NURS 133 Paroxetine Hydrochloride and Phenelzine

jasmine's version from 2016-04-30 23:00

Section 1

Question Answer
Paroxetine Hydrochloride (Paxil) Anti-depressants; Selective serotonin reuptake inhibitors (SSRIs); Major depressive disorder, panic disorder; Obsessive compulsive disorder (OCD), generalized anxiety disorder (GAD); Social anxiety disorder; Post-traumatic disorder (PTSD); Pre-menstrual dysphoric disorder (PMDD); Brisdelle: Moderate to severe vasomotor symptoms associated with menopause
Paroxetine actions Inhibits neuronal reuptake of serotonin in the CNS, thus potentiating the activity of serotonin; has little effect on norepinephrine or dopamine; mechanism for benefit in treating vasomotor symptoms unknown
Paroxetine therapeutic uses Anti-depressant action; decreased frequency of panic attacks, OCD, or anxiety; Improvement in manifestations of PTSD; Decreased dysphoria prior to menses; Brisdelle: Decreased vasomotor symptoms in post-menopausal women
Elimination/Excretion of Paroxetine Highly metabolized by the liver (partly by P450 2D6 enzyme system); Genetic implication the CYP2D6 enzyme system exhibits genetic polymorphism; -7 percent of population may be poor metabolizers (PMs), and may have significantly increase paroxetine concentrations and an increase risk of adverse effects; 2 percent excreted unchanged in urine
Adverse/Side Effects of Paroxetine Neuroleptic malignant syndrome, suicidal thoughts, anxiety, dizziness, drowsiness, headache, insomnia, weakness; Constipation, diarrhea, dry mouth, nausea; Ejaculatory disturbance; Stevens-Johnson syndrome, seating; Serotonin syndrome
Contraindications of Paroxetine Hypersensitivity; Concurrent use of MAO inhibitors or MAO-like drugs (linezolid or methylene blue); Concurrent use of thioridazine or pimozide; OB: Use during first trimester (may be associated with an increase risk of cardiac malformations); Lactation: Safety not established; Pedi: May increase risk of suicide attempt/ideation, especially during early treatment or dose adjustment; Safety in children/adolescents not established; Geri: Severe renal hepatic impairment (daily dose should not exceed 40 mg)-history of mania/risk of suicide
Drug/Food interactions of Paroxetine Concurrent use with MAO inhibitors may result in serious, potentially fatal reactions (wait at least 2 weeks after stopping MAO inhibitor before initiating paroxetine; wait at least 2 weeks after stopping paroxetine before starting MAO inhibitors). 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 blue need to be started in a patient receiving paroxetine, immediately discontinue paroxetine and monitor for signs/symptoms of serotonin syndrome for 2 weeks or until 24 hours after last dose of linezolid or methylene blue, whichever comes first [may resume paroxetine therapy 24 hours after last dose of linezolid or methylene blue]). Concurrent use with pimozide or thioridazine may increase risk of QT interval prolongation and torsades de pointes-concurrent use contraindicated; May decrease metabolism and increase effects of certain drugs that are metabolized by the liver, including other anti-depressants, phenothiazines, class IC anti-arrhythmics, risperidone, atomoxetine, theophylline, and quinidine; Concurrent use should be undertaken with caution; Cimetidine increase blood levels; Phenobarbital and phenytoin may decrease effectiveness; Concurrent use with alcohol is not recommend; May decrease the effectiveness digoxin and tamoxifen; May increase risk of bleeding with warfarin, aspirin, or NSAIDS; Drugs that affect serotonergic neurotransmitter systems, including tricyclic anti-depressants, SNRIs, fentanyl, buspirone, tramadol and triptans increase risk of serotonin syndrome; Increase risk of serotonergic side effects, including serotonin syndrome, with St. John’s wort, SAMe, and tryptophan
Medication administration of Paroxetine PO
Nursing interventions of Paroxetine Monitor appetite and nutritional intake; Weigh weekly; Depression: Monitor mental status (orientation, mood, behavior); Assess for suicidal tendencies, especially during early therapy. Restrict amount of drug available to patient. Risk may be increased in children, adolescents, and adults less than or equal to 24 years of age; 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); Monitor for development of neuroleptic malignant syndrome (fever, respiratory distress, tachycardia, seizures, diaphoresis, hypertension or hypotension, pallor , tiredness). Discontinue paroxetine and notify health care professional immediately if these symptoms occur; Assess for rash periodically during therapy. May cause Stevens-Johnson syndrome. Discontinue therapy if severe or if accompanied with fever, general malaise, fatigue, muscle or joint aches, blisters, oral lesions, conjunctivitis, hepatitis and/or eosinophilia; 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; Social Anxiety Disorder: Assess frequency and severity of episodes of anxiety; PTSD: Assess manifestations of PTSD periodically during therapy; PMDD: Ass symptoms of pre-menstrual distress prior to and during therapy; Lab test considerations: Monitor CBC and differential periodically during therapy-report leukopenia or anemia; Periodically reassess dose and continued need for therapy; Tablets are swallowed whole not crushed, broken, or chewed; Note: may administer with food to minimize GI irritation, and taper to avoid potential withdrawal reactions
Client education of Paroxetine Instruct patient to take paroxetine as directed; Caution patient to avoid driving and other activities requiring alertness until response to drug is known; 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 or neuroleptic malignant syndrome occur; Inform patient frequent mouth rinses, good oral hygiene, and sugarless gum or candy may minimize dry mouth; 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 if 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 Paroxetine 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 frequency and severity of episodes of anxiety; Improvement in manifestations of PTSD; Decreased dysphoria prior to menses
Potential nursing diagnoses of Paroxetine Ineffective coping (indications); Risk for injury (side effects)

Section 2

Question Answer
Phenelzine (Nardil) Monoamine oxidase inhibitor (MAOI); Used to treat symptoms of depression not severe depression or bipolar disorder; Depression in patients who have failed other modes of therapy (tricyclic anti-depressants, SSRIs, SSNRIs or electroconvulsive therapy)
Phenelzine actions Inhibit the enzyme monoamine oxidase, resulting in an accumulation of various neurotransmitters (dopamine, epinephrine, norepinephrine, and serotonin) in the body
Phenelzine therapeutic uses Improved mood in depressed patients
Elimination/Excretion of Phenelzine Metabolized by the liver and excreted in urine as metabolites and unchanged drug
Adverse/Side Effects of Phenelzine Seizures, dizziness, headache; Hypertensive crisis, arrhythmias; Diarrhea, weight gain
Contraindications of Phenelzine Hypersensitivity; Liver disease; Severe renal disease; cardiovascular disease; Uncontrolled hypertension; Cerebrovascular disease; Pheochromocytoma; HF; History of severe or frequent headache; Patients undergoing elective surgery requiring anesthesia (should be discontinued at least days before surgery); concurrent meperidine, SSRI anti-depressants, tricyclic anti-anti-depressants, tetracyclic anti-depressants, nefazodone, trazodone, procarbazine, selegilene, linezolid, carbamazepine, cyclobenzaprine, bupropion, buspirone, sympathomimetics, dextromethorphan, narcotics, alcohol, anesthetics, diuretics, tryptophan, or anti-histamines; Excessive consumption of caffeine; Concurrent use of food containing high concentrations of tyramine; Lactation; OB: Safety not established; Pedi: Safe use in children/adolescents not established; Geri: Increase risk of adverse reactions-begin therapy at lower end of dosage ranges
Drug/Food interactions of Phenelzine Serious, potentially fatal adverse reactions may occur with concurrent use of other anti-depressants (SSRIs, SSNRIs, buproprion, tricyclics, tetracyclics, nefazodone, trazodone), carbamazepine, cyclobenzaprine, linezolid, procarbazine, or selegiline. Avoid using within 2 weeks of each other (wait 5 weeks from end of fluoxetine therapy). Hypertensive crisis may occur with amphetamines, methyldopa, levodopa, dopamine, epinephrine, norepinephrine, methylphenidate, reserpine, or vasoconstrictors. Hypertension or hypotension, coma, seizures, respiratory depression, and death may occur with meperidine (avoid using within 2-3 weeks of MAO inhibitor therapy); Concurrent use with dextromethorphan may produce psychosis or bizarre behavior; hypertension may occur with concurrent use of buspirone-avoid using within 10 days of each other; Additive hypotension may occur with anti-hypertensives, spinal anesthesia, opioids, or barbiturates; Additive hypoglycemia may occur with insulins or oral hypoglycemic agents; Risk of seizures may be increased with tramadol; Serious, potentially fatal adverse effects (serotonin syndrome) may occur with concomitant use of St. John’s wort and SAMe; Hypertensive crises may occur with large amounts of caffeine-containing herbs (cola nut, guarana, malt, coffee, tea); Insomnia, headache, tremor, hypomania may occur with ginseng; Hypertensive crises, disorientation, and memory impairment may occur with tryptophan or supplements containing tyrosine or phenylalanine; Hypertensive crises may occur with ingestion of foods containing high concentrations of tyramine; Consumption of foods or beverages with high caffeine content increase risk of hypertension and arrhythmias
Medication administration of Phenelzine PO
Nursing interventions of Phenelzine Assess mental status (orientation, mood, behavior) and anxiety level frequently; Assess for suicidal tendencies, especially during early therapy; Restrict amount of drug available to patient; Monitor BP and pulse before and frequently during therapy. Report significant changes-headache is often first symptom of a hypertensive crisis; Monitor intake and output ratios and daily weight; Assess patient for urinary retention; Monitor weight and BMI initially and throughout treatment; For overweight/obese individuals, monitor fasting blood sugar and cholesterol levels; Lab test considerations: Assess hepatic function periodically during prolonged or high-dose therapy; Monitor serum glucose closely in diabetic patients-hypoglycemia may occur; Signs and symptoms of hypertensive crisis include chest pain, tachycardia, severe headache, nausea, vomiting, photosensitivity, neck stiffness, sweating, and enlarged pupils-Treatment includes IV phentolamine or a single dose of oral calcium channel blocker (nifedipine); Symptoms of overdose include anxiety, irritability, tachycardia, hypertension or hypotension, respiratory distress, dizziness, drowsiness, hallucinations, confusion, seizures, sluggish reflexes, fever, and diaphoresis-Treatment includes induction of vomiting or gastric lavage and supportive therapy as symptoms arise; Do not administer medications in the evening due to psychomotor stimulation or other sleep disturbances; Tablets may be crushed and mixed with food or fluids
Client education of Phenelzine Instruct patient to take medication as directed; Caution patient to avoid alcohol, CNS depressants, OTC drugs, and foods or beverages containing tyramine or excessive caffeine during and for at least 2 weeks after therapy has been discontinued-they may precipitate a hypertensive crisis. Instruct patient to notify health care professional immediately if symptoms of hypertensive crisis (severe headache, palpitations, chest or throat tightness, sweating, dizziness, neck stiffness, nausea, or vomiting) develop; Instruct patient and caregivers to contact health care professional if child exhibits any suicidal thought or behaviors (worsening depression, new or worsening anxiety, agitation, panic attacks, insomnia, new or worsening irritability, violent behavior, impulsive actions, excessive talking, unusual changes in mood or behavior); Caution patient to avoid driving and other activities requiring alertness until response to medication is known; Advise patient to notify health care professional if dry mouth, urinary retention, or constipation occurs; Instruct patient to carry identification describing medication regimen at all times; Emphasize the importance of participation in psychotherapy to improve coping skills; Refer to ophthalmic testing periodically during long-term therapy; Advise patient of possibility of weight gain and cholesterol elevation and recommend appropriate nutritional, weight, or medical management; Refer patient/family to local support group
Evaluation/Desired outcomes of Phenelzine Improved mood in depressed patients; Increased sense of well-being; Decreased anxiety; Increased appetite; Improved energy level; Improved sleep; Note: Patient may require 3-6 weeks of therapy before therapeutic effects of medication are seen
Potential nursing diagnoses of Phenelzine Ineffective coping (indications); Ineffective therapeutic regimen management (patient/family teaching); Risk for falls (side effects); Imbalanced nutrition: more than body requirements (side effects); Sexual dysfunction (side effects); Impaired oral mucous membrane (side effects)