WCU Mental Health Exam 2 with complete solutions

Anxiety Meds : Anxiolytics (BZD-Non BZD) - Answer- Indication: anxiety, excessive worry, restlessness, irritability, insomnia, alcohol withdrawal symptoms and seizure Anxiety Meds: Anxiolytics (BZD) - Answer- Side effects: sedation, mental confusion, dizziness, anterograde amnesia (loss of the ability to create new memories after the event that caused the amnesia), ataxia (uncoordinated movement), risk for falls with elderly. Withdrawal symptoms: anxiety, seizure, muscle tension Anxiolytics: Benzodiazepine (BZD) - Answer- - lorazepam (Ativan) - diazepam (Valium) - alprazolam (Xanax) - clonazepam (Klonopin) - chlordiazepoxide (Librium) ***expected pharmacological action of meds: enhances the inhibitory effects of gamma-aminobutyric acid (GABA) in the central nervous system. Relief of anxiety occurs rapidly following administration. Adverse effect and RN intervention of Benzodiaepine (BZD) - Answer- CNS depression, such as sedation, light headedness, ataxia, and decreased cognitive function. -Intervention: notify provider if effects occur, advise the client to avoid hazardous activities (driving etc...) Adverse effect and RN intervention of Benzodiaepine (BZD) - Answer- Anterograde amnesia, difficulty recalling events that occur after dosing. -Intervention: notify provider, withhold medication if effects occur Adverse effect and RN intervention of Benzodiaepine (BZD) - Answer- Acute toxicity (-oral toxicity, -iv toxicity (valium ativan)): Intervention: flumazeril (Romazicon) is administered to counteract sedation and reverse adverse effects, Oral toxicity use gastric lavage (activated charcoal), monitor Pt vitals, maintain patent airway, provide fluids to maintain BP. Ensure availability of resuscitation equip Adverse effect and RN intervention of Benzodiaepine (BZD) - Answer- Paradoxical response (insomnia, excitation, euphoria, anxiety, rage): Intervention: observe for signs, notify provider Adverse effect and RN intervention of Benzodiaepine (BZD) - Answer- Withdrawal effects ( anxiety, insomnia, diaphoresis, tremors, and light headedness). Intervention: taper dose over several weeks using prescribed tapered dosing schedule Anxiolytics: Non Benzodiazepine - Answer- - buspirone (Buspar): Indication: Anxiety. Side Effects: headache, dizziness, nausea, agitation. *** Bonus: no physical dependence or withdrawal. Takes 2-3 weeks to see full therapeutic effect, therefore need maintenance dose and cannot be taken on a PRN basis. Anxiolytics: Non Benzodiazepine - Answer- ***expected pharmacological action: exact anti anxiety mechanism is unknown. Med binds w/serotonin and dopamine receptors. Less dependency than with other anxiolytics, and use of Buspar will NOT result in sedation or effects of other CNS depressants Other meds used to treat anxiety besides Anxiolytics - Answer- - antidepressants ( Paxil, Zoloft, Effexor, Elavil, Anafranil). -antihistamines (Vistaril). -beta blockers (Inderal). - anticonvulsants ( Neurontin) Depressive disorder meds: (TCA, SSRI, MAOI, Atypical) - Answer- 4 main groups: TCA&s, SSRI, MAOI, Atypical. Depressive disorders are a leading cause of disability. Relief is not immediate, may take several weeks or more to reach full therapeutic effect, encourage continued compliance. Pts may require hospitalization until peak effect is achieved. Depressive disorder meds: Tricyclic Antidepressants (TCAs) - Answer- - amitriptyline (Elavil) - imipramine (Tofranil) - doxepin (Sinequan) - amoxapine (Asendin) ***Expected pharmacological action: block reuptake of norepinephrine and serotonin in the synaptic space, thereby intensifying the effects of these neurotransmitters. ** should not be taken w MAOs due to severe hypertension Tricyclic Antidepressants (TCAs): adverse effects and RN interventions - Answer- orthostatic hypotension: advise client to sit or lie down, monitor blood pressure and heart rate, if significant decrease in blood pressure and/or increase in heart rate do not administer the med and notify the provider Tricyclic Antidepressants (TCAs): adverse effects and RN interventions - Answer- Anticholinergic effects (dry mouth, blurred vision, photophobia, urinary retention, constipation, tachycardia): have client minimize anticholinergic effects -chewing sugarless gum -sipping on water -wearing sunglasses outdoors -eating high fiber foods -exercise -increase fluid intake to 2L/day -void just before taking med Tricyclic Antidepressants (TCAs): adverse effects and RN interventions - Answer- Toxicity: give no more than 1 wk supply of med to clients who are acutely ill due to risk of overdose, obtain baseline ECG, monitor vital signs, monitor for signs of toxicity Tricyclic Antidepressants (TCAs): other adverse effects and RN interventions - Answer- - Sedation (avoid hazardous activity) -decreased seizure threshold -excessive sweating -weight gain -arrhythmia Depressive disorder meds: Serotonin Reuptake Inhibitors (SSRIs) - Answer- - fluoxetine (Prozac) - citolopram (Celexa) - escitalopram (Lexapro) - paroxetine (Paxil) - setraline (Zoloft) - vilazodone (Vibryd) ***expected pharmacological action: selectively block reuptake of the monamine neurotransmitter serotonin in the synaptic space thereby intensifying the effects of serotonin ** Do not take concurrent with MAOIs, TCAs, or St. Johns Wort Selective Serotonin Reuptake Inhibitors (SSRIs): adverse effects and RN interventions - Answer- - Sexual dysfunction (anorgasmia, impotence, decreased libido): lower the dose, medication holiday, using adjunct meds to improve function, switch to atypical anti-depressant such as Wellbutrin Selective Serotonin Reuptake Inhibitors (SSRIs): adverse effects and RN interventions - Answer- CNS stimulation (insomnia, agitation, anxiety): take medication in the morning, avoid caffeinated beverages, teach relaxation techniques Selective Serotonin Reuptake Inhibitors (SSRIs): adverse effects and RN interventions - Answer- Serotonin syndrome: may begin 2-72 hr after the start of treatment and it may be lethal, manifestations include confusion, difficulty concentrating, abdominal pain, diarrhea, agitation, fever, anxiety, hyperreflexia: instruct client to withhold medication and notify provider Selective Serotonin Reuptake Inhibitors (SSRIs): adverse effects and RN interventions - Answer- -occurrence of weight loss early in therapy that may be followed by weight gain with long term treatment - withdrawal syndrome - hyponatremia - rash - sleepiness, faintness, lightheadedness -gastrointestinal bleeding - bruxism (grinding of the teeth) Depressive disorder meds: Monoamine Oxidase Inhibitors (MAOIs) - Answer- PaNaMa - tranytcypromine (Parnate) - phenelzine (Nardil) - isocarboxazid (Marplan) ***Expected pharmacological action: block MAO in the brain, thereby increasing the amount of norepinephrine, dopamine, and serotonin available for transmission of impulses. An increased amount of those neurotransmitters at nerve ending intensifies responses and relieves depression. Monoamine Oxidase Inhibitors (MAOIs): adverse effects and RN interventions - Answer- -CNS stimulation (anxiety, agitation, hypomania, mania), -Orthostatic hypotension: hold medication and notify provider, advise client to change positions slowly, -Hypertensive crisis due to intake of tyramine, - Local rash when using transdermal prep Monoamine Oxidase Inhibitors (MAOIs): hypertensive crisis/tyramine intake adverse effects - Answer- Tyramine intake revisited: hypertensive crisis can result from intake of dietary tyramine. Tyramine is an amino acid released from proteins during aging, fermentation, pickling, smoking, and spoiling. Manifestations may include headache, nausea, increased heart rate, increased BP. Monoamine Oxidase Inhibitors (MAOIs): hypertensive crisis/tyramine intake Interventions - Answer- RN interventions: Adverse effects: administer phentolamine (Regitine) IV, or nifedipine (Procardia), provide continuous cardiac monitoring and respiratory support. Med/Food interactions: strict dietary restrictions, provide written instructions regarding foods to avoid, avoid taking meds w/o provider approval. Tyramine enriched foods: aged cheese, pepperoni, salami, avocados, figs, bananas, smoked fish, protein, some dietary sups, beers, and red wine. Depressive disorder meds: Atypical antidepressants - Answer- - bupropion (Wellbutrin). ***expected pharmacological action: acts by inhibiting dopamine uptake Atypical antidepressants: adverse effects and RN interventions - Answer- - headache, dry mouth, GI distress, constipation, increased HR, nausea, restlessness, insomnia: treat headache w/mild analgesic, advise client to sip water to treat dry mouth and increase dietary fiber to prevent constipation. - suppression of appetite resulting in weight loss: monitor the client's food intake and weight. - seizures, especially at higher dose ranges: avoid administering to clients at risk, such as clients with HEAD INJURY Atypical antidepressants: food interactions - Answer- do not use with MAOIs such as phenelzine (Nardil) due to higher risk of toxicity. Bipolar disorder meds - Answer- Mood stabilizer: lithium carbonate (Eskalith, Lithane, Lithobid). Antiepileptic: valproic acid (Depakote), carbamazepine (Tegretol), lamotrigine (Lamactil). Bipolar disorder meds: mood stabilizer - Answer- lithium carbonate (Eskalith, Lithane): expected pharm action: produces neurochemical changes in the brain, including serotonin receptor blockade, evidence that lithium decreases neuronal atrophy and/or increases neuronal growth. 1. Bipolar disorder meds: mood stabilizer: adverse effects and RN intervention - Answer- - gastrointestinal distress (nausea, diarrhea abdominal pain): administer meds w/meal or milk. - fine hand tremors: administer beta-adrenergic blocker (proprnaolol (Inderal)), adjust dosage to be as low as possible, increase tremor = lithium toxicity. - weight gain: advise healthy diet and exercise regimen 2. Bipolar disorder meds: mood stabilizer: adverse effects and RN intervention (contd) - Answer- - polyuria, thirst: use K+ sparing diuretic (spironolactone (Aldactone), advise consumption of 2-3L fluid per day. - renal toxicity: monitor I&O, use lowest dose necessary, assess BUN & creatinine and monitor kidney function. -goiter and hypothyroidism: TSH levels (T3/T4), administer levothyroxine (Synthroid). - bradydysrhythmias, hypotension, electrolyte imbalances: maintain adequate fluid intake Mood stabilizer (lithium): blood levels - Answer- Therapeutic: 0.8-1.4 Maintenance: 0.4-1.3 Toxic: 1.5 and greater lithium toxicity levels: clinical manifestations - Answer- - less than 1.5: diarrhea, nausea, vomiting, thirst, polyuria, muscle weakness , tremors, slurred speech. -1.5 to 2.0: mental confusion, poor coordination, coarse tremors, GI distress. -2.0 to 2.5: extreme polyruia of dilute urine, tinnitus, blurred vision, ataxia, seizures, hypotension leading to coma, death , respiratory probe. - 2.5 and up: rapid progression of manifestations leading to death. lithium toxicity levels: RN intervention - Answer- -less than 1.5: withhold meds, administer new dose based on lithium and Na levels. - 1.5 to 2.0: withhold, new dose based on levels, promote excretion. - 2.0 to 2.5: administer emetic or gastric lavage, (urea, mannitol, or aminophylline) may be given to increase excretion. - 2.5 and up: hemodialysis Mood stabilizer (lithium): med/food interaction - Answer- - diuretics, - NSAIDS, - Anticholinergics. ***no breast feeding. Bipolar disorder meds: anti epileptic drugs (AEDs) - Answer- - carbamazepine (Tegretol, Equetro), - valproic acid (Depakote), - lamotrigine (Lamactil). ***expected pharmacological action: - slow entrance of Na and Ca back into the neuron, thus extending the time it takes for the nerve to return to active state. - potentiating inhibitory effects of GABA. - inhibit glutamate which suppresses CNS excitation Bipolar disorder meds: anti epileptic drugs (AEDs): adverse effects/RN intervention: carbamazepine (Tegretol, Equetro) - Answer- - Steven Johns Syndrome: treat mild cases w/ anti-inflammatory, advise use of sunscreen, withhold meds and notify provider effect on cognitive function, - CNS effects (nystagmus, double vision, vertigo, stagger giant, headache): gradually increase dose, advise this should subside in a few weeks, bedtime doses. - blood dyscrasias (leukopenia, anemia, thrombocytopenia): check CBC and platelet, observe for bleeding gums and bruising, monitor for indications of infection (fever/lethargy). - teratogenisis: avoid use during pregnancy. - hypo-osmolarity: monitor serum Na, monitor edema. Bipolar disorder meds: anti epileptic drugs (AEDs): adverse effects/RN intervention: lamotrigine (Lamactil) - Answer- - double or blurred vision, headache, nausea, vomiting: discourage activities that require concentration/visual acuity. - Steven Johns Syndrome: treat mild cases w/ anti-inflammatory, advise use of sunscreen, withhold meds and notify provider Bipolar disorder meds: anti epileptic drugs (AEDs): adverse effects/RN intervention: valproic acid (Depakote) - Answer- - GI effects (nausea, vomiting, indigestion): effects are self limiting, take meds w/food or switch to enteric formulations. - hepatoxicity (anorexia, nausea, fatigue, jaundice): assess liver function every 2-6 mos, avoid use in children younger than 2, administer low dose. - pancreatitis (nausea/vomiting): monitor amylase levels, discontinue med. - thrombocytopenia: observe for bruising/bleeding gums. - teratogenesis: avoid during pregnancy Bipolar disorder meds: anti epileptic drugs (AEDs): med/food interaction:carbamazepine (Tegretol, Equetro) - Answer- - oral contraceptives, - grapefruit juice, - phenytoin or phenobarbital (concurrent use decreases effects by stimulating metabolism) Bipolar disorder meds: anti epileptic drugs (AEDs): med/food interaction: lamotrigine (Lamactil) - Answer- - carbamazepine (Tegretol), phenytoin or phenobarbital (concurrent use decreases effects by stimulating metabolism). - valproic acid (Depakote), oral contraceptives Bipolar disorder meds: anti epileptic drugs (AEDs): med/food interaction: valproic acid (Depakote) - Answer- - phenytoin or phenobarbital (serum levels of meds are increased when used together) Bipolar I Disorder (Most severe) - Answer- characterized by at least one week-long manic episode that results in excessive activity and energy. Manic episodes may alternate with depression or a mixed state of agitation and depression. Mania: The presence of three of the following constitutes mania - Answer- -extreme drive and energy -inflated sense of self importance -drastically reduced sleep requirements -excessive talking combined with pressured speech -personal feeling of racing thoughts -distraction by environmental events -unusually obsessed with goals -purposeless arousal and movement -indiscriminate spending, sexual encounters, or risky investments Mania - Answer- Mania can be euphoric (feels wonderful in the beginning, but turns scary and dark as pt loses control) or dysphoric (depressive symptoms along with mania) Bipolar II disorder (2nd most severe) - Answer- low level mania alternates with profound depression (low level mania = hypomania). Hypomania of bipolar II disorders tends to be euphoric and often increases functioning. Like mania, hypomania is accompanied by excessive activity and energy for at least four days and involves at least three of the behaviors listed under mania. Cyclothymic disorder (3rd most severe) - Answer- symptoms of hypomania alternate with symptoms of mild to moderate depression for at least two years in adults and one year in children. Difficult to distinguish from Bipolar II Rapid Cycling (Least severe) - Answer- at least four mood episodes in a 12 month period. Characteristics of mania - Answer- -mood -behavior -thought processes and speech patterns -cognitive function Flight of ideas - Answer- a nearly continuous flow of accelerated speech with abrupt changes from topic to topic that are usually based on understandable associations or plays on words. Clang associations - Answer- stringing together of words bc of their rhyming sounds, without regard to their meaning Grandiosity - Answer- exaggerated achievements or importance, state that they know famous people, believe they have great powers Limit setting (mania) - Answer- Limit setting is the main theme in treating a person in mania. Consistency among staff is imperative if the limit setting is to be carried out effectively 3 phases of mania associated with bipolar disorders - Answer- -Acute phase: primary outcome is injury prevention. -Continuation phase: last for 4-9 months. overall outcome of this phase is relapse prevention. -Maintenance phase: continue to focus on prevention of relapse and limitation of the severity and duration of future episodes Bipolar disorders with acute depressive episodes - Answer- Lithium and Lamactil are the first line of treatment for a person with bipolar disorder experiencing an acute depressive episode. since Pt's CNS may become overactive antidepressants are not recommended. Psychopharmacological interventions: Bipolar Disorders - Answer- Individuals with bipolar disorder often require multiple medications. For sever manic episodes, Lithium or Depakote and a second generation antipsychotic such as Zyprexa or Risperdal are recommended. Antidepressants that may have been prescribed previously are often tapered and possibly discontinued to reduce mania/hypomania Bipolar and related disorders: Lithium Carbonate - Answer- Lithium is effective in the treatment of bipolar I acute and recurrent manic and depressive episodes. Lithium must reach therapeutic levels in the PT's blood to be effective, this usually takes 7-14 days. An antipsychotic or benzodiazepine can be used to prevent exhaustion, until lithium reaches therapeutic levels. Lithium: Lithane, Eskalith, and Lithonate - Answer- therapeutic level: 0.8-1.4, maintenance level: 0.4-1.3. To avoid serious toxicity lithium levels should not exceed 1.5 Lithium Side Effects and Signs of Lithium Toxicity: Expected Sides - Answer- 0.4-1.4: Fine hand tremors, polyuria, mild thirst, mild nausea, general discomfort, and weight gain. Intervention: symptoms may persist throughout therapy or symptoms may subside after a period of time. weight gain is controlled by diet Lithium Side Effects and Signs of Lithium Toxicity: Early signs - Answer- 1.5: nausea, vomiting, diarrhea, thirst, polyuria, lethargy, slurred speech, muscle weakness, fine hand tremor Lithium Side Effects and Signs of Lithium Toxicity: advanced signs - Answer- 1.5-2.0: coarse hand tremor, persistent gastrointestinal upset, mental confusion, muscle hyper irritability, electroencephalographic changes, incoordination, sedation Lithium Side Effects and Signs of Lithium Toxicity: severe - Answer- ataxia, giddiness, serious electroencephalographic changes, blurred vision, clonic movements, large output of dilute urine, seizures, stupor, severe hypotension, coma. Death is usually secondary to pulmonary complications Lithium Side Effects and Signs of Lithium Toxicity: > 2.5 - Answer- >2.5: convulsions, oluguria, and death can occur Lithium therapy - Answer- 2 major long term risks of lithium therapy are hypothyroidism and impairment of the kidney's ability to concentrate urine Lithium contraindications - Answer- laboratory examinations should include assessment of renal function, determination of thyroid status (levels of thyroxin and thyroid stimulating hormone), and a electrocardiogram Bipolar and related disorders: Anticonculsant - Answer- 3 anticonvulsant drugs have demonstrated efficacy for the treatment of mood disorders: Depakote, Tegretol, and Lamactil Depakote - Answer- Monitor liver function and platelet count periodically. Tegretol - Answer- works better for Pt with rapid cycling and paranoid. Monitor liver function and platelet count. Blood levels should be monitored for the first 8 weeks due to increased levels of liver enzymes that can speed up the drugs metabolism. Lamactil - Answer- first line of treatment for bipolar depression and is approved for acute and maintenance therapy. Generally well tolerated, but can cause deadly rash (Steven Johnsons Syndrome. Depressive Disorder: Major Depressive disorder - Answer- characterized by persistent depressed mood lading for a minimum of 2 weeks. May be a single episode or recurrent episode. Depressed mood is accompanied by a lack of interest in previously enjoyable activity (anhedonia), fatigue, sleep disturbance, change in appetite, feelings of hopelessness, thoughts of death or suicide, inability to concentrate or make decisions, and a change in physical activity. Not only does Pt have a depressed mood or anhedonia but also has at least five of the other 8 symptoms listed above. No episodes of mania or hypomania Depressive Disorder: Dysthymic disorder - Answer- occurs when feelings of depression persist consistently for at least 2 years. Onset of disorder usually occurs during teenage years, but is usually not severe enough to require hospitalization Depressive Disorder: Premenstrual dysphoric disorder - Answer- a cluster of symptoms that occur in the last week prior to the onset of a woman's period. Symptoms usually not severe enough to interfere with the ability to work or interact with others Depressive Disorder: Substance-induced depressive disorder - Answer- applies when symptoms of a major depressive episode arise as a result of prolonged drug or alcohol intoxication or as the result of withdrawal from drugs of alcohol Depressive Disorder Facts - Answer- - Depression is the leading cause of disability in the United States. - The combination of anxiety and depression is perhaps one of the most common psychiatric presentations. -The incidence of major depression greatly increases with the occurrence of a magical