OVERVIEW:
Neuro System
Tri-Cyclic
Antidepressant
Antidepressant /
Anxiolytic
MAOIs
lorazepam (Ativan)
diazepam (Valium)
Benzodiazepines
GABAA
zolpidem (Ambien)
Antagonist
Phenytoin-Like
Drugs
phenytoin (Dilantin)
valproic acid (Depakote)
Succinimides
ethosuximide (Zarontin)
Barbiturates
phenobarbital (Luminal)
Phenothiazines
Non-Phenothiazines
Opioids
Salicylates
NSAIDs
Non-Opioid
morphine (Infumorph)
Atypical
Antipsychotics
aspirin (ASA)
ibuprofen (Motrin)
acetaminophen (Tylenol)
Central Acting
tramadol (Ultram)
Anti-Migraine
ergotamine (Cafergot)
Sumatriptan (Imitrex)
escitalopram (Lexapro)
Opioid Antagonists
naloxone (Narcan)
chlorpromazine (Thorazine)
halperidol (Haldol)
risperidone (Risperdal)
Psychoses
• Severe mental and behavioral disorders characterized by:
• Delusions
• Hallucinations
• Illusions
• Paranoia Acute episode – occur over hours or days
• Chronic episode – develop over months or years
Factors Attributed to
Development of Psychoses
• Genetic
• Neurological
• Environmental
Schizophrenia
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Abnormal thoughts and thought processes
Disordered communication
Withdrawal from other people and outside environment
Severe depression
High risk for suicide
Most common psychotic disorder
Manifests in men aged 15 to 24 years
Manifests in women in aged 25 to 34 years
Symptoms of Schizophrenia
• Variety of symptoms that may change over time
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Hallucinations, delusions, or paranoia
Strange and irrational behavior, actions
Rapid alteration between extreme hyperactivity and stupor
Attitude of indifference; detachment
Deterioration of hygiene, job, academic performance
Withdrawal from social and interpersonal relationships
• Characterized by positive and negative symptoms
• Positive: add on to normal behavior
• Negative: subtract from normal behavior
• Diagnosis of positive and negative symptoms important for
selection of appropriate drug
Causes of Schizophrenia
• Cause yet to be determined
• Genetic
• Neurotransmitter imbalance
• Symptoms seem to be associated with dopamine type 2
receptor in brain
• Antipsychotic drugs enter dopaminergic synapses and compete
with dopamine
Conditions That May Mimic the Behaviors of
Schizophrenia
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Drug use
Brain neoplasm
Infections
Hemorrhage
Selection of Antipsycotics
• No single drug of choice
• Selection of drug type depends on
• Clinician experience
• Side effects
• Patient needs
Categories of
Antipsychotic Drugs
• Conventional antipsychotic
• Phenothiazines and phenothiazine-like drugs
• Atypical antipsychotic
• Nonphenothiazines
Patient Drug Compliance
• Goal is to reduce psychotic symptoms so patients
have ability to self-care
• Drugs do not cure mental illness
• Patients must continue drug regimen to remain in
remission
• Relapse rate for those who discontinue medication
is 60% to 80%
Role of the Nurse
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Monitor client’s condition
Give client drug education
Obtain health history (long-term physical problems)
Obtain drug history (use of illegal drugs, alcohol, etc.)
Obtain baseline assessment (liver and kidney function, vision,
mental status)
• Monitor for extrapyramidal symptoms, and report to the
physician immediately
Conventional (Typical)
Antipsychotics
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Monitor for decrease of psychotic symptoms, side effects
Monitor for anticholinergic side effects
Monitor for alcohol, illegal-drug, caffeine, and nicotine use
Monitor for cardiovascular changes
Monitor for seizures and patient’s environment
Conventional (Typical)
Antipsychotics (continued)
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Monitor for decrease of psychotic symptoms, side effects
Monitor for anticholinergic side effects
Monitor for alcohol, illegal-drug, caffeine, and nicotine use
Monitor for cardiovascular changes
Monitor for seizures and patient’s environment
Atypical Antipsychotic
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Monitor RBC and WBC and hematologic side effects
Observe for side effects and anticholinergic side effects
Monitor for decrease of psychotic symptoms
Monitor for alcohol, illegal-drug use, caffeine, nicotine use
Monitor elderly closely
Extrapyramidal Symptoms
(EPS)
• Tremor, muscle rigidity, stooped posture
(pseudoparkinsonism)
• Muscle spasms of face, tongue, neck or back (acute
dystonias)
• Inability to rest and relax; pacing (akathisia)
• Lip smacking; wormlike movements of the tongue;
uncontrolled chewing and grimacing (tardive dyskinesias)
Neuroleptic Malignant
Syndrome (NMS)
• Client suffers a toxic reaction to therapeutic doses of
antipsychotic drug
• Client exhibits
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Elevated temperature
Unstable blood pressure
Profuse sweating
Dyspnea
Muscle rigidity
Incontinence
Phenothiazines
• Prototype drug: chlorpromazine HCI (Thorazine)
• Mechanism of action: blocks positive symptoms of
schizophrenia
• Primary use: for severe mental illness
• Adverse effects: acute dystonia, akathisia, Parkinsonism,
tardive dyskinesia, anticholinergic effects, sedation,
hypotension, sexual dysfunction, and neuroleptic malignant
syndrome
Prototype Drug: Chlorpromazine hydrochloride
Nonphenothiazines
haloperidol (Haldol)
Mechanism of action: blocking of the dopamine type
2 receptor
Primary use: severe mental illness
Adverse effects: identical to that of phenothiazines
• Prototype drug:
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Prototype Drug: Haloperidol
Atypical Antipsychotics
risperidone (Risperdal)
Mechanism of action: block dopamine type 2
receptors, serotonin and alpha-adrenergic
receptors
Primary use: severe mental illness; treats both
positive and negative symptoms
Adverse effects: fewer than those of
phenothiazines and nonphenothiazines, but
obesity and its risk factors need to be monitored
• Prototype drug:
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Atypical Antipsychotics
(continued)
• Dopamine System Stabilizers
• Newest antipsychotic class
• Aripiprazole (Abilify) controls both positive and negative
symptoms
• Serious side effects compared to other antipsychotic drugs is low
Prototype Drug: Risperidone
Conventional (Typical)
Antipsychotic Agents
• Phenothiazines
• Action blocks positive symptoms
• Mellaril, Compazine, Permitil
• Nonphenothiazines
• Action same as that of phenothiazines
• Taractan, Loxitane, Navane
Atypical Antipsychotics
• Treats both the positive and negative symptoms
• Less dramatic side effects, but still significant
• Examples: Seroquel, Risperdal, Zyprexa
Nursing Process Focus: Patients Receiving Atypical Antipsychotic Therapy
NCLEX-RN Review
Question 1
The patient states that he has not taken his antipsychotic drug
for the past 2 weeks because it was causing sexual
dysfunction. The name antipsychotic explains that continuing
the medication as prescribed is important because:
1.
2.
3.
4.
Hypertensive crisis may occur with abrupt
withdrawal.
Muscle twitching may occur.
Parkinson-like symptoms will occur.
Symptoms of psychosis are likely to return.
NCLEX-RN Review
Question 1 – Answer
1.
2.
3.
4.
Hypertensive crisis may occur with abrupt withdrawal.
Muscle twitching may occur.
Parkinson-like symptoms will occur.
Symptoms of psychosis are likely to return.
NCLEX-RN Review
Question 1 – Rationale
Rationale: Symptoms of psychosis are likely to return and
manifest as agitation, distrust, and frustration.
NCLEX-RN Review
Question 2
Prior to discharge, the nurse provides teaching related to side
effects of phenothiazines to the patient, family, or caregiver.
Which of the following should be included?
1.
2.
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4.
The patient may experience withdrawal and
slowed activity.
Severe muscle spasms may occur early in
therapy.
Tardive dyskinesia is likely early in therapy.
Medications should be taken as prescribed to
prevent side effects.
NCLEX-RN Review
Question 2 – Answer
1.
2.
3.
4.
The patient may experience withdrawal and slowed activity.
Severe muscle spasms may occur early in therapy.
Tardive dyskinesia is likely early in therapy.
Medications should be taken as prescribed to prevent side
effects.
NCLEX-RN Review
Question 2 – Rationale
Rationale: Acute dystonias occur early in the course of
therapy. These are severe muscle spasms, particularly
of the back, neck, tongue, and face.
NCLEX-RN Review
Question
3
A 20-year-old man is admitted to the in-patient psychiatric unit
for treatment of acute schizophrenia and is started on
risperidone (Risperdal). Therapeutic outcomes of this drug will
include:
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Restful sleep, elevated mood, and coping
abilities
Decreased delusional thinking and lessened
auditory/visual hallucinations
Orthostatic hypotension, reflex tachycardia, and
sedation
Relief of anxiety and improved sleep and
dietary habits
NCLEX-RN Review
Question 3 – Answer
1.
2.
3.
4.
Restful sleep, elevated mood, and coping abilities
Decreased delusional thinking and lessened
auditory/visual hallucinations
Orthostatic hypotension, reflex tachycardia, and sedation
Relief of anxiety and improved sleep and dietary habits
NCLEX-RN Review
Question 3 – Rationale
Rationale: Antipsychotic drugs such as risperiodne
(Risperdal) treat the positive and negative effects of
the underlying mental disorder.A decrease in
delusional thinking, lessened hallucinations, and
overall improvement in mental thought processes
should be noted. Improvement in sleep patterns,
anxiety, and nutrition may be noted as secondary
effects of treatment of the underlying thought
disorder. Orthostatic hypotension, reflex tachycardia,
or sedation are potential adverse effects.
NCLEX-RN Review
Question 5
Which of the following data collected by the nurse during the
history and physical is a contraindication for a patient to receive
fluphenazine (Permitil, Prolixin)?
1.
2.
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4.
Diabetes mellitus
Age older than 70
Bone marrow depression
Hypertension
NCLEX-RN Review
Question 5 – Answer
1.
2.
3.
4.
Diabetes mellitus
Age older than 70
Bone marrow depression
Hypertension
NCLEX-RN Review
Question 5 – Rationale
Rationale: Fluphenazine (Prolixin) is a phenothiazine
drug. Use is contraindicated in patients with CNS
depression, bone marrow depression, and alcohol
withdrawal.
NCLEX-RN Review
Question 6
A female, age 39, has been on haloperidol (Haldol) for 3
months for severe psychosis. The nurse is monitoring the
patient for the development of acute dystonias with
haloperidol, and will monitor for:
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2.
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4.
Dry mouth, constipation, and blurred vision
Pacing, squirming, or difficulty with gait such as
bradykinesia
Severe spasms of the muscles of the tongue,
face, neck, or back
Tremors, wormlike tongue movements, and
involuntary lip puckering
NCLEX-RN Review
Question 6 – Answer
1.
2.
3.
4.
Dry mouth, constipation, and blurred vision
Pacing, squirming, or difficulty with gait such as
bradykinesia
Severe spasms of the muscles of the tongue,
face, neck, or back
Tremors, wormlike tongue movements, and
involuntary lip puckering
NCLEX-RN Review
Question 6 – Rationale
Rationale: Acute dystonias are characterized by acute
spasms of the face, tongue, neck, or back. Dry mouth,
constipation, and blurred vision are adverse effects
related to anticholinergic activity. Pacing and squirming
are signs of akathisia, and bradykinesia and tremors are
symptoms of pseudoparkinsonism.
Involuntary lip-puckering and wormlike movements of the
tongue are symptomatic of tardive dyskinesias.
Drug Therapy for Psychoses
• Assessment
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Monitor client’s condition
Obtain health assessment
Ascertain past mental illness
Obtain information on smoking and use of illegal drugs, alcohol,
and caffeine
• Ascertain current medications and dietary habits
• Obtain baseline blood and urine samples
• Assess family’s knowledge of psychoses and medication
regimen
Drug Therapy for Psychoses
(continued)
• Planning
• Goal is to remain compliant with medication regimen and free of
symptoms
• Implementation
• Encourage compliance with medication regimen
• Provide additional education
Drug Therapy for Psychoses
(continued)
• Evaluation
• Client to remain free of symptoms related to psychoses
• Client to verbalize importance of taking prescribed medications
Nursing Process Focus: Patients Receiving Conventional Antipsychotic Therapy
Nursing Process Focus: Patients Receiving Conventional Antipsychotic Therapy
Nursing Process Focus: Patients Receiving Conventional Antipsychotic Therapy
Nursing Process Focus: Patients Receiving Conventional Antipsychotic Therapy
Nursing Process Focus: Patients Receiving Conventional Antipsychotic Therapy
Nursing Process Focus: Patients Receiving Conventional Antipsychotic Therapy
Nursing Process Focus: Patients Receiving Conventional Antipsychotic Therapy
Nursing Process Focus: Patients Receiving Atypical Antipsychotic Therapy
Nursing Process Focus: Patients Receiving Atypical Antipsychotic Therapy
Nursing Process Focus: Patients Receiving Atypical Antipsychotic Therapy
Nursing Process Focus: Patients Receiving Atypical Antipsychotic Therapy
Nursing Process Focus: Patients Receiving Atypical Antipsychotic Therapy
Nursing Process Focus: Patients Receiving Atypical Antipsychotic Therapy
Nursing Process Focus: Patients Receiving Atypical Antipsychotic Therapy