N365 Exam #2

Inhalation anesthetics

drugs administered through respiratory tract

How does a gaba-receptor agonist work?

it is a neuroinhibitor that slows down the brain and has a very calming effect

actions of a nitrous oxide anesthetic:

gaba-receptor agonist, opioid agonist; HIGHLY analgesic medication, but not the greatest anesthetic (it drops CNS just enough, but not dramatically)

how does nitrous oxide put you under?

it produces narcosis, amnesia and analgesia

nitrous oxide must be given with AT LEAST 30% oxygen because

it compromises normal tissue oxygen since nitrous oxide can block some movement of O2 in the body, resulting in an inadequate oxygen balance

ADRs you want to educate your patient on pre-op before administering nitrous oxide?

post-op N/V, toxic suppression of CNS

when would you want to use nitrous oxide?

as an induction agent, it is the best to get the patient in the state you want

what are things you should look out for in a patient receiving nitrous oxide?

• hypoxia

• CNS depression

• Post-op N/V

compared to general gaseous anesthetics, volatile anesthetic agents

cause slower onset in induction and slower recovery

isoflurane (Forane) action

GABA and glutamate receptor antagonist; it is a really good anesthetic that will significantly depress your CNS, it’s not as good as an analgesic though

Isoflurane was administered in a patient who is going into surgery. While waiting, the nurse anesthesiologist notices that the pt has become tachycardic and feverish with a temperature that quickly rose up to 105F in a matter of minutes. She has severe muscle rigidity and is becoming hypercarbic. These are the signs and symptoms of:

malignant hyperthermia

ADRs to monitor for when administering isoflurane includes:

• hypotension

• significant respiratory depression

• malignant hyperthermia

why might hypotension occur in a patient receiving isoflurane?

vasodilation occurs because of the CNS depression

if a patient is getting muscle rigidity after being administered isoflurane, the nurse should give them what drug to relax their muscles?

dantrolene/dantrium

if you need to quickly and easily intubate a patient, you should give them:

isoflurane

because isoflurane has mild skeletal muscle relaxant effects, it can also relax the uterine muscle which can ___

slow down labor

why might someone prefer IV anesthetics in comparison to the forms of anesthesia?

• rapid pleasant induction

• absence of explosive hazards

• low incidence of postop N/V

what is the major difference between barbiturates and gaseous agents?

safety

uses for IV anesthetics

induce and maintain general surgical anesthesia and hypnosis

the classification of barbiturates

IV general anesthetic, ultra short-acting, “HYPNOTIC”

propofol (Diprivan) action

promotes release of GABA; has short duration of anesthesia action. it is very lipid soluble, which means it can really go to a lot of different places in the body

ADRs to monitor in a patient on propofol:

• Respiratory depression

• Hypotension

• propofol infusion syndrome

• risk of bacterial infection

A patient is given propofol in high doses, which results in propofol infusion syndrome. What assessment findings would you expect to see in a patient who has this?

• metabolic acidosis

• kidney failure

• heart rhythm changes

• hyperkalemia

propofol has antiemetic properties. t or f

true

what is the “milk of amnesia”?

propofol

what agents could you administer with isoflurane for quick induction and muscle relaxant?

propofol & dantrium

fentanyl classification

opioid/narcotic anesthetic

fentanyl action

morphine-like action that is 100x as potent as morphine

ADRs to look out for when administering fentanyl to an intra-op patient:

• miosis

• pruritus

• euphoria

a black box warning found on fentanyl is:

significant abuse potential

Why should you not rapidly inject IV fentanyl or give it in large doses?

may cause muscle rigidity and apnea

how often should you change topical fentanyl patches?

every 72 hours for pain control

an anesthetic that is categorized as “dissociative”

ketamine

why is ketamine dangerous?

it’s a date rape drug — this is used because it induces a trance-like effect characterized by analgesia, quietude and detachment from the environment without loss of consciousness

what drug is being used to treat resistant major depression now?

ketamine (Ketalar)

classification of midazolam (Versed)

IV anesthetic, benzodiazepine

what are benzodiazepines?

depressants that produce sedation and hypnosis, relieve anxiety and muscle spasms, reduce seizures

when is misazolam used?

used for induction, it is a short acting medication

why is midazolam called a “twilight “ anesthesia?

it’s considered a “conscious-sedation” anesthesia; you’re not all the way asleep, but not all the way awake either

midazolam (Versed) action

neuroleptic effect: decreased pain, anxiety, sort of calmness. it causes skeletal muscle relaxation by potentiating GABA

What is a black box warning to think about when administering midazolam to a patient?

respiratory depression

ADRs to look for in midazolam

• decreased alertness and amnesia

• muscle tremors

• tachycardia

• SOB

Midazolam usually produces an ____ effect

anterograde amnesic effect

what is anterograde amnesic effect

loss of memory about the procedure — won’t remember anything from the time it was given to you until it wears off

midazolam has a ____ post anesthetic recovery period than ___

prolonged, barbiturates

classification of lidocaine

local anesthetic

how does lidocaine work in the body?

it blocks sodium into the neuron, which decreases sensation and movement somehow; elevate threshold of excitation of nerve cell membrane without affecting resting potential

A patient was given high doses of lidocaine, which resulted in drastic mood changes, hallucinations and delusions. The patient also reports feeling doom anxiety. This patient is exhibiting signs and symptoms of:

lidocaine psychosis

ADRs to look out for in a patient receiving lidocaine

• overdose = lidocaine psychosis

• bradycardic, hypotension, cardiac arrest

what gets affected first when administering lidocaine?

pain fibers → loss of all sensation

what can happen in someone whose lidocaine administration becomes systemic?

they have have serious reactions in the heart and brain

how do you keep lidocaine local?

vasoconstrictors are used to shrink blood vessels and keep the medication from escaping into the bloodstream

what are the two different types of skeletal muscle relaxants?

• non-depolarizing neuromuscular blocking agents

• depolarizing neuromuscular blocking agents

depolarizing neuromuscular blocking agents action

prevent the action of ACh at the neuromuscular junction, preventing skeletal muscle contraction

nondepolarizing neuromuscular blockers

competitive ACh antagonists, blocks the binding of ACh so the motor endplate cannot depolarize

classification of rocuronium (Zemuron)

nondepolarizing neuromuscular blocking agents

rocuronium (Zemuron) action

affects movement; there is no action and muscles can’t depolarize = flaccid, cannot move as long as anesthesia is sitting in the receptor bc Ach cannot get there

ADRs to watch out for rocuronium

• tachycardia

• muscles weakness

• salivation

• hypertension

when might you want to use rocuronium?

intubation, endoscopy

how is the effects of rocuronium reversed?

by anticholinesterase (which allows for accumulation of ACh)

succinylcholine (Anectine) is categorized as

depolarizing neuromuscular blocking agent

ADRs to monitor for when administering succinylcholine`

• muscle weakness

• bronchospasm

• apnea

• increased salivation

• post-op muscle pain

• more twitching, seizure-y looking

both lidocaine and rocuronium paralyze patients but doesn’t affect pain sensation and consciousness. t or f

true

how long does it take for succinylcholine to peak and how long does it last?

a minute, 10 minutes

succinylcholine has ___ level of toxicity

low

succinylcholine has ___ depolarization and ____ acetylcholine

prolonged, resembles

both succinylcholine and rocuronium cause

muscle paralysis

Which person has an increased risk for adverse effects with isoflurane?

a) a 70 year old man with COPD
b) a 66 year old woman with hypothyroidism
c) a 16 year old girl with anorexia nervosa
d) an 80 year old woman with Parkinson’s disease

a 70 year old man with COPD

a local anesthetic like lidocaine is not useful during

a) suturing of a deep laceration
b) regional blocks
c) general anesthesia
d) ophthalmic anesthesia

c) general anesthesia

what are schedule II drugs?

they have a high risk of abuse, like morphine

what do opioids lead to?

sedation

morphine has a ___ action on perception of pain

central

which receptors does morphine bind to?

mu and kappa

morphine effects on the body

• mental clouding

• pinpoint constricted pupils

• RESPIRATORY DEPRESSION

• triggers the VOMIT center

• dilates RESISTANCE VESSELS, leading to postural hypotension

• CONSTIPATION, slows down motility

• URINARY RETENTION

• pruritus d/t histamine effect

why should we avoid giving opioids to someone with a potential head injury?

opioids provoke the release of histamine, and dilates resistance and cerebral vessels, this can increase intracranial pressure

why do we give high doses of oral morphine?

it has a high first pass metabolism

why might someone prefer meperidine (Demerol) over morphine?

it’s synthetic, so there’s fewer GI problems, no biliary spasms or constipation; less urinary retention

what is the purpose of naloxone?

it is a “pure” antagonist, only purpose is to block the effects of opioid

a nurse is worried about a patient who seem to be displaying symptoms of opioid overdose following a surgery. her best course of action is to

give them naloxone

what are you worried about when giving naloxone to a patient who is addicted to opioids?

withdrawal symptoms

what does nalbuphine (nubain) do?

combines with kappa receptors to produce analgesia

what are some ADRs to monitor for when dealing with nalbuphine?

• sedation

• sweatiness

• N/V

• Vertigo

• dry mouth

• respiratory depression

nalbuphine is not reversible by narcan. t or f

false

a patient with pneumonia asks why you are giving them codeine even though they report no pain. you explain that codeine:

is also an antitussive/cough suppressant

what does codeine turn into when metabolized?

morphine

the main use for codeine is as a:

cough suppressant

ADRs to look out for with codeine:

• respiratory depression

• constipation

• urinary retention

why do we need higher doses of codeine to achieve pain relief?

it’s just not as effective as an analgesic

what classification is zolpidem (Ambien)?

hypnotic, non-BZD

zolpidem is a benzodiazepine

false, they are structurally different but binds to BZD receptors in the brain

What would you want to educate your patient who is taking zolpidem on?

educate them to not drive after taking this medication, can lead to a DUI

What schedule of drugs is zolpidem?

Schedule IV

the most hazardous adverse effects with the use of morphine (and any narcotic/opioid for that matter) occur to the ___

respiratory system

Why might codeine be a poor choice for someone with a respiratory disorder?

it can lead to accumulation of secretions, we want them to cough it out to prevent aspiration

inflammation is

a complex and natural occurrence in the body, when it’s chronic and extreme —> pain and discomfort

what does prostaglandin start off as?

arachidonic, then converted by an enzyme called COX — cyclooxygenase

What makes cox-1 different from cox-2?

COX-1 is protective, we want to keep this circulating in the body

COX-2 is the __ of __ effects

mediator, bad

Where is COX-2 mostly found?

found mainly in injured tissues

What does COX-2 do in the body?

it increases inflammation, pain, and causes fever