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32
Antipsychotic Drugs
294
CHAPTER 32 Antipsychotic Drugs 295
chlorpromazine HCL Thorazine, generic Psychotic disorders, Hypotension, postural Psychiatric disorders: up
klor-proe-ma-zeen nausea, vomiting, hypotension, tardive to 2000 mg/d PO in
intractable hiccups dyskinesia, photophobia, divided doses, 25 IM;
urticaria, nasal nausea and vomiting:
congestion, dry mouth, 1025 mg PO, 2550
akathisia, dystonia, mg IM, 50100 rectal;
pseudoparkinsonism, hiccups: 2550 mg PO,
behavioral changes, IM, IV TIDQID
headache,
photosensitivity
clozapine Clozaril, generic Severely ill schizophrenic Drowsiness, sedation, Up to 900 mg/d PO in
kloe-za-peen patients with no akathisia, seizures, divided doses
response to other dizziness, syncope,
therapies tachycardia, hypotension,
nausea, vomiting
fluphenazine HCL Permitil, Prolixin, Psychotic disorders Drowsiness, 0.510 mg/PO in divided
floo-fen-a-zeen generic extrapyramidal effects, doses up to 20 mg/d;
dystonia, akathisia, 2.510 mg/d IM in
hypotension divided doses
haloperidol Haldol Psychotic disorders; Extrapyramidal symptoms, 0.55 mg PO BID, TID
ha-loe-per-i-dole Tourettes syndrome, akathisia, dystonia, tardive with dosages up to
behavior problems in dyskinesia, drowsiness, 100 mg/d in divided
children headache, dry mouth, doses; 25 mg IM;
orthostatic hypotension children 0.050.075 mg/
kg/d PO
lithium Eskalith, Lithobid, Manic episodes of bipolar Headache, drowsiness, Based on lithium serum
lith-ee-um Lithonate, generic disorder tremors, nausea, polyuria levels; average dose
(see Table 32-1) range is 9001800 mg/d
PO in divided doses
loxapine Loxitane Psychotic disorders Extrapyramidal symptoms, 60250 mg/d PO in
lox-a-peen akathisia, dystonia, divided doses;
tardive dyskinesia, 12.550 mg IM
drowsiness, headache,
dry mouth, orthostatic
hypotension
olanzapine Zyprexa Schizophrenia, short-term Agitation, dizziness, 520 mg/d PO
oh-lan-za-peen treatment of manic nervousness, akathisia,
episodes of bipolar constipation, fever,
disorder weight gain
perphenazine Trilafon, generic Psychotic disorders Hypotension, postural Psychotic disorders:
per-fen-a-zeen hypotension, tardive 416 mg PO BID to
dyskinesia, photophobia, QID, 510 mg IM
urticaria, nasal
congestion, dry mouth,
akathisia, dystonia,
pseudoparkinsonism,
behavioral changes,
headache,
photosensitivity
pimozide Orap Tourettes syndrome Parkinson-like symptoms, Initial dose: 12 mg/d
pi-moe-zide motor restlessness, PO; maintenance dose:
dystonia, oculogyric up to 10 mg/d PO
crisis, tardive dyskinesia,
dry mouth, diarrhea,
headache, rash,
drowsiness
(continued)
296 UNIT IV Drugs That Affect the Neuromuscular System
*The term generic indicates that the drug is available in generic form.
decrease in dosage may eliminate some of these symp- total cumulative dosage administered increase. It is best
toms, but it also may be necessary to try another drug. to use the smallest dose and the shortest duration of
treatment that produces a satisfactory clinical response.
The highest incidence of TD is found in patients receiv-
Extrapyramidal Effects ing an antiparkinson drug for extrapyramidal effects
Among the most significant adverse reactions associated along with an antipsychotic drug. Although any patient
with the antipsychotic drugs are the extrapyramidal taking an antipsychotic can experience TD, elderly
effects. The term extrapyramidal effects refers to a women are at highest risk.
group of adverse reactions occurring on the extrapyrami-
dal portion of the nervous system as a result of antipsy-
Neuroleptic Malignant Syndrome
chotic drugs. This part of the nervous system affects body
posture and promotes smooth and uninterrupted move- Neuroleptic malignant syndrome (NMS) is a rare
ment of various muscle groups. Antipsychotics disturb reaction characterized by a combination of extrapyrami-
the function of the extrapyramidal portion of the nervous dal effects, hyperthermia, and autonomic disturbance. It
system, causing abnormal muscle movement. Extrapyra- may occur hours to months after the antipsychotic drug
midal effects include Parkinson-like symptoms (see regimen is begun. Once NMS begins, it progresses rap-
Chap. 29), akathisia, and dystonia (see Display 32-1). idly during the next 24 to 72 hours. The syndrome most
Extrapyramidal effects usually diminish with a often occurs in patients taking haloperidol, but has
reduction in the dosage of the antipsychotic drug. The occurred with administration of thiothixene, thiori-
primary health care provider may also prescribe an dazine, and clozapine. NMS is potentially fatal and
antiparkinsonism drug, such as benztropine (see requires intensive symptomatic treatment and immedi-
Chap. 29) to reduce the incidence of Parkinson-like ate discontinuation of use of the causative drug.
symptoms.
Lithium
Tardive Dyskinesia Lithium carbonate is rapidly absorbed after oral admin-
Tardive dyskinesia (TD) is a syndrome consisting of istration. The most common adverse reactions include
potentially irreversible, involuntary dyskinetic move- tremors, nausea, vomiting, thirst, and polyuria. Toxic
ments. TD is characterized by rhythmic, involuntary reactions may be seen when serum lithium levels are
movements of the tongue, face, mouth, or jaw and some- greater than 1.5 mEq/L (Table 32-1). Because some of
times the extremities (see Fig. 32-1). The tongue may these toxic reactions are potentially serious, lithium
protrude, and there may be chewing movements, puck- blood levels are usually obtained during therapy, and the
ering of the mouth, and facial grimacing. TD may be dosage of lithium is adjusted according to the results.
observed in patients receiving an antipsychotic drug or
after discontinuation of antipsychotic drug therapy.
When symptoms of TD occur during the course of ther-
apy, use of the drug must be discontinued. Depending TABLE 32-1 Lithium Toxicity
on the severity of the condition being treated, the pri-
mary health care provider may slowly taper the drug LITHIUM LEVEL SIGNS OF TOXICITY
dose because abrupt discontinuation may result in a
1.52 mEq/L Diarrhea, vomiting, nausea, drowsiness,
return of the psychotic symptoms. There is no known muscular weakness, lack of
treatment of TD, although partial or complete remission coordination (early signs of toxicity)
may occur if the antipsychotic drugs are withdrawn. 23 mEq/L Giddiness, ataxia, blurred vision, tinnitus,
The risk of TD and the likelihood that it will become vertigo, increasing confusion, slurred
irreversible increase as the duration of treatment and speech, blackouts, myoclonic twitching
or movement of entire limbs,
choreoathetoid movements, urinary or
fecal incontinence, agitation or
manic-like behavior, hyperreflexia,
DISPLAY 32-1 Extrapyramidal Effects hypertonia, dysarthria
3 mEq/L May produce a complex clinical picture
Parkinson-like symptomsfine tremors, muscle rigidity, mask-like involving multiple organs and organ
appearance of the face, slowness of movement, slurred speech, and systems, including seizures (generalized
unsteady gait and focal), arrhythmias, hypotension,
Akathisiaextreme restlessness and increased motor activity peripheral vascular collapse, stupor,
Dystoniafacial grimacing and twisting of the neck into unnatural muscle group twitching, spasticity,
positions coma
298 UNIT IV Drugs That Affect the Neuromuscular System
Rated By
0 1 2 3 4
0 1 2 3 4 Ask patient to protrude tongue. (Observe abnormalities
of tongue movement.) Do this twice.
Ask patient to tap thumb, with each finger as rapidly as
possible for 1015 seconds; separately with right hand, then
with left hand. (Observe facial and leg movements.)
0 1 2 3 4
0 1 2 3 4
Ask patient to extend both arms outstretched in front with
Flex and extend patient's left and right arms. (One at a time.) palms down. (Observe trunk, legs, and mouth.)
0 1 2 3 4
0 1 2 3 4
Ask patient to stand up. (Observe in profile. Observe all body
areas again, hips included.) Have patient walk a few paces, turn, and walk back to chair.
*Activated movements. (Observe hands and gait.) Do this twice.
FIGURE 32-1. A simple method to determine tardive dyskinesia symptoms: Abnormal Involuntary Scale*
examination procedure. (From Clayton & Stock [1997]. Basic pharmacology for nurses 11th ed., p. 580, St Louis:
Mosby.)
Gerontologic Alert
In elderly or debilitated patients, doses may be instituted at 12
each visit of the patient to the primary health care
providers office or clinic, the nurse observes the patient
for a response to therapy. In some instances, the nurse
to 13 the recommended dose for younger adults and increased
more gradually than dose increases in younger adults.
may question the patient or a family member about the
response to therapy. The questions asked depend on the
patient and the diagnosis and may include questions
such as
Oral administration requires great care because some
patients have difficulty swallowing (because of a dry How are you feeling?
mouth or other causes). Other patients may refuse to Do you seem to be less nervous?
take the drug. The nurse should never force a patient to Would you like to tell me how everything is going?
CHAPTER 32 Antipsychotic Drugs 301
Many times the nurse may need to rephrase questions with eating, dressing, and ambulating. However, the
or direct conversation toward other subjects until these nurse must protect extremely hyperactive patients from
patients feel comfortable and are able to discuss their injury to themselves or others.
therapy.
The nurse asks the patient or a family member about
adverse drug reactions or any other problems occurring
during therapy. The nurse brings these reactions or Nursing Alert
The antipsychotic drugs may cause extreme drowsiness and
problems to the attention of the primary health care
sedation, especially during the first or second weeks of therapy.
provider. The nurse should document in the patients This reaction may impair mental of physical abilities.
record a general summary of the patients outward Drowsiness usually diminishes after 23 weeks of therapy.
behavior and any complaints or problems. The nurse However, if the patient continues to be troubled by drowsiness
then compares these notations to previous notations and sedation, the physician may prescribe a lower dosage.
and observations.
2. As a nurse on the psychiatric unit, you are assigned to 4. In giving discharge instructions to a patient taking
discuss extrapyramidal effects at a team conference. lithium the nurse stresses that the patient should
Discuss how you would present and explain this topic. .
Describe the points you would stress. A. eat a diet high in carbohydrates and low in pro-
3. Your patient is prescribed clozapine for schizophrenia teins
that has not responded to other drugs. You must discuss B. increase oral fluid intake to approximately 3000
this new therapy with the family. Discuss what points mL/day
to include in this family teaching session. C. have blood drawn before each dose of lithium is
administered
D. avoid eating foods high in amines
Review Questions