Nursing Care for Patients Receiving Medications Related to Psychosocial Adaptation

Cebu Normal University

College of Nursing

Unit VIII Nursing Care of Patients Receiving Medications Related to Psychosocial Adaptation
by: Domino B. Puson

ASSIGNMENT: Write in a short bond paper examples of Anti-anxiety Medications in the following format: generic name, trade name and dosages. Also find literatures of the following: EEG, CT Scan, MRI, CSF Analysis, and Cerebral Angiography.

Psychotherapeutic Agents

Many of the drugs introduced in the following subsections act on more than one type of receptor. Each agent acts differently, making it possible for certain drugs to be given for specific actions without many adverse reactions. It should be clear that, if dosages are exceeded, many receptors may be excessively stimulated, causing widespread and serious effects. ANTI-ANXIETY AGENTS Anxiety is a common problem associated with many medical and surgical conditions, as well as primary symptom in many psychiatric disorders. Anxiety is a normal human emotion, but when it is felt too frequently or interferes with a persons ability to perform ADL, it is considered abnormal. Anxiety creates subjective feelings of helplessness, indecision, worry, apprehension, and irritability. Patients may complain of H/A, gastric distress, insomnia, and inability to concentrate. It may also produce objective symptoms of restlessness, tremor, constipation, diarrhea, nausea and muscle tension. Antianxiety Medications or Tranquilizers are used to reduce some of the symptoms. They do not prevent anxiety. Used only for short time until other remedies are found. These medications are for short term only because of their potential for addiction. The major products used today are benzodiazepines. Mechanism of Action Benzodiazepines act in the limbic system, thalamic, and hypothalamic levels of the CNS, producing calming effect. Indication Benzodiazepines are used to relieve anxiety, tension, and fears that occur by themselves or as a result of illness. Adverse Reactions

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Nursing Care for Patients Receiving Medications Related to Psychosocial Adaptation Hypotension, tachycardia, confusion, depression, drowsiness, fatigue, insomnia, paradoxic reactions (excitement, hallucinations, agitation, hostility or rage), visual disturbances, difficulty swallowing, and dry mouth. Overdose: sleepiness, confusion, coma, diminished reflexes and hypotension.

Drug Interactions Alcohol, anesthetics, MAO inhibitors, or CNS Depressants if used with benzodiazepines may increase either agents effects. Nursing Implication and Patient Teaching Assessment Learn the health History of the patient. Including hypersensitivities, underlying systemic Disease and possibility of pregnancy. Patient may have history of feeling of apprehensions, uncertainty, fear, an unpleasant state of tension, insomnia, irritability, difficulty concentrating or nightmares. Diagnosis Does he have family support, or is he isolated and lonely? Is the patient able to work and take care of his daily needs, or is he incapacitated with anxiety? Planning Elderly Patients and those with chronic illness require a decreased in initial dose. Benzodiazepines have a long half life. Implementation Administer during or immediately after meals decreases GI side effects. Patients must be questioned and observed for suicidal tendencies. Tell the patient the following: Take as ordered and not stop taking unless advised. Maintain a regular appointment with nurse or physician. The patient should not drive, operate hazardous machinery, or perform activities requiring alertness until response to the drug has been determined. Notify troublesome symptoms (ulcers, difficulty breathing etc) Keep out of reach of children. Do not drink alcohol Cigarette smoking and caffeinated beverages decrease the effect of anti-anxiety agents. Not intended for use in pregnant women. Habit forming. Evaluation Mental alertness, cognitive functions, and physical abilities may be impaired with the use of anti-anxiety agents. Should be used in conjunction with psychotherapy. Abrupt termination of these agents may cause delayed withdrawal symptoms (up to 1 week later) of abdominal or muscle cramps, vomiting, diaphoresis, tremor, or convulsions. You should take lying, sitting, and standing blood pressures when monitoring hypotensive changes. Alternatives for coping with stress and change should be discussed with the patient.

ANTIMANICS Mechanism of Action Lithium is the primary drug used to treat patients in manic states. The exact mechanism of lithium is not known.

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Nursing Care for Patients Receiving Medications Related to Psychosocial Adaptation The mood-stabilizing effect of the drug may be attributed to its ability to alter sodium transport at the nerve endings, inhibit cyclic AMP formation in nerve cells, and enhance the uptake of serotonin and norepinephrine by nerve cells, thus increasing the inactivation of these neurotransmitters. It has no sedative, depressant, or euphoric actions, making it unique from all other psychiatric drugs.

Uses For manic depressive psychosis who are in an acute manic phase. It also may be used to prevent recurrent episodes of mania in the manic-depressive patient. Adverse Reactions Dysrhythmias, hypotension, ataxia, coma, dizziness, drowsiness, motor retardation, restlessness, slurred speech, tinnitus, anorexia, diarrhea, blurred vision, and weight gain. Overdose: diarrhea, vomiting, muscle weakness, drowsiness and ataxia. Drug Interactions Use of lithium together with diuretics can lead to lithium toxicity. Nursing Implication and Patient Teaching Assessment Learn health history of the patient including hypersensitivity, underlying disease, the possibility of pregnancy and other medications used. The patient may have a history of excessive talkativeness, restlessness, hyperactivity, aggressiveness, and perhaps ideas of being very important, talented, or powerful. Diagnosis If the patient becomes dehydrated, forgets to take medication on a regular basis, or become so excitable that he believes that medication is not needed, this may result in significant problems for the patient. Planning Not safe to use in pregnant patients. Elderly patients are often more sensitive to lithium toxicity. Implementation Make sure that patient has adequate hydration and that her electrolytes are balanced during lithium therapy. Tell the patient: Take the medication as ordered. Take with milk or food. The serum lithium levels can become toxic if the patient takes too much or becomes dehydrated from vomiting or diarrhea or does not eat. Avoid activities that cause excessive sweating and things that produce excessive urination (large amount of caffeine etc). Notify new or troublesome symptoms occur. (jerky movements of arms or legs) Patient will need these blood tests every few days when beginning treatment, and then every 1 to 2 months. Keep out of reach of children. Wear Medic Alert bracelet or necklace. Evaluation The therapeutic level of serum lithium is relatively close to the toxic level. Blood should be drawn 12 hours after the dose of lithium is given. The therapeutic serum lithium level is 1 to 1.5 mEq/L in most laboratories. Lithium is tolerated better when the patient is in an acute manic stage than when he is in a stage when symptoms of mania have decreased.

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Nursing Care for Patients Receiving Medications Related to Psychosocial Adaptation Patients who develop diarrhea or become ill and do not eat are at increased risk of toxicity, and their condition should be followed closely. ANTIPSYCHOTIC Severe mental illness such as schizophrenia, psychotic depression, mania, or organic brain syndrome is commonly treated with major tranquilizers or antipsychotic drugs. These medications are used to sedate or slow the patient down, thereby reducing some of the psychotic symptoms. This allows other therapy to be used. Antipsychotic medications are usually given for long periods of time. Antipyschotic are grouped into two broad categories: 1. The phenothiazines and thioxanthenes, which are chemically and pharmacologically similar. 2. The nonphenothiazines including haloperidol, loxapine, and molindone. All antipsychotics acts by blocking the action of dopamine in the brain. Because they are from different chemical groups, however, they work at different sites in the brain and also produce side effects on different body systems. Phenothiazines and Thioxanthenes Action 1. Blocking dopamine at the postsynaptic receptor sites in the brain, thus increasing the metabolism of dompamine. Decrease the uptake of norepinephrine and serotonin. In the CNS, these drugs decrease the level of cyclic adenosine monophosphate (AMP), particularly in the areas of the brain that control emotions and behaviour. 2. Reducing sensory stimulation of the reticular activating system in the brainstem, thereby producing a sedative effect. 3. Acting as an antiemetic by inhibiting action in the chemoreceptor center. Uses To reduce or relieve the symptoms of acute and chronic psychoses. Thioxantene is preferred for use in psychotic patients who are withdrawn or are exhibiting retarded behaviour. Adverse Reaction Postural hypotension, tachycardia, confusion, drowsiness, hyperactivity, insomnia, amenorrhea, gynecomastia, hyperglycemia, , hyperreflexia, tardive dyskinesia, blood cell abnormalities, contact dermatitis, photosensitivity, constipation, dry mouth, dyspnea, incontinence, nasal congestion, opaque deposits on the cornea and lens, and urinary retention Drug Interactions Phenothiazines taken concurrently with CNS depressants may increase and prolong the effects of either the CNS depressant or the phenothiazine. Effects of MAOI and tricyclic antidepressants are increased when they are taken at the same time as phenothiazines, and antacids and antidiarrheal drugs reduce the absorption rate. Nursing Implication and Patient Teaching Assessment Learn as much as possible about the health history of the patient. History of cardiac, respiratory, or blood diseases, current use of other medication and possibility of pregnancy. May have a history of emotional unrest, agitation, paranoid ideas, hallucinations, delusions, inability to think clearly, severe mood swings, and inability to cope with reality. Diagnosis What other needs does this patient have? Safety? Nutrition? Page 4 of 10

Nursing Care for Patients Receiving Medications Related to Psychosocial Adaptation Does the patient have a support system of family or friends? Planning Phenothiazines and thioxanthenes are not recommended for use in pregnant women or nursing mothers. Patients with severe asthma, emphysema, or acute respiratory infections may have slowing of respirations as a result of the CNS depressant effects of phenothiazines. Phenothiazines may also depress the cough reflex putting a patient who is vomiting in danger of aspirating. Implementation Taken either orally or parenterally. Absorption is slowed when taken with antacids or antidiarrheal. Take with bland food or 8 ounces of water. Tell the patient; Take medication exactly as ordered. Avoid alcohol Avoid driving and other activities that require alertness. Move slowly when changing from a lying or sitting position. Use sunblock and limit exposure to sun and sun lamps. Liquid form can cause irritation Take with food, milk, 8 ounces of water. Chew gum, sucking on hard candy, or rinsing the mouth frequently may help relieve dry mouth. Avoid becoming overheated in hot and humid weather or when exercising drug make patient perspire more than usual. Contact if troublesome symptoms develop. Medication should be kept out of the reach of children. Wear Medic Alert Evaluation Desired antipsychotic effects may take several weeks to appear after therapy is started. The beginning dose should be the lowest recommended amount, according to the individuals tolerance and the severity of psychosis, until the psychotic symptoms are controlled. Dosage must be maintained for 2-3 weeks and gradually reduced until the lowest effective maintenance dosage is reached. The patient must have a complete eye examination, including the inspection of the internal structures and the lens, to establish baseline data. Nonphenothiazines A variety of chemically unrelated products have come on the market over years to help in treating psychotic clients. The mechanism of action is not precisely understood. Antimanics Lithium is the primary drug use to treat patients in manic states. Exact mechanism of action is not known. The mood stabilizing effect of the drug may be attributed to its ability to alter sodium transport at the nerve endings, inhibit cyclic AMP formation to nerve cells, and enhance the uptake of serotonin and norepiniphrine by nerve cells, thus increasing the inactivation of these neurotransmitters. It has no sedative, depressant, or euphoric actions, making it unique from all other psychiatric drugs. Page 5 of 10

Nursing Care for Patients Receiving Medications Related to Psychosocial Adaptation

USES Specifically for manic-depressive psychosis who are in acute manic phase. Used to prevent recurrent episodes of mania in the manic-depressive patient. Adverse Effects Dysrhythmias, hypotension, ataxia, coma, dizziness, drowsiness, motor retardation, restlessness, slurred speech, tinnitus, anorexia, diarrhea, vomiting, polyuria, hypothyroidism, leukocytosis, weight gain. Overdose: diarrhea, vomiting, muscle weakness, drowsiness and ataxia. Drug Interactions Use of lithium with diuretics can lead to lithium toxicity. Nursing Implication and Patient Teaching Assessment Health history of the patient hypersensitivity, possibility of pregnancy etc. The patient might have a history of excessive talkativeness, restlessness, hyperactivity, aggressiveness, and perhaps ideas of being very important, talented, or powerful. Diagnosis If the patient becomes dehydrated, forgets to make medication on a regular basis, or becomes so excitable that he believes that medication is not needed, this may result in significant problems for the patient. Planning Not safe in pregnancy Elderly are sensitive to lithium toxicity Implementation You should make sure that the patient has an adequate hydration and that her electrolytes are balanced. Tell the patient: Take medication exactly as ordered. Serum lithium levels can become toxic if the patient takes too much or becomes dehydrated from vomiting or diarrhea or does not eat. Report troublesome symptoms (N/V, shakiness, trembling, jerky movements of arms or legs, or generalized weakness) Blood test every 1 to 2 months. Medication must be kept out of children Wear Medic Alert Evaluation Blood should be drawn 12 hours after the dose of lithium is given. Monitoring should be carried out every few days during the initial therapy and then atleast every 2 months after the patient is stabilized. The therapeutic serum lithium level is 1 to 1.5 mEq/L in most laboratories. Lithium is tolerated better when the patient is in acute manic stage than when he is in a stage where symptoms of mania have decreased. Patients who develop diarrhea or become ill and do not eat are increased risk of toxicity, and their condition should be followed closely. Antidepressants Depression whether mild or severe that it interferes with activities of daily living, has been recognized for centuries.

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Nursing Care for Patients Receiving Medications Related to Psychosocial Adaptation Only in the past 30 years have medications been discovered that significantly help to improve a patients mood without extensive side effects. Patients may experience different side effects with each drug. MAOIs antidepressant effect was discovered as an unexpected effect of its initial use to treat diseases. MAOI are used primarily when tricyclic therapy is unsatisfactorily or when other therapy is inappropriate or refused. In the last few years, a number of chemically related SSRIs have entered the field for treatment of depressed patients. Tricyclic Antidepressants Action Not completely understood. Inhibit the uptake of norepinehrine and or serotonin (biogenic amines) by the presynaptic neuronal membrane in the CNS, thereby increasing the concentration of these biogenic amines at the synapse. Uses Used primarily to relieve the symptoms of severe depression that has internal biological cause. Also used for mild depression caused by factors in the patients life which is not self limiting and does not interfere with usual activities of daily living. Less frequently used for manic-depressive disorders as adjunctive or additional therapy. Adverse Reactions Dysrhytmias, postural hypotension, confusion, head ache, drowsiness that last a long time, constipation, fever, photosensitivity, tremors, urinary retention, altered liver function test, blurred vision, and nervousness. Overdose: initially produce stimulation of the CNS, resulting in irritability, agitation, hallucinations, delirium, hyperpyrexia. This initial CNS stimulation is followed by CNS depression. Drug interaction Increases CNS depressant effect of alcohol. There may be a reduction in the antidepressant effects of tricyclics and an increase in their side effects when used concurrently with estrogen, including oral contraceptives containing estrogen. Nursing Implication and Patient Teaching Assessment Learn health history. The complementary and alternative box provides a summary of herbal products that the patients may be taking to help with symptoms of depression and their drug interactions. (St. John Worth Potential interaction with antidepressants. Ginkgo potential interaction with anticoag, aspirin, MAOI etc.) The patient might have a history of insomnia, anorexia, constipation, loss of motivation and fatigue. Diagnosis What other problems the patient might have? Often a depressed patient does not eat, bathe, or dress appropriately. She may cut off contact with other people, and maybe unable to work. Any of these problems may be addressed with the patient when she is starting to feel better. Planning Not given if patient has hypersensitivity Recent M.I., narrow angle glaucoma or severe hepatic and renal disorder should not be given. Antidepressant may cause manic-depressive patients to go into the manic phase of their illness. Page 7 of 10

Nursing Care for Patients Receiving Medications Related to Psychosocial Adaptation

Implementation The initial and maintenance dosages of these drugs must be carefully determined, based on the patients age, physical health status and response to the drug. Started with a single bedtime dose. Tell the patient: Take medications exactly as ordered. Takes 8 weeks before patient gets better. Should not be stopped rapidly (increase the following symptoms: Nausea, headache and listlessness. Avoid driving or doing activities that require alertness. Dryness of the mouth may occur. Avoid alcohol Kept out of reach of children (Tricyclics are very powerful) Light-headedness, dizziness, or feelings of faintness occur in some people therefore patient should move slowly when changing position. Stopped several days before the patient has any surgery. Report trouble some symptoms (Urinary retention constipation, blurred vision etc) Wear medic alert. Evaluation The desired antidepressant effect of the drug will usually occur within 1 to 4 weeks after therapy is initiated. If a tricyclic antidepressant is given in large doses or for a long time, the drug should be stopped by gradually reducing the dose over 4 to 8 weeks to avoid withdrawal symptoms (general listlessness, headache and nausea.) Monoamine Oxidase Inhibitors Action MAO is an enzyme found in the mitochondria of the cells, located in nerve endings and other body tissues such as the kidney, liver, and intestines. This enzyme normally acts as a catalyst by inactivating dopamine, norepinephrine, epinephrine, and serotonin and therefore regulating the intracellular levels of these neurotransmitters. MAOI blocks the inactivation of the biogenic enzyme, resulting in an increased concentration of dopamine, epinephrine, norepinephrine, and serotonin in neuronal synapse. The antidepressant effects of MAOI are thought to be directly related to this increased concentration of biogenic enzymes. Uses Used to relieve symptoms of severe reactive or of endogenous depression that have not responded to tricylic depressants, ECT, or other modes of therapy. Adverse Reaction Postural Hypotension, hallucination, drowsiness, headache, hyperactivity, insomnia, seizures, tremors, N/V, fever, photosensitivity, blurred vision, dry mouth and impotence. Overdose: mental confusion, restlessness, hypotension, respi depression, tachycardia, and shock. Drug and Food Intereactions Potentiate with CNS depressants Foods (cheese, yogurt, sour cream, raisins, bananas, avocados, bean pods, chicken livers, or pickled herring, and should avoid meat tenderizers and soysauce. Only a very small amount of coffee, tea, cola drinks, and chocolate are permitted.) Nursing Implication and Patient Teaching Page 8 of 10

Nursing Care for Patients Receiving Medications Related to Psychosocial Adaptation

Assessment Health History of the patient. Pregnancy Check for suicidal ideas Diagnosis Is the patient able to understand the dietary restrictions that must be followed when he is taking these medications? What assistance does the patient need in taking care of himself? The nurse should focus on things she may be able to teach the patient or learn about the patient that will be helpful to the patient in getting well. Planning Safe use of MAOI in pregnant and nursing mothers has not been established. Implementation MAOI are given orally. Desired antidepressant effects occur 1 to 4 weeks of drug therapy. MAOI are not given in the evening. The maintenance dose can be given in either single or divided doses. Discontinued 2 weeks before surgery. (Emergency anesthetics and analgesics are reduced) Evaluation All patients taking MAOI should be monitored for symptoms of postural hypotension. If these occurs it must be discontinued The effects of MAOI continues for approximately 2 weeks after the drug is stopped. Selective Serotonin Reuptake Inhibitor and Miscellaneous Antidepressants Actions SSRIs antidepressant action is presumed to be linked to their inhibition of CNS neuronal uptake of serotonin. These products are potent and selective inhibitors of neuronal serotonin reuptake, and they also have a weak effect on norepinephrine and dopamine neuronal reuptake. Causes fewer side effects. There are also three antidepressant products that have an effect on serotonin uptake but that are chemically unrelated to the SSRIs: bupropion, venlafaxine and nefazodone. There are three related products: maprotiline, mirtazapine and trazodone. Uses Short term treatment (less than 5 weeks) Adverse Effects Dizziness, tachycardia, hypertension, hypotension, weight loss, N/V, anorexia, diarrhea, appetite increase, dyspepsia, impotence, dry mouth, urinary frequency, excessive sweating, confusion, and disturbed concentration. Drug Interactions Flouxetine increases the half life of some drugs. The drug must be stopped before general anesthesia because interactions are unknown. Nursing Implication and Patient Teaching Page 9 of 10

Nursing Care for Patients Receiving Medications Related to Psychosocial Adaptation

Assessment Health Assessment Recent use of MAOI. After stopping MAOI therapy, the patient should wait atleast 14 days before starting bupropion. Diagnosis Assessment deficits in nutrition, safety, and knowledge are important. What other problems does this patient have specifically? Evaluate the extent of side effects and the impact on the patients ability to function. Planning The incident of seizures in patients taking bupropion is approximately four time greater than that in patients taking other antidepressant medication. Fluoxetine has a relatively long half-life (2 to 3 days), and problems with liver or renal failure may prolong the drugs action in the body. Dosage levels must be individualized based on symptoms. Implementation To reduce the risk of seizures while the patient is taking bupropion, the daily dosage should be kept below 450mg, it should be given in 3 divided doses, and the dosage should be increased gradually. Evaluation Many patients taking bupropion experience some sort of agitation, increased restlessness, anxiety, and insomnia. If these symptoms cannot be controlled with a sedative hypnotic, the medication should be stopped. The desired antidepressant effect usually occurs within 1 to 2 weeks after initiating therapy. You shoul assess the level of depression and watch for suicidal ideas. Assignment: To be submitted on March 1, 201. Find a literature on Sedative-Hypnotic Medications and write or print them on a short bond paper. Include complementary and Alternative Therapies. Thank you!

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