NORTRIPTYLINE Suzanne Barron, SN NUR 308 Psychiatric Nursing

Goals & Objectives Goals To give 1st year nursing students a deeper knowledge and understanding of the psychiatric drug nortriptyline. Objectives Learner will be able to: Identify 3 contraindications for nortriptyline. Identify 3 adverse signs and symptoms of nortriptyline. List 5 symptoms of nortriptyline toxicity.

Nortriptyline Generic Name: Nortriptyline Trade Name: Pamelor Drug Category: Tricyclic Antidepressent

Indications Nortriptyline is mainly prescribed for Major Depression It does have several unlabeled uses including: Chronic pain management Premenstrual dysphoric disorder (PMDD) Social phobia Neuropathy Panic disorder Migraine prophylaxis

Dosage & Route Nortriptyline comes as both pill and liquid and is given by mouth. It can be given in divided doses or daily at bedtime. Adult dosing at 25 mg and may increase to 150 mg/day Adolescent dosing 1-3 mg/kg/day, max dose 150 mg/day Geriatric dosing 10-25 mg at bedtime, increase by 10-25 mg at weekly intervals to desired dose; usual maintenance 75 mg/day, max 150 mg/day

Action Blocks reuptake of norepinephrine and serotonin into nerve endings, thereby increasing action of norepinephrine and serotonin in nerve cells. Mechanism of action of nortriptyline

Pharmacokinetics Nortriptyline is taken orally Metabolized by the liver Excreted by the kidneys Crosses the Placenta Excreted in breast milk Half life 18-28 hours Protein binding 93% to 95% Route PO Onset 2-3 wk Peak 6 wk Duration Ukn

Contraindications Do not use within 14 days of MAOIs Pregnancy (D) Hypersensensitity to tricyclic's Recovery Phase of MI Seizure disorders Prostatic Hypertrophy Precautions Breastfeeding, suicidal patients, severe depression, increased intraocular pressure, closed-angle glaucoma, urinary retention, cardiac/hepatic disease, hyperthyroidism, electroshock therapy, elective surgery Black Box Warning: Children, suicidal ideation

Side Effects Cardiovascular: Orthostatic hypotension, ECG changes, tachycardia, hypertension, palpitations, dysrthymias Psychiatric: Confusion, disorientation, delusions, anxiety, restlessness, agitation, insomnia, panic, nightmares Neurologic: Numbness, tingling, paresthesias of extremities, incoordination, ataxia, tremors, seizures, alteration in EEG patterns, tinnitus Allergy: Rash, urticaria, itching, photosensitization, edema, drug fever, cross-sensitivity with other tricyclic drugs. Endocrine: Increased/decreased libido, breast enlargement, gynecomastia

Side Effects Continued Anticholinergic: Dry mouth, blurred vision, constipation, paralytic ileus; urinary retention, delayed micturition, dilation of the urinary tract Gastrointestinal: Nausea and vomiting, anorexia, epigastric distress, diarrhea, peculiar taste, stomatitis, abdominal cramps Hematologic: Agranulocytosis, thrombocytopenia, eosinophilia, leukopenia Other: Jaundice, altered liver function, weight gain or loss, perspiration; flushing, urinary frequency, nocturia, drowsiness, dizziness, weakness, fatigue, headache, parotid swelling

Nortriptyline Toxicity Warning signs: confusion, restlessness, disturbed concentration, transient visual hallucinations, agitation, muscle rigidity, vomiting, hypothermia, hyperactive reflexes Critical manifestations: cardiac dysrhythmias, sever hypotension, shock, congestive heart failure, pulmonary edema, convulsions, and CNS depression including coma Treatment of overdose: Patient should receive gastrointestinal decontamination. This should include large volume gastric lavage and activated charcoal. A Stimulant cathartic should be given. Patients respiratory, cardiac function, and temperature should be monitored and maintained. ECG will need to be monitored for at least 5 days. May required administration of digoxin for heart failure, antiarrhythmics, and anticonvulsants.

Nursing Considerations Assess and Monitor Mental status must be monitored to include orientation, mood, and behavior Weight and BMI Blood Pressure and pulse ECGs in geriatric patients or those with heart disease Fasting blood sugar Cholesterol levels especially in overweight patients Suicidal tendencies (especially early in therapy) Signs of toxicity

Nursing Considerations Assess and Periodically Monitor Labs Leukocyte and differential blood counts Liver function Serum glucose Serum nortriptyline levels may be monitored (usually patients placed on higher than recommended doses for therapeutic reasons) Some Lab Considerations May Increase Bilirubin & Alkaline phosphatase Bone Marrow Depression May Cause Serum glucose may increase or decrease

Nursing Considerations Implementation Nortriptyline can be administered with meals to minimize gastrointestinal effects Administer at bedtime to minimize daytime sedation Any dose increases should be administered at bedtime to avoid sedation When stopping nortriptyline, taper dose to avoid withdrawal effects Dose should be decreased at 50% for 3 days, then 50% for three more days, then drug can be discontinued

Nursing Considerations Patient Teaching Take as directed. Take missed doses as soon as possible unless close to next dose. Do not stop medication without consulting provider. Abrupt discontinuation may cause illness. May cause drowsiness or blurred vision. Avoid driving and other activities requiring alertness until affect of drug is known. Watch for suicidality. especially in early therapy Notify provider immediately if this occurs. Avoid alcohol and other CNS depressant drugs. Maintain avoidance for 7 days after discontinuation. Make position changes slowly. You may become dizzy if you stand to quickly. Monitor food intake. Weight gain can occur from increase in appetite.

Nursing Considerations Patient Teaching Notify provider if urinary retention occurs or if symptoms of constipation persist. Dry mouth can be diminished by with sugarless gum or candy. Increase fluid consumption. Report if dry mouth persists for more than 2 weeks.. Notify your provider if you suspect pregnancy. Medication could effect your baby if you become pregnant. Notify all health care professionals of medications before treatment or surgery. Use sunscreen and protective clothing when in the sun to avoid complications from photosensitivity Monitor food intake. Weight gain can occur from increase in appetite.

Nursing Considerations Outcomes and Evaluations Patient should experience: Increase in sense of well being New interest in surroundings Refreshing sleep More energy Increased appetite

Summary Nortriptyline is a tricyclic antidepressant that works by increasing the amounts of norepinephrine and serotonin in the brain. It is prescribed mostly for patients with major depression but it is prescribed for other uses. It is comes in the form of a capsule or a liquid and is taken by mouth. It can be taken in split doses up to four times a day or one large dose at bedtime and may be taken with or without food. It is approved for adults, adolescents, and geriatric patients. It is not recommended for children. Dose needs to be increased slowly to avoid side effects and needs to be decreased slowly to avoid withdrawal symptoms. Two of the major risks involved in prescribing nortriptyline include suicidality early in treatment and toxicity.

Questions Name at least 3 contraindications for nortriptyline. Do not use within 14 days of MAOIs Pregnancy (D) Hypersensensitity to tricyclic's Recovery Phase of MI Seizure disorders Prostatic Hypertrophy

Questions Name 3 adverse signs and symptoms of nortriptyline. Orthostatic hypotension, ECG changes, tachycardia, hypertension, palpitations, dysrthymias Psychiatric: Confusion, disorientation, delusions, anxiety, restlessness, agitation, insomnia, panic, nightmares Neurologic: Numbness, tingling, paresthesias of extremities, incoordination, ataxia, tremors, seizures, alteration in EEG patterns, tinnitus Allergy: Rash, urticaria, itching, photosensitization, edema, drug fever, cross-sensitivity with other tricyclic drugs. Endocrine: Increased/decreased libido, breast enlargement, gynecomastia Anticholinergic: Dry mouth, blurred vision, constipation, paralytic ileus; urinary retention, delayed micturition, dilation of the urinary tract Gastrointestinal: Nausea and vomiting, anorexia, epigastric distress, diarrhea, peculiar taste, stomatitis, abdominal cramps Hematologic: Agranulocytosis, thrombocytopenia, eosinophilia, leukopenia Other: Jaundice, altered liver function, weight gain or loss, perspiration; flushing, urinary frequency, nocturia, drowsiness, dizziness, weakness, fatigue, headache, parotid swelling

Questions List 5 symptoms of nortriptyline toxicity. Warning signs: confusion, restlessness, disturbed concentration, transient visual hallucinations, agitation, muscle rigidity, vomiting, hypothermia, hyperactive reflexes Critical manifestations: cardiac dysrhythmias, sever hypotension, shock, congestive heart failure, pulmonary edema, convulsions, and CNS depression including coma

References Deglin, J. H., Vallerand, A. H., & Sanoski, C. (2013). Davis's drug guide for nurses (13th ed.). Philadelphia, Penn.: F.A. Davis Company. Lehne, R. A. (2013). Pharmacology for Nurses (8 th ed.). St. Louis: Elsevier Saunders. Nortriptyline. (n.d.). ATI Testing. Retrieved April 5, 2014 from http://www.atitesting.com/ati_next_gen/Student/DrugGui deSearchPage.aspx?TermHint=nortriptyline Nortriptyline (n.d.). Epocrates Online. Retrieved March 15, 2014 from https://online.epocrates.com/u/10a57/nortriptyline.

Documents

NORTRIPTYLINE Suzanne Barron, SN NUR 308 Psychiatric Nursing