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psychopharmacology

psychopharmacology

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PSYCHOPHARMACOTHERAPY

Neurotransmitters  chemical messengers that conduct impulses from one neuron to another  Stored in synaptic vesicles  Manufactured in the neuron (nerve cells)  Either inhibitory or excitatory Functions (DANGS)  DA: regulation of movements/ coordination, integration of thoughts/emotions  Ach: memory acquisition/retention /learning  Ne: sleep, arousal, mood regulation, energy  GABA: calmness  5ht: sleep, arousal, libido, appetite, mood, aggression, temperature

Neurotransmitters and disorders Neurotransmitter (DANGS) Excess Dopamine (DA) Schizophrenia (+)sym Acetylcholine (Ach) Norephinephrine (NE/NA) Mania GABA Serotonin (5HT) Schizophrenia (-)sym

Deficient P.D,depression A.D Depression Anxiety Depression

TYPES ANTI ANXIETY / ANXIOLYTICS/ MINOR TRANQUILIZERS REMEMBER: A.N.X.I.E.T.Y A= ACTION: Decrease  BENZODIAZEPINES(BZA’s) =CNS depressant , increase anxiety, sleep disorder, for GABA, sedation vaginismus and rapid • Calming effect ejaculation  NON BENZODIAZEPINES= Interacts with serotonin / dopamine, less adverse effect, given to px prone to substance abuse  SSRI’s= for GAD, Ocd, Panic attacks, Ptsd, Social phobia N= NO TO……(ACALA RA) ……..(ACALA RA)  ALCOHOL (FATAL and impairs liver function)  CAFFEINE (decrease drug effect)  ANTACIDS (interferes absorption)  LONG TERM USE (abuse and dependence)  ACTIVITIES that requires concentration or handling complex machineries, driving  RISING immediately (hypotension: mgmt; Levarterenol(Levophed).  ABRUPT stopping (Switch from BZA to non BZA ,Use tapering (if not :seizures, insomnia, vomiting to px) X= CONTRAINDICATIONS  pregnant  hypersensitive  client with COPD  renal/ hepatic dysfunction I= INDICATIONS  BZA’s- anxiety, sleep disorder, sedation, Clonazepam (Klonopin)- anti convulsant  Non BZA’s Buspirone( BuSpar) therapeutic effect; 3-6 weeks treatment E= EFFECTS OF THE  BZA’S DRUG SHOULD BE CNS DEPRESSION 4D’S(over dosage manifestations) OBSERVED Drowsiness, dizziness, decrease BP, diminished reflex, dry mouth + it can lead to drug dependence

A. T. bulimia nervosa . px with impaired liver function Buspirone (BuSpar)*non BZA’s. OCD.same as ativan (BEH) Alprazolam (Xanax).oldest TCA’s  (E)lavil: most cardiotoxic  (Vi)Vivactyl: for elderly  (A)sendin: can cause tardive dyskinesia.PD Clonazepam (Klonopin).depression. OCD. for .GAD.C. (Non BZA is non prn drug) BEST GIVEN BEFORE MEALS TYPES ANTI DEPRESSANTS Remember: S. bulimia nervosa. 5ht  desired effect. childhood enuresis.T= TYPES (VLAB VSeX K TAE)  Mgmt: gastric lavage followed by activated charcoal.R.D.O. SELECTIVE SEROTONIN REUPTAKE INHIBITORSSSRI’S  blocks reuptake of serotonin  fewer side effects than TCA’s  first drug of choice in treating depression  Unfortunately . anxiety reduction  With cardiovascular effects. Flumazenil (Romazicon)IV. P. A= ALLOWED/ INDICATION D= DIFF. elderly alert 2.5ht  TCA’s. improved appetite. recline position (VLAB VSeX K TAE) Diazepam (Valium). OCD  (T)ofranil: childhood enuresis. Prescribed.antihistamine Oxazepam (Serax) –elderly. antihistamine Meprobamate(Equanil)*non BZA’s.mst. MONOAMINE OXIDASE INHIBITORS-MAOI’S  inhibits MAO that breaks down/inactivates NA.E. GAD Hydroxyzine (Vistaril)* non BZA’s. sedation. panic attacks.S. non BZA by 2-4 weeks ).A Si ATE Vi at ANA  (Si) Sinequan: orthostatic hypotension  (A)nafranil: 1st TCA. panic disorders 1. social anxiety disorders  MAOI’s. they can cause sexual dysfunction and GI symptoms 3.atypical depression. 1st anxiolytic drug (V)alium (L)ibrium (A)tivan (B)uspar (V)istaril (Se)rax (X)anax (K)lonopin (T)ranxene (A)tarax (E)quanil Y= YOU should know that this drug is used for short time (BZA thera effect by 1 week or less.depression.N S= STUDY DEPRESSION AND DRUG MECHANISM OF ACTION TRICYCLIC ANTIDEPRESSANTS-TCA’S  blocking reuptake of NA. panic disorder.anti convulsant Clorazepate (Tranxene) Hydroxyzine (Atarax)*non BZA’s. pre surgery jitters Chlordiazepoxide (Librium) 1st BZA Lorazepam (Ativan) –elderly. CLASSIFICATION Doxepin (Sinequan) Clomipramine (Anafranil) Imipramine (Tofranil) Amitryptiline (Elavil) Protriptyline (Vivactyl) Amoxapine (Asendin) Desipramine (Norpramin) panic. panic attacks  SSRI’s.

bulimia  (Pa)xil: panic 3. (insomnia) 3. SSRI Ce-Lo-Zo na.HATS= Hypotension. Monitor V/S 3. Given at AM. salami. Antacids decrease absorption 2. P= PLANNING PREGNANCY E= Effects/ Side effects R= REMEMBER (usually taken with meals) . Check BP. inform physician 2. Anticholinergic effects. Serotonin syndrome  SSRI’s + MAOI’s= serotonin syndrome signs and symptoms.hypotension 2. beer Soy sauce. SSRI’S + MAOI= FATAL 5. use Physostigmine (Antilirium) 2. Lag period(therapeutic effect can be felt) of 2-4 weeks 4. Given at PM 3. preserved foods “ occipital headache” – initial sign of hypertensive crisis MANAGEMENT: 3M’s for MAOI 1.for TCA’S 1. MEDS: Nifedipine( Procardia) Phentolamine (Regitine) A. TCA’S + MAOI’S= FATAL B. may Le-Pro-Pa  (Ce)lexa  (Lu)vox:newest SSRI’s. MAOI D/C. dysthymia. Lag period of 2-4 weeks 4. for SSRI’S 1. elderly depressed pt. Tachycardia. MAOI’S (PaMaNa) Tranylcypromine ( Parnate) Isocarboxacid (Marplan) Phenelzine (Nardil) –atypical depression xxxxxxReversible type xxxxxx  Moclobemide (Manerix)*TYRAMINE rich food OK to eat!!!!!!  Consult your provider of care TCA’S.if tyramine rich food is eaten: (CABSS) Cheddar/ aged cheese Avocado Banana. OCD  (Zo)loft: can cause sexual dysfunction  (Le)xapro  (Pro)zac: 1st SSRI’s. bulimia nervosa  (A)ventyl: good choice for elderly SSRI Citalopram (Celexa) Fluvoxamine (Luvox) Sertraline (Zoloft) Escitalopram (Lexapro) Fluoxetine (Prozac) Panoxetine (Paxil) 2.MAOI’S ORTHOSTATIC HYPOTENSION-common side effect  HYPERTENSIVE CRISIS. Sedation  TCA poisoning/overdosage (anticholinergic toxicity) vs.Nortriptyline (Aventyl) psychotic/depressed  (N)orpramine: panic.

SUN EXPOSURE SHOULD BE AVOIDED Y.T. Common in high potency anti psychotic drugs. P. blinking. HYPERSENSITIVE. CVD S= SHIFTING O= OBSERVE N= NOT ALLOWED/ CONTRAINDICATED. tremors of the arms and legs. altered consciousness. shades. abnormal movements. Lag period of 2-4 weeks at least 2-3 weeks interval when shifting from one antidepressants to another FOR SUICIDAL TENDENCIES(suicidal monitoring) PREGNANT. rigidity. foot tapping.H. (NMS)  Haloperidol. delusions.I.       mental status changes: confusion/hypomania Restlessness/agitation Diaphoresis Tremors/shaking chills Nausea. akinesia (muscle weakness). irreversible stereotyped movement of face and neck generally manifested by lip smacking.C A. (1-5 days after initiation of the therapy) “PHOTOSENSITIVITY”  MANAGEMENT: SSS: sun protection.s MALIGNANT SYNDROME hyperactivity). 30 mmHg). the condition will usually resolve in its own within 24 hours  Provide supportive measure E.N. I. smacking. grinding of teeth. headache.  Appears after months or years of drug use.“ Inability to sit” or “ I feel as if ants in my pants.Monitor V/S:  BP: orthostatic hypotension (systolic decr.TARDIVE DYSKINESIA side effect. increase temperature (cardinal sign 42. TYPES Antipsychotic/ neuroleptic/major tranquilizer Remember: A. tongue twitching. SEIZURES. .” (AKATHISIA)  the most common EPSE.ACTION blocks dopamine receptors sites in the brain= decrease psychotic symptoms ex: hallucinations.common cause  muscular rigidity. ALCOHOLICS.g.stopping SSRI and starting MAOI C.PARKINSONISMS.dorsogluteal= drug route N-NEUROLEPTIC fatal reaction/side effect to antipsychotic drugs( sympathetic n. involuntary. Appears 50-60 days after initiation of the therapy P.stopping MAOI and starting SSRI *4/ 5 weeks. rage  IM.Y.O.C. abdominal cramps Ataxia (incoordination) headache Management for serotonin syndrome:  D/c the involve drug.T. Given at AM 2.S.I. give analgesics *2 weeks.YES FOR A NURSE: like tremors.2 C) T.for MAOI’S 1. tremors. sunscreen 1.

Given at bedtime.CONTRAINDICATIONS: ADD ONS BATTLE OF THE ANTI PSYCHOTIC DRUGS Typical Atypical Or traditional/conventional/standard Old drug s(discovered in 50’s) For (+) symp Or nontraditional/unconventional/novel New drugs (discovered 90’s) Discovered in 2000’s For (+) and (-) symp Dopamine(DA) System Stabilizer DSS . take antacids 1 hour before or 2 hours after taking antipsychotics  ALCOHOL. tachycardia.profound CNS depression  Pregnant  Severe CNS depression  Parkinson’s dis. BARBITURATES.HALOPERIDOL (Haldol) O.C.major side effect: agranulocytosis  Thioridazine (Mellaril) LP . Instruct client to avoid operating heavy machineries.TYPES:  TEMP: NMS. 1st antipsych  Perphenazine (Trilafon) MP . ANXIOLYTICS. Pregnancy considerations 7. sedating and can cause wt.for + and – symptoms. drowsiness 3. ANTICHOLINERGIC DRUGS 5. effective in children with severe behavioral problem.OBSERVE FOR DESIRED EFFECT T.INTERACTION OF ANTI PSYCHOTIC DRUG TO OTHER DRUG C.gain Watch out for NMS sedation.CHLORPROMAZINE (Thorazine) H. OVERDOSE: gastric lavage 6. effective for positive symptoms.  Hepatic . Leads to (EPSE) 1st anti psychotic drug.used with anti depressants for patients who are both psychotic and depressed Trilafon+ Elavil= Triavil  Clozapine (Clozaril). AND SIDE EFFECTS: anti.renal. Do not stop abruptly. emotional quieting.  CBC(WBC)  SUGAR LEVELS( incr.short term treatment for marked depression accompanied by anxiety. insulin-hyperglycemia(metabolic disturbance).cholinergic effects.EPSE’s vs. Impairs night vision  Risperidone (Risperidal) Atyp -orthostatic hypotension  Haloperidol (Haldol)HP Fluphenazine (Prolixin) HP  ANTACIDS= decrease absorption.sedation. gain) 2.1st Atyp . parkinsonism  Trifluoperazine (Stelazine) HP  Mesoridazine (Serentil) LP  Olanzapine (Zyprexia)Atyp . EPSE’s.wt. no agranulocytosis  Chlorpromazine (Thorazine)LP. ANTIDEPRESSANTS. coronary disease I. hypotension. with meals or after meals 4.

g: Clozaril MOA: increase DA in areas with less DA.appearance)  dyskinesia. 1. foot tapping. If WBC drops below 2000/mm3 D/C permanently ADD ONS EXTRAPYRAMIDAL SIDE EFFECTS (EPSE)  major cause is a deficiency in dopamine  Antipsychotics effect: decrease dopamine CNS effects. grinding of teeth. Once started. zyprexa)  E. shuffling gait and fine tremors  DOC: Biperiden (Akineton) 4. irreversible stereotyped movement of face and neck generally manifested by lip smacking. NE)  Reduced or no risk for EPSE  Effective in treating negative symptoms  Minimal risk of TD  Usual side effect. late onset. a. lack of facial responsiveness. tongue twitching. blinking.s hyperactivity). risperidal.MOA: decrease DA (anti dopamine) S/E: high risk for EPSE e.g : clozapine (Clozaril). Akathisia. olanzipine (Zyprexa) Clozapine (Clozaril).TARDIVE DYSKINESIA: side effect. abnormal movements. or ocular movement  DOC: Benztropine (Cogentin). tremors of the arms and legs. sore throat. weight gain (idiopathic)  CloRZ (clozaril. involuntary. malaise. b. smacking. monitor WBC weekly for 6 mos. agranulocytosis  Fatal side effect. risperidone (Risperidal). leukopenia  Management. Trihexyphenidyl (Artane) 3. gait. anti cholinergic agents 2. Dystonia.  Appears after months or years of drug use.rigidity in muscles that control posture. can occur 24 weeks after the initiation of the therapy  Characterized by fever. Common in . most common EPSE  DOC: Benztropine (Cogentin).NMS: fatal reaction/side effect to antipsychotic drugs( sympathetic n. (5HT. Drug-induced parkinsonism/ pseudoparkinsonism (false)  symptoms resemble those of Parkinson’s disease (idiopathic Parkinson’s Disease)  drooling.(hence. tardive..g: Chlorpromazine (Thorazine MOA: decrease 5HT (anti serotonin) S/E: low risk for EPSE e. decrease DA in areas with more DA S/E: low risk for EPSE e.g: Aripiprazole (Ablify) ADD ONS Atypical antipsychotics.” .“ Inability to sit” or “ I feel as if ants in my pants. abnormal voluntary skeletal muscle movements usually jerky motions  Drug of choice : Bromocriptine ( Parlodel) 5..

(Symmetrel)  Bromocriptine. shaking  BRADYKINESIA.K.NURSING CONSIDERATIONS T.first sign. mask like appearance because facial movements slow down. tremors.Levodopa.P. increase temperature (cardinal sign 42.(Dopar). Da agonist 3. pseudoparkinsonism.coach freddie ROACH) Rise slowly (hypotension) Observe therapeutic effect.  Symptoms: muscular rigidity.salivation.R. improve balance and gait) Avoid alcohol. lactation) Have a meal before taking meds (GI upset)  TREMORS. Monitor V/S 2.slow and retarded movements.INDICATIONS .T. high protein foods. muscle relaxant Bromocriptine (Parlodel).TRIADS OF PD’s (primary symptoms) I. D/c meds(haloperidol). stiffness  RIGIDITY.N.stat.decrease Ach  Trihexyphenidyl (Artane)  Benztropine (Cogentin)  Biperidon (Akineton)  Diphenhydramine (Benadryl) (ROACH…. altered consciousness.2 C) Neuroleptic/Antipsychotic S/E Remember: Anti A HOPE Anti cholinergic side effects Agranulocytosis Hyperglycemia Orthostatic hypotension Photosensitivity Extrapyramidal side effects TYPES Anti Parkinson’s Drug Remember: A. Dopaminergic agents.(Eldepryl) 2.ACTION: MANAGEMENT:NMS(neuroleptic malignant syndrome) 1. (decrease tremor and salivation. A.I .(Sinemet)  Amantadine.increase DA  Levodopa. should not reinstitute meds for at least 2 weeks after resolution of NMS symptoms BALANCE dopamine and acetylcholine *Balance is accomplished 1. Anti cholinergic drugs.(Parlodel)  Selegine. bathing. Vit B6(decrease absorption) Cautiously used during pregnancy (decr.A. difficulty in dressing. notify physician. pill rolling. EPSE N. (Larodopa)  Carbidopa. handwriting Parkinson’s disease. Meds: Dantrolene ( Dantrium).high potency anti psychotic drugs.

ice chips. normal vision usually returns in a few weeks. 2500-3000 ml.given PO  Take 10-12 glasses of water. PNSS .ANTICHOLINERGIC DRUGS R-REMEMBER: CAPABLaDES PRIMARY symptoms can lead to secondary symptoms .U.for NMS Biperiden (Akineton) Diphenhydramine (Benadryl) Levodopa (Larodopa) (Dopar) Selegiline (Eldepryl) Amantadine (Symmetrel) (C)ogentin (A)rtane (P)arlodel (A)kineton (B)enadryl (LA)rodopa.I.  For toxicity-acetazolamide (Diamox). sips of water  CAN’T PEE. weight loss. constipation. dry mouth.T.prevent nausea. impair respiration. caution when driving  CAN’T SPIT. sunglasses. high fiber diet  CAN’T SWEAT. feversponge bath K.g dysphagia.most prescribe anticholinergic drug Trihexyphenidyl (Artane).KNOW the side effects TYPES ANTI MANIC or mood stabilizers Remember: L. constipation are used alone in the treatment of Parkinsonism induced by anti psychotic drugs. of water/ day.I. laxatives. compromise breathing. urinary retention. diarrhea. (E)ldepryl (S)ymmetrel  CAN’T SEE: blurred vision. choking.(D)opar. (first indicators) followed by vomiting.e.P. bladder and bowel function. take temperature.1. excessive saliva accumulation. gastric lavage. abdominal pains.M L= LEVEL (therapeutic (0. must be drawn at least 8-12 hours after the last dose and performed in the morning.so that balance of the two neurotransmitters will be restored CAPABLaDES Benztropine (Cogentin).6. encourage frequent voiding.thirst/toxicity  Sodium intake(3gm/day)-prevent toxicity  Monitor serum level. anhidrosis.2 mEq/l) level) TOXICITY INDICATORS: NAVDAD  Nausea.1st anticholinergic used for EPSE’s Bromocriptine (Parlodel).H. drowsiness I= INTERVENTIONS  Take it with meals or after meals. catheterization  CAN’T SHIT. sugarless candy. anorexia. urinary retention.PRIMARY symptoms A.for severe use hemodialysis T= TEN-14 DAYS TEN-14 DAYS BEFORE THERAPEUTIC EFFECT BECOMES EVIDENT . frequent rinses.

D (preserve cognitive function longer) • Cholinesterase inhibitors targets Ach deficiency. beta amyloids.nausea.OD at HS) With peripheral S/E Presents typically cholinergic S/E such as GI symptom MGMT: Take it with meals .D 1st available for use Linked to hepatic effects. lowers cholesterol + reduce risk of A.Anti convulsants. Lithium alters sodium transport in the nerve and muscle cells and inhibits the release of NE and Da. Donepezil (Aricept) • • • • 3.D (BENS) B vitamins (B6. ANTI MANIC AGENTS  pregnant  renal diseases  Hypersensitivity  cardiovascular dis.D Agents that restore acetylcholine • For mild to moderate A. GI upset  Carbamazepine (Tegretol)WOF(NAV). wt. action: decrease hyperactivity Mechanism of action is unclear. stimulates GABA which provides a calming effect  Valproic acid (Depakene)WOF: hair loss.B12 and folic acid) Estrogen: anti oxidants vs.D MEMANTINE: • no to patient with renal problem • Prevents glutamate from stimulating NMDA • Often co prescribed with Donepezil • Over dosage can lead to psychosis Drugs that prevent A. treatment for manic. increase cholinergic function NSAIDS (Celebrex): WOF CVA. inhibits cholinesterase which increase Ach 1. heart attacks Statins: dual benefit.gain.  Lithium Carbonate(Eskalith)  Valproic acid (Depakene)  Carbamazepine (Tegretol) (NAV.I problem. agranulocytosis  Lamotrigine (Lamictal)WOF rashes TYPES Anti Dementia  Common approach to treatment attempts to restore neurotransmitter loss(focus on Ach)  No known treatment can stop or reverse A.Lithium carbonate 2.H= HOLD IT/ CONTRAINDICATIONS: I= INDICATION U= UNCLEAR M= MANIA VS. Galantamine(Razadyne) • • Agents that retard neurogeneration  NMDA (N-methyl-D-Aspartate) receptors antagonist  For moderate to severe A. Rivastigmine (Exelon) • 4.Tacrine (Cognex) • • 2. anorexia. vomiting) Anti manic types 1. seldom prescribed Fewer peripheral S/E Absence of hepatotoxicity Problem includes G. bradycardia Given at bedtime (PO.

gingko.D • Captopril (Capoten) • Codeine • Cimetidine (Tagamet) • Digoxin (Lanoxin) • Furosemide (Lasix) • Nifedipine (Procardia) • Ranitidine (Zantac) • Warfarin (Coumadin) • • • • • ADD ONS Stages of A. sardines Lecithin: soy beans. or A drug or medication when it is used as a restriction to manage the person’s behavior or restrict the person’s freedom of movement and is not a standard treatment or dosage for the person’s condition R’s of Restraints Restraints: last resort (least restrictive interventions first) Requires special training and competency on staff members or person top decide or initiate this measure Review institutional policy or protocol FIRST Reassess patient every 10-15 minutes (face to face) R . Seclusion and restraint should not be used as a means of coercion or punishment.D Stage Mild Duration 2-3 years Changes • • • Denial Difficulty performing usual activities Decision making. strawberries Omega 3 fish oil: salmon. body or head freely. problem solving • Decreased short term memory(amnesia) ABCD 2 W Apraxia.D (sleep disturbance) Vit E/C: anti oxidants. a major component of cell membranes. judgment. garlic. mackerel. agnosia. green tea. prunes. A. for the convenience of the staff. Seclusion may only be used for the management of violent or self destructive behavior Restraints A physical restraint is any manual method or physical or mechanical device. or when less restrictive measures to manage behaviors are available. aphasia Blunt affect Changes in sleep patterns Disoriented/delusional 2LONG(assistance) for ADL’s Wandering TOTAL bed bound TOTAL incontinence TOTAL gait disturbance TOTAL care needed (24 hours supervision) Moderate 3-4 years Severe 5-10 years Restraints and Seclusion • Persons are never restrained and left alone in a locked room. concentration. slows/reverse the cognitive decline of A.D ANTI CHOLINERGIC MEDS SHOULD BE AVOIDED IN PATIENT WITH A. material or equipment that immobilizes or reduces the ability of a person to move his or her arms. Seclusion is the involuntary confinement of a person alone in a room or an area where the person is physically prevented from leaving. legs. like nerve cells Music therapy: increase melatonin concentration (sleep) vs.Others Herbs: anti oxidants like grape seed extract.

Record events/ interventions (documentation/ before-during-after the restraints) .

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