NUR 360 Pharmacology Exam 1 Study Guide PDF

NUR 360 Pharmacology Exam 1 Study Guide SLO 1.6: Describe how the therapeutic index and half-life of medications determine the necessary nursing care. o Therapeutic Index § Medications with a high therapeutic index (TI) have a wide safety margin – no need for routine blood-medication level monitoring. § Medications with a low therapeutic index (TI) require close monitoring of medication levels. § Consider the route of administration when monitoring for peak levels. § For trough levels, obtain a blood sample immediately before the next dose, regardless of the route of administration. § A plateau is a medication’s concentration in plasma during a series of doses. o Half-Life § Half-life (t½) refers to the time for the medication in the body to drop by 50%. Liver and kidney function aZect half-life. It usually takes about 4 half-lives to achieve a steady blood concentration (medication intake = medication metabolism and excretion). § Short Half-Life Medications leave the body quickly (4 to 8 hr). Short-dosing interval or MEC drops between doses. § Long Half-Life Medications leave the body more slowly: over more than 24 hr, with a greater risk for medication accumulation and toxicity. Medications can be given at longer intervals without loss of therapeutic eZects. Medications take a longer time to reach a steady state. SLO 2.7: Explain the process and purpose of medication reconciliation. o Purpose of Medication Reconciliation § Identify and prevent medication errors § Optimize medication use § Improve patient health and safety § Promote communication and collaboration § Reduce healthcare costs from unnecessary or ineZective treatments o Steps of Medication Reconciliation § Step 1: review the patient record prior to the interview. § Step 2: conduct medication history. § Step 3: reconcile the list obtained from the medication history. § Step 4: update the medication list in the medical record. SLO 5.1 – 5.2: Describe each of the adverse drug reactions that occur. Detail the nursing care for each of the diZerent types of drug reactions. o Cardiovascular § Can involve the blood vessels and the heart. § Many medications (ex. antihypertensives) can cause orthostatic hypotension (postural hypotension). § Client Education Monitor for indications of orthostatic hypotension (lightheadedness, dizziness). If these occur, sit or lie down. Postural hypotension can be minimized by getting up and changing positions slowly. o CNS & Anticholinergic § General CNS Depressive EZects Assessment Findings: o Altered LOC, sleepiness, sedation o Intervention: prevent injury! § Atropine-like (Anticholinergic) EZects Stimulates the sympathetic side of the PNS o Most eZects are seen in the eyes, smooth muscle, exocrine glands, and the heart. Assessment Findings: o Dry mouth, urinary retention, blurred vision Interventions: o Sugarless lozenges to keep mouth moist o Have the patient void before administration of the medication. Client Education o Manage these eZects to minimize danger and discomfort. o Avoid activities that could lead to overheating, because there is a decreased ability to produce sweat to cool the body. § Nursing Actions If CNS stimulation is expected, clients can be at risk for seizures, and precautions should be taken. If CNS depression is likely, advise the client not to drive, operate heavy machinery, or participate in other activities that can be dangerous. o Extrapyramidal Symptoms (EPS) § Abnormal body movements often associated with medications aZecting the CNS – typical antipsychotics (ADAPT). Acute Dystonia (usually within days) o The patient experiences severe spasms of the tongue, neck, face, or back. If the laryngeal muscles are aZected, respiration can decrease – crisis that requires rapid treatment. o Nursing Actions § Monitor for AD from a few hours to 5 days after the administration of the ﬁrst dose. § Manage eZects of AD with other medications as needed and prescribed. Akathisia (weeks to months) o The patient is unable to stand or sit still and is continually pacing and agitated – restless, agitated, need to move/rock/pace, frantic/panicked o Nursing Actions § Observe for akathisia within 2 months of the initiation of treatment. Manage eZects of akathisia with other medications as needed and prescribed. Parkinsonism (weeks to months) o Findings include bradykinesia, rigidity, shuZling gate, drooling, and tremors. o Nursing Actions § Observe for parkinsonism within 1 month of the initiation of therapy. § Manage eZects with other medications as needed and prescribed. After improvement, discontinue these medications to determine if they are still needed. If manifestations return, an atypical antipsychotic may be prescribed. Tardive Dyskinesia (months to years) o Tardive = delayed; symptoms start later o Dyskinesia = uncontrolled abnormal movements o Manifestations include involuntary movements of the tongue and face, such as lip smacking, which cause speech and/or eating disturbances. o Can also include involuntary movements of the arms, legs, or trunk. o Nursing Actions § TD is a late EPS that can occur months to years after the start of therapy and can improve following medication change or can be permanent. § Evaluate the client after 12 months of therapy and then every 3 months. If indications of TD appear, dosage should be lowered, or the client should be switched to atypical agents. o Gastrointestinal § Can result from local irritation of the GI tract. Very common side eZects include nausea, vomiting, diarrhea, and constipation. § Stimulation of the vomiting center also result in adverse eZects. § Client Education NSAIDs can cause GI upset. Take these medications with food. Opioid analgesics slow peristalsis and can cause nausea. Perform methods to avoid constipation and GI irritation. These can also cause sedation so promote safety! o Hematologic § Relatively common and potentially life-threatening with some groups of medications. § Nursing Actions Bone marrow depression/suppression is generally associated with anticancer medications and hemorrhagic disorders treated with anticoagulants and thrombolytics. § Client Education Monitor for bleeding (bruising, discolored urine/stool, petechiae, bleeding gums). Notify the provider if these manifestations occur. o Toxicity § An adverse medication eZect that is considered severe and can be life-threatening. § It can be caused by an excessive dose or at therapeutic levels. § Nursing Actions Know how to treat the overdose or high medication levels. Liver damage will occur with an acetaminophen overdose. There is a greater risk of liver damage with chronic alcohol use. The antidote, acetylcysteine, can be used to minimize liver damage. § Client Education Teach about the medications that require blood monitoring and adverse eZects to monitor speciﬁc to medications being taken. o Hepatotoxicity § Can occur with many medications. § Because most medications are metabolized in the liver, it is particularly vulnerable to drug-induced injury. § Damage to the liver cells can impair metabolism of many medications, causing medication accumulation and producing adverse eZects. § Many medications can alter normal values of liver function tests with no obvious clinical indications of liver dysfunction. § Nursing Actions When two or more medications that are hepatotoxic are combined, the risk for liver damage is increased. Liver function tests are indicated when clients start a medication known to be hepatotoxic and periodically thereafter. Monitor clients for manifestations of hepatotoxicity (nausea, vomiting, jaundice, dark urine, abdominal discomfort, and anorexia). Advise clients to monitor for these manifestations. o Nephrotoxicity § Can occur with several medications, but it is primarily the result of certain antimicrobial agents and NSAIDs. § Damage to the kidneys can interfere with medication excretion, leading to medication accumulation and adverse eZects. § Nursing Actions Aminoglycosides can injure cells in the renal tubules of the kidneys. Monitor blood creatinine and BUN, as well as peak and trough medication levels for clients taking medications that are nephrotoxic with a narrow therapeutic index. o Hypersensitivity/Allergies § Occurs when an individual develops an immune response to a medication. § The individual has been previously exposed to the medication and has developed antibodies. § Can result in: A mild reaction (itching, rash, watery eyes, sneezing, rhinosinusitis) or A severe reaction resulting in more severe signs and symptoms such as hives, angioedema, or anaphylaxis. o Rapid or Immediate Hypersensitivity (Atopic Allergy) § Causes an overproduction of IgE antibodies, resulting in acute inﬂammation, histamine release, and release of basophils, eosinophils, and mast cells. § Can result in: Mild signs and symptoms such as hay fever or rhinosinusitis or can become Severe resulting in angioedema, anaphylaxis, or allergic asthma o Either reaction can occur by inhaling, ingesting, injection, or direct contact with an allergen. o Angioedema § A severe allergic reaction that aZects deep tissues (blood vessels, skin, subcutaneous tissue, mucous membranes). § Generally, involves the lips, face, oropharyngeal cavity and neck, but can also aZect the intestinal system and other parts of the body. § NSAIDs and ACE inhibitors are the most common medications that can cause angioedema and can occur within 24 hours or anytime thereafter. § Nursing Actions Get a complete medical history to determine the type of medication the client is taking. Intervention: apply oxygen, alleviate anxiety with reassurance, and if needed, maintain an open airway with intubation or tracheostomy if laryngeal edema, stridor, and inability to swallow develops. Treatment: corticosteroids, diphenhydramine and epinephrine depending on the severity. Monitor for recurrence when the medications wear oZ. o Anaphylaxis and Allergic Asthma § Anaphylaxis: life-threatening, immediate systemic reaction caused from an allergic response to a medication, dye, food, insect bite or sting. § Allergic asthma also has a rapid onset with similar causes and can lead to a medical emergency if not properly treated initially. § Signs and symptoms of anaphylaxis can start with anxiety, weakness, generalized itching and hives that progress to erythema and angioedema of the head and neck. Crackles, wheezing, decreased breath sounds, and a feeling of a lump in the throat, hoarseness, and stridor can develop into a life-threatening condition that results in respiratory failure, hypoxemia, hypotension, tachycardia, and death. § Allergic asthma has similar manifestations that involve the pulmonary system that can become life-threatening. § Nursing Actions: Prevention and rapid intervention are vital! If the allergy is known, the client should wear a medical alert bracelet. The client should always have injectable epinephrine available. Stop the medication immediately if that’s the allergen and notify RRT if in the hospital setting. Establish an airway and administer bronchodilators if needed. Treat with epinephrine IM or IV to constrict blood vessels, improve cardiac contraction, and promote bronchodilation, every 5-15 minutes as needed. Administer diphenhydramine, an antihistamine, to decrease the manifestations of the angioedema and urticaria. Continue to administer oxygen, obtain ABGs, plan for the client to receive inhaled beta-adrenergic agonist or bronchodilators (albuterol, metaproterenol) every 2-4 hours. Administer corticosteroids for late recurrence of manifestations. Monitor hemodynamics; watch for ﬂuid overload from too rapid of IV ﬂuid infusions and pulmonary status. o Immunosuppression § Decreased or absent immune response § Nursing Actions Immunosuppressant medications (glucocorticoids) can mask the usual manifestations of infection (fever). Monitor clients taking an immunosuppressant (glucocorticoid) for delayed wound healing and subtle manifestations of infection (sore throat). § Client Education Avoid contact with anyone who has a communicable disease. SLO 2,4,5 Central Lines: Explain why central lines are used. Describe the diZerent types of central lines. Explain the nursing care for central line insertion, care during, and removal. o Why use a central line? § A central line is used to deliver ﬂuids, blood, and medications into a vein. § They are often used when a patient needs frequent IVs or blood draws or if large amounts of ﬂuids or medications need to be administered. §It is easy to access for quick placement. It is easy to access for blood draws (increased infection risk). § Some medications need to be administered into a large vein due to the irritant or vesicant properties, also diluting the medication as well. Some medications also need a central line (ex. vasoactive). § It can also be used for multiple infusions. It can be safer than peripheral IVs. § It is secure access. § It can also be used to deliver nutrition (try to avoid but can be used if necessary). § Some patients have poor vascular access for peripheral IV access. o DiZerent Types of Central Lines § Peripherally Inserted Central Catheter (PICC) Basilic vein à SVC; less prone to infection; tunneled insertion approach; inserted through the skin; access vein under the skin; cuZ; patients can go home with it § Tunneled Catheters (External Central Lines) Passed under the skin and into a vein in the chest or neck § Implanted Port Surgically placed under the skin Used for long-term access Less visible and requires less daily care than a tunneled catheter o Nursing Care for Central Lines § Insertion Beside procedure most often with nurse assisting New, clean lines Sterile procedure – inserter fully sterile; CHG prep, sterile drape Lidocaine to prep insertion area Ultrasound with sterile probe cover available Dressing supplies Securement with stat lock or suture § Active Use Line Patency o Flush and check blood return (not always able) o Flush 10 mL after blood return o Push/pause – keep ﬁbrin clot from forming Don’t use 3 mL syringe o Increased pressure may cause rupture o Use 5 mL or 10 mL Don’t draw cultures from line o Peripheral sticks o Line colonization with bacteria o Suspect infection from line – discontinue or place new line Dressing/site care o Dressing is clean, dry, and intact o Change dressing every 7 days or PRN o Change gauze every 24 hours o Sterile gloves and CHG prep – masked o Anti-microbial patch – correct size and impregnated with CHG Line Care o Change every 72-96 hours o Minimize access o Curos caps – keeps the port clean when not in use; still scrub with antiseptic prior to use Pressure Caps o Prevent blood backﬂow o Clamp if not in use Monitor for signs of infection § Removal Big concern – air embolism; sudden SOB and coughing; lay patient on left side if suspected Patient is lying ﬂat Vented – insp. pause while removing Extubated – deep breath and forced exhale through pursed lips when removing (Valsalva maneuver) SLO 6.2: Explain the purpose of medications from each of the main drug categories (what are they used to treat?) (Anxiety and Stress-Related Disorders). o Sedative Hypnotic Anxiolytics: Benzodiazepines § Most common therapeutic use: Generalized Anxiety Disorder (GAD) and panic disorder § Other uses for benzodiazepines Trauma- and stress-related disorders: Acute stress disorder (ASD) and PTSD Hyperarousal manifestations of dissociative disorders Seizure disorders (diazepam and lorazepam are given IV to treat ACTIVE seizures) Insomnia Muscle spasms Alcohol withdrawal (for prevention and treatment of acute manifestations) Induction of anesthesia (preoperative relaxation) o Atypical Anxiolytics/Nonbarbiturate Anxiolytic § Panic disorder § Social anxiety disorder § OCD and related disorders § Trauma- and stress-related disorders, PTSD § GAD § Bruxism (grinding and clenching of teeth) o Selective Serotonin Reuptake Inhibitors (SSRIs) § Paroxetine (Paxil) – prototype for anxiety § Fluoxetine (Prozac) – prototype for depression § Therapeutic uses: GAD Panic disorder: decrease both the frequency and intensity of panic attacks and prevents anticipatory anxiety about attacks OCD: reduces manifestation by increasing serotonin Social anxiety disorder Trauma- and stress-related disorders Dissociative disorders Depressive disorders (ﬂuoxetine) Adjustment disorders SLO 6.3: Correlate complications of medications from each of the main drug categories (focus on common and serious/life-threatening) (Anxiety and Stress-Related Disorders). o Sedative Hypnotic Anxiolytics: Benzodiazepines § CNS depression, sedation, lightheadedness, ataxia (lack of coordination), and decreased cognitive function § Client Education Observe for CNS depression. Notify the provider if these eZects occur. Avoid activities that require alertness. Avoid alcohol and other antianxiety medications doe to the potentiated depressant eZects such as severe respiratory depression. § Anterograde Amnesia: diZiculty recalling events that occur after dosing Client Education o Observe for manifestations. Notify the provider if these eZects occur. § Toxicity Acute toxicity Oral toxicity: drowsiness, lethargy, confusion IV toxicity: can lead to respiratory depression, severe hypotension, or cardiac/respiratory arrect o Only diazepam and lorazepam can be given IV Nursing Actions o For oral toxicity, gastric lavage is used, followed by the administration of activated charcoal o saline cathartics. o Administer ﬂumazenil (Romazicon), a GABA antagonist, for benzodiazepine toxicity to counteract sedation and reverse adverse eZects. o Monitor vital signs, maintain patent airway, and provide ﬂuids to maintain blood pressure. o Have resuscitation equipment available. Client Education o Watch for manifestations. Notify the provider if these occur. § Paradoxical response: insomnia, excitation, euphoria, anxiety, rage Client Education o Watch for manifestations. Notify the provider if these occur. § Withdrawal EZects: include anxiety, insomnia, diaphoresis, tremors, lightheadedness, delirium, hypertension, muscle twitching, and seizures. Client Education o Withdrawal eZects are not common with short-term use. o If taking benzodiazepines regularly and in high doses, taper the dose over several weeks. o Atypical Anxiolytics/Nonbarbiturate Anxiolytics: Buspirone (Buspar) § Dizziness, nausea, headache, lightheadedness, agitation Client Education o Take with food to decrease nausea. o Avoid activities that require alertness until eZects are known. o Most adverse eZects are self-limiting. § Constipation Client Education o Increase ﬁber and ﬂuid. § Suicidal Ideation Nursing Actions o Monitor and report manifestations of depression and thoughts of suicide (applies to any medication that increases serotonin; more common in the late teens and early 20s; beginning of therapy or with a dosage increase). o Selective Serotonin Reuptake Inhibitors (SSRIs): paroxetine (Paxil) – prototype for anxiety; ﬂuoxetine (Prozac) – prototype for depression. § Early Adverse EZects First few days/weeks: nausea, diaphoresis, tremor, fatigue, drowsiness Client Education o Report adverse eZects to the provider. o Take the medication as prescribed. o These eZects should soon subside. § Later Adverse EZects After 5-6 weeks of therapy: insomnia, headache, and sexual dysfunction (impotence, delayed or absent orgasm, delayed or absent ejaculation, decreased sexual interest) Client Education o Report problems with sexual function (managed with dose reduction, medication holiday, changing medications). § Weight changes Occurrence of weight loss early in therapy followed by wight gain with long- term treatment. Nursing Actions o Monitor the client’s weight. Client Education o Follow a well-balanced diet and exercise regularly. § GI Bleeding Nursing Actions o Use caution in clients who have a history of GI bleeding or ulcers and in clients taking other medication that aZect blood coagulation. Client Education o Report indications of bleeding (dark stool, coZee-ground emesis). § Hyponatremia More likely in older adult clients taking diuretics. Nursing Actions o Obtain baseline blood sodium level and monitor level periodically throughout treatment. § Serotonin Syndrome Agitation, confusion, disorientation, diZiculty concentrating, anxiety, hallucinations, myoclonus (spastic, jerky muscle contractions), hyperreﬂexia, incoordination, tremors, fever, diaphoresis, hostility, delirium, seizures, tachycardia, labile blood pressure, nausea, vomiting, diarrhea, abdominal pain, coma leading to apnea, and death in severe cases. Nursing Actions o Serotonin syndrome usually begins 2 to 72 hours after initiation of treatment. o This resolves when the medication is discontinued. o Watch for and advise clients to withhold the medication and report any of these manifestations, which could indicate a lethal problem. § Sexual Dysfunction – anorgasmia, impotence, decreased libido Client Education o Remain aware of possible adverse eZects and to notify the provider if intolerable. o Utilize ways to manage sexual dysfunction, which can include lowering dosage, discontinuing medication temporarily (medication holiday), and using adjunct medications to improve sexual function (sildenaﬁl, buspirone). o An atypical antidepressant (bupropion) has fewer sexual dysfunction adverse eZects. § CNS Stimulation – inability to sleep, agitation, anxiety Client Education o Notify the provider. The dose might need to be lowered. o Take the dose in the morning. o Avoid caZeinated beverages. o Perform relaxation techniques to promote sleep. § Bruxism Grinding and clenching of the teeth, usually during sleep. Nursing Actions o Report bruxism to the provider, who might switch the client to another class of medication. o Treat with low dose buspirone. Client Education o Use a mouth guard during sleep. § Withdrawal Syndrome: nausea, sensory disturbances, anxiety, tremor, malaise, unease Nursing Actions o Minimized by tapering the medication slowly. Client Education o Do not discontinue use abruptly but slowly taper the dose of medication before stopping, especially with long-term use. § Postural Hypotension Nursing Actions o Monitor for hypotension and advise the client to change positions slowly. § !!!Suicidal Ideation!!! This is common in the young (teens and young adults and happens EARLY in treatment). Nursing Actions o Monitor and report manifestations of depression and thoughts of suicide. SLO 6.5: Analyze nursing interventions of medications from each of the main drug categories (Anxiety and Stress-Related Disorders). o Sedative Hypnotic Anxiolytics: Benzodiazepines § Nursing Administration Administer the medication with meals or snack if gastrointestinal upset occurs. Administer the medication at bedtime if possible due to sedation. Advise clients to swallow sustained-release tablets and to avoid chewing or crushing the tablets. § Client Education Do not take benzodiazepines in larger amounts or more often than prescribed without consulting the provider. Dependency can develop during or after treatment. Notify the provider if indications of withdrawal occur. Store benzodiazepines in a secure place to prevent misuse by others. Swallow sustained-release tablets and do not crush or chew them. o Atypical Anxiolytics/Nonbarbiturate Anxiolytics: Buspirone (Buspar) § Nursing Administration Labeled for short-term treatment of anxiety but has shown therapeutic beneﬁts for as long as a year. § Client Education Take the medication with meals to prevent gastric irritation. EZects do not occur immediately. It can take a week to notice the ﬁrst therapeutic eZects and 2 to 4 weeks for the full beneﬁt. Take on a regular basis and not PRN. Tolerance, dependence, or withdrawal eZects are not an issue with this medication. o Selective Serotonin Reuptake Inhibitors (SSRIs): paroxetine (Paxil) – prototype for anxiety; ﬂuoxetine (Prozac) – prototype for depression § Nursing Administration Administer with food to reduce stomach upset. § Client Education It can take up to 4 weeks to achieve therapeutic eZects. Taking the medication at the same time daily promotes therapeutic levels. Taking the medication in the morning can prevent sleep disturbances. SLO 7.1: Identify prototype medications from each of the main drug categories (Depressive Disorders). o Selective serotonin reuptake inhibitors (SSRIs) § Prototype medication: ﬂuoxetine (Prozac) for depression o Serotonin-norepinephrine reuptake inhibitors (SNRIs) § Prototype medication: venlafaxine (EZexor) o Atypical antidepressants § Prototype medication: Bupropion (Wellbutrin) o Tricyclic antidepressants (TCAs) § Prototype medication: amitriptyline (Elavil) o Monoamine oxidase inhibitors (MAOIs) § Prototype medication: Phenelzine (Nardil) SLO 7.3: Correlate complications of medications from each of the main drug categories (Focus on common and serious/life-threatening) (Depressive Disorders). o Selective serotonin reuptake inhibitors (SSRIs) – ﬂuoxetine (Prozac) § Sexual dysfunction: anorgasmia, impotence, decreased libido. Client Education o Remain aware of possible adverse eZects and to notify the provider if intolerable. o Utilize ways to manage sexual dysfunction, which can include lowering dosage, medication holiday, and using adjunct medications to improve sexual function (sildenaﬁl, buspirone). o An atypical antidepressant (bupropion) has fewer sexual dysfunction adverse eZects. § CNS Stimulation: inability to sleep, agitation, anxiety. Client Education o Notify the provider. Dose might need to be lowered. o Take dose in the morning. o Avoid caZeinated beverages. Perform relaxation techniques to promote sleep. § Neuroleptic Malignant Syndrome Nursing Actions o Monitor client for manifestations (fever, respiratory distress, and tachycardia). o Monitor client for seizure activity. § Suicidal thoughts Nursing Actions o Observe client for suicidal tendencies (especially during early therapy). o Children, adolescents, and adults 24 or under may be at higher risk. o Monitor client for torsade’s de pointes (ventricular tachycardia). § Weight loss early in therapy Can be followed by weight gain with long-term treatment. Nursing Actions o Monitor the client’s weight. o Encourage clients to participate in regular exercise and to follow a healthy, well-balanced diet. § Serotonin Syndrome Can begin 2 to 72 hours after starting treatment and can be lethal. Manifestations o Confusion, agitation, poor concentration, hostility o Disorientation, hallucinations, delirium o Seizures leading to status epilepticus o Tachycardia leading to cardiovascular shock o Labile blood pressure o Diaphoresis o Fever leading to hyperpyrexia o Incoordination, hyperreﬂexia, tremors o Nausea, vomiting, diarrhea, abdominal pain o Coma leading to apnea (and death in severe cases) o Anxiety Nursing Actions o Start symptomatic treatment (medications to create serotonin- receptor blockade and muscle rigidity, cooling blankets, anticonvulsants, artiﬁcial ventilation). Client Education o Observe for manifestations. If any occur, notify the provider, and withhold the medication. § Withdrawal syndrome Resulting in headache, nausea, visual disturbances, anxiety, dizziness, and tremors. Manifestations begin days to weeks following the last dose and can last for 1 to 3 weeks. Client Education o Taper dose gradually § Hyponatremia More likely in older adult clients taking diuretics. Nursing Actions o Obtain baseline blood sodium and monitor level periodically throughput treatment. § Rash Client Education o A rash is treatable with an antihistamine or withdrawal of medication. § Sleepiness, faintness, lightheadedness Client Education o These adverse eZects are not common but can occur. o Avoid driving if these adverse eZects occur. § GI Bleeding Nursing Actions o Use caution in clients who have a history of GI bleeding and ulcers, and those taking other medications that aZect blood coagulation. § Bruxism Nursing Actions o Changing to a diZerent classiﬁcation of antidepressants or adding a low dose of buspirone can decrease this adverse eZect. Client Education o Report to the provider. o Use a mouth guard. o Serotonin-norepinephrine reuptake inhibitors (SNRIs) § Nausea, anorexia, weight loss Nursing Actions o Monitor weight and food intake. § Headache, insomnia, anxiety Nursing Actions o Monitor for these ﬁndings. § Hypertension, tachycardia Nursing Actions o Monitor vital signs and report changes. § Neuroleptic Malignant Syndrome Nursing Actions o Monitor clients for manifestations (fever, respiratory distress, and tachycardia). o Monitor clients for seizure activity. § Suicidal thoughts Nursing Actions o Observe clients for suicidal tendencies (especially during early treatment). o Children, adolescents, and adults 24 or under may be at higher risk. o Monitor clients for torsade’s de pointes (ventricular tachycardia). § Dizziness, blurred vision Client Education o Avoid driving or use of machinery until the eZects are known. o Venlafaxine can cause mydriasis (pupil dilation) and can increase ocular damage if taken when the client has glaucoma. § Withdrawal syndrome Resulting in headache, nausea, visual disturbances, anxiety, agitation, tachycardia, tinnitus, dizziness, tremors, and worsening of pretreatment manifestations. Client Education o Withdraw from medication gradually. § Risk for suicide in children and adolescents Nursing Actions o Assess children/adolescents carefully for suicidal ideation and thought disorders. § Sexual Dysfunction Anorgasmia, decreased libido, impotence, menstrual changes Client Education o Report sexual dysfunction to the provider. o Utilize ways to manage sexual dysfunction, which can include lowering dosage, medication holiday, and using adjunct medications to improve sexual function (sildenaﬁl, buspirone). o An atypical antidepressant (bupropion) has fewer sexual dysfunction adverse eZects. § Serotonin Syndrome Can begin 2 to 72 hours after starting treatment and can be lethal. Manifestations o Confusion, agitation, poor concentration, hostility o Disorientation, hallucinations, delirium o Seizures leading to status epilepticus o Tachycardia leading to cardiovascular shock o Labile blood pressure o Diaphoresis o Fever leading to hyperpyrexia o Incoordination, hyperreﬂexia, tremors o Nausea, vomiting, diarrhea, abdominal pain o Coma leading to apnea (and death in severe cases) o Anxiety Nursing Actions o Start symptomatic treatment (medications to create serotonin- receptor blockade and muscle rigidity, cooling blankets, anticonvulsants, artiﬁcial ventilation). Client Education o Observe for manifestations. If any occur, notify the provider, and withhold the medication. o Atypical antidepressants § Headaches, dry mouth, GI distress, constipation, increased heart rate, hypertension, restlessness, and insomnia. Nursing Actions o Treat headaches with mild analgesics. Client Education o Observe for eZects and notify the provider if intolerable. o Sip on ﬂuids to treat dry mouth and increase dietary ﬁber to prevent constipation. § Nausea, vomiting, anorexia, weight loss. Nursing Action o Monitor food and weight loss § Seizures Nursing Actions o Avoid administering to clients at risk for seizures (clients with head injuries). Monitor for seizures and treat accordingly. o Tricyclic antidepressants (TCAs) § Orthostatic Hypotension Nursing Actions o Monitor blood pressure and heart rate for clients in the hospital for orthostatic changes before and 1 hour after administration. § If a signiﬁcant decrease in blood pressure or increase in heart rate is noted, do not administer the medication and notify the provider. o Be aware of the eZects of postural hypotension (lightheadedness, dizziness). If these occur, advise the client to sit or lie down – can be minimized by changing positions slowly. o Avoid dehydration due to the increased risk for hypotension. o Monitor the client for suicidal tendencies. § Anticholinergic EZects Manifestations o Dry mouth o Blurred vision o Photophobia o Urinary hesitancy or retention o Constipation o Tachycardia Client Education o Minimize anticholinergic eZects: § Chewing sugarless gum § Sipping on water § Wearing sunglasses when outdoors § Eating foods high in ﬁber § Participating in regular exercise § Increasing ﬂuid intake to at least 2 to 3 L a day from beverages and food sources § Voiding just before taking medications o Notify the provider if eZects persist. § Sedation This eZect usually diminishes over time. Client Education o Avoid hazardous activities (driving) if sedation is excessive. o Take medication at bedtime to minimize daytime sleepiness and to promote sleep. § Toxicity Resulting in cholinergic blockade and cardiac toxicity evidenced by dysrhythmias, mental confusion, and agitation, followed by seizures, coma, and possible death. Nursing Actions o Obtain baseline ECG o Monitor vital signs frequently o Monitor manifestations of toxicity o Notify the provider if manifestations of toxicity § Decreased Seizure Threshold Nursing Actions o Monitor clients who have seizure disorders § Excessive sweating Client Education o Be aware of adverse eZects. Perform frequent linen changes. o Monoamine oxidase inhibitors (MAOIs) § CNS Stimulation Anxiety, agitation, mania, or hypomania Client Education o Observe for eZects and notify the provider if they occur. § Orthostatic Hypotension Nursing Actions o Monitor blood pressure and heart rate for orthostatic changes. Hold medication and notify the provider of signiﬁcant changes. Instruct the client to change positions slowly. § Hypertensive crisis, severe hypertension, headache, nausea, increased heart rate, and increased blood pressure. Hypertensive crisis resulting from intake of dietary tyramine, which could lead to a cerebral vascular accident. Severe hypotension because of intensive vasoconstriction and stimulation of the heart Headache, nausea, and increased heart rate and blood pressure Nursing Actions o Administer phentolamine IV (a rapid-acting alpha-adrenergic blocker) or nifedipine SL. o Provide continuous cardiac monitoring and respiratory support as indicated. § Local rash with transdermal preparation. Nursing Actions o Choose a clean, dry area for each application. o Apply a topical glucocorticoid on the aZected area. o Avoid hairy, irritated, calloused areas. o Wash hands after applying new patches and disposing old patches. SLO 7.4: Identify the contraindications/precautions/interactions of meds from each of the main drug categories (Depressive Disorders). o Selective Serotonin Reuptake Inhibitors (SSRIs): ﬂuoxetine § Contraindications/Precautions The use of SSRIs during late pregnancy can cause pulmonary hypertension of the newborn. Most are considered safe during lactation. Paroxetine increases the risk of birth defects. Therefore, other SSRIs are recommended. Safety is not established during lactation. SSRIs are contraindicated in clients taking MAOIs or TCAs. SSRIs need to be discontinued at least 2 weeks before initiating an MAOI. Use cautiously in clients who have liver and kidney dysfunction, cardiac disease, seizure disorders, diabetes, ulcers, and a history of GI bleeding. § Interactions TCAs, MAOIs, and St. John’s wort o These increase the risk of serotonin syndrome. o Discontinue MAOIs 14 days prior to starting an SSRI. If already taking ﬂuoxetine, wait 5 weeks before starting an MAOI. Warfarin o Fluoxetine can displace warfarin from bound protein and result in increased risk of bleeding. o Monitor PT and INR. o Assess for indications of bleeding and the need for dosage adjustment. TCAs and Lithium o Fluoxetine can increase the levels of TCA and lithium. o Avoid concurrent use. NSAIDs and Anticoagulants o Fluoxetine suppresses platelet aggregation and thus increases the risk of bleeding when used concurrently with NSAID and anticoagulants. o Monitor for indications of bleeding and notify the provider if they occur. o Serotonin Norepinephrine Reuptake Inhibitors (SNRIs): venlafaxine § Contraindications/Precautions Avoid during the third trimester due to the risk of withdrawal syndrome for the newborn. Avoid if the client is lactating. Precautions needed for older adults and clients who have bipolar disorder, mania, seizure disorder, recent MI, hypertension, liver/kidney impairment, or interstitial lung disease. Taper slowly when discontinuing antidepressant medication, especially venlafaxine, which can cause severe withdrawal syndrome if not stopped abruptly. § Interactions Serotonin syndrome can occur if given concurrently with MAOIs, SSRIs, or TCAs. o Stop MAOIs at least 14 days before beginning an SNRI. Precautions are needed for older adults, and clients who have bipolar disorder, mania, seizure disorder, recent MI, or interstitial lung disease. Taper slowly when discontinuing antidepressant medications. o Atypical Antidepressants: Bupropion § Contraindications/Precautions Pregnancy risk category B; serious adverse reactions to nursing infants. Contraindicated in clients taking MAOIs. Contraindicated for clients who have seizure disorders or eating disorders. Use cautiously in clients with hepatic/renal impairment. § Interactions MAOIs (phenelzine) increase the risk for toxicity. o Tricyclic Antidepressants (TCAs): amitriptyline § Contraindications/Precautions Pregnancy risk category C – these medications are not generally recommended for use during pregnancy or breastfeeding. Contraindicated in clients who have seizure disorders or who have recently experienced a myocardial infarction. Clients are at an increased risk for suicide should receive a 1-week supply of medication at a time due to the lethality of a toxic dose. § Interactions Concurrent use with MAOIs or St. John’s wort can lead to serotonin syndrome. Concurrent use with MAOIs can cause severe hypertension. Antihistamines and other anticholinergic agents have additive anticholinergic eZects. Alcohol, benzodiazepines, opioids, and antihistamines cause additive CNS depression when used concurrently. o Monoamine Oxidase Inhibitors (MAOIs): phenelzine § Contraindications/Precautions If the client is pregnant, use only if the beneﬁt to the client outweighs the risks to the fetus. Safety not established for clients who are lactating. QS Contraindicated in clients taking SSRIs and in those who have pheochromocytoma, heart failure, cardiovascular and cerebral vascular disease, and severe renal insuZiciency. Use cautiously in clients who have diabetes and seizure disorders or those taking TCAs. Transdermal selegiline is contraindicated for clients taking carbamazepine or oxcarbazepine, which can increase blood levels of the MAOI. § Interactions Indirect-acting sympathomimetic medications (ephedrine, amphetamine) promote the release of norepinephrine and can lead to hypertensive crisis. o Avoid over-the-counter decongestants and cold remedies, which frequently contain medications with sympathomimetic action. Use of tricyclic antidepressants can lead to hypertensive crisis. Use of SSRIs can lead to serotonin syndrome. Antihypertensives have an additive hypotensive eZect. Use of meperidine can lead to hyperpyrexia. Tyramine-rich foods can lead to hypertensive crisis. o Clients will most likely experience headache, nausea, increased heart rate, and increased blood pressure o Tyramine-rich foods include aged cheese, pepperoni, salami, avocados, ﬁgs, bananas, smoked ﬁsh, protein dietary supplements, soups, soy sauce, some beers, and red wine. o The MAOI transdermal patch does not seem to aZect tyramine sensitivity at its low dose, but tyramine restriction is recommended at higher doses. § Concurrent use of vasopressors (phenylethylamine, caZeine) can result in hypertension. SLO 7.5: Analyze nursing interventions of medications from each of the main drug categories (Depressive Disorders). o Nursing Administration for all medications in this chapter: § Assis with medication regimen adherence by informing clients that it can take 1 to 3 weeks to being experiencing therapeutic eZects. Full therapeutic eZects can take 2 to 3 months. § Assess for suicide risk. Antidepressant medications can increase a client’s risk for suicide, particularly during initial treatment. Antidepressant-induced suicide is mainly associated with clients younger than age 25. o Client education for all medications in this chapter: § Take these medications as prescribed daily to establish therapeutic plasma levels. § Continue therapy after achieving therapeutic eZects. Sudden discontinuation of the medicant can result in relapse. § Therapy usually continues for 6 months after resolution of manifestations and can continue for a year or longer. o SSRIs and SNRIs § Avoid use of MAOIs. § Obtain baseline sodium levels for older adults taking diuretics and monitor periodically. § Client education Take medication in the morning to minimize sleep disturbances. Take medications with food to minimize GI disturbances. These medications can cause sexual adverse eZects. o Atypical Antidepressants § For all atypical antidepressant medications, avoid use with MAOIs. § Client education If taking bupropion for prevention of seasonal pattern depression, take medication beginning in the autumn each year and gradually taper dose and discontinue by spring. o TCAs § Monitor for toxicity manifested by cardiac dysrhythmias. § Administer at bedtime due to sedation and risk for orthostatic hypotension. § Monitor for clients “cheeking” or hoarding TCAs due to potential lethality in toxicity. o MAOIs § Give clients a list of tyramine-rich foods so hypertensive crises can be avoided. o Nursing Evaluation of Medication EZectiveness § Depending on therapeutic intent, eZectiveness is evidenced by the following: Verbalizing improvement in mood Increased hopefulness and will to live Ability to perform ADLs Increased interaction with peers SLO 8.4: Identify the contraindications/precautions/interactions of meds from each of the main drug categories (Bipolar Disorders). o Mood Stabilizers: lithium § Contraindications/Precautions Warnings o Pregnancy: not recommended for use during pregnancy – avoid during ﬁrst trimester unless beneﬁts outweigh the risk. o Lactation: contraindicated o Reproductive: recommend avoiding the use of lithium for clients who are considering pregnancy. Use cautiously in clients who have renal dysfunction, heart disease, sodium depletion, hypovolemia, schizophrenia, or dehydration. Use cautiously in older adult clients who have thyroid disease, seizure disorder, or diabetes. § Interactions Diuretics o Sodium is excreted – reduced blood sodium decreases lithium excretion, which can lead to toxicity. o Monitor for indications of toxicity. o Client education § Observe for indications of toxicity and notify the provider. § Maintain a diet adequate in sodium and get 1.5 to 3 L of ﬂuid daily. NSAIDs (ibuprofen and celecoxib) o Concurrent use will increase renal absorption of lithium, leading to toxicity. o Avoid use of NSAIDs to prevent toxic accumulation of lithium. o Use aspirin as a mild analgesic. Anticholinergics o Antihistamines and TCAs can induce urinary retention and polyuria, leading to abdominal discomfort. o Avoid medications with anticholinergic eZects. SLO 8.5: Analyze nursing interventions of medications from each of the main drug categories (Bipolar Disorders). o Nursing Administration § Monitor plasma lithium levels during treatment Obtain a lithium level with each dosage change and after beginning lithium therapy every 2 to 3 days. Once a therapeutic level is obtained, monthly monitoring can occur, then every 3 to 6 months after a period of stability. Older adult clients often require more frequent monitoring because of increased risk for toxicity. Lithium blood levels should be obtained in the morning, 10 to 12 hr after the last dose. During initial treatment of a manic episode, higher levels can be required (1 to 1.5 mEq/L). Maintenance level range is between 0.6 to 1.2 mEq/L. Plasma levels at or greater than 1.5 mEq/L can result in toxicity. § Severe toxicity Care for clients who have advanced or severe lithium toxicity in an acute care setting and provide supportive measures. Hemodialysis can be indicated. Monitor CBC, blood electrolytes, renal function tests, and thyroid function tests during lithium therapy. Advise clients that eZects begin within 5 to 7 days. Advise clients to take lithium as prescribed. Lithium must be administered in 2 to 3 doses daily due to a short half-life. Taking lithium with food will help decrease GI distress. Encourage clients to adhere to laboratory appointments needed to monitor lithium eZectiveness and adverse eZects. Emphasize the high risk of toxicity due to the narrow therapeutic range. Provide nutritional counseling. Stress the importance of adequate ﬂuid and sodium intake. Instruct clients to monitor for manifestations of toxicity and when to contact the provider. Clients should withhold medication and seek medical attention if experiencing diarrhea, vomiting, or excessive sweating. Conditions that cause dehydration (exercising in hot weather or diarrhea) put client at risk for lithium toxicity. SLO 9.2: Explain the purpose of medications from each of the main drug categories (what are they used to treat?) (Psychotic Disorders). o Antipsychotics (ﬁrst generation): chlorpromazine (Thorazine) – low potency; haloperidol (Haldol) – high potency § Mainly control positive manifestations of psychotic disorders (hallucinations, delusions, bizarre behavior) § Expected pharmacologic action Block dopamine (D2), acetylcholine, histamine, and norepinephrine receptors in the brain and periphery. Inhibition of psychotic manifestations, believed to be a result of D2 blockade in the brain. § Therapeutic uses Acute and chronic psychotic disorders Schizophrenia spectrum disorders Bipolar disorders (primarily the manic phase) Tourette syndrome Agitation Prevention of nausea/vomiting through blocking of dopamine in the chemoreceptor trigger zone of the medulla o Antipsychotics (second and third generation) (atypical): risperidone § Expected pharmacologic action These medications work mainly by blocking serotonin, and to a lesser degree, dopamine receptors. These medications also block receptors for norepinephrine, histamine, and acetylcholine. The third-generation medications work by stabilizing the dopamine system as both an agonist and antagonist. § Therapeutic uses Schizophrenia spectrum disorders (negative and positive manifestations) Psychotic episodes induced by levodopa therapy Bipolar disorders Impulse control disorders § Advantages Relief of both the positive and negative manifestations of the disease Decrease in aZective manifestations (depression, anxiety) and suicidal behaviors Improvement of neurocognitive deﬁcits, such as poor memory Fewer or no EPSs, including TD, because of less dopamine blockade Fewer anticholinergic adverse eZects because most atypical antipsychotics, except for clozapine, cause little or no blockade of cholinergic receptors Less relapse SLO 9.3: correlate complications of medications from each of the main drug categories (focus on common and serious/life-threatening) (Psychotic Disorders). o Antipsychotics (ﬁrst generation): chlorpromazine (Thorazine) – low potency; haloperidol (Haldol) – high potency § Complications EPS – acute dystonia o The client experiences severe spasms of tongue, neck, face, or back. If the laryngeal muscles are aZected, respiration can decrease. This is a crisis, which requires rapid treatment. o Nursing actions § Monitor for acute dystonia between a few hours to 5 days after administration of the ﬁrst dose. § Treat with anticholinergic agents, such as benztropine IM or IV. Expect improvement within 5 min (IV dosing) to 20 min (IM dosing). EPS – parkinsonism o Findings include bradykinesia, rigidity, shuZling gate, drooling, and tremors. o Nursing actions § Observe for parkinsonism within 1 month of initiation of therapy. § Treat with benztropine, diphenhydramine, or amantadine. Discontinue these medications to determine if they are still needed. If manifestations return, administer atypical antipsychotic as prescribed. EPS – akathisia o The client is unable to stand still or sit and is continually pacing and agitated. o Nursing actions § Observe for akathisia within 2 months of the initiation of treatment. § Manage eZects with beta blocker, benzodiazepine, or anticholinergic medication. EPS – tardive dyskinesia (TD) o Manifestations include involuntary movements of the tongue and face, such as lip-smacking, which cause speech and/or eating disturbances. o Can also include involuntary movements of arms, legs, or trunk. o Nursing actions § TD is a late EPS that can occur months to years after the start of therapy and can improve following medication change or can be permanent. § Administer the lowest dosage possible to control manifestations. § Evaluate the client after 12 months of therapy and then every 3 months. If indications of TD appear, dosage should be lowered, or the client should be switched to an atypical agent. § Valbenazine can be prescribed to treat TD for adult clients. § Other adverse eZects Neuroleptic malignant syndrome o Life-threatening medical emergency. o Manifestations include sudden high-grade fever, blood pressure ﬂuctuations, dysrhythmias, muscle rigidity, diaphoresis, tachycardia, and change in level of consciousness developing into coma. o Nursing Actions § Stop antipsychotic medication. § Monitor vital signs. § Apply cooling blankets. § Administer antipyretics (aspirin, acetaminophen). § Increase ﬂuid intake. § Administer diazepam to control anxiety. § Administer dantrolene and bromocriptine to induce muscle relaxation. § Administer medication as prescribed to treat dysrhythmias. § Assist with immediate transfer to intensive care. § Wait 2 weeks before resuming therapy. Consider switching to an atypical agent. Anticholinergic eZects o Symptoms § Dry mouth § Blurred vision § Photophobia § Urinary hesitancy/retention § Constipation § Tachycardia o Nursing actions § Suggest strategies to decrease anticholinergic eZects. Chew sugarless gum Sip water Avoid hazardous activities Wear sunglasses when outdoors Eat foods high in ﬁber Participate in regular exercise Maintain ﬂuid intake of 2 to 3 L water daily from food and beverage sources Void prior to taking medication Neuroendocrine eZects o EZects include gynecomastia (breast enlargement), galactorrhea (leakage from breasts due to prolactin stimulation), and menstrual irregularities. § Client education Observe for manifestations and notify the provider if these occur. Seizures o The greatest risk for developing seizures occurs with those with existing seizure disorders. § Nursing actions An increase in antiseizure medication can be necessary. § Client education Report seizure activity to the provider. Skin eZects o EZects include photosensitivity resulting in severe sunburn and contact dermatitis from handling medications. o Client education § Avoid excessive exposure to sunlight, use sunscreen, and wear protective clothing. § Avoid direct contact with medication. Orthostatic hypotension o In the hospital setting, monitor blood pressure and heart rate for orthostatic changes. If a signiﬁcant decrease in blood pressure or increase in heart rate is noted, do not administer the medication and notify the provider. o Client education § Tolerance to orthostatic hypotension should develop in 2 to 3 months. § If ﬁndings of postural hypotension occur, sit or lie down. Orthostatic hypotension can be minimized by getting up or changing positions slowly. Sedation o EZects should diminish within a few weeks. o Take this medication at bedtime to avoid daytime sleepiness. o Do not drive until sedation has subsided. Sexual dysfunction o Altered libido, diZiculty achieving orgasm, erectile and ejaculatory dysfunction o Client education § Report these eZects to the provider. § A lower dosage or changing to a high-potency agent can minimize these eZects. Agranulocytosis o Nursing actions § If indications of infection appear, obtain a baseline WBC. Medications should be discontinued if lab tests indicate the presence of infection. o Client education § Observe for indications of infection and notify the provider if these occur. Severe dysrhythmias o Nursing actions § Obtain baseline ECG and potassium level prior to treatment and periodically throughout the treatment period. § Avoid concurrent use with other medications that prolong QT interval. Liver impairment o Assess liver function. o Observe for indications (anorexia, nausea, vomiting, fatigue, abdominal pain, jaundice) and notify the provider. Anticholinergic agents o Concurrent use with other anticholinergic medications will increase anticholinergic eZects. o Client education § Avoid OTC medications that contain anticholinergic agents, such as sleep aids and antihistamines. CNS depressants o Alcohol, opioids, and antihistamines have additive CNS depressant eZects. o Client education § Avoid alcohol and other medications that cause CNS depression. § Avoid hazardous activities, such as driving. Levodopa (treatment for Parkinson’s – levels out dopamine) o By activating dopamine receptors, levodopa counteracts the eZects of antipsychotic agents. o Nursing actions § Avoid concurrent use of levodopa and other direct dopamine receptor agonists. o Antipsychotics (second and third generation) (atypical): risperidone § Diabetes mellitus New onset of diabetes mellitus or loss of glucose control in clients who have diabetes (referred to as metabolic syndrome and also includes weight gain and dyslipidemia) Nursing Actions: o Obtain baseline fasting blood glucose and monitor throughout treatment. Client education: o Report indications (increased thirst, urination, and appetite). § Weight gain Follow a healthy low-calorie diet, engage in regular exercise, and monitor weight gain. § Hypercholesterolemia With increased risk for hypertension and other cardiovascular disease Nursing Actions: o Monitor cholesterol and triglycerides. § Orthostatic hypotension Nursing Actions: o Monitor blood pressure and heart rate for orthostatic changes. Client education: o Change positions slowly. § Anticholinergic eZects Include urinary hesitancy or retention, and dry mouth Nursing Actions: o Monitor for eZects and report occurrence to the provider. Client education: o Practice measures to relieve dry mouth, such as sipping ﬂuids. § Agitation, dizziness, sedation, sleep disruption Nursing Actions: o Monitor for eZects and report to the provider if they occur. o Administer alternative medication if prescribed. § Mild EPS, such as tremor or akathisia Nursing Actions: o Monitor for and teach clients to recognize EPSs. o Use AIMS assessment to screen for EPSs. § Elevated prolactin levels Nursing Actions: o Obtain prolactin level if indicated. Client education: o Observe for galactorrhea, gynecomastia, and amenorrhea. Notify the provider if these occur. § Sexual dysfunction (anorgasmia, impotence, low libido) Client Education: o Observe for possible sexual adverse eZects and notify the provider if they are intolerable. o Talk to the provider about ways to manage sexual dysfunction, which can include using adjunct medications to improve sexual function (such as sildenaﬁl). SLO 9.5: Analyze nursing interventions of medications from each of the main drug categories (Psychotic Disorders). o Antipsychotics (ﬁrst generation): chlorpromazine (Thorazine) – low potency; haloperidol (Haldol) – high potency § Nursing Administration These medications are reserved for clients who are: o Using them successfully and can tolerate the adverse eZects. o Violent or particularly aggressive. Use the Abnormal Involuntary Movement Scale (AIMS) to screen for the presence of EPS. Assess clients to diZerentiate between EPSs and worsening of psychotic disorder. Administer anticholinergics, beta blockers, and benzodiazepines to control early EPSs. If adverse eZects are intolerable, the client can be switched to a low-potency or an atypical antipsychotic agent. Consider depot preparations administered IM once every 2 to 4 weeks for clients who have diZiculty maintaining medication regimen. Inform the client that lower doses can be used with depot preparations, which will decrease the risk of adverse eZects and the development of tardive dyskinesia. Start oral administration with twice-a-day dosing, then switch to daily dosing at bedtime to decrease daytime drowsiness and promote sleep. § Client Education Antipsychotic medications do not cause addiction. Some therapeutic eZects can be noticeable within a few days, but signiﬁcant improvement can take 2 to 4 weeks, and possibly several months for full eZects. o Antipsychotics (second and third generation) (atypical): risperidone § Nursing Administration Administer by PO or IM route. Therapeutic eZect occurs up to several weeks following the ﬁrst depot injection. Clients often require oral preparations until eZectiveness is achieved. Advise clients that low doses of medication are given initially and are then gradually increased. o Risperidone is also available as a depot injection administered IM once every 2 weeks, and the long-acting injectable of paliperidone is administered every 28 days. o Aripiprazole also has a long-acting injectable, which is administered monthly. Use for clients who have diZiculty adhering to medication regimen. Use oral disintegrating tablets for clients who might attempt to “cheek” (or pocket) tablets or have diZiculty swallowing them. Administer lurasidone and ziprasidone with food (at least 350 calories) to increase absorption. The cost of antipsychotic medications can be a factor for some clients. Assess the need for case management intervention. After administering olanzapine extended-release injection, monitor the client for at least 3 hr for adverse eZects. § Client Education While taking asenapine, avoid eating or drinking for 10 min after each dose. o Nursing Evaluation of Medication EZectiveness § Depending on therapeutic intent, eZectiveness can be evidenced by improvement in the following. § Positive and negative manifestations (prevention of acute psychotic manifestations, absence of hallucinations, delusions, anxiety, and hostility) § Ability to perform ADLs § Ability to interact socially with peers § Sleeping and eating habits

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