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EPS
a side effect of antipsychotic medications from blockage of dopamine
- psuedoparkinsoniasm-tremors
- tardive dyskinisia
- dystonia
- akinesia
- akithesia
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Suicidal ideation vs. intention
ideation-thoughts about or unusual preoccupation with suicide
intention-thoughts plus plan
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dystonia
- involuntary muscle spasms of the:
- face
- arms
- legs
- neck
Side effect of antipsychotic meds
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Suicide protective factors
- intact positive support system
- religious/faithful
- dependent children
- relationship with supportive caregiver
- absence of mental disorder/drug user
- living close to mental/medical health resource
- good problem solving/coping skills
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pseudoparkinsonism
symptoms occur 1-5 days after start of antipsychotic med
tremor, shuffle, drools, rigid
occurs most often in women, elderly and dehydrated
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What are suicide precautions?
- monitor q10-15min
- remove all harmful items
- make sure haven't "pocketed" pills and saved to take as an OD
- listen to them if they mention it
- write a contract to seek staff if thinking to do
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tardive dyskinesia
- antipsychotics cause....
- bizarre facial and tongue movements
- stiff neck
- difficulty swallowing
PERMANENT
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Self injurious behavior
don't want to kill themselves, but are 18x more likely to do it by accident
cutting/burning/opening existing wounds
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akathisia
inner restlessness and feeling of having to move
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Neuroleptic Malignant Syndrome
complication of neuroleptic drugs-fatal
- sever muscle rigidity
- high fever
- tachy
- fluctuations in BP
- diaphoresis
- rapid deterioration of mental status-stupor then coma
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Typical/Conventional antipsychotic meds
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List 3 factors that reduce client compliance with taking antipsychotic meds
- undesireable side effects
- cost concerns
- don't feel they have any or enough + benefits
- stigma of meds
- don't feel they need meds
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Why are atypical antipsychotics preferred?
- Lower risk for EPS/NMS
- ALSO-improve positive as well as negative symptoms of schizo which makes for a better quality of life
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What is meant by potency of a med and what this means in terms of comparing dosing.
- high potency drugs are given at a lower dosage
- higher potency drugs are responsible for a greater number of undesireable side effects
meds are given and titrated up.
Want to have the desired effect with the least amount of side effects, which is hopefully achieved at the lower dosage of a drug
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What ancillary medication may be used to treat side effects from antipsychotic meds?
Benadryl-treats EPS
Cogentin-prevents/treats EPS
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Geodon S/E
- Prolonged QT
- sedation
- rhinitis(runny nose)
- muscle weakness
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What do you need to check before giving Geodon?
EKG
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Zyprexa S/E
Weight gain
Teach patient that will get really hungry, and need to pick healthy snacks...and drink water
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What do you need to watch out for when a persons on Zyprexa?
may get diabetes
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What fatal side effect should be monitored with clozapine?
agranulocytosis
monitor CBC and WBC weekly for 1st 6 months
tell patient to report signs of fever, sore throat or rash
lowers seizure threshold
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How do you rate suicide lethality?
- Is the pt rational....are they having hallucinations/delusions?
- Do they have a plan?
- Do they have the means to carry out the plan?
- Do they have access to the means?
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All typical psychotics cause
- disorders of movement-EPSE
- endocrine disorders-gynocomatsia and galacturia
- cognitive problems-cant problem solve, sluggish and slow to respond
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What do typical antipsychotics do?
causes a reduction in hallucinations and delusions ONLY
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List atypical antipsychotics
- Clozaril
- Risperdal
- Zyprexa
- Seroquel
- Geodon
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S/E for all Atypical antipsychotic meds
- sedation
- hypotension
- weight gain
- anticholinergic
LOWER POTENTIAL for EPS, but still can occur
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What's an anticholinergic s/e look like?
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Which type of antipsychotic is more likely to cause seizures?
typical....with an exception of clozapine
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Which type of antipsychotic is more likely to cause agranulocytosis?
Typicals....with the exception of clozapine
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Which drug causes hypersalvation?
clozapine
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Which type of antipsychotic is more likely to cause tardive dyskinesia?
typical
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Which type of antipsychotic is more likely to cause NMS?
typical
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Which type of antipsychotic is more likely to cause diabetes and hyperglycemia?
atypicals
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Which type of antipsychotic is more likely to have anticholinergic effects? Exception?
typicals
clozapine and olanzapine
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What side effects will you see in both typical and atypical antipsychotics
- Nausea
- rash
- sedation
- orthostatic hypotension
- photosensitivity
- hormonal effects
- ecg changes
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How do you treat EPSE?
- IM Benadryl
- Cogentin PO for ongoing prevention
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How do you treat NMS?
- stop medication immediately
- fluids
- monitor heart and labs
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How do you treat photosensitivity?
sunscreen and wear protective clothing
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How do you treat anticholinergic side effects?
- sip on water/chew ice chips
- chew gum/suck on candy
- good oral care
- high fiber diet
- use caution when driving
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Who's at risk for suicide culturally?
- whites....in the highest and lowest socioeconomic classes
- professional healthcare personnel and business executives.
- Also...law enforcement, attorneys and mechanics
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Discuss community strategies to reduce incidence of suicide....
- community mental health
- assist pt with creating crisis care card
- teach pt/family how to handle recurrent suicidal thoughts and behaviors
- encourage pt/family to read books on suicide for knowledge
- provide support to family of a successful suicide
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Name community mental health facilities
- outpatient clinics
- supportive housing
- clubhouse model
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What's listed in a crisis care card?
- names and phone numbers of family/friends
- same for community resources and support groups
- reasonable, non suicidal responses to problems
- list of activities that have helped in the past
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What are curative factors?
interpersonal growth a person can achieve through group therapy
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List some Yalom curative factors
- instillation of hope
- universatility
- imparting information
- altruism
- corrective recapitulation of primary family
- socialization
- imitative behavior
- interpersonal learning
- existential factors
- catharsis
- group cohesiveness
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If I am going to give antipsychotics I first need to....
make sure there is a signed consent on file.
Doctor or prescriber is responsible to get this
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Do I need a signed consent to administer Benzos ("pams")?
NO
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Steady state
it takes 5 half lives to achieve affected by food, fluid and exercise
after steady state is reach, it will take 4 more weeks for change to occur in the brain
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definition of steady state
the same amount is in the body as there is being excreted
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Only medication you see immediate effects from?
sedatives
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Dopamine=
Norepinephrine=
Serotonin=
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Effects of dopamine
- reward
- motivation
- motor activity
- learning
- short term memory development
occurs in hypothalamus
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Describe dystonia
- arched back
- oculogyric crisis
- asapiration
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Tardive dyskinesia is commonly seen in...
elderly.
prescribed in ltc facility....doctor prescribes then doesn't seen them for awhile
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schizo and what go together?
diabetes
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When a person has NMS and severe muscle rigidity what happens?
CPK levels rise causing renal failure
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Seroquel make sure....
- you get a baseline EKG and watch for
- hypotension
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Which drug doesn't cause weight gain?
Geodon
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Which drug is an antidepressant but is given as an antipsychotic too?
Abilify
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General medication teaching for atypical antipsychotics
- how to prevent dizziness
- management of dry mouth
- oral hygiene
- constipation
- sun exposure
- reportable symptoms to provider
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most important thing to teach a pt on atypical antipsychotics
what to do if miss a dose.
Don't double up....take next dose close to the next scheduled dose
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Atypical antipsychotics are black box for
elderly and pregos
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Most common way to commit suicide
fire arms
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Most common way for women to commit suicide?
Children?
- overdose for women
- and
- hanging/jumping for kids
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What does ambivalence of act mean?
they want to end their pain and turmoil, but don't necessarily want to end their life
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chorea
involuntary movements
brief non repetitive muscle contractions
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Who shouldn't have Prolixin?
person with Parkinsons
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What is the minimum WBC count for pt on Clozapine?
3500
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Which two antipsychotics need to have EKG's done prior to administration and during?
Seroquel and Geodon
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Teach patients to NEVER....
stop medication abruptly
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Nursing process...intervene for pt. suicidal or schizo
- observe for signs of hallucinations
- convey acceptance of clients need for the false belief, but indicate you don't share the belief
- convey acceptance by brief/frequent contacts
- observe clients behavior frequently...while doing routine activities
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Common factors with Self Injurious Behavior
- starts between 10-16 yo
- caused by major change in life-divorce/death
- history of family violence, abuse or sexual abuse
- intense feelings of fear, hurt, anger, rejection, abandonment, loss or need for control
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By attending Yalom's curative factors people get:
- hopeful from watching others
- know they aren't alone
- gain knowledge from others
- feel good about sharing/helping others
- resolve old issues
- gain social skills
- become a role model/empowered
- will get help with accountability
- cathartic
- sense of belonging
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Don't use typicals on people with
- blood dyscrasias
- Parkinsons
- Narrow angle glaucoma
- people in a coma
- people with CNS depression
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Give atypicals cautiously to elderly cuz....
- cause hypotension when given with antihypertensives
- cause further CNS depression when taking meds that cause CNS depression
additive effects
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What does depression look like in the elderly?
- dementia
- memory loss
- confused thinking
- apathy
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What's the best way to treat elderly for depression
ECT
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crises intervention does not include....
psychological interpretations
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Outcome of a crisis
through adaptive change a person will have resolution of the crisis and growth will occur
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Precautions for antipsychotics and elderly
- watch for...
- anticholinergic rxns
- parkinsonian
- tardive dyskinesia
- orthos
- cardiac conduction disturbances
- sedation
- cognitive slowing
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