COMMON PSYCHOTROPIC DRUGS

  1. Antipsychotics (also called neuroleptics, major tranquilizers)
    1. Phenothiazines (prochlorperazine [Compazine], promazine HO [Sparine], chlorpromazine HC1 [Thorazine], thioridazine [Mellaril], trifluoperazine HC1 [Stelazine], perphenazine [Trilafon], triflupromazine HC1 [Vesprin], fluphenazine enanthate [Prolixin]).
    2. Butyrophenones (haloperidol [Haldol, Serenace], droperidol fentanyl citrate [Innovar]).
    3. Thiothixenes (chlorprothixene [Taractan], thiothixene [Navane]) - chemically related to phenothiazines, with similar therapeutic effects.
    4. Dibenzoxazepines - atypical antipsychotics (clozapine [Clozaril], loxapine succinate [Loxitane])
      1. Use - those who do not respond to other neuroleptic antipsychotic drugs; offers relief from schizophrenic symptoms: hallucinations, delusions, flat affect, apathy.
      2. Assessment - side effects:
        1. Most serious is agranulocytosis (potentially fatal; reversible if diagnosed within 1-2 wk of onset).
          1. Symptoms of agranulocytosis: infection, high fever, chills, sore throat, malaise, ulceration of mucous membranes
          2. Lab value: Discontinue drug with white blood cells (WBC) <2000 μL or granulocyte <1000 μL.
        2. Other side effects: seizures, tachycardia, orthostatic hypotension.
        3. Caution: must have weekly blood tests for WBC; do not resume clozapine once it is discontinued, due to side effects.
    5. Benzisoxazole derivative - risperidone (Risperdal)
      1. Use - incremental increases for first 3 days to manage psychotic symptoms. Benefit: less incidence of extrapyramidal symptoms.
      2. Assessment - side effects: same as for phenothiazines.
    6. General use - acute and chronic psychoses; most useful in cases of disorganization of thought or behavior; to decrease panic, fear, hostility, restlessness, aggression, and withdrawal.
    7. General assessment - side effects:
      1. Hypersensitivity effects:
        1. Blood dyscrasia - agranulocytosis, leukopenia, granulocytopenia.
        2. Skin reactions - solar sensitivity, allergic dermatitis, flushing, blue-gray skin.
        3. Obstructive jaundice.
      2. Extrapyramidal symptoms (EPS) affecting voluntary movement and skeletal muscles
        1. Parkinsonism (also called pseudoparkinsonism) - tremors, cogwheel rigidity, shuffling gait, pill-rolling, masklike facies, salivation, and difficulty starting muscular movement (dyskinesia).
        2. Dystonia - limb and neck spasms (torticollis), extensive rigidity of back muscles (opisthotonos), oculogyric crisis, speech and swallowing difficulties, and protrusion of tongue.
        3. Akathisia - motor restlessness, pacing, foot tapping, inner tremulousness, and agitation.
        4. Tardive dyskinesia (TD) - excessive blinking; vermiform tongue movement; stereotyped, abnormal, involuntary sucking, chewing, licking, and pursing movements of tongue and mouth; grimacing, blinking, frowning, rocking.
          1. Cause - long-term use of high doses of antipsychotic drugs.
          2. Predisposing factors - age, women, organic brain syndrome (OBS); history of electroconvulsive therapy (ECT) or use of tricyclics or anti-Parkinson drugs.
      3. Potentiates central nervous system depressants.
      4. Orthostatic hypotension (less with butyrophenones).
      5. Anticholinergic effects (atropine-like) - dry mouth, stuffy nose, blurred vision, urinary retention, and constipation.
      6. Pigment retinopathy - ocular changes (lens and corneal opacity).
      7. Neuroleptic malignant syndrome (NMS)
        1. Description: a rare complication of antipsychotic drugs, with a rapid progression ( 1-3 days) and a 20% mortality rate. It is a serious medical emergency for which early recognition of symptoms is critical. Onset: at start, after change, or dose increase, when used with combination of medications.
        2. Assessment:
          1. Vital signs: extreme temperature of 107°F (leading to seizures, diaphoresis, confusion, stupor, and coma), fluctuating BP, tachycardia.
          2. Lab values: increased creatine phosphokinase (CPK), increased potassium, leukocytosis (WBC).
          3. Renal failure.
          4. Muscular: parkinsonian rigidity (lead pipe skeletal muscle rigidity) that leads to dyspnea and dysphagia, tremors, dyskinesia.
          5. At risk: patients with organic brain disorders and severe dehydration.
        3. Medical treatment
          1. Discontinue all drugs stat.
          2. Institute supportive care.
          3. Administer Parlodel or Dantrium, dopamine function-enhancing substances (e.g., levodopa, carbidopa, bromocriptine, amantadine).

    8. Antipsychotic agents - comparison of side effects
      9. Classification Generic Trade Extrapyramidal Symptoms(EPS) Sedation Anticholinergic Orthostatic Hypotension
      Phenothiazine Chlorpromazine Thorazine 3 4 3 4
        Fluphenazine Prolixin 5 2 2 2
        Perphenazine Trilafon 4 2 2 2
        Prochlorperazine Compazine 4 3 2 2
        Promazine Sparine 3 3 4 3
        Thioridazine Mellaril 2 4 4 4
        Triflupromazine Vesprin 3 4 4 3
      Butyrophenone Haloperidol Haldol 5 1 1 1
      Thioxanthene Thiothixene Navane 4 2 2 2
      Dibenzoxazepine Clozapine Clozaril 1 5 5 4
        Loxapine Loxitane 4 3 2 3
      Benzisoxazoie Risperidone Risperdal 1 1 1 3
      1 = very low; 2 = low; 3 = moderate; 4 = high; 5 = very high.

    9. General nursing care plan/implementation:
      1. Goal: anticipate, observe for, and check for side effects.
        1. Protect the person’s skin from sunburn when outside.
        2. For hypotension: take BP and have person lie down for 30 min, especially after an injection.
        3. Watch for signs of blood dyscrasia: sore throat, fever, malaise.
        4. Observe for symptoms of hypothermic or hyperthermic reaction due to effect on heat-regulating mechanism.
        5. Observe for, withhold drug for, and report early symptoms of jaundice and bile tract obstruction, high fever, upper abdominal pain, nausea, diarrhea, rash; monitor liver function.
        6. Relieve excessive mouth dryness: mouth rinse, increase fluid intake, gum or hard candy.
        7. Relieve gastric irritation, constipation: take with and increase fluids and roughage in diet.
        8. Observe for and report changes in carbohydrate metabolism (glycosuria, weight gain, polyphagia): change diet.
      2. Goal: health teaching.
        1. Dangers of drug potentiation with alcohol or sleeping pills.
        2. Advise about driving or occupations where blurred vision may be a problem.
        3. Caution against abrupt cessation at high doses.
        4. Warn regarding dark urine (sign of jaundice, urinary retention).
        5. Have client with respiratory disorder breathe deeply and cough (drug is a cough depressant).
        6. Need for continuous use of drug and follow-up care.
        7. Prompt reporting of hypersensitivity symptoms: fever, laryngeal edema; abdominal distention (constipation, urinary retention); jaundice; blood dyscrasia.
    10. General evaluation/outcome criteria:
      1. Behavior is less agitated.
      2. Knows side effects to observe for, lessen, and/or prevent.
      3. Continues to use drug.

  2. Antidepressants
    1. Tricyclic antidepressants (TCAs) - (imipramine HC1 [Tofranil], desipramine HC1 [Norpramine, Pertofrane], nortriptyline HC1 [Pamelor, Aventyl], trimipramine [Surmontil], clomipramine [Anafranil], amitriptyline HC1 [Elavil, Endep], amitriptyline HCl/perphenazine [Triavil], protriptyline HC1 [VivactU], doxepin HQ [Sinequan, Adapin], bupropion (Wellbutrin), trazodone (Desyrel), amoxapine (Asendin) - effective in 2-4 wk.
      1. Use - elevate mood in depression, increase physical activity and mental alertness; may bring relief of symptoms of depression so that client can attend individual or group therapy; bipolar disorder, depressed; dysthymic disorder; sleep disturbance; agitation.
      2. Assessment - side effects:
        1. Behavioral - activation of latent schizophrenia (hallucinations); hypomania; suicide attempts; mental confusion. Withhold drug if observed.
        2. Central nervous system (CNS) - tremors, seizures, ataxia, jitteriness, irritability.
        3. Autonomic nervous system (ANS) - dry mouth, nasal congestion, aggravation of glaucoma (blurred vision), constipation, urinary retention, edema, paralysis, ECG changes (flattened T waves; arrhythmia severe in overdose).
      3. Nursing care plan/implementation:
        1. Goal: assess risk of suicide during initial improvement: careful, close observation.
        2. Goal: prevent risk of tachycardia and cardiac arrhythmias and orthostatic hypotension: use caution with client with cardiovascular disease, hyperthyroidism, having ECT or surgery (gradually discontinue 2-3 days before surgery). Monitor BP, pulse twice a day; ECGs, 2-3/weeks until dose adjusted.
          1. Avoid long hot showers or baths.
        3. Goal: observe for signs of urinary retention, constipation: monitor intake and output (I&O) and weight gain (encourage exercise).
          1. Fiber diet.
          2. Reduced calories.
        4. Goal: cautious drug use with glaucoma or history of seizures. Observe seizure precautions due to lowered seizure threshold.
        5. Goal: health teaching:
          1. Advise against driving car or participating in activities requiring mental alertness, due to sedative effects.
          2. Encourage increased fluid intake and frequent mouth rinsing to combat dry mouth; use candy, ice; take with food.
          3. Avoid smoking, which decreases drug effects.
          4. Avoid use of alcohol and other drugs, due to adverse interactions, especially over-the-counter (OTC) (e.g., antihistamines).
          5. Advise of delay in desired effect (2-4 weeks).
          6. Instruct gradual discontinuance to avoid withdrawal symptoms.
      4. Evaluation/outcome criteria: diminished symptoms of agitated depression and anxiety.

    2. Monoamine oxidase inhibitors (MAOIs) (phenelzine sulfate [Nardil], isocarboxazid [Marplan], tranylcypromine sulfate [Parnate], iproniazid [Marsilid], pargiline HC1 [Eutonyl], nialamide [Niamid]).
      1. Assessment - side effects:
        1. Behavioral - may activate latent schizophrenia, mania, excitement.
        2. CNS - tremors; hypertensive crisis (avoid: cheese, colas, caffeine, red wine, beer, yeast, chocolate, chicken liver, and other substances high in tyramine or pressor amine, e.g., amphetamines and cold and hay fever medication); intracerebral hemorrhage; hyperpyrexia.
        3. ANS - dry mouth, aggravation of glaucoma, bowel and bladder control problems; edema, paralysis, ECG changes (arrhythmia severe in overdose).
        4. Allergic hepatocellular jaundice.
      2. Nursing care plan/implementation:
        1. Goal: reduce risk of hypertensive crisis: diet restrictions of foods high in tyramine content.
        2. Goal: observe for urinary retention: measure I&O.
        3. Goal: health teaching.
          1. Therapeutic response takes 2-3 weeks.
          2. Food and alcohol restrictions: avocado, bananas, raisins, licorice, chocolate, aged cheese, yogurt, sour cream, papaya, figs, over-ripe fruit, sausages, liver, herring, soy sauce, meat tenderizes, red wine, beer, caffeine, cola, yeast, chocolate.
          3. Change position gradually to prevent postural hypotension.
          4. Report any stiff neck, palpitations, chest pain, headaches because of possible hypertensive crises (can be fatal).
          5. Take no nonprescribed drugs.
      3. Evaluation/outcome criteria:
        1. Improvement in sleep, appetite, activity, interest in self and surroundings.
        2. Lessening of anxiety and complaints.

    3. Selective serotonin reuptake inhibitors (SSRIs) (fluoxetine [Prozac], paroxetine [Paxil], sertraline [Zoloft], fluvoxamine [Luvox]). SSRIs are generally the first line choice because of fewer side effects, do not require blood monitoring, and are safe in overdose.
      1. Assessment - side effects: CNS stimulation insomnia, agitation, headache (especially with Prozac); weight loss; sexual dysfunction (men: impotence; women: loss of orgasm). Other side effects are similar to TCAs (dry mouth, sedation, nausea).
      2. Nursing care plan/implementation:
        1. Goal: reduce insomnia, agitation: take early in day; avoid alcohol, caffeine; teach relaxation before sleeptime.
        2. Goal: reduce headaches: give analgesics.
        3. Goal: prevent weight loss: weigh every day or every other day, same time and scale; do not use with patients who are anorexic.
      3. Evaluation/outcome criteria:
        1. Improvement in mood and hygiene, thought and communication patterns.
        2. Has not harmed self.
        3. No significant anticholinergic and cardiovascular side effects.