Term
| Adaptation of the CNS to Prolonged Drug Exposure |
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Definition
Increased therapeutic effects – takes longer for drugs to work.
Decreased side effects – over time.
Tolerance – decreased response over time
Physical dependence – discontinuation = withdrawl syndrome |
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Term
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Definition
Mechanism of Action – Reversible blockade of adenosine receptors.
Decreases drowsiness and fatigue.
Therapeutic uses: Neonatal apnea, wakefulness
S/E: palpitations, dizziness, vasodilation, bronchodilation, diuresis. |
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Term
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Definition
Patho: Neuromuscular disorder with muscle weakness and fatigue. Autoimmune response attacking nicotinic M receptors on skeletal muscles.
S/S:ptosis, difficulty swallowing, & weak muscles
Treatment: Cholinesterase Inhibitors ie: Pyridostigime (Mestinon)
**NO Cure – treat the symptoms |
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Term
Pyridostigime (Mestinon)
Myasthenia Gravis |
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Definition
Mechanism of Action – Prevent ACh inactivation = increased muscle strength.
Therapeutic use: symptomatic relief of muscle weakness
S/E: Increase Ach at muscarinic junctions– tremors, Increases GI motility, Inc. secretions.
**Modify dosage based on response**
ALWAYS assess for difficulty swallowing. |
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Term
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Definition
neurodegenerative disorder of the extrapyramidal system associated with disruption of neurotransmission within the striatum of the brain. *Regulates voluntary movements*
characterized by dyskinesias or TRAP (Tremor at rest, Rigidity, & Bradykinesia or akinesia (absence of movement) & Postural instability)
Other S/S: Dementia, Depression, & Impaired memory.
Proper function of the striatum requires a balance between the neurotransmitters dopamine and acetylcholine (ACh). 70-80% neurons lost or 5-20 years.
Imbalance between dopamine (inhibitory) and ACh (excitatory) results from degeneration of the neurons that supply dopamine to the striatum. Underlying cause = loss of dopaminergic neurons in the substantia nigra.
Treatment of choice = Levodopa + Carbidopa= Sinemet |
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Term
Parkinson’s Disease
Therapeutic goals |
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Definition
Improve patient’s ability to carry out activities of daily life – provide symptomatic relief but no cure.
Drug selection and dosages are determined by extent to which PD interferes with work, dressing, eating, bathing, etc |
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Term
Levodopa (Dopar)
Dopaminergic agent
Parkinson's |
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Definition
stimulate dopamine
By far the most commonly used for PD
Promote activation of dopamine receptors
Levodopa: Promotes dopamine synthesis- most commonly used.
Dopamine agonists: Stimulate dopamine receptors directly. 1st line drug in younger pt. due to more tolerance of side effects (daytime drowsiness & postural hypotension).
Adverse effects – N/V, drowsiness, dyskinesia, (head bobbing and tics), Postural hypotension, & psychosis (Clozapine – antipsychotic can reduces these symptoms)
Drug holiday – ie: 10 days stop med. Should be supervised in hospital due to immobilization.
Drug interactions – MAO inhibitors = hypertensive crisis, Pyridoxine (B6) enhance destruction of Levodopa.
Administer without food or low protein meal due to effect on absorption. |
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Term
Trihexyphenidyl (artane)
Anticholinergic agent |
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Definition
MOA:
Prevent activation of cholinergic
receptors or blockade of muscarinic
receptors
Side effect:
N/V, (Atropine like effect) – dry mouth, blurred vision, mydriasis, urinary retention, constipation. |
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Term
Amantadine(Symmetrel)
Antiviral
Parkinson's |
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Definition
Promotes dopamine release and prevents reuptake.
Blockade of cholinergic receptors
2nd line drug.
See responses in 2-3 days which diminish in 3-6 mo.
Adverse effect – CNS effects (confusion, lightheadedness, anxiety.
Atropine like effects = Blurred vision, urinary retention, & dry mouth.
Discoloration of skin – Livido reticularis
Adverse effect – CNS effects (confusion, lightheadedness, anxiety |
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Term
| CARbidopa-levodopa (Sinemet) |
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Definition
| helps decrease peripheral degradation and allows Levodopa to cross blood brain barrier. |
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Term
Parkinson's Drug Therapy
Nursing Implications |
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Definition
Levodopa may be taken with food to dec. N/V, although high protein foods should be avoided.
Benefits may take weeks to months
Forewarn about “on-off” phenomenon
Levodopa induced movement disorders
Excessive cardiac stimulation or dysrhythmias
Hypotension (dizziness, lightheadedness) sit or lie down if this occurs. Move slowly & increase Na and H2O consumption
Psychosis not uncommon – hallucinations
Never D/C abruptly, must be tapered off. |
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Term
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Definition
seizure disorder
Brain condition characterized by recurrent seizures.
Group of disorders characterized by excessive excitability of neurons in the CNS. |
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Term
| Antiepileptic Drugs (AED’s) |
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Definition
Effects
Suppress discharge of neurons within a seizure focus (electrical storm)
Suppress propagation of seizure activity from the focus to other areas of the brain
Mechanisms of action:
Suppression of sodium influx
Suppression of calcium influx
Antagonism of glutamate
Potentiation of GABA
Diagnosis and drug selection – specific drugs for specific types
Drug evaluation – Trial period
Monitoring plasma drug levels- guide dosage adjustments
Promoting patient adherence – may need a med chart.
Withdrawing antiepileptic drugs- should be withdrawn slowly over a period of 6 weeks to several months. |
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Term
Phenytoin (Dilantin)
Antiepileptic |
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Definition
Mechanism of action: Stabilizes neuronal membranes, therefore limiting seizure activity by selective inhibition of sodium channels
Therapeutic Use: All major seizures
Varied oral absorption given IV for emergencies (status epilepticus)
Half-life: 8 to 60 hours
Therapeutic level – 10-20 mcg/ml
Toxic level: 30-50 mcg/ml
Adverse effects
CNS
Nystagmus – twitching eyes
Sedation
Ataxia – staggering gait
Diplopia – double vision or blurred vision
Cognitive impairment or stroke like appearance
Gingival hyperplasia – tender swelling gums, bleeding
Skin rash – measles like rash or Stevens Johnson Syndrome.
Effects in pregnancy - teratogen
Cardiovascular effects- dysrhythmias
Drug interactions
Decreases the effects of oral contraceptives, warfarin, and glucocorticoids
Increases levels with diazepam (Valium), isoniazid (INH), cimetidine (Tagamet), alcohol, valproic acid.
Can increase serum glucose levels.
with meals, shake bottle well, good oral hygiene. |
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Term
Carbamazepine [Tegretol]
Antiepileptic |
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Definition
Uses
Epilepsy – not absence seizures
Bipolar disorder
Trigeminal and glossopharyngeal neuralgias
Adverse effects
Neurologic effects: nystagmus, ataxia (< dilantin)
Hematologic effects: leukopenia, anemia, thrombocytopenia
– Birth defects
Hypo-osmolarity- monitor serum sodium and edema.
Dermatologic effects: rash, photosensitivity reactions
Take with meals, forewarn about hematologic abnomalities (fever, sore throat, weakness, petechiae), do NOT take with grapefruit juice.
Drug interactions
Decreases the effects of oral contraceptives, & coumadin (warfarin).
Grapefruit juice effect. |
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Term
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Definition
Management of Status Epilepticus
IV benzodiazepine
Tonic-clonic seizures lasting 20-30 min. |
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Term
Nursing Implications
Antiepileptic Drugs |
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Definition
Take AED’s exactly as prescribed
Seizure frequency chart
Avoid driving & medic alert bracelet
Forewarn about CNS depression
Never stop abruptly – must be weaned! |
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Term
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Definition
Somatic (bones, joints, & muscles), Visceral (organs), Central, Cancer
Neuropathic, Psychogenic, Phantom |
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Term
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Definition
More common w/ cancer)
Results from injury to tissues
Two forms: somatic (localized, sharp) or visceral pain (diffuse, aching |
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Term
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Definition
Results from injury to peripheral nerves (burning, shooting, numb, cold)
Responds poorly to opioids but respond well to adjuvant analgesics such as antidepressants & anticonvulsants |
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Term
Management Strategy
ABCDE |
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Definition
ASK about pain regularly
Assess pain systematically
BELIEVE the patient and family in their reports of pain and what relieves it
CHOOSE pain control options appropriate for the patient, family, and setting
DELIVER interventions in a timely, logical, coordinated fashion
EMPOWER patients and their families
Enable patients to control their treatment to the greatest extent possible |
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Term
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Definition
Ongoing Evaluation
Reassess frequently
Evaluate after sufficient time has elapsed
Alert for the development of new pain
Barriers to Assessment
Inaccurate reporting by patient
Under-reporting by patient
Language and cultural barriers |
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Term
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Definition
Block impulses along axons
Mechanism of action – block sodium channels
Suppresses pain without generalized CNS depression like general anesthesia
Use with vasoconstrictors (Epinephrine) which decreases local blood flow and thereby delays systemic absorption of anesthetic. It prolongs anesthesia and reduces the risk of toxicity.
Adverse effects
CNS excitation followed by depression
Cardiac – bradycardia & heart block |
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Term
Procaine (Novocain)
Local Anesthetic |
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Definition
| Available in solution (1%, 2%, and 10%) Injection only |
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Term
Lidocaine (xylocaine)
Local Anesthetic |
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Definition
| Preparations : Cream, Ointment, Jelly, Solution, Aerosol, Patch |
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Term
| Alkylphenol- Propofol (Diprivan) |
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Definition
Intravenous sedative-hypnotic agent commercially introduced in the United States in 1989 by Zeneca Pharmaceuticals.
It was the first of a new class of intravenous anesthetic agents - the alkylphenols.
Propofol – (Diprivan) used for induction & maintenance of anesthesia. Adverse effects – resp. depression & hypotension. **High risk for bacterial infection due to mixture supplied in** Discard after 6 hours.
DIPRIVAN is indicated for:
Induction of general anesthesia in adult patients and pediatric patients > 3 years of age
Maintenance of general anesthesia in adult patients and pediatric patients >2 months of age
Intensive Care Unit(ICU) Sedation for intubated, mechanically ventilated adults. |
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Term
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Definition
Mechanism of Action for Anxiety
Low dosages
Decrease anxiety by acting on the limbic system and other areas of the brain that help regulate emotional activity
Calm the patient without causing drowsiness
Therapeutic Uses
five principal benzodiazepine actions:
sedative/hypnotic Lorazepam (Ativan) & Temazepam (Restoril)
muscle relaxant
Anxiety
amnestic
Anticonvulsant –Diazepam (Valium)
Benzodiazepines – unconsciousness & amnesia ie: Valium onset 1 min., & Midazolam (Versed) conscious sedation. S/E: Cardioresp. Depression.
B’s used to treat anxiety include: alprazolam, chlordiazepoxide, conazepam, diazepam (Valium), halazepam, lorazepam (ativan), oxazepam
Short-acting barbiturates- commonly preferred over Benzo’s |
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Term
Nursing Implications
Local Anesthetics |
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Definition
Self-inflicted injury – due to lack of pain sensation.
Spinal headache & urinary retension – Posture dependent and will be minimized by remaining supine for 12 hours & should void within 8 hours |
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Term
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Definition
| - A general term defined as any drug, natural or synthetic, that has actions similar to those of morphine |
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Term
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Definition
| analgesia, resp. depression, euphoria, & sedation |
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Term
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Definition
|
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Term
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Definition
|
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Term
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Definition
Meperidine (Demerol) (toxic metabolite accumulates with prolonged use)
Morphine
Fentanyl (Wildnil or Sublimaze)
Methadone (Dolophine) |
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Term
Moderate to Strong
Opioid agonists |
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Definition
Codeine II
Hydrocodone (Vicodin or Lortab) Sch. III
Oxycodone (Percocet) Schedule III
Propoxyphene (Darvocet-N) Sch. IV
Pure opioid agonists- Schedule II (High abuse liability) Table 28-3, pg 263.
Activate mu receptors and kappa receptors |
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Term
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Definition
Narcan
Bind to Mu receptors
Act as antagonists at mu and kappa receptors = Naloxone (Narcan) – stops overdose |
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Term
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Definition
Reduce pain by binding to opiate receptor sites in the peripheral nervous system and CNS
When they stimulate the opiate receptors – mimics the effects of endorphins (body’s naturally occurring opiates for pain relief)
Analgesia (severe, chronic, and acute) & Sedation
Cough Suppression
Dilate blood vessels
Adverse Effects
Respiratory depression (Mu receptors on medulla oblongata)
Constipation (slows peristalsis), N/V
Hypotension – peripheral Vasodilation
Monitor patient for:
Over sedation, seizures, dizziness, nightmares, bradycardia, shock, cardiac arrest, thrombocytopenia, and respiratory depression, pinpoint pupils, & coma. |
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Term
| Clinical Use of Opioids- Dosing Guidelines |
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Definition
Assessment of pain
Pain status should be evaluated prior to opioid administration and about 1 hour after.
Dosage determination
Opioid analgesics must be adjusted to accommodate individual variation.
Dosing schedule
As a rule, opioids should be administered on a fixed schedule. Ie: Q4 hours instead of PRN
Avoiding withdrawal – 20 days or more, physical dependence may develop |
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Term
Patient-Controlled Analgesia
(PCA) |
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Definition
Drug selection and dosage regulation – Morphine most common & Demoral
Comparison of PCA with traditional intramuscular therapy- maintains plasma levels more consistently
Patient education- decrease fear of overdose, explain lag time of 10 min., activate prophylactically prior to treatments or physical therapy. |
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Term
| Opioid Agonists – Nursing Implications |
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Definition
Teach patient
Take drug exactly as prescribed – Must assess resp. prior to giving. (12 or < HOLD)
Be careful getting out of bed and walking
Avoid alcohol while taking Opioids
Increase fiber and use a stool softener while on Opioids
Breathe deeply, cough, and change positions every 2 hours to avoid respiratory complications
Report continued pain
Wait 4-6 hours after ingestion to breast feed.
Give IV slowly over 4-5 minutes.
No ceiling response – wean slowly |
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Term
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Definition
Metabolized to normeperidine
Normeperidine
Toxic metabolite
Longer ½ life than meperidine
Accumulates in renal failure
May cause CNS excitation
Administration >48 hours increases risk for neurotoxicity and seizures
Adverse Effects
Tremors
Palpitations
Tachycardia
Delirium
Neurotoxicity and seizures |
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Term
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Definition
Dilates the smooth muscle of the GI and genitourinary tracts
Dilates the peripheral blood vessels
Decreased pre-load
>blood in periphery
< returned to heart
Relieves shortness of breath
Pulmonary edema
Left-sided heart failure
Adverse Effects
Decreased rate and depth of breathing
Periodic, irregular breathing
May trigger asthmatic attacks in susceptible patients
Flushing, orthostatic hypotension, pupil constriction |
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Term
| Moderate to Strong Opioid Agonists – less analgesia & lower abuse potential |
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Definition
Codeine
Actions and uses – mild to moderate pain, effective cough suppressant.
Oxycodone - (OxyContin, Roxicodone, Combunox (Ibuprofen), Percodan (ASA), Percocet (Tylenol))
Analgesic actions equivalent to codeine
A long-acting analgesic
Hydrocodone – (Lortab, Vicodin)
Analgesic actions equivalent to codeine
Propoxyphene (Darvon, Darvocet)
Analgesic actions equivalent to ASA |
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Term
| Other Strong Opioid Agonists |
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Definition
Fentanyl – 100 x’s stronger than Morphine
Parenteral – surgical anesthesia
Transdermal – Persistent severe pain
Transmucosal – (Actiq) lozenge on stick
Alfentanil and sufentanil
Remifentanil
Meperidine (Demerol) mod – severe pain
Methadone – relieve pain and treat opioid addicts
Heroin- high abuse liability.
Hydromorphone (Dilaudid) |
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Term
Acetaminophen (Tylenol)
Non-opioid |
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Definition
Over the Counter Medication
Analgesic and antipyretic
Absorbed rapidly and completely from the GI tract
Absorbed well from mucous membranes of the rectum
Widely distributed in body fluids and readily crosses the placenta
Metabolized by the liver and excreted by the kidneys
Therapeutic Uses
Reduces pain and fever
often the drug of choice for children for fever and flu-like symptoms
Does not affect inflammation or platelet function
May potentiate Warfarin and increase INR
Mechanism of Action
Pain control - not well understood
May work in CNS by inhibiting prostaglandin synthesis and in the peripheral nervous system in some unknown way
Anti-Pyretic
Acts directly on the heat regulating center in the hypothalmus
Antidote – Mucomyst dilluted and given via NG tube.
Patient Teaching
Consult physician
before giving to a child younger than 2 y/o
Children
> 5 consecutive days or
Adults
> 10 consecutive days
High doses or unsupervised long-term use can cause liver damage
Excessive alcohol intake may increase risk of hepatotoxicity
Don’t exceed the total recommended dose of acetaminophen (including OTC meds) 4 gm per day.
Loop diuretics may be reduced when taken with Acetaminophen |
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Term
| Physical Dependence, Abuse, and Addiction as Clinical Concerns |
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Definition
Definitions
Tolerance – Specific doses produces a smaller effect than when began treatment.
Physical dependence – abstinence syndrome will occur with immediate withdrawal
Abuse – why it is taken? Pain relief vs. euphoria
Addiction – compulsive drug use.
Minimizing fears about physical dependence – stick to therapeutic use of opioids.
Minimizing fears about addiction – we treat the pain.
Balancing the need to provide pain relief with the desire to minimize abuse- administer the lowest effective dose with good judgement |
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Term
| Drug Therapy – 3 Types of Analgesics |
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Definition
Opioid analgesics- oxycodone & morphine
Nonopioid analgesics – NSAIDS & acetaminophen
Adjuvant analgesics – Tricyclic Antidepressant: amitriptyline (Elavil), Anti-Seizure: carbamazepine (Tegretol) |
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Term
|
Definition
Step 1—mild to moderate pain
Nonopioid analgesic
NSAIDS and acetaminophen
Step 2—more severe pain
Add opioid analgesic, oxycodone, hydrocodone
Step 3—severe pain
Substitute powerful opioid—morphine, fentanyl |
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Term
| JCAHO Pain Management Standards |
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Definition
Purpose is to make assessment and management of pain a priority in healthcare
Compliance is mandatory |
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Term
| Pain Management in Young Children |
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Definition
Assessment
Verbal children
Preverbal and nonverbal children
Treatment |
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Term
| Pain Management in the Elderly |
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Definition
Heightened drug sensitivity
Undertreatment of pain
Misconceptions
Elderly are insensitive to pain
Elderly can tolerate it well
Elderly are highly sensitive to opioid side effects
Increased risk of side effects and adverse interactions |
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Term
|
Definition
| complement the effects of opioids |
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Term
|
Definition
NSAIDs (aspirin, ibuprofen)
Pain relief, suppression of inflammation & reduce fever
SE: Gastric upset/ulceration, acute renal failure & bleeding |
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Term
| Oxycodone - (OxyContin, Roxicodone, Combunox (Ibuprofen), Percodan (ASA), Percocet (Tylenol)) |
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Definition
Analgesic actions equivalent to codeine
A long-acting analgesic
Schedule III |
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Term
| Hydrocodone – (Lortab, Vicodin) |
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Definition
Analgesic actions equivalent to codeine
Sch. III |
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Term
| Propoxyphene (Darvon, Darvocet) |
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Definition
Analgesic actions equivalent to ASA
Sch. IV |
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Term
|
Definition
Actions and uses – mild to moderate pain, effective cough suppressant.
Schedule II |
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Term
|
Definition
100 x’s stronger than Morphine
Parenteral – surgical anesthesia
Transdermal – Persistent severe pain
Transmucosal – (Actiq) lozenge on stick |
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Term
| Patient Education- Opioids |
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Definition
General issues
Nature and causes of pain
Assessment and the importance of honest self-reporting
Plans for drug and nondrug therapy
Drug therapy
Tolerance
Physical dependence and addiction
Fear of severe side effects
Nondrug therapy
Focuses on psychosocial interventions |
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