McKenna's Pharmacology for Nursing, 2e

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C H A P T E R 2 1 Antidepressant agents

the need for periodic monitoring and evaluation to enhance knowledge about drug therapy and to promote compliance. ■ ■ Offer support and encouragement to help the person cope with the disease and the drug regimen. Evaluation ■ ■ Monitor response to the drug (alleviation of signs and symptoms of depression, OCD, bulimia, panic disorder).

■ ■ Monitor for adverse effects (sedation, dizziness, GI upset, respiratory dysfunction, GU problems, skin rash, serotonin syndrome). ■ ■ Evaluate the effectiveness of the teaching plan (person can give the drug name, dosage, possible adverse effects to watch for, specific measures to help avoid adverse effects, importance of continued follow-up and importance of avoiding pregnancy). ■ ■ Monitor the effectiveness of comfort measures and compliance with the regimen.

CRITICAL THINKING SCENARIO Selective serotonin reuptake inhibitors

THE SITUATION D.J., a 46-year-old married woman, complains of weight gain, malaise, fatigue, sleeping during the day, loss of interest in daily activities and bouts of crying for no apparent reason. On examination, she weighs 4 kilograms more than the standard weight for her height; all other findings are within normal limits. In conversation with a nurse, D.J. says that in the past 10 months, several events have occurred. She lost both of her parents, her only child graduated from high school and went away to university, her nephew died of renal failure, her only sister learned she had metastatic breast cancer, and she lost her job as a day care provider when the client family moved out of town. In addition, the family cat of 17 years was diagnosed with terminal leukaemia. D.J. is prescribed fluoxetine ( Prozac ) and is given an appointment with a counsellor. CRITICAL THINKING What nursing interventions are appropriate at this time? What sort of crisis intervention would be most appropriate? Balance the benefits of pointing out all of the losses and points of grief that you detect in D.J.’s story with the risks of upsetting her strained coping mechanisms . What can D.J. expect to experience as a result of the SSRI therapy? How can you help D.J. cope during the lengthy period it takes to reach therapeutic effect? What other future interventions should be planned with D.J.? DISCUSSION Many people in severe crisis do not consciously identify the many things that are causing them stress. They have developed coping mechanisms to help them survive and cope with their day-to-day activities. D.J. seems to have reached her limit and exhibits many of the signs and symptoms of depression. However, it is important to make sure that she does not have some underlying medical condition that could be contributing to her complaints.

Because of her age, she may also be perimenopausal, which could account for some of her problems. It is hoped that the fluoxetine, an SSRI, will enable D.J. to regain her ability to cope and her normal affect. The drug should give her brain a chance to reach a new biochemical balance. Before she begins taking the fluoxetine, she should receive a written sheet listing the pertinent drug information, adverse effects to watch for, warning signs to report, and a telephone number to call in case she has questions later or just needs to talk. The written information is especially important because she may not remember drug-related discussions or instructions clearly. Once the SSRI reaches therapeutic levels, which can take as long as 4 weeks, D.J. may start to feel like her “old self” and may be strong enough to begin dealing with all her grief. She may recover from her need for the SSRI over time, and use of the medication can then be discontinued. Allergies to fluoxetine or any other antidepressant SSRI; renal or hepatic dysfunction; pregnancy or breastfeeding; diabetes Concurrent use of TCAs, cyproheptadine, lithium, MAO inhibitors, benzodiazepines, alcohol, other SSRIs CV: blood pressure, pulse CNS: orientation, affect, reflexes, vision Skin: colour, lesions, texture CARE GUIDE FOR D.J.: FLUOXETINE Assessment: History and examination

Respiratory: respiration, adventitious sounds GI: abdominal examination, bowel sounds Laboratory tests: hepatic and renal function tests Implementation

Administer drug in morning; divide doses if GI upset occurs. Provide comfort, safety measures; small meals; void before dosing; side rails; pain medication as needed; suggest barrier contraceptive; limit dosage with people who are potentially suicidal; lower dose with renal or hepatic impairment.