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Mental Health Nursing · Chapter 12

Psychopharm Bench: Give or Hold, and Which Emergency Is This?

The drugs in this chapter are modest in benefit and serious in risk, and almost all of the nursing lives in the check you do before you administer and the change you notice afterwards. Work a seven-item medication round deciding give or hold, sort nine findings into neuroleptic malignant syndrome, serotonin syndrome or both, and place each extrapyramidal effect on its time course.

The 08:00 round — give or hold?

Seven people, seven decisions. “Hold” here always means hold and notify the provider with your reasoning — withholding a drug silently is not an intervention.

Neuroleptic malignant syndrome or serotonin syndrome?

Both are hyperthermic emergencies with altered mental status and autonomic instability, and students lose marks and patients by treating them as one thing. Sort each finding into the syndrome it points to — or to both, where it does not discriminate at all.
Both are stop-the-drug emergencies. In NMS, stop the antipsychotic, notify as an emergency, cool actively, monitor the cardiac rhythm and urine output for rhabdomyolysis, and anticipate intravenous fluids, dantrolene, bromocriptine and benzodiazepines — one of the three situations in which benzodiazepines are correct. In serotonin syndrome, stop all serotonergic agents, including the ones that are easy to forget: tramadol and linezolid.

Monitoring board

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Round decisions
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Correct
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Findings sorted
Each rule lights when you reach the person it belongs to. These are the checks that make the difference between administering a drug and nursing someone who is taking one.

Extrapyramidal effects — place them in time

Timing is the discriminator, and it is what turns “he seems restless” into a named, treatable finding. Choose when each one appears.
Restlessness is a diagnosis, not a description. Before charting “increasingly agitated” on a person taking an antipsychotic, ask directly: “Is the restlessness inside your body, like you have to keep moving?” If yes, this is akathisia, and the classic error — increasing the dose — makes it worse. Akathisia is genuinely distressing and is associated with suicidal thinking, which is reason enough to catch it.

Beyond the medication chart

The boxed warning. Antipsychotics carry a boxed warning of increased mortality in older adults with dementia-related psychosis, first- and second-generation alike — roughly 1.6 to 1.7 times the risk of death over a short course, driven by cardiac events, pneumonia and stroke. Where a trial is genuinely justified, the rules are: informed discussion with the person where possible and the surrogate decision-maker, a documented target symptom, the lowest effective dose, a defined review date, and an active plan to taper and stop. Deprescribing is a nursing advocacy role — ask at every admission and care conference why each psychotropic is still there and what it is for.
The antidepressant window. Sertraline and citalopram are reasonable for depression in dementia, with citalopram limited to 20 mg daily over the age of 60 for QT prolongation and paroxetine avoided for its anticholinergic load. Benefit takes 2 to 6 weeks, and a family watching for a change within days needs told that plainly. Watch the early window closely: psychomotor energy can return before mood lifts, so ask about suicidal thoughts directly rather than reading returning activity as recovery.
The care partner is also your patient. Dementia care partners have measurably elevated rates of depression, anxiety, sleep deprivation, physical illness and mortality. The Zarit Burden Interview is one tool; “How are you sleeping?” opens the same door. Connect people to respite, adult day programmes, the Alzheimer’s Association 24-hour helpline and support groups — and screen for elder abuse, neglect and financial exploitation in an unhurried private interview, because exhausted unsupported caregiving is itself a risk factor for harm. Nurses are mandatory reporters.
Capacity is clinical, situational and fluctuating — the ability to understand, appreciate, reason and communicate a choice for a specific decision at a specific time. Competence is a legal determination made by a court. Someone may lack capacity for complex finances while retaining full capacity to decide who visits and whether to accept an antibiotic. Assume capacity, assess for the decision in front of you, and support it: simplify, use the person’s best hour, involve a trusted person, re-ask.
Escalate with SBAR and lead with the change from baseline, because “more confused” buried in paragraph three does not get a response. “Mrs Okafor in 412 has an acute change in mental status” — then the background, then the CAM result and observations, then a concrete list of what you want ordered. Safety planning is equally concrete: driving raised honestly and early, firearm access asked about directly and secured, suicide asked about directly because risk is elevated in the year after a dementia diagnosis while insight is intact, and stockpiled medications secured.