NR546 Advanced Pharmacology: Psychopharmacology for Psychiatric-Mental Health Nurse Practitioner with accurate verified solutions + rationales ( GUARANTEED SUCCESS )

Week 1

When prescribing medications, what must the psychiatric mental health nurse practitioner (PMHNP) consider?

The patients:

symptoms

age

physical health

previous response to treatment

lifestyle

What is the priority data used to determine a treatment plan for mental health disorders?

Patient symptoms

Changes or losses in grey matter can be associated with psychiatric diagnoses such as?

Alzheimer's disease, schizophrenia, and major depressive disorder.

Many psychotropic medications can cause weight gain. True of False.

True, caution is taken when prescribing to obese patients.

Which lifespan group respond differently to drugs than adults, have heightened drug sensitivity, show greater individual variation, and have increased risk for adverse drug reactions? Dosage selection can be challenging because their brains and bodies are still developing.

Pediatric patients

Which lifespan group have several psychotropic drugs that are not safe to use, certain drugs resulting in birth defects and certain drugs presenting in breastmilk, affecting the breastfed child, or affecting milk production?

Pregnancy/breastfeeding patients

The physiologic changes associated with aging impact the drug processes of absorption, distribution, metabolism, and excretion of medications, so lower than normal dosages may be needed. The most recent Beers Criteria should be reviewed to avoid prescribing potentially inappropriate medications to this lifespan group.

Older adult patients

Brain tissue composed of gray matter includes?

The cerebellum, cerebrum, brain stem, and butterfly-shaped portion of the central spinal cord.

The gray matter of the brain focuses on?

Psychiatry and neurology and is associated with learning.

Brain tissue composed of white matter includes?

Nerve fibers that connect neurons from different regions into functional circuits.

Why is white matter considered the transit system?

Necessary for electrical impulse transmission. If there are breaks in the system, it can affect neural communication, affecting behavior. Damage to the myelin can impair transmission which can impact not only sensory and motor function, but also cognition.

White brain matter is associated with which disease processes?

Autism and vascular dementia.

Frontal Lobe

Associated with movement, intelligence, abstract thinking. the ability to organize, personality, behavior, and emotional control. Traumatic brain injuries can result in personality changes, difficulty controlling emotions, and other cognitive functions.

Parietal Lobe

Middle part of the brain

Responsible for proprioception.

Helps a person to identify spatial relationships, interpret pain and touch in the body, and identify and give meaning to objects.

Damage to the anterior portion of the parietal lobe may cause asterogenesis, the loss of ability to recognize objects via the sense of touch.

May be experienced post cerebral vascular accidents.

Temporal Lobe

Located on the sides of the brain

Involved in short-term memory, speech, auditory signals, and smell recognition.

Identifies "what" things are - object identification.

Contains the limbic system, amygdala, and hippocampus.

A dominant temporal lobe lesion can present as Wernicke's aphasia.

Temporal Lobe Disorders

Temporal lobe disorders include dementia, affective disorders, and attention deficit hyperactivity disorders (ADHD).

Occipital Lobe

Back part of the brain and controls visual processing. Damage to this lobe results in the inability to form visual memories.

Bilateral lobe damage results in the inability to recognize items by sight even though vision is normal.

Occipital lobe seizures can cause hallucinations, such as lines of color.

Dorsal Striatum

Complex motor actions and linkage of cognition to motor actions.

Main input area for the basal ganglia and is activated when anticipating or engaging in pleasure.

Corpus Callosum

Controls the communication between the two brain hemispheres.

Involved in attention, impulse control, and emotion regulation.

Integrates impulses from both sides of the brain.

Persons with an underdeveloped or missing corpus collosum may have intellectual impairment.

Thalamus

An egg-shaped structure involved in sensory organ and motor command processing.

All sensory systems except for the olfaction process through the thalamus, which is responsible for processing all external information.

Associated with symptoms related to schizophrenia and post-traumatic stress disorder (PTSD).

Basal Ganglia

Involved in voluntary motor movements, cognition, and emotion. Involved in facilitating voluntary movement.

Basal ganglia movement disorders include?

Include Parkinson's disease, obsessive-compulsive disorder (OCD), and Tourette syndrome.

Limbic System

Associated with pleasure, reward, and reinforcing behavior. Drug abuse affects the limbic system, disrupting emotions and feelings associated with normal behavior.

Nucleus Accumbens

This is involved in the reward circuit and reinforces addictive behaviors.

Amygdala

Located deep in the temporal lobes and involved in emotional regulation and perception of odors.

All smells travel directly to the amygdala.

Cooking smells can elicit memories of childhood events and holidays.

A traumatic event can result in the formation of the fear response, causing the fight or flight reflex within the autonomic nervous system and affects the hypothalamic-pituitary-adrenal (HPA) axis causing the release of stress hormones (e.g. cortisol).

The amygdala also is involved in the interpretation of facial expressions and sexual stimuli.

Hippocampus

Located deep in the temporal lobes and is involved in anxiety and memory, and shifting short-term to long-term memory.

Hippocampal function is impaired in schizophrenia and dementia. There is ongoing research into the role the hippocampus plays in anxiety and decision making.

What are epigenetic modifications

Affect how genes are turned on or off, influencing the production of proteins that carry out various functions in the body.

Can be influenced by a variety of factors, including environmental stimuli, lifestyle, and experiences.

Normal and abnormal genes both contribute to disease and drug efficacy.

Epigenetics can contribute to the risk of any disorder or disease.

Psychiatric disorders can also be due to normal genes that are "on" that should be "off."

How does reviewing the genetic makeup of a client help guide the PMHNP in selecting medication for clients?

Provide information on:

How clients may respond to certain psychotropic medications

How a client may break down and metabolize medications based on the cytochrome P450 system

If there may be an environmental exposure that turned a gene "on" that should have been "off"

Visit Note

Provide

The chief complaint

Context of the visit, and/or special circumstances where additional time was needed beyond what is considered "usual".

Note serves as a tool for the recall of memory when more information is requested.

Prescription Drug Monitoring Programs (PDMPs)

Electronic databases enable providers to access information regarding a client's prescription history of controlled substances.

Central Sulcus

Separates the frontal lobe from the parietal lobe

Frontal lobe

Associated with movement, intelligence, abstract thinking etc.

Broca's area

Speech

Temporal lobe

Involves object identification and auditory signals

Cerebellum

Coordination

Wernicke's area

Speech comprehension

Occipital lobe

Primary visual area

Parietal lobe

Keeps us alert to what is going on around us (think proprioception)

Sensory cortex

Pain heat and other sensations

Motor cortex

Movement

Hippocampus

Involved in both memory and anxiety

Nucleus accumbens

Involved in the reward process

Thalmus

Involved in sensory organs and motor command processing

Striatum

Involved in complex motor actions also links cognition to motor activities

Limbic System

Includes circuits that are associated with pleasure and reward

Basal Ganglia

Group of structures involved in voluntary muscle movements

Amygdala

Involved in emotional regulation and perception of odors

Corpus Callosum

Controls the communication between the two brain hemispheres

White Matter

Contains nerve fibers that connect neurons from different regions into functional circuits

Gray Matter

Contains nerve cells and dendrites

Brain Tissue

Made up of gray and white matter

Week Two

Phase I of Metabolism

Drug is ingested

Phase 1 Metabolism - oxidation, reduction, hydrolysis

Three possible outcomes - drug becomes completely inactive, partially inactive, or drug is not pharmacologically active

Inhibitors

Decrease medication metabolism

Inhibitors

Valproate

Isoniazid

Sulfonamides

Amiodarone

Chloramphenicol

Ketoconazole

Grapefruit Juice

Quinidine

Remember: VISA credit card debt inhibits spending on designers like CK to look GQ.

Inducers

Increase medication metabolism

Inducers

Carbamazepine

Rifampin

Alcohol

Phenytoin

Griseofulvin

Phenobarbital

Sulfonylureas

Increase medication metabolism

Neurotransmitters

Chemicals released by neurons to send communication across synaptic clefts to other neurons

The neurotransmitters that most impact mental health can be classified into four major categories.

Cholinergics (acetylcholine)

Monoamines (norepinephrine, dopamine, serotonin, and histamine)

Amino acids (gamma- amino-butyric acid and glutamate), Neuropeptides

GABA (gamma-aminobutyric acid).

The chief inhibitory neurotransmitter (NT)

The opposite of Glu

GABA (gamma-aminobutyric acid).

Bring "chill" to the party

Decrease neuroexcitability

Help people relax, destress, and get some sleep

When people don’t have enough GABA, they may experience anxiety or even schizophrenia.

Can help with sleep

GABA (gamma-aminobutyric acid).

Caution with alcohol and benzodiazepines can slow down everything, even breathing, and affect the executive function and motor coordination, increasing risk for accidents.

Norepinephrine (NE)

Monoamine neurotransmitter

Flight, fight or fright response (with excess)

Norepinephrine (NE)

Helps with alertness and orientation, focus and productivity

Pep in your step

Excess can come from stress, medications, caffeine and other stimulants. Can make you antsy, nervous, and affect your ability to focus.

Norepinephrine (NE)

Can apply to both physical and mental health, including mood, cognition, cardiac functioning, sleep, and arousal.

Acetylcholine ACH

One of the key neurotransmitters that psychotropic drugs target.

Within the central nervous system, affects arousal, motivation, attention, learning, and REM sleep

Works within the parasympathetic nervous system also.

Can make you sweat and salivate.

Acetylcholine ACH

The link between the brain and muscles.

With ACH deficiency can be involved in Alzheimer’s and Parkinson’s disease.

Increased ACH can help with symptoms, be cautious, to avoid addiction. Dr. Stahl refers to me as “the brain’s own nicotine” when he talks about my role in addiction.

Best receptors are nicotinic and muscarinic receptors.

Serotonin (5HT)

Help to regulate mood, the "happy hormone," (not a hormone at all; serotonin (5HT) is a monoamine neurotransmitter.

Serotonin (5HT)

Amino Acid

Helps you feel relaxed, comfortable, and less stressed.

Help to regulate sleep, arousal, libido, aggression, and pain perception. Same action in medications.

Dopamine (DA)

One of the key monamine neurotransmitters that regulate mood.

Associated with executive function, ability to perform well, be organized, and emotional intelligence.

Works in the prefrontal cortex.

Essential to your movement and coordination.

Dopamine (DA)

Balance is very important.

Too low you’ll lose pleasure, interest, alertness, and even self-confidence.

Low levels are also found in clients who have Parkinson’s disease.

Too much can lead to the hallucinations you see in schizophrenia and psychosis.

Works in your reward center.

The reward properties can lead to addictions.

Has its own pathways

Glutamate (Glu)

An amino acid and THE excitatory neurotransmitter.

The workhorse of the brain because glutamate affects almost every neuron in the brain.

Affects energy, memory, learning, and neural plasticity.

Relays sensory information and regulate spinal and motor reflexes.

If levels are too high, associated with schizophrenia, epilepsy, and mania.

Receptors, NMDA and AMPA, work across many regions.

The cytochrome P450 enzyme system

Responsible for metabolizing many psychotropic medications

Outcomes of drug metabolism

Accelerate renal excretion

Inactivate drug

Increase therapeutic action

Activate prodrugs

Increase toxicity

Decrease toxicity

Citalopram

Maximum dose is 20 mg due to increased risk of QT prolongation.

Vortioxetine

Maximum dose is 10 mg for a 2D6 poor metabolizer

Aripiprazole, Brexpiprazole, Iloperidone

Maximum dose is half of the normal maximum dose for a 2D6 poor metabolizer​.

If prescribed with a CYP 3A4 inhibitor, the dose should be ¼ of the recommended maximum dose.

Atomoxetine

A 5-fold higher peak concentration for a 2D6 poor metabolizer

A client who is a poor metabolizer

Has a lower concentration of the necessary enzyme to metabolize a drug, which results in higher blood concentrations of the drug.

Higher concentrations of drugs increase the risk of side effects and adverse reactions.

Selective Serotonin Reuptake Inhibitors (SSRIs)

Inhibits the reuptake of serotonin, which can cause nausea, agitation, headache, and sexual dysfunction.

Serotonin and Norepinephrine Reuptake Inhibitors (SNRIs)

Inhibits the reuptake of serotonin and norepinephrine, which can cause nausea, sweating, insomnia, tremors, sexual dysfunction

Tricyclic

Inhibits the reuptake of serotonin and norepinephrine, which can cause sexual dysfunction

Blocks norepinephrine receptors, which can cause hypotension and tachycardia

Blocks histamine receptors, which can cause sedation and weight gain

Blocks acetylcholine receptors, which can cause dry mouth, constipation, blurred vision, and urinary retention

Monoamine Oxidase Inhibitors (MAOIs)

Increases norepinephrine and serotonin by inhibiting the enzyme that inactivates it, which can cause sedation, dizziness, sexual dysfunction, and hypertensive crisis

Benzodiazepines

Increases the receptor affinity for GABA, which can cause dependence and confusion

Bupropion

Inhibits the reuptake of norepinephrine and dopamine, which can cause insomnia, dry mouth, tremors, and seizures

The most common action of psychotropic drugs

To modify the actions of G-protein-linked receptors, which occurs on a spectrum.

The agonist spectrum

Antagonist, which blocks the action of a neurotransmitter Agonists, which fully stimulate G-protein-linked receptors. Partial agonists, which stimulate receptors to a lesser degree than an agonist or natural neurotransmitter

Increases serotonin levels

Serotonin and norepinephrine reuptake inhibitor

Selective serotonin reuptake inhibitor

Tricyclic antidepressant

No effect on serotonin levels

Benzodiazepine

Is nicotine an inducer or an inhibitor of the CYP 1A2 enzyme?

Inducer

Nicotine is an inducer of the CYP 1A2 enzyme, so it lowers the concentration of drugs.

Therefore, a higher dose of olanzapine may be needed to control his symptoms.

Facts​

Selective serotonin reuptake inhibitor blocks the reuptake of serotonin, leaving a larger amount of serotonin available.

Increasing the amount of serotonin regulates feelings of fear and anxiety. Reducing the occurrence of fear reduces the release of norepinephrine. ​

A serotonin and norepinephrine reuptake inhibitor prevents the reuptake of norepinephrine, which would not reduce the level of norepinephrine as needed.

Benzodiazepines increase the levels of GABA and do not impact norepinephrine.

A monoamine oxidase inhibitor would increase levels of norepinephrine.

The nurse should assess for sexual dysfunction and anticipate the potential need for a phosphodiesterase inhibitor such as sildenafil (Viagra). After 4 to 6 weeks of taking?

SSRIs

Herbal medication contraindicated with SSRIs

St. John's Wort it can cause serotonin syndrome.

Week Three

Symptoms of psychosis include?

Hallucinations, delusions, disorganized speech, disorganized behavior, and distortions of reality.

Inappropriate or very strong emotions or apathy

Withdrawn behavior

Sudden decline in self-care

Difficulty concentrating or thinking clearly

Diagnosis requiring the presence of psychosis include?

Schizophrenia

Substance-induced psychotic disorders

Schizophreniform disorder

Schizoaffective disorder

Delusional disorder

Brief psychotic disorder

Psychotic disorder d/t a medical condition

Diagnosis with psychosis as a feature include?

Mania

Depression

Cognitive disorders

Dementia

Prevalence of schizophrenia and related psychotic disorders in the U.S.

Between 0.25% and 0.64%