Unit 5 Chapter Depression Pharma Treatment Methods 14

Question 1

Antidepressants and
the older adult Considerations..

Answer 1

Concerns: polypharmacy,
metabolism, smaller kidney-slower excretion rate , smaller liver- increased half time

 TCAs and MAOIs – dangerous
side effect for older population
 SSRIs – 1st line treatment
 Starting dose is ½ the lowest adult
dose, increase slowly

Question 2

What is Antidepressants used to treat

Answer 2

Antidepressants can positively impact poor self-concept, social withdrawal, vegetative signs of depression, and activity level. Target symptoms include the following:

• Sleep disturbance (decreased or increased)
• Appetite disturbance (decreased or increased)
• Fatigue
• Decreased sex drive
• Psychomotor retardation or agitation
• Diurnal (i.e., daily cycle) variations in mood (often worse in
  the morning)
• Impaired concentration or forgetfulness * Anhedonism

Question 3

A client diagnosed with major depressive disorder began taking a tricyclic antidepressant 1 week ago. Today the client says, “I don’t think I can keep taking these pills. They make me so dizzy, especially when I stand up.” The nurse will implement which intervention?
a. limit the client’s activities to those that can be performed in a sitting position.
b. withhold the drug, force oral fluids, and notify the health care provider.
c. teach the client strategies to manage postural hypotension.
d. update the client’s mental status examination.

Answer 3

c. teach the client strategies to manage postural hypotension.

Drowsiness, dizziness, and postural hypotension usually subside after the first few weeks of therapy with tricyclic antidepressants. Postural hypotension can be managed by teaching the client to stay well hydrated and rise slowly. Knowing this information may convince the client to continue the medication. Activity is an important aspect of the client’s treatment plan and should not be limited to activities that can be done in a sitting position. Withholding the drug, forcing oral fluids, and notifying the health care provider are unnecessary actions. Independent nursing action is called for. Updating a mental status examination is unnecessary.

Question 4

A client diagnosed with depressive disorder begins selective serotonin reuptake inhibitor (SSRI) antidepressant therapy. What information should the nurse provide to the client and family?
a. Need to restrict sodium intake to 1 gram daily.
b. Need to minimize exposure to bright sunlight.
c. Importance of reporting increased suicidal thoughts.
d. Importance of maintaining a tyramine-free diet.

Answer 4

c. Importance of reporting increased suicidal thoughts.

ANS: C
Some evidence indicates that suicidal ideation may worsen at the beginning of antidepressant therapy; thus, close monitoring is necessary. Avoiding exposure to bright sunlight and restricting sodium intake are unnecessary. Tyramine restriction is associated with monoamine oxidase inhibitor (MAOI) therapy.

Question 5

A nurse taught a client about a tyramine-restricted diet. Which menu selection would the
indicate the client understood the information?
a. Macaroni and cheese, hot dogs, banana bread, caffeinated coffee
b. Mashed potatoes, ground beef patty, corn, green beans, apple pie
c. Avocado salad, ham, creamed potatoes, asparagus, chocolate cake
d. Noodles with cheddar cheese sauce, smoked sausage, lettuce salad, yeast rolls

Answer 5

b. Mashed potatoes, ground beef patty, corn, green beans, apple pie

Question 6

A nurse provided medication education for a client diagnosed with major depressive disorder who began a new prescription for phenelzine. Which behavior indicates effective learning?l
The client
a. monitors sodium intake and weight daily.
b. wears support stockings and elevates the legs when sitting.
c. can identify foods with high selenium content that should be avoided.
d. confers with a pharmacist when selecting over-the-counter medications.

Answer 6

d. confers with a pharmacist when selecting over-the-counter medications.

Over-the-counter medicines may contain vasopressor agents or tyramine, a substance that must be avoided when the client takes MAOI antidepressants. Medications for colds, allergies, or congestion or any preparation that contains ephedrine or phenylpropanolamine may precipitate a hypertensive crisis. MAOI antidepressant therapy is unrelated to the need for sodium limitation, support stockings, or leg elevation. MAOIs interact with tyraminecontaining foods, not selenium, to produce dangerously high blood pressure.

Question 7

A client being treated for depression has taken sertraline daily for a year. The client calls the clinic nurse and says, “I stopped taking my antidepressant 2 days ago. Now I am having nausea, nervous feelings, and I can’t sleep.” The nurse will advise the client to:
a. “Go to the nearest emergency department immediately.”
b. “Do not to be alarmed. Take two aspirin and drink plenty of fluids.”
c. “Take a dose of your antidepressant now and come to the clinic to see the health care
provider.”
d. “Resume taking your antidepressants for 2 more weeks and then discontinue them
again.”

Answer 7

c. “Take a dose of your antidepressant now and come to the clinic to see the health care
provider.”

Serotonin withdrawal symptom- life threatening

ANS: C
The client has symptoms associated with abrupt withdrawal of the antidepressant. Taking a dose of the drug will ameliorate the symptoms. Seeing the health care provider will allow the client to discuss the advisability of going off the medication and to be given a gradual withdrawal schedule if discontinuation is the decision. This situation is not a medical emergency, although it calls for medical advice. Resuming taking the antidepressant for 2 more weeks and then discontinuing again would produce the same symptoms the client is experiencing.

Question 8

SSRI’S
*Citalopram (Celexa) Escitalopram (Lexapro) Fluoxetine (Prozac, Prozac
Weekly)
Paroxetine (Paxil, Paxil CR,
Pexeva) Sertraline (Zoloft)

Answer 8

They do not create anticholin- ergic effects, dry mouth, blurred vision, or urinary retention, making it easier for patients to take these medications as pre- scribed.

Question 9

Side effects of SSRI’S

Answer 9

Side Effects: sleep disturbance, tremor, sexual disfunction, GI side effects, tension
headache, weight change

Question 10

What is Serotonin Syndrome

Answer 10

One rare and life-threatening event associated with SSRIs is serotonin syndrome. This syndrome is thought to be related to overactivation of the central serotonin receptors caused by either too high a dose or interaction with other drugs.

Question 11

What is the risk factor for Serotonin Syndrome

Answer 11

The risk of this syndrome seems to be greatest when an SSRI is administered in combination with a second serotonin- enhancing agent, such as a monoamine oxidase inhibitor (MAOI).

A patient should discontinue all SSRIs for 2 to 5 weeks before starting an MAOI.

Question 12

Serotonin Syndrome s/s

Answer 12

• Hyperactivity or restlessness
• Tachycardia → cardiovascular shock
• Fever → hyperpyrexia
• Elevated blood pressure
• Altered mental states (delirium)
• Irrationality, mood swings, hostility
• Seizures → status epilepticus
• Myoclonus(muscle spasms), incoordination, tonic rigidity
• Abdominal pain, diarrhea, bloating
• Apnea → death

Question 13

Interventions for Serotonin Syndrome

Answer 13

• Remove offending agent(s)
• Initiate symptomatic treatment
• Serotonin-receptor blockade with cyproheptadine, methysergide, proprano-
  lol
• Cooling blankets, chlorpromazine for hyperthermia
• Dantrolene, diazepam for muscle rigidity or rigors
• Anticonvulsants
• Artificial ventilation
• Induction of paralysis

Question 14

Your patient who has been diagnosed with depression for 2 years has reported that their suicidal symptoms has not decreased while taking Paroxetine. On primary assessment the patients 105 degrees. As a nurse what is your priority action?

A. Monitor their liver enzymes
B. Advocate for the patient about a new antidepressant to their healthcare provider.
C. Ask them if they are taking any herbs such as St Johns worth.
D. Educate them that they will not be prescribed Phenelzine until 2-5 weeks off of Paroxetine

Answer 14

Your patient who has been diagnosed with depression for 2 years has reported that their suicidal symptoms has not decreased while taking Paroxetine. On primary assessment the patients 105 degrees. As a nurse what is your priority action?

Question 15

Your patient who has been diagnosed Major Depression Disorder. She states that her prescribed medication isn’t decreasing her insomnia. When should your patient be prescribed an MAOI?

A. 2-5 weeks
B. 5-10 days
C. 4-8 weeks
D. 2-3 months

Answer 15

A. 2-5 weeks

A patient should discontinue all SSRIs for 2 to 5 weeks before starting an MAOI.

Question 16

Liver Function- AST AND ALT LAB

Answer 16

AST-0-35 I
ALT-4-36

Question 17

Renal Function- LAB

Answer 17

BUN-10-20
GFR- 90-120

Question 18

Patient and Family Teaching for SSRI

Answer 18

• May cause sexual dysfunction or lack of sex drive. Inform nurse or primary care provider if this occurs.
• May cause insomnia, anxiety, and nervousness. Inform nurse or primary care provider if this occurs.
• May interact with other medications. Tell primary care provider about other medications patient is taking (e.g., digoxin, warfarin). Selective serotonin reuptake inhibitors (SSRIs) should not be taken within 14 days of the last dose of a monoamine oxidase inhibitor.
• No over-the-counter drug should be taken without first notifying primary care provider.
• Common side effects include fatigue, nausea, diarrhea, dry mouth, dizziness, tremor, and sexual dysfunction or lack of sex drive.
• Because of the potential for drowsiness and dizziness, patient should not drive or operate machinery until these side effects are ruled out.
• Alcohol should be avoided.
• Liver and renal function tests should be performed and blood counts checked periodically.
• Medication should not be discontinued abruptly. If side effects become bothersome, patient should ask primary care provider about changing to a
  different drug. Abrupt cessation can lead to serotonin withdrawal.
  Any of the following symptoms should be reported to the primary care provider immediately:
• Increase in depression or suicidal thoughts
• Rash or hives
• Rapid heartbeat
• Sore throat
• Difficulty urinating
• Fever, malaise
• Anorexia and weight loss
• Unusual bleeding
• Initiation of hyperactive behavior
• Severe headache

Question 19

Your patient who has depression is at risk for Coronary artery disease. He has been taking his Paroxetine as prescribed and has been newly prescribed warfarin. What is the appropriate nursing teaching?

A. “Since you are at risk for Coronary Artery disease, take both your antidepressants and warfarin together.
B. You should come in every 6 months to get your labs drawn.
C. There is drug interactions with paroxetine with warfarin
D. There are no drug interactions with warfarin and paroxetine.

Answer 19

• May interact with other medications. Tell primary care provider about other medications patient is taking (e.g., digoxin, warfarin).
  *Selective serotonin reuptake inhibitors (SSRIs) should not be taken within 14 days of the last dose of a monoamine oxidase inhibitor.

Question 20

What are the S/s of Serotonin Withdrawal

Answer 20

Abrupt cessation can lead to serotonin withdrawal.
Any of the following symptoms should be reported to the primary care provider immediately:
* Increase in depression or suicidal thoughts
* Rash or hives
* Rapid heartbeat
* Sore throat
* Difficulty urinating
* Fever, malaise
* Anorexia and weight loss
* Unusual bleeding
* Initiation of hyperactive behavior
* Severe headache

Question 21

Your psychiatric patient has been admitted due to an intensifying sore throat and high fever. You assessed that your patient has abruptly stopped taking Paroxetine due to the side effects. What is the next action of the nurse?

A. Assess for suicidal ideation
B. Take the clients blood pressure to rule out hypertension
C.Monitor weight changes from the last visit
D. Maintain good rapport with patient

Answer 21

A. Assess for suicidal ideation

Abrupt cessation can lead to serotonin withdrawal.
Any of the following symptoms should be reported to the primary care provider immediately:
* Increase in depression or suicidal thoughts
* Rash or hives
* Rapid heartbeat
* Sore throat
* Difficulty urinating
* Fever, malaise
* Anorexia and weight loss
* Unusual bleeding
* Initiation of hyperactive behavior
* Severe headache

Question 22

Tricyclic Antidepressants (TCAs)- side effects
*Amitriptyline (generic only) *Amoxapine (generic only) *Desipramine (Norpramin) Doxepin (Sinequan)
* Imipramine (Tofranil) *Maprotiline (generic only) *Nortriptyline (Aventyl,
Pamelor)
*Protriptyline (Vivactil) *Trimipramine (Surmontil)

Answer 22

LAST RESORT OF TREATMENT

-Orthostatic hypotension
 Anticholinergic Side Effects: Dry mouth, Constipation, blurred vision, tachycardia,
urinary retention, weight gain, and esophageal reflux

Urinary Retention & Severe Constipation – Immediate medical attention

Question 23

Contraindications of TCA(Amtriptiline)

Answer 23

People who have recently had a myocardial infarction (or other cardiovascular problems), those with narrow-angle glaucoma or a history of seizures, and women who are pregnant should not be treated with TCAs except with extreme caution and careful monitoring.

*Cardiotoxic effects – Lethal in overdose, contraindicated w/ recent MI, cardiovascular
disease, narrow angle glaucoma, hx of sz, pregnant women

Question 24

Should your patient with Suicdal ideation be prescribed Amtriptline?

A. Yes
B. No

Answer 24

B. No

Cardiotoxic effects – Lethal in overdose, contraindicated w/ recent MI, cardiovascular
disease, narrow angle glaucoma, hx of sz, pregnant women

Question 25

S/S of TCA’s overdose or toxicity

Answer 25

TCA overdose carries a risk of death from cardiac conduction abnormalities: dysrhythmias, tachycardia, myocardial infarction, and heart block. Initial symptoms are CNS stimulation, including hyperpyrexia, delirium, hypertension, hallucinations, seizure, hyperreflexia, nd parkinsonian symptoms. This phase is followed by CNS depression. Immediate medical care is essential with TCA overdose. The TCAs should be used cautiously in suicidal patients since they are lethal in overdoses.

Question 26

TCA sedation effects , patient education

Answer 26

Give at night – sedative effect, minor side effects will occur while patient is
sleeping

Question 27

MAOI DRUG LIST

Answer 27

MAOI’S

*Isocarboxazid (Marplan) *Phenelzine (Nardil)
*Selegiline (Emsam Transder-
mal System Patch) *Tranylcypromine (Parnate)

Question 28

Should your patient take over the counter medications with MAOI drugs without contacting their provider?

A. Yes
B. No

Answer 28

B. No

DRUG INTERACTIONS WITH MAOI’S

*Over-the-counter medications for colds, allergies, or congestion (any product containing ephedrine, phenylephrine hydrochloride, or phenylpropanol-amine)
* Tricyclic antidepressants (imipramine, amitriptyline)
* Narcotics
* Antihypertensives (methyldopa, guanethidine, reserpine)
* Amine precursors (levodopa, L-tryptophan)
* Sedatives (alcohol, barbiturates, benzodiazepines)
* General anesthetics
* Stimulants (amphetamines, cocaine)

Question 29

Is MAOI’S the number one resort for depresion?

Answer 29

Indicated for someone with treatment resistant depression

Question 30

What is your patient at risk for when drinking wine while taking Phenlezine?

A. Pseudoparkinsinism
B. Tardive Dyskinesia
C. Tremors at rest
D. Hypertensive Crisis

Answer 30

D. Hypertensive Crisis

No tyramine diet – Risk for Hypertensive Crisis – Can lead to Cerebrovascular accident

This crisis results in severe hypertension that can lead to such events as a cerebrovascular accident, intracranial hemorrhage, and death. Blood pressure should be monitored during treatment with these drugs. Also, a reduction or elimination of foods and drugs that contain high amounts of tyramine needs to happen

Question 31

Food to avoid while taking Phenelzine

Answer 31

Picnic food

Dietary restrictions
* No Tyramine
* Aged cheeses,
*pickled or smoked fish and wine

• Can produce significant vasoconstriction – threat of hypertensive crisis

smoked, or otherwise aged; spoiled meats; liver, unless very fresh
*Protein dietary supplements; soups (may contain protein extract); shrimp paste; soy sauce

Question 32

Contraindications of MAOI

Answer 32

Contraindications. The use of MAOIs may be contraindicated with each of the following:
* Cerebrovascular disease
* Hypertension and congestive heart failure
* Liver disease
* Consumption of foods containing tyramine, L-tryptophan,
and dopamine (see Table 14.7)
* Use of certain medications (see Box 14.5)
* Recurrent or severe headaches
* Surgery in the previous 10 to 14 days
* Age younger than 16 years

Question 33

Early S/s of hypertensive crisis

Answer 33

The hypertensive crisis usually occurs within 15 to 90 minutes of ingestion of the offending substance.
Early symptoms include irritability, anxiety, flushing, sweating, and a severe headache. The patient then becomes anxious, restless, and develops a fever. Eventually the fever becomes severe, seizures ensue, and coma or death is possible.

Question 34

Interventions for hypertensive crisis

Answer 34

When a hypertensive crisis is suspected, immediate medi- cal attention is crucial. If ingestion is recent, gastric lavage and charcoal may be helpful. Pyrexia is treated with hypothermic blankets or ice packs. Fluid therapy is essential, particularly with hyperthermia. A short-acting antihypertensive agent such as nitroprusside, nitroglycerine, or phentolamine may be used. Intravenous benzodiazepines are useful for agitation and sei- zure control.

Question 35

Patient teaching and Eduacation for MAOI

Answer 35

Tell the patient and family to avoid certain foods (especially those thatare aged, cured, or ripened) and all medications (especially cold remedies) unless prescribed by and discussed with the patient’s primary care provider.

• Give the patient a wallet card describing the monoamine oxidase inhibitor (MAOI) regimen.
• Instruct the patient to avoid Asian restaurants (sherry, brewer’s yeast, and other contraindicated products may be used).
• Tell the patient to go to the emergency department immediately if he or she has a severe headache.
• Ideally, blood pressure should be monitored during the first 6 weeks of treatment (for both hypotensive and hypertensive effects).
• After the MAOI is stopped, instruct the patient that dietary and drug restric- tions should be maintained for 14 days.

Question 36

Considerations for the older adult

Answer 36

Starting doses are recommended to be half the lowest adult dose, with dose adjustments occurring no more frequently than every 7 days (“start low and go slow”).

Question 37

Electroconvulsi,ve therapy use?

Answer 37

Has a bad reputation but is a highly effective

used for..
-Severely malnourished, exhausted and dehydrated due to depression
-due to resistance to antidepressant medications

done under general anesthesia to induce sleep, with a muscle relaxant to prevent muscle spasms, distress or fractures.
^These medications have revolutionized the comfort and safety of ECT.

Preop-MONITOR
Patients should have a pre-ECT workup, including a chest x-ray, electrocardiogram (ECG), urinalysis, complete blood count, blood urea nitrogen, and an electrolyte panel.

An electroencephalogram (EEG) monitors brain waves, and an ECG monitors cardiac responses.

Question 38

Which of the following drugs should be discontinues before ECT Therapy? Select all that apply

A. Alprazolam
B. Buspirone
C. Valproate
D. Acetaminophen
E. Coaching

Answer 38

Benzodiazepines should be discontinued since they will inter- fere with the seizure process.

A. Alprazolam
C. Valproate

Anticonvulants must be discontinued due to the risk of not allowing a seizure too start.

Question 39

Contraindications of ECT

Answer 39

ECT also stresses the brain as a result of
*increased cerebral oxygen,
*blood flow, and
*intracranial pressure. Conditions such as
*brain tumors and
*subdural hematomas may increase the risk of using ECT.

Question 40

What is an expected finding after ECT therapy , Patient education Post Op ECT therapy

Answer 40

-Amnesia

Potential adverse reactions. Patients wake about 15 minutes after the procedure. The patient is often confused and disoriented for several hours. The nurse and family may need to orient the patient frequently during the course of treatment. Most people experience what is called retrograde amnesia, which is a loss of memory of events leading up to and including the treatment itself.

Question 41

Informed Consent for ECT

Answer 41

*The procedure is explained to the patient, and informed consent is obtained if the patient is being treated voluntarily.

• For a patient treated involuntarily, permission may be obtained from the next of kin although in some states treatment must be court-ordered.

Question 42

How long does the seizure last for ECT Therapy?

Answer 42

Brief seizures (30 to 60+ seconds) are deliberately induced by an electrical current (as brief as 1 second) transmitted through electrodes attached to one or both sides of the head (Fig. 14.5).
The usual course of ECT for a patient with depression is two or three treatments per week to a total of 6 to 12 treatments. Continuation of ECT along with medication may help to decrease relapse rates.

Question 43

Drug interactions MAOI to avoid