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NR546/ NR 546 Study Guide
Week 1 to Week 4
Advanced Pharṃacology Psychopharṃacology
for the Psychiatric-Ṃental Health Nurse Practitioner
The Ultiṃate Study Guide to Pass Your Exaṃ
Inside, you'll get:
Key areas to focus on in your NR 546 study
guide:
Review course:
Review notes:
Practice questions with answers:
Case studies:
key terṃs and definitions:
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- How does reviewing the genetic makeup of a client help guide the PMHNP in selecting medication for clients
Answer> -Genetic testing can assist by providing more information on
how clients may respond to certain psychotropic medications -provides information on how a client may break down and metabolize medications based on the cytochrome P450 system.
- Tanr1kulu and Erba_ (2020) investigated identical twins to determine the presence of an inherited link for schizophrenia and why one twin may develop schizophrenia when the other does not. When two people have 100% identical DNA, why don't both persons develop the exact illnesses? Studies of identical Danish twins found that if one twin had schizophrenia, the other twin had a 50% lifetime risk of developing schizophrenia (Lemvigh et al., 2020). Why is there only half the risk
Answer> Both environmental and psychosocial stressors can im- pact
mental health. Although twins may have identical genes, their gene expression may be different. There may be an environmental exposure that turned a gene "on" that should have been "off" for one twin to develop schizophrenia and not the other.
- The field of epigenetics is rapidly growing and can help
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- What should the PMHNP consider when prescribing chemical restraints
Answer> -
-allergy status -prior med hx for adverse drug reactions r/t the meds ordered in the chemical restraint -state regulations regarding chemical restrains must be reviewed
- Are the PMHNP and other staff liable if the client has an allergic reaction or adverse side effects to the drugs used for chemical restraint
Answer> No.
The client has been court-ordered to take the prescribed medications and the standing order for chemical restraints is approved. The PMHNP and other staff are not liable if the patient has an allergic reaction or adverse side effects.
- Informed consent: Clients have the right to receive enough information to make decisions about treatment. -must also be informed about potential risks associated with medications. -have the right to refuse treatment -cannot be forcibly medicated in non-emergencies. However, clients can
5 / be forcibly medicated if they are violent toward themselves or others and when less restrictive methods have failed
- Compliance: A court order may be issued for a client to receive treatment against their wishes if they are considered a danger to themselves or others. -Examples: clients with schizophrenia or sex offenders -Guardians can provide consent for clients who have limited cognitive capabilities or are incompetent to make decisions -PMHNPs are responsible for being knowledgeable about their state laws and abiding by them.
- Off-Label Prescribing: Some clients may benefit from the unapproved use of a drug for symptom management. -Example: many SSRIs used to tx anxiety and OCD but are not FDA approved for use in this disorder. -potentially raises ethical and legal concerns -PMHNP must remain up to date with the latest recommendations for off-label prescribing.
- Incidence of mental illness-what factors are increasing the incidence: Psy- chological and sociological factors
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- Pharmacokinetics: the study of what happens to a drug from the time of administration until the parent drug and all metabolites leave the body
- CYP450: CYP450 enzymes in the gut wall or liver convert drug substrate into a biotransformed product in the bloodstream, responsible for degradating of a large # of psychotropic drugs -Not all ind. have same genetic form of CYP450 enzymes, determined with pharma- cogenetic testing *Most individuals have "normal" rates of drug metabolism from the major CYP450 enzymes and are said to be "extensive metabolizers", most drug doses are set for these individuals. *genetic variants of these enzymes can make poor metabolizers or ultra rapid metabolizers Five of the most important: CYP450 1A2, 2B6, 2D6, 2C9, 2C19, and 3A4.
- ultra rapid metabolizers: elevated enzyme activity subtherapeutic drug levels poor efficacy with standard doses
- genotyping: the patient for pharmacogenomic use -genes for these CYP450 enzymes can now be readily measured and used to predict which patients might need to have dosage adjustments
8 / -measurement of genes for drug metabolism
- most common targets of psychotropic drugs: G-protein receptors -Drug actions at these receptors occur in a spectrum, from full agonist actions, to partial agonist actions, to antagonism, and even to inverse agonism.
- Pharmacokinetics concepts: absorption distribution metabolism excretion
- Flockhart Table: drug interactions that are mediated by cytochrome P450 en- zymes comprehensive list of drugs and the interactions related to the cytochrome P450 system
- Neurotransmitters: chemicals released by neurons to send communication across synaptic clefts to other neurons -impact human emotion and behavior
- Neurotransmission
Answer> the chemical transmission of information between neu-
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- Volume neurotransmission: Neurotransmission without a synapse or nonsy- naptic diffusion neurotransmission -Chemical messengers sent by one neuron to another can spill over to sites distant to the synapse by diffusion -neurotransmission can occur at any compatible receptor within the diffusion radius of the neurotransmitter -neurotransmission occurs in chemical "puffs" -sophisticated "chemical soup." -example: dopamine action in the prefrontal cortex, at the sites of autoreceptors on monoamine neurons
- Excitatory neurotransmitters
Answer> increase the likelihood that the neuron will fire an action
potential
- inhibitory neurotransmitters
Answer> decrease the likelihood that a neuron will fire an action
- neurotransmitters that most impact mental health can be classified into four major categories
Answer> cholinergics
1 / -acetylcholine monoamines -norepinephrine, dopamine, serotonin, histamine amino acids -gamma- amino-butyric acid and glutamate neuropeptides
- Inhibitors: VISA CKGQ: Valproate Isoniazid Sulfonamides Amiodarone Chloramphenic ol Ketoconazole Grapefruit Juice Quinidine -decrease medication metabolism
- Inducers: CRAP GPS: Carbamazepine Rifampin Alcohol Phenytoin Griseofulvin
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- thalamus: involved in sensory organ and motor command processing
- striatum: involved in complex motor actions, also links cognition to motor actions
- limbic system: includes circuits that are associated with pleasure and reward
- basal ganglia: group of structures involved in voluntary motor movements
- amygdala: involved in emotional regulation and perception of odors
- corpus callosum: controls the communication between the two brain hemi- spheres
- white matter: contains nerve fibers that connect neurons from different regions into functional circuits
- grey matter: contains nerve cells and dendrites
- brain tissue: made up of grey matter and white matter
- dorsal striatum: involved in complex motor actions and linkage of cognition to motor actions -main input area for basal ganglia *activated when anticipating or engaging in pleasure
- neurotransmitters that may be responsible for a client's symptoms of de- pression: Imbalanced levels of acetylcholine, norepinephrine, serotonin, histamine, or glutamate can contribute to symptoms of depression
- client who is a poor metabolizer
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Answer> has a lower concentration of the necessary enzyme to
metabolize a drug, which results in higher blood concentrations of the drug. -increase the risk of side effects and adverse reactions
- Why is trazodone not used as a front-line antidepressant: Its antidepressant that has a secondary effect of blocking histamine and adrenergic receptors -causes sedation and somnolence and as a result *often used as an adjunct in therapy when a depressed patient has difficulty sleeping
- effect on neurotransmitters and side effects: Selective Serotonin Reuptake Inhibitors (SSRIs): Inhibits the reuptake of serotonin, which can cause nausea, agitation, headache, and sexual dysfunction
- effect on neurotransmitters and side effects: Serotonin and Norepineph- rine Reuptake Inhibitors (SNRIs): Inhibits the reuptake of serotonin and norepi- nephrine, which can cause nausea, sweating, insomnia, tremors, sexual dysfunction
- effect on neurotransmitters and side effects: Tricyclic Antidepressants: - -Inhibits the reuptake of serotonin and norepinephrine, which can cause sexual dysfunction -Blocks norepinephrine receptors, which can cause hypotension and tachycardia -Blocks histamine receptors, which can cause sedation and weight gain
6 / olanzapine to achieve a therapeutic response
Answer> Higher
-Nicotine is an inducer of the CYP 1A2 enzyme, so it lowers the concentration of drugs. Therefore, a higher dose of olanzapine may be needed to control his symptoms.
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- Ernesto, a 60-year-old, presents to the PMHNP with report of having anx- iety, frequent occurrences of feeling frozen in place and like his heart is pounding out of his chest, as well as having difficulty sleeping. The PMHNP suspects the client has an elevated level of which neurotransmit- ter
Answer> Norepinephrine
-responsible for the regulation of fight or flight responses and can impact mood and sleep.
- Which of the following is the best medication class for the PMHNP to prescribe for Ernesto to address his elevated norepinephrine levels
Answer> selec- tive serotonin reuptake inhibitor would block the
reuptake of serotonin, leaving a larger amount of serotonin available. Increasing the amount of serotonin would help regulate the feelings of fear and anxiety. Reducing the occurrence of fear would help reduce the release of norepinephrine. A serotonin and norepinephrine reuptake inhibitor would prevent the reuptake of norepinephrine, which would not reduce the level of norepinephrine as needed. Benzodiazepines increase the levels of GABA and do not impact norepinephrine. A monoamine oxidase inhibitor would increase levels of norepinephrine.
- During a follow up appointment after 4 weeks, the PMHNP should assess for the need to add which medication to
9 / -affect executive function and motor coordination, increase risk for accidents -Increased levels of gamma-aminobutyric acid have a calming effect.
- 5HT: Serotonin -help regulate mood -makes relaxed, comfortable, decreases stress, regulate sleep, arousal, libido, ag- gression, pain perception
- NE: norepinephrine -monoamine neurotransmitter -focus and productivity -too much due to stress, meds, caffein, stimulants can cause: nervous, antsy, affect focus
- DA: dopamine -monoamine neurotransmitter -regulate mood -associated with executive function, ability to perform well, be organized, emotional intelligence -movement and coordination -to little: lose pleasure, interest, alertness, self-confidence, parkinson's disease -to much: schizophrenia and psychosis -reward center: can lead to addiction -has own pathways
- Ach: acetylcholine -in CNS: affects arousal, motivation, attention, learning, REM sleep,
10 / impacts sleep, pain perception, memory -in PNS: makes you sweat and salivate -link between brain and muscles -not enough: Alzheimer's, Parkinson's, Schizophrenia -too much: Depression -Role in addiction -Receptors: nicotinic & muscarinic
- Histamine (Neurotransmitter): Histamine impacts alertness, pain sensation, and inflammatory responses; increased levels result in depression.
- Melatonin (neurotransmitter): Act at MT1-3 G-protein coupled receptors Sleep/wake cycle insomnia: melatonin agonists
- Psychotropic drug metabolism may be impacted by factors such as
Answer> -age
-smoking -caffeine intake
