ATI – Psychopharmacological Therapies – Flashcards
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Major Medications used to treat ANXIETY DISORDERS
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1. BENZODIAZEPINE (diazepam/Valium) 2. ATYPICAL ANXIOLYTIC/NONBARBITURATE ANXIOLYTIC (buspirone/BuSpar) 3. Selective Serotonin Reuptake Inhibitor (SSRI) (paroxetine/Paxil)
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Other groups that treat ANXIETY DISORDERS
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1. Antidepressants (a) Amitriptyline (Elavil) - TCA (b) Phenelzine (Nardil) - MAOI (c) Venlafaxine (Effexor) or duloxetine (Cymbalta), both serotonin-norepinephrine reuptake inhibitors 2. CNS stimulants - methylphenidate (Ritalin) 3. Sertraline (Zoloft) - SSRI 4. Antihistamines - hydroxyzine pamoate (Vistaril) 5. Beta Blockers - propanolol (Inderal) 6. Anticonvulsants - gabapentin (Neurontin)
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Action of Benzodiazepine
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Enhances the inhibitory effects of gamma-aminobutyric acid (GABA) in the central nervous system. Relief from anxiety occurs rapidly following administration.
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Therapeutic Use of Benzodiazepine
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1. Generalized anxiety disorder (GAD) and panic disorder 2. Seizure disorders, 3. Insomnia, 4. Muscle Spasm 5. Alcohol Withdrawal (prevention and treatment of acute symptoms) 3. Induction of anesthesia
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Complications of BENZODIAZEPINE 1. CNS depression (sedation, lightheadedness, ataxia, decreased cognitive function)
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NURSING INTERVENTION/CLIENT EDUCATION 1. Observe symptoms 2. Avoid hazardous activity (driving, operating heavy machinery)
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Complications of BENZODIAZEPINE 2. Anterograde Amnesia - difficulty recalling events that occur after dosing
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NURSING INTERVENTION/CLIENT EDUCATION 1. Observe symptoms and notify provider 2. Stop medication if symptoms occur
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Complications of BENZODIAZEPINE 3. Acute oral toxicity - Drowsiness, lethargy, and confusion
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NURSING INTERVENTION/CLIENT EDUCATION 1. Watch for overdose and notify provider 2. Use gastric lavage followed by administration of activated charcoal or saline cathartics for oral toxicity. 3. Monitor clients receiving flumazenil (Romazicon) by IV bolus to counteract sedation and reverse the side effects. 4. Assist with emergency care if needed
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Complications of BENZODIAZEPINE 4. Paradoxical response - (insomnia, excitation, euphoria, anxiety, rage)
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NURSING INTERVENTION/CLIENT EDUCATION 1. Observe symptoms and notify provider
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Complications of BENZODIAZEPINE 5. Withdrawal symptoms (anxiety, insomnia, diaphoresis, tremors, light-headedness) which occur infrequently with short-term use.
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NURSING INTERVENTION/CLIENT EDUCATION 1. Taper medication dosage after a long period of use to avoid withdrawal symptoms.
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CONTRAINDICATIONS and PRECAUTIONS of BENZODIAZEPINE
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1. Pregnancy Risk Category D 2. Classified under Schedule IV of the controlled substances act 3. Diazepam is contraindicated in clients with sleep apnea/respiratory depression 4. Use cautiously in clients who have liver disease and/or history of SUBSTANCE ABUSE
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MEDICATION/FOOD INTERACTION of BENZODIAZEPINE - CNS depressants (alcohol, barbiturates, opioids) may cause respiratory depression
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Nursing Intervention / Client Education 1. Advise clients to observe symptoms 2. Avoid hazardous activities (driving, operating heavy machinery)
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Nursing administration of Benzodiazepine
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Instruct or advise client to... 1. Take medication as prescribed, avoid abrupt discontinuation, long term treatment to prevent withdrawal symptoms 2. Taper the dose over several weeks when the medication is discontinued 3. Advise clients to administer with meals or snacks if GI upset occurs 4. Swallow sustained release tablets and avoid chewing or crushing the tablets 5. Advise clients about potential for dependency during and after treatment and notify provider 6. Medication can relieve symptoms but not take away stressor. Psychotherapy is important with medication.
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ATYPICAL ANXIOLYTIC / NONBARBITURATE ANXIOLYTICS - buspirone (BuSpar)
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Expected Pharmacological Action 1. It binds to serotonin and dopamine receptors. It has less potential for abuse than with other anxiolytics 2. Use of buspirone does not result in sedation or potentiate the effects of other CNS depressants.
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THERAPEUTIC USES of TYPICAL ANXIOLYTIC / NONBARBITURATE ANXIOLYTICS - buspirone (BuSpar)
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1. Panic disorder 2. OCD 3. SAD 4. PTSD
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SIDE EFFECTS of ATYPICAL ANXIOLYTIC / NONBARBITURATE ANXIOLYTICS - buspirone (BuSpar) 1. Dizziness 2. Nausea 3. Headache 4. Lightheadedness 5. Agitation
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Nursing Intervention / Client Education, Advise Clients to: 1. Take with food to decrease nausea 2. Most side effects are self limiting
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CONTRAINDICATIONS/ Precautions of ATYPICAL ANXIOLYTIC / NONBARBITURATE ANXIOLYTICS - buspirone (BuSpar)
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1. Pregnancy Risk Category B 2. Not recommended for use by nursing mothers 3. Use cautiously in older adults and clients with liver and/or renal dysfunction 4. Contraindicated for concurrent use of MAOI antidepressants or for 14 days after MAOIs are discontinue. Hypertensive crisis may occur.
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Medication/Food interaction of buspirone (BuSpar) 1. Erythromycin 2. Ketoconazole and grapefruit juice (may increase the effects of buspirone)
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NURSING INTERVENTION 1. Avoid concurrent use 2. Avoid Grapefruit Juice
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Nursing Administration of buspirone (BuSpar)
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Advise or instruct client to/that: 1. Take medication with meals to prevent gastric irritation 2. Effect do not occur immediately. May take a week to have first therapeutic effects, several weeks for complete benefit. 3. Take medications on a regular basis and not PRN 4. Tolerance, dependence or withdrawal symptoms should not occur with this medication.
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SELECTIVE SEROTONIN REUPTAKE INHIBITOR (SSRIs) - Select Prototype: paroxetine (Paxil)
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1. sertraline (Zoloft) 2. escitalopram (Lexapro) 3. fluoxetine (Prozac) 4. fluvoxamine (Luvox)
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PURPOSE of SELECTIVE SEROTONIN REUPTAKE INHIBITOR (SSRIs) - Select Prototype: paroxetine (Paxil)
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1. Selectively inhibits serotonin reuptake, allowing more serotonin to stay at the junction of the neurons. 2. It does not block uptake of dopamine or norepinephrine 3. Paroxetine causes CNS stimulation, which can cause insomnia 4. Has long effective half-life, about 4 weeks are necessary to produce therapeutic levels.
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THERAPEUTIC USE of SELECTIVE SEROTONIN REUPTAKE INHIBITOR (SSRIs) - Select Prototype: paroxetine (Paxil)
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1. GAD 2. Panic disorder - decreases frequency and intensity of panic attacks; prevents anticipatory anxiety about attacks 3. OCD - reduces symptoms be increasing serotonin 4. SAD 5. PTSD 6. Depressive Disorder
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SSRI - Medication 1. sertraline (Zoloft)
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USES 1. Panic disorder, 2. OCD 3. Social Anxiety Disorder 4. PTSD
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SSRI Medication 2. escitalopram (Lexapro)
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USES 1. GAD 2. OCD
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SSRI Medication 3. fluoxetine (Prozac)
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USES 1. Panic Disorder 2. OCD
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SSRI Medication 4. Fluvoxamine
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USES 1. OCD 2. Social Anxiety Disorder
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SIDE / ADVERSE EFFECTS of SSRI Early adverse effects (first few weeks) 1. nausea 2. diaphoresis 3. tremor 4. fatigue 5. drowsiness
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NURSING INTERVENTION / CLIENT EDUCATION 1. Effects subside soon 2. Take medication as prescribed
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SIDE / ADVERSE EFFECTS of SSRI Later adverse effects (after 5 to 6 weeks of therapy) 1. sexual dysfunction (impotence, delayed or absent orgasm, delayed or absent ejaculation, decreased sexual interest) 2. weight gain 3. headache
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NURSING INTERVENTION / CLIENT EDUCATION 1. Report problems with sexual function 2. Managed with dose reduction, medication holiday, and/or change medication
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SIDE / ADVERSE EFFECTS of SSRI - paroxetine (Paxil) 1. Weight gain 2. GI Bleeding 3. Hyponatremia - among older adults taking diuretics
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NURSING INTERVENTION / CLIENT EDUCATION 1. Follow a well balanced diet and exercise regularly 2. Report signs of bleeding (dark stools, emesis, appearance of coffee grounds) 3. Obtain baseline serum sodium, and monitor level periodically throughout treatment
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SIDE / ADVERSE EFFECTS of SSRI Serotonin Syndrome - paroxetine (Paxil) a) Agitation, confusion, disorientation, difficulty concentrating, anxiety, hallucinations, hyperreflexia, fever, diaphoresis, lack of coordination, and tremors b) Begins 2 to 72 hours after initiation of treatment c) Resolves when medication is discontinued
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NURSING INTERVENTION / CLIENT EDUCATION Watch for and report any of these symptoms which would indicate a priority problem
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SIDE / ADVERSE EFFECTS of SSRI - paroxetine (Paxil) Bruxism - Grinding and clenching of teeth, usually during sleep
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NURSING INTERVENTION / CLIENT EDUCATION Instruct clients to report to the provider who may: 1. Switch clients to another class of medication 2. Treat bruxism with low-dose buspirone (anxiolytic) 3. Advise clients to use a mouth guard during sleep
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Withdrawal symptoms of SSRI - paroxetine (Paxil) 1. Nausea, sensory disturbances, anxiety, tremor, malaise, and unease 2. Minimized by tapering the medication slowly
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NURSING INTERVENTION / CLIENT EDUCATION - Advise clients how to slowly taper the medication dosage after a long period of use to avoid withdrawal symptoms
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CONTRAINDICATIONS / PRECAUTIONS of SSRI - paroxetine (Paxil)
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1. Pregnancy risk category D. Other SSRI pose less risk during pregnancy 2. Contraindicated in clients taking MAOI 3. Avoid alcohol 4. Use cautiously in clients with liver and renal dysfunction, seizure disorders, history of GI bleeding and those taking NSAIDS or anticoagulants.
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MEDICATION / FOOD INTERACTION OF SSRI - paroxetine (Paxil)
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1. Concurrent use with MAOIs can cause serotonin syndrome 2. Concurrent use with Tricyclic Antidepressant
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Nursing Administration of SSRI - paroxetine (Paxil)
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Advise or instruct client: 1. Paroxetine (Paxil) may be taken with food. 2. Sleep disturbances may be minimized by taking the medication in the morning. 3. Take medication daily to establish therapeutic plasma 4. Therapeutic effects may not be experienced for 1 to 3 WEEKS
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Effectiveness of SSRI - paroxetine (Paxil)
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1. Maintenance of normal sleep pattern 2. Verbalization of feeling less anxious and more relaxed 3. Greater ability to participate in social and occupational interactions
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ANTIDOTE for BENZODIAZEPINE overdose or toxicity
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flumanezil (Romazicon) - a Benzodiazepine receptor antagonist which specifically reverses an overdose of benzodiazepines.
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ANTIDOTE for OPIOID intoxication
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naloxone (Narcan) - An opioid antagonist used to reverse an overdose of opioids, such as Morphine Sulfate
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What is DEPRESSION?
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A mood affective disorder that is a prevalent disease, ranking high causes of disability.
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What is the time frame for antidepressant medications to starts its therapeutic benefits?
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1 to 3 weeks, possible 2 to 3 months for full therapeutic benefits.
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FOUR MAIN GROUPS OF ANTIDEPRESSANT MEDICATION
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1. TCA - tricyclic antidepressant 2. SSRI - selective serotonin reuptake inhibitor 3. MAOI -monoamine oxidase inhibitor 4. Atypical antidepressant
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TRICYCLIC ANTIDEPRESSANTS (TCAs). Select prototype medication: amitryptyline (Elavil)
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Other medication 1. imipramine (Tofrantil) 2. doxepin (Sinequan) 3. nortriptyline (Aventyl) 4. trimipramine (Surmontil)
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Pharmacological Action of TRICYCLIC ANTIDEPRESSANTS (TCAs). Select prototype medication: amitryptyline (Elavil)
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1. Block reuptake of norepinephrine and serotonin in the synaptic space, thereby intensifying the effects of these neurotransmitters 2. Therapeutic use - depression; depressive episodes of BIPOLAR DISORDERS 3. Other uses - Chronic pain, enuresis (inability to control urination)
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SIDE / ADVERSE EFFECTS of TRICYCLIC ANTIDEPRESSANTS (TCAs). Select prototype medication: amitryptyline (Elavil) 1) Orthostatic hypotension
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NURSING INTERVENTION / CLIENT EDUCATION Advise / instruct client to 1. Change position slowly 2. Monitor BP and heart rate for orthostatic changes. Is significant decrease, hold medication and notify provider.
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SIDE / ADVERSE EFFECTS of TRICYCLIC ANTIDEPRESSANTS (TCAs). Select prototype medication: amitryptyline (Elavil) 2) ANTICHOLINERGIC effects: 1. dry mouth 2. blurred vision 3. photophobia 4. urinary hesitancy or retention 5. constipation 6. tachycardia
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NURSING INTERVENTION / CLIENT EDUCATION To minimize cholinergic effects, instruct clients to...: a) chew sugarless gum b) sip water c) wear sunglasses when outdoors d) eat foods high in fiber e) exercise regularly f) increase fluid intake to at least 2 to 3 L / day from beverage and food sources g) Void just before taking medication
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SIDE / ADVERSE EFFECTS of TRICYCLIC ANTIDEPRESSANTS (TCAs). Select prototype medication: amitryptyline (Elavil) 3) SEDATION
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NURSING INTERVENTION / CLIENT EDUCATION Advice clients that... 1. This effect usually diminishes over time. 2. Avoid hazardous activities (driving) if sedation is excessive 3. take medication at bedtime to minimize daytime sleepiness and to promote sleep.
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SIDE / ADVERSE EFFECTS of TRICYCLIC ANTIDEPRESSANTS (TCAs). Select prototype medication: amitryptyline (Elavil) 4) TOXICITY resulting in a CHOLINERGIC blockade and cardiac toxicity evidenced by dysrhythmias, mental confusion, and agitation; followed by seizures, coma,. and possible death
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NURSING INTERVENTION / CLIENT EDUCATION a. Give 1-week supply of medication to clients who are acutely ill. b. Obtain baseline ECG c. Monitor vital signs frequently d. Monitor signs for toxicity
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SIDE / ADVERSE EFFECTS of TRICYCLIC ANTIDEPRESSANTS (TCAs). Select prototype medication: amitryptyline (Elavil) 1. Decreased seizure threshold 2. Excessive sweating
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NURSING INTERVENTION / CLIENT EDUCATION 1. Monitor Clients for seizures 2. Inform clients for this side effect
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Contraindications / Precautions of TCA
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1. Pregnancy risk C 2. Contraindicated for seizure disorders 3. Use cautiously in clients with coronary artery disease, diabetes, liver, kidney and respiratory disorders. 4. Use cautiously for patients with urinary retention and obstruction, angle closure glaucoma, benign prostatic hypertrophy, hyperthyroidsim
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MEDICATION / FOOD INTERACTION WITH TCA's - amitryptyline (Elavil) (1) Concurrent use with MAOI
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may cause hypertension
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MEDICATION / FOOD INTERACTION WITH TCA's - amitryptyline (Elavil) (2) Concurrent use with antihistamines and other anticholinergic agents
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may result in additive anticholinergic effects
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MEDICATION / FOOD INTERACTION WITH TCA's - amitryptyline (Elavil) (3) Increased effects of EPINEPHRINE and DOPAMINE (direct-acting sympathomimetics) occur
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because uptake into the nerve terminals is blocked by TCAs and they remain for a longer amount of time in the synaptic space
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MEDICATION / FOOD INTERACTION WITH TCA's - amitryptyline (Elavil) (4) decrease the effects of EPHEDRINE and AMPHETAMINE (indirect acting sympathomimetic)
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because uptake into the nerve terminal is blocked and they are unable to reach site of action
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MEDICATION / FOOD INTERACTION WITH TCA's - amitryptyline (Elavil) (5) Concurrent use with alcohol, benzodiazepines, opioids, and antihistamines
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may result in additive CNS depression
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SSRI - fluoxetine (Prozac) - for DEPRESSION
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Other SSRI for Depression: 1.citalopram (Celexa) 2. escitalopram (Lexapro) 3. paroxetine (Paxil) 4. sertraline (Zoloft)
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Expected pharmacological action of SSRI for depression
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SSRI blocks reuptake of the monoamine neurotransmitter serotonin in the synaptic space, thereby intensifying the effects of SEROTONIN.
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Therapeutic uses of SSRI - fluoxetine (Prozac)
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1. major depression 2. OCD 3. bulimia nervosa 4. premenstrual dysphoric disorders 5. panic disorders 6. posttraumatic disorder (PTSD)
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SIDE / ADVERSE EFFECTS OF SSRI - fluoxetine (Prozac) (1) Sexual Dysfunction
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1. anorgasmia 2. impotence 3. decreased libido
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SIDE / ADVERSE EFFECTS OF SSRI - fluoxetine (Prozac) (2) CNS stimulation
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1. inability to sleep (take medication in the morning) 2. agitation, anxiety (avoid caffeine, practice relaxation)
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SIDE / ADVERSE EFFECTS OF SSRI - fluoxetine (Prozac) (3) weight loss early in therapy followed by weight gain with long-term treatment
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1. Monitor client's weight 2. Encourage clients to participate in regular exercise and to follow a healthy, well balanced diet
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SIDE / ADVERSE EFFECTS OF SSRI - fluoxetine (Prozac) (4) Serotonin syndrome may begin 2 to 72 hours after start of treatment and may be lethal
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Manifestations may include: a) mental confusion or difficulty concentrating b) agitation c) fever d) anxiety e) hallucinations f) hyperreflexia or incoordination g) diaphoresis h) tremors
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SIDE / ADVERSE EFFECTS OF SSRI - fluoxetine (Prozac) (5) WITHDRAWAL SYNDROME:
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1. headache 2. nausea 3. visual disturbances 4. anxiety 5. dizziness 6. tremors * Do not discontinue abruptly. Slowly taper the dosage to avoid withdrawal symptoms
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SIDE / ADVERSE EFFECTS OF SSRI - fluoxetine (Prozac) (6) Hyponatremia
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- more common among older adults taking diuretics - obtain baseline serum sodium, monitor level throughout treatment
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SIDE / ADVERSE EFFECTS OF SSRI - fluoxetine (Prozac) (7) Rash
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Advise clients to treat rash with antihistamines and notify provider
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SIDE / ADVERSE EFFECTS OF SSRI - fluoxetine (Prozac) (8) Sleepiness, faintness, and lightheadedness
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- These are not common, but can occur - Advise clients not to drive
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SIDE / ADVERSE EFFECTS OF SSRI - fluoxetine (Prozac) (9) GI bleeding
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- use cautiously in clients with a history of GI bleeding, ulcers, and those taking NSAIDs or anticoagulants
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SIDE / ADVERSE EFFECTS OF SSRI - fluoxetine (Prozac) (10) Bruxism
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- switch to another class of medication - treat with LOW DOSE BUSPIRONE - advise use of mouthguard during sleep
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MEDICATION / FOOD INTERACTION of SSRI - fluoxetine (Prozac) - Concurrent with: 1. MAOI 2. TCA 3. St. John's Wort
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1. MAOI should be discontinued
