PSYCH MEDS PHARM II

Benzodiazepines

hese are “calm down” medicines.

Examples:

• alprazolam

• estazolam

• flurazepam

• lorazepam

• temazepam

• triazolam 

MOA of benzos

These are “calm down” medicines.

Examples:

• alprazolam

• estazolam

• flurazepam

• lorazepam

• temazepam

• triazolam 

Alprazolam

used for anxiety and panic disorders

SE OF alprazolam

• drowsiness

• dry mouth

• diarrhea

• constipation 

Nursing points of alprazolam

• not recommended for long-term use

• do not stop abruptly

• sudden stopping can cause seizures

Dangerous Interactions regardinging benzos

When benzodiazepines are mixed with other CNS depressants like:

• alcohol

• anticonvulsants

the patient can have:

• more sedation

• lower level of consciousness

• bad coordination

• respiratory depression

• death 

memory trick regarding benzos

Benzos = brain slowers

Benzo + booze = bad breathing

Never stop benzos cold
→ cold stop = seizures

A patient takes alprazolam and says, “I’m going to stop taking it today because I feel better.” Nursing thoughts

No. Do not stop suddenly. This can cause withdrawal and seizures. 

Nonbenzodiazepine Sleep Drugs

• eszopiclone

• zaleplon

• zolpidem 

MOA for nonbenzo sleep drugs

• These are for short-term sleep help only. 

memory trick for nonbezo sleep drugs

Z-drugs= zzz drugs

Antianxiety Drugs

• benzodiazepines

• barbiturates

• buspirone 

Why is buspirone special?

It has:

• less sedation

• no increase in CNS depression with alcohol or sedative-hypnotics

• lower abuse potential 

NCLEX point regarding buspirone

It has:

• less sedation

• no increase in CNS depression with alcohol or sedative-hypnotics

• lower abuse potential 

SE of buspirone

• dizziness

• light-headedness

• insomnia

• rapid heart rate

• palpitations

• headache 

memory trick fro buspirone

Buspirone = better for steady anxiety, not sudden panic

A patient having a panic attack asks for buspirone for immediate relief.

Buspirone is not effective when quick relief is needed. 

SSRIs

are antidepressants.

Examples:

• citalopram

• escitalopram

• fluoxetine

• fluvoxamine

• paroxetine

• sertraline 

SSRI’s MOA

They help increase serotonin in the brain by stopping its reuptake. 

What is fluoxetine used for?

• depression

• binge eating and vomiting behaviors in bulimia nervosa

• premenstrual dysphoric disorder

• anorexia nervosa

• panic disorder

• alcohol dependence 

SE of fluoxetine

• anxiety

• insomnia

• drowsiness

• nausea

• diarrhea

• dry mouth 

nursing teaching regarding fluoxetine

• give in the morning to help prevent insomnia

• warn patient to avoid hazardous activities until drug effects are known

• monitor for suicidal ideation and aggression

memory trick regarding fluoxetine

• Fluoxetine = first thing in the morning
  because it can cause insomnia.

  SSRIs = watch suicide risk

A teen starts fluoxetine and becomes more agitated and talks about hopelessness.

what is the Nursing priority:

Monitor closely for suicidal ideation and aggression. 

If SSRIs are stopped abruptly, the patient may get:

• dizziness

• vertigo

• ataxia

• nausea

• vomiting

• muscle pains

• fatigue

• tremor

• headache

• anxiety

• crying spells

• irritability

• sad feelings

• memory problems

• vivid dreams 

SSRI Discontinuation Syndrome Prevention

Taper slowly over several weeks. 

A patient suddenly stops paroxetine and now has dizziness, vivid dreams, nausea, and crying spells.What does this suggest ?

SSRI discontinuation syndrome.

MAo Inhibitors

Examples:

• rasagiline

• selegiline

• isocarboxazid

• phenelzine

• tranylcypromine 

Switching Rule regarding MAO inhibitors

• stop MAOI 2 weeks before starting another antidepressant

• if switching to an MAOI from another antidepressant, wait 2 weeks

• wait 5 weeks for fluoxetine before starting an MAOI 

food rule regarding MAO

Avoid tyramine-rich foods:

• chocolate

• red wine

• aged cheese

• smoked or processed meats

• fava beans 

• large amounts of caffeine. 

can cause severe reactions, including hypertensive crisis.
The file says tranylcypromine is the MAOI most commonly linked to hypertensive crisis when tyramine foods are eaten. 

Nursing teaching regarding MAOI

• sit up for 1 minute before getting out of bed to avoid dizziness

• avoid overexertion

• consult provider before OTC or prescription drugs

• do not stop suddenly

• avoid cold meds, hay fever meds, and diet aids unless approved 

A patient taking phenelzine wants wine and aged cheese at a party. what are the nursing thoughts

No — tyramine foods can cause a severe reaction/hypertensive crisis. 

TCA

Examples:

• amitriptyline

• clomipramine

• desipramine

• doxepin

• imipramine

• nortriptyline

• trimipramine 

What are TCA’s used for

• major depression

• especially depression with weight loss, anorexia, or insomnia

How fast do TCA’s work

Symptoms may improve:

• as early as 1 week

• as late as 4 weeks 

Taking TCA’S with MAO inhibitors can cause

• extremely high body temperature

• excitation

• seizures 

TCA have strong antichollinergic effects

• dry mouth

• urine retention

• constipation 

Imipramine MOA

May increase norepinephrine and serotonin in the synapse.
Also has:

• antihistaminic

• sedative

• anticholinergic

• vasodilatory effects 

Imipramine used for

• depression

• enuresis in children older than 6 

Nursing Considerations Imipramine

Watch for:

• sedation

• anticholinergic effects

• orthostatic hypotension 

nurse teaching imipramine

• do not stop abruptly

• taper over several weeks

• avoid hazardous activities until effects are known 

memory trick TCA

TCA = Too dry, can’t pee, can’t poop

• dry mouth

• urine retention

• constipation

A patient on imipramine stands up and gets dizzy.

ORTHOSTATIC HYPOTENSION

buprpion can causse

• headache

• confusion

• tremor

• agitation

• tachycardia

• anorexia

• nausea and vomiting 

venlafaxine and duloxetine can cause

• headache

• somnolence

• dizziness

• nausea 

trazadone can cause

dizziness

drowsiness

what is lithium

A mood stabilizer used to:

• prevent mania

• treat mania

• help with bipolar disorder 

salt rule lithium

• low sodium diet can make lithium more toxic

• high sodium intake can lower its therapeutic effect 

SE of lithium

• reversible ECG changes

• thirst

• polyuria

• elevated WBC count 

lithium toxicity signs

• confusion

• lethargy

• slurred speech

• increased reflexes

• seizures 

nursing teaching lithium

• take with plenty of water

• take after meals to reduce GI upset

• narrow therapeutic margin of safety

• even slightly high levels can be dangerous

• watch for toxicity:

  • diarrhea

  • vomiting

  • tremor

  • drowsiness

  • muscle weakness

  • ataxia

• if toxicity symptoms appear, withhold one dose and call the prescriber

• do not stop abruptly

• avoid hazardous activities until effects are known

• do not switch brands without approval

• carry medical identification 

• Lithium likes salt balance

Lithium likes salt balance

Lithium = lots of thirst and lots of pee

A patient on lithium starts vomiting, becomes shaky, sleepy, and unsteady.What does this finding suggest?

lithium toxicity

Antipsychotic drugs

These help control psychotic symptoms like:

• delusions

• hallucinations

• thought disorders 

what disorders are antipsychotics used in ?

used in:

• schizophrenia

• mania

• other psychoses 

Two big groups

• atypical antipsychotics

• typical antipsychotics 

Atypical antipsychotics

Examples:

• clozapine

• lurasidone

• olanzapine

• risperidone

• quetiapine

• ziprasidone

• brexpiprazole

• aripiprazole 

key nursing points regading atypical antipsychotics

• Olanzapine: minimal EPS risk, but weight gain is common

• Risperidone: higher risk for EPS at doses over 6 mg/day

• Quetiapine and aripiprazole: associated with sedation

• Ziprasidone: not recommended in heart patients because it can cause ECG changes, prolonged QT, and heart block

memory trick atypical antipsychotics

Olanzapine = overweight
Risperidone = more EPS at higher dose
Ziprasidone = zip the QT monitor on

A patient with heart disease is prescribed ziprasidone.What is the nursing concern

This drug can cause ECG changes and prolonged QT

Typical Antipsychotics

Examples:

• chlorpromazine

• fluphenazine

• perphenazine

• trifluoperazine

• thioridazine

• haloperidol

• molindone 

what is chlorpromazine MOA

It blocks dopamine receptors in the CNS.
It also has:

• antiemetic effects

• anticholinergic effects

• alpha-adrenergic blocking actions 

What is chlorpromazine used for?

It blocks dopamine receptors in the CNS.
It also has:

• antiemetic effects

• anticholinergic effects

• alpha-adrenergic blocking actions 

Nursing considerations regarding Chlorpromazine

Monitor for:

• adverse effects

• extrapyramidal symptoms (EPS)

  • early: akathisia

  • long-term: tardive dyskinesia

• neuroleptic malignant syndrome

• elevated liver enzymes progressing to obstructive jaundice may signal allergy 

Do not stop abruptly.
Reduce dose gradually over weeks.

PT teaching for antipsychotics

• take as prescribed

• do not increase dose or stop without approval

• if daytime sedation happens, take full dose at bedtime

• full effect may take weeks

• report unusual effects, especially involuntary movements

• avoid alcohol

• do not take OTC or herbal drugs without approval

• avoid hazardous tasks until effects are known

• avoid too much sun, heat lamps, tanning beds

• avoid extreme heat or cold

• phenothiazines may turn urine pink or brown 

memory trick antipsychotics

Typical antipsychotics = think EPS
Chlorpromazine = check for strange movements

A patient taking chlorpromazine develops restlessness and later involuntary movements.What are your thoughts as the nurse?

Watch for EPS, including akathisia and tardive dyskinesia.

BENZODIAPZEPINES

• calm down

• sedating

• do not stop abruptly

• no alcohol/CNS depressants

BUSPIRONE

• less sedation

• not for fast panic relief

SSRI’S

• serotonin drug

• monitor suicide risk

• taper slowly, don’t stop abruptly

MAOI’s

• many interactions

• no tyramine foods

• wait 2 weeks before switching

• 5 weeks for fluoxetine

TCA’s

• dry mouth

• constipation

• urine retention

• orthostatic hypotension

LITHIUM

• mood stabilizer

• narrow safety range

• thirst/polyuria

• watch sodium balance

• watch toxicity

ANTIPSYCHOTICS

• watch for sedation

• watch for EPS

• avoid alcohol

• report involuntary movements