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Reuptake Inhibitors SSRIs Citalopram (Celexa) Escitalopram (lexapro) Fluoxetine (Prozac) Fluvoxamine(Luvox) Paroxetine (Paxil, Pexeva) Sertraline(Zoloft) Serotonin-NE-RIs

Venlafaxine (Effexor) Duloxetine (Cymbalta) Desvanlafaxine (Pristiq) Atypical Antidepressants Amoxapine Bupropion (wellbutrin) Mirtazapine (Remeron) Nefazodone Trazodone (Desyrel)
Selective Serotonin Reuptake Inhibitors (SSRI's)

15. Educate the pt about the potential for discontinuation syndrome if the medication is stopped abruptly rather than tapered; the syndrome is characterized by GI distress, hehavioral or perceptual oddities, movement problems, & sleep disturbances 16. be aware of the potential for Serotonin syndrome, characterized by elevated temperature,musclerigidity, & elevated creatinephokinase levels; this risk is greatly Increased when SSRIs are given with MAOIs. AVOID this medication combination 17. Instruct the pt that OTC cold meds can the likelyhood of serotonin syndrome 18. In pregnancy, consultation with obstetricianis recommended regarding taking these meds 19. monitor the medication response in children, adolescents & older adults bc the response may be different than in adult pts 20. Encourage psychotherapy

Tricyclic Antidepressants:
Amitriptyline Clomipramine (Anafranil) Desipramine (Norpramine)

A. Description: Doxepin (Sinequan) 1. Inhibit serotonin uptake & elicit an antidepressant response 2. The potentional for medication interactions is high & complete Imipramine (Tofranil) medication assessments must be obtained and evaluated; inquire Nortriptyline (Aventyl HCL, Pamelor) about the use of herbal therapies,especially St. John's Wort B. Side Effects: Protriptyline (Vivactil) 1. N/V/D &cramping Trimipramine (Surmontil) 2. dry mouth 3. CNS $ including akathisia (restlessness, agitation) Tricyclic Antidepressants 4. BP changes 5. photosensitivity A. Description: 6. Insomnia, somnolence (sleepy, drowsy), apathy 1. Block the reuptake of NE (& serotonin) at the presynaptic 7. Nervousness neuron; used to Tx depression 8. Seizure activity 2. May reduce seizure threshold 9. Wt loss or Gain 3. may reduce effectiveness of antihypertensive agents 10. libido 4. Concurrent use with alcohol or antihistamines can cause CNS 11. Apathy depression 12. Tremors 5. *Concurrent use with MAOIs can cause hypertensive crisis 13. sweating 6. *Cardiac toxicity can occur & all the clients should receive ECG C. Interventions: before TX & periodically thereafter 1. SSRIs interact with numerous medications 7. OD is life-threatening, necessitating immediate Tx 2. Monitor VS bc SSRIs can potentially lower or elevate BP 8. The tricyclic antidepressant clomipramine (Anafranil) may be 3. Monitor Wt used to tx OCD 4. Initiate safety precautions, particularly if dizziness occurs ***PRIORITY NSG ACTIONS*** 5. Instruct pt to avoid alcohol 6. Administer w/ a snack or meal to reduce the risk of dizziness or Actions to take for a Tricyclica Antidepressant OD lightheadedness 1.Check airway & maintain a patent airway 7. Monito the suicidal pt, especially during improved mood & energy levels 2. Administer O2 8. Instruct the pt taking Fluoxetine (Prozac) or Bupropion 3. Check VS (Wellbutrin) to take the med early in the AM to prevent 4. Obtain ECG interference with sleep 9. for pt on long-term therapy, monitor liver & renal function test 5. Prepare for gastric lavage with activated charcoal results; altered values may occur requiring dosage adjustments 6. Prepare to administer physostigmine ( a cholinesterase inhibitor) 10. monitor WBC & neutrophil counts; the med may be discontinued & antidysrhythmic medications if levels below normal 11. If priapism (painful, prolonged penile erection) occurs, the med is 7. Document the event, actions taken, & the pts response withheld & the physician is notified 12. Inform the pt about the possibility of libido 13. Instruct the pt to change positions slowly to avoid hypotensive event 14. Instruct the pt report any visual changes to Dr

B. Side Effects: B. Side Effects: 1. Anticholinergic effects: dry mouth, difficulty voiding, dialated 1. Orthostatic hypotention pupils & blurred vision, decreased GI motility, constipation 2. restlessness 2. Photosensitivity 3. insomnia 3. CV disturbances (Tachycardia or Dysrhythmias; Othostatic 4. dizziness hypotention) 5. weakness, lethargy 4. Sedation 6. GI upset 5. Seizures (w/ Bupropion) 7. dry mouth 6. wt gain 8. wt gain 7. Anxiety, restlessness, irritability 9. peripheral edema 8. or libido with ejaculatory & erection disturbances 10. anticholinergic effects C. Interventions: 11. CNS $ (anxiety,agitation, mania) 1. Monitor the suicidal pt, especially during improved mood and 12. delay in ejaculation increased energy levels * 2. Instruct pt to change positions slowly to avoid hypotensive effect C. **Hypertensive Crisis* 3. Monitor pattern of daily bowel activity * 1. HTN 4. Assess for urinary retention 2. Occipital HA radiating frontally 5. For the pt on long-term therapy, monitor liver and renal function 3. Neck stiffness & soreness test results 4. N/V 6. Administer with food or milk ifGI distress occurs* 5. Sweating 7. Administer the entire daily PO dose at one time, preferably @ 6. Fever & chills bedtime 7. Clammy skin 8. Instruct pt to avoid alcohol & nonpresciption meds to prevent 8. Dilated pupils adverse medication interactions 9. Palpitations, tachycardia,or bradycardia 9. Instruct the pt to avoid driving & other activities requiring 10. Constricting chest pain alertness until the response is known; sedation is expected in 11. Antidote for hypertentive crisis: phentolamine by IV injection early therapy & may subside with time 10. When the med is d/c by the Dr, it should be tapered gradually D. Interventions: 11. The potential for medication interactions w/OTC cold meds 1. Monitor BP frequently for HTN * exists 2. Monitor for signs of hypertensive crisis 12. Caution the pt for photosensitivity & to take measures to prevent 3. If palpitations or frequent HA occur, withhold the medication & exposure to sunlight notify Dr. 13. Encourage PO hygiene & the use of hard candies & mouth rinses 4. Administer with food if GI distress occurs to relieve dry mouth 5. Instruct pt that the medication effect may be noted during the first 14. Encourage psychotherapy week of therapy, but maximum benefit may take 3 weeks 6. instruct the pt to report HA, neck stiffness, or neck soreness immediately Inform the pt that antidepressant medication may take several weeks to 7. Instruct pt to change positions slowly to prevent orthostatic produce the desired effect (pts response may not occur until 2-4 weeks after hypotention the first dose) 8. Instruct the pt to avoid caffeine or OTC preparations such as wt reducing pills or medications for hay fever & colds MONOAMINE OXIDASE INHIBITORS (MAOIs) 9. Monitor for pt compliance with medication administration Isocarboxazid (Marplan) 10. Instruct the pt to carry a Medic-Alert card indicating that an MAOI med is being taken Pheneizine ( Nardil) 11. Avoid administering the med in the evening bc insomnia may Tranycypromine (Parnate) results 12. When the med is d/c by the Dr.,it should be d/c gradually Selegiline (Emsam) 13. Instruct the pt to avoid foods that contain tyramine

Teach the pt about foods that contain tyramine. Consuming tryeamineA. Description: containing foods when taking MAOI can cause hypertensive crisis 1. Inhibit the enzyme monoamine oxidase, which is present in the brain, bld plateletsm liver, spleen, & Kidneys Avocadoa 2. Monoamine oxidase metabolizes amines, NE, & Serotonin, so the Bananas concentration of these amines s with MAOIs Beef or chicken liver Brewer's yeast 3. pts who havedepression & have not responded to other Broad beans antidepressant therapies, including ECT, are given MAOIs 4. Concurrent use with amphetamines, antidepressants, dopamine, Caffeine (coffee, tea, chocolate) *Cheese especially aged ,except cottage cheese epinephrine, guanethidine, levodopa, methyldopa, nasal Figs decongestants, NE,resperpine, tyramine-containing foods, or Meat extracts & tenderizers vasoconstrictors may cause hypertentive crisis Overripe fruit 5. Concurrent use with opiod analgesics may cause HTN or Papaya hypoTN, coma, or seizures Pickled herring
Raisins Red wine, beer, shrry Sausage, bolgona, pepperoni, salami Sour cream Soy sauce Yogurt

MOOD STABILIZERS D. Interventions: 1. Monitor the suicidal pt, especially during improved mood and increased energy levels ** 2. Administer the med w/ food to minimize GI irritation Other Mood stabilizers: 3. Instruct the pt toavoid excessive amounts of coffee, tea, or cola, Aripiprazole (Abilify) which have a diuretic effect Carbamazepine ( Tegretol) 4. Do NOT administer diuretics while the pt is taking lithium Gabapentin ( Neurontin) 5. Instruct pt to avoid alcohol Lamotrigine (Lamictal) 6. instruct the pt to avoid OTC meds Olanzapine (Zyprexa) 7. Instruct the pt that he or she may take a missed dose within 2 Olanzapine/fluoxetine ( Symbyax) Oxcarbazepine (Trileptal) hours of the scheduled time; otherwise the pt shouldskip the Quetiapine (Seroquel) missed dose and take the next dose at the scheduled time Risperidone (Risperdal) 8. Instruct the pt not to adjust the dosage without consulting with Valproate sodium (Depacon), valproic acid (Depakene), divalproex sodium the Dr. bc lithium should betapered & not be d/c abruptly (Depakote) 9. Instruct the pt about the s/s of lithium toxicity Ziprasidone (Geodon) 10. Instruct the pt to notify the Dr. if polyuria, prolonged vomitting, diarrhea, or fever occurs A. Description: Affect cellular transport mechanism & enhance serotonin or 11. Instruct the pt that the therapeutic response to the medication is -aminobutyric acid (GABA) function, or bother, which are associated with noted in 1-3 weeks mood 12. Monitor the ECG, renal function tests, and thyroid tests (ensure that these tests are performed before the start of therapy) B. Lithium 13. Instruct the pt to take the medication with food or milk to 1. Concurrent use with diuretics, fluoxetine (Prozac), methyldopa, decrease GI upset or NSAIDs lithiums reabsorption by the kidneys orinhibits 14. Monitor wt lithium excretion, either of which s therisk of lithium toxicity Instruct the pt taking lithium (Lithobid) to maintain fluid intake of 6-8 2. Acetazolamide (Diamox), aminophylline, phenothiazines, or glasses of H2O a day and an adequate salt intake to prevent lithium toxicity. sodium bicarbonate may renal excretion of lithium, reducing its effectiveness E. ** Lithium Toxicity** 3. the therapeutic dose is only slightly less than the amount 1. Description: producing toxicity a. Occurs when ingested lithium cannot be detoxified & 4. the therapeutic drug serum level of lithium is 0.6 to 1.2 mEq/L; excreted by the kidneys the actural dose at which the therapeutic effect is achieved & the b. Symptoms of toxicity begin to appear when the serum lithium levels at which toxicity is highly variable among individual pts level is 1/5-2 mEq/L 5. the cause of an in the lithium level include Na+ intake; fluid 2. Mild Toxicity: & electrolyte loss associated with excessive sweating, a. Serum lithium levelis 1/5 mEq/L dehydration; and illness or OD b. Apathy 6. Serum lithium levels should be checked Q1-2mo. Or whenever c. Lethargy any behavioral change suggests an altered serum level d. diminished concentration 7. blood samples to check serum lithium levels should be drawn in e. mild ataxia the AM, 12 hours after the last dose was taken f. coarse hand tremors g. slight muscle weakness C. Side Effects: 3. Moderate Toxicity: 1. Polyuria a. serum lithium level 1.5-2.5 mEq/L 2. polydipsia b. N/V 3. anorexia, nausea c. Severe diarrhea 4. dry mouth d.mild to moderate ataxia & incoordination 5. mild thirst e. slurred speech 6. wt gain f. Tinnitus 7. abd.bloating g.blurred vision 8. soft stools or diarrhea h. muscle twitching 9. fine hand tremors i. Irregular tremor 10. inability to concentrate 4. Severe Toxicity: 11. muscle weakness a. Serumlithium level >2.5 mEq/L 12. lethargy b. Nystagmus (involuntary eye movement Dancing eyes) 13. fatigue c. muscle fasciculations (twitching) 14. HA d.Deep tendon hyperflexia 15. hair loss e. Visual or tactile hallucinations 16. hypothyroidism f. impaired LOC h. Tonic-clonic seizures or coma, leading to death 5. Interventions for lithium toxicity: a. withhold lithium & notify Dr.* b. Monitor VS & LOC c. Monitor cardiac status d. Prepare to obtain samples monitoring lithium, electrolyte, BUN, & creatinine levels& CBC count e. Monitor for suicidal tendencies & institute suicide precautions
Lithium Preparations Lithium carbonate (Lithobid) Lithium citrate

for the pt with impaired liver function ANTIANXIETY OR ANXIOLYTIC MEDICATIONS 7. Initiate safety precautions bc the older adult is at risk for falling A. Description: when taking the medication for sleep or anxiety 1. Antianxiety medications depress the CNS, increasing the effects 8. assisst with ambulation if drowsiness or lightheadedness occurs of GABA, which produces relaxation & may depress the limbic 9. Instruct the pt that drowsiness usually disappears during system continual therapy 10. Instruct pt to avoid tasks that require alertness until the response BENZODIAZEPINES: to the medicationis established Alprazolam (Xanax, Niravam) 11. Avoid alcohol Chlordiazepoxide (Librium) 12. Instruct the pt not to take other medications without consulting Clonazepam (Klonopin) the Dr. Clorazepate (Tranxene) 13. Instruct the pt not to stop the medication abruptly (can result in Diazepam (Valium) seizure activity Flurazepam (Dalmane) E. Withdrawal: Lorazepam (Ativan) Midazolam ( Versed) 1. to lessen withdrawal symptoms, the dosage of a benzo should be Oxazepam ( Serex) tapered gradually over 2-6 weeks Quazepam (Doral) 2. Abrupt or too rapid withdrawal results in the following: Temazepam (Restoril) a. restlessness Triazolam (Halcion) b. irritability c. insomnia NONBENZO Anxiolytic d. hand tremors Buspirone(BuSpar) e. abd. Or muscle cramps f. sweating 2. Benzo's have anxiety reducing (anxiolytic), sedative-hypnotic, h. vomiting muscle relaxing & anticonvolsant actions g. seizures 3. Benzodiazepines are contraindicated in pts with acute narrowangle glaucoma & should be used cautiously in children & older BARBITURATES & SEDATIVE-HYPNOTICS adults Barbiturates: 4. Benzos interact with other CNS medications,producing and Amobarbital sodium (Amytal Sodium) additive effect 5. Abrupt withdrawalof benzos can be potentially life-threatening, Butabarbital sodium ( Butisol sodium) Pentobarbital sodium ( Nembutal sodium) & withdrawal should occur only under medical supervision Phenobarbital sodium ( Luminal Sodium) B. Side Effects: Secobarbital sodium (Seconal Sodium) 1. Daytime sedation 2. Ataxia Sedative-hypnotics: 3. Dizziness Chloral hydrate (Aquachoral Supprettes, Somnote) 4. HA Eszopiclone (Lunesta) 5. blurred or double vision Meprobamate (Miltown) 6. hypotention Ramelteon (Rozerem) 7. tremor Zaleplon (Sonate) 8. amnesia Zolpidem (Ambien) 9. slurred speech 10. urinary incontinence 11. constipation A. Description: 12. paradoxical CNS excitement 1. Depress thereticular activating systems by promoting the 13. Letharygy inhibitory synaptic action of the neurotransmitter GABA 14. Behavioral change 2. usedfor short-term treatment of insomnia or for sedation to relieve anxietym tension, & apprehension C. Acute Toxicity 1. somnolence B. Side Effects: 2. confusion 1. Dizziness & drowsiness 3. diminished reflexes & coma 2. confusion 4. Flumazenil(Romazicon), a benzo antagonist administered IV, 3. irritability reverses benzo's intoxication in 5 minutes 4. allergic reactions 5. a pt being treated for an OD of benzo's may experience agitation, 5. agranulocytosis restlessness, discomfort & anxiety 6. Thrombocytopenic purpura D. Interventions: 7. Megaloblastic anemia 1. Monitor for motor responses such as agititation, trembling & C. Overdose: tension 1. Tachycardia 2. Monitor for autonomic responses such as cold clammy hands & 2. hypotension sweating 3. cold & clammy skin 3. Monitor for paradoxical CNS excitement during early therapy, 4. dilate pupils particularly in older adults & debilitated pts 5. weak & rapid pulse 4. Monitor for visual disturbances bc the medications worsen 6. signs of shock glaucoma 7. depressed respiration 5. Monitor liver & renal function test results & CBC counts 8. absent reflexes 6. reduce the medication dose as prescribed for the older adult pt & 9. coma & death may result from respiratory & CV collapse

D. Withdrawal 1. Severe withdrawal symptoms begin within 24 hours after the medication is d/c in an individual with severe medication dependence 2. Gradual withdrawal is used to detoxify a dependent pt 3. Anxiety 4. Insomnia 5. Nightmares 6. daytime agitation 7. tremors 8. delirium 9. seizures 10. behavioral changes E. Interventions: 1. Administer lowerdoses as prescribed for the older pt 2. medications should be used withcaution in the pt who has suicidal tendencies or hasa hx or drug addiction 3. Maintain safety by supervising ambulation & using side rails at night 4. Instruct the pt to take the medication as directed 5. Instruct the pt to avoid driving or opperating heavy hazardous equipment if drowsiness, dizzinessm or unsteadiness occurs 6. Avoid alcohol 7. For insomnia, instruct the pt to take the medication30 minutes before bedtime; avoid taking with a large amount of food to help absorption 8. Instruct the pt that a hangover effect may occur in the morning 9. Instruct the pt not to d/c the medication abruptly 10. Instruct the pt taking chloral hydrate to take the medication with food & a full glass of H2O, fruit juice, or ginger ale to prevent gastric irritation.

Side Effects of Antipsychotic Medications Anticholinergic Effects: Dry mouth Increased HR Urinary retention Constipation Hypotention Extrapyramidal S/Es Parkinsonism Tremors Mask-like facies Rigidity Shuffling gait Dysphagia Drooling Dystonias Abnormal or involuntary eye movements, including oculogyric crisis facial grmicing Twisting of the torso or other muscle groups Akathisia Restlessness constant moving about Tardive Dyskinesia Protrusion of the tongue chewing motion Involuntary movements of the body & extremities Other S/Es drowsiness Blood dyscrasias Pruritus Phototsensitivity Elevated BG levels Increased wt Impaired body temperature gynecomastia Lactation

Typical: Chlorpromazine (Thorazine) Fluphenazine deconate (Prolixin Decanoate) Haloperidol Loxapine (Loxitane) Moloddone (Moban) Pimozide (Orap) Thiothixene (Navane) Trifluperazine Atypical: Aripiprazole (Abilify) Clozapine (Clozaril) Olanzapine (Zyprexa) Quetiapine (Seroquel) Risperidone (Risperdal) Ziprasidone (Geodon)

A. Description: 1. Improve the though process and the behavior of the pt with psychotic symptoms, especially pts with schizophrenia 2. Affect dopamine receptors in the brain, reducing the psychotic symptoms 3. Typical antipsychotics are more effective for positive symptoms of schizophrenia, such as hallucinations, aggression, and delusions; typical antipsychotic medications also block the chemoreceptor trigger zone and vomiting center in the brain, producing anantiemetic effect 4. Atypical: are more effective for the negative symptoms of schizophrenia, such as avolition, apathy,and alogia, 5. The effects of antipsychotic medications are potentiated when give with other medications acting on the CNS. C. Interventions:

Monitor VS 1. A potentially fatal syndrome that may occur at any time during Monitor for symptoms of neuroleptic malignant sysndrome (can therapy with neuroleptic (antipsychotic meds) occur w/ other antipsychotic medications) 2. Although rare, NMS more commonly occurs in the initiation of 3. Monitor urine output therapy, after the pt has changed from one medication to another, 4. Monitor serum glucose level after a dosage increase, or when a combination of medications is 5. Th pt taking an antipsychotic medication may require long-term used medication for parkinoian symptoms B. AssessmentL 6. Administer the med with food or milk to decrease gastric upset 1. Dyspnea or tachypnea 7. For PO use, the liquid formmight be preferred bc some pts hide 2. Tachycardia or irregular pulse rate tablets in there mouths to avoid taking them 3. Fever 8. the absorption rate is faster with the liquid form 4. High or low BP 9. Avoid skin contact with liquid concentrate to prevent contact 5. Increased sweating dermatitis 6. loss of bladder control 10. protect the liquid concentrate from light 7. skeletal muscle rigidity 11. dilute the liquid concentrate with fruit juice 8. pale skin 12. Inform the pt that a full therapeutic affect maynot be evident for 9. excessive weakness or fatigue 3-6 weeks after initiation of therapy; however an observable 10. altered LOC therapeutic response may be apparent I n 7-10 days 11. Seizures 13. Inform the pt that some medications may cause a harmless 12. Severe EPSE change in urine color pinkish-to red brown 13. Difficulty swallowing 14. instruct the pt to use sunscreen, wear hats & protective clothing 14. Excessive salivation when outdoors 15. Oculogyric Crisis 15. Instruct the the pt to Avoid alcohol or other CNS depressants 16. Dyskinesia 16. Change positions slowly to avoid orthostatic hypotention 17. Elevated WBC count, liver function results, & creatinine 17. Instruct the pt to report s/s of agranulocytosis, including sore phosphokinase level throat, fever, & malaise C. Interventions 18. Instruct the pt to report signs of liver dysfunction, including 1. Notify the Dr. jaundice, malaise, fever & RUQ (abd) pain 2. Monistor VS 19. When d/c anti-psychotics, the medication dosage should be 3. Initiate safety &seizure precautions reduced gradually to avoid sudden occurrence of psychotic 4. Prepare to d/c the medication symptoms. 5. Monitor LOC 6. Administer antipyretics as prescribed Monitor for EPSE in the pt taking anti-psychotics meds! 7. Use a cooling blanket to lower the body temperature 8. Monitor electrolytelevels & administer fluids IV as prescribed

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