Test 1 - Medications for Mental Health Flashcards
What are the nurse’s role in medication administration for mental health?
- Informed consent must be on file for EACH medication
- Assess for changes in behavior
- assess if causes side effects
- awareness of interactions with other medications
- Pt/Fam education re: meds, compliance, labs
NOT A CURE!!!
WHat is steady state?
an even level of the medication in the blood. A balance between metabolism/elimination and distribution of the medication.
What is half life?
time it takes for blood plasma concentration in blood to be reduced to 50%
Who might need a smaller dose?
elderly pt with decreased kidney and liver function and children.
drugs must be ____ soluble to pass through the blood brain barrier
lipid
Catecholimines are derived from _____
tyrosine
What are some examples of catecholamines?
epinephrine
norepinephrine
dopamine
(all end in ine)
What are the three ways that medication can acts on the body?
block (block receptors…ex decrease dopamine by blocking receptors)
inhibit reuptake (allowing more to pass through synapse)
metabolism (liver, first pass effect, etc)
An agonist ______ activity of neurotransmitter
An antagonist ______ activity of neurotransmitter
Ag - increases
Antag - decreases
P450 System - easy to read nurse’s overview
http://www.drugguide.com/ddo/view/Davis-Drug-Guide/109519/all/The_Cytochrome_P450_System:What_Is_It_and_Why_Should_I_Care
An inducing agent can ______ the rate of another drug’s metabolism by as much as two- to threefold.
increase. increase metabolism = decreased effects of the medication.
Need to increase med that is being metabolized quickly to ensure therapeutic effect.
When an inducing agent is prescribed with another medication, the dosage of the other medication may need to be adjusted since the rate of metabolism is increased and the effect of the medication reduced. This can lead to a therapeutic failure of the medication.
If a medication is taken with an agent that inhibits its metabolism, then the drug level can _____ and possibly result in a harmful or adverse effect.
rise
no metabolism means it is building up in the body
Some substances can increase the production of isoenzymes that metabolize several antipsychotics and antidepressants. This INCREASES the metabolism, thereby decreasing their plasma level. What is a common example?
smoking cigarettes
When grapefruit is consumed with antidepressants or anti-anxiety medication, what happens to the level of medication plasma level?
The plasma level increases. Grapefruit juice inhibits the enzyme that metabolizes the drug. If not metabolized, more drug remains in the plasma.
Neurotransmitters are _____ messengers released from the axons into the synaptic cleft
chemical
Antipsychotic meds work by blocking/partially blocking _______ receptors. This reduces agression, decreases psychotic symptoms.
dopamine
If 80% block of dopamine occurs, what might it cause?
EPS - extrapyramidal symptoms
What are eps symptoms?
- Dystonia
- Drug induced parkinsonism
- Akathisia
- Tardive Dyskinesis
What is dystonia? examples?
Dystonia is an uncontrolled contraction of the muscles. Examples are:
- Torticollis - neck twisting
- Opisthonos - neck bending backward (causing upward facing position)
- oculogyric crisis - eyes are stuck looking back into head. Can only see whites. (SEEN WITH 1st GEN)
What happens in drug induced parkinsonism?
Looks like parkinsons:
- shuffling gate
- cogwheeling.
- pinrolling
- tremors
- mask like face
What is akathisia mistaken for?
anxiety
restless, not able to sit, need to keep moving
Is Tardive Dyskinesis reversible?
What does it look like?
No
lip smacking licking lips grimacing foot tapping rocking
caused by over-abundance of acetylcholine.
What medications can be taken to control EPS (given with the med that can cause EPS)?
Medications with anticholinergic properties (anti cholinergic = against rest and digest…puts you in fight or flight…increases fight or flight properties)
Examples:
TrihexyPHENidyl (Artane)
^DiPHENhydramine (Benedryl)
^BENZTROPINE/Benxtropine Mesylate (Cogentin)
memory trick: TriDiBenzphenhydraminpine
PHEN-PHEN-BENZ
What is NMS?
Neuroleptic Syndrome - severe and life threatening (movie we watched)
What are the signs of NMS?
- rigid muscles
- altered LOC
- fever
- sweating (diaphoresis)
- increased CPK (can lead to kidney failure)
*Sometimes there is no change in vitals or sweating
T or F: Tagamet and St. John’s word can interact with drugs.
True
Tagamet reduces effectiveness of antipsychotics.
Serotonin syndrome can occur with st. John’s wort
Antipsychotic meds are used to treat psychois/schizophrenia and bipolar disorder/manic phase. How does it do this?
decreases agitation, confusion, belligerence, uncooperativeness.
What type of effect do Antipsychotics have at first? After 2-8 weeks?
at first sedative
after 2-8 weeks, works on hallucinations/delusions
What is a route to administer medication to avoid the first pass effect?
IM, IV
Do older 1st generation antipsychotics treat negative symptoms, positive symptoms or both?
1ST GEN WORKS ON DOPAMINE ONLY!
positive symptoms which include: Hallucinations, delusions, agitation.
Also includes:
- disordered thoughts, perceptions and behavior (the visible signs)
- abnormal/bizarre behavior
- de-personalization
- Feelings or behaviors that are usually not present, such as: Believing that what other people are saying is not true (delusions) - Hearing, seeing, tasting, feeling, or smelling things that others do not experience (hallucinations)
- Disorganized speech and behavior
“I am positive that you have schizophrenia by what I see”
To remember: 1st we get rid of what we see you going through. (1st gen)
What is the risk with older antipsychotics?
1ST GEN WORKS ON DOPAMINE ONLY!
- more potential to cause EPS
- Thorazine should not be given to elderly due to orthostatic hypotension
Why should a patient taking phenothiazines (1st gen antipsychotics) avoid the sun?
1ST GEN WORKS ON DOPAMINE ONLY!
it can cause a skin rash (A PURPLE BLUE RASH).
What are examples of phenothiazines (1st gen antipsychotics)?
1ST GEN WORKS ON DOPAMINE ONLY!
^ CHLORPROMAZINE, HALOPERIDOL (
Trifluoperazine, Thiothixene, fluphenazine, chlorpromazine, loxapine, perphenazine, prochlorperazine, haloperidol (haldol), and molindone (NOT LEGAL IN US).
Notice most end in the sound ZEEN
Remember: First (first generation), people used to read papers and magaZINES. Now (2nd generation), we carry tablets or nooks.
T or F: deconate/depot is long acting
true.
Prolixin, haldol, risperdal, zyprexa.
Given IM - lasts 2-4 weeks
Best IM, oral is hard to get patient to comply with ABC’s and end up with EPS
Do newer 2nd generation antipsychotics work on negative symptoms, positive symptoms or both for schizophrenia?
both.
You know positive symptoms.
What are negative symptoms?
the opposite of positive/manic - who are agitated/”wound up” seeing thing, over the top…negative is flat, blunted, no energy, no speech/alogia, low interest, autism, withdrawn, avolition aka low motivation, pacing/rocking, posturing, deteriorated.
How do 2nd generation antipsychotics work?
They have an affinity for dopamine (D2) and serotonin (5HT) receptors.
They decrease dopamine - slowing the manic/positive. In some instances the dopamine in the mesocortical system is increased by antagonizing serotonin.
They increase serotonin - the mood balancer/ brings up the negative. DECREASES SUICIDE RISK.
If 2nd gen antipsychotic is taken with ETOH (alcohol) it becomes?
toxic
ETOH = contraindicated
T or F: 2nd generation is also called atypical
true
__ ___ __ is reduced with atypicals
EPS
A common contraindication for ANY med is?
liver insufficiency
typically renal insufficiency
2nd gen antipsychotic meds are contraindicated with what two meds? why?
SSRIs - increases risk of EPS
Beta Blockers - hypotension
2nd generation antipsychotics have names ending in APINE and IDONE
^CLOZAPINE ^OLANZAPINE Quetiapine Asenapine (Loxapine is 1st gen- only one that doesn't fit in).
^RISPERIDONE zipraidone lursidone iloperidone paliperidone
What is the most serious side effect of clozapine (clozaril)?
agranulocytosis (decreases WBCs) - deadly
Must do CBC/wbc/neutrophil count weekly.
RESERVED FOR PT WHO DOES NOT RESPOND TO OTHER ANTIPSYCHOTICS
Olanazapine and Quetiapine cause weight gain
Memory: Olana and Quetia are big girls.
olana - used for mania
Risperidone, quetiapine, and iloperidone have a risk for what?
hypotension
RisQUe-i-Lo
RIsk of low BP
remember where there is hypotension there is a likelihood of dizziness
Zipraidone causes several issues including constipation, GI discomfort and sometimes sleepiness. What is the heart related issue?
QT interval problems.
Remember: ZIP, Zipper on your hoodie runs down the center –>From brain that is insomnia down past your heart to your tummy.
T or F: Thorazine is the preferred antipsychotic for the elderly
FALSE! Don’t give it!
Lurasidone has ablack box warning for elderly, CV & Infection
Which med is used for PTSD flashbacks?
paliperidone
It can cause change in HR rhythm, heat/sensitivity
Memory: Palip - palpitations from PTSD - can change heart rhythm….
Asenapine should not be touched! It should not be removed from package until ready to use. Why do we avoid food or fluids for ten minutes?
This medication is given sublingual. It may cause numbness of the tongue (probably a good reason not to touch it!)
The only third generation antipsychotic med is thought to block DA where it is too high and moderate it in other areas (a DA stabilizer) is called?
^ARIPIPRAZOLE (Abilify)
Rip pip hurray! 3rd generation is here to save the day!
T or F: All antidepressants have a black box warning for increased risk of suicide for children and adolescents.
True
What are symptoms of depression?
SIGECAPS+M
S- Sleep changes (not enough/too much) I- Interest is low (anadonia) G- Guilty feelings E- Energy is low C- Concentration ability is decreased A- Appetite decreased P- Psychmotor depression/retardation/agitation S- Suicidal thoughts
+M- Mood is depressed
How do antidepressants work?
Act on serotonin (5HT) and sometimes NE by decreasing reuptake and increasing availability in the synapse. More serotonin = more joy in ya life.
What are general nursing considerations for antidepressants?
- Takes several weeks to achieve therapeutic blood level. Educate patient on this!
- May cause anticholinergic effects (against rest and digest)
- My cause orthostatic hypotension
4.
What is the difference between endogenous vs exogenous depression?
Exogenous - caused OUTSIDE of the person; social, environmental.
endogenous - comes from within the person; clinical depression
What test can we use to diagnose if depression is endogenous vs exogenous?
DST - Dexamethasone suppression test.
Give tabe of DST–>Draw blood–>When cortisol level is above baseline, person is positive for clinical depression (endogenous)
What are the three main groups of antidepressants?
TCAs - tricyclics
SSRIs - selective serotonin reuptake inhibitors
MAOIs - Monoamine oxidase inhibitors
How do tricyclics antidepressants work? Why are they dangerous?
block reuptake of serotonin (5HT) and NE
dangerous because they can easily be used to overdose. patient should not be given more than 4 days worth. Do not give to suicidal patient!!!
What are common side effects of TCAs?
- Photophobia (due to pupil dilation)
- EKG needed due to possibly cardiac changes (do not give to cardiac d/o patients)
- Alcohol + TCA = cardiotoxic
- Do not combine with ssri
- anticholinergic effects enhanced with antipsychotic (includes slowing of heart)
What are the drug names for TCAs?
End in TRIPTYLINE and PRAMINE with the exception of amoxapine/doxepin
Amitriptyline
nortriptyline
protriptyline
Imipramine
desipramine
clomipramine
trimipramine
Amoxapine rhymes with doxepin - pin down depression and X it out
How do MAOI’s work?
interfere with enzyme that breaks down neurotransmitter which allows an increase of dopamine and tyramine.
How long should we wait between starting a new antidepressant?
2 weeks
MAOIs have many side effects, list them.
- Orthostatic hypotension, palpitations and heart attack
- Insomnia
- Sexual dysfunction
- drug and dietary interactions
How do MAOIs work in the body?
MAOIs inhibit MAOs = increase of amines at synaptic cleft.
MAOs break down NE, DA and 5HT and Tyramine. MAOI inhibits, allowing build up of these in synaptic cleft. Leads to increased stimulation in post synapse, thereby relieving depression.
Why should a person taking an MAOI avoid foods like pickled/fermented salmon, cheese, wine/beer, sauerkraut, soy sauce, liver, yogurt, sardines, pizza?
These foods contain tyramine and can cause hypertensive crisis.
Signs of impending hypertensive crisis include:
headache, stiff neck, nausea and vomiting and increased BP.
Why should a person taking an MAOI avoid stimulants, caffeine, opiates, antihistamines, antihypertensices, beta 2 agonists, decongestants, nasal sprays, acetaminophen, pseudophed, and chocolate?
Combined it can cause an increase in BP.
avoid cough medicine and anesthetics as well.
What happens if you take demerol with an MAOi?
Serotonin Syndrome
There’s no pattern to naming of MAOIs…
Isocarboxazid
^PHENELZINE
^TRANYLCYPROMINE
Moclamine
IPTM
How do SSRIs work?
The are selective serotonin reuptake inhibitors. They inhibit reuptake allowing a build up of serotonin in the synapse. More available–>more delivered.
What types of issues does SSRI treat?
- Decreases risk of depression and suicide
- Treats symptoms of OCD, PTSD, EDO, Enuresis and GAD.
Why is SSRI preferred?
main reason is because these are safer, not potentially lethal like others. also lower risk for birth defects.
When discontinuing an ssri, can you stop abruptly?
no. taper. Withdrawal will occur.
Why should you avoid MAOi + the SSRI Fluoxetine (Prozac)?
fatal interaction
What are side effects of SSRI?
This medication helps bring you “up”
You may feel agitated, stimulated, nauseous. Weight loss (too up to care about food?).
Increased risk for seizures. Do not give to someone who has seizure DO.
SSRIs also have no naming convention that determines their group…
^FLUOXETINE (Prozac;serafem for kids) ^PAROXETINE (sexual side effects - paralyzed genital) ^SERTRALINE (Zoloft) Fluvoxamine Vilazodone Citalopram (celexa) Escitalopram
Endings:
- xetine
- traline
- xamine
- odone
Why should you avoid St, John’s Wort when taking SSRI?
St. John’s wort increases serotonin levels. Combining can lead to death by serotonin syndrome
What are signs and symptoms of serotonin syndrome?
Note: this can happen due to incomplete 2 week period between MAOI and SSRI.
Symptoms may include:
- restlessness
- unstable VS
- increased BP
- diarrhea
- seizures
- hyperthermia
- myoclonus (spasmodic jerky contraction of groups of muscles)
- loss of consciousness
- collapse of CV system
leads to death
What is an SNRI?
selective serotonin AND norepinephrine reuptake inhibitor
examples:
venlafaxine
desvenlafaxine
duloxetine
What is an NRI?
norepinephrine reuptake inhibitor
reboxetine
What is an NDRIs?
norepinephrine and dopamine reuptake inhibitor
do not give to edo
^BURPROPION (Wellbutrin) leads to smoking cessation
Heterocyclics?
mirtazpine
What happens during manic switch?
It can be a side effect of bipolar given antidepressant for depressive symptoms if Dr fails to find out about mania. Never assume depression.
S&S: sleeplessness, agitation, loss of inhibitions and delusional thinking. (Mania = manic symptoms)
Antimanic agents decrease manie by….
stabilizing mood
Why must we do an EKG (ECG) before administering LIthium (and antimanic drug)?
^LITHIUM is thought to work by stabilizing membrane potential.
Lithium is a salt and is eliminated by the kidneys without being metabolized by the liver. The kidney cannot tell the different between sodium and lithium salt. If the body releases too much sodium, it will hold onto lithium and become toxic.
Salt greatly affects heart rate/rhythm, etc.
Note creatine serum level before starting.
Make sure patient has good salt and water intake.
T or F: ibruprofen has no effect on lithium levels
false, ibuprofen will increase lithium levels.
Do not give lithium with ibuprofen, fluoxetine, ACEi, diuretics or NSAIDs for this reason.
What are side effects of lithium?
Side effects:
- nausea
- polyuria/polydipsia (salt effects water balance in body) - don’t give to urinary retention pt or renal disease.
- fine hand tremor
- weight gain (water balance per salt)
- Dry mouth (again salt - water)
signs of lithium toxicity?
Has a VERY narrow therapeutic window. Watch closely! Check blood levels before administering.
>1.5 is toxic
**The range should be 1-1.5*
signs are:
vomiting, diarrhea (body trying to expel extra salts through water loss)
lethargy - if you are NV, you wont feel like doing anything
ataxia/loss of coordination, tremor, muscle weakness, seizures (salt/water loss - muscles will be effected)
What are the health issues that may arise with long term lithium use?
Thyroid and kidney issues - must complete labs to watch condition of organs including TSH,BUN, Urinalysis, Creatinine.
Acne, psoriasis, leukocytosis (fixed with DC of lithium), hyperthyroidism
What is GABA?
GABA’s natural function is to reduce the activity of the neurons to which it binds. Some researchers believe that one of the purposes that GABA serves is to control the fear or anxiety experienced when neurons are overexcited.
Anticonvulsants can be used as an antimanic med in psychiatry to ?
stabilize mood
How do anticonvulsants work to stabilize mood?
increase GABA which slows neuron firing thereby reducing anxiety/fear.
examples: ^CARBAMAZEPINE (DO NOT TAKE WITH LITHIUM-dual toxic) oxcarbazepine ^CLONAZEPAM gabapentin ^TOPIRAMATE lamotrigine (lamictal)
How must you discontinue an anticonvulsant?
taper. if you stop abruptly the patient will have a seizure
T orF: 2nd and 3rd generation antipsychotics are approved to be used as mood stabilizers
true
Valproics, a group of anticonvulsants,have some serious side effects including diplopia (double vision), dizziness, confusion, anxiety, alopecia and jaundice. What are the meds in this group?
depakote, depakene, VALPROATE
A patient took lamotrigine (lamictal) and developed a rash which is the first sign of _____ _____ ____.
steven johnson syndrome
FATAL!
What do anxiolytics do?
Decrease anxiety
ANXIO LYTIC
Lyse Anxiety
T or F: There is low likelihood of dependency to anxiolytics.
False.
Can lead to both physical and mental dependence, addiction, and tolerance (requiring more and more to get the same effect).
Besides anxiety, what are other uses for anxiolytics?
- induce sleep
- treat wd/detox
- decrease NV from chemo
- decrease movement disorders (solved my vertigo)
It does these things by supressing CNS. Therefore, if you go ever so far in that direction your side effects are going to be sedation (past sleep), drowsiness/confusion (beyond relaxed), N/V & Dizziness, hypotension.
Respiratory depression = toxicity
Benzodiazepines are a group of anxiolytics. What are the med names?
END IN AM
^ALPRAZOLAM ^LORAZEPAM ^DIAZEPAM Clonazepam Chlodi-AZE-poxide
T or F: Benzodiazepines ending in “PAM” are recommended for elderly
False. They depress CNS so we should not give them to the elderly, especially diazepam (Valium). It increases confusion and memory impairment.
______ can be used as sort of an antidote when given via IV to pull a patient out of sedation due to an OD on benzos and ETOH
Flumaxenil (Flu right out of that sedation)
If someone has a history of addiction, which anxiolytic can we give (nonbenzo)?
^BUSPIRONE (Buspar)
less potential for dependency and is good for patients with dual diagnosis or recovering substance abuse dependent. Less sedating.
Unlike Benzos, this one works after 2-4 weeks.
What is the RAS?
Reticular Activating System - responsible for arousal, wakefulness and sleep regulation.
How do hypnotics (sedatives) work?
- sedates in low doses, induces sleep in large doses
- potentiates the effects of GABA (I imagine snoop saying gaba gaba muthatrucka - in his stoned voice)
Since hypnotics/sedatives cause sleepiness, what might the side effects be?
lapses in memory, drowsiness, ataxia, dizziness, mood swings (just picture someone way too high on this drug and having these issues).
Toxic effects can slow things down so much you stop breathing (respiratory depression).
What are some things we need to avoid when dealing with hypnotics?
Abrupt DC - taper!! if you do not wd might happen and person can become depressed/paranoid/delirious or have seizures!
Avoid ETOH, addiction pt, CNS depressant (layering of similar effects), cardiac disease.
Non Barbituate Hypnotic?
Barbituate Hypnotic?
NonBenzo hypnotic?
Non Barbituate Hypnotic - dalmane, temazepam (Restoril)
Barbituate Hypnotic - secobarbital, pentobarbital
NonBenzo hypnotic - zolpidem, zaleplon
What is acetylcholinesterase inhibitor used to treat?
How does it work?
treatment of dementia which is thought to be caused by an imbalance between DA and ACh.
Acetylcholinesterase is an enzyme that basically destroys ACh in the synaptic cleft. If we inhibit this enzyme, we INDIRECTLY allow ACh to build up.
What are the ACh inhibitor medications used to treat dementia/alzheimers?
Donepezil (Uncle Don forgets his pill) Tacrine Memantine Galantamine Revastigmine
What are stimulants used for?
improve attention
decrease distractibility
hyperactivity
impulsivity
Treat ADHD which is characterized by hyperactive, inattention and impulsive behavior.
Stimulants cause catecholamines, particularly DA to be released from presynapse and inhibit reuptake in presynapse. As a result, what happens?
several brain regions are stimulated, especially RAS.
What time should you take a stimulants?
Morning preferred. Never after 4pm.
Wakes you up! JOLT!!!
Side fx: anorexia, wt loss, insomnia, HA/Tachycardia/TIC DO.
Examples of stimulants….
Methylphenidate (Ritalin) Detramphetamine (Adderal) Pemoline Lisdexamfetamine Guanfacine
