Psychopharmacological

Therapies & Nursing

Implications
Antianxiety agents
Antidepressant Agents
Mood stabilizers
Antipsychotic agents
Psychotropic medications & usage
Anxiolytics- Antianxiety agents
Used for treatment of anxiety disorders –
 Panic disorder (++++ efficacy)
 Generalized Anxiety Disorder (GAD)
(++++ efficacy)
 Obsessive-Compulsive Disorder (OCD)
(+ efficacy)
 Posttraumatic Stress Disorder (PTSD)
(+ efficacy)
 Simple Phobias
 Social Phobias
Benzodiazepines
Action – CNS depressants
 Depress activity in the brain stem and
limbic system
 Increase action of gamma-aminobutyric
acid GABA (inhibitory neurotransmitter)
thus inhibiting nerve transmission is the
CNS
 Benzo’s bind with receptor proteins>
effects of sedation/muscle relaxation.
Anxiolytics –Nursing implications
 Benzodiazepines  Do not give with other
CNS depressants
(CNS depressants)
 Use cautiously in elderly
• Alprazolam(Xanex)
 Monitor for physical &
• Lorazepam(Ativan) psychological dependence
• Clonazepam(Klonopin) with long term use
• Diazepam(Valium)  Monitor confusion, memory
• Oxazepam (Serax) impairment & motor
coordination- ataxic gait
 Decreased effects with
cigarettes/caffeine
Benzodiazepines -
 Hypnotic-sleep  Monitor drowsiness,
agents sedation the day
• Temazepam(restoril) following
• Triazolam(halcion) use “hangover effect”
• Flurazepam  Elderly have more
( Dalmane) difficulty with side
effects i.e. confusion,
 Chlordiazepoxide unsteady gait, urinary
(Librium) incontinence.
 Diazepam(Valium)
 Assess for nausea,
Nonbenzodiazepine headache, dizziness
 Buspirone(Buspar)  Not for immediate
relief
Anti-convulsants-Mood stabilizers
Used for treatment of manic episodes and
Bipolar disorder
Mood stabilizer --Nursing Implications
 Valproic Acid(Depakote)  Check liver functions (at
etc. start & q 6 mos.)
Can cause hepatic
failure/life threatening
pancreatitis
 Can cause aplastic
 Carbamazepine
anemia & agranulocytosis
(Tegretol)
(5-8x’s greater than
population)
Mood stabilizer --Nursing Implications
 Lamotrigine (Lamictal)  Can cause serious rashes
(3rd generation > in children; eg.
anti-convulsant) Stevens-Johnson
syndrome (severe form of
erythemia multiforme)
 Topiramate(Topamax)
 Gabapentin (Neurontin)
 Common side effects of
 Oxcarbazepine all mood stabilizers:
(Trileptal) Dizziness, hypotension,
ataxia- Monitor gait, &
B/P ;give w/food;
Pt. teaching re: s/e’s
Antidepressant –---Nursing Implications
SSRI’s: Monitor for:
 Fluoxetine(Prozac) • Hyponatremia/sexual
give in AM dysfunction; orthostatic
 Sertaline (Zoloft)
B/P
give in PM if drowsy Give w/food;encourage
adequate fluids
 Paroxetine (Paxil)
give in PM if drowsy
 Citalopram(Celexa)
 Escitalopram (Lexapro)
 Fluvoxamine (Luvox)
Selective Serotonin Reuptake
Inhihibitor’s
Atypical Antidepressant Actions
Mirtazapine(Remeron) –
 promotes presynaptic release of two
neurotransmitters(norepinephrie &
seratonoin)
 No inhibition of neurotransmitters in pre-
synaptic or post synaptic reuptake.
Bupropion(Wellbutrin); Venlafaxine (Effexor)
 Affect all 3 major neurotransmitters –
Seratonin, norepinephrine & dopamine.
Atypical
antidepressants- -Nursing Implications
 Venlafaxine(Effexor)  May alter labs: AST ALT, alk
phos, Createnine,gluc,lytes;
 Monitor for inc B/P & HR
 Can lower seizure threshold;
 Duloxetine(Cymbalta) inc. B/P,HR
 (as above)
 Bupropion(Wellbutrin)  Check labs:AST,ALT LDH,chol,
 Nefazodone(Serzone) gluc,Hct
 Sedation: Give in PM,
 Mirtazapine(Remeron)  Monitor wt. gain,
 Monitor: sex dysfunction,
 constipation
Tricyclic
Antidepressants--Nursing Implications
 Amitriptyline(elavil)
 Amoxapine(Asendin)
 Doxepin(Sinequan)
 Imipramine(Tofranil)
 Desipramine(Norpramine)
 Nortriptyline
(Pamelor)
 Monitor & educate re:
cholinergic s/e’s: dry
mouth, blurred vision,
constipation,Ortho-B/P,
**cardiac
dysrhythmias/functionleth
al in OD
*caution use in elderly
Monoamine
Oxidase Inhibitors-----Nursing Implications
Used in treatment resistant
depression
Work to increase levels of
norepinephrine, seratonin
tyramine & dopamine
 Isocarboxazid (Marplan)
 Phenelzine (Nardil)
 Tranlcypromine (Parnate)
 Educate re:
low tyramine diet;
*Hypertensive crisis if
diet is contains tyramine
foods.
 potentially fatal drug to
drug interactions i.e.
Meperidine, SSRI’s,TCA’s,
Amphetamines
*can be lethal in OD
CLINICAL USE //EFFICACY
Antipsychotic medications
 *MOST TOXIC DRUGS USED IN
PSYCHIATRY!!
 Use lowest possible dose –especially in
Geriatric client –start low go slow!
 Positive (aggressive symptoms) –most
responsive-relieved within hours
 Negative( Affective symptoms)- may take
up to 2-4 weeks to respond.
Use/clinical efficacy
Antipsychotic medications con’t
 Cognitive/Perceptual symptoms i.e.:
hallucinations, delusions, thought
broadcasting –2 to 8 weeks to respond
 Increasing meds will not hasten relief of
slow responding symptoms
 Usually start with divided doses
(minimizes s/e’s)
 Once effective –change to Daily or BID
dosing (increases med compliance)
Use/clinical efficacy
Antipsychotic medications con’t
 Absorption– absorbed well in GI tract
 Metabolism – metabolized in the liver
 Half Life –Adults (20 – 40 hours)
 Half Life – Elderly client may be doubled
 Adult steady state 4-7 days
 Monitor liver functions esp. elderly and
physically compromised
Use/clinical efficacy
Antipsychotic medications con’t
 INJECTABLE form– I M use for
emergencies only
(client imminent danger to self/others)
 Simultaneous use of a benzodiazepine
may help client to gain control more
rapidly ie: combination of Haldol and
Ativan
 LIQUID form-used when client has hx. of
non-compliance or has been suspected of
“cheeking” meds.
Antipsychotic medications
 LONG ACTING INJECTABLE –
 Used to increase compliance
 Eg. Haldol Decanoate/Prolixin Decanoate
 Given monthly or bi-weekly
 Half –life Haldol decanoate- 21 days
 Half-life for Prolixin decanoate –14 days
 Monitor carefully as out patient
Extrapyramidal Side Effects- EPS
 Serious neurological symptoms that are
major side effects of antipsychotic drugs.

 Cause: Blockade of D2(dopamine)in

midbrain region of the brainstem
EPS- Acute dystonia
 Symptoms may include:
 Blepharospasm [eye
closing]
 Torticolis [neck muscle
contraction –pulling head
to side]
 Oculogyric Crisis [severe
upward deviation of
eyeballs]
 Opisthotonos [severe
dorsal arching of neck and
back]
 Larngospasm/involve-
ment of tongue
[dysphasia- difficulty
swallowing]
EPS –Parkinsonism symptoms
 Tremors
 Bradykinesia/akinesia
[slowness, absence of
movement]
 Cogwheel rigidity[slow
regular muscular jerks]
 Postural instability
 Stooped/hunched posture
 Shuffling gait
 Restricted movements
 Masked face[loss of
mobility in facial muscles]
 Hypersalivation &drooling
EPS – Akathesia symptoms
 AKATHISIA – “not sitting”
 Pacing, Motor restlessness,Rocking, Foot
taping
 Subjective c/o inner restlessness, irritability,
inability to sit still or lie down.
 Need to differentiate between Akathisia and
psychomotor agitation or restlessness
Neuroleptic Malignant Syndrome
 A rare but potentially  Assessment – check
fatal complication of elevation of-B/P, high
treatment with fever-(hyperpyrexia),
neuroleptic drugs. rigidity, diaphoresis,
 Can occur within first pallor, delirium
2 weeks of use  LABS – elevated CPK
 Increased risk with (createnine
high dose- high phosphokinase)
potency drugs,
concurrent medical
conditions
(dehydration, poor
nutrition)
Neuroleptic Malignant Syndrome
Severe
Opisthotonos
[severe dorsal
arching of neck
and back]
As seen in NMS
TARDIVE DYSKINESIA
( late occurring abnormal movements)

 Effects 4% of persons taking

antipsychotics
 Choreoathetoid
movements [rapid,jerky
and slow,writhing
movements] may occur
anywhere in the body –
arms,feet,legs,trunk
 Classic description—
oral,buccal, lingual,&
masticatory
movements[ tongue
thrusting,lip pursing &
smacking,facial
grimaces and chewing
movements.