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115 Cards in this Set

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clozapine
Clozaril
Atypical Antipsychotics
Not the first line; refractory cases only!
clozapine (Clozaril) mechanism
Blocks the dopamine receptors in the limbic system rather than those in the neostratal area of the basal ganglia.
clozapine (Clozaril)side effects/toxic effects
1. Can produce fatal side effect by suppressing bone marrow and induce agranylocytosis rendering patient prone to infection. Regular WBC is mandatory: weekly for the first 6 months and then biweekly.
2. Can induce convulsions and myocarditis. Monitor patient closely.
3. High seizure rate (increases the risk for seizure).
4. Significant weight gain (67%)
5. Excessive salivation
6. Tachycardia
clozapine (Clozaril)
EPSs, ACh, OH, Sed?
No, High, High, High
risperidone
Risperdal
Atypical Antipsychotics
risperidone (Risperdal)
treats delusions, and hallucinations without motor abnormalities
risperidone (Risperdal)complications
1. orthostatic hypotension
2. sedation
3. weight gain (18%)
4. sexual dysfunction.
5. insomnia
Compliance issues; Talk to patient.
risperidone (Risperdal)Serious SE
Increased CVA in elderly with dementia and being treated for agitation.
risperidone (Risperdal)
EPSs, ACh, OH, Sed?
Mild, Very Low, Moderate, Low
quetiapine
Seroquel
Atypical Antipsychotics
quetiapine (Seroquel) mechanism
binds and antagonizes D1, D2, 5-HT1, α1, α2, and H1.
quetiapine (Seroquel)
side effects
1. orthostatic hypotension
2. drowsiness
3. weight gain (23%)
4. headache
quetiapine (Seroquel)
EPSs, ACh, OH, Sed?
Low, Mide, Moderate, Moderate
olanzapine
Zyprexa
Atypical Antipsychotics
olanzapine (Zyprexa)
mechanism
antagonizes D2, 5-HT1, α1, α2, H1, and muscarinic receptors.
olanzapine (Zyprexa)
side effects
1. sedation
2. significant weight gain (34%)
3. insomnia
4. agitation and restlessness
5. possibly akathisia or parkinsonism
6. hyperglycemia, and new on-set of type 2 diabetes.
olanzapine (Zyprexa)
EPSs, Ach, OH, Sed?
Low, Moderate, Moderate, Low
ziprasidone
Geodon
Atypical antipsychotic
ziprasidone (Geodon)
mechanism
Serotonin-norepinephrine reuptake inhibitor and also binds to 5-HT1, D2, α, and H1.
ziprasidone (Geodon)
Main effect/SE:
1. ECG changes
2. Low propensity for weight gain
3. Targets depressive symptoms
4. hypotension
5. sedation
ziprasidone (Geodon)
Caution:
can cause prolongation of the QT interval. Not to be used with other drugs known to prolong QT interval. Check Patient history for cardiac arrhythmias, perform ECG and blood chemistry for magnesium and potassium level.
aripiprazole
Abilify
Atypical antipsychotic
aripiprazole (Abilify)
mechanism
Dopamine system stabilizer, function as a partial agonist at the D2 receptor.
aripiprazole (Abilify)
SE:
1. sedation
2. hypotension
3. anticholinergic effects
4. Low propensity for weight gain or increase in glucose, HDL, LDL, or triglyceride levels.
aripiprazole (Abilify)
EPSs, Ach, OH, Sed?
Low, Low-mild, Low-mild, Low
ziprasidone (Geodon)
EPSs, Ach, OH, Sed?
Low, Mild, Mild, Low
Typical (Traditional) Antipsychoyics (7)
haloperidol (Haldol)
trifluoperazine (Stelazine)
flupenazine (Prolixin)
Thiothixene (Navan)
loxapine (Loxitane)
molindone (Moban)
chlorpromazine (Thorazine)
haloperidol ()
Haldol
trifluoperazine ()
Stelazine
flupenazine ()
Prolixin
Thiothixene ()
Navan
loxapine ()
Loxitane
molindone ()
Moban
chlorpromazine ()
Thorazine
SE/Adverse effects of Typical (Traditional) Antipsychoyics
1. EPS
2. Neurobiological effects (sedation, apathy, flat effects)
3. ACh effects
4. Skin rash
5. photosensitivity
6. weight gain
7. withdrawal symptoms of gastritis, nausea, vomitting, headache, tachcardia, insomnia, and dizziness.
8. reduction of seizure thresshold
9. orthostatic hypotension
10. galactorrhea
11. sexual dysfuction
haloperidol (Haldol)
special considerations
1. Has low sedative properties; is used in large dose for assultive client to avoid the severe side effect of hypotension
2. Appropriate for the elderly for the same reason as above; lessen the chance of fall from dizziness or hypotension
3. High incidence of EPSs.
2.
trifluoperazine (Stelazine)
special considerations
1. Low sedative effects- good for symptoms of withdrawal or paranoia
2. High incidence of EPSs
3. Neuroleptic malignant syndrome may occur.
flupenazine (Prolixin)
special consideration
among the least sedating
Thiothixene (Navan)
special consideration
High incidence of akathisia
chlorpromazine (Thorazine)
special considerations
1. Increases sensitivity to the sun
2. Highest sedative and hypotensive effects; least potent
3. May cause irreversible retinitis pigmentosa at 800 mg/day
Lithium Carbonate (Eskalith, Lithobid)
Mood Stabilizers
Mood stabilizing drug in clients with mania (bipolar) and depression affect electrical conductivity in neurons. Level initial and maintenance.
Lithium Carbonate (Eskalith, Lithobid)
Special considerations
1. Because lithium represents a potential threat to body functions that are regulated by electrical activity it can induce cardiac dysrhythmias or convulsions, extreme motor dysfunction.
2. Disturbance of calcium and potassium by Lithium, it can altered with the body's ability to regulate fluid balance and the distribution of fluid leading to polyuria, edema, and risk of kidney and thyroid disease.
3. LOWEST THERAPUTIC INDEX: check drug level frequently.
Lithium Carbonate (Eskalith, Lithobid)
Side Effects
1. Nervous and Muscular: tremor, ataxia, confusion, convulsion.
2. Digestive: Nausea, vomiting, diarrhea
3. Cardiac: Arrhythmias
4. Fluid and Electrolytes: polyuria, polydipsia, edema
5. Endocrine: Goiter and hypothyroidism
Antiepileptic Drugs (6)
Carbamazepine (Tegretol, Valproic Acid, Clonazepam)
Divalproex (Depakote)
Lamotrigine (Lamictal)
Gabapentin (Neuerontin)
Topiramate (Topamax)
Clonazepam (Klonopin)
Carbamazepine ()
Tegretol, Valproic Acid, Clonazepam
Antiepileptic
Divalproex ()
Depakote
Antiepileptic
Lamotrigine ()
Lamictal
Antiepileptic
Gabapentin ()
Neuerontin
Antiepileptic
Topiramate ()
Topamax
Antiepileptic
Clonazepam ()
Klonopin
Antiepileptic
Carbamazepine (Tegretol, Valproic Acid, Clonazepam)
Indications
- Treatment of bipolar disease, reduce the firing rate of very high frequency neurons in the brain can reduce mood swings, reduce excitement of the manic phase, effective in conditions such as trigeminal neuralgia that involve paroxsysms (bursts) of severe pain, analgesic reduce firing rate and calm.
Carbamazepine (Tegretol, Valproic Acid, Clonazepam)
SE
1. nausea
2. sedation
3. ataxia
4. rash may occur.
Carbamazepine (Tegretol, Valproic Acid, Clonazepam)
Special considerations
- Recommended baseline laboratory: Liver function tests (AST, ALT), CBC, ECG, and electrolytes levels. Also monitor the therapeutic blood level regularly.
Divalproex (Depakote)
Indications
First-line treatment for bipolar disorder
Divalproex (Depakote)
SE/ special considerations
SE:
hair loss, tremor, weight gain, and sedation.

Serious SE: thrombocytopenia, pancreatitis, hepatic failure, and birth defects.

Baseline level: liver function, CBC, and therapeutic blood level.
Neuroleptic malignant syndrome is characterized by:
1) decreased level of consciousness
2) greatly increased muscle tone
3) autonomic dysfunction including:
Hyperpyrexia (over 103)
Labile hypertension
Tachycardia
Tachypnea
Diaphoresis
Drooling.
Treatment of Neuroleptic malignant syndrome consists of:
1) early detection
2) discontinuation of the antipsychotic agent
3) management of fluid balance
4) reduction of tem­perature
5) monitoring for complications.
Medications for the treatment of Neuroleptic malignant syndrome are:
Mild cases of neuroleptic malignant syndrome are treated with bromocriptine (Parlodel)

more severe cases are treated with intravenous dantrolene (Dantrium) and even with electroconvulsive therapy in some cases.
Pseudoparkinsonism:
masklike fades, stiff and
stooped posture, shuffling
gait, drooling, tremor, "pill-rolling" phenomenon
Pseudoparkinsonism:
Onset
5 hours-30 days
Pseudoparkinsonism:
Nursing Measures
Alert medical staff.
An anticholinergic agent (e.g., trihexyphentdyl [Artane] or benztropine [Cogentin]) may be used
Acute dystonic reactions:
acute contractions of
tongue, face, neck, and
back (tongue and jaw first)

Opisthotonos: tetanic
heightening of entire body,
head and belly up

Oculogyric crisis: eyes
locked upward
Acute dystonic reactions:
Onset
1 -5 days
Acute dystonic reactions:
Nursing Measures
First choice: diphenhydramine hydrochloride (Benadryi) 25-50 mg IM/IV. Relief occurs in minutes.

Second choice: benztropine, 1-2 mg IM/IV. Prevent further dystonias with any anticholinergic agent.

Experience is very frightening. Take client to quiet area and stay with him or her until medicated.
Akathisia:
motor inner-driven restlessness (e.g.,
tapping foot incessantly,
rocking forward and backward in chair, shifting weight from side to side.
Akathisia:
Onset
2 hours-60 days
Akathisia:
Nursing Measures
Physician may change antipsychotic agent or give antiparkinsonian agent.

Tolerance does not develop to akathisia, but akathisia disappears when neuroleptic is discontinued.

Propranolol (Inderal), lorazepam (Ativan), or diazepam (Vaiium) may be used.
Tardive dyskinesia:
Onset
Months to years
Tardive dyskinesia:
Nursing Measures
No known treatment Discontinuing the drug does not always relieve symptoms.

Possibly 20% of clients taking these drugs for >2 years may develop tardive dyskinesia.

Nurses and doctors should encourage clients to be screened for tardive dyskinesia at least every 3 months.
Agranulocytosis:
symptoms include sore throat, fever, malaise, and mouth sores.

It is a rare occurrence, but a possibility the nurse should be aware of; any flulike symptoms should be carefully evaluated.
Agranulocytosis:
Onset
Usually occurs suddenly and becomes evident in the first 12 weeks
Agranulocytosis:
Nusing Measures
Blood work usually done every week for 6 months, then every 2 months.

Physician may order blood work to determine pres ence of leukopenia or agranulocytosis. If test results are positive, the drug is discontinued, and reverse isolation may be initiated. Mortality is high if the drug is not ceased and if treatment is not initiated.
Cholestatic jaundice:
rare, reversible, and usually benign if caught in time; prodromal symptoms are fever, malaise, nausea, and abdominal pain; jaundice
appears 1 week later.
Cholestatic jaundice:
Nusing Measures
Discontinue drug; give bed rest and high-protein, high-carbohydrate diet. Liver function tests should be performed every 6 months.
Neuroleptic malignant syndrome (NMS):
somewhat potentially fatal. Severe extrapyramidal: severe muscle rigidity, oculogyric crisis, dysphasia, flexor-extensor posturing, cogwheeling

Hyperpyrexia: elevated temperature (over 103° F or 39° C)

Autonomic dysfunction: hypertension, tachycardia, diaphoresis, incontinence.
Neuroleptic malignant syndrome (NMS):
Onset
Can occur in the first week of drug therapy but often occurs later.

Rapidly progresses over 2 to 3 days after initial manifestation.
Neuroleptic malignant syndrome (NMS):
Risk factors
Concomitant use of psychotropics
Older age
Female gender (3:2]
Presence of a mood disorder (40%)
Rapid dose titration
Neuroleptic malignant syndrome (NMS):
Nusing Measures
Stop neuroleptic.
Transfer STAT to medical unit.
Bromocriptine (Parlodel) can relieve muscle rigidity and
reduce fever.
Dantrolene (Dantrium) may reduce muscle spasms,
Cool body to reduce fever
Maintain hydration with oral and IV fluids.
Correct electrolyte imbalance.
Arrhythmias should be treated.
Small doses of heparin may decrease possibility of
pulmonary embolism
» Early detection increases client's chance of survival.
Bupropion
(Wellbutrin)
(Zyban)
Atypical antidepressants
Bupropion (Wellbutrin)(Zyban)
Advantages:
Sexual dysfunction rare
No weight gain
Stimulant properties
Antianxiety properties
Bupropion (Wellbutrin)(Zyban)
Adverse Effects
Medication-induced seizures if over 300 mg.
High seizure risk in "at risk" individuals.
Some nausea
Trazodone
(Desyrel)
Atypical antidepressants
Trazodone (Desyrel)
Advantages:
No anticholinergic side effects
low potential for cardiac effects
In conjunction with other antidepressants, can aid sleep
Trazodone (Desyrel)
Adverse Effects
Possible priapism
Postural hypotension
Weight gain
Memory dysfunction
Venlafaxine
(Effexor)
Atypical antidepressants
Dual-Action Reuptake Inhibitors—SNRIs (Serotonin and Norepinephrine)
Venlafaxine (Effexor)
Advantages:
Useful for treatment-resistant chronic depression

Low potential for drug interaction
Venlafaxine (Effexor)
Adverse Effects
Possible increase in blood pressure (10-15 mm Hg)

Possible somnolence, dry mouth, and dizziness
Mirtazapine
(Remeron)
Atypical antidepressants
Dual-Action Reuptake Inhibitors—SNRIs (Serotonin and Norepinephrine)
Mirtazapine (Remeron)
Advantages:
Antidote to SSRI sexual dysfunction

Noninterference with sleep
Low interference with metabolism of other drugs

Anxiolytic properties
Mirtazapine (Remeron)
Adverse Effects
Strong sedating effect

Possible increased appetite, weight gain, and cholesterol elevation
Duloxetine
(Cymbalta)
Atypical antidepressants
Dual-Action Reuptake Inhibitors—SNRIs (Serotonin and Norepinephrine)
Duloxetine (Cymbalta)
Advantages:
Response to medication within 1-4 weeks

Mild side effects
Duloxetine (Cymbalta)
Adverse Effects
Nausea
Somnolence
Dry mouth
Constipation
Decreased appetite
Increased sweating
Fatigue
Twice-a-day dosing
Contraindications for bupropion (Wellbutrin)
seizure disorders
seizure-prone client (head injury)
Nonadherence to twice-daily dosing, agitaion or insomnia.
Contraindications for venlafaxine (Effexor)
Mental condition with poor impluse control.
Borderline or labile hypertension.
Insomnia
Agitation
Manic phase of bipolar disorder.
amitriptyline
Elavil
Endep
TCAs
amoxapine
Asendin
TCAs
desipramine
(Norpramin)
TCAs
doxepin
Adapin
Sinequan
TCAs
imipramine
Tofranil
TCAs
nortriptyline
Aventyl
Pamelor
TCAs
protripryline
(Vivactil)
TCAs
Trimipramine
(Surmontil)
TCAs
maprotiline
Ludiomil
TCAs
Common Adverse Reactions of TCAs
anticholinergic actions: dry mouth
blurred vision
tachycardia
constipation
urinary retention
esophageal reflux
*Urinary retention and severe constipation warrant immediate medical attention.
postural-orthostatic hypotension
tachycardia
*Postural hypotension can lead to dizziness and increase the risk of falls.
Potential Toxic Effects of TCAs are
cardiovascular:
(1) dysrhythmias
(2) tachy­cardia
(3) myocardial infarction
(4) heart block have been reported
*Because the cardiac side effects are so serious, TCA use is considered a risk in clients with cardiac disease and in the elderly. Clients should have a thorough cardiac workup before beginning TCA therapy.
Contraindications for TCAs
myocardial infarction (or other cardiovascular problems)
narrow-angle glaucoma
history of seizures
pregnant women
TCAs:
Client Teaching
mood elevation may take from 7 to 28 days. Up to 6 to 8 weeks may be required for the full effect
drowsiness, dizziness, and hypotension usually subside after the first few weeks.
be careful working around machines, driving cars, and crossing streets
No Alcohol
take the full dose at bedtime
If the client forgets the bedtime dose for the once-a-day dose), the client should take the dose within 3 hours; otherwise the client should wait until the usual medication time the next day. The client should not double the dose.
Suddenly stopping TCAs can cause nausea, altered heartbeat, nightmares, and cold sweats in 2 to 4 days. call the physician or take one dose of TCA until the physician can be contacted.
phenelzine
(Nardil)
Monoamine Oxidase Inhibitors
tranylcypromine sulfate
(Parnate)
Monoamine Oxidase Inhibitors
Common Adverse Reactions of MAOIs
orthostatic hypotension, weight gain, edema, change in cardiac rate and rhythm, constipation, uri­nary hesitancy, sexual dysfunction, vertigo, overactivity, muscle twitching, hypomanic and manic behavior, insomnia, weakness, and fatigue.
Potential Toxic Effects of MAOIs
Hypertensive crisis: increase in blood pressure, with the possible development of intracranial hemorrhage, hyperpyrexia, convulsions, coma, and death
Hypertensive crisis:
Signs and symptoms
headaches
stiff or sore neck
palpitations
increase or decrease in heart rate, often associated with chest pain
nausea
vomit­ing
increase in temperature (pyrexia).
Hypertensive crisis:
Treatments
Antihypertensive medications, such as phentolamine (Regitine), are slowly administered intravenously.

Pyrexia is treated with hypothermic blankets or ice packs.
Use of MAOIs may be con­traindicated when one of the following is present:
Cerebrovascular disease
Hypertension and congestive heart failure
Liver disease
Consumption of foods containing tyramine, tryptophan, and dopamine
Use of certain medications
Recurrent or severe headaches
Surgery in the previous 10 to 14 days
Age younger than 16 years