The document discusses extrapyramidal symptoms caused by antipsychotic medications, detailing various types such as acute dyskinesias, tardive dyskinesia, akinesia, akathisia, and neuroleptic malignant syndrome. It also addresses the use of seclusion and restraints as behavioral interventions, emphasizing their risks and the necessity of alternative management strategies. The important role of nursing interventions in monitoring and addressing the needs of patients experiencing these conditions is highlighted.

1. EXTRAPYRAMIDAL
SYMPTOMS, SECLUSION &
RESTRAINTS

2. EXTRA PYRAMIDAL SYMPTOMS
• Antipsychotic medications commonly produce extrapyramidal
symptoms as side effects.
• Extrapyramidal symptoms are caused by dopamine blockade or
depletion in the basal ganglia; this lack of dopamine often
mimics idiopathic pathologies of the extrapyramidal system

3. • The extrapyramidal symptoms include
1. ACUTE DYSKINESIAS and DYSTONIC REACTIONS,
2. TARDIVE DYSKINESIA
3. PSEUDO-PARKINSONISM
4. AKINESIA
5. AKATHISIA
6. NEUROLEPTIC MALIGNANT SYNDROME.

4. ACUTE DYSKINESIAS and DYSTONIC
REACTIONS
• An acute dystonic reaction is characterized by involuntary contractions of
muscles of the extremities, face, neck, abdomen, pelvis, or larynx in either
sustained or intermittent patterns that lead to abnormal movements or
postures.
• The etiology of acute dystonic reaction is thought to be due to
dopaminergic-cholinergic imbalance in the basal ganglia.

5. • Acute dystonic reactions are often transient but can cause significant distress to the
patient. Although rare, laryngeal dystonia can cause life-threatening airway
obstruction
• Anticholinergic agents and benzodiazepines are the most commonly used agents to
reverse or reduce symptoms in an acute dystonic reaction.
• The most commonly available drugs in the emergency setting for the treatment of
acute dystonic reactions are diphenhydramine and benztropine.
• Symptoms usually improve or resolve dramatically within 10 to 30 minutes of
administration of parenteral anticholinergics.

8. TARDIVE DYSKINESIA
• Tardive dyskinesia (TD) is a movement disorder characterized
by uncontrollable, abnormal, and repetitive movements of the
face, torso, and/or other body parts.
• TD is caused by prolonged use of treatments that block
dopamine receptors in the brain, such as antipsychotics
commonly prescribed to treat mental illnesses such as
schizophrenia, bipolar disorder, and depression, and certain
anti-nausea medications.

9. • The symptoms of TD often can be persistent and potentially
disabling. The uncontrollable movements may be disruptive to
people's lives due to the symptoms themselves and the impact
they have on emotional and social well-being.

12. Akinesia
• Akinesia is an extrapyramidal behavioral side-effect of
antipsychotic medication characterized by a lessening of
spontaneity, paucity of gestures, diminished conversation, and
apathy

14. AKATHESIA
• Akathisia is an inability to remain physically still.
• It’s a movement disorder that’s linked to certain types of
medications, especially antipsychotic medications.
• People with akathisia feel an intense and uncontrollable need
to move — mainly, their lower body.
• In most cases, the movement is repetitive. This uncontrollable
need to move can cause extreme distress.

15. NEUROLEPTIC MALIGNANT
SYNDROME
• Neuroleptic malignant syndrome (NMS) is a life-threatening
idiosyncratic reaction to antipsychotic drugs characterized by
• Fever
• Altered Mental Status,
• Muscle Rigidity
• Autonomic Dysfunction.

17. • NMS in hospitalized patients is considered a neurologic emergency as a
delay in treatment or withholding of therapeutic measures can
potentially lead to serious morbidity or death
• The role of a nurse is vital in identifying NMS

18. MANAGEMENT OF NMS
• cessation of the suspected offending neuroleptic pharmacologic agent
• supportive medical therapy
• Aggressive hydration is often required, especially if highly elevated CPK levels threaten to
damage the kidneys
• treatment of hyperthermia with cooling blankets or ice packs to the axillae and groin may
be needed.
• Metabolic abnormalities may need to be corrected, and bicarbonate loading should be
considered in some cases as it may be beneficial in preventing renal failure
• intensive care monitoring and support

19. PSEUDO-PARKINSONISM
• Pseudo parkinsonism is a reaction to medications that imitates
the symptoms and appearance of Parkinson’s disease. The
most recognizable symptoms include slowed movements,
muscle stiffness, and a shuffling walk.
• This condition is generally reversible and can be treated by
stopping the medication causing the reaction.

22. SECLUSION AND RESTRAINTS
• Restraint and seclusion are behavioural management interventions that
should be used as a last resort to control a behavioural emergency.
• Behavioural emergencies are often the result of unmet health, functional,
or psychosocial needs, and you can often reduce, eliminate, or manage
such emergencies by addressing the conditions that produced them.
• Restraints include the use of physical force, mechanical devices, or
chemicals to immobilize a person. Seclusion, a type of restraint, involves
confining a person in a room from which the person cannot exit freely.

23. • Restraint and seclusion are not therapeutic care procedures. In
fact, restraint and seclusion can induce further physical or
psychosocial trauma.
• In short, these procedures pose a safety risk to the emotional
and physical well-being of the person and have no known long-
term benefit in reducing behaviours.

24. SECLUSION
• Seclusion is containment of the patient alone in a room or other enclosed
area from which the patient has no means of freely leaving the area. This
does not include the use of locked wards.

25. Restraints
• restricting the patient's ability to move by using different devices
designed for this purpose or holding the patient down by physical force.
• TYPES
• PHYSICAL
• CHEMICAL
• MECHANICAL
• ENVIRONMENTAL

27. PHYSICAL RESTRAINTS
• Physical restraints- which limit a person’s movement
• May include devices that limit a specific part of the body, such as arms
or legs
• Belts or vests may be used to keep a patient in a bed or chair
• Trays may keep a person in a wheelchair
• Bed rails or belts may keep a person confined to a bed

28. CHEMICAL RESTRAINTS
• Chemical restraints are medications not used to treat illness,
but used to sedate people
• Includes sedatives or antipsychotics
• May be used to quickly sedate violent patients
• Usually given as a pill or injection

29. MECHANICAL RESTRAINTS
• Mechanical restraint involves the use of equipment.
• Examples include specially designed mittens in intensive care settings,
everyday equipment such as using a heavy table or belt to stop the person
getting out of their chair, or using bedrails to stop a person from getting
out of bed.
• Controls on freedom of movement – such as keys, baffle locks, and
keypads– can also be a form of mechanical restraint

30. ENVIRONMENTAL RESTRAINTS
• Environmental restraint is the restriction of a resident's movement
without their explicit and informed consent. Examples of
environmental restraint include:
• Limiting a resident to a particular environment: e.g. confining a
resident to their bedroom, excluding a resident from an area to which
they want to go;
• Restricting access to an outside courtyard or sitting room;
• Preventing a resident from leaving the building.

31. NURSING CONCERNS ASSOCIATED
WITH RESTRAINTS
• Limiting a person’s ability to function independently
• Chemical restraints may leave a person too sedated to act
• Physical restraints such as a tray on a wheelchair may keep a person from moving
about freely
• Increased frustration and restlessness
• Restriction of freedoms
• May be inappropriate or excessive
• Can lead to loss of self-confidence and self-esteem
• Creates stress

32. • Risk of injury or harm
• Restraints can cause injuries, e.g. attempts to climb a bed rail can result
in a fall
• Confusion and disorientation
• Loss of abilities
• Prolonged sedation can lead to loss of physical or cognitive abilities

33. Nursing interventions when a patient is
restraints
• The timing of nursing interventions for the restrained patient is
crucial!
1) Assess the patient's status every 15 minutes.
2) Offer fluids, ROM exercises, and toileting every 2 hours.
3) Immediately remove restraints once the patient is no longer a
danger to themselves or others.

34. THANK YOU