009 Mark Klimek

The speaker discusses interpreting medical measurements like platelet counts and red blood cell counts in thousands and emphasizes memorizing high-priority values like the "five Ds" related to blood pH, potassium, CO2, O2, and platelet count. They also cover psychotropic drugs, focusing on phenothiazines and their side effects like anticholinergic effects, blurred vision, constipation, drowsiness, EPS, photosensitivity, and granulocytosis. Nursing care for side effects and the significance of the term "deconate" for long-acting injections are also highlighted. Now, you'll hear people say, he has 40 platelets, or 35 platelets. They don't mean 35. They mean 35,000. So if they say his platelet count is 3, what do they mean, 3,000? They don't mean 30. See, now the ANC means what it says, but this is usually in thousands. And then red blood cells are 4 to 6 million. Red blood cells are 4 to 6 million. And an abnormal risk count is just a B. It's no big deal. Okay, now, that's a lot of info. Here's what I want you to do with it. Memorize the five Ds. Why should you memorize the five Ds? Because those are the really high ones that if you don't know, you're unsafe, and you don't want to show that on this test. So what are the five Ds? pH in the 6s. Not like that. Okay, but there's one before that. Potassium in the, so a potassium in the 6s, a pH in the 6s. Got that? Now, what is the next one? CO2 in the 16s and an O2 in the 16s. So a pH or a potassium in the 6s or a CO2 or an O2 in the 16s. So what pattern are you seeing already? 6s and 16s. You don't lie. And then what's the fifth one? Plan a count of less than 40,000. Those are your highest priority people. Nobody will beat them. And boards will not put those people against each other. Because it's not fair. Okay, now, what I would then do is learn all the Cs. There's probably about a good 8 of them to 10 of them. Then I would not remember the priority on any of the others. Why? That way, if you don't remember them, they are what priority? Low. You see what I'm saying? So just remember the high ones and everything else is low. So remember your Ds, which I think are easy. Your 6s and 16s and the 40,000. And then your Cs and probably what to do for them. And then you're good to go. You really will be so much better prepared for the questions than anybody else in there. You know? Because everybody else is just going to watch. Yes. And say, well, potassium. And then if it's not potassium, they're dead in the water. Okay, let's turn to something near the back of the book. I want to get it done earlier because it's just a horrible lecture to do late in the day. And that is page 64, Psych Drugs. We'll do this one and then take a break. Psychotropic Drugs, page 64. This is a big laundry list of psych drugs that you have to know. But don't panic because you're going to find that psych drugs, even though the classes of drugs are different, there's a lot in common between them. And so you're not, even though you may memorize 10 different classes, there isn't going to be 10 totally different discrete pieces of information. A lot of it's going to overlap, which is nice. And to start out with showing you this, the note in the box is very important. All, how many does that mean? All. Thank you. All means all. All psych drugs cause low blood pressure and weight changes. There isn't a psych drug made today that does not lower your blood pressure and make your weight change. Now, the vast majority of psych drugs will do what to your weight? Increase. But Prozac and a couple others make you lose weight. But even Prozac makes you gain weight. In fact, you can go either weight gain or weight loss. Weight loss is more common, but you wouldn't rule out weight gain from Prozac either. So if you really wanted to make it specific, you could say all psych drugs cause low blood pressure and weight gain. But you have to understand that Prozac and a couple others will also cause weight loss. Could cause weight loss. If we just stopped right there, you'd probably do better on your psych drugs. They like to test those universal kinds of principles. But let's not do that. Let's go into the major classes more specifically. The first one are the phenothiazines. This is an old class of drug, speaking pharmacologically. They're called the first generation antipsychotics or they're called the typical antipsychotics. Have you heard those words? Typical antipsychotics. First generation antipsychotics. Those are your phenothiazines. They all end in zine. Z-I-N-E, which I love. I think every drug should be that way. I think every drug in a class should end with the same ending and it should be the ending of the name of the class of the drug. So all steroids should end in oint. All calcium channel blockers should have CAL at the beginning of the name. You know what I'm saying? All beta blockers should have beta beginning in the name. All benzodiazepines should end in zepine. You see what I'm saying? I just think that's the way it should be and it isn't. So we have to get over it. But anyhow, this class is great. They all end in zine. Like thorazine, stelazine, placetazine, hyperazine, proponazine, hydroxazine. All those zines are phenothiazines. Actions. They do not cure psych diseases. They just reduce your symptoms. In large doses, they are antipsychotics. I remember this by saying we use zine for the zany. Zine for the zany. So you see a drug ending in zine, what did you immediately think? Zany. It's for an antipsychotic for a crazy person. In small doses, they are anti-emetic. Have you ever given compazine? Have you ever given phenerganfomethazine for nausea? Have you ever given visceralhydroxazine for nausea? But if you double the dose, it will treat psychosis. Have you ever given thorazine for psychosis? If you cut the dose in half, it will treat nausea. Letter C, they are considered major tranquilizers. Major tranquilizers. These are the big guns. I'm going to make an analogy here. Aminoglycosides are to infection like phenothiazines are to psychosis. Tranquilizers. Okay? I should make it different. Aminoglycosides are to antibiotics like phenothiazines are to tranquilizers. What's that mean? They're both the big guns. You pull these out when nothing else is going to work. Okay, these major, major tranquilizers have a major, major side effect list. In fact, this has been the marketing dilemma manufacturers of these drugs have had for decades. They manufacture these drugs that really work well, but they have this long list of side effects that really hinders their marketability. I'm going to use the alphabet here to help you remember the side effects of the major tranquilizers. A will stand for anticholinergic. Primarily drying out. Anticholinergic, dry mouth. B stands for blurred vision. C stands for constipation. D stands for drowsiness. Anybody know what E stands for? EPS, extrapyramidal syndrome. The thing that looks like Parkinson's. Extrapyramidal syndrome, EPS, like Parkinson's. Remember where they get the pill rolling and the cogwheel rigidity and the shuffling gait and all that? F, I cheated. I needed the F. Photosensitivity, I know it's above the pH, but I needed the F to work for me. So, photosensitivity. And then with the G, I want you to put a little A in front of the G and write A. Granulocytosis, which means low life count. So, they have a dry mouth, they have blurred vision, they have constipation, they have drowsiness, they have the Parkinson's, extrapyramidal, their skin burns, polite photosensitivity, and they're immunosuppressed. So, that's the side effects of... Now, those are all side effects, not toxic effects. What do you do when a patient displays a side effect? What's the nursing action when a patient displays a side effect? Do you hold the drug? No. You teach the patient, inform the doctor, and keep giving the pill. When someone experiences a toxic effect, what's the nursing action? Hold the drug, call the doctor immediately. So, for EPS, would you call the doctor immediately and hold the drug? No, we have Parkinson's drugs like Cogentin and Artane, we'll give to them. To treat the EPS? The only problem is when you give Parkinson's drugs to treat the EPS, do you know what two of their major side effects are? Dry mouth and constipation. So, that gets worse, but it's kind of a thing. Alright, number five. The nursing care is treating the side effects. So, what's the number one nursing diagnosis? Well, they have blurred vision. What's the number one nursing diagnosis related to blurred vision? Injuries, risk for injury, safety, right? Drownsiness, what's the number one nursing diagnosis with that? Same thing. Extrapyramidal, what's the number one diagnosis there? Same thing. So, what is the number one nursing diagnosis when a client is on a major tranquilizer? Risk for injury, safety issues. Number six is a vocabulary word. I want you to know what the word deconate means. Deconate can come after the name of a lot of different drugs. Sometimes they'll abbreviate it. They'll say Thorazine D or something D. The D means deconate. And what deconate means is after the name of a drug, it means it is a long-acting, long-acting. Sometimes it works for two weeks, sometimes it works for a month. One shot for a month. It's a long-acting IM form given to non-compliant clients. In fact, this is usually court-ordered or could be court-ordered. What do I mean by that? Again, they've probated the client and the judge ordered monthly prolixin injection. It's court-ordered. So if the client does not come in to the psychiatrist's office or the community mental health center for their prolixin shot, because it is court-ordered, what can the staff at the clinic do? Contact the police who will put out a warrant because they're in violation of a court order, and they will arrest them, bring them in, you stab their butt, and they go home. So that's the way it goes. And the police just love that. Okay, tricyclic antidepressants. Tricyclic antidepressants are an old class of antidepressants, and most of them have now been grandfathered into a new class of antidepressants called the NSSRI. Which means what? Non-selective serotonin reuptake inhibitors. Did you understand? They were not invented as NSSRIs. They were invented as tricyclic antidepressants. But chemically, they're so much like the NSSRIs that they've sort of been grandfathered into that group. They are mood elevators used to treat depression. They are mood elevators. Happy pills. Examples of these are Elevil, Copranil, Adetil, and Desiril. Elevil, Copranil, Adetil, and Desiril. Elevil, Copranil, Adetil, and Desiril. It rhymes. They all rhyme. Do you hear the rhyme? I'm serious about this. I want you to put these on a 3x5 cartoway, and take them to your steering wheel. And for the next four days, every time you come to a red light or a stop sign, I want you to stop texting, and I want you to say Elevil, Copranil, Adetil, and Desiril. Elevil, Copranil, Adetil, and Desiril. Elevil, Copranil, Adetil, and Desiril. And after three or four days, guess what will be forever linked in your brain? Elevil, Copranil, Adetil, and Desiril. Now, why do I want you to link those four? Because if you link the other three, Copranil, Adetil, and Desiril, with Elevil, Elevil's real easy to remember that Elevil elevates. Elevil elevates. Well, what's it elevate? Your mood. So, if you know Elevil elevates your mood, and you link Copranil, Adetil, and Desiril with Elevil, then you'll know Copranil, Adetil, and Desiril are also mood elevators. See why I want you to link them? So that you know what they do. And Copranil is a very famous one that they love to test. What reason, I don't know. It's been decades since I've been in Copranil. Okay, um... In fact, I don't even know why they still test these trucks. They're not given that much. Okay, what are the side effects? Well, Elevil starts with the letter E, so this group's side effects use the alphabet, but it only goes through the letter E. A for anticholinergic, primarily dry mouth. B for blurred vision. C for constipation. D for drowsiness. And E is euphoria. E-U-P-H-O-R-I-A, which means happy, joy, joy. Way too happy. Have you ever met anybody that's so happy it irritates you? That's what this is. What do you notice about that letter? It's very similar to the major tranquilizers, but you don't have that extra Pranil or the bug sensitivity of a granulocyte. But the big thing they'll ask about these antidepressants is you must take them for about two to four weeks before you get that official effect. You take them for two to four weeks. So do they work right away? No. So what's a patient going to say, typically, after one week of antidepressant therapy? What will they say? It's not working. And you need to keep them. It's going to take a little while. Letter C, the benzodiazepines. The benzos, real famous. Everybody should know about the benzos. The benzodiazepines. These are anti-anxiety meds. They are considered to be minor tranquilizers. As opposed to what? The zines, which were the majors, the zeps are the minors. Number two, they always have Z-E-P in the name. Zeps. Always. So how do you tell a xenophiazine? A benzine. How do you tell a benzodiazepine? Zep. But both tranquilizers, majors and minors, the identifying syllable starts with what letter? Z. Zeps and zines are tranquilizers. Now the way I remember that is, in cartoons, when somebody is tranquilized, meaning they go to sleep, what do they write on the page? Z. A bunch of Zs, right? So if you want to put somebody to sleep, give them Zs, use the Zs. What Zs? The zeps and the zines. Zines for the? Zany. Those are the what? The majors. And zeps are the? Minors. The way I used to remember that when we were in school, doesn't work as well for you guys when you're younger. Well, back when I was in school, the greatest rock band of all time was Led Zeppelin. Have you ever heard of Led Zeppelin? Who's never heard of Led Zeppelin? Oh, wow, I'm so impressed. You still haven't heard of it? What? They must be in their wheelchair still making music. Rock band. What's that? Rock band. With all the toys. The game. The game is bringing in all that. Okay. Yeah. I used to remember Zeppelin. Zeppelin starts with what? Three. Three. Zep. Zep. Zeppelin. And we used to say, what do you find at a Zeppelin concert? A bunch of minors on tranquilizers. So that links what? Zep with minor, tranquilizer. So we kind of remembered that. Okay. The prototype is valium, diazepam, lorazepam, florazepam, chlorazepam, chlorozepoxide. They always have ZEP in them. Indications? They are more than just minor tranquilizers. These drugs are more than that. Yes, that's their major use. That's letter A, they can also be used as a pre-op to induce anesthesia. Letter B, they can be used as a muscle relaxer. Letter C, they're good for alcohol withdrawal. D, they're good for seizures. And E, they help people when they're fighting the ventilator. They help them relax and calm down. Okay, number five. Yes. Do they put the generic and the brand name on? On boards, they're going more and more for the generic. Used to be that they always put both. About two years ago, they started flooding the exam with experimental questions where they only gave generic names for drugs. Because they were trying to find out which drugs is it reasonable to expect new graduates to know by just the generic and which ones would it be totally unfair to ask them by just the generic. That happened a year and a half to two years ago. It was two years in June. So, usually, questions stayed in the experimental phase for about two years, maybe less. So, pretty soon, all of those are going to start counting. Okay? Up until now, I would have said, no, they don't count. They're still in the experimental phase. But it's been long enough that they've been doing that that, yes, there probably will be questions on your board where you are given a drug just by its generic name. And you have to know what it is. That's why I'm trying to do phenothiazine, bendovazepine, calcium channel block, you know what I mean, Depine, Sones, you know, those kinds of things so that you learn the generic names, the mices, rather than the actual trade. Now, don't panic. Because if the only questions that have generic name only, the only questions that have made it into the test pool are ones that are reasonable to expect a new graduate to know. So, it's not going to be one that you probably wouldn't know. It's probably going to be one you wouldn't know anyhow. Like acetaminophen. Okay? Or warfarin. Or meparidine. Or acetylsalicylic acid. Or, you know, but those are, you should have known what all those were. What was warfarin? Acetaminophen. What's acetaminophen? What's acetylsalicylic acid? What is meparidine? Demerol. So, those are things that you need, those would be like there. They probably won't say something like, I doubt that they would say pentoprazole. They'd probably say protonics. Or protonics pentoprazole. You see what I'm saying? So, yes, there's a big trend to make it generic only. And I don't like that. I think that's stupid. I don't understand the point of it. You know? Because you always look a drug up. So, I don't understand why that, you know, what's unsafe for nursing practice is not looking up a drug. Not having the PDR memorized. You see? So, I don't know, I don't know where they're headed with it. But I'd like you to really, from now on, if you work, learn your generic names. Learn your generic names. Call them by their generic names. Until you take your boards in, you can call them whatever you want. Yes? Oh, just praising the Lord? I didn't know if that was it. Number five. They work quickly, but you must not take them for more than two to four weeks. How many of you know people who have been on Valium for years? That's not what the FDA ever approved. So, what's the relationship? Think about this. What's the relationship between an antidepressant and a minor tranquilizer? Right. So, one takes how long to work? Two to four weeks. Two to four weeks. And that one you can be on for how long? The rest of your life. However, the other one works right away, but you can't be on it for longer than two to four weeks. So, if somebody comes in anxiously depressed, they'll throw them on both. An antidepressant and a minor tranquilizer at the same time. On admission. Why? Well, it's going to make them feel better right now. The minor tranquilizer. But somewhere in the next two to four weeks, what's going to kick in? They're antidepressant, and then you pull them off the minor tranquilizer, and they go home on the antidepressant. So, stay on your tranquilizer until your antidepressant kicks in. Another analogy. Can I pick another analogy for you? Heparin is huminant as a tranquilizer is for an antidepressant. Heparin is to huminant as a tranquilizer is to an antidepressant. Did you get the analogy? Heparin works how? Fast. Right away, but you can't be on it for very long. Huminant takes longer to work, but you can be on it for the rest of your life. And you're only on your heparin until your huminant kicks in. Well, that's the same relationship between a tranquilizer and an antidepressant. Turn the page. Let's talk about the side effects. A, B, C, D. Do I have to repeat them, or can you write them down? Antichlorinated dry mouth and gout in the patient. Androgyny. Blood pressure. A, B, C, D. And the number one prescription diagnosis is? And the number one prescription diagnosis is? Is it the tranquilizer? Safety, injury? Are you seeing anything different from the major versus the minor? Just a few side effects. Okay, which brings up the monamine oxidase inhibitors. The MAO inhibitors. These are antidepressants. I don't understand why they're still being tested on boards. It has been 17 years since I gave one of these. And it's not because I didn't work site. Because I did. And I taught site clinicals, too. So, I mean, it's... So, I don't know why they give them. Now, they still give them in Veterans Administration Hospitals. You'll see, the most likely place you'll see an MAO inhibitor given is a Veterans Administration Hospital. Why? And they're dirt cheap. Dirt cheap compared to the other antidepressants. You can buy a month's worth of MAO inhibitor for the price of three days of Provac. You know, they're pennies. They cost pennies for a pill. Now, number two tells you how they work. You can just read that yourself. It's not a big issue. But the drug names. You need to spot an MAO inhibitor when you see it. You need to spot it from the beginning of the name, not the end of the name. The beginnings of the names all rhyme. They are Mar, Nar, and Par. Mar, Nar, Par. Marplan, Nar, Dil, Par, Nate. You see it there? Marplan, Nar, Dil, Par, Nate. Now, the only problem with Mar, Nar, Par is that is their trade name. Not their generic. Okay? But I've not seen a lot of generic names on standardized tests. Almost every standardized test I ever see has the Mar, the Nar, and the Par there. Side effects. Write it down. Okay? But, the number one thing they test is on page 67. Patient teaching. Do you remember these drugs? Letter A. To prevent severe, acute, sometimes fatal, hyper-tensive crisis. Hyper-tensive crisis. High blood pressure. Hyper-tensive crisis. The patient must avoid all foods containing tyramine. Remember this one? This is that diet that they're not allowed to have certain foods. I saw this one. And I was the one that put the blood pressure in the ER. And I got 300 plus over 220. And the only reason why I wrote 300 plus was back in 1978. Our manometers only went up to 300. So, who knows what it really, really was. I wish I had a dynamath back then that they weren't invented yet. When I was the nurse, all we had was metal IV needles. We never had the plastic. We had metal needles stuck in people's throats. Try to get somebody through a shift without a metal needle in the throat. Well, who cares? Okay. So, you have to know what foods have tyramine. Which foods they're not allowed to have. They test this all the time. Every time I try to pull this out of my lecture, somebody says, Okay, put it back in. Okay, here are the foods you're not allowed to have. In the fruit and veggie food group, generally speaking, fruits and veggies do not have tyramine. So, these people can eat all the fruits, all the veggies they want, until the cows come home. No problem. Just have at it. However, there are three fruits and veggies that they're not allowed to have. And I always say, remember the salad bar. These are the foods that you're not allowed to have. The salad bar. D-A-R. The salad bar. B for bananas. A for avocados. And R for raisins. Which actually stands for any dried fruit. They're not allowed to have any dried fruit. Now, be careful, because on certain tests, including the boards, they're very likely to talk about guacamole. Which is what? Avocados. See, they always do that kind of thing where you almost have to be a cook to know what's in food. The guacamole. Now, number two, grains are fine. They can eat cookies, pie, cake, bread. No big deal. Meats? They're not allowed to have organ meats, so the liver, kidney, tripe, intestine, brain, heart, lung, tongue. No preserved meats, which means nothing smoked, dried, cured, tickled. Or anything like that. Now, they're not allowed to have hot dogs and certain processed munchies. Why? What's the last thing in the label on a hot dog? And other assorted parts. Which means heart, lung, tongue, kidneys, brain, intestines, the whole shipment. Now, my entire family, back one generation, is all about my grandparents and my dad. We're not born in America, so I'm first generation American. But in Slovak, we ate Slovak foods. And I ate heart, tongue, lung soup. You know, all that fantastic stuff. And heart and tongue are great. Fantastic. Back in when I was in high school, the big rage in the 60s was to steal other kids' munchies and eat them. No one would touch my lunch. I could leave my lunch, I could leave my lunch out, as long as you put Mark Clement on it, nobody would touch that bag. Because they never knew what was in it. Okay. Dairy. They're not allowed to eat cheeses except for cottage and mozzarella. Now, there are a few other cheeses they are allowed to have, but Ford just really wants to know can they eat mozzarella, can they eat cottage cheese? Yeah. So those aged cheeses are no good for them. And also, they're not allowed to have yogurt. This is probably the only diet where yogurt's bad. And then number five. I know this is not a food group, but for some of you it is. No alcohol before chocolate. Okay. So no alcohol, which rules out elixirs, tinctures, no caffeine, which rules out chocolate, licorice, soy sauce, all of that. So those are the things that are not allowed to have. And B, teach the patients not to take over-the-counter meds when they're on an MAO inhibitor. Have you ever read drug labels at a drugstore? What do they all say? Don't take if you're on an MAO inhibitor. Classic. Okay, lithium. We talked about it a little bit yesterday, didn't we? Notice it's an electrolyte, like potassium, magnesium, calcium. Is it lithium on the periodic table of chemistry? Second row, first column, Li, lithium. It's used for treating bipolar disorder because it decreases what? What did I say yesterday? Mania. It does not treat what? Depression. It decreases the mania. You're going to find out that of all psych drugs, lithium is the most unique because its side effects are not A, B, C, D or any variation thereof. The reason is, is all other psych drugs, all other psych drugs, other than lithium, are what I call neurotransmitter messer-wippers. Okay? They have their action by what? Altering neurotransmitters. This drug is the only thing in psych drugs which does not mess with neurotransmitters. It stabilizes nerve cell membranes. So because it has a unique action, it will have a unique set of side effects. And its side effects will act more like an electrolyte. So it will have the three P's. Pian, Pupin, and Parasthesia. Pian, Pupin, and Parasthesia. Why Parasthesia? Why will this drug have Parasthesia as a side effect? What did I say yesterday about electrolytes? The earliest sign of all electrolyte imbalances is numbness and tingling. Parasthesia. When you give somebody large doses of lithium and make their lithium tie, first thing is numb and tingling. Now what you do if someone on lithium is Pian, Pupin, and Parasthetic? Give the drug, hold the drug, call the doctor, don't call the doctor. Which one? Give and don't call. You can tell them later on when it comes in. What do you do with these? Hold and call. Tremors, a metallic taste, and severe diarrhea. Tremors, a metallic taste, and severe diarrhea. Those are the toxic effects. Now letter A should actually be pulled out to the margin. It really doesn't belong under toxic. I need to switch that. Number one intervention when someone is on lithium is increase fluid. The number one nursing intervention when someone is on lithium is make sure these people get ample fluid. Why? What do they do it all the time? Pian and Pupin, which makes them lose fluid, which makes them high risk for fluid volume deficit dehydration. So what are you watching? What other blood values are you watching? Dehydration. What other blood value are you watching? Sodium. Letter B, if they are sweating like they're outside working, if they say you've got a living patient and he's out re-roofing everybody in the neighborhood's house, if they get that wetting when they get maniche and it's 90 degrees and they're sweating like crazy, don't give them free water. Give them Gatorade because you have to have a normal sodium for lithium to work. Number four, lithium is closely linked to sodium. So when you're on lithium you must monitor the sodium levels. Low sodium makes lithium more toxic. High sodium will make lithium ineffective. So if sodium is low, lithium is toxic. So the only way lithium will work is if sodium is what? Normal. That's why in addition to monitoring the lithium level, you've got to monitor the sodium level. Otherwise you don't know what you're doing. So watch that sodium level when somebody has his own lithium. They're called competitive binders. Have you ever heard of that term? Prozac, everybody's favorite drug. Prozac is a selective serotonin reuptake inhibitor. It is similar to Elevil, the non-selective serotonin reuptake inhibitor. So the same set of side effects belong. So what are the side effects for Prozac? A, B, C, D, and euphoria. However, number three is more what they're going to test. Prozac causes insomnia. So give it before noon. Do not give Prozac at bedtime. Not a good idea. Number four, when changing the dose of Prozac for an adolescent or young adult, watch for increased suicidal risk. What age group? Adolescents and young adults only. Now, if I were on Prozac and the doctor changed my dose of Prozac, would you have to watch me for increased suicidal ideation? Yes or no? No, because I'm not an adolescent or a young adult. I may look it, but I'm not. Uh-huh. Do you think I'm screwing in the glasses? The other thing is, what if an adolescent is on Prozac? Does that make them increased risk for suicide? No. It's only when you change the dose. So you have to have both. In order to say there's increased suicidal risk, you have to have recently changed the dose and they have to be an adolescent or a young adult. If you changed my dose, it wouldn't be increased risk. And if you kept their dose the same, it wouldn't be a risk. It's only when you change the dose for an adolescent. Which brings up the last three drugs and we'll take a break. Haldol. My favorite drug. I love Haldol. Give me a Haldol on the dart gun and I'll be happy and psyched all year long. It has a decadent effect It has a decadent form which means what? Long acting IN that you can zap somebody with. It's basically the same as Thorazine. So what are the side effects? A, B, C, D, E, F, G. This is also called a typical first generation anti-psychotic just like the Zine side. It's the old drug. The old anti-psychotic. The big thing they'll test with Haldol is NMS. And you must know NMS. Do not go to boards not knowing what NMS is. Elderly patients and young white schizophrenics also may develop NMS from an overdose of Haldol. NMS is Neuroleptic Malignant Syndrome. It is a potentially fatal hyperpyrexia. That word hyperpyrexia means fever. With temps of potentially 106 to 108. Certainly over 105. But you know, I mean it can start at 102. But it's going to go up way up. Therefore the dose for elderly patients should be half the adult dose. But the big thing they're going to do Haldol tests is this. NMS also has had some tremors with it. And anxiety and tremors. EPS has anxiety and tremors with it. And you get EPS and NMS with the same drug. So boards is going to want to know do you know the difference between EPS and NMS. EPS is a side effect. No big deal. NMS is a medical emergency. Huge big deal. Patient can die. So they're going to want to know do you know the difference between EPS and NMS. Because one's a big deal and one is not. How do you tell the difference between EPS and NMS? Take a temperature which any LPN and any nurse RN could do without a doctor's order. So there's no excuse for any nurse missing EPS or NMS. So they tell you that you've got a patient on one of these major tranquilizers and he's having tremors and anxiety and confusion. What would be the first action you would take? Take the temperature. And if it's 102, 103, 104 what do you do? Immediately call a squad if you're in a nursing home or a psych facility. If you're in a hospital call an emergency response team. That's a bad situation. I would say even though classically it's the 106 to 108 range you if it's over 102 you call that half the time when you call 102 they're going to be okay. So you have to call them even though you know that not everybody with a 102 is going to be actually in NMS. It's so life-threatening that actually happened to us last spring when I was a nursing instructor at a certain hospital with some students we had a guy who was just I remember the patients were saying he's not himself, he's not himself and they were trying to figure out what was wrong, what's wrong, what's wrong and so I told my student I said go measure his temperature. So the student went and measured his temperature it was 102.8. So we called the doctor and I'm thinking you know why didn't these nurses do this? But sometimes you forget those basic kinds of things when you're a nurse you're thinking about a million things so you do see it and it's common. Alright, HALDOL number three there are safety concerns related to the side effects. I love HALDOL because if somebody comes in the ER and they're acutely psychotic and they're tearing the place up and they're wild and crazy and then what we like to do although I never have done this officially, although unofficially I've done it all the time it's fun to take bets on when they're going to hit the floor 5 minutes, 10 minutes, 20 minutes because it's almost have you ever seen those wildlife shows where they shoot the rhinoceros in the rear end with a dart gun you know and it runs around and then all of a sudden what's it do? like that well that's what happens to these guys they run around and all of a sudden they go bam and they hit you know it's kind of fun to watch I don't make a good spectator because I find things way too entertaining and I've got lots of advice and you're not supposed to give advice or say things are funny sorry, they are funny sometimes Okay, Clozapine Clozapine What's the big danger with this drug? Name one Name one Look at the name What's the big danger with the name? Zap Z-A-P which if you're not careful you think says what? Zap, Z-E-P and you'll miss what this drug is Question? Is there a medical emergency then? Like a medical would you like to go online? No, you just stay with your patient there's not much you can do just make sure the vital signs are stable you're with them, the squad comes and then they'll manage them medically at the hospital Many people die because there's not a whole lot we can do for it you know, we just you know, not a good thing Clozaril, Clozapine These are, this is the prototype do you know what I mean by prototype? What do I mean by prototype? The original first This is the original first second generation antipsychotic This is the new class for the Zanine Number one, it is used to treat severe schizophrenia which, the Zanine It was meant to replace the Zine and Haldol It was originally developed to replace the Zine and the Haldol and it looked real promising at first because it had an advantage Number two, it had an advantage It does not have the side effects A B C D E or F Now, it can have slight effects like that but very, very minor compared to the Zines and Haldol The patient doesn't even notice usually So, originally we thought this was going to put the Zines and Haldol out of business But then, after it was on the market for about six months we started to see a problem And what was that problem? Number three No, I mean, number two The disadvantage It does have the side effect A, granulocytosis In fact, this drug is horrendous in trashing your bone marrow Your white count can fall horribly low and you can get unbelievable infections from being on this drug So, they really So, they then tried to they altered the formula came up with different drugs like Geodon, Abilify, Zyprexa, Olanzapine and all of those and those are variations of this drug called Slawdril And they are some of them are less likely to mess up your white count some are just as bad The thing is is that not everybody gets the low white count when they're on these drugs So, the upshot is some people can take this drug and some people can't But the big thing you've got to know is with any of your atypical antipsychotics white count is a big deal Measuring the white count is a very important nursing monitoring function The only thing I do want to say is I want to say something about Geodon Geodon has a black box warning which means a fatal drug situation And that is Geodon prolongs the QT interval and can cause sudden cardiac arrest Geodon prolongs the QT interval and can cause sudden cardiac arrest Therefore, you shouldn't really use Geodon with people with heart problems In general, with your second generation atypicals end in the ending Z-A-P-I-N-E Zapine Z-A-P-I-N-E Zapine So, once again a tranquilizer class ends in a Z So you have your Z What is your Z? What is your Z? Typical old time antipsychotics What does a Zapine mean? Second generation atypical new antipsychotics And what are the Z's? The minor tranquilizers So, Zine, Zapine and Zep are all your tranquilizers One's an old major new major minor You got that? Can you match them? Minor, old major, new major Zep Zapine and Z Okay, the last drug Zoloft They are loving Zoloft and they will call it Sertraline not Zoloft It's another SSRI like Prozac It also causes insomnia but you can give it as bedtime But the big thing they are now testing more and more with Sertraline is the interaction Has anyone ever heard of the cytochrome P450 system in the liver? What is it responsible for? Cytochrome P450 system in the liver It's the major enzyme pathway by which drugs are broken down and deactivated in the liver You remember how drugs are detoxified and deactivated in the liver? Well, the cytochrome P450 enzyme system does that You don't have to write this down Zoloft, Sertraline is notorious for interfering with that system The cytochrome P450 system So what does it do when you take other drugs? It increases toxicity because they aren't broken down So the reason why boards and other ones are testing Sertraline is because when you're on Sertraline other drugs don't get metabolized and you have problems with too high levels of the other drugs So when you add Sertraline to the drug regimen of a patient what do you probably have to do with all the other drugs they're on? Lower the dose Okay, so let's talk about this Number three Watch for interaction with St. John's wort This herbal preparation that people are taking right now If you take St. John's wort and Sertraline together you're going to get serotonin syndrome which is a potentially life-threatening problem It looks a lot like those MAO guys that eat the Tyramine It looks a lot like that So what are the symptoms? I remember the symptoms from sad head S for sweating A for apprehension D for dizziness and head ache So they sweat they're apprehensive they're dizzy and they have a headache Now apprehension is often called an impending sense of doom Have you heard of that? That's what we mean by apprehension But the big one is interaction with Warfarin Coumadin And that is when you're on Sertraline and Coumadin you're going to bleed out You've got to reduce that Coumadin So watch for increased bleeding When you're on Coumadin and Sertraline watch for increased bleeding because the Coumadin is going to go toxic Alright, take a break Come back at Bye Beth We're getting there We're getting there We're getting there We're getting there We're getting there We're getting there We're getting there We're getting there We're getting there We're getting there We're getting there We're getting there We're getting there We're getting there We're getting there We're getting there We're getting there We're getting there We're getting there We're getting there We're getting there We're getting there We're getting there We're getting there We're getting there We're getting there We're getting there We're getting there We're getting there We're getting there