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TOPIC 1: Nursing and Pharmmacology
Pharmacology is the study of drugs and their actions on living organisms.
Learning Objectives:
Upon completion of this lesson the learner will be able to:
Describe the LPN role and legal responsibilities in the administration of medication Explain how drug standards and the drug legislation affect drug regulation in Canada.
Explain the purpose of the Canadian Drug Acts and their application to nursing practice.
Define pharmacodynamics and pharmacokinetics
Define basic terminology used in pharmacology
Define the following terms:
o Pharmacologyo Pharmacodynamicso Pharmacokinetics
Drugs have a variety of names. Define the following terms:
o Chemical nameo Generic nameo Trade (or brand)
Explain the purpose of these two drug standards, and an example of a drug controlled by each Act.
o Canadian Food & Drug Acto Controlled Substances Act
Nursing and Pharmacology
Nurses must value their clients’ dignity and respect choices. Nurse/client/family/multidisciplinary team work together for optimal health.
A Holistic view must be incorporated and include a view of cultural values/practices/medication use.
Canadian Drug Legislation (Federal)
There are a number of levels of legislation for drugs distributed in Canada:
"Canada Food and Drug Act" – differentiates drugs that can be sold only with a prescription (Rx.) from those that do not need a Rx.
"Controlled Drugs and Substances Act" – defines categories of controlled drugs, to prevent and treat drug dependence.
Legislation states that:
Therapeutics drugs can be obtained by two methods only – prescription or over the counter (OTC)
Prescriptions are written ONLY by specified professionals.
"Controlled Drugs and Substances Act" consists of:
Narcotic and Control Regulations Benzodiazepine and Other Targeted Substances Regulation
Marijuana Medical Access Regulations
This act is for medications that are more frequently misused or abused.(Kozier & Erb p. 798)
"Marijuana Medical Access Regulation"
This gives the authorization to possess or produce marijuana for medical reasons – HIV, cancer (nausea), MS, glaucoma
In 2001, Canada passed this act, being the first country in the world to do so.
"Food and Drug Regulations"
This act is responsible for regulation of all drugs in Canada and is categorized as:
Part A: administration of drugs Part C: drugs
Part D: vitamins, minerals, amino acids
Part E: cyclamide, saccharin sweeteners
Schedule F: require a prescription
Part G: controlled drugs
Part J: restricted drugs
Federal regulation of drugs divided into two categories:
1. Prescription(Categories with mandatory labelling “x”)1. Prescription: “Pr”
2. Controlled: “C”
3. Narcotic: “N”
4. Targeted drugs: “TC”
2. Nonprescription
Provincial Scheduling System
This method of categorizing drugs is further to the above Federal legislation.
Schedule I: all prescription drugs, including narcotics, control drugs, target drugs Schedule II: drugs do not require a prescription but can only be sold with the direct
involvement of a pharmacist “ Over the Counter “ e.g.. Gravol in package of more than 30 tabs, Tylenol #1( 8 mg codeine)* Table 2.4 in Adams et al text
Schedule III: over the counter drugs “OTC”s that do not require a prescription but must be kept in an area not more than 6metres from the pharmacy. Eg. acetaminophen more than 650 mg/tab or in a container of more than 50 tabs
Schedule 4: Prescribed by pharmacists eg. “Morning after Pill”
Unscheduled Drugs: over the counter drugs do not require a prescription and can be sold in a non-pharmacy cough remedies, aspirin
Narcotic Drugs
All products containing the symbol N on the drug label are Narcotics Examples: morphine, methadone, opium, codeine, heroin, hydromorphone
Prescriptions must be written or faxed
Orders must be signed and dated by a physician, dentist, veterinarian or nurse practitioner
Narcotic Preparations Exempt from Prescription
Products containing codeine plus 2 or more non-narcotic active ingredients are exempt from a prescription.
The amount of the codeine may not exceed 8 mg per solid dose form or 20mg/30 ml for liquid dosage forms.
In B.C. these products are kept behind the pharmacy counter
Controlled Drugs
All products containing a controlled drug have the symbol ‘C’ on the drug label
All controlled drugs require a prescription
Examples: secobarbital, pentobarbital, anabolic steroids, Percocet, Dilaudid
Targeted Drugs
Targeted Drugs identified with a ‘T/C’ on drug label , have same regulations as C and N drugs.
These drugs also have the potential for physical and psychological dependence.
The prescription requirements are the same as for the Controlled Part 1 drugs, but targeted drug substances do not need to be recorded in a register.
i.e. benzodiazepines (lorazepam, Ativan), their salts and derivatives.
Considerations for Practice
Narcotic and Controlled drugs are kept in a locked cupboard Nurses are responsible for administering these meds as prescribed, and for maintaining an
accurate inventory of the drugs for each shift
Prescription Drugs
Drugs not under regulation by Narcotics, Control or Target guidelines Eg. antibiotics, antihypertensives, birth control
Who Can Prescribe Medications?
Physicians Dentists
Veterinarians
Podiatrist
Midwife – limited
Nurse
Practitioner
Pharmacists (restricted privileges)
Role of the Nurse
RN’s and LPN’s are legally allowed to administer narcotics and controlled drugs. Narcotics are kept in a locked cabinet
Strict record keeping is mandatory
Drugs are counted once per shift or according to agency policy
For competency in medication administration, the nurse must:
Competently administer medication utilizing knowledge, skills, judgment and attitude to:o Assess the appropriateness of the medication for a particular client. That is,
knowledge of the actions, interactions, usual dose, route and use of drug.
The nurse must:
Prepare the medication correctly Monitor the client while administering the medication including perform appropriate
intervention as necessary
Evaluate the outcome of the medication on the client’s health status
Document the process
Ethical, Responsible and Accountable
Ethical medication administration is to be upheld at all times. LPNs are expected to involve clients in their own care by assessing their understanding of
medications and by providing them with information about medications that is truthful, understandable and sensitive to their needs.
LPNs are Responsible
Responsible medication administration is to be upheld at all times. LPN’s must assume responsibility for their own knowledge, competence and limitations.
LPNs are Accountable
Accountable medication administration is to be upheld at all times. LPNs are accountable for ten rights of medication administration (CLPNBC 2010
Practice Directives)
LPNs are accountable for maintaining timely, accurate records of all medications they administer
10 Rights (CLPNBC 2010)
Right client
Right medication
Right dose
Right route
Right time
Right reason
Right documentation
Right for the client to be educated as deemed able to participate
Right of the client to refuse as deemed able to so
Right evaluation
Basics of Nursing and Pharmacology
Pharmacology
Pharmacology: deals with the study of drugs and their actions on living organisms
Pharmacology includes knowledge of how drugs are administered, how they are absorbed by the body and how the body responds. This will require a solid foundation in anatomy and physiology, chemistry, microbiology and pathophysiology.
There are many different drugs for the many different diseases, and each one can be influenced by multiple factors such as age, sex, body mass...
Therefore sound knowledge of pharmacology is pertinent to LPNs as they administer medications to patients.
Pharmacokinetics
Pharmacokinetics: the study of the absorption, distribution, biotransformation (metabolism) and excretion
There are four phases of medication action in the body:
1. Absorption2. Distribution
3. Metabolism
4. Excretion
* These phases will be explored in more detail in the next class: Principles of Pharmacology.
Pharmacodynamics
Pharmacodynamics: the process by which a drug alters cell physiology.
An understanding of pharmacodynamics will aid the LPN in predicting a client's response to a medication. The specifics of this will be further explored in the next module: Principles of Pharmacology.
Drug Names
Chemical Name
This provides the exact description of the medication's composition and molecular structure.
Chemical names rarely used in clinical practice: example N-acetyl-para-aminophenol is Tylenol
Generic Names
Can be used in any country and by any manufacturer. The first letter of the generic name is NOT capitalized.
Pharmacists use the generic name
Example: acetaminophen
Trade Names
Trademark or brand name and followed by the symbol ® and indicates that the name is registered and its use is restricted to the owner/manufacturer
Name is capitalized
Example : Tylenol
Learning Activity
Using your drug textbook (Davis’s Drug Guide), look up the following drugs: find generic and trade name
Valium Tylenol
Gravol
Aspirin
Lasix
TOPIC 2: Principles of Pharmacology
Principles of Pharmacology
All body functions and disease processes and most drug actions occur at the cellular level. Drugs are chemicals that alter basic processes in body cells. They can stimulate or inhibit normal cellular function and activities; they cannot add functions and activities. To act on body cells, drugs given for systemic effects must reach adequate concentrations in blood and other tissue fluids surrounding the cells. Thus, they must enter the body and be circulated to their sites of action (target cells). After they act on cells, they must be eliminated from the body (Kee, Hayes, & McCuistion, 2009).How do systemic drugs reach, interact with, and leave the body cells? How do people respond to drug actions? The answers to these questions are derived from cellular physiology, pathways, and mechanisms of drug transport, pharmacokinetics, pharmacodynamics, and other basic concepts and processes. These concepts and processes form the foundation of rational drug therapy.
Learning Objectives:
Upon completion of this class, the learner will be able to:
Describe the principles of pharmacology as related to common drug actions and interactions.
Describe the principles of pharmacology as related to food/ drug actions and interactions.
Describe the human factors that influence drug action
Define the following terms:
1. Antagonists2. Agonists
3. Partial agonists
4. Polypharmacy
Pharmacokinetics: Once administered, all drugs go through four stages. Explain the action that takes place in each of these stages, and name the body organ/area where the action mainly occurs.
1. Absorption2. Distribution
3. Metabolism
4. Excretion
Define the following terms:
1. “half-life”2. additive effect
3. synergistic effect
4. adverse effect
5. therapeutic effect
6. nephrotoxicity
7. allergic reaction
8. idiosyncratic effect
Human factors affect drug action. State how each of the factors below affects medication.
1. Age2. Body mass
3. Body weight
4. Sex
5. Metabolic rate
6. Presence of other conditions
7. Community and environment
8. Psychological/social/spiritual state
9. Culture and ethnicity
Principles of Pharmacology
Definitions:
Pharmacodynamics
Pharmacodynamics is the study of the actions and interactions between drugs and their receptors. A receptor is a specific site in the body with which the drug forms a chemical bond.
Pharmacokinetics
The term Pharmacokinetics refers to “Drug movement through the body”.
*Stages involved are:
1. Absorptiono Drug Admin Routes: Drugs are administered by many routes:
Oral
Percutaneous – inhalations, topical, sublingual
Parenteral – subcutaneous, intramuscular, intravenous
Intravenous - medications do not need to be absorbed as they are administered directly into the blood stream.
o Rate of Absorption
The intravenous route of administration is the quickest for absorption as the medication directly enters the bloodstream.
The next fastest routes (in decending order) are:
Intramuscular
Subcutaneous
Percutaneous
Oral
2. Distribution
o Distribution refers to the transportation of the drug from the site of absorption to the site of action in the circulatory system (blood)
o A drug must have a certain blood level of the drug circulating for it to be effective.
o Effectiveness depends on the amount of the drug and the vascularity of the tissues. Eg. Muscle tissue is far more vascular then adipose tissue
3. Metabolism
o Metabolism is the process by which the body inactivates drugs.
o This is mainly done in the liver and to a lesser degree by the lungs, GI tract, white blood cells
4. Excretion
o Excretion refers to the elimination of the drugs from the body
o Excretion is mainly done in the kidneys (urine) and bowels (feces) Other places Lungs (exhalation), skin (sweat/evaporation) and breast milk
* You must know these stages and how they are involved in pharmacokinetics.
Serum Half Life
The half life of a drug refers to the time required for the body to eliminate 50% of the drug.
Knowledge of the half life is important is determining the frequency of dosing.
Drugs with a shorter half life need to be administered frequently and drugs with a longer half life less frequent.
Half Life Example
20 mg of a drug that has a half life of two hours. 10 mg (50%) remains after 2 hours
How much drug remains after 4 hours? Answer 5 mg
After 6 hours = 2.5 mg After 8 hours = 1.25 mg
Effects of Drugs
Therapeutic Effect: relates to the reason the drug is prescribed. Also know as the desired effect/response
Adverse Effect: undesired response, can be severe or mild
Side Effect: secondary effect, unintended, mild adverse effect but still drug is producing a therapeutic effect
Nephrotoxicity: nephritis, renal insufficiency or failure occurs with several antimicrobial agents, NSAI. Drug excretion is impaired. Could lead to drug accumulation
Idiosyncratic Effect: an unexpected reaction
Allergic Reaction: immune response, mild to severe; rash to anaphylactic shock
Additive Effect:two drugs with same action are taken for double effect.
o Example: Tylenol and Codeine
Synergistic Effect:Occurs when two drugs are given together and one drug enhances the effect of the other drug. This produces a greater effect than each drug given alone.
o Example - Morphine and Gravol
Adverse Reactions
Side effects Toxic effects
Allergy
Accumulation
Drug Interaction
Tolerance
Dependence
Factors Affecting Drug Action
Age Body mass
Sex or gender
Environment
Route of administration
Time of administration
* Refer to the resource under "Resources and Activities"
More Definitions:
Agonist versus Antagonist
Agonists are drugs that interact with a receptor to stimulate a response ie the key fits. They can accelerate or slow normal cellular processes.
Antagonists are drugs that attach to a receptor but do not stimulate a response, i.e. the key doesn’t fit. They inhibit cell function.
Partial Agonist
Partial Agonists are drugs that attach to a receptor creating a small response, but also block the responses of other drugs, i.e. the key partially fits and gets in the way of other drugs.
Pharmacokinetics is an essential subject in pharmacology. It describes how the body handles drugs. Drug movement involves four processes: absorption, distribution, metabolism, and excretion. A thorough knowledge of pharmacokinetics enables the healthcare provider to understand the thearpeutic effects of a drug, as well as to predict potential adverse effects of drug therapy.
TOPIC 3: Math Calculation
Medication Calculations
Calculating medication dosages for pills is a common math skill you will be using in your career. When a practitioner orders a medication, that specific dosage may not be available to you. While the pharmacy department will do their calculations, it is also your responsibility as the bedside nurse to make sure your patient get the correct dosage.
Calculating how much medication your patient will need is easy.It's all about basic division.
Formula for Calculating Dosages
D x Q = X Desired x Quanity = Dose to give to patientH Have
Let’s put this formula to work:
Example # 1
The medication label reads : 0.25 mg per tablet. The dose ordered is 0.5 mg How many tablets do you give?
Solve this using the formula
D x Q = X H
Medication Calculation Cont’d
Values Equation
Desired D = 0.5 mg
Have H = 0.25 mg
Quantity Q = 1 tablet
X = Dose to give patient
(make sure desired and have are in same units)
Step1: Fill in the numbers( D ) 0.5 mg x (Q) 1 tab = X(H) 0.25 mg
Step2: Divide (D) by (H)(D) 0.5 '/. (H) 0.25 = 2
Step3: Multiply answer x (Q)2 x (Q) 1 = 2 (X)
Step 4 X = 2 Give the patient 2 tablets.
What happens to the units of measure in this equation?
(D) and (H) must be in the same unit of measure. Cancel all units eg. mg, that you see on both the top (D) and bottom (H).
Note that if the unit measure is only present once on the top, you can only mark it out once on the bottom, and vice versa.
Eg.1 mg x 1 tablet = X1 mg
The mg cancel each other out - you are now solving for how many tablets to give.
Why do units of measure matter?
The units of measure in drugs indicate the actual concentration of the medication. For example the concentration of Tylenol is 325mg / tablet. However the concentration of
“Extra Strength” Tylenol is 500mg / tablet.A single tablet of each contains a very different amount of medication!
This is very important to consider when calculating how much of a medication to give.
Important points to remember:
round decimals to two places when necessary always put a 0 before a decimal i.e. 0.25 ml (without the 0, the decimal might get missed
and 25 ml administered instead of 0.250
never put a decimal and 0 after a whole number i.e. do not write 2.0 ml (the decimal might get missed and 20 ml administered instead of 2)
when the unit is tablets, write the answer in a fraction i.e. 1 1/2 tablets.
when the unit is ml, write the answer as a decimal i.d. 1.5 ml.
Example #2
The physician has ordered 1.0 g of Ampicillin.The Ampicillin bottle label reads that one capsule contains 0.5 g. (0.5g / capsule) How many capsules would you give?
D = 1.0 g (Dose ordered)H = 0.5 g (Dose on hand)Q = 1 capsule (Quantity)X = How many capsules you will give
(Scroll down for the solution...)
Example #2 Solution
Step 1:( D ) 1.0g x (Q)1 capsule = X (H) 0.5g
Step 2:1.0 x 1 capsule = X 0.5
Step 3:2 x 1 capsule = X
Step 4:2 capsules = X
Therefore, give 2 capsules to the patient. Simple right?.
Example # 3
The doctor orders 0.25mg of digoxin PO daily. Your pharmacy has 0.5mg tablets. How many tablets do you give?
Remember: D x Q = X H
(Scroll down for the solution...)
Example #3 Solution
(D) 0.25mg x (Q) 1 tablet = X (amount to give) (H) 0.5 mg
0.25 x 1 tablet = X 0.5
0.5 x 1 tablet = X
0.5 tablets = X
Therefore give 0.5 or ½ of a tablet.
Splitting Pills
On Example # 3, the dose required 0.5 of a pill.HOWEVER:
Not all pills can be split. Make sure you check with the pharmacy if you are unsure if it is safe to split a pill or not.
As a general rule, most pills that are scored (indented line in the middle) can be split safely, but NOT ALL.
Example # 4 – Liquid Medication
The doctor orders 5mg of Robitussin PO daily. Your medication bottle from the pharmacy states 1mg / 2ml of Robitussin. There are 30ml in the bottle.
How many mls do you give the patient?
Solution for Example # 4
(D) 5mg x (Q) 2ml = X (H) 1mg
5 x 2 ml = X 1
5 x 2 ml = X
10 ml = X
Therefore, give the patient 10 ml of Robitussin Liquid.
Example # 5
The physician has ordered 250 mg of acetaminophen at dinner. How many tablets will you give?
Watch Out!There is something missing from Example # 5
(D) = 250 mg
(H) = this is not provided
(Q) = this is not provided
Tell me, what more do you need to know?
Example # 6
A drug is labelled 100 mg/ 2ml.Give 80 mg.
(D) = ? (H) = ? (Q) = ? X = ?
Example # 6 Solution
( D ) 80mg x (Q) 2 ml = X(H)100mg
0.8 x 2 ml = X
1.6 ml = X
Therefore, give the patient 1.6 ml.
Example #7
Medication is labelled 500mg/tabletGive 2 g.
Think about this:What do you need to do with your units of measure before you calculate the dosage? You MUST convert all units to the unit of measure of the medication you have on hand.
Example #7 Solution
Convert the D & H to the same units
(D) 2g = 2000mg
(D) 2000mg x (Q) 1 tablet = X(H) 500mg
2000 x 1 tablet = X 500
4 x 1 tablet = X
4 tablets = X
Therefore, give the patient 4 tablets.
Math for Meds – Rule Summary
Always use the formula: D x Q = X H
Put the “like” units on the left of the equation.
(D) and (H) must be in the same unit of measure.
Cancel all units e.g. mg, that you see on both the top (D) and bottom (H).
TOPIC 4: Drug Classifications
Learning Objectives:
Upon completion of the class, the learner will be able to:
Describe the drug classifications according to body systems.
Discuss drug research and explore various methods and sources for obtaining credible information.
Begin to develop a method of organizing pharmacological data that is individually suited, and allows for quick and accurate reference
Class Preparation:
Refer to Reading List for required reading
Complete the following activity:
oDrugs are classified in many different ways, such as how they affect a particular body system (i.e. those that affect the respiratory system).
o Other classifications focus on the general effect of certain drugs on specific disease conditions or disorders, such as hypertension. Explain the purpose of these headings:
1. Action2. Uses
3. Drug names
4. Dosages and routes
5. Contraindications
6. Precautions
7. Interactions
8. Nursing responsibilities
Classifications
Think back to the introduction concept in this course: Where can you find information on drugs?
Have a look through your Davis Drug Guide: Do you see a pattern to how the drugs are categorized? There is a section in your Davis’s Drug Guide titled “Classifications”. Have a look at it, what information can you find here?
As you learned in class # 1, the CPS is THE most reliable and complete source of information on medications. It is a compilation of drug monographs from all drug manufacturers.You also have access to eCPS. This is an online version of the Compendium of Pharmaceuticals and Specialties.
Understanding the Reason for Medications
Classifications provide important information as to why the patient might be receiving the medication.
Take care to understand the individual reason for taking a medication based on history.
The same medication may be given for entirely different reasons to two different people.
Be aware of 'Pregnancy' Category as some medications are teratogenic to the fetus.
Drug Classifications
Classifications are based on how they affect body systems i.e. digestive system or respiratory system.
They are also based on the effect of certain drugs on specific disease conditions (i.e. hypertension, Parkinson's).
Getting to know classifications
This presentation will briefly discuss a number of drug classifications. Please refer to your textbook if you want further detail or understanding.
You are also provided in this concept with a “table of classifications” which summarizes a number of classifications and gives examples of drugs for each.
Anti-inflammatory
Nonsteroidal anti-inflammatory drugs (NSAID):
Indication: Control mild to moderate pain, fever and various inflammatory conditions. Action: inhibits production of prostaglandins
Eg. acetylsalicylic Acid (Aspirin), ibuprofen, indomethacin.
Topical Corticosteroid Anti-inflammatory
Corticosteroid anti-inflammatory:
Action: Suppression of inflammatory response
Eg. hydrocortisone topical ointment (local effects), dexamethasone (systemic effects).
Corticosteroids
hydrocortisone - (systemic effect) taken in oral tablets or IV.
Anti-inflammatory. Used to treat adrenal insufficiency.
Immunosuppression in transplant surgery.
Analgesics
1. Non-opioid Analgesicso Indications: Mild to moderate pain and fever
o Actions: Inhibits prostaglandin synthesisEg.
acetylsalicylic acid (Aspirin)
ibuprofen (Advil)
acetaminophen (Tylenol)
o Note the following specific sub classifications:
indomethacin (Antirheumatic).
pyridium (Specifically for urinary tract).
2. Opioid Analgesics
o Indications: Moderate to severe pain
o Actions: Opiates bind to opiate receptors in the CNS, acting as agonists of endogenous opiodsEg.:
codeine (30 mg in Tylenol #3).
morphine.
Demerol (meperidine).
Dilaudid (hydromorphone).
Antipyretic
Indication: used to lower fever of many causes Action: affects thermoregulation of the CNS and inhibit effect of prostaglandins
peripherally.Eg:
o acetylsalicylic acid (Aspirin), ibuprofen (Advil).
adverse effects: both of these meds can cause GI bleeding.
o acetaminophen (Tylenol).
inhibits synthesis of prostaglandins but does not have the GI side effects.
Antiplatelet
Indications: Antiplatelet agents are used to treat and prevent thromboembolic events such as stroke and MI.
Action: inhibits platelet aggregation, prolongs bleeding time
Eg. acetylsalicylic acid (Aspirin)
Anticoagulant
Indication: prevention and treatment of thromboembolic disorders. Action: prevent clot extension and formation
Eg.: heparin (may be given IV for acute thromboemboli), Coumarin or Coumadin(warfarin).
o This medication is given orally to patients who have pacemakers, heart valve replacement surgery, venous thrombus, pulmonary emboli or have atrial fibrillation.
o Is also used as rat poisoning in large doses.
* Adverse reaction and side effect is Hemorrhage. Nurses must monitor for bleeding and teach patient how to protect self from injuries etc.
Anticonvulsant
Indications: Used to decrease incidence and severity of seizures. Actions: Depress abnormal neuronal discharge in the CNS that results in seizures
Eg.:
o phenytoin (Dilantin) most commonly used anticonvulsant
o phenobarbital (a controlled drug)
o valproic acid
o diazepam (Valium)
o carbamazepine (Tegretol)
Digitalis Glycosides
Indications: Treatment of tachyarrhythmia (rapid irregular heart rate) and congestive heart failure
Action: slows and strengthens heart contractions.
Eg.: digoxin (Lanoxin)
Nursing considerations:
o * adverse effect bradycardia, digitoxicity
o monitor apical heart rate for one minute prior to administration, hold if HR < 60bpm
o blood levels drawn to monitor for therapeutic level.
Antacid
Indications: Used for indigestion, GERD, heartburn, hyperacidity (GI complaints) Action: Neutralize gastric acid
Eg.:
o Diovol - magnesium hydroxide/aluminum hydroxide.
o Maalox -magnesium hydroxide/aluminum hydroxide.
Laxatives
Indications: used to treat or prevent constipation. Actions: Induce one or more bowel movements per day
Types: stimulants, stool softeners, bulk forming agents, osmotic cathartics
Covered in detail in next concept - see course resources.
Antidepressant
Indications : used in the treatment of endogenous depression Action: Generally, prevents the reuptake of dopamine, norepinephrine and serotonin by
presynaptic neurons in the CNS.
Two major types:
o 1. Tricyclic antidepressants – amitriptyline (Elavil)
o 2. SSRIs – Prozac,Paxil, Zoloft, Luvox.
Skeletal Muscle Relaxant
Indications: spasticity associated with CNS disorders, or therapy for acute musculo-skeletal conditions
Action: Act centrally or directly to relieve muscle tension and spasticity
Eg.: Baclofen, Zanaflex,Valium.
Anti-infective / Antibiotics
Indication: treatment and prevention of bacterial infection Action: Kill or inhibit the growth of susceptible pathogenic bacteria. Culture and
sensitivity of infection site determines right medication.
Eg.:
o Penicillins (Bind to cell wall resulting in cellular death).
Ampicillin.
Amoxicillin. * check for allergy to penicillin.
o Sulfonimides (Stop bacterial synthesis of folic acid = cell death).
Sulfisoxasole
Sulfamethoxazole
Cough Suppressant / Allergy, Cold, Cough Remedies
Indications: symptomatic relief of coughs by minor upper resp. tract infections Actions: Suppresses the cough reflex by a direct effect on the cough centre in the CNS
Eg.: Benylin, Robitussin
Cough Expectorant
Indications: coughs associated with viral upper respiratory infections
Actions: reduces viscosity of tenacious secretions
Eg.:guaifenesin
o added to Benylin cough syrup (Benylin E)
Note: Elixirs may be mixed with alcohol and may contain sugar.
Antipsychotic
Indications: treatment of chronic psychoses Actions: block dopamine receptors in the brain, also alters dopamine release and
turnover.
Eg.:lithium carbonate (antimanic), haloperidol, chlorpromazine.
Antianxiety
Indications: used in the treatment of anxiety disorders Actions: Generalized CNS depression
Eg.: Lorazepam
o usually sublingual if acute anxiety (acts within 15 min)
o diazepam.
An important nursing responsibility is to monitor respirations as an *adverse side effect of benzodiazepines is suppression of respirations.
Bronchodilator
Indications: used in the treatment of airway obstruction (asthma or COPD) Actions: bronchodilation
Eg.:
o Theo-dur- (theophylline)
Relaxes bronchioles, dilates bronchioles
o Aminophylline
converts to theophylline
blood levels drawn to monitor therapy
* Side effect is tachycardia, anxiety. Monitor: breath sounds and vital signs for side effects.
Artificial Tears / Ocular Lubricant
Indications: management of dry eyes due to lack of tears Action: provide lubrication and protection to dry or artificial eyes
Eg.:Isopto tears.
Spasmolytic / Urinary Tract Antispasmodic / Anticholinergic
Indications: treatment of urinary symptoms of neurogenic bladder – frequency, urgency, overactive bladder. Relief of bladder spasms
Action: inhibits the action of acetylcholine, reduces smooth muscle spasm. Delays desire to void.
Eg.: oxybutynin - Ditropan
* Monitor voiding pattern.
Antiparkinson
Indications: used in the treatment of parkinsonism of various causes. Therapeutic relief of tremor and rigidity.
Action: aimed at restoring the natural balance of acetylcholine and dopamine in the CNS
Eg.: Sinemet - levodopa.
o levodopa is converted to dopamine in CNS.
Hypnotic / Sedative
Indications: to provide sedation Actions: Generalized CNS depression
Eg.:
o phenobarbital. (hypnotic)
o diazepam
o lorazepam
* Respiratory depression is a life threatening adverse effect. Resp. rate must be monitored.
Antiulcer
Indications: treatment and prevention of peptic ulcer Action: neutralizing or decreasing gastric acid,
Eg.:
o cimetidine
* Side effect is confusion, particularly in the elderly.
o Maalox
o Diovol
* Note that Ampicillin is used to treat h.pylori, a bacteria involved in the disease process of peptic ulcer disease. Therefore is listed under antiulcers in the Davis drug book.
Antihypertensive
Indications: Treatment of hypertension of many causes Action: Used to lower blood pressure to a normal level by a variety of mechanisms
Eg.:
o Ace Inhibitors. Vasotec (enalapril, captopril)
o Beta Blockers
o Calcium Channel Blockers
o Diuretics
* Nursing responsibility: monitor blood pressure.
Routes of Medication Administration
Po (by mouth) - swallowed, absorbed in gut, (enteric coated must not be crushed). SL (Sublingual) - under the tongue, dissolves.
IM (Intramuscular) - absorbed by muscle.
SC (Subcutaneous) - delivered into the subcutaneous fatty tissue.
Intradermal - under the epidermal layer to the dermis.
IV (Intravenous) - directly into the bloodstream. This is the fastest route.
Topical - for local affect, ung.(Ointment) absorbed by skin.
Transdermal - controlled slow release; topical patch.
Rectal
Right Time
Medications must be given at the right time to assure therapeutic levels. 1/2 hour before or 1/2 hour after the scheduled time is allowed.o Use the 2400 hour clock, i.e. 0100 is 1:00a.m and 1900 is 7:00 p.m. Use
appropriate abbreviations.
Antibiotics are usually started after a culture has been obtained
Certain medications have a sustained release to assure a prolonged action for the medication - do not crush/chew or dilute.
TOPIC 5: Quiz 1 and Math Calculations Quiz 1st Attempt
Read first- Info re Quiz and Review
Review the following:
Quiz # 1 Theory Exam 15% of grade Look at the Learning Objectives for each topic.
Exam questions will be based on the course material and required readings covered in Topic 1-4
Here is a bit of a study guide to help you focus on what’s important. Please make sure you review the following concepts.
Pharmacodynamics
Pharmacokinetic
Absorption, distribution, metabolism, excretion
Generic, trade, chemical names
Canada Food and Drug Act – what is it? What is the purpose of it?
Agonists, antagonists, partial agonists, receptors
Half life - what is it and how do you calculate it?
Side effects, idiosyncratic reactions/unexpected reactions
Tolerance, dependence, accumulation
Reliable vs unreliable sources of drug information
Classifications – know the classification, use/action and common drug examples
TOPIC 6: Principles and Routes of Medication Administration
There are many ways that drugs may be delivered to body tissues. Drugs may be swallowed, inhaled, injected, inserted, or rubbed onto the body's surface. The method of drug delivery depends upon the nature of the drug itself and how it is used. The different routes affect important aspects of pharmacology including how quickly the drug acts and how long the effects will last.
In general, all categories of drug delivery are associated with one of three major routes. The first major route is the digestive tract, or the enteral route. Drugs gaining access by this route enter the body either by the mouth, under the tongue, or into the rectum.
The second major route is the parenteral method. By this method, drugs enter the body by a way other than the digestive tract, usually by injection directly into the cardiovascular circulation, the skin, or body cavities. If injected into the general circulation, drugs may be administered into veins or arteries. If injected through the skin, drugs may be administered into the dermis, beneath the dermis, or into muscles. If injected into a body cavity, drugs may be administered into spaces surrounding the spinal cord, abdominal organs, or into joints.
The third major route of drug delivery is the topical route. Here drugs are placed directly onto the skin or associated membranes, such as nasal and respiratory passages, the ears, the eyes, or the vagina.
Learning Objectives:
Upon completion of the class, the learner will be able to:
Explain the principles of medication administration. Identify the ten (10) Rights of Drug Administration
Identify the three (3) checks related to the administration of medications.
Describe the routes of medication administration. Identify commonly used drug distribution systems in Canada.
Identify types of drug orders
Complete the following questions:
As a practical nurse, observing the Ten Rights of drug administration is an ethical and legal responsibility. Using your pharmacology text and your CLPNBC Practice Guidelines, expand on the “reason” for these Rights:
1. Right reason2. Right patient3. Right drug4. Right dose5. Right route
6. Right time7. Right to refuse8. Right to education9. Right documentation10. Right evaluation
What is meant by “three (3) checks”?
Explain how these legal and ethical responsibilities as a practical nurse might affect your nursing practice?
What is your role as a Practical Nurse in administering medications?
How do you find out the care facility's policies on administration of medication?
How do you identifying and report a medication error made by you or a colleague?
Although no two drug distribution systems function exactly alike, some basicsystems currently in use are:
1. Floor or Ward Stock System
2. Individual Prescription Order System
3. Unit Dose System
4. Long-term (bubble pack) System
Identify the guidelines related to the Narcotic Control System.
Describe the 4 types of Drug Orders:
1. Stat
2. Standing
3. Renewal
4. PRN
State the nursing responsibilities related to physician’s Verbal Orders.
Medical Distribution Systems,
Orders of Drugs
What are Distribution Systems?
Medications are supplied and administered to patients using organized and specific systems and methods in order to reduce risk of medication errors.
There are a number of distribution systems set up by the pharmacists or facilities.
Medical Distribution Systems
1. Unit Dose System:o Uses portable carts containing a drawer with medications for each client
o The unit dose is the ordered dose of medication that the client receives at one time.
o Pharmacy/pharmacist refills daily or prn
2. Bubble Pack System:
o Medications are packaged with one tablet or one dose per bubble
o 2 wk/1 month supply on a card
3. Floor or Ward Stock System
o Medications are available in large quantities, in multidose containers
o Kept on ward or unit.
4. Individual Prescription
o Supply of 3 – 5 days from pharmacy for individual client
5. Automated Dispensing System
o Computerized access system automates the distribution, management and control of meds.
o Protected by password
Drug Orders
Physicians write drug orders Must contain – patient’s name, drug name, dose, route, time and duration that order is in
effect
Must be dated and signed
Agency policy usually determines when the order is outdated
Types of Drug Orders
1. Telephone Order:o RNs and LPNs may take a drug order by telephone communication with the
physician (check facility policy)
o The physician must come into the facility to sign the telephone order within 24 hours
2. Stat Drug Orders:
o Must be administered to the patient immediately & only once
o Are usually indicated in an emergency
o Are given on one occasion only and then discontinued
o “Give diazepam 10 mg IV stat”
o “Give diphenhydramine 50 mg IM stat”
3. Standing Orders:
o An agency or physician specific order approved for administration for a specific reason
o Usually for a specified number of doses and then automatically outdated and discontinued by pharmacy
o Most common type of order
o “Give cephazolin 1 G IV q6h x 4 doses”
o “Give Sinemet 25/100 PO TID”
4. Renewal or Re-Order:
o Physician must write a renewal or re-order for a medication to be continued after it is outdated by pharmacy
o Usually applies to standing orders
o “Re-order Sinemet 25/100 PO TID”
5. PRN (pro re nata = as necessary )
o A written order to be administered “as necessary”
o Is intended to be given at the nurse’s discretion after assessing it is appropriate
o “Give Tylenol 650 mg PO q 4-6 h for oral T >38° C” – can be given by the nurse upon assessing the patient’s temp to be > 38° C
o Requires assessment before and after
Drug Dose Forms
Drugs come in many forms:
Tablets – compressed dry drug that may be scored; may be enteric coated to pass through the acid of the stomach in order to dissolve in the alkaline pH of the intestine
Capsules – cylindrical gelatin containers for dry or liquid drug
Lozenges/torches – flat disk of drug (usually flavoured) which is held in the mouth until dissolved
Elixirs – drug is dissolved in a clear, alcohol or water-based liquid that may be flavoured
Emulsions – dispersions of small droplets of water in oil, or oil in water
Suspensions – dry drug particles are dispersed in a liquid and must be shaken before administration
Syrups – drug is dissolved in a concentrated solution of sugar
Professional Drug Safety
Administer meds immediately after pouring Observe the medication being taken
DO NOT use outdated medications
DO NOT use a medication whose label is illegible
DO NOT alter a drug label
DO NOT return any drug to a drug container
REPORT MEDICATION ERRORS IMMEDIATELY to the charge nurse
NEVER give a medication that another nurse has poured.
Medication Administration
In order to ensure that you SAFELY administer all medications, you must follow very specific protocols and routines.o 10 rights
o 3 checks
o General rules of medication administration
10 RIGHTS of Medication Administration
Right Patient
Watch for name alerts (similar names between two or more patients) Check name - MAR, ID band, photo, verify by staff, have pt. state name.
Take MAR to bedside
Check MAR against resident’s name band (or picture, or have another staff person confirm that you have identified the “right patient”)
Ask the resident their name
Right Medication
Right drug, correct spelling Right concentration of med.
o Eg. 50 mg/1 mL or 50 mg/2 mL
Right Dose
A “dose” is the amount of drug prescribed by a physician in mg (usually) or units, u (insulin)
You may need to assess the concentration of medication in a liquid or tablet and then calculate the dose
Is the dose on the MAR the usual or an acceptable dose for this drug? Question any dosage outside of usual dosage range
Double-check all calculations.
Right Route
The route must be as per the physician’s order Make sure the medication supplied is. for the prescribed route
Right Time
Know abbreviations (specific time may not be indicated)o Eg. Order may say "30 minutes ac meals"
Must be given within 30 minutes of scheduled time.
Right Reason
Does this medication make sense for this patient?
If giving insulin, does this patient have diabetes? If giving hydrochlorothiazide, does this patient have hypertension?
The right reason is checked during the “preliminary check” and the right documentation is done after the medication is taken.
Right Documentation
Chart on the MAR immediately after giving the medication For a PRN medication, document pre- and post-med findings
Document in the correct date and time line on the MAR
Assess agency policy regarding documentation of a “refused” medication and provide the patient’s stated reason
Promptly assess and document any adverse effects in progress notes
Documenting Narcotic Use
In a facility, the nurse must:
Record name and quantity of all narcotics received from pharmacy Record name of patient receiving and physician ordering narcotics
Record patient, narcotic name, dose, time given
Two nurses must sign for a wasted amount of narcotic
Report missing narcotic immediately
All narcotic records must be safely stored
Right to Education
Explain information to the patient about the medication What they can expect, why they are receiving it, any precautions.
Right of Refusal
Adult patients have the right to refuse any medication. The nurse must ensure that the patient is fully informed of the effects of the medications
and communicate any refusal to the appropriate Health Care Professional
Right Evaluation
“The nurse should always assesses the patient’s health status ...medication history….before administering any medication to obtain baseline data by which to evaluate the effectiveness of the medication.
The extent of the assessment depends on the patient’s illness or current condition. It is essential that the effect/response of the client to the medication be documented” (Kozier et. al. 2010, pp. 812-813).
3 CHECKS
* 5 rights - patient, medication, dose, route, time are done 3 times:
1. When removing medication from cart or shelf2. Before pouring
3. After pouring
General Rules of Drug Administration
NEVER give a med you did not pour NEVER give a medication that isn’t labeled
NEVER chart for someone else
NEVER leave medications unattended
Chart immediately after giving the medication on the MAR
Give medications within 30 minutes of “time”
Report a medication error immediately
Lock medication cart if unattended
Return to assess medication response especially for PRN medications
Routes of Administration
Enteral- via the Gastrointestinal tract (swallowed or via a feeding tube)o PO (tablets, capsules, liquids)
Percutaneous- across the skin or mucous membranes
o SL, buccal, rectal, vaginal, transdermal, topical, inhalations, gtts (eye or ear)
Parenteral- bypasses the GIT
o SC, IM, IV
Medication ERRORS - Why do they happen?
Inadequate knowledge, skill and judgment - about patient, diagnosis, medication name/reason, proper administration.
Failure to comply with policies - poor attention to safety policies for medication administration.
Incorrect writing/transcribing of orders, verbal orders, illegible writing, misunderstood abbreviations, failure to document properly medications given or not given, unclear MARs (medication administration record)
Individual or system problems – nurse inexperienced, overtime worked, rotating shifts, use of casual or float nurses, interruptions, unclear labeling, drugs spelled or sound similar, packaging looks similar
TOPIC 7: The Nursing Process and Medications for Specific Disorders
The Nursing Process and Pharmacology
The Nursing Process is a problem solving technique that uses 5 stages:
Assessment Diagnosis
Plan
Implementation
Evaluation
Assessment Stage involves:
Collection of data from client, family, chart, doctor Taking a Drug history to evaluate the patients need for the medication
Obtaining a history of past/present over the counter drug use, prescription use, herbal use, street use
Identifying problems related to drug therapy - side effects, known allergies
Diagnosis Stage involves:
Identifying concerns/problems with drug side effects Managing swallowing problems (dysphagia) – can’t take meds Noting Impaired
Cognition – If forgetful, may miss med times
Identify concerns that maybe a medication could resolve eg. headache – obtain a Tylenol order?
Knowledge deficit leads to non compliance or over medication
Planning Stage involves:
Identifying what the medications are required for. Reviewing side effects of medications, be prepared to teach the client/family
Identify recommended dosage – does it follow the guidelines?
Review med admin times with pt. and family
Implementation Stage involves:
Collecting data related to patient condition and medications in use. Collaborate with the pharmacists on medication information/side effects, interactions, use
reference books
Design education plan as needed for the patient and family
Administer medication using the 9 RIGHTS of medication administration
Evaluation Stage involves:
The nurse must evaluate/assess the effectiveness of the medication Observe for side effects
Chart and record medications given and their effectiveness.
Laxatives
Constipation
Normally waste travels through the large intestine, reabsorbing water as it passes along. This keeps the stool of a normal soft consistency.
However, if the stool remains in the colon for too long, the water is reabsorbed and small hard stools form. This causes discomfort and distension in the abdomen.
Constipation can be caused by a number of factors:
Lack of exercise Insufficient food or fluid intake
Medication regimes
Sometimes pharmacologic intervention is required to ease constipation.
Laxatives are given:
To relieve constipation To prevent straining during bowel movement
To empty the bowel in preparation for bowel surgery or diagnostics tests
Laxatives are contraindicated when there is:
Undiagnosed abdominal pain Intestinal obstruction
* You must assess your client, including a physical abdominal assessment, prior to administration of a laxative
There are different types of laxatives:
Bulk –forming: substances that are largely unabsorbed from intestine, adding bulk to fecal mass to stimulate peristalsis; they pull water into intestinal lumen
Saline and osmotic agents: increase osmotic pressure in intestinal lumen and cause water to be retained; distension of bowel promotes peristalsis
Stimulants: the strongest and most abused laxative; they irritate GI mucosa and pull water into bowel lumen.
Osmotic laxatives: not absorbed in the intestine. Pulls water into the fecal mass to create a more watery stool.
Miscellaneous:
o Mineral oil – acts by lubricating the stool and the colon mucosa
Classification: Bulk Forming
Metamucil (psyllium) Not absorbed from the intestine
When water is added the substance swells and become gel like
The added size to fecal matter stimulates defecation
Similar results as fibre intake
Act within 12 –24 hours but may take up to 2 –3 days
Must take with 8 –10 oz. water
Classification: Osmotic Laxatives
Magnesium Citrate (Citro-Mag), Milk of Magnesia Lactulose – pulls water into the intestine, softening stool and irritating bowel by
distension.
Not well absorbed from the intestine and cause water to be retained in the bowel and absorbed into the stool
Distention of the bowel leads to increased peristalsis, watery stool
Results 1/2 – 6 hours
Sodium phosphate retention enemas give results in 15 minutes
Classification: Stool Softeners
Docusate sodium (Colace) Decreases the surface tension of fecal mass and allow water and fat to be absorbed into
the mass
Results in softer stool and easier passage.Acts within 1 –3 days
Classification: Stimulant Cathartics
Act by irritating the gastric mucosa and pulling water into the bowel Oral Dulcolax, castor oil, Senokot
Produce results in 6 – 12 hours
Rectal suppositories bisacodyl results 15 min. – 2 hours. Glycerine 30 minutes
Pt. may experience abdominal cramping
Classification: Miscellaneous - Laxative (Lubricant)
Mineral oil Lubricates fecal mass
Effective 6 –8 hours
Classification: Miscellaneous - Laxatives
Pulls waters into the intestine Can produce electrolyte imbalances – use with caution
sorbitol( Microlax)
Nursing Responsibilities
Assessment: abdominal assessment, check bowel records, assess diet and fluid intake, activity level, medications, age related concerns
Document findings, document interventions, document/assess results
Incorporate patient teaching as needed
Laxatives
See pages 513 –516 ( Normal Function of the Lower Digestive tract) in Pharmacology for Nurses (Adams et al, 2010)
Review Student Guide questions.
Make a drug card for each laxative:
o Bisacodyl
o Psyllium powder
o Docusate Sodium(Include Action, Trade name, Route given, Nursing measures/assessment that accompany administration of this med.)You will need these drug cards for nursing arts!
Otic and Topical Medications
Otic Medications
1. How are medications labeled for use in the ear?2. Research Auralgan eardrops.(Hint: look online).
3. What are the indications for this medication?
4. What are the nursing considerations?
Topical Medications
Research the following classifications of Topical medications:
1. Antimicrobials2. Antipruritics
3. Anti-inflammatory
4. Antineoplastics
What are your nursing considerations when applying topical medications?
TOPIC 8: Complementary, Indigenous and Alternative Remedies
Learning Objectives:
Upon completion of the class, the learner will be able to:· Identify complementary, indigenous and alternative remedies· Identify the implications of the use of herbal, vitamin and indigenous remedies with
other medications· Identify the main nursing considerations related to these groups of drugs.
Reflect on the following quote from Cook (2005):
A Royal Commission on Aboriginal Peoples widely consulted Aboriginals in Canada. The Commission's 1996 Report advocated 4 cornerstones of Aboriginal health reform, one of which was "the appropriate use of traditional medicine and healing techniques [that] will assist in improving outcomes . . ." It reported that many expressed the sentiment that ". . . the integration of traditional healing practices and spirituality into medical and social services is the missing ingredient needed to make those services work for Aboriginal people."
Nutritional Supplements and Herbal Medications
Terms and Concepts
Herbal Medicines
Medicines of botanical origin
Minerals
essential components of enzymes, hormones, bones & teeth regulate cell membrane permeability, pH, osmotic pressure, muscle contractility, O2
transport etc
Vitamins
essential chemicals that regulate metabolism fat soluble are A, D, E & K
What is the significance of a vitamin being fat-soluble - as opposed to water soluble?
Mineral – Calcium Salts
Actions – activates nerve impulses (blood coagulation, essential for cardiac, smooth and skeletal muscle function)
Uses – treatment & prevention of hypocalcemia, Osteoporosis
Adverse Effects – arrhythmia, constipation
NC – assess for hypocalcemia (paresthesias, arrhythmia, muscle twitching), monitor VS & labs
Supplements – calcium carbonate, calcium gluconate
Best absorbed if taken with magnesium
Anemia & Iron
Anemia - ↓ in RBC number or ↓ in quantity of hgb
Iron is required for hgb synthesis Only 5% - 10% of dietary iron is absorbed
Vitamin C increases absorption Ca+ inhibits absorption
Types of Anemia
1. Iron-deficiency Anemia (nutritional anemia) – low or absent iron stores due to diet2. Pernicious Anemia – lack of intrinsic factor → ↓ B12 absorption & malformed RBCs
3. Megaloblastic Anemia – low folic acid
Minerals – Ferrous Sulphate
Action – iron source for production of hgb Uses – prevention & treatment of iron deficiency anemia (only)
Adverse Effects – dark stools, epigastric pain, diarrhea, constipation
NC – monitor hgb, hct, reticulocytes, monitor BMs
Supplements - ferrous gluconate, ferrous sulphate
Vitamin B12 – Cyanocobalamin
Action – co-enzyme for RBC production Uses – pernicious anemia, prevention of B12 deficiency
Adverse Effects – well tolerated
NC - IM route only in pernicious anemia because...
Minerals – Zinc
Action – co-factor for many enzyme reactions, wound healing Uses – replacement & supplemental for those with deficiency, impaired wound healing
Adverse Effects – well tolerated
NC – teach not to exceed RDA, dietary sources (wheat germ, seafood, organ meat)
Supplement – zinc sulphate
Vitamin D
Action – converted to active form in liver/kidneys, promotes absorption of Ca+ and phosphorus, helps regulate Ca+ levels
Uses – treatment of hypocalcemia, some bone diseases, vitamin D deficiency
Adverse Effects – toxicity (muscle pain, ↓LOC arrhythmia, bradycardia) – why is toxicity possible with this vitamin?
Meds – calcifediol, calcitriol, cholecalciferol
Herbal Medicines
¼ of prescription drugs are from herbs Pharmaceutical industry uses ~ 120 compounds derived from plants which it discovered
by studying folk remedies
Quinine, from South American cinchona tree bark is used to treat malaria
Digitalis (digoxin), a widely prescribed heart medication, is from the foxglove plant
Salicylic acid, the source of aspirin, from willow bark
Lack of Regulation
As yet, the (OTC) herbal medicine industry is unregulated False claims are not uncommon (effectiveness, “organic”, safety)
Studies have found wide discrepancies between the labeled contents and the actual contents of many products
Some herbs, like pharmaceuticals, have potentially harmful side effects
Many herbal products lack scientific study and validation of claims
Nurses need to be aware of herbs potential for;
o Toxicity
o Potential interactions with other medications
Your Role Regarding Use of Herbs
Our role is NOT to discourage their use but to ensure the MD knows about them prior to ordering regular pharmaceuticals.
Herbs and the Nursing Process
Assessment
Plant and other allergies? List of herbal/vitamin supplements used
Client’s understanding of the indications for their use
Is the physician aware? (check MD’s history/progress notes)Why is this essential?
Planning
Ask client/family if herbs are being used Locate resources for client teaching
Check facility policy/MD/facility pharmacist for administration & documentation policies – why?
Clients or their family members sometimes store herbs in the room & don’t think to alert the nurse/MD
Implementation / Evaluation
Advise MD of use of products, allergies Teach client importance of advising MD/nurse about use of herbal products
Teach client about the products being used – what source will you use?
Assess client’s complaints and therapeutic response to supplemental products
Consult with team for appropriate action
Herb – Gingko Biloba
Action – relaxes smooth muscle (vasodilation with improved arterial & capillary perfusion), free radial combatant, inhibits platelet aggregation
Uses – ↑ cerebral blood flow in elders (Alzheimer’s, ST memory loss, HA, dizziness), ↑ walking distance in intermittent claudication, ↑ peripheral perfusion in diabetes, improved wound healing
Adverse Effects – diarrhea, nausea, vomiting, dizziness (in large doses)
Interactions – caution in clients on platelet inhibitors & anticoagulants
Nursing Considerations – monitor:
Herb – Black Cohosh
Action – compounds bind to estrogen receptors, suppress luteinizing hormone Uses – PMS symptoms, dysmenorrhea, menopause
Adverse Effects – well tolerated
Precautions – safety in breast cancer not established, do not use for > 6 mo, not in first 2 pregnancy trimesters
Nursing Considerations – do not confuse with BLUE cohosh
Herb – Feverfew
Action – smooth muscle relaxant, ↓ prostaglandin & leukotrienes, ? antiplatelet Uses – prevention of migraine HA (smooth muscle relaxant), RA (antiinflammatory
properties)
Adverse Effects – mouth ulcers, “post feverfew syndrome” (insomnia, headache, myalgia, anxiety so DC use gradually)
Nursing Considerations – teach for migraine HA prevention only, avoid NSAIDs (↓s effectiveness of feverfew)
Herb – St. John’s Wort
Action – inhibits reuptake of serotonin etc, effects vary with product manufacturer Uses – mild depression, OCD, topical (antiinflammatory, wound healing)
Adverse Effects – “serotonin syndrome” (sudden onset of confusion, nausea, vomiting, muscle spasm, tremor, fever → coma), photosensitivity
Nursing Considerations – not to use other serotonin-active drugs together, teach about serotonin syndrome
Food / Drug Interactions
The potency & effectiveness of many medications is altered by the presence or absence of food/other medications etc in the stomach – read drug labels/orders carefully
Eg. Grapefruit increases the potency of many conventional medications, such as calcium channel blockers & benzodiazepines
TOPIC 9: Nervous System Part 1
Learning Objectives:
Upon completion of the class, the learner will be able to:· Describe major classes of drugs used to treat diseases/illnesses of the nervous system
(Autonomic nervous system, Parkinson’s Disease, seizures, and anxiety/mood disorders and psychoses).
· Describe the main nursing considerations related to this group of drugs.
· Explain drug interactions, polypharmacy, and food/drug effects to medication used across the lifespan, particularly the older adult.
· Explain the potential interaction of complementary, Indigenous and herbal preparations with nervous system medications.
· Organize research of drugs used to treat diseases/illnesses of the nervous system in a way that allows for easy and accurate reference.
Medications Used to Treat Disorders in the Nervous System
Drug Calculations Practice
Read the questions carefully!
1. Acetaminophen elixir is stocked as 160 mg/5 mL. The physician has ordered 15 mL to be given q4-6h prn for pain.How many mg will you be administering per dose?
2. MD order reads - KCl 15 mEq PO once daily. On hand - KCl 10 mEq/15 mL.What volume of medication will you administer per dose?
3. Desired medication – 1.0 g ibuprofen total daily in two equally divided doses. Medication on hand is 200 mg tablets.How many tablets will you administer per dose?
Equivalents & Conversions
1 tsp = _____ mL
45 mL = _____ oz
0.17 G = _____ mg
0.01 mg = _____ mcg
2500 mcg = _____ mg
125 mg = _____ G
Nervous System Classifications
(This content is relevant for both Part 1 and 2).
Adrenergic Agents (agonists) Adrenergic / Beta Blockers (adrenergic antagonists)
Cholinergic Agents (agonists)
Anticholinergic Agents (cholinergic antagonists)
Sedatives / Hypnotics (benzodiazepines, other)
Anti-Parkinson Agents (dopamine agonists)
Anxiolytics
Antidepressants
Antipsychotics
Anticonvulsants
Analgesics (opioid, non-opioid, salicylates, NSAIDs)
Nervous System A & P – the Directors & Actors
Central Nervous System (CNS) “directors”
Brain & Spinal Cord
Peripheral Nervous System (PNS) “actors”
Spinal/Peripheral nerves1. Somatic System
2. Autonomic system
Cranial nerves
Neurotransmitters (nt)
Are chemicals that are released by one neuron, diffuse across the synaptic cleft, and are taken up by receptor sites on the next neuron
Thereby, passing on the action potential
Each neuron releases only one kind of nt
Neurotransmitters either stimulate or inhibit a function of a neuron
ANS - Autonomic Nervous System–
Sympathetic Agonists & Antagonists
Term “adrenergic” comes from nt name adrenalin (aka epinephrine) Adrenergic agonist medications are called adrenergic agents (sympathomimetics)
Adrenergic antagonist medications are called adrenergic blocking agents
What does sympathomimetic mean?
Adrenergic Agents
Catecholamine drugs that stimulate adrenergic receptors (alpha, beta, dopaminergic) Meds – albuterol (Salbutamol, Ventolin), dopamine, epinephrine
Mechanism of action by Receptor Type:
o In blood vessels - vasoconstriction (alpha)
o In heart - ↑ HR (beta 1)
o In lungs - bronchodilation (beta 2)
o Other - ↓s Parkinson’s symptoms & ↑ renal perfusion & urine output (dopamine)What drug class will antagonize the effects of the adrenergic agonists?
General Uses – asthma, bronchospasm, hypotension, shock, decongestant, digitalis toxicity, COPD, cardiac arrest
Adverse reactions – arrhythmia, angina, severe hypertension, n/v, palpitations, tachycardia, skin flushing, dizziness, tremors
Eg. albuterol (adrenergic agonist, bronchodilator)
Use – bronchodilator in asthma, COPD Action – binds to beta 2 receptors to relax bronchiolar smooth muscle
Adverse Effects – nervousness, tremor, chest pain, palpitations
NC – assess HR, BP, respiratory asmt, monitor for bronchospasm, hyperglycemia in DM, give with meals
Beta Adrenergic Blockers
General Effects - block access to naturally occurring catecholamines (epinephrine, norepinephrine, dopamine) thereby reducing their effects
General Uses – hypertension, arrhythmia, angina, post MI, controlled CHF, migraine HA, tremor
Precautions – asthma, diabetes (masks s/s of hypoglycemia) – Actual hypoglycemia could be misread as therapeutic effects of β-blockers mask S/S of hypoglycemia
BETA ADRENERGIC RECEPTORS
Types / Action of Beta Receptors
Regarding β-blockers – ‘olol’
Some beta blockers are selective, only blocking either beta 1 or beta 2 receptors Others are non-selective, blocking both beta 1 & beta 2 sites
Client history, medication selection & ongoing nursing asmt are extremely important in assessing & intervening in adverse effects especially with non-selective drugs
Beta Adrenergic Blockers
Adverse Effects - bradycardia, peripheral skin mottling, hypotension, bronchoconstriction, wheezing, worsening of CHF
Interactions - Additive effect with antihypertensive effects of other classes (additive effect may be desired)Why?
Meds - metoprolol (Betaloc, Lopresor) atenolol, timolol, propanolol
o Metoprolol(β-blocker, antianginal, antihypertensive)
Use – hypertension, angina, prevention of MI
Action – blocks beta 1 (cardiac) adrenergic receptors, fairly selective) →↓BP & ↓HR
Adverse Effects – fatigue, weakness, CHF, pulmonary edema, bradycardia, impotenceWhy do these adverse effects make sense?
NC – assess apical & BP pre/post dose, monitor for S&S of CHF
ANS – Parasympathetic Agonists & Antagonists
Term “cholinergic” from neurotransmitter name acetylcholine Cholinergic agonist medications - called cholinergics (parasympathomimetics)
Cholinergic antagonist medications - called anticholinergic agents
Parasympathomimetic means...?
Cholinergic Agents
Action - enhances parasympathetic effects of Ach in PSNS → ↓ HR, ↑ GI motility & secretions, ↑ contraction strength of skeletal muscle, ↑s bladder contractions
Use – ↑ bladder muscle contraction in urinary retention
Meds – bethanechol, neostigmine, pilocarpine
It is thought that boxwood may interact with cholinergic agents.
Anticholinergic Agents
Action - inhibits cholinergic effects of acetylcholine → ↓ in parasympathetic activity (↑HR , ↑IOP, ↓s oral & URT secretions, ↓s GIT secretions & motility) muscle, ↓s bladder contractions
Adverse Effects – constipation, urinary retention, blurred vision, insomnia, confusion, agitation, dry mouth
Meds – atropineWhat NIs are necessary for these adverse effects?
some herbs like aloe, senna, buckthorn and cascara sagrada may have atropine-like actions and may increase atropine's effect.
What is your nursing responsibility regarding the patient's use of herbal medications?
Sedatives / Hypnotics
Many are controlled substanceso Hypnotics induce sleep
o Sedatives induce calm which can cause sleep (dose related)
Chronic insomnia – 20% of elders & often associated with mental illness
General Action – CNS depression
Uses – improve sleep patterns, anxiolytic (prn, not routinely), pre-op sedation
Benzodiazepines
Adverse Effects - dependence, over sedation, drowsiness, lightheadedness, confusion, hypotension
NC - Assess cause of anxiety/insomnia (attempt non-med interventions first) Safety precautions for ↓ LOC & ↓BP Monitor VSWhat might you expect?
Monitor for dependency
Advise client not to drink alcohol – Why?
Assess for additive effects with other CNS depressants
Meds:
o Lorazepam (Ativan), oxazepam (Serax), diazepam (Valium)
o Non-benzo (miscellaneous) - eszopiclone (non-benzodiazepine)
Lorazepam – anxiolytic, S/H
Uses – (variable) anxiety, etoh withdrawal, sleep, anticonvulsant, pre-op sedation
General action – CNS depression, ↑s GABA
Adverse Effects – dependence, dizziness, ↓ LOC
NC – controlled substance, assess for falls risk (implement fall prevention protocol), CNS depression, ensure safety.
Some herbal supplements may have an additive effect when taken with lorazepam. For example, kava, valerian, chamomile and hops have a sedating effect of their own. Other drugs have a stimulating effect and may reduce the effectiveness of lorazepam. Examples include gotu kola and ma huang.
Who is most at risk for the “hangover effect” & why?
Eszopiclone (Lunesta)– S/H
Non-benzodiazepine
Use – insomnia Action – CNS depression (enhances GABA), rapid onset, peak 1 hr
Adverse Effects – additive with other CNS depressants, tolerance
NC – give immediately prior to bedtime, ensure safety due to rapid onset
Antiparkinson Agents
Parkinson’s disease:
Is a neurodegenerative disease caused by a lack of dopamine in the extrapyramidal motor system in the basal ganglia
Dopamine is inhibitory and is lacking in Parkinson's disease causing what S&S … ?
“parkinsonism” – Parkinson-like symptoms associated with medication side effects, head trauma, tumour, infections
Extrapyramidal Symptoms Associated with Parkinsonism
Characterized by involuntary movements:
Akinesia - ↓ in spontaneous movements
Dystonia – impairment in muscular tone
Tardive Dyskinesia – repetitive involuntary movements (thrusting of tongue, lip smacking, puckering, pill rolling)
Parkinsonism – resting tremors, rigidity, shuffling gait, cogwheel movements
Meds Used for Parkinson’s Disease (PD)
Principles of Medication Therapy in PD
1. There is no known cure2. Pharmacologic Goals are to control symptoms & slow progression (selegiline)
3. With onset of functional impairment, dopamine agonists are added (amantadine, bromocriptine)
4. carbidopa/levodopa (Sinemet) is most effective in relieving symptoms but effectiveness is 3-5 years (dose-related) → “on-off effect”
5. entacapone maybe added to slow metabolism of levodopa, so the required dose of levodopa is smaller
Carbidopa / Levodopa (Sinemet)
Antiparkinson Agent
Action - carbidopa - enzyme inhibitor that reduces metabolism of levodopa → ↑ in half-life of levodopa & a 75% reduction in required dose of levodopa (which leads to longer therapeutic effect)
levodopa crosses blood/brain barrier, is metabolized to dopamine and replaces dopamine deficiency in the basal ganglia
10/100, 25/100 – usual starting dose 25/100, 25/250 – as levodopa effect is diminished
Anticholinergics may also be used to control drooling & tremor – Explain this...
Adverse effects – nausea, vomiting, hypotension, extrapyramidal symptoms
NC:
o Separate anticholinergics by 2 hours
o Give on time (why?) with food
o Obtain baseline asmt of PD symptoms (pill-rolling, tremors, rigidity, drooling)
o Obtain ongoing asmt of symptoms & report to MD prnExactly what are you assessing for?Why do you need to continually assess & report to MD?
Kava can potentially worsen the symptoms of Parkinson's disease.
Anxiolytic Medications
Anxiety disorders are common...
Symptoms of anxiety – tension, ↓ ability to concentrate & comprehend, tachycardia, palpitations, tremor, GI disturbance, panic attacks, OCD, (dyspnea, diaphoresis, dizziness), phobias
Benzodiazepines
o Favoured because less drug interactions than barbiturates
o Dependency is a risk (withdraw slowly)
o Action – CNS depression (stimulate GABA)
o Adverse Effects – hangover, sedation, excessive use/abuse, hepatotoxicity
o NC – monitor for toxicity, dependence, safety
o Meds – lorazepam (Ativan), diazepam (Valium), oxazepam (Serax), hydroxizine (Atarax)
Sedating herbs such as kava and chamomile may increase the effect of benzodiazepines. They should be taken with caution.
Antidepressant Medications
For mood disorders (abnormal depression & euphoria) Mood disorders are either unipolar (depression) or bipolar (manic depression)
Depression is the second leading cause of disability (next to ischemic heart disease)
Etiology – nt dysfunction (norepinephrine, serotonin, GABA, dopamine, ACh), ↑ cortisol, situational stressors, genetics
Choice is based on therapeutic effect & tolerance of adverse effects
Therapeutic response takes 2 – 4 weeks
Therapy enhances response significantly
What are the nursing assessments for a client with a mood disorder?What finding are you legally & ethically obliged to report?Define “affect”...
Subclasses of Antidepressants
1. MAO inhibitors – inhibits destruction of many nt (selegiline), ++++ drug interactions2. Tricyclics – block reuptake of nt in synaptic cleft (amitriptyline, imipramine
3. Selective serotonin reuptake inhibitors - As effective as tricyclics without anticholinergic & cardiac adverse effects
Tricyclic antidepressants may interact with herbs such as evening primrose and ginko (they may lower the pts seizure threshold). When using tricyclic antidepressants with St. John's wort, the health care professional must remain alert to signs of serotonin syndrome.
What is serotonin syndrome?
MAOIs interact with a number of herbal preparations. Ginseng, when taken with Nardil for example, can cause visual hallucinations, irritability, insomnia, mania, tremors and headache. When taken with ephedra, St. John's wort, or ma huang, hypertensive crisis could occur.
What is hypertensive crisis?
Citalopram (Celexa) - SSRI
Action – inhibits reuptake of serotonin in synaptic cleft → prolonged effect Adverse effects – restlessness, agitation, insomnia, anxiety, GI disturbance, suicidal
thoughts, sexual dysfunction
NC – monitor affect, suicidal thoughts
Other SSRIs – fluoxetine (Prozac), sertraline (Zoloft)
Taking SSRIs in conjunction with St. John's wort or L-tryptophan may also put the patient at risk of serotonin syndrome. Kava may increase the effect of the SSRI
Antipsychotic Medications
Psychosis – a thought disorder with loss of reality, hallucinations, delusions, often severe functional impairment (disability & handicap)What was the major neurochemical cause of psychosis?
First generation phenothiazines: (chlorpromazine, perphenazine)
Second generation phenothiazines have fewer side effects (quetiapine, loxapine, olanzapine, risperidone)
Taking chlorpromazine along with herbs such as kava or St. John's wort can increase the risk of experiencing dystonia. Kava has also been known to increase the effect of haloperidol. Kava can also increase the risk of CNS depression when taken with clozapine.
2nd Generation Anti-psychotics
Loxapine, Quetiapine
Adverse effects:o Seizures, parkinsonism, tardive dyskinesia Adverse effects can be very serious
and requires knowledge and excellent asmt skills What accounts for the adverse effect of ‘parkinsonism’ associated with these medications?
Drug Interactions:
o Meds that ↓ therapeutic effects: dopamine agonists (carbidopa/levodopa, bromocriptine, amantadine)Why?
o Others: beta blockersWhat adverse effect may be exacerbated?
Quetiapine (Seroquel) – 2nd generation phenothiazine
Uses – treatment of psychosis associated with schizophrenia, psychotic depression, agitation in dementia
Action – blocks dopamine and/or serotonin
Adverse Effects – extrapyramidal effects, fatigue, drowsiness, OH, anticholinergic s/s (dry mouth, blurred vision, constipation, urinary retention)
NC – monitor for extrapyramidal effects (dystonia, tardive dyskinesia, Parkinsonism), OH, anticholinergic effectsSuch as…? Describe the above signs...
Cholinesterase Inhibitors
Use – myasthenia gravis, mild-moderate dementia Action – inhibits destruction of cholinesterase → prolonged action of Ach → improved
memory and motor function
Adverse Effects – excessive cholinergic/parasympathetic effects (hypersecretion, bradycardia, nausea, diarrhea, abdominal pain)
Meds – donepezil (Aricept), rivastigmine (Exelon)
Anticonvulsant Medications
Seizures
Brief periods of abnormal electrical activity in the brain May be convulsive or non-convulsive with many subtypes
Associated with altered LOC, sensory & motor effects
Causes – epilepsy, head injury (traumatic, infectious, chemical), hypoglycemia
Ongoing medication use when underlying cause cannot be identified and/or resolved
May require trial of different meds until a therapeutic effect is seen
Goal is to reduce frequency of seizures
Med classes used – benzodiazepines (diazepam, clonazepam), hydantoins (phenytoin - Dilantin), miscellaneous (carbamazepine)
o carbamazepine (Tegretol)
o Uses – prevention of some types of seizures (also used as an analgesic & anti-manic)
o Action – chiefly unknown, affects Na+ channels
o Adverse effects – N&V, drowsiness, dizziness, REPORT – OH, hypertension, dyspnea, edema (in HF), nephrotoxicity, hepatotoxicity, pruritic rash, bone marrow depression …Causing what?
o NC:
HOLD med & contact MD for reportable adverse effects
Implement seizure precautions
Monitor CBC
Assess/document seizure activity
Safety related to hypotension, dizziness, other adverse effects
When a client is taking Dilantin, they must use great caution when using herbs that may increase potassium loss. Such herbs include herbal laxatives (buckthorn, cascara sagrada, and senna).
PART 2
Medications Used in the Management of Pain
Analgesics
opiate agonists NSAIDs
salicylates
miscellaneous
Pain & Its Management
All of the following are subjective & variable:
Pain perception – awareness of the sensation Pain threshold – point at which the pain is perceived as “pain”
Pain tolerance – ability to endure pain
Analgesics – relieve pain without loss of consciousness or reflexes
Acute Pain – a symptom
Acute pain...
Short term due to sudden injury Is a warning of tissue injury
Is purposeful
Activates the sympathetic nervous system
Pain ↓s with healing
Chronic Pain – a disease
Gradual onset lasting > 3 months Not related to an injury
Is NOT PURPOSEFUL
Divided into malignant (cancer) & non-malignant
Can arise from organs, muscular/connective tissues (nociceptive pain) or nervous tissue (neuropathic pain)
When uncontrolled, affects every aspect of life
Can have very serious harmful affects
Is now viewed as a disease (whereas acute pain is viewed as a symptom)
Properties of a ‘good analgesic’
Maximum pain relief Will not cause dependence
Minimal adverse effects (constipation, hallucinations, respiratory depression, N&V)
Rapid onset & long duration of action
Minimal sedation
Inexpensive
Mechanisms of Pain
Injury to tissues → release of prostaglandins, bradykinins, leukotrienes, histamine, substance P which stimulate nociceptors → pain impulse transmission to spinal cord and up to brain
opiate receptors – receptors that block pain when stimulated by opioids (naturally occurring or in med form)
Pain Med Classes
3 Mechanisms of Action
Analgesic action works either by interfering with nociceptor stimulation, impulse transmission or reception of the impulse in the brain:
1. ↓s release of prostaglandins etc2. Interferes with impulse at spinal cord level
3. Binds to opiate receptors in the brain
Opioids & the Ceiling Effect
Ceiling effect – point at which a larger dose does not produce a better analgesic effect but does cause more adverse effects
How is this different than tolerance?
Opiate Agonists
Use – moderate to severe pain (acute, chronic, cancer) Action– relieve severe pain without LOC
o Stimulate opiate receptors in brain
o Longer term use can cause dependence & tolerance
Interactions – additive effect with other CNS depressants
Adverse effects – respiratory depression, urinary retention, excessive use/abuse, dizziness, sedation, N&V, diaphoresis, confusion, OH, constipation
confusion is a sign of opiod toxicity.
Meds – morphine, codeine, hydromorphone, fentanyl, meperidine, methodone, oxycodone
Naloxone (Narcan) - Opioid antagonistWhat is the indication?
Morphine (M-Eslon, MS Contin) – opioid analgesic
Use – moderate to severe pain Action – binds to opiate receptors to ↓ pain perception
Adverse Effects – CNS depression (→ respiratory depression, hypotension, ↓ RR & depth, ↓ LOC/sedation/confusion, hypotension, constipation, diaphoresis), tolerance, dependence
NC:
o Pre/post dose PQRST
o Monitor VS & compare with baseline values, hold for shallow respirations < 12/min (or facility policy)
o Hold in undiagnosed abd pain
o Ensure safety
o Assess/intervene for constipation
o Assess for dependence (? methadone)
Certain herbs may potentiate the effect of morphine. One of these is yohimbe. Also use extreme caution when combining herbs that cause CNS depression with morphine as the risk of respiratory depression increases.
Salicylates (Aspirin - ASA)
Uses:o Relief of mild - mod pain but no longer the med of choice for analgesia – Why?
o Antipyretic, antiinflammatory for RA/OA, analgesic without sedation
Actions:
o inhibits prostaglandin synthesis → ↓ pain, ↓ inflammation & ↓ fever
o inhibits platelet aggregation (↓s risk of TIA & CVA, MI in those with unstable angina)
Adverse effects – GI bleeding, GI irritation
Interactions – ↑ risk of bleeding with concurrent use of NSAIDs, warfarin, heparin
NC – PQRST, T, pain, s/s of CVA/TIA according to specific indication, s/s of GI or other bleeding (oral etc), s/s of toxicity (tinnitus, confusion, N & V), no antacids within 2 hrs of EC tabs, give with food
Feverfew is an herb known to have an action similar to ASA. When taken together, the risk of bleeding may increase. Avoid other herbs that may also increase bleeding when on ASA therapy.
Non Steroidal Anti-Inflammatories (NSAIDs)
Uses- analgesic, antiinflammatory, antipyretico Not as effective as salicylates but less risk of GI bleeding
o For pain & inflammation associated with RA, OA, spondylitis, gout and pain of other nociceptive origins, fever
Action – inhibits prostaglandin synthesis
Adverse effects – GI bleeding/irritation, constipation, nephrotoxicity, hepatotoxicity
Interactions – ↑ risk of bleeding with concurrent use of other NSAIDs, aspirin, warfarin, heparin
Meds – ibuprofen, diclofenac, naproxen
Because NSAIDs increase the risk of bleeding, herbs that may have a similar action should be avoided. Some of these include cat's claw, dong guai, evening primrose, feverfew, ginko biloba and red clover. There are many other herbs that may have a similar effect. Ensure that you do research.
Non-Opioid Analgesic - acetaminophen
Use – mild to moderate pain, fever (has become drug of choice for antipyretic & analgesic as adverse effects are minimal)
Action - is unknown
Adverse effects – GI irritation, OD, hepatotoxicity (anorexia, N&V, jaundice, hepatomegaly, altered LFTs)
Trade names – Tempra, Tylenol
Pharmacology & the Older Adult
THIS INFORMATION IS RELEVANT FOR ALL THE FOLLOWING UNITS!!!!
‘Start low, go slow’
Important Concepts
Define "Polypharmacy" Explain "Start low & go slow"
Pharmacokinetics & the Elder
In what ways are the following affected by aging?
Drug absorption Drug distribution
Drug metabolism
Drug excretion
Factors Influencing Absorption
Feeling unwell, ↓ appetite
Dysphagia
Dentition
Delayed gastric emptying
More alkaline gastric pH
Slowed GI transit time
Constipation & diarrhea
Nausea & vomiting
↓ circulation
Absorption in the Elder
Dysphagiao Elders often have ↓ saliva production
o Some tablets/capsules are very large
o Many drugs cannot be crushed (ER, EC, SR)
o Phone pharmacy or follow agency protocol
o Crush and mix in applesauce
o Give liquid form if available
o Obtain order for alternate route
Dentition
o May be incomplete or uncomfortable – How will you assess?
Delayed gastric emptying
o Can lead to more absorption than same dose in a younger adult
o NSAIDs & salicylates (ulcergenic drugs) may be more harmful to stomach lining – Why?
More Alkaline Gastric pH
o ↑ absorption of meds destroyed by acid → higher serum levels than younger adult and possible toxicity (antibiotics)
o ↓ absorption of meds that need acid for absorption → lower therapeutic effect than usual adult (acetaminophen, aspirin)
o Carefully monitor TACT & report prn
Miscellaneous GIT Factors
o Slowed transit time, ↓ intestinal circulation, constipation, diarrhea, vomiting
o Think about the effects each of these have on absorption...
For IM Administration
o Muscle atrophy & ↓ perfusion (from aging but also inactivity) slows absorption
For Transdermal Administration
o Skin is thinner (↑ing absorption) but skin is drier and perfusion to the skin is impaired (↓ing absorption)
Factors Influencing Drug Distribution in the Elder
Factors affecting distribution:
Body water distribution CO
Regional blood flow
pH
↓ albumin level in blood oft
Percentage of body water
Elders have a lower body water concentration so med is more concentrated in their blood
Lower albumin levels
from liver/kidney disease and/or poor nutritional status → ↓ protein binding & more unbound drug available for receptor binding → more rapid onset of action & shorter duration
Drug Metabolism
Occurs mainly in the __________________________________________ ↓ function in this organ → ____________ (↑ or ↓) rate of drug metabolism which can
cause ________________________________________ leading to _________________________
Explain “START LOW, GO SLOW”
Explain why the nurse must monitor liver function tests & report results to the MD
Drug Excretion
Metabolites of drugs are mainly excreted by the __________________________ & ________________________ tracts
Antibiotics are given on a relatively frequent schedule (Q 6-8 H) because they are excreted rapidly by the kidneys – what is the significance of giving antibiotics late?
Monitor kidney function – BUN, urine creatinine, GFR (glomerular filtration rate)
Serum drug levels
o Can indicate problems in absorption, distribution, metabolism & excretion
o Can be used to assess cumulation & toxicity
o Some medications are potent and require monitoring – digoxin, T4, antibiotic levels
o Also useful for making dose or schedule adjustments
Risks for the Elder
Cumulation & toxicity from ? _______________________ & ___________________________ function
The ‘hang over effect’
Drug interactions caused by concurrent use of many medications _______________________________
Altered pharmacokinetics from chronic illnesses
Under treatment due to fear of polypharmacy
Nursing Considerations
Assess drug Hx including herbal products, nutritional supplements, laxatives, antacids Nutrition Hx which would include current & baseline __________________________?
Oral assessment
New symptom - Medication related? – how will you assess this?
Start low & go slow monitoring TACT
Teach use of calendars, daily containers
Review need for meds – call MD prn
If using a med that is cautioned for the elderly, there should be documentation supporting its use for a specific client
Use facility protocols for med administration with dysphagia, get order for alternate route if available
Monitor for adverse effects – including toxicity, altered LOC & potential for lack of safety
TOPIC 10: Nervous System Part 2 Pain and Substances of Addiction
Learning Objectives:
·Describe major classes of drugs used to treat diseases/illnesses of the nervous system (sedative/hypnotics, pain management, and substances of addiction).
· Describe the main nursing considerations related to this group of drugs.
· Explain drug interactions, polypharmacy, and food/drug effects to medication used across the lifespan, particularly the older adult.
· Identify pharmaceuticals that support end-of-life care.
· Explain the potential interaction of complementary, Indigenous and herbal preparations with nervous system medications.
Organize research of drugs used to treat diseases/illnesses of the nervous system in a way that allows for easy and accurate reference.
Medications Used to Treat Disorders in the Nervous System
Nervous System Classifications
(This content is relevant for both part 1 and 2).
Adrenergic Agents (agonists) Adrenergic / Beta Blockers (adrenergic antagonists)
Cholinergic Agents (agonists)
Anticholinergic Agents (cholinergic antagonists)
Sedatives / Hypnotics (benzodiazepines, other)
Anti-Parkinson Agents (dopamine agonists)
Anxiolytics
Antidepressants
Antipsychotics
Anticonvulsants
Analgesics (opioid, non-opioid, salicylates, NSAIDs)
Nervous System A & P – the Directors & Actors
Central Nervous System (CNS) “directors”
Brain & Spinal Cord
Peripheral Nervous System (PNS) “actors”
Spinal/Peripheral nerves1. Somatic System
2. Autonomic system
Cranial nerves
Neurotransmitters (nt)
Are chemicals that are released by one neuron, diffuse across the synaptic cleft, and are taken up by receptor sites on the next neuron
Thereby, passing on the action potential
Each neuron releases only one kind of nt
Neurotransmitters either stimulate or inhibit a function of a neuron
ANS – Sympathetic Agonists & Antagonists
Term “adrenergic” comes from nt name adrenalin (aka epinephrine) Adrenergic agonist medications are called adrenergic agents (sympathomimetics)
Adrenergic antagonist medications are called adrenergic blocking agents
What does sympathomimetic mean?
Adrenergic Agents
Catecholamine drugs that stimulate adrenergic receptors (alpha, beta, dopaminergic) Meds – albuterol (Salbutamol, Ventolin), dopamine, epinephrine
Mechanism of action by Receptor Type:
o In blood vessels - vasoconstriction (alpha)
o In heart - ↑ HR (beta 1)
o In lungs - bronchodilation (beta 2)
o Other - ↓s Parkinson’s symptoms & ↑ renal perfusion & urine output (dopamine)What drug class will antagonize the effects of the adrenergic agonists?
General Uses – asthma, bronchospasm, hypotension, shock, decongestant, digitalis toxicity, COPD, cardiac arrest
Adverse reactions – arrhythmia, angina, severe hypertension, n/v, palpitations, tachycardia, skin flushing, dizziness, tremors
Eg. albuterol (adrenergic agonist, bronchodilator)
Use – bronchodilator in asthma, COPD Action – binds to beta 2 receptors to relax bronchiolar smooth muscle
Adverse Effects – nervousness, tremor, chest pain, palpitations
NC – assess HR, BP, respiratory asmt, monitor for bronchospasm, hyperglycemia in DM, give with meals
Beta Adrenergic Blockers
General Effects - block access to naturally occurring catecholamines (epinephrine, norepinephrine, dopamine) thereby reducing their effects
General Uses – hypertension, arrhythmia, angina, post MI, controlled CHF, migraine HA, tremor
Precautions – asthma, diabetes (masks s/s of hypoglycemia) – Actual hypoglycemia could be misread as therapeutic effects of β-blockers mask S/S of hypoglycemia
BETA ADRENERGIC RECEPTORS
Types / Action of Beta Receptors
Regarding β-blockers – ‘olol’
Some beta blockers are selective, only blocking either beta 1 or beta 2 receptors Others are non-selective, blocking both beta 1 & beta 2 sites
Client history, medication selection & ongoing nursing asmt are extremely important in assessing & intervening in adverse effects especially with non-selective drugs
Beta Adrenergic Blockers
Adverse Effects - bradycardia, peripheral skin mottling, hypotension, bronchoconstriction, wheezing, worsening of CHF
Interactions - Additive effect with antihypertensive effects of other classes (additive effect may be desired)Why?
Meds - metoprolol (Betaloc, Lopresor) atenolol, timolol, propanolol
o Metoprolol(β-blocker, antianginal, antihypertensive)
Use – hypertension, angina, prevention of MI
Action – blocks beta 1 (cardiac) adrenergic receptors, fairly selective) →↓BP & ↓HR
Adverse Effects – fatigue, weakness, CHF, pulmonary edema, bradycardia, impotenceWhy do these adverse effects make sense?
NC – assess apical & BP pre/post dose, monitor for S&S of CHF
ANS – Parasympathetic Agonists & Antagonists
Term “cholinergic” from neurotransmitter name acetylcholine Cholinergic agonist medications - called cholinergics (parasympathomimetics)
Cholinergic antagonist medications - called anticholinergic agents
Parasympathomimetic means...?
Cholinergic Agents
Action - enhances parasympathetic effects of Ach in PSNS → ↓ HR, ↑ GI motility & secretions, ↑ contraction strength of skeletal muscle, ↑s bladder contractions
Use – ↑ bladder muscle contraction in urinary retention
Meds – bethanechol, neostigmine, pilocarpine
It is thought that boxwood may interact with cholinergic agents.
Anticholinergic Agents
Action - inhibits cholinergic effects of acetylcholine → ↓ in parasympathetic activity (↑HR , ↑IOP, ↓s oral & URT secretions, ↓s GIT secretions & motility) muscle, ↑s bladder contractions
Adverse Effects – constipation, urinary retention, blurred vision, insomnia, confusion, agitation, dry mouth
Meds – atropineWhat NIs are necessary for these adverse effects?
some herbs like aloe, senna, buckthorn and cascara sagrada may have atropine-like actions and may increase atropine's effect.
What is your nursing responsibility regarding the patient's use of herbal medications?
Sedatives / Hypnotics
Many are controlled substanceso Hypnotics induce sleep
o Sedatives induce calm which can cause sleep (dose related)
Chronic insomnia – 20% of elders & often associated with mental illness
General Action – CNS depression
Uses – improve sleep patterns, anxiolytic (prn, not routinely), pre-op sedation
Benzodiazepines
Adverse Effects - dependence, over sedation, drowsiness, lightheadedness, confusion, hypotension
NC - Assess cause of anxiety/insomnia (attempt non-med interventions first) Safety precautions for ↓ LOC & ↓BP Monitor VSWhat might you expect?
Monitor for dependency
Advise client not to drink alcohol – Why?
Assess for additive effects with other CNS depressants
Meds:
o Lorazepam (Ativan), oxazepam (Serax), diazepam (Valium)
o Non-benzo (miscellaneous) - eszopiclone (non-benzodiazepine)
Lorazepam – anxiolytic, S/H
Uses – (variable) anxiety, etoh withdrawal, sleep, anticonvulsant, pre-op sedation
General action – CNS depression, ↑s GABA
Adverse Effects – dependence, dizziness, ↓ LOC
NC – controlled substance, assess for falls risk (implement fall prevention protocol), CNS depression, ensure safety.
Some herbal supplements may have an additive effect when taken with lorazepam. For example, kava, valerian, chamomile and hops have a sedating effect of their own. Other drugs have a stimulating effect and may reduce the effectiveness of lorazepam. Examples include gotu kola and ma huang.
Who is most at risk for the “hangover effect” & why?
Eszopiclone (Lunesta)– S/H
Non-benzodiazepine
Use – insomnia Action – CNS depression (enhances GABA), rapid onset, peak 1 hr
Adverse Effects – additive with other CNS depressants, tolerance
NC – give immediately prior to bedtime, ensure safety due to rapid onset
Antiparkinson Agents
Parkinson’s disease:
Is a neurodegenerative disease caused by a lack of dopamine in the extrapyramidal motor system in the basal ganglia
Dopamine is inhibitory and is lacking in Parkinson's disease causing what S&S … ?
“parkinsonism” – Parkinson-like symptoms associated with medication side effects, head trauma, tumour, infections
Extrapyramidal Symptoms Associated with Parkinsonism
Characterized by involuntary movements:
Akinesia - ↓ in spontaneous movements Dystonia – impairment in muscular tone
Tardive Dyskinesia – repetitive involuntary movements (thrusting of tongue, lip smacking, puckering, pill rolling)
Parkinsonism – resting tremors, rigidity, shuffling gait, cogwheel movements
Meds Used for Parkinson’s Disease (PD)
Principles of Medication Therapy in PD
1. There is no known cure2. Pharmacologic Goals are to control symptoms & slow progression (selegiline)
3. With onset of functional impairment, dopamine agonists are added (amantadine, bromocriptine)
4. carbidopa/levodopa (Sinemet) is most effective in relieving symptoms but effectiveness is 3-5 years (dose-related) → “on-off effect”
5. entacapone maybe added to slow metabolism of levodopa, so the required dose of levodopa is smaller
Carbidopa / Levodopa (Sinemet)
Antiparkinson Agent
Action - carbidopa - enzyme inhibitor that reduces metabolism of levodopa → ↑ in half-life of levodopa & a 75% reduction in required dose of levodopa (which leads to longer therapeutic effect)
levodopa crosses blood/brain barrier, is metabolized to dopamine and replaces dopamine deficiency in the basal ganglia
10/100, 25/100 – usual starting dose 25/100, 25/250 – as levodopa effect is diminished
Anticholinergics may also be used to control drooling & tremor – Explain this...
Adverse effects – nausea, vomiting, hypotension, extrapyramidal symptoms
NC:
o Separate anticholinergics by 2 hours
o Give on time (why?) with food
o Obtain baseline asmt of PD symptoms (pill-rolling, tremors, rigidity, drooling)
o Obtain ongoing asmt of symptoms & report to MD prnExactly what are you assessing for?Why do you need to continually assess & report to MD?
Kava can potentially worsen the symptoms of Parkinson's disease.
Anxiolytic Medications
Anxiety disorders are common...
Symptoms of anxiety – tension, ↓ ability to concentrate & comprehend, tachycardia, palpitations, tremor, GI disturbance, panic attacks, OCD, (dyspnea, diaphoresis, dizziness), phobias
Benzodiazepines
o Favoured because less drug interactions than barbiturates
o Dependency is a risk (withdraw slowly)
o Action – CNS depression (stimulate GABA)
o Adverse Effects – hangover, sedation, excessive use/abuse, hepatotoxicity
o NC – monitor for toxicity, dependence, safety
o Meds – lorazepam (Ativan), diazepam (Valium), oxazepam (Serax), hydroxizine (Atarax)
Sedating herbs such as kava and chamomile may increase the effect of benzodiazepines. They should be taken with caution.
Antidepressant Medications
For mood disorders (abnormal depression & euphoria) Mood disorders are either unipolar (depression) or bipolar (manic depression)
Depression is the second leading cause of disability (next to ischemic heart disease)
Etiology – nt dysfunction (norepinephrine, serotonin, GABA, dopamine, ACh), ↑ cortisol, situational stressors, genetics
Choice is based on therapeutic effect & tolerance of adverse effects
Therapeutic response takes 2 – 4 weeks
Therapy enhances response significantly
What are the nursing assessments for a client with a mood disorder?What finding are you legally & ethically obliged to report?Define “affect”...
Subclasses of Antidepressants
1. MAO inhibitors – inhibits destruction of many nt (selegiline), ++++ drug interactions2. Tricyclics – block reuptake of nt in synaptic cleft (amitriptyline, imipramine
3. Selective serotonin reuptake inhibitors - As effective as tricyclics without anticholinergic & cardiac adverse effects
Tricyclic antidepressants may interact with herbs such as evening primrose and ginko (they may lower the pts seizure threshold). When using tricyclic antidepressants with St. John's wort, the health care professional must remain alert to signs of serotonin syndrome.
What is serotonin syndrome?
MAOIs interact with a number of herbal preparations. Ginseng, when taken with Nardil for example, can cause visual hallucinations, irritability, insomnia, mania, tremors and headache. When taken with ephedra, St. John's wort, or ma huang, hypertensive crisis could occur.
What is hypertensive crisis?
Citalopram (Celexa) - SSRI
Action – inhibits reuptake of serotonin in synaptic cleft → prolonged effect Adverse effects – restlessness, agitation, insomnia, anxiety, GI disturbance, suicidal
thoughts, sexual dysfunction
NC – monitor affect, suicidal thoughts
Other SSRIs – fluoxetine (Prozac), sertraline (Zoloft)
Taking SSRIs in conjunction with St. John's wort or L-tryptophan may also put the patient at risk of serotonin syndrome. Kava may increase the effect of the SSRI
Antipsychotic Medications
Psychosis – a thought disorder with loss of reality, hallucinations, delusions, often severe functional impairment (disability & handicap)What was the major neurochemical cause of psychosis?
First generation phenothiazines: (chlorpromazine, perphenazine)
Second generation phenothiazines have fewer side effects (quetiapine, loxapine, olanzapine, risperidone)
Taking chlorpromazine along with herbs such as kava or St. John's wort can increase the risk of experiencing dystonia. Kava has also been known to increase the effect of haloperidol. Kava can also increase the risk of CNS depression when taken with clozapine.
2nd Generation Anti-psychotics
Loxapine, Quetiapine
Adverse effects:o Seizures, parkinsonism, tardive dyskinesia Adverse effects can be very serious
and requires knowledge and excellent asmt skills What accounts for the adverse effect of ‘parkinsonism’ associated with these medications?
Drug Interactions:
o Meds that ↓ therapeutic effects: dopamine agonists (carbidopa/levodopa, bromocriptine, amantadine)Why?
o Others: beta blockersWhat adverse effect may be exacerbated?
Quetiapine (Seroquel) – 2nd generation phenothiazine
Uses – treatment of psychosis associated with schizophrenia, psychotic depression, agitation in dementia
Action – blocks dopamine and/or serotonin
Adverse Effects – extrapyramidal effects, fatigue, drowsiness, OH, anticholinergic s/s (dry mouth, blurred vision, constipation, urinary retention)
NC – monitor for extrapyramidal effects (dystonia, tardive dyskinesia, Parkinsonism), OH, anticholinergic effectsSuch as…? Describe the above signs...
Cholinesterase Inhibitors
Use – myasthenia gravis, mild-moderate dementia Action – inhibits destruction of cholinesterase → prolonged action of Ach → improved
memory and motor function
Adverse Effects – excessive cholinergic/parasympathetic effects (hypersecretion, bradycardia, nausea, diarrhea, abdominal pain)
Meds – donepezil (Aricept), rivastigmine (Exelon)
Anticonvulsant Medications
Seizures
Brief periods of abnormal electrical activity in the brain May be convulsive or non-convulsive with many subtypes
Associated with altered LOC, sensory & motor effects
Causes – epilepsy, head injury (traumatic, infectious, chemical), hypoglycemia
Ongoing medication use when underlying cause cannot be identified and/or resolved
May require trial of different meds until a therapeutic effect is seen
Goal is to reduce frequency of seizures
Med classes used – benzodiazepines (diazepam, clonazepam), hydantoins (phenytoin - Dilantin), miscellaneous (carbamazepine)
o carbamazepine (Tegretol)
o Uses – prevention of some types of seizures (also used as an analgesic & anti-manic)
o Action – chiefly unknown, affects Na+ channels
o Adverse effects – N&V, drowsiness, dizziness, REPORT – OH, hypertension, dyspnea, edema (in HF), nephrotoxicity, hepatotoxicity, pruritic rash, bone marrow depression …Causing what?
o NC:
HOLD med & contact MD for reportable adverse effects
Implement seizure precautions
Monitor CBC
Assess/document seizure activity
Safety related to hypotension, dizziness, other adverse effects
When a client is taking Dilantin, they must use great caution when using herbs that may increase potassium loss. Such herbs include herbal laxatives (buckthorn, cascara sagrada, and senna)
PART 2
Medications Used in the Management of Pain
Analgesics
opiate agonists NSAIDs
salicylates
miscellaneous
Pain & Its Management
All of the following are subjective & variable:
Pain perception – awareness of the sensation Pain threshold – point at which the pain is perceived as “pain”
Pain tolerance – ability to endure pain
Analgesics – relieve pain without loss of consciousness or reflexes
Acute Pain – a symptom
Acute pain...
Short term due to sudden injury Is a warning of tissue injury
Is purposeful
Activates the sympathetic nervous system
Pain ↓s with healing
Chronic Pain – a disease
Gradual onset lasting > 3 months Not related to an injury
Is NOT PURPOSEFUL
Divided into malignant (cancer) & non-malignant
Can arise from organs, muscular/connective tissues (nociceptive pain) or nervous tissue (neuropathic pain)
When uncontrolled, affects every aspect of life
Can have very serious harmful affects
Is now viewed as a disease (whereas acute pain is viewed as a symptom)
Properties of a ‘good analgesic’
Maximum pain relief Will not cause dependence
Minimal adverse effects (constipation, hallucinations, respiratory depression, N&V)
Rapid onset & long duration of action
Minimal sedation
Inexpensive
Mechanisms of Pain
Injury to tissues → release of prostaglandins, bradykinins, leukotrienes, histamine, substance P which stimulate nociceptors → pain impulse transmission to spinal cord and up to brain
opiate receptors – receptors that block pain when stimulated by opioids (naturally occurring or in med form)
Pain Med Classes
3 Mechanisms of Action
Analgesic action works either by interfering with nociceptor stimulation, impulse transmission or reception of the impulse in the brain:
1. ↓s release of prostaglandins etc2. Interferes with impulse at spinal cord level
3. Binds to opiate receptors in the brain
Opioids & the Ceiling Effect
Ceiling effect – point at which a larger dose does not produce a better analgesic effect but does cause more adverse effects
How is this different than tolerance?
Opiate Agonists
Use – moderate to severe pain (acute, chronic, cancer) Action– relieve severe pain without LOC
o Stimulate opiate receptors in brain
o Longer term use can cause dependence & tolerance
Interactions – additive effect with other CNS depressants
Adverse effects – respiratory depression, urinary retention, excessive use/abuse, dizziness, sedation, N&V, diaphoresis, confusion, OH, constipation
confusion is a sign of opioid toxicity.
Meds – morphine, codeine, hydromorphone, fentanyl, meperidine, methodone, oxycodone
Naloxone (Narcan) - Opioid antagonistWhat is the indication?
Morphine (M-Eslon, MS Contin) – opioid analgesic
Use – moderate to severe pain Action – binds to opiate receptors to ↓ pain perception
Adverse Effects – CNS depression (→ respiratory depression, hypotension, ↓ RR & depth, ↓ LOC/sedation/confusion, hypotension, constipation, diaphoresis), tolerance, dependence
NC:
o Pre/post dose PQRST
o Monitor VS & compare with baseline values, hold for shallow respirations < 12/min (or facility policy)
o Hold in undiagnosed abd pain
o Ensure safety
o Assess/intervene for constipation
o Assess for dependence (? methadone)
Certain herbs may potentiate the effect of morphine. One of these is yohimbe. Also use extreme caution when combining herbs that cause CNS depression with morphine as the risk of respiratory depression increases.
Salicylates (Aspirin - ASA)
Uses:o Relief of mild - mod pain but no longer the med of choice for analgesia – Why?
o Antipyretic, antiinflammatory for RA/OA, analgesic without sedation
Actions:
o inhibits prostaglandin synthesis → ↓ pain, ↓ inflammation & ↓ fever
o inhibits platelet aggregation (↓s risk of TIA & CVA, MI in those with unstable angina)
Adverse effects – GI bleeding, GI irritation
Interactions – ↑ risk of bleeding with concurrent use of NSAIDs, warfarin, heparin
NC – PQRST, T, pain, s/s of CVA/TIA according to specific indication, s/s of GI or other bleeding (oral etc), s/s of toxicity (tinnitus, confusion, N & V), no antacids within 2 hrs of EC tabs, give with food
Feverfew is an herb known to have an action similar to ASA. When taken together, the risk of bleeding may increase. Avoid other herbs that may also increase bleeding when on ASA therapy.
Non Steroidal Anti-Inflammatories (NSAIDs)
Uses- analgesic, antiinflammatory, antipyretico Not as effective as salicylates but less risk of GI bleeding
o For pain & inflammation associated with RA, OA, spondylitis, gout and pain of other nociceptive origins, fever
Action – inhibits prostaglandin synthesis
Adverse effects – GI bleeding/irritation, constipation, nephrotoxicity, hepatotoxicity
Interactions – ↑ risk of bleeding with concurrent use of other NSAIDs, aspirin, warfarin, heparin
Meds – ibuprofen, diclofenac, naproxen
Because NSAIDs increase the risk of bleeding, herbs that may have a similar action should be avoided. Some of these include cat's claw, dong guai, evening primrose, feverfew, ginko biloba and red clover. There are many other herbs that may have a similar effect. Ensure that you do research.
Non-Opioid Analgesic - acetaminophen
Use – mild to moderate pain, fever (has become drug of choice for antipyretic & analgesic as adverse effects are minimal)
Action - is unknown
Adverse effects – GI irritation, OD, hepatotoxicity (anorexia, N&V, jaundice, hepatomegaly, altered LFTs)
Trade names – Tempra, Tylenol
Substances of Addiction
There are many reasons that people turn to substances of addiction. The Centre for Addiction and Mental Health lists the following: genetic factors, how drugs interact with the brain, environment, mental health issues, coping with thoughts and feelings and spiritual or religious affiliation.
Drugs and alcohol stimulate the brain in ways that make the user "feel good" which of course, makes the user want to repeat the process. All addictive substances stimulate a flood of a brain chemical called dopamine which is linked to feelings of reward and pleasure. This alters the chemistry of the brain which tries to keep a state of equilibrium, leading to drug tolerance and a need for higher doses of the drug to experience the same degree of pleasure. Without the drug, people often feel flat and depressed, further reinforcing the need to use the substance of addiction.
Substance abuse is not a new phenomenon. It has occurred throughout history. Many substances of addiction are naturally occuring and have been used for hundreds or even thousands of years. For example, opium comes from certain varieties of the poppy plant; mescaline comes from certain types of cactus plants; cocaine comes from the cocoa plant; nicotine comes from the tobacco plant. Other more recent drugs are synthetically manufactured such as methamphetamine, LSD and PCP, among others.
Substance abuse is defined as "the self-administration of a drug in a manner that does not conform to the norms within one's given culture or society" (Adams, 2010, p. 112).
Substances of addiction may or may not be illegal.
Which addictive substances are considered legal vs. illegal? What makes one addictive drug legal and another illegal? What are your thoughts on this?
What is the most commonly used psychoactive substance?
Define the following terms: addiction, physical dependence, psychological dependence, withdrawal syndrome
Differentiate between tolerance and resistance.
Describe the withdrawal symptoms of the following substances: opioids, barbiturates and sedative-hypnotics, benzodiazepines,alcohol, cocaine and amphetamines, nicotine, marijuana, hallucinogens.
CNS Depressants
These substances lead to feelings of sedation and relaxation. Why are they
controlled under the Controlled Drugs and Substances Act?
sedatives
Also known as tranquilizers have traditionally been used to treat sleep disorders
and epilepsy.
The two main classes of sedatives are barbiturates and non-barbiturate sedative-
hypnotics. Discuss the similarities and difference between these two classes.
What is the biggest danger associated with overdoses of these types of drugs? Why
is this risk so high for barbiturates?
Common barbiturates include amobarbital, pentobarbital, phenobarbital,
secobarbital and tuinal.
Common non-barbiturate sedative-hypnotics include chloral hydrate, eszopiclone,
ramelteon, zaleplon, zolpidem.
benzodiazepines
This type of CNS depressant is most often prescribed for anxiety but may also be
prescribed to treat seizures and prevent muscle spasms.
Common benzodiazepines are alprazolam, diazepam, temazepam, triazolam, and
midazolam.
Why is overdose with benzodiazepines not as big of a risk as overdose of
barbiturates?
opioids
Known as narcotic analgesics and prescribed for severe pain, persistent cough and
diarrhea.
Drugs in this class include opium, morphine, codeine, meperidine, oxycodone,
fentanyl, methadone, and heroin.
Discuss the effects of oral vs. parenteral administration of opiods.
Why is methadone, itself a narcotic, used to treat opioid addiction?
ethyl alcohol (alcohol)
CNS depressant with huge health, economic and social consequences that is legally
available.
Why is alcohol considered a CNS depressant?
What factors must the nurse consider when doing an assessment before making any
assumptions regarding alcohol use or abuse?
What signs and symptoms do you expect to see in an alcohol overdose?
What should the nurse teach regarding the use of alchol along with other CNS
depressants? Why?
Describe the effects of chronic alcohol consumption.
Briefly discuss alcohol withdrawal.
Cannabinoids
Cannabinoids are obtained from the hemp plant and include marijuana, hashish
and hash oil.
The main psychoactive ingredient is delta-9-tetrahydrocannabinol (THC).
marijuana
Most commonly used illicit drug in Canada. Marijuana is commonly referred to as
the "gateway" drug. It makes subsequent use of other illicit drugs more likely.
Metabolites of THC remain in the body for a very long time (months-years). This
has lead certain olympic athletes to test positive for THC even though they claimed not
to have used marijuana for several months.
What symptoms or side effects does marijuana use produce?
Hallucinogens
Chemicals that cause an altered, dream-like state of consciousness.
Referred to as psychedelics - they have no medical use and are considered Schedule
1 drugs.
LSD
Differentiate between halucinogens such as LSD and other addictive drugs.
One unusual and disturbing side effect of LSD is that the user can experience the
effects of the drug again, weeks, months or even years after it was initially taken. This is
a drug that can really come back to haunt you.
Other hallucinogens include: mescaline,ecstasy, MDMA,DOM, MDA,PCP (angel
dust),ketamine
CNS Stimulants
Increase the activity of the CNS.
Some are available by prescription, some are considered street drugs and others,
like caffeine, are often overlooked as substances of addiction.
Taken to produce a sense of exhiliration, improve mental and physical performance,
decrease appetite, stay awake, and get "high".
This includes amphetamines, methylphenidate, cocaine, and caffeine.
amphetamines
According to Adams (2010), CNS stimulants have effects similar to the neurotransmitter norepinephrine. Norephinephrine affects awareness and wakefulness by activating neurons in a part of the brain called the reticular formation" (p. 117).
What are the short and long term effects of these drugs?
What effects do these drugs have on the cardiovascular and respiratory systems?
methylphenidate (Ritalin)
methylphenidate or Ritalin has a calming effect on children as it stimulates the alertness center in the brain, allowing them to focus on the task at hand.
methylphenidate has the opposite effect on teens and adults and has the potential to be abused by those trying to achieve a "high"
methamphetamine
known as "crystal meth" or "ice" on the streets
cocaine
second most commonly used illicit drug in Canada describe the effects that cocaine has on the user.
caffeine
found in 63 different plant species consumed in foods and beverages such as coffee, tea, chocolate, soft drinks
increases the effectiveness of OTC pain relievers
Why is caffeine considered a CNS stimulant?
What are the physical effects of caffeine?
Nicotine
Describe the effects of nicotine on the body. What makes nicotine unique from other stimulant drugs?
How does nicotine affect other body systems?
Nurse's Role in Substances of Addiction
Describe the nurse's role in working with clients experiencing substance addiction.
Medications Used During End of Life Care - A Case StudyMr. Singh, 76 years old and 80 kgs has advanced lung cancer with metastases to the spine. He lives in the LTC facility where you work. He has recently decided not to undergo further treatment and he has opted for palliative care in the hopes of having a comfortable, peaceful death. The nurses have developed a comprehensive care plan addressing all facets of Mr. Singh's care. Part of this care plan is administering the medications ordered by his physician.
Mr. Singh has significant back pain which he currently rates as an 8 out of 10. Originally, his pain was managed with Tylenol 650 mg q4-6 h. As his pain progressed, he was given Tylenol #3 with codeine 2 tabs q4-6h. When his pain became severe his doctor ordered morphine 0.3 mg/kg q3-4h. The doctor has also discussed the possibility of prescribing a fentanyl patch 25 mcg/hr with an additional short-acting opioid for breakthrough pain.Because of the opioids he has been taking, Mr. Singh is experiencing constipation. He has not had a BM in 3 days. The doctor has left a standing order for sennosides 36 mg po at hs on day 3. If no BM by day 4, give milk of magnesia 60 ml po at suppertime. And, if no BM by day 5, give bisacodyl 1 supp rectally if rectal check indicates soft stool OR glycerin 1 supp rectally if rectal check indicates hard stool.When Mr. Singh was first started on morphine he experienced severe itching as well as nausea and vomiting. For the itching, he was prescribed hydroxyzine (Atarax) which also has antiemetic properties. When the Atarax was no longer effective to control the nausea and vomiting, he was given metoclopramide 1-2 mg/kg q2-4h prn.As Mr. Singh becomes closer to death he begins to experience "wet breathing." This gurgling like sound is caused by an accumulation of saliva and mucous in the throat. This type of breathing is usually an indication that death will likely occur within 24-48 hours. To ease his respirations and decrease his respiratory secretions, the physician decides to order an anticholinergic. He chooses atropine 0.4-0.8 mg SC q4h.Research the medications discussed in this case study. Include the following: name (trade and generic) classification
action/effect
use(s)
route
side effects
nursing responsibilities
How much morphine will Mr. Singh receive?Why does morphine cause constipation?Describe the assessments you need to do when your patient is receiving morphine?
What should you be alert to when caring for a patient on morphine?How much metoclopramide will he receive?What is the benefit of a fentanyl patch vs. oral morphine?