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DRUGS AFFECTING THE CENTRAL NERVOUS SYSTEM

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DRUGS AFFECTING THE CENTRAL NERVOUS SYSTEM Chap. 11, 13, 15, 16, 17 * Winter 2013 * * * * * * * * * * Signs and symptoms Shuffling gait Fine tremors Muscle rigidity ... – PowerPoint PPT presentation

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Title: DRUGS AFFECTING THE CENTRAL NERVOUS SYSTEM


1
DRUGS AFFECTING THE CENTRAL NERVOUS SYSTEM Chap.
11, 13, 15, 16, 17
2
REVIEW
  • BRAIN AND SPINAL CORD
  • PRIMARY FUNCTION CONTROLS AND COORDINATES THE
    BODY AND BODY SYSTEMS
  • DRUGS CAN ALTER BEHAVIOR / CONSCIOUSNESS
  • BY STIMULATING OR DEPRESSING CNS FOR DESIRED
    AFFECT



3
Neurotransmitters
  • A substance (norepinephrine, acetylcholine,
    dopamine, or hormone) that is released when the
    terminal axon of a presynaptic neuron is excited
    and acts by exciting or inhibiting a target cell.

4
CNS REVIEW
  • DEPRESS CNS
  • DRUGS CAN CAUSE THE BRAIN TO BE CALM ? SLEEP ?
    ANESTHESIA ? COMA ? DEATH
  • STIMULATE CNS DRUGS CAN
  • STIMULATE RESPIRATIONS
  • KEEP A PATIENT AWAKE
  • DEPRESS APPETITE

5
PAIN (Box 11-2 pg 155)
  • ACUTE V. CHRONIC PAIN
  • ACUTE OCCURS QUICKLY, IS SHORT IN DURATION
  • USUALLY CAN BE RESOLVED
  • CHRONIC LONGER LASTING, USUALLY AT LEAST 3
    MONTHS IN DURATION
  • POSSIBLY WILL NOT GO AWAY
  • PAIN IS THE SIXTH (6th) VITAL SIGN

6
  • CAUSES OF PAIN / DISCOMFORT
  • TRAUMA
  • TISSUE DAMAGE
  • PRESSURE ON TISSUE AND NERVES
  • INFLAMMATION OF TISSUES AND NERVES

7
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8
MECHANISMS TO CONTROL PAIN
  • MASSAGE
  • POSITION CHANGE
  • BIOFEEDBACK
  • EXERCISE
  • NON-OPOID ANALGESICS
  • ANTIDEPRESSANTS
  • Opioid ANALGESICS
  • STEROIDS

9
Opioid Analgesics
  • Pain relievers that contain opium, derived from
    the opium poppy or chemically related to opium
  • Very strong pain relievers
  • Very addicting

10
Opioid Analgesics (contd)
  • codeine sulfate
  • meperidine HCl (Demerol)
  • methadone HCl (Dolophine)
  • morphine sulfate
  • propoxyphene HCl
  • hydromorphone
  • oxycodone
  • fentanyl
  • Many Others

11
Agonists
  • Bind to an Opioid receptor in the brain
  • Cause an analgesic response (reduction of pain
    sensation)

12
Opioid AnalgesicsIndications
  • Main use to alleviate moderate to severe pain
  • Often given with adjuvant drugs to assist primary
    drugs with pain relief
  • Muscle relaxant
  • Sedative
  • Alternate with non-narcotic analgesic

13
Opioid AnalgesicsIndications (contd)
  • Opioids are also used for
  • Cough center suppression
  • Treatment of diarrhea
  • Balanced anesthesia

14
Opioid Analgesics Contraindications
  • Known drug allergy
  • Severe asthma
  • Use with extreme caution if
  • Respiratory insufficiency
  • Elevated intracranial pressure
  • Morbid obesity
  • Sleep apnea
  • Paralytic ileus

15
Opioid Analgesics Adverse Effects
  • Euphoria
  • CNS depression
  • Leads to respiratory depression
  • Most serious adverse effect
  • Nausea and vomiting
  • Urinary retention
  • Diaphoresis and flushing
  • Pupil constriction (miosis)
  • Constipation
  • Itching

16
Opioids Opioid Tolerance
  • A common physiologic result of chronic Opioid
    treatment
  • Result larger dose is required to maintain the
    same level of analgesia

17
Opioids Physical Dependence
  • Physiologic 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)

18
Opioids Psychological Dependence
  • 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

19
Opioids
  • Misunderstanding of these terms leads to
    ineffective pain management and contributes to
    the problem of undertreatment
  • Physical dependence is seen when the Opioid is
    abruptly discontinued or when an Opioid
    antagonist is administered
  • Opioid withdrawal/Opioid abstinence syndrome

20
Antagonists
  • Reverse the effects of these drugs on pain
    receptors
  • Bind to a pain receptor and exert no response
  • Also known as competitive antagonists

21
Toxicity and Management of Overdose
  • ANALEPTICS
  • naloxone (Narcan)
  • naltrexone (Revia)
  • These drugs bind to opiate receptors and prevent
    a response
  • Used for complete or partial reversal of
    Opioid-induced respiratory depression
  • Regardless of withdrawal symptoms, when a patient
    experiences severe respiratory depression, an
    Opioid antagonist should be given.

22
NURSING CONSIDERATIONS WHEN GIVING NALOXONE
  • ADMINISTER MEDICATION VERY SLOWLY
  • ANTICIPATE PATIENT RESPONSE TO TREATMENT
  • MONITOR PATIENT VERY CLOSELY
  • VITAL SIGNS, RESPIRATORY RATE, PULSE OX
  • CONTINUE TO MONITOR CLOSELY
  • ½ LIFE OF NARCAN 60 90 MINUTES
  • ½ LIFE OF MORPHINE 2 4 HOURS

23
Toxicity and Management of Overdose
  • Symptoms of Abstinence Syndrome
  • Pulmonary edema
  • Withdrawal symptoms
  • Nausea
  • Vomiting
  • Agitation
  • Anxiety
  • Confusion
  • Pain

24
Opioid AnalgesicsNursing Implications
  • Oral forms should be taken with food to minimize
    gastric upset
  • Ensure safety measures, such as keeping side
    rails up, to prevent injury
  • Withhold dose and contact physician if there is a
    decline in the patients condition or if vital
    signs are abnormal, especially if respiratory
    rate is less than 10 to 12 breaths/min

25
Opioid Analgesics Nursing Implications (contd)
  • Check dosages carefully
  • Follow proper administration guidelines for IM
    injections, including site rotation
  • Follow proper guidelines for IV administration,
    including dilution and rate of administration

26
Opioid Analgesics Nursing Implications (contd)
  • 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

27
Monitor for Therapeutic Effects
  • Decreased complaints of pain
  • Decreased severity of pain
  • Increased periods of comfort
  • Improved activities of daily living, appetite,
    and sense of well-being
  • Decreased fever (acetaminophen)

28
Monitor for Adverse Effects
  • Contact physician immediately if vital signs
    change, patients condition declines, or pain
    continues
  • Respiratory depression may be manifested by
    respiratory rate of less than 10 breaths/min,
    dyspnea, diminished breath sounds, or shallow
    breathing

29
Prototype Morphine
  • Opioid agonist
  • Schedule II narcotic
  • Pregnancy Category C
  • Given orally or parenterally
  • Half life 2 4 hours
  • Used for severe pain (chronic or acute)

30
Morphine
  • Indications
    Relief of severe/acute/chronic pain, analgesia
    during labor.
  • Morphine is the drug of choice for pain due to
    Myocardial Infarction, dyspnea from pulmonary
    edema not resulting from chemical respiratory
    irritant.

31
Morphine
  • Contraindications
    Severe respiratory depression, acute/severe
    asthma, severe hepatic/renal impairment. Used
    with extreme caution in COPD, hypoxia, head
    injury, increased intracranial pressure

32
Morphine
  • Drug-Drug Interactions
  • Use with EXTREME CAUTION in patients taking MAOIs
  • Increased CNS depression and hypotension with
    alcohol, sedatives, hypnotics, barbiturates,
    tricyclic antidepressants, antihistamines
  • May INCREASE the anticoagulant effect of Warfarin
    (Coumadin)

33
ADVERSE REACTIONS TO NARCOTIC PAIN MEDICATION
  • CNS
  • Impaired judgment
  • Drowsiness (decrease in LOC)
  • Decrease in respiratory effort

34
ADVERSE REACTIONS TO NARCOTIC PAIN MEDICATION
  • Gastrointestinal
  • Dry mouth
  • Nausea, vomiting
  • Decreased intestinal peristalsis


35
ADVERSE REACTIONS TO NARCOTIC PAIN MEDICATION
  • CARDIOVASCULAR (CV)
  • Bradycardia
  • Vasodilation
  • Tachycardia
  • Flushing

36
ADVERSE REACTIONS TO NARCOTIC PAIN MEDICATION
  • GENITOURINARY
  • URINARY RETENTION
  • ALLERGIC
  • RASH
  • ITCHING
  • RESPIRATORY
  • RESPIRATORY DEPRESSION

37
Opioid HERBAL INTERACTIONS
  • Concurrent use of
  • Kava kave
  • Valerian root
  • Camomile
  • Can result in increased CNS depression

38
ROUTES OF ADMINISTRATION FOR NARCOTIC ANALGESIA
  • IV
  • PO
  • IM
  • IN (intra-nasal)
  • SC (SQ)
  • TRANSDERMAL
  • EPIDURAL
  • RECTAL

39
ROUTES OF ADMINISTRATION FOR NARCOTIC ANALGESIA
  • INTRAVENOUS
  • Effective within 5 10 min. Of administration
  • Most common route (in hospitalized patients)
  • Frequently administered as patient controlled
    analgesia (PCA)

40
PCA PATIENT CONTROLLED ANALGESIA
  • DOUBLE LOCK SYSTEM
  • TIME
  • AMOUNT
  • NURSE MUST DOCUMENT
  • AMOUNT USED
  • EFFECTIVENESS
  • VITAL SIGNS INCLUDING RESPIRATIONS
  • ANY UNTOWARD EFFECTS
  • TEACH FAMILY ABOUT USE AND ABUSE


41
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42
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43
EPIDURAL PAIN MANAGEMENT
  • Catheter is placed into the epidural space to
    inject a narcotic or anesthetic drug
  • Obstetrics
  • Surgical procedures
  • Pain management
  • Catheter may be left in for follow up injections
    by physician or patient controlled analgesia

44
TRANSDERMAL PATCH
  • SEVERE PAIN CHRONIC PAIN
  • FENTANYL PATCH (DURAGESIC) MOST COMMON
  • Slower onset but more consistent pain relief
  • Patch usually changed every 72h
  • Treated just as any other narcotic must account
    for every patch
  • Patch must be dated, timed and signed when placed
  • Old patch must be removed when the new one is
    placed

45
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46
Nursing Considerations when giving Opioid
Analgesic medication
  • Assess effectiveness of medication
  • Use the 0 10 scale to measure intensity of pain
  • Assess for adverse effects
  • Assess rate, depth, and rhythm of RESPIRATIONS
  • Provide for patient safety

47
NEUROMUSCULARBLOCKING AGENTS
  • Blocks acetylcholine at the neuro-muscular
    junction
  • Produces paralysis
  • Does NOT effect LOC
  • Drugs include
  • Pancuronium
  • Succinycholine
  • Vecuronium

48
CONSCIOUS SEDATIONMODERATE SEDATIONPROCEDURAL
SEDATIONTWILIGHT SLEEP
  • Used for uncomfortable procedures such as
  • Colonoscopy
  • Endoscopy
  • X-ray procedures
  • Minor surgery
  • Patient is unconscious but still able to protect
    their airway
  • Amnesia is common
  • midazolam (Versed)
  • lorazepam (Ativan)

49
Chapter 13 CNS depressants and muscle relaxants
50
SEDATIVE AND HYPNOTIC DRUGS
  • Sedative effect
  • Given during waking hours
  • May cause drowsiness
  • Hypnotic effect
  • Given at bedtime with the purpose of inducing
    sleep
  • MAY BE THE SAME DRUG GIVEN AT DIFFERENT DOSAGES

51
Benzodiazepines
  • Prototype
  • Diazepam (Valium)
  • Antianxiety, anticonvulsant, sedative/hypnotic,
    skeletal muscle relaxant
  • Schedule IV drugs Moderate potential for abuse
  • Pregnancy category D
  • Half-life 20-50 hours (metabolites also cause
    sedation up to 100 hours)
  • Drug of choice to treat status epilepticus
    (sustained seizures)

52
BENZODIAZEPINES
  • alprazolam (Xanax)
  • chlordiazepoxide (Librium)
  • flurazepam (Dalmane)
  • lorazepam (Ativan)
  • midazolam (Versed)
  • triazolam (Halcion)

53
BENZODIAZEPINES
  • MECHANISM OF ACTION
  • Binds with benzodiazepine receptors in nerve
    cells of the brain these cells also have binding
    sites for GABA (gamma-aminobutyric acid) which is
    an inhibitory neurotransmitter.
  • Excitatory v. Inhibitory transmitters
  • Excitatory Norepinephrine
  • Inhibitory - GABA

54
GABA
  • Benzodiazapines and barbiturates work by
    increasing the action of gaba in the brain
  • Gaba is an amino acid that inhibits nerve
    transmissions in the brain

55
BENZODIAZEPINES
  • Indications Not all drugs are appropriate for
    all uses
  • Antianxiety
  • Hypnotic
  • Anticonvulsant
  • Preoperative sedation
  • Prevent DTs in alcohol withdrawal

56
BENZODIAZEPINES
  • Contraindications
  • Respiratory depression
  • Liver disorder
  • Kidney disorder
  • History of alcohol or drug abuse
  • Used cautiously with other CNS depressants

57
BENZODIAZEPINES
  • Drug-Drug interactions
  • Cimetidine, hormonal contraceptives, disulfiram,
    fluoxetine, isoniazid, ketoconazole, metoprolol,
    propoxyohene, propranolol, and valproic acid may
    enhance the effects of sedatives by decreasing
    their metabolism.
  • May decrease the efficacy of levodopa
  • Rifampin, barbiturates may increase the
    metabolism of benzodiazepines, decreasing their
    effectiveness.

58
BENZODIAZEPINES
  • Herbal products to avoid when using
    benzodiazepines
  • Kava kava
  • Valerian root
  • Camomile
  • CAN INCREASE SEDATION
  • THIS APPLIES TO ALL CNS DEPRESSANTS

59
BENZODIAZEPINES
  • Adverse Effects
  • CNS depression drowsiness, lightheadedness
  • Paradoxical effects insomnia, excitation
  • Respiratory depression
  • Hypotension
  • Constipation/diarrhea
  • Nausea, vomiting
  • Rash

60
BENZODIAZEPINES
  • REVERSAL AGENT FOR OVERDOSE OF BENZODIAZEPINES
  • FLUMAZENIL
  • INDICATED FOR THE REVERSAL OF MODERATE SEDATION
    OR GENERAL ANESTHIA

61
NURSING CONSIDERATIONS
  • ASSESS PATIENT WITH FOCUS ON REASON FOR GIVING
    SEDATION
  • ANXIETY
  • NERVOUSNESS
  • REASSESS PATIENT FOR RESPONSE TO DRUG
  • SEDATIVE Q 4-6 H
  • HYPNOTIC AT BEDTIME
  • MONITOR VS AND POTENTIAL FOR DEPRESSION

62
CONTRAINDICATIONS TO SEDATIVES AND HYPNOTICS
  • Patient with a history or current use of
    recreational drugs or alcohol abuse
  • Respiratory compromise
  • Pregnancy or lactation

63
NURSING IMPLICATIONS
  • Administer accurately
  • Teach patient about expected effects and
    possible side effects
  • Provide for patient safety
  • Observe for therapeutic effects
  • Decrease in anxiety
  • Positive signs of sleep

64
NURSING IMPLICATIONS
  • Observe for adverse effects
  • Excessive sedation
  • Hypotension
  • Observe for drug interactions
  • Concurrent use of other cns depressants

65
What is the most widely used sedative / hypnotic?
  • ALCOHOL

66
ALCOHOL
  • Stimulant and depressant
  • Stimulates the adrenal gland
  • Depresses the CNS
  • Physical manifestations
  • Acts as a diuretic
  • Increases gastric acidity
  • Cardiomyopathy
  • Peripheral vasodilation
  • Electrolyte imbalance

67
WHAT ARE DTs?
  • Delirium tremens Latin for shaking frenzy
  • Abrupt alcohol (ETOH) withdrawal
  • Mismatch between excitatory (norepinephrine) and
    inhibitory (GABA) receptors in the brain

68
SIGNS AND SYMPTOMS
  • Confusion
  • Diarrhea
  • Insomnia
  • Disorientation
  • Agitation
  • Fever
  • Tachycardia
  • Hypertension
  • Visions of insects
  • Severe anxiety
  • Fear of death

69
NURSING CONSIDERATIONS FOR THE PATIENT USING /
ABUSING ALCOHOL
  • Many safety issues
  • Do not mix with other CNS depressants
  • Monitor patients liver function
  • Patient may have altered clotting factors
  • Patient may have withdrawal symptoms

70
PSYCHOTHERAPEUTIC MEDICATIONS
71
Anxiety Disorders
  • A group of mental disorders characterized by a
    vague uneasy feeling of discomfort or dread. The
    symptoms of anxiety prevent the individual from
    normal functioning . can be an exaggerated
    response to an actual event or anxiety unrelated
    to an identifiable event or condition.

72
Anxiety disorders
  • Panic disorder
  • Generalized anxiety disorder
  • Obsessive-compulsive disorder
  • Post-traumatic stress disorder
  • Simple phobia
  • Social phobia

73
Antianxiety Medications(Anxiolytics)
  • Tricyclic antidepressants
  • Benzodiazepines
  • MAOIs
  • Buspirone
  • SSRIs

74
BUSPIRONE (BuSpar)
  • Mechanism of action unknown
  • Interacts with serotonin and dopamine in the
    brain
  • No muscle relaxant effects
  • No anticonvulsant effects
  • Does not cause sedation

75
BUSPIRONE (BuSpar)
  • Uses / indications
  • Short term management of anxiety disorders
  • Not appropriate for immediate relief may take
    several weeks to see effects

76
BUSPIRONE (BuSpar)
  • Side effects
  • Dizziness, nausea, headache, anxiety, fatigue,
    insomnia
  • Contraindications
  • Renal/hepatic failure
  • Use of MAOIs

77
ANTIDEPRESSANTS AND MOOD STABILIZERS DRUGS
78
ETIOLOGY OF DEPRESSION
  • Monoamine neurotransmitter dysfunction
  • Deficiency of norepinephrine and/or serotonin.
  • Balance, integration and interactions among
    norepinephrine, serotonin, and other
    neurotransmission systems is an important
    etiological factors.

79
ETIOLOGY OF DEPRESSION
  • Neuroendocrine factors
  • AN INCREASE IN CRF (corticotropin releasing
    factor/hormone) HAS BEEN NOTED IN PATIENTS WITH
    DEPRESSION.

80
CLASSIFICATIONS OF ANTIDEPRESSANT MEDICATIONS
  • Tricyclic antidepressants
  • Monoamine oxidase inhibitors
  • Selective serotonin reuptake inhibitors
  • Unclassified drugs

81
TRICYCLIC ANTIDEPRESSANTS
  • imipramine (Tofranil) prototype
  • nortriptyline (Pamelor)
  • amitryptyline (Elavil)
  • desipramine (Norpramin)

82
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83
TRICYCLIC ANTIDEPRESSANTS(TCAs)
  • First generation of antidepressant therapy
  • Mechanism of action
  • Corrects the imbalance in the neurotransmitter
    concentrations of serotonin and norepinephrine at
    the nerve endings in the CNS. This is done by
    blocking the reuptake of the neurotransmitters
    and thus causing these neurotransmitters to
    accumulate at the nerve endings.
  • Also have nonselective receptor antagonism
    causing many side effects.

84
TRICYCLIC ANTIDEPRESSANTS
  • Indications
  • Depression
  • Childhood enuresis(bed wetting)
  • Imipramine
  • Obsessive compulsive disorder
  • Clomipramine
  • Chronic pain syndromes
  • Neuropathic pain (trigeminal neuralgia)

85
TRICYCLIC ANTIDEPRESSANTS
  • Adverse effects
  • Sedation
  • Impotence
  • Orthostatic hypotension
  • Disturbs cardiac conduction
  • Delayed micturation
  • Edema
  • Muscle tremors

86
TRICYCLIC ANTIDEPRESSANTS
  • Interactions
  • WHEN TAKEN WITH MAOIs MAY RESULT IN INCREASED
    THERAPEUTIC LEADING TO TOXIC EFFECTS
    (HYPERPYRETIC CRISIS)
  • TCAs can inhibit the metabolism of warfarin,
    resulting in an increase in anticoagulation

87
TRICYCLIC ANTIDEPRESSANTS
  • Toxicity and management of overdose
  • TCA overdoses are fatal 70 - 80 of the time
  • Death usually results from seizures or
    dysrhythmias
  • THERE IS NO SPECIFIC ANTIDOTE FOR TCAs

88
MONOAMINE OXIDASE INHIBITORS (MAOIs)
  • First generation of antidepressant drugs
  • Highly effective
  • Many side effects and drug/drug, drug/food
    interactions
  • Disadvantage potential to cause hypertensive
    crisis when taken with tyramine

89
MAOIs
  • phenelzine (Nardil)
  • tranylcypromine (Parnate)

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91
MAOIs Mechanism of Action
  • Inhibit the MAO enzyme system in the CNS
  • Amines (dopamine, serotonin, norepinephrine) are
    not broken down, resulting in higher levels in
    the brain
  • Result alleviation of symptoms of depression

92
MAOIs Indications
  • Depression, especially types characterized by
    symptoms such as increased sleep and appetite
    depression that does not respond to other drugs
    such as tricyclics

93
MAOIs Adverse Effects
  • Tachycardia
  • Dizziness
  • Insomnia
  • Anorexia
  • Blurred vision
  • Palpitations
  • Drowsiness
  • Headache
  • Nausea
  • Impotence

94
MAOIs Overdose
  • Symptoms appear 12 hours after ingestion
  • Tachycardia, circulatory collapse, seizures,
    coma
  • Treatment protect brain and heart, eliminate
    toxin

95
Hypertensive Crisis and Tyramine During MAOI
Therapy
  • Ingestion of foods and/or drinks with the amino
    acid tyramine leads to hypertensive crisis, which
    may lead to cerebral hemorrhage, stroke, coma,
    or death

96
Hypertensive Crisis and Tyramine (contd)
  • Avoid foods that contain tyramine!
  • Aged, mature cheeses (cheddar, blue, Swiss)
  • Smoked/pickled or aged meats, fish, poultry
    (herring, sausage, corned beef, salami,
    pepperoni, pâté)
  • Yeast extracts
  • Red wines (Chianti, burgundy, sherry, vermouth)
  • Italian broad beans (fava beans)

97
Antidepressants MAOIs
  • Concurrent use of MAOIs and SSRIs may lead to
    serotonin syndrome
  • If the decision is made to switch to an SSRI,
    there must be a 2- to 5-week wash-out period
    between MAOI therapy and SSRI therapy

98
Serotonin SyndromeRESULTING FROM TOO MUCH
SEROTONIN

Delirium Agitation Tachycardia Sweating Hyp
er-reflexia Muscle spasms Shivering Coarse
tremors More severe cases Hyperthermia
Seizures Renal failure DIC
Rhabdomyolysis Dysrhythmias
99
Selective Serotonin Reuptake Inhibitors(SSRIs)
  • fluoxetine (Prozac)
  • paroxetine (Paxil)
  • sertraline (Zoloft)
  • fluvoxamine (Luvox)
  • citalopram (Celexa)
  • escitalopram (Lexapro)

100
SSRIs Newer-Generation Antidepressants
  • Fewer adverse effects than tricyclics and MAOIs
  • Very few drug-drug or drug-food interactions
  • Still takes about 4 to 6 weeks to reach maximum
    clinical effectiveness

101
SSRIs
  • Mechanism of action
  • Selectively inhibits serotonin reuptake
  • Little or no effect on norepinephrine or dopamine
    reuptake
  • Result in increased serotonin concentrations at
    nerve endings
  • Advantage over tricyclics and MAOIs little or
    no effect on cardiovascular system

102
SSRIs
  • INDICATIONS
  • Depression
  • Bipolar disorder
  • Obesity
  • Eating disorders
  • Obsessive-compulsive disorder

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104
SSRI Antidepressants Adverse Effects
  • Body System Effects
  • CNS Headache, dizziness, tremor, nervousness,
    insomnia, fatigue
  • GI Nausea, diarrhea, constipation, dry mouth
  • Other Sexual dysfunction,
  • weight gain, weight loss, sweating
  • Most common and bothersome

105
Serotonin-Norepinephrine Reuptake Inhibitors
  • Duloxetine (Cymbalta)
  • Venlafaxine (Effexor)

106
Serotonin-Norepinephrine Reuptake Inhibitors
  • Indicated
  • For depression and general anxiety disorder
  • Also pain associated with diabetic peripheral
    neuropathy
  • Contraindicated
  • CONCURRENT USE OF MAOIs
  • Angle closure glaucoma

107
SNRIs
  • Drug Interactions
  • Highly bound to plasma proteins
  • Compete with other protein-binding drugs,
    resulting in more free, unbound drug to cause a
    more pronounced drug effect
  • Inhibition of cytochrome P-450 system

108
OTHER ANTIDEPRESSANTS NOT CLASSIFIED
  • bupropion
  • Wellbutrin, zyban
  • Commonly prescribed for smoking cessation
  • maprotiline
  • Similar to TCAs
  • Mirtazapine
  • Remeron
  • Often prescribed to enhance appetite

109
NURSING CONSIDERATIONS WHEN PATIENTS ARE TAKING
ANTIDEPRESSANTS
  • Comprehensive patient history
  • Complete medication history
  • Monitor patient for therapeutic effects
  • Monitor patients for adverse effects
  • Education of patient on drug expectations
    and adverse effects
  • Educate patient regarding drug-drug, drug-food
    and drug-herbal interactions

110
MOOD STABLIZING AGENTS
  • lithium carbonate
  • Eskalith, lithobid
  • MOA not completely understood
  • Managed using serum levels
  • Indications mania, bipolar disorder
  • Adverse effects
  • vomiting, diarrhea, drowsiness, difficult
    coordination, hand tremors, muscle twitching,
    mental confusion

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NURSING CONSIDERATIONS
  • Monitor serum lithium levels
  • Therapeutic levels are 1.0 1.5 meq/L
  • Lithium is eliminated intact by the kidneys.
    Encourage fluids to completely eliminate the drug
  • Monitor for therapeutic and adverse effects

112
PSYCHOSIS
  • A severe mental disorder characterized by
    disordered thought process and often bizarre
    thinking.
  • Hypoactivity or hyperactivity
  • Agitation
  • Aggressiveness
  • Hostility
  • Social withdrawal

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Antipsychotic Drugs
  • Antipsychotic AKA Neuroleptic
  • Any drug that modifies or treats psychotic
    behaviors usually by blocking dopamine receptors
    in the brain

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Antipsychotic Drugs
  • Thioxanthenes
  • thiothixene (Navane)
  • Phenylbutylpiperidines
  • haloperidol (Haldol)
  • Dihydroindolones
  • molindone (Moban)
  • Dibenzodiazepines
  • loxapine (Loxitane)
  • Benisoxazoles
  • Risperidone
  • Quinolinine
  • Aripiprazole (Abilify)
  • Phenothiazines
  • Chlorpromazine (Thorazine)

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HALDOL- FIRST GENERATION ANTIPSYCHOTIC
  • Schizophrenia
  • Long half-life facilitates better compliance
    by patients
  • Long-term treatment of psychosis
  • Can be given either IV or po

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ADVERSE REACTIONS TO ANTIPSYCHOTIC MEDICATION
  • Seizures
  • Extrapyramidal reactions
  • Blurred vision, dry eyes
  • Neuroleptic malignant syndrome
  • Tartive dyskinesia

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NEUROLEPTIC MALIGNANT SYNDROME
  • A potentially fatal syndrome with symptoms
  • Hyperthermia
  • Catatonic rigidity
  • Altered mental status
  • Profuse sweating
  • Rhabdomyolysis
  • Renal failure
  • Seizures
  • Death

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Tardive dyskinesia (TD)
  • Involuntary contractions of oral and facial
    muscles
  • Choreoathetosis (wavelike movements of
    extremities)
  • Occurs with continuous long-term antipsychotic
    therapy (esp. phenothiazines)

120
Extrapyramidal symptoms (EPS)
  • Involuntary muscle symptoms similar to those of
    Parkinsons disease
  • Akathisia (distressing muscle restlessness)
  • Acute dystonia (painful muscle spasms)
  • Treated with benztropine (Cogentin) and
    trihexyphenidyl (Artane)

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  • Recognizing extrapyramidal symptoms
  • http//www.youtube.com/watch?vWAg2iLEWVh0playnex
    t1listPLFA09E8C6FCF4EC70featureresults_main

122
ATYPICAL ANTIPSYCHOTICSNEWER-GENERATION
ANTIPSYCHOTICS
  • clozapine (Clozaril)
  • risperidone (Risperdal)
  • olanzapine (Zyprexa)
  • quetiapine (Seroquel)
  • ziprasidone (Geodon)
  • aripiprazole (Abilify)

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Mechanism of Action
  • Block dopamine receptors in the brain (limbic
    system, basal ganglia)areas associated with
    emotion, cognitive function, motor function
  • Dopamine levels in the CNS are decreased
  • Result tranquilizing effect in psychotic patients

124
ADVANTAGES OF NEWER GENERATION ANTIPSYCHOTICS
  • Reduced effect on Prolactin levels
  • Stimulates mammary glands to produce milk
  • Lower risk of
  • Neuroleptic malignant syndrome
  • Extrapyramidal adverse effects
  • Tartive dyskinesia

125
Indications
  • Treatment of serious mental illnesses
  • Bipolar affective disorder
  • Depressive and drug-induced psychoses
  • Schizophrenia
  • Autism
  • Movement disorders (such as Tourettes syndrome)
  • Some medical conditions
  • Nausea, intractable hiccups

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Adverse Effects
  • Body System Adverse Effects
  • CNS Sedation, delirium
  • Cardiovascular Orthostatic hypotension,
    syncope, dizziness, EKG changes
  • Dermatologic Photosensitivity, skin rash,
    hyper-pigmentation, pruritus

127
Adverse Effects (contd)
  • Body System Adverse Effects
  • GI Dry mouth, constipation
  • GU Urinary hesitancy or retention, impaired
    erection
  • Hematologic Leukopenia and agranulocytosis

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Adverse Effects (contd)
  • Body System Adverse Effects
  • Metabolic/endocrine Galactorrhea,
    irregular menses, increased appetite,
    polydipsia

129
Nursing Implications
  • Before beginning therapy, assess both the
    physical and emotional status of patients
  • Obtain baseline vital signs, including postural
    BP readings
  • Obtain liver and renal function tests

130
Nursing Implications (contd)
  • Assess for possible contraindications to therapy,
    cautious use, and potential drug interactions
  • Assess LOC, mental alertness, potential for
    injury to self and others
  • Check the patients mouth to make sure oral
    doses are swallowed

131
Nursing Implications (contd)
  • Provide simple explanations about the drug, its
    effects, and the length of time before
    therapeutic effects can be expected
  • Abrupt withdrawal should be avoided
  • Advise patients to change positions slowly to
    avoid postural hypotension and possible injury

132
Nursing Implications (contd)
  • 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

133
Skeletal Muscle Relaxants
  • Skeletal muscle relaxants are used to decrease
    muscle spasm or spasticity that occurs in certain
    neurologic and musculoskeletal disorders.

134
Muscle Relaxants
  • Indications
  • Relief of painful musculoskeletal conditions
  • Muscle spasms
  • Management of spasticity of severe chronic
    disorders
  • Multiple sclerosis, cerebral palsy
  • Work best when used along with physical therapy

135
MUSCULAR DISORDERS
  • Muscle spasms
  • Sudden involuntary muscle contraction
  • Can occur secondary to trauma, inflammation,
    sprains, strains, arthritis, spinal disorders

136
Muscle Relaxants
  • MECHANISM OF ACTION
  • 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
  • Direct acting
  • Acts directly on skeletal muscle
  • Closely resembles GABA (an inhibitory
    neurotransmitter)

137
Common Muscle Relaxants
  • baclofen (Lioresal)
  • cyclobenzaprine (Flexeril)
  • carisoprodol (Soma)
  • metaxalone (Skelaxin)
  • methocarbamol (Robaxin)
  • tizanidine (Zanaflex)
  • DIRECT ACTING
  • dantrolene (Dantrium)

138
MUSCULAR DISORDERS
  • Muscle spasticity
  • Spasticity involves increased muscle tone or
    contraction
  • Can occur secondary to spinal cord injury,
    multiple sclerosis, cerebral palsy, muscular
    dystrophy

139
Muscle Relaxants Adverse Effects
  • Extension of effects on CNS and skeletal muscles
  • Euphoria
  • Lightheadedness
  • Dizziness
  • Drowsiness
  • Fatigue
  • Muscle weakness, others

140
Muscle Relaxants
  • Nursing implications
  • Monitor therapeutic response to medication
  • Monitor for adverse reactions
  • Nursing diagnosis appropriate to specific patient

141
AnticonvulsantsAntiseizure drugs Antiepileptic
drugs (AEDs) Chapter 15MEDICATION TO CONTROL
SEIZURES
142
SEIZURES
  • A brief episode of abnormal electrical activity
    of nerve cells in the brain

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ANTICONVULSANT ANTIEPILEPTIC MEDICATION(AEDs)
  • GOAL OF TREATMENT
  • Control seizures without causing undue sedation
    and experiencing minimal adverse reactions

146
DRUGS TO CONTROL SEIZURES
FOSPHENYTOIN CEREBYX GABAPENTIN NEURONTIN LORAZEP
AM ATIVAN PHENYTOIN (PROTOTYPE) DILANTIN VALPROIC
ACID DEPAKENE
CARBAMAZAPINE TEGRETOL CLONAZEPAM KLONOPIN CHLORAZ
EPATE TRANXENE DIAZEPAM VALIUM PHENOBARBITAL LUMIN
AL
147
BARBITURATES
  • FIRST USED IN 1903
  • PHENOBARBITAL
  • MOST COMMONLY PRESCRIBED FOR STATUS EPILEPTICUS
  • MORE OFTEN USED IN NONINDUSTRIALIZED COUNTRIES
    BECAUSE OF LOW COST
  • CLINICAL CLASSIFICATION ANTICONVULSANT,
    HYPNOTIC
  • LONG HALF-LIFE

148
Phenytoin (Dilantin)
  • Classification
  • Anticonvulsant
  • Antiarrhythmic
  • MOA
  • Stabilize neuronal membranes in the motor cortex
    of the brain. Limits the spread of seizure
    activity

149
Phenytoin (Dilantin)
  • Contraindications
  • Seizures caused by hypoglycemia or high fever
  • Side effects
  • Drowsiness, lethargy, confusion, slurred speech
  • Gingival hyperplasia
  • Fever, rash, lymphadenopathy
  • Monitor serum dilantin levels
  • 10 -20 mcg/ml IS THERAPEUTIC
  • Monitor liver function
  • Decreases many drug levels including oral
    contraceptives

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Phenytoin (Dilantin)
  • NURSING CONSIDERATIONS
  • REVIEW HISTORY OF SEIZURES
  • INITIATE SEIZURE PRECAUTIONS
  • PATIENT EDUCATION
  • WHAT TO EXPECT FROM MEDICATION
  • DO NOT EVER OMIT A DOSE
  • MUST MAINTAIN THERAPEUTIC BLOOD LEVELS OR
    SEIZURES WILL RECUR
  • SEE NURSING PROCESS ASSESSMENT P.238
  • DOCUMENT TYPE AND CHARACTER OF SEIZURE

152
VALPROIC ACIDDEPAKOTE
  • Classification
  • Anticonvulsant
  • Vascular headache suppressant
  • Mechanism of action
  • Increases levels of gaba in the CNS
  • Adverse reactions

153
VALPROIC ACIDDEPAKOTE
  • Adverse reactions
  • Agitation
  • Dizziness
  • Headache
  • Insomnia
  • Sedation
  • Visual disturbances
  • Tremor
  • Ataxia

154
FOSPHENYTOINCEREBYX
  • Classification anticonvulsant
  • Mechanism of action
  • Alters ion transport in the CNS
  • Indicated for short term management of
    generalized seizures, status epilepticus
  • Parenteral administration only

155
CARBAMAZEPINETEGRETOL
  • Indications treatment of clonic-tonic, mixed
    and complex seizures
  • Mechanism of action decreases synaptic
    transmission in the CNS by affecting sodium
    channels in the neurons

156
CARBAMAZEPINETEGRETOL
  • Adverse reactions
  • Ataxia
  • Drowsiness
  • Drug-drug interactions
  • Many
  • Drug food interactions
  • Grapefruit juice increases serum levels and
    increases the drug effects (toxicity?)
  • THERAPEUTIC SERUM DRUG LEVELS 4-12mcg/ml

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DRUGS FOR PARKINSONS DISEASE
159
PARKINSONS DISEASEChapter 16
  • Progressive, degenerative neurologic disorder
    caused by a imbalance between acetylcholine and
    dopamine in the brain

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PARKINSONS DISEASE
  • Signs and symptoms
  • Shuffling gait
  • Fine tremors
  • Muscle rigidity
  • Slurred speech
  • Emotionless facial expression (mask-like)
  • Difficulty chewing and swallowing

163
MEDICATION TO TREAT PARKINSONS DISEASE
  • Anticholinergic drugs
  • Antihistamines
  • Dopaminergics
  • Direct acting dopamine receptor agonists
  • Indirect acting dopamine receptor agonists

164
ANTICHOLINERGIC DRUGS
  • benztropine, procyclidine, trihexyphenidyl
  • Drugs that block the effects of acetylcholine
  • As dopamine decreases, acetylcholine increases
    causing muscle tremors and rigidity (more
    pronounced at rest)
  • Pill rolling

165
ANTICHOLINERGIC DRUGS
  • Anticholinergic effects DECREASE
  • Salivation
  • Tearing of the eyes,
  • Urination
  • Diarrhea
  • Increased GI motility
  • Emesis (vomiting)

166
ANTICHOLINERGIC DRUGS
  • Contraindications
  • Known drug allergy
  • GI or bladder obstruction
  • Cardiac disease
  • Glaucoma
  • Myasthenia gravis

167
ANTIHISTAMINES
  • Used for their anticholinergic effects
  • diphenhydramine (Benadryl)

168
DRUGS THAT AFFECT DOPAMINE
  • Direct acting medication increase the levels of
    dopamine at the synapse.
  • bromocriptine dopamine agonist
  • pergolide dopamine agonist
  • pramipexole - dopamine agonist
  • levodopa dopamine replacement

169
DRUGS THAT AFFECT DOPAMINE
  • Indirect acting increase dopamine levels by
    inhibiting enzymes that break down dopamine
  • Carbidopa inhibits enzyme AADC
  • Entacapone COMT inhibitor
  • Tolcapone COMT inhibitor
  • Selegiline MAOI
  • Others
  • Amantadine synthetic antiviral

170
DRUGS THAT AFFECT DOPAMINEMOA
  • Levodopa (prototype)
  • Precursor to dopamine
  • Dopamine does not cross the blood-brain barrier.
    Can cross as levodopa and is then converted to
    dopamine
  • Carbidopa
  • Prevents the conversion of levodopa to dopamine
    in the peripheral tissues
  • Does not cross the blood brain barrier

171
SELECTIVE MONOAMINE OXIDASE INHIBITOR THERAPY
  • ACTION OF MAO
  • Primary roll is the catabolism or breakdown of
    catecholamines such as dopamine, norepinephrine
    and epinephrine. Also breaks down serotonin.
  • Rasagiline (azilect)

172
COMT INHIBITORS
  • Catechol-o-methytransferase
  • A naturally occurring enzyme in the body that
    breaks down dopamine molecules
  • By inhibiting this enzyme, the action of levodopa
    is prolonged
  • Medications
  • tolcapone (Tasmar)
  • entacapone (Comtan)

173
ADVERSE REACTIONS TO ANTI-PARKINSONS MEDICATION
  • Drowsiness
  • Confusion
  • Orthostatic hypotension
  • Dystonia
  • Dyskinesia

174
NURSING CONSIDERATIONS
  • Risk for injury due to postural hypotension
  • Rise slowly from sitting or lying position
  • Difficulty with communication
  • Safety issues r/t unsteady, shuffling gait
  • Never stop meds abruptly
  • Take meds on time
  • Watch for adverse reactions

175
ON-OFF ANDWEARING OFF PHENOMONEN
  • ON OFF
    Disease is worsening, too little
    dopamine is present
  • WEARING OFF
    Gradual worsening of Parkinsons
    symptoms as the drugs lose their effectiveness
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