• Psychosis

– is a generic psychiatric term for a mental state in which thought and

perception are severely impaired
• Extrapyramidal syndrome
– A variety of signs and symptoms, including muscular rigidity,
parkinsonism, restlessness , peculiar involuntary postures , motor inertia ,
and many other neurologic disturbances.
• Pseudoparkinsonism
– stiff, stooped posture; masklike face, decreased arm swing, shuffling and
festinating gait, cogwheel rigidity, coarse pill rolling movement of thumb
& fingers at rest.
• Torticollis
– Torticollis is prolonged contraction of the neck muscles that causes the
head to turn to one side.
• Dystonia
– Acute muscular rigidity & cramping, a stiff or thick tongue with difficulty
swallowing to laryngospasm & respiratory difficulty. This is painful and
frightening.
• Oculogyric crisis
– Eyes rolled back and in locked position
• Tardive dyskinesia
– Irreversible, permanent, involuntary movement of the tongue, facial and
neck muscle, upper and lower extremities and truncal musculature
• Agranulocytosis
– Agranulocytosis usually refers to patients with fewer than 100 neutrophils
per microliter.
• Priapism
– the presence of a persistent, usually painful, erection of the penis
unrelated to sexual stimulation or desire
• Opisthotonos
– Thightness in the entire body with head and back and arched neck
• Akathesia
– Intense need to move about
• Anorectics
– appetite suppressants
• Neuroleptic malignant syndrome
– Potentially fatal condition of high fever with autonomic instability and
rigidity esp due to Antipsychotics with dehydration, poor nutrition, and
concurrent illness
– Neuroleptic malignant syndrome is the rarest of the neuroleptic induced
movement disorders. It is the most serious and represents a neurologic
emergency in most cases

Psychopharmacology
 • Medication management greatly influences the outcomes of treatment for many
clients with mental disorders

• Psychotropic drugs- antipsychotics, antidepressants, mood stabilizers, anxiolytics,

& stimulants.

• Efficacy- refers to the maximal therapeutic effect that a drug can achieve
• Potency- describes the amount of drug needed to achieve that maximum effect.
• Half-life – is the time it takes for half of the drug to be removed from the
bloodstream
• Black box warning- when a drug is found to have serious or life-threatening side
effects, even if side effects are rare.

• Reuptake
– is the reabsorption of a neurotransmitter by the molecular transporter of a
pre-synaptic neuron after it has performed its function of transmitting a
neural impulse. This prevents further activity of the neurotransmitter,
weakening its effects.
• Narcolepsy
– Attack of unwanted but irreversible daytime sleepiness that disrupt the
person’s life

Characteristics of Psychotropic drugs:

• Use to modify behavior
• Affect the CNS & Autonomic NS
• Do not cure mental illness but relieve its symptoms
• Types:
– Antipsychotics
– Antidepressants
– Mood stabilizers
– Anxiolytic
– Stimulants.

Anti-psychotic agents:
• Thorazine (Chlorpromazine Hydrochloride)
 • Clozapine (clozaril), Dopamine System Stabilizer, olanzapine (Zyprexa)
• Paripripazole (abilify)- headache, anxiety
• Depot injection-Prolixin (decanoate fluphenazine) can be given every 2-4 wks
• Haldol (haloperidol, haloperidol decanoate) can be given every 4 weeks
• Ziprasidone (Geodon)-rare EPS
• Thioridozine (Mellaril), Deoperidol (Inapsine), Mesoridazone (Serentil)-
dysrhythmia

• known as ataractic, neuroleptic, major tranquilizer, psychic energize

• Blocks DOPAMINE (D1, D2, D3, D4, D5) associated with mental illness.

• Treat the symptoms of psychosis such as the delusions and hallucinations (seen in
schizophrenia, schizoaffective disorder, manic phase of bipolar disorder)

• Off label use: treatment of anxiety and insomnia, aggressive behavior &
disruptive behavior.

– General considerations
• Calms an excited patient without producing impairment of motor
function sleep
• Have a high therapeutic index & can be given a high dose with
minimal risk
• Are not addicting & patients do not develop tolerance to their
antipsychotic effects
• Use of psychotic drugs during pregnancy is not recommended

Side effects:
• EPS
• NMS
• Anticholinergic side effects
• Tardive dyskinesia
• Agranulocytosis
• Sexual dysfunctions

– EPS: dystonia to torticollis, opisthothonus, oculogyric crisis

(anticholinergic to relieve the symptom), Pseudoparkinsonism, akathisia
To relieve EPS, change to other antipsychotic or lower the dose, or add
anticholinergic agent or antiparkinsonian drug
– NMS: (potentially fatal)
rigidity, High fever, autonomic instability, agitation to stupor
• NMS (Neuroleptic Malignant Syndrome)
– Potentially fatal reaction to antipsychotic drug
– s/s:
 • Rigidity
• High fever
• Autonomic instability (unstable BP, diaphoresis
• Pallor
• Delirium
• Elevated CPK
• Confused and mute
• Agitation to stupor

• Anticholinergic side effects:

– Orthostatic hypotension, dry mouth, constipation, urinary hesitancy or
retention, blurred near vision, dry eyes, photophobia, nasal congestion,
decreased memory
• Dry mouth- calorie free and sugar free beverages and hard candy
• Constipation- stool softener but not laxative, IOFI, grains and
fruits in the diet
• Photophobia- wear sunscreen
• Decreased memory- chart

• Tardive dyskinesia-permanent involuntary movement of the tongue, facial & neck

muscle, upper and lower extremities, lip smacking. (irreversible)
• Akathisia- movement disorder characterized by a feeling of inner restlessness and
a compelling need to be in constant motion as well as by actions such as rocking
while standing or sitting, lifting the feet as if marching on the spot and crossing
and uncrossing the legs while sitting

• Agranulocytosis
– Fever, malaise, ulcerative sore throat, leukopenia
– Nursing action: Monitor WBC

• Other side effects:

– Gynecomastia and sexual dysfunction, menstrual irregularities, weight
gain- due to increased Prolactin (except Ziprasidone (Geodon))
– Nursing action: avoid calorie laden beverages
• Breast enlargement & tenderness
• Decreased libido
• Erectile and orgasmic dysfunction-Priapism
• Weight gain

Antidepressants:
• Treatment of major depressive illness, anxiety disorders, depressed phase of
bipolar disorder, psychotic depression
 • Treatment of chronic pain, migraine, headache, peripheral and diabetic
neuropathy
• NOREPINEPHRINE & SEROTONIN -regulate mood, arousal, attention,
sensory processing, and appetite.
• MOA: work by slowing the removal of Neurotransmitters needed for normal
brain function. Antidepressants help people with depression by making these
natural chemicals more available to the brain
• S/E: Sexual dysfunction and weight gain

DIVISIONS:
• Tricyclic (overdose-lethal)
• Cause sedation, orhtostatic hypotension, anticholinergic side effect, sexual
dysfunction and weight gain
• Nursing action: take at night for safety
• If missed within 3 hrs, omit meds for the day.
• Lethal when OVERDOSED
• Effects after 4-6 weeks

• Tofranil (Imipramine)
• Elavil (amittriptyline)
• SSRI
• A medication that acts as a selective serotonin reuptake inhibitor (SSRI)
blocks the reuptake of serotonin and thereby increases the level of serotonin in
the brain.
• S/E: anxiety, agitation, akathisia, nausea, decreased sexual dysfunction,
weight gain
• SSRI: Selective serotonin reuptake inhibitors
• Only drug with once a week dosage for depression
• Effects after 2-3 weeks

• Venlafaxine (Effexor)
• Bupropion (Wellbotrin)-seizure 450mg/d
• Trazodone (Desyrel)- Priapism
• Nefazodone(Serzone)-hepatotoxic
• Fluoxetine (Prozac)
• Zoloft
• Nursing actions to relieve side effects:
– Nausea- give with food
– Akathisia- with beta blockers (inderal)
– Insomnia- with low dose trazodone

– If missed within 8 hrs, may take the forgotten meds.

• MAOI (hypertensive crisis)
Tricyclic antidepressant (TCA)
 Tofranil (Imipramine)
 Elavil (amittriptyline)
  Cause sedation, orhtostatic hypotension, anticholinergic side effect, sexual
dysfunction and weight gain
 Nursing action: take at night for safety
 If missed within 3 hrs, omit meds for the day.
 Lethal when OVERDOSED
 Effects after 4-6 weeks

SSRI antidepressant
 A medication that acts as a selective serotonin reuptake inhibitor (SSRI) blocks
the reuptake of serotonin and thereby increases the level of serotonin in the brain.
Bupropion (Wellbotrin)-seizure 450mg/d
Trazodone (Desyrel)- Priapism
Nefazodone(Serzone)-hepatotoxic
Fluoxetine (Prozac)
Zoloft

S/E
 Anticholinergic side effects:
 Orthostatic hypotension, dry mouth, constipation, urinary hesitancy or
retention, blurred near vision, dry eyes, photophobia, nasal congestion,
decreased memory
 Dry mouth- calorie free and sugar free beverages and hard candy
 Constipation- stool softener but not laxative, IOFI, grains and
fruits in the diet
 Photophobia- wear sunscreen
 Decreased memory- chart
 S/E: anxiety, agitation, akathisia, nausea, decreased sexual dysfunction, weight
gain

 SSRI: Selective serotonin reuptake inhibitors

 Only drug with once a week dosage for depression
 Effects after 2-3 weeks
 Nursing actions to relieve side effects:
 Nausea- give with food
 Akathisia- with beta blockers (inderal)
 Insomnia- with low dose trazodone

 If missed within 8 hrs, may take the forgotten meds.

Monoamine oxidase inhibitors (MAOIs) antidepressant

o Nardil (Phenelzine)
 o Hypertensive crisis as its limitation for use
o A life threathening situation when patient ingested tyramine containing
food
o Tyramine is a building block of norepinephrine. MAOIs inhibit MAO so
that it can't get rid of excess norepinephrine. Excessive amounts of
norepinephrine can lead to a hypertensive crisis and can even cause
intracerebral hemorrhage and death after consumption of certain tyramine-
containing foods or drinks.
o Tyramine containing food: Avocado, banana, cheddar and aged cheese,
soy sauce and preserved foods. Box 2.1 p36
o Nursing actions:
 health teaching on foods containing tyramine.
 Monitor BP
o Emsam- a MAOI patch
o Effects after 2-4 weeks
o S/E: daytime sedation, insomnia, anticholinergic s/e, weight gain, sexual
dysfunction
o Anticholinergic side effects:
o Orthostatic hypotension, dry mouth, constipation, urinary hesitancy or
retention, blurred near vision, dry eyes, photophobia, nasal congestion,
decreased memory
 Dry mouth- calorie free and sugar free beverages and hard candy
 Constipation- stool softener but not laxative, IOFI, grains and
fruits in the diet
 Photophobia- wear sunscreen
 Decreased memory- chart
o Fatal drug interaction:
o MAOI + other types of antidepressant
o CNS depressant + antihypertensive + general anesthetics
o MAOI + SSRI = serotonergic syndrome (SSRI overdose)
o SSRI + Cyclic antidepressant = treat OCD
o Drug intervals should be considered.

MOOD STABILIZER
  Lithium**
 Clonazepam (Klonopin)- acute mania, anti anxiety
 Anticonvulsant
 Carbamezipine (Tegretol)
 Depakote
 Depakene
 Gabopentin (Neurontin)
 Lamotrigine (Lamictal)

 Treat bipolar disorder by stabilizing the client’s mood, preventing or minimizing

the highs and lows.
 Treat acute episode of mania

LITHIUM
 Normalizes the reuptake of dopamine, norepinephrine, serotonin, acetylcholine
 NO parenteral form
 S/E:
 Nausea, diarrhea, anorexia, fine hand tremor (propranolol is given),
polydipsia, polyuria, metallic taste, fatigue, lethargy, weight gain, acne
 Toxic effect: Lithium toxicity
 NAVDA
 drowsiness, muscle weakness, lack of coordination
 Renal failure, coma, death
 Nursing action: administer Mannitol as prescribe

S/E
 Carbamezipine & Valproic acid
 Side effects: Drowsiness, sedation, dry mouth, blurred vision
 Carbamezipine:
 Adverse effect: rashes, orthostatic hypotension, aplastic anemia,
agranulocytosis
 Valproic acid:
 Adverse effect: Weight gain, hand tremor, liver failure, pancreatitis,
teratogenic effect (neural tube defect)
 Lamotrigine:
 Adverse effects: serious rashes, Steven Johnson syndrome, toxic
epidermal necrolysis
STEVEN JoHNSON - - - A serious systemic (bodywide) allergic reaction with a
characteristic rash involving the skin and mucous membranes, including the buccal
mucosa (inside of the mouth).
 Lithium: .5-1.0 mEq/L
 12 hours after last dose
 Carbamazepine: 200-2,000 mg/d
 Valproic: 750-3,000 mg/d
  Nursing action: monitor serum level
ANXIOLYTICS
 Treat anxiety and anxiety disorders: insomnia, obsessive compulsive disorder,
post traumatic stress disorder, alcohol withdrawal.
 Benzodiazepine- most effective in treating anxiety, also an anticonvulsant, and
muscle relaxant
 Buspirone- relief anxiety but not as well as Benzodiazepine

SLEEP DISORDER
 Tamazepam (Restoril)
 Triazolam (Halcion)
 Flurazepam (Dalmane)**

ALCOHOL WITHDRAWAL & ANXIETY RELIEF

 Diazepam (Valium)**
 Chlordiazepoxide (Librium)
 Clonazepam

NO alcohol with benzediazepines

STIMULANTS
 For children and adolescents with ADHD and residual attention deficit and
narcolepsy in adults
 Amphetamines- potential for abuse is high
 Dextroamphetamines- makes one high for long periods
 Methylphenidate (Ritalin)*- for ADHD
 Pemoline (Cylert)- Highly hepatotoxic
 Doxedrine & Ritalin- for narcolepsy(20-200 mg/d)
 Anorexia, weight loss, nausea, irritable
 Less common s/e: dizziness, dry mouth, blurred vision, palpitation
 Nursing actions:
 Health teachings:
 Avoid caffeine, sugar, and chocolates-worsen s/e
 Monitor Growth & development
 Cautiously give Ritalin to emotionally unstable clients
 Ritalin suppresses appetite when given before meals