Psychotic Disorders ebook

Unit 3: Psychobiologic Disorders

Page 1

SECTION 1 | Psychobiologic Disorders

Chapter 15: Psychotic Disorders

Schizophrenia spectrum and other psychotic disorders affect thinking, behavior, emotions, and the ability to perceive reality. Schizophrenia probably results from a combination of genetic, neurobiological, and nongenetic (injury at birth, viral infection, and nutritional) factors.

The typical age at onset is mid teens and mid 20s, but schizophrenia has occurred in young children and can begin in later adulthood. A prodromal period can occur during which the client experiences negative symptoms (anergia) or a reduced level of positive symptoms. Psychotic disorders become problematic when manifestations interfere with interpersonal relationships, self-care, and ability to work.

Types of disorders

The various types of psychotic disorders recognized and defined by the DSM-5-TR include the following.

Schizophrenia: The client has psychotic thinking or behavior present for at least 6 months. Areas of functioning, including school or work, self-care, and interpersonal relationships, are significantly impaired.

Schizotypal personality disorder: The client has impairments of personality (self and interpersonal) functioning. However, impairment is not as severe as with schizophrenia.

Delusional disorder: The client experiences delusional thinking for at least 1 month. Self or interpersonal functioning is not markedly impaired.

Brief psychotic disorder: The client has psychotic manifestations that last 1 day to 1 month in duration.

Schizophreniform disorder: The client has manifestations similar to schizophrenia, but the duration is 1 to 6 months, and social/occupational dysfunction might not be apparent.

Schizoaffective disorder: The client’s disorder meets the criteria for both schizophrenia and depressive or bipolar disorder.

Substance/medication-induced psychotic disorder: The client experiences psychosis due to substance intoxication or withdrawal or after exposure to or withdrawal from a medication. However, the psychotic manifestations are more severe than typically expected.

Psychotic or catatonic disorder due to another medical condition: The client exhibits psychotic features (impaired reality testing), bizarre behavior (psychotic), or a significant change in motor activity behavior (catatonic), but does not meet criteria for diagnosis with another specific psychotic disorder.

Data collection

Expected findings

Characteristic dimensions of psychotic disorders

Positive symptoms: Manifestation of things that are not normally present. These are the most easily identified manifestations.

  • Hallucinations

  • Delusions

  • Alterations in speech

  • Bizarre behavior (walking backward constantly)

Negative symptoms: Absence of things that are normally present. These manifestations are more difficult to treat successfully than positive symptoms.

  • Affect: Usually blunted (narrow range of expression) or flat (facial expression never changes).

  • Alogia: Poverty of thought or speech. The client might sit with a visitor but only mumble or respond vaguely to questions.

  • Anergia: Lack of energy.

  • Anhedonia: Lack of pleasure or joy. The client is indifferent to things that often make others happy, such as looking at beautiful scenery.

  • Avolition: Lack of motivation in activities and hygiene. For example, the client completes an assigned task, such as making their bed, but is unable to start the next common chore without prompting.

Cognitive Findings: Problems with thinking make it very difficult for the client to live independently.

  • Disordered thinking

  • Inability to make decisions

  • Poor problem-solving ability

  • Difficulty concentrating to perform tasks

  • Short-term memory deficits

  • Impaired abstract thinking

Affective Findings: Manifestations involving emotions

  • Hopelessness

  • Suicidal ideation

  • Unstable or rapidly changing mood

Determine which symptom is positive or negative symptoms of schizophrenia.

Drag each symptom to the whether it is is a positive or negative symptom.

Hallucinations

Avolition

Alterations in speech

Delusions

Bizarre Motor movements

Flat affect

Anhedonia

Anergia

Positive

Negative

Alterations in thought (delusions)

Alterations in thought are false fixed beliefs that cannot be corrected by reasoning and are usually bizarre. These include the following.

  • Ideas of reference: Misconstrues trivial events and attaches personal significance to them, such as believing that others, who are discussing the next meal, are talking about them

  • Persecution: Feels singled out for harm by others, such as being hunted down by the FBI

  • Grandeur: Believes that they are all powerful and important, like a god

  • Somatic delusions: Believes that their body is changing in an unusual way, such as growing a third arm

  • Jealousy: Believes that their partner is sexually involved with another individual even though there is not any factual basis for this belief

  • Being controlled: Believes that a force outside their body is controlling them

  • Thought broadcasting: Believes that their thoughts are heard by others

  • Thought insertion: Believes that others’ thoughts are being inserted into their mind

  • Thought withdrawal: Believes that their thoughts have been removed from their mind by an outside agency

  • Religiosity: Is obsessed with religious beliefs

  • Magical thinking: Believes their actions or thoughts are able to control a situation or affect others, such as wearing a certain hat makes them invisible to others

Alterations in speech

The following examples can occur.

  • Associative looseness: Unconscious inability to concentrate on a single thought. Can progress to flight of ideas in which the client’s speech moves so rapidly from one thought to another that it is incoherent.

  • Neologisms: Made-up words that have meaning only to the client (“I tranged and flittled.”).

  • Echolalia: The client repeats the words spoken to them.

  • Clang association: Meaningless rhyming of words, often forceful, such as, “Oh fox, box, and lox.”

  • Word salad: Words jumbled together with little meaning or significance to the listener (“Hip hooray, the flip is cast and wide-sprinting in the forest.”).

  • Circumstantiality: Including multiple and unneeded details during a conversation, such as describing in great detail the weather and clothes they are wearing when asked what their plans are for the day

  • Tangentiality: Starts talking about trivial information rather than focusing on the main topic of conversation, such as talking about what they will have for lunch when the discussion is about discharge medications.

Alterations in perception

Hallucinations are sensory perceptions that do not have any apparent external stimulus. Examples include:

  • Auditory: Hearing voices or sounds

    • Command: The voice instructs the client to perform an action (to hurt self or others). QS 

  • Visual: Seeing persons or things

  • Olfactory: Smelling odors

  • Gustatory: Experiencing tastes

  • Tactile: Feeling bodily sensations

Personal boundary difficulties

Disenfranchisement with one’s own body, identity, and perceptions. This includes the following.

  • Depersonalization: Nonspecific feeling that a client has lost their identity. Self is different or unreal.

  • Derealization: Perception that the environment has changed, such as the client believing that objects in their environment are shrinking.

  • Illusions: Misperceptions or misinterpretations of a real experience

Alterations in behavior

  • Extreme agitation: Including pacing and rocking

  • Stereotyped behaviors: Motor patterns that had meaning to client (sweeping the floor) but now are mechanical and lack purpose

  • Automatic obedience: Responding in a robot-like manner

  • Waxy flexibility: Maintaining a specific position for an extended period of time

  • Stupor: Motionless for long periods of time, coma-like

  • Negativism: Doing the opposite of what is requested

  • Echopraxia: Purposeful imitation of movements made by others

  • Catatonia: Pronounced decrease or increase in the amount of movement. Muscular rigidity, or catalepsy, may be so severe that limbs may be so severe that the limbs remain in whatever position they are placed.

  • Motor retardation: Pronounced slowing of movement

  • Impaired impulse control: Reduced ability to resist impulses

  • Gesturing or posturing: Assuming unusual and illogical expressions

  • Boundary impairment: Impaired ability to see where one person’s body ends and another’s begins

Standardized Screening Tools

Abnormal Involuntary Movement Scale (AIMS): This tool is used to monitor involuntary movements and tardive dyskinesia in clients who take antipsychotic medication. QEBP

Patient-Centered Care

Nursing Care

  • Milieu therapy is used for clients who have a psychotic disorder both in acute mental health facilities and in community facilities (residential crisis centers, halfway houses, and day treatment programs).

    • Provide a structured, safe environment (milieu) for the client in order to decrease anxiety and to distract the client from constant thinking about hallucinations.

    • Assertive Community Treatment (ACT): Intensive case management and interprofessional team approach to assist clients with community-living needs. QTC 

  • Promote therapeutic communication to lower anxiety, decrease defensive patterns, and encourage participation in the milieu.

  • Establish a trusting relationship with the client.

  • Use appropriate communication to address hallucinations and delusions.

    • Ask the client directly about hallucinations. The nurse should not argue or agree with the client’s view of the situation, but can offer a comment, such as, “I don’t hear anything, but you seem to be feeling frightened.”

    • Do not argue with a client’s delusions, but focus on the client’s feelings and possibly offer reasonable explanations, such as, “I can’t imagine that the President of the United States would have a reason to kill a citizen, but it must be frightening for you to believe that.”

    • Monitor the client for paranoid delusions, which can increase the risk for violence against others.

    • If the client is experiencing command hallucinations, provide for safety due to the increased risk for harm to self or others. QS​​​​​​​

    • Attempt to focus conversations on reality-based subjects.

    • Identify manifestation triggers (loud noises [can trigger auditory hallucinations in certain clients]) and situations that seem to trigger conversations about the client’s delusions.

    • Be genuine and empathetic in all dealings with the client.

A nurse is speaking with a client who has schizophrenia when the client suddenly seems to stop focusing on the nurse’s questions and begins looking at the ceiling and talking to themself. Which of the following actions should the nurse take?

A

Stop the interview at this point, and resume later when the client is better able to concentrate.

B

Ask the client, “Are you seeing something on the ceiling?”

C

Tell the client, “You seem to be looking at something on the ceiling. I see something there, too.”

D

Continue the interview without commenting on the client’s behavior.

  • Determine discharge needs (ability to perform activities of daily living [ADLs]).

  • Promote self-care by modeling and reinforcing teaching about self-care activities within the mental health facility.

  • Relate wellness to the elements of manifestation
    management.

  • Collaborate with the client to use manifestation management techniques to cope with depressive findings and anxiety. Manifestation management techniques include such strategies as using music to distract from “voices,” attending activities, walking, talking to a trusted person when hallucinations are most bothersome, and interacting with an auditory or visual hallucination by telling it to stop or go away. QPCC​​​​​​​

  • Reinforce teaching regarding medications.

  • Whenever possible, incorporate family in all aspects of care.

Client Education

  • Develop social skills and friendships.

  • Participate in group work and psychoeducation.

  • Comply with the medication.

Medications for psychotic disorders

Schizophrenia spectrum disorders are the primary reason for the administration of antipsychotic medications. The clinical course of schizophrenia usually involves acute exacerbations with intervals of semi-remission in which manifestations remain present but are less severe.

Manifestations

Medications are used to treat the following.

Positive symptoms related to behavior, thought, perception, and speech: Agitation, bizarre behavior, delusions, hallucinations, flight of ideas, loose associations

Negative symptoms: Social withdrawal, lack of emotion, lack of energy, flattened affect, decreased motivation, decreased pleasure in activities

Goals of treatment

The goals of psychopharmacological treatment for schizophrenia and other psychotic disorders include the following.

  • Suppression of acute episodes

  • Prevention of acute recurrence

  • Maintenance of the highest possible level of functioning

First-generation antipsychotics

  • First-generation (conventional) antipsychotic medications are used mainly to control positive symptoms of psychotic disorders.

  • Due to adverse effects, first-generation antipsychotic medications are reserved for clients who are

    • Using them successfully and can tolerate the adverse effects.

    • Concerned about the cost associated with second-generation antipsychotic medications. 

  • First-generation agents are classified as either low-, medium-, or high-potency depending on their association with extrapyramidal symptoms (EPSs), level of sedation, and anticholinergic adverse effects.

    • Low potency: low EPSs, high sedation, and high anticholinergic adverse effects

    • Medium potency: moderate EPSs, moderate sedation, and low anticholinergic adverse effects

    • High potency: high EPSs, low sedation, and low anticholinergic adverse effects

Second-generation antipsychotics

Second-generation (atypical) antipsychotic agents are often chosen as first-line treatment for schizophrenia. They are the current medications of choice for clients receiving initial treatment, and for treating breakthrough episodes in clients on conventional medication therapy, because they are more effective with fewer adverse effects.

Advantages

  • Relief of both positive and negative symptoms

  • Decrease in affective findings (depression, anxiety) and suicidal behaviors

  • Improvement of neurocognitive defects, such as poor memory

  • Fewer or no EPSs, including tardive dyskinesia, due to less dopamine blockade

  • Fewer anticholinergic effects, with the exception of clozapine, which has a high incidence of anticholinergic effects. This is because most of the atypical antipsychotics cause little or no blockade of cholinergic receptors.

  • Less relapse

Third-generation antipsychotics

Third-generation antipsychotic agents are used to treat both positive and negative symptoms while improving cognitive function.

Advantages

  • Decreased risk of EPSs or tardive dyskinesia

  • Lower risk for weight gain and anticholinergic effects

A nurse is discussing manifestations of schizophrenia with a newly licensed nurse. Which of the following manifestations should the nurse identify as being effectively treated by first-generation antipsychotics?

Select all that apply.

A

Auditory hallucinations

B

Withdrawal from social situations

C

Delusions of grandeur

D

Severe agitation

E

Anhedonia

Antipsychotics: First-generation (conventional)

Select Prototype Medication: Chlorpromazine

Other Medications

  • Haloperidol, high potency

  • Fluphenazine, high potency

  • Loxapine, medium potency

  • Thiothixene, high potency

  • Perphenazine, medium potency

Purpose

Expected Pharmacological Action

  • First-generation antipsychotic medications block dopamine (D2), acetylcholine, histamine, and norepinephrine receptors in the brain and periphery.

  • Inhibition of psychotic findings is believed to be a result of D2 blockade in the brain.

Therapeutic Uses

  • Treatment of acute and chronic psychotic disorders

  • Schizophrenia spectrum disorders

  • Bipolar disorder: primarily the manic phase

  • Tourette disorder

  • Agitation

  • Prevention of nausea/vomiting through blocking of dopamine in the chemoreceptor trigger zone of the medulla

Complications

Agranulocytosis

Nursing actions: If indications of infection appear, obtain a CBC. Medication should be discontinued if WBC count is less than 3,000 mm3.

Client education: Observe for indications of infection (fever, sore throat), and notify the provider if these occur.

Anticholinergic effects

Manifestations

  • Dry mouth

  • Blurred vision

  • Photophobia

  • Urinary hesitancy or retention

  • Constipation

  • Tachycardia

Nursing actions: Suggest the following strategies to decrease anticholinergic effects.

  • Chewing sugarless gum

  • Sipping on water

  • Avoiding hazardous activities

  • Wearing sunglasses when outdoors

  • Eating foods high in fiber

  • Participating in regular exercise

  • Maintaining fluid intake of 2 to 3 L/day from beverages and food sources

  • Voiding just before taking medication

Extrapyramidal Adverse effects

Acute dystonia

Manifestations

  • Severe spasm of the tongue, neck, face, and back

  • Crisis situation that requires rapid treatment

Nursing actions

  • Begin to monitor for acute dystonia anywhere between 1 to 5 days after administration of first dose.

  • Treat with an antiparkinsonian agents such as benztropine.

  • IM or IV administration diphenhydramine can also be beneficial.

  • Stay with the client and monitor the airway until spasms subside (usually 5 to 15 min).

Pseudoparkinsonism

Manifestations

  • Bradykinesia

  • Positive symptoms of schizophrenia

  • Rigidity

  • Shuffling gait

  • Drooling

  • Tremors including pill-rolling

  • Mask-like face

Nursing actions

  • Observe for pseudoparkinsonism for the first month after the initiation of therapy. Can occur in 5 to 30 days following the first dose.

  • Treat with an antiparkinsonian agent (benztropine, trihexyphenidyl).

  • Implement interventions to reduce the risk for falling.

Akathisia

Manifestations

  • Inability to sit or stand still

  • Continual pacing and agitation

Nursing actions

  • Observe for akathisia for the first 2 months after the initiation of treatment. Can occur in as little as 5 to 60 days following the first dose.

  • Manage with antiparkinsonian agents, beta blockers, or lorazepam/diazepam.

  • Monitor for increased risk for suicide in clients who have severe akathisia.

Tardive dyskinesia (TD)

Manifestations

  • Late EPSs, which can require months to years of medication therapy for TD to develop

  • Involuntary movements of the tongue and face, such as lip smacking and tongue fasciculations

  • Involuntary movements of the arms, legs, and trunk

Nursing actions

  • Evaluate the client after 12 months of therapy and then every 3 months. If TD appears, dosage should be lowered, or the client should be switched to a second-generation antipsychotic agent.

  • Once TD develops, it usually does not decrease, even with discontinuation of the medication.

  • There is no reliable treatment for TD.

  • Reinforce to the client that purposeful muscle movement helps to control the involuntary TD.

A nurse is caring for a client who is currently taking perphenazine. Which of the following findings should the nurse identify as an extrapyramidal symptom (EPS)?

Select all that apply.

A

Decreased level of consciousness

B

Drooling

C

Involuntary arm movements

D

Urinary retention

E

Continual pacing

Neuroendocrine effects

Manifestations

  • Gynecomastia

  • Weight gain

  • Menstrual irregularities

  • Galactorrhea

Nursing actions: Monitor weight.

Client education: Observe for these manifestations and to notify the provider if they occur.

Neuroleptic malignant syndrome

Manifestations

  • Sudden high fever

  • Blood pressure fluctuations

  • Diaphoresis

  • Tachycardia

  • Muscle rigidity

  • Decreased level of consciousness

  • Coma

Nursing actions

  • This life-threatening medical emergency can occur within the first week of treatment or any time thereafter.

  • Stop antipsychotic medication.

  • Monitor vital signs.

  • Apply cooling blankets.

  • Administer antipyretics.

  • Increase the client’s fluid intake.

  • Administer dantrolene or bromocriptine to induce muscle relaxation.

  • Administer medication as prescribed to treat arrhythmias.

  • Assist with immediate transfer to an ICU.

  • Wait 2 weeks before resuming therapy. Consider switching to an atypical agent.

Orthostatic hypotension

Nursing actions

  • The client should develop tolerance in 2 to 3 months.

  • Monitor blood pressure and heart rate for orthostatic changes. Hold medication until the provider is notified if there is a significant decrease in blood pressure or increase in heart rate.

  • Encourage the client to increase fluid intake to maintain hydration.

Client education: If indications of orthostatic hypotension (lightheadedness, dizziness) occur, sit or lie down. Orthostatic hypotension can be minimized by getting up or changing positions slowly.

Sedation

Client education

  • Effects should diminish within a few weeks.

  • Take the medication at bedtime to avoid daytime sleepiness.

  • Do not drive until sedation has subsided.

Seizures

Indications: Greatest risk in clients who have an existing seizure disorder

Nursing actions: An increase in antiseizure medication can be necessary.

Client education: Report seizure activity to the provider.

Severe dysrhythmias

Nursing actions

  • Obtain baseline ECG and potassium level prior to treatment, and periodically throughout the treatment period.

  • Avoid concurrent use with other medications that prolong QT interval.

Sexual dysfunction

Note: Common in all genders.

Nursing actions: The client can need dosage lowered or be switched to a high-potency agent.

Client education

  • Observe for possible adverse effects.

  • Report effects to the provider.

Skin effects

Manifestations

  • Photosensitivity that can result in severe sunburn

  • Contact dermatitis from handling medications

Client education

  • Avoid excessive exposure to sunlight, use sunscreen, and wear protective clothing.

  • Avoid direct contact with the medication.

Liver impairment

Nursing actions

  • Monitor baseline liver function, and monitor periodically.

  • Inform clients to observe for indications (anorexia, nausea, vomiting, fatigue, abdominal pain, jaundice) and to notify the provider.

Contraindications/Precautions

  • These medications are contraindicated in clients who are in a coma or have Parkinson’s disease, liver damage, or severe hypotension.

  • Use of conventional antipsychotic medications is contraindicated in older adult clients who have dementia. G

  • Use cautiously in clients who have prostate enlargement, heart disorders, glaucoma, paralytic ileus, liver disease, kidney disease, or seizure disorders.

Interactions

Concurrent use with other anticholinergic medications increases effects.

Client education: Avoid over-the-counter medications that contain anticholinergic agents (sleep aids and antihistamines).

Additive CNS depressant effects with concurrent use of alcohol, opioids, and antihistamines.

Client education

  • Avoid alcohol and other medications that cause CNS depression.

  • Avoid hazardous activities, such as driving.

By activating dopamine receptors, levodopa counteracts effects of antipsychotic agents.

Client education: Avoid concurrent use of levodopa and other direct dopamine receptor agonists.

Nursing Administration

  • Use the Abnormal Involuntary Movement Scale (AIMS) to screen for the presence of EPSs.

  • Monitor the client to differentiate between EPSs and worsening of a psychotic disorder.

  • Administer anticholinergics, beta blockers, and benzodiazepines to control early EPS. If adverse effects are intolerable, a client can be switched to a low-potency or atypical antipsychotic agent. 

  • Consider depot preparations (haloperidol decanoate, fluphenazine decanoate), administered IM once every 2 to 4 weeks, for clients who have difficulty maintaining a medication regimen. Inform the client that lower doses can be used with depot preparations, which will decrease the risk of adverse effects and the development of tardive dyskinesia. QPCC

  • Begin administration with twice-daily dosing, but switch to daily dosing at bedtime to decrease daytime drowsiness and promote sleep.

Client education

  • Antipsychotic medications rarely cause physical or psychological dependence.

  • Take medication as prescribed and on a regular schedule.

  • Some therapeutic effects can be noticeable within a few days, but significant improvement can take 2 to 4 weeks, and possibly several months for full effects.

Antipsychotics: Second- and third-generation (atypical)

Select Prototype Medication: Risperidone

Other Medications

  • Asenapine

  • Clozapine

  • Iloperidone

  • Lurasidone

  • Olanzapine

  • Paliperidone

  • Quetiapine

  • Ziprasidone

  • Aripiprazole (third generation)

  • Cariprazine (third generation)

  • Brexpiprazole (third generation)

Purpose

Expected Pharmacological Action

These antipsychotic agents work mainly by blocking serotonin, and to a lesser degree, dopamine receptors. These medications also block receptors for norepinephrine, histamine, and acetylcholine. The third-generation medications work by stabilizing the dopamine system as both an agonist and antagonist.

Therapeutic Uses

  • Negative and positive symptoms of schizophrenia spectrum disorders

  • Psychosis induced by levodopa therapy

  • Relief of psychotic manifestations in other disorders, such as bipolar disorder

  • Impulse control disorders

Complications

Agranulocytosis

Nursing actions

  • Advise clients to observe for indications of infection.

  • If indications of infection appear, obtain a CBC.

  • Onset is gradual and usually occurs during the first 6 months of therapy.

  • Can occur with chlorpromazine.

Metabolic syndrome

  • New onset of diabetes mellitus or loss of glucose control in clients who have diabetes

  • Dyslipidemia with increased risk for hypertension and other cardiovascular disease

  • Weight gain

Nursing actions

  • Obtain baseline fasting blood glucose, and monitor the value periodically throughout treatment.

  • Monitor cholesterol, triglycerides, and blood glucose if weight gain is greater than 14 kg (31 lb).

Client education

  • Report indications (increased thirst, urination, appetite), to the provider.

  • Follow a healthy, low-calorie diet, engage in regular exercise, and monitor weight gain.

Orthostatic hypotension

Nursing actions

  • Monitor blood pressure and heart rate for orthostatic changes.

  • Hold medication while notifying the provider of significant changes.

Anticholinergic effects

Such as urinary hesitancy or retention, dry mouth

Nursing actions

  • Monitor for these adverse effects, and report their occurrence to the provider.

  • Encourage the client to use measures to relieve dry mouth, such as sipping water throughout the day.

Agitation, dizziness, sedation, sleep disruption

Nursing actions

  • Monitor for these adverse effects, and report their occurrence to the provider.

  • Administer an alternative medication if prescribed.

Mild EPS, such as tremor

Nursing actions

  • Monitor for and instruct clients to recognize EPS.

  • Use AIMS test to screen for EPS.

Elevated prolactin levels

Nursing actions: Obtain prolactin level if indicated.

Client education: Observe for galactorrhea, gynecomastia, and amenorrhea, and notify the provider if these occur.

Sexual dysfunction

Anorgasmia, impotence, low libido

Client education

  • Observe for possible sexual adverse effects.

  • Notify provider if intolerable.

  • Methods for managing sexual dysfunction can include using adjunct medications to improve sexual function, such as sildenafil.

Contraindications/Precautions

Risperidone

  • These medications should not be used for clients who have dementia. Use of these medications can cause death related to cerebrovascular accident or infection. QS

  • Clients should avoid the concurrent use of alcohol.

  • Use cautiously in clients who have cardiovascular or cerebrovascular disease, seizures, or diabetes mellitus. Clients who have diabetes mellitus should have a baseline fasting blood sugar, and blood glucose should be monitored carefully.

Other Atypical Antipsychotic Agents

Aripiprazole (third-generation antipsychotic)

  • Tablets

  • Orally disintegrating tablets

  • Oral solution

  • Short-acting injectable

  • Long-acting injectable

Nursing actions

  • Low or no risk of EPS

  • Low or no risk of diabetes, weight gain, dyslipidemia, orthostatic hypotension, and anticholinergic effects

Adverse effects

  • Sedation

  • Headache

  • Anxiety

  • Insomnia

  • Gastrointestinal upset

Asenapine

Sublingual tablets

Nursing actions: Low risk of diabetes, weight gain, dyslipidemia, and anticholinergic effects. Warn clients not to swallow tablets, and instruct to avoid eating and drinking for 10 minutes after dosing

Other adverse effects

  • Drowsiness

  • Prolonged QT interval

  • EPS (higher doses)

  • Causes temporary numbing of the mouth

Clozapine

The first atypical antipsychotic developed, it is no longer considered a first-line medication for schizophrenia spectrum disorders due to its adverse effects.

  • Tablets

  • Orally disintegrating tablets

Nursing actions

  • Low risk of EPS

  • High risk of weight gain, diabetes, and dyslipidemia

  • Risk for fatal agranulocytosis, typically occurs within the first 6 months with gradual onset

  • Baseline and regular monitoring of WBC per protocol (weekly, bi-weekly, then monthly) required

  • Notification of the provider of indications of infection (fever, sore throat, mouth lesions) is necessary

Other adverse effects

  • Sedation

  • Orthostatic hypotension

  • Hypersalivation

  • Anticholinergic effects

Iloperidone

Tablets

Nursing actions

  • Significant risk for weight gain, prolonged QT interval, and orthostatic hypotension

  • Low risk for diabetes, dyslipidemia, and EPS

Client education: Follow titration schedule during initial therapy to minimize hypotension.

Common adverse effects

  • Dry mouth

  • Sedation

  • Fatigue

  • Nasal congestion

Lurasidone

Tablets

Nursing actions

  • Low risk for diabetes, weight gain, and dyslipidemia.

  • Does not cause anticholinergic effects.

  • Administer with food, at least 350 kcals, for maximum absorption.

Common adverse effects

  • Sedation

  • Akathisia

  • Parkinsonism

  • Agitation and anxiety

  • Nausea

Olanzapine

  • Orally disintegrating tablets

  • Short-acting injectable

  • Extended-release injection

Nursing actions

  • Low risk of EPS

  • High risk of diabetes, weight gain, and dyslipidemia

Other adverse effects

  • Sedation

  • Orthostatic hypotension

  • Anticholinergic effects

! Following administration of extended-release injection, the client requires observation for at least 3 hr to monitor for adverse effects.

Paliperidone

  • Extended-release tablets

  • Extended-release injections

Nursing actions: Significant risk for diabetes, weight gain, and dyslipidemia

Other adverse effects

  • Sedation

  • Prolonged QT interval

  • Orthostatic hypotension

  • Anticholinergic effects

  • Mild EPS

Quetiapine

  • Tablets

  • Extended-release tablets

Nursing actions

  • Low risk of EPS

  • Moderate risk of diabetes, weight gain, and dyslipidemia

Other adverse effects

  • Cataracts

  • Sedation

  • Orthostatic hypotension

  • Anticholinergic effects

Ziprasidone

This medication affects both dopamine and serotonin, so it can be used for clients who have concurrent depression.

  • Capsules

  • Short-acting injectable

Nursing actions

  • Low risk of EPS

  • Low risk of diabetes, weight gain, and dyslipidemia

  • For maximum absorption, administer with food

Other adverse effects

  • Sedation

  • Orthostatic hypotension

  • Anticholinergic effects

  • ECG changes and QT prolongation that can lead to torsades de pointes

Interactions

Immunosuppressive medications, such as anticancer medications, can further suppress immune function.

Nursing actions: Avoid use in clients who are taking clozapine.

Additive CNS depressant effects can occur with concurrent use of alcohol, opioids, antihistamines, and other CNS depressants.

Client education

  • Avoid alcohol and other medications that cause CNS depression.

  • Avoid hazardous activities, such as driving.

By activating dopamine receptors, levodopa counteracts the effects of antipsychotic agents.

Nursing actions: Avoid concurrent use of levodopa and other direct dopamine receptor agonists.

Tricyclic antidepressants, amiodarone, and clarithromycin prolong QT intervals, thereby increasing the risk of cardiac dysrhythmias.

Nursing actions: Atypical antipsychotics that prolong the QT interval should not be used concurrently with other medications that have the same effect.

Barbiturates and phenytoin stimulate hepatic medication-metabolizing enzymes, thereby decreasing medication levels of aripiprazole, quetiapine, and ziprasidone.

Nursing actions: Monitor medication effectiveness.

Fluconazole inhibits hepatic medication-metabolizing enzymes, thereby increasing medication levels of aripiprazole, quetiapine, and ziprasidone.

Nursing actions: Monitor medication effectiveness.

Nursing Administration

Risperidone also is available as a depot injection administered IM once every 2 weeks, and the extended-release injection of paliperidone is administered every 28 days. LAI Invega Trinza is administered every 3 months (paliperidone palmitate: generic). Aripiprazole also has a long-acting injectable which is administered on a monthly basis. This method of administration is a good option for clients who have difficulty adhering to a medication schedule. Therapeutic effect occurs 2 to 6 weeks after first depot injection.

  • Use oral disintegrating tablets for clients who can attempt to “cheek” or “pocket” tablets, or for those who have difficulty swallowing them.

  • Administer lurasidone and ziprasidone with food to increase absorption.

  • The cost of antipsychotic medications can be a factor for some clients. Monitor the need for case management intervention. QTC​​​​​​​

Client education

  • Low doses of medication are given initially, and dosages are then gradually increased. (“Start low and go slow.”)

  • If taking asenapine, avoid eating or drinking for 10 min after each dose

Determine which category each medication listed below belongs.

Drag each medicate to the desired image. If you select the wrong category, the description will automatically move to the correct category.

Risperidone

Haloperidol

Quetiapine

Loxapine

Olanzapine

Clozapine

Typical Antipsychotics

Atypical Antipsychotics

Antidepressants

Used to treat the depression seen in many clients who have a psychotic disorder.

  • Paroxetine

Nursing Actions

  • Used temporarily to treat depression associated with psychotic disorders.

  • Monitor the client for suicidal ideation because this medication can increase thoughts of self-harm, especially when first taking it. QS

  • Notify the provider of any adverse effects (deepened depression).

Client education: Avoid abrupt cessation of this medication to avoid a withdrawal effect.

Mood stabilizing agents and benzodiazepines

Used to treat the anxiety often found in clients who have psychotic disorders, as well as some of the positive and negative symptoms.

  • Valproate

  • Lamotrigine

  • Lorazepam

Nursing Actions: Use these medications with caution in older adult clients.

Client Education

  • Medication could have sedative effects.

  • Case management to provide follow up for the client and family. QTC​​​​​​​

  • Group, family, and individual psychoeducation to improve problem-solving and interpersonal skills.

  • Social skills training focuses on reinforcing teaching about social and ADL skills.

Reinforce Health teaching regarding the following

  • Understanding of the disorder

  • Need for self-care to prevent relapse

  • Medication effects, adverse effects, and importance of compliance

  • Importance of attending support groups

  • Abstinence from the use of alcohol and/or other substances

  • Keeping a log or journal of feelings and changes in behavior to help monitor medication effectiveness

Nursing Evaluation of Medication Effectiveness

Depending on therapeutic intent, effectiveness can be evidenced by the following.

  • Improvement and/or prevention of acute psychotic manifestations, absence of hallucinations, delusions, anxiety, hostility

  • Improvement in ability to perform ADLs

  • Improvement in ability to interact socially with peers

  • Improvement of sleeping and eating habits

Active Learning Scenario

A nurse is caring for a client who has schizophrenia and is reviewing discharge instructions which include a new prescription for risperidone. Use the ATI Active Learning Template: Medicationto complete the following.

Therapeutic Use: Identify the therapeutic uses of risperidone.

Client Education: Describe at least three education points.

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Active Learning Scenario Key

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