Clinical Pharmacology NURS 314 (Fall) 2024-2025 PDF

Clinical Pharmacology NURS 314 (Fall) 1st Semester 2024-2025 December 15, 2024 1  Drugs Affecting the Nervous System 6h Lecture December 15, 2024 2 ...

Clinical Pharmacology NURS 314 (Fall) 1st Semester 2024-2025 December 15, 2024 1  Drugs Affecting the Nervous System 6h Lecture December 15, 2024 2  Learning Objectives Identify the basic functions of the nervous system. Identify important divisions of the peripheral nervous system. Discuss the pharmacotherapy of neurological disorders Describe the side effects, interaction, and contraindications for different neurological medications Use the nursing process as a framework to provide care for patient on neurological disorders drugs December 15, 2024 3  Cholinergic Drugs Pain Adrenergic Med. Drugs Nervous & Muscular Skeletal Anticonvuls ant drugs Drugs muscle relaxants Antiparki Neurom Antimigraine drugs nsonian uscular Anesthetic blocking Drugs drugs December 15, 2024 drugs 4  What are the Common Neurovascular disorders? December 15, 2024 5  Overview What is the main structure of nervous System? What are the main function of the nervous System? What are the Primary Neurotransmitters of Autonomic Nervous System? https://youtu.be/_BsRVOG9cZM December 15, 2024 6 December 15, 2024 7  Autonomic Nervous System Sympathetic nervous system – Activated under stress – Fight-or-flight response – Readies the body for an immediate response to a potential threat Parasympathetic nervous system – Activated under non stressful conditions – Rest-and-digest response – Digestive processes promoted; heart rate and blood pressure decline December 15, 2024 8  Sympathetic and Parasympathetic Divisions Branches produce mostly opposite effects Homeostasis –Proper balance of the two branches –Achieved by changing one or both branches Branches do not always produce opposite effects (e.g., sweat glands only controlled by sympathetic nerves) December 15, 2024 9  Effects of the parasympathetic and sympathetic nervous systems December 15, 2024 10  Synaptic Transmission Synapse—junction of neurons Connection of two neurons outside CNS—ganglionic synapse –Preganglionic neuron –Postganglionic neuron Many drugs affect autonomic function by altering neurotransmitter activity at the second synapse December 15, 2024 11  Primary Neurotransmitters of Autonomic Nervous System Acetylcholine (Ach) – Neurotransmitter of parasympathetic nervous system. It regulating cardiac contractions and blood pressure, intestinal peristalsis, glandular secretion Norepinephrine (NE) – Neurotransmitter of sympathetic nervous system. It is peripheral vasoconstrictor by acting on alpha- adrenergic receptors. December 15, 2024 12  Receptors in the autonomic nervous system: (a) Parasympathetic pathway: AC h is released at both the ganglia (nicotinic receptor) and effector organ (cholinergic receptor); (b) Sympathetic pathway: AC h is released at the ganglia (nicotinic receptor) and NE at the effector organ (adrenergic receptor) December 15, 2024 13  Acetylcholine and Cholinergic Transmission Released by cholinergic nerves Two types of cholinergic receptors –Nicotinic receptors (named this because nicotine binds to these receptors) –Muscarinic receptors (named this because muscarine from poisonous mushrooms binds to these receptors) December 15, 2024 14  Nicotinic Receptors Located at ganglionic synapse in both sympathetic and parasympathetic divisions Response –Stimulates smooth muscle –Stimulates gland secretion December 15, 2024 15  Muscarinic Receptors Located in parasympathetic target organs except the heart. Response ▪ Stimulates smooth muscle ▪ Stimulates gland secretion In the heart; decreases heart rate and force of contraction December 15, 2024 16  Classification of Autonomic Drugs Based on two possible actions affecting the parasympathetic nervous system: Stimulation of parasympathetic nervous system ❖ Cholinergic agents or parasympathomimetic Inhibition of parasympathetic nervous system ❖Cholinergic-blocking agents, anticholinergics, parasympatholytics, or muscarinic blockers December 15, 2024 17  Video Activity December 15, 2024 18  Cholinergic Drugs Cholinergic drugs promote the action of the neurotransmitter acetylcholine. These drugs are also called para sympathomimetic drugs because they produce effects that imitate parasympathetic nerve stimulation. Mimic or inhibit There are two major classes of cholinergic drugs: ✓ Cholinergic agonists mimic the action of the neurotransmitter acetylcholine. ( direct action) ✓ Anticholinesterase drugs work by inhibiting the destruction of acetylcholine at cholinergic receptor sites. (indirect action) December 15, 2024 19  Cholinergic Agonists Acetylcholine, Bethanechol, Carbachol, Pilocarpine Pharmacodynamic: Cholinergic agonists work by mimicking the action of acetylcholine on the neurons in certain organs of the body, called target organs. Salivation Bradycardia Dilation of blood vessels, Constriction of the pulmonary bronchioles, Increased activity of the GI tract Constriction of the pupils, Increased tone and contraction of the muscles of the bladder. December 15, 2024 20  Cholinergic Agonists Acetylcholine, Bethanechol, Carbachol, Pilocarpine Pharmacotherapeutics Atonic bladder conditions, postoperative or postpartum urine retention, postoperative abdominal distention and GI atony, Salivary gland hypofunction, Myasthenia gravis. Side Effects: ✓Cramps and diarrhea, Blurred vision, Decreased heart rate and low blood pressure, Shortness of breath, Urinary frequency, Increased salivation and sweating. Nursing Implementation ✓ The cholinergic agonists rarely are administered by IM or IV injection because they’re almost immediately broken down by cholinesterase in the interstitial spaces between tissues and inside the blood vessels. Moreover, they begin to work rapidly and can cause a cholinergic crisis. ✓ Monitor side effects: urinary symptoms, Stomach upset ✓ Taken on an empty stomach December 15, 2024 21  Activity Medication name Therapeutic class Pharmacologic class Action Uses Administration alert Adverse Effects Contraindication Interactions Treatment of overdoses December 15, 2024 22  Anticholinesterase Drugs Physostigmine (Antilirium) Pharmacodynamic: Anticholinesterase drugs, like cholinergic agonists, promote the action of acetylcholine at receptor sites. Depending on the site and the drug’s dose and duration of action, they can produce a stimulant or depressant effect. It is to prevent the hydrolysis of acetylcholine. Pharmacotherapeutics Reduce eye pressure(eye surgery, glaucoma), diagnosis of myasthenia gravis(Neostigmine), dementia & Alzheimer’s disease, Antidotes to anticholinergic drugs. December 15, 2024 23  Anticholinesterase Drugs Physostigmine (Antilirium) Side Effects: ✓Cardiac arrhythmias, Seizures, Anorexia, Insomnia, Pruritus, Urinary frequency and nocturia, Uterine irritability and induction of preterm labor. Nursing Implementation ✓Administer anticholinesterase drugs as prescribed. Give these drugs before meals unless otherwise directed. ✓Assess for signs of respiratory adequacy and perform measures to promote adequate gas exchange, such as deep breathing and coughing, suctioning, and proper positioning of the patient. ✓Assess for urinary adequacy and signs of urine retention. ✓Administer IV very slowly over 5 minutes December 15, 2024 24  Anticholinergic Drugs Atropine, Ipratropium, Benztropine, Dicyclomine Pharmacodynamic: ✓ Anticholinergic drugs can have paradoxical effects on body, depending on the dosage, the condition being treated, and the target organ. ✓ It is blocking acetylcholine, atropine speeds up the heart rate. ✓ Antagonize the actions of acetylcholine and other cholinergic agonists. Pharmacotherapeutics ✓ Symptomatic sinus bradycardia, ✓ Arrhythmias resulting from anesthetics, ✓ Antidotes to cholinergic and anticholinesterase drugs, poisoning from organophosphate pesticides. ✓December Adjunct 15, 2024 treatment of peptic ulcer disease. 25  Anticholinergic Drugs Atropine, Ipratropium, Benztropine, Dicyclomine Side effects: Dry mouth, Reduced bronchial secretions, Increased heart rate, Blurred vision Decreased sweating Nursing Implication: ✓Follow dosage recommendations. ✓Some drugs should be given with meals. ✓Monitor vital signs, cardiac rhythm, urine output, and vision for potential drug toxicity. ✓Monitor for adverse reactions, such as dry mouth, increased heart rate, and blurred vision. ✓Have emergency equipment available to treat new cardiac arrhythmias. ✓Help alleviate symptoms if adverse effects occur, For example, frequent mouth care for patients experiencing dry mouth December 15, 2024 26  Activity Medication name Therapeutic class Pharmacologic class Action Uses Administration alert Adverse Effects Contraindication Interactions Treatment of overdoses December 15, 2024 27  Adrenergic Drugs Adrenergic drugs are also called sympathomimetic drugs because they produce effects similar to those produced by the sympathetic nervous system. It stimulates the sympathetic nervous system function (fight–or-flight) Adrenergic drugs are classified into two groups based on their chemical structure: catecholamines (naturally occurring as well as synthetic) and non-catecholamines. December 15, 2024 28  Adrenergic Drugs Neurotransmitter Receptor Primary location Response Medication Disease Alpha 1 All sympathetic target Constriction of Oxymetazoline Nasal congestion, organs, e.g. kidney, blood vessel, (Afrin) mydriasis muscles, except the heart dilation of pupil Alpha 2 Presynaptic adrenergic Releasing of Clonidine HTN nerve terminals norepinephrine Norepinephrine inhibition Adrenergic agonist Beta 1 Heart & Kidney Increased HR and Adrenaline Cardiac arrest, HF, force of contraction; Shock release of renin Beta 2 All sympathetic target Inhibition of smooth Albuterol, Bronchoconstriction, organs, e.g. kidney, muscle Ventolin asthma, preterm muscles, except the heart labor contraction Beta 3 Adipose tissue, Lipolysis Mirabegron Overactive bladder Urinary bladder Relaxation of the detrusor muscle December 15, 2024 29  Catecholamines Dobutamine, Dopamine, Epinephrine, Norepinephrine, Isoproterenol Pharmacodynamic: Dobutamine directly stimulates beta-1 receptors of the heart to increase myocardial contractility and stroke volume, resulting in increased cardiac output. Beta 2 caused bronchodilation Pharmacotherapeutics Hypotension correction, Heart block, Ventricular fibrillation, Asystole, Cardiac Arrest, Emphysema Side effects: restlessness, anxiety, hypotension, headache palpitation, hyperglycemia, angina and stroke December 15, 2024 30  Catecholamines Dobutamine, Dopamine, Epinephrine, Norepinephrine, Isoproterenol Nursing Role: ✓Close monitoring ECG ✓Before starting catecholamines, correct hypovolemia with plasma volume expanders ✓Give cardiac glycosides before catecholamines; cardiac glycosides increase atrioventricular (AV) node conduction and patients with atrial fibrillation may develop rapid ventricular rate. ✓Administer the drug using a central venous catheter or large peripheral vein (Use an infusion pump). Adjust the infusion according to the prescriber’s order and the patient’s condition. December 15, 2024 31  Catecholamines Dobutamine, Dopamine, Epinephrine, Norepinephrine, Isoproterenol Nursing Role: ✓Dilute the concentrate for injection before administration, according to pharmacy guidelines. ✓Watch for irritation and infiltration; extravasation can cause an inflammatory response. ✓Don’t mix dobutamine or dopamine with sodium bicarbonate injection or phenytoin because the drug is incompatible with alkaline solutions. ✓Change IV sites regularly to avoid phlebitis. ✓After dopamine is stopped, watch closely for a sudden drop in blood pressure December 15, 2024 32  Neurologic & neuromuscular Drugs 1-Skeletal 2- Neuromuscular 3-Antiparkinsonian 4-Anticonvulsant 5-Antimigraine musclerelaxants blocking Drugs Drugs Drugs Drugs Drug  1- Skeletal muscle relaxants ❖ Skeletal muscle relaxants relieve musculoskeletal pain or spasms and severe musculoskeletal spasticity (stiff, awkward movements). ❖ They’re used to treat acute, painful musculoskeletal conditions and muscle spasticity associated with multiple sclerosis (MS), Cerebral palsy, Stroke, and spinal cord injuries, December 15, 2024 34  Centrally Acting Agents carisoprodol, chlorzoxazone, cyclobenzaprine, metaxalone, methocarbamol, orphenadrine Pharmacodynamic: The centrally acting drugs don’t relax skeletal muscles directly or depress neuronal conduction, neuromuscular transmission, or muscle excitability. Rather, centrally acting drugs are known to be central nervous system (CNS) depressants. The skeletal muscle relaxant effects that they cause are likely related to their sedative effects. Pharmacotherapeutics Acute, painful musculoskeletal conditions December 15, 2024 35  Centrally Acting Agents carisoprodol, chlorphenesin, chlorzoxazone, cyclobenzaprine, metaxalone, methocarbamol, orphenadrine, tizanidine Side effects: Physical and psychological dependence, severe withdrawal symptoms (Abrupt cessation), Common reactions :dizziness , drowsiness. Severe reactions : allergic reactions, arrhythmias, and bradycardia Nursing Role: ▪ Avoid abrupt discontinuation to reduce risk of experiencing withdrawal symptoms, such as returning spasticity, hypotension, paresthesia, and muscle rigidity. ▪ Institute safety precautions as needed. ▪ Give oral forms of these drugs with meals or milk to prevent GI distress. December 15, 2024 36  Activity Medication name Therapeutic class Pharmacologic class Action Uses Administration alert Adverse Effects Contraindication Interactions Treatment of overdoses December 15, 2024 37  Direct-Acting Agents: Dantrolene sodium, Video Pharmacodynamic: Dantrolene is chemically and pharmacologically unrelated to other skeletal muscle relaxants. It acts directly on muscle to interfere with calcium ion release from (storage area inside the skeletal muscle) the sarcoplasmic reticulum and weaken the force of contractions. Dantrolene has little effect on cardiac or intestinal smooth muscle at therapeutic concentrations. Pharmacology class is direct-acting antispasmodic; calcium-release blocker Pharmacotherapeutics: Cerebral palsy, MS, Spinal cord injury, Stroke, Malignant hyperthermia, Anesthesia antidote December 15, 2024 38  Direct-Acting Agents: Dantrolene sodium Side effects: Common adverse effects: drowsiness, dizziness, malaise, muscle weakness, nausea, diarrhea, and tachycardia. Serious adverse effects: bleeding, seizures, and hepatitis or hepatic problems increased among females over 35 years old and after 3 months of therapy. Nursing Role: ✓Avoid abrupt discontinuation to reduce risk of experiencing withdrawal symptoms, such as returning spasticity, hypotension, paresthesia, and muscle rigidity. ✓Institute safety precautions as needed. ✓Give oral forms of these drugs with meals or milk to prevent GI distress. December 15, 2024 39  Activity Medication name Therapeutic class Pharmacologic class Action Uses Administration alert Adverse Effects Contraindication Interactions Treatment of overdoses December 15, 2024 40  Other Skeletal Muscle Relaxants Diazepam (IV, IM, Oral ), Baclofen( IM, IV, IT) Pharmacodynamic: Baclofen probably acts in the spinal cord. It reduces nerve impulses from the spinal cord to skeletal muscle, decreasing the number and severity of muscle spasms and the associated pain. Pharmacotherapeutics: Spasticity (Drug of choice: Baclofen), Paraplegia or Quadriplegia result from MS or trauma December 15, 2024 41  Other Skeletal Muscle Relaxants Diazepam (IV, IM, Oral ), Baclofen( IM, IV, IT) Side effects: Transient drowsiness. nausea, fatigue, vertigo, hypotonia, muscle weakness, depression, and headache. Nursing Role: ✓Avoid abrupt discontinuation of Baclofen to reduce risk of experiencing withdrawal symptoms, such as returning spasticity, hypotension, paresthesia, and muscle rigidity. ✓Institute safety precautions as needed. ✓Give oral forms of these drugs with meals or milk to prevent GI distress. December 15, 2024 42  2- Neuromuscular blocking drugs Neuromuscular blocking drugs relax skeletal muscles by disrupting the transmission of nerve impulses at the motor end plate (the branching terminals of a motor nerve axon). Neuromuscular blockers have three major clinical indications: ✓to relax skeletal muscles during surgery ✓to reduce the intensity of muscle spasms in drug-induced or electrically induced seizures ✓to manage patients who are fighting the use of a ventilator to help with breathing. There are two main classes of natural and synthetic drugs used as neuromuscular blockers—nondepolarizing and depolarizing.  Nondepolarizing Blocking Drugs Atracurium, Cisatracurium, Doxacurium, Mivacurium, Pancuronium, Rocuronium Pharmacodynamic: Nondepolarizing blockers compete with acetylcholine at the cholinergic receptor sites of the skeletal muscle membrane. This blocks acetylcholine’s neurotransmitter action, preventing the muscle from contracting. Pharmacotherapeutics: intermediate or prolonged muscle relaxation (Insertion ET tube, during electroconvulsive therapy, broken bones and dislocated joints, Using Mechanical Ventilator ) Video December 15, 2024 44  Nondepolarizing Blocking Drugs Atracurium, Cisatracurium, Doxacurium, Mivacurium, Pancuronium, Rocuronium Side effects: Apnea, hypotension, bronchospasm, excessive bronchial & salivary secretions. Pancuronium causes tachycardia, cardiac arrhythmias, and hypertension. Nursing Role: ✓Administer sedatives or general anesthetics before neuromuscular blockers. ✓Keep in mind that neuromuscular blockers should be used by personnel skilled in airway management. ✓Store the drug in a refrigerator. Don’t store it in plastic containers or syringes. December 15, 2024 45  Depolarizing Blocking Drugs Succinylcholine Pharmacodynamic: After administration, succinylcholine is rapidly metabolized, although at a slower rate than acetylcholine. As a result, succinylcholine remains attached to receptor sites on the skeletal muscle membrane. This prevents repolarization of motor end plate result muscle paralysis. Pharmacotherapeutics: Drug of choice for short-term muscle relaxation such as that needed during intubation and ECT Side Effect: Hypotension and prolonged apnea December 15, 2024 46  Depolarizing Blocking Drugs Succinylcholine Nursing Role: ✓Administer sedatives or general anesthetics before neuromuscular blockers. ✓Keep in mind that neuromuscular blockers should be used only by personnel skilled in airway management. ✓For IV use, to evaluate the patient’s ability to metabolize succinylcholine, give a test dose after he has been anesthetized. A normal response (no respiratory depression or transient depression for up to 5 minutes) ✓For IM use, give deep IM, preferably high into the deltoid. https://youtu.be/4neBKL9XJBo December 15, 2024 47  3- Antiparkinsonian drugs ❖ Parkinson’s disease, a progressive neurologic disorder characterized by four cardinal features: Muscle rigidity (inflexibility) Akinesia (loss of voluntary muscle movement) Tremors at rest Disturbances of posture and balance. ❖ The goal of drug therapy is to provide symptom relief and maintain the patient’s independence and mobility. This can be achieved by correcting the imbalance of neurotransmitters in one of several ways, including: ✓ Inhibiting cholinergic effects (with anticholinergic drugs) ✓ Enhancing the effects of dopamine (with dopaminergic drugs) 48  Dopaminergic drugs Levodopa, Carbidopa-levodopa, Amantadine, Bromocriptine, Selegiline Pharmacodynamic: Dopaminergic drugs act in the brain to improve motor function in one of two ways: by increasing the dopamine concentration or by enhancing the neurotransmission of dopamine. Video Pharmacotherapeutics: Parkinson’s disease(Levodopa is the most effective drug used), mild Parkinson’s disease with tremor (Amantadine), early Parkinson’s disorder (Selegiline) Side Effect: Orthostatic hypotension, neuroleptic malignant syndrome (Levodopa) Insomnia, dizziness, arrhythmias (Selegiline), worsening angina, persistent orthostatic hypotension, bradycardia (Bromocriptine) December 15, 2024 49  Dopaminergic drugs Levodopa, Carbidopa-levodopa, Amantadine, Bromocriptine Nursing Role: ✓Administer the drug (except levodopa) with food to prevent GI irritation. ✓Give the drug at bedtime if the patient receives a single daily dose. ✓A patient receiving long-term therapy should be tested regularly for diabetes and acromegaly and should have periodic tests of liver, renal, and hematopoietic function. ✓Discontinuing the levodopa for 8 hours before starting Carbidopa- levodopa. ✓Check the mental status, and VS then any changes withhold the dose. December 15, 2024 51  Question Which of the following medications are effective in treating mild Parkinson’s disease with tremor? A. A. Levodopa B. Amantadine C. Selegiline D. Bromocriptine December 15, 2024 50  Question Which of the following nursing diagnoses is priority for parkinsonism patient treating with dopaminergic drugs? A. Risk for fluid balance alteration related to decrease oral intake B. Risk for bleeding related to side effects of medication C. Risk for fall / injury related to side effects of medication D. Altered nutrition pattern related to disease process December 15, 2024 52  Activity Medication name Therapeutic class Pharmacologic class Action Uses Administration alert Adverse Effects Contraindication Interactions Treatment of overdoses December 15, 2024 53  4- Anticonvulsant drugs ✓ Epilepsy is a common condition that affects the brain and causes frequent seizures. ✓ Anticonvulsant drugs inhibit neuromuscular transmission. They can be prescribed for: Long-term management of chronic epilepsy (recurrent seizures) Short-term management of acute isolated seizures not caused by epilepsy, such as seizures after trauma or brain surgery. ✓ In addition, some anticonvulsants are used in the emergency treatment of status epilepticus (a continuous seizure state). ✓ Treatment of epilepsy should begin with a single drug, increasing the dosage until seizures are controlled or adverse effects become problematic.  4- Anticonvulsant drugs Hydantoins Phenytoin, Phenytoin sodium, Fosphenytoin, Ethotoin Pharmacodynamic: In most cases, the hydantoin anticonvulsants stabilize nerve cells to keep them from getting overexcited. Phenytoin appears to work in the motor cortex of the brain, where it stops the spread of seizure activity. Pharmacotherapeutics: Complex partial seizures, Tonic- clonic seizures (phenytoin), status epilepticus (Phenytoin, fosphenytoin) Side Effect: Drowsiness, ataxia, irritability and restlessness, nystagmus, ventricular fibrillation (in toxic states), bradycardia, hypotension, and cardiac arrest (with IV) December 15, 2024 55  4- Anticonvulsant drugs Hydantoins Phenytoin, Phenytoin sodium, Fosphenytoin, Ethotoin Nursing Role: ✓Mix with normal saline solution if necessary and infuse over 30 to 60 minutes with an in-line filter. ✓Avoid giving phenytoin by IV push into veins on the back of the hand to avoid discoloration known as purple glove syndrome. Inject into larger veins or a central venous catheter, if available. ✓Discard any unused drug 4 hours after preparation for IV administration. ✓Don’t give phenytoin IM unless dosage adjustments are made. ✓Be aware that the drug may discolour the urine (red, pink or red brown December 15, 2024 57  Question In the showing picture, what is the total dose of medication in the box? A. 200 mg B. 500 mg C. 1000 mg D. 1500 mg December 15, 2024 56  4- Anticonvulsant drugs Benzodiazepines: Diazepam (in the parenteral form), Clonazepam, Clorazepate, Lorazepam Pharmacodynamic: Benzodiazepines act as: anticonvulsants antianxiety agents, sedative-hypnotic, muscle relaxants. Pharmacotherapeutics: Drug of choice of status epilepticus (IV lorazepam) Control status epilepticus (IV diazepam), Long-term treatment of epilepsy (Clonazepam). Side effects: Dizziness, nystagmus, vertigo, dysarthria, tremor, glassy-eyed appearance. Nursing Implementation ✓If giving the IV form of diazepam, administer no more than 5 mg/minute and inject directly into a vein. ✓Have emergency resuscitation equipment and oxygen at the bedside when giving these drugs IV. ✓Use IM forms only when the IV and oral routes aren’t applicable; IM forms aren’t recommended because absorption is variable and injection is painful. ✓Don’t store parenteral diazepam solutions in plastic syringes. December 15, 2024 60  4- Anticonvulsant drugs Barbiturates: Phenobarbital, Mephobarbital Pharmacodynamic: Barbiturates exhibit anticonvulsant action at doses below those that produce hypnotic effects. For this reason, barbiturates usually don’t produce addiction when used to treat epilepsy. Barbiturates elevate the seizure threshold by decreasing postsynaptic excitation. Pharmacotherapeutics: Partial seizure, Tonic-clonic seizure, Febrile seizure Status epilepticus (IV phenobarbital) Side Effects: Nystagmus, confusion, and ataxia (with large doses) Laryngospasm, respiratory depression, and hypotension (when IV Adm.). Nursing Implementation ✓IV phenobarbital is reserved for emergency treatment; monitor the patient’s respirations closely and don’t give more than 60 mg/ minute. Have resuscitation equipment available. ✓Don’t stop the drug abruptly because seizures may worsen. Call the prescriber immediately if adverse reactions occur. ✓Give the IM injection deeply. Superficial injection may cause pain, sterile abscess, and tissue sloughing. December 15, 2024 59  Activity Medication name Therapeutic class Pharmacologic class Action Uses Administration alert Adverse Effects Contraindication Interactions Treatment of overdoses December 15, 2024 58  5- Antimigraine Drugs ❖ A migraine, an episodic headache disorder, is one of the most common primary headache disorders described as a unilateral headache pain that’s pounding, pulsating, or throbbing. Other symptoms typically associated with a migraine are sensitivity to light or sound, nausea, vomiting, and constipation or diarrhea. ❖ Treatment for migraines is targeted at altering an attack after it’s underway (abortive and symptomatic treatment) or preventing the attack before it begins.  5- Antimigraine Drugs: 5-HT Agonists Almotriptan, Eletriptan, Frovatriptan, Naratriptan, Rizatriptan, Sumatriptan Pharmacodynamic: Triptans are specific serotonin 5-HT1 receptor agonists that result in cranial vessel constriction as well as inhibition and reduction of the inflammatory process along the trigeminal nerve pathway. These actions may abort or provide symptomatic relief for a migraine. Triptans are effective in controlling the pain, and vomiting associated with migraines Pharmacotherapeutics: Migraine attacks Side Effects: Tingling, warm or hot sensations or flushing, nasal and throat discomfort, visual disturbances, paresthesia, dizziness, neck or throat pain, jaw pain, injection site reaction (S/C sumatriptan), taste disturbances (intranasal sumatriptan) Nursing Implementation ✓Give the dose as soon as the patient complains of migraine symptoms. ✓Reduce the dosage in a patient with poor renal or hepatic function. ✓Repeat the dose as ordered and as needed. ✓Don’t give more than two doses within 24 hours. December 15, 2024 62  5- Antimigraine Drugs: Ergotamine Preparations Ergotamine , Dihydroergotamine Pharmacodynamic: Ergotamine-derivative antimigraine effects as blockage of neurogenic inflammation. It also act as partial agonists or antagonists at serotonin, dopaminergic, and alpha- adrenergic receptors, depending on their site. Ergotamine preparations need to be prescribed with antiemetic preparations when used for migraines. Pharmacotherapeutics: Vascular headaches (migraines, migraine variants, and cluster headaches) Side Effect: Numbness, tingling, muscle pain, leg weakness Nursing Implementation ✓Give the dose as soon as the patient complains of migraine symptoms. ✓Avoid prolonged administration and don’t exceed the recommended dosage. ✓Tell the patient to withhold food and drink while the sublingual tablets are dissolving. ✓Sublingual tablets are preferred during the early stage of an attack because of their rapid absorption. December 15, 2024 63  Pain Medications Drugs and pain control ❖ Pain management is an aspect of medicine and health care involving relief of pain in various dimensions, from acute and simple to chronic and challenging. ❖ Drugs used to control pain range from mild, over- the-counter (OTC) preparations, such as acetaminophen, to potent general anesthetics. ❖ Drug classes in this category include: ✓Nonopioid analgesics, antipyretics, and nonsteroidal anti-inflammatory drugs (NSAIDs) ✓Opioid agonist and antagonist drugs ✓Anesthetic drugs.  Nonopioid analgesics, antipyretics, and NSAIDs Nonopioid analgesics, antipyretics, and NSAIDs are a broad group of pain medications. In addition to pain control, they produce antipyretic (fever control) and anti- inflammatory effects. The drug classes included in this group are: Salicylates (especially aspirin), which are widely used Acetaminophen, a para-aminophenol derivative NSAIDs (nonselective and selective) Phenazopyridine hydrochloride, urinary tract analgesic 65  Activity Medication name Therapeutic class Pharmacologic class Action Uses Administration alert Adverse Effects Contraindication Interactions Treatment of overdoses December 15, 2024 66  Salicylates: Aspirin –Diflunisal -Olsalazine Pharmacodynamic: They relieve pain primarily by inhibiting the synthesis of prostaglandin. In addition, they may reduce inflammation by inhibiting prostaglandin synthesis and release that occur during inflammation. Salicylates reduce fever by stimulating the hypothalamus and producing peripheral blood vessel dilation and increased sweating. One salicylate, aspirin, inhibits platelet aggregation. Pharmacotherapeutics: Pain, Fever, Rheumatoid arthritis, Osteoarthritis December 15, 2024 67  Salicylates: Aspirin –Diflunisal -Olsalazine Side Effects: Gastric distress, nausea, vomiting, and bleeding tendencies. Hearing loss (when taken for prolonged periods) Nursing Implementation ✓Give aspirin with food, milk, antacids, or a large glass of water to reduce GI reactions. ✓If the patient has trouble swallowing the drug, crush tablets or mix them with food or fluid. On the other hand, don’t crush enteric- coated aspirin. ✓Stop aspirin 5 to 7 days before elective surgery as ordered. December 15, 2024 68  Nonselective NSAIDs: Indomethacin, Ibuprofen, Diclofenac Pharmacodynamic: Inflammatory disorders produce and release prostaglandins from cell membranes, resulting in pain. Nonselective NSAIDs produce their effects by inhibiting prostaglandin synthesis and cyclooxygenase activity. Pharmacotherapeutics: Inflammation (primary action) as ankylosing spondylitis, rheumatoid arthritis, osteoarthritis, gouty arthritis) pain (dysmenorrhea, migraines, tendinitis, Headache), fever. Side Effects: Liver toxicity, pedal edema, kidney necrosis, ulcers, hypertension, and heart failure. Nursing Implementation ✓Administer oral NSAIDs with 240 mL of water to ensure adequate passage into the stomach. ✓Have the patient sit up for 15 to 30 minutes after taking the drug to prevent it from lodging in the esophagus. ✓Give the drug with meals or milk or administer it with antacids to reduce adverse GI reactions December 15, 2024 69  Opioid agonists & antagonists ✓ The word opioid refers to any derivative of the opium plant or any synthetic drug that imitates natural narcotics. ✓ Opioid agonists (also called narcotic agonists) include opium derivatives and synthetic drugs with similar properties. They’re used to relieve or decrease pain without causing the person to lose consciousness. ✓ Opioid antagonists aren’t pain medications. They block the effects of opioid agonists and are used to reverse adverse drug reactions, such as respiratory and CNS depression, produced by those drugs.  Opioid Agonists Codeine, Fentanyl, Morphine, Meperidine, Tramadol Pharmacodynamic: Opioid agonists reduce pain by binding to opiate receptor sites in the peripheral nervous system and the CNS. When these drugs stimulate the opiate receptors, they mimic the effects of endorphins. This receptor-site binding produces the therapeutic effects of analgesic and cough suppression as well as respiratory depression and constipation. Pharmacotherapeutics: Severe pain (acute, chronic, and terminal ill), GA (fentanyl), Shortness of breath (pulmonary edema, HF) (Morphine). Side Effects: Resp. Depression, Pupil Constriction, Palpitations, delirium, neurotoxicity and seizures if administrated more than 48 hours December 15, 2024 71  Opioid Agonists Codeine, Fentanyl, Morphine, Meperidine, Tramadol Nursing Implementation ✓Keep resuscitative equipment and a narcotic antagonist (naloxone) available. ✓Give the IV form of the drug by slow injection, preferably in a diluted solution. ✓Rapid IV injection increases the risk of adverse effects. ✓Give IM or subcutaneous injections cautiously to a patient with a decreased platelet count and to a patient who’s chilled, hypovolemic, or in shock; decreased perfusion may lead to drug accumulation and toxicity. ✓Rotate injection sites to avoid induration. ✓If breast feeding wait for 4-6 hours before starting feeding. ✓Avoid alcohol intake which increases CNS depression. December 15, 2024 72  Activity Medication name Therapeutic class Pharmacologic class Action Uses Administration alert Adverse Effects Contraindication Interactions Treatment of overdoses December 15, 2024 73  Opioid Antagonist Naloxone hydrochloride, Naltrexone hydrochloride Pharmacodynamic: Opioid antagonists block the effects of opioids by occupying the opiate receptor sites, displacing opioids attached to opiate receptors, and blocking further opioid binding at these sites Pharmacotherapeutics: Opioid overdose (respiratory depression) Side Effect: Phlebitis, Shortness of breath, Disorientation Nursing Implementation ✓Provide oxygen, ventilation, and other resuscitation measures when the drug is used in the management of acute opiate overdose and when the patient has severe respiratory depression. ✓Keep in mind that these drugs are effective in reversing respiratory depression only when it’s caused by opioids. When they’re used for this purpose, monitor the patient for tachypnea. ✓Be prepared to give continuous IV naloxone infusion to control the effects of epidural morphine. December 15, 2024 74  Anesthetic Drugs Inhalation Anesthetics: Desflurane, Sevoflurane, Enflurane Pharmacodynamic: Inhalation anesthetics work primarily by depressing the CNS, producing loss of consciousness, loss of responsiveness to sensory stimulation (including pain), and muscle relaxation. They also affect other organ systems. Pharmacotherapeutics: General Anesthesia Side Effects: Malignant hyperthermia, depression of breathing circulation collapse, ataxia, hypothermia. Nursing Implementation ✓Explain the preoperative and expected postoperative phases of the recovery period. ✓Review postoperative recovery requirements, such as deep breathing exercises, coughing, leg exercises, early ambulation, maintaining fluid balance, and urine output. ✓Monitor the patient’s vital signs, level of consciousness (LOC), respiratory and cardiovascular status, and laboratory results, as indicated. December 15, 2024 75  Anesthetic Drugs IV Anesthetics: Ketamine, Midazolam, Fentanyl, Propofol, Thiopental Pharmacodynamic: Ketamine appears to induce a profound sense of dissociation from the environment by acting directly on the cortex and limbic system of the brain Pharmacotherapeutics: General Anesthesia (shorter surgical procedures) Side Effect: Prolonged recovery, Delirium or hallucinations, Increased cerebrospinal fluid and eye pressure Nursing Implementation ✓Explain the preoperative and expected postoperative phases of the recovery period. ✓Review postoperative recovery requirements, such as deep breathing exercises, coughing, leg exercises, early ambulation, maintaining fluid balance, and urine output. ✓Monitor the patient’s vital signs, level of consciousness (LOC), respiratory and cardiovascular status, and laboratory results, as indicated. December 15, 2024 76  Anesthetic Drugs Local Anesthetics: Amide drugs (Lidocaine, Ropivacaine) - Ester Drugs (Chlorprocaine, Tetracaine). Pharmacodynamic: Local anesthetics block nerve impulses at the point of contact in all kinds of nerves. For example, they can accumulate and cause the nerve cell membrane to expand. As the membrane expands, the cell loses its ability to depolarize, which is necessary for impulse transmission Pharmacotherapeutics: General Anesthesia (elderly and co-morbidities surgery) Side Effect: tachycardia, Blurred Vision, irritability, Angina, Hypertension, Palpitation Nursing Implementation ✓Explain the purpose of therapy and its intended effect. ✓Monitor the patient’s vital signs, level of pain, respiratory and cardiovascular status, and laboratory results as indicated. ✓Monitor the patient’s response to medication. December 15, 2024 77