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PMHNP Boards Review > Scientific Foundation & Advanced Practice > Flashcards

Scientific Foundation & Advanced Practice Flashcards

1
Q

Lithium Levels

A

0.6-1.2 mEq/L

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2
Q

What is the gold standard to treating mania?

A

Lithium

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3
Q

Which mood stabilizer has evidence of anti-suicidal effects?

A

Lithium. It is the neuroprotective treatment of choice for Bipolar D/O.

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4
Q

What level can Lithium toxicity occur?

A

1.5 mEq/L or higher

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5
Q

What are the baseline labs to initiate Lithium?

A
  • Thyroid panel – assess for hyperthyroid which can mimic mania.
  • Serum creatinine
  • Blood urea nitrogen (BUN)
  • Pregnancy test – do no want female patients on this while pregnant
  • ECG for >50 yo – cardiac side effects
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6
Q

How can enzyme inDucers alter pharmacokinetics?

A

Enzyme inducers can DECREASE the serum level of other drugs that are substrates of that enzyme – can cause sub therapeutic drug levels
- I.E. tobacco and carbamazepine
- Example: X dose of Olanzapine (Zyprexa)
– Start smoking = increase dose of Olanzapine
– Stop smoking/start smoking cessation program = decrease dose

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7
Q

How can enzyme inHibitors alter pharmacokinetics?

A

Enzyme inhibitors can INCREASE the serum level of other drugs that are substrates of that enzyme – causing toxic levels.
- I.E. Clarithromycin & Ketonazole
- Think inHibitor – think High

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8
Q

What are some S&S of Lithium toxicity?

A
  • Severe nausea
  • Vomiting
  • Diarrhea
  • Confusion
  • Convulsions
  • Drowsiness
  • Blurred vision
  • Slurred speech
  • Muscle weakness
  • Heart palpitations
  • Coarse hand tremors
  • Unsteadiness while standing and walking (ataxia)
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9
Q

What do you do if a patient has Lithium toxicity?

A
  • Immediately D/C Lithium
  • Check their serum lithium levels
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10
Q

What are some clinically significant side effects of lithium?

A
  • Fine hand tremors
  • Coarse hand tremors with toxicity
  • GI upset becomes severe
  • Leukocytosis – Lithium can increase WBC so MONITOR CBC
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11
Q

What is the BBW for Carbamazepine (Tegretol)?

A
  • Agranulocytosis (decreased WBCs)
  • Aplastic anemia (pallor, fatigue, headache, fever, nose bleeds, bleeding gums, skin rash, shortness of breath)
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12
Q

What is a major side effect to watch out for with Carbamazepine (Tegretol)?

A

Stevens-Johnson syndrome (particularly in Asian) – screen for HLA-B 1502 allele before initiating – HLA-B*1502 is highly associated with the outcome of carbamezapine-induced SJS

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13
Q

What is Stevens-Johnson Syndome (SJS)?

A

SJS is a rare, potentially life-threatening immune reaction to a foreign antigen that can occur with exposure to any anticonvulsant drug.

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14
Q

How do you treat SJS?

A

Treatment includes stopping the offending agent with supportive measures, often in a hospital burn unit.

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15
Q

What are the S&S of SJS?

A
  • Facial swelling
  • Tongue swelling
  • Macules, papules, and “burning,” confluent erythematic rash
  • skin sloughing
  • prodromal headache, malaise, arthralgia, and painful mucous membranes may occur before rash occurs
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16
Q

What is the BBW for Valproic Acid/Divalproex Sodium?

A
  • Hepatotoxicity
  • Pancreatitis
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17
Q

What is the BBW for Lamotrigine?

A
  • Serious rash
  • SJS but does not have HLA-B1502 screening
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18
Q

What are the drugs used for mood disorders?

A

Anticonvulsants:
1. Lithium
2. Carbamazepine/Tegretol – Alternate to lithium & valproic acid
3. Valproic Acid/Depakote – effective for rapid cycling and mixed bipolar
4. Lamotrigine/Lamictal – maintenance only, helps in depressive phase of bipolar
5. Topamax – can be used as well but can cause kidney stones

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19
Q

What should be checked before starting a female patient of childbearing age (12-51 yo) on a psychotropic medication?

A

Check pregnancy status (human chorionic gonadotropin (HCG))
- Folic acid supports neural tube development during the first month that a woman is pregnant – take 0.4 - 0.8 mg daily

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20
Q

Lithium & Pregnancy

A
  • Ebstein’s Anomaly – heart defect
  • Avoid in pregnancy, especially the first trimester
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21
Q

What to monitor when a patient is on Lithium?

A
  • Risk for hypothyroidism
  • Kidney function is important
  • Concurrent use of NSAIDs and ACE inhibitors may DOUBLE lithium level
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22
Q

What to monitor when a patient is on Carbamazepine?

A

Monitor LFTs

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23
Q

Valproic Acid & Pregnancy

A

Neural tube defects

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24
Q

Which mood stabilizer can cause SIADH?

A

Carbamazepine
- SIADH – syndrome of inappropriate antidiuretic hormone secretion
- SIADH is impaired water excretion leading to hyponatremia with hypervolemia or euvolemia

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25
Q

When does a hypertensive crisis occur?

A

It occurs when a MAOI is taken in conjunction with foods containing tyramine

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26
Q

What is a hypertensive crisis?

A

When MAO is inhibited, tyramine exerts a strong vasopressor effect, stimulating the release of catecholamines, epinephrine, and norepinephrine, which can increase blood pressure and heart rate.
- It is life-threatening and can’t be reversed unless more MAO is made by the body

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27
Q

What medications can cause hypertensive crisis and death when taken with MAOIs?

A
  • Meperidine
  • Decongestants
  • TCAs
  • Atypical antipsychotics
  • St. John’s wort
  • L-tryptophan
  • Stimulants and other sympathomimetics
  • Asthma medications
  • These are strictly prohibited in patients taking any MAOIs
28
Q

What are symptoms of a hypertensive crisis?

A
  • Sudden, explosive-like headache, usually in occipital region
  • Elevated blood pressure
  • Facial flushing
  • Palpitations
  • Pupillary dilation
  • Diaphoresis
  • Fever
29
Q

What is the treatment for a hypertensive crisis?

A
  • Discontinue the MAOI
  • Give phentolamine (binds with norepinephrine receptor sites/blocks norepinephrine
  • Stabilize fever
  • Reevaluate the patient’s diet and adherence, reiterate medication guidelines as necessary
30
Q

What foods have tyramine in them?

A
  • Cheese: aged cheeses (blue, brie, Camembert, Roquefort)
  • Meat: smoked, aged, cured (sausages, pastrami, salami)
  • Fish: smoked, aged, cured (pickled herring, salted fish)
  • Beverages: aged, fermented (red wine, aged liquors, whiskey, beer)
  • Other: bean curd (tofu), soy products, sauerkraut, miso, yeast extract, MSG, ripe bananas, avocado
31
Q

What are the teratogenic risks of common psychiatric medications?

A
  • Benzodiazepines – floppy baby syndrome, cleft palate
  • Carbamazepine – neural tube defect
  • Lithium – Ebstein’s anomaly
  • Divalproex/Depakote – neural tube defect, specifically spina bifida, atrial septal defect, cleft palate, and possible long-term developmental defects
32
Q

What is the association between Clozaril & Carbamazepine with neutropenia?

A
  • There is a risk for neutropenia.
  • Absolute neutrophil count (ANC) needs to only be monitored for neutropenia, NOT in conjunction with WBC
33
Q

What is the normal ANC level?

A

2,500 - 6,000

34
Q

What is the normal range of WBCs in blood?

A

4,500 to 11,000 WBC per microliter

35
Q

When do you D/C Clozaril/Carbamazepine?

A
  • ANC less than 1000 mm3 (bc of risk of neutropenia)
  • WBC of 2,000 to 3,000 (bc of risk of agranulocytosis)
  • Monitor for signs of infection (sudden fever, chills, sore throat, weakness)
36
Q

Explain the management of Clozaril?

A
  • Monitor ANC labs
  • First 6 months: weekly
  • Second 6 months: Q2weeks
  • Then monthly if ANC is normal
37
Q

What are the BMI categories?

A
  • Underweight: <18.5
  • Normal weight: 18.5 - 24.9
  • Overweight: 25 - 29.9
  • Obesity: 30 or greater
38
Q

What is bulimia nervosa?

A
  • Recurrent, episodic binge eating
  • Both binge eating and inappropriate compensatory behaviors occur at least 2x weekly for 3 months
  • BMI is usually within normal range
39
Q

What are the recurrent, inappropriate compensatory behaviors that occur to prevent weight gain with bulimia?

A
  • Self-inducing vomiting
  • Laxatives
  • Enemas
  • Diuretics
  • Stimulants
  • Abuse of diet pills
  • Fasting
  • Excessive exercise
40
Q

What are the two types of bulimia?

A
  • Purging type: regularly engage in purging or the misuse of laxatives, enemas, or diuretics
  • Nonpurging type: use other inappropriate compensatory behaviors (fasting, excessive exercise without engaging in purging as mentioned above)
41
Q

What are some physical exam findings in bulimia?

A
  • Weight is within normal limits
  • Erosion of dental enamel
  • Russell’s sign
  • Hypertrophy of salivary glands
  • Rectal prolapse
42
Q

What are some physical exam findings in anorexia nervosa?

A
  • Low body mass index
  • Amenorrhea
  • Emaciation (being abnormally thin)
  • Erosion of dental enamel (repeated self induced vomiting)
43
Q

What are the pharmacological management of eating disorders?

A
  • Med management is adjunctive therapy to psychotherapy
  • There is no specific medication for anorexia nervosa
  • Fluoxetine is FDA-approved for bulimia nervosa
  • SSRIs and TCAs are effective in reducing the frequency of bingeing and purging
  • Treat associated symptoms (depression, anxiety) with appropriate pharmacological therapy
44
Q

What are the nonpharmacological management of eating disorders?

A
  • Medical and nutritional stabilization
    – weight restoration
    – correction of electrolyte disturbance
    – vitamin supplementation
    – nutrition counseling
  • Psychotherapeutic interventions
    – individual psychotherapy
    – behavioral therapy
    – cognitive behavioral therapy (overcome distorted thinking)
    – family therapy
    – group therapy
45
Q

What is the appropriate medication to prescribe for someone with depressed/low energy/fatigue?

A
  • NDRI (Norepinephrine Dopamine Reuptake Inhibitor)
    – Wellbutrin
46
Q

What type of patient is Wellbutrin contraindicated in?

A
  • Seizure disorders/history of seizures
  • Conditions that increase the risk of seizures (anorexia nervosa, bulimia)
    – increases seizure risks by decreasing seizure threshold
47
Q

What type of antidepressants help with chronic neuropathic pain?

A

SNRIs (Duloxetine)

48
Q

Which atypical antipsychotic is metabolized by the cytochrome P450 enzyme CYP1A2?

A

Clozapine (Clozaril)

49
Q

NSAIDs, thiazides, ACE inhibitors

A

Reduce renal clearance which can increase concentration of drugs

50
Q

Inducers Mnemonic:
BullShit CRAP GPS INDUCES my rage!

A
  • Barbiturates
  • St. John’s Worts
  • Carbamazepine
  • Rifampin
  • Alcohol (chronic)
  • Phenytoin
  • Griseofulvin
  • Phenobarbital
  • Sulfonylureas
  • Plus cigarette smoking
51
Q

Inhibitors Mnemonic:
SICKFACES.COM

A
  • Sodium Valproate
  • Isoniazid
  • Cimetidine
  • Ketoconazole
  • Fluconazole
  • Alcohol (acute)
  • Chloramphenicol
  • Erythromycin
  • Sulfanomide
  • Ciprofloxacine
  • Omeprazole
  • Metronidazole
52
Q

What are the lobes of the brain and their responsibilities?

A
  • Frontal Lobe: thinking, planning, problem solving, emotions, behavioral control, decision making
  • Parietal Lobe: perception, object classification, spelling, knowledge of numbers, visuospatial processing
  • Temporal Lobe: memory, understanding language, facial recognition, hearing, vision, speech, emotion
  • Occipital Lobe: vision, visual processing, color identification
  • Cerebellum: gross and fine motor skills, hand eye coordination, balance
  • Brain Stem: regulates body temperature, heart rate, swallowing, breathing
53
Q

Which part of the brain regulates and receives pain?

A

Prefrontal cortex

54
Q

What is the cerebrum?

A
  • Largest part of the brain
  • Divided into 2 halves
    – Right cerebral hemisphere
    – Left cerebral hemisphere
    – Each hemisphere is divided into 4 major lobes (frontal, temporal, occipital, parietal lobes)
55
Q

Left Hemisphere

A
  • Dominant in most people
  • Logical, analytical side
56
Q

Right Hemisphere

A
  • Controls most left-sided body functions
  • Facial expression, recognition, aspects of musical and visual processing
  • Impairment in this area can affect tasks such as clock drawing
57
Q

What is the corpus callosum?

A
  • Large bundle of white matter that connects the two cerebral hemispheres
    – communication between hemispheres
58
Q

Frontal Lobe

A
  • Largest and most developed
  • Functions:
    –motor function (voluntary motor activity)
    – premotor area (coordinates movement of multiple muscles)
    – association cortex (trigger memory and decision-making)
    – seat of executive functions (working memory, reasoning, planning, prioritizing, sequencing behavior, insight, flexibility, judgement, impulse control, behavioral cueing, intelligence, abstraction)
    – language (Broca’s area): expressive speech
    – personality variables (personality development)
  • Problems in this area can lead to personality changes, emotional, and intellectual changes
59
Q

Temporal Lobe

A
  • Language (Wernicke’s area): receptive speech or language comprehension
  • Primary auditory area
  • Memory
  • Emotion
  • Integration of vision with sensory information
  • Problems in this area can lead to visual or auditory hallucinations, aphasia, and amnesia
60
Q

Occipital Lobe

A
  • Primary visual cortex
  • Integrates vision with other sensory info
  • Problems in this area can lead to visual field defects, blindness, and visual hallucinations
61
Q

Parietal Lobe

A
  • Primary sensory area
  • Taste
  • Reading and writing
  • Problems in this area can lead to sensory-percetual disturbances and agnosia
62
Q

Limbic System

A
  • Essential system for the regulation and modulation of emotions and memory
  • Composed of the hypothalamus, thalamus, hippocampus, and the amygdala
63
Q

Hypothalamus

A

Plays key role in various regulatory functions: appetite, sensations of hunger and thirst, water balance, circadian rhythm, body temperature, libido, hormonal regulation, and satiety

64
Q

Thalamus

A
  • Sensory relay station except for smell
  • Modulates flow of sensory information to prevent overwhelming the cortex
  • Regulates emotions, memory, and related affective behaviors
65
Q

Hippocampus

A

Regulates memory and converts short-term memory into long-term memory, regulates motivation, stress, emotions, and learning

66
Q

Amygdala

A
  • Responsible for mediating mood, fear, emotional memories, aggression, anxiety, anger, and emotions
  • Responsible for connecting sensory smell information with emotions
67
Q

What is the clock drawing test (CDT)?

A
  • Screens for signs of neurological problems such as Alzheimer’s and other dementias
  • Also used to assess executive function and cognitive dysfunction
  • Only requires a minute or two for completion
  • Impairments on the CDT can be associated with damage to the Right Parietal Lobe (Right Hemisphere)
  • Constructional apraxia: an inability or difficulty to build, assemble, or draw objects
    – may be caused by lesions in the parietal lobe following a stroke or it may serve as an indicator for Alzheimer’s disease

PMHNP Boards Review (3 decks)

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