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Course: Mental Health Nursing�Topic: Psychopharmacology Part - II

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Module Goals

Learners will be able to:

Identify the psychotropic medications.
Describe the mechanism of action, indications and contraindications for the classes of psychotropic medications.
Describe the client considerations concerning use of psychotropic medications.
Describe the nursing responsibilities related psychotropic medications.

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Antimania: Lithium

Also called mood stabilizers

Mechanism of action

Alters the sodium transport in the nerve and muscle.

Indications Treatment of maniac episode of bipolar disorder.

Adverse effects Hyponatremia, tremor, cardiac arrhythmia, polyuria, thirst and lithium toxicity.

Ernstmeyer & Christman, 2020

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Antimania: Lithium

Nursing Considerations

Monitor closely for adverse effects or signs of lithium toxicity.
Hyponatremia: Monitor serum sodium level.
Contraindicated in clients with renal or cardiovascular disease, severe dehydration or sodium depletion (May cause lithium toxicity).
Contraindicated in clients who are pregnant and in children below 12 years of age.
Therapeutic effect may be seen in 1-3 weeks.

Ernstmeyer & Christman, 2020

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Antimania: Lithium

Client Teaching & Education

Take medication as directed.
Explain the adverse effects and when to seek medical help.
Dizziness, drowsiness, and confusion may occur.
Seek immediate emergency assistance for:

fainting, lightheadedness, abnormal heart beats, or shortness of breath.

Weight gain may occur.

Ernstmeyer & Christman, 2020

Contact info: info@nursesinternational.org

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Critical Thinking Question

The nurse notices that a client in an inpatient psychiatric facility is experiencing vomiting, muscle weakness, and drowsiness. The client takes lithium to manage their bipolar disorder.

What should the nurse do next?

Administer the next dose of lithium as ordered
Administer an antiemetic medication
Hold the next dose of lithium and notify the provider
Reassure the client of these expected side effects

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Antipsychotic Drugs

Also referred as tranquilizers

Classes:

1st generation or conventional antipsychotics: Haloperidol.
2nd generation also called atypical antipsychotics: Risperidone.

Mechanism of action: Bllocks dopamine receptors.

Indications: Schizophrenia, Tourette’s disease, acute manic episodes due to autism, depression that is resistant to other therapy.

Ernstmeyer & Christman, 2020

Contact info: info@nursesinternational.org

Antipsychotics are sometimes referred to as tranquilizers because they produce a state of tranquility. There are two types of antipsychotic:

First-generation antipsychotics/Conventional antipsychotics: Mechanism of action of both generation drugs are same. However, first generation tend to have more severe adverse effects. Example: Haloperidol.
Second-generation antipsychotics/ Atypical antipsychotics: Have fewer adverse effects. An example: Risperidone.

Mechanism of Action

Block dopamine receptors in the brain. However, the precise mechanism of action has not been clearly established.

Conventional antipsychotics, such as haloperidol, block dopamine receptors in certain areas of the CNS, such as the limbic system and the basal ganglia. These areas are associated with emotions, cognitive function, and motor function, and blockage thus produces a tranquilizing effect in psychotic clients. However, several adverse effects are also caused by this dopamine blockade.

Second-generation, or atypical, antipsychotics block specific dopamine 2 receptors and specific serotonin 2 receptors, thus causing fewer adverse effects.

Indications: Haloperidol is primarily indicated for schizophrenia and Tourette’s disorder. Risperidone is primarily indicated for schizophrenia but is also used for acute manic episodes and for irritability caused by autism. Some atypical antipsychotics are also used as adjunct therapy for depression.

Elderly clients with dementia-related psychosis treated with antipsychotic drugs should be closely monitored for signs and symptoms of cardiovascular events or infections such as pneumonia.

Haloperidol is contraindicated in clients with Parkinson’s disease or dementia with lewy bodies.

Clients who are concurrently taking lithium and antipsychotics should be monitored closely for neurotoxicity (weakness, lethargy, fever, tremulousness, confusion, and extrapyramidal symptoms) and symptoms should be immediately reported.

Adverse/Side Effects

Elderly clients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death due to cardiovascular or infection-related causes.

Conventional antipsychotic medications have several potential serious adverse effects such as tardive dyskinesia, neuroleptic malignant syndrome (NMS), and extrapyramidal symptoms. These adverse effects are due to the blockage of alpha-adrenergic, dopamine, endocrine, histamine, and muscarinic receptors. For additional details about these types of receptors, see the “Autonomic Nervous System” chapter. Figure 8.8 describes adverse effects associated with conventional antipsychotics. Clients should be warned to not consume alcohol and that their ability to operate machinery or drive may be impaired

Second-generation, or atypical, antipsychotics are less likely to cause adverse effects, but have a potential to do so. Atypical antipsychotics may also cause metabolic changes such as hyperglycemia, hyperlipidemia, and weight gain.

Client Teaching & Education

Advise client to take medication at directed. Medication doses should be evenly spaced throughout the day. This drug may require several weeks to obtain desired effects. Clients should be advised regarding the possibility of extrapyramidal symptoms and that abrupt withdrawal may cause dizziness, nausea and vomiting, uncontrolled movements of mouth, tongue, or jaw. Additionally, the client should be careful to avoid alcohol or other CNS depressants while using the medication.

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Antipsychotic Drugs

Adverse Effects

Life-threatening cardiovascular events or infections in eldely clients.
Conventional antipsychotic: Tardive dyskinesia, Neuroleptic Malignant Syndrome, Extrapyramidal symptoms.
Hypersensitivity reactions.
Falls related to sedation, motor instability, and postural hypotension.
Atypical antipsychotics: Metabolic changes like hyperglycemia, hyperlipidemia and weight gain.
clozapine may cause neutropenia.

Ernstmeyer & Christman, 2020

Contact info: info@nursesinternational.org

Adverse/Side Effects

Increase risk of death and severe cardiovascular infection in elderly clients with dementia with Lewy bodies treated with antipsychotic drugs.
Conventional antipsychotic medications have several potential serious adverse effects such as tardive dyskinesia, neuroleptic malignant syndrome (NMS), and extrapyramidal symptoms.
Tardive Dyskinesia: Involuntary contraction of the oral and facial muscles (such as tongue thrusting) and wavelike movements of the extremities.
Neuroleptic Malignant Syndrome (NMS): Potentially life-threatening adverse effect that includes high fever, unstable blood pressure, and myoglobinemia.
Extrapyramidal Symptoms: Involuntary motor symptoms similar to those associated with Parkinson’s disease. Includes symptoms such as akathisia (distressing motor restlessness) and acute dystonia (painful muscle spasms.) Often treated with anticholinergic medications such as benztropine and trihexyphenidyl.
Second-generation, or atypical, antipsychotics are less likely to cause adverse effects, but have a potential to do so. Atypical antipsychotics may also cause metabolic changes such as hyperglycemia, hyperlipidemia, and weight gain.

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Antipsychotic Drugs

Nursing Considerations

Monitor elderly client for cardiovascular symptoms.
Monitor vital signs, report deviations.
Haloperidol contraindicated in clients with Parkinson’s disease or dementia with lewy bodies.
Monitor clients on Lithium and antipsychotics for neurotoxicity; immediately report any abnormal symptoms.
Instruct client not to consume alcohol and that their ability to operate machinery or drive may be impaired.

Ernstmeyer & Christman, 2020

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Antipsychotic Drugs

Client Teaching & Education

Importance of taking medication as directed and evenly spaced doses throughout the day.
Therapeutic effect may require several weeks to obtain.
Warn client not to consume any alcoholic beverages or other CNS depressants.
Adverse effects and when to seek medical attention.
Withdrawal symptoms associated with abrupt discontinuation.

Ernstmeyer & Christman, 2020

Contact info: info@nursesinternational.org

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Critical Thinking Question

A client who takes clozapine (Clozaril) is admitted to an inpatient healthcare facility.

Which laboratory tests should the nurse review?

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Anticonvulsants

Also called antiseizure drugs

All anticonvulsants works by stabilizing the cell membrane and suppressing the abnormal electrical impulses in cerebral cortex.
Prevents seizures but does not cure them.
Medication used in treatment of seizure: phenytoin, phenobarbital, benzodiazepines, carbamazepine, valproate, and levetiracetam.

Ernstmeyer & Christman, 2020

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Anticonvulsants: Phenytoin

Mechanism of action: Interferes with sodium channel in the brain and improves evidence of seizure.

Indications: Used in the treatment of tonic-clonic and psychomotor seizures, prevention and treatment of seizures during and after surgery.

Adverse effects: Cardiovascular risk with intravenous infusion, arrhythmias, hypotension, ataxia, slurred speech, mental confusion, constipation, hepatotoxicity, pancytopenia, agranulocytosis, fatal dermatological reactions.

Ernstmeyer & Christman, 2020

Contact info: info@nursesinternational.org

Mechanism of Action

Phenytoin improves evidence of seizures by interfering with sodium channels in the brain, resulting in a reduction of sustained high-frequency neuronal discharges.

Indications for Use

Phenytoin is indicated for the treatment of tonic-clonic (grand mal) and psychomotor (temporal lobe) seizures and for the prevention and treatment of seizures occurring during or following neurosurgery.

Adverse/Side Effects

Acute hepatotoxicity has been reported with phenytoin.
Hematopoietic complications: Thrombocytopenia, leukopenia, granulocytopenia, agranulocytosis, and pancytopenia with or without bone marrow suppression.
Cardiovascular: arrhythmia and hypotension
CNS: Nystagmus, ataxia, slurred speech, decreased coordination, somnolence, and mental confusion
GI: Constipation, gingival hyperplasia, and hepatotoxicity
Hematology: Thrombocytopenia, pancytopenia, and agranulocytosis
Serious and sometimes fatal dermatologic reactions, including toxic epidermal necrolysis (TEN) and Stevens-Johnson syndrome (SJS), have been reported with phenytoin treatment.
Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) These events have been fatal or life threatening.

Symptoms of DRESS include: Fever, rash, lymphadenopathy, facial swelling, in association with other organ system involvement.

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Severe reactions to anti seizure medication

Drug rash with eosinophilia and systemic symptoms (DRESS) syndrome is a distinct, severe, idiosyncratic reaction to a drug characterized by a prolonged latency period.

Followed by variety of clinical manifestations: Fever, rash, lymphadenopathy, eosinophilia, and a wide range of mild-to-severe systemic presentations.

Typical symptoms of DRESS: Fever, rash, lymphadenopathy, facial swelling, in association with other organ system involvement.

Choudhary et.al., 2013

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Anticonvulsants: Phenytoin

Nursing Considerations

Contraindicated for pregnant women.
Careful cardiac monitoring needed during and after administering intravenous phenytoin.
May not be given with D5W due to precipitation and no faster than 50 mg/minute in adults and (1-3 mg/kg/minutes) in pediatric population.
Caution in client with renal and hepatic impairment.
Cannot be discontinued abruptly.

Ernstmeyer & Christman, 2020

Contact info: info@nursesinternational.org

Nursing Considerations:

Phenytoin should not be administered to pregnant women because it will cause harm to the fetus.

Intravenous rate of phenytoin should not exceed 50 mg per minute in adults and (1-3 mg/kg/minutes) in pediatric population because of the risk of severe hypotension and cardiac arrhythmias.

Careful cardiac monitoring is needed during and after administering intravenous phenytoin.

For IV infusions, an in-line filter (0.22 to 0.55 microns) should be used. Cannot be given with D5W due to precipitation and no faster than 50 mg/minute in adults

Phenytoin has a narrow therapeutic drug level, usually between 10-20 mcg/ml, so serum drug monitoring is required. Serum levels of phenytoin sustained above the therapeutic range may produce confusional states referred to as delirium, psychosis, or encephalopathy.

Abrupt discontinuation can cause status epilepticus, so in the event of an allergic or hypersensitivity reaction, rapid substitution of alternative therapy may be necessary.

Use with caution in clients with renal or hepatic impairment. Elderly clients may require dosage adjustment.

There are many potential drug interactions with phenytoin. Read drug label information before administering.

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Anticonvulsants: Phenytoin

Nursing Considerations

Read drug label information regarding interactions before administering.
Monitor serum drug values on a regular basis.
Cardiovascular risk associated with rapid intravenous infusion.
Discontinue and notify the provider if a rash occurs.
Notify the provider immediately if fever, rash, lymphadenopathy, and/or facial swelling occur.

Ernstmeyer & Christman, 2020

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Anticonvulsants

Client Teaching & Education

Take medications as directed, space doses evenly throughout the day.
Advise client that it may take several weeks to obtain the desired medication effect.
Status epilepticus with abrupt withdrawal of medication.
Risk associated with alcohol use and other CNS depressants while taking this medication.
Monitor blood sugar levels in Diabetic client.

Ernstmeyer & Christman, 2020

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Anticonvulsants: Levetiracetam

Mechanism of action: May work by interfering with sodium, calcium, potassium, or GABA transmission.

Indications: Used for partial onset seizure in epilepsy.

Adverse effects: Behavioral/mood changes, anaphylaxis or angioedema, somnolence, fatigue, and irritability, serious skin conditions, coordination difficulties, hematopoietic abnormalities.

Ernstmeyer & Christman, 2020

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Anticonvulsants: Levetiracetam

Nursing Considerations

Monitor plasma levels in pregnant women.
Caution with renal impairment.
Taper dose- Do no stop abruptly.
Monitor psychiatric signs and symptoms.
Advise client to take medication as per direction.
Advise family or caregiver to monitor for suicidality.
Advise client not to drive or operate machinery until they gain sufficient experience on this medication.

Ernstmeyer & Christman, 2020

Contact info: info@nursesinternational.org

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Anticonvulsants: Gabapentin

Mechanism of action: Unknown

Indications: Used to treat neuropathic pain and partial seizures.

Adverse effects: Increased suicidal ideation, Fever, rash, and/or lymphadenopathy, CNS depression: dizziness, somnolence, and ataxia.

Note: Dose range for gabapentin is different for clients with Diabetes

Ernstmeyer & Christman, 2020

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Anticonvulsants: Gabapentin

Nursing Considerations

Monitor elderly clients for peripheral edema and ataxia.
Observe fall precautions.
Taper drug before discontinuing.
Monitor for the emergence or worsening of depression, suicidal thoughts or behavior, and/or any unusual changes in mood or behavior.
Report any fever, rashes or lymphadenopathy.
Contraindicated in pregnancy.

Ernstmeyer & Christman, 2020

Contact info: info@nursesinternational.org

Nursing Considerations:

In elderly clients, peripheral edema and ataxia tended to increase in incidence with age.
Take fall precautions
This drug should not be abruptly discontinued because of the possibility of increasing seizure frequency.
Monitored for the emergence or worsening of depression, suicidal thoughts or behavior, and/or any unusual changes in mood or behavior
Immediately report any fever, rashes or lymphadenopathy
This drug can cause harm to the fetus of pregnant women.

Gabapentin use in pediatric clients with epilepsy 3 to 12 years of age is associated with the occurrence of central nervous system related adverse events.

The most significant of these can be classified into the following categories: 1) emotional lability (primarily behavioral problems); 2) hostility, including aggressive behaviors; 3) thought disorder, including concentration problems and change in school performance; and 4) hyperkinesia (primarily restlessness and hyperactivity).

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Anticonvulsants: Gabapentin

Client Teaching & Education

Take medication as directed, careful to not exceed dosage recommendations.
Do not take gabapentin within 2 hours of antacid medications.
Increased drowsiness and dizziness.
Monitor for suicidality.
Do not drive or operate other complex machinery until sufficient experience on gabapentin.
Possible side effects and when to seek medical help.

Ernstmeyer & Christman, 2020

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Critical Thinking Question

A 21-year-old client with bipolar disorder has not responded well to lithium (Escalith) therapy for mood stabilization. What medication does the nurse expect the provider to order next?

Hydroxyzine pamoate (vistaril)
Fluoxetine (Prozac)
Divalproex (Depakote)
Olanzapine (Zyprexa)

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Antiparkinson Drugs: Carbidopa/Levodopa

Most common drug to treat Parkinson’s disease. Started as soon as the client becomes functionally impaired.

Mechanism of Action: Crosses the blood brain barrier, assumed to be converted to dopamine in the brain.

Indications for Use: Parkinson’s disease and restless leg syndrome.

Adverese Effects: Depression, suicidal ideation, hallucinations, and intense urges, somnolence and fatigue, dyskinesia, discolored body fluids, hypomobility.

Ernstmeyer & Christman, 2020

Contact info: info@nursesinternational.org

Carbidopa/Levodopa

Most common drug used to treat Parkinson’s disease.
Usually started as soon as the client becomes functionally impaired.

Mechanism of Action: Crosses the blood brain barrier and converted to dopamine in the brain

Administration of dopamine is ineffective in the treatment of Parkinson’s disease because it does not cross the blood-brain barrier, but levodopa, the metabolic precursor of dopamine, does cross the blood-brain barrier and presumably is converted to dopamine in the brain. Carbidopa is combined with levodopa to help stop the breakdown of levodopa before it is able to cross the blood-brain barrier. Additionally, the incidence of levodopa-induced nausea and vomiting is less when it is combined with carbidopa.

Indications for Use: Carbidopa/levodopa is indicated for Parkinson’s disease. It is also used to treat restless leg syndrome.

Adverse/Side Effects:

Hallucinations and psychotic-like behavior
Intense gambling urges, increased sexual urges, intense urges to spend money, binge eating, and/or other intense urges, and the inability to control these urges, risk for developing melanoma
Occasionally, dark red, brown, or black color may appear in saliva, urine, or sweat after ingestion of carbidopa and levodopa. Garments may get discolored.

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Carbidopa: Nursing Considerations

Avoid high-protein diets-decreases absorption.
Monitor for sudden somnolence, increased depression and suicidal tendencies.
Contraindicated with MAOs.
Periodically monitor hepatic, renal, and hematopoietic functions.
Prescribed for clients above 18 years.
Warn client to avoid activities that need attention like driving or operating machines.
Discontinuation of this medication may cause neuroleptic malignant syndrome (NMS).

Ernstmeyer & Christman, 2020

Contact info: info@nursesinternational.org

Nursing Considerations:

Carbidopa/Levodopa is recommended for use in clients older than age 18.
It can take several weeks to see positive effects and this should be explained to clients and their caregivers.
The drug is contraindicated for use with MAOIs.
Observed carefully for the development of depression with concomitant suicidal tendencies
Clients taking carbidopa and levodopa have reported suddenly falling asleep without prior warning of sleepiness while engaged in activities of daily living (including operation of motor vehicles). Clients should be advised to exercise caution while driving or operating machines during treatment with carbidopa and levodopa.
Sporadic cases of symptoms resembling neuroleptic malignant syndrome (NMS) have been reported in association with dose reductions or withdrawal of certain antiparkinsonian agents. Therefore, clients should be observed carefully when the dosage of levodopa is reduced abruptly or discontinued.
Clients should be instructed to plan their meal times around medication times to improve the ability to use their utensils and to avoid diets high in protein due to decreased absorption of the medication.

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Antiparkinson Drugs: Carbidopa/Levodopa

Client Teaching & Education

Take medication at regular intervals as directed.
In event of gastric irritation eat food shortly after taking medication.
High-protein foods may impair drug action.
Medications may cause increased drowsiness, dizziness, and orthostatic changes.
Carefully assess skin to monitor for lesions
Any abnormality should be reported to the healthcare provider.

Ernstmeyer & Christman, 2020

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Antiparkinson Drugs: Selegiline

Often used conjunction with carbidopa.

Mechanism of action: Inhibits MAO-B, blocks the breakdown of dopamine.

Indications: Management of Parkinson's and major depressive disorder.

Adverse effects: Dose dependent, hypertensive crisis with tyramine.

Ernstmeyer & Christman, 2020

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Antiparkinson Drugs

Nursing Considerations

If on a large dose(above 10mg /day) , avoid food containing tyramine as may cause hypertensive crisis.
Advise clients to avoid foods high in tyramine.
Advise client that this medication may cause drowsiness, dizziness, and orthostatic changes.
Report any kind of abnormal behaviors like sexual urges, hallunications, gambling immediately.

Ernstmeyer & Christman, 2020

Contact info: info@nursesinternational.org

Nursing Considerations:

Large doses of selegiline may inhibit MAO-A that promotes metabolism of tyramine in the GI tract, which can cause a hypertensive crisis.

Client Teaching & Education

Clients should be advised to avoid foods high in tyramine. Additionally, medications may cause increased drowsiness, dizziness, and orthostatic changes. If clients experience abnormal behaviors such as hallucination, sexual urges, gambling, etc., this should be reported promptly to the healthcare provider.

Foods that are high in Tyramine include (MayoClinic, 2018):

Strong or aged cheeses, such as aged cheddar, Swiss and Parmesan; blue cheeses such as Stilton and Gorgonzola; and Camembert. Cheeses made from pasteurized milk are less likely to contain high levels of tyramine — for example, American cheese, cottage cheese, ricotta, farmer cheese and cream cheese.
Cured meats, which are meats treated with salt and nitrate or nitrite, such as dry-type summer sausages, pepperoni and salami.
Smoked or processed meats, such as hot dogs, bologna, bacon, corned beef or smoked fish.
Pickled or fermented foods, such as sauerkraut, kimchi, caviar, tofu or pickles.
Sauces, such as soy sauce, shrimp sauce, fish sauce, miso and teriyaki sauce.
Soybeans and soybean products.
Snow peas, broad beans (fava beans) and their pods.
Dried or overripe fruits, such as raisins or prunes, or overripe bananas or avocados.
Meat tenderizers or meat prepared with tenderizers.
Yeast-extract spreads, such as Marmite, brewer's yeast or sourdough bread.
Alcoholic beverages, such as beer — especially tap or homebrewed beer — red wine, sherry and liqueurs.
Improperly stored foods or spoiled foods. With MAOI prescription, doctor may recommend eating only fresh foods — not leftovers or foods past their freshness dates.

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Antiparkinson Drugs: Amantadine

Mechanism of action: Unknown

Indications: Used for Parkinson’s disease, medication-induced extrapyramidal symptoms and influenza A.

Adverse effects: Increased suicidal ideation and urges, congestive heart failure and peripheral edema, neuromalignant syndrome (NMS) when dosage decreased, orthostatic hypotension, nausea, dizziness, insomnia, anticholinergic side effects.

Ernstmeyer & Christman, 2020

Contact info: info@nursesinternational.org

Amantadine

Mechanism of Action:The exact mechanism of action is unknown. Amantadine is an antiviral drug that acts on dopamine receptors.

Indications for Use: Amantadine is used for Parkinson’s disease, medication-induced extrapyramidal symptoms, and influenza A.

Adverse/Side Effects:

Suicide ideation, congestive heart failure, and peripheral edema can occur. This drug can cause intense gambling urges, increased sexual urges, intense urges to spend money uncontrollably, and other intense urges with an inability to control them. There is an increased risk of melanoma.

Adverse reactions reported most frequently are nausea, dizziness (lightheadedness), and insomnia. This drug can also cause anticholinergic side effects, impaired thinking, and orthostatic hypotension.

Anticholinergic side effects symptoms: According to Lieberman (2004) the typical symptoms of anticholinergic side effects are: dry mouth, constipation, urinary retention, bowel obstruction, dilated pupils, blurred vision, increased heart rate, and decreased sweating, impaired concentration, confusion, attention deficit, and memory impairment

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Antiparkinson Drugs: Amantadine

Nursing Considerations

Use cautiously with renal impairment.

Be aware of suicidal ideation and parkinsionian crisis with abrupt discontinuation
Monitor blood pressure
Monitor mental state and renal functioning
Neuroleptic Malignant Syndrome (NMS) has been reported in association with dose reduction or withdrawal of amantadine therapy.

Ernstmeyer & Christman, 2020

Contact info: info@nursesinternational.org

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Antiparkinson Drugs: Amantadine

Client Teaching & Education

Take medications as directed (not skip or double doses).
Side effects: i.e. drowsiness, dizziness, and orthostatic blood pressure changes.
Avoid all alcohol beverages and OTC cold medication with this medication.
Educate clients, family, or caregivers to monitor changes.
Report any worsening depression or suicidality.

Ernstmeyer & Christman, 2020

Contact info: info@nursesinternational.org

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Critical Thinking Question

A client who is taking Levodopa verbalized that he is having flu like symptoms and says that Benadryl will probably make him feel better.

What would the nurse suggest to this client?

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Suicidal Behaviors: Warning Signs

Talking about:

Wanting to die or to kill oneself
Feeling hopeless or having no reason to live
Feeling trapped
Being in unbearable pain
Being a burden to others

Looking for a way to kill oneself (making a plan).
Increasing the use of substance; alcohol or drugs.
Acting anxious or agitated, behaving recklessly.

Mental Health. gov, 2018

Image by: Max Pixel

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Suicidal Behaviors: Warning Signs (continued)

Extreme mood swings
Sleeping too little or too much
Withdrawing or feeling isolated
Being sad, moody or sudden calmness
Showing rage or talking about seeking revenge

Mental Health. gov, 2018

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General Nursing Considerations

on Medication Administration

Ensure the client knows about the medication being prescribed.
Identifying patients with swallowing difficulties; Oral medication usage may also be complicated in patients with neurological and/or psychological conditions, such as: dementia, severe mental illness.
Client with Dysphagia: Consider modified diets, bioavailability and pharmacokinetics.
Stay with patient until all medications are swallowed

Ask the client to open their mouth
Ask them to drink a small glass of water

Contact info: info@nursesinternational.org

Dysphagia is common—not only associated with stroke, dementia, Parkinson’s but also in many non-neurological medical problems—and is increasingly prevalent in ageing patients, where malnutrition is common and pneumonia is frequently the main cause of death.

When a person has significant dysphagia, modified diets (food and liquids) may be recommended prescribed by the speech and language therapist; many clinical staff give no thought as to the effect that this may have on the bioavailability and pharmacokinetics of orally taken medication. Where medications are to be continued, there is often no structured medication review undertaken with a pharmacist. The lack of consideration regarding how medicines are to be given to people with dysphagia by the prescriber (usually a doctor) creates significant difficulties for those who are expected to administer them (usually nursing staff). UK guidelines for management of medicines in patients with dysphagia recommend that, at the point of diagnosis, the presence of dysphagia should be assessed for, and medicines should be reviewed for ongoing suitability for the oral route and for those which are still required the formulation should be considered.

The act of crushing or dispersing medicines can be a safe alternative providing the medicine is not formulated such that drug release is modified. Slow release medicines frequently contain more than one ‘usual’ dose of the drug and consequently releasing this all at once can result in overdose and has resulted in reformulation of modified release products such as Oxycodone to reduce overdose associated deaths. Similarly, if a medicine has a coating to either protect it from the stomach’s acidic environment, protect the gastrointestinal tract from the medicine itself or to deliver the medicine further down the gastro-intestinal tract, then any disruption of this can potentially harm the patient.

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General Nursing Considerations

on Medication Administration

Dementia and delirium: If the patient finds it easier to take their medication with food, advise them, or their carers to check that the food does not interact with the medication.

Respect the client’s personal preference against taking certain medications.

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Red Flags

There is no specific antidote for lithium toxicity/poisoning, therefore treatment focuses on the elimination of the medication.

Dysphagia is common—not only associated with stroke, dementia, Parkinson’s but also in many non-neurological medical problems—and is increasingly prevalent in aging clients, where malnutrition is common and pneumonia is frequently the main cause of death.

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References:

Choudhary, S., McLeod, M., Torchia, D., & Romanelli, P. (2013). Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) Syndrome. The Journal of clinical and aesthetic dermatology, 6(6), 31–37.

Doyle. G. R., McCutcheon. J. A. (2015). Clinical Procedures for Safer Patient Care. Victoria, BC: BCcampus. Retrieved on 29th of December 2020 from https://opentextbc.ca/clinicalskills/

Ernstmeyer, K. and Christman, E. (Eds.). (2020). Open RN Nursing Pharmacology by Chippewa Valley Technical College licensed under CC BY 4.0.

Lieberman J. A., 3rd (2004). Managing anticholinergic side effects. Primary care companion to the Journal of clinical psychiatry, 6(Suppl 2), 20–23.

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References:

MayoClinic. (2018). MAOIs and Diet: Is it necessary to restrict Tyramine?. https://www.mayoclinic.org/diseases-conditions/depression/expert-answers/maois/faq-20058035

Mental Health.gov. (2018). What to Look for: Suicidal Behavior. https://www.mentalhealth.gov/what-to-look-for/suicidal-behavior

Wright, D. J., Smithard, D. G., & Griffith, R. (2020). Optimising Medicines Administration for Patients with Dysphagia in Hospital: Medical or Nursing Responsibility?. Geriatrics (Basel,Switzerland), 5(1), 9. https://doi.org/10.3390/geriatrics5010009

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