Contemporary PsychiatricMental Health Nursing Chapter 32 Psychopharmacologic Nursing

Assessing the Effectiveness of Medications = Include how well the medications are helping the

Administering Medications A careful assessment is needed to decide the right form of the

Assess the Client’s Learning Capacity = Cognitive abilities = Readiness to learn = Knowledge

Assess the Client’s Learning Capacity - continued = Beliefs = Preferences = Lifestyle =

Assess the Client’s Cultural Perspective = The cultural perspective influences the client’s ideas about:

When Using an Interpreter = Be clear and descriptive = Focus on the client’s

Extrapyramidal Side Effects (EPSEs) = The first generation (conventional) antipsychotics may cause significant extrapyramidal

Extrapyramidal Side Effects (EPSEs) - continued = The five categories of EPSEs are dystonia,

Dystonia = Occurs usually within 48 hours of initiation of the medication = Involves

Drug-induced Parkinsonism = Usually occurs after 3 or more weeks of treatment = Characterized

Akathisia = Usually occurs after 3 or more weeks of treatment = Subjectively experienced

Akathisia - continued = Mild: a vague feeling of apprehension or irritability = Severe:

Tardive Dyskinesia = Usually occurs late in the course of long-term treatment = Characterized

Complications of Tardive Dyskinesia = Inability to wear dentures = Impaired respirations = Weight

Dopamine-Acetylcholine Imbalance in the Extrapyramidal System = A rare side effect = Characterized by

Methods to Improve Assessment of EPSEs = Use rating scales. – AIMS – Simpson

Positive Effects of Medications = Alleviation of the symptoms of the disorder, often improving:

Negative Effects of Medications = May include side effects and their management = Some

Discontinuation Syndrome = Many medications also have a discontinuation syndrome and must be gradually

Medication Adherence = Adherence to prescribed medications by clients in psychiatric services is less

Long-Term Medication Use = Clients may find it difficult to take medications over the

Ethical Concerns = Children and adolescents: consider the risk versus benefit = Potential impact

Common Interferences to Learning = Clients with psychosis: – Cognitive difficulties – Lack of

Common Interferences to Learning - continued = Clients with mood disorders: – Persistent dysphoria

Common Interferences to Learning - continued = Clients with anxiety disorders: – Addiction to

Interventions for the Major Side Effects of Antipsychotics = A primary nursing role is

Autonomic Nervous System Effects: Anticholinergic Side Effects = Dry mouth = Blurred vision =

Antiadrenergic Effect: Orthostatic Hypotension = Take the client’s blood pressure in a supine position

EPSEs = Dsytonia and drug-induced parkinsonism are treated by anticholinergics. = Akathisia may be

Other Central Nervous System Effects = Sedation = Lowering of the seizure threshold: –

Cardiac Effects = Some antipychotics may contribute to prolongation of the QTc interval and

Agranulocytosis = Early symptoms: beginning signs of infection = White blood cells are routinely

Endocrine Effects = Hyperprolactinemia may cause: – Oligomenorrhea or amenorrhea in women – Galactorrhea

Weight Gain = Monitor weight = Teach about diet and exercise = Weight gain

Neuroleptic Malignant Syndrome = Typically occurs in the first 2 weeks of treatment or

Side Effects of TCAs = Anticholinergic side effects = Changes in the electrical conduction

Issues with SSRIs = May precipitate hypomania or mania in a susceptible client =

Serotonin Syndrome = Symptoms: mental status changes, agitation, myoclonis, hyperreflexia, ataxia, diaphoresis, and cardiovascular,

SNRIs = Anticholinergic side effects = Dose-related elevated blood pressure with venlafaxine (Effexor) –

Suicidal Risk = Children, adolescents, and adults treated with antidepressants can experience greater suicidal

Side Effects of Mood Stabilizers = Address activating and sedating side effects = Common

Lithium Toxicity = Early signs: vomiting, diarrhea, lethargy, and muscle twitching = Occurs at

Side Effects with Anxiolytics = Problems in daytime functioning and drowsiness can lead to

Acetylcholinesterase Inhibitors = Generally safe, effective, well tolerated Contemporary Psychiatric-Mental Health Nursing, Second Edition

Interventions with Herbal Medicines = Assess herbal side effects and drug-drug interactions. – St.

Resources = http: //www. fda. gov/cder/drug/Drug. Safety/Drug. Index. htm#top The U. S. Food and

Resources - continued = http: //www. bipolarbrain. com/meds. html The Psychiatric Medication Guide is

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Contemporary Psychiatric-Mental Health Nursing Chapter 32 Psychopharmacologic Nursing Interventions Contemporary Psychiatric-Mental Health Nursing, Second Edition Carol R. Kneisl and Eileen Trigoboff Copyright © 2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Assessing the Effectiveness of Medications = Include how well the medications are helping the client to cope with psychiatric symptoms. = Assess whether the medications are causing side effects. = Observe for the subtle differences between symptoms and side effects. Contemporary Psychiatric-Mental Health Nursing, Second Edition Carol R. Kneisl and Eileen Trigoboff Copyright © 2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Administering Medications A careful assessment is needed to decide the right form of the medication: = PO - by mouth (for routine use) = Liquid form = Quick-dissolving formulation = PRN injection Contemporary Psychiatric-Mental Health Nursing, Second Edition Carol R. Kneisl and Eileen Trigoboff Copyright © 2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Assess the Client’s Learning Capacity = Cognitive abilities = Readiness to learn = Knowledge = Background = Environment Contemporary Psychiatric-Mental Health Nursing, Second Edition Carol R. Kneisl and Eileen Trigoboff Copyright © 2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Assess the Client’s Learning Capacity - continued = Beliefs = Preferences = Lifestyle = Support systems Contemporary Psychiatric-Mental Health Nursing, Second Edition Carol R. Kneisl and Eileen Trigoboff Copyright © 2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Assess the Client’s Cultural Perspective = The cultural perspective influences the client’s ideas about: – Mental health and illness – Medications – Beliefs related to caring Contemporary Psychiatric-Mental Health Nursing, Second Edition Carol R. Kneisl and Eileen Trigoboff Copyright © 2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

When Using an Interpreter = Be clear and descriptive = Focus on the client’s behaviors = Do not focus on who the client is personally or spiritually = Avoid euphemisms = Avoid Anglocentric health concepts Contemporary Psychiatric-Mental Health Nursing, Second Edition Carol R. Kneisl and Eileen Trigoboff Copyright © 2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Extrapyramidal Side Effects (EPSEs) = The first generation (conventional) antipsychotics may cause significant extrapyramidal side effects. = EPSEs require careful assessment and management Contemporary Psychiatric-Mental Health Nursing, Second Edition Carol R. Kneisl and Eileen Trigoboff Copyright © 2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Extrapyramidal Side Effects (EPSEs) - continued = The five categories of EPSEs are dystonia, drug- induced parkinsonism, akathisia, tardive dyskinesia, and dopamine-acetylcholine imbalance Contemporary Psychiatric-Mental Health Nursing, Second Edition Carol R. Kneisl and Eileen Trigoboff Copyright © 2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Dystonia = Occurs usually within 48 hours of initiation of the medication = Involves bizarre and severe muscle contractions = Can be painful and frightening = Characterized by odd posturing and strange facial expressions Contemporary Psychiatric-Mental Health Nursing, Second Edition Carol R. Kneisl and Eileen Trigoboff Copyright © 2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Drug-induced Parkinsonism = Usually occurs after 3 or more weeks of treatment = Characterized by: – Cogwheeling rigidity – Tremors – Rhythmic oscillations of the extremities – Pill rolling movement of the fingers Contemporary Psychiatric-Mental Health Nursing, Second Edition Carol R. Kneisl and Eileen Trigoboff Copyright © 2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Akathisia = Usually occurs after 3 or more weeks of treatment = Subjectively experienced as desire or need to move = Described as feeling like jumping out of the skin Contemporary Psychiatric-Mental Health Nursing, Second Edition Carol R. Kneisl and Eileen Trigoboff Copyright © 2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Akathisia - continued = Mild: a vague feeling of apprehension or irritability = Severe: an inability to sit still, resulting in rocking, running, or agitated dancing Contemporary Psychiatric-Mental Health Nursing, Second Edition Carol R. Kneisl and Eileen Trigoboff Copyright © 2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Tardive Dyskinesia = Usually occurs late in the course of long-term treatment = Characterized by abnormal involuntary movements (lip smacking, tongue protrusion, foot tapping) = Often irreversible Contemporary Psychiatric-Mental Health Nursing, Second Edition Carol R. Kneisl and Eileen Trigoboff Copyright © 2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Complications of Tardive Dyskinesia = Inability to wear dentures = Impaired respirations = Weight loss = Impaired gait = Impaired posture Contemporary Psychiatric-Mental Health Nursing, Second Edition Carol R. Kneisl and Eileen Trigoboff Copyright © 2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Dopamine-Acetylcholine Imbalance in the Extrapyramidal System = A rare side effect = Characterized by hallucinations, dry mouth, blurred vision, decreased absorption of antipsychotics, decreased gastric motility, tachycardia, and urinary retention Contemporary Psychiatric-Mental Health Nursing, Second Edition Carol R. Kneisl and Eileen Trigoboff Copyright © 2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Methods to Improve Assessment of EPSEs = Use rating scales. – AIMS – Simpson Neurological Rating Scale = Videotape the exam for comparison at a later date. Contemporary Psychiatric-Mental Health Nursing, Second Edition Carol R. Kneisl and Eileen Trigoboff Copyright © 2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Positive Effects of Medications = Alleviation of the symptoms of the disorder, often improving: – Ability to think logically – Ability to function in one’s daily life – Ability to function in relationships Contemporary Psychiatric-Mental Health Nursing, Second Edition Carol R. Kneisl and Eileen Trigoboff Copyright © 2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Negative Effects of Medications = May include side effects and their management = Some necessitate lifestyle changes – MAOIs require a low-tyramine diet that includes avoiding foods that are pickled, fermented, smoked, or aged Contemporary Psychiatric-Mental Health Nursing, Second Edition Carol R. Kneisl and Eileen Trigoboff Copyright © 2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Discontinuation Syndrome = Many medications also have a discontinuation syndrome and must be gradually tapered to lower doses before being stopped. Contemporary Psychiatric-Mental Health Nursing, Second Edition Carol R. Kneisl and Eileen Trigoboff Copyright © 2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Medication Adherence = Adherence to prescribed medications by clients in psychiatric services is less than 35% = Reasons for nonadherence: – Clients do not know what to expect from medications. – The schedule of doses or routes may be inconvenient. – Friends/relatives may not be supportive. Contemporary Psychiatric-Mental Health Nursing, Second Edition Carol R. Kneisl and Eileen Trigoboff Copyright © 2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Long-Term Medication Use = Clients may find it difficult to take medications over the long term. = Nurses should partner with clients to create a collaborative environment. – – Supportive contacts with client Family meetings Psychoeducation regarding medications An interest in how the medications are affecting the client Contemporary Psychiatric-Mental Health Nursing, Second Edition Carol R. Kneisl and Eileen Trigoboff Copyright © 2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Ethical Concerns = Children and adolescents: consider the risk versus benefit = Potential impact of pharmaceutical advertising = Conflict of interest = Right to refuse medications Contemporary Psychiatric-Mental Health Nursing, Second Edition Carol R. Kneisl and Eileen Trigoboff Copyright © 2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Common Interferences to Learning = Clients with psychosis: – Cognitive difficulties – Lack of motivation (negative symptom) – Side effects Contemporary Psychiatric-Mental Health Nursing, Second Edition Carol R. Kneisl and Eileen Trigoboff Copyright © 2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Common Interferences to Learning - continued = Clients with mood disorders: – Persistent dysphoria may lead to a lack of motivation. – Manic behaviors may interfere with learning. – Unpleasant side effects may be discouraging. Contemporary Psychiatric-Mental Health Nursing, Second Edition Carol R. Kneisl and Eileen Trigoboff Copyright © 2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Common Interferences to Learning - continued = Clients with anxiety disorders: – Addiction to antianxiety medication may be an issue. – The medication quick action may lead to the desire to take more. – Effective non-medication treatment may not be readily available. Contemporary Psychiatric-Mental Health Nursing, Second Edition Carol R. Kneisl and Eileen Trigoboff Copyright © 2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Interventions for the Major Side Effects of Antipsychotics = A primary nursing role is to teach patients about the major side effects of psychotropic medications and how to manage them. = Nurses must monitor for side effects and intervene when necessary. Contemporary Psychiatric-Mental Health Nursing, Second Edition Carol R. Kneisl and Eileen Trigoboff Copyright © 2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Autonomic Nervous System Effects: Anticholinergic Side Effects = Dry mouth = Blurred vision = Constipation = Urinary retention = Tachycardia Contemporary Psychiatric-Mental Health Nursing, Second Edition Carol R. Kneisl and Eileen Trigoboff Copyright © 2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Antiadrenergic Effect: Orthostatic Hypotension = Take the client’s blood pressure in a supine position and then in a standing position. = Caution clients to rise slowly from a supine position. Contemporary Psychiatric-Mental Health Nursing, Second Edition Carol R. Kneisl and Eileen Trigoboff Copyright © 2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

EPSEs = Dsytonia and drug-induced parkinsonism are treated by anticholinergics. = Akathisia may be treated with anticholinergics but is not always responsive. = Tardive dyskinesia treatment is preventive through careful and routine assessment. Contemporary Psychiatric-Mental Health Nursing, Second Edition Carol R. Kneisl and Eileen Trigoboff Copyright © 2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Other Central Nervous System Effects = Sedation = Lowering of the seizure threshold: – Observe clients with seizures disorders carefully when treatment is initiated. Contemporary Psychiatric-Mental Health Nursing, Second Edition Carol R. Kneisl and Eileen Trigoboff Copyright © 2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Cardiac Effects = Some antipychotics may contribute to prolongation of the QTc interval and lead to arrhythmias. – An EKG can identify those at risk. Contemporary Psychiatric-Mental Health Nursing, Second Edition Carol R. Kneisl and Eileen Trigoboff Copyright © 2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Agranulocytosis = Early symptoms: beginning signs of infection = White blood cells are routinely monitored in clients taking clozapine (Clozaril). Contemporary Psychiatric-Mental Health Nursing, Second Edition Carol R. Kneisl and Eileen Trigoboff Copyright © 2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Endocrine Effects = Hyperprolactinemia may cause: – Oligomenorrhea or amenorrhea in women – Galactorrhea in women and rarely in men – Osteoporosis if prolonged = Impotence in males may occur. = Diabetes – Monitor blood glucose levels. Contemporary Psychiatric-Mental Health Nursing, Second Edition Carol R. Kneisl and Eileen Trigoboff Copyright © 2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Weight Gain = Monitor weight = Teach about diet and exercise = Weight gain may contribute to physical as well as psychosocial stressors Contemporary Psychiatric-Mental Health Nursing, Second Edition Carol R. Kneisl and Eileen Trigoboff Copyright © 2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Neuroleptic Malignant Syndrome = Typically occurs in the first 2 weeks of treatment or when the dose is increased = Hold the medication, notify the physician, and begin supportive treatments. = Symptoms: muscle rigidity, hyperpyrexia, altered consciousness, and diaphoresis Contemporary Psychiatric-Mental Health Nursing, Second Edition Carol R. Kneisl and Eileen Trigoboff Copyright © 2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Side Effects of TCAs = Anticholinergic side effects = Changes in the electrical conduction of the heart = Cardiotoxic = Overdosing---a medical emergency – Perform a suicidal assessment routinely Contemporary Psychiatric-Mental Health Nursing, Second Edition Carol R. Kneisl and Eileen Trigoboff Copyright © 2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Issues with SSRIs = May precipitate hypomania or mania in a susceptible client = Serotonin syndrome: may occur if taking 2 or more medications that increase serotonin, including other SSRIs, TCAs, and MAOIs – Allow 1 -2 weeks between an MAOI and SSRI for most SSRIs – For fluoxetine (Prozac), allow a 5 week gap Contemporary Psychiatric-Mental Health Nursing, Second Edition Carol R. Kneisl and Eileen Trigoboff Copyright © 2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Serotonin Syndrome = Symptoms: mental status changes, agitation, myoclonis, hyperreflexia, ataxia, diaphoresis, and cardiovascular, GI, and motor abnormalities = Treatment: discontinue the suspected medication, initiate supportive treatments Contemporary Psychiatric-Mental Health Nursing, Second Edition Carol R. Kneisl and Eileen Trigoboff Copyright © 2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

SNRIs = Anticholinergic side effects = Dose-related elevated blood pressure with venlafaxine (Effexor) – Monitor blood pressure Contemporary Psychiatric-Mental Health Nursing, Second Edition Carol R. Kneisl and Eileen Trigoboff Copyright © 2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Suicidal Risk = Children, adolescents, and adults treated with antidepressants can experience greater suicidal ideation and behavior during the first few months of treatment – Monitor closely for suicidal risk Contemporary Psychiatric-Mental Health Nursing, Second Edition Carol R. Kneisl and Eileen Trigoboff Copyright © 2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Side Effects of Mood Stabilizers = Address activating and sedating side effects = Common side effects of lithium: tremor, nausea, thirst, polyuria = Monitor lithium levels: significant side effects are correlated with levels above 1. 2 m. Eq/l Contemporary Psychiatric-Mental Health Nursing, Second Edition Carol R. Kneisl and Eileen Trigoboff Copyright © 2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Lithium Toxicity = Early signs: vomiting, diarrhea, lethargy, and muscle twitching = Occurs at levels of 2 to 3 m. Eq/l = May be a medical emergency = Can be caused by restricted food and salt intake, diuretics, or overdose Contemporary Psychiatric-Mental Health Nursing, Second Edition Carol R. Kneisl and Eileen Trigoboff Copyright © 2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Side Effects with Anxiolytics = Problems in daytime functioning and drowsiness can lead to falls, especially in elders. = Respiratory depression (elders, those with respiratory diseases, those taking other CNS depressants) Contemporary Psychiatric-Mental Health Nursing, Second Edition Carol R. Kneisl and Eileen Trigoboff Copyright © 2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Acetylcholinesterase Inhibitors = Generally safe, effective, well tolerated Contemporary Psychiatric-Mental Health Nursing, Second Edition Carol R. Kneisl and Eileen Trigoboff Copyright © 2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Interventions with Herbal Medicines = Assess herbal side effects and drug-drug interactions. – St. John’s wort is a naturally occurring MAOI and may interact with other antidepressants. = The CAM industry is not regulated and monitored. Contemporary Psychiatric-Mental Health Nursing, Second Edition Carol R. Kneisl and Eileen Trigoboff Copyright © 2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Resources = http: //www. fda. gov/cder/drug/Drug. Safety/Drug. Index. htm#top The U. S. Food and Drug Administration Center for Drug Evaluation and Research is a federal agency. The website has consumer information on drugs approved by the FDA. = http: //www. mentalhelp. net Mental. Help is a website where consumers can find information related to medications and mental health disorders. = http: //www. nami. org The National Alliance on Mental Illness (NAMI) website provides current information about specific mental health disorders and medications, family support, and related links. Contemporary Psychiatric-Mental Health Nursing, Second Edition Carol R. Kneisl and Eileen Trigoboff Copyright © 2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Resources - continued = http: //www. bipolarbrain. com/meds. html The Psychiatric Medication Guide is a National Institute of Mental Health brochure to educate consumers about psychiatric medications. Contemporary Psychiatric-Mental Health Nursing, Second Edition Carol R. Kneisl and Eileen Trigoboff Copyright © 2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.