Psychotropic Drug Therapy

Potency

amount of drug needed to achieve maximum effect

This should be avoided in treating patients with severe hypotensive reactions.

epinephrine (use norepinephrine!)

Steady state

amount of drug absorbed is constantly balanced by the competing processes of metabolism, distribution, and elimination (some psychiatric drugs work only after steady state is achieved)

Indications for use of antipsychotic drugs include

1. schizophrenia 2. acute mania/bipolar mania 3. psychotic depression 4. drug-induced psychosis 5. other psychotic symptoms

antiepileptic drugs

1. carbamazepine (Tegretol) 2. valproic acid (Depakene, Depakote) 3. gabapentin (Neurontin)

Contraindications for antipsychotic medications

1. nervous system depression 2. circulatory collapse 3. Parkinson's disease 4. coronary disease 5. severe hypotension 6. bone marrow suppression 7. blood dyscrasias (disorders)

Functions of histamine

1. alertness 2. control of gastric secretions 3. cardiac stimulation 4. inflammatory response

Common side effects of antimarkinsonian agents to treat EPS

1. anticholinergic effects 2. nausea and GI upset 3. sedation 4. orthostatic hypotension

Another name for antipsychotic medications

1. neuroleptics 2. major tranquilizers

Emergency treatment for lithium overdose and toxicity

(no known antidote) 1. stop drug 2. maintain airway and ventilation 3. give emetic if alert 4. gastric lavage if necessary 5. increase excretion 6. hemodialysis in life-threatening toxicity

Efficacy

maximal effect drug can achieve

What assessments are important to monitor for neuroleptic malignant syndrome?

Routine assessments of: 1. temperature 2. observaton for parkinsonian symptoms

Most of a drug is removed in this time period

seven half-lives

lithium competes with this electrolyte

sodium

What are the biggest issues related to antiphyschotic medication

1. relapse 2. noncompliance

These antipsychotic drugs are available in a rapidly disintegrating tablet form to increase compliance

1. risperidone (Risperdal M-Tab) 2. olanzapine (Zyprexa, Zydis)

Anxiolytic drugs

1. clonazepam (Klonopin) 2. lorazepam (Ativan)

What is the priority action if you observe a patient with symptoms of neuroleptic malignant syndrome?

**1. discontinue the antipsychotic medication immediately 2. transfer STAT to medical facility 3. monitor vital signs, degree of muscle rigidity, intake and output, and LOC 4. treat presenting symptoms

Side effects of antipsychotic medications

1. sedation 2. anticholinergic effects 3. orthostatic hypotension 4. seizures 5. agranulocytosis (low white count) 6. rash - contact dermatitis 7. photosensitivity 8. cataracts 9. elevated prolactin

Neuroleptic malignant syndrome (NMS)

1. A severe form of EPS symptoms 2. rare but can be fatal

Potentially dangerous responses to antipsychotics

1. anticholinergic toxicity 2. neuroleptic malignant syndrome 3. agranulocytosis 4. cholestatic jaundice 5. altered regulation of body temperature (heat intolerance increasing risk of dehydration)

Functions of norepinephrine

1. attention and learning/cognition 2. memory 3. sleep 4. wakefulness 5. mood regulation 6. cardiovascular function

At serum lithium levels of 1.5 to 2.0, you would expect these symptoms

1. blurred vision 2. ataxia 3. tinnitus 4. persistent nausea and vomiting 5. severe diarrhea

The physician may order one of these medication to counteract the effects of neuroleptic malignant syndrome.

1. bromocriptine (Parlodel) 2. dantrolene (Dantrium)

Nursing actions for patients taking antipsychotic medication

1. change position slowly, monitor vitals 2. monitor weight - diet, fluids, exercise 3. assess for tardive dyskinesia - report for possible dose change 4. protect from sun exposure 5. safety measures if experience sedation 6. avoid alcohol

Examples of Typical antipsychotic agents

1. chlorpromazine (Thorazine) 2. fluphenazine (Prolixin) 3. haloperidol (Haldol)

Examples of Atypical antipsychotic agents

1. clozapine (clozaril) 2. olanzapine (Zyprexa) 3. quetiapine (Seroquel) 4. resperiodone (Risperdal)

Contraindications for atypical antipsychotics

1. comatose state 2. severely depressed patients 3. elderly with dementia-related psychosis 4. lactation

Contraindications for typical antipsychotics

1. comatose state, CNS depression 2. blood dyscrasias 3. Parkinson's disease 4. narrow angle glaucoma 5. liver, renal, or cardiac insufficiency 6. poorly controlled seizure disorders 7. elder clients with dementia-related psychosis (also in hypersensitivity)

Functions of dopamine

1. control of complex movements 2. motivation, cognition 3. resolution of emotions 4. inhibits release of prolactin

What dietary considerations should be taught to the patient on lithium?

1. diet adequate in sodium 2. 2,500 to 3,000 mL of lfuid per day 3. record intake and output 4. daily weights

Patient/family education for patients on lithium includes

1. do not stop medication, even if feeling well - results in return of symptoms 2. do not drive or operate dangerous machinery until lithium levels stable 3. dietary sodium, fluid intake, avoid caffeine 4. report vomiting, diarrhea 5. carry card indicating taking lithium 6. maintain sodium intake while reducing calories if seeking weight loss 7. report pregnancy immediately 8. know side effects to report 9. follow up care, lithium levels checked

side effects of lithium

1. drowsiness, dizziness, headache 2. dry mouth, thirst 3. GI upset, nausea/vomiting 4. fine hand tremors 5. hypotension; arrhythmias; pulse irregularities 6. polyuria, dehydration 7. weight gain

Anticholinergics cause

1. dry mouth 2. blurred vision 3. constipation 4. urinary retention 5. tachycardia

Side effects of anticholinergics

1. dry mouth 2. blurred vision 3. constipation 4. urinary retention 5. tachycardia (**blocking the parasympathetic nervous system, so you will have increased sympathetic nervous system effects**)

Factors that decrease lithium excretion, which can lead to toxicity

1. elderly age 2. sodium deficiency 3. extreme exercise 4. diarrhea and vomiting 5. post-partum state

A nurses assesses a patient with agitation. The nurse may observe these characteristics.

1. escalating anxiety and anger 2. complaining 3. destructive behavior

At serum lithium levels of 2.0 to 3.5, you would expect these symptoms

1. excessive output of dilute urine 2. increasing tremors 3. muscular irritability 4. psychomotor retardation 5. mental confusion 6. giddiness

In addition to the benefits of dopamine blockage in treating the positive symptoms of schizophrenia, dopamine can cause these side effects

1. extrapyramidal symptoms (think connection between dopamine and parkison's) 2. prolactin elevation - galactorrhea, gynecomastia

A nurse assesses a patient with akathisia. The nurse may observe these characteristics.

1. feeling "antsy" 2. inability to sit still 3. pacing floor 4. not frightened

Cardiac effects associated with lithium

1. flat or inverted T wave 2. cardiac arrest

black box warning for valproate (Depakote)

1. hepatotoxicity 2. pancreatitis 3. teratogenicity

side effects of Risperidone (Risperdal)

1. high potency 2. high level sedation 3. low anticholinergic efffect 4. medium hypotension 5. medium risk of extrapyramidal effects

Describe low potency drugs as they pertain to: 1. sedation 2. ACH 3. EPS

1. high sedation 2. high ACH 3. low EPS

Factors that increase lithium excretion

1. high sodium intake 2. pregnancy 3. caffeine

At serum lithium levels above 3.5, you would expect these symptoms

1. impaired consciousness 2. nystagmus 3. seizures 4. coma 5. oliguria/anuria 6. arrhythmias 7. myocardial infarction 8. cardiovascular collapse

Metabolic syndrome includes these characteristics

1. insulin resistance 2. high blood pressure 3. obese or overweight 4. abnormal cholesterol levels

Important labs for patient on lithium therapy

1. kidney function 2. thyroid function 3. EKG 4. blood levels to monitor for toxicity

Describe high potency drugs as they pertain to: 1. sedation 2. ACH 3. EPS

1. low sedation 2. low ACH 3. High EPS

Function of GABA (Gamma-Aminobutyric Acid)

1. modulate other neurotransmitters 2. slow down body activity

key nursing interventions for patients on anticonvulsants

1. monitor liver function and blood count for hepatoxicity 2. monitor for bone marrow depression: agranulocytosis, leukopenia, anemia, thrombocytopenia 3. check blood level of drug

Side effects of anticonvulsants

1. nausea/vomiting 2. drowsiness, dizziness 3. blood dyscrasias 4. prolonged bleeding time (valproic acid) 5. risk of severe rash 6. decreased efficacy with oral contraceptives 7. risk of suicide**

Key nursing diagnoses related to antipsychotic drug therapy

1. noncompliance 2. disturbed thought processes 3. impaired physical mobility

Monoamines include these neurotransmitters

1. norepinephrine 2. dopamine 3. serotonin 4. histamine

These 6 atypical antipsychotic medications are linked to metabolic syndrome

1. olanzapine (Zyprexa) 2. aripiprazole (Abilify) 3. ziprasidone (Geodon) 4. clozapine (Clozaril) 5. risperidone (Risperdal) 6. quetiapine (Seroquel)

How often should serum lithium levels be monitored?

1. once or twice a week after initial treatment until stable 2. monthly during maintenance therapy

Indications for use of anticonvulsant drugs as mood stabilizers

1. rapid-cycling disorder (manic-depressive) 2. mood stabilization in schizoaffective disorder 3. control impulses and aggressive behavior 4. withdrawal from alcohol and Benzos

Functions of serotonin

1. regulation of emotions, agression 2. sleep, wakefulness 3. food intake, appetite 4. sexual behaviors 5. pain control 6. judgement

Symptoms of neuroleptic malignant syndrome (NMS)

1. severe parkinsonian muscle rigidity 2. high fever 3. tachycardia 4. tachypnea 5. fluctuations in blood pressure, hypertension 6. diaphoresis 7. hyperpyrexia 8. elevated CPK 9. rapid deterioration of mental status to stupor and coma

For patients taking anticonvulsant drugs, teach them to

1. take with food 2. be aware of decreased effects of oral contraceptives 3. report unusual bleeding or brusing 4. photosensitivity - wear sunscreen and protective clothing

Extrapyramidal symptoms (EPS)

1. tremors 2. chorea 3. dystonia, acute dystonic reactions 4. akinesia 5. akathisia 6. neuroleptic malignant syndrome (side effects of antipsychotic drugs)

Two major classifications of antipsychotic medications

1. typical (first generation, conventional) 2. atypical (newer, novel)

Ways of increase excretion of lithium in a patient experiencing toxicity

1. urea 2. mannitol 3. aminophylline

Examples of anticonvulsants used for mood stabilization

1. valproate (Depakote) 2. carbamazepine (Tegretol)

Side effects of histamine blockers

1. weight gain 2. sedation

A nurses assesses a patient with anxiety. The nurse may observe these characteristics.

1. worry or concerns 2. fears 3. somatic (physical) complaints

half life of triazolam (Halcion)

10 hours

When should blood samples be drawn when monitoring lithium levels?

12 hours after last dose

What is the duration of risperidone (Risperdal)?

2 weeks

What is the duration for haloperidol (Haldol)

4 weeks

half life of chlorpromazine (Thorazine)

7 days

What is the duration of fluphenazine deconaoate (Prolixin)?

7-28 days

In monitoring blood levels for the patient on lithium therapy, lithium levels should be: A. for acute mania: B. for maintenance:

A. 1.0 -1 .5 mEq/L B. 0.6 - 1.2 mEq/L

Clint, a client on the psychiatric unit, has been diagnosed with Schizophrenia. He begins to tell the nurse about how the CIA is looking for him and will kill him if they find him. Clint's belief is an example of a A. delusion of persecution B. delusion of reference C. delusion of control or influence D. delusion of grandeur

A. delusion of persecution

The nurse is interviewing a client on the psychiatric unit. The client tilts his head to the side, stops talking in midsentence, and listens intently. The nurse recognizes from these behaviors as a symptom of the client's illness. The most appropriate nursing intervention for this symptom is to: A. ask the client to describe his physical symptoms B. ask the client to describe what he is hearing C. administer a dose of benztropine D. call the physician for additional orders

B. ask the client to describe what he is hearing

The primary goal in working with an actively psychotic, suspicious client would be to A. promote interaction with others B. decrease his anxiety and increase trust C. improve his relationship with his parents D. encourage participation in therapy activities

B. decrease his anxiety and increase trust

Tony, age 21, has been diagnosed with Schizophrenia. He has been socially isolated adn hearing voices telling him to kill his parents. He has been admitted to the psychiatric unit from the emergency department. The initial nursing intervention for Tony is to A. give him an injection of Thorazine B. ensure a safe environment for him and others C. place him in restraints D. order him a nutritious diet

B. ensure a safe environment for him and others

The nurse is interviewing a client on the psychiatric unit. The client tilts his head to the side, stops talking in midsentence, and listens intently. The nurse recognizes from these signs that the client is likely experiencing A. somatic delusions B. catatonic stupor C. auditory hallucinations D. pseudoparkinsonism

C. auditory hallucinations

When a client suddenly becomes aggressive and violent on the unit, which of the following approaches would be best for the nurse to use first? A. provide large motor activities to relieve the client's pent-up tension. B. administer a dose of prn chlorpromazine to keep the client calm. C. call for sufficient help to control the situation safely. D. convey to the client that his behavior is unacceptable and will not be permitted.

C. call for sufficient help to control the situation safely.

The nurse is caring from a client with schizophrenia. Orders from the physician include 100 mg chlorpromazine IM STAT and then 50 mg PO bid; 2mg benztropine PO bid prn. Why is chlorpromazine ordered? A. to reduce extrapyramidal symptoms B. to prevent neuroleptic malignant syndrome C. to decrease psychotic symptoms D. to induce sleep

C. to decrease psychotic symptoms

Clint, a client on the psychiatric unit, has been diagnosed with Schizophrenia. He begins to tell the nurse about how the CIA is looking for him and will kill him if they find him. The most appropriate response by the nurse is: A. that's ridiculous, Clint. No one is going to hurt you. B. The CIA isn't interested in people like you, Clint. C. Why do you think the CIA wants to kill you? D. I know you believe that, Clint, but it's really hard for me to believe.

D. I know you believe that, Clint, but it's really hard for me to believe.

The nurse is caring for a client with schizophrenia. Orders from the physician include 100 mg chlorpromazine IM STAT and then 50 mg PO bid; 2 mg benztropine PO bid prn. Because benztropine was ordered on a prn basis, which of the following assessments by the nurse would convey a need for this medication? A. the client's level of agitation increases B. the client complains of a sore throat C. the client's skin has a yellowish cast D. the client develops tremors and a shuffling gait

D. the client develops tremors and a shuffling gait

The primary focus of family therapy for clients with schizophrenia and their families is A. to discuss concrete problem-solving and adaptive behaviors for coping with stress. B. to introduce the family to others with the same problem. C. to keep the client and family in touch with the health-care system. D. to promote family interaction and increase understanding of the illness.

D. to promote family interaction and increase understanding of the illness.

What are extrapyramidal side effects?

Drug-induced movement disorders

Mnemonic for remembering symptoms of Neuroleptic Malignant Syndrome

F - fever E - encephalopathy (delirium) V - vitals unstable E - elevated enzymes - CPK R - rigid muscles

dystonia

Involuntary muscle contractions that cause repetitive or twisting movements.

A big reason why many patients discontinue antipsychotic medication

It takes several weeks for the antipsychotics to effectively treat positive symptoms.

What EKG change is related to antipsychotic medication?

QT prolongation (particularly thioridazine (Mellaril) and ziprasidone (Geodon)

What is important client and family education related to a patient just newly taking antipsychotic medications.

The importance of waiting for several weeks before medications take full effect

akathisia

a state of agitation, distress, and restlessness

Third generation antipsychotic drugs

aripiprazole (Abilify)

How do typical antipsychotics work?

block dopamine receptors

This drug is effective for patients who need long-term maintenance but cannot tolerate lithium

carbamaepine (Tegretol)

This drug is used for rapid-cycling bipolar disorder or secondary mania

carbamazepine (Tegretol)

What careful monitoring should be done in patients taking medications that can prolong the QT segment such as tioridazine and ziprasidone?

careful monitoring of conditions that can cause hypokalemia and hypomagnesemia

Acetylcholine is this type of neurotransmitter

cholinergic

This medication lowers seizure threshold

clozapine (Clozaril)

This medication requires a weekly WBC

clozapine (Clozaril) (can cause agranulocytosis)

In patients with depression, increased mania, anxiety states, and schizophrenia, what would be expected of norepinephrine levels?

decreased levels

What would expected levels of serotonin be in the patient with depression?

decreased serotonin

This neurotransmitter may play a role in physical activation of the body

dopamine

How do third generation antipsychotics (aripiprazole - Abilify) work?

dopamine system stabilizer: 1. increases dopamine transmition if low 2. decreases if too high

This type of tremors is an emergent situation in patients taking lithium.

gross tremors as opposed to fine tremors

Medications prescribed with antipsychotics to treat EPS side effects

helps restore balance between acetylcholine and dopamine (antiparkinsonian agents): 1. benztropine (Cogentin) 2. trihexyphenidyl (artane 3. diphenhydramine (Benadryl)

What would expected levels of serotonin be in the patient with schizophrenia and anxiety states?

increased serotonin

The increased risk of death in the elderly with neurocognitive disorder (NCD) taking antipsychotic medications is related to

infections and cardiovascular problems

Function of acetylcholine

involved in: 1. sleep, arousal 2. pain perception 3. movement 4. memory

chorea

jerky involuntary movements affecting especially the shoulders, hips, and face.

Mood stabilizing agent - antimanic

lithium carbonate (LiCo3)

What effect will decreased sodium in the body have when taking lithium?

lithium is reabsorbed by kidneys, increasing possibility of toxicity

akinesia

loss or impairment of the power of voluntary movement.

Why are antipsychotics not approved for dementia-related psychosis?

may cause change in heart rhythm - increased heart rhythm

The fight or flight syndrome of symptoms occurring in response to stress is associated with this neurotransmitter

norepinephrine

if hand tremors appear in the patient taking lithium, what might the physician order to counteract this effect?

propranolol

Half-life

time it takes for half of the drug to be removed from the bloodstream

Neuroleptic malignant syndrome (NMS) is more common with this type of antipsychotics

typical

How do atypical antipsychotics work?

weaker dopamine receptor antagonists than typical, but are more potent antagonists of serotonin type 2A receptors