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Chapter 18
Drugs Used for Psychoses
Learning Objectives
Identify signs and symptoms of psychotic behavior
Describe major indications for the use of antipsychotic agents
Identify common adverse effects observed with antipsychotic medications
Develop a teaching plan for a patient taking haloperidol and one receiving clozapine
Psychosis
Clinical descriptor; no exact definition
Characteristics include:
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Being out of touch with reality
Perceptual deficits
Deterioration in social functioning
Psychotic symptoms:
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Can be associated with many illnesses
Are common in mood disorders
Can be caused by many drugs
Symptoms
Delusions
Hallucinations
Disorganized thinking, loosening of associations
Disorganized behavior
Changes in affect
Treatment
Perform thorough initial assessment
Consider both drug and nondrug therapies
Determine baseline level of functioning
Define treatment goals
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Identify and document target symptoms
Target Symptoms
Frequency and type of agitation
Degree of suspiciousness
Delusions
Hallucinations
Loose associations
Grooming habits/hygiene
Sleep patterns
Speech patterns
Social skills
Judgment
Drug Therapy
Antipsychotic (neuroleptic) agents
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Phenothiazines and nonphenothiazines
Low potency and high potency
Typical and atypical
Other agents
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Benzodiazepines
Control of adverse effects
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Beta-adrenergic blocking agents
Antiparkinsonian agents
Anticholinergic agents
Actions
Blocks dopamine from acting on the brain
Stimulate or block cholinergic, histaminic, nicotinic, and alpha and beta adrenergic
neurotransmitter receptors (cause of adverse effects)
Adverse Effects
Extrapyramidal symptoms (EPS)
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Dystonic reactions/acute dystonia
Pseudoparkinsonism (tremor, muscular rigidity, masklike expression, shuffling
gait, loss/weakness of motor function)
Akathisia (pacing, rocking, subjective feelings of anxiety and restlessness)
Tardive dyskinesia (hyperkinetic abnormal movements)
Neuroleptic malignant syndrome
Nursing Process: Assessment
History of behavior
Basic mental status
Interpersonal relationships
Mood/affect
Clarity of thoughts/perception
Thoughts of death
Psychomotor function
Sleep pattern
Dietary history
Nursing Process: Planning
History of psychotic behavior
Basic mental status
Mood/affect
Clarity of thought/perception
Thoughts of death
Psychomotor function
Sleep pattern
Dietary needs
Nursing Process: Implementation
Create individualized interventions
Provide safe, structured, accepting environment
Provide opportunity for expression
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Allow opportunity for patient to make decisions (if capable)
Involve the patient in self-care activities
Do not reinforce hallucinations, delusions
Be open and direct when handing suspicious patients
Nursing Process: Implementation
Set limits and enforce them kindly
Provide diversionary activities for patients with altered perceptions
Monitor suicidal patients
Use physical restraints within guidelines
Provide for nutritional needs
Handle manipulative behavior in consistent manner
Antipsychotic Agents
Used to treat schizophrenia, mania, psychotic depression, and psychotic organic brain
syndrome
Typical
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Phenothiazines
Nonphenothiazines (haloperidol, molindone, loxapine, thioxanthenes)
Atypical
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Clozapine, olanzapine, quetiapine, risperidone, ziprasidone
Premedication Assessment
Obtain blood pressures in supine, sitting, and standing positions
Check
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Electrolytes
Hepatic function
Renal function
Cardiac function
Thyroid function
Perform baseline clinical evaluation rating scales and adverse effect scales
Side Effects to Expect
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Chronic fatigue/drowsiness
Orthostatic hypotension
Blurred vision
Constipation
Urinary retention
Dry mouth/throat/nose
Weight gain
Side Effects to Report
Seizure activity
Parkinsonian symptoms
Tardive dyskinesia
Hepatotoxicity
Blood dyscrasias
Hives/rash
Photosensitivity
Drug Interactions
Increase toxic effects:
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Antihistamines
Alcohol
Analgesics
Tranquilizers
Decrease therapeutic effects:
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Carbamazepine
Cimetidine
Phenytoin
Insulin/oral hypoglycemic medications
Venlafaxine