Chapter 22: Medications for Psychotic disorders
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| Clinical course of schizophrenia usually involves: | Acute exacerbations w intervals of semi remission where symptoms are less severe
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| Meds can treat positive symptoms which are? | Hallucinations, delusions, alterations in speech, agitation)
-alterations in speech, though and behavior
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| Meds are used to tx negative symptoms which are? | Social withdrawal, lack of emotion, lack of energy, flat affect, decreased motivation, decreased pleasure in activities
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| Goal of med therapy? | Suppress acute episodes, prevent acute recurrence, maintain highest level of functioning
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| First-generation antipsychotics also known as? | Conventional
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| 1st gen (conventional) are used to tx? | Positive symptoms
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| 1st gen are used for clients who..? | can handle the adverse effects & are violent or particularly aggressive
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| Second generation antipsychotics also called? | Atypical
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| 2nd gen are the..? | Current meds of choice for initial tx, and for tx breakthrough episodes in clients on 1st gen
-more effective & less s/e
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| Advantages of 2nd gen? -symptoms they treat? -decrease in? -improvement in? -less.. | tx both neg and pos, decrease affective findings (depression/anxiety) & suicidal behaviors, improve neuro defects (poor memory), fewer to no EPS (tardive dyskinesia)
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| 2nd gen also have fewer ___ effects? | Anticholinergic; except clozapine (clozaril)
-bc most 2nd cause little to no blockage of cholinergic receptors
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| First generation (Conventional) meds -Select protocol med: | Chloropromazine (Thorazine), low potency
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| Way to remember the 1st gen: abbreviation | TTTPLFH
T3 people like fancy hair
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| TTTPLFH; name them | Thioridazine, low potency
Thiothixene (Navane), high potency
Trifluperazine, high potency
Perphenazine, medium potency
Loxapine, medium potency
Haloperidol (Haldol), high potency
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| How do 1st generation's work/act? | Block dopamine (D2), acetylcholine, histamine and NE receptors in the brain and periphery.
-Inhibition of psychotic symptoms is believed to be a result of D2 blockade in the brain
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| Uses of 1st gen? | tx acute/chronic psychotic disorders, schizophrenia spectrum, bipolar disorders, tourette's, prevent N/V by blocking dopamine in medulla.
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| Complications of 1st gen 1. agranulocytosis | Observe for infection; (fever, sore throat), notify provider
-Get baseline WBC if infection s/s
-Discontinue if so
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| Complications of 1st gen 2. Anticholinergic effects | Dry mouth, blurred vision, photophobia, urinary hesitancy/retention, constipation, tachycardia
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| Methods of reducing anticholinergic effects: | Chew sugarless gum, sip water, avoid hazardous activities, wear sunglasses outside, eat foods high in fiber, regular exercise, fluid intake 2-3L, void before medication
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| 3. EPS (Extrapyramidal symptoms) | Acute dystonia, parkinsonism, akathisia, tardive dyskinesia
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| EPS examples Acute dystonia: s/s | Severe spasm of the tongue, face, neck, & back
-Crisis requires rapid tx
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| Nursing w/ acute dystonia's? When to look for them? and what to tx with? | Begin to monitor for them between 5hr to 5 days after administration of 1st dose.
Tx with anticholinergics such as benztropine (convention) or diphenhydramine (benadryl).
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| EPS examples Parkinsonism s/s | Bradykinesia, rigidity, shuffling gait, drooling, tremors
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| Nursing w/ parkinsonisms? When to look for and what to tx with? | -Look for the first month after initial therapy
-Tx with benzotropine, diphenhydramine, or amantadine (Symmetrel)
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| EPS examples Akathisia s/s | Inability to sit still, continual pacing and agitation
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| Nursing w/ akathisia? When to look for and what to tx with? | -first 2 months after initial tx
-BB, benzodiazepines & anticholinergic meds
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| EPS examples Tardive dyskinesia (TD) | Late EPS
-Involuntary movements of the tongue and face, such as lip smacking & tongue fasciculations
-Involuntary movements of the arms, legs and trunk
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| Nursing w/ TD: Dose & look for when? | Administer lowest dose possible (if occurs or switch)
-Evaluate after 12 months of therapy & then q3months
-s/s can occur months to years after initial tx
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| 4. Neuroendocrine effects | Gynecomastia, galactorrhea, menstrual irregularities
-notify provider if you observe
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| 5. Neuroleptic malignant syndrome s/s | Sudden high fever, BP fluctuations, dysrhythmias, muscle rigidity, changes in LOC, coma
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| Nursing for NMS? -when does it occur? what do you do? | first 2 weeks, stop med, VS, cooling blankets, antipyretics (aspirin, tylenol), increase fluid
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| What can you administer to relax the muscles in NMS? | Dantrolene (Dantrium) and bromocriptine (Parlodel)
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| How long should you wait before resuming therapy with NMS? | 2 weeks or consider switching
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| 6. orthostatic hypotension | should develop a tolerance in 2-3 months, monitor HR, BP. Hold med.
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| 7. Sedation | effects should diminish in a few weeks, take med at bedtime to avoid daytime sleepiness, don't drive
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| 8. Seizures | Risk if existing seizure disorder, may need to increase AED if necessary
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| 7. Severe dysrhythmias | Baseline ECG & potassium prior to tx
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| 8. Sexual dysfunction | F/M, maybe lower dose
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| 9. Skin effects | Photosensitivity; severe sunburn
-contact dermatitis from handling meds
-avoid direct contact w meds
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| 1st gen (conventional) are contraindicated in what? | Coma, severe depression, parkinson's disease, prolactin-dependent cancer of the breast or severe hypotension, elderly w dementia
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| Levadopa use: | Avoid! activates dopamine receptors (counteracts antipsychotic agents)
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| How should you screen for EPS? | AIMS
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| Do antipsychotic meds cause addiction? | No
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| How long do the meds take to work? | Some effects seen in a couple days but may take 2-4 weeks or several months for full effects
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| Depot preps advantages? | IM, q2-4wks, lower doses, decreases adverse effects and TD
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| How do you begin dosing? | 2x daily then decrease to 1x at bedtime
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| Second-generation antipsychotics also called? | Atypical antipsychotics
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| 2nd gen prototype med: | Risperidone (Risperdal)
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| Abbreviation to help remember 2nd gen: | AACILOPQZ: alligators are careful in lakes of piranhas QZ
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| What does AACILOPQZ stand for? | Aripiprazole (Ablify), Asenapine (Saphris), Clozapine (Clozaril), Iloperidone (Fanapt), Lurasidone (Latuda), Olanzapine (Zyprexa), Paliperidone (Invega), Quetiapine (Seroquel), Ziprasidone (Geodon)
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| 2nd gen action? | Block serotonin, and to a lesser degree-dopamine receptors. Also block NE, histamine & acetylcholine.
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| Uses of 2nd gen? | Negative & positive symptoms of schizophrenia spectrum disorders
-psycosis induced by levodopa therapy
-relief in other psychotic disorders; bipolar
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| Adverse effects of 2nd gen? 1. new onset of DM or loss of control w/ current DM | baseline glucose, report s/s of hyperglycemia to provider
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| Adverse effects of 2nd gen? wt | Wt gain
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| Adverse effects of 2nd gen? Cholesterol levels | Hypercholesterolemia w/ ^ risk for htn and cad
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| Adverse effects of 2nd gen? BP | Orthostatic hypotension
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| Adverse effects of 2nd gen? Anticholinergic effects | Dry mouth, urinary hesitancy/retention
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| Adverse effects of 2nd gen? behavior/sleep | Agitation, dizzy, sedation & sleep disruption
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| Adverse effects of 2nd gen? Mild EPS, | ex. tremor
-use AIMS to test
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| Risperidone monitoring parameters? | Preg C, avoid dementia clients, and heart issues, DM (baseline sugars), avoid alcohol
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| Aripiprazole (Abilify) | Low or no risk EPS/DM/wt. gain/dyslipidemia/hypotension/anticholinergic
-adverse: sedation, headaches, anxiety, insomnia, GI upset
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| Asenapine (Saphris) (Pg. 219) | low risk DM/WT/DYL/antichol
-drowsy, prolonged QT, EPS, numbing of mouth
-avoid eating/drinking 10 min after each dose
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| Clozapine (Clozaril) | 1st atypical developed no longer first-line d/t adverse effects
-risk for fatal agranulocytosis
-wt gain, dylip, DM!!
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| Avoid immunosuppressants especially with? | Clozapine (Clozaril)
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| Risperidone can be administered how? | IM injection
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