pharmacology test 2

• what is the clients actual sensation of pain
• •Involvesnerve pathways and the brain
• •Alsoknown as the “pain threshold”- The actual stimulus needed to produce the perception of pain
• •Thisis the measurement of the physiological response of the nervous system

• The client’s emotional response to pain
• •Greatly effected by the client’s age, gender, culture, previous pain experiences andlevels of anxiety
• •Alsoknown as “pain tolerance”- his is the amount of pain the client can endure without effecting the clients normal function

• •Suddenonset
• •Typicallysubsides when treated
• •Usuallysharp and localized
• •Assessincreased Bp, pallor, sweating, increased respiration rate

• •Persistentand recurring
• •Oftendifficult to treat
• •Onsetis usually slow
• •Maybe explained as dull and aching vs. sharp and stabbing as seen in acute pain

originates from the skeletal muscles, joints andligaments

• originates from smooth muscle and organs
• usually responds better to NSAID’s (non-opioids)

• originates from the skin or mucous membranes
• usually requires treatment with opioids

possibly originates from vascular or peri-vascular tissues,commonly thought to be the cause of migraine headaches

pain that is felt in a place other that where the painactually originates. (ex: cholecystitis- pain felt in the back and scapular region due toinflammation of the gallbladder)

results from an injury or damage to peripheral nervefibers or damage to the CNS (this is often in the absence of disease)

occurs when a part ofthe body has been removed or severed traumatically

caused by pressure on nerves, organs or tissues,hypoxia, mets, muscle spasms,effects secondary to chemo, radiation, surgery

real pain due to psychological pain, NOT physicalconditions

occurs with tumors, trauma, inflammation of the brain-seen often in incidence that yields CNS damage

• may be used to assist the primary agent to help alleviate pain, so…..
• •Opioids and non-opioids can be used for “synergisticeffects”
• •Opioids can cause unwanted effects- they work on the CNS to reduce pain, but causes decreases in Bp, decreased respirations, confusion, dizziness, light-headedness, constipation, urinary retention, sedation, etc..

given IV –reverses the effects quickly

reverses opioids and to treat the abuse of opioids

• •Muscle rigidity
• •Restlessness
• •Screaming
• •Fear of moving
• •Pedi patients often go un-medicated and under medicated due to the difficulty in assessment of pain

<12/min or there are changes in LOC

meperidine (Demerol)

N/V, anorexia, fever, cramps, faintness

• nerve fibers thatfree norepi are adrenergicfibers and they accelerate the heart rate, stimulate organs and smooth muscle
• •Adrenergics- aka catacholemines
• •There are 3 naturally occuring in the body
• - Norepi, epi and dopamine
• These increase HR and Bp, dilate pupils and more…
• Can increase blood glucose and cause headache

• nerve fibers that free ACH arecholinergic
• - they slow the HR

• Norepinephrine or (levophed)- unfortunately thisdrug can cause necrosis to the distal areas (finger tips and toes)
• •These are vasoconstrictors to restart the heart
• •Adrenergics are drugs that cause a similar effect produced by epi, norepi

• •These relieve pain but do not cause a loss of consciousness
• •Used for moderate-severe pain
• •Opioid analgesics and narcotic analgesics differ- they tend to alter CNS and can cause loss of consciousness

• •What is this: proposed in 1965 uses a gate opening and closing to reference how impulses from damaged tissue is sensed by the brain to cause pain
• •2 fibers- one with fast conduction, one with slow
• •Fast conduction = large fiber covered by myelin- pain is sharp and localized
• •One is slow- fiber is small, not covered by myelin- pain is dull and non-localized
• •These nerve and sensory fibers enter spinal cord and to the brain- message of pain sent
• •“Gates” are located in this region
• •If pain impulses stopped- gate stays closed- patient feels no pain
• •If not stopped- gate opens and pain is felt

• produced within thebody that bind with opioid receptors to inhibitpain (keep the gate closed)
• •These are released when pain is sensed
• •Rememberother things can closed the gate- massage, acupuncture, medications such as opioids

• •Originated from the opium plant
• •Very strong pain relievers
• •Only 3 alkaloids from the plant clinically useful
• -Morphine (MSO4)
• -Codeine
• -Paparavine (smooth muscle relaxant)
• -Only morphine/codeine are pain killers

• •Morphine-like drugs- morphine/heroin
• •Meperidine-like- fentanyl/meperedine (demerol)
• •Methadone-like- methadone, propoxyphene (Darvon- now off the market)

• -agonist- binds to receptors and has a response
• -Partial agonist- binds and causes limited action
• -Antagonists- reverses the effects on the pain receptors or binds to receptor and causes no response

• •Alleviate moderate to severe pain
• •ADJUVANTS- may be used to assist the agent to relieve pain (discuss)
• •These have a synergistic effect
• •NSAIDS are commonly adjuvants
• •Opioids (especially large doses or frequent use) can cause some unwanted effects too

• •Constipation r/t decreased GI motility and slowed peristalsis
• •HOWEVER… this causes increased water absorption so these meds can also be used to treat diarrhea (lomotil, peragoric)
• •Resp. depression
• •Urinary retention
• •Cough suppression (codeine commonly used for this)

• •Opioid tolerance- require larger doses r/t long-term use
• •Physical dependence- body relies on the drug (seen commonly with long-term use)
• •DO not confuse physiological and psychological dependency!
• •Opioids should never be discontinued abruptly

• •Chills
• •Anxiety
• •Diaphoresis
• •Tremors
• •Hot flashes
• •Lacrimation
• •Rhinorrhea
• •N/V/D, abdominal pain and cramping
• •This can actually happen after only 2 weeks of therapy!

• •ETOH
• •Barbiturates
• •Benzodiazapines
• •Antihistamines
• •They cause added sedation and resp. depression
• •ALSO-NOT WITH MAOI’s- especially demerol
• •FYI- not much mixes with MAOI’s!

• •Opioids can cause an increase in:
• -Serum lipase and amylase
• -Bilirubin
• -Alk Phos
• -CK

• •Not used if there is a known hypersensitivity
• •Not used for head injury patient’s
• •Used for sever pain
• •Rapid onset
• •IM- peak 30-60 minutes
• •Duration can be up to 6-7 hours
• •Oral, IM, SR tabs, IV, SC, Rectal, Epidural, PCA

• •Used for moderate to severe pain
• •Can also be used as an anti-tussive
• •Peak about 35 minutes
• •Duration about 4 hours
• •Often used after T&A’s on children as opposed to Morphine

• •Mod-severe pain
• •Duragesic patch= fentanyl- great for chronic pain- last about 72 hours
• •Also available in a buccal lozenge
• •IM- Sublimaze
• •Very potent
• •IV peak in minutes, lasts 30-60 minutes
• •IM- peak 20-30 min, lasts 1-2 hours
• •Patch- peak 12-24 hours, duration up to 72 hours

• •Not used in those with known renal dysfunction
• •“Normeperidine” metabolite that can accumulate and cause seizures!
• •Can cause coma-death
• •Peak 30-60 min IM
• •Caution under 18 y/o!
• •If ordered under 18, pharm requires documentation why demerol and not another drug

• •Narcan- used for reversal of effects
• •If Narcan does not reverse effects in a suspected opioid od- it wasn’t an opioid!
• •Onset < 2 minutes- duration based on the dose amount given
• •Revia- not for those in liver failure
• •Used to treat opioid dependency or those in acute withdrawal
• •Can cause nose bleeds, phlebitis, nasal congestion and nightmares

• •0-10 pain scale monitoring
• •Oral opioids with food
• •May need an anti-emetic
• •SAFETY!
• •Monitor VS
• •Can cause confusion and increased sedation in elderly- if so once- do not give call dr.
• •If od? Narcan- take a friend- these folks tendto code! (always have emergency equipment nearby)

• •CV- hypotension, flushing, palpitations
• •CNS- sedation, euphoria, confusion, lowered seizure threshold, tremors
• •GI-N/V, constipation, biliary tract spasms
• •GU-urinary retention
• •Resp- depression, aggravation of asthma
• •Other- itching, rash, wheal formation

• •Opioids can cause euphoria- abused and recreational
• •Psychologic dependence (addiction) can happen
• •Opioids cause a histamine release so peripheral arteries and veins dilate = itching
• •Depression of respirations- most serious s/e
• •If with COPD, asthma- may want to avoid

• _{•Extent of sedation = extent of resp depression}
• •Monitor closely- if O2 sats drop or RR drops, may be able to arouse easily and correct- if not you have trouble! (O2, vent)
• •Narcan- reverses resp depression AND PAIN
• •Narcan is given slowly – it is short lived for only about an hour- redosing may be necessary of pt. cannot be arousedWatch for anaphylaxis!

• •If od- must give an antagonist- do you see why?
• •Narcan (as discussed)
• •ReVia
• •Revex
• •ReVia- used for those with addiction to opioids, but can also reverse opioids
• •Revex- for acute od and to reverse resp depression (causes
• sever nausea and can cause tachy)

• •NSAIDS
• •Acetominophen
• •Ultram
• •Has no effect on the CNS or the CV system!
• •Does not effect platelet counts or bleeding times
• •Used for mild-mod pain
• •Can also be used as an antipyretic
• •But can cause some side effects

• •Can cause hepatic necrosis when od
• •150mg/kg can cause liver toxicity
• •Nephropathy can happen if taken over long periods
• •Acetylcystine- if OD to prevent hepatic metabolites from forming
• •Initial loading dose- the q 4 hours x 17 doses!

• •Used to decrease body temp
• •Decrease body temp if fever is present, but not if body temp is WNL
• •Acts on the hypothalmus
• •Vasodilation happens and increased peripheral blood flow = decreased ody temp
• •No effect on the CNS

• •Also used to decrease pain
• •Most do not experience side effects- fairly safe
• •Can effect liver- so if with disease- DO NOT TAKE
• •4000 mg max in 24 hours for adults
• •Any allergic reaction at home- 911
• •Limit ETOH (liver)
• •Does pass via breast milk- so call doc 1st
• •Anticoagulants or antiepileptics- check with dr
• •OD-
• call poison control if at home
• •What you will see:
• -Jaundice
• -N/V
• -Abdominal pain
• -Amber urine
• -Liver and kidney
• dysfunction- test to check
• -Check acetominophen levels

• •If suspected OD:
• -Mucomyst
• -140 mg/kg, then 70mg/kg q 4 hrs x 17 doses
• -Muscomyst smells like rotten eggs! L
• -Is also used as an inhaler to decrease thickened secretions

• •3200mg max per day adults
• •Increased risk of GI bleeding with an NSAID
• •What you will see:
• -black, tarry stool, frank red blood
• -Coffee grounds emesis, hemoptysis
• -Stroke
• -Eliminated via the kidney

• •Upset stomach
• •Constipation/diarrhea
• •Easy bruising
• •Tachycardia
• •Dizziness
• •Increased bleeding risks of on an anticoagulant of ASA regimen
• •Can cause sensitivity to sublight

• •Acetylsalicylic acid
• •Can be used for an antipyretic, analgesic, anticoagulant and antiplatelet
• •Can be used to decrease risk of blood clots- so MI patients, stroke patients
• •Increases the risks of bleeding
• •Is excreted by the kidneys so watch who is taking it!

• •Bleeding, bruising
• •Heartburn, upset stomach
• •Ulcers
• •Hemoptysis, coffee grounds emesis
• •Gi and/or rectal bleeding
• •Rash, swelling of the tongue
• •SOB

• •ETOH/smoking increases bleeding risks
• •Tell Dr. if taking daily ASA- some meds should not be mixed such as- other blood thinners, Ginko Biloba (otc)
• •If a bleeding disorder or Vit K deficiency- talk to Dr. first
• •Tell dentist if on ASA- 1 week prior to surgery and any surgery

• •Should not be taken during pregnancy except if under care of Dr. passes via breastmilk
• •Not under age 12 (Reyes)
• •Also increased risk for Reyes if with chickenpox and some other viral infections if with ASA
• •If recent live flu or varicella vaccine- no ASA
• - Can cause brain swelling, kidney dysfunction, seizure, coma, death

• •Liver and kidney dysfunction- so test!
• •Check salicylate levels
• •Clotting times/bleeding times
• •Levels of > 300 ug/mL- serious side effects of OD
• •Can also happen with chronic ingestion- AKA- “chronic salicylate intoxication”
• •One to remember- OD*Tinitus
• •Sodium Bicarbinate is the antidote

• •ASA
• •NSAIDS
• •Anti-gout medications
• •Anti-rheumatoid agents

• •These help with joint pain and arthritis pain commonly in those with osteoarthritis, but with any inflammation
• •They do have antiinflamatory properties but are not among the strongest ones available- FYI
• •NSAIDS can also cause noncardiogenic pulmonary edema

• •If A/Ox3- ipecac syrup to induce vomiting
• •May also require sodium bicarb
• •Gastric lavage with activated charcoal- effective up to 3-4 hours after ingestion of up to 10hours with MASSIVE ingestion
• •Replace F&E, may need HD
• •May need Vit K for bleeding
• •Mechanical ventilation if decrease in RR
• •May need anticonvulsants

• •ETOH can increase GI bleed
• •Anticoagulants can increase bleeding tendencies
• •ASA and NSAID’s together can cause increased GI toxicity
• •Corticosteroids can increase the ulcerogenic effects
• •Hypotensives and diuretics can
• reduce the effects of those drugs

• •Will
• compete for protein binding with other protein binding meds

• •
• Not with dilantin (antiepileptic)

• •Not
• with sulfonimides (antibiotics)

• •POTENT analgesic
• •Has very little anti-inflammatory action, but is an NSAID*
• •Therefore, not given specifically for arthritis or gout, but still classified so
• •Used only for short term pain-up to 5 days

• •Is an NSAID so review NSAID info
• •Used primarily for Rheumatoid arthritis and gouty arthritis
• •Rx only
• •NOT for pregnancy or lactating- is passed to fetus and thru breastmilk

• •Is a DMARD
• •Disease modifying anti-rheumatic drug
• •Decreases progression of RA
• •Has little effect on platelet function
• •Cause fewer GI effects, but CAN still cause GI bleeding
• •May have an increased risk of MI/stroke

• •Enbrel- IV,SQ
• •Fewer side effects than other DMARDS
• •Humira- neutralizes immune system signals leading to joint damage- so slows process
• •Cautious use with CHF- can exacerbate symptoms
• •Imuran- also used at times- can cause severe N/V/D and abd. pain

• •ALLAPURINOL- prevents uric acid accumulation/production
• •Can cause a potentially fatal skin condition- “exfoliative dermatitis”, Steven’s Johnson Syndrome
• •CHOLCHICINE-
• •Can cause renal failure
• •Can cause hemorrhagic gastroenteritis

• •Both are CNS depressants
• •Anti-anxieties promote relaxation
• •Sedatives- promote sleep
• •Some also used for anesthetics and anticonvulsants
• •Benzo’s are the main class used for both
• •SSRI’s and antidepressants are also used for antianxieties
• •Many client’s require a combo of drug therapy with psychotherapy for GAD (generalized anxiety disorder)

• Common treatment for anxiety
• •Can also be used to help decrease pain-
• •PAIN often causes an increase in anxiety-
• •Use carefully with pain medications due
• to an increased effect
• •Watch for dependency!
• •Not to be used with other CNS depressants
• •Taper- do not withdraw abruptly
• •Can cause excessive sedation which can cause resp. depression, CNS side effects- SAFETY!
• •Can accumulate- especially if the drugs have a long half life- watch dosing, especially in pedi’s and elderly
• •Therapeutic effects and side effects are commonly seen within 2-3 days of initial treatment- TEACH
• •Absorbed well with oral admin.- most are po
• •Ativan and Valium are available po and IV
• •Highly lipid soluble- highly bound to proteins*
• •These drugs move rapidly through the CNS so sedation should be fairly minimal

• •Metabolized by the liver and excreted by the kidneys
• •Benzos used widely for DT’s, acute ETOH withdrawal, preop sedation, with anti-psychotics and antidepressants
• •Often used for clients with critical illness to decrease anxiety- in turn it also reduces cardiac workload!
• •Used to sedate those who are on a vent, confused client’s from pulling out lines and tubes!

• •Resp. depression
• •Severe liver/kidney d/o’s
• •ETOH and other drug abuse
• •Hypersensitivity
• •Caution with other CNS depressants

• •Multi use drug
• •Can have a cumulative effect*
• •PO/IV
• •Chinese and Japanese clients may require smaller dosing- difficulty metabolizing

• •Used for anxiety and panic disorders
• •Available PO prep
• •Used commonly along with Valium and Ativan to decrease anxiety before exams and testing
• •Widely misused for recreation
• •Cheap on the streets
• •“Bars”

• •Used for anxiety and commonly in the client with ETOH withdrawal symptoms
• •Also drug of choice for mania- remember?
• •PO/IV

• •Anxiety and preop sedation
• •Used for acute ETOH withdrawal
• •Can be used to curb n/v in chemo clients
• •Po/IV/SL
• •Often the drug of choice for elderly and those with liver disease because of a SHORT half-life
• •Remember the term short half-life?

• •Does not cause sedation or physical/psychological dependence
• •May be drug of choice for the elderly and those with renal impairment
• •Is not a controlled substance
• •Typically will not cause increased CNS sedation with other meds or ETOH
• •Used for short term treatment
• •May require 3-4 weeks for optimal effects- so not used for acute anxiety
• •Educate
• •Commonly used for clients who have anxiety and we DON’T want to risk resp. depression- COPD

• •Used mainly for insomnia
• •PO
• •Side effects are the unwanted ones- daytime sleepiness, nausea, diarrhea
• •Halcion- I for the treatment of insomnia
• •PO
• •Same side effects

• •Hypnotic used for insomnia
• •Structuarally different than a benzo but still causes
• similar effects
• •Same side effects as Halcion and Restoril
• BUT… Ambien has been reported to cause amnesia- people reported to be “awake” at night and doing routine tasks with no memory of them!
• All of these meds require safety education

• •The oldest hypnotic
• •Fairly safe, effective, inexpensive
• •Tolerance can develop but is often MISUSED and ABUSED!
• •Multipurpose- helps with anxiety, insomnia and can be helpful for those with alcohol withdrawal

• •Zoloft
• •Paxil
• •Prozac
• •Effexor
• •Classified as antidepressants but can help with anxiety

•Individualized

• •Lowest
• effective dosaging is the best to
• decrease sleepiness

• •When
• mixing with anything like antidepressants or anti-psychotics or analgesics
• (especially narcotic analgesics)- BE AWARE that side effects can be greater-

• •Short
• acting agents may need to be dosed 3-4 times daily to control anxiety

• •Hypnotics
• should be taken at bedtime*

• •Be
• wary of physical and physiological dependence- take only for short periods of
• time if able

• •The higher the dosing and the longer the client takes benzo’s
• - the higher the risk of withdrawal symptoms
• •These meds should be weaned slowly- NOT stopped abruptly! EDUCATE
• •Recommended: REDUCE the drug by 10-25% every 1 to 2 weeks over 4-16 weeks
• •Common effects are insomnia, increased anxiety and irritation, h/a, tremors and palpitations
• •More serious s/e’s: confusion, abnormal movements, seizure, psychosis, depersonalization
• •These may occur up to 4-5 days after stopping *valium

• •S/S= increased sedation, resp. depression, coma
• •FLUMAZENIL is a specific antidote that competes with benzo’s and reverses toxicity
• •ONSET is 1-2 minutes- PEAKS at 6-10 minutes
• •Short half life so re-dosing is usually necessary
• •Adverse reaction: Increased s/s of the benzo withdrawal symptoms!
• •Given slowly IV to awaken the client, but be careful of acute withdrawal s/s

• •Be careful of paradoxical effects
• •Lowest effective doses for a short period of time if able
• •Remember decrease in body fat and water in children!
• •Faster metabolism- may need higher doses(???????)
• •SSRI”S (may be given for anxiety but usually used for depression)- may have increased suicide risk

• •Are there any unwanted side effects
• •Can the client handle ADL’s
• •Is the client excessively sleepy
• •Ramsay scale of sedation- (especially in those with critical illness receiving benzo’s-
• •1= wide awake & agitated, 6= sedated & unresponsive
• •Desired level = 2-3.Client is drowsy but easily arousable and responsive to commands

• • amnesia- may be beneficial to the client with critical illness or the client that cannot be given anesthesia
• •Hold the dose and document if the client has increased sedation
• •Be careful when administering any of these meds- SAFETY
• •Be careful with oral preps- do not crush ER tabs, etc…

• First- what is EPILEPSY?
• •d/o of the brain that is the symptom of a disease
• •Most likely due to excessive electrical discharges from nerves located in the cerebral cortex
• •Chronic, recurrent pattern of seizures
• •CONVULSION- spasmodic contractions of voluntary muscles
• •SEIZURE- brief episode of abnormal electrical activity in nerve cells of the brain
• •Can be detected on an EEG, CT, MRI along with the symptoms to make a diagnosis (the tests would show possible structural lesions of the CNS)
• •There can be loss of consciousness, altered sensory awareness, psychic changes

• •PRIMARY- cause cannot be identified
• •IDIOPATHIC- cause cannot be identified
• •SECONDARY- due to trauma, CVA, infection, other illness

• •Classification of seizures: (Traditional classifications)
• •TONIC-CLONIC- Grand mal seizure
• •Petit mal seizure-
• •Jacksonian epilepsy-
• •Psychomotor attacks-

• •Short alterations in consciousness, repetitive, unusual movements, psychological changes/confusion
• •SIMPLE seizure- No impaired consciousness
• •Motor symptoms- seen in face, arms, legs
• •Visual/auditory/taste hallucinations
• •Personality changes

• •Partial
• -Simple
• -Complex
• •Generalized

• •Seizure- impaired consciousness
• •Memory impairment
• •Behavioral effects, purposeless behaviors
• •Aura- unreal feelings, biting or chewing may be present
• •Typically higher risk type of seizure

• •Most often seen in children
• •temporary lapses in consciousness lasting a few seconds
• •Daydreaming, staring
• •Eyes, head, hands may exhibit movement, but no convulsions
• •Both cerebral hemispheres involved
• •Head drop or falling-down symptoms

• •May be either partial or generalized
• •There is NO recovery in b/t seizures!
• •Can be life threatening!
• •Patient does not regain consciousness b/t the many convulsions
• •Patient becomes hypoxic
• •Hypotension typically ensues
• •Cardiac dysrythmias
• •Can lead to extensive brain damage
• •DEATH can occur
• •VALIUM is the drug of choice
• •Once controlled- long term drug therapy will begin

• •AKA anti-epileptic drugs (AED)
• •GOAL is to control/prevent seizures while maintaining quality of life
• •By Rx only
• •Oral/injectable/rectal
• •FDA regulated
• •Constant levels of AED’s must be in the blood system or some patient’s will suffer repeated seizures
• •Treatment is usually started after a second seizure!
• •Single drug therapy is usually attempted first, and this must fail before a combination therapy is tried!
• •Some need very close monitoring- weekly and biweekly labs
• •Many have s/e’s
• •Constant levels of AED’s must be in the blood system or some patient’s will suffer repeated seizures
• •Treatment is usually started after a second seizure!
• •Single drug therapy is usually attempted first, and this must fail before a combination therapy is tried!
• •Single drug started with a gradual increase in dosage until seizures are controlled
• •If the first drug does NOT control the seizure activity, that drug is slowly wiened while the second drug is initiated
• •AED”S should NEVER be stopped abruptly unless SEVERE s/e’s begin
• •Single drug therapy is less likely to have adverse reactions and result in higher serum concentration levels
• •Serum concentrations of Dilantin, phenobarb, carbamazepine, and primidone correlate better with seizure control and toxicity than valproic acid and clonazepam
• •Therapeutic serum drug levels : decrease risk of toxicity, has fewer adverse reactions and control seizures better
• •THE PATIENT is the main guide- some need higher and some only require lower serum levels to control activity
• •The goal of AED’s is to prevent the spread of the excessive discharges while protecting the surrounding, normal cells

• •Acting directly on abnormal neurons
• •Seizures may be reduced by raising the seizure threshold
• • Preventing the spread of excessive discharges and still maintaining the normal cells
• •NA, K, Ca, Mag ions are altered by AED’s and thus the cell membranes are more stabilized and less responsive

• •Prevention/control of seizures
• •Maintenance therapy for those with chronic seizures
• •Can be used for acute seizure such as Status epilepticus- VALIUM
• •Patient’s s/p brain surgery with severe head injury may be started on AED’s b/c if seizure activity starts, can cause severe complications

• •Vary from drug to drug-
• •Most common s/e:
• •Vomiting/ nausea
• •Drowsiness, confusion, lethargy
• •Rash, itching
• •Bone marrow suppression
• •Heart dysrythmias
• •Thrombophlebitis
• •Thrombocytopenia
• •Lupus, lymphoma
• •Stevens-Johnson syndrome
• •Liver toxicity
• •Aplastic anemia

• •Carbamazepine (Tegretol)- Coumadin, doxycycline, dilantin, theophylline
• •Valproic acid (Depakote)- Barbiturates, dilantin
• •Hydantoins (Dilantin)- tricyclic antidepressants, isoniazide (to treat Tb)

• •Benzo’s- valium/ativan = used as first line in Status Epilepticus
• •second-line drug for treatment of epilepsy
• •Valium first choice for SE, quick onset

• •Most widely used benzo for seizure control
• •Has high incidence of toxicity
• •Can cause personality changes, drowsiness, ataxia
• •Possible aggressive behavior, moodiness
• •Tolerance common = repeat seizures

• •Zarontin – safe-effective first line drug
• •Used primarily for absence seizures
• •Primarily in childhood
• •Can cause n/v, abdominal discomfort, rash, headache, drowsiness

• •Phenobarbitol and Primidone-
• •Primidone- metabolized in the liver
• •Phenobarb- first line drug for SE and used to control seizures as well in chronic sufferers – MOST COMMON s/e = sedation, but tolerance will occur
• •Interacts with MANY drugs
• •Has the LONGESt ½ life of all the AED’s
• •Most inexpensive AED

• •First line drug
• •s/e – confusion, lethargy, abn. movements
• •Long-term use can cause acne, encephalopathy, ataxia, nystygmus, hypertrophy of sc facial tissue (Dilantin facies), gingival hypertrophy, so educate good oral hygiene!
• •Educate- vitamin D replacement due to s/e of osteoporosis
• •Those with lower albumin levels (malnourished, CRF) may need to keep serum levels lower than usual- there will be more free, unbound dilantin in the system b/c the drug binds to albumin
• •Levelsv= 10-20 mcg/mL (narrow window!!)

• •Depakote, depakene, depacon
• •Can cause n/v, dizziness, weight gain, tremors, hair loss
• •Pancreatitis and hepatotoxicity can be deadly
• •Interacts with many other meds
• •Also highly bound to plasma protein( albumin)
• •Highly metabolized in the liver
• •Levels= 50-100 mcg/mL

• •Tegretol = first line AED (carbamazepine)
• •Goes through “AUTOINDUCTION”- when a drug increases it’s own metabolism over time,causing lower than expected drug concentrations
• •Neurontin – Used with a primary AED
• •Also reduces neuropathic pain
• •Abrupt withdrawal can cause “withdrawal seizures”

• •Drug history
• •Allergies
• •Labs- liver, kidney, CBC, Chem 7, Heart/resp system, CNS d/o
• •Many of the AED’s can interact with ETOH, oral contraceptives, Dig, CNS depressants
• •If theses drugs have “drug levels” we need to follow carefully!

• •Taken at the same time of day
• •No abrupt discontinuation
• •Take with meals to decrease GI s/s
• •Capsules should not be chewed, opened or crushed
• •When given IM, rotate sites and place deep in the muscle (gluteal is the choice)
• •Parenterally – vein ONLY, never arterial
• •Skin sloughing, ischemia can occur if given and then it infiltrates
• •(Especially Dilantin) Should be given SLOW IVP and VS monitored carefully
• •Given only with NS
• •Medic alert tags for those on AED’s
• •SAFETY ISSUES!!!
• •High fiber secondary to risk of constipation
• •Educate that therapy may be life-long and that driving may be prohibited by Dr.
• •Keep journal of seizure activity

• •Skin rashes on infant- notify Dr. ASAP
• •Chewables are avoided for once daily dosage
• •IM dilantin should be avoided
• •Encourage family to keep records of seizure activity, and any side effects noted
• •Educate to call Dr. asap for any unusual behavior
• •Suspensions need to be shaken well
• •Use a graduated syringe for safe dosing
• •May need lower than usual doses and are highly sensitive to barbiturates
• •Watch for paradoxical effects- excitability, confusion
• •Safe responses for neonates not established in benzo’s
• •Oral valproic acid should not be given with MILK-
• •Can cause early dissolving and irritate the local mucosa
• •Should not be mixed with ANY milk products at all!
• •Educate

• •If under age 23 – susceptible to gingival hyperplasia (gum inflammation)- esp. with dilantin
• •Usually happens within the first 6 months of treatment
• •Can also cause increase body hair growth
• •Valproic Acid- increased risk of toxicity in kids
• •Do frequent labs for blood levels

• •Metabolize more slowly
• •Watch for drug accumulation and toxicity
• •Frequent labs for levels
• •May need decreased doses because some binding with proteins (remember?)
• •Iv doses very slowly

• •Fist-what is Parkinson’s?
• •PARKINSONS DISEASE- chronic, progressive, degenerative d/o affecting the dopamine-producing neurons in the brain that control smooth muscle movement. AKA- “shaking palsy”.
• •FYI: The correct balance of Dopamine and Ach
• (Acteylcholine) is necessary in regulating posture, muscle tome and voluntary movement! People with Parkinson’s Disease have an imbalance- a decrease in inhibitory dopamine and an increase in excitatory Ach…
• Fyi for later…
• •Other chronic CNS neuromuscular d/o = Myasthenia gravis, dementia, Alzheimer’s

• •Rarely effects those under 40 years of age
• •Primarily seen in the elderly
• •Men and women equally affected
• •Caused by an imbalance of dopamine and acetylcholine- a balance of the 2 is needed for correct posture, muscle contol/tone, and voluntary movement
• •Theories: May be from an early head injury in childhood, may be due to decreased iron levels, dopamine levels decrease with age
• •No lab tests to confirm
• •CT/MRI/EEG’s are usually normal!
• •Dx. based on classic symptoms =
• •BRADYKENESIA- slow movement
• •RIGIDITY- “cogwheel rigidity”- resistance to passive movement
• •Tremor- tremor against the thumb and forefinger “pill-rolling”- seen mostly at rest, starts on one side and progresses to the other, presenting sign in 70% of cases
• •POSTURAL INSTABILITY- Danger of falling, hesitation in gait

• •WORSENING Parkinsonian s/s = DYSKENESIA-
• difficulty with voluntary movement
• •Chorea- irregular, spasmodic, involuntary movements in the limbs, facial muscles
• •Dystonia- abnormal muscle tone in any tissue

•Education

•PT/ST

• •Drug
• therapy- levadopa in early stages to
• help correct neurotransmitter imbalances

• •Drug
• therapy to help lessen effects of disease- not a cure

• •ELDEPRYL- (MAO-B)- monoamine oxidase B- derived from amphetamine-small dosages do not cause effects with tryamines
• •Used to use MAOI’s- INTERACTS WITH TRYAMINES!!- causes severe hypertension
• •Has a neuroprotective effect
• •Studies show that high doses of C and E may help slow progression of PD (as well as Alzheimer’s)

• •MAO-B one of 2 pathways by which dopamine is degraded
• •MAO-B- accounts for 70% of all MAO in the brain
• •Blocks destruction of cells
• •MAO-B is in the CNS- primarily the brain
• •(Ps- MAO-A is used for the treatment of depression)

• •DRUG EFFECTS:
• •High concentration of MAO’s in the kidneys and liver, as well as intestinal wall, brain and stomach.
• •MAO’s catabolize dopamine, norepi and epi, so… MAO-B blocks the breakdown

• •ELDAPRYL is currently used with levadopa and levadopa-carbidopa to decrease the amounts of those drugs needed
• •Decreased s/s are seen
• •50-60% of patient’s have shown improvement
• •Rx only
• •Oral form only

• •N/V- abdominal pain
• •dizziness
• •insomnia
• •confusion
• •dry mouth
• •If the dose exceeds 10mg q D -can cause hypertensive crisis if ingestion of tryamine containing foods, confusion, muscular twitching, teeth grinding, memory loss

• •Number of drugs that interact is small
• •Dose over 10mg/d can cause “cheese effect
• •Demerol is contraindicated- can cause a FATAL htpertensive episode
• •All opioids should be avoided if on >10 mg/d

• •Used to help replace the lost dopamine or enhance the function of the neurons left that are still functioning
• •Ultimate goal is to increase the levels of dopamine in the brain
• •By doing so, AKENESIAS can be reversed
• •AKENESIA- masklike facial expressions, impaired postural reflexes (these render the patient unable to care for self)

• •LEVADOPA- and the combo drug- levadopa-carbidopa, directly replace the deficient dopamine (Sinamet)
• •Large doses are usually needed, thus causing increased s/e, so… carbidopa is added
• •SYMMETREL- antiparkinsonian- helps with dyskenesias
• •Others include Parlodel and Permax- activates dopamine
• receptors and more dopamine is produced
• •MIRAPEX AND REQUIP- NEW, effective in early stages of PD

• •Levadopa and carbadopa together = more levadopa to the
• brain(increasing dopamine levels) and works to offset imbalances d/t dopamine and Ach.
• •Used for:
• •Promotion of voluntary movement

• •GI upset
• •Heart dysrythmias
• •Dizziness
• •Dry mouth
• •Involuntary movements(dyskenesia)
• •Educate to change positions slowly b/c postural hypotension can occur
• •Avoid any sudden withdrawal of the meds
• •Levadopa can darken sweat and urine
• •No B6 supplements- (reverses effects)
• •Take with a low protein snack
• •Keep a journal of progress and s/e

• •Hydantoins-(valproic acid, dilantinNeurontin)- decreases the effects of levadopa, also Haldol.
• •MAOI’s can cause hypertensive crisis
• •Vit B6 can reverse the effects of levadopa- (carbidopa helps inhibit that!)

• •Drugs that block Ach (Acetylcholine)- used to treat
• tremors and muscular rigidity caused by excessive cholinergic activity
• •SIDE EFFECTS are dry mouth, blurred vision and urinary retention
• •How do they work?
• •Block Ach
• •Ach accumulates in PD patients

• •Ach (Acteylcholine) causes “SLUDGE”
• Salivation
• Lacrimation
• Urination
• Diarrhea
• Increased gastric motility
• Emesis

• •Salivation = dry mouth
• •Lacrimation = dry eyes, lack of tears
• •Urination = urinary retention
• •Diarrhea = constipation
• •increased GI motility = constipation
• •Emesis = none
• •ALSO CAUSES- mydriasis =dilated pupils and smooth
• muscle relaxation

Causes relaxation in the smooth muscles therefore lessening rigidity and akinesia (non-movement)

• •Hallucination, drowsiness, confusion
• •N/V/C
• •Urinary retention, pain w/urination
• •Dilated pupils
• •Dry skin
• •Photophobia
• •Blurred vision
• •Can cause postural hypotension- rise and turn slowly

• •CNS depressants
• •ETOH
• •Trycyclic antidepressants
• •Antihistamines
• •Amantadine
• •THESE all enhance CNS depression
• •ANTACIDS- decreases the effect of anticholinergics due to altered gastric Ph
• •Treatment w/ anticholinergics are used with primary PD drugs
• •Started in small doses
• •Commonly used = Cogentin, Benadryl, Parsidol, Artane
• •Can cause increased s/e in the elderly!!- SAFETY
• •Most are synthetic deriviatives
• •* Cogentin
• •* Artane

• •Assess ADL’s and drug history
• •Assess gait, weakness, tremors, LOC
• •Assess bowel patterns, urinary patterns, appetite
• •Assess mood, affect, depression, personality changes
• •Assess speech problems, facial expressions, dysphagia
• •Assess motor function, rigidity
• •Assess glaucoma, cataracts- mydriasis can lead to
• intraocular pressure
• •Age- inceased risk of toxicity
• •Liver function, Bp
• •Any hypersensitivity to these drugs in the past

• •Anticholinergics after meals and
• single doses at HS
• •Increase fluid intake unless otherwise contraindicated
• •Frequent oral care
• •Contraindicated drugs/OTC’s- ask Dr. First!!
• •High fiber diet
• •NO MAOI’s- may cause hypertensive crisis- need 2 weeks b/t meds if one is to be dc’d and one started
• •Any of the drugs that are sustained release (SR) cannot be crushed

• •Monitor side effects- decreased appetitie, constipation, n/v, abd pain, dry mouth
• •Monitor for concentrated urine or pain
• •Monitor CNS- confusion, hallucination, etc, mood…
• •Monitor therapeutic effect

• •May have increased effects and s/e
• •Men with hx. of BPH (benign prostatic hypertrophy)- beware of the urinary retention, it will be increased
• •Hx. of glaucoma and urinary retention may not be good candidates for anticholinergics
• •Watch for paradoxical effects
• •Avoid excessive heat exposure, with anticholinergics- decrease in sweat and cooling mechanism
• •Levadopa is used with caution- increased risk for s/e
• •Levadopa-carbidopa started at low dosages due to increased sensitivity

• •Elevate mood
• •Decrease appetite
• •Used for treatment of ADD and ADHD
• •Stimulate respirations
• •Appetite suppressant
• •Narcolepsy and migraine HA’s
• •They are controlled substances

• •Increase RR
• •Enhance the mood
• •Increase motor activity
• •Diminish sense of fatigue
• •Stimulate spinal cord and the brain
• •PS- there is a high abuse potential
• •Some can be found on the streets

• •Adderal- ADD and ADHD and appetite suppressant
• •Caffeine- in many food and drink products, No Doz- to stay awake (OTC)
• •Dopram- for resp. depression, not ever used in newborns or those with hx. Of CVA or increased Bp
• •Ritalin- ADHD and narcolepsy
• •Imitrex- migraines, not actually classified as a stimulant- classified as a “seratonin agonist”
• •Meridia/Xenical- for appetite control
• -For obesity
• -Causes fecal urgency!
• * Remember Fen/Phen? That is now of the market as a combo drug.

• •Anacin
• •Exedrine
• •Vivarin
• •NoDoxz
• •Dristan AF

• •Increase dHR and RR
• •Nervousness
• •Insomnia
• •HA*
• •Blurred vision
• •n/v/d, abdominal pain
• •Diuresis
• •Relaxation of bronchial smooth muscle

• •Beta-blockers- hypertension, dysrythmias
• •Other CNS stimulants- too increased, toxic
• •Digoxin- increased risk of dysrythmia
• •MAOI’s- HA, severe hypertension (crisis)
• •TCA’s- tachy, increased Bp
• •EDUCATE

• •Toxicity- agitation, seizures, confusion, coma, hypertension
• •Drug witdrawl- depression, agitation, tiredness, HA
• •Wean- do not stop abruptly
• •Watch for weight loss
• •Only with Rx.
• •Keep out of reach of children- can also be abused

• •Avoid other stimulants
• •Do not skip, omit, double up
• •Watch OTC’s and herbals
• •Take at least 6 hours before bed
• •If appetite suppresant- take 30-45 min before meal
• •Mouth may become dry
• •Be aware of Tryamines!! (look over your foods)

• •Cocaine
• •Crack cocaine
• •Crystal meth
• •Ecstacy

• —This works more on the PNS
• —The PNS is the opposition of the SNS
• —ACH is the neurotransmitter responsible here for the transmission of nerve impulses
• —Cholinergics cause SLUDGE

• —Salivation
• —Lactrimation
• —Urination
• —Diarrhea
• —Increased GI motility
• —Emesis

—Cholinergics mimic ACH = Rest and Digest

• —ACH is in short
• supply in those with AD

• —It is needed fro
• normal brain function

—Cardiac- cholinergics slow heart rate and vasodilate

—Hence… SLUDGE

• —Glaucoma patients use
• them to decrease occular pressure

• —Can be used to
• decrease occular pressure for surgery

• —Indirectly- the y
• cause skeletal muscle contraction for the treatment and dx. of MG

• —AD- increases
• concentrations of ACH in the brain to maintain function
• —MG- autoimmune
• disease causing breakdown of the skeletal muscles
• —This causes muscle weakness and decreased contraction of the muscles
• —Post op- can be used to treat paralytic ileus*
• —Can be used to treat urinary retention
• —ANTIDOTE- phasostygmine- reverses sludge

• —CV- brady, hypotension, cardiac arrest
• —CNS-HA, dizziness, convulsions
• —GI- N/V, abdominal cramping (should not be used with GI obstruction)
• —Resp- increased bronchial secretions and bronchospasms (Not to be used with asthma) —Other-increased
• sweating, salivation, lacrimation

• —Cholinergic crisis! (can be deadly)
• —Circulatory collapse
• —Hypotension
• —Bloody diarrhea
• —Shock
• —Cardiac arrest
• —EARLY S/S- abd. cramping, n/v, skin flushing, dyspnea, heart block, ortho. hypo

• —Can often be reversed by atropine
• —Bronchoconstricion can be reversed by Epinephrine
• —So you see you will be in an emergency as these are code drugs!
• —Phasostygmine is the direct antidote for toxicity

• —DO not give with anticholinergics
• —DO not give with antihistamines
• —Why?

• Urecholine (Bethanecol)- this is direct acting:
• can be used for:
• •Paralytic ileus
• •Smoothing the wall of the bladder for the treatment of post-op or post delivery urinary retention
• •Used to treat TCA induced ur. Retention
• •Can be used for post-op gastric retention
• •Is often used for the dx. of infantile c. f.

• —Works indirectly
• —Works centrally on the brain to increase ACH levels by blocking its breakdown
• —Is highly plasma bound
• —Used to treat AD
• —Avoid other drugs with anti-cholinergic properties
• —This delays AD progression- not a cure

• —Improves muscle strength for those with MG
• —Should not be used in those with a dx. Of epilepsy,
• bronchial asthma, dysrythmias, peptic ulcers
• —Other- Tensilon- can be used for the dx. Of MG
• —Mestinonin- for MG- longer acting than the neostygmine
• —* can be used to reverse NMBA post-op*

• —Pilocarpine
• —Charbachol
• —These meds are used for the treatment of glaucoma
• —They aid in decreasing occular pressure
• —More to come on glaucoma later!

• —Other meds?
• —Allergies?
• —Remember they will decrease HR
• —Increase GI ad GU tone
• —Increase bronchial smooth muscle

—Increases resp secretions

—Causes miosis

—No anticholinergics, no NSAIDS

• —May take 6 weeks or
• more to see results! Educate

• —If patient is on theses- start back ASAP after surgery
• —MG- give meds 30 min before meals to decrease symptoms of dysphagia
• —Have Atropine/Epi on hand at all times
• —AD- not a cure but will decrease symptoms and progression
• —Do not stop abruptly

• —If given post-op- should hear BS soon after
• —Hypotonic bladder- micturation within 60 minutes of med admin
• —MG- s/s should be somewhat alleviated
• —Watch for increased resp secretions, dyspnea, aspiration is a
• risk, hypotension, brady, increase urinary frequency/urgency
• —If any more than usual while on meds- call Dr.

• Muscle rigidity
• Restlessness
• Screaming
• Fear of moving
• Pedi patients often go un-medicated and under medicated due to the difficulty in assessment of pain

• Watch
• carefully for CNS reactions and if any, hold further medication and call
• the Dr.
• Monitor
• VS before, during and after opioid admin.
• WITHHOLD
• OPIOIDS IF RR IS <12/min or there are changes in LOC
• Frequently
• and carefully assess RR = depth, rate, rhythm, and is there any difficulty
• Smaller
• doses are indicated in pedi patients

• 18
• years of age and under- should not give meperidine (Demerol)
• Oral
• opioid derivatives should be given with food or milk to decrease GI tract
• distress
• Allergic
• reactions may present as rash, itching
• Withdrawal
• s/s = N/V, anorexia, fever, cramps, faintness

• If there is any confusion, decreased RR, or excessive CNS depression- withhold meds and call Dr.
• REMEMBER- polypharmacy risk- get a thorough drug hx.
• Reduced circulation = reduced absorption with pain meds
• They may hesitate to ask for pain meds so as not to “bother” you- encourage them to ask