PSYCHIATRIC NURSING

COPING AND ADAPTATION MENTALLY HEALTHY INDIVIDUAL ATTITUDE OF SELF ACCEPTANCE AUTONOMY ABILITY TO ABSTRACT,TRUST ,COPE WITH STRESS ACCURATE SELF PERCEPTION AWARENESS OF SELF MENTAL HEALTH balance in a persons internal life and adaptation to reality

Mental ILL Health state of imbalance characterized by a disturbance in a persons thoughts,

feelings and behavior Poverty and abuses are major risk factors

Psychiatric nursing interpersonal process whereby the professional nurse practitioner

,through the therapeutic use of self(art) and nursing theories (science), assist clients to achieve psychosocial well being. Core of psych nursing interpersonal process human to human relationship(both for mentally healthy and ill)

Mental hygiene measures to promote mental health , prevent mental illness and suffering
and facilitate rehabilitation.(and if necessary find meaning in these experiences)

Main tool therapeutic use of self It requires self-awareness Methods to increase self-awareness: Introspection ,Discussion, Experience, Role play
Neurosis

any long term mental or behavioral d/o in which contact with reality is retained the condition
is recognized by the patient as abnormal. Essentially features anxiety or behavior exagerrated designed to avoid anxiety ( anxiety d/o ; hysteria to conversion d/o,amnesia,fugue,multiple personality and depersonalization- dissociative d/o ;oc d/o) Result of inappropriate early programming(psychoanalysis little value) Benefits from Behavior Therapy Psychosis

Mental or behavioral disorder wherein patient looses contact with reality Presence of delusions, hallucinations,severe thought disturbances,alteration of mood, poverty
of thought and abnormal behavior organic mental disorder

(schizophrenia , major disorder of affect ( mania depression), major paranoid states and Benefits from psychoanalysis and antipsychotics
Common Behavioral Signs and Symptoms

Disturbances in perception Illusion- misinterpretation of an actual external stimuli Hallucinations false sensory perception in the absence of external stimuli
Disturbances in thinking and speech neologism coining of words that people do not understand Circumstantiality over inclusion of inappropriate thoughts and details Word salad incoherent mixture of words and phrases with no logical sequence Verbigeration meaningless repetition of words and phrases

Perseveration persistence of a response to a previous question Echolalia pathological repetition of words of others Aphasia speech difficulty and disturbance Expressive , receptive or global

Flight of ideas- shifting of one topic from one subject to another in a somewhat related way Looseness of association-incoherent ,illogical flow of thoughts(unrelated way) Clang association sound of word gives direction to the flow of thought Delusion persistent false belief,rigidly held
Delusions of grandeur- special /important in a way Persecutory-threatened Ideas of reference-situation/events involve them Somatic- body reacting in a particular way

Magical thinking primitive thought process thoughts alone can change events Autistic thinking regressive thought process-subjective interpretations not validated with
objective reality

Disturbances of affect Inappropriate disharmony between the stimuli and the emotional reaction Blunted affect severe reduction in emotional reaction Flat affect absence or near absence of emotional reaction Apathy dulled emotional tone Depersonalization feeling of strangeness from ones self Derealization feeling of strangeness towards environment Agnosia lack of sensory stimuli integration Disturbances in motor activity Echopraxia imitation of posture of others Waxy flexibility maintaining position for a long period of time Ataxia loss of balance Akathesia extreme restlessness Dystonia- uncoordinated spastic movements of the body Tardive dyskenisia involuntary twitching or muscle movements Apraxia involuntary unpurposeful movements Disturbances in memory Confabulation filling of memory gaps Dj vu 2 time-like feeling Jamais vu- not having been to the place one has been before Amnesia memory loss (inability to recall past events) Retrograde-distant past Anterograde immediate past Anomia lack of memory of items
nd

Dynamics of Human Behavior

Personality integration of systems and habits representing anindividuals characteristic

adjustment to his environment expressed through behavior

Individualistic, unique, predictable(stability and consistency)

Determinants: psychological,cultural, biological ( not inhereted) and familial

Analysis

Potential support systems or stressors Potential risk factor Satisfaction of human needs Physiological(oxygen , fluids, nutrition, temp.,elimination,shelter,rest,sex) Safety and security(physical and psychological) Love and belongingness Self esteem Self actualization

3 divisions of the mind

Conscious focussed on awareness Subconscious recalled at will Unconscious never recalled / largest part
Learning change in behavior through insight , relearning and remotivation Theories of personality development Freuds psychosexual theory

Libido inner drive Parts of body focus of gratification Unsuccesful resolution - fixation Structures of personality
Id pleasure principle-instinct Ego controls action and perception reality principle Superego moral behavior - conscience

0-18 m0s ;oral mouth trust and discriminating 18 mos. 3 years ; anal bowels holding on or letting go Negativism and toilet training age 3 -6 years phallic ; genitals exploration and discovery ( inc. sexual tension) Gender identification and genital awareness Oedipus and Electra complex // Castration anxiety and penis envy 6-12 years latency (quiet stage) sexual energy diverted to play. Institution of superego
control of instinctual impulses

12 young adult genital ; reawakening of sexual drives relationships Sexual maturation Sexual identity ,ability to love and work
Psychosocial Erickson developmental milestones //delay

0-12mos; 1-3y

TRUST AUTONOMY

3-6 6-12 12-18 18-25 25-60 60 and above

INITIATIVE INDUSTRY IDENTITY INTIMACY GENERATIVITY EGO INTEGRITY PIAGETS COGNITIVE THEORY 0-2 SENSORIMOTOR

REFLEXIVE IMITATIVE REPETITIVE BEHAVIOR SENSE OF OBJECT PERMANENCE AND SELF SEPARATE FROM ENVT. TRIAL AND ERROR RESULTS IN PROBLEM SOLVING
2-7Y PRE-OPERATIONAL SELF-CENTERED,EGOCENTRIC

CANNOT CONCEPTUALIZE OTHERS VIEW ANIMISTIC THINKING IMAGINARY PLAYMATE SYMBOLIC MENTAL REPRESENTATION CREATIVITY 2-4 PRE-CONCEPTUAL (PRE-LOGICAL) 4-7 INTUITIVE (UNDERSTANDING OF ROLES)
7-12Y CONCRETE OPERATIONAL

LOGICAL CONCRETE THOUGHT INDUCTIVE RESAONING (SPECIFIC TO GENERAL) CAN RELATE ,PROBLEM SOLVING ABILITY REASONING AND SELF-REGULATION Abstract thinking Separation of fantasy and fact Reality oriented Deductive reasoning Apply scientific method

12-ABOVE FORMAL OPERATIONAL THOUGHT

Kohlberg MORAL DEVELOPMENT/ THINKING/ JUDGEMENT

PRE-CONVENTIONAL (0-6) PUNISHMENT AND OBEDIENCE OBEDIENCE TO RULES TO AVOID PUNISHMENT CONVENTIONAL ( 6-12 ) MUTUAL INTERPERSONAL EXPECTATIONS,RELATIONSHIPS AND CONFORMITY SOCIAL SYSTEM AND CONSCIENCE MAINTENANCE BEING GOOD IS IMPORTANT SELF RESPECT OR CONSCIENCE POST CONVENTIONAL (12 18 Y)
PRIOR RIGHT OR SOCIAL CONTRACT UNIVERSAL ETHICAL PRINCIPLE ABIDE FOR COMMON GOOD RATIONAL PERSON-VALIDITY OF PRINCIPLES-AND BECOME COMMITTED TO THEM INNER CONTROL OF BEHAVIOR UNDERSTANDING THE EQUALITY OF HUMAN RIGHTS AND DIGNITY OF HUMAN BEINGS AS INDIVIDUALS

DEFENSE MECHANISMS

unconscious intrapsychic adoptive efforts to resolve emotional conflict and cope with anxiety automatic pathology is determined by the frequency of use
examples of DEFENSE MECHANISMS DENIAL failure to acknowledge an intolerable thought , feeling, experience or reality

DISPLACEMENT redirection of emotions or feelings to a subject that is more acceptable or

less threatening PROJECTION attributing to others ones feelings, impulses , thought or wishes

UNDOING an attempt to erase an act , thought , feeling or desire COMPENSATION an attempt to overcome real or imagined shortcoming SYMBOLIZATION a less threatening object or idea is used to epresent another SUBSTITUTION replacing desired , impractical , unattainable object with one that is
acceptable

INTROJECTION a form of identification

characteristic of another(love object)

in which there is a taking into oneself the

REPRESSION unacceptable thoughts is kept from awareness(unconscious) SUPPRESSION- consciously putting a disturbing thought or incident out of awareness

REACTION FORMATION - expressing attitude directly opposite to unconscious wish or fear REGRESSION returning to an earlier developmental phase in the face of stress DISSOCIATION detachment of painful emotional conflicts from consciousness CONVERSION emotional problems are converted into symptoms FANTASY conscious distortion of unconscious feelings or wishes IDENTIFICATION conscious patterning of ones self from another person INTELLECTUALIZATION - over use of intellectual concepts by an individual to avoid
expression of feelings

RATIONALIZATION justifying ones actions which are based on other motives SUBLIMATION - rechanneling of unacceptable instinctual drives with one hat is aceptable
NURSE PATIENT RELATIONSHIP SULLIVANS THEORY ON INTERPERSONAL RELATIONSHIP DEVELOPED BY PEPLAU INTO NURSE- PATIENT RELATIONSHIP SERIES OF INTERACTION BETWEEN THE NURSE AND PATIENT IN WHICH THE NURSE ASSISTS THE PATIENT TO ATTAIN POSITIVE BEHAVIORAL CHANGE T RUST

R APPORT U NCONDITIONAL POSITIVE REGARD S ETTING LIMITS T HERAPEUTIC COMUNICATION

PHASES PRE-INTERACTION SELF AWARENESS

ORIENTATION PHASE DEVELOP A MUTUALLY ACCEPTABLE CONTACT WORKING IDENTIFICATION AND RESOLUTION OF THE PATIENTS PROBLEMS TERMINATION ASSIST PATIENT TO REVIEW WHAT HE HAS LEARNED AND TRANSFER
HIS LEARNING TO HIS REL. W/ OTHERS WHEN TO TERMINATE NPR

GOALS ACCOMPLISHED EMOTIONALLY STABLE GREATER INDEPENDENCE ABLE TO COPE WITH ANXIETY, LOSS , FEAR AND SEPARATION

COMMON PROBLEMS - NPR TRANSFERENCE DEVELOPMENT OF EMOTIONAL ATTITUDE + OR TOWARDS THE NURSE RESISTANCE DEVELOPMNET OF AMBIVALENT FEELINGS TOWARDS SELF EXPLORATION COUNTER TRANS FERENCE TRANSFERENCE AS EXPERIENCED BY THE NURSE PRINCIPLES OF CARE ACCPETS PATIENT AS UNIQUE WITH INHERENT VALUE AND WORTH

PATIENT IS VIEWED AS HOLISTIC HUMAN BEINGS WITH INTERDEPENDENT AND

INTERRELATED NEEDS FOCUS ON STRENGTHS AND ASSETS

NON JUDGEMENTAL ASSISTANCE TOWARDS COPING EXPLORE THE PATIENTS BEHAVIOR AND THE NEED IT IS DESIGNED TO MEET AND THE
MESSAGE IT IS COMMUNICATING LEVELS OF INTERVENTION PRIMARY INTERVENTIONS AIMED AT THE PROMOTION OF MENTAL HEALTH AND LOWERING THE RATE OF CASES BY ALTERING THE STRESSORS SECONDARY INTERVENTIONS THAT LIMIT THE SEVERITY OF THE DISORDER CASE FINDING AND PROMPT Tx

TERTIARY REDUCING THE DISABILITY AFTER A DISORDER

PREVENTION OF COMPLICATION AND ACTIVE PROGRAM OF REHABILITATION CHARACTERISTICS OF A PSYCHIATRIC NURSE-major roles of a nurse - socializing agent and patient advocate

EMPATHY- ability to see beyond outward behavior and sense accurately another persons inner
experience

GENUINENESS/CONGRUENCE ability to use therapeutic tools appropriately UNCONDITIONAL POSITIVE REGARD - respect
THERAPEUTIC COMMUNICATION

CLARIFICATION LIMIT SETTING EMPATHETIC / ENCOURAGE EXPRESSION ANSWERS NEEDS REFLECTIVE AND INSIGHTFUL

THERAPEUTIC COMMUNICATION

FOCUS ON FEELING TONE ,NEEDS ,MOTIVATION MUST HAVE CONSISTENCY AND IS NON JUDGEMENTAL CRITERIA OF SUCCESSFUL COMMUNICATION FEEDBACK , APPROPRIATENESS,
FLEXIBILITY AND EFFICIENCY TECHNIQUES OF COMMUNICATION

TO INITIATE A CONVERSATION giving broad openings giving recognition / acknowledgement TO ESTABLISH RAPPORT GIVING INFORMATION USE OF SILENCE TO GATHER INFORMATION FOCUSING

VALIDATING REFLECTING RESTATING TO CLOSE A CONVERSATION summarizing

TYPES OF PSYCHOTHERAPIES
REMOTIVATION THERAPY TREATMENT MODALITY THAT PROMOTES EXPRESSION OF FEELINGS THROUGH INTERACTION FACILITATED BY DISCUSSION OF NEUTRAL TOPICS STEPS : climate of acceptance creating bridge to reality sharing the world we live in appreciation of works of the world climate of appreciation MUSIC THERAPY

INVOLVES USE OF MUSIC TPO FACILITATE EXPRESSION OF FEELINGS,FACILITATE

RELAXATION AND OUTLET OF TENSION PLAY THERAPY

enables patient to experience intense emotion in a safe environment with the use of play children express themselves more easily in play. revealing as reflection of childs situation
in the family

provide toys and materials facilitate interaction observe and help child resolve
problems through play Group therapy Treatment modality involving three or more patients with a therapist to relieve emotional difficulties, increase self esteem, develop insight , LEARN NEW ADAPTIVE WAYS TO COPE WITH STRESS and improve behavior with others( RELATIONSHIP WITH OTHERS CAN BE WORKED THROUGH) IDEAL 8 10 MEMBERS MILIEU THERAPY CONSISTS OF TREATMENT BY MEANS OF CONTROLLED MODIFICATION OF THE PATIENTS ENVIRONMENT , FACILITATE POSITIVE BEHAVIORAL CHANGE INCREASE PATIENTS AWARENESS OF FEELINGS, INCREASE SENSE OF RESPONSIBILITY AND HELP ETURN TO COMMUNITY clients plan social and group interaction

token programs , open wards and self medication

FAMILY THERAPY

A METHOD OF PSYCHOTHERAPY WHICH FOCUSES ON THE TOTAL FAMILY AS AN

INTERACTIONAL SYSTEM PROBLEM IS A FAMILY PROBLEM

focus on sick members behavior as source of trouble / symptom serve a function for the family members develop sense of identity points out function of the sick member for the rest of the family
PSYCHOANALYTIC focuses on the exploration of the unconscious, to facilitate identification of the patients defenses

ANXIETY RESULTS BETWEEN CONFLICTS OF ID AND EGO(DEFENSE MECHANISMS

FORM TO WARD OFF)

BECOMES AWARE OF UNCONSCIOUS THOUGHTS AND FELINGS.UNDERSTAND ANXIETY

AND DEFENSES HYPNOTHERAPY

VARIOUS METHODS AND TECHNIQUES TO INDUCE A TRANCE STATE WHERE PATIENT

BECOMES SUBMISSIVE TO INSTRUCTIONS BEHAVIOR MODIFICATION A THERAPEUTIC INTERVENTION INVOLVOING THE APPLICATION OF LEARNING PRINCIPLES IN ORDER TO CHANGE MAL-ADAPTIVE BEHAVIOR PSYCHOLOGICAL PROBLEMS ARE A RESULT OF LEARNING DEFICIENCIES CAN BE CORRECTED THROUGH LEARNING

OPERANT CONDITIONING

EXTERNAL DESENSITIZATION SLOW ADJUSTMENT OR EXPOSURE TO FEARED OBJECTS(USED IN PHOBIAS) PERIODIC EXPOSURE,UNTIL UNDESIRABLE BEHAVIOR DISAPPEARS OR LESSENS

USE OF REWARDS TO EINFORCE POSITIVE BEHAVIOR PERCEIVED AND SELF REINFORCEMENT BECOMES MORE IMPORTANT THAN

AVERSION THERAPY - EXAMPLE OF BEHAVIOR MODIFICATION IN WHICH PAINFUL

STIMULUS IS INTRODUCED TO BRING ABOUT AN AVOIDANCE OF ANOTHER STIMULUS WITH THE END VIEW OF FACILITATING BEHAVIORAL CHANGE OTHER THERAPIES TOKEN ECONOMY-REWARDING DESIRED BEHAVIOR ECONOMY-REWARDING COGNITIVE THERAPY SHORT TERM STRUCTURED THERAPY ORIENTED TOWARDS PRESENT PROBLEMS ABD SOLUTIONS AMIN FOCUS OF DEPRESSIVE DISORDERS HUMOR THERAPY TO FACILITATE EXPRESSION AND ENHANCE INTERACTION ACTIVITY THERAPY GROUP INTERACTION WHILE WORKING ON A TASK TOGETHER

PSYHCHOPHARMACOLOGIC AGENTS
I. SUB-CLASSIFICATIONS PHENOTHIAZINES ANTI-PSYCHOTICS NON-PHENOTHIAZINES

MOA

Chlorpromazine (Thorazine) Fluphenazine (Prolixin) Perphenazine ( Trilafon) Prochlorperazine (Compazine) Thioridazine ( Mellaril) Triflouperazine (Stelazine)
-

Clozapine ( Clozaril) Haloperidol ( Haldol) Olanzapine ( Zyprexa ) Risperidone ( Risperdal) THIOXANTHENES Thiothixene ( Navane)

antagonizes dopamine in the CNS and also blocks Cholinergic, Histaminic, Serotogenic, Adrenergic neurotransmitters ( anticholinergic, antihistaminic, anti-emetic ) blocks activity of the CNS receptors and sympathetic nervous system formerly called major tranquilizers / neuroleptics. used to relieve psychotic symptoms( delusions , hallucinations and looseness of association)of schjizophrenia, mania and psychotic depression and organic mental disorders acute management of agitation and hyperactivity

INDICATION -

SIDE/ ADVERSE EFFECTS:

 ANTICHOLINERGIC EFFECTS (EPS)EXTRAPYRAMIDAL SYMPTOMS PSEUDOPARKINSONISM-tremor , mask like facies drooling , restlesssness AKATHISIA- restlessness,and anxiety DYSTONIA-grimacing , torticollis ,oculogyric crisis, intermittent muscle spasms - TARDIVE DYSKINESIA-lip smaking and tongue and mouth (NMS) NEUROLEPTIC MALIGNANT SYNDROME* - hyperthermia, and severe EPS -muscular rigidity, tremors, trismus, choreiform movements,autonomic instability /hyperactivity and alterations in LOC SEIZURES HEPATOTOXICITY* ORTHOSTATIC HYPOTENSION PHOTOSENSITIVITY and HYPERSENSITIVITY ENDOCRINE DISORDERS DYSCRASIAS * AGRANULOCYTOSIS sorethroat,chills,fever,malaise LEUKOPENIA

CONTRAINDICATIONS AND SPECIAL PRECAUTIONS: C/I : hypersensitivity , glaucoma , convulsive d/o , pregnancy and lactation, elderly clients NURSING CARE GUIDELINES: C- antipsychotics, neuroleptics, major tranquilizers H- decreased overt or positive manifestations of psychosis E- p.c. C- rise slowly avoid sunlight Report sorethroat,fever,muscular rigidity Reduced psychomotor agitation and insomnia 1 week Reduction of hallucinations, delusions and thought disorder takes 6-8 weeks for full therapeutic effect K monitor BP and temperature blood levels Seizures, NMS and EPS L.F.T.s CBC with differential medical management : NMS Bromocriptine or Amantadine( dopamine agonist) and Dantrolene (Dantrium) muscular relaxant Dystonia Diphenhydramine,Benztropine , Diazepam, Lorazepam Pseudoparkinsonism Antiparkinsonian, Anticholinergic Akathisia Anticholinergic, Benzodiazepines, Beta-blockers,Clonidine Tardive dyskinesia early referral-dose reduction , no anticholinergics II. CLASSIFICATIONS 2 TYPES : 1.) DOPAMINERGIC DRUGS MOA: enhance dopaminergic activity slows deterioration of dopaminergic nerve cells Increasing dopamine ANTI-PARKINSONIAN AGENTS

Carbidopa Levodopa ( Sinemet) Amantadine ( Symmetrel) Bromocriptine Mesylate ( Parlodel) Levodopa ( Larodopa) Pergolide Mesylate ( Permax) Ropinirole(Requip) Tolcapone ( Tasmar)

2.) ANTI-CHOLINERGIC AGENTS MOA:inhibit relative excess in cholinergic activity, symptomatic relief Decrease signs and symptoms ( tremors,rigidity, drooling promote optimal levels of motor function (gait, posture and speech )

Trihexypheiedil ( Artane) Biperiden Hydrochloride ( Akineton) Benztropine Mesylate ( Cogentin) Diphenhydramine Hydrochloride (Benadryl) Misc. agent Selegiline ( Eldepryl) INDICATIONS: For management of anti psychotic induced EPS- pseudoparkinsonism
SIDE AND ADVERSE EFFECTS Anticholinergic Effects Blurring of vision, constipation, 3Ds and orthostatic hypotension, sorethroat* Headache, photosensitivity, drowsiness, CHF and halluciantions CONTRAINDICATIONS AND SPECIAL PRECAUTION Glaucoma, tachycardia, HPN, Cardiac D/O, asthma, duodenal ulcer NURSING CARE GUIDELINES C- dopaminergic or anti-cholinergic H- decrease tremors and rigidity in 2-3 days E- p.c. C- avoid sudden position change Avoid Vit. B6 and CHON rich foods- dec. absorption of medication Avoid alcohol-increases sedative effects K- check BP- orthostatic hypotension drugs not withdrawn abruptly III. ANTI DEPRESSANTS COMMON TYPES TRICYCLICS MONO AMINE OXIDASE INHIBITORS SELECTIVE SEROTONIN REUPTAKE INHIBITORS

Imipramine(Tofranil) Amitriptryline ( Elavil) Clomipramine (Anafril) Doxepin ( Sinequan) Nortryptyline ( Aventyl) Tranylcypromine (Parnate) Isocarboxazid ( Marplan) Phenelzine (Nardil)

Citalopram ( Celexa) Flouxetine (Prozac) Paroxetine ( Paxil) Sertraline ( Zoloft) Fluvoxamine (Luvox)

Mechanism of Action

Prolongs the action of norepinephrine Dopamine Serotonin by blocking the reuptake of this CNS STIMULANTS neurotransmitters

Blocks the metabolic destruction of neurotransmitters by the enzyme monoamine oxidase

Inhibits reuptake and destruction of serotonin to prolong its action

Ritalin ( Methylphenidate) Amphetamine ( Benzedrine)

Increases levels of neurotransmitters in the brain thereby increasing CNS activity and decreasing hyperactivity.
INDICATIONS effective in management and treatment of depression and related mood and depressive disorders such as: Obsessive compulsive ,Eating d/o,Obesity,Bipolar disorder,Panic d/o

SIDE EFFECTS AND ADVERSE REACTIONS: TCAS Cardiac arrhythmias, palpitations,orthostatic hypotension Constipation,Sedation, anticholinergic effects Confusion Bone marrow depression MAOI Hypertensive crisis Liver and cardiovascular disease Weight gain Sexual dysfunction photosensitivity SSRI Tremors, decreased libido, NAVDA Nervousness, insomnia, drowsiness anxiety CNS Stimulants Growth suppression, insomnia

CONTRAINDICATIONS AND SPECIAL PRECAUTIONS TCAS Hypersensitivity, liver disease , glaucoma MAOI Hypertension Cardiovascular disease and Liver disease SSRI same CNS Stimulants

NURSING CARE GUIDELINES C- anti-depressants H- decreased signs and symptoms of depression(increased appetite and sleep E p.c. TCAS C2-3 wks initial effect 3-6 wks full therapeutic effect MAOI 2-3 initial 3-4 full ther. Effect Avoid foods rich in SSRI 2-3 initial 3-4 full ther. effect CNS Stimulants Give in AM , not beyond 2 pm 6 hours before bedtime

Emphasize compliance Avoid citrus juice decrease absorption KMonitor BP, HR and ECG

tyramine leads to hypertensive crisis ( processed,preserved and fermented )

Monitor BP and food items IV. ANTI MANIC EXAMPLES

Lithium Carbonate ( Eskalith, Lithane, Quilinium R, Lithionate) Carbamazepine (Tegretol )

MOA Exact mechanism unknown , alters the level of norepinephrine and other neurotransmitters INDICATIONS

Treatment of

acute mania and for prophylaxis of recurrent manic and depressive episodes in bipolar disorder SIDE AND ADVERSE EFFECTS NAVDA Fine tremors leading to coarse tremors Thirst Nystagmus Nephrotoxicity* Cardiac toxicity* Hyperthyroidism Thyroid Crisis*

CONTRAINDICATIONS AND SPECIAL PRECAUTION Cardiovascular disease , renal disease, clients on low sodium diet and on diuretic therapy, brain damage, pregnancy and lactation NURSING CARE GUIDELINES C- mood stabilizer anti manic H- decrease hyperactivity/manic episodes Initial effect 10-14 days Full therapeutic effect 3-4 weeks E- after meals with milk or food C- antipsychotics given with lithium for immediate management of manic episodes. Diet Na 6-10 grams a day; fluids- 3 liters per day Avoid caffeine , diuretics and activities that increase perspiration K- monitor for untoward signs and symptoms Monitor serum level at least once a month(A.M. 12 hours after the last dose maintenance dose - .5 1.2 mEq / L acute level 1.5 mEq / L level for the elderly .4 1.0 mEq / L Antidote for toxicity Mannitol (Osmitrol) or Acetazolamide (Diamox) V. ANTI ANXIETY CLASSIFICATION: BENZODIAZEPINES AZASPIRONES Alprazolam ( Xanqax) Chlordiazepoxide ( Librium) Clorazepate ( Tranxene) Diazepam ( Valium) Lorazepam ( Ativan) Oxazepam ( Serax) NON-BENZODIAZEPINE Miscellaneous agents

Buspirone (Buspar)

Hydroxyzine ( Vistaril) Meprobamate ( Equanil)

MOA: depresses Reticular Activating system and reduces anxiety by stimulating the action of an inhibitory neurotransmitter called GABA INDICATIONS; treatment of anxiety disorders and for short term relief of symptoms of Anxiety; selective medications effective for skeletal muscle relaxation, pre and post-op sedation, seizure control. SIDE AND ADVERSE EFFECTS Sedation and Dizzinees,drowsiness and dry mouth Paradoxical reactions*(hallucination and delusions),CNS depression* Addisons disease , Dependency*, hepatotoxicity* CONTRAINDICATIONS AND SPECIAL PRECAUTION Glaucoma, hypersensitivity, liver and kidney dysfunction, psychoses, elderly , pregnancy and lactation NURSING CARE GUIDELINES C- anxiolytics, minor tranquilizers H- decrease anxiety E- a.c. food delays absorption C- rise slowly Avoid caffeine and alcohol K- monitor CBC, LFTs, report sorethroat, jaundice, weakness and fever