Introduction to Pharmacology Principles: Steps of the Nursing Process - ADPIE, Exams of Nursing

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PHARMACOLOGY PRINCIPLES 2022

STEPS OF THE NURSING PROCESS – ADPIE:

- ASSESSMENT: o Systematic validation and documentation of information o Data collection must include subjective and objective data ▪ Subjective = symptoms/how the pt feels - Current health hx (incl prob w/ swallowing) - Pt symptoms - Current meds (incl herbal, vitamins, and OTC) o Dosage/frequency/route o Pt knowledge of drug/side effects o Med compliance o Allergies o Use of tobacco, alcohol, caffeine, and illicit drugs - Past health hx (major injuries, illnesses, mental issues) - Pts environment – home safety, language needs, ability to read and follow instructions, ability to perform ADLs, support network (family/friends), readiness to learn, dietary patterns, cultural barriers, financial limitations, etc) ▪ Objective = signs/measurable by HCP - Physical health assessment – motor control, muscle strength, ROM, eye sight - Lab and dx tests – always get baseline data o Data collection here should target the organs most likely to be affected by the treatment ▪ Ask these 3 questions to check ability for med compliance: - What things help you take your meds as prescribed? - What things prevent you from taking your meds as prescribed? - What would you do if you forgot to take a dose of meds? - NURSING DIAGNOSIS – made based on the analysis of the assessment data. Data serves as the defining characteristic or risk factors for nursing diagnoses. More than one may be applicable to a certain problem. o NANDA list o Help develop individualized care plans - PLANNING – goal setting/expected outcomes o Goals = patient centered, describe a specific activity, and include a time frame for achievement 1

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o Needs to be realistic, measurable, acceptable to the pt, and shared w/ other HCPs involved in the pts care. o EX: patient will independently administer prescribed dose of insulin by end of the 4 th^ session of instruction

- IMPLEMENTATION – nurse provides education, med admin, pt care, and other interventions necessary to assist the pt in accomplishing their goals o Pt teaching readiness to learn is the most important part o Use assessment data to know who needs the teaching (family/friends) o For med admin teach general info about the med (why it’s needed, why med compliance is important, etc.), teach self-administration (psychomotor skills assessment important here), diet (what to eat/avoid and when), side effects (know what things to report), cultural considerations ▪ PROMOTE PT INDEPENDENCE - EVALUATION – how well goals are obtained o Interventions may need to be revised, or teaching repeated to reach goals o If goal not met – nurse collabs w/ pt/family to determine why and what they can change

5 + 5 RIGHTS OF MED ADMIN:

- PATIENT (2 identifiers – name/DOB) - DRUG (always know why you are giving the drug and make sure it makes sense) - DOSE (is the dose safe for this patient, did you draw up the correct amount) - ROUTE (PO for NPO pt or PO for drug that is destroyed in GI tract) - TIME (w/ food? Maintaining a therapeutic level?) - ASSESSMENT - DOCUMENTATION - PTs RIGHT TO EDUCATION - EVALUATION - PTs RIGHT TO REFUSE

NURSES RIGHTS OF MED ADMIN:

- Right to a complete and clear order - Right to have the correct drug, route, and dose dispensed (pharmacist) - Right to have access to information (drug reference guide) - Right to have policies to guide safe med admin - Right to admin meds safely and to identify problems in the system - Right to stop, think, and be vigilant when admin meds

SCHEDULES OF DRUGS:

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↓

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- 1 – high abuse potential, NO medical purpose. Illicit drugs (Heroin, LSD, etc) - 2 – high abuse potential but have medical purpose. (fentanyl, morphine, hydrocodone, codeine) 2 o REQUIRE WRITTEN PRESCRIPTION – no phone orders - 3 – lower abuse potential. (Tylenol w/ codeine) o Prescriptions rewritten after 6 mos or 5 refills (need to reassess pt) - 4 – less abuse potential than 3. o Prescriptions written or oral. Refills limited to 5x - 5 – low abuse potential (terpin hydrate – no alcoholics, Lomotil)

DRUG ABSORPTION:

- Affected by route of admin (IV fast, PO moderate, Rectal slow) - Drugs carried to site of action by albumin binds to drug to get out of plasma concentration o If hypoalbuminemia - ↑ amt of drug in plasma OD and toxicity. See w/ geriatrics and liver disease pts. o Only free, unbound drugs can cause pharmacologic response o Liver issues - ↓ dosage of drugs - Half-Life = time required for the total amt of a drug to decrease by ½. o Determines how frequently a drug needs to be given to maintain therapeutic levels test w/ serum blood levels o Most excretion done thru kidneys renal func = ↓ dosages o Most drugs are eliminated after 5 half-lives – take 5 half-lives to reach steady state (Dig loading dose and maintenance doses to reach steady state faster)

FIRST PASS EFFECT: partially metabolized in the liver before passing into the

circulatory system.

- Oral doses are far greater than IV doses to account for this breakdown - Ex: dopamine, lidocaine, morphine, nitro, propranolol, warfarin

EFFECTS OF AGING ON DRUG METABOLISM & EXCRETION

- PEDIATRIC PTS: give very small doses (measure carefully and double check all math – easily OD). Pts have immature livers (breakdown and absorption) and kidneys (excretion) - GERIATRICS: o ↓ peristalsis – slower absorption of drugs o ↓ CO – impaired circulation of drugs o Drugs are metabolized slower in the liver

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o ↓ blood flow and GFR – less excretion o ↓ albumin levels o Usually need smaller doses. o Be aware of POLYPHARMACY – admin of many drugs together d/t several HCPs, herbal meds, OTC drugs, and continued use of discontinued drugs

PEAK AND TROUGH:

3

- Peak measured 30 mins-2hrs after admin - Trough measured 30 mins – right before next dose only one we care about now o Usually done for potent antibiotics (vancomycin) o Want consistent level in therapeutic range o If low: ↑ dose or frequency o If high: ↓ dose or frequency

AGONIST AND ANTAGONIST:

- Agonist = drugs that display affinity for receptors and enhance or stimulate the receptors functional properties. Drugs that produce a response! - Antagonist = drugs that occupy receptor sites and prevent the action of agonists - An agonist causes an action, an antagonist blocks the action of the agonist

DRUG COCKTAIL FOR ANAPHYLAXIS (ALLERGIC RESPONSE):

- Epinephrine - Benadryl - Steroids - Inhaler/bronchodilator

MOD 2: DRUGS AFFECTING THE AUTONOMIC NERVOUS SYSTEM

CHOLINERGIC AGENTS (parasympathoMIMETICS) “fluids flow”:

Drugs:

- Bethanechol (Urecholine) – prototype o Cholinergic agonist o Tx urinary retention (beth can’t pee) o Should work w/in 1 hr - Pilocarpine (Isopto Carpine, Pilocar) o Cholinergic agonist

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o Tx ↑ IOP – eye drops for glaucoma (miotics to constrict pupils and allow fluids to flow)

- Metocloprimide (Reglan) o Cholinergic agonist o Tx GERD (GI prokinetic) - Edrophonium (Tensilon) – MG drugs given several times daily – ON TIME! o Used to diagnose Myasthenia Gravis, drug of choice because of short duration; IV or IM – give as drip until other meds can start working 4 o ↓ muscle weakness – anticholinesterase agent – destroys enzyme that destroys ACh. MG is a neuromuscular disease process – can’t get enough ACh at the synapses. o Ex: gave to pt who presented with weakness and lost consciousness. Pt was aroused and alert with drug, but bc it is so short acting, they lost consciousness again very soon after. Dx of MG. (initially thought stroke but it wasn’t unilateral) - Neostigmine (Prostigmin) o Diag and tx Myasthenia Gravis, prevent and tx post-op distention and urinary retention; po and injectable o Antidote for neuromuscular blockers - Pyridostigmine Bromide (Mestinon) o Tx Myasthenia Gravis o Antidote for neuromuscular blockers

How They Work:

- Work by stimulation of cholingeric receptors by mimicking acetylcholine (cholinergic agonist) or inhibition of enzyme acetylcholinesterase (the enzyme that breaks down ACh) to prolong action of acetylcholine (anticholinerestase agents)

Indications and Toxicity:

• Reduce IOP in glaucoma (causes miosis, increasing outflow of aqueous humor)
• Treat atony (loss of muscle tone) of GI tract or bladder (urinary retention) - Diagnose and treat myasthenia gravis - Antidote for: neuromuscular blocking agents, tricyclic antidepressants, and Belladonna alkaloids (B&O suppositories)

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DRUG INTERACTIONS: Cholinergic blocking agents (e.g., atropine): antagonism of acetylcholine's effect at muscarinic receptors, serving as antidote

- Pt has MG, too high of med dose give atropine! ADVERSE REACTIONS: blurred vision, decreased accommodation (near to far vision), miosis, diaphoresis, ↑ salivation, BRONCHOCONSTRICTION – NO COPD OR ASTHMA PTS!, vasodilation (↓ HR – hypotension). FLUIDS FLOW! - SLUDGE o Salivation o Lacrimation o Urination (helps w/ urinary retention) o Diaphoresis o GI secretions increased o Elimination/diarrhea 5 - DUMBELS o Diarrhea o Urination o Miosis o Bronchoconstriction o Emesis o Lacrimation o Salivation NURSING INTERVENTIONS: - Keep respiratory support equipment nearby (bronchoconstriction)

• Have atropine available for use as an antagonist or antidote (0.6 mg in a syringe) o Sx to be alert for: decreased B/P, shock, cardiac arrest o S&S of Cholinergic Overdose: flushing, salivation, sweating, nausea, abdominal cramps
• Check client's vision frequently if an ocular condition is being treated with a cholinergic agonist realizing that visual acuity may be diminished - Report signs of excessive cholinergic activity (or cholinergic crisis). o Sx of toxic response: dysphagia, resp weakness (leading to paralysis – need for mech vent), fasciculations (uncontrollable twitching of a single muscle group. ex in the heart is fibrillation), miosis, pallor, sweating, vertigo, excessive salivation, n/v, abdominal cramping, diarrhea, bradycardia

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- Monitor for urination. After giving urecholine for urinary retention, should void within the hour if effective! - Monitor and record changes in muscle strength daily. o EX: If effective for Myasthenia Gravis, speech will be clear not slurred, able to handle own oral secretions, breathing status adeq etc. TEACH: - show client how to instill cholinergic agent into eye - tell client that drug may affect visual acuity, impacts accommodation - show client receiving anticholinesterase therapy how to assess and record changes in muscle strength - stress need to take drugs on time (may be several times daily in MG to prevent muscle weakness) – PREVENT ASPIRATION! ACh bronchoconstriction!

CHOLINERGIC BLOCKING AGENTS (parasympathoLYTICS,

anticholinergics):

Drugs:

- atropine – prototype 6 o po, IV, IM o used to treat bradycardia, minimizes vagal reflexes, blocks vagal effects on the heart, pre-anesthesia to decrease secretions - belladonna o decreases GI motility in IBS, treats bladder spasms after a TURP (B&O supp) - propantheline (Pro-Banthine) o GI and GU spasmolytic - benztropine (Cogentin) o used to tx Parkinsonism o Given for EPS from antipsychotics - ditropan (Detrol LA) o GU spasmolytic o “gotta go, gotta go, gotta go right now!” - ipratropium bromide (Atrovent) o tx COPD by blocking action of acetylcholine at bronchial smooth muscle sites, promoting bronchodilation

How They Work:

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- Cholingeric blocking agents interrupt parasympathetic nerve impulses in the central and ANS. They compete with acetylcholine at muscarinic receptor sites

Indications and Toxicity:

- Used to treat: o Spasticity of GI or urinary tract o Cardiac arrhythmias, bradycardia (blocks vagal effects of the SA node - Pacemaker of the heart) o Motion sickness o Parkinsonism o Chronic asthma o Used as pre-anesthesia medications to dry up secretions (atropine) o Relaxants for GI tract during diagnostic procedures (ERCP, EGD) o Dilate eye during surgery (mydriatic) – cataract removal, etc. NOT GLAUCOMA! ADVERSE REACTIONS: ↓ salivation and sweating HEATSTROKE (esp in elderly), pupils dilate (↓ accommodation), ↑ HR, urinary retention, ↓ GI motility, CNS toxicity manifested by restlessness followed by depression, irritability, disorientation, delirium (Signs of toxicity that can be remembered as "hot as a hare, blind as a bat, dry as a bone, mad as a hatter, red as a beet) - STORY: Pt was given scopolamine for n/v – became combative and manic. When removed, returned to normal 7 - 3-D Effect: o Drying o Decreased GI/GU motility o Dilated pupils CONTRAINDICATIONS: glaucoma, (why can’t you dilate the pupils in glaucoma? - ↑ IOP). Coronary artery disease, renal or GI obstructive disease, reflux esophagitis, myasthenia gravis – throw into MG crisis! Benign prostate enlargement (already retain urine – would make it worse!) NURSING INTERVENTIONS: - If prescribed for GI spasticity, administer 30 minutes before meals and at bedtime - Keep client's room cool – no diaphoresis (prevent heatstroke) - Watch for signs of heatstroke and dehydration (flushing, altered LOC)

• Measure fluid intake and output, particularly in clients with benign prostate

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enlargement. Monitor for urinary retention - frequency and voiding small amounts o Assess for Urinary Retention – palpate for bladder distention. Bladder scan after.

- Good oral hygiene to decrease periodontal disease caused by decreased salivation (sugarless gum, hard sugarless candies or ice to reduce dry mouth, saliva substitute). o Saliva = mouth cleaning agent. Prevents dental carries.

ADRENERGIC AGENTS (sympathoMIMETICS):

Drugs:

- Beta 1 Agonists: ↑ HR and strength of contraction

o Norepinephrine (Levophed)

▪ Tx acute hypotension and shock ▪ Use central line/PICC PREVENT EXTRAVASATION (vasocontriction necrosis. Make sure IV site is patent) ▪ Pt in shock need to vasoconstrict to shunt blood to heart, lungs, and brain (GIVE LEVOPHED)

o Dopamine (Intropin)

▪ Shock, MI, ↑ renal blood flow ▪ Small doses = renal ▪ Large doses = heart

- Beta 2 Agonists: Dilate bronchioles, arteries, and GI tract

o Epinephrine – NO PO

▪ Causes bronchodilation (help asthma and anaphylaxis) ▪ Also causes vasoconstriction in periphery for shock tx ▪ If given IV stops bleeding/cardiac arrest 8

o Terbutaline (Brethine)

▪ Bronchodilation and pre-term labor (↓ contractions)

o Albuterol (Proventil)

▪ Rescue inhaler ▪ Tx bronchospasm

- Alpha Agonists: vasoconstriction to ↑ BP

o Phenylephrine (Neo-Synephrine)

▪ Tx shock. Nasal spray for allergies ▪ Dilates pupils – NO GLAUCOMA PTS

How They Work

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- Cause responses similar to sympathetic nervous system (fight/flight)

Indications and Toxicity:

- Tx: hypotension, shock, bradycardia, asthma, COPD, allergic responses, nasal and ophthalmic congestion ADVERSE REACTIONS: restlessness, anxiety, palpitations, tachycardia, HTN, angina (chest pain tissue doesn’t get enough O2 = tissue death/MI), local necrosis and tissue sloughing w/ extravasation (levophed, dopamine) - If extravasation occurs or BP gets too high ANTIDOTE = Phentolamine (Regitine) – POTENT VASODILATOR NURSING INTERVENTIONS: - administer dopamine only by intravenous infusion, using a dedicated line (not mixed/run w/ anything else), IV pump NOT gravity drip (critical care drug – want a central line) - Measure glucose levels in client with diabetes o Brain needs glucose, so liver kicks in and dumps stored glucose. May need more insulin! o Need ↓ 180 for wound healing - Monitor electrocardiogram, blood pressure, cardiac rate, and cardiac rhythm during infusion - Have O2 and emergency equipment available (crash cart) - Monitor serum K+ level for hypokalemia if prolonged infusion of terbutaline(Brethine) for pre-term labor - Place client in left lateral recumbent position to prevent hypotension during IV infusion of terbutaline – gets baby off of vena cava to allow blood to flow and return to the heart. - Infuse IV into a large vein to avoid extravasation, monitor site every 10 – 15 min. Some agencies have policy to only infuse in a central line. 9 o Symptoms of extravasation: IV site coldness, hardness, pain o If extravasation occurs, HCP injects the area SQ within 12 hours with 10- 15 ml of normal saline solution containing Regitine 5-10 mg, as prescribed to vasodilate! - Monitor urinary output, notify MD if decreased (shock – meds aren’t working) - Routine monitoring with vasoconstrictors such as dopamine: o Monitor vital signs continuously, want to see an increase in pulse and B/P. Keep SBP above 90, don’t want tachycardia. (w/ shock, HR ↑ and

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BP ↓ - want to reverse it!) o Monitor hourly urine output - catheter; output should increase since drug improves perfusion to vital organs (min 30 ml/hr). o Monitor peripheral pulses at least every 2 – 4 hours (CMS checks); assess temp, color, tingling or numbness of fingers or toes (should be bilateral. If unilateral, something else is wrong) vasoconstrict periphery to shunt blood to heart, brain, and lungs (rob peter to pay paul. Life > limb). o When titrating off vasoconstrictors, monitor for drop in B/P TEACH:

- Teach client how to measure pulse rate and when to report it - Show client how to use inhalant device o Advise client to use smallest number of inhalations to accomplish drug administration (1 puff may be all that’s needed. Teach to follow Drs orders) and to minimize dry mouth by rinsing mouth after inhalation - Teach about rebound nasal congestion if vasoconstrictors (NeoSynephrine or epinephrine) are used too often or too long as nasal spray o Only use for acute symptoms. Follow med admin orders. - Teach use of Epi pen o Have available and store in cool, dark place (not fridge) o Don’t use if discolored or has particles o Take at 1 st^ sign of trouble (immediately) o Inject SQ on outer thigh – hold in place for 5-10 seconds, massage for 10 sec

ADRENERGIC BLOCKING AGENTS (sympathoLYTICS):

How They Work:

- disrupt SNS function. They block impulse transmissions at adrenergic neurons or adrenergic receptor sites

Alpha-Adrenergic Blockers:

Drugs:

- Phentolamine (Regitine) 10 o diagnose pheochromocytoma and control associated hypertension o Potent vasodilator - Ergotamine o Tx: vascular headaches, (migraines) it allows vasoconstriction of

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dilated cerebral arterial vessels. o Give early in the migraine to maximize effectiveness. o Dose: 2 mg po or sl, then 2 mg every 30 min until resolution occurs or max dose of 6 mg per attack. Max 3x/attack!

How They Work:

- Regitine vasodilates to ↓ BP

Indications and Toxicity:

ADVERSE REACTIONS: orthostatic hypotension, bradycardia or tachycardia

- Ergotamine toxicity - prolonged vasoconstriction marked by cold, numb extremities; diminished or absent arterial peripheral pulse; seizures; and tissue damage, including gangrene. o Treatment includes immediate discontinuation of the drug and symptomatic therapy – can give Regitine to vasodilate. NURSING INTERVENTIONS: - administer oral drugs with milk to minimize GI effects - administer meds early in a migraine attack, while reducing light and noise in client's environment - note any change in blood pressure when client rises from supine position - auscultate breath sounds - note signs and symptoms of light-headedness, weakness, or altered mental functioning (orthostatic hypotension). Elevate client's bed side rails and give assistance if CNS symptoms occur - monitor client taking ergotamine for signs of vascular insufficiency, including numbness, coldness, tingling, or weakness in extremities - notify physician immediately if client reports chest pain

Beta-Blockers (olols):

Drugs:

- Atenolol (Tenormin) – selective (less lung impact) - Metoprolol (Lopressor) – selective (less lung impact) - Propranolol (Inderal) – nonselective (NO COPD OR ASTHMA PTS) o decreases heart rate so ↑ exercise tolerance, ↓ O2 demands in angina, MI, migraine, anxiety. 11

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o Can cause bronchoconstriction

How They Work:

- Block beta receptors on heart and lungs - ↓ HR (hold if <50), ↓ CO, ↓ BP

Indications and Toxicity:

- treat hypertension, angina, arrhythmias, migraine ADVERSE REACTIONS: arrhythmias, orthostatic hypotension, bradycardia, exacerbates congestive heart failure, edema, cold extremities, bronchospasm, blocks ↑ HR seen w/ hypoglycemia – teach other S&S NURSING INTERVENTIONS: - administer oral drug before meals or at bedtime to speed absorption - Refrain from administering in evening if insomnia occurs - administer any needed antacids several hours before or after beta- blocker administration - check client's apical pulse rate before drug administration; if under 50 hold med and inform the HCP - monitor vital signs, fluid intake and output, breath sounds, and peripheral circulation before and during drug administration - monitor blood glucose levels in clients with diabetes - use safety precautions, including use of bed side rails, if client develops adverse CNS effects Neuromuscular Blocking Agents - Neuromuscular blocking agents relax skeletal muscles by disrupting nerve impulse transmission. They do not cross the blood-brain barrier, thus the patient remains conscious and aware of pain. Dr. will order analgesics for pain. Client **can't communicate pain or anxiety because of flaccid paralysis. Must have respiratory support (bag or ventilator).

• Nondepolarizing agents o** Mechanism of action: blocks acetylcholine at cholinergic receptors in skeletal muscle membrane, **preventing depolarization and contraction o Examples ▪ pancuronium (Pavulon) for intubation and ventilation ▪ vecuronium (Norcuron)
• used in heart disease and asthma because it doesn’t cause decreased BP and bronchospasm** ▪ ANTIDOTE: Prostigmine (treats MG), an anticholinesterase agent o Adverse effects: apnea (PROTECT THE AIRWAY!) , hypotension and bronchospasm; increased bronchial and salivary secretions - Depolarizing Blocking Agents o Mechanism of action: mimics acetylcholine to depolarize postsynaptic muscle membrane, resulting in repeated contractions followed by muscle

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paralysis 12 o Example: succinylcholine (Anectine) IV; drug of choice for short term muscle relaxation during intubation and ECT o Adverse effects: apnea , hypotension, and bronchospasm; increased bronchial and salivary secretions, muscle pain o Contraindications: malignant hyperthermia ( Dantrium reverses ), acute narrow- angle glaucoma, penetrating eye injury, myopathy o Nursing implementation factors ▪ Administration procedures

- keep antagonists at hand - have endotracheal equipment, suction equipment, oxygen, and mechanical ventilator available for emergency, must protect **the airway

• maintain a calm environment, provide reassurance and explain all** procedures and outcomes to the patient pt paralyzed but alert – VERY SCARY! - administer these agents in conjunction with an anxiolytic **(Xanax, Ativan) or analgesics for pain!
• monitor vital signs and respiratory rate and pattern** **during succinylcholine infusion ▪ Daily monitoring and measurements
• monitor respirations - q. 5-10 minutes - until client recovers completely from neuromuscular blockade
• signs of complete recovery include a renewed ability to cough and return to previous levels of muscle strength on hand-grip and head- lift tests
• suction client as necessary
• monitor serum potassium level during succinylcholine infusion**
• monitor intake and output of fluids and electrolyte levels in client with renal disease receiving nondepolarizing agent **DRUGS TO TREAT NEUROLOGIC AND NEUROMUSCULAR SYSTEM DISORDERS Skeletal muscle relaxing agents
• Relieve musculoskeletal pain or spasm and severe musculoskeletal spasticity
• Used to treat o Multiple sclerosis (MS) o Cerebral palsy (CP) o CVA (stroke/brain attack) o Spinal cord injury (SCI)
• Centrally acting o** They inhibit interneuron activity in the spinal cord and the brain; they are CNS depressants

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o Used as adjuncts to rest and physical therapy o Examples ▪ carisoprodol (Soma) ▪ chlorzoxazone (Paraflex) 13

- take with food to avoid GI distress; may discolor urine orange or purple-red (harmless, but teach pt so they don’t think it is blood) ▪ cyclobenzaprine hydrochloride (Flexeril) Prototype

• short term , no longer than 3 weeks. Makes you drowsy. **▪ methocarbamol (Robaxin)
• po, deep IM or IV (Mix in NS)**
• also used in tetanus management. **- May color urine green, black, or brown ▪ Effects of centrally acting agents are felt as early as one hour after administration
• Peripherally acting or Direct Acting o** Acts directly on skeletal muscle to inhibit calcium ion release ; lower incidence of adverse CNS effects, but high therapeutic doses are hepatotoxic or prolonged use. Most effective for spasticity of cerebral origin. Affects contractile mechanism of muscles. o Only drug is dantrolene (Dantrium) – used for malignant hyperthermia o Dosage titrated to individual response, using lowest dosage possible , initial effects not evident for a week or more, increase dosage slowly o Drugs of choice to treat malignant hyperthermic crisis ▪ Hereditary and fatal defect triggered by anesthetics, muscle relaxants and neuromuscular blocking agents. ▪ They prolong an increase in the release of calcium from the muscle, producing intense muscle contraction, body heat, and metabolic acidosis. ▪ Dantrium reduces release of calcium – calcium is the culprit!
• Adverse effects; drowsiness, dizziness , GI distress, ataxia (unsteady gait) , hypotension, blurred vision, bradycardia, urine retention, physical and psychologic dependence (with prolonged use), muscle weakness, depressed liver function, headache, confusion, nausea, fatigue, vertigo , hypotonia, muscle weakness, hallucinations, euphoria, depression, anxiety - Nursing implementation factors o monitor neuromuscular status o Check bowel and bladder function o measure liver and kidney function. What labs? **AST/ALT/Bilirubin and BUN/Creatinine. o monitor for respiratory depression. Have emergency equipment available
• Points for client teaching o caution client receiving skeletal muscle relaxants that mental alertness may be impaired. Do not use other CNS depressants at the same time, including alcohol.**

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o advise client receiving baclofen that maximum benefit may not be attained for 1- 2 months (central acting are faster) Antiparkinsonian Agents

• Parkinson's disease is a progressive, idiopathic neurologic disorder caused by depletion, degeneration, or destruction of dopamine (NT) in the neurons of the brain's basal ganglia.
• It is an involuntary movement disorder known by 4 cardinal features: tremor at rest, akinesia (complete or partial loss of muscle movement), rigidity (increased muscle tone), and disturbances of posture and equilibrium, however no change in cognition. - The disease can also result from drugs, encephalitis, neurotoxins, trauma, and arteriosclerosis (arteries narrowing, not plaque). Not uncommon to be on more than one drug at a time. 14

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- Anticholingeric o Inhibit cerebral motor centers and suppress central cholinergic activity and the characteristic tremor of parkinsonism (↓ tremors) o Used in early stages when symptoms are mild o Used alone or with amantadine (Symmetrel) o If discontinued, reduce dose gradually. Abrupt withdrawal can produce confusion, exhaustion, exacerbation of symptoms o Examples: ▪ benztropine mesylate (Cogentin) ▪ trihexyphenidyl hydrochloride (Artane) ▪ diphenhydramine (Benadryl) – rarely used o Adverse effects - same as previously discussed anticholingerics ▪ 3D effect. In what disease process are anticholinergics contraindicated? Glaucoma - Dopaminergic Agents o Act in the brain by increasing the dopamine concentration in the basal ganglia or by enhancing neurotransmission of dopamine

• Examples: o carbidopa - levodopa (Sinemet) prototype ▪ combination drug, allows more levodopa to be converted to dopamine in the brain ▪ B6 causes ↑ levodopa metabolism - ↓ efficacy – will see more Parkinson’s o amantadine (Symmetrel) ▪ a dopamine agonist, increases dopamine in the CNS. ▪ if must be withdrawn do so gradually to avoid parkinsonian crisis ▪ effective against rigidity so maybe added with other drugs for this effect **▪ is also classified as an antiviral drug – can be used in place of Tamiflu
• Adverse effects** o Levodopa ▪ GI: nausea, vomiting, anorexia ▪ cardiovascular: orthostatic hypotension (SAFETY – prevent falls!), palpitations, tachycardia ▪ CNS: irritability, confusion, hallucinations , depression ▪ other: dark-colored urine and sweat, urinary frequency or retention **▪ eye winking and muscle twitching are early signs of Sinemet overdosage
• Drug interactions o Levodopa ▪** Antipsychotics, anticholnergics, reserpine, benzodiazepines , pyridoxine (Vit B6), phenytoin: causes **decreased dopaminergic effects of levodopa
• B6 from foods and OTC supplements. Daily vitamins are okay – fixed amount
• Nursing implementation factors** o Administration procedures ▪ Anticholinergic agents : same as previously stated. Give during or shortly after meals to prevent GI adverse reactions ▪ Dopaminergic agents

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• give after meals to reduce GI symptoms and avoid drug-food interaction 15
• refrain from administering amantadine late at night if insomnia occurs - If any antiparkinsonian agent must be discontinued dosage should be reduced gradually. Abrupt withdrawal causes confusion, exhaustion, and an increase in symptoms. o Daily monitoring and measurements ▪ anticholinergic agents: same as previously stated ▪ assess client's mobility (want to see improvement) ▪ monitor client's blood pressure for orthostatic hypotension ▪ elevate client's legs to reduce edema - Points for client teaching o warn client not to exceed daily dosage o reassure client that levodopa may cause harmless darkening of urine and sweat o show client methods of minimizing orthostatic hypotension ▪ get up slowly. No quick mvmts. o because scheduling of medications is very client specific, encourage close follow-up ▪ MUST BE ON TIME! o for anticholinergics : ▪ may relieve xerostomia by drinking cold beverages, sucking on hard candy, or using a nonprescription saliva substitute. Encourage proper oral hygiene. Avoid getting too hot, prone to heatstroke; photophobia, wear sunglasses. o Proteins may compete with levodopa transport to the brain, rather than restrict protein intake, it should be divided in equal parts to be taken over the entire day. ▪ Don’t restrict protein! Keep level constant. o Vitamins and foods high in pyridoxine (Vit B6) {liver, green veg, fortified cereals, whole grain cereals, beans (lima & navy)} may decrease the effects of levodopa and should be avoided, they interfere with absorption. o On off syndrome – usually seen in LTC. When pts have bad days, don’t automatically change meds. If several days in a row clustered, then call Dr. Always documents off days. o Adequate fluid intake (3D effects) o Teach methods to prevent constipation (3D effects). - Nursing evaluations o client achieves good therapeutic effects with antiparkinsonian agent, improving mobility and functioning, decreasing tremors and rigidity, decreases bradykinesia. o client maintains normal mental functioning – If LOC ↓, won’t be d/t parkinsons. Will be d/t meds. o client maintains normal urinary elimination pattern Anticonvulsant Agents/ Antiepileptic Drugs (AED)

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PHARMACOLOGY PRINCIPLES 2022

- Prescribed for long-term treatment of epilepsy and for short-term control of acute isolated seizures not caused by epilepsy. Drug choice depends on an accurate diagnosis of seizure type, the ability of the drug to control seizures with minimal adverse effects, the use of a single drug **if possible, and appropriateness of the drug for the patient's age and health

• Hydantoins – most effective.** o Treat seizures by depressing abnormal neuronal activity in motor cortex to prevent spread of seizure activity. It alters ion movement across cell membranes so it inhibits the spread of seizure activity (esp Na, K, Ca) o Examples 16 ▪ phenytoin (Dilantin) - prototype - most commonly prescribed anticonvulsant because of its efficacy and relatively low toxicity - because of general effect of stabilizing excitable cells, exerts significant effects on excitable tissues outside CNS. It exhibits antiarrhythmic properties. Also exerts a membrane-stabilizing effect on the pancreas and may inhibit effective insulin release – careful w/ diabetics - Is not compatible with dextrose – only saline!! o Adverse effects: drowsiness (will adjust w/ time), gingival hyperplasia (Dilantin only – overgrowth of gums. Need oral hygiene and to see dentist regularly), blood dyscrasias , headache, nausea, vomiting , anorexia, hirsutism (Dilantin only) and hypersensitivity reactions such as: ▪ Stevens-Johnson Syndrome (SJS): serious, sometimes fatal inflammatory disease (hypersensitivity) usually affecting young children and young adults. Onset of fever, bullae (large blister) on the skin, ulcers on mucous membranes of lips, eyes, mouth, nasal passages and genitalia, pneumonia, arthralgia (joint pain), prostration. May have perforation of the cornea. - Shed skin like a snake. Hard to get IV/blood draws - TX: bedrest, antibiotics for pneumonia, glucocorticoids (↓ inflammatory response) , analgesics (very painful) , mild mouthwashes (ulcers) , sedatives ▪ Dilantin Toxicity: If pt is on Dilantin and still having seizures – check serum levels to make sure they are taking their meds and getting a high enough dose - Coordination problems, slurred speech, lethargy, diplopia, nystagmus (jerking mvmt on eye) , nausea o Drug interactions ▪ Decreases effectiveness of oral contraceptives - Young female put on seizure meds – need to teach to prevent pregnancy another way - Valproates o unrelated structurally to other anticonvulsants o mechanism of action may be related to increased availability of inhibitory neurotransmitter GABA to brain neurons

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PHARMACOLOGY PRINCIPLES 2022

o used to treat manic episodes of bipolar disorder, unlabeled use for migraine headaches o Examples ▪ valproic acid (Depakene)

- not prescribed routinely because of possible **hepatotoxicity ▪ divalproex sodium (Depakote)

• Adverse effects** : headache, drowsiness , sedation, confusion, diplopia, nystagmus, vertigo, dizziness, ataxia, tremor, muscle weakness, dry mouth, nausea, vomiting, diarrhea, constipation, thrombocytopenia, agranulocytosis, aplastic anemia , urinary frequency; **hepatotoxicity (rare, with valproic acid)
• Nursing implementation factors o Administration procedures ▪ administer intravenous (IV) phenytoin (Dilantin) slowly to avoid cardiotoxicity** (arrhythmias) , will cause hypotension – MONITOR BP! 17 ▪ monitor blood pressure, pulse, and respiration during phenytoin and barbiturates IV administration and afterward until client is stable ▪ reduce phenytoin (Dilantin) infusion rate if blood pressure drops, have emergency equipment available (crash cart) ▪ avoid mixing other drugs in same syringe with phenytoin; for IV administration do not mix in D5W ▪ discontinue phenytoin immediately and notify the doctor if patient develops a skin rash, a hypersensitivity reaction (Stevens Johnson Syndrome) ▪ avoid intramuscular (IM) or intravenous (IV) administration of valproates to reduce chance of bleeding. Have patient use a soft-bristle toothbrush and an electric razor **o Daily monitoring and measurements ▪ monitor serum drug concentration (Dilantin 10 – 20 mcq/ml)
• observe for Dilantin Toxicity ▪ periodically check liver function tests (AST, ALT, bilirubin) and blood count esp when taking valproates – hard on the liver** ▪ Symptoms of liver compromise : fatigue, nausea, abd pain (URQ), easy bruising/bleeding, petechiae, ecchymosis, jaundice (late sign) ▪ monitor client's mental status and take precautions if mental status alters (dizziness, drowsiness) - Points for client teaching o recommend that a female patient who uses an oral contraceptive use an additional or different contraceptive method (hydantoins) o tell client taking phenytoin that drug may cause harmless urine discoloration o warn client with diabetes o hydantoins may increase blood glucose levels and that valproates may produce a false- positive result on a urine ketone test

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PHARMACOLOGY PRINCIPLES 2022

o instruct client taking Dilantin - regarding good oral hygiene and routine visits to dentist o instruct client to take meds as ordered, abrupt withdrawal can precipitate a seizure o It is not uncommon for the client to be drowsy during the initial therapy; client should be cautioned so they can avoid driving a car or operating hazardous equipment ▪ Body will adjust with time o Medic alert card or bracelet

MOD 3: DRUGS AFFECTING THE CNS/PAIN

NON-NARCOTIC ANALGESIA, ANTIPYRETICS, and

NSAIDs SALICYLATES:

Drugs:

- Aspirin (ASA, Bayer) - PROTOTYPE o Contraindicated in children with varicella/influenza (viral infections). Not used in children under 12 yo – REYE’S SYNDROME o If you see an MI pt who is taking ASA, don’t think that it is for pain/fever it is to prevent clotting and another MI. 18 - Ecotrin- enteric coated aspirin (↓ GI irritation)

• Ascriptin- ASA & Maalox (↓ GI irritation)

How they Work:

• Pain relief by inhibiting prostaglandin synthesis
• ↓ Fever thru hypothalamic stimulation leading to vasodilation/↑ sweating
• ↓ Inflammation by inhibiting prostaglandin synthesis - Inhibit platelet aggregation (↓ clotting)

Indications and toxicity:

TREATS:

• HA

• Neuritis – nerve inflammation
• Neuralgia – nerve pain
• Myalgia – muscle pain
• RA
• Painful periods
  • Prevent: TIA/MI

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ADVERSE EFFECTS:

• GI (N/V, GI distress) o Tarry stools, bleeding gums, petechiae, ecchymosis
• Tinnitus, hearing problems (buzzing, ringing, roaring, hissing, etc.) - Salicylism Toxicity SALICYLISM TOXICITY: (usually seen w/ arthritis – taking high doses LT)
• N/V and Diarrhea
• Thirst/Sweating
• Confusion
• Hyperventilation
• Dizzy/ Tinnitus CONTRAINDICATIONS: active GI bleed, gastric ulceration, or kids under 12 w/ viruses TOXIC TO WHICH SYSTEMS: hepatic and renal. NEPHROTOXIC! NURSING INTERVENTIONS:
• Give w/ 8oz of H2O (helps dilute meds in stomach, ↓ ulcer risk - Assess hearing changes to look for Salicylate Toxicity (tinnitus!)

NSAID’s:

Drugs:

19

- Ibuprofen (Motrin) – PROTOTYPE - Ketorolac (Toradol) – only non-PO. Can be given PO, IM, or IV. o Only injectable NSAID – ST pain mgmt. o Used for breakthrough pain w/ epidural or PCA pain mgmt. (↓ narcotic usage) - Celecoxib (Celebrex) – COX-2 inhibitor o ↓ GI issues o SAFETY – sounds like a lot of other meds, so always know why you are giving your patient this med.

How They Work:

Relieve/alter pain by acting in peripheral nervous system to:

- Inhibit formation/reactivity of prostaglandins – Controls Fever

• Inhibit COX enzyme (1st enzyme in the prostaglandin pathway) - ↓ inflammatory response

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Indications and toxicity:

ADVERSE EFFECTS: better tolerated by stomach than salicylates or steroids

• GI issues – give w/ food
• NEPHROTOXIC (don’t give to renal pts) CONTRAINDICATIONS: active GI bleed, gastric ulceration, kidney issues/failure INTERVENTIONS: - Monitor for fluid retention
• Take w/ full glass of H2O and remain upright for 30 mins after admin (↓ chance of esophageal ulcer)
• Take w/ meal to ↓ GI irritation GENERAL NOTES: you must assess and reassess pain level before and after pain interventions. (pain scale, ask where is the pain, describe the pain, etc.)

NARCOTIC AGONISTS

Drugs:

- Morphine Sulfate (Duramorph) – prototype o Gold standard – all others are compared to MS 10mg IM o Given for severe pain (acute, chronic, and terminal) o ↓ pre-op anxiety o ↓ dyspnea of pulmonary edema and left ventricular failure (CHF) by ↓ anxiety and causing peripheral vasodilation - ↓ BP and workload of heart ▪ Morphine is cardiac friendly – give for angina 20 o NO CEILING EFFECT – the more you give, the greater the effect o Almost all routes of admin available – PO, IM, IV, SQ, SL, rectal, etc. o Crosses placenta – can cause fetal respiratory compromise o SAFE DOSE RANGE: IVP – 1-2mg q3-4h ▪ If gave 1mg and 3 hrs later still in pain – give 2 mg! GET PAIN UNDER CONTROL - MS Contin (Morphine Sustained Release) o Used for terminal pts o Pain free for 6-12 hrs o In terminal pts – care more about pain control than respiratory depression

• Codeine (combine w/ ASA or Tylenol)

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o Additive analgesia o Antitussive (cough prevention) o Has a ceiling effect

• Fentanyl (Sublimaze) – “pain patch” o Only parenteral o Can be used for epidural analgesia o Assessment – always locate patch and look at time/date. Good for 72 hrs. o DISPOSAL – fold in half and either flush or put in sharps container - Hydromorphone (Dilaudid) o More potent than morphine o Admin via PCA pump ▪ Loading dose to get pain under control, then constant basal dose with intermittent bolus doses as pt needs them ▪ Need patent IV site ▪ Teach that can’t overdose – lockout feature
• Methadone (Dolophine) o Synthetic narcotic used for detox from narcotics o Used for LT chronic pain o Still produces tolerance and dependence

How They Work:

• They alter pain perception by: o inhibiting transmission of pain impulses o ↓ cortical responses to painful stimuli in the brain stem o Altering behavioral responses to pain

Indications and toxicity:

• ↓ pain, pt is less tense and more tranquil/euphoric good feeling leads to addiction 21 ADVERSE EFFECTS: respiratory depression, vasodilation - ↓ BP (orthostatic hypotension), flushing, constipation, urinary retention, miosis, euphoria, sedation, tolerance, dependence
• Be alert for WITHDRAWAL SYNDROME d/t physical dependence o S&S: (occur w/in 24-48 hrs) irritability, diaphoresis, restlessness, twitching muscles, ↑ HR/BP CONTRAINDICATIONS: head injury (masks changes in LOC) – don’t give until after

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MRI, CAT scan, and Dx. Narcotics ↓ RR which ↑ CO2 levels leading to ↑ ICP.

• Don’t give to pregnant clients – fetal respiratory compromise!

NARCOTIC ANTAGONIST

Drugs:

• Naloxone (Narcan) – drug of choice for reversal of resp. depression from narcotic overdose o IV, IM, SQ: IV preferred o Push in small doses every 2-3 mins as needed ▪ Want to stimulate the pt to arouse them without reversing all analgesia from the narcotic ▪ If push too much too fast, pt will be awake but in pain. Won’t be able to get pain under control until Narcan is out of system ▪ If 10mg (full ampule) given w/ no response – re-evaluate dx of narcotic OD o May need to give multiple doses because Narcan life is shorter and narcotics o If on PCA pump – remove or lower basal dose ADVERSE EFFECTS: n/v, ↑ BP & HR – stimulant!

GENERAL NURSING IMPLEMENTATION FOR NARCOTICS:

- Monitor RR before and after admin: if rate is 8-10/min or less hold the drug and call HCP o Have respiratory support equipment on hand

• SAFETY: siderails up and bed in low position – cause drowsiness and orthostatic hypotension - DO NOT discontinue narcotics abruptly in narcotic-dependent client withdrawal syndrome! - Always assess pain before and after admin for effectiveness – admin prior to pain becoming severe o Educate pts that is taking ST for pain mgmt., won’t become addicted
• Monitor V/S – look for trends!!
• Teach nonpharmacologic pain relief measures to augment analgesic use 22
• When in pain, geriatrics may become restless, agitated and confused. Don’t know how to report pain or ask for meds. o If pt just had surgery and becomes combative – reach for the morphine before the Haldol. - Teach to AVOID alcohol and other CNS depressants

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