ATI Capstone Mental Health Remediation

ATI Capstone Mental Health Remediation

Common Psychiatric Medications

SSRIs: Selective Serotonin Reuptake Inhibitors. These medications include Citalopram (Celexa), Fluoxetine (Prozac), or Sertraline (Zoloft). The client should avoid using St. John’s Wort with these medications, and should eat a healthy diet while on these medications.

TCAs: Tricyclic Antidepressants. Amitriptyline (Elavil) is an example. Anticholinergic effects and orthostatic hypotension may occur.

MAOIs: Monoamine Oxidase Inhibitors. Phenelzine (Nardil) is an example. Hypertensive crisis may occur with tyramine food ingestion, so care must be taken to avoid these substances. Educate the client to avoid all medications until discussed with provider.

Atypical antidepressants. Bupropion (Wellbutrin) is the most common example. Appetite suppression is a common side-effect. Headache and dry mouth may be severe and client should notify the provider if this occurs. Atypical antidepressants should not be used with clients with seizure disorders.

Serotonin Norepinephrine Reuptake Inhibitors. Common SNRIs include Venlafaxine (Effexor) and Duloxetine (Cymbalta). Adverse effects may include nausea, weight gain, and sexual dysfunction.

All clients should have aMental Status Exam, which includes:

Level of consciousness

Physical appearance

Behavior

Cognitive and intellectual abilities

The nurse conducts the MSE as part of his or her routine and ongoing assessment of the client. Changes in Mental Status should be investigated further and the provider notified.

There are two types of mental health hospitalizations:Voluntary commitment and involuntary or civil commitment. Involuntary commitment is against the client’s will. Despite that, unless proven otherwise, clients are still considered competent and have the right to refuse treatment.

Use the following communication tips when answering questions on NCLEX:
* If the client is anxious or depressed – use open-ended, supportive statements
* If the client is suicidal – use direct, yes or no questions to assess suicide risk
* If the client is panicked – use gentle guidance and direction
* If the client is confused – provide reality orientation
* If the client has delusions / hallucinations / paranoia – acknowledge these, but don’t reinforce
* If the client has obsessive / compulsive behavior – communicate AFTER the compulsive behavior
* If the client has a personality or cognitive disorder – be calm and matter-of-fact

Treatment for mental health illnesses and disorders can include medications, talk and behavior therapy, and / or brain stimulation. Clients undergoing care for mental health disorders may feel pressure to deny behavior or issues to appear ‘normal’. The nurse should always carefully assess each individual to ensure optimal response to therapies.

The most common type of brain stimulation therapy is electronconvulsive therapy or ECT. ECT is generally performed for major depressive disorders, schizophrenia or acute manic disorders. Most clients receive therapy three times a week for two to three weeks. Prior to ECT, carefully screen the client for any home medication use. Lithium, MAOIs and all seizure threshold medications should be discontinued two weeks prior to ECT. After therapy, reorient the client as short term memory loss is common.

Anxiety disorders are common mental health disorders. Generalized Anxiety Disorder, Panic Disorder, Phobias, Obsessive Compulsive Disorder, and Posttraumatic stress disorder (PTSD) are all considered types of anxiety disorders. Assess the client for risk factors, triggers and responses.

A classic symptom of depression is change in sleep patterns, indecisiveness, decreased concentration, or change in body weight. Any client who shows these signs or symptoms should be asked if they have suicidal ideation. Teach clients to never discontinue anti-depressants suddenly.

Bipolar disorders are mood disorders with periods of depression and mania. Clients have a high risk for injury during the manic phase related to decreased sleep, feelings of grandiosity and impulsivity. Hospitalization is often required and nurses should provide for client safety.

There are several different types of abuse, including physical, sexual, or emotional. Abuse tends to be cyclic, following a pattern on tension building, battering and honeymoon phase. When test questions appear related to abuse, look for the phase to determine the correct response.

For the aggressive or violent client, setting boundaries and limits on behavior are important. The nurse should maintain a calm approach and use short, simple sentences.

More drug tips!

Common Psychiatric Medications

SSRIs: Selective Serotonin Reuptake Inhibitors. These medications include Citalopram (Celexa), Fluoxetine (Prozac), or Sertraline (Zoloft). The client should avoid using St. John’s Wort with these medications, and should eat a healthy diet while on these medications.

TCAs: Tricyclic Antidepressants. Amitriptyline (Elavil) is an example. Anticholinergic effects and orthostatic hypotension may occur.

MAOIs: Monoamine Oxidase Inhibitors. Phenelzine (Nardil) is an example. Hypertensive crisis may occur with tyramine food ingestion, so care must be taken to avoid these substances. Educate the client to avoid all medications until discussed with provider.

Atypical antidepressants. Bupropion (Wellbutrin) is the most common example. Appetite suppression is a common side-effect. Headache and dry mouth may be severe and client should notify the provider if this occurs. Atypical antidepressants should not be used with clients with seizure disorders.

Serotonin Norepinephrine Reuptake Inhibitors. Common SNRIs include Venlafaxine (Effexor) and Duloxetine (Cymbalta). Adverse effects may include nausea, weight gain, and sexual dysfunction.

Antagonists

In order to understand howantagonistdrugs work, you need to understand howagonistdrugs produce therapeutic effects.Agonistsare simply drugs that allow the body’s neurotransmitters, hormones, and other regulators to perform the jobs they are supposed to perform. Morphine sulfate, codeine, and meperidine (Demerol) are opioids agonists that act on the mu receptors to produce analgesia, respiratory depression, euphoria, and sedation. These drugs also work on kappa receptors, resulting in pain control, sedation and decreased GI motility.Antagonists, on the other hand, are drugs that prevent the body from performing a function that it would normally perform.To quote William Shakespeare & the US Army, these drug classes allow the body’s functions “to be or not to be…all that they can be”.

Common uses of antagonists:

• Treatment of opioids overdose, reversal of effects of opioids, or reversal of respiratory depression in an infant
• Example: a post-operative client receiving morphine sulfate for pain control experiences respiratory depression and is treated with naloxone (Narcan)

Nursing Interventions for antagonists:

• Monitor for side/adverse effects
• Tachycardia and tachypnea
• Abstinence syndrome in clients who are physically dependent on opioids agonists
• Monitor for symptoms to include cramping, hypertension, and vomiting
• Administer naloxone by IV, IM or subcutaneous routes, not orally
• Be prepared to address client’s pain because naloxone will immediately stop the analgesia effect of the opioid the client had taken
• When used for respiratory depression, monitor for return to normal respiratory rate (16-20/min for adults; 40-60/min for newborns)

Antidotes

Antidotesare agents given to counteract the effects of poisoning related to toxicity of certain drugs or substances.Antidotesare extremely valuable, however most drugs do not have a specific antidote.

Bronchodilators

Bronchodilatorsare used to treat the symptoms of asthma that result from inflammation of the bronchial passages, but they do not treat the inflammation. Therefore, most clients with asthma take an inhaled glucocorticoid concurrently to provide the best outcomes. The two most common classes of bronchodilators arebeta2-adrenergicagonistsandmethylxanthines.

Beta2-adrenergic agonists: act upon the beta2-receptors in the bronchial smooth muscle to provide bronchodilation and relieve spasm of the bronchial tubes, inhibit release of histamines and increase motility of bronchial cilia. These short-acting preparations provide short-term relief during an asthma exacerbation, while the long-acting preparations provide long-term control of asthma symptoms.

The generic names for the inhaled form of these drugs end in“terol” = “TakingEasesRespiratory distressorLabored breathing”

• Albuterol(Proventil, Ventolin)
• Formoterol(Foradil Aerolizer)
• Salmeterol(Serevent)

The brand names of some drugs in this class provide a hint as well because they contain the words “vent” or “breth” referring to ventilation or breathing:

• Albuterol (Proventil,Ventolin)
• Salmeterol (Serevent)
• Terbutaline (Brethine)

Nursing interventions and client education:

• Short-acting inhaled preparations of albuterol (Proventil, Ventolin) can cause systemic effects of tachycardia, angina, and tremors.
• Monitor client’s pulse rate before, during, and after nebulizer or inhaler treatments
• Long-acting inhaled preparations can increase the risk of severe asthma or asthma-related death if used incorrectly—mainly if used without concurrent inhaled glucocorticoid use
• Oral preparations can cause angina pectoris or tachydysrhythmias with excessive use
• Instruct clients to report chest pain or changes in heart rate/rhythm to primary care provider
• Client should be taught proper procedure when using metered dose inhaler (MDI) and spacer
• If taking beta2-agonist and inhaled glucocorticoid concurrently, take the beta2-agonist first to promote bronchodilation which will enhance absorption of the glucocorticoid
• Advise client not to exceed prescribed doses
• Advise client to observe for signs of impending asthma attacks and keep log of frequency and intensity of attacks
• Instruct to notify primary care provider if there is an increase in frequency or intensity of asthma attacks

Methylxanthines: cause bronchial smooth muscle relaxation resulting in bronchodilation.

Theophylline (Theolair) is the prototype medication and is used for long-term control of chronic asthma

Nursing interventions:

• Monitor serum levels for toxicity at levels >20 mcg/mL
• Mild toxicity can cause GI distress and restlessness
• Moderate to severe toxicity can cause dysrhythmias and seizures
• Educated client regarding potential medication and food interactions that can affect serum theophylline levels
• Caffeine, cimetidine (Tagamet), and ciprofloxacin (Cipro) can increase levels
• Phenobarbital and phenytoin can decrease levels

ACE Inhibitors

ACE inhibitorsblock the production ofangiotensin II which results in vasodilation, sodium and water excretion, and potassium retention. Drugs in this class are used for treating heart failure, hypertension, myocardial infarction, and diabetic or nondiabetic nephropathy. Clients taking captopril (Capoten) should be instructed to take med at least 1 hour before meals; all other ACE inhibitors are not affected by food.

The generic names of ACE inhibitors end in “pril”:

• Captopril(Capoten)
• Enalapril(Vasotec)
• Fosinopril(Monopril)
• Lisinopril(Prinivil)
• Ramipril(Altace)

Side/adverse effects include:

• Orthostatic hypotension with first dose
• Instruct client to monitor BP for at least 2 hours after first dose
• Cough, rash or altered or distorted taste (dysgeusia)
• Instruct client to notify health care provider
• Angioedema
• Treated with epinephrine and symptoms will resolve once medication is stopped
• Neutropenia is rare but serious with captopril (Capoten)
• Instruct client to report signs of infection

Hyperkalemiacan be life-threatening

Monitor potassium levels to maintain normal range of 3.5-5.0 mEq/L

Medication/food interactions:

• Concurrent use with diuretics can lead to first-dose orthostatic hypotension
• Concurrent use with other antihypertensives can lead to increase effect resulting in hypotension
• Concurrent use with potassium supplements or potassium-sparing diuretics increases the risk of hyperkalemia
• Concurrent use with lithium can increase serum lithium levels, leading to lithium toxicity
• Concurrent use with NSAIDs can decrease the therapeutic effects of the ACE inhibitor

Vasodilators

The term“vasodilators”refers to drugs that improve oxygenation of tissues by dilating or opening up the body’s vascular system. While several classes of drugs dilate vessels through different mechanisms, the goal is the same—to provide improved circulation of oxygen to the body’s tissues. It should be noted that concurrent use of any of these drugs with other antihypertensive drugs can lead to severe hypotension.

Electrolyte Replacements

Electrolytesrefer to salts that carry either positive or negative charges to carry electrical impulses in the form of muscle contractions and nerve impulses. Electrolyte balance must be maintained in the body to protect cardiac and nerve function. Therefore, replacement is critical when electrolytes are lost due to sweating, vomiting, diarrhea, or gastric suctioning.