NEED TO KNOW Flashcards
Metoprolol (Lopressor) should not be used with (3)
Paroxetine, Fluoxetine, or Bupropion due to risk of serious adverse effects like hypotension and bradycardia
What supplements can improve depressive symptoms (4)
B12, B6, Folate, Omega 3 fatty acid
What medications can cause QT prolongation (4)
Ziprasidone
Quetiapine
Haloperidol
Citalopram
What medications are LESS Likely to prolong QT interval (3)
aripriprazole
lurasidone
olanzapine
Least sedating SSRIs (2)
Lexapro (escitalopram)
Fluoxetine
Safest SSRIs for patients with heart issues
sertraline
escitalopram
Symptoms of serotonin discontinuation syndrome (6)
muscle soreness
achiness
n&v
fatigue
lethargy
agitation
Effective tx for serotonin discontinuation syndrome
resume taking the antidepressant at the previously prescribed dose
Mood stabilizer with least weight gain
Lamictal
Migraine medications
Triptans and sumatriptan (imitrex)
What conditions present likely with homicidal ideation
Antisocial personality d/o very common
why do studies online show more efficacy for antidepressants with adults versus children
because studies contain more adults not children
Medications that can cause mania (4)
steroids like prednisone and dexamethason
Disulfiram (antabuse)
Isoniazid (INH)
Antidepressants for bipolar
Medications that can cause depression (9)
steroids **
liothyronine
beta blockers
interferon
Isotretinoin
retroviral drugs
antineoplastic drugs
benzodiazepines
progesterone
Paradoxical effects
prescribe patient with anxiety and agitation with Geodon, but instead of it helping the anxiety- it makes it worse- so patient is experiencing the opposite effect
Risk factors for osteoporosis 5
smoking, drinking caffeine, lack of calcium i diet, and vitamin D, lack of weight-bearing exercise
if pt has RA what is a common test
erythrocyte sedimentation rate
if pt is positive for RA what happens to teh erythrocyte sedimentation rate
increased
the infant is producing a shrill cry (high pitch) can be due to
can be due to increased intracranial pressure
postmenopausal women have low sex drive can be due to
hormonal decrease in testosterone, progesterone, and estrogen, and reduced pelvic blood flow
what hormonal therapy can help menopausal depression
estrogen and progesterone
what kind of diet helps with depression
low fat diets
who is more prone to alcohol related liver damage
women because they have lower levels of alcohol dehydrogenase, which is the enzyme that metabolizes alcohol
Macrocytic normachromic anemia you want to check
b12 and folic acid levels because b12 deficiency can lead to symptoms
major cause of microcytic anemia is
iron deficiency
what happens with low levels of iron
less oxygen gets to the cells keeping them from properly functioning and often leads to fatigue, weakness and anxiety
protects patients against unlawful hospitalization- esp mental illness, if they were hospitalized for no just reason they can use this to leave AMA
habeas corpus
in order to provide evidenced based care we need access to
current journal articles
you wanted the patient to review timeline but they couldn’t remember within a specific time frame what can you do
ask more specific questions or ask questions that link memorable events
if you wanted to educate patient about a medication you must first assess what
patients knowledge of the medication and their beliefs around it
disseminated encephalomyelitis symptoms
nervous system disorder- headache, confusion, ataxia, asymmetrical body movements
if patient has disseminated encephalomyelitis may need
neuroexam
if you are trying to implement a policy that will affect nurse practitioners nationwide you want to
create an online forum so questions and concerns can be addressed there
if you want to implement new policy but your coworkers are against the new policy what can you do
prove how the new policy can improve quality of patient care
PICOT QUESTIONS stands for
Population problem patient
intervention issues interest
comparison
outcome
time
starting investigation for nursing what should you do
start with PICOT question
evidence from a systemic review or meta analysis of all relevant randomized controlled trials or evidence-based clinical practice guidelines based on a systematic review of RCTs or three or more RCTs of good quality that have similar results
level 1
evidence obtained from at least one well designed RCT
level 2
how to ensure continuous improvement of quality of care in an outpatient clinic
develop an instrument to monitor clinical outcomes
how to ensure continuous quality improvement when treating patients with mental illness like depression and anxiety
use a rating scale to determine baseline scores and at regular intervals during treatment
how to monitor clinical progress
standardized rating scales
Diabetic keto acidosis is common complication of type 1 dm symptoms:
kussmaul respirations rapid and deep
fruity-scented breath
excessive thirst and urination
fatigue
confusion
medication for enuresis
desmopressin to reduce urine production
night time bedwetting non pharmacological interventions
set alarm for night time voiding and use moisture alarms
looking up patients info on social media is
violating their trust
patient has been taking a medication and is stable but then FDA releases a black box warning of medication so waht do you do
research benefits and risks of continued use and make decision with patient
off label you want to make sure to provide patient with
FULL DISCLOSURE add evidence supporting of off label use document risks and pros
sleep apnea risk factors
smoking,
excess weight
obesity
diabetes
high BP
narrowed airways
reflective practicing
is a debriefing strategies after an event or cause with the goal of improving practice
pt use to take on pill of clonazepam for two years but now is requesting two pills to achieve the same effect of the one pill
tolerance - decrease effect with continuous use of the SAME dose over time
legal telemed
confidentiality concerns
medical errors
jurisdiction authority over licensure always verify where the patient is (if the client moves to another state in a state not under your license that is illegal)
pt with Substance use disorder in IOP when do you transfer them to less IOP
patient is taking responsibility for their actions and has developed coping skills
med errors what is the first thing you want to do to develop policy
assess common types of med errors and then assess learning needs of staff
MMSE score
0-30
MMSE mild score
21-24 Mild cognitive impairment possibly early to mild alzheimers
MMSE Moderate score
10-20 moderate Alzheimer disease
MMSE normal score
25-30
MMSE severe score
0-9 severe alzheimer
SLUM normal score
27-30
SLUM mild score
21-26
Slum dementia score
0-20
MoCA normal score
26-30
MoCa mild cognitive impairement
18-25
moderate cognitive impairement MoCA
10-17
MoCA less than 10 means
severe cognitive impairment
if someone has Alzheimers they should not be scoring a
20-25 it should be reassessed
PHQ moderate score depression
10-14
HAM D moderate score depression
14-18
MADRS moderate score depression
20-34
Beck moderate depression
19-29
HAM for anxiety moderate range
18-24
GAD moderate
10-14
COWS opioid moderate score
13-24
when to start tx on COWS score
> 7
CIWA ETOH moderate score
16-20
when to start tx on CIWA
8 and above PRNS only
when to start meds for CIWA score
15 and above (valium, Ativan, or librium
what can you give patient scoring a mild on COWS 5-12?
clonidine
when can you give buprenorphine or suboxone on COWS
moderate to severe 13 and above
Suboxone is
buprenorphine and naloxone
methadone can cause
cardiac issues not first choice
clonidine common s/e
drowsiness more than buprenorphine or suboxone
Collecting data can look like? (4)
vital signs, ordering CMP, lab results, and literature search
The assessment process includes: (3)
Identify, survey, and collect data
When does behavioral management and support begin?
AFTER pt is admitted
with cultural questions what should you always do first?
Always respect before assess or intervention with cultural questions
What medication can exacerbate tics? and what would an alternative be especially for an adolescent?
Stimulants exacerbate tics and another alternative is guanfacine
Be wary of absolutes
all, only, always, every, must, never, none, everything, nothing, etc 🡪 usually wrong. The ONLY answer option is USUALLY WRONG.
If a question has 3 interventions and 1 assessment, most likely the answer is the assessment.
Questions that use adjectives like “priority” and “initial action” test your ability to prioritize.
How would you usually prioritize?
-ABC
-Maslow’s hierarchy of needs (physiologic needs (food, water, warmth, rest, safety and security)
-Nursing Process (assessment before intervention) Assessment is collecting data
- Urine drug screen, Vital signs, CMP, literature data etc
What do you do if a patient tells you they are a victim of abuse?
1st, reassure them of their safety and provide them with an environment of safety- Do this before assessing them or intervening
A child comes in with the parents and the child tells you they have been sexually abused, what do you do?
You will interview the child separate from the parents FIRST and then report to CPS 2nd
A Child comes in alone and has a toy, based on the play with this toy in a sexual way you suspect sexual abuse what is your next action?
You will contact and report to CPS immediately. Do not start investigating with parents or caregivers
You work as a PMHNP inpatient and want to discharge a patient, what must you confirm first?
You need to ensure patient can stay safe and cope effectively
You work inpatient and you want to interview a patient, what is the best way to interview them?
Do not interview the patient in their room, - this could be an unsafe environment. Do not interview in the day room.
CORRECT-Interview in a private area with the door open/partially open. SAFETY over PRIVACY
How do you build a rapport with teens / adolescents 12-20 years old
Let them know their information is confidential with exceptions to confidentiality such as danger to self or to others. If interviewing a teen, do not interview with parents in the room. Ask the parents to stay in the waiting room.
When a teen tells you they are attracted to the same gender or dating someone of the same age,
Adolescents have a right to _____
No need to tell parents.
- You may tell parents if they are dating someone older or younger but not if they are the same age.
-You are advocating for adolescents and they have the right to CONFIDENTIALITY.
-Parents may feel like they have the right to know everything and this can create an ethical dilemma. However, the teen has a right to confidentiality (not privacy)
Collaboration vs delegation in answering questions:
Interprofessional collaboration is encouraged. If a question had collaborate🡪 this is most likely right
-When answering, choose options you are actively getting involved
-Delegating is usually wrong
-Collaboration with the nurse manager or dietician is usually correct option (Look for KEY WORD collaborate)
Call provider to discuss patient care in interprofessional collaboration.
Example: You notice a lot of women attempt suicide post partum because OB doctor doesn’t do risk assessment before discharge
- Collaborate with OB doctor and recommend the OB doctor does suicide risk assessment before discharging patients
- Discrepancy in care by OB, Collaborate to correct the gap in care
You are discharging a patient to rehab and they request labs. Do you print labs and give to patients? Do you get informed consent and fax labs?
Get informed consent and fax the labs.
- Get actively involved helping patients.
-Printing labs and giving them to patients increases the chance of labs being lost.
Is a medical evaluation within the PMHNP scope?
NO- -Only correct if referring to someone else to do a medical evaluation.
-Is there something I could do within my scope of practice for this patient BEFORE referring out?
-Referring out is usually the last part
For example, a 15-year-old comes into the office and tells you they inhaled acetone and are feeling weird. As an NP, what is your priority action?
-Correct thing is to do a urine drug screen (UDS).
-Patient could be at increased risk of using other substances
-Don’t need to refer out for emergency evaluation yet; Do the UDS and see if they are using other substances.
Cultural Syndrome (something that is normal in that culture)- what is the next action?
-Don’t need to start on psychotropics
-Validate symptoms based on culture
-Offer brief supportive therapy
Cultural question: Somatic complaints of pain “ My pcp hasn’t found any medical reason for this” What do you do?
Validate symptoms based on cultural context.
Interpret the cultural meaning of pain, Ask patient, understand their pain based on cultural significance of pain.
Cultural assessment = cultural formulation interviews: (3)
-Clarify the meaning of illness or predicament
-Contextualize their situation in their local world
-Empower the patient
If you want to provide psychoeducation to patient from a specific culture what do you do? (2)
-Information should be based on developed cultural concepts specific to their culture
-Pt diagnosed w schizophrenia, based information on cultural context 🡪 benefits of meds, psychoeducation
Community Education: with multiple cultures what is your approach?
-Health promotion in the community.; Not everyone who lives in the community is from the same culture -Multicultural community. Ex: Long beach
-Based on the assessment of identifying people in the community who are of different ethnicities 🡪 Provide multicultural education/ teaching. (don’t use the same assessment parameters for every household. Use ETHNO SPECIFIC assessment parameters.
The ethnic group in the US with the Highest rate of Suicide and suicide attempts.
Native Americans
RESPECT related to culture is important
-Respect BEFORE assessment or intervention
-Respect the interpretation of what is causing mental illness
Example:
Native Americans think mental illness of substance use can be caused by an imbalance between individual relationships with the world. (Respect their interpretation of what is causing their illness)
The Patient wants you to release information to the traditional healer what do you do?
yes it is ok to release to the healer or to include the healer in their care 🡪 AFTER INFORMED CONSENT is obtained 🡪 Need to obtain clearance for informed consent first. If an interpreter is needed for this, make accommodations for one (culturally sensitive)
Thyroid Stimulating Hormone TSH Levels:
0.5-5.0 Mu/L
Steps in checking thyroid levels include?
First we check TSH to see if it is abnormal BEFORE checking t3 and t4
Symptoms of hypothyroidism can mimic __________
Symptoms of hyperthyroidism can mimic __________
Depression for hypothyroidism
mania for hyperthyroidism
-HYPERTHYROIDISM- TSH is
symptoms are:
TSH is low, T3/T4 are high
-Agitation, anxiety, heat intolerance, irritability, tachycardia, mood swings, weight loss.
HYPOTHYROIDISM- TSH is
Symptoms are:
HIGH T3/T4 are low
-Cold intolerance, lethargy, weight gain, decreased libido
T3 and T4 relationship with TSH
T3 and T4 have an inverse relationship with TSH. So when one is up, the other is down.
Pts TSH level is 0.04 and has ______
t3 and t4 indicative of
high, hyperthyroidism
Pt comes in with low t3 and t4 with a TSH of 0.07
hypothyroidsim
What intrauterine adverse rx can depakote create?
Spina Bifida
What organ can depakote injure the most? Black box warning?
Hepatotoxicity
signs of hepatotoxicity
abdominal pain in RUQ, reddish brown urine, yellowing of the skin, whites of the eyes and fatigue
Pt taking Depakote presents with signs of hepatotoxicity 🡪 abdominal pain in the upper right portion of the abdomen, reddish brown urine, yellowing of the skin and whites of the eyes and fatigue.
Discontinue the medication first
-Check liver function tests second. AST (5-40) ALT (5-35)
Normal values of AST and ALT
(5-40) ALT (5-35)
Therapeutic range for valproic acid is
50-125
TOXIC level for valproic acid and signs and symptoms
greater than 150
disorientation, lethargy, resp depression, nausea and vomiting
What do you do if a patient comes in with s/s of valproic acid?
Interventions: Discontinue med, check valproic acid levels, LFT and ammonia levels (15-45)
Ammonia level rises causes disorientation
Kava Kava: is used for
anxiety, stress and insomnia.
Kava can cause what adverse reaction? what is the priority lab?
CAN CAUSE LIVER DAMAGE
LFT labs
What medications do patients want to avoid mixing Kava with
Sedatives or benzos
because it can cause drowsiness
Lamictal can cause what adverse rx?
Steven Johnsons syndrome
S/s of steven johnson’s syndrome??
Severe rash- Fever, body aches, red rashes, peeling skin, facial and tongue swelling.
If patient starts lamictal and has a sudden onset of fever what is the next step?
DC medication
What is the mood stabilizer that causes the LEAST amount of weight gain? and least amount of risk for metabolic syndrome
Lamictal
What antipsychotics cause the least amount of weight gain? (3)
Geodon, Aripiprazole, Lurasidone (latuda)
For patients taking antipsychotics that cause weight gain, check routine labs such as (4)
BMI, Hip to waist ratio, glucose and lipid panel. These patients have an increased chance of metabolic syndrome
Management of Antipsychotic induced weight gain (AIWG) pharmacological and non pharmacological txs?
Exercise and nutritional counseling are nonpharmacologic strategies
Pharmacologic interventions consist of switching to another antipsychotic that has a less potential to cause weight gain such as a ZAL.
pt is taking quetiapine (Seroquel) , paliperidone (Invega) or risperidone (Risperdal) but its causing them to gain weight and they aren’t exercising, your INITIAL action as a PMHNP
to encourage exercise and nutritional counseling FIRST.
🡪 if this doesn’t work, THEN you can talk about switching their med to a ZAL
Carbamazepine (Tegretol) - Black Box warning
Agranulocytosis (decreased WBC)
(Agranulocytosis, Asians, Aplastic anemia)
Agranulocytosis (decreased WBC) S/S
aplastic anemia (pallor, fatigue, headaches,fever, nosebleeds, bleeding gums, skin rash, shortness of breath)
DC MED
Tegretol and Asians
Steven johnsons Syndrome, particularly in ASIANS 🡪 screen for HLAB 1502 allele BEFORE initiating Tegretol
If the question asks what needs to be done before initiating Tegretol and specifying Asians, answer is HLAB 1502 Allele.–> this is highly associated with the outcome of carbamazepine induced steven johnsons.
Agranulocytosis can be caused by Carbamazepine and Clozaril.
Monitor patients taking this for signs and symptoms
infections (sudden fever, chill\s, sore throat, weakness)
When do you dc Carbamazepine/ Clozaril r/t ANC
is less than 1000mm, even If the patient is NOT showing signs of infection. DC med and recheck lab.
Lithium levels? and toxicity level
Lithium 0.6-1.2 eq/L
Lithium toxicity can occur when this level reaches 1.5 or higher.
If lithium level is 1.3 or 1.4 what do you do? ( no signs of toxicity)
Keep monitoring patient for toxicity
once 1.5 IMMEDIATELY discontinue
-If the level is 1.3 or 1.4 and showing signs of toxicity, DISCONTINUE.
Neuroprotective treatment of choice for bipolar
is lithium. This can protect nerve cells from damage.
-GOLD STANDARD FOR TREATING MANIC EPISODES
if pt is suicidal what is the medication with evidence of antisuicidal effect
-If pt is suicidal= lithium. *Evidence of antisuicidal effect.
only known antipsychotic that has been shown to reduce the risk of suicide in patients with schizophrenia-
Clozaril, watch for agranulocytosis
Labs before Lithium
TSH, thyroid panel, Kidney function tests, a risk for kidney disease and a greater risk for lithium toxicity.
Normal creatinine and BUN monitor for lithium
0.6-1.2 and BUN 10-20.
Urinalysis for lithium
check for proteins in urine, a large amount of protein 4+ 🡪 may indicate kidney disease. Do not stop lithium, just monitor closely for toxicity.
females of childbearing age 12-51 years old what is a priority lab.
-HCG-
Choose hcg if pt is of child bearing age. Can cause neural tube defect
Side effects of lithium:
-Hypothyroid- tiredness, weight gain, dry skin, constipation, coarse hair, puffy face
-Fine hand tremors, MACULOPAPULAR RASH, GI upset (diarrhea, vomiting, cramps, anorexia, polyuria, polydipsia, diabetes insipidus, T WAVE inversions and LEUKOCYTOSIS
lithium can cause what to ECG?
T WAVE inversions
Ebstein Anomaly (congenital heart defect) can be caused by what medication?
lithium
Lithium toxicity s/s (9)
Severe nausea, vom, diarrhea, confusion, drowsiness, muscle weakness, palpitations, coarse hand tremors , UNSTEADINESS WHILE STANDING OR WALKING- ATAXIA
DC MED and check lithium levels first
What medications can effect lithium levels in body? (4)
drugs that have renal clearance
therefore increasing lithium levels
NSAIDS, Thiazide, ACE inhibitors, lisinopril.
What sodium levels can increase lithium levels?
hyponatremia:
The kidneys treat lithium and sodium similarly which is the reason sodium depletion can significantly elevate lithium reabsorption
Neuroleptic malignant syndrome is caused by what class of drugs
antipsychotics
NMS s/s (6)
-extreme muscle rigidity
-Mutism
*hyperthermia
*tachycardia
*diaphoresis
*altered level of consciousness
LIFE THREATENING
What labs need to be checked with NMS: (4)
-Elevated CPK (creatinine phosphokinase) caused by muscle contraction and destruction
-Myoglobinuria (from the breakdown of muscle cells 🡪rhabdo)
-Elevated WBC
-Elevated LFT
what medication can be given for NMS for dopamine agonist?
Bromocriptine
Bromocriptine is given to reverse the hypodopaminergic state
what medication can be given for NMS for muscle relaxant
Dantrolene
Due to a risk of hepatoxicity, dantrolene is typically discontinued once symptoms begin to resolve.
how does a dopamine agonist work
A dopamine agonist is a type of medication that mimics the effects of dopamine by activating dopamine receptors in the brain, essentially “tricking” the brain into thinking it is receiving dopamine, and is primarily used to treat conditions where dopamine levels are low
how do antipsychotics work on dopamine?
most antipsychotic medications act as dopamine antagonists. They block the activity of dopamine receptors in the brain, reducing the excessive dopamine signaling that is believed to contribute to psychotic symptoms such as hallucinations and delusions.
serotonin syndrome caused by and 2 s/s
antidepressants
hyperreflexia and myoclonic jerks
tx for serotonin syndrome
DC offending agent and give Cyproheptadine- antihistamine/anticholinergic
Cyproheptadine is an H1 blocking antihistamine, but it also has serotonin receptor blocking activity. Specifically, it acts to block 5-HT1A and 5-HT2A receptors, which are the receptors responsible for the symptoms of serotonin syndrome. The typical dose of cyproheptadine for serotonin syndrome is 12 mg
what group of meds can cause serotonin syndrome?
SSRI/ SNRI/ TCA/ MAO and ST John’s Wort
Patients should not be on more than one class of these meds
When switching from SSRI to MAOI you wait
14 days for the SSRI to DEGENERATE (clear out of the body)
When switching from MAOI/TCA/SSRI/SNRI to PROZAC you wait
14 days
when switching from Prozac (fluoxetine) to an MAOI/TCA/SSRI/SNRI wait
wait FIVE TO SIX WEEKS because of prozacs long half life.
what migraine medications can cause serotonin syndrome?
Triptans (sumatriptan, Imitrex)
If patient comes in and is taking a triptan, DO NOT give
SSRI/SNRI/MAOI/TCA because it will INCREASE the chance of serotonin syndrome
If patient is on a triptan what type of medication can be prescribed
NDRI (Wellbutrin) or contact PCP to change their migraine medication
If a patient is depressed and has cancer, Give ?
SSRI such as citalopram or Lexapro because they have fewer drug to drug interactions.
a patient comes in and says they don’t want a drug that messes with their sexual function🡪 you can give
NDRI such as wellbutrin. This helps w depression and doesn’t cause sexual dysfunction.
If a patient comes in with low energy and fatigue what else can you give them?
Wellbutrin it’s increases energy levels
Contraindication of Wellbutrin?
hx of seizures because it lowers the seizure threshold. History of eating disorders.
if patient has chronic neuropathy and is deprthe essed best type of medication to prescribe is?
SNRI
SNRIs (Serotonin-Norepinephrine Reuptake Inhibitors) are effective for treating neuropathy because they increase the levels of serotonin and norepinephrine in the brain, which are neurotransmitters involved in pain modulation,
protocol for tx neuropathic pain
first: SNRI (safer)
TCA,
Alpha 2 delta ligand (pregabalin and gabapentin).
Choose SNRI over TCA bc of less adverse reactions
16 year old on Prozac or paxil what do you want to do frequently
Assess thoughts of self harm frequency and severity everytime they come to their appointment.
If a patient is depressed🡪 assess for
alcohol intake because etoh can exacerbate depressive symptoms which act as a barrier to treatment.
Prozac can cause insomnia what do you then recommend
take it in morning before prescribing new medication
antisocial personality disorder has an increase in what type of ideation
homicidal
increased dopamine in the MESOLIMBIC pathway “reward pathway”- dopaminergic is responsible for
positive symptoms of schizophrenia
mesolimbic pathway connects:
connects the ventral tegmental area in the midbrain to the ventral striatum of the basal ganglia in the forebrain.
Yes, the mesolimbic pathway connects the ventral tegmental area (VTA) to the ventral striatum, which includes the nucleus accumbens, making it essentially a “reward pathway” in the brain responsible for motivation and pleasure-related behaviors
positive symptoms in schizophrenia are, and tx is
(8)
- Symptoms can be controlled w antipsychotics (they respond positively)
-Hallucinations, delusions, referential thinking, disorganized behavior, hostility, grandiosity, mania and suspiciousness.
negative symptoms in schizophrenia are (7) and tx
Flattened affect, alogia or poverty of speech, apathy, abstract thinking problems, anhedonia and attention deficits.
atypical antipsychotics
decreased dopamine in the MESOCORTICAL pathway- connects the ventral tegmentum to the prefrontal cortex
negative symptoms of schizophrenia
schizophrenia age of onsets for males and females
Age of onset- 18-25 males
25-35 females
MRI or PET scan to visualize the brain structures of schizophrenic patients what are the findings
everything decreasing in size except the ventricles
-Abnormalities or changes/ deficits in the prefrontal cortex, amygdala, basal ganglia, hippocampus and limbic regions of the brain can cause aggression, impulsivity and abstract thinking issues
stimulants and schizophrenia
AVOID stimulants bc they can increase dopamine and make positive s&s worse
what dx has low tolerance to guanfacine and clonidine.
schizophrenia
ACT TEAM
Non pharmacologic tx for schizophrenia
- For patients with severe mental illness in the community when they are discharged
- Case management approach
Ex: if patient has long term history (keyword) of noncompliance with meds, the act team will go to their homes and administer the meds
-this is a 24/7 service
Primary prevention-
aimed to decrease the incidence of new cases- helps people avoid stressors/ cope easier
stress management, smoking PREVENTION classes, DARE, vaccinations are what levels of prevention
primary
b) Secondary prevention
aimed at decreasing the prevalence # of already existing cases🡪 early case findings, SCREENINGS and prompt and effective treatment
phone hotline, crisis intervention, disaster response, SCREENINGS are examples of what level of prevention
secondary
c) Tertiary prevention
aimed to decrease the disability and severity of a mental disorder🡪 rehab services, avoidance or postponement of complications
day treatment programs, case management for physical, housing or vocational needs, SOCIAL SKILLS TRAINING are examples of what levels of prevention
tertiary
pt with schizophrenia might need you to refer them to an exercise program, specially AEROBIC to improve cognition, quality of life and overall long term health
example of what level of prevention
tertiary
Say a patient is currently taking Haldol and is at high risk of relapse
Haldol 5MG BID
This pt has been hospitalized frequently, has had many ineffective antipsychotics and many med trials.
what is the next intervention?
Switch them from ORAL to IM (CLOSE MONITORING NEEDED)
how to calculate haldol switch from PO to IM?
20X DAILY DOSE for monthly injection
10mg daily x20 = 200mg
100mg is the max dose at one time so you give 100mg and have them come back in 5-7 days and give the second dose of 100mg
When doing a MSE on a preschooler 3-5 years old tips (2)
Listen and observe cues
-HEAVILY dependent on CLINICAL OBSERVATION
pt thinks church members and family members are in a cult🡪 delusion disorder
ex: pt thinks they are out to get them
which one is delusion based vs paranoia based
Delusion: ex: pt thinks church members and family members are in a cult🡪 delusion disorder
Paranoid: ex: pt thinks they are out to get them
tangential means
thought to thought with no point.
-Circumstantial thought process
talks in circles providing unnecessary detail BEFORE getting to the point
Themes that occupy thoughts and perceptual disturbances
Thought content
Suicidal ideations/ homicidal ideations/plan, visual hallucinations, auditory hallucinations are all part of what part in MSE
thought CONTENT
FOLSTEIN SCALE AKA as
mini mental exam
FOLSTEIN SCALE is used for
assess cognition/quantify the cognitive status in ADULTS
concentration/attention/calculation
orientation
registration
recall
fund of knowledge
clock drawing test
all are parts of the
MMSE
I would like you to count backwards from 100 by sevens, or do serial sevens, months backwards is an example of what part of the MMSE
concentration, attention, calculation
what’s the year? Season? Date? Where are we? are parts of what segment of the MMSE
orientation
say the name of 3 unrelated objects clearly and slowly, allowing ONE second for each. After you said them, ask patient to repeat them is an example of what part of the MMSE
registration
Wait five minutes, and ask pt if they can repeat the words in registration is what part of the MMSE
recall
who is the president? is what part of the MMSE
fund of knowledge
Clock drawing test (CDT) : used for
Used to screen for signs of neuro problems, such as Alzheimer’s or dementia.
-Very quick and only requires a minute or two
-If they are unable to draw, it can be caused by damage to the right parietal lobe, right hemisphere.
(Draw the clock to the right-right hemisphere)
inability to build, assemble or draw objects
can be caused by lesions in the parietal lobe following strokes or can indicate Alzheimer’s
is called
Constructional Apraxia
how do a typical and typical antipsychotics differ ?
Both atypical and typical antipsychotics have a dopamine antagonism, but ATYPICAL antipsychotics have an addition of serotonin receptor antagonism
are atypicals or typical antipsychotics less likely to cause EPS and why
Atypical because of of the serotonin antagonism
what makes atypical antipsychotics atypical?
Serotonin receptor antagonism 5HT2A
If patient comes in with 1st psychotic episode caused by mental illness- what do you want to start them on
atypical
when a pt is psychotic, they are at an increased risk of being dangerous to themself or others so you want to give med by
IM (Stabilizes quicker)
IM atypticals (3)
geodon, Abilify, invega
mesolimbic- ________ dopamine = ________ symptoms
increases and positive
mesocortical- _________ dopamine = _________ symptoms
decreases and negative
nigrostriatal pathway- Mediates _________-& __________ dopamine levels 2/2 dopamine blockade- _________ acetylcholine
motor movements,
decreases
increases
________ dopamine levels lead to an increase in __________ Causing a ___________ in salivation (sialorrhea), teary eyes (Epiphora), diarrhea.
decreased
ACH
increase
what happens to dopamine that causes the 5 types of EPS
blockade in dopamine
painful neck, stiff neck, muscle spasms of neck muscles is what type of EPS
acute dystonia
shuffling gait, motor slowing, mask facial expressions, pill rolling, tremors and muscle rigidity is what type of EPS
pseudo parkinson’s
motor restlessness, inability to sit still, rocking, pacing or constant motion of unilateral limb “jump out of my skin”
is what type of EPS
Akathisia
absence of movement, difficulty initiating motion, subjective feeling of lack of motivation to move is what type of EPS
Akinesia
involuntary abnormal movement of muscles of the mouth, tongue, face, and jaw that can progress to limbs. This is from a long time of decreased dopamine and increased acetylcholine is what type of EPS
Tardive Dyskinesia
what other medication can cause TD?
reglan
tx for all EPS except TD is
cogentin
what medication can worsen TD
cogentin
TX for TD?
For TD you want to reduce the dose of the typical antipsychotic OR switch to an ATYPICAL antipsychotic
prolactin increase, amenorrhea and galactorrhea (nipple discharge) occurs in what pathway and how
Tuberoinfundibular Pathway – decrease of dopamine because of the D2 blockage
When a pt is on risperidone this is extremely important to look
for prolactin levels, sexual dysfunction, gynecomastia and osteoporosis
in men less than 20 and women less than 25
-Clozapine is metabolized majorly by the
P450 enzyme CYP1A2
Enzyme Inducers- ________ the metabolic activity of the drug thus
increases
DECREASES the drug level so you want to INCREASE the drug
tobacco and oral contraceptives are examples of
enzyme INducers
Patient is a non-smoker and on olanzapine they come back and tell you they started smoking. What do you do with the dose?
increase
this patient comes back and says they stopped smoking, you would do what to the olanzapine
decrease
Enzyme inhibitors- ______ the metabolism of the drug thus
inhibits
INCREASES the drug level so you want to DECREASE the drug
can inducers or inhibitors cause toxic levels of drugs
inHIBITORS
A patient comes in and is taking clarithromycin and erythromycin, you will do what to their drug dosage
decrease
What if the patient is taking meds and is smoking and taking clarithromycin?
You will DECREASE the drug because the inhibitor takes preference, this is stronger and they take over the inducer.
patient is on Tegretol and antibiotics- what would you do
you need to DECREASE Tegretol because the antibiotics will cause high levels
Medications that can cause mania (4)
steroids
antabuse (disulfiram)
Isoniazid (INH)
antidepressants for bipolar pt
Medications that can cause depression (7)
-steroids
-beta blockers (metoprolol, atenolol etc)
-interferon
-ISOTRETINOIN (ACCUTANE)
-Retroviral drugs (tenofovir, abacavir)
-benzos
-progesterone
patient being treated for mood disorder with Tegretol and they are also taking flonase or prednisone if they come back weeks later saying Tegretol is not effective you would
- increase the dose of mood stabilizer because of the steroids.
-This is because flonase and prednisone have steroids which can exacerbate mood symptoms
A patient being treated for depression and is taking Lexapro and interferon and says Lexapro is not effective 4-6 weeks later you would
increase lexapro
This is because the interferon can be exacerbating the depressive symptoms
A Pt being treated for psychosis with abilify but is also taking flonase-
increase abilify
-this is because the flonase can be exacerbating the psychosis
If patient is taking a medication that exacerbated their mental illness, you need to
increase the psychotropics
Neurotransmitters involved in addiction-
dopamine and gaba gamma amino butyric acid
Patient with anorexia comes in and complains of pain after eating, bloating or stomach fullness
delayed gastric emptying
Medications that can cause delayed gastric emptying (3)
Ranitidine (Zantac)
Famotidine (Pepcid)
Omeprazole (Prilosec)
Antacids/PPi’s can
decrease the absorption of psychotropics
After taking the antacid or PPI, how long to wait until taking psychotropics
2 hours
SSRIs can cause what in older adults
anxiety
Ziprasidone (Geodon) is a ______ that fan cause what on the EKG
antipsychotic and QT prolongation/interval
Citalopram (celexa) can cause what on EKG (max doses)
prolonged QT interval
not recommended to tx more than 40mg a day for adults and 20mg for older adults
Chlorpromazine (Thorazine) is a __________ that can cause
Typical antipsychotic photosensitivity
Apoptosis
neuronal loss/ cell death
GREATEST RISK FACTOR for bipolar d/o
family history
how to differentiate mania from hypomania
mania is at least 1 week, hypomania is 4 days (if test says 2-3 days it is still bipolar dx)
Severely dysfunctional early relationship between caregiver and child, when caregiver consistently neglects the child the child fails to develop a stable attachment some become fearful and withdrawn or aggressive and disorganized
reactive attachment disorder
SBIRT stands for and is often used when
screening brief intervention referral treatment
screen for SUD
Donaldson vs O’connor case is about what
Donaldson was hospitalized for 15 years and had no insight he was mentally ill
it is unconstitutional to commit a person involuntarily for a long time who is not a danger to self or others
centers on the standards for involuntary commitment itself, establishing that a person cannot be committed unless they pose a danger to themselves or others.
Rennie vs. Klein is about
involuntary committed patient who has NOT been found incompetent and has a qualified right to refuse medications
primarily deals with a patient’s right to refuse medication once involuntarily committed,
How is the HAM-D scored?
Each item is rated on a scale from 0 to 4, with higher scores indicating greater symptom severity. The total score ranges from 0 to 52.
0-7: No depression, 8-16: Mild depression, 17-23: Moderate depression, and 24+: Severe depression.
How is the GAD scored
The Generalized Anxiety Disorder-7 (GAD-7) is a screening tool used to assess the severity of generalized anxiety disorder (GAD). It consists of seven questions, each rated on a 0-3 scale, with higher scores indicating greater anxiety.
Score Interpretation:
0-4: Minimal anxiety
5-9: Mild anxiety
10-14: Moderate anxiety
15-21: Severe anxiety
0-4:
No further action is typically recommended.
5-9:
Consider monitoring symptoms and discussing with a healthcare professional.
10-14:
Seek professional evaluation and treatment from a mental health professional.
15-21:
Immediate professional attention and comprehensive treatment are highly recommended.
how do you know if a patient with dementia can give consent?
if they can explain the risks and benefits, as well as to why they want to take the medication they can consent
if a patient is too sick to sign consent what do you do?
assess and evaluate if the patient needs involuntary tx, do not FORCE medication
how does an NP reduce stigma?
Target wide audiences versus family, radio over school meeting, trying to target MORE people
what are the four components of health policy
process, policy reform, policy environment, policy makers (assess barriers of organization FIRST then brainstorm with stakeholders)
when do you medicate anxiety based off of the scoring ranges?
Moderate scores so HAM-A is 18-24 and GAD is 10-14
when do you initiate buprenorphine or suboxone on a COWs scale
once it hits 13
why do you choose suboxone or buprenorphine over methadone
methadone can create cardiac arrhythmias
Buprenorphine, sold under the brand name Subutex among others, is an opioid used to treat opioid use disorder, acute pain, and chronic pain.
when do you initiate clonidine on a COWs
score is 5-12 start clonidine
opioid w/d symptoms
yawning
anxiety
pupils dilated
piloerection
muscle aches
lacrimation
rhinorrhea
why is diazepam better than lorazepam
diazepam has a longer half life and lorazepam has shorter half life
when do you administer scheduled and PRN based off CIWA
15 and above
when do you administer PRNS based off of CIWA
8 and above
When would lorazepam be prefered?
patients who have Hep c, d or liver disease
diazepam is metabolized by the liver. The liver metabolizes diazepam into an active metabolite that is then excreted in the urine.
Explanation
The liver metabolizes diazepam through the CYP3A4 and CYP2C19 enzymes.
What do you give a patient who is withdrawing and has anxiety
hydroxyzine or buspar NOT a benzo
treatments for ETOH disorder (3)
Campral (Acamprosate) because its NOT metabolized by the Liver
Acamprosate is thought to work by helping to restore the balance between excitatory and inhibitory neurotransmitters (chemical messengers) in the brain, which are altered by drinking alcohol. Research suggests it primarily works by decreasing the excessive excitation that accompanies alcohol dependence.
disulfram (antabuse)
When alcohol enters the body, it is converted into acetaldehyde and then into acetic acid. Disulfiram’s mechanism of action blocks the conversion of acetaldehyde to acetic acid, resulting in an upsurge of acetaldehyde. This upsurge is toxic and causes the individual to become ill. not to be used during active detox
Naltrexone (Revia) used for prevention after detox is completed
REVIA is a pure opioid antagonist. It markedly attenuates or completely blocks, reversibly, the subjective effects of intravenously administered opioids.
if pt scores a 20 on HAM-D what is the priority action
assess for suicide
latrogenic and iatrogenic
The terms “latrogenic” and “iatrogenic” are identical. They refer to adverse effects or illnesses caused by medical treatment or interventions, such as:
Drugs: Medication side effects or allergic reactions.
Procedures: Complications from surgery, injections, or other invasive procedures.
Diagnoses: Misdiagnoses or incorrect interpretations of test results.
how does desmopressin work and what is it used for
night time urination enuresis, it works by decreasing urine production
RA does what to ESR labs
ESR levels are increased with rheumatoid arthritis (RA) because the disease causes inflammation in the body, which leads to an increase in acute phase proteins like fibrinogen in the blood, causing red blood cells to clump together and settle faster, resulting in a higher ESR reading; essentially, a higher ESR indicates a greater level of inflammation present in the body, a common feature of RA.
why are women more likely to get drunk quicker and develop alcohol induced liver issues
they have a decrease in alcohol dehydrogenase
palmar grasp reflex is normal up to?
5-6 months
motor/startle reflex is normal to
5-6 months (arms are thrown outwards if position is changed too quickly)
Babinski refelx is normal up to
2 years old -toes fan out when foot is scratched, after 2 toes should curl
what are PDE-5 meds and give an example
viagra, rapidly absorbed after oral administration
if a patient has macrocytic normochromic anemia what do you want to check for?
folic acid and b12 because macrocytes are abnormally large RBCs not formed correctly with a deficiency in B vitamins
Habeas Corpus is
AMA
hallmark sign of disseminated encephalomyelitis?
inflammation of brain and spinal cord- assymetrical movements of extremities (do neuro exam)
PICOT
evidence based decisions that replicate old treatment with new method must have access to current articles
neurotransmitters that effect mood
DNS, GABA, Glutamate
multisystemic family therapy targets
youth 12-17 because it helps parents to identify support and reduce barriers
pt education on disulfiram
should have regular liver function tests done, as disulfiram can cause elevations in liver enzymes. Monitoring liver function tests is necessary because disulfiram can elevate liver enzymes, indicating potential liver toxicity.
Tremors, hallucinations, and agitation are characteristic signs and symptoms of alcohol withdrawal, particularly during the initial hours after discontinuing alcohol use. Tremors (shakes), visual or auditory hallucinations, and restlessness (agitation) are indicative of the more severe form of alcohol withdrawal known as delirium tremens (DT). Monitoring these symptoms closely is crucial, as DT can be life-threatening if not managed promptly and appropriately. This option aligns with the essential elements of assessing and managing alcohol withdrawal in psychiatric settings. The signs and symptoms of alcohol withdrawal can include: Anxiety, Tremors, Nausea and Vomiting: Some individuals may experience stomach upset, nausea, and vomiting, Sweating, rapid hear rate, high blood pressure, insomnia, Hallucinations (Visual, auditory, or tactile hallucinations can occur, especially in severe cases), headache, Seizures, Delirium Tremens (DTs):
(DTs are a severe form of alcohol withdrawal characterized by severe confusion, agitation, hallucinations, high fever, and seizures. DTs are a medical emergency and require immediate attention)
DT
While alcohol withdrawal can lead to symptoms such as hypertension (high blood pressure) and an increased heart rate, these symptoms are more commonly associated with the
later stages of withdrawal. During the initial hours of admission, the focus is on monitoring for
more immediate and severe symptoms.
