Download - Drugs Acting on the CNS and PNS 2011 Mps
Major P. Salipot, RN Page 1 of 15 St. Mary’s College
Selected Neurotransmitters
Acetycholine – communicates between nerve and muscle.
Norepinephrine/epinephrine – found in limbic system; involved in arousal
Dopamine – involved in coordination of impulses and responses (motor and
intellectual)
GABA – inhibits nerve activity and impt in preventing overexcitability or
stimulation such as seizure
Serotonin – found in limbic system, impt for arousal and sleep; prevent
depression and promote motivation.
ANTIANXIETY
A void abrupt discontinuation after prolonged use
N ot give if increase BP, renal/hepatic dysfunction or
history of drug abuse
X anax, Ativa, Serax - a few examples
I ncrease in 3 D’s- drowsiness, dizziness, decrease BP
E nhances action of GABA
T each to rise slowly from supine
Y es, alcohol should be avoided
Anxiolytic and Hypnotic agents
Anxiolytics – prevents feelings of tension or fear
Sedatives - calm patients and make them unaware of the environment
Hypnotics - cause sleep
Minor tranquilizers – causes state of tranquility in anxious patients
STATES AFFECTED BY ANXIOLYTIC AND HYPNOTIC DRUGS
1. Anxiety - feeling of tension, nervousness, apprehension, or fear that usually
involves unpleasant reactions to a stimulus , whether actual or unknown
2. Sedation - loss of awareness and reaction to environmental stimuli
a. For patients who are restless, nervous, irritable or overreacting to stimuli
3. Hypnosis – extreme sedation results in further CNS depression and sleep
a. Act on RAS
BENZODIAZEPINES
- most frequently uses anxiolytic drug
- prevents anxiety without much sedation
- act on limbic system and RAS to make GABA more effective
- peak 30 mins
- lipid soluble
- cross the placenta/ enters the milk
- Schedule IV
Indication:
anxiety disorders,
alcohol withdrawal,
hyperexcitability and agitation
pre-op relief of anxiety and tension to aid in balanced anesthesia
Contraindication:
- allergy - acute alcohol intoxication
- psychosis - pregnancy
- acute narrow-angle glaucoma - shock
Adverse Reaction:
- headache - dizziness
- drowsiness - cognitive impairment
- nervousness - lethargy
- palpitation - nausea
- dry mouth - vomiting
Overdose:
- hypotension and respiratory depression
- somnolence, confusion, coma, diminished reflexes
- only if taken with CNS depressants such as alcohol and barbiturates
- nursing intervention: do not give syrup of ipecac (this is contraindicated if pt
has ingested a medication that can cause sedation)
o gastric lavage
Flumazenil
- treat benzodiazepines overdose
- reverse sedation caused by benzodiazepines that are used as adjunct
anesthesia
- reverse sedation produced for diagnostic tests and other medical procedures
1. diazepam (Valium)
- prototype
- anxiety, alcohol withdrawal, muscle relaxant, antiepileptic, antitetanus, pre-op
anxiolytic
- monitor injection sites
2. estazolam (Prosam)
- hypnotic, txt of insomia
- give with food to minimize GI upset
3. flurazepam (Dalmane)
- give 15 – 30 mins before bedtime
- causes less REM rebound than any other benzodiazepines
4. halazapam (Paxipam)
5. lorazepam (Ativan) - prototype
6. temazepam (Restoril)
- induces sleep within 20 – 40 mins
- give 20 – 30 mins before bedtime
7. clonazepam (Klonapin) - seizure, panic attacks, neuralgia
8. clorazepate (Tranxene) - anxiety, alcohol withdrawal, adjunct therapy for Partial
seizure
9. chlordiazepoxide (Librium) first benzodiazepene
BARBITURATES
- 1st introduced in 1903
- standard drug for tx of insomia and producing sedation
Major P. Salipot, RN Page 2 of 15 St. Mary’s College
- habit forming; low therapeutic index
- Category D
Mechanism of Action
- acts on reticular formation
- reduces nerve impulse traveling to the cortex
- potentiate GABA
- raises seizure threshold
- enzyme- inducer (stimulates enzyme responsible for metabolism and
breakdown in the liver of many drugs causing quick biotransformation
Contraindicaiton: drug allergy, respiratory difficulty, liver disease
Adverse reaction: drowsiness, lethargy, dizziness, excitement
Overdose: respiratory depression to respiratory arrest
- sleep, profound coma, death
- cold clammy skin
- fever, areflexia, tachycardia, hypotension
- TX: symptomatic, supportive
o Activated charcoal ( pulls drug from the circulation and eliminating it
by GIT
o Forced diuresis
Drug Interaction:
- alcohol, antihistamine, benzodiazepines, opioids, tranquilizers
- MAOI prolonged barbiturate effect
- Anticoagulant decrease coagulation and possible clot formation
- Oral contraceptives increase metabolism of contraceptive drug
pentobarbital (Nembutal)
- principally used pre-op to relieve anxiety and provide sedation
phenobarbital (Luminal)
- most commonly prescribed
- prototype
- long-acting
- prevents generalized tonic-clonic seizures
- for fever-induced convulsions
- for neonatal hyperbilirubinemia
amobarbital (Amytal sodium)
- sedative/hypnotic; convulsions; manic reactions
secobarbital (Seconal)
- preanesthetic sedation; convulsive seizure of tetanus
Nursing interventions:
1. give slow IV.
2. provide standby life support facilities
3. taper dosage gradually
4. provide comfort measures
5. provide thorough patient teachings
6. do not administer these drugs intra-arterially
7. do not mix IV drugs in solution with other drugs
OTHER ANXIOLYTIC AND HYPNOTIC DRUGS
1. chloral hydrate (Aquachloral)
a. Oldest non-barbiturate sedative-hypnotic
b. Frequently used to produce nocturnal sedation
c. Can cause tachyphylaxis (rapid appearance of a progressive
decrease in response to a pharmacologically or physiologically
active substance after its repetitive administration)
2. antihistamine (promethazine [Phenergan], diphenhydramine [Benadryl])
a. used to decrease need for narcotics
b. monitor for thickened respiratory secretion
3. buspirone (Buspar)
a. No sedative, anti-convulsant or muscle relaxant properties
ANTIDEPRESSANTS OR MOOD ELEVATORS
used to treat depressive disorders caused by emotional or environmental
stressors, losses, drugs, disease states such as cerebrovascular accidents or
depression that cannot be related to identifiable cause
these drugs are classified as:
o tricyclic antidepressants (TCAs)
o monoamine oxidase inhibitors (MAOI)
o selective serotonin reuptake inhibitors (SSRI)
TRICYCLIC ANTISEPRESSANTS (TCA)
for patients with insomnia, decreased libido, loss of appetite, feelings of
worthlessness
increases the levels of neurotransmitters serotonin or norepinephrine in the
space between nerve endings
1. nortriptyline (Pamelor)
2. amitriptyline (Elavil)
3. clomipramine (Anafranil)
4. desipramine ( Norpramin)
5. imipramine (Tofranil)
6. doxepin ( Sinequan)
Nursing responsibilities:
1. Asses the patients level or severity of depression, including the presence of
suicidal ideation
2. identify usual coping mechanism
3. Observe for side effects ( dry mouth, blurred vision, tachycardia, urinary
retention, constipation)
4. Observe for drug interaction
5. Observe for therapeutic effects of TCAs 2 to 3 weeks after the initial dose -
therapeutic window (serum plasma level)
If no therapeutic response occurs in 4 weeks to 8 weeks, another drug is prescribed.
Patient education:
1. Take drug as prescribed.
Major P. Salipot, RN Page 3 of 15 St. Mary’s College
2. Avoid taking OTC cold remedies or drugs without the physician’s knowledge.
Antihistamine and narcotic analgesics will increase the effect.
3. Avoid excessive exercise and high temperature because anticholinergic
effects of these agents block perspiration.
MONOAMINE OXIDASE INHIBITORS (MAOI)
Well known for their multiple drug and food interactions because they inhibit
the enzyme that breaks down amino acid tyramine and tryptophan
An accumulation of these substances triggers the release of norepinephrine
and a HYPERTENSIVE CRISIS can occur
Clinical symptoms:
i. Elevated Bp
ii. Headache
iii. Diaphoresis
iv. Dilation of pupil
v. Rapid heart rate and arrhythmia
vi. Intracerebral hemorrhage
DIET RESTRICTIONS FOR PATIENTS ON MAOI THERAPY
High tyramine content
(avoid while on MAOI
therapy)
Moderate tyramine
content
(May eat occasionally
while on MAOI therapy)
Low tyramine Content
(Limited quantities
permissible while on
MAOI therapy)
Aged cheese (cheddar,
Swiss, camembert, blue
cheese, parmesan,
provolone, Romano, brie)
Raisins, fava beans, flat
Italian beans, Chinese
pea pods
Red wines (Chianti,
burgundy, sauvignon)
Smoked and processed
meats (salami. Bologna,
pepperoni, summer
sausage)
Caviar, pickled herring,
corned beef, chicken of
beef liver
Soy sauce, brewer’s
yeast, meat tenderizer
Gouda cheese,
processed American
cheese, mozzarella
Yogurt, sour cream
Avocados, banana
Beer, white wine, coffee,
colas, tea, hot chocolate
Meat extracts, such as
bouillon
Chocolate
Pasteurized cheese 9
cream cheese, cottage
cheese, ricotta)
Figs
Distilled spirits (in
moderation)
1. tranylcypromine (Parnate)
2. isocarboxazid (Marplan)
3. phenelzine (Nardil)
Maximum therapeutic effect: 2 – 6 weeks of therapy
Medication for overdose:
phentolamine (Regitine) for excessive response
diazepam ( valium) for excessive agitation
Patient Education:
1. take drugs as prescribed.
2. avoid ingestion of tyramine-containing foods
3. report any symptoms indicative of hypertensive crisis, such as headache and
palpitations
SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRI)
became popular because of its advantageous safety profile and its broad
spectrum of potential indications
depend on neuronal release of serotonin for their action, which is blocking
of neuronal uptake of serotonin
the inhibition of serotonin reuptake into the nerve terminal by an SSRI
increases synaptic transmitter levels to exert a clinically significant
antidepressant effect
used in treatment of depression alone or in the presence of concurrent
disorders such as anxiety, panic attacks, eating disorders, sleep
disorders, alcoholism, or schizophrenia
Generic name Trade name
Sertraline Zoloft
Fluoxetine Prozac
Fluvoxamine Luvox
Paroxetine Paxil
cetaprolam Celexa
Client education:
1. Take the dugs as prescribed. Avoid altering the dosage of the medication.
Contact the physician before discontinuing use of the drug.
2. Report any unusual symptoms such as tremors, nausea and vomiting, anorexia,
weight loss, nervousness, or sexual dysfunction
3. Avoid the use diazepam, alcohol and tryptophan.
4. Inform the physician if taking anticoagulant or theophylline
5. Avoid operating hazardous machinery, including automobile if drowsiness
occurs.
6. have the blood pressure and pulse monitored initially and after each dosage
change to detect hypotension, hypertension, and irregular heart rates
ANTIPSYCHOTICS
Action: Blocks dopamine receptor sites in the brain. There is a depression of the limbic
system and cerebral cortex that controls aggression. Antiemetic effects by inhibiting the
chemoreceptor trigger zone in the medulla. May inhibit anticholinergic, antihistamine
and/or sedative effects.
Major P. Salipot, RN Page 4 of 15 St. Mary’s College
Indications: Schizophrenic disorders, mania, agitated organic disorders, delusional
disorders, antiemetic, intractable hiccups. Preoperative sedation (i.e. Compazine,
Phenergan)
Warnings: Alcoholism, other CNS depression, hepatic, renal or coronary disease,
cerebral insufficiency, severe hypotension, glaucoma, bone marrow depression, blood
dyscrasias; young children. Use cautiously in elderly debilitated clients.
Undesirable effects: STANCE on the next page will help you remember these effects.
Other specific information: Alcohol, CNS depressants may increases CNS and respiratory
depression, TCA and MAOI may increase sedation, hypotensive and anticholinergic
effects. Decrease levodopa effects. Lithium, antacids, and antidiarrheals may decrease
absorption.
Interventions: Monitor periodic liver function tests. WBC, serum glucose, VS and
psychological testing during therapy. Orthostatic hypotension is likely to occur, rise
slowly with assistance and initiate safety measures. Suicidal precautions, if necessary. Do
not mix parenteral solutions with other drugs in same syringe. Give deep IM injections.
Following parenteral route, remain in supine position for at least 30 minutes/ Liquids
should be protected from light and should be diluted with fruit juice before
administering. Avoid skin contact with oral suspension solution. Treat extrapyramidal
symptoms with anticholinergics (i.e. Cogenin0. Discontinue at least 48 hours prior to
surgery.
Education: teach that urine may urn pink or reddish brown. Advise that he medication
may take 6 weeks or linger to achieve a therapeutic effect. Instruct to give the daily
dose 1-2 hours before bedtime. Oral concentrate must be diluted in 2- 3 oz. fluid (water,
fruit juice, carbonated drink or milk). Avoid sun exposure, (use sunblock). Caution
against driving a car. Explain the importance of reporting sore throat, fever or symptoms
of infection. Undesirable effects usually subside approximately 2 weeks of therapy
decrease by dose adjustment. Inform other providers when taking these drugs. Advise
client to wear an ID bracelet indication medication therapy.
Evaluation: The client is able to cope with performance of activities of daily living
independently.
Drugs: Phenothiazines: chlorpromazine (Thorazine); fluphenazine (Prolixin); mesoridazine
(Serentil); Perphenazine (Trifalon); prochlorperazine (Compazine); promazine (Sparine);
thioridazine (Mellaril); trifluoperazine (Stelazine); triflupromazine (Vesprin);
Non phenothiazine: clozapine (Clorazil); haloperidol ( haldol); loxapine (Loxitane);
molindone (Moban); olanzapine (Zyprexa); pimozide (Orap); quetiapine (Seroquel);
risperidone ( Risperdal); thiothixene (Navane)
S edation
unlight
T ardive dyskenesia
achycardia
remors
A nticholinergic
granulocytosis
ddiction
N euroleptic malignant syndrome
C ardiac arrhythmias (orthostatic hypotension)
E xtrapyramidal (Akathesia)
ndocrine (change in libido)
EPS? Remember PANAT: Psuedoparkinsonism, Akathisia, Neuroleptic Malignant
Syndrome (Fever, Encephalopathy, Vital signs unstable, Elevated enzymes esp CPK,
Rigidity of muscles), Acute Dystonic Reactions, Tardive Dyskinesia
MOOD STABILIZERS
given during the manic phase of manic-depressive phase
treatment of choice for the manic phase of the bipolar disorder and for long-
term prophylaxis of this bipolar disorder
level out the activity of neurotransmitter in the area of the brain that controls
emotions, thus preventing a decreased activity of nerve impulses, resulting in
depression or an increased activity of nerve impulses, resulting in MANIA.
Thought to maintain a constant Na concentration in the brain, regulating
impulses along the nerve cells as well as mood swings
The body does not metabolized Lithium; approximately 80% of a Lithium dose is
reabsorbed in the proximal convoluted tubules and excreted by the kidneys
Lithium Toxicity:
The usual range of therapeutic serum concentrations are:
For therapeutic mania: 1.0 to 1.5 mEq/L
For maintenance: 0.6 to 1.2 mEq/L
Symptoms include:
At serum levels of 1.5 to 2.0 mEq/L
o Blurred vision, ataxia, tinnitus, persistent nausea and vomiting, severe
diarrhea
At serum levels of 2.0 to 3.5 mEq/L
o Excessive output of diluted urine, increasing tremors, muscular
irritability, psychomotor retardation, mental confusion
At serum levels above 3.5 mEq/L
o Impaired consciousness, nystagmus, seizure, coma, oliguria, anuria,
arrhythmia, myocardial infarction, cardiovascular collapse
MOOD STABILIZING AGENTS
classification Generic name Trade name
antimanic Lithium carbonate
Lithium citrate
Eskalith,Lithane. Lithobid,
Eskalith CR
Cibalith-S
Anticonvulsants Clonazepam
Carbamazepine
Valproic acid
Gabapentin
Lamotrigine
Topiramate
Klonopin
Tegretol
Depakene, Depakote
Neurontin
Lamictal
Topamax
Major P. Salipot, RN Page 5 of 15 St. Mary’s College
Calcium Channel Blockers verapamil Calan, isoptin
Give after meal to avoid gastric irritation
Cautions:
o Heart disease
o Sodium restricted diet
o Hypotension
o Epilepsy
o Parkinsonism
Lithium level: taken 2x/ week during initiation of therapy and before stability of
manic episode
o Serum levels taken q 12 hours after dose
Drugs that increase effect of lithium :
o Diuretics
o Anti inflammatory
Drugs that decrease effects of lithium
o Azetazolamide ( Diamox)
o Na bicarbonate
o Drugs with theophylline components
L evel - therapeutic (0.6 to 1.2 mEq/L)
I ncreased urination
T hirst increased
H eadache
H and tremor
I ncrease fluids
U nsteady
M onitor Salt - adequate intake
CNS Stimulants
Used to clinically tx attn deficit dos and narcolepsy.
Paradoxically, calm hyperkinetic children and keep them focus on one activity for
a longer period.
methylphenidate (Ritalin, Concerta): tx of attn deficit, other behavioral syndromes
assoc with hyperactivity, narcolepsy
dexmethylphenidate (Focalin): tx of attn deficit for 6 y/o +
dextroamphetamine (Dexedrine): adjunct therapy for exogenous obesity (short
term)
modafinil (Provigil): tx narcolepsy, improving wakefulness in people with obstructive
sleep apnea/hypopneas syndrome
MOA/Indication
Possibly increase the release of catecholamines from presynaptic neurons, leading
to increase in stimulation of the postsynaptic neurons.
Paradoxical effect of calming to attn deficit syndrome is believed to be r/t
increased stimulation of an immature RAS, which leads to the ability to be more
selective in response to incoming stimuli.
CI/Cautions
Presence of known allergy
Marked agitation, anxiety, tension (exacerbation)
Severe fatigue or glaucoma
Cardiac dses
Pregnancy and lactation
Caution: history of drug dependence and hypertension
AE
Nervousness
Insomia
Dizziness
HA
Blurred Vision
Difficulty with accommodation
Anorexia, nausea, weight loss
HTN, arrhythmias, angina
Nursing Implications
Ensure proper dx of behavioral syndromes and narcolepsy
Arrange to interrupt the drug periodically for behavioral syndromes
Arrange to dispense the least amount of drug
Adm before 6 pm
Monitor weight, CBC, ECG
Consult with school nurse and counselor for comprehensive care
Safety measures
Pt teaching (SOP)
ANTIEPILEPTIC AGENTS
Epilepsy
- most prevalent of the neurological disorders, is not a single disease, but a
collection of different syndromes
- all of these conditions are characterized by the same feature: sudden
discharge of excessive electrical energy from nerve cells located within the
brain which leads to a seizure
- in some cases, this release stimulates motor nerve resulting in convulsions, with
tonic-clonic muscle contractions that have potential to cause injury, tics and
spasm
Antiepileptics
- these agents are sometimes called as anticonvulsants, but because all types
of epilepsy do not involve convulsions, this term is generally not acceptable.
Classification of Seizures:
1. generalized seizure
begin in one area of the brain and rapidly spread throughout both
hemisphere of the brain
usually experience a loss of consciousness resulting from massive
electrical activity throughout the brain
a. tonic-clonic seizure (formerly known as grand mal seizure)
Major P. Salipot, RN Page 6 of 15 St. Mary’s College
dramatic tonic-clonic muscle contraction, loss of consciousness,
and a recovery period characterized by confusion and
exhaustion
tonic- prolonged muscular contraction
clonic – series of alternating contractions and partial relaxation
of muscle
b. absence seizure (formerly known as petit mal seizure)
involved abrupt, brief ( 3-5 seconds) period of loss of
consciousness
occur commonly in children and frequently disappears at
puberty
c. myoclonic seizure
involve short, sporadic periods of muscle contractions that last
for several minutes. Relatively rare and are often secondary
seizure
d. febrile seizure
related to very high fever and usually involves convulsions
occur in children and are usually self-limiting and do not
reappear
e. status epilepticus
potentially the most dangerous of seizure conditions, is a state in
which seizures rapidly recur again and again
without recover of consciousness
2. partial seizure (also called focal seizure)
involve one area of the brain and do not spread throughout the
entire organ
a. simple partial seizure
occur in a single area of the brain and may involve a single
muscle movement or sensory alteration
b. complex partial seizure
involve complex sensory changes such as hallucinations, mental
distortion, changes in personality loss of consciousness and social
inhibitions
motor changes may include involuntary urination, chewing
motions, and diarrhea
onset usually occurs by late teens
DRUGS FOR TREATING TONIC-CLONIC SEIZURE
1. HYDANTOINS
Stabilize nerve membranes and limit the spread of excitability form the
initiating focus
Less sedating than many other epileptics, they may be the drug of choice
inpatients who are not willing to tolerate sedation and drowsiness
a. phenytoin (Dilantin)
for tonic-clonic seizure and status epilepticus as well as in the
prevention and treatment of seizure following neurosurgery
b. ethotoin (Peganone)
for tonic-clonic seizure and myoclonic seizure
c. fosphenytoin (Cerebyx)
For short-term control of status epilepticus and to prevent seizure
following neurosurgery
d. Mephenytoin (Mesantoin)
For tonic-clonic, myoclonic and partial seizure in patients who do not
respond to less toxic antiepileptic agents
Has been associated with severe hepatic toxicity, bone marrow
suppression and often unacceptable dermatologic reactions
2. BARBITURATES and BARBITURATE-LIKE DRUGS
a. Phenobarbital (Luminal)
Available in oral and parenteral forms
Used for emergency control of status epilepticus and acute seizure
associated with eclampsia and tetanus
b. Primidone ( Mysoline)
Alteranate choice in the treatment of tonic-clonic or partial seizure
Have longer half-life than Phenobarbital and is available only in oral
form
3. BENZODIAZEPINES
THERAPEUTIC ACTION:
- In generael, hydrantoins, barbiturate and benzodiazepine all stabilize nerve
membranes throughout the CNS to decrease excitability and hyperexcitability
to stimulation
CONTRAINDICAITON:
- pregnancy
- lactation
ADVERSE EFFECTS:
- depression, confusion, drowsiness, lethargy, fatigue, constipation, dry mouth,
anorexia, cardiac arrhythmia
- hydrantoins - severe liver toxicity, bone marrow suppression, gingival
hyperplasia, and potentially serious dermatologic reactions ( hirsutism,
coarsening of facial skin) which are all related to cellular toxicity
NURSING RESPONSIBILTIES:
1. discontinue drug at any sign if hyperexcitability reaction or liver dysfunction, or
severe skin rash to limit reaction and prevent potentially serious reactions
2. administer drug with food to alleviate GI irritation if GI upset is a problem
Major P. Salipot, RN Page 7 of 15 St. Mary’s College
3. suggest the wearing or a carrying a medic-alert bracelet to alert emergency
workers and healthcare providers about the use of epileptic drug
DRUGS FOR TREATING ABSENCE (PETIT MAL) SEIZURE
1. SUCCINIMIDES
– drugs that modulate the inhibitory neurotransmitter GABA are most
frequently used
a. Ethosuximide ( Zarontin)
Drug of choice for treating absence seizure
Relatively few adverse effects compared to other antiepileptic drug
b. Methsuximide ( celontin)
Oral drug, used to treat absence seizures that are resistant to other
drugs
Associated with bone marrow suppression
c. Phensuximide ( Milontin)
Used for treatment of absence seizure that are resistant to other
agents
Therapeutic action:
- suppress the abnormal activity in the brain associated with absence seizure
Contraindication:
- allergy
- renal or hepatic disease
adverse effects:
- depression,. Drowsiness, fatigue, insomnia, headache, blurred vision
- nausea, vomiting, anorexia, weight loss, GI pain, constipation or diarrhea
- bone marrow suppression and dermatologic reactions such as pruritus,
urticaria, alopecia, Steven-Johnson syndrome may occur as a result of direct
chemical irritation of the skin and bone marrow
Nursing Responsibilities:
1. Administer the drug with food to alleviate GI irritation
2. Monitor CBS prior to and periodically during drug therapy to detect bone
marrow suppression early and provide appropriate intervention
3. discontinue the drug if skin rash, bone marrow suppression or unusual
depression or personality changes occur to prevent the development of
serious adverse effects
4. discontinue the drug slowly and never withdraw the drug quickly because
rapid withdrawal may precipitate absence seizure
OTHER DRUGS FOR TREATING ABSENCE SEIZURES
1. valproic acid ( Depakene)
Reduces abnormal electrical activity in the brain and may also
increase GABA activity at inhibitory receptors
Drug of choice in treating myoclonic seizures
2. zonisamide ( Zonegram)
Inhibits voltage-sensitive sodium and calcium channels, thus
stabilizing nerve cell membranes and modulating calcium-
dependent presynaptic release of excitatory neurotransmitters
Patients who take this drug should be very well hydrated; there is a
risk of renal calculi development
DRUGS FOR TREATING PARTIAL (Focal) SEIZURE
1. carbamazepine ( Tegetrol, atretol)
drug of choice for treating partial seizures
2. gabapentin ( Neurontin)
used as adjunct therapy in the treatment of focal seizure
3. Lamotrigine (Lamictal)
4. Tiagabaine (Gabritil)
5. Topiramate ( Topamax)
Adjunct therapy for partial seizure in adults
Therapeutic actions:
- stabilize nerve membranes by:
o directly by allowing sodium and calcium channels
o indirectly by increasing the activity of GABA
Contraindications:
- allergy
- bone marrow suppression
- severe hepatic dysfunction
ANTIPARKINSONIAN DRUGS
PARKINSON’S DISEASE
- a chronic neurologic disorder that affects the extrapyramidal motor tract(
which controls posture, balance and locomotion)
- three major features: rigidity, bradykinesia and tremors
- postural changes: chest and head thrust forward with knees and hips flexed
- with shuffling gait and absence of arm swing, with masked fasci. Involuntary
movement of head and neck and pill-rolling motion of the hands
- first described by James Parkinson in 1817
Pathophysiology
- caused by imbalance of the dopamine and acetylcholine
- marked by degeneration of the neurons in the substancia nigra and at the
basal ganglia
- there is an unexplained degeneration of the dopaminergic neurons
- drugs that are used to treat Parkinson’s Disease
1. anticholinergics
2. dopaminergics
3. dopamine agonist
Major P. Salipot, RN Page 8 of 15 St. Mary’s College
4. MAO-B inhibitor
5. COMT inhibitors- inhibits catechol-O-methyltranferase enzyme
ANTICHOLINERGICS
- drugs that oppose the effects of acetylcholine receptor sites in the substancia
nigra and corpus striatum
- has greater affinity for cholinergic receptors site sin the CNS
- block the action of acetylcholine in the CNS t help normalize acetylcholine-
dopamine imbalance
- reduce rigidity and to a lesser extent, tremor but have minimal effect on
bradykinesia
- are parasymphatolytics
- first used to treat Parkinson’s Disease before levodopa and dopamine agonist
were introduced
- peak in 1 – 4 hours
- cross the placenta
contraindications:
- allergy
- narrow angle glaucoma
- GI obstruction
- GU obstruction
- Prostatic hypertrophy
Side effects:
- dry mouth
- blurred vision
- constipation
- paralytic ileus
o rare but potentially very serious side effect. Monitor for abdominal
distension, absent bowel sounds, nausea, vomiting, epigastric pain.
Report immediately to the physician if these are present.
- urinary retention
- tachycardia, decreased sweating, elevated temperature
Nursing interventions:
1. arrange to decrease dosage.
2. arrange for a decrease in dosage in hot weather
3. give the drug with meal if GI upset occurs, before meals if dry mouth is a
problem
4. monitor bowel function
5. ensure that the patient voids before taking the drug if urinary retention is a
problem
6. provide thorough patient teaching
anticholinergic drugs:
1. benztropine mesylate ( Cogentin) – larger dose at bedtime
2. biperiden ( Akineton) - prototype
a. with prolonged use tolerance may occur
b. avoid taking with other CNS depressant and alocohol
c. start at 2mg/day in 1-4 divided doses
3. ethopropazine ( Parsidol)
4. Procyclidine (Kemadrin)
5. trihexyphenidyl ( Artane)
DOPAMINERGICS
- increases the amount of dopamine and enhances transmission of dopamine
- more effective than anticholinergics in treating Parkinson’s Disease
- directly stimulates the dopamine receptors
- after neurodegeneration has progressed to the extent that the nerves are
damaged or gone, these drugs are not effective
- levodopa is the first drug to be invented in 1961, it is a precursor to dopamine
that can cross blood-brain-barrier
- this increases mobility
- dopa decarboxylase converts levodopa to dopamine in the brain
Side effects:
- anxiety, nervousness, headache, malaise, fatigue, confusion, mental changes
- anorexia, nausea, vomiting, dysphagia, constipation
Drug-drug interactions:
1. with MAOI – increases the risk of hypertensive crisis
2. with Vit B6 and phenytoin may lead to decrease efficacy
1. levodopa (Dopar)
a. Prototype
b. Can cross the BBB
c. Immediate precursor of dopamine\loss of effectiveness after 3-5
years
d. Twitching of eyelids is an early sign of dug toxicity
e. Common side effects: fatigue, weakness, drowsiness, dizziness,
fainting, increased sweating darkening of the urine
f. If given with carbidopa ( SINEMET) more effective
i. Carbidopa inhibits the enzyme dopa decarboxylase
diminishing the metabolism of levodopa
3. amantadine (Symmetrel)
a. Antiviral drug that increases levels of dopamine
4. bromocriptine (Parlodel)
5. pergolide (Permax)
a. Inhibits prolactin secretion and rise in growth hormone
6. ropinirole (Requip)
Adjunct to levodopa therapy
1. entacapone (Comtan)
a. Increase the plasma concentration and duration of action of
levodopa
b. Inhibits catecholamine O-methyl transferase (COMT)
2. tolcapone (Tasmar)
a. Works in similar ways with carbidopa-levodopa
b. Blocks COMT
Major P. Salipot, RN Page 9 of 15 St. Mary’s College
c. Used in later stage of the disease when the effectiveness of
cerbidopa-levodopa decreases
3. selegiline (Carbex, Eldepryl)
a. Inhibits MAO
Muscle Relaxants
Muscle Spasm
Often result from injury to musculoskeletal system
Violent and painful involuntary muscle contraction
Flood of sensory stimuli – stimulate intense muscle contraction – cut off blood
supply – increase lactic acid – pain
Muscle Spasticity
Result of injury to CNS rather than at the periphery
Permanent
Result from increase in excitatory influence or decrease in CNS control
Hypertonia – excessive stimulation of opposing muscle groups which may
cause contractures
CENTRAL ACTING MUSCLE RELAXANTS
Interfere with the reflexes that causes muscle spasm
MOA/Indication
Unknown but believed to be involved in action in the upper or spinal
interneurons.
Relief of discomfort assoc with acute, painful musculoskeletal condition as an
adjunct to rest, physical therapy etc.
CI/Cautions
Presence of known allergy
Baclofen shld not be used to treat spasticity that contributes to locomotion or
increased function
Caution: history of epilepsy, cardiac dysfunction, any condition marked by
muscle weakness, hepatic/renal dysfunction, pregnancy/lactation
AE
CNS Depression: drowsiness, fatigue, weakness, confusion, HA, insomnia
GI: nausea, dry mouth, anorexia, constipation
Hypotension, arrhythmias
Urinary frequency, enuresis, urgency
Chlorzoxazone may discolor urine (orange-purple red)
Nursing Implications
Provide additional comfort measures (heat, rest, NSAIDS, positioning)
Discontinue if + hypersensitivity reactions or liver dysfunctions
Taper baclofen slowly over 1-2 weeks
If baclofen is adm by delivery pump: pt should understand the pump, reason
for frequent monitoring, how to adjust dose and program.
Monitor respiratory status
DIRECT-ACTING SKELETAL MUSCLE RELAXANTS
dantrolene (Dantrium) currently available in market in treating spasticity that
directly affect peripheral muscle contraction.
Used primarily for cerebral palsy, MS, muscular dystrophy, polio, tetanus,
quadriplegia, amyotrophic lateral sclerosis (ALS)
Not used for tx of muscle spasm assoc with musculoskeletal injury or rheumatic
dos
MOA/Indication
Dantrolene acts within skeletal muscle fibers, interfering with release of calcium
from muscle tubules.
Dantrolene is indicated for the control of spasticity resulting from upper motor
neuron disorders and prevention of malignant hyperthermia
Botulinum toxin type B (Myobloc) approved for the reduction of the severity of
abnormal head position and neck pain assoc with cervical dystonia.
Botulinum toxin type A (Botox Cosmetic) approved for cervical dystonia,
strabismus, blepharospasm and primary maxillary hyperhidrosis
CI/Cautions
Presence of known allergy
Spasticity that contributes to locomotion, upright position or increased function
Active hepatic dses
Lactation
Caution with the use of dantrolene: in women and all patients 35 y/o +, history
of liver dse or dysfunction, respi depression, cardiac dse, pregnancy
Caution for botulinum toxins: with peripheral neuropathic dse, neuromuscular
disorders, pregnancy and lactation
AE
CNS depression: drowsiness, fatigue, weakness, confusion, HA, insomnia, visual
disturbances
GI: irritation, diarrhea, constipation, abd cramps
Dantrolene: direct hepatocellular damage, urinary frequency, enuresis,
urgency, crystalline urine with pain or burning
Botulinum: anaphylactic reactions, HA, dizziness, muscle pain, paralysis,
redness and edema at injection site.
Nursing Implications
Discontinue at signs of liver dysfunction
Monitor for possible extravasation
Institute for supportive care for malignant hyperthermia (cooling blankets,
ventilation, anticonvulsants as needed)
Periodically discontinue (2-4 days) to monitor therapeutic effects
Discontinue if severe diarrhea
NARCOTICS
- Opioid, derived from opium
Opioid Receptors
- respond to naturally occuring peptins, endorphins, and enkephalin
- BRAINSTEM: control BP, pupil diameter, GI secretions, chemoreceptor trigger
zones (regulates nausea and vomiting, cough and respiration)
- SPINAL CORD AND THALAMUS: integrate and relate incoming info about pain
Major P. Salipot, RN Page 10 of 15 St. Mary’s College
- PERIPHERAL NERVE SITES: block release of neurotransmitters that are related to
pain and inflammation
4 types:
1. mu – analgesia, respiratory depression, feeling of euphoria, decrease GI activity, pupil
constriction, development of physical dependence
2. kappa – analgesia, pupil constriction, sedation
3. beta – react with enkephalins to modulate pain transmission
4. Sigma – pupil dilation, hallucination
Narcotic Agonist
- react with opioid receptor
Indication: analgesia, sedation, and sense of well-being, antitusssives
- severe acute and chronic pain, pre-op medication, analgesia during
anesthesia
- given IVTT, IM, SC
Contraindication: Allergy, pregnancy, labor, lactation
- diarrhea caused by poisons
- biliary surgery
Adverse reaction:
- apnea, cardiac arrest, shock
- orthostatic hypotension
- nausea and vomiting, constipation and biliary spasm
- lightheadedness, dizziness, anxiety, fear, hallucinations, pupil constriction,
impaired mental processes
- ureteral spasm, urinary retention, hesitancy, loss of libido
Nursing Interventions:
1. provide narcotic antagonist and equipment for assisted ventilation on standby
during IV administration.
2. Monitor site for irritation and extravasation
3. Monitor timing of analgesic doses
4. use extreme caution when injecting a narcotic into any body area that is
chilled or has poor perfusion
Drugs:
1. morphine ( Roxanol) – prototype
2. codeine – for mild to moderate pain; coughing
3. fentanyl ( Duragesic)
4. hydrocodone ( Hycodan) - relief of cough, for moderate pain
5. meperidine ( Demerol) – obstetrical anesthesia
6. opium ( Paregoric) – treatment of diarrhea, relief of moderate pain
7. oxycodone ( OxyContin)
Narcotic Agonist- Antagonist
- stimulates certain opioid receptor but block other such receptor
- less abuse potential than pure narcotic agonist
- like morphine, causes sedation, respiratory depression, constipation
1. Buprenorphine (Buprenex)
2. Nalbuphine (Nubain)
a. For moderate to severe pain, adjunct for general anesthesia
b. To relieve pain during labor and delivery
c. Should not be given to patients allergic to sulfites
3. Pentazocine ( Talwin)
a. Prototype
Narcotic Antagonist
- useful in blocking unwanted adverse effects associated with narcotics
- play a role in treatment of narcotic overdose
Adverse effect:
- Narcotic abstinence Syndrome characterized with nausea, vomiting,
sweating, tachycardia, hypertension, feelings of anxiety
Drugs:
1. Nalmefene ( Revex)
2. Naloxone ( narcan) – used to diagnose suspected narcotic overdose
3. Baltrexone (ReVita) – orally for alcohol or narcotic dependence
NON-OPIOID ANALGESIC
- includes acetaminophen, NSAID, cyclo-oxygenase 2 (COX-2)
ACETAMINOPHEN
- most widely used nonopioid analgesic
- action similar to salicylate
- blocks peripheral pain impulses by inhibition of prostaglandin synthesis
- lowers febrile body temperature
- for mild to moderate pain and fever
Contraindication:
- allergy
- glucose-6-phosphate dehydrogenase (G6PD) deficiency
Adverse effects:
- rash, nausea, vomiting
- can cause hepatotoxicity
- nephropathy
Acetylcysteine - recommended antidote for acetaminophen toxicity
- prevents the hepatotoxic metabolites of acetaminophen from forming
TRAMADOL HYDROCHLORIDE
- forms weak bond to sigma receptors
- inhibits re uptake of both norepinephrine and serotonin
Major P. Salipot, RN Page 11 of 15 St. Mary’s College
- for moderate to severe pain
Adverse effects:
- drowsiness, dizziness, headache, nausea , constipation and respiratory
depression
Contraindication:
- allergy
- acute alcohol intoxication, centrally acting analgesic, opioids
- can cause seizure to patients taking MAOI, TCA and neuroleptics
ANTIMIGRAINE DRUGS
Migraine
- term used to describe several syndromes usually includes severe, throbbing
headaches on one side of the head. Affects personality, GI, CNS, and mood.
- types include: Common and Classic
- Common migraine is without aura, cause severe unilateral, pulsating pain
frequently accompanied by nausea, vomiting, sensitivity to light and sound.
- Classic migraine is usually preceded by aura or sensation involving sensory or
motor disturbances which usually occurs 10 mins before the pain begins
- has two drugs, ergot derivatives and triptans.
Ergot Derivatives
- cause constriction of the cranial blood vessels and decrease the pulsation of the
cranial arteries. Reduces hyperperfusion.
- because of many side-effects, has limited use in some patients.
- dihydroergotamine(Migranal) is IV or IM form or as nasal spray which provide rapid
relief.
- ergotamine (generic) prototype which is usually given SL. Cafergot is popular
(ergotamine+caffeine) because of rapid absorption at GI tract.
MOA/Indication
-block alpha-adrenergic and serotonin receptor sites to cause a constriction of
cranial blood vessels, a decrease in cranial artery pulsations, and a decrease in the
hyperperfusion of basilar artery bed.
-for prevention, abortion of migraine or vascular HA.
CI
-CAD, HTN Peripheral Vascular Dse
-impaired liver function
-Pregnancy and lactation
-Caution: pruritus (exacerbation), malnutrition (cause severe GI reactions)
AE
-numbness, tingling of extremities, muscle pain
-pulselessness, weakness, chest pain arrhythmia, localized edema, itching, MI may
occur
-GI upset, Nausea, vomiting, diarrhea
-Ergotism: syndrome which is manifested by nausea, vomiting, severe thirst,
hypoperfusion, chest pain, BP changes, confusion, drug dependency, drug withdrawal
D-D
-beta-blockers + ergotamine = risk for peripheral ischemia and inc. gangrene
Nsg Implementation
-avoid prolonged use
-use of atropine or phenothiazine if NV is severe
-provide comfort measures
-assess extremities carefully because of decrease in perfusion especially those with
decubitus ulcer or gangrene
-provide supportive measure to ensure patient safety if acute OD.
Triptans
-new drugs cc cause cranial vasoconstriction
-not assoc with all vascular and GI effects of ergot
-triptan of choice depends on personal experience
Sumatriptan (Imitrex) – used to tx migraine attacks; PO, SQ, nasal spray; effective
against cluster HA; CI for elderly
Naratripan (Amerge) - PO; tx of acute migraine; assoc with several birth defects; CI
for severe hepatic/renal dysfunction
Rizatriptan (Maxalt) – PO; tx of migraine with/out aura; have more angina effects so
CI for CAD
Zolmitriptan (Zomig) – PO; tx of migraine with/out aura in adults
Almotriptan (Axert) – tx of tx of migraine with/out aura
Frovatriptan (Frova) – has advantage of long-life; PO tx for acute migraine with/out
aura; prevents rebound HA
Eletriptan (Relpax) – PO; tx of migraine with/out aura
MOA/Indications
- triptans bind to SSR sites to cause vasoconstriction of cranial blood vessels,
relieving s/sx of migraine HAs.
-used as tx not prevention
-sumatriptan injection is also indicated for cluster HA
CI
-allergy
-pregnancy
-active CAD
-caution: elderly, lactation, renal/hepatic dysfunction
D-D Interaction
-triptans + ergot = prolonged vasoaction effect
-triptans + MAOI = increase vasoconstriction, must be avoided; more than two
weeks not receiving MAOI before use
AE
-numbness, tingling, burning sensation, feelings of coldness or strangeness, dizziness,
weakness, myalgia, vertigo
-dysphagia, abd discomfort
-BP alterations, tightness or pressure in the chest
Major P. Salipot, RN Page 12 of 15 St. Mary’s College
Nsg Implementation
- adm to relieve acute migraine
- arrange safety precautions for CNS or visual changes
- provide comfort measures such as environmental controls and stress reduction
- monitor: BP if with history of CAD; D/C if there is sign of angina or prolonged
HTN
- patient teaching
ANESTHETICS -drugs that can cause complete or partial loss of sensation
General anesthetics
CNS depressants used to achieve the ff goals:
Analgesia, unconsciousness and amnesia
- blocks body reflexes
- depresses the RAS and cortex
- lipid soluble
- metabolized in the liver
- cross the placenta
Contraindication:
1. status asthmaticus
2. absence of suitable veins for intravenous administration
Risk Factors:
- CNS Factors; Presence of underlying neurological disease
- Cardiovascular factors: CAD, hypotension
- Respiratory factor: COPD
- Renal and hepatic factor: conditions that interfere with the metabolism of and
excretion of anesthetics
Balanced Anesthesia
- use of combination drugs, each with specific effect, to achieve analgesia,
muscle relaxation, unconsciousness and amnesia, rather than the use of single
drug
- involves the ff:
1. Pre-op medication: which may include the use of anticholinergics that
decrease secretions to facilitate intubations and prevent bradycardia
associated with mental depression
2. sedative/hypnotic to relax patient, facilitate amnesia and decrease
sympathetic stimulation
3. Antiemetics to decrease nausea and vomiting associated with GI depression
4. Antihistamine to decrease the chance of allergic reaction and to help dry
secretion
5. Narcotics to aid analgesia and sedation
Stages of Anesthesia
Stage 1 (Analgesia)
- begins with consciousness and ends with loss of consciousness. Speech is
difficult, sensation of smell and pain are lost. Dreams and auditory and visual
hallucinations may occur. This stage may be called the induction stage.
Stage 2 (Excitement or delirium)
- produces loss of consciousness caused by depression of the cerebral cortex.
Confusion, excitement, or delirium occurs. Short induction time.
Stage 3 (Surgical)
- Surgical procedure is performed during this stage. There are 4 phases. The
surgery is usually performed on phase 2 and upper phase 3. As anesthesia
deepens, respirations become more shallow and respiratory rate increases.
Stage 4 (Medullary paralysis)
- toxic stage of anesthesia. Respirations are lost and circulatory collapse occurs.
Ventilatory assistance is necessary.
Induction – from beginning until stage 3; danger is in stage 2 because of systemic
stimulation
Maintenance – stage 3 until completion of surgery
Recovery – from time of D/C of anesthesia until patient regains consciousness
Types of GA
1. Barbiturate Anesthetics are IV drugs used to induce rapid anesthesia which is
then maintained by inhaled drugs.
b. Thiopental (Pentothal)
i. Most widely used of the IV anesthetics
ii. Rapid onset and ultra short recovery period
iii. Has no analgesic property
c. Methotexital ( Brevital)
i. Rapid onset and shorter recovery period
ii. Cannot come in contact with silicon
iii. Lacks analgesic property
iv. Causes respiratory depression and apnea
2. Nonbarbiturate Anesthetics given IV
a. Midazolam (Versed)
i. Prototype
ii. Rapid onset with peak effectiveness for 30 to 60 mins.
iii. Causes nausea and vomiting
b. Droperidol( Inapsime)
i. Use cautiously in patients with renal and hepatic failure
ii. Causes hypotension, chills, hallucination and drowsiness
during recovery period
c. Etomidate ( Amidate)
i. Sometimes used for sedation of patients on ventilators
ii. May experience myoclonic and tonic movements as well as
nausea and vomiting
iii. Not recommended for children younger than 10 years old
Major P. Salipot, RN Page 13 of 15 St. Mary’s College
d. Ketamine ( Ketalar)
i. Patient appears to be awake but is unconscious and
cannot feel pain
ii. Causes sympathetic stimulation
iii. Crosses the BBB
iv. Cause hallucinations, dreams and psychotic episode
e. Propofol (Diprivan)
i. Short-acting; rapid onset
ii. For short procedures
iii. Causes local burning sensation
iv. Cause bradycardia, hypotension, extreme: pulmonary
edema
3. Anesthetic gases
- enter the bronchi and alveoli
- very high affinity to fats
a. Nitrous oxide ( blue cylinder)
i. Prototype
ii. Potent analgesic
iii. Weakest pf the gas anesthetic and least toxic
b. cylopropane ( orange cylinder)
i. experience of pain, headache, nausea, vomiting, and
delirium during recovery phase
c. Ethylene ( red cylinder)
i. Leave patient with headache and unpleasant taste
4. Volatile Liquids
- inhaled anesthetic
- most are halogenated hydrocarbons
a. Halothane (Fluothane)
i. Prototype
ii. Vomiting, bradycardia and hypotension
iii. Increased risk for hepatic failure
iv. Recovery syndrome: fever, anorexia, nausea and vomiting
eventual hepatitis
b. Desflurane ( Suprane)
i. With respiratory reactions: cough, increased secretions,
laryngospasm
ii. Not recommended for pediatric patients
c. Enflurane ( Ethrane)
i. Associated with renal toxicity,cardiac arrhythmia and
respiratory depression
d. Isoflurane ( generic)
i. Associated with hypotension, hypercapnia, muscle soreness
and bad taste in the mouth
ii. Does not cause cardiac arrhythmia or respiratory irritation
e. Methoxyflurane ( Penthrane)
i. Can cause renal toxicity, respiratory depression and
hypotension
ii. Rarely used except during labor and delivery, because it
does not relax the uterus
f. Sevoflurane ( Ultane)
i. Newest
Nursing responsibilities:
1. must be administered by a trained personnel
2. have equipment standby to maintain airway and provide mechanical
ventilation
3. Monitor temperature for prompt detection and treatment of malignant
hyperthermia have dantrolene on standby.
4. Monitor VS ECG, cardiac output during administration
5. monitor patient until recovery phase is complete and patient is conscious and
able to move and communicate
6. provide comfort measures
7. provide thorough pre-op teachings
LOCAL ANESTHETICS
- cause loss of sensation in limited areas of the body
- very powerful nerve blockers
- are either esters and amides
- esters are broken down by plasma esterases
- amides are metabolized by the liver
- temporary interrupt the production and conduction of nerve impulses
- prevents sodium ions from entering the nerve they stop the nerve from
depolarizing
- used for: infiltration anesthesia, peripheral nerve block, spinal anesthesia , relief
of local pain
- Contraindication: allergy, heart block, shock, decrease plasma esterase
Modes of Administration:
1. Topical
2. Infiltration
a. Involves injecting the anesthesia directly into the tissues to be treated
3. Field Block
a. Injecting the anesthetic all around the area that will be affected by
the operation
b. Often used for tooth extraction
4. Nerve Block
Major P. Salipot, RN Page 14 of 15 St. Mary’s College
a. Injecting the anesthetic at some point along the nerve or nerves that
run to and from the region to which loss of pain sensation or muscle
paralysis is required.
b. Could be a peripheral nerve block (Blocks the sensory and motor
aspects of a particular nerve for relief of pain or diagnostic
procedure) or a central nerve block ( injected through a roots of the
nerves in the spinal cord)
c. Epidural anesthesia, the drug is injected into the space where the
nerve emerge from the spinal cord
d. Caudal block, injection into the sacral canal below the epidural area
5. Intravenous Regional Anesthesia
a. Carefully draining all the blood from the patient’s arm or leg, securing
a tourniquet to prevent anesthesia from entering the general
circulation, and then injecting the anesthesia into the vein of arm or
leg.
Adverse reaction:
- headache, restlessness, anxiety, dizziness
- tremors, blurred vision, backache
- nausea and vomiting, peripheral vasodilation, myocardial depression
- arrhythmia, BP changes
Nursing Interventions:
1. Have equipment standby.
2. Ensure drugs for hypotension, cardiac arrest and CNS alteration
3. Ensure patient receiving spinal anesthesia are well hydrated and remain lying
down for up to 12 hours.
4. Establish safety precaution
5. Provide comfort measure
6. Provide thorough patient teaching
Drugs:
Esters: 1. benzocaine (Dermoplast)
2. Procaine ( Novocain)
Amides: 1. bupivacaine ( Marcaine)
2. Lidocaine ( Xylocaine)
3. Mepivacaine ( Isocaine)
Neuromuscular Junction Blocking Agents
- divided into 2: nondepolarizing and depolarizing
- Nondepolarizing acts as antagonist to Ach while nondepolarizing acts as
agonist for Ach
- Cause paralysis during surgical procedure or facilitation of mechanical
ventilation
Nondepolarizing NMJ Blockers
-curare: first discovered NNMJB which is a poison
-destroyed in cooking
-clinical usage: tubocurarine
-occupies muscular cholinergic receptor sites which prevents Ach from reacting
with the receptor
-effect is more long-lasting
- used when muscle paralysis is required.
Depolarizing NMJ Blockers: Succinylcholine
-attaches to the Ach receptor site of muscle causing stimulation of the muscle and
muscle contraction and can’t be broken down instantly causing prolonged contraction
-hydrophilic that’s why not readily cross BBB
-rapid onset and short duration bec it is broken down by cholinesterase
- indicated for:
a. to serve as adjunct therapy for GA during surgery when reflex when reflex
muscle movement could interfere with procedure or delivery of gas
anesthetics
b. to facilitate mechanical intubation by preventing resistance to passing ET
and in instances in which patient fight or resist the respirator.
c. to facilitate ECT therapy when intense skeletal muscle contractions as a
result of electric shock could cause the patient broken bones or other injuries.
CI
-know allergy
-myasthenia gravis
-hepatic/renal dses
-pregnancy/lactation
-caution:
History of malignant hyperthermia
Pulmonary/CV dysfunction
Altered Fluids and Electrolyte imbalances
Respiratory condition
Fractures
Narrow-angle glaucoma
SCI, paraplegia
-extreme caution:
Dse conditions causing low plasma cholinesterase levels such as:
Cirrhosis, metabolic dos, carcinoma, thyroid toxicosis, collagen
diseases, burns, DHN, hyperpyrexia, exposure to neurotoxic
insecticides
AE
-assoc with muscle paralysis:
Apnea
Histamine release causes wheezing and bronchospasm
Hypotension, cardiac arrhythmias
Constipation, vomiting, regurgitation, aspiration
Decubitus ulcer
Hyperkalemia
Muscle pain (aspirin after procedure)
Malignant hyperthermia (massive muscle contraction, sharp elevated temp,
severe acidosis, death); tx with dantrolene
D-D Interaction
-DNMJB + halothane = increased effect
Major P. Salipot, RN Page 15 of 15 St. Mary’s College
-DNMJB + aminoglycoside antibiotics = increased neuromuscular blockage
-DNMJB + calcium channel blockers = increased effect
-DNMJB + cholinesterase inhibitors = decreased effect
-DNMJB + xanthines = reversal effect
Nsg Implementation
-adm by trained personnel
-supplies and equipments, peripheral stimulator, cholinesterase inhibitors are on
standby
-do not mix with alkaline sol’n such as barbi
-test pt response and recovery periodically
-monitor temp
-maintain dantrolene for malignant hyperthermia
-adm small dose of NNMJB to decrease adverse effect of succinylcholine
-provide comfort measures
-monitor VS
-drug teaching