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, muscularirritability, 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 malignantsyndrome.
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.