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I. ANTIPSYCHOTIC DRUGS Class Antipsychotic agents Other Nomenclature Major Tranquilizer Neuroleptic drugs Antischizophrenic drugs Indication Schizophrenia Psychotic disorders Tourettes syndrome Organic Mental disorders Main Effects Treatment of psychotic symptoms: thought disorders, perceptual disturbances, hostility, agitation, anxiety, control of tics and vocal utterances; can be used in combination with analgesics for pain management

SUMMARY OF ANTIPSYCHOTIC MEDICATIONS Classification Generic (Trade Name) Phenothiazines chlorpromazine (Thorazine) thioridazine (Mellaril) mezoridazine (Serentil) perphenazine (Trilafon) trifluoperazine (Stelazine) Fluphenazine (Prolixin) Thioxanthenes Butyrophenone Dihydroindolone Dibenzodiazepine Benzisoxazole Thienobenzoxazepine Dibenzodiazepine thiotixene (Navane) Haloperidol (Haldol) molindone (Moban) loxapine (Loxitane) risperidone (Risperidal) olanzapine (Xyprexa) Clozapine (clozaril)

Adult daily dosage range 30-200 mg 150-800 mg 30-400 mg 12-64 mg 2-40 mg 1-40 mg 8-30 mg 1-100 mg 15-225mg 20-250mg 2-6mg 5-20mg 300-900 mg

Therapeutic Notes Potent hypotensive effect May cause retinitis pigmentosa in doses above 800 mg

Available in long acting form; may be used in clients with history of noncompliance Available in long acting form; may be use din clients with history of noncompliance

Weight gain Increased risk for angranulocytosis, higher incidence of seizures reported

NURSING PROCESS RELATED TO SIDE EFFECT OF ANTIPSYCHOTIC DUGS A. Anticholinergic Effects Adverse Reaction Dry mouth Blurred vision Retinitis pigmentosa Urinary retention, hesitancy Constipation Assessment/Evaluation Subjective statement Dry cracked lips Subjective statement Use antipsychotic drugs with caution in clients with glaucoma Impaired acuity, pigmentary deposits on retina on ophthalmic exam Subjective complain Percuss bladed for distention Observe symptoms of infection Review history for underlying causes Subjective complaint Record bowel movements Observe for abdominal distention Assess for pain Auscultate for bowel sounds Assess pain Complaints of fatigue, sleepiness Increased number of hours asleep Reaction time slowed Decreased dexterity in performing tasks Complaints of palpitations, dizziness, syncope, decreased blood pressure Get a baseline sitting and standing B/P when antipsychotic medication is initiated Intervention Encourage frequent sips of water, good oral hygiene, chew sugarless gum, artificial saliva preparation Reassure client of transient nature of blurred vision Stop or change drug. Mellaril (thioridazine) should never be given in doses greater than 800 mg Instruct client to report any difficulty in urinating Record intake and output Withhold medication pending medical evaluation Encourage diet high in fiber Increase fluid intake and increase exercise Discuss possibility of stool softener with provider Withhold medication pending medical evaluation Client teaching regarding need to restrict driving or operation of machinery while feeling sedated Promote environmental safety Prevent falls due to lethargy Instruct client to rise slowly from a lying or sitting position Take blood pressure lying and standing; if more than 20 mm drop in pressure withhold doe, take B/P again, and if

Paralytic ileus Sedation

Orthostatic hypotension

Tachycardia B. Dermatologic Effects Adverse Reaction Skin rash Photosensitivity C. Hormonal Effects Adverse Reaction Decreased libido Failure to achieve orgasm Amenorrhea

Review history of cardiac disease, concurrent medication for other hypotensives

no change, notify provider prior to giving dose Notify provider for pulse above 120

Assessment/Evaluation Observe for maculopapular rash involving most of the body Sunburn on exposed areas of the skin

Intervention Hold medication dose, notify provider Instruct the client to wear protective sunscreens, clothing and sunglasses and to limit exposure time in the sun

Assessment/Evaluation Subjective complaints Serum test for pregnancy if indicated

Weigh gain

Baseline and periodic weights

Intervention Explain this may be transient Notify provider; drug may be stopped, decreased or changed Explain that this is reversible Instruct client not to discontinue the use of birth control as ovulation is continuing and pregnancy is possible Encourage proper diet and exercise

C. Extrapyramidal Effects Adverse Reaction Dystonia (involuntary muscular movements of face, arms, legs and neck Assessment/Evaluation Observe client closely during acute treatment Check tendons for cogwheel jerkiness Intervention Teach clients to recognize onset of dystonic symptoms Respond to symptoms of dystonia immediately; pursue dose reduction and/or antiparkinson drug order Severe dystonic reactions may be treated with dipenhydramine (Benadryl) 25-100 mg or Benztropine (Cogentin) 1 mg IM or IV Notify provider Prepare to administer antiparkinsonian drug; may be given IM/IV Anticipate need for respiratory/emergency support p.r.n Pursue drug reduction and/or administer antiparkinsonian drug Pursue dose reduction and/or administer antiparkinsonian drug Pursue dose reduction and or administer antiparkinsonian drug Notify provider immediately if signs are observed Withhold antipsychotic medication until discussion with provider Monitor vital signs Initiate supportive measures to lower temperature Monitor electrolytes and intake and output

Oculogyric crisis (uncontrolled rolling back of the eyes) Akinesia (muscular weakness and fatigue like symptoms) Akathisia (restlessness , fidgeting, pacing beyond conscious control of the client Pseudoparkinsonism (mimic symptoms of parkinsonism) Tardive Dykenisia (characterized by bizarre facial and tongue movements, stiff neck , difficulty swallowing) Irreversible side effect

Observe client closely; side effect may become psychiatric emergency as it can be a precursor to muscular/respiratory collapse Subjective complaints of muscle weakness, lethargy Insomnia, pacing, constant movement Observe for tremor, shuffling gait, drooling, rigidity, pill rolling of the fingers Observe for changes in gait and facial and extremity movements Be alert to signs of possible development of neuroleptic malignant syndrome; elevated temperature, severe extrapyramidal rigidity, diaphoresis, tachycardia or an altered level of consciousness

D. Other Effects Adverse Reaction Reduce seizure threshold Agranulocytosis potentially fatal blood disorder in which the clients WBC drop to dangerously low levels (clozapine) II. ANTIANXIETY AGENTS Class Antianxiety agents Other Nomenclature Minor tranquilizers Anxiolytic drugs Purpose To treat anxiety, panic phobias, insomnia, OCD, PTSD Some benzodiazepines may be used as muscle relaxants and anticonvulsants Main effects Buspirone has been used to treat psychotic symptoms Decrease in anxiety Increase in sleep Decrease in nervous system activation Decrease in skeletal muscle spasm Produces anticonvulsant activity Assessment/Evaluation History of seizures Periodic complete blood counts Observe clients for bruising, bleeding, mouth sores, lethargy Intervention Closely observe with history of seizures Stop medication if rbc is below 3000 cubic mm or if granulocytes fall below 1500 cubic mm

SUMMARY OF COMMONLY USED ANTINXIETY DRUGS Chemical group Antihistamines Benzodiasepines Generic name (Trade name) Hydoxyzine (Vistaril, Atarax) Alprazolam (Xanax) Chlordiapoxide( Librium) Clonazepam (Klonopin) Diazepam (valium ) Lorazepam (Ativan) Daily dosage range 100-400 mg .75-4 mg 10-100 mg 1.5-60 mg 7.5-60mg 2-9 mg Duration of Action I.A. (10-20 hrs) L.A. (1-3 days) L.A. (1-3 days) L.A. (1-3 days) I.A. (10-20 hrs)

Miscellaneous

Termazepam (Restoril) Razolam (halcyon) Buspirone (Buspar)

15-30 mg 0.125-0.5 mg 15-60 mg

I.A. (10-20 hrs) S.A (3-8 hrs)

SIDE EFFECTS Drowsiness, confusion and lethargy Orthostaic hypotension Nausea and vomiting Dry mouth Potentiate effects of other CNS depressants Blood dyscrasias Paradoxical excitement Tolerance Liver dysfunction

NURSING IMPLICATION Instruct client not to drive or operate dangerous machinery while taking medication Monitor vital signs; instruct client to change positions slowly Advise that this medication may be taken with meals Frequent sips of water, sugarless gum, or candy Instruct client to avoid alcohol and to check with provider before taking another medications Symptoms of sore throat, fever, malaise, easy bruising or unusual bleeding should be reported t the provider immediately Report to provider immediately Instruct client on long term therapy not to discontinue drug abruptly Symptoms of nausea, upper abdominal pain, jaundice, fever, rash, monitor liver function tests

REMEMBER Should not be taken with other CNS depressants Are strictly contraindicated in clients with narrow angle glaucoma, shock or coma and during pregnancy. May exacerbate depression BENZODIASEPINES WITHDRAWAL SYMPTOMS Begins within 12-48 hours after the last dose Withdrawal may last from 12-48 hours Some symptoms persist for weeks Medication dosages must be reduced gradually to avoid possible seizures Symptoms of withdrawal include, anxiety, agitation, tremors, insomnia, dizziness, neuromuscular irritability, psychosis and seizures

III. ANTIDEPRESSANTS Class Antidepressant agents Other Nomenclature Mood elevators Energizers Purpose To treat dysthymia, major depression with melancholia or psychotic symptoms, depression associated with organic disease, bipolar disorders, dual diagnosis Main Effects Decrease depressive symptoms, improve mood, improve sleep, increase ability to experience pleasure Decrease psychomotor retardation Daily dose range 20-300 mg 25-200 mg 25-300 mg 30-300 mg 50-150 mg 10-30 mg 15-75 mg 10-30 mg 40-80 mg 10-50 mg 50-200 mg 300-450 mg 200-600 mg

SUMMARY OF COMMON ANTIDEPRESSANT MEDICATIONS Classification Generic (Trade Name) Tricyclics Amitriptyline (Elavil Desipramine (Norpramin) Doxepin HCl (Sinequan) Imipramine (Tofranil) Nortriptyline (Pamelor) Monoamine oxidase (MAO) Isocarboxazid ( Marplan) inhibitors Phenelzine sulfate (Nardil) Tranylcypropamine sulfate (Parnate) Selective Serotonin Reuptake Fluoxetin (Prozac) Inhibitors (SSRI) Paroxetine (Paxil) Setraline (Zoloft) Miscellaneous Bupropion (Wellbutrin) Trazodone (Desyrel)

THINGS TO KEEP IN MIND Antidepressants affect the actions of norepinephrine, dopamine or serotonin in the brain Response time to the antidepressant varies, but in general takes from 2-3 weeks to see therapeutic effect .SSRIs are generally seen as the first line of treatment because of their lower side effect profile and decreased potential for overdose. Tricylic and tetracyclic antidepressants have anticholinergic side effects: dry mouth, blurred vision, constipation, urinary hesitancy, orthostatic hypotension and drowsiness Adverse effects include exacerbation of psychosis and cardiac arrhythmias SIDE EFFECTS OF MAO inhibitors HYPERTENSIVE CRISIS which is considered a medical emergency Symptoms of Hypertensive Crisis General Nursing Interventions Headaches Hold next MAO inhibitor dose Elevated B/P Monitor vital signs Palpitations and chest pain Cooling techniques for fever Sweating Maintain hydration/electrolyte imbalance Nausea/vomiting Fever Neck stiffness Photophobia Nosebleed IN ORDER TO AVOID HYPERTENSIVE CRISIS, A CLIENT TAKING MAOI MUST CONSULT HIS PROVIDER BEFORE TAKING ANY OVER THE COUNTER MEDICATION OR ANY OTHER PRESCRIPTION MEDICATIN Food to Avoid Aged or mature cheese (cheddar, parmesan) Aged protein and fermented foods (salami, sausage) Broad beans Pickled herring; beef or chicken livers Beer, red wine Yeast or protein extracts (marmite, Oxo, Bovril) Yogurt Overripe fruit Use in Moderation Soy sauce Chocolate Caffeine drinks

IV. ANTIMANIC AGENTS OR MOOD STABILIZERS Class Antimanic agents Other nomenclature Mood stabilizer Purpose To treat bipolar disorder, mania, depression, or schizoaffective disorder Main effects Stabilization of mood, decrease in and prevention of manic episodes, decrease in depression

LITHIUM CARBONATE Is the drug of choice for acute manic symptoms as well as for prophylactic treatment of cyclical mood swings. Lithiums mode of action is not known, but it takes 7-10 days for the medication to work. During that time, antipsychotic drugs are often used to control the acute symptoms of mania until lithium takes effect. Serum lithium blood levels are used to titrate the dose, with therapeutic levels ranging from 0.5 to 1.5 meq/L. Dose stabilization usually takes 1 year ANTICONVULSANTS the second line of treatment for mood stabilization in bipolar disorder is anticonvulsants. These drugs are usually prescribed for those who do not respond to lithium or for whom lithium may be contraindicated ANTICONVULSANT DRUGS TO TREAT BIPOLAR DISORDER Drug Daily dose/Therapeutic Level Side Effects Carbemazapine 300-1,200 mg Skin rash, sore throat, low grade fever, mucosal ulceration, ataxia, (Tegretol) serum level 6-12 mg/L vertigo, nausea and vomiting, hepatotoxicity, < WBC, agranulocytosis Valproic acid/valpoate 500-1000 mg Anorexia, nausea and vomiting, diarrhea, tremor, sedation, ataxia (Depakene/Depakote) serum level of 50-125 mcg/L Clonazepam (Klonapin) 4-24 mg Ataxia, drowsiness, headache, increased salivation Lamotigine (Hamictal) 200-500 mg Dizziness, sedation, headache, diplopia, ataxia. Rash occurs in about 10% of all cases