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Analgesic Drugs

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Remember that Pain is...

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Whatever the patient says it is Exists when the patient says it exists An unpleasant sensory and emotional experience associated with actual or potential tissue damage A personal and individual experience

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Classification of Pain by Onset & Duration -Acute Pain:

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Sudden onset (min to hours) Usually subsides once treated Sharp, localized (usually see tachycardia, sweating, pallor, increased BP) ex: MI, appendicitis, dental procedures, kidney stones, surgical procedures

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Classification of Pain by Onset & Duration -Chronic Pain:

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Persistent or recurring lasts 3-6 months Often difficult to treat--doctors sometimes get into a routine, pts build up tolerance to a pain med ex: Arthritis, cancer, low backpain, peripheral neuropathy Pain in some cancers may be both acute & chronic (cancer)

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Adjuvant Drugs

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Assist primary drugs in relieving pain: -NSAIDS, Antidepressants, Anticonvulsants**, Corticosteroids Adjuvant: is a pharmacological or immunological agent that modifies the effect of other agents, such as a drug or vaccine. They are thought to work by increasing the levels of certain chemicals (norepinephrine, serotonin) at nerve endings that help to inhibit pain signals.

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Adjuvant Drugs for neuropathic pain:

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Amitriptyline (antidepressant) *Gabapentin* or *Pregabalin (Lyrica)* (anticonvulsants)

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Opioid Analgesics: Indications

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Main use is to alleviate moderate to severe pain Often given in conjunction with analgesic drugs to assist primary drugs with pain relief Cough center suppression (Codeine, hydrocodone) Tx of Diarrhea (paregoric, diphenoxylate/atropine tabs) Balanced anesthesia (Fentanyl) Balanced anesthesia: anesthesia produced by smaller doses of two or more agents considered safer than the usual large dose of a single agent

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Opioid examples:

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Morphine sulfate (IM, rapid onset, lasts 6-7 hours) Codeine Sulfate (PO, onset 15-30 min, lasts 4-6 hours) Fentanyl (IV: rapid onset, lasts 30-60 min, Patch: onset 12-24 hrs, lasts 13-40 hours, PO: onset 5-15 min, unknown lasting time) Demerol (IM: rapid onset, lasts 2-4 hours) Dolophine (PO: onset 30-60 min, lasts 22-48 hours) -also used for pts experiencing withdrawal -given by a doctor

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Other Opioid examples:

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Codeine sulfate (cough relief) Fentanyl citrate (sedation) Demerol (analgesia, quick/strong effect-watch them to ensure they don't fall) Methadone (chronic pain also for detox or addition maintenance) Morphine sulfate/Roxanol/MS Contin (analgesia) Oxycodone/Oxycontin (moderate to severe pain)

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Opioid reversal drugs (antagonists):

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Naloxone HCL (Narcan) Naltrexone HCL (Trexan) Given to reverse narcotic use. If you are using any narcotic pain medication, the pain-relieving effects of the narcotic will be reversed while you are also receiving naloxone. -as soon as it hits the pt, every bit of pain comes back instantly -use lowest dose

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Opioid Analgesics: Contraindications

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Known drug allergy Severe asthma (Extreme caution if:) Respiratory insufficiency Elevated ICP (severe head injury) Morbid obesity Sleep apnea Paralytic ileus Myasthenia Gravis Pregnancy Morphine causes itching due to histamine release. Codeine causes nausea. These are not true allergies. Myasthenia Gravis: is an autoimmune neuromuscular disease leading to fluctuating muscle weakness and fatigue.

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Before giving Opioids always assess:

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Always know their HR, BP, and respiratory rate before giving opioids. Any respiratory rate 10-12—hold opioids. Esp. less than 10 (will knock out respiratory drive)

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Opioid Analgesics: Adverse Effects

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Euphoria CNS depression (leads to respiratory depression, most serious adverse effect) -use Narcan or Trexan N/V Urinary retention Diaphoresis and flushing Pupil constriction (Miosis) Constipation (pt should be on stool softener) Itching, rash, wheal formation Hypotension/Palpitations, bradycardia Possible aggravation ofasthma

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Physical Dependence:

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Physiological adaptation of the body to the presence of an opioid Opioid tolerance and physical dependence are expected with long-term opioid treatment and should not be confused with psychologic dependence (addiction) Physical dependence is seen when the opioid is abruptly discontinued or when an opioid antagonist is administered (Opioid withdrawal/Opioid abstinence syndrome) Body has adapted to the presence of the medicine-when its taken away, the pain returns

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Psychological Dependence:

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A pattern of compulsive drug use characterized by a continued craving for an opioid and the need to use the opioid for effects other than pain relief Craving, addicted

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Toxicity and Management of Overdose:

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Naloxone (Narcan)-IV 0.4-2mg q2-3 min, no more than 10mg Naltrexone (Revia, Trexan)-PO 25-50 mg daily -these drugs bind to opiate receptors and prevent a response -used for complete or partial reversal of opioid-induced respiratory depression Morphine causes itching due to histamine release. Codeine causes nausea. These are not true allergies. Myasthenia Gravis: is an autoimmune neuromuscular disease leading to fluctuating muscle weakness and fatigue.

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Non-opioid Analgesics: Acetaminophen

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Analgesic and antipyretic effects Little to no antiinflammatory effects Available OTC and in combination products with opioids (Norco) Indicated for: Mild to moderate pain Fever Alternate for those who cannot take aspirin products

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Acetaminophen: Dosage

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Maximum daily dose for healthy adults is being lowered to 3000mg/day (2000 mg for elderly or those with liver disease) Inadvertent excessive doses may occur when different combination drug products are taken together Be aware of the acetaminophen content of all medications taken by the patient (OTC and prescription)

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Toxicity and Managing Overdose of Acetaminophen

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Even though available OTC, lethal when overdose *Causes hepatic necrosis: hepatotoxicity can result from 150mg/kg or more* Long-term ingestion of large doses can also cause nephropathy Recommended antidote: *Acetadote* regimen given in 3 IV doses over 21 hours, can be given PO as well with loading dose followed by additional doses q4hr for 17 additional doses -most effective if given within 10 hours of an overdose -if not effective --> liver failure Acetadote (acetylcysteine) injection will be used in an emergency room setting to prevent or lessen potential liver damage resulting from an overdose of acetaminophen. Acetaminophen dose limit is 4000 mg/24hr period in a healthy adult.

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Herbal Products: Feverfew

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Antiiinflammatory properties Used to tx migraine headaches, menstrual cramps, inflammation, and fever May cause GI distress, altered taste, muscle stiffness May interact with aspirin and other NSAIDS, and anticoagulants

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Analgesics: Nursing Implications

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Be sure to medicate patients before pain becomes severe Pain management includes pharmacologic and nonpharmacologic approaches-be sure to include other interventions as indicated Monitor for therapeutic effects: decrease pain, increase comfort, improve ADL's, appetite and sense of well being, and decrease fever (Tylenol) Patients should not take other medications or over-the-counter preparations without checking with their physician Instruct patients to notify physician for signs of allergic reaction or adverse effects Respiratory depression may be manifested by respiratory rate of less than 10 breaths/min, dyspnea, diminished breath sounds, or shallow breathing

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Opioid Analgesics: Nursing Implications

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Oral forms should be taken with food to minimize GI upset Ensure safety measures-keep side rails up to prevent injury Withhold dose and contact physician if there is a decline in the pt's condition or if VS are abnormal-especially if respiratory rate is less than 10-12 breaths/min Constipation is a common adverse effect and may be prevented with adequate fluid and fiber intake Instruct patients to follow directions for administration carefully and to keep a record of their pain experience and response to treatments Patients should be instructed to change positions slowly to prevent possible orthostatic hypotension

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General and Local Anesthetics

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Anesthesia

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A state of depressed CNS activity General anesthesia or Local anesthesia Balanced anesthesia: involves use of general anesthesia in conjunction with other drug classes discussed int his chapter

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General Anesthesia:

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complete loss of consciousness, loss of body reflexes, elimination of pain, skeletal/smooth muscle paralysis including respiratory muscles requires use of ventilatory support to avoid brain damage and suffocation

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Local Anesthesia:

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Does not involve paralysis of respiratory muscles does involve elimination of pain sensation in tissues innervated by anesthetized nerves

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*General Anesthetics* Drugs that induce a state in which the CNS is altered to produce varying degrees of:

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Pain relief, Depression of consciousness, Skeletal muscle relaxation, Reflex reduction

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*General Anesthetics* Inhaled anesthetics:

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Nitrous Oxide (laughing gas) Volatile liquids or gases that are vaporized in oxygen and inhaled Suprane Ethrane Forane Ultane

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*General Anesthetics* Parenteral anesthetics:

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Adminsitered IV Used to: -induce or maintain general anesthesia -induce amnesia -as an adjunct to inhalation-type anesthetics Amidate Ketalar Brevital Diprivan (doc must do) Pentothal

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Adjunct Drugs:

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Sedative-hypnotics Opioid Analgesics Neuromuscular blocking drugs (NMBDs) Anticholinergics

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Adjunct Drugs -Sedative-hypnotics:

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Barbituates (Pentobartibal, Secobarbital) Benzodiazepines (Diazepam, Versed) Hydroxyzine (Vistaril, Atarax) Promethazine (Phenergan)

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Adjunct Drugs -Opioid analgesics:

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Fentanyl Sufentanil Demerol Morphine

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Adjunct Drugs -Neuromusclar blocking drugs:

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Depolarizing drugs (Succinylcholine) Nondepolarizing drugs (Pancuronium, D-tubocurarine, Vecuronium)

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Adjunct Drugs -Anticholinergics:

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Atropine Robinul Scopalamine

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General Anesthesia: Indications

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used during surgical procedures to produce: -Unconsciousness, skeletal muscle relaxation, visceral smooth muscle relaxation Rapid onset; quickly metabolized Also used in electroconvulsive therapy treatments for depression

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Commonly used general anesthetics:

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Isflurane (Forane) Ketamine (Ketalar) Nitrous Oxide Propofol (Diprivan)

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Moderate Sedation:

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aka: conscious sedation, procedural sedation can be given IV, IM, Spinal or PO (usually only in peds) Combination of an IV benzo and an Opiate analgesic Anxiety and sensitivity to pain are reduced, and patient cannot recall the procedure Preserves the pts ability to maintain own airway and respond to verbal commands Always keep a crash cart near by-potential of going unconscious MSO4 and Versed (combinatin)

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Moderate Sedation:

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Used for diagnostic procedures and minor surgical procedures that do not require deep anesthesia (EGD, colonoscopy, oral endoscopy) Topical anesthetic may be applied also Rapid recovery time and greater safety profile than general anesthesia Those who administer this type of anesthesia must be certified in ACLS, and one who can intubate if needed ACLS: (advanced certified life supporter) able to give drugs, epinephrine, etc... Nurses can do moderate sedation Cannot leave them until they are awake and able to drink/swallow (back to baseline)

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Local Anesthetics

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Work at the level of peripheral nerves aka: Regional anesthetics (-caine drugs (lidocaine, tetracaine, etc...) Used to render a specific portion of the body insensitive to pain (such as with child birth, dental procedures, suturing, biopsies, lumbar punctures, others) Interfere with nerve impulse transmission to specific areas of the body, thus decrease pain Do not cause loss of consciousness

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Local Anesthetics -Topical:

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Applied directly to skin or mucus membranes (Benzocaine, Lidocaine) Creams, solutions, ointments, gels, opthalmic drops, lozenges, suppositories

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Local Anesthetics -Parental:

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Injected IV or into CNS by various spinal injection techniques Lidocaine, Procaine, Tetracaine, Mepivacaine

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Types of Local Anesthesia (2):

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Spinal or Intraspinal (work in CNS) Peripheral Nervous System

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Local Anesthesia -Spinal or Intraspinal:

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(work in CNS) Intrathecal: drug injected into subarachnoid space (major abdominal surgery or limb which general is too risky), drug pumps for outpatient procedures Epidural--childbirth, lumbar puncture, thoracentesis, ortho surgery

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Local Anesthesia -Peripheral nervous system:

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Infiltration: injected into tissue at operative site; wound suturing, dental surgery; also epinephrine can be given via infiltration to reduce blood loss during a procedure Nerve block: into nerve, cancer pain, chronic orthopedic pain Topical: surface of skin, eye or mucous membrane; diagnostic eye examinations or skin suturing

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Parental Anesthetics:

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Lidocaine (Xylocaine) Mepivacaine (Carbocaine) Procaine (Novocain) Tetracaine (Pontocaine) Drug effects: paralysis First, autonomic activity is lost Then pain and other sensory functions are lost Last, motor activity is lost As local drugs wear off, recovery occurs in reverse order (motor, sensory, then autonomic activity are restored) Various drugs from this class may also be mixed in opioids during PCA administration for pain relief

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Neuromuscular Blocking Drugs

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When used during surgery, artificial mechanical ventilation is required These are high alert drugs because: -they paralyze respiratory and skeletal muscles -pt cannot breathe on their won -do not cause sedation or pain relief -pt may be paralyzed yet conscious

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Example of NMBD:

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Succinylcholine only drug in the depolarizing class of NMBD's Works similarly to neurotransmitter Ach, causing depolarization Metabolism is slower than Ach, so as long as Succinylcholine is present, repolarization cannot occur Results in flaccid muscle paralysis Used to facilitate endotracheal intubation NMBD's are categorized as: Depolarizing and Non-depolarizing

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NMBDs: Non-depolarizing drugs:

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Short-acting (Mivacron) Intermediate acting (Tacrium, Norcuron, Zemuron) Long-acting (Pavulon, Nuromax) The cell membrane of the nerve cell is not depolarized Don't have to memorize which drugs are in which category

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NMBDs -order of sensations:

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First sensation is muscle weakness Then, total flaccid paralysis Small rapidly moving muscles affected (fingers, eyes), then limbs, neck, trunk Finally, intercostal muscles and diaphragm are affected, resulting in cessation of respirations (no respirations/breathing) (KNOW^) Recovery of muscular activity usually occurs in reverse order Transient muscle fasciculations may result in later muscle soreness

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Antedote for reversal of NMBDs:

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Anticholinesterase drugs -- Neostigmine (Prostigmin)*******

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NMBDs: Indications

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Main use is maintaining controlled ventilation during surgical procedures Endotracheal tubing (short-acting) To reduce muscle contraction in an area that needs surgery Diagnostic drugs for myasthenia gravis

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NMBDs: Side effects:

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Few when used appropriately May cause: HypoTN, Tachycardia Effects vary according to drug BP should be taken q5-10 min

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NMBDs: Safety

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Respiratory muscle paralysis occurs with these drugs Emergency ventilation equipment must be immediately available

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NMBDs: Nursing Implications

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Perform close and frequent observation of the patient and all body systems During a procedure monitor VS, ABC's Watch for sudden elevation in body temperature, which may indicate malignant hyperthermia Closely monitor HR, BP, & temp-may increase

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Central Nervous System Depressants & Muscle Relaxants

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Sedatives:

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Drugs that have an inhibitory effect on the CNS to the degree that they reduce: Nervousness, Excitability, and Irritability without causing sleep

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Hypnotics:

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Cause sleep A sedative can become a hypnotic if it is given in a large enough dose

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CNS Depressants: Benzodiazepines

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Formerly the most commonly prescribed sedative-hypnotic drug Prescribed for sedation, relief of agitation, tx of depression, sleep induction, skeletal muscle relaxation, anxiety relief, and treatment of seizure disorder Can be given as alcohol withdrawal (diazepam) Favorable drug effect profiles, efficacy, and safety Classified as either: sedative-hypnotic OR Anxiolytic

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Benzodiazepines: Sedative-Hypnotic Types

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Long-acting (Valum, Klonopin) Intermediate-acting (Xanax, Ativan, Restoril) Short-acting (Versed, Halcion) Benzodiazepines should be avoided in the elderly due to fall risks. When given for sleep patients may experience nightmares. Also may experience rebound insomnia when stopped suddenly.

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CNS Depressants: Nonbenzodiazepine Hypnotics

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Share many characteristics of benzodiazepines Used to tx Insomnia Sonata, Ambien, Lunesta, Rozerem Ambien CR: extended release, approved for long-term therapy Rozerem -does not cause CNS depression, no potential for abuse, no withdrawal S/S *DO NOT GIVE TO PTS WITH LIVER DISEASE*

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Benzodiazepines: Indications

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Sedation Sleep induction (short term use to tx insomnia due to potential for dependency) Skeletal muscle relaxation (following surgery) Anxiety relief Tx of alcohol withdrawal (diazepam) Agitation Tx of Depression Tx of Seizure disorders Used in combination with anesthetics, analgesics, and NMBD's in balanced anesthesia for their amnesic properties for pt to forget painful procedures Moderate sedation

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Herbal Products: Valerian

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Used to relieve anxiety, restlessness, and sleep disorders May cause CNS depression, hepatotoxicity, n/v, anorexia, restlessness, insomnia Many interactions: CNS depressants, MAOI's, Phenytoin, Warfarin, alcohol Contraindicated in cardiac and liver disease Pt should not operate heavy machinery during use

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Herbal Products: Kava

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Used to relieve anxiety, stress, restlessness, promotion of sleep May cause skin discoloration, pupillary enlargement, and scaly skin with long term use Potential interactions: alcohol, barbituates Contraindicated in Parkinson's disease, liver disease, alcoholism, pregnancy, or breast feeding No operation of heavy machinery

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Sedative-Hypnotics: Barbituates

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Habit forming Only a handful commonly used today in part to the safety and efficacy of benzodiazepines

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Barbituates -Therapeutic index:

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Dosage range within which a drug is effective but above which it is rapidly toxic Barbituates have a very narrow therapeutic range Can produce many unwanted adverse effects because of this! *KNOW THIS*

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Barbituates: 4 Categories:

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*Ultra short-acting* (anesthesia for short surgical procedures, other uses) *Short-acting* (sedation/sleep induction and control of convulsion conditions) *Intermediate-acting* (Sedation/sleep induction and control of convulsive conditions) *Long-acting* (Sleep induction, epileptic seizure prophylaxis) ALL barbiturates have a sedative-hypnotic effect but some are more potent than others. They are used as sedatives, hypnotics, anticonvulsants, and anesthesia for surgical procedures. Phenytoin is long acting

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Barbiturates -Ultra short-acting: -Short-acting: -Intermediate-acting: -Long-acting:

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Brevital, Pentothal Nembutal, Seconal Butisol Solfoton, Luminal, Mebaral Sometimes short and intermediate acting are grouped together. Ultra short acting: occur within 20 minutes. Short acting 40 minutes and last 5-6 hours. Long-acting: last several hours to days. Phenobarbital: most commonly used barbiturate and rarely used as a sedative. Also used for seizures.

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Barbiturates: Toxicity and Overdose

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Overdose frequently leads to respiratory depression and subsequent respiratory arrest Overdose produces DNS depression (sleep to coma and death) Exhibit cold, clammy skin then progresses to fever with hypotension and tachycardia Can be therapeutic: anesthetic induction, uncontrollable seizures ("Phenobarbital coma")

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Tx of Overdose:

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Symptomatic and supportive Maintain adequate airway Assisted ventilation/oxygen therapy Fluids Pressor support Activated charcoal-liquid form, neutralizes all drugs and inhibits them from being absorbed -can also use with a gastric lavage Monitor pt for adequate airway at all times Need IV fluids Something to keep BP up

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Muscle Relaxants

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Act to relieve pain associated with skeletal muscle spasms Majority are central-acting -CNS is the site of action -Similar in structure and action to other CNS depressants like Diazepam Work best when used along with physical therapy

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Muscle Relaxants -2 examples:

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Dantrium -used for malignant hyperthermia crisis Lioresal -relief of hiccups

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Muscle Relaxants: Adverse Effects

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Extension of effects on CNS and skeletal muscles Euphoria Light headedness Dizziness Drowsiness Fatigue Sexual difficulty in males Muscle weakness (experienced early in tx)

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Common Muscle Relaxants:

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Lioresal Flexeril Dantrium Skelaxin Zanaflex Soma Paraflex Robaxin

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CNS Depressants: Nursing Implications

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Before beginning therapy, obtain thorough history Obtain baseline VS and I&O, including supine and erect BPs (orthostatic) Assess for potential disorders or conditions that may be contraindications, and for potential drug interactions Give hypnotics 30-60 min before bedtime for maximum effectiveness in inducing sleep (depends on drug's onset) *Most benzos cause REM rebound and a tired feeling the next day; use with caution in the elderly* Instruct pts to avoid alcohol and other CNS depressants Safety is important! -avoid smoking, assist with ambulation, call light, keep rails up Check with physician before taking any other med Rebound insomnia may occurs a few nights after 3-4 week regimen has been D/C'd Monitor for therapeutic effects: ability to sleep, decreased spasticity & rigidity

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CNS Stimulants & Related Drugs

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CNS Stimulants -Uses:

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Analeptics (CNS stimulants) Appetite suppressants (anorexiant) Tx of: -ADHD, Narcolepsy, Migraine headaches

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CNS Stimulants -ADHD drugs:

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Amphetamine (Adderall, dexedrine) Methylphenidate (Concerta, Ritalin) Atomoxetine (Straterra) -nonaddictive, may cause suicidal thinking/behavior Lisdexamfetamine (Vyvanse)

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CNS Stimulants -Narcolepsy:

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Provigil

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Anorexiants:

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used to treat obesity Didrex Desoxyn Ionamin Xenical -lipase inhibitor, not a CNS stimulant -also used to treat obesity -may cause fecal incontinence pts need to reduce fat intake

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CNS Stimulants -Anti-migraine (serotonin agonists):

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Axert Relpax Frova Amerge *Maxalt* *Imitrex* *Zomig* (-triptan drugs contraindicated in pts with CAD bc of vasoconstrictive effects) Not used to prevent migraine, just decrease symptoms Floricet-can be given to prevent those having one or more migraines a week Stimulate 5-HT receptors in cerebral arteries, causing vasoconstriction and reducing headache symptoms

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Nursing Implications -Assess for:

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Potential contraindications, interactions including herbal therapies, conditions such as abnormal cardiac rhythms, seizures, palpitations, liver problems For children, assess baseline height and weight

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Nursing Implications -Drugs for ADHD:

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Last daily dose should be given 4 to 6 hours before bedtime to reduce insomnia Take on an empty stomach, 30 to 45 minutes before meals Drug "holidays" may be ordered Instruct parents to keep a journal to monitor child's response to therapy Monitor child for continued physical growth, including height and weight

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Nursing Implications -Orlistat (Xenical):

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Used for weight loss in obese pts Decreased fat leads to GI upset follow instructions for diet & exercise Limit dietary fat to 30% of total intake to reduce adverse effects Take with meals that contain fat Fat-soluble vitamin supplmentation may be needed

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Nursing Implications -Serotonin agonists (anti-migraines):

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Dissolvable wafers, nasal spray, and self-injectable forms Provide specific teaching about correct administration Instruct patients to avoid foods that contain tyramine Instruct patients to keep a journal to monitor response to therapy

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Nursing Implications -Monitor for therapeutic responses:

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ADHD: decreased hyperactivity, increased attention span & concentration Anorexiant: appetite control and weight loss Narcolepsy: decreased in sleepiness Serotonin agonists: decrease in frequency, duration, and severity of migraines

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Antiepileptic Drugs

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*Epilepsy* Seizure: Convulsion: Epilepsy:

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Seizure: brief episode of abnormal electrical activity in nerve cells of the brain Convulsion: involuntary spasmodic contractions of any or all voluntary muscles throughout the body, including skeletal and facial muscles Epilepsy: chronic, recurrent pattern of seizures

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Classification of Epilepsy:

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Generalized onset seizures (aka: grand mal seizures) Partial onset seizures (simple, complex, secondary generalized tonic-clonic) Unclassified seizures

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Antiepileptic Drugs (AEDs) -goals:

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aka: anti-convulsants Goals are to control or prevent seizures while maintaining a reasonable quality of live & minimize adverse effects and drug-induced toxicity AED therapy is usually life-long Combinations of drugs may be used -if first drug is not effective, the drug should be tapered while second drug is introduced -Therapeutic monitoring helps control seizures and reduce adverse effects

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Antiepileptic Drugs: Indications

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Prevention or control of seizure activity Long-term maintenance therapy for chronic, recurring seizures Acute treatment of convulsions and status epilepticus Single-drug therapy started before multi-drug therapy is tried Serum drug concentrations must be measured -therapeutic drug monitoring Patients who are seizure free for 1 to 2 years may be able to discontinue antiepileptic therapy

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Antiepileptic Drugs -examples:

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Barbiturates (phenobarbital, Luminal) *once a day dosing due to long half life-longest of all AEDs* Tegretol Depakene Mysoline Dilantin *Valium*-drug of choice for status epilepticus -can be given rectally if no IV access

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Long term therapy with Phenytoin (Dilantin):

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may cause gingival hyperplasia, acne, hirutism *thus, good oral care is important to prevent gingival hypertrophy*

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Second-Line Antiepileptic Drugs (Adjunct) -exmaples:

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Zarontin Benzos (Clonazepam, Clorazepate) Neurontin Lamictal Lyrica Keppra Topamax Gabitril

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Contraindications for AEDs:

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drug allergy pregnancy (weight risk vs. benefits of treatment)

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Nursing Implications for AEDs -Assessment:

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Health history, including current medications Drug allergies Liver function studies, CBC Baseline vital signs Drugs should be monitored for therapeutic levels due to narrow index!!!

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Nursing Implications -Oral drugs:

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Take regularly, same time each day Take with meals to reduce GI upset Do not crush, chew, or open extended released forms -regular release capsules may be opened and sprinkled onto a small amount of soft food-but no more than 1 teaspoon of food to ensure entire dose is taken (Topamax) If pt is NPO for a procedure, contact HCP regarding AED dosage

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Nursing Implications -IV forms:

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Follow manufactor's recommendations for IV delivery-usually given slowly Monitor VS during administration-watch for decrease in BP, decrease in HR Avoid extravasation of fluids Usually only NORMAL SALINE with IV Phenytoin (Dilantin) -as piggy back only with NS -to prevent IV precipitation caused by incompatibilities Instruct pts to wear a medical alert tag or ID AEDs should not be D/C abruptly-rebound seizure activity Keep in mind tx is long term so cannot miss/skip doses for any reason

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Antiparkinsonian Drugs

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Parkinson's Disease:

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Progressive condition Rapid swings in response to levodopa occur ("on-off phenomenon") resulting in the following: -PD worsens when too little dopamine is present -Dyskinesia occurs when too much dopamine is present Dyskinesia: difficulty in performing voluntary movements

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2 Common types of Dyskinesia:

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Chorea: irregular, spasmodic, involuntary movements of the limbs or facial muscles Dystonia: abnormal muscle tone leading to impaired or abnormal movements; often involves the head, neck, and tongue

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Parkinson's Disease -Drug therapy is aimed at:

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increasing levels of dopamine and/or antagonizing the effects of acetylcholine to slow progression of the disease

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PD -Indirect-acting dopamine-receptor agonists:

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MAOB inhibitors: Selegiline, Rasagiline COMT inhibitors: Entacapone, Tolcapone Presynaptic dopamine release enhancer: Amantadine (Symmetrel)

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Drug Therapy for PD:

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Anticholinergics: Cogentin Antihistamines: Benadryl Nondopamine-receptor agonists: Ergot, Nonergot (mirapex, requip), Dopamine replacement drugs: -Carbidopa, -*Carbidopa-Levodopa*-Sinemet combination drug bc it will help increase the dopamine level in teh brain rather than either drug being given alone

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Selective MAOI Therapy:

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*Selegiline (Eldepryl)* MAOIs break down catecholamines (including dopamine, norepi, epi) in the CNS, primarily in the brain Selegiline is a selective MAO-B inhibitor -causes an increase in levels of dopaminergic stimulation in the CNS Selegiline is a newer, potent, irreversible MAOI that selectively inhibits MAOB MAOB: causes increase dopamine since there is a deficiency with PD

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Selegiline:

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improves functional ability decreases severity of symptoms only 50-60% of patients show a positive response to therapy prophylactically it may delay the development of serious debilitating PD for 9-18 years Rasagiline (Azilect) approved in 2008 with similar action to selegiline

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Selegiline: Adverse effects:

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Usually mild Nausea, lightheadedness, dizziness, abdominal pain, insomnia, confusion, dry mouth *doses higher than 10 mg/day may cause more severe adverse effects, such as HTN crisis*

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Presynaptic Dopamine Release Enhancer Amantadine

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(Symmetrel) helps to control the symptoms of dyskinesia, including motor rigidity -used early in the course of the disease -usually effective for only 6-12 months -also used as an antiviral for influenza virus infection Common side effects: *dizziness, insomnia, nausea*

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COMT Inhibitors (Catechol Ortho-Methyltransferase Inhibitors)

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only 2 drugs: (Tolcapone) Tasmar & Comtan Inhibit COMT, the enzyme responsible for the breakdown of levodopa, the dopamine precursor Advantage of this class: Prolong the duration of action of levodopa; reduce wearing off phenomenon (when anti-Parkinson's disease meds begin to lose their effectiveness, despite maximal dosing, as the disease progresses) -prolonged therapeutic benefits -quicker onset and longer duration of action than traditional drugs Tolcapone has been associated with severe liver failure This drug should only be considered when all others have failed

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Direct-Acting Dopamine Receptor Agonists 1. Nondopamine dopamine receptor agonists (NDDRAs):

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Further divided into: -Ergot derivatives: Parlodel, Permax -Nonergot drugs: Mirapex, Requip directly stimulate the dopamine receptors in the brain

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Direct-Acting Dopamine Receptor Agonists 2. Dopamine replacement drugs:

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Levodopa Carbidopa Sinemet

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Nondopamine dopamine receptor agonists (NDDRAs):

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Used in early or late stages Often used as last resort Bromocriptine (Parlodel) -Inhibits production of prolactin, which stimulates lactation -Given to women with excessive or undesired breast milk production -Also for prolactin-secreting tumors Ropinirole (Requip) -Newer, nonergot NDDRA -Used for PD and restless leg syndrome Should not be taken until at least 14 days after the discontinuation of MAOIs, with the exception of selegiline and rasagiline which are selective MAO-B inhibitors

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Dopamine Replacement drugs:

answer

Replacement drugs -Carbidopa is given with levodopa -Carbidopa does not cross the blood-brain barrier and prevents levodopa breakdown in the periphery -As a result, more levodopa crosses the blood-brain barrier, where it can be converted to dopamine Given in latter stages of the disease levodopa and carbidopa are both contraindicated in patient's with angle closure glaucoma (can cause rise in intraocular pressure) Never give to patients with undiagnosed skin disorder because can activate malignant melanoma

question

Anticholinergic Therapy -*Benztropine Mesylate (Cogentin)*

answer

Also used to treat extrapyramidal symptoms caused by use of antipsychotic drugs Antihistamines also have anticholinergic peroperties (Benadryl)

question

Anticholinergic therapy: indications

answer

Used in tx of PD to cause smooth muscle to relax, resulting in reduced muscle rigidity and akinesia also used to treat drug-induced extrapyramidal reactions to certain antipsychotic drugs

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Anticholinergic therapy: Adverse effects

answer

Drowsiness, confusion, disorientation Constipation, nausea, vomiting Urinary retention, pain on urination Blurred vision, dilated pupils, photophobia, dry skin Decreased salivation, dry mouth -this can be managed with artificial saliva drops or gum -frequent mouth care, forced fluids -sugarless gum or hard candy Use cautiously in elderly patients due to potential for confusion, urinary retention, visual blurring, and increased intraocular pressure

question

Anticholinergic therapy: Nursing implications

answer

Include questions about the patient's: -CNS -GI and GU tracts -Psychological and emotional status Assess for signs and symptoms of PD -Masklike expression -Speech problems -Dysphagia-able to eat okay? -Rigidity of arms, legs, and neck Assess for conditions that may be contraindications

question

Anticholinergic therapy: Teaching

answer

Inform patient not to take other medications with PD drugs unless he or she checks with physician Patient should be taught not to discontinue antiparkinsonian drugs suddenly Teach patient about what therapeutic and adverse effects to expect with antiparkinsonian drug therapy When starting dopaminergic drugs, assist patient with walking because dizziness may occur Administer oral doses with food to minimize GI upset Encourage patient to force fluids to at least 2000 mL/day (unless contraindicated) Taking levodopa with MAOIs may result in hypertensive crisis

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More nursing implications:

answer

Levodopa preparations may darken the patient's urine and sweat Therapeutic effects of COMT inhibitors may be noticed within a few days; it may take weeks with other drugs Monitor for response to drug therapy -Improved sense of well-being and mental status -Increased appetite -Increased ability to perform ADLs, to concentrate, and to think clearly -Less intense parkinsonian manifestations, such as less tremor, shuffling gait, muscle rigidity, and involuntary movements Always do a neuro exam-want to know their mental status Want to know whether the drug is actually working or they need to try something else

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Psychotherapeutic Drugs

answer

...

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Psychotherapeutic drug uses:

answer

Used in the tx of emotional and mental disorders -ability to cope with emotions can range from occasional depression or anxiety to constant emotional distress -when emotions significantly affect an individual's ability to carry out normal daily functions, treatment with a psychotherapeutic drug is possible option

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3 main emotional and mental disorders:

answer

Anxiety Affective disorders Psychosis

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Types of Psychotherapeutic drugs:

answer

Anxiolytic drugs Mood-stabilizing drugs Antidepressant drugs Antipsychotic drugs

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Anxiety

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Unpleasant state of mind, characterized by a sense of dread and fear Six major anxiety disorders (persistent anxiety) -Obsessive-compulsive disorder (OCD) -Posttraumatic stress disorder (PTSD) -Generalized anxiety disorder (GAD) -Panic disorder -Social phobia (also called social anxiety disorder) -Simple phobia

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Antianxiety Drugs -mechanism of action -types:

answer

Reduce anxiety by reducing overactivity in CNS Benzodiazepines (primary anxiolytic drugs) -used for both acute and chronic anxiety -depress activity in the brainstem and limbic system Miscellaneous drug: *Buspirone (BuSpar)* Given to treat anxiety disorder: -nonsedating and non-habit forming -may have drug interaction with SSRIs -do not administer with MAOI's

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Indications for Anti-anxiety drugs:

answer

Anxiety Insomnia Sedation Muscle spasms Seizure disorders Adjunct in anesthesia Adjuvant therapy for depression Alcohol (ethanol) withdrawal

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Common Benzodiazepines:

answer

Valium Ativan Xanax Versed* -reduces anxiety and patient's memory of painful procedures that do not require general anesthesia (moderate sedation) -injection only-limited to use as sedative and anesthetic during invasive medical or surgical procedures (-zepam, -zolam)

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Benzodiazepines: Overdose

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Dangerous when taken with other sedatives or alcohol Can cause confusion, coma, and respiratory depression Treatment is generally symptomatic and supportive, if ingestion is recent can decontaminate GI system *Flumazenil (Romazicon) may be used to reverse benzodiazpine effects*

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Affective Disorder Drugs

answer

Mood stabilizers used to treat Bipolar disorder -involves cycles of mania, hypomania, and depression Antidepressants-used to tx depression

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Mood Stabilizers: Antimanic Drugs

answer

*Lithium is drug of choice for tx of mania* Antimanic effect of lithium is not fully understood -It is thought to potentiate serotonergic neurotransmission -May be used with other medications to stabilize mood, treatment of manic episodes in bipolar disorders -Narrow therapeutic range: maintenance serum levels should range between 0.6 and 1.2 mEq/L -Monitor sodium levels (normal 135-145 mEq/L) to help maintain therapeutic lithium levels -Variety of conjunctive drugs used with lithium: benzo's, antipsychotic, antiepileptic, and dopamine receptor agonists

question

Antidepressant types:

answer

Tricyclic antidepressants Monoamine oxidase inhibitors (MAOIs) Second-generation antidepressants: -SSRIs -SNRIs (serotonin norepinephrine reuptake inhibitors)

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Tricyclic Antidepressants: First generation antidepressants:

answer

Have largely been replaced by SSRIs as first-line antidepressant drugs Considered second-line -For patients who fail with SSRIs or other newer-generation antidepressants -As adjunct therapy with newer-generation antidepressants COMMON TRICYCLICS: Amitriptyline (Elavil) Imipramine (Tofranil) Desipramine (Norpramin)

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TCAs:

answer

TCAs: now used to treat neuropathic pain and insomnia. Lethal—70% to 80% die before reaching the hospital. Death results from seizures or dysrhythmias *Cardiac dysrhythmias* should be an immediate concern with this group of drugs *good rule of thumb is never give a patient more than a 30 day supply because of the risk of suicide attempts No specific antidote -Decrease drug absorption with activated charcoal -Speed elimination by alkalinizing urine with sodium bicarb -Manage seizures and dysrhythmias -Basic life support

question

MAOIs

answer

Highly effective Rarely used anymore Considered second-line treatment for depression, not responsive to cyclics **Disadvantage: potential to cause hypertensive crisis when taken with Tyramine Examples -Phenelzine (Nardil) -Tranylcypromine (Parnate) -Selegiline transdermal patch (oral form used to treat Parkinson's)

question

MAOIs: INdications

answer

Depression, especially types characterized by reverse vegetative symptoms such as increased sleep and appetite Depression that does not respond to other drugs such as tricyclics

question

If switching from SSRI to MAOI:

answer

there must be a 2- to 5-week "wash-out" period between MAOI therapy and SSRI therapy Also, many OTC drugs (especially for cough and cold) can interact with these drugs so patients must always read labels and consult pharmacist or physician before taking any additional medication.

question

MAOIs: Overdose

answer

Symptoms appear 12 hours after ingestion Tacycardia, ciculatory collapse, seizures, coma Tx: protect brain and heart, eliminate toxin -urine acidification -hemodialysis

question

Hypertensive Crisis and Tyramine

answer

Ingestion of foods or drinks with Tyramine leads to hypertensive crisis, which may lead to cerebral hemorrhage, stroke, coma, or death *Avoid foods that contain tyramine!* -Aged, mature cheeses (cheddar, blue, Swiss) -Smoked/pickled or aged meats, fish, poultry (herring, sausage, corned beef, salami, pepperoni, paté) -Yeast extracts -Red wines (Chianti, burgundy, sherry, vermouth) -Italian broad beans (fava beans)

question

Second-Generation Antidepressants:

answer

called SSRIs -still take about 4-6 weeks to reach maximum clinical effectiveness -now considered first line drugs for depression SSRIs: Selective serotonin re-uptake inhibitors- Medications which increase serotonin in the brain (SSRI's such as citalopram, escitalopram, fluoxetine, paroxetine, and sertraline) give patients more self-confidence, and a feeling of safety and security.

question

Examples of SSRIs:

answer

Prozac Paxil Zoloft Luvox Celexa Lexapro

question

SNRI examples:

answer

Effexor, Cymbalta, Pristiq

question

Miscellaneous Second generation antidepressants:

answer

Desyrel, Oleptro, Wellbutrin, Serzone, Remeron

question

SSRIs Indications:

answer

Depression Bipolar disorder Obesity Eating disorders OCD Panic attacks or disorders Social anxiety disorder PTSD Treatment of various substance abuse problems (Zyban) is used for smoking cessation tx

question

Serotonin Syndrome -Symptoms: -Symptoms of severe cases:

answer

Delirium, tachycardia, hyperreflexia, shivering, agitation, sweating, muscle spasms, coarse tremors Hyperthermia, seizures, renal failure, rhabdomyolysis, dysrythmias, disseminated intravascular coagulation (DIC) Concurrent use of MAOIs and SSRIs may lead to serotonin syndrome.

question

Antipsychotics

answer

Drugs used to treat serious mental illness -Behavioral problems or psychotic disorders Have been known as tranquilizers or neuroleptics Thioxanthenes: thiothixene (Navane) Butyrophenones: Haloperidol (Haldol)*-given IM Dihydroindolones: Molindone (Moban) Dibenzoxazepine: Loxapine (Loxitane) Phenothiazines: three structural groups Atypical antipsychotics: new class includes Clozapine (Clozaril) and Risperidone (Risperdal)*

question

Know adverse effects of antipsychotics:

answer

...

question

Antipsychotics: Indications

answer

Tx of serious mental illness -bipolar affective disorder -depressive & drug-induced psychoses -schizophrenia -autism Movement disorders (Tourette's syndrome) Some medical conditions (nausea, intractable hiccups)

question

Herbal Products: St. John's Wort

answer

Used for depression, anxiety, sleep disorders, nervousness May cause GI upset, fatigue, dizziness, confusion, dry mouth, photosensitivity Severe interactions if taken with MAOIs and SSRIs; many other drug interactions Food-drug interaction with tyramine-containing foods

question

Herbal Products: Ginseng

answer

Uses: stress reduction, improvement of physical endurance and concentration May cause elevated BP, chest pain, palpitations, anxiety, insomnia, headache, GI symptoms Interactions with anticoagulants, immunosuppressants, anticonvulsants, antidiabetic drugs

question

Psychotherapeutic Drugs: Nursing Implications

answer

Before beginning therapy, assess physical and emotional status of patients Obtain baseline vital signs, including postural BP readings Obtain liver and renal function tests Assess for possible contraindications to therapy, cautious use, and potential drug interactions Assess for LOC, mental alertness, potential for injury to self and others Check the patient's mouth to make sure oral doses are swallowed Provide simple explanations about the drug, its effects, and the length of time before therapeutic effects can be expected Advise patients to avoid abrupt withdrawal Advise patients to change positions slowly to avoid postural hypotension and possible injury The combination of drug therapy and psychotherapy is emphasized because patients need to learn and acquire more effective coping skills Only small amounts of medications should be dispensed at a time to minimize the risk of suicide attempts Simultaneous use of these drugs with alcohol or other CNS depressants can be fatal

question

Nursing Implications -Antianxiety drugs:

answer

In elderly patients, monitor closely for over sedation and profound CNS depression

question

Nursing Implications -Antidepressants:

answer

Many cautions, contraindications, and interactions exist pertaining to the use of antidepressants Inform patients that it may take several weeks to see therapeutic effects Monitor patients closely during this time, assess for suicidal tendencies, and provide support Assist elderly or weakened patients with ambulation and other activities because falls may occur because of drowsiness or postural hypotension Tricyclics may need to be weaned and discontinued before undergoing surgery to avoid interactions with anesthetic drugs Monitor for adverse effects, and discuss with patients Encourage patients to wear medication ID badges naming the drugs being taken Caffeine and cigarette smoking may decrease effectiveness of medication therapy Instruct patients and family regarding tyramine-containing foods and signs and symptoms of hypertensive crisis

question

Nursing Implications -Antipsychotics-Phenothiazines:

answer

Instruct patients to wear sunscreen because of photosensitivity Tell patients to avoid taking antacids or antidiarrheal preparations within 1 hour of a dose Inform patients to avoid alcohol or other CNS depressants with these medications Long-term haloperidol therapy may result in tremors, nausea, vomiting, or uncontrollable shaking of small muscle groups; report these symptoms to the physician Oral forms may be taken with meals to decrease GI upset These drugs may cause drowsiness, dizziness, or fainting; instruct patients to change positions slowly

question

Monitoring for therapeutic effects:

answer

Monitor mental alertness, cognition, affect, mood, ability to carry out activities of daily living, appetite, and sleep patterns Monitor potential for self-injury during the delay between the start of therapy and symptomatic improvement

question

Therapeutic effects of Lithium:

answer

less mania Therapeutic lithium levels of 0.6-1.2 mEq/L

question

Substance Abuse

answer

...

question

Substance Abuse: Leads to Dependence

answer

Physical dependence Psychological dependence Habituation Addiction

question

Commonly abused substances:

answer

Opioids Stimulants (Methamphetamine, ecstasy/MDMA, cocaine) Depressants (benzos, barbiturates, marijuana) Alcohol Anabolic steroids Destromethorphan Lysergic acid diethylamide (LSD) Nicotine Phencyclidine (PCP)

question

Opioids:

answer

Normally used to relieve pain, reduce cough, relieve diarrhea, and induce anesthesia

question

Opioids -Heroin:

answer

injected ("mainlining" or "skin popping") Sniffed ("snorted") Smoked Causes a brief rush, followed by a few hours of a relaxed, contented state Large doses can stop respirations Methadone

question

Opioid Drug Withdrawal -Peak period: -Duration: -Signs: -Symptoms:

answer

peak period: 1-3 days duration: 5-7 days Signs: drug seeking, mydriasis, diaphoresis, rhinorrhea, lacrimation, diarrhea, elevated BP, elevated pulse Symptoms: intense desire for drug, muscle cramps, arthalgia, anxiety, nausea, vomiting, malaise

question

Opioid Drug Withdrawal: Treatment

answer

Block opioid receptors so that use of opioid drugs does not produce euphoria Naltrexone—an opioid antagonist Vivitrol—injectable form of naltrexone Naloxone combined with buprenorphine (Subutrex) or used alone (Suboxone)

question

Stimulants

answer

Amphetamines (Methamphetamine, MDMA (ecstasy)) cocaine Ritalin (methylphenidate)

question

Stimulant Withdrawal -peak period: -duration: -signs: -symptoms:

answer

Peak period: 1-3 days Duration: 5-7 days Signs: social withdrawal, psychomotor retardation, hypersomnia, hyperphagia Symptoms: depression, suicidal thoughts and behavior, paranoid delusions No specific pharmacologic treatments

question

Depressants

answer

Drugs that relieve anxiety, irritability, and tension Used to treat seizure disorders and induce anesthesia Marijuana

question

2 main pharmacologic classes of deprssants:

answer

Benzodiazepines (flunitrazepam) Barbituates

question

Depressants withdrawal -Peak period: -duration: -Signs: -symptoms:

answer

Peak period -short acting drugs: 2-4 days -long acting drugs: 4-7 days Duration -short acting drugs: 4-7 days -long acting drugs: 7-12 days Signs: increased psychomotor activity, agitation, hyperthermia, diaphoresis, delirium, convulsions, elevated BP, pulse rate, and temperature Symptoms: anxiety, depression, euphoria, incoherent thoughts, hostility, gradiosity, disorientation, hallucinations, suicidal thoughts

question

Treatment of Depressant withdrawal:

answer

involves tapering of the drug over a course of 7-10 or 10-14 days

question

Alcohol (Ethanol)

answer

More accurately known as ethanol (ETOH) Causes CNS depression by dissolving in lipid membranes in the CNS Few legitimate uses of ethanol and alcoholic beverages Used as a solvent for many drugs

question

Effects of Chronic Ethanol Ingestion

answer

Nutritional and vitamin deficiencies (esp. B vitamins) -Wernicke's encephalopathy -Korsakoff's psychosis -Polyneuritis -Nicotinic acid deficiency encephalopathy Seizures Alcoholic hepatitis, progressing to cirrhosis Cardiomyopathy

question

Ethanol Withdrawal -S/S: -Classified as:

answer

Elevated BP, HR, and temp Insomnia, Tremors, Agitation Classified as: mild, moderate, severe

question

Ethanol withdrawal treatment:

answer

Benzodiazepines are tx of choice! -Valium (diazepam), Ativan (lorazepam), or Chlordiazepoxide (Korsakoff's psychosis) -dosage and frequency depend on severity For severe withdrawal, monitoring in an ICU is recommended

question

Treatment for Alcoholism

answer

Antabuse (disulfiram) -Acetaldehyde syndrome Naltrexone Campral (acamprosate) -newest treatment Counseling-individual, AA

question

Nicotine

answer

Many smoke to "calm nerves" Releases epinephrine, which creates physiologic stress rather than relaxation Tolerance develops Physical and psychologic dependency Withdrawal symptoms occur if stopped No therapeutic uses 200 known poisons present in cigarette smoke

question

Nicotine Withdrawal

answer

Manifested by cigarette craving -Irritability, restlessness, decreased heart rate and BP Cardiac symptoms resolve in 3 to 4 weeks, but cigarette craving may persist for months or years

question

Nicotine Withdrawal Treatment

answer

Treatments provide nicotine without the carcinogens in tobacco : -Nicotine transdermal system (patch) -Nicotine polacrilex (gum) -Inhalers -Nasal spray bupropion (Zyban) may be prescribed to aid in smoking cessation -First nicotine-free prescription medicine to treat nicotine dependence varenicline (Chantix) -Stimulates nicotine receptors -Often causes nightmares

question

Nursing Implications

answer

Patient safety is of utmost importance at all times during patient care but especially when the patient is experiencing the signs and symptoms of withdrawal Provide monitoring and support as needed throughout the withdrawal process Educate the patient and family members or significant others about the recovery process Emphasize that recovery is lifelong

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