CNS and ANS Flashcards
Cholingeric
acetylcholine, excitatory
Dopaminergic
dopamine, inhibitory
Noradrenergic
norepinephrine, excitatory, increases activity
Serotonergic
serotonin, sleep/wake/pain
Pain
- tissue damage activates free endings (nocicepters) of peripheral nerves
Opioid analgesics
- stimulate opiate receptors and bind to the receptors in CNS causing inhibition of ascending nerve pathways
- Receptors: mu, kappa, and delta
- used for severe to moderate acute pain, terminal malignancy
- most schedule II, well absorbed orally
- oral - significant first pass
- contraindicated: allergy, increase ICP, respiratory problems, dependence, tolerance or addiction
Opioid analgesics - adverse/nursing
- Adverse effects: sedation, respiratory depression, postural hypotension, flushing, N/V, constipation, urinary retention, and pupil constriction
- monitor VS
- use: for acute and chronic pain, MI, burns, trauma, post-op
- Use in chronic pain only when other methods fail (such as terminal cancer pain)
Morphine
- prototype for opiods
- po, IM, IV, SQ, IT, epidural
- sustained release or immediate release
- effects: 15-20 min IV, 60 min po
- oral: roxanol
- fentanyl patch - anesthesia, epidural, IT (duragesic, transdermal) - works for 72 hrs (up to 24 hrs after removal of patch)
IM not given often - it’s erratic
Types of opioids
- codeine - usually with acetaminophen
- hydrocodone - vicodin and norco
- meperidine (Demerol) - synthetic, may cause tremors, hallucinations, and seizures
- tramadol (Ultram) - synthetic, low potential for tolerance - may use for chronic pain
- oxycodone (OxyContin)
- – popular drug of abuse
- – w/aspirin - Percodan
- – w/acetaminophen - Percocett
-hydromorphone (Dilaudid)
- propoxyphene (Darvon)
- – w/acetaminophen (Darvocett) – NOW REMOVED FROM MARKET
Nursing Implications of Opioids
- MONITOR FOR SEDATION
- alternate with non-narcotics
- no alcohol use!
- do not drive, operate machinery, or smoke
- constipation is common
- IR vs SR
- may be used in PCA pumps
- unlikely to cause addiction with acute pain
naloxone (Narcan)
(opioid antagonist)
- given when too much opioid is administered
- uses: reverse or block anesthesia, CNA and resp depression from narcotics
- competes with opioid receptor sites in brain
- adverse: increased HR/BP/resp and RETURN of pain
- produces withdrawal symptoms
- repeated injections may be needed
butorphanol (Stadol)
nalbuphine (Nubain)
(opioid agonist/antagonist)
- agonist at some receptors and antagonist activity at others
- reduced potential for abuse
- never give to someone who has received opioid analgesics (due to antagonist activity)
methadone (Dolophine)
- use: opioid addiction
- longer acting than morphine, abuse, wean
- use for cancer pain
Analgesic-Antipyretic-Anti-Inflammatory drugs
- Action: inhibit the formation of prostaglandins in inflamed tissue, preventing the stimulation of pain
- may have anti-inflammatory, antipyretic, or anti-platelet effects
- NSAIDs
Aspirin (ASA)
- prototype
- mild to moderate pain, fever, inflammation, and decrease risk of thrombus
- low dose ASA for MI, angina, stroke, primary prevention of MI, prevent thromboembolism in surgery patients
- non-selective cyclooxygenase (COX) inhibitor
- adverse: stomach irritation, bleeding
Nursing Implications of aspirin
- toxicity: salicyism (toxic effects of overdose of salicyclic acid), tinnitus (ringing in the ears)
- avoid other OTC preparations that contain ASA
- stop use 2 weeks before and after invasive procedures
- take with food, drink adequate fluids
- high bound to blood albumin
- do not give to kids - reye’s syndrome
- watch for signs of bleeding
- increased effects with alcohol, anticoagulants, opioids, and steroids
- not for use in pregnancy
acetaminophen (tylenol)
- antipyretic effects, no inflammatory or platelet effects
- used to reduce pain and fever
- may use with GI problems
- additive effects with other opioids
- adverse: hepatic failure with high dose and nephrotoxicity with overdose
- overdose treatement: Mucomyst (po)
Nursing Implications of acetaminophen
- read labels
- no more than 4g (4000mg) per day
- drug of choice for febrile children, elderly and impaired renal function, pregnancy
- watch for duration of use
- avoid alcohol
ibuprofen (Motrin, Advil)
(NSAIDs)
- used to treat fever, pain, inflammation, arthritis, and menstrual cramps
- has less GI upset than ASA
- Same nursing imp. as ASA
Indomethacin (Indocin)
(NSAIDs)
- strong anti-inflammatory effect
- higher risk of side effects than Motrin
naproxen (Naprosyn, Aleve)
ketorolac (Toradol)
(NSAIDs)
Naprosyn is prescribed
Aleve is OTC
Toradol:
- used for severe pain
- given IV
- duration of use 5 days - produces bleeding
celecoxib (Celebrex)
(selective COX-2 inhibitor)
- blocks prostaglandins associated with pain and inflammation without gastric upset, with no GI bleeding
- use for arthritis
- Black box warning: increased risk for adverse cardiovascular event, risk of GI bleeding with long term use - patients should be advised
pregabalin (Lyrica)
(selective COX-2 inhibitor)
- decreases number of pain signals sent out by damaged nerves
- use: neuropathic pain, fibromyalgia, and partial seizures
- adverse: tiredness, dizziness, N/V
allopurinol (Zyloprim)
colchicine
probenecid (Benemid)
(anti gout agents)
- prevent uric acid formation
- gout = body’s inability to metabolize uric acid
- symptoms: hyperuricemia (> 6mg/dl), severe pain, inflammation and edema in musculoskeletal system
Nursing implications for anti-gout
- obtain baseline serum data
- give with food
- increase fluids to 3000mL/day
- rest and immobilize affected area
- avoid alcohol
- low purine diet: anchovies, sardines, game meats, organ meats and yeast
pentobarbital (Nembutal)
phenobarbital
(barbiturates)
- depress CNS
- treat seizures, promote anesthesia, promote sedation and sleep
- considered the prototype drugs - limited use today
- serious dependence and withdrawl
- Adverse: hangover, drowsiness and decreased resp
diazepam (Valium)
alprazolam (Xanax)
lorazepam (Ativan)
midazolam (Versed)
(benzodiazepines)
- release GABA substances - inhibit transmission of impulses in CNS
- Use: sleep, decrease anxiety, preop, alcohol withdrawal
- replaced barbiturates as drugs for insomnia - these are safer and lower potential for abuse
- Valium = prototype
- –decrease anxiety, break status epilecticus (ongoing seizures), alcohol withdrawl
- Xanax/Ativan for anxiety
- Versed = preop
- –produced amnesia - used for conscious sedation
- adverse: oversedation, hangover, decrease resp
- caution in elderly
Nursing implications for benzodiazepines
- safety!
- assess resp rate
- Flumazenil (Romazicon) - reversal for benzos
- give with food
- abstain from alcohol
- taper off drugs
zolpidem (Ambien)
eszopiclone (Lunesta)
diphenhydramine (Benadryl)
- sleep agents
- Ambien - short term use only
- – reported problems with sleepwalking, doing things while sleepwalking and not remembering, rebound insomnia after stopping
Lunesta - longer term
—tastes funny
Benadryl - antihistamine
—drowsiness side effect for sleep aid
buspirone (BuSpar)
sertraline (Zoloft)
(anti-anxiety drugs)
- episodic, situational anxiety and panic
- used to reduce/relieve anxiety
- cautions same as benzos
Nursing implications for anti-anxiety
- assess signs/symps of severe anxiety
- signs of depression/suicide
- safety
- avoid alcohol
carisoprodol (Soma)
baclofen (Lioresal)
cyclobenzaprine (Flexeril)
(skeletal muscle relaxants)
- depresses polysynaptic reflexes in the CNS
- use: acute musculoskeletal pain, relieve musculoskeletal spasticity (trauma, MS, spinal injury), as an adjunct to other therapies
Adverse reactions and Nursing implications for skeletal muscle relaxants
Adverse:
- drowsiness, dizziness, N/V, flaccid muscles, psychological/physical dependence
Nursing Imp:
- assess muscular strength
- check I&O
- safety
- physical therapy
dantrolene (Dantrium)
(other relaxant)
- interfere with the release of calcium from the sarcoplasmic reticulum, weakening the force of muscle contraction
- use: malignant hyperthermia
- also: spasticity with MS, cerebral palsy, and stroke
anti-seizure drugs
- used to treat seizures and epileps
- decrease movement of ions into nerve cells, alternating activities of neurotransmitters
- start with single dose - may need to add second drug
- guide based on therapeutic levels
phenytoin (Dilantin)
(anti-seizure)
- prototype
- stabilizes nerve membranes
- used with all types of seizures accept absence
- caution: severe kidney/liver disease, elderly
- therapeutic range - 5-20mcg/ml
- adverse: gingival hyperplasia, cardiovascular collapse with rapid IV dose
Nursing implications of Dilantin
- monitor serum levels
- careful IV infusion
- give with food
- good oral hygiene
- generic/trade brands not always the same
other seizure drugs
- phenobarbital sodium (luminol) - decline in use
- benzodiazepines - ativan, valium, and clonazepam (Klonopin) - status epilecticus, severe recurrent seizures
- carbamazepine (Tegretol)
- ethosuximide (Zarontin)
- lamotrigine (Lamictal)
- valproic acid (Depakene/Depakote)
- topiramate (Topamax)
levodopa (Dopar)
carbidopa-levodopa (Sinemet)
(antiparkinsons drugs)
Dopaminergic drugs
- drug goal: strengthen dopaminergic action or decrease cholinergic action
- increase amount of dopamine concentration
- adverse:
- –early: N/V, anorexia, orthostatic hypotension, dizziness.
- –late: involuntary movements, akinetic spells, anxiety, and depression
- –use with caution with patients with narrow angle glaucoma, melanoma, GI, heart disease
Nursing implications for antiparkinsons drugs
- assess symptoms
- skin assessment
- wearing off effect
- give with food
- watch protein intake
- darkening urine
- safety
trihexyphenidyl (Artane)
benztropine (Cogentin)
(anticholingeric - antiparkinsons)
- counteract the cholingeric activity in brain
- use alone in early Parkinson’s, young patients
- caution: glaucoma, GI-GU obstructions, heart disease, elderly, very young
Nursing:
- monitor I&O
- taper drug
- sit up slowly
- watch heat, fiber/water
migraines
- pain associated with dilation of arteries of the scalp and face
- HA with periodic attacks of nausea, pain, sensitivity to light
- treatment: treat acute pain and prevention
- prophylactic: use of beta blockers, calcium channel blockers, anticonvulsants and TCAs
Ergot alkaloids
(main class of antimigraine drugs)
- reduce extracranial blood flow
- ergotamine tartare (Ergomar)
- –with caffeine (Cafergot)
- –sublingual or inhaled
- – adverse: N/V, cramps, confusion, decreased circulation to extremities
- – contraindicated with pregnancy, severe HTN and CAD
sumatriptan (Imitrex)
zolmitriptan (Zomig)
(antimigraine drugs)
- triptans/serotonin agonists
- stimulate receptors on the basilar artery to vasoconstrict the vessels of the dura mater
- adverse: nausea, HTN, dizziness, weakness
- contraindications: CAD, HTN, do not give within 24 hours of ergot alkaloids
General anesthesia
- state of profound CNS depression - complete loss of sensation, consciousness, pain, perception and memory
- Balanced anesthesia: allows anesthesiologist to not have to use too much of the potent general anesthetics - using many different types
- IV - used for rapid induction and maintenance
- – etomidate (Amidate)
- – propofol (Diprivan)
- – fentanyl citrate (sublimaze)
- Inhalant
- – enflurane (Ethrane)
- – nitrous oxide
- Neuromuscular blocking agents - to keep patient from moving
- –atracurium (Tracrium)
- – vecuronium (Norcuron)
Moderate or conscious sedation
- does not cause complete loss of consciousness or respiratory arrest
- use: procedural areas including peds
- drugs:
- –Versed - benzos
- – Fentanyl, Morphine - opioids
- more rapid recovery
- must have advanced life support certification to administer and monitor
- intubation capabilities must be available
lidocaine (Xylocaine)
buprivacaine (Marcaine)
- local anesthesia
- no paralysis of resp function
- elimination of pain sensation
- –topical
- –infiltration
- – field block
- –nerve block
- –spinal/epidural/intrathecal
amphtamine (Adderall)
methylphenidate (Ritalin)
dextroamphetamine (Dexedrine)
atomoxetine (Strattera)
- CNS stimulants
- use: ADHD (for kids, it has the opposite effect - rather than stimulating, it calms), narcolepsy, weight reduction
- adverse: nervousenss, irritability, HA
- caution: anxiety, glaucoma, pregnancy, HTN, dependence
- tolerance and psychological dependence
substance abuse
- self administration of a drug for prolonged time periods or in excessive amounts which can lead to psychological or physical dependence
- for alcohol abuse - Antabuse is used
- anxiety, sedative, hypnotics - taper to withdraw
- for opioids - methadone
- CNS stimulants: amphetamines, nicotine, cocaine
- hallucinogens
chloropromazine (Thorazine)
fluphenazine (Prolixin)
trifluoperazine (Stelazine)
(antipsychotics)
- actions: occupy or block dopamine receptors
- use: schizophrenia, acute mania, psychotic depression, N/V
- caution: elderly
Thorazine is prototype
Phernergan fits in this category
Adverse and Nursing Imp of antipsychotics
Adverse:
- excessive sedation, slurred speech, impaired mental processess
- –extrapyramidal symptoms (EPS)
Nursing:
- assess behavior
- watch for adverse effects
- photosensitivity
- safety
- Phernergan - highly sedative
haloperidol (Haldol)
clozapine (Clorazil) - prototype
risperidone (Risperdal)
olanzapine (Zyprexa)
(nonphenothaizines)
- used to control flat affect and hallucinations, schizophrenia, and Touretts syndrome
- adverse: agranulocytosis, seizures, decrease BP, EPS symptoms (Haldol)
Nursing Imp for nonphenothaizines
- determine baseline WBC
- VS
- assess for constipation
- administer with food
- watch photosensitivity
- do not take with other CNS depressants
Lithium carbonate (Eskalith)
(mood stabilizing drugs)
- use: bipolar, treat/prevent manic episodes
- caution: significant cardiac/renal disease, hyponatremia, pregnancy, leukemia
- interacts with Haldol, Tegretol, thiazide diuretics
- therapeutic level: 0.5-1.2mEq/L
Adverse and Nursing Imp of mood lithium
Adverse:
- metallic taste, twitching, diarrhea, thirst
Nursing:
- assess mood
- monitor Na+ levels
- increase fluid intake, monitor use of diuretics
- take with food
- avoid changes in salt intake
Antidepressants
- used: for depressed mood, feelings of sadness and emotional upset
- depression occurs in all age groups
- 3 types
- –Tricyclic antidepressants (TCA)
- –Selective Serotonin Reuptake Inhibitors (SSRIs)
- –Monoamine Oxidase Inhibitors (MAO)
amitriptyline hydrochloride (Elavil) imipramine hydrochloride (Tofranil) - prototype
- TCA
- decrease reuptake of serotonin and norepinephrine
- adverse: sedation, orthostatic hypotension, decreased GI motility, dry mouth, cardiac arrythmias, urinary retention
- caution: suicidal, adverse effects mimic panic
Nursing:
- do not give concurrently with SSRIs
- take in PM
- do not take with St. John’s Wort
fluoxetine (Prozac)
citalopram (Celexa)
proxetine (Paxil)
sertraline (Zoloft)
- SSRIs
- increase available serotonin
- use: depression, OCD, bulimia
- adverse: anxiety, nausea, decreased appetite, weight loss, HA
- caution: risk of suicide, those taking MAOIs, anticoagulants
phenelzine sulfate (Nardil)
- MAO Inhibitors
- prevent the metabolism of neurotransmitter molecules
- adverse: orthostatic hypotension, weight gain, edema, toxicity, hypertensive crisis with tyramine foods (cheese, beer, chocolate, yogurt, smoked meats)
- many drug interactions
other antidepressants
- burpropion (Wellbutrin, Zyban)
- –Wellbutrin also used for smoking cessation, has CNS stimulant effects - causes agitation, anxiety, insomnia
- –do not use Wellbutrin with seizure patients - lowers threshold - seizures more likely
- venlafine (Effexor) - not to be used during pregnancy
- duloxetine (Cymbalta) - not be used with alcohol dependency - liver damage
- mirtazapine (Remeron) - causes weight gain, drowsiness
Nursing Implications for antidepressants
- therapeutic effects - 2-4 weeks
- assess depression, suicide precautions
- encourage diet and exercise
- watch with children/adolescents
- recommend counseling/support groups
adrenergic agents
- mimic SNS
- widespread action, used in emergencies
- adverse: arrhythmias, HTN, palpitations, angina, nervouseness
- interactions: TCAs, MAOIs
epinephrine HCL (Adrenaline) - prototype norepinephrine (Levophed) dopamine HCL (Intropin) phenylephrine (Neo-Synephrine) albuterol (Proventil) Isoproterenol (Isuprel)
- Adrenaline used anaphylaxis and cardiac emergencies
- Levophed - stimulates alpha - causes peripheral vasoconstriction - “leave em dead, Levophed” - last ditch effort
- Intropin - results dependent on size of dose
- – Low: increased renal perfusion
- – Med: increased cardiac output
- – High: increased BP
Neo-Synephrine
- alpha, vasoconstrictor, nasal decongestant
albuterol
- beta, bronchodilator
Isuprel
- beta, used in shock
Nursing Imp for adrenergic drugs
- extreme care with calculations of meds
- monitor VS, ECG, urine output, cardiac output
- allergies, carry epi pen at all times
- tolerance can develop
antiadrenergic drugs
- block SNS - whole or part
- –decrease BP, increase renal perfusion
- suppress pathological responses to activity, stress
phentolamine mesylate (Regitine) - prototype
prazosin (Minipress)
tamsulosin (Flomax)
alpha adrenergic blocking agents
- block alpha 1 receptor sites
- Regitine used for phenochromocytoma - tumor in adrenal glands
- Flomax used for Benign prostatic hyperplasia (BPH)
- Minipress used for hypertension
- also used for Reynaud’s - discoloration of fingers/toes
- adverse: tachycardia, hypotension
Nursing implications for alpha adrenergic blocking agents
- monitor VS
- supine with IV Regitine
- change positions slowly
- taper doses
- give with food
- take same time everyday
propranolol (Inderal) - prototype
atenolol (Tenormin)
carvedilol (Coreg)
beta adrenergic blocking agents
- can block beta 1 and/or beta 2
- block beta 1: decrease in HR, decrease in contraction and conduction
- –cardioselective beta blockers only block beta 1
- block beta 2: bronchoconstriction of smooth muscles
Inderal - prototype, nonselective
Tenormin - cardioselective
Coreg - alpha-beta
- uses: angina, post MI, dysrhythmias
Nursing Implications for beta blockers
- monitor VS esp HR
- watch for symptoms of hypoglycemia
- change position slowly
- taper dose
- avoid hot tubs, hot showers, saunas
- interacts with alcohol
acetylcholine - prototype
bethanechol (Urecholine)
metoclopramide (Reglan)
(parasympathetic drugs)
- direct acting cholinergic drugs
- Urecholine - urinary retention
- Reglan - delayed gastric emptying
- action: decrease HR, increase GI muscle tone, increase bladder tone, relax sphincters, increase resp secretions, constrict pupils
- use: glaucoma, GI reflux, neurogenic bladder, N/V with chemo
Adverse and Nursing Implications for parasympathetic drugs
Adverse:
- bradycardia, hypotension, HA, restlessness, coma
Caution:
- CAD, MI, heart block, intestinal obstruction, resp disorders
Nursing:
- monitor HR, rest rate
- watch for GI problems
- can exacerbate peptic ulcers
- atropine sulfate - antidote
neostigmine (Prostigmine)
edrophonium (Tensilon)
donepezil (Aricept)
(indirect acting cholingerics)
- inhibit action of acetylcholinesterase and prolongs the effects of acetylcholine
- use: myasthenia gravis, glaucoma, bladder distension, paralytic ileus
- Prostigmin - urinary retention and myasthenia gravis
- Tensilon - diagnosis of MG
- Aricept - alzheimers
Adverse and Nursing Implications for indirect acting cholingerics
Caution:
- bradycardia, parkinson’s intestinal/bladder obstructions, resp disorders, ulcerative colitis
Adverse:
- hypotension, bradycardia, intestinal spasm, resp arrest, vasodilation
Nursing:
- watch for signs of neurotoxicity
- monitor resp rate
- assess for abdominal cramping
- measure urinary output
atropine sulfate - prototype
oxybutynin (Ditropin)
tolterodine (Detrol)
(anticholinergic drugs)
- block parasympathetic nerve impulses by competing withe acetylcholine for sites on muscarinic receptors
- drugs used for urinary frequency
- use: GI disorders that have increased motility, bradycardia, relieve spastic bladder, decreased saliva
Adverse and Nursing Implications for anticholingeric drugs
Caution:
- glaucoma, heart disease, paralytic ileus
Adverse:
- dry mouth, constipation, tachycardia, difficult urination, blurred vision, and confusion
Nursing:
- monitor pulse, BP, urine output
- encourage fluids
- provide ice chips
