Finals-Pharma-Elearning PDF

ANTIBIOTICS- TOPICAL: NURSING them to cleanse the area with mild soap and PHARMACOLOGY water, and to gently pat the area dry. Remind them to always wash their hands before...

ANTIBIOTICS- TOPICAL: NURSING them to cleanse the area with mild soap and PHARMACOLOGY water, and to gently pat the area dry. Remind them to always wash their hands before and Topical antibiotics are medications used to after application of the topical antibiotic. Then, prevent or treat infections in damaged skin, show them how to apply the medication to the including burns, wounds, cuts, or scrapes, as affected area, and then cover it with a sterile well as surgical incisions. Some of the most dressing. Stress the importance of applying commonly used topical antibiotics include their medication to the affected area only, and bacitracin-polymyxin B, as well as mafenide to avoid mucous membranes like the eyes and acetate, and silver sulfadiazine. These are non- nose. Let them know they might experience prescription antibiotics that are applied locally some mild skin irritation or itching; also, prompt in the form of an ointment. Once applied, they them to notify their healthcare provider if these prevent infections by interfering with bacterial side effects increase, or if the incisional site growth and proliferation. In terms of side becomes red, swollen, warm, if it produces a effects, topical use of bacitracin-polymyxin B purulent discharge, if bleeding increases, or if usually doesn’t cause any adverse reactions, but the edges of the wound begin to separate. some clients may present with mild skin Finally, monitor your client for any side effects irritation or urticaria. On the other hand, they may experience, as well as the therapeutic mafenide can cause mild skin irritation and a effects of the medication, including resolution burning sensation. Less frequent but more of the skin infection. Alright, as a quick recap … severe side effects include hypersensitivity Topical antibiotics are medications used to reactions leading to urticaria, as well as swelling prevent or treat infections in damaged skin, of the face, lips, tongue, or throat. Mafenide including burns, wounds, cuts, scrapes, and can also cause metabolic acidosis, and some surgical incision. These medications include clients with G6PD deficiency have developed bacitracin-polymyxin B, as well as mafenide fatal hemolytic anemia with disseminated acetate, and silver sulfadiazine. Some clients intravascular coagulation. Lastly, silver may develop side effects like mild skin irritation sulfadiazine can leave a temporary black or urticaria. Nursing considerations include discoloration skin, and can cause a burning performing an assessment of the affected skin sensation, a skin rash like erythema multiforme, area, as well as monitoring for side effects and or even skin necrosis. Finally, systemic therapeutic effects of the medication. Finally, absorption of silver sulfadiazine has also been client teaching is focused on correct application associated with severe hypersensitivity of the medication topically, as well as side reactions, such as Stevens-Johnson syndrome effects they may experience, and when to notify and toxic epidermal necrolysis, as well as leukopenia, and interstitial nephritis. Topical antibiotics should be used with caution during pregnancy and breastfeeding, as well as in clients with a history of other skin conditions, such as eczema, and viral skin infections like herpes, varicella, or shingles. In addition, prolonged use of topical antibiotics is not recommended, since it can result in bacterial or fungal superinfection. Finally, mafenide should also be used with caution in clients with G6PD deficiency, as well as pulmonary or renal disease. Okay, when your client is prescribed a topical antibiotic to prevent or treat infection of a skin wound, first assess the affected area, making note of the presence of any drainage, odor, redness, warmth, swelling, or pain. Lastly, if your client’s surgical site incision is sutured or stapled, be sure to confirm that the edges of the incision are approximated. Now, if you are caring for a client with a surgical site incision, let their healthcare provider. them know that their medication can help to prevent or treat local infection. When teaching about care of their incision site at home, remind EXERCISE them to avoid immersing the wound in water until it has completely healed; instead, instruct  administered, topical antifungals work by disrupting and damaging the fungal cell membranes, ultimately resulting in a fungistatic action, meaning that they stop fungal growth, or a fungicidal action, meaning they kill the fungi. As far as side effects go, topical administration of antifungals can cause the development of a skin rash, as well as itching, and burning of the skin area. Additionally, some clients may present with serious hypersensitivity reactions, such as Stevens- Johnson syndrome. Fortunately, there are no major contraindications for the use of topical antifungals. Alright, when caring for a client that is prescribed a topical antifungal medication like ketoconazole, first assess the affected skin area, making note of the presence of moist, red patches, papules, pustules, and discharge, as well as itching, burning, and pain. Then, review recent laboratory test results, including results from skin scrapings. Next, be sure to teach your 1. Vasoconstriction, stinging client how the prescribed medication can help 2. Telangiectasia treat their cutaneous fungal infection. Remind them that the medication is for topical use only, and not for ophthalmic, oral, or vaginal use. Then, show them how to clean the affected area with mild soap and water, and then thoroughly dry by gently patting with a clean towel. Next, teach your client to wash their hands and apply the antifungal cream in a thin layer, exactly as directed. Lastly, instruct your client to wash their hands after application. In terms of side effects, teach your clients that the medication is not absorbed into the body to a significant degree, so there are few systemic side effects. Instead, let them know they might experience local skin irritation, burning, or rash at the application site, and prompt them to notify their healthcare provider if these side effects increase or if the infection worsens despite treatment. Finally, when caring for a client that’s been prescribed a topical antifungal medication, be sure to monitor for potential 3. Hypercortisolism, hyperglycemia side effects, assess their understanding of the medication and how to apply it, and evaluate the therapeutic effect of the medication, ANTIFUNGAL- TOPICAL: NURSING including resolution of the skin infection. Alright, PHARMACOLOGY as a quick recap… Topical antifungals are used to treat fungal infections involving the skin, hair, Topical antifungals are medications used to or nails. These medications work by disrupting treat cutaneous fungal infections, which are and damaging the fungal cell membranes, conditions that affect the skin, hair, and nails, ultimately resulting in a fungistatic or fungicidal and can be caused by a variety of fungi, such as action. Side effects are usually limited to local Candida albicans or dermatophytes. The most reactions, such as skin irritation, burning, rash, commonly used topical antifungals include or swelling. When caring for a client that is nystatin, tavaborole, ciclopirox, and azoles like prescribed a topical antifungal medication, ketoconazole, miconazole, econazole, and nursing considerations include assessing the efinaconazole. These medications are applied affected skin area, as well as monitoring for side topically on the affected skin, in the form of effects and the resolution of the infection. ointments, creams, gels, or foams. Once  Corticosteroids, also commonly known as steroids, are a group of anti-inflammatory Finally, client teaching is focused on correct medications used to treat a variety of application of the medication, and learning to conditions in almost all healthcare fields! In this recognize side effects they may experience, and video, we’re going to focus on topical when to notify their healthcare provider. corticosteroids used for dermatological conditions, including psoriasis, eczematous rashes, lichen sclerosus, bullous pemphigoid, and pemphigus foliaceus. They can also be used to relieve the symptoms of urticaria or pruritic lesions, such as those caused by allergic reactions, insect bites, or poison ivy. Alright, now topical corticosteroids can be classified according to their potency into low, intermediate, or high potency. Low potency corticosteroids include hydrocortisone; while intermediate potency corticosteroids include triamcinolone and certain betamethasone formulations; and finally, high potency corticosteroids include stronger betamethasone formulations and clobetasol. Most of the topical corticosteroids are available in different formulations, including ointments, creams, gels, or lotions. Once applied to the skin, topical corticosteroids reduce inflammation locally by acting on glucocorticoid receptors of skin cells and white blood cells, ultimately decreasing their production of inflammatory mediator molecules, such as prostaglandins and leukotrienes, as well as increasing their EXERCISE production of anti-inflammatory molecules. In addition, topical corticosteroids cause local vasoconstriction of cutaneous blood vessels, which also helps reduce inflammation. Common side effects of topical corticosteroids include stinging, itching, and skin irritation with the first few applications. Over time, they may lead to impaired wound healing and collagen formation, as well as skin atrophy, stretch marks, telangiectasia, and easy bruising. Prolonged use can also cause facial dermatoses like acne, rosacea, and perioral dermatitis. Additionally, they can increase the risk of developing skin infections, as well as alter the appearance of previously existing ones. If corticosteroid therapy is suddenly discontinued, clients may experience a rebound flare of their condition. Finally, a rare but potentially serious side effect of topical corticosteroids, especially high potency ones, is systemic absorption, which can cause symptoms of hypercortisolism, such as acne, mood changes, muscle weakness, weight gain, and hyperglycemia; and may even cause suppression of the hypothalamic-pituitary- adrenal axis. Precautions for topical corticosteroids include untreated bacterial, viral, or fungal skin infections, as well as active facial dermatoses, like acne, rosacea, and perioral dermatitis. Now, if your client is prescribed a COSTICOSTEROIDS topical corticosteroid, start by performing a baseline assessment of the affected skin. Before applying the medication, be sure that the skin area is free of any open blisters, cuts, or burns, as well as signs of an existing bacterial or fungal infection, like redness, swelling, or pus. Next, teach your client to apply the cream or ointment to the affected skin area exactly as directed. Let them know that the medication can cause side effects like burning, itching, dryness, or irritation. Remind them to avoid direct sunlight on the affected area, since the medication can make the skin more prone to sunburn. Then, stress the importance of reporting signs that their medication is being absorbed systemically, such as weight gain, mood changes, muscle weakness, or new acne. Finally, advise them to contact their healthcare provider if the affected area worsens or does not improve with treatment. Okay, when you’re applying a topical corticosteroid, remember to wear clean gloves to protect your own skin from the medication. Use a gloved finger, tongue DEBRIDEMENT AGENTS: NURSING blade, or cotton-tipped applicator, being careful PHARMACOLOGY to avoid the client’s eyes and mucous membranes. After application, leave the skin Debridement agents are a group of medications area either uncovered or just lightly covered, to that are used to remove debris or dead tissue decrease the risk of systemic absorption. During from a burn, ulcer, or wound, which helps treatment, monitor for any side effects of the promote healing and decrease the risk of medication. If your client develops signs or infection. Some commonly used debridement symptoms of an infection, such as an agents include collagenase, and a combination unexplained fever, or if the affected area medication containing trypsin, balsam peru, and worsens, notify the healthcare provider right castor oil. These medications come in the form away. Finally, be sure to reassess your client’s of ointments that are applied topically on the skin for the desired therapeutic effect. Alright, skin. Once applied, collagenase is an enzyme as a quick recap … Topical corticosteroids are that acts by breaking down collagen in non- used to treat dermatological conditions, such as viable tissue, and helps in forming granulation psoriasis, eczematous rashes, lichen sclerosus, tissue, which contains healthy cells that fill up bullous pemphigoid, pemphigus foliaceus, and the dead tissue from the wound and fight off urticaria. These medications suppress the infections. Similarly, sutilain breaks down inflammatory response, so should not be used proteins of the intercellular matrix, which fills when there’s an untreated bacterial, viral, or the spaces between neighboring skin cells. This fungal infection. While caring for a client who is allows the cells of the outer skin layers to shed, prescribed a topical corticosteroid, nursing which is known as desquamation. Finally, considerations include applying the medication trypsin activates an enzyme called to intact skin using clean technique, as well as metalloproteinase, which breaks down the monitoring for side effects such as development intercellular matrix, making it easier for skin of infection or irritation at the application site, cells to slough off; while balsam peru stimulates and monitoring for the desired therapeutic blood flow to the wound area, as well as castor effect. Finally, client teaching is focused on how oil, which prevents the breakdown of healthy to apply the medication as directed, and to skin cells. Additionally, both balsam peru and report symptoms of systemic absorption or if castor oil help prevent wound infection by the affected area does not respond to inhibiting bacterial and fungal growth in the skin. treatment. Unfortunately, debridement agents may cause side effects, such as skin irritation, which can manifest as pain, erythema, as well as a burning, itching, or a tingling sensation. Luckily, there are no contraindications for the healing, as well as monitoring for improved use of debridement agents. If a client with a healing, and the absence of infection. necrotic wound is prescribed a debridement agent, first review their medical record for any health conditions that could affect healing, such as impaired mobility, impaired circulation to the wound site, deficient nutrition, or conditions like diabetes mellitus. Then, perform a baseline assessment of the affected area, noting the location, and size, measuring length, width, and depth of the wound, and the amount of necrotic tissue. Next, assess for signs of local infection, including redness, swelling, warmth, pain, drainage, or foul odor, and be sure there is a clear line of demarcation between the necrotic tissue and healthy tissue. Lastly, review their latest laboratory test results, including CBC, serum albumin, hemoglobin, and hematocrit; if your client has diabetes mellitus, be sure to EXERCISE check their blood glucose and HbA1C. Now, before applying the debridement agent, explain to your client how the medication will remove dead tissue from their wound, which will ultimately help with healing and prevent infection. Let them know that they may feel a tingling or burning sensation. Then, clean the wound bed with normal saline, apply the debridement agent as directed, and dress the wound to absorb any exudate that’s produced. Throughout treatment, reapply the debridement agent as directed, and change the wound dressing as needed. Promote healing by providing proper nutrition and helping your client maintain normal glucose levels. Continue to monitor your client for side effects, as well as for the therapeutic effect, evaluating for signs of improved healing, including a wound bed that is clear of necrotic tissue and debris, and free of infection. Alright, as a quick recap … Debridement agents are medications used to remove debris and dead tissue from a burn, ulcer, or wound, which helps promote healing and decrease the risk of infection. Debridement agents are applied topically, and include collagenase, and a combination medication containing trypsin, balsam peru, and castor oil. Collagenase is an enzyme that is applied to break down collagen in non-viable tissue, and helps in forming granulation tissue. On the other hand, trypsin works by activating the enzyme metalloproteinase, which helps skin cells to slough off, while balsam peru stimulates blood flow to the wound area, and castor oil prevents the breakdown of healthy skin cells. Side effects of debridement agents include pain, erythema, burning, tingling, or itching. Nursing considerations include performing a baseline assessment of the affected area and identifying conditions that can interfere with wound  confirm a negative pregnancy test before administering the medication. Next, teach your client that they should always wear gloves when they are applying their topically prescribed medication, and they should always wash their hands afterwards. Stress the importance of applying their medication to the affected area only, and to avoid mucous membranes, like the KERATOLYTICS: NURSING PHARMACOLOGY eyes and nose. Let your client know that they Keratolytics are a group of medications used to may experience blistering, burning, stinging, treat rough or scaly skin, which can be caused itching, and redness, as well as dry and peeling by a variety of skin conditions, such as mild to skin after application, and advise them to avoid moderate acne, seborrheic keratosis, warts, scratching or touching the affected area during dandruff, psoriasis, and skin hyperpigmentation treatment. Then, instruct them to wash their as a result of other conditions like eczema. Now, skin gently twice a day with a mild cleanser, and commonly used keratolytics include salicylic avoid the use of harsh soaps or chemicals. If acid, pyrithione zinc, coal tar, retinoids like your client is being treated with a retinoid or an tretinoin and acitretin, and alpha-hydroxy acids, alpha-hydroxy acid, be sure to let them know like glycolic and lactic acid. These medications that these medications can increase the risk of a are applied topically on the skin, while retinoids sunburn, so instruct them to avoid sunlight as can also be taken orally. Once administered, much as possible, and to wear protective keratolytics primarily work by softening and clothing along with sunscreen while outside. shedding of the stratum corneum, which is the Lastly, let them know that it may take 2 to 3 outer layer of the skin, decreasing the skin’s weeks before they start seeing any changes in thickness and improving its moisture. their skin. Finally, monitor your client for any Unfortunately, this shedding of the stratum side effects they may experience, as well as the corneum may result in side effects, such as skin therapeutic effects of the medication, such as a irritation, which can manifest as erythema, as decrease in the size and number of lesions. well as a burning, itching or tingling sensation. Alright, as a quick recap …. Keratolytics are a In addition, retinoids often cause dry eyes and group of medications that treat skin conditions mouth, chapped lips, and skin peeling. Finally, that cause rough or scaly skin such as acne, retinoids and alpha-hydroxy acids cause seborrheic keratosis, warts, dandruff, psoriasis, photosensitivity, so clients must avoid exposure and eczema. These medications work by to sunlight. As far as contraindications go, softening and shedding the outer layer of the keratolytics should not be used on open skin, which decreases the skin’s thickness and wounds or any areas of burnt, cut, irritated or improves its moisture. Nursing considerations scraped skin. In addition, sensitive areas such as include performing a skin assessment, providing near the eyes or mouth should also be avoided. client teaching about correct application of the Acitretin has an important boxed warning for medication topically, as well as side effects they hepatotoxicity. Finally, retinoids have a very may experience, and monitoring them for important boxed warning for pregnancy. Now, therapeutic effects of the medication. when your client is prescribed a keratolytic, first ask them about the onset and duration of their symptoms. Then, assess the affected area of skin, making note of its type and location, as well as the presence of drainage. In addition, be sure to assess the affected skin for open areas, as well as problems like burns, cuts, and irritated or scraped skin. Lastly, if a female client is prescribed a retinoid, be sure to  understood, there are a few main factors that are known to contribute to acne formation. These include keratin plugs that block the opening of the hair follicle; increased sebum released by sebaceous glands, which sometimes occurs in response to increased androgen production during puberty; and overgrowth of bacteria like Cutibacterium acnes that trigger local inflammation. Acne vulgaris can be categorized into different types based on specific characteristics. Mild acne usually consists of comedones, while moderate acne usually consists of pustules, and severe acne usually consists of cysts and nodules. Depending on the severity and location of acne, there are various medications that can be used to treat EXERCISE acne. These include topical medications, such as keratolytics like salicylic acid, azelaic acid, and benzoyl peroxide, vitamin A derivatives like tretinoin and adapalene, and topical antibiotics like erythromycin or clindamycin; as well as systemic medications, such as oral antibiotics like the tetracyclines tetracycline and doxycycline, oral retinoids like isotretinoin, and hormonal agents like spironolactone or oral contraceptives containing a combination of estrogen and progestin. Okay, now let’s dive deeper into the different classes of medications, starting with topical agents. Keratolytics include salicylic acid, azelaic acid, and benzoyl peroxide, and once administered, they primarily work by softening and shedding the stratum corneum, which is the outer layer of the skin. As a result, keratolytics help decrease the skin’s thickness and improve its moisture. Next, vitamin A derivatives include tretinoin and adapalene, and they work by blunting the inflammatory process, modulating keratinization, and ultimately helping to eliminate comedones. Lastly, the most commonly used topical antibiotic for acne is erythromycin, which works by limiting bacterial growth and proliferation and thus, reducing inflammation. Now, let’s switch gears to systemic medications to treat acne. The most commonly used oral antibiotics include tetracycline and doxycycline, which also act by limiting bacterial growth and proliferation. On MEDICATIONS FOR ACNE VULGARIS: NURSING the other hand, oral retinoids, like isotretinoin, PHARMACOLOGY have multiple effects. They can decrease sebum formation and secretion, blunt inflammation, Acne vulgaris is a common skin disorder and they also have keratolytic effects. Finally, characterized by raised, red bumps that occur oral contraceptives, such as ethinylestradiol when hair follicles get clogged by particles like with levonorgestrel, can be used to treat acne dead skin cells or oil, and it primarily occurs on because they decrease androgen levels and the face, neck, chest, and back. Although the thus, they reduce sebum production. The bad exact cause of acne is not completely news is that these medications can cause side effects. Topical medications can cause local skin alcohol as well as any supplements containing irritation, which can manifest as erythema, as vitamin A during treatment. Lastly, instruct well as a burning, itching, tingling sensation, them to wash their skin gently twice a day with and photosensitivity. On the other hand, a mild cleanser, and avoid the use of harsh systemic medications can also lead to more soaps or chemicals. Then, inform your client widespread side effects, such as gastrointestinal about some of the side effects they could disturbances like nausea, vomiting, and experience during treatment. If they experience diarrhea. Clients may also present with dry eyes or contact lens discomfort, advise headaches, dizziness, conjunctivitis, epistaxis, them that lubricating eye drops can be helpful. and hirsutism. In addition, these systemic Additionally, explain that the medication can medications can cause photosensitivity and affect their ability to see in the dark, so advise hepatotoxicity. Tetracyclines can also them to avoid driving at night and to take accumulate in the bones, affecting bone growth precautions when it is dark. Also let them know in children under the age of 8. Oral retinoids that because the medication can cause often cause dry eyes and mouth, chapped lips, photosensitivity, they should avoid sunlight as and skin peeling; they can cause increased much as possible and wear protective clothing triglycerides, increase blood glucose levels, along with sunscreen when spending time cause visual changes, and increase the risk of outside. Now, if your client is a diabetic, advise depression; they are also highly teratogenic. them to check their blood glucose levels more Finally, oral contraceptives can lead to often during treatment, and to monitor formation of clots. As far as contraindications themselves for symptoms of hyperglycemia like go, these medications should be avoided before increased thirst and hunger, along with passing or after sun exposure or sunburn. These a lot of urine. Then, encourage your client to medications are also contraindicated during recognize and report symptoms of altered pregnancy and breastfeeding, which is a boxed mood and behavior, including anxiety, warning for systemic retinoids! Additionally, depression or thoughts of self-harm; symptoms tetracyclines are contraindicated for children of liver impairment, such as fatigue, anorexia, younger than 8 years old. Finally, these nausea, dark urine, or yellowing of their eyes or medications should be used with caution in skin; or problems with hearing which could clients with hepatic or renal disease. Okay, if manifest as tinnitus or a decrease in their your client with severe acne vulgaris is hearing acuity. Lastly, advise your client to avoid prescribed an oral retinoid like isotretinoin, first any procedures like skin resurfacing treatments perform a baseline assessment of the affected during therapy and for 6 months afterwards, area, making note of the acne lesion since isotretinoin can increase the risk of characteristics, including type and location. developing scars from these treatments. Finally, Then, review their most recent laboratory test while your client is taking an oral retinoid like results, including CBC, blood glucose, renal and isotretinoin, continue to monitor your client’s hepatic function, and lipid panel. Finally, before hepatic function, lipid panel, as well as monthly any client assigned female at birth who is able pregnancy status. If your client is a diabetic, to become pregnant can receive the medication, keep a close eye on their blood glucose level. confirm two negative pregnancy tests, ensure Additionally, monitor for any side effects they they have been registered with the iPLEDGE may experience, as well as for the therapeutic program, and confirm informed consent has effects of the medication, such as a decrease in been obtained. Answer any questions they have the size and number of lesions. Alright, as a about the iPLEDGE program, and reinforce key quick recap …. Acne vulgaris is a common skin information, including the need to use two disorder characterized by comedones, pustules, reliable forms of birth control; to obtain a cysts, and nodules that occur when hair follicles negative pregnancy test before each medication get clogged by particles like dead skin cells or oil. refill; and to let their healthcare provider know Depending on the severity and location of the right away if they become pregnant. Next, acne, there are various medications that can be explain how the medication will help to treat used to treat it, including topical medications their acne; but let them know that the lesions like keratolytics, vitamin A derivatives, and may get worse during the first few weeks of antibiotics; as well systemic medications like treatment, and that it can take 4 to 6 months oral antibiotics, retinoids, and hormones. for their acne to fully resolve. Then, instruct Topical medications can cause photosensitivity them to take their medication two times each and local skin irritation, which can manifest as day with food and a full glass of water. Be sure erythema, as well as a burning, itching, tingling to remind them to maintain a well-balanced sensation. On the other hand, systemic diet, and stress the importance of avoiding medications can lead to gastrointestinal disturbances, headaches, photosensitivity, and hepatotoxicity. Acne medications should be avoided during pregnancy and breastfeeding. When caring for clients who are prescribed a medication to treat acne, nursing considerations include performing a baseline assessment, monitoring for side effects, and evaluating for the therapeutic response. Client teaching is focused on safe self-administration, as well as learning about side effects that should be reported. EXERCISE LESSON 10 ACETYLCHOLINESTERASE INHIBITORS FOR MYASTHENIA GRAVIS: NURSING PHARMACOLGY Myasthenia gravis is an autoimmune disorder caused by antibodies that bind to and destroy acetylcholine receptors on the surface of prescribed an acetylcholinesterase inhibitor like skeletal muscle cells, resulting in fatigue and neostigmine, first, perform a baseline muscle weakness due to impaired muscle assessment, including vital signs and their contractions. Although there’s no cure, certain current symptoms, including fatigue, eyelid medications, called acetylcholinesterase drooping, vision problems, peripheral muscle inhibitors, can be used to help mitigate some of weakness, as well as any difficulty breathing or the symptoms and improve the client’s quality swallowing. Next, review their most recent of life. Now, the most commonly used laboratory test results, specifically renal and acetylcholinesterase inhibitors for myasthenia liver function; and diagnostic test results, gravis are neostigmine and pyridostigmine. including electromyography, or EMG, Tensilon These medications can be administered orally, test, and pulmonary function tests. Next, intravenously, or intramuscularly, while explain to your client how the medication will neostigmine can be also given subcutaneously help improve their muscle strength and to children. Once absorbed into the decrease their fatigue. Instruct them to take bloodstream, acetylcholinesterase inhibitors their medication three times daily on an empty travel to the skeletal muscles and inhibit the stomach, either 1 hour before or 2 hours after a enzyme acetylcholinesterase, which normally meal. For maximum medication effect, stress breaks down the neurotransmitter the importance of taking their medication acetylcholine. As a result, these medications consistently, on a regular schedule. Encourage cause acetylcholine to build up in the synaptic your client to keep a record of when they take cleft, causing its cholinergic effects to be their medication, as well as their symptoms increased and prolonged. This helps counteract before and after administration. Also, be sure the effect of acetylcholine receptor antibodies, your client can recognize if the prescribed dose and ultimately results in improved muscle is insufficient to control their symptoms, which strength and contraction. However, increased could result in a myasthenic crisis. If their acetylcholine levels can also cause cholinergic symptoms don’t improve or get worse, prompt side effects, such as miosis, blurred vision, your client to notify their healthcare provider so headaches, dizziness, and drowsiness. At the dosage adjustments can be individualized. Then, same time, in the airways, acetylcholine triggers teach your client how to recognize symptoms of bronchoconstriction and increases bronchial excessive cholinergic stimulation that can lead secretions, which can lead to dyspnea and a to a cholinergic crisis, including diaphoresis, persistent cough. In the cardiovascular system, diarrhea, urinary urgency, bradycardia, acetylcholine reduces blood pressure and slows bronchospasm, cough, or dyspnea, as well as down the heart rate, which can result in excessive lacrimation and salivation. Stress the hypotension, bradycardia, heart block, and even importance of immediately seeking medical cardiac arrest. In the gastrointestinal tract, attention if they experience these symptoms. In these medications can cause increased motility addition, prompt your client to seek medical and secretions, leading to increased salivation, attention immediately should they experience nausea, vomiting, cramps, diarrhea, and symptoms like extreme muscle weakness, as involuntary defecation; and in the urinary tract, well as difficulty speaking or breathing. Lastly, acetylcholine stimulates the bladder muscles teach your client to wear medical alert and sphincter relaxation, which may cause a identification at all times. Finally, during sense of urgency. Finally, excessive cholinergic treatment with an acetylcholinesterase inhibitor stimulation can lead to a cholinergic crisis, like neostigmine, be sure to monitor for the which can be managed with atropine. As far as development of side effects, especially signs contraindications go, acetylcholinesterase and symptoms of excessive cholinergic inhibitors should not be administered to clients stimulation. And lastly, evaluate for the desired with bradycardia, as well as in those with therapeutic effect of increased muscle strength, gastrointestinal or urinary obstruction. decreased fatigue, and improvement in their Acetylcholinesterase inhibitors should also be ability to perform activities of daily living. used with caution during pregnancy and Alright, as a quick recap… Myasthenia gravis is breastfeeding, as well as in clients with a history an autoimmune disorder that is caused by of seizures. Additional precautions should be destruction of acetylcholine receptors at the taken in clients with asthma or chronic neuromuscular junction, leading to fatigue and obstructive pulmonary disease, as well as in muscle weakness. To help relieve these those with cardiovascular disease like symptoms, clients with myasthenia gravis can arrhythmias, hyperthyroidism, and in clients be prescribed acetylcholinesterase inhibitors, with gastrointestinal disease like peptic ulcer. which are medications that make more Now, if a client with myasthenia gravis is acetylcholine available at the neuromuscular junction. Potential side effects include cholinergic side effects, such as miosis, blurred vision, headaches, dizziness, and drowsiness; as well as effects in the respiratory, cardiac, and gastrointestinal systems; and excessive cholinergic stimulation, which can lead to a cholinergic crisis. When caring for a client prescribed an acetylcholinesterase inhibitor, nursing considerations include performing a baseline assessment, as well as monitoring for side effects and the desired therapeutic effects. Client teaching is focused on safe self- administration, as well as learning to recognize side effects, and when to notify the healthcare provider. ANALGESICS: NURSING PHARMACOLOGY Analgesics, also commonly known as painkillers, are medications primarily used to relieve pain, such as a headache, muscle and neuropathic pain, as well as pain related to trauma and fractures. Analgesics can be subdivided into two EXERCISE main groups: non-opioid analgesics, and opioid analgesics. Keep in mind though that there are a number of other medications that primarily serve other purposes, but can be used as analgesics. These medications include antidepressants like amitriptyline, anticonvulsants like gabapentin, and corticosteroids like dexamethasone, as well as local anesthetics like lidocaine. Now, let’s start with non-opioid analgesics, which include non- steroidal anti-inflammatory drugs or NSAIDs, and acetaminophen. NSAIDs inhibit the enzyme cyclooxygenase or COX, both in the central nervous system and peripheral tissues. Now, there are two types of COX enzymes. The first one is called COX-1, which is indirectly involved in platelet aggregation, production of protective mucus in the stomach and vasodilation of the renal vasculature. On the flip side, COX-2 is only active in inflammatory cells and vascular endothelium during inflammation, and is involved in the production of small pro- acetaminophen is preferred to treat fever or inflammatory compounds like prostaglandins. pain in clients with bleeding disorders, peptic Now, a very commonly used NSAID is ulcers and individuals allergic to aspirin. Also, acetylsalicylic acid, often referred to as aspirin, it’s the first-line therapy for children with fever which is taken orally. On the other hand, non- or pain, especially when it’s associated with a aspirin NSAIDs can be further classified as non- viral infection. selective COX inhibitors that act on both COX-1 and COX-2, like ibuprofen, naproxen and ketorolac; and selective COX-2 inhibitors, like Now, oral acetaminophen is metabolized in the celecoxib. Non-aspirin NSAIDs are most often liver, so it can precipitate acute liver failure in administered orally, but some can also be given some clients and intravenous acetaminophen intramuscularly, intravenously, topically, or poses an increased risk for medication errors rectally. Now the most important side effects of and overdose. An important boxed warning is to NSAIDs include gastrointestinal problems, such limit acetaminophen from all sources, including as gastritis, gastric ulcers, or even bleeding, and cold medicines, to no more than 4 grams/day. that’s a boxed warning! Additionally, chronic Early symptoms of acetaminophen overdose use of NSAIDs can impair normal blood flow in include nausea, vomiting, and abdominal pain; the kidneys and may increase the risk of while late symptoms include jaundice, hyperkalemia, nephropathy, or renal failure. It’s coagulopathy, hepatic encephalopathy, and important to note that these side effects are even renal failure. Acetaminophen is less frequent with selective COX-2 inhibitors. contraindicated in clients with hepatic disease. Other side effects that can occur in clients Now, switching gears, opioid analgesics are taking NSAIDs include headache, drowsiness primarily administered orally, intravenously, and dizziness, as well as severe hypersensitivity intramuscularly, or subcutaneously. Other reactions, such as anaphylaxis and Stevens- routes of administration include transdermal, Johnson Syndrome. NSAIDs should not be used epidural, intrathecal, and topical. These during the third trimester of pregnancy, as well medications primarily work by activating opioid as in clients with renal or hepatic impairment. receptors mu, delta, and kappa in the brain. Also, NSAIDs should be avoided in individuals Now, based on the effect on opioid receptors, who have experienced allergic reactions to one opioid analgesics are subdivided into three main NSAID because they can experience the same groups. The first group covers full agonists and reaction when taking other NSAIDs, due to it includes morphine, methadone, meperidine, cross-hypersensitivity. NSAIDs also have a codeine, oxycodone, and fentanyl; while the boxed warning in the setting of coronary artery second group includes partial agonists, such as bypass graft, due to the increased risk of tramadol. Finally, the third group includes adverse thrombotic events leading to mixed agonist-antagonists, such as myocardial infarction or stroke. A specific buprenorphine, which has an agonist effect on contraindication for aspirin is children with viral kappa opioid receptors, and a weak antagonist infections, as it is associated with Reye effect on mu receptors. Common side effects syndrome, which is characterized by liver include sedation, nausea, vomiting, constipation, damage and progressive hepatic as well as urinary retention, which is typically encephalopathy. The only exception is the seen in older clients. Also, analgesic opioids can treatment of children with Kawasaki disease, decrease blood pressure or cause orthostatic which is a condition associated with hypotension. An important thing to keep in inflammation of blood vessels. Lastly, ketorolac mind is that opioids have a number of boxed has a few boxed warnings; it is contraindicated warnings, including respiratory depression, for children, while for adults, it indicated for severe sedation, coma, and death. In addition, only short term use, no longer than 5 days, and using opioids during pregnancy can result in clients older than 65 require dosage adjustment; neonatal opioid withdrawal syndrome. Finally, a ketorolac is also contraindicated in clients with very important boxed warning is that clients can renal disease, cerebrovascular bleeding, and a develop dependence and addiction to opioids, history of peptic ulcers; and finally, it is leading to abuse and misuse. Contraindications contraindicated during labor. Moving on, to opioid analgesics include respiratory acetaminophen is often referred to as depression, head trauma, increased intracranial paracetamol, and can be administered orally, pressure, and clients in a coma. It’s important to rectally or intravenously. This medication is not note that opioid analgesics should not be used classified as an NSAID because it reversibly in combination with other CNS depressants like inhibits COX enzymes only in the central alcohol, barbiturates, or benzodiazepines, since nervous system. For that reason, their additive effect can lead to respiratory depression, coma, and even death. Now, when the medication, assess your client’s baseline caring for a client who’s experiencing pain, you level of consciousness and vital signs, paying can choose to administer the appropriate close attention to their respiratory rate and analgesics prescribed based on your nursing blood pressure. If your client’s respiratory rate pain assessment. So, before administering an is lower than 12 breaths per minute, or their analgesic medication, be sure to thoroughly blood pressure is significantly lower than their assess your client’s pain, including the type of pretreatment reading, hold the medication and pain, along with its onset, quality, location, contact the healthcare provider right away. severity, and duration. Then, collaborate with After administration, continue to monitor their your client to establish their goal for pain vital signs and level of sedation. In addition, let management and their tolerable level of pain. the healthcare provider know right away if you Also be sure to document their baseline vital detect respiratory depression or if your client is signs. Always review their medical record to not easily arousable with verbal or physical confirm there are no medical conditions that stimulation. Also monitor closely for side effects will require close monitoring, as well as current like constipation and urinary retention, and take medications that could interact with the measures to keep your client safe from falls. analgesics. Lastly, incorporate non- Assist your client to turn in bed, cough, and pharmacological interventions for pain, such as deep breathe at regular intervals while awake relaxation, guided imagery and distraction, to decrease accumulation of respiratory whenever possible. Okay, if your client has mild secretions. Lastly, be sure to have an opioid pain, a non-opioid analgesic, such as an NSAID antagonist like naloxone readily available in the or acetaminophen, could be administered. event of over-sedation or respiratory Before administering an NSAID like ibuprofen, depression. Now, if your client is discharged be sure to check their laboratory tests, including home on an opioid medication, advise them to CBC, BUN and creatinine. Also confirm that your take the medication exactly as prescribed, and client does not have a history of peptic ulcer warn them that sedation is a common side disease. Then, administer the medication with effect, so they should use caution when meals or a glass of milk to help limit engaging in activities that require alertness and gastrointestinal upset. After administration, concentration, like driving. Also be sure to assess for side effects like headache, dizziness, stress the importance of avoiding alcohol while or epigastric pain, and continue to monitor their taking this medication. Explain that the renal function, especially if you are caring for an hypotensive effects of opioids can be minimized elderly client. If your client will be discharged by making position changes slowly; advise them home on ibuprofen, advise them to avoid to sit or lie down if they feel dizzy. Next, remind drinking alcohol while taking the medication, them to increase their daily intake of fiber and since it can increase the risk of gastrointestinal fluids to avoid constipation. Lastly, explain how irritation. Lastly, advise them to report any opioids can decrease their awareness of a full symptoms of persistent gastric distress. On the bladder, and advise them to to empty their other hand, before administering bladder at least every 4 hours to avoid urinary acetaminophen, pay close attention to your retention. Finally, after administering any client’s baseline liver function. If your client is analgesic medication, remember to reassess discharged home on acetaminophen, let them your client’s pain level and therapeutic outcome, know that they can take their medication with and contact the healthcare provider if the or without food. Then, caution them to avoid prescribed pain management regimen is not drinking alcohol when taking acetaminophen, adequately managing your client’s pain. Alright, and be sure to stress the importance of taking as a quick recap… Analgesics are medications their medication as directed; this includes primarily used to relieve pain, and include non- reminding them to avoid taking more than 4 opioid medications, like NSAIDs and grams of acetaminophen in a 24-hour period acetaminophen, and opioid medications. from all sources, including other over the NSAIDs are the medication of choice for mild to counter medications like cold medicines. Lastly, moderate pain. They are contraindicated in prompt them to contact their healthcare clients with renal impairment or gastric ulcers, provider if they develop side effects like nausea, in children under six months of age, in clients vomiting and abdominal pain, which could be with an active source of bleeding, or during the early signs of liver damage. Alright, when your third trimester of pregnancy. On the other hand, client has moderate to severe pain, an opioid acetaminophen is typically used for mild to analgesic like morphine or tramadol can be moderate non-inflammatory pain like administered, either by itself or combined with headaches. Acetaminophen can be toxic to the a non-opioid analgesic. Before administering liver, so clients are advised to limit acetaminophen from all sources, including cold medicines, to no more than 4 grams per day. Finally, opioid analgesics are preferred for moderate to severe pain. Major side effects of opioids include respiratory depression, sedation, constipation, and urinary retention; and naloxone should be readily available to reverse severe side effects. When caring for clients receiving analgesics for pain management, nursing considerations include conducting a thorough pain assessment, reassessment for effectiveness of the prescribed pain management regimen, and monitoring for side effects as well as the therapeutic outcome. Client teaching centers around non- pharmacological methods of managing pain, safe self-administration, and side effects that should be reported to their healthcare provider. EXERCISE  muscle relaxants, such as benzodiazepines, but they’re most commonly used as anxiolytics, sedatives, or anticonvulsants. On the other hand, direct-acting muscle relaxants include dantrolene. All of these medications can be taken orally. Additionally, methocarbamol can also be administered intravenously or intramuscularly, while dantrolene can be given intravenously, and baclofen can be given intrathecally. Once administered, centrally-acting muscle relaxants act on the neurons of the central nervous system or CNS to interfere with muscle reflexes and decrease the skeletal muscle tone. Although the exact mechanism by which they act is poorly understood, the site of action of some of these medications is known. Cyclobenzaprine and methocarbamol primarily act on the brainstem and the spinal cord neurons. Carisoprodol and chlorzoxazone block the nerve conduction in the descending reticular formation in the brain, which is responsible for maintaining muscle tone and posture. Tizanidine acts by stimulating alpha-2 adrenergic receptors on the presynaptic neurons in the CNS, which decreases the release of norepinephrine in the sympathetic neurons. Baclofen activates GABAB, receptors in the spinal cord to reinforce the action of GABA, which is an inhibitory neurotransmitter, and decreases the release of the excitatory neurotransmitter, glutamic acid. Finally, orphenadrine acts by blocking the muscarinic SKELETAL MUSCLE RELAXANTS: NURSING receptors as well as NMDA receptors in the CNS, PHARMACOLOGY which interferes with the transmission of nerve Skeletal muscle relaxants are medications that impulses from the spinal cord to the muscles. reduce muscle contraction, so they are primarily On the other hand, the direct-acting muscle used to relieve both acute or chronic muscle relaxant, dantrolene, enters skeletal muscle spasms and spasticity. Muscle spasms are cells and prevents the release of calcium ions sudden and involuntary muscle tightness or from the sarcoplasmic reticulum. Due to its contractions, and are most often caused by action, dantrolene has a special use in the muscle fatigue or injury. On the other hand, treatment of malignant hyperthermia, which is muscle spasticity is a sustained muscle spasm caused by certain inhaled anesthetics and associated with decreased dexterity that succinylcholine in genetically susceptible originates from the central nervous system, individuals. That leads to a massive release of which can occur due to damage to the nerves calcium from the sarcoplasmic reticulum, that coordinate muscle activity, and can also be causing excessive muscle rigidity and seen with chronic neurological disorders, such hyperthermia. The general side effects of as multiple sclerosis and stroke; as well as in skeletal muscle relaxants are caused by CNS cerebral palsy and spinal cord damage. Now, depression, and include drowsiness, dizziness, skeletal muscle relaxants can further be divided headaches, and weakness. There may also be into centrally-acting and direct-acting muscle gastrointestinal effects, including anorexia, relaxants. Centrally-acting muscle relaxants nausea, vomiting, and constipation. Additionally, include cyclobenzaprine, methocarbamol, depression of other reflex pathways can lead to metaxalone, chlorzoxazone, tizanidine, baclofen, hypotension and arrhythmias. In the renal carisoprodol, and orphenadrine. Other system, there may be urinary frequency and medications can also act as centrally-acting urgency. Regarding specific side effects, orphenadrine and cyclobenzaprine cause medication as directed with a glass of water, anticholinergic side effects, such as dry mouth, but if this upsets their stomach they can take it blurred vision, tachycardia, urinary retention, with food or milk. Next, talk to them about and constipation. Additionally, cyclobenzaprine possible side effects they could experience and can cause visual hallucinations. how to manage them. If they experience drowsiness, caution them to avoid activities that require alertness, such as driving, until they On the other hand, baclofen can cause know how the medication affects them; and hyporeflexia, hypothermia, and bradycardia. In remind them to avoid alcohol and medicines addition, long-term use of baclofen and like cough or cold treatment during treatment, carisoprodol can lead to tolerance, and since these can increase drowsiness. If they therefore require an increased dose to achieve experience dizziness, advise them to change the original response. Moreover, these result in positions slowly to avoid injury from falls. And if dependence, causing withdrawal symptoms a dry mouth becomes bothersome, suggest they when discontinued abruptly. Next, use sugar-free chewing gum or lozenges, or take chlorzoxazone produces a metabolite that is frequent sips of water. Additional side effects, excreted in the urine, giving it an orange or such as constipation and urinary retention can purplish-red color. Finally, high doses of be managed by increasing their consumption of dantrolene have a boxed warning for severe fiber and fluids, as well as emptying their hepatotoxicity. As far as contraindications and bladder regularly. Finally, teach your client to cautions, dantrolene is contraindicated in contact their healthcare provider if they clients with hepatic disease. On the other hand, experience symptoms of liver damage, such as skeletal muscle relaxants, especially metaxalone, nausea, fatigue, or anorexia; or symptoms of tizanidine and cyclobenzaprine, should be used cardiac arrhythmias, such as palpitations or a with caution in clients with severe hepatic or feeling of a fast heartbeat. Alright, if your client renal disease. Now, the effects of skeletal has chronic muscle spasticity from conditions muscle relaxants on pregnancy and like multiple sclerosis or spinal cord injury, they breastfeeding are not clear, but they should can receive baclofen directly into the generally be avoided as they can cross the intrathecal space inside the spinal canal through placenta and are also secreted into breast milk. an implanted pump. This is a small metal Moreover, they should also be used with canister that contains a reservoir for the caution for clients with a seizure disorder, medication, and is surgically implanted under which can get triggered by the depression and the skin in the lower abdomen. Attached to the imbalance of the neuronal activity in the brain pump is a catheter that delivers the medication caused by these medications; and heart disease into the intrathecal space. When caring for a because they can depress heart muscle activity. client with an intrathecal baclofen pump, be Finally, skeletal muscle relaxants should be sure to monitor them closely for infection at the avoided in clients taking CNS depressants such insertion site. Ensure they understand the as barbiturates, opioids, tricyclic warning signs of getting too much medication, antidepressants, and alcohol, as their such as increased drowsiness and low muscle depressant effect can add up, resulting in tone; or too little medication, such as a sudden respiratory depression, coma, or even death. return of spasticity, as well as auditory or visual Okay, if your client is prescribed a skeletal hallucinations, or other psychotic symptoms. muscle relaxant, be sure to perform a baseline Stress the need to visit their healthcare provider assessment, focused on pain and mobility of the regularly to ensure their equipment is in good affected muscles. Review any diagnostic test working order, as well as to receive medication results such as X-ray, CT or MRI, as well as refills so they won’t run out of it. Finally, while laboratory tests like baseline CBC, liver and caring for a client taking a skeletal muscle renal function tests. Then, explain how the relaxant, continue to monitor for side effects medication will help relieve muscle spasms and and for the therapeutic effect of decreased pain pain, and advise them to contact their and discomfort from spasticity. Alright, as a healthcare provider if their symptoms don’t quick recap …. Skeletal muscle relaxants are improve. Now, if your client has experienced a used to help relieve muscle spasms or spasticity. musculoskeletal injury, they could be prescribed Centrally-acting skeletal muscle relaxants work a central-acting muscle relaxant like by depressing neuron activity in the CNS, cyclobenzaprine. Explain that the medication whereas direct-acting skeletal muscle relaxants works best when combined with other prevent the release of calcium ions from muscle interventions, such as rest, heat, massage and cells. General side effects include CNS physical therapy. Instruct them to take the depression, headaches, hypotension and weakness. When caring for a client taking a skeletal muscle relaxant, nursing considerations center around client assessment, as well as continued monitoring for side effects and decreased pain and discomfort from spasticity. Client education includes how to safely self- administer their medication, and ways to minimize side effects like sedation, anticholinergic effects, constipation, urinary frequency or hesitancy. For clients receiving intrathecal baclofen, priority nursing considerations include monitoring the insertion site for infection, and providing education about ensuring their equipment is in good working order, and understanding symptoms caused by receiving either too much or too little medication. EXERCISE  avoided during pregnancy, as well as in clients with sinus bradycardia, heart block, and Adams- Stokes syndrome, which refers to a condition characterized by syncopal episodes caused by cardiac arrhythmias. The next group of sodium channel blockers covers iminostilbene derivatives, such as carbamazepine, which can be administered orally or intravenously. LESSON 11 ANTIEPILEPTICS: NURSING PHARMACOLOGY Important side effects include pancreatitis, Antiepileptics, also known as anticonvulsants, hepatotoxicity, and renal dysfunction which are medications primarily used to treat epilepsy, could result in fluid retention and hyponatremia, as well as generalized or partial seizures. On as well as cardiovascular side effects, such as rare occasions, these medications can be used hypertension and AV block. In addition, to treat mood disorders. Now, the most carbamazepine has boxed warnings for severe commonly used antiepileptics can be side effects, including Stevens-Johnson subdivided, based on their mechanism of action, syndrome, toxic epidermal necrolysis, and into four main groups: sodium channel blockers, DRESS, as well as bone marrow depression, calcium channel blockers, GABA inhibitors, and which can result in blood dyscrasias. Now, GABA analogues. In addition, other medications carbamazepine should not be administered can be used as antiepileptics, including within 14 days of monoamine oxidase inhibitors, barbiturates like phenobarbital and or concomitantly with non-nucleoside reverse benzodiazepines like diazepam, which are transcriptase inhibitors that are CYP3A4 primarily used as anxiolytics and sedative- substrates, such as nefazodone. Finally hypnotics. Now, let’s focus on sodium channel carbamazepine is contraindicated during blockers first. These medications work by pregnancy, and should be used with caution in blocking voltage-gated sodium channels, clients who are breastfeeding, as well as in eventually inhibiting excitatory neurons from those with alcoholism, cardiac, hepatic, or renal firing action potentials. Decreased activity of disease, and in children younger than 6 years of excitatory neurons results in the reduction and age. The next group includes valproate alleviation of seizures. Sodium channel blockers derivative forms, called valproic acid and include hydantoins, iminostilbene derivatives, sodium valproate, which can be administered valproate derivatives, and lamotrigine. First, orally and intravenously. Now, in addition to let’s focus on hydantoins. These medications working as sodium channel blockers, these include phenytoin, which can be administered medications can increase the concentration of orally or intravenously; and its prodrug, gamma-aminobutyric acid, or GABA for short, fosphenytoin, which can be administered which is one of the main inhibitory intravenously or intramuscularly. Common side neurotransmitters in the brain. Ultimately, this effects of these medications include headaches, results in decreased seizure activity. The most dizziness, visual disturbances, such as blurred common side effects are gastrointestinal vision, nystagmus, and diplopia, as well as problems, such as dyspepsia, nausea, vomiting, gingival hyperplasia. Some clients might diarrhea, and constipation. Some clients might experience hypersensitivity reactions like also experience hematologic side effects, like Stevens-Johnson syndrome and toxic epidermal thrombocytopenia and leukopenia; while others necrolysis, as well as drug reactions with can develop DRESS. In addition, valproate can eosinophilia and systemic symptoms or DRESS cause suicidal thoughts, as well as central for short. In addition, these medications can nervous system depression or even coma. cause hepatotoxicity, as well as impaired Finally, it’s important to note that valproate has metabolism of vitamin D, which can result in boxed warnings for pancreatitis and osteomalacia. Moreover, these medications can hepatotoxicity, as well as regarding fetal toxicity, impair the absorption of folic acid and vitamin since valproate may result in congenital B12; this can lead to hematologic side effects, malformations, especially neural tube defects. often referred to as blood dyscrasias, such as For that reason, valproate is contraindicated agranulocytosis, leukopenia, thrombocytopenia, during pregnancy. In addition, it should be and anemia. As a boxed warning, rapid IV avoided in clients with urea cycle disorders, administration can result in hypotension and mitochondrial disease, or hepatic disease. The cardiac arrhythmias. Finally, a very important last sodium channel blocker is lamotrigine, side effect is suicidal thoughts. As far as which is taken orally. The most common side contraindications go, phenytoin should be effects include headache, dizziness, and synaptic cleft, which helps control the seizure. dysmenorrhea. On rare occasions, lamotrigine The most common side effects associated with can also cause more severe side effects, such as vigabatrin include dizziness, gastrointestinal suicidal thoughts, and hematologic side effects, problems, weight gain, and edema. Additional including disseminated intravascular side effects include a decrease in hemoglobin coagulation, leukopenia, and thrombocytopenia. and hematocrit, as well as peripheral Also, lamotrigine has a boxed warning for neuropathy, usually involving the toes and feet. causing serious and potentially life-threatening skin rash, as well Stevens-Johnson syndrome and toxic epidermal necrolysis. Now, Vigabatrin can cause some life-threatening side lamotrigine must not be stopped abruptly, since effects, including suicidal thoughts, malignant clients may present with uncontrolled seizures. hyperthermia, respiratory depression, and even In addition, this medication should be used with pulmonary embolism. In addition, vigabatrin caution during pregnancy and breastfeeding, as has a boxed warning for visual impairment! well as in clients with severe depression, and in Regarding contraindications, this medication clients younger than 16 or elderly. Finally, should be used with caution during pregnancy precaution should be taken in clients with and breastfeeding, as well as in children cardiac disease, such as heart failure or younger than 2 years or elderly clients. Finally, conduction disorders like second or third precaution should be taken in clients with degree heart block, as well as in clients with hepatic or renal disease, as well as in those with hepatic or renal disease. The next group of a history of psychosis or depression. The last antiepileptics is calcium channel blockers. These group of antiepileptics are GABA analogues like medications work by blocking voltage-gated gabapentin, which can be administered orally. calcium channels, subsequently inhibiting Although the exact mechanism of action is excitatory neurons from firing action potentials, unclear, gabapentin is structurally similar to and ultimately decreasing seizure activity. First, GABA, so it may exert an inhibitory effect that let’s start with succinimides, more specifically ultimately helps control the seizure. ethosuximide, which is taken orally. The most Unfortunately, this inhibitory effect may cause common side effects include gastrointestinal side effects like depression, amnesia, problems, such as nausea, vomiting, and somnolence, and ataxia. Gabapentin may also diarrhea. Some clients might also complain of cause blurred vision, nystagmus, diplopia, and headaches, fatigue, and pruritus; while others dry mouth; as well as gastrointestinal side might even develop blood dyscrasias or effects like increased appetite, nausea, vomiting, hypersensitivity skin reactions like DRESS. and diarrhea or constipation. Finally, some Finally, these medications should be used with clients might experience cough, pruritus, caution during pregnancy and breastfeeding, as hypersensitivity reactions like DRESS, and may well as in clients with hepatic or renal disease. develop leukopenia. Important precautions Another important medication is levetiracetam, should be taken during pregnancy and which can be administered orally or breastfeeding, as well as in children younger intravenously. The exact mechanism of action of than 3 years old or elderly clients. In addition, levetiracetam is not fully understood, but it’s gabapentin should be used with caution in thought to act as a calcium channel blocker. clients experiencing suicidal thoughts, Important side effects associated with depression, and those with renal disease or levetiracetam include suicidal thoughts, undergoing hemodialysis. Now, before Stevens-Johnson syndrome, as well as toxic beginning antiepileptic therapy, review your epidermal necrolysis. Some clients can also client’s medical record to determine the type of develop hepatitis. Finally, this medication is seizures they experience, how often the contraindicated in clients who are breastfeeding, seizures occur, and how long the seizures and should be used with caution during typically last. In addition, check their history for pregnancy, as well as in pediatric or elderly conditions such as depression, and screen for clients, and those with cardiac, hepatic, or renal suicidal thoughts. Then, review the laboratory disease. The next group of antiepileptics are test results, such as CBC, as well as liver and GABA inhibitors. The most commonly used renal function tests. Next, for any client medication in this group is vigabatrin, which is prescribed phenytoin, carbamazepine, or taken orally. Once administered, vigabatrin acts lamotrigine, be sure to review recent diagnostic on presynaptic neurons by inhibiting the tests like ECG; and if your client is prescribed reuptake of GABA, which is an inhibitory vigabatrin, obtain a baseline vision test as well. neurotransmitter. As a result, there’s an For clients of child-bearing age, confirm a increased concentration of free GABA in the negative pregnancy test, and stress the importance of using reliable contraception burning or numbness in their toes or feet. while taking an antiepileptic medication. Lastly, Finally, be sure to closely monitor your client for advise them to wear medical identification to side effects by regularly monitoring your client’s assist diagnosis and treatment by emergency mental status, mood, and behavior, as well as personnel. Be sure to teach your client how CBC, liver, and renal function tests during antiepileptics will help control their seizures. treatment. Evaluate for therapeutic effects of a Stress the importance of taking the medication decrease in seizure frequency, severity, and exactly as prescribed and to never stop taking it duration. abruptly, as this can increase the risk of breakthrough seizures. Let them know that CNS depression can occur, so caution your client Alright, as a quick recap… Antiepileptics are against consuming other CNS depressant medications that are used to treat seizures. medications or alcohol; and advise them to There are four main classes of antiepileptics: avoid activities that require alertness, such as sodium channel blockers, calcium channel driving, until they adjust to the medication’s blockers, GABA inhibitors, and GABA analogues. effects. Next, teach your client about side Sodium channel blockers suppress action effects that should be reported to the potentials by blocking overactive voltage-gated healthcare provider immediately. Explain how sodium channels, while calcium channel anxiety, agitation, depression, or other changes blockers reduce seizure activity by blocking in their mood or behavior could indicate an voltage-gated calcium channels. GABA increased risk of suicidal behavior. And let them inhibitors inhibit the reuptake of GABA, an know that liver dysfunction could manifest as inhibitory neurotransmitter and thus increasing symptoms such as anorexia, nausea, vomiting, its availability in the synaptic cleft. And GABA and fatigue. Also be sure to describe signs of analogues are structurally similar to GABA. Side blood dyscrasias, such as fever, sore throat, effects of antiepileptics include central nervous pallor, weakness, petechiae, or easy bruising. system depression, hepatotoxicity, blood Lastly, prompt your client to keep a close eye on dyscrasias, and suicidal thoughts. Nursing any changes in their skin, especially if an considerations are focused on assessment unusual rash develops. Now, if your client is before administration, client education about prescribed phenytoin, teach them how to serious side effects, regular monitoring, as well recognize signs of gingival hyperplasia such as as evaluating the effectiveness of treatment. sore, swollen gums; and explain how performing daily dental hygiene, taking a folic acid supplement, and regular visits to the dentist can decrease the risk. Also explain how the risk of bone loss can be reduced by increasing dietary calcium and vitamin D as well as doing weight-bearing exercises as tolerated. Lastly, advise your client to report visual disturbances, such as blurred vision, nystagmus, or diplopia. If your client is prescribed carbamazepine, instruct them to avoid grapefruit or grapefruit juice in order to decrease the risk of carbamazepine toxicity. Also teach them to contact their healthcare provider right away if they notice symptoms of pancreatitis, such as upper abdominal pain, nausea and vomiting, or anorexia. In addition, instruct them to report symptoms of water retention and hyponatremia like swelling, weight gain, headache, muscle weakness, or cramps. Okay, if your client is prescribed vigabatrin, stress the importance of vision checks every 3 months during therapy, and instruct them to report any changes in their EXERCISE vision, such as blurred vision, difficulty controlling eye movements, or vision loss. In addition, teach your client to report symptoms of peripheral neuropathy, such as a feeling of MEDICATIONS FOR ALZHEIMER DISEASE: NURSING PHARMACOLOGY Alzheimer disease is the most common cause of there’s too much of a neurotransmitter called dementia, and although there’s no cure, certain glutamate, which binds to NMDA receptors and medications can be used to help mitigate some allows an excessive influx of calcium, ultimately of the symptoms and improve the client’s causing neuronal damage and cellular death. So, quality of life. Now, these medications can be NMDA receptor antagonists can limit the broadly divided into two classes; calcium influx and prevent neuronal damage. acetylcholinesterase inhibitors and NMDA Now, side effects commonly associated with receptor antagonists. Starting with NMDA receptor antagonists include drowsiness, acetylcholinesterase inhibitors, these include headache, and agitation. Other side effects rivastigmine, galantamine, and donepezil. include nausea, vomiting, and either Acetylcholinesterase inhibitors are taken orally, constipation or diarrhea. Finally, NMDA while rivastigmine can be taken in the form of a receptor antagonists should be used with transdermal patch as well as orally. Once caution in pregnant or breastfeeding clients, as absorbed into the bloodstream, they travel to well as those with epilepsy or a history of the brain. Here, they inhibit the enzyme seizures and severe hepatic or renal impairment. acetylcholinesterase, which normally breaks Okay, before administering either an down the neurotransmitter acetylcholine. As a acetylcholinesterase inhibitor or a NMDA result, acetylcholine builds up in the synaptic receptor antagonist, first perform a baseline cleft, causing increased and prolonged effects. assessment that includes weight, vital signs, And since there's some evidence suggesting hepatic and renal function, as well as cardiac that Alzheimer disease is related to low levels of and respiratory function. Also assess cognitive acetylcholine in the brain, acetylcholinesterase and behavioral functions such as memory, inhibitors can help improve symptoms. reasoning, mood and ability to perform However, increased acetylcholine levels can activities of daily living. Moving onto client also cause cholinergic side effects like miosis, education. Start by teaching your client why the blurred vision, headaches, dizziness, and medication is prescribed and how it will help drowsiness. At the same time, in the airways, slow the progression of their disease; stress the acetylcholine triggers bronchoconstriction and importance of taking their medication as increases bronchial secretions, which can directed and to not stop taking it abruptly. manifest with dyspnea and a persistent cough. Lastly, remind them that drowsiness and In the cardiovascular system, acetylcholine dizziness are common side effects of both slows down the heart rate and reduces blood acetylcholinesterase inhibitors or NMDA pressure, which can result in bradycardia, heart receptor antagonists, and advise them to make block, hypotension, and even cardiac arrest. In position changes slowly and to use caution with the gastrointestinal tract, these medications can ambulation. Now, if an acetylcholinesterase cause increased motility and secretions, leading inhibitor is prescribed, teach your client to take to nausea, vomiting, cramps, diarrhea, their medication with food to reduce gastric increased salivation, and involuntary defecation, upset. And advise them to contact their or even gastrointestinal bleedi