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PSYCHIATRIC NURSING

COPING AND ADAPTATION

MENTALLY HEALTHY INDIVIDUAL


ATTITUDE OF SELF ACCEPTANCE
AUTONOMY
ABILITY TO ABSTRACT,TRUST ,COPE WITH STRESS
ACCURATE SELF PERCEPTION
AWARENESS OF SELF

MENTAL HEALTH – balance in a persons internal life and adaptation to reality


Mental ILL Health – state of imbalance characterized by a disturbance in a persons thoughts,
feelings and behavior
Poverty and abuses are major risk factors
Psychiatric nursing – interpersonal process whereby the professional nurse practitioner
,through the therapeutic use of self(art) and nursing theories (science), assist clients to achieve
psychosocial well being.
Core of psych nursing – interpersonal process – human to human relationship(both for
mentally healthy and ill)
Mental hygiene – measures to promote mental health , prevent mental illness and suffering
and facilitate rehabilitation…….(and if necessary find meaning in these experiences)
Main tool – therapeutic use of self
It requires self-awareness
Methods to increase self-awareness:
–Introspection ,Discussion, Experience, Role play
Neurosis
any long term mental or behavioral d/o in which contact with reality is retained the condition
is recognized by the patient as abnormal. Essentially features anxiety or behavior exagerrated
designed to avoid anxiety
( anxiety d/o ; hysteria to conversion d/o,amnesia,fugue,multiple personality and
depersonalization- dissociative d/o
;oc d/o)
Result of inappropriate early programming(psychoanalysis little value)
Benefits from Behavior Therapy
Psychosis
Mental or behavioral disorder wherein patient looses contact with reality
Presence of delusions, hallucinations,severe thought disturbances,alteration of mood, poverty
of thought and abnormal behavior
(schizophrenia , major disorder of affect ( mania – depression), major paranoid states and
organic mental disorder
Benefits from psychoanalysis and antipsychotics

Common Behavioral Signs and Symptoms


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

Disturbances of affect
Inappropriate – disharmony between the stimuli and the emotional reaction
Blunted affect – severe reduction in emotional reaction
Flat affect – absence or near absence of emotional reaction
Apathy – dulled emotional tone
Depersonalization – feeling of strangeness from one’s self
Derealization – feeling of strangeness towards environment
Agnosia – lack of sensory stimuli integration

Disturbances in motor activity


Echopraxia – imitation of posture of others
Waxy flexibility – maintaining position for a long period of time
Ataxia – loss of balance
Akathesia – extreme restlessness
Dystonia- uncoordinated spastic movements of the body
Tardive dyskenisia – involuntary twitching or muscle movements
Apraxia – involuntary unpurposeful movements

Disturbances in memory
Confabulation – filling of memory gaps
Déjà vu – 2 time-like feeling
nd

Jamais vu- not having been to the place one has been before
Amnesia – memory loss (inability to recall past events)
Retrograde-distant past
Anterograde – immediate past
Anomia – lack of memory of items
Dynamics of Human Behavior
Personality – integration of systems and habits representing anindividuals characteristic
adjustment to his environment expressed through behavior
Individualistic, unique, predictable(stability and consistency)
Determinants: psychological,cultural, biological ( not inhereted) and familial
Analysis
Potential support systems or stressors
Potential risk factor
Satisfaction of human needs
–Physiological(oxygen , fluids, nutrition, temp.,elimination,shelter,rest,sex)
–Safety and security(physical and psychological)
–Love and belongingness
–Self esteem
–Self –actualization

3 divisions of the mind


Conscious – focussed on awareness

Subconscious – recalled at will

Unconscious – never recalled / largest part


Learning – change in behavior through – insight , relearning and remotivation

Theories of personality development

Freuds psychosexual theory


Libido – inner drive
Parts of body –focus of gratification
Unsuccesful resolution - fixation
Structures of personality

–Id – pleasure principle-instinct

–Ego – controls action and perception –reality principle

–Superego – moral behavior - conscience

0-18 m0s ;oral – mouth – trust and discriminating


18 mos. – 3 years ; anal – bowels – holding on or letting go
–Negativism and toilet training age
 3 -6 years phallic ; genitals –exploration and discovery ( inc. sexual tension)
–Gender identification and genital awareness
–Oedipus and Electra complex //
–Castration anxiety and penis envy
6-12 years –latency (quiet stage) sexual energy diverted to play. Institution of superego…
control of instinctual impulses
12 – young adult – genital ; reawakening of sexual drives –relationships
–Sexual maturation
–Sexual identity ,ability to love and work
Psychosocial – Erickson
developmental milestones //delay
0-12mos; TRUST
1-3y AUTONOMY
3-6 INITIATIVE
6-12 INDUSTRY
12-18 IDENTITY
18-25 INTIMACY
25-60 GENERATIVITY
60 and above EGO INTEGRITY

PIAGET’S COGNITIVE THEORY

0-2 SENSORIMOTOR
REFLEXIVE
IMITATIVE REPETITIVE BEHAVIOR
SENSE OF OBJECT PERMANENCE AND SELF SEPARATE FROM ENVT.
TRIAL AND ERROR RESULTS IN PROBLEM SOLVING
2-7Y PRE-OPERATIONAL
SELF-CENTERED,EGOCENTRIC
CANNOT CONCEPTUALIZE OTHER’S VIEW
ANIMISTIC THINKING
IMAGINARY PLAYMATE – SYMBOLIC MENTAL REPRESENTATION – CREATIVITY
2-4 PRE-CONCEPTUAL (PRE-LOGICAL)
4-7 INTUITIVE (UNDERSTANDING OF ROLES)
7-12Y CONCRETE OPERATIONAL
LOGICAL CONCRETE THOUGHT
INDUCTIVE RESAONING (SPECIFIC TO GENERAL)
CAN RELATE ,PROBLEM SOLVING ABILITY
REASONING AND SELF-REGULATION
12-ABOVE FORMAL OPERATIONAL THOUGHT
Abstract thinking
Separation of fantasy and fact
Reality oriented
Deductive reasoning
Apply scientific method

Kohlberg – MORAL DEVELOPMENT/ THINKING/ JUDGEMENT

PRE-CONVENTIONAL (0-6)
–PUNISHMENT AND OBEDIENCE
–OBEDIENCE TO RULES TO AVOID PUNISHMENT
CONVENTIONAL ( 6-12 )
–MUTUAL INTERPERSONAL EXPECTATIONS,RELATIONSHIPS AND CONFORMITY
–SOCIAL SYSTEM AND CONSCIENCE MAINTENANCE
–BEING GOOD IS IMPORTANT SELF RESPECT OR CONSCIENCE

POST –CONVENTIONAL (12 – 18 Y)


PRIOR RIGHT OR SOCIAL CONTRACT
UNIVERSAL ETHICAL PRINCIPLE
ABIDE FOR COMMON GOOD
RATIONAL PERSON-VALIDITY OF PRINCIPLES-AND BECOME COMMITTED TO THEM
INNER CONTROL OF BEHAVIOR UNDERSTANDING THE EQUALITY OF HUMAN
RIGHTS AND DIGNITY OF HUMAN BEINGS AS INDIVIDUALS
DEFENSE MECHANISMS
•unconscious intrapsychic adoptive efforts to resolve emotional conflict and cope with anxiety
•automatic
•pathology is determined by the frequency of use
examples of DEFENSE MECHANISMS
•DENIAL – failure to acknowledge an intolerable thought , feeling, experience or reality
•DISPLACEMENT – redirection of emotions or feelings to a subject that is more acceptable or
less threatening
•PROJECTION – attributing to others one’s feelings, impulses , thought or wishes
•UNDOING – an attempt to erase an act , thought , feeling or desire
•COMPENSATION – an attempt to overcome real or imagined shortcoming

SYMBOLIZATION – a less threatening object or idea is used to epresent another


SUBSTITUTION – replacing desired , impractical , unattainable object with one that is
acceptable
INTROJECTION – a form of identification in which there is a taking into oneself the
characteristic of another(love object)
REPRESSION – unacceptable thoughts is kept from awareness(unconscious)
SUPPRESSION- consciously putting a disturbing thought or incident out of awareness

•REACTION FORMATION - expressing attitude directly opposite to unconscious wish or fear


•REGRESSION – returning to an earlier developmental phase in the face of stress
•DISSOCIATION – detachment of painful emotional conflicts from consciousness
•CONVERSION – emotional problems are converted into symptoms
•FANTASY – conscious distortion of unconscious feelings or wishes
•IDENTIFICATION – conscious patterning of one’s self from another person
•INTELLECTUALIZATION - over use of intellectual concepts by an individual to avoid
expression of feelings
•RATIONALIZATION – justifying ones actions which are based on other motives
•SUBLIMATION - rechanneling of unacceptable instinctual drives with one hat is aceptable
NURSE – PATIENT RELATIONSHIP
•SULLIVANS THEORY ON INTERPERSONAL RELATIONSHIP – DEVELOPED BY PEPLAU
INTO NURSE- PATIENT RELATIONSHIP
•SERIES OF INTERACTION BETWEEN THE NURSE AND PATIENT IN WHICH THE NURSE
ASSISTS THE PATIENT TO ATTAIN POSITIVE BEHAVIORAL CHANGE
•T RUST
•R APPORT
•U NCONDITIONAL POSITIVE REGARD
•S ETTING LIMITS
•T HERAPEUTIC COMUNICATION
PHASES
•PRE-INTERACTION – SELF – AWARENESS
•ORIENTATION PHASE – DEVELOP A MUTUALLY ACCEPTABLE CONTACT
•WORKING – IDENTIFICATION AND RESOLUTION OF THE PATIENT’S PROBLEMS
•TERMINATION – ASSIST PATIENT TO REVIEW WHAT HE HAS LEARNED AND TRANSFER
HIS LEARNING TO HIS REL. W/ OTHERS
WHEN TO TERMINATE NPR
•GOALS ACCOMPLISHED
•EMOTIONALLY STABLE
•GREATER INDEPENDENCE
•ABLE TO COPE WITH ANXIETY, LOSS , FEAR AND SEPARATION
COMMON PROBLEMS - NPR
•TRANSFERENCE – DEVELOPMENT OF EMOTIONAL ATTITUDE + OR – TOWARDS THE
NURSE
•RESISTANCE – DEVELOPMNET OF AMBIVALENT FEELINGS TOWARDS SELF –
EXPLORATION
•COUNTER – TRANS FERENCE – TRANSFERENCE AS EXPERIENCED BY THE NURSE
PRINCIPLES OF CARE
•ACCPETS PATIENT AS UNIQUE WITH INHERENT VALUE AND WORTH
•PATIENT IS VIEWED AS HOLISTIC HUMAN BEINGS WITH INTERDEPENDENT AND
INTERRELATED NEEDS
•FOCUS ON STRENGTHS AND ASSETS
•NON – JUDGEMENTAL ASSISTANCE TOWARDS COPING
•EXPLORE THE PATIENTS BEHAVIOR AND THE NEED IT IS DESIGNED TO MEET AND THE
MESSAGE IT IS COMMUNICATING
LEVELS OF INTERVENTION
•PRIMARY – INTERVENTIONS AIMED AT THE PROMOTION OF MENTAL HEALTH AND
LOWERING THE RATE OF CASES BY ALTERING THE STRESSORS
•SECONDARY – INTERVENTIONS THAT LIMIT THE SEVERITY OF THE DISORDER
–CASE FINDING AND PROMPT Tx
•TERTIARY – REDUCING THE DISABILITY AFTER A DISORDER
–PREVENTION OF COMPLICATION AND ACTIVE PROGRAM OF REHABILITATION
CHARACTERISTICS OF A PSYCHIATRIC NURSE-major roles of a nurse - socializing agent
and patient advocate

•EMPATHY- ability to see beyond outward behavior and sense accurately another persons inner
experience
•GENUINENESS/CONGRUENCE – ability to use therapeutic tools appropriately
•UNCONDITIONAL POSITIVE REGARD - respect
THERAPEUTIC COMMUNICATION
•CLARIFICATION
•LIMIT SETTING
•EMPATHETIC / ENCOURAGE EXPRESSION
•ANSWERS NEEDS
•REFLECTIVE AND INSIGHTFUL
THERAPEUTIC COMMUNICATION
•FOCUS ON FEELING TONE ,NEEDS ,MOTIVATION
•MUST HAVE CONSISTENCY AND IS NON JUDGEMENTAL
•CRITERIA OF SUCCESSFUL COMMUNICATION – FEEDBACK , APPROPRIATENESS,
FLEXIBILITY AND EFFICIENCY

TECHNIQUES OF COMMUNICATION
•TO INITIATE A CONVERSATION –
–giving broad openings
–giving recognition / acknowledgement
•TO ESTABLISH RAPPORT
–GIVING INFORMATION
–USE OF SILENCE
•TO GATHER INFORMATION
–FOCUSING
–VALIDATING
–REFLECTING
–RESTATING
•TO CLOSE A CONVERSATION
–summarizing

TYPES OF PSYCHOTHERAPIES

REMOTIVATION THERAPY
•TREATMENT MODALITY THAT PROMOTES EXPRESSION OF FEELINGS THROUGH
INTERACTION FACILITATED BY DISCUSSION OF NEUTRAL TOPICS
• STEPS :
climate of acceptance
creating bridge to reality
sharing the world we live in
appreciation of works of the world
climate of appreciation

MUSIC THERAPY
•INVOLVES USE OF MUSIC TPO FACILITATE EXPRESSION OF FEELINGS,FACILITATE
RELAXATION AND OUTLET OF TENSION

PLAY THERAPY
enables patient to experience intense emotion in a safe environment with the use of play
children express themselves more easily in play. revealing as reflection of child’s situation
in the family
provide toys and materials – facilitate interaction – observe and help child resolve
problems through play

Group therapy
•Treatment modality involving three or more patients with a therapist to relieve emotional
difficulties, increase self – esteem, develop insight , LEARN NEW ADAPTIVE WAYS TO COPE
WITH STRESS and improve behavior with others( RELATIONSHIP WITH OTHERS CAN BE
WORKED THROUGH)
•IDEAL 8 – 10 MEMBERS
MILIEU THERAPY
•CONSISTS OF TREATMENT BY MEANS OF CONTROLLED MODIFICATION OF THE
PATIENTS ENVIRONMENT , FACILITATE POSITIVE BEHAVIORAL CHANGE
•INCREASE PATIENTS AWARENESS OF FEELINGS, INCREASE SENSE OF
RESPONSIBILITY AND HELP ETURN TO COMMUNITY
•clients plan social and group interaction
•token programs , open wards and self medication
FAMILY THERAPY
•A METHOD OF PSYCHOTHERAPY WHICH FOCUSES ON THE TOTAL FAMILY AS AN
INTERACTIONAL SYSTEM
•PROBLEM IS A FAMILY PROBLEM
•focus on sick members behavior as source of trouble / symptom serve a function for the family
•members develop sense of identity
•points out function of the sick member for the rest of the family
PSYCHOANALYTIC
•focuses on the exploration of the unconscious, to facilitate identification of the patients defenses
•ANXIETY RESULTS BETWEEN CONFLICTS OF ID AND EGO(DEFENSE MECHANISMS
FORM TO WARD OFF)
•BECOMES AWARE OF UNCONSCIOUS THOUGHTS AND FELINGS.UNDERSTAND ANXIETY
AND DEFENSES
HYPNOTHERAPY
•VARIOUS METHODS AND TECHNIQUES TO INDUCE A TRANCE STATE WHERE PATIENT
BECOMES SUBMISSIVE TO INSTRUCTIONS

BEHAVIOR MODIFICATION
A THERAPEUTIC INTERVENTION INVOLVOING THE APPLICATION OF LEARNING
PRINCIPLES IN ORDER TO CHANGE MAL-ADAPTIVE BEHAVIOR
PSYCHOLOGICAL PROBLEMS ARE A RESULT OF LEARNING
DEFICIENCIES CAN BE CORRECTED THROUGH LEARNING

•OPERANT CONDITIONING
–USE OF REWARDS TO EINFORCE POSITIVE BEHAVIOR
–PERCEIVED AND SELF REINFORCEMENT BECOMES MORE IMPORTANT THAN
EXTERNAL
•DESENSITIZATION
–SLOW ADJUSTMENT OR EXPOSURE TO FEARED OBJECTS(USED IN PHOBIAS)
–PERIODIC EXPOSURE,UNTIL UNDESIRABLE BEHAVIOR DISAPPEARS OR LESSENS
•AVERSION THERAPY - EXAMPLE OF BEHAVIOR MODIFICATION IN WHICH PAINFUL
STIMULUS IS INTRODUCED TO BRING ABOUT AN AVOIDANCE OF ANOTHER STIMULUS
WITH THE END VIEW OF FACILITATING BEHAVIORAL CHANGE
OTHER THERAPIES
TOKEN ECONOMY-REWARDING
ECONOMY-REWARDING DESIRED BEHAVIOR
COGNITIVE THERAPY – SHORT TERM STRUCTURED THERAPY –ORIENTED TOWARDS
PRESENT PROBLEMS ABD SOLUTIONS – AMIN FOCUS OF DEPRESSIVE DISORDERS
HUMOR THERAPY – TO FACILITATE EXPRESSION AND ENHANCE INTERACTION
ACTIVITY THERAPY – GROUP INTERACTION WHILE WORKING ON A TASK TOGETHER

PSYHCHOPHARMACOLOGIC AGENTS

I. ANTI-PSYCHOTICS

SUB-CLASSIFICATIONS
PHENOTHIAZINES NON-PHENOTHIAZINES

Chlorpromazine (Thorazine) Clozapine ( Clozaril)


Fluphenazine (Prolixin) Haloperidol ( Haldol)
Perphenazine ( Trilafon) Olanzapine ( Zyprexa )
Prochlorperazine Risperidone ( Risperdal)
(Compazine) THIOXANTHENES
Thioridazine ( Mellaril) Thiothixene ( Navane)
MOA Triflouperazine (Stelazine)
- antagonizes dopamine in the CNS and also blocks Cholinergic, Histaminic,
Serotogenic, Adrenergic neurotransmitters
- ( anticholinergic, antihistaminic, anti-emetic ) blocks activity of the CNS
receptors and sympathetic nervous
system

INDICATION
- formerly called major tranquilizers / neuroleptics. used to
relieve psychotic symptoms( delusions , hallucinations
and looseness of association)of schjizophrenia, mania and psychotic
depression and organic mental disorders
- acute management of agitation and hyperactivity

SIDE/ ADVERSE EFFECTS:


 ANTICHOLINERGIC EFFECTS
 (EPS)EXTRAPYRAMIDAL SYMPTOMS
–PSEUDOPARKINSONISM-tremor , mask like facies drooling , restlesssness
–AKATHISIA- restlessness,and anxiety
–DYSTONIA-grimacing , torticollis ,oculogyric crisis, intermittent muscle spasms
- TARDIVE DYSKINESIA-lip smaking and tongue and mouth

 (NMS) NEUROLEPTIC MALIGNANT SYNDROME*


- hyperthermia, and severe EPS -muscular rigidity, tremors, trismus, choreiform
movements,autonomic instability /hyperactivity
and alterations in LOC

 SEIZURES
HEPATOTOXICITY*
ORTHOSTATIC HYPOTENSION
PHOTOSENSITIVITY and HYPERSENSITIVITY
ENDOCRINE DISORDERS
DYSCRASIAS *
AGRANULOCYTOSIS – sorethroat,chills,fever,malaise
LEUKOPENIA

CONTRAINDICATIONS AND SPECIAL PRECAUTIONS:


C/I : hypersensitivity , glaucoma , convulsive d/o , pregnancy and lactation, elderly clients

NURSING CARE GUIDELINES:

C- antipsychotics, neuroleptics, major tranquilizers


H- decreased overt or positive manifestations of psychosis
E- p.c.
C- rise slowly
avoid sunlight
Report –sorethroat,fever,muscular rigidity
Reduced psychomotor agitation and insomnia – 1 week
Reduction of hallucinations, delusions and thought disorder takes 6-8 weeks for full
therapeutic effect

BP and temperature
K – monitor blood levels
Seizures, NMS and EPS
L.F.T.’s
CBC with differential

medical management :
NMS – Bromocriptine or Amantadine( dopamine agonist) and
Dantrolene (Dantrium) muscular relaxant
Dystonia – Diphenhydramine,Benztropine , Diazepam, Lorazepam
Pseudoparkinsonism – Antiparkinsonian, Anticholinergic
Akathisia – Anticholinergic, Benzodiazepines, Beta-blockers,Clonidine
Tardive dyskinesia – early referral-dose reduction , no anticholinergics

II. ANTI-PARKINSONIAN AGENTS

CLASSIFICATIONS

2 TYPES :

1.) DOPAMINERGIC DRUGS


MOA: enhance dopaminergic activity
slows deterioration of dopaminergic nerve cells
Increasing dopamine

Carbidopa – Levodopa ( Sinemet)


Amantadine ( Symmetrel)
Bromocriptine Mesylate ( Parlodel)
Levodopa ( Larodopa)
Pergolide Mesylate ( Permax)
Ropinirole(Requip)
Tolcapone ( Tasmar)
2.) ANTI-CHOLINERGIC AGENTS
MOA:inhibit relative excess in cholinergic activity, symptomatic relief
Decrease signs and symptoms ( tremors,rigidity, drooling promote optimal levels
of motor function (gait, posture and speech )

Trihexypheiedil ( Artane)
Biperiden Hydrochloride ( Akineton)
Benztropine Mesylate ( Cogentin)
Diphenhydramine Hydrochloride
(Benadryl)

Misc. agent
Selegiline
INDICATIONS: For ( Eldepryl)
management of anti psychotic induced EPS- pseudoparkinsonism

SIDE AND ADVERSE EFFECTS


Anticholinergic Effects Blurring of vision, constipation, 3D’s and orthostatic hypotension,
sorethroat*
Headache, photosensitivity, drowsiness, CHF and halluciantions

CONTRAINDICATIONS AND SPECIAL PRECAUTION


Glaucoma, tachycardia, HPN, Cardiac D/O, asthma, duodenal ulcer

NURSING CARE GUIDELINES


C- dopaminergic or anti-cholinergic
H- decrease tremors and rigidity in 2-3 days
E- p.c.
C- avoid sudden position change
Avoid Vit. B6 and CHON rich foods- dec. absorption of medication
Avoid alcohol-increases sedative effects
K- check BP- orthostatic hypotension
drugs not withdrawn abruptly

III. ANTI DEPRESSANTS

COMMON TYPES

TRICYCLICS MONO AMINE OXIDASE SELECTIVE SEROTONIN


INHIBITORS REUPTAKE INHIBITORS

Imipramine(Tofranil) Citalopram ( Celexa)


Amitriptryline ( Elavil) Flouxetine (Prozac)
Clomipramine (Anafril) Paroxetine ( Paxil)
Doxepin ( Sinequan) Sertraline ( Zoloft)
Nortryptyline ( Aventyl) Fluvoxamine (Luvox)

Tranylcypromine (Parnate)
Isocarboxazid ( Marplan)
Phenelzine (Nardil)
Mechanism of
Action

Prolongs the action Blocks the


of norepinephrine metabolic
Dopamine destruction of
Serotonin by neurotransmitters by Inhibits reuptake and
blocking the the enzyme mono- destruction of
reuptake of this amine oxidase serotonin to prolong its
CNS STIMULANTS action
neurotransmitters

Ritalin ( Methylphenidate)
Amphetamine ( Benzedrine)

Increases levels of neurotransmitters


in the brain thereby increasing CNS
activity and decreasing
hyperactivity.

INDICATIONS
effective in management and treatment of depression and related mood and depressive disorders
such as:
Obsessive compulsive ,Eating d/o,Obesity,Bipolar disorder,Panic d/o

SIDE EFFECTS AND ADVERSE REACTIONS:

TCA’S MAOI SSRI CNS Stimulants


Cardiac arrhythmias, Hypertensive crisis Tremors, decreased Growth suppression,
palpitations,orthostatic Liver and cardiovascular libido, NAVDA insomnia
hypotension disease Nervousness, insomnia,
Constipation,Sedation, Weight gain drowsiness
anticholinergic effects Sexual dysfunction anxiety
Confusion photosensitivity
Bone marrow depression

CONTRAINDICATIONS AND SPECIAL PRECAUTIONS

TCA’S MAOI SSRI CNS Stimulants


Hypersensitivity, liver Hypertension same
disease , glaucoma Cardiovascular disease
and Liver disease

NURSING CARE GUIDELINES

C- anti-depressants
H- decreased signs and symptoms of depression(increased appetite and sleep
E – p.c.

TCA’S MAOI SSRI CNS Stimulants


C-
2-3 wks initial effect 2-3 initial 2-3 initial Give in AM , not
3-6 wks full therapeutic 3-4 full ther. Effect 3-4 full ther. effect beyond 2 pm
effect Avoid foods rich in 6 hours before bedtime
tyramine –leads to
Emphasize compliance hypertensive crisis
Avoid citrus juice – ( processed,preserved and
decrease absorption fermented )

K-
Monitor BP, HR and
ECG
Monitor BP and food
items

IV. ANTI – MANIC

EXAMPLES

Lithium Carbonate ( Eskalith,


Lithane, Quilinium –R,
Lithionate)

Carbamazepine (Tegretol )

MOA
Exact mechanism unknown , alters the level of norepinephrine and other neurotransmitters

INDICATIONS
•Treatment of acute mania and for prophylaxis of recurrent manic and depressive episodes in
bipolar disorder

SIDE AND ADVERSE EFFECTS


NAVDA Nephrotoxicity*
Fine tremors leading to coarse tremors Cardiac toxicity*
Thirst Hyperthyroidism – Thyroid Crisis*
Nystagmus

CONTRAINDICATIONS AND SPECIAL PRECAUTION


Cardiovascular disease , renal disease, clients on low sodium diet and on diuretic therapy, brain damage,
pregnancy and lactation

NURSING CARE GUIDELINES

C- mood stabilizer – anti manic


H- decrease hyperactivity/manic episodes
Initial effect – 10-14 days
Full therapeutic effect 3-4 weeks
E- after meals with milk or food
C- antipsychotics given with lithium for immediate management of
manic episodes.
Diet – Na 6-10 grams a day; fluids- 3 liters per day
Avoid caffeine , diuretics and activities that increase perspiration

K- monitor for untoward signs and symptoms


Monitor serum level at least once a month(A.M. 12 hours after
the last dose
maintenance dose - .5 – 1.2 mEq / L
acute level – 1.5 mEq / L
level for the elderly .4 – 1.0 mEq / L
Antidote for toxicity – Mannitol (Osmitrol) or Acetazolamide (Diamox)

V. ANTI ANXIETY

CLASSIFICATION:

Alprazolam ( Xanqax)
BENZODIAZEPINES AZASPIRONES NON-BENZODIAZEPINE
Chlordiazepoxide ( Librium) Miscellaneous agents
Clorazepate ( Tranxene)
Diazepam ( Valium)
Lorazepam ( Ativan)
Oxazepam ( Serax)
Hydroxyzine ( Vistaril)
Meprobamate ( Equanil)
Buspirone
(Buspar)

MOA: depresses Reticular Activating system and reduces anxiety by stimulating the action of an inhibitory
neurotransmitter called GABA

INDICATIONS; treatment of anxiety disorders and for short term relief of symptoms of
Anxiety; selective medications effective for skeletal muscle relaxation, pre
and post-op sedation, seizure control.

SIDE AND ADVERSE EFFECTS


Sedation and Dizzinees,drowsiness and dry mouth
Paradoxical reactions*(hallucination and delusions),CNS depression*
Addison’s disease , Dependency*, hepatotoxicity*

CONTRAINDICATIONS AND SPECIAL PRECAUTION


Glaucoma, hypersensitivity, liver and kidney dysfunction, psychoses,
elderly , pregnancy and lactation

NURSING CARE GUIDELINES

C- anxiolytics, minor tranquilizers


H- decrease anxiety
E- a.c. – food delays absorption
C- rise slowly
Avoid caffeine and alcohol

K- monitor CBC, LFT’s,


report sorethroat, jaundice, weakness and fever