N231 Pharm Exam I - Antipsychotics

Front 1

Extrapyramidal syndrome (EPS):
- Cause
- symptoms

Back 1

Cause: Dopamine antagonists
such as antipsychotics
Symptoms:
Dystonia
Akathisia
Pseudoparkinsonism
Tardive dyskinesia

Front 2

Dystonia
symptoms

Back 2

EARLY symptom of EPS:
- Occurs early in tx with ~5% of antipsychotics
- Facial, neck muscle spasms
- Eyes roll up
- May cause laryngospasms - (can risk airway)

Front 3

Dystonia
interventions

Back 3

- Monitor closely and maintain airway patency
- Cogentin (benztropine): anticholinergic,
- Benzodiazepine (ex: Valium): GABA agonist

Front 4

Akathisia
symptoms

Back 4

EARLY symptom of EPS:
- Uncontrolled mvmnt. Ex: RLS, rocking, pacing

Front 5

Akathisia
interventions

Back 5

- Benzodiazepine (ex: Valium): GABA agonist
- Beta blocker

Front 6

Pseudoparkinsonism
symptoms

Back 6

- tremoring
- rigidity / trouble getting started with movements
- "pill rolling"
- shuffling gait "Thorazine shuffle"

Front 7

Pseudoparkinsonism
interventions

Back 7

- for shuffle: have pt walk with hands behind back
- Rx:

Front 8

Tardive dyskinesia
symptoms

Back 8

PERMANENT, long term
- LATE onset, but may occur as early as 5-30 days into tx
- Occurs in ~20% of pts
- Higher risk for older adults
- grimacing, tongue protrusion, lip smacking, puckering and pursing of the lips, and rapid eye blinking. Rapid, involuntary movements of the limbs, torso, and fingers.
- legs can be so affected that walking becomes difficult
- symptoms opposite of Parkinson's disease.

Front 9

Tardive dyskinesia
interventions

Back 9

- STOP DRUG
- Benzodiazepine (ex: Valium): GABA agonist
- Ca channel blockers
- beta blockers
- Clozapine
- Vitamin E

Front 10

Neuroleptic Malignant Syndrome (NMS)
Symptoms

Back 10

RARE, but potentially fatal.
- Muscle rigidity
- Sudden high fever spikes
- BP fluctuations
- Dysrhithmias
- Seizures
- Rabdomyalosis

Front 11

Neuroleptic Malignant Syndrome (NMS)
Interventions

Back 11

- STOP DRUG
- hydration
- cooling measures
- antipyretics
- benzodiazapines / muscle relaxors to relieve muscle rigidity.

Front 12

Blood Dyscrasias

Back 12

- Agranulocytosis
- sudden drop in WBC
- Stop drug if WBC < 3000
- Infection symptoms

Front 13

Antipsychotics
Common SFX

Back 13

- These are major tranquilizers, often sold as street drugs
-Drowsiness
- Anticholinergic effects (dry as a bone, hot as a hare, etc)
- Derm effects: rash, itchiness
- Photosensitivity
- Sexual: irregular menses, amenorrhea, gynecomastia

Front 14

Typical Antipsychotics classifications

Back 14

- Phenothiazines
- Nonphenothiasines

Front 15

Phenothiazines

Back 15

- Chlorpromazine (Thorazine): urine may turn pink or red/brown
- Fluphenazine (Prolixin)

Front 16

Pathophysiology and S/Sx: Psychosis

Back 16

Pathophysiology: Dopamine imbalance in the brain
S/Sx: losing contact with reality. Characterized by difficulty in processing info, delusions, hallucinations, incoherence, aggressive or violent behavior. Symptoms are either positive or negative.
Drugs are usually dopaminergic antagonist, and have many side effects.

Front 17

Class: Antipsychotic

Back 17

Drugs used to treat psychosis.
Two subclasses:
Typical
Atypical

Front 18

Subclass: Typical Antipsychotics

Back 18

Class: Antipsychotics
Note: First drugs to be used for psychosis, but has many side effects
Classes Include:
Phenothiazines
Non-phenothiazines

Front 19

Types: Phenothiazines

Back 19

Subclass: Typical Antipsychotics
Class: Antipsychotic
Includes drugs:
Chlorpromazine HCL (Thorazine) Fluphenazine HCL (Prolixin)
Thronidazine (Mellaril)

Front 20

Drug: Thorazine

Back 20

Generic: Chlorpromazine HCL
Class: Antipsychotic
Subclass: Typical Antipsychotic
Type: Phenothiazine
Note: First drug to be used for psychosis

Front 21

Drug: Prolixin

Back 21

Generic: Fluphenazine HCL
Class: Antipsychotic
Subclass: Typical Antipsychotic
Type: Phenothiazine
Note:

Front 22

Drug: Mellaril

Back 22

Generic: Thronidazine
Class: Antipsychotic
Subclass: Typical Antipsychotic
Type: Phenothiazine
Note:

Front 23

Types: Non-Phenothiazines

Back 23

Subclass: Typical Antipsychotics
Class: Antipsychotic
Includes drugs:
Haloperidal (Haldol)
Loxapine (Loxitane)
Molindone (Navane)

Front 24

Drug: Haldol

Back 24

Generic: Haloperidal
Class: Antipsychotic
Subclass: Typical Antipsychotic
Type: Non-Phenothiazine
Note:

Front 25

Drug: Navane

Back 25

Generic: Molindone
Class: Antipsychotic
Subclass: Typical Antipsychotic
Type: Non-Phenothiazine
Note:

Front 26

Side Effects: typical Antipsychotics

Back 26

Extrapyramidal symptoms, hypotension, dystonia, akathesia, tardine dyskinesia, agranulocytosis, photosensitivity, pseudoparkinsonism, NMS

Front 27

Subclass: Atypical Antipsychotics

Back 27

Subclass: Atypical Antipsychotics
Class: Antipsychotic
Includes drugs:
Clozapine (clozaril)
Resperidone (Risperdal)
Olanzapine (Zyprexia)
Ziprasidone (Geodon)
Avetiapine (Seroquel)
Aripiprazole (Abilify)

Front 28

Drug: CLozaril

Back 28

Generic: Clozapine
Class: Antipsychotic
Subclass: Atypical Antipsychotic
Note: Less side effects but causes agranulocytosis

Front 29

Drug: Risperdal

Back 29

Generic: Resperidone
Class: Antipsychotic
Subclass: Atypical Antipsychotic
Note: Does not cause agranulocytosis

Front 30

Drug: Zyprexia

Back 30

Generic: Olanzapine
Class: Antipsychotic
Subclass: Atypical Antipsychotic
Note:

Front 31

Drug: Geodon

Back 31

Generic: Ziprasidone
Class: Antipsychotic
Subclass: Atypical Antipsychotic
side effects: Prolonged QT interval (do EKG)
Weight gain, dizziness, sedation, increased HR, orthostatics, constipation, hyPERglycemia

Front 32

Drug: Seroquel

Back 32

Generic: Avetiapine
Class: Antipsychotic
Subclass: Atypical Antipsychotic
Note:

Front 33

Drug: Abilify

Back 33

Generic: Aripiprazole
Class: Antipsychotic / mood stabilized
Subclass: Atypical Antipsychotic
side effects:
Prolonged QT interval (do EKG)
Agranulocytosis,
Neuroleptic Malignant Syndrome,
CVA,
EPS,
Weight gain, constipation, insomnia, fatigue.

Front 34

Important Nursing Assessment for Antipsychotics

Back 34

Look for positive and negative signs.
Drug Hx of anticonvulsants.
Mental status, cardiac, eye and respiratory disorders.

Front 35

Side Effect: Tardive Dyskinesia

Back 35

Protrusion and rolling of tongue, sucking and smacking movements of the lips, chewing motion, facial dyskinesia, involuntary movements of body and extremities

Front 36

Side effect: Acute Dystonia

Back 36

Facial grimacing, involuntary upward eye movement, muscle spasm of the tongue, face, neck, and back (spasm causes trunk to arch forward), laryngeal spasms

Front 37

Side effect: Akathesia

Back 37

Restlessness, trouble standing still, paces the floor, feet in constant motion, rocking back and forth

Front 38

Side Effect: Pseudoparkinsonism

Back 38

Stopped posture, shuffling gait, rigidity, bradykinesia, tremors at rest, pill-rolling motion of hand

Front 39

Assessment: Positive symptoms

Back 39

Characterized by exaggeration of normal function, incoherent speech, hallucination, delusion, and paranoia

Front 40

Assessment: Negative assessment

Back 40

Decrease or loss in function and motivation, poor self care, poverty of speech content, and social withdrawal

Front 41

Important nursing Implications for antipsychotics

Back 41

Observe for orthostatic hypotension, observe for EPS for typical antipsychotics, make sure client is compliant

Front 42

Side effect: NMS
Neuroleptic Malignant syndrome:

Back 42

Potentially fatal condition associated with antipsychotic drugs
S/Sx: Muscle rigidity, sudden high fever, AMS, BP fluctuations, tachycardia, dysrhythmias, seizures, rhambdomyolysis, acute renal failure, respiratory failure, and coma
Tx:
Withdrawal of antipsychotic, adequate hydration, hypothermic blankets, adminnistration of antipyretics, benzodiazapines, and muscle relaxants such as dantrolene (Dantrium)

Front 43

Side effect: agranulocytosis

Back 43

Failure of bone marrow cells to make enough neutrophils. Check CBC.

Front 44

Symptoms are: sedated / un-arousable
unstable BP, tachycardia / dysrhythmia
altered LOC
organ failure

Back 44

Antipsychotics
Phenothiazines overdose

Front 45

Antipsychotics
Phenothiazines overdose treatment:

Back 45

If conscious: gastric lavage, activated charcoal (will cause black fecal output), anticholinergic, hydration
If very severe: norepinephrine
1st priority for altered LOC: airway maintenance

Front 46

Typical long acting preparations (injectable)
- Indications
- drugs
- considerations

Back 46

- for pts who have a hard time taking daily meds
- Haldol or Prolixin
- q 2-4 weeks
- very viscous, must use large gauge needle, into large muscle
- Z-track only - DO NOT MASSAGE, extremely caustic
- No more than 15min in syringe
- absolutely NO subQ

Front 47

Typical long acting preparations (injectable)

Back 47

Risperdal Consta
q2weeks to start, then q4w
no subq

Front 48

Cocktail (5,1,50)
*** Don't forget incompatibility!

Back 48

May be given PO or IM
Haldol (5), Ativan (1-2), Benadryl (50 or 25).
Haldol and Benadryl cannot be given in same syringe!
May be given in an emergency w/o reese: Danger to self or others. Must ALWAYS have MD order.

Front 49

Smoking / APs interactions

Back 49

Smoking decreases the metabolism of the antipsychotic because it uses the same pathway.

Front 50

Kava Kava / APs interaction

Back 50

Increased risk for DYSTONIA with phenothiazines and fluphenazine

Front 51

AtypicalAntipsychotics black box warning:

Back 51

Increased Death Warning.
- increased risk of sever side effects, dosage should be 25%-50% less, must be individualized.

Front 52

NSG Process

Back 52

- Assess: get baseline, VS (prthostatics)
- EPS: dystonia, akathisia --> Pseudoparkinsonism, Tardive dyskinesia
- NMS: temp, BP, cardiac, seizures
- Agranulocytosis: Assess for infection s/s
- Urine output: Rabdomyelosis
- Hyperglycemia: accuchecks

Front 53

Teaching:

Back 53

- outcome expectation management
- complience
- smoking cessation
- Oral hygiene - d/t dry mouth. Suggest gum.
- family planning - teratogenic
- Follow up care
- Labs: CBC q 3 months
- Sun exposure precautions
- diet / exercise d/t drug related weight gain