1. Drugs Used for Psychoses Chapter 18 Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

2. Slide 2 Chapter 18 Lesson 18.1 Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

3. Slide 3 Objectives Identify signs and symptoms of psychotic behavior Describe major indications for the use of antipsychotic agents Identify common adverse effects observed with antipsychotic medications Develop a teaching plan for a patient taking haloperidol and one receiving clozapine Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

4. Slide 4 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 Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

5. Slide 5 Symptoms of Psychosis Delusions Hallucinations Disorganized thinking Disorganized behavior Changes in affect Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

6. Slide 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 Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

7. Slide 7 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 Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

8. Slide 8 Drug Therapy Antipsychotic (neuroleptic) agents classified as:  Phenothiazines and nonphenothiazines  Low potency and high potency – refers to the milligram dose  Typical or atypical – refers to first and second generation agents Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

9. Slide 9 Antipsychotic Agents Actions:  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) Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

10. Slide 10 Antipsychotic Agents (cont’d) Two types – typical and atypical Typical (examples)  Phenothiazines  Nonphenothiazines  Thioxanthenes Atypical (examples)  Aripiprazole (Abilify)  Olanzapine (Zyprexa)  Risperidone (Risperdal) Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

11. Slide 11 Common Adverse Effects of Antipsychotic Agents Chronic fatigue/drowsiness Orthostatic hypotension Blurred vision Constipation Urinary retention Dry mouth/throat/nose Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

12. Slide 12 Serious Adverse Effects of Antipsychotic Agents Seizure activity Parkinsonian symptoms Tardive dyskinesia Hepatotoxicity Blood dyscrasias Hives, pruritus, rash Photosensitivity Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

13. Slide 13 Serious Adverse Effects of Antipsychotic Agents (cont’d) 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 Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

14. Slide 14 Drug Interactions with Antipsychotic Agents Increase toxic effects  Antihistamines  Alcohol  Analgesics  Tranquilizers  St. John’s wort Decrease therapeutic effects  Carbamazepine  Cimetidine  Phenytoin  Insulin/oral hypoglycemic medications  Venlafaxine Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

15. Slide 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 Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

16. Slide 16 Patient Education and Health Promotion for Haloperidol (Haldol) Create individualized interventions Provide safe, structured, and accepting environment Provide opportunity for expression Allow opportunity for patient to make decisions (if capable) Involve the patient in self-care activities Do not reinforce hallucinations, delusions Be open and direct when handling suspicious patients Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

17. Slide 17 Patient Education and Health Promotion for Clozapine (Clozaril) Set limits and enforce them kindly Provide diversionary activities for patients with altered perceptions Monitor suicidal patients Use physical restraints within guidelines Provide for nutritional needs Handle manipulative behavior in consistent manner Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.