. It is a stimulant. Also caffeine promotes excessive urine output which can cause sodium depletion leading to an increased chance of toxicity.

Why should caffeine be avoided by patients who are manic and or are taking lithium?

Alcohol

___________ in combination with chlordiazepoxide (Librium) could suppress the respiratory system leading to respiratory arrest and death.

Atypical antipsychotics work

by blocking a specific serotonin receptor

antipsychotics work

by blocking dopamine receptors, and some affect muscarinic, cholinergic, histaminergic, and adrenergic receptors.

antidepressants work

by blocking the reuptake of serotonin norepinephrine

Benzodiazepines work

by facilitating the transmission of the inhibitory neurotransmitter GABA.

psychostimulants work

by increasing norepinephrine, serotonin, and dopamine release

anti anxiety agents action

depress subcortical levels of the CNS, particularly in the limbic system and reticular formation. They may potentiate the effects of the inhibitory NT GABA in the brain thereby producing a calming effect. All levels of CNS depression can be affected from mild sedation to hypnosis to coma.

Planning/Implementation for mood stabilizing agents

monitoring for side effects -Lithium toxicity- levels should be monitored once a wk after initial treatment until dosage and serum levels are stable, then monthly during maintenance. Blood samples should be drawn 12 hours after the last dose. Client must consume 2500, 3000 mL of fluid per day and maintain adequate sodium intake

Reuptake

process of neurotransmitter inactivation by which the neurotransmitter is reabsorbed into the presynaptic neuron from which it had been released

therapeutic effects

related to the nervous system's adaptation to increased levels of neurotransmitters. These adaptive changes result from a homeostatic mechanism, much like a thermostat, that regulates the cell and maintains equilibrium