Sertraline

Generic Name: Sertraline Hydrochloride

Brand Name: Zoloft
Classification: SSRI Antidepressant
Mode of Action:
-Acts as antidepressant by inhibiting CNS neuronal uptake of serotonin; blocks
uptake of serotonin with little effect on norepinephrine, histaminergic, and alpha 1 –
adrenergic receptors

Suggested Dose:

major depressive disorder and OCD: 50 mg PO daily. May be increase up to 200

mg/day.

Panic disorder: 25 mg PO daily. After one week increase to 50 mg once daily.

PMDD: 50 mg/day PO daily. Or just during luteal phase of menstrual cycle.

Social anxiety disorder: 25 mg a day PO.

Indications:

 Major Depressive Disorder

 Obsessive-Compulsive Disorder

 Panic Disorder

 Premenstrual Dysphoric Disorder (PMDD)

 Social Anxiety Disorder

Contraindication:

All Dosage Forms of ZOLOFT:

Concomitant use in patients taking monoamine oxidase inhibitors (MAOIs) is

contraindicated). Concomitant use in patients taking pimozide is contraindicated
ZOLOFT is contraindicated in patients with a hypersensitivity to sertraline or any of
the inactive ingredients in ZOLOFT.

Oral Concentrate:

ZOLOFT oral concentrate is contraindicated with ANTABUSE (disulfiram) due to the

alcohol content of the concentrate.

Adverse Effects:

 CNS: headache, nervousness, drowsiness, anxiety, insomnia, tremor, fatigue,

seizures, psychosis

 CV: hot flashes, palpitations, chest pains

 Dermatologic: sweating, rash, pruritus, acne

 GI: nausea, vomiting, diarrhea, dry mouth, dyspepsia, constipation, gingivitis

 GU: painful menstruation, frequency, cystitis, impotence, vaginitis

 Respiratory: URIs, cough, bronchitis, rhinitis, dyspnea

 Others: hot flashes, fever, pain, thirst

Drug Interactions:
 Sertraline is a moderate inhibitor of CYP2D6 and CYP2B6 in vitro.
 In a placebo-controlled study, the concomitant administration of sertraline and
methadone caused a 40% increase in blood levels of the latter, which is
primarily metabolized by CYP2B6.
 Sertraline had a slight inhibitory effect on the metabolism of diazepam
(Valium), tolbutamide (Orinase) and warfarin (Coumadin), which are CYP2C9
or CYP2C19 substrates; this effect was not considered to be clinically
relevant.
  Sertraline had no effect on the actions of digoxin (Lanoxin) and atenolol
(Tenormin), which are not metabolized in the liver.
 Clinical reports indicate that interaction between sertraline and the MAOIs
isocarboxazid (Marplan) and tranylcypromine (Parnate) may cause serotonin
syndrome.

Nursing Interventions:

1. Use lower dose in elderly patients and with hepatic or renal

impairment.
2. Dilute oral concentrate in four ounce water, ginger, ale, lemon, lime
soda, lemonade, or orange juice only; administer immediately after
diluting.
3. Establish suicide precautions for severely depressed patients, limit
number of tablets given at any time.
4. Give drug once a day, morning or evening.
5. Increase dosage at intervals of not less than one week
6. Counsel patients to use non-hormonal contraceptives; pregnancy
should be avoided due to risk to fetus.
7. Take this drug once a day, morning or evening; do not exceed the
prescribed dose, it may take 4-6 weeks to see any improvement.
8. Consult your health care provider if you think that you are pregnant or
wish to be pregnant.
9. You may experience these side effects: dizziness, drowsiness,
nervousness, insomnia, nausea, and vomiting, dry mouth, excessive
sweating.
10. Report rash, mania, seizures, edema, difficulty breathing, increased
depression and thoughts of suicide.
Generic Name: Risperidone
Brand Name: Risperdal, Risperdal Consta, Risperdal M-Tab
Classification: Antipsychotic
Mode of Action:
- Unknown; may be mediated through both DOPamine type 2 (D2) and sero-tonin
type 2 (5-HT2) antagonism

Suggested Dose:

Posttraumatic Stress Disorder (Off-label)

0.5-8 mg/day PO

Indications:

 Irritability associated with autism,

 Bipolar disorder,
 Mania
 Schizophrenia

Contraindication:

- Hypersensitivity

- seizure

Precautions:
Pregnancy C, children, geriatric, cardiac/renal/hepatic disease, breast cancer,
Parkinson’s disease, CNS depression, brain tumor, dehydration, diabetes,
hematologic disease, seizure disorders, breastfeeding, abrupt discontinuation,
suicidal ideation, phenylke-tonuria

Adverse Effects:

CNS: EPS (pseudoparkinsonism, akathisia, dystonia, tardive dyskinesia),

drowsiness, insomnia, agitation, anxiety, headache, neuroleptic malignant syndrome,
dizziness, seizures, suicidal ideation, head titubation (shaking)

CV: Orthostatic hypotension, tachycardia, heart failure, sudden death (geriatric),

AV block

EENT: Blurred vision, tinnitus

GI: Nausea, vomiting, anorexia, constipation, jaundice, weight gain

GU: Hyperprolactinemia, gynecomastia, dysuria

HEMA: Neutropenia, Granulocytopenia

MS: Rhabdomyolysis

MISC: Renal artery disease; weight gain, hyperprolactinemia (child)

RESP: Rhinitis, sinusitis, upper respiratory infection, cough

INTERACTIONS

Alcohol: increased sedation

CarBAMazepine: increased risperiDONE excretion

Chloroquine, clarithromycin, droperidol, erythromycin, haloperidol, methadone,

pentamidine, thioridazine, ziprasidone: increased QT prolongation

Furosemide: increased risk of death in dementia-related psychosis

Levodopa: decreased levodopa effect

TraMADol: increased seizures

Valproic acid, verapamil: increased risperidone levels

Nursing Interventions:
1. Suicidal thoughts, behaviors often occur when depression is lessened; assess
mental status: orientation, mood, behavior, presence and type of
hallucinations before initial administration, monthly; this product should
significantly reduce psychotic behavior

2. Monitor bilirubin, CBC, liver function tests monthly

3. Assess affect, orientation, LOC, reflexes, gait, coordination, sleep pattern

disturbances

4. QT prolongation: Monitor B/P with patient in sitting, standing, and lying

positions; take pulse and respirations q4hr during initial treatment; establish
baseline before starting treatment; report drops of 30 mm Hg; obtain baseline
ECG and monitor Q- and T-wave changes

5. Check for dizziness, faintness, palpitations, tachycardia on rising; severe

orthostatic hypotension is common

6. EPS: Assess for akathisia (inability to sit still, no pattern to movements),

tardive dyskinesia (bizarre movements of the jaw, mouth, tongue, extremities),
pseudoparkinsonism (rigidity, tremors, pill rolling, shuffling gait); an antipar-
kinsonian product should be prescribed

7. Assess for constipation, urinary retention daily; if these occur, increase bulk,
water in diet

8. Assess for weight gain, hyperglycemia, metabolic changes in diabetes,

increased lipids
9. Assess for neuroleptic malignant syndrome: hyperpyrexia, muscle rigidity, in-
creased CPK, altered mental status; product should be discontinued

10. Teach patient to use good oral hygiene; frequent rinsing of mouth, sugarless
gum for dry mouth
Generic Name: Propranolol
Brand Name: Inderal, Inderal LA, InnoPran XL
Classification: Antihypertensive
Mode of Action:
- Nonselective b-blocker with negative inotropic, chronotropic, dromotropic
properties

Suggested Dose:

For acute heart attack:

Adults—180 to 240 milligrams (mg) per day, given in divided doses.

Children—Dose is based on body weight and must be determined by your

doctor.

For chest pain (angina):

Adults—At first, 80 milligrams (mg) once a day. Your doctor may increase
your dose if needed. The dose is usually not more than 320 mg per day.

Children—Use and dose must be determined by your doctor.

For high blood pressure (hypertension):

Adults—At first, 80 milligrams (mg) once a day, given at bedtime. Your doctor
may increase your dose if needed. However, the dose is usually not more
than 120 mg per day.

Children—Use and dose must be determined by your doctor.

Indications:

Chronic stable angina pectoris, hypertension, supraventricular dysrhythmias,

migraine prophylaxis, pheochromocytoma, cyanotic spells related to hypertrophic
subaortic stenosis, essential tremor, acute MI

Unlabeled uses: Prevention of variceal bleeding caused by portal hypertension,

akathisia induced by antipsychotics, lithium-induced tremor

Contraindication:

Hypersensitivity to this product, cardiogenic shock, AV heart block, bronchospastic

disease, sinus bradycardia, bronchospasm, asthma, pregnancy C

Adverse Effects:

CNS: Depression, hallucinations, dizziness, fatigue, lethargy, paresthesia, bizarre

dreams, disorientation
CV: Bradycardia, hypotension, CHF, palpitations, AV block, peripheral vascular
insufficiency, vasodilatation, pulmonary edema,
EENT: Sore throat, laryngospasm, blurred vision, dry eyes
GI: Nausea, vomiting, diarrhea, colitis, constipation, cramps, dry mouth,
hepatomegaly, gastric pain, acute pancreatitis
GU: Impotence, decreased libido, UTIs
HEMA: Agranulocytosis, thrombocytopenia
INTEG: Rash, pruritus, fever, Stevens-Johnson syndrome, toxic epidermal necrolysis
META: Hyperglycemia, hypoglycemia
MISC: Facial swelling, weight change, Raynaud’s phenomenon
MS: Joint pain, arthralgia, muscle cramps, pain
RESP: Dyspnea, respiratory dysfunction, bronchospasm, cough

INTERACTIONS

Cimetidine: increased b-blocking effect

Disopyramide: increased negative inotropic effects
Haloperidol, prazosin, quiNIDine: increased hypotension
Propafenone: increased propranolol levels
Smoking: decreased propranolol levels

Nursing Interventions:

Assessment

1. Monitor B/P during beginning treatment, periodically thereafter; pulse q4hr;

note rate, rhythm, quality; check apical/radial pulse before administration;
notify prescriber of any significant changes (pulse ,50 bpm or systolic B/P ,90
mm Hg)

2. Check for baselines in renal, liver function tests before therapy begins and
periodically thereafter
3. Assess for edema in feet, legs daily; monitor I&O, weight daily; check for
jugular vein distention, crackles bilaterally; dyspnea (CHF)

4. Monitor skin turgor, dryness of mucous membranes for hydration status,

especially geriatric

5. Assess for headache, light-headedness, decreased B/P; may indicate need

for decreased dose; may aggravate symptoms of arterial insufficiency

6. Teach patient not to use OTC products containing a-adrenergic stimulants

(such as nasal decongestants, cold preparations); to avoid alcohol, smoking
and to limit sodium intake as prescribed; blood glucose (diabetes mellitus)

7. Teach patient how to take pulse and B/P at home; advise when to notify
prescriber

8. Instruct patient to comply with weight control, dietary adjustments, modified

exercise program

9. Instruct patient to carry/wear emergency ID to identify product being taken,

allergies; tell patient product controls symptoms but does not cure

10. Caution patient to avoid hazardous activities if dizziness, drowsiness are

present
MANAGEMENT

Cognitive Processing Therapy

CPT is a 12-week course of treatment, with weekly sessions of 60-90 minutes.
At first, you'll talk about the traumatic event with your therapist and how your thoughts
related to it have affected your life. Then you'll write in detail about what happened. This
process helps you examine how you think about your trauma and figure out new ways to
live with it.
For example, maybe you've been blaming yourself for something. Your therapist will help
you take into account all the things that were beyond your control, so you can move
forward, understanding and accepting that, deep down, it wasn't your fault, despite things
you did or didn't do.

Prolonged Exposure Therapy

If you've been avoiding things that remind you of the traumatic event, PE will help
you confront them. It involves eight to 15 sessions, usually 90 minutes each.
Early on in treatment, your therapist will teach you breathing techniques to ease
your anxiety when you think about what happened. Later, you'll make a list of the
things you've been avoiding and learn how to face them, one by one. In another
session, you'll recount the traumatic experience to your therapist, then go home and
listen to a recording of yourself.
Doing this as "homework" over time may help ease your symptoms.

Eye Movement Desensitization and Reprocessing

With EMDR, you might not have to tell your therapist about your experience. Instead, you
concentrate on it while you watch or listen to something they're doing -- maybe moving
a hand, flashing a light, or making a sound.
The goal is to be able to think about something positive while you remember your
trauma. It takes about 3 months of weekly sessions.

Stress Inoculation Training

SIT is a type of CBT. You can do it by yourself or in a group. You won't have to go into
detail about what happened. The focus is more on changing how you deal with
the stress from the event.
You might learn massage and breathing techniques and other ways to stop negative
thoughts by relaxing your mind and body. After about 3 months, you should have the
skills to release the added stress from your life.