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PATIENT INFORMATION: NAME: PATIENT X PSEUDONYM ETHNICITY: NEW ZEALAND…

- - - - Family dynamics: Severe relationship issues with mum, sense of ambivalent attachment or sense of abandonment by main figures in her life and impaired self esteem as a result
        
        Patient's relationships
        patient currently is living with her grandmother, describes her living situation as stable. Describes her younger half brother as her favourite person in the world.
        
        It was noted that there was significant strain in the relationship with the patients mother, both parties have different views on the the world. Was noted that the mother does not ackknowlege the patients own views of her struggles with her own mental health, there is a significant lack in maternal support.
        
        patient perceives her relationship with her grandmother to be a positive one, it was disclosed that she was her main support system. However it was noted that the grandmother tends to be smothering in a sense where she constantly tells the patient that situations can always be fixed through talking it through. Throughout the assessment it was noted that the grandmother looks at the patient through rose tinted glasses
        
        Patient has lived with the grandmother on and off for half her life, moved to Singapore for 18 months due to step fathers job. Patient disclosed that this was an unahppy to time for her trouble adjusting to the cultural differences.
        
        The patient has no contact with her biological father, the death of a maternal uncle was a signficant loss in the patients life she described him as the only father figure she had ever known.
- - - - amiodarone: both medications have a high risk of prolonging the QT interval which can lead to the potentially fatal torsade de pointes arrhythmia. Dangerous QT prolongation is likely if medications are used together,
      - Pimozide: a risk of serious increase in serum levels if pimozide if both medications are used together. If used together there is also a risk of prolonging the QT interval causing the torsade de pointes arrhythmia.
      - Amorophine: the use of this and ondansetron should be avoided due to the risk of severe hypotension and bradycardia
      - tramadol: ondansetron should be avoided when administering ondansetron, as ondansetron is thought to decrease the analgesic effects of tramadol.
      - Warfarin: When taking ondansetron there is a decreased effectiveness of warfarin if they are combined, patient must be monitored closely if they are used in combination.
      - Hormonal contraceptives: thought to be a decrease in contraceptive effectiveness if taken in combination, use of a barrier contraceptive should be included.
      - Phenytoin: When given together with ondansetron it is thought to decrease the effectiveness of the ondansetron
        
        Carbamazepine: this increases the clearance of ondansetron and decreases the effects of it also
      - Pharmacokinetics: Metabolised in the liver, Excreted in urine and faces. If given orally it is distributed via the GI tract, if IV distributed via plasma
    - - IV route adverse reactions: injection site reaction, in rare cases torsade de points, transient visual disturbances.
    - - patients that experience hypersensitivity to the medication are contraindicated.
        
        Should not be used in pregnancy due to the potential adverse effects to the fetus or infant. Ondansetron is known to cross the placenta and is excreted in breast milk
        
        Caution should be taken in patients with hepatic impairment
  - - - Dosage ranges Therapeutic dosage ranges of 10-80mg, depending on the severity of the symptoms displayed in associated with the particular disorder. Depression: adult 20 mg daily then increased after 3-4 weeks if needed. Bulimia nervosa: 60 mg is the recommended dosage. Obsessive compulsive disorder 20-60 mg per day is the recommended dose. Premenstrual dysphoric syndrome: 20 mg is the recommended dose, initial treatment should be limited to six months.
      - Routes of administration Fluoxetine is only administered orally. Fluoxetine capsules should be swallowed whole and can be given with or without food. Fluoxetine dispersible tablets may be swallowed whole, broken in half for a 10mg dose or dispersed in approximately 100mL of water
    - - Pharmacokinetics: Fluoxetine is absorbed in the GI tract post oral administration and reaches peak plasma levels at 6-8 hours, It is highly protein bound and ha distributed via plasma, it is metabolized in the liver and is excreted via the kidneys.
    - - Monoamine Oxidase inhibitors: Fluoxetine should not be used in conjunction with this class of medication or within 14 days of discontinuing fluoxetine. Severe and fatal cases of serotonin syndrome which may mimic and be diagnosed as neuroleptic malignant syndrome has been reported in patients that had treatment of fluoxetine and [MAOI] in close temporal proximity.
        
        Caution should be taken in patients with with impaired renal function and hepatic functioning as alterations in the drugs excretion and metabolism could occur resulting in toxicity in the blood.
      - Fluoxetine should not be administered if the patient enters into a severe manic episode of phase
      - Caution:
        
        Cardiovascular effects: QT prolongation can occur with fluoxetine treatment. fluoxetine should be used with caution with patients with risk factors for QT prolongation incuding congenital long QT syndrome, age >65 years, female, sturctural health disease/ left ventricular dysfunction, hepatinc disease, electrolyte imbalance (hypokalemia and hypomagnesaemia should be treated prior to taking fluoxetine, ECG should be performed
      - Fluoxetine should only be taken in pregnancy if the benefits to the mother out balance the risk of the fetus, SSRIs enter breast milk and can cause adverse effects to the infant
    - - There is some debate as to weather anti-depressants increase the risk of increased suicide ideation the risk is increased by 60 %.
      - serotonin syndrome can occur in patients that are subjected to long term use of SSRI
      - the adverse effects associated with SSRI which are linked to the effects of increased 5HT levels include CNS effects such as head ache, tremours, drowsiness,, diziness, insomnia, afitation and seizures
      - Gastrointestinal symptoms include nausea, vomiting, diarrhea dry mouth, decreased appetite, constipation
    - - Gilteritinib: this potientially decreases the efficiency of fluoxetine, should not take together due to this
        
        ozanimod: fluoxetine is thought to increase the likelihood of adverse effects of ozanimod.
        
        Medications affecting platelet aggregation: SSRI's increase the likelihood and risk of bleeding or hemorrhaging
        
        Medications affecting blood glucose levels: SSRIs can increase blood glucose level; monitor blood glucose
      - isocarboxazid: serious and potential fatal reactions such as serotonin syndrome can develop if fluoxetine and non selective irreversible MAOIs are administered concurrently or if insufficient time is left between administration of the two medication
      - moclobemide: cases of severe serotonin syndrome and increase of adverse effects have been noted following use of both medications
        
        Warfarin: co-administration of this and fluoxetine can increase chances of hameorhaging
      - phenelzine: increases the chances of serotonin syndrome
        
        Bupropion: The use of bupropion is related to a dose-related risk of seizures. The risk may be further increased when co-administered with other agents that can reduce the seizure threshold, including antidepressants.
        
        St Johns wart: reported cases of serotonin syndrome in patients taking SSRIs and St Johns wart.
      - Tramadol: due to the medications serotonergic activity avoid coadministration can increase the risk of serotonin syndrome
      - amitriptyline: fluoxetine is thought to significantly increase the plasma concentrations of some tricyclic antidepressants
        
        Phentermine: several reports suggest that ssris can potentiate the pharmacologic response to sypathoimetric agents. One report noted symptoms of jitteriness, racing thoughts, stomach cramps, dry eyes, palpitations, tremors, and restlessness following a single dose of phentermine ingested by a patient.
      - CNS active medicines alterations in blood levels of medications such as phenytoin, carbamazepine, haloperidol, clozapine, diazepam and lithium in some cases toxicity has been reported
  - - - Histamine: should avoid concurrent use of antihistamines as they will antagonize or block the effects of histamine
      - Isocarboxazid: concurrent use of MAOIs and phenothiazines is normally effective however in rare cases neuroleptic malignant syndrome and/or hyperlexia have been reported.
      - Phenelzine: concurrent use of MAOIs and phenothiazines is normally effective however in rare cases neuroleptic malignant syndrome and/or hyperlexia have been reported.
        
        Should be 14 days between taking this and promethazine
- - - - B. Determination for each practitioner of the scope of practice what they practice under.
        
        C. Systems to ensure that no scope of practice is breached
        
        D. restriction of specified activities to particular classes of clinicians to protect health consumers from serious harm
        
        E. certain protection for clinicians that partake in protected quality insurance activities
        
        F. Additional information for health professions that fall under the act.
    - - The misuse of Drugs Act 1975 and Misuse of Drugs regulations 1977: this act stipulates the classification of controlled drugs in determination of their risk to the public. The regulations provide for the prescribing and storage of controlled medications. Nurses need to be aware of the legislation in terms of the storage, recording and administration of medications and controlled drugs
        
        NZNO guidelines to medication administration 5.7 the registered Nurse: thus outlines the scope of practice of nursing students in terms of medication administration. NZNO recommends that medication administration is always under the direct supervision of a registered nurse.
        
        Mental health compulsory treatment act 1992: this act looks at the circumstances in which the conditions under where individuals may be subject to compulsory psychiatric assessment and assessment and treatment.