1. Chapter 17: Drugs Used for Psychoses
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2. Objectives 1. Identify the signs and symptoms of psychotic behavior.
2. Describe the major indications for the use of antipsychotic agents.
3. Discuss the antipsychotic medications used to treat psychoses.
4. Identify the common adverse effects observed with the use of antipsychotic medications.
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3. Psychosis No exact definition; term used as a clinical descriptor
Characteristics
Being out of touch with reality
Perceptual deficits like hallucinations, delusions
Deterioration in social functioning
Psychotic symptoms
Can be associated with illnesses like dementia
Common in mood disorders
Can be caused by many drugs
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4. Psychosis Schizophrenia is the most common psychotic disorder.
Psychotic disorders are influenced by biologic, psychosocial, and environmental circumstances.
May require several months of observation and testing before a final diagnosis is made.

5. Symptoms of Psychosis
Delusions-false or irrational belief (ex, grandios persecutory, sexual)
Hallucinations-false sensory perceptions that are experienced without an external stimuli and seem real to the patient
Disorganized thinking- flight of ideas
Disorganized behavior-decline in every day functioning not purposeful or non functional
Changes in affect- expressiveness is diminished
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6. Treatment of Psychosis
Focus on decreasing symptoms that most interfere with functioning
Target symptoms are critical monitoring parameters used to assess clinical status and response to drug therapy
Consider both drug and nondrug therapies
Determine baseline level of functioning
Define treatment goals in terms of decreasing the severity of target symptoms
Long-term outcome is much better with combination treatment.
Most patients have recurring symptoms for most of their lives.
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7. Drug Therapy Antipsychotic (neuroleptic) agents classified as
Phenothiazines and nonphenothiazines
Low potency and high potency—refer to the milligram dose
Typical or atypical—refers to first- and second- generation agents
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8. Antipsychotic Agents Actions Uses
Typical agents—block action of dopamine in the brain
Atypical agents—block serotonin receptors in addition to dopamine receptors
Uses
Treat psychoses associated with mental illnesses (schizophrenia, mania, psychotic depression, psychotic organic brain syndrome)
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9. Antipsychotic Agents (cont.)
Typical (1st generation)—
Phenothiazines (chlorpromazine)
Atypical (2nd generation)-
Risperidone (Risperdal)
Atypical agents block dopamine and serotonin receptors; are more effective and have fewer adverse effects than typical agents.
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10. Premedication Assessment
Blood pressure in supine, sitting, and standing positions
Electrolytes
Hepatic function
Renal function
Cardiac function
Thyroid function
Baseline clinical evaluation rating scales and adverse effect scales
Baseline clinical evaluation rating scales include BPRS, CGI, and PANSS.
Adverse effect scales include GDS and TWSTRS (for dystonias), DISCUS (for type of tardive dyskinesia), and AIMS (for extrapyramidal symptoms).
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11. Common Adverse Effects of Antipsychotic Agents
Chronic fatigue/drowsiness
Orthostatic hypotension
Blurred vision
Constipation
Urinary retention
Dry mouth/throat/nose
Sedative effects can be minimized by administering drugs at bedtime.
Other adverse effects include weight gain, hyperglycemia, dyslipidemia, and dysrhythmias.
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12. Serious Adverse Effects of Antipsychotic Agents
Seizure activity
Parkinsonian symptoms
Tardive dyskinesia
Hepatotoxicity
Blood dyscrasias
Hives, pruritus, rash
Photosensitivity
Dosage adjustments may be necessary.
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13. Serious Adverse Effects of Antipsychotic Agents (cont.)
Extrapyramidal symptoms—four types
Dystonic reactions/acute dystonia
Pseudoparkinsonism (tremor, muscular rigidity, masklike expression, shuffling gait, loss/weakness of motor function)
Akathisia (pacing, rocking, subjective feelings of anxiety and restlessness)
Tardive dyskinesia (hyperkinetic abnormal movements)
Neuroleptic malignant syndrome-characterized by fever, altered mental status, muscle rigidity, and autonomic dysfunction. Can be fatal.
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14. Drug Interactions with Antipsychotic Agents
Increase toxic effects
Antihistamines
Alcohol
Analgesics
Tranquilizers
St. John’s wart
Decrease therapeutic effects
Carbamazepine
Cimetidine
Phenytoin
Insulin/oral hypoglycemic medications
Venlafaxine
Diabetic patients must be monitored for hyperglycemia.
Beta blockers enhance hypotensive effects of antipsychotics.
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15. Nursing Assessment for Antipsychotic Therapy
History of behavior
Basic mental status
Interpersonal relationships
Mood/affect
Clarity of thoughts/perception
Thoughts of death
Psychomotor function
Sleep pattern
Dietary history
Premedication assessment is used to rule out other causes of psychosis.
Baseline assessment gathers information from the patient regarding onset, duration, and progression of symptoms.
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16. Implementations Safe, structured environment
Acceptance, encourage expression of feelings
Encourage self-care activities
Use kind, firm manner to handle inappropriate behaviors
Be open and direct with suspicious patients
High-protein, high-calorie foods for patients who are active, pace
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17. Audience Response Question 1
A patient states that voices are telling her she is evil and that she should leave the hospital. From which condition is the patient suffering?
a) Delusions
b) Hallucinations
c) Disorganized thinking
d) Change in affect
Answer: b
Rationale: Hallucinations are false sensory perceptions, without an external stimulus. It seems real to the patient.
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18. Audience Response Question 2
A patient has been admitted for further treatment of a psychotic disorder. After 5 days, the patient reports fatigue, dizziness, dry mouth, and constipation. The nurse explains to the patient that these symptoms are due to which factor related to the prescribed antipsychotic medication?
a) Toxicity
b) Common adverse effect
c) Serious adverse effects
d) Allergic response
Answer: b
Rationale: These symptoms are common adverse effects of antipsychotic medications. The nurse should implement appropriate interventions for the patient’s safety and comfort.
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19. Audience Response Question 3
A patient with a history of schizophrenia has been on antipsychotic medications for a prolonged time. The patient is exhibiting new symptoms of tremors, hypotension, and tardive dyskinesia. Laboratory results show an increase in liver enzymes. What does the nurse suspect?
a) These are common adverse effects of the medications.
b) These are serious adverse effects of the medications and the health care provider must be notified.
c) The patient has been taking increased amounts of antipsychotic medication.
d) The patient’s schizophrenia is progressing predictably.
Answer: b
Rationale: These findings are significant and require prompt reporting to the provider. Tardive dyskinesia typically appears after antipsychotic dosage reduction or discontinuation and improves when the antipsychotic dosage is increased. Early signs of tardive dyskinesia may be reversible but over time may become irreversible, even with discontinuation of the antipsychotic medication.
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20. Audience Response Question 4
A patient has been taking an antipsychotic agent for 2 days, when suddenly his eyes roll back and his jaw develops spasms. The nurse notifies the prescriber that the patient is experiencing:
a) pseudoparkinsonian symptoms.
b) akathisia.
c) tardive dyskinesia.
d) dystonia.
Answer: d
Rationale: Dystonia is characterized by jaw spasms, eyes rolled back, and neck torsion (torticollis).
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21. Audience Response Question 5
Which symptoms are most likely associated with neuroleptic malignant syndrome? (Select all that apply.)
a) Bradycardia
b) Lead-pipe rigidity
c) Hypothermia
d) Comatose state
e) Hypertension
Answer: b, d, e
Rationale: The patient with NMS has tachycardia, lead-pipe rigidity, hyperthermia, comatose state, and hypertension. The mortality rate ranges from 4% to 30%.
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