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  1. 1. MR. JAYESH
  2. 2. INTRODUCTION…• Psychopharmacology is the study ofdrugs used to treat psychiatric disorders.• Medications that affect psychic function,behavior or experience are calledpsychotropic medications.• They have significant effect on highermental functions.• Psychopharmacological agents are firstline treatment for almost all psychiatricailments now a days.4/24/2013 2JAYESH PATIDAR
  3. 3. Count…• With the growing availability of a widerange of drugs to treat mental illness, thenurse practicing in modern psychiatricsettings needs to have a soundknowledge of the pharmacokineticsinvolved, the benefits & potential risks ofpharmacotherapy, as well as her ownrole & responsibility.4/24/2013 3JAYESH PATIDAR
  4. 4. DEFINITION OF PSYCHOTROPICDRUGSPsychotropic drug is any drugthat has primary effects on behavior,experience, or other psychological functions(Logman Dictionary of Psychology &Psychiatry). Psychotropic or psychoactivedrugs can also be defined as chemical thataffects the brain & nervous system, alterfeelings & emotions. These drugs also affectthe consciousness in various ways. A broadrange of these drugs is used in emotional &mental illnesses.4/24/2013 4JAYESH PATIDAR
  5. 5. GENERAL GUIDELINES REGARDINGDRUG ADMINISTRATION IN PSYCHIATRY• The nurse should not administer any drug unlessthere is a written order. Do not hesitate to consultthe doctor when in doubt any medication.• All medications given must be charted on thepatient‘s case record sheet.• In giving medication:– Always address the patient by name & make certain ofhis identification.– Do not leave the patient until the drug is swallowed.– Do not permit the patient to go to the bathroom to takemedication.– Do not allow one patient to carry medicine to another.4/24/2013 5JAYESHPATIDAR
  6. 6. Count…• If it is necessary to leave the patient to getwater, do not leave the tray within the reach ofthe patient.• Do not force oral medication because of thedanger of aspiration. This is especiallyimportant in stuporous patients.• Check drugs daily for any change in color, odor& number.• Bottle should be tightly closed & labeled. Labelsshould be written legibly & in bold lettering.Poison drugs are to be legibly labeled & to bekept in separate cupboard.4/24/2013 6JAYESH PATIDAR
  7. 7. Count…• Make sure that an adequate supply of drugsis on hand, but do not overstock.• Make sure no patient has access to the drugcupboard.• Drug cupboard should always be keptlocked when not in use. Never allow apatient or worker to clean the drugcupboard. The drug cupboard keys shouldnot be given to patients.4/24/2013 7JAYESH PATIDAR
  8. 8. PATIENT EDUCATION RELATED TOPSYCHOPHARMACOLOGY…• Nurses assess for drug side effects, evaluatedesired effects, & make decisions about prn(pro re neta) medication.• Nurses must understand general principles ofpsychopharmacology & have specificknowledge related to psychotropic drugs.• Teaching patients can decrease the incidenceof side effects while increasing compliancewith the drug regimen.4/24/2013 8JAYESH PATIDAR
  9. 9. Specific areas of education includethe following…1. Discussion of side effects: Side effects candirectly affect the patient‘s willingness toadhere to the drug regimen. The nurse shouldalways inquire about the patient‘s response toa drug, both therapeutic responses & adverseresponses2. Drug interactions: Patients & families mustbe taught to discuss the effects of the additionof over-the-counter drugs, alcohol & illegaldrugs to currently prescribed drugs.4/24/2013 9JAYESH PATIDAR
  10. 10. Count…3. Discussion of safety issues: Because somedrugs, such as tricyclic antidepressants, have anarrow therapeutic index, thoughts of self harmmust be discussed.• Discuss on abruptly discontinued effects.• Many psychotropic drugs cause sedation ordrowsiness, discussions concerning use ofhazardous machinery, driving must be reviewed4. Instructions for older adult patients: Becauseolder individuals have a differentpharmacokinetic profile than younger adults,special instructions concerning side effects &drug-drug interactions should be explained.4/24/2013 10JAYESH PATIDAR
  11. 11. Count…5. Instructions for pregnant or breastfeedingpatient: As pregnant or breastfeeding patientshave special risks associated withpsychotropic drug therapy, specialinstructions should be tailored for theseindividuals. Teaching patients about theirmedications enables them to be matureparticipants in their own care & decreasesundesirable side effects4/24/2013 11JAYESH PATIDAR
  12. 12. CLASSIFICATIONS OF PSYCHOTROPICDRUGS1. Antipsychotic agents2. Antidepressant agents3. Mood stabilizing drug4. Anxiolytics & hypnosedatives5. Antiepileptic drug6. Antiparkinsonian drugs7. Miscellaneous drugs which include stimulants,drugs used in eating disorders, drugs used indeaddiction, drugs uses in child psychiatry,vitamins, calcium channel blockers etc.4/24/2013 12JAYESH PATIDAR
  14. 14. DESCRIPTION:-• Antipsychotic agents are also known asneuroleptic, major tranquillizers, orphenothaiazines.• This group of drugs has a major clinicaluse in the treatment of psychosis.• Psychosis is a state in which a person‘sability to recognize reality tocommunicate & to relate to others isseverely impaired.4/24/2013 14JAYESH PATIDAR
  15. 15. MODE OF ACTION:-• Antipsychotic agents are thought to block thedopamine receptors.• Dopamine is a chemical which is released inthe brain & causes psychotic thinking.• Increased production of dopamine transmits thenerve impulses to the brainstem faster thannormal. This result in strange thoughts ,hallucination & bizarre behavior.• Antipsychotics helps in blocking or reducing theactivity of dopamine.• Antiemetic is another property of antipsychoticagents. They are also used in hiccoughs.4/24/2013 15JAYESH PATIDAR
  16. 16. Class Examples ofdrugsTrade name Oral dosemg/dayParenteraldose (mg)Phenothiazines ChlorpromazineTriflupromazineThioridazineTrifluoperazineFluphenazinedecanoateMegatilLargactilTranchlorSiquilThioril, MellerilRidazinEspazineprolinate300-1500100-400300-80015-60-50-100 IMonly30-60 IM only1-5 IM25-50 IMevery 1-3weeks.Thioxanthenes flupenthixol fluanxol 3-40CLASSIFICATION:-4/24/2013 16JAYESH PATIDAR
  17. 17. Class Examples ofdrugsTrade name Oral dosemg/dayParenteraldose (mg)Diphenylbutyl Pimozide orap 4-20piperidines penfluridol flumap 20-60 weekly -Indolicderivativesmolindone mobam 50-225 -Dibenzoxazepines loxapine loxapac 25-100 -AtypicalantipsychoticsClozapineRisperidoneOlanzapineQuetiapineZiprasidoneSizopine, LozapinSizodon, sizomaxOleanzQutanZisper50-4502-1010-20150-750 mg20-80 mgOthers reserpine serpasil 0.5-50Count…4/24/2013 17JAYESH PATIDAR
  18. 18. INDICATIONS Organic psychiatricdisorders:• Delirium• Dementia• Delirium tremens• Drug-induced psychosis &other organic mentaldisorders Functional disorders:• Schizophrenia• Schizoaffective disorders• Paranoid disorders Mood disorders:• Mania• Major depression withpsychotic symptoms Childhood disorders:• Attention-deficithyperactivity disorder• Autism• Enuresis• Conduct disorder4/24/2013 JAYESH PATIDAR 18
  19. 19. Count… Neurotic & otherpsychiatric disorders:• Anorexia nervosa• Intractable obsessive-compulsive disorder• Severe, intractable &disabling anxiety Medical disorders:• Huntington‘s chorea• Intractable hiccough• Nausea & vomiting• Tic disorder• Eclampsia• Heart stroke severepain in malignancytetanus4/24/2013 JAYESH PATIDAR 19
  20. 20. PHARMACOKINETICS• Antipsychotics when administered orally are absorbedvariably from the gastrointestinal tract, with unevenblood levels.• They are highly bound to plasma as well as tissueproteins. Brain concentration is higher than theplasma concentration.• They are metabolized in the liver, & excreted mainlythrough the kidneys. The elimination half-life variesfrom 10 to 24 hours.• Most of the antipsychotics tend to have a therapeuticwindow. If the blood level is below this window, thedrug is ineffective. If the blood level is higher than theupper limit of the window, there is toxicity or the drugis again ineffective.4/24/2013 JAYESH PATIDAR 20
  21. 21. SIDE-EFFECTS1) Extrapyramidal symptoms (EPS)i. Neuroleptic-induced parkinsonism:- occurin 40% of the patients presentingextrapyramidal symptoms. There are twovarieties of parkinsonia symptoms:a. Akinetic Form:- Appears in the first weekof administration of antipsychotic drugs.The characteristics of akinetic form are:Difficulty in masticating movements,weakness & muscle fatigue.4/24/2013 JAYESH PATIDAR 21
  22. 22. Count…b. Agitating Form of parkinsonian Symptomsinclude:- Tremors at rest, rigidity & mask-likeface. Most characteristic features of parkinsonismare:-Rigidity of musclesMotor retardationsalivationslurred speechmask-like faceshuffling gaitAnticholinergi drugs are given as treatments.4/24/2013 JAYESH PATIDAR 22
  23. 23. Count…ii. Akathisia:-Akathisia occurs in 50% ofall the patients presentingextrapyrimidal symptoms. The commoncharacteristics: Restless ―walking inplace‖. Difficulty in sitting still, or strongurge to move about- referred to as―Walkies & Talkies‖ by haris . generallyoccurs after two weeks of treatment.Before administering anti-parkinsonianmedication anxiety should be ruled out.4/24/2013 JAYESH PATIDAR 23
  24. 24. Count…iii. Dystonia:-Dystonia occurs in 6% of total numberof patient‘s presenting EPS. The characteristicfeatures are: rapidly developing contraction ofmuscles of the tongue, jaw, neck (producingtorticollis) & etraocular muscles. Combinedtorticolis & extraocular spasm results in anoculogyric crisis in which eyes looked upward,head is turned to one side. Dystonia is painful& gives a frightening experience to the patient.Constant observation of the patient should bemade. Dystonia occurs within a few minutes ofgiving medicine or after several hours.4/24/2013 JAYESH PATIDAR 24
  25. 25. Count…iv. Tardive Dyskinesia:-This occur due to abrupttermination or reduction of the antipsychoticdrug after long-term-high-dose therapy.Tardive dyskinesia is characterized byinvoluntary rhythmic, stereotyped movements,protrusion of the tongue, puffing of cheeks,chewing movements, involuntary movementsof extremities & trunk. These symptoms occurin 3% of patients. Antipsychotics should bestoped immediately. There is no treatment,symptoms may appear for years. It isirreversible.4/24/2013 JAYESH PATIDAR 25
  26. 26. Count…V. Neuroleptic Malignant Syndrome (NMS):-This is a rarecomplication of antipsychotic agents & isusually fetal. Many develop within hours orafter years of continued drug use. Symptomsinclude hyperpyrexia, severe muscle rigidity,altered consciousness, blood pressurechanges, increased count of W.B.C.symptoms appear suddenly when medicationis started & can persist for 10-14 days orlonger. Symptomatic treatment is given topatients.4/24/2013 JAYESH PATIDAR 26
  27. 27. Count…2) Autonomic Nervous System:-Dry mouth, blurred vision,constipation, urinary hesitance or retention & underrare circumstances paralytic ileus.3) Cardio-Vascular:-Tachycardia, orthostatic hypotension &reversible arrhythmias.4) Blood or Hematopoietic:-Agrunulocytosis (marked decrease inleukocytes system especially with chlorpramozine)leucopenia, leukocytosis.4/24/2013 JAYESH PATIDAR 27
  28. 28. Count…5) Endocrine Disruptions:-Menstrual irregularities, includingamenorrhea & false positive pregnancy tests, breastenlargement, lactation, weight gain, changes in libido,impotence, glycosuria, hyperglycemia.6) Gastro-Intestinal:-Anorexia, constipation, diarrhea, hypersalivation,nausea, vomiting, obstructive jaundice.7) Allergic effects:-Dermatitis, photosensitization, pigmentdeposits.4/24/2013 JAYESH PATIDAR 28
  29. 29. Count…8) Occular Effcts:-Blurring of vision, pigmentation ofcornea & lens & retinopathy.9) Hepatic Side-effects:-Liver toxicity occurs in 0.5% of casespresenting EPS. It is a hypersensitivity reaction &dose dependent. Onset of symptoms is within thefirst one month of treatment. Symptoms may befever, chills, nausea, malaise, prurites & jaundice.4/24/2013 JAYESH PATIDAR 29
  30. 30. NURSE’S RESPONCIBILITY Close observation, especially when the antipsychotic arejust started. The expected results are reduction inaggressive hyperactive behavior & disorganized thoughts.Look for the possible side-effects. Extrapyramidal reaction, i.e. Parkinsonism, akinesia,akathisia, dystonia, & tardive dyskinesia. These symptomsare reduced/treated with early observation, reporting &use of anti-parkinsonion or anticholinergic medication. Observe drowsiness. Medicine should be administered atbed time. Report if the drowsiness persists for a very longtime. The patient should be advised not to drive & handlehazardous machinery while taking antipsychotic drugs.Observe for sore throat, fever due to agranulocytosis.4/24/2013 JAYESH PATIDAR 30
  31. 31. Count… Record blood pressure of the patient onantipsychotic drugs. If the BP is drops by 20 to30mm of hg in the patient, immediate reporting &intervention should be done. The patient should bemade aware of the possibility of dizziness & injuriesafter receiving medication & injection due toorthostatic hypotension. Accurate rout of medication- antipsychotic drugs arenot given subcutaneously unless specially prescribedas they cause tissue irritation. These drugs shouldbe given deep IM. Dry mouth may be may be reduced by encouragingthe patient to rinse his or her mouth frequently. Givea piece of lemon or chewing gum. Good oral hygieneshould also be maintained.4/24/2013 JAYESH PATIDAR 31
  32. 32. Count… Blurred or impaired vision in the patient causes anxiety& annonyance to him. The patient should beencouraged to inform these symptoms immediately.Blurred vision or brown coloured vision, night blindnesscan be permanent due to pigmentary retinopathy. The patient on antipsychotic drugs may have weightgain. Weight record should be maintained. The patientmay be encouraged on a low salt & planned caloric diet. The patient may complain of gastric irritation. He shouldbe discouraged to take antacid as there will bedecreased absorption of antipsychotic drugs. An intake output chart should be maintained speciallyfor male patients who are confined to bed & have anenlarged prostate gland. Encourage at least 2500 ml ofliquid intake.4/24/2013 JAYESH PATIDAR 32
  33. 33. Count… The patient should be advised to protect his skin, by not goingin the sun & to wear protective clothing & sunglasses. The patient should be explained not to increase or decreaseor stop taking drugs without discussing with his doctor. Thedrugs should be withdrawn slowly to avoid nausea orseizures. The nurse should find out menstrual changes from the femalepatient. Sometimes the patient may complain of fever, upperabdominal pain, nausea, jaundice & diarrhea. Thesesymptoms can be due to cholestatic jaundice. The nurseshould stop the medicine immediately & inform the doctor. Reassurance to relatives- The patient & his relatives shouldbe explained that desired effects will be achieved after weeksof medication, so the relatives need to wait for the effects ofthe drugs.4/24/2013 JAYESH PATIDAR 33
  35. 35. DESCRIPTION• Antidepressant agents are used inaffective disorders or disturbancesmainly to treat depressive disorderscaused by emotional or environmentalstressors.• Several groups of affectivedisturbances are treatable byantidepressants.4/24/2013 JAYESH PATIDAR 35
  36. 36. MODE OF ACTION• Antidepressant drugs are classified as Tricyclics,Tetracyclics & MAO inhibitors. Research studieshave shown reduced levels of norepinephrine (NE) &serotonin (5-HT) in the space between nerve endingcarrying message from one nerve cell to anothercause depression.• Tricyclic antidepressants & MAO inhibitors increasethese neurotransmitters i.e. norepinephrine & sertininto the synaptic receptors in the central nervoussystem. Tricyclic inhibitors block the reuptake of NE& 5-HT & MAO inhibitors block the action ofMONOamine oxidize in breaking down excess of NE& 5-HT at the presynaptic neuron.4/24/2013 JAYESH PATIDAR 36
  37. 37. CLASSIFICATIONCLASS EXAMPLES OFDRUGSTRADE NAME ORAL DOSE(mg/day)Tricyclicantidepressants (TCAs)ImipramineAmitriptylineClomipramineDothiepinmianserinAntidepTryptomerAnafranilProthiadendepnon75-30075-30075-30075-30030-120Selective serotoninreuptake inhibitors(SSRIs)FluoxetineSertralineFludacSerenata10-8050-200Dopaminergicantidepressantsfluvoxamine faverin 50-300Atypicalantidepressantsamineptine survector 100-400Monoamine oxidaseinhibitors (MAOIs)TrazodoneisocarboxazidTrazalonMarplan150-60010-304/24/2013 JAYESH PATIDAR 37
  38. 38. INDICATIONS Depression• Depressive episode• Dysthymia• Reactive depression• Secondary depression• Abnormal grief reaction Childhood psychiatricdisorders• Enuresis• Separation anxiety disorder• Somnambulism• School phobia• Night terrors Other psychiatric disorders• Panic attack• Generalized anxiety disorder• Agrophobia, social phobia• OCD with or without depression• Eating disorder• Borderline personality disorder• Post-traumatic stress disorder• Depersonalization syndrome Medical disorder• Chronic pain• Migraine• Peptic ulcer disease4/24/2013 JAYESH PATIDAR 38
  39. 39. PHARMACOKINETICS• Antidepressants are highlylipophilic & protein-bound. Thehalf-life is long & usually morethan 24 hours.• It is predominantly metabolized inthe liver.4/24/2013 JAYESH PATIDAR 39
  40. 40. CONTRAINDICATION• Antidepressants are given with cautionto patients with cardiovascular disorderbecause they cause arrhythmias.• They increase symptoms of psychosis& mania in cases of manic-depressivepsychosis.• Drugs are given with caution toprevents with liver disorders.4/24/2013 JAYESH PATIDAR 40
  41. 41. SIDE EFFECTS1) Autonomic side-effects:Dry mouth, constipation,cycloplegia, mydriasis, urinary retention, orthostatichypotension, impotence, impaired ejaculation,delirium & aggravation of glaucoma.2) CNS effects:-Sedation, tremor & other extrapyramidalsymptoms, withdrawal syndrome, seizures,jitteriness syndrome, precipitation of mania.3) Cardiac side-effects:-Tachycardia, ECG changes, arrhythmias,direct myocardial depression, quinidine-likeaction(decreased conduction time).4/24/2013 JAYESH PATIDAR 41
  42. 42. Count…4) Allergic side-effects:-Agranulocytosis, cholestaticjaundice, skin rashes, systemic vasculitis.5) Metabolic & endocrine side-effects:-weight gain6) Special effects of MAOI drugs:-Hypertensive crises, severehepatic necrosis, hyperpyrexia.4/24/2013 JAYESH PATIDAR 42
  43. 43. NURSE’S RESPONSIBILITY Observation of the side-effects & monitoring thechanges noted are very significant to preventcomplications due to antidepressant agents. Encourage the patient to take medicine at bedtime due to a sedative effect. Dryness of mouth todecrease. Give plenty of fluids orally. Lemonade or chewinggum should be given. A few sips of water alsohelp the patient. Do not give medicine empty stomach as thepatient complains of nausea & vomiting.4/24/2013 JAYESH PATIDAR 43
  44. 44. Count… Accurate recording of intake & output of the patientshould be maintained to check if he has retention ofurine. If the patient complains of dizziness or light headednesshe/she should be encouraged to get up slowly & sit in thebed before standing. These symptoms may due toorthostatic hypotension. The patient should be reassuredthat these symptoms are for a short period only. Somepatients may present hypertension. Accurate recording of vital signs like B.P. & pulse. The nurse should be able to interpret the blood reportsspecially blood sugar level & W.B.C. count. If the patientcomplains of sore throat, fever, malaise, it should bereported to the physician on duty. These symptoms maybe due to agranulocytosis or hyperglycemia.4/24/2013 JAYESH PATIDAR 44
  45. 45. Count… To relieve constipation plenty of fluids &roughage should be encouraged in the diet. If the patient complains of sexual dysfunctioninform the physician immediately & stop thedrug. If the patient is presenting symptoms ofpressure of speech, increased motor activity &elated mood, the physician should be informed& the drug should be stopped immediately. Antidepressant tricyclic drugs begintherapeutic effects within four to eight weeks. Accurate recording of the observation made.4/24/2013 JAYESH PATIDAR 45
  47. 47. Mood stabilizers areused for the treatment of bipolaraffective disorders. Some commonlyused mood stabilizers are:-1. Lithium2. Carbamazepine3. Sodium Valproate4/24/2013 JAYESH PATIDAR 47
  48. 48. LITHIUM4/24/2013 JAYESH PATIDAR 48
  49. 49. DESCRIPTION• Lithium is an element with atomicnumber 3 & atomic weight 7.• It was discovered by FJ Cade in1949, & is a most effective &commonly used drug in thetreatment of mania.4/24/2013 JAYESH PATIDAR 49
  50. 50. MODE OF ACTIONThe probable mechanisms of action can be:• It accelerates presynaptic re-uptake &destruction of catecholamines, likenorepinephrine.• It inhibits the release of catecholamines at thesynapse.• It decreases postsynaptic serotonin receptorsensitivity.All these actions result in decreasedcatecholamine activity, thus amelioratingmania.4/24/2013 JAYESH PATIDAR 50
  51. 51. INDICATION Acute mania Prophylaxis forbipolar & unipolarmood disorder. Schizoaffectivedisorder Cyclothymia Impulsivity &aggressionOther disorders:– Premenstrualdysphoric disorder– Bulimia nervosa– Borderlinepersonality disorder– Episodes of bingedrinking– Trichotillomania– Cluster headaches4/24/2013 JAYESH PATIDAR 51
  52. 52. PHARMACOKINETICS• Lithium is readily absorbed with peak plasmalevels occurring 2-4 hours after a single oraldose of lithium carbonate.• Lithium is distributed rapidly in liver & kidney &more slowly in muscle, brain & bone. Steadystate levels are achieved in about 7 days.• Elimination is predominately via tubules & isinfluenced by sodium balance. Depletion ofsodium can precipitate lithium toxicity.4/24/2013 JAYESH PATIDAR 52
  53. 53. DOSAGESLithium is available in the market in the form of thefollowing preparation:– Lithium carbonate: 300mg tablet (eg. Licab);400mg sustained release tablets (eg.Lithosun-SR).– Lithium citrate: 300mg/5ml liquid.The usual range of doseper day in acute mania is 900-2100mg given in2-3 divided doses. The treatment is started afterserial lithium estimation is done after a loadingdose of 600mg or 900mg of lithium to determinethe pharmacokinetics.4/24/2013 JAYESH PATIDAR 53
  54. 54. BLOOD LITHIUM LEVEL• Therapeutic levels = 0.8-1.2 mEq/L(for treatment of acute mania)• Prophylactic levels = 0.6-1.2 mEq/L(for prevention of relapse in bipolardisorder)• Toxic lithium levels>2.0 mEq/L4/24/2013 JAYESH PATIDAR 54
  55. 55. SIDE EFFECTS• Neurological: Tremors, motor hyperactivity,muscular weakness cogwheel rigidity, seizures,neurotoxicity (delirium, abnormal involuntarymovements, seizures, coma).• Renal: Polydipsia, polyuria, tubular enlargement,nephritic syndrome.• Cardiovascular: T-wave depression.• Gastrointestinal: Nausea, vomiting, diarrhea,abdominal pain & metallic taste.• Endocrine: Abnormal thyroid function, goiter &weight gain.•4/24/2013 JAYESH PATIDAR 55
  56. 56. Count…• Dermatological: Acneiform eruptions,popular eruptions & exacerbation ofpsoriasis.• Side-effect during pregnancy &lactation: Teratogenic possibility,increase incidence of Ebstein‘s anomaly(distortion & downward displacement oftricuspid value in right ventricle) whentaken in first trimester. Secreted in milk& can cause toxicity in infant.4/24/2013 JAYESH PATIDAR 56
  57. 57. Count…• Sign & symptoms oflithium toxicity (serumlithium level>2.0mEq/L):– Ataxia– Coarse tremor (hand)– Nausea & vomiting– Impaired memory– Impaired concentration– Nephrotoxicity– Muscle weakness– Convulsions– Muscle twitching– Dysarthria– Lethargy– Confusion– Coma– Hyperreflexia– Nystagmus4/24/2013 JAYESH PATIDAR 57
  58. 58. MANAGEMENT OF LITHIUM TOXICITY:-• Discontinue the drug immediately.• For significant short-term ingestions, residualgastric content should be removed by induction ofemesis, gastric lavage adsorption with activatedcharcoal.• If possible instruct the patient to ingest fluids.• Assess serum lithium levels, serum electrolytes,renal functions, ECG as soon as possible.• Maintenance of fluid & electrolyte balance.• In a patient with serious manifestations of lithiumtoxicity, hemodialysis should be initiated.4/24/2013 JAYESH PATIDAR 58
  59. 59. CONTRAINDICATION OF LITHIUM:-• Cardiac, renal, thyroid or neurologicaldysfunctions• Presence of blood dyscrasias• During first trimester of pregnancy &lactation• Severe dehydration• Hypothyroidism• History of seizures4/24/2013 JAYESH PATIDAR 59
  60. 60. NURSE’S RESPONSIBILITY:-• The pre—lithium work up: A completephysical history, ECG, blood studies (TC, DC,FBS, BUN, Creatinine, electrolytes) urineexamination (routine & microscopic) must becarried out. It is important to assess renalfunction as renal side-effects are common &the drug can be dangerous in an individualwith compromised kidney function. Thyroidfunctions should also be assesses, as thedrug is known to depress the thyroid gland.4/24/2013 JAYESH PATIDAR 60
  61. 61. Count…To achieve therapeutic effect & prevent lithium toxicity,the following precaution should be taken:• Lithium must be taken on a regular basis,preferably at the same time daily (for example, aclient taking lithium on TID schedule, who forgeta dose should wait until the next scheduled timeto take lithium & not take twice the amount at onetime, because toxicity can occur).• When lithium therapy is initiated, mild side-effectssuch as fine hand tremors, increased thirst &urination, nausea, anorexia etc may develop,Most of them are transient & do not representlithium toxicity.4/24/2013 JAYESH PATIDAR 61
  62. 62. Count…• Serious side-effects of lithium that necessitate itsdiscontinuance include vomiting, extreme hand tremor,sedation, muscle weakness & vertigo. The psychiatristshould be notified immediately if any of these effectsoccur.• Since polyuria can lead to dehydration with risk of lithiumintoxication, patients should be advised to drink enoughwater to compensate for the fluid loss.• Various situations may require an adjustment in theamount of lithium administered to a client, such as theaddition of the new medicine to the client drug regimen, anew diet or an illness with fever or excessive sweating.They must be advised to consume large quantities ofwater with salts, to prevent lithium toxicity due todecreased sodium levels.4/24/2013 JAYESH PATIDAR 62
  63. 63. Count…• Frequent serum lithium level evaluation isimportant. Blood for determination of lithiumlevels should be drawn in the morningapproximately 12-14 hours after the last dosewas taken.• The patient should be told about the importanceof regular follow up. In every six months, bloodsample should be taken for estimation ofelectrolytes, urea, creatinine, a full blood count& thyroid function test.4/24/2013 JAYESH PATIDAR 63
  65. 65. DESCRIPTION• It is available in the market underdifferent trade names like Tegretol,Mazetol, Zeptol & Zen Retard.4/24/2013 JAYESH PATIDAR 65
  66. 66. MECHANISM OF ACTION• Its mood stabilizing mechanism isnot clearly established. Itsanticonvulsant action mayhowever be by decreasingsynaptic transmission in the CNS.4/24/2013 JAYESH PATIDAR 66
  67. 67. INDICATIONS• Seizures-complex partial seizures, GTCS,seizures due to alcohol withdrawal.• Psychiatric disorders- rapid cycling bipolardisorder, acute depression, impulse controldisorder, aggression, psychosis withepilepsy, schizoaffective disorders,borderline personality disorder, cocainewithdrawal syndrome.• Paroxysmal pain syndromes- trigeminalneuralgia & phantom limb pain.4/24/2013 JAYESH PATIDAR 67
  68. 68. DOSAGE• The average daily dose is 600-1800mg orally, in divided doses. Thetherapeutic blood levels are 6-12µg/ml. toxic blood levels are attained atmore than µg/ml.4/24/2013 JAYESH PATIDAR 68
  69. 69. SIDE EFFECTS• Drowsiness, confusion, headache,ataxia, hypertension, arrhythmias, skinrashes, steven-Johnson syndrome,nausea, vomiting, diarrhea, dry mouth,abdominal pain, jaundice, hepatitis,oliguria, leucopenia, thrombocytopenia,bone marrow depression leading toaplastic anemia.4/24/2013 JAYESH PATIDAR 69
  70. 70. NURSE’S RESPONCIBILITY• Since the drug may cause dizziness &drowsiness advise him to avoid driving &other activities requiring alertness?• Advise patient not to consume alcoholwhen he is on the drug.• Emphasize the importance of regularfollow-up visits & periodic examination ofblood count & monitoring of cardiac,renal, hepatic & bone marrow functions.4/24/2013 JAYESH PATIDAR 70
  72. 72. MECHANISM OF ACTION• The drugs acts on gamma-aminobutyric acid (GABA) aninhibitory amino acidneurotransmitters. GABAreceptors activation serves toreduce neuronal excitability.4/24/2013 JAYESH PATIDAR 72
  73. 73. INDICATION• Acute mania, prophylactic treatment ofbipolar-I disorder, rapid cycling bipolardisorder.• Schizoaffective disorder.• Seizures.• Other disorders like bulimia nervosa,obsessive-compulsive disorder, agitation& PTSD.4/24/2013 JAYESH PATIDAR 73
  74. 74. DOSAGE• The usual dose is 15mg/kg/day with a maximum of60mg/kg/day orally.4/24/2013 JAYESH PATIDAR 74
  75. 75. SIDE EFFECTS• Nausea, vomiting, diarrhea,sedation, ataxia, dysarthria,tremor, weight gain, loss of hair,thrombocytopenia, plateletdysfunction.4/24/2013 JAYESH PATIDAR 75
  76. 76. NURSE’S RESPONSIBILITY• Explain to the patient to take the drugimmediately after food to reduce GIirritation.• Advise to come for regular follow-up &periodic examination of blood count,hepatic function & thyroid function.Therapeutic serum level of valproicacid is 50-100 micrograms/ml.4/24/2013 JAYESH PATIDAR 76
  78. 78. DESCRIPTION• Anxiety is a state which occurs in allhuman being at sometime or the other.• It is also a cardinal symptoms of manypsychiatric conditions.• The drugs used to relieve anxiety arecalled ANTIANXIETY OR ANXIOLYTICAGENTS. Antianxiety drugs relievemoderate-to-severe anxiety & tension.4/24/2013 JAYESH PATIDAR 78
  79. 79. MODE OF ACTION• These non-barbiturate benzodiazepinesact as CNS depressants.• It is believed that these drugs increaseor help the inhibitory neurotransmitteraction of gama-aminobutyric inhibitor inall areas of CNS. So, there is inhibitionor control on the cortical & limbic systemof the brain, which is responsible foremotions such as rage & anxiety.4/24/2013 JAYESH PATIDAR 79
  80. 80. INDICATIONS• Antianxiety agents are used to relieve mild, moderate &severe anxiety associated with: emotional disordersphysical disorders excessive environmental stressneuroses & mild depressive states without causingexcessive sedation or drowsiness.• For control of alcohol withdrawal symptoms.• To control convulsions.• To produce skeletal muscle relaxation.• To provide short-term sleep preoperatively, prior todiagnosis & insomnia.• Antianxiety agents should always be used in time-limitedregimen.4/24/2013 JAYESH PATIDAR 80
  81. 81. CONTRAINDICATIONS• Patients with renal or liver &respiratory impairment aregiven antianxiety drugs withcaution.4/24/2013 JAYESH PATIDAR 81
  82. 82. CLASSIFICATION OF ANTIANXIETYAGENTS:-CHEMICAL GROUP &GENERIC NAMETRADE NAME RANGE OF DAILYDOSAGE IN mgmACTIONI. Non-BarbituratesA. BenzodiazepinesChlordiazepoxideDiazepamOxazepamPrazepamChlorazapateFlurazepamNitrazepamlorazepamLibrium,EquibromeValium,CalmposeSerepaxVerstranTranzeneAzeneDalmane,NitravetMogadonativan15-1006-5030-12020-6011.25-6015-6010-302-6These are non-barbituratebenzodiazepines.They produce atranquillizingeffect withoutmuch sedation.These drugs arepotential forabuse.4/24/2013 JAYESH PATIDAR 82
  83. 83. COUNT…CHEMICAL GROUP &GENERIC NAMETRADE NAME RANGE OF DAILYDOSAGE IN mgmACTIONA.Non-BenzodiazepinePropanediolsMeprobamateEquanilMiltownTybamate1.2-1.61.2-1.61.2-1.6These drugshave sedativeaction &present a highrisk of abuse &physicaldependence.II. AntihistaminesHydroxyzineAtaraxvistaril30-20030-2004/24/2013 JAYESH PATIDAR 83
  84. 84. CLASSIFICATION OF SEDATIVES ANDHYPNOTICS:-CHEMICAL GROUP& GENERIC NAMETRDE NAME HYPNOTICDOSE RANGE-DAILY IN mgmSEDATIVE DOSEDAILY IN mgm.ACTIONIII. BarbituratesAmobarbidtal SAButabarbital SAPentobarbital LAPhenobarbital LAThiopental USAAmytalButisolNembutalLuminalpentothal100-200100-200100-200100-200Used foranasthesia60-15020-20060-15030-90These drugscause drowsinesslethargy,decrasedalertness & sleep.Tolerance to drugcan occur within7-14 days,resulting inphysicaldependence.IV. Nonbarbiturates4/24/2013 JAYESH PATIDAR 84
  85. 85. COUNT…CHEMICAL GROUP &GENERIC NAMETRDE NAME HYPNOTICDOSE RANGE-DAILY IN mgmSEDATIVE DOSEDAILY IN mgm.ACTIONV. QuinazolinesMethaquualone QuaaludeParestOptimalmandrax150-300 250-300VI. Acetylinic AlcoholsEthchlorvynol placidyl0.5gm-1gms 200-600mgmVII. ChloralDerivativesChloral hydrateChloral betaineNoctaecBeta-chlor0.5gm-2gms870mg-1gmVIII. Monoureides4/24/2013 JAYESH PATIDAR 85
  86. 86. SIDE – EFFECTS OF ANTIANXIETY,SEDATIVES & HYPNOTICS1)Central nervous system: drowsiness,ataxia, confusion, depression, blurredvision.2)Cardiovascular system: hypotension,palpitation, syncope.3)Endocrine: change in libido.4)Allergic: skin rash.4/24/2013 JAYESH PATIDAR 86
  87. 87. COUNT…5) Physical/psychological dependence non-benzodiazepines & barbiturate group ofdrugs has a high risk of abuse & physicaldependence.6) Acute toxicity of barbiturate that can befetal when taken in excessive dosageusually for suicide attempts. Overdose cancause tachycardia, hypotension, shock,respiratory depression, coma & death.4/24/2013 JAYESH PATIDAR 87
  88. 88. NURSE’S RESPONSIBILITY Assessment of the patient, prior to the use ofantianxiety, sedative-hypnotic agents. If the patientcomplains of sleep disturbance the causative factorshould be identified. Appropriate nursing measures to induce sleepshould be taken such as a calm & quiteenvironment, a cup of hot milk, good back care,allowing the patient to read magazines, sitting withthe patient for some time for reassurance purpose. While administering the drug daily dose should begiven at bed time to promote a normal sleeppattern, so that day-time activities are not affected.4/24/2013 JAYESH PATIDAR 88
  89. 89. COUNT… Give IM injection deep into muscles to preventirritation. Look for side-effects, record & report immediately. If the patient complains of drowsiness tell him toavoid using knife or any other dangerous equipment.He should be instructed not to drive. Instruct the patient not to take any stimulant likecoffee, alcohol as they alter the effect of drugs. Avoid excessive use of these drugs to prevent theonset of substance abuse or addiction. Drug should be reduced gradually, sudden stoppage of thedrug may cause REM (Rapid Eye Movements), insomnia,dreams or nighmare, hyperexcitability, agitation or convulsions.4/24/2013 JAYESH PATIDAR 89
  91. 91. DESCRIPTION• Antiparkinsonian agents are the specificdrugs to treat the extrapyramidal side-effects of antipsychotic agents.• Side-effects are parkinsonism,akathisia, acute dystonia & tardivedyskinesia.• Anticholinergics, antihistamines &amantidne are used to treat these side-effects.4/24/2013 JAYESH PATIDAR 91
  92. 92. MODE OF ACTION• Anticholinergic drugs block thesecretion, thereby reducing the symptomsof akathesia & acute dystonia. It is noteffective against tardive dyskinesia.• Antihistamines have effects likeanticholinergic drugs. Amantadines aredopamine-releasing agents from centralneurons. Studies show that this drug mayaffect some clients with tardivedyskinesia.4/24/2013 JAYESH PATIDAR 92
  93. 93. INDICATION• Antiparkinsonian drugs areused to treat theextrapyramidal symptoms.4/24/2013 JAYESH PATIDAR 93
  94. 94. CONTRINDICATION• Patient with history of closed angle glaucoma,urinary or intestinal obstruction, hypersensitivity,prostatic hypertrophy, tachycardia are not giventhese drugs.• The drugs are given with caution to patients withmysthesia gravis, arthesclerosis & chronicrespiratory problems.• Anticholinergic drugs: Amantadine is given withcaution to patients with renal impairment asmost of the medication is excreted through thekidney.4/24/2013 JAYESH PATIDAR 94
  95. 95. CLASSIFICATIONCHEMICAL & GENERICNAMETRADE NAME DOSE RANGE PERDAY mgm/DayFROM OFAVAILABILITYI. AnticholinergicBenztropineBiperiden HCLHydrochirideTrihexyphenidylHydrochirideProcyclidinehydrochirideCogentinAkinetoneDyskinonPacitaneParbenzkemadrin0.5-6.02.0-8.02.0-12.05.0-20mgTab, injection-do--do-Tab.Tab.II. AntihistamineDiphenhydramine Benadryl 75-100Capsule & syrupIII. Dopamine DrugsL. DopaAmantadine HydrochirideSeleglineCarbidopa & L.Dopa.LarodopaSymmetrelDeprenylSinemet2 gms-3gms100-200gms5-10mg10-100mgTab.Tab .Tab.Tab.4/24/2013 JAYESH PATIDAR 95
  96. 96. SIDE-EFFECTS• Anticholinergic:- Side-effects are dry mouth,flushed, dry skin, blurred vision, photophobia,increased heart rate, constipation, urinaryretention, mental confusion & excitement.• Antihistamines:- Side-effects are drowsiness,dizziness, anorexia, nausea, vomiting, euphoria,orthostatic hypotension, weight gain, weakness &tingling of hands.• Amantadine:- Side-effects are mood changes,slurred speech, insomnia, inability to concentrate,dry mouth, livedo reticularis that is a red-bluenetlike discolouration of the skin which becomesworse in winter.4/24/2013 JAYESH PATIDAR 96
  97. 97. NURSE’S RESPONSIBILITY Observation- observation of the patient for side-effects of anti-parkinsonian drugs such astachycardia, palpitation, sedation, drowsiness &blurred vision. Maintain an intake output chart in case the patienthas urinary retention or constipation. Encourage adequate intake of fluids & roughage inthe diet. Record vital sign such as B.P., pulse & respirationevery four hours. Advise the patient not to get up quickly from a lying-down position to sitting because of orthostatichypotension.4/24/2013 JAYESH PATIDAR 97
  98. 98. COUNT…Educate the patient not to use hazardousmachinery or driving when he is onanticholinergic drugs.Encourage the patient to get his routineeye check-up done for early detection ofblurred vision or glaucoma.Record the medicine & side-effectsaccurately.Report & record any side-effectsobserved to the physician.4/24/2013 JAYESH PATIDAR 98
  101. 101. CLONIDINE4/24/2013 JAYESH PATIDAR 101
  102. 102. MECHANISM OF ACTION• Alpha2- adrenergic receptors agonist.• The agonist effects of clonidine onpresynaptic alpha 2-adrenergicreceptors result in a decrease in theamount of neurotransmitters releasedfrom the presynaptic nerve terminals.This decrease serves generally to resetthe sympathetic tone at a lower level &to decrease arousal.4/24/2013 JAYESH PATIDAR 102
  103. 103. INDICATION• Control of withdrawal symptoms fromopioids.• Tourette‘s disorder• Control of aggressive or hyperactivebehavior in children• Autism.4/24/2013 JAYESH PATIDAR 103
  104. 104. DOSAGE• Usual starting dosage is 0.1mgorally twice a day; the dosage canbe raised by 0.3 mg a day to anappropriate level.4/24/2013 JAYESH PATIDAR 104
  105. 105. SIDE-EFFECTS• Dry mouth, dryness of eyes,fatigue, irritability, sedation,dizziness, nausea, vomiting,hypotension & constipation.4/24/2013 JAYESH PATIDAR 105
  106. 106. NURSE’S RESPONSIBILITY• Monitor BP, the drug should bewithheld if the patient becomeshypotensive.• Advise frequent mouth rinses &good oral hygiene for dry mouth.4/24/2013 JAYESH PATIDAR 106
  108. 108. DESCRIPTION• Methylphenidate ,dextroamphetamine &pemoline aresympathominetics.4/24/2013 JAYESH PATIDAR 108
  109. 109. MECHANISM OF ACTION• Sympathomimetics cause the stimulation ofalpha & beta-adrenergic receptors directly asagonists & indirectly by stimulating the releaseof dopamine & norepinephrine frompresynaptic terminals.• Dextroamphetamine & methylphenidate arealso inhibitors of catecholamine reuptake,especially dopamine reuptake & inhibitors ofmonoamino oxidase.• The net result of these activities is believed tobe the stimulation of the several brain regions.4/24/2013 JAYESH PATIDAR 109
  110. 110. INDICATION• Attention-deficit hyperactivity disorder• Narcolepsy• Depressive disorders• Obesity4/24/2013 JAYESH PATIDAR 110
  111. 111. DOSAGE• Starting dose is 5-10 mg perday orally, maximum dailydose is 80mg/day.4/24/2013 JAYESH PATIDAR 111
  112. 112. SIDE-EFFECTS• Anorexia or dyspepsia, weightloss, slowed growth, dizziness,insomnia or nightmares,dysphoric mood, tics &psychosis.4/24/2013 JAYESH PATIDAR 112
  113. 113. NURSE’S RESPONSIBILITY• Assess mental status for chang in mood, level ofactivity, degree of stimulation & aggressiveness.• Ensure that the patient is protected from injury.• Keep stimuli low & environment as quiet aspossible to discourage over stimulation.• To decrease anorexia, the medication may beadministered immediately after meals. Thepatient should be weighed regularly duringhospitalization & at home while on therapy withCNS stimulants, due to the potential for anorexia/weight loss & temporary interruptions of growth &development.4/24/2013 JAYESH PATIDAR 113
  114. 114. COUNT…• To prevent insomnia administer last dose atleast 6 hours before bedtime.• In children with behavioral disorders a drug‗holiday‘ should be attempted periodicallyunder the direction of the physician todetermine effectiveness of the medication &the need for continuation.• Ensure that parents are aware of the delayedeffects of Ritalin. Therapeutic response maynot seen for 2-4 weeks; the drug should not bediscontinued for lack of immediate results.4/24/2013 JAYESH PATIDAR 114
  115. 115. COUNT…• Inform parents that OTC (over-the-counter)medications should be avoided while the childis on stimulant medication. Some OTCmedications, particularly cold & hay feverpreparation contain certain sympathomimeticagents that could compound the effects of thestimulants & create drug interactions that maybe toxic to the child.• Ensure that parents are aware that the drugshould not be withdraw abruptly. Withdrawalshould be gradual & under the direction of thephysician.4/24/2013 JAYESH PATIDAR 115
  116. 116. 4/24/2013 JAYESH PATIDAR 116
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