Exam 1 Study Guide PDF

STUDY GUIDE for Exam 1 ====================== UNIT 1 ====== Pharmacokinetics is movement of medication through the body. Thus, what the body does to the drug. Pharmacokinetics involves four phases: Absorption, Distribution, Metabolism and Excretions. Absorption o The movement of the drug from the...

STUDY GUIDE for Exam 1 ====================== UNIT 1 ====== Pharmacokinetics is movement of medication through the body. Thus, what the body does to the drug. Pharmacokinetics involves four phases: Absorption, Distribution, Metabolism and Excretions. Absorption o The movement of the drug from the GI tract into the bloodstream after administration. o About 80% of drugs are taken by mouth (drugs in solid form with disintegrate into small particles and combine with a liquid to form a solution, this is a process known as **dissolution**). **Excipients** are the fillers and other substances that make up tablets as a pill is not 100%. Sometimes it enhances absorption of drug. - Factors influencing o Blood flow (circulation) - Pain o Stress o Hunger o Fasting o Food: texture, fat content, temperature. - pH - Route of administration - First pass effect o After absorption of oral drugs from the GI tract, they pass from the intestinal lumen to the liver via the portal vein. In the liver, some drugs are metabolized to an inactive form and are excreted, thus reducing the amount of active drug available to exert a pharmacologic effect. - Bioavailability o Percentage of administered drug available for activity Drug Distribution o The movement of the drug from the circulation to body tissues ( target tissues) - Factors influencing 1. Vascular Permeability and Permeability of cell membranes 2. Regional blood flow and pH 3. Cardiac output 4. Tissue perfusion 5. Ability of the drug to bind tissue and plasma proteins 6. The drugs lipid solubility - Protein binding o As drugs are distributed in the plasma, many bind with plasma proteins - Albumin: low levels indicate decrease protein-binding sites, and more free drugs in circulation ( Acidic and neutral drugs bond with it.) - Lipoproteins (Acidic and neutral drugs bond with it) - AGP- ( basic drugs bunds with it) o Drugs that are more than 90% bound to protein are known as **highly protein bound drugs** (Warfarin, Sertraline, Glyburide, Furosemide & Diazepam) - Labs to monitor o Protein and Albumin levels - Free drug - Portion of the drug that remains unbound to protein is free, active drug. - Able to exit blood vessels and reach their site of action, causing a pharmacologic response. Drug Metabolism - the enzymatic conversion of one Chemical compound into another. - Biotransformation is the process by which the body chemically changes drugs into a form that can be excreted. - The liver is the primary site of Metabolism. - Half-life o The time it takes for the amount of drug in the body to be reduced by half. Patients with liver or kidney dysfunction tend to have prolong half-life - Loading dose - Used in the case of drugs with long half-lives (ex: Phenytoin) - By giving a large initial dose (Loading Dose), that is significantly higher than maintenance dosing, therapeutic effects can be obtained while a steady state is reached., Drug Excretion o Elimination of waste products of drugs from the body - Routes o MAIN ROUTE is through the **Kidneys** - Bile o Lungs o Saliva - Sweat - Breast Milk - Labs to monitor o Monitor Kidney Function (eGFR used to determine Kidney functions) o BUN and Creatinine - May run CMP's and BMP's to assess (eGFR) levels Pharmacodynamics: the effect a drug has on the body Primary effect is when the drug has the desired effect (main indication of the drug) and Secondary effect mayor may not be desired ( the side effect of the drug) Onset, peak, duration of meds o **Onset:** The time it takes for a drug to reach the minimum effective concentration after administration. - **Peak:** When a drug reaches its highest concentration in the blood. - **Duration:** The length of time the drug exerts a therapeutic effect. - High potency drugs are therapeutic at lower concentrations. - low potency do not have a therapeutic response at low concentrations. Therapeutic drug monitoring - Peak levels o Highest plasma concentration of drug at a specific time and it indicates the rate of drug absorption. - Trough levels o Lowest plasma concentration of a drug and it measures the rate at which the drug is eliminated. - Drawn just before the next dose of the drug regardless of the route administered Agonists & Antagonists o **Agonist:** Drugs that activate receptors and produce a desired response. - **Antagonist:** Drugs that prevent receptor activation and block a response. Types of reactions (side effects, allergic, adverse, drug toxicity) o **Side Effects:** Secondary effects of drug therapy. All drugs have Side Effects (N/V/D) o **Adverse Reactions:** Unintentional, unexpected reactions to drug therapy that occur at normal drug dosages. May be mild to severe reactions. [Undesirable] and must be reported and documented. - **Allergic Reactions:** Allergy to that specific medication and will always monitor especially if the medication is new to them. - **Drug Toxicity:** Occurs when drug levels exceed the therapeutic range. May occur Secondary to Overdose or drug accumulation. Factors influencing include Disease, Age and Genetics. Pharmacodynamic interactions - Additive - When 2 drugs are administered in combination, and the response is increased beyond what either could produce alone. - The sum of the effects of 2 drugs o Can be desirable or undesirable - Synergistic - Antagonist o When drugs with Antagonistic effects are administered together, one drug reduces or blocks the effect of the other. - May be desirable (ex: for morphine overdose, Naloxone can be given to counteract the effects of the morphine) **Chapter 7- Geriatrics**- polypharmacy, nursing care plan for medication administration to geriatric population, pharmacokinetics in older adults **o Polypharmacy:** The use of more medications than is medically necessary. - **Risk factors:** Advanced age, female, multiple HCP, use of Herbal Therapies, OTC drugs, multiple chronic diseases, and increased \# of hospitalizations. - **\*\***[Always carry updated list of current medications]**\*\*** - **Adverse Drug Effects (ADEs) often seen in patients taking anticoagulants, antidiabetic, anticonvulsants, cardiac and pain medication.** - **Nursing Care Plan:** Assess Liver and Kidney Functions, Adverse reactions can cause issues, Toxicity is big issue, Memory could cause issue, compliance, encourage pill sorter, child proof containers **o** [First thing could see for Drug Toxicity:] Change in mental status - **Pharmacokinetics in older adults:** - Decreased GI gastric secretions & GI motility causes slower absorption rate **o** Distribution is decreased due to a decrease in body water & decrease in protein **o** Decreased liver function decreased the liver's ability to metabolize and can prolong the drug half-life. Check liver enzymes (elevated ALT and AST may indicate possible liver dysfunction) because older adults can have normal liver function test but impaired hepatic enzyme. - Decreased GFR causes a decrease in the excretion of drugs - **Pharmacodynamics** **Chap 8- Nursing process** as it relates to drug therapy and patient education **Chap 9- Quality and safety** related to medication administration **o Six Rights of Medication Administration:** 1. Right Patient 2. Right Drug 3. Right Dose 4. Right Time 5. Right Route 6. Right Documentation o Medication orders: 1. Date & Time 2. Drug name 3. Dose 4. Route 5. Frequency/Duration 6. Provider Signature **Chap 10-** How to prepare, administer, patient teaching for various routes, advantages for the route (as applicable) - Tablets/capsules o Most Common Drug Form - Not Given to patients who are vomiting, lack a gag reflex or are comatose o Enteric Coated and time released capsules must be swallowed whole and cannot be crushed. - **Sublingual or Buccal**: remain in place until fully absorbed and no food or fluid should be taken while medication is in place. - Liquids o Suspension - Liquids in which particles are mixed but not dissolved - Use plastic dosing cups to measure mL's o Elixir - Sweetened, Hydro-alcoholic liquids used in the preparation of oral liquid medications - Transdermal patches o Patched placed on the skin and medication is absorbed through the skin o May be left in place from 12hr-7 days o To prevent skin breakdown, rotate patch sites - Skin should be cleaned before administration of a new patch - Perform Hand-hygiene and apply gloves o Never Cut the Patch - May secure with tape but not too tight - Rectal suppository o Position in Sims position (left side): Side-lying for 20-30 minutes - Suppositories will soften at room temperature (keep refrigerated until ready to insert) o Lubricate with water-soluble lubricant ([NOT Vaseline]) - Encourage breathing while inserting with gloved hand o Insert beyond internal sphincter - Remain in a side-lying position for 30 minutes to help with retaining medication - Topical o Applied with applicator, tongue blade or gloved finger o Ensure skin is clean and dry - Nasal spray o Wash hands/wear gloves - Blow nose - Position upright or bending over (Follow MD order) - Administer without touching the tip of the applicator to nasal passages o For sprays that instruct to close one nostril (tilt head to closed side, and hold the breath or breathe through the nose for 1 minute) - Eye drops - Pull down the lower lid exposing the conjunctival sac o Instill drops in conjunctival sac - Eye should be cleansed from the inner to outer canthus (cotton Ball) - Drainage of the medication should be directed toward the outer canthus to prevent systematic absorption - Gentle pressure can be applied to the inner canthus - Ear drops o Clean Hands/wear gloves o Drops at room temperature - Sit up with head tilted slightly toward the unaffected side - Children: Pull ear down and back o Adults: Pull ear up and back - Administer drops without contamination the dropper o Remain in position for 2-3 mins **[UNIT 2]** [Chapter 18] - [Midazolam , lorazepam ] - [Alprazolam ] - This drug group is ordered as sedative-hypnotics for seizures, substance abuse, anxiety, and insomnia. Ends with "pam" or "lam". - Dizziness - Drowsiness - Lethargy - H/A, Blurred Vision o Adverse Reaction - Hypotension - Respiratory Depression - Dependency/tolerance - Hepatic failure o Contraindications/Interactions - Respiratory Depression - Allergy - Do not take with other CNS depressants or Alcohol o Assessment needed before you give the medication - Medical history - History of Substance abuse o Interventions/Teaching/Monitor - Avoid use of Herbal products (can increase side effects of benzos) - Sedation and Confusion can occur: Increased risk for injury - Gradually withdrawn (taper off slowly) o Caution: Older adults, Depression, Suicide ideation, severe liver and Kidney problems. Nonbenzodiazepine: work the same with GABA-inhibitory neurotransmitters causing CNS depression but are chemically different than benzodiazepine - [Zolpidem] o Given for Insomnia o Recommended for short-term use (can cause dependency) o [Teaching: ] - Take before bedtime - Avoid other CNS depressants - Avoid alcohol - Food decreases absorption - Sleep measures & Nonpharmacological measures (drinking warm milk, bath or showering, low stimulation, dark room, no physical exercise before bed) - **Side Effects:** Dizziness, confusion, hangover effect, drowsiness, residual Sedation, headache and blurred vision. - **Adverse effects:** Hypotension, Tolerance, psychological and physical dependence - [Safety: ] - Monitor VS (especially RR) - Bed alarm as appropriate - Falls precautions - No driving or operating heavy machinery - Medications used causes CNS depression, alleviates pain, causes a loss of consciousness - Patient do not respond on arousal or have memory of pain and event upon arousal. Do not respond to verbal commands. - Balance anesthesia minimizes the amount of anesthesia needed and decrease post anesthesia effect and adverse effect like respiratory depression. - [Side effects:] Confusion, drowsiness, dizziness, N/V, shivering/ feeling cold and sore throat. - [Adverse effects:] Respiratory depression, cardiac depression and aspiration. - Lidocaine - Used for Dental procedures, Suturing skin lacerations, Minor surgery to Localized area - [Contraindication:] Hypersensitivity to local anesthetics Spinal/epidural anesthesia- nursing interventions, adverse reactions (NSAIDS)  Local anesthesia where it is injected right below the first lumbar space. - Used frequently for lower body surgery/procedures (Primarily for labor and delivery) - **Main Concern**: Respiratory Issues (if injected wrong or pushed too fast, can cause paralysis in the lungs) - [Hypotension] is the **most common adverse reacti**on (IV bolus administered first to help minimize hypotension) (BP frequently monitored q15min) - Pt. cannot get up right away, they are numb, increased risk for falls. - Pt. needs to wear SCD's to promote circulation - Spinal Headaches can occur when spinal fluids leak from puncture site (Hydration and supine position helps) (if severe enough, blood patch can be performed) - Frequent respiratory assessment (remain flat, increase fluids) - DifÏcult urination - **[Nursing interventions:]** Monitor sensorium, urine output, VS, injection site and headache, administer analgesic with caution, ensure safety. [Chapter 24] - Ibuprofen - Produces pain relief by inhibiting both **COX1** and **COX 2** but causes stomach irritation. o Most commonly used NSAIDS - Obtain drug history- NSAID's may interfere with highly protein-bound medications o **Contraindications-** Severe liver/renal disease, peptic ulcer, GI bleeding o [Observe for signs of bleeding (] bleeding gums, ecchymosis, black tarry stools, petechial) o Give with food to decrease GI discomfort - Don't take NSAID with aspirin/acetaminophen (GI irritation/bleeding risk) o Avoid Alcohol o Don't take while Pregnant - **Side Effects:** Peripheral edema, Dizziness, GI distress - **Adverse reactions:** Blood dyscrasia, thrombocytopenia, hearing loss or Tinnitus, GI bleeding. - Notify dentist/surgeon before a procedure when taking o May interact with Herbal products - May take several weeks for desired therapeutic effect - Aspirin (salicylate) o Oldest Anti-inflammatory o [Side Effects: ] - Dizziness, Abd pain, Drowsiness, Headache o [Adverse Reactions: ] - Tinnitus, Hearing loss - GI Distress, Bleeding (Ulcers) - Reye Syndrome in children - Thrombocytopenia, Leukopenia, hemolytic Anemia, agranulocytosis - Hepatoxicity o [Contraindications: ] - GI Bleeding, Hypersensitivity to NSAIDS, flu or viral illness in children, pregnancy o [Interactions: ] - Increase PT and bleeding at times o Risk for hypoglycemia with oral hypoglycemic agents. - Celecoxib selectively inhibits cox 2 , having less potential for GI adverse reactions. - Can still cause GI Irritation - Pt. teaching for ibuprofen applies to Celecoxib (both NSAID's) - Adverse reactions: Peripheral edema, bleeding, Hypertension, Cardiac events o Should be taken with meals to reduce GI upset o Interact with lithium and herbal products, anticoagulants o - Allopurinol o Decreases Uric Acid Synthesis (taken daily not PRN) - Prevents GOUT Attacks o Monitor I's & O's o Encourage fluids o Avoid Acidic foods o Monitor Liver & Kidney functions - Take with food - Yearly eye exam (this med can cause vision issues) o Encourage fluid intake o [Side Effects: ] - GI Distress - Dizziness - Pruritus - H/A, Flushed skin o [Adverse Reactions:]  Blood Dyscrasias o [Contraindications: ] - Severe Kidney Disease (Anti gout drugs are excreted through the kidneys) [Chapter 25] - Acetaminophen: - Analgesic and antipyretic drug used for muscular aches, Pain and fever caused by viral infection in infants, children and adults. - Absorbed in GI-tract, causes little to no GI irritation - Bleeding not an issue - Assess medical history for liver dysfunction o Monitor liver enzymes o **DO NOT** take longer than 10 days o Maximum dose 4g/day to avoid liver damage o [ **Acetylcysteine** ] (antidote to treat overdose) o **[Side Effects:]** Headaches and constipation - **[Adverse]** Reaction: Oliguria, elevated hepatic enzymes. Life threatening effects include hepatoxicity, hemolytic anemia and renal failure. - Contraindications: Liver or Renal disease, Alcoholism - Education: Contact poison control if overdose occurs, check OTC to ensure they do not contain Acetaminophen - Morphine sulfate (Opioid agonists) o moderate to severe pain o Potential addiction o Most popular Opioid prescribed o Assessment: - Monitor Pain (scale 1-10) - Monitor VS (need baseline VS) - Monitor RR, BP - Medical Hx, Substance Abuse Hx - Monitor for Urinary Retention & Constipation - Pupils (pinpoint can mean overdose) o Interactions: - CNS Depressants & Alcohol o Contraindication: - Hypersensitivity - CNS & Respiratory Depression - Increased ICP o Adverse Reactions: - Decreased BP - Life Threatening: Respiratory Depression & Psychological Dependency o Side Effect: - Constipation - Urinary Retention - Rash, itching - Orthostatic Hypotension/Dizziness - Naloxone - Sweating, flushing, agitation, Dyspnea - N/V - Elevated PTT, Bleeding o Adverse Reactions - Reversal of Analgesia - Hypo/Hypertension & tachycardia - CNS Effects of stimulants: Increased mental alertness and capacity for work, Decreased fatigue and drowsiness, prolong wakefulness - Sumatriptan - Dizziness, Vertigo, Drowsiness o [Contraindications: ] - Significant Cardiovascular disease - Uncontrolled hypertension - Liver failure - Pregnancy - Hyper/Hypotension, Bradycardia, Cardiac Arrest, Cardiac Dysthymias - Suicidal Ideation o [Interactions: ] - Avoid taking Antidepressants (selective serotonin reuptake inhibitors (SSRI's), UNIT 3 ====== [Chapter 17] Amphetamine-like drugs o CNS Effects of Stimulants - Increased mental alertness and capacity for work - Decreased fatigue and drowsiness - Prolonged wakefulness - Increases production of Dopamine which is the neurotransmitter responsible for alertness and concentration. - First Prescription drug indicated for ADHD and can also be used to treat narcolepsy and appetite suppression - Given to children to increase their attention span and cognitive performance. - Side Effects: - Nervousness - Anorexia - Restlessness - Tremors - Insomnia - Dry Mouth o Adverse Reactions: - Tachycardia, Hypertension, Growth Suppression, Palpitations o Contraindications: - Hypertension, Hyperthyroidism, Coronary artery disease, Hx of seizures  Interactions: - Increased effects of other stimulants /caffeine/ sympathomimetic - Increased effects of anticoagulants, barbiturates, anticonvulsants - Decrease effects of antihypertensive meds o Nursing Considerations: - Monitor VS (Can cause tachycardia, palpitations, irritability, Adverse reactions - Monitor weight/height/growth in children - Assess medical/medication history - Assess mental status o Teaching - Avoid Caffeine - Taper off medication - Give before breakfast and lunch. Don't take at night (may cause insomnia) o Evaluation - Improvement of ADHD symptoms - Impulsiveness - Poor attention span - Restlessness - Disorganization - Trouble multitasking - Experiencing less daytime drowsiness - Experiencing less episodes of abruptly falling sleep during the day [Chapter 19] **Therapeutic use for anti seizure drugs:** - To control or prevent seizures while maintaining a reasonable quality of life - AED (anti-epileptic drug) therapy is usually lifelong - Combination of drugs may be used - Serum drug concentrations must be measured. - Phenytoin \*\*10-20mcg/mL\*\* - Anti-Epileptic, Anti-convulsant, Prevention of Seizures o Side Effects - Headache, Drowsiness, Dizziness, Slurred Speech, Decreased Coordination - Gingival Hyperplasia \*\*Want to use a soft toothbrush\*\* - Harmless Urine Discoloration o Adverse Reactions - Thrombocytopenia, Leukopenia, Hyperglycemia - \*\*Suicidal Ideation\*\* o Contraindications - Pregnancy (teratogenic) \*\*Want to promote additional contraceptive methods\*\* - Aspirin, ibuprofen, anticoagulants o Interactions - Folic Acid - Decreased Effects of anticoagulants - Decreased effects of oral contraceptives - Inhibits Vitamin K which can contribute to hemorrhage in newborns - Valproic acid o Given for Chronic Seizure management - Hepatotoxicity is a concern \*\*Monitor Liver Enzymes\*\* o Take with food - Serious Teratogenic properties \*\*Women must discuss pregnancy plans with provider\*\* - Phenobarbital o Long-acting Barbiturate (CNS Depressant) o Usually given for chronic seizure management - In high doses (monitor for dependency, respiratory depression, or coma) o Monitor therapeutic serum levels o Gradual Discontinuation - Benzodiazepines o Diazepam - Has anti-seizure effects - Given for acute seizure management (drug of choice for acute status epilepticus -- IV route) - Has a short-term effect, so a long term antiseizure drug must also be given with it. - May Cause - Fatigue, weight loss/gain, dizziness, drowsiness, appetite stimulant, urinary retention and incontinence and respiratory depression - Lorazepam - To control status epilepticus, anxiety, and insomnia and for sedation induction - May Cause - Drowsiness, dizziness, memory impairment, ataxia, confusion, weakness, restlessness, constipation, EPS, Hypotension, dependency - [Anti-seizure drugs and pregnancy:] - Seizure episodes increase during pregnancy, - many antiseizure drugs have teratogenic properties (valproic acid linked to major congenital abnormalities) - Discuss pregnancy plans with provider before conception if possible - Must gradually wean off medication o Antiseizure drugs - inhibits vitamin K which can contribute to hemorrhage in newborns, - Decrease Folic acid which is associated with Spinal malformation - Taking supplements will not prevent fetal harm, helps to reduce risk o Nursing Assessment - Vital Signs - Medical history - Baseline CBC - Check therapeutic range (above 10 but less than 20)  Check liver function. [Chapter 22] - Haloperidol - non- phenothiazine antipsychotic. - Blocks dopamine receptors in the brain. - Used to treat psychosis and schizophrenia - Tachycardia: Dysrhythmias - Extrapyramidal Syndrome/Tardive Dyskinesia - Neuroleptic Malignant Syndrome (NMS) - Seizures - [Blood Dyscrasias]: Agranulocytosis and Neutropenic - Blood Glucose Changes - Drowsiness - Photosensitivity - GI Upset - Orthostasis - Aripiprazole - Atypical anti-psychotic: Works by blocking D2 dopamine receptors in the brain and also Commonly used for Schizophrenia, psychotic disorders, Bipolar disorder, Tourette syndrome and Autism o Side Effects: - Adverse Reactions: - Contraindications: - Blood Dyscrasias, Renal/Liver impairment, Parkinson's disease, CNS Depression o Interactions: - Alcohol, Hypnotics, CNS depressants, Antiseizure medications, antacids, Herbal products - Atypical anti-psychotic interacts with antidiabetic agents, antihypertensive medications, grapefruit products - Nursing interventions: - Check VS, give with food, Observe for EPS and NMS, monitor urine output, can take up to 6 weeks for full effectiveness, Compliance is essential, Avoid CNS depressants, Do not stop abruptly, discuss family planning with women of child bearing age - Monitor WBC (report signs of infection promptly, (malaise, fever, sore throat) o Safety: - Caution with driving until medication dosing is stable - Orthostatic hypotension (falls risk) - Photosensitivity measures - Good oral hygiene (dry mouth) - Wear medical alert bracelet Neuroleptic malignant syndrome (NMS) o Rare potentially fatal condition o Symptoms: - Altered mental status, seizures, Muscle rigidity, sudden high fever, BP fluctuations, tachycardia, dysrhythmias, acute renal failure, respiratory failure, coma o Treatment: - Immediate withdrawal of antipsychotics, hydration, hypothermic blankets, antipyretics, benzodiazepines, muscle relaxants Pseudoparkinsonism (EPS) o Frequently occurs as an adverse reaction to chlorpromazine, haloperidol, lithium, metoclopramide, methyldopa, and reserpine - Benzodiazepines (also discussed in chapter 19) [Chapter 23] - Tricyclic Antidepressants (TCA) -- works by blocking reuptake of neurotransmitter, causing accumulation at the nerve ending. - Sedation, Orthostatic hypotension, Dizziness, Memory Impairment, Weight loss, anticholinergic effects (dry mouth, constipation), impotence o Adverse Reactions: - Blood dyscrasias, Cardio toxicity, tachycardia o Contraindications: - Older patients should not take tricyclic anti-depressants - Severe cardiovascular disease o Interactions: - Alcohol and CNS depressants - MAOI's - Fluoxetine (SSRI) o Used for: Depression, Bulimia, OCD, Panic disorder, Anxiety, phobias, premenstrual dysphoric disorder - Side Effects: - Orthostatic hypotension, dizziness, drowsiness, weight loss, sexual dysfunction, insomnia o Adverse Reactions: - Suicidal Ideation, Bleeding, Hepatic Dysfunction o Contraindications: - Caution with anticoagulant therapy o Interactions: - St. Johns Wort - Grapefruit products - NSAIDs, aspirin and anticoagulants - MAOIs - Lithium (Therapeutic range 0.6-1.2) - Severe hyponatremia, hyperglycemia, cardiac dysrhythmias/arrest, seizure o Interactions: - NSAIDs, Caffeine - \*\*Should be given with Acetaminophen instead of NSAIDs\*\* o Contraindications: - Pregnancy (may have teratogenic effects) o Toxic levels of lithium (levels higher than 1.5-2.5) - Tremors, confusion, somnolence, seizures, possible death NOTE: Serotonin: SER the word starts with and that helps me remember affects sleep, emotion and remembering, \"Happy Hormone\" Dopamine: DOP the word starts with and that helps me remember Determination, obsession, and pleasure NorEpi: NOR the word starts with and that Flight or fright, NO hesitation, on alert and recall memory \"cognitive awareness\" Easy way to remember. General teaching with All Antidepressants D. driving is out until response to drug has been determined E. effect has a delay onset of 7-21 days P- planning pregnancy - consult with HCP R- Relieves symptoms but not a cure E- Evaluate vital signs S- Stopping the drug abruptly is OUT of the question! S- Safety measures (orthostatic) I - Instruct client to report side effects to HCP O- observe for suicidal tendencies N- No alcohol, OTC, herbs or any other CNS depressants without consulting HCP