Scientific Foundation & Advanced Practice 2 Flashcards
What makes an antipsychotic “atypical”?
The mechanism of action that makes antipsychotics “atypical” is related to the serotonin (5HT2A) receptor antagonism.
Dopamine Pathways
- Explains the therapeutic effects and the side effects of the atypical antipsychotics
- Mesolimbic Pathway
- Mesocortical Pathway
- Nigrostriatal Pathway
- Tuberoinfundibular Pathway
Mesolimbic Pathway
- Hyperactivity of dopamine mediates positive psychotic symptoms
- Antagonism of D2 receptors treats positive psychotic symptoms (decreases positive symptoms)
Mesocortical Pathway
Decreased dopamine is responsible for the negative and depressive symptoms of schizophrenia
Nigrostriatal Pathway
- Mediates motor movements
- Dopamine blockade can lead to increased acetylcholine levels (increased salivation, lacrimation, blurry vision)
- Blockade of D2 can lead to EPS (dystonia, parkinsonian symptoms, akathisia)
- Long acting D2 blockade can lead to tardive dyskinesia
Tuberoinfundibular Pathway
-
Blockade of D2 in this pathway can lead to increased prolactin levels
– hyperprolactinemia manifesting as amenorrhea, galactorrhea (risperdone), sexual dysfunction, gynecomastia - Long term hyperprolactinemia can be associated with osteoporosis
What is extrapyramidal side effects (EPSE)?
- It is caused by D2 receptor antagonism (dopamine receptors are blocked, ACh increases causing EPSE).
- Dopamine blockade in nigostriatal pathway.
What are the common EPSE?
- Akathisia
- Akinesia
- Dystonia
- Pseudo-Parkinson’s
- Tardive Dyskinesia
Acute Dystonia
- Muscle spasm
- Spasticity of muscle group (back or neck muscles)
- Stiff neck, painful
- Subjectively painful
- Facial grimacing
- Laryngeal spasms
-
Oculogyric crisis can lead to permanent damage.
–on physical exam, prolonged involuntary upward deviation of eyes bilaterally - Mistaken for agitation or unusual, stereotypic movements characteristic of schizophrenia
How do you treat Acute Dystonia?
Cogentin (Benztropine)
Akathisia
- Motor restlessness
- Inability to remain still
- Rocking, pacing, or constant motion of unilateral limb
- Common used rating scale: Barnes Akathisia Rating Scale and Extrapyramidal Symptom Rating Scale
- Mistaken for increasing anxiety
What is the treatment for Akathisia?
- Betablocker (Propranolol)
–can cause bronchospasm so contraindicated in patients taking bronchodilators like albuterol - Benztropine
- Benzodiazepine
Akinesia
- Absence of movement
- Difficulty initiating motion
- Subjective feeling of lack of motivation to move
- Mistaken for laziness or lack of interest
How do you treat Akinesia?
Cogentin (Benztropine)
Pseudo-Parkinson’s
- Stooped posture
- Shuffling gait
- Motor slowing
- Mask-like facial expression
- Pill rolling
- Tremors
- Muscle rigidity
- Mask-like facial expression often confused as affective blunting or flattening
How to treat Pseudo-Parkinson’s
Cogentin (Benztropine)
Tardive Dyskinesia
- Involuntary abnormal muscle movement of the mouth, tongue, face, and jaw that may progress to the limbs
- Can be irreversible
- Lip smacking and sucking
- Chewing motion
- Facial dyskinesia
- Can take up to 1-2 years to occur
- Can occur as an acute process at initiation of medication or as a chronic condition at any time
- The AIMS (Abnormal Involuntary Movement Scale) aids in the early detection of TD
- Tx: reduce the current dose or change to an atypical agent
- Deutetrabenzene (Austedo) and Valbenazine (Ingrezza) are FDA approved to treat TD
- Cogentin should NOT be used bc it can worsen symptoms
- Reglan (Metoclopramide) can cause EPS like TD and pseudoparkinson’s
What is pharmacokinetics?
Study of what the body does to drugs including absorption, distribution, metabolism, and excretion
What is absorption?
Method and rate at which drugs leave the site of administration.
– Oral medications: occurs in the small intestine and then in the liver
What is distribution?
Occurs after the drug leaves the systemic circulation and enters the interstitial and cells
– Drugs are redistributed in organs according to their fat and protein content
– Most psychotropic drugs are lipophilic and highly protein bound. Only the unbound (free) portion of the drug is active. – People with low protein (albumin) levels (malnutrition, wasting, or aging) can potentially experience toxicity from an increased amount of free drug.
What is metabolism?
- Process by which the drug becomes chemically altered in the body.
- First pass metabolism: Process by which the drug is metabolized by cytochrome P450 enzymes in the intestines and liver prior to going to the systemic circulation
What is elimination?
Process by which the drug is removed from the body.
What is half-life?
Time needed to clear 50% of the drug from the plasma.
– determines the dosing interval and the length of time to reach a steady state
What is a steady state?
Point at which the amount of drug eliminated between doses is approximately equal to the dose administered.
– it takes approximately 5 half lives to achieve a steady state and 5 half lives to completely eliminate a drug
How can liver disease affect pharmacokinetics?
Liver disease will affect liver enzyme activity and first pass metabolism that results in toxic plasma drug levels
How can kidney disease affect pharmacokinetics?
- Kidney disease or drugs that reduce renal clearance (NSAIDs) may increase serum concentration of drugs that are excreted by the kidneys (Lithium).
– Older adults are more sensitive to psychotropic drugs because of their decreased intracellular water, protein binding, low muscle mass, decreased metabolism, and increased body fat concentration
– body fat concentration is the only thing that increases because of less exercise
What is pharmacodynamics?
- Study of what drugs do to the body
- Target sites for drug actions include receptor, ion channels, enzymes, and carrier proteins
– Agonist effect
– Inverse agonist effect
– Partial agonist effect
– Antagonist effect - Example: Someone takes medication and it causes nausea, diarrhea, etc.
Agonist
Drug binds to receptors and activates a biological response
– opens ion channels
Inverse agonist
- Drug causes the opposite effect of agonist
- Binds to same receptor
- Cause receptor to close ion channel by activating biological response
Partial agonist
Drug does not fully activate the receptors
Antagonist
Drug binds to the receptor but does not activate a biological response
Potency
Relative dose required to achieve certain effects
Tolerance
The process of becoming less responsive to a particular drug over time
Lithium metabolization
Lithium is not metabolized.
It is excreted unchanged in urine.
What medications induce depression?
- Beta blockers
- Steroids
- Interferon
- Isotretinoin (Accutane) – can also cause birth defects
- Some retroviral drugs
- Antineoplastic drugs
- Benzodiazepines
- Progesterone
What medications induce mania?
- Steroids
- Disulfiram (Antabuse)
- Isoniazid (INH)
- Antidepressants in persons with bipolar disorder
- Prednisone/Flonase
Neuroleptic Malignant Syndrome (NMS)
-
Caused by antipsychotics
– most common with typical but can happen with atypical antipsychotics - Can occur at any point during treatment
- Extreme muscular rigidity
- Mutism
- Hyperthermia
- Tachycardia
- Diaphoresis
- Altered level of consciousness
What are the abnormal labs to look for in NMS?
- Elevated creatine phosphokinase (CPK) – muscle contraction/muscle destruction
- Myoglobinuria (Rhabdomyolysis)
- Elevated WBCs (Leukocytosis)
- Elevated liver function tests (LFTs)
What is the treatment for NMS?
- Seek immediate treatment for medical care
- DC the offending agent (antipsychotics)
- Administer Bromocriptine (Parlodel) – direct acting dopamine receptor agonist which decrease dopamine blockade
- AND/OR administer Dantrolene – muscle relaxant for muscle rigidity
Serotonin Syndrome
- Caused by antidepressants
- Combo of MAOI with a serotonergic agent is contraindicated because it can cause SS
What are symptoms of Serotonin Syndrome?
- Hyperreflexia
- Myoclonic jerks
- Agitation, restlessness
- Rapid HR and elevated BP
- Headache
- Sweating, shivering, and goose bumps
- Loss of coordination
- Confusion, fever, seizures, unconsciousness
What is the treatment of Serotonin Syndrome?
- D/C offending agent
- Supportive treatments
- Cyproheptadine
What are drug combinations that can cause Serotonin Syndrome?
- SSRI/TCA/MAOI/SNRI
- SSRIs & MAOIs
– MAOIs should not be taken in combo with SSRIs or anytime before 5 half lives after discontinuing a SSRI - Placing a patient on more than one SSRI
- Drug and herbal interactions
- SSRIs and St. John’s wort
- Ex: When switching from a SSRI to MAOI – wait 2 weeks
- When switching from Fluoxetine (Prozac) to MAOI – wait 5-6 weeks
- When switching from MAOI to Prozac – wait 2 weeks
- Note: a washout period of 5 half lives between cessation of previous drug and the introduction of a new drug is the safest switching strategy from the point of view of drug interaction
Serotonin Discontinuation Syndrome
- Discontinue SSRIs slowly
- Don’t D/C SSRI/TCA/MAOIs abruptly
- SSRI/SNRI Discontinuation Syndrome in Adults
– F.I.N.I.S.H.
Serotonin Discontinuation Syndrome: FINISH
- Flu-like symptoms: fatigue, muscle aches, headache, diarrhea
- Insomnia: vivid or disturbing dreams
- Nausea
- Imbalance: gait instability, dizziness, lightheadedness, vertigo
- Sensory disturbance: paresthesia, “electric shock” sensation, visual disturbance
- Hyperarousal: anxiety, agitation
- Onset: 24-72 hours + Resolution: 1-14 days
- Incidence: 20-40% (who have been treated at least 6 weeks)
Delusion
A false belief firmly maintained despite evidence to the contrary
Referential Thinking
Patients may, for example, believe that certain news bulletins have a direct reference to them, that music played on the radio is played for them, or that car license plates have a meaning relevant to them
Components of a Mental Status Exam (MSE)
- Appearance
- Behavior
- Speech
- Mood
- Affect
- Thought Process
- Thought Content
Thought Process
- Assess the organization of the patient’s thoughts and ideas
- Normal: logical, linear, coherent, and goal oriented
- Abnormal: associations are not clear, organized, or coherent
- Tangentiality: move from thought to thought that may or may not relate in some way but never get to the point
- Circumstantial: Provide unnecessary detail but eventually get to the point
Thought Content
- Refers to the themes that occupy the patient’s thoughts and perceptual disturbances
– suicidal ideations, homicidal ideations (SI or HI), plan, visual hallucinations, auditory hallucinations
Mini Mental Status Examination (MMSE)
- Folstein Scale
- A screening tool that provides a quantitative evaluation of cognitive impairment and records cognitive changes over time in adults
- The MMSE can screen for dementia (severity) and measure progression over time
Components of the MMSE
- Concentration/attention/calculation
- Orientation
- Registration/ability to learn new material
- Recall (memory)
- Fund of knowledge
Concentration/attention/calculation (MMSE)
I would like for you to count backwards from 100 by 7s or do serial 7s, or subtract 7 from 100, or list all 12 months in reverse order.
Orientation (MMSE)
What is the year? Season? Date? Day? Month? Where are we (state) (country) (town) (hospital) (floor)?
Registration/ability to learn new material (MMSE)
Say the names of three unrelated objects clearly and slowly, allowing approximately one second for each. After you have said all three, ask the patient to repeat them.
Recall (memory) (MMSE)
Ask the patient if he or she can recall the three words you previously asked him or her to remember (Repeat three objects after 5 minutes).
Fund of knowledge (MMSE)
Who is the president/governor?
What are other instruments for assessing level of cognitive impairments?
- Mini-Mental State Examination (MMSE)
– Not in public domain - Montreal Cognitive Assessment (MoCA)
– Public domain - Mini-Cog
– Public domain - St. Louis University Mental Status Examination (SLUMS)
– Public domain
Suicide Assessment
- Pay significant attention to positive assessments for suicidality
- Always assume client is serious when he or she vocalizes suicidal thoughts
- Consider hospitalization
- Consider mobilizing available social resources
- Identify current stressors that may be contributing to crisis
Risk factors for suicide
- Ages 45 or older if male
- Ages 55 or older if female
- Divorced, single, or separated
- White
- Living alone
- Psychiatric disorder
- Physical illness
- Substance abuse
- Previous suicide attempt (highest risk factor)
- Family history of suicide
- Recent loss
- Male gender
What is the BBW for antidepressants in children?
- All antidepressants indicated for children, adolescents, and young adults (24) carry a BBW about an increase in suicidal thoughts.
- Monitor closely for suicidal thoughts, behavior, agitation, and aggression in children taking antidepressants.
Therapeutic Relationships
- Assumes the client and nurse enter into a mutual, interactive, interpersonal relationship specifically to focus on the identified needs of the client.
- Focus on the client’s needs, and are goal-directed, theory-based, and open to supervision.
- There are three phases of the therapeutic relationship
What are the characteristics of a therapeutic relationship?
- Genuineness
- Acceptance
- Nonjudgment
- Authenticity
- Empathy
- Respect
- Professional boundaries
What are the three phases of a therapeutic relationship?
- Introduction (Orientation)
- Working (Identification and Exploitation)
- Termination (Resolution)
What are the two key concepts in the nurse-client relationship?
- Transference
- Countertransference
Transference
Displacement of feelings for significant people in the client’s past onto the PMHNP in the present relationship.
Countertransference
The nurse’s emotional reaction to the client based on her or his past experiences
Signs of countertransference in the PMHNP
- Intense emotional reaction, positive or negative, on first contact with client
- Recurrent anxiety or uneasiness while dealing with the client
- Uncharacteristic carelessness in interaction and follow-up with client
- Difficult empathizing
- Resistance to others treating or interacting with the client
- Preoccupation with or dreaming about the client
- Frequently running overtime or cutting time short with client
- Depression or other strong emotions during or after interaction with client
- Feedback from others over involvement with client
