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2010-07-22 02:18:03

ch 22
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  1. depression
    felling sad, unhappy, or down

    Dysphoric- major depressive episode (exagerated sadness, anxiety, unhappiness) that interferes w/ daily functioning

    • S/S:
    • feeling hopelessness & helplessness, worthlessness
    • decreased intrest in activities of life
    • significant wt loss or gain (w/o diet)
    • insomnia or hypersomnia
    • agitation, restlessness, irritability
    • fatigue
    • guilt
    • inability to think, concentrate, indecisiveness
    • thoughts of death or suicide even attempted
  2. Tricyclic antidepressants
    • slow adaptive changes in norepinephrine & serotonin receptor system
    • tx thought to increase sensitivity of postsynaptic receptors, & decrease sensitivity of presynaptic

    • Use:
    • bipolar disorder
    • OCD
    • chronic neuropathic pain
    • enuresis
    • unlabeled uses: peptic ulcer, sleep apnea, panic disorder, bulimia, premenstrual symptons, & dermatologic problems, psychotherapy in severe cases

    • AR:
    • anticholinergic effect(sedation, dry mouth, visual disturbance, urinary retention)
    • constipation & photosensitivity
    • tachycardia
    • heart block
    • ortho hypotension

    • Cont:
    • not given w/i 14 days of the MAOI antidepressants
    • pt w/ myocardial infarction
    • children
    • lactating, preg.

    • pre:
    • pt w/ cardiac disease, hepatic & renal impairment, thyroid disease, hx seizure, narrow glucoma, increasesd intraocular pressure, suidical thought/behavior, urinary retention

    • Inter:
    • sedatives, hypnotics, analgesics- increased risk 4 resp. & NS depression
    • dicumarol(blood thinner)- increase risk 4 bleeding
    • cimetidine(tx gastric upset)- increased anticholinergic symptoms
    • MAOIs- increased risk 4 hypertensive episodes, convulsions, hyperpyretic
    • adrengic agent(neuromuscular agent)- increased risk 4 arrhythmias & hypertension
  3. tricyclic antidpressant
    • amitriptyline
    • use: depression,bipolar, OCD, peptic ulcer, sleep apnea, neuropathic pain, bulimia
    • AR: sedation, anticholinergic effect, constipation

    • amoxapine
    • use: depression w/ anxiety
    • AR: tardive dyskinesia, sedation, constipation, anticholinergic
  4. selective serotonin reuptake inhibitors
    increase in serotonin levels thought to act as stimulant to reverse depression

    • use:
    • depression, anxiety,OCD, bulimia, panic disorders, prementrual symptoms, migraines
    • raynauds disease
    • DM neuropathy

    • prec:
    • pt w/ DM, impaired liver & kidney, cardiac disease, risk 4 suicide thought/behaviors
    • pt shouldnt be switched to SSRI w/i 2wk of stopping MAOI

    • Inter:
    • other antidepressant- increases risk 4 toxicity
    • cimenidine(gastric upset)- increased anticholinergenic symptoms
    • NSAID- increase risk 4 GI bleeding
    • lithium(bipolar)- increased rosk 4 lithium toxicity

    herbal alert- st john wort shouldnt be given w/ SSRI increases sedation
  5. SSRIs
    • citalopram (celexa)
    • use:
    • depression, panic disorder, PTSD, premenstrual disorder
    • AR:
    • nausea, dry mouth, sweating, somnolance, insomnia, anorexia, diarrhea

    • fluoxtine (prozac)
    • use:
    • depression, bulimia, OCD, panic disorder
    • AR:
    • anxiety, nervouseness, somnolance, insomnia, drowsiness, asthenia, headache, nausea, diarrhea, constipation, dry mouth, anorexia

    • paroxetine(paxil)
    • use:
    • depression, OCD, panic disorder, anxiety, social anxiety, PTSD
    • AR:
    • headache, tremors, somnolance, nervouseness, dizzieness, insomnia, nausea, diarrhea, constipation, dry mouth, sweating, weakness, sexual dysfunction

    • sertraline (zoloft)
    • use:
    • depression, OCD, panic disorder, PTSD
    • AR:
    • headache, drowsiness, anxiety, fatique, dizzieness, insomnia, nausea, diarrhea, dry mouth, sweating, weakness, ejaculatory disturbance
  6. Monoamine Oxidase inhibitors
    • complex enzyme system responsible 4 inactivaton of certain neurotransmitters
    • blocking MAOIs increases endogenous epinephrine, norpinephrine, dopamin & serotonin in NS

    • use:
    • depressive episodes, phsycotherapy in severe cases
    • unlabeled use: bulimia, night terrors, migraine, seasonal affective disorders, multiple sclerosis

    • AR:
    • vertigo, othro hypotension, blurred vision, constipation, dry mouth, impotance, nausea, diarrhea
    • severe case hypertensive crises(very high B/P), occurs w/ food high in tyramine(amino acid), followed by headache, stiff/sore neck, nausea, vomiting, sweating, fever, chest pain, dilated pupils, brady/tachy cardia

    • cont:
    • elders, phechromocytoma, liver &kidney disease, cerebralvascular disease, HTN, hx of headache, CHF, preg. younger then 16y, hx seizures, hyperthyroidism, rick 4 suicide
    • pt shoudnt take decongestion w/o Dr approving

    • Inter:
    • sedative/hypnotic/analgesic- increase risk AR during surgery
    • thiazide(diuretic)- increases hypotension effect MAOI
    • meperidine(pain)- increase risk 4 hypertension, severe convulsion, hyperpyretic episodes
    • adrenergic(neuromuscular)-increase risk 4 arrhythmias & hypertension
    • tyramine/tryptophan(amino acid)- hypertensive crisis, 2wk after MAOI d/c
    • antitussive(cough)- hypotension, fever, nausea, jerkinh, legs, coma

    Ex. phenelzine (nardil)- atypical depression
  7. atypical antidepressant
    thought that affect neurotramsmission of serotonin, norepinephrine, & dopamine

    • use:
    • Depression, anxiety, neripheral neuropathic pain, wt loss, fibromylagia, alcohol & cocain withdrawal, stop smoking

    • AR:
    • hypotension, lightheadedness, blurred vision, bitter taste

    • Prec:
    • pt w/ cardiac disease, renal & hepatic impairment, hypothyriod disease, risk 4 suicide

    • inter:
    • Sedative/hypnotic/anagesic- increase risk 4 resp. & nervous depression
    • warfarin(blood thinner)- increases risk 4 bleeding
    • cimetidine(GI upset)- increased anticholinergic symptoms
    • antihypertensive(B/P)- increase risk 4 hypotension
    • MAOIs- increase risk 4 hypertensive, convulsion, hyperpyrtic
  8. Atypical antidepressant
    • Bupropion (welbutrin)
    • use:
    • depression, neuropathis pain, ADHD, stop smoking
    • AR:
    • agitation, dizziness, dry mouth, sedation, headache, GI problems, tremors, wt loss, sweating

    • duloxetine(cymbalta)
    • use:
    • depression, diabetic peripheral neuropathy, fibromylagia, stress, incontinance
    • AR:
    • insomnia, dry mouth, nausea, constipation

    • venlafaxine(effexor)
    • use:
    • depression, anxiety, premenstrual disorder
    • AR:
    • headache, insomnia, dizziness, nervousness, weakness anorexia, constipation, dry mouth, somnolance, sweating
  9. food containing tyramine
    • aged cheese(blue, camembert, chedder, mozzorella, parmesan)
    • sour cream
    • yogurt
    • beef/chicken live
    • pickeled herring
    • fermanted meats(salami, bolongna, pepperoni, dried fish)
    • undistilled alcoholic beverages
    • caffeinated drinks
    • chocolate
    • certain fruits & veggie (avocado, bananas, fava beans, raisins)
    • yeast extracts
    • soy sauce
  10. Implementation
    • slow therapuetic respons
    • w/ fluoxetine AR sometime seen before therapeutic resopnse
    • 2 AR why pt stop taking meds are somnolance & dry mouth
    • when given IM give in gluteus, keep pt laying down 4 30 min
  11. monitoring pt needs
    • often pt dont have physical/emotional energy 4 ADL
    • assist when ambulation/ADL
    • possible othro hypotension
    • provide positive feed back
    • when somnolance give med @ night, except SSRIs
    • asses enviroment to promote sleep
    • foods high in fiber & increase of fluids b/c nausea & constipation
    • check wt daily
    • pt on MAOI no foods containg tyramine, list foods to pt/family, & importance/reason why not to take
    • well supervised b/c risk 4 suicide, b/c therapeutic effect take 10days-14wks pt gains energy to carry out suicide
    • report expressions of hopelessness, helplessness, guilt, insomnia, wt loss, direct/indirect threats of suicide
    • always inspect that pt did take med b/c they could use it 4 suicide, if pt doesnt allow then give med parenterally
  12. empowering pt responsibility 4 drug therapy
    • explain reason 4 drug therapy & how to take
    • ask family to help make sure pt taking meds
    • instruct to take med as RX
    • advise that therapeutic effect might take several wks to be seen
    • advise about S/S whether drug is working or not
    • review measures 2 reduce suicide
    • advise about AR
    • reinforce safety measures of taking drugs
    • advice no alcohol or nonRX drugs
    • instruct measures to reduce dry mouth
    • emphysizes on not taking food high in tyramine, give list of foods
    • reassurence that labs will be done on follow-up appt
    • assist with arrangements of follow-up appt.