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Antipsychotics: First-Generation (Conventional) Cheat Sheet by

These medications control mainly positive manifestations of psychotic disorders (hallucinations, delusions, bizarre behaviors)


Chlorp­rom­azine: low potency
Halope­ridol: high potency
Fluphe­nazine: high potency
Thioth­ixene: high potency
Perphe­nazine: medium potency
Loxapine: medium potency
Triflu­ope­razine: high potency


Block dopamine acetyl­cho­line, histamine, and norepi­nep­hrine receptors in the brain and periphery
Inhibition of psychotic manife­sta­tions, believed to be a result of dopamine blockade in the brain

Therap­eutic Uses

Acute chronic psychotic disorders
Schizo­phrenia spectrum disorders
Bipolar disorders (primarily the manic phase)
Tourette syndrome
Prevention of nausea­/vo­miting through blocking of dopamine in the chemor­ece­ptors trigger zone of the medulla

Compli­cat­ions, Extrap­yra­midal Side Effects (EPSs)

Nursing Action and Education
Acute Dystonia: the client experi­ences severe spasms of tongue, neck, face, or back. If the laryngeal muscle are affected, respir­ations can decrease. This is a crisis situation, which requires rapid treatment
Monitor for acute dystonia between a few hrs to 5 days after admini­str­ation of the first dose. Treat with antich­oli­nergic agents, such as benztr­opine or diphen­hyd­ramine. Use oral dose for less acute effects and IM or IV doses for serious effects. Expect improv­ement within 5min (IV dosing) to 20min (IM dosing)
Parkin­sonism: findings including bradyk­inesia, rigidity, shuffling gait, drooling, tremors
Occurs within 1 month of initiation therapy. Treat with benztr­opine, diphen­hyd­ramine, or amanta­dine. Discon­tinue these medica­tions to determine f they are still needed. If manife­sta­tions return, administer atypical antips­ych­otics as prescr­ibed.
Akathisia: client is unable to stand still or sit, and is contin­ually pacing and agitated
Within 2 months of the initiation of treatment. Manage effects with betabl­ocker, benzod­iaz­epine, or antich­oli­nergic medica­tions
Tardive Dyskinesia (TD): involu­ntarily movements of the tongue and face, lip smacking, which causes speech or eating distru­bances
TD are late EPS that can occur months to years after the start of therapy, and can improve following medication change or can be permanent. Administer the lowest dosage possible. Evaluate the client after 12 months of therapy and then every 3 months. Valben­azine can be prescribed to treat TD for adult clients

Other Adverse Effects

Nursing Action and Education
Neurol­eptic Malignant Syndrome: Life Threat­ening Medical Emergency. Sudden high grade fever, blood pressure fluctu­ations, dysrhy­thmias, muscle rigidity, diapho­resis, tachyc­ardia, and change in LOC developing into coma
Stop medica­tion. Monitor vital signs. Apply cooling blankets, administer antipy­retics, increase fluids, administer diazepam, administer dantrolene and bromoc­riptine to induce muscle relaxa­tion, ICU immedi­ately, with 2 weeks before resuming therapy
Antich­oli­nergic Effects: dry mouth, blurred vision, photop­hobia, urinary hesita­ncy­/re­ten­tion, consti­pation, tachyc­ardia
Chewing sugarless gum, sipping water, avoid hazardous activi­ties, wearing sunglasses outdoors, eating high fiber, regular exerci­sing, 2-3L of water daily, voiding before medica­tions
Neuroe­ndo­crine Effects: gyneco­mastia (breast enlarg­ement), galact­orrhea, and mensural irregu­lar­ities
Observe for manife­sta­tions and notify provider if these occur
Seizures: greatest risk for developing seizures is existing seizure disorder
Increase in anti-s­eizure medication can be necessary
Skin Effects: photos­ens­itivity resulting in severe sunburns, and contact dermatitis from handling medica­tions
Avoid excessive exposure to sunlight, use sunscreen. Avoid direct contact with medica­tions
Orthos­tatic Hypote­nsion
Monitor blood pressure and heart rate for orthos­tatic changes. If signif­icant decreases in BP or increases in HR is noted don't administer medica­tion. Tolerance should develop in 2-3months. If lighth­ead­edness or dizziness occurs, sit or lie down. Change positions slowly
Effects should diminish within a few weeks. Take this medication at bedtime to avoid daytime sleepi­ness. Don't drive until sedation has subsidede
Sexual Dysfun­ction: altered libido, difficulty achieving orgasm, erectile and ejacul­atory dysfun­ction
Report to provider. Lower dosage or chaging to high-p­otency agents can minimize these effects
Indica­tions of infections appear, obtain baseline WBC. Medication should be discon­tinued if infection. Observe for infection.
Severe Dysrhy­thmias
Obtain baseline ECG and potassium level prior to treatment and period­ically throughout treatment. Avoid concurrent used with other medica­tions that prolong QT interval
Liver Impair­ments
Assess baseline liver function and monitor liver function. Observe for anorexia, nausea, vomiting, fatigue, abdominal pain, jaundice

Contra­ind­ica­tions/ Precau­tions

Contra­ind­icated in clients in a coma, and clients who have Parkin­son's disease, liver damage, prolactin dependent cancer of the breast, and severe hypote­nsion
Contra­ind­icated in older clients who have dementia
Use cautiously in clients who have glaucoma, paralytic ileus, prostate enlarg­ement, heart disorders, liver or kidney disease, and seizure disorders.


Nursing Action and Education
Antich­oli­nergic agents
Avoid over the counter medica­tions containing antich­oli­nergic agents, such as sleep aids and antihi­sta­mines
CNS Depres­sants: alcohol, opioids, and antihi­sta­mines have additive CNS depressant effects
Avoid alcohol and other medica­tions that cause CNS depres­sion, Avoid hazardous activities such as driving
Levodopa: by activating dopamine receptors, levodopa counte­racts the effects of antips­ychotic agents
Avoid concurrent use of levodopa and other direct dopamine receptors agonists

Nursing Admini­str­ation

These medica­tions are reserved for clients who are using them succes­sfully and can tolerate the adverse effects, or violen­t/p­art­icu­larly aggressive
Use the abnormal involu­ntary movement scale (AIMS) to screen for the presence of EPS
Assess the client to differ­entiate between EPS and worsening of psychotic disorder
Administer antich­oli­ner­gics, beta blockers, and benzod­iaz­epines to control early EPSs. If adverse effects are intole­rable, the client can be switched to a low potency or atypical antips­ychotic agent.
Consider depot prepar­ation admini­str­ation IM once every 2-4 weeks for clients who have difficulty mainta­ining medication regimen. Inform the client that lower doses can be used with depot prepar­ations, which will decrease the risk of adverse effects
Antips­ychotic medica­tions don't cause addiction
Some therap­eutic effects can be noticeable within a few days, but signif­icant improv­ements can take 2-4weeks, and possibly several months for full effects


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