Term
| Bipolar Disorder DSM-IV Mania |
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Definition
| Elevated mood, at lease 3 of these: infalted self-esteem or grandiose, decreased sleep, increase talkativeness, pressured speech, flight of ideas, throughts racing, distractibility, agitation, increase in gaol directed activity, excessive involvement in pleasurable activity, sexual indiscretions, buying sprees, foolish business investments. |
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Term
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Definition
Hypomania is less severe than mania, less impairment in social/occupational functioning, does not usually need hospitalization.
Mania- mairked impairment in social and occupational functioning, delusions may be present, graniose, paranoid, or both, needs to be hospitalized. |
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Term
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Definition
| Predominately manic with a few depressed episodes |
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Term
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Definition
| Predominately depressed with a few manic or hypomanic episodes. Harder to diagnose. |
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Term
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Definition
| Genetically realted and a chemical imbalance. |
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Term
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Definition
| Mood swings greater than normal and not to the degree of mania and depression (medication not effective) |
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Term
| Bipolar Disorder-Depression |
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Definition
| More amenable for treatment, symptoms similar to major depression, monitor for suicidality. Medication used to treat are different (Use mood stabilizers, antidepressants used with caution since they can precipitate manic episodes) |
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Term
| Cognitive responses for Manic Episode |
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Definition
| Poor concentration, flight of ideas, distracted easily, thoughts racing, delusions |
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Term
| Affective responses for Manic Episode |
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Definition
| Expanded mood, inflated self-esteem, feels good |
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Term
| Behavioral responses for manic episode |
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Definition
| Decreased sleep, distractibility, pressured speech, decreased nutrition, agitation, sexual indiscretions, buying sprees |
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Term
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Definition
| Behavior less agitated and expanisve, talking slowed down, staying on one topic, sleeping 5-6 hours per night, eating while seated at a table, stops spending excessively, stops inappropriate sexual behavior |
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Term
| Nursing interventions for bipolar and manic patients |
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Definition
Administer medications and monitor the side effect (Lithium, tegretol, depakote)
Administer low doses of antipsychotics, PRN benzodiazapines, give finger foods, give fluids to drink, do not laugh at jokes, use firm, calm approach, use short, simple words and explanations, be consistent with approach, set limits on behavior, provide a structured environment, avoid power struggles, sent to room to calm down if excalates, de-escalate with anit psychotics and benzo, use time outs, distractions, reidrect energy constructively, protect from self harm, remain clam. |
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Term
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Definition
| 2.0 level indicates anorexia, nausea/vomitting, diarrhea, coarse hand tremor, twitching, lethargy, hyperactive deep tendon reflexes, tinnitus, vertigo, weakness, drowsiness, over 2.5 fever, decrease urine output, decreased BP, irregular pulse, ECG changes, impaired consciousness, seizures, coma and death. |
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Term
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Definition
Used for the treatment of mania and depression from bipolar disorder, and schizoaffective disorders.
Side effects are: nausea, vomiting, diarrhea, slurred speech, muscle weakness, hand remors, weight gain, hypotention, kidney dysfunction, confusion, coam and death. |
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Term
| Nursing Implications of Lithium |
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Definition
Hydration- Fluid intake of 1500-3000cc/day, Diet with adequate salt, montiro blood levels, Do not give diuretics, Monitor BUN and creatinine
Toxic level is above 1.5 |
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Term
| Anticonvulsants used as mood stabilizers MOA |
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Definition
| enhancing the effects of GABA and desensitizing the kindling effects of bipolar disorder. Kindling-sensitizing the brain neurochemically to events such as stress, trauma or street drugs where the brain spontaneously responds in a dysfunctional manner in the absence of these events. The brain is sensitized to bipolar disorder and the anticonvulsants desensitize the brain. |
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Term
| Carbmazepine (Tegretal &Equestro) |
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Definition
Anticonvulsant used as a mood stabilizer.
S/E: Dizziness, vertigo, blurred vision, drowsiness, incoordination, hypertention, sedation, heart failure, hypotension, abdominal pain, nausea, vomiting, decreased white blood count, Stevens-Johnson Syndrom, Liver problems, dysrhytmias.
Used for: Bipolar disorder, schizoaffective disorder, and resltess leg syndrome. |
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Term
| Nusring Implications of Carbmazepine |
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Definition
| Teach patients not to stop taking their medication, meds must be tapered off, may decrease the effectiveness of oral contraceptives, avoid taking alcohol while on medication because it potentiates seizures, do not eat or drink grapefruit. |
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Term
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Definition
Used for: Bipolar disorders, first line for mania, agent of choice for rapid cyclers, schizoaffective disorder, rage reactions, and mood instability.
S/E: Insomnia, nervousness, somnolence, tremor, headache, dizziness, fatigue, blurred vision, abdominal pain, weight gain, possible poor blood clotting, liver problems. |
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Term
| Nursing implications of Valporic acid/ Depakote |
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Definition
| Interacts with aspirin, monitor liver, Need a PT and INR before starting the medication, don't give liquid form to patients on sodium restrictions, avoid drinking alcohol while on medication, teach patients not to abruptly stop medication but to taper off the medication. |
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Term
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Definition
Uses: Good for rapid cyclers, not as effective for acute bipolar disorder, no weight gain noted, no blood work needed.
S/E: Dizziness, ataxia, diarrhea, blurred vision, rhinitis, nausea, vomiting, Stevens-Johnson Syndrome |
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Term
| Nursing Implications of Lamicatol/Lomotrigine |
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Definition
| Do not stop taking the drug abruptly, stop the medication immediately at first sign of rash, Female patients should report changes to estrogen-containing oral contraceptives since this alters blood levels of lamictal/lomtigine. |
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Term
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Definition
| Loss of ocntrol, uses despite problems, tend to relapse |
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Term
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Definition
| appearance of withdrwawal symptoms (physicial) when decrease or stop substance |
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Term
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Definition
| Physical symptoms occurs when substance is decreased or stopped |
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Term
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Definition
| Need to use more to gain desired effect |
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Term
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Definition
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Term
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Definition
| using more than 3 substances at the same time |
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Term
| Type 1 drinker (Problem drinker) |
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Definition
| Social drinker then has alchol problem, positive family hx (Father/Mother) pass on, less neurotransmitters available, get a neruotransmitter dump when drink, 50% of treamtent population prone to relapse. |
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Term
| Type II Genetic alcholoic- adolescent onset |
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Definition
| Begins drinking a lot early and continues to drink a lot, folows male line-father to sone, can develop liver and other diseases more quickly, 1 st drink sky rockets neurotransmitters, like drinking form 1st drink. May not look drunk because of hyperactive brain |
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Term
| Start Substance stop development |
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Definition
| When people start using alcohol and drugs development stops. 1 year in recovery= 3 yeas of developments |
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Term
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Definition
| 25mg/liter metabolized every hour |
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Term
| Breathalyzer vs. Blood Alcohol |
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Definition
Intoxication 0.08
Blood Alcohol equivalency 80 |
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Term
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Definition
| Mesolimbic dopamine system of the brain, "I can't stop without help" |
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Term
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Definition
Alcohol- DT's
Benzodiazepines- seizures
Barbiturates- Seizures |
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Term
| DSM IV-TR Substance dependence |
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Definition
| Maladaptive use of substances with significant impairment in 3 or more of tolerance develops, withdrawal symptoms occur, substance taken in larger amounts over a longer time. Has persistent desire for substances, unsuccessful efforts to cut down, spend time in procuring substance, social occupational recreational interests given up, continues to use despite physical and or psychological problems |
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Term
| DSM IV-TR Sybstance Incuded Delirium |
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Definition
Impaired consciousness, reduced awareness of environment, changs cognition (memore, disorientation, hallucinations, illusions) Develops over a short time (hours to days) and fluctuates over day
Evidence of substance use history |
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Term
| DSM IV-TR substance abuse |
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Definition
| Maladaptive pattern of use, one or more of Inability to fulfill major role obligations at work, school or home, recurrent legal or interpersonal problems, continues to use despite ptroblems, participates in physicallhazardous situations wile impaired. |
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Term
| Psychological Theory of Substance Abuse |
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Definition
| Low tolerance for frustration and pain, lack of success in life, lack of affectionate, meaningful relationships, low self-esteem, takes risks |
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Term
| Psychoanalytic theory of substance abuse |
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Definition
| Forming a relathionship wit a bottle and not people |
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Term
| Biological Influence of alchol |
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Definition
| Less alcohol dehygrogenase in Native Americans, Japanese,Women |
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Term
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Definition
| Recent Ingestion, slurred speech, lack of coordination, unsteady gait, ataxia, nystagmus, impaired attention or memory, lethargic, increased reaction time, maladaptive behavior, depression of brain function, decreased REM sleep, Stupor or coma |
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Term
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Definition
Tremors, agitation and axiety, diaphoresis, sleep disturbances, seizures, hallucinations, nausea/vomitting, insomnia
Autonomic activity- Increase Pulse over 100, Increase in BP, sweating, hand tremors |
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Term
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Definition
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Term
| Alcohol Withdrawal Medications |
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Definition
Use benzodiazepines used for safe withdrawal
Chlordizepoxide (Librium)
Clorzepate (Tranxene)
Lorazepam (Ativan) |
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Term
| Delirium Tremens/ Major Withdrwawls |
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Definition
| Anxiety, Insomnia, Anorexia, Autonomic hyperactivity, severely disturbed sensorium, Fluctuating levels of consciousness, peceptual distrubances, delusions, elevated fever, 72 hours after last drin |
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Term
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Definition
Drinking and antabuse, disulfram produces a reaction- feels like a heart attack (flushing, chest pain, diaphorese)
500 mg in water three times a week or 750 mg two time pers week. |
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Term
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Definition
blocks the pleasure from drinking alcohol and decreases cravings
Vivitrol- injections of naltrexone extended relase once/month |
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Term
| Stimulants- Cocaine, Crack and Amphetamin and Methamphetamine |
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Definition
Withdrawal- depression, agitation, anxiety, drug craving, fatigue, sleeps, insomnia, hunger, anergia, anhedonia.
No need for detoxification, needs sleep, proper nutrition, and exercise. |
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Term
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Definition
Intoxication- Psychotic experience, confused, disoriented, paranoid, euphoria, bizarre, perceptions, agitation, enchancement of strength, rage, dilated pupils, red skin, ataxia, hypertention, rigidity, seizures
NO withdrwawal, Person on PCP is very unpredictalbe. |
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Term
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Definition
Withdrawal- Headaches, chills, abdominal cramping, delirium
Most commonly used by school students |
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Term
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Definition
| Produces reversible brain changes and sex changes, causes emphysema quicker than smoking, contains 60 toxins |
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Term
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Definition
C- Cut down
A- Annoyed with other people
G- Feels guilty
E- Need an eye opener |
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Term
| Assessment factors- Drugs |
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Definition
| What were you using? How much were you using? For how long? When did you last you it? Have you ever tried to quit? How did it go? Did you have any bad things happen? Detox for opiods, Detox for benzodiazepines |
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Term
| Outcomes/ Drug Rehabiilitation |
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Definition
| Owsn substance problem, attends aftercare meetings, Is substance free, plans sobr leisure activities, accepts responsibility for own behavior, changes faulty thinking, deals with feelings, uses healthy coping mechanisms. |
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Term
| Assessment factors for Alcohol |
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Definition
| Vital Signs because of autonomic rebound, CIWA, what were you using, how much were you using, Examine Lab work- BC, H&H, platelets, K+, CA, MG+ GGT |
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Term
| Typical Orders for Alchol Withdrawal |
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Definition
| Benzodiazepines, vital signs every 4 hours, Folic acid, Thimaine, Atacids and antiemetics, Ecotring for headache and pain, Pepsid, for gastritis, lactulose for liver damage |
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Term
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Definition
| Side effects associated with GHB may include nausea, vomiting, delusions, depression, vertigo, hallucinations, seizures, respiratory distress, loos of consciousness, slowed heart rate, lowered blood pressiure, amnesia, and coma. GHB can become addictive with sustained use. |
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Term
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Definition
Adverse physical effects include muscle tesion, involuntary teeth clenching, nausea, blurred vision, feeling faint, tremors, rapid eye movement, and seating or chills. Beacuase of MMDA's ability to increase heart rate and BP an extra risk is involves with ingestion for people with circulatory problems or heart disease. Some evidence suggests that long term use of ecstasy produces Parkinson's Syndrome.
Damage to the parts of the brain that are critical to thought and memory. |
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Term
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Definition
A benzodiazepine like valium, yet 10 times more potent
Some of the adverse effects are drowsiness, headaches, memory impairment, dizziness, nightmares, confusion, and tremors. Although classified as a depressant Rohypnol can induce aggession and or excitability. |
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Term
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Definition
Produces a dissociative state in a user. Similar to phencyclidine or PCP. Effects include numbness, loss of coordination, sense of invulnerability, muscle rigidity, aggressive/violent behavior, slurred or blocked speech, exaggerated sense of strength and a blank stare. There is depression of respiratory function but not of the central nervous system, and ardiovascular function is maintained. Since ketamine is an anesthetic it stops the user from feeling pain, which could lead the user to inadvertently cause injury to themselves. Ketamine may relieve tension and anxiety, is puported to be a swxual stimulant and intesifies colors and sounds.
Large doses can produce vomiting and convulsions and may lead to oxygen starvation to the brain and muscles, one gram can cause death. Flashbacks may even occur one year after use. Long term effects incluse tolerance and possible physical and or psychological dependence. |
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Term
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Definition
| Needy, Pose many challenges to care providers, often lack ability to change, unable to tolerate frustration, pain, overreact to stimuli, unable to identify feelings properly |
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Term
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Definition
Pattern is manifest in two or more areas- Cognition (ways of percieving self, others and events)
Affect- rante intesity lability and appropriateness of emtoinal response
Poor interpersonal functioning, poor impulse control
Inability to attach to others, manipulative of others, power struggles, fears closeness, disturbance in who they are |
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Term
| Paranoid Personality Disorder |
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Definition
| Distruts others, suspicious, expects exploitation, preoccupied with unjustified doubts about loyalty of others, hypervigilant for betrayal, reluctantly confides in others, fears others will use info against them, reads hidden meaning into benign remarks, bears grudges, percieves attacks on character not apparent to others, quick to counterattck, suspicious without justification, cold, aloof, objective |
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Term
| Nursing Inteventions for Paranoid Personality Disorder |
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Definition
| Build Relationships with skill and caution, teach, (Social Skills), Give permission to have feelings and help them cope, Confront excessive self importance if needed, ask indirect quiestions and let them set the interpersonal distance, be consistent as a tem of care providers. |
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Term
| Schizoid Personaltiy Disorder |
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Definition
| Pattern of detachment, Restricted interaction in interpesonal settings, neither desires or enjoys close relationships, chooses solitary activities, little sexual interets, finds pleasure in few activities, lacks close friends, is indifferent to praise, is emotionally cold and detaches. |
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Term
| Nursing Interventions for Schizoid Personality Disorder |
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Definition
| Desentitize to interpesonal relationships, Teach social skills, provide goal directed activities, provde solitary activities where the patient can be successful |
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Term
| Schizotypal Personality Disorder |
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Definition
| Has social and interpersonal deficits and is uncomfortable with close relationships, Cognitive or perceptual distortions, eccentric behavior, Idease of reference, odd beliefs, magical thinking, superstitiuos, clarvoyance, telepathy, bizarre fantasy, odd perecptural experiences, odd thinking, speech, behaviors, suspicious or paranoid ideation, inappropriate affect, lacks close friends, excessive social anxiety |
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Term
| Nursing Interventions for Schizotypal Personality Disorder |
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Definition
| Replace fantasy life with real interactions and activities, monitor anxiety level, talk with them during an axtivity, place in successful group activities, teach social skills, let the patient set interpersonal distance, ignor magical talk, focus on here and now. |
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Term
| Antisocial Personality Disorder |
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Definition
Disregards and violates rights of others since age 15
Failure to conform to social norms/law, deceitful, repeated lying or conning of others, highly impulsive, irritable and agressive, gets into fights, disregards the safety of others, irresponsible, unable to work or honor financial obligations, lack of remorse, does not profit from experience |
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Term
| Nursing Interventions for Antisocial Personality Disorder |
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Definition
| Intervene in manipulation and impulsivity, Direct confrontation, Point out responsibility, set limits and establish consequences, Encourage to talk things out rather than act out, encourage patient to accept responsibility for behavior, teach social skills, group therapy preferred. |
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Term
| Borderline Personality Disorder |
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Definition
| Has unstable interpersonal relationships, highly impulsive, poor self esteem, avoids abandonment, indentity disturbances, unstable, intense relationships, overvalues and devaules others, excess behaviors- spending, sex, substance abuse, reckless driving, binge eating, suicidal behavior or self mutilating, affect instability or emotional labiality, chronic feelings of empitness, inappropriate intese anger, frequent displays of temper- impulsive agression is the hallmark, Suspicousness or dissociative symptoms, Uses splitting with others |
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Term
| Nursing Interventions for Borderline Personality Disorder |
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Definition
| DBT- teaches life skills, social skills, anger management, mindfulness,stress management, avoid splitting- use consistency among staff, avoid being alone with them if possible, support staff who are the brunt of anger, Set limits on impulsivitiy, Group therapy, monitor suicidality and mutilation |
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Term
| Narcissistic Personality Disorder |
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Definition
| Grandiose but with underlying fragile self esteem, lacks empathy, exaggerated self importance, preoccupied with fanatasies of unlimited success, believes they are special, requires excessive admiration, entitled, expoitative, envious of others, arroagant and haughty |
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Term
| Nursing Interventions for Narcissistic Personality Disorder |
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Definition
| Gain a therapeutic alliance, teach social skills, assist with appropriate self esteem, assist in putting self in others place, deal with manipulations, offer a reality check |
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Term
| Histrionic Personality Disorder |
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Definition
| Excessively emotional, seeks constant attention, seek to be the center of attention, seductive, Rapid shifts in emotion, can be shallow or exaggerated, uses appearance to draw attention, dramatic, theatrical, is suggestible, considers relationships more intimate than they are. |
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Term
| Nursing Interventions for Histrionic Personality Disorder |
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Definition
| Give attentions when not demanding it, withdraw attention when behavior is inappropiate, if threatens self harm take action, point out innapropriate behaviors, protect staff member of opposite sex from patients advances, remove from audience if needed, set limits on seductiveness, Focus attention away from somatic complaints, assist to focus on own problems. |
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Term
| Dependent Personality Disorder |
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Definition
| Excessive need to be taken care of, is submissive and clingy, Fears separation, has difficulty making decisions, needs excessive advice, needs others to assume responsibilty for major life areas, has trouble disagreeing, has trouble initiating projecs, goes to length to obtain nurturance and support, feels helpless when alone, exaggerated fears of not being abe to care for self, seeks another caretaking relationship when one ends, unrealisisticall preoccupied with fears of being along and taking care of self. |
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Term
| Nursing Interventions for Dependent Personality Disorder |
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Definition
| Ascertain level of functioning and set realistic goals with patient, Teach problem-sovleing, Teach self reliance, reward any independet action, |
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Term
| Obsessive Compulsive Personality Disorder |
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Definition
| Preoccupied with orderliness, perfectionism, and interpersonal contraol at the expense of efficiency and emotional availability. |
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Term
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Definition
Impairment in reality testing
Loss of ego boundaries
50% of schizophrenic patients have substance abuse disorders
Is treatable with medications and behavioral interventions
Obtain a level of functioning
Lay term for a psychotic break is “Nervous breakdown”
Has a biological basis
Is related to genetics
Problem with the way they think & perceive
Takes over the person’s life |
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Term
|
Definition
Major tranquilizers:
Block the release of dopamine’s release
Reduces some signs and symptoms of schizophrenia |
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Term
| Course of the disease Schizophrenia |
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Definition
Experience symptoms 1 month to 1 year before first break:
Way be withdrawn,
Lonely, depressed as adolescent
Patient reports:
Mind wandering
Difficulty concentrating
Unwanted intrusive thoughts
Misinterprets things
Mistakes others as having a harmful intent
As disease develops:
Feels rejected
Lonely, hopeless
Withdraws emotionally & physically, isolates
Unable to trust others
Withdraws from reality
Begins delusions & hallucinations
Has odd mannerisms
Some think their thoughts are controlled by others or broadcasted
Voices seem to come from outside the person
Preoccupied with religion, mysticism or metaphysical |
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Term
|
Definition
Two or more of:
Delusions
Hallucinations
Disorganized speech
Derailment
Incoherence
Disorganized or catatonic behavior
Negative symptoms
Flat affect
Social/occupational or ADL’s dysfunction
Signs persist for 6 months with at least 1 month of symptoms
R/O medical condition or other psychiatric disorder |
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Term
|
Definition
Delusions- persecutory & grandiose & may be organized around a theme
Associated features: anxiety, anger, aloofness, & argumentativeness
Has a superior, patronizing manner, stilted or formal quality
Highly suspicious |
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Term
|
Definition
Motor immobility or stupor, waxy flexibility
Excessive motor activity, purposeless
Negativism- moveless resistance, mute
Peculiarities of voluntary movement
Posturing ( assuming inappropriate bizarre postures], prominent mannerisms & grimacing
Echolalia
Echopraxia |
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Term
| Disorganized type-DSM IV-TR |
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Definition
Disorganized speech
Disorganized behavior
Flat or inappropriate affect |
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Term
| Undifferentiated type-DSM IV-TR |
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Definition
| Does not meet the s/s of any other type of schizophrenia and schizophrenic symptoms are present. |
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Term
| Brief Psychotic Reaction- DSM IV-TR |
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Definition
Not schizophrenia
One or more Of:
Hallucinations
Delusions
Disorganized speech
Disorganized behavior
Duration: 1 day to 1 month
With or without marked stressor present |
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Term
|
Definition
Either a manic or depressive episode +
Symptoms of hallucinations and delusions
And:
Speech has obscure symbolism
Speech often understood as their relating to a private world
May have doubts about sexuality & may become hypersexual
Has fears of intimacy
Regression occurs:
Preoccupied with self
Isolation |
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Term
| Assessment Factors for Psychotic Disorders |
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Definition
Alterations in thinking
Hallucinations
Visual
Auditory
Tactile
Illusions
Ideas of reference
Flight of ideas
Delusions
Grandiose
Persecutory
Common delusional themes
Thought broadcasting
Thought insertion
Thought withdrawal
Delusions of being controlled
Religious
Somatic
Clang associations
Loss of ego boundaries
Depersonalization-a feeling of unreality from self, difficulty distinguishing self from others
Behavioral alterations
Odd and unusual
Bizarre behavior
Agitation
Stereotyped behavior
Automatic obedience
Waxy flexibility
Bizarre posturing
Stupor
Comma like |
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Term
|
Definition
Positive symptoms: (Exaggeration or distortion of normal function)
Delusions
Hallucinations
Disorganization of speech & Behavior
Thought disorder (incoherence, word salad, loose associations, etc
Bizarre behavior |
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Term
|
Definition
Negative symptoms (Less of or loss of normal
function)
Flat affect & blunting
Decreased energy
Anhedonia
Lack of motivation
Impaired decision-making
Alogia-restricted thought & speech
Avolition-Apathy & lack of goal directed behavior
Impairment in attention |
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Term
| Paranoid Schizophrenia Interventions |
|
Definition
Ask indirect questions
Be honest & consistent
Let patient set interpersonal distance
Evaluate delusional themes & feeling content
Use non-defensive stance
Use simple, clear words
Do not argue with content of delusions
Clarify & restate role
No touching
Maintain boundaries
Not close, limit time &
No touching |
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Term
|
Definition
| Extrapyramidal effects, anticholinergic effects Monitor weight for changes a reason patients will not want to take the medication, Typical antipsychotic |
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Term
|
Definition
Uses: Schizophrenia, psychotic disorders, schizoaffective disorders.
Side effects: agranulocytosis-lowering of white blood cells, risk for seizures,
hypersalivation, hypotension, sedation, tachycardia, weight gain and Type-2
diabetes, may increase triglycerides and cholesterol.
Atypical antipsychotic
: Prescriber needs to monitor white blood cell count |
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Term
|
Definition
Uses: Psychotic disorders, bipolar disorders, schizoaffective disorders, and to calm
aggressive and agitated behavior in children, adolescents and adults.
Avoid activities requiring mental alertness until adjusted to medication.
Alcohol use is contraindicated because medication is sedating.
Diabetic patients should monitor for signs and symptoms of hyperglycemia. |
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Term
|
Definition
: Moderate sedation, weight gain and Type II diabetes Rapidly calms agitation
Produces the most weight gain of the atypical antipsychotics.
Patient is at risk for type-2 diabetes.
Don't break the pills into halves. The medication oxidizes and looses the active
ingredient.
If the nurse gets the medication on the skin, can cause a rash. |
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Term
|
Definition
Do not suddenly stop the medication.
Do not drink alcohol with medication. |
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Term
|
Definition
Uses: Psychotic disorders, bipolar disorder, schizoaffective disorder, and sometimes
used off label for sleeplessness in patients with other disorders.
Side effects: sedation, hypotension, restless legs syndrome, weight gain, can cause Type II diabetes. |
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Term
|
Definition
Available only in sublingual tablets.
Can cause EPS like typical antipsychotics.
Side effects: weight gain, oral numbness, sedating.
Nursing measures:
Can cause oral numbing. Keep from getting bit if place under the tongue |
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