PSYCHIATRIC NURSING

By: Meeko Videña, RN

Psychopharmacology

• Psychotropic drugs• Includes:

antipsychoticsantidepressantsmood stabilizersanxiolyticsstimulants

• Efficacy• Potency• Half-life

Principles That Guide Pharmacologic Treatment

• A medication is selected based on its effect on the client’s target symptoms.• Must be given in adequate doses for

some time before their full effect is realized.• The dosage is often adjusted to the

lowest effective dosage for the client.• Older adults require lower doses than

younger clients to experience effects.

Principles That Guide Pharmacologic Treatment

• Medications are decreased gradually rather than abruptly.• Follow-up care is essential to ensure

compliance, to make dosage adjustments and mange side effects.• Compliance is enhance if the

medication regimen is as simple as possible.

Antipsychotic Drugs• Neuroleptics• Treatment of symptoms in

schizophrenia and manic phase of bipolar disorder• Blocks dopamine receptors• Examples:

Chlorpromazine (Thorazine)Haloperidol (Haldol)Loxapine (Loxitane)Risperidone (Risperdol)

•Typical and atypical•Dopamine System Stabilizers (DSS)

Side Effects• Extrapyramidal Side Effects:

Acute dystoniaPseudoparkinsonismakathisia

• Neuroleptic Malignant Syndrome• Tardive Dyskinesia• Anticholinergic Side Effects• Elevated prolactin• Weight gain• Minor CV adverse effects• Agranulocytosis (Clozapine)

Antidepressant Drugs• Interacts with norepinephrine and

serotonin• Four Groups:

Tricylic antidepressantsSelective serotonin reuptake inhibitors

(SSRIs)Monoamine oxidase inhibitors

(MAOIs)Others such as venlafaxine (Effexor)

and bupropion (Wellbutrin)

Side Effects• SSRIs

AnxietyAgitationAkathisiaNauseaInsomniaSexual dysfunctionWeight gainSweating SedationDiarrheaHA

Side Effects• MAOIs

Daytime sedationInsomniaWeight gainDry mouthOrthostatic hypotensionSexual dysfunctionHypertensive crisis

Side Effects• Cyclic antidepressants

Dry mouthConstipationUrinary hesitancy or retentionDry nasal passagesBlurred near visionWeight gainSexual dysfunction

Side Effects• Other antidepressants

HA (nefazodone and trazodone)Dry mouth and nausea (nefazodone)Loss of appetite, nausea, agitation and

insomnia (bupropion and venlafaxine)Dizziness, sweating or sedation

(venlafaxine)Priapism (trazodone)Liver damage (nefazodone)Seizures (bupropion)

Drug Interactions• Taking MAOI and SSRI at the same

time can cause serotonin or serotonergic syndrome• Symptoms:

AgitationSweatingFeverTachycardiaHypotensionRigidityHyperreflexiaComa Death

Mood Stabilizing Drugs• Bipolar Disorder• Stabilizes mood• Prevents or minimizes the highs and

lows of bipolar illness• Treats acute episodes of mania• Lithium• Anticonvulsants:

carbamazepine (Tegretol)valproic acid (Depakote)gabapentine (Neurontin)

Side Effects• Lithium

Mild nausea or diarrheaAnorexiaFine hand tremorPolydipsiaPolyuriaMetallic taste in mouthFatigue or lethargyWeight gainAcne

Side Effects• Lithium Toxicity

Severe diarrheaVomitingDrowsinessMuscle weaknessLack of coordinationIf untreated can lead to renal failure,

coma and death

Side Effects• Carbamazepine

DrowsinessSedationDry mouthBlurred visionRashesOrthostatic hypotensionAplastic anemiaAgranulocytosis

Side Effects• Valproic acid

DrowsinessSedationDry mouthBlurred visionWeight gain AlopeciaHand tremorHepatic failureTeratogenic effectsPancreatitis

Antianxiety Drugs (Anxiolytics)• Anxiety and anxiety disorders• Insomnia• OCD• PTSD• Alcohol withdrawal• Mostly benzodiazepines except for

BuspironeDiazepam (Valium)Chlordiazepoxide (Librium)

Side Effects• Physical and psychological

dependence• Drowsiness• Sedation• Poor coordination• Impaired memory • Clouded sensorium• Next day sedation (hangover effect)• Dizziness, sedation, nausea and HA

(Buspirone)

Stimulants• ADHD• Residual attention deficit disorder• Narcolepsy• Amphetamines

Methylphenidate (Ritalin)Pemoline (Cylert)Dextroamphetamine

• Causes release of neurotransmitters

Side Effects• Dependence• Anorexia• Weight loss• Nausea• Irritability• Dizziness• Dry mouth• Blurred vision• Palpitations• Growth and weight suppression in

children

Disulfiram (Antabuse)• Treatment for alcoholism• Causes reaction to alcohol in the body:

Facial and body flushing Throbbing HASweatingDry mouthN&VDizzinessWeaknessChest painDyspneaSevere hypotensionConfusion Death

Reproductive Health and FertilityTubal Patency• The Ability of the egg to move from

the ovary to the uterus.• Hysterosalpingography• Previous damage to tubes can cause

infertility.• Usual cause is Pelvic Inflammatory

Disease.

PregnancySigns of Pregnancy1. Presumptive (Subjective) Signs

▫Breast changes (fullness, enlargement, color)

▫N & V▫Amenorrhea▫Urinary Frequency▫Quickening (18-20 wks)▫Skin Pigmentation (linea nigra, striae

gravidarum, chloasma)

PregnancySigns of Pregnancy2. Probable Signs

▫Serum HCG▫Chadwick’s sign▫Goodell’s sign ▫Hegar’s sign▫Ultrasound (gestational sac)▫Ballottement▫Braxton Hicks contractions (at least

12th wk)▫Fetal outline felt by examiner

PregnancySigns of Pregnancy2. Positive signs

▫Ultrasound (fetal outline)▫Fetal heart is audible▫Fetal movement felt by examiner

PregnancyCirculatory System During Pregnancy• Increase in blood volume (30-50%)• Pseudoanemia (first trimester)• Increase in heart rate (10 beats)• BP decreases slightly (second

trimester), but rises again (third trimester)• Blood fibrinogen increases• Blood lipids increase by one third• Serum cholesterol level increase by

90-100%

PregnancyPregnancy Related Problems• Ectopic Pregnancy

Implantation occurs outside the uterusCan cause bleeding in pregnancyMost common site is the fallopian tube

(95%)Tubal scarring due to PIDCommon to women who smoke

PregnancyPregnancy Related Problems• Hyperemesis Gravidarum

N & V past the 12th week of pregnancySevere N &V that dehydration,

ketonuria and significant weight loss occurs within the first 12 wks of pregnancy

NPOIVF with vitamin BIf no vomiting after the first 24 hrs of

NPO, small amounts of clear fluid may be given

PregnancyPregnancy Related Problems• Hyperemesis Gravidarum

N & V past the 12th week of pregnancySevere N &V that dehydration,

ketonuria and significant weight loss occurs within the first 12 wks of pregnancy

NPOIVF with vitamin BIf no vomiting after the first 24 hrs of

NPO, small amounts of clear fluid may be given

PregnancyPregnancy Related Problems• PIH

Cause is still unknownOccurs in 5-7% of pregnanciesMultiple pregnanciesPrimipara younger than 20 and older

than 40Five or more pregnanciesHave underlying disease like heart

diseases or diabetes

PregnancyPregnancy Related Problems• Gestational HPN

BP 140/90Increase in systolic 30mmHg or

diastolic 15mmHg above prepregnancy level

No proteinuria or edemaReturns to normal after birth

PregnancyPregnancy Related Problems• Mild pre-eclampsia

BP 140/90Increase in systolic 30mmHg or

diastolic 15mmHg above prepregnancy level

Proteinuria 1-2+Weight gain of 2lbs/wk (2nd trimester),

1lb/wk (3rd trimester)Mild edema in upper extremities and

face

PregnancyPregnancy Related Problems• Severe pre-eclampsia

BP 160/110Proteinuria 3-4+Oliguria (500ml or less in 24hrs)Cerebral or visual disturbances

(headache, blurred vision)Epigastric painthrombocytopenia

PregnancyPregnancy Related Problems• Eclampsia

Seizure or coma accompanied by symptoms of pre-eclampsia

Cerebral edema

Labor and DeliveryFetal Presentation and Position• Attitude

The degree of flexion a fetus assumes during labor

Good Attitude: Complete flexion Head is flexed (chin touching the

sternum) Arms flexed and folded into chest Thighs flexed into abdomen Calves are pressed against posterior

aspect of thighs

Labor and DeliveryFetal Presentation and Position• Engagement

Settling of the presenting part of the fetus into the pelvis

At the level of the ischial spinesFloating – presenting part not yet

engagedDipping – has not reached the ischial

spine yet

Labor and DeliveryFetal Presentation and Position• Station

Relationship of the presenting part to the level of the ischial spine

0 station – at level with ischial spine (engaged)

+3 - +4 station – presenting part is at the perineum (crowning)

Labor and DeliveryFetal Presentation and Position• Lie

Relationship between the long axis of the fetal body and the long axis of the mother’s body

Either horizontal (transverse) or vertical (longitudinal)

Longitudinal Lie: Cephalic Breech

Labor and DeliverySigns of Labor• Uterine Contractions

Begins irregularly but become regular and predictable

Felt first in the lower back and sweep around the abdomen in a wave

Continues regardless of woman’s activity

Increases in duration, frequency, and intensity

Achieves cervical dilation

Labor and DeliverySigns of Labor• Show• Rupture of Membranes

Sudden gush or scanty, slow seeping of clear fluid from the vagina

Can be advantageousRisk for intrauterine infection and

prolapsed cord

Labor and DeliveryStages of Labor1. First Stage

a) Latent Phase Contractions last 20-40 seconds Cervix dilates from 0-3cm Lasts 6hrs (nullipara) to 4.5hrs

(multipara)b) Active Phase

Dilation from 4-7cm Contractions last 40-60 seconds every 3-5

mins Lasts 3hrs (nullipara) to 2hrs (multipara) Show and ROM may occur

Labor and DeliveryStages of Labor1. First Stage

a) Transition Phase Contractions last 60-90 seconds every

2-3 mins Cervix dilates from 8-10cm Show and ROM Full dilatation N & V may sometimes be felt Irresistible urge to push

Labor and DeliveryStages of Labor2. Second Stage• Period from full dilatation and cervical

effacement to birth of infant• Takes about 1 hour• Crowning

Labor and DeliveryStages of Labor3. Third Stage• Placental stage• From birth of infant to delivery of

placenta• Sudden gush of blood, lengthening of

umbilical cord (placental separation)4. Fourth Stage• First 1 to 4 hrs after birth of the

placenta• Oxytocin is given

Congenital Heart Disorders1. Ventricular Septal Defect

▫Most common type of CHD (30%)▫Opening is present between the two

ventricles▫Left to right shunting of blood▫Right ventricular hypertrophy and

increased pulmonary artery pressure▫Postop – be alert for arrhythmias

Congenital Heart Disorders2. Atrial Septal Defect

▫Abnormal communication between two atria

▫More common in girls▫Can be caused by patent foramen

ovale▫Left to right movement of blood▫Ventricular hypertrophy and increased

pulmonary artery pressure

Congenital Heart Disorders2. Atrial Septal Defect

▫Abnormal communication between two atria

▫More common in girls▫Can be caused by patent foramen

ovale▫Left to right movement of blood▫Ventricular hypertrophy and increased

pulmonary artery pressure

Congenital Heart Disorders3. Atrioventricular Canal Defect

▫Incomplete fusion of the endocardial cushion

▫Low ASD and high VSD and distortion of the mitral and tricuspid valves

▫May have left to right blood flow or between all chambers of the heart

▫Common in children with trisomy 21 (50%)

Congenital Heart Disorders4. Aortic Stenosis

▫Prevents blood from passing freely from the left ventricle to the aorta

▫Increased pressure and hypertrophy of LV▫LA pressure increase ▫Back pressure to pulmonary veins and

pulmonary edema▫Decreased CO:

Faint pulses Hypotension Tachycardia Inability to suck for long periods

Congenital Heart Disorders5. Tetralogy of Fallot

▫Four anomalies are present:• Pulmonary stenosis• VSD• Overriding aorta (dextroposition)• RV hypertrophy

▫ Cyanosis▫ Polycythemia▫ Dyspnea