2107 psychopharmacology townsend_5th_edition_spring_2013

Psychiatric Mental Health Nursing, 5th EditionPsychiatric Mental Health Nursing, 5th Edition

Chapter 21Chapter 21

Psychopharmacology


Historical Perspectives Before 1950, sedatives and amphetamines

were the only significant psychotropic drugs available.

Since the 1950s, psychopharmacology has expanded to include antipsychotic, antidepressant, and antianxiety drugs.

Psychotropic drugs are intended to be used as an adjunct to individual or group psychotherapy.


How Do Psychotropics Work? Neurotransmitters

– Chemicals that are stored in the axon terminals of the presynaptic neuron.

– An electrical impulse through the neuron stimulates its release into the synaptic cleft, which in turn determines whether another electrical impulse is generated.


How Do Psychotropics Work? (cont.)

Receptors– Molecules situated on the cell membrane that are

binding sites for neurotransmitters.


How Do Psychotropics Work? (cont.) Reuptake

– The process of neurotransmitter inactivation by which the neurotransmitter is reabsorbed into the presynaptic neuron from which it had been released.


How Do Psychotropics Work? (cont.) Antidepressants

– Block reuptake of neurotransmitters Antipsychotics

– Block dopamine and other receptors Benzodiazepines

– Facilitate transmission of GABA Psychostimulants

– Increase release of neurotransmitters


The Nursing Process: Antianxiety AgentsBackground Assessment Data Indications: anxiety disorders, anxiety symptoms, acute alcohol withdrawal, skeletal muscle spasms, convulsive disorders, status epilepticus, and preoperative sedation

Action: depression of the CNS

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 addiction, and those who are depressed or suicidal


The Nursing Process: Antianxiety Agents (cont.)

Background Assessment Data (cont.) Interactions

– Increased effects when taken with alcohol, barbiturates, narcotics, antipsychotics, antidepressants, antihistamines,

neuromuscular blocking agents, cimetidine, or disulfiram

– Decreased effects with cigarette smoking and caffeine consumption


The Nursing Process: Antianxiety Agents (cont.)

Nursing Diagnosis Risk for injury Risk for activity intolerance Risk for acute confusion


The Nursing Process: Antianxiety Agents (cont.) Planning/Implementation Monitor client for these side effects

– Drowsiness, confusion, lethargy; tolerance; physical and psychological dependence; potentiation of other CNS depressants; aggravation of depression; orthostatic hypotension; paradoxical excitement; dry mouth; nausea and vomiting; blood dyscrasias; delayed onset (with buspirone only)

Educate client/family about the drugOutcome Criteria/Evaluation


The Nursing Process: Antidepressants

Background Assessment Data Indications: dysthymic disorder; major depression; depression associated with organic disease, alcoholism, schizophrenia, or mental retardation; depressive phase of bipolar disorder;

and depression accompanied by anxiety Action: increase concentration of norepinephrine and

serotonin in the body, either by blocking their reuptake by the neurons (tricyclics, tetracyclics, SSRIs) or by inhibiting the release of monoamine oxidase (MAOIs)


The Nursing Process: Antidepressants (cont.)

Background Assessment Data (cont.) Contraindications/precautions

– Contraindicated in known hypersensitivity (SSRIs, MAOIs, tricyclics); acute phase of recovery from myocardial infarction; angle-closure glaucoma (tricyclics); and concomitant with MAOIs (SSRIs and tricyclics).

– Caution with elderly or debilitated clients; clients with hepatic, cardiac, or renal insufficiency; psychotic clients; clients with benign prostatic hypertrophy; and those with history of seizures (tricyclics, MAOIs).



Background Assessment Data (cont.) Interactions (with tricyclics)

– Increased effects of tricyclics with bupropion, cimetidine, haloperidol, SSRIs, and valproic acid

– Decreased effects of tricyclics with rifamycin, carbamazepine, and barbiturates

– Hyperpyretic crisis, convulsions, and death can occur with MAO inhibitors

– Hypertensive crisis can occur with clonidine– Decreased effects of levodopa and guanethidine– Potentiation of pressor response with direct-acting

sympathomimetics



Background Assessment Data (cont.) Interactions (MAOIs)

– Hypertensive crisis with amphetamines, methyldopa, levodopa, dopamine, epinephrine, norepinephrine, reserpine, vasoconstrictors, or foods with tyramine

– Hypertension, hypotension, coma, convulsions, and death with narcotic analgesics

– Additive hypotension with antihypertensives– Additive hypoglycemia with antihyperglycemic agents– Potentially fatal reactions with other antidepressants,

carbamazepine, cyclobenzaprine, maprotiline, furazolidone, procarbazine, or selegiline (avoid use within 2 weeks of each other)


The Nursing Process: Antidepressants (cont.) Background Assessment Data (cont.) Interactions (SSRIs)

– Toxic, sometimes fatal, reactions have occurred with concomitant use of MAOIs

– Increased effects of SSRIs with cimetidine, L-tryptophan, and lithium

– Concomitant use of SSRIs may increase effects of hydantoin, tricycle antidepressants, benzodiazepine, beta-blockers, carbamazepine, clozapine, haloperidol, phenothiazine, St. John’s wort, sumatriptan, sympathomimetics, tacrine, theophylline, and warfarin.

– Concomitant use of SSRIs may decrease effects of buspirone and digoxin

– Serotonin syndrome can occur with concurrent use of other drugs that increase serotonin



Nursing Diagnosis Risk for suicide Risk for injury Social isolation Constipation


The Nursing Process: Antidepressants (cont.) Planning/Implementation Monitor client for the following side effects

– May occur with all chemical classes• Dry mouth, sedation, nausea• Discontinuation syndrome

– Most commonly occur with tricyclics

• Blurred vision, constipation, urinary retention, orthostatic hypotension, reduction of seizure threshold, tachycardia, arrhythmias, photosensitivity, weight gain


The Nursing Process: Antidepressants (cont.) Planning/Implementation (cont.) Side effects (cont.)

– Most commonly occur with SSRIs• Insomnia, agitation, headache, weight loss, sexual dysfunction,

serotonin syndrome

– Most commonly occur with MAOIs• Hypertensive crisis

– Miscellaneous side effects• Priapism (with trazadone)• Hepatic failure (with nafazodone)

Educate client/family about drug

Outcome Criteria/Evaluation


The Nursing Process: Mood-Stabilizing Agents

Background Assessment Data Indications: prevention and

treatment of manic episodes

associated with bipolar disorder

Examples: lithium carbonate, clonazepam, carbamazepine, valproic acid, lamotrigine, gabapentin, topiramate, verapamil, various antipsychotics


The Nursing Process: Mood-Stabilizing Agents (cont.)

Background Assessment Data (cont.) Action

– Lithium enhances the reuptake of norepinephrine and serotonin in the brain, lowering levels in the body and resulting in decreased hyperactivity

– The role of anticonvulsants, verapamil, and antipsychotics in the treatment of bipolar mania is not fully understood.

Interactions Contraindications/precautions


The Nursing Process: Mood-Stabilizing Agents (cont.) Nursing Diagnosis Risk for injury Risk for self-directed or

other-directed violence Risk for activity intolerance



Planning/Implementation Monitor for side effects of lithium

– Drowsiness, dizziness, headache– Dry mouth; thirst; GI upset; nausea/vomiting– Fine hand tremors– Hypotension; arrhythmias, pulse irregularities– Polyuria; dehydration– Weight gain– Potential for toxicity



Planning/Implementation (cont.) Lithium Toxicity

– Therapeutic range: 1.0–1.5 mEq/L– Initial symptoms of toxicity include

• Blurred vision, ataxia, tinnitus, persistent nausea and vomiting, and severe diarrhea

– Ensure that client consumes adequatesodium and fluid in diet



Planning/Implementation (cont.) Monitor for side effects of anticonvulsants

– Nausea and vomiting– Drowsiness; dizziness– Blood dyscrasias– Prolonged bleeding time (with valproic acid)– Risk of severe rash (with lamotrigine)– Decreased efficacy with oral contraceptives (with

topiramate)



Planning/Implementation (cont.)

• Monitor for side effects of verapamil– Drowsiness; dizziness

– Hypotension; bradycardia

– Nausea

– Constipation



Planning/Implementation (cont.)• Monitor for side effects of antipsychotics

– Drowsiness; dizziness– Dry mouth; constipation– Increased appetite; weight gain– ECG changes– Extrapyramidal symptoms– Hyperglycemia and diabetes



Planning/Implementation (cont.) Educate client and family

about the medication



The Nursing Process: AntipsychoticsBackground Assessment Data Indications: Treatment of acute and chronic psychoses; selected agents are also used as antiemetics in the treatment of intractable hiccoughs and for control of tics

and vocal utterances in Tourette’s disorder Actions: Unknown; thought to block postsynaptic

dopamine receptors in the basal ganglia, hypothalamus, limbic system, brainstem, and medulla. Newer antipsychotics may block action on receptors specific to dopamine, serotonin, and other neurotransmitters.


The Nursing Process: Antipsychotics (cont.)

Background Assessment Data (cont.) Contraindications/precautions

– Contraindicated with known hypersensitivity; with CNS depression; when blood dyscrasias exist; in clients with Parkinson’s disease; or those with liver, renal, or cardiac insufficiency

– Caution with elderly, debilitated, or diabetic clients or those with

respiratory insufficiency, prostatic hypertrophy, or intestinal obstruction

Interactions


The Nursing Process: Antipsychotics (cont.) Background Assessment Data (cont.) Interactions

– Additive anticholinergic effects with other drugs that produce these properties

– Additive hypotensive effects with beta-blockers– Decreased absorption of antipsychotics with antacids and

antidiarrheals– Decreased effectiveness of antipsychotics with

barbiturates– Additive CNS depression with alcohol, antihistamines,

antidepressants, sedative-hypnotics, and anxiolytics


The Nursing Process: Antipsychotics (cont.)

Nursing Diagnosis Risk for other-directed violence Risk for injury Risk for activity intolerance Noncompliance


The Nursing Process: Antipsychotics (cont.) Planning/Implementation

Monitor client for these side effects– Anticholinergic effects, nausea, GI upset, skin rash,

sedation, orthostatic hypotension, photosensitivity, hormonal effects, ECG changes, reduction of seizure threshold, agranulocytosis (especially with clozapine), hypersalivation (with clozapine), extrapyramidal symptoms (EPS), tardive dyskinesia, neuroleptic malignant syndrome (NMS), hyperglycemia and diabetes





The Nursing Process: Antiparkinsonian Agents

Background Assessment Data

Indications: treatment of

parkinsonism of various causes,

including degenerative, toxic,

infective, neoplastic, or drug-induced

Action: work to restore the natural balance of acetylcholine and dopamine in the CNS



The Nursing Process: Antiparkinsonian Agents (cont.) Background Assessment Data (cont.) Contraindications/precautions

– Contraindicated in known hypersensitivity; angle-closure glaucoma; pyloric, duodenal, or bladder neck obstructions; prostatic hypertrophy; or myasthenia gravis

– Caution with hepatic, renal, or cardiac insufficiency; elderly and debilitated clients; those with a tendency toward urinary retention; those exposed to high environmental temperatures


The Nursing Process: Antiparkinsonian Agents (cont.) Background Assessment Data (cont.) Interactions

– Additive anticholinergic effects and potentially fatal paralytic ileus with other drugs that possess these properties

– Concurrent use with haloperidol or phenothiazine may result in decreased effect of the antipsychotic and increased incidence of anticholinergic side effects.

– Additive CNS effects with CNS depressants


The Nursing Process: Antiparkinsonian Agents (cont.)

Planning/Implementation Monitor client for these side effects

– Anticholinergic effects, nausea, GI upset, sedation, dizziness, exacerbation of psychoses, orthostatic hypotension




The Nursing Process: Sedative-HypnoticsBackground Assessment Data Indications: short-term management

of various anxiety states and treatment of insomnia

Action: depression of the CNS

Contraindications/precautions: contraindicated in known hypersensitivity; caution advised with clients with hepatic dysfunction, severe renal impairment, those who are suicidal, and those who have been addicted to drugs


The Nursing Process: Sedative-Hypnotics (cont.)

Background Assessment Data (cont.) Interactions

– Additive CNS depression with alcohol, antihistamines, antidepressants, phenothiazine, or other CNS depressants

– Barbiturates decrease effectiveness of drugs metabolized by the liver

– Adverse effects when taken with MAOIs


The Nursing Process: Sedative-Hypnotics (cont.)

Nursing Diagnosis Risk for injury Disturbed sleep pattern Risk for activity intolerance Risk for acute confusion


The Nursing Process: Sedative-Hypnotics (cont.)Planning/Implementation Monitor client for side effects:

– Drowsiness, confusion, lethargy; tolerance; physical and psychological

dependence; potentiation of other CNS depressants; aggravation of

depression; orthostatic hypotension; paradoxical excitement; dry mouth; nausea and vomiting; blood dyscrasias

Client/family educationOutcome Criteria/Evaluation


The Nursing Process: ADHD Agents

Background Assessment Data Indications: ADHD in children

and adults

Action: The CNS stimulants increase levels of norepinephrine, dopamine, and serotonin in the CNS. Atomoxetine inhibits the reuptake of norepinephrine and bupropion blocks the neuronal uptake of serotonin, norepinephrine, and dopamine. The exact mechanism by which these drugs produce therapeutic effects in ADHD is unknown.


The Nursing Process: ADHD Agents (cont.)

Background Assessment Data (cont.) Contraindications

– CNS Stimulants: Contraindicated in clients with hypersensitivity to sympathomimetic amines; clients with advanced arteriosclerosis, symptomatic 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



Background Assessment Data (cont.) Contraindications

– Atomoxetine and bupropion: Contraindicated in clients with hypersensitivity to the drugs; in concomitant use with, or within 2 weeks of using MAO inhibitors.

– Atomoxetine: In clients with narrow-angle glaucoma– Bupropion: In clients with known or suspected seizure

disorder; acute phase of MI, and in clients with bulimia or anorexia nervosa



Background Assessment Data (cont.) Precautions:

– CNS Stimulants: Caution with lactating clients; psychotic children; clients with Tourette’s disorder,

anorexia, or insomnia; elderly, debilitated, or asthenic clients; and clients with history of suicidal

or homicidal tendencies– Atomoxetine & Bupropion: Caution in clients with

urinary retention; hepatic, renal, or cardiovascular disease; suicidal clients; pregnancy and lactation; and elderly and debilitated clients.

Interactions



Nursing Diagnoses Risk for injury Risk for suicide Imbalanced nutrition, less than body requirements Disturbed sleep pattern Nausea related to side effects of atomoxetine or

bupropion Pain related to side effect of headache with atomoxetine

or bupropion Risk for activity intolerance



Planning/Implementation Monitor client for these side effects

– Overstimulation, restlessness, insomnia, palpitations, tachycardia, anorexia, weight loss, tolerance, physical and psychological dependence, nausea and vomiting, constipation, potential for seizures (bupropion)








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2107 psychopharmacology townsend_5th_edition_spring_2013