Drugs for Psychoses

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Drugs for Psychoses
Chapter 17
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OVERVIEW Neuro System
escitalopram (Lexapro)
Tri-Cyclic Antidepressant
Antidepressant / Anxiolytic
MAOIs
Benzodiazepines
lorazepam (Ativan) diazepam (Valium)
GABA Antagonist
zolpidem (Ambien)
A
phenytoin (Dilantin) valproic acid (Depakote)
Phenytoin-Like Drugs
Succinimides
ethosuximide (Zarontin)
Barbiturates
phenobarbital (Luminal)
Phenothiazines
chlorpromazine (Thorazine)
Non-Phenothiazines
halperidol (Haldol)
Opioids
morphine (Infumorph)
Atypical Antipsychotics
risperidone (Risperdal)
aspirin (ASA)
Salicylates
ibuprofen (Motrin)
NSAIDs
acetaminophen (Tylenol)
Non-Opioid
tramadol (Ultram)
Central Acting
ergotamine (Cafergot) Sumatriptan (Imitrex)
Anti-Migraine
Opioid Antagonists
naloxone (Narcan)
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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

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Factors Attributed to Development of Psychoses

• Genetic
• Neurological
• Environmental

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Schizophrenia

• 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

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Symptoms of Schizophrenia

• Variety of symptoms that may change over time
• 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

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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

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Conditions That May Mimic the Behaviors of
Schizophrenia

• Drug use
• Brain neoplasm
• Infections
• Hemorrhage

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Selection of Antipsycotics

• No single drug of choice
• Selection of drug type depends on
• Clinician experience
• Side effects
• Patient needs

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Categories of Antipsychotic Drugs

• Conventional antipsychotic
• Phenothiazines and phenothiazine-like drugs
• Atypical antipsychotic
• Nonphenothiazines

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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

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Role of the Nurse

• Monitor clients 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

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Conventional (Typical) Antipsychotics

• 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 patients environment

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Conventional (Typical) Antipsychotics (continued)

• 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 patients environment

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Atypical Antipsychotic

• 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

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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)

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Neuroleptic Malignant Syndrome (NMS)

• Client suffers a toxic reaction to therapeutic
  doses of antipsychotic drug
• Client exhibits
• Elevated temperature
• Unstable blood pressure
• Profuse sweating
• Dyspnea
• Muscle rigidity
• Incontinence

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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

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Prototype Drug Chlorpromazine hydrochloride
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Nonphenothiazines

• Prototype drug haloperidol (Haldol)
• Mechanism of action blocking of the dopamine
  type 2 receptor
• Primary use severe mental illness
• Adverse effects identical to that of
  phenothiazines

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Prototype Drug Haloperidol
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Atypical Antipsychotics

• Prototype drug 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

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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

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Prototype Drug Risperidone
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Conventional (Typical) Antipsychotic Agents

• Phenothiazines
• Action blocks positive symptoms
• Mellaril, Compazine, Permitil
• Nonphenothiazines
• Action same as that of phenothiazines
• Taractan, Loxitane, Navane

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Atypical Antipsychotics

• Treats both the positive and negative symptoms
• Less dramatic side effects, but still significant
• Examples Seroquel, Risperdal, Zyprexa

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Nursing Process Focus Patients Receiving
Atypical Antipsychotic Therapy
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Review Questions
Chapter 17
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NCLEX-RN ReviewQuestion 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. Hypertensive crisis may occur with abrupt
   withdrawal.
2. Muscle twitching may occur.
3. Parkinson-like symptoms will occur.
4. Symptoms of psychosis are likely to return.

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NCLEX-RN ReviewQuestion 1 Answer

1. Hypertensive crisis may occur with abrupt
   withdrawal.
2. Muscle twitching may occur.
3. Parkinson-like symptoms will occur.
4. Symptoms of psychosis are likely to return.

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NCLEX-RN ReviewQuestion 1 Rationale

• Rationale Symptoms of psychosis are likely to
  return and manifest as agitation, distrust, and
  frustration.

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NCLEX-RN ReviewQuestion 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. The patient may experience withdrawal and slowed
   activity.
2. Severe muscle spasms may occur early in therapy.
3. Tardive dyskinesia is likely early in therapy.
4. Medications should be taken as prescribed to
   prevent side effects.

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NCLEX-RN ReviewQuestion 2 Answer

1. The patient may experience withdrawal and slowed
   activity.
2. Severe muscle spasms may occur early in therapy.
3. Tardive dyskinesia is likely early in therapy.
4. Medications should be taken as prescribed to
   prevent side effects.

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NCLEX-RN ReviewQuestion 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.

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NCLEX-RN ReviewQuestion 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

1. Restful sleep, elevated mood, and coping
   abilities
2. Decreased delusional thinking and lessened
   auditory/visual hallucinations
3. Orthostatic hypotension, reflex tachycardia, and
   sedation
4. Relief of anxiety and improved sleep and dietary
   habits

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NCLEX-RN ReviewQuestion 3 Answer

1. Restful sleep, elevated mood, and coping
   abilities
2. Decreased delusional thinking and lessened
   auditory/visual hallucinations
3. Orthostatic hypotension, reflex tachycardia, and
   sedation
4. Relief of anxiety and improved sleep and dietary
   habits

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NCLEX-RN ReviewQuestion 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.

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NCLEX-RN ReviewQuestion 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. Diabetes mellitus
2. Age older than 70
3. Bone marrow depression
4. Hypertension

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NCLEX-RN ReviewQuestion 5 Answer

• Diabetes mellitus
• Age older than 70
• Bone marrow depression
• Hypertension

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NCLEX-RN ReviewQuestion 5 Rationale

• Rationale Fluphenazine (Prolixin) is a
  phenothiazine drug. Use is contraindicated in
  patients with CNS depression, bone marrow
  depression, and alcohol withdrawal.

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NCLEX-RN ReviewQuestion 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

1. Dry mouth, constipation, and blurred vision
2. Pacing, squirming, or difficulty with gait such
   as bradykinesia
3. Severe spasms of the muscles of the tongue, face,
   neck, or back
4. Tremors, wormlike tongue movements, and
   involuntary lip puckering

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NCLEX-RN ReviewQuestion 6 Answer

• 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

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NCLEX-RN ReviewQuestion 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.

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Nursing Process.Chapter 17
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Drug Therapy for Psychoses

• Assessment
• Monitor clients 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 familys knowledge of psychoses and
  medication regimen

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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

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Drug Therapy for Psychoses (continued)

• Evaluation
• Client to remain free of symptoms related to
  psychoses
• Client to verbalize importance of taking
  prescribed medications

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Nursing Process Focus Patients Receiving
Conventional Antipsychotic Therapy
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Nursing Process Focus Patients Receiving
Conventional Antipsychotic Therapy
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Nursing Process Focus Patients Receiving
Conventional Antipsychotic Therapy
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Nursing Process Focus Patients Receiving
Conventional Antipsychotic Therapy
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Nursing Process Focus Patients Receiving
Conventional Antipsychotic Therapy
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Nursing Process Focus Patients Receiving
Conventional Antipsychotic Therapy
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Nursing Process Focus Patients Receiving
Conventional Antipsychotic Therapy
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Nursing Process Focus Patients Receiving
Atypical Antipsychotic Therapy
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Nursing Process Focus Patients Receiving
Atypical Antipsychotic Therapy
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Nursing Process Focus Patients Receiving
Atypical Antipsychotic Therapy
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Nursing Process Focus Patients Receiving
Atypical Antipsychotic Therapy
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Nursing Process Focus Patients Receiving
Atypical Antipsychotic Therapy
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Nursing Process Focus Patients Receiving
Atypical Antipsychotic Therapy
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Nursing Process Focus Patients Receiving
Atypical Antipsychotic Therapy