Psychiatric Nursing + Neuro Flashcards
Alcohol Deterrent
Acamprosate
Used for alcohol abstinence management
PO
Interactions: Increase glucose, bilirubin, uric acid
Decreases Hgb/Hct and platelets
Side effects: Anxiety Dizziness Insomnia Chills Rhinitis Constipation N/V Depression Headache Tremors Drowsiness Anorexia Diarrhea
Adverse:
SI and Dyspnea
Intervention
Assess Mental status for depression, abnormal thoughts, suicidal thoughts
Obtain v/s
Evaluate therapeutic response
Education:
Notify prescriber of depression, abnormal/suicidal thoughts
Don’t engage in hazardous activities
Don’t drink alcohol
Aldehyde Dehydrogenase Inhibitor / Disulfiram
Used for alcoholism
Contraindications: Myocardial disease, Psychoses, Pregnancy
PO: 2 – 12 hours
Interactions: Severe unpleasant side effects when
taken with alcohol, or foods/ products containing alcohol such as mouthwash, cough medicine, cooking wine, vinegar.
Use with phenytoin can lead to phenytoin intoxication.
MoA: Disulfiram blocks the oxidation of alcohol. Blocks an enzyme that is involved in metabolizing alcohol intake. Disulfiram produces very unpleasant side effects when combined with alcohol in the body.
Side Effects: Flushing Sweating Increased thirst Swelling Rapid weight gain Nausea Severe vomiting Confusion Blurred vision Weakness Throbbing headache
Adverse Effects: Allergic reaction: hives; difficult breathing; swelling of your face, lips, tongue, or throat. Severe abdominal pain Sudden vision loss Optic neuritis/Peripheral neuritis Hepatitis
Interventions:
Monitor liver function studies.
Assess for recent alcohol use. Do not administer for 12 hr
following alcohol ingestion.
If a severe disulfiram reaction occurs administer oxygen,
monitor ECG and serum potassium levels, and provide
supportive measures.
Monitor CBC and blood chemistry every 6 months during
therapy
Education:
Do NOT drink alcohol while taking this medication. Severe unpleasant side effects when taken with alcohol, or foods/ products containing alcohol such as mouthwash, cough medicine, cooking wine, vinegar.
Wear a medical alert tag or carry an ID card.
Used with behavior modification, psychotherapy, and counseling support.
Inform patient of purpose of disulfiram and the consequences of drinking alcohol during therapy.
Avoid driving and other activities requiring alertness
Anti Anxiety: Antihistamines - Hydroxyzine
Common use: Anxiety disorders, Pre and post op sedation, N/V
Contraindications: 1s trimester of pregnancy
PO/IM/ 15 to 60 mins
Interactions:
Increased CNS effect with use of barbiturates, opioids, analgesics, alcohol, sedative/hypnotics.
Increased anticholinergic effects with use of phenothiazines, antihistamines, antidepressants,
atropine, haloperidol, MAOIs
MoA: Depresses subcortical levels of CNS, including the limbic system.
Side Effects: Headache Dry mouth Dizziness Fatigue Increased appetite Nausea Diarrhea Weight gain
Adverse Effects:
Hypotension
Hives
Seizures
Nursing Interventions: Administer IM deep in large muscle using Z-track method to decrease pain, chance of necrosis. Do NOT give IV or SQ. Monitor for sedative effects. Monitor BP Assist with ambulation
Education: Avoid OTC medications. Avoid driving, activities that require alertness. Avoid alcohol, psychotropic medications. Do not discontinue quickly. Rise slowly.
Benzodiazepines - Diazepam (Valium), Lorazepam (Ativan), Alprazolam (Xanax), Triazolam (Halcion), Midazolam (Versed)
Common Uses: Anxiety disorders, Alcohol withdrawal Personality disorders Panic attacks Seizures Pre-op sedation
Contraindications: Narrow angle glaucoma Hypersensitivity Myasthenia gravis Sleep apnea
PO/iM/IV/RECTAL
Interactions:
Increase diazepam effect with amiodarone, cimetidine, verapamil, valproic acid.
Increase toxicity with barbiturates, SSRIs, cimetidine, CNS
depressants, valproic acid
MoA: Potentiates the actions of GABA, especially in the limbic system.
Advantages:
Does not produce life-threatening respiratory depression or coma if taken in excessive amounts.
Result is less physical dependence than the
barbiturates.
Disadvantages: Increased risk of falls with elderly
Side Effects: Drowsiness Dizziness Sedation Headache Depression Blurred vision Tinnitus Constipation Diarrhea Anorexia Nausea/Vomiting
Adverse: Retrograde amnesia Hypotension Tachycardia Neutropenia Respiratory depression
Intervention:
BP lying, sitting, standing.
Monitor CBC, AST, ALT, bilirubin, creatinine, LDH, alkaline phosphate.
Monitor degree of anxiety, mental status.
Education:
May take with food.
Do not use for everyday stress or for > 4 months unless directed by prescriber.
Avoid OTC medications.
Avoid driving, activities that require alertness. Rise slowly.
Avoid alcohol.
Anticonvulsant - Topiramate
Common uses: Seizures, Bipolar Disorder, Alcohol dependence, mania, bulimia
Contraindications: Metabolic acidosis, Pregnancy
PO
Interactions: Increased CNS depression with alcohol, CNS
depressants. Decreased level of oral contraceptives,
estrogen, digoxin, lithium.
MoA: May prevent seizure spread as opposed to an elevation of seizure threshold.
Side Effects: Dizziness Fatigue Insomnia Anxiety Memory loss Tremors Diplopia Anorexia Nausea Dyspepsia Weight loss
Adverse:
SI, Pancreatitis and Death
Interventions: Assess mental status, mood, behaviour. Monitor seizures. Assess renal and hepatic studies. Assist with ambulation. Seizure precautions.
Education:
Swallow whole. Do not break, crush, or chew.
Carry emergency ID.
Avoid driving, other activities that require alertness.
Notify prescriber of blurred vision, periorbital pain.
Maintain adequate fluid intake to prevent kidney stones.
May need to increase amount of food consumed since weight loss may occur
Antidepressant Agents: Monamine Oxidase Inhibitors (MAOIs) - Phenelzine (Nardil),
Tranylcypromine
(Parnate)
Common uses: Severe depression, Psychosis / PTSD, Dissociative disorders Bulimia, Panic disorders when other agents are ineffective.
PO - up to three weeks
Interactions:
High serotonin levels result in confusion, high BP, tremor, hyperactivity, coma, and death when taken with paroxetine, fluoxetine, amitriptyline, nortriptyline,bupropion; pain
medications like methadone, tramadol, and meperidine;
dextromethorphan, St. John’s Wort, cyclobenzaprine, and mirtazapine.
MoA:
Affects chemical messengers (neurotransmitters) used to communicate between brain cells. MAOIs work by effecting changes in the brain
chemistry. An enzyme called monoamine oxidase is involved in removing the neurotransmitters norepinephrine, serotonin and dopamine from the brain. MAOIs prevent this from happening, which makes more of these brain chemicals available to effect changes in both cells and circuits that have been impacted by depression.
Advantage:
Prescribed when client does not respond to other antidepressants.
Disadvantages: Hypertensive crisis can be triggered by
foods rich in tyramine.
Side Effects: Dizziness Constipation Diarrhea Tremors Diaphoresis Sexual dysfunction Weight gain
Adverse: Orthostatic hypotension Seizures Coma Tachycardia
Interventions: Monitor vital signs, reflexes, affect, orientation, UOP.
Obtain CBC, urinalysis, thyroid function tests, ECG, EEG.
Monitor for symptoms of hypertensive crisis (elevated BP and severe headache)
Education:
Avoid tyramine containing foods and beverages (pickled
foods, aged cheese, fermented alcohol, sour cream, figs, shrimp, bananas, chocolate or caffeinated drinks).
Do not take any other medications without checking with primary healthcare provider when taking a MAOI.
Agents: Selective Serotonin Reuptake Inhibitors (SSRIs) - Fluoxetine (Prozac), Paroxetine (Paxil), Escitalopram (Lexapro), Citalopram (Celexa), Sertraline HCL (Zoloft)
Common uses: Depression, Bi-polar disorder Eating disorders, OCD Panic attacks, Anxiety disorder PTSD / Phobia Dissociative disorder Premenstrual dysphoric disorder
Contraindications: Hypersensitivity MI Taking MAOIs Dehydration Breastfeeding
PO - 2 - 4 weeks Interactions: Increase effects of CNS and respiratory depression, and hypotensive effect with alcohol and CNS depressants. Increase effect of hypoglycemic.
MoA: Serotonin is increased in nerve cells because of blockage from nerve fibers.
Side Effects: Insomnia Weight loss Sexual dysfunction Palpitations Headache Diaphoresis GI complaints
Adverse effects: Seizures Hyponatremia Dehydration Bleeding Suicidal ideation
Interventions:
Do NOT give with MAOIs. Wait 14 days after stopping MAOIs to administer.
Monitor liver functions.
Withdrawal should be gradual.
Education: Therapeutic effect may take several weeks. Do not discontinue abruptly. Use with caution when driving. Avoid alcohol, other CNS depressants.
Antidepressant Agents: Tricyclic Antidepressants - Amitryptyline (Elavil),
Nortriptyline (Pamelor),
Imipramine (Tofranil)
Common Uses: Depression Anxiety Panic disorder OCD Bulimia Depression related to alcohol and cocaine withdrawal. Chronic pain disorder. Tofranil – childhood enuresis
Contraindications:
Clients with suicidal ideations.
History of seizures
Chronic cardiac disease.
PO/ 45 minutes
Interactions: Alcohol, hypnotics, sedatives,
barbiturates potentiate central nervous system depression
when taken with tricyclic antidepressants.
Concurrent use of MAOIs with amitriptyline may lead to cardiovascular instability and toxic psychosis.
Antithyroid medications taken with amitriptyline may increase the risk of dysrhythmias.
MoA: Blocks the uptake of the neurotransmitters norepinephrine and serotonin in the brain.
Advantages: Effective and less expensive than SSRI’s and other drugs
Disadvantages: Overdose is generally lethal
Side Effects: Headache Dry mouth Sedation Impotence Urinary retention Photosensitivity
Adverse: Orthostatic Hypotension, dysrhythmias
Interventions:
Increase fluids, bulk in diet if constipation, urinary retention occur.
Administer with food, milk for GI symptoms.
Crush is client unable to swallow medication whole.
Administer at bedtime if over sedation occurs during day
Education:
Therapeutic effects may take 2-3 weeks.
Use caution when driving, performing activities that require alertness.
Avoid alcohol, other CNS depressants.
Wear sunscreen or large hat when outdoors.
Antipsychotic Agents: Phenothiazines -
Chlorpromazine
(Thorazine),
Fluphenazine
Common Uses: Psychotic disorders Schizophrenia Mania Paranoia Tourette’s syndrome
Contraindications: Hypersensitivity Subcortical brain damage Blood dyscrasias Renal or liver damage Coma
PO/IM/IV/Rectal
Interactions:
Kava kava may increase the risk and severity of dystonic
reactions when taken with phenothiazines.
Increase depressive effects when taken with alcohol or
other CNS depressants.
MoA:
Blocks norepinephrine, causing sedation and hypotensive effects early in treatment. Also blocks the actions of dopamine.
Side Effects: Anorexia Urinary retention Dry mouth Sedation Polyuria Dizziness Headache Nasal congestion
Adverse Effects: Orthostatic hypotension Hypertension Extrapyramidal reactions Seizures Leukopenia Agranulocytosis Tardive dyskinesia Neuroleptic malignant syndrome
Interventions:
Assess baseline vital signs. Monitor serum glucose level.
Assess mental status, cardiac, eye, and respiratory disorders.
Remain with client while medication is taken and swallowed.
Avoid skin contact with liquid concentrations to prevent contact
dermatitis.
Protect liquid from light. Dilute liquid with fruit juice.
Administer with food or milk to decrease gastric irritation.
Administer IM deep into muscle.
Observe for Extra Pyramidal Symptoms.
Education:
Encourage client to take the drug exactly as prescribed.
Medication may take 6 weeks or longer to achieve full
clinical effect. Advise to wear an ID bracelet.
Do not consume alcohol or other CNS depressants, such
as narcotics.
Do not abruptly discontinue the drug.
Teach smoking cessation (Smoking increases metabolism of some antipsychotics).
Guide client to maintain good oral hygiene by frequent brushing and flossing of teeth.
Tardive Dyskinesia
Tardive dyskinesia is a side effect of antipsychotic medications. These drugs are used to treat schizophrenia and other mental health disorders.
TD causes stiff, jerky movements of your face and body that you can’t control. You might blink your eyes, stick out your tongue, or wave your arms without meaning to do so.
Symptoms Stick out your tongue without trying Blink your eyes fast Chew Smack or pucker your lips Puff out your cheeks Frown Grunt
It can also affect your arms, legs, fingers, and toes. That can cause you to:
Wiggle your fingers
Tap your feet
Flap your arms
Thrust out your pelvis
Sway from side to side
These movements can be fast or slow. You may find it hard to work and stay active.
Some psychiatric medications block a brain chemical called dopamine. It helps cells talk to each other and makes the muscles move smoothly. When you have too little of it, your movements can become jerky and out of control.
Includes: Chlorpromazine (Thorazine) Fluphenazine (Prolixin) Haloperidol (Haldol) Thioridazine (Mellaril) Trifluoperazine (Stelazine)
Extra-pyramidal reactions
Antipsychotic medications commonly produce extrapyramidal symptoms as side effects. The extrapyramidal symptoms include acute dyskinesias and dystonic reactions, tardive dyskinesia, Parkinsonism, akinesia, akathisia, and neuroleptic malignant syndrome.
Neuroleptic Malignant syndrome
Neuroleptic malignant syndrome (NMS) is a life-threatening idiosyncratic reaction to antipsychotic drugs characterized by fever, altered mental status, muscle rigidity, and autonomic dysfunction.
Mental status change is the initial symptom in 82 percent of patients [37]. It is not surprising, given the usual psychiatric comorbidity of the typical patient, that its significance is often underappreciated. This often takes the form of an agitated delirium with confusion rather than psychosis. Catatonic signs and mutism can be prominent. Evolution to profound encephalopathy with stupor and eventual coma is typical [16].
●Muscular rigidity is generalized and is often extreme. The increased tone can be demonstrated by moving the extremities and is characterized by “lead-pipe rigidity” or stable resistance through all ranges of movement. Superimposed tremor may lead to a ratcheting quality or a cogwheel phenomenon. Other motor abnormalities include tremor (seen in 45 to 92 percent), and less commonly, dystonia, opisthotonus, trismus, chorea, and other dyskinesias [3,5]. Patients can also have prominent sialorrhea, dysarthria, and dysphagia.
●Hyperthermia is a defining symptom according to many diagnostic criteria. Temperatures of more than 38°C are typical (87 percent), but even higher temperatures, greater than 40°C, are common (40 percent) [5]. Fever may be a less consistent symptom in patients with NMS associated with second-generation antipsychotic agents [38,39].
●Autonomic instability typically takes the form of tachycardia (in 88 percent), labile or high blood pressure (in 61 to 77 percent), and tachypnea (in 73 percent) [3,20]. Dysrhythmias may occur. Diaphoresis is often profuse.
Akinesia
loss or impairment of the power of voluntary movement.
Akathisia
is a movement disorder characterized by a feeling of inner restlessness and inability to stay still.
Atypical Antipsychotics -Risperidone (Risperdal),
Quetiapine (Seroquel),
Aripiprazole (Abilify)
Common uses: Psychotic disorders Schizophrenia Bipolar mania Paranoia Personality disorder
Contraindications:
Seizures disorders, suicidal ideation
PO/IM
Interactions: Use with other CNS depressants, alcohol will increase sedation. Use with other antipsychotics, lithium increase risk of EPS.
Advantages:
Less likely to cause extrapyramidal effects,
neuroleptic malignant syndrome and
tardive dyskinesia than the phenothiazines.
Side Effects: Sedation Drowsiness Headache Dry mouth Agitation Anxiety Appetite stimulation with weight gain
Adverse effects: Orthostatic hypotension Seizures Stroke Suicidal ideation Neuroleptic malignant syndrome
Interventions:
IM – give deeply into muscle mass.
Monitor for hoarding / not swallowing medication.
I&O
Check bilirubin, CBC, weight, lipid profile, fasting glucose monthly.
BP lying, sitting, standing
Education
Rise slowly from lying or sitting position.
Avoid hot tubs, hot showers, hot tub baths as hypotension may
occur.
Avoid OTC medications unless approved by prescriber.
Avoid use with alcohol.
Heat stroke may occur in hot weather.
CNS Stimulants: ADHD/ADD Stimulants - Methylphenidate (Ritalin), Amphetamine (Adderall), Lisdexamfetamine (Vyvanse), Dexmethylphenidate (Focalin)
ADD/ ADHD
Contraindications: Heart problems Bipolar disorder Glaucoma Tourette’s Syndrome
PO/ 20 - 30 minutes
Interactions:
Taking MAO inhibitors with this medication may cause a serious (possibly fatal) drug interaction.
MoA: Blocking the dopamine transporter and norepinephrine transporter, leading to increased concentrations of dopamine and
norepinephrine within the synaptic cleft
Disadvantages: High abuse potential due to stimulant effects.
Sudden death has been reported in children
taking amphetamine with structural cardiac
abnormalities.
Side Effects: Headache Insomnia Dry mouth Blurred vision Anxiety Nervousness Weight loss Nausea/Vomiting Decreased Appetite
Adverse Effect: Hypertension Tachycardia Suicidal thoughts Sudden death in children with structural Cardiac abnormalities.
Interventions:
Monitor mental status and observe for changes in level of consciousness
and adverse effects such as persistent drowsiness, psychomotor agitation
or anxiety, dizziness, trembling or seizures.
Monitor vital signs.
Monitor gastrointestinal and nutritional status.
Monitor laboratory tests such as CBC, differential, and platelet count.
Monitor effectiveness of drug therapy. Monitor growth and development.
Monitor sleep–wake cycle
Education:
May be habit forming. Avoid drinking alcohol.
To prevent sleep problems, take this medicine in the morning.
Methylphenidate may impair thinking or reactions. Do not drive or do anything that requires alertness.
Instruct client to report any significant increase in motor behavior,
changes in sensorium, or feelings of dysphoria.
Take drug with meals to reduce GI upset and counteract anorexia; eat frequent, small nutrient-and calorie-dense snacks.
Weigh weekly and report significant losses over 1 lb. Report shortness of breath, profound fatigue, pallor, bleeding or excessive bruising (these are signs of blood
disorder).
CNS Stimulants: Anorexiants - Phentermine
Ionamin
Common Uses: Appetie suppressant, Obesity
Contraindication: Hypersensitivity Hypertension Glaucoma Heart disease
PO
Interactions: Taking MAO inhibitors with this medication may cause a serious (possibly fatal) drug interaction.
MoA: Reduces hunger perception, a cognitive process mediated through nuclei within the hypothalamus. Outside the brain, phentermine releases norepinephrine and epinephrine causing fat cells to break down stored fat as well.
Advantages: Indicated for treatment of obesity (BMI
>30) and for those overweight (BMI
27-30) who have comorbidities such as
hypertension, high cholesterol, diabetes
Side Effects: Anxiety Dizziness Insomnia Headache Dry mouth Nausea/Vomiting Diarrhea Constipation
Adverse: Hypertension Hallucinations Seizures Pulmonary hypertension Chest pain
Interventions:
Assess for tolerance to the anorectic effect of the drug. Withhold drug and report to physician when this occurs.
Lab tests: Periodic CBC with differential and blood glucose.
Monitor periodic cardiovascular status, including BP, exercise tolerance, peripheral edema.
Monitor weight at least 3 times/wk.
Education:
Take 1 or 2 hours after breakfast. Do not crush or chew.
Avoid drinking alcohol with Ionamin. May affect blood sugar of client with diabetes. Do not breast feed while taking this drug.
Report immediately any of the following: Shortness of breath, chest pains, dizziness or fainting, swelling of the extremities.
Tolerance to the appetite suppression effects of the drug usually develops in a few weeks. Notify physician, but do not increase the drug dose. Weigh self at least 3 times/week at the same time with the same amount of clothing.
CNS Stimulants - Caffeine
Common Uses: Migraine headache Tension headache Promotes alertness Alleviates fatigue In combination with pain medication.
Contraindications: History of cardiac disease or peptic ulcer disease Pregnancy
PO/Rectal/IV
Interactions:
Taking caffeine along with ephedrine might
cause heart problems. Caffeine might block the effects of adenosine,dipyridamole.
Ciprofloxacin, cimetidine, disulfiram, estrogen
decrease how quickly the body breaks down
caffeine. Caffeine decreases how quickly the body breaks down clozapine. Taking caffeine along with medications that slow clotting might increase the chances bleeding
MoA: Stimulates the CNS, especially the medullary respiratory center. Has a pronounced diuretic effect and is a myocardial stimulant. It can worsen peripheral vasoconstriction in those with hypertension and causes cerebral vasodilation, making it an effective treatment for
migraines and headaches.
Disadvantages: Caffeine combined with alcohol
appears to improve response time but does not reduce the errors in judgment caused by alcohol.
Side Effects:
Nervousness Insomnia
Irritability Flushing
Palpitations Headache
Adverse: Cardiac arrhythmias Hypertension Tachypnea Confusion Dehydration
Interventions:
For IV use: Assess respiratory status frequently.
Monitor for signs of necrotizing enterocolitis (abdominal
distension, vomiting, bloody stools, lethargy).
Monitor serum caffeine levels before and during therapy.
Monitor serum glucose levels.
Education:
Instruct on correct technique for administration. Measure oral dose accurately with a 1-mL syringe.
Advise to consult health care professional immediately if signs of necrotizing enterocolitis occur.
Necrotizing
Enterocolitis
Necrotizing enterocolitis (NEC) is a devastating disease that affects mostly the intestine of premature infants. The wall of the intestine is invaded by bacteria, which cause local infection and inflammation that can ultimately destroy the wall of the bowel (intestine).
CNS Depressants - Barbiturates - Phenobarbital
(Luminal), Secobarbital
(Seconal), Pentobarbital
(Nembutal)
Common Uses: Anesthesia induction. Short-term anesthesia Seizures Short-term use of insomnia
Contraindication: Pregnancy Hypersensitivity Depression Suicidal tendency Liver disease Respiratory disease
PO/IM/IV Interactions: Increased CNS depression with alcohol, narcotics, sedativehypnotics. Decreased effectiveness of beta-adrenergic blockers, clozapine, corticosteroids, digitoxin, doxycycline, estrogens, oral contraceptives, quinidine, theophyllines, voriconazole, or warfarin
MoA: Acts on GABAA receptors, increasing synaptic inhibition. This has the effect of elevating seizure threshold. Phenobarbital may also
inhibit calcium channels, resulting in a decrease in excitatory transmitter release. The sedative-hypnotic effects of phenobarbital are likely the result of its effect on the polysynaptic midbrain reticular formation, which controls CNS arousal.
Disadvantages: Loading dose may be required. Cautious use in elderly, associated with increased risk of falls
Side Effects: Drowsiness Lethargy Dizziness Headache Hangover effect Interferes with REM sleep
Adverse Effects: Respiratory depression Mental depression Hepatic toxicity Renal toxicity
Interventions:
Monitor vital signs. Ensure patient safety. Perform neuro-checks regularly.
Keep resuscitative equipment accessible.
Monitor response to and effectiveness of drug therapy.
Monitor for signs of hepatic or renal toxicity.
Monitor laboratory blood tests and urinalysis: CBC with differential,
electrolytes, BUN, PT, PTT, liver enzymes.
Education:
Do not drive or perform unsafe tasks.
Do not drink alcohol or use medicines that may cause
drowsiness
Hormonal birth control may not work as well.
To prevent pregnancy, use an extra form of birth control
Gabapentin
Seizures Peripheral neuropathy Migraine prophylaxis Vasomotor symptoms in women with breast cancer or postmenopausal women
PO/ 1-3 hours
Interactions:
CNS depression with alcohol, sedatives, antihistamines.
Increase gabapentin levels with morphine.
Decrease gabapentin levels with antacids, cimetidine.
MoA: Acts on the peripheral nerves and CNS by inhibiting spontaneous neuronal firing. May increase seizure threshold.
Should be used cautiously with the elderly
Side Effects: Drowsiness Dizziness Fatigue Confusion Anxiety Rhinitis Constipation
Adverse Effects: Increased frequency of partial seizures Leukopenia Depression Leukopenia Thrombocytopenia
Interventions: Monitor seizure activity. Monitor mental status. Seizure precautions Increase fluids, bulk in diet for constipation
Education: Do not crush or chew caps. Take at least 2 hours from antacids. May take without regard to meals. Carry ID Avoid driving and other activities requiring alertness.
Phenytoin
Seizures Status epilepticus Unlabeled: migraines, paroxysmal atrial tachycardia, ventricular tachycardia
Contraindications: Pregnancy Hypersensitivity Bradycardia Heart block Stokes-Adams syndrome
PO/IV
Interactions: Increase phenytoin effect with benzodiazepines, cimetidine, tricyclics, salicylates, alcohol. Decrease phenytoin effects with antacids, barbiturates, rifampin.
Side Effects: Gingival hyperplasia Dizziness Insomnia Paresthesias Depression Nystagmus Blurred vision Anorexia Weight loss Nausea/vomiting
Adverse Effects: Aplastic anemia Agranulocytosis Pancytopenia Hepatitis Suicidal tendency Bradycardia Ventricular fibrillation Cardiac arrest Stevens-Johnson Syndrome Blue-Glove syndrome
Interventions:
IV administration should not exceed 50 mg/min in adults. Administer slow IVP.
Monitor phenytoin level.
Monitor seizure activity.
Monitor EKG, BP, respiratory function during IV infusion.
Education:
Take with meals to decrease side effects.
Take antacids two hours before or after phenytoin.
Urine may turn pink
Oral hygiene
Avoid hazardous activities.
Carry ID
Chloral Hydrate
Common uses: Short term treatment of insomnia Sedation Alcohol withdrawal
Contraindications:
Hepatic failure
Renal failure
PO/ 10 - 20 minutes interactions: Side effects of barbiturates may be increased. Use with loop diuretics may cause tachycardia and blood pressure changes. Anticoagulants side effects may increase.
Advantages: Does not interfere with REM sleep
Side Effects:
Drowsiness Hangover effect
Nausea/Vomiting Flatulence
Diarrhea Confusion
Adverse Effects: Cardiac arrhythmias Sudden death Difficulty breathing Chest pain
Interventions:
May dilute syrup in water or other oral liquid (eg, fruit juice or ginger
ale) to minimize gastric irritation.
Administer capsules after meals (when used as sedative).
Education:
If stomach upset occurs, take with food.
Swallow chloral hydrate whole.
Take chloral hydrate with a full glass of water or other.
Do not take 2 doses at once.
Chloral hydrate may cause drowsiness or dizziness. Do not
drive, operate machinery, or do anything else that could be
dangerous.
Avoid drinking alcohol or taking other medications that cause
drowsiness while taking chloral hydrate.
Eszopiclone, Zolpidem
Insomnia
Contraindications: Hypersensitivity to benzodiazapine, Respiratory depression
PO/ 10 minutes Interactions: Decrease CNS function with alcohol, CNS depressants, anticonvulsants. Food decreases absorption.
MoA: The precise mechanism of action of eszopiclone as a hypnotic is unknown, but its effect is believed to result from its interaction with GABA-receptor complexes at binding domains located close to benzodiazepine receptors.
Zolpidem interacts with a GABA-BZ receptor complex and shares †fsome of the pharmacological properties of the benzodiazepines.
Side Effects: Headache Nervousness Anxiety Drowsiness Hot flashes Irritability Nausea / vomiting Erectile dysfunction
Adverse Effects: Tachycardia Depression Hypotension Sleep driving (Zolpidem)
Interventions: Assess vital signs. Check for signs of respiratory depression. Use bed alarm for older clients. Observe for side effects.
Education:
Teach nonpharmacologic ways to induce sleep – warm bath,
listening to music, drinking warm fluids, avoiding caffeine.
Avoid alcohol, antidepressants, antipsychotics, and narcotic
drugs.
Take 15-30 minutes before bedtime.
Carbamazepine
Tegretol
Acute mania associated with bipolar disorder. Alcohol withdrawal Seizure disorder Trigeminal neuralgia Diabetic neuropathy
PO/Slow Interactions: Increase CNS toxicity with Lithium. Fatal reaction with use of MAOIs. Decrease anticonvulsant effect with use of St. John’s wort.
Side Effects: Drowsiness Dizziness Confusion Fatigue Headache Hallucinations Tinnitus Dry mouth Blurred vision Photosensitivity Constipation Diarrhea Nausea/vomiting
Adverse Effects: A plastic anemia Agranulocytosis Respiratory depression Arrhythmias AV block Stevens-Johnson Syndrome
Interventions:
Monitor drug effectiveness.
Assess urinalysis, BUN, creatinine q 3 months.
Provide hard candy, gum, frequent rinses for dry mouth.
Education:
Carry emergency ID regarding medication.
Avoid driving and other activities that require alertness.
Report chills, rash, light colored stools, dark urine, jaundice.
Urine may turn pink to brown.
Valproic Acid
Depakote
Used in Mania Schizophrenia Seizure disorder Migraine prophylaxis Unlabeled: Febrile seizures
PO Interactions: Increase risk of toxicity with erythromycin, salicylates, NSAIDs. Increase CNS depression with alcohol, opioids, barbiturates, MAOIs, tricyclics.
SIde Effects: Drowsiness Dizziness Headache Weakness Nausea/Vomiting Diarrhea Constipation Dyspepsia Weight loss
Adverse: Bone marrow depression Pancreatitis Hepatotoxicity Stevens-Johnson syndrome Coma/Death with overdose
Interventions:
Monitor mental status, mood activity, sleeping/eating behavior,
suicidal thoughts.
Monitor CBC, PT/PTT, serum ammonia, platelets.
Monitor for signs of pancreatitis.
Education:
Physical dependency may result from extended use.
Avoid driving, other activities that require alertness
Drink plenty of fluids.
Report visual disturbances, rash, abdominal pain, lightcolored stools, jaundice, protracted vomiting
Mood Stabilizers: Lithium
Mania and Bipolar disorder
Contraindications: Children < 12 years Thyroid disease Liver disease Renal disease
Interactions
May increase lithium level with thiazide, methyldopa, haloperidol, NSAIDS, calcium channel blockers, ACE inhibitors. May increase hyperglycemia with
antidiabetics. Caffeine may decrease lithium levels
MoA: Alteration of ion transport in muscle and nerve cells. Increased receptor sensitivity to serotonin.
Long term therapy may cause hypothyroidism
Side Effects: Headache Memory impairment Blurred vision Metallic taste Dental caries Lethargy Drowsiness Tremors Slurred speech Dry mouth Anorexia Vomiting Diarrhea Polyuria Dehydration
Adverse Effects: Toxic effects: tremor, confusion, seizures, death. Hypotension Hyperglycemia Hyponatremia Proteinuria Cardiac dysrhythmias
Intervention:
Monitor serum sodium (Normal serum sodium helps to maintain therapeutic lithium levels).
Frequently monitor Lithium level (Therapeutic range – 1-1.5 mEq/L for acute mania; Maintenance levels are 0.6-1.2 mEq/L. Levels exceeding 1.5-2.5 mEq/L begin to produce toxicity. Normal levels and toxicity levels are very close).
Education:
Maintain adequate fluid intake of 1-2 L daily.
Importance of lab tests and follow-up visits.
Do not drive until stable lithium level.
Take with meals to decrease gastric irritation.
Wear ID indicating medication taking.
Neuromuscular Blocker: Succinylcholine
Chloride (Anectine)
Common uses:
Facilitation of ET intubation.
Skeletal muscle
relaxation.
Contraindications: Hypersensitivity Malignant hyperthermia Trauma
IM/IV Interactions: Increase dysrhythmias with theophylline. Melatoninblocks succinylcholine. Increase neuromuscular blockade with aminoglycosides, beta blockers, glycosides, procainamide, lithium, opioids, thiazides.
MoA:
Inhibits transmission of nerve impulses by binding with cholinergic receptor sites, thus antagonizing action of acetylcholine.
Causes release of histamine.
Side Effects: Bradycardia Tachycardia Flushing Weakness Muscle pain Increased secretions
Adverse Effects: Sinus arrest Dysrhythmias Myoglobulinemia Rhabdomyolysis Apnea Bronchospasm Respiratory depression Anaphylaxis Angioedema
Interventions:
Monitor for electrolyte imbalances: May lead to increased action
of product.
Monitor vital signs until fully recovered.
I&O
Check for urinary retention, frequency, hesitancy.
Client Education:
Use of medication, Care during recovery
Haloperidol
Common uses: Acute and chronic psychosis Schizophrenia resistant to other medications. Tourette’s syndrome Paranoia Children with severe behaviour problems who are combative. Suppress narcotic withdrawal.
Contraindications: Narrow angle glaucoma Severe hepatic, renal, cardiovascular disease. Parkinson’s disease Bone marrow depression
PO/IM/IV Interactions: Increase sedation with alcohol, CNS depressants. Increase toxicity with anticholinergics, CNS depressants, Lithium. Decrease effects with phenobarbital, caffeine.
MoA: Blocks the dopamine receptors.
SIde Effects: Tachycardia Urinary retention Constipation Blurred vision Headache Dry mouth Nausea/vomiting Weight gain Photosensitivity
Adverse effects: Seizures Respiratory depression Laryngospasm Dysrhythmias Neuromalignant syndrome Tardive dyskinesia Orthostatic hypotension
Interventions:
Assess CBC
Obtain BP lying, sitting, standing.
Monitor for dizziness, faintness, tachycardia on rising.
Monitor for EPS.
Supervise ambulation until client stabilized on medication.
Provide sips of water, sugarless candy, gum for dry mouth
Education:
Rise slowly from lying or sitting position.
Avoid hazardous activities until stabilized on medication.
Avoid abrupt withdrawal of medication.
Avoid OTC preparations.
About EPS.
Oral care.
Report impaired vision, jaundice, tremors, muscle twitching
Opioid Antagonists - Naltrexone
Common uses:
Opiate addiction
Alcoholism
Nicotine withdrawal
Contraindications: opioid dependence
PO/IM
Interactions: Increased lethargy with phenothiazines
Increased hepatotoxicity with disulfiram.
Increased bleeding risk with
anticoagulants.
Side Effects: Stimulation Drowsiness Dizziness Confusion Headache Flushing Nervousness Irritability Anxiety Tinnitus Blurred vision Diarrhea Constipation Impotence Nausea/vomiting
Adverse Effects: Seizures Suicidal ideation Pulmonary edema DVT Hepatotoxicity
Interventions:
Give with food, antacid to prevent N/V.
Do not give until opioid free for 7-10 days to prevent opioid withdrawal.
Administer IM deep in gluteal. Alternate injection sites.
Aspirate before injection.
Monitor cardiac status and respiratory function.
Education:
Must be drug free to start treatment.
Using opioid while taking this medication could be fatal.
Carry emergency ID.
Use caution while driving or performing hazardous tasks.
Report suicidal thoughts.
Serotonin Agonists (SSRAs – Selective Serotonin Receptor Agonists) - Ergot Alkaloids: Ergotamine tartrate (Ergostat), Ergotamine with caffeine (Cafergot, Ercaf)
Used for migraine headaches
Contraindications: BF, Heart disease and HTN
SL/Intranasal/IM/IV
Interactions:
Severe hypertension can occur with the use of Droxidopa or sympathomimetics.
Risk of increase ergotamine side effects can occur with Azole antifungals, beta-blockers, fluconazole, fluoxetine, fluvoxamine, HIV
protease inhibitors, sumatriptan,
macrolide antibiotics.
Advantages:
Can be used to prevent or treat acute
migraine headache with or without an aura.
Disadvantages:
Toxicity may occur
Side effects: Dizziness, Nausea/vomiting
Adverse Effects:
Angioedema Chest pain
Arrhythmias Muscle pain
SOB
Interventions:
Assess frequency, location, duration, and characteristics
headaches. During acute attack, assess type, location, and intensity of pain before and 60 min after administration.
Monitor BP and peripheral pulses periodically during therapy.
Report any increases in BP.
Assess for nausea and vomiting.
Assess for toxicity manifested by severe ergotism (chest pain,
abdominal pain, persistent paresthesia in the extremities) and
gangrene. Vasodilators, dextran, or heparin may be ordered to improve circulation.
Education:
Proper use of inhaler.
Take at the first sign of a migraine attack.
Do not swallow, crush, or chew sublingual tablets. Do not eat,
drink, or smoke while tablet is dissolving.
If more than 1 dose needed to treat a migraine, take the second dose at least 30 minutes after the first dose. Do not take more than 2 tablets for any migraine attack. Do not take more than 3 tablets in a 24 hour period. Do not take more than 5 tablets within
a 7 day period.
Do not use ergotamine daily on a regular basis.
Serotonin Agonists (SSRAs – Selective Serotonin Receptor Agonists) - Triptans: Sumatriptan
(Imitrex), Almotriptan
(Axert)
Used in Migraine headaches and cluster headaches.
Contraindications: History of coronary artery disease, uncontrolled hypertension, cerebrovascular disease, MI. Obesity, diabetes, smoking, hepatic disease
Po/SubQ/Intranasal Interactions: Increase vasospastic effects with ergot derivatives. Increase serotonin syndrome with SSRIs
MoA: Causes vasoconstriction of cranial arteries to relieve migraine headaches.
Side Effects: Nausea/vomiting Dizziness Numbness Tingling Dry mouth Diarrhea Abdominal cramping
Adverse Effects: Hypertension Hypotension Cardiac arrhythmias MI Seizures Stroke Coronary artery vasospasms
Interventions:
Assess type of headache, pain, aura, alleviating and aggravating
factors.
Monitor for serotonin syndrome (delirium, coma, agitation, diaphoresis,
hypertension, fever, tremors).
Monitor BP, ECG
Monitor neurologic status
Education:
Keeping a journal: Ingestion of tyramine foods, food
additives, preservatives, coloring, artificial sweeteners, chocolate, caffeine, may precipitate a migraine attack.
Report chest pain or tightness, sudden and severe abdominal pain, swelling around eyes, face, lips.
Do not use for more than 3-4 headaches per month.
Nasal spray: Use 1 spray in 1 nostril. Repeat if headache
returns, but not if pain continues after 1st dose. Lie in dark, quiet environment.
Avoid hazardous activities if dizziness, drowsiness occurs.
Avoid alcohol: may increase headache.
Serotonin Syndrome
Serotonin is a chemical produced by the body that enables brain cells and other nervous system cells to communicate with one another. Too little serotonin in the brain is thought to play a role in depression. Too much, however, can lead to excessive nerve cell activity, causing a potentially deadly collection of symptoms known as serotonin syndrome.
Serotonin Syndrome Symptoms
Serotonin syndrome symptoms often begin within hours of taking a new medication that affects serotonin levels or excessively increasing the dose of one you are already taking. Symptoms may include:
Confusion Agitation or restlessness Dilated pupils Headache Changes in blood pressure and/or temperature Nausea and/or vomiting Diarrhea Rapid heart rate Tremor Loss of muscle coordination or twitching muscles Shivering and goose bumps Heavy sweating In severe cases, serotonin syndrome can be life threatening. If you experience any of these symptoms, you or someone with you should seek medical attention immediately:
High fever
Seizures
Irregular heartbeat
Unconsciousness
Skeletal Muscle Relaxants : Lioresal (Baclofen),
Cyclobenzaprine (Flexeril),
Dantrolene (Dantrium),
Methocarbamol (Robaxin)
Common Uses: Muscle spasms. Baclofen and
Dantrium: multiple sclerosis, cerebral palsy.
PO/Intrathecal/IM/IV
Interactions: CNS depression with alcohol, tricyclics, opiates, barbiturates, sedatives. Increase hypotension with antihypertensives.
MoA: Inhibits synaptic responses in CNS by stimulating GABAb receptors. This decreases neurotransmitter function; decreases frequency, severity of muscle spasms.
Side Effects: Dizziness Drowsiness Fatigue Lightheadedness Dry mouth Muscle weakness Constipation Urinary retention Anorexia Nausea/vomiting
Adverse Effects: Hypotension Bradycardia Angioedema Anaphylaxis Hepatotoxicity CNS depression Seizures
Interventions:
Assess spasms, spasticity, ataxia for improvement with medication.
Assess BP, weight, glucose, hepatic function studies periodically.
Monitor ALT, AST with long-term Dantrium use.
I&O
Education:
Methocarbamol may turn urine green, brown, or black.
Take with meals for GI symptoms.
Do not discontinue abruptly.
Do not take with alcohol, other CNS depressants.
Avoid hazardous activities if drowsiness/dizziness occurs.
Parkinson’s Disease
Parkinson’s disease is a progressive disorder of the nervous system that affects movement. It develops gradually, sometimes starting with a barely noticeable tremor in just one hand. But while a tremor may be the most well-known sign of Parkinson’s disease, the disorder also commonly causes stiffness or slowing of movement.
In the early stages of Parkinson’s disease, your face may show little or no expression, or your arms may not swing when you walk. Your speech may become soft or slurred. Parkinson’s disease symptoms worsen as your condition progresses over time.
Tremor. A tremor, or shaking, usually begins in a limb, often your hand or fingers. You may notice a back-and-forth rubbing of your thumb and forefinger, known as a pill-rolling tremor. One characteristic of Parkinson’s disease is a tremor of your hand when it is relaxed (at rest).
Slowed movement (bradykinesia). Over time, Parkinson’s disease may reduce your ability to move and slow your movement, making simple tasks difficult and time-consuming. Your steps may become shorter when you walk, or you may find it difficult to get out of a chair. Also, you may drag your feet as you try to walk, making it difficult to move.
Rigid muscles. Muscle stiffness may occur in any part of your body. The stiff muscles can limit your range of motion and cause you pain.
Impaired posture and balance. Your posture may become stooped, or you may have balance problems as a result of Parkinson’s disease.
Loss of automatic movements. In Parkinson’s disease, you may have a decreased ability to perform unconscious movements, including blinking, smiling or swinging your arms when you walk.
Speech changes. You may have speech problems as a result of Parkinson’s disease. You may speak softly, quickly, slur or hesitate before talking. Your speech may be more of a monotone rather than with the usual inflections.
Writing changes. It may become hard to write, and your writing may appear small.
NOT GRIPPY SHOES
Alzheimer’s Disease : Symptoms
A common form of dementia. Alzheimer’s is a type of dementia that causes problems with memory, thinking and behavior. Symptoms usually develop slowly and get worse over time, becoming severe enough to interfere with daily tasks.
Memory loss that disrupts daily life
Challenges in planning or solving problems
Difficulty completing familiar tasks at home, at work or at leisure
Confusion with time or place
Trouble understanding visual images and spatial relationships
New problems with words in speaking or writing
Misplacing things and losing the ability to retrace steps
Decreased or poor judgment
Withdrawal from work or social activities
Changes in mood and personality
Alzheimer’s Disease - Nursing Considerations
Always identify yourself and call clients by name
Speak slow
Use short simple sentences and words. Focus on one piece of info at a time.
Communicate face to face with one to two arms length distance to help attn and maximize vernal and non verbal cues
Talk about meaningful things - Helps client to focus on a successful life and increases self esteem
Do not reminisce if client has a troubled life
Keep clocks calenders or personal items within reach and vision. mark calender with a X for each day
Alzheimer’s Disease - Nursing Considerations
Always identify yourself and call clients by name
Speak slow
Use short simple sentences and words. Focus on one piece of info at a time.
Communicate face to face with one to two arms length distance to help attn and maximize vernal and non verbal cues
Talk about meaningful things - Helps client to focus on a successful life and increases self esteem
Do not reminisce if client has a troubled life
Keep clocks calenders or personal items within reach and vision. mark calender with a X for each day
Glasses and Hearing aids are accessible
Identify all doors
Monitor food or fluid intake
Weigh Weekly
Group activities
Dress in their own clothes
Calm
Use their capacity to maintain self esteem
Babinski reflex
Normal in a child up to 1 year, Abnormal in an adult.
In adult, it means that there is a severe problem in the central nervous system ( tumor, lesion on the brain or spinal cord, MS, ALS)
Grading Reflexes
Document as 2+/4+ for a normal reflex
CT
With or Without contrast Consent needed before test Takes pictures in slices/layers Keep head still No Talking
MRI
MRI picks up on pathology earlier
Dye is used sometimes.
No radiation, A magnet
TUBE
Remove jewellery, Credit cards, Pacemakers
Tattoos matter because old ones have lead in them/ shrapnel in veterans
THUMPING SOUND
don’t do this for claustrophobic clients
Can talk and hear others while in the tube
Cerebral Angiography
Consent for dye
Goes through the Femoral Artery
Pre Procedure
Well hydrated/ void/ PP/ Groin prepped/complete neuro assessment
Anytime an iodine based dye is used, the client will need to be well hydrated to promote excretion of the dye
WATCH BUN CREATININE UO and hold metformin
Explain that they will have warmth in the face and a metallic taste
Allergies: Iodine and shellfish is a NO
Post Procedure
Bed rest for 4 to 6 hours
Watch for bleeding at femoral site
Possible complication is embolus
An embolus can go alot of different places. - Arms (decreased circulation/ DVT), Heart (MI), Lung (PE) and Kidney (decreased Kidney function), Brain (Decreased LOC)
Client will have change of LOV, one sided weakness and paralysis and moto/sensory deficits
Electroencephalography (EEG)
Records electrical activity of the brain
Helps diagnose seizure disorders and evaluate the types of seizures occuring
Evaluates loss of consciousness and dementia
Screening procedure for coma
Indicator of brain death
Used to diagnose sleep disorders like narcolepsy, cerebral infarct and brain tumors or abcesses
Pre Procedure
HOLD sedatives because it decreases electrical activity
No caffeine
NO NPO
Beginning of procedure
Will get a baseline first with client lying quietly
May be asked to hyperventilate to assess brain circulation, assess photo stimulation for seizures or sedate for sleep study
If you have someone completely unconscious, a pain response or noxious stimuli may be introduced to stimulate a brain wave. This can be anything from a strong smell like ammonia to a bright light.
Lumbar Puncture
Into the lumbar subarachnoid space
Purpose is to obtain spinal fluid to analyze for blood, infection and tumor cells
To measure pressure readings with a manometer
To admin drugs intrathecally ( brain, spinal cord)
Back is arched with head down or Side lying fetal position
Inspect the surrounding skin at the puncture site for any infection
SF should be like WATER
Post procedure
Lie flat or prone for 2 -3 hours
Increase Fluids to replace the lost spinal fluid
Common complication is headache - pain increases when the client sits up and decreases when they lie down
How is this headache treated? Bed rest, fluids, pain meds and a blood patch to instantly seal puncture site
Life threatening complications:
Brain herniation: With known increasedICP, a lumbar puncture is contraindicated.
Meningitis
Bacteria get into the puncture site and spinal fluid
General Care for Any Client with Increased Intracranial Pressure: Signs and Symptoms of ICP (EARLY)
Earliest sign is a change in LOC Speech is slurred or slowed Delay in response to verbal suggestion - Slow to respond to commands Increasing drowsiness Restless with apparent reason Confusion
General Care for Any Client with Increased Intracranial Pressure: Signs and Symptoms of ICP (LATE)
Marked change in LOC progressing to stupor then coma
Vital sign changes: CUSHINGS TRIAD - requires emergency intervention to prevent brain brain ischemia
Cushing Triad:
Systolic hypertension with a with a widening pulses pressure/ Slow full and bounding pulse/ Irregular respirations
General Care for Any Client with Increased Intracranial Pressure
Changes in vitals
Posturing: A response to pain or noxious stimuli
Posturing indicates that the motor response centers of the brain are compromised.
Decorticate/Decerebrate Posturing - Client will be rigid, tight and burning more calories
Misc Signs:
Headaches
Changes in pupils and response. (In profound coma - fixed and dilated)
Projectile vomiting can occur because the vomiting center in the brain is being stimulated
Decorticate Posturing
Arms flexed inward and bent in toward to the body and the legs are extended
Decerebrate Posturing
All four extremities in rigid extension; THIS IS WORST. Indicates serious brain damage.
Complications of Increased ICP
Brain Herniation: This herniation obstructs the blood flow to the brain leading to anoxia and then death
DI and SIADH: Can be either, so you must assess for both.
Treatment of Increased ICP
Maintain Oxygenation : Decreased O2 levels and high CO2 levels cause cerebral vasodilation which increase ICP ( so they should be on a ventilator)
Maintain Cerebral Perfusion: Don’t want tachycardia or bradycardia because that decrease brain perfusion. Isotonic saline and inotropic agents: dobutamine and norepinephrine (vasodilation)
Keep temperature below 38 degree: An increased temperature will increase cerebral metabolism which ICP. The hypothalamus may not be working properly, and a cooling blanket may be needed. Hypothermia is used as a treatment to decreasing the metabolic demands of the brain
Elevate the HOB
Keep head midline so the jugular veins can drain
Watch the ICP monitor with turning etc
Avoid restraints, bowel/bladder distention, hip flexion, Valsalva, and isotremics. No sneezing and no nose blowing.
Limit suctioning and coughing
Spaced nursing interventions - Anytime you do something to your client, ICP increases.
Monitor the Glasgow coma scale ( Under 8 intubate)
Monitor vital signs for Cushing’s Triad
Barbiturate induced coma - decreases cerebral metabolism: phenobarbital
Osmotic Diuretics: Mannitol - Draws fluid from the brain cells and filters it out through the kidneys ( MAKE SURE U USE A FILTER) This decreases the ICP
Steroids - dexamethasone decreases the cerebral edema
ICP monitoring devices: Vent. cath monitor or subarachnoid screw Greatest risk is infection No loose connections Keep dressing Sterile and dry
Meningitis
Inflammation of the spinal cord or brain. CAn be Viral or bacterial.
Chills and fever, Severe Headache, Nausea and Vomiting, Nuchal Rigidity, Photophobia
Treatment:
Steroids: Decrease Inflammation
Antibiotics if bacterial
Analgesics
Droplet precautions for bacterial ( very contagious, medical emergency, high mortality, immunization recommended in college students)
Contact precautions for viral meningitis as it is transferred through poop
Seizures
Should be thought of as a symptom of an under;ying disorder rather than a disease
Not considered epilepsy if they discontinue once the disease has gone away
Partial seizures
Limited to a specific local area of the brain
An aura may be the only manifestation - perceptual disturbances ( called focal seizures)
Symptoms can range from simple to complex
Simple means without loss of consciousness; will see numbness, tingling, prickling or pain
Complex means impaired consciousness, confused and unable to respond
Generalized seizures
Also known as NON-FOCAL
Involves the entire brain.
Loss of consciousness is the initial manifestation
Tonic/Clonic
formerly known as grand mal.
The tonic phase comes first.
All the muscles stiffen.
Air being forced past the vocal cords causes a cry or groan.
The person loses consciousness and falls to the floor.
A person may bite their tongue or inside of their cheek. If this happens, saliva may look a bit bloody.
After the tonic phase comes the clonic phase.
The arms and usually the legs begin to jerk rapidly and rhythmically, bending and relaxing at the elbows, hips, and knees.
After a few minutes, the jerking slows and stops.
The person’s face may look dusky or a bit blue if they are having trouble breathing or the seizure lasts too long.
The person may lose control of their bladder or bowel as the body relaxes.
Consciousness, or a person’s awareness, returns slowly.
These seizures generally last 1 to 3 minutes. Afterwards, the person may be sleepy, confused, irritable, or depressed.
A tonic-clonic seizure that lasts longer than 5 minutes needs immediate medical help. Call 911 for emergency help.
A seizure that lasts more than 10 minutes, or three seizures in a row without the person coming to between them, is a dangerous condition. This is called status epilepticus; emergency treatment in a hospital is needed.
Myoclonic
Sudden brief contractions of a muscle or group of muscles
Abscence
Formerly called petit mal and characterized by a brief loss of consciousness
Complications of seizures
Status Epilepticus: a continuous seizure without returning to consciousness between seizures
Trauma: Protect the client - can be severe/cause death
Seizure Treatment
Neurological examination including lab and xray
Anticonvulsants:
Can be long or short term therapy. Rapid acting -lorazapam and diazepam. Long acting - phenytoin or phenobarbital
Have toxic effects - monitor for drug toxicity - Abrupt withdrawal can cause a seizure.
Don’t forget the basics of airway and safety during a seizure. DON’T PUT SHIT IN THEIR MOUTH
Skull Injury
May/May not damage Brain
Open fracture - dura is torn
Closed Fracture - Dura is NOT torn
With a basal skull fracture, you see bleeding EENT
Battles Sign: Bruising over the mastoid
Raccoon eyes ( peri-orbital bruising)
Cerebrospinal rhinorrhea- leaking spinal fluid from NOSE
it is CSF if it tests positive for glucose and the halo test
Non-depressed skull fractures usually do not require surgery; depressed fractures do require surgery.
Concussion
Temporary loss of neurologic function with complete recovery
Will have a short period of unconsciousness or may just get dizzy/see spots
Teach caregiver to bring client back to ED if the following occur: Difficulty awakening/speaking, confusion, severe headache, vomiting, pulse changes, unequal pupils, one sided weakness (all signs of increasing ICP)
Hematomas
A small Hematoma that develops rapidly may be fatal while a massive hematoma that develops slowly may allow the client to adapt
Epidural Hematomas: Patho and Treatment
This is rupture of the middle meningeal artery (fast bleeder under high pressure)
Injury - loss of consciousness - Recovery period - can’t compensate any longer - neuro changes (agitation, restlessness, seizures, posturing)
Treatment: Burr hole and remove the clot; control the ICP
Ask questions to ID the type of injury and the treatment needed
-Did they pass out and stay out?
- Did they pass out then wake up and pass out again?
Did they just see stars?
Epidural Hematoma is an emergency
Subdural Hematoma Patho and Treatment
Usually a slow bleed ( usually venous)
Can be acute, subacute or chronic ( usually imitates other conditions)
Bleeding and compensating
Neuro changes = maxed out
Acute or chronic: Immediate crainiotomy and remove clot - control the ICP
Spinal Cord injury : Autonomic dysreflexia
With upper spinal cord injury (above T6), the major complication to look for is this or hyperreflexia
Severe HTN, Headache, Bradycardia, Nasal stuffiness, flushing, sweating, blurred vision and anxiety
Sudden onset. It is a medical emergency - if not treated, a hypertensive stroke can occur
Caused by distended bladder, constipation or painful stmuli
Treatment
SIT CLIENT UP to lower blood pressure
Treat the cause - put in cath, remove impaction, look for skin pressure, painful stimuli or cool draft in room
Take prevention measures
ECT treatment
Can induce tonic clonic seizures
Is useful for clients with severe depression
Pre procedure
NPO, Void, atropine given to prevent aspiration
A signed consent is necessary
Succinylcholine is given to relax muscles
Given as a series of treatments depending on the client response
Post procedure
Position client on side to prevent aspiration
Stay with client
Temporary mem loss is expected
REorientate them repeatedly
Return to day to day functioning as soon as possible
Schizophrenia
Focus is inward. They create their own world
Inappropriate affect, flat affect or blunted affect
Disorganized thoughts ( looseness of associations)
Ineffective communication skills: Communication is one of their biggest problems
Echolalia - Hear a word and repeat it Neologism - making up new words Word Salad Concrete thinking Religiosity Delusions Hallucinations
Nursing Considerations
Decrease Stimuli
Observe frequently without looking suspicious
Orient frequently
Keep conversations reality based
Observe for hallucinations ( warn before you touch them)
Don’t refer to the voices as they because this makes th hallucinations seem real
Let the client know you do not share the perception
Hallucinations are connected to times of anxiety
Get them involved in ACTIVITY
Turn off the TV
Offer reassurance because the client is frightened
Command Hallucinations
Paranoid Personality
Always suspicious
Cannot explain away their delusions or paranoid beliefs
Pathologic jealousy
Hypersentitive to comments or actions
Can’t relax - no humor - unemotional
Abnormal anger response, responds with rage when provoked - always rationalizes behaviour
Treatment Be reliable Your goal is to build trust. If you say you will do something, you must do it ! Be honest Consistent nurses and brief visits Be matter of fact Respect personal spaces Be careful with rouch Don't mix meds, and always ID them May need to eat sealed food
Restraints
Can be used when the nurse assesses that the client is a danger to themselves or others
Used as a last resort
Client must be evaluated in person by a PHP within one hour of restraints
Orders must be renewed every 4 hours for adults, Every 2 Hours for 9 - 17 and Every hour for less than 9
Check client face to face every 15 minutes
Remember hydration, nutrition and elimination. Provide something to eat/drink and use of the washroom
Client can suffocate and die while in restraints
Somatic symptom disorder (SSD)
is a psychological disorder that develops from stress, resulting in medically unexplainable physical symptoms (eg, abdominal pain) that disrupt daily life. Clients with SSD focus an excessive amount of time, thought, and energy on the symptoms, often seeking medical care from multiple health care providers. Nursing interventions focus on minimizing indirect benefits and developing client insight.
To minimize the indirect benefits from being “sick” (secondary gains), the nurse should:
Redirect somatic complaints to unrelated, neutral topics
Limit time spent discussing physical symptoms (Option 2)
To promote insight and healthy coping mechanisms, the nurse should assist the client to:
Identify secondary gains (eg, increased attention, freedom from responsibilities)
Recognize factors that intensify symptoms (eg, increased stress, reminders of a deceased family member)
Incorporate appropriate coping strategies (eg, relaxation training, physical activity)
Cranial Nerve 1
The olfactory nerve (I): This is instrumental for the sense of smell, it is one of the few nerves that are capable of regeneration.
Cranial Nerve 2
The optic nerve (II): This nerve carries visual information from the retina of the eye to the brain.
Cranial Nerve 3
The oculomotor nerve (III): This controls most of the eye’s movements, the constriction of the pupil, and maintains an open eyelid.
Cranial Nerve 4
The trochlear nerve (IV): A motor nerve that innervates the superior oblique muscle of the eye, which controls rotational movement.
Cranial Nerve 5
The trigeminal nerve (V): This is responsible for sensation and motor function in the face and mouth.
Cranial Nerve 6
The abducens nerve (VI): A motor nerve that innervates the lateral rectus muscle of the eye, which controls lateral movement.
Cranial Nerve 7
The facial nerve (VII): This controls the muscles of facial expression, and functions in the conveyance of taste sensations from the anterior two-thirds of the tongue and oral cavity.
Cranial Nerve 8
The vestibulocochlear nerve (VIII): This is responsible for transmitting sound and equilibrium (balance) information from the inner ear to the brain.
Cranial Nerve 9
Cranial nerve IX (glossopharyngeal) is involved in the gag reflex, ability to swallow, phonation, and taste. Postoperative partial laryngectomy clients will need to undergo evaluation by a speech pathologist to evaluate their ability to swallow safely to prevent aspiration. Clients are taught the supraglottic swallow, a technique that allows them to have voluntary control over closing the vocal cords to protect themselves from aspiration. Clients are instructed to:
Inhale deeply
Hold breath tightly to close the vocal cords
Place food in mouth and swallow while continuing to hold breath
Cough to dispel remaining food from vocal cords
Swallow a second time before breathing
Cranial Nerve 10
The vagus nerve (X): This is responsible for many tasks, including heart rate, gastrointestinal peristalsis, sweating, and muscle movements in the mouth, including speech and keeping the larynx open for breathing.
Cranial Nerve 11
The spinal accessory (XI): This nerve controls specific muscles of the shoulder and neck.
Cranial Nerve 12
The hypoglossal nerve (XII): This nerve controls the tongue movements of speech, food manipulation, and swallowing.
Bell’s palsy
is an inflammation of cranial nerve VII (facial) that causes motor and sensory alterations. Clients are usually managed as outpatients, with corticosteroids to reduce inflammation, and taught eye/oral care. In Bell’s palsy, the eyelids do not close properly. This may result in eye dryness and risk of corneal abrasions. However, weakness of the lower eyelid may cause excessive tearing due to overflow in some clients. Facial muscle weakness results in poor chewing and food retention.
Client teaching should include the following:
Eye care: Use glasses during the day; wear a patch (or tape the eyelids) at night to protect the exposed eye. Use artificial tears during the day as needed to prevent excess drying of the cornea.
Oral care: Chew on the unaffected side to prevent food trapping; a soft diet is recommended. Maintain good oral hygiene after every meal to prevent problems from accumulated residual food (eg, parotitis, dental caries)
Bell’s palsy is an inflammation of cranial nerve VII (facial) that results in facial muscle weakness and inability to close the eyelids. Eye care (patch at night, artificial tears as needed) and oral care (eating on the unaffected side, oral hygiene after meals) are vital for these clients.
