NURS 310 Exam 2 Study Guide PDF

NURS 310: Exam 2 Study Guide Chapter 20 – Anxiolytics and Hypnotics Know these terms: o Anxiolytics: Prevent feelings of tension or fear. o Sedatives: Calm and make patients unaware of the environment. o Hypnotics: Cause sleep. o Minor tranquilizers: P...

NURS 310: Exam 2 Study Guide Chapter 20 – Anxiolytics and Hypnotics Know these terms: o Anxiolytics: Prevent feelings of tension or fear. o Sedatives: Calm and make patients unaware of the environment. o Hypnotics: Cause sleep. o Minor tranquilizers: Produce a state pf tranquility in anxious patients. o Psychological States Affected by Anxiolytic and Hypnotic Drugs ▪ Anxiety: Feeling of tension, nervousness, apprehension, or fear involving unpleasant reactions to a stimulus. ▪ Sedation: Loss of awareness and reaction to environmental stimuli. ▪ Hypnosis: Extreme sedation resulting in further CNS depression and sleep. Benzodiazepine MOA, adverse effects, drug-drug interactions, patient education, effect on neonate, signs of withdrawal or overdose. o Actions: Act on the limbic system and the RAS. Make GABA more effective. Causes interference with neurons firing. o Lower doses assist with anxiety. Higher doses cause sedation and hypnosis. o Indications: Anxiety disorders, alcohol withdrawal, hyperexcitability and agitation, preop relief anxiety and tension. o Adverse effects: Sedation, drowsiness, depression, lethargy, blurred vision, confusion, dry mouth, constipation nausea, vomiting, hypotension, urinary retention. o Contraindications: Acute alcohol intoxication (added or increased sedation), allergy, psychosis, acute narrow angle glaucoma, shock, coma, pregnancy o Drug-drug interactions: alcohol (increased CNS depression), Increased in effect when taken with cimetidine, oral contraceptives, or disulfiram, decrease in effect if given with theophylline or ranitidine. o Patient education: after long term use, they need to be tapered to be stopped, instead of stopping suddenly. o Effect on neonate: cleft lip palate, cardiac issues, neonatal withdrawal. o Signs of withdrawal or overdose ▪ Overdose: antidote is flumazenil is a competitive benzodiazepine receptor antagonist; many SEs including risk for seizures ▪ Withdrawal: Worse if stopped abruptly, SX: GI sx, diaphoresis, high HR, high BP, tremor, lethargy, dizziness, irritability, anxiety, restlessness, insomnia, irritability, depersonalization, perceptual disturbances, SEIZURES: abrupt discontinue, NAS (neonatal abstinence syndrome). o Prototype: Diazepam MOA, Indications, Adverse side effects of oral diazepam ▪ MOA: Acts on limbic system and reticular formation to potentiate the effects of GABA, and inhibitory neurotransmitter; may act in spinal cord and supraspinal sites to produce muscle relaxants.  ▪ Inhibitions: Management of disorders, alcohol withdrawal, muscle relaxants, tetanus, epilepticus, preop ▪ Adverse effects: drowsiness, libido… o Other names: alprazolam (Xanax), chlordiazepoxide, clonazepam…. o Nursing considerations: Assess known allergies, Impaired liver or kidney function, baseline status before beginning therapy, VS, skin lesions: affect, orientation, reflexes, and vision, renal and liver function studies and CBCs Barbiturates o Action: CNS depressants, inhibit neuronal impulse conduction in the ascending RAS, depress cerebral cortex, depress motor output, Cause: sedation, hypnosis, anesthesia, and coma. o Indications: Relief of the signs and symptoms of anxiety, sedation, insomnia, pre- anesthesia, and seizures o Long half life o Contraindications and Cautions: Allergy, previous history of addiction to sedative- hypnotic drugs, latent or manifest porphyria, marks hepatic impairment or nephritis, respiratory distress or severe respiratory dysfunction, pregnancy. o Adverse reactions: CNS depression, physical dependency, drowsiness, somnolence, lethargy, ataxia, vertigo, nausea, vomiting, constipation. o Drug-to-drug interactions: Increase in CNS depression when given with alcohol, antihistamines, or other tranquilizers, altered response to phenytoin, MAO cause increase serum levels and effects, Decrease effectiveness of the following drugs: anticoagulants, digoxin, tricyclic antidepressants, corticosteroids, and oral contraceptives. o Nursing Considerations: Allergies, history of addiction, Impaired cardiac, respiratory, hepatic, and renal function, VS. o Prototype: Phenobarbital ▪ Indications: Sedation, short-term of insomnia, long term tonic-clonic seizures and focal seizures, emergency control of certain acute convulsive episodes, preanesthetic. ▪ Therapeutic level of Phenobarbital 10 to 40 mcg/ml o Other Drug names: amobarbital, butabarbital, pentobarbital… Buspirone (BuSpar) o Reduce the signs and symptoms of anxiety without severe CNS and adverse effects. o MOA is not clear, bind to serotonin and dopamine receptors. o Adverse effects: dizziness, nausea, constipation, headache, constipation. o Not fast acting may take 1-4 weeks to take effect. o Due to decreased depressive effects on CNS, may be a good choice for pts who cannot tolerate SE of other drugs. Onset of action times in barbiturates (fastest) indications for use Indications for the use of hypnotics: barbiturates?  Patient teaching regarding zolpidem (Ambien) o Oral drug for short-term treatment of insomnia. o Dispense the least amount possible to depressed or suicide patients. o Withdrawal gradually if taken for a long amount of time. o Pt should take before bed and dedicate 4-8 hours of sleep. o Use w caution in patients with hepatic or renal impairment. o Elderly pts are especially sensitive to these drugs – administer lower dose. Chapter 21 – Antidepressant Agents Know these terms: o Affective disorder: A persons mood goes far beyond the usual, normal ups and downs. o Depression: Severe and long-lasting feelings of sadness lasting beyond period identified with precipitating event. ▪ S/S: low energy levels, sleep disturbance, lack of appetite, lack of libido, inability to perform ADLs, overwhelming sadness o Biogenic Amine Theory of Depression: Depression results from a deficiency of norepinephrine (NE), dopamine, or serotonin (5HT). ▪ Monoamine oxidase (MAO) may break them down to be recycled or restored in the neuron. ▪ Rapid fire of the neurons may lead to their depletion. ▪ The number or sensitivity of postsynaptic receptors may increase, depleting neurotransmitter levels. Actions of Antidepressant therapy o Inhibit the effects of MAO, leading to increase NE or 5HT in the synaptic cleft. o Block reuptake by the releasing nerve, lead to increased neurotransmitter levels in the synaptic cleft. o Regulate receptor sites and breakdown of neurotransmitters, leading to an accumulation of neurotransmitters in the synaptic cleft. Drug classes used to treat depression: TCA, MAOI, SSRI o Patient educations: delay typically 3-6 weeks after therapeutic dose is achieved before symptoms improve. If no improvement after a trial (2 months) and adequate dose, either switch or augment with other agent. o Black box warning: Increase suicide idealation. o Tricyclic Antidepressants (TCAs) ▪ Action: Reduce the reuptake of 5HT and NE into nerves. ▪ Use: All TCAs are similar. Choice depends on individual response to the drug and tolerance of adverse effects. ▪ Indications: Relief of symptoms of depression. Used in pts with sleep disorders. Treatment of enuresis. Chronic pain. ▪ Pharmacokinetics: Bound to plasma proteins and lipid soluble to enter the blood brain barrier, long half-life.  ▪ Contraindications: allergy, recent MI, myelography, pregnancy, and lactation ▪ Cautions: CV disease, angle closure glaucoma, urinary retention, manic depression. ▪ Adverse reactions: sedation, sleep disturbances, fatigue, hallucinations, ataxia, dry mouth, constipation, nausea, vomiting, visual disturbances. ▪ Drug-to-drug interactions: MAOIs, cimetidine, fluoxetine, ranitidine, anticoagulants ▪ Prototype: Imipramine Use: Relief symptoms of depression, enuresis in children older than 6, off label – chronic pain. ▪ Other names: Desipramine o MAO Inhibitors (MAOIs) ▪ Avoided in pediatrics mainly due to food-drug interactions. ▪ HYPERTENSIVE CRISIS ▪ Ex: Isocarboxid, Phenelzine, and Tranylcypromine ▪ Actions: irreversible bind to MAO, allowing norepinephrine, serotonin, and dopamine to accumulate in the synaptic cleft. ▪ Indications: Tx for depression who are unresponsive or unable to take other drugs for tx. ▪ Contraindications: allergy, pheochromocytoma (adrenal tumor causing HTN), CV disease, headaches, renal or hepatic impairment. ▪ Adverse effects: dizziness, excitement, nervousness, mania, hyperreflexia, tremors, confusion, insomnia, agitation, liver toxicity, nausea, vomiting, diarrhea or constipation, anorexia, wt gain, dry mouth, and abdominal pain ▪ Drug-to-drug interactions: Other antidepressants – hypertensive crisis, coma Methyldopa – sympathomimetic effects increase Insulin or oral antidiabetic agents – additive hypoglycemia ▪ Food interactions: Tyramine or pressor amines – Increase blood pressure Cheddar, Gouda, Parmesan, Roquefort, Sauerkraut, kimchi, soy sauce, miso, yeast extract, Salami, pepperoni, bologna, Peanuts, almonds, cashews, Overripe bananas, avocados, raisins, Snow peas, broad beans, spinach, alcohol ▪ Prototype: Phenelzine Adverse effects: potential for hypertensive crisis! o Selective Serotonin Reuptake Inhibitors (SSRIs) ▪ The newest group of antidepressants. Specifically block 5HT, with little to no known effect on NE. Do not have as many adverse effects. ▪ Action: Inhibits CNS neuronal reuptake of serotonin with little effect on NE.  ▪ Indication: Depression, OCDs, panic attacks, bulimia, PMDD, PTSD, social phobias, social anxiety disorder. ▪ Associated with congenital abnormalities of the fetus. ▪ Contraindications: Allergy, pregnancy, lactation, impaired renal or hepatic function. ▪ Adverse effects: headache, drowsiness, dizziness, insomnia, anxiety, tremor, agitation. ▪ Drug-to-drug interactions: MAOIs, TCAs increase of therapeutic and toxic effects, St johns wort, other SSRIs, and triptans ▪ Prototype: Fluoxetine (Prozac) Pros: Long half-life so decreased incidence of discontinuation syndromes. Initially activating so may provide increased energy. Take in AM. Cons: long half-life. Significant P450 interactions; more likely to produce mania. Sexual dysfunction. May take 4 weeks to work. ▪ Other drugs: Paroxetine (Paxil), Sertraline (Zoloft), Citalopram (Celexa), Escitalopram (Lexapro)/Fluvoxamine (Luvox) o Serotonin/Norepinephrine reuptake inhibitors (SNRIs) ▪ Inhibit both serotonin and norepinephrine reuptake like TCAs but without the SEs. ▪ Indications: Major depressive disorder, smoking cessation, wt loss, fibromyalgia, neuropathy, musculoskeletal pain. ▪ Examples: venlafaxine, duloxetine, desvenlafaxine. Patients with Cardiovascular Disease should avoid which class of antidepressant. o MAO Inhibitors (MAOIs) Chapter 22 – Psychotherapeutic Agents Classifications of Antipsychotics o Neurologic effects of antipsychotic drugs p 376 o Typical: Primarily dopamine receptor blockers. ▪ Causes several adverse effects including hypotension, anticholinergic effects, and extrapyramidal side effects (EPS) o Atypical: Blocks both dopamine and serotonin receptors. ▪ May alleviate some of the unpleasant neurological effects and depression of typical antipsychotics. o Indications: schizophrenia, hyperactivity, combative behavior, agitation in the elderly, severe behavioral problems in kids. o Contraindications: Underlying diseases that could be exacerbated by dopamine- blocking effects of these drugs. CNS depression. Circulatory collapse, Parkinson’s, coronary disease, severe hypotension, prolonged QT interval.  o Adverse effects: Sedation and weakness. Extrapyramidal effects (Can’t control their mouth or a tick/twitch). ▪ Types of Extrapyramidal effects: Pseudo parkinsonism, dystonia, akathisia, tardive dyskinesia, potentially irreversible neuroleptic malignant syndrome. o Prototype: Clozapine ▪ Indications: severely ill pts with schizophrenia who are unresponsive to other drugs, reduce SI in schizophrenic patients. ▪ Actions: block dopamine and serotonin receptors o Examples: Chlorpromazine, haloperidol. o Risk of Haldol use ▪ Antipsychotic medicines, like haloperidol, can cause a rare but serious condition called neuroleptic malignant syndrome. NMS can lead to death. Patient monitoring on Lithium, adverse effects, therapeutic level, s/s of toxicity o Ex: Lithium salts, lamotrigine, olanzapine, quetiapine. o Indications: Mania/bipolar disorder o Action: Alters sodium transport in nerve and muscle cells. Inhibits the release of norepinephrine and dopamine, but not serotonin, from stimulated neurons. Increases the intraneuronal stores of norepinephrine and dopamine slightly. o Adverse effects: ▪ Effects directly related to lithium serum levels. ▪ Less the 1.5 – lethargy, slurred speech, N/V, muscle weakness, polyuria ▪ Levels 1.5-2 – above reactions plus ECG changes, bradycardia. ▪ Levels 2-2.5 – ataxia, clonic movements, hyperreflexia, seizures, severe EKG changes, hypotension ▪ Greater than 2.5 – complex multiorgan toxicity, significant risk of death. o Drug-to-drug interactions: thiazide diuretics, haloperidol, carbamazepine. o Check Therapeutic levels! o Nursing Considerations: Assess them for dehydration, kidney disease, dehydration, sodium depletion, use of diuretics, sweating diarrhea, SI, pregnancy, infection, CNS orientation, urinary output, use barrier contraceptive. o Should not be used in kids. o Patients need to stay hydrated and maintain their salt intake. Central Nervous System Stimulants o Actions: CNS stimulants act as cortical and RAS, possible by increasing the release of catecholamines from presynaptic neurons leading to an increase in stimulation of the postsynaptic neurons. o Indications: Narcolepsy, attention deficit syndromes o Adverse effects: Increased CNS stimulation, nervousness, insomnia, dizziness, headache, blurred vision, anorexia, nausea, weight loss. o Drug-to-drug interactions: MAOIs, tricyclic antidepressants, phenytoin. o Prototype: Methylphenidate (Ritalin) ▪ Indications: Narcolepsy and attention-deficit disorder  ▪ Child monitoring: Growth monitoring, Cardiac, and psychosocial monitoring. Chapter 23 – Anti Seizure Agents Types of Seizures o Focal seizures: subdivided as those with motor and non-motor (sensory) S/S. Occurs in a specific area of the brain. o Generalized: Involves both hemispheres; loss of consciousness. Whole body S/S. Medication Action: Slow entrance of Na and Ca back into the neuron, slows repolarization, suppresses neuron firing to decrease SZ activity. Enhances inhibitory effect of GABA. Hydantoins o Ex: Ethotoin, Fosphenytoin, Phenytoin o Generally, less sedating than other antiepileptics. o May be the drug of choice for patients unable to tolerate sedation and drowsiness. o Significant adverse effects: gingival hyperplasia, depression, fatigue, confusion, cardiac arrhythmias, urinary retention, hirsutism, bone marrow suppression, severe liver toxicity o Therapeutic: All forms of epilepsy o Contraindications and cautions: bradycardia and heart block. Avoid alcohol, pregnancy, elderly. o Drug to drug interactions: Decreased effect of oral warfarin, glucocorticoids, oral contraceptives, primrose, ginkgo o Prototype: Phenytoin. Normal phenytoin level, MOA, adverse effects ▪ Indications: tonic-clonic seizures, psychomotor seizures. Not absent seizures. ▪ MOA: Stabilizes neuronal membranes and prevents hyperexcitability caused by excessive stimulation. ▪ Therapeutic Blood Level: 10-20 MCG/mL Barbiturates and Barbiturate-like drugs o Ex: Mephobarbital, phenobarbital, primidone. o Used for focal and generalized tonic clonic seizures. Not absent. o Prototype: Phenobarbital ▪ Therapeutic Blood levels: 15-40 MCG/Ml Benzodiazepines o Ex: Diazepam (Valium), Lorazepam, Clonazepam o Indication: Used in status epilepticus. o Contraindications and Cautions: retrograde amnesia, monitor vitals, resuscitation equipment ready. o Adverse effects: respiratory depression, confusion, lethargy o Drug-to-drug: alcohol o Prototype: Diazepam Succinimides o Ex: Ethosuximiden (Zarontin), Methsiximide.  o Indication: absent seizures o Drug-to-drug - primidone o Prototype: Ethosuximide ▪ Absence seizures. ▪ SE: drowsiness, dizziness, irritability Valproic acid (Depakote) – used for focal, generalized, and absence SZ, bipolar, migraine HA o Contraindications: liver disorders and pregnancy (Category X) Zonisamide (Zonegran) o For generalized and absence SZ o Associated w bone marrow suppression, renal calculi, GI upset Drugs for treating Partial Seizures o *all have a black box warning for increased potential for suicide o Prototype: Carbamazepine (Tegretol) ▪ SE: CNS effects ▪ Pharm kinetics – increase GABA activity, metabolized in liver by cytochrome P450 system ▪ Drug-to-drug: decrease oral contraceptives, warfarin (monitor INR/PT), avoid grapefruit juice, phenytoin ▪ Therapeutic level: 4-12 mcg/ml Chapter 24 – Anti Parkinson Agents No cure for Parkinson’s – therapy is aimed at management of signs and symptoms by restoring the balance between declining dopamine levels and dominating cholinergic neurons. Know the cautions of Dopaminergic drugs Cautions and Adverse Reactions o Dopaminergic Agents work to increase dopamine levels in the substantia nigra. o Adverse reactions: anxiety, nervousness, confusion, headache, blurred vision, arrhythmias. o Cautions: CV disease, bronchial asthma, H/O peptic ulcer, UT obstruction, psych disorder o Drug-to-drug interactions: MAOIs and Vit B6 o Prototype: Levodopa ▪ Indications: Parkinson’s ▪ Action: precursor of dopamine, can cross BBB ▪ Almost always combo with carbidopa which decreases the amount of levodopa needed to reach therapeutic effects in the brain reducing adverse SE o Amantadine ▪ Indications: Antiviral, treatment for Parkinson’s Anticholinergic agents, MOA, indications, adverse effects. o Ex: Benztropine, Biperiden, Diphenhydramine (Benadryl), Procyclidine, Trihexyphenidyl o Action: Block the action of acetylcholine in the CNS to help normalize the acetylcholine- dopamine imbalance  o Treatment of Parkinson’s and relief of extrapyramidal symptoms. o Adverse rxns: disorientation, confusion, agitation, delirium, N/V, paralytic ileus o Cautions: dysrhythmias, HTN, Hypotension, hepatic dysfunction, pregnancy o Only one approved for use in pediatrics: Diphenhydramine (Benadryl) o Prototype: Benztropine ▪ Action: Reduce the severity of rigidity, akinesia, and tremors; peripheral anticholinergic effects help reduce drooling and other secondary effects of parkinsonism. ▪ Adverse effects: Disorientation and confusion. o Nursing Considerations: Assess urinary output. Chapter 25 – Muscle Relaxants Cautions for patients taking central acting muscle relaxants. Know the difference between Central and Direct-Acting Muscle Relaxants. o Centrally Acting – Relaxants work in the brain and spinal cord. Interfere with cycle of muscle spasm and pain. ▪ Action: Works in upper levels of CNS to interfere with reflexes causing the muscle spasm. ▪ Prototype: Baclofen Indication: Alleviation S/S of spasticity may be used for spinal cord injuries. Action: CNS depressant. Adverse effects: drowsiness, dizziness, weakness, fatigue, hypotension, constipation, headache, insomnia, urinary frequency. ▪ Cyclobenzaprine: Relieve of discomfort of acute MSK conditions. ▪ Tizanidine: Relief of discomfort of MSK, manages increased muscle tone with spasticity. ▪ Caution pt about alcohol, opioids, other CNS depressants. ▪ Other Adverse effects: hypotension and liver toxicity. o Direct Acting – Botulism toxin and Dantrolene. Enter muscle fibers directly. ▪ Action: Interferes with the release of Ca from muscle tubules and prevents the fibers from contracting. ▪ Prototype: Dantrolene Indication: Control for clinical spasticity, malignant hyperthermia prevention preop, IV management of MH, spinal cord injury, myasthenia gravis, cerebral palsy, MS, muscular dystrophy, polio, tetanus, quadriplegia Action: Interferes with release of Ca on MSK, not neural. Caution: Fatal liver disease, hepatotoxicity, people 35 and older. Women who are on estrogen therapy (birth control and hormone therapy), or women in general.  ▪ Onabotulinumtoxin (Botox) Treatment for overactive bladder, detrusor overactivity associated with neurological conditions. Treatment of chronic migraine. Chapter 26 – Narcotics, Narcotic Antagonists, and Antimigraine Agents Drugs Used to relieve pain. o Narcotics: opium derivative used to treat many types of pain. o Antimigraine drugs: Reserved for the treatment of migraine headaches. Narcotic agonists MOA, adverse effects, teaching o Examples: codeine, hydrocodone, hydromorphine, opium o Action: Act on specific opioid receptor sites in the CNS to stimulate the effects of the receptors. o Indications: Relieve of severe acute or chronic pain. o Adverse Effects: Treatment of opioid induced constipation: Relistor/ methylnaltrexone bromide. o Cautions: Respiratory dysfunction, GI or GU surgery, acute abdomen or ulcerative colitis. o Prototype: Morphine Narcotic agonist - antagonists MOA, adverse effects, teaching o Ex: Buprenorphine, Butorphanol, Nalbupine, Pentazocine. o Nalbuphine (Nubain) ▪ Indications: Relieves pain during labor and delivery. o Action: Act on specific opioid receptor sites in the CNS to produce analgesia, sedation, euphoria, and hallucinations. Can cross placenta. o Indications: Moderate to severe pain. Adjunct to general anesthesia. L&D. o Cautions: Physical dependence on a narcotic, COPD and disease of the respiratory tract, Acute MI or documented CA. o Adverse Effects: Respiratory depression, N/V, constipation, headache, psychoses, anxiety, hallucinations, ureteral spasms, urinary retention, biliary spasm. o Teaching: dependence/ addiction o Prototype: Buprenorphine ▪ Indications: moderate to severe opioid use disorder. ▪ Action: Agonist on specific opioid receptors and antagonist at the kapp-opioid receptor Narcotic antagonists MOA, adverse effects, teaching o Action: Binds to opioid receptors but do not activate them. They block the effects of the opioid receptors. o Indications: Reversal of the adverse effects of narcotic use, including o Naloxone (Narcan) ▪ Action: Reverses adverse effects of narcotics; diagnoses suspected acute narcotic overdose. Not given orally.  ▪ Indications: Complete or partial reversal of narcotic depression; diagnosis of suspected opioid overdose ▪ Adverse effects ▪ Dosing o Naltrexone (ReVia, Vivitrol) ▪ Used orally in the management of alcohol or narcotic dependence, adjunct. Headaches o Migraines: severe, throbbing on one side of head o Cluster: begins during sleep; sharp, steady eye pain o Tension: times of stress, dull band of pain around head Ergot derivatives: Cause constriction of cranial blood vessels and decrease the pulsation of cranial arteries. As a result, they reduce the hyper perfusion of the basilar artery vascular bed. o Drug-to-Drug Interactions: Beta Blockers (gangrene and peripheral vasoconstriction), Triptans (Vasospasm) o Action: blocks alpha-adrenergic and serotonin receptor sites in the brain to cause constriction of cranial vessels. o Indication: Prevention or abortion of migraine or vascular headaches. o Think vasoconstriction and cardiac/vascular side effects. o Prototype: Ergotamine ▪ Indication: Vascular headaches MOA, indications, Patient teaching on “triptans” o Used for migraine headaches. Cause cranial vasoconstriction but have less SE. o Action: Bind to selective serotonin receptors to cause vasoconstriction of cranial vessels. o Indications: Tx for acute migraine and are not used for prevention of migraines. o Contraindications and Cautions: CAD, allergy, pregnancy, elderly o Drug-to-drug interactions: Ergot (vasoconstriction and spasm), and MAOI’s (risk of severe HTN and cannot give within 2 weeks of taking) o Nursing Considerations: Cardiac SE – History of MI, CAD, or HTN. o Prototype: Sumatriptan ▪ Action: vasoconstrictive effect on cranial blood vessels. ▪ Dose: 50-100 mg PO at first sign of headache, may repeat in 2 hours; by nasal spray in one nostril, may repeat in 2 h; do not exceed 40 mg/day Calcitonin Gene-Related Peptide: potent vasodilator released during migraines. o Can take inhibitors for migraine relief. o Galcanezumab