Editing Mental Health and Psychosocial Nursing – RN Flashcards (section)

== Psychopharmacology ==

;Lithium: therapeutic range, toxic threshold, and the sodium rule
:Maintenance level 0.6 to 1.2 mEq/L; acute mania is often managed at 1.0 to 1.5 mEq/L. Toxicity begins above 1.5 and is severe above 2.0 mEq/L. Sodium loss from vomiting, diarrhea, sweating, fever, or a low-sodium diet raises lithium levels because lithium is reabsorbed in place of sodium. Maintain 2 to 3 liters of fluid and consistent sodium daily. NSAIDs, thiazide diuretics, and ACE inhibitors also raise levels. Draw trough levels 12 hours after the last dose and monitor renal and thyroid function.

;Neuroleptic malignant syndrome versus serotonin syndrome
:NMS develops over days on a dopamine blocker with hyperthermia, "lead-pipe" rigidity, autonomic instability, altered consciousness, and markedly elevated creatine kinase; treat by stopping the antipsychotic, cooling, hydrating, and giving dantrolene or bromocriptine. Serotonin syndrome develops within hours of a serotonergic increase with hyperthermia, agitation, diarrhea, and neuromuscular hyperactivity, specifically hyperreflexia and clonus greater in the legs; treat by stopping the agent, cooling, giving benzodiazepines, and considering cyproheptadine.

;Four extrapyramidal syndromes by onset
:Acute dystonia in hours to days (torticollis, oculogyric crisis, laryngospasm) treated with IM diphenhydramine or benztropine; akathisia in days to weeks (inner restlessness, linked to suicide risk) treated with dose reduction, propranolol, or a benzodiazepine; pseudoparkinsonism in weeks (shuffling gait, mask facies, cogwheel rigidity); tardive dyskinesia in months to years (lip smacking, tongue protrusion), screened with the AIMS and treated with valbenazine or deutetrabenazine.

;Clozapine monitoring priorities
:Absolute neutrophil count for agranulocytosis (report fever, sore throat, or flu-like symptoms immediately), plus myocarditis, seizures at higher doses, orthostatic hypotension, sialorrhea, and severe constipation or ileus that can be fatal. Assess bowel function routinely.

;MAOI teaching: the food rule and the washout rule
:Avoid tyramine-containing foods (aged cheese, cured and smoked meats, fermented foods, soy sauce, sauerkraut, tap and draft beer, red wine, fava beans, overripe fruit) to prevent hypertensive crisis with severe occipital headache and stiff neck. Allow a 2-week washout between an MAOI and most serotonergic drugs, and 5 weeks after fluoxetine.

;Bupropion, lamotrigine, and valproate: one critical caution each
:Bupropion lowers the seizure threshold and is contraindicated in seizure disorder, bulimia, and anorexia. Lamotrigine must be titrated slowly because of the risk of serious rash including Stevens-Johnson syndrome; any rash requires immediate provider notification. Valproate is highly teratogenic (neural tube defects) and requires liver, ammonia, and platelet monitoring.