Patients name: Amy Rose B.

Reyes Age: 30y/o Gender: Female Status: Single Address: Palanas, Masbate City Date of Admission: 11-20-1983 Chief complaint: According to mother: nantatapon ng gamit, irritable, ayaw uminom ng gamot According to patient: ok lang ako Diagnosis: Undifferentiated Schizophrenia Dr. In-charge: Dr. Afroilan Medications: Clozapine 50mg bid Biperiden hydrochloride 2mg x EPS DRUG STUDY
Generic Name : Clozapine Brand Name: Clozaril, FazaClo, Gen-Clozapine (CAN) Classification: Antipsychotic, Dopaminergic blocker Pregnancy Category B Dosage & Route Adults

Initial therapy: 12.5 mg PO once or twice daily. If using orally disintegrating tablets, begin with 1/2 (12.5 mg) of a 25-mg tablet and destroy the remaining half. Continue to 25 mg PO daily or bid; then gradually increase with daily increments of 2550 mg/day, if tolerated, to a dose of 300450 mg/day by the end of second week. Adjust later dosage no more often than twice weekly in increments < 100 mg. Do not exceed 900 mg/day. Maintenance: Maintain at the lowest effective dose for remission of symptoms. Discontinuation of therapy: Gradual reduction over a 2-wk period is preferred. If abrupt discontinuation is required, carefully monitor patient for signs of acute psychotic symptoms. Reinitiation of treatment: Follow initial dosage guidelines, use extreme care; increased risk of severe adverse effects with re-exposure.

Pediatric Patients

Safety and efficacy in patients < 16 yr not established.

Therapeutic actions

Clozapine has relatively weak dopamine receptor-blocking activity at D1, D2, D3 and D5 receptors but has high affinity for the D4 receptor. It has also blocking effects on serotonin, -adrenergic histamine H1 and cholinergic receptors.

Indications

Management of severely ill schizophrenics who are unresponsive to standard antipsychotic drugs Reduction of the risk of recurrent suicidal behavior in patients with schizophrenia or schizoaffective disorder (not orally disintegrating tablet)

Adverse effects

Drowsiness, dizziness, headache; nausea, vomiting, constipation; anxiety, confusion, fatigue, transient fever. Rarely, dysphagia, acute pancreatitis, cholestatic jaundice; orthostatic hypotension, tachycardia; seizures; hypersalivation. Potentially Fatal: Rarely, thromboembolism. Reversible neutropenia which may progress to a potentially fatal agranulocytosis. Fatal myocarditis.

Contraindications

History of bone marrow disorders including agranulocytosis, circulatory collapse, alcoholic or toxic psychosis, drug intoxication, uncontrolled epilepsy, severe renal, hepatic or cardiac disease; paralytic ileus. Pregnancy and lactation.

Nursing considerations Assessment

History: Allergy to clozapine, myeloproliferative disorders, history of clozapine-induced agranulocytosis or severe granulocytopenia, severe CNS depression, comatose states, history of seizure disorders, CV disease, narrow-angle glaucoma, lactation, pregnancy Physical: T, weight; reflexes, orientation, IOP, ophthalmologic examination; P, BP, orthostatic BP, ECG; R, adventitious sounds; bowel sounds, normal output, liver evaluation; prostate palpation, normal urine output; CBC, urinalysis, LFTs, renal function tests, EEG

Interventions

BLACK BOX WARNING: Use only when unresponsive to conventional antipsychotic drugs; risk of serious CV and respiratory effects. Obtain clozapine through the Clozaril Patient Assistance Program. For more information, call 1-800-448-5938.

Dispense only 1 wk supply at a time. Monitor WBC carefully prior to first dose. BLACK BOX WARNING: Weekly monitoring of WBC during treatment and for 4 wk thereafter. Dosage may be adjusted based on WBC count. Potentially fatal agranulocytosis has been reported. Monitor T. If fever occurs, rule out underlying infection, and consult physician for comfort measures. BLACK BOX WARNING: Monitor for seizures; with history of seizures, risk increases as dose increases. Monitor elderly patients for dehydration. Institute remedial measures promptly; sedation and decreased thirst related to CNS effects can lead to dehydration. Monitor patient regularly for signs and symptoms of diabetes mellitus. Encourage voiding before taking drug to decrease anticholinergic effects of urinary retention. Follow guidelines for discontinuation or reinstitution of the drug. Educate patient on seriousness of potential agranulocytosis.

Teaching points

Weekly blood tests will be taken to determine safe dosage; dosage will be increased gradually to achieve most effective dose. Only 1 week of medication can be dispensed at a time and will depend on your white blood cell count. Do not take more than your prescribed dosage. Do not make up missed doses, instead contact your health care provider. Do not stop taking this drug suddenly; gradual reduction of dosage is needed to prevent side effects. If you think you are pregnant or wish to become pregnant, contact your health care provider. You may experience these side effects: Drowsiness, dizziness, sedation, seizures (avoid driving or performing tasks that require concentration); dizziness, faintness on arising (change positions slowly); increased salivation (reversible); constipation (consult your health care provider for correctives); fast heart rate (rest, take your time). Report lethargy, weakness, fever, sore throat, malaise, mouth ulcers, and flulike symptoms.

Generic Name : biperiden hydrochloride(oral) biperiden lactate (injection) Brand Name: Akineton Classification: Antiparkinson Agents Pregnancy Category C Dosage & Route Adults Parkinsonism: 2 mg PO tidqid; individualize dosage with a maximum dose of 16 mg/day. Drug-induced extrapyramidal disorders

Oral: 2 mg PO daily to tid. Parenteral: 2 mg IM or IV; repeat q 30 min until symptoms are resolved, do not give more than 4 consecutive doses per 24 hr. Pediatric patients Safety and efficacy not established. Geriatric patients Strict dosage regulation may be necessary; patients > 60 yr often develop increased sensitivity to the CNS effects of anticholinergic drugs.

Therapeutic actions Anticholinergic activity in the CNS that is believed to help normalize the hypothesized imbalance of cholinergic and dopaminergic neurotransmission in the basal ganglia in the brain of a parkinsonism patient. Reduces severity of rigidity, and to a lesser extent akinesia and tremor characterizing parkinsonism; less effective overall than levodopa; peripheral anticholinergic effects suppress secondary symptoms of parkinsonism, such as drooling.

Indications Adjunct in the therapy of parkinsonism (post-encephalitic, arteriosclerotic, and idiopathic types) Relief of symptoms of extrapyramidal disorders that accompany phenothiazine therapy Adverse effects CNS: Some are characteristic of centrally acting anticholinergic drugs: disorientation, confusion, memory loss, hallucinations, psychoses, agitation, nervousness, delusions, delirium, paranoia, euphoria, excitement, light-headedness, dizziness, depression, drowsiness, weakness, giddiness, paresthesia, heaviness of the limbs Peripheral anticholinergic effects CV: Tachycardia, palpitations, hypotension, orthostatic hypotension Dermatologic: Rash, urticaria, other dermatoses EENT: Blurred vision, mydriasis, diplopia, increased intraocular tension, angle-closure glaucoma GI: Dry mouth, constipation, dilation of the colon, paralytic ileus, acute suppurative parotitis, nausea, vomiting, epigastric distress GU: Urinary retention, urinary hesitancy, dysuria, difficulty achieving or maintaining an erection Other: Flushing, decreased sweating, elevated temperature, muscular weakness, muscular cramping

Contraindications and Cautions Contraindicated with hypersensitivity to benztropine; glaucoma, especially angle-closure glaucoma; pyloric or duodenal obstruction, stenosing peptic ulcers, achalasia (megaesophagus); prostatic hypertrophy or bladder neck obstructions; myasthenia gravis. Use cautiously with tachycardia, cardiac arrhythmias, hypertension, hypotension, hepatic or renal dysfunction, alcoholism, chronic illness, people who work in hot environment; hot weather; lactation.

Nursing considerations Assessment History: Hypersensitivity to benztropine; glaucoma; pyloric or duodenal obstruction, stenosing peptic ulcers, achalasia; prostatic hypertrophy or bladder neck obstructions; myasthenia gravis; cardiac arrhythmias, hypertension, hypotension; hepatic or renal dysfunction; alcoholism, chronic illness, work in hot environment; lactation Physical: Body weight; T; skin color, lesions; orientation, affect, reflexes, bilateral grip strength, visual exam, including tonometry; P, BP, orthostatic BP; adventitious sounds; bowel sounds, normal output, liver evaluation; normal urinary output, voiding pattern, prostate palpation; liver and kidney function tests Interventions . Decrease dosage or discontinue temporarily if dry mouth makes swallowing or speaking difficult. Give with caution, and reduce dosage in hot weather. Drug interferes with sweating and ability of body to maintain heat equilibrium; anhidrosis and fatal hyperthermia have occurred. Give with meals if GI upset occurs; give before meals to patients with dry mouth; give after meals if drooling or nausea occurs. Ensure that patient voids just before receiving each dose of drug if urinary retention is a problem. Teaching points Take this drug exactly as prescribed. Avoid the use of alcohol, sedative, and OTC drugs (can cause dangerous effects). These side effects may occur: drowsiness, dizziness, confusion, blurred vision (avoid driving or engaging in activities that require alertness and visual acuity); nausea (try frequent small meals); dry mouth (suck sugarless lozenges or ice chips); painful or difficult urination (empty the bladder immediately before each dose); constipation (maintain adequate fluid intake and exercise regularly); use caution in hot weather (you are susceptible to heat prostration). Report difficult or painful urination; constipation; rapid or pounding heartbeat; confusion, eye pain, or rash. SUBMITTED BY: Camille M. Pineda
Student Nurse