NERVE cells – are called neurons and

nerve fibers.
 Physiological Actions:

◦ They respond to stimuli

◦ They conduct electric impulses ( Na+ - K+ ),
depolarization- repolarization.
◦ They release chemicals called
neurotransmitters.
 Neurotransmitter, is a chemical
substance that function as a
neuromessenger.
1
◦ Acethylcholine VS acethylcholinesterase
◦ Norepinephrine monoamine{ reuptake) VS
monamine oxidase (MAO).

◦ Reuptake – other transmitters are taken back

into the presynaptic cell from which they were
originally released by a process.

2
 A. BIOAMINES
1. Dopamine ( brainstem)
◦ Excitatory
controls complex movements,
motivation
Cognition
regulates emotional response
 2. Norepinephrine (noradrenaline)– Brain stem
◦ Excitatory –
attention * memory
mood regulation * sleep, and wakefulness
learning,

◦ Epinephrine – excitatory - fight or flight response by

peripheral nervous system.
 3. Serotonin – ( brain) –
◦ Inhibitory –
control of food intake,
sleep and wakefulness
temperature regulation
pain control
sexual behavior, and
regulation of emotions
B. NEUROPEPTIDES
1. Histamine –
 Neuromodulator
 Peripheral allergic responses, control of
gastric secretions, cardiac stimulations
and alertness.

C. CHOLINERGICS
1. Acetylcholine ( brain, spinal cord,
PNS, neuromuscular junction of skeletal
muscle) from dietary choline in red meat,
vegetables.
 Excitatory or inhibitory
 Sleep and wakefulness cycle, signals
muscles to become alert.
D. AMINOACIDS
1. GABA – Gamma- Aminobutyric ACID -
amino acid
◦ Major inhibitory , modulate other
neurotransmitters
◦ Increases – Benzodiazepines  induce sleep.

2. Glutamate – excitatory
◦ High levels – major neurotoxic effects
◦ Disorder: brain damage – stroke,
hypoglycemia, sustained hypoxia or ischemia,
degenerative diseases i.e. Huntington’s and
Alzheimer’s.
1. Brain
A. Cerebrum ( cortex)
- conscious sensation and the initiation of
movement.

 Left hemisphere – controls the right side of the

body,
◦ Center for logical and analytical functions i.e.
reading, writing, and mathematical tasks.

 Right hemisphere – controls the left side of the

body.
◦ Center for creative thinking, intuition, and artistic
abilities
 Four lobes
1. Frontal- Control the organization of thought,
body movement, memories, emotions, and moral
behavior Frontal- Thought process
• helps regulate arousal, focuses attention and
allows problem solving and decision making.
Abnormalities : schizophrenia, attention
deficit/hyperactivity disorder, dementia
2. Parietal
◦ Interpret sensations of taste, touch and spatial
orientation. Receives & identify sensory
information
◦ Concept formation and abstraction
◦ Proprioception and body awareness
◦ Reading, mathematics
◦ Right – left orientation
 3. Temporal
 Centers for the sense of smell, hearing,
memory, and expression of emotions.
( Auditory)
◦ Language comprehension
◦ Stores sounds – memory – language, speech
◦ Connects the limbic system “emotional brain” to
allow esxpression of emotions ( sexual,
aggressive, fear, etc.)
4. Occipital
Assist in the coordinating language
generation and visual interpretation,
i.e. depth perception.
◦ Vision
◦ Interprets visual images
◦ Visual association
◦ Visual memories
◦ Involved with language formation
b. Cerebellum
◦ involved in the regulation of skeletal muscle
coordination and contraction
◦ Center for coordination of movements and
postural adjustments.
◦ It receives and integrates information from all
areas of the body i.e. muscle, joints, organs,
and other components of the CNS.
c. Brain stem
Regulates the internal organs ( regulation of
blood gases , maintenance of blood pressure.)
Initial processing center for sensory information
that is then sent on to cerebral cortex.
Midbrains, pons, medulla oblongata and the
nuclei of cranial nerves 3 to 12.
 RAS –motor activity, sleep, consciousness, &
awareness
 Extrapyramidal system - relays information
about movement and coordination from the
brain and spinal nerves.
 Locus seruleus – is the area of brain stem
associated with stress, anxiety and impulsive
behavior.
d. Limbic system -
1. Thalamus- regulates activity, sensation,
and emotion
2. Hypothalamus - temperature regulation,
appetite control, endocrine function,
sexual drive and impulsive behavior
associated with feelings of anger, rage or
excitement.
3. Hippocampus and amygdale – are
involved in emotional arousal and memory.
4. Disturbances: dementia or memory loss;
poorly controlled emotions and impulses seen
in psychotic and manic behavior.
 spinal cord
 nerves
 Definition of terms used in describing
drugs and drug therapy.
 Efficacy - refers to the maximal therapeutic
effect that can be achieved by a
drug.
 Potency – describes the amount of the drug
needed to achieve the maximum
effect.
Low potency – require higher dosages for efficacy.
High potency – require low dosages for efficacy.
 Half life – is the amount of time it takes for half
of the drug to be removed from the
blood stream.
Shorter half life – given 3-4 X/day
Longer half life – once a day
The amount of time needed for a drug to leave the body
completely after it has been discontinued is about five
times its half life.
 Psychotropic medications DO NOT CURE
mental illness.
 Clients require physical and psychiatric
assessments
 Various view about the use of psychotropic
medications; may bring about non-adherence
to medication treatment.
 Clients must give informed consent --
explanation of the risks vs. benefits.
 Psychotropic medications have different
onset of actions. ----
Most medications require daily administrations for one - weeks
before their intended effects are evident
some medications act more immediately.
( benzodiazepines, antipsychotic)
a. Its selection is based on its target symptoms ( i.e.
delusional thinking; panic attacks; hallucinations)
b. The dosage of medications is often adjusted
- Minimum dosage effective for the client.  lower dosages
to sustain effects over time.
- Higher dosages for target symptoms

AS A RULE: Elderly requires lower dosages – with longer

time to achieve full potential.

h. Tapering of drugs is a must;

a. This is due to potential problems with;
 Rebound – temporary return of symptoms
 Recurrence of the original symptoms
 Withdrawal – new symptoms resulting from
discontinuation of the drug.

i. Follow-up care is essential – to ensure compliance with the

medication regimen, adjustment of dosages, manage side
effects.
 PHASES OF DRUG TREATMENT
Inititation Phase: Assessment
Psychiatric evaluation - diagnosis and target
symptoms
A nursing assessment
Physical examination
N. assesses, observes and monitor’s C’s responses,
teaches ( action, dosage, frequency, side effects)
Stabilization Phase:
Medication is adjusted or titrated – achieve max.
amount of improvement; minimum side effects.
Monitor body temp., BP, pulse, mental status, side
effects and unusual adverse reactions.
May have Augmentation strategy
Polypharmacy – using more than one group from a
class of medications.
 Maintenance Phase
Target symptoms have improved; continuity of
medications – prevents relapse.
Discontinuation Phase
Discontinuance, tapering
 18
◦ Relieve or reduce symptoms
of dysfunctional thoughts,
moods, or actions, mental
illness or disorder.
◦ Improve client’s functioning.
◦ Increase client’s adherence
( or compliance) and
amenability to other
therapies.
Psychotropic medications are often not approved
for children by FDA

Elderly clients are more susceptible to side

effects – cardiac effects.

Lower doses – elderly – decreases liver and renal

function.

Elderly are likely to be taking other drugs;

therefore, they have an increased risk for drug –
drug interactions.
 Other names: neuroleptics; major
tranquilizer, ataractic, psychic energize.
 Effective in the treatment of psychoses. Use
to modify behavior and relieve the
symptoms.
 Used to lessen : hallucinations, dementia,
delusions, illusions, aggressive behaviors,
disorganized speech, inappropriate affect
and behavior.
 Action: Block postsynaptic dopamine receptors. The
newer also affect serotonin levels.
 Effects:
◦ Treatment of hallucination, and delusion ( also called
positive symptoms)
◦ Reduction of aggressive behaviors.
◦ Non- addicting; clients do not develop tolerance.
Side Effects:
 Sedation
 Weight gain
 Insomnia
 Agitation
Minimal anticholinergic effects
 High therapeutic effects --- can be given in high dose with
minimal risk.
 Non addicting—patients do not develop tolerance.

 Teaching:

Patient Teaching
Adhering to medication regimen
Reducing sugar and caloric intake
Clozaril
Weekly WBC monitoring
Discontinue medication and seek care at first sign of
infection
 Action: Mechanism of Actions:
block receptors to dopamine
◦ Calms an excites patients without producing
impairment of motor function sleep.
 Effects:
Treatment for psychotic symptoms
( hallucinations and delusions)
or positive symptoms—schizophrenia, bipolar,
major depression, and delusional disorders.
Treatment of tics and vomiting – intractable
hiccups.
Reduction of aggressive behavior
◦ Side Effects:
 EPS Sedation
 Anticholinergic effects
 Skin rash
 Weight gain
 Photosensitivity
 Reduction of seizure thresholad
 Orthostatic hypotension
 Galactorrhea/ amenorrhea
 Sexual dysfunction
◦Teaching:
Failure to take antipsychotic
medication -- lead to relapses
and repeated hospitalization.
It should be lowered to elderly
 Side Effects:
1. Extrapyramidal effects (EPS) Management:
Mgt:
 Lowering the dosages
 Changing to another antipsychotic drugs
 Administering anticholinergic drugs

Acute dystonia
Torticollis
Opisthotonus
Oculogyric
Management:
Anticholinergic drugs i.e. muscular benztropine
(Cogentin), or dipenhydramine.
Recurrent  lowering or change of drugs.
2. Pseudoparkinsonism – drug induced parkinsonism;
◦ Akinesia – absent or slowed movement
◦ Stiff, stooped posture
◦ Masklike facies
◦ Decreased arm swing
◦ Shuffling, festinating gait ( with small steps)
◦ Cogwheel rigidity ( ratchet like movements of joints)
◦ Drooling
◦ Tremor
◦ Bradycardia
◦ Coarse pill rolling movements of the thumb and fingers while at
rest.
 Management:
 Change of drugs
 Adding anticholinergic drugs e.g. Amantadine ( Symmetrel)
 3. Akathisia – an intense need to move
about.
Restlessness
anxious and agitated,
rigid posture/gait lack of spontaneous gestures.
Internal restlessness, inability to sit still ( leads to
discontinue drugs).
 Management:
◦ Change of antipsychotic drugs
◦ Beta blocker
◦ Anticholinergic or benzodiazepines
4. Neuroleptic Malignant Syndrome (NMS)
 - Potentially fatal, idiosyncratic reaction of
antipsychotic or neuroleptic drugs
 Signs and symptoms:
Rigidity
High fever
Autonomic instability ( unstable BP, diaphoresis, pallor, delirium,
elevated CPK enzyme
Confused or mute
Dehydration, poor nutrition, concurrent medical illness ( high risk)
◦ Management:
 Discontinuance of all antipsychotic medications
 Supportive medical care – rehydration and
hypothermia
 5. Tardive Dyskinesia (TD)
A syndrome of permanent, involuntary movements
Tongue thrusting and protrusion, lip smacking,
blinking, grimacing , unnecessary facial movements.
 Management:
Maintenance dosages as low as possible
Changing medications
Monitoring periodically
 NEW-GENERATION ANTIPSYCHOTIC
DRUGS aripiprazole (Abilify)
 Side Effects
 Headache
 Anxiety
 Nausea
 Patient Teaching
 Adhering to medication regimen
 Antidepressant Drugs
SSRIs; TCAs; MAOIs
 Uses:
 Major depression, panic disorder and other anxiety
disorders, bipolar depression, psychotic depression
 Drink sugar free fluids and hard candies to ease
dry mouth.
 avoid calorie-laden beverages and candies –to
avoid dental caries, weight gain
 increase fluid and bulk forming food, exercise –
prevent constipation.
 Stool softeners but no laxative.
 Use of sunscreen – prevent burning.
 rising slowly – prevent hypotension or dizziness.
 Monitor drowsiness or sleepiness. Avoid driving.
 Medication can be taken 3-4 hrs. late. If more
than 4 hrs.late omit the dose.
 USES: major depressive illness, panic,
anxiety, bipolar, and psychotic
depression.
 Used primarily to treat the related
symptoms of dysphoria, anhedonia,
reduced energy level, change in appetite
and sleep, hopeless feelings, and suicidal
ideations.
 Interact with two monoamine
neurotransmitters:
Norepinephrine
Serotonin
 Tricyclic and the related cyclic
antidepressants.
 Selective serotonin reuptake inhibitors
( SSRIs)
 Monoamine oxidase inhibitors (MAOIs)
 Other antidepressants or non tricyclic
Effects:
Decreased symptom of depression
Sedative/ hypnotic
Treatment of depression associated with organic
illness and addiction
Amoxapine – with neuroleptic effects
Clomipramine – OCD
 Contraindications:
◦ Alcohol intake
◦ Dementia
◦ Suicidal clients ( toxic in overdose)
◦ Cardiac disease
◦ Multiple concominant medications ( TCA drug
indications)
◦ Daytime sedation, urinary retention, or
constipation
Teachings:
◦ Elderly – ½ of adult dosage.
◦ Alcohol – sedation and ataxia
◦ Suicidal precaution
2. MAOIs – has also positive effects on depression
 Low incidence of sedation and anticholinergic
effects,
◦ Effects:
Reduces atypical depression ( with weight gain
and hypersomnia) or refractory depression in
compliant patients.
 Side effects:
1. hypertensive crisis - if taken with foods
containing tyramine ( amino acids) or
sympatomimetics.( severe hypertension, high
temperature, tachycardia, diaphoresis,
arrhythmias.
 Drug interactions: potentially fatal with
Other MAOIs
SSRIs – serotonin syndrome
Meperidine ( Demerol)
Buspirone (Buspar)
Dextromethorpan
General anesthetics
 ◦ Toxic effects:
Cardiac toxicity, and are toxic in overdose
◦ Contraindications:
Noncompliant or poorly motivated patients,
insomnia, agitation.
 Teachings:
◦ Avoid foods with tyramine: (cheese, liver,
avocados, figs, anchovies, yeast extract, deli
meats, herring, beer, red wine, ale, chocolate,
protein extracts, and stimulants, diet pills, cold
and decongestant medications, nasal sprays.)
◦ Never Combine with SSRI
 fluoxetine (Prozac), paroxetine (Paxil), sertraline
(Zoloft), citalopram (Celexa), escitalopram
(Lexapro)
 Have replaced the cyclic drugs as the first
of choice in treating depression.
 Drug of choice for highly suicidal and
impulsive, no risk for lethal overdose.
 Suicide precautions: feel energized;
feels frustrated on peak effects of drugs.
◦ Treatment for anxiety disorders: OCD,
PTSD, and panic disorder, eating disorder,
enuresis
 Teachings:
◦ Effects not seen for 10-21 days- it will take
weeks longer.
◦ Relief not immediate but will be experienced –
do not discontinue prematurely.
 SEROTONIN NOREPINEPHRINE REUPTAKE INHIBITORS
(SNRIs)- decreased activity of norepinephrine
◦ Venlafaxine ( effexor)- mild sedation and anticholinergic
symptoms- depressed, sleeping excessively and little
energy
◦ Nefazodone(Serzone) -
◦ duloxetine ( Cymbalta)
 NOREPINEPHRINE DOPAMINE REUPTAKE INHIBITOR (NDRI)
◦ )- inhibits norepinephrine, serotonin, and dopamine
◦ Bupropion (wellbutrin, Zyban) – depression
◦ Zyban – nicotine addiction
ALPHA 2 ANTAGONIST ( NaSSA)
Mirtazapine (Remeron) boosts
norepinephrine/noradrenaline and serotonin by
blocking the a2adrenergic presynaptic receptors,
histamine receptor is also blocked – sedative
effect. Indicated for depression
SEROTONIN 2 ANTAGONIST/REUPTAKE
INHIBITORS (SARI)
Trazadone ( Desyrel)- blocks serotonin 2A
receptor potentially and blocks serotonin reuptake
pump less potentially.
Indication: insomnia, anxiety, depression
 USE: Bipolar Affective Disorder by
stabilizing mood and treating acute mania.
◦ A mood disorder - characterized by an
expansive emotional state, extreme excitement
and elation, flight of ideas, increased
psychomotor activity, violent and self
destructive behavior.
 Drugs used:
◦ Lithium

◦ Other drugs:
ANTICONVULSANT – Carbamazepine ( Tegretol),
Valproic acid ( Depakote, Depakene) are effective
mood stabilizer.
 Lithium normalizes the reuptake of neurotransmitter.
 Effects:
◦ Mood disorders: mood swings, excitement, elation, flight of
ideas, violent/self destructive behavior.
◦ Manic episodes – Bipolar disorder –maintenance
◦ Daily dosage: 900-3,600 mg; serum lithium level @ 1.0 -1.2
mEq/L.

 Toxic effects: severe diarrhea, vomiting, drowsiness,

muscle weakness, lack of coordination – renal failure,
coma, death.
 Management: Food; and propranolol for hand tremor.
Fluid intake 2-3 liters/day, balanced diet with
normal sodium intake.
Effectiveness—it takes 2-3 weeks
 Anticonvulsant –
◦ Cause a decrease in the catabolism of
GABA, resulting in increased
concentration of GABA in the CNS.

◦ Effects:
Treatment of bipolar disorder, acute mania, aggressive
behavior
Reduction in mood swings
Maintenance – bipolar and seizure disorder
 short term basis to decrease anxiety
,insomnia, OCD, PTSD, and alcohol
withdrawal.
 Used to reduce the manifestations of

anxiety: trembling, sweating, chest pain,

dizziness, fear of losing control or dying,
feeling of panic
 BENZODIAZEPINES – for relieving
anxiety, anticonvulsant and muscle
relaxant.
 Indications: panic and generalized
anxiety, alcohol detoxification and
withdrawal, skeletal muscle spasms.
 Single dose: induce sedation --- long
term may lead to dependence on the
drug.
 Clonazepam: also as anti -convulsant.
◦ SIDE EFFECTS:
◦
Physical and psychological dependence.
◦ CNS depression,
◦ drowsiness, confusion and lethargy
◦ sedation,
◦ poor coordination
◦ impairment of memory.
 Teaching:
Short term basis or results in drug dependence
Avoid alcohol and other CNS depressants.
Impairs ability to drive or operate machineries.
Not to be taken – prior or current drug
dependence.
Discontinuation  Withdrawal.
2. Non Benzodiazepine - Buspirone
( BuSpar) – acting as a partial agonist at
serotonin receptors.
Intended Effects:
Decreased anxiety
generalized anxiety disorders
Augmented antidepressant therapy
1.Amphetamines – 1930, used for psychiatric
treatment, CNS stimulation
Indication: ADHD in children and adolescents,
residual ADD in adult, narcolepsy.
Drugs: Methylphenidate (Ritalin), pemoline
(Cylert), dextroamphetamine (Dexedrine),
Nortriptyline (Pamelor)-best result.
Side effects:
 Anorexia, weight loss, nausea and irritability
 Growth and weight suppression
 Management:
 Avoid caffeine, sugar, and chocolate to lessen the
side effects.
 Drug holidays – usually weekends, holidays,
summer vacation.
 Uses:
 Aversion therapy for treatment of
alcoholism
 Action:
 Causes an adverse reaction when
alcohol is ingested
 Disulfiram
 Side Effects
 Fatigue
 Drowsiness
 Halitosis
 Tremor
 Impotence
 Patient Teaching
 Avoiding alcohol (including products such as

shaving cream, aftershave, cologne, many

OTC medications)
 Family should never administer without the

person's knowledge
 Cultural Considerations
 St John’s Wort and Kava – hypericum perforation L –
used for depression, pain, anxiety, insomnia and
premenstrual syndrome.
◦ Modulate serotonine, dopamine, and norepinephrine.
 KAVA – PIPER Methysticum Plant - anxiety reduction
 Nutritional Therapies and Supplements:
 Melatonin – (pineal gland) – treatment of insomnia and
jetlag.
 , Dimethylaminoethanol (DMAE)- ADHD, Alzheimer’s d.,
Huntinggton’s chorea, & Tardive Dyskinesia
 lecithin – precursor of acethylcholine – improve memory
and treat dementia.
OTHERBIOLOGIC
TREATMENTS:
 an electrical current - produce a gradmal seizure
 It causes changes in monoamine neurotransmitter systems
– similar to anti- depressants.

 Most clients require 6-10 treatments --- 20-25 treatments.

 Maintenance ECT – after initial therapy, q 6 weeks to 6
months.
Indications:
 Major depression – medications are ineffective; high
suicidal potential; dehydration; stupor; catatonia; delusions;
 Recurrent major depression
 Severe mania – not controlled by medications
 Schizophrenia – catatonic
 Movement disorders refractory to treatment -- e.g.
Parkinson’s disease, neuroleptic malignant syndrome,
tardive dyskenesia.
Types:
◦ Unmodified ECT - no medications are given prior to
treatment.
◦ Modified ECT - with medications prior to treatment.
Medications:
1. ATROPINE ; prototypical anticholinergic
◦ Used: Inhibition of salivation and respiratory tract
secretions – minimize aspiration.
◦ Vagal stimulation – decreases the potential for
cardiovascular depression
◦ SE: typical anticholinergic effects
2. Succinylcholine – ( Anectine) – ultra short
neuromuscular blocker.
◦ Prevents the musculoskeletal complications from induced
convulsions.
◦ Causes paralysis but not SEDATION
◦ SE: Proplonged apnea, respiratory depression,
fasciculations.
3. Methohexital (Brevital) – anesthesia – short acting
barbiturate;
◦ Induces a light coma preceding delivery of ECT.
◦ Pharmacokinetics: Onset: 10-15 seconds, duration- 5-7
minutes.
◦ Metabolism: liver, half life 4 hours.
◦ Dosage: 1.5mg/kg ( typically 50 – 120 mg)
◦ SE: Respiratory depression, hypotension, myocardial
depression, decreased cardiac output.
◦ Pre treatment evaluation: physical exam,
laboratory work – CBC, blood chemistries,
urinalysis) baseline memory abilities.
◦ Explain – confusion and disorientation upon
awakening.
◦ Consent – family members, and facility legal
staff should be involved.
◦ No benzodiazepines and barbiturates – no
sedation at night – It increases the seizure
threshold.
◦ A trained electrotherapist and an
anesthesiologist should be available.
◦ NPO – 8 hrs. prior to ECT.
◦ Atropine as per ordered given 1 hr. prior to
treatment/ IV immediately preceding treatment.
( reduces secretions and subsequent risk of
aspirations)
◦ Voiding prior to treatment
◦ VHairpins and dentures should be removed.
◦ Vital signs – baseline
◦ Reduce anxiety.
◦ IV line inserted.
◦ Electrodes are attached- held in place by a
rubber strap.
◦ Bite-block is inserted / mouth.
◦ Methohexical ( Brevital or other short acting
barbiturates) – causes immediate anesthesia
– preempting the anxiety associated with
waiting for the “ jolt to hit” and the anxiety
caused by succinylcholine ( w/c causes
paralysis but not sedation, thereby leaving
the patient conscious but unable to breathe)
1. Typical post anesthesia nursing care. ( the
client recovers quickly from the brief
procedure: V/S and observation are
important.
2. Upon recovery – provide fluids and food.
3. Assist in walking until stable.
4. Remain with client until alert
5. Re-orientation, reassure regarding memory
loss( confusion) --- time, place, person
6. Administer O2/ suction if necessary. ( before
and after the treatment)
7. Benzodiazepine – PRN ( awake agitated)
 Side Effects Of ECT:
◦ Memory loss for recent events.
◦ Difficulty learning new information
◦ Headaches, weight gain, hypertension,
occasional cardiac arrhythmias
 LIGHT THERAPY ( PHOTOTHERAPY)
◦ cycle of daylight and darkness
◦ circadian rhythm- seasonal variations in their
depressions.
◦ Exposing to an artificial light
 TRANSCRANIAL MAGNETIC STIMULATION ( Rtms)
◦ Stimulate cerebral cortex
◦ A time varying magnetic field will induce inhibitory and
excitatory neurons, modulating neuroplasticity iin the
brain
◦ At prefrontal cortex –depressed patient
 VAGUS NERVE STIMULATION
◦ A parasympathetic efferent nerve regualting autonomic
functions ( heart, gastric tone)
◦ Vagus nerve CNX- carries sensory information to the
brain from the neck, head, thorax, and abdomen,
◦ Changing serotonin, norepinephrine GABA and glutamate
– antidepressants.