PSYCHIATRIC NURSING

COPING AND ADAPTATION MENTALLY HEALTHY INDIVIDUAL ATTITUDE OF SELF ACCEPTANCE AUTONOMY ABILITY TO ABSTRACT,TRUST ,COPE WITH STRESS ACCURATE SELF PERCEPTION AWARENESS OF SELF MENTAL HEALTH balance in a persons internal life and adaptation to reality Mental ILL Health state of imbalance characterized by a disturbance in a persons thoughts, feelings and behavior Poverty and abuses are major risk factors Psychiatric nursing interpersonal process whereby the professional nurse practitioner ,through the therapeutic use of self(art) and nursing theories (science), assist clients to achieve psychosocial well being. Core of psych nursing interpersonal process human to human relationship(both for mentally healthy and ill) Mental hygiene measures to promote mental health , prevent mental illness and suffering and facilitate rehabilitation.(and if necessary find meaning in these experiences) Main tool therapeutic use of self It requires self-awareness Methods to increase self-awareness:

Introspection ,Discussion, Experience, Role play

Neurosis any long term mental or behavioral d/o in which contact with reality is retained the condition is recognized by the patient as abnormal. Essentially features anxiety or behavior exagerrated designed to avoid anxiety ( anxiety d/o ; hysteria to conversion d/o,amnesia,fugue,multiple personality and depersonalization- dissociative d/o ;oc d/o) Result of inappropriate early programming(psychoanalysis little value) Benefits from B ehavior Therapy Psychosis Mental or behavioral disorder wherein patient looses contact with reality Presence of delusions, hallucinations,severe thought disturbances,alteration of mood, poverty of thought and abnormal behavior (schizophrenia , major disorder of affect ( mania depression), major paranoid states and organic mental disorder

Benefits from psychoanalysis and antipsychotics Common Behavioral Signs and Symptoms Disturbances in perception Illusion- misinterpretation of an actual external stimuli Hallucinations false sensory perception in the absence of external stimuli Disturbances in thinking and speech neologism coining of words that people do not understand Circumstantiality over inclusion of inappropriate thoughts and details Word salad incoherent mixture of words and phrases with no logical sequence Verbigeration meaningless repetition of words and phrases Perseveration persistence of a response to a previous question Echolalia pathological repetition of words of others Aphasia speech difficulty and disturbance Expressive , receptive or global Flight of ideas- shifting of one topic from one subject to another in a somewhat related way Looseness of association-incoherent ,illogical flow of thoughts(unrelated way) Clang association sound of word gives direction to the flow of thought Delusion persistent false belief,rigidly held Delusions of grandeur- special /important in a way Persecutory-threatened Ideas of reference-situation/events involve them Somatic- body reacting in a particular way Magical thinking primitive thought process thoughts alone can change events Autistic thinking regressive thought process-subjective interpretations not validated with objective reality Disturbances of affect Inappropriate disharmony between the stimuli and the emotional reaction Blunted affect severe reduction in emotional reaction Flat affect absence or near absence of emotional reaction

Apathy dulled emotional tone Depersonalization feeling of strangeness from ones self Derealization feeling of strangeness towards environment Agnosia lack of sensory stimuli integration Disturbances in motor activity Echopraxia imitation of posture of others Waxy flexibility maintaining position for a long period of time Ataxia loss of balance Akathesia extreme restlessness Dystonia- uncoordinated spastic movements of the body Tardive dyskenisia involuntary twitching or muscle movements Apraxia involuntary unpurposeful movements Disturbances in memory Confabulation filling of memory gaps Dj vu 2nd time-like feeling Jamais vu- not having been to the place one has been before Amnesia memory loss (inability to recall past events) Retrograde-distant past Anterograde immediate past Anomia lack of memory of items Dynamics of Human Behavior Personality integration of systems and habits representing anindividuals characteristic adjustment to his environment expressed through behavior Individualistic, unique, predictable(stability and consistency) Determinants: psychological,cultural, biological ( not inhereted) and familial Analysis Potential support systems or stressors Potential risk factor

Satisfaction of human needs

Physiological(oxygen , fluids, nutrition, temp.,elimination,shelter,rest,sex) Safety and security(physical and psychological) Love and belongingness Self esteem Self actualization
3 divisions of the mind Conscious focussed on awareness Subconscious recalled at will Unconscious never recalled / largest part Learning change in behavior through insight , relearning and remotivation Theories of personality development Freuds psychosexual theory Libido inner drive Parts of body focus of gratification Unsuccesful resolution - fixation Structures of personality

Id pleasure principle-instinct Ego controls action and perception reality principle Superego moral behavior - conscience
0-18 m0s ;oral mouth trust and discriminating 18 mos. 3 years ; anal bowels holding on or letting go

Negativism and toilet training age

3 -6 years phallic ; genitals exploration and discovery ( inc. sexual tension)

Gender identification and genital awareness Oedipus and Electra complex // Castration anxiety and penis envy
6-12 years latency (quiet stage) sexual energy diverted to play. Institution of superego control of instinctual impulses 12 young adult genital ; reawakening of sexual drives relationships

Sexual maturation Sexual identity ,ability to love and work

Psychosocial Erickson developmental milestones //delay 0-12mos; TRUST

1-3y AUTONOMY 3-6 INITIATIVE 6-12 INDUSTRY 12-18 IDENTITY 18-25 INTIMACY 25-60 GENERATIVITY 60 and above EGO INTEGRITY PIAGETS COGNITIVE THEORY 0-2 SENSORIMOTOR REFLEXIVE IMITATIVE REPETITIVE BEHAVIOR SENSE OF OBJECT PERMANENCE AND SELF SEPARATE FROM ENVT. TRIAL AND ERROR RESULTS IN PROBLEM SOLVING 2-7Y PRE-OPERATIONAL SELF-CENTERED,EGOCENTRIC CANNOT CONCEPTUALIZE OTHERS VIEW ANIMISTIC THINKING IMAGINARY PLAYMATE SYMBOLIC MENTAL REPRESENTATION CREATIVITY 2-4 PRE-CONCEPTUAL (PRE-LOGICAL) 4-7 INTUITIVE (UNDERSTANDING OF ROLES) 7-12Y CONCRETE OPERATIONAL LOGICAL CONCRETE THOUGHT INDUCTIVE RESAONING (SPECIFIC TO GENERAL) CAN RELATE ,PROBLEM SOLVING ABILITY REASONING AND SELF-REGULATION 12-ABOVE FORMAL OPERATIONAL THOUGHT Abstract thinking Separation of fantasy and fact Reality oriented

Deductive reasoning Apply scientific method Kohlberg MORAL DEVELOPMENT/ THINKING/ JUDGEMENT PRE-CONVENTIONAL (0-6)

PUNISHMENT AND OBEDIENCE OBEDIENCE TO RULES TO AVOID PUNISHMENT

CONVENTIONAL ( 6-12 )

MUTUAL INTERPERSONAL EXPECTATIONS,RELATIONSHIPS AND CONFORMITY SOCIAL SYSTEM AND CONSCIENCE MAINTENANCE BEING GOOD IS IMPORTANT SELF RESPECT OR CONSCIENCE
POST CONVENTIONAL (12 18 Y) PRIOR RIGHT OR SOCIAL CONTRACT UNIVERSAL ETHICAL PRINCIPLE ABIDE FOR COMMON GOOD RATIONAL PERSON-VALIDITY OF PRINCIPLES-AND BECOME COMMITTED TO THEM INNER CONTROL OF BEHAVIOR UNDERSTANDING THE EQUALITY OF HUMAN RIGHTS AND DIGNITY OF HUMAN BEINGS AS INDIVIDUALS DEFENSE MECHANISMS

unconscious intrapsychic adoptive efforts to resolve emotional conflict and cope with anxiety automatic pathology is determined by the frequency of use
examples of DEFENSE MECHANISMS

DENIAL failure to acknowledge an intolerable thought , feeling, experience or reality DISPLACEMENT redirection of emotions or feelings to a subject that is more acceptable or
less threatening

PROJECTION attributing to others ones feelings, impulses , thought or wishes UNDOING an attempt to erase an act , thought , feeling or desire COMPENSATION an attempt to overcome real or imagined shortcoming
SYMBOLIZATION a less threatening object or idea is used to epresent another SUBSTITUTION replacing desired , impractical , unattainable object with one that is acceptable INTROJECTION a form of identification in which there is a taking into oneself the characteristic of another(love object) REPRESSION unacceptable thoughts is kept from awareness(unconscious) SUPPRESSION- consciously putting a disturbing thought or incident out of awareness

REACTION FORMATION - expressing attitude directly opposite to unconscious wish or fear REGRESSION returning to an earlier developmental phase in the face of stress

DISSOCIATION detachment of painful emotional conflicts from consciousness CONVERSION emotional problems are converted into symptoms FANTASY conscious distortion of unconscious feelings or wishes IDENTIFICATION conscious patterning of ones self from another person INTELLECTUALIZATION - over use of intellectual concepts by an individual to avoid
expression of feelings

RATIONALIZATION justifying ones actions which are based on other motives SUBLIMATION - rechanneling of unacceptable instinctual drives with one hat is aceptable
NURSE PATIENT RELATIONSHIP

SULLIVANS THEORY ON INTERPERSONAL RELATIONSHIP DEVELOPED BY PEPLAU

INTO NURSE- PATIENT RELATIONSHIP

SERIES OF INTERACTION BETWEEN THE NURSE AND PATIENT IN WHICH THE NURSE
ASSISTS THE PATIENT TO ATTAIN POSITIVE BEHAVIORAL CHANGE

T RUST R APPORT U NCONDITIONAL POSITIVE REGARD S ETTING LIMITS T HERAPEUTIC COMUNICATION

PHASES

PRE-INTERACTION SELF AWARENESS ORIENTATION PHASE DEVELOP A MUTUALLY ACCEPTABLE CONTACT WORKING IDENTIFICATION AND RESOLUTION OF THE PATIENTS PROBLEMS TERMINATION ASSIST PATIENT TO REVIEW WHAT HE HAS LEARNED AND TRANSFER
HIS LEARNING TO HIS REL. W/ OTHERS WHEN TO TERMINATE NPR

GOALS ACCOMPLISHED EMOTIONALLY STABLE GREATER INDEPENDENCE ABLE TO COPE WITH ANXIETY, LOSS , FEAR AND SEPARATION
COMMON PROBLEMS - NPR

TRANSFERENCE DEVELOPMENT OF EMOTIONAL ATTITUDE + OR TOWARDS THE

NURSE

RESISTANCE DEVELOPMNET OF AMBIVALENT FEELINGS TOWARDS SELF

EXPLORATION

COUNTER TRANS FERENCE TRANSFERENCE AS EXPERIENCED BY THE NURSE

PRINCIPLES OF CARE

ACCPETS PATIENT AS UNIQUE WITH INHERENT VALUE AND WORTH PATIENT IS VIEWED AS HOLISTIC HUMAN BEINGS WITH INTERDEPENDENT AND
INTERRELATED NEEDS

FOCUS ON STRENGTHS AND ASSETS NON JUDGEMENTAL ASSISTANCE TOWARDS COPING EXPLORE THE PATIENTS BEHAVIOR AND THE NEED IT IS DESIGNED TO MEET AND THE

MESSAGE IT IS COMMUNICATING LEVELS OF INTERVENTION

PRIMARY INTERVENTIONS AIMED AT THE PROMOTION OF MENTAL HEALTH AND

LOWERING THE RATE OF CASES BY ALTERING THE STRESSORS

SECONDARY INTERVENTIONS THAT LIMIT THE SEVERITY OF THE DISORDER

CASE FINDING AND PROMPT Tx

TERTIARY REDUCING THE DISABILITY AFTER A DISORDER

PREVENTION OF COMPLICATION AND ACTIVE PROGRAM OF REHABILITATION
CHARACTERISTICS OF A PSYCHIATRIC NURSE-major roles of a nurse - socializing agent and patient advocate

EMPATHY- ability to see beyond outward behavior and sense accurately another persons inner
experience

GENUINENESS/CONGRUENCE ability to use therapeutic tools appropriately UNCONDITIONAL POSITIVE REGARD - respect
THERAPEUTIC COMMUNICATION

CLARIFICATION LIMIT SETTING EMPATHETIC / ENCOURAGE EXPRESSION ANSWERS NEEDS REFLECTIVE AND INSIGHTFUL
THERAPEUTIC COMMUNICATION

FOCUS ON FEELING TONE ,NEEDS ,MOTIVATION MUST HAVE CONSISTENCY AND IS NON JUDGEMENTAL CRITERIA OF SUCCESSFUL COMMUNICATION FEEDBACK , APPROPRIATENESS,
FLEXIBILITY AND EFFICIENCY TECHNIQUES OF COMMUNICATION TO INITIATE A CONVERSATION giving broad openings giving recognition / acknowledgement TO ESTABLISH RAPPORT GIVING INFORMATION USE OF SILENCE TO GATHER INFORMATION FOCUSING VALIDATING REFLECTING RESTATING TO CLOSE A CONVERSATION summarizing

TYPES OF PSYCHOTHERAPIES
REMOTIVATION THERAPY

TREATMENT MODALITY THAT PROMOTES EXPRESSION OF FEELINGS THROUGH

INTERACTION FACILITATED BY DISCUSSION OF NEUTRAL TOPICS

STEPS :

climate of acceptance creating bridge to reality sharing the world we live in appreciation of works of the world climate of appreciation MUSIC THERAPY

INVOLVES USE OF MUSIC TPO FACILITATE EXPRESSION OF FEELINGS,FACILITATE

RELAXATION AND OUTLET OF TENSION PLAY THERAPY enables patient to experience intense emotion in a safe environment with the use of play children express themselves more easily in play. revealing as reflection of childs situation in the family provide toys and materials facilitate interaction observe and help child resolve problems through play Group therapy

Treatment modality involving three or more patients with a therapist to relieve emotional
difficulties, increase self esteem, develop insight , LEARN NEW ADAPTIVE WAYS TO COPE WITH STRESS and improve behavior with others( RELATIONSHIP WITH OTHERS CAN BE WORKED THROUGH)

IDEAL 8 10 MEMBERS
MILIEU THERAPY

CONSISTS OF TREATMENT BY MEANS OF CONTROLLED MODIFICATION OF THE

PATIENTS ENVIRONMENT , FACILITATE POSITIVE BEHAVIORAL CHANGE

INCREASE PATIENTS AWARENESS OF FEELINGS, INCREASE SENSE OF

RESPONSIBILITY AND HELP ETURN TO COMMUNITY

clients plan social and group interaction token programs , open wards and self medication
FAMILY THERAPY

A METHOD OF PSYCHOTHERAPY WHICH FOCUSES ON THE TOTAL FAMILY AS AN

INTERACTIONAL SYSTEM

PROBLEM IS A FAMILY PROBLEM focus on sick members behavior as source of trouble / symptom serve a function for the family members develop sense of identity points out function of the sick member for the rest of the family
PSYCHOANALYTIC

focuses on the exploration of the unconscious, to facilitate identification of the patients defenses ANXIETY RESULTS BETWEEN CONFLICTS OF ID AND EGO(DEFENSE MECHANISMS
FORM TO WARD OFF)

BECOMES AWARE OF UNCONSCIOUS THOUGHTS AND FELINGS.UNDERSTAND ANXIETY

AND DEFENSES HYPNOTHERAPY

VARIOUS METHODS AND TECHNIQUES TO INDUCE A TRANCE STATE WHERE PATIENT

BECOMES SUBMISSIVE TO INSTRUCTIONS BEHAVIOR MODIFICATION A THERAPEUTIC INTERVENTION INVOLVOING THE APPLICATION OF LEARNING PRINCIPLES IN ORDER TO CHANGE MAL-ADAPTIVE BEHAVIOR

PSYCHOLOGICAL PROBLEMS ARE A RESULT OF LEARNING DEFICIENCIES CAN BE CORRECTED THROUGH LEARNING

OPERANT CONDITIONING
USE OF REWARDS TO EINFORCE POSITIVE BEHAVIOR PERCEIVED AND SELF REINFORCEMENT BECOMES MORE IMPORTANT THAN
EXTERNAL

DESENSITIZATION
SLOW ADJUSTMENT OR EXPOSURE TO FEARED OBJECTS(USED IN PHOBIAS) PERIODIC EXPOSURE,UNTIL UNDESIRABLE BEHAVIOR DISAPPEARS OR LESSENS

AVERSION THERAPY - EXAMPLE OF BEHAVIOR MODIFICATION IN WHICH PAINFUL

STIMULUS IS INTRODUCED TO BRING ABOUT AN AVOIDANCE OF ANOTHER STIMULUS WITH THE END VIEW OF FACILITATING BEHAVIORAL CHANGE OTHER THERAPIES TOKEN ECONOMY-REWARDING DESIRED BEHAVIOR COGNITIVE THERAPY SHORT TERM STRUCTURED THERAPY ORIENTED TOWARDS PRESENT PROBLEMS ABD SOLUTIONS AMIN FOCUS OF DEPRESSIVE DISORDERS HUMOR THERAPY TO FACILITATE EXPRESSION AND ENHANCE INTERACTION ACTIVITY THERAPY GROUP INTERACTION WHILE WORKING ON A TASK TOGETHER

PSYHCHOPHARMACOLOGIC AGENTS
I. ANTI-PSYCHOTICS SUB-CLASSIFICATIONS PHENOTHIAZINES NON-PHENOTHIAZINES MOA - antagonizes dopamine in the CNS and also blocks Cholinergic, Histaminic, Serotogenic, Adrenergic neurotransmitters - ( anticholinergic, antihistaminic, anti-emetic ) blocks activity of the CNS receptors and sympathetic nervous system INDICATION - formerly called major tranquilizers / neuroleptics. used to relieve psychotic symptoms( delusions , hallucinations and looseness of association)of schjizophrenia, mania and psychotic depression and organic mental disorders - acute management of agitation and hyperactivity SIDE/ ADVERSE EFFECTS:

Chlorpromazine (Thorazine) Fluphenazine (Prolixin) Perphenazine ( Trilafon) Prochlorperazine (Compazine) Thioridazine ( Mellaril) Triflouperazine (Stelazine) Clozapine ( Clozaril) Haloperidol ( Haldol) Olanzapine ( Zyprexa ) Risperidone ( Risperdal) THIOXANTHENES Thiothixene ( Navane)
ANTICHOLINERGIC EFFECTS (EPS)EXTRAPYRAMIDAL SYMPTOMS

PSEUDOPARKINSONISM-tremor , mask like facies drooling , restlesssness AKATHISIA- restlessness,and anxiety DYSTONIA-grimacing , torticollis ,oculogyric crisis, intermittent muscle spasms
- TARDIVE DYSKINESIA-lip smaking and tongue and mouth (NMS) NEUROLEPTIC MALIGNANT SYNDROME* - hyperthermia, and severe EPS -muscular rigidity, tremors, trismus, choreiform movements,autonomic instability /hyperactivity and alterations in LOC SEIZURES HEPATOTOXICITY* ORTHOSTATIC HYPOTENSION PHOTOSENSITIVITY and HYPERSENSITIVITY ENDOCRINE DISORDERS DYSCRASIAS * AGRANULOCYTOSIS sorethroat,chills,fever,malaise LEUKOPENIA CONTRAINDICATIONS AND SPECIAL PRECAUTIONS: C/I : hypersensitivity , glaucoma , convulsive d/o , pregnancy and lactation, elderly clients NURSING CARE GUIDELINES: C- antipsychotics, neuroleptics, major tranquilizers H- decreased overt or positive manifestations of psychosis E- p.c. C- rise slowly avoid sunlight Report sorethroat,fever,muscular rigidity Reduced psychomotor agitation and insomnia 1 week Reduction of hallucinations, delusions and thought disorder takes 6-8 weeks for full therapeutic effect BP and temperature K monitor blood levels Seizures, NMS and EPS L.F.T.s CBC with differential medical management : NMS Bromocriptine or Amantadine( dopamine agonist) and Dantrolene (Dantrium) muscular relaxant Dystonia Diphenhydramine,Benztropine , Diazepam, Lorazepam Pseudoparkinsonism Antiparkinsonian, Anticholinergic Akathisia Anticholinergic, Benzodiazepines, Beta-blockers,Clonidine Tardive dyskinesia early referral-dose reduction , no anticholinergics II. ANTI-PARKINSONIAN AGENTS CLASSIFICATIONS 2 TYPES : 1.) DOPAMINERGIC DRUGS MOA: enhance dopaminergic activity slows deterioration of dopaminergic nerve cells Increasing dopamine

Carbidopa Levodopa ( Sinemet) Amantadine ( Symmetrel) Bromocriptine Mesylate ( Parlodel) Levodopa ( Larodopa) Pergolide Mesylate ( Permax) Ropinirole(Requip)

Tolcapone ( Tasmar)
2.) ANTI-CHOLINERGIC AGENTS MOA:inhibit relative excess in cholinergic activity, symptomatic relief Decrease signs and symptoms ( tremors,rigidity, drooling promote optimal levels of motor function (gait, posture and speech ) INDICATIONS: For management of anti psychotic induced EPS- pseudoparkinsonism SIDE AND ADVERSE EFFECTS Anticholinergic Effects Blurring of vision, constipation, 3Ds and orthostatic hypotension, sorethroat* Headache, photosensitivity, drowsiness, CHF and halluciantions CONTRAINDICATIONS AND SPECIAL PRECAUTION Glaucoma, tachycardia, HPN, Cardiac D/O, asthma, duodenal ulcer NURSING CARE GUIDELINES C- dopaminergic or anti-cholinergic H- decrease tremors and rigidity in 2-3 days E- p.c. C- avoid sudden position change Avoid Vit. B6 and CHON rich foods- dec. absorption of medication Avoid alcohol-increases sedative effects K- check BP- orthostatic hypotension drugs not withdrawn abruptly III. ANTI DEPRESSANTS COMMON TYPES TRICYCLICS MONO AMINE OXIDASE SELECTIVE SEROTONIN INHIBITORS REUPTAKE INHIBITORS

Trihexypheiedil ( Artane) Biperiden Hydrochloride ( Akineton) Benztropine Mesylate ( Cogentin) Diphenhydramine Hydrochloride (Benadryl) Misc. agent Selegiline ( Eldepryl) Imipramine(Tofranil) Amitriptryline ( Elavil) Clomipramine (Anafril) Doxepin ( Sinequan) Nortryptyline ( Aventyl) Tranylcypromine (Parnate) Isocarboxazid ( Marplan) Phenelzine (Nardil) Citalopram ( Celexa) Flouxetine (Prozac) Paroxetine ( Paxil) Sertraline ( Zoloft) Fluvoxamine (Luvox)
Mechanism of Action CNS STIMULANTS INDICATIONS effective in management and treatment of depression and related mood and depressive disorders such as: Obsessive compulsive ,Eating d/o,Obesity,Bipolar disorder,Panic d/o

SIDE EFFECTS AND ADVERSE REACTIONS: TCAS MAOI SSRI CNS Stimulants Cardiac arrhythmias, palpitations,orthostatic hypotension Constipation,Sedation, anticholinergic effects Confusion Bone marrow depression Hypertensive crisis Liver and cardiovascular disease Weight gain Sexual dysfunction photosensitivity Tremors, decreased libido, NAVDA Nervousness, insomnia, drowsiness anxiety Growth suppression, insomnia CONTRAINDICATIONS AND SPECIAL PRECAUTIONS TCAS MAOI SSRI CNS Stimulants Hypersensitivity, liver disease , glaucoma Hypertension Cardiovascular disease and Liver disease same NURSING CARE GUIDELINES C- anti-depressants H- decreased signs and symptoms of depression(increased appetite and sleep E p.c. TCAS MAOI SSRI CNS Stimulants C2-3 wks initial effect 3-6 wks full therapeutic effect 2-3 initial 3-4 full ther. Effect Avoid foods rich in 2-3 initial 3-4 full ther. effect Give in AM , not beyond 2 pm 6 hours before bedtime

Inhibits reuptake and destruction of serotonin to prolong its action Blocks the metabolic destruction of

neurotransmitters by the enzyme monoamine oxidase Prolongs the action of norepinephrine Dopamine Serotonin by blocking the reuptake of this neurotransmitters Ritalin ( Methylphenidate) Amphetamine ( Benzedrine) Increases levels of neurotransmitters in the brain thereby increasing CNS activity and decreasing hyperactivity.
Emphasize compliance Avoid citrus juice decrease absorption KMonitor BP, HR and ECG tyramine leads to hypertensive crisis ( processed,preserved and fermented ) Monitor BP and food items IV. ANTI MANIC EXAMPLES MOA Exact mechanism unknown , alters the level of norepinephrine and other neurotransmitters INDICATIONS

an Treatment of acute mania and for prophylaxis of recurrent manic and depressive episodes in
bipolar disorder SIDE AND ADVERSE EFFECTS NAVDA Fine tremors leading to coarse tremors Thirst Nystagmus Nephrotoxicity* Cardiac toxicity* Hyperthyroidism Thyroid Crisis* CONTRAINDICATIONS AND SPECIAL PRECAUTION Cardiovascular disease , renal disease, clients on low sodium diet and on diuretic therapy, brain damage, pregnancy and lactation NURSING CARE GUIDELINES C- mood stabilizer anti manic H- decrease hyperactivity/manic episodes Initial effect 10-14 days Full therapeutic effect 3-4 weeks E- after meals with milk or food

C- antipsychotics given with lithium for immediate management of manic episodes. Diet Na 6-10 grams a day; fluids- 3 liters per day Avoid caffeine , diuretics and activities that increase perspiration K- monitor for untoward signs and symptoms Monitor serum level at least once a month(A.M. 12 hours after the last dose maintenance dose - .5 1.2 mEq / L acute level 1.5 mEq / L level for the elderly .4 1.0 mEq / L Antidote for toxicity Mannitol (Osmitrol) or Acetazolamide (Diamox) V. ANTI ANXIETY CLASSIFICATION: BENZODIAZEPINES AZASPIRONES NON-BENZODIAZEPINE Miscellaneous agents

Lithium Carbonate ( Eskalith, Lithane, Quilinium R, Lithionate) Carbamazepine (Tegretol ) Alprazolam ( Xanqax) Chlordiazepoxide ( Librium) Clorazepate ( Tranxene) Diazepam ( Valium) Lorazepam ( Ativan) Oxazepam ( Serax)
MOA: depresses Reticular Activating system and reduces anxiety by stimulating the action of an inhibitory neurotransmitter called GABA INDICATIONS; treatment of anxiety disorders and for short term relief of symptoms of Anxiety; selective medications effective for skeletal muscle relaxation, pre and post-op sedation, seizure control. SIDE AND ADVERSE EFFECTS Sedation and Dizzinees,drowsiness and dry mouth Paradoxical reactions*(hallucination and delusions),CNS depression* Addisons disease , Dependency*, hepatotoxicity* CONTRAINDICATIONS AND SPECIAL PRECAUTION Glaucoma, hypersensitivity, liver and kidney dysfunction, psychoses, elderly , pregnancy and lactation NURSING CARE GUIDELINES C- anxiolytics, minor tranquilizers H- decrease anxiety E- a.c. food delays absorption C- rise slowly Avoid caffeine and alcohol K- monitor CBC, LFTs, report sorethroat, jaundice, weakness and fever

Buspirone (Buspar) Hydroxyzine ( Vistaril) Meprobamate ( Equanil)