1. Introduction to Clinical Pharmacology Chapter 23 Antipsychotic Drugs

2. Introduction
Psychosis refers to a spectrum of disorders that affect mood and behavior
Schizophrenia is most recognized disorder characterized by disordered thinking, perceptual disturbance, behavioral abnormality, affective problems, and impaired socialization; symptoms can be positive or negative Box 23.1

4. Introduction Positive and Negative Symptoms in Schizophrenia

5. Antipsychotic Drugs: Actions
Inhibit or block release of neurotransmitter dopamine; increase firing of nerve cells in certain areas of brain; produce unpleasant extrapyramidal effects
first-generation antipsychotics (FGAs) work to diminish the positive symptoms-chlorpromazine, haloperidol (Haldol), and fluphenazine
Atypical antipsychotics: Also called second generation antipsychotics-helps to both diminish the positive symptoms and enhance behaviors to reduce the negative symptoms-clozapine (Clozaril) and aripiprazole (Abilify)
Believed that they act on serotonin receptors as well as dopamine receptors in brain

7. Antipsychotic Drugs: Uses
Used for the treatment of:
Acute and chronic psychoses such as schizophrenia; bipolar illness; agitated behaviors associated with dementia
Chlorpromazine: used to treat uncontrollable hiccoughs
Chlorpromazine and prochlorperazine are used as antiemetics

8. Antipsychotic Drugs: Adverse Reactions #1
Generalized system reactions:
Sedation; headache; hypotension; dry mouth; nasal congestion; urticaria; photophobia; photosensitivity
Behavioral changes:
Intensity of the psychotic symptoms; lethargy; hyperactivity; paranoid reactions; agitation; confusion
Recidivism-becomes a “revolving door” of hospitalizations and discharges; major concern is adherence; takes about 6 to 10 weeks for effects to be seen; some adverse reactions unpleasant and stops medications causing psychotic symptoms such as hallucinations, anhedonia, delusions, and a flattened affect return

9. Antipsychotic Drugs: Adverse Reactions #2
Extrapyramidal syndrome:
Reactions occurring on extrapyramidal portion of nervous system
Antipsychotics: abnormal muscle movement such as fine tremors
Extrapyramidal effects: akathisia, dystonia (muscles rigidity)
Extrapyramidal effects diminish with reduction in the dosage
May be given aripiprazole and clozapine are classified as atypical antipsychotics since they are SGA and help to lessen the extrapyramidal effects.

10. Antipsychotic Drugs: Adverse Reactions #3
Tardive dyskinesia:
Consists of irreversible, involuntary dyskinetic movements
Characterized by rhythmic, involuntary movements of the tongue, face, mouth, jaw, extremities
Less likely w/atypical psychotics and can occur after antipsychotic drugs discontinued
Neuroleptic malignant syndrome:
Combination of extrapyramidal effects, hyperthermia, autonomic disturbance

11. Antipsychotic Drugs: Contraindications and Precautions #1
Contraindicated in clients:
With hypersensitivity; who are comatose; who are severely depressed; with bone marrow depression; with blood dyscrasias; with Parkinson disease; with liver impairment; with coronary artery disease; with severe hypotension or hypertension
Used when potential good outweighs any potential harm to fetus

12. Antipsychotic Drugs: Contraindications and Precautions #2
Used cautiously in patients with:
Respiratory disorders, glaucoma, prostatic hypertrophy, epilepsy, decreased renal function, and peptic ulcer disease

13. Antipsychotic Drugs: Interactions
Interactant drug
Effect of interaction
Anticholinergic drugs
Increased risk for TD and psychotic symptoms
Immunologic drugs
Increased severity of bone marrow suppression
Alcohol
Increased risk for CNS depression

14. Nursing Process: Assessment #1
Preadministration assessment:
Assess patient’s mental status
Note and record presence of hallucinations or delusions; agitation
Obtain complete mental health, social, and medical history; behavior patterns such as poor eye contact, failure to answer questions completely, inappropriate answers to questions, a monotone speech pattern, and inappropriate laughter, sadness, or crying
Assess blood pressure; pulse; respiratory rate; weight
Review lab work especially WBC

15. Nursing Process: Assessment #2
Preadministration assessment (cont.)
Outpatients:
Obtain complete medical history and history of symptoms of mental disorder
Observe patient’s behavior pattern
Assess vital signs and body weight

16. Nursing Process: Assessment #3
Ongoing assessment:
Determine therapeutic drug effects; monitor adverse reactions
Assess response to drug therapy around the clock for inpatients
Accurate assessments for adverse drug effects

17. Nursing Process: Nursing Diagnoses and Planning
Risk for Injury; Impaired Physical Mobility; Risk for Infection; Risk for Unstable Blood Glucose Level
The expected outcome includes an optimal response to therapy:
Reason for drug administration
Meeting of patient needs related to management of adverse drug reactions
Compliance with prescribed treatment regimen

18. Nursing Process: Implementation #1
Promoting an optimal response to therapy:
Managing care of the inpatient:
Record behavioral changes
Poor response to drug therapy: requires dosage changes or a drug change
Violent behavior; refuses medication; refuses to have oral cavity inspection may warrant giving drug parentally; ensure client reassessed after 30 min of receiving injection
Inspect oral cavity to make sure drug is swallowed

19. Nursing Process: Implementation #2
Promoting an optimal response to therapy (cont.)
Managing care of the inpatient (cont.)
Patient refuses to take drug: contact primary health care provider
Use oral liquid for patients who have problems swallowing

20. Nursing Process: Implementation #3
Promoting an optimal response to therapy (cont.)
Managing care of the outpatient:
Observe patient for response to therapy; ask questions of client and family
Ask about adverse drug reactions; notify primary health care provider about problems; document a summary of patient’s behavior; record and compare with previous observations

21. Nursing Process: Implementation #4
Monitoring and managing patient needs:
Offer frequent sips of water; assist patient out of bed or chair; supervise all ambulatory activities
Risk for injury:
Provide total assistance with activities of daily living; monitor vital signs
Report significant change in vital signs to primary health care provider

22. Nursing Process: Implementation #5
Monitoring and managing patient needs (cont.)
Impaired physical mobility:
Observe adverse drug reactions
Use Abnormal Involuntary Movement Scale (AIMS)
Report to primary health care provider change in behavior or appearance of adverse reactions

23. Nursing Process: Implementation #6
Monitoring and managing patient needs (cont.)
Impaired physical mobility (cont.)
Observe for extrapyramidal effects
Assists with ambulation; reassure patient that symptoms will decline
Risk for infection:
Monitor weekly WBC count; monitor for adverse reactions that indicate bone marrow suppression

24. Nursing Process: Implementation #7
Educating the patient and family:
Evaluate patient’s ability to assume responsibility for taking drugs at home
Points in teaching plan:
Keep all primary health care provider and clinic appointments
Report any unusual changes or physical effects
Take drug exactly as directed

25. Nursing Process: Implementation #8
Educating the patient and family (cont.)
Do not drive or perform other hazardous tasks if drowsiness occurs
Do not take any nonprescription drugs
Inform physicians, dentists, and other medical personnel of therapy
Do not drink alcoholic beverages

26. Nursing Process: Implementation #9
Educating the patient and family (cont.)
Take frequent sips of water, suck on hard candy, or chew gum
Notify your primary health care provider if pregnant or intending to become pregnant during therapy
Report adverse reactions
Avoid exposure to sun

27. Nursing Process: Implementation #10
Educating the patient and family (cont.)
Note that only a 1-week supply of clozapine is dispensed at a time. The drug is obtained through a special program designed to ensure the required blood monitoring
Note that olanzapine is available as a tablet to swallow or as an orally disintegrating tablet and hands should be thoroughly dry when handling tablet

28. Nursing Process: Evaluation #1
The therapeutic effect is achieved
Adverse reactions are identified, reported, and managed
No evidence of injury
Patient verbalizes an understanding of treatment modalities and the importance of continued follow- up care

29. Nursing Process: Evaluation #2
Patient verbalizes the importance of complying with the prescribed therapeutic regimen
Patient and family demonstrate understanding of the drug regimen

30. Question #1 How many weeks’ worth of clozapine is dispensed at a time?
A. 1 week
B. 2 weeks
C. 3 weeks
D. 4 weeks

31. Answer to Question #1 A
Note that only a 1-week supply of clozapine is dispensed at a time. The drug is obtained through a special program designed to ensure the required blood monitoring. Weekly WBC laboratory tests are required. Any signs of weakness, fever, sore throat, malaise, or flu-like symptoms should immediately be reported to the primary health care provider.

32. Question #2 Is the following statement true or false?
Olanzapine is available as a disintegrating tablet.

33. Answer to Question #2 True
Note that olanzapine is available as a disintegrating tablet. If using the orally disintegrating tablet, peel back the foil on the blister packaging. Using dry hands, remove the tablet, and place the entire tablet in the mouth. The tablet will disintegrate immediately with or without liquid.

34. Question #3 Is the following statement true or false?
Psychosis is a spectrum of moods and behaviors, with schizophrenia being the most recognized.

35. Answer to Question #3 True
Psychosis is a spectrum of moods and behaviors, with schizophrenia being the most recognized. Symptoms of the disease are categorized as positive and negative. Antipsychotic medications are designed to diminish the behaviors so people can function in society.