Patient Case 2019
A 17-year-old African American male was admitted due to psychotic behavior, possibly due to marijuana use, urine drug screen was positive for marijuana. He had no past medical or psychological history; he was adopted, family history was unknown. The psychiatrist ordered Haldol 10 mg by mouth to be given twice daily, as well as other IM antipsychotic medications that were available PRN for agitation. After three days inpatient, the patient developed extra pyramidal side effects (EPS), he was unable to talk, his tongue was swollen, and his neck was stiff. EPS symptoms include; dystonia, akathisia, pseudo-Parkinsonism, tardive dyskinesia, and muscle stiffness (John Hopkins Medicine, 2018). A treatment for EPS is Cogentin; this medication was on his EMAR, listed under as-needed medications, however he had not received it. After receiving IM Cogentin, the symptoms resolved. The psychiatrist ordered Cogentin 0.5 mg po to be given twice daily.
Pharmacokinetic and Pharmacodynamic processes
Pharmacokinetics is the study of drug movement throughout the body (Rosenthal & Burchum, 2018). There are four basic pharmacokinetic processes: absorption, distribution, metabolism, and excretion. Pharmacodynamics is the study of the biochemical and physiologic effects of drugs on the body and the molecular mechanisms by which those effects are produced (Rosenthal & Burchum, 2018).
Haldol is prescribed for manifestations of psychotic disorders and Tourette’s syndrome to control tics. Haldol blocks dopamine 2 receptors reducing positive symptoms of psychosis and possibly combative, explosive, and hyperactive behaviors (Stahl, 2017). Oral half-life is approximately 12-38 hours, deconate half-life is approximately 3 weeks. A usual dose is 0.05/mg/kg once or twice a day for adolescents. This patient weighed 76 kg, so the dose of 10 mg twice daily was high, and without administration of Cogentin lead to EPS. In the above care the patients age, ethnicity, and behavior are factors that contribute to his overall outcome. Recent research has found that people who use marijuana and carry a specific variant of the AKT1 gene, which codes for an enzyme that affects dopamine signaling in the striatum, are at increased risk of developing psychosis (NIH, 2019). African Americans are 10% more likely to experience serious psychological distress (NAMI, 2020). Adolescents who smoke marijuana regularly may contribute to adult psychosis, it appears to depend on whether a person already has a genetically based vulnerability to the disorder (NIH, 2019).
Tardive dyskinesia is a side effect that develops with prolonged use of antipsychotics; symptoms include grimacing, sucking, and smacking of lips. EPS is another side effect of this medication, all patients taking first or second-generation antipsychotics should have an Abnormal Involuntary Movement Scale (AIMS) completed regularly by their healthcare provider (NAMI, 2020). This drug can cause weight gain, monitor BMI and weight during treatment (Stahl, 2017). Consider monitoring fasting triglycerides and fasting blood glucose during treatment. Haldol may increase the effects of antihypertensive drugs, and it reduces the effects of anticoagulants (Stahl, 2017).
Cogentin is prescribed for extrapyramidal disorders, parkinsonism, and dystonia (Stahl, 2017). Cogentin diminishes the excess acetylcholine activity caused by the removal of dopamine inhibition when dopamine receptors are blocked. The half-life is 36 hours, although the greatest effect lasts about 6-8 hours (Stahl, 2017). Cogentin can cause drowsiness if patients are taking pain medications, anti-anxiety medications, or sleeping medications, they may have an increase in sleepiness. Drinking alcohol with Cogentin can cause side effects (Drugs, 2020). Cogentin and other anticholinergic agents may increase serum levels of Digoxin (Stahl, 2017). This medication can lower the concentration of Haldol and other phenothiazines, causing worsening of schizophrenia symptoms (Stahl, 2017).
Plan of care
A personalized plan of care takes into consideration the patient as a whole, reviewing all pertinent data. Research suggests the AIMS scale should be done regularly by healthcare providers. Nursing staff and the psychiatrist should have started Cogentin on day 1, since the patient was receiving scheduled Haldol and other antipsychotic drugs to control
Order this paper