ncm 105 overview

NCM105 – PSYCHIATRIC/MENTAL HEALTH NURSING

Lectured by Leila T. Salera, RN, MD, DPSP

OVERVIEW

Lectured by Leila T. Salera, RN, MD, DPSP

Historical overview of psychiatric care

• Primitive beliefs1. People with mental illness has been dispossessed by his

or her soul2. People with mental illness are possessed by evil spirits• Hippocrates (400 BC)1. Associated insanity and mental illness with an

irregularity in the interaction of the four body fluids or humors (blood, black bile, yellow bile, and phlegm)

2. Disequilibrium of these humors led to being treated with potent cathartic agents

(Chapter 2 of Townsend)


• Middle Ages1. Middle Eastern Islamic countries start to believe that

people with mental illness are actually ill2. Establishment of special units within general hospitals• 16th and 17th Centuries1. Mental institutions did not exist in the US, and care for the

mentally ill is a family responsibility2. Those without family became the responsibility of the

community and are incarcerated



1790s – The Period of Enlightenment• Phillippe Pinel in France and William Tukes in

Englang formulated the concept of asylum as a safe refuge or haven offering protection at institutions where people have been whipped, beaten, and starved just because they were mentally ill

(Chapter 1, Videbeck)


• 18th Century1. First hospital for the mentally ill was established in the US2. Benjamin Rush – the father of American Psychiatry, introduced

more humane treatment but also used methods like bloodletting, purging, various types of restraints, and extremes of temperatures

• 19th Century1. Establishments of the asylum thanks to Dorothea Dix, a former

New England schoolteacher, who lobbied on behalf of the mentally ill

2. Humanistic therapeutic care3. Asylums became overcrowded over time and conditions

deteriorated and therapeutic care reverted to custodial care.(Chapter 2 of Townsend)


• 18731. Linda Richards – graduated from New England Hospital for

Women and became known as the first American Psychiatric Nurse

2. She was instrumental in the establishment of a number of psychiatric hospitals and the first school of psychiatric nursing at the McLean Asylum in Waverly , Massachusettes in 1882

3. Focus: training in how to provide custodial care in psychiatric asylums



• After WWII1. US government passed the National Health Act of 19462. This legislation provided funds for the education of

psychiatrists, psychologists, social workers, and psychiatric nurses

3. Introduction of antipsychotic medications• 19551. Incorporation of psychiatric nursing curicula2. Incorporation of nursing interventions in the somatic

therapies (insulin shock and electroconvulsive therapy)(Chapter 2 of Townsend)


• 20th Century onwards• Diagnostic and Statistical Manual (DSM) I – 1952• DSM II - 1962• DSM III – 1980• DSM III-R – 1987• DSM IV – 1994• DSM IV-TR – 2000• DSM V – soon to be released (May 2013)(The Internet)

Hellingly hospital (East sussex mental asylum)

the “Tranquilizer,” which was designed to “keep the maniacs in the inflammatory stage of their disease in a perpendicular position so as to save the head from the impetus of the blood as much as possible.”

“We went through the top of the head, I think she was awake. She had a mild tranquilizer. I made a surgical incision in the brain through the skull. It was near the front. It was on both sides. We just made a small incision, no more than an inch… We put an instrument inside… We made an estimate on how far to cut based on how she responded.” James Watts

These words describe the lobotomy that was carried out in 1941 on Rosemary Kennedy, sister of the then future US President. Said to have been intended to cure her mood swings, the procedure left Rosemary with urinary incontinence and the mental age of a child – staring blankly at walls for hours, her speech unintelligible. (http://www.coolpicturegallery.net/2010/02/chilling-pictures-of-prefrontal.html)

First lobotomy procedure

Went into relapse – second lobotomy

Development of Psychopharmacology

• Began in about the 1950s• Chlorpromazine (Thorazine), and lithium – the first

to be developed• Over the following 10 years – MAOIs, haloperidol

(Haldol), TCAs and benzodiazepines• Hospital stays were shortened and many people

were well enough to go home

(Chapter 1, Videbeck)

Mental health

• Maslow – a “healthy” or “self-actualized” individuals possessed the following characteristics

1. An appropriate perception of reality2. The ability to accept oneself, others, and human nature3. The ability to manifest spontaneity4. The capacity for focusing concentration on problem solving5. A need for detachment and desire privacy6. Independence, autonomy, and a resistance to enculturation(Chapter 2 Townsend; pages 1 to 2, Student Guide)

Mental health

• Maslow – a “healthy” or “self-actualized” individuals possessed the following characteristics

7. An intensity of emotional reaction8. A frequency of “peak” experiences that validates the

worthwhileness of, richness, and beauty in life9. An identification with humankind10. A democratic character structure and strong sense of ethics11. Creativity12. A degree of nonconformance(Chapter 2 Townsend; pages 1 to 2, Student Guide)

Mental health

• Jahoda (1958) – identified six indicators that are a reflection of mental health

1. A positive attitude toward self2. Growth, development, and the ability to achieve self-

actualization3. Integration4. Autonomy5. Perception of reality6. Environmental mastery(Chapter 2 Townsend; pages 1 to 2, Student Guide)

Mental health• The American Psychiatric Association (APA) (2003) – a state of being

that is relative rather than absolute. The successful performance of mental functions shown by productive activities, fulfilling relationships with other people, and the ability to adapt to change and to cope with adversity

• Robinson (1983) – 1. A dynamic state in which thought, feeling, and behavior that age-

appropriate and congruent with local and cultural norms is demonstrated

2. It is viewed as the successful adaptation to stressors from the internal or external environment, evidenced by thoughts, feelings, and behaviors that are age-appropriate and congruent with local and cultural norms (Robinson)

(Chapter 2 Townsend; pages 1 to 2, Student Guide)

Mental health

• WHO 1. A state of complete physical, mental, and social wellness and

not just merely the absence of disease or infirmity2. Emphasis is on health as a positive state of well-being3. People in a state of emotional, physical, and social well-

being fulfill responsibilities, function effectively in life, and are satisfied with their interpersonal relationships and themselves

(pages 2 to 3, Videbeck)

Mental health

• Factors that influence:1. Individual make-up2. Interpersonal3. Social/cultural, or environmental(pages 2 to 3, Videbeck)

Mental illness

• Horowitz has identified two elements that are associated with individuals’ perceptions of mental illness, regardless of cultural origin

1. Incomprehensibility – relates to the inability of the general population to understand the motivation behind the behavior

2. Cultural relativity – considers that some behaviors that are considered “normal” and “abnormal” is defined by one’s cultural or social norms

(Chapter 2, Townsend)

Mental illness

• APA (2000)1. Mental disorder is a clinically significant behavioral or

psyschological syndrome or pattern that occurs in an individual and is associated with present distress (i.e., painful symptom) or disability (i.e., impairment in one or more important areas of functioning) or with a significantly increased risk of suffering death, pain, disability, or an important loss of freedom

(pages 2 to 3, Videbeck)

Mental illness

• APA (2000)2. General criteria to diagnose mental illness:a. Dissatisfaction with one’s characteristics, abilities, and

accomplishmentsb. Ineffective or unsatisfying relationshipsc. Dissatisfaction with one’s place in the worldd. Ineffective coping with life eventse. Lack of personal growth(pages 2 to 3, Videbeck)

Mental illness

• Factors contributing to mental illness:1. Individual2. Interpersonal3. Social/cultural or environmental(pages 2 to 3, Videbeck)

DSM-IV-TR

• Diagnostic Statistical Manual 4th Edition Text Revision• Multiaxial evaluation system• Endorsed by the APA to facilitate comprehensive and

systematic evaluation with attention to the various mental disorders and general medical problems, and level of functioning that might be overlooked if the focus were on assessing a single presenting problem

• 5 Axes (Axis I, II, III, IV and V)(Chapter 2 of Townsend; pages 2 to 3, Videbeck)

DSM-IV-TR

• Axis I – Clinical Disorders and other Conditions That May Be a Focus of Clinical Attention. This includes all mental disorders: depression, schizophrenia, anxiety and substance abuse disorder (except personality disorders and mental retardation)

• Axis II – Personality Disorders and Mental Retardation. These disorders usually begin in childhood or adolescence and persist in a stable form into adult life; also for reporting prominent maladaptive personality features and defense mechanisms

(Chapter 2 of Townsend; pages 2 to 3, Videbeck)

DSM-IV-TR• Axis III – General Medical Condition. These include any current

general medical condition that is potentially relevant to the understanding or management of the individual’s mental disorder

• Axis IV – Psychosocial and Environmental Problems. These are problems that may affect the diagnosis, treatment, and prognosis of mental disorders named on Axes I and II.

• Axis V – Global Assessment of Functioning. This allows clinician to rate the individual’s overall functioning on the Global Assessment of Functioning (GAF) Scale. This scale represents in global terms as a single measure of the individual’s psychological , social, and occupational functioning

(Chapter 2 of Townsend; pages 2 to 3, Videbeck)

DSM-IV-TR

• Note: A copy of the GAF can be seen in Chapter of Townsend page 26

• Note: DSM-IV-TR Classification of Diseases are in pages 465 to 473 of Videbeck 5th ed

DSM-IV-TR

• Example of a Psychiatric Diagnosis:Axis I 300.4 Dysthymic DisorderAxis II 301.6 Dependent Personality DisorderAxis III 244.9 HypothyroidismAxis IV UnemployedAxis V GAF = 65 (current)(Chapter 2 of Townsend; pages 2 to 3, Videbeck)

The mental health nurse

• Peplau (1991) applied interpersonal theory to nursing practice and, most specifically, to nurse-client relationship development

• She provided a framework for “psychodynamic nursing”, the interpersonal development of the nurse with the client in a given nursing situation

• She states, “Nursing is helpful when both the patient and the nurse grow as a result of the learning that occurs in the situation.”

(Chapter 2 of Townsend page 44 to 45)


• Psychodynamic Nursing – being able to understand one’s own behavior, to help others identify felt difficulties, and apply principles of human relations to the problems that arise at all levels of experience

• Roles of the Nurse1. Resource person – provides specific, needed information

that helps the client understand his or her problem and the new situation

2. Counselor – listens as the client reviews feelings related to difficulties he or she is experiencing in any aspect of life

(Chapter 2 of Townsend page 44 to 45)


• Roles of the Nurse3. Teacher – identifies learning needs and provides information

to the client or family that may aid in improvement of the life situation

4. Leader – directs the nurse-client interaction and ensures that appropriate actions are undertaken to facilitate achievement of the designated goals

5. Technical expert – understands various professional devices and possesses the clinical skills necessary to perform the interventions that are in the best interest of the client

6. Surrogate – serves as a substitute figure for another(Chapter 2 of Townsend page 44 to 45)

The interdisciplinary team• Multidisciplinary team• Functioning as an effective team member requires the

development and practice of several core skill areas:1. Interpersonal skills2. Humanity3. Knowledge4. Communication skills5. Personal qualities, such as consistency, assertiveness, and

problem-solving abilities6. Teamwork skills, such as collaborating, sharing, and integrating7. Risk assessment and risk management skills(pages 72 to 73, Videbeck)

The interdisciplinary team

• Pharmacist • Psychiatrist• Psychologist• Psychiatric Nurse• Psychiatric social worker• Occupational therapist• Recreation therapist• Vocational rehabilitation specialist(pages 72 to 73, Videbeck)

The mental health/mental illness continuum

• Mental Health Continuum

Interpersonal Adequacy Interpersonal Competency

• Mental Illness Continuum

Interpersonal inadequacy Interpersonal incompetency

(Chapter 2 of Townsend; Student Guide page 3)


Interpersonal Adequacy Interpersonal Inadequacy and and competency Incompetency

Mental Health Mental Illness

(Chapter 2 of Townsend; Student Guide page 3)


• Anxiety- Peplau (1963) described four levels of anxiety1. Mild anxiety2. Moderate anxiety3. Severe anxiety4. Panic

(Chapter 2 of Townsend; Student Guide pages 8 to 11)


• Anxiety- Behavioral responses to anxiety1. Mild anxiety – (coping mechanisms) sleeping, eating,

physical exercise, smoking, crying, pacing, yawning, drinking, daydreaming, laughing, cursing, nail biting, foot swinging, fidgeting, finger tapping, talking to someone whom one feels comfortable



• Anxiety- Behavioral responses to anxiety2. Mild to Moderate Anxiety a. Sigmund Freud (1961) identified the ego as the reality

component of the person that governs problem solving and rational thinking, and as the level of anxiety increases, the strength of the ego is tested, and energy is mobilized to confront the threat

b. Anna Freud (1953) identified a number of defense mechanisms employed by the ego in the face of threat to biological or psychological integrity


Ego defense mechanisms

(Chapter 2 of Townsend; Videbeck , page 46; Student Guide pages 14 to 16)

Defense Mechanism Definition Example

Compensation Covering up a real or perceived weakness by emphasizing a trait one considers more desirable

A physically handicapped boy is unable to participate in football, so he compensated by becoming a great scholar

Denial Refusing to acknowledge the existence of a real situation or the feelings associated with it

A woman drinks alcohol every day and cannot stop, failing to acknowledge that she has a problem

Displacement The transfer of feelings from one target to another that is considered less threatening or that is neutral

A client is angry with his physician, does not express it, but becomes verbally abusive with the nurse


((Chapter 2 of Townsend; Videbeck , page 46; Student Guide pages 14 to 16)


Rationalization Attempting to make excuses or formulate logical reasons to justify unacceptable feelings or behaviors

John tells the rehab nurse “I’ll drink because it’s the only way I can deal with my bad marriage and my worse job.”

Reaction Formation Preventing unacceptable or undesirable thoughts or behaviors from being expressed by exaggerating opposite thoughts or types of behaviors

Jane hates nursing and attends nursing school to please her parents. During career day, she speaks to prospective students about the excellence of nursing as a career




Regression Retreating in response to stress to an earlier level of development and the comfort measures associated with that level of functioning

A 2-year-old boy is hospitalized and he only drinks from a bottle, even though his mom says that he has been drinking from a cup for 6 months

Identification An attempt to increase self-worth by acquiring certain attributes and characteristic of an individual one admires

A teenager who required lengthy rehabilitation after an accident decides to become a physical therapist as a result of his experiences




Intellectualization An attempt to avoid expressing actual emotions associated with a stressful situation by using the intellectual processes of logic, reasoning, and analysis

S’s husband is being transferred with his job to city far away from her parents. She hides the anxiety by explaining to her parents the advantages associated with the move

Introjection Integrating the beliefs and values of another individual into one’s own ego structure

Children integrate their patents’ value system into the process of conscience formation. A child says to a friend, “Don’t cheat. It’s wrong.”




Isolation Separating a thought or memory from the feeling tone or emotion associated with it

A young woman describes being attacked and raped without showing any emotion

Projection Attributing feelings of impulses unacceptable to one’s self to another person

Sue feels a strong sexual attraction to her track coach and tells a friend, “He’s coming on to me!”

Repression Involuntarily blocking unpleasant feelings and experiences from one’s awareness

An accident victim can remember nothing about the accident




Sublimation Rechanneling of drives or impulse that are personally or socially unacceptable into activities that are constructive

A mother whose son was killed by a drunk driver channels her anger and energy into being the president of the local chapter of Mothers Against Drunk Drivers

Suppression The voluntary blocking unpleasant feelings and experiences from one’s awareness

“I don’t want to think about that now. I’ll think about that tomorrow.”

Undoing Symbolically negating or cancelling out an experience that one finds intolerable

Joe is nervous about his new job and yells at his wife. On his way home he stops and buys her flowers.


• Anxiety- Behavioral responses to anxiety3. Moderate to Severe Anxietya. If not resolved can contribute to a number of physiological

disorders (pain, anorexia, arthritis, colitis, ulcers, asthma, etc…)

b. The presence of one or more specific psychological or behavioral factors that adversely affect a general medical condition (DSM-IV-TR)



• Anxiety- Behavioral responses to anxiety4. Severe Anxietya. Extended periods can lead to psychoneurotic patterns of

behaving5. Panic Anxietya. At this level of extreme anxiety, an individual is not capable

of processing what is happening in the environment, and may lose contact with reality

b. Psychosis may develop(Chapter 2 of Townsend; Student Guide pages 8 to 11)


• Grief1. Is a subjective state of emotional, physical, and social

responses to the loss of a valued entity2. Stages (Kubler-Ross, 1969):a. Denialb. Angerc. Bargainingd. Depressione. Acceptance(Chapter 2 of Townsend)


• Anxiety and grief just two of the major responses to stress• Both are presented on a continuum• Disorders appear in the DSM-IV-TR are identified at their

appropriate placement along the continuum


Feelings of sadness

DytshymiaCyclothymia

Major DepressionBipolar Disorder

Life’s everyday disappointments

Neurotic responses

Psychotic responses

Mental Health

Mental Illness

Mild Moderate Severe Grief Grief

Anxiety

Mild Moderate Severe Anxiety

Panic

Coping mechanisms

Defense mechanisms

Psychoneurotic responses

Psychotic responses

Psychiatric nursing practice – the standards of care (psychiatric nursing process)

The Psychiatric History

• The record of the patient’s life• It is to better understand who the patient is,

where the patient has come from, and where is likely to go into the future

(Synopsis of Psychiatry by Kaplan and Sadock)

The nursing process – the standards of care

• Standard 1 – Assessment • Standard 2 – Diagnosis• Standard 3 – Outcomes Identification• Standard 4 – Planning • Standard 5 – Implementation1. Standard 5a – Coordination of Care2. Standard 5b – Health Teaching and Health Promotion3. Standard 5c – Milieu Therapy4. Standard 5d – Pharmacological, Biological, and Integrative Therapies5. Standard 5e – Prescriptive Authority and Treatment6. Standard 5f – Psychotherapy7. Standard 5g – Consultation• Standard 6 – Evaluation (Videbeck page 9 to 10)

Standard 1. Assessment

• Identifying data• Chief complaint“I am having thoughts of wanting to harm myself.”“People are trying to drive me insane.”“I feel I am going mad.”“I am angry all the time.”• History of Present Illness• Family History


• Personal Historya. Prenatal and perinatalb. Infancy and early childhoodc. Middle childhoodd. Adolescencee. Young adulthoodf. Middle adulthood and old age


• Sexual History• Mental status examination – part of clinical

assessment that describes the sum total of the examiner’s observations and impressions of the psychiatric patient at the time of the interview

Mental Status examination (MSE)

• General description• Mood and affect• Perception• Sensorium and cognition• Impulsivity• Judgment and insight

General Description

• Appearance• Attitude toward the examiner• Speech characteristics• Overt behavior and psychomotor activity

Mood and Affect• Mood – how does the client say he or she feels; depressed,

euphoric, empty, guilty, irritable, anxious terrified• Affect – how the examiner evaluates client’s affect; broad,

restricted, blunted, flat, shallow, amounta. Blunted – showing little or a slow-to-respond facial expressionb. Broad affect – displaying a full range of emotional expressionsc. Flat affect – showing no facial expressiond. Inappropriate affect – displaying a facial expression that is

incongruent with the mood or situation; often silly or giddy regardless of circumstances

e. Restricted affect – displaying one type of expression, usually serious or somber

Perception

a. Hallucinations – false sensory perceptions or perceptual experiences that do not exist; visual, auditory, tactile, olfactory

b. Illusion - mental impression derived from misinterpretation of an actual experience

c. Depersonalization – feelings of being disconnected form him/herself; the client feels detached from his/her behavior

d. Derealization – client senses that events are not real, when, in fact, they are

Perception

• Thought content and thought process• Thought content – refers to what a person is

actually thinking about: ideas, beliefs, preoccupations, obsessions; refers to what the client thinks

• Thought process – refers to the way in which a person thinks; refers to what the client says

Perception

• Circumstantial thinking – a client answers a question but only after giving excessive unnecessary detail

• Delusion – a fixed false belief not based on reality• Flight of ideas – excessive amount and rate of

speech composed of fragmented or unrelated ideas

• Ideas of reference – client’s inaccurate interpretation that general events are personally directed to him or her

Perception

• Loose associations – disorganized thinking that jumps from one idea to another with little or no evident relationship between the thoughts

• Tangential thinking – wandering off topic and never providing the information requested

• Thought blocking – stopping abruptly in the middle of a sentence or train of thought; sometimes unable to continue the idea

• Thought broadcasting – a delusional belief that others can hear or know what the client is thinking

Perception

• Thought insertion – a delusional belief that others are putting ideas or thoughts into the client’s head – that is, the ideas are not those of the client

• Thought withdrawal – a delusional belief that others are taking the client’s thoughts away and the client is powerless to stop it

• Word salad – flow of unconnected words that convey no meaning to the listener

Sensorium and Cognition• Intellectual functioninga. Abstract ability – can be assessed by asking the client

to interpret proverbsb. Calculationsc. Alertness d. Concentration and attentione. Reading and writingf. Information and intelligence• Ego defense mechanisms• Level of self esteem

Sensorium and Cognition• Orientation and memorya. Remote memory loss– memory impairment involves

experiences or incidents 6 months or longer or data of personal identification

b. Recent memory loss– memory loss includes experiences or incidents which happened hours or a few days ago

impulsivity

• Is the patient capable of controlling sexual, aggressive, and other impulses?

• To ascertain the patient’s awareness of socially appropriate behavior and is a measure of the patient’s potential danger to self and others

Judgment and Insight

• Judgment – refers to the ability to interpret one’s environment and situation correctly and to adapt one’s behavior and decisions accordingly

• Insight – the ability to understand the true nature of the situation and accept some personal responsibility for that situation

Standard 2 - diagnosis

• The psychiatric-mental health nurse analyzes the assessment data to determine diagnoses of problems, including level of risk

1. Sensory perception disturbed (auditory)2. Disturbed thought process related to impaired judgment

associated with manic behavior3. Impaired verbal communication – flight of ideas related to

accelerated thinking4. Risk for violence related to hostile and angry behavior5. Potential for self harm related to poor impulse control

associated with substance abuse

Standard 3 – outcomes identification and standard 4 - planning

• Standard 3 - The psychiatric-mental health nurse identifies outcomes for a plan individualized to the patient or the situation

• Standard 4 - The psychiatric-mental health nurse develops a plan that prescribes strategies and alternatives to attain expected outcomes

• Clarifying goals is an essential step in the therapeutic process. Therefore the patient nurse relationship should be based upon mutually agreed goals. Once the goals are a greed on they must be stated in writing


• Expected outcomes and short term goals should be developed with short tem objectives contributing to the long term expected outcomes.

• Example of short term goals:1. At the end of the two weeks patients will stay out of

bed and participate in activities 2. At the end of the one week patient will sleep well at

night. 3. At the end of the one week patient will eat properly

and maintain weight.


• As soon as the patient‘s problems are identified, nursing diagnosis made, planning nursing care begins.

• The planning consists of:1. Determining priorities 2. Setting goals 3. Selecting nursing actions 4. Developing /writing nursing care plan • In planning the care the nurse can involve the patient, family, members of

the health team. • Once the goals are chosen the next task is to outline the plan achieving

them. • On the basis of an analysis, the nurse decides which problem requires

priority attention or immediate attention.

Standard 3 – outcomes identification and Standard 4 – planning

• Example: A client with schizophrenia having delusionsExpected Outcomes (Goals)A. Immediate (Short-term Goals) – The client will be:1. Free from injury2. Demonstrate decreased level of anxiety3. Respond to reality-based interactionsB. Stabilization (Long-term Goals) – The client will be:1. Interact on reality-based topics such as daily activities or local

events2. Sustain attention and concentration to complete task or

activities

Standard 5 – implementation – psychiatric treatment modalities: psychopharmacology

• The psychiatric-mental health nurse implements the identified plan

• Psychotropic drugs - drugs used to treat mental disorders

• ECT – electroconvulsive therapy (?)• Psychotherapy• Community-based care

Standard 5 – implementation – psychiatric treatment modalities: psychopharmacology

• The psychiatric-mental health nurse implements the identified plan

• Psychotropic drugs - drugs used to treat mental disorders

1. Antipsychotics2. Antidepressants3. Mood stabilizers4. Anxiolytics5. Stimulants

Antipsychotics

• Also known as neuroleptics• Used to treat the symptoms of psychosis, such

as delusions and hallucinations seen in schizophrenia, schizoaffective disorder and the manic phase of bipolar disorder

• Used to modify behavior• Affect the CNS and ANS• Do not cure mental illness but relieve symptoms( Videbeck, pages 24 39; Student Guide, pages 43 to 53)

Antipsychotics – mode of action

• Major action in the nervous system is to block receptors for the neurotransmitter dopamine

• Dopamine are classified into subcategories (D1 to D5)• D2, D3 and D4 have been associated with mental illness• Effective in treating target symptoms• But also produces side effects, the extrapyramidal

symptoms (EPS)• Conventional or first generation antipsychotics• Atypical of second generation antipsychotics• New generation antipsychotics( Videbeck, pages 24 39; Student Guide, pages 43 to 53)

Antipsychotics

Conventional Antipsychotics:• Phenothiazines:1. Chlorpromazine (Thorazine)2. Thioridazine (Mellaril)• Butyrophenones1. Haloperidol (Haldol)Atypical Antipsychotics• Clozapine (Clozaril)• Risperidone (Risperidal)New Generation Antipsychotics• Aripirazole (Abilify)( Videbeck, pages 24 39; Student Guide, pages 43 to 53)

Antipsychotics – side effects

Extrapyramidal side effects/symptoms (EPS)• Serious neurologic symptoms1. Acute dystonia – acute muscular rigidity and cramping,

stiff or thick tongue with dysphagia, and in severe cases laryngospasm and respiratory difficulties

2. Pseudoparkinsonism – drug-induced parkinsonism3. Akathisia – reported by the client as an intense need to

move about. The client appears restless or anxious and agitated, often with a rigid posture or gait and a lack of spontaneous gestures

( Videbeck, pages 24 39; Student Guide, pages 43 to 53)

Drugs used to treat eps

• Amantidine (Symmetrel)• Benztropine (Cogentin)• Biperiden (Akineton)• Diazepam (Valium)• Diphenhydramine (Benadryl)• Lorazepam (Ativan)• Propanolol (Inderal)



Neuroleptic Malignant Syndrome (NMS)• Potentially fatal• Rigidity, high fever, autonomic instability such

as unstable BP, diaphoresis, and pallor• Delirium and elevated enzymes, particularly

creatine phosphokinase( Videbeck, pages 24 39; Student Guide, pages 43 to 53)

Antipsychotics – side effectsTardive dyskinesia (TD) • Syndrome of permanent involuntary movements, is

most commonly caused by the long-term use of conventional antipsychotics.

• Involuntary movements of the tongue, facial and neck muscles, upper and lower extremities, and truncal musculature

• Tongue thrusting and protruding, lip smacking, blinking, grimacing, and other excessive unnecessary facial movements are characteristic



Anticholinergic Side-Effects• Orthostatic hypotension• Dry mouth• Constipation• Urinary hesitance or retention• Blurred near vision• Dry eyes• Photophobia• Nasal congestion• Decreased memory( Videbeck, pages 24 39; Student Guide, pages 43 to 53)


Other Side Effects• Increase prolactin levels – may cause breast

enlargement and tenderness in men and women; diminished libido, erectile and orgasmic dysfunction; menstrual irregularities; increased risk for breast cancer; may contribute to weight gain

• Postural hypotension• Agranulocyctosis – always check CBC particularly

the WBC count( Videbeck, pages 24 39; Student Guide, pages 43 to 53)

Antipsychotics – client teaching

• Inform the client about the types of side effects that may occur and encourage the client to report such problems to the physician instead of discontinuing the medication

• Teach the client methods of managing or avoiding unpleasant side effects and maintaining medication regimen

• Sugar-free fluids and sugar-free candies for dry mouth• Avoid calorie-laden beverages and candy because of dental

caries, weight gain, and do little to relieve dry mouth• Dietary modifications as well as exercise to prevent

constipation• Sunscreen for photosensitivity( Videbeck, pages 24 39; Student Guide, pages 43 to 53)

Antipsychotics – client teaching

• Causes drowsiness and sleepiness so avoid any activities that require alertness

• A missed dose (because the client forgets) can be taken if it is only 3 to 4 hours late, a missed dose that is more than 4 hours should be omitted

• Encourage the client to use a chart and record doses if they have difficulty remembering doses


Antidepressant drugs

• Primarily used in the treatment of major depressive illness, anxiety disorders, the depressed phase of bipolar disorder, and psychotic depression

• 4 groups:1. TCA – Tricyclic antidepressants2. SSRI – Selective serotonin reuptake inhibitors3. MAOI – Monoamine oxidase inhibitors4. Others: Wellburtin, Effexor, Desyrel( Videbeck, pages 24 39; Student Guide, pages 43 to 53)

Antidepressant drugs - TCAs

• Imipramine (Tofranil)• Amitriptyline (Elavil)• Cause varying degrees of sedation, orthostatic

hypotension, and anticholinergic side effects• Potentially fatal if taken in overdose• Clients should report sexual dysfunction• Sexual dysfunction and weight gain are common

reasons for noncompliance( Videbeck, pages 24 39; Student Guide, pages 43 to 53)

Antidepressant drugs - SSRIs• Fluoxetine (Prozac)• Sertraline (Zoloft)• Paroxetine (Paxil)• Have replaced the TCAs as the first line of drugs • Cause fewer troublesome side effects• Preferred drug along with Effexor for suicide which is always a

primary consideration in depression• Carry no risk for lethal overdose• Effective only for mild to moderate depression• There is FDA-required warning and increased suicide risk among

children and adolescent( Videbeck, pages 24 39; Student Guide, pages 43 to 53)

Antidepressant drugs - SSRIs

• Side effects: anxiety, agitation, akathisia (motor restlessness), nausea, insomnia, and sexual dysfunction (due to enhanced serotonin transmission), weight gain (initial and ongoing problem, but less compared to other antidepressants)

• Less common side effects: sedation, sweating, diarrhea, hand tremor, and headaches

• Taking with food usually minimizes the nausea• Akathisia can be treated with beta-blockers or a

benzodiazepine• Insomnia can be treated with low dose sedative-hypnotic( Videbeck, pages 24 39; Student Guide, pages 43 to 53)

Antidepressant drugs - MAOIs

• Phenelzine (Nardil)• Tranylcypromine (Parnate)• Isocarboxazid (Marplan)• Most common side effects: sedation, insomnia, weight gain,

dry mouth, orthostatic hypotension, and sexual dysfunction• Life-threatening side effect: hypertensive crisis• Must not be combined with other antidepressants• Avoid foods rich in tyramine, tryptophan and tryptamine

because of the development of hypertensive crisis (see page 32 of Videbeck 5th edition for the list of foods to avoid)


Antidepressant drugs – client teaching

• Clients should take SSRIs first thing in the morning unless sedation is a problem

• If a client forgets a dose of SSRI, he or she can take it up to 8 hours after the missed dose

• To minimize side effects, clients generally should take TCAs at night in a single daily dose when possible

• If a client forgets a dose of a TCA, he or she should take it within 3 hours of the missed dose or omit the dose for that day


Antidepressant drugs – client teaching

• Clients should exercise caution when driving or performing activities requiring sharp, alert reflexes until sedative effects can be determined

• Dietary restrictions when taking MAOIs• Avoid taking OTC medications without telling

the nurse or the physician( Videbeck, pages 24 39; Student Guide, pages 43 to 53)

Mood stabilizers

• Used to treat bipolar disorder• Stabilizes mood, preventing or minimizing the highs and

lows that characterize bipolar disorder• Treats acute episodes of mania• Lithium – the most established mood stabilizer• Some anticonvulsants, particularly carbamazepine

(Tegretol) and valproic acid (Depakote, Depakene), are effective mood stabilizers

• Occasionally clonazepam (Klonopin) an anxiolytic is also used to treat acute mania


Mood stabilizers - Lithium

• Mode of action is poorly understood• Normalizes the reuptake of certain neurotransmitters

such serotonin, norepinephrine, acetylcholine, and dopamine

• It also reduces the release of norepinephrine through competition with calcium and produces its effects intracellularly rather than within the neuronal synapses

• Considered as a first-line agent in the treatment of bipolar disorder



• Serum levels should be about 1.0 mEq/L• Less than 0.5 mEq/L are rarely therapeutic• More than 1.5 mEq/L are usually considered toxic• Levels should be monitored every 2 to 3 days while

the therapeutic dosage is being determined; then, it should be monitored weekly

• When the client’s condition is stable, the level may need to be checked once a month or less frequently



• Side-effects: mild nausea or diarrhea, anorexia, fine hand tremor (can be treated by propanolol), polydipsia, polyuria, a metallic taste in the mouth, and fatigue or lethargy

• Later side effects: weight gain and acne• Toxic effects: severe diarrhea, vomiting, drowsiness,

muscle weakness, and lack of coordination• When toxic signs occur, the drug should be discontinued• If levels exceed 3.0 mEq/L, dialysis may be indicated( Videbeck, pages 24 39; Student Guide, pages 43 to 53)


• Other side effects include hair loss – thyroid function tests should be performed

• Always check and record accurately intake and output

• Also competes with Na in its absorption in the renal tubules – check for serum electrolytes (Na and Ca)


Anxiolytics • Or antianxiety medications• Used to treat anxiety and anxiety disorders, insomnia, OCD, depression,

posttraumatic stress disorder, and alcohol withdrawal• Benzodiazepinesa. Clonazepam (Klonopin)b. Alprazolam (Xanax)c. Diazepam (Valium)d. Lorazepam (Ativan)• Nonbenzodiazepines a. Buspirone (Buspar)b. Diphenhydramine (Benadryl)( Videbeck, pages 24 39; Student Guide, pages 43 to 53)

Anxiolytics • Mechanism of action: mediates the action of GABA, the

major inhibitor neurotransmitter in the brain• CNS depressant• Side effects: physical dependence, which is not

considered a side effect in the true sense, but is a major problem

• Psychological dependence (clients fear the return of the anxiety or believe they are incapable of handling anxiety without the drug) is also common, although buspirone does not cause this type of physical dependence


Anxiolytics

• The side effects most commonly reported with benzodiazepines are those associated with CNS depression

• Elderly clients may have more difficulty managing the effects of CNS depression and may have more pronounced memory deficits, urinary incontinence, particularly at night


Anxiolytics – client teaching

• The drugs are aimed at relieving symptoms, but do not treat the underlying disorder that cause anxiety

• Avoid other CNS depressants like alcohol and any activity that require alertness

• Benzodiazepine withdrawal can be fatal, and should not be discontinued abruptly after the course of therapy without the supervision of the physician


Stimulants

• Specifically amphetamines are primarily being used for treating ADHD in children and adolescents, residual attention deficit disorder in adults, and narcolepsy (attacks of unwanted but irresistible daytime sleepiness that disrupt the person’s life)

• Amphetamines – potential for abuse, may lead to dependence in prolonged use

• Methylphenidate – used with caution in emotionally unstable clients such as those with alcohol or drug dependence because they may increase the dosage on their own


Stimulants • Drugs used to treat ADHD1. Stimulants: a. methylphenidate (Ritalin)b. Amphetamine (Adderall)2. Selective Norepinephrine Reuptake Inhibitor (SNRI)a. Atomoxetine (Strattera)• Mode of action: stimulates the inhibitory centers of the brain, so

that there is greater ability to filter out distractions and manage behavior (stimulants)

• Mode of action of SNRI: prevents the reuptake of NE, thereby leaving more of the neurotransmitter in the synapse to help convey electrical impulses in the brain


Stimulants • Side effectsa. Anorexiab. Weight lossc. Nausead. Irritability• Client teaching:a. Avoid caffeine, chocolate and sugar, which may worsen the symptomb. May cause growth and weight suppression in some children – clients must

have “drug holidays” during the weekend, holidays or summer vacationc. Potential for abused. Give with mealse. Keep medications out of reach of children (as little as a 10-day supply can

be fatal)( Videbeck, pages 24 39; Student Guide, pages 43 to 53)

Disulferam • Antabuse• A sensitizing agent that causes an adverse reaction when

mixed with alcohol in the body• Only used as a deterrent to drinking alcohol in persons

being treated for alcoholism• Inhibits the enzyme aldehyde dehydrogenase, which is

involved in the metabolism of ethanol, leading to an increase in the levels of acetaldehyde in the blood, resulting in disulferam-alcohol reaction within 5 to 10 minutes


Disulferam

• Disulferam-Alcohol Reactionsa. Facial and body flushing from vasodilationb. Throbbing headachec. Sweatingd. Dry mouthe. Nausea and vomitingf. Dizzinessg. Weaknessh. Chest pain, dyspnea, severe hypotension, confusion, and

even death – in severe cases( Videbeck, pages 24 39; Student Guide, pages 43 to 53)

Disulferam

• Education is extremely important • Many common products such as shaving cream,

aftershave lotion, cologne, and deodorant and OTC medications such as cough preparations contain alcohol

• When the above products are used by the client taking disulferam, these products can produce the same reaction as drinking alcohol

• Read the labels carefully( Videbeck, pages 24 39; Student Guide, pages 43 to 53)