Biopsychosocial N3

What are tricyclic antidepressants?

Names: ▪ Amitriptyline ▪ Amoxapine ▪ Clomipramine ▪ Desipramine ▪ Doxepin ▪ Imipramine ▪ Nortriptyline ▪ Protriptyline ▪ Trimipramine - Indications: 1. Block the reuptake of norepinephrine (and serotonin) at the presynaptic junction; used to treat depression 2. Clomipramine can treat OCD

How to treat tricyclic antidepressant overdose?

1. Check airway and maintain a patent airway. 2. Administer oxygen. 3. Check vital signs. 4. Obtain an electrocardiogram. 5. Prepare for gastric lavage with activated charcoal. 6. Prepare to administer physostigmine (a cholinesterase inhibitor) and antidysrhythmic medications. 7. Document the event, actions taken, and the client's response.

Interventions for lithium toxicity?

a. Withhold lithium and notify the HCP. b. Monitor vital signs and level of consciousness. c. Monitor cardiac status. d. Prepare to obtain samples to monitor lithium, electrolyte, blood urea nitrogen, and creatinine levels and perform a complete blood cell count. e. Monitor for suicidal tendencies and institute suicide precautions.

What is serotonin syndrome?

- Caused by medications that increase serotonin - Signs and symptoms: ▪ Diaphoresis ▪ Nausea, vomiting ▪ Diarrhea ▪Mental status changes ▪ Neuromuscular hyperactivity ▪ Fever ▪ Tachycardia ▪ Mydriasis ▪ Cog wheel rigidity ▪ Trismus ▪ Bruxism (grinding teeth) - Antidote: Cyproheptadine (antihistamine), 5HT agonists

What is OCD? What are the nursing interventions for this disorder?

- Description: A. Obsessions: Preoccupation with persistently intrusive thoughts and ideas B. Compulsions 1. The performance of rituals or repetitive behaviors designed to prevent some event, divert unacceptable thoughts, and decrease anxiety. 2. Obsessions and compulsions often occur together and can disrupt normal daily activities. 3. Anxiety occurs when one resists obsessions or compulsions and from being powerless to resist the thoughts or rituals. 4. Obsessive thoughts can involve issues of violence, aggression, sexual behavior, orderliness, or religion and uncontrollably can interrupt conscious thoughts and the ability to function. - Nursing interventions: 1. Ensure that basic needs (food, rest, hygiene) are met. Identify situations that precipitate compulsive behavior; encourage the client to verbalize concerns and feelings. 2. Be empathetic toward the client and aware of his or her need to perform the compulsive behavior. 3. Do not interrupt compulsive behaviors unless they jeopardize the safety of the client or others (provide for client safety related to the behavior). 4. Allow time for the client to perform the compulsive behavior, but set limits on behaviors that may interfere with the client's physical well-being to protect the client from physical harm. 5. Implement a schedule for the client that distracts from the behaviors (structure simple activities, games, or tasks for the client). 6. Establish a written contract that assists the client to decrease the frequency of compulsive behaviors gradually. 7. Recognize and reinforce positive nonritualistic behaviors.

Nursing interventions while patient on SSRIs?

- Interventions: 1. SSRIs interact with numerous medications. 2. Monitor vital signs because SSRIs can potentially lower or elevate blood pressure. 3. Monitor weight. 4. Initiate safety precautions, particularly if dizziness occurs. 5. Instruct the client to avoid alcohol. 6. Administer with a snack or meal to reduce the risk of dizziness and lightheadedness. 7. Monitor the suicidal client, especially during improved mood and increased energy levels. 8. Instruct the client taking fluoxetine or bupropion to take the medication early in the day to prevent interference with sleep. 9. For the client on long-term therapy, monitor liver and renal function test results; altered values may occur, requiring dosage adjustments. 10. Monitor white blood cell and neutrophil counts; the medication may be discontinued if levels decrease below normal. 11. If priapism (painful, prolonged penile erection) occurs, the medication is withheld and the health care provider (HCP) is notified. 12. Inform about the possibility of decreased libido. 13. Instruct to change positions slowly to avoid a hypotensive effect. 14. Caution the client about photosensitivity and to take measures to prevent exposure to sunlight. 15. Educate about the potential for discontinuation syndrome if medication is stopped abruptly rather than tapered; the syndrome is characterized by gastrointestinal distress, peculiar behavioral or perceptual presentations, movement problems, and sleep disturbances. 16. Be aware of the potential for serotonin syndrome, characterized by elevated temperature, muscle rigidity, and elevated creatine phosphokinase levels; this risk is greatly increased when SSRIs are given with monoamine oxidase inhibitors (MAOIs). This medication combination needs to be avoided. 17. Instruct that over-the-counter (OTC) cold medicines can increase the likelihood of serotonin syndrome. 18. In pregnancy, consultation with an obstetrician is recommended regarding taking these medications. 19. Monitor the medication response in children, adolescents, and older adults closely because the response may be different than in an adult client. 20. Encourage psychotherapy.

What are mood stabilizers?

- Lithium Preparations ▪ Lithium carbonate ▪ Lithium citrate - Other Mood Stabilizers ▪ Aripiprazole ▪ Carbamazepine ▪ Clozapine ▪ Gabapentin ▪ Lamotrigine ▪ Olanzapine ▪ Olanzapine/fluoxetine ▪ Oxcarbazepine ▪ Paliperidone ▪ Quetiapine ▪ Risperidone ▪ Valproate ▪ Ziprasidone

What is Munchausen syndrome? What is Munchausen by Proxy?

- Munchausen = a factitious disorder where the person intentionally causes injury or physical symptoms to self to gain attention and sympathy from health-care providers, family, and others - Munchausen by Proxy = when a person inflicts illness or injury on someone else to gain the attention of emergency medical personnel or to be a hero for "saving" the victim

What are SSRI's?

- Names ▪ Citalopram ▪ Escitalopram ▪ Fluoxetine (take in morning) ▪ Fluvoxamine ▪ Paroxetine ▪ Sertraline ▪ Vilazodone - Indications: 1. OCD 2. Anxiety 3. Depression

What are MAOI's?

- Names: Marplan ▪ Isocarboxazid ▪ Phenelzine ▪ Selegiline ▪ Tranylcypromine - Indications: 1. Inhibit the enzyme monoamine oxidase, which is present in the brain, blood platelets, liver, spleen, and kidneys 2. Monoamine oxidase metabolizes amines, norepinephrine, and serotonin, so the concentration of these amines increases with MAOIs. 3. Clients who have depression and have not responded to other antidepressant therapies, including electroconvulsive therapy, may be given MAOIs. These medications are not the first choice because of other available medications and the possible serious side and adverse effects that can occur. 4. Concurrent use with amphetamines, antidepressants, dopamine, epinephrine, levodopa/carbidopa, methyldopa, nasal decongestants, norepinephrine, reserpine, tyramine-containing foods, or vasoconstrictors may cause hypertensive crisis. 5. Concurrent use with opioid analgesics may cause hypertension or hypotension, coma, or seizures.

What are the second generation antipsychotic drugs?

- The -DONEs and -PINEs - Block both dopamine and serotonin - Effective on both positive and negative symptoms of schizophrenia Clozapine (Clozaril) --> Concerns = Agranulocytosis, neutropenia, seizures, cardiomyopathy, QT prolongation, arrhythmias, stroke, torsades de pointes. Risperidone (Risperdal) --> Might cause Neuroleptic malignant syndrome --> Stop all antipsychotic meds and notify physician Olanzapine (Zyprexa) --> Quetiapine (Seroquel) --> Might cause hypotension Ziprasidone (Geodon) --> Contraindication to prolong QT, recent MI, and compensated heart failure. Paliperidone (Invega) Iloperidone (Fanapt) --> hypotension Asenapine (Saphris) Lurasidone (Latuda)

What are the first generation antipsychotic drugs?

- The -ZINEs - Target the POSITIVE signs of schizophrenia Chlorpromazine (Thorazine) --> Treats bipolar, acute mania, schizophrenia, intractable hiccups. Perphenazine (Trilafon) --> Fluphenazine (Prolixin) --> might cause tardive dyskinesia Thioridazine (Mellaril) Mesoridazine (Serentil) Thiothixene (Navane) --> EPS Haloperidol (Haldol) Loxapine (Loxitane) --> SE = EPS such as reversible movement, dystonic reactions, Parkinsonism, akathisia Molindone (Moban) --> Perphenazine (Etrafon) --> SE = Hypotension, sedation Trifluoperazine (Stelazine) -->Treats anxiety, Schizophrenia

Interventions for hypertensive crisis (caused by MAOI's)?

-Signs and symptoms: 1. Hypertension 2. Occipital headache radiating frontally 3. Neck stiffness and soreness 4. Nausea and vomiting 5. Sweating 6. Fever and chills 7. Clammy skin 8. Dilated pupils 9. Palpitations, tachycardia, or bradycardia 10. Constricting chest pain 11. Antidote for hypertensive crisis: Phentolamine by intravenous injection

What is somatic symptom?

1. Somatic symptom disorders are characterized by persistent worry or complaints regarding physical illness without supportive physical findings. 2. The client focuses on the physical signs and symptoms and is unable to control the signs and symptoms. 3. The physical signs and symptoms increase with psychosocial stressors. 4. The anxiety is redirected into a somatic concern. 5. The client may unconsciously somatize for secondary gains, such as increased attention and decreased responsibilities.

What is neuroleptic malignant syndrome (NMS)?

1. A potentially fatal syndrome that may occur at any time during therapy with neuroleptic (antipsychotic) medications. 2. Although rare, neuroleptic malignant syndrome more commonly occurs at the initiation of therapy, after the client has changed from 1 medication to another, after a dosage increase, or when a combination of medications is used. - Signs and symptoms 1. Dyspnea or tachypnea 2. Tachycardia or irregular pulse rate 3. Fever 4. High or low blood pressure 5. Increased sweating 6. Loss of bladder control 7. Skeletal muscle rigidity 8. Pale skin 9. Excessive weakness or fatigue 10. Altered level of consciousness 11. Seizures 12. Severe extrapyramidal side and adverse effects 13. Difficulty swallowing 14. Excessive salivation 15. Oculogyric crisis 16. Dyskinesia 17. Elevated white blood cell count, liver function results, and creatine phosphokinase level

Adverse effects of tricyclic antidepressants?

1. Anticholinergic effects: Dry mouth, difficulty voiding, dilated pupils and blurred vision, decreased gastrointestinal motility, constipation 2. Photosensitivity 3. Cardiovascular disturbances such as tachycardia or dysrhythmias; orthostatic hypotension 4. Sedation 5. Seizures (with bupropion) 6. Weight gain 7. Anxiety, restlessness, irritability 8. Decreased or increased libido with ejaculatory and erection disturbances 9. May reduce seizure threshold 10. May reduce effectiveness of antihypertensive agents 11. Concurrent use with alcohol or antihistamines can cause CNS depression. 12. Concurrent use with MAOIs can cause hypertensive crisis. 13. Cardiac toxicity can occur, and all clients should receive an electrocardiogram (ECG) before treatment and periodically thereafter. 14. Overdose is life-threatening, necessitating immediate treatment

What to know about lithium?

1. Concurrent use with diuretics, fluoxetine, methyldopa, or nonsteroidal antiinflammatory drugs increases lithium reabsorption by the kidneys or inhibits lithium excretion, either of which increases the risk of lithium toxicity. 2. Acetazolamide (anticonvulsant), theophylline (broncho dilator), phenothiazines (antipsychotic), or sodium bicarbonate (cardiac med) may increase renal excretion of lithium, reducing its effectiveness. 3. The therapeutic dose is only slightly less than the amount producing toxicity. i4. The therapeutic medication serum level of lithium is 0.6 to 1.2 mEq/L (0.6 to 1.2 mmol/L); the actual dose at which the therapeutic effect is achieved and the levels at which toxicity occurs are highly variable among individual clients. 5. The causes of an increase in the lithium level include decreased sodium intake; fluid and electrolyte loss associated with excessive sweating, dehydration, diarrhea, or diuretic therapy; and illness or overdose. 6. Serum lithium levels should be checked frequently after initiation of therapy and then every 1 to 2 months or whenever any behavioral change suggests an altered serum level. 7. Blood samples to check serum lithium levels should be drawn in the morning, 12 hours after the last dose was taken. 8. Lithium is classified as pregnancy category D; it crosses the placental barrier freely and has been associated with fetal toxicity.

Describe lithium toxicity?

1. Description a. Occurs when ingested lithium cannot be detoxified and excreted by the kidneys b. Symptoms of toxicity begin to appear when the serum lithium level is 1.5 to 2 mEq/L (1.5 to 2 mmol/L). 2. Mild toxicity a. Serum lithium level of 1.5 mEq/L (1.5 mmol/L) b. Apathy c. Lethargy d. Diminished concentration e. Mild ataxia f. Coarse hand tremors g. Slight muscle weakness 3. Moderate toxicity a. Serum lithium level of 1.5 to 2.5 mEq/L (1.5 to 2.5 mmol/L) b. Nausea, vomiting c. Severe diarrhea d. Mild to moderate ataxia and incoordination e. Slurred speech f. Tinnitus g. Blurred vision h. Muscle twitching i. Irregular tremor 4. Severe toxicity a. Serum lithium level greater than 2.5 mEq/L (2.5 mmol/L) b. Nystagmus c. Muscle fasciculations d. Deep tendon hyperreflexia e. Visual or tactile hallucinations f. Oliguria or anuria g. Impaired level of consciousness h. Tonic-clonic seizures or coma, leading to death

What is Conversion disorder (functional neurological symptom disorder)? Signs and symptoms of this disorder?

1. Description a. The sudden onset of a physical symptom or a deficit suggesting loss of or altered body function related to psychological conflict or a neurological disorder b. Conversion disorder is an expression of a psychological conflict or need. c. The most common conversion symptoms are blindness, deafness, paralysis, and the inability to talk. d. Conversion disorder has no organic cause. e. Symptoms are beyond the conscious control of the client and are directly related to conflict. f. The development of physical symptoms reduces anxiety. 2. Assessment a. Rule out a physiological cause for symptoms or deficits. b. "La belle indifference": Unconcerned with symptoms c. Physical limitation or disability d. Feelings of guilt, anxiety, or frustration e. Low self-esteem and feelings of inadequacy f. Unexpressed anger or conflict g. Secondary gain

Interventions when administering MAOIs?

1. Monitor blood pressure frequently for hypertension. 2. Monitor for signs of hypertensive crisis. 3. If palpitations or frequent headaches occur, withhold the medication and notify the HCP. 4. Administer with food if gastrointestinal distress occurs. 5. Instruct the client that the medication effect may be noted during the first week of therapy, but maximum benefit may take 3 weeks. 6. Instruct the client to report headache, neck stiffness, or neck soreness immediately. 7. Instruct the client to change positions slowly to prevent orthostatic hypotension. 8. Instruct the client to avoid caffeine or OTC preparations such as weight-reducing pills or medications for hay fever and colds. 9. Monitor compliance with medication administration. 10. Instruct the client to carry a MedicAlert card indicating that an MAOI medication is being taken. 11. Avoid administering the medication in the evening because insomnia may result. 12. When the medication is discontinued by the HCP, it should be discontinued gradually. 13. Instruct the client to avoid foods that require bacteria or molds for their preparation or preservation and foods that contain tyramine

Nursing interventions for lithium?

1. Monitor the suicidal client, especially during improved mood and increased energy levels. 2. Administer the medication with food to minimize gastrointestinal irritation. 3. Instruct the client to avoid excessive amounts of coffee, tea, or cola, which have a diuretic effect. 4. Do not administer diuretics while the client is taking lithium. 5. Instruct the client to avoid alcohol. 6. Instruct the client to avoid OTC medications. 7. Instruct the client that he or she may take a missed dose within 2 hours of the scheduled time; otherwise, the client should skip the missed dose and take the next dose at the scheduled time. 8. Instruct the client not to adjust the dosage or stop the medication without consulting the HCP because lithium should be tapered and not discontinued abruptly. 9. Instruct the client about the signs and symptoms of lithium toxicity. 10. Instruct the client to notify the HCP if polyuria, prolonged vomiting, diarrhea, or fever occurs. 11. Instruct the client that the therapeutic response to the medication is noted in 1 to 3 weeks. 12. Monitor the ECG, renal function tests, and thyroid tests (ensure that these tests are performed before the start of therapy). 13. Monitor weight.

Nursing interventions for tricyclic antidepressants?

1. Monitor the suicidal client, especially during improved mood and increased energy levels. 2. Instruct the client to change positions slowly to avoid a hypotensive effect. 3. Monitor pattern of daily bowel activity. 4. Assess for urinary retention. 5. For the client on long-term therapy, monitor liver and renal function test results. 6. Administer with food or milk if gastrointestinal distress occurs. 7. Administer the entire daily oral dose at 1 time, preferably at bedtime because of the sedative effect. 8. Instruct the client to avoid alcohol and nonprescription medications to prevent adverse medication interactions. 9. Instruct the client to avoid driving and other activities requiring alertness until the response is known; sedation is expected in early therapy and may subside with time. 10. When the medication is discontinued by the HCP, it should be tapered gradually. 11. The potential for medication interactions with OTC cold medications exists. 12. Caution the client about photosensitivity and to take measures to prevent exposure to sunlight. 13. Encourage oral hygiene and the use of hard candies and mouth rinses to relieve dry mouth. 14. Encourage psychotherapy.

Interventions for antipsychotics?

1. Monitor vital signs. 2. Monitor for symptoms of neuroleptic malignant syndrome (can occur with antipsychotic medications); refer to Section VIII. 3. Monitor urine output. 4. Monitor serum glucose level. 5. Administer the medication with food or milk to decrease gastric irritation. 6. For oral use, the liquid form might be preferred because some clients hide tablets in their mouths to avoid taking them. 7. The absorption rate is faster with the liquid form of oral medication. 8. Avoid skin contact with the liquid concentrate to prevent contact dermatitis. 9. Protect the liquid concentrate from light. 10. Dilute the liquid concentrate with fruit juice. 11. Inform the client that a full therapeutic effect of the medication may not be evident for 3 to 6 weeks after initiation of therapy; however, an observable therapeutic response may be apparent after 7 to 10 days. 12. Inform the client that some medications may cause a harmless change in urine color to pinkish to red-brown. 13. Instruct the client to use sunscreen, hats, and protective clothing when outdoors. 14. Instruct the client to avoid alcohol or other CNS depressants because these substances will allow more of the medication to enter the brain, causing feelings of depression and drowsiness, dizziness, slow and difficult breathing, confusion, and coma. 15. Instruct the client to change positions slowly to avoid orthostatic hypotension. 16. Instruct the client to report signs of agranulocytosis, including sore throat, fever, and malaise. 17. Instruct the client to report signs of liver dysfunction, including jaundice, malaise, fever, and right upper abdominal pain. 18. When discontinuing antipsychotics, the medication dosage should be reduced gradually to avoid sudden recurrence of psychotic symptoms.

Side effects of SSRIs?

1. Nausea, vomiting, cramping, and diarrhea 2. Dry mouth 3. Apathy 4. Increased sweating 5. Blood pressure changes 6. Photosensitivity 7. Insomnia, somnolence (sleepy, drowsy) 8. Nervousness 9. Headache, dizziness 10. Weight loss or gain 11. Decreased libido

Interventions for NMS?

1. Notify the HCP. 2. Monitor vital signs. 3. Initiate safety and seizure precautions. 4. Prepare to discontinue the medication. 5. Monitor level of consciousness. 6. Administer antipyretics as prescribed. 7. Use a cooling blanket to lower the body temperature. 8. Monitor electrolyte levels and administer fluids intravenously as prescribed.

Interventions for somatic symptoms disorders?

1. Obtain a nursing history and assess for physical problems. 2. Explore the needs being met by the physical symptoms with the client. 3. Assist the client to identify alternative ways of meeting needs. 4. Assist the client to relate feelings and conflicts to the physical symptoms. 5. Convey understanding that the physical symptoms are real to the client. 6. Assure the client that physical illness has been ruled out. 7. Report and assess any new physical complaint. 8. Use a pain assessment scale if the client complains of pain, and implement pain reduction measures as required. 9. Explore the source of anxiety and stimulate verbalization of anxiety. 10. Assist the client in recognizing his or her own feelings and emotions. 11. Encourage the use of relaxation techniques as the anxiety increases. 12. Encourage diversional activities. 13. Provide positive feedback. 14. Administer antianxiety medications if prescribed.

Adverse effects of MAOIs?

1. Orthostatic hypotension 2. Restlessness 3. Insomnia 4. Dizziness 5. Weakness, lethargy 6. Gastrointestinal upset 7. Dry mouth 8. Weight gain 9. Peripheral edema 10. Anticholinergic effects 11. CNS stimulation (anxiety, agitation, mania) 12. Delay in ejaculation

What is hypochondriasis/malingering?

Preoccupation with the fear that one has a serious disease or will get a serious disease; also called hypochondriasis

Adverse affects of lithium?

Side and adverse effects 1. Polyuria 2. Polydipsia 3. Anorexia, nausea 4. Dry mouth, mild thirst 5. Weight gain 6. Abdominal bloating 7. Soft stools or diarrhea 8. Fine hand tremors 9. Inability to concentrate 10. Muscle weakness 11. Lethargy, fatigue 12. Headache 13. Hair loss 14. Hypothyroidism

What are dystonias?

▪ Abnormal or involuntary eye movements, including oculogyric crisis ▪ Facial grimacing ▪ Twisting of the torso or other muscle groups *** Treatment = Cogentin + Benadryl

Foods contain tyramine?

▪ Avocados ▪ Bananas ▪ Beef or chicken liver ▪ Brewer's yeast ▪ Broad beans ▪ Caffeine, such as in coffee, tea, or chocolate ▪ Cheese, especially aged, except cottage cheese ▪ Eggplant ▪ Figs ▪ Meat extracts and tenderizers ▪ Overripe fruit ▪ Papaya ▪ Pickled herring ▪ Raisins ▪ Red wine, beer, sherry ▪ Sauerkraut ▪ Sausage, bologna, pepperoni, salami ▪ Sour cream ▪ Soy sauce ▪ Yogurt

What are anticholinergic effects?

▪ Dry mouth ▪ Increased heart rate ▪ Urinary retention ▪ Constipation ▪ Hypotension

What is EPS? (Extrapyramidal symptoms) What are early and late sx?

▪ Parkinsonism ▪ Tremors ▪ Masklike facies ▪ Rigidity ▪ Shuffling gait ▪ Dysphagia ▪ Drooling ***Treatment = COGENTIN (benztropine) + BENADRYL (diphenhydramine)

What is tardive dyskinesia?

▪ Protrusion of the tongue ▪ Chewing motion ▪ Involuntary movements of the body and extremities ***Treatment = switching medications