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CLASSIFICATION MEDICATION ROUTE OF ADMINISTRATION INDICATIONS ACTIONS Cholinesterase inhibitor Antispasticity agent Cholinergic Antiarrhythmics--- anticonvulsants Edrophonium (Tensilon) Neostigmine (Prostigmin) Pyridostigmine (Mestinon) Baclofen (Lioresal) Dilantin (Phenytoin) IV PO,IM,SQ: Prostigmin PO, IM, IV: Mestinon PO PO, IV Diagnosis of myasthenia gravis. Assessment of adequacy of anticholinesterase therapy in myasthenia gravis. Differentiating myasthenic from cholinergic crisis. Reversal of non-depolarizing neuromuscular blocking agents. Symptomatic treatment of myasthenia gravis Relief of muscle spasticity, bowel and bladder function may also be improved. Treatment / prevention of tonic-clonic (grand mal) seizures and complex seizures. Unlabeled uses: Management of neuropathic pain, including trigeminal neuralgia. Inhibits enzyme cholinesterase, allows accumulation of acetylcholine at the myoneural junction, restoring normal transmission of nerve impulses. Improvement in muscle strength in symptomatic treatment of myasthenia gravis by inhibiting the breakdown of acetylcholine and prolongs the effect Inhibits reflexes at the spinal level. Limits seizure propagation by altering ion transport. May also decrease synaptic transmission. Cholinergic crisis, seizures, Miosis Increased intestinal and skeletal muscle tone, Bronchial and ureteral constriction, Bradycardia, Increased salivation, Lacrimation Sweating, Hypotension Abdominal cramps, diarrhea, vomiting, nausea Ataxia, Seizures, Dizziness, Drowsiness, Fatigue, Weakness, Confusion, Depression, Headache, Insomnia, Edema, Hypotension, Nausea, Constipation Pruritus, rash, Hyper-glycemia, Weight gain Hypersensitivity reactions. Ataxia, Agitation, Coma, Drowsiness, Headache, Nervousness, Weakness Hypotension, Nausea, anorexia, vomiting, Gingival hyperplasia Hypocalcemia, Back pain, pelvic pain, Rashes, Weight loss, Dry mouth Acts within 30-60 seconds and has an extremely short duration of action, seldom exceeding 10 minutes. SIDE EFFECTS Miosis, Increased intestinal and skeletal muscle tone, Bronchial constriction, Bradycardia (may lead to increased bradycardia in patients receiving digoxin) Increased salivation, Lacrimation, Sweating, Seizures, Dizziness, Abdominal cramps, diarrhea, dysphagia, Nausea, Vomiting Incontinence, Abdominal cramps, anorexia, anxiety, bronchiolar spasm, cardiac arrhythmias and arrest, convulsions, ptosis, respiratory arrest, urinary frequency and incontinence NURSING IMPLICATIONS A physician should be present when this drug is administered Assessment: monitor respiratory status, cardiac status and for other possible side effects listed above. Should not be given to patients with active asthma, bradycardia, hypotension Antidote: Atropine 0.4 to 0.5 mg IV A physician should be present when this drug is used IV. Oral and parenteral doses are not interchangeable. PO: Administer with food or milk to minimize side effects, administer 30 minutes prior to meals for patients who have difficulty swallowing Assessment: pulse, respiratory rate, B/P prior to administering, neuromuscular status, vital capacity, ptosis, diplopia, chewing, swallowing, hand grasp, gait prior to administering and at peak effect. Assess for overdosage and underdosage. Monitor for postoperative ileus and urinary retention. Watch BUN/Creatinine because dose may need adjusted with renal failure. Patient Teaching: Patient should be instructed to notify physician/ primary care provider of any weakness of the intercostals muscles, a decrease in diaphragmic movement, dyspnea, breathlessness Patient should be instructed to take medication as ordered; not to skip dose or double up on a missed dose Patients with dysphagia must take po medication on time; may not be able to swallow if not taken on time Instruct patient to report any muscle weakness that occurs 3 or more hours after medication administration, this is a major symptom of myasthenic crisis Instruct patient to report any difficulty with vision or swallowing Patients should be instructed to carry medical alert regarding condition PO: Administer with milk or food to minimize gastric irritation. For orally disintegrating tablets, just prior to administration place tablet on tongue with dry hands. Table will disintegrate, then swallow with water or saliva. Assess muscle spasticity before and periodically during therapy. Observe patient for drowsiness, dizziness, or ataxia. Patient / Family Teaching Instruct patient to take baclofen as directed. Take a missed dose within 1 hr; do not double doses. Caution patient to avoid abrupt withdrawal of this medication, may precipitate an acute withdrawal reaction (hallucinations, increased spasticity, seizures, mental changes, restlessness) Instruct patient to avoid driving until response to drug is known. Avoid concurrent use of alcohol or other CNS depressants Assess: Neuralgia: Assess pain, (locations, duration, intensity, precipitating factors) prior to and periodically throughout therapy. Serum phenytoin levels should be routinely monitored. Patient / Family Education: PO: Administer with or immediately after meals to minimize GI irritation. Shake liquid preparations well before pouring. Do not interchange chewable phenytoin tablets with phenytoin sodium capsules. May cause drowsiness or dizziness. Caution patient to avoid driving or other activities requiring alertness until response to medication is known. Advise patient to carry identification at all times Instruct patient on importance of maintaining good dental hygiene and seeing dentist frequently for teeth cleaning. Emphasize the importance of routine exams to monitor progress/ efficacy of drug Advise patient that brands of phenytoin may not be equivalent. Advise the patient that phenytoin may color urine pink, red, or reddish brown, but change of urine color is not significant. Advise patient not to take phenytoin within 2-3 hrs of antacids or antidiarrheals. Decrease in muscle spasticity and associated musculoskeletal pain with increased ability to perform activities of daily living Relief of pain due to neuralgia Antidote: Atropine 0.4 to 0.5 mg IV EXPECTED OUTCOMES Short-lived improvement in muscular function in patients with myasthenia gravis CLASSIFICATION Cholinesterase inhibitor Improved muscular function in patients with myasthenia gravis Cholinergic Antispasticity agent Antiarrhythmics--- anticonvulsants CLASSIFICATION MEDICATION NURSING IMPLICATIONS Cholinesterase inhibitor Cholinergic Antispasticity agent Antiarrhythmics--anticonvulsants Edrophonium (Tensilon) Neostigmine (Prostigmin) Pyridostigmine (Mestinon) Baclofen (Lioresal) Dilantin (Phenytoin) A physician should be present when this drug is administered A physician should be present when this drug is used IV. Oral and parenteral doses are not interchangeable. PO: Administer with food or milk to minimize side effects, administer 30 minutes prior to meals for patients who have difficulty swallowing Assessment: pulse, respiratory rate, B/P prior to administering, neuromuscular status, vital capacity, ptosis, diplopia, chewing, swallowing, hand grasp, gait prior to administering and at peak effect. Assess for overdosage and under-dosage. Monitor for postoperative ileus and urinary retention. Watch BUN/Creatinine because dose may need adjusted with renal failure. Patient Teaching: Patient should be instructed to notify physician/ primary care provider of any weakness of the intercostals muscles, a decrease in diaphragmic movement, dyspnea, breathlessness Patient should be instructed to take medication as ordered; not to skip dose or double up on a missed dose Patients with dysphagia must take po medication on time; may not be able to swallow if not taken on time Instruct patient to report any muscle weakness that occurs 3 or more hours after medication administration, this is a major symptom of myasthenic crisis Instruct patient to report any difficulty with vision or swallowing Patients should be instructed to carry medical alert regarding condition PO: Administer with milk or food to minimize gastric irritation. For orally disintegrating tablets, just prior to administration place tablet on tongue with dry hands. Table will disintegrate, then swallow with water or saliva. Assess muscle spasticity before and periodically during therapy. Observe patient for drowsiness, dizziness, or ataxia. Patient / Family Teaching Instruct patient to take baclofen as directed. Take a missed dose within 1 hr; do not double doses. Caution patient to avoid abrupt withdrawal of this medication, may precipitate an acute withdrawal reaction (hallucinations, increased spasticity, seizures, mental changes, restlessness) Instruct patient to avoid driving until response to drug is known. Avoid concurrent use of alcohol or other CNS depressants Assess: Neuralgia: Assess pain, (locations, duration, intensity, precipitating factors) prior to and periodically throughout therapy. Serum phenytoin levels should be routinely monitored. Patient / Family Education: PO: Administer with or immediately after meals to minimize GI irritation. Shake liquid preparations well before pouring. Do not interchange chewable phenytoin tablets with phenytoin sodium capsules. May cause drowsiness or dizziness. Caution patient to avoid driving or other activities requiring alertness until response to medication is known. Advise patient to carry identification at all times Instruct patient on importance of maintaining good dental hygiene and seeing dentist frequently for teeth cleaning. Emphasize the importance of routine exams to monitor progress/ efficacy of drug Advise patient that brands of phenytoin may not be equivalent. Advise the patient that phenytoin may color urine pink, red, or reddish brown, but change of urine color is not significant. Advise patient not to take phenytoin within 2-3 hrs of antacids or antidiarrheals. Decrease in muscle spasticity and associated musculoskeletal pain with increased ability to perform activities of daily living Relief of pain due to neuralgia Assessment: monitor respiratory status, cardiac status and for other possible side effects listed above. Should not be given to patients with active asthma, bradycardia, hypotension Antidote: Atropine 0.4 to 0.5 mg IV Antidote: Atropine 0.4 to 0.5 mg IV EXPECTED OUTCOMES Short-lived improvement in muscular function in patients with myasthenia gravis Improved muscular function in patients with myasthenia gravis CLASSIFICATION MEDICATION ROUTE OF ADMINISTRATION INDICATIONS ACTIONS SIDE EFFECTS NURSING IMPLICATIONS EXPECTED OUTCOMES Anticonvulsant Interferon Interferon Corticosteroids Carbamazepine (Tegretol) Interferon beta-1b (Betaseron) Interferon beta -1a Avonex, Rebif Prednisone PO SQ IM: AvonexSQ: Rebif PO, IV Decrease pain in trigeminal neuralgia; prevent seizures; decrease mania in Bipolar disorder Management of relapsing-remitting multiple sclerosis in ambulatory patients. Management of relapsing forms of multiple sclerosis in ambulatory patients. Autoimmune disorders; inflammatory conditions: used in exascerbations of Multiple Sclerosis Decreases synaptic transmission in the CNS by affecting sodium channels in neurons. Antiviral and immunoregulatory properties produced by interacting with specific receptor sites on cell surfaces may explain beneficial effects. Antiviral and immunoregulatory properties produced by interacting with specific receptor sites on cell surfaces may explain beneficial effects. Suppress inflammation & normal immune response Ataxia, Drowsiness, Fatigue, Psychosis, Sedation, Vertigo, Blurred vision, Pneumonitis, CHF, Hypertension, Hepatitis / Pancreatitis, Weight Gain, Urinary Retention / hesitancy, Photosensitivity, SIADH (syndrome of inappropriate antidiuretic hormone), Agranulocytosis, aplastic anemia, thrombocytopenia Depression and suicidal ideations, Seizures, headache, Weakness, Conjunctivitis, Constipation, diarrhea, dyspepsia, nausea, vomiting, Sweating Menstrual disorders, Neutropenia, myalgia, chills, fever, Flu-like symptoms, pain, Elevated liver enzymes Fluid retention, decrease Ca+ absorption and decrease K+, increase BP, depression, euphoria, decrease wound healing, increase glucose, mood swings, long term use may cause osteoporosis, skin fragility, hirsutism, acne Trigeminal Neuralgia Assessment: Facial pain (location, intensity, duration) Ask patient to identify stimuli that may precipitate facial pain (hot or cold foods, bedclothes, touching face, smoking, shaving, brushing teeth) Serum blood levels should be routinely monitored during therapy. Patient / Family Teaching: Instruct patient to take medication around the clock, as directed. Take missed doses as soon as possible but not just before next dose; do not double doses. Medication may cause dizziness or drowsiness. Advise patients to avoid driving or other activities requiring alertness until response to medication is known. Instruct patients that fever, sore throat, mouth ulcers, easy bruising, petechiae, unusual bleeding, abdominal pain, chills, rash, pale stools, dark urine, or jaundice should be reported to health care professional immediately. Caution patients to use sunscreen and protective clothing to prevent photosensitivity reactions. Advise female patients to use a nonhormonal form of contraception while taking this medication Relief of pain in trigeminal neuralgia. Prevention of seizures. Decreased mania in Bipolar I disorder Do not confuse products: Interferon beta – 1a and Interferon beta – 1b ARE NOT INTERCHANGEABLE. Assess frequency of exacerbations of symptoms of multiple sclerosis periodically during therapy. Monitor patient for signs of depression during therapy. Monitor hemoglobin, WBC, platelets, and blood chemistries, including liver function tests prior to and during therapy. Depression and suicidal ideations Seizures, headache, Sinusitis Upper respiratory tract infections Chest Pain, heart failure, Abdominal pain, nausea, dry mouth UTI, urinary continence, polyuria Alopecia, rash, Neutropenia, anemia, thrombocytopenia Injection-site reactions, Myalgia, arthralgia, back pain, muscle spasm Flu-like symptoms, Pain Do not confuse products: Interferon beta – 1a and Interferon beta – 1b ARE NOT INTERCHANGEABLE. Assess frequency of exacerbations of symptoms of multiple sclerosis periodically during therapy. Monitor patient for signs of depression during therapy. Monitor hemoglobin, WBC, platelets, and blood chemistries, including liver function tests prior to and during therapy. Patient / Family Teaching: Patient / Family Teaching: Instruct patient / family correct technique for drawing up medication, injecting meds. Instruct patient to take medication as directed, prescribed dose and time Flu-like symptoms may occur during therapy. Acetaminophen may be used for relief of fever and myalgias. Caution patients to use sunscreen/ photosensitivity reactions Drug may cause spontaneous abortion Instruct patient / family correct technique for drawing up medication, injecting meds. Instruct patient to take medication as directed, prescribed dose and time Flu-like symptoms may occur during therapy. Acetaminophen may be used for relief of fever and myalgias. Caution patients to use sunscreen/ photosensitivity reactions Drug may cause spontaneous abortion Reduce incidence of relapse and slow physical disability in patients with multiple sclerosis Reduce incidence of relapse and slow physical disability in patients with multiple sclerosis Monitor blood sugars. Monitor WBC and other signs of infection. Monitor I&O and daily weight. Teach patient to avoid abrupt discontinuation of medication (should taper) Assess for signs of Adrenal insufficiency. Assess for Cushingoid appearance in patient with long term use. Decrease symptoms of multiple sclerosis CLASSIFICATION MEDICATION ROUTE OF ADMINISTRATION INDICATIONS ACTIONS SIDE EFFECTS NURSING IMPLICATIONS Neurologic Dopamine agonist Anti-cholinergic COMT inhibitors Riluzole (Rilutek) Levodopa/carbidopa (Simemet, Sinemet CR, Parcopa) bromocriptine (Parlodel) ropinirole (Requip) pramipexole (Mirapex) Apomorphine (Apokyn injection) trihexyphenidyl (Artane) benztropine (Cogentin) Entacapone (Comtan) Tolcapone (Tasmar) Stalevo- (combination therapy of carbidopa/levodopa/entacapone) PO Treatment of amyotrophic lateral sclerosis PO, injection Parkinson’s motor symptoms PO Parkinson’s tremors PO Parkinson’s motor symptoms Actions may be related to: Works by stimulating the parts of the brain that receive dopamine therefore the brain thinks it is receiving it Inhibition of glutamate release Supposed to help prevent dyskinesias and motor Inactivation of sodium channels or Interference with neurotransmitter binding fluctuations and maybe neuroprotective at receptor sites Levodopa converts to dopamine by an enzyme in the brain where is serves as a neurotransmitter Carbidopa prevents peripheral destruction of levodopa therefor increasing the amount of levodopa to reach the brain Works by decreasing the activity of acetylcholine Blocks cholinergic activity in the CNS restoring the balance of neruotransmitters Blocks the breakdown of levodopa therefore allowing more to reach the brain. Dizziness, weakness, headache Decreased lung function Hypertension, peripheral edema Abdominal pain, anorexia, diarrhea, dyspepsia, flatulence nausea, vomiting, weight loss, Arthralgia, back pain, Circumoral paresthesia Use cautiously in patients with hepatic or renal impairment Use cautiously in female and Japanese patients due to decreased metabolism Hypotension, nausea, vomiting- levodopa/carbidopa Headache, somnolence, back pain, nausea, vomiting, edema and nightmares- Parlodel, Requip, Mirapex, Apokyn Blurred vision, dry mouth, urinary retention. Gastrointestinal upset, dizziness, drowsiness and occasional increasein dyskinesias, diarrhea Monitor hepatic, renal function and CBC. Monitor blood pressure and pulse during dosage adjustment. Assess parkinsonian symptoms. Educate patient to change position slowly if experiencing orthostatic hypotension. Avoid alcohol and other CNS depressants. Do not stop abruptly! (neuroleptic malignant syndrome) Use cautiously with glaucoma, tardive dyskinesia, cardiac arrhythmias, seizures, prostate enlargement. Assess for symptoms of Parkinsons. Monitor patient for development of diarrhea that usually occurs within 4-12 weeks of start of therapy. Monitor for signs similar neuroleptic malignant syndrome (Parkinson Crisis). Don’t stop medication abruptly; taper Patient / Family Teaching EXPECTED OUTCOMES Effects of drug may be decreased by cigarette smoke, rifampin, omeprazole Effects of drug may be decreased by charcoal-broiled foods, high-fat meals decrease absorption Take medication on an empty stomach 1 hr or 2 hr after meals. Effects may be increased by amitriptyline, caffeine, fluoroquinolones, theophylline Extended survival or time to tracheostomy in ALS patients. Monitor pulse, blood pressure, bowel function, urinary retention and worsening of psychiatric conditions. Decrease in motor symptoms of Parkinsons References Adams, M., Josephson, D., & Holland, L. (2005). Pharmacology for nurses: a pathophysiologic approach. Upper Saddle River: Pearson Prentice Hall. Deglin, J.H., & Vallerand, A. H. (2007). Davis’s drug guide for nurses (10th ed.).Philadelphia: F.A. Davis. Gahart, B., & Nazareno, A. (2007). 2007 intravenous medications (23rd ed.).St. Louis: Mosby Elsevier Decrease in tremors in Parkinsons Decrease in motor symptoms of Parkinson’s CLASSIFICATION MEDICATION ROUTE OF ADMINISTRATION Monoamine oxidase type-B Antiviral dopamine agonist Neurologic Amantadine (Symmetrel) Tetrabenazine (Xenazine) PO Treatment of Parkinson motor symptoms PO Treatment of Huntingtons blocks viral particle uncoating and nucleic acid release into host cell, inhibiting viral replication; exact mechanism in Parkinson dz unknown; potentiates CNS dopaminergic responses treats chorea, works to decrease the amount of dopamine available at synapses in the brain and thus decreases the involuntary movements Arthralgia, increases in systolic blood pressure, angina, depression, delirium, postural hypotension, confusion, nausea Monitor blood pressure, teach patient to avoid tyramin containing foods (alcohol, caffeine, OTC or herbal cough and cold medication) because of the possible increase in blood pressure and hypertensive crisis. Do not give with opioid analgesics, SSRIs or tricyclic antidepressants unless reviewed with doctor/pharmacist. Nausea, dizziness, insomnia, depression, anxiety, arrhythmias, CHF, seizures, diarrhea, constipation, peripheral edema, orthostatic hypotension Somnolence, fatigue, depression, nausea, decrease in appetite, ecchymosis, headache, dysphagia Monitor blood pressure and neurological status. Monitor I&O. monitor for edema. Patient teaching: Do not give with Flumist nasal influenza vaccine. Do not drive until you know how it will effect you with vision, thinking and dizziness. Do not stop abruptly! Monitor for symptoms of depression, behavior changes, blood pressure, orthostatic blood pressures Decrease in motor symptoms of Parkinsons Decrease in motor symptoms of Parkinsons Decrease in symptoms of Huntingtons Rasagiline (Azilect) Selegiline (Eldepryl, Carbex) Selegiline oral disintegrating tablet (Zelapar) PO Treatment of Parkinson motor symptoms INDICATIONS ACTIONS SIDE EFFECTS NURSING IMPLICATIONS EXPECTED OUTCOMES MAO-B is an enzyme found in the brain that has a major role in the metabolism of dopamine in the brain. Therefore if these medications can inhibit the enzyme it can help conserve the available dopamine in the early stage of PD and also allow lower does of carbidopa/levodopa in the late-stage PD