bipolar & psychotic

• Accurate diagnosis necessary for anxiety

  • Nurse needs to take complete history:
  • Medications that may worsen/cause anxiety symptoms
  • Medical conditions that may be associated with anxiety
  • Consider nonpharmacological interventions that will reduce environmental, physical, and emotional stressors prior to Rx intervention
• Benzodiazepines


  Also known as "azepam"
• Lorazepam


  Antianxiety medication
• Depression


  Mood disorder - a persistent disturbance in emotion that impairs ability to effectively deal with activities of daily living
• Types of mood disorder

  Depression and bipolar disease
• Causes of depression


  • Environmental
  • Situational
  • Hereditary
  • No longer thought to be related to parenting or unresolved childhood conflicts
• Depression often coexists with other conditions
• Assessment of depression


  • Majority of persons who commit suicide have been diagnosed with major depression
  • Three or more weeks of antidepressant therapy may be required before patient's mood begins to increase
  • 6-8 weeks for maximum benefit
  • Risk of attempted suicide highest in the month before pharmacotherapy
  • Nurse's role: careful monitoring of talk of suicide, weekly or daily patient contact, careful monitoring of medications
• Tricyclic antidepressants


  Disadvantages: side effects (anticholinergic effects/sympathomimetic effects, orthostatic hypotension, sedation), worsened by concurrent use of other CNS depressants, relatively high incidence of sexual dysfunction, withdrawal symptoms if not tapered, may take 3 weeks to see effects and 6 weeks to see optimum benefits
• Imipramine


  Tricyclic antidepressant, norepinephrine reuptake inhibitor
• Monoamine oxidase inhibitors (MAOIs)


  Rare use, high incidence of adverse effects
• Monoamine oxidase inhibitors (MAOIs) have a high incidence of adverse effects and a high level of non-compliance
• bipolar disorder:

  §Alternates between extreme feelings of sadness and extreme mania

  §Significantly impacts social and occupational functioning

  §Nonpharmacologic interventions (Triggers include lack of sleep, excessive stress, poor nutrition, Support groups, ECT)

  §Pharmacologic interventions (Highly individualized based on severity and predominant symptoms)

  §Nonadherence is a serious problem
• -          Lithium: (antimanic, agent for bipolar)

  o   Drug interactions:

  §  Diuretics = increased risk of lithium toxicity (ex Lasix)

  §  NSAIDs, thiazide diuretics à can increase lithium levels

  §  Antithyroid drugs, drugs containing iodine cause increased hypothyroid effect

  §  Haloperidol causes increased neurotoxicity

  §  SSRIs, MAOIs, dextromethorphan may result in SES

  §  Some herbal food interactions
• lithium Considerations:

  §  Monitor serum levels q1-3 days initially & 2-3 months after

  §  Assess for symptoms of bipolar disorder before and during treatment

  §  Obtain baseline thyroid, kidney, cardiac function, electrolyte levels

  §  Monitor for symptoms of lithium toxicity

  §  Assess daily for weight changes, edema, changes in skin turgor

  §  Lithium is a salt so think water levels, dehydrated increases lithium, overhydrated decreases lithium

  §  Monitor sodium intake – continue to take table salt to maintain osmotic hydration but don’t over do it
• Lithium

  Overhydration decreases lithium
• Monitor sodium intake

  1. Continue to take table salt to maintain osmotic hydration

  2. Don't over do it
• Etiology of Schizophrenia


  The precise etiology remains unknown
• Schizophrenia

  • Genetic component
  • 5-10x greater risk if first degree relative has disorder
• Schizophrenia

  • Neurotransmitter imbalance
  • Overactive dopaminergic pathways in basal nuclei
  • Associated with dopamine type 2 (D2) receptors
• Antipsychotic drugs

  Block dopamine type 2 (D2) receptors
• Second generation (atypical) antipsychotics


  • Become drugs of choice for treatment of schizophrenia
• Management of psychosis

  -          Initial trmt

  o   First doses of antipsychotic drug may be higher than normal

  §  Produces sedation if pt agitated, aggressive, or posing danger to others

  o   Most drugs provided orally

  o   Benzodiazepines (lorazepam)

  §  Provided IM to relax pt and may allow initial dose of antipsychotic to be reduced

  o   Acute symptoms usually resolve in 3-7 days
• Extrapyramidal side effects (EPS)


  Refers to locations in CNS associated with postural and automatic movements
• Extrapyramidal side effects (EPS) include

  • Acute dystonia
  • Akathisia
  • Parkinsonism
  • Tardive dyskinesia
• Neuroleptic malignant syndrome (NMS)


  Potentially fatal adverse reaction
• Symptoms of Neuroleptic malignant syndrome (NMS) include


  • High fever
  • Diaphoresis
  • Muscle rigidity
  • Tachycardia
  • BP fluctuations
• Treatment for Neuroleptic malignant syndrome (NMS)


  1. Antipyretics

  2. Electrolytes

  3. Muscle relaxants
• Adverse effects on reproductive system

  Major cause of noncompliance
• Adverse effects on reproductive system include

  • Sexual dysfunction
  • Menstrual dysfunction
  • Breast dysfunction
• Extrapyramidal side effects include

  • Akathisias
  • Ambulatory tardive dyskinesias
  • Oral tardive dyskinesias
• -          Haloperidol (antipsychotic 1st gen)

  o   AE:

  §  Anticholinergic symptoms

  ·       Blurred vision, dry eyes, glaucoma

  §  Weight gain

  §  Headache

  §  Anemia

  §  Phototoxicity

  §  MOST LIKELY TO PRODUCE EPS

  o   Serious AE:

  §  Tachycardia

  §  Cardiac arrest

  §  Laryngospasm

  §  Respiratory depression

  §  Seizures

  §  Agranulocytosis/leukopenia/leukocytosis

  §  Neuroleptic malignant syndrome (NMS)
• Risperidone


  Antipsychotic 2nd gen
• Considerations for Risperidone

  • If meds cause drowsiness - take at bedtime
  • Watch pt for orthostatic
  • Assess for EPS/TD/akathesias/NMS
  • Educate pt for S&S of above and what to watch for and when to contact HCP
  • Encourage sips of water or hard candies for dry mouth and anticholinergic like symptoms
  • Avoid alcohol and caffeine
  • Increase fluids and fiber
  • Watch liver lab results and educate pt of S&S of liver involvement (jaundice/stool)
  • Tell pt to report significant wt gain 5lbs/week
  • Ensure pt knows that definite improvement may not be seen for 6-8 weeks
• Drugs similar to Risperidone

  • Quetiapine
  • Olanzapine
  • Clozapine
• -          Second generation (atypical) antipsychotics

  o   Considerations:

  §  Monitor for EPS or anticholinergic effects

  §  Ensure adequate nutrition and fluid

  §  Monitor for signs of NMS

  §  Watch labs (liver)

  §  Patient educations includes:

  ·       Monitor for weight gain or changes in sexual characteristics (lactation in men)

  ·       No alcohol or illegal drugs

  ·       No smoking

  ·       No caffeine use
• -          Considerations of all psych meds

  o   Be sure to know S&S of and which drugs cause:

  §  TD

  §  EPS

  §  NMS

  §  SES/SS