Download Ch. 15-Drugs Used for Mental Health Disorders

Chapter 15
Drugs Used for
Mental Health Disorders
People with mental health disorders have problems
with coping and adjusting to stress in their lives
Causes of mental health disorders:
- not being able to cope/adjust to stress
- chemical imbalances
- genetics
- drug/substance abuse
- social/cultural factors
Anxiety Disorders
Obsessive-Compulsive Disorder (OCD)
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obsession: recurrent/unwanted thought, idea, image
compulsion: repeating an act over and over again
with OCD the act may not make sense, but the person has
a lot of anxiety if it is not performed
rituals can include many things: hand washing, checking
stove, checking locks, counting things
these rituals can be very time consuming and usually are
distressing and affect daily life
Anxiety Disorders continued…
Panic Disorder
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panic: highest level of anxiety
intense and sudden feeling of fear, anxiety, terror or dread
onset is usually sudden, and usually no obvious reason
signs and symptoms:
- chest pain
- shortness of breath
- heart pounding
- numbness/tingling in hands
- dizziness
- feeling of impending doom/loss of control
can last 10 minutes or longer
Anxiety Disorders continued…
Phobia
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intense fear of object, situation or activity that has little to no actual
danger
when faced with fear the person has high anxiety and cannot
function
common phobias:
- being in large, crowded places (agoraphobia)
- being in pain or seeing others in pain (algophobia)
- water (aquaphobia)
- being trapped in closed/narrow space (clasutrophobia)
- the slightest uncleanliness (mysophobia)
- night/darkness (nyctophobia)
- fire (pyrophobia)
- strangers (xenophobia)
Anxiety Disorders continued…
Post-Traumatic Stress Disorder (PTSD)
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occurs after a terrifying ordeal
this may have involved physical harm or threat of harm
most people have flashbacks (reliving trauma in thoughts
and nightmares)
flashbacks may involve:
- images, sounds, smells, feelings
- often triggered by everyday things
- during flashback person loses touch with
reality
signs/symptoms usually develop 3 months after event or
can be years later
can develop at any age
Mood Disorders
Bipolar Disorder:
- severe extremes in mood, energy and ability to function
- there emotional lows (depression) and highs (mania)
- tends to run in families
- requires life-long management
- mood changes are called episodes
Major Depression:
- involves body, mood, thoughts
- can affect work, sleep, eating
- usually very sad, loss of interest in daily activities
- can occur because of stressful events, physical disorders,
hormones
(see box 15-2, 15-3 pg. 197 for signs and symptoms)
Mood Disorders Continued...
Schizophrenia:
- means split mind
- severe, chronic, disabling brain disorder
- severe mental impairment (psychosis)
- thinking and behavior are affected
- false beliefs (delusions)
- hallucinations
- paranoid about people and situations
- unorganized thoughts, disturbed communication
hard to understand, makes up words
- may withdraw, lack on interest in others
- can have disorders with movement
- do not tend to be violent, if paranoid schizophrenia usually
violence is directed at family members
-some attempt suicide
Drugs Used for Mental Health Disorders
(Delegation Guidelines)
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Some used to treat mental health disorders are given
parenternally (by injection)
You do NOT give parenteral dose forms
Should a nurse delegate the administration to you
REFUSE the delegation, explain why
Do NOT ignore request, makes sure nurse knows you
cannot give the drug and why
Drugs used for anxiety disorders
Anti-anxiety drugs are also known as tranquilizers
Benzodiazepines:
- have few side effects
- consistently effective
- less likely to have drug interactions
- lower risk for abuse
- examples:
alpraolam (Xanax, Niravam, Xanax XR
chlordiazepoxide (Liprium)
clorazepate (Tranxene)
diazepam (Valium)
lorazepam (Ativan)
oxazepam (Serax)
Drugs used for anxiety disorders continued…
Assisting with nursing process for benzodiazepines
ASSESSMENT:
-measure BP in sitting and supine positions
-observe for signs/symptoms of anxiety
PLANNING: see table 15-1 (pg. 198) for “oral dose forms”
IMPLEMENTATION: see table 15-1 (pg. 198) for “initial adult dose” and “maximum daily dose”
-long term use may cause physical and psychological dependence
- mild withdrawal symptoms can occur after taking drug 4-6 weeks
signs/symptoms: restlessness, worsening of anxiety, insomnia, tremors, muscle tension, rapid
pulse, hearing sensitivity, delirium, seizures
EVALUATION:
report and record:
- drowsiness, hangover, sedation, lethargy, provide safety
- orthostatic hypertension, provide safety
- excessive use or abuse
- anorexia, nausea, vomiting, jaundice
Drugs used for anxiety disorders continued…
Other anti-anxiety agents:
Buspirone (BuSpar)
- causes less sedation than other meds
- does not alter psycho-motor function
- improvement after 7-10 days
- 3-4 weeks of therapy
- risk of abuse is low
Assisting with nursing process for buspirone (BuSpar):
ASSESSMENT:
-observe for signs/symptoms of anxiety
PLANNING:
- 5, 10, 15, 30 mg tablets (15/30 are scored to divide into 2 or 3 doses)
IMPLEMENTATION
- initial adult does is 5-7.5mg orally 2x/day
- dosage may be increased by 5mg every 2-3 days
- maximum daily dose is 60mg
EVALUATION:
- report and record:
- insomnia, nervousness, drowsiness, light-headedness, provide for safety
- slurred speech, dizziness (excess dosing)
Drugs used for anxiety disorders continued…
Fluvoxamine (Luvox)
- used to treat OCD
- symptoms reduced but not prevented
- person has more control
- intent is to:
- decrease anxiety
- improve coping with obsessions
- reduce frequency of compulsive activity
- for Assisting with nursing process see p. 203 for SSRI’s
Other anti-anxiety agents continued….
hydroxyzine (Vistaril and Atarax)
- produce sedation and reduce anxiety (can be used pre-op)
- also prevent vomiting and control allergic reactions (and itching)
- decrease anxiety
- reduce need for pain meds post-op
Assisting with the Nursing Process for hydroxyzine:
ASSESSMENT: observe for signs/symptoms of anxiety
PLANNING: oral dose forms are:
-Vistaril: 25 and 50mg capsules or 10mg/5mL syrup
-Atarax: 10, 25, 50, 100mg tablets or 10mg/5mL syrup
IMPLEMENTATION: 25-100mg are given orally 3-4x/day
EVALUATION: report and record:
- blurred vision, provide for safety
- constipation, give stool softeners as ordered
- dryness of mouth, nose and throat, hard candy, ice, gum if nurse allows
- sedation, see pg. 199
- dizziness, slurred speech (excess dosing)
Drugs used for mood disorders
Before regaining full function person must pass through 3
therapy phases:
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Acute phase:
- time from diagnosis to 1st treatment response
- symptoms reduced
- usually takes 6-8 weeks
Continuation phase:
- involves preventing relapse and reaching a full recovery
- should be symptom free for 6 months
Maintenance phase:
- goal is to prevent disorder from recurring
Mood disorders are treated with anti-depressants
These drugs prolong action of neurotransmitters:
- norepinephrine
- doapmine
- serotonin
The drug classes are:
- monoamine oxidase inhibitors (MAOI’s)
- tri-cyclic anti-depressants (TCA’s)
- selective serotonin re-uptake inhibitors (SSRI’s)
**anti-depressants may increase risk of suicidal thinking and
behavior, when started observe person carefully, report
concerns to nurse. Follow precautions according to care plan
Anti-depressants continued…
MAOI’s:
- prevent breakdown of neurotransmitters that are involved in areas
of the brain that control mood and emotion
- effects usually seen in 2-4 weeks
- serious side effects when taken with certain drugs, fluids, foods
(pg. 202 for list)
- last dose given no later than 6:00 (1800) to prevent insomnia
Examples of MAOI’s:
- phenelzine (Nardil)
- tranylcypromine (Parnate)
- isocarboxazid (Marplan)
- selegiline (Emsam)
MAOI’s continued…
Assisting With the Nursing Process for MAOI’s:
ASSESSMENT:
- measure pulse rate
-measure BP (supine and standing positions)
- measure blood glucose
- ask about food/fluids consumed in past few days
PLANNING:
- see table 15-2 (p. 201) for “oral dose forms”
IMPLEMENTATION:
- see table 15-2 for “Initial Adult Dose, Daily Maintenance Dose and Maximum daily
dose”
EVALUATION:
- report and record:
orthostatic hypertension: most common side effect, provide for safety
dizziness and weakness
drowsiness/sedation, provide for safety
restlessness, agitation, insomnia, last dose given before 1800 (6:00pm)
blurred vision, provide for safety
constipation, urinary retention, follow care plan
dryness of mouth, nose, throat, hard candy, ice, gum if nurse allows
hypertension, many foods can cause serious hypertension see chart p. 202
Anti-depressants continued…
SSRI’s:
-these affect serotonin
-re-uptake means re-absorption
- SSRI’s block certain nerve cells from re-absorbing serotonin
- mood improved because the sending of nerve impulses is improved
- used to improve mood and reduce depression
- effect of drug seen in 2-4 weeks
Examples of SSRI’s
- citalopram (Celexa)
- escitalopram (Lexapro)
- fluvoxamine (Luvox)
-sertraline (Zoloft)
- duloxetine (Cymbalta)
- fluoxetine (Prozac)
- paroxetine (Paxil or Paxil CR)
SSRI’s continued…
Assisting With the Nursing Process for SSRI’s
ASSESSMENT:
- measure blood pressure, supine and standing
- weigh person weekly
- observe for insomnia, nervousness and other CNS signs and symptoms
- ask person about GI symptoms
PLANNING: see table 15-2 for oral dose forms (p. 202)
IMPLEMENTATION: see table 15-2 for “Initial Adult Dose, Daily Maintenance
Dose and Maximum daily dose”
EVALUATION:
report and record:
- restlessness, agitation, anxiety, insomnia, give drug before 1800 (6:00pm)
- sedative effects
- GI effects, give drug with food
- suicidal actions, see promoting safety and comfort for mood disorders p. 200
Anti-depressants continued…
TCA’s
- prolong action of norepinephrine, dopamine, serotonin
- blocks re-uptake of these neurotransmitters
- these drugs produce anti-depressant and tranquilizing effects
- 2-4 weeks of therapy and then usually they elevate mood, improve appetite and
increase alertness
- several other uses for these drugs:
-phantom limb pain
-chronic pain
-cancer pain
-peripheral neuropathy with pain
-arthritic pain
-eating disorders
-pre-menstrual symptoms
TCA’s continued…
Examples of TCA’s:
- amitriptyline (Elavil)
- amoxapine
- clomipramine (Anafranil)
- desipramine (Norpramin)
- doxepin (Sinequan)
- imipramine (Tofranil)
- nortriptyline (Aventyl, Pamelor)
- protriptyline (Vivactil)
- trimipramine (Surmontil)
TCA’s continued…
Assisting With the Nursing Process for TCA’s
ASSESSMENT:
-constipation is common, ask about bowel movements
-measure blood pressure, supine and sitting
-measure pulse rate and rhythm, report tachycardia or irregular pulse
PLANNING: see table 15-2 (p. 201) for “Oral Dose Forms”
IMPLEMENTATION: see table 15-2 for “Initial Adult Dose, Daily Maintenance Dose and
Maximum daily dose”, dose increases usually started in evening because of sedation
EVALUATION: report and record
-blurred vision, provide for safety
-constipation, urinary retention, follow care plan
-dryness of mouth, nose, throat, hard candy, ice, gum if nurse allows
-orthostatic hypertension, provide for safety
-sedative effects, provide for safety
-tremors, numbness, tingling, parkinsons-like symptoms, provide for
safety
-tachycardia, dysrhythmias, signs/symptoms heart failure, see ch.20/21
-seizures, see ch.16
-suicidal actions, see promoting safety and comfort.. p. 200
Other anti-depressants
bupropion hydrochloride (Wellbutrin)
- weak inhibitor of re-uptake of neurotransmitters
- used for those who do not respond to TCA’s
- used if person cannot tolerate the adverse effects of TCA’s
Assisting With the Nursing Process for buproprion (Wellbutrin)
ASSESSMENT: weigh the person
PLANNING: oral dose forms are:
75 and 100mg tablets
100, 150, 200mg sustained-release tablets
150, 300 mg extended-release tablets
IMPLEMENTATION: initial dose usually 100mg 2x/day, may be increased to 3x/day after
several days, maximum daily dose is 450mg. Avoid a dose close to bedtime
EVALUATION: report and record:
- GI effects, give with food, stool softeners as ordered
- restlessness, agitation, anxiety, insomnia, avoid bedtime doses
- seizures, see ch.16
- suicidal actions, see promoting safety and comfort….p.200
Other anti-depressants continued…
maprotiline
- enhances norepinephrine and serotonin at nerve endings
- elevates mood and reduces depression symptoms
- used to treat:
- depression
- treat depressive phase of bipolar disorder
- relief of anxiety associated with depression
Assisting With the Nursing Process for maprotiline
ASSESSMENT: measure blood pressure in supine and standing positions, weigh
person weekly
PLANNING: oral dose forms 25, 50, 75 mg tablets
IMPLEMENTATION: adult starting dose is 75 mg daily in 2 or 3 doses
usual maintenance dose is 150mg/day
maximum daily dose 225mg
dose increases usually made in the evening, increased sedation
EVALUATION: report and record
see TCA’s on p. 203
Other anti-depressants continued…
mirtazapine (Remeron)
- serotonin antagonist (antagonist exerts opposite
action to that of another, or competes for
receptor sites)
- elevates mood and reduces depression symptoms
Assisting With the Nursing Process:
ASSESSMENT: measure blood pressure in supine, sitting, standing positions
weigh weekly
PLANNING: oral dose 15, 30, 45 mg tablets, 15 mg Soltabs (dissolves on
tongue)
IMPLEMENTATION: starting dose is 15 mg daily, every 1-2 weeks dosage may
be increased, maximum daily dose 45mg. Increases made in evening
because of sedation
EVALUATION: see TCA’s on p. 203
Other anti-depressants continued…
nefazodone
- inhibits serotonin and norepinephrine re-uptake
- blocks some serotonin receptors
- elevates mood
- reduces symptoms of depression
- carries risk of life-threatening liver failure
Assisting With the Nursing Process for nefazodone:
ASSESSMENT: measure blood pressure in supine, sitting and standing position,
measure heart rate, ask about GI symptoms, observe CNS symptoms
PLANNING: oral dose 50, 100, 150, 200, 250 mg tablets
IMPLEMENTATION: adult starting dose is 100mg 2x/day, dosage increased by 100200mg 2x/day. Normal dose range is 300-600mg daily
EVALUATION: report and record:
- drowsiness, sedations, symptoms tend to disappear with continued therapy or
dose adjustment
- blurred vision, provide safety
- constipation, urinary retention, follow care plan
- dryness of mouth, throat and nose, hard candy, ice or gum if nurse allows
- orthostatic hypotension, provide for safety
- sedative effects
Other anti-depressants continued…
trazodone hydrochloride (Desyrel)
- elevates mood
- reduces symptoms of depression
- treats:
- depression
- depression associated with schizophrenia
- depression/tremors/anxiety
- insomnia in persons with substance abuse
Assisting With the Nursing Process for trazodone (Desyrel):
ASSESSMENT: measure blood pressure in supine, sitting and standing positions
PLANNING: oral dose forms 50, 100, 150 and 300mg tablets
IMPLEMENTATION: starting dose is 150mg, divided into 3 doses
drug is increased by 50mg/day every 3-4 days
maximum daily dose is 400mg (600mg for hospital patients)
dose increases in evening bc of sedation, give drug with meal or light snack
EVALUATION: report and record:
- confusion, dizziness, light-headedness, provide for safety
- drowsiness
- orthostatic hypotension, provide for safety
-dysrhythmias, tachycarida, report irregular pulse
Other anti-depressants continued…
venlafaxine (Effexor)
- strong inhibitor of the re-uptake of serotonin and norepinephrine
- used to treat and reduce symptoms of depression and
anxiety
- elevates mood
- reduces
Assisting With the Nursing Process for venlafaxine(Effexor):
ASSESSMENT: measure blood pressure, measure weight, ask about GI symptoms, observe
for CNS symptoms such as insomnia or nervousness
PLANNING: oral dose forms: 25, 37.5, 50, 75, and 100mg tabs
37.5, 75, 150mg sustained-release capsules
IMPLEMENTATION: daily adult does is 75mg in 2 or 3 doses
dosages may be increased by 75mg daily after every 4 days
maximum dose is 375mg/day, usually divided into 3 doses
drug is given with food
EVALUATION: report and record:
- dizziness, drowsiness
- nausea, anorexia, give drug with food
- restlessness, agitation, anxiety, insomina, usually occur early in
therapy, avoid bedtime doses
- suicidal actions, see promoting safety and comfort….p. 200
Anti-Manic agents
- Lithium is used to treat acute mania
- Eskalith and Lithane are brand names for lithium carbonate
- also used to prevent manic and depressive episodes in bipolar
disorder
- goal of therapy is maintain at optimal level of functioning with few
mood swings
- acute anti-manic effect occurs within 5-7 days
- therapeutic effect takes 10-21 days
- lithium may cause a loss of sodium (drink 10-12 glasses of 8oz water)
report and record:
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nausea, vomiting, anorexia, abdominal cramps
excessive thirst and increased/decreased urination, fine hand tremor
vomiting, diarrhea, increased reflex reactions, lethargy, weakness
progressive fatigue, weight gain
itching, ankle edema, metallic taste, hyperglycemia
Lithium continued…
Assisting With the Nursing Process for Lithium:
ASSESSMENT: measure blood pressure in supine, sitting standing, measure
weight, record intake and output, measure blood glucose
PLANNING: oral dose forms are:
150, 300, 600mg capsules and tablets
300 and 450 mg slow-release tablets
300 mg/5 mL syrup
IMPLEMENTATION: daily adult dose is 300 to 600 mg, 3 or 4x/day, give food
or milk with drug
EVALUATION: report and record:
- nausea, vomiting, anorexia, abdominal cramps, usually mild
- excessive thirst and increased/decreased urination, fine hand tremor
- vomiting, diarrhea, increased reflex reactions, lethargy, weakness,
signal toxicity, next dose only with nurses permission
- progressive fatigue, weight gain, early signs of thyroid problem
- itching, ankle edema, metallic taste, hyperglycemia, rare
- increased or decreased urinary output, renal toxicity
Drugs Used for Psychoses
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psychosis: state of severe mental impairment
Person does not view real/unreal correctly
Common symptoms:
-Delusion: false belief
-Hallucination: seeing, hearing, smelling or feeling something that isn’t real
-Paranoia: a disorder of the mind, person has false beliefs (delusions) usually
suspicious about a person or situation
-Delusion of grandeur: exaggerated belief about one’s importance, wealth, power or
talents
-Delusion of persecution: false belief that on is mistreated, abused or harassed
- Schizophrenia is the most common psychotic disorder
- Psychotic symptoms can occur from medical problems:
- Dementia and delirium
- Mood disorders
- Drugs and substance abuse
Drugs Used for Psychoses continued…
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Drug and non-drug therapies used to treat
Unless the psychosis is caused by medical problem,
symptoms will re-occur most of persons life
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Anti-psychotic drugs:
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- Typical or first-generation anti-psychotic agents
- these antagonize dopamine in CNS
- Atypical or second-generation
- Inhibit dopamine receptors, also serotonin
- Tend to be more effective than typical/first-generation
- Fewer side effects that typical/first-generation
Drugs Used for Psychoses continued…
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Initial goals of therapy:
-calm agitated person
- begin treatment
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Therapy often involves benzodiazepines and anti-psychotics
-this allows a lower dose of the anti-psychotic
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Most disorders are treated with a low maintenance dose
Drugs Used for Psychoses continued…
Assisting With the Nursing Process for anti-psychotics:
ASSESSMENT: measure blood pressure supine, sitting and standing, measure weight
and height, measure blood glucose
PLANNING: see table 15-3 (p. 208) for oral and rectal “dose forms”
IMPLEMENTATION: see 15-3 for “adult dosage range”, dosage adjusted according to
degree of mental/emotional disturbance. Takes several weeks to show desired
improvement
EVALUATION: Report or record:
-fatigue, drowsiness, dose usually ordered for bedtime
-orthostatic hypotension, provide for safety
-blurred vision, provide for safety
-constipation, give stool softeners as ordered
-dryness of mouth, nose, throat, hard candy, ice chips or gum if
nurse allows
-seizures, see ch.16
-Parkinsons-like symptoms, provide for safety
-involuntary body movements, see box 15-6 (p. 209), provide for
safety
-anorexia, nausea, jaundice, signal liver toxicity
-hives, itching, rash, signal allergic rea
Drugs Used for Psychoses continued…
Typical (first-generation):
-Phenothiazines
-chlorpromazine (Thorazine)
-fluphenazine (Prolixin)
-perphenazine
-prochlorperazine (Compazine)
-thioridazine
-trifluoperazine
-Thioxanthenes
-thiothixene (Navane)
-Non-Phenothiazines
-haloperidol (Haldol)
-loxapine (Loxitane)
-molindone (Moban)
Drugs Used for Psychoses continued…
Atypical (second-generation):
-aripiprazole (Abilify)
-clozapine (Clozaril)
-olanzapine (Zyprexa)
-quetiapine (Seroquel)
-risperidone (Risperdal)
-ziprasidone (Geodon)
Drugs Used for Alcohol Rehabilitation
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alcohol slows down brain activity
over time heavy drinking damages the brain, CNS, liver,
heart, kidneys and stomach
it causes changes in heart and blood vessels
alcoholism is a chronic disease, lasts throughout life
risk factors: life-style and genetics
there is no cure, but it can be treated through counseling and
drugs
2 main drugs used to treat alcoholics:
- acamprosate (Campral)
- disulfiram (Antabuse)
Drugs Used for Alcohol Rehabilitation continued…
acamprosate (Campral):
- used for chronic alcohol patients who want to be sober
- enhances ability not to drink
- does NOT treat withdrawal symptoms
- reduces drinking rates for those who stop drinking at start of tx
Assisting With the Nursing Process for acamprosate (Campral):
ASSESSMENT: observe persons level of alertness and orientation to person, time
and place, measure vital signs, ask about GI symptoms
PLANNING: oral dose form is two 333mg delayed-release tablets
IMPLEMENTATION: adult dose is two 333mg tablets 3x/day, tablets taken without
regards to meals
EVALUATION: report and record:
- diarrhea, usually mild and tends to resolve as tx continues
- suicidal actions, observe for negative thoughts, feelings,
behaviors, depression or suicidal thinking, report to
nurse, follow suicide precautions according to care plan
Drugs Used for Alcohol Rehabilitation continued…
disulfiram (Antabuse):
- produces a very unpleasant reaction when taken before alcohol
- nausea, severe vomiting, sweating, throbbing headache, dizziness,
blurred vision, confusion
- reactions depend on amount alcohol in the blood, can last 30-60
minutes or hours
- taking the drug over prolonged period does NOT produce tolerance,
person becomes more sensitive to alcohol
- person should not consume any OTC products with alcohol,
including: sleep aids, cough/cold products, after-shave lotions,
mouthwash, rubbing alcohol or foods/sauces containing alcohol
Drugs Used for Alcohol Rehabilitation continued…
Assisting with Nursing Process for disulfiram (Antabuse):
ASSESSMENT: observe persons level of alertness and orientation to
person, time and place, measure vital signs, ask about GI
symptoms
PLANNING: oral dose form is 250 mg tablets
IMPLEMENTATION: initial adult dose is 500mg once/day for 1-2 weeks,
maintenance dose ranges from 125-500mg daily, max daily dose
500mg, never give drug to intoxicated person, person cannot have
alcohol for 12 hours prior to receiving drug
EVALUATION: report and record:
-drowsiness, fatigue, headache, impotence, metallic taste
-anorexia, nausea, vomiting, jaundice, may signal liver toxicity
-hives rash, itching, signal allergic reaction, tell nurse immediately