pharmacology test 2

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pharmacology test 2
2012-02-28 16:55:56
pharmacology test

pharmacology test 2
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    • what is the clients actual sensation of pain
    • •Involvesnerve pathways and the brain
    • •Alsoknown as the “pain threshold”- The actual stimulus needed to produce the perception of pain
    • •Thisis the measurement of the physiological response of the nervous system
    • The client’s emotional response to pain
    • •Greatly effected by the client’s age, gender, culture, previous pain experiences andlevels of anxiety
    • •Alsoknown as “pain tolerance”- his is the amount of pain the client can endure without effecting the clients normal function
  3. ACUTE pain-
    • •Suddenonset
    • •Typicallysubsides when treated
    • •Usuallysharp and localized
    • •Assessincreased Bp, pallor, sweating, increased respiration rate
  4. CHRONIC pain-
    • •Persistentand recurring
    • •Oftendifficult to treat
    • •Onsetis usually slow
    • •Maybe explained as dull and aching vs. sharp and stabbing as seen in acute pain
  5. Somatic pain-
    originates from the skeletal muscles, joints andligaments
  6. Visceral pain-
    • originates from smooth muscle and organs
    • usually responds better to NSAID’s (non-opioids)
  7. Superficial pain-
    • originates from the skin or mucous membranes
    • usually requires treatment with opioids
  8. Vascular pain-
    possibly originates from vascular or peri-vascular tissues,commonly thought to be the cause of migraine headaches
  9. Referred pain-
    pain that is felt in a place other that where the painactually originates. (ex: cholecystitis- pain felt in the back and scapular region due toinflammation of the gallbladder)
  10. Neuropathic pain-
    results from an injury or damage to peripheral nervefibers or damage to the CNS (this is often in the absence of disease)
    occurs when a part ofthe body has been removed or severed traumatically
  12. Cancer pain-
    caused by pressure on nerves, organs or tissues,hypoxia, mets, muscle spasms,effects secondary to chemo, radiation, surgery
  13. Psychogenic pain-
    real pain due to psychological pain, NOT physicalconditions
  14. Central pain-
    occurs with tumors, trauma, inflammation of the brain-seen often in incidence that yields CNS damage
  15. Adjuvant agents
    • may be used to assist the primary agent to help alleviate pain, so…..
    • •Opioids and non-opioids can be used for “synergisticeffects”
    • •Opioids can cause unwanted effects- they work on the CNS to reduce pain, but causes decreases in Bp, decreased respirations, confusion, dizziness, light-headedness, constipation, urinary retention, sedation, etc..
  16. Narcan-
    given IV –reverses the effects quickly
  17. ReVia-
    reverses opioids and to treat the abuse of opioids
  18. pain assessment look for:
    • •Muscle rigidity
    • •Restlessness
    • •Screaming
    • •Fear of moving
    • •Pedi patients often go un-medicated and under medicated due to the difficulty in assessment of pain
    <12/min or there are changes in LOC
  20. •18 years of age and under- should not give
    meperidine (Demerol)
  21. Withdrawal s/s =
    N/V, anorexia, fever, cramps, faintness
  22. Norepinephrine-
    • nerve fibers thatfree norepi are adrenergicfibers and they accelerate the heart rate, stimulate organs and smooth muscle
    • •Adrenergics- aka catacholemines
    • •There are 3 naturally occuring in the body
    • - Norepi, epi and dopamine
    • These increase HR and Bp, dilate pupils and more…
    • Can increase blood glucose and cause headache
  23. Acetylcholine-
    • nerve fibers that free ACH arecholinergic
    • - they slow the HR
  24. •Epinephrine-1st line drug for a code
    •Another first line drug?
    • Norepinephrine or (levophed)- unfortunately thisdrug can cause necrosis to the distal areas (finger tips and toes)
    • •These are vasoconstrictors to restart the heart
    • •Adrenergics are drugs that cause a similar effect produced by epi, norepi
  25. Analgesics
    • •These relieve pain but do not cause a loss of consciousness
    • •Used for moderate-severe pain
    • •Opioid analgesics and narcotic analgesics differ- they tend to alter CNS and can cause loss of consciousness
  26. gate theory
    • •What is this: proposed in 1965 uses a gate opening and closing to reference how impulses from damaged tissue is sensed by the brain to cause pain
    • •2 fibers- one with fast conduction, one with slow
    • •Fast conduction = large fiber covered by myelin- pain is sharp and localized
    • •One is slow- fiber is small, not covered by myelin- pain is dull and non-localized
    • •These nerve and sensory fibers enter spinal cord and to the brain- message of pain sent
    • •“Gates” are located in this region
    • •If pain impulses stopped- gate stays closed- patient feels no pain
    • •If not stopped- gate opens and pain is felt
  27. endorphins and enkephalins
    • produced within thebody that bind with opioid receptors to inhibitpain (keep the gate closed)
    • •These are released when pain is sensed
    • •Rememberother things can closed the gate- massage, acupuncture, medications such as opioids
  28. Opioid analgesics
    • •Originated from the opium plant
    • •Very strong pain relievers
    • •Only 3 alkaloids from the plant clinically useful
    • -Morphine (MSO4)
    • -Codeine
    • -Paparavine (smooth muscle relaxant)
    • -Only morphine/codeine are pain killers
  29. 3 chemical classes of opioids
    • •Morphine-like drugs- morphine/heroin
    • •Meperidine-like- fentanyl/meperedine (demerol)
    • •Methadone-like- methadone, propoxyphene (Darvon- now off the market)
  30. mechanism of action- opioids:
    • -agonist- binds to receptors and has a response
    • -Partial agonist- binds and causes limited action
    • -Antagonists- reverses the effects on the pain receptors or binds to receptor and causes no response
  31. therapeutic uses:
    • •Alleviate moderate to severe pain
    • •ADJUVANTS- may be used to assist the agent to relieve pain (discuss)
    • •These have a synergistic effect
    • •NSAIDS are commonly adjuvants
    • •Opioids (especially large doses or frequent use) can cause some unwanted effects too
  32. unwanted effects
    • •Constipation r/t decreased GI motility and slowed peristalsis
    • •HOWEVER… this causes increased water absorption so these meds can also be used to treat diarrhea (lomotil, peragoric)
    • •Resp. depression
    • •Urinary retention
    • •Cough suppression (codeine commonly used for this)
  33. •Opioid tolerance-
    •Physical dependence-
    • •Opioid tolerance- require larger doses r/t long-term use
    • •Physical dependence- body relies on the drug (seen commonly with long-term use)
    • •DO not confuse physiological and psychological dependency!
    • •Opioids should never be discontinued abruptly
  34. What if we do stop them abruptly?
    • •Chills
    • •Anxiety
    • •Diaphoresis
    • •Tremors
    • •Hot flashes
    • •Lacrimation
    • •Rhinorrhea
    • •N/V/D, abdominal pain and cramping
    • •This can actually happen after only 2 weeks of therapy!
  35. interactions
    • •ETOH
    • •Barbiturates
    • •Benzodiazapines
    • •Antihistamines
    • •They cause added sedation and resp. depression
    • •ALSO-NOT WITH MAOI’s- especially demerol
    • •FYI- not much mixes with MAOI’s!
  36. lab changes:
    • •Opioids can cause an increase in:
    • -Serum lipase and amylase
    • -Bilirubin
    • -Alk Phos
    • -CK
  37. Morphine Sulfate
    • •Not used if there is a known hypersensitivity
    • •Not used for head injury patient’s
    • •Used for sever pain
    • •Rapid onset
    • •IM- peak 30-60 minutes
    • •Duration can be up to 6-7 hours
    • •Oral, IM, SR tabs, IV, SC, Rectal, Epidural, PCA
  38. Codeine Sulfate-
    • •Used for moderate to severe pain
    • •Can also be used as an anti-tussive
    • •Peak about 35 minutes
    • •Duration about 4 hours
    • •Often used after T&A’s on children as opposed to Morphine
  39. Fentanyl
    • •Mod-severe pain
    • •Duragesic patch= fentanyl- great for chronic pain- last about 72 hours
    • •Also available in a buccal lozenge
    • •IM- Sublimaze
    • •Very potent
    • •IV peak in minutes, lasts 30-60 minutes
    • •IM- peak 20-30 min, lasts 1-2 hours
    • •Patch- peak 12-24 hours, duration up to 72 hours
  40. Meperidine (demerol)
    • •Not used in those with known renal dysfunction
    • •“Normeperidine” metabolite that can accumulate and cause seizures!
    • •Can cause coma-death
    • •Peak 30-60 min IM
    • •Caution under 18 y/o!
    • •If ordered under 18, pharm requires documentation why demerol and not another drug
  41. Narcan- Opioid antagonists
    • •Narcan- used for reversal of effects
    • •If Narcan does not reverse effects in a suspected opioid od- it wasn’t an opioid!
    • •Onset < 2 minutes- duration based on the dose amount given
    • •Revia- not for those in liver failure
    • •Used to treat opioid dependency or those in acute withdrawal
    • •Can cause nose bleeds, phlebitis, nasal congestion and nightmares
  42. Implementation of opioids
    • •0-10 pain scale monitoring
    • •Oral opioids with food
    • •May need an anti-emetic
    • •SAFETY!
    • •Monitor VS
    • •Can cause confusion and increased sedation in elderly- if so once- do not give call dr.
    • •If od? Narcan- take a friend- these folks tendto code! (always have emergency equipment nearby)
  43. opioid side effects
    • •CV- hypotension, flushing, palpitations
    • •CNS- sedation, euphoria, confusion, lowered seizure threshold, tremors
    • •GI-N/V, constipation, biliary tract spasms
    • •GU-urinary retention
    • •Resp- depression, aggravation of asthma
    • •Other- itching, rash, wheal formation
  44. FYI opioids:
    • •Opioids can cause euphoria- abused and recreational
    • •Psychologic dependence (addiction) can happen
    • •Opioids cause a histamine release so peripheral arteries and veins dilate = itching
    • •Depression of respirations- most serious s/e
    • •If with COPD, asthma- may want to avoid
  45. opioids
    • •Extent of sedation = extent of resp depression
    • •Monitor closely- if O2 sats drop or RR drops, may be able to arouse easily and correct- if not you have trouble! (O2, vent)
    • •Narcan- reverses resp depression AND PAIN
    • •Narcan is given slowly – it is short lived for only about an hour- redosing may be necessary of pt. cannot be arousedWatch for anaphylaxis!
  46. Toxicity and OD management
    • •If od- must give an antagonist- do you see why?
    • •Narcan (as discussed)
    • •ReVia
    • •Revex
    • •ReVia- used for those with addiction to opioids, but can also reverse opioids
    • •Revex- for acute od and to reverse resp depression (causes
    • sever nausea and can cause tachy)
  47. Non-opioid analgesics
    • •NSAIDS
    • •Acetominophen
    • •Ultram
    • •Has no effect on the CNS or the CV system!
    • •Does not effect platelet counts or bleeding times
    • •Used for mild-mod pain
    • •Can also be used as an antipyretic
    • •But can cause some side effects
  48. side effects
    • •Can cause hepatic necrosis when od
    • •150mg/kg can cause liver toxicity
    • •Nephropathy can happen if taken over long periods
    • •Acetylcystine- if OD to prevent hepatic metabolites from forming
    • •Initial loading dose- the q 4 hours x 17 doses!
  49. Antipyretics
    • •Used to decrease body temp
    • •Decrease body temp if fever is present, but not if body temp is WNL
    • •Acts on the hypothalmus
    • •Vasodilation happens and increased peripheral blood flow = decreased ody temp
    • •No effect on the CNS
  50. Acetominophen
    • •Also used to decrease pain
    • •Most do not experience side effects- fairly safe
    • •Can effect liver- so if with disease- DO NOT TAKE
    • •4000 mg max in 24 hours for adults
    • •Any allergic reaction at home- 911
    • •Limit ETOH (liver)
    • •Does pass via breast milk- so call doc 1st
    • •Anticoagulants or antiepileptics- check with dr
    • •OD-
    • call poison control if at home
    • •What you will see:
    • -Jaundice
    • -N/V
    • -Abdominal pain
    • -Amber urine
    • -Liver and kidney
    • dysfunction- test to check
    • -Check acetominophen levels
  51. Acetominophen antidote
    • •If suspected OD:
    • -Mucomyst
    • -140 mg/kg, then 70mg/kg q 4 hrs x 17 doses
    • -Muscomyst smells like rotten eggs! L
    • -Is also used as an inhaler to decrease thickened secretions
  52. Ibuprophen
    • •3200mg max per day adults
    • •Increased risk of GI bleeding with an NSAID
    • •What you will see:
    • -black, tarry stool, frank red blood
    • -Coffee grounds emesis, hemoptysis
    • -Stroke
    • -Eliminated via the kidney
  53. Ibuprophen may cause
    • •Upset stomach
    • •Constipation/diarrhea
    • •Easy bruising
    • •Tachycardia
    • •Dizziness
    • •Increased bleeding risks of on an anticoagulant of ASA regimen
    • •Can cause sensitivity to sublight
  54. ASA
    • •Acetylsalicylic acid
    • •Can be used for an antipyretic, analgesic, anticoagulant and antiplatelet
    • •Can be used to decrease risk of blood clots- so MI patients, stroke patients
    • •Increases the risks of bleeding
    • •Is excreted by the kidneys so watch who is taking it!
  55. ASA can cause:
    • •Bleeding, bruising
    • •Heartburn, upset stomach
    • •Ulcers
    • •Hemoptysis, coffee grounds emesis
    • •Gi and/or rectal bleeding
    • •Rash, swelling of the tongue
    • •SOB
  56. ASA more info.
    • •ETOH/smoking increases bleeding risks
    • •Tell Dr. if taking daily ASA- some meds should not be mixed such as- other blood thinners, Ginko Biloba (otc)
    • •If a bleeding disorder or Vit K deficiency- talk to Dr. first
    • •Tell dentist if on ASA- 1 week prior to surgery and any surgery
  57. ASA continued:
    • •Should not be taken during pregnancy except if under care of Dr. passes via breastmilk
    • •Not under age 12 (Reyes)
    • •Also increased risk for Reyes if with chickenpox and some other viral infections if with ASA
    • •If recent live flu or varicella vaccine- no ASA
    • - Can cause brain swelling, kidney dysfunction, seizure, coma, death
  58. OD of ASA
    • •Liver and kidney dysfunction- so test!
    • •Check salicylate levels
    • •Clotting times/bleeding times
    • •Levels of > 300 ug/mL- serious side effects of OD
    • •Can also happen with chronic ingestion- AKA- “chronic salicylate intoxication”
    • •One to remember- OD*Tinitus
    • •Sodium Bicarbinate is the antidote
    and Anti-rheumatoid agents
    • •ASA
    • •NSAIDS
    • •Anti-gout medications
    • •Anti-rheumatoid agents
  60. Review ASA and NSAIDS
    • •These help with joint pain and arthritis pain commonly in those with osteoarthritis, but with any inflammation
    • •They do have antiinflamatory properties but are not among the strongest ones available- FYI
    • •NSAIDS can also cause noncardiogenic pulmonary edema
  61. Treatment of OD
    • •If A/Ox3- ipecac syrup to induce vomiting
    • •May also require sodium bicarb
    • •Gastric lavage with activated charcoal- effective up to 3-4 hours after ingestion of up to 10hours with MASSIVE ingestion
    • •Replace F&E, may need HD
    • •May need Vit K for bleeding
    • •Mechanical ventilation if decrease in RR
    • •May need anticonvulsants
  62. interactions of ASA and NSAID's
    • •ETOH can increase GI bleed
    • •Anticoagulants can increase bleeding tendencies
    • •ASA and NSAID’s together can cause increased GI toxicity
    • •Corticosteroids can increase the ulcerogenic effects
    • •Hypotensives and diuretics can
    • reduce the effects of those drugs

    • •Will
    • compete for protein binding with other protein binding meds

    • Not with dilantin (antiepileptic)

    • •Not
    • with sulfonimides (antibiotics)
  63. Toradol
    • •POTENT analgesic
    • •Has very little anti-inflammatory action, but is an NSAID*
    • •Therefore, not given specifically for arthritis or gout, but still classified so
    • •Used only for short term pain-up to 5 days
    • •Is an NSAID so review NSAID info
    • •Used primarily for Rheumatoid arthritis and gouty arthritis
    • •Rx only
    • •NOT for pregnancy or lactating- is passed to fetus and thru breastmilk
  65. Celebrex
    • •Is a DMARD
    • •Disease modifying anti-rheumatic drug
    • •Decreases progression of RA
    • •Has little effect on platelet function
    • •Cause fewer GI effects, but CAN still cause GI bleeding
    • •May have an increased risk of MI/stroke
  66. other DMARDS
    • •Enbrel- IV,SQ
    • •Fewer side effects than other DMARDS
    • •Humira- neutralizes immune system signals leading to joint damage- so slows process
    • •Cautious use with CHF- can exacerbate symptoms
    • •Imuran- also used at times- can cause severe N/V/D and abd. pain
  67. Anti-gout medications
    • •ALLAPURINOL- prevents uric acid accumulation/production
    • •Can cause a potentially fatal skin condition- “exfoliative dermatitis”, Steven’s Johnson Syndrome
    • •Can cause renal failure
    • •Can cause hemorrhagic gastroenteritis
  68. Anti-anxiety and sedative drugs
    • •Both are CNS depressants
    • •Anti-anxieties promote relaxation
    • •Sedatives- promote sleep
    • •Some also used for anesthetics and anticonvulsants
    • •Benzo’s are the main class used for both
    • •SSRI’s and antidepressants are also used for antianxieties
    • •Many client’s require a combo of drug therapy with psychotherapy for GAD (generalized anxiety disorder)
  69. Bezodiazapines
    • Common treatment for anxiety
    • •Can also be used to help decrease pain-
    • •PAIN often causes an increase in anxiety-
    • •Use carefully with pain medications due
    • to an increased effect
    • •Watch for dependency!
    • •Not to be used with other CNS depressants
    • •Taper- do not withdraw abruptly
    • •Can cause excessive sedation which can cause resp. depression, CNS side effects- SAFETY!
    • •Can accumulate- especially if the drugs have a long half life- watch dosing, especially in pedi’s and elderly
    • •Therapeutic effects and side effects are commonly seen within 2-3 days of initial treatment- TEACH
    • •Absorbed well with oral admin.- most are po
    • •Ativan and Valium are available po and IV
    • •Highly lipid soluble- highly bound to proteins*
    • •These drugs move rapidly through the CNS so sedation should be fairly minimal
  70. Benzo's continued
    • •Metabolized by the liver and excreted by the kidneys
    • •Benzos used widely for DT’s, acute ETOH withdrawal, preop sedation, with anti-psychotics and antidepressants
    • •Often used for clients with critical illness to decrease anxiety- in turn it also reduces cardiac workload!
    • •Used to sedate those who are on a vent, confused client’s from pulling out lines and tubes!
  71. benzo's Contraindications
    • •Resp. depression
    • •Severe liver/kidney d/o’s
    • •ETOH and other drug abuse
    • •Hypersensitivity
    • •Caution with other CNS depressants
  72. Valium (Daizepam)
    • •Multi use drug
    • •Can have a cumulative effect*
    • •PO/IV
    • •Chinese and Japanese clients may require smaller dosing- difficulty metabolizing
  73. Xanax (Alpralozam)-
    • •Used for anxiety and panic disorders
    • •Available PO prep
    • •Used commonly along with Valium and Ativan to decrease anxiety before exams and testing
    • •Widely misused for recreation
    • •Cheap on the streets
    • •“Bars”
  74. Librium
    • •Used for anxiety and commonly in the client with ETOH withdrawal symptoms
    • •Also drug of choice for mania- remember?
    • •PO/IV
  75. Ativan (Lorazapam)
    • •Anxiety and preop sedation
    • •Used for acute ETOH withdrawal
    • •Can be used to curb n/v in chemo clients
    • •Po/IV/SL
    • •Often the drug of choice for elderly and those with liver disease because of a SHORT half-life
    • •Remember the term short half-life?
  76. Buspar
    • •Does not cause sedation or physical/psychological dependence
    • •May be drug of choice for the elderly and those with renal impairment
    • •Is not a controlled substance
    • •Typically will not cause increased CNS sedation with other meds or ETOH
    • •Used for short term treatment
    • •May require 3-4 weeks for optimal effects- so not used for acute anxiety
    • •Educate
    • •Commonly used for clients who have anxiety and we DON’T want to risk resp. depression- COPD
  77. Restoril (Temapzapam) & Halcion
    • •Used mainly for insomnia
    • •PO
    • •Side effects are the unwanted ones- daytime sleepiness, nausea, diarrhea
    • •Halcion- I for the treatment of insomnia
    • •PO
    • •Same side effects
  78. Ambien
    • •Hypnotic used for insomnia
    • •Structuarally different than a benzo but still causes
    • similar effects
    • •Same side effects as Halcion and Restoril
    • BUT… Ambien has been reported to cause amnesia- people reported to be “awake” at night and doing routine tasks with no memory of them!
    • All of these meds require safety education
  79. Chloral Hydrate
    • •The oldest hypnotic
    • •Fairly safe, effective, inexpensive
    • •Tolerance can develop but is often MISUSED and ABUSED!
    • •Multipurpose- helps with anxiety, insomnia and can be helpful for those with alcohol withdrawal
  80. other meds
    • •Zoloft
    • •Paxil
    • •Prozac
    • •Effexor
    • •Classified as antidepressants but can help with anxiety
  81. Doasges of Benzodiazapines

    • •Lowest
    • effective dosaging is the best to
    • decrease sleepiness

    • •When
    • mixing with anything like antidepressants or anti-psychotics or analgesics
    • (especially narcotic analgesics)- BE AWARE that side effects can be greater-

    • •Short
    • acting agents may need to be dosed 3-4 times daily to control anxiety

    • •Hypnotics
    • should be taken at bedtime*

    • •Be
    • wary of physical and physiological dependence- take only for short periods of
    • time if able
  82. Benzo withdrawal
    • •The higher the dosing and the longer the client takes benzo’s
    • - the higher the risk of withdrawal symptoms
    • •These meds should be weaned slowly- NOT stopped abruptly! EDUCATE
    • •Recommended: REDUCE the drug by 10-25% every 1 to 2 weeks over 4-16 weeks
    • •Common effects are insomnia, increased anxiety and irritation, h/a, tremors and palpitations
    • •More serious s/e’s: confusion, abnormal movements, seizure, psychosis, depersonalization
    • •These may occur up to 4-5 days after stopping *valium
  83. OD/Toxicity
    • •S/S= increased sedation, resp. depression, coma
    • •FLUMAZENIL is a specific antidote that competes with benzo’s and reverses toxicity
    • •ONSET is 1-2 minutes- PEAKS at 6-10 minutes
    • •Short half life so re-dosing is usually necessary
    • •Adverse reaction: Increased s/s of the benzo withdrawal symptoms!
    • •Given slowly IV to awaken the client, but be careful of acute withdrawal s/s
  84. children anxiety meds
    • •Be careful of paradoxical effects
    • •Lowest effective doses for a short period of time if able
    • •Remember decrease in body fat and water in children!
    • •Faster metabolism- may need higher doses(???????)
    • •SSRI”S (may be given for anxiety but usually used for depression)- may have increased suicide risk
  85. assessment on anxiety meds
    • •Are there any unwanted side effects
    • •Can the client handle ADL’s
    • •Is the client excessively sleepy
    • •Ramsay scale of sedation- (especially in those with critical illness receiving benzo’s-
    • •1= wide awake & agitated, 6= sedated & unresponsive
    • •Desired level = 2-3.Client is drowsy but easily arousable and responsive to commands
  86. Benzo’s can cause
    • • amnesia- may be beneficial to the client with critical illness or the client that cannot be given anesthesia
    • •Hold the dose and document if the client has increased sedation
    • •Be careful when administering any of these meds- SAFETY
    • •Be careful with oral preps- do not crush ER tabs, etc…
  87. Anti-seizure medications
    • First- what is EPILEPSY?
    • •d/o of the brain that is the symptom of a disease
    • •Most likely due to excessive electrical discharges from nerves located in the cerebral cortex
    • •Chronic, recurrent pattern of seizures
    • •CONVULSION- spasmodic contractions of voluntary muscles
    • •SEIZURE- brief episode of abnormal electrical activity in nerve cells of the brain
    • •Can be detected on an EEG, CT, MRI along with the symptoms to make a diagnosis (the tests would show possible structural lesions of the CNS)
    • •There can be loss of consciousness, altered sensory awareness, psychic changes
  88. Types of Epilepsy
    • •PRIMARY- cause cannot be identified
    • •IDIOPATHIC- cause cannot be identified
    • •SECONDARY- due to trauma, CVA, infection, other illness
  89. Traditional classification of seizures
    • •Classification of seizures: (Traditional classifications)
    • •TONIC-CLONIC- Grand mal seizure
    • •Petit mal seizure-
    • •Jacksonian epilepsy-
    • •Psychomotor attacks-
  90. Partial (simple)
    • •Short alterations in consciousness, repetitive, unusual movements, psychological changes/confusion
    • •SIMPLE seizure- No impaired consciousness
    • •Motor symptoms- seen in face, arms, legs
    • •Visual/auditory/taste hallucinations
    • •Personality changes
  91. Newer Classifications
    • •Partial
    • -Simple
    • -Complex
    • •Generalized
  92. Complex
    • •Seizure- impaired consciousness
    • •Memory impairment
    • •Behavioral effects, purposeless behaviors
    • •Aura- unreal feelings, biting or chewing may be present
    • •Typically higher risk type of seizure
  93. Generalized
    • •Most often seen in children
    • •temporary lapses in consciousness lasting a few seconds
    • •Daydreaming, staring
    • •Eyes, head, hands may exhibit movement, but no convulsions
    • •Both cerebral hemispheres involved
    • •Head drop or falling-down symptoms
  94. Status Epilepticus
    • •May be either partial or generalized
    • •There is NO recovery in b/t seizures!
    • •Can be life threatening!
    • •Patient does not regain consciousness b/t the many convulsions
    • •Patient becomes hypoxic
    • •Hypotension typically ensues
    • •Cardiac dysrythmias
    • •Can lead to extensive brain damage
    • •DEATH can occur
    • •VALIUM is the drug of choice
    • •Once controlled- long term drug therapy will begin
  95. Anticonvulsants
    • •AKA anti-epileptic drugs (AED)
    • •GOAL is to control/prevent seizures while maintaining quality of life
    • •By Rx only
    • •Oral/injectable/rectal
    • •FDA regulated
    • •Constant levels of AED’s must be in the blood system or some patient’s will suffer repeated seizures
    • •Treatment is usually started after a second seizure!
    • •Single drug therapy is usually attempted first, and this must fail before a combination therapy is tried!
    • •Some need very close monitoring- weekly and biweekly labs
    • •Many have s/e’s
    • •Constant levels of AED’s must be in the blood system or some patient’s will suffer repeated seizures
    • •Treatment is usually started after a second seizure!
    • •Single drug therapy is usually attempted first, and this must fail before a combination therapy is tried!
    • •Single drug started with a gradual increase in dosage until seizures are controlled
    • •If the first drug does NOT control the seizure activity, that drug is slowly wiened while the second drug is initiated
    • •AED”S should NEVER be stopped abruptly unless SEVERE s/e’s begin
    • •Single drug therapy is less likely to have adverse reactions and result in higher serum concentration levels
    • •Serum concentrations of Dilantin, phenobarb, carbamazepine, and primidone correlate better with seizure control and toxicity than valproic acid and clonazepam
    • •Therapeutic serum drug levels : decrease risk of toxicity, has fewer adverse reactions and control seizures better
    • •THE PATIENT is the main guide- some need higher and some only require lower serum levels to control activity
    • •The goal of AED’s is to prevent the spread of the excessive discharges while protecting the surrounding, normal cells
  96. How exactly do they work?
    • •Acting directly on abnormal neurons
    • •Seizures may be reduced by raising the seizure threshold
    • • Preventing the spread of excessive discharges and still maintaining the normal cells
    • •NA, K, Ca, Mag ions are altered by AED’s and thus the cell membranes are more stabilized and less responsive
  97. Therapeutic uses
    • •Prevention/control of seizures
    • •Maintenance therapy for those with chronic seizures
    • •Can be used for acute seizure such as Status epilepticus- VALIUM
    • •Patient’s s/p brain surgery with severe head injury may be started on AED’s b/c if seizure activity starts, can cause severe complications
  98. seizure side effects
    • •Vary from drug to drug-
    • •Most common s/e:
    • •Vomiting/ nausea
    • •Drowsiness, confusion, lethargy
    • •Rash, itching
    • •Bone marrow suppression
    • •Heart dysrythmias
    • •Thrombophlebitis
    • •Thrombocytopenia
    • •Lupus, lymphoma
    • •Stevens-Johnson syndrome
    • •Liver toxicity
    • •Aplastic anemia
  99. Drug interactions (some) seizure meds
    • •Carbamazepine (Tegretol)- Coumadin, doxycycline, dilantin, theophylline
    • •Valproic acid (Depakote)- Barbiturates, dilantin
    • •Hydantoins (Dilantin)- tricyclic antidepressants, isoniazide (to treat Tb)
  100. BENZO’s
    • •Benzo’s- valium/ativan = used as first line in Status Epilepticus
    • •second-line drug for treatment of epilepsy
    • •Valium first choice for SE, quick onset
  101. Clonazepam- Klonipin = second-line
    Still a Benzo!
    • •Most widely used benzo for seizure control
    • •Has high incidence of toxicity
    • •Can cause personality changes, drowsiness, ataxia
    • •Possible aggressive behavior, moodiness
    • •Tolerance common = repeat seizures
  102. Succinimides
    • •Zarontin – safe-effective first line drug
    • •Used primarily for absence seizures
    • •Primarily in childhood
    • •Can cause n/v, abdominal discomfort, rash, headache, drowsiness
  103. Barbiturates
    • •Phenobarbitol and Primidone-
    • •Primidone- metabolized in the liver
    • •Phenobarb- first line drug for SE and used to control seizures as well in chronic sufferers – MOST COMMON s/e = sedation, but tolerance will occur
    • •Interacts with MANY drugs
    • •Has the LONGESt ½ life of all the AED’s
    • •Most inexpensive AED
  104. Hydantoins- (Phenytoin)Dilantin
    • •First line drug
    • •s/e – confusion, lethargy, abn. movements
    • •Long-term use can cause acne, encephalopathy, ataxia, nystygmus, hypertrophy of sc facial tissue (Dilantin facies), gingival hypertrophy, so educate good oral hygiene!
    • •Educate- vitamin D replacement due to s/e of osteoporosis
    • •Those with lower albumin levels (malnourished, CRF) may need to keep serum levels lower than usual- there will be more free, unbound dilantin in the system b/c the drug binds to albumin
    • •Levelsv= 10-20 mcg/mL (narrow window!!)
  105. Valproic Acid
    • •Depakote, depakene, depacon
    • •Can cause n/v, dizziness, weight gain, tremors, hair loss
    • •Pancreatitis and hepatotoxicity can be deadly
    • •Interacts with many other meds
    • •Also highly bound to plasma protein( albumin)
    • •Highly metabolized in the liver
    • •Levels= 50-100 mcg/mL
  106. other seizure meds
    • •Tegretol = first line AED (carbamazepine)
    • •Goes through “AUTOINDUCTION”- when a drug increases it’s own metabolism over time,causing lower than expected drug concentrations
    • •Neurontin – Used with a primary AED
    • •Also reduces neuropathic pain
    • •Abrupt withdrawal can cause “withdrawal seizures”
  107. Assessment
    • •Drug history
    • •Allergies
    • •Labs- liver, kidney, CBC, Chem 7, Heart/resp system, CNS d/o
    • •Many of the AED’s can interact with ETOH, oral contraceptives, Dig, CNS depressants
    • •If theses drugs have “drug levels” we need to follow carefully!
  108. Implementation
    • •Taken at the same time of day
    • •No abrupt discontinuation
    • •Take with meals to decrease GI s/s
    • •Capsules should not be chewed, opened or crushed
    • •When given IM, rotate sites and place deep in the muscle (gluteal is the choice)
    • •Parenterally – vein ONLY, never arterial
    • •Skin sloughing, ischemia can occur if given and then it infiltrates
    • •(Especially Dilantin) Should be given SLOW IVP and VS monitored carefully
    • •Given only with NS
    • •Medic alert tags for those on AED’s
    • •High fiber secondary to risk of constipation
    • •Educate that therapy may be life-long and that driving may be prohibited by Dr.
    • •Keep journal of seizure activity
  109. Pedi considerations
    • •Skin rashes on infant- notify Dr. ASAP
    • •Chewables are avoided for once daily dosage
    • •IM dilantin should be avoided
    • •Encourage family to keep records of seizure activity, and any side effects noted
    • •Educate to call Dr. asap for any unusual behavior
    • •Suspensions need to be shaken well
    • •Use a graduated syringe for safe dosing
    • •May need lower than usual doses and are highly sensitive to barbiturates
    • •Watch for paradoxical effects- excitability, confusion
    • •Safe responses for neonates not established in benzo’s
    • •Oral valproic acid should not be given with MILK-
    • •Can cause early dissolving and irritate the local mucosa
    • •Should not be mixed with ANY milk products at all!
    • •Educate
  110. Some FYI to add:
    • •If under age 23 – susceptible to gingival hyperplasia (gum inflammation)- esp. with dilantin
    • •Usually happens within the first 6 months of treatment
    • •Can also cause increase body hair growth
    • •Valproic Acid- increased risk of toxicity in kids
    • •Do frequent labs for blood levels
  111. FYI
    for the elderly:
    • •Metabolize more slowly
    • •Watch for drug accumulation and toxicity
    • •Frequent labs for levels
    • •May need decreased doses because some binding with proteins (remember?)
    • •Iv doses very slowly
  112. Antiparkinsonians
    • •Fist-what is Parkinson’s?
    • •PARKINSONS DISEASE- chronic, progressive, degenerative d/o affecting the dopamine-producing neurons in the brain that control smooth muscle movement. AKA- “shaking palsy”.
    • •FYI: The correct balance of Dopamine and Ach
    • (Acteylcholine) is necessary in regulating posture, muscle tome and voluntary movement! People with Parkinson’s Disease have an imbalance- a decrease in inhibitory dopamine and an increase in excitatory Ach…
    • Fyi for later…
    • •Other chronic CNS neuromuscular d/o = Myasthenia gravis, dementia, Alzheimer’s
  113. Parkinsons
    • •Rarely effects those under 40 years of age
    • •Primarily seen in the elderly
    • •Men and women equally affected
    • •Caused by an imbalance of dopamine and acetylcholine- a balance of the 2 is needed for correct posture, muscle contol/tone, and voluntary movement
    • •Theories: May be from an early head injury in childhood, may be due to decreased iron levels, dopamine levels decrease with age
    • •No lab tests to confirm
    • •CT/MRI/EEG’s are usually normal!
    • •Dx. based on classic symptoms =
    • •BRADYKENESIA- slow movement
    • •RIGIDITY- “cogwheel rigidity”- resistance to passive movement
    • •Tremor- tremor against the thumb and forefinger “pill-rolling”- seen mostly at rest, starts on one side and progresses to the other, presenting sign in 70% of cases
    • •POSTURAL INSTABILITY- Danger of falling, hesitation in gait
  114. Advanced Parkinsons
    • •WORSENING Parkinsonian s/s = DYSKENESIA-
    • difficulty with voluntary movement
    • •Chorea- irregular, spasmodic, involuntary movements in the limbs, facial muscles
    • •Dystonia- abnormal muscle tone in any tissue
  115. treatment


    • •Drug
    • therapy- levadopa in early stages to
    • help correct neurotransmitter imbalances

    • •Drug
    • therapy to help lessen effects of disease- not a cure
  116. Neuroprotective Therapy (slows process)
    • •ELDEPRYL- (MAO-B)- monoamine oxidase B- derived from amphetamine-small dosages do not cause effects with tryamines
    • •Used to use MAOI’s- INTERACTS WITH TRYAMINES!!- causes severe hypertension
    • •Has a neuroprotective effect
    • •Studies show that high doses of C and E may help slow progression of PD (as well as Alzheimer’s)
  117. How does it work?
    • •MAO-B one of 2 pathways by which dopamine is degraded
    • •MAO-B- accounts for 70% of all MAO in the brain
    • •Blocks destruction of cells
    • •MAO-B is in the CNS- primarily the brain
    • •(Ps- MAO-A is used for the treatment of depression)
  118. Drug Effects for parkinsons med
    • •High concentration of MAO’s in the kidneys and liver, as well as intestinal wall, brain and stomach.
    • •MAO’s catabolize dopamine, norepi and epi, so… MAO-B blocks the breakdown
  119. Therapeutic uses for parkinsons med
    • •ELDAPRYL is currently used with levadopa and levadopa-carbidopa to decrease the amounts of those drugs needed
    • •Decreased s/s are seen
    • •50-60% of patient’s have shown improvement
    • •Rx only
    • •Oral form only
  120. S/E’s and adverse reactions parkinsons med
    • •N/V- abdominal pain
    • •dizziness
    • •insomnia
    • •confusion
    • •dry mouth
    • •If the dose exceeds 10mg q D -can cause hypertensive crisis if ingestion of tryamine containing foods, confusion, muscular twitching, teeth grinding, memory loss
  121. Interactions
    • •Number of drugs that interact is small
    • •Dose over 10mg/d can cause “cheese effect
    • •Demerol is contraindicated- can cause a FATAL htpertensive episode
    • •All opioids should be avoided if on >10 mg/d
  122. Dopaminergic Therapy
    • •Used to help replace the lost dopamine or enhance the function of the neurons left that are still functioning
    • •Ultimate goal is to increase the levels of dopamine in the brain
    • •By doing so, AKENESIAS can be reversed
    • •AKENESIA- masklike facial expressions, impaired postural reflexes (these render the patient unable to care for self)
  123. Mechanisms of action
    • •LEVADOPA- and the combo drug- levadopa-carbidopa, directly replace the deficient dopamine (Sinamet)
    • •Large doses are usually needed, thus causing increased s/e, so… carbidopa is added
    • •SYMMETREL- antiparkinsonian- helps with dyskenesias
    • •Others include Parlodel and Permax- activates dopamine
    • receptors and more dopamine is produced
    • •MIRAPEX AND REQUIP- NEW, effective in early stages of PD
  124. Drug effects and therapeutic uses
    • •Levadopa and carbadopa together = more levadopa to the
    • brain(increasing dopamine levels) and works to offset imbalances d/t dopamine and Ach.
    • •Used for:
    • •Promotion of voluntary movement
  125. Side Effects/Adverse Reactions
    • •GI upset
    • •Heart dysrythmias
    • •Dizziness
    • •Dry mouth
    • •Involuntary movements(dyskenesia)
    • •Educate to change positions slowly b/c postural hypotension can occur
    • •Avoid any sudden withdrawal of the meds
    • •Levadopa can darken sweat and urine
    • •No B6 supplements- (reverses effects)
    • •Take with a low protein snack
    • •Keep a journal of progress and s/e
  126. Interactions
    • •Hydantoins-(valproic acid, dilantinNeurontin)- decreases the effects of levadopa, also Haldol.
    • •MAOI’s can cause hypertensive crisis
    • •Vit B6 can reverse the effects of levadopa- (carbidopa helps inhibit that!)
    • •Drugs that block Ach (Acetylcholine)- used to treat
    • tremors and muscular rigidity caused by excessive cholinergic activity
    • •SIDE EFFECTS are dry mouth, blurred vision and urinary retention
    • •How do they work?
    • •Block Ach
    • •Ach accumulates in PD patients
  128. Drug Effects
    • •Ach (Acteylcholine) causes “SLUDGE”
    • Salivation
    • Lacrimation
    • Urination
    • Diarrhea
    • Increased gastric motility
    • Emesis
  129. ANTI-cholinergics cause the opposite:
    • •Salivation = dry mouth
    • •Lacrimation = dry eyes, lack of tears
    • •Urination = urinary retention
    • •Diarrhea = constipation
    • •increased GI motility = constipation
    • •Emesis = none
    • •ALSO CAUSES- mydriasis =dilated pupils and smooth
    • muscle relaxation
  130. Therapeutic uses
    Causes relaxation in the smooth muscles therefore lessening rigidity and akinesia (non-movement)
  131. Adverse reactions
    • •Hallucination, drowsiness, confusion
    • •N/V/C
    • •Urinary retention, pain w/urination
    • •Dilated pupils
    • •Dry skin
    • •Photophobia
    • •Blurred vision
    • •Can cause postural hypotension- rise and turn slowly
  132. Interactions
    • •CNS depressants
    • •ETOH
    • •Trycyclic antidepressants
    • •Antihistamines
    • •Amantadine
    • •THESE all enhance CNS depression
    • •ANTACIDS- decreases the effect of anticholinergics due to altered gastric Ph
    • •Treatment w/ anticholinergics are used with primary PD drugs
    • •Started in small doses
    • •Commonly used = Cogentin, Benadryl, Parsidol, Artane
    • •Can cause increased s/e in the elderly!!- SAFETY
    • •Most are synthetic deriviatives
    • •* Cogentin
    • •* Artane
  133. Assessment
    • •Assess ADL’s and drug history
    • •Assess gait, weakness, tremors, LOC
    • •Assess bowel patterns, urinary patterns, appetite
    • •Assess mood, affect, depression, personality changes
    • •Assess speech problems, facial expressions, dysphagia
    • •Assess motor function, rigidity
    • •Assess glaucoma, cataracts- mydriasis can lead to
    • intraocular pressure
    • •Age- inceased risk of toxicity
    • •Liver function, Bp
    • •Any hypersensitivity to these drugs in the past
  134. Implementation
    • •Anticholinergics after meals and
    • single doses at HS
    • •Increase fluid intake unless otherwise contraindicated
    • •Frequent oral care
    • •Contraindicated drugs/OTC’s- ask Dr. First!!
    • •High fiber diet
    • •NO MAOI’s- may cause hypertensive crisis- need 2 weeks b/t meds if one is to be dc’d and one started
    • •Any of the drugs that are sustained release (SR) cannot be crushed
  135. Evaluation
    • •Monitor side effects- decreased appetitie, constipation, n/v, abd pain, dry mouth
    • •Monitor for concentrated urine or pain
    • •Monitor CNS- confusion, hallucination, etc, mood…
    • •Monitor therapeutic effect
  136. Geriatric considerations
    • •May have increased effects and s/e
    • •Men with hx. of BPH (benign prostatic hypertrophy)- beware of the urinary retention, it will be increased
    • •Hx. of glaucoma and urinary retention may not be good candidates for anticholinergics
    • •Watch for paradoxical effects
    • •Avoid excessive heat exposure, with anticholinergics- decrease in sweat and cooling mechanism
    • •Levadopa is used with caution- increased risk for s/e
    • •Levadopa-carbidopa started at low dosages due to increased sensitivity
  137. CSN Stimulants
    • •Elevate mood
    • •Decrease appetite
    • •Used for treatment of ADD and ADHD
    • •Stimulate respirations
    • •Appetite suppressant
    • •Narcolepsy and migraine HA’s
    • •They are controlled substances
  138. CSN Stimulants-How do they work?
    • •Increase RR
    • •Enhance the mood
    • •Increase motor activity
    • •Diminish sense of fatigue
    • •Stimulate spinal cord and the brain
    • •PS- there is a high abuse potential
    • •Some can be found on the streets
  139. CSN Stimulants-The drugs
    • •Adderal- ADD and ADHD and appetite suppressant
    • •Caffeine- in many food and drink products, No Doz- to stay awake (OTC)
    • •Dopram- for resp. depression, not ever used in newborns or those with hx. Of CVA or increased Bp
    • •Ritalin- ADHD and narcolepsy
    • •Imitrex- migraines, not actually classified as a stimulant- classified as a “seratonin agonist”
    • •Meridia/Xenical- for appetite control
    • -For obesity
    • -Causes fecal urgency!
    • * Remember Fen/Phen? That is now of the market as a combo drug.
  140. CSN Stimulants- Caffeine containing OTC’s
    • •Anacin
    • •Exedrine
    • •Vivarin
    • •NoDoxz
    • •Dristan AF
  141. CSN Stimulants- Side effects
    • •Increase dHR and RR
    • •Nervousness
    • •Insomnia
    • •HA*
    • •Blurred vision
    • •n/v/d, abdominal pain
    • •Diuresis
    • •Relaxation of bronchial smooth muscle
  142. CSN Stimulants- Common drug interactions
    • •Beta-blockers- hypertension, dysrythmias
    • •Other CNS stimulants- too increased, toxic
    • •Digoxin- increased risk of dysrythmia
    • •MAOI’s- HA, severe hypertension (crisis)
    • •TCA’s- tachy, increased Bp
    • •EDUCATE
  143. CSN Stimulants- Pediatric considerations
    • •Toxicity- agitation, seizures, confusion, coma, hypertension
    • •Drug witdrawl- depression, agitation, tiredness, HA
    • •Wean- do not stop abruptly
    • •Watch for weight loss
    • •Only with Rx.
    • •Keep out of reach of children- can also be abused
  144. CSN Stimulants- Education
    • •Avoid other stimulants
    • •Do not skip, omit, double up
    • •Watch OTC’s and herbals
    • •Take at least 6 hours before bed
    • •If appetite suppresant- take 30-45 min before meal
    • •Mouth may become dry
    • •Be aware of Tryamines!! (look over your foods)
  145. CSN Stimulants- Street amphetamines
    • •Cocaine
    • •Crack cocaine
    • •Crystal meth
    • •Ecstacy
  146. Cholinergics
    • —This works more on the PNS
    • —The PNS is the opposition of the SNS
    • —ACH is the neurotransmitter responsible here for the transmission of nerve impulses
    • —Cholinergics cause SLUDGE
  147. Cholinergics-SLUDGE
    • —Salivation
    • —Lactrimation
    • —Urination
    • —Diarrhea
    • —Increased GI motility
    • —Emesis
  148. Cholinergics- ACH
    —Cholinergics mimic ACH = Rest and Digest

    • —ACH is in short
    • supply in those with AD

    • —It is needed fro
    • normal brain function

    —Cardiac- cholinergics slow heart rate and vasodilate

    —Hence… SLUDGE
  149. Therapeutic effects of anticholinergics
    • —Glaucoma patients use
    • them to decrease occular pressure

    • —Can be used to
    • decrease occular pressure for surgery

    • —Indirectly- the y
    • cause skeletal muscle contraction for the treatment and dx. of MG

    • —AD- increases
    • concentrations of ACH in the brain to maintain function
    • —MG- autoimmune
    • disease causing breakdown of the skeletal muscles
    • —This causes muscle weakness and decreased contraction of the muscles
    • —Post op- can be used to treat paralytic ileus*
    • —Can be used to treat urinary retention
    • —ANTIDOTE- phasostygmine- reverses sludge
  150. Cholinergics-Adverse reactions
    • —CV- brady, hypotension, cardiac arrest
    • —CNS-HA, dizziness, convulsions
    • —GI- N/V, abdominal cramping (should not be used with GI obstruction)
    • —Resp- increased bronchial secretions and bronchospasms (Not to be used with asthma) —Other-increased
    • sweating, salivation, lacrimation
  151. Cholinergics-Toxicity and OD
    • —Cholinergic crisis! (can be deadly)
    • —Circulatory collapse
    • —Hypotension
    • —Bloody diarrhea
    • —Shock
    • —Cardiac arrest
    • —EARLY S/S- abd. cramping, n/v, skin flushing, dyspnea, heart block, ortho. hypo
  152. Cholinergics-SO now what?
    • —Can often be reversed by atropine
    • —Bronchoconstricion can be reversed by Epinephrine
    • —So you see you will be in an emergency as these are code drugs!
    • —Phasostygmine is the direct antidote for toxicity
  153. Cholinergics- Interactions
    • —DO not give with anticholinergics
    • —DO not give with antihistamines
    • —Why?
  154. Cholinergics- The drugs
    • Urecholine (Bethanecol)- this is direct acting:
    • can be used for:
    • •Paralytic ileus
    • •Smoothing the wall of the bladder for the treatment of post-op or post delivery urinary retention
    • •Used to treat TCA induced ur. Retention
    • •Can be used for post-op gastric retention
    • •Is often used for the dx. of infantile c. f.
  155. Cholinergics- Aricept
    • —Works indirectly
    • —Works centrally on the brain to increase ACH levels by blocking its breakdown
    • —Is highly plasma bound
    • —Used to treat AD
    • —Avoid other drugs with anti-cholinergic properties
    • —This delays AD progression- not a cure
  156. Cholinergics- Neostygmine
    • —Improves muscle strength for those with MG
    • —Should not be used in those with a dx. Of epilepsy,
    • bronchial asthma, dysrythmias, peptic ulcers
    • —Other- Tensilon- can be used for the dx. Of MG
    • —Mestinonin- for MG- longer acting than the neostygmine
    • —* can be used to reverse NMBA post-op*
  157. Cholinergics- Others
    • —Pilocarpine
    • —Charbachol
    • —These meds are used for the treatment of glaucoma
    • —They aid in decreasing occular pressure
    • —More to come on glaucoma later!
  158. Cholinergics- Assessment
    • —Other meds?
    • —Allergies?
    • —Remember they will decrease HR
    • —Increase GI ad GU tone
    • —Increase bronchial smooth muscle

    —Increases resp secretions

    —Causes miosis

    —No anticholinergics, no NSAIDS

    • —May take 6 weeks or
    • more to see results! Educate
  159. Cholinergics- Implementation
    • —If patient is on theses- start back ASAP after surgery
    • —MG- give meds 30 min before meals to decrease symptoms of dysphagia
    • —Have Atropine/Epi on hand at all times
    • —AD- not a cure but will decrease symptoms and progression
    • —Do not stop abruptly
  160. Cholinergics-Evaluation
    • —If given post-op- should hear BS soon after
    • —Hypotonic bladder- micturation within 60 minutes of med admin
    • —MG- s/s should be somewhat alleviated
    • —Watch for increased resp secretions, dyspnea, aspiration is a
    • risk, hypotension, brady, increase urinary frequency/urgency
    • —If any more than usual while on meds- call Dr.
  161. OPIOID-Assessment of pain is difficult. Look for:
    • Muscle rigidity
    • Restlessness
    • Screaming
    • Fear of moving
    • Pedi patients often go un-medicated and under medicated due to the difficulty in assessment of pain
  162. OPIOID-
    • Watch
    • carefully for CNS reactions and if any, hold further medication and call
    • the Dr.
    • Monitor
    • VS before, during and after opioid admin.
    • OPIOIDS IF RR IS <12/min or there are changes in LOC
    • Frequently
    • and carefully assess RR = depth, rate, rhythm, and is there any difficulty
    • Smaller
    • doses are indicated in pedi patients

    • 18
    • years of age and under- should not give meperidine (Demerol)
    • Oral
    • opioid derivatives should be given with food or milk to decrease GI tract
    • distress
    • Allergic
    • reactions may present as rash, itching
    • Withdrawal
    • s/s = N/V, anorexia, fever, cramps, faintness
    • If there is any confusion, decreased RR, or excessive CNS depression- withhold meds and call Dr.
    • REMEMBER- polypharmacy risk- get a thorough drug hx.
    • Reduced circulation = reduced absorption with pain meds
    • They may hesitate to ask for pain meds so as not to “bother” you- encourage them to ask