Pharm 1 Flashcards
SNS
adrenergic system
fight or flight
receptor cells: Alpha 1 and 2, Beta 1 and 2
Neurotransmitter: norepinephrine
PNS
cholinergic system
rest and digest
receptor cells: Nicotinic and muscarinic
neurotransmitter: acetylcholine
sympathetic stimulants
sympathomimetics (adrenergic, adrenomimetics, or adrenergic agonists)
increase blood pressure
increase pulse rate
relax bronchioles
dilate pupils
relax uterine muscles
increase blood glucose
sympathetic depressants
sympatholytics (adrenergic blockers, adrenolytics, or adrenergic antagonists)
decrease pulse rate
decrease blood pressure
constrict bronchioles
direct-acting parasympathetic stimulants
parasympathomimetics (cholinergic or cholinergic agonists)
decrease blood pressure
decrease pulse rate
constrict bronchioles
constrict pupils
increase urinary contraction
increase peristalsis
Adrenergic agonist
sympathomimetics
stimulate the adrenergic receptors
4 main receptor sites: Alpha 1 and 2, Beta 1 and 2
Alpha 1
- blood vessels, vasoconstriction, increased blood pressure, increased contractibility of the heart
- eye, mydriasis (pupil dilatation)
- bladder, relaxation
- prostate, contraction
Alpha 2
- blood vessels, decrease blood pressure
- smooth muscle, decrease GI tone and motility
Beta 1
- heart, increase heart contraction, increase heart rate
- kidney, increase renin secretion, increased angiotensin, increase blood pressure
Beta 2
- smooth muscle, decrease GI tone and motility
- lungs, bronchodilation
- uterus, relaxation of uterine smooth muscle
- liver, activation of glycogenolysis, increased blood sugar
adrenergic antagonist
sympatholytic
block the adrenergic recptors
adrenergic agonist
- neurotransmitter inactivation
inactivation by
- reuptake of transmitter back into the neuron
- enzymatic transformation or degradation
- diffusion away from the receptor
- two enzymes that deactivate the metabolism of norepine: MAO, COMT
classification of adrenergic agonists
direct-acting (epinephrine, norepinephrine)
- directly simulates adrenergic receptor
indirect-acting (amphetamine)
- stimulates the release of norepinephrine from terminal nerve endings
Mixed-acting (ephedrine)
- stimulates adrenergic receptors sites and stimulates the release of norepinephrine from terminal nerve endings
epinephrine (adrenaline)
nonselective
action
- alpha 1 increases BP
- Beta 1 increases HR
- Beta 2 promotes bronchodilation
-inotropic
- vasoconstrictor
- bronchodilator
contradictions and caution
- cardiac tachyarrhythmias, glaucoma
- hypertension, hyperthyroidism, diabetes mellitus, pregnancy
uses
- anaphylaxis, anaphylactic shock, bronchospasms, status asthmatics, cardiogenic shock, cardiac arrest
side effects
- cardiac dysrhythmias, palpations, tachycardia, hypertension, dizziness, headache, sweating, insomnia, restlessness, tremors, hyperglycemia (stim liver produce more sugar)
drug interactions
-beta-blockers - decrease epinephrine action
-digoxin - can cause cardiac dysrhythmias
Nursing interventions
- monitor BP, HR, and urine output
- report tachycardia, and palpations, avoid when breastfeeding, and cold medicines
Albuterol
selective
- acts on beta 2- adrenergic receptors
- promotes bronchodilation
uses
- treats bronchospasm, asthma, bronchitis, COPD
caution
- severe cardiac disease, hypertension, hyperthyroidism, diabetes, renal dysfunction, pregnancy (cat C)
side effects
- tremors, nervousness, restlessness, dizziness
- tachycardia, palpations, cardiac dysthymias
drug interactions
- may increase effect with other sympathomimetics, MAOIs, and increased tricyclic antidepressants
- antagonize effect w beta blockers
nursing process: adrenergic agonist
nursing interventions- monitor IV sites frequently when administering norepinephrine or dopamine, monitor ECG for dysrhythmias when adrenergic agonists are given IV
central-acting alpha agonist
clonidine
- selective alpha-2 adrenergic agonist
- used primarily to treat hypertension (pretty good at it)
side effects
- headache, nasal congestion, drowsiness, nightmares, constipation, edema, ED, elevated liver enzymes
short half life
adrenergic antagonist
block effects of adrenergic neurotransmitter
- block alpha and beta receptor sites; directly and indirectly
types
- alpha- adrenergic antagonist
- beta- adrenergic antagonist
- adrenergic neuron antagonist
alpha adrenergic antagonist
drugs that inhibit a response at alpha- adrenergic receptor site
- selective (block alpha 1)
- non selective (block alpha 1 and 2)
action
- promote vasodilation
use
- decrease symptoms of BPH, PVD
- not frequently used
beta-adrenergic antagonists
beta blocker actions
- decreases HR and BP
nonselective beta blockers
- blocks beta 1 ( decrease BP and pulse)
- blocks beta 2 ( bronchoconstruction, use w caution w pt w COPD or asthma)
- propranolol HCI (uses- angina, cardiac dysthymia
beta-adrenergic blockers
selective beta blockers
- metoprolol, atenolol
- blocks beta1 only
side effects/adverse reactions
- bradycardia, hypotension, dysthymias, heart failure, headaches, dizziness, fainting, fatigue, drowsiness, depression, N/V, diarrhea
adrenergic neuron antagonist
block release of norepinephrine
- clinically used to decrease BP
Nursing interventions
- monitor vital signs, report marked changes for example significant decrease in BP, watch for falls, and orthostatic hypertension
cholinergic agonists
drugs that stimulate PNS
- mimics acytocoline
cholinergic receptors
- muscarinic receptors (effects smooth muscles, slow heart rate
- nicotinic receptors ( affects skeletal muscles)
types of cholinergic agonists
- direct acting ( acts on receptors to activate tissues response)
- indirect acting (inhibits action of enzyme cholinesterase)
direct-acting cholinergic agonists
primarily selective to muscarinic receptors
muscarinic receptors located in smooth muscles
- heart, GI, GU, glands
- metocloprimide (used to increase gastric emptying, treats gasoparistis, nausea and gerd)
- pilocarpine (constrict pupils, treat glaucoma)
- bethanechol chloride (used to increase urination, treats urination retention, pee easily)
bethoanechol
urinary retention
side effects
- blurred vision, miosis
- hypotension, bradycardia, cardiac dysrhythmias, sweating, flushing
contraindications
- bradycardia, hypotension, COPD, peptic ulcer, hyperthyroidism
nursing interventions bethanechol
BP, heart rate, orthostatic hypotension, listen to breathe sounds rales and crackling, cholinergic crisis (overdoes) - muscle weakness and increased salvation
effects of cholinergic antagonist
heart
- large doses increase HR; small doses decrease HR
lungs
- bronchodilation, decrease secretions
GI
- relax smooth muscle tone, decrease motility and peristalisis
Ocular
- dilate pupils
Glandular
- decrease salvation and perspiration
CNS
- tremors and muscle rigidity decreased
GU
- relax detrusor muscle, increase sphincter construction
anticholinergics
atropine
- action/use ( increase HR, used for preop to decrease salvation)
side effects/ adverse reactions
- photophobia, headache, blurred vision
- abdominal distention, nausea, constipation, dry mouth and skin, decreased sweating
nursing interventions
- vitals, urine output, bowel sounds (slowing down GI)
- mouth care and eye drops, bedrails, driving
- avoid hot environments
- wear sunglasses
antiparkinsonism - anticholinergics
benzotropine
biperiden
trihexyphenidyl HCI
action - decreases involuntary movement, tremors, muscle rigidity
nursing process - atropine
assessment - urine output as urinary retention may occur
diagnosis - urinary retention related to atropine
planning - pt secretions w decrease before surgery
interventions - monitor vitals, intake and output, mouth care, bowel sounds
anticholinergic for motion sickness
antihistamine
- scopolamine
- treats motion sickness, N/V
- patch delivers dose for 3 days
side effects
- tachycardia, hypotension, dry mouth, constipation, blurred vision, flushing, muscle weakness
CNS stimulants
ADHD
narcolepsy
reversal of respiratory destress
categories
- amphetamines, caffeine (stimulate cerebral cortex, euphoria, alertness)
- analeptics, caffeine ( stimulate respiration)
- anorexiants (suppress appetite)
amphetamines
action
- stimulate release of norepinephrine and dopamine
- inhibit repuptake of norepinephrine and dopamine
side effects
- CV: tachycardia, palpitations, hypertension dysrhythmias
- Neuro: restlessness, irritability, confusion, euphoria, insomnia, blurred vision
GI: anorexia, dry mouth, weight loss, diarrhea, constipation
excess used: psychosis
amphetamine- like drugs for adhd
demethylphenidate
methylphenidate
controlled substance schedule II
uses
- increases attention span and cognitive performance
- decreases impulsiveness, hyperactivity, and restlessness
dosing
- 30-45 min before meals
- caffeine to increase effect
- no evening or before bed
cautions
- CVD, HTN, PD, psychosis, hyperthyroidism, seizures
- increases effects of oral anticoagulants, barbiturates, anticonvulsant, hypertensive crisis w MAOIs
amphetamine- like drugs for narcolepsy
methylphenidate
modafinil
increases wakefulness in pt w sleep disorders
unknown mechanism of action
nursing process amphetamine
baseline VS, mental status, height, weight, growth
baseline labs
planning- hyperactivity will be decreased within 3 days, pt HR and BP with be within normal limits
teaching - before meals, no alcohol, monitor weight
anorexiants
causes stimulate effect on hypothalamic and limbic areas of brain to suppress appetite
no one under 12
side effects
CV: Tachycardia, hypertension, palpitations
Neuro: seizures nervousness, irritability
sexual: ED
example: benzphetamine, most commons is phentermine
analeptics
primary use: stimulate respiration
examples - caffeine, theophylline (asthma), used for neonatal apnea
doxapram - used for post anesthesia respiratory destress
side effects - (similar to those of anorexiants)
sleep disorders
insomnia- fall asleep / stay asleep
- more common in females and older pt
- non- pharm sleep hygiene first
- pharm- sedative hypnotics
non-pharm management
- wake up at same time
- no napping
- avoid caffeine, alcohol, and nicotine
- no heavy meals
- take warm bath
sedative - hypnotics
sedatives - treat sleep disorders
sedative hypnotics cat
- barbiturates
- benzodiazepines
- non benzodiazepines
can be short or long term acting
short term at lowest dose
no hypnotics in those w severe respiratory disorders
general side effects
- hangover
- vivid dreams and nightmares
- drug dependence
- drug tolerance
- excessive depression
- respiratory depression
- hypersensitivity
barbiturates
long- intermediate- short/ ultrashort - acting
restrict to short term - no longer than 2 weeks
interactions
- alcohol, opioid, other sedative hypnotics
- decreases effects of oral anticoagulants, glucocorticoids, tricyclics antidepressant, quinidine
short acting - secobarbital
intermediate- butabarbitol
benzodiazepines
hypnotics
- flurazepam, alprozolam, temazepam, triazolam( intermediate sedation), estazolam, quazepam
sleep disorders and anxiety
- lorazepam and diazepam
action
- interacts w neurotransmitter GABA to reduce neuron excitability
Uses
- reduce anxiety, treat insomnia
antidote- flumazenil - vivid dreams and nightmares
nursing process
- assessment ( determine whether the pt has history of insomnia or anxiety
- planning - receive hood sleep
- observe for adverse reactions, teach about non pharm methods
no benzodiazepines
zolpidem
action
- neurotransmitter inhibition
- duration of action is 6-8 hours
schedule IV - “4”
use
- treat short term (less than 10 days insomnia
- often used for longer periods
melatonin agonists
newest cat
ramelteon - not a controlled substance
- first FDA approved hypnotic nit classified as a controlled substance
- selective targets melatonin receptors to regulate circadian rhythm to treat insomnia
- nit been shown to decrease REM sleep
- adverse effects
- drowsiness, dizziness, fatigue, headache, nausea, and suicidal ideation
nursing process: sedative hypnotic
ascertain the pt problem w sleep disturbance
sleep deprivation due to anxiety
pt will sleep 6-8 hours
observe pt for side effects if non benzodiazepines
anesthetics
types
general (depresses the CNS)
- alleviate pain
- loss of consciousness
local
- pain relief in limited area
routes
- inhalation
- IV
- topical
- local
- spinal
balanced anesthesia
- a hypnotic given night before surgery
- premedication ( w an opioid analgesic or benzodiazepines- example: midazolam)
- with an anticholinergic - decreases secretions (atropine)
- a short acting nonbarbiturates - propofol
- inhaled gas - nitrous oxide and oxygen
- muscle relaxant given as needed
inhalation anesthetics
nitrous gas (laughing gas) - doesn’t last long
provides smooth induction
usually combined w
- non barbiturate - propofol
- strong analgesic- morphine
- muscle relaxant - pancuronium
adverse effects
- respiratory depression, hypotension, dysrhythmias, malignant hyperthermia
intravenous anesthetics
droperidol, etomidate, ketamine - rapid onset and short duration of action
midazolam and propofol - sedation for minor surgery, can still be responsive to commands
adverse effects - respiratory depression, hypotension
topical anesthetics
limited to mucous membranes, broken or unbroken skin surfaces, and burns
forms - solution, liquid spray, ointment, cream, gel, and powder
decreases sensitivity of nerve endings of the affected area
local anesthetics
block pain at the site where the drug is given (decrease nerve sensitivity)
consciousness is maintained
use
- dental procedure
- suturing skin
two groups
ester and amides
- have very low allergic reaction
procaine hydrochloride- dental
lidocaine hydrochloride - rapid onset, longer duration
bupivacaine hydrochloride 3-10 hours
spinal anesthesia
local ejected in the subarachnoid space
adults - below first lumbar space
children - below third lumbar space
side effects
- respiratory distress
- headache
- hypotension
spinal column nerve blocks
spinal block - penetration of the anesthetic into subarachnoid membrane between the pia mater and arachnid membrane
epidural block - placement of the local anesthetic in the epidural space posterior to the spinal cord or dura mater
caudal block - placed through the sacral hiatus
saddle block - placed at the lower end of the spinal column to block the perineal area
nursing process anesthetics
monitor the post op state of sensorium
urine output
vital signs
epilepsy
seizure disorder resulting from abnormal electric discharge from cerebral neurons
characteristics
- loss of consciousness
- involuntary, uncontrolled movements
cause
- unknown
- second to brain trauma or anoxia, infection, stroke
isolated seizures (not epileptic) can occur due to fever, acid base imbalance, alcohol, drugs
international classification of seizures
common generalized seizure types
- tonic- clonic (grand mal)
• most common
• generalized alternating muscle spasms and jerkiness
- absence (petit mal)
•brief loss of consciousness (10 seconds or less)
• usually occurs in children
common partial seizures
- psychomotor- repetitive behavior - chewing or swallowing motions
• behavioral changes
• motor seizures
anti seizure drugs
-anticonvulsants or anti epileptic drugs
- are CNS depressants that
• stabilize nerve cell membranes
• suppress abnormal electric impulses in cerebral cortex
prevent seizures but not curative
hydantions
phenytoin
- contraindications
• pregnancy
- therapeutic serum level
• 10-20 mcg/mL
- side effects
• gingival hyperplasia, nystagmus, headache, dizziness, slurred speech, ventricular fibrillation, depression, hyperglycemia, thrombocytopenia, leukopenia (low platelets and low WBC), purple glove syndrome, stevens- johnson syndrome
drug interactions
- increased effects w cimetidine, isoniazid
- decreases effects w folic acid, ginko, antipsychotic
nursing process phenytoin
renal and hepatic functions lab
look at drug and herb use
pt seizure frequency will lower
seizure precautions
female pt taking BC
barbiturates
phenobarbital
action
- enhances GABA activity
uses
- tonic clonic, partial, myoclonic seizures, status epilepticus
therapeutic serum level
- 20-40
side effects
- sedation
- tolerance
discontinuation
- should be gradual
benzodiazepines
clonazepam
- treats absence and myoclonic seizures
- tolerance may occur in 6 months
diazepam
- treats status epilepticus
- must be administered IV for status epilepticus
- short term effect
• other antiseizure drugs must be given during it immediately after administration of diazepam
“bridge” - still needs to do more
Iminostibenes
carbamazepine
uses
- tonic clonic, partial seizures
- also used for psychiatric disorders, trigeminal neuralgia and alc withdraw
therapeutic serum range
4-12
no grapefruit juice
valproate
valproic acid
- uses- tonic clonic, absence, mixed seizures
therapeutic range
- 50-100
side effects
- dizziness, drowsiness, insomnia, diplopia, weakness, GI distress
anti seizure drugs in pregnancy
seizures increase during pregnancy
anti seizure drugs are teratogenic
anti seizure drugs tend to inhibit vitamin K
- contributes to hemorrhage soon after birth
anti seizure drugs increase loss of folate acid
anti seizure drugs and febrile seizure
seizures associated w a fever- children 3 months to 5 years
prophylactic treatment for high risk pt
phenobarbital- barbiturates
diazepam - benzo
anti seizure drugs and status epilepticus
medical emergency
treatment must begin immediately
treatment
- IV diazepam
-IV lorazepam
-followed by phenytoin IV
for continued seizures: midazolam, propofol
-slow IV admin to avoid respiratory depression
parkinson’s disease
imbalance between dopamine and acetylcholine occurs due to degeneration of dopamine neurons excess acetylcholine stimulates GABA
Characteristics
- involuntary tremors
- rigidity of muscles
- bradykinesia ( slow movement )
- postural changes ( head and chest thrown forward, shuffling gate, lack of facial expression)
parkinson’s disease treatment
non pharm measures - education - steps, rugs in house, increase mobility and flexibility, well balanced diet
treatments
- anticholinergic (inhibit the release of acetylcholine)
- dopamine replacement (stimulate dopamine receptors)
- dopamine agonist ( stimulate dopamine receptors)
- MAO- B
- COMT inhibitors
antiparkinson drugs
anticholinergics
action
- inhibit release of acetylcholine
- reduce muscle rigidity and some tremors
- minimal effect of bradykinesia
examples: benztropine, trihexphenidyl
side effects
- dizziness, drowsiness, weakness, anxiety, headache, insomnia, paresthesia, restlessness, blurred vision, GI distress, urinary retention
anti parkinson’s drugs
dopaminergics
- carbidopa - levodopa
action
- converts to dopamine and increased mobility
side effects
- fatigue, insomnia, dry mouth, blurred vision, GI distress, orthostatic hypertension
dopamine agonist
dopaminergics
example: apomorphine
action:
-stimulates dopamine receptors
orphan drug
side effects
- dizziness, drowsiness, yawning, hallucinations, N/V
Monoamine Oxidate B Inhibitors
selegiline
action
- inhibit MAO-B enzyme that interferes w dopamine
side effects
- dizziness, headache, impulse control disorder, dry mouth, suicidal, hypertension, ortho hypotension
interaction
- large does may inhibit MAO-A, an enzyme that promotes metabolism of tyramine
catechol- O- Methyltransferase inhibitors
Tolcapone
action
- gino it COMT enzyme that inactivates dopamine
side effects
- dizziness, drowsiness, headache, excess dreams, insomnia, hepatic dysfunction
Entacapone
- does nit affect liver
- combo pill w carb
alzheimer’s disease
incurable
chronic, progressive, neurodegenerative disorder
marked cognitive function usually between 45-65
symptoms
- mem loss, confusion, unable to communicate
- agressive behavior, depression
progression leads too loss of mem, logical thinking, and judgment, personality changes, time disoriented
acetylcholinesterase/ cholinesterase inhibitors
Rivastigmine
action
- allow more acetylcholine in neuron receptors
- increase cognitive function, slow disease process
side effects
- dizziness, headache, dry mouth, GI distress, Bradycardia, orthostatic, hypotension, dysrhythmias
nursing process -
mental and physical abilities
mem and judgement
pt mem will be improved
maintain care
vitals
myasthenia gravis
autoimmune disorder
lack of acetylcholine impairs transmission of messages at neuromuscular junctions
myasthenia crisis- severe generalized muscle weakness
acetylcholinesterase inhibitors
over dosing and underdosing
similar symptoms
-muscle weakness, dyspnea, bradiacardiac, drooling, abdominal cramping
myasthenia crisis
- caused by under dosing
cholinergic crisis
- symptoms become worse
- caused by over dosing
- atropine “antidote”
acetylcholinesterase inhibitors
- edrophonium - ultra-short acting for diagnosing
- neostigmine - short acting
- ambenonium - long acting
action
- increase muscle strength in pt w myasthenia gravis
side effects
- increased salivation and tearing, miosis, blurred vision, bradycardia, hypotension, GI distress
Pt unresponsive to acetylcholine inhibitors
prednisone
- drug of choice
Plasma exchange
IV immune globulin IVIG
immunosuppressive drugs
- azathioprine
- need to monitor for leukopenia and hepatoxicity
nursing process: acetylcholine inhibitors
myasthenia crisis
muscle weakness w be reduced in 2-3 days
take drug before meals
admin in time
multiple sclerosis
autoimmune disorder
characteristics
- remissions and exacerbation
- motor: weakness or paralysis of extremities, muscle spasticity, diplopia
sensory: numbness and tingling, neuropathic pain, severe fatigue
classifications
- relapsing remitting - full recovery and residual deficit
- primarily progressive - slowly worsening neurologic function with no relapses or remissions
- secondary progressive relapsing - progressive w onset w acute relapses with it without full recovery
-clinically isolated syndrome- only one flare up
MS drug treatment
immunomodulators
- first line treatment
- slows disease progression and prevents relapses
immunosuppressants
- mitoxantrone (IV)
corticosteroids
- exacerbatations
- reduces edema
skeletal muscle relaxants
central acting muscle relaxants
- mechanisms of action not fully known
- relieves muscle spasm and spasticity
- have sedative effect
peripherally acting muscle relaxants
- dantrolene
- decreases muscle spasm pain and increases range of motion
side effects
- drowsiness, dizziness, headache, nausea, vomiting
cyclobenzaprine
action
- relax skeletal muscles
uses
- relieves muscle spasms
side effects
- blurred vision, dried mouth, GI distress, drowsiness, dizziness
substance use disorder
factors that play
- age/cognitive function
- family related
- social
- individual
positive fam relationships help
neuro biology
misuse of drugs hits on the reward circuit in our brain
drugs mimic our own neurotransmitters
related use = tolerance
alcohol use disorder (AUD
action - inhibits the effect of GABA
short term effects- N/V, headaches, impaired judgment
long term- high rates of cancer, liver damage, brain issues
alcohol toxicity
- life threatening condition that can occur by drinking large amounts of alc over short period of time
complications - dehydration, seizures, brain damage
treatment of AUD
few seek treatment
inpatient and outpt
drug-assisted treatment
- disulfiram (Antabuse) - with any alc will get really sick
- acamprosate (Campral) - can use through relapse
- naltrexone (Vivitrol, Revia ) - have to watch for opioid withdraw
should be used with therapy also
cannabis use disorder
short-term- mem, learning impairment, inability to focus
long term - res. issues, exposes to cancer
treatment - no meds are currently approved for treatment
non-pharm- CBT, MET, may help
opioid use disorder
effects - drowsiness, confusion, nausea, constipation
- dose-dependent respiratory depression
most get it from someone they know
treatment
- non-pharm
drug assisted
- naloxone (Narcan) - may have to give more than 1 time
- Naltrexone (methadone - long term, tolerance will be low after using this med if opioids are taken while on med they will most likely overdose
tobacco use disorder
short term- high HR and BP
long term - cancer
treatment
-cognitive behavior therapy - helps develop new ways of thinking
- self help materials - apps related to $$ save if they quit
- telephone-based counseling- from own home
drug assisted
- nicotine replacement
- bupropion (zyban) - increases levels of dopamine or ephi, after comfy taper pff
- varenicline (Chantix
start meds a week before
other substance use disorder
cold meds
dextromethorphan - euphoria, dissociative effects
promethazine- codeine - euphoria and relaxation
special needs of pt w substance use disorder
surgical pt
post op and during
psychosis
Loss of contact with reality
Theory
- Results from imbalance in neurotransmitter dopamine in the brain
Characteristics
- Difficulty in processing information
- Disorganized thoughts, incoherence
- Distortion of reality
- Delusions, hallucinations, catatonia
- Aggressive or violent behavior
Schizophrenia
Chronic psychotic disorder
Symptoms usually develop in adolescence or early adulthood
Major category of symptoms
- Cognitive symptoms
- Positive symptoms- agitation and speech doesn’t make sense
- Negative symptoms- decrease in function
Antipsychotic
Also known as neuroleptics or psychotropics
Theory – dopamine imbalance in the brain
Many antipsychotics block dopamine receptors
Block dopamine – side effects are EPS or parkinsonism
Two categories
Typical
Phenothiazines - block norepinephrine causing sedative/hypotensive effects
Nonphenothiazines - block neurotransmitter dopamine
Atypical
Now are first-line therapy
Decreased side effects than typical antipsychotics
Adverse reactions
Extrapyramidal syndrome
Stooped posture, masklike facies, rigidity, tremors at rest
Shuffling gait, pill-rolling motion of hands, bradykinesia
Acute dystonia
Akathisia
Tardive dyskinesia
Neuroleptic malignant syndrome (rare, potentially fatal)
Symptoms: Muscle rigidity, hyperthermia, altered mental status, diaphoresis, blood pressure fluctuations, tachycardia, dysrhythmias, seizures, rhabdo, acute renal failure, respiratory failure, and coma
Treatment: stop antipsychotic!, hydration, hypothermic blankets, and antipyretics, benzos, and muscle relaxant
Typical Antipsychotic
Phenothiazine groups
Aliphatic: chlorpromazine
Side effects
Strong sedation, orthostatic hypotension, moderate EPS
Piperazine: fluphenazine, perphenazine
Side effects
Dry mouth, urinary retention, agranulocytosis, more EPS than other groups
Piperidines: thioridazine
Side effects
Strong sedation, low to moderate effect on blood pressure, few EPS
Typical Antipsychotics: Phenothiazine
Fluphenazine
Action
Blocks dopamine receptors in brain
Use
Manages symptoms of schizophrenia and psychosis
Interactions
Increase depression when taken with alcohol or other CNS depressants
Increased effects with MgSO4, lithium, beta blockers
Side effects
Sedation, dizziness, headache, seizures
Dry mouth, nasal congestion, blurred vision, photosensitivity
Urinary retention, sexual dysfunction, GI distress, peripheral edema, tachycardia, EPS
Typical Antipsychotics: Nonphenothiazin
Haloperidol
Action
Blocks dopamine receptors
Use
Treats psychoses, schizophrenia, attention-deficit/hyperactivity disorder, Tourette’s syndrome
Contraindications
Narrow-angle glaucoma
CNS depression
Severe liver, kidney, and cardiovascular disease
Blood dyscrasias
Haloperidol
Side effects
Drowsiness, headache, insomnia
Dry mouth, blurred vision, photosensitivity
Tachycardia, orthostatic hypotension, dysrhythmias
Seizures, weight gain
Urinary retention, sexual dysfunction
Blood dyscrasias, strong EPS, NMS
Interactions
Increased sedation with alcohol, CNS depressants
Increased toxicity with anticholinergics
Decreased effects with phenobarbital, carbamazepine, caffeine
Atypical Antipsychotics
Advantages
Effective in treating both positive and negative symptoms of schizophrenia
Less likely to cause EPS or tardive dyskinesia
Action
Block serotonin and dopaminergic D4 receptors
Clozapine
Use
Severe schizophrenic patients unresponsive to traditional antipsychotics
Side effects and adverse effect
Dizziness, sedation, constipation
Tachycardia, orthostatic hypotension
Tremors, occasional rigidity
Seizures, agranulocytosis
Low likelihood of EPS
Risperidone
Use
Manage symptoms of psychosis
Side effects/adverse reactions
Sedation, headaches, photosensitivity
EPS, seizures
Dry mouth, weight gain
Tachycardia, orthostatic hypotension
Urinary retention, sexual dysfunction
Low possibility of EPS and tardive dyskinesia
Aripiprazole
Use
Manage symptoms of schizophrenia, bipolar disorder, autism, depression, Tourette syndrome
Side effects/adverse reactions
Drowsiness, dizziness, headache
Insomnia, anxiety, agitation, memory impairment
Blurred vision, photosensitivity
GI distress, weight gain/loss
Tachycardia, orthostatic hypotension, dysrhythmias
Seizures, sexual dysfunction
Suicidal ideation, NMS
Low possibility of EPS and tardive dyskinesia
Nursing Process: Phenothiazines and Nonphenothiazines
Assessment
Assess baseline vital signs
Obtain a health history including present drugs
Nursing diagnosis
Relationship, ineffective related to social withdrawal
Sleep pattern, disturbed related to medication adverse effects
Planning
Patient’s psychotic behavior will improve with medication, psychotherapy, and adjunct therapies
Nursing interventions
Monitor vital signs
Remain with patient while medication is taken and swallowed
Observe for EPS
Assess for symptoms of NMS
Inform patients that medication may take 6 weeks or longer to achieve full clinical effect
Caution patients not to consume alcohol or other CNS depressants such as opioids
Anxiety
Nonpharmacologic treatment
Relaxation techniques
Psychotherapy
Support groups
Pharmacologic treatment
Benzodiazepines
Miscellaneous anxiolytics
SSRIs
SNRIs
TCAs
MAOIs
Anxiolytics
Lorazepam
Action
Inhibits GABA neurotransmission by binding to specific benzodiazepine receptors
Use
Anxiolytic, antiseizure, sedative-hypnotic, preoperative drug, substance abuse withdrawal
Side effects
Drowsiness, dizziness, ataxia, restlessness, weakness
Headache, confusion, amnesia, blurred vision
GI distress, sleep disturbance, hallucinations
Bradycardia, hypotension/hypertension
Seizures, suicidal ideation, NMS, respiratory depression
Discontinuation
Gradually decrease dose over several days
Withdrawal symptoms
Develops slowly, in 2 to 10 days, and may last several weeks
Withdrawal symptoms
Tremor, agitation, nervousness
Sweating, insomnia
Anorexia, muscle cramps
Nursing Process: Benzodiazepines
Assessment
Assess for suicidal ideation
Obtain a history of patient’s anxiety reaction
Determine patient’s support system
Nursing diagnosis
Anxiety related to situational crisis
Noncompliance related to adverse effects of medications
Planning
Patient’s anxiety and stress will be reduced
Nursing interventions
Observe patient for side effects of anxiolytics
Monitor vital signs
Encourage family to be supportive of patient
Advise patient not to drive a motor vehicle or operate dangerous equipment when taking anxiolytics because sedation is a common side effect
Warn patient not to consume alcohol or CNS depressant while taking an anxiolytic
Miscellaneous Anxiolytics: Buspirone
Buspirone (BusPar)
Action
Binds to serotonin and dopamine receptors
May not be effective until 1 to 2 weeks after continuous use
Has fewer side effects of sedation and physical and psychological dependency associated with many benzodiazepines
Common side effects
Drowsiness, dizziness
Headache, excitement
Nausea, nervousness
Interaction with grapefruit juice
Miscellaneous Anxiolytics: Buspirone
Buspirone (BusPar)
Action
Binds to serotonin and dopamine receptors
May not be effective until 1 to 2 weeks after continuous use
Has fewer side effects of sedation and physical and psychological dependency associated with many benzodiazepines
Common side effects
Drowsiness, dizziness
Headache, excitement
Nausea, nervousness
Interaction with grapefruit juice
Depression
Etiology
Genetic predisposition
Social and environmental factors
Biologic conditions
Pathophysiology theories
Decreased levels of monoamine neurotransmitters
Norepinephrine, serotonin, dopamine
Signs and symptoms
Depressed mood, despair, weight loss or gain
Loss of interest in normal activities
Fatigue, insomnia or hypersomnia
Decreased ability to think or concentrate
Suicidal thoughts
Types of depression
Reactive depression - after an event (bre)
major depression - disease, loss of interest, worthlessness
Bipolar disorder - #1 periods of depression along w mana
Complementary and Alternative Therapy for Depression
Ginkgo biloba and St. John’s wort
Should not be taken with prescription antidepressants
Discontinue use of herbal products 1 to 2 weeks before surgery
Check with the health care provider before taking herbal treatments
Tricyclic Antidepressants
Action
Blocks uptake of neurotransmitters norepinephrine and serotonin in brain
Elevates mood, increases interest in ADLs, decreases insomnia
Use
Major depression
Response occurs after 2-4 wks of drug therapy
- increase mood
Side effects/adverse reactions
Drowsiness, dizziness, blurred vision
Dry mouth and eyes, GI distress
Urinary retention, sexual dysfunction
Weight gain, seizures
Sleep-related behaviors, suicidal ideation
Orthostatic hypotension, dysrhythmias
Blood dyscrasias, cardiotoxicity
EPS, NMS
Interactions
Alcohol and other CNS depressants potentiate CNS depression
MAOIs may lead to toxic psychosis, cardiotoxicity
Antithyroid drugs may increase dysrhythmias
Selective Serotonin Reuptake Inhibitors
Action
Block uptake of neurotransmitter serotonin
Do not block uptake of dopamine, norepi & do not block cholinergic receptors (fewer side effects)
Uses
Major depression
Anxiety disorders
Obsessive-compulsive disorder
Panic disorders
Phobias
Posttraumatic stress disorder
Prevention of migraine headaches
SSRI
effective for sadness, panic, compulsion
E- escitalopram
F- Fluvoxamine, Fluoxetine
S- sertraline
P- paroxetine
C- citalopram
SSSS = Stomach upset, Sexual dysfunction, Serotonin sydrome,
Suicidal thought
SSRI, Fluoxetine
Action
Decreases reuptake of serotonin, enhancing action of serotonin in nerve cells
Use
Depression, bulimia, OCD, anxiety/panic, PMDD
Initial effect: 3-4 wks; therapeutic effect: 4-6 wks
Side effects/adverse effects
Headache, dizziness, drowsiness, insomnia, weakness, confusion, abnormal dreams, tremors, dry mouth, anorexia, nausea, constipation, sexual dysfunction, electrolyte disturbances, GI bleeding or obstruction, OH, tachycardia, SJS, serotonin syndrome, EPS, stroke, SI
Serotonin Norepinephrine Reuptake Inhibitors
Action
Inhibit the reuptake of serotonin and norepinephrine
Use
Major depression
Generalized anxiety disorder
Social anxiety disorder
Examples
Venlafaxine
Duloxetine
Desvenlafaxine
Side effects
Drowsiness, dizziness, insomnia
Headache, euphoria, amnesia
Blurred vision, photosensitivity
Adverse effects
Tachycardia, hypertension
Angioedema, seizures, suicidal ideation
Atypical Antidepressants
Action
Affect one or two of the three neurotransmitters: serotonin, norepinephrine, and dopamine
Use
Major depression, reactive depression, anxiety
Interaction
Do not take with MAOIs and do not use within 14 days after discontinuing MAOIs
Trazodone may have a potential drug interaction with ketoconazole, ritonavir, and indinavir that may lead to increased trazodone levels and adverse effects
Monoamine Oxidase Inhibitors
Action
Monoamine oxidase enzyme inactivates norepinephrine, dopamine, epinephrine, and serotonin
Use
Depression not controlled by TCAs and second-generation antidepressants
For mild, reactive, and atypical depression
Used less frequently due to adverse reactions
Drug interactions
CNS stimulants such as vasoconstrictors and cold medications containing phenylephrine and pseudoephedrine can cause a hypertensive crisis
Food interactions
Foods that contain tyramine
Some cheeses, cream, yogurt, coffee, chocolate, bananas, raisins, Italian green beans, liver, pickled foods, sausage, soy sauce, yeast, beer, and red wines can cause a hypertensive crisis
Side effects/adverse effects
Agitation, restlessness, insomnia
Anticholinergic effects
Orthostatic hypotension
Hypertensive crisis from tyramine interaction
Nursing Process: Antidepressant Agents
Assessment
Assess the patient’s baseline vital signs and weight for future comparisons
Obtain a health history of depression episodes; assess for mental status and suicidal ideation
Nursing Diagnosis
Social isolation related to feelings of sadness
Self-directed violence, risk for
Planning
Patient’s depression will be decreased
Nursing interventions
Observe patient for signs of depression, mood changes, insomnia, apathy, or lack of interest in activities
Monitor vital signs
Monitor for drug-drug and food-drug interactions
Provide patient with a list of foods to avoid
Caution patient not to consume alcohol or other CNS depressant concurrently
Mood Stabilizer: Lithium
Lithium
Use
Bipolar affective disorder
Action
Alteration of ion transport in muscle and nerve cells
Increased receptor sensitivity to serotonin
Therapeutic serum range
0.8 to 1.2 mEq/L
Serum lithium levels greater than 1.5 mEq/L may lead to toxicity
Also need to monitor sodium levels
Has a calming effect but may cause some memory loss and confusion
Side effects/adverse reactions
Headache, drowsiness, dizziness, blurred vision
Restlessness, tremors, memory impairment
Dry mouth, metallic taste, GI distress
Hypotension, dysrhythmias
Edema of hands and ankles, dehydration
Increased urination, blood dyscrasias, NMS
Serotonin syndrome, nephrotoxicity
Interactions
Increased lithium level with
Thiazides, methyldopa, haloperidol, NSAIDs, antidepressants, theophylline, phenothiazines
Decreased lithium level with
Caffeine, loop diuretics
Nursing Process: Lithium
Assessment
Assess for suicidal ideation
Assess for baseline vital signs
Obtain health history and drug history
Nursing diagnosis
Injury, Risk for
Coping, Ineffective related to manic behavior
Planning
The patient’s manic-depressive behavior with decrease
Nursing interventions
Observe patient for depression, mood changes, insomnia, apathy, or lack of interest in activities
Monitor vital signs
Monitor lithium levels
Check cardiac status
Advise patient to avoid caffeine products
Advise patient to maintain adequate sodium intake
Inflammation
Protective response to tissue injury and infection
Inflammatory phases
Vascular phase
Occurs 10 to 15 minutes after injury
Associated with vasodilation and increased capillary permeability
Occurs when fluid, blood elements, leukocytes, and chemical mediators (histamines, kinins, prostaglandins) to accumulate at the injured site
Delayed phase
Leukocytes infiltrate inflamed tissue
Cyclooxygenase (COX) enzyme
Converts arachidonic acid into prostaglandins (which cause inflammation and pain at tissue injury site)
Has two enzyme forms:
COX-1: protects stomach lining and regulates blood platelets
COX-2: triggers inflammation and pain
antiinflammatory drugs
Antiinflammatory drug groups
Nonsteroidal antiinflammatory drugs (NSAIDs)
Corticosteroids
Disease-modifying anti-rheumatic drugs
Antigout drugs
NSAIDS
Action
Inhibit the enzyme COX which is needed for biosynthesis of prostaglandins
Effects
Analgesic effect
Antipyretic effect
Inhibit platelet aggregation
Mimic effects of corticosteroids but are not chemically related
Most often used for musculoskeletal conditions
First-generation NSAIDs
Salicylates
Para-chlorobenzoic acid derivatives
Phenylacetic acids
Propionic acid derivatives
Fenamates
Oxicams
Second-generation NSAIDs
Selective COX-2 inhibitors
Salicylates
Aspirin (acetylsalicylic acid) (ASA)
Action
Prostaglandin inhibitor; inhibits the COX enzyme
Antiinflammatory, antiplatelet, antipyretic effects
Therapeutic serum salicylate level
15 to 30 mg/d
Lab/Food/Drug Interaction of Salicylates
Lab
Increase PT, bleeding time, INR, uric acid
Decrease cholesterol, T3 and T4 levels
Foods containing salicylates
Prunes, raisins, licorice
Certain spices such as curry and paprika
Drugs
Increased bleeding with anticoagulants and other NSAIDs
Risk for hypoglycemia with oral antidiabetics
Increased gastric ulcer risk with glucocorticoids
Decreased effects of ACE inhibitors, loop diuretics, probenecid
Salicylate effects are decreased by corticosteroids
Side effects/adverse reactions
Dizziness, drowsiness, headache
Tinnitus, hearing loss
GI distress, bleeding, ulceration
Thrombocytopenia, leukopenia, agranulocytosis, hemolytic anemia
Hepatotoxicity
Hypersensitivity/OD: Tinnitus, dizziness, bronchospasm
Do not take with other NSAIDs
Avoid in last trimester
Avoid in children with flu-like symptoms – may cause Reye syndrome
Nursing Process: Salicylates
Assessment
Determine patient’s medical history
Obtain a med/drug history
Nursing diagnosis
Injury, Risk for
Pain, Chronic related to tissue swelling from injury
Planning
The patient’s inflammation will be reduced within 1 week
Nursing interventions
Monitor serum salicylate level (if on high doses)
Observe the patient for evidence of bleeding
Advise patient not to take aspirin with alcohol or warfarin to prevent increased bleeding
Instruct patient to discontinue aspirin approximately 7 days before surgery to reduce risk of bleeding
Warn parents not to give aspirin for virus or flu symptoms to children to avoid risk of Reye syndrome
Educate parents to call the poison control center immediately if a child has taken a large or unknown amount of aspirin
Inform patient that aspirin tablets can cause GI distress
Para-Chlorobenzoic Acid
Action
Inhibits prostaglandin synthesis
Use
Rheumatoid arthritis, osteoarthritis, gouty arthritis
Side effects/adverse effects
Dizziness, headache, weakness
GI distress and bleeding
Sodium and water retention -> Hypertension
Phenylacetic Acid Derivatives
Action
Inhibits prostaglandin synthesis
Use
Rheumatoid arthritis, osteoarthritis, ankylosing spondylitis, and pain
Minimal to no antipyretic effect
Examples
Ketorolac
Oral, IV, IM, intranasal
Efficacy equal or superior to opioids
Diclofenac
Oral or topical
Propionic Acid Derivatives
buprofen
Most widely used NSAID
OTC
Action
Inhibits prostaglandin synthesis
Use
Pain, osteoarthritis, rheumatoid arthritis
Side effects
Drowsiness, dizziness, headache, confusion, insomnia, dreams
Gastric distress and bleeding
Tinnitus, dysrhythmias, nephrotoxicity, blurred vision, edema
Drug interactions
Increased bleeding with warfarin
Increased effects with phenytoin, sulfonamides, warfarin, cephalosporins
Decreased effect with aspirin
Nursing Process: Ibuprofen
obtain drug and herbal history
assess for GI distress
observe pt for bleeding gumd, report ant GI issues, no alc
Fenamates and Oxicams
Fenamates
Example: meclofenamate
Use: For mild to moderate pain/arthritis
Oxicams
Examples: piroxicam and meloxicam
Indicated for long-term arthritic conditions
Long half life; typically dosed once daily
Well tolerated; lower incidence of GI distress
Selective COX-2 Inhibitors
Action
Selectively inhibits COX-2 enzyme without inhibition of COX-1
2nd generation NSAID
Use
Osteoarthritis, rheumatoid arthritis, ankylosing spondylitis, pain, dysmenorrhea
Corticosteroids
Action
Control inflammation by suppressing or preventing many of the components of the inflammatory process at the injured site
Use
Arthritic flare-ups
Not the drug of choice for arthritis because of their numerous side effects
Discontinuation
Taper off over 5-10 days if it has been used long-term
Disease-Modifying Antirheumatic Drugs
Types
Immunosuppressive agents
Immunomodulators
Antimalarials
Use
Alleviate symptoms of rheumatoid arthritis when other treatments fail
Osteoarthritis
Severe psoriasis
Crohn disease, ulcerative colitis
Antigout Drugs
Colchicine
Action
Inhibits migration of leukocytes to inflamed site
Alleviates gout symptoms
Side effects
GI distress
Taken with food to avoid GI distress
Contraindications
Severe renal, cardiac, or GI problems
Uric acid biosynthesis inhibitors (febuxostat, allopurinol)
Action
Decreases uric acid synthesis and lowers serum uric acid levels
Prophylactic; prevents gout attacks
Side effects
Dizziness, headache, dry mouth, GI distress
Arthralgia, pruritus
Nursing Process: Allopurinol
Assessment
Assess serum uric acid value for
future comparisons
Nursing diagnoses
Tissue integrity, Impaired related to inflammation of the great toe
Pain, Acute related to tissue swelling
Planning
Patient’s pain will be controlled without side effects
Nursing interventions
Record urine output
Monitor lab tests for renal and hepatic function
Instruct patient to increase fluid intake to increase drug and uric acid excretion
Advise patient to have a yearly eye exam as visual changes can result from prolonged use of allopurinol
Uricosurics
Action
Increase the rates of uric acid excretion by inhibiting its reabsorption
Use
Chronic gout
Example
Probenecid
Usually given with colchicine
Side effects
Flushed skin, fever, dizziness, headache
Blood dyscrasias
Avoid aspirin as it inhibits action of probenecid
Nonopioid Analgesics
less potent
mild to moderate pain
effective for dull, throbbing pain of headaches, muscles aches and pain
action site - PNS at pain receptor sites
NSAIDs
OTC NSAIDs
Aspirin
Ibuprofen
Naproxen
Action
Analgesic
Antipyretic
Antiinflammatory effects
Acetaminophen
Acetaminophen is not an NSAID
Uses
Muscular aches and pain, fever
No anti-inflammatory properties
Maximum dose
4 g/day
If taken frequently 2 g/day
Side effects
Headache, insomnia
Anorexia, nausea, vomiting, constipation – low incidence
Rash
Opioid Analgesics
Use
Moderate and severe pain
Action site
Act on CNS
Suppress pain impulses
Suppress respiration and coughing by acting on respiratory and cough centers in the medulla
Many opioids possess antidiarrheal effects
Opioid Analgesics: Morphine
Use -> moderate to severe pain
Antidote -> naloxone
Route -> PO, SC, IM, IV, rectal
Side effects/adverse reactions
Drowsiness, dizziness, euphoria, confusion, depression,
Miosis, blurred vision
GI distress, flatulence, constipation
Orthostatic hypotension, weakness
Urinary retention
Psychological dependence
Respiratory depression
Nursing Process: Morphine
Assessment
Determine drug history and check for drug allergies
Assess the type of pain, location, and duration before giving opioids
Nursing diagnoses
Pain, Acute related to surgical tissue injury
Breathing Pattern, Ineffective related to excess morphine dosage
Planning
The patient’s pain will be reduced or alleviated within ____ time (depending on route)
Nursing interventions
Administer morphine before pain reaches its peak to maximize drug effectiveness
Monitor vital signs frequently to detect respiratory changes
Check for pupil changes and reaction
Have naloxone available as an antidote to reverse respiratory depression if morphine overdose occurs
Meperidine
Use
Primarily effective in GI procedures
Preferred to morphine during pregnancy
Route: PO, IM, IV
Side effects
Less constipation and urinary retention than morphine
Hypotension
Caution with large doses in older adults and patients with advanced cancer
Neurotoxicity -> nervousness, agitation, irritability, tremors, seizures
Not for long-term use
Hydromorphone
For moderate to severe pain
Can be PO, rectal, SC, IM, IV
Analgesic effect is approximately six times more potent than morphine
Fewer hypnotic effects and less GI distress than morphine
Monitor respirations closely
Side Effects, Adverse Reactions, and Contraindications of Opioids
SE/AR
Respiratory distress
Orthostatic hypotension, drowsiness, dizziness, confusion, weakness
Constipation
Miosis
Urinary retention
Tolerance, dependence
Contraindications
Head injuries
Respiratory distress/asthma
Shock/Hypotension
Adjuvant Therapies
Adjuvant therapy
Usually used along with a nonopioid and opioid
Developed for other uses but found to be beneficial for pain
Adjuvant analgesics
Anticonvulsants - gabapentin
Tricyclic antidepressants - amitriptyline
Corticosteroids
Antidysrhythmics - mexiletine
Local anesthetics – lidocaine patch
Opioid Antagonists
Action
Blocks receptor and displaces opioid
Use
Antidote for opiate overdoses
Reverse effects of opiates including respiratory depression, sedation, hypotension
Example -> Naloxone (Narcan)
Side effects/adverse effects
Sweating, flushing, agitation, dyspnea
Hypo/hypertension, tachycardia
Nausea, vomiting
Elevated PTT, bleeding
Reversal of analgesia
Nursing interventions
Monitor vital signs and bleeding continuously
Migraine Headaches
Characteristics
Unilateral throbbing pain
Nausea, vomiting, photophobia
Can be with or without aura
Lasts hours to days
Triggers
Cheese, chocolate, red wine, aspartame, fatigue, stress, monosodium glutamate, missed meals, odors, light, hormone changes, drugs, weather, too much or too little sleep
Cluster Headaches
Characteristics
Severe unilateral non-throbbing pain
Usually located around eye
Occur in a series of cluster attacks
One or more attacks every day for several weeks
Not associated with an aura
Do not cause nausea and vomiting
More common in males
Migraine Headaches Prevention
Beta-adrenergic blockers
Propranolol
Atenolol
Anticonvulsants
Valproic acid
Gabapentin
Tricyclic antidepressants
Amitriptyline
Imipramine
Management
Analgesics
Aspirin with caffeine, acetaminophen
NSAIDs: ibuprofen, naproxen
Opioid analgesics
Meperidine, butorphanol nasal spray
Ergot alkaloids
Dihydroergotamine mesylate
Selective serotonin1 receptor agonists
Sumatriptan, zolmitriptan
