This document provides an outline on depression, antidepressant drugs, and related nursing care. It discusses types of depression like major depressive disorder and dysthymic disorder. It then covers the four main classes of antidepressant drugs - SSRIs, TCAs, atypical antidepressants, and MAOIs. For each drug class, it discusses mechanisms of action, indications, dosages, drug interactions, side effects, and relevant nursing considerations. The document aims to inform nurses on properly assessing, treating and caring for patients taking antidepressants.
depression ,symptoms, mechanism of depression ,classification of antidepressants , tri cyclic anti depressants and its pharmacological actions ,acute poisoning and treatment
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The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and offering a wide range of dental certified courses in different formats.
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The average cost of treatment has been rising across the board, creating additional financial burdens to governments, healthcare providers and insurance companies. According to MCG, cost-per-inpatient-stay in the United States alone rose on average annually by over 13% between 2014 to 2021, leading MedTech to focus research efforts on optimized medical equipment at lower price points, whilst emphasizing portability and ease of use. Namely, 46% of the 1,008 medical technology companies in the 2021 MedTech Innovator (“MTI”) database are focusing on prevention, wellness, detection, or diagnosis, signaling a clear push for preventive care to also tackle costs.
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Antibiotic Stewardship by Anushri Srivastava.pptxAnushriSrivastav
Stewardship is the act of taking good care of something.
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
WHO launched the Global Antimicrobial Resistance and Use Surveillance System (GLASS) in 2015 to fill knowledge gaps and inform strategies at all levels.
ACCORDING TO apic.org,
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
ACCORDING TO pewtrusts.org,
Antibiotic stewardship refers to efforts in doctors’ offices, hospitals, long term care facilities, and other health care settings to ensure that antibiotics are used only when necessary and appropriate
According to WHO,
Antimicrobial stewardship is a systematic approach to educate and support health care professionals to follow evidence-based guidelines for prescribing and administering antimicrobials
In 1996, John McGowan and Dale Gerding first applied the term antimicrobial stewardship, where they suggested a causal association between antimicrobial agent use and resistance. They also focused on the urgency of large-scale controlled trials of antimicrobial-use regulation employing sophisticated epidemiologic methods, molecular typing, and precise resistance mechanism analysis.
Antimicrobial Stewardship(AMS) refers to the optimal selection, dosing, and duration of antimicrobial treatment resulting in the best clinical outcome with minimal side effects to the patients and minimal impact on subsequent resistance.
According to the 2019 report, in the US, more than 2.8 million antibiotic-resistant infections occur each year, and more than 35000 people die. In addition to this, it also mentioned that 223,900 cases of Clostridoides difficile occurred in 2017, of which 12800 people died. The report did not include viruses or parasites
VISION
Being proactive
Supporting optimal animal and human health
Exploring ways to reduce overall use of antimicrobials
Using the drugs that prevent and treat disease by killing microscopic organisms in a responsible way
GOAL
to prevent the generation and spread of antimicrobial resistance (AMR). Doing so will preserve the effectiveness of these drugs in animals and humans for years to come.
being to preserve human and animal health and the effectiveness of antimicrobial medications.
to implement a multidisciplinary approach in assembling a stewardship team to include an infectious disease physician, a clinical pharmacist with infectious diseases training, infection preventionist, and a close collaboration with the staff in the clinical microbiology laboratory
to prevent antimicrobial overuse, misuse and abuse.
to minimize the developme
Defecation
Normal defecation begins with movement in the left colon, moving stool toward the anus. When stool reaches the rectum, the distention causes relaxation of the internal sphincter and an awareness of the need to defecate. At the time of defecation, the external sphincter relaxes, and abdominal muscles contract, increasing intrarectal pressure and forcing the stool out
The Valsalva maneuver exerts pressure to expel faeces through a voluntary contraction of the abdominal muscles while maintaining forced expiration against a closed airway. Patients with cardiovascular disease, glaucoma, increased intracranial pressure, or a new surgical wound are at greater risk for cardiac dysrhythmias and elevated blood pressure with the Valsalva maneuver and need to avoid straining to pass the stool.
Normal defecation is painless, resulting in passage of soft, formed stool
CONSTIPATION
Constipation is a symptom, not a disease. Improper diet, reduced fluid intake, lack of exercise, and certain medications can cause constipation. For example, patients receiving opiates for pain after surgery often require a stool softener or laxative to prevent constipation. The signs of constipation include infrequent bowel movements (less than every 3 days), difficulty passing stools, excessive straining, inability to defecate at will, and hard feaces
IMPACTION
Fecal impaction results from unrelieved constipation. It is a collection of hardened feces wedged in the rectum that a person cannot expel. In cases of severe impaction the mass extends up into the sigmoid colon.
DIARRHEA
Diarrhea is an increase in the number of stools and the passage of liquid, unformed feces. It is associated with disorders affecting digestion, absorption, and secretion in the GI tract. Intestinal contents pass through the small and large intestine too quickly to allow for the usual absorption of fluid and nutrients. Irritation within the colon results in increased mucus secretion. As a result, feces become watery, and the patient is unable to control the urge to defecate. Normally an anal bag is safe and effective in long-term treatment of patients with fecal incontinence at home, in hospice, or in the hospital. Fecal incontinence is expensive and a potentially dangerous condition in terms of contamination and risk of skin ulceration
HEMORRHOIDS
Hemorrhoids are dilated, engorged veins in the lining of the rectum. They are either external or internal.
FLATULENCE
As gas accumulates in the lumen of the intestines, the bowel wall stretches and distends (flatulence). It is a common cause of abdominal fullness, pain, and cramping. Normally intestinal gas escapes through the mouth (belching) or the anus (passing of flatus)
FECAL INCONTINENCE
Fecal incontinence is the inability to control passage of feces and gas from the anus. Incontinence harms a patient’s body image
PREPARATION AND GIVING OF LAXATIVESACCORDING TO POTTER AND PERRY,
An enema is the instillation of a solution into the rectum and sig
R3 Stem Cells and Kidney Repair A New Horizon in Nephrology.pptxR3 Stem Cell
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One of the most developed cities of India, the city of Chennai is the capital of Tamilnadu and many people from different parts of India come here to earn their bread and butter. Being a metropolitan, the city is filled with towering building and beaches but the sad part as with almost every Indian city
1. Presented by :
Mohammad Al-oran
Mohammad Awad
Moussa Abo-Tabeekh
Ala’a Salem
Supervision by :
Dr.Ahmad Rayan
2. Outline :
Depression :
Type
Signs & Symptoms
Treatment
Anti-depressant drug :
Definition
Classification
Doses
Mechanism of action
Indication
Contra-indication
Side effect
Nursing intervention
Nursing care
Nursing diagnosis
Summery
References
3. **Mood : is prolonged emotional state that influences
the person's whole personality and life functioning
**Grief : is the subjective state that follows loss
** anxiety (sense of fear and intense worry) is other
mood accompanies
4. - Depression :is a type of mental disorder that
affects a person's mood
- it is a pathological grief reaction know as
melancholia
- -It is abnormal extension of sadness and
grief
- depression and anxiety may show diurnal
variation , certain time of the day
4
5. Major depressive disorder (unipolar depression)
requires at least 2 weeks of depression/loss of interest
and 4 additional depressive symptoms, with one or
more major depressive episodes.
Dysthymic disorder (Persistent Depression )
is an ongoing low-grade depression of at least 2
years’ duration for more days than not and does not
meet the criteria for major depression.
Symptoms in the major and dythymia is the same the
different in severity and duration.
6. anger , anxiety , apathy, helplessness , hopelessness,
low self-esteem , overeating , sleep disturbances ,
nausea, vomiting , weight changes , confusion ,
lack of concentration , loss of interest and
motivation , self-blame
6
10. Mechanism of action
Inhibit serotonin reuptake so increase synaptic
serotonin levels
Many SSRIs affect other receptors especially at high
doses
Clinical effect usually takes weeks so mechanism
goes beyond simply increasing synaptic serotonin
levels
Several serotonin (5-HT) receptor subtypes
Serotonin receptors are located throughout the body
(especially GI tract)
11.
12. Indications & off-label uses
Various class members also approved to treat:
generalized anxiety , Obsessive Compulsive Disorder
(OCD), panic , Posttraumatic stress disorder PTSD,
eating disorders, social anxiety
Off-label uses: Attention deficit-hyperactivity
disorder ADHD, insomnia, chronic pain syndromes,
seasonal affective , behavioral problems in
individuals with dementia and mental retardation, …
other uses
13. Half-life
Short: paroxetine & fluvoxamine (missed doses can
result in uncomfortable symptoms)
Moderate: sertraline, citalopram, escitalopram
Long: fluoxetine (good for people who may miss
doses)
14. Decreased sex drive and impaired sexual function tend
not to resolve with time
Nausea, diarrhea, anorexia, vomiting
- all increase with dose and can resolve with time
Weight gain (esp. paroxetine) after initial GI effects
Headache, dizziness, anxiety (esp. fluoxetine), rash,
insomnia, sedation, sweating, vivid dreams, tremor, dry
mouth (esp. paroxetine), bruising, ↑ prolactin
15. RouteUsual Adult Daily
Dose(mg/day)
Generic name (Trade
Name)
PO
PO
PO
PO
PO
PO
20-40
10-20
20-60
100-200
20-60
50-200
Selective serotonin
reuptake
inhibitors(SSRIs)
** Citalopram (Celexa)
Escitalopram (Lexapro)
** Floxetine (Prozac)
** Fluvoxamine ( Luvox
Paroxetine (Paxil)
Sertraline (Zoloft)
** venlafaxine (effexor)
15
16. 1. Citalopram and paroxetine with warfarin may lead to
increased bleeding
2. Citalopram may be excreted more rapidly with
carbamazepine
3. Fluoxetine increases the half-life of diazepam
4. Fluvoxamine with diltiazem may cause bradycardia
5. Paroxetine metabolism may be decreased by
cimetidine, phenobarbital, and phenytoin
6. Paroxetine shouldn’t be used with tryptophan because
headache, nausea, sweating and dizziness may occur.
Note :
Always check all medications that the patient is taking and notify the
practitioner of any possible interactions.
16
17. 1. Provide comfort measures for the patient so they can
tolerate the adverse effects.
2. Administer the medication in the morning to help prevent
insomnia.
3. Encourage the patient to change position slowly to help
prevent orthostatic hypotension.
4. Teach the patient about the risks of abruptly stopping
their medication. Encourage them to take the medication as
ordered.
17
19. Mechanism of action :
Serotonin, histamine, muscarinic (cholinergic)
and α-adrenergic receptor activity although in
differing ratios
Anticholinergic activity leads to many of the
side effects of these drugs
20. Indications & off-label uses for TCAs
Depression and similar spectrum of disorders as SSRIs
Especially helpful with chronic pain and depression
secondary to medical conditions such as AIDS
enuresis, narcolepsy, premature ejaculation,
insomnia, migraine prophylaxis
Blood levels: May be obtained to monitor dose
effectiveness
21. Drug-drug interactions (DDI) :
Multiple significant interactions in each direction with potentially
serious consequences
Side effects (SE) :
Anticholinergic SE include: dry mouth, constipation, blurred
vision and urinary retention
Cardiac arrhythmias and conduction changes
Orthostatic hypotension
Sedation
Weight gain
urinary retention and sever constipation
Cautions :
Overdose is frequently fatal
Pts with bipolar d/o may be pushed into mania or rapid cycling
22. Patient received MAOIs should wait 2-3 weeks
before starting TCAs becaused MOAIs slowly
excreted from the body
- Enlarge prostate and glucoma
- Epileptic client
- Cardiovascular disorder and recent myocardial
infarction
- CNS depressant as phenothiazenes , barbitural,
alcohol , anticholinergic agents
- Pregnancy and lactaion
24. 1. TCAs taken with amphetamines and
sympathomimetics may cause hypertension.
2. TCA metabolism is increased when taken with
barbiturates.
3. TCA metabolism is decreased when taken with
cimetidine.
4. TCAs taken with anticholinergics increase adverse
effects such as dry mouth, constipation, and urine
retention.
5 .TCAs decrease the antihypertensive effects of
clonidine.
24
25. 1. If the patient has diabetes, or is on an oral hypoglycemic
agent carefully monitor their glucose level; it may be altered
by the TCA.
2. Give the patient ice chips, hard candy, or sugarless gum to
help relieve their dry mouth.
3. Carefully monitor the patient’s blood pressure before,
during, and after therapy.
4. Tell the patient to avoid exposure to sunlight or artificial
ultraviolet light because of the risk of photosensitivity
reactions.
5. TCAs can be lethal when taken in large doses- carefully
monitor a suicidal patient and make sure they aren’t hoarding
the pills for a suicide attempt.
25
27. Mechanism of action :
Atypical antidepressants ease depression by
affecting chemical messengers
(neurotransmitters) used to communicate
between brain cells. Most antidepressants work
by changing the levels of one or more of these
naturally occurring brain chemicals.
Atypical antidepressants affect neurotransmitters
including dopamine, serotonin and
norepinephrine . Changing the balance of these
chemicals seems to help brain cells send and
receive messages, which in turn boosts mood.
27
Atypical antidepressants
28. Mechanism of action
venlafaxine and duloxetine are both serotonin and
norepinepherine reuptake inhibitors- “SNRIs”
mirtazapine has serotonin subtype & norepinephrine
activity
trazodone, nefazodone have different serotonin
activity than SSRIs
bupropion has dopamine and norepinephrine activity
28
29. Indications & off-label uses
All have FDA approval to treat depression
SNRIs shown effective in chronic neuropathic pain
(pain produced by normally non-painful stimuli )
Nicotine addiction (bupropion)
Insomnia (mirtazepine, trazodone)
Many similar uses to SSRIs
bupropion, mirtazepine, trazodone & nefazodone do
not usually have associated sexual dysfunction
29
30. Venlafaxine (Effexor)
Similar to TCAs with less safety
& side effect concerns
FDA approval for depression and
generalized anxiety & social
anxiety
SNRI- activity depends on dose
Minimal DDI
SE with missed doses
dose is 75 mg per day
maximum of 375 mg per day
30
31. Mirtazapine (Remeron, Avanza, Zispin)
Complex serotonin, NE (α2) & histamine
activity
Receptor activity changes with changes in
dose
Sedation & weight gain especially at lower
dose
Lipid abnormalities
Minimal DDIs (except MAOIs)
Avoid alcohol while taking Remeron as it can
worsen these side effects.
starting dose is 15 (mg) once a day taken as a
single dose,
may increase the dose up to 45 mg once a day
31
32. Nefazodone (Serzone, Nefadar)
Rarely used due to irreversible liver
toxicity
Pulled from market by initial
manufacturer in 2004 although still
available as generic
Still popular with some patients
start at 100 mg twice daily (200
mg/day) to a maximum of 600
mg/day (300 mg twice daily),
Food and Drug Administration
(FDA) regulations
32
33. Trazodone (Desyrel)
- Sedation, weight gain, low blood
pressure
- Used most commonly (off label) for
insomnia.
Rare reports of sustained painful
erection (priapism) that should be
treated in ER (can lead to
impotence)
starting dose is 150 (mg) per day in
divided doses
increase the dose by 50 mg per day
every 3 to 4 days if needed. The
maximum daily dose should not
exceed 400 mg per day.
33
34. Bupropion (Welibutrin)
-NE, dopamine reuptake inhibition
- Zyban to toxic smoking addiction
- Seizure risk in certain patients (↑
risk at ↑ dose)
Potential DDIs not often significant
(except MAOIs)
starting dose is 200 (mg) a day, taken
as 100 mg twice a day. 300 mg a day,
taken as 100 mg three times a day.
The maximum daily dose is 450 mg.
Taking doses greater than 450 mg a
day may increase the risk of serious
side effects, including seizures.
34
35. Duloxetine (Cymbalta )
- SNRI profile minimally dose
dependent
- Indicated for depression & chronic
neuropathic pain
The recommended dose is 60
milligrams (mg) once a day. A lower
starting dose of 30 mg once a day
for 1 week may be desirable for
some patients.
35
37. Monoamine Oxidase Inhibitors
Monoamine oxidase inhibitors (MAOIs) were the first
type of antidepressant developed. They're effective,
but have generally been replaced by antidepressants
that are safer and cause fewer side effects. MAOIs
generally require diet restrictions because they can
cause dangerously high blood pressure when taken
with certain foods.
In spite of side effects, these medications are still a
good option for some people. In certain cases, they
relieve depression when other treatments have
failed.
38. Tyramine is a naturally occurring amino acid that
forms from the breakdown of protein in food.
Though tyramine helps regulate blood pressure, it
can also affect the human body in many different
negative ways.
What is tyramine?
39. Antidepressants such as MAOIs ease
depression by affecting chemical messengers
(neurotransmitters) used to communicate
between brain cells.
Most antidepressants work by changing the
levels of one or more of these naturally
occurring brain chemicals.
How MAOIs work
40. The enzyme monoamine oxidase is involved in
removing the neurotransmitters norepinephrine,
serotonin and dopamine from the brain. MAOIs
prevent this from happening, which makes more of
these brain chemicals available.
This is thought to boost mood by improving brain cell
communication. MAOIs also affect other
neurotransmitters in the brain and digestive system,
causing side effects.
41. On the other hand ,monoamine oxidase is also responsible
for the metabolism of tyramine, therefore persons who
take MAOIs can not metabolize tyramine and with the
ingestion of foods high in tyramine a hypertensive
crisis can result, as tyramine can cause the release of
stored monoamines, such as dopamine, norepinephrine
and epinephrine
Therefore, dietary restrictions are required
for patients receiving MAOIs
41
43. 43
Nursing CareSide Effect
Discontinuing of drug
immediately when physician
orders
Monitor vital signs
Administer short _ acting
antihypertensive medication
as ordered
Use external cooling
measures to control
hyperpyrexia
hypertensive crisis
Symptoms:
Severe occipital
headache , palpitation
Fever , sweating ,
increase blood pressure
,chest pain , coma
44. Contraindicated with
hypersensitivity to the drugs .
Use cautiously with impaired hepatic
or renal function, diabetes mellitus,
lactation, seizures, history of suicide
attempts.
44
45. 1. MAOIs administered with meperidine may lead to
excitation, hyper- or hypotension, hyperthermia, and
coma.
2. MAOIs and doxapram may cause hypertension and
arrhythmias.
3. MAOIs with amphetamines, methylphenidate,
levodopa, or sympathomimetics may cause a
hypertensive crisis by increasing the catecholamine
release.
4. MAOIs with fluoxetine, TCAs, citalopram,
trazodone, sertraline, paroxetine, and fluvoxamine
may cause an increased body temperature and
excitation and seizures.
45
46. 1. Closely monitor the patient’s blood pressure and
be alert for signs of hypertensive crisis.
2. Continue to monitor the patient for adverse
reactions for up to 10 days after stopping the
medication because of its long-lasting effects.
3. Teach the patient about tyramine-containing
foods and stress the importance of avoiding them.
4. Help the patient slowly change position to
minimize orthostatic hypotension.
5. Watch patient older than 60 because they are
more prone to adverse reactions.
46
47. Foods that can interact with
monoamine oxidase
inhibitors (MAOIs)
47
48. Safe foodsUnsafe foodscategory
Most vegetablesAvocados, especially if overripe
fermented bean curd
Vegetables
Most fruitsFigs, especially if overripe
Bananas ,in large amounts
fruits
Meats that are known to be
fresh
Meats that are fermented, smoked or
otherwise aged ,liver ,unless very fresh
meats
Un Fermented varietiesFermented varieties
,bologna,pepperoni,salami
Sausages
fish that are known to be
fresh
Dried or cured fish, otherwise aged ,liverfish
Milk,yogurt,cottage
cheese,cream cheese
Practically all cheesesMilk, milk products
Baked goods that contain
yeast
Yeast extract (Bovril)Food with yeast
Major domestic of beer
most wine
Some imported beers ,chianti winesBeer, wine
48
49. commentsFoods
Contains phenylethylamine ,a pressor agent, large
amount can cause a reaction
chocolate
Contains dopamine, a pressor agent, reaction are most
likely with overripe beans
Fava beans
Headache, tremulousness, mania-like reaction have
occurred
ginseng
Caffeine is a weak pressor agent, large amount may
cause a reaction
Caffeinated
beverages
food that contain other vasopressors
49
50. 1. Provide explanations of drug action and side
effects.
2. Monitor vital signs and observe for
orthostatic hypotension
3. Advise to change positions slowly
4. Administer with food or milk to avoid
gastrointestinal upset.
5. Assist with ambulation or activity requiring
mental alertness.
6. Encourage increase in fluid intake.
50
51. 7. Offer hard candy or sugarless gum for dry
mouth.
8. Assess for suicidal ideation
9. Monitor mood at frequent intervals
10. Ensure use of protective sunscreen and wear
sun glasses when outdoors (TCAs).
11. Discourage caffeinated beverages.
51
52. 1. take medication exactly as directed by
physician.
2. Not use more of the drug, use it more often, or
for a longer period than the physician ordered.
3. Take the drug for several weeks to see the
therapeutic effect.
4. Take the medication with food or milk to avoid
stomach upset.
5. Use caution when driving, operating dangerous
equipment, or engaging in activities that
require mental alertness.
6. Not mix with alcohol, or other CNS
depressants.
52
53. 7. Report any side effects to physician.
8. Not suddenly stop taking the medication, it must be
withdrawn gradually.
9. Take a missed dose as soon as possible, if several
hours have lapsed or it is nearing the time for the next
dose, the dose should not be doubled to catch up.
10. Avoid smoking when taking TCAs, smoking can
enhance the metabolism and increased dosage may be
required.
11. Wear protective sunscreen when outdoors (TCAs).
12. Rise slowly from a reclining position
53