Chapter 65: Psychiatric Medications

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["Pomp and Circumstance"] Ever feel like the world of health information is just a lot?

Like you're trying to swim in this giant ocean of data.

It's definitely overwhelming sometimes.

Exactly, and that's why we do this deep dive.

We try to cut through all that noise, get right to the core stuff you need.

And today we're tackling a really big one.

We're diving deep into the Saunders Comprehensive Review for the NCLE -XPN Examination, the seventh edition.

It's basically a cornerstone for practical nursing knowledge.

Right, a huge resource.

We're talking everything from medications, patient care basics, safety, infection control, even how to approach those review questions.

It's dense.

It really is incredibly thorough.

It covers such a broad range.

Medications, assessment skills, safety protocols, how the body adapts to illness.

It really shows you the sheer amount of knowledge nurses need.

So our plan today is to pull out the absolute must -knows from this review.

We'll break down the medical terms, highlight the key takeaways, essentially give you the rundown as if you'd read it all yourself.

Think of us as your guides.

Sounds good.

Where should we start?

Let's kick off with pharmacology.

Always a critical area.

Absolutely crucial.

Saunders goes into a lot of detail on medication classes.

It's not just about names, but how they work, what to watch for.

Okay, so first up.

Let's look at reuptake inhibitors.

You've got SSRIs, selective serotonin reuptake inhibitors like citilbram, plooxetine,

and SNRIs, serotonin norepinephrine reuptake inhibitors like venlafaxine.

The core idea, they block the reabsorption or reuptake of serotonin, or sometimes both serotonin and norepinephrine in the brain.

So they keep more of those neurotransmitters active, like available for longer.

Exactly, keeps them in the communication gap, the synapse, doing their job for a bit longer.

Okay, and what are some common side effects people might run into?

The review mentions things like sleep issues, headaches,

weight changes.

Precisely, you might also see decreased libido, apathy sometimes, tremors, even potential for seizures or blood pressure changes.

Which leads right into nursing interventions, I imagine.

Definitely.

Monitoring vital signs is key because of that blood pressure effect.

Watching weight, too.

And safety precautions are important because dizziness can happen.

Laws, great.

Big risk.

Taking them with food can sometimes help with dizziness or feeling lightheaded.

Makes sense.

And the review stresses avoiding alcohol and other non -prescription meds.

Very important.

Alcohol can increase drowsiness

and some over -the -counter cold meds can mess with serotonin levels, too.

Huge potential for interactions.

And suicide risk, that's mentioned, too.

Crucial point.

Especially early on, when a patient's energy might return before their mood fully lifts,

that combination can paradoxically increase risk, so close monitoring is essential.

And it takes time to work, right?

Patients need to know that.

Yes, two to four weeks, typically for the full effect.

Education on that is vital so they don't get discouraged and stop taking it too soon.

Okay, let's shift to MAOIs.

Monoamine oxidase inhibitors.

These sound like they need extra caution.

They absolutely do.

Their mechanism involves inhibiting the enzyme monoamine oxidase, which is the enzyme that breaks down neurotransmitters like serotonin, norepinephrine, and dopamine.

So inhibiting it means higher levels of these chemicals.

They're often used when other antidepressants haven't worked.

So kind of a later line treatment?

Often, yes.

Sometimes even after things like ECT.

And the big warning sign with MAOIs,

something about food.

That's the critical one, the tiramine interaction.

Taking MAOIs with foods high in tiramine, think cheeses, cured meats, fermented stuff.

Some wines can cause a hypertensive crisis.

A dangerous spite in blood pressure.

Extremely dangerous.

So a strict tiramine restricted diet is non -negotiable.

Patients need really thorough education on what to avoid.

Wow, what else besides the diet?

Other side effects can include agitation, restlessness, insomnia, orthostatic hypotension, that dizziness when standing up,

GI upset, dry mouth, blurred vision, constipation, urinary hesitancy, even impotence.

So nursing interventions focus heavily on that diet, obviously.

Absolutely, and avoiding other meds like tricyclic antidepressants, certain decongestants, those sympathomimetics, and CNS depressants.

Very close blood pressure monitoring is needed.

And like other antidepressants, keep watching for suicide risk.

Got it.

Okay, moving to another big one, lithium.

Mainstay for bipolar disorder, isn't it?

It is.

A key mood stabilizer helps manage both mania and depression, but it has a narrow therapeutic index.

Meaning the difference between a helpful dose and a toxic dose is small.

Exactly, so monitoring for toxicity is absolutely critical.

What are some common side effects even when the dose is right?

Well, the review lists quite a few.

Things like drowsiness, dizziness, headache, dry mouth, thirst, GI upset, fine hand tremors.

Okay.

Also potential hypotension, arrhythmias, increased urination, polyuria, weight gain, sometimes hypothyroidism develops over time, muscle weakness, fatigue, even hair loss.

And the toxicity signs, you said they're crucial to spot.

Yes, and it's important to know the difference between mild and severe.

Mild might be like persistent diarrhea, vomiting, drowsiness, muscle weakness,

maybe poor coordination,

coarser hand tremors.

Okay, manageable maybe.

Needs action, but severe toxicity is a true emergency.

You're looking at neurological signs like nystagmus, those rapid involuntary eye movements.

Muscle twitching, which are fasciculations, exaggerated reflexes, hallucinations, very low or no urine output that's oliguria or anuria.

Decreased consciousness, seizures, coma,

can be fatal.

Wow, so if you suspect toxicity, what's the immediate plan?

First step, withhold the lithium.

Immediately notify the provider.

There's continuous monitoring vitals, level of consciousness, cardiac status.

Prepare for stat labs.

Lithium level, electrolytes.

BUN, creatinine for kidney function.

And general care for someone on lithium.

Giving it with food helps with GI upset.

Educate them to avoid too much caffeine, tea, cola, alcohol, things that can affect hydration.

Usually avoid diuretics too because they mess with sodium balance, which is closely tied to lithium levels.

So maintain good sodium and fluid intake.

Consistent intake is key.

And of course, ongoing suicide risk assessment is vital for anyone with bipolar disorder.

All right, let's talk benzodiazepines next, often used for anxiety, sleep.

Correct.

They work by enhancing the effect of GABA, an inhibitory neurotransmitter.

Basically calms down the central nervous system.

Good for short -term insomnia, sedation for anxiety.

Common side effects?

Dizziness, drowsiness, confusion, sometimes irritability.

But there are rarer, more serious adverse effects too.

Like what?

Things like allergic reactions, a granulocytosis, this big drop in white blood cells, thrombocytopenic purpura, a platelet issue causing bleeding, and megaloblastic anemia.

And overdose is a risk too.

Overdose can cause rapid heart rate, low blood pressure, clammy skin, dilated pupils, weak pulse, shock, severely depressed breathing, absent reflexes, potentially coma and death from respiratory or cardiovascular collapse.

And withdrawal, is that common?

It's a significant concern, especially with long -term use or high doses.

It can start pretty quickly after stopping.

Gradual tapering is usually needed.

What does withdrawal look like?

Increased anxiety, insomnia, nightmares, agitation, tremors, delirium, even seizures,

also important.

Older adults usually need lower doses and use extreme caution in anyone with suicidal thoughts.

Okay, now, antipsychotics or neuroleptics.

For psychotic disorders like schizophrenia.

That's their main use.

But they come with a significant side effect profile that needs close watching.

A major category is EPS extra pyramidal symptoms.

Movement issues, right?

Yes, Parkinsonism -like symptoms, rigidity, slow movement,

akathisia, that awful inner restlessness, feeling like you have to move, dystonia, muscle spasms, and tardive dyskinesia and voluntary movements, often face and tongue, can be long -term.

Sounds distressing.

Other side effects.

Can be lots.

Drowsiness, blood problems, itching, photosensitivity, high blood sugar, weight gain, trouble regulating temperature,

gynecomastia, male breast enlargement, even lactation.

And stopping them requires care.

Definitely.

Gradual dose reduction is crucial to avoid withdrawal or rebound psychosis.

Constant monitoring for EPS is standard care.

The review also mentions neuroleptic malignant syndrome, NMS.

Sounds serious.

It is.

Rare, but potentially fatal.

Can happen any time, but maybe more common early in treatment, after dose changes, or with multiple antipsychotics.

What are the signs?

Sudden high fever, fast heart rate, severe muscle rigidity, altered mental status, confusion, and autonomic dysfunction, like unstable blood pressure, sweating.

Needs immediate medical intervention.

Okay.

And briefly, meds for ADHD.

Yes.

Saunders mentions examples like amphetamine stimulants, atomoxetine, a non -stimulant, and methylphenidate.

Different mechanisms, but all aimed at improving focus and reducing impulsivity hyperactivity.

Before we leave pharmacology, any general administration tips from the review?

The good practical points.

Giving MAOIs and lithium with food to reduce GI upset.

Liquid forms might be easier for some patients and absorb faster.

Avoid skin contact with liquid antipsychotic concentrates can cause irritation.

Protect them from light.

Dilute them in juice, maybe.

And a big one.

Patient education about the timeline.

And depressants, antipsychotics.

They take weeks for the full effect.

Manage expectations.

Excellent.

Okay, let's move from meds to more hands -on stuff.

Basic care and comfort.

Foundational nursing.

Things like oral hygiene, especially for dry mouth, which is common with antidepressants.

Simple things like water sips, sugar -free candy help.

Nutrition fits here too.

Absolutely.

Like recommending high fiber foods for constipation, another common side effect or issue.

And positioning is huge.

How so?

Fowler's position sitting up helps breathing for COPD patients.

Side -line positions like lateral or sims are used for procedures or pressure relief.

Prone is on the stomach, supine on the back.

Trendelenburg head down has specific uses, but also contraindications like head injury.

And restraints.

Always a sensitive topic.

Physical and chemical restraints are last resorts for safety under strict guidelines and policies.

Basic hygiene like bathing is fundamental.

Addressing sleep issues, insomnia, or excessive sleepiness, somnolence is part of basic comfort too.

Okay, next up.

Safety and infection control.

Absolutely critical.

Underpins everything.

Includes simple things like safety precautions if someone's dizzy from SSRIs.

Suicide precautions for those on antidepressants or lithium, especially early on.

Latex allergy awareness.

Essential.

Creating latex -safe environments.

Then there's transmission -based precautions airborne.

Contact vital for stopping infection spreading.

Flyer safety.

Knowing, race rescue, activate alarm, contain fire, extinguish if safe, needle disposal in sharps containers to prevent injuries, and understanding the national patient safety goals, patient ID, communication, med safety, et cetera.

Good overview.

Now, physiological adaptation.

How the body responds to illness and treatment.

This looks like a big section.

It is.

Starts with vital signs monitoring crucial for those on SSRIs, lithium, or suspected toxicity.

Then dives into fluid and electrolyte balance.

Osmosis, diffusion, all that.

Understanding how fluids and electrolytes move.

And recognizing imbalances, sodium, potassium, calcium, magnesium, phosphate.

Knowing the causes and signs.

Like our review question mentions hypernutremia, high sodium.

What would you do for that?

Monitor vitals, electrolytes, push oral fluids if possible, track intake output.

You wouldn't give more sodium, obviously.

Makes sense.

Acid -based balance is in here, too.

Crucial.

Understanding buffers by carbonate phosphate protein, and how lungs and kidneys regulate pH.

Identifying acidosis and alkalosis with a metabolic or respiratory.

And oxygenation, of course.

Absolutely.

Hypoxia, low tissue oxygen, hypoxemia, low blood oxygen.

Knowing the different delivery devices.

Nasal cannula, masks simple.

Venturi non -rebreather, T -piece, track collars masks.

Tracheostomy care.

Yes, including suctioning.

Key points are hyperoxygenating before,

intermittent suction only on withdrawal, rotating the capillary, limiting passes to 10 seconds, and using appropriate suction pressure, like 80, 120 millimeter HG.

Mobility and immobility are covered, too.

Yes.

Positioning to prevent pressure injuries, range of motion exercises.

Using assistive devices correctly, canes, walkers, crutches, including the different gates.

Pain management.

Essential.

Assessing pain thoroughly, using non -drug methods like heat cold and giving pain meds appropriately, monitoring effectiveness and side effects.

And perioperative care before, during, after surgery.

A whole process.

Pre -op teaching, deep breathing, coughing, leg exercises, NPO status, intra -op care, post -op, vital signs, positioning, pain control, respiratory, circulation checks, wound care, monitoring urine and bowel function, safety, discharge planning.

And potential complications.

Big list.

Hemorrhage, shock, atelectasis, collapsed lung, pneumonia, embolism, thrombophlebitis, clot inflammation in a vein, ilious lack of bowel movement, urinary retention, infection, wound adhesive edges separating, or evisceration organs protruding.

Evisceration sounds bad.

Priority.

Cover immediately with sterile saline soak dressing.

Notify the surgeon.

Stack.

Burns get special attention.

Yes.

Classification.

Yeah.

Superficial, partial thickness, full thickness.

The rule of nines for estimating burn area, initial ED care, ABCs, stop the burning, cover the wound long -term, fluid desicitation, pain control, infection prevention, wound care, nutrition.

And general wound care principles.

Assessment, cleansing, choosing the right dressings, debridement to removing dead tissue, and understanding skin grafts.

Okay.

Shifting gears to health promotion and maintenance.

What's key here?

Preventive stuff like immunizations.

Hepatitis B is an example.

Growth and development across the lifespan is huge.

Freud, Erickson, Piaget, Kohlberg stages.

Developmental milestones from infant to older adult.

And caring for hospitalized kids.

Visual considerations,

yeah.

Separation, anxiety, fear of pain or injury.

Addressing those specifically.

Nutrition comes up again here.

Definitely.

These change across the lifespan.

Also covers therapeutic diets for specific conditions.

Exercise recommendations are in here too.

And prenatal care.

Prenatal care is extensive, I bet.

It is.

Signs of pregnancy presumptive, probable positive, physiological changes, common discomforts, antepartum testing like CVS, nutrition needs, fetal development milestones,

labor and delivery stages, assessments, interventions, pain management, and postpartum care assessments, recovery, potential complications.

And newborn care right after.

Apgar scores.

Full assessments.

Reflexes.

Feeding guidance breast and bottle.

Hygiene.

Safety like SIDs prevention.

Common issues like jaundice, hypoglycemia, respiratory distress.

All right, let's delve into psychosocial integrity.

Mental, emotional, social well -being.

Starts with basics.

Coping mechanisms, defense mechanisms, therapeutic communication techniques.

Then moves into specific disorders.

Anxiety disorders, GAD, panic, phobias, OCD, PTSD.

Mood disorders, depression, bipolar.

Schizophrenia, positive and negative symptoms.

Personality disorders, antisocial.

Borderline, narcissistic.

Eating disorders, anorexia, bulimia.

Substance use disorders, alcohol, stimulants, opioids.

Covering intoxication and withdrawal.

Crisis intervention.

Important skill.

Types of crises, phases people go through.

How nurses intervene to help them cope.

Also covers violence and abuse.

Child, elder, domestic.

Grief and loss processes.

They're in a therapeutic environment.

You therapy, yeah.

Creating that supportive setting.

And it revisits the psychiatric medications we discussed earlier.

Antidepressants, MAOIs, lithium benzos, antipsychotics, et cetera.

Okay, management of care.

This sounds like where it all comes together.

It really is.

It covers the nursing process.

Assessment, diagnosis, planning, implementation, evaluation.

Prioritization using ABCs, Maslow's Hierarchy.

Delegation, the five rights.

Leadership, ethics.

Leadership and management concepts.

Ethical principles, autonomy, beneficence, non -maleficence, justice, veracity, informed consent.

Legal issues like negligence, high PA privacy rules, interprofessional collaboration working with the whole team and quality improvement efforts.

The review then gives specific examples in MedCirc nurses.

Right, broken down by system.

Cardiovascular, hypertension, heart failure, CAD, MI, arrhythmias, respiratory, COPD, asthma, pneumonia, TB, GI, ulcers, IBD, diverticulitis, liver disease, renal, AKI, CKD, UTIs, BPH, kidney stones, endocrine, diabetes, thyroid, adrenal issues, neuro, stroke, seizures, ICP, spinal cord injury, MS, Parkinson's, musculoskeletal, fractures, arthritis, osteoporosis, oncology basics and specific cancers.

Immune, HIV AIDS, autoimmune -like lupus, RAI ear, glaucoma, cataracts, hearing loss.

And similar examples for PEDs and maternity.

Exactly, PEDs covers common childhood illnesses, congenital disorders like heart defects or cleft palate,

respiratory issues like croup or CF, GIGU problems specific to kids, neuro conditions like seizures or cerebral palsy, musculoskeletal like scoliosis, blood disorders like sickle cell, diabetes type one and child maltreatment signs.

And maternity.

Covers the whole journey.

Antepartum, intrapartum, postpartum care, complications of pregnancy, newborn assessment, labor delivery complications, postpartum complications for the mother.

Wow, and throughout all this, it's defining medical terms constantly.

Yes, terms are woven right in.

Nostagmus, fasciculations, oliguria, enuria,

agranulocytosis, akathisia, tardive dyskinesia, atelectasis, dehiscence, evisceration, hypoxia, osmosis, diffusion.

The list is huge.

Understanding the language is fundamental.

And it includes review questions testing these concepts.

It does.

And by covering the content like we have, we've touched on the knowledge needed for those questions.

Things like hemophilia, A being a factor of eight deficiency or needing a bone marrow biopsy for all diagnosis.

Those are the specifics of track suctioning we discussed.

Right, or age related changes increasing fall risk.

Or avoiding aspirin in Ray's syndrome, medication math principles,

cryptorchidism meaning undescended tests, interventions for skin conditions like pemphigus, causes of acne, recognizing 4V infiltration.

Oral care with anti -tubes.

Exactly, how potassium sparing diuretics work, taste changes with some meds like Fosinople, hypothyroidism care basics, why ovulation stops in pregnancy, using therapeutic communication for depression.

Priority for an open fracture infection prevention.

Yes, plaster cast care points,

home care instructions for TB, the link between strep and rheumatic endocarditis, what paraphrasing means in communication.

Skincare after cast removal.

Communicating with the hearing impaired.

Defining abuse.

Honoria meaning no urine.

Autonomic dysreflexia signs.

Bare receptor function.

Cardiac output definition.

What a cataract is.

Chest tube purpose.

CKD and COPD characteristics.

Client's bill of rights.

Compartment syndrome.

Cardiac conduction contractility.

Conversion meaning, crackle sound, cross matching blood.

Collins sign.

Cultural awareness versus assimilation.

Cushing's triad meaning.

Cynosis cause.

Cycloplegia effects.

Dawn phenomenon.

Burn depths.

Defense mechanisms.

Delegation principles.

Developmental age.

Diabetes insipidus versus mulletus versus DKA.

Dialysis purpose.

Diverticulitis versus osis.

Dumping syndrome.

Entral versus parenteral nutrition.

EPS again.

False labor signs.

Fiber antigen roll.

Fontanelle closure.

Full thickness burn.

Gestational age.

Hepatitis types.

Hereditary meaning.

Herpes, Soster virus.

Hyperhypoglycemia.

Hyperhypothyroidism.

Immediate post -op priorities.

Implantation timing.

Inactivated vaccines.

Informed consent elements.

Inspection technique.

Intermediate post -op.

Internal fixation.

Interprofessional collaboration.

IBS symptoms, just principle.

Koerning sign.

Labor stages.

Lateral position uses.

Leadership roles.

LS ratio meaning.

Legal blindness criteria.

Leukemia basics.

Libido definition.

Low kea types.

Low birth weight.

Lumbar puncture procedure.

Magnesium rule.

Malignant versus benign.

Mastitis.

Meconium.

Malanus significance.

Metabolic respiratory acidosis alkalosis.

Metabolism.

Metastasis.

Meliotherapy.

Minority group definition.

Meiosis effect.

Menilial infection.

Moral reflex.

MRSA.

Multi -drug resistant TB.

Murphy's sign.

Medriasis effect.

Noedier meaning.

Noedier's rule.

Nasal flaring sign.

Nephrotic syndrome.

Neurogenic shock.

Newborn neo definition.

Non -morphism principle.

Noedier meaning.

Noedier's rule.

Nasal flaring sign.

Passive immunity.

Percussion technique.

Preferral IVs.

Phlebitis signs.

Phototherapy use.

Placenta previa.

Poison definition.

Polypharmacy risks.

Portal hypertension.

Postural hypotension.

Potassium role.

Preload definition.

Presbycusis cause.

Pressure injury stages.

Prioritizing actions.

Prodromal meaning.

Prone position.

Puberty stages.

Pulse pressure calculation.

Pylonephritis.

Pyloroplasty purpose.

Quickening timing.

Race racism concepts.

Reduction meaning.

Regurgitation.

Respiratory acidosis alkalosis causes.

Restraint use.

Resuscitation goals.

Rheumatic fever endocarditis link.

Rhinitis symptoms.

Rigor meaning.

Romberg's test.

Scabies transmission.

Scoliosis.

Seju type scare.

Septicemia.

Serum components.

Shunt purpose.

Sims position.

Skin cancer types.

Smoke inhalation dangers.

Sodium role.

Sumoji phenomenon.

Spinal shock.

Standard precautions.

Stereotyping dangers.

Stretch receptors.

Stridor significance.

Stroke volume.

Subcultures.

Subjective data.

Suctioning procedure.

At suicide attempts.

Burn classification again.

Supine position.

Surfactant role.

Cystolic pressure.

Thyroid storm thyroidectomy.

TP and administration.

Trash traditions.

Truceau sign.

Tuberculin skin test.

Tuberculosis facts.

Tumor markers.

Turner sign.

Ulcerative colitis.

Unconscious client care.

Undifferentiated cells.

Unilateral neglect.

Unit definition.

Meds.

Urolithiasis.

Veracity principle.

Warfare aging considerations.

Wheezing significance.

Okay, that was incredibly thorough.

A real sweep through a massive amount of essential nursing knowledge from that Saunders review.

It really was a comprehensive journey.

We managed to touch on all those core areas.

Pharmacology, basic care, safety, physiological adaptation,

health promotion, psychosocial integrity, management of care, and examples from Medsurg, PEDS, and maternity.

Yeah, we covered a lot of ground.

I hope this condensed version, this deep dive, gives you listening a really solid foundation and highlights those absolutely crucial concepts.

It really emphasizes just how much knowledge and skill goes into nursing.

It absolutely does.

And it shows how interconnected everything is, doesn't it?

Yeah.

You need all these pieces to provide that truly holistic, patient -centered care.

Maybe think about which areas we covered really sparked your interest.

There's always more to learn, more to explore in this field.