260 Exam #2 Study Guide

Anxiety

• emotional response to anticipation of danger, NOT the same as stress

• subjective/normal response that helps people cope with threatening situations

• beneficial warning system for survival

• problematic when it becomes disabling and functioning becomes adversely affected

Everyday Anxiety vs. Anxiety Disorder

Anxiety Disorders

• Generalized Anxiety Disorder (GAD)

• Panic Disorder

• Agoraphobia

• Social Anxiety Disorder

• Separation Anxiety Disorder

• Phobias

Generalized Anxiety Disorder

DSM 5 Criteria:

• the presence of excessive anxiety and worry about a variety of topics, events, or activities

  • worry occurs more often than not for at least 6 months

  • worry in both adults and children may easily shift from one topic to another

• accompanied by at least three or more of the following physical or cognitive symptoms (only one required for children): edginess or restlessness, tiring easily or more fatigued than usual, impaired concentration or feeling as though the mind goes blank, irritability (which may or may not be observable to others), difficulty sleeping

  • patients often become: indecisive, irritable, and lose motivation to participate in life

  • can cause many issues in relationships and family support systems

Defense Mechanisms

• serve to help the patient subconsciously distance themselves from unwanted feelings and prevent new unwanted ones from forming

• tension reduction is the overall goal of defense mechanisms because it is a protective mechanism

Recovery

• the patient must explore and acknowledge their feelings rather than displace or ignore them

Panic Disorder

DSM 5 Criteria:

• characterized by a discrete period of intense fear or discomfort in which at least 4 of 13 symptoms develop abruptly and reach a peak within 10 minutes

• palpitations (pounding heart or accelerated hear rate), sweating, trembling, shaking, sensations of SOB or smothering, feelings of choking, chest pain or discomfort, nausea or abdominal discomfort, feeling dizzy, unsteady, or lighthearted, de-realization (feelings of unreality) or depersonalization (being detached from oneself), fear of losing control or going crazy, fear of dying, parasthesias, chills or hot flashes

Phobias

• an irrational and disproportionate fear of an object or situation

• person is generally aware that the fear is unreasonable and excessive

• these clients have overwhelming symptoms of panic when exposed to the phobic stimulus. if the stimulus is removed, the anxiety goes away.

• sudden onset which may occur in situations that previously did not cause any discomfort or anxiety

• diagnosis made only if avoidant behavior causes problems in functioning (occupational or social relationships) or if pt. is distressed about having the fear

Specific Phobia

• fear of a specific object

Social Phobia

• fear of being scrutinized by others or fears of being humiliated (evaluated by others)

Agoraphobia

• with panic

• without panic

Physical Symptoms of Phobias

• overwhelming feelings of anxiety, panic attacks (frightening without warning), sweating trembling, hot flushes or chills, shortness of breath or difficulty breathing, a choking sensation, rapid heartbeat (tachycardia)

• pain or tightness in the chest, a sensation of butterflies in the stomach, nausea, headaches, dizziness, feeling faint, numbness or pins and needles, dry mouth, a need to go to the toilet, a ringing in your ears

Psychological Symptoms of Phobias

• confusion or disorientation, fear of losing control, fear of fainting, feelings of dread, fear of dying

Assessing Anxiety - Recognizing Cues

• assess and acknowledge presence of anxiety (behavioral and somatic symptoms)

• assess patient’s perception of the situation

• evaluate psychosocial stressors, and developmental issues

• assess for suicidal ideation, intent and/or plan

• conduct head-to-toe (identify cues and vital signs)

• explore history of mental illness or substance use

• assess patient’s ability to focus and concentrate

• observe and assess patient’s speech

• assess current coping mechanisms

• request labs, including thyroid function, blood glucose, echo, tox screen

• GAD-7 screening tool

Assessment

• Review past medical history

• Many medical disorders present with anxiety as a primary symptom

  • Angina and myocardial infarction (eg, dyspnea, chest pain, palpitations, diaphoresis)

  • Cardiac dysrhythmias (palpitations, dyspnea, syncope)

  • Mitral valve prolapse

  • Pulmonary embolus (dyspnea, hyperpnea, chest pain)

  • Asthma (dyspnea, wheezing)

  • Hyperthyroidism (palpitations, diaphoresis, tachycardia, heat intolerance)

  • Hypoglycemia

  • Pheochromocytoma (headache, diaphoresis, hypertension)

  • Hypoparathyroidism (muscle cramps, paresthesia's)

  • Transient ischemic attacks (TIAs)

  • Seizure disorders

Defense Mechanisms

• the way individuals seeks to reduce anxiety

  • it is a protective mechanism

  • overall goal is tension reduction

  • recognize

  • don’t try to eliminate

• conversion, compensation, denial, displacement, identification, idealization, intellectualization, introjection, isolation, projection, rationalization, reaction formation, regression, repression, splitting, sublimation, suppression, undoing

Diagnosis/Analysis

• review data, determine what they mean or identify potential complications for which the individual is at risk

Nursing Interventions for GAD

• actively listen to the individual and encourage exploration of feelings

• reassure the individual about their safety

• validate their feelings and concerns

• help acknowledge anxiety rather than deny or intellectualize it

• assist in identifying behaviors that indicate individual is feeling anxious

• assist individual with connecting anxiety with uncomfortable physical, emotional, or behavioral responses

• discourage use of caffeine, nicotine, or alcohol to cope with anxiety

Nursing Interventions for Panic Attack

• recognize signs, remain calm, stay with individual, don’t make assumptions, speak in short sentences, avoid saying “don’t worry”

• be predictable, teach breathing techniques, do not touch individual unless invited to do so

Nursing Interventions for Phobias

• psychotherapy: individual talk therapy, CBT

• medication: benzodiazepines (episodic) → xanax for social phobias, beta blockers, SSRIs

• behavioral: systematic desensitization → creation of graduate exposure to fear stimuli, encouraged to refrain from using avoidance response, implosion → bombarding or flooding the pt. with an exaggerated version of the phobic stimuli

• education: explore the concept that phobias are learned behaviors that can be unlearned an discuss how new behaviors can be learned

Goals & Outcome Criteria for Phobias

The patient will:

• acknowledge and discuss fears and concerns

• verbalize feelings of anxiety and present ideas for how to manage those feelings

• recognize signs of escalating anxiety and intervene before reaching panic level

• function adaptively in the presence of the phobic object or situation without experiencing panic anxiety (phobic disorder)

• verbalize a plan of action for responding in the presence of the object or situation without developing panic anxiety (phobic disorder)

Coping Strategies

• a process used by individuals to manage anxiety

  • general life management strategies: time management, nutrition, exercise, sleep

  • problem focused coping: work to eliminate or change the source of anxiety

  • emotional focused coping: reinterpreting the meaning for the situation

Cognitive Behavioral Therapy

• premise: “how people think significantly influences their feelings and behavior.”

• short term, highly structured, goal oriented

• 3 components: didactic/educational, cognitive techniques, behavioral interventions

Focus (teaching)

• the relationship between illness and distorted thinking patterns

• helps individualize recognize their negative thoughts

• using cognitive and behavioral techniques to assist the individual in modifying the dysfunctional patterns

Group Therapy

• a form of psychosocial treatment in which several clients meet together with a therapist for purposes of sharing, gaining personal insight, and improving interpersonal coping strategies

Medications Used to Treat Anxiety

• antidepressants, anxiolytics, MAOIs, beta blockers, alpha-2 agonists, antihistimines

Antidepressants (first line of treatment for anxiety disorders)

• Indication: MDD and anxiety disorders

• Course of Treatment: 6-9 months, taper off if symptom free, relapse = more maintenance, does not usually develop tolerance, addiction, psychological dependence, or long term adverse effects

SSRIs

• serotonin and norepinephrine help regulate mood and anxiety

• all SSRIs inhibit the reuptake of serotonin at the presynaptic membrane → increase of available serotonin in the synapse and at the post-synaptic receptors, promoting serotonin neurotransmission

SNRI: Venlafaxine (Effexor)

• SNRI: Venlafaxine (Effexor)

• Mechanism of Action: inhibits the reuptake of the serotonin and norepinephrine, resulting in an increase in the extracellular concentrations of serotonin an norepinephrine (better for pain control and increased energy)

• Side Effects: dizziness, headache, insomnia, nausea, diarrhea, palpitations, increased blood pressure, dry mouth, and sexual dysfunction

NsSSA (Noradrenergic and specific Serotonin Antidepressant): Mirtazapine (Remeron)

• Medication: Mirtazapine (Remeron)

• Mechanism of Action: increase norepinephrine and specific serotonin neurotransmission without inhibiting reuptake (provide better sedation, less sexual dysfunction), used when patient cannot tolerate S/S of other meds

• Side Effects: dizziness, sedation, weight gain, increased appetite

NDRI: Wellbutrin (Bupropion)

• Medication: Wellbutrin (Bupropion)

• Mechanism of Action: enhances monoaminergic neurotransmission by reducing the reuptake of dopamine and norepinephrine increasing extracellular dopamine and norepinephrine concentrations

• Side Effects: tremors, dizziness, headache, insomnia, lowers the seizure threshold, nausea, dry mouth, tachycardia, diaphoresis, dry mouth

TCAs

• Mediations: amitriptyline (elavil) and imipramine (tofranil)

• Mechanism of Action: works by raising the levels of serotonin and norepinephrine by slowing the rate of reuptake (reabsorption) by nerve cells

• Side Effects: dizziness, tremors, constipation, nausea, vomiting, weight gain, postural hypotension, tachycardia, prolonged qt interval, dry mouth blurred vision, lethal in overdoes

Nursing Implications for Antidepressants

Benzodiazepines

• Mechanism of Actions: increases the efficiency of GABA to decrease the excitability of neurons, blocking the release of stress hormones (cortisol) associated with anxiety and panic. → reduces the communication between neurons and therefore has a calming effect on many of the functions of the brain especially the limbic system.

• most commonly used anti-anxiety (anxiolytic drugs) that act through the CNS and have muscle relaxation, sedative, anxiolytic and anticonvulsant effects → wide safety margin, rapid onset, cause dose-related suppression of the CNS, varying from slight impairment to hypnosis

• Clinical Use: anxiety, panic, alcohol withdrawal, skeletal relaxation, dental procedures, insomnia, substance-induced agitation

Short Acting Benzodiazepines

• short-acting metabolites

• not used for anxiety

• median half life of less than 6 hours

• Medication: versed (midazolam) and halcion (triazolam)

Long Acting Benzodiazepines

• Medications: librium (chlordiazepoxide), valium (diazepam), xanax (alprazolam), klonopin (clonazepam), ativan (lorazepam)

• used in conjunction with antidepressants in the treatment of panic

• fast acting with acute symptoms of panic (racing pulse, and SOB) but long enough to control residual anxiety and worry about future panic episodes

• rate of absorption varies

• important to know half-life

• treatment should be brief

• highly addictive

Alprazolam (Xanax)

• fast-intermediate → 12-15 hours

Lorazepam (Ativan)

• intermediate → 12-20 hours

Chlordiazepoxide (Librium)

• intermediate → 8-28 hours

Diazepam (Valium)

• fast → 20-80 hours

Clonazepam (Klonopin)

• slow → 18-50 hours

Side Effects of Benzodiazepines

• drowsiness, sedation, confusion, ataxia, respiratory depression, increased irritability, tolerance, dependency, rebound insomnia, anxiety

• overdose → slurred speech and memory problems

Benzodiazepine Withdrawal Syndrome → potentially life-threatening!

• do not suddenly stop

• withdrawals begin 6-8 hours after last dose of short acting benzos, and within 24-48 hours after last dose of long acting benzos

• more common with higher doses of short acting benzos

• alcohol/sedatives increase the risk of dependence

• high dose withdrawals can lead to psychosis, altered mental status, seizures, and status epilepticus

• moderate dose withdrawals can lead to rebound anxiety and insomnia

Treatment of Withdrawal Syndrome

• gradual titration (7 days to 3 months)

• replacement therapy → use same or a longer acting benzo to taper and/or adjunctive (barbiturates and/or anticonvulsants) to mitigate withdrawal symptoms

• shorter acting → intense, serious and life-threatening symptoms (Xanax)

• Longer acting: less intense symptoms (Valium, Klonopin, Librium)

• withdrawal symptoms highly variable based on the type, amount, duration, tolerance, half-life

Benzodiazepine Withdrawal Syndrome Symptoms

• agitation, anorexia, rebound anxiety, generalized seizures, psychosis (hallucinations)

• diaphoresis, autoimmune arousal, dizziness, hyperactivity, irritability, n/v, sensitivity to light, tinnitus, tremulousness

Nursing Implications for Benzodiazepines

• there is a significant risk of dependence → ordered for short time periods

• dangerous in overdose, especially with alcohol

• severe withdrawal symptoms if abruptly withdrawn

Warnings!

• CNS depressant → don’t operate machinery or drive, dangerous with alchol,

• Glaucoma → do not use with people with glaucoma unless they are receiving appropriate anti-glaucoma therapy

• Pregnancy → don’t use when pregnant or breastfeeding

• elderly are more vulnerable to side effects ½ to 1/3 of dose

Buspirone (Non-Benzodiazepine)

• initially developed as an anti-psychotic but was not effective → not used for withdrawal or panic

• binds to serotonin and dopamine receptors (partial agonist) → has no effect on gaba

• no CNS depression or potential for abuse, dependence, tolerance, or potentiation with alcohol

• may have paradoxical effects (anxiety, depression, insomnia)

• slow onset of action. may not be fully effective for 6-8 weeks

• use with caution with individuals with liver or kidney damage

Beta Blockers

• Inderal (propranolol)

• Atenolol (tenormin)

• act by blocking peripheral or central norepinephrine activity and symptoms of anxiety including palpitations, sweating and tremors

• used for PTSD & performance anxiety: weakness, fatigue, bradycardia, hypotension, depression

• contraindicated in people with asthma and emphysema

Alpha 2 Agonist

• Catapres (clonidine)

• effective in easing peripheral symptoms associated with opiate and alcohol withdrawal: tremulousness, profuse sweating, motor restlessness, anxiety, agitation

• eases insomnia due to sedation effects

• side effects: dizziness, drowsiness, postural hypotension, bradycardia, dry mouth

Antihistamines

• Benadryl (diphenhydramine)

• can be used to reduce anxiety through sedative effects, sometimes used to treat insomnia

• will help individual fall asleep, but not stay asleep or prevent early morning wakening

• may produce a hangover

A patient has beenprescribed alprazolam(Xanax) and paroxetine(Paxil).

1. assess for suicidal ideation

2. monitor sedation level

3. teach about avoiding alcohol

4. educated about delayed SSRI effects

5. evaluate medication adherence

Psychosis

• a syndrome of neurocognitive symptoms that impairs cognitive capacity, leading to deficits in perception, functioning, and social relatedness

• severe mental condition in which there is disorganization of the personality, deterioration in social functioning, and loss of contact with, or distortion of reality

• there may be evidence of hallucinations and delusional thinking

• can occur with or without the presence of organic impairment

• no specific cause

• associated with symptoms of mental illness, sleep deprivation, medical conditions, and prescription medications

Psychotic Disorders

• mental health disorders that feature abnormal thinking, perceptions (hallucinations, delusions)

Schizophrenia

• one type of psychotic disorder that features psychotic symptoms like hallucinations and delusions, reduced emotional expression, difficulty in social relationships, and motor impairment

• a primary psychotic disorder → disturbances in thought processes, perception, and affect resulting in severe deterioration of social and occupational functioning

DSM 5 Criteria for Schizophrenia

Positive Symptoms of Schizophrenia

• additions to a person’s experience (not normally present)

• Disturbances in Thought Content: hallucinations, delusions, illusions

• Disturbances in Thought Process: disorganized thoughts and speech

• Disturbances in Behaviors (4th dimension): erratic, strange, unexpected movements, posturing, waxy flexibility; interpersonal interactions may be unpredictable or inappropriate in social situations.

Negative Symptoms of Schizophrenia

• a loss or deficiency in normal functioning

• Disturbances in Emotion: affective flattening, anhedonia, avolition (decrease in the ability to initiate or sustain purposeful activities), alogia (poverty of speech), asociality

• Cognitive Symptoms (3rd dimension): attention issues, verbal fluency, executive function, decreased ability to understand social situations, memory issues, reasoning

Hallucinations

• false sensory perceptions not associated with real external stimuli and may involve any of the five senses

• auditory, visual, tactile, gustatory, olfactory

Hallucination Interventions

• observe the patient for signs of hallucinations

• do not reinforce but validate the hallucination

• provide an attitude of acceptance

• ask about content

• ask if the voices are familiar

• distract the patient from the hallucinations

• educate: voice dismissal

• avoid touching the patient

• assess for suicide risk

• assess the level of anxiety

Illusions

• a perception that occurs when a sensory stimulus is present but incorrectly perceived and misinterpreted, such as hearing the wind as someone crying

Depersonalization

• feeling disconnected from one’s body and thoughts

Derealization

• alteration in the perception or experience of the external world so that it seems unreal

Delusions

• fixed, false beliefs

• irrational and cannot be corrected by reasoning, even with evidence to the contrary

• beliefs are not explainable as part of the person’s usual religious or cultural precepts

• experienced as real

• 75% of individuals with schizophrenia will experience delusions

• can be intertwined with hallucinations and can be further complicated by thought, withdrawal, insertion, control, and broadcasting

Delusion Interventions

• most do not realize their delusions are problematic or incorrect, so do not try to talk a person out of their delusional thought process → disputing rationality of delusions isn’t likely to have the intended outcome

• pay attention to the emotions the person is expressing and reinforce focus on reality

• convey acceptance of the patient’s need for the false belief but indicate that you do not share the belief → the patient must understand that you do not view the idea as real

Disturbance in Thought Process as Manifested through Speech Core of Communication

• disorganized or alterations in speech (form/organization)

• arises from alterations in though process or how thoughts are connected

• the threads are missing and connections are interrupted

• ex. loose associations, word salad, tangentiality, circumstantiality, pressured speech, alogia, poverty of speech or distractible speech, clanging

Impaired Communication Interventions

• facilitate trust and understanding by maintaining staff assignments

• attempt to decode incomprehensible communication patterns by seeking validation and clarification

• anticipate and fulfill the patient’s needs until functional communication has been established

• orient the patient to reality as required to facilitate restoration of functional communication

• call the patient by name

• validate those aspects of communication that help differentiate between what is real and not real

Affect (Negative Symptom)

• diminished affective response

  • hypoexpression

• inappropriate affect/incongruent affect

  • emotional tone is incongruent with circumstances

• flat affect

  • mask-like: void of emotional tone

  • no modulation

Disturbance in Emotion ( Negative Symptoms)

• Alexithymia: difficulty naming and describing emotions

• Anhedonia: inability or decreased ability to experience pleasure, joy, intimacy, closeness

• Anosognosia: lack of awareness of having an illness even though symptoms are obvious to others

• Apathy: lack of feelings, emotions, interests, concern, indifference, bland

• Avolition: inability to initiate goal directed activity, lack of emotion, neglect ADLs

• Anergia: chronic state of lethargy or lack of energy

Impaired Cognition/cognitive Deficit: Memory

• memory problems associated with schizophrenia include: forgetfulness, disinterest, difficulty learning new information (when in symptoms), lack of compliance

Impaired Cognition: Attention

• The ability to focus on one activity in a sustained, concentrated manner

• impairment in ability to pay attention

• difficulty completing tasks

• difficulty concentrating

• easily distracted

• auditory hallucinations often distract the individual: problems with attention

Impaired Cognition: Concrete Thinking

• tend to place an overemphasis on specific details and literal interpretation of ideas

• the answer is literal; the ability to use abstract reasoning is lessened or absent

• represents regression to an earlier level of cognitive development

Impaired Cognitions: Decision Making

• problems with decision making affects: insight, logic, judgment, decisiveness, planning, ability to carry out decisions, abstract thought

Deterioration of Social Skills

Direct Effects:

• deterioration of social skills

• inability to communicate coherently

• loss of drive and interest (avolition)

• poor personal hygiene: deterioration of appearance

• paranoia

• agitation/aggression

Indirect Effects:

• low self-esteem related to poor academic achievement

• specific problems in the development of relationships

  • social inappropriateness

  • disinterest in recreational activities

  • inappropriate sexual behavior

  • stigma related withdrawal by friends, family, and peers

Phases of Schizophrenia

• premorbid phase

• prodromal phase

• acute (active) phase

• stabilization phase

• residual or recovery phase

Premorbid Phase of Schizophrenia

• occurs before clear evidence of illness

• may include personality traits and behaviors

  • shy and withdrawn

  • poor peer relationships

  • poor academic performance

  • asocial behaviors

Prodromal Phase of Schizophrenia

• early signs and symptoms indicating an onset of disease → may be barely noticeable

  • mood swings, anxiety, difficulty sleeping, difficulty concentrating, early signs of memory loss, lack of appetite, fatigue, usually recognized retrospectively but can be seen weeks, months, years before

  • not experienced by everyone

  • allows for early initiation of treatment with improved outcomes and decreased functional deficits

Active Phase of Schizophrenia

• can start subtlety

• symptoms include positive, negative, and affective: hallucinations, delusions, disorganized thinking

• thoughts and behaviors become: confusing and frightening to individual and family; bizarre and can no longer be overlooked (ex. staying up all night, incoherent conversations, aggressive acts towards self or others, failing school, isolating)

• less and less able to attend to basic personal needs

Stabilization Phase of Schizophrenia

• Goal: prevent psychotic relapse and improve level of functioning

• symptoms become less acute but remain present

• treatment is intense as medication regimes are being established

• patient and family trying to adjust to family member having a chronic, long term mental illness

• use of substance eliminated (hopefully)

• stable patients (patients who are maintained on neuroleptics) have a much lower relapse rate than those who discontinue their medication

• rehabilitation/recovery begins

Recovery or Residual Phase of Schizophrenia

• Focus of Care: regaining a level of functioning and quality of life that provides a meaningful life

• medication is necessary but not a cure

• reduce stress because it can exacerbate symptoms

• family support and involvement are crucial

• educate to anticipate and expect relapse and know how to cope when it does occur

Relapse of Schizophrenia

• can occur anytime during treatment/recovery

• detrimental but not inevitable

• with each relapse, recovery is longer and more difficult

• factors triggering relapse: refusal to follow medical regime, impairment in cognition and coping leave patient vulnerable to stressors

• limited availability to community resources (public transportation, housing, entry level jobs,)

• stigma attack self-concept of patients

• family/peer support are vital

Schizophrenia Treatment Goals

• targeting symptoms

• preventing relapse

• increase adaptive functioning

Treatment Options for Schizophrenia

• medical, psychological treatment

• therapeutic mileu

• supportive care

• assertive community treatment

Neuroleptic/Antipsychotic Medications

• used to treat schizophrenia, schizoaffective disorder, organic brain syndrome with psychosis and delusional disorder, agitation associated with alzheimer’s disease, bipolar disorder, depression with psychotic features, substance-induced psychosis, pdd, tourette’s syndrome

Antipsychotic Medications

• Mechanism of Action: blocking dopamine transmission (block D2 receptors)

  • typical antipsychotics more than atypical antipsychotics

• Concern: the anti-dopamine effect is not specific to the mesolimbic and mesocortical tracks associated with schizophrenia; but instead travel to all of the dopamine receptor sites throughout the brain

  • this results in desirable anti-psychotic effects and creates undesirable and unpleasant side effects i.e. dystonia

• Typical → first generation (can cause tardive dyskinesia)

• Atypical → second generation (associated with metabolic syndrome)

• these do not differ in efficacy but they do differ in their side effect profile

• both can cause EPS and dystonia

First Generation (Typical) Antipsychotics

• Dopamine Antagonists

  • Mechanism of Action: blocks dopamine receptors in a number of CNS receptor sites

  • effective in treating positive symptoms, less effective with negative symptoms

  • also effective in the treatment of bipolar disorder, acute mania, and agitations

• Some meds include: thorazine (chlorpromazine), haldol (haloperidol), prolixin (fluphenazine)

Thorazine (Chlorpromazine)

• very first antipsychotic (1950)

  • develops as an anesthetic, not effective, but had calming effects

• supplanted by new antipsychotics due to wide undesirable side effect profiles including:

  • blocks dopamine and antagonizes acetylcholine, norepinephrine, and histamine receptors causing memory impairment (anticholinergic), hypotension (antiadrenergic), and sedation (anti-histaminergic))

• use primarily when sedative effect is desired

Haldol (Haloperidol)

• most popular of the FGA’s

  • frequently used to treat schizophrenia and agitation

  • for agitation often used with Ativan and Benadryl

• also used for delirium in acute care

  • generally requires IV administration and cardiac monitoring as haldol prolongs the QT interval

• less anticholinergic, antihistaminic or antiadrenergic effects, but significant EPS

  • dystonia, akathisia, parkinsonian, and tardive dyskinesia

Side Effects of First Generation (Typical) Antipsychotic Medications

• anticholinergic effects, EPS, agranulocytosis, orthostatic hypotension, tardive dyskinesia, neuroleptic malignant syndrome

• agitation, N/V, elevation in prolactin levels, sedations, seizures

Nursing Interventions for Anticholinergic Side Effects

Agranulocytosis

• rare and life threatening, with no known etioglogy

• neutropenia less than 500

• cold symptoms: sore throat, fever, chills

• increase heart rate and hypotension

• muscle weakness and fatigue

Psychotropic Adverse Effects: Extrapyramidal Symptoms

• Definition: neurologic and motor symptoms that occur in the context of anti-psychotic use

• Caused by: blocakde of D2 receptros in the basal ganglia; throwing off the normal balnace between acetylcholine and dopamine therby increasing acetylcholine transmission

• occur more often with first generation anti-psychotic agents

Akathisia

• Caused by the same biologic mechanisms as EPS.

• symptoms include: restlessness, movement of body, unable to keep still, movement of feet, discomfort

• often mistaken for anxiety or increase in psychotic symptosm: unfortunately also given more psychotropic medications

• treatment: reduce antipsychotic medication, cogentin, benadryl, benzodiazepine, beta-blocker (comfort measures)

• inderal

Akinesia

• rigidity, bradykinesia

• the inability to perform a clinically perceivable movement

• presents as a delayed response, freezing mid-action, or even total abolition of movement

• caused by dopamine-blocking medications like antipsychotics

• treatment includes switching to atypical antipsychotics with lower risk (e.g., olanzapine) or using anticholinergic

Dystonia

• spasmodic and painful spasm of muscle (torticollis)

• a neurological movement disorder characterized by involuntary sustained muscle spasm or painful contractions of the face, neck, turnk of limbs

• generally, occurs after initiating or increasing antipsychotic medications

• caused by a dopamine receptor blockade

• young men are most vulnerable to this type of EPS

• Treatment of choice for Dystonia: Benztropine (Cogentin) → 1mg-2mg IM, Trihexypenidyl (Artane), Diphenhydramine (Bendadryl) → 25mg-50mg IM

• Start daily administration of anticholinergic medications

• decrease antipsychotic medication dosage

Pseudoparkinsonism

• stimulates Parkinson’s disease with shuffling gait, drooling, muscular rigidity, and tremor

• akinesia, badykinesia, cogwheeling, resting hand tremor, drooling, mask-like face, shuffling gait

• treatment: lower antipsychotic dose, add anticholinergic, change to atypical antipsychotic agent

Cogentin

Rabbit Syndrome

• rapid movement of the lips that stimulates a rabbits mouth movement

Tardive Dyskinesia

• caused by the supersensitivity of the dopamine receptors in the basal ganglia

Long Term Effects:

• choking (due to loss of control of muscles used for swallowing)

• compromised respiratory function (infections, respiratory alkalosis)

• neurological syndrome caused by long term use of neuroleptic medications especially first generation

• characterized by repetitive, involuntary, purposeless movements: grimacing, tongue protrusion, lip smacking, puckering, and pursing, rapid eye blinking, rapid movement of arms, legs, trunk, fingers

Treatments:

• if possible, fully withdraw from medication

• switch from a first generation to a second generation antipsychotic with a lower D2 affinity

  • Clozapine (Clozaril)

  • Quetiapine (Seroquel)

  • use the minimum effective dose

  • minimize the duraton of therapy, consider a VMAT inhibitor (Deutetrabenazine → austedo and Valbenazine → ingrezza) MOA: cause a depletion of neuroactive peptides (like dopamine) in nerve terminals to regulate the amoungt of dopamine flow in the brain areas that control certain kinds of movements

• Side effects: drowsiness, depression

Second Generation (Atypical) Antipsychotic Agents

• MOA: transiently occupies D2 receptors and then rapidly dissociates to allow normal dopamine neurotransmission (dopamine blockade)

• Assists in: keeping prolactin levels normal, spares some cognitive decline/changes, and eliminates EPS

• improves positive and negative symptoms of schizophrenia

• rarely causes EPS or TD (often cause of pt. non-adherence)

• higher cost to patient

• potential for metabolic syndrome

• take several months to reach maximum efficacy

• Medications:

  • Clozaril (clozapine)

  • Risperdal (risperidone)

  • Zyprexa (olanzipine)

  • Seroquel (quetiapine)

  • Abilify (aripiprazole)

Common Side Effects of Second Generation (Atypical) Antipsychotic Medications

• drowsiness (fatigue, irritability, headache, insomnia), light-headedness, anticholinergic sx (constipation, dry mouth, blurred vision), metabolic syndrome (weight gain, hyperglycemia), QT interval prolongation, orthostatic hypotension

• nausea/vomiting, NMS, salivation, hypertension, tachycardia, EPS

• black box warning: elderly patients with dementia related psychosis treated with antipsychotic drugs are at an increased risk of death

Atypical Antipsychotic Medication Side Effect: Metabolic Syndrome

• glucose dysregulation: new onset DM II or dysregulation of current DM II

• lipid disturbance: hyperlipidemia and hypercholesteremia

• weight gain: increased food intake, increased visceral fat, reduced motor activity

olanzipine and clozapine have the highest metabolic risk

Prolonged QT Interval and Myocarditis

Nursing Implications for Monitoring and Administering Psychotropic Medications

• takes 1-2 weeks to effect change

• common: 6-12 weeks before changing prescription → a change in medication is indicated if a reduction in symptoms is not seen

• do not withdraw suddenly unless du to a medical emergency

• clazaril may be considered if a trial of atypical and typical anti-psychotic agents provided are ineffective

• adherence is a challenge → medications are taken for a lifetime unless patient develops: neuroleptic malignant syndrome, agranulocytosis or tardive dyskinesia