CASE

You are the nurse assigned to care for Charles Grey, hospitalized 2 weeks ago and started on
perphenazine (Trilafon) to treat acute psychotic symptoms. During your assessment, Charles
appears restless, unable to sit still, and uncoordinated. You also observe that he has developed a
fine hand tremor. How would you interpret this collective information and how would you
respond as Mr. Grey’s nurse?

CASE FACTS
 Mr. Grey was hospitalized 2 weeks ago
 Perphenazine (trilafon)
 Acute psychotic symptoms
 Restless and uncoordinated
 Fine hand tremor

PERPHENAZINE (TRILAFON)
 Perphenazine (per-fen’-a-zeen)
 Trade name: Trilafon, generic
 Psychotic disorder
 Hypotension, postural hypotension, tardive dyskinesia, photophobia, urticaria, nasal
congestion, dry mouth, akathisia, dystonia, pseudoparkinsonism, behavioral changes,
headache, photosensitivity

TARDIVE DYSKINESIA
 characterized by rhythmic, involuntary movements of the tongue, face, mouth, or jaw
and sometimes the extremities
 may be observed in patients receiving an antipsychotic drug or after discontinuation of
antipsychotic drug therapy.
 When symptoms occur during therapy, use of the drug must be discontinued. Depending
on the severity of the condition being treated, the primary health care provider may
slowly taper the drug dose.

How would you interpret this collective information and how would you respond as Mr.
Grey’s nurse?

Possible Nursing Diagnosis

 Anxiety, related to symptoms of psychosis

 Risk for injury related to side effects of medication
 Deficient knowledge related to unfamiliarity with medications and their effects
As Mr. Grey’s nurse;

 Monitor for decrease of psychotic symptoms

 Monitor for use of medications (antipsychotic drugs must be taken as ordered)
 Monitor the patient closely