CHAPTER 76: PSYCHIATRIC MEDICATIONS PYRAMID POINTS CHAPTER 76: PSYCHIATRIC MEDICATIONS

PYRAMID POINTS I. Selective Serotonin Reuptake Inhibitors (SSRIs) Description Inhibit serotonin uptake and elicit an antidepressant response Side effects Gastrointestinal disturbances Central nervous system (CNS) stimulation Interventions Initiate safety precautions Administer with snack or meal Monitor suicidal client Instruct client taking fluoxetine (Prozac) and bupropion (Wellbutrin) to take medication early in day Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.

PYRAMID POINTS II. Tricyclic Antidepressants Description Side effects Concurrent use with monoamine oxidase inhibitors can cause hypertensive crisis Cardiac toxicity can occur Evaluate electrocardiogram (ECG) prior to treatment, periodically thereafter Side effects Anticholinergic effects Photosensitivity Cardiovascular disturbances Hypotension Ejaculatory or erection disturbances Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.

PYRAMID POINTS continued … Interventions Instruct client that medication may take several weeks to produce desired effect Monitor suicidal client Monitor pattern of daily bowel activity Administer with food or milk Administer entire daily oral dose at one time, preferably at bedtime Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.

PYRAMID POINTS III. Monoamine Oxidase Inhibitors (MAOIs) Description Inhibits the enzyme monoamine oxidase; used to treat depression Side effects CNS stimulation Anticholinergic effects Gastrointestinal (GI) disturbances Orthostatic hypotension Hypertensive crisis Occurs as a result of consuming tyramine-containing foods or medications that interact with MAOIs Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.

PYRAMID POINTS continued … Interventions Instruct client about the importance of avoiding tyramine-containing foods in the diet Monitor blood pressure Administer with food if GI distress occurs Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.

PYRAMID POINTS IV. Mood Stabilizers Description Lithium Side effects Affect cellular transport mechanism and enhance serotonin and gamma-aminobutyric acid (GABA) functioning, which is associated with mood Lithium Common prescribed mood stabilizer Side effects GI disturbances Polyuria, polydipsia Weight gain Abdominal bloating, diarrhea Muscle weakness, fatigue Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.

PYRAMID POINTS IV. Mood Stabilizers (Continued) Interventions Monitor suicidal client, especially during improved mood and increased energy levels Administer with food Maintain adequate fluid and salt intake Avoid diuretics, alcohol, over-the-counter (OTC) medications Monitor lithium levels and for signs of toxicity Instruct client about signs requiring reporting Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.

PYRAMID POINTS V. Antianxiety or Anxiolytic Medications Description Depress CNS, producing relaxation Side effects Sedation Dizziness Hypotension Acute toxicity Results in confusion, diminished reflexes, coma Interventions Monitor for side effects and signs of toxicity Initiate safety precautions Withdrawal Should be tapered gradually over 2 to 6 weeks when discontinued to prevent withdrawal Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.

PYRAMID POINTS VI. Barbiturates and Sedative-Hypnotics Description Used for short-term treatment of insomnia or for sedation to relieve anxiety, tension, and apprehension Side effects Dizziness Drowsiness Confusion Interventions Maintain safety Instruct client to take medication exactly as prescribed and to avoid driving or operating hazardous equipment if drowsiness, dizziness, or unsteadiness occurs For insomnia, instruct client to take 30 minutes before bedtime Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.

PYRAMID POINTS VII. Antipsychotic Medications Description Side effects Improve thought processes and behaviors of the client with psychotic symptoms Side effects Anticholinergic effects Extrapyramidal effects (parkinsonism, dystonias, akathisia) Interventions Monitor for side effects Teach client about signs and symptoms to report Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.

PYRAMID POINTS VIII. Neuroleptic Malignant Syndrome Description Rare but potentially fatal syndrome that can occur at any time during therapy with neuroleptic medications Assessment Dyspnea Tachycardia Tachypnea Fever Skeletal muscle rigidity Altered level of consciousness Seizure activity Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.

PYRAMID POINTS continued … Interventions Notify physician Monitor vital signs Initiate safety and seizure precautions Treat symptoms and prepare to administer medications as prescribed Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.

PYRAMID POINTS IX. Medications to Treat Attention-Deficit/Hyperactivity Disorder (ADHD) Children with ADHD may require medication to reduce hyperactivity, lengthen attention span CNS stimulants Most effective Have calming effect on children with ADHD Increase alertness Side effects Tachycardia, anorexia, weight loss, agitation Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.

PYRAMID POINTS continued … Interventions Monitor for side effects Avoid OTC medications Instruct that last daily dose needs to be taken at least 6 hours before bedtime to prevent insomnia Monitor dietary intake and weight Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.

PYRAMID POINTS X. Medications to Treat Alzheimer’s Disease Acetylcholinesterase inhibitors improve cognitive function in early stages Donepezil (Aricept) Can slow heart rate Galantamine (Razadyne) Can cause bronchoconstriction Use with caution in clients with asthma, chronic obstructive pulmonary disease Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.

PYRAMID POINTS X. Medications to Treat Alzheimer’s Disease (continued) Memantine (Namenda) Sodium bicarbonate, other alkalinizing medications can decrease renal excretion of medication Rivastigmine (Exelon) Use with caution in clients with peptic ulcer disease, bradycardia, sick sinus syndrome, urinary obstruction, lung disease Tacrine (Cognex) Hepatotoxic; monitor liver function test results Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.

1. Maintain a fluid intake of 2 to 3 L/day. 2. Limit salt intake. A client has been started on therapy with lithium carbonate (Eskalith). The nurse instructs the client to do which of the following? 1. Maintain a fluid intake of 2 to 3 L/day. 2. Limit salt intake. 3. Limit fluid intake. 4. Stop the medication if gastrointestinal (GI) disturbances occur. Answer: 1 Rationale: The client who begins taking lithium carbonate must maintain a fluid intake between 2 and 3 L/day. The client should also maintain normal salt intake. Both of these are necessary to avoid dehydration. GI disturbances generally disappear during continued therapy. Test-Taking Strategy: Focus on the medication in the question and recall the client teaching points related to the administration of lithium. Remember that the client taking lithium carbonate must maintain a fluid intake between 2 and 3 L/day. If you had difficulty with this question, review this medication. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Pharmacology Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 699). Philadelphia: W.B. Saunders. Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.

1. Red wine, such as Chianti or sherry 2. Avocados, figs, and raisins The client has begun taking phenelzine (Nardil). At the initiation of therapy, the nurse teaches the client that which of the following items are allowed in the diet? 1. Red wine, such as Chianti or sherry 2. Avocados, figs, and raisins 3. Lunch meats, such as bologna or salami 4. Carrots, sweet potatoes, and squash Answer: 4 Rationale: Phenelzine is a monoamine oxidase inhibitor (MAOI). The client should avoid foods that are high in tyramine because they could trigger a potentially fatal hypertensive crisis. Foods to avoid include aged cheeses, smoked or processed meats, red wine, and avocados, raisins, and figs. Vegetables are generally acceptable, with the exception of broad beans, including fava beans. Test-Taking Strategy: To answer this question accurately, you must be familiar with this medication and the foods that must be avoided while it is being administered. Recalling that this medication is an MAOI will direct you to the correct option. Review the client teaching points related to the administration of MAOIs if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Pharmacology Reference: Lehne. R. (2007). Pharmacology for nursing care (6th ed., pp. 345-346). Philadelphia: W.B. Saunders. Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.