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NSG 552 LATEST EXAM WITH
PSYCHOPHARMACOLOGY DETAILED
QUESTIONS AND VERIFIED ANSWERS
question-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 question-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 Naloxone (Narcan) - answer-opioid antagonist question-Narcan - answer-Treatment of choice for opiate overdose It is prescribed routinely for all patients with opiate use disorder Very short half-life
question-Methadone - answer-Long acting full opioid receptor agonist at mu receptor Restricted use to abuse trx facilities Monitor for QTC prolongation(cardiac abnormalities question-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 question-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 question-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 question-Alcohol intoxication - answer-Impaired fine motor control
15+=Severe question-Naltrexone - answer-Opiod receptor antagonist Can be used for both ETOH and Opioid Use d/o Reduces desires/cravings 1st Trx: PO/IM Will precipitate withdrawal in patients with physical opioid dependence question-Acamprosate (Campral) - answer-Likely modulates glutamate transmission First line trx in maintaining abstinence after detox Used for relapse prevention(post detoxification) Can be used in liver disease-not metabolized by liver Can be administered to patients with hepatitis, liver dz and those who continue to drink alcohol Contraindicated in severe renal disease Decreases craving question-Disulfiram (Antabuse) - answer-2 nd Line Blocks enzymes(Aldehyde dehydrogenase) in liver Causes aversion reaction to ETOH(flushing, HA, n/v, palpitation, SOB, vertigo, hypotension) Do not administer until the person has been alcohol free for at least 12 hrs Educate patients to refrain from using anything that contains alcohol(vinegar, aftershave, perfumes, mouthwash, cough medicine) while taking and up to 2 weeks after d/c Contraindicated in severe cardiac disease, pregnancy, psychosis
For highly motivated patients question-Bupropion(Wellbutrin) - answer-Increases the risk for withdrawal seizures in ETOH question-Alcohol Intoxication/withdrawal treatments - answer-Benzos(lorazepam, diazepam, chlordiazepoxide-librium)= to keep patient and lightly sedated MOA: enhances the effects of GABA question-Tegretol, Valproic acid or Gabapentin - answer-Use in mild alcohol withdrawal question-thiamine, folic acid, multivitamin in alcohol withdrawal - answer-for nutritional deficiencies Thiamine-to prevent or treat Wernicke's encephalopathy=B1 and folate deficiency Fluid and electrolyte question-Varenicline (Chantix) - answer-Smoking Cessation Aid mimics action of nicotine The most effective tobacco cessation Reduces rewarding aspects prevents withdrawal symptoms question-Bupropion(Zyban, Wellbutrin) - answer-Inhibits reuptake of dopamine and norepinephrine
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) question-Dementia - answer-group of symptoms marked by memory loss and loss of other cognitive functions such as perception, thinking, reasoning, and remembering
- Irreversible question-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 question-vascular disease - answer-2nd most common Cognitive decline secondary to large vessel strokes Risk factors: HTN,DM, smoking, obesity, HLD, A-fib, Age question-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) question-Frontotemporal degeneration(FTD) - answer-40% familial Atrophy of the frontal and temporal lobes Personality/behavioral Disinhibition(verbal,physical,sexual)
question-Aggression/Agitation/Psychosis - answer-Consider atypical antipsychotics zyprexa, seroquel, risperdal,haldol Note: Reserve Benzos for short-term and acute episodes question-Memantine (Namenda) - answer-NMDA receptor antagonist Moderate to severe dz Fewer side effects as compared to the cholinesterase inhibitors
- Promotes synaptic plasticity May be used inconjunction with cholinesterase inhibitors May cause hallucinations question-Anticholinergics side effects in the elderly - answer-Eyes: Blurred vision, dry eyes, dry mouth, bowel-constipation Skin: flushing, unable to sweat, overheating, Brain: Drowsiness, dizziness question-Interllectual disability Disorde(IDD) - answer-Impaired cognitive and adaptive/social functioning. •Deficits in intellectual functioning (i.e. reasoning, problem solving, planning, abstract thinking, judgement and learning) •Deficits in adaptive functioning i.e. communication, social participation and independent living. •Severity is mild, moderate, severe and profound
Causes: Genetic (Down syndrome); Prenatal (rubella, herpes simplex etc.) Perinatal (Anoxia, prematurity, birth trauma) and Postnatal (malnutrition, toxin exposure, trauma) Management: Behavioral Therapy Caution with patients with IDD as they may not be able to self-report drug-related problems. question-Treatment of ADHD - answer-•The first-line pharmacological tx are stimulants which help to increase DA in PFC •These also, notably, can increase DA in the nucleus accumbens and reward circuitry •Treatment: Multimodal(i.e., Medications + educational and behavioral interventions) •1st line: Stimulants (methylphenidate compounds, dextroamphetamine, mixed amphetamine salts)= Ritalin, Concerta, Adderall (Scchedule II) MOA: Increase DA in the prefrontal cortex, nucleus accumbens and reward circuitry question-ADHD treatment - answer-•2nd line: Alpha-2 agonists (Clonidine, guanfacine) •****Monitor Height, weight, BP, CBC w/ diff; Pulse quarterly (Height and weight d/t risk of growth restriction) •In healthy individuals, it is not necessary to obtain an EKG prior to initiating a stimulant •Prescription Monitoring Program should be checked •Note: With stimulants, evidence of growth suppression is not clear, seems transient and resolves in mid-adolescence
•Note: If a child is taking their medication twice daily (i.e. at home and school) and parents request to solely administer the medication= consider switching to an extended release form (e.g. Methylphenidate CD= extended release)
Children 5+ and Adolescents less than 18 (weight based) question-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 question-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. question-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. question-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) question-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 question-personality disorders - answer-Cluster A: Familial association with psychotic disorders Patient seem eccentric, peculiar or withdrawn •Schizoid •Schizotypal •Paranoid
question-borderline personality disorder - answer-•Fear of abandonment •Aggression •Impulsive •Repeated SI attempts/gestures/self-mutilation •"Splitting" question-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 •Avoid the use of Benzodiazepines question-antisocial personality disorder - answer-•Failure to conform to social norms •Deceitful, manipulative for personal gain •Reckless, irritable •Lack remorse question-antisocial personality disorder - answer-•NOTE: Begins as conduct disorder in childhood •Txt:
•Psychotherapy is ineffective •Treat symptoms of anxiety, depression or aggression but with caution d/t high comorbidity with substance use disorders. question-General guidelines for txt of personality disorder - answer-•First-line treatment for personality disorders is psychotherapy. •Symptom-focused, medication treatment of personality disorders is generally considered to be an adjunct to psychotherapy. •Avoid prescribing medications that can be fatal in overdose, such as tricyclic antidepressants. •Avoid prescribing medications that can induce physiological dependence and tolerance, including benzodiazepines. •Avoid changing medication each time there is a crisis or change in mood symptoms, which may occur frequently and suddenly, and also remit suddenly in some people with personality disorders. •Symptom expression in patients with personality disorders often waxes and wanes in relationship to life circumstances. question-personality disorders - answer-•Cognitive and perceptual disturbances •Impulsivity or behavioral dyscontrol •Affective dysregulation Antidepressants and mood stabilizers are dosed as they would be for major depressive disorder and bipolar disorder (e.g. Lithium, Lamictal) Antipsychotics are in general used at a lower dosing range compared with doses used in the treatment of schizophrenia (e.g. Abilify, Risperdal, Seroquel)
question-opioid withdrawal - answer-Symptoms include N/V/D and dehydration, irritability, restlessness, yawning, and twitching, increased HR/BP, chills, increased temperature, rhinorrhea, lacrimation, dilated pupils. question-naloxone - answer-Treatment for opioid intoxication during which cardiac or respiratory depression is a concern. question-cocaine intoxication - answer-Symptoms include dilated pupils, HA, tremor, hyper- reflexia, twitching, seizures, or coma, increased HR/BP, arrhythmias, and MI, N/V, incontinence/ARF, or rhabdomyolysis question-cocaine intoxication - answer-Treatment includes BZD, antipsychotics, and management of medical problems including HTN, stroke, cardiac arrhythmias, hyperthermia, and seizures. question-cocaine - answer-The use of beta blockers for treatment of chest pain and MI during this intoxication is to be avoided due to unopposed a adrenergic stimulation. question-alcohol intoxication - answer-Signs vary with blood levels, from decreased reaction time, muscle incoordination, ataxia, dysarthria, to respiratory failure and coma. question-severe alcohol intoxication - answer-Treatment includes cardiopulmonary function maintenance, thiamine, and haloperidol PRN agitation.
question-thiamine - answer-Given IM/IV for 3 days to prevent Wernicke's encephalopathy, along with IV fluids and a banana bag. question-benzodiazepines - answer-Class of drugs to avoid for acute alcohol intoxication. question-uncomplicated alcohol withdrawal - answer-Treatment includes BZD in either symptom triggered or fixed dose; diazepam and chlordiazepoxide have a longer half life, and oxazepam and lorazepam are suitable for patients with hepatic dysfunction. question-diazepam and chlordiazepoxide - answer-BZDs with a long half-life used to treat AUD. question-oxazepam and lorazepam - answer-BZDs with moderate half-life used in AUD patients with liver disease. question-alcohol withdrawal seizures - answer-Treatment includes diazepam IV or lorazepam IV/IM, thiamine IV/IM, and addressing electrolyte imbalances. question-DT - answer-Treatment includes acute care management, parenteral diazepam or lorazepam, thiamine, and antipsychotics if necessary. question-disulfiram - answer-MOA is via negative reinforcement, where drinking is avoided due to unpleasant effects. question-acamprosate - answer-NMDA receptor antagonist that is renally cleared, suitable for AUD patients with hepatic dysfunction.
