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Medications Commonly Prescribed in Psychiatric / Mental Health
Settings
ANXIOLYTIC AGENTS
alprazolam (Xanax)
buspirone (BuSpar)
chlordiazepoxide (Librium)
clorazepate (Tranxene)
diazepam (Valium)
lorazepam (Ativan)
ANTICONVULSANTS
clonazepam (Klonopin)
carbamazepine (Tegretol)
divalproex sodium (Depakote)
gabapentin (Neurontin)
valproic acid (Depakene)
ANTIDEPRESSANTS
amitriptyline (Elavil)
citalopram (Celexa)
desipramine (Norpramine)
escitalopram oxalate (Lexapro)
fluoxetine (Prozac)
fluvoxamine (Luvox)
imipramine (Tofranil)
nefazodone (Serzone)
paroxetine (Paxil)
phenelzine (Nardil)
sertraline (Zoloft)
trazodone (Desyrel)
venlafaxine (Effexor)
usually used for sedating effect
as a mood stabilizing agent
as a mood stabilizing agent
as a mood stabilizing agent
as a mood stabilizing agent
SSRI (selective serotonin reuptake inhibitor)
SSRI
SSRI
SSRI
SSRI
SSRI
MOOD STABILIZING AGENTS
lithium carbonate / citrate
ANTIPARKINSONIAN AGENTS
benztropine mesylate (Cogentin)
diphenhydramine (Benadryl)
trihexyphenidyl (Artane)
ANTIPSYCHOTICS
aripiprazole (Abilify)*
chlorpromazine (Thorazine)
clozapine (Clozaril)*
fluphenazine (Prolixin)
haloperidol (Haldol)
STIMULANT AGENTS
methylphenidate (Ritalin)
pemoline (Cylert)
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olanzapine (Zyprexa)*
quetiapine (Seroquel)*
risperidone (Risperdal)*
thioridazine (Mellaril)
thiothixene (Navane)
ziprasidone (Geodon)
*ATYPICAL ANTIPSYCHOTICS
Role of Drugs in Psychiatric Care
I.
Assumptions
A. Not a "cure"
B. Used to alleviate symptoms and therefore allow individual to participate more
easily in other forms of treatment
II.
Seven major drug groups
A. Major Tranquilizers ( also known as neuroleptics, ataractics, antipsychotics, or
phenothiazines)
B. Minor Tranquilizers (also known as anti-anxiety or anxiolytic agents)
C. Antidepressants (also known as psychostimulants, or psychic-energizers)
D. Lithium (also known as antimanic or a mood stabilizer)
E. Antiparkinson Agents
F. Anticonvulsants (used as mood stabilizers)
G. Stimulants (usually used for attention deficit disorders)
III.
Major Tranquilizers - the "Antipsychotic agents" See previous page
A. Characteristics:
1. Have an antipsychotic activity
 calm aggressive, overactive, highly disturbed people
2. Do not produce deep coma and anesthesia even with large doses
3. Are not addictive, either psychologically or physically
4. Produce extrapyramidal side effects (may be reversible or irreversible)
Notes:
 Clozapine and olanzapine infrequently cause EPS and perhaps never
tardive dyskinesia
 Weekly blood work must be performed on individuals taking clozapine
to monitor for agranulocytosis
B. Side effects: Will be marked variation in sensitivity from person to person.
1. Oversedation:
a. Phenothiazines act like local anesthetics on sensory nerve endings,
clouding out stimuli
b. Most individuals will feel groggy the first few days when taking
medication
c. Usually disappears in one week
2. Extra-pyramidal effects (EPS) Four general types
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a. Pseudo-parkinsonism
 Tremor - "pill-rolling" of fingers, especially first and thumb
 Mask-like facial expression
 Rigidity (esp. "lead-pipe" and "cog-wheel "types) Drooling
 Shuffling gait
b. Akathisia
 Most prevalent EPS & most common side effect to cause
individualsto discontinue medication
 Motor, inner-driven restlessness
 The “jitters,” “fidgety,” or “inner itch”
 Tapping feet incessantly, “restless legs”
 Shifting weight from side to side
 Rocking forward and backward in chair
 Ask if “muscle” or “head” feeling; head feeling more likely to be
anxiety
c. Akinesia
 Lack of spontaneous gestures or voluntary useful movements
 Apathy
 Rigid posture
 Diminished or total lack of conversation
 Decreased arm swing
 Feelings of fatigue and weakness, especially legs
d. Dystonic reactions
 Onset is usually sudden, symptoms may come and go and are usually
distressing to individual
 Acute contractions of tongue, face, neck, &/or back; may
describe stiff, thick tongue
 Tongue, jaw and neck spasms are first to erupt - few hours to days
 Other symptoms
 Opisthotonos - tightening of entire body, head back, and belly up
 Oculogyric crisis - eyes locked upward
 Laryngospasm - can have breathing difficulties
 Torticollis - twisting of cervical muscles, unnatural head position
 Voluntary control does not mean individual faking
 More common with mania than with schizophrenia
 Prophylactic anticholinergics often prescribed with high-potency
neuroleptics, especially in males < 30 years and females < 25 years
NOTE: All of the above extra-pyramidal symptoms might be controlled by the use
of antiparkinson medications or by lowering dosage, or by changing drug
classification.
3. Tardive Dyskinesia (TD) - most serious side effect of long-term use of neuroleptics
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Arises after 3-6 months of treatment
a. May appear when antipsychotic lowered or stopped
b. May be irreversible
c. Three major types of symptoms
 Facial-lingual-oral involuntary hyperkinesis (most common)
 Limb choreoathetoid movements
 Trunk movements
 See AIMS Scale must complete test in clinical rotation
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4. Anticholinergic effects on the autonomic nervous system. Most decrease in
weeks but don’t completely remit
 Hypotension
 Dry mouth
 Constipation
 Paralytic ileus
 Urinary hesitancy or retention
 Blurred near vision
 Dry eyes
 Narrow angle glaucoma
 Photophobia
 Nasal congestion
 Confusion and decreased memory
5. Endocrine effects:
 Breast enlargement and tenderness
 Galactorrhea
 Diminished libido
 Amenorrhea, menstrual irregularities, delayed ovulation
 Increase breast cancer growth
6. Skin, Allergies and Temperature Effects
 Photosensitivity - Chlorpromazine (Thorazine) highest; may have severe
sunburn after 30-60 minutes of direct sunlight
 Skin rashes
 Hyperthermia more common than hypothermia
 Decreased sweating
7. Other types of side effects:
 Decrease the convulsive threshold - persons with seizure disorders are
more likely to have seizures
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 Antiemetic drugs (e.g. Compazine)
 Potentiate alcohol barbiturates, and analgesics - individual should be
cautioned
 Neuroleptic Malignant Syndrome -Can be fatal
 Characterized by severe muscle rigidity, hyperthermia, stupor,
elevated CPK

IV. Minor Tranquilizers - the "Anti-anxiety agents" or “anxiolytic agents”
(See list of Medications Commonly Prescribed)
A. Characteristics
1. Used to treat:
 Generalized anxiety disorders
 Acute panic disorders
 To augment treatment in bipolar disorder, especially during the manic
phase
2. Tolerance can develop and physical addiction can result from use; HIGH
POTENTIAL FOR ABUSE
3. Most have strong muscle relaxing effect
4. Strong sedative effect with decreased mental alertness. Side effects:
 Drowsiness
 Dizziness
 Dry mouth
 Headache
5. Larger doses may cause slurred speech, ataxia, mental confusion
6. Sometimes may cause paradoxical reactions of excitement or rage
7. May cause withdrawal symptoms if stopped abruptly after prolonged use:
 Tremors
 Muscle twitching
 Vomiting
 Confusional states
 Convulsions
8. Buspirone differs from benzodiazepines:
 Lacks anticonvulsant, sedative, or muscle relaxant properties
 Not effective in panic disorder or acute anxiety
 Used for generalized anxiety disorders
 Not known to develop drug dependency
 One to 2 week onset IV.
V.
Anti-Depressants
A. Characteristics
1. Are used in the treatment of depressive states
2. Create an energy producing action that results in
 Elevation of mood
 Increased physical activity and mental alertness
 Improved appetite and sleep patterns
 Reduction in preoccupations and delusions
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3. Typically require 10 -14 days on a therapeutic dose to start working and full
effect
may take 6 weeks
4. Four types of drugs in this classification:
 Tricyclics (TCAs)
 Monoamine oxidase inhibitors (MAOIs)
 Selective serotonin reuptake inhibitors (SSRIs)
 Atypical (bupropion, nefazodone, trazodone, venlafaxine)
*Look up individual medications
5. Overall, all yield same improvement rates
6. Danger of suicide is highest when antidepressants first begin to work.Be
aware and monitor individual’s closely
B. Tricyclic Antidepressants
1. Much more anticholinergic than neuroleptics (see above list of SEs)
2. Contraindicated in individuals with history of cardiovascular problems,
hypertension and acute myocardial infarction
3. Potentiate the effects of alcohol
4. Do not provoke dependence, tolerance or addiction but may have a Flu-like
withdrawal syndrome
5. High risk of mortality with overdose
C. MAO Inhibitors (MAOIs)
1. Potentiate alcohol, barbiturates, and sedatives - incompatible with insulin,
Cogentin, diuretics, phenothiazines, tricyclic antidepressants
2. Must wait 10 days after taking MOA drugs to use these other drags
3. Main problem is danger of Hypertensive Crisis with subsequent intracranial
hemorrhage and possible death
4. Onset of Hypertensive Crisis is signaled by headache (either generalized or
occipital)
 Diaphoreses
 Increased restlessness
 Nausea and vomiting
 Muscle twitching.
5. To avoid hypertensive crisis the individual must not eat anything containing
pressor amines
 Six - 8 mg of tyramine usually needed to precipitate crisis
 Four major food groups:

Aged cheeses

Air-dried sausages

Fava pods (beans are okay, pod contains dopamine)

Sauerkraut

Tap and microbrewery beers

Chianti wine

Concentrated yeast extracts - powdered protein diet supplements

Pickled herring

Chinese foods
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
Phenylalanine
 No longer at risk:
 Chocolate
 Figs, raisins, overripe fruit avocados, bananas (not skin)
 < 3 oz. red or white wine
 Bottled or canned US or Canadian beer (< 4 servings)
 Many drug interactions, always check
D. Selective Serotonin Reuptake Inhibitors (SSRIs)
1. Chemically unrelated to and have fewer side effects than other
antidepressants
2. Most common side effects (always check individual medication)
 Headache
 Nausea, vomiting, diarrhea
 Nervousness
 Sleep disturbance
 Sexual dysfunction
3. Also used to treat other disorders such as
 Eating disorders
 Obsessive-compulsive disorders
 Tourette’s syndrome
 Social phobia
4. Powerful serotonergic effects are potentiated when tryptophan or lithium
concurrently prescribed. Watch for:
 Nausea
 Headache
 Diarrhea
 Ataxia
 Seizures
 Agitation
VI. Lithium
A. Characteristics
1. Lithium salts prevent and treat manic and depressive swings in bipolar
disorders
2. Drugs modulating “highs” and “lows” are called “mood stabilizers.”
Mood stabilizers are lithium and some anticonvulsants
3. Lithium aborts 60-80% of acute manic and hypomanic episodes in 10-21
days.
4. Therapeutic and toxic blood plasma levels are close. Extreme plasma level
range is 0.5-1.5 mEq/L. Monitor closely when level > 1.0 mEq/L
5. Maximum daily dose is usually 1800 mg. in divided doses
B. Side Effects
1. Most common at beginning of treatment
 Hand tremor
 Dyspepsia
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 Diarrhea
 Polyuria and/or polydipsia
2. Most common in later treatment
 Weight gain
 Polyuria
 Thirst
 Edema
 Hair loss
 Acne
 20% of lithium individual develop thyroid abnormalities
3. Contraindicated in:
 Renal disease
 Cardiovascular disease
 Febrile conditions
 Pregnancy
4. Signs of developing toxicity: increasing
 Sluggishness and lethargy
 Fine tremor or muscle twitching
 Ataxia
 Nausea, vomiting, and diarrhea.
5. Severe toxicity includes:
 Excessive thirst with polyuria
 Gradual development of coma
 Seizures
 Can lead to death
C. Nursing Concerns
1. Follow mental status carefully
2. Individuals started on lithium that are already on salt-restricted diets or
diuretics
3. Individuals already on lithium who are started on a diuretic, salt-restricted
diet or
vigorous exercise program
4. The ability to excrete lithium dwindles with age, use reduce doses in the
elderly
Note: The individual on lithium must maintain an adequate sodium intake along
with adequate fluid intake. In the absence of sufficient sodium in diet or
with conditions that deplete sodium, the individual will become rapidly
toxic.
VII. Anticonvulsants
A. Carbamazepine, valproic acid, gabapentin and clonazepam are anticonvulsants
that treat the symptoms and prevent the recurrence of bipolar disorders,
especially mania
B. Carbamazepine is structurally similar to the TCA imipramine and should be
monitored for the same side effects
C. Carbamazepine and valproic acid may cause massive hepatic cellular necrosis.
Baseline and regular hepatic function tests are essential
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D. Clonazepam is a benzodiazepine is also classified a an anti-anxiety agent
E. 20-30% of bipolar individuals do not respond to or tolerate lithium.
F. Carbamazepine and valproic acid efficacy is 55-76%
 Can be prescribed with lithium but carbamazepine often triggers confusion
 Synergistic therapeutic and toxic effects are often seen
 Toxic effects can be seen when each medication is in the “normal” serum
range.
 Petechiae, bruising, hemorrhage, nose bleeds, and anemia may occasionally
occur on valproic acid. Avoid concurrent aspirin or blood thinners
VIII. Antiparkinson agents
A. Used primarily to treat and prevent side effects of the major tranquilizers
B. Effects:
 Inhibits the contraction of smooth muscle
 Increases cardiac rate and conduction irritability
 Decrease in body secretions such as gastric, salivary, perspiration
 Pupillary dilatation
C. Problem Side Effects:
 Constipation
 Urinary hesitancy and urinary retention
 Impotence
 Tachycardia
 Palpitations
 Dizziness
 Nervousness
 Blurred vision
 Photo-phobia ( light will bother eyes)
 Dryness of mouth
 Inability to sweat with resultant hyperthermia
 Serotonin Syndrome
Because of possible side effects, many individuals will not be started on these
drugs until extra-pyramidal symptoms develop
Neuroleptic Malignant Syndrome
Neuroleptic Malignant Syndrome (NMS) is a rare, underdiagnosed, and
potentially fatal complication of neuroleptic treatment. Syndrome is not highly correlated
with dosage and is considered to be an idiosyncratic reaction to neuroleptics. It may
develop within hours, or even after. years of continued drug exposure. Underlying
pathophysiology is not well understood.
Syndrome is most commonly seen in individuals who are:
 Male (two to one ratio)
 Under 20 or over 60 years old
 Dehydrated
 Taking lithium
 Receiving decanoate injections
 Being prescribed rapid neuroleptization
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 Prescribed high neuroleptic dosages
 Mentally retarded, drug addicted or have CNS syndromes
 Anemic with low serum iron
 Exposed to high ambient temperatures
 Taking 2 or more neuroleptics
Signs and Symptoms:
 The development of severe muscle rigidity and elevated temperature
associated with the use of neuroleptic medication
 Two or more of the item labeled * below (not accounted for by other
conditions)

Severe parknsonism with

Muscle rigidity, catatonic appearance

Tremors *, dyskinesias

“Lead-pipe” muscle tone

Flexor-extensor posturing
 Hyprerpyrexia (101˚ 107˚ F)
 Altered consciousness

Alert look

Dazed mutism *

Agitated, confused, or comatose *

Obtunded *, or incontinent *
 Autonomic dysfunction with

Tachycardia (>130 beads/minute) *

Increased BP (>20 pts diastolic) or labile *

Profuse sweating *, more salivation

Tachypnea (>25 respriations/minute)

Pallor

Dysphagia *
 Severe abnormalities on laboratory tests

Evidence of severe muscle damage with high creatine
phosphokinase (CPK 347-4286 U/ml) or myoglobinuria *

Renal decline or failure

Raised WBCs (15,000-30,000/mm) *

Often elevated LFTs
 Mortality is estimated 15% to 30%. Death most often results from
respiratory failure (especially laryngospasm) or kidney failure.
 Symptoms may mimic functional catatonia, heat stroke, and CNS infection
Nursing Care:
1.
Most important measure is recognition of the syndrome and stopping
neuroleptics
immediately.
2.
No specific treatment, the nursing care is supportive. Areas of nursing
concern will be:
 Potential for injury
 Impairment of physical mobility (may need eye patches and
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3.
4.
5.
6.
7.
8.
9.
lubricants)
 Monitoring and maintenance of fluid balance
 Monitoring and maintenance of respiratory status
 Emotional support
Maintain hydration by oral or IV routes
Correct electrolyte abnormalities
Use antipyretic agents
Cool body to reduce fever
Keep room temperatures cool
Monitor temperature and other vital signs frequently
Check WBC and CPK regularly
沊Major Tranquilizers Side Effects
Assessment (side effect or discomfort)
Nursing intervention
Blurred vision
Reassurance (generally subsides in 2-6 weeks)
Dry mouth
Frequent rinsing of mouth
Lozenges
Constipation
Mild laxative
Roughage in diet
Exercises
Fluids
Nasal congestion
Nose drops
Moisturizer.
Decreased libido and
inhibition of ejaculation
Prepare individual for effect.
Reassurance (reversible)
Ask physician about change to less
antiadrenergic drug
Postural hypotension
Frequent monitoring of blood pressure during
dosage adjustment period
Advise individual to get up slowly. Elastic
stockings if necessary
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Photosensitivity
Protective clothing
Dark glasses
Use of sunscreen
Dermatitis
Stop medication
Request physician to change order and
prescribe systemic antihistamine
Initiate comfort measures
Impaired psychomotor functions
Advise individual to avoid dangerous tasks
Drowsiness
Give single daily dose at bedtime
Weight gain
Caloric control; exercise-diet teaching
Edema
Reassurance
Request physician to prescribe diuretic
Irregular menstruation
and decreased sex drive
Reassurance (reversible)
Have physician change class of drugs
Amennorhea
Reassurance and counseling (does not indicate
lack of ovulation)
Instruct individual to continue birth control
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ABNORMAL INVOLUNTARY MOVEMENT SCALE: AIMS
Ratings are done on Likert type scale from 1- 5.
1 = None
2=
Minimal
3 = Mild
4 = Moderate
5=
Severe
FACIAL
AND ORAL
MOVEMENTS:
1.
Muscles of Facial Expression
e.g., movements of forehead, eyebrows, periorbital area, cheeks;
include frowning, blinking, smiling, grimacing
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2..
Lips and Perioral Area
e.g.. puckering. pouting, smacking
12345
3.
Jaw
e.g., biting, clenching. chewing, mouth opening. lateral movement
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4.
Tongue
Rate only increase in movement both in and out of mouth,
NOT inability to sustain movement
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5.
Upper (arms, wrists, hands, fingers)
Include choreic movements, (i.e., rapid, objectively purposeless.
Irregular, spontaneous), athetoid movements (i.e., slow, irregular,
complex, serpentine).
Do NOT include tremor (i.e., repetitive, regular, rhythmic)
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6.
Lower (legs, knees, ankles, toes)
e.g., lateral knee movement, foot tapping, heel dropping, foot
squirming, inversion and eversion of foot
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7.
Neck, shoulders, hips
e.g., rocking, twisting, squirming, pelvic gyrations
12345
8.
Severity of abnormal movements
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9.
Incapacitation due to abnormal movements
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10.
Individual's awareness of abnormal movements
Rate only individual’s report
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11.
no
Current problems with teeth and/or dentures
yes
12.
no
Does individual usually wear dentures?
yes
EXTREMITY
MOVEMENTS:
TRUNK
MOVEMENTS:
GLOBAL
JUDGMENTS:
DENTAL
STATUS:
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EXAMINATION PROCEDURE
Either before or after completing the Examination Procedure observe the individual unobtrusively, at rest (e.g.,
in waiting room).
The chair to be used in this examination should be a hard, firm one without arms.
1.
Ask individual to remove shoes and socks.
2.
Ask individual whether there is anything in his/her mouth (i.e.. gum, candy, etc.) and if there is, to
remove it.
3.
Ask individual about the current condition of his/her teeth. Ask individual if he/she wears dentures.
Do teeth or dentures bother individual now?
4.
Ask individual whether he/she notices any movements in mouth, face, hands, or feet. If yes, ask to
describe and to what extent they currently bother individual or interfere with his/her activities.
5.
Have individual sit in chair with hands on knees, legs slightly apart, and feet flat on floor. (Look at
entire body for movements while in this position.)
6.
Ask individual to sit with hands hanging unsupported. If male, between legs, if female and wearing
a dress, hanging over knees. (Observe hands and other body areas.)
7.
Ask individual to open mouth. (Observe tongue at rest within mouth.) Do this twice.
8.
Ask individual to protrude tongue. (Observe abnormalities of tongue movement .) Do this twice.
9.
Ask individual to tap thumb, with each finger, as rapidly as possible for 10-15 seconds; separately
with right hand, then with left hand. (Observe facial and leg movements.)
10.
Flex and extend individual's left and right arms (one at a time). (Note any rigidity.)
11.
Ask individual to stand up. (Observe in profile. Observe all body areas again. hips included
12.
Ask individual to extend both arms outstretched in front with palms down. (Observe trunk, legs, and
mouth.)
13.
Have individual walk a few paces, turn, and walk back to chair. (Observe hands and gait.) Do this
twice.
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