PSU Pharm Test 5 (Psychotherapeutic, Antiemetic, & Dermatologic Drugs)

A patient is taking lithium for bipolar disorder. Which of the following labs would you report to the primary care provider?

Sodium 124 mEq/L

MAOI overdose

Symptoms appear 12 hrs after ingestion. Tachycardia, circulatory collapse, seizures, coma. Treatment: protect brain & heart, eliminate toxin: gastric lavage, urine acidification, hemodialysis

Caution when combined with warfarin, results in an inc. anticoagulant effect

TCAs

A nurse is teaching a female client who has bipolar disorder about her new prescription for lithium carbonate. Which of the following is appropriate for the nurse to include in the teaching?

Take this medication with food or a glass of milk, avoid pregnancy while taking this medication, & thyroid function is assessed prior to lithium therapy.

Lithium Teaching:

Takes 1-2 weeks to see therapeutic effects. Short 1/2 life, so dosing 2-3x/day (compliance). Encourage adequate fluids and sodium intake. Use Tylenol instead of NSAIDs (NSAIDs inc lithium levels).

A nurse performs an Abnormal Involuntary Movement Scale (AIMS) assessment on a client who began taking lozapine 2 years ago for treatment of schizophrenia. Findings include lip smacking, tongue protrusion, and facial grimacing. The nurse should suspect which of the following?

Tardive Dyskinesia

A nurse is caring fro a client who has a new prescription for valproic acid. The nurse should instruct the client that while taking this medication he will need to have which of the following laboratory test completed periodically?

Thrombocyte count, Amylase, & Liver function tests

TCA Caution

Toxicity evidenced by dysrhythmias, mental confusion, and agitation. Later Seizures, coma, & death. Give a 1-week supply of medication. Obtain baseline EKG. Concurrent use of MAOIs and St. John's wort may lead to serotonin syndrome. Instruct patient to notify PCP if signs of toxicity.

Antipsychotics: indications

Treatment of serious mental illnesses: bipolar affective disorder, Acute and chronic psychotic disorders, Schizophrenia, Tourette's syndrome. Some medical conditions: nausea prevention, intractable hiccups.

Antidepressants

Tricyclic antidepressants, Monoamine oxidase inhibitors (MAOIs), Newer-generation antidepressangs: SSRIs & "Other antidepressants"

Psychotherapeutic Drugs

Types include: Antianxiety drugs, Antimanic drugs, Antidepressant drugs, and Antipsychotic drugs

Anxiety

Unpleasant state of mind, characterized by a sense of dread or fear. May be based on actual anticipated experiences or past experiences.

Serotonin Syndrome

Usually 2-72 hours after starting SSRI-may be lethal. Manifestations include: mental confusion, fever, agitation, anxiety, hallucinations, incoordination, hyperreflexia, diaphoresis, and tremors. Symptoms of severe cases: hyperthermia, seizures, renal failure, rhabdomyolysis, dysrhythmias, disseminated intravascular coagulation. If symptoms occur, notify PCP and DC med.

Is schizophrenia genetic?

YES

A patient is prescribed haloperidol for acute psychosis. What is an adverse effect to report to the primary care provider?

acute dystonia or neck spasms

Common Tricyclics

amitriptyline, doxepin, imipramine, amoxapine, nortriptyline, trimipramine

Signs of Benzodiazepine withdrawal

anxiety, insomnia, diaphoresis, tremors, light-headedness (tapor dose over several weeks to discontinue) <-- can seize. shakey, hypersensitive

1st generation Antipsychotics mechanism of action

block dopamine receptors in the brain (limbic system, basal ganglia)- areas associated w/ emotion, cognitive function, motor function. Dopamine levels in the CNS dec. Result: tranquilizing effect in psychotic patients

1st Generation Antipsychotics

clorpromazine, thiothixene, haloperidol, fluphenazine.

Benzodiazepine overdose:

dangerous when taken w/ other sedatives, opioids or alcohol. Oral toxicity: gastric lavage, activated charcoal or saline cathartics. For IV antidote: Flumazenil may be used to reverse benzodiazepine effects. Monitor VS and fluids to maintain BP. Have resuscitation equipment available.

TCA therapeutic uses:

depressions, depressive episodes of bipolar disorder, neuropathic pain, fibromyalgia, anxiety disorders, insomnia

Buspirone AE

dizziness, nausea (take w/ food), HA, lightheadedness, agitation. *Potential hypertensive crisis if taken with MAOIs w/i 14 days of starting buspirone.

Best choice for people suffering from psychological disorders...

is drug and psychotherapy combo

Schizophrenia

loss of ego boundaries, inability to trust, withdrawn or peculiar behavior, indifferent-aloof, love/hate feelings, personality changes, confused-chaotic thoughts, retreat to fantasy world, autism, auditory hallucinations & delusions, hypersensitivity to sounds and sights and smells, difficulty relating to others, negativism, religiosity, lack of social awareness, disorganzied

MAOIs (Names)

phenelzine, tranylcypromine, isocarboxazid, selegiline

Benzodiazepines

potentially habit-forming and addictive. Should be used at lowest effective dosages and frequencies needed for symptom control. Require written script.

A nurse is providing teaching to a client who has a new prescription to start buspirone in place of diazepam. The client has a history of panic disorder and cirrhosis of the liver. The client asks why his provider is making the medication change. Which of the following statements is an appropriate response by the nurse?

"Buspirone has less risk for dependency than other treatment options."

A nurse is caring for a client who is to begin taking escitalopram for treatment of generalized anxiety disorder. Which of the following statements by the client indicates understanding of the use of this medication?

"I need to discontinue this medication slowly."

A nurse working in a mental health clinic is caring for a client who has obsessive-compulsive disorder and recently started a new prescription for buspirone. The client tells the nurse that the medication has not helped him sleep and that he is still having obsessive compulsions. Which of the following statements is an appropriate response by the nurse?

"It make take several weeks before you feel like the medication is helping."

A nurse is providing discharge teaching to a client who is to begin taking fluoxetine for posttraumatic stress disorder. Which of the following statements is appropriate for the nurse to include in the teaching?

"You may have a dec. desire for intimacy while taking this medication."

A nurse is providing discharge teaching for a client who has a new prescription for clozapine. Which of the following statements is appropriate for the nurse to include in the teaching?

"You should have your WBC count monitored every week."

A nurse is providing discharge teaching for a patient who has a new prescription for clozapine. Which of the following statements is appropriate for the nurse to include in the teaching?

"You should have your WBC count monitored every week."

2nd Generation Antipsychotics

(-apine or idone) clozapine, risperidone, olanzapine, quetiapine, ziprasidone, paliperidone, asenapine, lurasidone, aripiprazole

Common Benzodiazepines

(-zepam & -zolam) diazepam, lorazepam, alprazolam, clonazepam, oxazepam, and chlodiazepoxide

A patient is prescribed lithium for bipolar disorder. What is the maintenance level range?

0.4-1.0 mEq/L

What is a normal serum sodium range?

135-145 mEq/L

Neuroleptic Malignant Syndrome:

AE of antipsychotics. Potentially life threatening. High fever, unstable BP.

1st Generation Antipsychotics AE

Acute Dystonia (severe spasms of neck, back, tongue, and face), Parkinsonism (bradykinesia, rigidity, shuffling gait, drooling, and tremors), akathisia (continual pacing), Tarditive dyskinesia (involuntary movements), neuroleptic syndrome (fever, BP fluctuations, dysrhythmias, changes in LOC), Anticholinergic effects, Neuroendocrine effects (gynecomastia, galactorrhea, & menstrual irregularities), seizures, skin effects (wear sunscreen), orthostatic hypotension, agranulocytosis (baseline WBC), sever dysrhythmias (obtain baseline ECGs and K level)

Foods that contain Tyramine:

Aged cheeses (cheddar, blue, swiss), Smoked/pickled or aged meats or fish or poultry (herring, sausage, corned beef, salami, pepperoni), preserved meats, yeast extracts, Red wines (chianti, burgundy, sherry, vermouth), Italian broad beans (fava beans), pasteurized light and pale beer-limit

Bupropion Indications for use:

Aid to smoking cessation, depression, alternative to SSRIs if sexual dysfunction, prevention of seasonal depression.

Therapeutic uses of benzodiazepines

Anxiety, generalized anxiety disorder, panic attacks, insomnia, muscle spasms, alcohol withdrawal, seizure treatment, amnesic prior to surgery or procedure

AE/SE bupropion

Appetite suppression and weight loss, HA, dry mouth, constipation, seizures

Patient Teaching before starting MAOIs

Avoid tyramine-give written list, Avoid OTC decongestants, Avoid Caffeine, Monitor BP, Avoid Meperidine- may cause hyperpyrexia (high fever)

A nurse is providing follow-up dietary teaching for a client who recently was prescribed phenelzine. When reviewing the client's dietary log, which of the following foods requires a need for further teaching?

Banana Bread

Benzodiazepines AE

Benzodiazepine AE are an overexpression of their therapeutic effects. CNS depressions, sedation (dec cognitive funtion, caution w/ driving), anterograde amnesia, paradoxical response

Three Major anxiety meds

Benzodiazepines (-zolam & -zepam), Atypical anxiolytic/ nonbarbituate (buspirone), Selective Serotonin Reuptake Inhibitors (paroxetine)

Antianxiety drugs

Benzodiazepines: (ie alprazolam) depress activity in the brainstem and limbic system. Potentially habit forming (very addictive.) Miscellaneous Drugs: (ie buspirone) nonsedating and non-habit forming. May have drug interaction with SSRIs (serotonin syndrome). Do NOT administer with MAOIs

Psychotherapeutics: Pathophysiology

Biochemical imbalance theory. Brain levels of certain neurotransmitters play an important role in maintaining mental health. Catecholamines: Dopamine and norepinephrine. Indolamines: Serotonin and Histamine

AE of SSRIs

Bruxism (use mouth guard, change to different SSRI, or add low dose buspirone), Sexual dysfunction (more common w/ higher doeses), CNS stimulation (avoid caffeine), Wt loss then Wt. gain, Hyponatremia (obtain baseline serum sodium), Sleepiness, faintness, lightheadedness, Serotonin Syndrome. *To avoid withdrawal symptoms taper dosage gradually to discontinue* *Take in AM to prevent insomnia*

Atypical/ Anxiolytic Nonbarbituate

Buspirone (nonaddictive).

Carbamazepine AE

CNS effects include: nystagmus, vertigo, staggering gait, & HA. Blood dyscrasia: monitor for bruising and infection. Steven-Johnson syndrome

A nurse is providing teaching to a client who has a new prescription for amitriptyline for treatment of depression. Which of the following should the nurse include in the teaching?

Change positions slowly to minimize dizziness & Chew sugarless gum to prevent dry mouth

Affective Disorders (Mood disorders)

Changes in mood that range from mania to depression. Some patients may exhibit both mania and depression: bipolar disorder.

A nurse is teaching a client who has schizophrenia strategies to cope with anticholinergic effects of fluphenazine. Which of the following should the nurse suggest to the client to minimize anticholinergic effects?

Chew sugarless gum to moisten the mouth.

A nurse in a primary care clinic is assessing a client who takes lithium carbonate for the treatment of bipolar disorder. The nurse should recognize which of the following findings as a possible indication of toxicity of this medication?

Coarse Tremors

A nurse in a primary care clinic is assessing a client who takes lithium for the treatment of bipolar disorder. The nurse should recognize which of the following findings as a possible indication of toxicity to this medication?

Coarse Tremors

A nurse is caring for a client who takes paroxetine to treat posttraumatic stress disorder. The client states that he grinds his teeth during the night, which causes jaw pain. The nurse should identify which of the following as possible measures to manage the client's bruxism?

Concurrent administration of buspirone, use of a mouth guard, and changing to a different class of antianxiety medication.

MAOIs and SSRIs

Concurrent use of MAOIs and SSRIs may lead to serotonin syndrome. If the decision is made to switch to an SSRI, there must be a 2-5 week "wash-out" period between MAOI therapy and SSRI therapy.

Hypertensive Crisis Nursing Interventions:

Continuous EKG monitoring and respiratory support. Nifedipine SL. Phentolamine IV.

Carbamazepine interactions:

Dec. oral contraception meds and alters warfarin. Grapefruit can lead to toxicity

Tricyclic's Treat:

Depression (doxepin), Childhood enuresis (imipramine), OCD (clomipramine), Andjunctive analgesics for chronic pain conditions such as trigeminal neuralgia (amitriptyline).

A nurse working in the emergency department is caring for a client who has a possible benzodiazepine overdose. Which of the following is the priority nursing diagnosis?

Determine the patient's LOC

A nurse is preparing to perform a follow-up assessment on a client who take chlorpromazine for the treatment of schizophrenia. The nurse should expect to find the greatest improvement in which of the following manifestation?

Disorganized speech, bizarre behavior, and hallucinations

Antipsychotics

Drugs used to treat serious mental illness- behavior problems or psychotic disorders. Have been known as tranquilizers or neuroleptics- "zombies"

A nurse is caring for a client who has been taking sertraline for the past 2 days. Which of the following assessment findings should alert the nurse to the possibility that the client is developing serotonin syndrome?

Fever

SSRIs (antidepressants)

Fewer adverse effects than tricyclics & MAOIs. Very few drug-drug or drug-food interactions. Still take about 4-6 weeks to reach maximum clinical effectiveness. Now considered 1st-line drugs for depression. Must continue to monitor for self-injury or suicidal ideations.

AE of SSRIs (antidepressants)

HA, Dizziness, tremor, nervousness, *insomnia, fatigue, nausea, diarrhea, constipation, dry mouth, GI bleeding, *sexual dysfunction, *weight gain, *weight loss, sweating, & bruxism (most common & bothersome)

SSRI withdrawal symptoms

HA, Nausea, anxiety, dizziness, tremors, and visual disturbances. Causes hyponatremia, so obtain a baseline Na level. Take in the morning to avoid insomnia and avoid caffeinated drinks. Taper dose if discontinuing SSRI.

SE of lithium:

Hand tremors (teach to report) <-- coarse tremors, polyuria, wt. gain, GI distress (take with food)

Tricyclic Antidepressants:

Have largely been replaced by SSRIs as 1st-line antidepressant drugs. Considered 2nd-line: for patients who fail w/ SSRIs or other newer generation antidepressants. As adjunct therapy with newer-generation antidepressants

MAOIs

Highly Effective. Therapeutic use: Bulimia & atypical depression. Considered 2nd-line treatment for depression, not responsive to cyclics. Disadvantage: potential to cause hypertensive crisis when taken with Tyramine.

A patient is prescribed paroxetine. What are possible side effects of this medication?

Hyponatremia, sleepiness, sexual dysfunction, & bruxism

A nurse working in an emergency department is caring for a client who has benzodiazepine toxicity due to an overdose. Which of the following is the priority nursing diagnosis?

Identify the client's LOC

Buspirone

Indications for use: panic disorder, social anxiety disorder, OCD, & PTSD. dec risk of dependency over benzodiazepines. Requires 3-6 weeks for full therapeutic effect. Use consciously with liver or renal impairment.

MAOI hypertensive crisis w/ Tyramine

Ingestion of foods or drinks with tyramine leads to hypertensive crisis. Initial symptoms are HA, nausea, inc HR, & inc BP which may lead to cerebral hemorrhage, stroke, coma, or death.

Tricyclic Overdose

Lethal- 70-80% die before reaching the hospital... long half-life CNS and cardiovascular systems are mainly affected. Dec. Seizure threshold. Death results from seizures or dysrhythmias. No specific antidote: dec. drug absorption w/ activated charcoal, but protect airway. Sodium bicarbonate (reversed metabolic acidosis). Manage seizures and dysrhythmias. Basic life support.

A nurse is caring for a client who has a new prescription for lithium carbonate. When teaching the client about ways to prevent lithium toxicity, the nurse should advise the client to do which of the following?

Limit aerobic activity in hot weather

Mood Stabilizers: Antimanic Drugs

Lithium is the drug of choice for the treatment of mania. Controls mania, prevents return of mania or depression, and dec. suicide incidence. (Also used to treat alcohol use disorder, bulimia, psychotic disorders)

A nurse if providing teaching for a patient with a new prescription for phenelzine. What are some of the foods to avoid?

Lunch meat, Cheese, & Wine

Fluoxetine Interactions

MAOIs, TCAs, & St. John's Wart inc risk of serotonin syndrome. Fluoxetine can in warfarin levels, so check PT-INR. Avoid TCA & Lithium. Avoid NSAIDs and use cautiously with anticoagulants- can inc bleeding.

Therapeutic uses of SSRIs

Major depression, OCD, bulimia, Premenstrual dysphoric disorder (PMS), Panic disorders, PTSD, Myoclonus-twitching or clonic spasm of a muscle

SSRI (general info)

Mechanism of action: selective inhibit serotonin reuptake. Result in inc. serotonin concentrations at nerve endings. Advantages over tricyclics and MAOIs: little to no effect on cardiovascular system. Always monitor for suicide ideations or self harm.

2nd Generation Antipsychotics require you to monitor

Monitor WBC (ANC) baseline during treatment and >4 weeks after treatment. High Agranulocytosis risk increases w/ clozapine. All of these meds can dec WBCs (DC if ANC <1000)

Affective Disorder Drugs

Mood Stabilizers: used to treat bipolar disorder. Involves cycle of mania, hypomania, & depression. Antidepressants: used to treat depression.

Valproic Acid AE

N/V/D (take with food), Hepatoxicity (monitor Liver function tests), Pancreatitis (monitor amylase), thrombocytopenia (monitor platelets)

Lithium therapeutic range

Narrow therapeutic range: maintenance serum levels should range between 0.4 & 1.0 mEq/L (>1.5 toxicity). Monitor sodium levels-avoid hyponatremia (lower the sodium the greater the risk of toxicity) (135-145)

A nurse is assessing a male client who recently began taking haloperidol. Which of the following findings is the highest prioriry to report to the provider?

Neck Spasms.

AE w/ 2nd generation antipsychotics

New onset of diabetes or uncontrolled diabetes, weight gain, hypercholesterolemia, orthostatic hypotension, anticholinergic effects, agitation, sedation, sleep disruption, mild EPS (such as tremors)

Manic

Onset before age 30, mood: elevated, expansive,& irritable, Speech: loud-rapid, punning, rhyming, clanging, and vulgar, wt. loss, grandiose delusions, distracted, hyperactive, dec need for sleep, inappropriate, flight of ideas, begins suddenly and escalates over several days

A nurse is caring for a client who has a new prescription for phenelzine for the treatment of depression. Which of the following indicates that the client has developed and AE of this medication?

Orthostatic Hypotension

A patient is prescribed phenelzine. What is a common adverse side effect?

Orthostatic Hypotension

MAOIs AE

Orthostatic hypotension is the most common (change position slowly). Others: Anxiety, Agitation, Local Rash, Mania or Hypomania.

Tricyclic SE/AE

Orthostatic hypotension, sedation, anticholinergic effects, excessive sweating

SSRI Antidepressants used to treat anxiety

Paroxetine, sertraline, escitalopram, fluoxetine, fluvoxamine

A nurse is reviewing laboratory findings and notes that a client's plasma lithium level is 2.1 mEq/L. Which of the following is an appropriate action by the nurse?

Perform immediate gastric lavage.

Depressive

Previous manic episodes, Mood: anxious, depressed, and hopelessness, dec interest in pleasure, negative views, fatigue, dec appetite, constipation, insomnia, dec libido, suicidal preoccupation, may be agitated or have movement retardation

New Generation Antidepressants:

SNRI: venlafaxine, duloxetine, desvenlafaxine Other antidepressants: nefazodone & mirtazapine

Antidepressants:

SSRIs:fluoxetine, paroxetine, sertraline, citalopram, escitalopram, vilazodone Other antidepressants: trazodone (atypical) & bupropion (miscellaneous-also used for smoking cessation)

AE of antipsychotics (summary)

Sedation, delirium, orthostatic hypotension, syncope, dizziness, ECG changes, photosensitivity, skin rash, hyperpigmentation, pruritus, dry mouth, constipation, urinary hesitancy or retention, impaired erection, agranulocytosis, leukopenia, galactorrhea, irregular menses, inc appetite, polydipsia

Psychosis

Severe emotional disorder that impairs the mental function of the affected individual to the point that the individual can't participate in ADLs. Hallmark: loss of contact with reality. Ex: Schizophrenia & Drug-induced psychosis