Major Psychiatric Disorders & Psychotropic Medications | Symptom Clusters, Medical Differential, Drug Side Effects, and the ECT Decision Sequence | MyMerci
제안하기
0 / 2000
Korean English Japanese Traditional Chinese (Taiwan) Vietnamese Malay (Malaysia) Mongolian

Major Psychiatric Disorders & Psychotropic Medications | Symptom Clusters, Medical Differential, Drug Side Effects, and the ECT Decision Sequence

CHAPTER 08 · Psychiatric Nursing Major Psychiatric Disorders & Psychotropic Medications

The core of psychiatric nursing isn't just matching a diagnosis. It's about first looking for sudden changes and medical causes, then evaluating current symptoms, function, and safety, and finally choosing the next action based on treatment response and the acuity of medication side effects. The same anxiety, agitation, or auditory hallucinations will have different priorities depending on whether they stem from delirium, withdrawal, drug toxicity, a mood disorder, or psychosis.

Core Goal: Make your clinical judgment in this order: ABCs, vital signs, level of consciousness, hypoglycemia, hypoxia, intoxication/withdrawal → acute delirium screening → safety regarding suicide, homicide, nutrition, and dehydration → symptom clusters and function → medication, interactions, and adherence history → acuity of side effects → prescriptions and team-based interventions → reassessment of response.

In local feedback materials, we've only seen recurring themes like depression, bipolar disorder, schizophrenia, PTSD, eating disorders, somatic symptoms, personality disorders, substance use, sleep, adverse psychotropic drug reactions, and ECT. We haven't reconstructed actual test questions, answer choices, tables, or images. After removing stigmatizing language, fixed time limits, and rigid protocols, this content was independently rewritten using current, publicly available resources from NIMH, VA/DoD, FDA, DailyMed, and MedlinePlus.

A new psychiatric nursing education illustration centered on a nurse-client collaborative treatment plan, connecting mood and sleep, psychotic symptoms, post-trauma stabilization, medical monitoring for eating disorders, addiction and withdrawal, long-term psychotropic medication monitoring, acute adverse reactions, and post-ECT recovery.
In psychiatric nursing, you look at the current state, medical causes, function, and safety together—before focusing on the diagnosis. This illustration was newly created for this decision-making framework and does not reproduce any past exam screens or original charts/images.

1. For any new psychiatric symptom, first rule out 'medical emergencies, delirium, substances, and medications'

1
Immediate Life Threats

Check the airway, breathing, circulation, oxygenation, vital signs, level of consciousness, blood glucose, temperature, trauma, seizures, overdose, and severe dehydration. Even if a patient is having hallucinations or is agitated, don't delay stabilizing the ABCs and calling for emergency help.

2
Sudden, Fluctuating Attention

An onset within hours to days, fluctuations throughout the day, poor concentration, and a change in the level of consciousness should make you suspect delirium first. Look for causes like infection, hypoxia, metabolic imbalances, pain, surgery, medications, or withdrawal.

3
Substance & Medication Timeline

Check for recent starts, dose increases, or discontinuations of prescription drugs, over-the-counter meds, and supplements, as well as alcohol and substance use, the time of last use, and any history of withdrawal or seizures. Don't just rely on the patient's self-report; cross-reference with prescription lists, family, the pharmacy, and lab results.

4
Current Safety & Function

Assess for suicidal or homicidal ideation, command hallucinations, self-care, sleep, food and fluid intake, impulse control, judgment, gait and fall risk, and support systems and housing. A diagnosis cannot replace this assessment.

5
Baseline & Trends

Compare the patient's current state to their usual cognitive, functional, and mental status and reassess repeatedly. A single 'normal' test result or a moment of quiet calm does not rule out an acute risk or a medical cause.

CluePriority InterpretationNext Action
Sudden confusion & fluctuating attentionPossible delirium or acute change in brain functionEvaluate for causes: vital signs, oxygen, blood glucose, infection, electrolytes, medications, withdrawal
New visual hallucinations & altered consciousnessDo not assume this is a primary psychotic disorderFirst, check for neurological, toxic, and medical causes and ensure safety
Decreased need for sleep & increased energy over several daysPossible mania/hypomania, or substance/medication-inducedAssess for functional impairment, risky behavior, psychosis, substance/medication use, and past episodes
Fever, rigidity, confusionPossible life-threatening medication-related syndromeHold the suspected drug, initiate emergency evaluation, and monitor vital signs and organ function
Immediate Action: For new-onset confusion, decreased consciousness, respiratory depression, seizures, high fever, severe rigidity, fainting, severe dehydration, overdose, or a current plan for suicide or homicide, emergency stabilization and a rapid specialist evaluation take priority over a lengthy psychiatric interview.

2. For a major depressive episode, look at duration, function, safety, and the possibility of bipolar disorder—not just the number of symptoms

Centered on a depressed mood or a loss of interest/pleasure, you'll check for changes in sleep, appetite/weight, energy, psychomotor activity, concentration/decision-making, feelings of guilt/worthlessness, and thoughts of death or suicide. You must also evaluate the persistence of symptoms, functional impairment, and the influence of medical conditions, medications, and substances.

Safety First

Ask directly about suicidal thoughts and assess their current nature: the plan, intent, access to means, past behavior, and protective factors. A single statement like "I don't have suicidal thoughts" does not confirm safety.

Bipolar Screening

Check for any past history of an abnormally elevated or irritable mood, increased energy/activity, a decreased need for sleep, racing thoughts/speech, or risky behavior. This is especially crucial before starting antidepressant monotherapy.

Physical & Substance Causes

Review for thyroid issues, anemia, pain, infection, neurological conditions, medications like steroids, alcohol and substance use, the pregnancy/postpartum context, and sleep disorders.

Small, Concrete Activities

For severe lethargy, instead of saying "cheer up," offer a choice of single-step activities like washing up, drinking water, having a short meal, or taking a brief walk, and provide factual feedback on their achievement.

ObservationInterpretation to watch forNursing focus
Sleep and appetite improve firstDoes not mean mood recovery is completeReassess increased energy and any change in suicide capability
Agitation, insomnia, or increased impulsivityEarly side effects, mixed features, or possible switch to maniaReport to prescriber immediately; check safety and medication history
Accompanied by delusions or auditory hallucinationsPsychotic features of severe depression or another causeReality testing, command content and safety, medical/substance differentiation
Sadness after a lossDo not rigidly split normal grief from depressive disorderAssess duration, function, self-blame, hopelessness, safety, and cultural context
Pitfall: A person who does not look depressed or who smiles is not necessarily free of depression or suicide risk. Conversely, sadness alone is not immediately diagnosed as a disorder.

3. In bipolar disorder, look at changes in energy, activity, sleep, and judgment together — not just mood

Mania isn't just about feeling good. It involves an abnormally elevated, expansive, or irritable mood along with increased energy and goal-directed activity, decreased need for sleep, grandiosity, pressured speech, flight of ideas, distractibility, and risky behaviors — and it can seriously impair functioning. When depressive and manic symptoms appear together in a mixed episode, safety assessment becomes especially critical.

DomainChanges seen in maniaNursing judgment
Safety & judgmentImpulsivity, overspending, sexual/driving/business risks, aggressive reactionsSpecify current risks and actual access; set consistent limits
SleepDecreased need for sleep rather than insomnia with fatigue from lack of sleepLow-stimulation environment, activity regulation, monitor sleep trends and medication response
Nutrition & hydrationConstantly moving, missing meals and fluidsOffer easy-to-eat meals and fluids rather than insisting on long sit-down meals
CommunicationRapid speech, abruptly shifting topics, easily distractedShort, concrete single sentences; one request at a time; avoid arguments
MedicationPossible temporal link to antidepressants, steroids, stimulants, etc.Review all prescriptions, OTCs, and substances; report immediately instead of discontinuing on own

Priority: Nursing care for mania follows this flow: Safety → Sleep → Hydration & Nutrition → Low-stimulation environment → Brief, consistent limit-setting → Medication response and side effects.

Pitfall: Don't diagnose mania based solely on a talkative, energetic personality or a temporary mood lift. Also, in bipolar depression, giving an antidepressant alone can trigger a switch into mania, so don't miss clues pointing to a past manic or hypomanic episode.

4. In schizophrenia, we categorize positive, negative, cognitive, and disorganized symptoms — but never reduce the person to a diagnosis

Symptom DomainExamplesNursing Focus
PositiveDelusions, hallucinations, disorganized thinking/behaviorCheck distress, functioning, command content, safety, and coping — not whether the content is factually true
NegativeReduced emotional expression, low motivation, reduced speech, social withdrawalDon't label the person as lazy or uncooperative; support them with small goals and functional assistance
CognitiveDifficulties with attention, working memory, planning, and problem-solvingUse brief information, repetition, visual cues, verify understanding, and support daily living
Mood & SuicideDepression, hopelessness, anxiety, possible suicidal thoughtsConduct a direct safety assessment, separate from the diagnosis
Medication & PhysicalMovement-related side effects, metabolic abnormalities, smoking, cardiovascular riskTrack changes in psychotic symptoms and medication adverse reactions separately

In a first episode of psychosis, we evaluate for medical causes such as substance or medication use, delirium, seizure or neurological conditions, and endocrine or infectious disorders. The diagnosis itself does not mean violence; risk assessment is based on specific factors like current threats, plans, means, access, control, past behavior, and intoxication.

Function-focused questions: Don’t stop at “What diagnosis did you receive?” Ask, “How have the voices changed your sleep, eating, taking medication, or going out?” and “Are there moments when it’s hard to keep yourself safe?”

5. For hallucinations, delusions, and catatonia, check safety, medical causes, and functional decline first—before debating

Hallucinations

Acknowledge the distress of the experience, such as “I don’t hear that sound, but I can see it’s very real to you,” and ask about content, commands, control, and coping. Don’t play along with the hallucination or agree it’s real.

Delusions

Rather than persuading about right or wrong, check emotions and current safety, and connect to reality-based activities. Detailed interrogation can increase anxiety.

Command hallucinations

Directly assess who is told to do what, intent, means, access, past compliance, ability to refuse, and current control, and activate a safety pathway appropriate to the acuity level.

Catatonia

Don’t see unresponsiveness or reduced movement as stubbornness or choice. Evaluate urgently, including risks of dehydration, malnutrition, blood clots, and pressure injuries, as well as medication, neurological, and metabolic causes.

Share what you observe

State what you actually see, like “You seem to be listening to something.”

Check the experience

Ask directly what the person is experiencing, how distressing it is, and how much control they feel they have.

Clarify safety

Check for command hallucinations, self-harm, harm to others, access to means, and any medical abnormalities.

Choose a coping strategy

Pick from possible strategies such as telling a staff member, using a quiet space, or engaging in reality-based activities.

Reassess the response

Check whether distress, behavior, functioning, or medication response has actually changed.

6. PTSD care restores present safety and choice — don’t force someone to talk about the trauma

PTSD is assessed by looking for persistent re-experiencing, avoidance, negative changes in cognition and mood, and changes in arousal and reactivity that interfere with functioning. Also check whether symptoms are better explained by medications, substances, or another medical condition. Reactions after trauma vary, and not everyone goes on to develop PTSD.

Symptom clusterExamplesNursing approach
Re-experiencingIntrusive memories, nightmares, flashbacks, physical tensionOrient to current time and place, sensory grounding, breathing and a safe space
AvoidanceAvoiding trauma-related thoughts, feelings, or placesExplain treatment options without pushing for detailed rehashing before the person is ready
Cognition & moodGuilt, numbness, negative beliefs, feeling disconnectedCheck functioning, depression, and suicide risk while offering nonjudgmental support
Arousal & reactivityHypervigilance, exaggerated startle, sleep/concentration problems, irritabilityGive predictable explanations, avoid sudden touch, and adjust environmental stimulation

Trauma-informed principles: Explain what you’re going to do first and ask permission, offer choices whenever possible, and check preferences around interpreters, privacy, and having a support person present. Avoid unnecessary repeated questioning and sudden physical contact that can make the person feel a loss of control.

Pitfall: Don’t memorize recovery as fixed stages or assume that healing only begins once the person describes the event in detail. During a flashback, rather than analyzing the past, help the person recognize they are in a safe place right now and guide them back to present-moment sensations.

7. For anxiety, panic, OCD, phobias, and insomnia, match your approach to the level of acuity without reinforcing avoidance

Panic

Rule out medical causes first — chest pain, shortness of breath, risk of syncope — then reduce stimulation and support the person with short, calm sentences and slow breathing. Hold off on complex education during acute panic.

OCD

Don’t ridicule compulsions or suddenly forbid all of them. Assess functioning, skin breakdown, nutrition, and time consumed, and support gradual exposure and response prevention according to the treatment plan.

Specific phobia

Look at how the feared object or situation and the avoidance affect functioning. Don’t force a confrontation or permanently accommodate the avoidance — support a prepared, step-by-step treatment approach.

Insomnia

Check for pain, breathing disorders, substances, medications, mania, and environmental factors first. Prioritize CBT-I–based stimulus control and a consistent wake-up time. Don’t apply a rigid rule like “everyone must get out of bed after exactly 30 minutes” to every person.

Distinguishing sleep issues: Insomnia — feeling tired but unable to fall asleep — is different from the reduced need for sleep seen in mania, where the person sleeps very little yet doesn’t feel fatigued. Snoring, apnea, and daytime sleepiness should prompt an evaluation for sleep apnea.

8. In eating disorders, prioritize vitals, electrolytes, cardiac status, fluid balance, and refeeding risk over body shape

Eating disorders are not a choice or a lack of willpower, and they can occur in people of any age, gender, race, or weight. Even when someone’s weight looks “normal,” serious electrolyte imbalances, arrhythmias, dehydration, and malnutrition can still be present.

Assessment areaRisk cluesNursing actions
Circulation & cardiacSyncope, bradycardia or tachycardia, hypotension, orthostatic changes, chest painMonitor vitals and ECG, ensure fall safety, and obtain immediate medical evaluation
Electrolytes & fluidVomiting, laxative or diuretic use, dehydration, muscle weakness, arrhythmiasMonitor electrolytes, renal function, and intake/output trends as prescribed
RefeedingStarting nutrition after prolonged restriction or severe nutritional deficiencyFollow the specialized team’s plan; monitor phosphorus, potassium, magnesium, fluid status, and cardiac/neurologic changes
Meal supportMeal avoidance, binge–purge behaviors, severe anxietyUse a predictable meal and observation plan, neutral nonjudgmental language, and check safety after behaviors
Psychiatric safetyDepression, anxiety, obsessions/compulsions, suicidal thoughts, self-harmConduct direct safety assessment and link to treatment while simultaneously stabilizing the person physically
Pitfall: Don’t compliment or compare weight or appearance, and avoid food arguments and power struggles. Instead of publicly sharing weight after every meal or applying the same bathroom restrictions to every person, follow the prescribed individualized plan and protect the person’s dignity.

9. Don’t label somatic symptoms, illness anxiety, functional neurological symptoms, factitious disorder, or malingering as “fake” just because tests are normal

CategoryCore featureNursing approach
Somatic symptom disorderExcessive thoughts, anxiety, and behaviors related to actual physical symptoms; there may be a medical cause for the symptomsEvaluate new warning signs while managing with a consistent team, scheduled appointments, and functional goals
Illness anxiety disorderPersistent anxiety about having a serious illness even when symptoms are absent or mildAddress health anxiety and functioning with planned evaluations rather than simply offering repeated reassurance
Functional neurological symptom disorderChanges in neurological function, diagnosed by clinical inconsistency cluesRespect the symptoms as real and support safety, rehabilitation, and functional recovery
Factitious disorderIntentional symptom fabrication driven by an internal motivation to assume the sick role, when provenAvoid solo confrontation; use objective documentation, a team approach, and safety assessment
MalingeringIntentional falsification for external gain, when proven; this is not a psychiatric diagnosisDon’t stigmatize based on suspicion alone; evaluate using objective inconsistencies and institutional procedures

Important correction: “Medically unexplained symptoms” is not a required criterion for somatic symptom disorder. You also shouldn’t jump to conclusions about factitious disorder or malingering just because test results are normal or the person has visited multiple hospitals.

Therapeutic statement: “It sounds like these symptoms are really having a big impact on your daily life. Let’s first check for any new warning signs today, and then our team will regularly track your symptoms and functioning together.”

10. In personality disorder nursing, look at repeated patterns, functioning, safety, and a consistent team plan — not stigma

A personality disorder isn’t diagnosed based on a single behavior or a difficult relationship. A professional assessment confirms that long-standing patterns of inner experience and behavior, appearing across many situations, are affecting functioning and relationships. Don’t pin the cause on one specific parenting experience.

Borderline personality disorder

You may see difficulty regulating emotions, impulsivity, and an unstable sense of self and relationships. Don’t dismiss self-harm or suicidal statements as “attention-seeking” — assess the current risk every single time.

Consistent team approach

Different team members shouldn’t make different promises. Calmly explain which behaviors are acceptable and which are not, along with the reasons. Validate the emotions while keeping clear limits around dangerous behaviors.

DBT and skills

Dialectical behavior therapy teaches mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness skills. During a crisis, connect the person back to their existing coping plan and the skills they can actually use right now.

Antisocial traits

Don’t use the diagnosis to predict risk. Objectively assess current behavior, specific threats, rule violations, impulsivity, substance use, and access. Avoid getting drawn into emotional arguments.

Language traps: Labels like “manipulative,” “splitting,” or “attention-seeking” can obscure the person’s needs and risks while fueling the team’s emotional reactions. Instead, document observable facts and responses, such as “requests differed between shifts” or “stated a plan for self-harm.”

11. Distinguish delirium from major neurocognitive disorder by onset speed, attention, fluctuation, and reversibility of the cause

FeatureDeliriumMajor neurocognitive disorder
OnsetAcute change over hours to daysGradual change, usually over months to years
CourseCan fluctuate significantly throughout the dayRelatively stable but can progress
Attention & consciousnessDecreased attention and altered level of consciousness are keyMay be relatively preserved in early stages
CauseAcute causes such as infection, hypoxia, metabolic issues, medications, surgery, pain, or withdrawalVarious chronic causes like neurodegeneration or vascular issues
Priority actionsTreat the cause and support safety, hydration, oxygenation, sensory input, and sleepSupport functioning, safety, decision-making, and caregivers with a long-term plan

A person with dementia can also develop a new delirium. Don’t just chalk it up to “their dementia” — look for a sharp change from their baseline in attention, alertness, or behavior. Support them with glasses and hearing aids, day-night cues, pain and bowel/bladder management, hydration and nutrition, mobility, and sleep. Avoid unnecessary restraints and sedating medications.

Evaluate immediately: A rapid change in mental status can be a medical emergency, including infection, hypoxia, hypoglycemia, stroke, drug toxicity, or withdrawal. Don’t miss quiet hypoactive delirium either.

12. With substance use, distinguish the physiological patterns of intoxication and withdrawal, and connect detox to ongoing treatment

ConditionKey cluesPriority nursing care
Opioid overdoseHard to wake, slow or shallow breathing, possible cyanosis and bradycardiaCall emergency, support airway and ventilation, give naloxone, monitor for repeated response and re-sedation
Opioid withdrawalDilated pupils, runny nose and tearing, pain, vomiting and diarrhea, restlessnessAssess dehydration, electrolytes, pregnancy, and comorbidities; relieve symptoms and link to ongoing treatment
Alcohol withdrawalTremors, anxiety, sweating, tachycardia, insomnia, progressing to possible seizures and deliriumUse standardized tools and prescribed medications; monitor vital signs, neurological status, electrolytes, and fall risk
Sedative-hypnotic withdrawalAnxiety, insomnia, tremors, possible seizures and deliriumAvoid abrupt self-discontinuation; provide medically supervised tapering and monitoring
Stimulant intoxicationAgitation, hypertension and tachycardia, chest pain, hyperthermia, paranoiaProvide a low-stimulation environment; assess cardiovascular status, temperature, hydration, and safety; deliver emergency treatment

Opioid overdose: Naloxone is only a temporary treatment, so even if the person wakes up after receiving it, you still need to call for emergency help and keep monitoring their breathing. The effects can wear off, causing consciousness and breathing to decline again, so repeat doses may be needed.

Pitfall: Don't assume a fixed timeline for when withdrawal starts or peaks — it varies from person to person. Alcohol and benzodiazepine withdrawal can be life-threatening, and treatment doesn't end with opioid detoxification alone. In hypoglycemic emergencies, don't delay giving glucose because of thiamine; for patients at nutritional risk, give thiamine promptly as prescribed.

13. Antidepressants: Distinguish onset of effect, early activation, interactions, and discontinuation symptoms

ClassKey observationsImportant teaching
SSRI·SNRIGI effects, sleep disturbance/agitation, sexual dysfunction, bleeding risk, possible hyponatremiaEffects take time; avoid abrupt self-discontinuation; report early changes in suicidality or mania
TCAAnticholinergic effects, orthostatic hypotension, sedation, cardiac conduction/overdose toxicityAssess for falls, constipation, urinary retention, and overdose safety
MAOIHypertensive crisis and serious drug/food interactionsFollow prescribed restrictions and washout periods exactly; check before starting any new medication or supplement
bupropionInsomnia/activation, seizure riskVerify contraindications such as eating disorder or seizure history and appropriateness of the prescription
mirtazapineSedation, appetite/weight changesEvaluate effects together with individual symptoms, fall risk, and metabolic context
Initiation & dose changes

Monitor for changes in anxiety, agitation, insomnia, impulsivity, suicidal thoughts, and unusual energy or decreased need for sleep.

Serotonin burden

Check the full list of other antidepressants, tramadol, linezolid, triptans, dextromethorphan, St. John's wort, and more.

Discontinuation symptoms

Dizziness, paresthesia, anxiety, and flu-like symptoms can be mistaken for relapse. Instead of stopping abruptly on your own, work with the prescriber on a tapering plan.

Bipolar possibility

If decreased need for sleep, increased talking/energy/activity, or impulsivity emerge, don't view it as simple improvement — report it immediately.

14. Mood stabilizers: Look at symptoms, organ function, hydration, and interactions — not just the blood level

DrugCore monitoringClues to report immediately
lithiumPrescribed blood levels, renal/thyroid/electrolytes, hydration/sodium, pregnancy, interactionsNew vomiting/diarrhea, coarse tremor, ataxia, slurred speech, confusion
valproate·divalproexLiver function, CBC/platelets, pregnancy potential, bleeding/sedation/weightSevere abdominal pain/vomiting, jaundice, abnormal bleeding, altered consciousness
carbamazepineCBC, liver/sodium, skin, interactions and genetic risk assessmentFever/sore throat, severe rash/mucosal lesions, confusion/seizure
lamotrigineSlow titration, skin/mucosa and systemic hypersensitivity, interactionsNew rash, blistering/mucosal pain, fever/lymph node/organ symptoms

Lithium safety: Dehydration, rapid sodium changes, and drugs like NSAIDs, diuretics, and renin-angiotensin agents can affect levels. If you have persistent vomiting, diarrhea, fever, excessive sweating, or start a new medication, don't adjust the dose yourself — contact the prescriber right away.

Lamotrigine rash: The patient can't tell whether a rash is benign or serious. Teach them not to keep taking the next dose on their own if a new rash appears — they should report it to the prescriber immediately for evaluation.
Pregnancy safety: Valproate carries significant fetal risk, so always check for pregnancy or pregnancy planning. However, abrupt self-discontinuation can also be dangerous, so work with a specialist prescriber on an alternative or tapering plan.

15. Antipsychotics: Track psychotic symptom response alongside movement, metabolic, cardiac, and hematologic side effects

DomainObservationsNursing actions
MovementAcute dystonia, akathisia, parkinsonism, tardive dyskinesiaDocument onset, pattern, and functional impact; report to prescriber — treatments differ
MetabolicWeight/waist circumference, blood pressure, blood glucose, lipidsCheck baseline and trends; provide non-stigmatizing lifestyle and medical support
CardiovascularOrthostatic hypotension, syncope, QT riskCheck falls, vitals, cardiac history/electrolytes/interactions, and prescribed ECG
Endocrine/sexualProlactin-related changes, sexual/menstrual changesAsk about sensitive symptoms privately; counsel before stopping medication
clozapineANC, infection, chest pain/dyspnea, seizures, severe constipation, metabolic changesMonitor ANC and organ-specific warning signs according to current prescribing information

Clozapine still carries a risk of severe neutropenia, so ANC monitoring according to current prescribing information remains necessary. The FDA removed the Clozapine REMS participation and ANC reporting mandate in 2025, but that does not mean blood monitoring itself is no longer needed.

Clozapine — report immediately: Fever, sore throat, signs of infection, chest pain, shortness of breath, tachycardia, seizures, severe constipation, abdominal distension, or vomiting can be signals of severe neutropenia, myocarditis/cardiomyopathy, seizures, or gastrointestinal hypomotility.
EPS pitfall: Don't mistake akathisia — where the person feels intensely restless and can't sit still — as just "anxiety from their illness," and don't treat every abnormal movement with benztropine. Especially with tardive dyskinesia, anticholinergics can make it worse, so accurate differentiation and a prescriber evaluation are needed.

16. EPS, NMS, serotonin syndrome, and lithium toxicity — it's all about "stop the drug and figure out how urgent it is"

ConditionKey cluesPriority action
Acute dystoniaSudden spasms of the neck, jaw, or eyes; possible tongue or laryngeal involvementCheck the airway first, report immediately, and give the prescribed emergency medication while observing closely
AkathisiaInner restlessness, constant movement, extreme distressAssess suicide risk and medication timing, report to the prescriber; never interpret this as noncompliance
NMSHigh fever, severe rigidity, altered consciousness, autonomic instabilityHold the suspected antipsychotic, call for emergency help, and monitor cooling, fluids, and organ function
Serotonin syndromeAgitation, sweating, high fever, clonus, hyperreflexia, tremor, possible diarrheaHold serotonergic drugs, get an emergency evaluation, check for interactions, and provide supportive care
Lithium toxicityVomiting, diarrhea, coarse tremor, ataxia, slurred speech, confusion, seizuresHold lithium, get an emergency evaluation, and check the level, kidney function, electrolytes, hydration status, and interactions

How to tell them apart: NMS may stand out with severe "lead-pipe" rigidity and hyporeflexia, while serotonin syndrome is more characterized by clonus and hyperreflexia. But in the clinical setting, don't spend time trying to self-diagnose — just stop the suspected drug and start the emergency evaluation right away.

Airway risk: Dystonia involving the neck, tongue, or larynx, decreased consciousness, seizures, or severe hyperthermia all require an immediate ABC assessment and emergency support. Don't reassure yourself that it's "just EPS" and wait.

17. Anti-anxiety and sedative-hypnotic drugs — manage sedation, breathing, falls, dependence, and withdrawal all together

Drug classKey characteristicsNursing focus
BenzodiazepinesRapid anxiety relief; possible sedation, memory effects, falls, respiratory depression, and dependenceCheck for other depressants like opioids or alcohol, and prevent abrupt self-discontinuation
BuspironeNot an immediate PRN effect — it works after regular dosingExplain the onset of effect and check for dizziness and interactions
Non-benzodiazepine hypnoticsSedation; possible complex sleep behaviors and fallsEnsure a safe sleep duration and environment after taking it, and check next-day functioning
Antihistamines and OTC productsAnticholinergic and sedative burdenWatch for confusion, urinary retention, constipation, and falls in older adults, and check for duplicate ingredients
Herbal products and supplementsVariability in ingredients and possible drug interactionsDon't assume "natural" means "safe" — share the complete list with the healthcare team
Pitfall: Don't advise a client who has been on a benzodiazepine for a long time to stop it abruptly. Withdrawal can progress beyond anxiety and insomnia to seizures and delirium, so a medically supervised taper is needed.

18. ECT is a planned treatment that requires general anesthesia, muscle relaxation, and recovery monitoring

ECT is one of the longest-used brain stimulation treatments for severe depressive episodes, and it may be considered in treatment-resistant depression or situations that need a rapid response, like catatonia, suicidality, or malnutrition. It is also used in specific circumstances for mania, schizoaffective disorder, and schizophrenia. A specialist team evaluates the individual risks, benefits, and alternatives for each client.

PhaseWhat to checkNursing focus
BeforeCapacity to consent and legal procedures, history and anesthesia risks, medications, NPO status and prescribed testsProvide understandable explanations, address questions and alternatives, and check teeth, prosthetics, and baseline cognition and memory
DuringBrief general anesthesia and muscle relaxation; monitor oxygenation, blood pressure, and heart rateA trained team monitors the airway, circulation, and seizure activity
Immediately afterAirway, breathing, vital signs, consciousness, orientation, pain, nausea, and fall riskDon't let the client walk alone while confused; support them with repeated explanations and a safe recovery
Follow-upHeadache, muscle aches, nausea, temporary confusion and memory changes, and symptom responseDocument findings compared to baseline, and report any severe or persistent changes immediately

Correction: ECT is not a "shock treatment without anesthesia." Modern ECT is performed under brief general anesthesia with muscle relaxation, and the most common side effects are headache, GI discomfort, muscle aches, confusion, and memory changes.

Pitfall: Don't memorize all cardiovascular and neurological conditions as simple absolute contraindications. Anesthetic, cardiovascular, and neurological risks are assessed individually, and consent is verified according to current capacity, legal requirements, and institutional procedures.

19. Psychiatric medication safety is about closing the gaps — before prescribing, early in treatment, long-term, and at transition points

Before Prescribing

Check the indication, past response and allergies, pregnancy potential, kidney/liver/heart/metabolic status, seizure/fall history, and the complete medication list.

Early Initiation & Dose Increase

Track activation, suicidality, mania, sedation, orthostasis, rash, movement abnormalities, and the patient’s understanding of the medication early on.

Long-Term

Monitor effectiveness and functioning, along with weight, blood pressure, blood glucose, lipids, organ function, blood parameters, movement, and sexual function on a drug-specific basis.

During Illness & Dehydration

Check for vomiting, diarrhea, fever, dietary changes, and the impact of new prescriptions or over-the-counter drugs on drug levels and toxicity.

Transfer & Discharge

Directly hand off the last dose given, the next dose due, lab schedules, prohibited combinations, warning signs, and contact pathways.

Reassessment

Confirm that target symptoms and functioning have improved and that harm is acceptable—not just that the patient “is taking it.”

Shared Decision-Making

Discuss efficacy goals, key side effects, alternatives, and the patient’s priorities together. Do not dismiss side effect complaints as “non-adherence.”

Medication Barriers

Identify cost, transportation, lab access, literacy, culture, stigma, daily routines, and side effects, then turn the plan into one that is actually feasible.

Preventing Abrupt Discontinuation

Drugs with withdrawal, relapse, or rebound risks require professional tapering. However, for life-threatening adverse reactions, holding the suspected drug and emergency evaluation come first.

Accurate Documentation

Record symptom onset time, last dose, new medications and supplements, vital signs, labs, interventions, and responses in chronological order.

20. Integrated Cases Ask for the Most Dangerous Hypothesis and the Next Action, Not Just the Diagnosis

Case A · An older adult being treated for a UTI who suddenly cannot recognize people and whose condition fluctuates between day and night

Do not assume it is dementia progression or psychosis. View it as acute delirium and assess oxygen, blood glucose, vital signs, infection, electrolytes, pain, medications, and voiding, while supporting orientation with glasses and hearing aids and ensuring fall safety.

Case B · A patient who, after starting an antidepressant, is barely sleeping, has surging energy, and has begun overspending

Do not interpret this as the depression improving. Evaluate for manic or mixed features, suicide and impulsivity risk, bipolar history, and substance use, and report to the prescriber immediately.

Case C · A patient with schizophrenia who says a voice is commanding them to harm a neighbor

Do not argue with the hallucination or predict violence based on the diagnosis alone. Specify the target, command, intent, means, access, past compliance, and control, along with substance use and delirium, and activate a safety pathway.

Case D · A patient who freezes upon sudden touch before an exam after trauma and forgets where they are

Do not view this as uncooperativeness. Stop the touch, briefly reorient them to the safe place and time here and now, assist with sensory grounding, and explain the next step to ask for permission and choice again.

Case E · A patient whose weight is in the average range but who has fainting and palpitations after repeated vomiting

Do not judge stability by appearance alone. Assess fall risk, vital signs, ECG, electrolytes, fluid status, compensatory behaviors, refeeding risk, and suicide safety together.

Case F · A patient using opioids who is difficult to arouse and has shallow breathing

Before asking about withdrawal, the priorities are calling for emergency help, airway and ventilation support, naloxone, and respiratory monitoring. Even if they wake up, the effect may be temporary, so monitor for re-sedation and the need for repeat doses, and link to ongoing treatment.

Case G · A patient on lithium who develops coarse tremor and unsteady gait after gastroenteritis, dehydration, and NSAID use

Do not view this as simple anxiety or a common fine tremor. Hold the lithium, seek emergency evaluation, and check the blood level, kidney function, electrolytes, fluid status, and interactions.

Case H · A patient who develops high fever, severe generalized rigidity, confusion, and tachycardia after an antipsychotic dose increase

Do not wait, attributing it only to common EPS or an infection. Consider neuroleptic malignant syndrome (NMS), hold the suspected drug, call for emergency help, and monitor ABCs, cooling, fluids, kidney function, muscle damage, and autonomic status.

Final 15-Second Check
  • Did you check ABCs, oxygen, vital signs, blood glucose, temperature, trauma, seizure, and overdose first?
  • Did you compare the speed of new confusion onset, attention, consciousness, and fluctuation throughout the day against the baseline?
  • Did you confirm the start, dose increase, discontinuation, and last use time of prescription drugs, over-the-counter drugs, supplements, and substances?
  • Did you directly assess suicide, homicide, command hallucinations, means, target access, and control?
  • Did you avoid ruling out risk or a medical cause based solely on the diagnosis, personality, or a single normal test?
  • In depression, did you check for past mania or hypomania and recent activation or decreased need for sleep?
  • Did you avoid stigmatizing the negative and cognitive symptoms of schizophrenia as laziness or uncooperativeness?
  • In PTSD, did you offer choice, forewarning, and permission, and avoid forcing a detailed trauma narrative?
  • In eating disorders, did you look at vital signs, ECG, electrolytes, fluid status, and refeeding risk rather than appearance or weight?
  • Did you avoid defining somatic symptom disorder as “fake symptoms” or “normal tests”?
  • In personality disorders, did you document observable behaviors and functioning, and assess self-harm and threats each time?
  • Did you monitor for the seizure and delirium risk of alcohol and benzodiazepine withdrawal, and the re-sedation risk of opioid overdose?
  • Did you check for early suicidality, activation, manic switch, and serotonin interactions with antidepressants?
  • Did you check lithium’s fluid, sodium, kidney, and thyroid status, interactions, and neurotoxicity clues?
  • Did you educate about lamotrigine rash, valproate pregnancy risk, and carbamazepine blood and skin risks?
  • Did you track antipsychotic movement, metabolic, cardiac, blood, and gastrointestinal side effects separately from changes in psychosis?
  • In NMS, serotonin syndrome, and lithium toxicity, did you avoid delaying holding the suspected drug and emergency evaluation?
  • Did you check for overlapping sedation from benzodiazepines, opioids, and alcohol, and for withdrawal from abrupt discontinuation?
  • Before ECT, did you confirm consent, anesthesia risk, NPO status, and medications; and after, check ABCs, cognition, falls, and memory changes?
  • At discharge or transfer, did you directly hand off the last dose, next dose, labs, warning signs, and contact pathways?
Official & Primary Sources

This material is a study summary and is not a guideline for deciding an individual patient's diagnosis, risk level, drug choice, dosage, target blood level, admission, discharge, involuntary treatment, withdrawal protocol, ECT indication, consent, or emergency care. In actual practice, follow the latest prescribing information, current jurisdictional laws, institutional policies, prescriptions, and the judgment of pharmacists, poison control, mental health, emergency, and anesthesia specialist teams. The original sources were used only to confirm the existence of exam topics; questions, answers, choices, tables, and images have not been reproduced.

One-line summary: Nursing care for major psychiatric disorders and psychopharmacology is a process where you first look for medical causes and delirium in any new change, assess current safety, function, and symptom clusters, then separate drug effects and side effects along a timeline to connect them to the most urgent next action.

다음 이론을 계속 학습하려면 로그인하세요.

로그인하고 계속 학습
컨텐츠를 그만볼래?

필기노트, 하이라이터, 메모는 잘 쓰고 있어?

내보내줘
어떤 폴더에 저장할래?

컨텐츠 노트에는 총 0개의 폴더가 있어!

폴더 만들기
컨텐츠 만들기
만들기
신고했어요.

운영진이 검토할게요!

해당 유저를 차단했어요.

마이페이지에서 차단한 회원을 관리할 수 있어요.