Module 1

Chpt 11 - Anesthetics

General Anesthetics

• Alters CNS nerve impulses to reduce pain and other sensations

• Complete loss of consciousness and respiratory drive depression

• Types

  • Inhalation (Ex: Laughing gas in dental procedures)

  • Parenteral

  • Adjunct - Enhances clinical therapy when used simultaneously with another drug

Overton-Meyer Theory

• Potency of anesthetics varies with lipid solubility

• Fat-soluble drugs are more potent than water-soluble drugs because they easily cross the blood-brain barrier

• Progression reduction of cerebral and spinal sensory function

Indications

• Used during surgical procedures to produce:

  • Unconsciousness

  • Skeletal muscular relaxation

  • Visceral smooth muscle relaxation

Contraindications

• Known drug allergy

• Depending on drug type

  • Pregnancy

  • Narrow-angle glaucoma (causes increased intraocular pressure)

  • Acute porphyria (Metabolic disorder; triggers severe attacks)

  • Known history of malignant hyperthermia

Effects of Inhaled and IV General Anesthetics

Adverse Effects

• Vary according to dosage and drug used

• Sites primarily affected

  • Heart, peripheral circulation, liver, kidneys, respiratory tract

• Myocardial depression is commonly seen

• Malignant Hyperthermia

  • Occurs during or after volatile inhaled general anesthesia or use of th neuromuscular blocking drug (NMBD) succinylcholine

  • Sudden elevation in body temp (greater than 104 F)

  • Tachypnea, tachycardia, muscle rigidity

  • Life-threatening emergency

  • Treated with cardiorespiratory supportive care and dantrolene (skeletal muscle relaxant - administered via IV and looks like a bright orange tang juice)

• Toxicity and management of overdose

  • In large doses, anesthetics are potentially life threatening

  • Cardiac and respiratory arrest ultimate causes of death in an overdose

  • Administered in a controlled environments

• General anesthetics: interactions

  • Antihypertensives: increased hypotensive effecfts

  • Beta blockers: increased myocardial depression

Anesthetics

Moderate Sedation

• Also called conscious sedation or procedural sedation

• Does not cause complete loss of consciousness and does no normally cause respiratory arrest

• Combination of an IV benzodiazepine (e.g., midazolam) or propofol and an opiate analgesic (e.g., fentanyl or morphine)

Local Anesthetics

• Topical

  • Applied directly to skin or mucous membranes

  • Creams (ex: Emla to numb the skin), solutions, ointments, gels, ophthalmic drops, powders, suppositories

• Parenteral

  • Injected IV or into the CNS by various spinal injection techniques

Types

• Spinal or intraspinal

• Infiltration

• Nerve block

• Topical

• Peripheral nerve catheter attached to a pump containing the local anesthetic: Pain Buster and On-Q pump

Medications

• Lidocaine

• Bupivacaine

• Chloroprocaine

• Mepivacaine

• Prilocaine

• Procaine

• Propoxycaine

• Ropivacaine

• Tetracaine

Drug Effects: Paralysis

• First, autonomic activity is lost

• Then pain and other sensory functions are lost

• Last, motor activity is lost.

• As local drugs wear off, recovery occurs in reverse order (motor, sensory, then autonomic activity are restored)

Indications for Local Anesthesia

• Used for:

  • Surgical, dental, and diagnostic procedures

  • Treatment of certain types of chronic pain

  • Spinal anesthesia: to control pain during surgical procedures and childbirth

• Local anesthetics are given by:

  • Infiltration anesthesia

  • Nerve block anesthesia

Adverse Effects

• Usually limited

• Adverse effects results if:

  • Inadvertent IV injection

  • Excessive dose or rate of injection

  • Slow metabolic breakdown

  • Injection into highly vascular tissue

  • Allergy

    • Generally limited

    • Most common with “ester type” anesthetics

• Spinal headache

  • 70% of patients who either experience inadvertent dural puncture during epidural anesthesia or undergo intrathecal anesthesia

    • Causes severe, postural headache (specifically when sitting up)

  • Usually self-limiting

  • Treatment: bed rest, analgesics, caffeine

    • Blood patch for severe cases (small amount of pt’s blood and injected into pt’s injection hole)

Neuromuscular Blocking Drugs

• Also known as NMBDs

• Prevent nerve transmission in muscle, resulting in muscle paralysis including those required to breathe

• Used with anesthetics (as adjuncts for things like intubation) during surgery

• Respiratory muscle paralysis occurs with these drugs

• Does not cause an sedation (sedative needed)

• Emergency ventilation equipment must be immediately available

• Indications

  • Main use: facilitating controlled ventilation during surgical procedures

  • Endotracheal intubation (short acting)

  • To reduce muscle contraction in an area that need surgery

• Contraindications

  • Malignant hyperthermia

    • Antidotes: anitcholinesterase

• Two Categories

  • Depolarizing (Succinylcholine): Works similarly to neurotransmitter acetylcholine (ACh), causing depolarization

    • Succinylcholine isn’t broken down quickly, causing prolonged depolarization and preventing further muscle contractions

    • Used for rapid sequence intubation and short surgical procedures

  • Rocuronium: Rapid-to-intermediate acting

    • Rocuronium blocked ACh at the neuromuscular junction; can also lead to paralysis

Nursing Implications

• Preop

  • Assess past surgeries and anesthesia response

  • Review allergies, medications, and medical history

  • Evaluate alcohol, illicit drug, and opioid use

• Intraoperative

  • Vital signs

  • perform baseline lab tests and ECG

  • Ensure ABCs

  • Monitor all body systems

• Postop

  • Watch for cardiovascular and respiratory depression

  • Identify anesthesia-related complications

  • Implement safety measures if motor/sensory loss occurs

Chpt 10 - Analgesics

Analgesics

• Medications the relieve pain without causing loss of consciousness

• “Painkillers”

• Opioid analgesics

• Adjuvant analgesic drugs

Pain

• An unpleasant sensory and emotional experience associated with actual or potential tissue damage

• A person and individual experience

• Pain involved:

  • Physical factors

  • Psychologic factors

  • Cultural factors

Key Terms

• Pain Tolerance: Amount of pain a person can endure without it interfering with normal function

• Pain Threshold: Level of stimulus needed to produce the perception of pain

• Nociception: Pain results from stimulation of sensory nerve fibers called nociceptors

Classification by Onset and Duration

• Acute:

  • Sudden onset

  • Usually subsides once treated

• Chronic:

  • Persistent or recurring

  • Lasts 3 to 6 months

  • Often difficult to treat

  • Tolerance of meds

  • Physical dependence of meds

Gate Theory of Pain Transmission

• Most common and well-described theory

• Uses the analogy of a gate to describe how impulses from damaged tissues are sensed in the brain

• Many current pain management strategies are aimed at altering this system

Pain Transmission

• Tissue injury causes the release of the following (all cause inflammatory response and pain):

  • Bradykinin

  • Histamine

  • Potassium

  • Prostaglandins

  • Serotonin

• Body has endogenous neurotransmitters (that we make in our body to fight pain)

  • Enkephalins

  • Endorphins

Stopping Pain Transmission

• Rubbing a painful area with massage or liniment stimulates large sensory fibers

• Result

  • Closes gate

  • Reduces transmission

Adjuvant Drugs

• Assist primary drugs in relieving pain

  • NSAIDS

  • Antidepressants

  • Anticonvulsants

  • Corticosteroids

• Example: Adjuvant drugs for neuropathic pain

  • Amitriptyline (antidepressant)

  • Gabapentin or pregabalin (anticonvulsants)

World Health Organization: Three-Step Analgesic Ladder

• Step 1: Nonopioids (with or without adjuvant medications) after the pain has been identified and assessed. If pain persists or increases, treatment moves to…

• Step 2: Opioids with or without nonopioids and with or without adjuvants. If pain persists or increases, management then rises to

• Step 3: Opioids indicated for moderate to severe pain, administered with or without nonopioids or adjuvant medications

Opioid Analgesics: Mechanism of Action

• Three classification based on their actions

  • Agonists (Morphine, fentanyl): Activate opioid receptors and produce strong analgesic effect for pain management

  • Agonists-antagonists (Pentazocine, nalbuphine): Partially activate opioid receptors while blocking others for moderate pain relief and lower risk of respiratory depression or addiction

  • Antagonists (Naloxone, Naltrexone): Block opioid receptors to reverse overdoses of opioids (not for actual pain relief)

Opioid Drugs

• Mild Agonists (moderate pain relief) (found in prescription pain meds and cough syrups)

  • Codeine

  • Hydrocodone

• Strong Agonists (severe pain relief)

  • Morphine

  • Hydromorphone

  • Oxycodone

  • Meperidine

  • Fentanyl

  • Methadone

Equianalgesia

• Ability to provide equivalent pain relief by calculating dosages of different drugs or routes of administration that provide comparable analgesia

• Hydromorphone (Dilaudid): 7x more potent than morphine

Opioid Analgesics

• Indications

  • Alleviate moderate to severe pain

  • Often given with adjuvant analgesics drugs to assist primary drugs with pain relief

• Also used for:

  • Cough center supression

  • Treatment of diarrhea

  • Balanced anesthesia

• Contraindications

  • Known drug allergy

  • Severe asthma

• Use with extreme caution in patients with:

  • Respiratory insufficiency

  • Elevated intracranial pressure

  • Morbid obesity or sleep apnea

  • Paralytic ileus

  • Pregnancy

• Adverse Effects

  • CNS depression

    • Leads to respiratory depression

    • Most serious adverse effect

  • Nausea and vomiting

  • Urinary retention

  • Diaphoresis and flushing

  • Pupil constriction (miosis)

  • Constipation

  • Itching

Opioid Tolerance

• A common physiologic result of chronic opioid treatment

• Result: Larger dose to maintain same level of analgesia

Physical Dependence (not psychologic)

• Physiologic adaptation of the body to the presence of an opioid

• Opioid tolerance and physical dependence are expected with long-term opioid treatment and should not be confused with psychologic dependence (addiction)

Psychologic Dependence

• Pattern of compulsive drug use characterized by a continued craving for an opioid and the need to use the opioid for effects other than pain relief

Toxicity and management of Overdose

• Opioid withdrawal or opioid abstinence syndrome

• Manifested as:

  • Anxiety, irritability, chills and hot flashes, joint pain, lacrimation, rhinorrhea, diaphoresis, nausea, vomiting, abdominal cramps, diarrhea, confusion

Interactions

• Alcohol

• Antihistamines

• Barbiturates

• Benzodiazepines

• Monoamine oxidase inhibitors

• Others

Naloxone Hydrochloride (Narcan)

• Pure opioid antagonist

• Drug of choice for the complete or partial reversal of opioid-induced respiratory depression

• Indicated in cases of suspected acute opioid overdose

• Failure of the drug to significantly reverse the effects of the presumed opioid overdose indicates that the condition may not be related to opioid overdose

Management of Overdose

• Naloxone now available without a prescription and is being used by 1st responders for opioid/illegal drug overdoses

• Naltrexone

  • Opioid antagonist

  • Oral form

  • Used for alcohol and opioid addiction

Assessment

• Thorough H&P

• Thorough Pain assessment

Nursing Implications

• Be sure to medicate patients before the pain becomes severe so as to provide adequate analgesia and pain control

• Pain management includes pharmacologic and nonpharmacologic approaches; be sure to include other interventions as indicated

• Take with food

• Ensure safety measures (beware of falls)

• Withhold dose and contact physician if there is a decline in the patient’s condition

• Check dosages carefully

• Constipation

• Orthostatic hypotension

• Monitor for:

  • Adverse effects

    • Vital sings change, patient’s condition declines, or pain continues

    • Respiratory depression

  • Therapeutic Effects

    • Decreased complaints of pain

    • Decreased severity of pain

    • Increased ability to perform ADL’s

Chpt 12 - CNS Depressants and Muscle Relaxants

CNS Depressants

• aka Sedatives

  • Drugs that have an inhibitory effect on the CNS to the degree taht they reduce:

    • Nervousness

    • Excitability

    • Irritability

• Hypnotics

  • Cause sleep

  • Much more potent effect on CNS than sedatives

  • A sedative can become a hypnotic if it is given in large enough doses

• Sedative-hypnotics: dose dependent

  • At low doses, calm the CNS without inducing sleep

  • At high doses, calm the CNS to the point of causing sleep

  • Classified into three main groups

    • Barbiturates

    • Benzodiazepines (many end in pam)

    • Miscellaneous drugs

Sleep

• Transient, reversible, and periodic state of rest

  • Decrease in physical activity and consciousness

• Normal sleep is cyclic and repetitive

  • Sleep architecture - characterized by different brainwave patterns

    • R.E.M. sleep (causes dreams and muscles are paralyzed)

      • Said that it helps emotional regulation and consolidates memories

    • Non-rem sleep (3 Stages - N1, N2, N3)

      • N1 - Transition from wakefulness to sleep

      • N2 - Light sleep

      • N3 - Deep sleep

    • Stress, alcohol, some meds can affect REM sleep

    • After a period of REM sleep deprivation, individuals often will experience REM rebound where the proportion and intensity of REM sleep increases

• A sleeping person is unaware of sensory stimuli within the immediate environment

Benzodiazepines

• Most commonly prescribed sedative-hypnotic drug

• Nonbenzodiazepines are currently more frequently prescribed for people who can’t sleep

• Favorable adverse effect profiles, efficacy, and safety when used appropriately

• Classified as either sedative-hypnotic (calm or sedate for sleeping purposes) and anxiolytics (treats anxiety)

• Mechanism of Action

  • Depress CNS activity

  • Affect hypothalamic, thalamic, and limbic systems of the brain

  • Benzodiazepine receptors

    • closely linked (enhance)to the activity of Gamma-aminobutyric acid (GABA)

      • GABA is the brain’s major inhibitory neurotransmitter

  • Do not suppress rapid eye movement (REM) sleep as much as barbiturates do (to prevent grogginess and poor sleep quality)

  • Do not increase metabolism of other drugs

• Drug Effects

  • Calming effect on the CNS

  • Useful in controlling agitation and anxiety

  • Reduce excessive sensory stimulation, inducing sleep

  • Induce skeletal muscle relaxation (for muscle spasms and muscle tension)

• Indications

  • Sedation

  • Sleep innduction

  • Skeletal muscle relaxation

  • Anxiety relief

  • Anxiety-related depression

  • Treatment of acute seizure disorders

  • Treatment of alcohol withdrawal

  • Agitation relief

  • Balanced anesthesia

  • Moderate or conscious sedation

• Contraindications

  • Drug allergy

  • Narrow-angle glaucoma

  • Pregnancy

• Adverse Effects (Mild and Infrequent)

  • Headache

  • Drowsiness

  • Dizziness

  • Cognitive Impairment

  • Vertigo

  • Lethargy

  • Fall hazard for older adults

  • “Hangover” effect or day time sleepiness

• Toxicity, Overdose and Interactions

  • Somnolence, Confusion, Coma, Diminished reflexes

  • Do not cause hypotension and respiratory depression unless taken with other CNS depressants

  • Treatment symptomatic and supportive

    • Flumazenil as an antidote

  • Interactions: things metabolized by the liver, opioids, Etoh, azoles, herbals, high protein

• Common Benzodiazepines

  • Diazepam (Valium): first clinically available benzo used for anxiety, anesthesia adjunct, anticonvulsant and muscle relaxer (PO, IM, PR)

  • Midazolam (Versed): used for sedation, causes amnesia (IV, Liquid peds)

  • Temazepam (Restoril): intermediate acting, metabolite of diazepam, sleep inducted 20-40 min

  • Eszopiclone (Lunesta): First hynotic to be FDA approved

  • Ramelteon (Rozerem): Structurally similar to the hormone melatonin: works as an agonist at melatonin receptors in the CNS

  • Zolpidem (Ambien): Lower incidence of daytime sleepiness compared with benzodiazepine hypnotics

Barbiturates

• First introduced in 1903; were the standard drugs for insomnia and sedation

• Habit forming; low therapeutic index

• Only a few are commonly used today partly because of the safety and efficacy of benzodiazepines

• Indications

  • Ultrashort acting

    • Anesthesia for short surgical procedures

    • Anesthesia induction

    • Control of convulsions

    • Reduction of intracranial pressure in neurologic patients

  • Short acting

    • Sedation and control of convulsive conditions

  • Intermediate acting

    • Sedation and control of convulsive conditions

  • Long acting

    • Epileptic seizure prophylaxis

• Contraindications

  • Drug Allergy

  • Pregnancy

  • Significant respiratory difficulties

  • Sever kidney or liver disease

  • Caution in older adults

• Toxicity and Overdose

  • Overdose frequently leads to respiratory depression and subsequent respiratory arrest

  • Overdose produces CNS depression (sleep to coma and death)

  • Can be therapeutic

    • Anesthesia induction

    • Uncontrollable seizures or severe head injury: “phenobarbital coma”

  • Treatment of overdose

    • Symptomatic and supportive

    • Maintain adequate airway

    • Assisted ventilation and oxygen therapy

    • Fluids

    • Pressor support

    • Urine alkalization (raising urine pH) to hasten elimination

• Interactions

  • Additive effects

    • Alcohol, antihistamines, benzodiazepines, opioids, tranquilizers

  • Inhibited metabolism

    • MAOIs prolong the effects of barbiturates

  • Increased metabolism (enzyme inducers)

    • Reduces anticoagulant response, leading to possible clot formation

• Drugs

  • Pentobarbital (Nembutal)

    • Long acting drug

    • Uses:

      • Preoperatively to relieve anxiety and provide sedation

      • occasionally to control status epilepticus

      • No longer used as a sedative hypnotic drug for insomnia

  • Phenobarbital

    • Prototypical barbiturate

    • Long acting

    • Uses

      • Prevention of generalized tonic-clinic seizures

      • Hyperbilirubinemia in neonates

      • Rarely used as a sedative

      • No longer recommended as a hypnotic

OTC Hypnotics

• Nonprescription sleeping aids often contain antihistamines, which have CNS depressant effect

• Doxylamine (Unisom) and diphenhydramine (Sominex / Benadryl), acetaminophen/diphenhydramine (Extra Strength Tylenol PM); melatonin

• As with other CNS depressants, concurrent use of alcohol can cause respiratory depression or arrest

Muscle Relaxants MOA

• Act to relieve pain associated with skeletal muscle spasms

• Resemble GABA

  • Binds to GABA receptors and enhance sedation

• Indications

  • Relief of painful musculoskeletal conditions

  • Work best when used along with physical therapy

• Adverse Effects

  • Extension of effects on CNS and skeletal muscles

    • Euphoria

    • Lightheadedness

    • Dizziness

    • Drowsiness

    • Fatigue

    • Muscle weakness

• Toxicity and Management of Overdose

  • Primarily involve the CNS

  • No specific antidote or reversal

  • If taken along with other CNS depressants

    • Adequate airway must be maintained

    • EKG monitoring

    • Administer fluids to avoid crystalluria

  • Caution with other CNS depressants

    • Benzodiaepines

    • Alcohol

• Common Muscle Relaxants

  • Baclofen (Lioresal)*

  • Cyclobenzaprine (Flexeril)*

  • Dantrolene (Dantrium)*

  • Metaxalone (Skelaxin)

  • Tizanidine (Zanaflex)

  • Carisoprodol (Soma)

  • Chlorzoxazone (Paraflex)

  • Methocarbamol (Robaxin)

Nursing Implications

• Before beginning therapy, obtain a thorough history regarding allergies, use of other medications, health history, and medical history

• Obtain baseline vital signs and I&O, including supine and erect blood pressure

• Assess for potential disorders and conditions that may be contraindications and for potential drug interactions

• Give hypnotics 30 to 60 min before bedtime

• Most benzodiazepines cause REM rebound

• Instruct patients to avoid alcohol and other CNS depressants

• Check with the prescriber before taking any other medications, including over-the-counter medications

• Rebound insomnia may occur for a few nights after a 3 to 4 week regimen has been discontinued

• Safety is important:

  • Keep side rails up or use bed alarms

  • Do not permit smoking

  • Assist patient with ambulation

  • Keep call light within reach

• Monitor adverse effects

• Age appropriate considerations

• Monitor for therapeutic effects

  • Increased ability to sleep at night

  • Fewer awakenings

  • Shorter time for falling asleep

  • Few adverse effects, such as “hangover” effects

  • Improved sense of well-being because of improved sleep

  • For muscle relaxants: decrease spasticity, decreased rigidity

Chpt 13 - CNS Stimulants, and Related Drugs

CNS Stimulants

• Drugs that stimulate a specific area of the brain or spinal cord

• Neurons contain receptors for excitatory neurotransmitters, including dopamine (dopaminergic drugs), norepinephrine (adrenergic drugs), and serotonin (serotonergic)

• “Sympathomimetic drugs”

Classification

• Classified according to

  • Chemical structural similarities, amphetamines, serotonin agonists, sympathomimetics, and xanthines

  • Site of therapeutic action in the CNS

  • Major therapeutic uses: attention deficit hyperactivity disorder, antinarcoleptic, anorexiant, antimigraine, and analeptic drugs

Indications

• ADHD

• Narcolepsy

• Obesity

• Migraine

• Analeptic Responsive type Syndromes

ADHD

• Most common psychiatric disorder in children, affection 10.8% of school-age children

• Boys are affected more often than girls (but girls may be underdiagnosed)

• Primary symptoms of ADHD are inappropriate ability to maintain attention span (when things are boring to the person) or the presence of hyperactivity and impulsivity

• Drug therapy for both childhood and adult ADHD is the same

Narcolepsy

• Incurable neurologic condition in which patients unexpectedly fall asleep in the middle of normal daily activities. These “sleep attacks” are reported to cause car accidents or near-misses in 70% or more of patients

• Cataplexy: sudden acute skeletal muscle weakness. Associated symptoms in at least 70% of narcolepsy cases. It involves sudden acute skeletal muscle weakness

Obesity

• According to the National Institutes of Health and the Centers for Disease Control and Prevention, approximately 42.2% of Americans are obese

  • Higher incidence in women and minorities

• Many associated health risks

Migraine

• Common type of recurring headache, usually lasting from 4 to 72 hours

• Typical features: pulsatile quality with pain that worsens with each pulse

• Most commonly unilateral but may occur on both sides of the head

• Associated symptoms: nausea, vomiting, photophobia (avoidance of light), and phonophobia (avoidance of sounds)

• Aura

Analeptic-Responsive Respiratory Depression Syndromes

• Neonatal apnea

  • Common in 70% of premature infants born before 34 weeks’ gestation

• Bronchopulmonary dysplasia

• Postanesthetic respiratory depression

• Treated with analeptic drugs such as theophylline, aminophylline, caffeine, doxapram

Drugs for ADHD and Narcolepsy

• CNS stimulants are first line drugs

• Amphetamines: methylphenidate (Ritalin)

• Nonamphetamine stimulants

  • Modafinil (Provigil)

  • Atomoxetine (Strattera): nonstimulant drug that is also used to treated ADHD

  • Lisdexamfetamine (Vyvanse) prodrug for dextroamphetamine

Mechanisms of Action and Drug Effects

• Amphetamines

  • Stimulate areas of the brain associated with mental alertness

• CNS Effects

  • Mood elevation or euphoria

  • Increased mental alertness and capacity for work

  • Decreased fatigue and drowsiness

  • Prolonged wakefulness

• Respiratory effects

  • Relaxation of bronchial smooth muscle

  • Increased respiration

  • Dilation of pulmonary arteries

Contraindications

• Known drug allergy

• Cardiac structural abnormalities

• Recent MAOI usage

Adverse Effects

• Wide range; dose related

• Tend to “speed up” body systems

• Common adverse effects:

  • Palpitation, tachycardia, HTN, angina, dysrhythmias, nervousness, restlessness, anxiety, insomnia, nausea, vomiting, diarrhea, dry mouth, increased urinary frequency, others

Anorexiants

• Any substance that suppresses appetite

• Used to treat obesity

• Anoxrexiants

  • Phentermine (Ionamin)

  • Benzphetamine (Regimex)*

  • Methamphetamine (Desoxyn)*

  • Diethylpropion (Tenuate)

            *Only ones approved for treatment of obesity

Mechanism of Action

• Suppress appetite control centers in the brain

• Increase the body’s basal metabolic rate

• Mobilization of adipose tissue stores

• Enhanced cellular glucose uptake

• Reduce dietary fat absorption

Other Drugs to Treat Obesity

• Qysmia (phentermine and topiramate)

• Orlistat (Xenical): related nonstimulant drug used to treat obesity

  • Works locally in the small and large intestines, where it inhibits absorption of caloric intake from fatty foods

  • Inhibits enzyme lipase

• Contrave ER (naltrexone and bupropion)

• Saxenda (liraglutide)

  • Liraglutide, when marketed as Victoza, is used to treat type II diabetes

Indications/Contraindication of Anorexiants

• Indications

  • used to treat obesity along with behavior medications (diet exercise)

  • Most often used in higher-risk patients

• Contraindications

  • Drug allergy

  • Sever cardiovascular disease

  • Uncontrolled HTN

  • Hyperthyroidism

  • Eating disorders

  • MAOI usage

Adverse Effects of Anorexiants

• Possible elevated blood pressure and heart palpitations

• Anxiety Agitation

• Dizziness

• Headache

• Orlistat: fecal incontinence with oily stools (reduces body’s ability to absorb fat)

Antimigraine Drugs

• Antimigraine (serotonin agonists; also called triptans)

  • Sumatriptan (Imitrex)

  • Others but all end in triptan

• Ergot alkaloids (largely replaced by triptans for first line therapy)

  • Ergotamine tartrate with caffeine (Cafergot): tablet form

Mechanism of Action and Drug Effects

• Triptans

  • Stimulate 5-HT receptors in cerebral arteries, causing vasocontriction and reducing headache symptoms

  • Reduce the production of inflammatory neuropeptides

  • Abortive therapy for migraines

• Ergot alkaloids

  • Narrow or constrict blood vessels in the brain

Adverse Effects of Antimigraine Drugs

• Triptans

  • Vasoconstriction

  • Irritation at injection site

  • Tingling, flushing

• Ergot alkaloids

  • Nausea and vomiting

  • Cold or clammy hands and feet

  • Muscle pain

  • Dizziness

  • Others

Drug for Specific Respiratory Depression Syndrome: Analeptics

• Used less frequently

• Still used for neonatal apnea

• Examples

  • Doxapram (Dopram)

  • Methylxanthines, such as aminophylline, theophylline, and caffeine

Mechanism of Action of Analeptics

• Stimulate areas of CNS that control respiration

• Methylxanthines

  • Inhibit phospodiesterase, leading to buildup of cyclic adenosine monophosphate (cAMP)

• Caffeine

  • Antagonizes adenosine receptors

Analeptics

• Caffeine

  • Found in:

    • Over-the-counter drugs: NoDoz

    • Combination prescription drugs: Fioricet, Fiorinal

    • Food and beverages

  • Use with caution in patients with a history of:

    • Peptic ulcer

    • Recent myocardial infarction

    • Dysrhythmias

  • Intravenous: caffeine citrate and caffeine sodium benzoate

• Doxapram (Dopram)

  • Treatment of respiratory depression associated with anesthetic drugs an drugs of abuse, COPD-induced hypercapnia

  • Monitor deep tendon reflexes, in addition to vital signs and heart rhythm, to prevent overdosage of this drug

Adverse Effects of Analeptics

• Vagal

  • Stimulation of gastric secretions, diarrhea, and reflex tachycardia

• Vasomotor

  • Flushing, sweating

• Respiratory

  • Elevated respiratory rate (usually the desired effect)

• Musculoskeletal

  • Muscular tension and tremors

Nursing Implications of Analeptics

• Assess for:

  • Potential contraindications

  • Potential interactions, including herbal therapies

  • Condition such as abnormal cardiac rhythms, seizures palpitations, liver problems

  • For children, assess baseline height and weight

Nursing Implications of ADHD Drugs

• Last daily dose should be given 4 to 6 hours before bedtime to reduce insomnia

• Take on an empty stomach 30 to 45 minutes before meals (except for Strattera = nonstimulant for ADHD)

• Needs to be taken with protein or else nausea or vomiting happens

• Drug “holidays” may be ordered

  • Take breaks from stimulants if they don’t have to be at work or school (if they don’t need it)

• Instruct parents to keep a journal to monitor the child’s response to therapy

• Monitor the child for continued physical growth, including height and weight (can decrease appetite)

Nursing Implications of Anorexiants

• Follow instructions for diet and exercise

• Take in the morning

• Avoid caffeine

• Fat-soluble vitamin supplementation may be needed

Nursing Implications (Cont.)

• Selective serotonin receptor agonists (SSRAs)

  • Dissolvable wafers, nasal spray, and self-injectable forms

  • Provide specific teaching about correct administration

  • Instruct patients to keep a journal to monitor response to therapy

• Ergot alkaloids

  • Chest pain, confusion, slurred speech, and vision changes need immediate medical attention

• Analeptics

  • Pay close attention to the ABCs because of the patient’s diminished sensorium

• Monitory for therapeutic responses

  • ADHD, decrease hyperactivity, increased attention span and concentration

  • Anorexiant: appetite control and weight loss

  • Narcolepsy: decrease in sleepiness

  • Serotonin agonist: decrease in frequency, duration, and severity of migraines

• Monitor for adverse effects