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Integumentary system

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The skin. We have covered this in med surge already. It is the body's largest organ, and the first line of defense against pathogens. Injuries to the skin provide opening for infection.

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Integumentary disorders are classified as

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-Infectious -Inflammatory -Cancerous

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Medications prescribed for the integumentary system depends on

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Classification. They can be topical -creams- (mild acne, psoriasis, cold sores) or systemic -pills- (Severe Acne, Infection)

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Acne

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Bacterial skin disorder affecting sebaceous glands. Skin produces bumps called pustules.

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In adolescents, acne is commonly caused by

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Hormones

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In adults, acne is commonly caused by

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bacteria (commonly Propionibacterium acnes, which grows inside the sebaceous glands and makes an irritating, acidic substance).

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Black Heads (Medically known as Comedos)

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oil glands plugged with melanin granules

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Nodules

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Inflammation deep below the skin. Can cause pain, deformity, and scarring.

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Topical meds

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Creams, Gels, lotions

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benzoyl peroxide

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Over the counter. inhibits bacterial growth

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benzoyl peroxide side effects

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peeling,erythema,edema.

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Contraindication for all of these meds

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Hypersensitivity (allergic reaction)

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Retinoids

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Contain vitamin A which increases the body's resistance to infection (acne) by reducing the oil production that clogs pores. Also reduces keratinization

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examples of retinoids

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tretinoin,tazarotene

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retinoids side effects

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photosensitivity (just means sensitivity to light), Local reactions (topical)

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retinoids contraindications

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pregnancy. retinoids are class C meaning that the potential risks of taking it during pregnancy should be outweighed by the benefits

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Oral contraceptives

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Have been shown to be effective in treating acne. Can help stop acne from forming by reducing androgen production.

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Severe acne

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Treatments - Sulfur (removes infected skin) -antibiotics (Tetracyclines. Not to be taken with dairy products, which can inhibit absorption.) -Keratolytics (removes infected skin)

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Keratolytics

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Examples: salicylic acid, ammonium lactate

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Keratolytic Side effects

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burning irritation tinnitus (ringing or buzzing in ears) dizziness ototoxicity (toxic to the ear) headaches (oral)

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Keratolytic contraindications

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prolonged use irritated skin moles birthmarks warts with hair growth mucous membranes

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Rosacea

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Bacterial skin disorder- small bumps and reddened skin irritation without pus. aggravated by sunlight, stress, hot temperatures, alcohol, spicy food, hot beverages. The treatment is same as acne. So think of this as just acne without the pust

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Rosacea appearance

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flushed, especially on the nose and cheek.

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Impetigo

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Common in children after URI where child excessively wipes their nose causing a break in skin for bacteria entry.

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Impetigo Treatment

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Antibiotics- topically, with severe cases requiring the systemic route. corticosteroids (topical) with examples being hydrocortisone and dexamethasone -side effects are burning, itching, and irritation. -Contraindicated in pregnancy

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Scabies

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Parasitic Infestation of the human itch mite that burrows into skin and lay eggs ›Treated with scabicides(topical) - permethrin

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Pediculosis

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Parasitic infestation caused by lice. Nits: lice eggs- need to be combed out and may need retreatment after hatched if not removed ›Treated with pediculicides (topical) - lindane -A neurotoxin

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Scabicides and pediculocide side effects

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rash, redness, itching, and burning -Contraindication: hypersensitivity

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Viruses

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Smaller than bacteria and depends on host cell to grow and reproduce. This makes it hard to kill

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Human papillomavirus (HPV)

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Responsible for most of cervical cancer in women and venereal warts in men and women

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HPV treatment

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cryosurgery (liquid nitrogen) to freeze warts, salicylic acid to shed skin or HPV vaccine to prevent virus

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HSV-1

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Causes cold sores or fever blisters on lips and mouth. This is above the waist

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HSV-2

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Sexually transmitted virus › Affects genital mucosa. This is below the waist.

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Herpes zoster (Shingles)

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Reactivation of chickenpox virus

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OTC antivirals for HSV-1

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Reduces duration of episodes › Examples: docosanol (Abreva) -Side effects: acne, itching, rash -Contraindications: Hypersensitivity

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Fungi- include Tinea and candidiasis

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-Dermatophytes invade keratin and can infect hair, nails and skin -Topical antifungals may be used when the infection is present on the trunk, extremities, groin, or feet -If infection is on scalp, oral agents may be needed

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Examples of antifungals

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clotrimazole, terbinafine -Side effects: Burning, stinging, pruritus (severe itching), erythema -Contraindication: Hypersensitivity

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Candidal Infections

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Caused by Candida Albicans ›Associated with pruritic red rash that may be painful ›If it occurs in the mouth it is called thrush -White plaques are present in mouth ›Treatment - Nystatin (topicalor oral)

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Burns

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- Damage skin by removing water causing it to blister or removing skin entirely - Classified as 1st, 2nd, or 3rd degree

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1st degree burn

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Epidermis › Most common is sunburn › Skin becomes red and painful to touch › Treatment: - Non pharmalogicalapplication of cool water for 20 minutes and aloe vera - Pharmalogical - lidocaine

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2nd degree burn

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Epidermis and dermis ›Blister forms over burn and yellow in appearance ›Treatment -Cover with sterile dressing -silver sulfADIAZINE

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3rd degree burn

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affects all layers of skin plus subcutaneous tissue and possible muscle and bone -Great risk for infection and fluid loss

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3rd degree burn treatment

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›Maintaining airway, administering IV fluids ›Antibiotics to prevent infection ›Medication to debride wound and cover with sterile non-adhering dressing -Examples - collagenase ›Medication to stimulate new tissue granulation -Examples- becaplermin

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Atopic dermatitis: Eczema

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-Allergic disorder causing cutaneous inflammation -Extremely dry, itchy patches of skin -Treatment ›Avoidance of allergens and maintaining hydration ›corticosteroids (topical) -Examples- hydrocortisone acetate Side effects: Burning, itching, irritation Contraindications: Hypersensitivity, pregnanc

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Immunomodulators

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Modify skins immune reactions -Examples - pimecrolimus, tacrolimus Side effects: Burning, pruritus Contraindications: Hypersensitivity, pregnancy, breastfeeding

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Oral antihistamines

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Examples - diphenhydramine Side effects: drowsiness, dizziness, blurred vision, photosensitivity, chest tightness, wheezing ›Contraindications: Hypersensitivity, Acute attacks of asthma, Lactation;

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Psoriasis

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Chronic inflammatory skin disease Life cycle of skin shortened, thus dead cells cannot be shed quickly enough causing build-up of skin cells on surface. -Flaky white appearance atop a reddened plaque

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Psoriasis Treatment

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Corticosteroids (topical) - Low-dose antihistamines - Salicylic acid -Phototherapy: UV light - Antipsoriatic agents › Examples - Coal tar, calcipotrine, methotrexate (used for severe disease) injectable or oral -Side effects : irritation to surrounding skin; discoloration of skin, hair, or fabrics -Contraindications: Hypersensitivity, use on the face, renal disease, pregnancy, breastfeeding, hypercalcemia (calcipotriene)

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Cancerous skin disorders

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Warning signs: if a nevus (mole) changes colors, grows, or its borders become irregular Good prognosis with early detection

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Basal Cell Carcinoma

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- Most common form - Rarely metastasizes - Treatment › Surgery: Liquid nitrogen › Topical preparations - fluorouracil (5-FU- affects rapidly dividing cancer cells - imiquimod- stimulates the immune system

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Squamous cell carcinoma

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-Malignant keratinocytes -Can metastasize -Treatment ›Surgical removal (Treatment of choice) ›Radiation therapy possible

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Malignant melanoma

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-Unpredictable cancer -Spreads through the lymphatic system and blood -Treatment ›Surgery ›Radiation ›Chemotherapy

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Nursing Assessment

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Assess for allergies. › Assess for pain. › Inspect skin for open areas, inflammation, swelling, drainage, itching, rash. - In dark-skinned patients, inflammation may not be visible; palpate skin for warmth. › Measure length and width of affected area. - Include depth in wounds.

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Ointments

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are more occlusive and preferred for dry, scaly lesions.

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Creams

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should be used on oozing wounds, or skin areas that rub together (axilla, thighs, nares, skinfolds of breasts, etc.).

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Gels, aerosols, lotions

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are useful in hairy areas. - Separate hair and apply a small amount to affected area; rub in gently.

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Patient teaching with topicals

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Wash hands before and after drug application. › Skin should be clean and dry before applying medication. › Avoid exposure to sunlight during drug therapy (for photosensivity) › Notify physician of any skin reactions to the medication. › If ordered, apply dressing after application of drug. › Teach patient the proper disposal of contaminated dressings. › Women of childbearing age should be warned of the possible birth defect risks regarding certain integumentary drugs.

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Minerals that bone store

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calcium, magnesium, and potassium. Endocrine system controls these minerals and must be healthy

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Thyroid Gland

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Produces calcitonin

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Parathyroid Gland

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Secretes parathyroid hormone. Whats the point of this even being on here duhhhh

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Medications used for musculoskeletal disorders can be placed into two categories:

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- Those to treat muscular disorders - Those to treat bone disorders Hell that's what musculoskeletal even stands for is muscle and bone

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Ailments that orginate in the brain

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- Cerebral palsy - Stroke - Multiple sclerosis

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Ailments that originate in muscle tissue itself

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- Muscle injuries - Muscular dystrophy Again it's in the name, whats the point

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Muscular Symptoms

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- Muscle spasms - Dystonia: abnormal tension

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Treatments for them muscular symptoms

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- Muscle relaxants and Antispasmotics › Both classifications work to inhibit neurological activity that causes muscle spasms or rigidity Examples - baclofen, cyclobenzaprine, dantrolene, metaxalone -Side effects - dizziness ,drowsiness, confusion, dry mouth, GI disturbances, and weakness -Contraindication -Asthma, muscular dystrophy, myasthenia gravis, pregnancy and breast feeding diazepam may be given to maximize effectiveness of above medications duloxetine decreases stress felt with chronic pain

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Antispasmotics

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Work on muscle itself botulinum toxin type A- a toxic substance that causes food poisoning; lower doses act by paralyzing muscle - Used to treat › Chronic migraines › Limb spasticity › Abnormal head position › Neck pain - Must be repeated every 3-6 months - Usually administered with local anesthetic because toxin causes pain

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Myasthenia gravis

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- Progressive, autoimmune disease with skeletal muscle fatigue and weakness and loss of acetylcholine receptors, causing a breakdown in communication between nerves and muscles - Treatment: cholinesterase inhibitors to facilitate acetylcholine accumulation - No cure, but treatment can reduce symptoms

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Example of Myasthenia gravis treatment

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- neostigmine -Side Effect - increased saliva, weakness, muscle cramps, diarrhea, frequent urination -Contraindications - Hypersensitivity, peritonitis, mechanical intestinal or urinary obstruction

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Fibromyalgia

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A difficult to manage chronic disorder of pain in muscles and soft tissue surrounding joints - Treatment › Decreasing contributory factors (lack of exercise, etc.) › Physical therapy › Antidepressants - duloxetine, milnacipram ›Antiepileptic - pregabalin (LYRICA) › Anti-inflammatory medications - ibuprofen ›Analgesics - acetaminophen Remember Lyrica

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Skeletal system

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› Comprises 206 bones › Repository for minerals such as calcium, potassium, and magnesium › Calcium needed for nerves, bones, and muscles to function properly

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Endocrine System

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Controls deposit of minerals - Thyroid produces calcitonin: allows calcium to remain in bone - Parathyroid gland: produces parathyroid hormone, which increases calcium in the blood (loss of calcium in bones) - Both work together to keep balance - If either gland fails, musculoskeletal disorders result

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Risk Factors for hypocalcemia

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- Smoking - Lack of exercise - High alcohol consumption (Nursing school ayyyy lmao) - Anorexia nervosa - Estrogen or testosterone deficiency - Poor nutrition - Obesity

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Osteomalacia in adults and rickets in children

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Calcium levels are low, it is not stored in bones, leading to soft, brittle deformed bones

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Osteoporosis

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Occurs with a lack of calcium - Holes are created in bones leading to a sponge-like appearance - Bones break easily

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Abnormal Calcium levels

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Treatment: - Calcium supplements - Vitamin D (assist in absorption of calcium) - calcitonin - Available in nasal spray or injectable form. It is naturally produced by thyroid to deposit calcium into bones

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calcitonin salmon

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Weird name - Side effects - Rhinitis, nasal irritation (nasal spray); hypertension, dizziness, injection site reactions, nausea, vomiting - Contraindication - hypersensitivity, pregnancy, and breastfeeding

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Estrogen Replacement Therapy

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- inhibit bone resorption of calcium › Examples- estradiol - Side effects - breast and uterine cancer, blood clots - Contraindications- history of breast or uterine cancer, pregnancy, thromboembolic disease

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Bisphosphonate

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Similar to estrogen, with fewer side effects › Examples- teriparatideacetate - Side effects -Headache, abdominal pain, bone pain -Contraindications- Hypersensitivity, hypocalcemia, esophageal stricture or achalasia

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Paget's Disease

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Weak and abnormally formed bones from excessive breakdown and formation of bone tissue. Pain, fractures and deformity is the result of the disease. - Treatment › Calcitonin and bisphosphonates › Calcium and vitamin D supplements as needed › NSAIDS › Exercise is encouraged to maintain bone health and joint mobility

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Osteoarthritis

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erosion of bone where bones meet at the joint

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Rheumatoid Arthritis

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chronic, autoimmune, progressive, systemic inflammatory disease that destroys synovial joints and other connective tissue, including major organs - Autoimmune condition

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Treatment For Arthritis

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- Nonsteroidal anti-inflammatory medications (NSAIDs) › Examples- aspirin, diclofenac with misoprostol, ibuprofen, naproxen › Side effects - GI ulcers and bleeding, GI upset, headache, tinnitus and hearing loss from toxicity, vision disturbances › Contraindication-Anemia, asthma, children with viral infections (aspirin), clotting disorders, disorders of the CV and GI systems , GERD, lactation, liver and kidney failure, pregnancy, sulfonamide hypersensitivity, thyroid disorders

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Gout

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Form of arthritis caused by build-up of URIC ACID in the joints. Uric acid is the byproduct of food metabolism and is excreted via the kidneys. Too much uric acid produced or not enough secreted causes this condition. - Sudden, severe attack of pain, inflammation and joint tenderness (usually joint of big toe) - Primarily affects men middle aged or older (Amat)

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Gout Treatment

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During acute attack - NSAIDs in high doses to halt attack and lower doses to prevent future attacks - For those unable to take NSAIDs: colchine is utilized for the pain of gout (Remember this and why they can't take nsaids) - Glucocorticoids › After acute attack ended - NSAIDS in lower doses to prevent future attacks - Anti-gout medications are given to lower uric acid levels in body - Examples - allopurinol, febuxostat - Side effects: Acute gouty attacks ,headache, GI symptoms - Contraindications-Hypersensitivity, uric acid kidney stones ,blood dyscrasias (disease/disorder), active peptic ulcer

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NSAIDS

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› Reduce inflammation in gout, osteoarthritis, and rheumatoid arthritis › Concerns - Increased GI bleeding - Renal and cardiac damage with long-term use › Take only as ordered › Long-term use monitored closely › Aspirin and other analgesics used topically and orally for pain - Topical medications containing medications such as menthol, salicylate and tromaline: Absorbine, Ben-Gay, Icy Hot, and capsaicin

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Cyclooxygenase-2 (COX-2) Inhibitors

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› Decrease the production of prostaglandins that cause pain and inflammation › Generally NSAIDs block both COX-1 & COX-2 enxymes › COX-2 inhibitors only block the COX-2 enzymes allowing the COX-1 enzyme to continue to be produced. COX-1 enzymes provide protection to the stomach and intestines reducing the risk of ulceration and GI bleed.

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celecoxib

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Example of a COX-2 inhibitor. Notice it has cox in the name - Side effects-Headache, insomnia, rash, abdominal pain, diarrhea, dyspepsia, upper respiratory infection - Contraindications- Hypersensitivity to sulfonamides Taking this May increase risk of heart problems. Remember that -Contraindications - Sulfa drug allergy. Remember that too

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Disease-Modifying Anti-Rheumatic Drugs (DMARDs)

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› Used in rheumatoid arthritis when other drugs ineffective › Suppresses the autoimmune response › Also suppresses immunity systemically › May slow down joint destruction although not a cure

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gold aurothioglucose (Solganal)

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A DMARD. Given by injection or orally. - Works best in early stages of disease - Rarely used because newer drugs more effective

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Rheumatrex (methotrexate), Neoral (cyclosporine), and Azulfidine (sulfasalazine)

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Newer, more effective DMARDs - Side effect- Hepatotoxicity, bone marrow suppression, GI disturbances, blood dyscrasias, pruritus ,rashes - Contraindications- Hepatic or renal impairment, pregnancy, breastfeeding, active infection, immunosuppression, known hypersensitivity, lupus, pulmonary fibrosis

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Drugs that DMARDS interact with

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Vaccines, NSAIDs, probenecid, corticosteroids Remember this, I bet you anything it will be on the test.

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Corticosteroids

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Mimic cortisol produced by adrenal gland to reduce inflammation › Used short-term due to decreased ability to fight infection during use › Examples - Decadron (dexamethasone) - Medrol (methylprednisolone)

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Phantom Limb Pain

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Impulse originating in brain and spinal cord does not recognize absence of limb › Some pts report pain diminishes over time others experience a lifetime of pain

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Phantom limb pain treament

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- Tricyclic antidepressants: alter chemical messengers and help with sleep › Elavil (amitriptyline) › Pamelor (nortriptyline) Notice those end with lines - Anticonvulsants: quiet damaged nerves to prevent or slow pain signals › Tegretol (carbamazepine) - Narcotics: dull pain perception center of brain › Roxanol (morphine)

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Musculoskeletal things to assess

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› Assess drug allergies. › Assess use of OTC drugs, herbs, etc. › Assess factors that interfere with activities of daily living (ADLs). › Assess pain and inflammation in joints. - Location, onset, intensity, duration › Inspect joints for immobility, deformities, limits of movement, swelling, and inflammation. Assess labs; renal, hepatic, and hematological functioning prior to NSAIDs, DMARDs, and anti-gout drugs.

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NSAID nursing implications

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- May cause GI bleeding, renal and cardiac damage with long-term use › Monitor CBC, BUN, sedimentation rates, and liver enzymes › Monitor for blood in stool and emesis - Monitor for adverse effects and toxicity - Therapeutic effects may take 3 to 4 weeks

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DMARD nursing implications

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- Suppress the immune system › Assess labs: CBC, hematocrit/hemoglobin, platelets - Assess for toxicity of DMARDs. › Monitor for elevation of liver function tests. - Assess for toxicity of gold products. › Decreased Hgb level, WBC level <4,000/mm⁣³, platelets <150,000/mm⁣ ³ › Hematuria, proteinuria, itching, severe diarrhea

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Cox-2 Inhibitor Nursing Implications

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- Assess patients for allergy to sulfonamides, aspirin, or NSAIDs. - Assess patients for skin rash frequently during therapy. › Discontinue immediately at first sign of rash; may be life-threatening; Stevens Johnson syndrome may develop

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Anti-gout nursing implications

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- Monitor joint pain and swelling. - Monitor serum and urine uric acid levels. - Monitor hematological, renal and liver function. › May ↓CBC, platelets › May ↑BUN, serum creatinine, and Cr may indicate nephrotoxicity › May ↑serum alkaline phosphatase, bilirubin, AST, ALT levels

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Bisphosphonates nursing implications

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- Assess serum calcium levels before and periodically during therapy. - In Paget's disease, monitor alkaline phosphatase before and during therapy. - In osteoporosis, assess for low bone mass before and during therapy

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Patient Teaching

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› Advise patient to not crush or chew sustained-release or enteric-coated tablets. › Instruct patient about adverse effects of aspirin, such as GI upset, GI bleeding, heartburn, flushing of face, bruising, rash. - Black tarry stools, gum bleeding, petechiae, or rash should be reported to health-care professional immediately. Physician may discontinue NSAIDs and aspirin several days before surgery (including dental surgery)

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How to reduce GI irritation caused by NSAIDS

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Take with food, milk, or antacids to decrease GI irritation.

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DMARD patient teaching

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Advise patient taking DMARDs to notify health-care professional if the following occur: - Skin rash, sore throat, fever, mouth sores, unusual bleeding or bruising, wheezing, hives › Instruct patient to report adverse effects of gold injections. - Headache, lethargy, pain at injection site

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Anti Gout patient teaching

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Advise patient taking anti-gout medications to increase fluid intake, and an alkaline diet may be ordered. - Fruits, except cranberries, prunes, plums - Vegetables, except corn - Milk - Nuts (almonds, chestnuts)

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bisphosphonates patient teaching

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- On the importance of taking these medications exactly as directed. - To eat a balanced diet and consult with health - care professional about the need for calcium and vitamin D supplements. - To discontinue medication and notify healthcare provider of pain or difficulty swallowing, new/worsening heartburn, retrosternal pain.

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The Nervous System

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› Divided into *Central nervous system (CNS) › Brain and spinal cord - neurons *Peripheral nervous system (PNS) › Include autonomic nervous system

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Nervous system medications

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› Used to treat - Pain - Anxiety - Depression - Mania - Insomnia - Convulsions - Schizophrenia › Act on CNS and peripheral nervous system › Most act at synapse to adjust message by neurotransmitters › Most cross blood-brain barrier - Serious side effects result

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Peripheral Nervous System

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› Somatic nervous system: voluntary - Muscles we have conscious control over › Autonomic nervous system: involuntary - Controls internal organs - Broken down into › Sympathetic nervous system: controls "fight or flight response" › Parasympathetic nervous system: helps body to rest and relax - Acetylcholine and norepinephrine are the two main neurotransmitters that affect the autonomic nervous systems

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Adrenergic

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a nerve cell that releases epinephrine or norepinephrine, which excites the body

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Cholinergic

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a nerve cell that releases acetylcholine which relaxes the body

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Adrenergic & Cholinergic

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› Both are naturally occurring substances - If not adequate to meet the body's needs, artificial equivalents are provided through medication

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Autonomic Drugs

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stimulate the sympathetic nervous system (excite) - Drugs are called Sympathomimetics or adrenergic antagonist

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Cholinergic Drugs

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stimulate the parasympathetic nervous system (calm) - Drugs are called Parasympathomimetics or cholinergic agonist

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Sympathomimetics (adrenergic agonists)

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- Used when body needs to be excited as they mimic the sympathetic nervous system - Stimulate the "fight or flight response" › Restore heart rhythm during cardiac arrest › Increase blood pressure during shock › Constrict capillaries if patient is bleeding › Dilate bronchioles of asthmatic › Dilate pupils for eye procedure

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Examples of sympathomimetics

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Levophed (norepinephrine), epinephrine › Side effects - Chest pain, fast heartrate, headache, in-crease blood glucose,nervousness, tissue death, tremors › Contraindication - Brain damage, CV and heart problems, glaucoma, hyperthyroidism › Interactions Adrenergic blockers ,CNS drugs - Use cautiously in patients with hypertension, MI, Afib, hypovolemia, children, pregnant and breastfeeding women.

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Adrenergic Blockers

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- Block the action of adrenergics - Have a parasympathetic effect - Used to calm (slow heart rate and relax blood vessels) › Treat cardiac arrhythmias › High blood pressure › Migraine headaches › Chest pain

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Adrenergic blockers are broken into these two groups based on muscles affected

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Alpha blockers and Beta blockers

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Alpha Blockers

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- Affect vascular smooth muscle - Treat hypertension and BPH › Examples - alfuzosin (uroxatral), doxazosin (Cardura), prazosin (minipress), tamsulosin (Flomax), and terazosin (hytrin)

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Beta Blockers

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- Block epinephrine - Slows heart rate and force - Treats: hypertension, migraines, glaucoma › Examples - acebutolol (spectral), atenolol (Tenormin), bisoprolol (zebeta), metoprolol (Lopressor), nadolol (corgard), nebivolol (bystolic), propranolol (Inderal LA)

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Alpha & Beta Blockers

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- Side effects - Confusion, decreased blood pressure, blood glucose, energy, heart rate - Contraindications- Asthma, atrioventricular block (heart block),chronic heart failure, diabetes, low blood pressure - Interactions- Alcohol, digitalis (digoxin), epinephrine, insulin, MAO inhibitors (drugs that inhibit the actions of MAO), theophylline, TCAs

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Parasympathomimetics (cholinergic agonists)

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- Mimic parasympathetic system - Rarely used due to severe decrease in heart rate and constriction of respiratory passages › Examples - Nerve gas - Pilocarpine(Pilopine) › Used to treat open-angle glaucoma › Increases drainage of fluid out of the eye reducing ocular pressure › Must be stopped several weeks before surgical procedures d/t increased risk of intraoperative breathing problems - Side effects-Bronchospasm; decreased heart rate, respirations, blood pressure; increased salivation, tears, and sweating; muscle cramps and weakness -Contraindications-Asthma, benign prostatic hypertrophy, cardiac disease, GI disorders, hyperthyroidism - Interactions Quinidine, procainamide

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Anticholinergics or cholinergic blockers

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- Inhibit parasympathetic nervous system - Promote "fight or flight" symptoms - Dry secretions - Used to treat › Asthma › Motion sickness › Preoperative relaxation › Neuromuscular blocking of spasms › Antidotes for insect stings › Cholinergic crisis - Extreme muscular weakness and respiratory depression - Commonly seen in patients with myasthenia gravis

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Cholinergic Example- Atro-pen(atropine

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› Side effects - Blurred vision, confusion, decreased GI motility, dilation of pupils, drying of secretions, fever, flushing, headache, increased heart rate › Contraindications- Asthma, cardiac arrhythmias, COPD, GI or GU obstruction, glaucoma, hypertension › Interactions - digoxin, nitroglycerin, TCAs

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Analgesics

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Reduce pain without eliminating feeling - Salicylates › Relieve mild-to-moderate pain › Reduce inflammation and fever › Improve CV flow by decreasing inflammation in blood vessels

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Aspirin

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ANALGESIC › Causes GI distress › Not to be used in children (Reyes syndrome- remember this) - Methyl salicylate (BenGay) › Topical anti-inflammatory used to irritate surface of skin which increases blood flow, thus decreases pain › Side effects - Coma, depression, dizziness, headache, drowsiness, increased bleeding time, bruising, GI bleeding, liver and kidney disorders, tinnitus, rash › Contraindications- Asthma, bleeding disorders, lactation, pregnancy, vitamin K deficiency › Interactions- Alcohol, antacids, anticoagulants, heparin, NSAIDs, insulin

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- acetaminophen (Tylenol

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ANALGESIC Decreases pain and fever › NO anti-inflammatory effect › Contained in many combination products such as cold medications › Combined with narcotics to treat moderate to severe pain - Oxycodone with acetaminophen (Percocet) - Side effects-Rash, urticaria (high dosages can cause liver failure) - Contraindications- Alcohol abuse, hypersensitivity, liver disease, malnutrition - Interactions- *Alcohol*, oral contraceptives, phenytoin, loop diuretics (water pill. Example-lasix-)

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ibuprofen (Motrin, Advil)

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ANALGESIC NSAID › Reduce pain, inflammation, and fever › May be combined with narcotics to relieve moderate to severe pain - Oxycodone with ibuprofen (Combunox) - Side effects - Blurred vision, constipation, dizziness, drowsiness, dyspepsia, edema, GI bleeding, headache, hepatitis, irregular heart rate, kidney disorders, prolonged bleeding, psychic disturbances, rash, tinnitus - Contraindications- Active GI bleeding, CV disease, hypersensitivity, liver disease, pregnancy, renal disease, ulcer - Interactions- Corticosteroids, salicylates, cyclosporine, anticoagulants, beta blockers, digoxin. So pretty much every other medicaiton we have been over, lol

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Narcotics

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- Stronger pain relievers - Suppress the central nervous system - Active ingredient in most is opium - Excess can cause › Decreased blood pressure, this may lead to risk of falls or death › *Decrease in respiration*

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Opioid Analgesics

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- Strongest pain relievers › Examples - morphine - codeine - fentanyl - Addiction potential with long-term use due to feelings of euphoria - Rarely addictive in patients who take them for relief of acute pain for a short period of time - Severe side effects › Side Effects- Decreased blood pressure, heart rate, and respirations; agitation, blurred vision, confusion, constipation, flushing, headache, over sedation, rash, restlessness, seizures, urinary retention › Contraindications- Lactation and pregnancy, patients with head injury, CNS depression, COPD, hypothyroidism, liver or kidney disease; used with caution in addicted patients, children, elderly patients, hypersensitive patients, suicidal patients › Interactions- Alcohol, antiemetics, antihistamines, antihypertensives, antiarrhythmics, muscle relaxers, psychotropics, sedative-hypnotics

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Limbic System of brain

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Integral to emotions, memory, and level of alertness - If not functioning problems occur with anxiety, insomnia, alertness, or seizure

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Anxiolytic medications (anxiety meds)

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- Reduce intensity of fears, dangers, and/or tension - Calming effect from mild sedation to coma - CNS depressants › Treat anxiety and restlessness

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Benzodiazapines

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- Treat anxiety, seizures, alcohol withdrawal symptoms, and muscle relaxation › Examples - Ativan (lorazepam) - Valium (diazepam) - Xanax (alprazolam) › Side effects - Agitation, amnesia, bizarre behaviors, con-fusion, decreased white blood cell count, depression, drowsiness, hallucinations, headache, lack of coordination, lethargy, over sedation, sensitivity to light, tremors › Contraindications- Not used in children, decreased vital signs, depression, lactation, pregnancy, suicidal ideation; observe for addiction and for evidence that the patient is considering suicide › Interactions - Alcohol, antiemetics, antihistamines, analgesics, CNS depressants, digoxin, *grapefruit juice*, muscle relaxants, phenytoin, psychotropics

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Insomnia Medications

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- Barbiturates: induce sleep by depressing CNS (slowing HR and respirations) - Non-narcotic benzodiazepine hypnotics › Promote sleep with few side effects (do not affect entire CNS) › Possible addiction risk › Examples - Ambien (zolpidem) Lunesta(eszopicolone) › Side effects - Outgoing or aggressive behavior, confusion, agitation, hallucinations, worsening of depression, suicidal thoughts or actions, memory loss, anxiety, sleep activity › Contraindications - Hypersensitivity to ingredients, pregnancy, lactation, children › Interactions - Alcohol, paroxetine, lorazepam, olanzapine

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› Barbiturates and anti-seizure medications

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-- Hydantoins such as phenytoin (Dilantin)-- › Delay sodium from crossing neural membranes, calming cells › Drug of choice for tonic-clonic (grand mal) and partial seizures --- Barbiturates such as phenobarbital-- › Used for tonic-clonic and febrile seizures --Succinimides such as ethosuximide (Zarontin) -- › Delay calcium moving over neurons to relax nerve cells › Drug of choice for absence (petit mal) seizures

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- Gamma-aminobutyric acid (GABA)

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› Naturally occurring neurotransmitter inhibitor, if present will decrease seizure activity › Example of this new drug is vigabatrin (Sabril)

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- Benzodiazepines such as diazepam (Valium)

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Intensifies effect of GABA transmitters in brain

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Other anti-seizure medication

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› Lamictal (lamotrigine) › Gabitril (tiagabine) › Topamax (topiramate) › Tegretol (carbamazepine) › Some medications that reduce seizures manage alcohol withdrawal symptoms by reducing anxiety symptoms. › Side effects - Multiple side effects different for each medication › Contraindications - Dilantin: hypersensitivity, caution in pregnancy, impaired liver function; Luminal: blood disorder porphyria, patients taking GHB; Zarontin: hypersensitivity to succinimides; Sabril: none Lamictal: hypersensitivity; Gabitril: hypersensitivity; Topamax: hypersensitivity, glaucoma; Tegretol: history of bone marrow depresion, hypersensitivity Valium: hypersensitivity, children under 6 months old, myasthenia gravis, severe respiratory or hepatic insufficiency, sleep apnea, acute narrow-angle glaucoma Interactions - Alcohol, salicylates, succinimides, sulfonamides, valproic acid, oral contraceptives, rifampin and many more than possible to list. Imagine that

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CNS Stimulants

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- Attention deficit disorder (ADD) and attention deficit with hyperactivity disorder (ADHD) - Common in both adults and children › Ineffectiveness of impulse control › CNS stimulants such as amphetaminedextroamphetamine (Adderall), pemoline (Cylert), and methylphenidate (Ritalin) have opposite effect of calming patient and increase ability to focus - Works as a stimulant in those without ADD or ADHD

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Amphetamines such as phentermine (Zantryl)

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› Prescribed for obesity › Given 30-60 min before meals to increase metabolism › Side effects - Nervousness, insomnia, irritability, seizures or psychosis; increased heart rate, blood pressure, and irregularity of heart rhythm; dizziness, headache, blurred vision, GI disorders, dependence › Contraindications - Nervousness, insomnia, irritability, seizures, or psychosis; increased heart rate, blood pressure, and irregularity of heart rhythm; dizziness, headache, blurred vision, GI disorders, dependence › Interactions - Antacids, anticoagulants, anticonvulsants, clonidine, TCAs

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Clinical Depression

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- Excess of sleeping and eating, inability to concentrate, avoidance of the companionship, decreased interest in activities, feelings of despair - Usually combination of genetic and environmental factors › When neurotransmitters are depleted, patient does not think clearly and mood is depressed.

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Anti-Depressants

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- Preserve neurotransmitters at the synapse - Three categories › MAOIs - monoamine oxidase inhibitors › TCAs- tricyclic antidepressants › SSRIs- selective reuptake inhibitors

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Monoamine oxidase inhibitors (MAOIs)

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- Inhibit enzyme that stops action of neurotransmitter - Rarely prescribed - Example: selegiline (Eldepryl) › Side effects - Nervousness, headache, stiff neck, increased heart rate and blood pressure, diarrhea, blurred vision › Contraindications - Known hypersensitivity, heart disease, hepatic or renal impairment, headaches, cerebrovascular disease, pregnancy, lactation › Interactions - Adrenergics, diuretics, antidepressants, CNS depressants, insulin, levodopa, foods containing tyramine, herbs such as St. John'swort - Requires dietary exclusion foods containing tyramine › causes critical HTN

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Tricyclic Anti Depressants

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› Three ring chemical structure that keeps norepinephrine and serotonin at nerve terminals › Drug of choice if patient has insomnia due to sedative side effect › amitriptyline - Many side effects - Drug of choice for severe depression and in-patient treatment - Side effects-Dry mouth, increased appetite, weight gain, blurred vision, drowsiness, dizziness, constipation, urinary retention, postural hypotension, irregular heart rhythms, headache - Contraindications- Pregnancy and lactation; cardiac, kidney, liver, and GI disorders; glaucoma; obesity; seizures - Interactions -Alcohol, CNS drugs, MAO inhibitors

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- Selective serotonin reuptake inhibitors (SSRIs)

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› Prevent serotonin from being used up at the synapse › Few side effects, thus usually first choice - Examples › Celexa (citalopram) › Prozac(fluoxetine) › Paxil (paroxetine) › Zoloft (sertraline) - Side effects - Sexual dysfunction, anorexia, diarrhea, sweating, insomnia, anxiety, nervousness, tremor, fatigue, dizziness, drowsiness, headache - Contraindications- Pregnancy and lactation; patients with thoughts of suicide, diabetes, bipolar disorders, eating disorders - Interactions - CNS drugs, MAO inhibitors, anticoagulants, beta blockers, antiarrhythmics

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Mood stabilizers (antimanic agents)

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- Stabilize extreme mood shifts seen in patients with bipolar disorder - Most common: Lithium › Lithium is a salt - Do not become dehydrated - Avoid table salt › Small therapeutic range - Blood levels drawn regularly - Fatal if toxic - Signs of toxicity › Drowsiness, blurred vision, confusion, sensitivity to light, tremors, muscle weakness, cardiovascular collapse, seizures, and coma - Side effects - GI distress, hypotension, cardiac irregularities, polyuria, tremors, thyroid problems - Contraindications- Seizure disorders; Parkinson's disease; CV, kidney, and thyroid diseases; dehydration, pregnancy, lactation - Interactions - NSAIDs, diuretics, ACE inhibitors, sodium salts

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Psychoses

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class of disorders characterized by abnormal thoughts, disorganized communication, and lack of interaction with environment.

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Frequent symptoms of psychoses

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delusions, hallucinations, paranoia, bizarre thoughts and behaviors.

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Antipsychotic medications (neuroleptics)

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› Treat abnormal actions and behaviors or psychoses such as talking and interacting with situation only they can see and hear › Used for other symptoms (nausea, vomiting, spasms, etc.); know why a patient is on this drug - Examples - chlorpromazine, Clozaril(clozapine), Haldol(haloperidol) - Side effects - ECG changes, hypotension, agitation, dizziness, sedation, drowsiness, dystonia, headache, constipation, dry mouth, photosensitivity, nausea - Contraindications -Hypersensitivity, cardiac arrhythmias, seizure disorder, thyroid disease, renal or hepatic impairment - Interactions - Anticholinergics, CNS depressants, alcohol, beta blockers, caffeine, antidepressants, lithium

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Dementia

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- Alzheimer's disease most common cause - Goal of therapy to prevent or slow down further deterioration... NO CURE - Cholinesterase inhibitor showing promise in slowing down progression › Aricept (donepezil HCL

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Parkinson's Disease

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Degenerative disorder of CNS - Neurons that produce dopamine die; muscle movements become disorganized - Lack of dopamine and increase in acetylcholine causes tremors, slow movement, rigid muscles, and balance problems. - Antiparkinsonian drugs focus on keeping dopamine and acetylcholine at the nerve synapse Michael J Fox

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- Antiparkinsonian drugs

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› Dopaminergic (replacing or increasing dopamine) - Eldepryl (selegiline), Requip (ropinirole), Sinemet (carbidopa/levodopa) › Cholinergic agents (those that inhibit the action of acetylcholine) such as biperiden (Akineton) - Side effects - Involuntary movements, loss of appetite, anxiety, confusion, depression, psychosis, decreased blood pressure, dizziness, fainting - Contraindications - Pregnancy and lactation, asthma and emphysema, cardiac disease, decreased blood pressure, peptic ulcer, diabetes, glaucoma - Interactions - Benzodiazepines, pyridoxine, phenothiazines, haloperidol, antihypertensives, phenytoin, vitamin B6, MAO inhibitors - Patients need a combination of drugs to achieve sufficient dopamine levels

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Drug Holiday

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Think Parkinsons. When dose cannot be increased or side effects intolerable, doctor orders drug holiday. Patient stops medications for a week or so and then restarts them at a lower dose with desired effects

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Anesthesia

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loss of sensation

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Local Anesthesia

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Creates a lack of feeling without a loss of consciousness › Creams: Emla (lidocaine/prilocaine) Aerosolspray:Exactacain(Benzocaine/butamben/tetracaine) › Otic: American otic (benzocaine) › Injectable solution: Xylocaine (lidocaine) › Classified as amides or esters - Amides last longer; adverse effects and allergies are rare - Esters have potential severe allergic reactions and thus are limited to topical preparations › Side effects - Heart block, hypotension, bradycardia, arrhythmias, restlessness, anxiety, dizziness, headache, nausea, vomiting › Contraindications - Known hypersensitivity, severe hypertension, shock, hematologic disorders, psychosis › Interactions - Sedatives, sulfonamides

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General Anasthesia

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Creates loss of both feeling and consciousness › IV infusion: midazolam(Versed), propofol(Diprivan) or ketamine (Ketalar) used initially for longer procedures followed by › Inhalation therapy: desflurane (Suprane), isoflurane (Forane), sevoflurane (Ultane) - Volatile; can depress respiratory and cardiovascular function - Use of IV medications allows lower doses of inhalation therapy, thus reduced risk of severe side effects with inhalation therapy - Side effects - Cardiopulmonary depression, confusion, sedation, nausea, vomiting, hypothermia, malignant hyperthermia - Contraindications - Known hypersensitivity, hepatic disorder, malignant hyperthermia, pregnancy, lactation - Interactions - CNS depressants, neuromuscular blockers, catecholamines

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Alcohol

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› CNS depressant - Interacts with many medications › Confusion, peripheral vasodilation, increased heart rate, electrolyte imbalances, decreased motor coordination, unsteady gait, and slurred speech - Prolonged use: damage to CNS and liver › S/S of chronic alcoholism - Irritability, tremors, GI disorders, frequent falling accidents, blackouts, memory loss, confusion, neural and muscular weakness, and conjunctivitis. › Treatments: disulfiram (Antabuse), behavior modification, vitamin B injections, and dietary changes

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Things To assess

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Assess drug allergies. › Assess pain. - Location, onset, intensity, duration › Assess physical and emotional status prior and during psychotropic drug therapy. › Assess neurological function and level of consciousness. › Assess sleep patterns › Assess for suicide tendencies during psychotropic drug therapy. › Assess motor responses. - Agitation, trembling › Assess autonomic responses. - Cold, clammy skin; sweating; pallor › Assess nutritional status. › Assess use of OTC drugs, herbs, etc › Assess activities of daily living (ADLs) and movement in patient taking antiparkinsonian drugs. › Assess patient's history of seizure disorder. - Duration/frequency, seizure activity intensity, precipitating factors › Assess for CNS toxicity in the elderly. - Confusion, hallucinations, excessive sedation › Assess for addiction tendencies. › Assess for sexual dysfunction (erectile dysfunction, decreased libido). › Assess vital signs. › HR, BP, and RR may increase with adrenergics, CNS stimulants . › HR, BP, and RR may decrease with narcotics, barbiturates, cholinergics, adrenergic blockers.

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Serum drug levels to assess during therapy

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-**** Lithium **** - Phenobarbital - Phenytoin (Dilantin) › Lithium: 0.6 to 1.2 mEq/L for long-term control › Phenobarbital: 10 to 40 mcg/mL › Phenytoin: 10 to 20 mcg/mL

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What to monitor in lithium patients

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MONITOR I&O - Patient needs 2,000 to 3,000 mL/day. - Monitor weight every 3 months

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Patient teaching that isn't common sense

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› Advise patient taking MAOIs to avoid foods containing tyramine, which may cause critical hypertension. - Avocados, bananas, chocolate, dairy, hot dogs, wine, yeast, raisins, and others › Advise patient taking anxiolytics to avoid grapefruit juice. - May affect metabolism of drug

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