MATERNAL NURSING

Phase I
&

Estrogen Menstruation Progesterone Estrogen (13th day)

Hypoalamus

Luteinizing hormone - releasing hormone

Follicle stimulating hormone - releasing
hormone
Anterior

pituitary gland

Luteinizing hormone
Follicle stimulating hormone

Progesterone
Estrogen

Increased blood flow in the uterus

Thickening of endometrium

Secretory phase (14th to 25th day)

Proliferative phase (6th to 14th day)
Two hormones that govern during menstruation:

1. Estrogen
Directly proportional
2. Progesterone

There should be a drop in the level of estrogen

-
-

and progesterone for menstruation to happen

-
-

Ovulation = hormones must be elevated

- -
- - -

IN oncologic nursing, the estrogen causes cancer, the and

-
progesterone prevents cancer, therefore these hormones
-
-

must be always balanced.

So yung mga nagtetake ng estrogen
pills ay at high risk for developing
cancer

SaBay umaakyat, sabay bumabagsak

Follicle stimulating hormone - releasing hormone

↑

Aka
Gonadtrophic hormone - releasing hormone
 28-day menstrual cycle

Proliferative phase happens during 6th to 14th day

- Average menstrual day: 5
-

Secretory phase happens during 14th to 25th day

-
-
Some will have 3-5 days, some 5-7 days
28th day = 1st day of menstruation
-
-

Ischemic phase happens days before the menstruation

Menstrual phase - Menstruation happens Hormone for ovulation

(Fsh) (Lh)
Estrogen Progesterone 1st day of
mens
13th to 14th day mataas SI ESTROGEN

12345 13 14 Ovulation 25262728

day!

Menstrual Secretory Ischemic

Proliferative

Sequence of menstruation

1. Menstrual ( Slough-off )
Thinnest endometrium or "just after menstruation"

2. Proliferative
Thickest endometrium

3. Secretory (Luteal phase)

Luteal phase is
Ovulation occurs the initial phase If both luteal and Secretory
of secretory appear in the choices, choose
the secretory because Luteal
4. Ischemic is only part of secretory

Period just before menstruation

Menstruation occurs 14 days after ovulation!

Menstruation = ovum Na hindi na-fertilize
-
-
 Normal bld lo

1. Menstruation
3o CC to 50 CC (Maximum of 80cc)
Per day
-
-

1/4 cup
4 tbsp.
5 days = average length
50cc (1 day) = 250 cc (5 days)

2. Normal spontaneous vaginal delivery (NSVD)

250 cc x 2 = 500 CC
-
-

Bleeding More than 500 cc Within 24 hrs. = post portal bleeding

-

3. Cesarean section
500 cc x 2 = 1 000 CC or 1L
-
-

Bleeding More than 1L may = post portal bleeding lead to A complication — hypovolemic shock
-
-

Terms:

1. Menarche
=
First menstruation
Ideal age = 12 years old
-
-

2. Menopause
Last menstruation
-
-
Menopause computation

Ideal age = 42 years old

-
-
Menarche + 30 = menopause
12 years old + 30 = 42 years old

How to delay your menopause?

= frequently use your uterus

Multiparity = one of the most common cause of late

menopause
 3. Menorrhagia 5. Amenorrhea
Heavy menstruation
-
Absence of menstruation
-

Complication: anemia Cause: presence of placenta

double dose your iron during menstruation Placenta maintains the high level of
estrogen and progesterone
1 tab in morning, 1 tab in evening

4. Metrorrhagia 6. Dysmenorrhea
Bleeding in between the menstruation
-
-
-
Painful menstruation
-

Drug of choice: NSAID

-
-

Ex. Mefenamic, ibuprofen

Menstruation generally occurs 14 days after ovulation -

Position of choice: knee-chest

-

Dierent menstrual cycles Ovulation Menstruation

25 day 11th day 14 days after ovulation
28 day 14th day 14 days after ovulation
30 day 16th day 14 days after ovulation
32 day 18th day 14 days after ovulation
35 day 21st day 14 days after ovulation
Constant
-
-

25-day cycle
-14 (menstruation)
First day of menstruation is -
11th day
-

the basis of LMP Ovulation day

25- Day cycle

Ovulation

Ovulation

Menstruation
· t
Menstruation
 Menstruation Menstruation
30-day cycle F

-14 cmenstruation)
-
-
16th day
Ovulation day Ovulation
· t

Best time to fertilize an ovum:

-
-
1 day before up to 2 days after ovulation
-
-

10th 11th day 12th 13th

Ovulation
4 days = fertile

Calendar meod

You must know your menstrual cycle! Menstruation

Mrs. Logan is having 35-day menstrual cycle.

On 9th day, she started menstruation. When
is the expected ovulation? t
Ovulation
35-day
-14 (m) 30-day cycle
Safe!
21st day -
-

Menstruation
To make it safe, avoid coitus:
5 days before ovulation Ovulation 3 days after
-
- -
-

Sperm lifespan: 3 days (72h) + 2

Egg lifespan: 1 day (24h) + 2 Ovulation
·

-
-
Fertile
No coitus!
-
-

CervIcal mucus (Billing's method)

If Clear and stretchable… “ L feel wet.”

during ovulation
It is called as spinnbarkheit sign = high estrogen = no coitus!
-
-
“I feel dry.”
(4 days before and 3 day after) during menstruation
Basal body temperature (bbt)

During ovulation, the temperature is increased

-
-

Progesterone = thermogenic = responsible for increased temperature

No coitus 3 to 4
You should monitor your temperature on morning for the whole month
days after!
=>
Temperature drops slightly before ovulation = High estrogen
Temp. Rises abruptlyO
-
during ovulation = high estrogen, high progesterone

Symptoermal Safest natural method

-
-

Combination of cervical mucus and BBT

Mucus is Clear and stretchable + high BBT

No coitus 3 to 4 days after

Coitus inteupts
Least effective natural
-
-

(Withdrawal)

Abstinence
0% chance
Monogamous relationship
I Natural method

Most effective
against STd
Condom
Artificial method
 Fertilization

Sites of fertilization

Ampua
Widest portion of Fallopian tube = site of fertilization
Common site of ectopic pregnancy
-

Implantation outside the uterus

Common cause of ectopic pregnancy:
Pelvic inflammatory disease
Inflammation of:
a) uterus
b) fallopian tube
c) ovaries
Ismus
Site of bilateral tubal ligation

BTL
A type of contraceptive
that causes immediate
sterility

Op
Once cut = ovum will not pass
through
 Uterus
Fundus
Site of implantation

②
Cervicitis
Inflammation of cervix

Cervix During or just after the menstruation

⑨
-

Opening of the uterus Cervix is slightly open

= best time to insert iud
Tail = exposed in the vagina
Corpus Intrauterine device (iud) Common complications:
Body of the uterus
Old: Prevents implantation Infection (toxic shock syndrome)
New: affects sperm motility A form of septic shock
Bleeding
Contraindicated to lactating/ breastfeeding
Common problem of iud:
Releases oxytocin which causes uterine contraction
Expulsion of device
Pills = suppresses the milk Contraindicated to
mothers with DM

Proce of fertilization
23 23
46 46
Sperm + egg = fertilization (in ampulla) Sperm Egg
-

Normal chromosomes:
46 chromosomes = 23 pairs Zygote
(46 chromosomes)
Sperm Egg 44 autosomes + xy = male Mitosis
44 autosomes + xx = female
Meiosis
(Divides into 2 haploid cells)

23 23
chromosomes chromosomes
(22 autosome + x or y) (22 autosome + x)
Types of chromosomes Sperm Egg
1. Genotype
-
-

”Genocide”
Responsible for the race of the offspring XX or xy (sex)
Zygote

2. Serotype
-
- Blastomere
“Serum”
Responsible for the blood type of the offspring
Morula Implantation in uterus

3. Phenotype
-
-

Responsible for the physical appearance of the

-
-
Blastocysts
offspring
4. Karyotype Amnion Chorion
Responsible for the dna structure of the
-

offspring
-

1. Amniotic sac Chorionic villi

Picture breakdown of the chromosomes
2. Umbilical cord
Will attach to
Amniotic fluid is
Karyotyping = dna testing Decidua basalis
formed through
Responsible for the behavior of the offspring fetal urine

Responsible for the traits of the offspring Implantation

(10 wks)
Hereditary = traits
That is why tracking the Fertilization
family history is important in ampulla Placenta
Down syndrome -
----
(trisomy 21)
Trisomy 13 = Patau syndrome
·
-
·
↑
Trisomy 18 = Edward syndrome ↑
↑ Morula
Mitosis
Sperm Egg ·

If from 1 to 23 are all

trisomy = 69 chromosomes
" i
Trisomy 21
H-mole
/ XX S Female
 Chorionic vii sampling
Done in early pregnancy Cas early
as 8 t0 12 wks)
-
-
First trimester
Done intravaginal (Organogenesis)
A thin catheter is inserted
in vagina through the
uterus
Purpose:
Genetic screening
Complication:
Fetal limb defect Cmissing digits)
Because it is done during Q
first trimester where the Excessive nausea and vomiting
organogenesis takes place (Hyperemesis gravidarum) H. Mole is aka as…

• Molar pregnancy
Hyaditiform mole HCG > 2 months
① • Gestational

Sperm Egg (
Pregnancy test
trophoblastic
pregnancy

A normal pregnancy test must

Zygote only be positive until first 1. Rapid abdominal Z
Shrinking into two months of the pregnancy enlargement (16 wks
Blastomere
⑤
a mole pregnant = 20 cm fundic
By 3rd month, matutunaw
height
Ang corpus luteum at
Degeneration Morula 2. High bp (pre-hypertension)
lalabas si placenta
3. Vaginal bleeding with
Once placenta started brown vesicles on 2nd
Blastocysts functioning hcg will be turned trimester
into human placental lactogen
(hpl)
Amnion Chorion
High blood pressure
1st trimester:
Formation of thromphoblastic tissues h. Mole
1. (-) fetal heart beat - “Grape-like clusters” 2nd/3rd trimester:
2. (-) fetal outline Pregnancy-induced
“Snow-ball clusters” hypertension (pih)

③ ⑭
Complications of h. Mole Plan of care
1. Hyperthyroidism 1. Avoid pregnancy at least 1 year
Due to increase in metabolic 2. Dilatation and curettage until hcg becomes negative
demand like overconsumption of 3. Contraindicated: oxytocin
oxygen
Grape-like clusters may be detached and may
lead to pulmonary embolism
2. Pulmonary embolism
H. Mole can be detached and 4. in case of choriocarcinoma (grape-like clusters
circulate through blood flow trophoblastic tissues)
and may travel into the lungs Drug of choice: methotrexate
-
-

Complications:
Predisposing factors of h. Mole 1. Bleeding
2. Decrease in folic acid (vitamin b 9)
1. High risk pregnancy (less than 18 years
old or more than 35 years old) Antidote: leucovorin
(Advancing age) To treat anemia
Ideal age to get pregnant:
20 to 30 years old
2. Taking oral contraceptive pills
3. Having a history of molar pregnancy
4. Common: south east Asia and far east Asia

Basis of grow and development

Age of gestation
Basis: last menstrual period (LMP) — first day
I T EASY
E
Because last day is not constant TAK
Example: LMP is June 7, date today is Aug. 25 11
June 30 30 - 7 = 23 7 79

July 31
-
11 weeks and 2 days
31 7
-

August 25 25 9 Naegel'S Rule

79 days 7
2
Edd/edc/edb (Naegel’s rule) Example: 10 — 28 — 2024
January to March = +9 +7 same year
-
-
Example: 2 — 15 — 2024 -3 +7 +1
April to December = -3 +7 +1
-
-
+9 +7 7 — 35 — 2025 (July 35)
11 — 22 — 2024 -31 (July)
8 — 4 — 2025
 -
Mcdonald’s rule
=
Measures the fundic height in cm
Purpose: To estimate the gestational Age
Basis: symphysis pubis Fundus
Mons pubis or mons veneris Or mountain of Venus * 30cm fundic height
&
T
I

Measurement: from symphysis pubis to uterine fundus I

↓ D
For 32 weeks, fundic height in cm = AOG in wks I
*
If >32 wks, Pubis
Fundic height in cm x 8/7 = AOG in wks
Fundic height in cm x 2/7 = AOG in mos

Bartholomew’s rule
=

-
Locates the fundus Haase’s rule
Measures the fetal length in cm
*
Xyphoid 9th 1 x 1 = 1 cm 6 x 5 = 30 cm
8th 10th 2 x 2 = 4 cm 7 x 5 = 35 cm
7th
6th X 3 x 3 = 9 cm 8 x 5 = 40 cm
5th Umbilicus 40 wks (edc)
4 x 4 = 16 cm 9 x 5 = 45 cm
4th
20 wks Y
3rd mos.
12 wks 5 x 5 = 25 cm 10 x 5 = 50 cm
Age of viability Pubis
Normal fetal length = 45 T 55 cm
Quickening = 5 months (2nd trimester)
Primi = 5 months (20 wks)
Multi = 4 months (16 wks)
 Psychiatric nursing

It is an interpersonal process whereby the nurse uses therapeutic self in assisting an individual, family or community
-
-
-
-

Most important task to become therapeutic: self-awareness

Mental heal
Ability of a person to adjust to whatever stress encountered everyday
-
-

(Adapt, cope up, flexible)

Criteria: self-acceptance

Mental ine
Disturbance of person's thought, feelings, and behavior
-
- - --

Risk factors:
1. Poverty - unable to meet the basic needs (physiologic)
2. Abuse - sexually, physically
3. Heredity - genetics

Which of the following is the most common predisposing factor

-
-

towards the development of mental illness?

A. Poverty
B. Abuse Predisposing factors = non-modifiable
C. Heredity Precipitating factors = modifiable
D. Lifestyle
 Major psychotic signs and symptoms

I. Altered sensory perception

1. Hallucination - no external stimuli
Example: pag tingin mo sa gilid, may white lady (wala ka namang katabi = no stimuli)

2. Illusion - with external stimuli

Example: pag tingin mo sa curtain, may white lady (with stimuli)
Speech
II. Altered thought process (beliefs)
1. Delusion - false belief Thought
A. Grandeur
B. Persecution
C. Control
D. Religion
E. Ideas of reference - Everything one perceives relates to one’s own destiny
The content of our speech is the content of our thought
2. Echolalia - repeating words of others
3. word salad - mixture of words
4. Neologism - coining of new words
5. Alogia - poverty of speech, reduction in the amount of speech, difficulty formulating thought
6. Circumstantiality - adding unnecessary details but relevant detail is still achieved
7. Tangentiality - diverting from one topic to another topic. Never approach the point of question
8. Clang association - rhymes, similarity of sound and not content
9. Dissociation - detached from normal function; disconnected
10. Flight of ideas - shifting from one topic to another but related naman
11. Loose of association - sequence of unrelated ideas

III. Inappropriate affect (feelings, mood, emotions)

1. Blunted affect - delayed response
2. Flat affect - more delayed response
3. Apathy - absence of emotions or feelings
4. Anhedonia - inability to experience pleasure
5. Ambivalence - opposing feelings
6. Labile - sudden mood swings
IV. Impaired motor
1. Echopraxia - repeating movements
2. Waxyflexibility - hold position for long (catatonic Patients)

V. Memory disturbance
1. Amnesia - forgetfulness
A. anterograde - forgetting of the recent or immediate past (short term)
B. Retrograde - forgetting of the distant past (long term)
2. Confabulation - creation of fantasy to fill in gaps
Stimuli
A patient diagnosed with schizophrenia is holding the curtain, shouting telling the
nurse “help! Help! The devil is here.”. What is the psychotic symptom manifested by
the patient?

A. Hallucination
B. Illusion
C. Delusion
D. Euphoria

A patient diagnosed with schizophrenia is holding the curtain, shouting telling the
nurse “help! Help! The devil is here.”. What is the external stimuli?

A. Radio
B. Tv
C. Curtain
D. Nurse

A patient diagnosed with schizophrenia is holding the curtain, shouting telling the
nurse “help! Help! The devil is here.”. What is the most appropriate response of
the nurse?

A. I see no devil around. Do you know whose the devil? I am the devil!
=
B. I see no devil around. You are the devil.
C. I see no devil around. This is the curtain. Presenting the reality but not therapeutic
D. I understand that you are seeing objects again. Acknowledgement = interpersonal > therapeutic
 Ego defense mechanism

• Protect self against anxiety

• normal reaction - but depends with the length of time
• automatic

1. Denial - failure to accept reality

2. Displacement - shift emotion to less threat
3. Projection - assimilate self to others
4. Substitution - replace unattainable goal to something attainable
5. Sublimation - channel unacceptable behavior towards something acceptable
6. Symbolization - use to represent another
7. Undoing - attempt to erase wrong act
8. Repression - involuntary forgetting (done when you keep yourself busy)
9. Suppression - voluntary forgetting (you have the intention to forget)
10. Identification - conscious patterning of behavior (ginagaya mo)
11. Introjection - unconscious patterning of behavior (dahil exposed ka, di mo sinasadyang magaya = you are highly influenced by your environment)
12. Rationalization - justify unacceptable behavior (excuses/palusot)
13. Intellectualization - explaining things in details (usually based on the books)
14. Regression - reversion to earlier stage of development to decrease anxiety
15. Compensation - weakness in one and a through gratification in another area
16. Acting out - performing extreme behavior in order to express thought or feelings

Mj had been frequently abused by her father who recently died. When the
nurse asked mj how her father was, she replied “my father was the best
father in the world.". How do you interpret the statement of mj?
- -
-

Not even asking for the defense mechanism

A. Denial You cannot accept the truth

!
B. Projection
C. Identification
“Thinkers are doers”

D. Dishonesty

Schizophrenia
“Schiz” - split; “phrenia” - mind = split of mind
Impaired reality
Causes of schizophrenia (unknown):
-
-
Or “Unclear" - most common cause
• 1% of population (worldwide or local)
• decreased brain (small frontal lobe)
• biologic (neurotransmitters) - increase dopamine (imbalanced norepinephrine, serotonin, gaba)
• Freud (psychoanalytic theory) - weak ego/self
• social factors (e.g. Single parent mothers)
• vitamin deficiency- b1, b6, b12, c
• organic factors - trauma, stroke, viral, bacterial
 Causes of schizophrenia (continuation):
• Environmental infection (prenatal or early pregnancy)
• autoimmune

Schizophrenia: claification of symptoms

Classic i: positive symptoms Classic ii: negative symptoms

• Absent to A mentally healthy individual • can be present to A mentally healthy
• major and hard symptoms (malala/grabe) individual
• minor and soft symptoms
A. Hallucination
B. Illusion A. Avolition (lack of motivation) H. poor hygiene
C. Delusion B. Anergia I. Pacing/rocking
D. Echopraxia C. Asocial J. Regression
E. Insomnia D. Anhedonia (lack of pleasure) K. Odd posture
F. Ambivalence E. Apathy
G. Bizarre behavior (catatonia) F. Alogia
G. Inappropriate affect

It is important to classify the symptoms because there are schizophrenics who

manifest either positive or negative symptoms only.
-

Positive symptoms are easier to manage with psychotics

Dsm5: signs and symptoms

1. Hallucinations (auditory: most common)
2. Delusions Major symptoms
3. Disorganized speech (word salad, neologism, clang association)
4. Disorganized or catatonic behavior
Minor symptoms
5. Negative symptoms

Criteria: at least 1 major symptom

Auditory hallucination: management

Assess the content: “what does the voice is telling you?”
= presence of command hallucination > safety
Delusion: management
• Acknowledge and present the reality
• Do not confront especially if persecution (you can express doubt but never confront)
 Paranoid schizophrenia

• suspicious, delusions, hostile and aggressive

-
Their way to protect themselves
-

• Do not touch (assault)

• Maintain distance (proxemics) To promote your safety
Nursing diagnosis: risk for injury directed to others
Defense mechanism: projection
Priority care:
• nutrition - give sealed food & open it in front of the patient
• Safety

Catatonic schizophrenia
• Excitement = hyperactive, talkative
• stupor = waxy flexibility, mute
Nursing diagnosis: impaired motor
Defense mechanism: repression
Priority care:
• circulation = talk (open communication) > movement
• Safety

SchizoAFFECTIVE DISORDER
Schizophrenia and (bipolar) mania

A patient diagnosed with paranoid schizophrenia tells the nurse that nurses are
spraying Poison into his food tray while removing inside the cart. What is the most
appropriate action of the nurse?

IA.B. Allow
Taste the food first
the client to cook his own food
C. Allow the client to remove his own food tray inside the cart “While removing inside the cart”
D. Offer packed goods This is the concept but does not address the question

Answer the question based on the situation presented!

A catatonic stupor is seated on the bed while staring widely opened window.
What is the highest priority nursing care?

A. Nutrition
B. Hygiene
IC. Safety
ID. None of the above
 Antipsychotics/neuroleptics

(Most important management)

Typical antipsychotics
• “-zine”, haloperidol (e.g. chlorpromazine)
• Old
• For positive symptoms
• High extrapyramidal symptoms
• Toxic/adverse - neuroleptic malignant syndrome (high fever, diaphoresis, aloc, muscle spasms)
• Can give with anxiolytics

NMs management: antiparkinsons drug (parlodel, dantrolin sodium)

Antipsychotics are not given prn = maintenance drug. Kahit mag present ng restlessness in the
morning, if ang schedule ay to take at evening, we will give anxiolytics instead.

Atypical antipsychotics
• “-pine”, “-done” (e.g. clozapine, resparadone)
• For positive and negative symptoms
• Toxic/adverse: agranulocytosis (first manifestation: sore throat), leukopenia
agranulocytosis: see the dr immediately
Leukopenia: obtaiin cbc
• do not give to patients with dementia
Ziprasidone: low bp, wide qt intervals

Antipsychotics: common side eects

1. Photosensitivity: patient can go to under the sun, just use caution: spf 30 and above
2. dry mouth & constipation: sugarless/sugar-freec candy, increase fluid intake, excercise, high fiber/low
residue diet
3. weight gain
4. hypotension
5. gi symptoms: take the drug with meals
6. Extrapyramidal symptoms (expected side effects = no need to hold the antipsychotic = give anticholinergics)

Extrapyramidal symptoms
Cause: low dopamine level due to antipsychotic
1. tardive dyskinesia
Tongue twitching and lip smacking = slurred speech
2. Pseudo Parkinson's
Tremors (reversible) > rigidity > bradykinesia > akinesia
Give anticholinergics: abc (akineton, benadryl, cogentin) + artane
3. Dystonia
Dysphagia + neck rigidity
4. Akathisia
Feeling of having ants under the pants = restless and irritable
Pupillary paralysis

Anticholinergics (muscle relaxants)

1. Benztropin mesaleate (cogentin) - best anticholinergic drug
2. diphenhydramine (benadryl) - 2nd best
3. Biperidine (akineton)
4. Trihexyphenedryl (artane)

Decanoate
• Given as injection, every month or every 2 weeks
• For patients who frequently miss a dose
Side effects:
• orthostatic hypotension

Md disorders
(Mood swings)
Types:
1. Unipolar - major depression (clinical depression)
-

2. Bipolar - depression and mania

-
-

Major depreion
(Clinical depression)
Causes:
1. Loss
2. Biologic: neurotransmitters (low serotonin, norepinephrine, dopamine)
3. Physical/sexual abuse
4. Substance abuse
5. Chronic illness

High incidence of depression: female (20%)

 Dsm5 criteria: major depreion

Patient must manifest 5 of 9 signs and symptoms

1. Depressed mood (overwhelming sadness/loneliness, feeling of isolation)
2. anhedonia (decreased sense of pleasure)
3. Weight loss or gain (decreased or increased appetite)
4. Sleep disturbances (insomnia, hypersomnia)
5. Psychomotor impairment/agitation
6. Fatigue
7. Low self-esteem (feeling of worthlessness, hopelessness)
8. decreased concentration (confusion, decreased focus, disorientation)
9. Suicidal ideation

Other types of depression:

1. Persistent depressive disorder (dysthymic)
• Lasting for 2 years or more
• Chronic
• Antidepressant is not used unless becomes worse
2. seasonal
• winter or fall season
• Light therapy
3. Atypical
• When exposed to happy stimuli, patient becomes happy
4. Melancholic
• even when exposed to happy stimuli, patient is still sad
5. Born end of March
• Between winter and fall season
6. Premenstrual dysphoric disorder (PMs)
• Due to low estrogen
7. Postpartum disorder
• After one month of delivery, estrogen and progesterone decreases = low serotonin

Danger of depression: suicide

 Suicide
• Self-destructive behavior
• cry for help
• ambivalence
• hostility towards self

Other types of suicide:

1. Threat
2. Gesture
3. Attempt
4. Complete
5. Plan
6. Ideation

Suicide risks (sad persons):

1. Sex - female (attempt suicide), male (complete suicide)

:
2. Age - 18 to 27 years old and above 40 years old
3. Depression
4. Prior attempts - high risk
5. Etoh (drug dependant)
6. Rational thought loss or psychosis
7. Organized plan
-

8. No spouse
-
-

9. Sickness/stress
=

Signs that the patient will commit suicide:

1. Sudden mood change
2. Give prized belongings
3. Verbalize
4. Will
5. Low self esteem
Management:
1. Safety
2. Unscheduled rounds
3. Remove pointed objects
4. Encourage verbalization: direct questions = direct answers (disorganized ang thought nila)

Choose the fastest way to die (nasaan yung bagay na kailangan

tanggalin sa loob ng kwarto ng pasyente?)
Transcultural (ways of suicide by race):
1. Japanese - harakiri (usie of sword)
2. Russsians/american - use of gun
3. Chinese/koreans/taiwanese - jumping out of the window/use of poison

Most common form in Filipino: strangulation

Anti-depreants

Four important rules:

1. Puts the patient at high suicide risk (less than 2 weeks of use, kasi di pa nag tetake effect but mag
iincrease na ang energy nya, otherwise, less risk)
2. slow onset & slow taper off (2 to 4 weeks before mag take effect, do not abruptly stop)
3. never mix with other drugs = serotonin syndrome (ssri to st john’s wort; maois to any other anti
depressants)
4. ALL PSYCH DRUGS: DECREASE BP, INCREASE WEIGHT, HEPATOTOXIC

Ssri: Selective serotonin reuptake inhibitors

• commonly used antidepressants today

• latest and most effective
• “-ine”, “-pram” (e.g. sertraline, fluoxetine, escitalopram)
• may cause sexual dysfunction (low libido)
• Can be mixed with benzodiazepines (anxiolytics)
• cannot be mixed with maois, st johns wort, tramadol) = serotonin syndrome
- -

S- weaty, hot fever

R- igidity, restless, tremors & agitation
Increases serotonin
I- ncreased hr

Tricyclic antidepreants

• “-pramine”, “-triptyline” (e.g. imipramine, clomipramine, amitriptyline)

• anticholinergic side effects:
• Blurred vision/photophobia
Contraindicated to • urinary retention (imipramine) Increases norepinephrine
patients with glaucoma • dry mouth
• constipation
• sedation
• amitriptyline - orthostatic hypotension
 Maois: Monoamine oxidase inhibitors

(Increases norepinephrine, serotonin, and dopamine)

• Tranylcypromine
• phenelzine
• ISOcarboxacid
• selegiline

Nursing responsibilities (maoi):

M- assive hypertension risk
A- void tyramine rich food (wine & cheese: swiss, cheddar, aged, mozzarella, beer, sausage, salami, pepperoni, soy, soya, yogurt)
- Low tyramine cheese: processed, cottage, cream
- no dry and fermented fruits, and chocolates
O- tc leads to hypertensive crisis
- “caan” (calcium, antacids, acetaminophen, nsaids)
I- ncrease suicide risk

Oer anti-depreants

Duloxetine
• for chronic pain
• Improves sleep

Trazodone
• priapism - prolonged penis erection
• No alcohol and sedatives

Bupropion (suspended & extended release)

• dont crush and chew
• Insomnia, headache, weight loss
• Stop smoking

Sertraline

• ssri
• for older adults due to its short half-life (di mag tatagal sa liver)

Fluoxetine
• ssri
• for below 18 years old due to its long half-life
 Bipolar disorder
Bipolar 1 - history of mania
Bipolar 2 - No history of mania (“patient previously diagnosed with depression, now recently diagnosed with mania”)
Cyclothymia - bipolar symptoms are minimal, but lasts for 2 years (chronic type)

u
May last for 1
High week or more
Hypomania (may
last for less than
a week only) Bipolar 2
Normal
Mood Unipolar (major depression)
Bipolar 1
Cyclothymia

Low
May last for
2 weeks

Unipolar (Major depression) - major depression with no mania

Bipolar 1 - major depression + high mania
Bipolar 2 - major depression + hypomania
Cyclothymia - minimal depression (dysthymic) + minimal mania (hypomanic)

Mania
(Basta sinabing manic ang patient = bipolar)

Characteristics of mania:
1. Manipulative - classic sign
• threat/danger/impulsive
• Hyperactive/happy/euphoria
• Insomnia
• Talkative - flight of ideas, pressured speech (mabilis mag salita)
• Racing thought (due to insomnia)
• Colorful
• Extravagant (grandiosity)
• Sexually provocative
Other symptoms:
1. Mixed episodes
• depression and mania at the same time
-
-

2. Rapid cycling
• 4 or more depression or mania episodes within one year

Causes: unknown
• genetic and environmental (biologic: serotonin, norepinephrine, dopamine, tryptophan)
• equal incidence for men and women
• Starts between 15 to 25 years old

Common triggers
• medication (antidepressants: ssri and steroids)
• Child birth
• Insomnia
• Recreational drugs

Associated disorders
• adhd Bipolar disorder has no cure but
• Substance abuse
• Personality disorders
symptoms are manageable
• Anxiety disorder

Defense mechanism
Reaction formation - acting opposite to what they feel (manipulating)
Management
1. Safety - due to manic episodes 6. Group therapy
2. Nutrition - high calories, finger food • support griup (7 to 10 members)
3. matter of fact • Leader - delegated to members,
Due to manipulation
4. Set limits di pwedeng same leader always
5. Anti manic agents • Nurse - facilitator
• Kailangan ng member na
Patient can be restrained without doctor’s order, so long nakarecover na to inspire the
you will obtain it immediately (not within 24 hrs) members

Drug of choice: lithium

 Anti manic agents

Lithium carbonate
• check the renal function (creatinine & urine output) before starting
Normal creatinine: 0.6 to 1.3
L- evel over 1.5 is toxic (normal lithium level: 0.5 to 1.5)
I- ncrease fluids and normal sodium intake (135 to 145 meq/l, low na = toxic, high na = less effective)
T- oxic signs: diarrhea, thirst, polyuria, vomiting
H- old nsaids because it decrease renal blood flow

Alternative drugs:
1. Valproic acid
2. Carbamazepine
3. Antipsychotics

Anxiety disorders

Anxiety
• Fear of the unknown
• normal, but when frequently experienced and in high level becomes abnormal
• subjective response to threat

Causes:
1. Biologic: low level of GABA
2. Life experiences (Unresolved past)
3. Familial factors
4. Social factors - peer pressure

Levels of anxiety
I. Mild/alertness
-
-

• power perception • dilated pupil

• high learning • high vital signs, headache, nausea
• daily tension, cope vomiting
• butterfly Tummy

II. MODERATE/APPREHENSION
-
-

• low perception • GI symptoms (lbm, constipation),

• selective inattention butterfly tummy
• low learning, cope
III. SeveRE/fight or flight/FREE floating
-
-

• feeling of impending doom • nervous (palpitation) dyspnea/hyperventilation

• cannot cope • constricted pupil, tunnel vision
-
-

IV. Panic/disorganized
-
-

• Danger to self or others, death

• Doom • exhaustion
• goal: decrease anxiety • Dilated pupil
-
-

• Cannot cope
Compensation of the adrenal
Give the medicine immediately glands

Management:
1. safety (whatever the level)
• Decrease stimuli
• promote rest
• make a command (must be delivered with authority)
• Restrain: may be chemical or mechanical
• If all of the four side rails = restraint, if only 2 = not considered restraint
• Tie the cloth in the bed frame not in side rails
• priority: circulation = release the tie every 1 to 2 hours
-
-

• 4-point restraint (use of leather) > release every 15 mins to 30 mins

-
-

2. Relaxation
• Encourage deep breathing
• use of positive imagery

3. Verbalization
• if mild or moderate = encourage to verbalize
• If severe or panic = use close-ended questions, direct, use simple words
4. Betablockers
• If the patient manifests palpitation
5. Anxiolytics
• Emergency management
• top priority for severe anxiety
• can be given IV or IM
• can be given as PRn
6. Antidepressants
• Given as maintenance
• Ssri: “-ine”, “-pram”
 Obseive-compulsive disorder

obsession - persistent intrusive thought which increases anxiety

Compulsion - uncontrolled ritual, compensatory mechanism in decreasing anxiety
Goal: do not stop, just limit, control or schedule the ritual
Management:
1. Psychotherapy
2. Drug of choice: clomipramine, or any ssri
3. Behavior modification

Generalized anxiety disorder

(Excessive worrying to simple stress consistently for
6 months or more)
Signs and symptoms:
1. Tension
• leads to confusion and/or disorganization
• Increase in vs
• Headache = irritability
• Restless
• Tremors
• Slurred speech
Management:
Same with anxiety
1. safety
2. Relaxation
3. verbalization
4. betablockers
5. Anxiolytics
6. Antidepressants

Post-traumatic stre disorder

(Anxiety that is related to previous traumatic experience)

Major presentation: flashback

• Reliving events, re-experience
• Can trigger panic attack
• Conversion: converting the traumatic thought into physical symptom
 • develops depression
• nightmares
• Triggered by familiar stimuli
Management:
1. Cognitive behavioral therapy: correcting/challenging the wrong belief by
presenting reality
2. flooding: doing the same scenario to make the patient realize it is not true

Phobia
(Irrational fear of specific object)
3 major types:
1. Agora phobia (public)
2. Social phobia (people); xenophobia (strangers)
3. simple phobia - specific

While you are inside the public market, you suddenly drop what you are holding.
Eventually, people look at you and you experience panic attack. What type of
phobia?
Social phobia

Management:
1. Systematic desensitization - exposing the patient into feared object
• use of imagery (present systematically - bago ang colored, pwedeng drawing
muna or black and white)
• video
• Expose to the feared object systematically

Acrophobia: Fear of heights

Astraphobia: Fear of electrical storms Claustrophobia: Fear of closed spaces
Hematophobia: Fear of blood
Hydrophobia: Fear of water
Monophobia: Fear of being alone Mysophobia: Fear of dirt or germs
Nyctophobia: Fear of darkness
Pyrophobia: Fear of fires
Social Phobia: Fear of situations in which one might be embar- rassed or criticized; fear of making a fool
of oneself Xenophobia: Fear of strangers
Zoophobia: Fear of animals
 Ect: electroconvulsive erapy

Indications:
1. Depression
• For patients not responding with antidepressants
• if highly suicidal
• most effective management for depression

2. Mania
• For patients not responding to antimanic agents
3. bipolar
4. Catatonic excitement: schizophrenia
Before the procedure:
1. Consent
• If patent is not able to give = next of kin
• If the next of kin unable to consent = court
2. Volts
• 70 to 150 volts
3. Frequency
• 6 to not more than 12 times
-
-

4. interval
• Every other day (48 hrs) or 3 times a week
5. Duration
• 0.5 to 2 seconds
How to know if the ECT is effective: presence of tonic clonic seizure
Contraindication:
1. Increased intracranial pressure
• Brain tumor
• Brain trauma
• stroke

Needed to defer (temporarily not indicated until resolved):

1. Fever
2. Fracture 5. Recently Underwent transplant
3. Hypertension
4. Present respiratory or cardiac problem History of respi/cardiac = allowed
Pacemaker = current > contraindicated
-
-
 The following are contraindications to ECT except:

A. Fever
B. Fracture
C. Pregnancy - antidepressant crosses the placental barrier > teratogenic
D. Hypertension
Less than 100 volts only

Not contraindications:
1. Pregnancy
2. Liver problem
3. Kidney problem

Preparations:
1. Same with prooperative or general anesthesia
• nPO postmidnight - 6 to 8 hours
• Remove nail polish
• Remove dentures
• Give pre ect medications
A. Atropine sulfate - addresses safety (prevents aspiration)
B. Succinylcholine (anectine) - muscle relaxation
C. Methohexital na (brevital) - anesthetic agent

Patient is asleep prior the ect.

Expected Side effects:

1. Temporary memory loss
2. Headache
3. Asleep
4. Muscle weakness = address safety

Nursing responsibilities:
1. Address the airway - position to side/oxygen
2. Raise the side rails or lower the height of bed
3. Orient the patient once awake
-

4. Continue to monitor especially the level of consciousness

-
 Delirium Vs Dementia

• Common in adult • Common in elderly

• reversible • Irreversible
• Acute • Chronic

Causes: Causes:
1. Substance abuse 1. Aging
2. Illness (liver cirrhosis = inc. in ammonia, 2. Organic factors - trauma, stroke,
Chronic/acute kidney failure) certain bacterial/viral infections
3. Threat to brain

Diagnostic test: eeg Diagnostic test: pet scan

• no need for the consent Confirmatory test: autopsy
• Light breakfast is allowed
• Shampoo the head before AND AFTER
the procedure
• Must be medyo puyat

Alzheimer's disease
• Chronic degenerative disease
• presence of senile plaque deposition in the cerebral cortex due to poor
metabolism of protein = neurofibrillary tangles
• Neurotransmitter: decrease in acetylcholine
• Lifespan: 2 to 20 years; average: 10 years
• Diagnostic test: pet scan (for early stage)
• confirmatory test: autopsy
• Defense mechanism: denial

Classic signs: 4as

1. Aphasia
• Expressive: hirap magsalita = talk slowly, use of pictures
• Receptive: hirap makaintindi = low pitched tone or normal tone
2. Anomnia
• difficulty of naming
3. Agnosia
• Difficulty of recognizing people or objects
4. Aphrasia
• slow movement = we can still give activities but give more time to accomplish the tasks
Stages of Alzheimer's:
1. Forgetfulness (not a classic sign because it can happen to everyone)
• poor decision-making
2. Moderate
• Difficulty performing complex task (e.g. scheduled medicine)
3. Active
• Confirmed
• confabulation
• recollection of past (use of pictures) = prevents depression
• sundown’s - wandering at night
-
-

Lock the door above or below eye

level - to prevent depression
• Insensitive to weather
• lucid interval - sudden awareness especially when exposed to familiar stimuli
-
-

4. End stage
• major problem: immobility
• Forget how to chew and swallow = ngt

Management:
1. safety
• well-lighted room
• Use alternate colors for stairs

2. Structured activities
• Same task at the same time
3. Orient to time, place and person
4. nutrition
5. Assist with the activities of daily living
6. Allow to socialize - to prevent depression
7. Cholinergics - to slow the progression, not to cure
• tacrine (cognex)
• Donetepil (aricept)
Side effect: dehydration = hydrate the patient
 Developmental disorders

causes:
1. Pregnancy complications - most common cause &

2. Heredity
3. Stress, nutrition, environment

ADHD: aention deficit hyperactivity disorder

Characteristics:
1. Impulsive - destructive behavior
Most common among male children confirming when
2. Hyperactive - fidgeting
they reach the age 6 to 7 years old
3. Inattention - easily distracted
4. Tourette’s syndrome - involuntary language, body
movements (tic’s), only 3% will develop

Management:
1. Safety
2. Behavioral therapy
3. Nutrition - high calorie like lasagna (not necessarily finger food)
4. Play
5. Cns stimulant: methylphenedate (ritalin)
• to increase focus
• Given at morning (because if at night = insomnia) after breakfast
before going to class
• side effect: growth retardation
• Important to monitor: skeletal system

the following are appropriate play for a

child with ADHD except:

A. Cycling
B. Skateboarding
C. Swimming
D. Mountain climbing
 Autism
Characteristics:
• Poor social interaction - most common characteristic
• unresponsive, No eye contact, act deaf
• not cuddly
• echolalia
• spin objects so no round toys because it will roll away = temper tantrums
• Toy of choice: blocks (inability to roll)
• intimate with inanimate objects
• love music
• tantrums (head bang): address safety by wearing helmet

Most common among male children confirming when

they reach the age 2 to 3 years old

Management:
• Safety: structure the environment
• nutrition
• behavior modification: to change the inappropriate behavior appropriate
• repetition (e.g. when giving instructions)
• role modeling
• refer with available resources

1. Establish rapport
2. make a contract
3. Set limits by being firm and consistent to make the patient follow the contract
Combined with token of economy (granting reward and punishment by limiting privileges)
 Levels of mental retardation
Mental retardation is now called as “learning disability”, “sub average iq” (below 70)
Not a mental illness!

Level Iq Tasks
1. mild/moron 50 to 70 • Grade 5 to 6
• educable
• no need for supervision

2. Moderate/imbecile 30 to 49 • Grade 1 to 2
• basic training
• less supervision

3. Severe/idiot 20 to 29 • Toddler
• needs supervision

4. Profound Below 20 • Custodial care

The nursing exam will ask: “if mild retardation, what is the mental age of the child?”
10 years old

Managementnp: same with autism

• Safety: structure the environment
• nutrition
• behavior modification: to change the inappropriate behavior appropriate
• repetition (e.g. when giving instructions)
• role modeling
• refer with available resources
 Domestic violence

Rape
• forcible insertion of penis, objects into the vagina, mouth or anus
Causes:
1. Power - to prove their masculinity
2. Anger
3. Sadism
Prevention: communicate clearly with the rapist for them to realize you are not an object and to
lower their libido
Types of rape:
whatever the type, there must be presence of force
1. Acquaintance rape
2. Incest - rapist is a relative
3. Statutory - rape with consent (victim is minor 15 yrs below, and the predator is adult)
4. blitz (stranger)
5. Accessory - victims cannot give consent (e.g. mentally ill victims, mute or deaf are not
included)
6. Date rape - most rampant
7. confidential rape - unreported (in a relationship)

Rape trauma syndrome

• Trauma developed immediately after the rape

Victim
• disorganized, shock, disbelief
• Increased anxiety due to fear of death
• Denial immediately after the rape - no feelings manifested when they start talking

Management:
1. Preserve the evidence
2. Safety, by staying with the patient
3. Proper documentation
4. Report the case - supervisor > police (choose if wala yung supervisor sa choice)
Child abuse

Forms of child abuse:

• neglect
• Emotional
• Physical
• Sexual

Priority
1. Assess (give privacy, talk with the child without the parents)
2. Report- child protection services
Signs
1. Injuries at different stages of healing
2. Aloof
3. unequal hair length (baka sinasabunutan)
4. nightmares
5. Knowledge with sex
6. Depression due to powerlessness
Management:
1. Safety: report, teach the child how to call the authorities, where to go
2. shelter
3. Play therapy - to temporarily divert fears and trauma of a child

Baered wife syndrome

Repeated cycle of violence

Forms of battered wife syndrome:

• neglect
• Emotional
• Physical
• Sexual

Characteristics of abusive husband:

• low self esteem (high insecurity)
• violent family
• previously abused
• Young age/poor parenting
 Phases
1. Tension building - no physical harm
2. Acute battery - victim asking for help, but once the help arrived = denial (co
dependency, dependency)
3. honeymoon - undoing

Management:
1. Safety: report, teach how to call the authorities, where to go
2. shelter
Most at risk: women product of broken family

Psycho pharmacology

Anti manic agents

Lithium carbonate
L- evel: 0.5 to 1.5 meq/l, extract the blood in the morning before breakfast
I- ncrease fluid intake with regular sodium (low = toxic, high = will not take effect)
T- oxic if above 1.5 meq/l (diarrhea, thirst, muscle problems)
H- old nsaids (naproxen, mefenamic, tramadol) decreases renal blood flow

Nephrotoxic: check the creatinine level and urine output

Avoid activities that increases perspiration = sodium loss > toxicity

Valproic acid
• Hepatotoxic: check the liver function (ast/alt)
• sometimes combined with lithium carbonate because lithium takes 2-4 wks before
being effective. Once become functional, Valproic can be abruptly stopped

Carbamazepine
• drug of choice for trigeminal neurolagia
• Assess for sore throat and fever = signs of agranulocytosis
• Monitor for leukopenia
• Not to be combined with oral contraceptives (makes oc ineffective)
 Anxiolytics/tranquilizers
• to decrease anxiety (reason why given preoperatively)
• Sedation (esp for mania - pampakalma)
• As muscle relaxant (seizures, lock jaw)

Common forms:
1. Benzodiazepine
Slow and low + addictive & matagal maexcrete
2. Barbiturates
3. Buspirone
-
-
No sedation = can drive A bus

Benzodiazepine Barbiturates

Ends with “-zepam” or “-zolam” Ends with “-bital” & causes respiratory depression
=

• diaezepam • alprazolam • phenobarbital

• Lorazepam • Midazolam
• Flurazepam • Estazolam
• Oxazepam
• Temazepam

Chlordiazepoxide (librium)
Manage the alcohol withdrawal syndrome
Chlorazepate dipotassium (tranxene)

Side effects:
1. Low vital signs and slow due to sedation
2. Dizziness/drowsiness, headache = hungover effect (most common se)

Antidote: flumazenil (rumasecon)

Important notes:
• guve at bedtime (causes sedation)
• Do not operate machineries
• Do not skip doses
• Do mot abruptly stop
• do not take with alcohol

• do not take valerian root (stimulant, it will contradict the effect

Diazepam
of diazepam)
• Ok to take with gingko biloba, ginsen
• No alcohol
 Buspirone (buspar)

• anxiolytic but not sedative

• Ok for long term use (Not responding immediately, should wait for 2-4 weeks)
• No withdrawal effect
• Not addictive
• Safest anxiolytic

Antidepreant

Four important rules

1. Once you started, it increases the risk of suicide risk (improves the mood)
2. Have slow onset (matagal bago mag respond = 2 to 4 weeks) & taper off slowly
3. Never mix = serotonin syndrome
• ssris to st johns wort (herbal antidepressant)
• maois to all antidepressants
if needed to change = wait for the half life of the drug (2 weeks)
4. All psychiatric drugs causes low vital signs especially blood pressure + weight loss

Ssri: selective serotonin reuptake syndrome

• Increases the serotonin
• Ends with “-ine” and “-pram”
• flouxetine • escitalopram
• Sertraline • Citalopram
• Paroxetine
• Fluvoxamine

Side effects
1. Sexual abnormalities - decreased libido, delayed ejaculation
2. Weight gain
3. Insomnia

Serotonin syndrome
S- weat and hot fever
R- igidity , restless, tremors, agitated
I- ncrease in heart rate

Do not mix with st john’s wort and maois

 Tricylic antidepreant
• increases the level of norepinephrine
• Ends with “-pramine” and “-triptryline”
• imipramine • amitriptyline
• Desipramine • Nortriptyline
• Clomipramine • Protriptyline

Trazodone (deseryl)
Side effects:
1. Anticholinergic side effects
• blurred vision
• Urinary retention Do not take with maois!
• Dry mouth
• Constipation
• Sweat, seizures, sedation

Maois: monoamine oxidase inhibitors

• increases the levels of serotonin, norepinephrine, dopamine

• Do not mix with any antidepressants (otherwise wait for 2 weeks)
T- ranylcipromine
P- henelzine
I- socarboxacid
S- elegeline
Important notes
1. Causes massive hypertension = hypertensive crisis > avoid tyramine-rich food
Tyramine-rich food: scam cheese
S- wiss Safe cheese:
C- heddar • cottage
A-ged • Processed
M-ozerella • Cream
• fermented fruits
• Chicken liver
• Soy, soya, tofu, yogurt
• Processed meat (salami)

2. Avoid over the counter drugs: caan (calcium, antacids, acetaminophen, nsaids)
3. Avoid combining with all other antidepressants
4. Increases suicide risk
 Oer antidepreants
Duloxetine
• manages the pain caused by fibromyalgia (chronic muscle pain)

Bupropion (wellbutrin)
• avoid smoking
• Do not crush or chew the medication (because it is extended/suspended release)

Antipsychotics/neuroleptics

Typical antipsychotics Atypical antipsychotics

• old antipsychotics • new antipsychotics
• indicated for positive symptoms only • Both positive and negative symptoms
• Ends with “-zine” • Ends with “-done” or “-pine”
• chlorpromazine • resperidone (2nd best)
• Chlorperazine • Molindone
• Fluphenazine • Ziprasidone
• Thioridazine • Clozapine (best drug)
• Pherphenazine • Olanzepine
• Haloperidol • Quetiapine
• Can be given with anxiolytics/tranquilizers
Ziprasidone (geodon) adverse effect:
• High eps - do not stop the medication
Wide qt interval & low bp
Side effects:
1. Anticholinergic side effects
• photosensitivity (can go under the sun, just needs protection)
• Weight gain
• Dry mouth and constipation = use sugar free gum
• Orthostatic hypotension
2. Extrapyramidal symptoms
• caused by low dopamine
• Tardive dyskinesia (tongue twitching + lip smacking)
• Pseudoparkinsonism (resting tremors > rigidity > bradykinesia > akinesia), mask face
Resting tremors can be reversible by anti-eps/anticholinergics:
1. cogentin
2. Benadryl Causes muscle to relax
3. Akineton
4. Artane
 • dystonia (dysphagia due to neck rigidity, pupillary paralysis)
• Akathisia (“ants crawling under the pants”) = restless, irritability, jittery, agitated

Toxic effects:
1. Neuroleptic malignant syndrome
• high fever
• Altered level of consciousness
• Muscle problems (spasm, rigidity, hyperexcitability, tremors, twitching)
Antidote: bromocriptine mesylate (parlodel) or dantrolene sodium (dantrium)
2. Agranulocystosis (suppressing the bone marrow to produce more wbc)
• sore throat - see the dr immediately, or bring the pt to emergency room
3. Leukopenia
• check the cbc
4. Hepatotoxic
• check alt/ast

Highly contraindicated to patients with dementia!