Exam 4 Blueprint: Intracranial Regulation - Antiepileptics

449 Exam 4 Blueprint Intracranial Regulation – Antiepileptics (anti-seizure) Drugs Review various seizure types o Partial (focal) ▪ simple partial – involves a single muscle or reaction olfactory, auditory, & visual hallucinations...

449 Exam 4 Blueprint Intracranial Regulation – Antiepileptics (anti-seizure) Drugs Review various seizure types o Partial (focal) ▪ simple partial – involves a single muscle or reaction olfactory, auditory, & visual hallucinations intense emotions twitching of the arms, legs, & face ▪ complex partial (psychomotor) – involving a series of reactions or emotional changes aura (feeling preceding a seizure) brief period of confusion or sleepiness following the seizure with no memory of the seizure (postictal confusion) fumbling with or attempting to remove clothing no response to verbalized commands o Generalized ▪ absence (petit mal) Lasting a few secs Seen most often in children o Child stares into space, doesn’t respond to verbal stimulation, may have fluttering eyelids or jerking Misdiagnosed often (esp. children) as ADHD or daydreaming ▪ atonic (drop attacks) Falling or stumbling for no reason Lasting a few secs ▪ tonic-clonic (grand mal) Aura (preceding) Intense muscle contraction (tonic phase) followed by alternating contraction & relaxation of muscles (clonic phase) Crying at beginning as air leaves lungs, loss of bowel/bladder control, shallow breathing w/ periods of apnea o Usually lasting 1-2 min. Disorientation & deep sleep after seizure (postictal state) o Special epileptic syndromes ▪ febrile seizure Tonic-clonic activity lasting 1-2 min. Rapid return to consciousness Occurs in children usually between 3 mos to 5 yrs of age ▪ myoclonic seizure  Large jerking movements of a major muscle group, such as an arm Falling from a sitting position or dropping what is held ▪ status epilepticus Considered a medical emergency Continuous seizure activity, which can lead to coma & death drug therapies for seizures o New FDA warnings: ▪ Popular antiseizure examples were found to almost double risk of suicidal behavior & ideation o Lifespan considerations: ▪ Pediatric: Can have impact on learning & social development May be more sensitive to sedating effects Older children (2 mos to 6 yrs) o Absorb & metabolize many of these drugs more quickly than adults & require a larger dosage per kg to maintain therapeutic levels Weight & age used to calculate dose ▪ Pregnancy: Most of these drugs associated w/ fetal abnormalities in animal studies Women of childbearing age should use other contraceptives while on these drugs o Several anti-seizure drugs decrease effectiveness of OCs Most anti-seizure drugs are pregnancy category D Eclampsia o Severe hypertensive disorder of pregnancy o Characterized by seizures, coma, & perinatal mortality ▪ Lactation: Find another way to feed baby to avoid the sedating & CNS effects these drugs can have on infants phenytoin (Dilantin) o Indication: ▪ Control of partial and generalized seizures ▪ Prevent/treat seizure after neurosurgery  o MOA: ▪ decreases Na influx ▪ Binds to Na channel Results in delay of return of excitable nerve cells to active state and prevents excessive muscle movement in generalized seizures o Therapeutic Level: ▪ Plasma blood level: 10 to 20 mcg/mL o Administration: ▪ Oral and IV ▪ NO IM o Adverse Effects: ▪ Gingival Hyperplasia Overgrowth of the gums ▪ Plasma levels above 20 mcg/mL: Nystagmus, ataxia, diplopia, cognitive impairment ▪ Skin Rash: Steve Johnson’s Peeling of the skin If you get a bad rash stop abruptly o Pt. Teaching: ▪ No ETOH and CNS depressants i.e Diazepam ▪ Teach oral hygiene → regular dental exams ▪ Don’t stop suddenly ▪ Wear medic alert ID ▪ May need a 2ndform of birth control ▪ INR may need to be checked when taking warfarin o Pt. Monitoring: ▪ Monitor blood levels ▪ Monitor response: Assess for AE, Assess for seizure activity, Assess plasma level ▪ if plasma levels are low, first nursing intervention is to ask about adherence Valproic Acid o indications: ▪ Indicated for treatment of partial and absent seizures ▪ Can also be used to prevent migraine o MOA: ▪ Reduces abnormal electrical activity in the brain and may also increase GABA activity at inhibitory receptors o Adverse Effects: ▪ Liver toxicity ▪ CNS suppression Weakness Fatigue Drowsiness  Dizziness o Pt. Monitoring: ▪ With change in dose nurse should: Assess plasma level Assess change in seizure activity Assess for adverse effects ▪ Nurse should also assess: Pt vital signs Assess for LOC Assess reflexes and grip strengths Assess affect monitor LFTs → d/t risk for liver toxicity Gabapentin o Indications: ▪ Used with other drugs for treatment of partial seizure ▪ used for neuropathic pain o MOA: ▪ Acts by enhancing GABA release, thus increasing GABA mediated inhibition and neuronal firing o Adverse Effects: ▪ Drowsiness ▪ Ataxia ▪ Dizziness ▪ Fatigue ▪ Nystagmus Usually diminish with duration of use levetiracetam (Keppra) o Uses: ▪ Adjunct treatment for partial, generalized or myoclonic seizure o Action: ▪ Selectively inhibits hyper synchronized neuronal firing that leads to seizure activity o Adverse Effects: ▪ Headache ▪ Ataxia ▪ Hostility ▪ Depression ▪ Flu-like symptoms: sore throat, stuffy nose ▪ Emotional lability ▪ Ear pain ▪ sleepiness  lamotrigine (Lamictal) o indications: ▪ Used in adjunct treatment for partial seizure o Action: ▪ Acts by reducing glutamate (an excitatory neurotransmitter) o Adverse Effect: ▪ Ataxia ▪ Headache ▪ Dizziness ▪ Drowsiness ▪ Blurred vision ▪ Serious skin rash Drug should be stopped and patient should be reevaluated o Carbamazepine (a phenytoin-like drug) ▪ Indications: Partial & tonic-clonic seizures Mixed seizures Trigeminal neuralgia ▪ Actions: Inhibits polysynaptic responses & blocks post-tetanic potentiations R/t tricyclic antidepressants ▪ Adverse effects: Drowsiness, dizziness NV Ataxia CV complications Hepatitis Hematological disorders Steven-Johnson syndrome ▪ Drug-drug interactions: CNS depressants & ETOH Many more o phenobarbital (a barbiturate): ▪ Indications: Long-term Tx of generalized tonic-clonic & cortical focal seizures  Status epilepticus Tetanus Eclampsia Meningitis Partial seizures ▪ Actions: Changing action of GABA o Enhances action of GABA CNS depressant ▪ Adverse effects: Dependence Drowsiness Vit. deficiencies Laryngospasm ▪ Nursing implications & interventions: Monitor patient’s condition & liver/kidney function Shouldn’t be used for pain relief because it may increase sensitivity to pain Warn about other CNS depressants & ETOH o Stabilize nerve membranes in 1 of 2 ways: ▪ Directly — altering Na & Ca channels ▪ Indirectly — increasing activity of GABA Absence seizures drugs: o valproic acid o ethosuximide o diazepam Partial seizure drugs o phenytoin o valproic acid o levetiracetam o carbamazepine o phenobarbital Status epilepticus o signs and symptoms ▪ continuous series of tonic-clonic seizures lasting for at least 20-30 min ▪ if status epilepticus persists >20 min, can cause permanent neurological injury and even death  o drug therapy goals ▪ patient safety!!! maintain ventilation check temp correct hypoglycemia terminate seizure o medication use to cease seizure activity ▪ IV benzodiazepine, either lorazepam or diazepam lorazepam: 2 mg total IV (0/4 mg/kg) diazepam: 5-10 mg slow IV, repeat Q5-10 min. if needed for total dose of 30 mg o patient monitoring ▪ ventilation ▪ temperature ▪ BG levels o nursing implications and interventions ethosuximide (a succinimide): o Indications: ▪ Absence seizures o Actions: ▪ Decrease Ca influx Suppress seizures ▪ Blocks Ca channels (esp. in hypothalamus) o Adverse effects: ▪ CNS effects are COMMON: Drowsiness, dizziness, lethargy Decrease w/ use ▪ GI distress is COMMON: NVD ▪ SLE ▪ Ataxia ▪ Irritability, nervousness ▪ HA ▪ Steven-Johnson syndrome ▪ Blurred vision ▪ Impaired hepatic/renal function ▪ Depression w/ overt suicidal intent  ▪ Very rare, but serious — blood dyscrasias: Aplastic anemia Agranulocytosis Pancytopenia Granulocytopenia o Nursing implications & interventions: ▪ Don’t abruptly withdraw medication ▪ Use w/ caution w/ other anti-seizure meds, phenothiazines, & antidepressants ▪ Monitor drug level in blood (40-110 mcg/mL) ▪ PO route only Caps Syrup ▪ Take drug w/ food or milk if GI distress occurs ▪ Notify provider if symptoms of serious adverse effects occur Skin rash, bleeding, bruising, severe CNS effects o Expected outcomes: ▪ Reduced freq. of absence seizures o Lifespan considerations: ▪ Pregnancy: Use birth control Consult provider before conceiving diazepam (a benzodiazepine): o Indications: ▪ Absence & myoclonic seizures ▪ Adjunct in status epilepticus o Actions: ▪ Increases effects of GABA ▪ Similar to that of barbiturates, but safer o Adverse effects: ▪ Resp. depression ▪ Dizziness, drowsiness, sedation ▪ Bradycardia ▪ Lethargy, apathy ▪ Dependance w/ withdrawal symptoms o Contraindications: ▪ Narrow-angle glaucoma o Nursing implications & interventions: ▪ Tolerance may develop quickly ▪ Monitor for drug-abuse potential ▪ OD — give flumazenil (Romazicon)  ▪ Warn about other CNS depressants & ETOH ▪ PO & IV Monitor resps. when administering IV Pregnancy, lactating, pediatric considerations of each drug/class o Children often require a larger mg/kg dose than adults ▪ d/t faster absorption and metabolism ▪ may require a larger dose to maintain therapeutic level o Pregnancy ▪ many seizure drugs have been associated with fetal abnormalities most seizure drugs are pregnancy category D ▪ eclampsia severe hypertensive disorder of pregnancy, characterized by seizures, coma, and perinatal mortality ▪ women of childbearing age should be encouraged to use contraceptives while taking these drugs → although many antiseizure drugs decrease the effectiveness of OC if a woman wants to become pregnant → benefits must outweigh the risks Migraines Drugs: migraine types o tension headache (MOST COMMON) ▪ self-limiting annoyance rather than emergency o migraine ▪ throbbing or pulsating pain ▪ may be preceded by an aura (similar to seizures) ▪ often causes NV ▪ often has triggers than can be avoided drug therapies o role of the nurse: ▪ careful monitoring of pt’s condition ▪ provide education ▪ obtain medical hx ▪ obtain list of allergies ▪ assess pain level before and after med admin ▪ obtain hx of meds, alcohol, and CNS depressant use ▪ assess frequency and intensity of migraine headaches ▪ assess stress levels, coping mechanisms, and neuro status ▪ provide a calm, quiet environment ▪ apply cold packs to help lessen the pain ▪ monitor for side effects of drug therapy Triptans — sumatriptan → first line therapy o indications ▪ to abort migraines with or w/o auras ▪ cluster HA (acute) o MOA ▪ serotonin agonists activates serotonin 5-HT1b/1D receptor, producing vasoconstriction and inhibiting pro-inflammatory neuropeptide release ▪ act by constricting certain intracranial vessels usually does not affect systemic BP o therapeutic response ▪ narrows blood vessels in the head → stops pain signals from being sent to the brain → block release of certain natural neurotransmitters that cause nausea, pain, and other migraine symptoms ▪ DOES NOT PREVENT OR REDUCE # of migraines o adverse effects  ▪ GI upset ▪ may produce ischemia in susceptible individuals with no previous cardiac events ▪ can cause HTN → may result in dysrhythmias or MI keep resuscitative equipment accessible ▪ drowsiness, dizziness, warming sensation not normally severe enough to DC ▪ vertigo ▪ flushing (when admin subq) ▪ chest pain or discomfort ▪ pain: throat, jaw, neck ▪ ** LESS AE than ergo ** o nursing implications ▪ route: PO, subq, and intranasal ▪ should be admin ASAP after the migraine is suspected (aura) or had begun ▪ not effective for long-term prophylaxis of migraines ▪ monitor for changes in LOC and observe for seizures ▪ monitor BP ▪ CV evaluation at baseline consider ECG at baseline in risk factors present o drug interactions ▪ increased effect of drug may occur when taken with MAOIs or SSRIs cannot take if taken MAOI in past 2 weeks ergot alkaloids o indications ▪ terminate ongoing migraines ▪ prevention of migraines ▪ vascular HAs o MOA ▪ interacts with adrenergic, dopaminergic, and serotonin receptors ▪ acts as vasoconstrictors ▪ decreases pulsation of cranial arteries o therapeutic response ▪ o adverse effects ▪ GI upset → NVD ▪ weakness in legs ▪ myalgia ▪ numbness and tingling in fingers and toes ▪ angina-like pain ▪ tachycardia ▪ arrhythmias  ▪ pulselessness nursing implications ▪ risk for peripheral ischemia and gangrene if taken w/ beta blockers o lifespan considerations ▪ pediatric “ergotism” : vomiting, diarrhea, and seizures → has been reported in infants ▪ pregnancy contraindicated Pregnancy, lactating, pediatric considerations of each drug/class Pain; Anesthetics; Muscle Relaxants Age related considerations o incidence increase with age o OA have a lot more pain Pain rating scales o Numeric rating scale ▪ Used with anyone who understands English numbers and is awake and alert used for cognitively intact patients o Smiley faces scale ▪ Used with children or adults with cognitive delays or anyone who is not familiar with English numbers o Other tools ▪ Behavioral scales, etc Non-pharmacologic interventions for pain o Immobilization (rest) o Application of heat or cold o Hydrotherapy o Therapeutic ultrasound o Supervised exercise o Massage o Manipulation o Physical therapy o Muscle stretching, strengthening o Repetitive motion o Surgery in extreme cases Stages of anesthesia o 1. analgesia stage ▪ loss of pain, but still conscious o 2. excitement stage ▪ often combative and resembles stimulation o 3. surgical anesthesia ▪ relaxation of the muscles, regular respirations, loss of eye reflexes, pupil dilation o 4. medullary paralysis (BAD, TOO DEEP) ▪ very deep CNS depression, loss of respiratory and vasomotor center  stimuli-critical situation phases of surgery o induction ▪ from beginning of anesthesia until stage 3 (surgical anesthesia) o maintenance ▪ from stage 3 until procedure is complete ▪ gasses are commonly used to maintain stage 3 o recovery ▪ from discontinuation of anesthetic until pt regains consciousness ▪ close monitoring is essential (PACU) o ** surgery safety risk = pt experiences powerlessness d/t unconsciousness ** Local anesthetic o Lidocaine ▪ MOA blocks action potentials on the sodium channel increases excitation threshold ▪ administration administration o topical ▪ cream, gel, ointment → numbing before IV o infiltration ▪ given directly into the tissue → sutures or cavity fillings o field block ▪ injection all around the area → more intense and used for procedure → blocks entire area o nerve block ▪ injection along the nerve ▪ uses local anesthesia used in o topical o infiltrations o nerve blocks o spinals ▪ adverse effects skin breakdown self-injury headache (spinal) dizziness arrhythmias  vasodilation ▪ routes of administration topical → cream infiltration → sutures o same as a field block nerve block → larger lacerations or wounds o ex → limb spinal → for surgery epidural → to block specific area (labor) General anesthetic o Propofol (Diprivan) — nonbarbiturate anesthetic ▪ action Activates gaba receptors in CNS; result is dose dependent CNS depression ▪ delivery route IV shake well before use ▪ patient monitoring monitor AIRWAYS BP ABGs potassium Liver and renal ▪ adverse effects hypotension Respiratory apnea Elevated triglycerides Respiratory acidosis ▪ nursing considerations pt must be on continuous cardiac monitoring Rapid onset and rapid clearance can cause hypotension Monitor for changes in respirations!! Midazolam (benzodiazepine and non barbiturate) o uses ▪ used preoperatively in order to relax the patient while taking them to the OR ▪ used in induction of general anesthesia and sedation for diagnostic procedures ▪ POTENT AMNESIAC USED IN PRE-OP SEDATION patient won’t remember o MOA:  ▪ Works in RAS and limbic systems; potentiates effects of gaba ▪ Amnesiac effect occurs at low doses o administration ▪ IV med (usually) o patient monitoring with use ▪ respiratory rate and pattern can cause respiratory depression ▪ BP can cause hypertension ▪ pt should be on continuous ECG monitor o patient teaching ▪ patient should avoid CNS depressants and ETOH for 24 hours can cause too much CNS depression diazepam (valium): o uses ▪ Acute alcohol withdrawal ▪ Seizure disorder ▪ Muscle relaxation ▪ Preoperative sedation and muscle relaxation Result is decrease in anxiety and restlessness, increased muscle relaxation ▪ Great choice for patients with anxiety that need a muscle relaxant o method of action ▪ acts in CNS by mimicking the actions of GABA at receptors in the spinal cord and brain → produce sedative effects and depress spasticity of the muscles o administration ▪ give the lowest ordered dose that is effective o patient monitoring with use ▪ LOC ▪ presence of anxiety ▪ respiratory status o patient teaching ▪ Give with food ▪ Taper drug when ready to stop ▪ Do not use OTCs ▪ No alcohol ▪ Avoid driving, other hazardous activities until effect of drug is known ▪ Change positions slowly ▪ Not safe in pregnancy Muscle spasm vs spasticity o muscle spasm (temporary) ▪ what causes our muscles to spasm overuse of skeletal muscle dehydration electrolyte imbalance multiple sclerosis residual from stroke epilepsy o muscle spasticity (Permanent) ▪ long term problems ▪ nerve damage to the CNS ▪ disorders that cause muscle spasticity stroke cerebral palsy (CP) Direct acting vs centrally acting muscle relaxants o Direct acting ▪ Used for spasms associated with CNS disorders Neuronal motor damage Neurologic disorders ▪ Suppress hyperactive reflexes ▪ Suppress the release of calcium ions from the skeletal muscle ▪ Prototype Dantrolene sodium (dantrium) ▪ MOA Interferes with release of calcium ions in skeletal muscle ▪ Primary use To relieve dystonias and leg cramps ▪ used to treat spasticity ▪ Adverse effects Hepatic toxicity, muscle weakness, drowsiness, diarrhea o Centrally acting muscle relaxants ▪ Used to treat local spasms resulting from muscular injury ▪ Inhibit motor neurons with brain or spinal cord: Depress CNS effects; alter spinal reflexes ▪ Reduce pain; increase range of motion ▪ Potential to cause sedation ▪ Prototype  Cyclobenzaprine (Flexeril), baclofen ▪ Moa Inhibits upper motor neuron activity Causes CNS depression, alters simple spinal reflexes ▪ Primary use To treat localized spasms ▪ Adverse effects CNS depression, hepatic toxicity, physical dependence, anticholinergic effects Safety considerations with use of muscle relaxants o Role of nurse ▪ Do complete health history, including allergies, drug history, drug interactions ▪ Establish baseline of consciousness and vital signs ▪ Assess for drowsiness and dizziness ▪ Monitor pain: location, duration, precipitating factors ▪ Monitor for withdrawal reactions ▪ Monitor muscle tone, range of motion, degree of muscle spasm ▪ Provide additional pain relief measure ▪ Monitor for side effects o Education of patient ▪ Those with liver disease, pulmonary/cardiac dysfunction should not take these drugs ▪ Warn against alcohol and drugs that depress CNS ▪ Abruptly stopping these drugs can result in seizures Age related considerations with use of muscle relaxants o children ▪ caution ▪ dantrolene can be used for children o adults ▪ aware of hepatotoxicity and women of childbearing age o older adults ▪ more likely to experience CNS depression that can occur such as confusion and risk for falls o pregnancy ▪ not advised to take in planning on getting pregnant Baclofen o indications  ▪ Alleviation of signs and symptoms of spasticity ▪ spinal cord injuries or diseases o MOA ▪ Gamma-aminobutyric acid analogue, exact mechanism of action is not understood, inhibits monosynaptic and polysynaptic spinal reflexes, CNS depressant. o contraindications ▪ known allergy ▪ pregnancy cat. C o adverse effects ▪ Transient drowsiness ▪ dizziness ▪ weakness ▪ fatigue ▪ constipation ▪ headache ▪ insomnia ▪ hypotension ▪ nausea ▪ urinary frequency cyclobenzaprine o indications ▪ used to treat localized spasms ▪ alleviation of S&S of spasticity ▪ use in SCI o MOA ▪ enhances GABA ▪ produces sedative effects and depress spasticity of muscle ▪ no direct muscle relaxant action → does not decrease muscle strength o contraindications ▪ pt with MI ▪ dysrhythmias ▪ hypothyroidism ▪ severe CV disease o adverse effects ▪ drowsiness ▪ blurred vision ▪ dizziness ▪ dry mouth ▪ rash ▪ tachycardia ▪ RARE: angioedema  dantrolene o indications treatment of SPASTICITY ▪ used with CNS disorders CP multiple sclerosis o MOA ▪ works on the muscle to prevent muscle contraction directly ▪ suppresses hyperactive reexes o contraindications ▪ pregnancy cat C ▪ women 35 and older with cardiac disease ▪ liver disease o adverse effects ▪ dantrolene toxicity jaundice drowsiness lethargy ▪ diarrhea ▪ BP changes ▪ can cause liver toxicity → hepatotoxicity o can be used in children Mood/Affect Difference between anxiety, depression, psychosis o anxiety: ▪ the feelings of tension, nervousness, apprehension, or fear involving unpleasant reactions to a stimulus o depression: ▪ inappropriate or intense negative emotions ▪ deficiency of neurotransmitters: norepinephrine, dopamine, or serotonin o psychosis: ▪ abnormal thoughts and thought processes, disordered communication, and withdrawal from other people and the outside environment Use of benzodiazepines in treating anxiety (diazepam, alprazolam) o uses: ▪ anxiety disorders ▪ alcohol withdrawal ▪ hyperexcitability and agitation ▪ insomnia ▪ preoperative relief from anxiety and tension ▪ in low doses→ anxiety ▪ in high doses→ sedation and hypnosis o action ▪ acts on the limbic system in the RAS ▪ makes GABA more effective o Adverse effects: ▪ Sedation, drowsiness, depression, lethargy ▪ Blurred vision, confusion ▪ Loss of libido ▪ Dry mouth ▪ Constipation, NV ▪ Hypotension ▪ Urinary retention ▪ Dependence ▪ Withdrawal syndrome Occurs after long-term use Characterized by insomnia, tremors, nausea, HA, vertigo, malaise, nightmares — even seizures o pt education ▪ do not take with ETOH or other CNS depressants ▪ change positions slowly d/t HTN Non-benzodiazepine drug class prototype buspirone  o Chemically unrelated to either benzodiazepines or barbiturates o Used mainly for Tx of social anxiety symptoms o indications ▪ anxiety o MOA: ▪ May inhibit neuronal firing & reduce serotonin turnover in selected parts of the brain o adverse effects: ▪ Dizziness, drowsiness ▪ Insomnia ▪ Blurred vision ▪ Dry mouth o nursing interventions ▪ PO ▪ Increase dose gradually PRN o expected outcome of med ▪ Decreased anxiety o benefit of usage ▪ No sedative, hypnotic, or muscle relaxant effects Preferred in certain circumstances (when a person must drive, go to work, or maintain alertness) ▪ Less habit forming Age related considerations with benzo use – elderly and children o elderly: ▪ older pts may be more susceptible to adverse effects of these drugs such as CNS effects, increased sedation, dizziness, and even hallucinations more prone to risk of falls! o children: ▪ the response of a child to benzos can be unpredictable common for child to experience inappropriate: o crying o irritability o tearfulness Safely withdrawing benzodiazepines o abrupt cessation of drug after long-term use can lead to withdrawal syndrome characterized by ▪ nausea ▪ HA ▪ vertigo  ▪ malaise ▪ seizure o TAPER OFF SLOWLY FOR 2 WEEKS Definition of anxiety vs sedation vs hypnosis o anxiety: ▪ the feelings of tension, nervousness, apprehension, or fear involving unpleasant reactions to a stimulus o sedation: ▪ loss of awareness and reaction to environmental stimuli o hypnosis ▪ extreme sedation resulting in further CNS depression and sleep Pregnancy considerations o should only be taken when benefits outweigh the risks SSRIs o indications ▪ depression ▪ bulimia ▪ panic disorder ▪ OCD o MOA ▪ inhibits the reuptake of serotonin to increase the amount that circulates through the brain o adverse effects ▪ HA ▪ sexual dysfunction ▪ nervousness ▪ insomnia ▪ NVD ▪ dry mouth ▪ anorexia ▪ sweating ▪ serotonin syndrome often due to a drug drug interactions o SSRI, SNRI, TAC, MAOI o pt teaching ▪ will take 3-5 weeks to achieve full therapeutic effect will not work right away ▪ SSRIs preferred over other classes d/t less adverse effects ▪ should be weaned off slowly for 2-4 weeks  SNRIs o indications ▪ treatment for major depressive disorder o MOA ▪ decreased neuronal reuptake of both serotonin AND norepinephrine o adverse effects ▪ NV ▪ constipation ▪ hyperhidrosis ▪ erectile dysfunction ▪ tachycardia ▪ abnormal bleeding ▪ angle closure glaucoma o pt teaching ▪ assess for worsening depression, suicidality, or bipolar disorder ▪ may cause impaired hepatic or renal function ▪ PREGNANCY: should only be taken when benefits outweigh the risks ▪ will take 3-4 weeks to achieve full therapeutic effect ▪ educate pt to avoid St. John’s Wort → can cause serotonin syndrome Tricyclic antidepressants: Amitriptyline o indications ▪ predominantly used for major depression, occasionally for milder situational depression ▪ neuropathy ▪ fibromyalgia o adverse effects ▪ orthostatic hypotension ▪ dysrhythmias ▪ sedation ▪ weight gain ▪ anticholinergic effects EVERYTHING DRY: mouth, eyes o blurred vision o oliguria o constipation o pt teaching ▪ monitor pt for suicide risk ▪ pt drug education slow position changes ▪ watch for cardiac problems for up to 5 days ▪ overdose: heart block, dysrhythmias, tachycardia, hypotension, seizure,  coma o use activated charcoal, sodium bicarbonate, gastric lavage (stomach pump) MAOIs — phenelzine & selegillin (transdermal) o indications ▪ pts who have been unresponsive to other antidepressants or in those whom other antidepressants are contraindicated o adverse effects ▪ Hypertensive crisis Caused by: Tyramine→ increased when using MAOIs o Antidote (calcium channel blocker) o Dry aged food, smoked ▪ Caused by release of NE→ causing acute hypertension ▪ Symptoms: Headache, hypertension, sweating, dilated pupils, tachycardia, chest pain o Patient teaching ▪ Do not take with OTC medication without consulting with provider ▪ Monitor blood pressure ▪ Low tyramine diet know foods that have tyramine o wine, cheese, beer, sausage, etc. ▪ Monitor CBC Typical vs atypical antipsychotic drugs o Typical (haloperidol): Older → Has more AE ▪ IV kicks in fast, lots of AE ▪ Block dopamine receptors, preventing the stimulation of postsynaptic neurons by dopamine o Atypical (olanzapine): Newer → Has less AE ▪ PO, Given regularly, Relieve hallucinations ▪ Both block dopamine and serotonin receptors o indications ▪ Schizophrenia, hyperactivity ▪ Combative behavior, agitation in elderly, severe behavioral problems in children o adverse effects ▪ Black Box: Older patients with dementia are at increased risk for death when taking conventional antipsychotics ▪ EPS: Extrapyramidal effects Involuntary facial movements, restlessness, tremor, and stiffness ▪ Sedation  ▪ Orthostatic hypotension, ▪ ALL ANTIPSYCHOTICS= agranulocytosis o patient teaching ▪ Importance of taking med as directed ▪ Do not stop abruptly o patient monitoring ▪ Monitor for involuntary movement (indicates EPSS) ▪ Monitor for orthostatic hypotension Lithium o indications ▪ bipolar disorder o MOA ▪ Inhibit release of norepinephrine and dopamine, but not serotonin from stimulated neurons o therapeutic levels ▪ *0.6 to 1.5 Desired* ▪ 1.5 to 2 Mild to Mod toxicity ▪ 2 to 2.5 Mod to Severe toxicity ▪ > 2.5 Life threatening o pt. teaching ▪ Excreted from the kidneys (95%), sweat, and feces The kidneys treat lithium and sodium similarly, which is the reason sodium depletion can significantly elevate lithium ▪ avoid Dehydration Sodium depletion Sweating Diarrhea Diuretic Metabolic disorders o pt. monitoring ▪ Lithium Levels Blood levels should be checked by nurses ▪ Sodium 135-145 o signs of lithium toxicity ▪ Early: Tremor, V/D, blurred vision and speech ▪ Late: Seizure, coma, arrhythmia ▪ Over 1.5 Lethargy, slurred speech, muscle weakness, N/V o complex multi organ toxicity = death  Stimulants, how they work to help ADHD o CNS stimulants act at the cortex and RAS, increasing stimulation of an immature RAS which leads to more selective response to incoming stimuli ▪ Helps them focus on specific stimuli Methylphenidate (Ritalin) — stimulant o indications ▪ ADHD ▪ narcolepsy o MOA ▪ CNS stimulants act at the cortex and RAS, increasing stimulation of an immature RAS which leads to more selective response to incoming stimuli Helps the reticular activating system to be more selective in response to incoming stimuli o adverse effects ▪ Nervousness, insomnia, dizziness ▪ Headache, blurred vision ▪ Anorexia, Weight loss Especially in children o pt. monitoring ▪ Monitor weight especially in children Daily weights ▪ Monitor CBC ▪ Monitor VS, appetite, anxiety, resp assessment o safety concerns ▪ risk for dependence ▪ keep in locked cabinet Hypnotics (sedative – hypnotics) Drugs Benzodiazepine o prototype: lorazepam o indications ▪ anxiety disorders ▪ insomnia o goals of therapy ▪ absence of panic attacks ▪ decrease or absence of anxiety ▪ normal sleep pattern ▪ absence of seizures ▪ absence of withdrawal manifestations from ETOH ▪ relaxation of the muscles  o therapeutic effects ▪ induce a sense of calm, decrease anxiety, and induction of sleep o adverse effects ▪ drowsiness, dizziness, sedation ▪ amnesia ▪ weakness, disorientation, ataxia ▪ respiratory depression Insomnia drugs o zolpidem — non-benzo, sedative-hypnotic ▪ indications hypnotic short-term insomnia management (7-10 days) ▪ MOA binds to GABA receptors o preserves sleep stage III o offers minor effects on REM sleep o affects serotonin levels in the brain ▪ adverse effects mild nausea dizziness NVD daytime drowsiness, amnesia, sleepwalking (safety concern), eating while asleep confusion depression w/ suicidal thoughts ▪ nursing implications (safety and discontinuation of drug) assess for common side effects and CNS depression assess neurological status and LOC monitor VS o observe respiratory patterns (esp. during sleep) monitor pt’s intake of stimulants (i.e. caffeine, nicotine) monitor affect and emotional status rapid onset, give immediately before bed o ramelteon — melatonin receptor drug ▪ indications insomnia characterized by difficulty w/ sleep onset ▪ MOA stimulates melatonin receptors which are thought to be be involved in the maintenance of circadian rhythm and sleep-wake cycle o has been shown to mainly improve sleep induction ▪ nursing implications (safety and discontinuation of drug)  will help pt fall asleep, but won’t keep them asleep short duration o suvorexant (Belsomra) — orexin receptor blocker ▪ indications difficulty falling and staying asleep insomnia ▪ actions blocks action of orexin (a chemical involved in the sleep-wake cycle of the brain) suppressed the drive to wake up prolongs stage III sleep ▪ nursing implications expect pt to have uninterrupted sleep lasting for about 7 hrs caution must be used when used in conjunction to ETOH and other CNS depressants → increased sedation take within 30 min of bedtime o pt should be in bed within 30 min of taking o plan to stay in bed for 7 hrs to decrease safety risks of CNS effects Pregnancy, lactating, pediatric considerations of each drug/class Cognition What is Alzheimer’s Disease? How does it affect the brain? Changes that occur in the brain o the gross diffuse atrophy of the cerebral cortex o progressive loss of ACh-producing neurons and their target neurons in the cortex of the brain ▪ these neurons are related to memory and associations between memories ability to see a face→ recognize the face → associate the face with a name → recognize that name belongs with a person o cause= unknown; no cure o chronic inflammation and oxidative cellular damage Important patient/family teaching related to Alzheimer’s Disease – what do they need to know about the disease process? Safety? Medication usage? Expected outcomes? o Alzheimer’s is a progressive disease and will only continue to get worse o educate family on the warning signs o medication will not cure the patient, but only slow the disease process ▪ common med= donepezil Drugs stimulate the parasympathetic nervous system: what does that mean? How do they work? o relaxes you o allows for digestion o increases secretion o slows the heart rate → bradycardia Indirect-acting cholinergic agonists: What are they? How do they work? o Mimic the effects of the parasympathetic nervous system ▪ Donepezil (Aricept) ▪ Rivastigmine (Exelon) Donepezil o Indications ▪ slow progression of alzheimer's disease slows loss of memory, cognition, and ability to perform ADLs ▪ severe dementia o MOA ▪ prevents the breakdown of acetylcholine ▪ enhances the transmission of acetylcholine in the neurons o adverse effects ▪ All are related to stimulation of the parasympathetic nervous system  Most COMMON is GI distress: o nausea, vomiting, cramps, diarrhea, increased salivation, involuntary defecation o cholinergic crisis: wet and wild ▪ remember: SLUDGE Cardiac: o bradycardia, heart block, hypotension, cardiac arrest – related to the cardiac suppressing eects of the parasympathetic nervous system GU: o urgency CNS: o miosis, blurred vision, headaches, dizziness, drowsiness – related to cholinergic eects o nursing interventions ▪ Offer small frequent meals ▪ Give drug with food ▪ Offer calorie and nutrient foods and liquids ▪ Discuss the progressive nature of the disease and be prepared to support patient and family throughout o expected outcome of medication ▪ must be taken for up to 6 mo. to see the maximum benefit of this med ▪ SLOWS the progression of Alzheimer's, DOES NOT cure Alzheimer's!! ▪ goal= slow progression and control undesirable behavioral manifestations rivastigmine o Indications ▪ mild to moderate Alzheimer’s slows symptoms of the disease o MOA ▪ bind to cholinergic receptors to produce the rest and digest response o adverse effects ▪ bradycardia ▪ hypotension ▪ pupil constriction ▪ increased secretions ▪ cardiac arrest ▪ tearing ▪ miosis  ▪ dysphagia ▪ nausea ▪ vomiting ▪ increased bronchial secretions ▪ urinary frequency ▪ incontinence o nursing interventions ▪ monitor for cholinergic crisis SLUDGE o S → SALVATION/SALIVA o L → LACRIMATION (CRYING) o U → URINATION o D → DIARRHEA o G → GI DISTRESS o E → EMOSIS (VOMIT) ▪ pt must be hydrated ▪ monitor BP o expected outcome of medication ▪ goal= slow progression and control undesirable behavioral manifestation  Antiparkinsonism medications: Levodopa: ○ indications most effective tx but benefits diminish after 5 years of therapy ○ MOA dopamine synthesis ○ drug interactions ○ adverse effects NV drowsiness dyskinesias → head bopping, tics, grimaces, tremors orthostatic hypotension CV effects psychosis ○ nursing interventions ○ patient teaching NV → take with food have family assist in meds monitor effects effects might not be noticeable for weeks medication holidays must be monitored in hospital high protein AVOID PREG dont d/c abrupt ○ expected outcome of medication improvement of manifestations: absence of tremors reduction of irritability reduction in stiffness carbidopa: SAME AS LEVO used to augment the amount of levo → results in larger amount of levo reaching the CNS preg with caution Practice Questions: 1. What is a pt at risk for AFTER surgery? a. respiratory depression b. hypersensitivity reaction c. hypertension d. falls 2. What class of medication is given during surgery so a patient does not remember? a. muscle relaxant b. sedative-hypnotic c. general anesthetic d. insomnia drug 3. Why are SSRIs preferred over other antidepressants? a. better safety profile 4. If parents feel hopeless about their child's unresponsiveness to schizo meds… a. know that multiple therapies may be used to see which is effective 5. what is the first line therapy for depression? a. SSRIs 6. where should ADHD meds be stored? a. controlled substance cabinet 7. what does a lithium level of 2.2 lithium indicate? a. seizures 8. an elevated lithium a. weakness & weakness 9. what should pts on lithium increase their intake of? a. water and sodium 10. TCA OD a. cardiac monitor 11. avoid st johns wort with any antidepressant 12. child with depression will present with low: a. serotonin b. dopamine c. norepinephrine 13. pressured speech → schizo a. non therapeutic levels of antipsychotic 14. What pt teaching should the nurse provide being discharged on cyclobenzaprine? a. NO ETOH until tx is over 15. A pt has muscle spasms and anxiety, what med should be prescribed a. diazepam 16. What type of lidocaine should be administered for an open laceration needing stitches? a. infiltration 17. What medication should be given to an agitated, combative 8 year old kid who has a foreign body in their nose? a. propofol 18. What teaching should you provide family of an alzheimer's pt a. The medication will not cure the pt, but it will slow the disease 19. A pt who was taking dantrolene is now pregnant and asks if she can still take her med a. Contact your provider to see if you can still take 20. dantrolene toxicity a. Jaundice b. Drowsiness c. Lethargy 21. donepezil a. Adequate fluid b. Adequate nutrition