Psychopharmacology (Ch 4) Flashcards
Role of the nurse in psychotropic medication administration: ethical and legal implications
- Nurses must understand the ethical and legal implications associated with the administration of psychotropic medications
- Most states adhere to the clients right to refuse treatment, except in emergency situations
Role of the nurse in psychotropic medication administration: assessment
- A thorough baseline assessment must be conducted before a client is placed on a regimen of psychopharmacological therapy – H&P, EKG, weight and waist circumference
- Cultural considerations are necessary in assessment (some pt.’s respond differently to meds depending on culture & genes, such as being more sensitive. more on next flashcard)
Role of the nurse in psychotropic medication administration: administration and evaluation
The nurse monitors for side effects and adverse reactions and evaluates the therapeutic effectiveness of the medication.
Role of the nurse in psychotropic medication administration: patient education
The nurse translates the complex information related to the medication into terms that can be easily understood by the client.
Education should be provided at about a 5th grade level: give verbal AND written information; Use “every-day language” pt.’s will understand.
Remember it is imperative to assess patient’s understanding of education; consider primary language, developmental stage, and literacy
How do psychotropics work?
Psychotropic medication affects neurotransmission.
Reuptake is the process of neurotransmitter inactivation.
Blocking the reuptake process allows more of the neurotransmitter to be available for neuronal transmission.
5 types of psychotropic medications
1) Antidepressants
2) Mood stabilizers
3) Antipsychotics
4) Benzodiazepines (& other antianxiety agents)
5) Psychostimulants
Antianxiety Agents: indications, action, contraindications/precautions, and interactions
Indications: anxiety disorders, anxiety symptoms, acute alcohol withdrawal, skeletal muscle spasms, convulsive disorders, status epilepticus, and preoperative sedation
Action: depression of the central nervous system (CNS) (exception: buspirone)
Contraindications/precautions: contraindicated in known hypersensitivity, in combination with other CNS depressants, in pregnancy and lactation, narrow-angle glaucoma, shock, and coma. Caution with elderly and debilitated clients, clients with renal or hepatic dysfunction, those with a history of drug abuse or addition, and those who are depressed or suicidal.
Interactions:
- Increased effects when taken with alcohol, barbiturates, narcotics, antipsychotics, antidepressants, antihistamines, neuromuscular blocking agents, cimetidine, disulfiram, kava kava, or valerian root (& other herbal depressants)
- Decreased effects with cigarette smoking and caffeine consumption
Benzodiazepine Drugs (Anti-Anxiety Agents) (6)
Diazepam (Valium)
Chlordiazepoxide (Librium)
Clorazepate (Tranxene)
Clonazepam (Klonopin)
Lorazepam (Ativan)
Alprazolam (Xanax)
Other anti-anxiety medications (9)
Buspirone (BuSpar) *
Gabapentin (Neurontin)
Hydroxyzine (Atarax, Vistaril)
Propanolol (Inderal)
Atenolol (Tenormin)
Guanfacine (Tenex)
Clonidine (Catapres)
Prazosin (Minipress)
Pregabalin (Lyrica)
Note: Some anti-depressants also used for anxiety
Anti-anxiety medication S/E
Drowsiness, confusion, lethargy, tolerance, physical and psychological dependance, potentiation of other CNS depressants, aggravation of depression, orthostatic hypotension, paradoxical excitement, dry mouth, nausea and vomiting, blood dyscrasias, delayed onset (with buspirone only)
Antidepressants: indications, action, and contraindications/precautions
Indications: Dysthymia (chronic depression), major depressive disorder, depression associated with organic disease, alcoholism, schizophrenia, intellectual disability, depressive phase of bipolar disorder, and depression accompanied by anxiety.
Action: Increase concentration of norepinephrine, serotonin,
and/or dopamine in the body either by blocking their reuptake by the neurons (tricyclics, heterocyclics, SSRIs, SNRIs) or by inhibiting the release of monoamine oxidase (MAOIs).
Contraindications: Contraindicated in known hypersensitivity (all), acute phase of recovery from myocardial infarction (MI) and in angle-closure glaucoma (tricyclics), and concomitant (naturally accompanying) with MAOIs (all).
Precautions: Caution with elderly or debilitated clients; clients with hepatic, cardiac, or renal insufficiency; psychotic clients; clients with benign prostatic hypertrophy; and those with a history of seizures.
What is the action of the enzyme monoamine oxidase?
The enzyme, monoamine oxidase breaks down excess tyramine in the body; blocking this enzyme helps decrease depression.
Antidepressant classifications (5 types)
1) MAOI (monoamine oxidase inhibitor)
- Many side effects, dietary restrictions (tyramine – see table
4-7 Pg. 71)
2) Tricyclics antidepressants (TCAs)
3) Serotonin Reuptake Inhibitors (SSRIs)
4) Serotonin/norepinephrine reuptake inhibitors (SNRIs)
sometimes called S-SNRI
5) Heterocyclics
Antidepressant - MAOI’s medications (4)
1) Tranylcypromine (Parnate)
2) Phenelzine (Nardil)
3) Isocarboxazid (Marplan)
4) Selegiline (Emsam) - patch
Antidepressant - TCA’s medications (5)
1) Imipramine (Tofranil)
2) Clomipramine (Anafranil)
3) Amitriptyline (Elavil)
4) Nortriptyline (Pamelor)
5) Doxepin
Antidepressant - SSRI’s medications (6)
1) Citalopram (Celexa)
2) Escitalopram (Lexapro)
3) Fluoxetine (Prozac)
4) Paroxetine (Paxil)
5) Sertraline (Zoloft)
6) Vilazodone (Viibyrd)
Antidepressant - SNRI’s medications (3)
1) Desvenlafaxine (Pristiq)
2) Duloxetine (Cymbalta)
3) Venlafaxine (Effexor)
Antidepressant - Heterocyclics medications (3)
1) Bupropion (Wellbutrin)
2) Mirtazapine (Remeron)
3) Trazodone
Antidepressant S/E - all chemical classes
Dry mouth, sedation, nausea, discontinuation syndrome (flu-like, insomnia, nausea, imbalance, hyperarousal)
Antidepressant S/E - tricyclics and heterocyclics
Blurred vision, constipation, urinary retention*, orthostatic hypotension, reduction of seizure threshold, tachycardia, arrhythmias, photosensitivity, weight gain
Antidepressant S/E - SSRI’s and SNRI’s
Insomnia, agitation, headache, weight loss, sexual dysfunction,
serotonin syndrome
Antidepressant S/E - MAOI’s
Hypertensive crisis (can be fatal), Site reactions (selegiline transdermal system)
Antidepressant S/E - miscellaneous side effects (not common)
Priapism (prolonged unwanted erection), hepatic failure
Antidepressant S/E: signs and symptoms of Serotonin Syndrome
Restlessness, agitation
Confusion
Tachycardia
High Blood Pressure
Dilated Pupils
Muscle rigidity
Loss of muscle coordination
Diarrhea
Sweating
IF NOT TREATED MAY LEAD TO SEVERE SYMPTOMS—HIGH FEVER, SEIZURES, ARRHYTHMIAS, UNCONSCIOUSNESS
Mood-Stabilizing Agents: Indications, Action, Interactions, Contraindications/precautions
Indications: Prevention and treatment of manic
episodes associated with bipolar disorder.
Action: Lithium is thought to modulate the effects of
norepinephrine, serotonin, dopamine, glutamate, and GABA,
which may contribute to the symptomatology of bipolar
disorder. The role of anticonvulsants, verapamil, and
antipsychotics in the treatment of bipolar mania is not fully understood.
Interactions: Because lithium is an imperfect substitute for sodium, anything that depletes sodium will make more receptor sites available to lithium and increase the risk for lithium toxicity
Contraindications/precautions: Avoid with kidney damage.
Mood-Stabilizing Agents: examples (3)
Lithium*, anticonvulsant medications,
and second-generation atypical antipsychotics.
Mood-Stabilizing Agents: Lithium planning/implementation
Lithium toxicity
- Initial symptoms of toxicity include: Blurred vision, ataxia (clumsy voluntary movements), tinnitus, persistent nausea and vomiting, and severe diarrhea
- CAN LEAD TO TREMORS, SEDATION, CONFUSION, DELIRIUM, SEIZURES, COMA, CARDIOVASCULAR COLLAPSE, DEATH
- Ensure that client consumes adequate sodium and fluid in diet.
- MUST HAVE PERIODIC BLOOD LEVEL MONITORING
MANY PROVIDERS NOW CHOOSE TO PRESCRIBE ANTICONVULSANTS OR ATYPICAL ANTIPSYCHOTICS AS FIRST-LINE TREATMENT INSTEAD OF LITHIUM.
Mood-Stabilizing Agents: Lithium therapeutic range *
Therapeutic range:
- 1.0–1.5 mEq/L (acute mania)
- 0.6–1.2 mEq/L (maintenance)
Antipsychotics: Indications and Contraindications/precautions
Indications: Used for the treatment of schizophrenia and other psychotic disorders; selected agents are also used in the treatment of bipolar mania, as antiemetics, in the treatment of intractable
hiccoughs, and for control of tics and vocal utterances
in Tourette’s disorder.
Contraindicated in hypersensitive, comatose, or severely depressed patients; elderly patients with dementia-related psychosis; certain medications are contraindicated in patients with a history of QT prolongation or other heart issues.
Caution with elderly or debilitated patients; patients with cardiac, hepatic, or renal insufficiency; those with a history of seizures; patients with diabetes or risk factors for diabetes; clients exposed to temperature extremes under conditions that cause hypotension; and pregnant clients or children.
Antipsychotics: Typical antipsychotics (first-generation -FGA) action
Block postsynaptic dopamine receptors in the basal ganglia, hypothalamus, limbic system, brainstem, and medulla.
Demonstrate varying affinity for cholinergic, alpha-1-adrenergic, and histaminic receptors.
Inhibit dopamine-mediated transmission of neural impulses at the synapses.
Antipsychotics: Atypical antipsychotics (second generation – SGA)
Weaker dopamine receptor antagonists than the typical antipsychotics
Potent antagonists of the serotonin type 2A (5HT-2A) receptors
Exhibit antagonism for cholinergic, histaminic, and adrenergic receptors
Antipsychotics: Typical antipsychotics (first-generation -FGA) examples
Chlorpromazine (Thorazine)
Fluphenazine (Prolixin)
Haloperidol (Haldol)
Perphenazine
Thiothixene
Antipsychotics: Atypical antipsychotics (second generation – SGA)
Aripiprazole (Abilify)
Asenapine (Saphris)
Clozapine (Clozaril) (monitoring required)
Iloperidone (Fanapt)
Lurasidone (Latuda)
Olanzapine (Zyprexa)
Paliperidone (Invega)
Quetiapine (Seroquel)
Risperidone (Risperdal)
Ziprasidone (Geodon)
Antipsychotic medication S/E
Anticholinergic effects, nausea, gastrointestinal upset, skin rash, sedation, orthostatic hypotension, photosensitivity, hormonal effects, electrocardiogram changes, reduction of seizure threshold, agranulocytosis (low WBC) (especially with clozapine), hypersalivation (with clozapine), extrapyramidal symptoms, tardive dyskinesia, neuroleptic malignant syndrome, hyperglycemia and diabetes, increased risk of mortality in elderly patients with NCD-related psychosis
Issues in Antipsychotic medication therapy
Clozapine (Clozaril) and Agranulocytosis risk
Extrapyramidal side effects
Hormonal side effects
Antipsychotics: EXTRAPYRAMIDAL SIDE EFFECTS
(EPS)
EPS IS POSSIBLE WITH ANY ANTIPSYCHOTIC
Pseudo parkinsonism (tremor, shuffling gait, drooling,
rigidity)
Akinesia (muscle weakness)
Akathisia (continual restlessness)
Dystonia and Oculogyric crisis (involuntary upward deviation of the eyes) – CAN BE LIFE THREATENING
Antipsychotics: NEUROLEPTIC MALIGNANT SYNDROME
NMS – Rare, but Life-threatening complication of
neuroleptic drugs.
Symptoms:
Severe muscle rigidity
High fever – 104 *
Tachycardia
Fluctuations in blood pressure
Diaphoresis – Panting
Stupor (lack of critical mental function)
Coma
Antipsychotics: TARDIVE DYSKINESIA
TD can occur with long-term use of antipsychotics
Symptoms can be permanent
ABNORMAL INVOLUNTARY MOVEMENT SCALE (AIMS) DEVELOPED TO SCREEN FOR TD by NIMH
Sedatives - Hypnotics: Indication, Action, and Contraindications/precautions
Indications: Short-term management of various anxiety states
and treatment of insomnia; selected agents are used as
anticonvulsants, as preoperative sedatives, and to reduce anxiety associated with alcohol withdrawal.
Action: Depression of the CNS
- Exception: Ramelteon’s sleep-promoting properties are the result of agonist activity on selective melatonin receptors.
Contraindicated in known hypersensitivity, pregnancy, and lactation, and in severe hepatic, cardiac, respiratory, or renal disease.
Precautions: Caution is advised with clients with hepatic, cardiac, renal, or respiratory insufficiency. Caution is also advised with those who are suicidal and those who have been addicted to drugs.
Sedatives - Hypnotics: S/E
Drowsiness, confusion, lethargy, tolerance, physical and psychological dependence, potentiation of other CNS depressants, aggravation of depression, orthostatic hypotension, paradoxical excitement, dry mouth, nausea, vomiting, and blood dyscrasias (abnormal decrease or increase in blood components).
Abnormal thinking and behavioral changes
ADHD Agents: Indication and Action (CNS stimulants)
Indications: Attention deficit/hyperactivity disorder (ADHD) in
children and adults
Action: The CNS stimulants (Amphetamines, Methylphenidate)
increase levels of norepinephrine, dopamine, and serotonin in the CNS. Their effectiveness in the treatment of ADHD is thought to be based on the activation of dopamine D4 receptors in the basal
ganglia and thalamus, which depress, rather than enhance, motor activity.
Sedatives - Hypnotics: examples
Temazepam (Restoril)
Triazolam (Halcion)
Zolpidem (Ambien)
Eszopiclone (Lunesta)
Ramelteon (Rozerem)
Diphenydramine (Benadryl)
Doxepin
ADHD Agents: Action (nonstimulants)
Atomoxetine (Straterra) inhibits the reuptake of norepinephrine, and Bupropion (Wellbutrin) blocks the neuronal uptake of serotonin, norepinephrine, and dopamine.
Clonidine and guanfacine stimulate central alpha-adrenergic receptors in the brain resulting in reduced sympathetic outflow from the CNS.
The exact mechanism by which these nonstimulant drugs produce the therapeutic effect in ADHD is unclear.
ADHD Agents: Contraindications (CNS stimulants)
CNS stimulants: Contraindicated in clients with hypersensitivity to sympathomimetic amines; clients with advanced arteriosclerosis, cardiovascular disease, hypertension, hyperthyroidism, glaucoma, agitated or hyperexcitability states; clients with a history of drug abuse; clients during or within 14 days of receiving therapy with MAOIs; in children younger than 3 years of age; and in pregnancy and
lactation
ADHD Agents: Contraindications (nonstimulants??)
Atomoxetine and bupropion: Contraindicated in clients with
hypersensitivity to the drugs, in lactation, and in concomitant use with or within 2 weeks of using MAOIs
Bupropion: Contraindicated in clients with known or suspected
seizure disorder, acute phase of MI, and in clients with bulimia or
anorexia nervosa
Alpha agonists: Contraindicated in clients with known
hypersensitivity to the drugs
ADHD Agents: Precautions (CNS stimulants and nonstimulants)
CNS stimulants: Use caution in children with psychoses; clients with Tourette’s disorder, anorexia, or insomnia; elderly, debilitated, or asthenic clients; and clients with history of suicidal or homicidal tendencies; prolonged use may result in tolerance and physical or psychological dependence.
Atomoxetine and Bupropion (nonstimulants): Use caution in clients with urinary retention; hepatic, renal, or cardiovascular disease; suicidal clients; pregnancy; and elderly and debilitated clients.
Alpha agonists (nonstimulant): Caution in clients with coronary insufficiency, recent MI, or cerebrovascular disease; in chronic renal or hepatic failure; the elderly; and in pregnancy and lactation
ADHD Agents: S/E
Overstimulation, restlessness, insomnia, palpitations, tachycardia, anorexia, weight loss, tolerance, physical and psychological dependence, nausea and vomiting, constipation, dry mouth, sedation or rebound syndrome (alpha agonists), potential for seizures (bupropion), liver damage (atomoxetine), and new or worsened psychiatric symptoms (CNS stimulants and atomoxetine)
