Final Exam Flashcards

Question

Traits of Good Dementia Clinicians

Answer 1

- Assessment - Problem-solving - Observational skills - Conflict resolution - Dementia-capable communication - Respectful - Prioritization

Answer 2

**Observe** the person's behaviour **Read** information in the pt's chart **Listen** carefully to what the patient and family are saying **Ask** questions and be respectful Understand the person and the situation Maintain eye contact Goal is to reduce/eliminate responsive behaviours by treating the REAL problem (i.e., what the older adult with dementia is responding to): - Assess the person and situation - What is really going on? - Reduce discomfort and increase function Requires EFFECTIVE COMMUNICATION!

Answer 3

Degenerative disease in which dopamine-producing neurons in the basal ganglia die: - Neurons projecting from substantia nigra to striatum are affected Reduction in DA in this pathway leads to characteristic motor problems: - Tremor, resting - Rigidity, cogwheel - Akinesia, bradykinesia - Postural Instability ETIOLOGY: Idiopathic (most common) - Genetic component Secondary to a medical condition: - Head trauma - Brain infection - Brain tumour - Neurotoxins Onset is typically between ages 40 – 70 Males affected more often than females

Answer 4

The striatium receives excitatory input from the cortex - Mediated by the excitatory neurotransmitter, glutamate The striatum also receives inhibitory input from inhibitory neurons mediated by GABA Dopamine neurons from the substantia nigra project to both of these exicitatory and inhibitory neurons

Answer 5

In PD Dopaminergic neurons that project from the substantia nigra to the striatum die The loss of the striatal dopamine neurons produces an imbalance in striatum The overall consequence is reduction in the thalamic-cortical pathway: - Which leads to suppression of the motor cortex

Answer 6

Since Dopamine neurons are deteriorating then replace dopamine to restore balance: - Increasing available dopamine - Give dopamine agonists

Answer 7

**Clinical Pharmacology:** Levodopa: - Amino acid precursor to dopamine - Cross blood brain barrier - Elevates dopamine levels in the striatum Carbidopa - Inhibits peripheral decarboxylation of levodopa so that enough can cross the blood brain barrier - Need 75mg/day to inhibit peripheral dopamine decarboxylase - **A first line therapy** (many Neurologist will delay until symptoms are bothersome) **Pharmacokinetics**: When given as immediate release product - Half life = 1-1.5 hours - TID dosing Slow-release/Delayed (or controlled release): - Product allows for few daily doses - BID-TID dosing - Don't crush or split tablets*** Titrate dose and may need combination of Immediate release and delayed Clinical effects: - Improves bradykinesia and rigidity Long-term adverse effects: - “Wearing off” phenomenon - “on-off” phenomenon - Dyskinensias

Answer 8

Available Agents: - Bromocriptine - Pergolide - Pramipexole (also used for restless leg) - Ropinirole (also used for restless leg) Clinical Pharmacology: - Directly stimulate dopamine receptors - D2 receptor agonists - Bromocriptine and pergolide are also ergot derivatives and also are D1 partial antagonists - Used as initial therapy or adjunctive to Levodopa**

Answer 9

Eg) Trihexyphenidyl, Benztropine, others Clinical Pharmacology: - Block muscarininc receptors in the striatum - Reduces striatal activity Modest effect on treating symptoms: - More beneficial for tremors

Answer 10

Clinical Pharmacology: - Enhances dopamine release - Blocks reuptake - Stimualtes receptors Clinical Effects: - Improves tremor, rigidity, and bradykinesia - Adjunctive therapy in advanced disease - Possible initial therapy for mild disease

Answer 11

Eg) Tolcapone, Entacapone Clinical Pharmacology: - Blocks the metabolism of dopamine and levodopa therefore can increase availability of levodopa (**Improves half-live of levodopa**) - Utilized with Levodopa/carbidopa (Given with each dose (max 8 tabs/day))

Answer 12

Neurodegenerative disease characterized by demyelination of neurons; both sensory and motor branches can be affected Demyelination thought to be related to an abnormal autoimmune response Several subtypes exist Clients often experience symptoms for a period of time, followed by remissions Early signs include: - Muscle weakness - Visual disturbances - Paresthesia - Bladder control problems Pharmacotherapy: - Focus is modifying progression of disease and managing symptoms - Immunomodulators are commonly used as therapy WATCH YOUTUBE VIDEO

Answer 13

Disturbance of the brain’s electrical activity that may affect consciousness, motor activity and sensation CAUSES: - Infectious diseases, trauma, neoplasms, metabolic disorders (hypoglycemia, electrolyte imbalances), vascular disease (stroke), febrile, certain medications, idiopathic, secondary to another condition - Seizures occur when “seizure threshold” is exceeded CONVULSIONS: - **Not synonymous w/ seizures** - Involuntary, violent spasms of large skeletal muscles of face, neck, arms, and legs All convulsions are seizures but not all seizures are convulsions

Answer 14

- Seizures can take on many different forms and seizures affect different people in different ways. Not every person with seizures will experience every symptom described **Seizures have a beginning, middle, & end** AURA: - Sometimes, the warning or aura is not followed by any other symptoms. ICTUS: The middle of the seizure may take several different forms: - The aura may simply continue or it may turn into a complex partial seizure or a convulsion. POST-ICTAL: - The end to a seizure represents a transition from the seizure back to the individual’s normal state. This period is referred to as the “post-ictal period” (an ictus is a seizure)

Answer 15

Seizures are symptoms of underlying disorder Exact etiology may not be identified Some known causes include: - Fever (rapid,febrile) - Infectious disease - Trauma - Metabolic disorder, pediatric disorder - Vascular disease, neoplastic disease

Answer 16

Any disorder in which client experiences recurrent seizures Clients with epilepsy tend to have lower seizure thresholds than others More than 50% of cases are idiopathic Divided into categories based on symptoms, distribution of abnormal activity in brain (generalized onset vs. partial onset) WATCH YOUTUBE VIDEO

Answer 17

Usually occur in limited portion of brain Symptoms may vary depending on part of brain affected 2 Types: **1) Simple:** Regional symptoms - Motor = can be tonic, clonic, atonic, or repeated motions - Non-Motor = autonomic, behavioural, cognitive, sensory, emotional changes **2) Complex:** - Altered LOC, often w/ aura - May be motor, sensory and autonomic symptoms

Answer 18

Multiple foci that spread abnormal neuronal discharges across both hemispheres of the brain simultaneously Absence seizures: - Staring, transient loss of consciousness - Used to be called petit mal - Usually in children, last a few seconds Atonic seizures: - Drop attacks, clients stumble/fall for no reason Tonic-Clonic: - Aura, intense muscle contraction, loss of consciousness - **MOST COMMON TYPE** - There may be warning or aura Myoclonic: - Contraction of major muscles, jerky motion, NO loss of consiousness

Answer 19

Series of generalized seizures tht occur without full recovery of consciousness between attacks Also includes continuous electrical seizures lasting at least 30 minutes even without impairment of consciousness Risk: - Respiratory arrest at height of each seizure leading to hypoxia which can lead to brain damage MEDICAL EMERGENCY Eg) cerbyx, Ativan, Valium IV - Oxygen & Airway device/intubation inserted between seizures - Suction - Hydration IV using glucose for hypoglycemia (high metabolic demand during seizure) - May have to anesthetize with short acting barbiturate to stop seizure - Serum levels of anti- seizure meds - Cardiac/respiratory depression may be life-threatening - Cerebral edema can occur

Answer 20

1) ABCDEFG (ABC's and **D**on't **E**ver **F**orget the **G**lucose) 2) Airway: lateral decubitus, nasal trumpets, O2, Suction 3) IV access 4) Concurrently search for reversible cause

Answer 21

Choice dependent on many factors: - Type of seizure, medical history, results of EEG and other diagnosis tests **4 MOA:** 1) Increasing the stimulation of GABA receptors 2) Reduce Na+ influx into neurons 3) Reduce Ca+2 influx into neurons 4) Block glutamate receptors

Answer 22

**Barbiturates**: Eg pentobarb, phenobarb -Indicated primarily for tonic-clonic seizures, but also used as sedative, hypnotic and general anaesthetic purposes **Benzodiazepines:** Eg diazepam, lorazepam - Indicated primarily for absence and myoclonic seizures but also used as anxiolytic and sedative - Often used in combination with other drugs **Gabapentin** – indicated for PARTIAL seizures

Answer 23

Desensitize Na+ channels thereby delaying opening of channels and reducing excitability of neurons **Hydantoins:** Eg phenytoin - Indicated for all seizures except absence **Phenytoin-like drugs:** Carbamezapine – indicated for tonic-clonic and partial Valproate – indicated for absence and tonic-clonic; also for bipolar disorder

Answer 24

**Succinimides are most commonly used in this category** Indicated primarily for absence seizures Reduce Ca+2 influx which reduces NT release by neurons, reducing the excitability of post-synaptic neurons

Answer 25

Inflammation is known to cause several neurological disorders. Recently, it is being acknowledged to have a role in Epilepsy. IVIG – Intravenous immunoglobulin – contains pooled, polyvalent, IgG antibodies that work to suppress inflammation. It’s on the horizon as an effective treatment for Epilepsy.

Answer 26

This is a rigid, mathematically calculated, doctor-supervised diet. It can only be attempted under close medical and dietary supervision. Who is a candidate? (***) – Individuals with uncontrolled seizures that have failed at least two medications for seizure control – More effective in = infantile spasms, Doose Syndrome, Rett Syndrome, and tuberous sclerosis complex. The Basics: - Ketogenic diet is a medical treatment for controlling seizures by switching the body's primary energy source to fat-based (ketones) verses sugar-based (glucose). - Don't know why diet is successful - The diet can be adapted using table foods or given formula based. - There are potential side effects associated with the diet, However, all are treatable and reversible without having to stop the diet. - They include, lack of weight gain, slightly decreased growth, somewhat high cholesterol, constipation, kidney stones, and acidosis. - There are a number of common misunderstandings about this therapy.

Answer 27

Following directions for administering anti-seizure medications ensures best chance to manage seizure activity Irregular dosing (missed dosing, doubling up) increases likelihood of seizure activity, occurrence of adverse effects Adherence can be improved by client documentation of drug administration and alterations, and responses in a “seizure diary”

Answer 28

Time the seizure. Don't hold the patient down or try to stop any movements. Clear the area of any hard or sharp objects and loosen ties or anything around the neck that may make breathing difficult. Place something flat and soft under the head. Turn the patient gently onto one side. This will help keep the airway clear. Do not try to force the mouth open with any hard objects or with fingers. A person having a seizure CANNOT swallow their tongue. Efforts to hold the tongue down can injure teeth or the jaw. Remain with patient the entire time. The patient may be disoriented and confused as they wake from the seizure, be reassuring during this time. Assess for injury and respiratory status. If the patient is sleepy following the seizure, allow them to rest. Nothing to eat or drink until able to swallow.

Answer 29

Immediate: - Lacerations - Bruises - Burns - Head trauma - Fractures - Drowning/near drowning Delayed: - Fever - Aspiration - Pneumonia - Subdural hematomas - Fractures

Answer 30

What happened before, during and after event Be detailed Include lots of information from the start to the end

Answer 31

Anxiety is a generalized feeling of worry, fear or uneasiness about a perceived threat Anxiety, as a part of the stress response, is adaptive and can improve performance When anxiety is excessive or irrational, anxiety is maladaptive and can affect normal functioning and promote GI and cardiovascular disorders

Answer 32

**Generalized anxiety disorder (GAD):** - Excessive anxiety that lasts more than 6 months - Symptoms = restlessness, fatigue, difficulty focusing, sense of dread, sleep disturbances - Sympathetic effects are common as part of stress response **Social anxiety disorder:** - Persistent fear of being judged, ridiculed, embarrassed - Type of phobia (fearful feeling attached to situations or objects) **OCD:** - Recurrent, intrusive thoughts or behaviours **PTSD:** - Anxiety assoc. w/ past events

Answer 33

Limbic System: - Associated with emotion, learning and memory - Connects to hypothalamus to mediate responses related to anxiety, fear, anger - Hypothalamus influences sympathetic response Reticular formation (part of reticular activating system): - Stimulation of reticular formation increases arousal and alertness - Inhibition of reticular formation promotes drowsiness and sleep - In anxiety, messages from hypothalamus and limbic are carried by way of reticular activating system to cortex –this is thought to be basis of fear and anxiety

Answer 34

Activity of reticular formation associated with sleep and wakefulness Normal sleep cycles include non-REM and REM stages of sleep Sleep patterns vary during the life cycle and can vary from person to person Circadian rhythms associated with sleep as well –occur due to changes in light during day and secretion of melatonin; melatonin can promote sleep

Answer 35

INSOMNIA: Lack of adequate sleep* - Sleep-onset insomnia: difficulty falling asleep - Sleep-maintenance insomnia: difficulty staying asleep - Sleep-offset insomnia: waking up too early - Non-restorative sleep: Adequate sleep but sleepy during day - Can be associated with forms of anxiety (depression, manic disorders, chronic pain) NARCOLEPSY: Severe daytime sleepiness - Client may also fall asleep at inappropriate times - Other symptoms: cataplexy, hypnagogic hallucinations, muscular paralysis, automatic behaviour

Answer 36

Melatonin: hormone produced in pineal gland, especially at night Decreases alertness, lowers temperature Supplements sold OTC, usually 0.5 to 3.0 mg at bedtime reported to be helpful - But many safety concerns

Answer 37

**CNS Depressants:** - Benzodiazepines - Barbiturates - Other agents Zopiclone →IDEALLY used for the short-term (7-14 days) treatment of insomnia in adults - Enhances GABAA activity leading to a calming, sedative, and hypnotic effect, promoting sleep - Similar action to benzodiazepines but chemically distinct **Act on a continuum in terms of effects:** - Anxiolytic –reduce anxiety - Sedative –promote relaxation - Hypnotic –promote sleep

Answer 38

Drugs of choice for GAD and short-term insomnia therapy (up to about 4 weeks) Route of administration = usually enteral MOA: – Bind GABAA receptor which causes its Cl-channel to open, decreasing excitability of post-synaptic neurons in limbic system Metabolized by liver, excreted by kidneys Tolerance develops with repeated use Dependency can develop as well Decrease time to fall asleep for clients with insomnia, reduce sleep interruptions Interactions: - Respiratory depression can occur when mixed with other CNS depressants Eg) Diazepam (Valium)

Answer 39

Used less commonly now for anxiety and insomnia compared to benzodiazepines Used as anti-seizure, IV anaesthetic Dependence –both psychological and physiological dependence occur; withdrawal is severe and can be fatal MOA: – Same as for benzodiazepines; bind GABAA receptors causing opening of its Cl-channels Adverse Effects - Similar to those of benzodiazepines - Respiratory depression - Paradoxical excitement Tolerance develops to CNS effects, but not to respiratory depression: - Increased dose to achieve therapeutic effect can be high enough to stop breathing Cross-tolerance –tolerance to barbiturates can promote tolerance to opioids and other CNS depressants Interactions: - Increase the activity of some liver enzymes which can alter metabolism of other drugs

Answer 40

**Major depressive disorder** –aka clinical depression **Dysthymic disorder** –mild, chronic depression for two or more years **Bipolar disorder** –alternating between manic and major depression phases **Manic and hypomanic episodes** –manic phases that impact social functioning **Cyclothymic disorder** –alternating between hypomanic and mild depression phases

Answer 41

Sad or despondent mood out of proportion to actual life events Most common mental health disorder One of oldest known mental health condition Causes still not entirely understood

Answer 42

Attributed to reduced levels of serotonin (5HT), dopamine (DA) and norepinephrine (NE) in limbic system Many hypotheses for why NTs are low in these clients including: - Endocrine factors –increased CRF secretion - Environmental factors –prolonged stress, traumatic life events - Genetic factors –people with first degree relatives with depression more likely to develop depression

Answer 43

**Antidepressants** –4 primary classes 1) Tricyclic antidepressants (TCAs) 2) Selective serotonin reuptake inhibitors (SSRIs) 3) Atypical antidepressants 4) Monoamine oxidase inhibitors (MAOIs)

Answer 44

MOA: - Prevents reuptake of NE and 5HT by blocking reuptake proteins Eg) Amitriptyline, Clomipramine, Desipramine Adverse Effects: - Anticholinergic effects (TCAs block mAchRs) - Orthostatic hypotension (TCAs block alpha1 adrenergic receptors) - Sedation (TCAs block histamine receptors) - Sexual dysfunction and weight gain May take 2 –6 weeks for therapeutic effect Increased risk of suicide as drug approaches therapeutic concentration Decreases seizure threshold (caution with clients with epilepsy) Adherence, due to weight gain and anticholinergics effects, is an issue especially if client feels better

Answer 45

Therapeutic Effect - Improve mood and emotional status in clients with depression MOA: - Prevent reuptake of 5HT, primarily - Therapeutic effects associated with increased sensitivity of post-synaptic receptors, usually 4 –6 weeks after start of treatment - Same efficacy as TCAs and MAO inhibitors Adverse Effects - Sedation - Sexual dysfunction - Loss or gain of weight, depending on drug Interactions: - SSRI + TCAs or MAO inhibitors can cause serotonin syndrome - Hyperpyrexia, hypertension, confusion, sweating, tremors, ataxia

Answer 46

Serotonergic overactivity in patients with exposure to serotonergic drugs Risk Factors: - Concurrent use of multiple serotonergic drugs or combo use w/ CYP450 inhibitors - Overdose - Switching serotonergic drugs without tapering Serotonergic Substances include: - Antidepressants (Eg MAOIs, SSRIs) - Recreational stimulants (Eg MDMA, cocaine) - 5-HT3 receptor antagonists (Eg ondansetron, granisetron) - Opioids (Eg Tramadol, meperidine) Symptoms: - Altered mental status - Neuromuscular Excitability (Lower extremities, hyperreflexia, myoclonus, rigidity, tremor clonus) - Autonomic dysfunction (Mydriasi, hyperthermia, diaphoresis, tachy, HTN, labile BP, D/V/N

Answer 47

Occurs when SSRI treatment stopped suddenly Antidepressant Withdrawal Symptoms: - Flu-like symptoms - Dizziness - Confusion - Lethargy - Vivid Dreams - Sleeping trouble - Anxiety - Tingling sensations - HTN - Sweating - Tremors - Nausea

Answer 48

Therapeutic effects may take up to 6 weeks Assess for drug history, especially other anti-depressant medications Increased risk of suicide as drug approaches therapeutic concentration Assess for baselines of weight, liver function Provide education to client regarding adherence and SSRI discontinuation syndrome

Answer 49

Enzyme that breaks down NE, DA and 5HT within the nerve terminal Role is to limit the amount of NE, DA or 5HT released by these neurons Enzyme also present in tissues throughout the body including the liver and small intestine Metabolizes tyramine, a NE-like substance found in bananas, raisins, some cheeses, beer, red wine, fava beans, soy sauce etc.

Answer 50

Indication: - Depression, for clients that do not respond to TCAs or SSRIs - Equal efficacy to TCAs and SSRIs but smaller margin of safety Eg) Selegiline MOA: - By inhibiting MAO, more NE, DA or 5HT is available for release by the neuron - More NE, DA or 5HT released into synapse to stimulate receptors Drug-Drug Interactions: -**Insulin and oral hypoglycemic** (Enhances hypoglycemia) - **Antihypertensive agents** (Profound hypotension) - **When used with SSRIs** →Serotonin syndrome - **Foods containing tyramine** (MAO inhibitors prevent breakdown of dietary tyramine - Tyramine promotes release of NE which causes acute hypertension, palpitations, occipital headache, flushing, sweating, nausea May take 4 –8 weeks for therapeutic effects Increased risk for suicide as drug approaches therapeutic levels Assess for contraindications including liver and renal function, cardiovascular disease Provide education regarding diet and avoiding foods that contain tyramine, interactions, and adherence Lowers seizure threshold

Answer 51

**Variations on TCAs and SSRIs** -Serotonin–norepinephrine reuptake inhibitors (SNRIs) Eg) Venlafaxine (Effexor); Duloxetine (Cymbalta) -Norepinephrine and dopamine reuptake inhibitors (NDRIs) Eg) Bupropion (Wellbutrin); Methylphenidate (Ritalin) -Norepinephrine reuptake inhibitors (NRIs) Eg) Atomoxetine (Strattera) -Serotonin Antagonist and Reuptake Inhibitors (SARIs) Eg) Trazodone (more often used as a sedative/sleep aid) Duloxetine is also indicated for fibromyalgia and other nerve pain disorders (e.g., diabetic peripheral neuropathy). Bupropion is used in smoking cessation. Atomoxetine and methylphenidate are commonly used in ADHD.

Answer 52

Clients alternate between extreme feelings of sadness and extreme mania Significantly impacts social and occupational functioning Symptoms of mania: - Agitation, intense excitement, elevated mood, talkativeness - Impulsive behavior, short attention span - No thoughts to consequences of actions

Answer 53

Biological, hormonal, genetic, and environmental components Focus on the levels and function of neurotransmitters in the limbic system Mania associated with too much NE and glutamate or too little inhibitory NTs such as GABA Associated with impaired levels of NE, 5HT, and DA in the limbic system

Answer 54

Mood stabilizers - Lithium carbonate –traditional medication - Valproic acid –anti-seizure medication that is becoming more common as a treatment Atypical Antipsychotics Therapy is highly individualized from client to client: - Severity of symptoms - Predominance of mania or depression

Answer 55

* MOA: - Uncertain, crosses cell membranes, altering sodium transport, not protein bound Side effects: - Thirst, metallic taste, increased frequency or urination, fine head-and-hand tremor, drowsiness, and mild diarrhea Blood levels monitored (lithium toxicity—severe diarrhea, vomiting, drowsiness, muscular weakness and lack of coordination, withhold) Monitor creatinine concentrations, thyroid hormones, and CBC every 6 months. Kidney damage may be a risk. Thyroid function may be altered usually after 6 to 18 months. Observe for dry skin, constipation, bradycardia, hair loss, and cold intolerance. Avoid during pregnancy.

Answer 56

A type of psychosis in which clients exhibit a set of diverse symptoms over time including: - Hallucinations, delusions, paranoia - Strange behaviours, actions, movements - Alternating hyperactivity and stupor - Indifference or detachment toward life - Abnormal thoughts, thought processes - Poor personal hygiene or job/academic performance - Withdrawal from people, environment

Answer 57

**Positive symptoms**: Behaviours in addition to normal behaviours - Hallucinations, delusions - Disorganized thought, speech pattern - Movement disorders **Negative symptoms**: Behaviours that take away from normal behaviours - Lack of interest in social activities - Lack of emotion, responsiveness - Lack of pleasure in daily activities - Reduced or repetitive speech - Lack of desire to care for personal hygiene **Cognitive symptoms**: Often not noticed as part of condition until positive or negative behaviours emerge - Significant learning and memory problems - Decreased ability to concentrate

Answer 58

Genetic component: - 5 to 10 times greater risk if a first-degree relative has disorder Neurotransmitter imbalance: - Overactive dopaminergic pathways in basal nuclei leads to overstimulation of dopamine type 2 (D2) receptors - Antipsychotic drugs block D2receptors - Blocking these receptors can produce extrapyramidal adverse effects, similar to what happens in Parkinson’s disease LOOK AT SLIDE 46 Picture

Answer 59

Primary goal to manage symptoms, so client can function independently Drug affects can be severe Initial treatment may be higher dose than normal, for sedation Maintenance is a long-term process High rates of nonadherence Psychotherapy is essential component of therapy

Answer 60

**First-generation antipsychotics:** - Includes phenothiazines and non-phenothiazines - Effective but with many adverse effects - Neuroleptic –term given to CNS drug that can cause Parkinson-like symptoms - Typical **Second-generation antipsychotics**: - Fewer adverse effects, much better adherence - Better for managing negative symptoms -Atypical

Answer 61

**Extrapyramidal side effects (EPS)**: - Acute dystonia –muscle spasms of back, neck and tongue at onset of treatment - Akathisia -restlessness - Pseudo-Parkinsonism (Tremors, Muscle rigidity, Stooped posture, shuffling gait) - Tardive dyskinesia (TD) –unusual tongue and face movements associated with long-term use **Neuroleptic Malignant Syndrome (NMS)**: - High fever, diaphoresis - Muscle rigidity - Tachycardia, blood pressure fluctuations - Treat with muscle relaxants, antipyretics

Answer 62

Dystonic movement result from a slow sustained muscular spasm that lead to an involuntary movement. Can involve neck, jaw, tongue & entire body (opisthotonus) There is also involvement of eyes leading to upward lateral movement of known as occulogyric crisis.

Answer 63

A subjective feeling of muscular discomfort that can cause patients to be agitated, restless, and feel generally dysphoric. Treated with propanolol, benzodiazepines, and clonidine.

Answer 64

It is a delayed one with abnormal , irregular movements of the muscles of the head , limb & trunk. Characterized by chewing ,sucking , grimacing and perioral movements.

Answer 65

Rare but serious Onset is often in first 10 days of treatment. Rapid onset of severe motor, mental & autonomic disorders. Prominent muscular symptom is muscular tonicity. Stiffness of the muscles in throat & chest may cause dysphasia & dyspnea.

Answer 66

**Phenothiazines**: - Similar potency, efficacy and range of adverse effects within class - Indicated for use as anti-emetic, for Tourette’s syndrome - Effective for positive symptoms **Non-phenothiazines**: - Similar potency and efficacy to phenothiazines - Produce less sedation and anticholinergic effects than phenothiazines but more EPS

Answer 67

Have become drug of choice for severe mental illness Diverse group of drugs with little in common All have lower incidence of adverse effects (especially EPS) than first-generation drugs Able to address negative symptoms as well as positive symptoms Eg) aripiprazole (Abilify), clozapine (Clozaril), olanzapine (Zyprexa), paliperidone (Invega), quetiapine (Seroquel), risperidone (Risperdal)

Answer 68

Substance Abuse / Substance Use Disorder: - Self-administration of a drug in a manner that does not conform to the norms within a user’s culture or society - Can be challenging to identify, especially with substances that are legally available Some substances are addictive, and create intense, overwhelming cravings for user to repeatedly use drug despite risks to health and relationships

Answer 69

Craving despite knowing the substance is lowering the client’s quality of life Failure to maintain normal relationships Tolerance to effects of a particular drug Recognition of withdrawal symptoms when drug is discontinued Repeated, unsuccessful attempts to discontinue Increased time used to seek or use drug

Answer 70

Many factors contribute to development of drug addiction Agent-or drug-related factors: - Cost, availability, dose, mode of administration, time to onset, duration of action, length of drug use User-related factors: - Genetic factors, propensity for risk-taking behaviours, prior experience with drugs, health condition that requires use of a drug with potential for abuse Environmental factors: - Social and community norms, role models, peer influences, educational opportunities

Answer 71

Physical: - Physiological change to nervous system in response to repeated use of drug; withdrawal symptoms occur if drug discontinued Psychological: - Overwhelming desire to seek out and use drug but does not suffer any physical consequences when drug is discontinued

Answer 72

Refers to signs and symptoms experienced by physically dependent user when drug is discontinued Signs and symptoms are transient and dissipate as more time passes from last usage Signs and symptoms are often opposite to effects attributed to use of drug Withdrawal syndrome is different depending on drug of abuse

Answer 73

Tolerance does not occur in all brain regions equally **Cross-tolerance**: – Occurs when tolerance to one drug causes tolerance to a second, structurally similar drug Tolerance is not the same as “resistance” or “immunity”

Answer 74

- Group of Drugs that cause client to feel sedated, relaxed - Controlled under CDSA due to their addictive potential Eg) Sedatives, Opioids, Ethyl Alcohol (Ethanol, relaxation, sedation, memory impairment, loss of coordination, flushed skin)

Answer 75

Most frequently used class of addictive substances, derived from Cannabis sativa THC is responsible for most of the psychoactive properties in cannabinoids Eg) Marijuana, Hashish (Decreased coordination, disconnected thoughts, paranoia, euphoria, blood shot eyes) Physiological dependence ONLY

Answer 76

Produce an altered, dream-like state of consciousness - All are schedule 1 drugs, no medical use Prototype substance is LSD Eg) LSD, MMDA, PCP, Ketamine Signs: - Laughter - Visions - Deep personal insights - Religious revelations - Afterimages - Bright lights - Vivi colours Tolerance ONLY

Answer 77

Amphetamines, Caffeine Eg) Cocaine, Adderall/Ritalin Increase the activity of the CNS Physical dependence, psychological dependence, tolerance = yes Symptoms: - Increased BP & RR - Euphoria - Alertness - Confidence - Restlessness - Anxiety

Answer 78

Strongly addictive, highly carcinogenic Can cause effects to those nearby Some effects similar to CNS stimulants Physical/psychological dependence, tolerance Symptoms: - Increased alertness and focus - relaxation - lightheadedness - Increased HR and BP

Answer 79

Vaporize or form a gas at room temp Usually placed in paper/plastic bag or soaked in cloth and inhaled Some can be easily found Tolerance = unknown Symptoms: - Lightheadedness - Drowsiness - Exhilaration - Euphoria Eg) Adhesives and glues, cleaning agents, fuels, nitrous oxide

Answer 80

Unlike other substances, effects may be delayed for weeks, months Provide a boost in athletic performance, similar to testosterone Long-term effects can cause the opposite No tolerance or dependence

Answer 81

Generally mental illness first: - Heredity - Biological factors Self-medicating Substance abuse first: - Brain chemistry altered - Guilt, depression, altered self-esteem Personality disorders Eg) Axis I Schizophrenia: Alcohol abuse Axis I Major depression: Anxiolytic dependency Axis I Major Depression: Marijuana abuse

Answer 82

Establish therapeutic alliance Help patient evaluate costs and benefits of continued substance abuse Individualize goals for change; include harm reduction as alternative to abstinence Help build an environment and lifestyle supportive of abstinence Acknowledge recovery long-term process

Answer 83

Liver is the largest internal organ & largest gland in the human body. Liver is at the epicenter of intermediary metabolism , performs versatile & massive biochemical pathways and destroys bacteria, inactivate antigens, detoxify harmful chemicals. Surgery and anesthesia impact hepatic function primarily due to their impact on hepatic blood flow and not primarily as a result of the medications or anesthetic technique utilized

Answer 84

Liver Gallbladder Left and Right hepatic ducts: - Come together to form the common hepatic duct Cystic Duct: - Extends to gallbladder Common Bile Duct: - Formed by the union of the common hepatic duct and cystic duct

Answer 85

Intermediary metabolism: carbohydrates, bile, lipids, proteins - Coagulation - Heme metabolism - Bilirubin metabolism - Storage - Endocrine functions - Immune & inflammatory response - Blood reservoir

Answer 86

Liver is an important homeostatic regulator of blood glucose. It can either produce glucose or store glucose In fed state-polymerize glucose to glycogen In unfed state-depolymerize glycogen to glucose

Answer 87

**Aspartate aminotransferase (AST):** -Normal Range: 8-33 U/L - Marker of hepatocellular damage - High serum levels are observed in = Chronic hepatitis, cirrhosis and liver cancer **Alanine aminotransferase (ALT):** - More liver-specific than AST - Normal range 7 –56 U/L - High serum levels in acute hepatitis (300-1000U/L) - Moderate elevation in alcoholic hepatitis (100-300U/L) - Minor elevation in cirrhosis, hepatitis C and non-alcoholic steatohepatitis (NASH) (60-100U/L) - Appears in plasma many days before clinical signs appear - A normal value does not always indicate absence of liver damage - Obese but otherwise normal individuals may have elevated ALT levels **Alkaline Phosphatase (ALP):** - A non-specific marker of liver disease - Produced by bone osteoblasts (for bone calcification) - Present on hepatocyte membrane - Normal range: 44 –147 U/L - Moderate elevation observed in: - Infective hepatitis, alcoholic hepatitis and hepatocellular carcinoma - High levels are observed in: - Extrahepatic obstruction (obstructive jaundice) and intrahepatic cholestasis - Very high levels are observed in: - Bone diseases **Gamma-glutamyltransferase (GGT):** - Used for glutathione synthesis - Normal range: <50 U/L - Moderate elevation observed in: - Infective hepatitis and prostate cancers - GGT is increased in alcoholics despite normal liver function tests - Highly sensitive to detecting alcohol abuse

Answer 88

Measures of liver cell failure; production: - Low serum albumin - Prolonged prothrombin time (PT) (synthetic function) Ultrasonography, CT scans, and MRI: evaluate liver structures Angiography: visualizes the hepatic or portal circulation Liver biopsy: used to obtain tissue specimens for microscopic examination

Answer 89

The liver produces approximately 500 to 600 mL of yellow-green bile daily. **Cholestasis** represents a decrease in bile flow through the intrahepatic canaliculi and a reduction in secretion of water, bilirubin, and bile acids by the hepatocytes

Answer 90

Excessive destruction of red blood cells Impaired uptake of bilirubin by the liver cells Decreased conjugation of bilirubin Obstruction of bile flow in the canaliculi of the hepatic lobules or in the intrahepatic or extrahepatic bile ducts Main cause = Hyperbilirubinemia (Increase in Bilirubin)

Answer 91

**Prehepatic:** - Major cause is excessive hemolysis of red blood cells. - Unconjugated bilirubin - Arising from the blood before it enters the liver **Intrahepatic:** - Caused by disorders that directly affect the ability of the liver to remove bilirubin from the blood or conjugate it so it can be eliminated in the bile - Due to disease of liver parenchyma - Conjugated bilirubin **Posthepatic:** - Occurs when bile flow is obstructed between the liver and the intestine (biliary tree) - Conjugated bilirubin

Answer 92

Fever Leukocytosis Hypotension - Ascending cholangitis Asterixis (Flapping tremor) Confusion Stupor - Severe hepatocellular dysfunction - Fulminant hepatocellular failure

Answer 93

ACUTE: - Sudden and severe loss of liver function - Typically occurring within days or weeks - Often in individuals without a history of liver disease CHRONIC: - Long term progressive decline in liver function - Usually as a result of chronic liver disease - Often leading to cirrhosis (scarring of liver)

Answer 94

Chronic disease characterized by replacement of normal liver tissue with diffuse fibrosis that disrupts the structure and function of the liver. 3 types of cirrhosis: 1) **Alcoholic cirrhosis** = scar tissue characteristically surrounds the portal areas. This is most frequently due to chronic alcoholism and is the MOST COMMON type of cirrhosis. 2) **Post necrotic cirrhosis** = there are broad bands of scar tissue as a late result of a previous bout of acute viral hepatitis. (eg, hepatitis A, B, C, D, or E) 3) **Biliary cirrhosis** = scarring occurs in the liver around the bile ducts. This type usually is the result of chronic biliary obstruction and infection; it is **much less common than the other two types**

Answer 95

Although several factors have been implicated in the etiology of cirrhosis, **alcohol consumption is considered the major causative factor.** Cirrhosis occurs with greatest frequency among alcoholics Nutritional deficiency with reduced protein intake contributes to liver destruction in cirrhosis as well Other factors: - Exposure to certain chemicals or infections Twice as many men as women are affected. Most patients are between 40 and 60 years of age.

Answer 96

Weight loss (sometimes masked by ascites) Weakness Anorexia Diarrhea or constipation Hepatomegaly Jaundice Abdominal pain Portal hypertension: - Ascites - Esophageal varices - Splenomegaly Physical Findings: - Spider angioma - Finger clubbing - Gynecomastia - Palmar erythmia - Skin pigmentation - Xanthoma - Caput medusae (cluster of swollen veins in abdomen)

Answer 97

Occurs when blood flow through the liver is obstructed, leading to a buildup of pressure in the portal vein (which carries blood from the digestive organs to the liver) **Ascites:** - a buildup of fluid in the abdomen, which is a common complication of cirrhosis, **the most frequent cause of portal HTN** - Paracentesis is performed **Esophageal varices:** - Dilated submucosal distal esophageal veins connecting the portal and systemic circulations **Splenomegaly:** - Increased pressure in the portal vein (which carries blood from the digestive organs to the liver) can cause the spleen to enlarge due to blood congestion and increased splenic blood flow

Answer 98

The extent of liver disease and the type of treatment are determined after reviewing the laboratory findings. Because the functions of the liver are complex, there are many diagnostic tests that may provide information about liver function. Bilirubin tests are performed to measure bile excretion or bile retention; elevated levels can occur with cirrhosis and other liver disorders. Prothrombin time is prolonged. Ultrasound scanning is used to measure the difference in density of parenchymal cells and scar tissue. CT, MRI, and radioisotope liver scans give information about liver size and hepatic blood flow and obstruction. Diagnosis is confirmed by liver biopsy.

Answer 99

Usually based on the presenting symptoms. Eg) antacids are prescribed to decrease gastric distress and minimize the possibility of GI bleeding. Vitamins and nutritional supplements promote healing of damaged liver cells and improve the general nutritional status. Potassium-sparing diuretics (spironolactone) may be indicated to decrease ascites, if present.

Answer 100

Eliminating alcohol intake when the condition is caused by alcoholic cirrhosis Preventing infections Providing sufficient carbohydrates and calories to prevent protein breakdown Correcting fluid and electrolyte imbalances Decreasing ammonia production in the gastrointestinal tract by controlling protein intake Liver transplantation

Answer 101

Inflammation of the liver that is caused by a variety of infectious viruses and noninfectious agents leading to a range of health problems, some of which can be fatal. 5 main strains of the hepatitis virus: - A, B, C, D and E They differ in important ways including modes of transmission, severity of the illness, geographical distribution and prevention methods. In particular, types B and C lead to chronic disease in hundreds of millions of people and together are the **most common** cause of liver cirrhosis, liver cancer and viral hepatitis-related deaths.

Answer 102

The acute illness usually subsides gradually over a 2-12-week period, with complete clinical recovery in 1 to 4 months depending on the type of hepatitis. **Prodromal or preicterus period:** S&S = general malaise, myalgia, arthralgia, lethargy, and anorexia, N/V,diarrhea/ constipation - RUQ pain, pruritus - Chills and fever - AST and ALT increase **Icterus period:** - Follows the prodromal phase by 1 to 2 weeks. - Jaundice is less likely to occur with HCV infection. - Rise in bilirubin- Severe pruritus and liver tenderness **Convalescent period:** - Return of appetite, and disappearance of jaundice. - **Carrier state:** - Infection with HBV and HCV can produce a carrier state

Answer 103

ACUTE: - Incubation = several weeks - "Flue like symptoms - Jaundice, enlarged, painful liver - Marked elevations in LFTs - Resolves spontaneously CHRONIC: - Often asymptomatic - Physical exam can show signs of portal HTN or liver inflammation - LFTs can be normal or elevated - Persists for years or decades

Answer 104

Autoimmune disorders Reactions to drugs and toxins Infectious disorders: - Malaria, infectious mononucleosis, salmonellosis, and amebiasis Hepatotropic viruses that primarily affect liver cells or hepatocytes: - Direct cellular injury and induction of immune responses against the viral antigens

Answer 105

Those at higher risk for HCV include individuals who: - Inject drugs - Have been incarcerated - Blood transfusion, organ transplant prior to 1992, in Canada - Have travelled or resided in endemic regions

Answer 106

LOCAL: - Loss of sensation to limited body area - No LOC changes - Few adverse effects and risks compared to general Eg) Carpals GENERAL: - Loss of sensation throughout whole body - Loss of consciousness REGIONAL: - Similar to local but affects larger area Eg) spinal/epidural Monitored Anesthesia Care (MAC): - Uses sedatives, analgesics or low dose drugs - Allows client to breathe without assistance - Used during diagnostic procedures, minor surgeries

Answer 107

Topical Infiltration: - Injection close to intended site of action (carpals) Nerve Block: - Injection distant to intended site of action, affecting larger tissue area Epidural: - Injection into space superficial to dura mater Spinal: - Injection into the cerebrospinal fluid

Answer 108

MOA: - Prevents conduction of action potentials by blocking sodium channels - Affects both sensory and motor neurons Pharm: - Onset and duration of drug action can be difficult to control - Onset depends on drug's ability to diffuse in tissues to surrounding nerves - Termination depends on blood flow to region - Epinephrine (vasoconstrictor) is sometimes given to extend duration of anesthetic by reducing perfusion of tissue - NaOH (Alkaline agent) sometimes given to raise pH of tissue (locals are less effective in acidic pH), pH of tissue can be more acidic during bacterial infections

Answer 109

**Benzocaine is most commonly used agent**: - Sunburns, insect bites, hemorrhoids MOA – prevent conduction of action potential along affected neurons by blocking sodium channels Metabolized by plasma esterases Adverse effects are uncommon - Skin rashes, urticarial (hives)

Answer 110

MOA – prevent conduction of action potential along affected neurons by blocking sodium channels Metabolized in liver by CYP450 enzymes Adverse Effects: - Lower incidence of adverse effects including allergic reactions compared to esters

Answer 111

Balanced anesthesia refers to achieving surgical anesthesia using several classes of medications including - Neuromuscular blockers - Short-acting benzodiazepines - Opioids - General anesthetics

Answer 112

Stage1 = Analgesia - Client is awake but has no sensations Stage 2 = Excitement/Hyperactivity - Client may become delirious, BP may increase, RR & HR may be irregular Stage 3 = Surgical - Skeletal muscles relax, stable BP and RR Stage 4 = Medullary Paralysis - Centres that control respiratory and cardiovascular activity do no function

Answer 113

Indication: - Maintain surgical anesthesia following administration of IV agents MOA – thought to stimulate GABA receptors in brain, depressing activity of neurons Classes: - Gas – nitrous oxide - Volatile Liquids – halothane, isoflurane, desflurane, sevoflurane (Liquids that vaporize at low temps and pressures. Anesthetic machine delivers precise controlled amounts, Typically depresses CV and Resp function, can increase sensitivity of heart to catecholamines = dysrhythmias)

Answer 114

Often used in combination with inhaled anesthetics so that doses can be reduced, to minimize risk of adverse effects Provide better muscle relaxation and analgesia than inhaled agents Can be used independently for short procedures Eg) benzodiazepines, opioids and barbiturates, as well as other agents (propofol, ketamine)

Answer 115

Purpose of adjuncts is to enhance anesthesia, or to minimize potential adverse effects of anesthesia in pre- and post-operative conditions Pre-operative medications - Reduce anxiety (sedatives) - Reduce gastric acid, salivary and airway secretions (anticholinergics) Intraoperative medications: - Reduce pain (analgesics – opioids) -Increase muscle relaxation (neuromuscular blocking agents); promote flaccid paralysis (Depolarizing & Non-depolarizing) Post-operative medications - Antiemetics (5HT receptor antagonists) - Increase GI motility (cholinergic agents)

Answer 116

Depolarizing Agents (Eg succinylcholine): - Bind Ach receptors at neuromuscular junction (NMJ) causing muscle fasciculations (result of depolarization) - Skeletal muscles do not repolarize resulting in flaccid paralysis - Rapidly metabolized by pseudocholin-esterase thus duration of action is short Non-depolarizing Agents (Eg pancuronium): - Binds Ach receptors at NMJ but does not depolarize leading to flaccid paralysis

Final Exam Flashcards

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