McKenna's Pharmacology for Nursing, 2e

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C H A P T E R 2 2 Psychotherapeutic agents

CRITICAL THINKING SCENARIO Antipsychotic drugs

THE SITUATION B.A., a 36-year-old, single, professional woman, was diagnosed with chronic schizophrenia when she was in high school. Her condition has been well controlled with chlorpromazine (Largactil) and she is able to maintain steady employment, live in her own home and carry on a fairly active social life. At her last evaluation, she appeared to be developing bone marrow suppression and her doctor decided to try to taper the drug dosage. As the dosage was being lowered, B.A. became withdrawn and listless, missed several days of work and cancelled most of her social engagements. Afraid of interacting with people, she stayed in bed most of the time. She reported having thoughts of death and paranoid ideation about her neighbours that she was beginning to think might be true. CRITICAL THINKING What care interventions are appropriate at this time? What supportive measures might be useful to help B.A. cope with this crisis and allow her to function normally again? What happens to brain chemistry after long-term therapy with phenothiazines? What drug options should be tried? Are there any other options that might be useful? DISCUSSION Schizophrenia is not a disorder that can be resolved simply with proper counselling. B.A., an educated woman with a long history of taking phenothiazines, realises the necessity of drug therapy to correct the chemical imbalance in her brain. She may need a high-potency antipsychotic to return her to the level of functioning she had reached before experiencing this setback. Her knowledge of her individual responses can be used to help select an appropriate drug and dosage. Her experiences may also facilitate her care planning and new drug regimen. B.A. will need support to cope with problems at work—from her inability to go in to work, to coping with feelings about not meeting her social obligations, to finding the motivation to get up and become active again. She might do well with behaviour modification techniques that give her some control over her activities and allow her to use her knowledge and experience with her own situation to her advantage in forming a new medical regimen. She may need support in explaining her problem to her employer and her social contacts in ways that will help her avoid the prejudice associated with mental illness and will allow her every opportunity to return to her regular routine as soon as she can.

Because it may take several months to find the drug or drugs that will bring B.A. back to a point of stabilisation, it is important to have a consistent, reliable healthcare team in place to support her through this stabilisation period. She should have a reliable contact person to call when she has questions and when she needs support.

CARE GUIDE FOR B.A.: ANTIPSYCHOTIC/ NEUROLEPTIC DRUGS Assessment: History and examination

Allergies to any of these drugs; CNS depression; CV disease; pregnancy or breastfeeding; myelography; glaucoma; hypotension; thyrotoxicosis; seizures Concurrent use of anticholinergics, barbiturate anaesthetics, alcohol, pethidine, beta blockers, adrenaline, noradrenaline CV: blood pressure, pulse, orthostatic blood pressure CNS: orientation, affect, reflexes, vision Skin: colour, lesions, texture Respiratory: respiration, adventitious sounds GI: abdominal examination, bowel sounds Laboratory tests: thyroid, liver and renal function tests, FBC Implementation Give drug in evening; do not allow person to chew or crush sustained-release capsules. Provide comfort and safety measures: void before dosing; raise side rails; provide sugarless lozenges, mouth care; institute safety measures if CNS effects occur; position person to relieve dyskinesia discomfort; taper dosage after long-term therapy. Provide support and reassurance to help person cope with drug effects. Teach person about drug, dosage, adverse effects, conditions to report and precautions. Evaluation Evaluate drug effects: relief of signs and symptoms of psychotic disorders. Monitor for adverse effects: sedation, dizziness, insomnia; anticholinergic effects; extrapyramidal effects; bone marrow suppression; skin rash. Monitor for drug–drug interactions as listed. Evaluate effectiveness of teaching program. Evaluate effectiveness of comfort and safety measures. TEACHING FOR B.A. • The drugs that are useful for treating schizophrenia are called antipsychotic or neuroleptic drugs. These drugs affect the activities of certain chemicals in your brain and are used to treat certain mental disorders.