Psychiatric Nursing Notes

PSYCHIATRIC NURSING COPING AND ADAPTATION MENTALLY HEALTHY INDIVIDUAL ATTITUDE OF SELF ACCEPTANCE AUTONOMY ABILITY TO ABSTRACT,TRUST ,COPE WITH STRESS ACCURATE SELF PERCEPTION AWARENESS OF SELF MENTAL HEALTH – balance in a persons internal life and adaptation to reality

Mental ILL Health – state of imbalance characterized by a disturbance in a persons thoughts, feelings and behavior Poverty and abuses are major risk factors

Psychiatric nursing – interpersonal process whereby the professional nurse practitioner

,through the therapeutic use of self(art) and nursing theories (science), assist clients to achieve psychosocial well being. Core of psych nursing – interpersonal process – human to human relationship(both for mentally healthy and ill)

Mental hygiene – measures to promote mental health , prevent mental illness and suffering and facilitate rehabilitation…….(and if necessary find meaning in these experiences)

Main tool – therapeutic use of self It requires self-awareness Methods to increase self-awareness: –Introspection ,Discussion, Experience, Role play Neurosis

any long term mental or behavioral d/o in which contact with reality is retained the condition is recognized by the patient as abnormal. Essentially features anxiety or behavior exagerrated designed to avoid anxiety ( anxiety d/o ; hysteria to conversion d/o,amnesia,fugue,multiple personality and depersonalization- dissociative d/o ;oc d/o) Result of inappropriate early programming(psychoanalysis little value) Benefits from Behavior Therapy Psychosis

Mental or behavioral disorder wherein patient looses contact with reality Presence of delusions, hallucinations,severe thought disturbances,alteration of mood, poverty of thought and abnormal behavior

(schizophrenia , major disorder of affect ( mania – depression), major paranoid states and organic mental disorder

Benefits from psychoanalysis and antipsychotics Common Behavioral Signs and Symptoms

Disturbances in perception Illusion- misinterpretation of an actual external stimuli Hallucinations – false sensory perception in the absence of external stimuli Disturbances in thinking and speech neologism – coining of words that people do not understand Circumstantiality – over inclusion of inappropriate thoughts and details Word salad – incoherent mixture of words and phrases with no logical sequence Verbigeration – meaningless repetition of words and phrases

Perseveration – persistence of a response to a previous question Echolalia – pathological repetition of words of others Aphasia – speech difficulty and disturbance Expressive , receptive or global

Flight of ideas- shifting of one topic from one subject to another in a somewhat related way Looseness of association-incoherent ,illogical flow of thoughts(unrelated way) Clang association – sound of word gives direction to the flow of thought Delusion – persistent false belief,rigidly held Delusions of grandeur- special /important in a way Persecutory-threatened Ideas of reference-situation/events involve them Somatic- body reacting in a particular way

Magical thinking – primitive thought process thoughts alone can change events Autistic thinking – regressive thought process-subjective interpretations not validated with objective reality

Disturbances of affect Inappropriate – disharmony between the stimuli and the emotional reaction Blunted affect – severe reduction in emotional reaction Flat affect – absence or near absence of emotional reaction Apathy – dulled emotional tone Depersonalization – feeling of strangeness from one’s self Derealization – feeling of strangeness towards environment Agnosia – lack of sensory stimuli integration Disturbances in motor activity Echopraxia – imitation of posture of others Waxy flexibility – maintaining position for a long period of time Ataxia – loss of balance Akathesia – extreme restlessness Dystonia- uncoordinated spastic movements of the body Tardive dyskenisia – involuntary twitching or muscle movements Apraxia – involuntary unpurposeful movements Disturbances in memory Confabulation – filling of memory gaps Déjà vu – 2 time-like feeling Jamais vu- not having been to the place one has been before Amnesia – memory loss (inability to recall past events) Retrograde-distant past Anterograde – immediate past Anomia – lack of memory of items nd

Dynamics of Human Behavior

Personality – integration of systems and habits representing anindividuals characteristic adjustment to his environment expressed through behavior

Individualistic, unique, predictable(stability and consistency)

Determinants: psychological,cultural, biological ( not inhereted) and familial Analysis

Potential support systems or stressors Potential risk factor Satisfaction of human needs –Physiological(oxygen , fluids, nutrition, temp.,elimination,shelter,rest,sex) –Safety and security(physical and psychological) –Love and belongingness –Self esteem –Self –actualization

3 divisions of the mind

Conscious – focussed on awareness Subconscious – recalled at will Unconscious – never recalled / largest part Learning – change in behavior through – insight , relearning and remotivation Theories of personality development Freuds psychosexual theory

Libido – inner drive Parts of body –focus of gratification Unsuccesful resolution - fixation Structures of personality –Id – pleasure principle-instinct –Ego – controls action and perception –reality principle –Superego – moral behavior - conscience

0-18 m0s ;oral – mouth – trust and discriminating 18 mos. – 3 years ; anal – bowels – holding on or letting go –Negativism and toilet training age  3 -6 years phallic ; genitals –exploration and discovery ( inc. sexual tension) –Gender identification and genital awareness –Oedipus and Electra complex // –Castration anxiety and penis envy 6-12 years –latency (quiet stage) sexual energy diverted to play. Institution of superego… control of instinctual impulses

12 – young adult – genital ; reawakening of sexual drives –relationships –Sexual maturation –Sexual identity ,ability to love and work Psychosocial – Erickson developmental milestones //delay

0-12mos; 1-3y

TRUST AUTONOMY

3-6 6-12 12-18 18-25 25-60 60 and above

INITIATIVE INDUSTRY IDENTITY INTIMACY GENERATIVITY EGO INTEGRITY PIAGET’S COGNITIVE THEORY 0-2 SENSORIMOTOR

REFLEXIVE IMITATIVE REPETITIVE BEHAVIOR SENSE OF OBJECT PERMANENCE AND SELF SEPARATE FROM ENVT. TRIAL AND ERROR RESULTS IN PROBLEM SOLVING 2-7Y PRE-OPERATIONAL SELF-CENTERED,EGOCENTRIC

CANNOT CONCEPTUALIZE OTHER’S VIEW ANIMISTIC THINKING IMAGINARY PLAYMATE – SYMBOLIC MENTAL REPRESENTATION – CREATIVITY 2-4 PRE-CONCEPTUAL (PRE-LOGICAL) 4-7 INTUITIVE (UNDERSTANDING OF ROLES) 7-12Y CONCRETE OPERATIONAL

LOGICAL CONCRETE THOUGHT INDUCTIVE RESAONING (SPECIFIC TO GENERAL) CAN RELATE ,PROBLEM SOLVING ABILITY REASONING AND SELF-REGULATION

12-ABOVE FORMAL OPERATIONAL THOUGHT

Abstract thinking Separation of fantasy and fact Reality oriented Deductive reasoning Apply scientific method Kohlberg – MORAL DEVELOPMENT/ THINKING/ JUDGEMENT

PRE-CONVENTIONAL (0-6) –PUNISHMENT AND OBEDIENCE –OBEDIENCE TO RULES TO AVOID PUNISHMENT CONVENTIONAL ( 6-12 ) –MUTUAL INTERPERSONAL EXPECTATIONS,RELATIONSHIPS AND CONFORMITY –SOCIAL SYSTEM AND CONSCIENCE MAINTENANCE –BEING GOOD IS IMPORTANT SELF RESPECT OR CONSCIENCE POST –CONVENTIONAL (12 – 18 Y)

PRIOR RIGHT OR SOCIAL CONTRACT UNIVERSAL ETHICAL PRINCIPLE ABIDE FOR COMMON GOOD RATIONAL PERSON-VALIDITY OF PRINCIPLES-AND BECOME COMMITTED TO THEM INNER CONTROL OF BEHAVIOR UNDERSTANDING THE EQUALITY OF HUMAN RIGHTS AND DIGNITY OF HUMAN BEINGS AS INDIVIDUALS

DEFENSE MECHANISMS

•unconscious intrapsychic adoptive efforts to resolve emotional conflict and cope with anxiety •automatic •pathology is determined by the frequency of use examples of DEFENSE MECHANISMS •DENIAL – failure to acknowledge an intolerable thought , feeling, experience or reality

•DISPLACEMENT – redirection of emotions or feelings to a subject that is more acceptable or less threatening •PROJECTION – attributing to others one’s feelings, impulses , thought or wishes

•UNDOING – an attempt to erase an act , thought , feeling or desire •COMPENSATION – an attempt to overcome real or imagined shortcoming SYMBOLIZATION – a less threatening object or idea is used to epresent another SUBSTITUTION – replacing desired , impractical , unattainable object with one that is acceptable

INTROJECTION – a form of identification

in which there is a taking into oneself the

characteristic of another(love object)

REPRESSION – unacceptable thoughts is kept from awareness(unconscious) SUPPRESSION- consciously putting a disturbing thought or incident out of awareness

•REACTION FORMATION - expressing attitude directly opposite to unconscious wish or fear •REGRESSION – returning to an earlier developmental phase in the face of stress •DISSOCIATION – detachment of painful emotional conflicts from consciousness •CONVERSION – emotional problems are converted into symptoms •FANTASY – conscious distortion of unconscious feelings or wishes •IDENTIFICATION – conscious patterning of one’s self from another person •INTELLECTUALIZATION - over use of intellectual concepts by an individual to avoid expression of feelings

•RATIONALIZATION – justifying ones actions which are based on other motives •SUBLIMATION - rechanneling of unacceptable instinctual drives with one hat is aceptable NURSE – PATIENT RELATIONSHIP •SULLIVANS THEORY ON INTERPERSONAL RELATIONSHIP – DEVELOPED BY PEPLAU INTO NURSE- PATIENT RELATIONSHIP •SERIES OF INTERACTION BETWEEN THE NURSE AND PATIENT IN WHICH THE NURSE ASSISTS THE PATIENT TO ATTAIN POSITIVE BEHAVIORAL CHANGE •T RUST

•R APPORT •U NCONDITIONAL POSITIVE REGARD •S ETTING LIMITS •T HERAPEUTIC COMUNICATION PHASES •PRE-INTERACTION – SELF – AWARENESS

•ORIENTATION PHASE – DEVELOP A MUTUALLY ACCEPTABLE CONTACT •WORKING – IDENTIFICATION AND RESOLUTION OF THE PATIENT’S PROBLEMS •TERMINATION – ASSIST PATIENT TO REVIEW WHAT HE HAS LEARNED AND TRANSFER HIS LEARNING TO HIS REL. W/ OTHERS WHEN TO TERMINATE NPR

•GOALS ACCOMPLISHED •EMOTIONALLY STABLE •GREATER INDEPENDENCE •ABLE TO COPE WITH ANXIETY, LOSS , FEAR AND SEPARATION

COMMON PROBLEMS - NPR •TRANSFERENCE – DEVELOPMENT OF EMOTIONAL ATTITUDE + OR – TOWARDS THE NURSE •RESISTANCE – DEVELOPMNET OF AMBIVALENT FEELINGS TOWARDS SELF – EXPLORATION •COUNTER – TRANS FERENCE – TRANSFERENCE AS EXPERIENCED BY THE NURSE PRINCIPLES OF CARE •ACCPETS PATIENT AS UNIQUE WITH INHERENT VALUE AND WORTH

•PATIENT IS VIEWED AS HOLISTIC HUMAN BEINGS WITH INTERDEPENDENT AND INTERRELATED NEEDS •FOCUS ON STRENGTHS AND ASSETS

•NON – JUDGEMENTAL ASSISTANCE TOWARDS COPING •EXPLORE THE PATIENTS BEHAVIOR AND THE NEED IT IS DESIGNED TO MEET AND THE MESSAGE IT IS COMMUNICATING LEVELS OF INTERVENTION •PRIMARY – INTERVENTIONS AIMED AT THE PROMOTION OF MENTAL HEALTH AND LOWERING THE RATE OF CASES BY ALTERING THE STRESSORS •SECONDARY – INTERVENTIONS THAT LIMIT THE SEVERITY OF THE DISORDER –CASE FINDING AND PROMPT Tx

•TERTIARY – REDUCING THE DISABILITY AFTER A DISORDER

–PREVENTION OF COMPLICATION AND ACTIVE PROGRAM OF REHABILITATION CHARACTERISTICS OF A PSYCHIATRIC NURSE-major roles of a nurse - socializing agent and patient advocate

•EMPATHY- ability to see beyond outward behavior and sense accurately another persons inner experience

•GENUINENESS/CONGRUENCE – ability to use therapeutic tools appropriately •UNCONDITIONAL POSITIVE REGARD - respect THERAPEUTIC COMMUNICATION

•CLARIFICATION •LIMIT SETTING •EMPATHETIC / ENCOURAGE EXPRESSION •ANSWERS NEEDS •REFLECTIVE AND INSIGHTFUL

THERAPEUTIC COMMUNICATION

•FOCUS ON FEELING TONE ,NEEDS ,MOTIVATION •MUST HAVE CONSISTENCY AND IS NON JUDGEMENTAL •CRITERIA OF SUCCESSFUL COMMUNICATION – FEEDBACK , APPROPRIATENESS, FLEXIBILITY AND EFFICIENCY

TECHNIQUES OF COMMUNICATION

•TO INITIATE A CONVERSATION – –giving broad openings –giving recognition / acknowledgement •TO ESTABLISH RAPPORT –GIVING INFORMATION –USE OF SILENCE •TO GATHER INFORMATION –FOCUSING

–VALIDATING –REFLECTING –RESTATING •TO CLOSE A CONVERSATION –summarizing

TYPES OF PSYCHOTHERAPIES REMOTIVATION THERAPY •TREATMENT MODALITY THAT PROMOTES EXPRESSION OF FEELINGS THROUGH INTERACTION FACILITATED BY DISCUSSION OF NEUTRAL TOPICS • STEPS : climate of acceptance creating bridge to reality sharing the world we live in appreciation of works of the world climate of appreciation MUSIC THERAPY

•INVOLVES USE OF MUSIC TPO FACILITATE EXPRESSION OF FEELINGS,FACILITATE RELAXATION AND OUTLET OF TENSION

PLAY THERAPY

enables patient to experience intense emotion in a safe environment with the use of play children express themselves more easily in play. revealing as reflection of child’s situation in the family

provide toys and materials – facilitate interaction – observe and help child resolve problems through play

Group therapy •Treatment modality involving three or more patients with a therapist to relieve emotional difficulties, increase self – esteem, develop insight , LEARN NEW ADAPTIVE WAYS TO COPE WITH STRESS and improve behavior with others( RELATIONSHIP WITH OTHERS CAN BE WORKED THROUGH) •IDEAL 8 – 10 MEMBERS MILIEU THERAPY •CONSISTS OF TREATMENT BY MEANS OF CONTROLLED MODIFICATION OF THE PATIENTS ENVIRONMENT , FACILITATE POSITIVE BEHAVIORAL CHANGE •INCREASE PATIENTS AWARENESS OF FEELINGS, INCREASE SENSE OF RESPONSIBILITY AND HELP ETURN TO COMMUNITY •clients plan social and group interaction

•token programs , open wards and self medication FAMILY THERAPY

•A METHOD OF PSYCHOTHERAPY WHICH FOCUSES ON THE TOTAL FAMILY AS AN INTERACTIONAL SYSTEM •PROBLEM IS A FAMILY PROBLEM

•focus on sick members behavior as source of trouble / symptom serve a function for the family •members develop sense of identity •points out function of the sick member for the rest of the family PSYCHOANALYTIC •focuses on the exploration of the unconscious, to facilitate identification of the patients defenses

•ANXIETY RESULTS BETWEEN CONFLICTS OF ID AND EGO(DEFENSE MECHANISMS FORM TO WARD OFF)

•BECOMES AWARE OF UNCONSCIOUS THOUGHTS AND FELINGS.UNDERSTAND ANXIETY AND DEFENSES

HYPNOTHERAPY

•VARIOUS METHODS AND TECHNIQUES TO INDUCE A TRANCE STATE WHERE PATIENT BECOMES SUBMISSIVE TO INSTRUCTIONS

BEHAVIOR MODIFICATION A THERAPEUTIC INTERVENTION INVOLVOING THE APPLICATION OF LEARNING PRINCIPLES IN ORDER TO CHANGE MAL-ADAPTIVE BEHAVIOR PSYCHOLOGICAL PROBLEMS ARE A RESULT OF LEARNING DEFICIENCIES CAN BE CORRECTED THROUGH LEARNING

•OPERANT CONDITIONING

–USE OF REWARDS TO EINFORCE POSITIVE BEHAVIOR –PERCEIVED AND SELF REINFORCEMENT BECOMES MORE IMPORTANT THAN

EXTERNAL •DESENSITIZATION –SLOW ADJUSTMENT OR EXPOSURE TO FEARED OBJECTS(USED IN PHOBIAS) –PERIODIC EXPOSURE,UNTIL UNDESIRABLE BEHAVIOR DISAPPEARS OR LESSENS

•AVERSION THERAPY - EXAMPLE OF BEHAVIOR MODIFICATION IN WHICH PAINFUL

STIMULUS IS INTRODUCED TO BRING ABOUT AN AVOIDANCE OF ANOTHER STIMULUS WITH THE END VIEW OF FACILITATING BEHAVIORAL CHANGE OTHER THERAPIES TOKEN ECONOMY-REWARDING ECONOMY-REWARDING DESIRED BEHAVIOR COGNITIVE THERAPY – SHORT TERM STRUCTURED THERAPY –ORIENTED TOWARDS PRESENT PROBLEMS ABD SOLUTIONS – AMIN FOCUS OF DEPRESSIVE DISORDERS HUMOR THERAPY – TO FACILITATE EXPRESSION AND ENHANCE INTERACTION ACTIVITY THERAPY – GROUP INTERACTION WHILE WORKING ON A TASK TOGETHER

PSYHCHOPHARMACOLOGIC AGENTS I. SUB-CLASSIFICATIONS PHENOTHIAZINES

MOA

ANTI-PSYCHOTICS NON-PHENOTHIAZINES

Chlorpromazine (Thorazine) Fluphenazine (Prolixin) Perphenazine ( Trilafon) Prochlorperazine (Compazine) Thioridazine ( Mellaril) Triflouperazine (Stelazine) -

-

Clozapine ( Clozaril) Haloperidol ( Haldol) Olanzapine ( Zyprexa ) Risperidone ( Risperdal) THIOXANTHENES Thiothixene ( Navane)

antagonizes dopamine in the CNS and also blocks Cholinergic, Histaminic, Serotogenic, Adrenergic neurotransmitters ( anticholinergic, antihistaminic, anti-emetic ) blocks activity of the CNS receptors and sympathetic nervous system

INDICATION -

-

formerly called major tranquilizers / neuroleptics. used to relieve psychotic symptoms( delusions , hallucinations and looseness of association)of schjizophrenia, mania and psychotic depression and organic mental disorders acute management of agitation and hyperactivity

SIDE/ ADVERSE EFFECTS:

 ANTICHOLINERGIC EFFECTS  (EPS)EXTRAPYRAMIDAL SYMPTOMS –PSEUDOPARKINSONISM-tremor , mask like facies drooling , restlesssness –AKATHISIA- restlessness,and anxiety –DYSTONIA-grimacing , torticollis ,oculogyric crisis, intermittent muscle spasms - TARDIVE DYSKINESIA-lip smaking and tongue and mouth 

(NMS) NEUROLEPTIC MALIGNANT SYNDROME* - hyperthermia, and severe EPS -muscular rigidity, tremors, trismus, choreiform movements,autonomic instability /hyperactivity and alterations in LOC



SEIZURES HEPATOTOXICITY* ORTHOSTATIC HYPOTENSION PHOTOSENSITIVITY and HYPERSENSITIVITY ENDOCRINE DISORDERS DYSCRASIAS * AGRANULOCYTOSIS – sorethroat,chills,fever,malaise LEUKOPENIA

CONTRAINDICATIONS AND SPECIAL PRECAUTIONS: C/I : hypersensitivity , glaucoma , convulsive d/o , pregnancy and lactation, elderly clients NURSING CARE GUIDELINES: C- antipsychotics, neuroleptics, major tranquilizers H- decreased overt or positive manifestations of psychosis E- p.c. C- rise slowly avoid sunlight Report –sorethroat,fever,muscular rigidity Reduced psychomotor agitation and insomnia – 1 week Reduction of hallucinations, delusions and thought disorder takes 6-8 weeks for full therapeutic effect BP and temperature blood levels

K – monitor

Seizures, NMS and EPS L.F.T.’s CBC with differential medical management : NMS – Bromocriptine or Amantadine( dopamine agonist) and Dantrolene (Dantrium) muscular relaxant Dystonia – Diphenhydramine,Benztropine , Diazepam, Lorazepam Pseudoparkinsonism – Antiparkinsonian, Anticholinergic Akathisia – Anticholinergic, Benzodiazepines, Beta-blockers,Clonidine Tardive dyskinesia – early referral-dose reduction , no anticholinergics II.

ANTI-PARKINSONIAN AGENTS

CLASSIFICATIONS 2 TYPES : 1.) DOPAMINERGIC DRUGS MOA: enhance dopaminergic activity slows deterioration of dopaminergic nerve cells Increasing dopamine

Carbidopa – Levodopa ( Sinemet) Amantadine ( Symmetrel) Bromocriptine Mesylate ( Parlodel) Levodopa ( Larodopa) Pergolide Mesylate ( Permax) Ropinirole(Requip) Tolcapone ( Tasmar)

2.) ANTI-CHOLINERGIC AGENTS MOA:inhibit relative excess in cholinergic activity, symptomatic relief Decrease signs and symptoms ( tremors,rigidity, drooling promote optimal levels of motor function (gait, posture and speech )

Trihexypheiedil ( Artane) Biperiden Hydrochloride ( Akineton) Benztropine Mesylate ( Cogentin) Diphenhydramine Hydrochloride (Benadryl) Misc. agent Selegiline ( Eldepryl) INDICATIONS: For management of anti psychotic induced EPS- pseudoparkinsonism SIDE AND ADVERSE EFFECTS Anticholinergic Effects Blurring of vision, constipation, 3D’s and orthostatic hypotension, sorethroat* Headache, photosensitivity, drowsiness, CHF and halluciantions CONTRAINDICATIONS AND SPECIAL PRECAUTION Glaucoma, tachycardia, HPN, Cardiac D/O, asthma, duodenal ulcer NURSING CARE GUIDELINES C- dopaminergic or anti-cholinergic H- decrease tremors and rigidity in 2-3 days E- p.c. C- avoid sudden position change Avoid Vit. B6 and CHON rich foods- dec. absorption of medication Avoid alcohol-increases sedative effects K- check BP- orthostatic hypotension drugs not withdrawn abruptly III. ANTI DEPRESSANTS COMMON TYPES TRICYCLICS

MONO AMINE OXIDASE INHIBITORS

SELECTIVE SEROTONIN REUPTAKE INHIBITORS

Citalopram ( Celexa) Flouxetine (Prozac) Paroxetine ( Paxil) Sertraline ( Zoloft) Fluvoxamine (Luvox)

Imipramine(Tofranil) Amitriptryline ( Elavil) Clomipramine (Anafril) Doxepin ( Sinequan) Nortryptyline ( Aventyl) Tranylcypromine (Parnate) Isocarboxazid ( Marplan) Phenelzine (Nardil)

Mechanism of Action

Prolongs the action of norepinephrine Dopamine Serotonin by blocking the reuptake of this CNS STIMULANTS neurotransmitters

Blocks the metabolic destruction of neurotransmitters by the enzyme monoamine oxidase

Inhibits reuptake and destruction of serotonin to prolong its action

Ritalin ( Methylphenidate) Amphetamine ( Benzedrine)

Increases levels of neurotransmitters in the brain thereby increasing CNS activity and decreasing hyperactivity. INDICATIONS effective in management and treatment of depression and related mood and depressive disorders such as: Obsessive compulsive ,Eating d/o,Obesity,Bipolar disorder,Panic d/o

SIDE EFFECTS AND ADVERSE REACTIONS: TCA’S Cardiac arrhythmias, palpitations,orthostatic hypotension Constipation,Sedation, anticholinergic effects Confusion Bone marrow depression

MAOI Hypertensive crisis Liver and cardiovascular disease Weight gain Sexual dysfunction photosensitivity

SSRI Tremors, decreased libido, NAVDA Nervousness, insomnia, drowsiness anxiety

CNS Stimulants Growth suppression, insomnia

CONTRAINDICATIONS AND SPECIAL PRECAUTIONS TCA’S Hypersensitivity, liver disease , glaucoma

MAOI Hypertension Cardiovascular disease and Liver disease

SSRI same

CNS Stimulants

NURSING CARE GUIDELINES C- anti-depressants H- decreased signs and symptoms of depression(increased appetite and sleep E – p.c. TCA’S C2-3 wks initial effect 3-6 wks full therapeutic effect

MAOI

SSRI

CNS Stimulants

2-3 initial 3-4 full ther. Effect Avoid foods rich in

2-3 initial 3-4 full ther. effect

Give in AM , not beyond 2 pm 6 hours before bedtime

Emphasize compliance Avoid citrus juice – decrease absorption

tyramine –leads to hypertensive crisis ( processed,preserved and fermented )

KMonitor BP, HR and ECG Monitor BP and food items IV. ANTI – MANIC EXAMPLES

Lithium Carbonate ( Eskalith, Lithane, Quilinium –R, Lithionate) Carbamazepine (Tegretol ) MOA Exact mechanism unknown , alters the level of norepinephrine and other neurotransmitters INDICATIONS

•Treatment of

acute mania and for prophylaxis of recurrent manic and depressive episodes in bipolar disorder SIDE AND ADVERSE EFFECTS NAVDA Fine tremors leading to coarse tremors Thirst Nystagmus

Nephrotoxicity* Cardiac toxicity* Hyperthyroidism – Thyroid Crisis*

CONTRAINDICATIONS AND SPECIAL PRECAUTION Cardiovascular disease , renal disease, clients on low sodium diet and on diuretic therapy, brain damage, pregnancy and lactation NURSING CARE GUIDELINES C- mood stabilizer – anti manic H- decrease hyperactivity/manic episodes Initial effect – 10-14 days Full therapeutic effect 3-4 weeks E- after meals with milk or food C- antipsychotics given with lithium for immediate management of manic episodes. Diet – Na 6-10 grams a day; fluids- 3 liters per day Avoid caffeine , diuretics and activities that increase perspiration K- monitor for untoward signs and symptoms Monitor serum level at least once a month(A.M. 12 hours after the last dose maintenance dose - .5 – 1.2 mEq / L acute level – 1.5 mEq / L level for the elderly .4 – 1.0 mEq / L Antidote for toxicity – Mannitol (Osmitrol) or Acetazolamide (Diamox) V. ANTI ANXIETY CLASSIFICATION: BENZODIAZEPINES AZASPIRONES Alprazolam ( Xanqax) Chlordiazepoxide ( Librium) Clorazepate ( Tranxene) Diazepam ( Valium) Lorazepam ( Ativan) Oxazepam ( Serax)

NON-BENZODIAZEPINE Miscellaneous agents

Buspirone (Buspar)

Hydroxyzine ( Vistaril) Meprobamate ( Equanil)

MOA: depresses Reticular Activating system and reduces anxiety by stimulating the action of an inhibitory neurotransmitter called GABA INDICATIONS; treatment of anxiety disorders and for short term relief of symptoms of Anxiety; selective medications effective for skeletal muscle relaxation, pre and post-op sedation, seizure control. SIDE AND ADVERSE EFFECTS Sedation and Dizzinees,drowsiness and dry mouth Paradoxical reactions*(hallucination and delusions),CNS depression* Addison’s disease , Dependency*, hepatotoxicity* CONTRAINDICATIONS AND SPECIAL PRECAUTION Glaucoma, hypersensitivity, liver and kidney dysfunction, psychoses, elderly , pregnancy and lactation NURSING CARE GUIDELINES C- anxiolytics, minor tranquilizers H- decrease anxiety E- a.c. – food delays absorption C- rise slowly Avoid caffeine and alcohol K- monitor CBC, LFT’s, report sorethroat, jaundice, weakness and fever