Psychopharmacology

Mr. Ibrahim Rawhi Ayasreh RN, MSN, ACNS

Definitions

Psychotropic medication: are medication that affects psychic function, behavior, or experience. Neurotransmitter: a chemical that is stored in the axon terminals of the presynaptic neuron. An electrical impulse through the neuron stimulates the release of the neurotransmitter into the synaptic cleft, which in turn determines whether another electrical impulse is generated. Receptor: molecules situated on the cell membrane that are binding sites for neurotransmitters.

Antianxiety Agents (anxiolytics)

Indications: - treatment of anxiety disorders. - anxiety symptoms. - acute alcohol withdrawal. - skeletal muscle spasms. - convulsive disorders, status epilepticus. - preoperative sedation.

Antianxiety Agents (anxiolytics)

Action: - Antianxiety drugs depress subcortical levels of the CNS, particularly the limbic system and reticular formation. - They may potentiate the effects of the powerful inhibitory neurotransmitter gamma-aminobutyric acid (GABA) in the brain, thereby producing a calmative effect. - All levels of CNS depression can be effected, from mild sedation to hypnosis to coma.

Antianxiety Agents (anxiolytics)

Antianxiety Agents (anxiolytics)

Interactions: - Increased effects of antianxiety agents can occur when they are taken concomitantly with alcohol, barbiturates, narcotics, antipsychotics, antidepressants, antihistamines, neuromuscular blocking agents, cimetidine, or disulfiram, and with herbal depressants (e.g., kavakava and valerian). - Decreased effects can be noted with cigarette smoking and caffeine consumption.

Antianxiety Agents (anxiolytics)

Diagnosis: - Risk for injury related to seizures; panic anxiety; abrupt withdrawal after long-term use. - Risk for activity intolerance related to side effects of sedation and lethargy. - Risk for acute confusion related to action of the medication on the CNS.

Antianxiety Agents (anxiolytics) Planning /Implementation

Drowsiness, confusion, lethargy (most common side Effects) * Instruct the client not to drive or operate dangerous machinery while taking the medication. Tolerance; physical and psychological dependence (does not apply to buspirone). * Instruct the client on long-term therapy not to quit taking the drug abruptly.

Antianxiety Agents (anxiolytics) Planning /Implementation

Ability to potentiate the effects of other CNS depressants * Instruct the client not to drink alcohol or take other medications that depress the CNS while taking this medication. Possibility of aggravating symptoms in depressed persons * Assess the clients mood daily. * Take necessary precautions for potential suicide. Orthostatic hypotension. * Monitor lying and standing blood pressure and pulse every shift.

Antianxiety Agents (anxiolytics) Planning /Implementation

Dry mouth * Have the client take frequent sips of water, suck on ice chips or hard candy, or chew sugarless gum. Nausea and vomiting * Have the client take the drug with food or milk. Blood dyscrasias * Symptoms of sore throat, fever, malaise, easy bruising, or unusual bleeding should be reported to the physician immediately.

Antidepressants

Indications - Treatment of dysthymic disorder. - Major depression with melancholia or psychotic symptoms. - Depression associated with organic disease, alcoholism, schizophrenia, or mental retardation; - Depressive phase of bipolar disorder; and depression accompanied by anxiety.

Antidepressants

Action - These drugs ultimately work to increase the concentration of norepinephrine, serotonin, and/or dopamine in the body - This is accomplished in the brain by blocking the reuptake of these neurotransmitters by the neurons (tricyclics, selective serotonin reuptake inhibitors, and others). - It also occurs when an enzyme, monoamine oxidase (MAO), that is known to inactivate norepinephrine, serotonin, and dopamine, is inhibited at various sites in the nervous system.

Antidepressant Medications

Antidepressant Medications

Antidepressant Medications

Interactions (Tricyclics): - Hyperpyretic crisis, hypertensive crisis, severe seizures, and tachycardia may occur when used with MAOIs. - Use of these drugs may decrease therapeutic response to some antihypertensives (clonidine, guanethidine).

Antidepressant Medications

Interactions (MAOIs): - Hypertensive crisis may occur with concurrent use of amphetamines, methyldopa, levodopa, dopamine, epinephrine, norepinephrine, reserpine, vasoconstrictors, or ingestion of tyramine-containing foods.

Antidepressant Medications

Diagnosis: - Risk for suicide related to depressed mood. - Risk for injury related to side effects of sedation, lowered seizure threshold, orthostatic hypotension, priapism, photosensitivity, arrhythmias, hypertensive crisis, or serotonin syndrome. - Social isolation related to depressed mood. - Constipation related to side effects of the medication

Antidepressant Medications planning/Implementation

For all chemical classes: - Dry mouth: * Offer the client sugarless candy, ice, frequent sips of water * Strict oral hygiene is very important. - Sedation: * Request an order from the physician for the drug to be given at bedtime. * Request that the physician decrease the dosage or perhaps order a less sedating drug. * Instruct the client not to drive or use dangerous equipment while experiencing sedation.

Antidepressant Medications planning/Implementation

- Nausea: * Medication may be taken with food to minimize GI distress. - Discontinuation syndrome * All classes of antidepressants have varying potentials to cause discontinuation syndromes. * All antidepressant medication should be tapered gradually to prevent withdrawal symptoms.

Antidepressant Medications planning/Implementation

Most commonly occur with tricyclics: - Blurred vision: * Offer reassurance that this symptom should subside after a few weeks. * Instruct the client not to drive until vision is clear. * Clear small items from routine pathways to prevent falls.

- Constipation: * Order foods high in fiber; increase fluid intake if not contraindicated; and encourage the client to increase physical exercise, if possible.

Antidepressant Medications planning/Implementation

- Urinary retention * Instruct the client to report hesitancy or inability to urinate. * Monitor intake and output. * Try various methods to stimulate urination, such as running water in the bathroom or pouring water over the perineal area. - Orthostatic hypotension * Instruct the client to rise slowly from a lying or sitting position. * Monitor blood pressure (lying and standing) frequently, and document and report significant changes. * Avoid long hot showers or tub baths.

Antidepressant Medications planning/Implementation

- Reduction of seizure threshold: * Observe clients with history of seizures closely. * Institute seizure precautions as specified in hospital procedure manual. * Bupropion (Wellbutrin) should be administered in doses of no more than 150 mg and should be given at least 6 hours apart. Bupropion has been associated with a relatively high incidence of seizure activity in anorexic and cachectic clients. - Tachycardia; arrhythmias * Carefully monitor blood pressure and pulse rate and rhythm, and report any significant change to the physician.

Antidepressant Medications planning/Implementation

- Photosensitivity: * Ensure that client wears a protective sunblock lotion, clothing, and sunglasses while outdoors. - Weight gain: * Provide instructions for reduced-calorie diet. * Encourage increased level of activity, if appropriate.

Antidepressant Medications planning/Implementation

Most commonly occur with SSRIs: - Insomnia; agitation: * Administer or instruct client to take dose early in the day. * Instruct the client to avoid caffeinated food and drinks. *Teach relaxation techniques to use before bedtime. - Headache * Administer analgesics, as prescribed. * Request that the physician order another SSRI or another class of antidepressants.

Antidepressant Medications planning/Implementation

- Weight loss (may occur early in therapy)
* Ensure that client is provided with caloric intake sufficient to maintain desired weight. * Caution should be taken in prescribing these drugs for anorectic clients. * Weigh client daily or every other day, at the same time, and on the same scale, if possible. *After prolonged use, some clients may gain weight on SSRIs - Sexual dysfunction: * Men may report abnormal ejaculation or impotence. * Women may experience delay or loss of orgasm. * If side effect becomes intolerable, a switch to another antidepressant may be necessary.

Antidepressant Medications planning/Implementation

Most commonly occur with MAOIs: - Hypertensive crisis * Hypertensive crisis occurs if the individual consumes foods containing tyramine while receiving MAOI therapy . * Symptoms of hypertensive crisis include severe occipital headache, palpitnuchal rigidity, fever, sweating, marked increase in blood pressure, chest pain, and coma. * Treatment of hypertensive crisis: discontinue drug immediately; monitor vital signs; administer short-acting antihypertensive medication, as ordered by physician; use external cooling measures to control hyperpyrexia.

Mood-Stabilizing Agents

For many years, the drug of choice for treatment and management of bipolar mania was lithium carbonate. However, in recent years, a number of investigators and clinicians in practice have achieved satisfactory results with several other medications, alone or in combination with lithium.

Nursing diagnosis

Risk for injury related to manic hyperactivity. Risk for self-directed or other-directed violence related to unresolved anger turned inward on the self or outward on the environment. Risk for injury related to lithium toxicity. Risk for activity intolerance related to side effects of drowsiness and dizziness.

Lithium Toxicity

The margin between the therapeutic and toxic levels of lithium carbonate is very narrow. The usual ranges of therapeutic serum concentrations are: - For acute mania: 1.0 to 1.5 mEq/L - For maintenance: 0.6 to 1.2 mEq/l Serum lithium levels should be monitored once or twice a week after initial treatment until dosage and serum levels are stable, then monthly during maintenance therapy. Blood samples should be drawn 12 hours after the last dose.

Lithium Toxicity

Symptoms of lithium toxicity begin to appear at blood levels greater than 1.5 mEq/L and are dosage determinate. Symptoms include: - At serum levels of 1.5 to 2.0 mEq/L: Blurred vision, ataxia, tinnitus, persistent nausea and vomiting, severe diarrhea. - At serum levels of 2.0 to 3.5 mEq/L: Excessive output of dilute urine, increasing tremors, muscular irritability, psychomotor retardation, mental confusion, giddiness. - At serum levels above 3.5 mEq/L: Impaired consciousness, nystagmus, seizures, coma, oliguria/ anuria, arrhythmias,

myocardial infarction, cardiovascular collapse.

Client/Family Education (for Lithium)

Take medication on a regular basis, even when feeling well. Discontinuation can result in return of symptoms. Not drive or operate dangerous machinery until lithium levels are stabilized. Drowsiness and dizziness can occur. Not skimp on dietary sodium intake. He or she should choose foods from the food pyramid and avoid junk foods. The client should drink six to eight large glasses of water each day and avoid excessive use of beverages containing caffeine (coffee, tea, colas), which promote increased urine output. Notify the physician if vomiting or diarrhea occurs. These symptoms can result in sodium loss and an increased risk of toxicity.

Client/Family Education (for Lithium)

Carry a card or other identification noting that he or she is taking lithium. Be aware of appropriate diet should weight gain become a problem. Include adequate sodium and other nutrients while decreasing the number of calories. Be aware of risks of becoming pregnant while receiving lithium therapy. Use information furnished by health care providers regarding methods of contraception. Notify the physician as soon as possible if pregnancy is suspected or planned.

Antipsychotic Agents

Antipsychotic drugs are also called major tranquilizers and neuroleptics. They are used in the treatment of acute and chronic psychoses, particularly when accompanied by increased psychomotor activity. Selected agents are used as antiemetics (chlorpromazine, perphenazine, prochlorperazine), in the treatment of intractable hiccoughs (chlorpromazine, perphenazine), and for the control of tics and vocal utterances in Tourettes disorder (haloperidol, pimozide).

Antipsychotic Agents
- Action The exact mechanism of action is not known. These drugs are thought to work by blocking postsynaptic dopamine receptors in the basal ganglia, hypothalamus, limbic system, brainstem, and medulla. Newer medications may exert antipsychotic properties by blocking action on receptors specific to dopamine, serotonin, and other neurotransmitters

Diagnosis

Risk for other-directed violence related to panic anxiety and mistrust of others. Risk for injury related to medication side effects of sedation, photosensitivity, reduction of seizure threshold, agranulocytosis, extrapyramidal symptoms, tardive dyskinesia, and neuroleptic malignant syndrome. Risk for activity intolerance related to medication side effects of sedation, blurred vision, and weakness. Noncompliance with medication regimen related to suspiciousness and mistrust of others

Side Effects and Nursing Interventions

- Dry mouth: * Provide the client with sugarless candy or gum, ice, and frequent sips of water. * Ensure that client practices strict oral hygiene. - Blurred vision: * Explain that this symptom will most likely subside after a few weeks. *Advise client not to drive a car until vision clears. *Clear small items from pathway to prevent falls.

Side Effects and Nursing Interventions

- Constipation: * Order foods high in fiber; encourage increase in physical activity and fluid intake if not contraindicated. - Urinary retention * Instruct the client to report any difficulty urinating; * monitor intake and output. - Nausea; GI upset * Tablets or capsules may be administered with food to minimize GI upset. * Concentrates may be diluted and administered with fruit juice or other liquid; they should be mixed immediately before administration.

Side Effects and Nursing Interventions

- Skin rash: * Report appearance of any rash on skin to physician. * Avoid spilling any of the liquid concentrate on skin; contact dermatitis can occur with some medications. - Sedation: * Discuss with the physician the possibility of administering the drug at bedtime. * Discuss with the physician a possible decrease in dosage or an order for a less sedating drug. * Instruct client not to drive or operate dangerous equipment while experiencing sedation.

Side Effects and Nursing Interventions

- Orthostatic hypotension * Instruct the client to rise slowly from a lying or sitting position * Monitor blood pressure (lying and standing) each shift; document and report significant changes. - Photosensitivity * Ensure that the client wears a protective sunblock lotion, clothing, and sunglasses while spending time outdoors.

Side Effects and Nursing Interventions

- Decreased libido, retrograde ejaculation, gynecomastia (men) * Provide an explanation of the effects and reassurance of reversibility. If necessary, discuss with the physician the possibility of ordering alternate medication. - Amenorrhea (women) * Offer reassurance of reversibility; instruct the client to continue use of contraception, because amenorrhea does not indicate cessation of ovulation. - Weight gain * Weigh client every other day; order a calorie controlled diet; provide an opportunity for physical exercise; provide diet and exercise instruction.

Side Effects and Nursing Interventions

- Agranulocytosis * Relatively rare with most of the antipsychotic drugs. It usually occurs within the first 3 months of treatment. Observe for symptoms of sore throat, fever, malaise. A complete blood count should be monitored if these symptoms appear. - Hypersalivation (with clozapine): *A significant number of clients receiving clozapine (Clozaril) therapy experience extreme salivation. *Offer support to the client because this may be an embarrassing situation. It may even be a safety issue (e.g., risk of aspiration) if the problem is very severe.

Side Effects and Nursing Interventions

- Extrapyramidal symptoms (EPS): * Observe for symptoms and report; administer antiparkinsonian drugs, as ordered . Pseudoparkinsonism (tremor, shuffling gait, drooling, rigidity) *Symptoms may appear 1 to 5 days following initiation of antipsychotic medication; occurs most often in women, the elderly, and dehydrated clients. Akinesia (muscular weakness) *Same as for pseudoparkinsonism. Akathisia (continuous restlessness and fidgeting) *This occurs most frequently in women; symptoms may occur 50 to 60 days following initiation of therapy. Dystonia (involuntary muscular movements [spasms] of face, arms, legs, and neck

Side Effects and Nursing Interventions Oculogyric crisis (uncontrolled rolling back of the eyes)

Side Effects and Nursing Interventions

- Tardive dyskinesia (bizarre facial and tongue movements, stiff neck, and difficulty swallowing) *All clients receiving long-term (months or years) antipsychotic therapy are at risk. * The symptoms are potentially irreversible. * The drug should be withdrawn at the first sign, which is usually vermiform movements of the tongue; prompt action may prevent irreversibility.