PSYCHO PHARMACOTHERAPY

ANTIPSYCHOTICS

Antipsychotics drugs are used to control psychosis, which is the ability to

perceive and interpret reality accurately, think clearly, respond correctly and function
in a socially appropriate manner. Antipsychotic drugs are also referred to as
neuroleptics or major tranquillizers

Classification

The antipsychotics are classified into two main categories they are:

Typical or classical antipsychotics: These are drugs, which produce extra pyramidal
symptoms at clinically effective doses in majority of the patients

Atypical antipsychotic drugs: are those drugs which produce comparatively less
extra pyramidal symptoms at clinically effective doses. They are also called “Novel
antipsychotics”

Typical antipsychotics: chlorpromazine, haloperidol and fluphernazine

A typical antipsychotics : risperidone, clozapine and olazappine.

Note: The adverse reactions and nursing management will be dealt in common for all
the antipsychotic drugs

CHLOROPROMAZINE

Indications : Schizophrenia, persistent or intractable hiccup, antiemetic action,

behavioral disturbances in children, senile dementia of Alzheimer’s type

Contraindications: Hypersensitivity to cLl’)f!)!wll1zii1e, CNS depression, coma,

bone marrow depression, blood dyserasias, hepatic dysfunction, severe hypertension
or hypotension

Special precautions

Special precaution must be taken in case of patients with history of epilepsy,

Parkinsonism, cariovascular disease, prolonged use, and myasthenia gravis

Dosage

Adults : oral 25 mg thrice daily. Usual maintenance dose is 75-30 mg daily.

HALOPERlDOL

Indications:

Acute and chronic schizophrenia, anxiety disorders, acute mania, hypomania

control of tics, Tourette - syndrome, Short – term treatment or hyperactive children
showing excessive motor activity, prolonged parenteral therapy in chronic
schizophrenia

Contraindications

Hypersensitivity to drug, blood dyscrasias, child below 3 years, brain damage,

bone marrow depression, alcohol and barbiturate withdrawal states, Parkinson’s
disease, angina, epilepsy, urinary retention, narrow angle glaucoma

Special precaution

Special precautions must be observed in pregnancy and lactation, seizure

disorders, hypertension, hepatic disease and cardiac disease dosage

Adult: Oral : 0.5 mg bid or tid initially depending on the severity of the condition
Maximum dosage 5 mg/day

ATYPICAL ANTIPSYCHOTICS

RESPERIDONE

Indications: Acute and chronic schizophrenia and other psychotic conditions

Contraindications: Children, renal disease, pregnancy, hepatic disease, elderly,

breast cancer.

Special precautions: Children, renal disease, pregnancy, hepatic disease, elderly,

breast cancer

Dosage: Adult: Oral 1 mg bid, followed by increase of I mg twice daily to a target

dose of 3 mg by 3 day

ADVERSE EFFECTS OF ANTIPSYCHOTIC DRUGS AND NURSING

MANAGEMENT
1. Anticholinergic effects
a) Dry mouth: Provide the client with sugarless candy, ice, and frequent sips
of water and ensure that the client practices strict oral hygiene

b) Blurred vision: Explain that symptom will most likely subside after a few
weeks and advise client not to drive until vision clears

c) Constipation: Order foods high in fiber; encourage increase in physical

activity and fluid intake if not contraindicated

d) Urinary retention: Instruct client to report any difficulty urinating; monitor

intake and output

2. Nausea; GI upset: Tablets or capsules may be administered with food to

minimize GI upset

3. Skin rash: Report appearance of any rash on skin to the physician and avoid
spilling any of the liquid concentrate on skin

4. Sedation: Discuss with the physician the possibility of administering the drug
at bedtime and a possible decrease in dosage or an order for a less sedating drug.
Instruct client not to drive or use dangerous equipment while experiencing sedation

5. Orthostatic hypotension: Instruct the client to rise slowly from a lying or

sitting position; monitor blood pressure (lying and standing) each shift; document and
report significant changes

6. Photosensitivity: Make sure that the client wears protective sunscreens,

clothing, and sunglasses while spending time outdoors

7. Hormonal effects

a) Decreased libido; retrograde ejaculation; gynecomastia (men): Provide an

explanation of the effects and reassurance of their reversibility

b) Amenorrhea (women), Offer reassurance of reversibility, and instruct the client to

continue the use of contraception, as amenorrhea does not indicate cessation of
ovulation

c) Weight gain: Weight client every other day; order calorie controlled diet, provide
opportunity for physical exercise; provide diet ad exercise
11. Extra pyramidal symptoms: Observe for symptoms and report; administer

anti parkinsonian drugs

 a. Pseudoparkinsonism (tremor, shuffling gait, drooling, rigidity):
Symptoms may appear 1 to 5 days following initiation of antipsychotic
medication. They occur most often in women, the elderly and
dehydrated clients

b. Akinesia (muscular weakness): same as above

c. Akathisia (continuous restlessness and fidgeting): This occurs most

frequently in women; symptoms may occur 50 to 60 days following
initiation of therapy

d. Dystonia (involuntary muscular movements/spasms) of face, arms, legs,

and neck). This occurs most often in men and in clients younger than 25
years of age

e. Oculogyric crisis (uncontrolled rolling back of the eyes): This may

appear as part of the syndrome described as dystonia. It may be
mistaken for seizure activity. Dystonia and oculogyric crisis should be
treated as an emergency situation.: The physician should be contacted,
and intravenous benztropine me.sylate (Cogentin) is commonly
administered. Sit with the client and offer reassurance and support
during this frightening time

12. Tardive dyskinesia (bizarre facial and tongue movements, stiff neck, and
difficulty swallowing)
 All clients receiving long - term (months or years) antipsychotic therapy are at
risk

 Symptoms are potentially irreversible

 Drug should be withdrawn at the first sign, which is usually vermiform

movements of the tongue: prompt action may prevent irreversibility
 ANTIDEPRESSANTS

Depression is a total body illness and one of the most common mental health
disorders. According to WHO report (2001) there are about 121 million people
suffering from depression. Depression is best treated by a combination of
psychotherapy and drug therapy

Classification of antidepressants

Antidepressants are classified into generations

First generation antidepressants

This includes tricyclic antidepressants (TCAs) and Mono amine oxidase

inhibitors (MAOls). These drugs affect various neurotransmitter systems, resulting in
many undesirable adverse effects

Second generation antidepressants

Antidepressant drugs are typical of the classic drugs as they are associated
fewer side effects e.g. heterocyclics, SSRls, NSRls etc

The antidepressants that will be dealt with are amitliptyline, imipramine,

fluoxeline, sertraiinc and venlafaxine

TRICYCLIC ANTIDEPRESSANTS

AMITRYPTILINE

Indications : Depression illness accompanied by anxiety agitation, restlessness, and

disturbances of sleep, masked depression, depression in alcoholics, childhood
bedwetting

Contraindications: Epilepsy, narrow angle glaucoma, severe heart disease, severe

liver impairment, retention of urine
Special precautions: Cardiac, hepatic or renal disease, hyperthyroidism, activation of
latent schizophrenia may occur, suicidal tendency in seriously depressed patients

IMIPRAMINE

Indications : All types of depression, nocturnal enuresis, intractable chronic pam,

mood disturbances, sleep apnoea syndrome

Special precautions: Epilepsy, cardiac arrhythmias and cardiac disease, glaucoma,

hypeI1hyroidism, renal and hepatic disease

FLUOXETINE

Indications : Major depressive disorder

Contraindications: Renal failure and lactation

Special precautions: Epilepsy, cardiac arrhythmias and cardiac disease, glaucoma,

hypeI1hyroidism, renal and hepatic disease

ADVERSE EFFECTS OF ANTIDEPRESSANTS AND NURSING

MANAGEMENT

NURSING MANAGEMENT

The nurse must monitor for the following side effects from antidepressant
medications. The adverse effects accompanied by nursing implications are given
below

1. May occur with all chemical classes:

a) Dry mouth: Offer the client sugarless candy, ice, frequent sips of water and strict
oral hygiene is very important

b) Sedation: Request an order from the physician for the drug to the given at bed
time and instruct client not to drive or use dangerous equipment while
experiencing sedation
c) Nausea: Advise client to take medication with food to minimize G.I distress

2. Most commonly occur with tricyclics

a) Blurred vision: Offer reassurance that this symptoms should subside after a few
days and instruct client to avoid driving u!1tiJ vision is clear

b) Constipation: Order foods high in fiber; increase fluid intake unless

contraindicated and encourage client to increase physical exercise if possible

c) Urinary retention: Instruct the client to report hesitancy and inability to urinate,
monitor intake and output, try various methods to stimulate urination, such as
n1nning water in bathroom or pouring water over the pelineal area

d) Orthostatic hypotension: Instruct the client to rise slowly from a lying or sitting
position, monitor blood pressure (lying and standing), avoid long hot showers or
bubble baths

e) Tachycardia; arrythmias: Carefully monitor B.P and pulse rate and rhythm

f) Photosensitivity: Advice patient to wear protective sunscreens, clothing and

sunglasses while outdoors

g) Weight gain: Provide instructions for reduced - caloric diet and encourage
increased level of activity, if appropriate

3. Most commonly occur with selective serotonin reuptake inhibitors (SSRIS)

a) Insomnia/agitation: Administer or instruct client at take dose early in the day,

instruct client to avoid caffeirrated food and drinks, teach relaxation techniques to
use before bed time.

b) Headache: Administer analgesics as prescribed, request physician regarding

change to another SSRI or another class of antidepressants

c) Weight loss: Provide sufficient - caloric intake, use with caution in anorectic
clients, weight client daily or every other day, at same time and on same scale if
possible

d) Sexual dysfunction: Men may report abnormal ejaculation or impotence; women

may experience delay or loss of orgasm, if side effect become intolerable, a switch
to another antidepressant may be necessary
 3.ANTIMANIC AGENTS

The drug of choice for treatment and management of bipolar disorder, mania, is
lithium carbonate.

LITHIUM CARBONATE

Functional class: Antimanic

Indications : Manic - depressive illness (manic phase); Prevention of bipolar manic -

depressive psychosis

Contraindications: Hepatic and renal disease, brain trauma, organic brain syndrome,
pregnancy and lactation, schizophrenia, severe cardiac disease and severe dehydration

Special precautions: Elderly, thyroid disease, seizure disorders, diabetes mellitus,

systemic infection, urinary retention, children below 12 years

Dosage :

Adult : Oral 300-600 mg t.i.d maintenance does 300 mg t.i.d or q.i.d

ADVERSE EFFECTS OF LITHIUM AND NURSING MANAGEMENT

Monitoring far side effects of lithium therapy and its management is an

important aspect of nursing

Lithium toxicity: The margin between the therapeutic and toxic levels of lithium
carbonate is very narrow. The usual ranges of therapeutic serum concentrations are:

 For acute mania: 1.0 -1.5 mEq/1

 For acute mania: 0.6 -1.2 mEq/1

Serum lithium levels should be monitored once or twice a week after initial
treatment until dosage and serum levels are stable, then monthly during maintenance
therapy. Both samples should be drawn 12 hours after the dose

Symptoms of lithium toxicity being to appear at the levels greater than 1.5 mEq/1

Symptoms include
  At serum levels of 1.5 to 2.0 Eq/l: Blurred vision, ataxia, tinnitus, persistent
nausea, vomiting and severe diarrhea

 At serum levels of 2.0 to 3.5 Eq/l: Excessive output if dilute urine, increasing
tremors, muscular irritability, psychomotor retardation, mental confusion,
giddiness

 At serum levels above 3.5 mEq/1: Impaired consciousness, nystagmus,

seizures, coma, oliguria, anuria, arrhythmias, myocardial infarction,. and
cardiovascular collapse

Lithium levels should be monitored prior to medication administration. The dosage

should be withheld and the physician notified if the level reaches 1.5 mEq/l as lithium
toxicity is life threatening

Client / family education (for lithium)

The client should :

 Take medication on a regular basis, even when feeling well.

Not to drive or operate dangerous machinery till lithium levels are stabilized.
Drowsiness and dizziness can occur

 Normal dietary sodium intake and drink 6 large glasses of water each day and avoid
excess use of beverages containing caffeine (coffee, tea etc) which promote
increased urine output.

 Notify the physician in case of vomiting or diarrhea. These symptoms can result in
sodium loss and increased risk of toxicity

 Carry card or other identification nothing lithium intake

 Be aware of risks of becoming pregnant while receiving lithium therapy. Use

information furnished by health care providers regarding methods of contraception.
Notify the physician as soon as possible if pregnancy is suspected or planned

 Be aware of side effects and symptoms associated with toxicity. Notify the
physician if any of the following symptoms occur: persistent nausea and vomiting,
severe diarrhea, ataxia, blurred vision, tinnitus, excessive output of urine,
increasing tremors, or mental confusion

 Keep appointments for outpatient follow - up; have serum lithium level checked
every 1 to 2 months, or as advised by physician
 4.ANXIOLYTICS

Anxiety disorders are the most common mental disorders. Unlike other
psychiatric disorders, anxiety may be present as a normal emotional response to
situations perceived as stressful or frightening or as a pathologic condition. Many of
the anxiolytic drugs are sedative - hypnotics. Sedative drugs reduce anxiety and exert
a calming effect. Hypnotic drugs produce drowsiness and induce a state of natural
sleep

DIAZEPAM

Indications: Anxiety and tension, muscle, behavioral disorders, cerebral palsy,

sedative for surgical procedures, tetanus, eclampsia, epilepsy

Contraindications: Myasthenia gravis, acute narrow angle glaucoma

Special precaution: Renal and hepatic impairment

Dosage:

Adult : Oral 2-10mg b.i.d/q.i.d

ALPROZOLAM:

Indications: Short term symptomatic treatment of anxiety disorders and panic

disorders

Contraindication: Acute narrow angle glaucoma and myasthenia gravis.

Special precautions: Patients below 18years, hepatic and renal disease

Dosage :

Adults: Oral Initially 0.25 - 0.5 mg 2 - 3 times daily; maintenance dose 0.5 - 4 mg
daily . in· divided doses

ADVERSE EFFECTS AND NURSING MANAGEMENT

1. Drowsiness, confusion, lethargy (most common side effects): Instruct the

 client not to drive or operate dangerous machinery while taking the medication

2. Tolerance: Physical and psychological dependence: Instruct the client on long

tern therapy not to quit taking the drug abruptly. Abrupt withdrawal can be life
threatening. Symptoms include depression, insomnia, increased anxiety,
abdominal and muscle cramps, tremors, vomiting, sweating conclusions and
delirium

3. Ability to potentate the effects of other CNS depressants: Instruct the client
not to drink alcohol or take other medications that depress the eNS while
taking this mediation

4. Possibility of aggravating symptoms in depressed persons: Assess the

client’s mood daily, take necessary precautions for potential suicide

5. Orthostatic hypotension: Monitor lying and standing blood pressure and

pulse every shift, instruct the client to arise slowly from a lying or sitting
position

6. Paradoxical excitement (client develops symptoms opposite of .the

DRUGS USED IN ALCOHOL AND DRUG DETOXIFICATION

DISULFIRAM

Indications : Chronic alcoholism

Contraindications: Cardiac failure, psychosis of drug addiction, coronary artery

disease, hypersensitivity

Special precautions : hepatic renal or respiratory disease, epilepsy and diabetes

mellitus

Side effects and adverse effects: Headache, drowsiness, restlcssness, dizziness,

tremors, convulsions, peripheral neuropathy, nausea, vomiting, and jaundice

Disulfiram reaction:

When alcohol is ingested the following reaction occurs

Flushing, throbbing headache, respiratory difficulty, nausea, vomiting,

sweating, thirst, chest pain, palpitations, dyspnoea, hyperventilation, tachycardia,
confusion, cardiovascular collapse and death

Nursing management

 Monitor for liver function test every 2 week as SGOT and SGPT may be
elevate

 Monitor complete blood count

 Assess for signs of hepatotoxicity: jaundice, dark urine, clay colored stools and
abdominal pain

 Caution patient and relatives about the use of products containing alcohol such
as cough syrups, shaving creams and lotions etc because alcohol even in small
amounts can produce a reaction
  Caution patient that disulfiram reaction can be fatal; occurs 15 minutes after
drinking and may last several hours

NURSES ROLE IN ADMINISTRATION OF ANTIPSYCHOTIC AGENTS

Early observation and prevention of complications, limiting the complications

are the main role of nurses.

 Close observation: - when antipsychotics are just started look for possible side
effects.
 Extra pyramidal reaction that is Parkinsonism, akathisia, dystonia and tardive
dyskinesia.
 Observe drowsiness: - medicine should be administered at bed time. Report if
the drowsiness persists for a very long time. Observe for sore throat, fever due
to agranulocytosis.
 Record blood pressure. If BP drops by 20 to 30 mm Hg intervention should be
done.
 Accurate route of medication- not given subcutaneously.
 Dry mouth may be reduced by encouraging the patient to rinse his or her mouth
frequently. Give a piece of lemon or chewing gum. Good oral hygiene should
be also maintained.
 Blurred or impaired vision in patient causes anxiety and annoyance to him.
Blurred vision or brown colored vision, night blindness can be permanent due
to pigmentary retinopathy.
 Weight record should be maintained. Encourage on a low salt and planned
caloric diet.
 The patient may complain of gastric irritation. He should be discouraged to
take antacids as there will be decreased absorption of antipsychotic drugs.


  An intake and out put chart should be maintained especially for male patient
who is bedridden with prostate hypertrophy. Encourage at least 2500 ml of

intake.
 The patient should be advised to protect his skin.
 Find out menstrual changes

PATIENT AND FAMILY EDUCATION

 The patient should be explained not to increase or decrease or stop taking

drugs without discussing with his doctor. The drugs should be withdrawn
slowly to avoid nausea or seizures.
 Explain to female patient that menstrual changes may occur.
 Give reassurance to relatives that desired effect will be achieved after weeks
of medication.
 The patient should be made aware of the possibility of dizziness and injuries
after receiving medications and injection due to orthostatic hypotension.
 Encourage frequent mouth wash.
 Explain that weight gain and sedation are the side effects of drugs.
 Instruct to maintain intake and output.
 Instruct to avoid exposure to sunlight because dermatitis may occur.

NURSES ROLE IN ADMINISTRATION OF ANTIMANIC AGENTS

 Give medicine during or after meal to decrease gastric irritability. It will also
reduce the metallic taste in the mouth.
  Make note of the serum lithium level, and observe the side effects and plan the
nursing interventions.
 Weight should be recorded before lithium therapy. Excessive weight gain or
swelling of ankles and wrists should be noted. Weekly weight record should be
maintained.
 Intake and output chart to be balanced because retention of fluid will increase
weight.
 Any change in the diet should be reported immediately less intake of diet will
affect the lithium level in the blood.

PATIENT AND FAMILY TEACHING

 Maintain strict intake and output chart.
 Maintain fluid intake.
 Any change in the diet should be reported immediately.
 About drugs that interact with lithium and decrease need for adequate stable
intake of salt and fluids.
 Advise the patient not to increase or decrease medicine unless advised.

NURSES RESPONSIBILITY FOR A PATIENT RECEIVING LITHIUM

 Do a complete physical history, ECG, blood studies.

 Do urine examination to find out renal function.

 Assess thyroid function.

 Give the medication same time a day.

 Educate the patient about side effects of drugs.

 The psychiatrist should be notified if severe side effects occurred.

 Advice to drink enough water with little salt.

 Monitor serum lithium frequently.( Blood should be collected 12 hrs after last

dose)
  Advice the patient about the follow up.

NURSES ROLE IN ADMINISTRATION OF ANTIANXIETY AGENTS

 Assessment of the patient, prior to the use of anti anxiety sedative hypnotic
agents. If the patient complaints of sleep disturbance the causative factor
should be identified.

 Appropriate nursing measure to induce sleep should be taken such as a calm

and quiet environment, a cup of hot milk, good back care, allowing the patient
to read magazine, sitting with the patient far some times for reassurance
purpose.

 While administering the drugs daily dose should be given at bed time to
promote a normal sleep pattern, so that day time activities are not affected.

 Give IM injection deep into muscles to prevent irritation.

 Look for side effects, record and report immediately.

 If the patient complaints of drowsiness tell him to avoid using knife or any
dangerous equipment.