Psychotropic Drugs

Antianxiety Drugs (aka Minor Tranquilizers or Anxiolytics)

1. Antihistamines
 Diphenhydramine - Benadryl (Also Antiparkinson Agent. Also part of a “Cocktail” 10mg Haldol,
25-50mg Benadryl, 4mg Ativan. Also used for itching.)
2. Benzodiazepines- depression, anxiety, vomiting, and others if quick withdrawal. Monitor these folks
carefully. Let physician decide and do not take alcohol, pain pills. Aggravate depression.
 Alprazolam – Xanax (very addictive/sedative. Long half life)
 Chlordiazepoxide – Librium (also used for alcohol withdrawal)
 Clonaxepam – Klonopin (Also a mood stabilizer/anticonvulsants)
 Diazepam – Valium (long half- life 72hrs/highly addictive. Check frequently if SA w/ it)
 Hydroxyzine – Atarax (also used for itching)
Vistaril (pre-op sedation 50mg, anti-emetic) 25mg used for anxiety
 Lorazepam – Ativan (short half-life 4hrs/sedative. Not many ppl allergic to it, drug of choice
for pregnant. Part of a “Dr. Pepper” 10mg Haldol, 2mg Cogentin, 4mg Ativan. Also part of a “Cocktail”
10mg Haldol, 25-50mg Benadryl, 4mg Ativan)
3. Azaspirodecanediones
 Buspirone – BuSpar
(Not addicting like benzodiazepines. Not sedating, have to be on every single day to maintain blood
levels. Be on 10-14 days before it kicks in. So maybe start with Ativan, and then back off as BuSpar
kicks in. NEVER used as a PRN due to delayed therapeutic onset.

Uses: Anxiety disorders (GAD), PTSD, anxiety symptoms, acute alcohol withdrawal, skeletal muscle spasms,
convulsive disorders, status epilepticus, and preoperative sedation.
 The benzodiazepines are the most commonly used group.
 They are CNS depressants and have a potential for physical and psychological dependence .Especially if for
two weeks, we need to be asking what other coping skills.
 They should not be discontinued abruptly following long-term use because they can produce life-threatening
withdrawal syndrome.
 The most common side effects are drowsiness, confusion, and lethargy.

Contraindications/Precautions: Contraindicated in individuals with known hypersensitivity to any of the drugs within
the classification.
 They should not be taken in combination with other CNS depressants and are contraindicated in pregnancy (Can
cause congenital malformations during 1st trimester) and lactation, glaucoma, shock, and coma.
 Caution should be taken in administering these drugs to elderly or debilitated clients and clients with hepatic or
renal dysfunction.
 Caution is also required with individuals who have a history of drug abuse or addiction
 Caution for those who are depressed or suicidal. In depressed clients, CNS depressants (antianxiety meds) can
exacerbate symptoms and make them more depressed.
 Grapefruit ↑ effects

Interactions: Increased effects of antianxiety agents can occur when taken concomitantly with alcohol, barbiturates,
narcotics, antipsychotics, antidepressants, antihistamines. Increased effects can also occur with herbal depressants (e.g.
kava; valerian). Decreased effects can occur with cigarette smoking and caffeine consumption.

Side Effects/Nursing Implications:

1. Drowsiness, confusion, lethargy (most common side effects) *Instruct the client not to drive or operate dangerous
machinery while taking the medication.
2. Tolerance; physical and psychological dependence (does not apply to Buspirone) *Instruct the client on long-term
therapy not to quit taking the drug abruptly. Abrupt withdrawal can be life threatening. Symptoms include depression,
insomnia, increased anxiety, abdominal and muscle cramps, tremors, vomiting, sweating, convulsions, and delirium.
3. Ability to potentiate the effects of other CNS depressants *Instruct the client not to drink alcohol or take other
medications that depress the CNS while taking this medication.
4. Possibility of aggravating symptoms in depressed persons. *Assess the client’s mood daily. *Take necessary
precautions for potential suicide.
5. Orthostatic Hypotension. *Monitor lying and standing blood pressure and pulse at every nursing shift. *Instruct the
client to rise slowly from a lying or sitting position.
6. Paradoxical excitement (client develops symptoms opposite of the medication’s desired effect). *Withhold drug and
notify physician.
7. Dry mouth. *Have the client take frequent sips of water, suck on ice chips or hard candy, or chew sugarless gum.
8. Nausea and vomiting. *Have the client take the drug with food or milk.
9. Blood dyscrasias. *Symptoms of sore throat, fever, malaise, easy bruising, or unusual bleeding should be reported to
the physician immediately.
10. Delayed onset (buspirone only). *Ensure that the client understands there is a lag time of 10 to 2 weeks between
onset of therapy with buspirone and subsiding of anxiety symptoms. Client should continue to take the medication
during this time.
11. Paradoxial excitement. Symptom opposite of the desired effect, withhold the drug and notify the provider

NOTE: Buspirone is not recommended for PRN administration because of this delayed therapeutic onset. There is no
evidence that buspirone creates tolerance or physical dependence as do the CNS depressant anxiolytics.

Client/Family Education: The client should:

1. Not drive or operate dangerous machinery. Drowsiness and dizziness can occur.
2. Not stop taking the drug abruptly, as this can produce serious withdrawal symptoms, such as depression,
insomnia, anxiety, abdominal and muscle cramps, tremors, vomiting, sweating, convulsions, delirium.
3. (With buspirone only): Be aware of lag time between start of therapy and subsiding of symptoms. Relief is
usually evident within 10 to 14 days. The client must take the medication regularly, as ordered, so that it has
sufficient time to take effect.
4. Not consume other CNS depressants (including alcohol).
5. Not take nonprescription medication without approval from the physician.
6. Rise slowly form sitting or lying position to prevent sudden drop in blood pressure. Warn orthostatic hypotension.
7. Immediately report symptoms of sore throat, fever, malaise, easy bruising, unusual bleeding, or motor restlessness
to physician.
8. Be aware of possible side effects. The client should refer to written materials furnished by healthcare providers
regarding the correct method of self-administration.
9. Carry a card or piece of paper at all times stating the names of medications being taken.
10. Be aware of risks taking this drug during pregnancy. (Congenital malformations have been associated with use
during the first trimester). The client should notify the MD of the desirability to discontinue the drug if pregnancy is
suspected or planned. (Exceptions: Although risk is less with clonazepam, it cannot be ruled out. With buspirone,
safety has been established only in animal studies. Use smallest dose in 2nd and third trimesters for all PSYCH
drugs.

Paradoxical effect- kid running around hyper, Grandma will not sit still. DO NOT GIVE THEM ANY MORE MEDS.
Dry mouth common- oral hygiene, ice chips, sugarless gum.
Blood dyscrasia- sore throat, fever, malaise. Unusual bruising and in various shades of bruising. RED FLAG.
Antidepressant Drugs
Tricyclics (TCA’s) - CONTRAINDICATED IN CLIENTS WITH AN MI OR GLAUCOMA- 1st generation of
antidepressants.
 Amtriptyline - Elavil (very low doses for sleep 25-50 mg, med doses pain, high doses 300mg)
 Clomipramine - Anafranil (works w/ double diagnosis clients & OCD clients) drug of choice for OCD
 Desipramine - Norpramin
 Doxepin - Sinequan
 Imipramine - Tofranil (children who have urine problems-bedwetting urinary retention side effect.)
 Nortriptyline - Aventyl, Pamelor
SSRI (Selective serotonin reuptake inhibitors)
 Citalopram - Celexa
 Escitalopram - Lexapro (Used for PTSD)
 Fluoxetine - Prozac (Side effect Headache/ Only antidepressant approved for children)
Sarafem
 Fluvoxamine - Luvox
 Paroxetine - Paxil
 Sertraline - Zoloft

MAOI (Hypertensive crisis with Tyramine)- Monoamine oxidase inhibitors. Rarely used. Last drugs to try for
depression. Takes one to two months to see maximum effect! Then if not work use ECT!
 Isocarboxazid - Marplan
 Phenelzine - Nardil (takes 1-2mos to see effects)
 Tranylcypromine - Parnate

(OTHERS) New category.

 Bupropion - Wellbutrin (depression ↓seizure threshold)
Zyban (Also a Nicotine replacement to help quit smoking)
 Venlafaxine Effexor
 Maprotiline Ludiomil
 Mirtazapine Remeron
 Trazadone Desyrel (Priapism-prolonged erection)
 Duloxetine Cymbalta
 Desvenlafaxine Pristiq

Order: 1st: Others/SSRI (If Other is used first, go to #2, if SSRI is used first, skip to #3)
2nd: SSRI
3rd: Tricyclics
4th: MAOI
5th: ECT

Uses: Antidepressant medications are used in the treatment of dysthymic disorder(=mild chronic); major depression w/
melancholia (like eeyore) or psychotic symptoms; depression associated w/ organic disease; alcoholism; schizophrenia,
or mental retardation; depressive phase of bipolar disorder; and depression accompanied by anxiety. These drugs
elevate mood and alleviate other symptoms associated with moderate-to-severe depression. Selected agents are also
used to treat anxiety disorders, bulimia nervosa, and premenstrual dysphoric disorder. Antidepressant meds take up to 4
weeks to produce the desired effect.

Contraindications/Precautions: Antidepressant drugs are contraindicated in individuals with hypersensitivity.

 · Others and Tricyclics are contraindicated in the acute recovery phase following myocardial infarction- can
result in an arrhythmia and in individual’s glaucoma.
· Caution should be used in administering these drugs to elderly or debilitated clients and those with hepatic,
renal- excreted through kidneys, or cardiac insufficiency. (The dosage usually must be decreased.)
· Caution is also required with psychotic clients, with clients who have enlarged prostate, and with individuals
who have a history of seizures (may decrease seizure threshold). Because of urinary retention.
· TEST- Note: HIGEST SUICIDE POTENTIAL- As these drugs take effect, and mood begins to lift, the
individual may have increased energy with which to implement a suicide plan. Suicide potential often increases
as level of depression decreases. The nurse should be particularly alert to sudden lifts in mood.
Side Effects/Nursing Implications:
1. May occur with all antidepressants:
· Dry mouth: *Offer the client sugarless candy, ice chips, frequent sips of water. *Strict oral hygiene is very
important.
· Sedation:
o *Request an order from the physician for the drug to be given at bedtime.
o *Request that the physician decrease the dosage or perhaps order a less sedating drug.
o *Instruct the client not to drive or use dangerous equipment while experiencing sedation.
o Sleeping- some need sleeping pill, but do not get it every night due to sedation.
· Nausea: Medication may be taken with food to minimize GI distress.
· Discontinuation syndrome: *All classes of antidepressants have varying potentials to cause discontinuation
syndromes. Abrupt withdrawal following long-term therapy may result in:
o Dizziness, lethargy, headache, and nausea.
o Hypomania, Hypersomnia, akathisia, cardiac arrhythmias, GI upset and panic attacks.
o All antidepressant meds should be tapered gradually to prevent withdrawal symptoms.
2. Most commonly occur with tricyclics (TCA’s)- covered alot!
· Blurred vision: *Offer reassurance that this symptom should subside after a few (2)weeks. *Instruct the client
not to drive until vision is clear. *Clear small items from routine pathway to prevent falls. Clear pathways in
house in commonly traveled areas.
· Constipation: *Oder foods high in fiber; increase fluid intake if not contraindicated; and encourage client to
increase physical exercise, if possible. HUGE problem here. Prunes- high fiber foods. Warmed prune juice.
More liquids also.
· Urinary retention: *Instruct the client to report hesitancy or inability to urinate. *Monitor intake and output.
*Try various methods to stimulate urinations, such as running water in the bathroom or pouring water over the
perineal area.
· Orthostatic hypotension: *Instruct the client to rise slowly from a lying or sitting position. *Monitor blood
pressure and pulse (lying and standing) frequently, and document and report significant changes. Do not spend a
lot of time in hot water, showers, tubs, or Jacuzzi’s.
· Reduction of seizure threshold: *Observe clients with history of seizures closely. *Institute seizure precautions
as specified in hospital procedure manual. *Bupropion (Wellbutrin) should be administered in doses of no more
than 150mg and should be given at least 4 hrs apart. Bupropion has been associated with a relatively high
incidence of seizure activity in anorexic and cachectic clients.
· Tachycardia; arrhythmias: *Carefully monitor blood pressure and pulse rate and rhythm, and report any
significant change to the physician.
· Photosensitivity: *Ensure that client’s Pt teaching- wears sun block lotion at least a 30 and preferably a 50,
protective clothing broad brimmed protect ears and nose. Hat, and sunglasses while outdoors. Long sleeve
cotton shirts.
· Weight gain: *Provide instructions for reduced-caloric diet. *Encourage increased level of activity- exercise, if
appropriate. 20, 40 lbs. or more.
3. Most commonly occur with SSRIs:
· Insomnia; agitation: *Monitor sleep patterns. Administer or instruct client to take dose early in the day.
*Instruct client to avoid caffeinated food and drinks. *Teach muscle relaxation techniques to use before
bedtime.
 · Headache: *Administer analgesics, as prescribed. *Request that the physician order another SSRI or another
class of antidepressants.
· Weight loss1/3 of folks (may occur early in therapy): *Ensure the client is provided with caloric intake
sufficient to maintain desired weight. *Caution should be taken in prescribing these drugs for anorectic clients.
*Weigh the client daily or every other day, at the same time, and on the same scale, if possible. *After
prolonged use, some clients may gain weight on SSRIs.
· Sexual dysfunction: *Men may report abnormal ejaculation or impotence, also not full erection.. *Women may
experience delay or loss of orgasm, not lubricated so painful. *If side effect becomes intolerable, a switch to
another antidepressant may be necessary.
· Serotonin syndrome- not excreted as rapidly as it needs to. (May occur when two drugs that potentiate
serotonergic neurotransmission are used concurrently). *Most frequent symptoms include changes in menstrual
status, restlessness, myoclonus (muscle spasms), hyperreflexia, tachycardia, labile blood pressure, diaphoresis,
shivering, and tremors, hyperthermia, HTN, ↑HR, flushing, ↑bowel sounds, diarrhea, mydriasis (prolonged
dilation of pupils) Cognitive s/s= agitation, drowsiness, coma anxiety, confusion, VH, delirium, Neuromuscular
s/s= akathesia (psychomotor restlessness). *Discontinue the offending agent immediately. *The physician will
prescribe the medications to block serotonin receptors, relive hyperthermia and muscle rigidity, and prevent
seizures. In severe cases, artificial ventilation may be required. The histamine-1 receptor antagonist
cyproheptadine is commonly used to treat the symptoms of serotonin syndrome. *The condition will usually
resolve on its own once the offending medication is not discontinued, the condition can progress to a more
serious state and become fatal.

4. Most commonly occur with MAOIs: (It takes 1-2 months for the MAOIs to kick in)
· Hypertensive crisis: *Hypertensive crisis occurs if the individual consumes foods containing tyramine while
receiving MAOI therapy. Tyramine free diet. 24H before first dose and must stay on diet. Two weeks after
MAOI must stay on diet.
o *Symptoms of hypertensive crisis include severe occipital headache, heart palpitations,
nausea/vomiting, muscle rigidity, fever; sweating, marked increase in blood pressure- can lead to stroke,
chest pain, and coma.
o *Treatment of hypertensive crisis:
o 1. discontinue drug immediately; monitor VS, Push fluids for 24 hrs
2. admin short acting antihypertensive meds, as ordered by physician; use external cooling measures to
control hyperpyrexia (↑ temp).
 · TEST: Application site reactions (with selegiline transdermal system (Emsam)) *The most common reactions
include rash, itching, erythema, redness, irritation, welling, or urticarial lesions. Most reactions resolve
spontaneously, requiring no treatment. However, if reaction becomes problematic, it should be reported to the
physician. Topical corticosteroids have been used in treatment
5. Miscellaneous side effects:
· Priapism (with Desyrel): *Priapism is a rate side effect, but it has occurred in some men taking trazodone. *If
the client complains of prolonged or inappropriate penile erection, withhold medication and notify the
physician immediately. *Priapism can become very problematic, requiring surgical intervention, and, if not
treated successfully, can result in impotence.
Drains the Vas Deferens with a long needle.
Tyramine Free Diet:
Clients must be on the tyramine free diet for 24 hours before beginning MAOI therapy. After MAOI use has been
discontinued clients must remain on the tyramine free diet for 2 weeks because the MAOIs have a long half-life.
High Tyramine Content (Avoid while on MAOI therapy):
· Aged cheeses (cheddar, Swiss, Camembert, blue cheese, Parmesan, provolone, Romano, brie)
· Raisins, fava beans, flat Italian beans, Chinese pea pods
· Red wines
· Smoked and processed meats (salami, bologna, pepperoni, summer sausage)
· Caviar, pickled herring, corned beef, chicken or beef liver
· Soy sauce, brewer’s yeast (in canned products), meat tenderizer (MSG)
· Gouda cheese, processed American cheese, mozzarella
· Yogurt, sour cream
· Avocados, bananas
· Beer, white wine, coffee, colas, tea, hot chocolate
· Meat extracts, such as bouillon, chocolate
· Pasteurized cheeses (cream cheese, cottage cheese, ricotta
· Figs
Distilled spirits (in moderation) Beef, chocolate, and others. All or none, teach people in moderation.
Aged or fermented foods- cheeses,
Can't have raisins but you can have grapes. No Fava Beans. Flat Italian Bean- Chinese Pea Pods, Red and White
Wines, no alcohol.
Smoked and processed meats. No beef jerky. No caviar, pickled herring. No corned beef and no beef or chicken
liver.
 Soy sauce, brewer's yeast no, can have tortillas. No MSG, meat tenderizer, yogurt, sour cream. No avocado,
bananas, no beer, coffee a big no-no. Only caffeine free soda. No tea. No hot chocolate or regular. No meet
extracts, boullion. No figs. No Sudafed!!
Drugs Restrictions:
Ingestion of the following substances, while on MAOI therapy, could result in a life-threatening hypertensive crisis. A
14 day interval is recommended between the use of these drugs and an MAOI.
· Other antidepressants (tricyclic, SSRIs, etc)
· St. Johns Wort
· Sympathomimetics (Epinephrine, Dopamine, Ephedrine, etc)
· Stimulants (amphetamines, cocaine, diet drugs)- ephedrine in diet drugs.
· Antihypertensives
· Meperidine and (possibly) other opioid narcotics (morphine, codeine), Vicodin, Oxycontin, Parkinson- drug.
· Antiparkinsonian agents (levodopa)

Smoking affects metabolism of drugs.

Client/Family Education
The client should:
· Continue to take the medication even though the symptoms have not subsided. The therapeutic effect may not
be seen for as long as 4 weeks. If after this length of time no improvement is noted, the physician may prescribe
a different medication.
· Use caution when driving or operating dangerous machinery. Drowsiness and dizziness can occur. If these side
effects become persistent or interfere with activities of daily living, the client should report them to the
physician. Dosage adjustment may be necessary.
· Not stop taking the drug abruptly. To do so might produce withdrawal symptoms, such as nausea, vertigo,
insomnia, headache, malaise, and nightmares.
· Use sun block lotion and wear protective clothing when spending time outdoors. The skin may be sensitive to
sunburn.
· Report occurrence of any of the following symptoms to the MD immediately: sore throat, fever, malaise,
yellowish skin, unusual bleeding, easy bruising, persistent nausea/vomiting, anorexia/weight loss, seizure
activity, stiff or sore neck, and chest pain.
· Raise slowly form a sitting or lying position to prevent a sudden drop in blood pressure.
· Take frequent sips of water, chew sugarless gum, or suck on hard candy if dry mouth is a problem. Good oral
care is very important.
· Not consume the following foods or meds while taking MAOIs: aged cheese, wine (especially Chianti), beer,
chocolate, colas, coffee, tea, sour cream, smoked and processed meats, beef or chicken liver, canned figs, soy
sauce, overripe and fermented foods, pickled herring, raisins, caviar, yogurt, yeast products, broad beans, cold
remedies, diet pills. To do so could cause a life-threatening hypertensive crisis.
· Avoid smoking while receiving tricyclic therapy: smoking increases the metabolism of tricyclics, requiring an
adjustment in dosage to achieve the therapeutic effect.
· Not drink alcohol with taking antidepressant therapy: These drugs potentiate the effects of each other.
· Not consume other meds (including over the counter): without the physician’s approval. Many meds contain
substances that in combination with antidepressant meds could precipitate a life-threatening HTN crisis.
· Notify physician immediately if inappropriate or prolonged penile erections occur while taking trazodone: if the
erection persists longer than 1 hour, seek ER treatment. This condition is rare, but has occurred in some men
who have taken trazodone. Impotence can result if measures not taken asap.
· Not “double up” on meds if a dose of bupropion (Wellbutrin) is missed: unless advised to do so by the
physician. Taking bupropion in divided doses will decrease the risk of seizure and other adverse effects.
· Follow the correct procedure for applying the selegiline transdermal patch: Apply to dry intact skin on upper
torso upper thigh or outer surface of upper arm. Apply approx same time each day to new spot on skin after
removing and discarding old patch. Wash hands thoroughly after applying the patch. Avoid exposing
application site to direct heat. If patch falls off. Apply new patch to a new site and resume previous schedule.
 · Be aware of possible risks of taking antidepressants during pregnancy. Safe use during pregnancy and lactation
has not been fully established. These drugs are believed to readily cross the placental barrier if so the fetus
could experience adverse effects of the drug. Contraindicated in first trimester of pregnancy but can be
cautiously used in second and third trimester.

Antiparkinsonian Agents
1. Anticholinergic
· Benztropine - Cogentin Part of a “Dr. Pepper” 10mg Haldol, 2mg Cogentin, 4mg Ativan
· Biperiden - Akineton
· Trihexphenidyl - Artane
2. Antihistamine
· Diphenhydramine - Benadryl (very few people have allergic reaction) (Also Antianxiety)

Uses: Used to counteract the extrapyramidal symptoms associated with antipsychotic medications. Antiparkinsonian
drugs work to restore the natural balance of acetylcholine and dopamine in the brain. The most common side effects of
these drugs are the anticholinergic effects. They may also cause sedation and orthostatic hypotension.

Miscellaneous:

Bromocriptine----------- Parlodel (management of Neuroleptic Malignant Syndrome)

Treatment of parkinsonism, amenorrhea, female infertility,
acromegaly

Dantrolene----------------Dantrium (management of Neuroleptic Malignant Syndrome)

Treatment of spasticity associated with spinal cord injury, stroke, cerebral
Palsy, & MS.

Cholinesterase Inhibitors (For Alzheimer’s Disease/Dementia)---not a cure only slows

down the rate of dementia/AD
· Donepezil -
· Memantine -
· Tacrine -
· Rivastigmine-
Aricept (mild/moderate dementia)
Namenda (moderate dementia)---antagonist
Cognex (mild dementia/moderate)
Exelon
Mood Stabilizing Agents
1. Antimanic- for bipolar disorder, only help 80%. Long term attacks kidneys. Diuretics can really mess them up.
Take in Li and K, too many diuretics, and K will be excreted out more than Na is taken in causing arrhythmia. Lithium-
the 1st drug of choice for bipolar-long term use.
· Lithium Carbonate: – (natural salt, different than regular salt)
Eskalith
Lithane
Lithobid
Lithonate
Lithotabs
Lithium Citrate- (liquid form not given IM or IV)
2. Anticonvulsants/Anti-epileptic- also mood stabilizers.
· Carbamazepine - Tegretol
· Clonazepam - Klonopin (also a Antianxiety/Benzo)
· Gabapentin - Neurontin (Blood dyscrasias/ neuropathy
· Lamotrigine – Lamictal (Lamictal rash on neck and trunk, skin can slough off! Check ALL
RASHES!!!)
· Topiramate – Topamax (decreases effectiveness of birth control pills. Also used to prevent
Alcohol and Cocaine relapse. Also used for headaches)
Valproic Acid Depakote- (blood dyscrasias) prolonged bleeding time w/ Coumadin- No blood
thinners.
Depakene
3. Antipsychotics:
· Olanzapine – Zyprexa- (Also an antipsychotic/other)
· Aripiprazole- Ability (Also an antipsychotic/other)
· Chlorpromazine- Thorazine- (Also an antipsychotic/Phenothiazine) (Also used for hiccups)
· Quetiapine- Seroquel (Also an antipsychotic/other
· Risperidone- Risperdal (Also an antipsychotic/other)
· Ziprasidone- Geodon (Also an antipsychotic/other)

Antimanic (Lithium Carbonate):

Uses: Prevention and treatment of manic episodes of bipolar disorder. Depressions & Rage disorders.
Contraindications/Precautions: Hypersensitivity with cardiac or renal disease, dehydration; sodium depletion; brain
damage; pregnancy and lactation. Caution with thyroid disorders, diabetes, urinary retention, history of seizures, and
with the elderly.
Nursing Implications:
Lithium Toxicity: The margin between the therapeutic and toxic levels of lithium carbonate is very narrow. The usual
ranges of therapeutic serum concentrations are:
· Acute mania: 1.0-1.5 mEq/L- once over
· Maintenance phase: 0.6-1.2mEq/L
Serum lithium levels should be monitored once or twice a week after initial treatment until dosage and serum levels are
stable, then monthly during maintenance therapy. Blood samples should be drawn 12 hours after the last dose.
Symptoms of lithium toxicity begin to appear at blood levels greater than 1.5mEq/L and are dosage determinate.
Symptoms include:
· At serum Li levels of 1.5 to 2.0 mEq/L: blurred vision, ataxia (unsteady), tinnitus- ringing in ears, persistent
nausea and vomiting, severe diarrhea - can lead to confusion, fine tremors. .
· At serum Li levels of 2.0 to 3.5 mEq/L: excessive output of dilute urine-is slightly yellow, increasing tremors,
muscular irritability, psychomotor retardation- slow walking, mental confusion, giddiness- silly. .
· At serum Li levels above 3.5 mEq/L: impaired consciousness, nystagmus (eyes move side to side), seizures- can
kill, coma, oliguria (scant urine)/anuria (no urine) lost kidney function. , arrhythmias- lead to, myocardial
infarction, and cardiovascular collapse causes death.
Lithium is similar in chemical structure to sodium, behaving in the body in much the same manner and competing at
various sites in the body with sodium. If sodium intake is reduced or the body is depleted of its normal sodium (due to
fever, diuresis, diaphoresis), lithium is reabsorbed by the kidneys, increasing the possibility of toxicity. Therefore the
client must consume a diet adequate in sodium as well as 2500 to 3000 mL of fluid per day.
Lithium Lab work: draw blood to assess the function of the kidneys/liver/UA/CBC etc. An EKG is performed to assess
the heart condition.

Nursing Intervention:
Regular serum level tests
Increase Na intake to prevent dehydration
Monitor thyroid function
Monitor kidney function for excretion of lithium
Lithium half-life is 24hrs.

Client/Family Education:
· Take the medication on a regular basis, even when feeling well. Discontinuation can result in return of
symptoms.
· avoid beverages with caffeine which promote urination
· Not drive or operate dangerous machinery until lithium levels are stabilized. Drowsiness and dizziness can
occur.
· Not skimp on dietary sodium intake. He or she should choose foods from the food pyramid and avoid “junk”
foods. The client should drink 6 to 8 large glasses of water (3000 mL per day) each day and avoid excessive use
of beverages containing caffeine (coffee, tea, colas) which promote urinary output.
· Be aware of appropriate diet should weight gain become a problem. Include adequate sodium and other
nutrients while decreasing number of calories.
· Be aware of risks of becoming pregnant while receiving lithium therapy.
· Dry Mouth-
· GI upset- tell pt to take one-half food, take medication and finish it. give food and milk
· Fine hand tremors- pt may only notice.
· Monitor hypotension and cardiac arrhythmia at least pulse rate and rhythm monitor at least once a shift,
· Polyuria and can also cause dehydration- test skin turgor.
· Toxic -side effects- Workups- blood work, causes WBC elevated, can cause thyroid dysfunction, urinalysis, and
renal function- can liver detox drug? Baseline BS- can cause drug induced diabetes. 2x a week blood draw in
hosp. once a month at home. Li toxic happens fast over a couple of days. May see SI attempts on Li.
· Depakote- prolonged bleeding time, Coumadin and other blood thinners contraindicated.

Anticonvulsants:-
Uses: Treatment of bipolar disorder and resistant schizophrenia.
Contraindications/Precautions: Hypersensitivity with MAOIs and lactation. Caution with elderly, liver/renal/cardiac
disease, and pregnancy.
Antipsychotic Drugs (Major Tranquilizers or Neuroleptics)
1. Phenothiazines
· Chlorpromazine - Thorazine (wonder drug, 1st psych drug 1950s)----Thorazine Shuffle (Also Mood
Stabalizer/Antipsychotic) (Also given for hiccups)
· Fluphenazine – Prolixin (Short acting-give IM, PO) (NMS is common side effect)
Prolixin Decanoate (long acting injection only IM-Z-track given q2wks can
cause contact dermatitis, use a large lumen because injection is sesame seed oil base, massage afterward.
Given for non-compliance)
· Prochlorperazine - Compazine (antiemetic quality prevent N/V)
· Thioridazine – Mellaril
· Trifluoperazine – Stelazine
2. Second Generation (OTHERS)
Haloperidol – Haldol (long acting- give as Z-track. Neuroleptic malignant
syndrome most common with Haldol and Prolixin. given for tourettes. Also part of a “cocktail” 10mg Haldol, 25-
50mg Benadryl, 4mg Ativan, Also part of a “Dr. Pepper” 10mg Haldol, 2mg Cogentin, 4mg Ativan)
Haldol Decanoate (long acting injection (1mo.) IM use a large lumen because
injection is sesame seed oil base, massage afterward. Given for non-compliance
· Thiothixene – Navane
· Risperidone – Risperdal (Also Mood Stabilizer/ Antipsychotic)
· Paliperidon- Invega
· Laurasidone HCL Latuda
· Loxapine Loxitane
· Clozapine – Clozaril (weekly CBC due to decrease in WBC, cause agranulocytosis-FDA
tracks this drug, pt must be compliant. Pharmacy will only give 7days at a time. Need lab results CBC can
cause autoimmune) Must be tried on 2-4 meds before trying Clozaril.
· Olanzapine – Zyprexa (Also Mood Stabilizer/ Antipsychotic) PO or IM)
· Quetiapine – Seroquel (Also Mood Stabilizer/ Antipsychotic)
· Ziprasidone – Geodon (Also Mood Stabilizer/ Antipsychotic)
· Aripirazole - Abilify (small antidepressant property-used to organize thinking/thought in
alignment) (Also Mood Stabilizer/ Antipsychotic)

Uses: Antipsychotics are used in the treatment of schizophrenia and other psychotic disorders, hallucinations,
delusions. Selected agents are used in the treatment of bipolar mania. Others are used as antiemetics; in the treatment of
intractable hiccoughs (Thorazine), and for the control of tics and vocal utterances in Tourette’s disorder (Haldol).
Contradictions/Precautions: They should not be used in comatose states or when CNS depression is evident; when
blood dyscrasias exist; in clients with Parkinson’s disease or glaucoma; those with liver, renal, or cardiac insufficiency;
or with poorly controlled seizure disorders.

Nursing Implications:
1. Anticholinergic effects:
· Dry Mouth: *Provide client with sugarless candy or gum, ice, frequent sips of water, strict oral hygiene.
· Blurred vision: *symptoms will most likely subside after a few weeks.
· Constipation: *Order foods high in fiber
· Urinary retention: *Instruct client to report any difficulty urinating; monitor intake/output.
2. Nausea; GI upset (may occur with all classifications): *Administer tablets/capsules with food. Concentrations
may be diluted and administered with fruit juice or other liquid; they should be mixed immediately before
administration.
3. Skin rash: *Avoid spilling any of the liquid concentrations on the skin; contact dermatitis can occur with some
medications.
4. Sedation: *Discuss with MD administering before bedtime.
5. Orthostatic hypotension
 6. Photosensitivity (may occur with all classifications): *ensure that the client wears sun block lotion, protective
clothing, and sunglasses while spending time outdoors.
7. Hormonal effects: 1) Men (decreased libido, retrograde ejaculation, gynecomastia (man boobs)) *Provide
explanation of the effects and reassurance of reversibility. If necessary discuss with MD about alternate
medication. 2) Women (Amenorrhea) *Offer reassurance of reversibility; instruct client to continue use of
contraception; because amenorrhea does not indicate cessation of ovulation. 3) Weight Gain *Weigh client
every other day; order calorie controlled diet; provide opportunity for physical exercise; provide diet and
exercise instruction.
8. ECG changes: prolonged QT interval. *Monitor VS Q shift and observe for dizziness, palpitations, syncope, or
weakness.
9. Reduction of seizure threshold: *Observe clients closely with history of seizures.
10. Agranulocytosis: These clients are very immunocompromised because a risk of decrease in WBC. Must wash
HANDS etc.
· Blood disorder where clients WBC count can drop to extreme low levels.
· Clozaril is bad with agranulocytosis so must try 2 other drugs first.
· Usually occurs within first 3 months of treatment.
· Observe for sore throat, fever, malaise.
11. Hypersalivation (most common with clozapine)
12. Extrapyramidal symptoms (EPS): *Administer antiparkinsonian drugs as ordered except for Tardive dyskinesia.
Tardive dyskinesia is not treatable.

• KNOW THESE 4 (EPS) SYMPTOMS:

1. Dystonia (involuntary muscular movements, spasms of face, arms, legs, and neck). Give IM for
dystonia
· Torticollis (twisted neck) in which the head is tipped to one side, and the chin is facing the
other side.
· Opisthotonus (arch in back): lying in bed with back extremely arched. Arched back. Give
Anticholinergic drugs.
· Oculogyric crisis (uncontrolled rolling back of the eyes): This may be mistaken for seizure
activity.
2. Akathisia (continuous motor restlessness and fidgeting-unable to sit still): Ants in the pants. Occurs
most frequently in women. Give Anticholinergics and Antihistamines by PO
3. Pseudoparkinsonism---drug induce Parkinsonism caused by Antipsychotic drugs (causes tremor,
shuffling, gait, drooling, and rigidity, pill rolling hands): IM/PO antiparkinson with antipsychotics.
4. Tardive dyskinesia (TD)---zero cure(bizarre facial and tongue thrusting/movements, stiff neck, and
difficulty swallowing, pelvic thrusting & shoulder shrugging).
· Bizarre tongue movements are usually the first sign.
· These are irreversible however you can go into periods of remission.
· Prompt action may prevent irreversibility,
13. Neuroleptic malignant syndrome (NMS): *Rare but Fatal- Likes to be on NCLEX!
· Symptoms include severe parkinsonian muscle rigidity
· Hyperpyrexia up to 107F
· Tachycardia, tachypnea, fluctuations in blood pressure, diaphoresis.
· The MD may order Parlodel or Dantrium to counteract the effects of neuroleptic malignant syndrome.
· Most common with Haldol and Prolixin but can happen with any of them.
· NMS is extremely rate with an onset of days to years. Can go into coma immediately.
14. Hyperglycemia and diabetes.
15. Increased risk of mortality in elderly patients with dementia-related psychosis.

Sedative-Hypnotics Agents
Barbiturates: also given for seizures and pre-op
  Amobarbital Amytal
 Pentobarbital Nembutal
 Phenobarbital Luminal
 Secobarbital Seconal
Benzodiazepines:
· Flurazepam - Dalmane
· Temazepam - Restoril
· Triazalom - Halcion

Others
 Chlorohydrate Noctec
· Zalepton - Sonata
· Zalpidem - Ambien (rapid onset 10min. Interferes with REM cycle. Can cause sleep activies)
Lunesta
Uses: Sedative-hypnotics are used in the short-term management of various anxiety states and to treat insomnia.
Selected agents are used as anticonvulsants (mephobarbital, pentobarbital, and phenobarbital) and preoperative
sedatives (pentobarbital, secobarbital) and to reduce anxiety associated with drug withdrawal.
Contraindications/Precautions: Sedative-hypnotics are contraindicated in individuals with hypersensitivity to the drug
or to any drug within the chemical class; in pregnancy (exceptions may be made in certain cases based on a benefit-to-
risk ratio); lactation; and in severe hepatic, cardiac, respiratory, or renal disease. Caution should be used in
administering these drugs to clients with cardiac, hepatic, renal, or respiratory insufficiency. They should be used with
caution in clients who may be suicidal or who may have been addicted to drugs previously. Hypnotic use should be
short term. Elderly clients may be more sensitive to CNS depressant effects, and dosage reduction may be required.

Agents for ADHD

Amphetamines: (CNS Stimulants-used in the treatment of narcolepsy & exogenous obesity)
Dexedrine
Dextrostat
Vyvanse
Adderall, Adderall XR
Cylert
OTHERS:
Ritalin, Ritalin SR, Ritalin LA
Concerta
Focalin
Nonstimulant:
· Strattera (Non addictive and non-stimulating so can take prior to eating breakfast)
Uses: The medications in this section are used for ADHD in children and adults (this drug suppress the appetite)
Nursing Implications:
· Monitor diet because reduces appetite and ADHD kids are skinny.
· Take meds in the morning after breakfast; if children take before breakfast it suppresses their appetite and
then they won’t eat breakfast.
· Monitor growth and development
· Monitor sleep pattern at night
· Avoid soda or anything with caffeine
· The medication is not habit forming for children.

Medications Used to Prevent Relapse

1. Opiates
 · Methadone*
· ReVia
· Campral
· Catapres
2. Alcohol
· Zofran
· Campral
· Topamax (Also a Mood stabilizer/Anticonvulsant. Also For headaches. Also for Cocaine w/d)
· Antabuse* (also for cocain w/d) *don’t allow anything with alcohol to even touch pt’s skin!
3. Cocaine
· Antabuse (Also for Alcohol w/d)
· Topamax (Also a Mood stabilizer/Anticonvulsant. Also For headaches. Also for Alcohol w/d)
· Provigil
· Inderal
· Neurontin
4. Nicotine
· Nicotine replacement
· Zyban (Also an antidepressant/other)

(* Must Know)

S/S of Alcohol Intox:

Slurred speech, N/V, incoordination, sedation, drowsiness, emotional instability

S/S of Amphetamine Intox:

Psychomotor activation, sweating, ↑BP, ↑HR, ↑RR, tremors, dilated pupils, insomnia, assaultive, grandiose, impaired
judgment and social and occupational functioning

S/S of Cannabis Intox:

Anxiety, suspiciousness, in high doses the sensation of slowed time, social withdrawal, impaired judgment, possible
hallucinations, ↑HF, conjunctival redness

S/S of Cocaine Intox:

Psychomotor activation, sweating, ↑BP, ↑HR, ↑RR, tremors, dilated pupils, insomnia, assaultive, grandiose, impaired
judgment and social and occupational functioning

S/S of Inhalants Intox:

Excitation, followed by drowsiness, staggering, lightheadedness, agitation, disinhibition

S/S of Opioid Intox:

Euphoria followed by dysphoria and impairment in attention, judgment, and memory, Pupils constrict, ↑RR, ↑BP,
slurred speech, psychomotor retardation

S/S of Hallucinogen Intox:

Fear of going crazy, marked anxiety/depression, depersonalization, grandiosity, hallucinations, synesthesia, ↑BP, ↑HR,
↑Temp

S/S of Sedatives/hypnotics/anxiolytics (benzo) Intox:

Slurred speech, N/V, incoordination, sedation, drowsiness, emotional instability

S/S of Club Drug Intox:

Tachycardia, HTN, arrhythmias, parkinsonism, Toxic and potentially fatal outcomes are extreme: hyperthermia, and
the associated “serotonin syndrome” which can result in acute renal and hepatic failure, adult respiratory distress and
end-organ damage. Hypersalivation, hypotonia, amnesia, ↑BP, mood swings, seizures, anterograde amnesia, lack of
muscle control, moss of consciousness

S/S of Alcohol w/d

N/V, Tachycardia, diaphoresis, anxiety or irritability, tremors in hands, fingers, eyelids, marked insomnia Grand mal
seizures, after 5-15 yrs of heavy use: delirium

S/S of Amphetamine w/d

Fatigue, Depression, Agitation, Apathy, Anxiety, Sleepiness, Disorientation, Lethargy, Craving

S/S of Cannabis w/d

None in book

S/S of Cocaine w/d

Fatigue, Depression, Agitation, Apathy, Anxiety, Sleepiness, Disorientation, Lethargy, Craving

S/S of Inhalants w/d

None in book

S/S of Opioid w/d

Yawning, insomnia, irritability, runny nose (rhinorrhea), panic, cramps, diaphoresis, N/V, muscle aches, chills, fever,
lacrimation (crying), diarrhea

S/S of Hallucinogen w/d

None in book

S/S of sedatives/hypnotics/anxiolytics (benzo) w/d

N/V, Tachycardia, diaphoresis, anxiety or irritability, tremors in hands, fingers, eyelids, marked insomnia Grand mal
seizures, after 5-15 yrs of heavy use: delirium

S/S of club drug w/d

Profound depression secondary to serotonin depletion, repeated use associated with cognitive impairment (Potentially
permanent memory loss) Anxiety, insomnia, tremors, ↑seizure potential, muscle pain, photosensitivity, headache.