Pharm Unit 6- Drugs for anxiety, insomnia, psychosis, seizures

Generalized Anxiety Disorders

-difficult to control, excessive anxiety that lasts six months or more

-interferes w/ daily activities

when taken properly, antidepressants reduce symptoms of

pain and anxiety

antidepressants

enhance mood by altering the levels of norepinephrine and serotonin & boosting the actions of neurotransmitters

classes of antidepressants

-Selective serotonin reuptake inhibitors (SSRIs)

-Atypical antidepressants (SNRIs)

-Tricyclic antidepressants (TCAs)

-Monoamine oxidase inhibitors (MAOIs)

what is the main thing to watch for when taking antidepressants

warning signs of suicide potential

benzodiazepines

are useful for the short-term treatment of insomnia caused by anxiety

how do benzodiazepines work

-"sedatives" or "hypnotics"

-CNS depressants slow neuronal activity in the brain by intensifying the effect of GABA

GABA

it calms you down

ex of benzodiazepines

"-pam" or "-lam"

-lorazepam

-alprazolam

-clonazepam

an adverse effect of benzodiazepines

respiratory distress

what's a risk when it comes to benzodiazepines

dependence and tolerance

s/e of benzodiazepines

-sedation

-drowsiness

pt teaching with benzodiazepines

-don't operate heavy machinery when first taking

-avoid CNS depressants and alcohol

-take only as prescribed

-avoid stimulants

what should you know about benzodiazepines

schedule 4 drug

nursing considerations with benzodiazepines

-assess for indications of anxiety or insomnia

-monitor VS, neuro status, stress/coping patterns

-watch for CNS depression (sedation, respiratory depression)

-monitor mood and emotional status

-teach the pt to take drug as prescribed

-encourage nonpharmacologic methods

antidote for benzodiazepines

flumazenil (risk for seizures w/ this med)

barbiturates

depress CNS function and cause drowsiness (more than benzodiazepines)

common used for barbiturates

-seizures

-anxiety

-procedural sedation

-pre anesthesia

barbiturates work for

short to long acting

examples of barbiturates

"-barbital"

-phenobarbital

-secobarbital

adverse effect of barbiturates

-respiratory depression

-CNS depression

side effects of barbiturates

-coma

-hypotension

-respiratory depression

short term effects of barbiturates

-relief of tension and anxiety

-slurred speech

-sleepiness

long term effects of barbiturates

-chronic tiredness

-breathing disorders

-vision problems

pt education w/ barbiturates

high risk for dependency

nursing care for barbiturates

-monitor respiratory rate <12

-monitor withdrawal side effects

-monitor blood pressure

-monitor LOC

additional drugs provide therapy for anxiety related symptoms and sleep disorders

-beta blockers & valproate

-buspirone

-insomnia: eszopiclone, zaleplon, zolpidem

zolpidem

-taken just before going to bed & only at bedtime

-insomnia only drug

-PRN

why is there a BBW for zolpidem

-complex sleep behaviors

-concerns like: very vivid dreams & bad nightmares

side effects of zolpidem

-daytime drowsiness & hangover effect

-dizziness

-confusion

-risk for injury

pt teaching w/ zolpidem

avoid using with CNS depressants or alcohol

nursing considerations with zolpidem

-do not administer w/ other CNS depressants

-*Watch for suicide ideation

-monitor for impaired liver and kidney disease

labs to watch for with a pt taking zolpidem

-ALT/AST

-BUN/creatinine

depression

situational and biological causes

situational

life event

ex: death of a family member or pet, isolation, financial difficulty

biological

genetics: predisposed due to family history

ex: hormonal changes

how long do you have to have signs of depression to get diagnosed

2 weeks

how many s/s of depression do you have to have to get diagnosed

5 or more for over 2 weeks

examples of signs of depression

-difficulty sleeping

-sleeping too much

-fatigue

-abnormal eating problems (increased or decreased)

-vague physical symptoms

-inability to concentrate

-feeling sad

-lack of self worth

-avoiding social interactions

-lack of interest in appearance or change in appearance

ways to treat depression

-medication

-cognitive behavior therapy

-psychotherapy

medications that can cause depression

-corticosteroids

-levodopa

-anticonvulsants

-opioids

medical causes that can casue depression

thyroid issues

drug and alcohol abuse w/ depression?

-ask the pt about it

-know exactly what and how much

what type of questions should you ask pts with depression

open ended

examples of questions you should ask pts with depression

-Any thoughts of harming yourself or others?

-Do you have a plan?

-Have you felt sad or hopeless?

-Do you feel safe at home?

general care for clients taking medications for mood disorders

-assess hx of depression or mood disorder

-baseline VS and labs and weight

-teach full effects of medications (may take a few weeks)

-teah to report SI immediately

-how to manage sedation/orthostatic hypotension

-no alcohol or other CNS depressants

-if miss a dose, take as soon as remember

-take w/ food if GI upset occurs

Tricyclic antidepressants (TCAs)

-used for major depression

-block the reuptake of norepinephrine and serotonin

examples of TCAs

-imipramine

-amitriptyline

side effects of TCAs

-most common: orthostatic hypotension & sedation

-anticholinergic s/e: blurry vision, urinary retention, dry mouth, constipated (can't see, can't pee, can't spit, can't shit)

many interactions w/ TCAs can cause

-tachycardia

-dysrhythmias

-sexual dysfunction

off label uses of TCAs

-neuropathy

-fibromyalgia

-anxiety disorders

-insomnia

-bipolar disorders

-dyspareunia (painful intercoarse)

pt teaching for TCAs

-Orthostatic hypotension (slow movements, feet dangle off bed before standing)

-Many interactions

nursing considerations for TCAs

-Watch for orthostatic hypotension

-watch for interactions

-monitor symptoms

-teach that it will take a few weeks for the effects to be known

-teach that they may cause sleep disturbances

-implement safety precautions until effects of meds are known

-assess for indications for antidepressants

-assess for SI

-teach pt to take as prescribed (no double doses)

-assess for suicidal tendencies

selective serotonin reuptake inhibitors (SSRIs)

- 2-4 weeks to start working, 6-8 weeks for full effect

-slow the reuptake of serotonin

-preferred bc they have the least amount of side effects

SSRIs treat

depression

examples of SSRIs

-sertraline

-citalopram

-escitalopram

-paroxetine

-fluoxetine

long term use of SSRIs can casue

withdrawal potential

ex: anxious, nervous, irritable, agitated, flu like symptoms

side effects of SSRI

depend on length of treatment

- <6 weeks: GI upset, tremors, fatigue

-at 6 weeks: sexual dysfunction, weight gain, increase for SI

-after 6 weeks: start to feel better & have more energy

what is the life threatening thing to worry about with SSRIs

Serotonin syndrome: can occur within 2 hours or several weeks

s/s of serotonin syndrome

-agitation

-confusion, disorientation, difficulty concentrating

-anxiety

-hallucinations

-fever, diaphoresis

-incoordination

-hypertension

what is it very important to get for serotonin syndrome

baseline vitals

when are you most at risk for serotonin syndrome

when taking an SSRI, but at increased risk if taking an SSRI along w/ an SNRI, also if taking lithium conjunction w/ an SSRI, also ondansetron (zofran- antiemetic), MAOIs, TCAs

if serotonin syndrome is severe what med can be prescribed as an "antidote"

cyproheptadine

what should you do if you start to develop signs of serotonin syndrome

stop the med ASAP, contact provider ASAP, supportive care for pt

what is an ex of supportive care

providing meds to help w/ anxiety like benzodiazepines

what should you monitor for in a pt with serotonin syndrome

-potential of seizure activity

-antipyretics for potential fevers

-IV fluids

-beta blockers as needed if tachycardia or hypertension occur

pt teaching w/ SSRIs

-avoid CNS depressants and alcohol

-immediately report any s/s of serotonin syndrome

nursing considerations with SSRIs

-Watch for s/s of serotonin syndrome (can occur within 2 hours or several weeks)

-Inform the pt of long-term use withdrawal potential symptoms

-inform the pt of what to do if serotonin syndrome does occur

-teach that it will take a few weeks for the effects to be known

-teach that they may cause sleep disturbances

-implement safety precautions until effects of meds are known

-assess for indications for antidepressants

-assess for SI

-teach pt to take as prescribed (no double doses)

-assess for suicidal tendencies

atypical antidepressants (SNRIs)

-Blocking the reuptake of two neurotransmitters: serotonin & norepinephrine

examples of atypical antidepressants (SNRIs)

-duloxetine

-venlafaxine

-bupropion

What are the primary uses of Duloxetine and Venlafaxine (SNRI examples)?

-Major depression

-generalized anxiety disorder

-panic disorder

-neuropathy

What are common side effects of Duloxetine and Venlafaxine (SNRI examples)?

-Nausea

-headache

-dry mouth

-hypertension

-sleep disturbances

-sexual dysfunction

What should Duloxetine and Venlafaxine (SNRI examples) not be taken with?

CNS depressants or alcohol

What can happen if Duloxetine and Venlafaxine (SNRI examples) are discontinued abruptly?

Withdrawal symptoms such as flu-like symptoms, insomnia, sensory changes, and balance problems

What type of medication is Bupropion?

SNRI (Serotonin-Norepinephrine Reuptake Inhibitor)

What conditions is Bupropion (SNRI example) used to treat?

-Mild depression

-seasonal depression

-smoking cessation

How long does it typically take for Bupropion (SNRI example) to start working?

Up to 4 weeks

What should be monitored while taking Bupropion (SNRI example)?

Food and water intake

What are some common side effects of Bupropion (SNRI example)?

notify provider if these symptoms occur

-Headaches

-dry mouth

-GI upset

-constipation

-increased heart rate

-nausea

-restlessness

-insomnia

What effect does Bupropion (SNRI example) have on seizure threshold?

It lowers the seizure threshold, making seizures more likely

pt teaching when it comes to SNRIs

-Not to take with CNS depressants or alcohol

-Avoid abrupt discontinuation: withdrawal: flu-like symptoms, insomnia, sensory changes, balance problems

-Bupropion: takes up to 4 weeks to work

nursing considerations when it comes to SNRIs

-Bupropion: Monitor food intake & weight

-Monitor S/E

-teach that it will take a few weeks for the effects to be known

-teach that they may cause sleep disturbances

-implement safety precautions until effects of meds are known

-assess for indications for antidepressants

-assess for SI

-teach pt to take as prescribed (no double doses)

-assess for suicidal tendencies

Monoamine oxidase inhibitors (MAOIs)

-block the breakdown of norepinephrine, dopamine, and serotonin by decreasing the effectiveness of MAO

-treat depression

examples of MAOIs

No Popular Meds

-Nardil

-Parnate

-Marplan

-phenelzine

isocarboxazid

-tranylcypromine

pt teaching with MAOIs

-Many interactions with drugs and foods

-Foods: smoked meats, cheese, beer, yogurt, soy sauce, yeast, avocadoes, chocolate, pineapple, alcoholic beverages

-Medications: SSRIs, TCA's, SNRI's, antibiotics, antihistamines, fentanyl

-s/s of tyramine (or hypertensive) crisis

why are MAOIs not commonly prescribed/ BBW

too many interactions with drugs and food

nursing considerations with MAOIs

-Warn the pt about tyramine crisis and the signs and symptoms

-Warn the pt about foods and medications that can lead to tyramine crisis

-Not very commonly prescribed

-If s/s of tyramine crisis aren't treated, it can lead to MI or stroke

-teach that it will take a few weeks for the effects to be known

-teach that they may cause sleep disturbances

-implement safety precautions until effects of meds are known

-assess for indications for antidepressants

-assess for SI

-teach pt to take as prescribed (no double doses)

-assess for suicidal tendencies

what is tyramine or hypertensive crisis

happens when eating tyramine foods

s/e of tyramine crisis

-headache

-stiff neck

-flushing

-sweating

-palpitations

-hypertension

what happens if s/s of tyramine crisis go untreated

can lead to MI or stroke

what is the main goal of mood stabilization

to regulate mood, maintain a normal state between violent swings and between mania and depression

mood stabilization in pts with bipolar disorder is accomplished with

-*lithium (main drug- primarily used)

-antiseizure meds

-atypical antidepressants

what is bipolar disorder

cycle from manic symptoms to depressive symptoms

pts w/ bipolar disorder don't always have to be one or the other..

they can cycle through & have more of a normal state for a period of time between swings from mania to depression

Lithium

-primarily used

-narrow safety margin: 0.6-1.5 (range when labs are drawn)

since lithium has a narrow safety margin..

there will be routine/frequent lab draws

lithium has a risk for

hyponatremia= risk for toxicity

how to keep sodium levels stable when taking lithium

avoid too much of the med in the system but want enough that the med is still effective

s/s of hyponatremia toxicity with lithium

-N/V/D

-weakness

-lack of muscle coordination

-confusion

-lethargy

-seizures

how is there a risk for hyponatremia (toxicity) when taking lithium

lithium acts as a salt in the body, when there is a decrease of sodium available in the body & lithium acts a a salt & we ingest it, the body is going to uptake & use that lithium in higher concentration because our body is looking for salt which leads to toxic levels of lithium if hyponatremic