MODULE 4

Nursing Process and

Psychotropic Drugs
in Clients with
Maladaptive Behaviors
Lesson 1: Assessment and Assessment Tools
Mental Health Assessment

The nursing process:

(1) Assessment: Data collection Mental& physical

(2) Data Analysis: Nursing Diagnosis
(3) Goal setting: Outcome identification
(4) Planning: Nursing Care Plan
(5) Implementation: Interventions
(6) Evaluation for the expected outcome

Client Assessment: - Collection of data about a person, family, or group by observing,

examining, and interviewing. Data included are about the medical and mental health
status of the client. Clinical interview: - It is a meeting between the client and
professional mental health team member as psychiatric nurse

Purposes of clinical interview:

1- Gathering information about the client.

2- To establish a therapeutic relationship with the client.
3- To conduct therapeutic intervention as counseling or psychotherapy

Clinical interview skills:

1. Active listening: psychiatric nurse should be a good listener.

2. Reflection: mirroring hidden painful feelings and thoughts
3. Paraphrasing: to assure accuracy of client words.
4. Summarizing: to give positive feedback that all data provided by client was
completely understood well.
5. Clarification: by ask client to explain ambiguity.
6. Confrontation: to direct the client toward his real problems
7. Probing: to explore deep unconscious feelings and desires.
8. Rapport: to convey complete attendance, empathy and willingness of
psychiatric nurse to help the client by verbal and nonverbal communication

Mental State Examination (MSE)

An assessment tool of the brain functions that helps mental health professionals to
reach a tentative psychiatric diagnosis. An experienced nurse can complete all the
components of (MSE) that include:
(1) General appearance: - Involves important information that can be taken from the first
sight objectively without asking the client
A- Dress, grooming, &hygiene (self-care)- Good and suitable in healthy or mentally
stable clients, delusional disorder, and most neurotic disorders.

* Schizophrenia may have strange style of dressing.

* Mania dressing is usually bright, multicolored, mismatched & excessive use of
cosmetics.\.
B- Facial expression:- Anxious in anxiety, sad in depression, euphoric or excited in
mania, & apathic in schizophrenia.
C- Eye contact: Lost in shyness, schizophrenia & depression Intermittent in anxiety
Good in mania.
D- Nutritional Status: - Thin client and emaciated in anorexia nervosa. Weight gain or
loss in depression. *

(2) Psychomotor behavior:

A- Hyperactivity: -Agitation, aggression or restlessness as in mania, schizophrenia

and mental retardation.
B- Hypo activity:-Rigidity or retardation as in depression, catatonic schizophrenia or
some forms of conversion disorder.
C- Posture: how client sits, walks, and behaves.- Catatonic p: Waxy flexibility,
bizarre and maintained for a long time as in catatonia.- Restless or agitated p: as
in mania.- Anxious p: as in anxiety disorders.-Depressed p: Leaning forward,
looking at the ground, non-responsive.
D- Stereotypy: Repetitive fixed pattern of action & speech (schizophrenia & mental
retardation.
E- Bizarre behavior: un acceptable Culturally & socially as in schizophrenia.
F- Mannerism: Involuntary, Unusual bizarre behavior, stylized movements. Clearly
uncomfortable or inappropriate as rocking, nodding, rubbing, or grimacing,
smearing

(3) Attitude: - Client's interaction with mental health team may be:
A- Cooperative: in anxiety disorders & residual schizophrenia
B- Resistive: As in acute psychosis and personality disorders.
C- Aggressive: As in mania and schizophrenia.

(4) Speech:
A- Quantity: -Poverty as in depression and catatonia.
B- Quality: -Monotonous, soft, & slow in depression. -Talkative, stereotyped, pressured
& loud in mania Incoherent in schizophrenia.- Stuttered and dysrhythmic in anxiety
disorders.- Repetitious as in dementia & organic brain disorder.

(5) Mood and affect:

A- Mood: Subjective emotional state reported by client. - Mood Variations involve:
*Euthymic mood: Normal range(absence - elevated)
*Dysphoric mood: Feeling unpleasant as in dysthymia.
*Depressed mood: feeling of sadness as in depression.

*Irritable mood: Easily annoyed provoked to anger as in mania.

* Euphoric mood: Intense elation with feeling of grandeur as in mania.
* Anxious mood: feeling of fear of unknown, tension, and expecting the worst.
* Mood swings: euphoria and depression as in bipolar disorder.
* Anhedonia: Loss of interest in all pleasurable activities as in depression.

B: Affect: External expression of feelings as observed by others.

* Appropriate affect: emotional tone is in harmony with the idea.
* Inappropriate affect: Disharmony between the emotional tone and the idea.
*Flat affect: Absence of any sings of affective expression as in schizophrenia.
*Blunt affect: Sever reduction in the external feeling tone as in schizophrenia.
*Labile affect: Rapid and abrupt changes in the external emotional tone, unrelated to
external stimuli as in senile dementia.

(6) Perception:disturbances include:

a. Hallucination: False sensory perception not associated with a real external

stimulus.

Types of hallucinations according to the affected sense:

* Auditory: False perception of sound usually voice.

* Visual: False perception of sight of people or flashes of light.
*Olfactory: False perception in smell.
* Gustatory: client taste something that is not present
*Tactile: client senses that he is being touched when he is not. One of the most
common complaints is the sensation of bugs crawling over the skin, and (phantom sign
) after amputation of limb.
* General somatic hallucination: client experiences a feeling of their body being
seriously hurt through mutilation such as snakes crawling into their stomach.

b. Illusions: Misperception or misinterpretation of real external stimuli.

c. Depersonalization: Subjective sense of being unreal, strange or unfamiliar to oneself

as in panic disorder.

d. Derealization: Subjective sense that the environment is changed or unreal as in panic

disorder.

7- Thinking:

A- disturbance in the form of thought:

* Neologism: New word created by the client, as in schizophrenia.
*Word salad: Incoherent mixture of words (extreme neologism) as in schizophrenia.
*Perseveration: repetition of the same word or idea in response to different questions as
in dementia.

*Loosing of association: ideas shift from one subject to another in unrelated way as in
schizophrenia.

*Flights of ideas: Rapid constant shifting from one idea to another, ideas tend to be
connected, some followed by listener as in mania.

*Clang association: Association of words similar in sound not meaning as in mania.

* Blocking: Abrupt interruption train of thinking before finishing the idea (depression and
schizophrenia)

B: Disturbance in content of thought:

1.Delusion: False fixed belief, not consistent with client intelligence or cultural
background. - Different forms of delusion: -Bizarre delusion: Very strange false belief "
e.g. Invaders from space have implanted electrodes in the client brain. -Delusion of
control: " Thought insertion, withdrawal, broadcasting" - Nihilistic delusion: belief that
self, others or the world is not existent.

- Delusion of poverty: belief of loss of all material possessions. –

Somatic delusion: belief involving the functioning of one's body. e.g. belief that
one's brain is melting
Paranoid delusion: includes persecutory, reference, grandeur.
Mood congruent delusion: e.g. Depressed client believe that he is responsible
about destruction of the world".- Mood incongruent delusion: not associated to mood "
as delusion of grandeur with a depressed client".
* Overvalued ideas: Unreasonable sustained false beliefs less firmly than
delusion.

2. Obsession: Pathological persistent of an irresistible thought cannot eliminated from

consciousness by logical efforts.
3. Hypochondriasis: Exaggerated health concern based on false interpretation of
physical signs and not supported by realistic pathology.
4. Phobia: Persistent, irrational, &exaggerated pathological dread of stimulus lead to a
pressing desire to avoid it.

Abstract thinking: The ability to deal with concepts. E.g. ability to explain similarity
between orange and apple are fruit.Concrete thinking client says both orange and apple
are round, as in schizophrenia and organic brain disease.

8-Sensorium and cognition:

A: Disturbance of orientation: Disorientation to time, person, and place.
B: Disturbance in consciousness:
Somnolence: Abnormal drowsiness.
Stupor: Lack of reaction and awareness to the surroundings.
Coma: Profound degree of unconsciousness

C: Attention: disturbances include:

*Distractibility: Inability to concentrate attention, it is drawn to unimportant external
stimuli as in anxiety and mania.
*Selective inattention: Blocking out things generate anxiety as in malinger.
*Hypervigilance: Excessive attention as in post-traumatic stress disorder and paranoid
state

D- Memory: ability to recall information. divided into:

* Immediate memory: recall perceived objects within seconds.
* Recent (short term) memory: recall events in the past few days.
* Remote (long term) memory: recall of the events in the distant past.
* Amnesia: Partial or total inability to recall past experiences may be organic or
emotional

E: Intelligence: ability to understand, recall previous learning in meeting new situation.

Mental retardation: Lack of intelligence classified as
-Mild retardation: IQ from 50-70, educable in special classes.
- Moderate retardation: IQ from 40-50, trainable simple crafts.
- Severe retardation: IQ from 20-40, maintain activity of daily living.
- Profound retardation: IQ below 20 dependent, and institutionalized.

9- Judgment: ability to assess and evaluate situation, make rational decision, and take
responsibility for actions.
A-Critical judgment: ability to assess situation and choose decision among different
options.
B: Automatic judgment: Reflex performance of action as in impulse control disorder.
C: Impaired judgment: Diminished ability to understand a situation and act properly as in
schizophrenia.
.
10- Insight: client's awareness that he is mentally ill.
A- Complete insight: client is aware that he has mental illness, and recognize the
precipitating and relieving causes, and the importance of treatment program as in
neurosis.
B- Partial insight: client realize he has mental health problem, but explain it as a
result of somatic or social cause, and not committed to his therapeutic program.
C- Loss of insight: client completely deny that he has mental health problem.As in
psychosis.

11- Reliability:The interviewer impression that the client give information accurately and
completely.- It is good in personality disorders and neurosis and impaired in psychosis
12- Spirituality: Involves the client's beliefs, values, and religious culture. These beliefs
helping or hindering (preventing) the client. For example, does hospitalized client exhibit
spiritual anxiety and verbalize a need to connect with his own spiritual support system?

13- Sexuality: Client may be impotent, hermaphrodite, may have lost a sexual partner,
or may have been a victim of sexual abuse.

14. Final conclusion: Summarize the information obtained from the interview with the
client and get an overview of the client's status professionally
Lesson 2: Nursing Diagnosis applicable in psychiatric situation based
on NANDA
Outlines
 Introduction
 Key terms (terminology) in nursing process.
Steps or Standards of nursing process.
 Assessment
 Diagnosis
 Planning
 Implementation &
 Evaluation
 Examples for nursing care plan.
 Summary
 Reference

Introduction
The time tested nursing process continues to guide nurses in clinical practice and
The nurse-patient relationship is the vehicle for applying the nursing process
 Nursing process in theory: is a multistep problem solving method in which client
problems and needs are assessed, diagnosed, treated and resolved.
 Nursing process in practice: is amore cyclic approach due to the client's changing
responses to health and illness.
 N.B: the client's condition is dynamic rather than static, the nurse uses the steps
of the nursing process interchangeably and continuously.

Key terms (terminology)

Nursing care plan:
It is a set of actions the nurse will implemented to resolve nursing problem identified by
assessment. The creation of the plan is an intermediate stage of the nursing process.

Nursing process in psychiatric care:

The nursing process is a process by which nurses deliver care to the psychiatric
patients to improve or solve their mental problems.
NANDA: NANDA diagnosis were first developed in1973
NANDA: North American Nursing Diagnosis Association,
NANDA is the main organization for defining standard diagnosis in North America, now
known as NANDA- international.

Steps or standards of Nursing process

1- Assessment.
2- Nursing Diagnosis.
3- Outcome Identification.
4- Planning.
5- Implementation
6- Evaluation.

ASSESSMENT
 In this phase, information is obtained from the patient in a direct and structured or
indirect manner through observation of verbal and nonverbal behaviors based on
the knowledge of normal and dysfunctional behaviors, interviews and
examination,
 The Assessment may be: subjective or objective.
Subjective assessment: when psychiatric nurse collecting data by herself directly from
the patient
Objective assessment: psychiatric nurse can use other information sources, or from
patient’s family rather than patient.
 The mental status examination: is the psychiatric-mental health component of
client assessment, it is the basic for medical and nursing diagnosis and
management of client care.

Components of psychiatric Nursing assessment

 Components of total client assessment= mental status examination criteria:
 Mental status examination:
 Appearance  dress, hygiene, grooming, facial expression.
 Behavior \ activity  hypo-activity or hyper-activity.
 Attitude  interactions with interviewer.
 Speech  quantity (poverty of speech)
 quality (monotonous, talkative, repetitious)
 Mood and affect  sad, fearful, anxious.
 Perceptions  hallucinations, illusions.
 Thoughts  flight of ideas, blocking, and word salad.
 Sensorium\ cognition  Levels of consciousness, concentration
 Judgment  take responsibility for action, make rational, decision making.
 Insight  ability to understand the cause and nature of own and others
situations.
 Reliability  reported information accurately and completely.

ASSESSMENT
Interview=Participant observation
Nursing role in participant observation:
To maintain massages conveyed by the patient
Be aware of her response to the patient
She should be prepared to consult with members or other people knowledgeable about
the patient
The nurse also might be using other information sources including: the patient's health
care record t reports, nursing care plan, nursing rounds, change of shift reports
Nursing diagnosis

 Nursing diagnosis: is a process whereby nurses interpret data collected during

the assessment phase of the nursing process and apply standardized labels to
clients' health problems and responses to illness

 Nursing diagnosis are statements that describe an individual's health state or

alteration in person's life processes.

Components of the nursing diagnosis PES

Three distinct components of an actual nursing diagnosis statement are:

 Problem
 Etiology &
 Signs & symptoms
This format known as the PES format

 P=Problem
It’s come from the list of approved NANDA nursing diagnosis such as ineffective coping
or, Disturbed thought processes
Some Diagnosis require qualifying statements based on the nature of the problems.
 E=etiology
 known as related factors or contributing factors considered to be the cause of the
problem nursing diagnoses
 often accompanied by several etiologic factors these factors may by psycho logic
biologic relational environmental situational developmental or socio cultural ,For
example:
Altered thought process related to psychosocial stressors
Altered thought process as a result of the schizophrenic process.

 S=signs and symptoms

Is the observable, measurable manifestations of client, also known as defining
characteristics.
 Often require more specific descriptions to better represent the needs of the
client being diagnosed. Ineffective coping has Ineffective problem solving
 Example: Believes the others are planning to kill or harm her. (Delusion of
persecution)

The Complete list of NANDA Nursing Diagnosis for 2012-2014

Below is the list of the 16 new NANDA Nursing Diagnoses

 Risk for Ineffective Activity Planning
 Risk for Adverse Reaction to Iodinated Contrast Media
 Risk for Allergy Response
 Insufficient Breast Milk
 Ineffective Childbearing Process
 Risk for Ineffective Child Bearing Process
 Risk for Dry Eye
 Deficient Community Health
 Ineffective Impulse Control
 Risk for Neonatal Jaundice
 Risk for Disturbed Personal Identity
 Ineffective Relationship
 Risk for Ineffective Relationship
 Risk for Chronic Low Self- Esteem
 Risk for Thermal Injury
 Risk for Ineffective Peripheral Tissue Perfusion

Domain 1 Health Promotion

 Deficient diversional activity
 Sedentary lifestyle
 Deficient community health
 Risk-prone health behavior
 Ineffective health maintenance
 Readiness for enhanced immunization status
  Ineffective protection
 Ineffective self-health management
 Readiness for enhanced self-health management
 Ineffective family therapeutic regimen management

Domain 2 Nutrition
 Insufficient breast milk
 Ineffective infant feeding pattern
 Imbalanced nutrition: less than body requirements
 Imbalanced nutrition: more than body requirements
 Risk for imbalanced nutrition: more than body requirements
 Readiness for enhanced nutrition
 Impaired swallowing
 Risk for unstable blood glucose level
 Neonatal jaundice
 Risk for neonatal jaundice
 Risk for impaired liver function
 Risk for electrolyte imbalance
 Readiness for enhanced fluid balance
 Deficient fluid volume
 Excess fluid volume
 Risk for deficient fluid volume
 Risk for imbalanced fluid volume

Domain 4 Activity/ Rest

 Insomnia
 Sleep deprivation
 Readiness for enhanced sleep
 Disturbed sleep pattern
 Risk for disuse syndrome
 Impaired bed mobility
 Impaired physical mobility
 Impaired wheelchair mobility
 Impaired transfer ability
 Impaired walking
 Disturbed energy field
 Fatigue
 Wandering
 Activity intolerance
 Risk for activity intolerance
 Ineffective breathing pattern
 Decreased cardiac output
 Risk for ineffective gastrointestinal perfusion
 Risk for ineffective renal perfusion
  Impaired spontaneous ventilation
 Ineffective peripheral tissue perfusion
 Risk for decreased cardiac tissue perfusion
 Risk for ineffective cerebral tissue perfusion
 Risk for ineffective peripheral tissue perfusion
 Dysfunctional ventilatory weaning response
 Impaired home maintenance
 Readiness for enhanced self-care
 Bathing self-care deficit
 Dressing self-care deficit
 Feeding self-care deficit
 Toileting self-care deficit
 Self-neglect

Domain 5 Perception/ Cognition

 Unilateral neglect
 Impaired environmental interpretation syndrome
 Acute confusion
 Chronic confusion
 Risk for acute confusion
 Ineffective impulse control
 Deficient knowledge
 Readiness for enhanced knowledge
 Impaired memory
 Readiness for enhanced communication
 Impaired verbal communication

Domain 6 Self-Perception
 Hopelessness
 Risk for compromised human dignity
 Risk for loneliness
 Disturbed personal identity
 Risk for disturbed personal identity
 Readiness for enhanced self-control
 Chronic low self-esteem
 Risk for chronic low self-esteem
 Risk for situational low self-esteem
 Situational low self-esteem
 Disturbed body image
 Stress overload
 Risk for disorganized infant behavior
 Autonomic dysreflexia
 Risk for autonomic dysreflexia
  Readiness for enhanced organized infant behavior
Disorganized infant behavior
 Decreased intracranial adaptive capacity

Domain 7 Role Relationships

 Ineffective breastfeeding
 Interrupted breastfeeding
 Readiness for enhanced breastfeeding
 Caregiver role strain
 Risk for caregiver role strain
 Impaired parenting
 Readiness for enhanced parenting
 Risk for impaired parenting
 Risk for impaired attachment
 Dysfunctional family processes
 Interrupted family processes
 Readiness for enhanced family processes
 Ineffective relationship
 Readiness for enhanced relationship
 Risk for ineffective relationship
 Parental role conflict
 Ineffective role performance
 Impaired social interaction

Domain 8 Sexuality
 Sexual dysfunction
 Ineffective sexuality pattern
 Ineffective childbearing process
 Readiness for enhanced childbearing process
 Risk for ineffective childbearing process
 Risk for disturbed maternal-fetal dyad

Domain 9 Coping/ Stress Tolerance

 Post-trauma syndrome
 Risk for post-trauma syndrome
 Rape-trauma syndrome
 Relocation stress syndrome
 Risk for relocation stress syndrome
 Ineffective activity planning
 Risk for ineffective activity planning
 Anxiety
 Compromised family coping
 Defensive coping
 Disabled family coping
  Ineffective coping
 Ineffective community coping
 Readiness for enhanced coping
 Readiness for enhanced family coping
 Death anxiety
 Ineffective denial
 Adult failure to thrive
 Fear
 Grieving
 Complicated grieving
 Risk for complicated grieving
 Readiness for enhanced power
 Powerlessness
 Risk for powerlessness
 Impaired individual resilience
 Readiness for enhanced resilience
 Risk for compromised resilience
 Chronic sorrow
 Stress overload
 Risk for disorganized infant behavior
 Autonomic dysreflexia
 Risk for autonomic dysreflexia
 Disorganized infant behavior
 Readiness for enhanced organized infant behavior
 Decreased intracranial adaptive capacity

Domain 10 Life Principles

 Readiness for enhanced hope
 Readiness for enhanced spiritual well-being
 Readiness for enhanced decision-making
 Decisional conflict
 Moral distress
 Noncompliance
 Impaired religiosity
 Readiness for enhanced religiosity
 Risk for impaired religiosity
 Spiritual distress
 Risk for spiritual distress

Domain 11 Safety/ Protection

 Risk for infection
 Ineffective airway clearance
 Risk for aspiration
  Risk for bleeding
 Impaired dentition
 Risk for dry eye
 Risk for falls
 Risk for injury
 Impaired oral mucous membrane
 Risk for perioperative positioning injury
 Risk for peripheral neurovascular dysfunction
 Risk for shock
 Impaired skin integrity
 Risk for impaired skin integrity
 Risk for sudden infant death syndrome
 Risk for suffocation
 Delayed surgical recovery
 Risk for thermal injury
 Impaired tissue integrity
 Risk for trauma
 Risk for vascular trauma
 Risk for other-directed violence
 Risk for self-directed violence
 Self-mutilation
 Risk for self-mutilation
 Risk for suicide
 Contamination
 Risk for contamination
 Risk for poisoning
 Risk for adverse reaction to iodinated contrast media
 Risk for allergy response
 Latex allergy response
 Risk for latex allergy response
 Risk for imbalanced body temperature
 Hyperthermia
 Hypothermia
 Ineffective thermoregulation

Domain 12 Comfort
 Impaired comfort
 Readiness for enhanced comfort
 Nausea
 Acute pain
 Chronic pain
 Social isolation
Example include the components of nursing diagnosis
 Problem+ Etiology+ Signs & symptoms

 For example:
Ineffective individual coping, related to response crisis ‘’retirement’’, as evidence
by isolative behaviour, changes in mood.

Risk nursing diagnosis

 Risk factors:
Are used in assessing potential health problems to describe exiting health states
that may contribute to the potential problem becoming an actual problem & there
is
 No defining characteristics and
 There is no etiologic factors

Also the risk Diagnosis carries a two-part statement

Part 1: nursing diagnosis

Risk for other directive violence
Part2: risk factors (predictors of risk problem)
 History of violence
 Panic state
 Hyperactivity, secondary to manic state
 Low impulse control
Long and short term goals

 Before defining expected outcomes, the nurse must realize that patient often
seek treatment with goals of their own.
 These goals may be expressed as relieving symptoms or improving functional
ability
 The expected out comes are derived from diagnosis, guide later nursing actions
and enhance the evaluation of care

Importance point in writing goals

 In writing goals psychiatric nurses should remember that they can be classified in
to the (ABCs) or three domain of knowledge:
 Affective ‘’feeling’
 ’Behavioral ’’psychomotor’’
  Cognitive ’’thinking
For example, it would be of limited help to teach a patient about medication if the patient
did not value taking medications based on personal belief system or previous life
experiences

Qualities of well written outcome criteria

 Specific rather than general
 Measurable rather than subjective
 Attainable rather than unrealistic
 Current rather than outdated
 Adequate in number rather than too few or too many
 Mutual rather than one sided

Outcomes identification
 The psychiatric mental health nurse identifies expected outcomes individualized
to the patient.
 Example of outcome identification
 For example: Ineffective individual coping, related to response crisis ‘’retirement’’,
as evidence by isolative behaviour, changes in mood.
 Client interacts socially with other clients and staff
Planning
 The nurse develops a plan of care that prescribes interventions
 The planning consists of:
 Prioritizing the nursing diagnoses
 Identifying long & short term goals
 Developing nursing interventions
 Recording /writing nursing care plan

Implementation
 The implementation phase of the nursing process: is the actual initiation of the
nursing care plan.
 Involves putting the nursing care plan into
Action
Nursing activities (interventions) to meet the goals set with the client begin

Evaluation
 Evaluation is an ongoing process
The evaluation phase consist of two steps:
 First, the nurse compares the client's current mental health state with that
described in the outcome criteria
 Second, the nurse considers all the possible reasons why client outcomes were
not attained, it may be too soon to evaluate, and the plan of action needs further
implementation
How to write and applied nursing process in psychiatric care
Outcome identification and evaluation:
1-expresses feeling calm, relaxed with absence of muscle tension.
2- Demonstrates absence of avoidance behaviors (withdrawal, lack of contact with
others and relief behaviors.
3- Exhibits ability to make decisions and problem-solve.

Planning and implementation:

1- Maintain client safety and the safety of the others.
2- Show the client how to use slow deep breathing exercises.
3-reduce all environmental stimulation (noise, bright lights, and people moving and
talking.
Conclusion
 Nursing process is a very important chain in each nursing specialty
 The purpose of the nursing process is to achieve scientifically, holistic,
individualized care for the client
 To achieve the opportunity to work collaboratively with clients and their families
or relatives
 To achieve continuity of care

https://slideplayer.com/slide/5726307/
Lesson 3: Planning and Intervention
Nurse-Client Communication- https://slideplayer.com/slide/10931622/
Nurse-Client Relationship- https://slideplayer.com/slide/8314416/

Communication and the Nurse-Patient Relationship

Learning Objectives

Theory
1. Describe the components of the communication process.
2. List three factors that influence the way a person communicates.
3. Compare effective communication techniques with blocks to communication.
4. Describe the difference between a therapeutic nurse-patient relationship and a
social relationship.

The Communication Process

 Communication occurs when one person sends a message and another person
receives it, processes it, and indicates that the message has been interpreted
 Is a continual circular process
 Can be either verbal or nonverbal
 Verbal communication: spoken or written words
 Nonverbal communication: without words
 Nonverbal communication may be by:
Gesture
Body posture
Intonation
General appearance
Factors Affecting Communication
 Cultural differences
 Past experiences
 Emotions and mood
 Attitude of the individual

Cultural Differences
 Personal space
 Eye contact
 Meanings of words
 Averting eyes is normal in some cultures
 Meanings of words
 “Yes” may not mean yes
 Cultural norms
 Older adults may not want instructions from younger people
 Religious beliefs

Past Experience and Communication

How we perceive what is communicated to us depends on:

 Cultural values
 Level of education
  Familiarity with the topic
 Occupation
 Previous life experiences

Emotions and Mood

 Anxious patients may not hear all that is said or may not interpret it correctly
 An upset person may speak more loudly than usual
 A depressed person may communicate minimally
 A person’s attitude may affect how a message is received

Communication Skills
 Active listening
 Requires concentration and focused energy
 Uses all the senses to interpret verbal and nonverbal messages
(feedback)
 Listens for feelings as well as words
 Maintains eye contact without staring and makes a conscious effort to
block out distractions

Interpreting Nonverbal Messages

 Observe for:
 Posture
 Gestures
 Tone
 Facial expression
 Smiling or frowning
 Eye contact

Obtaining Feedback
 A vital part of communication is checking to see if you interpreted a message in
the way the speaker meant it
 Accomplished by rephrasing the meaning of the message or directly asking a
feedback question

Focusing
 Keeping attention focused on the communication task at hand
 Continually check to see that the patient is still the topic of the interaction

Adjusting Style
 Patient’s style and level of usual communication should be considered when
interacting
 If the person is a slow, calm communicator, adjust to that pace
 If a response is slow in coming, allow plenty of time for consideration and a
response
Therapeutic Communication Techniques
 Promoting communication between sender and receiver, obtaining feedback
 Focusing on the communicator
 Using silence and open-ended questions
 Restating the message
 Clarifying
 Using therapeutic touch
 Giving general leads
 Offering self
 Encouraging elaboration
 Giving information
 Looking at alternatives
 Summarizing

Blocks to Effective Communication

 Changing the subject
 Offering false reassurance
 Giving advice
 Making defensive comments
 Asking prying or probing questions
 Not listening attentively
 Using clichés

Challenges for Nurses

 Developing interviewing skills
Using the nurse-patient relationship
 Using empathy
 Becoming nonjudgmental
 Maintaining hope
 Applying the nursing process
 Communicating with hearing-impaired patients, elderly, children, and people from
other cultures

Communicating with the Hearing-Impaired

 Speak very distinctly
 Do not shout
 Speak slowly
 Get the person’s attention
 Maintain a good distance (2 1/2 to 4 feet)
 Watch for nonverbal feedback
 Use short sentences
 Paraphrase for clarification
Communicating with the Elderly
 Assess for hearing deficits
 Assess for visual deficits
 Give time for elders to formulate responses
 Wait for an answer to one question before asking another
 Obtain feedback

Communicating with Children

 Approach at eye level
 Use a calm, friendly voice
 Keep parent in the room when possible
 Use short sentences
 Give simple explanations and demonstrations
 Allow child to handle equipment

Communicating with People from Other Cultures

 Determine the language spoken
 Obtain an interpreter if necessary
 Enlist the aid of a family member if appropriate
 Give printed materials if available and answer questions
 Beware of cultural differences in:
 Eye contact
 Personal space

Communicating with Health Care Team Members

 Nurses’ notes
 Physician’s orders and progress notes
 Dietitian’s notes
 OT, PT, and speech therapy notes
 Shift report
 Radiology and laboratory findings

Telephoning Physicians
 Have patient data on hand: laboratory data, vital signs, urinary output, medication
received
 Keep chart handy and anticipate information that the physician may request
 Know patient allergies and perform a quick assessment before calling
 Prepare a concise problem statement
 Document the call and physician’s response

Assignment Considerations and Delegating

 Give clear, concise messages and listen carefully to feedback
 Include the result desired and the time line for completion along with the task
assignment
  Ask person to whom you are assigning a task if any questions about what is to
be done, and ask for a summary of what is understood about the task to be done

Computer Communication
 Ability to use a computer for communication is essential for today’s nurse
 Transmit requests for laboratory, dietary, radiology, physical therapy, respiratory
therapy, and other services
 Medication orders
 Supplies for patient care
 Update patient care plans
 Computerized form of charting

Communication in the Home and Community

 Essential to state when instructions are about to be given so active listening can
occur
 Leave written step-by-step instructions with the patient whenever possible
 Office and clinic nurses often assess patients who call in to see if they have an
urgent need for medical attention
Lesson 4: Treatment Modalities
Therapeutic modalities in psychiatry

Treatment modalities

 The various treatment modalities in psychiatry are broadly divided as:

1. Somatic (physical) therapies
2. Psychological therapies
3. Milieu therapy
4. Therapeutic community
5. Activity therapy

1. Somatic (physical) therapies

 Psychopharmacology
 Electroconvulsive Therapy
 Psychosurgery

SOMATIC THERAPIES Psychopharmacology

 Drugs used in psychiatry are called as psychotropic (or psychoactive) drugs

General Guidelines
 The nurse should administer any drug ONLY WITH A written order.
 Consult the doctor when in doubt
 All medications given must be charted on the patient's case record sheet.
 Always address the patient by name and make certain of his identification
 Do not leave the patient until the drug is swallowed
 Do not permit the patient to go to the bathroom to take the medication
 Do not leave the tray within the reach of the patient.
 Bottles should be tightly closed and labeled

Classification of Psychotropic Drugs

1. Antipsychotics
2. Antidepressants
3. Mood stabilizing drugs
4. Anxiolytics and hypnosedatives
5. Antiepileptic drugs
6. Antiparkinsonian drugs
7. Miscellaneous drugs which include stimulants, drugs used in eating disorders,
addiction, child psychiatry, vitamins, and calcium channel blockers, etc.

 Antipsychotics
 Used for the treatment of psychotic symptoms.
 These are also known as neuroleptics
Indications
Organic psychiatric disorders

 Delirium
 Dementia
 Delirium tremens
 Drug-induced psychosis

Psychiatric disorders
 Schizophrenia
 Mania
 Major depression with psychotic symptoms

Childhood disorders
 Attention-deficit hyperactivity disorder
 Autism
 Conduct disorder Medical disorders
 Tic disorder
Adverse Effects of Antipsychotic Drugs

I. Extrapyramidal symptoms (EPS)

1. Neuroleptic-induced Parkinsonism: rigidity, tremors, bradykinesia, drooling The

disorder can be treated with anticholinergic agents.
2. Acute dystonia: Dystonic movements results from a slow sustained muscular spasm
that lead to an involuntary movement. Dystonia can involve the neck, jaw, tongue and
the entire body (opisthotonos).
3. Akathisia: Akathisia is a subjective feeling of muscular discomfort that can cause
Patients to be agitated. Akathisia can be treated with propranolol, benzodiazepines and
clonidine.
4. Tardive dyskinesia: It is a delayed adverse effect of antipsychotics. It consists of
abnormal, irregular choreoathetoid movements of the muscles of the head, limbs and
trunk. It is characterized by chewing, sucking, grimacing and peri-oral movements.

5. Neuroleptic malignant syndrome

 Serious
 In the first 10 days of treatment.
 generalized muscular hypertonicity - Stiffness of the muscles in the throat and
chest may cause dysphasia, and dyspnea mutism,
 Stupor or impaired consciousness.
 Hyperpyrexia
 Autonomic disturbances - unstable blood pressure, tachycardia, excessive
sweating, salivation, and urinary incontinence.
 Creatinine Phospho Kinase [CPK] levels may be raised to very high levels,
 Secondary features - pneumonia, thromboembolism, cardiovascular collapse,
and renal failure.
 The syndrome lasts for one to two weeks after stopping the drug.

Nurse's Responsibility for a Patient Receiving Antipsychotics

 Instruct the patient to take sips of water frequently to relieve dryness of mouth.
 A high-fiber diet, increased fluid intake
 Advise the patient to get up from the bed or chair very slowly.
  Observe the patient regularly for abnormal movements.
 Patient should be warned about driving a car or operating machinery when first
treated with antipsychotics.

Antidepressants

Indications

Depression
 Depressive episode
 Dysthymia
 Reactive depression
 Secondary depression
 Abnormal grief reaction

Childhood psychiatric disorders

 Separation anxiety disorder
 Somnambulism
 School phobia
 Night terrors
Other psychiatric disorders
 Panic attack
 Generalized anxiety disorder
 Agoraphobia, social phobia
 OCD with or without depression
Side Effects
1. Autonomic side-effects: Dry mouth, constipation, mydriasis, urinary retention,
orthostatic hypotension, impotence, impaired ejaculation.
2. CNS effects: Sedation, tremor, seizures, precipitation of mania.
3. Cardiac side-effects: Tachycardia, ECG changes, arrhythmias
4. Allergic side-effects
5. Metabolic and endocrine side-effects: Weight gain.
6. Special effects of MAOI drugs: Hypertensive crises, hyperpyrexia.

Nurse's Responsibility
 Patients on MAOis should be warned against the danger of ingesting tyramine-
rich foods which can result in hypertensive crisis. Some of these foods are beef
liver, chicken liver, dried fish, overripe fruits, chocolate and beverages like wine,
beer and coffee.
 Caution the patient to change his position slowly to minimize orthostatic
hypotension.
Mood Stabilizing Drugs
 Lithium
 Carbamazepine
 Sodium valproate

Lithium

Indications
 Acute mania
 Prophylaxis for bipolar and unipolar mood disorder.
 Schizoaffective disorder
 Cyclothymia
 Impulsivity and aggression

Lithium – MOA
 It accelerates presynaptic re-uptake and destruction of catecholamine, like
norepinephrine
 It inhibits the release of catecholamine at the synapse.
 It decreases postsynaptic serotonin receptor sensitivity.
 All these actions result in decreased catecholamine activity, thus ameliorating
mania.

Dosage
 The usual range of dose per day in acute mania is 900-1200mg given in 2-
3divided doses. Blood Lithium Levels
 Therapeutic levels = 0.8 - 1.2 mEq/L (for treatment of acute mania)
 Prophylactic levels = 0.6 - 1.2 mEq/L (for prevention of relapse in bipolar
disorder)
 Toxic lithium levels > 2.0mEq/L

Side Effects
1. Neurological: Tremors, motor hyperactivity, muscular weakness, cogwheel rigidity,
seizures, delirium, coma.
2. Renal: Polydipsia, polyuria, nephrotic syndrome.
3. Cardiovascular: T -wave depression.
4. Gastrointestinal: Nausea, vomiting, diarrhea, abdominal pain and metallic taste.
5. Endocrine: Abnormal thyroid function, goiter and weight gain.
6. Dermatological: Acneiform eruptions, popular eruptions and exacerbation of
psoriasis.
7. Side-effects during pregnancy and lactation: Teratogenic possibility, increased
incidence of Ebstein's anomaly
8. Signs and symptoms of lithium toxicity (serum lithium level >2.0 mEq/L):
 ataxia
 coarse tremor (hand)
  nausea and vomiting
 impaired memory
 impaired concentration
 nephrotoxicity
 muscle weakness
 convulsions
 muscle twitching
 dysarthria
 lethargy
 confusion
 hyperreflexia
 nystagmus

Nurse's Responsibilities
 Lithium must be taken on a regular basis, preferably at the same time daily
 Polyuria can lead to dehydration patients should be advised to drink enough
water
 People involved in heavy outdoor labor are prone to excessive sodium loss
through sweating. They must be advised to consume large quantities of water
with salt.
 Blood for determination of lithium levels should be drawn in the morning
approximately 12-14hours after the last dose
 The patient should be told about the importance of regular follow-up. In every six
months, blood sample should be taken for estimation of electrolytes, urea,
creatinine, a full blood count, and thyroid function test.

Carbamazepine – Tegretol

Indications
 Seizures-complex partial seizures, GTCS,
 Psychiatric disorders- rapid cycling bipolar disorder, impulse control disorder,
aggression, psychosis with epilepsy, borderline personality disorder
 Paroxysmal pain syndromes – trigeminal neuralgia Dosage
 The average daily dose is 600-1800mg orally, in divided doses.
 The therapeutic blood levels are 6- 12μg/ml. Mechanism of Action
 Its anticonvulsant action may however be by decreasing synaptic transmission
 Side Effects
 Drowsiness, headache, ataxia, skin rashes, Steven-Johnson syndrome, nausea,
vomiting, diarrhea, dry mouth, thrombocytopenia, aplastic anemia.

Sodium Valproate
Indications
 Acute mania, prophylactic treatment of bipolar I disorder, rapid cycling bipolar
disorder.
 Schizoaffective disorder.
  Seizures. Mechanism of Action
 The drug acts on (GABA) an inhibitory amino acid neurotransmitter. Dosage
 The usual dose is 15mg/kg/ day with a maximum of 60mg/kg/ day orally. Side
Effects
 Nausea, vomiting, diarrhea, sedation, weight gain, thrombocytopenia

Indications for Benzodiazepines

 Anxiety disorders
 Insomnia
 Depression
 Panic disorder and social phobia
 Obsessive-compulsive disorder
 Post-traumatic stress disorder
 Bipolar I disorder
 Other psychiatric indications include alcohol withdrawal, substance-induced and
psychotic agitation
Electroconvulsive Therapy
 Introduced by Bini and Cerletti in
 Electroconvulsive therapy is the artificial induction of a grandma! Seizure through
the application of electrical current to the brain.
 electrodes that are placed either bilaterally in the front-temporal region, or
unilaterally on the non-dominant side Parameters of Electrical Current Applied
 Voltage - 70-120 volts.
 Duration - 0.7-1.5 seconds Mechanism of Action
 possibly affects the catecholamine pathways between diencephalon) and Limbic
system Types of ECT
 Direct ECT
 Modified ECT
 Frequency and Total Number of ECT
 Frequency: Three times per week or as indicated.
 Total number: 6 to 10; up to 25 may be preferred as indicated.

Indications

a. Major depression: With suicidal risk; with stupor; with poor intake of food and fluids;
with psychotic features
b. Severe catatonia (functional)
c. Severe psychosis (schizophrenia or mania): With risk of suicide, homicide or danger
of physical assault; with depressive features; with unsatisfactory response to drug

Contraindications
A. Absolute:
 raised ICP (intracranial pressure)
B. Relative:
 cerebral hemorrhage
 brain tumor
 acute myocardial infarction
  congestive heart failure

Complications of ECT
 Fractures can sometimes occur in elderly patients with osteoporosis.
 In patients with a history of heart disease, dysrhythmias and respiratory arrest
may occur.

Side Effects of ECT

 Memory impairment.
 Drowsiness, confusion and restlessness.
 Headache, weakness/fatigue.
 Tongue bite

Role of the Nurse

a. Pre-treatment evaluation
 An informed consent should be taken.
 Assess baseline vital signs.
 Patient should be on empty stomach for 4-6 hours prior to ECT.
 Withhold night doses of drugs, which increase seizure threshold like diazepam,
barbiturates and anticonvulsants
 Any jeweler, prosthesis, dentures, metallic objects should be removed from the
patient's body.
 Administration of 0.6 mg atropine IM or SC 30 minutes before ECT, or IV just
before ECT.

b. Intra-procedure care
 Place the patient comfortably on the ECT table in supine position.
 Assist in administering the anesthetic agent (thiopental sodium 3-5 mg/kg body
weight) and muscle relaxant (1mg/kg body weight of succinylcholine).
 Mouth gag should be inserted to prevent possible tongue bite.
 During seizure monitor vital signs, ECG, oxygen saturation, EEG, etc.

c. Post-procedure care
 Monitor vital signs.
 Continue oxygenation till spontaneous respiration starts.
 Assess for post-ictal confusion and restlessness.
 Take safety precautions to prevent injury - side lying position and suctioning to
prevent aspiration of secretions

Psychosurgery

"A surgical intervention, to destroy fibers connecting one part of the brain with another
with the intent of modifying behavior, thought or mood disturbances
Indications

 Severe psychiatric illness.

 Chronic duration of illness of about 10years.
 Failure to respond to all other therapies.
 High risk of suicide.

PSYCHOLOGICAL THERAPIES
 Psychoanalytic therapy
 Behavior therapy
 Cognitive therapy
 Hypnosis
 Abreaction therapy
 Individual psychotherapy
 Supportive psychotherapy
 Group therapy
 Family and marital therapy

Psychoanalytic Therapy
 First developed by Sigmund Freud at the end of the 19thcentury.
 The most important indication for psychoanalytical therapy is the presence of
longstanding mental conflicts, which may be unconscious but produce
symptoms.
  The aim of the therapy is to bring all repressed material to conscious awareness
so that the patient can work towards a healthy resolution of his problems, which
are causing the symptoms.
 transference refers to the patient's development of strong positive or negative
feelings towards the analyst, and countertransference therapist's reciprocal
response to the patient

Behavior Therapy
 Behavior therapy involves identifying maladaptive behaviors and seeking to
correct these by applying the principles of learning derived from the following
theories:
 Classical conditioning model by Ivan Pavlov
 Operant conditioning model by BF Skinner

Behavior Techniques (A) Systematic desensitization

 It was developed by Joseph Wolpe, based on the behavioral principle of counter
conditioning.
 In this patients attain a state of complete relaxation and are then exposed to the
stimulus that elicits the anxiety response.
 It consists of three main steps:
 Relaxation training
 Hierarchy construction
 Desensitization of the stimulus

1. Relaxation training: There are many methods which can be used to induce relaxation
 Jacobson's progressive muscle relaxation
 Hypnosis
 Meditation or yoga
 Mental imagery
 Biofeedback
2. Hierarchy construction: Here the patient is asked to list all the conditions which
provoke anxiety. Then he is asked to list them in a descending order of anxiety
provocation.
3. Desensitization of the stimulus: At first, the lowest item in hierarchy is confronted. The
patient is advised to signal whenever anxiety is produced. With each signal he is asked
to relax. After a few trials, patient is able to control his anxiety gradually.
C. Aversion therapy:
Pairing of the pleasant stimulus with an unpleasant response. Unpleasant response is
produced by electric stimulus, drugs.

Indications:
Alcohol abuse
Paraphilia

D. Operant conditioning procedures for increasing adaptive behavior

1. Positive reinforcement
2. Token economy
Cognitive Therapy
 Behavior is secondary to thinking.
 Self-defeating and self-depreciating patterns of thinking result in depressed
mood.
 The therapist helps the patient by correcting this distorted way of thinking,
feelings and behavior.
 The cognitive model of depression includes the cognitive triad:
1. A negative view about self
2. A negative view about the environment and
3. A negative view about the future
 These negative thoughts are modified to improve the depressive mood.

Hypnosis
 Hypnosis is an artificially induced state in which the person is relaxed and
unusually suggestible.
 Hypnosis can be induced in many ways, such as by using a fixed point for
attention
 The person becomes highly suggestible to the commands of the hypnotist.
 There is an ability to produce or remove symptoms or perceptions.

Abreaction Therapy
 Abreaction is a process by which repressed material, particularly a painful
experience or conflict is brought back to consciousness.
 The person not only recalls but also relives the material, which is accompanied
by the appropriate emotional response.
 A safe method is the use of thiopentone sodium i.e. 500 mg dissolved in 10 cc of
normal saline

Individual Psychotherapy
 Trained person deliberately establishes a professional relationship with the
patient to remove, modify or retard existing symptoms
 Individual psychotherapy is conducted on a one-to-one basis, i.e. the therapist
treats one client at a time
 The patient is encouraged to discover for himself the reasons for his behavior.
The therapist listens to the patient and offers explanation and advice when
necessary.

Supportive Psychotherapy
 In this, the therapist helps the patient to relieve emotional distress and symptoms
without probing into the past and changing the personality.
 He uses various techniques such as:
 Ventilation: It is a free expression of feelings or emotions. Patient is
encouraged to talk freely whatever comes to his mind.
 Environmental modification/manipulation: Improving the well-being of
mental patients by changing their living condition.
  Persuasion: Here the therapist attempts to modify the patient's behavior
by reasoning.
 Re-education: Education to the patient regarding his problems, ways of
coping, etc.
 Reassurance

Group Therapy

 Carefully selected people who are emotionally ill meet in a group guided by a
trained therapist, and help one another effect personality change.

Therapeutic Factors Involved in Group Therapy

 Sharing experience
 Support to and from group members
 Socialization
 Imitation
 Interpersonal learning

Family and Marital Therapy

 The focus of treatment is not the individual, but the family.

 Family therapy is indicated whenever there are relational problems within a
family
 Components of Therapy
 Teaching communication skills
 Teaching problem solving skills
 Writing a behavioral marital contract
 Homework assignments

https://www.slideshare.net/mordecaiEnoch/therapeutic-modalities-in-psychiatry-
142524631

Psychopharmacology

 Psychopharmacology is the study of the effects of drugs on affect, cognition,

and behavior
 Efficacy refers to the maximal therapeutic that a drug can achieve.
 Potency describe the amount of the drug needed to achieve the maximum
effect.
 Half-life is the time taken for half of the drug to be removed from the blood
stream.
 Agonist a drug that binds to and activates a receptor
 Antagonist a drug that binds to but does not activate (block) a receptor
  Neurotransmitters are the chemical messengers that travel from one brain cell
to another and are synthesized by enzymes from certain dietary amino acids or
precursors
 Receptors are molecules situated on the cell membrane that are binding sites
for neurotransmitters.

Presynaptic Drug Actions

 Presynaptic auto receptors regulate the amount of NT released from the axon
terminal
 Drugs that activate presynaptic auto receptors reduce the amount of NT
released, an antagonistic action
 Drugs that inactivate presynaptic auto receptors increase the amount of
NT released, an agonistic action
 Presynaptic hetero receptors are sensitive to NT released by another neuron,
can be inhibitory or facilitatory

Effect of drug in neurotransmission

 Release
 Blockade
 Changes in receptor sensitivity
 Blocked reuptake
 Interference with storage vesicles
 Precursor chain interference Psychopharmacology
Classifications of psychotropic drugs
 Antipsychotics
 Antidepressants
 Mood stabilizing agents
 Anxiolytics
 Antiepileptic drugs
 Antiparkinsonian drugs
 Miscellaneous (stimulants, drugs used for de addiction, drugs used in child
psychiatry)
Antiparkinsonian drugs
 Classification of antiparkinsonian Drugs:
 Drugs acting on dopaminergic system:
 Dopamine precursors – Levodopa (l-dopa)
 Peripheral decarboxylase inhibitors – carbidopa and benserazide
 Dopaminergic agonists: Bromocriptyne, Ropinirole and Pramipexole
 MAO-B inhibitors – Selegiline, Rasagiline
 Dopamine facilitator – Amantadine
 Drugs acting on cholinergic system
 Central anticholinergics – Teihexyphenidyl (Benzhexol), Procyclidine,
Biperiden
 Antihistaminics – Orphenadrine, Promethazine

 Dopamine and Tyrosine Are Not Used for Parkinson Disease Therapy, Why?
– Dopamine Doesn't Cross the Blood Brain Barrier
– Huge amount of tyrosine decreases activity of rate limiting enzyme Tyrosine
Hydroxylase

 Levodopa
 Single most effective agent in PD
 Inactive by itself but immediate precursor of Dopamine
  Peripherally - 95% is decarboxylated in peripheral tissues in gut and liver to
dopamine
– This dopamine acts on peripheral organs like heart, blood vessels and CTZ
etc. (NOT CNS)
 1 - 2% crosses BBB, taken up by neurons and DA is formed
– Stored and released as neurotransmitter
 Actions of Levodopa – CNS
 Effective in Eliminating Most of the Symptoms of Parkinson Disease (initially
motor)
– Bradykinesia and Rigidity Respond Quickly
– Reduction in Tremor Effect with Continued therapy
 Secondary symptoms - Handwriting, speech, facial expression and interest in life
improves gradually
 L - Dopa less Effective in Eliminating Postural Instability and Shuffling Gait
Meaning Other Neurotransmitters are Involved in Parkinson Disease
 Behavioural Effects:
– Partially Changes Mood by elevating mood, and increases Patient sense of
well-being - General alerting response
– Disproportionate increase in sexual activity
– No improvement in dementia
– Psychiatric symptoms
 Actions of Levodopa – CVS:
– Cardiac Stimulation Due to Beta adrenergic effect on Heart
–Though stimulates peripheral adrenergic receptor – no rise in BP
– Orthostatic Hypotension - some individuals – central DA and NA action
– In elderly cardiovascular problems - transient tachycardia, cardiac arrhythmias
and hypertension
–Tolerance to CVS action develops within few weeks
 CTZ: DA receptors cause stimulation – nausea and vomiting – tolerance
 Endocrine: Decrease in Prolactin level and increase in GH release

Pharmacokinetics
 Absorbed rapidly from small intestine
 High First Pass Effect
– Competition for amino acids present in food competes for the carrier
– Also depends on gastric emptying and pH
 Peak plasma conc. 1-2 hrs. and half-life - 1 to 3 hrs.
 Metabolized in liver and peripherally - secreted in urine unchanged or conjugated
with glucoronyl sulfate
 Central entry into CNS (1%) - mediated by membrane transporter for aromatic
amino acids – competition with dietary protein
 In CNS – Decarboxylated and DA is formed – therapeutic effectiveness
 Transport back by presynaptic uptake or metabolized by MAO.
ADRs
Initial Therapy:
 Nausea and vomiting - 80% of patients
 Postural hypotension, but asymptomatic: 30 % of patient’s tolerance develops -
disappear after prolonged treatment
 Cardiac arrhythmias (due to beta adrenergic action and peripheral CA synthesis)
- tachycardia, ventricular extra systoles and, rarely, atrial fibrillation
 Exacerbation of angina

 Prolonged therapy:
1. Abnormal movements: Facial tics, grimacing, tongue thrusting, choreoathetoid
movements of limb after few months of treatment
2. Behavioural effects:
– 20 to 25% of Population
– Trouble in Thinking (Cognitive Effects)
– L- dopa can induce: Anxiety, psychosis, confusion, hallucination,
delusion
– Hypomania - Inappropriate Sexual Behavior; "Dirty Old Man", "Flashers“
- Drug Holiday (1 - 3 weeks)

Fluctuation in Motor Performance:

 Initial therapy – each dose - good duration of action 9more than half-life)
- Suggesting Nigrostriatum retains capacity to store and release
 Prolonged therapy – “buffering” capacity is lost – each dose causes fluctuation of
motor state - each dose has short duration of action– short therapeutic effect (1 –
2 hrs.) – bradykinesia and rigidity comes back quickly - "On-off" Phenomenon
- Like a Light Switch: Without Warning
 DYSKINESIA – excessive abnormal involuntary movements even in on phase
(more troublesome)
 Dyskinesia often with high plasma conc. of levodopa
 Dyskinesia = Bradykinesia and Rigidity in terms of patient comfortless

 Anti-anxiety medications, as the name implies, are prescribed to reduce anxiety.

 They are prescribed for a number of illnesses:

Generalized Anxiety (GAD)
Post-Traumatic Stress Disorder (PTSD)
Phobias
Obsessive Compulsive Disorder (OCD)
Panic Disorder
Insomnia related to Anxiety
 Classification
Barbiturates:
Benzodiazepines
Non barbiturates and non-benzodiazepines
 Benzodiazepines are considered CNS depressants.
  How do they work? Enhance the actions of the neurotransmitter, GABA, which
slows down brain activity. This produces a drowsy or calming effect.
 They are used to produce sedation, induce sleep, relieve anxiety and muscle
spasms, and to prevent seizures.
 Side Effects: drowsiness, dizziness, loss of coordination, fatigue, mental slowing,
confusion.
 Withdrawal reactions are possible. S/S: anxiety, shakiness, headache, dizziness,
seizures.
 Precautions: with elderly, lung disease, liver disease, kidney disease, sleep
apnea
 Contraindications: acute narrow angle glaucoma
Safety Concerns:
 Risk of addiction: should be only used short term.
 Patient should not drive or operate heavy machinery.
 Not to be mixed with ETOH, opiates, OTC cough/allergy medications,
dental anesthetics – can be life threatening (resp. depression)
 Discuss use of OTC medications and supplements and other prescribed
drugs with MD before taking them with this type of medication.
 MUST NOT be discontinued abruptly. Taper schedule is prescribed.
Synonymous
 Neuroleptic drugs
 Anti-schizophrenic drugs
 Major tranquilizers
 Dopamine receptor antagonists

Classification: TYPICAL ANTIPSYCHOTICS

a. Phenothiazine derivatives
 Aliphatic Derivative: CHLORPROMAZINE
 Piperidine Derivative: THIORIDAZINE
 Piperazine Derivative: FLUPENAZINE, PERPHENAZINE, TRIFLUOPERAZINE
b. Thioxanthene Derivative: THIOTHIXENE
c. Butyrophenone: HALOPERIDOL

Classification:
ATYPICAL ANTIPSYCHOTICS
CLOZAPINE LOXAPINE
OLANZAPINE QUETIAPINE
RISPERIDONE MOLINDONE
ZIPRASIDONE
SERTINDOLE A RIPIPRAZOLE

Difference between Typical Antipsychotics and Atypical Antipsychotics

1. The side effects
2. The efficacy
3. Atypical anti psychotics are excreted faster.
4. Atypical anti psychotics are less likely to cause extra pyramidal motor control and
tardive dyskinesia
5. Atypical anti psychotics are easier to discontinue and are less addictive.
6. Atypical anti-psychotic drugs are recommended over typical psychotic drugs.
7. Atypical anti psychotics fail to produce prolactin in the serum.
8. Withdrawal symptoms are less likely with atypical anti-psychotic drugs
9. Akathesia to be less intense with these drugs than the typical antipsychotic.
Pharmacological action of Anti-psychotic drugs: CNS
 Reduction in irrational behavior, agitation, aggressiveness.
  Disturbed thoughts and behavior gradually normalized
 Relives anxiety
 Hyperactivity, hallucination and delusions are suppressed
 Sedation
 Lowers seizures threshold level
 Extrapyramidal motor disturbances

 Exerts  adrenergic blocking activity results in-

- postural hypotension
- Palpitation
- Inhibition of ejaculation
 Exerts anticholinergic activity results in-
- dry mouth
- Blurring of vision
- Constipation
- Urinary hesitancy
• Hypotension due to  adrenergic blocking action
• Reflex tachycardia
• Q-T prolongation and T wave suppression

Endocrine-
• Increases secretion of prolactin hormone results in gynecomastia and agalactorrhea
• Reduction of gonadotropin hormone results in amenorrhea, infertility.

Pharmacokinetics:
• Most neuroleptic drugs are highly lipophilic, bind avidly to proteins, and tend to
accumulate in highly perfused tissues.
• Oral absorption is incomplete and erratic.
• IM injection is more reliable. With repeated administration, variable accumulation
occurs in body fat and possibly in brain myelin.
• Half-lives are generally long, and so a single daily dose is effective.
• After long-term treatment and drug administration is stopped, therapeutic effects may
outlast significant blood concentrations by days or weeks. This may result from tight
binding of parent drug of active metabolites in the brain.
• Metabolites are excreted in urine and bile.

Uses:
• Schizophrenia
• Schizoaffective disorder
• Mania
• Organic brain syndrome
• Anxiety
• Preanaesthtic medication
• Intractable hiccough
• Tetanus
• Alcoholic hallucination
• Huntington’s disease
• Tourette’s syndrome

Contraindications:
These drugs are contraindicated in
• Hypersensitivity
• CNS depression
• Blood dyscrasias
• Parkinson’s disease
• Liver, renal, or cardiac insufficiency

Precautions:
• Elderly, severely ill, or debilitated, and to diabetic clients or clients with respiratory
insufficiency, prostatic hypertrophy, or intestinal obstruction.
• Individuals should avoid exposure to extremes in temperature while taking
antipsychotic medication.
• Safety in pregnancy and lactation has not been established.

Adverse drug reactions:

 Anticholinergic effects-
Dry mouth
Blurred vision
Constipation
Urinary retention
 Nausea, GI upset
 Skin rashes
 Sedation
 Photosensitivity
 Orthostatic hypotension

 Hormonal effects
Decreased libido, gynecomastia
Amenorrhea
Infertility
Weight gain
 ECG changes
Q-T prolongation and T wave suppression
 Decreased threshold level
 Agranulocytosis
 Hyper salivation
 Extrapyramidal symptoms
Pseudo-parkinsonism (tremor, shuffling gait, drooling, rigidity)
Akinesia (muscular weakness)
Akathisia (continuous restlessness and fidgeting)
Dystonia (involuntary muscular movements [spasms] of face, arms, legs,
and neck)
Oculogyric crisis (uncontrolled rolling back of the eyes)
Adverse drug reactions:
 Neuroleptic malignant syndrome (NMS)
Symptoms include –
Severe parkinsonian muscle rigidity,
Hyperpyrexia up to 107 f,
Tachycardia,
Tachypnea,
Fluctuations in blood pressure,
Diaphoresis,
Rapid deterioration of mental status
Stupor and coma.

Nursing management of ADR:

For Anticholinergic effects:
 Provide the client with sugarless candy or gum, ice, and frequent sips of water.
 Ensure that client practices strict oral hygiene.
 Explain that this symptom will most likely subside after a few weeks.
 Advice client not to drive a car until vision clears.
 Clear small items from pathway to prevent falls.
 Order foods high in fiber
 Encourage increase in physical activity and fluid intake if not contraindicated.
 Instruct the client to report any difficulty urinating; monitor intake and output.
Nursing management of ADR:
For Nausea and GI upset:
 Tablets or capsules may be administered with food to minimize GI upset.
 Concentrates may be diluted and administered with fruit juice or other liquid.
 They should be mixed immediately before administration.
For Skin Rash:
 Report appearance of any rash on skin to physician.
 Avoid spilling any of the liquid concentrate on skin
 Contact dermatitis can occur with some medications.
For Sedation:
 Discuss with the physician the possibility of administering the drug at bedtime.
 Discuss with the physician a possible decrease in dosage or an order for a less
sedating drug.
 Instruct client not to drive or operate dangerous equipment while experiencing
sedation.
For Orthostatic hypotension:
 Instruct the client to rise slowly from a lying or sitting position
 Monitor blood pressure (lying and standing) each shift
 Document and report significant changes.
For Photosensitivity:
 Ensure that the client wears a protective sunblock lotion, clothing, and
sunglasses while spending time outdoors.
For Hormonal effects:
 Provide an explanation of the effects and reassurance of reversibility.
 If necessary, discuss with the physician the possibility of ordering alternate
medication.
 Offer reassurance of reversibility
 Instruct the client to continue use of contraception, because amenorrhea does
not indicate cessation of ovulation.
 Weigh client every other day
 Order a calorie controlled diet
 Provide an opportunity for physical exercise
 Provide diet and exercise instruction.
For ECG Changes:
 Caution is advised in prescribing this medication to individuals with history of
arrhythmias.
 Conditions that produce hypokalemia and/or hypomagnesemia, such as diuretic
therapy or diarrhea, should be taken into consideration when prescribing.
 Routine ECG should be taken before initiation of therapy and periodically during
therapy.
 Monitor vital signs every shift.
 Observe for symptoms of dizziness, palpitations, syncope, or weakness.

For Reduction of seizure threshold:

 Closely observe clients with history of seizures.
For Agranulocytosis:
 There is a significant risk of agranulocytosis with clozapine.
 A baseline white blood cell (WBC) count and absolute neutrophil count (ANC)
must be taken before initiation of treatment with clozapine and weekly for the first
6 months of treatment.
 Only a 1-week supply of medication is dispensed at a time.
 If the counts remain within the acceptable levels (i.e., WBC at least 3,500/mm3
and the ANC at least 2,000/mm3) during the 6-month period, blood counts may
be monitored biweekly, and a 2-week supply of medication may then be
dispensed
 If the counts remain within the acceptable level for the biweekly period, counts
may then be monitored every 4 weeks thereafter.
 When the medication is discontinued, weekly WBC counts are continued for an
additional 4 weeks.
For Hyper salivation (with clozapine):
 A significant number of clients receiving clozapine therapy experience extreme
salivation.
 Offer support to the client because this may be an embarrassing situation.
 It may even be a safety issue (e.g., risk of aspiration) if the problem is very
severe.
For Extrapyramidal symptoms (EPS):
 Pseudo Parkinsonism (tremor, shuffling gait, drooling, and rigidity) may appear 1
to 5 days following initiation of antipsychotic medication; occurs most often in
women, the elderly, and dehydrated clients.
 Akathisia (continuous restlessness and fidgeting) occurs most frequently in
women, symptoms may occur 50 to 60 days following initiation of therapy.
 Dystonia (involuntary muscular movements [spasms] of face, arms, legs, and
neck) and oculogyric crisis occurs most often in men and in people younger than
25 years of age.
 Pseudo Parkinsonism and akathisia can be treated with anticholinergics,
antihistamine and dopaminergic agents.
 Dystonia and oculogyric crisis should be treated as an emergency situation.
 The physician should be contacted, and intravenous or intramuscular
benztropine mesylate (Cogentin) is commonly administered.
 Stay with the client and offer reassurance and support during this frightening
time.
For Tardive dyskinesia:
 All clients receiving long-term (months or years) antipsychotic therapy are at risk.
 The symptoms are potentially irreversible.
 The drug should be withdrawn at the first sign, which is usually vermiform
movements of the tongue
 Prompt action may prevent irreversibility.
For Neuroleptic malignant syndrome (NMS):
 This is a rare, but potentially fatal, complication of treatment with neuroleptic
drugs.
 Routine assessments should include temperature and observation for
parkinsonian symptoms.
 Onset can occur within hours or even years after drug initiation, and progression
is rapid over the following 24 to 72 hours.
 Discontinue neuroleptic medication immediately.
 Monitor vital signs, degree of muscle rigidity, intake and output, level of
consciousness.
 The physician may order bromocriptine (Parlodel) or dantrolene (Dantrium) to
counteract the effects of neuroleptic malignant syndrome

Antidepressants
Indications
 Dysthymic disorder
 Major depression with melancholia or psychotic symptoms
 Depression associated with organic disease, alcoholism, schizophrenia, or
mental retardation
 Depressive phase of bipolar disorder
 Depression accompanied by anxiety.

Classification
 Tricyclics
 SSRIs (Selective serotonin reuptake inhibitor)
 MAOIs (Mono amine oxidase inhibitors)
 Others
 Tricyclics
Amitriptyline, Nortriptyline Protriptyline Amoxapine, Doxepin Clomipramine,
Desipramine, Imipramine, Trimipramine
 SSRIs (Selective serotonin reuptake inhibitor)
Citalopram, Escitalopram Flu , Par Fluvoxamine Sertraline
 MAOIs (Mono amine oxidase inhibitors)
Isocarboxazid
Phenelzine
Tranylcypromine
 Others Bupropion
Maprotiline
Mirtazapine
Trazodone
Nefazodone
Venlafaxine
Duloxetine
Pharmacokinetics
Lipophilic and protein bound
Half-life long usually more than 1 day
Metabolized in liver
Excreted in urine

Contraindications/Precautions
 Hypersensitivity.
 Myocardial infarction and angle-closure glaucoma.
 Caution-
 Elderly or debilitated clients
 Hepatic, renal, or cardiac insufficiency. (The dosage usually must be
decreased.) Psychotic clients,
 Prostatic hypertrophy
 History of seizures

Interactions
 Tricyclic antidepressants
 Hyper pyretic crisis, hypertensive crisis, severe seizures, and tachycardia
may occur when used with MAOIs.
 Additive CNS depression occurs with concurrent use of CNS depressants.
 Additive sympathomimetic and anticholinergic effects occur with use of
other drugs possessing these same properties.
 Increased effects of tricyclic antidepressants may occur with bupropion,
cimetidine, haloperidol, selective serotonin reuptake inhibitors (SSRIs),
and valproic acid.
 SSRIs
 Use of SSRIs with cimetidine may result in increased concentrations of
SSRIs. Hypertensive crisis can occur if SSRIs are used within 14 days of
MAOIs.
 Impairment of mental and motor skills may be potentiated with use of
alcohol.
  Serotonin syndrome may occur with concurrent use of MAOIs, and other
drugs that increase serotonin, such as tryptophan, amphetamines or other
psychostimulants
 MAOIs
 Hypertensive crisis may occur with concurrent use of amphetamines,
methyldopa, levodopa, dopamine, epinephrine, norepinephrine, reserpine,
vasoconstrictors, or ingestion of tyramine containing foods
 Hypertension or hypotension, coma, convulsions, and death may occur
with meperidine or other narcotic analgesics when used with MAOIs.
 Additive hypotension may result with concurrent use of antihypertensive or
spinal anesthesia and MAOIs.
 Additive hypoglycemia may result with concurrent use of insulin or oral
hypoglycemic agents and MAOIs.
 Serious, potentially fatal adverse reactions may occur with concurrent use
of other antidepressants, carbamazepine, cyclobenzaprine, maprotiline,
furazolidone, procarbazine, or selegiline.

Adverse effects
List of adverse effects with all classes of antidepressants
 Dry mouth
 Sedation
 Nausea and GI upsets
 Discontinuation syndrome
List of adverse effects with Tricyclics
 Blurred vision
 Constipation
 Urinary retention
 Orthostatic hypotension
 Reduction of seizure threshold
 Tachycardia; arrhythmias
 Photosensitivity
 Weight gain
List of adverse effects with SSRIs
 Insomnia; agitation
 Headache
 Weight loss
 Sexual dysfunction
 Serotonin syndrome
Symptoms include changes in mental status, restlessness, myoclonus, hyperreflexia,
tachycardia, labile blood pressure, diaphoresis, shivering, and tremors.

List of adverse effects with MAOIs

 Hypertensive crisis
Symptoms of hypertensive crisis include severe occipital headache, palpitations,
nausea/vomiting, nuchal rigidity, fever, sweating, marked increase in blood pressure,
chest pain, and coma.
 Priapism (With trazodone)
 Hepatic failure (with nefazodone)

Health education/ nursing management

 Treatment adherence
 Use caution when driving or operating dangerous machinery
 Not stop taking the drug abruptly
 If taking a tricyclic, use sunblock lotion and wear protective clothing
 Report occurrence of any of the following symptoms to the physician
immediately:
sore throat, fever, malaise, yellowish skin, unusual bleeding, easy bruising, persistent
nausea/vomiting, severe headache, rapid heart rate, difficulty urinating, anorexia/weight
loss, seizure activity, stiff or sore neck, and chest pain.

Health education/ nursing management

 Rise slowly from a sitting or lying position to prevent a sudden drop in blood
pressure
 Take frequent sips of water, chew sugarless gum, or suck on hard candy
 Good oral care
 Not consume the following foods or medications while taking MAOIs:
Aged cheese, wine (especially Chianti), beer, chocolate, colas, coffee, tea, sour cream,
beef/chicken livers, canned figs, soy sauce, overripe and fermented foods, pickled
herring, preserved sausages, yogurt, yeast products, broad beans, cold remedies, diet
pills. (TYRAMINE CONTAINING FOOD)

Health education/ nursing management

 Avoid smoking while receiving tricyclic therapy.
 Not drink alcohol while taking antidepressant therapy
 Not consume other medications (including over the-counter medications) without
the physician’s approval
 Notify the physician immediately if inappropriate or prolonged penile erections
occur while taking trazodone
 Establish seizure precaution especially with Bupripion

Health education/ nursing management

Serotonin syndrome
 May occur when two drugs that potentiate serotonergic neurotransmission such
as tryptophan, amphetamines or other psychostimulants are used concurrently
 Most frequent symptoms include changes in mental status, restlessness,
myoclonus, hyperreflexia, tachycardia, labile blood pressure, diaphoresis,
shivering, and tremors.
 Discontinue offending agent immediately.
  The physician will prescribe medications to block serotonin receptors, relieve
hyperthermia and muscle rigidity, and prevent seizures.
 Artificial ventilation may be required.
 The condition will usually resolve on its own once the offending medication has
been discontinued.
 However, if the medication is not discontinued, the condition can progress to a
more serious state and become fatal

Mood stabilizing agents

Any medication that is able to decrease vulnerability to subsequent episodes of mania
or depression; and not exacerbate the current episode or maintenance phase of
treatment.

Classification of mood stabilizing drugs

 Antimanic- Lithium carbonate
 Anticonvulsants- Carbamazepine, Clonazepam, Valproic acid, Lamotrigine,
Gabapentin & Topiramate
 Calcium channel blocker- Verapamil
 Antipsychotics

Antimanic (Lithium carbonate)

 Lithium as an antimanic drug was first discovered by FJ Cade in 1949.

 Indications
 Acute mania
 Prophylaxis for bipolar and unipolar mood disorder
 Schizoaffective disorder
 Cyclothymia
 Impulsivity and aggression
 Others like bulimia nervosa, trichotillomania, cluster headache, borderline
personality disorder.

Mechanism of action
 Exact mechanism is unknown, however it probably works by-
 Accelerating presynaptic reuptake and destruction of catecholamine.
 Inhibiting the release of catecholamine
 Decreasing postsynaptic serotonin receptor sensitivity.

Interaction
 Increased renal excretion of lithium with acetazolamide, osmotic diuretics, and
theophylline.
 Decreased renal excretion of lithium with NSAIDs and thiazide diuretics.
 There is an increased risk of neurotoxicity with carbamazepine, haloperidol, or
methyldopa.
 Fluoxetine or loop diuretics may result in increased serum lithium levels.
  Increased effects of neuromuscular blocking agents or tricyclic antidepressants,
 Use of lithium with phenothiazine may result in neurotoxicity,

Dosage
 900-2100 mg in 2-3 divided dose.

Blood lithium level

 Therapeutic level- 0.8-1.2 mEq/litre
 Prophylactic level- 0.6-1.2 mEq/litre
 Toxic lithium level - >2.0 mEq/litre

Pharmacokinetics
 Well absorbed orally
 Neither protein bound nor metabolized
 Kidney handles lithium in much same way as sodium.
 Plasma half-life is 16-30 hrs.

Contraindication and precaution

 Hypersensitivity
 Cardiac or renal disease
 Dehydration
 Sodium depletion
 Brain damage
 Pregnancy and lactation.
 Caution with thyroid disorders, diabetes, urinary retention, history of seizures,
and with the elderly

Adverse drug reaction

 Neurological
 Tremors
 Motor hyperactivity
 Muscular weakness
 Renal
 Polydipsia
 Polyuria
 Nephrotic syndrome
 CVS
 T-wave depression
 Dermatological
 Acne eruption
 Exacerbation of psoriasis
 Gastrointestinal
 Nausea, vomiting
 Diarrhea
 Abdominal pain
  Metallic taste
 Endocrine
 Abnormal thyroid function
 Goiter
 Weight gain
 Others
 Teratogenicity
 Ebstein’s anomaly
 Toxicity in infant

Lithium toxicity
 The margin between the therapeutic and toxic levels of lithium carbonate is very
narrow.
 Symptoms of lithium toxicity begin to appear at blood levels greater than 1.5
mEq/L
 Symptoms include:
 At serum levels of 1.5 to 2.0 mEq/L: Blurred vision, ataxia, tinnitus, persistent
nausea and vomiting, severe diarrhea.
 At serum levels of 2.0 to 3.5 mEq/L: Excessive output of dilute urine, increasing
tremors, muscular irritability, psychomotor retardation, mental confusion,
giddiness.
 At serum levels above 3.5 mEq/L: Impaired consciousness, nystagmus, seizures,
coma, oliguria/ anuria, arrhythmias, myocardial infarction, cardiovascular
collapse.
 Lithium levels should be monitored prior to medication administration.
 The dosage should be withheld and the physician notified if the level reaches 1.5
mEq/L or at the earliest observation or report by the client of even the mildest
symptom.
 If left untreated, lithium toxicity can be life threatening.
 The client must consume a diet adequate in sodium as well as 2500 to 3000 ml
of fluid per day.
 Accurate records of intake, output, and client’s weight should be kept on a daily
basis.

Nursing management
 Take medication on a regular basis
 Not drive or operate dangerous machinery
 Not skimp on dietary sodium intake.
 Avoid “junk” foods.
 The client should drink six to eight large glasses of water each day
 Avoid excessive use of beverages containing caffeine (coffee, tea, colas), which
promote increased urine output.
 Notify the physician if vomiting or diarrhea occurs.
 Carry a card or other identification noting that he or she is taking lithium.
 Notify the physician as soon as possible if pregnancy is suspected or planned.
  Be aware of side effects and symptoms associated with toxicity.
 Notify the physician if any of the following symptoms occur: persistent nausea
and vomiting, severe diarrhea, ataxia, blurred vision, tinnitus, excessive output of
urine, increasing tremors, or mental confusion.
 Refer to written materials furnished by health care providers while receiving self-
administered maintenance therapy.
 Keep appointments for outpatient follow-up; have serum lithium level checked
every 1 to 2 months, or as advised by physician.

Drugs used in child psychiartry

Clonidine
 Used to control withdrawal symptoms from opioids, Tourette’s disorder,
aggression and autism
 It is an alpha 2 adrenergic receptor agonist
 Dose is 0.1 mg BD
 Side effects are dry mouth, dryness of eye, fatigue, irritability, sedation,
dizziness, nausea, vomiting, hypotension and constipation.

Methylphenidate (Retalin)
 Used in attention deficit and hyperkinetic disorder, narcolepsy, depressive
disorder and obesity.
 It is sympathomimetic drug
 Dosage is 5-10 mg/day orally
 Side effects are dyspepsia, weight loss, slowed growth, dizziness insomnia,
nightmares, tics and psychosis

Antabuse drugs (Disulfiram)

 It is used in the de-addiction from alcohol.
 Its main effect is to produce a rapid and violently unpleasant reaction in a person
who ingests even a small amount of alcohol while taking disulfiram.
 It cause flushing, headache, nausea and vomiting if a person drinks alcohol while
taking drug
 One dose of disulfiram usually effective for 1-2 weeks.
 Overdose can be dangerous, causing low blood pressure, chest pain, shortness
of breath and even death.

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