Psychiatric Nursing Bullets

by: Michael Kenneth A. Desierto

A. Psychiatric Drugs
1. Psychiatric drugs (Psychotropic agents) are given after meals.
2. Psychotropic agents must be tapered (gradually stopped) to discontinue.
3. Benzodiazepines (antianxiety drugs) ends with -pam or –am.
-addicting, causes habituation (habit-forming).
4. Non-benzodiazepines are not habit-forming or addicting.
5. Most common anxiolytics are diazepam (Valium) & lorazepam (Ativan).
6. Drug of Choice(DOC) for status epilepticus: Diazepam (Valium); 2nd DOC: Barbiturates (-ital)
7. Diazepam is commonly prescribed and can cause SEDATION therefore SAFETY is the priority.
8. DOC for alcohol withdrawal: 1st: Chlordiazepoxide (Librium); 2nd: Chlorazepate (Tranxene);3rd: Valium
9. DOC for Generalized Anxiety Disorder: Buspirone (Buspar) non-benzodiazepine
10. DOC for OCD: SSRI: Fluvoxamine (Luvox); TCA: Clomipramine (Anafranil)
11. Antidote for Anxiolytic Overdose (OD): flumazenil (Romazicon)
Flumazenil, a specific benzodiazepine antagonist, is useful in reversing the sedation and
respiratory depression that often occur when benzodiazepines are administered to patients
undergoing anesthesia or when patients have taken an intentional benzodiazepine overdose.

12. Haloperidol (Haldol) is the most potent typical neuroleptic (antipsychotic), Chlorpromazine (Thorazine) is the oldest.
Haloperidol, a first-generation typical antipsychotic, is commonly used
worldwide to block dopamine D2 receptors (The function of each dopamine receptor
D2: locomotion, attention, sleep, memory, learning). in the brain and exert its
antipsychotic action. The medication is used to manage the positive
symptoms of schizophrenia, including hallucinations and
delusions.Chlorpromazine was the first antipsychotic and was followed by a large number of
other antipsychotics, many with diverse chemical structures.

13. Antipsychotics generally ends with –zine or –xene.

Haldol (haloperidol) and Thorazine (chlorpromazine) are the best known
typical antipsychotics. They continue to be useful in the treatment of severe
psychosis and behavioral problems when newer medications are ineffective.
14. Conventional or Typical neuroleptics (e.g. Haldol and Thorazine) can treat positive sx and cause more EPS.
All antipsychotics can cause EPS, but typical or first-generation antipsychotics like Thorazine
(chlorpromazine) and Haldol (haloperidol) carry the greatest risk.
Haldol (haloperidol) and Thorazine (chlorpromazine) are the best known typical antipsychotics.
They continue to be useful in the treatment of severe psychosis and behavioral problems when
newer medications are ineffective.
15. Atypical neuroleptics (Clozapine [Clozaril]) can treat both positive & negative sx but are primarily used because of lesser
EPS risk. Atypical antipsychotic drugs (APDs) have been hypothesized to show reduced
extrapyramidal side effects (EPS) due to their rapid dissociation from the dopamine
D2 receptor. Do not drive, operate machines, swimming, climbing, or do anything else that
could be dangerous until you know how this medicine affects you. This medicine can cause
changes in your heart rhythm, such as a condition called QT prolongation. It may cause
fainting or serious side effects in some patients.
16. Clozapine (Clozaril) can cause Agranulocytosis (low WBC) characterized by sore throat & fever. Client is required to
have CBC every 7 days or every week.
An uncommon but serious side effect of clozapine is severe neutropenia, defined as an absolute neutrophil
count (ANC) less than 500/μL. Agranulocytosis is usually a sudden drop of ANC to zero, is thought to be
autoimmune, is not permanent, is not related to dose, and is a medical emergency. When starting
clozapine, ANC is measured every week for 6 months, then every other week for 6 months, then monthly,
if all ANC results are adequate.

17. Common SE: PHOTOSENSITIVITY. Apply Sunblock & wear protective clothing when outdoors.
clozapine has been described to cause a photosensitivity. Since photosensitivity
often involves a mix of exposure to sunlight and prescription medication,
photosensitivity treatment requires blocking UV radiation via sunscreen
 lotion, staying out of the sun when UV rays are most intense, and wearing
hats and long-sleeved clothing
18. Benztropine (Cogentin) & Diphenhydramine (Benadryl) are drugs usually given to decrease EPS.
19. DOC for Dystonia: Diphenhydramine (Benadryl)
20. Beta-blocker used to treat Akathisia “Ants in the Pants”: Propranolol (Inderal)
21. NMS is an adverse reaction to neuroleptics. DOC: dantrolene (Dantrium); 2nd: bromocriptine (Parlodel)
22. Tardive Dyskinesia is the only EPS that is irreversible.
23. Anti-EPS drugs are also Anticholinergics (DRY effects) except for amantadine (Symmetrel)dopaminergic.
24. TCA antidepressants are the most effective antidepressants but are 2nd line drugs because of its many cardiovascular
SE’s. Remember, TCA’s end with –il.
25. SSRI’s are most recommended because it’s safe to use and with lesser cardiovascular SE’s.
26. MAOI’s (Parnate, Nardil, Marplan) should not be given along with Tyramine-rich foods e.g. Avocado, Alcohol, Banana,
Beans (FAVA), Cheese (except for cream and cottage), Caviar, Chianti, Soy Sauce, Salami
27. MAOI + Tyramine = Hypertensive Crisis; DOC: PHENTOLAMINE (REGITINE); 2nd: Nitroprusside (Nipride)
28. SSRI’s contains “x” or “z” in its brand name.
29. Watch out for suicide 2 weeks after the antidepressant therapy or if the patient feels better.
30. DOC for Mania: LITHIUM CARBONATE (Eskalith, Lithotabs, Lithobid, Lithonate);Li citrate (Cibalith)
31. 2-3 gms of salt and 3 L of fluids per day is recommended for clients under Lithium therapy.
32. Vomiting and persistent Diarrhea are early signs of Lithium Toxicity. Therapeutic range: 0.5-1.5 mEq/L
33. Acetazolamide (Diamox) and Mannitol (Osmitrol) are antidotes for Lithium toxicity.
34. Cognex and Aricept are drugs used to treat dementia.
35. Methylphenidate (DOC: Ritalin, Concerta), pemoline (Cylert), amphetamine (Adderall), dextroamphetamine
(Dexedrine)  stimulant drugs for ADHD. SE: AGI (Anorexia, Growth suppression, Insomnia)

B. Personality and it’s Components

1. a. ID – “Pleasure Principle” b. EGO – “Reality Principle” c. SUPEREGO – “Moral Principle”
2. a. Conscious – “Here & Now” b. Preconscious – “Watchman of the Mind” c. Unconscious – “Storehouse of Memories”
3. Weak Ego = ANXIETY

C. Treatment Modalities
1. Psychotherapy = Therapy of Choice (TOC) for PD’s
2. Crisis Intervention: GOAL: Return the client in the pre-crisis state.
3. CRISIS: when conventional coping skills failed to relieve the anxiety. Self-limiting: 4-6 weeks
4. Systemic Desensitization: gradual exposure to feared object/event. TOC for: PHOBIA & PTSD/ASD
5. Milieu therapy or Therapeutic Environment: Priority: Client’s safety
6. Play therapy is best for less than 5 years old; Psychodrama is best for adults.

D. Anxiety & Anxiety Disorders

1. Anxiety: “Fear of the Unknown”, “Mother of all Mental Disorders”
2. LOW GABA is the primary neurotransmitter that causes Anxiety.
3. Neurosis: appears normal and is found amongst normal people. Psychosis: is characterized by delusions and
hallucinations and are therefore institutionalized.
4. Mild Anxiety: “Motivating Force” and is desirable. Perceptual field is broad and organized.
5. Moderate Anxiety: Perceptual field is either NARROWED or SELECTIVE INATTENTION. Learning is possible.
6. Severe Anxiety: Perceptual field is greatly decreased. Learning does not take place. Best time to give PRN
anxiolytics.
7. Panic Anxiety: Perceptual field is disrupted/distorted reality. “FIGHT OR FLIGHT RESPONSE”
8. NEVER LEAVE the client alone, STAY with the client, SAFETY is the Priority.
9. PHOBIA: irrational fear. Accdg. to the National Epidemiology Center of the DOH, Specific Phobia is the leading Mental
Disorder in the Philippines accounting to about 15% out of 35% of Mental Disorders in the country.
10. Defense Mechanism (DM) in Phobia: DISPLACEMENT
11. OCD: Obsession –intrusive thoughts; Compulsion – rituals. Strong Superego, History of strict Toilet Training.
12. DM in OCD: UNDOING
13. Flashback is a characteristic of clients with PTSD/ASD.
14. Generalized Anxiety D/O (GAD): Diagnostic Criteria: Must persist for at least 6 months.
15. DM in Somatoform D/O: CONVERSION
16. Hypochondriasis: characterized by a belief that one has a serious disease. “Doctor Shoppers”
17. DM in Dissociative D/O: DISSOCIATION –splitting of the awareness.
18. Dissociative Identity Disorder (DID) aka Multiple Personality D/O. History of abuse during childhood.

E. Schizophrenia
1. Eugene Bleuler coined the word Schizophrenia (SPLIT MIND).
2. Nsg. Dx: “Altered thought process.” – PRIORITY nsg dx
3. Delusion – false, fixed belief. Nsg dx is the same with schizophrenia.
4. Hallucination – false sensory perception w/o a stimulus. Most common: Command Auditory
5. Illusion -false sensory perception w/ a stimulus.
6. Causal Neurotransmitter: Increased DOPAMINE
7. Negative Sx usually start with the letter “A”: Apathy, Avolition, Blunt/Flat Affect, Alogia, Anhedonia
8. Positive Sx: Hallucinations, Delusions, Associative Looseness (Loose associations)
9. DM in Disorganized/Hebephrenic schiz: REGRESSION
10. DM in Paranoid schiz: PROJECTION. NOTE: Nutrition: SEALED FOODS or CLIENT PREPARES OWN FOOD.
11. DM in Catatonic schiz: REPRESSION “Mother of all Defense Mechanism”
12. Schizophreniform: S/Sx of schizophrenia for more than 1 month but less than 6 months.
F. Mood Disorders
1. Depression is common in the ELDERLY r/t an experience of actual/possible LOSS. “ANGER turned INWARDS.”
2. Diagnostic Criteria: ANHEDONIA –lack of pleasure from formerly enjoyed activities.
3. Causal Neurotransmitter: LOW SEROTONIN, LOW NOREPINEPHRINE
4. “ALL DEPRESSED ARE POTENTIALLY SUICIDAL!”
5. Risk of suicide is highest 2 weeks after antidepressant therapy or if the client is feeling better.
6. Priority Nsg Dx: “High risk for Self-directed Violence.”
7. ECT is effective for the treatment of depression and works faster than antidepressants.
8. Atropine is given before ECT to reduce secretions and the risk of aspiration.
9. Succinylcholine (Anectine) a muscle relaxant used before ECT to prevent injuring the client during Sz activity.
10. Valium or a Barbiturate (-ital drugs e.g. Brevital) for sedation.
11. AFTER ECT, REMAIN WITH CLIENT UNTIL HE’S ALERT. Then, reorient to person, time, place.
12. Mania: high levels of NOREPINEPHRINE and SEROTONIN
13. Finger foods high in calorie, CHON, and electrolytes are best for manic clients. (e.g. peanut butter sandwich)
14. Avoid NSAIDs if the client is on Li therapy.

G. Personality Disorders
1. Cluster A: Paranoid PD, Schizoid, Schizotypal
2. PARANOID – suspicious, main issue is DISTRUST. SCHIZOID – aloof, distant, introvert, loner. SCHIZOTYPAL – weird,
odd, eccentric
3. Cluster B: BORDERLINE PD – unstable, suicidal; HISTRIONIC – dramatic, erratic; ANTISOCIAL –rule breaker, truancy
(lakwatsa), petty crimes; NARCISSISTIc – strong sense of importance, grandiose sense of importance
4. Cluster C: AVOIDANT –fears rejection and criticism; DEPENDENt – needs someone to make decisions for him; OCPD –
preoccupied with detail, standards, rules, perfectionists; PASSIVE-AGGRESSIVE PD – uses Reaction formation (plastic,
hypocrites), express anger thru procrastination, inefficiency
5. TOC: PSYCHOTHERAPY

H. Eating Disorders
1. Refusal to eat is the major problem in anorexia nervosa.
2. Weight loss of >15% from Ideal Body Weight (IBW) is a characteristic of Anorexia Nervosa. Weight is <85% of IBW.
3. Body Mass Index = Weight (kg)
Height (m2)
4. Amenorrhea and Lanugo are symptoms of Anorexia nervosa. Anorexics are also PERFECTIONISTS.
5. Binge-Purge Cycle is the main problem in Bulimia nervosa.
6. Dangerous Complication: HYPOKALEMIA r/t to vomiting or purging behaviors.
7. Bulimia is characterized by a near normal weight, binge-purge cycle,& dental/enamel erosion due to vomiting.
8. Priority Nsg. Dx: “Altered Nutrition: less than body requirements.”
9. STAY with the client during meals.
10. Weight gain indicates effective nursing intervention.

I. Pervasive Developmental Disorders

1. Safety and Nutrition (finger foods) should be prioritized for ADHD.
2. Impulsiveness, Hyperactivity, and Inattention are hallmark signs of ADHD.
3. Ritalin and Dexedrine are drugs commonly administered for ADHD.
4. Onset of ADHD is before the age of 7 years.
5. Autism: self-preoccupation, child has his own world.
6. Provide helmet for autistic children, head-banging is common.
7. Autism is common in boys and is diagnosed between 2 – 3 years of age.
8. Mental retardation is an IQ of <70.
9. MILD mental retardation: IQ of 50 – 70; IMBECILE
10. MODERATE mental retardation: 35 – 49 IQ; MORON
11. SEVERE mental retardation: 20 – 34 IQ; IDIOT
12. PROFOUND mental retardation: IQ of <20

J. Elderly Psych Problems

1. Parkinson’s disease results from decreased dopamine and increased level of acetylcholine due to degeneration of
the substantia nigra.
2. Tremors (pill rolling and resting), Rigidity (cog wheel), & Shuffling gait are common symptoms of Parkinson’s.
3. L-dopa is the DOC for Parkinson’s disease.
4. Alzheimer’s disease is due to decreased acetylcholine (Ach) and Cognex or Aricept is usually administered to
improve memory.
5. Altered thought process is the priority nursing diagnosis for AD.
6. Confabulation (filling in of gaps with made up stories) is commonly seen in AD, the most common type of dementia.

K. Substance abuse and Dependence

1. Alcohol is a CNS depressant and the most widely abused drug in ALL CATEGORIES.
2. Marijuana is the most widely used ILLICIT drug.
3. Wernicke’s-Korsakoff’s Syndrome are neurologic complications of alcoholism resulting from Vit. B1 (thiamine)
deficiency. Treatment: 100 mg Thiamine IM
4. Disulfiram (Antabuse) is used for alcoholism, Aversion Therapy. Client must be alcohol free 12 H before the
therapy is started.
5. Narcotic or pioid overdose cause pupil constriction (unique characteristic of opioids).
6. Yawning indicates brain hypoxia and is common in heroin withdrawal. Flu-like symptoms is also a withdrawal symptom of
heroin.
7. Perforated nasal septum is a physical complication of cocaine, a stimulant.
8. Hallucination, Pica, Blood-shot eyes are common manifestations of a person using marijuana.
9. Treatment of Narcotic Overdose (OD): Naloxone (Narcan), Naltrexone (ReVia)
10. Drug for Narcotic Withdrawal and Detoxification: Methadone
11. Ecstasy is also known as Methylene DioxyMethAmphetamine (MDMA).
12. Cocaine, a stimulant, is also called CRACK or COKE.
13. Cocaine is the second widely used illicit drug after marijuana.
14. Amphetamine is called “shabu” in the Philippines. It is a stimulant and may be taken orally, by injection, snorting, or
smoking.

MKD