TEST 2 Flashcards
Clozaril - Side effects, nursing assessment, labs associated with Clozaril
SIDE EFFECTS- AGRANULOCYTOSIS (Extreme drop in WBC); Leukopenia NMS, seizures, Myocarditis
NURSING ASSESSMENT- Monitor for signs of myocarditis, institute seizure precautions for pt with hx of seizures
LABS - A baseline WBC count and absolute neutrophil count (ANC) must be taken before initiation of treatment with clozapine and weekly for the first 6 months of treatment.
How often should serum lithium levels be monitored during the initiation of LITHIUM therapy?
Twice weekly
Pt education regarding LITHIUM toxicity?
- Decreases sodium levels will make more receptor sites available to lithium and increase the risk for lithium toxicity.
- significant increases in dietary sodium intake may reduce the effectiveness of lithium because sodium will bind at more receptor sites and lithium will be excreted.
- Other drugs that increase serum sodium levels also have an impact on lithium levels.
Pts using LITHIUM should report signs of hyponatremia which include …….? and Drink _____-_____ ml/day?
- Episodes of nausea, vomiting, headache, muscle weakness, confusion, seizures, since these may be signs of hyponatremia.
- 2,000 - 3,000 ml/day
When monitoring serum levels of LITHIUM , when should blood levels be drawn ?
- Blood levels should be drawn 12 hours after the last dose.
What are signs and symptoms of lithium toxicity?
-vomiting, diarrhea, slurred speech, decreased
coordination, drowsiness, muscle weakness, or twitching).
Medications used for treatment of EPS
Anticholinergic agents such as
- Benztropine (Cogentin)
Side effects of DONEPEZIL?
-Insomnia, dizziness, gastrointestinal upset, fatigue, and headache
Mechanism of action? Indications for Donepezil?
Action: Anticholinesterase drugs block the action of the enzyme acetylcholinesterase preventing the breakdown of the neurotransmitter acetylcholine.
- Alzheimer’s
What are the symptoms of the EPS side effect PSEUDOPARKINSONISM?
—tremor, shuffling gait, drooling, rigidity—may appear 1 to 5 days following initiation of antipsychotic medication. This side effect occurs most often in women, the elderly, and dehydrated clients.
What are the symptoms of the EPS side effect AKATHISIA? (Type of EPS). Which sex is most often affected?
- Continuous restlessness and fidgeting, or akathisia,
- Occurs most often in women and may manifest 50 to 60 days after therapy begins.
What are the symptoms of the EPS side effect DYSTONIA? Who is typically affected? Why is this a medical emergency?
—involuntary muscle spasms in the face, arms, legs, and neck
—occurs most often in men and those younger than age 25.
- Dystonia should be treated as an emergency situation because laryngospasm follows these symptoms and can be fatal.
What are the symptoms of the EPS side effect OCULOGYRIC CRISIS?
Uncontrolled rolling back of the eyes, or oculogyric crisis, is a symptom of acute dystonia and can be mistaken for seizure activity. As with other symptoms of acute dystonia, this side effect should be treated as a medical emergency.
What are the symptoms of the EPS side effect TARDIVE DYSKINESIA?
- bizarre face and tongue movements, stiff neck, and difficulty swallowing.
- *Symptoms are potentially irreversible.
- earliest signs of tardive dyskinesia (usually vermiform movements of the tongue)
Side effects of TRICYCLICS?
- POSTURAL HYPOTENSION
- Sexual dysfunction
- Sedation
- weight gain
- Dry mouth, constipation, blurred vision, -
urinary retention - tachycardia (α1)
SERTRALINE (zoloft)
Classifications?
Indications?
- Antidepressant
- SSRI
- Depression, Panic disorder, OCD, PTSD, PMDD
Assessment of a patient who took an extra dose of an SSRI?
Assess for serotonin syndrome which may include the following Symptoms
- diarrhea, nausea, vomiting,
- tremors, headache, agitation,
- restlessness, diaphoresis,
- Severe cases - muscle rigidity, high fever, irregular heartbeat, seizures, unconsciousness and death, if left untreated.
Treatment for TARDIVE DYSKINESIA?
- valbenazine (Ingrezza)
- Drug is typically discontinued
- Symptoms are potentially irreversible
Lithium levels for Acute Mania/Maintenance levels?
For acute mania: 1.0 to 1.5 mEq/L
For maintenance: 0.6 to 1.2 mEq/L
What is the therapeutic/Pharmacologic class for Donepezil, Galantamine, Rivastigmine (they are all in the same class)?
- Anti-Alzheimer agent
- Cholinergic; cholinesteraseinhibitor
How does Donepezil, Galantamine, Rivastigmine (same therapeutic/pharm class)
Improves cholinergic function, which is lacking in clients with Alzheimer’s, by inhibiting acetylcholinesterase, thus prolonging the effect of acetylcholine.
What are the cholinergic side effects associated with Donepezil, Galantamine, Rivastigmine ? (remember SLUDGE)
S salivation L lacrimation U urination D diarrhea G GI distress E emesis
Most common side effects of Most common side effects of Donepezil, Galantamine, Rivastigmine ?
Most common side effects include dizziness, gastrointestinal upset, fatigue, and headache.
What does a person with LITHIUM intoxication look like?
Looks like a person who is inebriated, with ataxia, slurred speech and drowsiness
Side effects of LITHIUM ? What should patients report immediately?
- Arrhythmias, EKG changes
- Palpitations and SOB
Which SSRI has been approved to treat depression in children aged 8 and older?
- Fluoxetine (prozac)
The combination of Fluoxetine and __________ is approved for treatment of bipolar disorder?
- Olanzapine
Indications for Fluoxetine?
- Depression
- General Anxiety
- Eating disorders
- Panic disorders
- PMDD
- OCD
Client outcomes diagnosed with bipolar disorder: manic episode ?
- Exhibits no evidence of physical injury
- Has not harmed self or others
- Is no longer exhibiting signs of physical agitation
- Eats a well-balanced diet with snacks to prevent weight loss and maintain nutritional status
- Verbalizes an accurate interpreta
Patient education regarding tricyclics?
- Best taken at bedtime b/c sedating effects
- May cause Orthostatic Hypotension
- Use sunscreen and protective clothing
What Anticholinergic effects should a person using Tricyclic Antidepressants look for?
- Hot as a hare
- Dry as a bone
- Red as a beet
- Mad as a hatter
- blind as a bat
Treatments for manic episodes besides LITHIUM?
- ECT has been known to be as effective as Lithium
- Quetiapine
- Olanzapine
- Valproic Acid
Bipolar I disorder
- Client is or has experienced a manic episode or has a history of one or more manic episodes.
- The client may also have experienced episodes of depression.
- This diagnosis is further specified by the current or most recent behavioral episode experienced. The specifier might be single manic episode or current episode manic, hypomanic, mixed, or depressed. Psychotic or catatonic features may also be present.
Bipolar II Disorder
- characterized by recurrent bouts of major depression with episodic occurrence of hypomania.
- may present with symptoms (or history) of depression or hypomania.
- client may never experience full manic episode
Cyclothymic Disorder
** essential feature of cyclothymic disorder is a chronic mood disturbance of at least 2 years’ duration
- Numerous episodes of hypomania and depressed mood of insufficient severity to meet the criteria for either BP1 or BP2
- The individual is never without the symptoms for more than 2 months.
Diagnostic Criteria for Manic Episode
- A distinct period of abnormally and persistently elevated, expansive, or irritable mood, and abnormally and persistently increased goal-directed activity or energy, lasting at least 1 week and present most of the day, nearly every day (or any duration if hospitalization is necessary).
- During the period of mood disturbance and increased energy or activity, three (or more) of the following symptoms (four if the mood is only irritable) are present
- Inflated self-esteem or grandiosity.
- Decreased need for sleep (e.g., feels rested after only 3 hours of sleep).
- More talkative than usual or pressure to keep talking.
- Flight of ideas or subjective experience that thoughts are racing.
- Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli), as reported or observed.
- Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation (i.e., purposeless non-
goal-directed activity). - Excessive involvement in activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying
sprees, sexual indiscretions, or foolish business investments).
- The mood disturbance is sufficiently severe to cause marked impairment in social or occupational functioning or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features.
- The episode is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) another medical condition.
Affective symptoms of PDD/dysthymia
- SAD, DOWN IN DUMPS
- essential feature is a chronically depressed mood for most of the day, more days than not, for at least 2 years
Schizophreniform Disorder
The essential features of this disorder are identical to those of schizophrenia except that the duration, including prodromal, active, and residual phases, is at least 1 month but less than 6 months
** often has a good prognosis if the individual’s affect is not blunted or flat, if there is a rapid onset of psychotic symptoms from the time the unusual behavior is noticed, or if premorbid social and occupational functioning was satisfactory
Schizoaffective Disorder
- manifested by signs and symptoms of schizophrenia along with a strong element of depression or mania.
- ** decisive factor in the diagnosis of schizoaffective disorder is the presence of hallucinations and/or delusions that occur for at least 2 weeks in the absence of a major mood episode
- prominent mood disorder symptoms must be evident for a majority of the time.
- *The prognosis for schizoaffective disorder is generally better than that for other schizophrenic disorders but worse than that for mood disorders alone
Delusional Disorders
characterized by the presence of delusions experienced for at least 1 month
Describe the Erotomanic type Delusional Disorder
- individual believes that someone, usually of a higher status, is in love with him or her.
Describe the Grandiose type Delusional Disorder
- irrational ideas regarding their own worth, talent, knowledge, or power.
- They may believe that they have a special relationship with a famous person or even assume the identity of a famous person
- may lead to assumption of the identity of a deity or religious leader.
Describe the Persecutory type Delusional Disorder
- individuals believe they are being persecuted or malevolently treated in some way. Frequent themes include being plotted against, cheated or defrauded, followed and spied on, poisoned, or drugged.
Describe the Somatic type Delusional Disorder
- false beliefs that they have some type of medical condition or that there has been an alteration in a body organ or its function
Delirium
is a mental state characterized by an acute disturbance of cognition, manifested by short-term confusion, excitement, disorientation, and clouded consciousness. Hallucinations and illusions are common.
Nursing care of client experiencing hallucinations
- Minimize focus on delusional thinking.
- Do not disagree with made-up stories. Instead, gently correct the client, offer reassurance that he or she is safe, and guide the conversation toward topics about real events and real people.
Delirium characteristics
- disturbance in attention and awareness and a change in cognition that develop rapidly over a short period
- Difficulty sustaining and shifting attention
- Disorganized thinking
- ## Speech that is rambling, irrelevant, inchoherent
What are the symptoms of the EPS side effect AKINESIA ?
Absence or impairment in voluntary movement
Delirium characteristics
- disturbance in attention and awareness and a change in cognition that develop rapidly over a short period
- Difficulty sustaining and shifting attention
- Disorganized thinking
- Speech that is rambling, irrelevant, inchoherent
- Illusions and false perceptions (hallucinations) prevail
- Disturbances in the sleep wake cycle
Lithium carbonate has a daily dosage range of _______- _________mg for acute mania.
1800 to 2400
education prior to ECT:
- all clients receiving ECT should be informed of the possibility for some degree of permanent memory loss.
- informed consent has been granted
- muscle relaxant is given
- inform them of the risks (mortality rate is low, memory loss, brain damage - even though there is no evidence of brain damage caused by ECT)
nursing care post ECT:
- Monitoring pulse, respirations, and blood pressure every 15 minutes for the first hour, during which time the client should remain in bed.
- Positioning the client on side to prevent aspiration.
- Orienting the client to time and place.
- Describing what has occurred.
- Providing reassurance that confusion and memory loss will subside and memories should return following the course of ECT therapy.
- Allowing the client to verbalize fears and anxieties related to receiving ECT.
- Staying with the client until he or she is fully awake, oriented, and able to perform self-care activities without assistance.
- Providing the client with a highly structured schedule of routine activities in order to minimize confusion
assessment of a pt going in for ECT:
- The client’s mood and level of interaction with others
- Evidence of suicidal ideation, plan, and means
- Level of anxiety and fears associated with receiving ECT
- thought and communication patterns
- Baseline memory for short- and long-term events
- Client and family knowledge of indications for, side effects of, and potential risks associated with ECT
- Current and past use of medications
- Baseline vital signs and history of allergies
- The client’s ability to carry out activities of daily living
maladaptive grieving:
- delayed or inhibited grief
- -exaggerated or distorted grief response
- chronic or prolonged grief
normal vs maladaptive grieving:
- one crucial difference between normal and maladaptive grieving is the LOSS OF SELF-ESTEEM
- research has shown that marked feelings of worthlessness are indicative of maladaptive rather than uncomplicated bereavement.
what is hospice?
- a program that provides palliative and supportive care to meet the special needs of people whoa re dying and their families.
- provides physical , psychological, spiritual, and social care for the person for whom aggressive treatment is no longer appropriate
Kubler-ross stages of grief
- stage one: denial
- stage two: anger
- stage three: bargaining
- stage four: depression
- stage five: acceptance
signs and symptoms of opioid withdrawal:
- Symptoms include dysphoric mood, nausea or vomiting, muscle aches, lacrimation or rhinorrhea, pupillary dilation, piloerection, sweating, diarrhea, yawning, fever, and insomnia.
- With short-acting drugs such as heroin, withdrawal symptoms occur within 6 to 8 hours after the last dose, peak within 1 to 3 days, and gradually subside over a period of 5 to 10 days
- With longer-acting drugs such as methadone, withdrawal symptoms begin within 1 to 3 days after the last dose, peak between days 4 and 6, and are complete in 14 to 21 days.
- Withdrawal from the ultra-short-acting meperidine begins quickly, reaches a peak in 8 to 12 hours, and is complete in 4 to 5 days (Sadock et al., 2015
opioid withdrawal treatment:
- early detox
- buprenorphine
- methadone
ETOH withdrawal symptoms:
- coarse tremor of hands, tongue, or eyelids
- nausea or vomiting
- malaise or weakness
- tachycardia
- sweating
- elevated blood pressure
- anxiety
- depressed mood or irritability
- transient hallucinations or illusions
- headache
- insomnia.
- In about 1 percent of alcoholic patients, complicated withdrawal syndrome may progress to alcohol withdrawal delirium
onset of ETOH withdrawal:
Within 4 to 12 hours of cessation of or reduction in heavy and prolonged alcohol use (several days or longer)
CAGE questionnaire:
- have you ever felt you should CUT down on your drinking?
- have people ANNOYED you by criticizing your drinking?
- have you ever felt bad or GUILTY about your drinking?
- have you ever head a drink first thing in the morning to steady your nerves? (EYE-opener)
Nursing Dx/interventions/Client outcomes commonly associated with psychotic disorders & ETOH
Diagnosis: ineffective denial related to weak, underdeveloped ego
outcome: client will demonstrate acceptance of responsibility for own behavior and acknowledge association between person problems and abuse of substances
Nursing Dx/interventions/Client outcomes commonly associated with psychotic disorders & ETOH
Diagnosis: ineffective coping related to inadequate coping skills and weak ego
outcome: client will be able to demonstrate more adaptive coping mechanisms that can be used in stressful situations (instead of taking substances)
Nursing Dx/interventions/Client outcomes commonly associated with psychotic disorders & ETOH
Diagnosis: imbalanced nutrition less than body requirements/fluid volume deficit related to drinking or taking drugs instead of eating
outcome: client will be free from signs or symptoms of malnutrition/ dehydration
Nursing Dx/interventions/Client outcomes commonly associated with psychotic disorders & ETOH
Diagnosis: risk for infection related to malnutrition and altered immune condition
outcome: show no signs or symptoms of infection
Nursing Dx/interventions/Client outcomes commonly associated with psychotic disorders & ETOH
Diagnosis: chronic low self-esteem related to weak ego, lack of positive feedback
outcome: exhibits evidence of increased self-worth by attempting new projects without fear of failure and by demonstrating less defensive behavior toward others
Nursing Dx/interventions/Client outcomes commonly associated with psychotic disorders & ETOH
Diagnosis: deficient knowledge (effects of substance abuse on the body) related to denial of problems with substances evidenced by abuse of substances
outcomes: verbalizes importance of abstaining from use of substances to maintain optimal wellness
Interventions:
For the client in substance withdrawal
- Assess the client’s level of disorientation to determine specific requirements for safety.
- Obtain a drug history. It is important to determine the type of substance(s) used, the time and amount of last use, the length and frequency of use, and the amount used on a daily basis.
- obtain a urine sample for laboratory analysis of substance content.
- It is important to keep the client in as quiet an environment as possible. Excessive stimuli may increase client agitation. A private room is ideal.
- Observe client behaviors frequently. If seriousness of the condition warrants, it may be necessary to assign a staff person on a one-to-one basis.
- Accompany and assist the client when ambulating, and use a wheelchair for transporting the client long distances.
- Pad the headboard and side rails of the bed with thick towels to protect the client in case of a seizure.
- Suicide precautions may need to be instituted for the client withdrawing from CNS stimulants.
- Ensure that smoking materials and other potentially harmful objects are stored away from the client’s access.
- Frequently orient the client to reality and the surroundings.
- Monitor the client’s vital signs every 15 minutes initially and less frequently as acute symptoms subside.
- Follow the medication regimen as ordered by the physician.
A decrease in the neurotransmitter _______ has been implicated in the etiology of Alzheimer’s disease
acetylcholine
Areas of the brain affected by Alzheimer’s disease and associated symptoms include the following:
- Frontal lobe: Impaired reasoning ability
- Parietal lobe: Impaired orientation ability
- Occipital lobe: Impaired language interpretation
- Temporal lobe: Inability to recall words
- Hippocampus: Impaired memory
- Amygdala: Impaired emotions
- Neurotransmitters: Alterations in acetylcholine, dopamine, norepinephrine, serotonin
Interventions for preventing injury in the cognitively impaired client include the following:
- Arrange the furniture and other items in the room to accommodate the client’s disabilities. Ensure that frequently used items are stored within easy access.
- Keep the bed in its lowest position.
- A room near the nurse’s station may be helpful to ensure that the client has close observation.
- If the client is a smoker, ensure that cigarettes and lighter are kept at the nurse’s station and dispensed only when someone is available to stay with the client while he or she is smoking.
- Assist the client with ambulation. Provide cane or walker for balance and instruct client in its proper use. Transport client in wheelchair when longer excursions are necessary.
- Teach client to hold on to hand railing
Interventions:
For the Client Who Is Disoriented
- Try to keep the client as oriented to reality as possible.
- Use clocks and calendars with large numbers that are easy to read.
- Place large, colorful signs on the doors to identify clients’ rooms, bathrooms, activity rooms, dining rooms, and chapel.
- Allow the client to have as many of his or her personal items as possible.
- If at all possible, encourage family and close friends to be a part of the client’s care, to promote feelings of security and orientation.
- Provide the client with radio, television, and music if they are diversions the client enjoys
- Ensure that noise level is controlled to prevent excess stimulation.
- Allow the client to view old photograph albums and utilize reminiscence therapy.
- Maintain consistency of staff and caregivers to the best extent possible.
- Continuously monitor for medication side effects.
- There has been criticism about reality orientation of individuals with NCD (particularly those with moderate to severe disease process), suggesting that constant relearning of material contributes to problems with mood and self-esteem
MDD (major depressive disorder) is characterized by:
- depressed mood or loss of interest or pleasure in usual activities
- impaired social and occupational functioning that has existed for at least 2 weeks
- no history of manic behavior
- symptoms that cannot be attributed to use of substances or a general medical condition
diagnosis MDD:
- Additionally, the diagnosis of MDD is specified according to whether it is a single episode (the individual’s first encounter with a major depressive episode) or recurrent (the individual has a history of previous major depressive episodes).
- The diagnosis will also identify the degree of severity of symptoms (mild, moderate, or severe)
- The presence of anxiety and severity of suicide risk may also be noted.
- MDD is differentiated from schizoaffective disorder, a condition in which the individual expresses symptoms of a mood disorder as well as symptoms of schizophrenia.
______________is a drug that can be administered as a deterrent to drinking to individuals who abuse alcohol. Ingestion of alcohol while disulfiram is in the body results in a syndrome of symptoms that produce substantial discomfort for the individual and even result in death if the blood alcohol level is high
Disulfiram (Antabuse)
What is the therapeutic/pharmacologic class for Amitriptyline? Side effects?
- Antidepressants
- Tricyclic Anti Depressants
- Arrhythmias
Therapeutic/Pharm drug class of OLANZAPINE (ZYPREXA) and INDICATIONS?
- Antipsychotic (Atypical)
- Atypical Antipsychotic
- Bipolar
- Agitation
What drugs can be used with Lithium in order to treat manic episodes?
- Olanzapine
Therapeutic/Pharm drug class for CLOZAPINE ?
- Antipsychotic
- Schizophrenia unresponsive to or intolerant of standard therapy with other antipsychotics
What is the drug librium used for?
- used to treat anxiety disorders and withdrawal symptoms associated with alcoholism.
Therapeutic/Pharm drug class for Librium (chlordiazepoxide)? Indications?
- Antianxiety agents, sedative/hypnotics
- Benzodiazepines
Indications:
- Anxiety (adjunct management)
- Alcohol withdrawal
What is the reversal agent for Librium (chlordiazepoxide) ?
Flumazenil
Which antihypertensive has been successful in alleviating nightmares, intrusive recollection, insomnia, startle responses, and angry outburst associated with PTSD?
Propranolol
Indications for Propranolol (Inderal) ?
- Situational anxiety (e.g. performance anxiety; test anxiety)
- PTSD (decrease angry outburst)
Nursing Diagnoses for a client diagnosed with Bipolar disorder?
- Risk for injury
- Risk for violence: Self-directed or other-directed
- Imbalanced nutrition: less than body requirements
- Disturbed thought process
- Disturbed sensory-perception
Impaired social interaction
-Insomnia
What is the primary focus regarding treatment modalities of Schizophrenia and other psychotic disorders?
Decrease anxiety and Increase trust
The _______have been identified as an at-risk population because of accounts of stroke and sudden death while taking antipsychotic medication.
elderly
Effects of antipsychotic medication on Elders? What are potential medication interactions?
Stroke and sudden death often related to infections or cardiovascular problems.
Treatment for manic episodes besides lithium?
- anticonvulsant drugs that have a mood-stabilizing effect, either alone or in combination with lithium.
What foods should a patient using an MAOI avoid?
- foods high in tyramine Aged cheeses (cheddar, Swiss, Camembert, blue cheese, parmesan, provolone, Romano, brie)
Raisins, fava beans, flat Italian beans, Chinese pea pods
Red wines (chianti, burgundy, cabernet sauvignon)
Liqueurs
Smoked and processed meats (salami, bologna, pepperoni, summer sausage)
Caviar, pickled herring, corned beef, chicken or beef liver
Soy sauce, brewer’s yeast, meat tenderizer (MSG)
Sauerkraut
Recognize/Teach types of therapy needed for clients recovering from schizophrenia
- Individual Psychotherapy
- Group therapy
- Behavioral therapy
- Social Skills Training
- Family therapy
- Assertive Community Treatment - provides comprehensive community-based psychiatric treatmetn
How should a therapeutic relationship be established with patient with schizophrenia?
- honesty, simple directness, and a manner that respects the client’s privacy and human dignity. ***Exaggerated warmth and professions of friendship are likely to be met with confusion and suspicion.
