1. Phenothiazines(prochlorperazine [Compazine], promazine HCl [Sparine], chlorpromazine HCl [Thorazine], thioridazine [Mellaril], trifluoperazine HCl [Stelazine], perphenazine [Trilafon], triflupromazine HCl [Vesprin], fluphenazine enanthate [Prolixin]).
2. Butyrophenones(haloperidol [Haldol, Serenace], droperidol fentanyl citrate [Innovar]).
3. Thiothixenes(chlorprothixene [Taractan], thiothixene [Navane])—chemically related to phenothiazines, with similar therapeutic effects.
4. Dibenzoxazepines—loxapine succinate [Loxitane])

1. Risperidone (Risperdal), olanzapine (Zyprexa), quetiapine (Seroquel), ziprasidone (Geodon).
1. Use—incremental increases for first 3 days to manage psychotic symptoms. Effective for both positive and negative symptoms of schizophrenia. Risperidone also available as long-acting injection (Risperdal Consta): IM q 2 wk in alternate gluteal muscle site; delayed onset of action. Benefit: lower incidence of extrapyramidal symptoms.
2. Assessment—side effects: same as for typical antipsychotics but with higher incidence of weight gain.
2. Clozapine (Clozaril).
1. Use—those who do not respond to other neuroleptic antipsychotic drugs; offers relief from schizophrenic symptoms: hallucinations, delusions, flat affect, apathy.
2. Assessment—side effects:
1. Most serious is agranulocytosis (potentially fatal; reversible if diagnosed within 1 to 2 weeks of onset).
1. Symptoms of agranulocytosis: infection, high fever, chills, sore throat, malaise, ulceration of mucous membranes.
2. Laboratory value: Discontinue drug with white blood cell (WBC) count less than 2,000 mcg/L or granulocyte count less than 1,000 mcg/L.
2. Other side effects: seizures, tachycardia, orthostatic hypotension.
3. Caution: must have weekly blood tests for WBC count; do not resume clozapine once it is discontinued, due to side effects.

1. Hypersensitivity effects:
1. Blood dyscrasia—agranulocytosis, leukopenia, granulocytopenia.
2. Skin reactions—solar sensitivity, allergic dermatitis, flushing, blue-gray skin.
3. Obstructive jaundice.
2. Extrapyramidal symptoms (EPS) affecting voluntary movement and skeletal muscles
1. Parkinsonism (also called pseudoparkinsonism)—tremors, cogwheel rigidity, shuffling gait, pill-rolling, masklike facies, salivation, and difficulty starting muscular movement (dyskinesia).
2. Dystonia—limb and neck spasms (torticollis), extensive rigidity of back muscles (opisthotonos), oculogyric crisis, speech and swallowing difficulties, and protrusion of tongue.
3. Akathisia—motor restlessness, pacing, foot tapping, inner tremulousness, and agitation.
4. Tardive dyskinesia (TD)—excessive blinking; vermiform tongue movement; stereotyped, abnormal, involuntary sucking, chewing, licking, and pursing movements of tongue and mouth; grimacing, frowning, rocking.
1. Cause—long-term use of high doses of antipsychotic drugs.
2. Predisposing factors—age, women, organic brain syndrome (OBS); history of electroconvulsive therapy (ECT) or use of tricyclic antidepressants or anti-Parkinson drugs.
3. Potentiates central nervous system depressants.
4. Orthostatic hypotension (less with butyrophenones).
5. Anticholinergic effects (atropine-like)—dry mouth, stuffy nose, blurred vision, urinary retention, and constipation.
6. Pigmentary retinopathy—ocular changes (lens and corneal opacity).
7. Photosensitivity.
8. Weight gain (especially true of the atypical antipsychotic medications).
9. Neuroleptic malignant syndrome (NMS):
1. Description: a rare complication of antipsychotic drugs, with a rapid progression (1 to 3 days) and a 20% mortality rate. It is a serious medical emergency for which early recognition of symptoms is critical. Onset: at start, after change, or dose increase, when used with combination of medications.
2. Assessment:
1. ↑ Vital signs: extreme temperature of 107°F (leading to seizures, diaphoresis, confusion, → stupor, coma), fluctuating BP, pulse: irregular, tachycardia.
2. Laboratory values: increased creatine phosphokinase (CPK), increased potassium, leukocytosis (↑ WBC).
3. Renal failure.
4. Muscular: parkinsonian rigidity (leadpipe skeletal muscle rigidity) that leads to dyspnea and dysphagia, tremors, dyskinesia.
5. At risk: clients with organic brain disorders and severe dehydration.
3. Medical treatment:
1. Discontinue all drugs STAT.
2. Institute supportive care.
3. Administer bromocriptine (Parlodel) or dantrolene (Dantrium), dopamine function–enhancing substances (e.g., levodopa, carbidopa, bromocriptine, amantadine).
4. Health teaching: avoid overheating or dehydration; diet: ↑ fluids, ↑ fiber, hard candy.

1. Goal: anticipate and check for side effects.
1. Protect the person's skin from sunburn when outside.
2. For hypotension: take BP and have person lie down for 30 minutes, especially after an injection.
3. Watch for signs of blood dyscrasia: sore throat, fever, malaise.
4. Observe for symptoms of hypothermic or hyperthermic reaction due to effect on heatregulating mechanism.
5. Observe for, withhold drug for, and report early symptoms of: jaundice and bile tract obstruction; high fever; upper abdominal pain, nausea, diarrhea; rash; monitor liver function.
6. Relieve excessive mouth dryness: mouth rinse, increase fluid intake, gum or hard candy.
7. Relieve gastric irritation, constipation: take with and increase fluids and roughage in diet.
8. Observe for and report changes in carbohydrate metabolism (glycosuria, weight gain, polyphagia); change diet.
9. Check blood sugar levels periodically.
2. Goal: health teaching.
1. Dangers of drug potentiation with alcohol or sleeping pills.
2. Advise about driving or occupations where blurred vision may be a problem.
3. Caution against abrupt cessation at high doses.
4. Warn regarding dark urine (sign of jaundice, urinary retention).
5. Have client with respiratory disorder breathe deeply and cough (drug is a cough depressant).
6. Need for continuous use of drug and follow-up care.
7. Prompt reporting of hypersensitivity symptoms: fever, laryngeal edema; abdominal distention (constipation, urinary retention); jaundice; blood dyscrasia.

1. Behavior is less agitated.
2. Knows side effects to observe for, lessen, and/or prevent.
3. Continues to use drug.

1. Use—elevate mood in depression, increase physical activity and mental alertness; may bring relief of symptoms of depression so that client can attend individual or group therapy; bipolar disorder, depressed; dysthymic disorder; sleep disturbance; agitation.
2. Assessment—side effects:
1. Behavioral—activation of latent schizophrenia (hallucinations); hypomania; suicide attempts; mental confusion. Withhold drug if observed.
2. Central nervous system (CNS)—tremors, seizures, ataxia, jitteriness, irritability.
3. Autonomic nervous system (ANS)—dry mouth, nasal congestion, aggravation of glaucoma (blurred vision), constipation, urinary retention, edema, paralysis, ECG changes (flattened T waves; arrhythmia severe in overdose).
3. Nursing care plan/implementation:
1. Goal: assess risk of suicide during initial improvement—careful, close observation.
2. Goal: prevent risk of tachycardia and cardiac arrhythmias and orthostatic hypotension—use caution with client with cardiovascular disease, hyperthyroidism, having ECT or surgery (gradually discontinue 2 to 3 days before surgery). Monitor BP, pulse twice a day; ECGs, 2 to 3/wk until dose adjusted.
1. Avoid long hot showers or baths.
3. Goal: observe for signs of urinary retention, constipation: monitor I&O and weight gain (encourage exercise).
1. Fiber diet.
2. Reduced calories.
4. Goal: cautious drug use with glaucoma or history of seizures. Observe seizure precautions due to lowered seizure threshold.
5. Goal: health teaching.
1. Advise against driving car or participating in activities requiring mental alertness, due to sedative effects.
2. Encourage increased fluid intake and frequent mouth rinsing to combat dry mouth; use candy, ice; take with food.
3. Avoid smoking, which decreases drug effects.
4. Avoid use of alcohol and other drugs, due to adverse interactions, especially over-the-counter (OTC) drugs (e.g., antihistamines).
5. Advise of delay in desired effect (2 to 4 weeks).
6. Instruct gradual discontinuance to avoid withdrawal symptoms.
4. Evaluation/outcome criteria: diminished symptoms of agitated depression and anxiety.

1. Assessment—side effects:
1. Behavioral—may activate latent schizophrenia, mania, excitement.
2. CNS—tremors; hypertensive crisis ( avoid: cheese, colas, caffeine, red wine, beer, yeast, chocolate, chicken liver, and other substances high in tyramine or pressor amines [e.g., amphetamines and cold and hay fever medication]); intracerebral hemorrhage; hyperpyrexia.
3. ANS—dry mouth, aggravation of glaucoma, bowel and bladder control problems; edema, paralysis, ECG changes (severe arrhythmia in overdose).
4. Allergic hepatocellular jaundice.
2. Nursing care plan/implementation:
1. Goal: reduce risk of hypertensive crisis—diet restrictions of foods high in tyramine content.
2. Goal: observe for urinary retention—measure I&O.
3. Goal: health teaching.
1. Therapeutic response takes 2 to 3 weeks.
2. Food and alcohol restrictions: avocados, bananas, raisins, licorice, chocolate, aged cheese, yogurt, sour cream, papaya, figs, overripe fruit, sausages, salami, bologna, liver, herring, soy sauce, meat tenderizers, red wine, beer, caffeine, cola, yeast, chocolate.
3. Change position gradually to prevent postural hypotension.
4. Report any stiff neck, palpitations, chest pain, headaches because of possible hypertensive crises (can be fatal).
5. Take no nonprescribed drugs.
3. Evaluation/outcome criteria:
1. Improvement in sleep, appetite, activity, interest in self and surroundings.
2. Lessening of anxiety and complaints.

(SSRIs) (fluoxetine [Prozac], paroxetine [Paxil], sertraline [Zoloft], fluvoxamine [Luvox], citalopram hydrobromide [Celexa])—SSRIs are generally the first-line choice because they have fewer side effects, do not require blood monitoring, and are safe in overdose.

1. Assessment—side effects: CNS stimulation—insomnia, agitation, headache (especially with Prozac); weight loss; sexual dysfunction (men: impotence; women: loss of orgasm, decreased libido). Other side effects are similar to TCAs (dry mouth, sedation, nausea).
2. Nursing care plan/implementation:
1. Goal: reduce insomnia, agitation—take early in day; avoid alcohol, caffeine; teach relaxation before sleep time.
2. Goal: reduce headaches—give analgesics.
3. Goal: prevent weight loss—weigh every day or every other day, same time and scale; do not use with clients who are anorexic.
3. Evaluation/outcome criteria:
1. Improvement in mood and hygiene, thought and communication patterns.
2. Has not harmed self.
3. No significant anticholinergic and cardiovascular side effects.

1. Use—acute alcohol withdrawal, tension, and irrational fears; anxiety disorders, preoperative sedation; have muscle relaxant and anticonvulsant properties.
2. Assessment—side effects: hypotension, drowsiness, motor uncoordination, confusion, skin eruptions, edema, menstrual irregularities, constipation, extrapyramidal symptoms, blurred vision, lethargy; increased or decreased libido.
3. Nursing care plan/implementation:
1. Goal: administer cautiously, because drug may:
1. Be habituating (causing withdrawal convulsions; therefore, gradual withdrawal necessary).
2. Potentiate CNS depressants.
3. Have adverse effect on pregnancy.
4. Be dangerous for those: with suicidal tendencies or severe psychoses, narrow-angle glaucoma, elderly or debilitated.
2. Goal: reduce GI effects—crush tablet or take with meals or milk; give antacids 1 hour before.
3. Goal: monitor effects on liver function: Periodic liver function tests and blood counts, especially with upper respiratory infection, hepatic or renal dysfunction.
4. Goal: reduce risk of—hypotension, respiratory depression, phlebitis, venous thrombosis.
5. Goal: health teaching.
1. Advise against suddenly stopping drug (withdrawal symptoms begin in 5 to 7 days).
2. Talk with physician if plans to be or is pregnant or lactating.
3. Urge to drink fluids.
4. Avoid: alcohol, OTC drugs (due to potentiation of other CNS depressants), and heavy smoking and caffeine.
5. Problem with habituation.
4. Evaluation/outcome criteria: decreased alcohol withdrawal symptoms or preoperative anxiety; no seizures or confusion; relief of tension, anxiety, skeletal muscle spasm.

1. Use—acute manic attack and prevention of recurrence of cyclic manic-depressive episodes of bipolar disorders.
2. Assessment:
1. Side effects—levels from 1.6 to 2.0 mEq/L may cause: blurred vision, tinnitus, tremors, nausea and vomiting, severe diarrhea, polyuria, polydipsia; ataxia. Levels greater than 2 mEq/L may cause: motor weakness, headache, edema, and lethargy. Levels greater than 2.5 mEq/L may exhibit signs of severe toxicity: arrhythmias, myocardial infarction (MI), cardiovascular collapse, oliguria/anuria; neurological (twitching, marked drowsiness, slurred speech, dysarthria, athetotic movements, convulsions, delirium, stupor, coma).
2. Precautions —cautious use with clients on diuretics; with abnormal electrolytes (sweating, dehydrated, and clients who are postoperative); with thyroid problems, on low-salt diets; with heart failure; with impaired renal function; with pregnancy and lactation; risk of suicide.
3. Dosage—therapeutic level 0.8 to 1.6 mEq/L; dose for maintenance 300 to 1,200 mg/day; toxic level greater than 2.0 mEq/L; blood sample drawn in acute phase 10 to 14 hours after last dose, taken three times a day.
3. Nursing care plan/implementation:
1. Goal: anticipate and check for signs and symptoms of toxicity.
1. Reduce GI symptoms: take with meals.
2. Check for edema: daily weight, I&O.
3. Monitor blood levels greater than 2.0 mEq/L for side effects and signs of toxicity: nausea, vomiting, diarrhea, anorexia, ataxia, weakness, drowsiness, fine tremor or muscle twitching, slurred speech.
4. Monitor results from repeat thyroid and kidney function tests.
5. Withhold drug and notify physician when 1.5 mEq/L is reached.
6. Monitor vital signs 2 to 3 times/day (pulse irregularities, hypotension, arrhythmias).
2. Goal: report fever, diarrhea, prolonged vomiting immediately.
3. Goal: monitor effect (therapeutic and toxic) through blood samples taken:
1. 10 to 14 hours after last dose.
2. Every 2 to 3 days until 1.6 mEq/L is reached.
3. Once a week while in hospital.
4. Every 2 to 3 months to maintain blood levels less than 2 mEq/L.
4. Goal: health teaching.
1. Advise client of 1-to 3-week lag time for effect.
2. Urge to drink adequate liquids (2 to 3 L/day), ice; strict oral hygiene.
3. Report: polyuria and polydipsia.
4. Diet: avoid caffeine, crash diets, diet pills, self-prescribed low-salt diet, alcohol, antacids, high-sodium foods (which increase lithium excretion and reduce drug effect); take with meals. Use sugarless candy.
5. Caution against driving, operating machinery that requires mental alertness until drug is effective.
6. Warn not to change or omit dose.
4. Evaluation/outcome criteria:
1. Changed facial affect.
2. Improved posture, ability to concentrate, sleep patterns; mood is stabilized.
3. Assumption of self-care.
4. No signs of lithium toxicity.

1. Use—counteract drug-induced extrapyramidal reactions.
2. Assessment:
1. Trihexyphenidyl HCl:
1. Side effects—anticholinergic: dry mouth, blurred vision, dizziness, nausea, constipation, drowsiness, urinary hesitancy or retention; pupil dilation; headache; weakness; tachycardia.
2. Precautions—cautious use with: cardiac, liver, or kidney disease or obstructive gastrointestinal-genitourinary disease, benign prostatic hyperplasia (BPH), or myasthenia gravis. Do not give if glaucoma present.
2. Benztropine mesylate—side effects: same as for trihexyphenidyl HCl plus:
1. Effect on body temperature (hyperpyrexia) may result in life-threatening state (heatstroke).
2. GI distress.
3. Inability to concentrate, memory difficulties, and mild confusion (often mistaken for senility); drowsiness.
4. May lead to toxic psychotic reactions.
5. Subjective sensations—light or heavy feelings in legs, numbness and tingling of extremities, light-headedness or tightness of head, and giddiness.
3. Nursing care plan/implementation:
1. Goal: relieve GI distress by giving after or with meals or at bedtime.
2. Goal: monitor adverse effects.
1. Hypotension, tachycardia: check pulse, blood pressure; increased temperature; decreased sweating.
2. Constipation and fecal impaction: add roughage to diet.
3. Dry mouth: increase fluid intake; encourage frequent mouth rinsing; offer sugarless candy or gum, ice.
4. Blurred vision: suggest reading glasses.
5. Dizziness: assist with ambulation; use side rails.
6. Urinary retention: maintain I&O.
3. Health teaching:
1. Avoid driving, and limit activities requiring alertness.
2. Delayed drug effect (2 to 3 days).
3. Potential abuse due to hallucinogenic effects.
4. Avoid alcohol and other CNS depressants; avoid hot weather.
5. Take with food.
6. Do not stop drug abruptly.
4. Evaluation/outcome criteria:
1. Less rigidity, drooling, and oculogyric crisis.
2. Improved gait, balance, posture.
3. Has not experienced symptoms of hyperthermia.