Exam II

AD pathophysiology

Amyloid plaques and neurofibrillary tangles that occurred from chronic inflammation and caused structural damage in brain.

Where in the brain does AD affect?

Hippocampus (memory and learning)

Symptoms of AD

• Memory loss

• Disorientation and confusion

• Inability to recognise family and friends

• Aggressive behaviour

• Depression

• Psychoses

• Anxiety

Mood stabilizers

Citalopram, sertraline, fluoxetine

Anxiolytics

Buspirone or some benzodiazepines

Mild stage of AD

• May function independently

• Memory lapses

Moderate stage of AD

• Longest stage, can last many years

• Difficulty with ADLs

• Memory loss

• Disoriented to time and place

• Wandering/pacing

Severe stage of AD

• Pharmacotherapy is not effective at this stage

• Loses ability to respond to their environment

• Total dependence on caretaker

• Dysphagia and dysphasia

Early onset AD

Symptoms appearing at 40 years old

Typical age of AD onset

Symptoms appearing at 65+ years old

Goals of AD pharmacological therapy

Slows and improve symptoms

No cure for AD

Cholinesterase Inhibitors

Prevents breakdown of Ach and slows progression of AD

donepezil (Aricept) Contraindications

Pts with bleeding and jaundice

donepezil (Aricept) OD treatment

Anticholinergics (e.g. Atropine)

donepezil (Aricept) Administration

• Give prior to bedtime

• Take with food or milk

• Monitor pt for hypotension

• Monitor for changes in mental status and mood

• Monitor for dizziness, insomnia or anorexia

• Assess baseline vitals

• Can be given 1x daily due to long ½ life

S/S of AchEI OD

• Severe N/V

• Sweating

• Salivation

• Hypotension

• Bradycardia

• Convulsions

• Increased muscle weakness

Parkinson’s disease pathophysiology

• Progressive loss of dopamine due to death and destruction of dopamine-producing neurons

• Affects (unconscious) muscle movement

Where in the brain does PD affect?

Corpus striatum & substantia nigra

Most common degenerative CNS disease

Parkinson’s disease

Symptoms of PD

• tremors

• muscle rigidity

• bradykinesia

• postural instability

• Pill rolling motion

Antiparkinsonian agents

Dopaminergics and Anticholinergics

• Restores balance of Dopamine and Ach in the brain

• Constantly needs adjustment based on s/s

Goal of PD pharmacotherapy

Increase the ability of the pt. to perform ADLs

Dopaminergic/dopamine agonist

Increases dopamine in brain

levodopa-carbidopa (Sinemet) Class

Dopamine agonist

donepezil (Aricept) Class

Acetylcholinesterase inhibitor

levodopa-carbidopa (Sinemet) adverse effects

• acute MI

• shock

• involuntary movements

• narrow angle glaucoma

• Neuroleptic Malignant Syndrome (NMS)

levodopa-carbidopa (Sinemet) interactions

Ca2+ antacids can decrease the drug’s effectiveness

levodopa-carbidopa (Sinemet) administration

• Take on an empty stomach for better absorption

• Abrupt withdrawal of drug can cause NMS

• Increase fibre and fluids

• May take several months for full effect

tolcapone (Tasmar)

• Dopaminergic adjunct agent

• Inhibits enzymes that break down dopamine

ropinirole (Requip)

• Dopaminergic adjunct agent

• Activates dopamine receptors

amantadine (Symmetrel)

• Dopaminergic adjunct agent

• Causes dopamine release from nerve terminals

Catechol-O-Methyl Transferase (COMT) inhibitors mechanism

Increases concentration of existing dopamine in nerve terminals

Catechol-O-Methyl Transferase (COMT) inhibitors side effects

• mental confusion

• nausea

• vomiting

• headache

• diarrhea

• possible liver damage

Anticholinergic agents primary use

• Used in early stages of PD therapy

• Centrally acting

• Not as effective as dopaminergics

Benztropine (cogentin) class

Anticholinergic agent

Benzatropine (cogentin) mechanism

• Blocks excess cholinergic stimulation of neurons in the corpus striatum

• Inhibits overactivity in the brain

Benztropine (cogentin) adverse effects

• sedation

• paralytic ileus

• cardiovascular collapse

• loss of balance

• hallucinations

treatment of Benztropine (cogentin) OD

• Physostigmine 1-2 mg subQ or IV

Benzatropine (cogentin) administration

• Take with food or milk to prevent GI upset

• Avoid alcohol

• Photosensitivity

• Monitor HR as it can cause tachycardia

• Avoid OTC cold medicine

• Do not stop abruptly

• Notify provider if eye twitches or tremors occur

Nursing actions for PD

• Monitoring chewing/swallowing to prevent aspiration

• Instruct pt to call for assistance prior to getting out of bed or attempting to walk alone

• Be cautious with older adults → higher risk for hypotension

• Teach pt to stand or sit up slowly to avoid dizziness or falls

• If dizziness occurs, teach pts to lie down until the sensation passes

Psychological factors+

Can decrease or increase the perception of pain

• Anxiety, depression or fatigue can increase pain perception

Acute pain

• Intense

• Defined period of time

• Sudden onset

Chronic pain

• lasts longer than 6 months

• Interferes with daily activities

Nociceptive pain

• Due to injury to tissues

Somatic pain

• Type of nociceptive pain

• sharp, localized sensation

visceral pain

• Type of nociceptive pain

• Dull, throbbing, aching sensation

Neuropathic pain

• Due to injury to nerves

• Burning, shooting, numbing pain

• Common in diabetics

• Treated with anti-seizure & antidepressants

Nonpharmacological techniques for pain management

• can be used alone or in conjunction with pharmacotherapy

• may allow for lower doses and possibly fewer side effects

Opioid agonist mechanism

stimulates mu and kappa receptor sites

Morphine class

opioid agonist

Morphine primary use

relieves moderate to severe pain.
analgesia and anesthesia

Morphine adverse effects

• Resp depression

• Sedation

• Nausea

• Hypoactive bowel sounds

• Constipation

• Decreased peristalsis

• Orthostatic hypotension → falls and injuries

Morphine contraindications

may mask pain of gallbladder disease due to biliary tract spasm

Morphine interactions

• alcohol

• other opioids

• general anesthesia

• MAOIs

• sedatives → severe resp. depression → death

Treatment of Morphine OD

• Naloxone (Narcan)

• Activated charcoal

• Laxatives

Opioid antagonists mechanism

• blocks opioid activity

• blocks mu and kappa receptors competitively

naloxone (Narcan) class

Opioid antagonist

naloxone (Narcan) administration

• Administered parenterally: IV, IM, subQ

• Administer for RR of <10 breaths/min

• Monitor resp status

• Have resuscitative equipment available

• Should NOT be used for resp. depression caused by NONOPIOID MEDICATIONS (NSAIDs & acetaminophen)

Treatment for opioid dependence

• switch from IV and inhalation forms to methadone PO

• Methadone does not cure but avoids withdrawal symptoms

• treatment may be needed for months or years

Buprenorphine

• Mixed opioid agonist-antagonist

• Sublingual or transdermal route

Non-opioid analgesics

Includes:

• NSAIDs

• Centrally-acting non-opioids

Non-opioid analgesics primary use

• used for fever, inflammation and analgesia

• Used for mild or moderate pain associated with inflammation

Signs of inflammation

• Pain

• Itching

• Warmth

• Redness

Aspirin class

Salicylates

Aspirin mechanism

anticoagulant, antipyretic, anti-inflammatory, analgesic

Aspirin adverse effects

• High doses may cause GI distress and bleeding

• May result in ulceration and bleeding (dark stools)

• May increase action of oral hypoglycemic agents

• Causes irreversible platelet aggregation inhibition

• Should be discontinued 1 week prior to surgery

Aspirin contraindications

Should not be given to pts. receiving anticoagulant therapy such as warfarin and heparin

Aspirin interactions

• GI ulcers when taken with NSAIDs, alcohol and steroids

• Antacids, glucocorticoids and Phenobarbitals decreases effects

NSAIDs

• Ibuprofen

• Selective COX-2 Inhibitors

Ibuprofen (Motrin, Advil) class

NSAID

Ibuprofen (Motrin, Advil) mechanism

to inhibit cyclo-oxygenase and prevent formation of prostaglandins

Celecoxib mechanism

to inhibit cyclo-oxygenase and prevent formation of prostaglandins

Ibuprofen (Motrin, Advil) primary use

for mild - moderate pain and to reduce inflammation

Ibuprofen (Motrin, Advil) adverse effects

• GI upset

• Acute renal failure and nephrotoxicity

Ibuprofen (Motrin, Advil) administration

• Take with food to prevent GI upset

• Max dose in 24 hrs: 4000 mg

• Older pts more prone to increased bleeding

• Report bleeding and bruising to provider

• Increase fluid intake to prevent nephrotoxicity

celecoxib (Celebrex) class

Selective COX-2 inhibitors

celecoxib (Celebrex) primary use

to relieve pain, fever and inflammation

celecoxib (Celebrex) adverse effects

Mild and related to GI system

acetaminophen (Tylenol) class

Centrally acting nonopioid analgesics

acetaminophen (Tylenol) mechanism

• treats fever at the level of the hypothalamus

• causes dilation of peripheral blood vessels, enabling sweating and dissipation of heat

acetaminophen (Tylenol) primary use

treatment of fever and to relieve pain

acetaminophen (Tylenol) adverse effects

uncommon with therapeutic doses

acetaminophen (Tylenol) administration

• Hepatotoxic and may cause problems in clients who consume alcohol

• inhibits the metabolism of warfarin → could result in a toxic accumulation of warfarin

Rheumatoid arthritis (RA) characteristics

• systematic autoimmune inflammatory disorder

• disfigurement and inflammation of multiple joints

• joint stiffness and pain

• pain more intense in the morning

• tender and warm joints

Autoantibodies

• a.k.a rheumatoid factor

• activates inflammatory response in joints

S/s of RA

• fever

• weakness

• fatigue

• weight loss

• scleritis

• corneal ulcers

• vasculitis

• nodules under the skin

Diseases associated with RA

pulmonary disease & pericarditis

Non-pharmacological measures for RA

• Physical therapy

• Massage

• Warm baths

• heat to affected areas

• exercise

• surgery: joint replacement

Pharmacological treatment goals for RA

• Relieve symptoms - reduce pain

• maintain joint function

• minimize systematic involvement/disability

• delay progression of disease

Classes of non-arthritic drugs

• NSAIDs

• DMARDs

• Glucocorticoids

Types of glucocorticoids

• Prednisone/prednisolone

• PO glucocorticoids (generalized symptoms)

• Intra-articular injections (for 1 or 2 affected joints)

Methotrexate class

Non-biologic DMARD

Methotrexate adverse effects

• Hepatic fibrosis

• Bone marrow suppression

• GI ulcerations

• Pneumonitis

Methotrexate therapeutic effect

• Most rapid acting DMARD

• 3-6 weeks

Sulfasalazine class

Non-biologic DMARD

Sulfasalazine primary use

• Used to treat IBD and RA

• Anti-inflammatory and immunomodulary actions

• Can slow progression of joint deterioration

• GI side effects may be intolerable

hydroxychloroquine sulfate (Plaquenil) class

Non-biologic DMARD

hydroxychloroquine sulfate (Plaquenil) primary use

relieves severe inflammation of arthritis and lupus for pts who have not responded well to other drugs

hydroxychloroquine sulfate (Plaquenil) mechanisms

not known

hydroxychloroquine sulfate (Plaquenil) adverse effects

• anorexia

• GI disturbances

• hair loss

• possible ocular effects

• headaches

• mood and mental changes