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ANTIPSYCHOTICS

SUBMITTED TO: SUBMITTED BY:


MRS. RENU SHARMA SHAILJA SHARMA
TUTOR, NINE MSC. NURSING
PGIMER, CHANDIGARH 1STYEAR
NINE,PGIMER,
CHANDIGARH
INTRODUCTION

 Antipsychotics are psychotropic drugs


which are used in the treatment of
psychotic disorders and psychotic
symptoms. These are also known as major
tranquilizers, neuroleptics,anti-
schizophrenic drugs and D2-receptor (
dopamine receptor) blockers
INDICATIONS

a) Organic Psychiatric
disorders

Other
Delirium organic
Delirium mental
tremens
disorders

Drug
Dementia induced
psychosis
INDICATIONS

b) NON ORGANIC PSYCHOTIC DISORDERS

-Schizophrenia

-Schizo affective disorder

-Acute psychosis

-Mania

-Maintenance treatment of bipolar disorders

-Major depression
INDICATIONS

c) Neurotic and
other
psychiatric
disorders

severe,
Anorexia
and
nervosa
disabling
anxiety
OCD
INDICATIONS

d) Medical disorders

Huntington’s chorea (haloperidol)

Intractable hiccupps (chlorpromazine)

Nausea and vomating ( ondansetron)

Tic disorders (haloperidol, resperidone)


CONTRAINDICATIONS

 Hypersenstivity
 Comatose patients
 CNS depression
 Blood dyscrasias
 Parkinson’s disease Specially with typical
antipsychotics
 Narrow angle glaucoma
 Liver, cardiac and renal insufficiency
CLASSIFICATION

Antipsychotics are broadly classified into 2


categories namely:
 Typical antipsychotics or first generation
antipsychotics
 Atypical antipsychotics or second generation
antipsychotics
TYPICAL ANTIPSYCHOTICS

 The typical antipsychotics drugs are


predominantly dopamine antagonist. They
block post synaptic D2 Receptors in the
several Dopamine antagonist tracts in the
brain, accounting for decrease in positive
symptoms as well as Extra pyramidal
symptoms.

 Typical antipsychotics are further of


following categories:
CHEMICAL NAME TRADE NAME DOSE

1. Phenoziathenes

 Chlorpromazine 40-400 mg

 Trifluoperazine 4-40 mg

 Thioridazine 150-800 mg

 Fluphenazine 2.5-10 mg

 Perphenazine 6-4 mg

2. Thioxanthenes

 Thiothixene Navane 6-30 mg


CHEMICAL TRADE DOSE
NAME NAME
3. Butyrophenones

 Haloperidol Haldol 1-100mg

4. Dibenzoxapine

 Loxapine 20-250 mg

5.Diphenylbutylpipe
ridine

 Pimozide 1-10 mg
ATYPICAL ANTIPSYCHOTICS

 The atypical antipsychotics exert blocking


affect on dopamine2 (D2) and serotonin2 (5-
HT2) post synaptic . Thus they are DA and 5-
HT antagonist.
 Like the typical antipsychotics, the atypical
antipsychotics improve the positive
symptoms of schizophrenia, but unlike the
typical drugs , they also improve the negative
symptoms.
CHEMICAL NAME TRADE DOSE
NAME
Aripiprazole Ablify 10-30 mg
Clozapine 300-900
Clozaril mg

Olanzapine 5-20 mg
Zyprexa

Respiridone Risperdal 4-8 mg


Quetiapine Seroquel 300-400
mg/day.
CHEMICAL NAME TRADE DOSE
NAME
Ziprasidone Geodon 40-160 mg

Paliparidone Invega 6 -12 mg

Lurasidone Latuda 40-80 mg

Iloperidone Fanapt 12-24 mg

Asenapine Saphris 10-20 mg


MECHANISM OF ACTION

 Typical Antipsychotic drugs block D 2-


receptors, which are mainly present in
mesolimbic-mesocortical system, nigro-
striatal system and tubero-infundibular
system.
 However, other neurotransmitters (such as
5-HT, acetylcholine) are clearly implicated.
 Sedation is caused by histaminergic blockade
which is usually highest for drugs such as
chlorpromazine and thioridazine.
Contd...
Contd..

 Atypical antipsychotics have similar blocking


effect on D2 receptors, however, most also
act on serotonin receptors. 5-HT antagonism
increases dopaminergic activity in the
nigrostraital pathway, leading to lowered
EPS.
PHARMACOKINETICS

 Well absorbed from gastrointestinal tract on oral


administration.
 Intramuscular and intravenous administration
provides much more reliable blood levels.
 The oral liquid dose produces a peak level at 1½
hours and the intramuscular dose peaks at 30
minutes.
 The antipsychotics are highly lipophilic and
highly protein-bound. Therefore they easily
enter areas with good blood supply such as
brain, lung, kidneys and foetus, and accumulate
there. They are not dialysable.
Contd..

 The half-lives of most antipsychotics are long


and theoretically a single daily dose is
sufficient to produce sustained therapeutic
blood levels. However in practice, divided
doses are administered, at least initially, to
decrease adverse effects. Later an attempt
can be made to give the whole dose or a
major part of total daily dose at night.
METABOLISM

 Steady state plasma levels are usually


reached in 5-10 days.
 Once the drug is withdrawn, it may remain in
body for many days to many months.
 The main metabolic pathway is through liver
(hepatic microsomal enzymes).
 The excretion of the metabolites is through
kidneys and liver (enterohepatic circulation).
Contd...

 Most of the antipsychotics tend to have a


therapeutic window. If the blood level is
below this ‘window’, the drug is ineffective. If
the blood level is higher than the upper limit
of the ‘window’, there is toxicity or the drug is
again ineffective.
SIDE EFFECTS
NURSING MANAGEMENT FOR SIDE
EFFECTS
 NURSING DIAGNOSIS
 1. Risk for other-directed violence related to
panic anxiety and mistrust of others.
 2. Risk for injury related to medication side
effects of sedation, photosensitivity, reduction of
seizure threshold, agranulocytosis,
extrapyramidal symptoms, tardive dyskinesia,
neuroleptic malignant syndrome, or QT
prolongation.
 3. Risk for activity intolerance related to
medication side effects of sedation, blurred
vision, and weakness.
 4. Noncompliance with medication regimen
related to suspiciousness and mistrust of others.
Planning/Implementation

 The plan of care should include monitoring


for the following side effects from
antipsychotic medications.
1. Anticholinergic Effects

 a. Dry mouth
 *Provide the client with sugarless candy or gum, ice,
and frequent sips of water.
 *Ensure that client practices strict oral hygiene.
 b. Blurred vision
 *Explain that this symptom will most likely subside
after a few weeks.
 *Advise client not to drive a car until vision clears.
 *Clear small items from pathway to prevent falls.
1. Anticholinergic Effects

 c. Constipation
 *Order foods high in fiber; encourage increase in
physical activity and fluid intake if not
contraindicated.
 d. Urinary retention
 *Instruct client to report any difficulty urinating;
monitor intake and output.
2.Nausea; GI upset

 *Tablets or capsules may be administered with food


to minimize GI upset.
 *Concentrates may be diluted and administered
with fruit juice or other liquid; they should be mixed
immediately before administration.
 3. Skin rash
 Report appearance of any rash on skin to the
physician.
 *Avoid spilling any of the liquid concentrate on skin;
contact dermatitis can occur with some medications.
4. Sedation

 Discuss with the physician the possibility of


administering the drug at bedtime.
 *Discuss with physician a possible decrease in
dosage or an order for a less sedating drug.
 *Instruct client not to drive or operate dangerous
equipment while experiencing sedation.
5. Orthostatic hypotension

 Instruct client to rise slowly from a lying or sitting


position
 *Monitor blood pressure (lying and standing) each
shift; document and report significant changes.
6. Photosensitivity

 Ensure that the client wears a sunblock lotion,


protective clothing, and sunglasses while spending
time outdoors.
7. Hormonal effects

 a. Decreased libido, retrograde ejaculation,


gynecomastia (men)
 *Provide explanation of the effects and reassurance of
reversibility. If necessary, discuss with physician
possibility of ordering alternate medication.
 b. Amenorrhea (women)
 *Offer reassurance of reversibility; instruct client to
continue use of contraception, because amenorrhea does
not indicate cessation of ovulation.
 c. Weight gain
 *Weigh client every other day; order caloriecontrolled
diet; provide opportunity for physical exercise; provide
diet and exercise instruction.
8. ECG changes.

 Prolongation of the QT interval, are possible with most of


the antipsychotics.
 Caution is advised in prescribing this medication to
individuals with a history of arrhythmias.
 Conditions that produce hypokalemia and/or
hypomagnesemia, such as diuretic therapy or diarrhea,
should be taken into consideration when prescribing.
 Routine ECG should be taken before initiation of therapy
and periodically during therapy.
 *Monitor vital signs every shift.
 *Observe for symptoms of dizziness, palpitations, syncope,
or weakness.
9. Reduction of seizure threshold

 *Closely observe clients with history of seizures.

 10. Agranulocytosis
 *It usually occurs within the first 3 months of
treatment. Observe for symptoms of sore throat,
fever, malaise.
 A complete blood count should be monitored if
these symptoms appear.
11. Hypersalivation

 It may even be a safety issue (e.g.,


risk of aspiration) if the problem is
very severe.
 Management has included the use
of sugar-free gum to increase the
swallowing rate, as well as the
prescription of medications such
as an anticholinergic (e.g.,
scopolamine patch) or α2-
adrenoceptor agonist (e.g.,
clonodine).
12. Extrapyramidal symptoms (EPS)

 a. Pseudoparkinsonism (tremor, shuffling gait,


drooling, rigidity)
 *Symptoms may appear 1 to 5 days following
initiation of antipsychotic medication; occurs most
often in women, the elderly, and dehydrated clients.
 b. Akinesia (muscular weakness)
 *Same as for pseudoparkinsonism.
EPS

 c. Akathisia (continuous restlessness and


fidgeting)
 *This occurs most frequently in women; symptoms
may occur 50 to 60 days following initiation of
therapy.
 d. Dystonia (involuntary muscular movements
[spasms] of face, arms, legs, and neck)
 *This occurs most often in men and in people
younger than 25 years of age.
EPS

 e. Oculogyric crisis (uncontrolled


rolling back of the eyes)
 *This may appear as part of the
syndrome described as dystonia. It
may be mistaken for seizure activity.
 Dystonia and oculogyric crisis should
be treated as an emergency situation.
 The physician should be contacted,
and intravenous Benztropine
Mesylate (Cogentin) is commonly
administered. Stay with the client and
offer reassurance and support during
this frightening time.
13. Tardive dyskinesia

 *All clients receiving long-term


(months or years) antipsychotic
therapy are at risk.
 *The symptoms are potentially
irreversible.
 *The drug should be withdrawn
at the first sign, which is usually
vermiform movements of the
tongue; prompt action may
prevent irreversibility.
14. Neuroleptic malignant syndrome (NMS)
 *This is a relatively rare, but potentially fatal,
complication of treatment with neuroleptic drugs.
 Routine assessments should include temperature and
observation for parkinsonian symptoms.
 *Onset can occur within hours or even years after drug
initiation, and progression is rapid over the following 24
to 72 hours.
 *Symptoms include severe parkinsonian muscle rigidity,
hyperpyrexia up to 107°F, tachycardia, tachypnea,
fluctuations in blood pressure, diaphoresis, and rapid
deterioration of mental status to stupor and coma.
Contd...

 *Discontinue neuroleptic medication immediately.


 *Monitor vital signs, degree of muscle rigidity,
intake and output, level of consciousness.
 *The physician may order bromocriptine (Parlodel)
or dantrolene (Dantrium) to counteract the effects of
neuroleptic malignant syndrome.
15. Hyperglycemia and diabetes

 Studies have suggested an increased risk of


treatment-emergent hyperglycemia-related adverse
events in clients using atypical antipsychotics (e.g.,
risperidone, clozepine, olanzapine, quetiapine,
ziprasidone, paliperidone, and aripiprazole).
 The FDA recommends that clients with diabetes
starting on atypical antipsychotic drugs be
monitored regularly for worsening of glucose control.

16. Increased risk of mortality in elderly patients
with dementia-related psychosis.

 Recent studies have indicated that elderly patients


with dementia-related psychosis who are treated
with atypical antipsychotic drugs (e.g., clozapine,
olanzapine, quetiapine, risperidone, paliperidone,
ziprasidone, and aripiprazole) are at increased risk of
death, compared with placebo. Causes of death are
most commonly related to infections or
cardiovascular problems.
CLIENT AND FAMILY EDUCATION

 The client should:


 Use caution when driving or operating dangerous
machinery. Drowsiness and dizziness can occur.
 Not stop taking the drug abruptly after long-term
use. To do so might produce withdrawal symptoms,
such as nausea, vomiting, dizziness, gastritis,
headache, tachycardia, insomnia, tremulousness.
 Use sunblock lotion and wear protective clothing
when spending time outdoors. Skin is more
susceptible to sunburn, which can occur in as little as
30 minutes.
Contd..

 ● Report weekly (if receiving clozapine therapy) to have


blood levels drawn and to obtain a weekly supply of the
drug.
 ● Report the occurrence of any of the following
symptoms to the physician immediately: sore throat,
fever, malaise, unusual bleeding, easy bruising,
persistent nausea and vomiting, severe headache, rapid
heart rate, difficulty urinating, muscle twitching,
tremors, darkly colored urine, excessive urination,
excessive thirst, excessive hunger, weakness, pale stools,
yellow skin or eyes, muscular incoordination, or skin
rash.
 ● Rise slowly from a sitting or lying position to prevent a
sudden drop in blood pressure.
Contd....

 Take frequent sips of water, chew sugarless gum, or suck


on hard candy, if dry mouth is a problem. Good oral care
(frequent brushing, flossing) is very important.
 Consult the physician regarding smoking while on
neuroleptic therapy. Smoking increases the metabolism
of neuroleptics, requiring an adjustment in dosage to
achieve a therapeutic effect.
 Dress warmly in cold weather, and avoid extended
exposure to very high or low temperatures. Body
temperature is harder to maintain with this medication.
Not drink alcohol while on neuroleptic therapy. These
drugs potentiate each other’s effects.
Contd..

 Not consume other medications (including over-


thecounter products) without the physician’s approval.
Many medications contain substances that interact with
neuroleptics in a way that may be harmful.
 Be aware of possible risks of taking neuroleptics during
pregnancy. Safe use during pregnancy has not been
established. Neuroleptics are thought to readily cross the
placental barrier; if so, a fetus could experience adverse
effects of the drug. Inform the physician immediately if
pregnancy occurs, is suspected, or is planned.
 Be aware of side effects of neuroleptic drugs. Refer to
written materials furnished by healthcare providers for
safe self-administration
Contd..

• Continue to take the medication, even if feeling well


and as though it is not needed. Symptoms may
return if medication is discontinued.
 Carry a card or other identification at all times
describing medications being taken.
CONCLUSION
REFERENCE

 Townsend M.C. Psychiatric mental health nursing.Fifth edition


(2007). Jaypee brothers publisher (New Dehli). Pp 321-327.
 Sreevani R. A guide to mental health and psychiatric nursing. Third
edition (2010). Jaypee brothers publisher (New Delhi). Pp 171-175.
 Rofman ES. Review of Kaplan and Sadock’s synopsis of psychiatry:
Behavioral sciences/clinical psychiatry, 10th ed [Internet]. Vol. 70,
The Journal of Clinical Psychiatry. 2009. 940 p. Available from:
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