1.3 Psychopharmacology Flashcards
Psychotropic Medications
- DOES NOT ELIMINATE MENTAL DISORDER
- Relieves physical and behavioral symptoms
- Used as a supplement with psychotherapy
Role of a Nurse
Legal/Ethical Issues - Patients have the right to refuse medications unless in emergency situations where client may harm themselves. Patients with history of violence can be court-ordered to take medications.
Assessment - Baseline assessment always done before beginning medications. These include history, physical, ethnocultural assessment and comprehensive medication assessment.
Medication administration/evaluation - Nurses are the key person in contact with individuals receiving medications. We monitor for side/adverse effects and evaluate therapeutic effectiveness
Patient Education - Education on medication
Psychotropic Medications
- Effects neuronal synapse and change neurotransmitter release/receptors.
- Antidepressants block re-uptake of neurotransmitters (serotonin and norepinephrine)
REUPTAKE - Inactivation of neurotransmitters by reabsorption into the presynaptic neuron where it came from. - Blocking re-uptake of neurotransmitters allows more of it to be available for neuronal transmission.
- Antipsychotic medications block dopamine, muscarinic cholinergic, histaminergic, and a-adrenergic receptors. Most block serotonin receptors.
- Benzodiazepines facilitate transmission of inhibitory neurotransmitter GABA
- Psychostimulants increase norepinephrine, serotonin, and dopamine release.
Anxiolytics
- Antianxiety medications (tranquilizers)
- Most appropriate for acute anxiety attacks, not long term treatment.
- Used for anxiety, alcohol withdrawal, muscle spasms, convulsive disorders, epilepticus, pre-operation sedation.
- Depresses subcortical levels in the CNS (limbic system and reticular formation)
- May potentiate GABA in the brain causing a calming effect.
- Most common is benzodiazepine (clonazepam (Klonopin), diazepam (Valium), alprozolam (Xanax)
INCREASED EFFECTS WHEN TAKEN WITH
- Alcohol, Barbiturates, Narcotics, Antipsychotics, Antidepressants, Antihistamines, Neuromuscular Blocking Agents, Cimetidine, Disulfiram
INCREASED EFFECTS WHEN TAKEN WITH HERBAL SUPPLEMENTS
- Kava, Valerian, Lemon Verbena, L-tryptophan, Melatonin, Chamomile
DECREASED EFFECTS WHEN TAKEN WITH
- Cigarettes and Caffeine
BLACK BOX WARNING
- Combining benzodiazepines with opioids or cough medicines.
Nursing Diagnosis
Risk of injury related to seizure, panic anxiety, agitation from alcohol withdrawal, abrupt withdrawal of long term medication, medication intoxication
Anxiety related to threat to physical integrity or self-concept
Activity Intolerance due to side effect of sedation, confusion, lethargy
Disturbed sleep pattern due to situational crises, physical condition, severe level of anxiety.
Evaluation of Anti-Anxiety Medication
- Reduction in anxiety, tension, restlessness
- No seizures or physical injury
- No evidence of confusion
- Tolerate usual activity without excessive sedation
- Tolerates medication without GI distress
- Understanding of side effects and self-administration
- Verbalizes possible side effects of withdrawal
Antidepressants
- Used for major depressive and dysthymic (low mood) disorders
SSRI’s
- Selective Serotonin Reuptake Inhibitors
Used to treat
- Anxiety disorders
- Bulimia Nervosa
- Premenstrual Dysphoric Disorder
- Borderline personality disorder
- Obesity
- Smoking Cessation
OTHER INDICATIONS
- Alcoholism
- Schizophrenia
- Intellectual disability
- Bipolar Disorder
- Depression with Anxiety
Antidepressant Action
- Increase concentration of norepinephrine, serotonin, dopamine
By.. - Blocking reuptake of these neurotransmitters
Or - Inhibiting release of monoamine oxidase
Antidepressant Drug Groups
MAOIs (Monoamine Oxidase Inhibitors)
- Inhibit release of Monoamine Oxidase
TCAs (Tricyclic Antidepressants)
- Block reuptake of norepinephrine and serotonin
SSRI’s (Serotonin Reuptake Inhibitor)
- Block reuptake of serotonin
SNRI’s (Serotonin/Norepinephrine Reuptake Inhibitor)
- Block reuptake of serotonin and norepinephrine
Atypical Antidepressant
- Dual mechanism antidepressants effecting both norepinephrine and serotonin
Antidepressant Medication Interactions
- Buspirone, TCA’s Selegiline Hydrochloride, St John’s Wort can cause SEROTONIN SYNDROME (fatal overstimulation of serotonin)
- Can also cause high fever, convulsions, severe hypertension, and psychosis
- TCA’s were developed due to MAOIs being potentially deadly due to interactions with drugs/food. TCA’s were found to cause urine retention and dry mouth and postural hypotension.
- Then SSRIs and SNRIs were developed which led to atypical antidepressants for those who did not respond well to SSRIs and SNRIs
SSRI Interactions
Buspirone, TCA, Selegiline, St Johns Wort - SEROTONIN SYNDROME
MAOIs - Hypertensive Crisis
Warfarin/NSAIDs - Risk of bleeding
Alcohol/Benzodiazepines - Increased sedation
Antiepileptics - Lowered seizure threshold
TCA Interactions
MAOIs - High fever, convulsion, death
St John Wort - Seizure, Serotonin Syndrome
Clonidine, Epinephrine - Severe Hypertension
Acetylcholine Blocker - Paralytic Ileus (Bowel Impairment)
Alcohol/Carbamazepine - Blocks antidepressant action and increases sedation
Cimetidine, Bupropion - Increased TSA blood levels and increased side effects
MAOIs Interactions
SSRI, TCA, atomoxetine, duloxetine, dextromethorphan (cough syrup), venlafaxine, St John Wort, ginkgo - Serotonin Syndrome
Morphine/Narcotic Pain Relievers - Hypotension
Antidepressants (pseudoephedrine, amphetamines, cocaine cyclobenzaprine, dopamine, methyldopa, levodopa, epinephrine, buspirone - Hypertensive Crisis (even if taken within 2 weeks of stopping MAOIs)
Buspirone - Psychosis, agitation, seizures
Antidiabetics - Hypoglycemia
Tegretol - Fever, Hypertension, Seizures
Medication Diagnosis (Antidepressants)
- Risk of suicide due to depression
- Risk of injury due to side effects
- Social isolation due to depressive mood
- Risk of constipation due to medication
- Risk of insomnia due to depressive mood
Outcome Criteria/Evaluation Antidepressants
- Patient has not harmed themselves
- Patient has not had injury from side effects
- Patients vitals are normal
- Patient has better mood (brighter mood, interaction with others, improved hygiene, clear thought, hopeful, ability to decision-make)
- Willing participation in activities and interaction with others
Mood Stabilizing Agents
- Used for bi-polar disorder
- Action is unclear
- May interact with lithium (salt). Decreased sodium allows more receptor sites for lithium and increases risk of toxicity. Patients should maintain normal sodium intake to reduce lithium level fluctuation. Increase in sodium decreases lithium and Decrease in sodium increases lithium.
- Those who respond well to lithium will be placed on it forever. Monitor for therapeutic range to prevent toxicity
Acute Mania - 1.0 - 1.5 mEq/L
Maintenance - 0.6 - 1.2 mEq/L
Nursing Diagnosis Mood Stabalizers
- Risk of injury due to manic activity
- Risk of violence due to unresolved anger
- Risk of lithium toxicity
- Risk of injury from adverse effects
- Risk of activity intolerance due to drowsiness/dizziness
Outcome of Mood Stabilizers
- Maintenance of mood stability
- Does not harm anyone or themselves
- No injury from hyperactivity
- Able to participate in activities without dizziness or sedation
- Maintain appropriate weight
- No signs of lithium toxicity
- Verbalizes importance of taking medication regularly with blood tests.
Antipsychotics
- Treatment of schizophrenia and other psychotic disorders
Antiemetics - chlorpromazine, perphenazine, prochlorperazine
Intractable Hiccups - Chlorpromazine
Tourette’s Disorder - Haloperidol, Pimozide
Typical Antipsychotic Contraindications
- Do not use when in coma or CNS depression
- Blood dyscarias (disease)
- Parkinson’s or Narrow-Angle Glaucoma
- Liver/Renal/Cardiac insufficiency
- Poorly controlled seizure disorders
- Dementia related psychosis
Atypical Antipsychotic Contraindications
- Do not use in coma/dementia/lactation
- -done and -pine contraindications
- History of prolonged QT intervals
- MI
- Uncompensated heart failure
- Concurrent use with other drugs that prolong QT interval
Clozapine Contraindications
- Myeloproliferative disorders
- Uncontrolled epilepsy
Typical Antipsychotic Action
- Blocks dopamine receptors in basal ganglia, hypothalamus, limbic system, brainstem, medulla
- Alter affinity for cholinergic, alpha-1, and histamine receptors
- Inhibits dopamine-mediated transmission of neural impulses
- Be careful when administering to elderly due to metabolic disturbances such as weight
(Caution with elderly who are ill, diabetic, respiratory insufficiency, prostatic hypertrophy, intestinal obstruction)
Atypical Antipsychotic Action
- Weak dopamine receptor antagonist but strong serotonin antagonist
Antipsychotic Interactions
- Severe hypotension with hypertensive drugs
- Reduces effects of oral anticoagulants
- Additive effects with medications that increase QT interval
Anti-Psychotic Nursing Diagnosis
- Risk of violence related to panic anxiety
- Risk of injury related to medication side effects
- Risk if inactivity due to medication side effects
- Non-compliance of medication due to mis-trust of others
Antipsychotic Education
- Smoking decreases effectiveness (increases metabolism)
- Temperature is hard to maintain with these medications (dress appropriately)
- Alcohol potentiates anti-psychotics
Clozapine
- Agranulocytosis (low neutrophil count less than 500 uL) is a major risk (Neutropenia)
- Must be monitored
EXTRAPYRAMIDAL SIDE EFFECTS OF ANTI-PSYCHOTICS
Pseudoparkinsonism
- Symptoms occur 1-5 days after starting medication. Mostly in women, elderly, and dehydrated patients
- Tremor, shuffling, gait, drooling, rigidity
Akinesia
- Muscular Weakness
Akathisia
- Frequent in women 50-60 days after beginning therapy
- Restlessness and fidgeting
Dystonia
- Involuntary muscle spasms of the face, arms, legs, neck
- Common in men under 25
- EMERGENCY
- TREATED WITH IM/IV Benztropine (Cogentin)
Oculogyric Crisis
- Uncontrolled rolling of eyes
- Happens with dystonia
- MEDICAL EMERGENCY
Tardive Dyskinesia
- Bizarre face/tongue movements, stiff neck, difficulty swallowing
- Most common with 1st gen anti-psychotics
Sexual Side Effects
- Decreased libido
- Retrograde ejaculation (semen ejected into bladder instead of urethra)
- Gynecomastia
- Amenorrhea
Outcome of Anti-psychotics
- No harm to self or others
- No injury from medication side effects of lowered seizure threshold and photosensitivity
- Maintain normal ANC (Absolute Neutrophil Count)
- No extrapyramidal side effects
- Maintain normal weight
- Tolerate activity
Sedative Hypnotics
- Short term management for anxiety and insomnia
- Reduces symptoms of alcohol withdrawal
- Anticonvulsant for pre-op
- Causes CNS depression and promotes sleep by agonist on melatonin receptors
- Can cause dependence except Ramelteon (Rozerem)
Sedative Hypnotics Contraindications
- Pregnancy
- Hepatic/Cardiac/Respiratory/Renal Disease
- Caution with suicidal patients
Barbiturate Interactions
- Effects are increased with alcohol, CNS depressants, MAOIs and Valproic Acid
- Effects decreased with rifampin
Decreases Effects Of
- Anticoagulants, beta blockers, contraceptives, corticosteroids, digitoxin,
Benzodiazepine Interactions
- Effects increased with CNS depressants, alcohol, oral contraceptives, isoniazid,
- Decreased with rifampin, st john wort, cigarettes
- Increases effects of digoxin, phenytoin
Eszopiclone
- Additive effects with alcohol and CNS depressants
- Decreased effects with rifampin, lorazepam, and HIGH FAT MEALS
Zaleplon
- Additive effects with other CNS depressants
Zolpidem
- Life threatening cardiac dysrhythmias with amiodarone
Sedative Hypnotic Diagnosis
- Injury due to withdrawal or mental alertness from residual sedation
- Disturbed sleep pattern
- Activity Intolerance
- Confusion due to affect on CNS
Outcome Sedative Hypnotics
- Reduced anxiety
- Asleep within 30 minutes for 6-8 hours
- Participation in usual activity without residual sedation
- No injuries or confusion
- Understanding that this is a short term treatment plan and prolonged use can cause dependence
ADHD Agents
- Amphetamines can also be used to treat narcolepsy (daytime drowsiness) and exogenous obesity.
- Bupropion is used for major depression and smoking cessation (Zyban)
- Clonidine and Guanfacine used to treat hypertension
ACTION
Atomoxetine - Inhibits reuptake of norepinephrine
Bupropion - Blocks uptake of serotonin, norepinephrine and dopamine
Clonidine and Guanfacine - Stimulates alpha-adrenergic receptors that reduces sympathetic flow to CNS
CNS Stimulants - Increases level of neurotransmitters in CNS
- WORKS BY ACTIVATING DOPAMINE RECEPTORS WHICH DEPRESS MOTOR ACTIVITY
CNS Stimulant Contraindications
- Arteriosclerosis
- CVD
- Hypertension
- Hyperthyroidism
- Glaucoma
- Drug abuse
- Within 14 days of MAOIs
- Young children and pregnancy
ADHD Medication Precautions
- CAUTION in children with psychosis, Tourette’s Disorder, anorexia/insomnia, elderly, history of suicidal thoughts, can cause dependence
- Atomoxetine and Bupropion caution with urinary retention patients, hypertension, hepatic/renal/cardiac disease patients, suicidal clients, elderly
- Alpha agonist use caution in patients with coronary insufficiency, recent MI, stroke, chronic renal/hepatic failure, elderly, pregnancy and lactation.
Nursing Diagnosis ADHD Medications
- Injury from overstimulation, hyperactivity in CNS, and seizures
- Risk of suicide from withdrawal (adults)
- BLACK BOX WARNING RISK OF SUICIDE IN ADOLESCENTS OF ATOMEXETINE AND BUPROPION
- Risk of anorexia and weight loss from CNS Stimulants
- Insomnia from over stimulation
- Risk of abdominal pain and headaches
- Activity Intolerance
Education for ADHD Medications
- Caution Driving
- Don’t stop taking abruptly
- Avoid taking late day to prevent insomnia
- Monitor blood sugar in diabetics due to change in diet and weight
- Avoid caffeine
- Carry Medication Card
