_[NUR 213] UNIT 4_ Autonomic Nervous System Drugs.pdf

NUR 213: PHARMACOLOGY UNIT 4: AUTONOMIC NERVOUS SYSTEM DRUGS LEVEL 2: DIVISION OF MATERNAL AND CHILD NURSING PERIPHERAL NERVOUS SYSTEM (PNS) OUTLINE...

NUR 213: PHARMACOLOGY UNIT 4: AUTONOMIC NERVOUS SYSTEM DRUGS LEVEL 2: DIVISION OF MATERNAL AND CHILD NURSING PERIPHERAL NERVOUS SYSTEM (PNS) OUTLINE Around or inside the center. Gives a message through impulse to CNS & produces I. Nervous System response from the CNS instructions. A. Central Nervous System B. Peripheral Nervous System PNS TWO MAIN SUBSYSTEMS 1. Somatic Somatic 2. Autonomic - Acts on the skeletal muscles to produce II. Autonomic Nervous System (ANS) movements and respiration (voluntary in A. Sympathetic Nervous System function). 1. Receptors Autonomic 2. Neurotransmitter Inactivation - Works with Endocrine system in regulating & B. Parasympathetic Nervous System integrating internal body functions 1. Receptors (involuntary). III. Drugs Acting on ANS A. Adrenergics AUTONOMIC NERVOUS SYSTEM (ANS) 1. 3 Categories of Sympathomimetics SYMPATHETIC NERVOUS SYSTEM (SNS) 2. Adrenergic Drugs Prepares the body to respond to stress. 3. Nursing Management: Adrenergics Neurotransmitter: Norepinephrine B. Adrenergic Blockers 1. Alpha 1 Blockers 2. Beta Blockers 3. Nursing Management: Adrenergic Blockers C. Cholinergics 1. Direct Acting Cholinergics 2. Indirect Acting Cholinergics a. Reversible Cholinesterase Inhibitors b. Irreversible Cholinesterase Inhibitors 3. Nursing Management: Cholinergics D. Anticholinergics 1. Muscarinic Antagonist 2. Antiparkinsonian-Anticholinergics 3. Nursing Management: Anticholinergics E. Anticholinergics F. Cholinergics G. Pharmacology Neuroleptics/ Mental and Figure 1. Sympathetic Responses Behavioral Health Drugs Antipsychotics a. Dopamine RECEPTORS b. Serotonin 1. Alpha 1 - constriction of arterioles & venules, c. Norepinephrine increases BP, increases peripheral resistance & blood d. Acetylcholine return to the heart. NERVOUS SYSTEM Receive stimuli and transmit information to nerve centers to produce a response. Two main parts: ○ Central nervous system ○ Peripheral nervous system CENTRAL NERVOUS SYSTEM (CNS) Brain & Spinal cord Receive and interpret messages from PNS and return the instruction to produce a response. 1  NUR 213: Unit 2 - Contemporary Issues in Pharmacology Figure 4. Beta 2 locations and their pharmacodynamics 4. Alpha 2 - Modulator of norepinephrine & insulin Figure 2. Alpha 1 locations and their pharmacodynamics release, decreases BP & prevents over stimulation. 2. Beta 1 - Increases myocardial contractility, increases HR, and breakdown fats to be used as energy. Figure 5. Alpha 2 locations and their pharmacodynamics NEUROTRANSMITTER INACTIVATION Prevents prolonging of effects through: 1. Reuptake back into the neuron. 2. Enzymatic transformation or degradation. 3. Diffusion away from the Receptors. PARASYMPATHETIC NERVOUS SYSTEM (PSNS) Figure 3. Beta 1 locations and their pharmacodynamics Rest & digest response. Neurotransmitter: Acetylcholine 3. Beta 2 - Dilate the bronchi & increase the passageway of air in & out of lungs. RECEPTORS 1. Muscarinic receptors - Slows HR & affect smooth muscles 2. Nicotinic receptors - Affect skeletal muscles & for locomotion DRUGS ACTING ON ANS Mimic or copies the functions of the receptors & neurotransmitters of ANS. ADRENERGICS Drugs that copy or imitate the function of SNS. 2  NUR 213: Unit 2 - Contemporary Issues in Pharmacology Stimulate adrenergic/SNS receptors 2. Monitor CR, PR and BP. 3. Monitor IV site for infiltration. CATEGORIES OF SYMPATHOMIMETICS 4. Monitor blood glucose level. 1. Direct Acting Sympathomimetics - The drug itself 5. Manage anticholinergics side effects, such as hard will stimulate the SNS receptors. candies for dry mouth, high fiber diet for constipation, Ex. Epinephrine (adrenalin) Norepinephrine monitor urine output & urinary retention, void first (Levophed) before taking oral drugs and prevent injury. Monitor for blurring of vision. 2. Indirect Acting Sympathomimetics - The drug will stimulate the release of SNS neurotransmitters. ADRENERGIC BLOCKERS Ex. Amphetamines Drugs that block or hinders the effects of adrenergics & SNS 3. Mixed Acting Sympathomimetics - The drug will do Ensembles some of the action of PSNS. the action of direct & indirect Sympathomimetics. Ex: Ephedrine ALPHA 1 BLOCKERS Block or inhibit a response at the alpha-adrenergic receptor site. Promote vasodilation, causing a decrease in blood pressure. Ex: amiodarone (Cordarone), bretylium (Bretylate) For antiarrhythmia BETA BLOCKERS 1. Beta 1 & 2 blockers / non-selectives ○ Ex: Propranolol (Indieral) Figure 6. (A) Direct-acting sympathomimetics. (B) ○ Decreases HR & BP, could not be given in Indirect-acting sympathomimetics. (C) Mixed-acting COPD clients. sympathomimetics. 2. Beta 1 blocker / selectives ADRENERGIC DRUGS ○ Ex. Metoprolol (Lopressor) ○ Could be given in COPD clients epinephrine treatment of shock & anaphylaxis 3. Adrenergic neuron blockers ○ Block norepinephrine release from the albuterol act on beta 2, for asthmatic client terminal neuron. ○ Ex: guanadrel (Hylonel), guanethidine norepinephrine given IVTT to treat shock or in (Ismelin) (Levophed) cardiac arrest NURSING MANAGEMENT (ADRENERGIC BLOCKERS) 1. Contraindicated in bradycardia and heart block with dopamine increases HR & BP, increase adverse effects such as paresthesia, hypotension, blood flow to the kidneys and bronchospasm. 2. Monitor CR, PR, RR and BP. 3. Rise slowly from sitting to standing position. dobutamine for Congestive Heart Failure, 4. Prevent orthostatic hypotension. increases the force or pumping action of the heart REVIEW QUESTIONS ephedrine use as nasal decongestants QUESTIONS CHOICES isoproterenol acts on beta 1&2, for bronchodilation 1. The nurse will monitor the a. Palpitations patient taking albuterol for b. Hypertension which conditions? (Select all c. Hypoglycemia clonidine (Catapres) acts on alpha 2, decreases BP, for that apply.) & methyldopa hypertension d. Bronchospasm (Aldomet) e. Uterine contractions f. Hypotension Table 1. Adrenergic Drugs g. Blurred vision NURSING MANAGEMENT (ADRENERGICS) The side effects of albuterol are chest pain and rapid 1. Adrenergics are contraindicated in ventricular heartbeat (stimulates beta 2 receptors in the heart), and it is fibrillation & with adverse effects such as arrhythmias used to treat bronchospasms in patients. & hypertension. 3  NUR 213: Unit 2 - Contemporary Issues in Pharmacology 2. Nadolol is prescribed for a a. Hypothyroidism for which condition? (Select all e. Erythema patient. The nurse realizes that b. Angina pectoris that apply.) this drug is a beta-adrenergic c. Bronchial asthma blocker and is contraindicated d. Liver dysfunction Metoprolol is a selective beta 1 - adrenergic blocker, for patients with which meaning it blocks beta 1 receptors located in the heart. It condition? lowers heart rate, myocardial contractility, and blood pressure. Nadolol is a non-selective beta-adrenergic blocker, meaning 7. The nurse is administering a. Ginseng it inhibits both beta 1 and beta 2 receptors. This is why nadolol is used to treat conditions such as angina but must atenolol to a patient. Which b. Insulin be used cautiously in patients with respiratory ailments such concurrent drugs does the nurse c. Atropine as asthma because the side effects of nadolol include expect to most d. Haloperidol shortness of breath. likely cause an interaction? e. Methyldopa (Select all that apply.) 3. The nurse realizes that beta1 a. Increased receptor stimulation is bronchodilation Atropine is anticholinergic which increases heart rate by differentiated from beta2 b. Decreased uterine blocking parasympathetic activity, while atenolol blocks beta stimulation in that stimulation of contractility 1 receptors which slows heart rate. beta1 receptors leads to which c. Increased myocardial condition? contractility Methyldopa lowers blood pressure by acting on the CNS, while atenolol reduces heart rate and cardiac output, which d. Decreased blood flow can result in excessive hypotension. to skeletal muscles Insulin with certain antibiotics, beta blockers such as Beta 1 receptors are located in the kidneys and primarily in atenolol, and other diabetes medications can increase the the heart. Their stimulation increases heart rate and risk of low blood glucose. contractility. While haloperidol can cause arrhythmias by prolonging the 4. A patient is given a. Decreased pulse QT interval but its interaction with atenolol in heart rate is epinephrine, an adrenergic b. Pupil constriction less direct. Also since ginseng have mild stimulant effects agonist (sympathomimetic). The c. Bronchial constriction with blood pressure medications, the interaction is generally not as significant and less likely. nurse should monitor the patient d. Increased blood for which condition? pressure Epinephrine targets the eyes, heart, airways, blood vessels in your skin and the adrenal gland. It functions primarily to increase cardiac output and to raise glucose levels in the blood. 5. A patient who is taking a. Albuterol epinephrine is also taking b. Metoprolol several other medications. The c. Propranolol nurse should realize that there d. Digoxin is a possible drug interaction e. Methyldopa with which drugs? (Select all that apply.) Beta blockers can block the effects of epinephrine. These include metoprolol and propanolol. Digoxin on the other hand may occasionally cause an irregular heart rhythm. The selective beta 2 receptor drug albuterol causes bronchodilation in the lungs, while methyldopa acts as an alpha 2 agonist which leads to vasoconstriction and an increase in blood pressure. 6. A patient is prescribed a. Bradycardia metoprolol to treat b. Hypotension hypertension. It is important for c. Diaphoresis the nurse to monitor the patient d. Agitation 4  NUR 213: Unit 2 - Contemporary Issues in Pharmacology Increased pupillary constriction or CHOLINERGICS miosis (pupil becomes smaller) and Drugs that copy or imitate the functions of PSNS. Ocular increased accommodation Stimulates cholinergic receptors. (flattening or thickening of eye lens for distant or near vision) Increased salivation, perspiration, Glandular and tears Stimulation of bronchial smooth Bronchial muscle contraction and increased (lung) bronchial secretions Increased neuromuscular Striated muscle transmission and maintenance of muscle strength and tone Table 2. Effects of Cholinergic Agonists 1. bethanechol - (Urecholine), (Duvoid) Figure 7. Parasympathetic transmitters and receptors. - Increases urination. 2. metoclopramide - (Reglan), (Plasil) - Increases gastric emptying time, for GERD and nausea and vomiting. 3. pilocarpine - Constrict pupils and for treatment of glaucoma by promoting drainage of aqueous humor. INDIRECT ACTING CHOLINERGICS Cholinesterase inhibitors, acetylcholinesterase Figure 8. (A) Direct-acting parasympathomimetic (cholinergic inhibitors, anticholinesterases agonists), (B) Indirect-acting parasympathomimetic Drugs for Myasthenia Gravis. (cholinesterase inhibitor) Increase the force of muscle contraction and tone. DIRECT ACTING CHOLINERGICS REVERSIBLE CHOLINESTERASE INHIBITORS Stimulate the muscarinic receptors. Binds cholinesterase temporarily. Produce pupil constriction (for glaucoma). Increases muscle strength (or Myasthenia Gravis). EFFECTS OF CHOLINERGIC AGONISTS a. Tensilon Decreased heart rate, lowered blood - Short acting, for MG diagnosis b. Neostigmine (Prostigmin) pressure because of vasodilation, Cardiovascular - Short acting and slowed conduction of - “a parasympathomimetic agent (AChE atrioventricular node inhibitor” (Pharmacology: A Patient-Centered Nursing Process Increased tone and motility of smooth Approach, Mccuistion et al., 11th Ed, p. 453) muscle of stomach and intestine, Gastrointestinal c. Pyridostigmine bromide (Mestinon) increased peristalsis, and relaxed - Intermediate acting. sphincter muscles - Action: Inhibits acetylcholinesterase, blocking destruction of acetylcholine from the Contraction of muscles of the urinary parasympathetic and somatic efferent nerves. bladder, increased tone of ureters, Genitourinary relaxed bladder sphincter - Acetylcholine accumulates, promoting muscles, and stimulated urination increased stimulation of the receptors. - Given in divided doses because of its short half-life 5  NUR 213: Unit 2 - Contemporary Issues in Pharmacology ➔ Overdosing can result in cholinergic EFFECTS OF CHOLINERGIC AGONISTS crisis → can lead to respiratory paralysis and arrest Heart rate increases with large doses; - Use cautiously in patients with bronchial Cardiovascular small doses can decrease heart rate. asthma, bradycardia, arrhythmias, epilepsy, recent coronary occlusion, vagotonia, renal Relaxed smooth muscle tone of GI impairment, hyperthyroidism, glaucoma, or tract, decreased GI motility and peptic ulcer.” Gastrointestinal peristalsis; gastric and (Nursing 2024 Drug Handbook, Wolters Kluwer, 44th intestinal secretions are decreased Ed., p. 1263) Relaxed bladder detrusor muscle and (Pharmacology: A Patient-Centered Nursing Process Urinary increased constriction of internal Approach, Mccuistion et al., 11th Ed, p. 453) sphincter; urinary retention can result. d. Ambenonium chloride (Metylase) -long acting. Dilated pupils (mydriasis) and e. Physostigmine - ophthalmic paralyzed ciliary muscles Ocular IRREVERSIBLE CHOLINESTERASE INHIBITORS (cycloplegia) cause a decrease in Binds cholinesterase permanently. accommodation. Antidote: pralidoxime (protopam) - reverse the permanent binding. Salivation, perspiration, and bronchial Glandular secretions are decreased. NURSING MANAGEMENT (CHOLINERGICS) 1. Contraindicated in clients with peptic ulcer disease, Bronchi are dilated, and bronchial intestinal and urinary obstructions with adverse effects Bronchial secretions decrease. of cardiac arrest and side effects of hypotension and bradycardia. Tremors and rigidity of muscles are 2. Monitor CR, PR, and BP. 3. Monitor urinary output. Central nervous decreased; drowsiness, Acceptable urinary output: at least 30cc/ 40 cc per system disorientation, and hallucinations can hour (if not it should be reported at once to the doctor) result from large doses. After surgery, some patients could have post op pain Table 3. Effects of Anticholinergic Agonists and is given morphine. Adverse reaction of morphine: CNS depression, urine output (decreased Atropine sulfate - Increases HR and urine output) decreases salivary & 4. Watch out for N/V, increase urination and diarrhea. 5. BRAT diet. respiratory secretions. Bread, rice, applesauce, and toast - Muscarinic antagonist Antiparkinsonian - - Decrease salivation & ANTICHOLINERGICS anticholinergics drooling, and decrease Drugs that block the effect of Cholinergics and PSNS. tremors & rigidity Resembles some of the action of SNS. - Ex. Biperidine (Alinelon), Benztropine mesylate (cogentin) propantheline - Skin patch behind the bromide ear (Probanthine) scopolamine - Increases HR & BP, increase blood flow to the kidneys meclizine HCI - Formation sickness. (Bonamine) Table 4. Effects of Cholinergic Agonists Figure 9. Anticholinergic Response. 6  NUR 213: Unit 2 - Contemporary Issues in Pharmacology NURSING MANAGEMENT (ANTICHOLINERGICS) which parasympathetic c. Cholinesterase 1. Contraindicated in glaucoma, intestinal atony, and neurotransmitter? d. Monoamine oxidase paralytic ileus with adverse effect of severe constipation and S/E of pupil dilation, blurring of vision, dry mouth, and insomnia. Cholinergic agonists mimic the action of acetylcholine, the 2. Manage anticholinergics side effects such as hard primary neurotransmitter of the parasympathetic nervous candies for dry mouth, high fiber diet for constipation, system. monitor urine output & urinary retention, void first before taking oral drugs and prevent injury. 6. The nurse is administering a. Increased heart rate 3. Monitor for blurring of vision. bethanechol, a cholinergic b. Decreased peristalsis agonist, and should know that c. Decreased salivation REVIEW QUESTIONS the expected cholinergic effects d. Increased pupil include which of the following? constriction QUESTIONS CHOICES Bethanechol, as a cholinergic agonist, produces parasympathetic effects such as miosis, increased 1. A patient is receiving a. Glaucoma peristalsis, and increased salivation. bethanechol. The nurse b. Urinary retention realizes that the action of this c. Delayed gastric 7. When a patient has a a. Atropine drug is to treat which emptying condition? d. Gastroesophageal cholinergic overdose from b. Tolterodine reflux disease excessive dosing of c. Benztropine e. Gastroparesis bethanechol, the nurse d. Metoclopramide f. Parkinsonism anticipates administration of g. Myasthenia gravis which drug as the antidote? Bethanechol is a cholinergic agonist that stimulates Atropine, an anticholinergic, is the antidote for cholinergic muscarinic receptors, promoting bladder contraction and overdose, reversing the excessive stimulation of muscarinic treating urinary retention. receptors caused by drugs like bethanechol. 2. The nurse teaches the patient a. Diarrhea receiving atropine to expect b. Sweating which side effect? c. Blurred vision d. Frequent urination PHARMACOLOGY NEUROLEPTICS/ MENTAL AND Atropine is an anticholinergic drug that blocks the action of acetylcholine, leading to effects such as blurred vision due BEHAVIORAL HEALTH DRUGS ANTIPSYCHOTICS to pupil dilation (mydriasis). Other expected side effects Book: CNS depressants used to manage symptoms include dry mouth, urinary retention, and constipation. of psychosis and anxiety disorders include antipsychotics and anxiolytics, which may cause 3. When benztropine is ordered a. Parkinsonism psychosis. Antipsychotics are also known as for a patient, the nurse b. Paralytic ileus neuroleptics or psychotropics, but the preferred name acknowledges that this drug is c. Motion sickness for this group is either antipsychotics or neuroleptics. an effective treatment d. Urinary retention The term neuroleptic refers to any drug that for which condition? modifies psychotic behavior and exerts an antipsychotic effect. Anxiolytics are also called Benztropine is an anticholinergic medication used to treat antianxiety drugs or sedative-hypnotics. Certain Parkinsonism by decreasing tremors and muscle rigidity. anxiolytics are used to treat sleep disorders, seizures, and withdrawal symptoms from alcohol or other abuse 4. Dicyclomine is an a. Mydriasis substances. Some of these drugs are also used for anticholinergic, which the nurse b. Constipation conscious sedation and anesthesia supplementation. realizes is given to treat which c. Urinary retention condition? d. Irritable bowel Hallucination - The patient is seeing based on their own syndrome perception, however it does not exist for a normal person. Dicyclomine is an antispasmodic anticholinergic drug that is used to treat irritable bowel syndrome (IBS) by reducing Types of Delusion muscle spasms in the gastrointestinal tract. Delusion of grandeur - It's when a person believes that they have more power, wealth, smarts, or other grand traits than is 5. The nurse realizes that a. Dopamine true. cholinergic agonists mimic b. Acetylcholine 7  NUR 213: Unit 2 - Contemporary Issues in Pharmacology Delusion of persecution- It's when a person is convinced that ○ Thoughts, distortion of reality, delusions, someone is mistreating, conspiring against, or planning to hallucinations, incoherence, catatonia, and harm you or your loved one. aggressive or violent behavior. SCHIZOPHRENIA DOPAMINE Most common type of psychosis characterized by Regulation of cognition, motivation and emotional hallucination, paranoia, delusions, speech responses. abnormalities,(repetitive sentences), and affective ○ Book: The theory is that psychotic problems. symptoms result from an imbalance in the Symptoms usually develop in adolescence or early neurotransmitter dopamine in the brain. adulthood Sometimes these antipsychotics are called dopamine antagonists. Antipsychotics block D2 dopamine receptors in the brain and PSYCHOTIC SYMPTOMS thus reduce psychotic symptoms. Many Results from imbalance of dopamine in the brain. antipsychotics block the chemoreceptor trigger zone (CTZ) and vomiting (emetic) 1. Cognitive symptoms center in the brain, producing an antiemetic ○ Characterized by disorganized thinking, (prevents or relieves nausea and vomiting) memory difficulty, and decreased ability to effect. focus attention. ○ However, when dopamine is blocked, 2. Positive symptoms symptoms of extrapyramidal syndrome ○ Exaggeration of normal function (e.g., (EPS) or parkinsonism (a chronic agitation), incoherent speech, hallucination, neurologic disorder that affects the delusion and paranoia. extrapyramidal motor tract) such as tremors, 3. Negative symptoms mask like facies, rigidity, and shuffling gait ○ Decrease or loss in function and motivation. may develop. Many patients who take ○ Poverty or simplicity of speech, blunted high-potency antipsychotic drugs may effect, inertia, poor self-care, social require long-term medication for symptoms withdrawal. of parkinsonism. ○ More chronic and persistent SEROTONIN Regulate sleep, wakefulness, mood and arousal. MAJOR DEPRESSION ○ Loss of interest in work and home, inability to complete tasks, depressed mood, and loss of energy. NOREPINEPHRINE Control of arousal, attention, mood and affect. BIPOLAR AFFECTIVE DISORDER (MANIC DEPRESSIVE Involved in thinking, planning and interpretation. ILLNESS) Swings of mood between manic (euphoric) and ACETYLCHOLINE depressive (dysphoria). Plays a role in sleep and wakefulness. Figure 2: Common drugs throughout life Prozac is anti-depressant Figure 1. Venn Diagram of Norepinephrine, Serotonin, and 38-65 viagra (increase in sexual dysfuntion) Dopamine REQUIRES PRESCRIPTION SHOULD ; NOT BE TAKEN BY THOSE WITH HYPERTENSION PSYCHOSIS Losing contact with reality. NEUROLEPTICS (ANTIPSYCHOTICS) ○ Book: manifested in a variety of mental or For schizophrenia psychiatric disorders 8  NUR 213: Unit 2 - Contemporary Issues in Pharmacology PHENOTHIAZINES Skin discoloration will disappear within 6 Control psychotic behavior months after drug is discontinued "hallucination, delusion, bizarre behavior" Sunscreen protection: hats, lotions, sun EPS- Major Concern glasses, long sleeves. 2-3 weeks: Therapeutic Effect 3-6 weeks: Full Effect 4. Blood Dyscrasias ORAL: Liquid form Leukopenia, Agranulocytosis Harmless to pinkish red brown urine Flu like symptoms which could develop 3-5 2 hours after meals/no antacids weeks after medication ○ Book: Chlorpromazine hydrochloride was Hematology once/twice in a month the first phenothiazine introduced for treating Protect from infection psychotic behavior in patients in psychiatric Gargle, lozenges and analgesics for sore hospitals. The phenothiazines are throat subdivided into three groups: ○ The aliphatic phenothiazines produce a 5. Neuroleptic Malignant Syndrome strong sedative effect and decreased blood Low grade fever/ BP fluctuations pressure and may cause moderate EPS Stop the next dose and report to doctor (pseudoparkinsonism). Chlorpromazine ANTIDOTE: hydrochloride is in the aliphatic group and ○ Dantrolene Na (Dantrium, Parlodel) may produce pronounced orthostatic - anti-parkinsonians hypotension, low blood pressure that occurs when an individual assumes an upright position from a supine position. ○ The piperazine phenothiazines produce more EPS than other phenothiazines. They EXTRAPYRAMIDAL SYMPTOMS MNEMONICS also cause dry mouth, blurred vision, weight Dystonia gain, and agranulocytosis. Examples of Akathisia piperazine phenothiazines are fluphenazine Pseudoparkinsonism and perphenazine. Incoordination ○ The piperidine phenothiazines have a Tardive dyskinesia strong sedative effect, cause few EPS, have And a low to moderate effect on blood pressure, Neuroleptic malignant syndrome and have no antiemetic effect. TYPES OF PHENOTHIAZINES NURSING MANAGEMENT 1. Aliphatics 1. Drowsiness and orthostatic hypotension Strong sedatives, moderate EPS Monitor BP, no alcohol and sedatives Ex. Chlorpromazine (Thorazine) Supine for 1 hour after administration Triflupromazine (Vesprin) Change position slowly No driving of automobile 2. Piperidines Strong sedatives, few EPS 2. EPS (Extra Pyramidal Symptom) Ex. Thioridazine (Mellaril) Pseudo-parkinsonism - characterized by Mesoridazine (Serentil) tremors, muscle spasms and bradykinesia. Akathisia - movement disorder, 3. Piperazines characterized by restlessness or the inability Strong anti emetics and EPS low sedative to stay still Ex. Fluphenazine (Prolixin) Dystonia - involuntary maintained Trifluoperazine (Stelazine) contraction of agonist and antagonist muscles yielding abnormal posturing, BUTYROPHENONE twisting and repetitive movements, or Control psychotic behavior tremulous and can be initiated or worsened Less sedative effect than phenothiazines by attempted movement. EPS - Major concern Tardive Dyskinesia - repetitive involuntary ORAL: After meals movements NURSING MANAGEMENT IF TAKEN WITH ANTICHOLINERGICS (AKINETON, 1. No alcohol and monitor BP BENADRYL, COGENTIN) SIDE EFFECTS: CANT - 2. EPS anticholinergics SEE - Change position slowly 3. Leukocytosis PEE - Monitor for retention ○ Protect from infection SPIT - Hard candy, sips of water ○ Ex. Haloperidol (Haldol, Innovar, Serenase) SHIT - Increase fiber in diet 3. Photosensitivity HALDOL AND PROLIXIN Haloperidol Decanoate 9  NUR 213: Unit 2 - Contemporary Issues in Pharmacology Fluphenazine Decanoate 1. Long acting type QUETIAPINE (SEROQUEL) 2. Given once a month Can cause drowsiness and dizziness 3. Slow injection, 21 gauge needle Change position slowly 4. Z-track technique, deep IM 5. Do not massage injection site ATYPICAL ANTIPSYCHOTIC SIDE EFFECTS MNEMONICS 6. Rotate sites Constipation 7. Should not remain in a plastic syringe longer than 15 Orthostatic hypotension minutes. Weight gain Agranulocytosis TYPICAL ANTIPSYCHOTIC SIDE EFFECTS MNEMONICS Reassess blood sugar (hyperglycemia) Extra, Drowsiness Drowsiness & EPS Orthostatic hypotension Photosensitivity Agranulocytosis ATYPICAL ANTIPSYCHOTIC DRUGS For (+) and (-) symptoms of schizophrenia without significant EPS Few side effects: Common S/E: weight gain CLOZAPINE (CLOZARIL) Agranulocytosis ○ WBC less than 3000 mm3= D/C Figure 6: Saphris tablets ○ Protect from infection ○ Monitor WBC count weekly for 6 months SAPHRIS Constipation Given SL ○ Increase fiber in diet S- water should not be given since its given SL, giving water ○ NMS may cause the drug to not be fully absorbed by the tongue S - SL : Fast dissolving tablet A - Asenapine P - Pertinent Atypical Antipsychotic H - Hypotension (orthostatic) R - Reduces (-) symptoms I - Improve cognitive function S - Should not be given with food and H2O for 10 min MINOR TRANQUILIZERS Figure 4: Clozapine tablets ANXIOLYTIC/ANTI ANXIETY MEDICATIONS RISPERIDONE (RISPERDAL) For anxiety and sleep disorders NMS Pre-op meds Muscle relaxants, anticonvulsants Alcohol and Drug withdrawal ○ Ex. Chlordiazepoxide (Librium) BETA BLOCKERS For stress anxiety resulting to ANS symptoms NURSING MANAGEMENT 1. No alcohol/other sedatives Figure 5: Risperdal tablets 2. Taper slowly the dose and frequency OLANZAPINE (ZYPREXA) 3. Don't stop abruptly for withdrawal S/Sx Effective for treating the (+) and (-) symptoms of 4. Severe withdrawal S/Sx schizophrenia - If taken in/ over 8 months (high dose) Side Effects: Drowsiness, dizziness, hyperglycemia, 5. Avoid driving/ operating of machinery orthostatic hypotension 10  NUR 213: Unit 2 - Contemporary Issues in Pharmacology 6. Lead to physical and emotional dependence and tolerance. 7. Benzodiazepines: - No with tobacco, caffeine and pregnancy EXAMPLES OF ANXIOLYTICS A. BENZODIAZEPINES - “AM” Diazepam (Vallum) Flurazepam (Dalmane) Lorazepam (Ativan) Triazolam (Helcion) Oxazepam (Serax) Clonazepam (Klonopin) - anticonvulsant B. PROPANEDIOLS Meprobamate (Equanil, Miltown) SUBSTANCE ABUSE Ingestion of any mind altering non prescribed substances which may result to physical, psychological dependence and tolerance Figure 7 : Uppers and Downers uppers - increase vital signs in the body. Withdrawals symptoms ALCOHOLISM give downers effects; Disulfiram (Antabuse) - “Anti alcoholic agent" downers - decrease in vital signs. Withdrawals symptoms gives Cause unpleasant reaction when combined with uppers effects alcohol: - Headache, dizziness, N/V, sweating, palpitation, and hypotension Use as last recourse NURSING MANAGEMENT 1. Avoid alcohol Reaction begins 5-10 minutes if combined anc is equal to amount of alcohol ingested 2. Best taken 12 hours after abstaining from alcohol 3. No alcohol containing substances: Ex. Mouthwash, Liniments, OTC cold remedies, Figure 8: MAO Mechanism: how it affects the body Menthol, After shave lotion, Vinegar 4. Monitor liver function test ANTIDEPRESSANTS TCA “BEDTIME DRUGS” For depression 2-3 weeks to achieve therapeutic effects Improve sleep and appetite After Meals Bedtime No alcohol and anti hypertensive drugs 1-3 weeks before shifting to MAOI EXAMPLES OF TCA ANTIDEPRESSANTS W/ SIDE EFFECTS Doxepin (Sinequan) S/E:HPON/ HEADACHE Imipramine (Tofranil) 11  NUR 213: Unit 2 - Contemporary Issues in Pharmacology ANTICHOLINERGIC EFFECTS Nortriptyline (Pamelor) TACHYCARDIA Amitriptyline (Elavil) SEDATION TCA ANTIDEPRESSANTS SIDE EFFECTS MNEMONICS Blood dyscrasia Orthostatic hypotension Anticholinergic effects Tachycardia Sedation SSRI “MORNING DRUGS” For depression, anxiety, panic disorder, aggression, OCD 2-3 weeks to achieve therapeutic effects Before noon Can decrease libido in men and inability to achieve orgasm in woman Elderly: Half of the Dose No sudden/ abrupt withdrawal 4-6 weeks before shifting to MAOI Figure 10&11:Examples and Effects of Serotonin MAOI “NO TYRAMINE FOOD” For depression, phobia, anxiety Increases appetite and improve sleep After meals 2-3 weeks to achieve therapeutic effects 2 weeks before shifting to ТСА Avoid Tyramine rich foods: banana, chocolate, aged cheese, cheddar, avocado, soy sauce, preserved foods, salami, beer, coffee, tea, raisins, yogurt, Figure 9: SSRI function pickles, chicken liver. EXAMPLES OF SSRIs HIGH TYRAMINE FOOD MNEMONICS Fluoxetine (Prozac) - 20 mg PO Chocolate Paroxetine (Paxil) Avocado Sertraline Raisins Preserved food Age cheese Salami Soy sauce SIDE EFFECTS: (headache, sweating, tremors, increase in BP, temperature, palpitation.) Give: IV: Phentolamine (Regitine) -vasodilator ORAL: Nifedipine (Adalat) MAOI EXAMPLES Ex. Phenelzine sulfate (Nardil) Tranylcypromine sulfate (Parnate) 12  NUR 213: Unit 2 - Contemporary Issues in Pharmacology Isocarboxacid (Marplan) NORADRENERGIC AND SPECIFIC SEROTONERGIC ANTIDEPRESSANTS (NASSA) MAOI without Hypertension Ex. Mirtazapine ○ Note for sedation and weight gain Figure 14: Mirtazapine MOOD STABILIZERS/ ANTIMANIC Decreases hyperactivity Figure 11: Moclobemide Actavis Mood elevated SNRIs A grandiose delusion Need for sleep S - Sexual dysfunction & Adrenergic SE's Inappropriate affect N - No to liver disease and with alcohol intake Clanging, loud, vulgar R - Route: Oral: gel capsules I - Indications: Major Depressive Disorder MDD Anti LITHIUM CARBONATE Inflammatory for the brain tissue. Normal serum level: 0.5-1.5 meq/L Maintenance margin: 0.6-1.2 meq/L Norepinephrine - Reuptake Inhibitors 10-21 days to achieve therapeutic level For MDD, ADHD, and Narcolepsy Serum lithium level: Reboxetine ○ PEAK: -1-3 hours Amedaline drawn before the 1 dose in AM, Viloxazine before breakfast, or 8-12 hours Atomoxetine after the previous dose. SIDE EFFECTS: dry mouth, thirst, mild hand tremors S.E.- Adrenergic side effects LITHIUM TOXICITY: anorexia, N/V, diarrhea, abnormal cramps, muscle weakness and confusion MANNITOL: for toxicity Increase fluid intake: 3L/ day Increase Na intake: 3gm/day Avoid activities that increases perspiration No with diuretics Wear ID bracelet No caffeinated products With meals Same time everyday LITHIUM TOXICITY Muscle weakness Excessive thirst & urination Drowsiness Incoordination Abdominal signs & symptoms LITHIUM TOXICITY Mannitol for toxicity Avoid perspiring activities No diuretics & caffeine Increase water & sodium intake Administer same time each day ANTICONVULSANTS MOOD STABILIZER VALPROIC ACID (DEPAKENE) Figure 12&13: Reboxetine & Triple reuptake inhibitors Maintenance serum level-50-125 mcg/ml - With meals ADVERSE REACTIONS: G. I. Distress, Hepatotoxic 13  NUR 213: Unit 2 - Contemporary Issues in Pharmacology CARBAMAZEPINE (TEGRETOL) Alternative to lithium Maintenance serum level-8-12g/ml Watch out for: BLOOD DYSCRASIAS STOP: WBC= less than 3000/mm3 Neutrophil less than 1500/mm3 Monitor hepatic and renal function. 14