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First Generation

D2 Antagonism. Effective against positive symptoms of schizphrenia.

Second Generation

D2/5-HT2a antagonism. Effective against positive and negative symptoms.
Drug specific side effects: metabolic (weight gain, glucose dysregulation, dyslipidemia), cardiac, sedation, EPS/hyperprolactinemia
Also known as Atypical antipsychotics. Are used for first line treatment (except for Clozaril)

First generation side effects

extrapyramidal symptoms, tardive dyskinesia, sedation and weight gain, orthostatic hypotension and tachycardia, dry mouth,constipation, blurred vision, hyperprolactinemia

Akathesia Symptoms

restlessness, jumping out of skin, uncomfortable, may be miss diagnosed as anxiety symptoms

Akathesia Nursing implications

reduce dose of antipsychotic and treat with a beta blocker (propanolol)

Parkinsonism Onset and etiology

Onset: later in treatment
Etiology: Blockade of D2 eceptor in basal ganglia

Parkinsonism Symptoms and Nursing implications

Symptoms re identical to symptoms of Parkinson's
Intervention: treat with anticholinergic medication.
Can increase confusion and psychosis

Nursing interventions for EPS

Diphenhydramine hydrochloride (Benadryl), Bromocriptine Mesylate (Parlodel), Benztropine mesylate (Congentin), Trihexyphenidyl (Artane)

Dystonia Onset, etiology and risk factors

Onset: 1st week of treatment
Etiology: imbalance of DA and ACH, more ACH
Risk factors: young men more vulnerable

Dystonia Symptoms

Oculogyric crisis (rotating eyeballs), torticollis (twisted neck), retrocollis, facial grimacing and laryngeal spasms

Dystonia Nursing intervention

Immediate administration of Benadryl 25-50 mg IM

Tardive Dyskinesia Symptoms

Onset: 6-8 months after initiation of antipsychotics
Initial stages are in facial-buccal area (lip smacking, sucking etc)
Later stages: impairment of involuntary movement, constant motion, movements in trunk, rocking

Tardive Dyskinesia Nursing Implications

IRREVERSIBLE, no treatment. See primarily with typical antipsychotics. Would d/c antipsychotic and switch to a newer atypical or Clozapine. Use AIMS to screen

Risk Factors for Tardive Dyskinesia

Older adult, women, African American, Psychiatric diagnosis, cognitive deficits, chemical abuse, extrapyramidal symptoms, brain damage, diabetes mellitus, history of mood disorders, treatment inconsistencies, early onset of EPSs. Higher rates in 1st generation antipsychotics

Second Generation Antipsychotics mechanism of action

Block dopamine and serotonin
Are newer and more efficacious and safer

Risperidone (Risperdal, M-Tabs and Consta)

second generation atypical.
Side effects: hypotension, insomnia, sedation, Rare TD or NMS, sexual dysfunction, weight gain, moderate lipid abnormalities

Olanzapine (Zyprexa)

Second generation atypical.
Side effects: Significant weight gain, high lipid abnormalities, drowsiness, agitation and restlessness, insomnia, possibly akathisia or parkinsonism

Quetiapine (seroquel)

second generation atypical
Side effects: weight gain, moderate lipid abnormalities, headache, drowsiness, orthostasis

Ziprasidone (Geodone)

Second generation atypical
Side effects: ECG changes, QT prolongation, low propensity for weight gain, targets depressive symptoms

Aripiprazole (Abilify)

Second generation atypical.
Side effects: Little or no weight gain or increase in glucose, HDL, LDL or triglyceride levels

Monitoring and administering second generation

takes 1-2 weeks to start working, will be some improvement immediately . Adequate trial is 6-12 weeks. Adherence to the prescribed medication is the best prevention of relapse

Second generation efficacy

Reduction of positive and negative symptoms, some improvement of cognition, broad range of efficacy

Side effects of second generation

Low rates of EPS and TD. Few anticholinergic effects. Pronounced weight gain (half of patients will have 20% increase), type II diabetes, QT prolongation

Risk factors for type II DIabetes

Obesity, >45 years of age, African American, hispanic, asian, south asian, native american, pacific islander, gestational diabetes, hypertension, dyslipidemia, impaired fasting glucose or glucose tolerance

Novel/ atypical Antipsychotics

Clozapine (Clozaril)

Efficacy of novel antipsychotics

reduction of positive and negative symptoms. Improvements for patients considered treatment-refractory. Decreased suicidal behavior

Side effects of Atypical antipsychotics

Low EPS, TD. Risk of agranulocytosis. Risk of significant orthostatic hypotension. Risk of respiratory/cardiac arrest. Moderate to high weight gain. Potential for seizures. Anticholinergic adverse effects

Agranulocytosis Symptoms

Onset: 4-10 weeks on medication.
Symptoms: sore throat, fever, malaise.
Lab values: Neutrophil count <500/mm, WBC =2,000-3,000/mm

Agranulocytosis Nursing interventions

Hold medication, reverse isolation, carefully monitor CBC's. Is often misdiagnosed as the flu.

Neuroleptic Malignant Syndrome Symptoms

severe muscle rigidity, elevated temperature. Change in level of consciousness, leukocytosis, elevated creatinine phosphokinaase, elevated liver enzymes or myoglobinuria

Neuroleptic Malignant syndrome Nursing interventions

Stop administration of drug, take vital signs, reduce body temperature, safety, protect muscles, IV fluids, cardiac monitoring, Dantrolene

Anticholinergic Crisis

potentially life threatening, anticholinergic delirium

Anticholinergic crisis Risk factors

Can occur in patients who are taking several medications with anticholinergic effects

Anticholinergic Crisis Symptoms

Confusion, hallucinations, dilated pupils, blurred vision, facial flushing,dry mucous membranes, difficulty swallowing, fever, tachycardia, hypertension, decreased bowel sounds, urinary retention, nausea, vomiting, seizures, coma

HOT as a hare, BLINd as a bat, MAD as a hatter, DRY as a bone

Anticholinergic crisis nursing implications

discontinue medication. Gastric lavage. Charcoal, catharsis. Physiostigmine 1-2 mg IV (an inhibitor of cholinesterase, improves in 24-36 hours)

Clozapine (Clozaril)

Not first line, for refractory cases only. Side effects: Agranulocytosis, high seizure rate, significant weight gain, high lipid abnormalities, excessive salivation, tachycardia

Haloperidol (Haldol)

High potency. First generation. Low sedative properties. Used in large doses for assaultive patients
Less chance of falls from dizziness or hypotension
High incidence of extrapyramidal effects

Trifluoperazine (Stelazine)

High potency. First generation. Low sedative effect. Good for symptoms of withdrawal or paranoia. high incidence of extrapyramidal side effects. Neuroleptic malignant syndrome may occur

Fluphenazine (Prolixin)

High potency. First generation. least sedating. Effective when given every 2-4 weeks

Thiothixene (Navane)

High potency. First generation. High incidence of akathisia

Loxapine (Loxitane)

Medium potency. First generation. Possibly associated with weight reduction

Molindone 9Moban)

Medium potency. First generation. Possibly associated with weight reduction

Perphenazine (Trilafon)

Medium Potency. First generation. Can help control severe vomiting

Chlorpromazine (Thorazine)

Low Potency. First generation. Increases sensitivity to sun. Highest sedative and hypotensive effects. May cause irreversible retinitis pigmentosa

Chloroprothixene (Taractan)

Low potency. First generation. Weight gain is common

Thioridazine (Mellaril)

Low potency. First generation. NOT Recommended as frst-line antipsychotic. Dose-related severe ECG changes, may cause sudden death

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