Transcript Chapter 17

Pharmacology for Nurses
A Pathophysiologic Approach
Third Edition
CHAPTER
17
Drugs for Psychoses
Pharmacology for Nurses: A Pathophysiologic Approach, Third Edition
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Directory
Classroom Response System
Lecture Note Presentation
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NCLEX-RN Review
Question 1
The patient states that he has not taken his
antipsychotic drug for the past 2 weeks
because it was causing sexual dysfunction.
The name antipsychotic explains that
continuing the medication as prescribed is
important because:
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NCLEX-RN Review
Question 1 – Choices
1. Hypertensive crisis may occur with abrupt
withdrawal.
2. Muscle twitching may occur.
3. Parkinson-like symptoms will occur.
4. Symptoms of psychosis are likely to
return.
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Question 1 – Answer
1. Hypertensive crisis may occur with
abrupt withdrawal.
2. Muscle twitching may occur.
3. Parkinson-like symptoms will occur.
4. Symptoms of psychosis are likely to
return.
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NCLEX-RN Review
Question 1 – Rationale
Rationale: Symptoms of psychosis are likely
to return and manifest as agitation, distrust,
and frustration.
Cognitive Level: Analysis
Nursing Process: Implementation
Patient Need: Physiological Integrity
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Question 2
Prior to discharge, the nurse provides
teaching related to side effects of
phenothiazines to the patient, family, or
caregiver. Which of the following should be
included?
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Question 2 – Choices
1. The patient may experience withdrawal
and slowed activity.
2. Severe muscle spasms may occur early
in therapy.
3. Tardive dyskinesia is likely early in
therapy.
4. Medications should be taken as
prescribed to prevent side effects.
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Question 2 – Answer
1. The patient may experience withdrawal
and slowed activity.
2. Severe muscle spasms may occur
early in therapy.
3. Tardive dyskinesia is likely early in
therapy.
4. Medications should be taken as
prescribed to prevent side effects.
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NCLEX-RN Review
Question 2 – Rationale
Rationale: Acute dystonias occur early in the
course of therapy. These are severe muscle
spasms, particularly of the back, neck,
tongue, and face.
Cognitive Level: Analysis
Nursing Process: Planning
Patient Need: Physiological Integrity
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NCLEX-RN Review
Question 3
A 20-year-old man is admitted to the inpatient psychiatric unit for treatment of acute
schizophrenia and is started on risperidone
(Risperdal). Therapeutic outcomes of this
drug will include:
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NCLEX-RN Review
Question 3 – Choices
1. Restful sleep, elevated mood, and
coping abilities
2. Decreased delusional thinking and
lessened auditory/visual hallucinations
3. Orthostatic hypotension, reflex
tachycardia, and sedation
4. Relief of anxiety and improved sleep and
dietary habits
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Question 3 – Answer
1. Restful sleep, elevated mood, and
coping abilities
2. Decreased delusional thinking and
lessened auditory/visual
hallucinations
3. Orthostatic hypotension, reflex
tachycardia, and sedation
4. Relief of anxiety and improved sleep and
dietary habits
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NCLEX-RN Review
Question 3 – Rationale
Rationale: Antipsychotic drugs such as risperiodne
(Risperdal) treat the positive and negative effects
of the underlying mental disorder.A decrease in
delusional thinking, lessened hallucinations, and
overall improvement in mental thought processes
should be noted. Improvement in sleep patterns,
anxiety, and nutrition may be noted as secondary
effects of treatment of the underlying thought
disorder. Orthostatic
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Question 3 – Rationale (cont)
hypotension, reflex tachycardia, or sedation
are potential adverse effects.
Cognitive Level: Application
Nursing Process: Assessment
Patient Need: Physiological Integrity
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NCLEX-RN Review
Question 5
Which of the following data collected by the
nurse during the history and physical is a
contraindication for a patient to receive
fluphenazine (Permitil, Prolixin)?
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NCLEX-RN Review
Question 5 – Choices
1.
2.
3.
4.
Diabetes mellitus
Age older than 70
Bone marrow depression
Hypertension
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Question 5 – Answer
1.
2.
3.
4.
Diabetes mellitus
Age older than 70
Bone marrow depression
Hypertension
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Question 5 – Rationale
Rationale: Fluphenazine (Prolixin) is a
phenothiazine drug. Use is contraindicated in
patients with CNS depression, bone marrow
depression, and alcohol withdrawal.
Cognitive Level: Analysis
Nursing Process: Assessment
Patient Need: Physiological Integrity
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NCLEX-RN Review
Question 6
A female, age 39, has been on haloperidol
(Haldol) for 3 months for severe psychosis.
The nurse is monitoring the patient for the
development of acute dystonias with
haloperidol, and will monitor for:
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NCLEX-RN Review
Question 6 – Choices
1. Dry mouth, constipation, and blurred
vision
2. Pacing, squirming, or difficulty with gait
such as bradykinesia
3. Severe spasms of the muscles of the
tongue, face, neck, or back
4. Tremors, wormlike tongue movements,
and involuntary lip puckering
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NCLEX-RN Review
Question 6 – Answer
1. Dry mouth, constipation, and blurred
vision
2. Pacing, squirming, or difficulty with gait
such as bradykinesia
3. Severe spasms of the muscles of the
tongue, face, neck, or back
4. Tremors, wormlike tongue movements,
and involuntary lip puckering
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Question 6 – Rationale
Rationale: Acute dystonias are
characterized by acute spasms of the face,
tongue, neck, or back. Dry mouth,
constipation, and blurred vision are adverse
effects related to anticholinergic activity.
Pacing and squirming are signs of akathisia,
and bradykinesia and tremors are symptoms
of pseudoparkinsonism.
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Question 6 – Rationale (cont)
Involuntary lip-puckering and wormlike
movements of the tongue are symptomatic
of tardive dyskinesias.
Cognitive Level: Application
Nursing Process: Assessment
Patient Need: Physiological Integrity
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Psychoses
• Severe mental and behavioral disorders
characterized by:
– Delusions
– Hallucinations
– Illusions
– Paranoia
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Classifications of Psychoses
• Acute episode – occur over hours or days
• Chronic episode – develop over months or
years
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Factors Attributed to
Development of Psychoses
• Genetic
• Neurological
• Environmental
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Schizophrenia
• Abnormal thoughts and thought processes
• Disordered communication
• Withdrawal from other people and outside
environment
• Severe depression
• High risk for suicide
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Schizophrenia (continued)
• Most common psychotic disorder
• Manifests in men aged 15 to 24 years
• Manifests in women in aged 25 to 34
years
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Symptoms of Schizophrenia
• Variety of symptoms that may change over
time
– Hallucinations, delusions, or paranoia
– Strange and irrational behavior, actions
– Rapid alteration between extreme
hyperactivity and stupor
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Symptoms of Schizophrenia
(continued)
(continued)
• Variety of symptoms that may change over
time
– Attitude of indifference; detachment
– Deterioration of hygiene, job, academic
performance
– Withdrawal from social and interpersonal
relationships
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Symptoms of Schizophrenia
(continued)
• Characterized by positive and negative
symptoms
– Positive: add on to normal behavior
– Negative: subtract from normal behavior
• Diagnosis of positive and negative
symptoms important for selection of
appropriate drug
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Causes of Schizophrenia
• Cause yet to be determined
– Genetic
– Neurotransmitter imbalance
• Symptoms seem to be associated with
dopamine type 2 receptor in brain
– Antipsychotic drugs enter dopaminergic
synapses and compete with dopamine
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Figure 17.1 Basal ganglia: overstimulation of dopamine receptors may be responsible for schizophrenia
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Conditions That May Mimic the
Behaviors of Schizophrenia
•
•
•
•
Drug use
Brain neoplasm
Infections
Hemorrhage
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Selection of Antipsycotics
• No single drug of choice
• Selection of drug type depends on
– Clinician experience
– Side effects
– Patient needs
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Categories of
Antipsychotic Drugs
• Conventional antipsychotic
– Phenothiazines and phenothiazine-like drugs
• Atypical antipsychotic
– Nonphenothiazines
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Figure 17.2 Mechanism of action of antipsychotic drugs: (a) overproduction of dopamine; (b) antipsychotic medication
occupies D2 receptors, preventing dopamine from stimulating the postsynaptic neuron
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Patient Drug Compliance
• Goal is to reduce psychotic symptoms so
patients have ability to self-care
• Drugs do not cure mental illness
• Patients must continue drug regimen to
remain in remission
– Relapse rate for those who discontinue
medication is 60% to 80%
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Role of the Nurse
• Monitor client’s condition
• Give client drug education
• Obtain health history (long-term physical
problems)
• Obtain drug history (use of illegal drugs,
alcohol, etc.)
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Role of the Nurse (continued)
• Obtain baseline assessment (liver and
kidney function, vision, mental status)
• Monitor for extrapyramidal symptoms, and
report to the physician immediately
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Conventional (Typical)
Antipsychotics
• Monitor for decrease of psychotic
symptoms, side effects
• Monitor for anticholinergic side effects
• Monitor for alcohol, illegal-drug, caffeine,
and nicotine use
• Monitor for cardiovascular changes
• Monitor for seizures and patient’s
environment
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Conventional (Typical)
Antipsychotics (continued)
• Monitor for decrease of psychotic
symptoms, side effects
• Monitor for anticholinergic side effects
• Monitor for alcohol, illegal-drug, caffeine,
and nicotine use
• Monitor for cardiovascular changes
• Monitor for seizures and patient’s
environment
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Atypical Antipsychotic
• Monitor RBC and WBC and hematologic
side effects
• Observe for side effects and
anticholinergic side effects
• Monitor for decrease of psychotic
symptoms
• Monitor for alcohol, illegal-drug use,
caffeine, nicotine use
• Monitor elderly closely
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Extrapyramidal Symptoms (EPS)
• Tremor, muscle rigidity, stooped posture
(pseudoparkinsonism)
• Muscle spasms of face, tongue, neck or
back (acute dystonias)
• Inability to rest and relax; pacing
(akathisia)
• Lip smacking; wormlike movements of the
tongue; uncontrolled chewing and
grimacing (tardive dyskinesias)
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Neuroleptic Malignant Syndrome
(NMS)
• Client suffers a toxic reaction to
therapeutic doses of antipsychotic drug
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Neuroleptic Malignant Syndrome
(continued)
• Client exhibits
– Elevated temperature
– Unstable blood pressure
– Profuse sweating
– Dyspnea
– Muscle rigidity
– Incontinence
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Phenothiazines
• Prototype drug: chlorpromazine HCI
(Thorazine)
• Mechanism of action: blocks positive
symptoms of schizophrenia
• Primary use: for severe mental illness
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Phenothiazines (continued)
• Adverse effects: acute dystonia,
akathisia, Parkinsonism, tardive
dyskinesia, anticholinergic effects,
sedation, hypotension, sexual dysfunction,
and neuroleptic malignant syndrome
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Prototype Drug: Chlorpromazine hydrochloride
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Nonphenothiazines
• Prototype drug: haloperidol (Haldol)
• Mechanism of action: blocking of the
dopamine type 2 receptor
• Primary use: severe mental illness
• Adverse effects: identical to that of
phenothiazines
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Prototype Drug: Haloperidol
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Atypical Antipsychotics
• Prototype drug: risperidone (Risperdal)
• Mechanism of action: block dopamine type
2 receptors, serotonin and alpha-adrenergic
receptors
• Primary use: severe mental illness; treats
both positive and negative symptoms
• Adverse effects: fewer than those of
phenothiazines and nonphenothiazines, but
obesity and its risk factors need to be monitored
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Atypical Antipsychotics
(continued)
• Dopamine System Stabilizers
– Newest antipsychotic class
• Aripiprazole (Abilify) controls both positive
and negative symptoms
– Serious side effects compared to other
antipsychotic drugs is low
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Prototype Drug: Risperidone
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Conventional (Typical)
Antipsychotic Agents
• Phenothiazines
– Action blocks positive symptoms
– Mellaril, Compazine, Permitil
• Nonphenothiazines
– Action same as that of phenothiazines
– Taractan, Loxitane, Navane
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Atypical Antipsychotics
• Treats both the positive and negative
symptoms
• Less dramatic side effects, but still
significant
• Examples: Seroquel, Risperdal, Zyprexa
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Drug Therapy for Psychoses
• Assessment
– Monitor client’s condition
– Obtain health assessment
– Ascertain past mental illness
– Obtain information on smoking and use of
illegal drugs, alcohol, and caffeine
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Drug Therapy for Psychoses
(continued)
• Assessment
– Ascertain current medications and dietary
habits
– Obtain baseline blood and urine samples
– Assess family’s knowledge of psychoses and
medication regimen
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Drug Therapy for Psychoses
(continued)
• Planning
– Goal is to remain compliant with medication
regimen and free of symptoms
• Implementation
– Encourage compliance with medication
regimen
– Provide additional education
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Drug Therapy for Psychoses
(continued)
• Evaluation
– Client to remain free of symptoms related to
psychoses
– Client to verbalize importance of taking
prescribed medications
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Nursing Process Focus: Patients Receiving Conventional Antipsychotic Therapy
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Nursing Process Focus: Patients Receiving Conventional Antipsychotic Therapy
Pharmacology for Nurses: A Pathophysiologic Approach, Third Edition
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Nursing Process Focus: Patients Receiving Conventional Antipsychotic Therapy
Pharmacology for Nurses: A Pathophysiologic Approach, Third Edition
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Nursing Process Focus: Patients Receiving Conventional Antipsychotic Therapy
Pharmacology for Nurses: A Pathophysiologic Approach, Third Edition
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Nursing Process Focus: Patients Receiving Conventional Antipsychotic Therapy
Pharmacology for Nurses: A Pathophysiologic Approach, Third Edition
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Nursing Process Focus: Patients Receiving Conventional Antipsychotic Therapy
Pharmacology for Nurses: A Pathophysiologic Approach, Third Edition
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Nursing Process Focus: Patients Receiving Conventional Antipsychotic Therapy
Pharmacology for Nurses: A Pathophysiologic Approach, Third Edition
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Nursing Process Focus: Patients Receiving Atypical Antipsychotic Therapy
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Nursing Process Focus: Patients Receiving Atypical Antipsychotic Therapy
Pharmacology for Nurses: A Pathophysiologic Approach, Third Edition
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Nursing Process Focus: Patients Receiving Atypical Antipsychotic Therapy
Pharmacology for Nurses: A Pathophysiologic Approach, Third Edition
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Nursing Process Focus: Patients Receiving Atypical Antipsychotic Therapy
Pharmacology for Nurses: A Pathophysiologic Approach, Third Edition
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Nursing Process Focus: Patients Receiving Atypical Antipsychotic Therapy
Pharmacology for Nurses: A Pathophysiologic Approach, Third Edition
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Nursing Process Focus: Patients Receiving Atypical Antipsychotic Therapy
Pharmacology for Nurses: A Pathophysiologic Approach, Third Edition
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Nursing Process Focus: Patients Receiving Atypical Antipsychotic Therapy
Pharmacology for Nurses: A Pathophysiologic Approach, Third Edition
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Nursing Process Focus: Patients Receiving Atypical Antipsychotic Therapy
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