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Drugs Affecting the Central Nervous System

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Title: Drugs Affecting the Central Nervous System


1
Drugs Affecting the Central Nervous System
  • Chapter 10

2
Pain
  • Defined as an unpleasant sensory and emotional
    experience associated with either actual or
    potential tissue damage.
  • Pain is what a client says it is.
  • Pain exists whenever the patient says it does.

3
Acute Pain
  • Pain that is sudden in onset, usually subsides
    when treated, and typically occurs over less than
    6-week period of time.

4
Chronic Pain
  • Persistent or recurring pain that is often
    difficult to treat. Typically lasts longer than 3
    months.

5
Pain Threshold
  • Level of stimulus needed to produce a painful
    sensation.

6
Pain Tolerance
  • The amount of pain a client can endure without it
    interfering with normal function.

7
Pain Source
  • Somatic pain originates from skeletal muscles,
    ligaments and joints.
  • Visceral pain originates from organs and smooth
    muscle.
  • Superficial pain originates from skin and mucous
    membranes.

8
Cultural Implications
  • Each culture has its own beliefs, thoughts, and
    ways of approaching, defining, and managing pain.
  • Prayer
  • Laying on of hands
  • Healers

9
Implications for Transcultural Nursing Practice
  • Assessment of the type of intervention the person
    desires.
  • Does the person wish traditional interventions,
    expressions of nurturance and compassion,
    psychological support, physical interventions
    (soothing, having a brow wiped, relaxation)?
    cultural support? medication? Or a combination of
    these?

10
Cultural Groups and Pain
  • Stereotypes
  • Mexican Americans have a low pain tolerance.
  • Italian Americans are very dramatic about their
    pain
  • Jewish Americans complain a lot about pain.
  • African Americans report higher levels of
    chronic pain and have a greater sensitivity to
    acute pain.
  • Asian Americans do not express their pain.

11
Alternative Methods
  • Acupuncture
  • Massage
  • Herbs
  • Heat or ice application
  • Relaxation techniques
  • Psychological counseling

12
Acupuncture
13
Nerve Pain Tincture
  • Recipe
  • 1 tsp Saint Johns Wort (flowering top), skull cap
    leaves, fresh oats licorice root.
  • ½ gtt each tincture
  • Ginger rhizome
  • Vervain leaves

14
Nursing Responsibilities
  • Do a thorough assessment that includes questions
    about the patients cultural background and
    practices is important in the effective and
    individualized delivery of nursing care.

15
JCAHO Pain Standards
  • The Joint Commission's 2001 pain management
    standards state that every patient has a right to
    have his or her pain assessed and treated.
  • JCAHO standards dictate that a nurse will
    evaluate the patients response to the pain
    medication within 30 minutes to one hour after
    administration of the pain medication.

16
Pain Tools
  • Universal Pain Assessment Tool

17
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18
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19
Opioid Drugs
  • Originate from the opium poppy.
  • 20 different alkaloids are obtained from the
    unripe seed of the plant.

20
Opioid Analgesics
  • Powerful pain relievers.
  • Classified according to their chemical structure
    and action.
  • Simple chemical modifications of the opium
    alkaloids produce three different drugs.
  • morphine-like drugs
  • meperidine-like drugs
  • methadone-like drugs

21
Anesthetic Drugs
  • Strong opioid analgesics used in combination with
    anesthetics during surgery.
  • fentanyl
  • sufentanil
  • alfentanil
  • Goal not only to relieve pain but also to
    maintain a balanced state of anesthesia.

22
General Anesthesia
  • Loss of sensation and usually of consciousness
    without loss of vital functions artificially
    produced by the administration of one or more
    agents that block the passage of pain impulses
    along nerve pathways to the brain

23
Local Anesthesia
  • Loss of sensation in a limited and usually
    superficial area especially from the effect of a
    local anesthetic.

24
Fentanyl
  • Fentanyl injection has a rapid onset and short
    duration.
  • Transdermal fentanyl patch is used for long-term
    pain management.

25
Opioids
  • Opioids used to control moderate to severe pain.

26
Schedule II Drugs
  • Classification Opioid analgesics
  • Morphine
  • Codeine often used in combination with
    acetaminophen Tylenol with codeine
  • Hydrocodone Vicodin - used in combination with
    acetaminophen / aspirin / ibuprofen
  • Hydromorphine Dilaudid - More potent than
    morphine
  • Meperidine Demerol
  • Oxycodone Percocet (with acetaminophen) or
    Percodan (with aspirin)

27
Opioid Adverse Effects
  • Cardiovascular hypotension, palpitations,
    flushing
  • Central nervous system sedation, disorientation,
    euphoria, light-headedness, tremors.
  • Gastrointestinal nausea, vomiting, constipation
  • Genitourinary urinary retention
  • Respiratory Respiratory depression and
    aggravation of asthma.

28
Contraindications
  • Known drug allergy
  • Severe asthma
  • Used with caution in
  • Patients with severe head injuries (mask level of
    consciousness or LOC)
  • Morbid obesity with sleep apnea (depress
    respirations while asleep)
  • Paralytic ileus (bowel paralysis) opioids tend
    to slow bowel

29
Psychologic Dependence
  • Addiction characterized by behaviors that
    include one or more of the following
  • Impaired control over drug use
  • Compulsive use
  • Continued use despite harm
  • Craving

30
Physical Dependency
  • Physiological adaption
  • Results in withdrawal symptoms when the drug is
    discontinued.
  • Withdrawal symptoms include
  • Mental agitation
  • Tachycardia
  • Elevated blood pressure
  • Seizures

31
Opioid Tolerance
  • State of adaption which results in reduced
    effects of drug resulting on use of higher dosing
    to get desired effect.

32
Toxicity
  • Opioid antagonist bind to occupy all the receptor
    sites blocking the action of the opiod drug.
  • nalaxone
  • naltrexone

33
Naloxone
  • Brand name Narcan
  • Classification Pharmacologic opioid antagonist
  • Classification Therapeutic antidote for opioid
  • Action Competitively blocks the effects of
    opioids, including CNS and respiratory
    depression, without producing any agonist
    (opioid-like) effects.
  • Therapeutic Effects reversal of signs of opioid
    excess.

34
Narcan
  • Route IV
  • onset in 2-3 minutes
  • peak unknown
  • duration 45 minutes
  • IM, Subq
  • onset 2-5 minutes
  • peak unknown
  • duration gt 45 minutes

35
Drug Calculation
  • The IV dose for naloxone (Narcan) is 0.02 to 0.2
    mg q 2-3 minutes until response is obtained.
  • Physician orders 0.1 mg
  • The drug is provided as 0.4 mg / mL
  • How much would you draw up to give the
    appropriate dose? ____________

36
Morphine Sulfate
  • Classification Pharmacologic Opioid agonist
  • Classification Therapeutic opioid analgesic
  • Indications severe pain (postoperative,
    fractures, burns), pulmonary edema, and pain
    associated with myocardial infarct (MI).

37
Morphine
  • Action Binds to opiate receptors in the CNS.
    Alters the perception of and response to painful
    stimuli while producing generalized CNS
    depression Therapeutic Effects decrease in
    severity of pain
  • Adverse Reactions severe respiratory depression,
    constipation

38
Morphine Effects
  • IV maximal analgesia and respiratory depression
    would occur within 10 to 20 minutes
  • IM within 30 minutes
  • Sub Q 60 to 90 minutes
  • PO peak activity occurs in about 60 minutes
    higher dosage needed due to metabolism of drug in
    the liver

39
Morphine Dosing
  • Tablets come in 15 mg or 30 mg
  • Solution for IM, IV or sub Q 10 mg/ml most common

40
Medication Calculation
  • Physician order 6 mg of morphine sulfate q 3-4
    hours prn for severe pain.
  • The drug is provided as 10 mg / 1 mL.
  • How much of the drug would you need to draw up
    the give the appropriate dose?

41
Nursing Responsibilities
  • Pain assessment
  • Base-line vitals
  • Re-assess vitals after pain med administered
  • Assess bowel function
  • Overdose Narcan used to reverse respiratory
    depression
  • Constipation ambulate! dietary fiber, fluids,
    stool softener

42
Meperidine
  • Therapeutic classification opioid analgesic
  • Pharmacologic classification opioid agonist
  • Schedule II drug
  • Action Binds to opiate receptors in the CNS.
    Alters the perception of and response to painful
    stimuli, while producing generalized CNS
    depression
  • Therapeutic effects Decrease in severity of pain.

43
Meperidine
  • Demerol is a synthetic drug with the same uses
    and adverse effects as morphine.
  • Less nausea and vomiting.
  • Use with caution due to neurotoxic metabolism
    with chronic use
  • CNS agitation (often exhibited as confusion)
  • Hallucinations
  • Tremors
  • seizures

44
Meperidine Dosing
  • IV or IM
  • Provided as 10 mg/mL, 50 mg /mL, 75 mg/mL or 100
    mg/mL
  • Dosage for adults 50 to 150 mg every 3-4 hours
  • Dosage for pediatrics 1 to 1.8 mg / kg q 3-4
    hours (not to exceed 100 mg dose)

45
Medication calculation
  • The physician order meperidine 75 mg prn q 3-4
    hours for pain.
  • The vial provided is 50 mg / 1 mL.
  • How much of the mediation would you need to draw
    up to give the appropriate dose?

46
Codeine
  • Classification Pharmacologic opioid agonist
  • Classification Therapeutic allergy, cold and
    cough remedies, antitussives, opioid analgesics
  • Schedule II drug

47
Codeine
  • Action Binds to opiate receptors in the CNS.
    Alters the perception of and response to painful
    stimuli while producing generalized CNS
    depression decreases cough reflex decreases
    GI motility

48
Codeine
  • Side Effects confusion, sedation, hypotension,
    constipation
  • Nursing responsibilities - same as morphine
  • Evaluation of effectiveness
  • Decrease in severity of pain without significant
    alteration in level of consciousness
  • Suppression of cough
  • Control of diarrhea

49
Codeine Dosing
  • Usually supplied in combination with other
    analgesics
  • Tylenol with codeine
  • Tylenol 2 15 mg codeine 300 mg Tylenol
  • Tylenol 3 30 mg codeine 300 mg Tylenol
  • Tylenol 4 60 mg codeine 300 mg Tylenol
  • Most often given po with food
  • Most common side-effect constipation

50
Methadone
  • The drug of choice for detoxification treatment
    for opioid addiction.

51
Nonopioid Analgesics
  • Acetaminophen Tylenol
  • Salicylates aspirin

52
Acetaminophen
  • Action blocks peripheral pain impulses by
    inhibition of prostaglandin synthesis.
  • Indication treatment of mild to moderate pain.
  • Contraindications
  • Drug allergy
  • Severe liver disease
  • G6PD disease

53
Toxicity
  • Ingestion of large amounts of acetaminophen, as
    in acute overdose, or even chronic unintentional
    misuse can cause hepatic necrosis.
  • Acute ingestion of acetaminophen doses of 150 mg
    / kg or more may result in hepatic toxicity.

54
Treatment
  • Acetylcysteine or Mucomyst
  • Action Works by preventing the hepatotoxic
    metabolites of acetaminophen from forming.
  • Initial loading dose of 140 mg / kg orally.
  • Followed by 70 mg / kg every 4 hours for 17
    additional doses.
  • Note if patient vomits within 1 hour the dose
    should be given immediately.
  • All 17 doses must be given.

55
Drug Calculation
  • A teenage girl is admitted for Tylenol overdose
    weight is 120 pounds.
  • Mucomyst is ordered at 140 mg / kg for the lst
    dose.
  • Weight in kg ______
  • What dose would you give __________ in mg?
  • What dose would you give ________ in grams?

56
Anti-inflammatories
  • Chapter 44

57
Inflammation
  • Localized protective response stimulated by
    injury to tissues that serves to destroy, dilute,
    or wall off both the injurious agent and the
    injured tissue.

58
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59
Inflammatory response
  • Mediated by two pathways
  • Prostaglandin (PG)
  • Leukotriene (TL)

60
Nonsteroidal anti-inflammatories
  • Most commonly prescribed drugs.
  • 70 million prescriptions per year
  • 23 different NSAIDS

61
How do they work?
  • Anti-inflammatories worth by inhibiting the
    leukotriene (LT) and prostaglandin (PG) pathways.
  • Most NSAIDS act on one or both of the pathways.
  • Two important enzymes Cox 1 and Cox 2 (they have
    a role in maintaining gastrointestinal mucosa.

62
Side Effects of NSAIDs
  • One of the more common complaints is
    gastrointestinal distress
  • Heart burn
  • Gastrointestinal bleeding

63
NSAIDs
  • Used to treat rheumatoid arthritis and
    osteoarthritis.

64
Rheumatoid Arthritis
  • Systemic inflammatory disease often effecting
    multiple joints. Involves inflammation of the
    tissue surrounding the joints that can lead to
    destruction of the joint.
  • Symptoms include pain, stiffness and reduced
    range of motion.
  • Goal of drug therapy is to reduce the symptoms
    no cure

65
Rheumatoid Arthritis
66
Drugs used in arthritis
  • Drugs
  • Aspirin (has been placed by newer drugs due to
    gastrointestinal bleeding)
  • NSAIDs
  • DMARDs (Disease-modifying antirheumatic drugs)

67
Acetic Acid Drugs
  • Most widely knows Aspirin
  • Aspirin (acetylsalicylic acid) was the first of
    this drug classification (1899).
  • Other acetic drugs
  • indomethacin (Indocin)
  • diclofenac (Voltaren, Cataflam)

68
Reyes Syndrome
  • The acetic classification of drugs (Aspirin) is
    contraindicated in children.
  • Reyes syndrome is a neurological disease process
    thought to be trigger by the use of aspirin in
    children (flu and chickenpox).
  • Fever in children should always be managed with
    acetaminophen (Tylenol).

69
naproxen
  • Trade name Naprosyn, Aleve
  • Therapeutic classification nonopioid analgesic,
    NSAIDs
  • Action inhibits prostaglandin synthesis.
  • Indications dysmenorrhea, inflammatory disorders
    including rheumatoid arthritis
  • Therapeutic effects decrease pain, suppression
    of inflammation.

70
Antirheumatic Drugs
  • Disease-modifying antirheumatic drugs
  • Drugs have a slow onset of action often taking up
    to several weeks to see results.
  • A whole new group of IV meds have been developed
    to control symptoms in patients with multiple
    joint involvement.

71
Gout
  • When the body has to much uric acid, deposits of
    uric acid crystals collect in tissue and joints

72
allopurinol
  • Trade name Lopurin, Aloprim
  • Action inhibits the production of uric acid.
  • Client teaching
  • Advise patient to take with large glass of water.
  • Alcohol may decrease effectiveness of the drug
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