Substance Use Disorders and Psychiatric Conditions, Exams of Nursing

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NSG 552 Naloxone (Narcan) - Answer opioid antagonist Narcan - Answer Treatment of choice for opiate overdose It is prescribed routinely for all patients with opiate use disorder Very short half-life Methadone - Answer Long acting full opioid receptor agonist at mu receptor Restricted use to abuse trx facilities Monitor for QTC prolongation(cardiac abnormalities Suboxone - Answer Opiod agonist/ antagonist Decreased cravings Can precipitate withdrawals if used too soon after full opioid agonist-it will displace any residual opioids from the mu receptors Sublingual preparation that is safer Waiver needed to prescribe outpatient Useful for patients with opiate use disorder with comorbid pain Suboxone can be used in pain management Naltrexone - Answer competitive opiod antagonist Precipitate withdrawal if used within 7 days of heroine use Available orally or monthly depot injections Treatment of choice for highly motivated patients Risk for LFT elevation Opoid(Heroin) - Answer Intoxication: miosis, hypotension, bradycardia, Low RR, unconscious Trx: Naloxone Withdrawal: Anxiety, lacrimation, muscle aches, abdominal cramps and diarrhea, seizures Mgt: Buprenorphine/naloxone, clonidine, Bentyl It is more effective at suppressing and controlling withdrawal than methadone Cocaine - Answer Intoxication: Auditiory hallucinations, agitation, violent behavior, muscle twitching, HTN, Tachycardia Txt: Lorazepam Withdrawal: Antabuse use in cocaine use d/o= increases dopamine in the brain reward circuit and act as an agonist trx in the setting of cocaine use d/o Cocaine induced chest pain and MI - Answer Txt: Nitoglycerin, Aspirin No Metoprolol Beta blockers are contraindicated in patients with cocaine induced chest pain-lowers coronary blood flow thereby worsening ischemia Alcohol intoxication - Answer Impaired fine motor control Impaired judgment and coordination Ataxic gait and poor balance Lethargic, difficulty sitting upright, difficulty with memory Nausea/Vomiting Coma=Levels 300mg/dl and over Respiratory depression and death possible Alchohol withdrawal - Answer Mild: Insomnia, irritability, Hand tremor 5A's of smoking cessation - Answer 1. Ask 2. Advise 3. Assess 4. Assist 5. Arrange nictotine replacement therapy - Answer Available in various forms Nicotine patch-watch for vivid dreams or sleep disruptions Gabapentin - Answer Has been considered as a treatment for insomnia in patients with substance use disorder Also helps with anxiety(No sedative effects, not metabolized by the liver, does not lower seizure threshold, no blood monitoring Methylphenidate - Answer Can be used in low doses as a adjunct to antidepressants for elderly patients with severe depression and/or psychomotor retardation Geriatric psychopharmacology - Answer If TCA is indicated=consider Nortriptyline(fewer anticholinergic side effects Consider Remeron=MDD w/symptoms of insomnia and decreased appetite delirium - Answer Medical Emergency Reversible 40% mortality rates Commonly experienced by elderly patients in the ICU and post-op Develops over hours to days=Acute Subtypes: Hyperactive(agitated, restless, hyperalert, Hypoactive(lethargy, slowed, apathetic) Mixed(cycles b/n hyperactive and hypoactive) Causes: DELIRIUM(Drugs, Electrolyte imbalance, low 02 levels, Infection, reduced sensory input, intracranial(strokes), Urinary retention, Myocardial) Treatments: 1:1 sitter Agitation and psychotic symptoms Haldol(PO,IM, IV) atypical antipsychotics) Dementia - Answer group of symptoms marked by memory loss and loss of other cognitive functions such as perception, thinking, reasoning, and remembering -Irreversible Alzheimer's disease - Answer -Gradual progressive decline -The most common type -Affects memory, learning, and language -Aphasia(difficulty with speech -Apraxia(inability to perform previous learned tasks) -Agnosia(inability to recognize an object) Etiology: Accumulation of beta-amyloid plaques and intraneuronal tau protein tangles Txt: Cholinesterase inhibitors NMDA receptor antagonists vascular disease - Answer 2nd most common Cognitive decline secondary to large vessel strokes Risk factors: HTN,DM, smoking, obesity, HLD, A-fib, Age Lewy body dementia - Answer characterized by wax and waning cognition Visual hallucinations(well formed images of animals and small pple) Develops EPS(Parkinsonism) @least 1 year after cognitive decline Etiology: Lewy bodies and lewy neurities in brain(primarily basal ganglia) Txt: Cholinesterase inhibitors -Seroquel and Clozaril(low doses/short term) -Levodopa/Carbidopa -Melatonin and/or Clonazepam(REM sleep disorder) -Be careful with antipsychotics(highly sensitive) Frontotemporal degeneration(FTD) - Answer 40% familial Atrophy of the frontal and temporal lobes Personality/behavioral Disinhibition(verbal,physical,sexual) Language: difficulty with speech and comprehension Kluver-Bucy syndrome: Hypersexual, hyperorality Txt: symptom focus SSRI to help with disinhibition Donepezil(cholinesterase inhibitors) - Answer Slows clinical deterioration by 6-12months Once daily dosing For mild-moderate NCD Not effective in severe, end-stage disease -Should stop if side effects of nausea/vomiting develop S/E diarrhea, weight loss, abnormal dreams, insomnia, dizziness Galantimine - Answer Twice daily dosing, GI side effects For mild-moderate NCD Rivastigmine (Exelon) - Answer cholinesterase inhibitor Twice daily dosing -For mild-moderate AD &Parkinson's jdisease dementia Transdermal patch available-daily form with fewer side effects •4:1 ration (male/female) •Recognized ages 12-24 months Autism Spectrum Disorder - Answer •Treatment Approach •Early intervention, behavioral therapy, psychoeducation •Alpha-2 agonists (clonidine, guanfacine) and low dose atypical antipsychotics (Risperidone, Abilify)= to help reduce disruptive behaviors, aggression and irritability •Melatonin for sleep, •Remeron for sleep, anxiety Autism Spectrum Disorder Treatment - Answer Risperidone (Risperdal): Autism associated irritability, aggression, temper tantrums, self-injurious behaviors, mood lability Children 5+ and Adolescents less than 18 (weight based) Autism Spectrum Disorder Treatment - Answer Aripiprazole (Abilify) Autism associated irritability, aggression, temper tantrums, self-injurious behaviors, mood lability Children and Adolescents 6-17 years old sexual dysfunction - Answer SSRI: •Most of the antidepressants EXCEPT Bupropion (Wellbutrin) & Mirtazapine (Remeron) cause sexual problems •Desire (libido) •●Frequency of sexual activity •●Arousal (lubrication in females and erectile function in males) •●Orgasm (delayed orgasm and anorgasmia) • •Management •Watchful waiting; if sexual impairment persists: •Decrease the dose of the SSRI within the therapeutic range. •Switch to Bupropion (Wellbutrin) • phosphodiesterase-5 inhibitor. sexual dysfunction - Answer Bupropion If a woman with a distressing sexual problem greatly desires a pharmacologic intervention, after nonpharmacologic treatments have been tried, bupropion is often the first choice. sexual dysfunction: Premature Ejaculation - Answer •Recurrent pattern of ejaculation during sex within 1 minute and before individual wishes it • •Treatment •Prolong time from SSRI and TCAs stimulation to orgasm •(e.g. Clomipramine- 15mg - 30 mg - take 2 hours before intercourse is effective and a safe treatment , Fluoxetine, Paroxetine) PDE-5 inhibitors - Answer •Sildenafil (Viagra)- take 30 min to 4hours before sexual activity •Tadalafil (Cialis)- take 30-60 min before sexual activity •Note: Avoid concomitant use w/ nitrates (e.g. nitroglycerine, isosorbide dinitrate, amyl nitrate "poppers") - can cause an unsafe drop in blood pressure •Caution with patients taking alpha-adrenergic blockers personality disorders - Answer Cluster A: Familial association with psychotic disorders Patient seem eccentric, peculiar or withdrawn •Schizoid •Schizotypal •Paranoid personality disorders - Answer Cluster B Familial association with mood disorders Patients seem emotional, dramatic or inconsistent •Antisocial •Borderline •Histrionic •Narcissistic personaty d/o - Answer Cluster c Familial association with anxiety disorders. Patients seem anxious or fearful •Avoidant •Dependent •Obsessive-compulsive personality disorders - Answer •Personality disorders are generally very difficult to treat especially since few patients will acknowledge they need help •These disorders tend to be chronic and lifelong •Pharmacologic treatments have limited usefulness except when treating comorbid mental conditions (e.g. MDD) borderline personality disorder - Answer •Fear of abandonment •Aggression •Impulsive •Repeated SI attempts/gestures/self-mutilation •"Splitting" Borderline Personality Disorder (BPD) - Answer •Txt: Gold standard=Dialectical behavior therapy(DBT) •Pharmacotherapy as adjunct to psychotherapy. •. Mood stabilizers and low dose antipsychotic meds have been found to be effective for mood swings and lability