Exam 2 Patho/Pharm #1

Mental Health and Gas Exchange

major depressive disorder

the primary reason antidepressant medications are given

Depression

Deficiency of one or more norepi, serotonin and dopamine is the biological basis.

norepi, serotonin, and dopamine are types of

monoamine neurotransmitters

General Treatment

individual symptoms 

medical history

side effects 

History of past response 

Patient Education

Antidepressant

Symptoms resolve slowly

The responses develop after 1-3 weeks

Max responses are not seen for 12 weeks

HIGH RISK FOR SUICIDE

Tricyclic Antidepressants

blocks reputake of monoamine transmitters, norepi and serotonin

off-label use of Tricyclic antidepressants

• fibromyalgia

• neuropathic pain

• chronic insomnia

• ADHD

• Panic Disorder

• OCD

adverse effects of tricyclic antidepressants

• sedation

• orthostatic hypotension

• cardiac toxicity (dysrhythmias)

• anticholinergic adverse reactions

Selective Serotonin Reuptake Inhibitors

produce selective inhibitions of serotonin reuptake 

produce CNS excitement 

Does not cause hypotension, sedation, or anticholinergic effects

used for bipolar disorder

Adverse effects of Selective Serotonin Reuptake Inhibitors

• teratogenesis (birth defects)

• Extrapyramidal side effects

• Serotonin syndrome (agitation, confusion, anxiety)

• Bleeding disorders (hemoglobin, hematocrit, platelets)

Monoamine Oxidase Inhibitors

converts monoamine neurotransmitters (norepi, serotonin, and dopamine) into active products

Off label use of monoamine oxidase inhibitors

• bulimia nervosa 

• agoraphobia

• ADHD

• OCD

• Panic Attacks

Adverse Effects of monamine Oxidase Inhibitors

CNS stimulations

Orthostatic Hypertension

Hypertensive Crisis/dietary tyramine

sending cell

pre-synaptic neuron

receiving cell

synaptic cell

hypertensive crisis

extreme blood pressure

tyramine

promotes the release of norepi from sympathetic neurons.

examples of tyramine foods

• yeast extracts 

• most cheeses

• fermented sausages 

• aged fish or meat

Bupropion (Wellbutrin)

Atypical Depressant

Actions and uses of Bupropion

acts as a stimulant and suppresses appetite

antidepressant effects begin in 1-3 weeks

Adverse Effects mostly known from First Generation Antipsychotics

Extrapyramidal symptoms (early)

Tardive Dyskinesia (Late)

Treatment for FGA’s

beta blockers 

benzodiazepines

Anticholinergics '

providers many prescribe other medications to slow down the side effects

Adverse Effects of Neuroleptic Malignant Syndrome

• Rigidity

• Fever

• Sweating

• Dysrhythmias

• Fluctuations in blood pressure

Nursing actions for Neuroleptic Malignant Syndrome

• Cooling blankets

• Rehydration

• Drug therapy

  • Dantrolene–muscle relaxer

What is orthostatic hypotension?

When the blood pressure drops critically low when someone stands up from sitting or lying down.

 Nursing interventions for Orthostatic hypertension

Check blood pressure 

• lying 

• sitting 

• standing 

• If blood pressure drops 20 mm/hg (positive sign) 

What is agranulocytosis?

critically low number of granulocytes (white blood cells).

Nursing actions for agranulocytosis

 Monitor White Blood Cell Count (low)

Absolute Neutrophil Count (ANC) (low)

Monitor for signs and symptoms of infection

Agranulocytosis/neutropenia ANC less than 500µL

Metabolic syndrome

• insulin resistance

• high blood pressure

• high triglyceride

• low HDL cholesterol

Adverse effects of Anticholinergic 

• dry mouth 

• blurred vision 

• photophobia 

• tachycardia 

• urinary retention 

• constipation 

• Anhidrosis–inability to sweat

Mood stabilizers warnings

• Check sodium level and kidney function labs

• lithium toxicity

medications used in combinations

• mood stabilizers

• antipsychotics

• antidepressants

• benzos

three major drugs primarily used for bipolar disorder

• mood stabilizers

• antipsychotics

  • antidepressants

frequently used for sedation 

benzodiazepines

mood stabilizers

drugs that play multiple key roles in managing bipolar disorders

Key roles of Mood Stabilizers

1. relieve symptoms during both manic and depressive episodes

2. prevent recurrence of manic and depressive episodes

3. do not worsen symptoms of mania or depression, nor do they accelerate the rate of cycling.

Antipsychotic Drugs 

• Given to help control symptoms during severe manic episodes 

• can be used even if psychotic symptoms are absent

Antidepressants

• May be needed during a depressive episode

• almost always combined with a mood stabilizer in patients with Bipolar disorder

principal mood stabilizers

• lithium

• Divalproex sodium (valproate–originally for epilepsy)

• Carbamazepine–originally for epilepsy

sometimes antipsychotics drugs are added to the regimen

Nursing actions for Lithium

• Minimize Toxicity Risk

  • levels must be monitored to minimize the risk of toxicity.

  • The trough level should be measured 12 hours after the evening dose.

  • Check the level before administering the drug.

Consideration for pregnancy

• Lithium may be teratogenic.

• It should be avoided during the first trimester of pregnancy.

•  Teach mothers to notify their provider if they are pregnant.

precautions about sodium levels

• A reduction in levels will decrease lithium excretion

• potentially lead to lithium accumulation, including toxic levels

• Patients must maintain normal intake and levels

  • Check levels if patients are prescribed lithiu

precautions about renal function

• Impairment can cause lithium accumulation 

• Kidney function should be assessed before treatment and once yearly thereafter

• labs to monitor

  • BUN

  • creatinine

  • glomerular filtration rate (GFR)

First Generation Antipsychotics relieve symptoms of schizophrenia by doing what?

strongly blocks dopamine receptors

Second Generation Antipsychotics relieve symptoms of schizophrenia by…

• blocking dopamine receptors

• strongly blocking 5-hydroxytryptamine receptors

the strong blockade of dopamine from FGAs produce what adverse effects

severe movement disorders…aka extrapyramidal symptoms (EPS)

How do SGA differ from FGAs?

1. produce a moderate blockade of dopamine receptors and serotonin

2. carry lower risk of EPS including Tardive dyskinesia 

   1. Higher metabolic effects–weight gain, diabetes and dyslipidemia, cardiovascular events

Schizophrenia

long term psychotic disorder marked by disorganized thinking and a diminished ability to understand reality.

How long does it take for significant improvement to show when taking antipsychotic drugs

initial effects 1-2 days

2-4 weeks

might not develop for several months

HCO₃^-

bicarb

PCO₂

carbon dioxide

anoxia

no oxygen

hypoxic

low oxygen

where does gas exchange happen?

in the alveoli

oxygenation and perfusion happens in 

cells 

tissues 

organs

oxygen transports to the cells and carbon dioxide away from the cells through what process?

ventilation and diffusion

diffusion

movement of oxygen and CO2 through the alveolar and capillary membrane, which is then exhaled.

oxygen and CO2 move through the…

alveolar and capillary membrane

Ventilation

Movement of atmospheric air (oxygen) into the lungs and removal of the carbon dioxide produced during metabolism.

Diagnostics of Gas Exchange

• chest x-ray

  • pulomary function studies

    • forced vital capacity (FVC)

    • Forced expiratory volume (FEV)

    • Peak expiratory flow rate (PEFR)

Labs for gas exchange

• Arterial Blood Gas (ABG)

• Sputum

the respiratory system compensates by

increasing hydrogen which then increases ventilation to blow off CO₂

the kidneys produce

bicarb

regulates pH via mechanisms of

the lungs and kidneys

Ph Levels

7.35-7.45

Respiratory Acidosis

elevation of pCO2 as a result of ventilation depression

Respiratory Alkalosis

depression of pCO2 results in alveolar hyperventilation

Metabolic Acidosis

depression of HCO3- or an increase in non-carbonic acid

Metabolic alkalosis

elevation of HCO3- usually caused by an excessive loss of metabolic acids.

how to obtain pH levels

ABGs sampling

PCO₂ Levels

35-45

HCO₃  Levels 

22-26

PO₂ Levels

80-110

Acidosis

increase in hydrogen (acid) concentration or decrease in bicarb (base)

Alkalosis

Decrease in hydrogen acid concentration or an increase in bicarbonate

Bronchodilators

• rescue drug

• Short-acting beta ₂ agonists

  • albuterol (inhaled)

• Long-acting beta 2

  • Salmeterol (inhaled) (maintenance)

Anticholinergic

• Inflammation 

  • Ipratropium

Mucolytics 

• secretions

  • Acetylcysteine (Anti-inflammatory–steroids, inflammation)

Glucocorticoids

• Beclomethasone (inhaled)

• Prednisone (oral)

Leukotriene Modifiers

prevention