NURS 6501 Final Exam with Complete Solution

What is the role of the primary care provider in mental health? - ANSWER - Screen for mental health issues - Improve outcomes and reduce health care costs - Assess and give care to mild-moderate disorders or patients w ...

What is the role of the primary care provider in mental health? - ANSWER - Screen for mental health issues - Improve outcomes and reduce health care costs - Assess and give care to mild-moderate disorders or patients with stable severe mental disorders - From strong links with mental health specialty care for complex cases Sharing patient info (ex: meds used) about PHQ2 - what does it screen for, what are the questions, scoring - ANSWER - Screens for MDD - It is the first two questions of the PHQ9 - In the last two week, have you been feeling these (not at all, several days, more than half the day, nearly everyday): - Little interest or pleasure in doing things? - Feeling down, depressed, or hopeless? Scoring: A single yes or score >3 (out of 0-6) = possible clinical depression ⇒ due the PHQ9 If the pt screens (+) ⇒ continue to eval with the PHQ9 about PHQ9 - what its used for, questions, scoring - ANSWER Used for screening, diagnosing, and treating - It asks about functioning impairments which is needed for the DSM-based diagnosis Includes asking about suicide or hurting self Scoring: 0-27 available 0-4: Minimal/none Monitor; may not require treatment 5-9: Mild Use clinical judgment; follow-up in one month 10-14: Moderate Use clinical judgment; may need meds if functionally impaired 15-19: Moderately Severe Warrants active treatment with psychotherapy, meds, or combo 20-27: Severe Warrants active treatment with psychotherapy, meds, or combo What is the appropriate initiation dose for fluoxetine for adults and geriatric adults? - ANSWER 20mg PO once daily in the AM - May ↑ daily dose after several weeks if inadequate response - Full therapeutic effect may be delayed 4 weeks or longer - Max dose: 80mg/day What labs would be appropriate to draw if you initiate fluoxetine in a geriatric patient? - ANSWER Sodium levels - Baseline screening & after 3-4 weeks in high-risk patients (> 65yrs, previous hx of antidepressant-induced hyponatremia, low body weight, concomitant use of thiazides or other hyponatremia-inducing agents) - monitor regularly in the elderly What are potential side effects of SSRI medications? - what are the common SSRIs, LEAP of them, and zoloft AE - ANSWER Common SSRIs: Lexapro, celexa, paxil, zoloft, prozac L = decreased libido and sleep E = Neutral effect on energy A = neural effect on addiction P = celexa may stop working after awhile (increase or switch) Zoloft AE: Insomnia, somnolence, fatigue, abnormal ejaculation, suicidal thoughts What are characteristics of major depressive disorder or MDD? 9 - ANSWER Diagnostics need 5 or more of the following: - SS occur more days than not in a 2 week period - SS cause significant impairment in any realm of functioning - Depressed mood - Loss of interest - Significant unintended ▲ in weight or appetite - Significant ▲ sleep - ▲ psychomotor activity (restlessness) - Fatigue, loss of energy - Worthlessness, guilt What is serotonin syndrome? - ANSWER - Increased serotonergic activity in the CNS - Can be due to therapeutic med use, inadvertent drug interactions, or self-OD Serotonin in the Body: CNS: Modulates attention, behavior, and thermoregulation PNS: Regulates GI motility, vasoconstriction, uterine contraction, and bronchoconstriction, promotes PLT aggregation PE of serotonin syndrome 11 - ANSWER - Hyperthermia, flushed skin, diaphoresis - Agitation - Slow, continuous, horizontal eye movements (ocular clonus) - Dilated pupils - Tremor, akathisia - Deep tendon hyperreflexia (common) - Inducible or spontaneous muscle clonus (common) - Muscle rigidity - Bilateral babinski - Dry mucus membranes - Increased bowel sounds What is discontinuation syndrome (from SSRIs)? "FINISH" - ANSWER 2-3 days after stopping SSRIs abruptly F: flu-like SS I: insomnia N: nausea I: imbalance S: sensory disturbances H: hyperarousal Bupropion - MOA - BENFITS AE CONTRA - ANSWER MOA - act to inhibit reuptake of NE, dopamine, and serotonin BENFIT - Depression - Smoking cessation - Seasonal affective disorder - Treat sexual dysfunction relative to SSRI therapy AE - weight loss - increases libido ⇒ combine with SSRI - can cause seizures by lowering the seizure threshold CONTRA - History of seizures - Do not prescribe to pts with psych disorders ⇒ ↑ risk for delusions or hallucinations RF for ETOH abuse 4 - ANSWER Younger adults (18-29 yrs) Men > women Native americans Genetics (low response to ETOH), environment (peer influences), specific personality traits (impulsivity, extroversion), cognitive fxn What are predisposing factors impacting the likelihood of someone developing a SA issue? - ANSWER Predisposing Factors: - Unhealthy use of one substance increases the likelihood of unhealthy use of other substances - Family history - Social history - Partner or friends with SA, living in a community with poverty, violence, and/or high ETOH/drug use Use of: - Caffeine, tobacco, ETOH, prescription meds, marijuana, illicit drugs - Mental health disorders - Highest in personality disorders What is withdrawal - ANSWER process of removal of the drug of dependence from the body SS of substance abuse withdrawal 3 - ANSWER Can last days to weeks - NVD - Flu-like SS: lacrimation, rhinorrhea, diaphoresis, shivering, piloerection - SNS/CNS Arousal: mydriasis, mild HTN and tachy, anxiety, irritability, insomnia, agitation, restless leg, general restlessness, tremor, low grade temp Which medications are central nervous system sedatives? - ANSWER Include sedatives, tranquilizers, hypnotics - Good for treating anxiety, panic, acute stress reactions, sleep disorders Examples: Benzos: - Diazepam (valium), clonazepam (klonopin), alprazolam (xanax) Non-Benzo Sedative Hypnotics - Zolpidem (ambien) Barbiturates - Mephobarbital Initiation Strategies for Antidepressants: - ANSWER Antidepressants are considered equivalent in efficacy for depression Decide on med by: - History of response - Family history of response - Symptoms - Medical history - Interactions - AE which antidepressant is good for smoking cessation, weight loss, and ADD? - ANSWER Bupropion which antidepressant is good for fibromyalgia - ANSWER Duloxetine which antidepressant is good for migraine prevention - ANSWER Amitriptyline what is grief - ANSWER - response to bereavement → varies over time as the person adapts to the loss - painful, impairing, should NOT be diagnosed as a mental disorder - Bereavement is a stressor ⇒ can worsen mental disorders (ex: depression) - can progress to complicated grief: intense, prolonged, and debilitating SS treatments for acute grief - ANSWER - Typical doesn't require treatment - For bereaved patients who don't have mental disorders, suggest not routinely administering grief counseling or other psychotherapies - Grief counseling can be helpful for bereaved patients who request it - Encourage pts to maintain regular patterns of activity, sleep, exercise, and nutrition How long is a preoperative evaluation valid? - ANSWER - Preop evaluation must occur 1-30 days prior to the surgery - The more time the better so that referrals and consults can be done if needed Factors that influence the testing performed for preop visit 5 - ANSWER Presenting diagnosis Patient's age Comorbidities Type of anesthetic agent planned Surgeon's preference American Society of Anesthesiologists Anesthesia Classification System 1-4 - ANSWER ASA Class 1: healthy, normal patient ASA Class 2: patient with mild systemic disease ASA Class 3: patient with severe systemic disease ASA Class 4: patient with severe systemic disease that is a threat to life major clinical predictors that increase surgical risk 7 - ANSWER - MI within 30 days - unstable angina - decompensated HF - High-grade AV block - symptomatic ventricular arrhythmias - supraventricular arrhythmias with uncontrolled ventricular rates