For several years, a client with chronic schizophrenia has received 10 mg of fluphenazine hydrochloride (Prolixin) by mouth four times per day. Now the client has a temperature of 102° F (38.9° C), a heart rate of 120 beats/minute, a respiratory rate of 20 breaths/minute, and a blood pressure of 210/140 mm Hg. Because the client also is confused and incontinent, the nurse suspects malignant neuroleptic syndrome. What steps should the nurse take?
A. Give the next dose of fluphenazine, call the physician, and monitor vital signs.
B. Withhold the next dose of fluphenazine, call the physician, and monitor vital signs.
C. Give the next dose of fluphenazine and restrict the client to the room to decrease stimulation.
D. Withhold the next dose of fluphenazine, administer an antipyretic agent, and increase the client’s fluid intake.
Correct Answer: B. Withhold the next dose of fluphenazine, call the physician, and monitor vital signs.
Malignant neuroleptic syndrome is a dangerous adverse effect of neuroleptic drugs such as fluphenazine. Although an antipyretic agent may be used to reduce fever, increased fluid intake is contraindicated because it may increase the client’s fluid volume further, raising blood pressure even higher. Rare but serious side effects include neuroleptic malignant syndrome, liver function abnormalities and jaundice, seizures, and agranulocytosis. Like other antipsychotic medications, fluphenazine carries a black-box warning for increased risk of cerebrovascular events and death in elderly patients with psychosis related to major neurocognitive disorder. There are reports of allergic reactions with the use of fluphenazine and other phenothiazine typical antipsychotics.
Option A: Patients taking any antipsychotic medication require close monitoring for the appearance of side effects. Baseline electrocardiograms should be obtained in all patients with preexisting cardiac conduction abnormalities starting fluphenazine; close monitoring for electrocardiogram changes is necessary. Assessments for the appearance of extrapyramidal side effects should be routine for patients taking fluphenazine; the Abnormal Involuntary Movement Scale is a well-studied, easy-to-administer assessment for the emergence of extrapyramidal effects.
Option C: Clinicians should routinely obtain complete blood counts and metabolic panels to monitor for changes in white blood cell counts, liver transaminases, and blood urea nitrogen and creatinine levels. Patients taking multiple medications also require monitoring for interactions with fluphenazine; this medication is a major substrate of the CYP-2D6 system and is a weak inhibitor of CYP-2C9 and CYP-2E1 systems. Although serum levels of fluphenazine are not a routine part of therapy and dosing typically depends on clinical response, the therapeutic reference range is 1 nanogram to 10 nanograms per milliliter.
Option D: Fluphenazine has an adverse effect profile similar to other first-generation or typical antipsychotics, which is due to its dopamine receptor antagonism as well as its anticholinergic, antihistaminic, and alpha-adrenergic antagonistic properties. Common side effects include sedation, dry mouth, constipation, dry eyes, blurred vision, constipation, orthostasis, dizziness, hypotension, and urinary retention. Other possible side effects include rebound tachycardia, urinary retention, and weight gain. Due to dopaminergic antagonism, fluphenazine can cause extrapyramidal symptoms, including akathisia, parkinsonian features such as resting tremor and shuffling gait, acute dystonic reactions, oculogyric crises, opisthotonos, and tardive dyskinesia.