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Exam 2 Flashcards

1
Q

Analgesic Drug Prototypes

A
  • Acetaminophen (Tylenol)
  • Tramadol hydrochloride (Ultram)
  • Morphine sulfate (MSIR, Roxanol)
  • Fentanyl (Sublimaze)
  • Codeine sulfate
  • Oxycodone (OxyIR)
  • Hydrocodone (Vicodin)
  • Naloxone (Narcan)
  • Naltrexone (ReVia)
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2
Q

pain

A
  • Pain is 6th vital sign
  • Pain results from the stimulation of the sensory nerve fibers known as nociceptors
  • Transmit pain receptors to from different body part to spine and brain which leads to the sensation of pain (aka nociception)
  • Visceral- organs and smooth muscles
  • Superficial- originated from skin and mucous membranes
  • Deep- pain deep below skin level
  • Referred- when visceral nerve fibers synapse at a level of spinal cord close to the fibers that supply specific tissues
  • Cholecystitis- referred to back and scapula areas (referred pain example)
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3
Q

nonpharm methods for pain

A
  • Acupressure/acupuncture
  • Art therapy
  • Music
  • Pet therapy
  • Relaxation techniques
  • Yoga
  • Repositioning
  • Hot or cold packs
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4
Q

opioid drugs

A
  • MOA: Agonists:bind to an opioid pain receptor in the brain and this causes and analgesic response or the reduction of the sensation of pain.
    agonists-antagonists:Binds to a pain receptor and causes a weaker pain response than a full agonist does.
    or antagonists: Bind to pain receptors, but they don’t reduce pain signals, they compete with and reverse the effects of agonists and agonists-antagonists opioid drugs
    Indications:
  • Alleviate moderate to severe pain; used in combo with anesthetics during surgery; alleviate post-op pain
  • Contraindications:
    Allergy, severe asthma, respiratory insufficiency, sleep apnea, increased ICP, pregnancy, paralytic ileus
  • Adverse Effects:
    CV, CNS, GI, GU, Integumentary, Respiratory, HTN, bradycardia, flushing, sedation, disorientation, euphoria, light headedness, dysphoria, low down GI tract, constipation, N/V, cause urinary retention, skin itching, respiratory depression, aggravate asthma
  • Interactions:
    Alcohol, antihistamines, CNS depressants (Increases depressant effects), MAOI’s (can increase respiratory depression in MAOIs)
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5
Q

Agonists, agonists-antagonists, or antagonists for opioid drugs

A

agonists- bind to an opioid pain receptor in the brain and this causes an analgesic response or the reduction of the sensation of pain
Agonist- antagonist- partial agonists, binds to a pain receptors and causes a weaker pain response than a full agonist
Antagonist- nonanalgesic drugs, bind to pain receptors but do not reduce pain signals they compete and reverse the effects of agonist- antagonist opioid drugs

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6
Q

opioid toxicity and management of overdose

A
  • Opioid antagonists- reverse effect of opioid drugs
  • Naloxone (Narcan)
  • Naltrexone (ReVia)
  • Regardless of withdrawal symptoms, if client experiences severe respiratory depression, an opioid antagonist should be given.
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7
Q

Codeine sulfate (opioid)

A
  • Similar to morphine sulfate in pharmacokinetic properties
  • 10% of codeine is metabolized to morphine in the body
  • Has a ceiling effect (increasing dose will not increase response)
  • Commonly used as an antitussive drug in cough preparations
  • Administered PO in liquid or tablet form
  • Commonly causes GI upset
  • Less effective than majority of analgesic drugs
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8
Q

Fentanyl (Sublimaze- opioid)

A
  • Treats moderate to severe pain
  • Available in several dosage forms:
    Transdermal
    IV
    Lozenges
  • Strength:
    Extremely potent!!!
  • A dose of 0.1 mg of Fentanyl IV is roughly equivalent to 10 mg of morphine IV
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9
Q

Morphine sulfate (MSIR, Roxanol- opioid)

A
  • Treats severe pain
  • High abuse potential
  • Oral, IV, and rectal dosage forms
  • Extended release forms are also available
  • Watch use in patients with renal impairment!
  • easy to get
  • Renal impairment- has a toxic metabolite that can accumulate and cause severe respiratory depression
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10
Q

Oxycodone hydrochloride (OxyIR- opioid)

A
  • Structurally similar to morphine
    Commonly used in tablets with acetaminophen and aspirin
    Has immediate release and sustained release forms
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11
Q

Hydrocodone (Vicodin- Opioid)

A
  • Weaker opioid but more commonly used
  • Used in combination tablets with acetaminophen
  • Long-acting products available
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12
Q

Naloxone hydrochloride (Narcan) & Naltrexone (ReVia):

A

Narcan

  • Pure opioid antagonist
  • Works like a blocking drug for opioids
  • Drug of choice for complete or partial reversal of opioid induced respiratory depression
  • Causes opioid withdrawal syndrome after administration
  • Available in IV forms

Revia

  • Only available orally
  • Used for alcohol and opioid addiction
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13
Q

Nonopioid and Miscellaneous Analgesics: Acetaminophen (Tylenol

A
  • MOA: Block pain impulses by inhibition of prostaglandin synthesis
  • Indications: Mild to moderate pain and fever
  • Contraindications:
    Drug allergy, severe liver disease, G6PD deficiency
  • AE’s: N/V, hepatotoxicity, nephrotoxicity
  • Interactions: Alcohol (most dangerous); phenytoin, warfarin, rifampin, beta blockers
  • Maximum daily dose for healthy adults:
    3000 mg/day, 2000 mg/day for older adults & those with liver disease
  • Inadvertent excessive doses may occur when different combination drug products are taken together
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14
Q

Nonopioid and Miscellaneous Analgesics: Tramadol (Ultram)

A
  • MOA: Centrally acting analgesic
  • Indications: Treatment of moderate to moderately severe pain
  • Contraindications: Drug allergy
  • AE’s: Similar to opioids: dizziness, drowsiness, HA, constipation, respiratory depression
  • Interactions: TCA’s (increases risk for seizures), SSRI’s (increases risk of serotonin syndrome), MAOI’s
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15
Q

Analgesics: Nursing Implications

A
  • Before beginning therapy, perform a thorough history including allergies, use of other medications, alcohol.
  • Obtain baseline VS and I&O.
  • Assess for potential contraindications & drug interactions.
  • Perform thorough pain assessment:
  • pain intensity and character
  • onset, location, description
  • precipitating and relieving factors
  • type
  • remedies and other pain treatments
  • Medicate before the pain becomes severe. This is to be able to provide adequate analgesia and pain control.
  • Pain management includes pharmacologic and nonpharmacologic approaches.
    (Include other interventions as indicated)
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16
Q

Analgesics: Assessment

A
  • Allergies
  • Medications, herbal remedies
  • Alcohol intake
  • Nature, type, precipitating & relieving factors of pain
  • VS
  • Most recent dose, time, & effectiveness (0-10 pain scale)
  • Consider potential drug interactions
  • Contraindications: allergies, bronchial asthma, opioid addiction, head injuries, IICP (for acetaminophen: yellow dye no. 5, & alcohol)
  • Caution: liver or kidney disease
  • oral- reassess in an hour
  • IV, IM- assess within 15-30 minutes
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17
Q

General and Local Anesthetics Prototype Drugs

A
  • Propofol
  • Sodium thiopental
  • Midazolam (Versed)
  • Fentanyl (Sublimaze): see Chapter 10
  • Morphine sulfate: see Chapter 10
  • Lidocaine (Xylocaine)
  • Succinylcholine (Anectine)
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18
Q

anesthetics

A

Drugs that reduce or eliminate pain by depressing nerve function in the CNS and peripheral nervous system (PNS), results in inability to feel pain

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19
Q

General anesthesia

A
  • drug induced state in which CNS nerve impulses are altered to reduce pain and alter sensations throughout entire body, complete loss of consciousness, depression of respiratory drive, Skeletal muscle relaxation, Reflex reduction
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20
Q

Local anesthesia

A
  • drug induced state in which peripheral or spinal nerve impulses are altered to reduce or eliminate pain
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21
Q

Balanced anesthesia

A
  • using different combos of drugs classes to produce anesthetic effect
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22
Q

Inhalation anesthetics

A

volatile liquids or gases that are vaporized in oxygen and inhaled

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23
Q

parenteral anesthetics

A

administered IV

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24
Q

General anesthetics

A
  • MOA: Progressive reduction of sensory and motor CNS function
  • Indications: Surgical procedure and electroconvulsive therapy (ECT)
  • Contraindications: Allergy, pregnancy, narrow-angle glaucoma, malignant hyperthermia
  • AE’s: Hypotension, N/V, malignant hyperthermia
  • Interactions: Antihypertensives, beta blockers (increase risk of hypotension)
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25
General Anesthetics: Malignant Hyperthermia
- Uncommon but potentially life-threatening metabolic reaction to general anesthesia - Genetic link - Signs include: rapid rise in body temperature, tachycardia, tachypnea, and muscular rigidity - Treated with cardiorespiratory support measures and the skeletal muscle relaxant dantrolene
26
General Anesthetics: Prototype Drug: Propofol (Diprivan)
- Uses: Induction & maintenance general anesthesia - Sedative-hypnotic (moderate sedation) GI procedures, Unfortunately used for Michael Jackson, Sedation for ventilation - Typically well tolerated with few undesirable effects
27
General Anesthetics: Prototype Drug: Sodium Thiopental (Pentothal)
- Route: IV injection or infusion - AE’s: Hypotension and tachycardia, Respiratory depression - Uses: Induction and maintenance of general anesthesia
28
General Anesthetics: Prototype Drug: midazolam (Versed)
- Used in general anesthesia and as a hypnotic - Causes marked sedation: used for conscious sedation at times - AE’s: Memory loss, Cardiac or respiratory arrest - Routes: IM for moderate sedation, IV for induction of anesthesia or moderate sedation
29
Local Anesthetics
- MOA: Block nerve conduction in specific portions of the body to block pain in that area (interfere with nerve transmission) - Indications: Surgical, dental, or diagnostic procedures; treatment of various types of chronic pain; spinal anesthesia - Contraindications: Drug allergy - AE’s: Limited in most cases; spinal HA with spinal anesthesia (epidural) - Interactions: Enflurane, halothane, and epinephrine
30
Local Anesthetics: Prototype Drugs: Lidocaine (Xylocaine)
- Indications: Dental, surgical, diagnostic procedures - Formulations: Topical (dermal, transdermal), nerve block, infiltration - One of the most commonly used local anesthetics
31
Neuromuscular Blocking Drugs (NMBD’s)
- MOA: Two groups: depolarizing and nondepolarizing - Depolarizing NMBD’s work like acetylcholine - Bind in place of acetylcholine at cholinergic receptors which will cause a paralysis to occur - Indications: Maintain skeletal muscle paralysis to facilitate controlled ventilation during surgical procedures - Contraindications: Allergy, hx of malignant hyperthermia, eye injuries, glaucoma, burns, CVA, crush injuries - AE’s: Muscle spasms, hyperkalemia, dysrhythmias, myoglobinuria, Malignant hypothermia - Interactions: Aminoglycoside and tetracycline antibiotics (additive effects)
32
Neuromuscular Blocking Drugs: Prototype Drug: Succinylcholine (Anectine)
- Uses: Facilitate controlled ventilation during surgery Induction of ET intubation - Duration: Short-acting: 4-6 minutes, Combined w/other anesthetics (inhaled & IV) Key Points: - Does not produce analgesia or reduce anxiety - Paralyzed but conscious!
33
Neuromuscular Blocking Drugs: Prototype Drug: Succinylcholine
- First sensation: muscle weakness - Then: small, rapidly moving muscles (fingers, eyes) - Then: limbs, neck, trunk - Last: intercostal muscles & diaphragm - Result: cessation of respirations - Recovery of muscular activity usually occurs in reverse order Important Safety Alert: - Respiratory muscle paralysis occurs with these drugs - Emergency ventilation equipment must be immediately available
34
Nursing Implications: Assessment
- Past history of surgeries & response to anesthesia - Allergies, medications - Use of alcohol, illicit drugs, opioids - VS: Watch for sudden elevation in temperature (may indicate malignant hyperthermia) - Baseline lab work, ECG - Respiration rate & rhythm; O2 saturation; ABCs - Monitor all body systems
35
Nursing Implications: Intervention
- During recovery, monitor for CV depression, respiratory depression, complications of anesthesia - Implement safety measures during recovery, especially if motor or sensory loss occurs because of local anesthesia - Reorient client to surroundings - Teach: post-op turning, coughing, deep breathing
36
Antiinflammatory and Antigout Prototype Drugs
``` Aspirin Ketorolac (Toradol) Ibuprofen (Motrin/Advil) Celecoxib (Celebrex) Allopurinol (Zyloprim) Methylprednisolone Prednisone ```
37
Inflammation
Localized protective response stimulated by injury to tissues, which serves to destroy, dilute, or wall off (sequester) both the injurious agent and the injured tissue Pain, fever, loss of function, redness, and swelling Endogenous compounds, including proteins of the complement system, histamine, serotonin, bradykinin, leukotrienes, and prostaglandins
38
Nonsteroidal Antiinflammatory Drugs: Method of Action
Inhibition of leukotriene pathway, the prostaglandin pathway, or both
39
Nonsteroidal Antiinflammatory Drugs: Indications
Used primarily for analgesic, anti-inflammatory, and antipyretic effects
40
Nonsteroidal Antiinflammatory Drugs: Contraindications
Drug allergy, conditions that increase the risk for bleeding, pregnancy
41
Nonsteroidal Antiinflammatory Drugs: Adverse Effects
Cardiovascular effects: pulmonary edema, MI, and stroke, GI: heartburn, epigastric effects, nausea and vomiting, GI bleed. Can cause liver toxicity and can be toxic to the kidneys. Hematologic Hepatic, Renal
42
Nonsteroidal Antiinflammatory Drugs: Various Uses
``` Mild to moderate headaches Myalgia Neuralgia Arthralgia Alleviation of postoperative pain Pain associated with RA, OA, juvenile arthritis, ankylosing spondylitis Pain assoc. with gout and hyperuricemia Have to be careful with postoperative effects because of the risk for bleeding. ```
43
Nonsteroidal Antiinflammatory Drugs: Prototypes and Classifications
Salicylates: aspirin Propionic acid derivatives: ibuprofen (Motrin/Advil) Acetic acid derivatives: ketorolac (Toradol) Cyclooxygenase-2 inhibitors: celecoxib (Celebrex)
44
NSAID's Prototype: Aspirin
Most commonly used salicylate Available OTC Common dosages: 81mg or 325mg daily prophylactically for adults with strong risk of developing coronary artery disease or stroke Uses: Reduce cardiac death following myocardial infarction (MI) Prevention of thrombotic events Pain associated with HA, neuralgia, myalgia, and arthralgia, and pain syndromes caused by inflammation
45
Aspirin: Reye's Syndrome
Acute and potentially life-threatening condition involving progressive neurologic deficits. Can lead to coma. May also involve liver damage. Triggered by viral illnesses such as influenza as well as by salicylate therapy itself in the presence of a viral illness. Highly lethal. Survivors of this condition may or may not have permanent neurologic damage. Do not give to children w/any elevation in temperature, chickenpox, influenza B infection.
46
Aspirin: Salicylism
Salicylism Increased HR Tinnitus, hearing loss, dimness of vision, headache, dizziness, mental confusion, drowsiness Nausea, vomiting, diarrhea Sweating, thirst, hyperventilation, hypoglycemia or hyperglycemia
47
NSAID's Prototype: Ketorolac (Toradol)
``` Acetic acid derivative Powerful analgesic effects Some antiinflammatory activity Indications: short-term use (up to 5 days) to manage moderate to severe acute pain AE/SE: Renal impairment Edema GI pain, dyspepsia, nausea ```
48
NSAID's Prototype: Ibuprofen
``` Propionic acid derivative Most commonly used NSAID Uses: analgesic effects in the management of RA, OA primary dysmenorrhea Gout dental pain musculoskeletal disorders antipyretic actions ```
49
NSAID's Prototype: Celecoxib (Celebrex)
1st & only remaining COX-2 inhibitor Indications: OA, RA, acute pain symptoms, ankylosing spondylitis, primary dysmenorrhea AE/SE: Headache, sinus irritation, diarrhea, fatigue, dizziness, lower extremity edema, and hypertension Little effect on platelet function Avoid in clients with known sulfa allergy.
50
Drug Therapy for Inflammation: Glucocorticoids: Method of action
Suppress inflammation and immune response
51
Drug Therapy for Inflammation: Glucocorticoids: Indications
Symptomatic relief of pain and inflammation for a variety of disorders including autoimmune and inflammatory disorders
52
Drug Therapy for Inflammation: Glucocorticoids: Contraindications
Systemic fungal infections, cataracts, allergy
53
Drug Therapy for Inflammation: Glucocorticoids: Adverse Effects
Suppression of adrenal function, hyperglycemia, bone loss, cataracts, myopathy, fat redistribution
54
Drug Therapy for Inflammation: Glucocorticoids: Interactions
-Live vaccines: patients with long therapy are going to have a suppressed immune system. So we wouldn’t want to inject them with a live vaccine. -Furosemide: Causes increase risk for Hypokalemia Digoxin: Increase the risk for dysthymias. NSAID’s: Increase the risk for bleeding Insulin and oral hypoglycemics: Have decreased therapeutic effects when given with Glucocorticoids, may need to increase the dose of these drugs for them to be effective.
55
Drug Therapy for Inflammation: Glucocorticoids: Prototype Drugs: Prednisone
Route: PO Must be tapered when discontinued to prevent adrenal crisis Most commonly used for anti-inflammatory or immunosuppressant purposes
56
Drug Therapy for Inflammation: Glucocorticoids: Prototype Drugs: Methylprednisolone
Route: IV | Most commonly used injectable glucocorticoid drug
57
Drug Therapy for Inflammation: Glucocorticoids: Interventions
Monitor blood glucose levels closely especially in patients with diabetes May need to adjust dosage of insulin and oral diabetic drugs Recommend lowest possible effective dose and alternate day dosing Monitor for s/s of infection Initiate gastric protective measures Give drug with food or meals They can increase blood sugar. Monitor for signs and symptoms of infection because of the immune suppressant response these drugs have.
58
Gout
Gout: condition that results from inappropriate uric acid metabolism Underexcretion of uric acid Overproduction of uric acid Uric acid crystals are deposited in tissues and joints, resulting in pain Hyperuricemia
59
Antigout Drugs: Prototype Drug: Allopurinol (Zyloprim): Method of Action
Inhibits xanthine oxidase to prevent production of uric acid
60
Antigout Drugs: Prototype Drug: Allopurinol (Zyloprim): Indications
Gout caused by excessive production of uric acid (hyperuricemia)
61
Antigout Drugs: Prototype Drug: Allopurinol (Zyloprim): Contraindications
Allergy
62
Antigout Drugs: Prototype Drug: Allopurinol (Zyloprim): Adverse Effects
Agranulocytosis, aplastic anemia, potentially fatal skin conditions
63
Antigout Drugs: Prototype Drug: Allopurinol (Zyloprim): Interactions
Azathioprine and mercaptopurine: May cause the need for dosages of allopurinol to be increased, the interactions can reduce its effectiveness.
64
Antiinflammatory & Antigout Drugs: Nursing Implications
Before starting therapy, assess for: Contraindications: GI lesions, PUD, bleeding d/o Conditions that require cautious use. Labs: cardiac, renal, liver function studies; CBC; platelet count Medication history, including potential drug interactions Several serious drug interactions exist. The various AE/SE. Inform to notify the hc provider if AE/SE become severe or if bleeding or GI pain occurs. Watch closely for the occurrence of any unusual bleeding (e.g., stool.) Enteric-coated tablets should not be crushed or chewed. Therapeutic effects, which vary according to the condition being treated. What therapeutic effects would be seen?
65
Why should not give salicylates to children or teenagers?
Leads to Reye's syndrome
66
Why should you take Anti-inflammatory and Antigout drugs with food or milk?
Help reduce the GI adverse effects
67
Antiepileptic drugs overview
- Antiepileptics: More appropriate term. Also known as anticonvulsants. - Goal of therapy: Control or prevent seizures while maintaining a reasonable quality of life Minimize adverse effects and drug-induced toxicity - AED therapy is usually lifelong. - Combination of drugs may be used. - antiseizure drugs - 70% can become seizure free (Only need to take one antiepileptic for this to happen) - Other 30% has more complicated cases (Need multiple drugs) - Explain the rationale for starting single-drug therapy before trying multiple-drug therapy. - Serum drug concentrations must be measured - If seizure-free for 1-2 years, may be able to stop meds. - AEDs not started after a single isolated seizure event.
68
CNS Depressants and Muscle Relaxants Prototypes
- Temazepam (Restoril) - Zolpidem (Ambien) - Baclofen (Lioresal) - Dantrolene (Dantrium)
69
Benzodiazepines: Method of Action
- Sedative & hypnotic - Related to ability to depress activity in the CNS - hypothalamic, thalamic, and limbic system in the brain- areas
70
Benzodiazepines: Indications
- Sedation - relief of agitation or anxiety - treatment of anxiety-related depression - sleep induction - skeletal muscle relaxation - acute seizure disorders
71
Benzodiazepines: Contraindications
- Allergy - narrow-angle glaucoma - pregnancy
72
Benzodiazepines: AE's/Se's
- Head ache - drowsiness - paradoxical excitement/nervousness - dizziness - vertigo - cognitive impairment - lethargy - Older Adult: Fall Risk
73
Antiepileptic Drugs: AE/SE
- birth defects | - suicidal thought and behaviors
74
Hyantoins (phenytoin): AE/SE
- Nystagmus (vision condition in which the eyes make repetitive, uncontrolled movements) - ataxia (damage to nervous system) - drowsiness - rash - gingival hyperplasia - thrombocytopenia - agranulocytosis - hepatitis - GI upset
75
Iminostilbenes (carbamazepine): AE/SE
- nausea - headache - dizziness - unusual eye movements - visual change - behavioral change - rash - abdominal pain - abnormal gait - GI upset
76
Valproic acid and derivative: Ae/SE
- dizziness - drowsiness - GI upset - weight gain - hepatotoxicity - pancreatitis
77
Gabapentin: AE/SE
- dizziness, drowsiness, nausea, visual and speech changes, edema
78
Antiepileptic Drugs: AE/SE
- birth defects | - suicidal thought and behaviors
79
Non-benzodiazepine Hypnotics-zolpidem (Ambien): SE/AE
- Somnambulation or ‘sleepwalking’ - Amnesia - Headache - Dizziness - Anxiety - Hallucinations
80
Benzodiazepines: Clinical Manifestations
Somnolence: A state of strong desire to sleep. - Confusion - Coma - Diminished reflexes - Overdose w/benzodiazepines alone rarely results in hypotension & respiratory depression. But when combined w/other CNS depressants, can be lethal.
81
Benzodiazepines: Management
- Symptomatic: To prevent or treat as early as possible the symptoms of a disease. - Supportive - Flumazenil (benzodiazepine antidote) can be used to acutely reverse the sedative effects.
82
Temazepam (Restoril)
- Intermediate-acting benzodiazepine - A metabolite of diazepam (Valium) - Induces sleep within 20-40 minutes - Long onset of action - Should take approximately 1 hour before going to bed!
83
Additional Benzodiazepines
Diazepam (Valium) Midazolam (Versed) Lorazepam (Ativan)
84
Non-benzodiazepine Hypnotics-zolpidem (Ambien): Method of Action
- Short-acting w/short half-life | - Contributes to lower incidence of daytime sleepiness
85
Non-benzodiazepine Hypnotics-zolpidem (Ambien): Indication
Induce Sleep | Must be ready to go to bed
86
Non-benzodiazepine Hypnotics-zolpidem (Ambien): SE/AE
- Somnambulation or ‘sleepwalking’ - Amnesia - Headache - Dizziness - Anxiety - Hallucinations
87
patient teaching for Antiepileptic Drugs
- Take at same time each day (maintain consistent blood levels) - Take w/food & 6-8 oz of water (Reduce GI upset. Avoid taking w/milk, juices (possible interactions)) - Do not crush, chew, open extended-release forms - If NPO, contact prescriber regarding AED dosage - Keep a journal to monitor: Response to AED Seizure occurrence & description AE/SEs - Wear a medical alert tag or ID. - Do not discontinue abruptly. - Follow driving recommendations. - Safety in day-to-day activities - Therapy is long term & possibly lifelong (Not a cure) - Monitor for therapeutic effects (Decreased or absent seizure activity) - Monitor for AE/SEs: Mental status changes, mood changes, change in LOC, sensorium Eye problems, visual disorders Sore throat, fever (blood dyscrasias may occur w/phenytoin)
88
Iminostilbenes: AE/SE
- nausea - headache - dizziness - unusual eye movements - visual change - behavioral change - rash - abdominal pain - abnormal gait - GI upset
89
Prototypes for Antiparkinson Drugs
- Dopamine replacement: levodopa/carbidopa (Sinemet) (Temporarily replenishing dopamine or mimicking the reaction of dopamine Increases brain levels of dopamine) - Directing-acting dopamine receptor agonist: pramipexole (Mirapex) (Increasing brain levels of dopamine) - Indirect-acting dopaminergic drug (monoamine oxidase inhibitor): selegiline (Eldepryl) (Help mimic action of dopamine)
90
Gabapentin: AE/SE
- dizziness, drowsiness, nausea, visual and speech changes, edema
91
Zolpidem (Abmien): Contraindications
- Children younger than 18 - Suicidal ideation - Labor and delivery
92
Zolpidem (Ambien): Cautions
- Older adults - Prone to substance abuse - Sleep apnea - Can cause an increased hypnotic effect
93
Zolpidem (Ambien): Interactions
- Alcohol | - Other CNS depressants
94
Muscle Relaxants: Method of Action
- Works in CNS | - Causes sedation & skeletal muscle relaxation
95
Dantrolene (Dantrium): Interactions
- Estrogen: Increases risk for liver toxicity - CNS depressants - Calcium channel blockers: Increase risk for severe cardiac dysrhythmias
96
Muscle Relaxants: Contraindications
Severe renal impairment
97
Selegiline (Eldepryl)indirect-acting dopaminergic (monoamine oxidase inhibitor): MOA
- Inhibit monoamine oxidase, type B | - nobody knows for sure
98
Muscle Relaxants: Interactions
CNS depressants
99
Selegiline (Eldepryl)indirect-acting dopaminergic (monoamine oxidase inhibitor): indications
- adjunct to carbidopa/levodopa when deterioration is seen | - Does not work w/out concurrent levodopa
100
Prototype-Centrally Acting Muscle Relaxant- Baclofen (Lioresal)
- Oral & injectable forms - Injectable form is used with an implantable pump device to treat chronic spastic muscular conditions - CNS
101
Peripherally Acting Muscle Relaxant: Dantrolene (Dantrium) Method of Action
Inhibits the release of calcium and blocks contraction of muscles
102
Dantrolene (Dantrium): AE/SE
Muscle weakness - Drowsiness - Dizziness - Diarrhea - Liver toxicity
103
Dantrolene (Dantrium): Administration
- IV form most common to treat malignant hyperthermia - Can be given by mouth - Reduce effects of malignant hyperthermia
104
Dantrolene (Dantrium): Contraindications
Liver disease
105
Sympathomimetics
-Stimulate excitatory neurons which contain receptors for excitatory neurotransmitters -Classifications according to therapeutic use: -Anti-attention deficit hyperactivity disorder & antinarcolepsy: mixture of dextroamphetamine sulfate, dextroamphetamine saccharate, amphetamine sulfate, amphetamine (Adderall) methylphenidate (Ritalin) -Antimigraine: sumatriptan (Imitrex) -Prevent or treat narcolepsy
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Dantrolene (Dantrium): Interactions
- Estrogen: Increases risk for liver toxicity - CNS depressants - Calcium channel blockers: Increase risk for severe cardiac dysrhythmias
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Hyantoins: interactions
- amiodarone, benzodiazepines, azole antifungals, isoniazid, proton pump inhibitors, sulfonamide antibiotics, carbamazepine, cyclosporine, meperidine, rifampin, quetiapine, theophylline, warfarin
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Iminostilbenes: interactions
- azole antifungals, diltiazem, isoniazid, macrocodes, protease inhibitor antiretrovirals, SSRIs, valproic acid, vermeil, barbiturates, hydantoins, rifampin, succinimides, theophylline, acetaminophen, antipsychotics, antidepressants, benzodiazepines, cyclosporine, oral contraceptives, MAOIs
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Valproic acid and derivative: interactions
- aspirin, carbamazepine, oxcarbazepine, lamotrigine, lorazepam, rifampin, tricyclic acid
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Gabapentin: interactions
alcohol
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A patient has been admitted to the emergency department because of an overdose of an oral benzodiazepine. He is very drowsy but still responsive. The nurse will prepare for which immediate intervention?
Administration of flumazenil
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The nurse will monitor the patient who is taking a muscle relaxant for which adverse effect?
CNS Depression
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CNS Depressants and Muscle Relaxants Nursing Implications
- Keep out of reach of children - Emphasize: should only be taken as prescribed. Do not double up on the dose unless directed. - Teach: Do not drive or perform activities that require mental alertness. - Do not abruptly discontinue these drugs (avoid rebound insomnia) - Sedative-hypnotics for sleep promotion are not intended for long-term use - Patients taking benzodiazepines should not eat grapefruit or drink grapefruit juice
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CNS Depressants and Muscle Relaxants
- Try non-pharmacologic methods to improve sleep BEFORE medications - It is important for the nurse to try non-pharmacologic methods to improve sleep before medications. The nurse should also educate the patient to try these methods as well. Cool room, dark, decreasing caffeine intake closer to bedtime. - Most sedative-hypnotic drugs suppress REM sleep and should only be used for a short time
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amphetamines (Adderall) & methylphenidate (Ritalin): Nursing Considerations
- Drug holidays- one day of the week, to diminish any risk of becoming addicted (weekend or when patient has a break from school) - Can exacerbate anxiety or agitation- be cautious - Start with the lowest dose and titrate up
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Non-benzodiazepines
- Lower incidence of daytime sleepiness, hypnotic effect only - Flumazenil is the antidote for benzo toxicity - These drugs just have a hypnotic effect so there is a lower incidence of daytime sleepiness. Our prototype in this category is zolpidem (Ambien) and it has a short half-life and is short-acting which also helps to reduce the incidence of daytime sleepiness. It is important to teach the patient taking Ambien to take it right before going to sleep because it can cause sleep-walking and amnesia. Most of the sedative-hypnotic drugs like the benzos suppress REM sleep and can only be used for a short time. It is important to remember this and to provide education to your patients about this. It is important that patients know they cannot take these drugs long-term
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-Muscle relaxants
- Cause sedation and smooth muscle relaxation - Do NOT take CNS depressants or muscle relaxants with other CNS depressants or alcohol! - Muscle relaxants work in the CNS and cause sedation and smooth muscle relaxation. They are used most often to reduce spasms in disorders such as MS and cerebral palsy. Sometimes they can be used to reduce tremors in Parkinson disease or Huntington disease. These drugs also cause CNS depression and they should not be taken with other CNS depressants or alcohol. There is not a specific antidote to treat an OD of muscle relaxants.
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CNS Stimulants Prototype drugs (4)
- Amphetamine/dextroamphetamine (Adderall) - Methylphenidate (Ritalin, Concerta) - Modafinil (Provigil) - Sumatriptan (Imitrex)
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Phenytoin (Dilantin)
- Highly bound to albumin: It can interact with other drugs, competes with other protein bound drugs for binding sites, Increase dose - Exaggerated effects are seen with malnutrition and renal failure - Increase metabolism of other drugs that are metabolized by these enzymes and reduced the blood level of these drugs - Induces hepatic microsomal enzymes (cytochromic P-450): Increase metabolism of other drugs that are metabolized by these enzymes and reduced the blood level of these drugs - Monitor CBC monthly for 1 year (thrombocytopenia, agranulocytosis) - Monitor liver enzymes to check for hepatitis.
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Phenytoin by IV route
- Very irritating! - Give slow IV push in large vein. - Do not exceed 50 mg/min - Monitor for bradycardia. - Dilute only in NS. - Use in-line filter.
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Carbamazepine (Tegretol)
- Only available PO. - Contraindicated in myoclonic or absence seizures. - Associated with autoinduction of hepatic enzymes: Process whereby overtime, a drug stimulates production of enzymes that enhance its own metabolism What result will occur with autoinduction? You have lower than expected drug concentrations- increase dose - Do not give with grapefruit, grapefruit juice. - Leads to increased toxicity.
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Valproic Acid (Depakote)
- Available IV or PO - Indications: generalized seizures (absence, myoclonic & tonic-clonic). - Also for bipolar disorder. - Contraindications: allergy; liver impairment; urea cycle disorders - AE: hepatotoxicity; pancreatitis; drowsiness; N/V/GI disturbances; weight gain
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Antimigraine: sumatriptan (Imitrex): Indications
- Abortive therapy for migraine: taken at first sign of a migraine, prevents it from getting worse. - Not for prevention. - Vasodilation of blood vessels, by vasoconstricting you reduce headache symptoms
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Antimigraine: sumatriptan (Imitrex): Contraindications
serious CV disease (d/t vasoconstrictive potential)
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Therapeutic plasma levels for Antiepileptic Drugs
- AEDs have a low therapeutic index - Therapeutic ranges are only guidelines. Phenytoin: 10-20 mcg/mL Carbamazepine: 4-12 mcg/mL Valproic acid: 50-100 mcg/mL - Goal: Titrate to lowest effective drug dose/plasma level that controls seizure disorder. - Have narrow range they are effective in
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Attention Deficit Hyperactivity Disorder (ADHD)
- Most common psychiatric disorder in children - Affects 4% -10% of school-age children - Boys affected 2-9 times more often than girls. - Primary S/S: inappropriate ability to maintain attention span or presence of hyperactivity & impulsivity - Drug therapy for childhood & adult ADHD is similar.
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Antimigraine: sumatriptan (Imitrex): Nursing Considerations
- Educate about different forms; teach patient this drug is NOT for prevention - Can take other meds everyday to prevent but not this one.
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Antimigraine: sumatriptan (Imitrex): Formulations
- By Mouth - Sublingual - Subcutaneous - Nasal sprays
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Migraine
-Recurring headache, usually lasting 4-72 hours -Typical features: pulsatile quality with pain that worsens with each pulse -Commonly unilateral. May be on both sides -Associated S/S: nausea, vomiting photophobia & phonophobia -Aura : take place before, hint (not every patient) -Sensitivity to light or loud noises
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amphetamines (Adderall) & methylphenidate (Ritalin): Method of Action
- Stimulates area of brain assoc. w/mental alertness - Elevates mood; increases mental alertness & capacity for work; decreases fatigue/drowsiness; prolongs wakefulness - Stimulates cerebral cortex and thalamus
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amphetamines (Adderall) & methylphenidate (Ritalin): Indications
- ADHD and Narcolepsy | - Trying to help: lack of attention, impulsivity, hyperactivity, and decrease ability to stay on task
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amphetamines (Adderall) & methylphenidate (Ritalin): Contraindications
Terrets syndrome or hypertension
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amphetamines (Adderall) & methylphenidate (Ritalin): AE
dose related. “speeds up” body systems Increase heartrate, tachycardia, increased blood pressure, dysrhythmias, nervousness, restlessness, anxiety, insomnia, palpitations
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amphetamines (Adderall) & methylphenidate (Ritalin): Interactions
- MAOI's: do not take within 14 days, Increased release of catecholamines, results in headaches, dysrhythmias, severe hypertension. - CNS stimulants: Additive toxicities, Cardiovascular adverse effects, nervousness, insomnia.
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amphetamines (Adderall) & methylphenidate (Ritalin): Nursing Considerations
- Drug holidays- one day of the week, to diminish any risk of becoming addicted (weekend or when patient has a break from school) - Can exacerbate anxiety or agitation- be cautious - Start with the lowest dose and titrate up
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Non-Amphetamines: modafinil (Provigil): Indications
- Improvement of wakefulness in pts with narcolepsy | - Shift work sleep disorder
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Non-Amphetamines: modafinil (Provigil): MOA
- Unclear | - May be r/t ability to block reuptake of norepinephrine
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Non-Amphetamines: modafinil (Provigil): AE/SE
- Nausea - Diarrhea - H/A - Tachycardia, HTN - Stevens-Johnson syndrome
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Non-Amphetamines: modafinil (Provigil):Contraindications
-History of valvular heart disease
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Non-Amphetamines: modafinil (Provigil): Cautions
- CV disease - HTN - Hepatic/Renal Impairment - Drug/ETOH abuse hx - Mania/Psychosis
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Non-Amphetamines: modafinil (Provigil): Interactions
- Decrease in effectiveness of Oral Contraceptives | - Methylphenidate interferes with absorption of modafinil
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Antimigraine: sumatriptan (Imitrex): Method of Action
Stimulate 5-HT receptors in cerebral arteries, causing vasoconstriction & reducing HA
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Antimigraine: sumatriptan (Imitrex): Indications
- Abortive therapy for migraine: taken at first sign of a migraine, prevents it from getting worse. - Not for prevention.
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Antimigraine: sumatriptan (Imitrex): Contraindications
serious CV disease (d/t vasoconstrictive potential)
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Antimigraine: sumatriptan (Imitrex): AE
vasoconstriction; injection site irritation; tingling/flushing
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Antimigraine: sumatriptan (Imitrex): Interactions
- additive toxicity w/ergot alkaloids, SSRIs, & MAOIs | - Can cause cardiovascular adverse effects, nervousness, insomnia, convulsions
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Antimigraine: sumatriptan (Imitrex): Nursing Considerations
Educate about different forms; teach patient this drug is NOT for prevention
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Antimigraine: sumatriptan (Imitrex): Formulations
- By Mouth - Sublingual - Subcutaneous - Nasal sprays
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Levodopa-carbidopa (Sinemet)Dopamine Replacement: MOA
- Levodopa is biologic precursor of dopamine - Levodopa is combined w/carbidopa to prevent breakdown of levodopa in periphery (Prevents levodopa from being converted into dopamine prematurely in the bloodstream, allowing more of it to get to the brain.) - Given PO as levodopa to pass BBB - Many different formulations & strengths: long-, short-acting; combined long- and short-acting capsule a form that melts in the mouth without water a combined form that includes the COMT inhibitor entacapone intestinal infusion pump (DUOPA) (need gastrostomy tube)
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Levodopa-carbidopa (Sinemet)Dopamine Replacement: AE/SE
- palpitations - hypotension - urinary retention - depression - dyskinesia
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Pramipexole (Mirapex)dopamine agonist: MOA
- mimic effects of dopamine (without having to be converted) - stimulates dopamine receptors in the striatum. - also used for restless legs syndrome - start low dose and titrate up to tolerability
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Pramipexole (Mirapex)dopamine agonist: Indications
early or late Parkinson's disease
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Pramipexole (Mirapex)dopamine agonist: administration
2-6 times/day
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Pramipexole (Mirapex)dopamine agonist: interactions
- sedatives - metoclopramide - cimetidine
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Pramipexole (Mirapex)dopamine agonist: AE/SE
- GI: N/D/constipation, dry mouth - Neuro: falling asleep during ADLs (“sleep attacks”), Somnolence/sleep may come without warning. Warn clients!, hallucinations (inc. risk > 65 years old), compulsive behaviors (gambling, sexual, spending, eating) - CV: impaired BP regulation (orthostasis) - cerebral palsy
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Selegiline (Eldepryl)indirect-acting dopaminergic (monoamine oxidase inhibitor): MOA
Inhibit monoamine oxidase, type B
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Selegiline (Eldepryl)indirect-acting dopaminergic (monoamine oxidase inhibitor): formulations
- PO - PO disintegrating tab - transdermal
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Selegiline (Eldepryl)indirect-acting dopaminergic (monoamine oxidase inhibitor): indications
- adjunct to carbidopa/levodopa when deterioration is seen | - Does not work w/out concurrent levodopa
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Nursing ImplicationsDrugs for ADHD
-Assess: Potential contraindications Potential interactions herbal therapies Conditions such as abnormal cardiac rhythms, seizures, palpitations, liver problems For children, assess baseline ht/wt -Last daily dose should be given 4-6 hours before bedtime to ↓ insomnia. -Take on an empty stomach 30-45 minutes before meals. -Drug “holidays” may be ordered. -Instruct parents to keep a journal to monitor child’s response to therapy. -Monitor for continued phys. growth, including ht/wt.
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Nursing Implications: modafinil (Provigil)
- Give with food to decrease GI effects - Monitor VS: tachycardia, HTN - Monitor for rash/blistering of skin - Administer in AM for narcolepsy - Administer 1 hour before work for shift-work sleepiness - Pt should report HA, nervousness, dizziness, palpitations, rash - Female pts should change contraceptive form if necessary
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Nursing Implications:sumatriptan (Imitrex)
- Formulations: SL (dissolvable wafers), nasal spray, & self-injectable forms - Provide specific teaching about correct administration. - Instruct patients to keep a journal to monitor response to therapy. - Track migraine symptoms to monitor therapy
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ADHD Therapeutic Responses
decreased hyperactivity, increased attention span and concentration
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Narcolepsy Therapeutic Response
Decrease in sleepiness
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Seratonin agonist Therapeutic Response
decrease in frequency, duration, and severity of migraines
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The nurse will include what information when providing teaching a client about antiparkinson drugs?
“Change positions slowly to prevent falling due to a drop in blood pressure.” -Orthostatic Hypotension
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Selegiline (Eldepryl)indirect-acting dopaminergic (monoamine oxidase inhibitor): contraindications
allergy
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Selegiline (Eldepryl)indirect-acting dopaminergic (monoamine oxidase inhibitor): interactions
- opioids, MAO inhibitors, dextromethorphan, St. John’s wort, cyclobenzaprine - antidepressants: serotonin syndrome (Wait 14 days after stopping & before starting antidepressant.)
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Selegiline (Eldepryl)indirect-acting dopaminergic (monoamine oxidase inhibitor): AE/SE
- GI: constipation, N/V - CV: HTN (serotonin syndrome) (dose-dependent), hypotension/orthostasis - Neuro: falling asleep during ADLs (inc. risk > 65 years old), insomnia, impaired impulse control, compulsive behaviors, hallucinations, psychotic-like behavior Skin: risk for melanoma
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Nursing assessment for Antiparkinson Drugs
- Past health & medical history, ROS & sensory & motor abilities (Table 15-1) - Older adults: at increased risk for AE, esp. confusion, anorexia, orthostasis start low dose; save higher dosages for later time during treatment Long-term levodopa/carbidopa: duration of effectiveness decreases over time (“wearing-off” phenomenon)
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Nursing Considerations & Teaching for antiparkinsons drugs
- Regimen: Take exactly as prescribed. Delaying dose by even 30 min. may lead to “off” period & may last hours. Give doses at bedtime. Give with food (minimize GI upset). - Diet: high-protein diet may slow or prevent absorption of carbidopa-levodopa. Eat higher-protein foods later in day or in small amts throughout. Timing is the issue! - Drink at least 3000 mL/day, unless contraindicated. - Disintegrating formulation (selegiline) Ensure it melts completely. Do not swallow. No food/fluids for 5 min. before & 5 min. after. - Avoid alcohol, OTC drugs, & herbals. - Notify prescriber immediately of a missed dose. - May take up to 3-4 weeks to see therapeutic response. - Evaluation: Participate in ADLs w/minimal difficulty.
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Psychotherapeutic prototype drugs
``` benzodiazepines- alprazolam (Xanaz) and diazepam (Valium) non-benzodiazepines- buspirone (Buspar) lithium (Eskalith or Lithobid) valproic acid (Depakote) amitriptyline (Elavil) phenelzine (Nardil) fluoxetine (Prozac) venlafaxine (Effexor) bupropion (Wellbutrin) chlorpromazine (Thorazine) haloperidol (Haldol) risperidone (Risperdal) ```
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Psychotherapeutic drugs
- Used in the treatment of emotional and mental disorders - Ability to cope with emotions can range from occasional depression or anxiety to constant emotional distress - When emotions significantly affect an individual’s ability to carry out normal daily functions, treatment with a psychotherapeutic drug is a possible option - Exact cause of mental disorders not fully understood - Thought to arise from abnormal levels or imbalances of neurotransmitters - Pharmacotherapy and psychotherapy is gold standard to treat mental illness - Neurotransmitters are: dopamine, epinephrine, serotonin, histamine, GABA, acetocholine - Normal mental function influenced by: sodium, magnesium, potassium - Block or stimulate release of endogenous neurotransmitters - Mental status affects ability to take care of self, leads to poor physical health
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Three main emotional and psychiatric disorders:
Anxiety disorders: - unpleasant state of mind, dread, fear. Based on anticipated experiences, past, or imaginary situations- normal reaction to stress. 18% of adults suffer mostly from general anxiety disorder and PTSD - OCD, panic disorder, social phobia, social anxiety disorder, or simple phobias Affective disorders: - changes in mood, mania to depression. May have both at same time (bipolar) - hypomania- less severe - Depression- 8-12% - Bipolar- 2.6% - Neuropsychiatric disorder- Leading cause of disability in US, 18.7% years of life lost - suicide 10th leading cost of deaths - Depressive symptoms- worthlessness, reduced energy, changes in sleep, changes in appetite Psychoses: - impairs mental function of individuals where they cannot participate in ADLS - Hallmark- loss of contact with reality, - Symptoms- hallucinations, false beliefs - Schizophrenia, psychosis - About 1% - Excessive dopaminergic activity in brain
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Types of psychotherapeutic drugs:
Anxiolytic drugs Mood-stabilizing drugs Antidepressant drugs Antipsychotic drugs Excessive dopaminergic activity in brain - Widely prescribed - Non-adherence common d/t it not being specifically tailored to client, side effects not tolerable
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Anxiolytic drugs-Benzodiazepines, alprazolam(Xanax) and diazepam (valium): MOA
Enhances inhibitory effect of GABA
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Anxiolytic drugs-Benzodiazepines, alprazolam(Xanax) and diazepam (valium): Indications
Anti-anxiety, hypnotic, anticonvulsant, can prevent agitation and delirium DTs- alcohol withdrawal, anxiety, depression, acute psychoses, mania
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Anxiolytic drugs-Benzodiazepines, alprazolam(Xanax) and diazepam (valium): Contraindications/cautions
COPD, sleep apnea, severe liver/kidney disease, use cautiously with adults (lower dose),higher fall risk Children may have stronger reaction or paradoxical effect (excitement), drug allergy, Can be addictive, Do not use in pregnant or breastfeeding mother, glaucoma
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Anxiolytic drugs-Benzodiazepines, alprazolam(Xanax) and diazepam (valium): AE/SE
CNS depression Overdose risk-treat with flumazenil (Romazicon) - Drowsiness, dizziness, confusion, depressed mood (suicidal ideation), shallow breathing, loss of bladder control, irritability, new or worsening seizures, nausea, vomiting - risk of OD (symptoms)- blurred or double vision, labored breathing, hypotension, weakness, could lead to stupor and coma
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Anxiolytic drugs-Benzodiazepines, alprazolam(Xanax) and diazepam (valium):
- Other CNS depressants increase effects (alcohol!). | - CCB decrease metabolism of alprazolam.
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Anxiolytics-Non-benzodiazepines Buspirone (buspar): MOA
unknown-agonist activity at serotonin and dopamine receptors
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Anxiolytics-Non-benzodiazepines Buspirone (buspar): Indications
Anxiety disorders including GAD
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Anxiolytics-Non-benzodi azepines Buspirone (buspar): Contraindications
Allergy
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Anxiolytics-Non-benzodiazepines Buspirone (buspar): AE/SE
paradoxical anxiety, dizziness, h/a, nausea
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Anxiolytics-Non-benzodiazepines Buspirone (buspar): Interactions
MAOIs, rifampin (reduces therapeutic affects)
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Mood Stabilizing drugs:lithium (Eskalith or lithobid): MOA
- Not fully understood - affects synthesis, release and reuptake of several neurotransmitters (acetocholine, dopamine, GABA, norepinephrine) - Stabilizes post synaptic receptor sensitivity to neurotransmitters- competes with sodium, magnesium, and potassium binding sites - Lithium may stimulate neuronal growth, exerting a neuroprotective effect on areas of the brain that are involved in mood
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Mood Stabilizing drugs:lithium (Eskalith or lithobid): Indications
Bipolar Disorder- helps manic episodes
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Mood Stabilizing drugs:lithium (Eskalith or lithobid): Contraindications:
- Pregnancy category D medication, dehydration, sodium imbalance, major renal or cardiovascular disease
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Mood Stabilizing drugs:lithium (Eskalith or lithobid): AE/SE
Cardiac dysrhythmias, choreoathetotic movements (involuntary wave-like movement of extremities), ataxia, hypotension, polyuria. Polydipsia, diarrhea, muscle weakness, fatigue, edema, weight gain Longer tern treatment may cause hyperthyroidism
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Mood Stabilizing drugs:lithium (Eskalith or lithobid): Interactions
- Alcohol, diuretics, ACE inhibitors, SSRI, theophylline, NSAIDS - alcohol and diuretics increase risk of dehydration which increases risk of lithium toxicity - ACE and diuretics (bp meds) increase serum level and risk of toxicity - SSRIs increase risk of AE like confusion, drowsiness, and issues with coordination - Theophylline and NSAIDS decrease affects of lithium
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Lithium
- Narrow therapeutic range: acute mania—lithium serum level of 1-1.5 mEq/L; maintenance serum levels should range between 0.6-1.2 mEq/L - Levels exceeding 1.5-2.5 mEq/L begin to produce toxicity, including GI discomfort, tremor, confusion, somnolence, seizures, and possibly death. - Keeping the sodium level in the normal range (135-145 mEq/L) helps to maintain therapeutic lithium levels. - Lithium and sodium relationship
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Mood stabilizing drugs: Valproic Acid (Depakote)
- MOA: Not fully understood, Thought to increase affects of GABA - Indications: AED medication used in Bipolar disorder, If unresponsive to lithium they may be prescribed this - Contraindications: significant hepatic impairment- If they have mild or moderate hepatic impairment then use this cautiously - AE/SE: drowsiness, N/V, trimmers, weight gain, hair loss, N/V, hepatic toxicity and pancreatitis - Interactions: Depakote is highly protein bound- Competes with warfarin a lot (highly protein bound too) - Therapeutic range 50-125 mcg/mL - Lithium/sodium-Kidneys treat lithium and sodium similarly which is the reason sodium depletion can significantly elevate lithium reabsorption. - Decreased sodium leads to increased lithium. - Increased sodium can lead to decreased lithium. - Dehydration r/t diarrhea, vomiting, sweating profusely can lead to increased lithium levels and toxicity. - Most serious adverse effect is cardiac dysrhythmias. - If lithium levels get too high, patient may need hemodialysis to detoxify. - Nursing considerations: PO (oral liquid, extended or delayed release tablets) or injectable - Do not crush, cut, chew tablets
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Antidepressant Drugs:Tricyclic Antidepressants (TCA)amitriptyline (Elavil): MOA
Block reuptake of neurotransmitters, causing accumulation at the nerve endings Have been largely replaced by SSRIs
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Antidepressant Drugs:Tricyclic Antidepressants (TCA)amitriptyline (Elavil): Indications
Depression, Used for patient who fail with SSRIs or other antidepressants or as an adjunct with newer antidepressents
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Antidepressant Drugs:Tricyclic Antidepressants (TCA)amitriptyline (Elavil): Contraindications
Pregnancy, acute/chronic cardiac problems, seizures, death more common if you have seizures and OD
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Antidepressant Drugs:Tricyclic Antidepressants (TCA)amitriptyline (Elavil): AE/SE
Sedation, dry mouth, impotence, orthostatic hypotension
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Antidepressant Drugs:Tricyclic Antidepressants (TCA)amitriptyline (Elavil): Interactions
MAO's
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Antidepressant Drugs:Monoamine Oxidase Inhibitors (MAOI)phenelzine (Nardil): MOA
Binds irreversibly to MAO, increasing the concentrations of epinephrine, norepinephrine, serotonin, and dopamine in CNS
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Antidepressant Drugs:Monoamine Oxidase Inhibitors (MAOI)phenelzine (Nardil): Indications
A third line therapy to treat depression, Not responsive to other antidepressants or refuses electric convulsive therapy (High risk of hypertensive crisis and stroke)
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Antidepressant Drugs:Monoamine Oxidase Inhibitors (MAOI)phenelzine (Nardil): Contraindications
use cautiously in hepatic and renal impairment; cautious in older adults; elective surgery
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Antidepressant Drugs:Monoamine Oxidase Inhibitors (MAOI)phenelzine (Nardil): AE/SE
Hypertensive crisis, dysrhythmias, drowsiness, dizziness, orthostatic hypotension, sexual disfunction
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Antidepressant Drugs:Monoamine Oxidase Inhibitors (MAOI)phenelzine (Nardil): Interactions
- Food interaction with tyramine- red wine, aged meats a cheeses, soy products, brewers yeast, seawee - Interaction with SSRIs, OTC cough and cold medications, caffeine, herbals (kava kava, saint johns wart)- increase effects of med and leads to hypertensive crisis
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Antidepressant Drugs:Selective Serotonin Reuptake Inhibitors (SSRI)fluoxetine (Prozac): MOA
Blocks reuptake of serotonin in the brain, helping to elevate mood.
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Antidepressant Drugs:Selective Serotonin Reuptake Inhibitors (SSRI)fluoxetine (Prozac): Indications
depression, bulimia, OCD, panic disorder, premenstrual dysphoric disorder
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Antidepressant Drugs:Selective Serotonin Reuptake Inhibitors (SSRI)fluoxetine (Prozac): Contraindications
concurrent MAOI therapy, Drug of choice In older adults, but slower elimination (lower dose), Use cautiously with hepatic impairment
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Antidepressant Drugs:Selective Serotonin Reuptake Inhibitors (SSRI)fluoxetine (Prozac): AE/SE
- GI symptoms, sexual dysfunction, CNS stimulation - Antidepressant - discontinuation syndrome - anxiety - diabetic patient may have hypoglycemic effect - Increased risk for GI bleeds if you take this - May experience serotonin syndrome- hypertensive crisis, hyperpyrexia, extreme agitation that progresses into delirium and then coma, muscle rigidity, seizures ((if taking warfarin or herbals)
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Antidepressant Drugs:Selective Serotonin Reuptake Inhibitors (SSRI)fluoxetine (Prozac): Interactions
- alcohol, amiodarone, haloperidol, warfarin - increase effects of fluoxetine - Highly protein bound- competes for binding sights, more free unbound drug, more pronounced drug affect, or toxicities
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Antidepressant Drugs:Serotonin/Norepinephrine Reuptake Inhibitors (SNRI)Venlafaxine (EFFEXOR): MOA
- increases levels of serotonin and norepinephrine in the brain by preventing the reuptake of these neurotransmitters known to play an important part in mood - Weakly inhibit reuptake of dopamine as well
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Antidepressant Drugs:Serotonin/Norepinephrine Reuptake Inhibitors (SNRI)Venlafaxine (EFFEXOR): Indications
depression, generalized anxiety disorder, social phobia, panic disorder
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Antidepressant Drugs:Serotonin/Norepinephrine Reuptake Inhibitors (SNRI)Venlafaxine (EFFEXOR): Contraindications
concurrent use with MAOIs, cautious with renal and hepatic impairment, pregnancy
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Antidepressant Drugs:Serotonin/Norepinephrine Reuptake Inhibitors (SNRI)Venlafaxine (EFFEXOR): AE/SE
CNS, GI, CV, GU, Derm - CNS- dizziness, weird dreams, insomnia - GI- anorexia, weight loss, N/V, diarrhea, constipation - CV- hypertension, tachycardia, vasodilation - GU- urinary frequency, sexual dysfunction - Derm- sweating, rash, puritis
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Antidepressant Drugs:Serotonin/Norepinephrine Reuptake Inhibitors (SNRI)Venlafaxine (EFFEXOR): Interactions
MAOIs-14-day period between
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Antidepressant Drugs:Atypical Antidepressants | Bupropion (Wellbutrin): MOA
weak effects on serotonin. Therapeutic activity primarily dopaminergic and norepinephrine
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Antidepressant Drugs:Atypical Antidepressants | Bupropion (Wellbutrin): Indications
depression, smoking cessation, seasonal affective disorder
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Antidepressant Drugs:Atypical Antidepressants | Bupropion (Wellbutrin): Contraindications
seizure disorder (Lowers seizure threshold, increases risk for developing seizures), concurrent MAOI use
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Antidepressant Drugs:Atypical Antidepressants | Bupropion (Wellbutrin): AE/SE
dizziness, tachycardia, agitation, trimmer, confusion, Fewer sexual side effects
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Antidepressant Drugs:Atypical Antidepressants | Bupropion (Wellbutrin): Interactions
- CNS depressants, alcohol | - Additive effect- increased affect of CNS
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COVENTIONAL ANTIPSYCHOTICS | HALOPERIDOL (HALDOL) AND CHLORPROMAZINE (THORAZINE): MOA
Not fully understood. - think it causes antipsychotic effects, blocking postsynaptic dopamine receptors - Previously Known as tranquilizers and neuroleptics
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COVENTIONAL ANTIPSYCHOTICS | HALOPERIDOL (HALDOL) AND CHLORPROMAZINE (THORAZINE): Indications
schizophrenia, acute psychosis, chronic psychotic disorders, - Can be indication for psychotic and nonpsychotic depression
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COVENTIONAL ANTIPSYCHOTICS | HALOPERIDOL (HALDOL) AND CHLORPROMAZINE (THORAZINE): Contraindiations
renal and hepatic impairment (use caution), Parkinson disease, seizure disorder, severe mental depression
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COVENTIONAL ANTIPSYCHOTICS | HALOPERIDOL (HALDOL) AND CHLORPROMAZINE (THORAZINE): AE/SE
- Less effective for management of negative symptoms - Much more effective with positive symptoms - EPS (Extra Pyramidal Symptoms), NMS (Neuroleptic Malignant Syndrome), cardiac dysrhythmias, parkinsonism - Positive symptoms: hallucinations, delusions, conceptual disorganization - Negative symptoms: apathy, social withdrawal, blunted affect, poverty of speech, catatonia - EPS extra paramedial symptoms: Involuntary muscle symptoms similar to those of Parkinson’s disease Akathisia (distressing muscle restlessness), Acute dystonia (painful muscle spasms), Tardive dyskinesia (can be permanent)- Involuntary contractions of oral and facial muscles, Choreoathetosis (wavelike movements of extremities), Occurs with continuous long-term antipsychotic therapy, Involuntary movements, which are repetitive, grimacing, eye blinking, lip smacking, tongue thrusting - NMS neuroleptic malignant syndrome: Potentially life threatening, High fever, unstable BP, Myoglobinemia, Can occur with the first dose or after many years of therapy, Not dose dependent, but higher doses do pose a greater risk
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COVENTIONAL ANTIPSYCHOTICS | HALOPERIDOL (HALDOL) AND CHLORPROMAZINE (THORAZINE): Interactions
CNS depressants, NSAIDS, ACE Inhibitors, antacids
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ATYPICAL ANTIPSYCHOTICS | RISPERIDONE (RISPERDAL)
MOA: block dopamine-2 receptors and serotonin 2 receptors - Indications: schizophrenia, including negative symptoms - Contraindications: drug allergy - AE/SE: Weight gain, hyperlipidemia, type 2 diabetes- These clients will typically have to start anti-diabetics, cholesterol lowering drugs, hypertension drugs. Non-adherence due to these side effects - metabolic syndrome - Interactions: CNS depressants (Additive CNS effect with interactions) - Advantageous properties over conventional drugs. See less risk of EPS, TD, and NMS with atypical anti-psychotics
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Benzodiaepine nursing considerations
- Can be habit forming - Risk of overdose - flumazenil (Romazicon) reverses benzos - Assess for s/s of CNS depression (Older the more complications) - assess for s/s of CNS depression-drowsiness, confusion, disinhibition, dizziness, decreased respirations - PRN
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Non-benzodiazepine nursing considerations
- Not habit forming- forming-good choice for pts with hx of abuse/addiction - Scheduled
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Anxiolytic drugs-Benzodiazepines, alprazolam(Xanax) and diazepam (valium): nursing considerations
- Diazepam Forms: PO, IM, IV - Alprazolam forms: PO only, sublingual if cant swallow - Should not be stopped abruptly- slower taper off - IM- use ventral gluteal, rotate injection site - IV push- 5mg/minute - Assess for therapeutic affects- decrease in HR and BP, more relaxed, sleepy, paradoxical affects (anger, aggression) - Paradoxical reactions are rare- see them in children and adolescents, or older adult with dementia - Assess for dependence, OD, and withdrawal (anxiety, insomnia, headache, trimmer, palpitations)
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Anxiolytics-Non-benzodiazepines Buspirone (buspar): nursing considerations
- Scheduled medication - If coming off benzo, ween them off slowly while beginning buspar - Wait 14 days after taking MAOIs - Taking MAOIs and buspar together can lead to hypertensive crisis - Not a controlled substance- good anti-anxiety med for clients with history of addiction
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Tricyclic Antidepressants (TCA): amitriptyline (Elavil): nursing considerations
- Overdose is very lethal- die before they reach the hospital (seizures, dysrhythmias) - Effects cardiovascular and central nervous system - No specific antidote - Do not give patient whole 30 day prescription at once- depressed patients at increases risk for suicide- more energy and focus on suicide plan
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Atypical Antidepressants: bupropion (Wellbutrin): nursing considerations
Lowers seizure threshold Important for all antidepressants-it typically takes 4-6 weeks before full therapeutic effect is seen. Psychotherapy in addition to pharmacotherapy is the gold standard treatment for depression.
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Antidepressant Drugs:Tricyclic Antidepressants (TCA): nursing considerations
- remember that OD is highly lethal, 70-80% die prior to reaching the hospital, most often from seizures or dysrhythmias. - They should not be given a full supply with initiation to help avoid OD. - Starting an antidepressant regimen may give the patient the energy and focus to carry out their suicide plan. - Can be used as an adjectival analgesic for chronic pain conditions - Also increase appetite (treat anorexia)
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Antidepressant Drugs:Monoamine Oxidase Inhibitors (MAOI)phenelzine (Nardil): nursing considerations
- Nurse needs to educate patient on medication | - Assess for therapeutic affect
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Antidepressant Drugs:Selective Serotonin Reuptake Inhibitors (SSRI)fluoxetine (Prozac): nursing considerations
- Antidepressant discontinuation syndrome- sudden termination of SSRI- dizziness, GI upset, lethargy, anxious, hyperarousal, dysphoria, sleep problems, headache - can last several day to several weeks - More serious symptoms- aggression, hypomania, mood disturbances, suicidal tendencies - Taper drugs off slowly
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Antidepressant Drugs:Serotonin/Norepinephrine Reuptake Inhibitors (SNRI)Venlafaxine (EFFEXOR): nursing considerations
- 14 day period after taking MOAIs - Black box warning- increased suicidal ideation in children, adolescents, and young adults from ages18-24 - Children more likely to experience weight loss - Smaller initial doses in older adults due to weight loss risk - Older adults- increased risk of syndrome of inappropriate ADH or hyponatremia (closely monitor sodium levels) - Take medication with food - Assess for improvement in moods, sleep patterns, suicidal ideation and hostility
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Nociception
1: Transduction: - Injured tissue releases chemicals that propagate pain message. - Action potential moves along an afferent fiber to the spinal cord. 2: Transmission: The pain impulse moves from the spinal cord to the brain. 3: Perception of Pain 4: Modulation: Neurons from brain stem release neurotransmitters that block the pain impulse.

Pharmacology (5 decks)

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