What is the nurse's order to assess for involuntary movement related to medication?

Nurse Assessment for Medication-Related Involuntary Movements

The nurse should use the Abnormal Involuntary Movement Scale (AIMS) to systematically assess for medication-related involuntary movements, with evaluations conducted at baseline and then every 3-6 months for patients on medications with tardive dyskinesia risk. 1, 2

Types of Medication-Induced Movement Disorders to Assess

Acute Extrapyramidal Symptoms (EPS)

• Acute dystonia: Assess for sudden spastic contractions of muscle groups including the neck (torticollis), eyes (oculogyric crisis), facial grimacing, rhythmic tongue protrusion, and trismus 1, 2
• Drug-induced parkinsonism: Evaluate for bradykinesia, tremor, cogwheel rigidity, and mask-like facies 1, 3
• Akathisia: Look for subjective restlessness manifesting as pacing, agitation, or inability to sit still, which can be misinterpreted as anxiety or psychotic agitation 1, 2

Tardive Dyskinesia (TD)

• Assess for involuntary, rhythmic movements primarily affecting the orofacial region (tongue, face, mouth, jaw) 2, 3
• Check for choreiform or athetoid movements of the trunk and extremities 3
• Note that TD typically develops after prolonged use (months to years) of antipsychotics or other dopamine-blocking agents 1, 2

Abnormal Involuntary Movement Scale (AIMS) Assessment

The AIMS examination should include the following components:

1. Level of consciousness assessment 1:

   • Alertness (0-3 scale)
   • Orientation (0-2 scale)
   • Response to commands (0-2 scale)

2. Motor examination 1:

   • Facial movements: Observe for grimacing, blinking, and other facial movements
   • Oral movements: Check for tongue protrusion, lip smacking, and chewing movements
   • Extremity movements: Assess arms and legs for choreiform or athetoid movements
   • Trunk movements: Look for rocking, twisting, or squirming movements

3. Severity rating for each body region (typically on a 0-4 scale) 1

4. Global judgment of severity and incapacitation 1

Timing of Assessment

• Baseline assessment: Before starting medications with movement disorder risk 1, 2
• Regular monitoring: Every 3-6 months for patients on antipsychotics or other medications with TD risk 1, 2
• Immediate assessment: When patient reports or staff observes abnormal movements 3

High-Risk Medications to Monitor

• Typical antipsychotics: Highest risk, especially high-potency agents 2, 3
• Atypical antipsychotics: Lower but still present risk 1, 2
• Metoclopramide: Significant risk for both acute EPS and TD 3
• Other medications with reported risk: Some antidepressants, mood stabilizers, and antiemetics 2, 4

Documentation Requirements

• Record baseline movement status before medication initiation 1
• Document the specific type, location, and severity of any observed movements 1, 2
• Note timing relationship between medication administration and symptom onset 5
• Record any dose changes that correlate with changes in movement symptoms 3, 5

Clinical Pearls and Pitfalls

• Acute dystonic reactions typically occur within 24-48 hours of starting treatment or increasing dose 3
• Tardive dyskinesia risk increases with duration of treatment and total cumulative dose 3
• Movements may be suppressed temporarily by increasing the medication dose, masking the underlying problem 3
• Some movement disorders can present atypically, such as abdominal rigidity mimicking an acute abdomen 6
• Early detection is crucial as there is no specific treatment for tardive dyskinesia other than discontinuing the medication 1, 2

By implementing this systematic assessment approach, nurses can help identify medication-induced movement disorders early, potentially preventing irreversible tardive dyskinesia and other serious complications.