NOTES VI - PSYCHIATRIC NURSING PART 2

NOTES VI -  PSYCHIATRIC NURSING PART 2

Psychopharmacologic Therapy

Benzodiazepines

•Indications

–Anxiety

–Sedation/sleep

–Muscle spasm

–Seizure disorder

–Alcohol withdrawal syndromes

Anti-anxiety drugs

       Generic                                         Trade name

Alprazolam                                                         Xanax

Chlordiazepoxide                                             Librium

Clorazepate                                                        Tranxene

Diazepam                                                            Valium

Lorazepam                                                          Ativan

Oxazepam                                                          Serax

Busipirone                                                          BuSpar

Side effects

•Drowsiness/ sedation

•Ataxia

•Feelings of detachment

•Increase irritability and hostility

•Anterograde amnesia

•Increased appetite & weight gain

•Nausea

•Headache, confusion

Anti-depressants

•Indications

–Depression

–Bipolar depression

–Panic disorder

–Bulimia

–Obsessive-compulsive d/o

•Possibly

–Attention deficit/Hyperactivity d/o

–Post Traumatic Stress D/o

–Conduct d/o

Tricyclic (TCA)

   Generic                                             Trade name

Amitriptyline                                      Elavil

Imipramine                                         Tofranil

Trimipramine                                     Surmontil

Nortriptyline                                      Pamelor

Trazodone                                          Desyrel

Bupropion                                           Wellbutrin

Side effects

•Orthostatic hypertension

•Anticholinergic effect

–Dry mouth, blurred vision, constipation, excessive sweating, urinary hesitancy/ retention, tachycardia, agitation, delirium, exacerbation of glaucoma

•Neurologic effects

–sedation, psychomotor slowing, poor concentration, fatigue, ataxia, tremors

•Decrease libido and sexual performance

Monoamine Oxidase inhibitors

     Generic                                           Trade name

Isocarboxazid                    Marplan

Phenelzine                                         Nardil

Tranylcypromine                              Parnate

Side effects

•Postural lightheadedness

•Constipation

•Delay ejaculation or orgasm

•Muscle twitching

•Drowsiness

•Dry mouth

Dietary restrictions

•Cheese, esp. aged and matured

•Fermented or aged protein

•Pickled or smoked fish

•Beer, red wine, sherry; liquor & cognac

•Yeast

•Fava or broad beans

•Beef or chicken liver

•Spoiled/ overripe fruits; banana peel

•yogurt

Hypertensive Crisis

•Signs

–Sudden elevation of BP

–Explosive headache, occipital may radiate frontally

–Head & face flushed

–Palpitations, chest pain

–Sweating, fever

–Nausea, vomiting

–Dilated pupils, photophobia

–Intracranial bleeding

•Treatment

–Hold next MAO dose

–Don’t let pt. lie down

–IM chlorpromazine 100 mg

–Fever: manage by external cooling techniques

Serotonin Reuptake Inhibitors

      Generic                                          Trade name

Fluoxetine                                          Prozac

Sertraline                                            Zoloft

Paroxetine                                          Paxil

Venlafaxine                                        Effexor

Side effects

•Nausea

•Diarrhea

•Insomnia

•Dry mouth

•Nervousness

•Headache

•Male sexual dysfunction

•Drowsiness

•Dizziness

•Sweating

Mood stabilizing drugs

•Indications

–Acute mania

–Bipolar prophylaxis

•Possibly

–Bulimia

–Alcohol abuse

–Aggressive behavior

–schizoaffective

•Mode of action

–Normalizes the reuptake of certain neurotransmitters such as serotonin, norepinephrine, acetylcholine and dopamine

–Reduces the release of norepinephrine thru competition with calcium

–Effects intracellularly

•Lag period: 7-10 to 14 days

Lithium carbonate

•Trade names

–Eskalith

–Lithotabs

–Lithane

–Lithonate

•MOA: unclear; interfere with metabolism of neurotransmitters; alter Na transport in nerves and muscle cells

•Prelithium workup

–Urinalysis (BUN and creatinine)

–ECG, FBC, CBC

Side effects

•Early

–Nausea and diarrhea

–Anorexia

–Fine hand tremor (propranolol)

–Thirst, Polydipsia (dec. crea, inc. albumin)

–Metallic taste

–Fatigue

–Lethargy

•Late

–Weight gain

–acne

Contraindications

•Brain damage/ CV disease

•Epilepsy

•Elderly/ debilitated

•Thyroid and renal disease

•Severe dehydration

•Pregnancy (1^st trimester)

•Can augment the effects of anti-depressants

Nursing considerations

•Therapeutic serum level: 0.5 – 1.2 meq/L

•Maintenance level: 0.6 -1.2 meq/L

•Toxic

–Mild to moderate: 1.5 to 2 meq/L

–Moderate to severe: 2 – 2.5 meq/L

–Needs dialysis: 3 meq and above

•Early signs of toxicity

–Lethargy, mild nausea, vomiting, fine hand tremors, anorexia, polyuria, polydipsia, metallic taste, fatigue

•Late signs of toxicity

–Ataxia, giddiness, tinnitus, blurred vision, polyuria

Nursing considerations

•Lithium levels should be checked q 2-3 mos

•Serum drawn in the AM, 12H after last dose

•Common causes of inc. levels

–Dec. Na intake

–Diuretic therapy

–Dec. renal functioning

–F&E loss

–Medical illness

–Overdose

–NSAIDS

Nursing considerations

•Diet: adequate Na+ and fluid

–3g NaCl/ day

–6-8 glasses of H2O

•No caffeine

•No driving: wait for clinical effect

Management

•Moderately severe toxicity

–Osmotic diuresis: urea/ mannitol

–Aminophylline & PLR IV

–Adequate NaCl

–Peritoneal/ hemodialysis

•Severe toxicity

–Assess hx quickly

–Hold next lithium dose

–Check BP, rectal T°, RR, LOC, support O2

–Obtain labs

–ECG

–Emetic, NGT lavage

–Hydrate: 5-6L/day c PLR; FBC-CDU

Other drugs

•Carbamazepine (Tegretol)

–Side effects

•Dizziness

•Ataxia

•Clumsiness

•Sedation

•Dysarthria

•Diplopia

•Nausea & GI upset

–Preparation: liq, tab, chewable tab

Nursing considerations

•Assess drug levels q 3-4 days

•Monitor salt and fluid intake

•Avoid alcohol and non-prescription drugs

•Refer dec. in UO

•Don’t stop abruptly

•C/I: pregnancy

•Take with meals

Other drugs

•Valproic acid (Depakote, Depakene)

–Side effects

•Nausea

•Hepatoxicity

•Neurotoxicity

•Hematological toxicity

•Pancreatitis

–Prep: tab, cap, sprinkles

•MOA: inc. levels of GABA; inhibits the kindling process or “snoball”-like effect seen in mania & seizures

Nursing considerations

•Therapeutic level: 50 – 100 ug/mL

•Dose: 1, 000 – 1,500 mg/day

•Monitor serum levels 12H after last dose

•Toxic effects

–Severe diarrhea, vomiting, drowsiness, mm. weakness, lack of coordination

–Renal failure, coma, death

Anti-psychotic drugs

•Indications

–Psychotic symptoms of schizophrenia, acute mania and depression

–Gilles de Tourette disorder

–Treatment-resistant bipolar disorder

–Huntington’s disease and other movement disorder

•Possibly

–Paranoid

–Childhood psychoses

•MOA: block receptors of dopamine (D2, D3, D4)

•If unresponsive after 6 weeks of therapy, another class is tried

•General considerations

–Calms without producing impairment of sleep

–High therapeutic index

–Non addicting, no tolerance

–Avoided in pregnancy

TYPICAL: High Potency

Fluphenazine (Prolixin)

Haloperidol (Haldol)

Thiothexene (Navane)

Trifluoperazine (Stelazine)

Moderate Potency         

Loxapine (Loxitane)

Molindone (Moban)

Perphenazine (Trilafon)

Low Potency

Chlopromazine (Thorazine)

Chlorprothixene (Taractan)

Mesoridazine (Serentil)

Thioridazine (Mellaril)

ATYPICAL

Clozapine (Clozaril)

Resperidone (Risperdal)

Olanzapine (Zyprexa)

Quetiapine (Seroquel)

Sertindole (Serlec’t)

Ziprasidone (Zeldox)

Contraindications

•CNS depression: brain damage, excess alcohol/ narcotics

•Parkinson’s disease

•Allergy

•Blood dyscrasias

•Acute narrow angle glaucoma

•BPH

Side effects

•Hypotension

•Sedation

•Dermal and ocular syndrome

•Neuroleptic malignant syndrome

•Anticholinergic syndrome

•Movement syndrome (Extrapyramidal Syndrome)

•Atropine psychosis

•Agranulocytosis

•Seizures

Neuroleptic Malignant Syndrome

•A potentially fatal, idiosyncratic reaction to an antipsychotic drug

•10-20% mortality rate

•Sx:

–rigidity,

–high fever,

–autonomic instability (BP, diaphoresis, pallor, delirium, elev. CPK), confused or mute, fluctuate from agitation to stupor

•Occurs in the first 2 weeks of therapy

•Risk: high dose of high-potency drugs; dehydration, poor nx, concurrent med illness

Movement Syndromes

•Akathisia

•Dystonia

•Tardive dyskinesia

•Bradykinesia

•Parkinsonism

Other s/e

•Atropine psychosis (geriatrics)

–Hyperactivity, agitation, confusion, flushed skin, sluggish reactive pupils

–TTT: IM physostigmine

•Agranulocytosis (Clozapine)

–Occurs 3-8 wks after

–Medical emergency

–s/s: fever, malaise, sore throat, leukopenia

–TTT: d/c, reverse iso, antibiotics

•Seizures (Clozapine)

–Occurs in 5% of patients; TTT: D/c drug

Anticholinergics

Benztropine (Cogentin)

Trihexyphenidyl (Artane)

Biperiden (Akineton)

Procyclidine (Kemadrin)

•Not withdrawn abruptly

•Provide cool environment

ANTIPARKINSONIAN MEDICATIONS

•Adjunct to anti-psychotic agents to balance dopamine/ acetylcholine in the brain

•s/e: glaucoma, tachycardia, HPN, cardiac dx, asthma, duodenal ulcer

•A/e: blurred vision, photosensitivity, drowsiness, orthostatic hypotension, CHF, hallucinations

•COMMON DRUGS:

–Trihexyphenidyl (Artane)

–benztropine (Cogentin)

–Biperiden (Cogentin)

–Selegiline (Eldepryl)

–Pergolide (Permax)

•ANTIHISTAMINE

–Diphenhydramine HCl (BENADRYL)

•DOPAMINE RELEASING AGENT

–Amantadine (SYMMETREL)

•Nursing considerations

–Best taken after meals

–Avoid driving

–Check BP

–Alcohol increases sedative effects

–Avoid sudden position change

–Drug is not withdrawn abruptly