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DRY MOUTH: Decreased production or
lack of saliva; anticholinergic effect;
difficulty with speech, swallowing,
maintaining oral hygiene, denture
Decreased BP of 30 mm/hg when change
in position from lying in bed to an upright
position. Client may complain of
dizziness when getting out of bed. Often
accompanied by nausea, palpitations,
light-headedness, and in the elderly
BLURRED VISION not clear sight,
anticholinergic effect, client may complain
that objects appear foggy, difficulty
reading or driving
CONSTIPATION: Decrease in persons
normal bowel movements, difficulty or
incomplete passing of stool; excess
hard/dry stool; abdominal pressure or
pain; feeling of rectal fullness, pain with
URINARY RETENTION difficulty with
urination, bladder distention

Pulse rate over 120; may be
asymptomatic or may be experienced as
WEIGHT GAIN; increase in body weight
from increased appetite with clients on
low potency antipsychotics.

Risk factors: using more than one anticholinergic.
Interventions: Reassure client that it usually resolves
untreated 1 or 2 weeks into treatment. Carry a cup of
water, take occasional sips, moisten mouth with
mouthwash, sugarless hard candy, gum, lip balm,
glycerin mouth swabs, lemon juice, good oral hygiene.
Risk factors: elderly, on low potency antipsychotic.
Interventions: Monitor BP, take BP when client sits and
when they stand up. Teach client to get out of bed
slowly, to sit for 1 minute before getting up.
Dehydration accentuates symptom, therefore increase
fluid intake
Risk factors: using more than 1 medication with anticholinergic effects.
Interventions: Reassure client that it usually resolves
untreated 1-2 weeks after final dose adjustments.
Provide large-print books or magazines in the interim;
avoid dangerous tasks like driving
Risk factors: more than 1 anti-cholinergic affect
medical; poor eating habits;
Interventions: Increase dietary fiber, increase bran,
fresh fruits, vegetables, Metamucil, increase fluids,
exercise, mild laxative, stool softeners such as Colace.
Infrequently, a paralytic ileus will develop and require
emergency surgical intervention
Monitor frequently for difficulty with urination, changes
in starting or stopping; notify doctor; palpate or percuss
abdomen for fullness, in some cases catheterization
may be necessary. May reduce or change medication
to a less anticholinergic agent, or a cholinergic agent
such as bethanechol (Urecholine).
If client is asymptomatic and has no coronary risk
factors, wait to see if HR returns to normal. If
symptomatic or coronary risk factors are present, may
be treated with a beta-blocker. Assess for infection,
monitor pulse for rate and irregularities, hold meds if
resting rate exceeds 120 BPM.
Risk factors: Risk factors: Low potency antipsychotics,
history of obesity, occurs in highest proportion with
clozaril and olanzapine.
Interventions: exercise, diet teaching, caloric control,
measure weight daily, keep food diary, labs- HDL,
cholesterol; join support group
Interventions: exercise, diet teaching, caloric control,

GYNECOMASTIA: Enlargement of breast

tissue in males due to
hyperprolactinemia, prolactin levels
increase, signs and symptoms enlarged
breast, tenderness of breast.

Interventions: inform doctor immediately; may change

or reduce medications, reassure client that problem will
go away, especially clients with delusions and


deceased set drive, inability to achieve
orgasm, inability to achieve an erection or
retrograde ejaculation, amenorrhea,
breast enlargement (in men or women),
production of milk from the breast occurs
from dopamine blockage

Risk factors: Stress

Interventions: Teach the client sexual problems are
common during periods of intense stress including
psychiatric hospitalization. Changing medication can be
helpful, reassure client that theses side effects are
reversible and benign. Menses usually return in
several months with or without a change in
antipsychotic. Remind client should continue birth
control measures even if the period has temporarily
Risk factors: low potency typical meds
Interventions: Wear sun block, wear protective
clothing, dark glasses, wear hats that cover most of
skin. Watch for retinopathy rarely irreversible may
cause blindness, usually caused by thioridazine
(Mellaril) in doses higher than 800 mg/d, it can be
prevented by avoiding doses above that limit.
Risk factors: all antipsychotics
Interventions: Prevention includes weekly WBC for
duration of clozapine therapy; after week supply of
Clozaril need to get WBC count to get next weeks
medicine; Call doctor immediately if fever. Teach
clients to observe for signs of high, spiking fever, sores
in the throat or mouth, or other signs of infection.
Monitor WBC, for WBC <3500, get CBC, 2 times per
week and continue clozapine. For WBC, 3000 or
granulocyte count below 1,500, stop clozapine and get
CBC qod. When WBC returns to 3,500 restart
clozapine. For WBC <2000 or granulocyte <1,000,
discontinue clozapine immediately and do not restart at
Initiate reverse isolation if agranulocytosis is confirmed.
Risk factors: early onset schizophrenia.
Symptoms: decreased NA, muscle cramps, muscle
twitching, confusion, weakness, headache, irritability,
polydypsia, polyuria, decreased specific gravity. The
alteration in sodium level leads to diverse neurologic
signs, ranging from ataxia to coma and possibly death.
Interventions: weigh daily, monitor NA levels, urine
specific gravity daily. If hyponatremia (serum Na+ <135
mEq/L), hyposthenuria (urine specific gravity <1.005)
target weight procedure, assess behavioral changes
daily, identify specific interventions for helping patient to
develop control over fluid intake and learn self-

sensitivity of skin to sunburn, to light;
symptoms: severe sunburn or rash;
discoloration of exposed areas, especially
neck, face, color changes to gray, blue or
purple. Discolration may progress from
deep orange color to blue gray.
reduction in the number of granulocytes,
acute disease, have abnormally low
WBC, its an adverse reaction;
suspected if pt has severe sore throat,
high fever, malaise, sores in mouth, WBC
<3500, granulocytes <500
Nsg dx: Risk for Infection


threatening. A severe state of fluid
overload; develops when large amounts
of water are ingested and serum sodium
levels rapidly fall to a level below
120mEq/L. Early sign -client will smell like
urine; pt always has water bottle in hand.
Etiology is unknown.
Ingesting large amounts of water over a
prolonged period may lead to
complications, such as renal dysfunction,
urinary incontinence, flaccid bladder,

hydronephrosis, cardiac failure,

malnutrition, hernia, dilation of the GI
tract, or permanent brain damage.
Nsg dx. Excess fluid volume

monitoring skills such as cognitive therapy approach,

individual or group therapy approaches, arrange access
to sugarless candies, gum, and fruit to reduce feelings
of thirst, limit access to fluids during the day. If weight
reaches or exceeds target weight initiate the following:
1. Prohibit fluid intake
2. Restrict to program and residential area
3. Assess vital signs q1h x 2
4. Provide low-fluid diet after symptoms subside

SYNDROME is an emergency state
characterized by severe muscle rigidity
and fever followed by 2 or more of the
following during next 48-72 hrs: BP, HR,
tachypnea, diaphoresis, incontinence,
leukocytes, change in LOC, elevated CK
(10-80 normal) tremors, drooling

Risk factors: occurs with first dose or if on high dosage.

At risk for dehydration
Interventions: Stop medication and call physician
immediately. Hold any anticholinergic meds, take
vitals, check CPK, WBCs, liver enzymes. Treat
symptoms: cooling blanket for fever, IVC fluids for
hydration, an airway if necessary, ROM exercises or
frequent changes in position for severe muscular
rigidity, frequent monitoring of BP, P, To, and
respirations, protect joints and extremities, hydrate,
give a muscle relaxant dantrolene if needed.

AKATHISIA motor restlessness,

inability to sit or stand still, client rocks,
paces, march in place, crosses and
uncrosses legs, client may feel anxiety,
unable to relax.
Uncommon in pts receiving atypical meds
Does not respond well to anticholinergic

Risk factors: antipsychotics -more common in middle

age women Interventions: change or reduce meds, Inderal -monitor
clients blood or urine glucose level for pt who have
diabetes, monitor pulse and BP when giving Inderal
can cause hypotension and bradycardia hold if P <60,
notify physician, validate client symptoms, reassure its
treatable, assist with eating and drinking if necessary,
adequate hydration and rest; Can give Artane,
Cogentin, benadryl, Symmetrel, monitor for
anticholinergic effects, an also can give Valium, Ativan.
Normal signs of hypoglycemia may be blocked by
Risk factors: Risk factors: antipsychotic - young men,
adolescents and children risk for aspiration #1 RN
Interventions: Acute reaction - give Benadryl IV, IM for
rapid reverse effect then give Cogentin, Artane,
Symmetrel. Monitor for anticholinergic effects.
Validate symptoms, assure its treatable, hydrate and
rest. Provide a quiet, non-stimulating environment until
the dystonia resolves.

DYSTONIA muscle spasm in any

muscle of the body, involuntary especially
of head and neck, may include torticollis
(stiffness of the neck which draws the
head to one side and the chin to the
opposite side), oculogyric crisis (an
involuntary dorsal arching of neck and/or
back- eyes roll back), protrusion of the
tongue, dysphagia, and laryngeal or
pharyngeal spasm with airway
compromise; usually frightening and
painful; abnormal posture, thick tongue,
tight jaw.
PSEUDOPARKINSONISM Parkinsonlike symptoms, acute EPS effect, triad

Risk factors: elderly, when pt. first start meds

Interventions: administer anti-Parkinson or

rigidity, akinesia slow movement, tremor,

mask-like face, loss of expression,
shuffling gait, hypersalivation and
drooling, propulsive gait, alterations of
posture, loss of associated movements,
RN DX: risk for injury, imbalanced
nutrition, lack of energy.
abnormal, involuntary movements that
usually begin in the face, neck, jaw
(tongue thrusting, writhing, or twisting;, lip
smacking or pursing, grunting, facial
grimacing, chewing, repetitive
movements, rapid eye blinking, abnormal
finger movements; neurological side

anticholinergics, Artane, Benadryl, Symmetrel, monitor

for anticholinergic effects. Validate symptoms,
educated client that it is treatable, assist with ADLs

Risk factors: age over 50, female, affective disorder,

brain damage or dysfunction. Increase duration of
antipsychotic meds
Interventions: no cure, prevention maintain on lowest
possible antipsychotic dose for the briefest possible
interval. Administer the Abnormal involuntary
Movement Scale (AIMS) at least every 6 months. If the
AIMS score increases, client must be informed and the
dose reduced as much as possible or discontinued
entirely. Teach client early warning signs to help
monitor for early symptoms; The symptoms of TD
either diminish or resolve when clients are switched to
novel antipsychotics.

Antipsychotics may lower seizure threshold.

EPS more common in typical meds.
Anticholinergic s/e
1. Dry mouth
2. Slowed gastric motility
3. Constipation
4. Urinary hesitancy or retention
5. Vaginal dryness
6. Blurred vision
7. Dry eyes,
8. Nasal congestion
9. Confusion
10. Decreased memory
Clozaril produce considerable orthostatic hypotension

Severe muscle rigidity

Elevated To
Rapidly accelerating cascade of symptoms (occurring during next 48 72 hrs) which can include 2 or more
1. HTN
2. Tachycardia
3. NMS occurs in about 1% of those who receive antipsychotic drugs especially conventional drugs like
4. Presenting symptom is To >99.5oF (usually between 101oF and 103oF) with no apparent cause.

Tx: asymptomatic
Diagnostic criteria for Neuroleptic Malignant Syndrome
1. Treatment with neuroleptics within 7 days of onset (2-4 weeks for depot neuroleptic medications).
2. Hyperthermia
3. Muscle rigidity
4. 5 of the following:
a. Change in mental status
b. Tachycardia
c. Hypertension or hypotension
d. Tachypnea or hypoxia
e. Diaphoresis or silorrhea
f. Tremor
g. Incontinence
h. Creatinine phosphokinase elevation or myoglobinuria
i. Leukocytosis
j. Metabolic acidosis
5. Exclusion of other drug-induced, systemic, or neuropsychiatric illnesses
Cognitive therapy
1. The use of cognitive therapy in the acute phase of treatment combined with medication has grown in the
past few years and now may be considered as first-line tx for mildly to moderate depressed outpatients.
2. This therapy uses techniques, such as thought stopping and positive self-talk, to dispel irrational beliefs
and distorted attitudes.
Nursing diagnosis
Paranoia schizophrenia
Delusion schizophrenia
Loosening of Association

Nsg dx : Disturbed sensory perception

Nsg dx: Disturbed sensory perception A/E/B person hears voices
Nsg dx: Disturbed thought perception A/E/B pt says I am Princess
Disturbed thought perception, 2. Impaired Verbal communication

Crisis intervention Page 48

1. Goal to help person get over this experience.
2. Organized approach required, including a mechanism for rapid access to care (within 24 hrs).
3. A referral for hospitalization, or access to outpatient services.
4. Crisis intervention tx is brief, usually fewer than 6 hours.
5. This type of short-term care focuses on stabilization, symptom reduction, and prevention of relapse
requiring inpatient services.
6. Can be found in the Emergency department of a general or psychiatric hospital or in crisis centers within
a community mental health center.
7. Pts. in crisis demonstrate severe symptoms of acute mental illness, including labile mood swings,
suicidal ideation, or self-injurious behaviors.
8. Crisis intervention treatment option commands a high degree of nursing expertise.
9. Pts. usually require meds. Such as anxiolytics or benzodiazepines for symptom management.
10. Key nursing roles include assessment of short-term therapeutic interventions and med administration.
11. Nurses also facilitate referrals for admission to the hospital or for outpatient services.
The nurses reactions to a patient that are based on the nurses unconscious needs, conflicts, problems, and
views of the world. It can significantly interfere with the nurse-patient relationship.

The unconscious assignment to others of feelings and attitudes that were originally associated with important
figures such as parents or siblings.
1. Magical thinking usually 3-5 year old
2. Haldol and Prolixin comes in decanoate give z-track IM form
3. Clozaril risk for sepsis
4. Zyprexa great increased tendency for hyperglycemia
5. Medications - the smaller the dosage they come in, the higher the potency
6. NMS detect muscle injury by looking at CPK lab
7. Cogentin do not abruptly stop med because a flu-like syndrome may develop.
8. Tardive dyskinesia AIMS test
9. Euthymic means normal; dysphoric depressed, disquieted, restless; euphoric - elated
Long-acting preparations:
1. Injection site may become sore and inflames if certain precautions are not taken
2. These liquids are viscous, and a large-gauge needle (at least 21 gauge) should be used.
3. The medication is meant to remain in the injection site, the needle should be dry, and a deep IM
injection should be dry, and a deep IM injection should be given by the Z-track method. Do not
massage the injection site. Rotate sites and document in the patients record.
1. Can be an acute reaction
2. Occurs more frequently in thin malnourished males.
3. Immediate tx. is to administer Cogentin or Benadryl IM or IV
4. Professor: Can give Benadryl IM, PO, liquid to reduce dystonia.
5. On Compazine, thioridazine? - may develop dystonia
6. Often starts with oculogyric crisis, may be followed by torticollis (neck muscles pull head to side, or
retrocollis (head is pulled back) or laryngeal-pharyngeal hypertonus in which pt has difficulty
A beta-adrenergic blocker such as propranolol (Inderal) 20 120 mg, may be required.
1. Long-acting risperdone gradually break down, releasing the active form of the medication.
2. This medication is administered IM q2w.
3. Initiation of this medication regimen requires that an oral antipsychotic be given during the 1st 3 weeks
to reach a therapeutic blood level.