1. Antianxiety (also called anxiolytics, minor tranquilizers)
    1. Chlordiazepoxide (Librium)
      1. Use - acute alcohol withdrawal, tension, and irrational fears; anxiety disorders, preoperative sedation; has muscle relaxant and anticonvulsant properties.
      2. Assessment - side   effects: hypotension, drowsiness, motor uncoordination, confusion, skin eruptions, edema, menstrual irregularities, constipation, extrapyramidal symptoms, blurred vision, lethargy; increased or decreased libido.
      3. Nursing care plan/implementation:
        1. Goal: administer cautiously, because drug may:
          1. Be habituating (causing withdrawal convulsions; therefore gradual withdrawal necessary).
          2. Potentiate CNS depressants.
          3. Have adverse effect on pregnancy.
          4. Be dangerous for those with suicidal tendencies or severe psychoses, narrow angle glaucoma, elderly or debilitated.
        2. Goal: reduce GI effects: crush tablet or take with meals or milk; give antacids 1 hr before.
        3. Goal: monitor effects on liver function:
          4. Periodic liver function tests and blood counts, especially with upper respiratory infection, hepatic or renal dysfunction.
        4. Goal: health teaching.
          1. Advise against suddenly stopping drug (withdrawal symptoms begin in 5-7 days).
          2. Talk with physician if plans to be or is pregnant or lactating.
          3. Urge to drink fluids.
          4. Avoid: alcohol, OTC drugs, and heavy smoking and caffeine.
      4. Evaluation/outcome criteria: decreased alcohol withdrawal symptoms or preoperative anxiety; no seizures or confusion.
    2. Diazepam (Valium)
      1. Use - muscle relaxant; not used for psychotic behavior.
      2. Assessment - side effects: same as for chlordiazepoxide, plus double or blurred vision, difficult speech, headache, hypotension, incontinence, tremor, urinary retention, liver damage.
      3. Nursing care plan/implementation:
        1. Goal: anticipate, observe for, and check for side effects, especially depression, suicidal risk, and constipation.
        2. Goal: reduce risk of hypotension, respiratory depression, phlebitis, venous thrombosis. Give IM: in large muscles, slowly, and rotate sites, have client lie down; IV: over 1 min period.
        3. Goal: observe for psychological and physical dependence: avoid abrupt discontinuation.
        4. Goal: health teaching: sedative effects, potentiation of other CNS-depressant drugs and alcohol, and problem of habituation.
      4. Evaluation/outcome criteria: relief of tension, anxiety, skeletal muscle spasm.

  2. Antimanic
    1. Lithium (Eskalith, Lithane, Lithobid) - effect occurs 1-3 weeks after first dose.
      1. Use - acute manic attack and prevention of recurrence of cyclic manic-depressive episodes of bipolar disorders.
      2. Assessment - side effects: levels from 1.6-2.0 mEq/L may cause blurred vision, tinnitus, tremors, nausea and vomiting, severe diarrhea,polyuria, polydipsia; ataxia. Levels >2 mEq/L may cause motor weakness, headache, edema, and lethargy; signs of severe toxicity: arrhythmias, MI, cardiovascular collapse, oliguria/ anuria; neurological (twitching, marked drowsiness, slurred speech, dysarthria, athetotic movements, convulsions, delirium, stupor, coma) with levels >2.5 mEq/L.
        1. Precautions - cautious use with clients on diuretics; with abnormal electrolytes (sweating, dehydrated, and postoperative clients); with thyroid problems, on low salt diets; with heart failure; with impaired renal function; with pregnancy and lactation; risk of suicide.
        2. Dosage - therapeutic level 0.8-1.6 mEq/L; dose for maintenance 300-1200 mg/day; toxic level >2.0 mEq/L; blood sample drawn in acute phase 10-14 hours after last dose, taken tid.
      3. Nursing care plan/implementation:
        1. Goal: anticipate, observe for, and check for signs and symptoms of toxicity.
          1. Reduce GI symptoms: take with meals.
          2. Check for edema: daily weight, I&O.
          3. Monitor blood levels (1.6-2.0 mEq/L) for signs of toxicity: nausea, vomiting, diarrhea, anorexia, ataxia, weakness, drowsiness, fine tremor or muscle twitching, slurred speech.
          4. Monitor results from repeat thyroid and kidney function tests.
          5. Withhold drug and notify MD when 1.5 mEq/L is reached.
          6. Monitor vital signs 2-3 times per day (pulse irregularities, hypotension, arrhythmias).
        2. Goal: report immediately fever, diarrhea, prolonged vomiting.
        3. Goal: monitor effect (therapeutic and toxic) through blood samples taken:
          1. 10-14 hours after last dose.
          2. Every 2-3 days until 11.6 mEq/L is reached.
          3. Once a week while in hospital.
          4. Every 2-3 months to maintain blood levels <2 mEq/L
        4. Goal: health teaching.
          1. Advise client 1-3 weeks lag time for effect.
          2. Urge to drink adequate liquids (2-3 L/day), ice; strict oral hygiene.
          3. Report: polyuria and polydipsia.
          4. Diet: avoid caffeine, crash diets, diet pills, self-prescribed low-salt diet, alcohol, antacids, high-sodium foods (which increase lithium excretion and reduce drug effect); take with meals. Use sugarless candy.
          5. Caution against driving, operating machinery that requires mental alertness until drug is effective.
          6. Warn not to change or omit dose.
      4. Evaluation/outcome criteria:
        1. Changed facial affect.
        2. Improved posture, ability to concentrate, sleep patterns; mood is stabilized.
        3. Assumption of self-care.
        4. No signs of lithium toxicity.

  3. Antiparkinsonian agents
    1. Trihexphenidyl HC1 (Artane).
    2. Benztropine mesylate (Cogentin).
      1. Use - counteract drug-induced extrapyramidal reactions.
      2. Assessment:
        1. Trihexyphenidyl HC1
          1. Side effects - anticholinergic: dry mouth, blurred vision, dizziness, nausea, constipation, drowsiness, urinary hesitancy or retention; pupil dilation; headache; weakness; tachycardia.
          2. Precautions - cautious use with: cardiac, liver, or kidney disease or obstructive gastrointestinal-genitourinary disease, BPH, or myasthenia gravis. Do not give if glaucoma present.
        2. Benztropine mesylate - side effects: same as for trihexyphenidyl HC1 plus:
          1. Effect on body temperature (hyperpyrexia) may result in life-threatening state (heatstroke).
          2. Gastrointestinal (GI) distress.
          3. Inability to concentrate, memory difficulties, and mild confusion (often mistaken for senility); drowsiness.
          4. May lead to toxic psychotic reactions.
          5. Subjective sensations - light or heavy feelings in legs, numbness and tingling of extremities, light-headedness or tightness of head, and giddiness.
      3. Nursing care plan/implementation:
        1. Goal: relieve GI distress by giving after or with meals or at bedtime.
        2. Goal: monitor adverse effects:
          1. Hypotension, tachycardia: check pulse, blood pressure; increased temperature; decreased sweating.
          2. Constipation and fecal impaction: add roughage to diet.
          3. Dry mouth: increase fluid intake; encourage frequent mouth rinsing; offer sugarless candy or gum, ice.
          4. Blurred vision, dizziness: assist with ambulation; use side rail.
          5. Urinary retention: maintain I&O.
        3. Health teaching:
          1. Avoid driving, and limit activities requiring alertness.
          2. Delayed drug effect (2-3 days).
          3. Potential abuse due to hallucinogenic effects.
          4. Avoid alcohol and other CNS depressants; avoid hot weather.
          5. Take with food.
          6. Do not stop drug abruptly.
      4. Evaluation/outcome criteria:
        1. Less rigidity, drooling, and oculogyric crisis.
        2. Improved gait, balance, posture.
        3. Has not experienced symptoms of hyperthermia.