Psychiatric Nursing

Introduction

Bipolar disorder is a disorder of mood, in which a person has episodes of both elevated and depressed mood. These episodes of major change of mood are associated with distress and disturbance of function. People with bipolar disorder can take control of their illness by working with a multidisciplinary team, and utilising the support of family and friends.

Treatment of bipolar disorder

When people with bipolar disorder experience acute mania, immediate referral to a specialist psychiatric service is usually necessary. Diagnosing bipolar disorder can be very complex and the first assessment may not provide a definitive diagnosis. To confirm the diagnosis, a mental health professional (usually a psychiatrist) should undertake a comprehensive assessment.

1. Hospitalization:

• Abnormal Behaviour ( loss of career, family disintegration)
• Delirious mania.

Comprehensive clinical assessment

Their full medical history will be taken which include:

• a) A 'risk assessment', which assesses a person's potential for experiencing harms associated with mania. These may include aggression, financial harm, risky sexual behaviour or vulnerability to exploitation, and the possibility of contracting communicable diseases (such as HIV, Herpes or Hepatitis C) due to sexual behaviour.
• b) Past episodes of psychiatric problems. If the person has established bipolar disorder, the doctor will also check their compliance with mood stabiliser medications and cease any antidepressants.
• c) Physical examination. Its purpose is to exclude organic causes of the manic behaviour, such as a neurological disorder, systemic disease, the misuse of alcohol or drugs or other substances, or the use of prescription medication.
• d) Also assess any physical consequences of mania (eg, dehydration, emaciation or injuries).
• e) A routine physical investigation (urea and electrolytes, full blood count, liver function tests, thyroid function test, and therapeutic drug monitoring of mood stabiliser serum concentrations).
• f) Finally, other investigations will be carried out if needed. These may include a brain scan, cognitive/dementia screen, and an electroencephalography (EEG).

Once this comprehensive assessment is carried out, a treatment plan is developed with the person to tailor the treatment of bipolar disorder to his or her individual needs.

Phases of treatment:

1.  Acute phase: the goal of the acute phase of treatment is symptom reduction and stabilization. Therefore, for the first few weeks of treatment, mood stabilizers may need to be combined with antipsychotics or benzodiazepines, particularly if the patient has psychotic symptoms, agitation or insomnia. If the clinical situation is not an emergency, it is desirable to start patients on a low dose and gradually increase the dose until the maximum therapeutic benefits has been achieved. Once stabilization is achieved, the frequency of serum level monitoring should be 1 to 2 weeks during the first 2 months and every 3 to6 months during the long term maintenance. 

2.  Continuum phase: the goal of this phase is to prevent relapse of the current episode or cycling into the opposite pole. It lasts about 2 to 9 months after acute symptoms have resolved. The usual pharmacologic procedure in this phase is to continue the mood stabilizer while closely monitoring the patient for signs or symptoms of relapse.

3. Maintenance phase: the goal of this phase is to sustain remission and to prevent new episodes. It is recommended that long term or life time prophylaxis with a mood stabilizer be instituted after two manic episodes or after one manic episode if t is severe or if there is family history of bipolar disorder.

4. Discontinuation: like major depressive disorder, the course of bipolar disorder is typically recurrent and progressive. Therefore, the same issues and principles regarding the decision to continue or discontinue pharmacotherapy apply.

2. Somatic treatment:

Acute treatment of manic episodes

Medications are the main way of managing an acute manic episode. The aim of the medications is to stabilise mood.

Components to the drug management of acute mania

• Commencement of a mood stabiliser (lithium, sodium valproate, carbamazepine or olanzapine). Mood stabilisers act upon the elevated mood but take about one week to start working for most people.
• Concurrent use of an antipsychotic or benzodiazepine (or a combination of these). These medications calm or sedate the person with mania as a temporary procedure, until the mood stabiliser starts to help the person to feel better.

If the manic episode does not respond to first line treatment

The timing of the decision to change treatment will depend on both clinical urgency and the degree of response, which varies from person to person. It can be

• Increase the dose and/or blood levels of the mood stabiliser
• Add an additional antipsychotic such as Risperidone, olanzapine or haloperidol.

If these strategies have being tried and there is still no relief from symptoms, electroconvulsive therapy (ECT) may be considered.

The benzodiazepine or antipsychotic should be withdrawn once the acute episode has resolved and just the mood stabiliser should be continued.

Management of mixed bipolar disorder

Medication options for the treatment of a mixed episode

The treatment of mixed episodes involves the choice of any of these medications:

• Valproate
• Carbamazepine
• Lithium
• Olanzapine

TREATMENT OF BIPOLAR DEPRESSION 

Comprehensive clinical assessment - bipolar depressive episode

Clinical assessment requires patient cooperation and may not be possible if the patient is severely slowed physically and mentally.

It is essential to obtain collaborative information especially in cases where cognitive impairment is suspected:

• Suicide risk assessment
• Exclude organic causes (neurological disorder, systemic disease, substance misuse, drug induced)
• Sophisticated appraisal of possible psychotic symptoms - especially pathological/delusional guilt and hallucinations
• Check compliance with mood stabilisers
• Conduct routine haematological and biochemical investigations (urea and electrolytes, full blood count, thyroid function tests, therapeutic drug monitoring)
• Additional investigations if indicated (eg, brain scan, cognitive/ dementia screen).

Pharmacological intervention - depressive episode

Continuing failure to respond

• Confirm correct diagnosis
• Re-evaluate psychological/social factors responsible for maintaining depression
• Consider adjunctive psychological therapies

Medications for long-term treatment of bipolar disorder

Long-term treatment is often called the 'maintenance' phase of treatment or 'relapse prevention'. The goal of long-term treatment for bipolar disorder is to maintain a stable mood and to prevent a relapse of mania or a depressive episode. 

3. Psychosocial treatments

Learning to live with a continuous illness that is episodic is a major issue for people with bipolar disorder and their families.

• As an adjunct to somatic treatment.
• Repeated episodes of mania and depression tend to lead to increased rates of divorce, family breakdown, and unemployment, a break in social networks and education, and financial difficulties

a) Cognitive Behaviour Therapy: Therapy aims at correcting the depressive negative conditions e.g. Hopelessness, worthlessness and replacing them by new cognitive ideas and behavioral responses. It is used in mild to moderate depression and can be used along with somatic treatment.

b) Interpersonal Therapy: Therapy attempts to recognize and explore interpersonal stressors, role disputes and transitions, social isolation or social skill deficits, which acts as precipitants for depression.

c) Psychoanalytic psychotherapy: Therapy aims at changing the personality itself rather than just ameliorating the symptoms. Their usefulness is uncertain.

d) Behaviour Therapy: This includes the various short term modalities like social skill training, problem solving techniques, assertiveness training, self control therapy, activity scheduling and decision making techniques. It is useful in mild cases of depression.

e) Group Therapy: Group psychotherapy can be useful in mild cases of depression. It is very useful method of    psycho education in both recurrent depressive disorder and bipolar disorder.

f) Family and Marital Therapy: The main purpose is to ensure continuity of treatment and to reduce the intrafamilial and interpersonal difficulties and to reduce or modify stressors which may help in a faster and complete recovery.

4. Complementary (non prescribed) medications

• Herbal remedies and other natural supplements have not been well studied and their effects on bipolar disorder are not fully understood.
• Omega-3 fatty acids (found in fish oil) are being studied to determine their usefulness for long-term treatment of bipolar disorder.
• St John's Wort (hypericum perforatum) is a herb which is being studied in regard to depression, but there is some evidence that it can reduce the effectiveness of some medications, can react with some prescribed antidepressants, or may cause a switch into mania.

Conclusion

People who manage their bipolar disorder well provide assurance and hope that living with it and achieving a good lifestyle is now possible. The wider community is now more aware and understanding of bipolar disorder, there is support and there are highly effective treatments now available. While there remains no cure, there is no reason to think that treatments will not improve even further in the future. Future research will aim to reduce the side effects of existing treatments and to develop better ones. With treatment, a person with bipolar disorder can lead a good quality of life.

References:

1. Townsend M C Psychiatric mental health nursing- concepts of care. (5 ^th edn). Philadelphia: F.A Dais company; 2005.
2. Kaplan. Comprehensive textbook of psychiatry (9 ^th edn). Philadelphia: Williams & Wlkins; 2007.

Introduction

The nurse may assess a client with a known history of schizophrenia or a client with a unknown to the mental health care system. Assessment begins with an interview and focuses on establishing the client's signs and symptoms, degree of impairment in the thought process, risk for self injury or violence towards others, and available support systems. The nurse may wish to interview the client with a family member or a friend to obtain all information regarding family history, previous episodes of psychotic symptoms, onset of symptoms, and thoughts of suicide or violent behaviour.

Assessment:

1.       Assessing mood and cognitive state:

• The nurse is alert for the signs and symptoms such as :
• Absence of expression of feelings
• Language content that is difficult to follow
• Pronounced paucity of speech and thoughts
• Preoccupation with odd ideas
• Ideas of reference
• Expression of feelings of unreality
• Evidence of hallucinations such as comments that the way they things appear, sound, or smell is different.

The nurse can also inquire about recent stressors, which can precipitate a psychotic episode in the client with a thought disorder, and signs and symptoms of impending relapse. These signs include disturbed sleep cycle, significant mood changes( mostly depression), decreased appetite, and somatic complaints such as headache, malaise, and constipation. Relapse eads to client withdrawal, resistance, and preoccupation with psychotic symptoms. 

2.       Assessing potential for violence:

The nurse assess the potential for violence by inquiring about the following:

• History of violent or suicidal behavior
• Extreme social isolation
• Feeling of persecution or being controlled by others.
• Auditory hallucinations that tells the client to commit violent acts.
• Concomitant substance use.
• Medication noncompliance
• Feelings of anger, suspiciousness, or hostility.

3.       Assessing social support:

• Availability and responsiveness of a social support network and the client's role in the family and community are important factors in nursing assessment

4.       Assessing knowledge

• The nurse assess the client's and families knowledge of schizophrenia, its treatment, and the potential for relapse. Adherence to medication regimens and other therapeutic schedules is bolstered when cients and families understand the biologic basis of the illness, signs of recovery and relapse, and their role in treatment.

NURSING DIAGNOSIS:

• 1. Disurbed thought process related to biochemical imbalances, as evidenced by hypervigilence, distractibility, por concentration, disordered thought sequencing, inappropriate responses, and thinking not based in reality.
• 2. Disturbed sensory perception( auditory/visual) related to biochemical imbalances, as evidencd by auditory or visual hallucinations.
• 3. Risk for other- directed or self directed violence related to delusional thoughts and hallucinatory commands, history of childhood abuse, or panic,as evidencedby overt aggressive acts, threatening stances, pacing, or suicidal ideation or plan.
• 4. Social isolation related to alterations in mental status and an ability to engage in satisfying personal relationships, as evidenced by sad, flat affect, absence of supportive significant others, withdrawal, uncommunicativeness and inability to meet the expectations of others.
• 5. Noncompliance with medication regimen related to health beliefs and lack of motivation, as evidenced by failure to adhere to medication schedule.
• 6. Ineffective coping related to disturbed thought process as evidenced by inability to meet basic needs.
• 7. Interrupted family process related to shift in health status of a family member and situational crisis, as evidenced by changes in the family's goals, plans, and activities and changes in family pattern and rituals.
• 8. Risk for ineffective family management of therapeutic regimen related to knowledge deficit and complexity of client,s healthcare needs.

 Disturbed Thought Processes

• Convey acceptance of client's need for false belief but that you do not share the belief
• Do not argue or deny the belief
• Reinforce and focus on reality   
• If client is suspicious
•  Consistent staff
• Honest, keep all promises

Disturbed Sensory Perception Auditory/Visual

• Observe for signs of hallucinations
• Avoid touching client without warning
• Do not reinforce the hallucination - let the client know that you do not share the perception - "Even though I know the voices are real to you, I do not hear them"
• Help client understand connection between anxiety and hallucinations
• Try to distract

Social Isolation

• Convey accepting attitude by making brief, frequent contacts. Show unconditional positive regard
• Offer to be with client during group activities that he/she finds frightening
• Give recognition and positive reinforcement for client voluntary interactions with others

Self Care Deficit

• Provide assistance as appropriate
• Encourage independence - positive reinforcement
• concrete communications

Impaired verbal communication

• Seek validation and clarification
• Consistent staff
• Verbalizing the implied
• Orient to reality

References:

1. Schultz J M & Videbeck S L. Lippincott,s Manual of psychiatric nursing care plans. (7 th edn). Philadelphia: Lippincott. Williams and Wilkins.
2. Mohr W K. Psychiatric mental health nursing ( edn 6).Lippincotts, Williams and Wilkins. Philadelphia:
3. Fortinash K M 7 Worret H. Psychiatric nursing care plan. ( 5 th edn). Mosby publications; 2003.

Introduction

Inhalant drugs (also called inhalants or volatile substances) are volatile hydrocarbons such as toluene, trichloroethylene, trichloroethane, dichloromethane, gasoline and butane. These chemicals are sold in four commercial classes:

• 1. Solvents for glues and adhesives.
• 2. Propellants for aerosol paint sprays, hairsprays, frying pan sprays, and shaving cream
• 3. Thinners( paint products)
• 4. Fuels

At room temperature these compounds volatilize to gaseous fumes that can be inhaled through the nose or mouth, entering the blood stream by transpulmonary route.

Epidemiology

Inhalant substances are easily available, legal and inexpensive. These three factors contribute to the high use of inhalants among poor persons and young persons. According to DSM IV- TR about 6% of persons in the United States had used inhalants at least once, and about 1% of persons are current users. In one study of high school seniors, 18% reported having used inhalants at least once, and 2.7% reported of having used inhalants within the preceding month.

Patterns of use/ abuse

• Methods of use include huffing"- a procedure in which a rag soaked with the substance is applied to the mouth and nose and the vapours breathed in.
• Another common method is called "bagging" in which the substance is placed in a paper or plastic bag and inhaled from the bag by the user. They may also be inhaled directly from the container or sprayed in the mouth or nose.
• Children with inhalant disorder may use inhalants several times a week, often weekends and after school. Adults with inhalant dependence may use the substance at varying times during each day, or they may binge on the substance during a period of several days.

Neuropharmacology

• Inhalants usually act as a central nervous system depressant.
• Tolerance for inhalants can develop, although withdrawal symptoms are usually fairly mild and are not classified as disorders in DSM-IV-TR. Inhalants are rapidly absorbed through the lungs and rapidly delivered to the brain.
• The effects appear within 5 minutes and can last for 30 minutes to several hours, depending on the inhalant substance and the dose. The concentration of the many inhalant substances is increased when used in combination with alcohol.
• Inhalants are detectable in the blood for 4-10 hours after use, and blood samples should be taken in the emergency room when inhalant use is suspected.

Inhalant dependence and inhalant use:

Most persons use inhalants for a short time without developing a pattern of long term use resulting in dependence and abuse.

Inhalant intoxication:

• The DSM IV -TR diagnostic criteria for inhalant intoxication specify the presence of maladaptive behavioural changes and at least two physical symptoms.
• The intoxicated state is often characterized by apathy; diminished social and occupational functioning, impaired judgement, and impulsive or aggressive behaviour and it can be accompanied by nausea, anorexia, Nystagmus, depressed reflexes and diplopia. With high doses and long exposures, a user's neurological status can progress to stupor and unconsciousness, and a person may later be amnestic for the period of intoxication.
• Clinicians can sometimes identify a recent user of inhalants by rashes around the patient's nose and mouth, unusual breath odours, the residue of the inhalant substances on the patient's face, hands or clothing and irritation of the patient's eyes, throat, lungs and nose.

DSM -IV diagnostic criteria for inhalant intoxication:

• a) Recent intentional use or short term , high dose exposure to volatile inhalants(excluding anaesthetic gases and short acting vasodilators)
• b) Clinically significant maladaptive behavioural or psychological changes ( eg: belligerence, assaultiveness, apathy, impaired judgement, impaired social or occupational functioning) that developed during, or shortly after, use of or exposure to volatile inhalants.
• c) Two( or more) of the following signs, developing during, or shortly after, inhalant use or exposure:

• d) The symptoms are not due to a general medical condition and are not better accounted for by another mental disorder.

Inhalant intoxication delirium

Delirium can be induced by the effects of the inhalants themselves, by pharmacodynamic interactions with other substances, and by hypoxia, that may be associated with either the inhalant or its method of inhalation.

If the delirium results in severe behavioural disturbances, short term treatment with a dopamine receptor antagonist, such as haloperidol may be necessary.

Benzodiazepines should be avoided because of the possibility of increasing the patient's respiratory depression.

Inhalant induced persisting dementia

Inhalant induced persisting dementia as with delirium, may result from the neurotoxic effects of the inhalants themselves; the neurotoxic effects of metals commonly used as inhalants, or the effects of frequent and prolonged periods of hypoxia. The dementia caused by inhalants is likely to be irreversible in all but the mildest cases.

Inhalant induced psychotic disorder

Clinicians can specify hallucinations or delusions as the predominant symptoms. Paranoid states are probably the most common psychotic syndromes during inhalant intoxication.

Inhalant induced mood disorder and inhalant induced anxiety disorder

Inhalant induced mood disorder and inhalant induced anxiety disorder are DSM IV TR diagnoses that allow the classification of inhalant related disorders characterized by prominent mood and anxiety symptoms. Depressive disorders are the most common mood disorders associated with inhalant use, and panic disorders and generalized anxiety disorder are the most common anxiety disorders.

DSM- IV Diagnostic criteria for inhalant disorder not otherwise specified.

This category is for disorders associated with the use of inhalants and is not classifiable as inhalant dependence, inhalant abuse, inhalant intoxication, Inhalant abuse, Inhalant intoxication, Inhalant intoxication delirium, Inhalant induced persisting dementia, Inhalant induced psychotic disorder, with delusions, Inhalant induced psychotic disorder, with hallucinations, Inhalant induced mood disorder, and Inhalant induced anxiety disorder.

 Clinical features:

• In small initial doses, inhalants can be disinhibiting and produce feelings of euphoria and excitement and pleasant floating sensations, the effects for which persons presumably use the drugs.
• High doses of inhalants can cause psychological symptoms of fearfulness, sensory illusions, auditory and visual hallucinations, and distortions of body size. The neurological symptoms can include slurred speech, decreased speed of talking, and ataxia.
• Long term can be associated with irritability, emotional lablity and impaired memory.
• Tolerance for inhalants does develop; although not recognized by DSM-IV TR , a withdrawal syndrome can accompany the cessation of inhalant use.
• The withdrawal syndrome does not occur frequently; when it does it can be characterized by sleep disturbances, irritability, jitteriness, sweating, nausea, vomiting, tachycardia, and delusions and hallucinations.

Effects on the body

Inhalants are absorbed the lungs and reach the CNS very rapidly. Inhalants generally act as a CNS depressant. The effects are relatively brief, lasting from several minutes to a few hours, depending on the specific substance and amount consumed.

a)      Central nervous system:

• Inhalants can cause both central nervous system and peripheral nervous system damage, which may be permanent. Neurological deficits, such as generalized weakness and peripheral neuropathies, may be evident.
• Other CNS effects that have been reported with heavy inhalant use include cerebral atrophy, cerebellar degeneration, and white matter lesions resulting in cranial nerve or pyramidal tract signs.

b)     Respiratory effects:

• Upper or lower airway irritation, including increased airway resistance, pulmonary hypertension, acute respiratory distress, coughing, sinus discharge, dyspnoea, rales, or rhonchi
• Rarely cyanosis may result from pneumonitis or asphyxia.
• Death may occur from respiratory or cardiovascular depression.

c)      Gastrointestinal effects:

• Abdominal pain, nausea and vomiting
• Rashes around the individual's nose or mouth
• Unusual breath odours

d)     Renal system effects:

• Chronic renal failure, hepatorenal syndrome, and proximal renal tubular acidosis

Treatment:

• Inhalant intoxication, as with alcohol intoxication, usually requires no medical attention and resolves spontaneously. Effects of the intoxication, such as coma, bronchospasm, laryngospasm, cardiac arrhythmias, trauma, or burns, need treatment, however.
• Otherwise care primarily involves reassurance, quiet support and attention to vital signs and level of consciousness.
• Sedative drugs including benzodiazepines are contraindicated because they worsen inhalant intoxication.
• Street outreach and extensive social service support have been offered to severely deteriorated, inhalant dependent and homeless adults. Patients may require extensive support within their families or in foster or domiciliary care.
• Confusion, panic, and psychosis mandate special attention to patient's safety. Severe agitation may require cautious control with haloperidol( 5 mg I M per 70 kg body weight)
• Inhalant induced anxiety and mood disorders may precipitate suicidal ideation, and patients should be carefully evaluated for that possibility.

Day treatment and residential programs: This has been used successfully, especially for adolescent abusers with combined substance dependence and other psychiatric disorders. Treatment address the co morbid state which, in most cases, is conduct disorder or in other instances, may be ADHD, major depressive disorder, dysthymic disorder and PTSD.

Both group and individual therapy are used that are behaviourally oriented, with immediate rewards for progress towards objectively defined goals in the treatment and punishments for lapses to previous behaviours.

Patient's families are often given a family therapy, which has good empirical support. Participation in 12 step program is needed. Treatment interventions are coordinated with interventions by the community social worker and probation officers.

Progress is monitored with urine and breath samples analyzed for alcohol and other drugs at intake and frequently during treatment. Treatment usually lasts 3 to 12 months. Termination is considered successful if the youth has practiced a plan to stay abstinent; is showing fewer antisocial behaviours.    

Nursing diagnosis:

Common nursing diagnosis can be:

1.      Ineffective denial related to knowledge deficit regarding negative effects of substance abuse or dependency.

 2.      Disabled family coping related to domestic violence/ abuse.

 3.      Risk for injury related to effects of drugs on body systems and functions, including mental status.

 4.      Risk for self directed violence/ other directed violence related to drug or substance use.

 Conclusion

Hallucinogens and inhalants are two substances of abuse. It is important for a nurse to first examine his or her own feelings personal substance use and the substance use by others. Only the nurse who can be accepting and non-judgemental of substance abuse behaviours will be effective in working with these clients. 

 JOURNAL REFERENCES 

1. Relation between social drug use/abuse and dental disease in California, U.S.A.

This study has explored the social drug use/abuse patterns associated with dental disease. Seventy-seven subjects from the Berkeley Free Clinic were given questionnaires on their drug-use habits and then were examined for OHI-S scores. Ninety-seven percent of the subjects indicated that they used one or more of the eight drugs being surveyed. The study indicated that persons who used barbiturates, miscellaneous hallucinogens and heroin have poorer oral hygiene than those in other categories. An unexpected finding was that subjects who used four or five of the surveyed drugs had lower OHI-S scores than those who used a lesser or a greater number of these drugs. The significance of these findings for an individual's oral health is not yet clear, but it is interesting that the oral hygiene index did not increase with the increasing number of drugs used, although the specific use of barbiturates, miscellaneous hallucinogens and heroin were related to higher OHI-S scores. The lower OHI scores probably can be explained by the frequency of tooth brushing. Ninety-five percent of the 4-5 drug-use groups brushed one or more times per day.

 2.  Epidemiology of inhalant use:

The aim of this article was to review recent research on the prevalence and correlates of inhalant use. During the review period more prevalence studies have been conducted in the developing world, adding information to the ongoing studies that are periodically undertaken in the more developed countries. These studies suggest that inhalant use is more among children and adolescents and is increasing among females in the developing and developed world. Not all surveys report inhalants as a separate group from other illegal substances; data by type of inhalants are even rarer, and few studies address abuse or dependence. New evidence suggests lower reliability rates for the diagnostic criteria of dependence as compared to other substances suggesting the need for a review including the evidence of withdrawal. Studies conducted in the period identify vulnerable groups and suggest an increased risk of injecting drug use, HIV, suicidality and psychiatric problems among inhalant users.

References:

1. Townsend M C Psychiatric mental health nursing- concepts of care. (5 ^th edn). Philadelphia: F.A Dais company; 2005
2. Kaplan. Comprehensive textbook of psychiatry (9 th edn). Philadelphia: Williams 7Wlkins; 2007.
3. Gelder M G, Lopez-Ibor J J$ Andereasen N. New oxford textbook of psychiatry. (Ist edn) Oxford university press. 2000.
4. Kaplan &Sadock's. Synopsis of psychiatry. Behavioural sciences clinical psychiatry (10 ^th edn). Lippincott. Williams &Wilkins. New Delhi: 2007.
5. Steven J. S. Relation between social drug use/abuse and dental disease in California, U.S.A. Community Dentistry and Oral Epidemiology. 2006 vol 1: 89-93.
6. Elena E, Mora M & Real T. Epidemiology of inhalant use: current opinion in psychiatry 2008, 21: 247-251.

Introduction

Substance related disorders are composed of two groups: the substance - use disorders (dependence and abuse) and the substance induced disorders (intoxication, withdrawal, delirium, dementia, amnesia, psychosis, mood disorder, sexual dysfunction and sleep disorders.). A wide variety of substances are produced for medicinal purposes. These include central nervous system stimulants, CNS depressants and other over the counter preparations designed to relieve nearly every kind of human ailment, real or imagined. Some illegal substances have achieved a degree of social acceptance by various sub cultural groups within our society. These illegal substances include hallucinogens and inhalants too.

 HALLUCINOGENS RELATED DISORDERS

Introduction

The term hallucinogens refers to a classification of drugs that produces euphoria or dysphoria, altered body image, distorted or sharpened visual and auditory perception, confusion, in co-ordination and impaired judgement and memory. Hallucinogens are natural and synthetic substances that are variously called psychedelics or psychotomimetics because, besides inducing hallucinations, they produce a loss of contact with reality and an experience of expanded and heightened consciousness.

A profile of the substance:

• Hallucinogenic substances are capable of distorting an individual's perception of reality. They have the ability to alter the sensory perception and induce hallucinations. For this reason they have been referred to as mind expanding. Some of the manifestations have been likened to a psychotic break.
• Substance induced hallucinations are visual most often, perceptual distortions have been reported by some users as spiritual, as giving a sense of depersonalization, or as being at peace with self and the universe.
• Others, who describe their experiences as "bad trips", report feelings of panic and a fear of dying or going insane.
• A common danger reported with hallucinogenic drugs is that of" flashbacks, or a spontaneous recurrence of the hallucinogenic state without ingestion of the drug.
• Recurrent use can produce tolerance, encouraging users to resort to higher and higher dosages. No evidence of physical dependence is detectable when the drug is withdrawn; however recurrent use appears to induce a psychological dependence.

 Historical aspects:

• Archaeological data obtained with carbon 14 dating suggests that hallucinogens have been used as a part of religious ceremonies and at social gatherings by Native Americans for as long as 7000 years.
• 1943: LSD was first synthesized by Dr. Albert Hoffman. It was used as a clinical research tool to investigate the biochemical etiology of schizophrenia. It soon reached the illicit market, however and its use began to overshadow the research effort.
• Late 1960s: the abuse of hallucinogens reached its peak
• 1970s: warned the use of hallucinogens
• 1980s: hallucinogens returned to favour with the so called designer drugs (3, 4 methylene dioxyamphetamine and methoxy amphetamine.
• One of the most commonly abused hallucinogen today is PCP even though many of its effects are perceived as undesirable.
• Several therapeutic uses of LSD have been proposed, including the treatment of chronic alcoholism and the reduction of intractable pain such as occurs in malignant disease.

Categories:

1.      Naturally occurring hallucinogens

2.      Synthetic compounds

Pattern of use/abuse:

Use of hallucinogens is usually episodic. Because cognitive and perceptual abilities are so markedly affected by these substances, the user must set aside time from normal daily activities for indulging in the consequences. The use of LSD does not lead to physical dependence or withdrawal symptoms.

However tolerance does develop quickly and to a high degree. In fact, an individual who uses LSD repeatedly for a period of 3 to 4 days may develop complete tolerance to the drug. Recovery from the tolerance also occurs very rapidly so that the individual is able to achieve the desired effect from the drug repeatedly and often.    

PCP is usually taken episodically, in binges that can last for several days. Some chronic users take the substances daily, however. Physical dependence does not occur with PCP; however, psychological dependence characterized by craving for the drug has been reported in chronic users, as has the drug has been reported in chronic users, as has the development of tolerance.

Psilocybin in an ingredient of the Psilocybin mushroom indigenous to the United States and Mexico. Ingestion of these mushrooms produces an effect similar to that of LSD but of shorter duration. This hallucinogenic chemical can now be produced synthetically.

Mescaline is the only hallucinogenic compound used legally for religious purposes today by members of the Native American church of the United States.

CLASSIFICATION

Hallucinogen dependence and hallucinogen abuse: Long term hallucinogen use is not common. No physical addiction occurs although psychological dependence occurs.

Hallucinogen intoxication: Intoxication with hallucinogens is defined in DSM IV -TR as characterized by maladaptive behavioural and perceptual changes and by certain physiological signs. The differential diagnosis for hallucinogen intoxication includes anticholinergic and amphetamine intoxication and alcohol withdrawal.

DSM IV -TR diagnostic criteria for hallucinogen intoxication:

a. Recent use of a hallucinogen

b. Clinically significant maladaptive behavioural or psychological changes.( marked anxiety, or depression, ideas of reference, fear of losing one's mind , paranoid ideation, impaired judgement, or impaired social or occupational functioning) that developed during, or shortly after hallucinogen use

c. Two or more of the following signs, developing during, or shortly after, hallucinogen use:

•  
  • Papillary dilation
  • Tachycardia
  • Sweating
  • Palpitation
  • Blurring of vision
  • Tremors
  • Inco-ordination

d) The symptoms are not due to a general medical condition and are not better accounted for by another mental disorder.

DSM IV -TR criteria for hallucinogen persisting perception disorder: (flashbacks)

Long after ingesting a hallucinogen, a person can experience a flashback of hallucinogenic symptoms. This syndrome is diagnosed as hallucinogen persisting perception disorder. Flashbacks are spontaneous, transitory recurrences of the substance- induced experience. Most flashbacks are episodes of visual distortion, geometric hallucinations, hallucinations of sounds or voices, false perceptions of movements of peripheral fields, flashes of colour, trails of images from moving objects, positive after images and halos, macropsia, micropsia, time expansion, physical symptoms or relieved intense emotion. The episodes usually last a  few seconds to a few minutes, but sometimes lasts longer. Most often even in the presence of distinct perceptual disturbances; the person has insight into the pathological nature of disturbance. Suicidal behaviour major depressive disorder and panic disorder are potential complications.

Hallucinogen intoxication delirium: A relatively rare disorder beginning during intoxication in those who have ingested pure hallucinogens. Hallucinogens are often mixed with other substances, however, and the other components or their interactions with the hallucinogens can produce clinical delirium.

Hallucination induced psychotic disorders: If psychotic symptoms are present in the absence of retained reality testing, a diagnosis of hallucinogen- induced psychotic disorder may be warranted. The most common adverse effect of LSD and related substances is a bad trip" an experience resembling the acute panic reaction to cannabis but sometimes more severe, a bad trip can occasionally produce true psychotic symptoms. The bad trip generally ends when the immediate effects of the hallucinogen wear off, but its course is variable.

Hallucinogen induced mood disorder: Mood disorder symptoms accompanying hallucinogens abuse can vary. Abusers may experience manic- like symptom feelings and ideas or mixed symptoms. As with the hallucinogen induced psychotic disorder symptoms, the symptoms of hallucinogen induced mood disorder usually resolve once the drug has been eliminated from the person's body.

Hallucinogen induced anxiety disorder: Hallucinogen induced anxiety disorder also varies in its symptom pattern, frequently report panic disorder with agoraphobia.

Hallucinogen- related disorder not otherwise specified: When a patient with a hallucinogen related disorder does not meet the diagnostic criteria for any of the standard hallucination related disorders, the patient may be classified as having hallucinogen related disorder not otherwise specified.

Clinical features:

Lysergic acid Diethylamide (LSD):

Physiological symptoms from LSD are typically few and relatively mild. Dilated pupils, increased deep tendon reflexes and muscle tension, and mild motor in coordination and ataxia are common. Increased heart rate, respiration, and blood pressure are modest in degree and variable, as nausea, decreased appetite and salivation.

The onset of action of LSD occurs within an hour, peaks in 2 to 4 hours, and lasts 8 to 12 hours. The sympathomimetic effects of LSD include tremors, tachycardia, hypertension, or hyperthermia can occur with hallucinogenic use.

Phenethylamines:

These are compounds with simple chemical structure and structural similarity to the neuro transmitters dopamine and norepinephrine.eg: Mescaline and MDMA (member of 3,4 methylene dioxyamphetamine)

a)      Mescaline:

It is usually consumed as peyote "buttons" picked from small blue- green cacti Lophophora williamsii and Lophophora diffusa. Peyote is not casually consumed usually  because of its bitter taste and sometimes severe nausea and vomiting preceding the hallucinogenic effects.

b)      MDMA:

It produces an altered state of consciousness with sensory changes and most important for some users, a feeling of enhanced personal interactions.

Effects of hallucinogens

Effects of hallucinogens depend on:

• how much is taken
• height and weight of the individual
• general health
• Mood
• past experience with hallucinogens
• used hallucinogens on their own or with other drugs
• Uses alone or with others, at home or at a party, etc.

The effects of hallucinogens are not easy to predict. The effects are different for different people and at different times. The main effects of hallucinogens are changes in the way you perceive things with your senses. They can include strange sensations such as floating or body becoming part of another object. Some people find such unusual sensations interesting and pleasant, while to others these same effects are unpleasant and disturbing.

Immediate effects

The effects of hallucinogens begin within half an hour of taking the drug, are strongest in three to five hours, and last for up to 12 hours.

They can include:

Two types of toxic reactions are known to occur. This may include:

Bad trips

The first is the panic reaction, or 'bad trip', and it is common among first time users. Effects of a bad trip can include:

• extreme anxiety or fear
• frightening hallucinations (e.g. spiders crawling on the skin)
• panic, leading to taking risks (e.g. running across a busy street)
• feelings of 'losing control' or 'going mad'
• paranoia (feeling that other people want to harm you)
• Suicide or violence (rare).

Flashbacks:

There are few known long term effects from hallucinogens. It includes the transient, spontaneous repetition of a previous LSD induced experience that occurs in the absence of the substance, can happen days, weeks or even years after taking the drug.

Flashbacks can include visual hallucinations and other effects. They can happen without warning, last for a minute or two and can be disturbing.

Flashbacks may be triggered by using other drugs or by stress, tiredness or physical exercise. Regular users are more likely to experience flashbacks than people who only use the drug  from time to time.

Some other long term effects of hallucinogens may be damaged memory and concentration. Using hallucinogens may increase the risk of mental problems in some people.

Hallucinogens and pregnancy

LSD may be related to an increased risk of miscarriage, but little is known about the effects of LSD in pregnancy.

Tolerance and dependence

Anyone can develop a 'tolerance' to hallucinogens. With hallucinogens this happens very quickly. Being tolerant to one kind of hallucinogen (e.g. LSD) can also make you tolerant to other kinds ('magic mushrooms'). Tolerance goes away while stopping the drug regularly.

There is little evidence that dependence or withdrawal syndromes exist for hallucinogens.

Hallucinogens and the law

Using, keeping, selling or giving hallucinogens to someone else is illegal. If you are caught you could get penalties starting from a $2 200 fine and/or two years in jail to a $550 000 fine and/or jail for life.

Treatment:

a) Hallucinogen intoxication:

Treatment of hallucinogen intoxication is the oral administration of 20 mg of diazepam. This medication brings the LSD experience and any associated panic to a halt within 20 mts.

b)     Hallucinogen persisting disorder:

• Treatment for hallucinogen persisting disorder is palliative.
• The first approach in this disorder is correct identification of this disorder, pharmacological approaches include long- lasting benzodiazepines, such as long lasting benzodiazepines such as clonazepam, and to lesser extent, anticonvulsants including valproic acid and carbamazepine.
• Antipsychotic agents should only be used in the treatment of hallucinogen- induced psychoses, because they have a paradoxical effect and exacerbate symptoms.
• A second dimension of treatment is behavioural. The patient must be instructed to avoid gratuitous stimulation in the form of over- the counter drugs, caffeine and alcohol and avoidable physical and emotional stressors.
• Finally three co morbid conditions are associated with hallucinogen persisting perception disorder: panic disorder, major depression and alcohol dependence. All these conditions require primary prevention and early intervention.

c)      Hallucinogen induced psychosis:

Treatment of hallucinogen induced psychosis does not differ from conventional treatment of psychoses. In addition to the antipsychotic medications, a number of agents are reportedly effective, including lithium carbonate, carbamazepine and electroconvulsive therapy. Antidepressant drugs, benzodiazepines and anticonvulsant agents may each have a role in the treatment as well

References:

1. Townsend M C Psychiatric mental health nursing- concepts of care. (5 ^th edn). Philadelphia: F.A Dais company; 2005
2. Kaplan. Comprehensive textbook of psychiatry (9 th edn). Philadelphia: Williams 7Wlkins; 2007.
3. Gelder M G, Lopez-Ibor J J$ Andereasen N. New oxford textbook of psychiatry. (Ist edn) Oxford university press. 2000.
4. Kaplan &Sadock's. Synopsis of psychiatry. Behavioural sciences clinical psychiatry (10 ^th edn). Lippincott. Williams &Wilkins. New Delhi: 2007.
5. Steven J. S. Relation between social drug use/abuse and dental disease in California, U.S.A. Community Dentistry and Oral Epidemiology. 2006 vol 1: 89-93.
6. Elena E, Mora M & Real T. Epidemiology of inhalant use: current opinion in psychiatry 2008, 21: 247-251.

Introduction

The middle of the 20 ^th centuries identifies a pivotal period in the treatment of mentally ill. Since the 1950's the development of psychopharmacology has expanded to include widespread use of antipsychotics, antidepressants and antianxiety medications. Psychotropic medications are not intended to cure the mental illness, but are used to relieve physical and behavioral symptoms. The psycho stimulants, also called sympathomimetics and analeptics, can improve the mood, apathy and anhedonia of depressed older persons and are effective in the treatment of various other mental illness.

History (Tyler 1986)

• The mild stimulant effect of cocaine found naturally in coca leaves when chewed by peasants in high altitude South American countries.  Freud supporting the psychotherapeutic use. Cocaine first isolated in 1860.
• Amphetamines widely used synthetic performance enhancing drugs used in wars and in peace.  First synthesised in 1880s.
• Amphetamine was first synthesized under the chemical name "phenylisopropylamine" in Berlin 1887 by the Romanian chemist Lazar Edeleanu. It was not widely marketed until 1932, when the pharmaceutical company Smith, Kline, and French (currently known as Glaxo smith cline) introduced it in the form of the Benzedrine.
• Three years later, in 1935, the medical community became aware of the stimulant properties of amphetamine, specifically dextroamphetamine, and in 1937 Smith, Kline, and French introduced tablets, under the trade name Dexedrine.

CNS stimulants or Sympathomimetics commonly used

• Geriatric dosage of psycho stimulants

Therapeutic indications:

• ADHD: It is the first line drug in the treatment of ADHD. Sympathomimetics improve the core ADHD symptoms of hyperactivity, impulsivity and inattentiveness and permit improved social interactions with teachers, family, older adults and peers. Methylphenidate and dextroamphetamine are equally effective and work within 15 to 30 mts.
• Narcolepsy: Narcolepsy consists of sudden sleep attacks, sudden loss of postural tone( cataplexy), loss of voluntary motor control going into( hypnagogic) or coming out of (hypnopompic) sleep (sleep paralysis) and hypnagogic and hypnopompic hallucinations.
  • - Sympathomimetics reduce narcoleptic sleep attacks and also improve wakefulness in other types of hyper somnolent states.
  • - Sympathomimetics are used to maintain wakefulness and accuracy of motor performance in persons subject to sleep deprivation, such as pilots and military personnel.
  • - Persons with narcolepsy, may develop tolerance for the therapeutic effects of the Sympathomimetics.
• Depressive disorders: Sympathomimetics may be used for treatment resistant depressive disorders, usually to augment standard antidepressant drug therapy.
  • - depression in elderly, who are at increased risk for adverse effects from standard antidepressant drugs.
  • - Depression in medically ill person especially persons with AIDS.
  • - Obtundation due to chronic use of opioids.
  • - Clinical situation in which rapid response is important but ECT is contraindicated.
  • - Depressed patients with abulia and anergia may also benefit.

Dextroamphetamine may be useful in differentiating pseudo dementia of depression from dementia. A depressed person generally responds to a 5 mg dose with increased alertness and improved cognition.

• Encephalopathy due to brain injury: Sympathomimetics increase alertness, cognition, motivation and motor performance in persons with neurological deficits caused by strokes, trauma, tumors or chronic infections.
• Obesity: Sympathomimetics are used in the treatment of obesity because of their anorexia inducing effects. Because tolerance develops for the anorexic effects and because of the drugs high abuse potential their use for this indication is limited.

Careful limitation of caloric intake and judicious exercise are at the core of any successful weight loss program. Sympathomimetics facilitate loss of, at most, an additional fraction of a pound per week. Sympathomimetics are effective appetite suppressants only for the first few weeks of use; then the anorexigenic effects tend to decrease.

• Other disorders:
  • Chronic fatigue syndrome
  • Neurasthenia
  • Fibromyalgia
  • Dysthymia
  • Depressive personality disorder.

Pharmacology

• Pharmacokinetics
  • amphetamine and cocaine salts readily water soluble (injecting misuse), free base designed for smoking (but crack cocaine also commonly injected)
  • Widely distributed in the body, crossing the blood brain barrier
  • Metabolised by liver, metabolites in the urine
• Pharmacodynamic
  • Peripheral effects
  • Cocaine is a local anaesthetic (dentistry)
  • Cocaine and amphetamines produce smooth muscle contraction; vaso-constriction and bronchoconstriction
  • Central nervous system effects
  • Cocaine inhibits dopamine re-uptake (more dopamine), 5HT and noradrenaline uptake (antipsychotics drugs are dopamine antagonists)
  • Amphetamine affects range of neurotransmitters but main action is inhibiting dopamine re-uptake (more dopamine)

Pharmacological actions:

Sympathomimetic drugs cause the stimulation of a- and b adrenergic receptors directly as agonists and indirectly cause the release of dopamine and norepinephrine from presynaptic terminals. They are variously referred to as stimulants, produces CNS and respiratory stimulation, dilated pupils, increased motor activity and mental alertness, diminished sense of fatigue and brighter spirits.

Effects on specific organs and systems

• Central nervous system: Amphetamine stimulates the medullary respiratory center and has excitatory effects on cortical function. Depending on the personality and contextual factors, amphetamine in adults can increase wakefulness, energy, alertness, initiative, self confidence and physical mental performance, lessen fatigue and produce euphoria. These effects occur shortly after dosing.
• Cardiovascular system: Amphetamines can raise blood pressure and can lead to cardiac arrhythmias (especially in patients with cardiovascular disease).Amphetamine is more potent in producing cardiovascular effects than dextroamphetamine because of stronger effects on norepinephrine.
• Endocrine effects: Early reports suggested that both dextroamphetamine and methylphenidate might suppress growth in children. But certain studies revealed that the effects on growth are seemed to be related to the disorder, not its treatment.

Side effects:

1. Most common adverse effects:  stomach pain, anxiety, irritability, insomnia, tachycardia, cardiac arrhythmias and dysphoria
2. Less common adverse effects: induction of movement disorders such as tics, tourette's disorder like symptoms and dyskinesias
3. others:

• Exacerbation of glaucoma, hypertension, cardiovascular disorders, hyperthyroidism, anxiety disorders, psychotic disorders and seizure disorders.
• High doses of sympathomimetics can cause dry mouth, papillary dilation, bruxism, formication, excessive ebullience, restlessness and emotional liability.
• Long term use of high dosages can cause a delusional disorder that resembles paranoid schizophrenia.
• Overdoses of sympathomimetics results in hypertension, tachycardia, hyperthermia, toxic psychiosis, delirium and occasionally seizures.
• Physiological and psychological dependence.

Management of common stimulant induced adverse effects

Contraindications:

• Hypersensitivity to Sympathomimetics.
• Advanced arteriosclerosis, symptomatic cardiovascular disease, hypertension, hyperthyroidism, glaucoma, agitated or hyper excitability states, in clients with history of drug abuse, during or within 14 days of receiving therapy with MAOIs, in children under 3 years of age and in pregnancy.

Precautions:

• Lactation
• Psychotic children
• Tourette's disorder
• Anorexia
• Insomnia
• Elderly, debilitated or asthenia clients
• Clients with suicidal or homicidal tendencies.

Drug-drug interactions:

• Co administration of Sympathomimetics and tricyclic or tetra cyclic antidepressants , warfarin, primidone, Phenobarbital,phenytoin or phenylbutazone decreases the metabolism of these compounds, resulting in increased plasma levels.
• Sympathomimetics decrease the therapeutic efficacy of many antihypertensive drugs, guanethidine.
• Use of CNS stimulants within 14 days following administration of MAOIs may result in hypertensive crisis, headache, hyperpyrexia, intracranial hemorrhage and bradycardia.
• Insulin requirements may be altered with CNS stimulants.
• Urine alkalinizers decrease excretion, enhancing the effects of amphetamines.
• Urine acidifiers increase excretion, decreasing the effects.
• Decreased effects of both the drugs can occur when administered concurrently with phenothiazines.

MODAFINIL:

• It is a unique compound among the currently approved psycho stimulant drugs.

Pharmacological action

• Modafinil is rapidly absorbed from the gastro intestinal tract and reaches peak plasma concentration in 2 to 4 hrs, has a half life of about 15 hrs, and reaches steady state after two to four days of daily dosing.
• The mechanism of action for the wakefulness- inducing properties of modafinil is not known. One possibility is that dopamine acts as a weak inhibitor of dopamine reuptake. This is supported by the observation of an extracellular dopamine levels without an increase in dopamine release.

Effects on specific organs:

• Central nervous system: Euphoric effects, alterations in mood, perception and thinking.
• Cardiovascular system: There were small numbers of cardiovascular related side effects in the narcolepsy clinical studies; there fore it is currently not recommended to be used in patients with cardiovascular disorders.

Therapeutic indications:

• Treatment of day time sedation in neurological and psychiatric disorders.
• Parkinson's disease and multiple sclerosis with day time sedation.

Dosage and administrations:

• Starting dosage is 200 mg a day given once in the morning. Some patients may require 300-400 mg a day, also given once in the morning.

Adverse effects:

• Headache, nausea.
• Abuse potential
• Precautions:
• Pregnancy, because it is excreted in human milk.
• Drug to drug interaction:
• Plasma concentration of low dose of steroidal contraceptive may be reduced to levels below therapeutic effectiveness.
• Co administration of modafinil may result in increased plasma concentrations of diazepam, phenytoin and propranolol.

NURSING MANAGEMENT

Diagnosis: The following nursing diagnosis can be considered for clients receiving therapy with CNS stimulants.

1. Risk for injury related to over stimulation and hyperactivity.

2. Risk for self- directed violence related to abrupt withdrawal after extended release.

3. Imbalanced nutrition less than body requirement related to side effects of anorexia and weight loss.

4. Imbalanced nutrition more than body requirements related to excess intake in relation to metabolic needs.

5. Insomnia related to over stimulation resulting from use of the medication.

Planning/ implementation:

• The plan of care should include monitoring for the following side effects from stimulants. Nursing implications related to each side effect are:

1. Over stimulation, restlessness, insomnia.

• Assess the mental status for changes in mood, level of activity, degree of stimulation and aggressiveness.
• Ensure that the client is protected from injury.
• Keep stimuli low and environment as quiet as possible to discourage overstimulation.
• To prevent insomnia, administer last dose at least 6 hours before bedtime. Administer sustained release forms in the morning.

2. Palpitations, tachycardia.

• Monitor and record vital signs at regular intervals throughout the therapy.
• Report significant changes to the physician immediately.

3. Anorexia and weight loss:

To reduce anorexia, the medication may be administered immediately after the meals.

• The client should be weighed regularly during hospitalization and at home while receiving the therapy with CNS stimulants because of the potential for anorexia/ weight loss and temporary interruption of growth and development.

4. Tolerance:

• Tolerance develops rapidly. If anorexigenic effects begin to diminish, the client should notify the physician immediately. Client should be on reduced- calorie diet and program of regular exercise in addition to the medication.
• In children with behavior disorders, a drug " holiday" should be attempted periodically under direction of the physician to determine the effectiveness of the medication and the need for continuation.
• The drug should not be withdrawn abruptly. To do so could initiate the following syndrome of symptoms: nausea, vomiting, abdominal pain, headache, fatigue, weakness, mental depression, suicidal ideation, increased dreaming and psychotic behavior.
• Client and family education:
• Use caution in driving or operating dangerous machinery. Drowsiness, dizziness and blurred vision can occur.
• Not stop taking the drug abruptly. To do so could produce serious withdrawal symptoms.
• Avoid taking the drug late in the day to prevent insomnia. Take no later than 6 hours before bed time.
• Not to take other medications without physicians approval. Many drugs contain substances that in combination with stimulants can be harmful.
• Diabetic clients should monitor blood sugar twor three times a day or as instructed by the physician. Be aware of need for  possible alteration in insulin requirements owing tchanges in food intake, weight and activity.
• Avoid consumption of large amounts of caffeinated products (coffee, tea, colas, and chocolate) as they may enhance the stimulant effect of these medications.
• Follow a reduced calorie diet provided by the dietitian, as well as program of regular exercise. Dnot exceed the recommended dose if the appetite suppressant effect is diminished. Contact the physician.
• Notify the physician if restlessness, insomnia, anorexia or dry mouth become more severe or if rapid , pounding heartbeat becomes evident.
• Be aware of potential side effects of CNS stimulants. Refer tthe written material furnished by health care providers for safe self administration.
• Be aware of possible risks of taking CNS stimulants during pregnancy. Safe use during pregnancy and lactation has not been established. Inform the physician immediately if pregnancy is suspected or planned.
• Carry a card or other identification at  all times describing the medications being taken.
• Outcome criteria/ evaluation: The following may be used for evaluating the effectiveness of therapy with CNS stimulants.

The client:

• Does not exhibit excessive hyperactivity.
• The overweight client is losing a safe 2 lb per week.
• Has not experienced injury.
• The behavior disorder client is maintaining expected parameters of growth and development.
• Verbalizes understanding of safe self administration and the importance of not withdrawing medication abruptly.

References:

1. Kaplan and Sadock. Synopsis of psychiatry-behavioral science, clinical approach. (6 th edition) Williams and Wilkins publishers. Baltimore: (1998).
2. Townsend M C. Psychiatric mental health nursing-concepts of care. (3 rd edition) F.H Davis publishers; Philadelphia :( 2005)
3. Anderson I, Reid I .Fundamentals of clinical psychopharmacology. Martin Dunitz publishers. London: (2002).
4. Charach A et.al. Stimulant treatment over 5 years: effects on growth. J AM ACAD. Child adollesc psychiatry. 2006. April 45(4).
5. Gorman, E B. et.al. Effects of methylphenidate on subtypes of attention deficit hyperactivity disorder. J AM ACAD. Child adollesc psychiatry. 2006. April 45(7).