Neuro Pharm

Acetaminophen

Treats: mild to moderate fever, reduces fever (antipyretic)

MOA: inhibiting prostaglandin synthesis

SE: hepatotoxicity in large doses (black box warning)

→can lead to liver failure or death

Nursing care: do not exceed 4g/day, 2-3g/day for very young & old patients, avoid ETOH & alcohol, can be used instead of NSAIDs to decrease bleed risk

Antidote: acetylcysteine

Prostaglandins

Hormones created at site of injury or infection→ promotes inflammation, blood flow & fever

acetaminophen & NSAIDs inhibit prostaglandin synthesis

Acetaminophen antidote

acetylcysteine

-smells like rotten eggs! (normal finding)

NSAIDs

ibuprofen (Advil, Motrin, Excedrin)

naproxen (Aleve)

ketorolac (Toradol)

indomethacin (Indocin)

salicylate acid (Aspirin)

ketorolac (Toradol)

only NSAID that can be given through IV

NSAIDs:

ibuprofen (Advil, Motrin, Excedrin)

naproxen (Aleve)

ketorolac (Toradol)

indomethacin (Indocin)

salicylate acid (Aspirin)

Treats: mild to moderate pain, fever, inflammation

-Indomethacin can treat patent ductus arteriosus (PDA) in premature babies

MOA: inhibits prostaglandin synthesis

SE: GI upset, GI bleeding, renal toxicity, rash, headache, hard on the kidneys

Nursing care: contraindicated for PUD or bleeding disorder, can be given with milk or antacids to reduce risk of injury to lining of stomach, avoid alcohol (increases GI bleed risk)

Difference between acetaminophen & NSAIDs

NSAIDs reduce inflammation, while acetaminophen does not

NSAIDs side effects:

N: not good for the entire body

• GI bleeding: BAD for ulcers

• Lungs: BAD for asthma (bronchospasms)

• Heart: HTN & ♥ failure

  • Kidney clogging: ↑ creatinine & BUN

KEY POINTS

• NEVER take 2 NSAIDs simultaneously

• use lowest dose for shortest time possible

S: sticky blood clots (increased risk for thrombosis)

• bad for patients with a clot history

  • MI: heart clot

  • stroke: brain clot

  • DVT

  • PE

• Aspirin: thins the blood for cardiac patients

A: asthma worsening

• NSAIDS are NOT safe for asthma

• asthma & nasal polyps

• nurse should CLARIFY ORDER

• NCLEX question: A patient with asthma or nasal polyps

  • use acetaminophen instead of an NSAID

I: increased bleed risk!

• notify health care provider of any bleeding

KEY WORDS

• easy bruising

• Tarry stool & coffee-ground emesis (indicates GI bleed)

• since NSAIDs block prostaglandins, which protects the lining of the stomach

• AVOID peptic ulcer patients, which leads to GI bleeding

• always take medicine with food, NEVER on an empty stomach

• if patient is on an acid reducer, like a PPI, then it is ok to use an NSAID

KEY POINTS

• avoid EGGO vitamins (this increases bleed risk)

  • E: vitamin E

  • G: ginko, garlic

  • O: omega 3 oils

HESI Questions

• ibuprofen: do NOT take on an empty stomach

• patient with acid reflux on Ranitidine (PPI) & NSAID

• I can occasionally take ibuprofen for my knees (rheumatoid arthritis patients)

D: Dysfunctional kidneys

• renal injury with long term use! (nephrotoxicity)

• AVOID renal patients

  • instead, use acetaminophen for renal patients

MEMORY TRICKS:

• creatinine over 1.3 = bad KIDNEY

• urine output 30 ml/hr or LESS= kidneys in DISTRESS

• Ketorolac- Kills the kidneys

S: swelling heart

• CHF (congestive heart failure) & HTN worsening

• most OTC NSAIDs contain Na+→ swell the body with fluid (bad for ♥ patients)

KEY WORDS

• patients with long term HTN or cardiovascular disease= NO NSAIDs; notify healthcare provider!

Salicylate acid (Aspirin) contraindication

• Aspirin: Avoid kids

  • possible Reye’s syndrome

  • if child has viral infection (flu/varicella): DO NOT GIVE ANY KIND OF SALICYLATE MEDS (aspirin & Pepto-Bismol)

  • instead, use ibuprofen & tylenol (acetaminophen)

• Reye’s syndrome: pediatric illness with non-inflammatory encephalopathy (brain disease) & fatty changes in the liver

Celecoxib

another type of NSAID

Treats: osteoarthritis & rheumatoid arthritis

With celecoxib, you can celebrate without arthritis pain.

MOA: inhibits COX, which is produced in the body & maintains GI lining; produced during an inflammatory response

SE: increased risk for thrombosis (blood clot)→ heart attack or stroke, GI bleeding, development of a rash

Contraindications: allergies to aspirin, NSAIDs, sulfonamides

Salicylate: Aspirin (Bayer)

Treats: pain, inflammation, fever, can prevent a heart attack in patients who are at risk (patients can get a baby aspirin every day to help prevent a MI), Kawasaki disease (systemic inflammation of BVs that can affect children)

MOA: inhibits prostaglandin synthesis & decrease platelet aggregation (this is how blood clots form)

SE: GI upset, GI bleeding, rash

-bleeding disorder: no (similar to NSAIDs basically)

Nursing care:

-monitor for s/s of salicylism (n/v, tinnitus, respiratory alkalosis-hyperventilation)

salicylism s/s

n/v, tinnitus, respiratory alkalosis

Pregabalin

Drug class: anticonvulsant

Treats: neuropathy, fibromyalgia, restless-leg syndrome, seizures

“Pregabalin prevents Gabby’s neuropathy pain.”

MOA: binds to Ca channel in CNS→ decreased excitatory NTs→ decrease AP communication to pain or involuntary movement

SE: drowsiness, dry mouth, dizziness, possible edema

Nursing care:

-avoid alcohol (makes sense b/c alc is a CNS depressant)

-d/c gradually d/t withdrawal symptoms like dizziness

Opioid agonists

fentanyl, morphine, hydromorphone, oxycodone, hydrocodone, codeine, oxycontin

fentanyl, morphine, hydromorphone, oxycodone, hydrocodone, codeine, oxycontin

Treats: moderate to severe pain

MOA: binds to opioid receptors in the CNS

SE: (serious)

• low RR: respiratory depression

  • hold opioid dose for RR <12

  • we never hold drug if patient is NOT practicing deep breathing exercises (we give the med)

• low BP (orthostatic hypotension)

  • slow position changes

  • if patient is dizzy & lightheaded: assist to seating position

  • do not get up unassisted: use call light

• low brain: CNS sedation

  • easily falls asleep when talking

  • unarousable

  • sedation comes before respiratory depression

• abuse & addiction

black box warning (resp depression & addiction)

Nursing care: monitor pain level, v/s, respiratory status, deliver via IV slowly, for constipation (fluid, fibers, ambulation)

Normal Tings

do not need to report to health care provider

• burning during IV push: just dilate & give a lil slower next time

• itchy: treat with antihistamine like benadryl

• nausea/vomiting when 1st starting taking med: TEACH that as tolerance develops, nausea will improve

  • nursing interventions:

    • take PO opioids with food (this decreases the risk for nausea)

    • give anti n/v meds at first

Antidote: naloxone

Opioid antidote

naloxone

SE: HTN, tachycardia, agitation

Nursing care:

• 1-2 hr half life

  • short, so need to give multiple doses

• reassess every 60 min

• monitor for low & slow

RR below 12, unarousable, falling asleep while talking to you→ prepare for a 2nd dose of Narcan & notify health care provider

Lidocaine

topical analgesic

Treats: conditions or procedures involving the skin or mucous membranes (wound vac dressing)→ numbs area for patients

SE: rare, stinging or redness at site of application

EMLA cream: for pediatric patients

→ apply, put occlusive dressing, wait one hour, remove dressing, insert IV

Ergotamine

Treats: migraines & cluster headaches

MOA: vasoconstriction of intracranial BVs

SE: GI upset, HTN

black box warning: contraindicated for patients with ischemic CAD or peripheral vascular disease (d/t patient already having restricted blood flow; the vasoconstriction would make it worse)

Nursing care:

-take one tablet immediately at onset of headaches

-avoid alcohol & tyramine (can sometimes trigger migraines)

-lay down in a dark quiet place to help with symptoms

-report pale extremities (may be a clot)

Sumatriptan

Treats: migraines & cluster headaches

MOA: vasoconstriction of intracranial BVs

SE: dizziness, vertigo, a warm, tingling sensation

Black Box Warning: contraindication for anyone with severe HTN

Nursing care: do NOT give to patients with uncontrolled HTN

-avoid alcohol & tyramine (can sometimes trigger migraines)

-lay down in a dark quiet place to help with symptoms

-report pale extremities (may be a clot)

Donepezil

May improve a patient’s memory, cognition & ability to perform ADLs; does not cure.

“Don’t forget things (like your Pez dispenser) when you take donepezil.”

MOA: increase acetylcholine by inhibiting the action of cholinesterase, which is an enzyme that breaks down acetylcholine.

It is theorized that Alzheimer's is associated with the loss of cholinergic neurons that produce acetylcholine.

SE: headache, diarrhea, nausea

Administration: at night

Myasthenia gravis

autoimmune disorder that causes severe muscle weakness, characterized by periods of exacerbation & remission

body attacks receptors that allow for voluntary muscle control

Neostigmine, pyridostigmine

Cholinergics!

Treats: myasthenia gravis- can help improve strength & mobility in patients

MOA: increase acetylcholine by inhibiting enzyme that breaks it down (cholinesterase)

“Stig (race car driver) pulls up and blocks cholinesterase with his car, which prevents the breakdown of ACh. Most contain “stig”.

Basically, with MG, the body is too dry, causing muscle cramping, so we want to lube up the body.

SE: it’s the opposite of an anticholinergic so→ pee, poop, spit (increased salivation, diarrhea, n/v, sweating, bradycardia)

-alert if cholinergic crisis!

Edrophonium

CHOLINERGIC!

Treats: diagnosis myasthenia gravis; differentiates MG from a cholinergic crisis

Basically, if we give this to a patient & they improve→ MG

If we give this to a patient & they get worse→ cholinergic crisis (give atropine, an anticholinergic)

(This makes sense bc you have muscle weakness in MG due to the inhibition of Ach. So, a cholinergic would give you more Ach)

MG s/s (think of muscle weakness patho)Ch

weakness

eyelid drooping (ptosis)

mask like expression: no expression, looks sleepy

difficulty swallowing

fatigue

strabismus

slurred speech

SOB

Cholinergic crisis antidote

Atropine (an anticholinergic)

Parkinson’s Disease

A progressive neurodegenerative causing muscle rigidity, akinesia (loss of voluntary movement), involuntary tremors.

Pathophysiology

• with Parkinson’s disease, we have ↓ dopamine, & ↑ acetylcholine & large protein clusters called Lewy bodies in the brain

• this results in jittery movements: muscle tremors, muscle rigidity & slow start & stop motions (shuffling gait & pit rolling of fingers)

• unsteady movements are called bradykinesia

• like “parking a car”

• low movement: “you can’t jump rope if you don’t got dope”

• “more dopa means more movement”

Carbidopa & Levodopa

Treats: Parkinson’s

MOA: increases the amount of dopamine in the CNS by activating dopamine receptors that regulate motor function and body movement

• basically Levodopa leaves dopamine in the brain, & Carbidopa prevents the breakdown of Levodopa

SE: n/v, drowsiness, dark urine & sweat, diarrhea, sweating, bradycardia

Adverse Effects

• hallucinations (psychosis)

• orthostatic hypotension

low dose to prevent adverse effects to prevent toxicity:

• dyskinesia: spontaneous or involuntary movement (too much dope→ too much movement)

  • report to HCP

Key Points

• slow onset: 2-6 weeks to become effective (usually true for any drug acting on the brain)

• slow position changes

• NORMAL: red, brown urine, sweat, saliva

• NO high protein meals→ interferes w/ absorption of levodopa

• only decreased tremors or rigidity

  • not lifelong drugs: not “cure” or “eliminate”

• never stop abruptly→ complete loss of movement

• MAOI (antidepressant) + levodopa + carbidopa enhance the effects of this

  • selegiline (MAOI)

• this med does not help with memory

Benztropine

Anticholinergic!

Treats: Parkinson’s disease, improves symptoms

MOA: decreases levels of acetylcholine

SE: it’s an anticholinergic, so→ no pee, poop, spit, see (dry mouth, blurry vision, urinary retention, and constipation)

Nursing care: chew gum, suck on sugar-free hard candy for dry mouth, wear sunglasses when going outside, and increase their intake of fluids and fiber to counteract constipation

Note- this also helps with EPS symptoms in 1st gen typical antipsychotics

Phenytoin & Fosphenytoin

Treats: seizures & prevention of seizures (anticonvulsant)

SE: gingival hyperplasia (overgrowth of gum tissue→ enlarged gums), vision issues, GI upset & rash, bradycardia & hypotension (CNS depressant)

Adverse: suicidal ideations, skin rash that is new & painful (PRIORITY)

Nursing care:

monitor therapeutic levels: 10-20 mcg/ml

-toxicity s/s: ataxia (unsteady gait), hand tremor, slurred speech

-routine blood draws to check for toxicity

-take med at same time every day

-do not d/c abruptly

-no oral contraceptives (deactivates)

-take folic acid, Ca2+, & vitamin D

• drug decreases folic acid absorption & bone density

• encourage foods high in folate & vitamin D such as milk, cantaloupe & kale

-bleeding gums is normal (gingival hyperplasia): teach good dental hygiene & use soft bristled toothbrush, inform dentist you are taking phenytoin

-administration

• STOP tube feeding 1-2 hours before & after administration!

  • will interfere with absorption & ↓ effectiveness

  • flush with 30-50 mL tap water before & after

  • normal saline not required, but required for IV administration

Topiramate

Treats: seizures & prevention of seizures; anticonvulsant

SE: vision issues, dizziness, sedation, metabolic acidosis

Nursing care: monitor bicarb levels

Levetiracetam (Keppra)

Treats: seizures & prevention of seizures; anticonvulsant

SE:

-behavioral abnormalities (suicidal thoughts & confusion)

-skin rash that is new & painful (Steven Johnson syndrome)

↑ same as phenytoin

-agranulocytosis: increases risk of infection

-fatigue, orthostatic hypotension, seizures, sedation, anticholinergic effects

-CNS depressant: low & slow body, w/ drowsiness & fatigue

Nursing care: CBC, monitor for infection

Primidone

Barbiturate!

Treats: seizures & prevention of seizures; anticonvulsant

SE: (barb)

-drowsiness, GI upset, blood dyscrasias (anemia, leukemia, blood clotting conditions)

“I am primiDONE with these seizures!”

Succinylcholine

• given to paralyze (flaccid paralysis) the body before ET tube, intubation & mechanical ventilation (deep muscle relaxation)

  • those who are difficult to intubate

• SCARY: this drug only paralyzes the body, but does not sedate the patient, so the patient is awake

  • brain is NOT sedated, so the patient can feel PAIN

  • no LOC

• always sedate with a benzodiazepine with this drug

  • sedation 1st, then succinylcholine 2nd, then immediate intubation

Adverse Effects

• respiratory arrest: diaphragm is not paralyzed!

• malignant hyperthermia

  • occurs bc of general anesthesia or acetylcholine

  • Ca2+ is released from the muscles when an anesthetic is administered→ causing muscle contraction→ muscle rigidity→ increases O2 demand & metabolism→ dangerously high body temp

  • IMMEDIATE INTERVENTION: NOTIFY HCP FIRST, then administer dantrolene (muscle relaxant; antidote), then give O2 & cooling measures

Key Nursing Tings

• screen for high risk malignant hyperthermia:

  • prior reaction to general anesthesia!!!

  • blood relatives with significant reactions to general anesthesia

  • alcoholics

Barbiturates: phenobarbital & pentobarbital

Sedative hypnotic agents

Treats: seizures, used for preop sedation, induce a coma in a patient with high ICP

MOA: increases GABA→ CNS depression
SE: CNS depressant, so lethargy, hypotension, respiratory depression, constipation

ICP

A measure of pressure inside the skull, including brain tissue and cerebrospinal fluid.

Normal levels: 10-15 mmHg

Increased levels can be caused by: head injury, tumor, meningitis, hydrocephalus, intracranial hemorrhage, or hypertension

S/s: irritability (an early sign), restlessness, headache, decreased levels of consciousness, pupil abnormalities, abnormal breathing and/or posturing

Propofol

Treats: used to induce & maintain anesthesia

MOA: increases effects of GABA→ CNS depression

“If you are given propofol, someone will have to prop you up (because you will be knocked out!)”

SE: CNS depressant so→ bradycardia, hypotension, respiratory depression

-amnesia

Administration: continuously monitor v/s, does NOT treat pain, use or discard within 12 hours d/t risk of bacterial contamination