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|Primarily used to relieve symptoms of depression Can HELP anxiety disorders Not indicated for uncomplicated bereavement
|WHAT IS DEPRESSION? depressed mood and loss of pleasure or interest in one’s usual activities and pastimes Symptoms must be present most of the day, nearly every day, for at least 2 weeks
| Insomnia (or sometimes hypersomnia) Anorexia (or sometimes hyperphagia) Mental slowing and loss of concentration Feelings of guilt, worthlessness, and helplessness Thoughts of death and suicide Overt suicidal behavior
|common psychiatric disorder 30% of the U.S. experience THIS Incidence in women twice as high as that in men Risk of SUICIDE s high with depression Often untreated
|WHAT IS THE Pathogenesis??
|Complex and incomplete Possible contributing factors Genetic heritage Difficult childhood Chronic low self-esteem Monoamine hypothesis of depression Depression is caused by the functional insufficiency of monoamine neurotransmitters
|WHAT ARE THE 3 Treatment Modalities? 1-Pharmacotherapy 2- Depression-specific psychotherapy (eg, cognitive behavioral therapy and interpersonal psychotherapy)
|THERE ARE: 3- Electroconvulsive therapy When drugs and psychotherapy have not worked When a rapid response is needed For severely depressed patients For suicidal patients For elderly patients at risk of starving
|IMPORTANT TO KNOW THAT
|Symptoms resolve slowly Initial responses develop after 1 to 3 weeks Maximal responses may not be seen for 12 weeks Must take AT LEAST 1 month before determining failure ALL ANTIDEPRESSANT DRUGS APPEAR EQUALY EFFECTIVE
|SUICIDAL RISK Dosing of inpatients should be directly observed DOESES SHOULD BE WRITTEN IN THE SMLLEST AMOUNT MONITOR BY FAMILY(OUTPATIENT)-CONVENIENT W/ PT MANAGEMENT
|May increase suicidal tendencies during early treatment Patients should be observed closely for the following: Suicidality Worsening mood Changes in behavior RISK-greatest in children and young adults.
|Selective Serotonin Reuptake Inhibitors-SSRIs MORE SEROTONIN AVAILABLE=CNS EXCITATION ADR-nausea, headache, and central nervous system stimulation.
|commonly prescribed antidepressants Effective as tricyclic antidepressants (TCAs) but do not cause hypotension, sedation, or anticholinergic effects Overdose does not cause cardiac toxicity Death by overdose is extremely rare
|Fluoxetine [Prozac, Sarafem] Most widely prescribed SSRI -DRUG OF CHOICE FOR postpartum depression-~80% WOMEN HAVE IT- Thyroid insufficiency has been indicated as a contributing factor in postpartum depression.
|TE: Bipolar disorder Obsessive-compulsive disorder Panic disorder Bulimia nervosa Premenstrual dysphoric disorder Off-label uses: Post-traumatic stress disorder, social phobia, alcoholism, ADHD disorder, Tourette’s syndrome, & obesity
|Mechanism of Action
|Produce selective inhibition of serotonin reuptake Produce central nervous system (CNS) excitation
|Adverse Effects Syndrome resolves spontaneously after STOPPING drug Deaths have occurred Risk increased by concurrent use of MAOIs and other drugs
|Serotonin syndrome Begins 2 to 72 hrs after treatment Mental (eg, agitation, confusion, disorientation, anxiety, hallucinations, and poor concentration) Incoordination, myoclonus, hyperreflexia, excessive sweating, tremor, and fever-
|Adverse Effects WITHDRAWAL S/S=ELECTRICAL FIRING-HEADACHE TAPER DRUG-DYSPHORIA, TREMOR, ANXIEY, SENSORY DISTURBANCE , DIZZINESS BRUSIXM-CLENCHING, GRINDING TEETH
|WEIGHT GAIN Withdrawal syndrome Neonatal effects when used during pregnancy Small risk Teratogenesis Very low risk Extrapyramidal side effects Bruxism Bleeding disorders SEXUAL DYSFUNCTION
|Monoamine oxidase inhibitors Risk of serotonin syndrome Antiplatelet drugs and anticoagulants Aspirin and nonsteroidal anti-inflammatory drugs Warfarin TCAs and lithium Can elevate levels of these drugs
|Citalopram [Celexa] Escitalopram [Lexapro, Cipralex] Fluvoxamine [Luvox] Paroxetine [Paxil, Pexeva] Sertraline [Zoloft]
|Serotonin/Norepinephrine Reuptake Inhibitors-SNRIs
|Indications Major depression Generalized ANXIETY disorder Social anxiety disorder (social phobia)
|Venlafaxine [Effexor] Duloxetine [Cymbalta]
|Blocks NE and serotonin uptake Does not block cholinergic, histaminergic, or alpha1-adrenergic receptors Serious reactions if combined with MAOIs
|Venlafaxine [Effexor] Can causes Serotonin syndrome
|Side effects NAUSEA Headache Anorexia Nervousness Sweating Somnolence Insomnia Weight loss/anorexia Diastolic hypertension Sexual dysfunction Hyponatremia (in older adult patients) Neonatal withdrawal syndrome
|Tricyclic Antidepressants block reuptake of NE and 5-HT and thereby intensify transmission at noradrenergic and serotonergic synapses. Over time, this induces adaptive cellular responses that are ultimately responsible for relieving depression.
|First choice for many patients with major depression T.USE Depression Bipolar disorder, ADHD Fibromyalgia syndrome Other uses Neuropathic pain Chronic insomnia Panic disorder Obsessive-compulsive disorder
|Adverse Effects- In the early phase of treatment for depression, suicide risk may increase. Patients should be monitored closely for worsening mood, unusual changes in behavior, and suicide risk i.e imipramine [Tofranil]
|Orthostatic hypotension Anticholinergic effects(DRY MOUTH, CONSTIPATION) Diaphoresis Sedation Cardiac toxicity Seizures Hypomania
|MAOIs( hypertensive crisis ) Direct-acting sympathomimetic drugs(EPINEPHRINE) Indirect-acting sympathomimetic drugs(AMPHETAMNINE) Anticholinergic agents CNS depressants
| Primarily from anticholinergic and cardiotoxic actions • Dysrhythmias • Tachycardia • Intraventricular blocks • Complete atrioventricular block • Ventricular tachycardia • Ventricular fibrillation May increase risk of suicide IN early treatment
|TREATMENT OF TOXICITY
|Gastric lavage Ingestion of activated charcoal Intravenous sodium bicarbonate to treat cardiac dysrhythmias caused by cardiotoxicity
|Monoamine Oxidase Inhibitors MAOIs increase neuronal stores of NE and 5-HT= intensify transmission at noradrenergic and serotonergic synapses. Over time, this induces adaptive cellular responses
|Drug of choice for atypical depression Second- or third-choice antidepressants for most patients As effective as TCAs and SSRIs but more hazardous Risk of triggering hypertensive crisis if patient eats foods rich in tyramine-AVOCADO,CHEESE
|Isocarboxazid [Marplan] Phenelzine [Nardil] Tranylcypromine [Parnate]
|T.USE Depression Other uses • Bulimia nervosa • Agoraphobia-NOT WANTING TO GO OUT • Attention-deficit/hyperactivity disorder • Obsessive-compulsive disorder • Panic attacks
|CNS stimulation-LIKE SSRI+SNRI Orthostatic hypotension- LIKE TCA Hypertensive crisis from dietary tyramine hypertension crisis S/S: severe headache, tachycardia, hypertension, nausea, vomiting, confusion, and profuse sweating—911
|MOAI-Hypertensive crisis/dietary tyramine
|Tyramine: Promotes the release of NE from sympathetic neurons Hypertensive crisis • Severe headache • Tachycardia • Hypertension • Nausea and vomiting • Confusion • Profuse sweating • Stroke • Death
|PREVENTION-MOAI-Hypertensive crisis/dietary tyramine
|TEACH PATIENT ABOUT TYRAMINE-RICH FOODS TEACH ABOUT S/S OF CRISIS IV vasodilator • Sodium nitroprusside (a nitric oxide donor) • Phentolamine (an alpha-adrenergic antagonist) • Labetalol (an alpha-adrenergic and beta-adrenergic antagonist)
|MAOIs must not be combined with SSRIs, SNRIs, or other serotonergic drugs because serotonin syndrome could result MAOIs must not be combined with indirect-acting sympathomimetics (e.g., amphetamine, cocaine) because hypertensive crisis can result
|ECT as practiced today is safer and less traumatic .-adjunctive use of (1) a short-acting IV anesthetic (e.g., propofol, etomidate) to produce unconsciousness and (2) a short-acting muscle relaxant (succinylcholine) to prevent convulsions
|SSRIs have two major advantages over TCAs: they cause fewer side effects and are safer when taken in overdose. Sexual dysfunction (e.g., impotence, anorgasmia) is more common with SSRIs than with most other antidepressants NEVER COMBINED WITH MOAIs
|Atypical Antidepressants-Bupropion [Wellbutrin] SMOKING CESSATION FOR SLEEPING ALOT+WEIGH GAIN PATIENT
|Acts as stimulant and suppresses appetite • Antidepressant effects begin in 1 to 3 weeks • Does not affect serotonergic, cholinergic, or histaminergic transmission • Does not cause weight gain
|Seizures • Agitation • Tremor • Tachycardia • Blurred vision • Dizziness • Headache • Insomnia • Dry mouth • Gastrointestinal upset • Constipation • Weight loss
|MAOIs can increase the risk of bupropion toxicity
|Preparations, dosage, and administration KEEP DRUG IN TACT CANT BE OPENED, CRUSHED
|IR, SR,ER tablets Light Therapy Exposure to bright light Effective treatment for seasonal affective disorder and nonseasonal major depression May enhance serotonergic neurotransmission The more intense the light, the greater the response
|A patient is prescribed isocarboxazid [Marplan] for the treatment of depression. Which foods should the patient be taught to avoid?
|Bananas, smoked fish, and cheese TYRAMINE release of accumulated norepinephrine to cause massive vasoconstriction and the excessive stimulation of the heart. A hypertensive crisis may occur. Foods to avoid include yeast extracts,
|known as manic-depressive illness Mainstays of therapy are lithium and valproic acid lifelong treatment-antipsychotic Cause may be disruption of neuronal growth and survival
|Cyclic disorder Recurrent fluctuations in mood Episodes of mania=LESS IMPULSE CONTROL-LITTLE SLEEP depression=DEPRESSED MOOD, LOST OF INTEREST persist for months without treatment HIGHLY INDIVIDUALIZED
|Characteristics of Bipolar Disorder
|Types of mood episodes seen with BPD Pure manic episode (euphoric mania)-MORE ENERGY-HAPPY Hypomanic episode (hypomania) TALKING MORE-LESS ENERGY Major depressive episode (depression) Mixed episode Characteristics of Bipolar Disorder
|Drug Therapy-Mood stabilizers
|Lithium, divalproex sodium, and carbamazepine • Relieve symptoms during manic and depressive episodes • Prevent recurrence of manic and depressive episodes • Do not worsen symptoms of mania or depression; do not accelerate the rate of cycling
|Antipsychotics • Given during severe manic episodes Antidepressants • Given during depressive episodes Promoting adherence Short-term hospitalization Long-term prophylactic therapy Education for both patient and family
|Lithium [Lithonate, Lithotabs] Chemistry Simple inorganic ion Found naturally in animal tissues
|NARROW THERAPEUTIC INDEX Therapeutic uses BPD Other uses • Alcoholism • Bulimia • Schizophrenia • Glucocorticoid-induced psychosis
|Lithium [Lithonate, Lithotabs]
|Pharmacokinetics Absorption and distribution Excretion • Short half-life • Excreted by the kidneys • Sodium levels: Lithium excretion reduced when sodium level low Plasma levels • 0.8 to 1.4 mEq/L
|Adverse effects TOXICITY= diarrhea, anorexia, muscle weakness, nausea, vomiting, tremors, slurred speech, and drowsiness. Later signs include blurred vision, seizures, trembling, confusion, and ataxia.
|> 1.5 mEq/L • Monitor levels Q2-3D at initiation of therapy and then Q3-6MNTHS • Levels >2.5mEq/L = death Therapeutic lithium levels • GI effects • Tremors • Polyuria • Renal toxicity • Goiter and hypothyroidism • Teratogenesis
|Drug interactions Aspirin is safe to use as an analgesic with lithium.
|DECREASE LITHIUM EXCRETION WITH Diuretics(THIAZIDES) Nonsteroidal anti-inflammatory drugs Anticholinergic drugs
|Preparations, dosage, and administration
| Lithium carbonate Lithium citrate Dosage is highly individualized
|Divalproex sodium [Valproate] Carbamazepine
|Reduces symptoms Protects against recurrence of mania and depression Target trough plasma level: 4 to 12 mcg/mL
|Indicated for long-term maintenance Can be used alone or in Combination with other drugs To minimize the risk of serious rash, dosage should be low initially (25 to 50 mg/day) and then gradually increased.
|Antipsychotic Drugs APPROVED: Olanzapine [Zyprexa], quetiapine [Seroquel], risperidone [Risperdal], aripiprazole [Abilify], and ziprasidone [Geodon
|Used to acutely control SYMPTOMS during manic episodes CAN BE USED FOR long term to help stabilize mood Benefit patients with or without psychotic SYMPTOMS Can be combined with mood stabilizer
|Education EDUCATE Patient and family Psychotherapy Individual, group, and family Electroconvulsive therapy Last resort
|PT W/ bipolar depression, using an antidepressant alone may induce mania— To minimize risk of mania, antidepressants should not be routinely used alone; rather, they should be combined with a mood stabilizing drug.
|To minimize the risk of toxicity, lithium levels must be monitored. The trough level, measured 12 hours after the evening dose, should be less than 1.5 mEq/L
|avoid LITHIUM during the first trimester of pregnancy. Unless the benefits outweigh the risks, lithium should be avoided during the second and third trimesters too. ■ A reduction in sodium levels will reduce lithium excretion
|A 24-year-old woman has been diagnosed with BPD. The patient has an order to receive lithium. Before administering the medication, it is most appropriate for the nurse to assess what?
|baseline patient’s cardiac status, serum electrolyte levels, renal function, hematologic status, and thyroid function. assess FOR pregnanCY or plans to become pregnant, because lithium should be avoided during the first trimester of pregnancy.
|When providing patient teaching regarding lithium therapy, what are some of the specifics the nurse should include related to this medication
|Take the medication W/ MEAL OR MILK as prescribed, even when you are feeling well. Encourage family members to oversee lithium administration. NEVER CRUSH SUSTAINED TABLETS
|The patient tells the nurse that she is afraid to take lithium because she has heard that she must have blood work done every day she takes the medication, and she doesn’t like needles. What is the most therapeutic response by the nurse?
|LITHIUM LEVEL monitored to ensure the therapeutic range (0.8 to 1.4 mEq/L for initial therapy and 0.4 to 1 mEq/L for maintenance). Levels should be measured every 2 to 3 days during initial therapy and only every 3 to 6 months during maintenance.
|A patient who is diagnosed with BPD is prescribed lithium. To monitor for lithium toxicity, the nurse should observe the patient for which signs and symptoms?
|Polydipsia, slurred speech, and fine hand tremors nausea, vomiting, persistent gastrointestinal upset, diarrhea, clonic movements, hyperirritability of muscles, muscle weakness, and hypotension.
|Drugs that depress central nervous system (CNS) function Primarily used to treat anxiety and insomnia Antianxiety (LOWER DOSE)agents or anxiolytics OR TRANQUILIZERS HYPNOTICS(HIGHEST DOSE)
|Drugs of choice to treat insomnia and anxiety Used to induce general anesthesia Used to manage seizure disorders, muscle spasms, panic disorder, and withdrawal from alcohol
|Diazepam [Valium], Lorazepam [Ativan] and alprazolam [Xanax ARE much safer - have a low abuse potential, cause less tolerance and dependence, and don’t induce drug-metabolizing enzymes.
|CNS=Reduce anxiety and promote sleep CVS=Oral – almost no effect • Intravenous – profound hypotension and cardiac arrest RESPIRATORY=Weak respiratory depressants unless combined with other respiratory depressants(OPIOID, ALCOHOL)
|Benzodiazepines NOT USED IN PREGNANCY
|Therapeutic uses Anxiety Insomnia Seizure disorders Muscle spasm Alcohol withdrawal Perioperative applications
|CNS depression-DAYTIME SEDATION Anterograde amnesia-DIFFICULTY MAKING MEMORIES Sleep driving Paradoxical effects Respiratory depression Abuse NOT Use in pregnancy and lactation
|CNS depressants NOT TAKEN WITH ALCOHOL
|IMPORTANT (except in patients who have undergone prolonged high-dose therapy). ■ To minimize withdrawal symptoms, benzodiazepines should be discontinued gradually, over several weeks or even months
|Tolerance and physical dependence Tolerance • With prolonged use, tolerance develops to some effects but not others Physical dependence • Can cause physical dependence, but the incidence of substantial dependence is low
|Oral overdose: Drowsiness, lethargy, and confusion Intravenous toxicity: Life-threatening reactions, profound hypotension, respiratory arrest, and cardiac arrest
|General treatment measures
|Oral: Gastric lavage, activated charcoal, saline cathartic, and dialysis IV= flumazenil [Romazicon] ANTIDOTE Reverses the sedative effects of benzodiazepines but may not reverse respiratory depression(WATCH O2)
|Zolpidem [Ambien] benzodiazepine-like drugs
|Sedative-hypnotic FOR hypnotic Short-term management of insomnia Long-term use: No apparent tolerance or increase in adverse effects Side effects: Daytime drowsiness and dizziness Pt teaching LET FMILY KNOW THAT THEY ON THIS, TO MONITOR PT
|Cause tolerance and dependence High abuse potential Multiple drug interactions Powerful respiratory depressants that can be fatal with overdose No specific antidote Replaced by benzodiazepines and the benzodiazepine-like drugs
|Ultrashort-acting (thiopental) Short- to intermediate-acting (secobarbital) Long-acting (phenobarbital) Mechanism of action Binds to the GABA receptor–chloride channel complex
|CNS depression Cv Induction of hepatic drug-metabolizing enzymes Tolerance and physical dependence • Develops to many—but not all—of the CNS effects • Very little tolerance develops to respiratory depression Physical dependence
|Respiratory depression Suicide Abuse respiratory depression, risk of suicide, risk of abuse, and hangover (sedation, impaired judgment, and reduced motor skills)
|Management of Insomnia
|Basic management principles Cause-specific therapy Nondrug therapy Sleep Hygiene Table 34.5, p.394
|Trazodone [Oleptro] • Atypical antidepressant with strong sedative actions • Can decrease sleep latency and prolong sleep duration • Does not cause tolerance or physical dependence
|Old tricyclic antidepressant with strong sedative actions • Used to treat patients who have trouble staying asleep
|Diphenhydramine Can be purchased without a prescription Less effective than others Tolerance develops quickly (in 1 to 2 weeks) Adverse effects: Daytime drowsiness and anticholinergic effects
|Drugs used for treatment
|Melatonin appears to be moderately effective Valerian root, chamomile, passionflower, lemon balm, and lavender have very mild sedative effects; proof of benefits for insomnia is lacking
|Benzodiazepines , the benzodiazepine-like drugs— zaleplon [Sonata], eszopiclone [Lunesta], and zolpidem [Ambien, others] produce their effects by enhancing the actions of GABA, the principal inhibitory neurotransmitter in the CNS.
|■ Benzodiazepines and the benzodiazepine-like drugs (zolpidem, zaleplon, eszopiclone) are drugs of choice for insomnia. ■ When benzodiazepines are used for transient insomnia, treatment should last only 2 to 3 weeks.
|Cognitive behavioral therapy is highly effective for insomnia, and hence is considered first-line treatment, even if drugs are also employed Exercise daily, but not later than 7:00 PM. Regular exercise helps deepen sleep.
|When insomnia has a treatable cause (e.g., pain, depression, schizophrenia), primary therapy should be directed at the underlying illness; hypnotics should be used only as adjuncts
|Stage I: 5% • Stage II: 50% to 60% • Stages III and IV: 10% to 20% • REM: 20% to 25
|Central Nervous System Stimulants
|Increase the activity of central nervous system (CNS) neurons Enhance neuronal excitation; a few suppress neuronal inhibition In sufficient doses, all can cause convulsions Limited clinical applications
|Mechanism of action Release norepinephrine Release dopamine
|Pharmacologic effects ABUSE High potential for abuse due to euphoria Physical dependence Abstinence syndrome with abrupt withdrawal
|CNS: prominent effects on mood and arousal CVS: Increased HR, AV conduction, and force of contraction Tolerance W/ regular use, tolerance develops to elevation of mood, suppression of appetite, and stimulation of the heart and blood vessels
| CNS stimulation Weight loss INSOMNIA Cardiovascular effects((dysrhythmias, angina, hypertension) Psychosis-LOSE CNTACT W/ REALITY
|Dizziness, confusion, hallucinations, paranoid delusions, palpitations, dysrhythmias, and hypertension Death is rare Fatal overdose: Convulsions, coma, and cerebral hemorrhage
|Hallucinations: Chlorpromazine • Hypertension: Alpha-adrenergic blocker (eg, phentolamine); chlorpromazine helps lower blood pressure • Seizures: Diazepam
|TYPES OF AMPHETAMINES
|Dextroamphetamine sulfate Immediate release Extended release Amphetamine/dextroamphetamine mixture Immediate release Extended release Lisdexamfetamine [Vyvanse] Methamphetamine [Desoxyn]
|Methylphenidate-Pharmacology nearly identical to that of amphetamines
|T.USE ADHD and narcolepsy Trade names Ritalin, Metadate, Methylin, Concerta, and Daytrana
| Preparations, dosage, and administration
| Immediate release • Ritalin and Methylin Sustained release • Ritalin SR, Metadate ER, and Quillivant XR Once-daily dosing • Concerta, Metadate CD, Ritalin LA, Daytrana, and Biphentin (Canadian)
|Derivatives of xanthine Caffeine • Few clinical applications • Widespread ingestion for nonmedical purposes Dietary sources • Chocolate • Soft drinks
|Mechanism of action
| Reversible blockade of adenosine receptors Calcium permeability Accumulation of cyclic adenosine monophosphate
|Low doses Decrease drowsiness and fatigue Increase capacity for prolonged intellectual exertion Increasing doses Nervousness, insomnia, and tremors Seizures with very large amounts
|Modafinil [Provigil, Alertec] (Miscellaneous CNS Stimulants)
|T.use • Promotes wakefulness • Narcolepsy • Shift-work sleep disorder • Obstructive sleep apnea/hypopnea syndrome MOA Pharmacokinetics • Rapidly absorbed in the gastrointestinal tract • Elimination by hepatic metabolism • Half-L: About 15 hours
|Headache • Nausea • Nervousness • Diarrhea • Rhinitis Drug interactions • Oral contraceptives • Cyclosporine
|ADHD in Children
|Signs and symptoms Inattention Hyperactivity Impulsivity Fidgety Unable to concentrate
|ADHD in Children
|Unable to wait his or her turn Switches excessively from one activity to another Calls out excessively in class Present before the age of 7 years Present for at least 6 months
|Adverse effects: Gastrointestinal reactions Reduced appetite Dizziness Somnolence Mood swings Trouble sleeping
|Norepinephrine uptake inhibitor Alpha2 Adrenergic agonist ■ In treatment of ADHD, the nonstimulants may be used alone or as add-on therapy with a stimulant less effective in ADHD, but also are safer and have a lower potential for abuse
|ADHD in Adults
|60% of ADHD cases persist into adulthood Symptoms • Poor concentration • Stress intolerance • Antisocial behavior • Outbursts of anger • Inability to maintain a routine Drug therapy • Methylphenidate
|Caffeine has two principal uses: treatment of apnea in premature infants and reversal of drowsiness LOW DOSE-decrease drowsiness and fatigue HIGH DOSE-nervousness, insomnia, and tremors HUGE DOSE- cause convulsions.
|A nurse instructs a parent about the administration schedule for Adderall XR (amphetamine/dextroamphetamine mixture) to treat the child’s ADHD. The nurse determines that teaching is successful if the parent makes which statement?
|“The drug should be given in the morning, before school.” Adderall XR is a long-acting drug that should be administered once in the morning, after breakfast.
|A child takes Adderall XR (amphetamine/dextroamphetamine mixture) for ADHD. The nurse should assess the child for which adverse effects?
|Weight loss, restlessness, and chest pain
|A child with ADHD has been prescribed Daytrana (a transdermal methylphenidate patch). When teaching the child’s caregiver how to administer the medication, which instruction should the nurse include in the teaching?
|Remove the patch within 9 hours of application. patch within 9 hours of application. blood level peak within about 9 hours, after which time the patch should be removed. PT should apply the patch to the hip in the morning and alternate hips QD.
|The nurse teaches a 16-year-old female patient about methylphenidate (Ritalin). Which statement by the patient indicates that more teaching is needed?
|“Decaffeinated coffee has a small amount of caffeine.” Caffeine is also present in many noncola soft drinks (eg, orange soda, Mountain Dew, Jolt Energy Drink). Eight ounces of decaffeinated coffee or tea may contain 1 to 5 mg of caffeine.