Nursing 3Rd Semester: Mental Health Exam 3: Depression & Bipolar Disorder

Front 1

What is the scale used to assess a person's risk for suicide? Describe this scale.

Back 1

SAD PERSONS scale
Sex- 1 point if male, 0 if female
Age- 1 point if 15-34; 35-44 or 65+
Depression- 1 if present
Previous attempt- 1 if present
Ethanol abuse- 1 if present
Rational thinking loss-1 point if patient is psychotic for any reason (schizophrenia, affective illness, organic brain
syndrome)
Support systems lacking- 1 point if these are lacking, especially with recent loss of significant other
Organized Plan- 1 point if plan made and method is lethal
No spouse- 1 if divorced, widowed, separated, or single (for males)
Sickness- 1 point especially if chronic, debilitating, severe (i.e non-localized cancer, epilepsy, MS, GI disorders)

Guidelines for reading results:

0-2 Send home with follow-up
3-4 Close follow-up; consider hospitalization
5-6 Strongly consider hospitalization, depending on confidence in the follow-up arrangement
7-10 Hospitalize or commit

Front 2

ECT or electroconvulsive therapy, is very difficult for what kinds of depression? Patient is NPO for ___ hours prior, usually it's done in the morning/afternoon/evening. What kinds of things need to be removed from the patient prior to ECT? What are some presurgery meds & interventions? It is performed by the MD, who presses a button to initiate a tiny electrical current which causes a small seizure, all you usually see is a little twitch in the ___, not like a gran mal or petite mal etc. The patient wakes up in about ___ minutes and will be alert/agitated/confused significantly at first in about __ hours they should be back to "normal." Will the patient remember the procedure? The patient will go to he recovery room for about hour where their physiological functioning is monitored, such as watching VS etc. How often and how many sessions are done typically? What is the goal? What are some contraindications?

Back 2

ECT or electroconvulsive therapy, is very difficult for what kinds of depression? Patient is NPO for 8 hours prior, usually it's done in the morning.. What kinds of things need to be removed from the patient prior to ECT? dentures, hearing aids, prosthetic limbs (same as for most preops). What are some presurgery meds & interventions? Atropine to reduce secretions, a short acting general anesthetic such as propathol, a musle relaxant, something like Versed, O2, bite block. It is performed by the MD, who presses a button to initiate a tiny electrical current which causes a small seizure, all you usually see is a little twitch in the toes, not like a gran mal or petite mal etc. The patient wakes up in about 15 minutes and will be confused and disoriented significantly at first in about 6 hours they should be back to "normal." Will the patient remember the procedure? No. The patient will go to he recovery room for about hour where their physiological functioning is monitored, such as watching VS etc. How often and how many sessions are done typically? 6-12 sessions over 2-4 weeks, sometimes have a tx every dau, may come back in a month for a few more sessions etc. What is the goal? to decrease level of depression, it can produce remarkable changes. A theory says it's kind of like resetting the chemicals for an antidepressant effect. What are some contraindications? recent MI or CVA, intracranial lesions, don't want to risk a rupture/brain bleed- lots of testing is done ahead of time, not given lightly.

Front 3

In the first few weeks on an antidepressant, this is the highest risk for ____ because the patient may have more energy but the depression is still there.

Back 3

suicide

Front 4

Tricyclic antidepressants block the re_____ of ______ and ___. Are there many or few side effects? What are some common side effects? What are some nursing implications? (contraindications, use cautiously for who, when best given, what needs to be monitored etc) What is another indication for this med?

Back 4

Tricyclic antidepressants block the reuptake of norepinephrine and serotonin. There are many side effects, so these drugs aren't tolerable for everyone. There is especially pronounced sedation even at low doses, so give at night (hs). It may stimulate the appetite causing eight gain. CNS- tremors, potentiation of other sedatives (makes them stronger such as valium, xanex) Cognitive clouding- feel in a blur, not thinking straight
Elderly- disorientation/confusion
anticholinergic SE: GI /GU disturbance- constipation, urinary hesitancy, dry mouth CV- orthostatic hypotension, tachycardia, PVCs
Tricyclics have a very narrow therapeutic range, need blood monitoring. Very toxic in terms of OD potential, high potential for toxicity even at low doses.
Contraindications: narrow angle glaucoma, pregnancy, seizures, recent MI
Use cautiously in suicidal patients- hx of attempts
These meds are sometimes used for enuresis.

Front 5

SSRI's are selective serotonin reuptake inhibitors. Some examples include Prozac, Celexa, Luvox, Paxil, Lexapro, Zoloft
These meds block the reuptake of of serotonin.
Doses are given how many times a day typically?
There are more/less _________ side effects than tricyclics. Are there many or few side effects? How well tolerated are these meds? What are some common side effects? What are some nursing implications?

Back 5

SSRI's are selective serotonin reuptake inhibitors. Some examples include Prozac, Celexa, Luvox, Paxil, Lexapro, Zoloft
These meds block the reuptake of of serotonin.
Doses are given once a day.
There are less anticholinergic side effects than tricyclics. They are usually well tolerated and effective for most people. What are some common side effects? anticholinergic (but more mild) dry mouth, blurred vision, urinary retention
What are some nursing implications? Teach patient to give the med a chance to start working and time for the body to adjust to the SE. There are many drug interactions (both OTC and Rx), especially potentiate meds that are protein -bound like benzodiazapines and antipsychotic, antihypertensives. If they are taking certain drugs that interact, it's not necessarily a contraindication but something that needs to be evaluated. These meds are best prescribed by a psychiatrist. St. John's Wart is contraindicated, because it can cause serotonin overload in the brain. These drugs are not as toxic as tricyclics and don't require blood levels. Review serotonin syndrome and serotonin withdrawal (p. 12 of powerpoint)

Front 6

MAOI's, or Monoamine Oxidase Inhibitors are commonly/rarely used. They are similar in chemical properties to the TB drug Isoniazid. They are usually used to treat ___ depression. They have many drug-drug interactions, especially to what 4 types? People on these meds should avoid... What is a medical emergency that can occur with these drugs? What are some contraindications?

Back 6

MAOI's, or Monoamine Oxidase Inhibitors are rarely used. They are usually used to treat atypical depression. They have many drug-drug interactions, especially to what stimulants, SSRIs, TCAs, and antihypertensives. People on these meds should avoid foods high in tyramine. What is a medical emergency that can occur with these drugs? Hypertensive crisis. What are some contraindications? taking antihistamines and many other drugs.... look up contraindications

Hypertensive crisis (ex 210/120) can cause CVA from hemorrhage, death

Front 7

_____ or novel antidepressants include effexor, wellbutrin, desyrel, cymbalta, and remeron.

Back 7

atypical

Front 8

_____ is similar to an SSRI in lower doses. In higher doses, it inhibits the reuptake of norepinephrine. It requires close monitoring. It is not good for everyone. It is effective for _____ and has an anti-____ component too. The main side effect is __ ____. Use cautiously with ____ ____ and ____.

Back 8

Effexor is similar to an SSRI in lower doses. In higher doses, it inhibits the reuptake of norepinephrine. It requires close monitoring. It is not good for everyone. It is effective for dystimia (chronic low mood) and has an anti-anxiety component too. The main side effect is GI disturbance. Use cautiously with heart disease and hypertension.

Front 9

_____ (zyban) is also used to stop smoking-- it reduces cravings. It's a selective ____ reuptake inhibitor. The main SE are _____ and _____. If the patient is prone to having ____ this drug should be avoided. What should be avoided with this drug?

Back 9

Wellbutrin (zyban) is also used to stop smoking-- it reduces cravings. It's a selective dopamine reuptake inhibitor. The main SE are stimulation and tachycardia. If the patient is prone to having seizures this drug should be avoided. (don't give to an epileptic, low seizure threshold is a SE) What should be avoided with this drug? Alcohol! Bad combination

Front 10

Desyrel should be given at ____ because it has a ___ component.

Back 10

bedtime, sedative

Front 11

Remeron has antihistamine activity...

Back 11

(she said know the categories but we don't need to know specific atypicals?)

should we look up this stuff..?

Front 12

___ ____ ____ is an herbal supplement with antidepressant properties. It is not regulated by the FDA so we don't recommend it. It needs more research about dosage and there are many interactions with other drugs. It is contraindicated in hypertension, major depression, pregnancy, if taking ampehetamines, if taking parkinson meds, may interact with anticonvulsants, and immunosuppressants. It can cause photosensitivity, tachycardia, and GI disturbance. Don't take foods high in tyramine with this med (see p. 12 for foods high in tyramine)

Back 12

St. John's Wart

Front 13

In treating bipolar disorder, ____is the drug of choice for controlling manic episodes and is used prophylactically for mania and _______.

Back 13

In treating bipolar disorder, lithium is the drug of choice for controlling manic episodes and is used prophylactically for mania and depression.

Front 14

Lithium displaces ____ at the cell membrane, no one knows the exact mechanism of action. People who respond best are those who.... Who is it not given to?
It usually works how soon?
People who take it are also put on antipsychotics for _____ or ____. What is a major issue with this drug and why?
Lithium appears to prevent repeated episodes of ____ and can also be used for ______ disorder and other mental illnesses with a ___ disorder as a prominent feature such as _____ personality disorder. Others with poor ____ control may be on lithium and antidepressants. It effects the ____ ___ system and increases/decreases levels of _____ and _____. It somehow makes these levels more stable. It helps with hyper_____. It has a very low ____ ____. It is used cautiously in ____ and the ___. Blood levels need to be drawn, and they are done ____ h after the dose is given. Blood levels are monitored how often? The patient may have PRN doses of other drugs in addition, such as antianxieties. What is a major cause of death with this drug if the dose is too high?

Back 14

Lithium displaces salt at the cell membrane, no one knows the exact mechanism of action. People who respond best are those who have a family hx of bipolar disorder and depression and those with relatively stable moods between manic episodes. It is not used for mixed manic.
It usually works in 1-2 weeks. Teach patient that they won't feel different right away, it may take several months to really stabilize.
People who take it are also put on antipsychotics for delisons or hallucinations. What is a major issue with this drug and why? Noncompliance is a major issue due to denial of illness/they don't think they need it anymore (think they're cured)/want to have that euphoric feeling (don't want the high to go away). When used for mania, they are aware of their thought processes slowing down, which is sometimes more uncomfortable to them than racing thoughts.
Lithium appears to prevent repeated episodes of depression and can also be used for schizoaffective disorder and other mental illnesses with a mood disorder as a prominent feature such as borderline personality disorder. Others with poor impulse control may be on lithium and antidepressants. It effects the central nervous system and decreases levels of serotonin and norepinephrine. It somehow makes these levels more stable. It helps with hyperactivity. It has a very low therapeutic range. It is used cautiously in children and the elderly. Blood levels need to be drawn, and they are done 12 h after the dose is given. Levels are monitored weekly or biweekly to determine correct dosage, then monthly until on same dose for 6 months, then every 6 months to 1 year levels are drawn every 3 months for maintenance. The patient may have PRN doses of other drugs in additon, such as antianxieties. What is a major cause of death with this drug if the dose is too high? cardiac dysrhythmias

Front 15

The neurotransmitter ____ is responsible for mania and _____ is responsible for psychotic symptoms.

Back 15

The neurotransmitter norepinephrine is responsible for mania and dopamine is responsible for psychotic symptoms.

Front 16

For lithium, What is the usual dosage, lithium levels for therapeutic range and acute mainia, and what ranges are considered early, severe, and lethal toxicity?

Back 16

Dosage
Adult and adolescent: 300-600 mg Q.I.D.
Children under 12: 15-20 mg/kg Q.I.D.

Lithium Levels
Therapeutic range: 0.4 to 1.3 mEq/L
Acute mania: 1.2 to 1.5 mEq/L

Toxicity
Early Toxicity > 1.5 mEq/L Severe Toxicity 2.0 to 2.5 Lethality > 3.0 mEq/L

Note that acute manic dose is close to the toxic range.

Front 17

What are some side effects of lithium? What kind of dosage can help minimize side effects?

Back 17

headache
nausea
fine hand tremor
fatigue
mental dullness
excessive thirst and urination
lethargy

extended release

Front 18

What are some signs of lithium toxicity? What is the main complication of toxicity? What is the treatment?

Back 18

Hypothyroidism
kidney damage
confusion
delirium
convulsions
coma
life-threatening dysrrhythmias

complications: Organ damage and failure

Tx: Stop med, IV fluid bolus, antiseizures (dilantin), tx for dysrhythmias, (t is r/t what is going on with patient, what organ is effected) It's an emergency.

Front 19

When taking lithium, routine monitoring of ______ needs to be done as well as ____ and ____ function. It blocks/enhances the effect of other drugs, it can can increase the potential for ___.

Back 19

When taking lithium, routine monitoring of electrolytes needs to be done as well as renal and thyroid function. It enhances the effect of other drugs, it can can increase the potential for toxicity.

Front 20

Patient/family teaching for lithium

Back 20

Drink at least 2-3 L of fluids daily
Don't restrict salt, but moderate amounts (it displaces salt at the cell membrane- responsible for lots of organ functions)
Low fat diet- Can cause weight gain
Teratogenic- don't take if pregnant!
Enhanced effect of other drugs
Lab considerations, need for regular blood draws

Front 21

Valproic acid or ____ is a med used for treating bipolar. It is an anti____ or anti_____. Is it is generally well tolerated or only helpful for certain patients? It is especially effective for who? What are some common side effects? What is the toxic level? Signs of toxicity? What needs to be monitored? What is an important nursing implication?

Back 21

Valproic acid or Depakote is a med used for treating bipolar. It is an antiepileptic or anticonvulsant. Is it is generally well tolerated. It is especially effective for people with rapid cycling and dysphoria. What are some common side effects? nausea, weight gain, hair loss (look up rest of SE) What is the toxic level? 125 mg/ml or higher. Signs of toxicity? ataxia, slurred speech, delirium (more) What needs to be monitored? Liver function tests- liver enzymes, need baseline when therapeutic levels are achieved, then yearly monitoring. What is an important nursing implication? It's teratogenic. (neural tube defects)

Front 22

Carbamazepine (Tegretol) may be used in conjunction with _____. It is effective for bipolar I/II and especially people with ___ ____ and ____. Side effects include.... What is a major nursing implication?

Back 22

Carbamazepine (Tegretol) may be used in conjunction with lithium/ It is effective for bipolar I and especially people with rapid cycling and paranoia. Side effects include nausea, sedation, drowsiness, loss of appetite. What is a major nursing implication? Can cause agranulocytosis- monitor WBC

Front 23

Gabapentin (Neurontin) is specific for bipolar I/II. It works well for _____ and gives an ____ affect, which helps with ____. It is used cautiously in people with ...
It is also used for people with chronic ____. Common side effects include what 2? To avoid excessive fatigue and staggering gait, what is done? Is blood monitoring necessary?

Back 23

Gabapentin (Neurontin) is specific for bipolar II- works especially for ii but also sometimes used for I. It works well for depression and gives an anxiolytic affect, which helps with anxiety. It is used cautiously in people with pre-senile demenita.
It is also used for people with chronic pain. Common side effects include what 2? Dizziness, sedation. To avoid excessive fatigue and staggering gait, what is done? Drug must be titrated.
Is blood monitoring necessary? No.

Front 24

Lamotrigine (Lamictal) is commonly/uncommonly prescribed. It is used for people with...
What are some common side effects?

Back 24

Lamotrigine (Lamictal) is uncommonly prescribed. Use cautiously! It is used for people with rapid cycling and mixed mood states.
What are some common side effects? insomnia, jitteriness, reduced appetite, Steven-Johnson Syndrome (awful rash)

Front 25

_______ meds that are short acting like ativan are quite useful in emergency situations for helping manic patients. They can be given IV, IM, and PO.

Back 25

anti-anxiety

Front 26

Antidepressants are utilized during major depression and are a component of bipolar I/II disorder.
Which drugs are usually used and which are avoided?

Back 26

both I and II
SSRI's are powerful mania inducers. Bipolar II is dx after client exposed to antidepressants. Client rapidly develops hypomanic or full-blown manic symptoms.
Wellbutrin is preferred.

Front 27

Anxiety is a frequent symptom of bipolar disorder. Benzodiazapines such as loraxepam (which is short/long acting) and Klonopin (which is short/long acting).

Back 27

Anxiety is a frequent symptom of bipolar disorder. Benzodiazapines such as loraxepam (which is short/acting) and Klonopin (which is long acting).

Front 28

Klonopin is best for main____ because it's longer acting and haws a longer half life. What are some common side effects? What can potentiate these effects?

Back 28

Klonopin is best for maintenance because it's longer acting and haws a longer half life. What are some common side effects? ataxia, dizziness (CNS depression) What can potentiate these effects? alcohol, prozac (avoid this rx)

Front 29

Antipsychotics helps with psychotic behaviors like hallucinations, grandiose delusions, religious delusions, unrealistic guilt, and paranoid thinking. ____ is an atypical antipsychotic for bipolar with mania and psychotic symptoms. It's the drug of choice to stabilize the mood.

Back 29

Zyprexa

Front 30

Clozaril is for _____ cases and is for short/long term use

Back 30

Clozaril is for resistant cases and is for long term use

Front 31

Risperdal is for ___ with bipolar to help with psychotic symptoms like _____.

Back 31

Risperdal is for children with bipolar to help with psychotic symptoms like delusions.

Front 32

Geodon may precipitate a ____ episode, it works in a similar way as SSRIs and is helpful for ______ symptoms. It is not used very often.

Back 32

Geodon may precipitate a hypomanic episode, it works in a similar way as SSRIs and is helpful for depressive symptoms. It is not used very often.

Front 33

How is major depressive disorder (MDD) diagnosed by the dsm-iv-tr? It's also known as unipolar

Back 33

Loss of interest in life and depressed mood that lasts at least 2 weeks

5 or more of the following symptoms:
Depressed mood (subjective & objective)
Anhedonia
Weight changes
Sleep disturbances
Restlessness/agitation or
psychomotor retardation
Fatigue or loss of energy
Feelings of worthlessness/guilt
Difficulty concentrating
Recurrent thoughts of death

Front 34

True or False: At least sixty percent of people with major depressive disorder will have a 2nd episode.

Back 34

true

Front 35

The subtypes of MDD include psychotic features, catatonic features, melancholic features, postpartum onset, and atypical features. Explain each type.

Back 35

psychotic- temporary lapse of reality d/t intensity of depression, such as postpartum psychosis

catatonic- not as bizarre as schizophrenia, literally has rigid movements, echopraxia, difficulty moving, or getting out of bed
melancholic- often in elderly, profound sadness, talks about feeling really down or blue, hard time getting through day, s/s worse in morning/upon awakening
postpartum- within 4 weeks of childbirth (beyond the baby blues- hormonaly changes-- 2 weeks)-- can lead to psychosis

atypical- feel rejection, feel no one cares about them or loves them, may even believe spouse or significant other is poisoning them, perceived rejection severely debilitates life, significant functional impairment
"hypersomnia" too much sleep, can't get out of bed
These people have suicidal ideation, may overeat, "leaden paralysis"- feels likes legs are made of lead