Module 10 Pharm
Examples of Monoamine Oxidase Inhibitors MAOI
•Non-selective(MAO-A and MAO-B):Tranylcypromine sulfate, isocarboxazid, phenelzine sulfate •Selective to MAO-B: selegiline (TD patch used for depression)
Drugs interactions with MAOIs?
•Phenylephrine and pseudoephedrine can cause a hypertensive crisis when taken with an MAOI -Must be off TCA, SSRI, and SNRI 14 days before starting MAOI
Tardive dyskinesia (TD)
•Protrusion and rolling of tongue, chewing action
When doing an admission drug history, the nurse notes that the patient has a prescription for lithium. The nurse suspects that this patient has been diagnosed with which condition? A. Bipolar disorder B. Absence seizures C. Paranoid schizophrenia D. Obsessive-compulsive disorder
A
Notice that the generic names of phenothiazines end in
"azine"
A patient is prescribed lithium for bipolar disorder. What information should the nurse provide to the patient when educating the patient about this medication?
-Lab work will be needed to monitor drug levels -Avoid caffeine as this can increase manic phases -Drink 2-3 liters per day during early therapy, once maintenance therapy is achieved, drink 1.5-2L per day
What nonpharmacologic interventions should be used before starting anxiolytics?
-Relaxation techniques: deep breathing, guided imagery, music -psychotherapy -support groups
The nurse is administering lithium. The therapeutic range is ___to___ mEq/L. (Enter a numerical value only in the blanks).
0.5-1.5
The nurse is aware that typical antipsychotics treat _1____symptoms and have a great chance for EPS, while the atypical antipsychotics treat both _2___ and_3___ symptoms and have a lower chance of causing EPS.
1. positive 2. positive 3. negative
What is good patient teaching for antidepressants?
1.*Warn that foods that contain tyramine can cause a hypertensive crisis with MAOIs. 2.Encourage taking drug as prescribed. 3.Encourage avoiding alcohol, CNS depressants, and cold medicines. 4.Teach to take drug with food if GI distress occurs. 5.*Warn patient against driving or using dangerous mechanical equipment until drug effect is known. 6.*Warn patient against abruptly stopping drug. 7.Instruct patient to take drug TCA' at bedtime and to rise in stages due to risk of orthostatic hypotension. 8.*Advise patient that a therapeutic response usually occurs in 2 to 4 weeks(at greatest risk for suicide during this early therapy) 9.*Inform patient that herbal supplements(e.g., St. John's wort, ginseng) may interact with antidepressants.
What should you asses prior to admintering antidepressants?
1.Assess baseline vital signs and weight. 2.Assess hepatic and renal function 3.Assess mental status and for thoughts of suicide/self harm 4.Obtain list of current medications, use of drugs and herbal substances (looking especially at MAOI's, St. John's Wort)
As a nurse what is it important to monitor while a patient is on lithium?
1.Monitor vital signs, sodium levels. 2.Monitor for drug effectiveness 3. ***Monitor for suicidal tendencies. 4.Monitor urine output, renal function tests(creatinine level).
What should we monitor while a patient is on antidepressants?
1.Monitor vital signs. 2.Monitor mood for drug effectiveness. 3.***Monitor for suicidal tendencies (all antidepressants) 4.Antidepressants lower seizure threshold, monitor for seizures.
Patient teaching for patients on lithium?
1.Teach patient signs of toxicity: persistent nausea, vomiting, severe diarrhea, slurred speech, blurred vision increased thirst, increasing tremors, lack of coordination, confusion, drowsiness, dysrhythmias, seizures, coma 2.Teach patient to wear medical alert identification. 3.Teach patient to take drug as prescribed and keep medical appointments. Lithium levels will be monitored every month. 4.Warn against driving motor vehicles or operating dangerous equipment until drug effect is known. 5.Advise patient that drug effect may take 1 to 2 weeks. 6.*Encourage patient to avoid caffeine(can cause manic-episodes), crash diets, NSAIDs, diuretics(wastes sodium). 7.*Encourage patient to maintain adequate sodium intake. These patients will be encouraged to eat sodium, instead of avoid sodium. 8.Encourage adequate fluid intake (2-3 L daily initially, 1.5 to 2 L daily maintenance). 9.Take with food to decrease GI irritation.
MAOIs with TCA's can cause cardio-vasular instability. The patient will need to discontinue the TCA how many days prior to initiating therapy on an MAOI and vice versa?
14 days
Patient will need to be off of SSRI for ___ prior to starting a MAOI. Patient will need to be off MAOI _____ before starting SSRI.
14 days 5 weeks
How long does a patient need to be off all other antidepressants before starting MAOIs?
2-5 weeks
A patient with a diagnosis of depression is being discharged with a prescription for an monoamine oxidase inhibitors (MAOI). Which instruction would the nurse include for this medication? A. Avoid eating aged cheese. B. Encourage use of fiber supplements. C. Explain the symptoms of tardive dyskinesia. D. Emphasize that tremors are a common adverse effect.
A
During therapy for depression with a selective serotonin reuptake inhibitor (SSRI), it is the most important for the nurse to instruct the family to monitor for which adverse effect? a. suicidal thoughts b. visual disturbances c. tardive dyskinesia d. bleeding tendencies
A
MAOI's should not be taken until the patient has been off SNRI's for ___ days. SNRI's should not be started until ___ days after the use of an MAOI.
7, 14
22-year-old patient has been taking lithium for 1 year, and the most recent lithium level is 0.9 mEq/L. Which statement about the laboratory result is correct? a. The lithium level is therapeutic. b. The lithium level is too low. c. The lithium level is too high. d. Lithium is not usually monitored with blood levels.
A
A patient has been diagnosed with neuroleptic malignant syndrome. The nurse anticipates administration of which medication to treat this patient? • A.Dantrolene B.Tetrabenazine C.Propranolol D.Benztropine
A
The nurse reads in the patient's medication history that the patient is taking buspirone (BuSpar). The nurse interprets that the patient may have which disorder? a. Anxiety disorder b. Depression c. Schizophrenia d. Bipolar disorder
A
"feeling so badly" when he started taking an over-the-counter St. John's wort herbal product at home. The nurse suspects that he is experiencing serotonin syndrome. Which of these are symptoms of serotonin syndrome? (Select all that apply.) a. Agitation b. Drowsiness c. Tremors d. Bradycardia e. Sweating f. Constipation
A C E
What are some foods that should be avoided while a client is taking monoamine oxidase inhibitors (MAOI's). SELECT ALL THAT APPLY
Aged cheeses Aged or fermented meat Yest extracts Red wine Italian broad bean
What are the 4 different types of extrapyramidal symptoms?
EPS has 4 different subsets: acute dystonia (occurring days-weeks after starting therapy); akathisia, pseudoparkinsonism tardive dyskinesia (occurs after long term therapy, normally greater than 1 year).
What happens within days to weeks of starting the drug. It causes muscle spasms especially of the face, tongue, neck and back. They can have torticollis and facial grimacing. Their tongue may protrude from their mouth due to spasms. They also have involuntary upward movement of the eye, which can be interpreted as psychosis.
Acute dystonia
The nurse is administering the antipsychotic drug clozapine and should monitor the patient for what long term problems associated with the drug?
Agranulocytosis weight gain increased appetite
A patient with schizophrenia started fluphenazine to help with their symptoms. Today, the patient is pacing back and forth and will not participate in group therapy, stating "I need to keep moving." Based on the assessment data, what adverse effect is this patient most likely experiencing?
Akathisia
is an acute in nature and normally occurs within days. Constant motion, like pacing, fidgeting. It can look like the patient is anxious.
Akathisia
Before beginning a patient's therapy with selective serotonin reuptake inhibitor (SSRI) antidepressants, the nurse will assess for concurrent use of which medications or medication class? a. Aspirin b. Anticoagulants c. Diuretics d. Nonsteroidal anti-inflammatory drugs
B
What are some common AE with need to worry with lithium?
hypertension GI Vomit headache metallic taste
What happens when you mix a sudophendrine/ cold medicine with an MAOI?
hypertensive crisis
What is a fatal adverse reaction to MAOIs?
hypertensive crisis from "fatal tyramine interaction."
Chlorpromazine (Thorazine) is prescribed for a patient, and the nurse provides instructions to the patient about the medication. The nurse includes which information? a. The patient needs to avoid caffeine while on this drug. b. The patient needs to wear sunscreen while outside because of photosensitivity. c. Long-term therapy may result in nervousness and excitability. d. The medication may be taken with an antacid to reduce gastrointestinal upset.
B
Selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants (TCAs) both function by which mechanism? A. Decrease the catecholamine release into the blood B. Block the reuptake of neurotransmitters at nerve endings C. Inhibit an enzyme that stops the action of neurotransmitters D. Stimulate areas of the brain associated with mental alertness
B
What is Aripiprazole known for?
is especially known for causing weight gain and weight should be monitored because we are worried about diabetes and heart disease.
What type of symptom do your typical antiphyscotic drugs treat?
just positive
How would you evaluate if the lithium is working?
less manic- improved mental health
What does TCA do to blood pressure?
lowers it-causes hypotension rise in stages
What is important to asses prior to admintering lithium?
Assess vital signs Assess sodium level (low sodium level puts the patient at risk for lithium toxicity, normal sodium levels 135-145 mEq/L) Assess serum lithium levels ( 0.5-1.5 mEq/ L is therapeutic range)
When do we take TCAs?
At bedtime-it causes sedation
What is special about Atypical antipsychotics?
Atypical have less side effects and are often used instead of traditional typical antipsychotics. They control positive and negative symptoms. weak affinity to D5
The nurse realizes more medication teaching is necessary when the 30-year-old patient taking lorazepam states A."I must stop drinking coffee and colas." B."I can stop this drug after 3 weeks if I feel better." C."I must stop drinking alcoholic beverages." D."I should not become pregnant while taking this drug."
B
A nurse caring for a patient in an outpatient setting notes that the patient is currently taking lorazepam for anxiety and her breath smells of alcohol. The nurse reports this to the health care provider because A.taking alcohol with Ativan can decrease effectiveness of Ativan. B.taking alcohol with Ativan may increase sedative effects. C.all patients using alcohol should be referred for assistance. D.Ativan and alcohol antagonize one another.
B
A patient diagnosed with depression is being discharged with a prescription for tricyclic antidepressants (TCA) after no improvement of symptoms on a selective serotonin reuptake inhibitors (SSRI). Which instruction would the nurse include specific to TCAs? A. There are no drug or food contraindications with this medication. B. There is a risk of toxicity when this medication is taken with alcohol. C. Take St. John's wort every day to minimize the adverse effects of the medication. D. This drug does not cause problems with sleep, constipation, or low blood pressure.
B
A patient prescribed lorazepam (Ativan) for the treatment of anxiety states, "I feel drowsy all the time, and it's interfering with every aspect of my life." The nurse knows that a better drug therapy option for this patient is which anxiolytic medication? A. Alprazolam (Xanax) B. Buspirone (BuSpar) C. Chlordiazepoxide (Librium) D. Hydroxyzine hydrochloride salt (Vistaril)
B
A young woman is being treated for psychosis with fluphenazine. Which sign would indicate the need to add an anticholinergic to the patient's medication regimen? A.A decrease in pulse and respiratory rate B.Facial grimacing and tongue spasms C.An increase in hallucinations D.A decrease in the patient's level of orientation
B
The wife of a patient who has been diagnosed with depression calls the office and says, "It's been an entire week since he started that new medicine for his depression, and there's no change! What's wrong with him?" What is the nurse's best response? a. "The medication may not be effective for him. He may need to try another type." b. "It may take up to 6 weeks to notice any therapeutic effects. Let's wait a little longer to see how he does." c. "It sounds like the dose is not high enough. I'll check about increasing the dosage." d. "Some patients never recover from depression. He may not respond to this therapy."
B
What is another approved and indicated use for the antidepressant bupropion (Zyban)? A. Nocturnal enuresis B. Smoking cessation C. Tourette's syndrome D. Orthostatic hypotension
B
When a patient is receiving a second-generation antipsychotic drug, such as risperidone (Risperdal), the nurse will monitor for which therapeutic effect? a. Fewer panic attacks b. Decreased paranoia and delusions c. Decreased feeling of hopelessness d. Improved tardive dyskinesia
B
Which laboratory test would be monitored closely to assess for a potential life-threatening adverse effect to clozapine (Clozaril)? A. Liver function studies B. Complete blood count C. Immunoglobulin levels D. Glomerular filtration rate
B
How long does it take for Buspirone to take effect?
may not be effective until 1-2 weeks after continuous use
A patient has been admitted to the emergency department with a suspected overdose of a tricyclic antidepressant. The nurse will prepare for what immediate concern? a. Hypertension b. Renal failure c. Cardiac dysrhythmias d. Gastrointestinal bleeding
C
A patient has been taking antipsychotic medication for years, and his wife has noticed that he has had some new physical symptoms. She describes him as having odd facial movements, sticking out his tongue, and having movements of his arms that he cannot seem to control. The nurse suspects that the patient is exhibiting signs of which condition? a. hypomania b. serotonin syndrome c. tardive dyskinesia d. neuroleptic malignant syndrome
C
A patient has been taking haloperidol (Haldol) for 3 months for a psychotic disorder, and the nurse is concerned about the development of extrapyramidal symptoms. The nurse will monitor the patient closely for which effects? a. Increased paranoia b. Drowsiness and dizziness c. Tremors and muscle twitching d. Dry mouth and constipation
C
A patient who is prescribed duloxetine (Cymbalta) comes to the medical clinic complaining of restlessness, sweating, and tremors. The nurse suspects serotonin syndrome and questions the patient regarding concurrent use of which herbal product or dietary supplement? A. Zinc B. Vitamin E C. St. John's wort D. Glucosamine chondroitin
C
Assessment findings for a patient with neuroleptic malignant syndrome (NMS) include A.bradycardia. B.hypothermia. C.muscle weakness. D.rhabdomyolysis.
C
Before administering an MAO inhibitor, it is most important for the nurse to assess the patient's A.sexual history. B. socioeconomic status. C. dietary intake. D. hydration status.
C
Primary side effects of the SSRIs include which symptoms? a. rash and alopecia b. gastritis and diarrhea c. weight gain and sexual dysfunction d. photosensitivity and discoloration of the skin
C
The nurse is reviewing medications used for depression. Which of these statements is a reason that selective serotonin reuptake inhibitors (SSRIs) are more widely prescribed today than tricyclic antidepressants? a. SSRIs have fewer sexual side effects b. Unlike tricyclic antidepressants, SSRIs do not have drug-food interactions. c. Tricyclic antidepressants cause serious cardiac dysrhythmias if an overdose occurs. d. SSRIs cause a therapeutic response faster than tricyclic antidepressants
C
The nurse is reviewing the food choices of a patient who is taking a monoamine oxidase inhibitor ( MAOI). Which food choice would indicate the need for additional teaching? a. Orange juice b. Fried eggs over-easy c. Salami and Swiss cheese sandwich d. Biscuits and honey
C
The wife of a patient who has started taking antidepressant therapy asks, "How long will it take for him to feel better?" what is the nurse's best response? a. "well, depression rarely responds to medication therapy" b. "He should be feeling better in a few days" c. "It may take 4 to 6 weeks before you see an improvement" d. "you may not see any effects for several months"
C
Which laboratory test is most important for the nurse to monitor when a patient is receiving lithium? A. Urinalysis B. Serum glucose C. Serum electrolytes D. Complete blood count
C
A patient is prescribed phenelzine for the diagnosis of major depressive disorder. When providing education to the patient, what are some foods that the nurse should teach the patient to avoided while taking this medication?
Cheddar cheese Pepperoni Red wine Foods high in tyramine include aged cheeses (cheddar, blue, swiss), Smoked or pickled meats (herring, sausage, corned beef, smoked fish or poultry, salami, pepperoni), aged or fermented meats, red wines, and Italian broad beans.
A patient has been taking the selective serotonin reuptake inhibitor (SSRI) sertraline (Zoloft) for about 6 months. At a recent visit, she tells the nurse that she has been interested in herbal therapies and wants to start taking St. John's wort. Which response by the nurse is appropriate? a. "That should be no problem." b. "Good idea! Hopefully you'll be able to stop taking the Zoloft." c. "Be sure to stop taking the herb if you notice a change in side effects." d. "Taking St. John's wort with Zoloft may cause severe interactions and is not recommended."
D
A patient with reactive depression is ordered to receive fluoxetine. Which information will the nurse include when teaching this patient? A.The medication takes effect in 1 week. B. The medication increases libido. C. The medication should be taken with grapefruit juice. D. The medication may cause headaches and insomnia.
D
The nurse instructs a patient who is undergoing therapy with monoamine oxidase inhibitors (MAOIs) to avoid tyramine-containing foods. What medical emergency may occur if the patient eats these foods while taking MAOIs? a. gastric hemorrhage b. toxic shock c. cardiac arrest d. hypertensive crisis
D
The nurse is monitoring a patient taking an antipsychotic medication for extrapyramidal symptoms. Which clinical finding indicates the patient is having an adverse effect from this drug? A. Dry mouth and constipation B. Blood pressure of 80/50 mm Hg C. Presence of myoglobin in the blood D. Muscle cramps of the head and neck
D
What atypical antipsychotic medication would the nurse anticipate the health care provider prescribing for treatment of refractory schizophrenia? A. Phenelzine (Nardil) B. Trazodone (Desyrel) C. Amoxapine (Asendin) D. Risperidone (Risperdal)
D
Which outcome represents the most serious adverse effect of lithium? a. renal failure b. hyponatremia c. respiratory depression d. cardiac dysrhythmia
D
Which statement by the patient indicates the need for additional teaching on phenothiazine (Thorazine) drug therapy? A. "I need to change positions slowly to prevent dizziness." B. "I will call my health care provider for abnormal tongue movements" C. "I will need to wear sunscreen and protective clothing when outdoors." D. "It is okay to take this drug with a small glass of wine to help relax me."
D
patient has been taking the monoamine oxidase inhibitor (MAOI) phenelzine (Nardil) for 6 months. The patient wants to go to a party and asks the nurse, "Will just one beer be a problem?" Which advice from the nurse is correct? a. "You can drink beer as long as you have a designated driver." b. "Now that you've had the last dose of that medication, there will be no further dietary restrictions." c. "If you begin to experience a throbbing headache, rapid pulse, or nausea, you'll need to stop drinking." d. "You need to avoid all foods that contain tyramine, including beer, while taking this medication."
D
patient with the diagnosis of schizophrenia is hospitalized and is taking a phenothiazine drug. Which statement by this patient indicates that he is experiencing a common adverse effect of phenothiazines? a. "I can't sleep at night." b. "I feel hungry all the time." c. "Look at how red my hands are." d. "My mouth has been so dry lately."
D
Adverse effects of SNRI's?
Drowsiness, dizziness, insomnia, headache, euphoria, amnesia, blurred vision, photosensitivity, sexual dysfunction, hypertension, angioedema, blood dyscrasias, suicidal ideation, Stevens-Johnson syndrome
Buspirone can be given "as needed" for anxiety and the patient will not be scheduled for a daily dose of this medication to treat their anxiety. T/F
False
Examples of Selective Serotonin Reuptake Inhibitors
Fluvoxamine, fluoxetine, sertraline, paroxetine, citalopram, escitalopram
What is the treatment for akathisia?
For treatment, make sure the patient is aware this is an adverse effect of their medication and taper them off of the drug. (as a nurse, you will contact the healthcare provider and alert them of the symptoms). A benzodiazepine can be used for treatment
What drug interactions are important to remember for Buspirone?
Grapefruit juice can lead to toxicity
An older-adult patient experiences acute psychosis at night during their hospitalization. What prescribed medication should the nurse administer for this problem?
Haloperidol is commonly used for acute psychosis. Benzodiazepines can increase the psychosis symptoms in an older adult patient, as can zolpidem.
Butyrophenone examples?
Haloperidol, haloperidol decanoate
When compared to "benzos" what is different about Buspirone?
Has fewer side effects of sedation and physical and psychological dependency associated with many benzodiazepines
A patient with schizophrenia appears disheveled and will not attend group therapy today. The nurse administers the scheduled morning tablets of the atypical antipsychotic medication. What priority intervention should the nurse implement?
Have the patient open their mouth and stick out their tongue after swallowing the tablet
The nurse is aware that serotonin syndrome can occur when a patient is prescribed Selective Serotonin Reuptake Inhibitors (SNRI's) and Serotonin Norepinephrine Reuptake Inhibitors (SNRI's). What are some common and severe signs and symptoms of Serotonin Syndrome?
Hyperreflexia Shivering Hyperthermia Coarse tremors Renal failure
Signs of lithium toxicity?
nephrontoxiticity
A patient has been taking lithium for the last month and have arrived for their monthly lab work. Which lab values are would be concerning to the nurse? SELECT ALL THAT APPLY
Lithium 2.1 mEq/L Sodium 121mEq/L Creatinine 4.2 mg/dL Lithium levels should be between 0.5-1.5 mEq/L Sodium should be between 135-145. Creatinine should be less than 1.2 mg/dL
What is important to help the patient maintain while on lithium?
Maintaining adequate sodium levels helps keep the patient within the therapeutic range. The patient on a diuretic will be at greater risk of sodium depletion, which leads to toxic levels of lithium in the body.
Indication for tricyclic antidepressants?
Major depression and agitated depression
What is one thing we should be aware of when treating anxiety with benzos?
suicide -do this by cheeking the pill
What is important patient teaching for patients on SSRIs?
takes 3-4 weeks to achieve therapeutic effect- suicide risks until then
What are the most common side effects of Buspirone?
Most common: drowsiness, dizziness, headache, nausea, nervousness, and excitement
What is the treatment for TD?
The drug will be tapered off and another drug started. Benztropine or diphenhydramine can be used to treat these symptoms.
adverse effect that can occur with the antipyschotics. It is rare, but it can be fatal, and it should be recognized quickly and the health care provider noted.
Neuroleptic Malignant Syndrome
Are TCA's recommended for people with seizure disorders?
No
Whats the difference between non-selective MAOI and selective MAOI?
Non-selective MAOI's are more likely to cause the food interactions and hypertensive crisis. The selective MAOI will have less adverse effects and less chance of the food interactions, however, the patient would still need to avoid food high in tyramine while on a selective MAOI.
What is the treatment for acute dystonia?
The treatment is to slowly withdraw the drug. (As a nurse, you will contact the healthcare provider and alert them of the symptoms). Sometimes, benztropine or diphenhydramine can be administered to help with the symptoms. If the muscle spasms are severe, a benzodiazepine may be prescribed.
____ looks like Parkinson's disease, and is related to the blocking of dopamine by the antipsychotic medications (especially the typical). Normally occurs over weeks to months.
Pseudo parkinsonism
What are the adverse effects of tricyclic antidepressants?
Sedation, dizziness, anticholinergic effects, weight gain, GI distress, sexual dysfunction, orthostatic hypotension, dysrhythmias, blood dyscrasias
What herbal supplement should the nurse teach the patient to avoid while on fluoxetine?
St. John's Wort
•Aliphatic: chlorpromazine Side effects
Strong sedation, severe orthostatic hypotension, moderate EPS
A patient has seen the physician due to severe anxiety and has received a prescription for alprazolam for anxiety. What priority assessment should the nurse preform prior to discharging the patient home?
Suicidal thoughts or ideation
What is the only EPS that can be permeant?
TD
is a later appearing EPS. It will normally occur after a year or more of treatment on an antipsychotic medication. It looks similar to acute dystonia. The main way to differentiate is onset of symptoms in relation to starting the antipsychotic drug. This is the only type of EPS that can be permanent.
Tardive dyskinesia (TD)
What is the indication of lithium?
Treat manic episodes in bipolar psychosis
If you see decanoate with haloperidol or fluphenazine, this means this medication cannot be given by intravenous route and it should be administered by Z-track method into a large muscle. It is a long-acting release of the medication used to treat chronic psychoses. T/F
True
How long does TCA's take to work?
a couple weeks
Tricyclic antidepressants examples:
amitriptyline and nortriptyline
What are the indications for Buspirone?
anxiety
When should tricyclic antidepressants be taken?
at bedtime because of the adverse effects of sedation
Patient teaching for someone who is on lithium?
avoid caffeine medical alert bracelet taking with food increase sodium takes a couple weeks before takes effect 2-3 L or water at first- then go down to 1-2 L Labs checked
NMS and malignant hyperthermia are the main indications for use of
dantrolene
What drug class would interact with lithium?
diuretics
What kind of education should we provide our patients who are going home on benzos?
don't drive until you know how it effects you no alcohol avoid grapefruit-prolongs the effect no kava kava or valerian
What are some of the adverse effects we should think about with benzos?
drowsiness dizziness cognitive impairment lethargy amnesia confusion hang over respiratory depression
What are typical drugs?
fluphenazine, haloperidol, decanoate
What food does a patient need to avoid while on MAOIs?
food high in tyramine
Whats important to remember with the MAOIs?
food interactions can kill them! big tyramine foods: aged cheeses, meats smoked cured, wine -can use low tyramine foods in moderation
What is special about typical antipsychotics?
older have more adverse effects control only positive symptoms strong affinity to D5
What are signs of lithium toxicity?
persistent nausea, vomiting, severe diarrhea, slurred speech, blurred vision increased thirst, increasing tremors, lack of coordination, confusion, drowsiness, dysrhythmias, seizures, coma
What are the four subcategories of EPS?
pesduo parksinsonism actue distonia akathesia TD-tardive dyskinesia
What are older, typical antipsychotics. They have a strong affinity to Dopamine 2. They have potential for causing EPS. These are typical antipsychotics and only treat Positive symptoms of schizophrenia.
phenothiazines
What is important to remember about SSRI and side effects?
side effects decrease after 2-3 weeks
Fill in the blank with the electrolyte that lithium depletes from the body.
sodium
What is important to asses with a patient on lithium?
sodium/ therapeutic level - 0.5-1.5* -normal sodium is 135-145 worried about too little
What OTC or herbal supplements we should worry about with SSRI?
st. johns wort-serotonin syndrome
How do we tell the difference between TD and acute dystonia?
the onset of symptoms in relation to starting the drug. TD-after a year or more AD- within days or weeks
How will we know if the benzo is effective?
the patient will report less anxiety
When administering certain antipsychotic drugs, the nurse monitors for which extrapyramidal effects?
tremors painful muscle spasms motor restlessness
How is Buspirone taken?
will be taken on a scheduled basis, not on an "as needed" basis
Symptoms of NMS (neuroleptic malignant syndrome)
•Altered mental status, seizures •Muscle rigidity, sudden high fever •BP fluctuations, tachycardia, dysrhythmias •Rhabdomyolysis, acute renal failure •Respiratory failure, coma
Mechanism of Action for all antipsychotic drugs
•Block action of dopamine •There are 5 subtypes D1-D5 •D2 promotes EPS
•Aripiprazole
•Block serotonin and dopaminergic D4 receptors Side effects •Hyperglycemia, drowsiness, memory impairment, weight gain, suicidal ideation, NMS, less likely but can cause EPS, Agranulocytosis
•Clozapine
•Blocks dopamine, but mostly D4. •Only indicated for severely ill schizophrenic patients who are intolerant of typical antipsychotics •Not likely to cause EPS Adverse effect •Agranulocytosis
Atypical Antipsychotics
•Clozapine •Olanzapine •Quetiapine •Asenapine •Risperidone •Ziprasidone •Aripiprazole
What are some cognitive symptoms associated with Schizophrenia?
•Disorganized thinking •Memory difficulty •Decreased ability to focus attention
Olanzapine
•Does not cause agranulocytosis •Less likely to cause EPS
•Risperidone
•Does not cause agranulocytosis •Low incidence of EPS Adverse effects •EPS, insomnia, akathisia
Indication of Phenothiazines?
•Manages positive symptoms of schizophrenia
What are some negative symptoms of Schizophrenia?
characterized by decrease or loss of function and motivation tend to be more chronic and persistent. •Poor self-care •Poverty of speech •Social withdrawal
What are some positive effects of Schizophrenia?
characterized by exaggeration of normal function •Agitation •Delusions •Paranoia •Hallucinations Incoherent speech
Nursing interventions for Clozapine
•Monitor weekly WBC counts •Stop if WBC count falls below 3,000
SSRI can also be used for?
chronic pain mirgaines seizures
When providing dietary teaching for a patient taking monamine oxidase inhibitors (MAOIs), the nurse should teach the patient to avoid which food? A.Summer Sausage B.Avocado C.Grapefruit D.Potato chips
A
Which statement about amitriptyline does the nurse identify as being true? A. The drug is administered first thing in the morning. B. The drug should be discontinued slowly. C. The onset of antidepressant effect is 48 hours. D. Hypertension is a frequent side effect of this drug.
B
While monitoring a depressed patient who has just started SSRI antidepressant therapy, the nurse will observe for which problem during the early time frame of this therapy? a. Hypertensive crisis b. Self-injury or suicidal tendencies c. Extrapyramidal symptoms d. Loss of appetite
B
patient wants to take a ginseng dietary supplement. The nurse instructs the patient to look for which potential adverse effect? a. Drowsiness b. Palpitations and anxiety c. Dry mouth d. Constipation
B
ecause of known adverse effects, when should the nurse administer tricyclic antidepressants, such as nortriptiline and amitriptiline? Fill in the blank with your answer
Because TCA's can cause drowsiness, they are most often administered at bedtime.
How do we treat pseudo parkinsonism?
Best treatment is to taper off of the medication that is causing these symptoms. (as a nurse, you will contact the healthcare provider and alert them of the symptoms). Diphenhydramine and benztropine can also help with the Parkinson's symptoms,
Which statement by a patient indicates that more teaching on phenothiazine therapy for the treatment of psychosis is needed? A."It might take 6 weeks or more for the drug to take effect." B."I will get up slowly from a seated position." C."When I start to feel better, I will cut the dose of my medication in half." D."I will avoid exposure to direct sunlight."
C
Which statements are true regarding the selective serotonin reuptake inhibitors (SSRIs)? (Select all that apply.) a. Avoid foods and beverages that contain tyramine. b. Monitor the patient for extrapyramidal symptoms. c. Therapeutic effects may not be seen for about 4 to 6 weeks after the medication is started. d. If the patient has been on an MAOI, a 2- to 5-week or longer time span is required before beginning an SSRI medication. e. These drugs have anticholinergic effects, including constipation, urinary retention, dry mouth, and blurred vision. f. Cogentin is often also prescribed to reduce the adverse effects that may occur.
C D
•A patient on risperidone may be at increased risk for injury due to A.increased potential for aspiration due to sedation. B.increased risk for falls due to orthostatic hypotension. C.increased risk for infection due to neutropenia. D.increased risk for suicide due to changes in thought processes.
D
Important things to remember with TCAs
DONT TAKE WITH MAOI
A patient is prescribed alprazolam as needed for anxiety. What nonpharmacologic interventions can the nurse encourage the patient to implement to help with anxiety in addition to taking their prescribed alprazolam? SELECT ALL THAT APPLY
Deep breathing Guided imagery Join a support group Listening to music Seek counseling from a trained professional
The nurse is aware that serotonin syndrome can occur when a patient is prescribed Selective Serotonin Reuptake Inhibitors (SNRI's) and Serotonin Norepinephrine Reuptake Inhibitors (SNRI's). What are some common Signs and symptoms of Serotonin Syndrome?
Hyperreflexia Shivering Hyperthermia Tremors Seizures Cardiac Dysrhythmias
What disorder do we take lithium for?
bipolar-manic and depressive states
What type of symptom do atypical drugs treat?
both, positive and negative
What are the atypical drugs?
clozapine, aripiprazole, olanzapine, risperidone, ziprasidone
Which symptom lasts longer with antiphsyctoics even with treatment?
negative
Acute dystonia signs
•Muscle spasms of face, tongue, neck, and back •Facial grimacing •Involuntary upward eye movements Laryngeal spasms
What are the adverse effects of lithium?
•Headache, drowsiness, dizziness, hypotension, dysrhythmias, Restlessness, slurred speech, dry mouth, metallic taste, GI distress, tremors, muscle weakness, edema of hands and ankles, increased urination, blood dyscrasias, nephrotoxicity
Adverse effects of SSRIs?
•Headache, nervousness, restlessness, insomnia, tremors, seizures, GI distress, sexual dysfunction, suicidal ideation Side effects often decrease over 2 to 4 weeks
Treatment of NMS?
•Immediate withdrawal of antipsychotics, •Hydration, hypothermic blankets, antipyretics, •Benzodiazepines, muscle relaxants
What are the drug interactions with tricyclic antidepressants?
•Increased CNS effects with alcohol and other CNS depressants •Do not take concurrently with MAOI's, leads to cardiotoxicity. •Increased sedation and anticholinergic effects with phenothiazines, haloperidol
Interactions with SSRIs?
•Increased CNS effects with alcohol and other CNS depressants •St. John's Wort increases chance of serotonin syndrome •Toxicity occurs with grapefruit juice •Concomitant use of MAOI's and SSRI's is contraindicated
What are the drug to drug interaction with lithium?
•Increased lithium level with diuretics, methyldopa, haloperidol, NSAIDs, antidepressants, theophylline, phenothiazines
•Piperazine: fluphenazine and perphenazine •Side effects:
•Low sedation, strong antiemetic effect, severe EPS (More than other phenothiazines)
Indications of SSRIs?
•Major depression, Anxiety disorders, obsessive-compulsive disorder, panic, phobias, prevention of migraine headaches
Indications of SNRIs?
•Major depression, anxiety disorder, social anxiety disorder, adjuvant treatment for chronic pain
Adverse effects of Phenothiazines
•Sedation, dizziness, headache, peripheral edema, weight gain, anticholinergic effects, seizures, tachycardia, EPS, hypotension/hypertension, NMS
Interactions with SNRIs?
•St. John's wort may increase the risk of serotonin syndrome •Concomitant use of MAOI with SNRI's is contraindicated
Extrapyramidal Symptoms (EPS): Pseudo parkinsonism symptoms
•Stooped posture •Masklike features •Rigidity •Tremors at rest •Shuffling gait •Bradykinesia •Pill-rolling motion of the hand
•Piperidines: Thioridazine HCl Side effects:
•Strong sedative, few EPS
Contraindications for tricyclic antidepressants?
•Use with MAOIs (within 14 days), pregnancy •Not recommended for patients with chronic cardiac problems or seizure disorders
Ziprasidone
•Use with caution in cardiac patients •Prolongs QT interval •Monitor ECG
Examples of Serotonin Norepinephrine Reuptake Inhibitors
•Venlafaxine, duloxetine, desvenlafaxine