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On completion of this chapter, the student will: ● List the uses, general drug actions, general adverse reactions, contraindi- cations, precautions, and interactions associated with the administration ● Discuss important preadministration and ongoing assessment activi- ties the nurse should perform on the patient taking an antipsychotic ● List some nursing diagnoses particular to a patient taking an antipsy- ● Discuss ways to promote an optimal response to therapy, how to manage common adverse reactions, and important points to keep in mind when educating patients about the use of the antipsychoticdrugs.
Antipsychotic drugs are also called neuroleptic ACTIONS
drugs. These drugs are given to patients with a psy-
chotic disorder, such as schizophrenia. A psychotic
disorder is characterized by extreme personality disor-
The exact mechanism of action of antipsychotic drugs ganization and the loss of contact with reality.
is not well understood. These drugs are thought to act Hallucinations (a false perception having no basis in
by inhibiting or blocking the release of the neurohor- reality) or delusions (false beliefs that cannot be
mone dopamine in the brain and possibly increasing changed with reason) are usually present. Other symp- the firing of nerve cells in certain areas of the brain.
toms include disorganized speech, behavior disturbance, These effects may be responsible for the ability of social withdrawal, flattened affect (absence of an emo- these drugs to suppress the symptoms of certain psy- tional response to any situation or condition), and chotic disorders. Examples of antipsychotic drugs include anhedonia (finding no pleasure in activities that are chlorpromazine (Thorazine), haloperidol (Haldol), and lithium. Lithium is an antimanic drug; although its Although lithium is not a true antipsychotic drug, it exact mechanism is unknown, it appears to alter is considered with the antipsychotics because of its use sodium transport in nerve and muscle cells and in regulating the severe fluctuations of the manic phase inhibits the release of norepinephrine and dopamine.
of bipolar disorder (a psychiatric disorder character-
Haloperidol may act to block postsynaptic dopamine ized by severe mood swings of extreme hyperactivity to receptors in the brain and depress the RAS, including depression). During the manic phase, the person expe- those parts of the brain involved with wakefulness riences altered thought processes, which can lead to and emesis. The Summary Drug Table: Antipsychotic bizarre delusions. The drug diminishes the frequency Drugs gives a more complete listing of the antipsy- and intensity of hyperactive (manic) episodes.
CHAPTER 32
SUMMARY DRUG TABLE ANTIPSYCHOTIC DRUGS
GENERIC NAME
TRADE NAME*
ADVERSE REACTIONS
DOSAGE RANGES
tachycardia, hypotension,nausea, vomiting range is 900–1800 mg/d PO in divided doses drowsiness, headache, dry mouth, orthostatic hypotension urticaria, nasal congestion, dry mouth, akathisia, dystonia, pseudoparkinsonism, behavioral changes, headache, photosensitivity crisis, tardive dyskinesia, dry mouth, diarrhea, headache, rash, drowsiness Drugs That Affect the Neuromuscular System SUMMARY DRUG TABLE ANTIPSYCHOTIC DRUGS (Continued)
GENERIC NAME
TRADE NAME*
ADVERSE REACTIONS
DOSAGE RANGES
Drowsiness, extrapyramidal 10—200 mg PO, constipation, dry mouth,diarrhea, headache, restlessness, blurredvision nervousness, akathisia, constipation, fever, weight gain photophobia, blurred vision, dry mouth, salivation, nasal congestion, nausea, urinediscolored pink to red-brown sedation, headache, arrhythmias, dyspepsia, fever, constipation, extrapyramidal effects *The term generic indicates that the drug is available in generic form.
ADVERSE REACTIONS
Antipsychotic drugs are used to manage acute and Administration of these drugs may result in a wide vari- chronic psychoses. In addition to its antipsychotic prop- ety of adverse reactions. The adverse reactions seen erties, chlorpromazine (Thorazine) is used to treat with the use of some of these drugs may include seda- uncontrollable hiccoughs. Clozapine (Clozaril) is used tion, hypotension, postural hypotension, dry mouth, only in patients with schizophrenia that is unresponsive nasal congestion, photophobia (an intolerance to
to other antipsychotic drugs. Lithium is effective in the light), urticaria, photosensitivity (abnormal response
management of bipolar (manic-depressive) illness.
or sensitivity when exposed to light), behavioral Some of these drugs, such as chlorpromazine changes, and headache. Photosensitivity can result in (Thorazine) and prochlorperazine (Compazine), are severe sunburn when patients taking antipsychotic used as antiemetics (see Chap. 34). When given in small drugs are exposed to the sun or ultraviolet light.
doses, neuroleptics are effective in the control of acute Behavioral changes may also occur with the use of the agitation in the elderly. More specific uses of these antipsychotic drugs. These changes include an increase in drugs are given in the Summary Drug Table: the intensity of the psychotic symptoms, lethargy, hyper- activity, paranoid reactions, agitation, and confusion. A CHAPTER 32
decrease in dosage may eliminate some of these symp- total cumulative dosage administered increase. It is best toms, but it also may be necessary to try another drug.
to use the smallest dose and the shortest duration oftreatment that produces a satisfactory clinical response.
Extrapyramidal Effects
The highest incidence of TD is found in patients receiv-ing an antiparkinson drug for extrapyramidal effects Among the most significant adverse reactions associated along with an antipsychotic drug. Although any patient with the antipsychotic drugs are the extrapyramidal taking an antipsychotic can experience TD, elderly effects. The term extrapyramidal effects refers to a
group of adverse reactions occurring on the extrapyrami-dal portion of the nervous system as a result of antipsy- Neuroleptic Malignant Syndrome
chotic drugs. This part of the nervous system affects bodyposture and promotes smooth and uninterrupted move- Neuroleptic malignant syndrome (NMS) is a rare
ment of various muscle groups. Antipsychotics disturb reaction characterized by a combination of extrapyrami- the function of the extrapyramidal portion of the nervous dal effects, hyperthermia, and autonomic disturbance. It system, causing abnormal muscle movement. Extrapyra- may occur hours to months after the antipsychotic drug midal effects include Parkinson-like symptoms (see regimen is begun. Once NMS begins, it progresses rap- Chap. 29), akathisia, and dystonia (see Display 32-1).
idly during the next 24 to 72 hours. The syndrome most Extrapyramidal effects usually diminish with a often occurs in patients taking haloperidol, but has reduction in the dosage of the antipsychotic drug. The occurred with administration of thiothixene, thiori- primary health care provider may also prescribe an dazine, and clozapine. NMS is potentially fatal and antiparkinsonism drug, such as benztropine (see requires intensive symptomatic treatment and immedi- Chap. 29) to reduce the incidence of Parkinson-like ate discontinuation of use of the causative drug.
Tardive Dyskinesia
Lithium carbonate is rapidly absorbed after oral admin- Tardive dyskinesia (TD) is a syndrome consisting of
istration. The most common adverse reactions include potentially irreversible, involuntary dyskinetic move- tremors, nausea, vomiting, thirst, and polyuria. Toxic ments. TD is characterized by rhythmic, involuntary reactions may be seen when serum lithium levels are movements of the tongue, face, mouth, or jaw and some- greater than 1.5 mEq/L (Table 32-1). Because some of times the extremities (see Fig. 32-1). The tongue may these toxic reactions are potentially serious, lithium protrude, and there may be chewing movements, puck- blood levels are usually obtained during therapy, and the ering of the mouth, and facial grimacing. TD may be dosage of lithium is adjusted according to the results.
observed in patients receiving an antipsychotic drug orafter discontinuation of antipsychotic drug therapy.
When symptoms of TD occur during the course of ther-apy, use of the drug must be discontinued. Depending TABLE 32-1
Lithium Toxicity
on the severity of the condition being treated, the pri-mary health care provider may slowly taper the drug LITHIUM LEVEL
SIGNS OF TOXICITY
dose because abrupt discontinuation may result in a return of the psychotic symptoms. There is no known treatment of TD, although partial or complete remission may occur if the antipsychotic drugs are withdrawn.
Giddiness, ataxia, blurred vision, tinnitus, The risk of TD and the likelihood that it will become irreversible increase as the duration of treatment and speech, blackouts, myoclonic twitchingor movement of entire limbs,choreoathetoid movements, urinary orfecal incontinence, agitation or manic-like behavior, hyperreflexia, DISPLAY 32-1 ● Extrapyramidal Effects
● Parkinson-like symptoms—fine tremors, muscle rigidity, mask-like appearance of the face, slowness of movement, slurred speech, and ● Akathisia—extreme restlessness and increased motor activity
● Dystonia—facial grimacing and twisting of the neck into unnatural
Drugs That Affect the Neuromuscular System Patient Identification
Either before or after completing the examination procedure, observe the patient unobtrusively at rest (e.g., in Have patient sit in chair with hands on knees, legs The chair to be used in this examination should be a hard, slightly apart, and feet flat on floor. (Look at entire body After observing the patient, he/she may be rated on a scale of 0 (none), 1 (minimal), 2 (mild), 3 (moderate), and 4 (severe) according to the severity of symptoms.
Ask the patient whether there is anything in his/her teeth (i.e., gum, candy, etc.) and if there is to remove it.
Ask patient to sit with hands hanging unsupported, ifmale, between legs, if female and wearing a dress, Ask patient about the current condition of his/her teeth. Ask hanging over knees. (Observe hands and other body areas.) patient if he/she wears dentures. Do teeth or dentures bother patient now? Ask patient whether he/she notices any movement in mouth, face, hands, or feet. If yes, ask to describe and to what extent they currently bother patient or interfere with Ask patient to open mouth. (Observe tongue at rest *Abnormal Involuntary Movement ScaleFrom Novartis Parmaceuticals, East Hanover, NJ 07936.
Ask patient to protrude tongue. (Observe abnormalitiesof tongue movement.) Do this twice.
Ask patient to tap thumb, with each finger as rapidly aspossible for 10–15 seconds; separately with right hand, thenwith left hand. (Observe facial and leg movements.) Ask patient to extend both arms outstretched in front withpalms down. (Observe trunk, legs, and mouth.) Flex and extend patient's left and right arms. (One at a time.) Ask patient to stand up. (Observe in profile. Observe all body Have patient walk a few paces, turn, and walk back to chair.
(Observe hands and gait.) Do this twice.
FIGURE 32-1. A simple method to determine tardive dyskinesia symptoms: Abnormal Involuntary Scale*
examination procedure. (From Clayton & Stock [1997]. Basic pharmacology for nurses 11th ed., p. 580, St Louis:
Mosby.)
CONTRAINDICATIONS
pregnancy and lactation has not been clearly estab-lished. They should be used only when clearly needed The antipsychotics are contraindicated in patients with and when the potential good outweighs any potential known hypersensitivity to the drugs, in comatose patients, and in those who are severely depressed, have Lithium is contraindicated in patients who have hyper- bone marrow depression, blood dyscrasias, Parkinson’s sensitivity to tartrazine, renal or cardiovascular disease, disease (haloperidol), liver impairment, coronary artery sodium depletion, dehydration, patients receiving diuret- disease, or severe hypotension or hypertension.
ics, and those who are dehydrated. Lithium is a Pregnancy Antipsychotic drugs are classified as Pregnancy Category D drug and is contraindicated during pregnancy Category C drugs (except for clozapine, which is and lactation. For women of childbearing age, contracep- Pregnancy Category B). Safe use of these drugs during tives may be prescribed while they are taking lithium.
CHAPTER 32
PRECAUTIONS
for any behavior patterns that appear to be deviations from normal. Examples of deviations include poor eyecontact, failure to answer questions completely, inap- The antipsychotic drugs are used cautiously in patients propriate answers to questions, a monotone speech pat- exposed to extreme heat or phosphorous insecticides tern, and inappropriate laughter, sadness, or crying.
and in those with respiratory disorders, glaucoma, pro- Physical assessments include obtaining blood pres- static hypertrophy, epilepsy, decreased renal function, sure measurements on both arms with the patient in a lactation, or peptic ulcer. The antipsychotic drugs are sitting position, pulse, respiratory rate, and weight. The used cautiously in elderly and debilitated patients hospitalized patient may ultimately be discharged from because these patients are more sensitive to the antipsy- the psychiatric setting. Some patients, such as those chotic drugs. Lithium is used cautiously in patients who with mild schizophrenia, do not require inpatient care.
are in situations in which they may sweat profusely and The nurse usually sees these patients at periodic inter- those who are suicidal, have diarrhea, or who have an vals in the psychiatric outpatient setting.
The initial assessments of the outpatient are basically the same as those for the hospitalized patient. Thenurse obtains a complete medical history and a history INTERACTIONS
of the symptoms of the mental disorder from the patient, a family member, or the patient’s hospital Administering the antipsychotic drugs with alcohol may records. During the initial interview, the nurse observes result in additive central nervous system (CNS) depres- the patient for what appear to be deviations from a nor- sion. Anticholinergics (see Chap. 25) may reduce the mal behavior pattern. The nurse also should assess the therapeutic effects of the antipsychotics, causing wors- patient’s vital signs and body weight.
ening of the psychotic symptoms and an increase in therisk of tardive dyskinesia. Clozapine acts synergistically Ongoing Assessment
with other drugs that suppress bone marrow, resulting Many antipsychotic drugs are administered for a long in an increase in the severity of bone marrow suppres- time, which makes the ongoing assessment an impor- sion. When lithium is administered with other antipsy- tant part of determining therapeutic drug effects and chotic drugs, lithium renal clearance may be reduced, monitoring for adverse reactions, particularly making a decreased dosage necessary to prevent lithium extrapyramidal effects and tardive dyskinesia (see toxicity. There may be a decreased effectiveness of Display 32-1 and Fig. 32-1). The role of the nurse is lithium when the agent is administered with antacids.
important in the administration of these drugs in both When thiazide or loop diuretics are administered with the psychiatric and nonpsychiatric setting for the fol- lithium, there is an increase in serum lithium levels, resulting in an increased risk for lithium toxicity.
• The patient’s response to drug therapy on an inpa- tient basis requires around-the-clock assessmentsbecause frequent dosage adjustments may be neces- N U R S I N G P R O C E S S
• Accurate assessments for the appearance of adverse ● The Patient Receiving an Antipsychotic Drug
drug effects assume a greater importance when thepatient may not be able to verbalize physical changes ASSESSMENT
to the primary health care provider or nurse.
Preadministration Assessment
A patient receiving an antipsychotic drug may be
NURSING DIAGNOSES
treated in the hospital or in an outpatient setting. The Drug-specific nursing diagnoses are highlighted in the nurse assesses the patient’s mental status before and Nursing Diagnoses Checklist. Other nursing diagnoses periodically throughout therapy. The nurse must note applicable to these drugs are discussed in depth in the presence of hallucinations or delusions and docu- ment them accurately in the patient’s record.
Before starting therapy for the hospitalized patient, PLANNING
the nurse obtains a complete psychiatric and medicalhistory. In the case of psychosis, patients often are The expected outcomes of the patient depend on the unable to give a reliable history of their illness. When a reason for drug administration but may include an opti- psychosis is present, the nurse obtains the psychiatric mal response to drug therapy, management of common history from a family member or friend. During the adverse drug reactions, an absence of injury, and com- time the history is taken, the nurse observes the patient pliance with the prescribed therapeutic regimen.
Drugs That Affect the Neuromuscular System take an oral drug. If the patient refuses the drug, the Nursing Diagnoses Checklist
nurse contacts the primary health care provider regard- ✓ Confusion related to adverse effects of the drug
ing this problem because parenteral administration ofthe drug may be necessary.
✓ Risk for Injury related to an adverse drug reaction
After administration of an oral drug, the nurse inspects the patient’s oral cavity to be sure the drug has ✓ Impaired Physical Mobility related to adverse drug reactions
been swallowed. If the patient resists having his or her oral cavity checked, the nurse reports this refusal to the ✓ Impaired Verbal Communication related to drug-induced
✓ Risk for Imbalanced Fluid Volume related to adverse drug
❄Gerontologic Alert
Dosages in older adults are usually in the lower range. Because IMPLEMENTATION
older adults are more susceptible to cardiovascular and neuro-muscular reactions to the antipsychotic drugs, the nurse must Promoting an Optimal Response to Therapy
closely monitor them. It is important to increase the dosages The nurse develops a nursing care plan to meet the patient’s individual needs. It is important to monitorvital signs at least daily. In some instances, such aswhen hypotensive episodes occur, the nurse should Oral liquid concentrates are available for use in monitor vital signs more frequently. The nurse should patients who can more easily swallow a liquid. These report any significant change in the vital signs to the concentrates are light sensitive and dispensed in amber or opaque bottles to help protect the concentrate from Behavioral records should be written at periodic light. They are administered mixed in liquids such as intervals (frequency depends on hospital or unit guide- fruit juices, tomato juice, milk, or carbonated beverages.
lines). An accurate description of the patient’s behavior Semisolid foods, such as soups or puddings, may also be aids the primary health care provider in planning ther- used. Perphenazine (Trilafon) concentrate should not be apy and thus becomes an important part of nursing mixed with beverages containing caffeine (coffee, cola), management. Patients with poor response to drug ther- tea, or apple juice because of the risk of incompatibility. apy may require dosage changes, a change to another When these drugs are given parenterally, the nurse psychotherapeutic drug, or the addition of other thera- should give the drugs intramuscularly in a large muscle pies to the treatment regimen. However, it is important mass, such as the gluteus muscle. The nurse keeps the for the nurse to know that full response to antipsychotic patient lying down (when possible) for about 30 min- The nurse may give antipsychotic drugs orally as a sin- gle daily dose or in divided doses several times a day.
Divided daily doses are recommended when beginning ❊Nursing Alert
drug therapy, but once-daily dosing may be used withcontinued therapy. Administration at bedtime helps to In combative patients or those who have serious manifestations minimize the postural hypotension and sedation associ- of acute psychosis (eg, hallucinations or loss of contact withreality), parenteral administration may be repeated every 1 to ated with these drugs. The exact dosage (milligram to mil- 4 hours until the desired effects are obtained or until cardiac ligram) has not been precisely identified. The primary arrhythmias or rhythm changes, or hypotension occur. care provider may prescribe small incremental dosageincreases until the patient’s symptoms are controlled.
MANAGING CARE OF THE OUTPATIENT. At the time of ❄Gerontologic Alert
each visit of the patient to the primary health careprovider’s office or clinic, the nurse observes the patient In elderly or debilitated patients, doses may be instituted at 1⁄2 for a response to therapy. In some instances, the nurse to 1⁄3 the recommended dose for younger adults and increased may question the patient or a family member about the more gradually than dose increases in younger adults. response to therapy. The questions asked depend on thepatient and the diagnosis and may include questionssuch as Oral administration requires great care because some patients have difficulty swallowing (because of a dry mouth or other causes). Other patients may refuse to take the drug. The nurse should never force a patient to • Would you like to tell me how everything is going? CHAPTER 32
Many times the nurse may need to rephrase questions with eating, dressing, and ambulating. However, the or direct conversation toward other subjects until these nurse must protect extremely hyperactive patients from patients feel comfortable and are able to discuss their The nurse asks the patient or a family member about adverse drug reactions or any other problems occurring ❊Nursing Alert
during therapy. The nurse brings these reactions orproblems to the attention of the primary health care The antipsychotic drugs may cause extreme drowsiness and provider. The nurse should document in the patient’s sedation, especially during the first or second weeks of therapy.
This reaction may impair mental of physical abilities. record a general summary of the patient’s outward Drowsiness usually diminishes after 2–3 weeks of therapy. behavior and any complaints or problems. The nurse However, if the patient continues to be troubled by drowsiness then compares these notations to previous notations and sedation, the physician may prescribe a lower dosage. LITHIUM. The dosage of lithium is individualized Tardive dyskinesia can occur in patients taking the according to serum levels and clinical response to the antipsychotics. The nurse must remain alert for any drug. The desirable serum lithium levels are 0.6 to 1.2 signs and symptoms of this condition.
mEq/L. Blood samples are drawn immediately beforethe next dose of lithium (8–12 hours after the last dose)when lithium levels are relatively stable. During theacute phase the nurse monitors serum lithium levels ❊Nursing Alert
twice weekly or until the patient’s manic phase is under Because there is no known treatment for tardive dyskinesia control. During maintenance therapy, the serum and because it is irreversible in some patients, the nurse must lithium levels are monitored every 2 to 4 months.
immediately report symptoms. These include rhythmic,involuntary movements of the tongue, face, mouth, jaw, or Monitoring and Managing Adverse Drug Reactions
During initial therapy or whenever the dosage isincreased or decreased, the nurse observes the patientclosely for adverse drug reactions, including tardive CLOZAPINE. This drug is available only through the dyskinesia (see Fig. 32-1) and any behavioral changes. It Clozaril Patient Management System (a program that is important to report to the primary health care combines WBC testing, patient monitoring, and phar- provider any change in behavior or the appearance of macy and drug distribution services). Only 1 week of adverse reactions. A further increase or decrease in this drug is dispensed at a time. Patients taking cloza- dosage may be necessary, or use of the drug may need to pine are at increased risk for bone marrow suppression.
A weekly WBC count is done throughout therapy andfor 4 weeks after therapy is discontinued. In addition, the nurse monitors the patient for adverse reactions Nursing Alert
that indicate bone marrow suppression: lethargy, weak-ness, fever, sore throat, malaise, mucous membrane When administering the antipsychotic drugs, the nurseobserves the patient for extrapyramidal effects, which include ulceration, or “flu-like” complaints.
muscular spasms of the face and neck, the inability to sleep orsit still, tremors, rigidity, or involuntary rhythmic movements. LITHIUM. Lithium toxicity is closely related to serum The nurse notifies the primary health care provider of the lithium levels and can occur even when the drug is occurrence of these symptoms because they may indicate a administered at therapeutic doses. Adverse reactions are seldom observed at serum lithium levels of less than l.5mEq/L, except in the patient who is especially sensitiveto lithium. Toxic symptoms may be seen with serum The patient may need to tolerate some adverse reac- lithium levels of 1.5 mEq/L or greater. Levels should not tions, such as dry mouth, episodes of orthostatic exceed 2 mEq/L (see Table 32-1). Therefore, the nurse hypotension, and drowsiness because drug therapy must continually monitor patients taking lithium for must continue. Nursing interventions to relieve some of signs of toxicity, such as diarrhea, vomiting, nausea, these reactions may include offering frequent sips of drowsiness, muscular weakness, and lack of coordina- water, assisting the patient out of the bed or chair, and tion. For early symptoms, the primary health care supervising all ambulatory activities. The nurse pro- provider may order a dosage reduction or discontinue vides total assistance with activities of daily living to the the drug for 24 to 48 hours and then gradually restart patient experiencing extreme sedation, including help Drugs That Affect the Neuromuscular System • Immediately report the occurrence of the following adverse reactions: restlessness, inability to sit still, ❄Gerontologic Alert
muscle spasms, masklike expression, rigidity, Older adults are at increased risk for toxicity because of adecreased rate of excretion. Lower dosages may be necessary tremors, drooling, or involuntary rhythmic move- ments of the mouth, face, or extremities. Inform allpatients about the risks of extrapyramidal symptomsand tardive dyskinesia. Avoid exposure to the sun. Ifexposure is unavoidable, wear sunblock, keep arms For patients receiving lithium, the nurse increases and legs covered, and wear a sun hat.
the oral fluid intake to about 3000 mL/d. It is important • Note that only a 1-week supply of clozapine is dis- to keep fluids readily available and to offer extra fluids pensed at a time. The drug is obtained through a throughout waking hours. If there is any question special program designed to ensure the required regarding the oral fluid intake, the nurse monitors blood monitoring. Weekly WBC laboratory tests are required. Immediately report any signs of weakness,fever, sore throat, malaise, or “flu-like” symptoms to Educating the Patient and Family
Noncompliance is a problem with some patients once • Note that olanzapine is available as a tablet to swal- they are discharged to the home setting. It is important low or as an orally disintegrating tablet. When using for the nurse to accurately evaluate the patient’s ability the orally disintegrating tablet, peel back the foil on to assume responsibility for taking drugs at home. The the blister. Using dry hands, remove the tablet and administration of antipsychotic drugs becomes a family place the entire tablet in the mouth. The tablet will responsibility if the outpatient appears to be unable to • Remember to take lithium with food or immediately The nurse explains any adverse reactions that may after meals to avoid stomach upset. Drink at least 10 occur with a specific antipsychotic drug and encourages large glasses of fluid each day and add extra salt to the patient or family members to contact the primary food. Prolonged exposure to the sun may lead to health care provider immediately if a serious drug reaction dehydration. If any of the following occurs, do not take the next dose and immediately notify the pri- The nurse includes the following points in a teaching mary health care provider: diarrhea, vomiting, fever, tremors, drowsiness, lack of muscle coordination, or • Keep all primary care provider and clinic appoint- ments because close monitoring of therapy is essential.
• Report any unusual changes or physical effects to EVALUATION
• Take the drug exactly as directed. Do not increase, • The therapeutic effect is achieved.
decrease, or omit a dose or discontinue use of this • Adverse reactions are identified, reported to the pri- drug unless directed to do so by the primary health mary health care provider, and managed successfully through appropriate nursing interventions.
• Do not drive or perform other hazardous tasks if • The patient verbalizes an understanding of treat- • Do not take any nonprescription drug unless use of ment modalities and the importance of continued a specific drug has been approved by the primary • The patient verbalizes the importance of complying • Inform physicians, dentists, and other medical with the prescribed therapeutic regimen.
personnel of therapy with this drug.
• The patient and family demonstrate understanding • Do not drink alcoholic beverages unless approval is obtained from the primary health care provider.
• If dizziness occurs when changing position, rise slowly when getting out of bed or a chair. If dizziness ● Critical Thinking Exercises
is severe, always have help when changing positions.
• If dryness of the mouth occurs, relieve it by taking 1. Ms. Brown comes to the mental health clinic for a follow-
frequent sips of water, sucking on hard candy, or up visit. She is taking lithium to control a bipolar disor- der. Ms. Brown tells you that she is concerned because her • Notify your primary care provider if you become “hands are always shaking” and “sometimes I walk like pregnant or intend to become pregnant during I have been drinking alcohol.” Explain how you would explore this problem with Ms. Brown. CHAPTER 32
2. As a nurse on the psychiatric unit, you are assigned to
4. In giving discharge instructions to a patient taking
discuss extrapyramidal effects at a team conference. lithium the nurse stresses that the patient should Discuss how you would present and explain this topic. Describe the points you would stress. A. eat a diet high in carbohydrates and low in pro-
3. Your patient is prescribed clozapine for schizophrenia
that has not responded to other drugs. You must discuss B. increase oral fluid intake to approximately 3000
this new therapy with the family. Discuss what points to include in this family teaching session. C. have blood drawn before each dose of lithium is
● Review Questions
D. avoid eating foods high in amines
1. A patient taking chlorpromazine (Thorazine) for
schizophrenia is also prescribed the antiparkinson ● Medication Dosage Problems
drug benztropine. What is the best explanation foradding an antiparkinson drug to the drug regimen? 1. A patient is prescribed haloperidol 3 mg IM. The
A. Antiparkinson drugs prevent symptoms of tar-
drug is available in solution of 2 mg/mL. The nurse dive diskinesia, such as involuntary movements 2. Thorazine 50 mg PO is prescribed. Use the drug label
B. Antiparkinson drugs promote the effects of
below to determine the correct dosage. The nurse C. Antiparkinson drugs are given to reduce the pos-
sibility of symptoms such as fine tremors, mus-cle rigidity, and slow movement.
D. Antiparkinson drugs help to decrease hallucina-
tions and delusions in patients with schizophrenia.
2. Which of the following reactions would the nurse
expect to see in a patient experiencing tardive dyski-nesia? A. Muscle rigidity, dry mouth, insomnia
3. Lithium 600 mg is prescribed. Use the drug label
B. Rhythmic, involuntary movements of the tongue,
below to determine the correct dosage. The nurse C. Muscle weakness, paralysis of the eyelids, diarrhea
D. Dyspnea, somnolence, muscle spasms
3. Which of the following symptoms would indicate to
the nurse that a patient taking lithium is experienc-ing toxicity? A. Constipation, abdominal cramps, rash
B. Stupor, oliguria, hypertension
C. Nausea, vomiting, diarrhea
D. Dry mouth, blurred vision, difficulty swallowing

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