1. Varcarolis, 7th edition, page 219-221 or Varcarolis 8th edition, page 215-217.  This is your texbook and please use only this and the following document as references for you paper.
2. Koegh and Doyle (2008) Psychopharmacolgical adverse effects.  I have attached the pdf file above.  
This week we will begin writing a short 1-2 page double spaced paper (not including title page or reference page) on neuroleptic malignant syndrome.  The primary purpose of this assignment is to get accustomed to 6th edition APA style.
For this paper I would like you to use only the following 2 references:
For this APA paper, please use only these references as I am more concerned with your APA formatting than the content and I need to be sure that you only use these two references and not any additional ones so that I can make corrections based on only these two references.

Your paper topic will focus on neuroleptic malignant syndrome.
Brian Keogh and Louise Doyle provide mental health nurses with guidance on
recognising and managing potentially fatal adverse effects of a range of medications
T
keywords
> drugs: adverse reactions
> psychiatric disorders:
drug therapy
These iceywords are based
on the subject headings
from the British Nursing
Index, This article has been
subject to a double-blind
review.
here have been many advances in the care of people
with mental health problemsin recent years. Those at
the forefront of the changes have called for a reduction
in the emphasis on medication-based treatments and for the
introduction of more interventions based on a psychosocial
approach. Despite this, psychopharmacology remains the
main treatment for most people in mental distress. The role
of the mental health nurse in the administration of medications has become increasingly complex, given the range of
preparations available and their potential to induce adverse
and toxic effects in susceptible individuals.
Recognising the adverse and toxic effects of psychopharmacology is a key part of the mental heaith nurse’s role and
involves assisting individuals to manage side effects which
may impact on their quality of life. Occasionally, medications
used in contemporary psychiatry can induce potentially lifethreatening adverse reactions in a small number of individuals.
Given the idiosyncratic nature of some of these effects, and
the difficulty in predicting people who are vulnerable, early
28 mental health practice march 2008 vol 11 no 6
recognition and intervention is imperative to a successful
outcome should these occur.
Agranulocytosi5
Agranulocytosis is a blood disorder (dyscrasia) characterised
by a selective reduction in white blood cells, particularly
neutrophils, resulting in an increased susceptibility to infection in those affected (Downie ef ai 2004), Rosenfeld and
Loose-Mitchell (1998) suggest that blood disorders are
relatively rare for clients taking anti psychotic drugs, except
in the case of clozapine which may induce agranuiocytosis in
up to 3 per cent of individuals taking the drug, Clozapine is
classed as an atypical anti psychotic drug which is indicated
in the treatment of resistant schizophrenia.
Although its side effect profile is similar to conventional |
anti psychotics, clozapine’s potential to induce agranulo-1
cytosis caused its removal from production in the 1970s, It t
was reintroduced in the 1990s and can only be prescribed ^’
under strict supervision by the Clo2apine Patient Monitoring 5-
Service. Individuals prescribed the drug must have a blood
test to ensure that agranulocytosis has not occurred, then
a weekly blood test for the first 18 weeks, fortnightly for up
to a year, and then monthly thereafter (Healy 2005),
Agranulocytosis is difficult to detect and is usually discovered
when symptoms of infection appear. These symptoms include
a raised temperature, sore throat and mucosal ulcers. Nurses
need to watch out for these symptoms in patients taking
clozapine and intervene accordingly. When detected early,
intervention should only require the drug to be stopped and
for symptomatic treatments to be given, such as for a sore
throat or raised temperature. People who continue on anti
psychotic medication, especially clozapine, after discharge
from hospital should also be aware of this side effect and
what to do if it occurs. Once agranucytosis has been detected,
the individual’s condition should be monitored closely There
is spontaneous recovery for most people within about two
weeks (Downie etal 2004),
mental status, fever and altered autonomic function. However, these symptoms could be indicative of changes to the
client’s mental health or could have an alternative medical
cause. Immediate discontinuation of the antipsychotic is
essential. Pharmacological interventions include the possible use of a dopamine agonist such as bromocriptine
to increase the production of dopamine and/or a muscle
relaxant such as dantrolene (BNF 2007). In conjunction
with this, antipyretics such as paracetamol can be given to
reduce fever if indicated, Electroconvulsive therapy (ECT)
may produce a rapid response to NMS and may also be
beneficial for the underlying psychiatric condition (Pelonero
era/1998, Healy 2005),
Because of the idiosyncratic nature of NMS, prevention can
be difficult as it is rarely possible to accurately predict who
will develop the syndrome, Pelonero eta/(1998) identify
that agitation, dehydration and a prior history of NMS are
risk factors to the development of the syndrome. Therefore
nurses should be familiar with a client’s previous reaction
to antipsychotic medication and be aware of and respond
Neuroieptic malignant syndrome
Neuroleptic malignant syndrome (NMS) Is a potentially life to deficits in fluid balance in clients taking antipsychotic
threatening, but relatively rare, idiosyncratic reaction to medications.
neuroleptic medications. It is generally more likely to occur
following the administration of high potency/low dose typical Nursing care ‘
antipsychotic such as haloperidol. However, it can occur in Apart from pharmacological interventions, the main course of
response to any neuroleptic medication and in some cases treatment for NMS is symptomatic management, A cooling
it can occur when the client is receiving antidepressants blanket and/or a fan may be required to help reduce pyrexia.
(Galbraith era/2007).
Clients with NMS should be cared for in a high observation
It also occurs more frequently in those who are on higher area as their physical and mental condition needs to be
doses of antipsychotic medications and where polypharmacy monitored closely. Routine observations should be taken
regularly and documented, with anomalies reported to the
responsible medical practitioner. The client may need assistAgranulocytosis
ance with activities of daily living, as well as careful use of
(pictured left)
appropriate interpersonal skills such reality reorientation if
confusion
exists. Intravenous fluids may also be needed to
Individuals prescribed clozapine must have
correct dehydration and electrolyte abnormalities.
a blood test to eliminate agranulocytosis
weekly for the first 18 weeks, fortnightly
for up to a year after this initial period and
then monthly thereafter
Attention to nutritional support is required as many clients may not be able to eat or drink due to altered mental
status. The syndrome, which usually lasts for five to seven
days after drug discontinuation, may be unduly prolonged
if depot antipsychotics have been used. Where possible,
clients with a history of NMS should not be given antipoccurs (Healy 2005). Many clients wiil experience NMS sychotic therapy again, and should instead be prescribed
shortly after initial exposure to antipsychotic medications, alternative medications such as lithium, carbamazepine or
and almost all clients who develop it do so within two weeks benzodiazepines. However, this may not always be posof commencing antipsychotic medications. However, it can sible and in these cases the client should be switched to
also develop in clients who have taken anti psychotics over a an antipsychotic in a different class and with a lower D2
long period of time. Diagnosis of NMS can be complicated affinity than the one which produced the NMS {for example,
as it initially presents in a similar way to serotonin syndrome atypical antipsychotics).
(discussed later in the article).
The symptoms associated with NMS include:
Serotonin syndrome
LJ muscular rigidity known as ‘lead pipe’ rigidity
Serotonin syndrome (SS) is a rare but life-threatening drug
• tremor
reaction caused by an excess of serotonin. In most cases it
LJ hyperthermia
is caused by a build up of serotonin which is caused when
U urinary incontinence
drugs which act on the serotonergic system are prescribed
U altered mental status (for example, confusion)
with other drugs that also work on this system (such as
• altered autonomic function (for example, high or low
selective serotonin reuptake inhibitors, (SSRIs), prescribed
blood pressure, elevated or rapid pulse)
with tricyclic medications). It is generally more likely to occur
within the first 24 hours of taking the medication or after
U elevated serum creatinine phosphokinase secondary to
an increase/overdose in medication. As SSRIs are now the
muscle breakdown
first line treatment for people with depression, nurses must
• elevated white blood cell count.
be familiar with the signs, symptoms and management of
this
potentially life-threatening condition.
Treatment and prevention
Early detection is essential if severe NMS is to be prevented.
The symptoms associated with SS include:
However, early diagnosis can be made difficult if the cardinal J jerks and twitches (myoclonus)
symptom of muscle rigidity is not clearly evident. Nurses LJ tremors of the tongue or fingers
must be familiar with other key symptoms such as altered LJ shivering
march 2008 vol 11 no 6 mental health practice 29
order to plan further interventions. No further lithium should
raised temperature
be administered and large volumes of intravenous isotonic
sweating
saline are usually prescribed (Healy 2005), In more severe
confusion, agitation or restlessness
cases, the client will need to be treated as an emergency
tachycardia
and may require haemodialysis (BNF 2007),
hyperreflexia
Individuals prescribed lithium require information about
diarrhoea
the drug’s actions, the side effects and
intoxication and euphoria
other specific information required to
(Galbraith era/2007).
assist the client to remain within his
Knowledge and vigilant
Before a diagnosis is made, at least
or her therapeutic index (Downie et
three major symptoms should be apparobservation for serious
a/2004), This information should be
ent and the client must be taking a
adverse effects are essential provided in a manner that is congruent
medication that affects the serotonergic
with the client’s ability to understand,
system. The main differential diagnosis
if mental health nurses are and verbal information should be
is NMS, as both conditions share many
to recognise, intervene and reinforced with as much written inforfeatures. However, the presence of
mation as possible. Clients receiving
diarrhoea, the more rapid onset of
prevent fatalities that may lithium should be encouraged to carry
the disorder and the absence of ‘lead
a ‘lithium card’ which explains how to
be caused by a range of
pipe’ rigidity can help to establish a
take the drug, what to do if they miss
diagnosis of SS (Birmes ef al 2003),
medications
a dose, side effects (including lithium
In most cases, SS will resolve once
toxicity) and what medications and
the offending agent(s) have been
illnesses
alter
serum
levels.
Other advice on the lithium card
stopped. Supportive care is essential in the management
should
include:
of SS, Intravenous fluids may be required and the nurse
should monitor vital signs and urine output regularly. As
J drink alcohol in small quantities only
with NMS, hyperthermia can be managed by introducing
J get advice from nursing, medical or pharmaceutical
measures to reduce the high temperature (for example,
practitioners before taking other medications and avoid
cooling blankets, fans and so on). The client should also be
some medications such as diuretics and non steroid anti
encouraged to drink plenty of fluids. In more severe cases,
inflammatory drugs such as brufen
a serotonin antagonist such as cyproheptadine may be used
J drink plenty of water (especially when hot or during
to reduce serotonin levels, although the beneficial effects of
exercise) and do not vary daily salt intake
such medications are not firmly established.
LJ if the client is a female, she should consult her medical
practitioner before getting pregnant (Downie et al
2004),
Lithium toxicity
•
Q
U
Q
a
•
•
Birmes P, Coppin, D,
Schmitt. L, Lauque
D (2003) Serotonin
syndrome; a brief
review, Canadian
Medical Association
Journal, 168. 11. 14391442,
Lithium is a commonly used drug in the treatment and
BNF (2007) British National prophylaxis of bipolar affective disorder and depression. It
Formulary. London, BMJ has many adverse effects and contraindications but the most
Publishing Group/RPS
worrying is lithium toxicity, which can be fatal and should
Publishing,
be treated immediately. Lithium is well known for its narrow
Downie G, MacKenzie
therapeutic/toxic range and doses are adjusted to a serum
J, Williams A (2004)
lithium level of 0,4 – 1 mmol/litre (BNF 2007), Patients can
Pharmacology and
become toxic for a number of reasons: overdose (accidental or
Medicines Management
purposeful), dehydration, or infections – although in certain
for Nurses. Edinburgh,
instances the cause is unclear (Healy 2005). Toxic symptoms
Churchill Uvinstone,
can occur at serum levels of 1,5mmol/!itre and require emerGalbraith A, Bullock S,
Manias E eta/(2007)
gency treatment if levels are 2mmol/litre or above.
Fundamentals of
Pharmacology: An
Applied Approach for
Nursing and Health.
London, Pearson
Education.
Recognising lithium
toxicity
The symptoms associated with lithium toxicity are:
U nausea and vomiting
3 diarrhoea
Healy D (2005) Psychiatric
U tremor {Healy 2005),
Drugs Explained.
However in more serious cases symptoms include:
Edinburgh, Churchtll
•
hyperf lexia
Livingstone,
LJ
hyperextension
of limbs
Pelonero AL. Levenson JL.
LJ convulsions
Pandurangi AK(1998)
Neuroleptic malignant
• toxic psychoses
syndrome: a review.
L3 syncope
Psychiatric Services. 49,
J renal failure
9,1153-1172,
G circulatory failure
Prosser S. Worster B,
• coma (BNF 2007).
MacGregorJ et
al (2000) Applied
Pharmacology. London,
Harcourt Publishers.
Rosenfeld G, LooseMitchell S (1998)
Pharmacology (3rd edn),
Philadelphia, Lippincott
Williams S Wilkins,
Treatment and prevention
Treatment is dependent on the seriousness of the toxicity and
careful observation is required by the nurse and the individual
to recognise symptoms early and to intervene accordingly A
doctor should review the client immediately and blood serum
levels should be taken to ascertain the client’s condition in
30 mental health practice march 2008 vol U no 6
Clients must also be assessed for their motivation to take
the drug and to attend for regular serum lithium levels and
thyroid and renal function tests (Prosser ef al 2000), Those
taking lithium should be advised to contact their community
mental health nurse, pharmacist or GP if they have any queries
or worries about lithium. They should also be aware of the
symptoms of lithium toxicity and be advised to get medical
help if they are feeling unwell, regardless of the cause.
Conclusion
The administration of medications is an integral part of
the mental health nurses’ roles and in doing so they have
a responsibility to be familiar with the preparations they
administer. Imperative to this role is the careful observation of
the medication’s effects and side effects, as well as educating
clients to manage their medication regimes. Knowledge and
vigilant observation for serious adverse effects such as the
ones discussed in this article are essential if mental health
nurses are to recognise, intervene and prevent fatalities that
may be caused by a range of medications •
Brian Keogh RPN, BNS, MSc is lecturer in mental
health nursing. School of Nursing & Midwifery,
Trinity College, Dublin
Louise Doyle RPN, BNS, RNT, MSc is lecturer
in mental health nursing, School of Nursing &
Midwifery, Trinity College, Dublin

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