2. Antidepressant / Anxiolytic Antidepressant / Anxiolytic escitalopram (Lexapro) Tri-Cyclic Antidepressant MAOIs Benzodiazepines lorazepam (Ativan) diazepam (Valium) GABA Antagonist A zolpidem (Ambien) Phenytoin-Like Drugs Phenytoin-Like Drugs Succinimides Barbiturates phenobarbital (Luminal) phenytoin (Dilantin) valproic acid (Depakote) ethosuximide (Zarontin) Phenothiazines chlorpromazine (Thorazine) Non-Phenothiazines halperidol (Haldol) Atypical Antipsychotics risperidone (Risperdal) Opioids Opioid Antagonists naloxone (Narcan) morphine (Infumorph) Salicylates aspirin (ASA) NSAIDs ibuprofen (Motrin) Non-Opioid acetaminophen (Tylenol) Central Acting tramadol (Ultram) Anti-Migraine ergotamine (Cafergot) Sumatriptan (Imitrex) OVERVIEW: Neuro System

3. Psychoses Severe mental and behavioral disorders characterized by: Delusions Hallucinations Illusions Paranoia Acute episode – occur over hours or days Chronic episode – develop over months or years

4. Factors Attributed to Development of Psychoses Genetic Neurological Environmental

5. Schizophrenia Abnormal thoughts and thought processes Disordered communication Withdrawal from other people and outside environment Severe depression High risk for suicide Most common psychotic disorder Manifests in men aged 15 to 24 years Manifests in women in aged 25 to 34 years

6. Symptoms of Schizophrenia Variety of symptoms that may change over time Hallucinations, delusions, or paranoia Strange and irrational behavior, actions Rapid alteration between extreme hyperactivity and stupor Attitude of indifference; detachment Deterioration of hygiene, job, academic performance Withdrawal from social and interpersonal relationships Characterized by positive and negative symptoms Positive: add on to normal behavior Negative: subtract from normal behavior Diagnosis of positive and negative symptoms important for selection of appropriate drug

7. Causes of Schizophrenia Cause yet to be determined Genetic Neurotransmitter imbalance Symptoms seem to be associated with dopamine type 2 receptor in brain Antipsychotic drugs enter dopaminergic synapses and compete with dopamine

8. Conditions That May Mimic the Behaviors of Schizophrenia Drug use Brain neoplasm Infections Hemorrhage

9. Selection of Antipsycotics No single drug of choice Selection of drug type depends on Clinician experience Side effects Patient needs

10. Categories of Antipsychotic Drugs Conventional antipsychotic Phenothiazines and phenothiazine-like drugs Atypical antipsychotic Nonphenothiazines

11. Patient Drug Compliance Goal is to reduce psychotic symptoms so patients have ability to self-care Drugs do not cure mental illness Patients must continue drug regimen to remain in remission Relapse rate for those who discontinue medication is 60% to 80%

12. Role of the Nurse Monitor client’s condition Give client drug education Obtain health history (long-term physical problems) Obtain drug history (use of illegal drugs, alcohol, etc.) Obtain baseline assessment (liver and kidney function, vision, mental status) Monitor for extrapyramidal symptoms, and report to the physician immediately

13. Conventional (Typical) Antipsychotics Monitor for decrease of psychotic symptoms, side effects Monitor for anticholinergic side effects Monitor for alcohol, illegal-drug, caffeine, and nicotine use Monitor for cardiovascular changes Monitor for seizures and patient’s environment

14. Conventional (Typical) Antipsychotics (continued) Monitor for decrease of psychotic symptoms, side effects Monitor for anticholinergic side effects Monitor for alcohol, illegal-drug, caffeine, and nicotine use Monitor for cardiovascular changes Monitor for seizures and patient’s environment

15. Atypical Antipsychotic Monitor RBC and WBC and hematologic side effects Observe for side effects and anticholinergic side effects Monitor for decrease of psychotic symptoms Monitor for alcohol, illegal-drug use, caffeine, nicotine use Monitor elderly closely

16. Extrapyramidal Symptoms (EPS) Tremor, muscle rigidity, stooped posture (pseudoparkinsonism) Muscle spasms of face, tongue, neck or back (acute dystonias) Inability to rest and relax; pacing (akathisia) Lip smacking; wormlike movements of the tongue; uncontrolled chewing and grimacing (tardive dyskinesias)

17. Neuroleptic Malignant Syndrome (NMS) Client suffers a toxic reaction to therapeutic doses of antipsychotic drug Client exhibits Elevated temperature Unstable blood pressure Profuse sweating Dyspnea Muscle rigidity Incontinence

18. Phenothiazines Prototype drug: chlorpromazine HCI (Thorazine) Mechanism of action: blocks positive symptoms of schizophrenia Primary use: for severe mental illness Adverse effects: acute dystonia, akathisia, Parkinsonism, tardive dyskinesia, anticholinergic effects, sedation, hypotension, sexual dysfunction, and neuroleptic malignant syndrome

20. Prototype Drug: Chlorpromazine hydrochloride

21. Nonphenothiazines Prototype drug: haloperidol (Haldol) Mechanism of action: blocking of the dopamine type 2 receptor Primary use: severe mental illness Adverse effects: identical to that of phenothiazines

23. Prototype Drug: Haloperidol

24. Atypical Antipsychotics Prototype drug: risperidone (Risperdal) Mechanism of action: block dopamine type 2 receptors, serotonin and alpha-adrenergic receptors Primary use: severe mental illness; treats both positive and negative symptoms Adverse effects: fewer than those of phenothiazines and nonphenothiazines, but obesity and its risk factors need to be monitored

25. Atypical Antipsychotics (continued) Dopamine System Stabilizers Newest antipsychotic class Aripiprazole (Abilify) controls both positive and negative symptoms Serious side effects compared to other antipsychotic drugs is low

27. Prototype Drug: Risperidone

28. Conventional (Typical) Antipsychotic Agents Phenothiazines Action blocks positive symptoms Mellaril, Compazine, Permitil Nonphenothiazines Action same as that of phenothiazines Taractan, Loxitane, Navane

29. Atypical Antipsychotics Treats both the positive and negative symptoms Less dramatic side effects, but still significant Examples: Seroquel, Risperdal, Zyprexa

30. Nursing Process Focus: Patients Receiving Atypical Antipsychotic Therapy

32. NCLEX-RN Review Question 1 The patient states that he has not taken his antipsychotic drug for the past 2 weeks because it was causing sexual dysfunction. The name antipsychotic explains that continuing the medication as prescribed is important because: 1.Hypertensive crisis may occur with abrupt withdrawal. 2.Muscle twitching may occur. 3.Parkinson-like symptoms will occur. 4.Symptoms of psychosis are likely to return.

33. NCLEX-RN Review Question 1 – Answer 1.Hypertensive crisis may occur with abrupt withdrawal. 2.Muscle twitching may occur. 3.Parkinson-like symptoms will occur. 4.Symptoms of psychosis are likely to return.

34. NCLEX-RN Review Question 1 – Rationale Rationale: Symptoms of psychosis are likely to return and manifest as agitation, distrust, and frustration.

35. NCLEX-RN Review Question 2 Prior to discharge, the nurse provides teaching related to side effects of phenothiazines to the patient, family, or caregiver. Which of the following should be included? 1.The patient may experience withdrawal and slowed activity. 2.Severe muscle spasms may occur early in therapy. 3.Tardive dyskinesia is likely early in therapy. 4.Medications should be taken as prescribed to prevent side effects.

36. NCLEX-RN Review Question 2 – Answer 1.The patient may experience withdrawal and slowed activity. 2.Severe muscle spasms may occur early in therapy. 3.Tardive dyskinesia is likely early in therapy. 4.Medications should be taken as prescribed to prevent side effects.

37. NCLEX-RN Review Question 2 – Rationale Rationale: Acute dystonias occur early in the course of therapy. These are severe muscle spasms, particularly of the back, neck, tongue, and face.

38. NCLEX-RN Review Question 3 A 20-year-old man is admitted to the in-patient psychiatric unit for treatment of acute schizophrenia and is started on risperidone (Risperdal). Therapeutic outcomes of this drug will include: 1.Restful sleep, elevated mood, and coping abilities 2.Decreased delusional thinking and lessened auditory/visual hallucinations 3.Orthostatic hypotension, reflex tachycardia, and sedation 4.Relief of anxiety and improved sleep and dietary habits

39. NCLEX-RN Review Question 3 – Answer 1.Restful sleep, elevated mood, and coping abilities 2.Decreased delusional thinking and lessened auditory/visual hallucinations 3.Orthostatic hypotension, reflex tachycardia, and sedation 4.Relief of anxiety and improved sleep and dietary habits

40. NCLEX-RN Review Question 3 – Rationale Rationale: Antipsychotic drugs such as risperiodne (Risperdal) treat the positive and negative effects of the underlying mental disorder.A decrease in delusional thinking, lessened hallucinations, and overall improvement in mental thought processes should be noted. Improvement in sleep patterns, anxiety, and nutrition may be noted as secondary effects of treatment of the underlying thought disorder. Orthostatic hypotension, reflex tachycardia, or sedation are potential adverse effects.

41. NCLEX-RN Review Question 5 Which of the following data collected by the nurse during the history and physical is a contraindication for a patient to receive fluphenazine (Permitil, Prolixin)? 1.Diabetes mellitus 2.Age older than 70 3.Bone marrow depression 4.Hypertension

42. NCLEX-RN Review Question 5 – Answer 1.Diabetes mellitus 2.Age older than 70 3.Bone marrow depression 4.Hypertension

43. NCLEX-RN Review Question 5 – Rationale Rationale: Fluphenazine (Prolixin) is a phenothiazine drug. Use is contraindicated in patients with CNS depression, bone marrow depression, and alcohol withdrawal.

44. NCLEX-RN Review Question 6 A female, age 39, has been on haloperidol (Haldol) for 3 months for severe psychosis. The nurse is monitoring the patient for the development of acute dystonias with haloperidol, and will monitor for: 1.Dry mouth, constipation, and blurred vision 2.Pacing, squirming, or difficulty with gait such as bradykinesia 3.Severe spasms of the muscles of the tongue, face, neck, or back 4.Tremors, wormlike tongue movements, and involuntary lip puckering

45. NCLEX-RN Review Question 6 – Answer 1.Dry mouth, constipation, and blurred vision 2.Pacing, squirming, or difficulty with gait such as bradykinesia 3.Severe spasms of the muscles of the tongue, face, neck, or back 4.Tremors, wormlike tongue movements, and involuntary lip puckering

46. NCLEX-RN Review Question 6 – Rationale Rationale: Acute dystonias are characterized by acute spasms of the face, tongue, neck, or back. Dry mouth, constipation, and blurred vision are adverse effects related to anticholinergic activity. Pacing and squirming are signs of akathisia, and bradykinesia and tremors are symptoms of pseudoparkinsonism. Involuntary lip-puckering and wormlike movements of the tongue are symptomatic of tardive dyskinesias.

48. Drug Therapy for Psychoses Assessment Monitor client’s condition Obtain health assessment Ascertain past mental illness Obtain information on smoking and use of illegal drugs, alcohol, and caffeine Ascertain current medications and dietary habits Obtain baseline blood and urine samples Assess family’s knowledge of psychoses and medication regimen

49. Drug Therapy for Psychoses (continued) Planning Goal is to remain compliant with medication regimen and free of symptoms Implementation Encourage compliance with medication regimen Provide additional education

50. Drug Therapy for Psychoses (continued) Evaluation Client to remain free of symptoms related to psychoses Client to verbalize importance of taking prescribed medications

51. Nursing Process Focus: Patients Receiving Conventional Antipsychotic Therapy

58. Nursing Process Focus: Patients Receiving Atypical Antipsychotic Therapy