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DRUGS ACTION SIDE EFFECT CONTRAINDICATION INDICATION CONSIDERATION

Olanzapine ( zyprexa)

AntipsychoticDopaminergic blocker5-10mgBID

RISPERIDONEThe exact mechanism of actionof risperidone is not known, but,like other anti-psychotics, it isbelieved that risperidone affectsthe way the brain works by

blocks dopamine receptors in thebrain, depresses the RAS;blocks serotonin receptorsites; anticholinergic,antihistaminic (H1), and alpha-adrenergic blocking activity maycontribute to some of itstherapeutic (and adverse)actions; producesfewer extrapyramidal effects thanmostantipsychotics

. Risperidone blocks several ofthe receptors on nerves includingdopamine type 2, serotonin type2, and alpha 2 adrenergicreceptors. It is believed that

Drowsiness, dizziness,lightheadedness, stomach upset,dry mouth, constipation,increased appetite, or weight gain

The most commonly-noted sideeffects associated withrisperidone areinsomnia,headache, dizziness,hyperactivity,drowsiness,

INDICATION

>Acute mixed ormanicepisodesassociatedwith bipolar1disorder andmaintenanceof bipolar1disorder asmonotherapyor combinedwithlithiumor valproate

>Agitationassociatedwithschizophreniaandbipolar 1maniaCONTRAINDICATIONContraindicated with allergytoolanzapine,myeloproliferativedisorders,severe CNSdepression,comatosestates,and lactation

LACK BOX WARNING:Monitor

lderly patients for dehydration and

stitute remedial measures promptly;

edation and decreased sensation of

irst related to CNS effects of drug can

ad to dehydration.

ncourage patient to void before taking

e drug to help

ecrease anticholinergic effects of

rinary retention.

onitor for elevations of temperature

nd differentiate between infection

nd neuroleptic malignant syndrome.

onitor for orthostatic hypotension and

rovide appropriate safety measures as

eeded.

Inspect I.M.solutionfor particulate matter anddiscoloration beforeadministration

Encourage patientto void beforetakingthe drug tohelpdecreaseanticholinergiceffects ofurinaryretention

Monitor for elevations of temperatureanddifferentiate betweeninfectionandneurolepticmalignantsyndrome

Maintain seizure

precautions, especially when

initiating therapy and increasing

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interfering with communicationamong the brain's nerves.Nerves communicate with eachother by making and releasingchemicals calledneurotransmitters. Theneurotransmitters travel to other

nearby nerves where theyattach to receptors on thenerves. The attachment of theneurotransmitters eitherstimulates or inhibits thefunction of the nearby nerves

ARIPIRAZOLE

many psychotic illnesses arecaused by abnormalcommunication among nerves inthe brain and that by alteringcommunication throughneurotransmitters.

Mechanism of Action:Thought to exert partial agonistactivity at D2 and serotonin 1Areceptors and antagonist activity

at serotonin 2A receptors.

abdominal pain,fatigue,fever,andnausea.Extrapyramidaleffects (sudden, often jerky,involuntary motions of the head,neck, arms, body, or eyes) alsooccur. Risperidone may cause acondition calledorthostatic

hypotensionduring the earlyphase of treatment (the first weekor two). Patients who developorthostatic hypotension have adrop in their blood pressure whenthey rise from a lying position andmay become dizzy or even loseconsciousness

anxiety, insomnia, light-headedness, somnolence,akathisia, tremor, asthenia,depression, nervousness,

hostility, suicidal thoughts,headache, manic behavior,confusion, abnormal gait,cogwheel rigidity, seizures, fever,tardive dyskinesia, neurolepticmalignant syndrome, increasedsuicide risk.increased salivation,conjunctivitis, ear pain.urinaryincontinence.Meabolic: weightgain, weight loss,hyperglycemia.Musculoskeletal:neck pain, neck stiffness, :dyspnea,

Contraindicated in patients

hypersensitive to aripiprazole.

Use cautiously in patients with

CV disease, cerebrovascular

disease, or conditions that could

predispose the patient to

hypotension, such as

dehydration or hypovolemia.

Use cautiously in patients with

history of seizures or with

conditions that lower the seizure

dosage.

Mix oral solution with 34

oz of water, coffee, orange juice,

or low-fat milk. Do notmix with

cola or tea.

Monitor T. If fever occurs,

rule out underlying infection, and

consult physician for appropriate

comfort measures.

Advise patient to use

contraception during drug

therapy.

Follow guidelines for

discontinuation or reinstitution of

the drug c

Nursing considerations:

Alert: Neuroleptic malignant

syndrome may occur with

aripiprazole use. Monitor

patient for hyperpyrexia,

muscle rigidity, altered

mental status, irregular pulse

or blood pressure,

tachycardia, diaphoresis, and

cardiac dysrhythmias.

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threshold.

Use cautiously in patients who

engage in strenuous exercise,

are exposed to extreme heat,

take anticholinergic medications,

or are susceptible to dehydration.

Use cautiously in patients at risk

for aspiration pneumonia, such

as those with Alzheimer's

disease.

Use cautiously in pregnant and

breast-feeding patients.

If signs and symptoms of

neuroleptic malignant

syndrome occur, immediately

stop drug and notify

prescriber.

Monitor patient for signs and

symptoms of tardive

dyskinesia. The elderly,

especially elderly women,

are at highest risk of

developing this adverse

effect.

Alert:Hyperglycemia may

occur. Monitor patient with

diabetes regularly. Patient

with risk factors for diabetes

should undergo fasting blood

glucose testing at baseline

and periodically. Monitor all

patients for symptoms of

hyperglycemia including

increased hunger, thirst,

frequent urination, andweakness. Hyperglycemia

may resolve when patient

stops taking drug.

Treat patient with the

smallest dose for the

shortest time and periodically

reevaluated for continued

treatment.

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Give prescriptions only for

small quantities of drug, to

reduce risk of overdose.

Substitute the oral solution

on a milligram-by-milligram

basis for the 5-, 10-, 15-, or

20-mg tablets, up to 25 mg.

Give patients taking 30 mg

tablets 25 mg of solution.

Patient teaching:

Tell patient to use caution

while driving or operating

hazardous machinery

because psychoactive drugs

may impair judgment,

thinking, or motor skills.

Tell patient that drug may be

taken without regard to

meals.

Advise patients that

grapefruit juice may interact

with aripiprazole and to limit

or avoid its use.

Advise patient that gradual

improvement in symptoms

should occur over several

weeks rather than

immediately.

Tell patients to avoid alcohol

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use while taking drug.

Advise patients to limit

strenuous activity while

taking drug, to avoid

dehydration.

NURSING CONSIDERATIONS: Assess mental status prior toand periodically during therapy. Monitor BP and pulse prior toand frequently during the periodof dosage adjustment. Maycause QT interval changes onECG. Observe patient carefully whenadministering medication, toensure that medication is actuallytaken and not hoarded.

Monitor I&O ratios and dailyeight. Assess patient for signsand symptoms of dehydration. Monitor for development ofneuroleptic malignant syndrome(fever, respiratory distress,tachycardia, seizures,diaphoresis, hypertension orhypotension, pallor, tiredness,severe muscle stiffness, loss ofbladder control. Reportsymptoms immediately. May alsocause leukocytosis, elevated liverfunction tests, elevated CPK. Advise patient to take

medication as directed. Takemissed doses as soon asremembered, witih remainingdoses evenly spaced through outthe day. May require severalweeks to obtain desired effects.Do not increase dose ordiscontinue medication withoutconsulting health careprofessional. Abrupt withdrawalmay cause dizziness, nausea,vomiting, GI upset, trembling, oruncontrolled movements of

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THORAZINE

ACTION:

Block dopamine receptors inthe brain; also alter dopamine

release and turnover.

Prevention of seizures

CS: neuroleptic

alignant syndrome, sedation,

extrapyramidal reactions, tardivedyskinesiaCV: hypotension (increased withIM, IV)EENT: blurred vision, dry eyes,lens opacities GI: constipation, dry mouth,anorexia, hepatitis, ileus GU: urinary retention Hematologic: agranulocytosis,leukopenia Skin: photosensitivity, pigmentchanges, rashes

INDICATION / USES:Acute and chronic psychoses,

particularly when accompanied byincreased psychomotor activity.Nausea and vomiting. Also used in the treatment ofintractable hiccups.

CONTRA-INDICATIONS:

Hypersensitivity.Cross-sensitivity may exist amongphenothiazines. Should not be usedin narrow-angle glaucoma.Should not be used in patients whohave CNS depression.

mouth, tongue or jaw.

Nursing Implications

Assessment & Drug Effects

Establish baseline BP(in standing andrecumbent positions),and pulse, beforeinitiating treatment.

Monitor BP frequently.Hypotensive reactions,dizziness, and sedationare common duringearly therapy,particularly in patients

on high doses and inthe older adultreceiving parenteraldoses. Patients usuallydevelop tolerance tothese adverse effects;however, lower dosesor longer intervalsbetween doses may berequired.

Lab tests: PeriodicCBC with differential,liver function tests,urinalysis, and bloodglucose.

Monitor cardiac statuswith baseline ECG inpatients withpreexistingcardiovasculardisease.

Be alert for signs ofneuroleptic malignantsyndrome (see

Appendix G). Reportimmediately.

Observe and recordsmoking since it

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increases metabolismof phenothiazines,resulting in shortenedhalf-life and more rapidclearance of drug.Higher dosage insmokers may be

required. Advisepatient to stop or atleast reduce smoking,if possible.

Monitor I&O ratio andpattern: Urinaryretention due to mentaldepression andcompromised renalfunction may occur. Ifserum creatininebecomes elevated,therapy should bediscontinued.

Monitor for antiemeticeffect ofchlorpromazine, whichmay obscure signs ofoverdosage of otherdrugs or other causesof nausea andvomiting.

Be alert to complaintsof diminished visualacuity, reduced nightvision, photophobia,and a perceivedbrownish discolorationof objects. Patient may

be more comfortablewith dark glasses.

Monitor diabetics orprediabetics on long-term, high-dosetherapy for reducedglucose tolerance andloss of diabetescontrol.

Ocular examinations,and EEG (in patients>50 y) arerecommended before

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and periodically duringprolonged therapy.

Patient & Family Education

Take medication asprescribed and keepappointments forfollow-up evaluation ofdosage regimen.Improvement may notbe experienced until 7or 8 wk into therapy.

Do not alter dosingregimen, and do notgive the drug toanother person.

May cause pink to red-brown discoloration ofurine.

Wear protectiveclothing and sunscreenlotion with SPF above12 when outdoors,even on dark days.Photosensitivityassociated withchlorpromazinetherapy is a phototoxicreaction. Severity ofresponse depends onamount of exposureand drug dose.Exposed skin areashave appearance of an

exaggerated sunburn.If reaction occurs,report to physician.

Practice meticulousoral hygiene. Oralcandidiasis occursfrequently in patientsreceivingphenothiazines.

Report extrapyramidalsymptoms that occurmost often in patientson high dosage, the

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pediatric patient withsevere dehydrationand acute infection, theolder adult, andwomen.

Avoid driving a car orundertaking activitiesrequiring precision andmental alertness untildrug response isknown.

Do not abruptly stopthis drug. Abruptwithdrawal of drug ordeliberate doseskipping, especiallyafter prolonged therapywith large doses, cancause onset ofextrapyramidalsymptoms (see

Appendix F) andsevere GIdisturbances. Whendrug is to bediscontinued, dosagemust be tapered offgradually over a periodof several weeks.

Do not breast feedwhile taking this drug.

Nursing Implications

Assessment & Drug Effects

Monitor diabetics forloss of glycemiccontrol.

Reassess need forcontinued treatmentperiodically.

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Withhold the drug and

immediately reportS&S of tardivedyskinesia orneuroleptic malignantsyndrome (see

Appendix F).

Lab tests: Periodicallymonitor liver function,lipid profile, thyroidfunction, bloodglucose, CBC withdifferential.

Monitor ECGperiodically, especiallyin those with knowncardiovasculardisease.

Perform baselinecataract exam whentherapy is started and

at 6 mo intervalsthereafter.

Monitor patients with ahistory of seizures forlowering of the seizurethreshold.

Patient & Family Education

Carefully monitor bloodglucose levels ifdiabetic.

Exercise caution with

potentially dangerousactivities requiringalertness, especiallyduring the first week ofdrug therapy or duringdose increments.

Make position changesslowly, especially whenchanging from lying orsitting to standing toavoid dizziness,palpitations, andfainting.

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Avoid alcohol

consumption andactivities that maycause overheating anddehydration.

Inform physician

immediately if youbecome pregnant.

Do not breast feedwhile taking this drug

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QUETIAPINE ( SEROQUEL)

Antagonizes multipleneurotransmitter receptors in thebrain including serotonin (5-HT1Aand 5-HT2) as well as dopamineD1and D2receptors. Mechanismof action is unknown, however,antipsychotic properties thoughtto be related to antagonizedresponses. Antagonizeshistamine H1receptors resulting

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in possible somnolence, andadrenergic alpha1and alpha2receptors which may lead toorthostatic hypotension

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GEODON

Actions

Unrelated to phenothiazine orbutrophenone antipsychoticagents. Exhibits high in vitrobinding affinity for the followingreceptors: dopamine D2and D3,

serotonin 5HT2A, 5HT2C, 5HT1A,5HT1D, and the alpha-1-adrenergic receptors, andmoderate affinity for thehistamine H1receptor.

Antagonist at the D2, 5HT2Aand5HT1Dreceptors, and an agonistat the 5HT1Areceptor.

Additionally, inhibits synapticreuptake of serotonin andnorepinephrine. Antagonism atother receptors may explainsome of the other therapeuticand adverse effects (e.g.,orthostatic hypotension).

Therapeutic Effects

Mechanism of action is unknown;probably related to inhibition ofsynaptic reuptake of serotoninand norepinephrine throughantagonism of dopamine type 2(D2) and serotonin type 2 (5HT2)antagonism

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