2107 psychopharmacology townsend_5th_edition_spring_2013

Psychiatric Mental Health Nursing, 5th Edition

Chapter 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.


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


 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 Agents
Background 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



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


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 drug
Outcome Criteria/Evaluation


The Nursing Process: Antidepressants
 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.)

 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).



 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



 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)


 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


 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


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


The Nursing Process: Mood-Stabilizing Agents

 Indications: prevention and
treatment of manic episodes
associated with bipolar disorder
 Examples: lithium carbonate, clonazepam,
carbamazepine, valproic acid, lamotrigine, gabapentin,
topiramate, verapamil, various antipsychotics


(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


(cont.)
Nursing Diagnosis
 Risk for injury
 Risk for self-directed or
other-directed violence


(cont.)

 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


(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 adequate
sodium and fluid in diet


(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)


(cont.)


• Monitor for side effects of verapamil
– Hypotension; bradycardia
– Nausea
– Constipation


(cont.)
• Monitor for side effects of antipsychotics
– Dry mouth; constipation
– Increased appetite; weight gain
– ECG changes
– Extrapyramidal symptoms
– Hyperglycemia and diabetes


(cont.)

 Educate client and family
about the medication



The Nursing Process: Antipsychotics
 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.)
– 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


 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



Nursing Diagnosis
 Risk for other-directed violence
 Risk for injury
 Noncompliance


– 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
 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


Antiparkinsonian Agents (cont.)
– 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


 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


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


The Nursing Process: Sedative-
Hypnotics
 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


Hypnotics (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


Hypnotics (cont.)

Nursing Diagnosis
 Risk for injury
 Disturbed sleep pattern
 Risk for acute confusion


Hypnotics (cont.)
 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 education


The Nursing Process: ADHD Agents
 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.)
 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


 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


 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



– 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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