psychiatric nursing psychopharmacology. objectives describe the indications, actions,...

Psychiatric nursing

Psychopharmacology

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Objectives

• Describe the indications, actions, contraindications, precautions, side effects and nursing implications for the following classifications of drugs:

Antianxiety agents Antidepressants Mood stabilizers Antipsychotics Antiparkinsonian agents Sedative-hypnotics Agents for attention deficit and hyperactivity disorders

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Neurological causes of mental illness

• 1- genetic/heredity• 2- Stress and the Immune System/

(Psychoimmunology)

• 3- Infection as a Possible Cause

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Why only these classifications of drugs?

• These are used in the treatment of more than 95% of the psychiatric cases.

Introduction and history of psychiatric treatment

•Early 20th century somatic (body) therapies in psychiatry was established (e.g. insulin shock therapy (ICT), hydrotherapy (wet sheet packs and ice baths), psychosurgery (trepanation) and Electroconvulsive Therapy (ECT)).

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Introduction and history of psychiatric treatment

• Before 1950, sedatives & amphetamines (increase wakefulness and focus and decrease fatigue) were the only significant psychotropic medications, even these had limited use because of their toxicity and addicting effect.

• Since 1950s, development of psychopharmacology has expanded to include antipsychotic, antidepressant, & antianxiety medications.

• These medications alone are not intended to cure the mental illness but they minimize the physical and emotional symptoms.

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• Prior to the 1950s, the focus was on behavioral interventions and sedatives. The first antipsychotic medication, chlorpromazine (Thorazine), was introduced in the mid-50s. Many advances have occurred since then that allow for the treatment of people with serious mental illness in the community.

• Medications allow for the correction of imbalances of brain chemicals.

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Antipsychotic medications• Antipsychotic medications are beneficial in disorders that

include psychotic states. Examples of such disorders are schizophrenia, mood disorders with psychotic features, and dementia with psychotic features.

• The major positive effect of antipsychotics is on decreasing the symptoms of delusional thinking, hallucinations, confusion, motor agitation, and motor retardation.

• Antipsychotic medications also decrease formal thought disorder, blunted affect, bizarre behavior, social withdrawal, belligerence, and uncooperativeness.

• Antipsychotic drugs work by blocking receptors of the neurotransmitter dopamine

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Side effect • The negative effects are primarily the side

effects that may include effects on the autonomic nervous system,

• Extrapyramidal symptoms (EPS), serious neurologic symptoms, include

• 1- acute dystonia, includes acute muscular rigidity and cramping, a stiff or thick tongue with difficulty swallowing, and, in severe cases, laryngospasm and respiratory difficulties.

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Side effect ‘• 2- pseudoparkinsonism, Drug-induced

parkinsonism: include a stiff, stooped posture; mask-like facies; decreased arm swing; a shuffling, festinating gait (with small steps); cogwheel rigidity (ratchet-like movements of joints); drooling; tremor; bradycardia; and coarse pill-rolling movements of the thumb and fingers while at rest

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• 3- akathisia: is 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.

• This feeling of internal restlessness and the inability to sit still or rest often leads clients to discontinue their antipsychotic medication.

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• Neuroleptic malignant syndrome (NMS) is a potentially fatal idiosyncratic reaction to an antipsychotic (or neuroleptic) drug

• Include: rigidity; high fever; autonomic instability such as unstable blood pressure, diaphoresis, and pallor; delirium; and elevated levels of enzymes, particularly creatine phosphokinase.

• Clients with NMS usually are confused and often mute; they may fluctuate from agitation to stupor.

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• Anticholinergic Side Effects. :include orthostatic hypotension, dry mouth, constipation, urinary hesitance or retention, blurred near vision, dry eyes, photophobia, nasal congestion, and decreased memory.

• These side effects usually decrease within 3 to 4 weeks but do not entirely remit.

• Tardive Dyskinesia. Tardive dyskinesia (TD), a syndro me of permanent involuntary movements

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• Other Side Effects. Antipsychotic drugs also increase blood prolactin levels. Elevated prolactin may cause breast enlargement and tenderness in men and women; diminished libido, erectile and orgasmic dysfunction, and menstrual irregularities; and increased risk for breast cancer, and may contribute to weight gain

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Client Teaching• the types of side effects that may occur and

encourages clients to report such problems to the physician instead of discontinuing the medication.

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

• Drinking sugar-free fluids and eating sugar-free hard candy ease dry mouth.

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• The client should avoid calorie-laden beverages and candy because they promote dental caries, contribute to weight gain, and do little to relieve dry mouth.

• Methods to prevent or relieve constipation include exercising and increasing water and bulk-forming foods in the diet. Stool softeners are permissible, but the client should avoid

• laxatives. The use of sunscreen is recommended because photosensitivity can cause the client to sunburn easily

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Antianxiety Drugs (Anxiolytics)• are used to treat anxiety and anxiety

disorders, insomnia, OCD, depression, posttraumatic stress disorder, and alcohol withdrawal

• Benzodiazepines have proved to be the most effective in relieving anxiety, also may be prescribed for their anticonvulsant and muscle relaxant effects.

• Buspirone is a nonbenzodiazepine often used for the relief of anxiety

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Mechanism of Action• Benzodiazepines mediate the actions of the

amino acid GABA, the major inhibitory neurotransmitter in the brain.

• Because GABA receptor channels selectively admit the anion chloride into neurons, activation of GABA receptors hyperpolarizes neurons and thus is inhibitory.

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Psychopharmacology: Antianxiety Agents

• Examples by chemical class and generic name (see table, page 157):

Antihistamines: Atarax, Vistaril Benzodiazepines: Alprazolam (Xanax), Diazepam (Valium),

Lorazepam (Ativan) Propanediols: Meprobamate (Miltown) Azaspirodecanediones: Buspirone (Buspar)

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Side effect

• Anxiolytic medications have the effect of disinhibition of fear-induced behavior. Their side effects include their addictive potential and overdose sequelae. The major classes of drugs used today are the benzodiazepines and nonbenzodiazepines

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Client Teaching• Clients should not drink alcohol while taking

benzodiazepines.• Clients should be aware of decreased

response time, slower reflexes, and possible sedative effects of these drugs when attempting activities such as driving or going to work

• he or she should never discontinue benzodiazepines abruptly or without the supervision of the physician

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Anxiolytic medications• These work through a process of synaptic

activity involving the neurotransmitter gamma-aminobutyric acid (GABA) in the brain and spinal cord. Benzodiazepines potentiate GABA, producing relaxation. There are two types of benzodiazepine receptors in the CNS. Type 1 receptors are located in parts of the brain responsible for sedation. Type 2 receptors are located in parts of the brain responsible for cognition, memory, and psychomotor functioning


Anxiolytics affect all levels of CNS depression (from mild sedation to coma), except BuSpar which does not depress the CNS but interacts with serotonin, dopamine, & other neurotransmitter receptors.

Contraindications: hypersensitivity, combination with other CNS depressants, pregnancy and lactation, narrow-angle glaucoma, shock, coma.

Precautions: caution with elderly or debilitated (weak) clients, hepatic or renal dysfunction (decrease dosage), history of drug abuse or addiction, depressed or suicidal patients (because CNS depressants can increase symptoms).

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Interactions: Increased effects of antianxiety with alcohol, barbiturates,

narcotics (opioids), antidepressants, antipsychotic, neuromuscular blocking agents.

Decreased effects with smoking and caffeine. Nursing diagnosis: the following diagnoses need to be considered for those on antianxiety medications:

Risk for injury RT seizures; panic anxiety and effects of medications intoxication or overdose.

Risk for activity intolerance RT side effects of sedation & lethargy

Risk for acute confusion RT action of the medication on the CNS

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Nursing interventions for common side effects

• drowsiness, confusion and lethargy. Instruct the client not to drive or operate dangerous machinery when taking the medication.

• Tolerance, physical and psychological dependence. Instruct the client on long-term therapy not to quit taking it abruptly. Abrupt withdrawal can be life threatening.

• Ability to potentiate the effect of other CNS depressant. Instruct the patient not to drink alcohol or take other medications that depress the CNS.

• Possibility of aggravating symptoms in depressed patients. Assess the client’s mood daily and take precaution of potential suicide.

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• Orthostatic hypotension. Monitor lying and standing blood pressure and pulse every shift. Instruct the patient to stand up slowly from lying or sitting position.

• Paradoxical excitement. Patients may develop symptoms opposite to the medication’s desired effect. Withhold the drug and notify the physician.

• Dry mouth. Instruct the client to take frequent sips of water.• Nausea and vomiting. Have the client take the drug with food

or milk.• Drug dyscrasias. Symptoms of sore throat, fever, malaise,

unusual bleeding should be reported to the physician immediately.

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• Delayed onset (buspirone/buspar only). Ensure that the client understands that there is a lag time of 10-14 days between the onset of therapy and the subsiding of anxiety symptoms. Client should continue to take the medication and this medication is not p.r.n and has no physical dependence.

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Antidepressant medications• are primarily used in the treatment of major

depressive illness, anxiety disorders, the depressed phase of bipolar disorder, and psychotic depression.

• Off-label uses of antidepressants include the treatment of chronic pain, migraine headaches, peripheral and diabetic neuropathies, sleep apnea, dermatologic disorders, panic disorder, and eating disorders

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Mechanism of action

• Although the mechanism of action is not completely understood, antidepressants somehow interact with the two neurotransmitters, norepinephrine and serotonin, that regulate mood, arousal, attention, sensory processing, and appetite.

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Antidepressants are divided into four groups

• 1. Tricyclic and the related cyclic antidepressants

• 2. Selective serotonin reuptake inhibitors (SSRIs)

• 3. MAO inhibitors (MAOIs)• 4. Other antidepressants such as venlafaxine

desvenlafaxine (Pristiq) (Effexor), bupropion (Wellbutrin), duloxetine (Cymbalta), trazodone (Desyrel), and nefazodone (Serzone).

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Side effect • The cyclic antidepressants block cholinergic

receptors, resulting in anticholinergic effects such as dry mouth, constipation, urinary hesitancy or retention, dry nasal passages, and blurred near vision.

• More severe anticholinergic effects such as agitation, delirium, and ileus may occur, particularly in older adults.

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• Other common side effects include orthostatic hypotension, sedation, weight gain, and tachycardia.

• Clients may develop tolerance to anticholinergic effects, but these side effects are common reasons that clients discontinue drug therapy.

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Side Effects of• Monoamine Oxidase Inhibitors Daytime

sedation, insomnia, weight gain, dry mouth, orthostatic hypotension, and sexual dysfunction.

Psychopharmacology: Antidepressants

Examples by chemical class and generic name or trade name (seTricyclics: Amitriptyline (Elavil), Imipramine (Tofranil)Monoamine Oxidase inhibitors: Phenelzine (Nardil)Selective serotonin reuptake inhibitors: Sertraline

(Zoloft)Heterocyclics: Trazodone (Desyrel)Contraindications: hypersensitivity, recovery from MI, & angle-closure glaucoma.

Precaution: caution with elderly or debilitated clients & hepatic, renal, or cardiac insufficiency, with seizures.

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Psychopharmacology: Antidepressants

Interactions: antihypertensive drugs (decrease therapeutic response to some antihypertensives & amphetamines) Nursing diagnosis

Risk for suicide RT depressed mood Risk for injury RT side effects of sedation, orthostatic HTN Social isolation RT depressed mood Constipation RT side effects

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• Dry mouth. Strict oral hygiene. Sips of water. Offer the patients a sugar less candy.

• Sedation.• Nausea.• Discontinuation syndrome. Decreased gradually to avoid

withdrawal syndrome.• Blurred vision (hazy and indistinct of the sight). Offer

reassurance that this subside after few weeks.• Constipation.

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• Urinary retention. Intake/output chart.• Orthostatic hypotension.• Tachycardia and arrhythmias. Monitor B.P, P.R and rhythm.• Photosensitivity. Protective sunscreen and sunglasses when

outdoor.• Weight gain. Reduce caloric intake.

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• The negative effects of antidepressants include their potential side effects and interactions. The tricyclic antidepressants may aggravate symptoms in a person with, or susceptible to, schizophrenia.

• Oral MAOIs may cause a potentially life-threatening hypertensive crisis when combined with foods containing tyramine, sympathomimetic medications, or the SSRIs. MAOIs require the client to follow a diet that restricts tyramine.

• The initiation of antidepressants may contribute to the risk of suicide in children, adolescents, and adults.

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Pt teaching • To minimize side effects, clients generally

should take cyclic compounds at night in a single daily dose when possible.

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

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

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Mood stabilizers• are used to treat bipolar disorder by stabilizing

the client’s mood, preventing or minimizing the highs and lows that characterize bipolar illness, and treating acute episodes of mania.

• Lithium is the most established mood stabilizer; some anticonvulsant drugs, particularly carbamazepine (Tegretol) and valproic acid

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• Mood stabilizers: Lithium aids in the reduction of neurotransmitter release into the synapse and enhances its return. Lithium and the anticonvulsants used as mood stabilizers may affect neurocellular changes that occur over weeks and months after their initiation

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Side effect • lithium therapy include mild nausea or

diarrhea, anorexia, fine hand tremor, polydipsia, polyuria, a metallic taste in the mouth, and fatigue or lethargy.

• Weight gain and acne are side effects that occur later in lithium therapy;

• Taking the medication with food may help with nausea, and the use of propranolol often improves the fine tremor. Lethargy and weight gain are difficult to manage or minimize and frequently lead to noncompliance.

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• Side effects of carbamazepine and valproic acid include drowsiness, sedation, dry mouth, and blurred vision

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Client Teaching• For clients taking lithium and the

anticonvulsants, monitoring blood levels periodically is important.

• The time of the last dose must be accurate so that plasma levels can be checked 12 hours after the last dose has been taken.

• Taking these medications with meals minimizes nausea.

• The client should not attempt to drive until dizziness, lethargy, fatigue, or blurred vision has subsided

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Guidelines for the treatment of bipolar disorder are:

– A mood stabilizer is used in all phases of treatment.

– Atypical antipsychotics are preferable to conventional older antipsychotics if psychosis is present.

– Mild depression is treated initially with a mood stabilizer.

– An antidepressant is used in the beginning of severe depression.

– Rapid cycling is treated from the beginning with a mood stabilizer alone, preferably divalproex.

Psychopharmacology: Mood Stabilizing Agents

Anti manic: Lithium carbonate (Lithane, drug of choice) Anticonvulsant: Carbamazepine (Tegretol) Calcium channel blocker: Verapamil (Isoptin)

Indications: Bipolar mania Action: decrease norepinephrine & serotonin levels in

the body resulting in decreased hyperactivity (Symptoms subside in 1-3 weeks).

Contraindications: hypersensitivity, cardiac or renal disease, dehydration (competes with ADH) and cardiogenic shock.

Caution with pregnancy, lactation, children, & elderly. Interactions: lithium increases neuromuscular blocking

agents (block the neuromuscular transmission); may result in neurotoxicity or lithium toxicity (especially in chronic cases).

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Mood Stabilizing AgentsNursing diagnosis

Risk for injury RT manic hyperactivityRisk for violence: self-directed or other-directed RT

unresolved anger turned inward on the self or outward on the environment

Risk for injury RT lithium toxicityRisk for activity intolerance RT side effects of

drowsiness & dizziness

Nursing interventions for common side effects.

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Psychopharmacology: Antipsychotic Agents• Psychosis: abnormal condition of the mind, in which the

thought and emotion are impaired involving loss of contact with reality.

• Also called major tranquilizers & neuroleptics. Phenothiazines: Chloropromazine (Thorazine), Thioridazine

(Mellaril) Butyrophenone: Haloperidol (Haldol)• Indications: acute and chronic psychosis, particularly when

accompanied by increased psychomotor activity, treatment of intractable hiccoughs, control of tics & vocal utterances. Action: block postsynaptic dopamine receptors in basal ganglia, hypothalamus, limbic system, brainstem, & medulla.

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Psychopharmacology: Antipsychotic AgentsContraindications: hypersensitivity, pregnancy & lactation, diabetic or respiratory insufficiency.Interactions: antacids & antidiarrheals may decrease absorption of antipsychotic; barbiturates may increase metabolism & decrease effectiveness of antipsychotic. Nursing diagnosis

Risk for other-directed violence RT panic anxiety & mistrust of others Risk for injury RT side effects of sedation Risk for activity intolerance RT side effects of sedation Noncompliance with medication regimen RT suspiciousness & mistrust of others

• Nursing interventions for common side effects.

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Psychopharmacology: Antiparkinsonian Agents

• Examples Anticholinergics: procyclidine (Kemadrin), Trihexyphenidyl

(Artane), Biperiden (Akineton) Antihistamines: Diphenhydramine (Benadryl)• Indications: agents are indicated for the treatment of all

parkinsonism (relief symptoms of Parkinson's disease) and for relief of drug-induced extrapyramidal reactions (movement disorders such as akinesia and akathesia).

• Action: restore the balance of acetylcholine and dopamine (increase dopamine or reducing acetylcholine activity in the CNS). Deficiency in dopamine resulting in excessive cholinergic activity (neurotransmitters of the parasympathetic nervous system).Contraindications: hypersensitivity, duodenal obstruction, peptic ulcer and myasthenia gravis. Caution with tachycardia, cardiac arrhythmias, HTN, & hypotension.

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Antiparkinsonian Agents

Nursing diagnosis: Risk for injury RT symptoms of Parkinson's disease Hyperthermia RT anticholinergic effect of decreased sweating Activity intolerance RT side effects of the medication Knowledge deficit RT medication regimen


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Psychopharmacology: Sedative-Hypnotics• Examples: Barbiturates: Phenobarbital (Luminal)

Secobarbital (Seconal)

• Indications: various anxiety states, insomnia, anticonvulsant and preoperative sedation. Action: they cause generalized CNS depression. They may produce dependence and tolerance.

Contraindications: hypersensitivity, hepatic dysfunction, or severe renal impairment. Should be short-term only.

Nursing diagnosis: Risk for injury r/t abrupt withdrawal from long-term use Sleep pattern disturbance r/t physical condition Risk for activity intolerance r/t side effects Risk for acute confusion r/t action on CNS


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Stimulants

• pronounced effects of CNS stimulation• Today, the primary use of stimulants is for

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)

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Psychopharmacology: CNS stimulants for ADHD • Examples: amphetamines –Dextroamphetamines (Dexedrine)

• Indications: narcolepsy (excessive daytime sleepiness) & ADHD with hyperactivity in children & adults.

• Action: increase level of neurotransmitters (increase mental alertness), diminish sense of fatigue.

Contraindications: hypersensitivity, cardiovascular diseases, hyperthyroidism, and glaucoma.

Nursing diagnosis: Risk for injury r/t hyperactivity Risk for suicide r/t abrupt withdrawal after extended use Sleep pattern disturbance overstimulation


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Side effect• The most common side effects of stimulants

are anorexia, weight loss, nausea, and irritability. The client should avoid caffeine, sugar, and chocolate, which may worsen these symptoms.

• Less common side effects include dizziness, dry mouth, blurred vision, and palpitations.

• The most common long-term problem with stimulants is the growth and weight suppression that occurs in some children

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Psychopharmacology: Nursing interventions

• Drowsiness: no driving, no working with machines, • Tolerance: not to stop medication abruptly, not to take other

medications and alcohol, • Physical: assess vital signs for tachycardia, monitor intake and

output, observe orthostatic hypotension, teach relaxation techniques, report any abnormalities such as rash, observe extrapyramidal symptoms, …

• Dry mouth: sips of water, sugar-free candy, ice, ..• Nutrition: high fiber, milk, take drug with food or milk, oral

hygiene, physical exercise, avoid caffeinated food,• Vision: not to drive, clear pathways.

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Client Teaching

• The potential for abuse exists with stimulants, but this is seldom a problem in children.

• Taking doses of stimulants after meals may minimize anorexia and nausea.

• Caffeine-free beverages are suggested; clients should avoid chocolate and excessive sugar.

• Most important is to keep the medication out of the child’s reach because as little as a 10-day supply can be fatal.

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Other disorder

• The treatment of simple insomnia includes antidepressants, benzodiazepines, nonbenzodiazepines, over-the-counter medications, barbiturates, and some miscellaneous substances. The treatment of choice is the nonbenzodiazepines because of their rapid absorption and efficient elimination with little hangover effect.

• Acetylcholinesterase inhibitors are used to improve or slow the decline of cognitive functioning and memory problems in clients with dementia of the Alzheimer’s type

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• Acetylcholinesterase inhibitors: These increase available acetylcholine in the CNS, thus improving cognitive functioning and memory. The action is to decrease acetylcholinesterase, an enzyme that breaks down acetylcholine

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Disulfiram (Antabuse)

• Disulfiram is a sensitizing agent that causes an adverse reaction when mixed with alcohol in the body.

• This agent’s only use is as a deterrent to drinking alcohol in persons receiving treatment for alcoholism.

• It is useful for persons who are motivated to abstain from drinking and who are not impulsive

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• Five to ten minutes after a person taking disulfiram ingests alcohol, symptoms begin to appear: facial and body flushing from vasodilation, a throbbing headache, sweating, dry mouth, nausea, vomiting, dizziness, and weakness.

• In severe cases, there may be chest pain, dyspnea, severe hypotension, confusion, and

even death. Symptoms progress rapidly and last from 30 minutes to 2 hours. Because the liver metabolizes disulfiram,

• it is most effective in persons whose liver enzyme levels are within or close to normal range

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