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Tell Me What You Know About Psychiatric Drugs

Vicki Notes

What are the most commonly used drugs in the Mental Health Setting?

Reference: Nursing Diagnosis in Psychiatric Nursing - Pocket Guide for Care Plan Construction. 3rd ed.

ANTIMANICS

Lithium Carbonate – a.k.a. Eskalith, Lithane & Lithobid.

Lithoum Citrate – a.k.a. Cibalith-S

Tegretol (carbamazepine)

  • Is an anticonvulsant but it is mentioned here because of its unlabled use for tx of Bipolar affective disorder - See anticonvulsants to review side effects.

 

Lithium facts:

  • It works by enhancing reuptake of amines in the brain, thus lowering levels in the body & alters Na+ within nerve & muscle cells.
  • Drug of choice to tx/prevent bipolar mania.
  • Most common side effects - drowsiness, dizziness, headache, dry mouth, thirst, GI upset, nausea/vomiting, fine hand tremors, hypotension, irregular pulse, arrhythmias, polyuria, dehydration & weight gain.
  • Give with food or milk to ¯ GI irritation.
  • Low Na+ levels may predipose to toxicity, teach pt to drink 2000-3000mL fluid & eat a diet moderate in salt. Also avoid excess coffee, tea or cola (has a diuretic effect). Avoid excess Na+ loss i.e. heavy exertion & exercise in hot weather & saunas (causes excess sweating). Other losses may be due to fever, vomiting & diarrhea.
  • The therapeutic range according to this reference is:
  • 1.0 - 1.5 mEq/L For acute mania
  • 0.6 - 1.2 mEq/L For maintenance (prevention)
  • Anything above the range is toxic because there is an extremely narrow margin between the therapeutic & toxic levels.
  • Contraindicated in the first three months of pregnancy & in the elderly.

The drug Lithium is tested extensively on State Boards, NLNs & in Mental Health Nursing - I highly recommend you also consult your drug book.

J Laugh… it's contagious!

ANTIPSYCHOTICS

Stelazine

Thorazine

Risperdal

Compazine

Prolixin/Prolixin Decanoate

Luvox

Effexor

Clozaril - 1%-2% of pts develop agranulocytosis

Haldol

Navane

Loxitane

Moban

Compazine

Daxolin

Lidone

Proketazine

Quide

Taractan

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Antipsychotics - a.k.a. major tranquilizers, neuroleptics & antiemetics.

  • Are thought to act by blocking dopamine receptors throughout the brain.
  • Are used to tx psychotic disorders, severe behavior problems in children & severe nausea, vomiting & intractable hiccups.

Noted side effects include:

  • Anticholingeric effects (dry mouth, blurred vision, constipation & urinary retention).
  • Nausea; GI upset (give with food).
  • Skin rash, orthostatic hypotension, photosensitivity & sedation (give at bedtime), weight gain, difficulty maintaining body temperature, urine may turn pink to reddish-brown, reduction in seizure threshold.
  • Hormonal effects - decreased Libido, retrograde ejaculation, gynecomastia(males), amenorrhea (females)
  • Agranulocytosis - a rare but serious side effect where WBC count drops extremely low HOWEVER 1%-2% of pts taking Clozaril (clozapine) develop it - so must have blood levels drawn weekly. If WBC count falls ¯ 3000mm3 or granulocyte count falls ¯ 1500mm3 the drug is discontinued.
  • Extrapyramidal Symptoms (EPS) (side effects) include:
  • Pseudoparkinsonism - tremor, shuffling gait, drooling & ridigity (can appear 1-5 days after starting the medication).
  • Akinesia - muscular weakness.
  • Akathisia - continuous restlessness & fidgeting (can occur 50-60 days after starting the med).
  • Dystonia - involuntary muscular movements (spasms) of the face, arms, legs & neck.
  • Oculogyric Crisis - uncontrolled rolling back of the eyes (Hey-don't teenagers have this!!!).

Tardive Dyskinesia - bizarre facial & tongue movements; stiff neck & difficulty swallowing.

Side effects continued:

Neuroleptic Malignant Syndrome - rare but potentially fatal. S/S include - hyperpyrexia (­ to 107°F), tachycardia, tachypnea, fluctuations in BP, diaphoresis, decreased in mental status.

If Neuroleptic Malignant Syndrome occurs - the drug must be stopped immediately.

 

ANTIDEPRESSANTS

Prozac (SSRI) - weight loss noted with drug.

Zoloft (SSRI)

Paxil (SSRI)

Wellbutrin

Elavil

Desyrel - priapism is a possible side effect.

Serzone

Nardil (MAOI) - hypertensive crisis possible

Pamelor

Anafranil

Tofranil

Norpramin

Sinequan

Aventyl

Parnate

Asendin

Imipramine

Work to increase the concentration of norepinephrine & serotonin in the body by blocking:

  • The reuptake of these chemicals by the neurons (such as with tricyclics & others).
  • Or inhibiting an enzyme (such as with MAO inhibitors).

Work to elevate mood & alleviate other symptoms (use with psychotherapy).

  • Symptomatic relief is usually achieved in 1 to 4 weeks.
  • As mood lifts remember to assess for suicide, as potential often increases as depression lifts.

Side effects include:

  • Anticholinergic effects (dry mouth, blurred vision, constipation & urinary retention).
  • Sedation, orthostatic hypotension, reduction of seizure threshold, tachycardia and arrhythmias and photosensitivity.
  • Hypertensive Crisis (with MAO inhibitors) to avoid such crisis teach the patients not to consume tyramine containing foods as follows: aged cheese, or other aged or fermented foods, pickled herring, beef & chicken livers, preserved sausages, beer, wine (esp. chianti), chocolate, caffeine, canned figs, sour cream, yogurt, soy sauce, diet pills & over-the-counter medications.

ANTIANXIETY

Xanax

Valium

Ativan

Librium

Tranxene

Vestran

Buspar - interacts with neurotransmitters

Miltown/Equanil

Paxipam

Librax

Centrax

a.k.a anxiolytics, minor tranquilizers and sedatives.

  • Work by depressing the CNS EXCEPT for BuSpar that instead interacts with serotonin, dopamine & other neurotransmitters.
  • Side effects include the following:
  • Drowsiness, confusion & lethargy
  • Tolerance: physical & psychological dependence (shouldn't stop abruptly).
  • Potentiates the effects of other CNS depressants i.e. alcohol & other meds.
  • Orthostatic hypotension, paradoxical excitement, dry mouth, nausea, vomiting, blood dyscrasias & delayed onset with BuSpar (7-10 days - thus this is not an effective prn medication).

 

HYPNOTICS

Serax

Ambien

Atarax

Dalmane

Noctec

Restoril

See same side effects as for antianxiety drugs.

STIMULANTS

Dexidrine

Ritalin

 

ANTICONVULSANTS

Depakote - valproic acid

Klonopin

Neurontin

Tegretol

Solfoton

Dilantin - a.k.a. phenytoin Check levels

Mysoline

With Depakote - Monitor CBC & serum levels of valproic acid - 50-100mcg is the therapeutic safe range.

  • A side effect to monitor with Depakote is prolonged bleeding time - noting any bruising or spontaneous bleeding.

Monitor Dilantin levels - Therapeutic blood levels are between 10 - 20 mcg/mL

 

ANTIPARKINSONISM

Cogentin

Eldepryl

Artane

Benedryl (diphenhydramine)

Akineton

Kemadrin

 

Antiparkinsonism drugs:

  • Work to restore the balance of neurotransmitters acetylcholine & dopamine à this imbalance results in excessive cholinergic activity.
  • Are used to tx all forms parkinsonism & drug-induced extrapyramidal reactions.
  • Side effects: exacerbation of psychosis.
  • Anticholinergic effects - dry mouth, blurred vision, constipation, Paralytic Ileus, urinary retention, tachycardia, decreased sweating (body may not be able to cool self), elevated temperatures & orthostatic hypotension.
  • Nausea & GI upset.
  • Sedation - drowsiness & dizziness (give at bedtime if possible).
  • Exacerbation of psychoses

 

STUDY QUESTIONS

1. What foods should be avoided for a patient on a MAO Inhibitor?

Chocolate, wine, cheese and…

2. Name a MAO Inhibitor?

Nardil

3. What drug level would be checked for a patient taking Depakene/Depakote?

CBC - Valproic Acid level

4. What is a side effect to consider with Depakote?

A side effect of Depakote may be prolonged bleeding time, therefore the nurse should monitor for bruising & spontaneous bleeding

5. What is the therapeutic range for valproic acid?

50-100 mcg

6. What classification of drugs would the nurse be observing the patient for EPS?

Neuroleptics

7. Why is it so important that a patient taking Lithium consume a diet adequate in sodium?

Lithium & sodium are so much alike in chemical structure that they act very much the same in the body. Because of this à if your body doesn't have enough sodium, it will keep that lithium salt instead of eliminating it as it normally would through urine… the end result is a buildup of lithium. If your diet contains adequate sodium, your body happily uses the sodium & lithium salt is eliminated through urine… cool, huh!

  1. Ms Baker asks how often a patient's blood lithium level must be monitored & why?

    2. Student nurse Kim knows off the top of her head that it is about once a month (regularly) because there is such a narrow margin between therapeutic & toxic levels. A level above 1.5 mEg/liter is considered toxic (this can vary according to instructor, textbook & facility).

  2. Student nurse Sandra should not administer chlorpromazine hydrochloride (Thorazine) to her patient who has ingested alcohol. Why not?

    3. It may cause oversedation & respiratory depression.

  3. Ms Montambo asks student nurse Trish when can lithium toxicity occur?

    4. Trish states that Lithium toxicity can occur when sodium & fluid intake are insufficient, causing Lithium retention.

  4. Amanda has a patient who takes a monoamine oxidase (MAO) inhibitor. She knows that if her patient eats foods rich in tyramine what will occur?

    5. Severe hypertension may occur if her patient eats tyramine rich foods such as aged cheese, chicken liver, avocados, bananas, chocolate, meat tenderizer, salami, bologna, wine & beer.

  5. Maria asks Amanda what other assessments should be considered for the patient on MAO inhibitors?

    6. Amanda states that the patient should also be weighed biweekly & monitored for suicidal tendencies. And if palpitations, headaches, or severe orthostatic hypotension occurs she should withhold the medication & notify the MD (gee… Amanda sure knows her MAOs).

  6. Ms Stevens asks Beth what the therapeutic serum level for Lithium is?

    7. Beth says that it is 0.5-1.5 mEq/liter but it may vary dependent upon textbook, facility or instructor.

  7. Anna is preparing to administer the anticonvulsant Dilantin (phenytoin), she knows that a possible adverse reaction to the medication is what?

    8. Gingival hyperplasia

    FYI: Dilantin is the drug of choice in treatment of status epilepticus.

  8. Elizabeth knows that a patient who consumes high-tyramine foods while taking a MAO inhibitor may experience a hypertensive crisis. What signs & symptoms will indicate this crisis?

    9. The crisis is marked by a dangerously elevated blood pressure, headache, chills, nausea & restlessness.

  9. Lorraine reads the latest serums Lithium levels on her patient & notes that the level is 1.9mEq/liter. She immediately calls the MD because:

    10. Lorraine, being the brainchild that she is, knows that serum Lithium levels that exceed 1.5mEq/liter are considered toxic.

  10. Soon-to-be-super-nurse Joycelyn has a patient that is taking Antabuse (disulfiram). What vital information must she teach her patient?

    11. To avoid ingesting products that contain alcohol, including cough syrup, sauces & soups made with cooking wine.

    FYI: Antabuse should not be taken while administering Flagyl (metronidazole) because they may interact causing a psychotic reaction.

  11. While in MH postconference, Ms Montambo asks student nurse Sharon White to tell the group the signs of lithium toxicity.

Sharon easily states that the signs of lithium toxicity are diarrhea, tremors, nausea, muscle weakness, ataxia & confusion (Ms Montambo, of course, is impressed).

19. The nurse knows that electroconvulsive therapy is primarily used in the treatment of severe depression. It is sometimes used in conjunction with what other type of therapy?

Antidepressant therapy
  1. What are contraindications to ECT?

    2. Brain tumors & recent MI.

  2. Define ECT?

    3. Electroconvulsive therapy is a type of somatic treatment where an electric current is applied to the brain through electrodes placed on the temples. The current is sufficient to induce a grand mal seizure, from which the desired therapeutic effect is achieved.

  3. How does ECT work to reduce depression?

    4. It is thought to produce biochemical changes in the brain by way of an increase in the levels of norepinephrine & serotonin, similar to the effects of antidepressant medications.

  4. What is the most common side effect of ECT?

    5. Temporary memory loss & confusion. The nurse should provide reassurance that the memory loss is only temporary & reorient the patient.

  5. What are the risks involved in ECT?

    6. Death - the major cause being cardiovascular complications (acute MI or cardiac arrest).

    Permanent memory loss - has been reported by some individuals

    Brain damage - minimal

    All of these risk's effects appear to be minimal but patients must be informed before consenting to treatment.

  6. Mr West asks Andy, "What's the therapeutic range for phenytoin?"

Andy of course without hesitation recalls that it is 10 - 20 mcg/mL.

 

 

If you need to practice your math calculations please see:

SoutheasternNurse Pages:

Fundamentals/Pharmacology & Mental Health Nursing

 

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Don't Sweat the Small Stuff - It's All Small Stuff J