What needs to be monitored before administering Lithium?
CBC (plasma levels), Renal (Renal changes over time-Nephrotoxicity), Thyroid (Decreased thyroids function over time)
What are the side effects of taking Lithium?
GI distress, fine hand tremor, Inability to concentrate urine.
antihistamine effects
reduce nasal, salivary, lacrimal secretions, sedative, reduce itching
Name the potential side effects of antidepressant medication by class: Cylics
antihistamine effects
anticholinergic effects
alpha blocking effects
seizure
Hypomania
mania
fatal in OD
Bipolar 1 is characterized by what types of episodes predominately?
Manic
Bipolar 2 is characterized by what types of episodes predominately?
Depressive
Approximately how many percent of bipolar patients discontinue pharmacological therapy?
50
How many months must pass for a patient to be in remission?
6
What is the preferred agent for treating euphoric mania?
Lithium
Name the potential side effects of antidepressant medication by class: MAOIs
Orthostatic hypotenstion
insomina
weight gain
sweating
muscle cramps
myclonic twitching
CNS hyperstimulation
hypertensive crisis
How do MAOI antidepressants work?
monoamine oxidase breaks down monoamines. These inhibitors prevent the breakdown and therefore allow more dopamine, norepinephrine and serotonins in the synapse
How long before an antidepressant therapy take to work?
10 days to 2 weeks
How long does a client need to remain on an antidepressant?
6 months to 1 year
Name dietary restrictions for MAOIs
No tyramine!
Avocados, fava beans, aged cheeses, chocolate, bananas, figs, ginseng, vasopressor agents, salami, pepperoni, sausage, red wines
Serotonin syndrome
*confusion/restlessness
*lack of coordination
*tremors, rigidity
*hypertension
*hyperthermia
*seizures
*can lead to coma and death
*tachycarida
What is the severe SE associated with Clozapine?
Agranulocytosis
What are the common side effects of antipsychotics?
Weight gain, Sedation, Diabetes, metabolic syndrome
At what level of lithium will a patient be needed to put on dialysis?
2
What is the therapeutic maintenance blood serum level of Lithium?
0.6 -1.2 mEq/L
What are the cardio vascular risks of tricyclic antidepressant medication?
tachycardia
Which antidepressant medication could have the highest lethality if used in an overdose?
cyclic antidepressants cause cardiotoxicity in small amounts
Name the first agent of choice for treatment of bipolar disorder?
Lithium
Name the early signs of lithium toxicity.
*Severe GI distress
*N/V
*slurred speech
*impaired coordination
*ataxia
*confusion
*drowsiness
*irritability
Name potential side effects of antidepressant : SSRI.
*insomnia
*headache
*weight loss
*sexual dysfunction
*serotonin syndrome
What are the preferred first line agents for an acute depressive episode?
Lithium, Quetiapine
What is the characteristic side effect associated with Lamotrigine (Lamictal)?
SJS-Rash
What woud you add to a lithium treatment if a patient is having a psychotic depression?
Lamotrigine, divalproex sodium
Name symptoms: given lithium serum levels of 2.0 to 3.5 mEq/L.
excessive output of dilute urine
increasing tremors
muscular irritability
psychomotor retardation
mental confusion
giddiness
What benzo can be used in refractory cases of depression?
Carbemazepine
What is the preferred class of antidepressants?
SSRI
What is the most common side effect of Olanzapine (Zyprexa)?
Weight gain
What is the most common side effect of Quetiapine (Seroquel)?
Sedation
What is the most common side effect of Risperidone (Risperdal)?
EPS
What is the most common side effect of Ziprasidone (Geodon)?
QT prolongation
anticholinergic effects
Antipsychotics can cause blurred vision, dry mouth, sedation, confusion, constipation, and urinary retention due to inhibition of smooth muscle.
Which bipolar agent is the only agent that requires thyroid function monitoring?
Lithium
How many glasses of water should a patient on lithium drink daily?
six to eight large glasses
Patient teaching for lithium: patient should notify physician if one or both symptoms occur?
vomiting or diarrhea
What are the symptoms associated with lithium toxicity?
*persistent nausea
*persistent vomiting
*severe diarrhea
*ataxia
blurred vision
*tinnitus
*excessive output of urine
*increasing tremors
*increasing mental confusion
If diarhea or vomiting occur while on lithium it may result in__________loss and increased risk for toxicity.
sodium
When can a person taking lithium resume driving or operate dangerous machinery?
when lithium levels are stabilized
What bevarges should a person taking lithium avoid drinking and why?
caffinated beverages becuae caffine promotes increased urine output. Which will lead to greater retenstion of lithium.
After administering lithium, when should the first blood draw be taken?
12 hours
Name mild side effects of lithium.
� Mild side effects include:
1- Nausea
2- Abdominal discomfort
3- Mild diarrhea
4- Polyuria
5- Polydipsia
6- Fine hand tremors
7- Metallic taste
8- Weight gain
9- Muscle weakness
10- Fatigue
11- General discomfort
Plan of care for patients receiving mood stabilizong agens should included two things
1. monitoring for side effects
2. intervening when required to prevent th occurance of adverse effects relat3e to medication administration
At what blood serum level should lithium be withheld and Doctor notified?
level reaches 1.5 mEq/L or earliest observation of mildest symptoms
Name symptoms: given lithium serum levels of 1.5 to 2.0 mEq/L.
*blurred vision
ataxia
tinnitus
persistent nausea
vomiting
severe diarrhea
Name symptoms: given lithium serum levels above 3.5 mEq/L.
impaired consciousness
nystagmus
seizures
coma
oliguria/anuria
arrhythmias
myocardial infarction
cardiovascular collapse
ataxia
-Loss of motor control including tremors, dysdiadochokinesia, dyssynergia, visual nystagmus
nystagmus
Involuntary rapid eye movements
alpha blocking effects
...
Which benzodiazepine is both beneficial as an anticonvulsant and a mood stabilizer?
Clonazepam is both a anticonvulsant and mood stabilizer
Name two anticonvulsant drugs that could be used to manage manic symptoms, or be added to augment effects of lithium.
1. Valporic Acid Depakote (added to lithium for mania)
2. Tegretol
What type of patient needs ECT considered to be a safer alternative to medications?
*clients who are high suicidal risk
*medically deteriorated
*pregnant
*those that do not respond to meds
*elderly
*those at high risk for anticholinergic side effects of meds
How does ECT affect the brain to treat depression?
mobilizes neurotransmitters as a result of grand map seizure
What medical conditions are contraindications for ECT?
heart conditions
After ECT, what can a client and family expect?
*memory initially imparied - past and recent
*transient confusion and memory impairment
*common for up to 6 weeks
*learn new material ability returns in 6-9 months
What medications are used when treating withe ECT?
*atropine sulfate (controls secretions & prevents bradycardia)
*sedative like Brevitol (muscle relaxant to prevent body response)
*succinylcholine (inhibits transmission of nerve impulses, outcome paralysis)
Name the risk factors for the development of depression.
1. family history
2. early childhood experience (trauma)
3. medications
4. substance abuse
5. medical illnesses
6. stress
7. tobacco
8. gender
9. Age
What is the black box warning issued by the FDA for all antidepressants?
increased risk of suicidal thinking and behavior, known as suicidality in young adults generally one to two months
*doubles the risk for suicide
Difference between cyclothymic disorder and bipolar disorder?
cylothymic disorders do not experience the extremes of the the mood spectrum of manic or major depression.
State the acute mania serum concentration.
1.0 - 1.5 mEq/L
How often are lithium serum levels check?
monitored 1x - 2x a week after initial treatment until dosage and serum levels are stable
State three medications that can give clients depression-like symptoms.
*valium (diazepam)
*percocet
*demerol
Name the side effects of clonazepam.
*drowsiness, tthrombocytobenia, increased salivation, nystagamus, diplopia, rash
Name side effects of Valporic acid (anticonvulsant)
*drowsiness, N/V, constipation, diarrhea, dyspepsia, increased bruising, rash, photosensitivity
Name side effects of Tegretol
GI and hematologic side effects
SSRI + MAOIs =
serotonine syndrome
Changes in circadian rhythms increases the risk for?
developining bipolar
What are the most common mod disorders that precede suicide?
major depression and bipolar disorders
Steps for ECT pre procedure.
*informed consent
*NPO 8 hours
*IV
*medications
*airway management
*cardiac monitor and vital signs
What does ECT induce?
grand mal seizure
At what age will morbid thoughts and worry begin in children with mood disorders?
9 -12 years old
What SSRI should be avoided by the elderly due to possible drug interaction?
prozac
State the national suicide rate for men 85+
4x the national suicide rate
bereavement overload
An accumulation of grief that occurs when an individual experiences many losses over a short period and is unable to resolve one before another is experienced. This phenomenon is common among the elderly.
*may lead to depression
Length of time before meds begin to work?
10 days to 2 weeks
How should a patient deal with orthostatic changes?
change position slowly
What can a patient do for anticholinergic effects of antidepressant medications?
dry mouth - candy, fluids, sugarless gum
Which antidepressant medication is the only one that does not cause weight gain?
Remerol
remerol
mirtazapine
How to manage weight gain?
advise patient to have a low calorie diet, exercise
In the elderly symptoms of depression can be confused with?
dementia
dementia
An abnormal condition marked by multiple cognitive defects that include memory impairment.
zoloft is in what medication class
SSRI
Name the drug class of Cymbalta.
(Duloxetine) Antidepressant SNRI
SNRI
Inhibits the reuptake of norepinephrine and serratonine in the synapse. Allowing for more of each neurotransmitter to be in synapse
Give the advantage of SNRI vs. Cyclics?
fewer side effects (GI, seizures)
What SNRI is useful for pain as well?
Cymbalta
What type of neuromuscular disoders does Cymbalta help to treat?
*fibromyalgia
*rheumatory arthritis
Name two SNRIs
Effexor
Cymbalta
DNRI
an active metabolite that blocks the reuptake of dopamine and norephinephrine and works in the brain as a psychostimulant
Bupropion
Antidepressant and smoking cessation
Bupropion is the same drug with two different brand names to treat two different issues, state the brand names and issue treated.
1. Wellbutrin an DNRI used to treat depression
2. Zyban an DNRI used as a smoking deterrent
Bupropion interacts with the following drugs:
alcohol
tricyclic's
MAOs (cause acute toxicity)
What is the wash out period for MAOIs, before another drug that may interact can be used?
2 weeks
Name six popular SSRIs.
1. lexapro
2. paxil
3. zoloft
4. celexa
5. luvox
6. prozac
Which antidepressant is approved for kids?
Prozac
down regulation
Phenomenon in which there is a decrease in the number of receptors in response to an excess of a hormone or neurotransmitter.
What medication can interact with MAOIs?
*Cold, sinus, asthma or allergy meds
*antihistamines
*deongestant and inhalers
*stimulants, diet pills
*cough meds
tyramine
a compound that occurs naturally in cheese and other foodsand can cause dangerously high blood pressure in people taking MAOIs, it acts as a catecholamine releasing agent.
MAOIs + tyramine =
hypertensive crisis
Name three popular MAOIs.
Remember.....No Popular Meds
*Nardil
*Parnate
*Marplan
serotonin modulators
ex. trazodone; commonly used for major depression, sleep problems, and premenstrual dysphoric syndrome
How does Trazodone work?
blocks histamine receptors and causes significant sedating properties. In men it may cause priapism
priapism
prolonged erection of the penis
Side effects of SARIs?
*agitation
*restlessness
*akathisia
*sexual dysfunction are decreased
Name two types of serotonin modulators
1. Tazadone
2. Nefazodone
Nursing diagnoses for depression involving "distrubed
*Disturbed though process
*Disturbed thought process
*Disturbed sensory perception
Nursing diagnoses for depression involving "risk
Risk for violence
Nursing interventions for depression.
1. provide safe environment
2. encourage socialization and participation in program
3. assess prior coping skills
4. teach adaptive coping (relaxation,journaling)
5. educate about disorder
6. assess mental status for suicidal thoughts
Name a MAOI that is in patch form.
Emsam (seligiline)
What is St. John's Wart used to treat?
depression
Cyclic antidepressant block re-uptake of 5HT and NE
will prevent the uptake pump in neuron from removing neurotransmitters from being reabsorbed and removed from synapse
euthymia
normal range of moods and emotions
up regulation
Increase in the number of receptors on the target organ. This takes place when there is a low level of stimulating hormone.
What is the purpose of all antidepressants?
balance neurotransmitters
Name the six classes of antidepressants
1. cyclic
2. MAOIs
3. SSRIs
4. serotonin modulators
5.DNRI
6. SNRI
DNRI mean
Dopamine Norepinephrine Reuptake Inhibitor
Nursing interventions for early lithium toxicity.
Hold medication and notify MD, measure blood lithium
What is the therapeutic serum concentration of lithium for acute mania?
1.0 to 1.5 mEq/L
Name an anticonvulsant that is used to treat bipolar disorder.
Valporic acid (Depakote)
hematologic
Abnormal blood cells, anemia, bleeding, bruising
What is the side effect of Lamictal lamotrigine(anticonvulsant)?
Stevens-Johnson syndrome, angio edema, hepatoxicity
What anticonvulsant is used to manage manic symptoms and used with lithium?
Valoporic Acid
State the therapeutic level of valporic acid.
50-100
What does valporic acid help prevent in patients with bipolar?
episodes of mania
trazodone (SARI)
(Desyrel) - Atypical antidepressant; one of the most commonly used meds in US; very sedating and sometimes used as sleeping aid; Can cause necrotizing priapism (sentinel erection is harbinger of priapism risk); Inhibits serotonin reuptake and may be serot