NCM 105 Overview

NCM105 – PSYCHIATRIC/MENTAL
HEALTH NURSING
Lectured by Leila T. Salera, RN, MD,
DPSP

OVERVIEW

Lectured by Leila T. Salera, RN, MD,
DPSP

Historical overview of psychiatric care
• Primitive beliefs
1. People with mental illness has been dispossessed by
his or her soul
2. People with mental illness are possessed by evil
spirits
• Hippocrates (400 BC)
1. Associated insanity and mental illness with an
irregularity in the interaction of the four body fluids
or humors (blood, black bile, yellow bile, and phlegm)
2. Disequilibrium of these humors led to being treated
with potent cathartic agents
(Chapter 2 of Townsend)

• Middle Ages
1. Middle Eastern Islamic countries start to believe that
people with mental illness are actually ill
2. Establishment of special units within general hospitals
• 16th and 17th Centuries
1. Mental institutions did not exist in the US, and care
for the mentally ill is a family responsibility
2. Those without family became the responsibility of the
community and are incarcerated


1790s – The Period of Enlightenment
• Phillippe Pinel in France and William Tukes in
Englang formulated the concept of asylum as
a safe refuge or haven offering protection at
institutions where people have been
whipped, beaten, and starved just because
they were mentally ill

(Chapter 1, Videbeck)

• 18th Century
1. First hospital for the mentally ill was established in the US
2. Benjamin Rush – the father of American Psychiatry,
introduced more humane treatment but also used methods
like bloodletting, purging, various types of restraints, and
extremes of temperatures
• 19th Century
1. Establishments of the asylum thanks to Dorothea Dix, a
former New England schoolteacher, who lobbied on behalf
of the mentally ill
2. Humanistic therapeutic care
3. Asylums became overcrowded over time and conditions
deteriorated and therapeutic care reverted to custodial care.

• 1873
1. Linda Richards – graduated from New England Hospital for
Women and became known as the first American Psychiatric
Nurse
2. She was instrumental in the establishment of a number of
psychiatric hospitals and the first school of psychiatric
nursing at the McLean Asylum in Waverly , Massachusettes
in 1882
3. Focus: training in how to provide custodial care in psychiatric
asylums

• After WWII
1. US government passed the National Health Act of 1946
2. This legislation provided funds for the education of
psychiatrists, psychologists, social workers, and psychiatric
nurses
3. Introduction of antipsychotic medications
• 1955
1. Incorporation of psychiatric nursing curicula
2. Incorporation of nursing interventions in the somatic
therapies (insulin shock and electroconvulsive therapy)

• 20th Century onwards
• Diagnostic and Statistical Manual (DSM) I – 1952
• DSM II - 1962
• DSM III – 1980
• DSM III-R – 1987
• DSM IV – 1994
• DSM IV-TR – 2000
• DSM V – soon to be released (May 2013)
(The Internet)

Hellingly hospital (East sussex mental asylum)

the “Tranquilizer,” which was
designed to “keep the maniacs
in the inflammatory stage of
their disease in a
perpendicular position so as to
save the head from the
impetus of the blood as much
as possible.”

“We went through the top of the head,
I think she was awake. She had a mild
tranquilizer. I made a surgical incision
in the brain through the skull. It was
near the front. It was on both sides.
We just made a small incision, no more
than an inch… We put an instrument
inside… We made an estimate on how
far to cut based on how she
responded.” James Watts

These words describe the lobotomy
that was carried out in 1941 on
Rosemary Kennedy, sister of the then
future US President. Said to have been
intended to cure her mood swings, the
procedure left Rosemary with urinary
incontinence and the mental age of a
child – staring blankly at walls for
hours, her speech unintelligible.
(http://www.coolpicturegallery.net/201
0/02/chilling-pictures-of-
prefrontal.html)

First lobotomy
procedure

Went into
relapse –
second
lobotomy

Development of Psychopharmacology
• Began in about the 1950s
• Chlorpromazine (Thorazine), and lithium – the first
to be developed
• Over the following 10 years – MAOIs, haloperidol
(Haldol), TCAs and benzodiazepines
• Hospital stays were shortened and many people
were well enough to go home

(Chapter 1, Videbeck)

Mental health
• Maslow – a “healthy” or “self-actualized” individuals
possessed the following characteristics
1. An appropriate perception of reality
2. The ability to accept oneself, others, and human nature
3. The ability to manifest spontaneity
4. The capacity for focusing concentration on problem solving
5. A need for detachment and desire privacy
6. Independence, autonomy, and a resistance to enculturation
(Chapter 2 Townsend; pages 1 to 2, Student Guide)

Mental health
• Maslow – a “healthy” or “self-actualized” individuals
possessed the following characteristics
7. An intensity of emotional reaction
8. A frequency of “peak” experiences that validates the
worthwhileness of, richness, and beauty in life
9. An identification with humankind
10. A democratic character structure and strong sense of ethics
11. Creativity
12. A degree of nonconformance

Mental health
• Jahoda (1958) – identified six indicators that are a reflection
of mental health
1. A positive attitude toward self
2. Growth, development, and the ability to achieve self-
actualization
3. Integration
4. Autonomy
5. Perception of reality
6. Environmental mastery

Mental health
• The American Psychiatric Association (APA) (2003) – a state of
being that is relative rather than absolute. The successful
performance of mental functions shown by productive activities,
fulfilling relationships with other people, and the ability to adapt
to change and to cope with adversity
• Robinson (1983) –
1. A dynamic state in which thought, feeling, and behavior that age-
appropriate and congruent with local and cultural norms is
demonstrated
2. It is viewed as the successful adaptation to stressors from the
internal or external environment, evidenced by thoughts, feelings,
and behaviors that are age-appropriate and congruent with local
and cultural norms (Robinson)

Mental health
• WHO
1. A state of complete physical, mental, and social wellness and
not just merely the absence of disease or infirmity
2. Emphasis is on health as a positive state of well-being
3. People in a state of emotional, physical, and social well-
being fulfill responsibilities, function effectively in life, and
are satisfied with their interpersonal relationships and
themselves
(pages 2 to 3, Videbeck)

Mental health
• Factors that influence:
1. Individual make-up
2. Interpersonal
3. Social/cultural, or environmental

Mental illness
• Horowitz has identified two elements that are associated
with individuals’ perceptions of mental illness, regardless of
cultural origin
1. Incomprehensibility – relates to the inability of the general
population to understand the motivation behind the
behavior
2. Cultural relativity – considers that some behaviors that are
considered “normal” and “abnormal” is defined by one’s
cultural or social norms
(Chapter 2, Townsend)

Mental illness
• APA (2000)
1. Mental disorder is a clinically significant behavioral or
psyschological syndrome or pattern that occurs in an
individual and is associated with present distress (i.e.,
painful symptom) or disability (i.e., impairment in one or
more important areas of functioning) or with a significantly
increased risk of suffering death, pain, disability, or an
important loss of freedom

Mental illness
• APA (2000)
2. General criteria to diagnose mental illness:
a. Dissatisfaction with one’s characteristics, abilities, and
accomplishments
b. Ineffective or unsatisfying relationships
c. Dissatisfaction with one’s place in the world
d. Ineffective coping with life events
e. Lack of personal growth

Mental illness
• Factors contributing to mental illness:
1. Individual
2. Interpersonal
3. Social/cultural or environmental

DSM-IV-TR
• Diagnostic Statistical Manual 4th Edition Text Revision
• Multiaxial evaluation system
• Endorsed by the APA to facilitate comprehensive and
systematic evaluation with attention to the various mental
disorders and general medical problems, and level of
functioning that might be overlooked if the focus were on
assessing a single presenting problem
• 5 Axes (Axis I, II, III, IV and V)
(Chapter 2 of Townsend; pages 2 to 3, Videbeck)

DSM-IV-TR
• Axis I – Clinical Disorders and other Conditions That May Be
a Focus of Clinical Attention. This includes all mental
disorders: depression, schizophrenia, anxiety and substance
abuse disorder (except personality disorders and mental
retardation)
• Axis II – Personality Disorders and Mental Retardation. These
disorders usually begin in childhood or adolescence and
persist in a stable form into adult life; also for reporting
prominent maladaptive personality features and defense
mechanisms

DSM-IV-TR
• Axis III – General Medical Condition. These include any current
general medical condition that is potentially relevant to the
understanding or management of the individual’s mental disorder
• Axis IV – Psychosocial and Environmental Problems. These are
problems that may affect the diagnosis, treatment, and prognosis
of mental disorders named on Axes I and II.
• Axis V – Global Assessment of Functioning. This allows clinician to
rate the individual’s overall functioning on the Global Assessment
of Functioning (GAF) Scale. This scale represents in global terms as
a single measure of the individual’s psychological , social, and
occupational functioning

DSM-IV-TR
• Note: A copy of the GAF can be seen in Chapter of Townsend
page 26
• Note: DSM-IV-TR Classification of Diseases are in pages 465
to 473 of Videbeck 5th ed

DSM-IV-TR
• Example of a Psychiatric Diagnosis:
Axis I 300.4 Dysthymic Disorder
Axis II 301.6 Dependent Personality Disorder
Axis III 244.9 Hypothyroidism
Axis IV Unemployed
Axis V GAF = 65
(current)

The mental health nurse
• Peplau (1991) applied interpersonal theory to nursing
practice and, most specifically, to nurse-client relationship
development
• She provided a framework for “psychodynamic nursing”, the
interpersonal development of the nurse with the client in a
given nursing situation
• She states, “Nursing is helpful when both the patient and the
nurse grow as a result of the learning that occurs in the
situation.”
(Chapter 2 of Townsend page 44 to 45)

• Psychodynamic Nursing – being able to understand one’s
own behavior, to help others identify felt difficulties, and
apply principles of human relations to the problems that
arise at all levels of experience
• Roles of the Nurse
1. Resource person – provides specific, needed information
that helps the client understand his or her problem and the
new situation
2. Counselor – listens as the client reviews feelings related to
difficulties he or she is experiencing in any aspect of life

• Roles of the Nurse
3. Teacher – identifies learning needs and provides information
to the client or family that may aid in improvement of the
life situation
4. Leader – directs the nurse-client interaction and ensures
that appropriate actions are undertaken to facilitate
achievement of the designated goals
5. Technical expert – understands various professional devices
and possesses the clinical skills necessary to perform the
interventions that are in the best interest of the client
6. Surrogate – serves as a substitute figure for another

The interdisciplinary team
• Multidisciplinary team
• Functioning as an effective team member requires the
development and practice of several core skill areas:
1. Interpersonal skills
2. Humanity
3. Knowledge
4. Communication skills
5. Personal qualities, such as consistency, assertiveness, and
problem-solving abilities
6. Teamwork skills, such as collaborating, sharing, and integrating
7. Risk assessment and risk management skills

The interdisciplinary team
• Pharmacist
• Psychiatrist
• Psychologist
• Psychiatric Nurse
• Psychiatric social worker
• Occupational therapist
• Recreation therapist
• Vocational rehabilitation specialist

The mental health/mental illness
continuum
• Mental Health Continuum

Interpersonal Adequacy Interpersonal Competency

• Mental Illness Continuum

Interpersonal inadequacy Interpersonal
incompetency

(Chapter 2 of Townsend; Student Guide page 3)

continuum

Interpersonal Adequacy Interpersonal Inadequacy
and and competency Incompetency

Mental Health Mental Illness

(Chapter 2 of Townsend; Student Guide page 3)

continuum
• Anxiety
- Peplau (1963) described four levels of anxiety
1. Mild anxiety
2. Moderate anxiety
3. Severe anxiety
4. Panic

(Chapter 2 of Townsend; Student Guide pages 8 to 11)

continuum
• Anxiety
- Behavioral responses to anxiety
1. Mild anxiety – (coping mechanisms) sleeping, eating,
physical exercise, smoking, crying, pacing, yawning, drinking,
daydreaming, laughing, cursing, nail biting, foot swinging,
fidgeting, finger tapping, talking to someone whom one feels
comfortable

continuum
• Anxiety
2. Mild to Moderate Anxiety
a. Sigmund Freud (1961) identified the ego as the reality
component of the person that governs problem solving and
rational thinking, and as the level of anxiety increases, the
strength of the ego is tested, and energy is mobilized to
confront the threat
b. Anna Freud (1953) identified a number of defense
mechanisms employed by the ego in the face of threat to
biological or psychological integrity

Ego defense mechanisms
Defense Mechanism Definition Example
Compensation Covering up a real or A physically handicapped
perceived weakness by boy is unable to participate
emphasizing a trait one in football, so he
considers more desirable compensated by becoming a
great scholar
Denial Refusing to acknowledge the A woman drinks alcohol
existence of a real situation every day and cannot stop,
or the feelings associated failing to acknowledge that
with it she has a problem
Displacement The transfer of feelings from A client is angry with his
one target to another that is physician, does not express
considered less threatening it, but becomes verbally
or that is neutral abusive with the nurse

(Chapter 2 of Townsend; Videbeck , page 46; Student Guide pages 14 to 16)

Rationalization Attempting to make excuses John tells the rehab nurse
or formulate logical reasons “I’ll drink because it’s the
to justify unacceptable only way I can deal with my
feelings or behaviors bad marriage and my worse
job.”
Reaction Formation Preventing unacceptable or Jane hates nursing and
undesirable thoughts or attends nursing school to
behaviors from being please her parents. During
expressed by exaggerating career day, she speaks to
opposite thoughts or types prospective students about
of behaviors the excellence of nursing as
a career

((Chapter 2 of Townsend; Videbeck , page 46; Student Guide pages 14 to 16)

Regression Retreating in response to A 2-year-old boy is
stress to an earlier level of hospitalized and he only
development and the drinks from a bottle, even
comfort measures though his mom says that he
associated with that level of has been drinking from a
functioning cup for 6 months
Identification An attempt to increase self- A teenager who required
worth by acquiring certain lengthy rehabilitation after
attributes and characteristic an accident decides to
of an individual one admires become a physical therapist
as a result of his experiences


Intellectualization An attempt to avoid S’s husband is being
expressing actual emotions transferred with his job to
associated with a stressful city far away from her
situation by using the parents. She hides the
intellectual processes of anxiety by explaining to her
logic, reasoning, and parents the advantages
analysis associated with the move
Introjection Integrating the beliefs and Children integrate their
values of another individual patents’ value system into
into one’s own ego structure the process of conscience
formation. A child says to a
friend, “Don’t cheat. It’s
wrong.”


Isolation Separating a thought or A young woman describes
memory from the feeling being attacked and raped
tone or emotion associated without showing any
with it emotion
Projection Attributing feelings of Sue feels a strong sexual
impulses unacceptable to attraction to her track coach
one’s self to another person and tells a friend, “He’s
coming on to me!”
Repression Involuntarily blocking An accident victim can
unpleasant feelings and remember nothing about
experiences from one’s the accident
awareness


Sublimation Rechanneling of drives or A mother whose son was
impulse that are personally killed by a drunk driver
or socially unacceptable into channels her anger and
activities that are energy into being the
constructive president of the local
chapter of Mothers Against
Drunk Drivers
Suppression The voluntary blocking “I don’t want to think about
unpleasant feelings and that now. I’ll think about
experiences from one’s that tomorrow.”
awareness
Undoing Symbolically negating or Joe is nervous about his new
cancelling out an experience job and yells at his wife. On
that one finds intolerable his way home he stops and
buys her flowers.


continuum
• Anxiety
3. Moderate to Severe Anxiety
a. If not resolved can contribute to a number of physiological
disorders (pain, anorexia, arthritis, colitis, ulcers, asthma,
etc…)
b. The presence of one or more specific psychological or
behavioral factors that adversely affect a general medical
condition (DSM-IV-TR)

continuum
• Anxiety
4. Severe Anxiety
a. Extended periods can lead to psychoneurotic patterns of
behaving
5. Panic Anxiety
a. At this level of extreme anxiety, an individual is not capable
of processing what is happening in the environment, and
may lose contact with reality
b. Psychosis may develop

continuum
• Grief
1. Is a subjective state of emotional, physical, and social
responses to the loss of a valued entity
2. Stages (Kubler-Ross, 1969):
a. Denial
b. Anger
c. Bargaining
d. Depression
e. Acceptance

continuum
• Anxiety and grief just two of the major responses to stress
• Both are presented on a continuum
• Disorders appear in the DSM-IV-TR are identified at their
appropriate placement along the continuum


Feelings Dytshymia Major Depression
of Cyclothymia Bipolar Disorder
sadness

Life’s everyday Neurotic Psychotic
disappointments responses responses

Mild Moderate Severe
Grief Grief
Mental Mental
Health Illness
Anxiety Anxiety
Mild Moderate Severe Panic

Coping Defense Psychoneurotic Psychotic
mechanisms mechanisms responses responses

Psychiatric nursing practice – the standards of care
(psychiatric nursing process)

The Psychiatric History
• The record of the patient’s life
• It is to better understand who the patient is,
where the patient has come from, and where
is likely to go into the future

(Synopsis of Psychiatry by Kaplan and Sadock)

The nursing process – the standards of
care
• Standard 1 – Assessment
• Standard 2 – Diagnosis
• Standard 3 – Outcomes Identification
• Standard 4 – Planning
• Standard 5 – Implementation
1. Standard 5a – Coordination of Care
2. Standard 5b – Health Teaching and Health Promotion
3. Standard 5c – Milieu Therapy
4. Standard 5d – Pharmacological, Biological, and Integrative Therapies
5. Standard 5e – Prescriptive Authority and Treatment
6. Standard 5f – Psychotherapy
7. Standard 5g – Consultation
• Standard 6 – Evaluation
(Videbeck page 9 to 10)

Standard 1. Assessment
• Identifying data
• Chief complaint
“I am having thoughts of wanting to harm myself.”
“People are trying to drive me insane.”
“I feel I am going mad.”
“I am angry all the time.”
• History of Present Illness
• Family History

• Personal History
a. Prenatal and perinatal
b. Infancy and early childhood
c. Middle childhood
d. Adolescence
e. Young adulthood
f. Middle adulthood and old age

• Sexual History
• Mental status examination – part of clinical
assessment that describes the sum total of the
examiner’s observations and impressions of
the psychiatric patient at the time of the
interview

Mental Status examination (MSE)
• General description
• Mood and affect
• Perception
• Sensorium and cognition
• Impulsivity
• Judgment and insight

General Description
• Appearance
• Attitude toward the examiner
• Speech characteristics
• Overt behavior and psychomotor activity

Mood and Affect
• Mood – how does the client say he or she feels; depressed, euphoric,
empty, guilty, irritable, anxious terrified
• Affect – how the examiner evaluates client’s affect; broad, restricted,
blunted, flat, shallow, amount
a. Blunted – showing little or a slow-to-respond facial expression
b. Broad affect – displaying a full range of emotional expressions
c. Flat affect – showing no facial expression
d. Inappropriate affect – displaying a facial expression that is
incongruent with the mood or situation; often silly or giddy
regardless of circumstances
e. Restricted affect – displaying one type of expression, usually serious
or somber

Perception
a. Hallucinations – false sensory perceptions or
perceptual experiences that do not exist; visual,
auditory, tactile, olfactory
b. Illusion - mental impression derived from
misinterpretation of an actual experience
c. Depersonalization – feelings of being
disconnected form him/herself; the client feels
detached from his/her behavior
d. Derealization – client senses that events are not
real, when, in fact, they are

Perception
• Thought content and thought process
• Thought content – refers to what a person is
actually thinking about: ideas, beliefs,
preoccupations, obsessions; refers to what the
client thinks
• Thought process – refers to the way in which a
person thinks; refers to what the client says

Perception
• Circumstantial thinking – a client answers a
question but only after giving excessive
unnecessary detail
• Delusion – a fixed false belief not based on
reality
• Flight of ideas – excessive amount and rate of
speech composed of fragmented or unrelated
ideas
• Ideas of reference – client’s inaccurate
interpretation that general events are personally
directed to him or her

Perception
• Loose associations – disorganized thinking that
jumps from one idea to another with little or no
evident relationship between the thoughts
• Tangential thinking – wandering off topic and
never providing the information requested
• Thought blocking – stopping abruptly in the
middle of a sentence or train of thought;
sometimes unable to continue the idea
• Thought broadcasting – a delusional belief that
others can hear or know what the client is
thinking

Perception
• Thought insertion – a delusional belief that
others are putting ideas or thoughts into the
client’s head – that is, the ideas are not those
of the client
• Thought withdrawal – a delusional belief that
others are taking the client’s thoughts away
and the client is powerless to stop it
• Word salad – flow of unconnected words that
convey no meaning to the listener

Sensorium and Cognition
• Intellectual functioning
a. Abstract ability – can be assessed by asking the client
to interpret proverbs
b. Calculations
c. Alertness
d. Concentration and attention
e. Reading and writing
f. Information and intelligence
• Ego defense mechanisms
• Level of self esteem

Sensorium and Cognition
• Orientation and memory
a. Remote memory loss– memory impairment involves
experiences or incidents 6 months or longer or data of
personal identification
b. Recent memory loss– memory loss includes
experiences or incidents which happened hours or a
few days ago

impulsivity
• Is the patient capable of controlling sexual,
aggressive, and other impulses?
• To ascertain the patient’s awareness of
socially appropriate behavior and is a measure
of the patient’s potential danger to self and
others

Judgment and Insight
• Judgment – refers to the ability to interpret
one’s environment and situation correctly
and to adapt one’s behavior and decisions
accordingly
• Insight – the ability to understand the true
nature of the situation and accept some
personal responsibility for that situation

Standard 2 - diagnosis
• The psychiatric-mental health nurse analyzes the assessment
data to determine diagnoses of problems, including level of
risk
1. Sensory perception disturbed (auditory)
2. Disturbed thought process related to impaired judgment
associated with manic behavior
3. Impaired verbal communication – flight of ideas related to
accelerated thinking
4. Risk for violence related to hostile and angry behavior
5. Potential for self harm related to poor impulse control
associated with substance abuse

Standard 3 – outcomes identification
and standard 4 - planning
• Standard 3 - The psychiatric-mental health nurse
identifies outcomes for a plan individualized to
the patient or the situation
• Standard 4 - The psychiatric-mental health nurse
develops a plan that prescribes strategies and
alternatives to attain expected outcomes
• Clarifying goals is an essential step in the
therapeutic process. Therefore the patient nurse
relationship should be based upon mutually
agreed goals. Once the goals are a greed on they
must be stated in writing

• Expected outcomes and short term goals should
be developed with short tem objectives
contributing to the long term expected
outcomes.
• Example of short term goals:
1. At the end of the two weeks patients will stay
out of bed and participate in activities
2. At the end of the one week patient will sleep
well at night.
3. At the end of the one week patient will eat
properly and maintain weight.

• As soon as the patient‘s problems are identified, nursing diagnosis made,
planning nursing care begins.
• The planning consists of:
1. Determining priorities
2. Setting goals
3. Selecting nursing actions
4. Developing /writing nursing care plan
• In planning the care the nurse can involve the patient, family, members of
the health team.
• Once the goals are chosen the next task is to outline the plan achieving
them.
• On the basis of an analysis, the nurse decides which problem requires
priority attention or immediate attention.

and Standard 4 – planning
• Example: A client with schizophrenia having delusions
Expected Outcomes (Goals)
A. Immediate (Short-term Goals) – The client will be:
1. Free from injury
2. Demonstrate decreased level of anxiety
3. Respond to reality-based interactions
B. Stabilization (Long-term Goals) – The client will be:
1. Interact on reality-based topics such as daily activities
or local events
2. Sustain attention and concentration to complete task
or activities

Standard 5 – implementation –
psychiatric treatment modalities:
psychopharmacology
• The psychiatric-mental health nurse
implements the identified plan
• Psychotropic drugs - drugs used to treat
mental disorders
• ECT – electroconvulsive therapy (?)
• Psychotherapy
• Community-based care

Standard 5 – implementation –
psychiatric treatment modalities:
psychopharmacology
• The psychiatric-mental health nurse implements
the identified plan
• Psychotropic drugs - drugs used to treat mental
disorders
1. Antipsychotics
2. Antidepressants
3. Mood stabilizers
4. Anxiolytics
5. Stimulants

Antipsychotics
• Also known as neuroleptics
• Used to treat the symptoms of psychosis, such as
delusions and hallucinations seen in
schizophrenia, schizoaffective disorder and the
manic phase of bipolar disorder
• Used to modify behavior
• Affect the CNS and ANS
• Do not cure mental illness but relieve symptoms
( Videbeck, pages 24 39; Student Guide, pages 43 to 53)

Antipsychotics – mode of action
• Major action in the nervous system is to block receptors
for the neurotransmitter dopamine
• Dopamine are classified into subcategories (D1 to D5)
• D2, D3 and D4 have been associated with mental illness
• Effective in treating target symptoms
• But also produces side effects, the extrapyramidal
symptoms (EPS)
• Conventional or first generation antipsychotics
• Atypical of second generation antipsychotics
• New generation antipsychotics

Antipsychotics
Conventional Antipsychotics:
• Phenothiazines:
1. Chlorpromazine (Thorazine)
2. Thioridazine (Mellaril)
• Butyrophenones
1. Haloperidol (Haldol)
Atypical Antipsychotics
• Clozapine (Clozaril)
• Risperidone (Risperidal)
New Generation Antipsychotics
• Aripirazole (Abilify)

Antipsychotics – side effects
Extrapyramidal side effects/symptoms (EPS)
• Serious neurologic symptoms
1. Acute dystonia – acute muscular rigidity and
cramping, stiff or thick tongue with dysphagia, and in
severe cases laryngospasm and respiratory difficulties
2. Pseudoparkinsonism – drug-induced parkinsonism
3. Akathisia – reported by the client as an intense need
to move about. The client appears restless or anxious
and agitated, often with a rigid posture or gait and a
lack of spontaneous gestures

Drugs used to treat eps
• Amantidine (Symmetrel)
• Benztropine (Cogentin)
• Biperiden (Akineton)
• Diazepam (Valium)
• Diphenhydramine (Benadryl)
• Lorazepam (Ativan)
• Propanolol (Inderal)


Neuroleptic Malignant Syndrome (NMS)
• Potentially fatal
• Rigidity, high fever, autonomic instability such
as unstable BP, diaphoresis, and pallor
• Delirium and elevated enzymes, particularly
creatine phosphokinase

Tardive dyskinesia (TD)
• Syndrome of permanent involuntary movements, is
most commonly caused by the long-term use of
conventional antipsychotics.
• Involuntary movements of the tongue, facial and neck
muscles, upper and lower extremities, and truncal
musculature
• Tongue thrusting and protruding, lip smacking, blinking,
grimacing, and other excessive unnecessary facial
movements are characteristic

Anticholinergic Side-Effects
• Orthostatic hypotension
• Dry mouth
• Constipation
• Urinary hesitance or retention
• Blurred near vision
• Dry eyes
• Photophobia
• Nasal congestion
• Decreased memory

Other Side Effects
• Increase prolactin levels – may cause breast
enlargement and tenderness in men and
women; diminished libido, erectile and orgasmic
dysfunction; menstrual irregularities; increased
risk for breast cancer; may contribute to weight
gain
• Postural hypotension
• Agranulocyctosis – always check CBC particularly
the WBC count

Antipsychotics – client teaching
• Inform the client about the types of side effects that may occur
and encourage the client to report such problems to the physician
instead of discontinuing the medication
• Teach the client methods of managing or avoiding unpleasant side
effects and maintaining medication regimen
• Sugar-free fluids and sugar-free candies for dry mouth
• Avoid calorie-laden beverages and candy because of dental caries,
weight gain, and do little to relieve dry mouth
• Dietary modifications as well as exercise to prevent constipation
• Sunscreen for photosensitivity

Antipsychotics – client teaching
• Causes drowsiness and sleepiness so avoid any
activities that require alertness
• A missed dose (because the client forgets) can
be taken if it is only 3 to 4 hours late, a missed
dose that is more than 4 hours should be
omitted
• Encourage the client to use a chart and record
doses if they have difficulty remembering doses

Antidepressant drugs
• Primarily used in the treatment of major
depressive illness, anxiety disorders, the
depressed phase of bipolar disorder, and
psychotic depression
• 4 groups:
1. TCA – Tricyclic antidepressants
2. SSRI – Selective serotonin reuptake inhibitors
3. MAOI – Monoamine oxidase inhibitors
4. Others: Wellburtin, Effexor, Desyrel

Antidepressant drugs - TCAs
• Imipramine (Tofranil)
• Amitriptyline (Elavil)
• Cause varying degrees of sedation, orthostatic
hypotension, and anticholinergic side effects
• Potentially fatal if taken in overdose
• Clients should report sexual dysfunction
• Sexual dysfunction and weight gain are common
reasons for noncompliance

Antidepressant drugs - SSRIs
• Fluoxetine (Prozac)
• Sertraline (Zoloft)
• Paroxetine (Paxil)
• Have replaced the TCAs as the first line of drugs
• Cause fewer troublesome side effects
• Preferred drug along with Effexor for suicide which is always a
primary consideration in depression
• Carry no risk for lethal overdose
• Effective only for mild to moderate depression
• There is FDA-required warning and increased suicide risk among
children and adolescent

Antidepressant drugs - SSRIs
• Side effects: anxiety, agitation, akathisia (motor
restlessness), nausea, insomnia, and sexual dysfunction
(due to enhanced serotonin transmission), weight gain
(initial and ongoing problem, but less compared to other
antidepressants)
• Less common side effects: sedation, sweating, diarrhea,
hand tremor, and headaches
• Taking with food usually minimizes the nausea
• Akathisia can be treated with beta-blockers or a
benzodiazepine
• Insomnia can be treated with low dose sedative-hypnotic

Antidepressant drugs - MAOIs
• Phenelzine (Nardil)
• Tranylcypromine (Parnate)
• Isocarboxazid (Marplan)
• Most common side effects: sedation, insomnia, weight
gain, dry mouth, orthostatic hypotension, and sexual
dysfunction
• Life-threatening side effect: hypertensive crisis
• Must not be combined with other antidepressants
• Avoid foods rich in tyramine, tryptophan and tryptamine
because of the development of hypertensive crisis (see
page 32 of Videbeck 5th edition for the list of foods to
avoid)

Antidepressant drugs – client
teaching
• Clients should take SSRIs first thing in the
morning unless sedation is a problem
• If a client forgets a dose of SSRI, he or she can
take it up to 8 hours after the missed dose
• To minimize side effects, clients generally should
take TCAs at night in a single daily dose when
possible
• If a client forgets a dose of a TCA, he or she
should take it within 3 hours of the missed dose
or omit the dose for that day

Antidepressant drugs – client
teaching
• Clients should exercise caution when driving
or performing activities requiring sharp, alert
reflexes until sedative effects can be
determined
• Dietary restrictions when taking MAOIs
• Avoid taking OTC medications without telling
the nurse or the physician

Mood stabilizers
• Used to treat bipolar disorder
• Stabilizes mood, preventing or minimizing the highs and
lows that characterize bipolar disorder
• Treats acute episodes of mania
• Lithium – the most established mood stabilizer
• Some anticonvulsants, particularly carbamazepine
(Tegretol) and valproic acid (Depakote, Depakene), are
effective mood stabilizers
• Occasionally clonazepam (Klonopin) an anxiolytic is also
used to treat acute mania

Mood stabilizers - Lithium
• Mode of action is poorly understood
• Normalizes the reuptake of certain
neurotransmitters such serotonin,
norepinephrine, acetylcholine, and dopamine
• It also reduces the release of norepinephrine
through competition with calcium and produces
its effects intracellularly rather than within the
neuronal synapses
• Considered as a first-line agent in the treatment
of bipolar disorder

• Serum levels should be about 1.0 mEq/L
• Less than 0.5 mEq/L are rarely therapeutic
• More than 1.5 mEq/L are usually considered toxic
• Levels should be monitored every 2 to 3 days
while the therapeutic dosage is being
determined; then, it should be monitored weekly
• When the client’s condition is stable, the level
may need to be checked once a month or less
frequently

• Side-effects: mild nausea or diarrhea, anorexia, fine
hand tremor (can be treated by propanolol),
polydipsia, polyuria, a metallic taste in the mouth, and
fatigue or lethargy
• Later side effects: weight gain and acne
• Toxic effects: severe diarrhea, vomiting, drowsiness,
muscle weakness, and lack of coordination
• When toxic signs occur, the drug should be
discontinued
• If levels exceed 3.0 mEq/L, dialysis may be indicated

• Other side effects include hair loss – thyroid
function tests should be performed
• Always check and record accurately intake and
output
• Also competes with Na in its absorption in the
renal tubules – check for serum electrolytes
(Na and Ca)

Anxiolytics
• Or antianxiety medications
• Used to treat anxiety and anxiety disorders, insomnia, OCD, depression,
posttraumatic stress disorder, and alcohol withdrawal
• Benzodiazepines
a. Clonazepam (Klonopin)
b. Alprazolam (Xanax)
c. Diazepam (Valium)
d. Lorazepam (Ativan)
• Nonbenzodiazepines
a. Buspirone (Buspar)
b. Diphenhydramine (Benadryl)

Anxiolytics
• Mechanism of action: mediates the action of GABA,
the major inhibitor neurotransmitter in the brain
• CNS depressant
• Side effects: physical dependence, which is not
considered a side effect in the true sense, but is a
major problem
• Psychological dependence (clients fear the return of
the anxiety or believe they are incapable of handling
anxiety without the drug) is also common, although
buspirone does not cause this type of physical
dependence


Anxiolytics
• The side effects most commonly reported with
benzodiazepines are those associated with
CNS depression
• Elderly clients may have more difficulty
managing the effects of CNS depression and
may have more pronounced memory deficits,
urinary incontinence, particularly at night

Anxiolytics – client teaching
• The drugs are aimed at relieving symptoms, but
do not treat the underlying disorder that cause
anxiety
• Avoid other CNS depressants like alcohol and any
activity that require alertness
• Benzodiazepine withdrawal can be fatal, and
should not be discontinued abruptly after the
course of therapy without the supervision of the
physician

Stimulants
• Specifically amphetamines are primarily being used for
treating ADHD in children and adolescents, residual
attention deficit disorder in adults, and narcolepsy
(attacks of unwanted but irresistible daytime
sleepiness that disrupt the person’s life)
• Amphetamines – potential for abuse, may lead to
dependence in prolonged use
• Methylphenidate – used with caution in emotionally
unstable clients such as those with alcohol or drug
dependence because they may increase the dosage on
their own

Stimulants
• Drugs used to treat ADHD
1. Stimulants:
a. methylphenidate (Ritalin)
b. Amphetamine (Adderall)
2. Selective Norepinephrine Reuptake Inhibitor (SNRI)
a. Atomoxetine (Strattera)
• Mode of action: stimulates the inhibitory centers of the brain, so
that there is greater ability to filter out distractions and manage
behavior (stimulants)
• Mode of action of SNRI: prevents the reuptake of NE, thereby
leaving more of the neurotransmitter in the synapse to help
convey electrical impulses in the brain

Stimulants
• Side effects
a. Anorexia
b. Weight loss
c. Nausea
d. Irritability
• Client teaching:
a. Avoid caffeine, chocolate and sugar, which may worsen the symptom
b. May cause growth and weight suppression in some children – clients
must have “drug holidays” during the weekend, holidays or summer
vacation
c. Potential for abuse
d. Give with meals
e. Keep medications out of reach of children (as little as a 10-day supply can
be fatal)

Disulferam
• Antabuse
• A sensitizing agent that causes an adverse reaction
when mixed with alcohol in the body
• Only used as a deterrent to drinking alcohol in
persons being treated for alcoholism
• Inhibits the enzyme aldehyde dehydrogenase, which
is involved in the metabolism of ethanol, leading to
an increase in the levels of acetaldehyde in the
blood, resulting in disulferam-alcohol reaction
within 5 to 10 minutes

Disulferam
• Disulferam-Alcohol Reactions
a. Facial and body flushing from vasodilation
b. Throbbing headache
c. Sweating
d. Dry mouth
e. Nausea and vomiting
f. Dizziness
g. Weakness
h. Chest pain, dyspnea, severe hypotension, confusion,
and even death – in severe cases

Disulferam
• Education is extremely important
• Many common products such as shaving cream,
aftershave lotion, cologne, and deodorant and
OTC medications such as cough preparations
contain alcohol
• When the above products are used by the client
taking disulferam, these products can produce
the same reaction as drinking alcohol
• Read the labels carefully

NCM 105 Overview

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