Download PMHNP Review (Georgette). Material from Review Courses and Pocket Prep Question Banks and more Exams Nursing in PDF only on Docsity!
PMHNP Review (Georgette)
Lithium Level - normal *** 0.6-1. Lithium Toxicity *** >1. Narrow therapeutic window Lithium Gold Standard *** Manic Episodes has some slight effects on depressive symptoms Long-standing history Lithium has evidence for *** Reducing suicidal ideation Lithium for Bipolar *** Is neuroprotective. The neuroprotective effects of lithium are attributed to its ability to regulate several biological pathways and processes: Neuroprotective *** has properties that help protect neurons (nerve cells) from damage, degeneration, or death. This effect is significant in the context of neurodegenerative diseases, mood disorders, and other conditions that involve neuronal injury. Baseline Labs for Lithium *** Thyroid Panel (TSH) Serum Creatinine (.06-1.2) Blood Urea Nitrogen (BUN) 10- Pregnancy test (HCG) - all females 12-51 on psychotropics EKG 50+ Side effects of Lithium *** Endo (wt gain, hypothyroid)
CNS (fine hand tremor, fatigue, brain fog, HA, nystagmus) Dermatological (maculopapular rash, acne, pruritis) GI (Diarrhea, vomiting, cramps, anorexia) Renal (Diabetes insipidus, polyuria/polydypsia, edema, tubular changes in the kidneys) Cardiac (T wave inversion, dysrhythmia) Hematologic (leukocytosis - increased WBC) Drugs that reduce renal clearance *** Kidney disease, reduces renal clearance NSAIDS (Ibuprophen, Indocin) Thiazides (HCTZ) Ace Inhibitors (Lisinopril) these drugs cause an increase in serum concentration of the drugs excreted by the kidney such as Lithium Lithium excretion *** Kidney - impacted by drugs that reduce renal clearance Lithium toxicity *** Severe Nausea, vomiting, diarrhea Confusion, convulsions drowsiness, blurred vision slurred speech Muscle weakness Heart palpitations Coarse hand tremors Ataxia (unstable gait)
Phenelzine Selegiline Tranylcypromine Foods containing Tyramine *** Fermented soy products Yeast extracts Chocolate and cocoa Vinegar-based foods and condiments Alcohol - wine, non alcoholic beer, cola Bananas, figs, raisins, Fava beans, broad beans Overripe avacado - fruits and vegetables Pickled foods, sourkraut Smoked processed and cured meats Liver Smoked for pickled fish Hypertensive Crisis S/S *** BP 180/120 or greater Elevated BP Sudden explosive-like headache, occipital region Facial flushing Palpitations Pupillary Dilation Diaphoresis Fever
Hypertensive Crisis Treatment *** Follow a Tyramine Free Diet (prevention) Life-threatening crisis - Cannot be reversed unless more MAOI is produced by the body Can cause death DC the offending agent (MAOI) Administer phentolamine Stabilize fever Phentolamine *** reversible non-selective alpha adrenergic antagonist used for vasodilatory effect (treatment of HTN Crisis) Medications that induce Hypertensive Crisis *** Meperidine Stimulants and other sympathomimetics Decongestants TCAs Atypical Antipsychotics St. Johns Wort L-tryptophan Asthma meds (long and short inhalers) Many OTC cold and allergy meds Teratogenic Risks with Psychotropics *** Benzodiazepines (floppy baby syndrome, cleft palate) Carbamazepine (Tegretol) (Neural tube defect) Lithium (Eskalith) (Ebstein's anomaly a congenital heart defect) Divalproex Sodium (Depakote) (Neural tube defect - spina bifida)(also - cleft palate, ASD, possible long term defecits, ASD risk
Asians Risk with Carbamazepine (Tegretol) *** Stevens Johnson Syndrome - Screen for HLAB-1502 allele before initiating Allele HLA-1502 correlated with SJS when taking Carbamazepine (Tegretol) Psychotropics in Women of Childbearing age *** Check pregnancy status first in any female 12- HCG blood test Folic Acid *** Supports neural tube development in the first month of pregnancy 0.4-0.8mg daily for any women planning to become pregnant Clozapine (Clozaril) and Carbamazepine (Tegretol) *** Risk for neutropenia Check ANC absolute neutrophil count Monitor for signs of infection Normal ANC *** 2500- Monitor with Clozapine (Clozaril) and Carbamazepine (Tegretol) Risk for Neutropenia *** Monitored by checkin ANC Not WBC WBC Normal Range *** 4500-11, Clozapine (Clozaril) Monitoring *** 1st 6 months - Weekly 2nd 6 Months - Every 2 weeks If ANC is normal then monthly
Monitor for signs of infection (fever, chills, sore throat, weakness) When to D/C Clozaril/Carbamazepine *** ANC < 1000 (Due to risk of neutropenia) WBC 2000-3000 (Due to risk of agranulocytosis) Monitor for signs of infection (fever, chills, sore throat, weakness) MAOI with Seratonergic Agent *** Contraindicated Can cause serotonin syndrome Pregnancy Risks of using Psychotropics *** Transient agitation, sedation Apetite changes Premature labor Drug discontinuation syndromes Teratogenic effects from some Pregnancy Risk of not taking Psychotropics *** Recurrence of mental health symptoms adverse effects on mother infant bonding poor maternal self-care Pregnancy Categories *** Not used anymore A - controlled studies, no risk B- No evidence of risk in humans C- Risk cannot be ruled out D- Positive evidence of risk X- Absolute contraindication in pregnancy
Lactation L Divalproex Sodium (Valproic Acid, Depakote) Side effects *** Common: Nausea, abdominal cramps Dizziness, sedation Tremors Rare - Increased liver enzymes, SJS Unlike Carbamazepine, do not need to test for the HLAB-1502 allele Lamotrigine (Lamictal) Need to know *** Does not need blood monitoring Indicated for maintenance only Helps more with the depressive phase of bipolar affective disorder Concomitant use with divalproex sodium (Depakote) may double lamotrigine level - consider this when dosing Concomitant use with Carbamazepine may increase the metabolism of Lamictal, factor this into dosing Often used with Lithium, SGA, and antidepressants Lamotrigine (Lamictal) Side effects *** Common: Nausea Dizziness, ataxia, somnolence diplopia, headache, hepatotoxicity Labs for levels of Carbamazepine (Tegretol) or Divalproex Sodium (Valproic Acid/Depakote) *** 1 week after starting
12 hour trough level CBC LFT Response to Treatment with Lithium/Anticonvulsants *** 1-2 weeks When to check Lithium levels *** 5-7 days after starting or After dose adjustment 12 hour trough level (after last dose) Stevens Johnson Syndrome *** Occurs as an immune reaction to a foreign antigen after exposure to any anticonvulsant drug. Rare but life threatening Treatment for Stevens Johnson Syndrome *** stop the offending agent supportive measures often hospital burn unit Body Mass Index (BMI) *** Weight in pounds divided by (height in inches) x (height in inches) all x by 703 BMI *** Below 18.5 = Underweight 18.5-24.9 = Normal 25.0-29.9 = overweight 30 and above = obese Bulimia Nervosa presenting characteristics *** Recurrent episodic binge eating with inappropriate compensatory behaviors 2x per week for 3 months
Anorexia Pharmacological Treatment *** No specific meds Adjunctive meds Therapy Anorexia Non- Pharmacological Treatment *** Treat the underlying symptoms (depression, anxiety) Medical and nutritional stabilization Weight restoration Correction of electrolyte imbalances Vitamin supplementation Nutritional Counseling Dental care Anorexia Psychotherapeutic Interventions *** Behavioral therapy CBT Family Therapy Group Therapy Anorexia Restricting Type *** During the current episode, person has not regularly engaged in binge eating or purging behavior Anorexia eating or purging type Type *** During the current episode, the person has regularly engaged in binge eating or purging behavior Compensatory Behaviors to prevent Weight gain *** Self induced vomiting laxatives Enemas
Diuretics Stimulants Abuse of diet pills fasting excessive exercise Bulimia Nervosa Purging Type *** During the current episode, the person regularly has engaged in purging or the misuse of laxatives, enemas, or diuretics Bulimia Nervosa Non-Purging Type *** During the current episode, the person has used other inappropriate compensatory behaviors such as fasting and excessive exercise but has not regularly engaged in purging or misuse of laxatives, enemas, diuretics Anorexia Psych Exam findings *** Fear of gaining weight or becoming fat Refusal to maintain normal body weight Weight less than 85% of expected weight Dysphoric mood, constricted, sad, anxious, labile Preoccupied with food and body weight SI Low self-esteem Decreased concentration Impaired insight and judgement Lab findings for Anorexia *** CBC, Chemistry profile, Thyroid Function Tests, B12, Anemia (normochromic, normocytic) Leukopenia Neutropenia
Dynamic is a drug characteristic so remember pharmacodynamic is what the drugs do Cytochrome P450 System *** The metabolic process whereby drugs are metabolized using certain enzymes. First pass Intestine and liver Prior to going into systemic circulation Half life (T1/2) *** Time needed to clear 50 % of the drug from plasma Alterations in Cytochrome P450 System *** They can induce or inhibit the metabolism of certain other drugs (substrates) - thus changing the desired concentration levels Substrate is the drug undergoing metabolism CYP Inducers (D decrease) *** It can decrease the levels of the drug (Substrate - one being metabolized by that enzyme) of that enzyme Can cause subtherapeutic levels CYP Inhibitors (I increase) *** It can increase the level of the drug that is a substrate of that enzyme Can cause toxicity of drug CYP 450 Facts to know *** Caucasians 10% poor metabolizers of 2D Asians 20% may be reduced in 2C Young children may metabolize faster (2C9, 2C19, 2D6, 3A4) Young children may metabolize slower (1A2)
CYP 450 *** 2C
2C
2D
3A
1A
Liver Disease and CYP 450 System *** Affects activity of the enzymes and first pass metabolism can lead to toxic drug levels Elderly and Psychotropics *** Most psychotropics are lipophilic (love fat) and highly protien bound older adults have more fat and less protien More likely to develop- toxicity due to accumulation and erratic blood levels of the drug Drug Action *** Targets the receptor sites Ion Channel action (inhibitory, excitatory) Act on enzymes (example Maoi) Act on reuptake pumps (carrier proteins) Agonist effect *** Binds to receptor and activates the biological response Inverse agonist *** Drug causes the opposite effect of agonist, binds to same receptor Partial agonist *** Drug does not fully activate the receptors
Cimetidine Clarithromycin Fluoroquinolones Grapefruit and grapefruit juice Ketoconazole Nefazodone SSRIs Bull shit crap GPS (inducers) *** Barbituates St. Johns wort Carbamazepine Rifampin Alcohol (chronic) Phenytoin Griseofulvin Phenobarbitol Sulfonylureas Smoking cigarettes Sickfaces.com (inhibitors) *** Sodium Valproate Isoniazid Cimetidine Ketoconazole Fluconazole Alcohol (acute)
Chloramphenicol Erythromycin Sulfonamide Ciprofloxacin Omeprazole Metronidazole Clozapine *** Metabolized by CYP 1A2 mainly Carbamazepine (Tegretol) and Tobacco *** Both induce If they start smoking you have to increase the dose, if they stop you decrease the dose Elderly (risks for toxicity) *** Decreased intracellular water Decreased protein binding (more free active drug remains in body, risk for toxicity) lower muscle mass decreased metabolism increased body fat concentration Liver disease *** affects liver enzyme activity, first pass metabolism may result in toxic plasma levels Norepinephrine (noradrenaline). (NE) *** Produced in locus coeruleus and medullary reticular formation Norepinephrine (nor adrenaline) action *** affects: attention focus
