Unit 1 Medications : Mobility, Periop, Parkinson's, Tissue Integrity

general info about local anesthetics

• generally safer than generalized, but there is less control over the onset and duration (effect may last longer than general anesthesia)

• can be topical or injected

MOA of local anesthetics

Blocks pain transmission in peripheral nerves;

blocks sodium channels on nerve cells. Prevents the transmission of nerve impulses and results in localized numbness and pain relief

what do local anesthetics do?

• decreases local pain and local reflexes

• decreases sensation

what are the adverse outcomes of local anesthesia

1. local skin reaction

2. systemic toxicity

monitor and response for local skin reaction r/t local anesthetics:

monitor: erythema(redness), pruritus (itching), warmth

response: educate that this is a normal response

monitor and response for systemic toxicity r/t localized anesthetics:

monitor:

• CNS depression (agitation followed by ↓LOC)

• CV depression (↓HR, BP, cardiac arrest)

response: call RRT, call code blue, notify provider

general info about general anesthetics:

• Multiple meds used to produce analgesia, relaxation, unconsciousness (hypnosis), amnesia, loss of reflexes which allows for invasive procedures

• can be inhaled or IV

• creates different levels of sedation

• monitored very closely

MOA of general anesthetics

• enhance transmission at inhibitory synapses

• inhibits transmission at excitatory synapses

• combination of analgesics, hypnotics, & anxiolytics to provide desired level of effect

what do general anesthetics do?

• ↓↓ pain (analgesia)

• ↓↓ agitation and anxiety (relaxation)

• ↓↓ alertness (hypnosis)

• ↓↓ memory of event (amnesia)

• ↓↓ reflexes (paralysis)

what are the adverse outcomes for general anesthesia

1. respiratory depression

2. spinal headache (post-dural puncture headache)

3. post-op N/V

4. malignant hyperthermia

monitor and response for respiratory depression r/t general anesthetics

monitor: ↓RR, ↓SpO2, cyanosis

response:

• oxygen (up the ladder of delivery methods)

• sternal rub

• Ambu bag

• code blue, notify provider

monitor and response for spinal headaches r/t general anesthetics

monitor: onset of headache, particularly when the patient is upright

response:

• notify provider

• encourage hydration

• anticipate orders to administer analgesics

• anticipate orders for blood patch if conservative measures fail

monitor and response for post-op N/V r/t general anesthetics

monitor: report of nausea, emesis

response:

• administer antiemetics (e.g., ondansetron)

• ensure hydration

• provide comfort measures

monitor and response for malignant hyperthermia r/t general anesthetics

monitor: muscle rigidity, hyperthermia

response:

• hold triggering agents (anesthesia meds), notify provider

• anticipate orders to administer dantrolene (more coming in Mobility)

• cool the patient

what is muscle spasticity?

Continuous state of contraction of muscle groups, hypertonia

how does muscle spasticity occur?

caused by damage to neurons in the CNS

what does muscle spasticity cause?

1. increased muscle tone

2. spasm

3. loss of dexterity

examples of muscle spasticity disorders

1. multiple sclerosis

2. cerebral palsy

3. strokes

4. ALS

5. spinal cord injury

what drugs are used to treat muscle spasticity?

1. direct acting muscle relaxants -dantrolene

2. centrally acting muscle relaxants - baclofen

what are muscle spasms?

involuntary contraction of a muscle or muscle group

what do muscle spasms cause?

Causes sudden and intense pain that gradually diminishes (ex: cramp, charley horse)

how do muscle spasms occur?

as a result of muscle injury or overuse

examples of muscle spasms

1. hypocalcemia

2. acute and chronic pain syndromes

3. localized muscle injury

what meds are used to treat muscle spasms?

1. NSAIDS (ibuprofen, naproxen)

2. centrally acting muscle relaxants (cyclobenzaprine)

what are the two types of centrally acting muscle relaxants called?

1. cyclobenzaprine

2. baclofen

MOA for centrally acting muscle relaxants

acts on the central nervous system (CNS) to reduce muscle tone by decreasing the transmission of nerve impulses, thereby relieving muscle spasms

indications for centrally acting muscle relaxants

• ↓ muscle spasm or spasticity

• ↓ muscle pain

• ↑ mobility

adverse outcomes of centrally acting muscle relaxants AND direct acting muscle relaxants

1. additive CNS depression

2. GI upset

3. dizziness & hypotension

4. drowsiness & muscle weakness

5. dry mouth

6. photosensitivity

7. hepatotoxicity

monitoring additive CNS depression for CAMRs:

monitor: ↓RR, ↓SpO2, concurrent use of other CNS depressants

response: do not take with ETOH, CNS depressants, accelerate care as needed (O2, rapid response, etc)

monitoring GI upset for CAMRs:

monitor: pt report of nausea

response: encourage to take with or after meal; try ginger candy or ginger capsules; notify provider

monitoring dizziness & hypotension for CAMRs:

monitor: ↓BP, patient report of dizziness

response: fall precautions, advise rise slowly, hold and notify provider

monitoring drowsiness & muscle weakness for CAMRs:

monitor: ↓LOC, report of weakness

response: advise patient to avoid activities requiring alertness, assess safety needs, hold med and notify provider

monitoring dry mouth for CAMRs:

monitor: patient report of dry mouth, oral examination

response: provide sips of water, sugar-free gum or lozenges, humidified air, notify provider if severe

monitoring photosensitivity for CAMRs:

monitor: patient report of light sensitivity; discomfort in bright light

response: educate patient on the use of sunscreen, protective clothing, and sunglasses hold med and notify provider

monitoring hepatoxicity for CAMRs:

monitor: : elevated liver function tests (↑LFTs), jaundice

response: hold med and notify provider

what are some medication considerations for using CAMRs?

1. cyclobenzaprines - watch for confusion, hallucinations

2. baclofen: can be used on a pump, do not discontinue abruptly

MOA for Direct-Acting Muscle Relaxants

directly relaxes spastic muscles by interfering with the release of calcium ions in the SR of skeletal muscle, this relaxation also lowers core body temperature

indications for Direct-Acting Muscle Relaxants:

• ↓ muscle spasticity

• ↓ muscle pain

• ↑ mobility

s/s of malignant hyperthermia caused by general anesthetics

1. muscle rigidity with a profound temperature increase

2. May also see increased HR, increased RR, rhabdomyolysis (muscle fiber breakdown), and acidosis

pathophysiology of malignant hyperthermia

Uncontrolled metabolic activity in muscle r/t increased calcium release in SR leads to elevated temp

what do dopaminergic medications do

increase dopamine

what do anticholinergic medications do

suppress acetylcholine

generic names of dopaminergic medications

1. Levodopa/Carbidopa → replacement

2. Pramipexole → dopaminergic agonist

3. Selegiline → MAO-B inhibitor

MOA for dopaminergic medications

Stimulate dopamine receptors and increase the amount of dopamine available in the CNS, or enhance the neurotransmission of dopamine

indications for dopaminergic medications

• ↓ muscle rigidity

• ↓ tremors

• ↓ bradykinesia

• Improvement of gait

adverse outcomes for dopaminergic medications

1. Dyskinesia, involuntary movements

2. Headache

3. Orthostatic hypotension, dizziness

4. Confusion, agitation

5. GI: N/V, urinary retention, constipation

6. Insomnia, sleep disturbances

monitoring dyskinesia, involuntary movements for dopaminergic medications

monitor: symptom tracking, comparison to baseline, fall risk

response: fall precautions prn, chat with provider if worsening or impacting daily life/med adherance

monitoring headaches for dopaminergic medications

monitor: pain level and quality

response: non-pharm techniques, prn pain medication, chat with provider if worsening or impacting daily life/med adherance

monitoring orthostatic hypotension & dizziness for dopaminergic medications

monitor: BP, transfer capabilities, activity level, fall risk

response: response: reinforce use of call light, safe transfer techniques, bed/chair alarms prn, fall precautions

monitoring confusion & agitation for dopaminergic medications

monitor: LOC, mood changes, A&O

response: calmly reorient patient, involve family for pt comfort and instructions prn, de-escalate prn, call provider if safety is a concern

monitoring N/V, urinary retention, & constipation for dopaminergic medications

monitor: severity of sx (I&O if ordered vs general tracking), watch fluid balance if vomiting is severe

response: non-pharm techniques (small meals, increase fiber, etc.), speak with provider if worsening

monitoring insomnia & sleep disturbances for dopaminergic medications

monitor: quality and hours of sleep, report of nightmares, restless legs, etc

response: reinforce sleep hygiene, chat with provider if worsening or impacting med adherance

what are some special considerations for dopaminergic medications?

1. Carbidopa/levodopa = on-off & wearing off effect (see next slide), full effect takes months

2. Pramipexole = hallucinations common in older patients

3. Selegiline = contraindicated with older antidepressants (MAOIs and tricyclics) and opioids

what do “On periods” look like for Levodopa/Carbidopa r/t long-term use?

1. Med is working effectively, pt experience good control of both motor and non-motor symptoms

2. Move more easily, stiffness reduces, and overall function improves

what do “Off periods” look like for Levodopa/Carbidopa r/t long-term use?

• Med's effect diminishes, and PD symptoms return or worsen.

  • Motor symptoms: Re-emergence of tremor, rigidity, stiffness, slowness of movement (bradykinesia), and difficulty initiating movement or walking (freezing of gait).

  • Non-motor symptoms: Anxiety, depression, pain, sweating, shortness of breath, and increased fatigue.

  • Timing: may be predictable, occurring regularly before the next dose ("wearing off"), or unpredictable and sudden.

what is a generic name brand for anticholinergics?

Benztropine

MOA for Anticholinergics

Decreases the activity of acetylcholine therefore restoring the balance of acetylcholine and dopamine

indications for Anticholinergics

• ↓ tremor

• ↓ rigidity

adverse outcomes associated with anticholinergics

1. dry mouth

2. blurred vision

3. constipation, urinary retention

what are anticholinergics contraindicated with?

pts with glaucoma and GI obstruction. caution with COPD

monitoring dry mouth r/t anticholinergics

• monitor: severity of sx, pt comfort

• response: increase fluid intake, or utilize ice chips, gum, sugarless candy if safe based on swallowing risks

monitoring blurred vision r/t anticholinergics

monitor: pt reports of symptoms, safety while moving, fall risk

response:

• increase fluids and fiber

• alert provider if concerned for paralytic ileus

monitoring constipation & urinary retention r/t anticholinergics

monitor: bowel & bladder function, output

response: increase fluids and fiber, alert provider if concern for paralytic ileus