Psychopharmacology for Schizophrenia

What client is being treated with a typical antipsychotic?

An agitated client who was given haloperidol during acute psychosis

True or False: TD and akathisia is curable with antihistamines if intervened early enough.

False. There is no cure, but symptoms can be lessened.

True or False: Giving a patient that is out of control with aggressive behavior medications to calm them down is not considered a restraint because there is an order.

False: this is a chemical restraint regardless of orders.

The client has been taking an atypical antipsychotic medication for several years. During annual physical examinations, what assessment best addresses a likely adverse effect?

Fasting blood glucose levels

A psychiatric nurse is reviewing various antipsychotic agents. The nurse should identify what drug as having the highest potency?

Fluphenazine

A client who is being treated with a typical antipsychotic reports frequent nasal congestion and urinary hesitation. To what should the nurse most likely attribute these symptoms?

Anticholinergic effects

The nurse is caring for a client who is prescribed haloperidol long term. What assessment should the nurse prioritize?

Assessment for involuntary movements

Contraindications for atypical antipsychotics

±Hyper-sensitivity ±Comatose or when CNS depression is evident ±Elderly pts with psychosis r/t neurocognitive disorders ±Lactation ±*Clozapine ±***BOTH: QT interval*** ±***Cautions***

Contraindications for Typical antipsychotics

±Hyper-sensitivity ±Comatose states or when CNS depression is evident ±Parkinson's or narrow-angle glaucoma ±hypotension, cardiac, kidney insufficiency ±Poorly controlled seizure disorders ±Elderly pts with psychosis r/t neurocognitive disorders

Pseudoparkinsonism

±Masklike face ±Excessive drooling ±Stooped posture (key identifier) ±Bradykinesia ±Shuffling gate ±Rigidity

Atypical antipsychotics

±Mnemonic: All Smart Industrious Students Rarely Get Free time, Vacations, Lazy days, Catnaps, or Zzzs °aripiprazole (Abilify) °asenapine (Saphris) °paliperidone (Invega) °quetiapine (Seroquel) °risperidone (Risperdal) °ziprasidone (Geodon) °iloperidone (Fanapt) ±not first line b/c of QT prolongation °cariprazine (Vraylar) °lurasidone (Latuda) °clozapine (Clozaril) °olanzapine (Zyprexa)

Clozapine (Clozaril)

- Antipsychotic medication - Want to watch for tachycardia and seizures - May cause severe agranulocytosis (weekly blood draws) ±Mandatory Clozaril registry and lab work for... °WBC/absolute neutrophil count (ANC) °Lab schedule: initially weekly for the first 6 months then biweekly for next 6 months then monthly °If pt develops this s/e, tx is to DISCONTINUE Blood work is continued for 1 month after medication is d/c.

Akathisia

- Motor restlessness, person needs to keep going - Tx with antiparkinsons meds - Can be mistaken for agitation

What assessment finding should lead the nurse to suspect that a client receiving antipsychotic therapy is developing tardive dyskinesia?

Lip smacking

Arirpiprazole (Abilify)

Not first line. Try other medications first because of the s/e. Causes drowsiness, nausea, vomiting, constipation, insomnia, agitation, lightheadedness. Adverse reactions: neuromalignant syndrome, seizures, tachycardia tx: d/c medications if s/e occur.

A client is prescribed benztropine. The nurse would anticipate administering this drug by which route?

Oral

A nurse is planning discharge teaching for a patient taking clozapine (Clozaril). Which of the following is most important to include?

Remind the patient to follow protocol for blood draws.

A nurse is planning the care of a client who has been diagnosed with schizophrenia and who will begin treatment with a typical antipsychotic. The nurse should identify what nursing diagnosis?

Risk for injury related to central nervous system depression

Dystonia

a condition of abnormal muscle tone that causes the impairment of voluntary muscle movement ±Neck = Torticollis ±Neck/spine = Opisthotonus ±Eyes = Oculogyric crisis

Abnormal Involuntary Movement Scale (AIMS)

tool used to screen for symptoms of movement disorders (side effects of neuroleptic medications) 0-1: Low risk 2 in only one of the areas: Borderline- observe closely 2 in two or more of the areas OR 3-4 in only one of the areas = indicative of TD.

Classes of medications

°Antipsychotics (aka neuroleptics) °Typical (first generation, conventional) °Atypical (newer, novel antipsychotics)

True or False: A client with schizophrenia will exhibit fluctuations in mood swings from depression to mania.

False

True or False: The development of diabetes mellitus is associated with the use of typical antipsychotics.

False

The nurse determines the client may be displaying extrapyramidal effects on the basis of what assessment findings? Select all that apply. a. The client's gait is uncoordinated. b. The client has an aversion to bright lights. c. The client exhibits hand tremors. d. The client has been experiencing insomnia and early morning awakening. e. The client has had uncharacteristic verbal outbursts.

A & C Rationale: Ataxia, parkinsonism, and tremors are signs and symptoms of extrapyramidal effects. Insomnia and photophobia are adverse effects of typical antipsychotic medications but are not indicative of extrapyramidal effects. Verbal outbursts are unlikely to be related to drug therapy.

Neuroleptic Malignant Syndrome

Adverse reaction to antipsychotics with: ±Autonomic hyperactivity °Very high fever, severe parkinsonian muscle rigidity, tachycardia, tachypnea, delirium, and rapid deterioration of mental status à coma °Treatment: D/C medication; IV dantrolene (muscle relaxant) or bromocriptine (dopamine agonist)

A client who has been taking chlorpromazine (Thorazine) for several months presents in the emergency department with EPS of restlessness, drooling, and tremors. What medication will the nurse expect the physician to order?

Benztropine (Cogentin)

Typical Antipsychotics

Examples: AZINE (phenothiazines) °chlorpromazine (Thorazine) °thioridazine (Mellaril) °fluphenazine (Prolixin) °trifluoperazine (Stelazine) °mesoridazine (Serentil) °perphenazine (Trilafon) ±this is not in all of your drug books Example: IDOLs °droperidol (Inapsine) °haloperidol (Haldol) Example: other °loxapine (Loxitane; Adasuve)

oculogyric crisis

Involuntary deviation and fixation of the eyeballs, usually in the upward position. It may last for several minutes or hours and may occur as an extrapyramidal side effect of some antipsychotic medications.

What is the antidote for anticholinergics?

Physostigmine (Antilirium)

While caring for a client receiving antipsychotic therapy, the nurse observes cogwheel rigidity, tremors, and drooling. The nurse interprets this as what?

Pseudoparkinsonism

A client is being treated with clozapine. What should the nurse monitor most closely?

White blood cell count

Saphris (asenapine)

atypical antipsychotic ±Saphris is SL: available as black cherry flavor and must not eat/drink for 10 min. afterwards

Which medication is given in the hospital to treat EPS s/e?

benztropine (Cogentin)

Which medication is most commonly used to treat EPS?

diphenhydramine (Benadryl)

Tardive dyskinesia (TD)

potentially disabling motor disorder that may occur following long term use of antipsychotic drugs. Symptoms potentially irreversible. Can be treated with valbenazine (Ingrezza) to help reduce symptoms. ±RN role: report s/s to provider IMMEDIATELY

The nurse just administered chlorpromazine to a client by intramuscular injection. The nurse should instruct the client to:

stay in bed for the next half hour.

Extra Pyramidal Symptoms

±Acute Dystonia ±Pseudoparkinsonism ±Akathisia ±Oculogyric Crisis ±Tardive Dyskinesia (TD) ±Antiparkinsonian agents may be prescribed to counteract EPS. ±Most common meds to treat benztropine (Cogentin) diphenhydramine (Benadryl) ±Antidote for anticholinergics? physostigimine (Antilirium)

Common side effects of typical antipsychotics

±Anticholinergic effects ±Nausea; gastrointestinal upset ±Skin rash ±Sedation ±Orthostatic hypotension ±Photosensitivity ±Hormonal effects ±Electrocardiogram changes ±Hypersalivation ±Weight gain ±Hyperglycemia/diabetes ±Increased risk of mortality in elderly clients with dementia ±Reduction in seizure threshold ±Agranulocytosis ±Extrapyramidal symptoms ±Tardive dyskinesia ±Neuroleptic malignant syndrome