Specific Drug Olanzapine (Apo-OLANZapine , ZyPREXA, ZyPREXA Relprevv, ZyPREXA Zydi)

Classification PHARMACOTHERAPEUTIC: Secondgeneration (atypical) antipsychotic.

CLINICAL: Antipsychotic.

Indication PO: Management of manifestations of schizophrenia. Treatment of acute mania associated with bipolar I
disorder as monotherapy or in combination with lithium or valproate.

In combination with FLUoxetine: treatment of depressive episodes associated with bipolar I disorder and
treatment of treatment-resistant bipolar depression. Maintenance treatment of bipolar I disorder.

IM: ZyPREXA
Intramuscular: Controls acute agitation in schizophrenia and bipolar mania. Relprevv: Long-acting
antipsychotic for IM injection for treatment of schizophrenia.

OFF-LABEL: Prevention of chemotherapy induced nausea/vomiting. Acute treatment of delirium.

Treatment of anorexia nervosa, Tourette’s syndrome, tic disorder.

Mechanism of Antagonizes alpha1-adrenergic, DOPamine,

Action histamine, muscarinic, serotonin receptors. Produces anticholinergic, histaminic, CNS depressant effects.

Therapeutic Effect: Diminishes psychotic symptoms through combined antagonism of dopamine and
serotonin receptors.

Side Effects & Frequent (26%–10%): Drowsiness, agitation, insomnia, headache, nervousness, hostility, dizziness,
Adverse Reactions rhinitis.
Occasional (9%–5%): Anxiety, constipation, nonaggressive atypical behavior, dry mouth, weight gain,
orthostatic hypotension, fever, arthralgia, restlessness, cough, pharyngitis, visual changes (dim vision).
Rare: Tachycardia; back, chest, abdominal, or extremity pain; tremor.

ADVERSE EFFECTS/TOXIC REACTIONS

Rare reactions include seizures, neuroleptic malignant syndrome, a potentially fatal syndrome
characterized by hyperpyrexia, muscle rigidity, irregular pulse or B/P, tachycardia, diaphoresis, cardiac
arrhythmias. Extrapyramidal symptoms (EPS), dysphagia may occur. Overdose (300 mg) produces
drowsiness, slurred speech.

Contra- indications Hypersensitivity to OLANZapine. Cautions: Disorders in which CNS depression is prominent; cardiac
disease, hemodynamic instability, prior MI, ischemic heart disease; hyperlipidemia, pts at risk for
aspiration pneumonia, decreased GI motility, urinary retention, BPH, narrow-angle glaucoma, diabetes,
elderly, pts at risk for suicide, Parkinson’s disease, severe renal/hepatic impairment, predisposition to
seizures.

Interactions DRUG: Alcohol, CNS depressants (e.g., LORazepam, morphine, zolpidem) may
increase CNS depressant effects. Anticholinergics (e.g., aclidinium, ipratropium, tiotropium,
umeclidinium) may increase anticholinergic effect. QT-prolonging agents (e.g., amiodarone, haloperidol,
moxifloxacin, sotalol) may cause QT interval prolongation.

HERBAL: Herbals with sedative properties (e.g., chamomile, kava kava, valerian) may increase CNS
depression.

1
 FOOD: None known.

LAB VALUES: May increase serum GGT, cholesterol, prolactin, ALT, AST.

Nursing BASELINE ASSESSMENT

Responsibilities and 1. Obtain baseline LFT, serum glucose, weight, lipid profile before initiating treatment.
Rationale 2. Assess behavior, appearance, emotional status, response to environment, speech pattern, thought
content.

INTERVENTION/EVALUATION
1. Monitor B/P, serum glucose, lipids, LFT.
2. Assess for tremors, changes in gait, abnormal muscular movements, behavior (antipsychotics are
potential causes of drug induced tremors)
3. Supervise suicidal-risk pt closely during early therapy (as depression lessens, energy level improves,
increasing suicide potential).
4. Assess for therapeutic response (interest in surroundings, improvement in self-care, increased ability
to concentrate, relaxed facial expression).
5. Assist with ambulation if dizziness occurs. (as part of side effects)
6. Assess sleep pattern. Notify physician if extrapyramidal symptoms (EPS) occur.

PATIENT/FAMILY TEACHING
1. Avoid dehydration, particularly during exercise, exposure to extreme heat, concurrent use of
medication causing dry mouth, other drying effects.
2. Sugarless gum, sips of water may relieve dry mouth. (Hypersalivation has been reported as a side
effect of atypical antipsychotics such as clozapine and olanzapine. As it is very common for
antipsychotics to cause dry mouth due to anticholinergic effects, hypersalivation seems to be
paradoxical.)
3. Report suspected pregnancy.
4. Take medication as prescribed; do not stop taking or increase dosage.
5. Slowly go from lying to standing (prevent othrostatic hypertension)
6. Avoid alcohol (increases nervous system side effects such as dizziness, drowsiness, difficulty of
concentrating)
7. Avoid tasks that require alertness, motor skills until response to drug is established.
8. Monitor diet, exercise program to prevent weight gain. (weight gain are common side effect of this
drug, the high likelihood of weight gain with these medications has been linked to their actions at
serotonin 5-HT2A and 5-HT2C, dopamine D2 and D3, histamine H1 and muscarinic M3 receptors)

Specific Drug Clozapine

Drug Antipsychotic
Classification Dopaminergic Blocking Agent

Indication Management of severely ill schizophrenics who are unresponsive to standard antipsychotic drugs.

Mechanism of Blocks serotonin and dopamine receptors in the brain.

Action

Side Effects and CNS: Drowsiness, sedation, seizures, dizziness, syncope, headache, tremor, disturbed sleep, nightmares,
Adverse restlessness, agitation, increased salivation, and sweating
Reactions

2
 GI: Nausea, vomiting, constipation, abdominal discomfort, dry mouth

Hematologic: Leukopenia, granulocytopenia, and granulocytopenia

GU: Urinary abnormalities

Other: Fever, weight gain, and rash

Contraindication Allergy to clozapine, myeloproliferative disorders, history of clozapine-induced agranulocytosis or severe

s granulocytopenia, severe CNS depression, comatose states, seizure disorders, cardiovascular disease, prostate
enlargement, narrow-angle glaucoma, and lactation

Interaction Drug-drug: Increased therapeutic and toxic effects with cimetidine. Decreased therapeutic effect with
phenytoin, mephenytoin, and ethotoin.

Nursing Assessment
Responsibilities 1. History: Allergy to clozapine, myeloproliferative disorders, history of clozapine-induced agranulocytosis
and Rationale or severe granulocytopenia, severe CNS depression, comatose states, history of seizure disorders, CV
disease, prostate enlargement, narrow-angle glaucoma, lactation
2. Physical: Temperature, weight, reflexes, orientation, intraocular pressure, ophthalmologic exam; pulse
rate, blood pressure, orthostatic blood pressure, ECG, respiratory rate, adventitious sounds, bowel sound,
normal output, liver evaluation, prostate palpation, normal urine output, CBC, urinalysis, liver, and
kidney function tests, EEG.

Implementation
1. Use only when unresponsive to conventional antipsychotic drugs.
2. Obtain clozapine through the Clozaril Patient Management System.
3. Dispense only 1 week supply at a time.
4. Monitor WBC carefully prior to the first dose.
5. Weekly monitoring of WBC during treatment and for 4 weeks thereafter.
6. Monitor temperature. If fever occurs, rule out underlying infection, and consult a physician for comfort
measures.
7. Monitor elderly patients for dehydration. Institute remedial measures promptly; sedation and decreased
thrust related to CNS effects can lead to dehydration.
8. Encourage voiding before taking drugs to decrease anticholinergic effects or urinary retention.
9. Follow guidelines for discontinuation or reinstitution of the drug.

Drug-specific teaching points

1. A weekly blood test will be taken to determine the safe dosage; the dosage will be increased gradually to
achieve the most effective dose. Only 1 week of medication can be dispensed at a time. Do not take more
than your prescribed dosage. Do not make up missed doses, instead, contact your care provider. Do not
stop taking this drug suddenly; a gradual reduction of dosage is needed to prevent side effects.
2. The following effects may occur as a result of drug therapy: drowsiness, dizziness, sedation, seizures
(avoid driving, operating machinery, or performing tasks that require concentration); dizziness, faintness
on arising (change positions slowly); increased salivation (reversible); constipation (consult care provider
for correctives); fast heart rate (rest, take your time).
3. This drug cannot be taken during pregnancy. If you think you are pregnant or wish to become pregnant,
contact your care provider.
4. Report lethargy, weakness, fever, sore throat, malaise, mouth ulcers, and “flu-like” symptoms.

Specific Drug Biperiden

Drug Antiparkisonism drug (anticholinergic type)

Classification

Indication Adjunct in the therapy of parkinsonism (postencephalitic, arteriosclerotic, and idiopathic types)

Relief of symptoms of extrapyramidal disorders that accompany phenothiazine therapy

3
Mechanism of Anticholinergic activity in the CNS that is believed to help normalize the hypothesized imbalance of
Action cholinergic/dopaminergic neurotransmission in the basal ganglia in the brain of a parkinsonism patient.
Reduces the severity of rigidity and to a lesser extent, akinesia and tremor characterizing parkinsonism; less
effective overall than levodopa; peripheral anticholinergic effects suppress secondary symptoms of
parkinsonism, such as drooling.

Side Effects and CNS: Some are characteristic of centrally acting anticholinergic drugs: disorientation, confusion, memory
Adverse Effects loss, hallucinations, psychoses, agitation, nervousness, delusions, delirium, paranoia, euphoria, excitement,
light-headedness, dizziness, depression, drowsiness, weakness, giddiness, paresthesia, heaviness of the limbs.

Peripheral Anticholinergic Effects

GI: Dry mouth, constipation, dilation of the colon, paralytic ileus, acute suppurative parotitis, nausea,
vomiting, epigastric distress.

CV: Tachycardia, palpitations, hypotension, orthostatic hypotension.

GU: Urinary retention, urinary hesitancy, dysuria, difficulty achieving or maintaining an erection.

EENT: Blurred vision, mydriasis, diplopia, increased intraocular tension, angle-closure glaucoma.

Dermatologic: Skin rash, urticaria, other dermatoses

Other: Flushing, decreased sweating, elevated temperature, muscular weakness, muscular cramping.

Contraindication Hypersensitivity to benztropine, glaucoma (especially angle-closure glaucoma), pyloric or duodenal

s obstruction, stenosing peptic ulcers, achalasia (megaesophagus), prostatic hypertrophy or bladder neck
obstructions, myasthenia gravis.

Use cautiously with tachycardia, cardiac arrhythmias, hypertension, hypotension, hepatic or renal dysfunction,
alcoholism, chronic illness, people who work in a hot environment, hot weather, and lactation.

Interactions Drug-drug:
1. Paralytic ileus, sometimes fatal, with other anticholinergic drugs, with drugs that have anticholinergic
properties (phenothiazines, tricyclic antidepressants).
2. Additive adverse CNS effects (toxic psychosis) with drugs that have CNS anticholinergic properties
(TCAs, phenothiazines).
3. Possible masking of extrapyramidal symptoms, tardive dyskinesia, in long-term therapy with
antipsychotic drugs (phenothiazines, haloperidol).
4. Decreased therapeutic efficacy of antipsychotic drugs (phenothiazines, haloperidol), possibly due to
central antagonism.

Nursing Assessment:
Responsibilities 1. History: Hypersensitivity to benztropine, glaucoma, pyloric or duodenal obstruction, stenosing peptic
and Rationale ulcers, achalasia, prostatic hypertrophy, or bladder neck obstructions, Myasthenia gravis, cardiac
arrhythmias, hypertension, hypotension, hepatic or renal dysfunction, alcoholism, chronic illness, work in
a hot environment, lactation.
2. Physical: Body weight, temperature, skin color, lesions, orientation, affect, reflexes, bilateral grip
strength, visual exam, including tonometry, pulse rate, blood pressure, orthostatic blood pressure,
adventitious sounds, normal output, liver evaluation, normal urinary output, voiding pattern, prostate
palpation, liver, and kidney function tests.

Implementation:
1. Decrease dosage or discontinue temporarily if dry mouth makes swallowing or speaking difficult.
2. Give with caution, and reduce dosage in hot weather. The drug interferes with sweating and the ability of
the body to maintain heat equilibrium, anhidrosis, and fatal hyperthermia have occurred.
3. Give with meals if GI upset occurs, give before meals to patients with dry mouth, and give after meals if
drooling or nausea occurs.
4. Ensure that patient voids just before receiving each dose of drug if urinary retention is a problem.

4
 Drug-specific teaching points
1. Take this drug exactly as prescribed.
2. Avoid the use of alcohol, sedative, and OTC drugs (which can cause dangerous effects).
3. The following side effects may occur, drowsiness, dizziness, confusion, blurred vision (avoid driving or
engaging in activities that require alertness and visual acuity), nausea (try frequent small meals), dry
mouth (such as sugarless lozenges or ice chips), painful or difficult urination (empty the bladder
immediately before each dose), constipation (maintain adequate fluid intake and exercise regularly), use
caution in hot weather (you are susceptible to heat prostration).
4. Report difficult or painful urination, constipation, rapid or pounding heartbeat, confusion, eye pain, or
rash

Specific Drug Sodium Divalproex (Valproic Acid)

Classification PHARMACOTHERAPEUTIC: Histone deacetylase inhibitor.

CLINICAL: Anticonvulsant, antimanic, antimigraine

Indication Monotherapy/adjunctive therapy of complex

partial seizures, simple and complex absence seizures. Adjunctive therapy of multiple seizures including
absence seizures.

Additional uses for Depakote, Depakote ER: Treatment of manic episodes with bipolar disorder,
prophylaxis of migraine headaches.

OFF-LABEL: Refractory status epilepticus, diabetic neuropathy. Mood stabilizer for behaviors in dementia.

Mechanism of Directly increases concentration of inhibitory neurotransmitter gamma-aminobutyric acid (GABA).

Action Therapeutic Effect: Decreases seizure activity, stabilizes mood, prevents migraine headache.

Interactions DRUG: Cholestyramine, rifAMPin may decrease concentration/effect. May

increase adverse effects of lamoTRIgine, LORazepam.
HERBAL: None significant.
FOOD: None known. LAB
VALUES: May increase serum LDH, bilirubin, ALT, AST. Therapeutic serum level: 50–100 mcg/mL; toxic
serum level: greater than 100 mcg/mL.

Side Effects Frequent: Epilepsy: Abdominal pain, irregular menses, diarrhea, transient alopecia, indigestion, nausea,
vomiting, tremors, fluctuations in body weight.
Mania (22%–19%): Nausea, drowsiness.
Occasional: Epilepsy: Constipation, dizziness, drowsiness, headache, skin rash,
unusual excitement, restlessness.
Mania (12%–6%): Asthenia, abdominal pain,
dyspepsia, rash.
Rare: Epilepsy: Mood changes, diplopia, nystagmus, spots before eyes, unusual bleeding/bruising.

Adverse Effects
Hepatotoxicity may occur, particularly in first 6 mos of therapy. May be preceded by loss of seizure control,
malaise, weakness, lethargy, anorexia, vomiting rather than abnormal LFT results. Blood dyscrasias may
occur.

Contraindication Contraindications: Hypersensitivity to valproic acid. Active hepatic disease, urea cycle disorders, known
s mitochondrial disorders caused by mutation in mitochondrial DNA polymerase gamma (POLG). Children
under 2 yrs of age suspected of having POLG-related disorder. Migraine prevention in pregnant women.

Cautions: Children younger than 2 yrs. Pts at risk for hepatotoxicity. History of hepatic impairment, bleeding
abnormalities, pts at high risk for suicide, elderly pts.

5
 LIFESPAN CONSIDERATIONS
Pregnancy/Lactation: Drug crosses placenta; is distributed in breast milk.
Children: Increased risk of hepatotoxicity
in pts younger than 2 yrs.
Elderly: No age-related precautions, but
lower dosages recommended.

Nursing BASELINE ASSESSMENT

Responsibilities - Anticonvulsant: Review history of seizure disorder (intensity, frequency, duration, level of
consciousness).
- Initiate safety measures, quiet dark environment.
- CBC should be performed before and 2 wks after therapy begins, then 2 wks following maintenance dose.
- Obtain baseline LFT.
- Antimanic: Assess behavior, appearance, emotional status, response to environment, speech pattern,
thought content.
- Antimigraine: Question pt regarding onset, location, duration of migraine, possible precipitating
symptoms.

INTERVENTION/EVALUATION
- Monitor CBC, LFT, serum ammonia.
- Anticonvulsant: Observe frequently for recurrence of seizure activity. Assess skin for ecchymoses,
petechiae.
- Monitor for clinical improvement (decrease in intensity/ frequency of seizures).
- Antimanic: Question for suicidal ideation. Assess for therapeutic response (interest in surroundings,
increased ability to concentrate, relaxed facial expression).
- Antimigraine: Evaluate for relief of migraine headache and resulting photophobia, phonophobia, nausea,
vomiting.
- Therapeutic serum level: 50–100 mcg/mL; toxic serum level: greater than 100 mcg/mL.

PATIENT/ FAMILY TEACHING

- Do not abruptly discontinue medication after long-term use (may precipitate seizures).
- Strict maintenance of drug therapy is essential for seizure control.
- Avoid tasks that require alertness, motor skills until response to drug is established.
- Drowsiness usually disappears during continued therapy.
- Avoid alcohol.
- Report liver problems such as nausea, vomiting, lethargy, altered mental status, weakness, loss of
appetite, abdominal pain, yellowing of skin, unusual bruising/ bleeding.
- Report if seizure control worsens, suicidal ideation (depression, unusual changes in behavior, suicidal
thoughts) occurs.

Specific Drug Diphenhydramine (Allerdryl , Banophen, Benadryl, Benadryl Children’s Allergy, Diphen, Diphenhist,
Genahist, Nytol)

Classification PHARMACOTHERAPEUTIC: Histamine-1 antagonist, first generation.

CLINICAL: Antihistamine, anticholinergic, antipruritic, antitussive, antiemetic,

anti dyskinetic

Indication Treatment of allergic reactions, including nasal allergies and allergic dermatoses; parkinsonism, including
drug-induced extrapyramidal symptoms; prevention/ treatment of nausea, vomiting, or vertigo due to motion
sickness; antitussive; short-term management of insomnia; adjunct to EPINEPHrine in treatment of
anaphylaxis. Topical form used for relief of pruritus from insect bites, skin irritations.

Mechanism of Competes with histamine for H-1 receptor site on effector cells in GI tract, blood vessels, respiratory tract.
Action Therapeutic Effect: Produces anticholinergic, antipruritic, antitussive, antiemetic, anti dyskinetic, sedative
6
 effects.

LIFESPAN CONSIDERATIONS
Pregnancy/Lactation: Crosses placenta.
Detected in breast milk (may produce irritability in breastfed infants). Increased risk of seizures in neonates,
premature infants if used during third trimester of pregnancy.
May prohibit lactation. Children: Not recommended in newborns, premature infants (increased risk of
paradoxical reaction, seizures).

Elderly: Potentially inappropriate due to potent anticholinergic effects. Increased risk for dizziness, sedation,
confusion, hypotension, hyperexcitability.

Interactions DRUG: Alcohol, other CNS depressants (e.g., LORazepam, morphine, zolpidem) may increase CNS
depressant effects. Anticholinergics (e.g., aclidinium, ipratropium, tiotropium, umeclidinium) may increase
anticholinergic effects.

HERBAL: Gotu kola,kava kava, valerian may increase CNS depression.

FOOD: None known.

LAB VALUES: May suppress wheal/flare reactions to antigen skin testing unless drug is discontinued 4 days
before testing.

Side Effects Frequent: Drowsiness, dizziness, muscle weakness, hypotension, urinary retention, thickening of bronchial
secretions, dry mouth, nose, throat, lips; in elderly: sedation, dizziness, hypotension.

Occasional: Epigastric distress, flushing, visual/hearing disturbances, paresthesia, diaphoresis, chills.

ADVERSE EFFECTS/TOXIC REACTIONS

Hypersensitivity reactions (eczema, pruritus, rash, cardiac disturbances, photosensitivity) may occur.

Overdose symptoms may vary from CNS depression (sedation, apnea, hypotension, cardiovascular collapse,
death) to severe paradoxical reactions (hallucinations, tremors, seizures).

Children, infants, neonates may experience paradoxical reactions (restlessness, insomnia, euphoria,
nervousness, tremors).

Overdosage in children may result in hallucinations, seizures, death.

Contraindication Contraindications: Hypersensitivity to di-phenhydrAMINE. Neonates or premature infants, breastfeeding.

Cautions: Narrowangle glaucoma, stenotic peptic ulcer, prostatic hypertrophy, pyloroduodenal/bladder neck
obstruction, asthma, COPD, increased IOP, cardiovascular disease, hyperthyroidism,
elderly.

Nursing BASELINE ASSESSMENT

Responsibilities - If pt is having acute allergic reaction, obtain history of recently ingested foods, drugs, environmental
exposure, emotional stress.
- Monitor B/P rate; depth, rhythm, type of respiration; quality, rate of pulse.
- Assess lung sounds for rhonchi, wheezing, rales.
INTERVENTION/EVALUATION
- Monitor B/P, esp. in elderly (increased risk of hypotension).
- Monitor children closely for paradoxical reaction. Monitor for sedation.

PATIENT/FAMILY TEACHING
- Tolerance to antihistaminic effect generally does not occur; tolerance to sedative effect may occur.
- Avoid tasks that require alertness, motor skills until response to drug is established.
- Dry mouth, drowsiness, dizziness may be an expected response to drug.

7
 - Avoid alcohol.

Specific Drug Quetiapine (SEROquel, SEROquel XR)

BLACK BOX ALERT: Increased risk of suicidal ideation and behavior in children, adolescents, young adults
18–24 yrs with major depressive disorder, other psychiatric disorders. Elderly with dementia related psychosis
are at increased risk for death.

Classification PHARMACOTHERAPEUTIC: Dibenzodiazepine derivative.

CLINICAL: Second- generation (atypical) antipsychotic.

Indication Treatment of schizophrenia. Treatment of acute manic episodes associated with bipolar disorder (alone or in
combination with lithium or valproate). Maintenance treatment of bipolar disorder as an adjunct to lithium or
valproic acid. Treatment of acute depressive episodes associated with bipolar disorder.

Extended-Release Only: Adjunctive treatment to antidepressants in major depressive disorder (MDD).

OFF-LABEL: Delirium in critically ill pts, psychosis/agitation related to Alzheimer’s dementia. Treatment of
autism, treatment-resistant obsessive compulsive disorder.

Mechanism of Antagonizes DOPamine and serotonin

Action (antipsychotic activity), histamine (somnolence), alpha1-adrenergic (orthostatic hypotension) receptors.

Therapeutic Effect: Diminishes symptoms associated with schizophrenia/bipolar disorders.

Lifespan Pregnancy/Lactation: Unknown if drug is distributed in breast milk. Not recommended for breastfeeding
Considerations mothers.

Children: Safety and efficacy not established in children less than 10 yrs of age (bipolar mania) or less than 13
yrs of age (schizophrenia).

Elderly: No age-related precautions noted, but lower initial and target dosages may be necessary.

Interactions DRUG: Medications prolonging QT interval (e.g., amiodarone, citalopram, dasatinib, haloperidol,
ondansetron) may increase risk of QT prolongation. Alcohol, other CNS depressants (e.g., LORazepam,
morphine, zolpidem) may increase CNS depression. May increase hypotensive effects of antihypertensives.
Strong CYP3A4 inducers (e.g., car-BAMazepine, phenytoin, rifAMPin) may decrease concentration/effect.
Strong CYP3A4 inhibitors (e.g., clarithromycin, ketoconazole) may increase concentration/effect.
Anticholinergic agents (e.g., aclidinium, ipratropium, tiotropium,
umeclidinium) may increase anticholinergic
effect.

HERBAL: Herbals with sedative properties (e.g., chamomile, kava kava, valerian) may
increase CNS depression. St. John’s wort may decrease concentration/ effect.

FOOD: None known.

LAB VALUES: May decrease total free thyroxine (T4) serum levels. May increase serum cholesterol,
triglycerides, ALT, AST, WBC, GGT. May produce false-positive pregnancy test result.

Side Effects Frequent (19%–10%): Headache, drowsiness, dizziness.

Occasional (9%–3%): Constipation, orthostatic hypotension, tachycardia, dry mouth, dyspepsia, rash,
asthenia, abdominal pain, rhinitis.

8
 Rare (2%): Back pain, fever, weight gain.

Adverse Reactions
Overdose may produce heart block, hypotension, hypokalemia, tachycardia.

Contraindication Contraindications: Hypersensitivity to QUEtiapine.

s
Cautions: Renal / hepatic impairment, preexisting abnormal lipid profile, pts at risk for aspiration pneumonia,
cardiovascular disease (e.g., HF, history of MI), cerebrovascular disease, dehydration, hypovolemia, history of
drug abuse/dependence, seizure disorder, hypothyroidism, pts at risk for suicide, Parkinson’s disease,
decreased GI motility, urinary retention, narrow-angle glaucoma, diabetes, visual problems, elderly, pts at risk
for orthostatic hypotension. Avoid use in pts at risk for torsades de pointes (hypokalemia, hypomagnesemia,
history of cardiac arrhythmias, congenital long QT syndrome, concurrent medications that prolong QT
interval).

Nursing BASELINE ASSESSMENT

Responsibilities - Assess behavior, appearance, emotional status, response to environment, speech pattern, thought content.
and Rationale - Obtain baseline CBC, hepatic enzyme levels before initiating treatment and periodically thereafter.
- Question medical history as listed in Precautions.

INTERVENTION/EVALUATION
- Monitor mental status, onset of extrapyramidal symptoms. Assist with ambulation if dizziness occurs.
- Supervise suicidal risk pt closely during early therapy (as psychosis, depression lessens, energy level
improves, increasing suicide potential).
- Monitor B/P for hypotension, lipid profile, blood glucose, CBC, or worsening depression, unusual
behavior.
- Assess pulse for tachycardia (esp. with rapid increase in dosage).
- Monitor daily pattern of bowel activity, stool consistency.
- Assess for therapeutic response (improved thought content, increased ability to concentrate, improvement
in self-care).
- Eye exam to detect cataract formation should be obtained q6mos during treatment.

PATIENT/ FAMILY TEACHING

- Avoid exposure to extreme heat.
- Drink fluids often, esp. during physical activity.
- Take medication as ordered; do not stop taking or increase dosage.
- Drowsiness generally subsides during continued therapy.
- Avoid tasks that require alertness, motor skills until response to drug is established.
- Avoid alcohol.
- Slowly go from lying to standing.
- Report suicidal ideation, unusual changes in behavior.

Specific Drug Risperidone

Justification for Based on the MHGAP, Risperidone can be used as an alternative to haloperidol in individuals with bipolar
the choice mania if availability can be assured, and the cost is not a constraint.

Mechanism of Decreases dopaminergic and serotonergic pathway activity in the brain, therefore decreasing symptoms of
Action schizophrenia and mood disorders.

Dosing Start 1 mg daily.

Increase to 2-6 mg daily (maximum 10 mg).
Route: Per Orem

Side Effects Common: Sedation, dizziness, tachycardia.

Serious: Orthostatic hypotension, metabolic effects (elevated lipids, insulin resistance, weight gain), EPS,
9
 elevated prolactin, sexual dysfunction, NMS.

Contraindication Caution in patients with: cardiac disease because risperidone could cause repolarization abnormalities.
s and Why Diabetic patients
- Affects the ketones in the blood causing ketoacidosis and adversely affecting insulin secretions and
sensitivity

High fat in the blood

- This medication increases the cholesterol and triglycerides in the body which may cause further cardiac
disease

Drug-drug interactions: carbamazepine can reduce levels of risperidone, whereas fluoxetine can increase
levels.

Nursing 1. Immediately notify the prescriber and expect to stop giving risperidone if the patient shows
Responsibilities evidence of neuroleptic malignant syndrome (altered mental status, autonomic instability,
and Rationale hyperpyrexia, muscle rigidity) – it can be fatal.

2. Monitor the patient’s blood glucose and lipid levels as ordered – the drug increases the risk of
hyperglycemia and hypercholesterolemia.

3. Monitor patient’s CBC, as ordered – serious adverse hematologic reactions may occur, such as
agranulocytosis, leukopenia, or neutropenia.

4. Caution the patient to avoid performing hazardous activities such as driving until CNS effects are
known and subside. Review fall precautions with the patient. – medication may cause dizziness/
drowsiness.

Specific Drug Lithium

Justification for Based on the MHGAP, the use of Lithium will be the first-line treatment of bipolar disorder only if clinical
the choice and laboratory monitoring is available, and prescribed only under specialist supervision.

Mechanism of In patients with bipolar affective disorder, the GABA neurotransmission is diminished, resulting in low
Action GABA levels that lead to excitatory toxicity. The use of lithium will increase the level of GABA by inhibiting
the glutamatergic neurotransmission resulting to decreased glutamate (major excitatory neurotransmitter)
level.

Dosing Start 300 mg daily.

Increase gradually every 7 days until the target blood level reaches (maximum 600-1200mg daily). Monitor
every 2-3 months.

Route: Per Orem

Target blood levels: 0.6-1.0 mEq/liter

- In acute manic episode: 0.8-1.0 mEq/liter
- For maintenance treatment: 0.6-0.8 mEq/liter.

6 months on medication is needed to determine the full effectiveness of maintenance treatment.

Side Effects Common: Sedation, cognitive problems, tremor, impaired coordination, hypotension, leukocytosis, polyuria,
polydipsia, nausea, diarrhea, weight gain, hair loss, rash.

Serious: Diabetes insipidus, hypothyroidism, ECG changes (arrhythmia, sick sinus syndrome, T-wave
changes).

10
Contraindication Renal failure
s & Why - Increased lithium levels can cause damage to the kidneys because lithium is increasingly toxic and the
kidneys would filter the lithium out of the body

Cardiovascular insufficiency
- Increased lithium levels cause sinoatrial block causing irregular heart rhythms

Addison's disease
- Lithium block the mineralocorticoid action of fludrocortisone which controls the sodium and fluids in the
body

Untreated Hyperthyroidism
- Untreated hyperthyroidism can cause irregular heartbeats, blood clots, heart failure and stroke which
combined with lithium carbonate can cause increased heart problems

Nursing 1. Monitor the patient for signs and symptoms of lithium toxicity (ataxia, drowsiness, weakness,
Responsibilities tremor, vomiting) – which indicates an accumulation of lithium that is not excreted properly by the
and Rationale kidneys.

2. Monitor baseline ECG, Thyroid studies, renal studies, and electrolytes level: ECG – identify
arrhythmias such as T‐wave inversions, sinus bradycardia, sinoatrial blocks, PR prolongation, incomplete
bundle branch block, QTc prolongation, increased QT dispersion ratio and ventricular tachyarrhythmias,
and provided needed interventions; thyroid studies – to identify if the thyroid gland is functioning
properly; renal studies – observe kidney health; electrolytes level – to identify and treat electrolyte
imbalances.

3. Weigh the patient daily, and check for edema or sudden weight gain – to recognize when fluid
overload is potentially or already happening.

4. Check laboratory results for urine-specific gravity and report if the level is below 1.005 – to
determine how well the kidneys are diluting the urine. Urine that's too concentrated could mean that
kidneys aren't functioning properly or that patient isn’t drinking enough water.

Specific Drug Carbamazepine

Justification for Based on the MHGAP, Carbamazepine can be used in clinical or laboratory monitoring for lithium is not
the choice available or if a specialist is not available to supervise lithium prescription.

Mechanism of In bipolar disorder, carbamazepine is thought to increase dopamine turnover and increase GABA
Action transmission, treating manic and depressive symptoms.

Dosing Start 200 mg daily. Increase by 200 mg weekly to 400-600 mg daily in two divided doses (maximum 1200
mg daily).

Route: Per Orem

Note: Dose may need to be adjusted after 2 weeks due to induction of its own metabolism.

Side Effects Common: sedation, confusion, dizziness, ataxia, double vision, nausea, diarrhea, benign leucopenia.

Serious: hepatotoxicity, cardiac conduction delay, low sodium levels, severe rash.

Contraindication Patient taking antidiuretic hormone

s & Why - Increases antidiuretic hormone (ADH) which leads to abnormal sensitivity of renal tubules to ADH activity
which can also cause hyponatremia

High cholesterol
- studies show that treatment with carbamazepine has been shown to increase total cholesterol and low-density

11
 lipoprotein cholesterol

Decreased blood platelets

- Induces platelet apoptosis and thrombocytopenia through protein kinase

Decreased function of bone marrow

- Metabolized in the liver causing toxic aromatic metabolites which cause direct damage to bone marrow

Nursing 1. Monitor for suicidal ideation and behavioral changes – Depression may worsen temporarily
Responsibilities during times when medication is taken, possibly leading to suicidal ideation.
and Rationale
2. Observe excessive sedation – because overuse of the CNS depressant drugs can slow body functions
to such a degree as to cause unconsciousness, respiratory failure, and death.

3. Give drug with food – to prevent GI upset/irritation.

4. Do not mix the suspension with other medications or elements – may decrease or increase the
therapeutic effect of the medication (as described in MOA).

5. Advise the patient to report adverse reactions and to immediately report fever, sore throat,
mouth ulcers, or easy bruising or bleeding – indicate unwanted effects and do needed
interventions.

Specific Drug Sodium Valproate

Justification for Based on the MHGAP, aside from Carbamazepine, Sodium Valproate can also be used in clinical or
the choice laboratory monitoring for lithium is not available or if a specialist is not available to supervise lithium
prescription.

Mechanism of Reduces or prevents manic episodes by increasing the amount of a chemical called gamma-aminobutyric acid
Action (GABA) in the brain. GABA blocks transmission across nerves in the brain and has a calming effect.

Dosing Start 500 mg daily. Increase slowly to 1000 - 2000 mg daily (maximum 60 mg/kg/day).

Route: Per Orem

Preferred choice in persons living with HIV/AIDS due to drug-drug interactions.

Side Effects Common: Sedation, headache, tremor, ataxia, nausea, vomiting, diarrhea, weight gain, transient hair loss.

Serious: Impaired hepatic function, thrombocytopenia, leucopenia, drowsiness/confusion, liver failure,

hemorrhagic pancreatitis.

Contraindication High ammonium in the blood

s & Why - Modulates the levels of substrates in the urea cycle

Liver disease
- can cause increased hepatocellular elevations of enzymes in the liver causing further hyperammonemia and
hepatocellular injuries

Decreased blood platelets

- Can cause increased disruption of platelets as well as the formation of antibodies destroying platelets due to
direct toxic effects on bone marrow

Depression/Mental disorders
- Reduces excessive electrical activity in the brain reducing feelings of excitability which can cause an
increased risk for suicidal thoughts and behaviors and reduces brain function

12
Nursing 1. Assess the patient for a history of hypersensitivity to valproic acid. – find alternative medication to
Responsibilities prescribe and indicate the right dosage based on obtained data.
and Rationale
2. Monitor the patient carefully for clotting defects (bruising, blood-tinged toothbrush). – to identify
evidence of hemorrhage, bruising, or disorder of hemostasis.

3. Monitor serum levels of valproic acid and other antiepileptic drugs that are given concomitantly,
especially during the first few weeks of therapy. – to identify needed adjustments in dosage on the
basis of data and clinical response.

4. Report bruising, pink stain on the toothbrush, yellowing of the skin or eyes, pale feces, rash,
pregnancy; abdominal pain with nausea, vomiting, and anorexia. – indicates thrombocytopenia,
jaundice, and gastritis, which are unwanted adverse effects.

Specific Drug Haloperidol

Justification for the Based on the MHGAP, Haloperidol can be used only if there is no clinical or laboratory monitoring
choice available to start lithium or valproate.

Mechanism of Manic episode in patients with bipolar disorder is mainly caused by increased dopamine levels in the brain.
Action The active mechanism of Haloperidol is to block postsynaptic dopamine (D2) receptors in the mesolimbic
system of the brain resulting in decreased dopamine levels and leading to the treatment of manic episodes.

Dosing Start 1.5-3 mg daily.

Increase as needed (maximum 20 mg daily).
Route: Oral or intramuscular

Side Effects Common: Sedation, dizziness, blurred vision, dry mouth, urinary retention, constipation.

Serious: Orthostatic hypotension, extrapyramidal side effects (EPS), ECG changes (prolonged QT
interval), weight gain, galactorrhea, amenorrhea, Neuroleptic malignant syndrome (NMS).

Contraindications Cardiovascular Disease

and Why - The drug may cause hypotension, (including orthostatic hypotension), reflex tachycardia, increased pulse
rate, syncope, and dizziness, particularly during initiation of therapy or rapid escalation of dosage.

QT-prolonging Medications
- Potential risk for torsade de pointes and sudden death

Untreated decreased thyroid hormones

- May cause thyroid toxicity and elevates TSH levels causing further hypothyroidism

Breast cancer
- Long term use of antipsychotic drugs can cause increase of hyperprolactinemia via the dopamine D2
receptor which can cause breast tumors or further breast cancer

13
Nursing 1. Monitor for therapeutic effectiveness. - Because of the long half-life, therapeutic effects are slow to
Responsibilities and develop in early therapy or when an established dosing regimen is changed. The "Therapeutic
Rationale window" effect (the point at which increased dose or concentration actually decreases therapeutic
response) may occur after a long period of high doses. Close observation is imperative when doses are
changed.

2. Monitor for neuroleptic malignant syndrome (NMS). - Symptoms of NMS can appear suddenly
after initiation of therapy or after months or years of taking neuroleptic (antipsychotic) medication.
Immediately discontinue the drug if NMS is suspected.

3. Observe patients closely for rapid mood shift to depression when haloperidol is used to control
mania or cyclic disorders. - Depression may represent a drug adverse effect or reversion from a
manic state.

4. Instruct patient to avoid overexposure to sun or sunlamp and use sunscreen. - The drug can cause
a photosensitivity reaction.

14