Psychiatric Nurse Practitioner
Assessment
Explain the clinical signifcance of the Stystematic Treatment Enhancement Program for
Bipolar Disorder: STEP-BD) –
As more contempts are tried with SSRIs to relieve depressive symptoms, the
client becomes more treatment resistant leading to poor outcomes.
Explain the clinical significance of the Sequenced Treatment Alternative to Relieve
Depression STAR D –
Strong behavioral therapy combined with medications lead to 30% better
outcomes as compared to monotherapy or medication or therapy alone.
Describe the mechanism of action of Typical Antipsychotics –
Blocking D2 receptors in the mesolimbic and mesocortical
The Blocking D2 receptors in the mesolimbic and mesocortical tract –
tract reducing positive symptoms of psychosis, does effect the negative
symptoms of the disorder, can create EPS symptoms in the nigro-striatal tract,
Nigrostriatal –
involved with muscular movement
Mesolimbic –
source of visual hallucinations and auditory hallucinations,
Mesocortical –
mesocortical area holds affective symptoms,
Blocking Alpha 1 adrenergic receptors through down regulation causing orthostatic
hypotention -
Pharmacological strategies in addressing EPS symptoms –
Change medication
Lower the dose
Prescribe cogentin
Second generation antipsychotics are pharmacology directed to –
blocking both D2 and 5HT receptors in the brain and also relieve the negative
symptoms of psychosi
down regulation blocking Alpha ! receptors –
Orthostatic hypotension and dizziness which comes
,down regulation of blocking Muscarinic and Histamine receptors –
Weight gain, dizziness
serontin down regulation in the gut –
constipation
Neuroleptic malignant syndrome –
cause by increased medication changes or treatment naive patients
What are notable side effects of Clozapine –
Induced by cigarette smoking which is through the 1A2 pathway
Recommended dosing schedule for clozapine –
Start at 12.5 first day,
then in divide doses of 25-50 mg/day up to 300-400 mg per day.
Clozapine maxes –
Maximum dose is 900 mg per day.
No single dose should exceed 450 mg
Clozapine monitoring –
Need to register at the clozapine website as a provider
Normal levels of WBCs > 3500
Normal levels of ANC > 2000
wbc –
WBC with differentials, Absolute Neutrophil Count
Blood draws are done weekly for the first 6 months, then every other week for 6
months, then monthly
Notable side effects of Risperidone –
Increase risk of seizure
Contraindicated for pregnancy
Increased prolactin
Metabolic syndrome diagnostic criteria –
Combination of any three of the following
Abdominal circumference > 37 in males > 31.5 in femaies
Plus any two of the following:
Elevated Triglycerides > 150 mg/dl
HDL less than 40 mg/dl in men, 50 mg/dl in women
Blood pressure >130/85, or receiving treatment for hypertension
Fasting blood sugar >110 mg/dl or prior type of DM diagnosis
A weight increase of 7% should prompt the provider –
,to consider a different medication.
Neuroleptic Malignant Syndrome criteria –
Within 2 weeks of beginning the medication or a significant medication increase /
or present with abrupt withdrawal of levodopa or exposure to a dopamine agonist
Classic triad: -
Hot, Stiff, and Out of it: includes extreme mental status change/confusion,
extreme muscle rigidity, and extremem autonomic instability/hyperthermia:
What is the appropriate treatment for Neuroleptic Malignant Syndrome –
Dantrolene bromocriptine to relieve rigidity
How are TCA metabolized –
the 2D6 pathway
The importance of TCA to be aware of: -
Toxicity causes heart block, torsade de pointes arrythmia or sudden death
Monoamine Oxidase Inhibitor (MAOIs) concern for treatment –
Low tyramine diet including red wine, cheese, processed foods, causes a
hypertensive crisis (high blood pressure)
Buproprion –
Can lower the seizure threshold, should avoid in children and the elderly, NDRI
class
Fluoxetine (Prozac) –
Longer half life 36-40 hours
Paroxetine (Paxil) –
known for withdrawl symptoms if not taken regular, short half-life, good for
anxiety disorders
Citalopram (Celexa) –
cardiac effect may require decreased doses (QT prolongation) do not go over 40
mg/day
Trazodone –
Can cause priaprism
Sertraline (Zoloft) –
Dose dependent, need to increase the dose
Venlafaxine –
Elevated blood pressure
, Signs and symptoms of serotonin syndrome –
High serotonin levels can cause agitation, confusion, hallucinations, tachycardia,
fever, anxiety, muscle rigidity, hyperreflexia, tremors, diarrha, hypo/hypertension
Treatment for Serontonin Syndrome –
Withdraw from the SSRI,
Stabilizing temperature,
Use benzodiazepines for muscle relaxation,
Beta-blocker for the tachycardia
Notable side effects of Lithium –
Muscle weakness,
tiredness,
slurred speech,
fine hand tremor,
thirst nausea,
diarrhea / vomiting
Maintenance value for Lithium is –
0.8 to 1.0
When do you check the Lithium level –
Check serum level 12 hours after the last dose and after 5 days of steady dosing.
What antipsychotic can not be used with Lithium –
Haldol, linked to mild encaphalopathy and mimics NMS
Lithium is contraindicted in pregnancy- why –
causes Epstein anomaly, heart defect in the fetus
Depakote is contraindicted in pregnancy- why –
Birth defects: spina bifida are found in this medication
What over the counter pain relievers can be used with lithium –
aspirin and tylenol
What over the counter pain reliever is contraindicated –
ibuprofen
What diuretic should be avoided with the use of the Lithium –
Thiazides, but all diuretics should be monitored closely due to risk of toxicity
What heart medicines are contraindicated with lithium –
calcium channel blocker are contraindicated with this mood stabilizer
Assessment
Explain the clinical signifcance of the Stystematic Treatment Enhancement Program for
Bipolar Disorder: STEP-BD) –
As more contempts are tried with SSRIs to relieve depressive symptoms, the
client becomes more treatment resistant leading to poor outcomes.
Explain the clinical significance of the Sequenced Treatment Alternative to Relieve
Depression STAR D –
Strong behavioral therapy combined with medications lead to 30% better
outcomes as compared to monotherapy or medication or therapy alone.
Describe the mechanism of action of Typical Antipsychotics –
Blocking D2 receptors in the mesolimbic and mesocortical
The Blocking D2 receptors in the mesolimbic and mesocortical tract –
tract reducing positive symptoms of psychosis, does effect the negative
symptoms of the disorder, can create EPS symptoms in the nigro-striatal tract,
Nigrostriatal –
involved with muscular movement
Mesolimbic –
source of visual hallucinations and auditory hallucinations,
Mesocortical –
mesocortical area holds affective symptoms,
Blocking Alpha 1 adrenergic receptors through down regulation causing orthostatic
hypotention -
Pharmacological strategies in addressing EPS symptoms –
Change medication
Lower the dose
Prescribe cogentin
Second generation antipsychotics are pharmacology directed to –
blocking both D2 and 5HT receptors in the brain and also relieve the negative
symptoms of psychosi
down regulation blocking Alpha ! receptors –
Orthostatic hypotension and dizziness which comes
,down regulation of blocking Muscarinic and Histamine receptors –
Weight gain, dizziness
serontin down regulation in the gut –
constipation
Neuroleptic malignant syndrome –
cause by increased medication changes or treatment naive patients
What are notable side effects of Clozapine –
Induced by cigarette smoking which is through the 1A2 pathway
Recommended dosing schedule for clozapine –
Start at 12.5 first day,
then in divide doses of 25-50 mg/day up to 300-400 mg per day.
Clozapine maxes –
Maximum dose is 900 mg per day.
No single dose should exceed 450 mg
Clozapine monitoring –
Need to register at the clozapine website as a provider
Normal levels of WBCs > 3500
Normal levels of ANC > 2000
wbc –
WBC with differentials, Absolute Neutrophil Count
Blood draws are done weekly for the first 6 months, then every other week for 6
months, then monthly
Notable side effects of Risperidone –
Increase risk of seizure
Contraindicated for pregnancy
Increased prolactin
Metabolic syndrome diagnostic criteria –
Combination of any three of the following
Abdominal circumference > 37 in males > 31.5 in femaies
Plus any two of the following:
Elevated Triglycerides > 150 mg/dl
HDL less than 40 mg/dl in men, 50 mg/dl in women
Blood pressure >130/85, or receiving treatment for hypertension
Fasting blood sugar >110 mg/dl or prior type of DM diagnosis
A weight increase of 7% should prompt the provider –
,to consider a different medication.
Neuroleptic Malignant Syndrome criteria –
Within 2 weeks of beginning the medication or a significant medication increase /
or present with abrupt withdrawal of levodopa or exposure to a dopamine agonist
Classic triad: -
Hot, Stiff, and Out of it: includes extreme mental status change/confusion,
extreme muscle rigidity, and extremem autonomic instability/hyperthermia:
What is the appropriate treatment for Neuroleptic Malignant Syndrome –
Dantrolene bromocriptine to relieve rigidity
How are TCA metabolized –
the 2D6 pathway
The importance of TCA to be aware of: -
Toxicity causes heart block, torsade de pointes arrythmia or sudden death
Monoamine Oxidase Inhibitor (MAOIs) concern for treatment –
Low tyramine diet including red wine, cheese, processed foods, causes a
hypertensive crisis (high blood pressure)
Buproprion –
Can lower the seizure threshold, should avoid in children and the elderly, NDRI
class
Fluoxetine (Prozac) –
Longer half life 36-40 hours
Paroxetine (Paxil) –
known for withdrawl symptoms if not taken regular, short half-life, good for
anxiety disorders
Citalopram (Celexa) –
cardiac effect may require decreased doses (QT prolongation) do not go over 40
mg/day
Trazodone –
Can cause priaprism
Sertraline (Zoloft) –
Dose dependent, need to increase the dose
Venlafaxine –
Elevated blood pressure
, Signs and symptoms of serotonin syndrome –
High serotonin levels can cause agitation, confusion, hallucinations, tachycardia,
fever, anxiety, muscle rigidity, hyperreflexia, tremors, diarrha, hypo/hypertension
Treatment for Serontonin Syndrome –
Withdraw from the SSRI,
Stabilizing temperature,
Use benzodiazepines for muscle relaxation,
Beta-blocker for the tachycardia
Notable side effects of Lithium –
Muscle weakness,
tiredness,
slurred speech,
fine hand tremor,
thirst nausea,
diarrhea / vomiting
Maintenance value for Lithium is –
0.8 to 1.0
When do you check the Lithium level –
Check serum level 12 hours after the last dose and after 5 days of steady dosing.
What antipsychotic can not be used with Lithium –
Haldol, linked to mild encaphalopathy and mimics NMS
Lithium is contraindicted in pregnancy- why –
causes Epstein anomaly, heart defect in the fetus
Depakote is contraindicted in pregnancy- why –
Birth defects: spina bifida are found in this medication
What over the counter pain relievers can be used with lithium –
aspirin and tylenol
What over the counter pain reliever is contraindicated –
ibuprofen
What diuretic should be avoided with the use of the Lithium –
Thiazides, but all diuretics should be monitored closely due to risk of toxicity
What heart medicines are contraindicated with lithium –
calcium channel blocker are contraindicated with this mood stabilizer
