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NURS 133 Doxepin and Sertraline

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jasmine's version from 2016-05-01 00:32

Section 1

Question Answer
Doxepin Anti-anxiety; Tricyclic anti-depressant; Anti-histamine (topical); Sedative/Hypnotics; PO: Management of: Depression, Insomnia; Topical: Short-term control of pruritus associated with eczematous dermatitis, lichen simplex chronicus
Doxepin actions PO: Prevents the reuptake of norepinephrine and serotonin by presynaptic neurons; resultant accumulation of neurotransmitters potentiates their activity; Also possesses significant anti-cholinergic properties; Topical: Anti-pruritic action due to anti-histamine properties
Doxepin therapeutic uses PO: Relief of depression Decreased anxiety; Sedation and improved sleep maintenance; Topical: Decreased pruritus
Elimination/Excretion of Doxepin Metabolized by the liver by the CYP2C19 and CYP2D6 isoenzymes; Genetic implications the CYP2C19 enzyme system exhibits genetic polymorphism; Percentage rates apparent of certain ethnicity groups may be poor metabolizers of CYPsC19, and may have significantly increase doxepin concentrations and an increase risk of adverse effects; Some conversion to active anti-depressant compound; May re-enter gastric juice via secretion from enterohepatic circulation, where more absorption may occur
Adverse/Side Effects of Doxepin Fatigue, sedation; Blurred vision; Hypotension; constipation, dry mouth
Contraindications of Doxepin Hypersensitivity; Concurrent use of MAO inhibitors; Some products contain bisulfites, and should be avoided in patients with known intolerance; Untreated angle-closure glaucoma; Severe urinary retention; Period immediately after myocardial infarction; History QT prolongation, heart failure, cardiac arrhythmia
Use Doxepin Cautiously In Geri: Pre-existing cardiovascular disease (increase risk of adverse reactions); Prostatic enlargement (more susceptible to urinary retention); Seizures; OB: Use only if potential maternal benefit outweighs risks to fetus; Lactation: Use during lactation may result in neonatal sedation-recommend discontinue drug or bottle-feed; Pedi: May increase risk of suicide attempt/ideation especially during dose early treatment or dose adjustment; Risk may be greater in children or adolescents-Safety not established; Geri: Appears on Beers list and is associated with increase falls risk secondary to anti-cholinergic and sedative effects; Geriatric patients should have initial dosage decrease
Drug/Food interactions of Doxepin Apply to both topical and oral use: Doxepin is metabolized by the cytochrome P450 2D6 enzyme, and its action may be affected by drugs that compete for metabolism by this enzyme, including other anti-depressants, phenothiazines, carbamazepine, propafenone, flecainide-when used concurrently, dosage decrease of one or the other or both may be necessary; Concurrent use of other drugs that inhibit the activity of the enzyme, including cimetidine, quinidine, amiodarone, and ritonavir, may result in increase effects of doxepin; May cause hypotension, tachycardia, and potentially fatal reactions when used with MAO inhibitors (avoid concurrent use-discontinue 2 weeks prior to doxepin); Concurrent use with SSRI anti-depressants may result in increase serotonin syndrome (fluoxetine should be stopped 5 weeks before); Concurrent use with clonidine may result in hypertensive crisis; Concurrent use with levodopa may result in delayed/decreased absorption of levodopa or hypertension; Blood levels and effects may be decreased by rifamycins; Increased CNS depression with other CNS depressants, including alcohol, anti-histamines, clonidine, opioid analgesics, and sedative/hypnotics; Barbiturates may alter blood levels and effects; Adrenergic and anti-cholinergic side effects may be increased with other agents having these properties; Phenothiazines or hormonal contraceptives increase levels and may cause toxicity; Smoking may increase metabolism and alter effects; Concomitant use of kava-kava, valerian, or chamomile can increase CNS depression; Increase anti-cholinergic effects with jimson weed and scopolia
Medication administration of Doxepin PO; Topical
Nursing interventions of Doxepin Monitor BP and pulse rate prior to and during initial therapy; Assess for sexual dysfunction (decreased libido; erectile dysfunction); Assess weight and BMI initially and throughout treatment; Obtain FBS and cholesterol levels in overweight/obese individuals; Geri: Assess falls risk and institute fall prevention strategies; Assess for anti-cholinergic effects; Depression: Assess mental status and mood changes (orientation, mood, behavior) frequently, especially during initial few months of therapy and during dose changes; confusion, agitation, and hallucinations may occur during initiation of therapy, and may require dose reduction. Assess for suicidal tendencies, especially during early therapy; Restrict amount of drug available to patient. Risk may be increased in less than or equal to 24 years of age. Inform health care professional if patient demonstrates significant increase in signs of depression. Assess for serotonin syndrome (mental changes [agitation, hallucinations, coma], autonomic instability [tachycardia, labile BP, hyperthermia], neuromuscular aberrations [hyper-reflexia, incoordination], and/or GI symptoms [nausea, vomiting, diarrhea]), especially in patients taking other serotonergic drugs (SSRIs, SNRIs, triptans); Anxiety: Assess degree and manifestations of anxiety prior to and during therapy; Pain: Assess pain prior to and periodically during therapy for effectiveness; Topical: Assess pruritic area prior to and periodically during therapy; Lab test considerations: Monitor WBS and differential blood counts, hepatic function, and serum glucose periodically
Client education of Doxepin Instruct patient to take as directed; Inform patient systemic side effects may occur with oral or topical use; Caution patient to avoid driving and other activities requiring alertness until response to the medication is known; Orthostatic hypotension, sedation, and confusion are common during early therapy, especially in geriatric patients-Protect patient from falls, and institute fall precautions; Advise patient to avoid alcohol or other CNS depressant drugs during and for at least 3-7 days after therapy has been discontinued; Inform patient that doxepin may cause getting up out of bed while not being fully awake and doing an activity that patient does not know he or she is doing. The next morning, he or she may not remember he or she did anything during the night, and may occur more frequently with alcohol or other sedatives (advise patient to notify health care professional if this occurs); Instruct patient to notify health care professional if urinary retention occurs or if dry mouth (more than 2 weeks) or constipation (after revising for increase in fluid intake or bulk) persists; PO: Advise patient, family, and caregivers to look for suicidality, especially during early therapy or dose changes. Notify health care professional immediately if thoughts about suicide or dying, attempts to commit suicide, new or worse depression or anxiety, agitation or restlessness, panic attacks, insomnia, new or worse irritability, aggressiveness, acting on dangerous impulses, mania, or other changes in mood or behavior or if symptoms of serotonin syndrome occur; Inform patient that urine may turn blue-green in color; Inform patient of need to monitor dietary intake-increase in appetite is possible, and may lead to undesired weight gain; Therapy for depression is usually prolonged-Emphasize the importance of follow up exams to monitor effectiveness and side effects; Topical: Instruct patient to apply a thin film of medication exactly as directed, and not to use longer than 8 days; Inform patient that topical preparation may cause burning, stinging, swelling, increased itching, or worsening of eczema, and to notify health care professional if symptoms become bothersome; Caution patient not to use occlusive dressings-may increase systemic absorption; Advise patient to notify health care professional if excessive drowsiness occurs with topical application
Evaluation/Desired outcomes of Doxepin Increased sense of well-being; Renewed interest in surroundings; Increased appetite; Improved energy level; Improved sleep; Decrease in anxiety; Decrease in chronic pain-Patients may require 2-6 weeks of oral therapy before full therapeutic effects of medication are evident; Decrease in pruritus associated with eczema
Potential nursing diagnoses of Doxepin Ineffective coping (indications); Risk for injury (side effects); Sexual dysfunction (side effects)
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Section 2

Question Answer
Sertraline (Zoloft) Anti-depressants; Major depressive disorder. Panic disorder. Obsessive compulsive disorder (OCD). Post-traumatic stress disorder (PTSD). Social anxiety disorder. Pre-menstrual dysphoric disorder (PMDD)
Sertraline actions Inhibits neuronal uptake of serotonin in the CNS, thus potentiating the activity of serotonin; Has little effect on norepinephrine or dopamine
Sertraline therapeutic uses Anti-depressant action; Decreased incidence of panic attacks; Decreased obsessive and compulsive behavior; Decreased feelings of intense fear, helplessness, or horror; Decreased social anxiety; Decrease in pre-menstrual dysphoria
Adverse/Side Effects of Sertraline Neuroleptic malignant syndrome, suicidal thoughts, dizziness, drowsiness, fatigue, headache, insomnia; Diarrhea, dry mouth, nausea,; Sexual dysfunction; Increase sweating; Tremor; Serotonin syndrome
Use Sertraline Cautiously In Severe hepatic or renal impairment; Patient with a history of mania; History of suicide attempt; OB: Use during 3rd trimester may result in neonatal serotonin syndrome requiring prolonged hospitalization, respiratory and nutritional support; Use only if potential benefit justifies potential risk to fetus; Lactation: May cause sedation in infant; discontinue drug or bottle-feed; Pedi: May increase risk of suicide attempt/ideation especially during early treatment or dose adjustment
Drug/Food interactions of Sertraline Serious, potentially fatal reactions (hyperthermia, rigidity, myoclonus, autonomic instability, with fluctuating vital signs and extreme agitation, which may proceed to delirium and coma) may occur with concurrent MAO inhibitors. MAO inhibitors should be stopped at least 14 days before sertraline therapy and vis versa. Concurrent use with MAO-inhibitor-like drugs, such as linezolid or methylene blue may increase risk of serotonin syndrome-concurrent use contraindicated-do not start therapy in patients receiving linezolid or methylene blue; if linezolid or methylene need to started, immediately discontinue sertraline and monitor for signs/symptoms of serotonin syndrome for 2 weeks or until 24 hours after last dose of linezolid or methylene blue). May increase pimozide levels and the risk of potentially life-threatening cardiovascular reactions-concurrent use contraindicated; May increase levels/effects of warfarin, phenytoin, tricyclic anti-depressant, some benzodiazepines (alprazolam), cloazapine or tolbutamide; Increase risk of bleeding with NSAIDs, aspirin, clopidogrel, or warfarin; Cimetidine increase blood levels and effects; Increase risk of serotinergic side syndrome with St. John’s wort and SAMe
Nursing interventions of Sertraline Assess for suicidal tendencies, especially during early therapy. Restrict amount of drug available to patient. Risk may be increased in less than or equal to 24 years of age. After starting therapy, children, adolescents, and young adults should be seen by health care professional at least weekly for 4 weeks, every 3 weeks, and on advice of health care professional thereafter; Monitor appetite and nutritional intake, and weigh weekly; Assess for serotonin syndrome (mental changes [agitation, hallucinations, coma], autonomic instability [tachycardia, labile BP, hyperthermia], neuromuscular aberrations [hyper-reflexia, incoordination], and/or GI symptoms [nausea, vomiting, diarrhea]); Depression: Monitor mood changes; Assess for suicidal tendencies, especially during early therapy; Restrict amount of drug available to patient; OCD: Assess patient for frequency of obsessive-compulsive behaviors; Note degree to which these thoughts and behaviors interfere with daily functioning; Panic Attacks: Assess frequency and severity of panic attacks; PTSD: Assess patient for feelings of fear, helplessness, and horror; Social Anxiety Disorder: Assess patient for symptoms of social anxiety disorder (blushing , sweating, trembling, tachycardia during interactions with new people, people in authority, or groups) periodically during therapy; PMDD: Assess patient for symptoms of PMDD (feeling angry , tense, or tired; crying easily, feeling sad or hopeless, arguing with family or friends for no reason; difficulty sleeping or paying attention; feeling out of control or unable to cope; having cramping, bloating, food craving, or breast tenderness) periodically during therapy; Lab test considerations: Monitor serum glucose if clinical symptoms occur for hyperglycemia and diabetes mellitus; Periodically re-assess dose and continued need for therapy
Client education of Sertraline Instruct patient to take as directed; Caution patient to avoid driving an other activities requiring alertness; Advise patient, family, and caregivers to look for suicidality, especially during early therapy or dose changes. Notify health care professional immediately if thoughts about suicide or dying, attempts to commit suicide; new or worse depression or anxiety; agitation or restlessness; panic attacks; insomnia; new or worse irritability, aggressiveness, acting on dangerous impulses, mania, or other changes in mood or behavior or if symptoms of serotonin syndrome occur; Inform patient that frequent mouth rinses, good oral hygiene, and sugarless gum or candy may minimize dry mouth-if dry mouth persists for more than 2 weeks, to consult health care professional; Advise patient to notify health care professional if headache, weakness, nausea, anorexia, anxiety, or insomnia persists; Instruct female patient to inform health care professional if pregnancy is planned or suspected or is breast feeding; Emphasize the importance of follow up exams to monitor progress; Encourage patient participation in psychotherapy to improve coping skills
Evaluation/Desired outcomes of Sertraline Increased sense of well-being; Renewed interest in surroundings-may require 1-4 weeks of therapy to obtain anti-depressant effects; Decrease in obsessive-compulsive behaviors; Decrease in frequency and severity of panic attacks; Decrease in symptoms of PTSD; Decrease in social anxiety disorder; Decrease in symptoms of PMDD
Potential nursing diagnoses of Sertraline Ineffective coping (indications); Risk for injury (side effects); Sexual dysfunction (side effects)
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