Agranulocytosis

     Akathisia:

     Akinesia:

 muscular weakness, or a loss or partial loss of muscle movement; a type of extrapyramidal side effects associated with some antipsychotic medications

Amenorrhea

cessation of the menses;  may be a side effect of some antipsychotic medications

  Dystonia

involuntary muscular movements (spasms) of the face, arms, legs, and neck; may occur as a extrapyramidal side effect of some antipsychotic medications

     Extrapyramidal symptoms (EPS)

 a variety of responses that originate outside the pyramidal tracts and in the basal ganglion of the brain. Symptoms may include tremors, chorea, dystonia, akinesia, akathisia, and others. May occur as a side effect of some antipsychotic medications

 Gynecomastia

enlargement of the breast in men; may be a side effect of some antipsychotic medications

 Hypertensive crisis

a potentially life-threatening syndrome that results when individual taking MAO inhibitors eat a product high in tyramine. Symptoms include severe occipital headache, palpitations, N&V, nuchal rigidity, fever, sweating, marked increase in BP, chest pain and coma. Foods with tyramine include aged cheese or other aged, overripe, and fermented foods; broad beans, pickled herring; beef or chicken liver; preserved meats; beers and wine; yeast products; chocolate; caffeinated drinks; canned figs; sour cream; yogurt; soy sauce; and some OTC cold medications and diet pills

Neuroleptic malignant syndrome (NMS)

a rare but potentially fatal complication of treatment with neuroleptic drugs. Symptoms include sever muscle rigidity, high fever, tachycardia, fluctuations in BP, diaphoresis, and rapid deterioration of mental status to stupor and coma

 Oculogyric crisis

an attack of involuntary deviation and fixation of the eye balls, 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

     Priapism

prolonged painful penile erection, may occur as an adverse effect of some antidepressant medications, particularly Trazodone

  Pseudoparkinsonism

tremors, shuffling gait, drooling rigidity) symptoms may appear 1-5 days drooling initiation of antipsychotic medication; occurs most often in women, the elderly, and dehydrated clients

 Retrograde ejaculation

ejaculation of the seminal fluid backwards into the bladder; may occur as a side effect of antipsychotic medications

    Serotonin syndrome

may occur when two drugs that potentiate serotonergic neurotransmission are used concurrently. Frequent symptoms include changes in mental status, restlessness, myoclonus, hyperreflexia, tachycardia, labile blood pressure, diaphoresis, shivering, and tremors. * discontinue offending agent immediately, symptoms will resolve on own once offending medication is discontinued. If medication is not discontinued, the condition can progress to a more serious state and become fatal.

 Tardive dyskinesia

syndrome of symptoms characterized by bizarre facial and tongue movements, a stiff neck, and difficulty swallowing. It may occur as an adverse effect of long-term therapy with some antipsychotic medications

    Anxiety medications produce a calming effect by

depressing the CNS pg. 186 action

   Explain why alprazolam (Xanax) is given rather than buspirone for panic disorders                                                                             

 Buspirone has delayed onset of action and cannot be used on a p.r.n. basis

pg. 189 client/family education

    Symptoms of lithium toxicity

1.5 mEq/

pg. 197 lithium toxicity

   Initial symptoms of lithium toxicity include

 Ataxia, tinnitus, blurred vision, diarrhea

pg. 197 lithium toxicity

     Antipsychotic medications decrease psychotic symptoms by

Blocking the action of dopamine in the brain

pg. 200 action

  Observable extrapyramidal symptoms from antipsychotic medications are

muscular weakness, rigidity, tremors, facial spasms

pg. 203 EPS symptoms

     Priority interventions if extrapyramidal symptoms continue

administer p.r.n. trihexyphenidyl (Artane)

pg. 203 table 11-10

 Concern with long term CNS stimulants or ADHA with kids are?

growth restriction

 Never administer bupropion less than 8 hrs. apart or double the doses because

to prevent seizures 

Pg194 client/family education

Contraindications of  Lithium Carbonate

Increased renal excretion with use of acetazolamide, osmotic diuretics, and theophylline, Decreased renal excretion with nonsteroidal anti-inflammatory drugs and thiazide diuretics

Increased risk of neurotoxicity with concurrent use with carbamazepine, haloperidol, or mthyldopa, Increased serum lithium levels with concurrent use of fluoxetine or loop diuretics

Decreased lithium levels or lithium toxicity with concurrent use of verapamil, Increased effects of neuromuscular blocking agents or tricycline antidepressants or decreased pressor sensitivity of sympathomimetic with concomitant use

Neurotoxicity, decreased phenothiazine concentrations, or increased lithium concentrations with use of phenothiazine

Psychotropic Drug Types

Antipsychotic: Reduce unrealistic thinking, aggression, agitation, improve mood, negative symptoms.

Antidepressant: Improve mood.

Antimanic: Stabilize mood.

Antianxiety: Calm mood.

CNS Stimulants: Calm hyperactivity.

Antiparkinson Drugs: Correct problems caused by antipsychotic drugs.

Important Points about Psychiatric Medications

Not always effective.

Not needed by every patient.

Best outcomes occur, then other interventions co-administered.

May be used to avoid “hard work of getting better”.

Many have significant/dangerous side effects.

Trial and error may be necessary to find the right medication.

Evaluation Required Before Medication Therapy Begins

Assessment of past adverse reaction.

Patient understanding and knowledge of the medication to be administered.

Patient should be able to voice common side effects, purpose and dosage of medication.

Patient should know how to manage common side effects at home and when to contact the physician.

Patient should know common drug interactions.

In the Inpatient Setting

Psychotropic medication is used to alleviate problem behaviors (crisis) as quickly as possible to promote and provide safety on the unit (for patient and other in the environment.

The nurse is responsible for deciding when and how to use the medication in the best interest of safety.

How Do Psychotropics Work?

Neurotransmitters:Chemicals that are stored in the axon terminals of the presynaptic neuron. An electrical impulse through the neuron stimulates its release into the synaptic cleft, which in turn determines whether another electrical impulse is generated. Antidepressants: Block reuptake of neurotransmitters.

Antipsychotics: Block dopamine and other receptors.

Benzodiazepines: Facilitate transmission of GABA.

Psychostimulants:Increase release of neurotransmitters.

Atypical Antidepressants

Bupropion (Wellbutrin, Zyban)

Mirtazapine (Remeron)

Trazodone (Desyrel)

Venlafaxine (Effexor)

Duloxetine (Cymbalta)

Interactions

 (Atypical Antidepressants)

Wellbutrin: Can cause seizures with high doses  Has a low overdose potential (so it is relatively safe to give to suicidal clients) Low sexual side effects.

Trazodone: Not used much for antidepressant effects. Very sedative

 Used primarily for sleep, Can cause priapism

Serotonin Syndrome

A condition characterized by serotonergic  hyperstimulation; includes:

Restlessness, Hyperthermia, Myoclonus, Hypertension, Hyperreflexia,

Diaphoresis, Lethargy, Confusion, Tremor which may cause death

Tricyclic Antidepressants (TCA’s)

Imipramine (Tofranil)

Desipramine (Norpramin)

Amitriptyline (Elavil)

Doxepin (Sinequan)

Clomipramine (Anafranil)

Tricyclic Antidepressants (TCA’s)

Side Effects

Anticholinergic (blurred vision, urinary retention, dry mouth, constipation)

Orthostatic hypotension

Sedation

Weight gain

Tachycardia

Sexual dysfunction

Cardiac arrhythmias

Tricyclic Antidepressants (TCA’s)

Patient Teaching

Taking in the evening???????????

Use caution when driving

Don’t combine with alcohol

Tricyclic Antidepressants (TCA’s)

Interactions

Increased effects of tricyclics with bupropion, cimetidine, haloperidol, SSRI’s, and valproic acid.

Decreased effects of tricyclics with rifamycin, carbamazepine, and barbiturates.

Hyperpyretic crisis, convulsions, and death can occur with MAOI’s.

Hypertensive crisis can occur with clonidine

Decreased effects of levodopa and guanethidine

Very cardio toxic –should get baseline ECG before administration.

MAOI Antidepressant Drugs

Phenelzine (Nardil)

Tranylcypromine (Parnate)

Isocarboxazid (Marplan)

MAOI Antidepressant Drugs

Side Effects

Sedation

Insomnia

Weight gain

Dry mouth

Orthostatic hypotension

Sexual dysfunction

Hypertensive crisis with excessive tyramine or sympathomimetic drugs.

MAOI Antidepressant Drugs

Patient Teaching

Following tyramine-free diet (avoid aged cheeses, aged meats, beer and wine, sauerkraut, and soy).

Avoid sympathomimetic drugs

Using caution when driving

MAOI Antidepressant Drugs

Interactions

Hypertensive crisis with amphetamines, methyldopa, levodopa, dopamine, epinephrine, norepinephrine, reserpine, vasoconstrictors, or foods with tyramine.

Hypertension, hypotension, coma, convulsions, and death with narcotic analgesics

Additive hypotension with antihypertensives

Additive hypoglycemia with antihyperglycemic agents, potentially fatal reactions with other antidepressants, carbamazepine, cyclobenzaprine, maprotiline, furazolidone, procarbazine, or selegiline (avoid use within 2 weeks of each other).

Sedatives, Hypnotics, Benzodiazepines, BuSpar, Antihistamines

Antianxiety Agents

Indications

Anxiety disorders

Anxiety symptoms

Acute alcohol withdrawal

Skeletal muscle spasms

Convulsive disorders

Status epilepticus

Preoperative sedation

Antianxiety Agents

Contraindications

Hypersensitivity  to anxiolytics or benzodiazepines, Not to be taken with other CNS , depressants, Pregnancy/ lactation, Narrow angle glaucoma, Shock, Coma,

Cautions: Elderly, debilitated, Hepatic or renal dysfunction, History of drug abuse or addiction, Depression , suicidal

Antianxiety Agents

Actions

Depression of the CNS

Moderate the actions of GABA

Antianxiety Agents

Commonly Agents Used

Lorazepam (Ativan)

Alprazolam (Xanax)

Clonazepam (Klonopin)

Diazepam (Valium)

Hydroxyzine (Atarax, Vistaril)

Chlordiazepoxide (Librium)

Antianxiety Agents

Side Effects

Tolerance and dependence

Drowsiness

Sedation

Poor concentration

Impaired memory

Clouded sensorium

Antianxiety Agents

Patient Teaching

Use caution during driving due to slower reflexes and response time.

Never discontinue abruptly as withdrawal can be fatal.

Avoid alcohol.

Antianxiety Agents

Interactions

Increased effects with alcohol, barbiturates, narcotics, antipsychotics, antidepressants, antihistamines, neuromuscular blocking agents, cimetidine, or disulfiram, and with herbal depressants (e.g., kava and valerian root).

Decreased effects with cigarette smoking and caffeine consumption.

Antianxiety Agents

Buspar (Buspirone)

Delayed onset

Works more like the SSRI’s

Takes 3-4 weeks to become effective so may continue to take a benzo for awhile.

Is not addictive like the benzo, therefore can be used for a longer period of time.

Antianxiety Agents

Other Medications Used To Treat Anxiety

Propranolol (Inderal)

Clomipramine (Anafranil)

Antipsychotics

Indications

Acute and chronic psychoses

Selected agents are also used as antiemetics in the treatment of intractable hiccups

Used for agitation and aggression

Atypical antipsychotics assist with negative symptoms such as apathy, flat affect, and lack of motivation/drive.

Antipsychotics

Contraindications

Sensitivity, When CNS depression is evident, When blood dyscrasias exist, Clients with Parkinson’s disease, With liver, renal, or cardiac insufficiency

Cautions: Elderly, severely ill, or debilitated clients, Diabetics, Respiratory, insufficiency, Prostatic hypertrophy, Intestinal obstruction, Seizures, Avoid extreme temperatures, Pregnancy and lactation

Antipsychotics

Action

Unknown

Thought to block postsynaptic dopamine receptors in the basal ganglia, hypothalamus, limbic system, brainstem, and medulla.

Newer antipsychotics may block action on receptors specific to blocking dopamine, serotonin, and other neurotransmitters.

Conventional Antipsychotic Drugs

Phenothiazines (Thorazine, Prolixin, Mellaril, Stelazine)

Theothixine (Navane)

Haloperidol (Haldol)

Loxapine (Loxitane)

Molindone (Moban )

Conventional Antipsychotic Drugs

Side Effects

Extrapyramidal Symptoms (EPS’s) –(various movement disorders-Pseudoparkinsonism,

Dystonia, Akathisia, Tardive dyskinesia "TD")

Anticholinergic side effects

Neuroleptic malignant syndrome (NMS)

Photosensitivity

Conventional Antipsychotic Drugs

Patient Teaching

Adhere to medication regimen

Managing side effects

Thirst

Constipation

Sedation

Conventional Antipsychotic Drugs

Extrapyramidal Symptoms (EPS)

Pseudoparkinsonism, Tremors, Shuffling gait, Drooling, Rigidity

Symptoms may appear 1-5 days after initiation of antipsychotics.

Akinesia (Loss of normal motor function), Akathisia (Restless Leg Syndrome)

Dystonia (A neurological movement disorder, in which sustained muscle contractions cause   twisting and repetitive movements or abnormal postures)

Oculogyric crisis (A dystonic reaction -The term "Oculogyric" refers to rotating of eyeballs.)

AIMS Scale used to evaluate

Conventional Antipsychotic Drugs

Tardive Dyskinesia

Bizarre facial and tongue movements, stiff neck, and difficulty swallowing.

Clients on long-term (months or years) antipsychotic Rx are at risk.

Symptoms potentially irreversible

Conventional Antipsychotic Drugs

Neuroleptic Malignant Syndrome (NMS)

Symptoms: Severe Parkinsonian muscle rigidity, hyperpyrexia (107 degree), tachycardia, tachypnea, fluctuations in BP, diaphoresis. Rapid deterioration of mental status to stupor and coma. Rare and potentially fatal

Onset may be hours or years Progression rapid 24-72 hours

Conventional Antipsychotic Drugs

Neuroleptic Malignant Syndrome Nursing Considerations

Stop neuroleptic meds immediately

Monitor vital signs

Extent of muscle rigidity

Intake and output

Level of consciousness

Medical emergency

Atypical Antipsychotic Drugs

Clozapine (Clozaril)

Risperidone (Risperdal)

Olanzapine (Zyprexa)

Quetiapine (Seroquel)

Ziprasidone (Geodon)

Atypical Antipsychotic Drugs

Side Effects

Fewer EPS’s

Weight gain

Agranulocytosis (Clozaril)

Atypical Antipsychotic Drugs

Patient Teaching

Adhere to medication regimen

Reducing sugar and caloric intake

Clozaril:

Weekly WBC monitoring

Discontinue medication and seek care at first sign of infection

New-Generation Antipsychotic Drug

      Aripiprazole (Abilify)

New-Generation Antipsychotic Drug

Side Effects

Headache

Anxiety

Nausea

New-Generation Antipsychotic Drug

Patient Teaching

     Adhere to medication regimen

Antimanic (Mood Stabilizing Agents)

Lithium Carbonate (Lithobid)

Clonazepam (Klonopin)

Carbamazepine (Tegretol)

Valproic Acid (Depakote)

Lamotrigine (Lamictal)

Gabapentin (Neurontin)

Topiramate (Topamax)

Verapamil (Calan)

Antimanic (Mood Stabilizing Agents)

Indications

Prevention and treatment of manic episodes associated with bipolar disorder.

Antimanic (Mood Stabilizing Agents)

Contraindications

     See page 195 of text.

Antimanic (Mood Stabilizing Agents)

Action

Lithium enhances the reuptake of norepinephrine and serotonin in the brain, lowering levels in the body and resulting in decreased hyperactivity

Action of anticonvulsants, verapamil, and olanzapine in the treatment of bipolar disorder is not fully understood.

Antimanic (Mood Stabilizing Agents)

Side Effects

Nausea, Diarrhea,  Anorexia,  Fine hand tremor, Polyuria, Fatigue,  Weight gain,          Acne

Antimanic (Mood Stabilizing Agents)

Patient Teaching

        Take with food, Have monthly blood levels drawn 12 hours after last dose maintain therapeutic levels between 0.5-1.5 mEq/L

Antimanic (Mood Stabilizing Agents)

Nursing Considerations

Monitor for side effects of anticonvulsants, N/V, Drowsiness, dizziness, Blood dyscrasias (A diseased state of the blood, usually one in which the blood contains permanent abnormal cellular elements.), Prolonged bleeding time

Weight gain, Liver dysfunction (with valproic acid), Risk of severe rash (with lamotrigine), Decreased efficacy with oral contraceptives (with topiramate)

Psychostimulants

Methylphenidate (Ritalin, Concerta)

Pemoline (Cylert)

Dextroamphetamine (Adderal, Dexedrine)

Lisdexamfetamine Dimesylate (Vyvanse)

Psychostimulants

Indications

ADHD

Residual ADD in adults

Narcolepsy

Psychostimulants

Contraindications

Hypersensitivity, Advanced arteriosclerosis, Cardiovascular disease, HTN, Hyperthyroidism, Glaucoma, Agitated states, History of drug abuse, During or within 14 days of MAOI’s, Seizures

 Caution: Pregnancy and Lactation, With psychotic children, In tourette’s syndrome,

Anorexia, Insomnia, Elderly, debilitated, or asthenic clients, History of suicidal or homicidal thoughts

Psychostimulants

Psychostimulants

Action

 Causes release of neurotransmitters

Psychostimulants

Side Effects

Anorexia

Weight loss

Nausea

Irritability

Tics

Heart palpations

Psychostimulants

Patient Teaching

Avoid caffeine, sugar, and chocolate

Take after meals

Long-term use can cause dependency

Medications should be taken in the morning

If given after 1600, could interfere with sleep

Central Alpha-Agonists (Alternative to CNS Stimulants)

         Clonidine (Cateress)

       Guanfacine (Tenex)

Central Alpha-Agonists (Alternative to CNS Stimulants)

Indications

Used as an alternative to the CNS stimulants

May not be listed as indicated for use with children for ADHD (Tenex not FDA approved)

Seems to work best for the inattentive aspects, not so well for distractibility.

Because these medications are used to treat blood pressure, must monitor BP closely in the children receiving this medication.

Central Alpha-Agonists (Alternative to CNS Stimulants)

Side Effects

Dry mouth, Hypotension, Weight gain, Nausea, Drowsiness, Nervousness, Agitation, Headache, Dizziness, Fatigue, Dry eyes

Non-Stimulant (Alternative to CNS Stimulants)

    Atomoxetine (Strattera)

Non-Stimulant (Alternative to CNS Stimulants)

Indications

Strattera is the first and only non-stimulant approved by the FDA for the treatment of ADHD in children, adolescents, and adults.

Strattera is a norepinephrine reuptake inhibitor, a class of ADHD treatment that works differently from the other ADHD medications available.

Non-Stimulant (Alternative to CNS Stimulants)

Side effects

Decreased appetite

Dizziness

N/V

Dry mouth

Problems with urination

Decreased sleep

Problems with liver function

Antiparkinsonian Agents

    Benztropine (Cogentin)

     Diphenhydramine (Benadryl)

Antiparkinsonian Agents

Indications

         Treatment of all forms of Parkinsonism and for the relief of drug-induced extrapyramidal reactions

Antiparkinsonian Agents

Actions

Antiparkinsonian Agents

Interactions

Additive anticholinergic effects and potentially fatal paralytic ileus with other drugs that possess these properties.

Concurrent use with haloperidol or phenothiazine may result in decreased effect of the antipsychotic and increased incidence of anticholinergic side effects.

Additive CNS effects with CNS depressants.

Antiparkinsonian Agents

Nursing Considerations

Monitor clients for side effects:

Anticholinergic effects

Nausea

GI upset

Sedation

Dizziness

Exacerbation of psychoses

Orthostatic hypotension