NURSING CARE MANAGEMENT

OF PATIENTS WITH

Psychopharmacology
Somatic Therapies
The Brain

Nerve Cell
NEUROTRANSMITTERS
• Are chemical substances
manufactured in the neuron that aid
in the transmission of information
throughout the body
• Could either be : Excitatory or
Inhibitory
– Excitatory – excite or stimulate an
action in the cells
– Inhibitory – inhibit or stop an action.
Examples of Neurotransmitters:

• Dopamine……………… Excitatory
• Norepinephrine and
Epinephrine…………….. Excitatory
• Serotonin…………………Inhibitory
• Histamine ………………..Neuromodulator
• Acetylcholine ……………Both E/I
• Gamma aminobutyric acid………….
……………Inhibitory
Dopamine
• Located primarily in the brainstem
• Has been found to be involved in the
control of complex movements,
motivation, cognition, and regulation of
emotional responses.
• Antipsychotics work by blocking
dopamine receptors and reducing
dopamine activity.
• In pt. with schizophrenia,

• in Parkinson’s Dse
Norepinephrine
• Aka: Noradrenaline
• Most prevalent neurotransmitter
• Located primarily in the brainstem
• Plays a role in changes in attention,
learning and memory, sleep and
wakefulness, and mood regulation.
• Excess : Anxiety d/o
• Deficit: memory loss, social withdrawal,
and depression
Epinephrine
• aka. Adrenaline
• Limited distribution in the brain
• Controls the fight or flight response
in the PNS
• Some ANTIDEPRESSANTS block
the reuptake of norepinephrine,
while others inhibit MAO from
metabolizing it
 Serotonin (5-HT)
• Found only in the brain
• Derived from TRYPTOPHAN, a dietary amino
acid
• Involved in the control of food intake, sleep and
wakefulness, temperature regulation, pain
control, sexual behavior, and regulation of
emotions .
• Plays an important role in anxiety and mood d/o
and schizophrenia
• It has been found to contribute to the delusions,
hallucinations, and withdrawn behavior seen in
schizophrenia.
• Some ANTIDEPRESSANTS block serotonin
reuptake, thus leaving it available for longer in
the synapse, which results in improved mood.
Acetylcholine
• Found in the brain, SC, and peripheral
nervous system particularly at the NMJ
of skeletal muscles
• Both e/i
• Synthesized from dietary CHOLINE
found in red meat and vegetables
• Found to affect the sleep/wake cycle
and to signal muscles to become active.
 Gamma Aminobutyric Acid
(GABA)
• An amino acid
• MAJOR inhibitory neurotransmitter in
the brain.
• Modulate OTHER neurotransmitter
systems, rather than to provide a
direct stimulus
• Benzodiazepines = increase GABA
 treat anxiety and induce sleep
PSYCHOPHARMACOLOGY

1. Antipsychotics
2. Anxiolytics
3. Antidepressants
• TCA
• MAOI
• SSRI
4. Anti-Parkinson’s Drugs
5. Anti-manic / Mood stabilizer
ANTIPSYCHOTICS
ANTIPSYCHOTICS

Action:
Block the dopamine receptors in the
brain, thereby reducing psychotic symptoms
 ANTIPSYCHOTICS
• Aka: Neuroleptics
• Considered as Major Tranquilizers
• Classified either by chemical, class, potency, but more
importantly by typicality.
• The most common SE for all antipsychotics 
drowsiness
• Many of the antipsychotics block the CTZ and
vomiting center in the brain producing an
ANTIEMETIC effect.
ANTIPSYCHOTICS
• Categories:
–Typical antipsychotics
–Atypical antipsychotics
Typical antipsychotics
• Are the traditional drugs effective for (+)
POSITIVE SYMPTOMS but it results in
several SE.
• Examples:
– Delusion False belief
– Illusion Misperception of stimulus
– Hallucination false sensory perception
– Bizzare behavior
Combative behavior
Exhibitionism
Typical antipsychotics
• Examples:
– Chlorpromazine – Thorazine
– Haloperidol – Haldol
– Fluphenazine – Prolixin
 Atypical antipsychotics
• The newer generation medications
• Fewer EPS
• Effective for (-) NEGATIVE SYMPTOMS
– Inability to experience pleasure
Anhedonia
– Apathy Absence of feelings
– Affect (flat) Dullness of emotions
– Attention (poor)

• No endocrine SE
• Potent antagonist of 5HT
 Atypical antipsychotics
• Indicated for :
– Schizophrenia
– Acute mania
– Psychotic depression
– Drug-induced psychosis
• Examples
– Clozapine – Clozaril
– Risperidone – risperdal
– Olanzapine – Zyprexa
– Quetiapine – seroquel (also used for insomnia)
Side Effects of
Antipsychotics:
Note:
Frightening / Upsetting to clients
Primary reason why clients
discontinue or reduce the dosage of
their medications

REVOLVING – DOOR
SYNDROME
Side Effects of
Antipsychotics:
1. Anticholinergic Effects
– Dry mouth
– Constipation
– Urinary retention
– Blurred vision
– Orthostatic Hypotension
– photosensitivity
Side Effects of
Antipsychotics:

2. Sedative Effect
3. Endocrine changes
– Lactation in females
– Gynecomastia in males
Side Effects of
Antipsychotics:
4. EPS
(EXTRAPYRAMIDAL SYMPTOMS)
a. Acute Dystonia
b. Pseudoparkinsonism
c. Akathisia
d. Akinesia
Acute Dystonia
• Acute muscular rigidity and
cramping
• A stiff thick tongue with dysphagia
• Other s/sx:
– Opisthotonus – arched back
– Torticollis – cervical torsion
– Oculogyric crisis – rolling up of the
eye with fixed stare
Pseudoparkinsonism
• Mask-like facies
• Stiff posture
• Stooped
• Shuffling festinating gait
• Cogwheel rigidity
• Bradykinesia
• Pill-rolling tremors
Akathisia

• Feeling of internal restless and

inability to sit down
• Patiet’s feel having “ants in the
pants”
• Fidgeting, restless, and pacing
Akinesia

• Fatigability and weakness

MANAGEMENT FOR EPS
• Antimuscarinics / anticholinergics
Ex.
– Biperiden Hcl (Akineton)
– Benztropine mesylate (Cogentin)
– Trihexyphenidyl (Artane)
• Antihistamine
• Dopamine Agonist
– Amantadine (symmetrel)
– Ropinirole (roquip)
Adverse Effects of
Antipsychotics

1. Neuromalignant Syndrome
(NMS)
2. Tardive Dyskinesia
3. Decreased convulsion threshold
4. Blood dyscrasias
Neuromalignant Syndrome
(NMS)
• Potentially FATAL rxn to an
antipsychotic drug
• S/sx:
• Hyperthermia
• Rigidity
• Palpitations
• Diaphoresis
• Automatic instability and may be
confusion and muteness
• Stupor
• coma
Tardive Dyskinesia
• Syndrome of PERMANENT involuntary
movements of the tongue, face and
neck,muscles, upper and lower
extremities, even truncal musculature.
• S/sx:
– Tongue thrusting and protrusion
– Lip smacking
– Blinking
– Grimacing
– Vermicular motion of the tongue
3. Decreased convulsion threshold
4. Blood dyscrasias
– r/t the use of Clozaril
Nursing Care Management:
1. Check BP prior to administration
2. Check liver function test and CBC
3. Check warning signs of adverse effects
4. Check signs and symptoms of bleeding and infection
5. Assure patient that drowsiness is the common SE
6. Teach that urine may turn pink or reddish brown.
7. Advise that the medication may take 6 weeks or longer to
achieve a full therapeutic effect.
8. Avoid alcohol
9. Increase fiber in diet, increase OFI if not contraindicated.
ANXIOLYTICS
 ANXIOLYTICS

Action:
 Depression of the CNS, thereby increasing the
effects of the GABA which produces relaxation
ANXIOLYTICS

• Minor tranquilizer
• Types:
–Benzodiazepines
–Non-Benzodiazepines
ANXIOLYTICS
• Benzodiazepines
• Diazepam
• Lorazepam
• Alprazolam
• Triazolam
• Chlordiazepoxide – Librium
• Clonazepam – Klonopin
• Clorazepate – Tranxene
• Non-Benzodiazepines
• Buspirone (Buspar)
• Beta-blockers
• Barbiturates (Phenobarbital)
Nursing Management
1. Causes sedation
2. Avoid OH and other CNS depressants
3. Avoid abrupt withdrawal
4. Memory impairment R/t intake of Inderal
5. Decreases HR r/t intake of Valium
6. Do not take with antacid
7. Take a.c.
ANTIDEPRESSANTS
 ANTIDEPRESSANTS
Action :
May inhibit reuptake of norepinephrine and
serotonin in the CNS nerve terminals, thus causing
the concentration of neurotransmitter in the
synaptic cleft.

Classifications:
1. Tricyclic Antidepressants (TCA)
2. Monoamine oxidase Inhibitor (MAOI)
3. Selective Serotonin Reuptake Inhibitor
(SSRI)
1. Tricyclic antidepressants
(TCA)
• Action: blocks the reuptake of 5HT
and norepinephrine
• 2-4 wks to take effect
• Examples:
– Amitriptyline – elavil
– Doxepin – sinequan
– Imipramine – tofranil  has lethal risk
NCM :
1. Check for SE and AE like : tremors,
convulsion, and arrhythmia.
2. Check for anticholinergic effects
3. Administer hs
4. Check ECG
5. These drugs can mask suicidal
tendencies
2. Monoamine Oxidase
Inhibitor (MAOI)
• Action : prevents the breakdown of
dopamine, 5HT, and norepinephrine
by interfering the MONOAMINASE
OXIDASE in the synaptic space.
• Drugs: PaMaNa
• Parnate – Tranylcypromine
• Marplan – isocarboxacid
• Nardil – phenelzine
Adverse Effect:
1. Hypertension Crisis
• BP > 200/100 mmHg
• Happens if the client ingested food with
TYRAMINE

• AVOID:
– Aged cheese - Aged/fermented meats
– Chicken pate - Yeast
– Pickled/preserved food - Red wines
– Beer - Corned beef
– Salami - saussage
Side effects:
1. Insomnia  Adm drug not later
than 3PM
2. Wt. Gain
3. Sexual dysfunction
3. Selective Serotonin
Reuptake Inhibitor (SSRI)
• 4weeks – full effect
• Action: Blocks the reuptake of serotonin
at the specific serotonin receptor sites
• Indicated for depression, OCD, panic
d/o, and appetite d/o
• Examples:
– Paroxetine – Paxil
– Sertraline – Zoloft
– Fluoxetine – Prozac
– Trazodone – Desyrel  The ONLY
antidepressant that has
NO ANTICHOLINERGIC
effect
NCM
1. Adm. pc
2. Monitor for signs of SEROTONIN
SYNDROME (AEB: s/sx of
anticholinergic effects)
3. Monitor wt.loss
4. Monitor suicidal client especially
during improved mood and increased
energy levels.
LEVELS OF SUICIDAL
BEHAVIOR
• SUICIDAL IDEATION
– Includes a person’s thought regarding suicide.
• SUICIDAL GESTURES
– “Attention-getting acts of the client.
• SUICIDAL THREATS
– Verbal statements that may declare their intent to commit
suicide.
• SUICIDAL ATTEMPT
– The actual implementation of a self-injurious act with the
express purpose of ending the person’s life.
 SAD PERSON’S SCALE
• Sex
– More women attempt suicide; more men commit
suicide.
• Age
– Between 18 and 25 and above 40
• Depression
– Especially that which is lifting, keep suicidal
precautions when antidepressants are expected to
effect 2-3 weeks after intake.
 SAD PERSON’S SCALE
• Previous Attempt
• Those who attempted suicide are likely to repeat the attempt and succeed
this time.
• The FIRST TWO YEARS after an attempt represent the HIGHEST risk
period, especially the first 3 months.
• Ethanol Abuse
”
• The alcoholics are most vulnerable
R N
• Rational Thinking that is impaired
W A
•
•
Social Support that is impaired
Organized Plan TO
• No spouse, or worse, Nagging Spouse! TY
U
“D
• Sickness, specially chronic or terminal
ANTIPARKINSON’S
DRUGS
ANTIPARKINSON’S DRUGS

Note:
“A balance between Ach and dopamine is
required for normal body movement”.
ANTIPARKINSON’S DRUGS
BALANCE is accomplished in 3 WAYS:
1. To increase dopamine
(dopaminergic)
2. To decrease Acetylcholine
3. Combination of the 2
Dopaminergics:
• Carbidopa + levodopa – Sinemet 
AVOID VITAMIN B6
• Amantadine – symmetrel
• Bromocriptine – Parlodel
• Pergolide - permax
• Selegiline – Eldepryl
Anticholinergic

• Benadryl
• Akineton
• Cogentin
• Artane
ANTIMANIC / MOOD
STABILIZER
ANTIMANIC / MOOD
STABILIZER
• Action: Normalize the Ach
• Use: Manic state of (bipolar d/o)
• DOC: LITHIUM CARBONATE
(Eskalith, Quilonium)
• If (x) Lithium carbonate:
– Valproic acid (Depakote)
– Carbamazepine (Tegretol)
 THERAPEUTIC LEVEL:

0.6 – 1.2 mEq / L

• Action: Lithium modulates the
hyperactivity of neuron that
contributes to manic episodes by
REPLACING SODIUM IN
SUPPORT OF A SINGLE ACTION
POTENTIAL.
• 1-2 wks to several months to
stabilize mood
NCM:
1. Check CBC q month
2. Check for serum SODIUM
Hyponatremia may lead to toxicity
3. Thiazide and K-sparing diuretics
increase level of lithium by decreasing
its clearance
4. Osmotic diuretics decrease levels of
lithium by increasing clearance
5. Check I&O
6. Avoid caffeine, vigorous exercise,
7. Wait for 5-14 days for clinical effect.
Side Effects
1. Lithium levels < 1.5 mEq/L
– FINE hand tremors
– Mild thirst
– Muscle weakness
– Restlessness
– Mild nausea
– drowsiness
2. Lithium levels between 1.5 – 2.0 mEq/L
“TOXIC LEVEL”
– COARSE hand tremors
– Diarrhea
– Drowsiness
– Lack of coordination  early sign of toxicity
– Vomiting
Side Effects
3. Lithium levels between 2.0 -3.0 meq /L
– Blurred vision
– Vertigo
– Tinnitus
– Slurred speech
– Twitching
– Hyperreflexia
– Confusion
4. Lithium levels > 3mEq/L
– Seizure
– Arrhythmia
– Peripheral vascular collapse
– coma
 SOMATIC THERAPIES
1. Seclusion
Destructive or
Harmful
2. Restrainta.to SELF
b.to OTHERS

3. Electroconvulsive therapy
body
a. Seclusion
• Process of containing the client to
a single room where he/she is
alone but constantly and carefully
observed by members of the health
team.
High
•Check irregularly but frequently
•Accompanied by watcher 24 hours

Low
•Check regularly and frequently
b. Restraint
• Is the direct application of physical
force to a person to restrict his/her
freedom of movement.
a. Human restraint
b. Mechanical restraint
• Are devices, usually ankle and wrist
restraints, fastened to the bed frame to
curtail the client’s physical aggression,
such as hitting, kicking, and hair pulling.
b. Restraint
• Notes:
– Patient in seclusion and restraint must
be checked every 15 minutes and
bathed every 24 hours.
– The maximum length of time for this
restrictive mechanism is 8 hours under
the original order.
– In emergency situations a nurse can
approve a seclusion or restraint order
when no physician is available.
b. Restraint
• Notes:
– A physician must see the patient within
4 hours.
– As soon as possible, staff members
must inform the client of the
behavioral criteria that will be used
to determine whether to decrease or to
end the use of restraint or seclusion
b. Restraint
• Notes:
– If restraint has to be applied for more
than 1 – 2 hours:
• Fluids must be offered every hour
• Limbs exercised every 2 hours
– free one limb at a time for movement and
exercise.
• Toileting and meals are offered as
scheduled.
b. Restraint
• Notes:
Document the following:
Type of restraint
Reason for restraint
Length of time of restraint
Observations to maintain safety
C. ELECTROCONVULSIVE
THERAPY
• Involves the application of
electrodes to the head of the patient
to deliver an electrical impulse to the
brain, causing a seizure.
• Introduced by Ugo Cerletti and
Luciano Bini in 1938.
C. ELECTROCONVULSIVE
THERAPY
• Formerly known as Electroshock
therapy or Shock Therapy.
– The term “SHOCK” is misleading
because the essential part of the
treatment is the programmed seizure
(Swartz, 1993).
• A treatment of LAST RESORT
C. ELECTROCONVULSIVE
THERAPY
2 Types:
a. Modified ECT
– Pre-meds are given 30 minutes to 1 hour
before ECT
– Most common
– NPO 6 – 8 hours
b. Non-Modified ECT
– No drugs are given
– NPO 2 – 4 hours
 C. ELECTROCONVULSIVE
B THERAPY
NURSING CARE MANAGEMENT
E a. Assess for the Indications of ECT
F – DEPRESSIONS, that have not responded to
multiple and adequate trials of medication.

O
– Patients who require a rapid response
(suicidal or catatonic patient)
– Patient who cannot tolerate pharmacotherapy
R or cannot be exposed to pharmacotherapy.
(pregnant patients)

E
 C. ELECTROCONVULSIVE
B THERAPY
NURSING CARE MANAGEMENT
E b. Consent form must be signed.
F c. Secure completeness of Pre-
treatment evaluation
O – Physical Examination
– Laboratory work ups (CBC, Blood
R Chem, UA)
– Baseline memory abilities
E
 C. ELECTROCONVULSIVE
B THERAPY
NURSING CARE MANAGEMENT
E d. Evaluate with the Physician the
F contraindications for ECT:
– Relative Contraindications:

O
• Fever
• Cardiac arrhythmias
• TB with Hx of Hge

R • Recent Fracture
• Retinal detachment

E
• Pregnancy
– Absolute Contraindication:
• Increased Intracranial pressure.
 C. ELECTROCONVULSIVE
B THERAPY
NURSING CARE MANAGEMENT
E e. As per Doctor’s order, advise the patient
F and communicate with other members of
the health team:

O – D.C. drugs which may increase/raise seizure

threshold (anticonvulsant, benzodiazepines,
lidocaine.
R – Antipsychotics – usually continued because
they decrease the seizure threshold and have

E few complicating effects.

 C. ELECTROCONVULSIVE
B THERAPY
NURSING CARE MANAGEMENT
E f. Start an IV line for the administration
F of medication.

O
R
E
 C. ELECTROCONVULSIVE
B THERAPY
NURSING CARE MANAGEMENT
E g. Administer Pre-med as ordered:
F – Atropine Sulfate
• Anticholinergic agent

O • Inhibition of salivation and respiratory tract

secretions to minimize aspiration.
• To prevent bradycardia r/t ECT, muscle
R relaxant, and/or methohexital.
• Dosage: 0.4 – 0.6 mg
E • SE: anticholinergic SE’s
 C. ELECTROCONVULSIVE
B THERAPY
NURSING CARE MANAGEMENT
E g. The patient should be asked to
F urinate before the treatment to
prevent urinary incontinence.
O h. Remove metals
i. Check VS before and after the
R administration of premeds and

E before ECT, report accordingly

 C. ELECTROCONVULSIVE
D THERAPY
NURSING CARE MANAGEMENT
U • Position the client on his back

R • Electrode placement
A. Bilateral

I
• 1 – 1.5 inches above midpoint between lateral
canthus of the eye and upper tragus of the ear.
B. Unilateral

N • Temporal, on the non-dominant side

Note:

G
– ALWAYS shave the area, remove debris and skin oil
to improve skin adhesion.
 C. ELECTROCONVULSIVE
D THERAPY
NURSING CARE MANAGEMENT
U
R • Check the VS, ECG, EEG before
and after ECT
I
N
G
 C. ELECTROCONVULSIVE
D THERAPY
NURSING CARE MANAGEMENT
U • Administration of Anesthesia, then

R Muscle relaxant by the anesthesiologist.

– Anesthesia

I
• Methohexital (Brevital),
• Ketamine (Ketalar),
• Thiopental (Pentothal)
N – Induces a light coma preceding delivery of ECT
– SE: Respiratory depression, hypotension, bradycardia,

G
decreased cardiac output
 C. ELECTROCONVULSIVE
D THERAPY
NURSING CARE MANAGEMENT
U • Succinylcholine (Anectine)
R •
•
Neuromuscular blocker (Muscle relaxant)
Prevention of fracture r/t induced convulsion

I
• Dosage: 0.6 mg/Kg
• SE: prolonged apnea, respiratory
depression, fasciculation
N – Curare
» A muscarinic antagonist

G
» May be added if the patient complains of muscle pain.
» Eliminates fasciculation
 C. ELECTROCONVULSIVE
D THERAPY
NURSING CARE MANAGEMENT
U • Administration of Anesthesia, then

R Muscle relaxant by the anesthesiologist.

– Anesthesia

I
• Methohexital (Brevital),
• Ketamine (Ketalar),
• Thiopental (Pentothal)
N – Induces a light coma preceding delivery of ECT
– SE: Respiratory depression, hypotension, bradycardia,

G
decreased cardiac output
 C. ELECTROCONVULSIVE
D THERAPY
NURSING CARE MANAGEMENT
U • Administer Oxygen inhalation at 2LPM

R • Apply mouth gag or bite block (if

indicated)
I • Application of electrical stimulus by
the physician.
N • Apply hand restraint through gentle
pressure on the joints of the patient.
G
 C. ELECTROCONVULSIVE
D THERAPY
NURSING CARE MANAGEMENT
U •Mechanism of action………………..…. UNCLEAR

R
•Voltage………………………………….. 70 – 150 volts
•Duration of administration ………….…. 0.5 – 2 seconds
•Number of treatment …………………... 6 – 12 treatments (Keltner)

I
6 – 15 treatments (Videbeck)
•Interval …………………………………. 48 hours
•Indicator of effectiveness ……………… occurrence of generalized
tonic – clonic seizure

N •Usual length of
seizure per treatment ………………… 30 – 60 seconds
•Cumulative length

G
of seizure to produce
therapeutic effect……………………. 220 – 250 seconds
 C. ELECTROCONVULSIVE
D THERAPY
NURSING CARE MANAGEMENT
U • Monitor and time the onset and
R duration of generalized grand-mal
seizure.
I – Tonic
» Client may lose consciousness; muscle
spasms may follow
N » Usually lasts 10-20 seconds
– Clonic

G » Rapid jerking movements occur.

» Tongue biting, incontinence, and heavy
salivation may occur
 C. ELECTROCONVULSIVE
THERAPY
A NURSING CARE MANAGEMENT

F • Mechanically ventilate the patient

with 100% Oxygen until the patient

T can breathe unassisted.

• Since ECT causes confusion and

E disorientation, it is important to help

with REORIENTATION (time, place,
person)
R
 C. ELECTROCONVULSIVE
THERAPY
A NURSING CARE MANAGEMENT

F • If agitation occurs, administer

benzodiazepine as ordered.

T • Continue monitoring until client is

fully awake.

E • Document pertinent information

including client’s response to the

R
therapy.
PSYCHOSURGERY
• For the treatment of severe or
incurable mental disorder.
• Frontothalamic tracts are severed.
• Reported to be useful in deteriorated
schizophrenic patients or intractable
obsessive-compulsive disorder.
• Not a recommended treatment and
rarely used.
Thank You
And
God Bless!!!