In this section, we'll look at anti-psychotic medications.
Now, they go by other names.
Neuroleptics, dopamine antagonist, or serotonin-dopamine antagonists.
They all work in the brain.
What we're trying to treat with these medications
are schizophrenia, bipolar, major depression, and delusional disorders.
If your patient is having hallucinations or delusions, as a nurse,
your job is to validate that what they're feeling might be scary,
it might make them angry, but that it's not real.
So in a textbook situation, you can say," I'm sure that is scary for you,
or feels uncomfortable for you but I don't see what you're seeing."
Now, with schizophrenia, these patients can have a real flat affect,
they can be apathetic, they can kinda withdraw.
They also have challenges with delusions
and recognizing reality from what they're seeing in their mind.
Now, there's first generation which we call conventional
and there's also second generation but I wanna talk to you first about the first generation.
You've got the names listed there and again, I know I keep reminding you
but I want you to recognize you have to know the generic names.
Names inside the parenthesis are the trade names put there for your convenience
but they won't be present on the NCLEX.
So the adverse effects of first generations, they tend to have more adverse effects than the second generations.
These are the drugs we discovered first which is why they're the first generation.
So you can have these extrapyramidal symptoms.
I'm sure you had these in your psych classes but we're talking about acute dystonia,
pseudoparkinsonism or they're shaking, akathisia where they just can't really be still,
and tardive dyskinesia so these kind of weird tics.
So you take somebody who already has some challenges with their mental health diagnosis
and they might end up with some of these symptoms that are gonna be less than helpful
in them coping with daily life. Now, this one, neuroleptic malignant syndrome, whoa.
That one needs to be circled. That can be life-threatening if it's not treated.
They can also have anticholinergic effects.
Dry eyes, dry mouth, urinary retention, dry stool so they get constipated,
those can be bothersome but they're not life-threatening like neuroleptic malignant syndrome.
Also just like the sedative hypnotics, these can also cause orthostatic hypotension
but don't miss out on that neuroleptic malignant syndrome.
That has an arched back, lead pipe rigidity,
and the patient could die usually from respiratory failure
but the patient could die without treatment.
Now, anti-psychotics are neuroleptics or serotonin-dopamine antagonists.
We told you they go by different names.
We've got names with the first generation there that you've already seen.
Now we've given you some atypical second generation anti-psychotics.
So come back and spend some time with those names so you remember them.
Now, these cause few to none of the extrapyramidal symptoms we talked about with first generation.
Sweet. That's because the second generation is usually better so those are the symptoms
but they're gonna less likely to have them if the second generation anti-psychotic than the first one.
The exception to that is clozapine.
You can have severe adverse effects like agranulocytosis,
they have an increased risk of serious metabolic effects like weight gain, diabetes, and dyslipidemia.
Wow, so why would we use that medication?
Well, hey, CNS medications are really tricky
and this may be the one medication that works effectively for your patient
so we're gonna use it but knowing what these risks are,
we're gonna keep an eye out for those and help the patient manage those.
So clozapine has some pretty unusual risks.
As you can tell, that's gonna be an area right for test question possibilities.
Nobody knows for sure except the people who create the test
but you don't know what's gonna be on your test.
But this is an area where you would need to recognize that a patient was at risk for their safety
because this agranulocytosis is a big deal.
It's dangerous, it's a really low white blood cell count or leukopenia.
So granulocytes including the neutrophils, the basophils, and the eosinophils are less than 5% of normal.
Commonly, the neutrophils causing the neutropenia.
So clozapine has a big problem with agranulocytosis.
We just define that for you there in case that word was unusual to you or unknown to you but it is severe.
So when clozapine is needed, it's a good alternative
however, you have to be on alert and monitor for agranulocytosis.
So you have to know normal CBC values so you would recognize when they're abnormal.
Now, neuroleptic malignant syndrome, we touched on it a little bit
but remember, it's a life-threatening emergency.
They have that lead pipe muscle rigidity, extreme, extreme extrapyramidal symptoms,
their temperature is very, very high hitting way, way up.
They have a high blood pressure, their heartbeat is going very, very fast
so if you wanna be thinking about what's a big overarching theme,
it's like sympathetic nervous system overdrive.
Blood pressure up, heart rate up, temperature up, and they are stiffer than a board with an arched back.
So how do we treat it? Dantrolene and boromocriptine are options.
This is rare but it's very serious.
Most ER nurses have seen cases of this because that's where patients would come for treatment.
But know that this is a possibility and this is a minimum standard
that every nurse recognizes what neuroleptic malignant syndrome looks like
and you should know what pharmacological agents we use to treat it.
That's why we put them right there for you.
Remember this one?
The nurse provides care for a patient in ER who's been receiving haloperidol.
Which of the following requires an immediate intervention?
Alright, that last sentence focuses us.
We're looking for an immediate intervention that usually requires something that's wrong or unsafe.
So all I know about this patient is we're in the ER and they're on haloperidol.
I know that's an anti-psychotic first generation. So a blood sugar of 70?
Well, that's normal. I'm not gonna intervene with that so I can get rid of that one.
2+ deep tendon reflexes?
That's normal so I'm not worried about that. It doesn't need an immediate intervention.
Now, picking between these last two.
That heart rate seems a little low so it's not exactly normal but that temperature is very high.
Which one is connected to haloperidol first generation anti-psychotic?
Ah, temperature. That's why the correct answer is C.
This may be a sign of impending neuroleptic malignant syndrome.
Now we've got the anti-psychotic adverse effects there.
They're kind of all over the map but make sure you take some time
to spend looking at that and reviewing that.
That covers what we just talked about in the previous slides.
Make sure you know what agranulocytosis means so you'll recognize
that when interpreting lab values.
The first generations are the original ones.
They're the older ones but they have some specific drug to drug interactions
that I've listed for you here to make sure you're clear on remembering these.
So because they have that sedative hypnotic effect,
you definitely don't want to take them with another drug or substance that will potentiate that.
So with the first generation anti-psych, you don't want to take other CNS depressants or alcohol.
It's really gonna increase your risk of CNS and respiratory depression.
Now, it can impact serum levels, cigarette smoking and Tegretol
are another two groups you don't wanna mix with these.
Beta blockers can cause severe low blood pressure,
antidepressants may have increased concentration effects, and SSRIs may cause sudden onset of EPSs.
So that's why the second generation is generally a better choice for the patient if it can be effective.