neuro drugs

Antiseizure Medications

classification of seizures

partial and generalized

drugs for generalized seizures

stabilize nerve membranes
affect entire brain
variety of categories of drugs :
- hydantoins: suppress sodium influx
- potentiate GABA (inhibitory neurotransmitter)

CNS: sedation effects

Hydantions \= phenytoin

indications: epilepsy

less sedative

contraindications: cannot take Ginko or evening primrose

Dilantin (phenytoin)

Anticonvulsant

Seizures, therapeutic levels are determined by blood test \= 10 to 20 mcg/mL

Meds should be taken at the same everyday.

Some antieplitic cause overgrowth of the gums, routine oral hygiene.

NO ORAL CONTRACEPTIVES OR COUMADIN.

phenytoin

pixorize

scenario \= girl dares this boy with $20 to climb a phone tower

phone tower \= phenytoin

anti-shake shocks on tower \= treats seizures

toxicity--\>

"do not climb high" sign \= acute toxicity at high doses

$10 - 20 \= narrow range of 10 - 20

boy falling \= ataxia

slurred words \= slurred speech

looking side to side - nystagmus

SE --\>
bubble gum \= gingival hyperplasia

simple nursing

phenytoin

phenytoin \= phenytoxic --\> last longer in the body and patients can get very toxic

below 10 \= seizure risk

over 20 \= toxic risk

take at the same time daily

phenytoin toxicity--\> early signs

1) ataxia (unsteady gait - phenytoxic \= 'pheny' walks)
2) hand tremor
3) slurred speech

KEY words
1) suicidal ideation
2) new skin RASH (steven johnson) - priority!

simple nursing

phenytoin

expected side effects

Expected side effect - low and slow vitals

1) bradycardia and hypotension

2) gingival hyperplasia - bleeding gums is normal

there is no metallic taste and no photosensitivity

simple nursing

phenytoin

patient teaching

no oral contraceptives

no stopping abruptly - always taper off drugs that act on the brain

take folic acid, calcium, and vit d

take 2 hours before or after eating

Steven Johnson Syndrome (SJS)

Severe blistering of the skin, with mucous membrane involvement and fever

Can be fatal

related to phenytoin

Barbiturates

drugs that depress the activity of the central nervous system, reducing anxiety but impairing memory and judgment

phenobarbital and primidone

barbiturates

pixorize

scenario \= barber shop

barber \= "-barbital" ending

anti-shake shocks on headrest \= treats seizures

sleeping customer \= causes sedation

broken fan \= causes respiratory depression

loyalty card \= causes tolerance/dependence

Barbiturates: Indications

when significant CNS depression is required

status epilepticus

CNS depression

Dizziness, sedation, and impaired respiration

Benzodiazepines

drugs that lower anxiety and reduce stress

Benzodiazepines: indications

anticonvulsant (epilepsy)

sedative

What is Parkinson's disease?

LOW dopamine
&
HIGH acetycholine

Characterized by resting tremor, slowed movement, shuffling gait, pill rolling of fingers

drug therapy aimed at managing s/s

Dopaminergic Agents

levodopa/carbidopa

carbidopa conserves more dopamine and levodopa leaves more dopamine

contraindications: asthma among others

does NOT help with memory

levodopa/carbidopa

pixorize

scene: park ranger raking up leaves

leaves \= levodopa

raking leaves into cardboard box \= carbidopa

park ranger and rattling walker \= treats parkinson's disease

park ranger saw a ghost \= causes psychiatric disturbances

park ranger gets dizzy \= causes orthostatic hypotension

park ranger is paralyzed with fear \= akinetic crisis if stopped suddenly

simple nursing

carbidopa + levodopa

SE--\>

hallucinations

orthostatic hypotension

AE--\>

signs of toxicity
1) dyskinesia - ticks and twitches

pt teaching--\>
1) red, brown urine, sweat, and saliva is NORMAL

2) NO high protein meals - leave the proteins and carb it up

can you combine levodopa/carbidopa with an MAOI?

no, can throw them into hypertensive crisis

Dopaminergic side effects

Nausea, confusion, hallucination, postural hypotension, sedation, edema, vivid dreams, impulsive behavior, psychosis, sleep attacks (rare) - Titrate slowly!

glaucoma \= do not administer

no MAOI's \= throws them into hypertensive crisis

Dopaminergic contraindications

- narrow angle glaucoma
- sever cardiac, renal, hepatic disease
- psychosis
- suicidal tendencies

muscle relaxants

relieve muscle spasms, pain, and stiffness

muscle spasms

localized

caused by the flood of sensory impulses coming to the spinal cord from the injured area

muscle spasticity

generalized

damage to neurons within the CNS

Centrally Acting Skeletal Muscle Relaxants

MOA

inhibit muscle innervation

Baclofen (Lioresal), carisoprodol (Soma), cyclobenzaprine, methocarbamol (Robaxin)

muscle relaxants

pixorize

scene: man getting a massage

masse \= muscle relaxants

back of the man \= baclofen

"CARESS massage" sign \= carisoprodol"

metal cart \= methocarbamol

cyclone blender for fresh smoothies during massage \= cyclobenzaprine

dizzy client \= causes orthostatic hypotension

lady giving massage is yawning \= cause sedation

no alcohol sign \= avoid alcohol

Centrally Acting Skeletal Muscle Relaxants

indications

alleviation of s/s of spasticity

use in spinal cord injuries or diseases

Centrally Acting Skeletal Muscle Relaxants

Contraindications/Caution:

Rheumatic disorders

Epilepsy

Conditions marked by muscle weakness

Centrally Acting Skeletal Muscle Relaxants

SE

Drowsiness, Fatigue, Weakness, Confusion, HA, Nausea, Dry mouth, Hypotension

Nursing Considerations for Centrally-Acting Skeletal Muscle Relaxants

assess for...

Epilepsy

Muscle weakness

Rheumatic disorder

CNS orientation, affect, reflexes, bilateral grip strength, and muscle spasticity

Bowel sounds, urine output

what are adrenergic agents?

Sympathomimetic

drug that stimulates the adrenergic receptors of the sympathetic nervous system, either directly (by reacting with receptor sites) or indirectly (by increasing norepinephrine levels)

Alpha-Agonist - specifically stimulating to the alpha-receptors

Beta-Agonist - specifically stimulating the beta-receptors

ANS

sympathetic

"to turn on" \= adrenergic agonist (fight or flight)

"to turn off" \= adrenergic antagonist/blockers (rest - feed, breed, pee, poo)

ANS

Parasympathetic

"to turn on" \= cholinergic agonist (sludge - salivation, lacrimation, urination, diarrhea, emesis)

"to turn off" \= anticholinergic (dry - no glaucoma)

ALPHA AND BETA MNEUMONIC

LOCATION
1 \= heart
2 \= lungs

ACTION
1 \= to constrict
2 \= to dilate

WHERE
A \= alpha \= arteries (of smooth muscle)

B \= beta \= Heart beats (beta 1 works on the heart beats) OR breaths (beta 2 works on the breaths)

Receptor types:
Alpha 1 receptor work to constrict the arteries in smooth muscle.
Beta 1 receptors constrict blood vessels in the heart, increasing the force of those beats.
Beta 2 receptors work to dilate the bronchioles in the lungs.

Applied to pharmacology:
Albuterol is a Beta 2 agonist. We know 2 means dilate the lungs. We know agonist means to stimulate the function of something. So, we know albuterol works to dilate the bronchioles of the lungs.

Alpha- and Beta-Adrenergic Agonists & Indications

Dobutamine: CHF

Dopamine: Shock
Prototype
IV: Onset 1-2 mins, peak 10 mins, duration is length of infusion

Ephedrine: seasonal rhinitis, hypotensive episodes

Epinephrine (Adrenalin): shock, glaucoma, prolongs effects of regional anesthesia (potent vasoconstrictor)

Norepinephrine (Levophed): treat shock or during cardiac arrest to get sympathetic activity

Alpha- and Beta-Adrenergic Agonists

indications

CHF (Dobutamine)

Shock (Dopamine, Epinephrine, Norepinephrine)

Hypotensive Shock (Ephedrine)

Bronchospasm (Epinephrine)

Some types of asthma

Alpha- and Beta-Adrenergic Agonists

Contraindications/Caution

PVD, Ventricular Fibrillation, Tachyarrhythmia

General Anesthetics

Hypovolemia

Pheochromocytoma (neuroendocrine tumor - BP would be through the roof)

Alpha- and Beta-Adrenergic Agonists

Side Effects/Adverse Effects

Arrhythmias, HTN, Palpitations, Angina, & Dyspnea

Nausea & Vomiting

HA & Sweating, Tension & Anxiety

discoloration at IV site \= administer SQ regitin

Alpha- and Beta-Adrenergic Agonists

Drug-Drug Interactions

Tricyclic antidepressants & MAOIs

Adrenergic antagonists

Alpha-Specific Adrenergic Agonists

Phenylephrine (Neo-synephrine)- prototype

Potent alpha 1 agonist

Phenylephrine

pixorize

scene: federal agents opening exam scores in the hotel room

federal agents \= eFEDrine

failed the final exam \= phenylephrine

federal agent has stuffy nose \= functions to treat rhinitis --\> reduce fluid secretions by decreasing blood flow through vasoconstriction

the other agent is nervous \= these drugs cause CNS stimulation - agitation, restlessness

Alpha-Specific Adrenergic Agonists

Indications

Cold and allergies

Shock

Dilation of pupils for ocular exams

Alpha-Specific Adrenergic Agonists

Contraindications/Caution

Severe HTN or Tachycardia

Narrow-angle glaucoma

CVD

Thyrotoxicosis or DM

Alpha-Specific Adrenergic Agonists

side effects

Beta-Specific Adrenergic Agonists

MOA

effect is related to its stimulation of the beta-adrenergic receptors

Isoproterenol (Isuprel)- prototype

Albuterol (Proventil, Proair)

Levalbuterol (Xopenex)

Salmeterol (Serevent)

Beta-Specific Adrenergic Agonists

indications

Increase in heart rate, conductivity, & contractility

bronchodilation

blood flow to skeletal muscle

relaxation of uterus

Beta-Specific Adrenergic Agonists

contraindications

Cautions

Allergies

Pulmonary HTN

Tachyarrhythmias/heart block/angina

Anesthesia

Pregnancy or lactation

caution in....

DM, Thyroid Disease
Heart Disease
Stroke
Renal impairment

Beta-Specific Adrenergic Agonists

side effects/adverse effects

Restless, Anxiety, & Fear

Tachycardia, Angina, MI, & Palpitations

Difficulty breathing, cough, & bronchospasm

Nausea & Vomiting

moving to antagonist...

Adrenergic Antagonists

MOA

Prevent Norepinephrine from activating the receptor sites

Adrenergic Antagonists

drugs

Amiodarone and beta blockers--\>

Carvedilol

Labetalol

Adrenergic Antagonists

indications

HTN

Lowers blood pressure

Increases renal perfusion

Tachycardia

Slows pulse rate

Treats HTN associated with pheochromocytoma and clonidine W/D

Adrenergic Antagonists

contraindications

Shock or CHF

Bradycardia or heart block

Bronchodilation

Adrenergic Antagonists

side effects

Dizziness, Insomnia , Depression, Fatigue, & Vertigo

N/V

Cardiac arrhythmias, Hypotension, & HF, Pulmonary Edema

Nursing Considerations of Adrenergic Antagonist or beta blockers

assess:

Bradycardia or Heart Block

Asthma or Bronchospasm

Shock or HF, ECG as appropriate, Lab values

deference between adrenergic and cholinergic?

Cholinergic Agonists

MOA

Drugs which react chemically with acetylcholinesterase to prevent it from breaking down into ACh.

Works mainly for Myasthenia Gravis and Alzheimer's disease

Cholinergic Agonists

Bethanechol

Bethanechol

simple nursing

bethanechol for bladder control --\> given for neurogenic bladder (functional urinary retention)

common SE: sweating, urinary urgency, low HR and BP

Cholinergics

when would you use them?

Increase bladder tone

Urinary Excretion

GI secretions

Ophthalmic agents

Cholinergics

contraindications

Bradycardia, Hypotension

Bladder or GI obstruction

Cholinergics

SE

Nursing Considerations of Cholinergics

assess:

Heart Rate & BP

GI status

Urinary status

what is Donepezil?

this is a cholinergic drug

pixorize

scene: donut stand by the castle

the alchemist donuts \= donepezil

cooler full with cola \= high choline levels (increases acetylcholine)

confused alchemist \= treats alzheimer disease

simple nursing

Cholinergics

Neostigmine, Pyridostigmine

given to patients with MG

think of tin man - MG pts require cholinergic meds to function

"-stigmine"

makes patients "wet and wild"

can lead to cholinergic crisis

Pyridostigmine / Neostigmine Mnemonic

scene: DJ at a pirate themed party in mexico

pirate \= pyridostigmine

neon sticks \= neostigmine

headphones \= edrophonium

mayan graves \= myasthenia gravis

ice bucket full of cola \= increase acetylcholine

DJ raising cola \= may cause cholinergic overload

man in tropical shirt ruining party \= reversed by atropine

Neostigmine, Pyridostigmine

contraindications

caution

Bradycardia or GI/GU obstruction

Neostigmine, Pyridostigmine

AE

Stimulation of the parasympathetic nervous system...

CNS: miosis, HA, dizziness, drowsiness
\-
CV: bradycardia, heart block, cardiac arrest
\-
GI/GU: N/V/D, involuntary defecation, cramps, increased salivation, urgency

what is cholinergic crisis?

cholinergic crisis is a secretion crisis

antidote - anticholinergic such as atropine

cholinergic crisis mnemonic

DUMBELLS
D - DIARRHEA
U - URINATION
M - MIOSIS (PUPIL CONSTRICTION)
B - BRADYCARDIA
E - EMESIS
L - LETHARGY
L - LACRIMATION
S - SALIVATION

cholinergic crisis versus MG crisis

what is edrophonium?

short acting anti cholinesterase. used for diagnostic purposes in MG

AFTER ADMIN:

if s/s improve \= MG crisis

if they worsen \= cholinergic crisis (overdose of medication)

Cholinesterase inhibitors increase the amount of acetylcholine and its effects. Anticholinergics block acetylcholine and stop it from working!

what are anticholinergics?

block acetylcholine receptors & act as cholinergic anatgonists

end in ''-tropine"

diphenhydramine

Parkinson's Anticholinergic Prototype

benztropine

Returns balance to basal ganglia and reduces severity of rigidity, akinesia, and tremors

simple nursing

anticholinergics

anticholinergics are anti-secretions

Tremors needs aTropines - does NOT treat pyschosis

key points:
1) treats EPS (dystonia)

2) treats parkinson's tremors (bradykinesia)

contraindications:
1) no bowel obstruction
2) no glaucoma
3) no BPH or urinary retention

pt teaching--\>
1) notify HCP if you develop urinary retention
2) med can reduce ability to sweat so do not overheat
3) sit/stand slowly

atropine

pixorize

scene: man stuck on a deserted tropical island

tropics \= atropine

sending messages in empty cola bottle \= anticholinergic

man looking at his watch \= treats bradycardia

sunblock over heart \= treats heart block

dry mouth/tongue \= decreases secretions

dilated pupils (mydriasis) \= anticholinergic effect

man rubbing eyes \= contraindicated in glaucoma

physician running out of boat onto island to rescue man \= effects reversed by physostigmine (cholinergic)

Anticholernergics work by turning off the...

PNS and turning on the SNS

Anticholinergic effects

dry mouth
constipation
photophobia
blurred vision
Tachycardia

BCDU: blurred vision, constipation, dry mouth, and urinary retention

Effects of Blocking the Parasympathetic System

Increase in Heart Rate

Decrease in GI activity

Decrease in Urinary Bladder Tone & Function

Pupil Dilation

Anticholinergic Agents

indications

Decrease GI secretions

Bradycardia

Restore Cardiac Rate & BP

Hyperactive Bowel

Uterine Hypertonicity

anticholinergic agents contraindications

GU obstruction, Prostatic hypertrophy, Myasthenia gravis

Tachycardia, dysrhythmias, changes in BP, hepatic dysfunction

Anticholinergic Agents

side effects

Blurred Vision

Mydriasis (Pupil Dilation)

Cycloplegia (near vision)

Photophobia

Dry mouth, Altered Taste Perception

Urinary hesitancy & retention

Decreased sweating

Anticholinergic Agents

drug-drug interactions

Antihistamines
Antiparkinsonism Drugs
MAOIs
TCAs
Phenothiazines

anticholinergic agents

Herbal Therapies to avoid...

belladona, mandrake, any mushrooms

Nursing Considerations for Anticholinergic Agents

assess:

Bowel & Bladder Patterns

Renal Function (GFR)

VS, ECG as appropriate

Neuro status

Part 2

Psychosis versus neurosis

Psychosis --\>
major personality disorder, loses contact with reality

schizophrenia, mania, depression, bipolar

Patient is not aware of illness and refers to treatment

Neurosis--\>
mild disorder and comes from stress, depression, or anxiety

OCD, Phobia, Anxiety, PTSD

Less serious and insight present

sedation

loss of awareness of and reaction to environmental stimuli

Hypnosis

extreme sedation resulting in further CNS depression and sleep

level below general anesthesia

Anxiolytics

primary -
1) not caused by a medical condition or drug
2) managed with short term anxiolytics

secondary -
1) related to drug use, medical, or psychiatric conditions
2) short term anxiolytics are not usually given for this
3) example: CHF (use diuretics to treat the fluid overload causing the anxiety)

panic disorder

An anxiety disorder marked by unpredictable minutes-long episodes of intense dread in which a person experiences terror and accompanying chest pain, choking, or other frightening sensations.

social phobia

a disorder that involves an irrational fear of being publicly humiliated or embarrassed

specific phobia

fear of objects or specific situations or events

PTSD

an anxiety disorder characterized by haunting memories, nightmares, social withdrawal, jumpy anxiety, and/or insomnia that lingers for four weeks or more after a traumatic experience

Benzodiazepines indications

The most common group of antianxiety drugs, which includes Valium and Xanax

indicated with anxiety disorders, withdrawal, hyper-excitability, pre-op, seizures with epilepsy

Benzodiazepines

pixorize

scene: benz dealership

benz \= benzodiazepines

car pamphlet \= "-pam ending" - clonazepam

lambo dealership across the street \= "-lam" ending - Midazolam or alprazolam

color diagram to customize car \= chlordiazepoxide

anxious man trying to steal car out of show room \= treats anxiety

anti-shake shocks \= treats seizures

thief left behind alcohol \= treats alcohol withdrawal

car salesman that is sleeping \= causes sedation

broken fan \= causes respiratory depression

loyalty cards \= causes tolerance/dependence

car fumes as the thief drives away \= flumazenil is the antidote

Benzodiazepines

contraindications and cautions

-acute alcohol intoxication (depress the CNS)

-psychosis (schizo - it puts them in a hyper-sensitive, or manic, state)

-depression

-acute narrow angle glaucoma (depresses ocular muscles)

-hepatic or renal dysfunction (dose altered by liver and kidneys must excrete it)

-coma

-pregnancy (tetragenic in 1st trimester)