PSYCH HESI - DRUGS

Anti-anxiety drug classes

- benzos: [Chlordiazepoxide HCl (Librium), Diazepam (Valium), Alprazolam (Xanax), Clorazepate dipotassium (Tranxene), Lorazepam (Ativan)]

- non-benzos: [Buspirone (BuSpar), Zolpidem (Ambien), Ramelteon (Rozerem)]

Benzo indications

- reduce anxiety

- induce sedation, relax muscles, inhibit convulsions

- treat alc & drug withdrawal symptoms

- safer than sedative-hypnotics

Benzo adverse effects

- sedation

- drowsiness

- ataxia

- dizziness

- irritability

- blood dycrasias

- habituation & increase tolerance

Benzo nursing implications

- admin at bedtime to alleviate daytime sedation

- greatest harm when combined w/ alc or other CNS depressants

- gradually taper therapy d/t withdrawal effects

- used only as short-term drug & supplement to other meds

Buspirone (BuSpar) indications

- reduce anxiety

- help control symptoms such as: insomnia, sweating, & palpitations assoc. w/ anxiety

Buspirone (BuSpar) adverse

dizziness

Buspirone (BuSpar) implications

- takes several weeks for optimal effects

- intended for short-term use

Zlopidem (Ambien) indications

short-term insomnia tx

Zlopidem (Ambien) adverse

daytime drowsiness

Zlopidem (Ambien) implications

give w/ food 1-1.5 hrs. before bedtime

Ramelteon (Rozerem) indications

- long-term insomnia tx

- selectively binds ot melatonin receptors

Ramelteon (Rozerem) adverse

dizziness

Ramelteon (Rozerem) implications

appropriate for clients w/ delayed sleep onset

Tricyclic antidepressants

- amitriptyline (Elavil)

- desipramine (Norpramin)

- imipramine (Tofranil)

- nortriptyline (Aventyl)

- protriptyline (Vivatcil)

- maprotiline (Ludiomil)

Tricyclic indications

depression

-- client's w/ morbid fantasies that don't response well to these drugs

Tricyclic adverse

- anticholinergic: dry mouth, blurred vision, constipation, urinary retention

- CNS: sedation, psychomotor slowing, poor concentration

- CV: tachycardia, ortho hypotension, quinidine effect on heart (assess hx of MI), prolong QT interval

- GI: N/V

- narrow therapeutic index (lethal overdose)

Tricyclic implications

- admin at bedtime b/c sedative effect

- take s 2-6 weeks to be therapeutic

- 1-3 wks between stopping tricyclics & starting MAOIs

- teach client to avoid alc

- Avoid taking anti-hypertensives w/ this

- eval suicide

- lethal overdose

MAOIs

isocarboxazid (Marplan), Phenelzine sulfate (Nardil), Tranlcypromine sulfate (Parnate), Selegine (Eldepryl)

MAOI indications

depression, phobias, anxiety

MAOI adverse

tachycardia, urinary hesitant, constipation, impotence, dizzy, insomnia, muscle twitch, drowsiness, dry mouth, fluid retention, HYPERTENSIVE CRISIS (severe HTN & HA, chest pain, fever, sweating, NV), confusion

MAOI implications

- DON'T USE W/ TRICYCLICS (HTN CRISIS)

- NO TYRAMINE FOODS (aged cheese, red wine, beer, beef & chicken, liver, yeast, yogurt, soy sauce, chocolate, bananas)

- don't use w/ SSRIs

- no OTCs w/o physician approval

- teach S&S HTN crisis: HA, palpitations, HTN

Common SE anti anxiety drugs

sedation, drowsiness

Extrapyramidal Effects

parkinsonism, akathisia, photosensitivity, neuroleptic malignant syndrome, serotonin syndrome, anticholinergic effects

Parkinsonism

rigidity, shuffling gait, pill-rolling hand movements, tremors, dyskinesia, mask like face

- occurs 1-4 wks after start tx

Tardive Dyskinesia

irregular, repetitive involuntary movements of the mouth, face, & tongue including

- chewing

- tongue protrusion

- lip smacking

- puckering of the lips

- rapid eye blinking

- choreiform movements of limbs & trunk

develop late in tx

Akathisia

inability to sit still or restlessness, agitation, pacing, sudden difficulty sitting still (can be confused w/ TD) & is more common in middle-aged clients

- occurs within 1-6 wks after start tx

Dystonia

impaired muscle tone that generally is the first extrapyramidal symptom to occur

- limb & neck spasms

- uncoordinated jerky movements

- difficulty speaking & swallowing

- rigidity & muscle spasms

usually within a few days of initiating use of an antipsychotic

EPS interventions

- admin: anticholinergic (Cogentin, Artane)

-- others like Benadryl, Symmetrel, Ativan, Klonopin

-- Inderal for akathisia

-- Vitamin E for tardive dyskinesia

- rule out anxiety (can ask client, "Are you feeling so restless that you can't sit still?")

- Emergency tx: IM anticholinergics (HAVE RESP EQUIPMENT AVAILABLE)

- Permanent SE: anticholinergics no help in decreasing symptoms

- teach client & family to report SE EARLY!

NMS interventions

- increased risk w/ phenothiazines

- early recognition important!

- transfer to med facility for hydration, nutritional support, & tx of possible resp failure & renal failure

NMS (neuroleptic malignant syndrome)

LIFE THREAT EMERGENCY that may result from antipsychotic medications, is characterized by: rigidity and high fever

- tachycardia

- stupor

- increased resp

- severe muscle rigidity

Serotonin syndrome

confusion, disorientation, autonomic dysfunction

Serotonin syndrome interventions

- notify HCP STAT

- provide systems support

Anticholinergic effects

dry mouth, blurred vision, tachycardia, nasal congestion, constipation, urinary retention, ortho hypo

Anticholinergic interventions

- encourage sips of water, chew sugarless gum/hard candy

- increase fiber in diet

- change positions slowly

- report urinary retention to HCP

- tolerance to these SE will eventually occur

Anticholinergic drugs

- trihexyphenidyl (Artane)

- benzotropine mesylate (Cogentin)

- amantadine (Symmetrel)

usually given in conjunction w/ antipsychotics

SE: anticholinergic effects, drowsiness, HA, urinary hesitancy, memory impairment

A client has been started on an antipsychotic medication and is exhibiting muscle stiffness of the arms, slowness of gait, and tremors. Which of the following extrapyramidal syndromes (EPS) is the client displaying?

Pseudoparkinsonism - symptoms include the classic triad of Parkinson's disease (rigidity, slowed movements, and tremor). The rigid muscle stiffness is usually seen in the arms

A client is undergoing ECT. The nurse would be correct to inform the client of which aspect prior to the ECT?

Prior to the ECT procedure, the client is NPO for 8 hours. The client will empty his bladder just before or after vital signs are taken prior to the ECT. The client will not be harmed or feel any pain. The client will be asleep during the procedure

A 28-year-old client is being treated with lithium carbonate for bipolar disorder. Which of the following factors will increase his risk for lithium toxicity?

a) The client eats cheeses and smoked meats.

b) The client runs marathons frequently.

c) The client drinks caffeinated beverages.

d) The client works in a paint factory.

b) The client runs marathons frequently.

Lithium toxicity can occur when the body's sodium levels are lowered and absorption is disrupted. Predisposing factors include excessive heat, diaphoresis, concurrent use of diuretics, and decreased sodium intake.

A 52-year-old woman is seeing a nurse therapist for moderate depression. The client has been taking fluoxetine (Prozac) for 3 weeks, but her mood has not improved. She states, "I need more than this to get better. I'm taking St. John's wort, too." Why does the nurse tell the client to immediately stop taking St. John's wort?

St. John's wort with fluoxetine may lead to serotonin syndrome

- It is not a proven treatment for depression, but it is thought to increase serotonin levels. Therefore, taking St. John's wort along with a prescription antidepressant may cause central serotonin syndrome.

The therapeutic level of lithium range includes what?

0.6-1.2 mEq/L

- Therapeutic levels in acute mania range from 0.8 to 1.4 mEq/L

- Therapeutic maintenance doses range from 0.4 to 1 mEq/L

Which of the following are anticholinergic side effects that may occur with the use of antipsychotic drugs? Select all that apply.

a) Urinary retention

b) Dry mouth

c) Runny nose

d) Diarrhea

e) Constipation

• Urinary retention

• Dry mouth

• Constipation

-- Anticholinergic side effects resulting from blockade of acetylcholine are common side effects associated with antipsychotic drugs. Others include dry mouth, slowed gastric motility, constipation, urinary hesitancy or retention, and nasal congestion. Diarrhea and a runny nose are not anticholinergic side effects.

A client with paranoid delusions and aggressive behavior has been administered Haloperidol (Haldol). The nurse finds that after administering the drug, the client has started having jerky and involuntary movements of the head and arms. Which drug should the nurse expect to be ordered for this client?

a) Risperidone (Risperdal)

b) Benztropine (Cogentin)

c) Clozapine (Clozaril)

d) Olanzapine (Zyprexa)

Benztropine (Cogentin)

- Jerky and involuntary movements of the head and arms are the extrapyramidal side effects associated with Haloperidol (Haldol). Benztropine (Cogentin) is known to be effective in rapid alleviation of these side effects. Extrapyramidal side effects are caused due to antipsychotic drugs. Clozapine (Clozaril), Risperidone (Risperdal), Olanzapine (Zyprexa) are all the antipsychotic drugs. Administration of these drugs would further aggravate the extrapyramidal symptoms.

Steven has been diagnosed with schizophrenia and is showing the following symptoms: immobility, rigidity, and stupor. What subtype of schizophrenia is Steven most likely suffering from?

Catatonic - clients show:

- motoric immobility or stupor

- rigidity

- excessive motor activity

- extreme negativism (resistance to instructions)

- excitement (severely agitated, out of control)

- stupor (decrease in reaction to environment) or mutism

- posturing, echolalia and echopraxia, mutism, & waxy flexibility

- risk for violence to self or others during stupor or excitement

Disorganized schizophrenia

- incoherence, flat/inappropriate affect

- disorganized, uninhibited behavior

- unusual mannerisms

- socially withdrawn, no delusions present

Paranoid schizophrenia

- systematized delusions, hallucinations r/t single theme, or both

- ideas of reference (misconstruing trivial events & remarks by giving them personal significance)

- potential for violence if delusions are acted upon

Residual schizophrenia

- socially withdrawn, inappropriate affect

- eccentric or peculiar behavior

- absence of prominent delusions & hallucinations

- no current psychotic behavior exhibited

Undifferentiated schizophrenia

- prominent delusions & hallucinations

- incoherence & grossly disorganized behaviors

- failure to meet any of the criteria for other types

Bleuer's 4 A's to help remember important characteristics of schizophrenia

- Autism (preoccupied w/ self)

- Affect (flat)

- Associations (loose)

- Ambivalence (difficulty making decisions)

Antipsychotic drug classes

- Phenothiazines [chlorpromazine (Thorazine), trifluoperazine (Stelazine), thioridazine (Mellaril), perphenazine (Trilafon), triflupromazine (Vesprin), loxapine (Loxitane), fluphenazine (Prolixin)]

- Nonphenothiazines [haloperidol (Haldol), thiothixene (Navane), pimozide (Orap)]

- Atypical antipsychotics [risperidone (Risperdal), olanzapine (Zyprexa), quetiapine (Abilify), ziprasidone (Geodon), clozapine (Clozaril)]

A client has been sitting in same position for 2 hrs. He is mute. What type of schizophrenia is this client experiencing?

catatonic

Phenothiazines indications

psychotic behavior: hallucinations, delusions, bizarre behavior

Phenothiazines adverse

drowsiness, ortho hypo, wt. gain, anticholinergic, EPS, photosensitivity, blood dyscrasis: granulocytosis, leukopenia, NMS

Phenothiazines implications

- EPS are MAJOR CONCERN

- monitor OA closely

- takes 2-3 wks to achieve therapeutic

- keep client supine for 1 hr after admin & advise change positions slowly b/c adverse ortho hypo

- teach client to avoid: alc, sedatives, antacids

Flupehazine (Prolixin) indications, adverse, implications

- control psychotic behavior, useful for psychomotor agitation assoc w/ thought disorders

- absorbs slowly

- used w/ non-compliant client's b/c can admin IM once q14 days

Schizophrenia vs. Schizoaffective disorder

One of the primary differences between the diagnosis of schizoaffective disorder and schizophrenia is that schizoaffective disorder is episodic in nature. Self-care difficulties may exist with both diseases. Clients with schizoaffective disorder also experience hallucinations that can be severe, have many more mood responses, and are very susceptible to suicide

When assessing a client with a delusional disorder who is experiencing somatic delusions, which of the following would the nurse expect as within normal parameters?

In clients with delusional disorders, mental status is not generally affected. Thinking, orientation, affect, attention, memory, perception, and personality are generally intact. Most clients who receive diagnoses of delusional disorder do not experience functional difficulties or impairments. Self-care patterns may be disrupted in clients with the somatic subtype by the elaborate processes used to treat perceived illness (e.g., bathing rituals, creams). Sleep may be disrupted because of the central and overpowering nature of the delusions.

MAOIs are advantageous in treating which of the following?

a) Depression refractory to electroconvulsive therapy

b) Depression with panic symptoms

c) Mild depression

d) Persistent depressive disorder

Depression with panic symptoms

The efficacy of the MAOIs is well established. Evidence suggests their distinct advantage in treating a specific subtype of depression, so-called atypical depression (characterized by increased appetite, reverse diurnal mood variation, and hypersomnia), depression with panic symptoms, and social phobia

- BUT usually reserved for those who don't respond to other antidepressants or can't tolerate typical antidepressants

ECT is reserved for depression that....

is refractory to antidepressant therapy

A client is admitted to a mental health unit with reports of fatigue, poor appetite, and difficulty making decisions. The client also states feeling unhappy most of the time for at least 3 years. Which of the following diagnoses should the nurse anticipate for this patient?

Dysthymic disorder

a milder but more chronic form of depression and is diagnosed when the depressed mood exists for most days for at least 2 years with two or more of the following symptoms: poor appetite or overeating, insomnia or oversleeping, low energy or fatigue, low self-esteem, poor concentration or difficulty making decisions, and feelings of hopelessness

Dysthymic disorder

This disorder is a long duration mood disorder that has a lower intensity of depressive symptomatology. It may precede major depression.

Persistent depressive disorder (dysthymic disorder)

Cognitive interventions for depression

thought stopping & positive self-talk

- can dispel irrational beliefs and distorted attitudes, and in turn reduce depressive symptoms during the acute phase of major depression

common side effects of TCAs

Orthostatic hypotension and urinary retention

common side effects of older antipsychotics

Photosensitivity, skin rashes, pseudoparkinsonism, and tardive dyskinesia

SE of lithium

Diarrhea and electrolyte imbalances

A client has been diagnosed with major depressive disorder. The clinical symptoms that would be included when the clinician makes this diagnosis are what?

a) Claims by family, friends, or coworkers that the client is depressed

b) Demonstrated examples of unwise decisions

c) A significant decrease in appetite

d) A significant failure in an occupational or relational setting

A significant decrease in appetite

-- among the 9 clinical symptoms of a major depressive episode is a significant increase or decrease in appetite

Failures may precipitate or exacerbate decisions and others may confirm the client's depression, but these are not diagnostic criteria. Unwise decision making is not a hallmark of depression, but indecisiveness is a diagnostic criterion