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Examples and doses of Antidepressant Medications: Tricyclic: (TCA’s)
amitriptyline (Elavil) 75-300 10-60 I

mipramine (Tofranil) 75-300 50-300
clomipramine (Anafranil) 75-300 10-60

desipramine (Norpramin) 75-300 release

doxepin (Sinequan) 75-300 25-200

nortriptyline (Pamelor, Aventyl) 40-200
Action of TCA's
Block reuptake of neurotransmitters serotonin, norepinephrine, and/or dopamine in body.
Side Effects of Antidepressants
and Nursing implications
A. Can occur with all antidepressants:
* Dry mouth -----sugarless candy, sips of water frequently Ice, oral hygiene.
* Sedation ----order to give med at bedtime, instruct pt to not drive, decrease dosage.
* Nausea------give with food.
Side Effects of TCAs and Nursing implications
B. Commonly occurs with TCAs
1. Blurred vision---------------symptoms should subside in few wks. Do not drive until vision clear.
2. Constipation-----------------high fiber diet, monitor fluid & food intake increase exercise, if possible.
3. Urinary retention-----------pt report hesitancy or inability to urinate, monitor intake & output, instruct pt to see Dr.
4. Orthostatic hypotension---------rise slowly from lying to sitting, Monitor BP (lying & sitting), avoid hot showers and tub baths.
* Seizure threshold---------observe closely if history of seizures, institute seizure precautions.
* Tachycardia, arrthythmias------Carefully monitor BP, pulse rate & rhythm, report any change to Dr.
• Photosensitivity-------------------wear protective sunscreens, clothing, sunglasses.
* Priapism (with Desyrel)---withhold drug & notify Dr.
* Weight gain---------------------encourage increased activity, instructions on reduced calorie diet.
Life threatening effects of TCAs
Anticholinergic Crisis----symptoms include; purposeless overactivity, agitation, confusion, disorientation, dysarthria, (difficult & defective speech) dry, flushed skin, tachycardia, sluggish & dilated pupils, change in level of consciousness. Discontinue drug & notify Dr. Related to effects of anticholinergic drugs. Cumulative effects of too much anticholinergics effects = anticholinergic intoxication.
Antidepressant Medications: Selective Serotonin Reuptake inhibitors
examples and dose
fluoxetine (Prozac) 10-60 sertraline (Zoloft) 5-200
fluvoxamine (Luvox) 50-300 paroxetine (Paxil) 10-60
citalopram (Celexa) 10-60 escitalopram (Lexapro)
Paxil------Continued release
Action of antidepressant meds
Block reuptake of neurotransmitters serotonin, norepinephrine, and/or dopamine in body.
Side Effects
&
Nursing
Interventions
for SSRIs
Commonly occurs with SSRIs:
Insomnia; agitation----------take dose early in day, avoid caffeinated food & drink.
Headache-----------administer analgesics as , ordered, may need to change antidepressants medication.
Weight loss-----give caloric intake to maintain desired wt. Weigh daily. Can occur sometimes with SSRI’s.
Sexual dysfunction-----if intolerable, a switch to another antidepressant may be necessary.
Dizziness------do not participate in activities that require alertness.
GI upset-------give with food.
Life threatening effects for SSRI's
Serotonin Syndrome—-potentially fatal, results from combining serotonin-enhancing psychotropic drugs: SSRI + MAOI, Anafranil + MAOI, MAOI + L-tryptophan; symptoms hyperreflexia, hyperthermia, myoclonus, & other symptoms suggestive of the better-known neuroleptic malignant syndrome (NMS). NMS is similar but related to use of antipsychotic medications. Combination of drugs cause dangerously high serotonin levels in brain.
Antidepressant Medications: Monoamine Oxidase Inhibitors
phenelzine (Nardil) 30-90
tranylcypromine (Parnate) 20-60
socarboxazid (Marplan) 30-60
Action of MAOI's
MAOIs block MAO enzyme from inactivating serotonin, norepinephrine, and dopamine
Side Effects
&
Nursing
Interventions
for MAOI's
Commonly occurs with MAOIs:
Anticholinergic effects---blurred vision, dry mouth, constipation, urinary retention.
Hypotension------monitor BP; have pt. rise slowly.
CNS hyperstimulation--reassure pt.; assess for psychosis, hypomania, or seizures; when warranted, may need to stop drug & notify physician.
Hepatic & hematologic dysfunction----blood cell counts & liver function tests; when dysfunction is apparent, MAOI should be discontinued
Life threatening effects
For MAOI
Hypertensive Crisis-----(MAOIs only) symptoms include: severe occipital headache, palpitations, nausea, vomiting, fever, raised BP, chest pain,& coma. Stop drug immediately, monitor VS, give short-acting antihypertensive, use cooling measures. Teach pt to avoid foods high in tyramine. (List of foods & meds in Textbook)
Serotonin Syndrome—-potentially fatal, results from combining serotonin-enhancing psychotropic drugs: SSRI + MAOI, Anafranil + MAOI, MAOI + L-tryptophan; symptoms hyperreflexia, hyperthermia, myoclonus, & other symptoms suggestive of the better-known neuroleptic malignant syndrome (NMS). NMS is similar but related to use of antipsychotic medications. Combination of drugs cause dangerously high serotonin levels in brain.
Antimanic Medications
Examples and doses
Lithium Carbonate (Eskalith, Lithane)
Acute mania 1800-2400 mg
Maintenance 300-1200 mg
Therapeutic blood levels for Lithium:Acute-1.0-1.5 mEq/L, Maintenance--0.6-1.2 mEq/L
Combination Drug (Note: Combination of antipsychotic & antidepressant for treatment of Bipolar depression. See S.E. profiles for each of these drug classes.)
Symbax—Zyprexia & Fluoxetine HCL 6/25-12/50 mg
Action
Of antimanic meds
Antimanic may enhance reuptake of serotonin & norepinephrine, thus decrease levels in body.
Anticonvulsants & Channel blockers--–unclear how they work
Side Effects
&
Nursing
Interventions
for antimanic meds
Lithium:
Drowsiness, dizziness, headache—-----do not participate in activities that require alertness; give anaglesics.
* Dry mouth, thirst-------------sugarless candy, ice, frequent sips of water, good oral hygiene.
* GI upset, nausea/vomiting------------give with meals.
* Fine hand tremors---------report to Dr. May give small dose of Propranolol to counteract this effect. (Propranolol-b- Adrenergic blocking agent used in treating hypertension)
* Hypotension, arrhythmias, pulse irregularities----------monitor VS 2 or 3 times a day; may  dose.
* Polyuria, dehydration------monitor daily I&O; may subside after 1-2 weeks; monitor skin tugor daily.
* Weight gain-------instruct pt on reduced calorie diet; instruct about adequate Na intake, 2500cc fluid/day.
Life threatening effects for antimanic meds
Lithium toxicity: symptoms are blurred vision, ataxia, tinnitus, persistent nausea & vomiting, severe diarrhea, severe tremor. Stop drug , notify the doctor.
Antimanic Medications
examples and doses
Anticonvulsants: (Mood stablizers)
clonazepam (Klonopin) 2-20 mg valproic acid (Depakene) 500-1500 mg
valproic sodium (Depakote) 500-1500 mg lamotrigine (Lamictal) 250-500 mg
oxcarbazepine (Trileptal) 18 mg topiramate (Topamax) 50-400 mg
carbamazepine (Tegretol) 400-1200 mg (therapeutic plasma range 4-12 ug/ml)
gabapentin (Neurontin) 900-1800 mg (given for pain also)
Calcium Channel Blockers
verapamil (Calan, Isoptin) 240-320 mg
Side Effects
&
Nursing
Interventions
for anticonvulsants and calcium channel blockers
Anticonvulsants:
Nausea/vomiting----------give with food.
Blood dyscrasias----------regular blood tests. CBC
Prolonged bleeding time with valproic acid---ensure platelet count & bleeding time before initiation of valproic acid.
Calcium Channel Blockers:
Drowsiness, dizziness----------do not operate dangerous equipment until alert.
Hypotension, bradycardia-----take VS before initiation of therapy & daily before administration of drug.
Nausea, constipation-----------give with food, raise fluid & fiber in diet.
Central Nervous System Stimulants
examples and doses
Amphetamines: Dose: mg/day
methyphenidate (Ritalin) 10-60
pemoline (Cylert) 37.5-112.5
Concerta (SR or long acting Ritalin) 18, 36, or 54 mg in AM
Adderall (combination product) 5,10,30 mg tablets
NonStimulant Drug for Tx. Of ADHD
atomoxetine (Straterra) 10-60 mg/day
Actions of Central Nervous System Stimulants
Increase levels of neurotransmitters (probably norepinephrine, dopamine, & serotonin) in the CNS. They produce CNS & respiratory stimulation, dilated pupils, increased motor activity & mental alertness, diminished sense of fatigue & brighter spirits.
Side Effects
&
Nursing
Interventions
for CNS stimulants
1. Overstimulation, restlessness, insomnia-----assess mental status for changes in mood, level of activity, degree of stimulation, & aggressiveness; ensure pt is protected from injury; keep stimuli low & environment as quiet as possible to discourage overstimulation; to prevent insomnia, administer last dose 6-8 hrs. before
bedtime. Administer sustained-released forms in morning.
2. Palpitations, tachycardia------monitor & record VS at regular intervals throughout therapy. Report significant changes to Dr. immediately.
3. Anorexia, weight loss-----to reduce anorexia, the medication can be administered immediately after meals.
Weigh pt regularly (at least weekly) during hospitalization & at home while receiving CNS stimulant
Therapy because of potential anorexia / weight loss & temporary interruption of growth & development.
4. Tolerance, physical & psychological dependence------Tolerance develops rapidly. If anorexigenic effects begin to diminish, the Pt should notify doctor. Pt. should then be on reduced-calorie diet & program of regular exercise in addition to the medication.
Antipsychotic Medications (Neuroleptics) Traditional Antipsychotics:
examples and doses
fluphenazine (Prolixin) 0.5-20
haloperidol (Haldol) 1-15
trifluoperazine (Stelazine) 20-80
cholopromazine (Thorazine) 30-800 loxapine (Loxitane) 20-250
fluphenazine decanoate (Prolixin decanoate) 12.5-25 IM q 1-3 wk
fluphenazine decanoate (Prolixin decanoate) 12.5-25 IM q 1-3 wk
haloperidol decanoate (Haldol LA) 50-300
thiothixene (Navane) 8-30
thioridazine (Mellaril) 150-800
Long acting drugs may be used to increase compliance
Action of Antipsychotic Medications (Neuroleptics) Traditional Antipsychotics:
Thought to block postsynaptic receptors in the basal ganglia, hypothalamus, limbic system, brainstem, and medulla.
Side Effects
&
Nursing
Interventions
for antipsychotic meds
1. Anticholinergic effects
A. Anticholinergic effects:
Dry mouth-----give sugarless candy, ice, sips of water frequently, oral hygiene.
Blurred vision-----symptoms should subside after few weeks. Clear items from pathway to prevent fall. Do not drive until vision clears.
Constipation-----high fiber diet, increase fluid intake & physical activity.
Urinary retention-----Patient report any difficulty urinating, monitor intake & output.
Antipsychotic Medications (Neuroleptics) Atypical Antipsychotics
Examples and doses
clozapine (Clozaril) 300-900
olanzapine (Zyprexa) 5-20
sertindole (Serlect) 12-24
Consta---Risperdal long-acting 25mg IM q 2wks
risperidone (Risperdal) 4-16
quetiapine (Seroquel) 300-400
ziprasidone (Geodon) 40-160
aripiprazole (Abilify) 10-30
Action of antipsychotic meds
may block postsynaptic receptors in the basal ganglia, hypothalamus, limbic system, brainstem, and medulla.
Side effects
&
Nursing
Interventions
for antipsychotic meds
Extrapyramidal symptoms
assess for symptoms; administer Antiparkinsonian drug as ordered. Can use Simpson Scale to monitor for the early onset movement disorders.
Psuedoparkinsonism (shuffling gait, drooling, tremor, akinesia, bradykinesia (diminished motor movement) blunted affect. (Akinesia-- muscular weakness)
Akathisia (restlessness) Motor agitation; shifting of weight from foot to foot, inability to sit still.
Dystonia (involuntary muscular movements of face, arms legs)-----Spasms of major muscle groups of the neck, back, & eyes---Oculogyric crisis (uncontrolled rolling back of eyes)---may be mistaken for seizure activity; should be treated as emergency situation; contact Dr. & Give IV benztropine mesylate (Cogentin) ; stay with pt & reassure during frightening time.
Tardive dyskinesia: Late onset (bizarre facial & tongue movements, stiff neck, lip smacking, tongue protrusion & thrusting, blinking, grimacing & other excessive, unnecessary facial movements)-----all pts receiving long-term antipsychotic therapy are at risk (month or years); symptoms are potentially irreversible; assess pt frequently for symptoms by doing rating scale for EPS such AIMS.
Life threatening
effects-antipsychotic
1. Agranulocytosis: rare S.E. with most antipsychotics. Usually occurs within 1st 3 mths of tx. Observe for s&s of sore throat, fever, malaise; a CBC should be done if symptoms appear. EXCEPT with Clozaril, pts need to be monitored very closely. Weekly blood counts for 6 mths for Clozaril.
2. Neuroleptic Maligant Syndrome (NMS): rare, but potentially fatal, complication of neuroleptic drug. Symptoms include; severe parkinsonian muscle rigidity, lead pipe rigidity hyperpyrexia up to 107oF, tachycardia, increase in CPK, tachpnea, fluctuations in BP, diaphoresis, rapid deterioration of mental status to stupor & coma.-routine assessments of temperature & observe for parkinsonian symptoms. Stop neuroleptic drug immediately; monitor VS, degree of muscle rigidity, intake & output, level of consciousness.
Antianxiety Medications (Anxiolytics)
examples and doses
hydroxyzine (Vistaril; Atarax) 100-400
Benzodiazepines:
alprazolam (Xanax) 0.75-4
chlordiazepoxide (Librium) 15-100
clorazepate (Tranxene) 15-60
diazepam (Valium) 4-40
lorazepam (Ativan) 2-6
oxazepam (Serax) 30-120 (less toxic on liver)
Action for antianxiety meds
Depress subcortical levels of the CNS, particularly the limbic system & reticular formation.
EXCEPTION: buspirone (BuSpar) does not depress CNS. It is believed to produce desired effects through interactions with serotonin, dopamine, & other neurotransmitter receptors.
Side effects
&
Nursing
Interventions
for antianxiety meds
1.Drowsiness, confusion, lethargy (most common side effects)- not to drive or operate dangerous equipment

2. Tolerance, physical & psychological dependence (does not apply to buspirone)- Abrupt withdrawal can be life-threatening. S&S include depression, insomnia, increased anxiety, abdominal & muscle cramps, tremors, vomiting, sweating, convulsions, & delirium. (does not occur with antihistamines or BuSpar)

3. Ability to potentiate effects of other CNS depressants- not to drink alcohol or take meds that depress the CNS while taking his medication.

4. Possibility of aggravating symptoms in depressed persons-assess pt’s mood daily; take necessary precautions for potential suicide.

5.Orthostatic hypotension-----monitor lying & standing BP & pulse every shift; instruct patient to rise slowly from lying to sitting or standing position.

6. Paradoxical excitement (patient develops symptoms opposite of the medication’s desired effect)----stop taking drug & notify the Dr.

7. Dry mouth-----give frequent sips of water, or ice chips or hard candy, or chewing sugarless gum.

8. N/V-----take medication with food or milk.
Life threatening effects for antianxiety meds
Blood dyscrasias---symptoms of sore throat, fever, malaise, easy bruising, or unusual bleeding should be reported to Dr. immediately. Abrupt withdrawal can be life threatening because of withdrawal symptoms. Symptoms include nausea, vomiting, malaise, weakness, tachycardia, sweating, anxiety, orthostatic hypotension, tremor, insomnia, seizures.
CNS stimulants
Children with behavior disorders, a "____ _______" should be attempted.... give words and explain why
Children with behavior disorders, a “drug holiday” should be attempted periodically under direction of the Dr. to determine the effectiveness of the medication & need for continuation. Drug should not be withdrawn abruptly. To do so could initiate the following syndrome of symptoms: nausea, vomiting, abdominal cramping, headache, fatigue, weakness, mental depression, suicidal ideation, increase in dreaming & psychotic behavior.
Side Effects
&
Nursing
Interventions
for antipsychotic meds
-Other effects
B. Other effects:
Nausea, GI upset----give with food, concentrates may be diluted & given with fruit juice or other liquid.
Skin rash------report appearance to Dr. Avoid spilling liquid on skin; contact dermatitis may occur.
Orthostatic hypotension-----tell pt to rise slowly from lying or sitting position. Monitor BP (lying & standing) each shift; document & report any changes.
Photosensitivity----- wear sunscreens, clothing, sunglasses when outdoors.
Side Effects
&
Nursing
Interventions
for antipsychotic meds
-Hormonal effects:
Hormonal effects: Decreased libido; retrograde ejaculation, gynecomastia (men) ----explanation of effects & reassure of their reversibility; check possibility of alternate drug.
Amenorrhea (women)- reversibility, instruct to continue contraception.
Wt gain----weigh pt E2D, order calorie controlled diet, provide physical exercise, instruction about diet & exercise.
Nursing
Interventions
for antipsychotic meds
-Reduction of seizure threshold
Reduction of seizure threshold-----observe if hx of seizures; be especially observant of pts on Clozaril; Salivation--with some pts on Clozapine (Clozaril); support pt because of embarrassment.
What does patient need to know about BuSpar?
Delayed onset buspirone (BuSpar) only-----ensure patient understands there is a lag time of 10 days to 2 weeks between onset of therapy with BuSpar & subsiding of anxiety symptoms. Patient should continue taking medication during this time. No evidence that BuSpar creates tolerance or physical dependence as do the CNS depressant anxiolytics.
Antiparkinsonian Agents
Name Anticholinergics
Anticholinergics
Dose:mg
Benztroine (Cogentin) 0.5-6
Biperiden (Akineton) 2-8
ethopropazine (Parsidol) 50-600
procyclidine (Kemadrin) 5-20
trihexyphenidyl (artane) 1-15
Antiparkinson agents
Name an antihistamine and 2 Dopaminergic agonists and give dose range
Antihistamines Dose:mg
diphenhydramine
(Benadryl) 75-200

Dopaminergic agonists
Amantadine (Symmetrel) 100-300
Bromocriptine (Parlode) 2.5-100
Action of Antiparkinson Agents
To restore the natural balance of two major neurotransmitters in CNS; acetylcholine & dopamine
Anticholinergic effects and nursing interventions for antiparkinsonian agents
Anticholinergics effects: the antiparkinsonian drugs produce the same anticholinergics side effects as those produced by antipsychotics medications. If person is taking both types of medications the anticholinergic side effects can be compounded. Thus, antiparkinsonian medications may be ordered only at onset of EPS.
1. Dry mouth-----give sugarless candy, sips of water, good oral hygiene.
2. Blurred vision------symptoms should subside after a few weeks. Don’t drive or operate heavy equipment
during time of blurred symptoms are occurring.
3. Constipation-----foods high in fiber, increase physical exercise and fluid intake.
4. Paralytic ileus-----rare but potentionally serious side effect of anticholinergic drugs. Monitor for abdominal
distention, absent bowel sounds, nausea, vomiting, epigastric pain; report symptoms to Dr.
5. Urinary retention-----tell patient to report any difficulty urinating; monitor intake & output.
6. Tachycardia, decreased sweating, increased temperature------assess VS each shift; report any changes.
Other effects and nursing interventions for antiparkinsonian agents
Other Effects:
1. Nausea, GI upset------give medication with food.

2. Sedation, drowsiness, dizziness------may give medication at bedtime; may need to decrease dosage; patient not to drive.

3. Exacerbation of psychoses------assess for signs of loss of contact with reality; intervene during
hallucinations; talk about real people & real events; orient to reality; stay with patient during period of agitation & delirium; remain calm & reassure patient of safety; may need decrease in dosage.

4. Orthostatic hypotension------tell patient to rise slowly from lying to sitting or standing position; monitor BP lying & standing; report any changes
Antidementia meds
Namenda: give other name, action, Dosage, and side effects
Memantine (Namenda)
Action: Regulates glutamate activation
Dosage: 5-10 mg q 2 x day
S.E.: Dizziness, headache, constipation, confusion
Antidementia meds
Cholinesterase Inhibitors:
Name, give dose and side effects
galantamine (Reminyl) 4, 8, and 12 mg tablets q 2xday
S.E.-nausea, vomiting, diarrhea, weight loss

rivastigmine (Exelon)-
1.5, 3, 4.5, and 6mg tablets q 2xday
S.E.-nausea, vomiting, weight loss, upset stomach, muscle weakness

donepezil (Aricept)
5 & 10 mg tablets
S.E. Nausea, diarrhea, vomiting

Tacrine (cognex)
-still available but not actively marketed
10-40 mg usually given 4x/day
S.E. Nausea, diarrhea, possible liver damage.