CH 4 psychopharm

Historical Perspectives on Mental Illness Treatment

• Historically, reactions to mental illness ranged from benign involvement to inhumane interventions.
• Mental illness was often feared due to associations with demons or the supernatural.
• Mistreatment of individuals with mental illness was common.
• In the late 18th century, a "moral reform" began in the treatment of mental illness.
• Community and state hospitals were established to address the needs of individuals with mental illness.
• These institutions fostered custodial care, providing food and shelter but little hope for change.
• Patients became dependent on the institutions, reducing their likelihood of returning to family or community.
• The early 20th century saw the advent of somatic therapies in psychiatry.
• Treatments included insulin-shock therapy, wet sheet packs, ice baths, electroconvulsive therapy, and psychosurgery.
• Before 1950, sedatives and amphetamines were the only available psychotropic medications, but their use was limited due to toxicity and physical dependence.
• Since the 1950s, psychopharmacology has expanded to include antipsychotic, antidepressant, antianxiety, and mood-stabilizer medications.
• Research into these drugs has provided an understanding of the biochemical influences in psychiatric disorders.
• Psychotropic medications are not a "cure" for mental illness.
• They are typically used as an adjunct to individual or group psychotherapy.
• These medications relieve some physical and behavioral symptoms but do not eliminate mental disorders.

The Nurse's Role, Ethics, and Legal Considerations in Psychopharmacology

• Nurses must understand the ethical and legal implications of administering psychotropic medications.
• Laws vary by state, but most recognize the patient's right to refuse treatment.
• Emergency exceptions exist when patients are likely to harm themselves or others.
• Some states allow courts to order outpatient treatment, including medication, for individuals with a history of violent behavior who are not seeking treatment.
• Kendra's Law, enacted in New York after a mentally ill man caused a subway tragedy, allows for court-ordered outpatient treatment.
• Kendra's Law includes a medication grant clause for uninterrupted medication during transitions from hospitals or correctional facilities.
• Nurses must be informed about local, state, and federal laws when providing care to patients with psychiatric disorders in any healthcare setting or correctional facility.

Patient Assessment Before Psychopharmacological Therapy

• Conduct a thorough baseline assessment before starting psychopharmacological therapy.
• Essential components include a nursing history and assessment, ethnocultural assessment, and comprehensive medication assessment.
• An ethnocultural assessment is needed because genetic variations and cultural factors may influence medication response.
• CYP450 isoenzyme variations, for example, affect medication metabolism.
• Pharmacogenetic testing may be ordered to identify individuals at risk for being poor metabolizers.
• Poor metabolizers are more vulnerable to adverse drug reactions, including toxicity.

Mood-Stabilizing Agents: Lithium

• Lithium is used to prevent and treat manic episodes in bipolar disorder.
• Other mood-stabilizing agents include anticonvulsants and certain atypical antipsychotics.
• Lithium's action is not fully understood but may involve affecting neurotransmitters.
• Common side effects include dry mouth, GI upset, polyuria, and weight gain.
• Fine hand tremor may occur and can be treated with propranolol.
• There is a narrow margin between therapeutic and toxic levels of lithium.
• Regular monitoring of serum blood levels is essential to prevent toxicity.
• Early signs of toxicity include vomiting and diarrhea at blood levels of around 1.2 mEq/L
• At blood levels greater than 1.5 mEq/L, GI and CNS effects occur.
• At blood levels greater than 2 mEq/L, disorientation and seizures can occur.
• Blood levels of 3.5 mEq/L or higher are associated with coma, cardiovascular collapse, and death.
• Instruct patients to report all medications, herbals, and caffeine use to evaluate for drug interactions.
• Encourage patients to maintain fluid intake at 2,000-3,000 mL/day and avoid activities that risk excessive sweating and fluid loss.
• Instruct patients about the importance of regular monitoring of serum lithium levels, 12 hours after the last dose.
• Assess for suicide risk regularly and inform patients of risks associated with antiepileptics.
• Instruct patients to maintain usual dietary intake of sodium.
• Assess for and educate patients to report any episodes of nausea, vomiting, headache, muscle weakness, confusion, seizures, because these may be signs of hyponatremia.
• Assess for and educate patients to report any signs of rash or unusual skin breakdown, as Stevents-Johnson syndrome can occur.
• Monitor vital signs and instruct patients to report any symptoms of dizziness or palpitations.
• Educate patients to report infections or other illness while on these medications, and monitor for spontaneous bleeding or bruising.
• Inform female patients of the risks of birth defects and provide education about contraception.
• Instruct patients to avoid driving or operating dangerous machinery when experiencing drowsiness.
• Monitor patients for level of alertness.

Lithium Maintenance

• Patients responding to lithium typically remain on it indefinitely.
• Patient education and regular monitoring are essential for safe maintenance and preventing lithium toxicity.
• Therapeutic range for lithium is 0.6 to 1.2 mEq/L.
• When initiating treatment, aim for levels closer to 1.2.
• In maintenance, optimum levels should be closer to 0.6.
• A more conservative range of 0.4 to 0.6 mEq/L may be appropriate if the patient responds well.
• Higher levels (closer to 1.0) may be more effective for patients prone to manic episodes.
• Higher levels are also associated with more adverse effects.
• At levels over 1.5 mEq/L, increasing nausea, anorexia, and diarrhea are common.
• CNS symptoms such as muscle weakness, drowsiness, ataxia, tremors, and muscle twitching can occur.
• Even higher levels can lead to delirium, seizures, cardiovascular collapse, or death.
• Serum lithium levels should be monitored once or twice a week after initial treatment until dosage and serum levels are stable.
• Levels should be monitored monthly during maintenance therapy.
• Blood samples should be drawn 12 hours after the last dose.
• Patients may miss the "high" feeling of being in a manic or hypomanic state.
• This can lead to self-adjusting or discontinuing medication.
• Weight gain is a generally undesirable side effect of lithium.
• Monitor weight and discuss low-calorie diets while stressing the importance of not making significant changes in sodium intake.
• Antiepileptic drugs carry a warning label indicating increased suicide risk.
• Patients should be monitored for the emergence or worsening of depression, suicidal thoughts or behavior, or any unusual changes in mood or behavior.

Outcome Criteria and Evaluation for Mood-Stabilizing Agents

• Criteria to evaluate the effectiveness of therapy:
• Maintaining stability of mood
• No self-harm or harm to others
• No injury from hyperactivity
• Able to participate in activities without excessive sedation or dizziness
• Maintaining appropriate weight
• Exhibits no signs of lithium toxicity
• Verbalizes importance of taking medication regularly and reporting for regular laboratory blood tests

Antipsychotic Agents: Background and Types

• Antipsychotic agents, also known as neuroleptics and historically as major tranquilizers, primarily alleviate psychotic symptoms.
• Introduced in the US in the 1950s with phenothiazines (typical or first-generation antipsychotics).
• First generation antipsychotics have the potential for extrapyramidal side effects (EPS) that interfere with normal movements.
• EPS can cause acute dystonias (muscle spasms), Parkinson-like symptoms, and tardive dyskinesia (later-onset involuntary movement disorders).
• Some EPS can be permanent.
• First generation, typical antipsychotics include the phenothiazines, haloperidol, loxapine, pimozide, and thiothixene.
• Second-generation antipsychotics (atypical antipsychotics) have less potential for EPS and are often preferred as first-line treatment.
• Atypical antipsychotics: aripiprazole, asenapine and asenapine transdermal, clozapine, olanzapine, quetiapine, risperidone, paliperidone, iloperidone, lurasidone, ziprasidone, brexpiprazole, cariprazine, pimavanserin, and lumateperone.
• Pimavanserin is indicated for hallucinations and delusions associated with Parkinson’s disease psychosis.
• Atypical antipsychotics can alleviate hallucinations, delusions, and agitation (positive symptoms)
• Atypical antipsychotics may be beneficial in treating some of the negative symptoms as well.
• Aripiprazole (Abilify) has minimal risk for EPS.
• In 2017, the FDA approved aripiprazole (Abilify MyCite) with a sensor device to track medication adherence.
• In 2020, the FDA approved lumateperone (Caplyta), which reportedly benefits both positive and negative symptoms of schizophrenia, mechanism unknown.

Antipsychotic Agents: Indications and Action

• Antipsychotics are used in the treatment of schizophrenia and other psychotic disorders.
• Selected agents are used in the treatment of bipolar mania.
• Also used as antiemetics (chlorpromazine, perphenazine, prochlorperazine).
• Also used in the treatment of intractable hiccups (chlorpromazine)
• Also used for the control of tics and vocal utterances in Tourette’s disorder (haloperidol, pimozide).
• Aripiprazole (Abilify) is an adjunct to the treatment of major depressive disorder.
• First generation, typical antipsychotics are antagonists that block postsynaptic dopamine receptors in the basal ganglia, hypothalamus, limbic system, brainstem, and medulla.
• First generation, typical antipsychotics also demonstrate varying affinity for cholinergic, alpha1-adrenergic, and histaminic receptors.
• Second generation, atypical antipsychotics are weaker dopamine receptor antagonists but more potent antagonists of the serotonin type 2A (5-HT2A) receptors.
• Second generation, atypical antipsychotics also exhibit antagonism for cholinergic, histaminic, and adrenergic receptors.
• Aripiprazole (Abilify) is a dopamine receptor antagonist with a unique mechanism of action and minimal risk of EPS.

Antipsychotic Agents: Contraindications, Precautions, and Interactions

• Older adults are at greater risk for side effects, including stroke and sudden death while taking antipsychotics.
• Antipsychotics are associated with increased risk of death in older patients with psychosis related to neurocognitive disorder (NCD).
• All antipsychotic drugs now carry a boxed warning about these risks.
• Boxed warning alerts consumers about serious or life-threatening side effects.
• Antipsychotic drugs are not approved for treatment of older patients with NCD-related psychosis.
• Both first and second generation antipsychotics are contraindicated in clients with known hypersensitivity.
• Contraindicated in clients who are comatose or with CNS depression evident.
• Contraindicated when blood dyscrasias exist.
• Contraindicated in clients with Parkinson’s disease or narrow-angle glaucoma (first generation agents)
• Contraindicated for those with liver, renal, or cardiac insufficiency.
• Contraindicated in individuals with poorly controlled seizure disorders.
• Contraindicated in elderly clients with dementia-related psychosis.
• Ziprasidone, risperidone, paliperidone, asenapine, and iloperidone are contraindicated in patients with a history of QT prolongation or cardiac arrhythmias, recent MI, uncompensated heart failure, and concurrent use with other drugs that prolong the QT interval.
• Clozapine is contraindicated in patients with myeloproliferative disorders, a history of clozapine-induced agranulocytosis or severe granulocytopenia, or uncontrolled epilepsy.
• Lurasidone is contraindicated in individuals using strong inhibitors or inducers of cytochrome P450 isozyme 3A4 (CYP3A4).
• Use caution when administering atypical antipsychotics to elderly or debilitated patients.
• Use caution when administering atypical antipsychotics to patients with cardiac, hepatic, or renal insufficiency.
• Use caution when administering atypical antipsychotics to those with a history of seizures.
• Use caution when administering atypical antipsychotics to patients with diabetes or risk factors for diabetes.
• Use caution when administering atypical antipsychotics to clients exposed to temperature extremes and under conditions that cause hypotension.
• Use caution when administering atypical antipsychotics during pregnancy (associated with congenital malformations).
• Aripiprazole, asenapine, olanzapine, paliperidone, quetiapine, and risperidone have FDA approval for use in children and adolescents.
• Aripiprazole and quetiapine carry boxed warnings about increased risk for suicidal thinking in children, adolescents, and young adults.
• Selected drug interactions with antipsychotics include:
  • Antihypertensives and central nervous system depressants: Additive and potentially severe hypotension
  • Epinephrine or dopamine with haloperidol or phenothiazines: Additive effects.
  • Oral anticoagulants with phenothiazines: Less effective anticoagulant effects
  • Drugs that prolong QT intervals: Additive effects
  • Drugs that trigger orthostatic hypotension: Additive hypotension
  • Drugs with anticholinergic effects: Additive anticholinergic effects, including anticholinergic toxicity

Antipsychotic Agents: Nursing Diagnoses and Safety Issues

• Nursing diagnoses for patients receiving antipsychotic therapy:
• Risk for other-directed violence related to panic anxiety and mistrust of others
• Risk for injury related to medication side effects
• Risk for activity intolerance related to medication side effects
• Nonadherence with medication regimen related to suspiciousness and mistrust of others
• Safety issues and nursing interventions for patients taking antipsychotic medication:
  • Extrapyramidal side effects: Instruct patient to report any signs of muscle stiffness or spasms. Administer antiparkinsonian agents as ordered. Assess for abnormal involuntary movements.
  • Hyperglycemia, weight gain, and diabetes: Assess for a history of diabetes, evaluate blood sugars, and instruct the patient in these risks and the importance of diet and exercise.
  • Hypotension: Educate the patient about the risk for hypotension and monitor blood pressure.
  • Orthostatic hypotension: Instruct patient to rise slowly from sitting to standing and monitor blood pressure lying and then standing.
  • Lower seizure threshold: Assess patient for history of seizure disorder and monitor for evidence of seizure activity.
  • Prolonged QT interval: Assess for history of arrhythmias, recent myocardial infarction, heart failure, and any other medications the patient is taking that prolong QT interval, and check baseline electrocardiogram.
  • Anticholinergic effects: Instruct patient about additive effects of other anticholinergic drugs, recommend hard candies and sips of water for minor symptoms, instruct patient about the importance of good oral hygiene, and assess for any evidence of urinary retention, tachycardia, tremulousness, or hypertension, which may be signs of anticholinergic toxicity
  • Sedation: Educate patient about this side effect and instruct patient not to drive or operate dangerous machinery if experiencing sedation.
  • Photosensitivity: Instruct patient to use sunblock and sunglasses and to wear protective clothing when in the sun because of the increased risk for severe sunburn while on these medications.
  • Agranulocytosis: Instruct the patient receiving clozapine that regular monitoring of white blood cell and absolute neutrophil counts is essential, and instruct patient to report any signs of sore throat, fever, or malaise.
  • Neuroleptic malignant syndrome (NMS): Instruct patient to report immediately any fever, muscle rigidity, diaphoresis, tachycardia, and assess vital signs regularly, including temperature.
  • Drug reaction with eosinophilia and systemic symptoms (DRESS): Assess for symptoms of DRESS including fever, rash, swollen lymph glands, swelling in the face.
  • New impulse control problems: Assess for newly developing impulse control problems for patients taking aripiprazole.

Antipsychotic Agents: Patient Education and the Risk for Agranulocytosis

• Inform Patients of Health Risks:
  • Smoking increases the metabolism of antipsychotics, requiring an adjustment in dosage to achieve a therapeutic effect.
  • Body temperature is harder to maintain with antipsychotic medication, so patients should be encouraged to dress warmly in cold weather and avoid extended exposure to very high or low temperatures.
  • Antipsychotic medications increase photosensitivity to sunlight.
  • Alcohol and antipsychotic drugs potentiate each other’s effects.
  • Avoid taking other medications, including over-the-counter products, without first discussing it with the prescriber.
  • A significant number of patients on clozapine report excessive salivation.
  • Safe use of antipsychotics during pregnancy has not been established.

Clozaril and the Risk for Agranulocytosis:

• The FDA requires close monitoring of patients on medications that increase the risk for life-threatening side effects.
• Clozaril’s monitoring is due to the risk of agranulocytosis, where absolute neutrophil count (ANC) drops to ≤ 500 µL.
• An ANC must be assessed before starting clozapine and weekly for the first 6 months.
• Initially, dispense only a 1-week supply of medication at a time.
• If the ANC remains within acceptable levels (≥ 1,500 µL) during the first 6 months, monitor blood counts biweekly for another 6 months and monthly thereafter.

Antipsychotic Agents: Extrapyramidal Side Effects (EPS)

• Pseudoparkinsonism: tremor, shuffling gait, drooling, rigidity—may appear 1 to 5 days after initiation of antipsychotic medication.
• Akinesia: Absence or impairment in voluntary movement.
• Akathisia: Continuous restlessness and fidgeting, may occur 50 to 60 days after therapy begins.
• Dystonia: This side effect—involuntary muscle spasms in the face, arms, legs, and neck—occurs most often. Requires emergency treatment.
• Contact the physician, and administer intravenous or intramuscular benztropine mesylate (Cogentin).
• Oculogyric crisis: Uncontrolled rolling back of the eyes, is a symptom of acute dystonia. This side effect should be treated as a medical emergency.
• Tardive dyskinesia: This extrapyramidal side effect involves bizarre face and tongue movements, stiff neck, and difficulty swallowing.
• Early signs of TD (usually vermiform movements of the tongue) to the prescribing physician or nurse practitioner. Symptoms are potentially irreversible.
• The FDA approved valbenazine (Ingrezza) for treating tardive dyskinesia in 2017.
• The Abnormal Involuntary Movement Scale (AIMS) aids in early detection of movement disorders and provides means for ongoing surveillance.
• The nurse’s empathic approach in listening to the patient’s wishes regarding medication and advocating for exploring other options for management of symptoms is one way to promote patient-centered care.
• Educating patients about the risks and benefits is important in assisting them to make informed decisions about medication treatment.

Antipsychotic Agents: Hormonal Side Effects

• Sexual side effects that may accompany antipsychotic medications:
  • Decreased libido, retrograde ejaculation, gynecomastia
  • Amenorrhea galactorrhea
• For a patient struggling with thought disturbances, they can become the foundation for delusions.
• It is important for the nurse to clarify that these are side effects of the medication and offer reassurance that they are reversible.
• Women with amenorrhea should be instructed that this side effect does not indicate cessation of ovulation, so contraception use should continue as usual.

Current treatment for Schizophrenia

• Limitations of current medication treatments for schizophrenia include cognitive deficits.
• Some atypical antipsychotics have demonstrated efficacy in lessening cognitive deficits but do not eliminate residual effects.
• Cariprazine (Vraylar) has demonstrated some efficacy in treating the negative symptoms of schizophrenia.
• Cariprazine demonstrates effectiveness in reducing substance misuse
• Positive symptoms can complicate the prognosis in treatment of schizophrenia.
• Lumateperone (Caplyta), is also being advanced as effective for treating both positive and negative symptoms of schizophrenia, although its action is unknown.

Outcome Criteria and Evaluation of Antipsychotic Agents

• Criteria for evaluating the effectiveness of therapy (the patient):
  • Has not harmed self or others
  • Has not experienced injury
  • Maintains an ANC within normal limits
  • Exhibits no symptoms of EPS, tardive dyskinesia, NMS, or hyperglycemia
  • Maintains weight within normal limits
  • Tolerates activity unaltered by the effects of sedation or weakness
  • Adheres to medication schedule
  • Verbalizes understanding of medication regimen and the importance of regular administration
  • Demonstrates improvement in self-care and prosocial behavior

Sedative-Hypnotic Agents: Background and Use

• Sedative-hypnotic agents are used in the short-term management of various anxiety states and to treat insomnia.
• Also used short term as anticonvulsants and preoperative sedatives and in the management of alcohol withdrawal.
• Clinical guidelines typically recommend CBT as the first choice of treatment for insomnia.
• Four categories of medications approved by the FDA for insomnia:
  • Benzodiazepines and alternative structured medications with benzodiazepine-like properties
  • Melatonin receptor agonists
  • Histamine receptor antagonist
  • Orexin receptor antagonists
• Sedative-hypnotics cause generalized CNS depression.
• May produce tolerance w/ chronic use & have potential for psychological / physical dependence.
• Ramelteon (Rozerem) is not a controlled substance and does not produce tolerance or physical dependence due to its selectively targeting of the melatonin receptors.

Sedative-Hypnotic Agents: Contraindications, Precautions, and Interactions

• Contraindicated in individuals with hypersensitivity to the drug.
• Contraindicated in individuals are pregnant (exceptions may be made in certain cases based on benefit-to-risk ratio).
• Contraindicated in individuals who are lactating.
• Contraindicated in severe hepatic, cardiac, respiratory, or renal disease.
• Contraindicated in children younger than age 15 years and/ or 18 years.
• Triazolam is contraindicated with concurrent use of medications that impair the metabolism of triazolam by cytochrome P4503A (CYP3A).
• Ramelteon is contraindicated with concurrent use of fluvoxamine.
• Zolpidem, zaleplon, eszopiclone, and ramelteon are contraindicated in children.
• Caution should be used in administering these drugs to patients with cardiac, hepatic, renal, or respiratory insufficiency.
• Caution should also be used in using these drugs for patients who may be suicidal.
• Hypnotic use should be short term.
• Elderly patients may be more sensitive to CNS depressant effects, and dosage reduction may be required.
• Effects of barbiturates are increased with concomitant use of alcohol, other CNS depressants, MAOIs, or valproic acid and may enhance renal toxicity.
• The effects of benzodiazepine hypnotics are increased with alcohol, cimetidine, oral contraceptives, disulfiram, isoniazid, or probenecid.
• Concomitant use with opioids increases the risk of respiratory depression, coma, and death.
• The effects of eszopiclone occur with alcohol or other CNS depressants.
• The effects of zaleplon with alcohol or other CNS depressants.
• Ramelteon, tasimelteon effects with alcohol, ketoconazole and fluvoxamine.
• Zolpidem increased effects occur with alcohol or other CNS depressants, azole antifungals, ritonavir, or SSRIs.

Sedative-Hypnotic Agents: Nursing Diagnoses and safety

• Nursing diagnoses for patients receiving therapy with sedative-hypnotics:
  • Risk for injury related to abrupt withdrawal from long-term use or decreased mental alertness
  • Disturbed sleep pattern or insomnia
  • Risk for activity intolerance related to side effects
  • Risk for acute confusion related to action of the medication on the CNS
• Safety Issues in Planning and Implementing Care
  • Abnormal thinking and behavioral changes, including aggressiveness, hallucinations, and suicidal ideation, can occur.
  • Certain complex behaviors, such as sleep-driving, preparing and eating food, and making phone calls, with amnesia for the behavior, have occurred.
  • The FDA added a boxed warning to prescribing information related to serious injuries and death associated with complex sleep behaviors.
• Emergence of any new behavioral sign or symptom of concern requires careful and immediate evaluation.

Sedative-Hypnotic Agents: Outcome Criteria and Evaluation

• Criteria to evaluate the effectiveness of therapy (the patient):
  • Demonstrates reduced anxiety, tension, and restless activity
  • Falls asleep within 30 minutes of taking the medication and remains asleep for 6 to 8 hours without interruption
  • Is able to participate in usual activities without residual sedation
  • Experiences no physical injury
  • Exhibits no evidence of confusion
  • Verbalizes understanding of taking the medication on a short-term basis
  • Verbalizes understanding of potential for development of tolerance and dependence with long-term use

Attention Deficit-Hyperactivity Disorder (ADHD) Agents: Background and Types

• ADHD agents include CNS stimulants and nonstimulants.
• Amphetamines are schedule II controlled substances.
• Also used in the treatment of narcolepsy and exogenous obesity.
• Nonstimulant medications: atomoxetine, bupropion, clonidine, and guanfacine.
• Agents for ADHD can be found in Chapter 32, “Children and Adolescents.”

Attention Deficit-Hyperactivity Disorder (ADHD) Agents: Action

• CNS stimulants increase levels of neurotransmitters in the CNS
• Produce CNS and respiratory stimulation, vasoconstriction, dilated pupils, increased motor activity and improved attention span
• CNS stimulants include dextroamphetamine sulfate, methamphetamine, lisdexamfetamine, amphetamine mixtures, methylphenidate, and dexmethylphenidate.
• Atomoxetine inhibits the reuptake of norepinephrine.
• Bupropion blocks the neuronal uptake of serotonin, norepinephrine, and dopamine.
• Clonidine and guanfacine stimulate central alpha-adrenergic receptors in the brain.
• Also a novel interactive video game, EndeavorRx.
• A second FDA-approved device: the Monarch external trigeminal nerve stimulation (eTNS) system
• Other advances: a delayed-release stimulant, FDA approval of an SNRI, viloxazine, and a combination CNS stimulant.

Attention Deficit-Hyperactivity Disorder (ADHD) Agents: Contraindications and Precautions

• CNS stimulants are contraindicated in individuals with hypersensitivity to sympathomimetic amines.
• Use of CNS stimulants should be avoided in clients with advanced arteriosclerosis, cardiovascular disease, hypertension, hyperthyroidism, glaucoma, or agitated or hyperexcitability states.
• Use of CNS stimulants should be avoided in clients with a history of substance misuse, during or within 14 days of receiving therapy with MAOIs, in children younger than age 3, or during pregnancy and lactation.
• Atomoxetine and bupropion are contraindicated in clients with hypersensitivity to the drugs, in lactation, and in concomitant use with or within 2 weeks of using MAOIs.
• Atomoxetine is contraindicated in clients with narrow-angle glaucoma and pregnancy.
• Bupropion is contraindicated in individuals with known or suspected seizure disorder, in the acute phase of myocardial infarction (MI), and in people with bulimia or anorexia nervosa.
• Caution is advised in using CNS stimulants in children with psychosis, in Tourette’s disorder, prolonged use may result in tolerance and physical or psychological dependence and a history of suicidal or homicidal tendencies. Alpha-agonists are contraindicated in clients with known hypersensitivity to the drugs.

Attention Deficit-Hyperactivity Disorder (ADHD) Agents: Interactions

• Effects of amphetamines are increased with furazolidone or urinary alkalinizers.
• Hypertensive crisis may occur with concomitant use of MAOIs.
• Increased risk of serotonin syndrome occurs with coadministration of SSRIs.
• Decreased effects of antihypertensive agents and pressor agents with methylphenidates and methylphenidate.
• Effects of atomoxetine and Viloxazine are increased with concomitant use of CYP2D6 inhibitors.
• Potentially fatal reactions may occur with concurrent use of MAOIs.
• Bupropion effects are increased with amantadine, levodopa, or ritonavir.

Attention Deficit-Hyperactivity Disorder (ADHD) Agents: Nursing Diagnoses

• Risk for injury related to overstimulation, suicide and seizures.
• Imbalanced nutrition, less than body requirements, related to side effects of anorexia and weight loss (CNS stimulants)
• Insomnia related to side effects of overstimulation
• Nausea related to side effects of atomoxetine or bupropion
• Pain of abdominal, headache, due to medication
• Risk for activity intolerance related to side effects of sedation and dizziness with atomoxetine or bupropion

Attention Deficit-Hyperactivity Disorder (ADHD) Agents: Safety Issues

• Monitoring side effects from agents for ADHD and Nursing interventions:
  • Overstimulation, restlessness, insomnia (CNS stimulants)
  • Palpitations, tachycardia (CNS stimulants, atomoxetine, bupropion, clonidine), or bradycardia (clonidine, guanfacine)
  • Note: monitor and record cardiovascular due to FDA warnings of death and side effects.
  • Anorexia, weight loss (CNS stimulants, atomoxetine, bupropion)
  • Tolerance, physical and psychological dependence (CNS stimulants)
  • Nausea and vomiting (atomoxetine and bupropion)
  • Constipation (atomoxetine, bupropion, clonidine, guanfacine)
  • Dry mouth (clonidine and guanfacine)
  • Sedation (clonidine and guanfacine)
  • Potential for seizures (bupropion)
  • Severe liver damage (with atomoxetine)
  • New or worsened psychiatric symptoms (with CNS stimulants and atomoxetine) Rebound syndrome (with clonidine and guanfacine)

Attention Deficit-Hyperactivity Disorder (ADHD) Agents: Patient and Family Education

• Instruct the patient and family that the patient should:
  • Use caution when driving or operating dangerous machinery. Drowsiness, dizziness, and blurred vision can occur.
  • Not stop taking CNS stimulants abruptly.
  • Avoid taking CNS stimulants late in the day to prevent insomnia.
  • Not take other medications without the physician’s approval.
  • Monitor blood sugar if the patient is diabetic.
  • Avoid consumption of large amounts of caffeinated products
  • Notify physician if restlessness, insomnia, anorexia, or dry mouth becomes severe or rapid.
• Report side effects to physician.
• Be aware if there is a suspected pregnancy to contact physician.

Attention Deficit-Hyperactivity Disorder (ADHD) Agents: Outcome Criteria and Evaluation

• The patient:
  • Does not exhibit excessive hyperactivity
  • Has not experienced injury
  • Is maintaining expected parameters of growth and development
  • Verbalizes understanding of safe self-administration and the importance of medication