midterm 2 Flashcards
1
Q
whos more effected by depression
A
women
2
Q
different kinds of antidepressants
A
selective serotonin reuptake inhibitors
selective antagonist receptor inhibitors
serotonin & norepinephrine reuptake inhibitors
norepinephrine dopamine reuptake inhibitor
tricyclic
3
Q
ex of SSRI
A
citlaopram, fluoxetine, sertraline, paroxetine, fluvoxamine
4
Q
SARI ex
A
trazadone
5
Q
SNRI ex
A
venlafaxine
6
Q
NDRI
A
bupropion
7
Q
TCA ex
A
amitriptyline, clomipramine
8
Q
MAOI ex
A
phenelzine, tranylcypromine
9
Q
is there an increased risk of suicide when a pt starts taking antidepressant
A
YES (increase mood & anxiety may feel more suicidal or may want to act more on feelings)
10
Q
how long does it take for effects to start being felt with antidepressants
A
2 weeks, 6 weeks for full therapeutic effect
11
Q
off label uses of antidepressants
A
smoking cessation, insomnia, fibromyalgia, pain
12
Q
depression due to an imbalance of
A
monoamine neurotransmitters
13
Q
what are the monoamine neurotransmitters
A
serotonin, norepinephrine, dopamine
14
Q
serotonin deficiency causes
A
disruptions in regulating mood, obsessions, anxiety, panic, sexual response, appetite, sleep, memory, learning
15
Q
norepinephrine works on
A
mobilization of body & brain for action
ANS
fight or flight
mood, attention, concentration, working memory, speed of processing information
16
Q
dopamine role is
A
motivating behaviour
17
Q
MAOI is
A
oldest med
18
Q
MAOI inhibits
A
MAO enzyme
19
Q
MAO enzyme usually…
A
breaks down serotonin, norepinephrine, dopamine
20
Q
when MAO is deactivated, there is
A
increase in serotonin, norepinephrine
21
Q
why is MAOI not first choice of treatment
A
bad side effects
22
Q
many side effects from MAOI occur becayse
A
interactions with norepinephrine & serotonin & CNS stimulation
23
Q
common side effects of MAOI
A
- ortho hypotension = effect on norepinephrine
- anticholinergic effects (dry effects = dry mouth, retention)
- anxiety, agitation, restlessness = CNS stimulation
- insomnia
24
Q
can OD on MAOI be fatal?
A
YES
25
can MAOI be taken with other antidepressants? why?
NO & serotonin syndrome
26
with MAOI, you need to . . . before new med started
2 week wash out period
MAOI + new antidepressant = too much serotonin = serotonin syndrome
27
before starting MAOI you need to
do a 1 week wash out period
28
what is the exception with with MAOI & wash out periods
fluoxetine = 5 to 8 week wash out period!!!!
29
MAOI need to avoid
foods tyramine
(aged, fermented, pickled, smoked)
30
why do certain foods need to be avoided with MAOI
hypertensive crisis
liver can't metabolize dietary tyramine --> moves into circulatory system == release of epinephrine = hypertensive crisis & risk for stroke
31
examples of foods to be avoided with MAOI
preserved meats
aged cheeses
fermented (beer, ale, soy sauce)
pickled herring
caffeine
32
hypertensive crisis symptoms
palpitations, increased HR, tight chest, stiff neck, throbbing/radiating headache, high BP, can be fatal
33
tricyclic inhibts
reutake of serotonin & norepinephrine = increasing amount of serotonin
34
TCA work in
synapse & inihibit reabsorption therefore increasing volume
34
CNS effects of TCA
works on norepinephrine
34
side effects TCA
tachycardia, dysrhythmias, ortho hypotension
CNS effects (sedation, nightmares, anixety)
weight gain
anticholinergic
34
TCA treat
depression, anxiety, OCD, insomnia, pain (chronic)
34
can TCA OD be fatal
highly lethal
less than week supply needed
35
1st choice treatment for depression
SSRI
36
SSRI block
reuptake of serotonin
37
SSRI treat
MDD, GAD, social anxiety, OCD, PTSD, panic
38
side effects of SSRI
GI complaints, headache, dizziness, anxiety, akathisia, insomnia/sedation, sexual dysfunction
39
since SSRI don't block norepinephrine, there is
less cardiac effects
40
SARI used for
sleeping
41
SNRI watch for
BP
42
NDRI 2 cateogires
wellbutrin (depression) = CNS stimulation
zyban (smoking cessation)
43
discontinuation syndrome effects
- flu symptoms (malaise, headache, GI upset, dizziness)
- mood disturbances
- aggression
- suicidal tendencies
- sleep disturbances
- electric shock sensations
- vivid dreams
- impaired concentration
44
how fast can discontinuation syndrome occur
1-3 days after stopping (depending on 1/2 life)
45
how to properly discontinue antidepressants
taper
46
do you need to avoid drug holidays with antidepressants?
YES because discontinuation syndrome
47
can discontinuation syndrome occur if antidepressants nottaken regularly
YES
48
serotonin syndrome is the
reaction to excess serotonin
happens when combo of agents given at same time w/o sufficient wash out period
49
serotonin syndrome can be fatal?
YES
50
symptoms of serotonin syndrome
sudden onset, fever (moderate), diaphoresis, muscle rigidity, hyperreflexia, increased HR & BP, delirium, hyperarousal, agitation
51
difference b/w serotonin syndrome & NMS
serotonin = sudden onset, mild fever, excess serotonin
NMS = gradual onset, increased CPK
52
NMS is the reaction to
dopamine
53
NMS symptoms
gradual onset
extreme stiffness/muscle rigidity, hyporeflexia, pupils normal, elevated CPK, fever, increased HR & BP, diaphoresis, changes in LOC
54
when switching meds...
do not abruptly stop med but taper off gradually increasing dose of different med
55
treatment options for depression
CBT, psychotherapy, ECT, transcranial magnetic stimulation, exercise
adjunctive therapy (gabapentin, thyroid meds, ritalin)
56
initial treatment needed for antidepressants to work
6-12 months
57
long term therapy use of antidepressants considered for
multiple episodes of depression, HX suicide, elderly
special considerations: liver/kidney impairment or pregnancy
58
why do pt need to report headache/palpitations & stiff neck immediately
hypertensive crisis
classic symptoms of high blood pressure
59
with venlafaxine you need to be careful with
increased BP
60
report eye pain immediately because
glaucoma
61
nursing process/pt teachnig
- 2 weeks before therapeutic effects
- do not stop abruptly
- careful w/ hypotension
- managing anticholinergic effects
- avoid driving if sedated
- stay out of sun = photophobic
- sexual dysfunction SSRI
- wash out periods
- side effects monitoring
- suicidal / homicial ideation
- OTC & prescription meds
- substance use
- assess for TD (AIMS)
62
bipolar I
manic episode which may have been preceded by & may be followed by hypomanic or major depressive epsiodes
63
bipolar II
current or past hypomanic episodes & a current or past major depressive episode
64
cyclothymic
episodes consisting of hypomanic and depressive symptoms that do not meet the full criteria for bipolar or major depressive disorder
65
mania
State of abnormally elevated arousal, affect, energy level, heightened overall activation with enhanced affective expression together with lability of affect
66
lithium salts
lithium carbonate, citrate
67
anticonvulsants
lamotrigine, valproic acid, carbamazepine
68
adjunctive for bipolar
antipsychotics, antidepressants, benzo, sedatives & hypnotics
69
purpose of mood stabilizers
stabilize mood (mania & depression)
70
does it take severeal weeks to reach therapeutic levels for mood stabilizers
YES
71
can other adjunctive meds be used to manage symptoms & behaviours until mood stabilizers reach therapeutic levels
YES
72
1st line tx for acute mania
lithium, valproates, 2nd gen antipsychotics, risperidone, aripiprazole, quetiapine, asenapine or combo TX
73
2nd line tx acute mania
olanzapine, ECT
74
depression 1st line for bipolar
lamotrigine, quetiapine, lithium or COMBO
75
2nd line tx depression for bipolar
divalproex, adjunctive SSRIs, bupropion
76
maintenance bipolar I 1st line
monotx w/ lithium, quetiapine (common), divalproex, lamotrigine, aripiprzaole
77
maintenance for bipolar II
quetiapine only recommended 1st line TX for BDII depression
78
2nd line tx for bipolar II
lithium, lamotrigine
79
body treats lithium like
salt
80
mechanism of action of lithium
increases inhibitory GABA neurotransmission & inhibits reuptake of post synaptic excitatory catecholamins (dopamine & norepinephrine)
81
symptoms of bipolar start to decrease
4-14days
82
max therapeutic response of lithium
10-21 days
83
1/2 life of lithium
18-20 hr
36hr for elderly
84
contraindications for lithium
severe cardiovascular disease, renal disease, sodium depletion, dehydration, diuretics, substance use,
85
NSAIDs, ibuprofen, naproxen does what to lithium
increase levels & risk of nephrotoxicity
86
hypernatremia leads to
decreased lithium concentrations
87
hyponatremia leads to
increased lithium concentrations
88
caffeine, metamucil, bronchial dilators do what to lithium
decrease lithium levels
89
N & V, diarrhea, sweating, ACE inhibitors, ARBS, CCBs, NSAIDs do what to kidneys
sodium loss leading to kidneys retaining more lithium (therefore increasing lithium levels)
90
target levels of lithium in acute phase mania
0.8-1.2mmol/L
91
maintenance levels of lithium
0.6-1mEq/L
92
elderly levels of lithium
0.4-0.6mEq/L
93
side effects of lithium
GI upset, muscle weakness, hand tremor, fatigue, headache, poor concentration & memory, weight gain, acne, hair loss, hypothyroidism, metabolic syndrome, leukocytosis
94
mild to moderate lithium toxicity levels
1-2mEq/L
95
side effects of mild to moderate lithium toxicitiy levels
diarrhea, vomiting, fatigue, tremors, increased drowisness, uncontrolled movement, blurred vision
96
severe lithium toxicity levels
> 2mEq/L
97
symptomsof severe lithium toxicity
delirium, slurred speech, seziuers, rapid heart rate, hyperthermia, nystagmus, confusion, kidney failure, coma
98
blood levels drawn how often with lithium
once a week initially, then monthly or longer if no problems
99
no withdrawal if lithium stopped abruptly?
TRUE
100
lithium pt teaching
- eat reg diet w/ reg amount of Na
- never double up on dose
- ensure all physicians aware of lithium
- report signs of toxicity
- ensure pt doesn't take lithium 12hr prior to blood drawns
101
are all anticonvulsants mood stabilizers
NO
102
examples of anticonvulsants
divalproex, valproic acid, lamotrigine, carbamazepine, topiramate, gabapentin
103
anticonvulsants are used as
adjuncts to lithium
104
lamotrigine mechanism of action
increases inhibitory GABA neurotransmission
105
indications of lamotrigine
epilepsy, bipolar depression acute TX & maintenance
off label use: borderline personality
106
side effects of lamotrigine
dizziness, somnolence (strong desire to sleep), diplopia (double vision), headache, nausea, vomiting, diarrhea, rash (steven-johnson syndrome)
107
dosing of lamotrigine
titrate slowly to prevent rash
25mg for 2 weeks then 200mg for maintenance
108
valproic acid is most prescribed for
epilepsy
109
valproic acid is preferred choice because
less side effects, better tolerated & fewer breakthrough manic episodes
110
valproic acid does not
prevent/treat depression
111
indications for valproic
mixed mania or rapid cycling
effective in treating mania secondary to other medical conditions
more rapid response than lithium
migraine prophylaxis
112
side effects valproic acid
transient hair loss, weight changes, tremors, GI upset, somnolence, dizziness, headache, sleep disturbances, metabolic syndrome, thrombocytopenia, hepatotoxicity
113
What is one of the most serious adverse effects of valproic acid
hepatotoxicty
114
carbamazepine is
absorbed erratically
taken with food and avoid grapefruit
115
mechanism of action of carbamazepine
increases inhibitory GABA neurotransmission
anticholinergic
116
indications for carbamazepine
effective antimanic agent
effective prophylactic agent
neuropathic pain
epilepsy
117
side effects carbamzaepine
sedation, fatigue, dizziness, headache, GI upset, blurred vision, slurred speech
rare but serious: rash, leukopenia, hyponatremia, agranulocytosis
118
seizures
Burst of uncontrolled electrical activity between brain cells (also called neurons or nerve cells) that causes temporary abnormalities in muscle tone or movements (stiffness, twitching or limpness), behaviours, sensations or states of awareness
119
convulsions
Describes the involuntary action of jerking and contraction
120
epilepsy
Chronic recurrent pattern of seizures
121
1st line TX for seizures
phenobarbital, phenytoin, carbamazepine
122
barbiturates mechanism of action
GABA involvement (inhibits excitement in neuron)
123
side effects barbs
sedation, dizziness, drowsiness, lethargy, paradoxical restlessness (awake, restless, opposite effects of sedation)
124
hydantoins: phenytoin is
1st line seizures maintenance
125
mechanism of action of phenytoin
GABA
126
side effects phenytoin
drowsiness, dizziness, lethargy, abnormal movement (ataxia), mental confusion & cognitive changes, rash
127
long term use of phenytoin can cause
gingival hyperplasia (gums severely swollen), dilantin facies (subcut tissue of face becomes swollen & thick), osteoporosis
128
toxicity levels of phenytoin can cause
nystagmus, ataxia, dysarthria, encephalopathy
129
topiramate & indications
chemically related to fructose
epilepsy, mania, rapid cycling
130
topiramate side effects
weight loss, word finding difficulties, agitation, fatigue
assess VS & LOC
131
gabapentin
increased synthesis & accumulation of GABA (calms neurons)
132
gabapentin indications
epilepsy, rapid cycling, BDII, adjunct neuropathic pain or migraines
133
side effects of gabapentin
sedation, tremor, hypotension, ataxia, GI upset, weight gain
134
diazepam
1st line TX for status epileptics & severe convulsions
used as muscle relaxant & decreasing anxiety
135
clonazepam
used to treat absence seizures & treating manic/panic disorders
antiepileptic & mood stabilizers
136
side effects of clonazepam
drowsiness, ataxia, hyperactivity, irritability, moodiness, aggressive behaviour changes & personality changes
137
clorzaepate
long acting benzo used as adjunct for partial seizures & anxiety & alcohol withdrawal
138
benzo side effects
CNS depression, headache, dizziness, lethargy, cognitive impairment, palpitations, dry mouth, physical dependency, withdrawal symptoms, GI upset, grapefruit alters absorption, effects normal sleep so experience hangover effect
139
nursing process for anticonvulsants
- discontinuation must be gradual
- monitoring side effects
- notify dr if seizures occur or develop vomiting, weakness, rash
- may reduce efficacy or oral contraceptives
- narrow therapeutic range
- medication adherence
140
painkiller neurotransmitters
endorphin & encephalin
bind to opioid receptors in body & give pain relief
141
transduction
noxious stimulus causes cell damage with release of sensitizing chemicals & activate nociceptors = generation of action potential
142
transmission
action potential continues from :
site of injury --> spinal cord --> brainstem & thalamus --> cortex for processing
143
perception
conscious expeirence of pain
144
modulation
neurons originating in brainstem descend to spinal cord & release endogenous opioids that inhibit nociceptive impulses
145
neuropathic
disruption of function of nerve
146
vascular
headache migraine
147
referred
injury in one area of your body but feel pain somewhere else
148
phantom
occurs in body part that has been removed
149
psychogenic
originates from psychological factors not physical
150
threshold
Level of stimulus needed to produce a painful sensation
151
tolerance
Level of pain a client can endure without it interfering with normal function
152
breakthrough
Pain occurs b/w doses of pain medication
Pain the lingers despite the client receiving doses of long acting pain mediation every 12 hr
153
Analgesic ceiling effect
What occur when a particular pain drug no longer effectively controls a pt’s pain despite the administration of the highest safest dose
154
opioids
Pain-relieving drugs derived from natural opium (unripe seed of opium poopy plant) or produced synthetically
155
Natural alkaloids
morphine & codeine
156
semisynthetic
hydromorphone & oxycodone
157
synthetic
fentanyl, meperidine (not recommended long-term use because accumulation of neurotoxic metabolite), methadone
158
opioid mechanism action
Binds to opioid pain receptors in CNS, PNS, & GI tract causes an analgesic response --> reduction in pain sensation
Considered CNS agonist
159
indications of opioids
To alleviate moderate to severe pain (> 5/10 pain) when non-opioids are insufficient
160
opioid naive
has not used opioids consistently
161
opioid tolerance
using opioids begins to experience a reduced response to medication, requiring more opioids to experience the same effect
162
physical dependence
state of chronic Dependence on a medication or drug resulting from prolonged abuse
163
psychological dependence
emotional and mental processes that are associated with the development of, and recovery from, a substance use disorder or process addiction
164
morphine
Relief of moderate to severe pain (above 5/10)
165
codeine
Cough relief & analgesia
166
fentanyl
Moderate to severe acute pain, relief of persistent pain
167
meperidine
Relief of moderate to severe pain (toxic effects)
168
methadone
Relief of persistent pain, opioid detox, & opioid addiction maintenance
169
oxy
Relief of moderate to severe pain
170
hydromorphone
Relief of moderate to severe pain (5-8x stronger than morphine)
171
interactions opioids
Alcohol, antihistamines, barbiturates, benzos, phenothiazine, MAOIs
172
Adverse effect & management opioids
Nausea & vomiting
Constipation
Sedation, mental clouding, euphoria
Respiratory depression
Itching, rash
Flushing & hypotension
Dry mouth
Urinary retention
Sleep disturbances
Depressed cough reflux
Sexual dysfunction
173
toxicity & management of overdose (opioid antagonists = reversal drugs)
naloxone, naltrexone
174
narcan dosing
IV push: 0.4-2mg q2-3min
IV infusion: 2mg in 500mL
Nasal spray
THN 0.4mg/mL IM injection
175
regular release opioids
Used for acute & breakthrough pain
Can be crushed
Onset: 30-90mins
Duration: 4-6 hr
176
controlled release opioids
Drug released slower & steadier into bloodstream
Should not be crushed, chewed, dissolved
Onset delayed
Duration: 8-12hrs
177
Tramadol hydrochloride (opioid like activity)
Schedule 1
Centrally acting
Moderate to severe pain
Instant & slow release available
Combined with tylenol – tramacet
178
2 sign side effects tramadol hydrochloride
Seizures & serotonin syndrome (when taking SSRIs)
179
side effects of tramadol
drowsiness, dizziness, headache, nausea, constipation, RR depression
180
Acetaminophen
Mild to moderate pain relief & antipyretic effects
No inflammatory action
Relatively safe nonopioid
Liver toxicity
181
NSAIDs
Mild to moderate pain relief
Analgesic, antigout, antinflammatory, antipyretic effects
Adverse GI effects; renal toxicity
ASA antiplatelet agent
182
action tylenol
Blocks peripheral pain impulses by inhibition of prostaglandin synthesis
Acts on hypothalamus to lower febrile body temperature – antipyretic
183
indications tylenol
Mild to moderate pain & fever
Pain (1-5/10, dental, dysmenorrhea, OA, headache, myalgia)
184
side effects tylenol
Rash, nausea, vomiting
Less common
Blood disorders or dyscrasia such as; neutropenia, pancytopenia, leukopenia
185
toxicity tylenol
85-90% metabolized by liver & excreted by kidneys
> 4g/day = hepatic toxicity or long term use of large dose more at risk
186
tylenol antidote
> 2g/day acetylcysteine = prevents the hepatotoxic metabolites of acetaminophen from forming
187
NSAIDs action
Tissue injury > inflammation within leukotriene pathway & prostaglandin pathway; both pathways result in inflammation, edema, headache, other pain characteristics = NSAIDs inhibit these pathways
Block chemical activity of enzyme cyclooxygenase (COX) and/or enzyme lipozygenase (LOX)
188
NSAIDs indication
Analgesic, antigout, arthritis, antipyretics effects; vascular headaches, platelet inhibition, post-op pain, dysmenorrhea, tendinitis, bursitis
189
contraindications NSAIDs
Allergy, bleeding risk, severe kidney or liver disease
190
Daily ASA tabs (81mg) routinely
prophylactic therapy for adults risk of thrombotic events
191
Salicylates used to treat
pain resulting from inflammation (arthritis, pleurisy, pericarditis)
192
Salicylates toxicity symptoms
Increased heart rate, tinnitus, hearing loss, headache, dizziness, mental confusion, nausea, vomiting, diarrhea, sweating, thirst, hypo/hyperglycemia
No antidote = severe cases may require dialysis
193
Propionic acid derivatives (ibuprofen)
Used to treat rheumatoid arthritis, osteoarthritis, primary dysmenorrhea, dental pain, musculoskeletal disorders
Used to treat fever & pain
194
Acetic acid derivatives (indomethacin)
Used to treat rheumatoid arthritis, osteoarthritis, acute bursitis/tendinitis, spinal arthritis, acute gouty arthritis
195
Carboxylic acids (salicylates) (ketorolac tromethamine)
Unique chemical structure – some anti-inflammatory but mostly analgesic
Short term management of moderate to severe acute pain
Powerful analgesic effect but lacks addictive properties of opioids: good for opioid users
196
COX-2 inhibitors (celecoxib)
Used to treat osteoarthritis, rheumatoid arthritis, acute pain symptoms, ankylosing spondylitis & primary dysmenorrhea
Causes fewer adverse GI effects
197
side effects NSAIDs
GI (abdominal pain)
Hematological = low platelet function (risk of bleeding)
Hepatic & renal impairment
Skin eruptions (petechiae)
198
Adjunctive therapies
Medications from other chemical categories that can be added to the opioid regimen to assist in relieving pain
199
adjunctive therapies include
Corticosteroids (dexamethasone, prednisone), anticonvulsant (dilantin, tegretal, gabapentin), tricyclic antidepressants (anitriptiline) & neuroleptics (haloperidol) & olanzepine (chronic pain)
200
benefits adjunctive therapies
Allows for use of smaller dosages of opioids
Diminishes some of the adverse effects seen with higher dosages of opioids
Approaches the pain stimulus by another mechanism
201
nursing assessment for pain
Pain assessment
Substance use
Lab values
Allergies
Anaphylaxis or overdose
202
Anaphylaxis or overdose = what do I do
Presents with decreased LOC & respirations < 8 breaths or anaphylaxis:
Call for help, Do not leave pt, Recumbent position, ABCs, VS, Apply O2 if sats > 98%, Code blue, Support patient
Epi will reduce bronchospasms, counteract histamine vasodilation, increase cardiac output, reduce histamine release
203
nursing interventions for pain
Pain flow sheets
Peak of medication (respiratory depression & sedation)
Meperidine restrictions
Pharm & non-pharm interventions
Safety measures to prevent falls
Documentation
204
tylenol 1
300 - 8 (codeine) -15 (caffeine)
205
percocet
acetaminophen 300, oxycodone 5
206
percodan
asa 300, oxycodone 5
207
older adult considerations for analgesics
Start low & go slow with amount
Similar pain threshold as other adults
Altered presentations of pain
Under-treatment of pain
Longer duration of effect
Anticholinergic side effects
208
COX2
COX = COX1 produces prostaglandins & protect the stomach and intestinal lining (prevent intestinal bleeding)
COX2 = dominant source of prostaglandin in inflammation
209
term used when opioids, non-opioids, and adjunctive medications used together
multimodal
210
tylenol 2,3,4
Tylenol #2 300-15 (codeine) -15 (caffeine)
Tylenol #3 300-30-15
Tylenol #4 300-60-none
