PMHNP Flashcards
Narrow down to ____ right answers
2
For medical evaluation..
refer out
Priority questions
- Airway
- Maslows hierarchy of needs
- Nursing process (assess before intervention)
Adolescents have a right to
confidentiality
Interprofessional collaboration is encouraged..
If answer has “collaborate” in it, high chance of being right
If there is something within the PMHNP scope of practice…
do that before referring out
Get informed consent
before faxing
A patient inhaled acetone, feeling weird and funny
Do a UDS to check if they do other drugs for the high
Culture Assessment
-if culture is mentioned, its prob a cultural question
- Is it a culturally expected response to a stressor?
- If someone is having a cultural syndrome then offer brief supportive therapy
- clarify meaning of illness, validate symptoms
- somatic complaints of pain, validate with cultural significance
- psychoeducation on schizophrenia is tailored towards a culture significance
TSH range
0.5-5.0
If patient is depressed, screen for
hypothyroidism
If patient has mania or bipolar disorder, screen for
hyperthyroidism
elevated T3 & T4, decreased TSH
hyperthyroidism
decreased T3 & T4, increased TSH
hypothyroidism
hyperthyroidism s/s
- heat intolerance
- agitation
- anxiety
- irritability
- tachycardia
- mood swings
- weight loss
hypothyroidism s/s
- cold intolerance
- lethargy
- weight gain
- decreased libido
divalproex sodium during pregnancy can cause
spina bifida (neural tube defect)
divalproex sodium black box warning
HEPATOTOXICITY ( abd pain in RUQ, reddish brown urine, yellowing of skin and whites of eyes, fatigue)
**Intervention- d/c offending agent and do LFT
- AST 5-40
- ALT 5-35
PANCREATITIS (upper abd pain radiating towards back, tender when touching abd, fever, rapid pulse, nausea, vomiting, oily stools)
Therapeutic valproic acid level & toxicity
- 50-125
- toxicity occurs >150
S/S of valproic acid toxicity
- disorientation
- lethargy
- respiratory depression
- nausea/vomiting
what to do for valproic acid toxicity
- d/c offending agent
- check valproic acid levels
- LFTs
- ammonia levels
KAVA (kava kava)
herbal supplement for anxiety, stress, insomnia
- can cause liver damage - do LFT
major kava kava interactions
- alprazolam (xanax) - increased drowsiness
- sedative meds (CNS depressants), may increase sleepiness and drowsiness
Lamictal
- can cause SJS/severe rash
- s/s: fever, body aches, red rash, peeling skin, facial and tongue swelling
** mood stabilizer with least amount of weight gain **
antipsychotics with least amount of weight gain
- least amount of weight gain : Ziprasidone, aripiprazole, lurasidone ZAL
labs for antipsychotics that cause weight gain
- BMI
- hip-to-waist ratio
- glucose
- lipid panel
management for antipsychotic-induced weight gain
- nonpharmacologic: exercise & nutritional counseling
- pharmacologic: switching to another antipsychotic with less potential to cause weight gain
Carbamazepine (Tegretol) black box
- agranulocytosis (decreased WBC): sudden fever, chills sore throat, weakness
- aplastic anemia: pallor, fatigue, HA, fever, nose bleeds, bleeding gums, skin rash, SHOB
carbamazepine & Clozaril
can cause agranulocytosis
Carbamazepine and Asians
- SJS
- HLAB-1502 allele before initiating
When to d/c carbamazepine and/or clozaril
if ANC is <1000
Lithium therapeutic range
0.6-1.2
lithium toxicity level
1.5 or higher
Lithium
gold standard for manic episodes and anti-suicidal effects
Labs for lithium
- thyroid panel (check for hyperthyroidism)
- serum creatinine (0.6-1.2)
- BUN (10-20)
- UA (check for proteins in urine; protein 4+ may indicate AKI)
- HCG (ages 12-51) choose if HCG is an answer for psychotropic medications
side effects of lithium
- hypothyroidism
- fine hand tremor
- maculopapular rash
- GI upset
-poly- uria, dypsia - diabetes insipidus
- T-wave inversions
- leukocytosis (increased WBC)
Lithium can cause what anomaly
Epstein (congenital heart defect)
interventions for lithium toxicity
discontinue lithium, check serum levels
S/S of lithium toxicity
- severe nausea
- vomiting
- diarrhea
- confusion
- drowsiness
- muscle weakness
- heart palpitation
- coarse hand tremors
- ataxia (unsteadiness while standing/walking)
drugs that increase serum lithium levels
- NSAIDs (ibuprofen, Indocin)
- kidney damage/drugs that reduce renal clearance
- thiazides (hydrochlorothiazide)
- ACE inhibitors (lisinopril)
dehydration and hyponatremia can cause what
increase lithium level
Neuroleptic Malignant Syndrome
caused by antipsychotics
s/s of NMS
- extreme muscle rigidity *
- mutism*
- hyperthermia
- tachycardia
- diaphoresis
- altered level of consciousness
- differ from Serotonin syndrome
labs for NMS
- elevated CPK (creatine phosphokinase): muscle contraction/destruction*
- myoglobinuria (breakdown of muscle): rhabdomyolysis
- elevated WBC (Leukocytosis)
- elevated LFT
treatment for NMS
- discontinue offending agent
- bromocriptine (Parlodel)- dopamine (D2) agonist given when exam asks for a dopamine agonist
- Dantrolene- muscle relaxant given when asked for muscle relaxant on exam or something to help for muscle rigidity
Serotonin Syndrome
caused by antidepressants
S/S of Serotonin syndrome
-hyperreflexia*
-myoclonic jerks*
* differ from NMS*
treatment for serotonin syndrome
- discontinue offending agent
- cyproheptadine
drugs that increase serotonin
- triptans (sumatriptin[Imitrex]), if patient is taking these stay away from these medications, consider starting on NDRI or talk to PCP to switch imitrex
- St. Johns Wort
SSRI
- first line treatment in depression
- safer in overdose
- If patient is depressed and has cancer consider citalopram or escitalopram d/t less drug interactions
- SSRI cause sexual dysfunction
Antidepressants black box
- increase in suicidality
- screen all patients for thoughts of self-harm, frequency, and severity*
What to prescribe for patient who is depressed and low energy
Wellbutrin
Wellbutrin contraindications
- seizure hx.
- eating disorders
Neuropathic pain
- SNRI helps with pain (TCAs can help, but dangerous)
- Alpha2 delta ligand medications (gabapentin & pregabalin)
Prozac
can cause insomnia if taken in the AM
SSRI to MAOI
wait 2 weeks
Prozac to MAOI
wait 5-6 weeks
MAOI to prozac
wait 2 weeks
washout period
5 half-lives between cessation of previous drug and introduction of new drug is the safest
* you want medication to degenerate*
Schizophrenia onset
-males: 18-25 y/o
-females: 25-35 y/o
schizophrenia imaging
- MRI/PET will show ventricles have an increase in size, everything else is decreased
abnormalities/changes in brain with schizophrenia
- prefrontal cortex
- amygdala
- basal ganglia
- hippocampus
- limbic regions
- can cause aggression, impulsivity, and abstract thinking problems*
alpha 2 adrenergic receptor agonist in schizophrenua
- clonidine & guanfacine- low tolerability in schizophrenic patients
stimulants and schizophrenia
not recommended especially those with positive symptoms due to increasing dopamine release
treatment for helping schizophrenic get back into community
- assertive community treatment
- long history of noncompliance, refer to case management for home health nurse to visit and do medications
- social skills training - tertiary level of prevention
aerobics and schizophrenia
can help improve cognition, quality of life, and overall long-term health
haldol PO to decanoate
20 x (daily dose) = mg
*max of 100mg at once, give next dose 5-7 days later
Delusions
false belief despite evidence to contrary, different from paranoid
mental status exam for 3-5 year olds
list and observe cues, based on clinical observation
Thought process
Assess the organization of the patient’s thoughts and ideas
-Normal: logical, linear, coherent, and goal-orinted
-Abnormal- associations are not clear, organized, or coherent
-Tangentiality: move from thought to thought that may or may not relate in someway but never get to the point
-Circumstantial: provide unnecessary detail but eventually gets to the point, patient goes in circles
Thought content
refers to themes that occupy the patient’s thought and perceptual disturbances
examples: suicidal ideation, homicidal ideation, and plan; hallucinations
Mini Mental Status Exam (MMSE)
- concentration/attention: I would like for you to count backward from 100 by 7s
-Orientation: what year is it?
-Registration/Ability to learn: say the names of 3 unrelated objects clearly and slowly; ask the patient to repeat - Recall: ask the patient if he or she can recall the three words you asked him to remember
Clock drawing test
a simple tool used to screen people for signs of neurological problems such as Alzheimers
- impairments on this test are associated with damage to the right parietal lobe (right hemisphere)
- constructional apraxia is the inability or difficulty to build, assemble, or draw objects can be caused by lesion in the parietal lobe following a stroke or may be indicator of alzheimers
Atypical antipsychotic
-serotonin (5HT2A) receptor antagonism: less likely to cause EPS
-first psychotic episode, give atypical antipsychotic, especially one that can be given IM (invega, haldol, geodon, abilify)
Mesolimbic pathway
-increased D2 positive psychotic symptoms
-hyperactivity of dopamine in the mesolimbic pathway mediates positive psychotic symptoms HYPER
Nigrostriatal pathway
- mediates motor movement
-dopamine blockade can lead to EG, EPS, acute dystonia (painful neck, stiff neck, muscle spasms), akathisia - long standing d2 blockade can lead to tardive dyskinesia
- reglan can cause EPS
-EPS: increased acetylcholine and decreased dopamine levels, treatment is benztropine, for TD lower dose or switch to an atypical
Mesocortical pathway
-decreased D2 negative and depressive symptoms
-decreased dopamine in the mesocortical projection to the dorsolateral prefrontal cortex is postulated to be responsible for negative and depressive symptoms of schizophrenia
Tuberoinfundibular pathway
-blockade of D2 receptors can lead to increase prolactin levels –> hyperprolactinemia, which manifests as amenorrhea, galactorrhea (risperidone), and sexual dysfunction, gynecomastia
longterm hyperprolactinemia can be associated with osteoporosis
prolactin levels M/F
-male: less than 20ng/ml
-female: less than 25ng/ml
clozapine
metabolized by cytochrome enzyme CYP1A2
enzyme inducers
decrease the serum level of other drugs that are substrates of that enzyme, which can cause subtherapeutic drug levels (tobacco)
enzyme inhibitors
increase the serum level of other drugs that are substrates of that enzyme, possibly causing toxic levels (erythromycin)
Medications that can cause mania
- steroids (can also cause psychosis)
- dilsulfiram (antabuse)
- isoniazid
- antidepressants in someone with bipolar
medications that can cause depression
- steroids
-beta-blockers
-interferon
-isotretinoin (can also cause birth defects) - some retroviral drugs
- benzodiazepines
- antineoplastic drugs
- ## progesterone
bipolar disorder risk factor
-inheritable
bipolar and medical condition
-related to medical condition at 45 years old or older, think of a stroke or a medical cause of the symptoms
mania/hypomania
mania is much longer than hypomania, can be irritable or agitated
symptoms of mania/hypomania
-distractibility and easily frustrated
-irresponsibility, indiscretion, impulsivity
- grandiosity
-flight of idea
-activity increased
-sleep decreased (denies feeling tired)
-talkativeness (pressured, rapid speech)
Borderline personality disorder
- self-harming behavior
- recurrent suicidal behavior
- interpersonal problems
-have patients keep a diary/journal of symptoms to establish diagnosis
-DBT can help decrease in suicidality
If a patient with borderline personality disorder presents with depressed mood, emotional lability, interpersonal problems, rejection sensitivity, aggression, and hostility…treat with
depakote
If a patient with borderline personality disorder presents with irritability, anger, and self-harming behaviors….treat with
lithium
Conversion disorder
-mental condition where person has blindness, mutism, paralysis, or parathesia, another nervous system symptoms that cannot be explained by medical evaluation
- symptoms usually begin after stressful experience
-therapy
Oppositional Defiant Disorder (ODD)
-diagnosed in children 6-17 years old; usually 6-10 years old
-enduring pattern of angry/irritable mood and argumentative, defiant, vindictive behavior lasting at least 6 months with at least 4 associated symptoms
ODD S/S
-loses temper
-touchy or easily annoyed
-angry/resentful
-argues with authority
-actively defies or refuses to comply with rules
-blames others
-deliberately annoys others
-spiteful/vindictive
ODD nonpharmacological treatment
-therapy
- family therapy with emphasis on child management skills, teaching parents positive reinforcement, and boundary settings
- child and parent problem-solving skills training
Conduct disorder
-repetitive and persistent pattern of behavior in which the rights of others or societal norms or rules are violated (think antisocial personality disorder but cannot diagnose a personality disorder until they are 18 years old)
conduct vs ODD
conduct is much more intense, think if child should go to juvenile prison
conduct disorder s/s
-aggression towards people/animals (bullies, threatens, intimidates, initiates physical fights, uses weapons to cause harm, physically cruel
-destruction of property (example: fire setting)
- deceit or theft (broke into house, cars; lies and steals)
-lack of remorse
conduct disorder treatment
-pharmacological treatment- target mood and aggression
- aggression and agitation with antipsychotics, mood stabilizers, SSRIs, and alpha agonists (clonidine and guanfacine)
Adjustment disorder
emotional or behavioral reaction to a stressful event or change in a persons life.
-reaction is considered an unhealthy or excessive response to the event or change, within 3 months of it happening
-stressful events or changes in the life of your child or adolescent may be a family move, parents divorce, loss of a pet, birth of a sibling
**If you read a question and can identify a stressor then symptoms start after that then it is an adjustment disorder rather than MDD or GAD
Adjustment disorder with depressed mood
presents with feelings of sadness, decreased interest, sleep disturbance, and appetite changes
Adjustment disorder with anxiety
presents with symptoms of feeling restless, nervous, lack of concentration
adjustment disorder with mixed anxiety and depression
patient has a mix of symptoms from both depressed mood and anxiety
adjustment disorder with disturbances of conduct
a child may violate other peoples rights/social norms, rules,
- examples: not going to school, destroying property, driving recklessly, fighting
adjustment disorder with mixed disturbance of emotions and conduct
stressor in a child’s life results in a mix of symptoms from all the above subtypes
-examples: child may present with truancy, peer conflict, verbal altercations, insomnia, frequent crying
Tourette’s syndrome diagnosis
atleast 2 motor tics (hand, leg, face) and atleast one vocal (phonic) tic have been present, not necessarily at the same time
-tics may wax and wane in frequency, but have occurred for more than 1 year
-tics have not started before the age of 18 (childrens motor tics are fairly common and can be temporary)
Tourette’s neurotransmitters involved
- dopamine
- norepinephrine (noradrenaline)
-serotonin
**DNS ** (hyperactivity of dopaminergic symptoms in the brain can cause tics
Tourette’s management
- atypical antipsychotic
*FDA approved: haldol, pimozide, abilify - clonidine and guanfacine can help control behavioral symptoms such as impulse control and rage attacks
Acute stress disorder
may occur in patients within/less than 4 weeks of a traumatic event
acute stress disorder s/s
-anxiety
-insomnia
-poor concentration
-intense fear
-helplessness
-reexperiencing the event
-avoidance behaviors
- traumatic incident and patient does not want to go back to work, insomnia, avoidance and startle for less than 4 weeks
PTSD s/s
- intrusive re-experiencing of an extremely traumatic event
- increased arousal (hyperarousal)
- avoidance of stimuli associated with the trauma
PTSD pharmacologic
- SSRIs
-TCAs - prazosin
PTSD nonpharmacologic
- EMDR** - desensitization phase, installation phase, body scan phase
- CBT
ADHD
- DNS
-frontal cortex
-basal ganglia
-abnormalities of reticular activating systems - abnormalities in the prefrontal cortex- inattentive type
ADHD treatment- stimulant
- assess cardiac hx before initiating stimulant ( if family hx. do ekg)
- amphetamines approved for children 3 years and older
-methylphenidate approved 6 years and older
*Tics are contraindication for stimulants (if you start on stimulants and they develop tic, stop the stimulant and switch to non-stimulant)
s/s of stimulant abuse
- insomnia
-tremor
-increased blood pressure/HR - heart palpitation
-agitation
-anxiety
-irritability and mood swings
Non-stimulants for ADHD
- alpha agonist or alpha 2 adrenergic receptors agonist (guanfacine and clonidine FDA approved in ages 6-17 with ADHD)
Strattera
approved for children ages 6 and older with ADHD
ADHD diagnosis
- must assess in atleast 2 different settings, school, and parents
- if symptoms are worsening, you can start the patient stimulant, if pt is re-experiencing the symptoms shortly after you can start them on multiple doses a day or extended-release
-parents may have anxiety from diagnosing child - give psychoeducation/therapy to parents
OCD (serotonin and norepinepherine)
presence of anxiety-provoking obsessions (recurrent and persistent thoughts, impulses or images), or compulsions, that function to reduce the persons subjective anxiety level
What to consider in pediatric patients with sudden onset OCD?
- PANDAS (pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections)
TIP for OCD vs Tourettes
- OCD: persistent thoughts and tics
- Tourettes: tics only
Factitious disorder
presents with physical or mental symptoms that are induced (for example: drinking contaminated urine samples, taking hallucinogens)
Malingering
similar to factitious disorder in that symptoms are faked, but the motive is malingering for secondary gain such as getting out of jail, or staying in the hospital for bed/food
Factitious disorder imposed on another
someone falsely claims that another person has physical or psychological s/s of illness or caused injury or disease in another person with the intention of deceiving others
Reactive attachment disorder
-product of severely dysfunctional relationship with the principal caregiver and the child
-when the caregiver consistently disregards the physical/emotional needs of the child and fails to develop a secure and stable attachment
- can cause child to be fearful, withdrawn, apathetic, and show no emotions towards caregiver
- some children are more aggressive, disruptive and disorganized
Generalized anxiety disorder
excessive worry, apprehension, or anxiety about events or activites
-occurs more days then not for a period of atleast 6 months
Panic Attack (acute)
abrupt surge of intense fear or discomfort that reaches a peak within minutes and during which time a variety of psychological and physical symptoms occur
- rapid HR
- sweating/shaking
-SHIB
-hot flashes/lightheadedness
-impending doom
-chills
-nausea/ abd pain
-chest pain
-HA
- numbness/tingling
Acute panic attack treatment
- beta blockers (propanolol) - can cause bronchospasms if pt is taking albuterol
- benzodiazepines- habit forming, give BB first if possible
panic disorder (chronic)
given to people who experience recurrent unexpected panic attacks (come from nowhere)
panic disorder treatment
- SSRI (prozac, paroxetine, sertraline)
- SNRI ( venlafaxine)
Disruptive Mood Dysregulation
most likely borderline personality disorder, but since child cannot be diagnosed until 18 with a personality, they are diagnosed with this.
-childhood depressive disorder diagnosed in ages 6-18
- chronic dysregulated mood “moody”
- frequent intense temper outbursts/temper tantrums
- severe irritability/anger
Anorexia Nervosa
- low BMI
-amenorrhea
-emaciation
-hypotension
**BMI <15– refer out for med. eval and hospitalization
**If parents unwilling to get treatment for child, call CPS
Autism spectrum disorder (Glutamate, GABA, serotonin)
- persistent deficits in social communication, and social interaction across multiple settings
- no response when called by name
- nonverbal communication
- little to no eye contact
-line up, stack or organize objects
