Download Ch. 14-Drugs Affecting the Nervous System

Drugs Affecting
The
Nervous System
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2 main divisions of the nervous system:
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Central Nervous System (CNS)
- brain and spinal cord
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Peripheral Nervous System (PNS)
- involves nerves throughout the entire body
Central Nervous System (CNS)
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Made up of brain and spinal cord
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3 main parts of brain:
 cerebrum
 cerebellum
 brainstem
Cerebrum
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largest part of brain
center of thought and intelligence
divided into 2 halves
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right hemisphere controls movement and activities on
bodies left side
Left hemisphere controls right side
outside of cerebrum is cerebral cortex
controls highest functions of brain
Cerebellum
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regulates and coordinates body movements
controls balance and smooth movements of
voluntary muscles
Brainstem
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connects cerebrum to spinal cord
contains: midbrain, pons, medulla
spinal cord lies within spinal column
conducts messages to and from brain
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Brain and spinal cord are covered/protected by 3
layers of connective tissue called meninges
 Dura mater (tough outer layer)
 Arachnoid (middle layer)
 Pia mater (inner layer)
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Arachnoid space: space between arachnoid and pia
mater. Filled with cerebrospinal fluid
Cerebrospinal fluid protects
the CNS, cushions shock
Nerves
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Nerves carry impulses and
messages to and from brain,
they connect spinal cord
Easily damaged
Take a long time to heal
Some have a myelin sheath, which is a
protective covering or insulation
Nerves with myelin sheath conduct impulses
faster
Peripheral Nervous System
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12 pairs of cranial nerves
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Conduct impulses between brain and the head, neck,
chest and abdomen
Conduct impulses for smell, vision, hearing, pain, touch,
temperature and pressure (5 senses)
Conduct impulses for voluntary and involuntary muscles
31 pairs of spinal nerves
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Carry impulses from skin, extremities and internal
structures not supplied by cranial nerves
Autonomic Nervous System (ANS)
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formed by some peripheral nerves
controls involuntary muscles and certain body
functions including:
-heartbeat
-blood pressure
-intestinal contractions
-glandular secretions
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these functions occur automatically
ANS consists of
- sympathetic nervous system
-parasympathetic nervous system
-these systems balance each other out
Drugs Affecting the Nervous System
(Delegation Guidelines)
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Some drugs affecting the nervous system are given
parenterally by subcutaneous, intramuscular or
intravenous injections
You do NOT give parenteral dose forms
Should a nurse delegate the administration to you
REFUSE the delegation, explain why
Do NOT ignore request, makes sure nurse knows
you cannot give the drug and why
Drugs affecting the ANS
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neuron: basic nerve cell of nervous system
each nerve is composed of a series of segments of
neurons
synapse: junction between one neuron and the next
neurotransmitter: chemical substances that cause
nerve signals or impulses
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neurotransmitter is released into synapse at the end of a
neuron
receptors on the next neuron in the chain or at the end of
nerve chain are activated
target organ is stimulated (ex: heart)
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neurotransmitters are either
-excitatory: stimulates the neuron
-inhibitory: slows down, interferes or reduces
chemical activity
a single neuron only releases one type of
neurotransmitter
neurotransmitter regulation with drugs is a way to
control diseases caused by an excess or deficiency of
neurotransmitters
ANS controls most tissue functions (except skeletal
muscle) including:
blood pressure
 GI secretion and motility
 urinary bladder function
 sweating
 body temp
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ANS maintains a constant internal environment, this is
homeostasis, the ANS also responds to emergencies
ANS has 2 major neurotransmitters:
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norepinephrine
acetylcholine
Adrenergic fibers: nerve endings that release norepinephrine
-drugs that cause effects like these adrenergic
neurotransmitters are called:
adrenergic
sympathomimetic
catecholamine drugs
-These drugs mimic action produced by stimulation of the
sympathetic nervous system.
-adrenergic blocking agents: inhibit adrenergic effects
ANS neurotransmitters cont….
cholinergic fibers: nerve endings that release acetylcholine
-drugs that cause effects like those produced by
acetylcholine neurotransmitters are called:
cholinergic
parasympathomimetic
-These drugs mimic action produced by stimulation of the
parasympathetic nervous system
- anti-cholinergic agents: drugs that block or inhibit
cholinergic activity
ANS neurotransmitters cont….
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most organs have both adrenergic and cholinergic fibers
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these fibers produce opposite responses
-
14-2 (p. 176-177) has the clinical uses of drugs affecting ANS
Drugs affecting the Nervous System:
Adrenergic Agents:
- 2 classes of adrenergic agents:
- catecholamines
- non-catecholamine
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Naturally occurring catecholamines:
- Norepinephrine: secreted from nerve terminals
- Epinephrine: secreted from medulla
- Dopamine: secreted at sites within brain, kidneys, GI
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Non-catecholamines are more selective for certain types of
receptors, do NOT act as fast and have a longer duration
Adrenergic Agents cont…
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ANS has 3 different types of receptors. When stimulated by chemicals of
certain shapes the receptors produce a certain action
Alpha-1 receptors: causes blood vessels to constrict
Alpha-2 receptors: prevent further release of norepinephrine
Beta-1 receptors: increase heart rate
Beta-2 receptors: relax smooth muscle in bronchi (broncho-dilation),
uterus and peripheral arterial blood vessels (vaso-dilation)
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Dopaminergic receptors:
in brain improve Parkinson's disease
symptoms, in the kidneys they increase urine output because of better
renal flow
Many drugs act on more than one type of adrenergic receptor, each agent
can only be used for a certain purpose without many adverse effects.
Excess doses may cause serious adverse effects
Assisting With the Nursing Process
Adrenergic Agents:
ASSESSMENT: measure heart rate and BP, also see “Assisting With the
Nursing Process” for respiratory tract diseases, broncho-dilators, and
decongestants (Ch. 24)
PLANNING: see table 14-1 (pg. 178) for “Dose Forms”
IMPLEMENTATION: see table 14-1 (pg. 178) for “Action” and “Clinical
Use”
EVALUATION: side effects are usually dose related,
report and record:
- palpitations, tachycardia, skin flushing, dizziness, tremors: tend to
resolve with continued therapy
- orthostatic hypotension: provide for safety
- dysrhythmias, chest pain, severe hypotension, hypertension, angina,
nausea, vomiting: report these side effects at once
Drugs affecting the Nervous System:
Alpha and Beta-Adrenergic Blocking Agents:
- these drugs plug the alpha or beta receptors,
this prevents other agents from stimulating the
receptors
- There are both selective and non-selective beta
blockers
- Non-selective beta blockers inhibit beta-1 and beta-2
receptors
- Selective beta-1 blocking agents act against the hearts
beta-1 receptors (cardio selective)
Alpha and Beta-Adrenergic Blocking Agents cont…..
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alpha receptor stimulants primary action is
vaso-constriction (blood vessels constrict)
therefore alpha blocking agents are used in persons
with diseases associated with vaso-constriction
alpha blockers cause vaso-dilation
beta blockers often used after MI (myocardial
infarction) to treat angina, dysrhythmias and
hyperthyroidism
beta blockers must be used with extreme caution in
those with respiratory disorders, they can produce
severe broncho-constriction
Assisting With the Nursing Process
Beta Blockers:
ASSESSMENT: measure heart rate and rhythm, BP, see “Assisting With
Nursing Process” for persons with hypertension (ch.19) anti-dysrhythmic
therapy (ch. 20)
PLANNING: see table 14-2 (p. 179) for “Oral Dose Forms”
IMPLEMENTATION: see table 14-2 (pg.179) for “Adult Dosage Range”.
Onset of action is fairly rapid, may take days/weeks for stabilization
EVALUATION: most adverse effects of beta blockers are dose related,
report and record:
- cardiovascular: bradycardia, peripheral vasoconstriction (purple, mottled
skin)
- respiratory: broncho-spasm, wheezing
- persons with diabetes: signs/symptoms of hypoglycemia: headache,
weakness, decreased coordination, general apprehension, sweating,
hunger, blurred or double vision
- persons with heart failure: increase in edema, dyspnea, bradycardia,
orthopnea
Drugs affecting the Nervous System:
Cholinergic Agents:
- cholinergic (parasympathomimetic) agents produce
effects similar to acetylcholine
- some cholinergic agents directly stimulate the
parasympathetic nervous system
- some inhibit acetylcholinesterase- the enzyme that
metabolizes acetylcholine when released by a
nerve ending, these agents are indirect-acting
cholinergic agents
Cholinergic Agents cont….
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Some cholinergic actions are:
- slow heart beat
- increased GI motility and secretions
- increased urinary bladder contractions with relaxation of
muscle sphincter
- increased secretions and contractility of bronchial smooth
muscle
- sweating
- miosis of the eye (reduces intra-ocular pressure)
- increased force of skeletal muscle contractions
- sometimes decreased blood pressure
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Cholinergic agents are used to diagnose and treat myasthenia
gravis
Assisting With the Nursing Process
Cholinergic Agents:
ASSESSMENT: measure heart rate and BP, see “Assisting With the
Nursing Process” for: Respiratory diseases (ch. 24), urinary
disorders (ch. 30), eye disorders (ch. 31)
PLANNING: see 14-3 (pg. 180) “Oral Dose Forms”
IMPLEMENTATION: see 14-3 (pg. 180) for “Clinical Use”
EVALUATION: cholinergic fibers are throughout the body, most
systems are affected by these drugs. All receptors do not respond to
the same dosage so adverse affects are not always seen, risk for
adverse affects increases with dosage
report and record:
- nausea, vomiting, diarrhea, abdominal cramping: dose
related symptoms
- dizziness, hypotension: persons BP and pulse are monitored
- broncho-spasm, wheezing, bradycardia: may need to withhold
dose until MD can eval
Drugs affecting the Nervous System:
Anti-Cholinergic Agents:
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also called cholinergic blocking or parasympatholytic agents
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block action of acetylcholine in PNS
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drugs occupy receptor sites at parasympathetic nerve
endings, by doing this they prevent action of acetylcholine,
parasympathetic response is reduced
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Anti-cholinergic effects:
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dilation of pupil with increased intra-ocular pressure (glaucoma)
dry, thick secretions of mouth, nose, throat, bronchi
decreased secretions/motility of GI tract
increased heart rate
decreased sweating
Anti-Cholinergic Agents cont…
-Anti-cholinergic effects:
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dilation of pupil with increased intra-ocular pressure
(glaucoma)
dry, thick secretions of mouth, nose, throat, bronchi
decreased secretions/motility of GI tract
increased heart rate
decreased sweating
-Anti-cholinergic agents are used to GI and eye disorders,
bradycardia, Parkinson’s disease and genito-urinary
disorders
-Used pre-operatively:
decrease respiratory secretions to prevent aspirations
• prevent vagal stimulation from skeletal muscle relaxants or
placement of an endo-tracheal tube
•
Assisting With the Nursing Process
Anti- Cholinergic Agents:
ASSESSMENT: measure heart rate/BP,
see “Assisting With the Nursing Process” for Drugs for Parkinson’s
(p.186), persons taking antihistamines (ch. 24), persons with eye disorders
(ch. 31)
PLANNING: see table 14-4 (p. 180) for “Oral Dose Forms”
IMPLEMENTATION: see table 14-4 (p. 180) for Clinical Use
EVALUATION: cholinergic fibers are throughout the body, most systems
are affected by these drugs. All receptors do not respond to the same
dosage so adverse affects are not always seen, risk for adverse affects
increases with dosage
report and record:
- blurred vision, constipation, urinary retention, dryness of mouth,
nose and throat: provide safety for blurred vision. Follow care
plan for constipation and urinary retention. If nurse allows
provide hard candy, ice chips or gum for dry mouth
- confusion, depression, nightmares, hallucinations: provide for safety
- orthostatic hypotension: provide for safety. Dizziness/weakness may
occur when drug is started. BP is monitored daily (supine and
standing)
-palpitations, dysrhythmias: tell nurse at once
Drugs affecting the Nervous System:
Barbiturates:
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barbiturates depress the CNS, respirations, BP and
temperature
 acts as a sedative or hypnotic
 some are used in anesthesia and to treat seizures
(ch.16)
 CNS depression can range from mild sedation to
deep coma and death. It depends on dose, route
administered, tolerance from previous use, CNS
excitability and person’s condition
 risk of addiction is high
barbiturates cont….
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rarely used for sleep or sedation
short-acting barbiturates (pentobarbital, secobarbital)
used for sedation before diagnostic procedures
long-acting barbiturate (phenobarbital) used as anticonvulsant (ch. 16)
Assisting With the Nursing Process
Barbiturates:
ASSESSMENT: measure pulse, respiration and BP, observe persons
level of alertness, ask person about pain/discomfort
PLANNING: see table 14-5 (pg. 182) for “Oral Dose Forms”
IMPLEMENTATION: see table 14-5 (pg. 182) for “Adult Oral
Dose”. Rapidly discontinuing the drug after long-term use of high
dosages may cause symptoms similar to alcohol withdrawal.
Withdrawal of drug should be gradual.
EVALUATION: can cause drowsiness, lethargy, headache, muscle
or joint pain and mental depression.
report and record the following:
- hangover, sedation, lethargy: person may also have coordination
issues
- excitement, restlessness, confusion: provide for safety, help calm
and orient the person to person, time and place
- allergic reactions: report hives, itching, rash, fever or inflammation
of mucous membranes at once. Do NOT give drug again until
the nurse gives approval
Drugs affecting the Nervous System:
Benzodiazepines:
-have actions similar to CNS depressants
-they act more selectively at specific sites
- agents should be used no more than 4 weeks
-variety of uses:
sedative-hypnotic * *most common use (mild sedation)
• muscle relaxant
• anti-anxiety
• anti-convulsant
• short term use to produces sleep
• pre-operative sedation)
•
Assisting With the Nursing Process
Benzodiazepines:
ASSESSMENT: measure vital signs, measure BP in sitting and
supine, ask person to rate their pain
PLANNING: see table 14-6 (pg. 183) for “Oral Dose Forms”
IMPLEMENTING: see table 14-6 for Adult Oral Dose, habitual
use of these drugs results In a physical and psychologic
dependence. Rapidly discontinuing the drug after long-term
use may cause symptoms similar to alcohol withdrawal
EVALUATION: report and record the following:
- confusion, agitation, hallucination, amnesia. All drugs in this
class can cause these symptoms. Older persons who have
taken high doses for a prolonged time are at risk
- anorexia, nausea, vomiting, jaundice abnormal liver
functions tests: may indicate liver toxicity
Drugs affecting the Nervous System:
Non-Barbiturate, Non-Benzodiazepine SedativeHypnotic Agents:
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these drugs depress the CNS
used to produce sleep
drugs in this class are used:
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produce mild sedation
short-term use to produce sleep
examples: Benadryl, Lunesta, Ambien
Assisting With the Nursing Process
Non-Barbiturate, Non-Benzodiazepine Sedative-Hypnotic
Agents:
ASSESSMENT: measure vital signs, BP (sitting and supine), ask person to rate
their pain
PLANNING: see table 14-7 (p. 185) for “Dose Forms”
IMPLEMENTATION: see table 14-7 (p. 185) for “Adult Oral Dose”
EVALUATION: general side effects include: drowsiness, lethargy, headache,
muscle or joint pain, mental depression. Dullness, moodiness and
coordination problems may occur.
report and record:
- hangover , sedation, lethargy: may complain of “morning hangover,” blurred
vision or dizziness on arising. Coordination problems: assist with walking
as needed
- restlessness, anxiety: usually mild
- excitement, restlessness, confusion: older persons or those in severe pain may
respond in ways opposite to sedation/sleep. provide for safety, help
calm/orient person to person, time or place
Drugs Used for Parkinson’s Disease
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slow, progressive disorder, no cure
area of brain that controls muscle movement is affected
persons over age of 50 at risk
signs and symptoms become worse over time, these include:
-tremors: start in one finger and spread to whole arm, may
have trembling in hands, arms, legs, jaw, face
-rigid, stiff muscles: in arms, legs, neck, trunk
-slow movements: person has slow, shuffling gait
-stooped posture and impaired balance: hard to walk and at
risk for falls
-mask-like expression: person cannot blink and smile, fixed
stare is common
other signs and symptoms develop over time (swallowing and
chewing problems, constipation, bladder problems, sleep trouble,
depression and emotional changes, memory loss, slow thinking,
slurred, monotone or soft speech)
Drugs Used for Parkinson’s Disease cont….
•
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symptoms are caused by a deficiency of dopamine
dopamine is an inhibitory neurotransmitter
with a dopamine deficiency there is an increase in
acetylcholine activity
no cure for Parkinson’s disease
goals of treatment:
-relieve signs/symptoms
-restore dopamine activity to as close to normal
as possible
lowest dosages possible are used, dosages increase as
the disease progresses
Drugs Used for Parkinson’s Disease cont….
Promoting Safety and Comfort
Drugs Used for Parkinson’s Disease:
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orthostatic hypotension is common with most drugs
used to treat Parkinson’s disease. Safety measures
are needed.
remind the person to rise slowly from a supine or
sitting position
have person sit or lie down if they feel faint
Drugs Used for Parkinson’s Disease cont…
Dopamine Agonists:
•
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•
agonists work on certain type of cells
produces a predictable response
the following dopamine agonists are used to treat Parkinson’s
Disease:
• amantadine hydrochloride (Symmetrel)
• bromocriptine mesylate (Parlodel)
• carbidopa, levodopa, (Sinemet and Parcopa)
• pergolide mesylate (Permax)
• pramipexole (Mirapex)
• ropinirole (Requip)
** pgs 187-189 list the above drugs and the duties that go with assisting
the nursing process**
Drugs Used for Parkinson’s Disease cont…
COMT Inhibitor:
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COMT= catechol O-methyltransferase
COMT is an enzyme that breaks down levodopa
an inhibitor is a drug that prevents/restricts a certain action
by preventing or restricting the breakdown of levodopa the
duration of levodopa is longer (levodopa replaces the
dopamine deficiency in the brain)
COMT inhibitor allows more dopamine to reach brain
COMT inhibitors used to treat Parkinson’s:
- entacapone (Comtan, Stalevo)
** pg. 189 lists the above drugs and the duties that go with assisting the
nursing process**
Drugs Used for Parkinson’s Disease cont…
Anti-Cholinergic Agents:
-with Parkinson’s disease there is a deficiency of dopamine, this
leaves an excess of acetylcholine
-anti-cholinergic agents are used to reduce the over stimulation
caused by excess amounts of acetylcholine
-anti-cholinergic agents used to reduce drooling and tremors
-more useful for persons with minor symptoms and not
cognitive impairment
-these agents have little effect on stiff/rigid muscles, slow
movement and stooped posture
Drugs Used for Parkinson’s Disease cont…
Assisting With the Nursing Process
Anti-Cholinergic drugs:
ASSESSMENT: measure vital signs, BP (sitting and supine), report persons urinary
and bowel eliminations. measure pulse and note if rhythm is regular or irregular,
observe persons level of alertness and orientation to person, time and place
PLANNING: see table 14-8 (pg.190) for “Dose Forms”
IMPLEMENTATION: see table 14-8 (pg.190) for “Adult Oral Dose” and “Maximum
Daily Dose”. Give drug with food or milk to prevent stomach irritation.
EVALUATION: report and record:
-constipation: give stool softeners if ordered, encourage fluid intake and
exercise
- urinary retention: record intake/output
- blurred vision: provide for safety if the person has blurred vision
- dryness of mouth/throat/nose: give hard candy, ice chips or gum if nurse allows
-confusion, depression, nightmares, hallucinations: provide for safety
-orthostatic hypotension: see providing safety/comfort…. pg 186
-palpitations, dysrhythmias: tell nurse at once, they should inform MD
Drugs Used for Parkinson’s Disease cont…
Other agents:
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selegiline (Eldepryl and Zelapar)
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reduce the destruction of dopamine in the brain, allows for more
dopamine activity
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as parkinsons progresses it is necessary to add other drugs
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selegiline along with carbidopa-levodopa improves memory and allows
to move faste
-
selegiline helps slow the development of symptoms and disease
progress
Drugs Used for Parkinson’s Disease cont…
Assisting With the Nursing Process
selegiline (Eldepryl and Zelapar):
ASSESSMENT: report GI symptoms, measure BP (supine/sitting),
observe persons level of alertness and orientation to person, time and
place
PLANNING: oral dose forms: Eldepryl: 5mg capsules, and Zelapar: 1.25mg
ODT
IMPLEMENTATION: dosage is adjusted to persons response and
tolerance. Make sure to read how to dispense Zelapar, the tab should not
be pushed through foil, used gloves, let dissolve on persons tongue.
EVALUATION: report and record:
- chorea, confusion and hallucinations: provide for safety
- orthostatic hypotension: provide for safety (see info pg. 186)
Drugs Used for Alzheimer’s Disease (AD):
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AD is a brain disease
nerve cells that control intellectual and social function are
damaged
memory, thinking, reasoning, judgment, language, behavior,
mood and personality are affected
person will have problems with work and everyday functions
problems with family and social relationships
steady decline in memory and mental function
gradual onset
usually occurs after age of 60, risk increases with age
nearly half of persons 85 and older have AD
classic sign: gradual loss of short-term memory (starts as
forgetfulness)
disease ends in death
Drugs Used for Alzheimer’s Disease (AD) cont…
7 Stages of AD:
-no impairment: no signs
-very mild cognitive decline: person thinks they have memory lapses,
problems not apparent to friends/family/health team
-mild cognitive decline: family, friends, others notice problems.
functioning in social/work settings declines
-moderate cognitive decline: memory of recent or current events
declines. person may withdraw in social situations
-moderately severe decline: major memory problems, confusion about
day or date, trouble choosing clothes to wear, knows close family and their
own names, help is NOT needed with eating or elimination
-severe cognitive decline: personality and behavior changes develop,
person needs much help with daily activities including elimination, names
forgotten but may recognize faces, sleep and incontinence problems,
wandering is common
-very severe decline: person cannot respond to their environment,
speak or control movement. Muscles become rigid, swallowing is
impaired
Drugs Used for Alzheimer’s Disease (AD) cont…
donepezil (Aricept):
with AD there is a loss of cholinergic neurons which results in
memory loss an dementia
Aricept inhibits acetylcholinesterase (the enzyme that
metabolizes acetylcholine when released by a nerve
ending)
the drug enhances cholinergic function, effects lessen as more
neurons are lost
used in mild-moderate dementia
goals of therapy are to improve cognitive skills:
-
word recall, naming objects, language, word finding, ability to do tasks
Drugs Used for Alzheimer’s Disease (AD) cont…
Assisting With the Nursing Process
for Aricept:
ASSESSMENT: measure vital signs, observe cognitive functions, observe
for GI symptoms
PLANNING: oral dose forms: 5 and 10 mg tabs as well as 5 and 10mg
orally disintegrating tabs
IMPLEMENTATION: initial dose: 5mg at bedtime, after 4-6 weeks
dosage may be increased to 10mg. Drug can be given with or without
food
EVALUATION: report and record:
-nausea, vomiting, indigestion, diarrhea. symptoms less with lower doses,
tend to subside after a few weeks
-bradycardia: tell nurse at once if persons pulse is less than 60 beats/min
Drugs Used for Alzheimer’s Disease (AD) cont…
memantine (Namenda):
- blocks a receptor in CNS that is activated in AD
- drug can be used alone or with others
- treats moderate-severe AD
-cognitive function and behaviors are improved
Assisting With the Nursing Process
for Namenda:
ASSESSMENT: measure vital signs, observe cognitive functions
PLANNING: oral dose forms: 5 and 10 mg tabs
IMPLEMENTATION: initial dose: 5mg once/day, can be increased
by 5mg every 7days to 10/15/20mg daily
EVALUATION: report and record:
-headache, dizziness, insomnia, restlessness, increased motor
activity, excitement, agitation. Tend to decline with continued
therapy
Drugs Used for Alzheimer’s Disease (AD) cont…
galantamine (Razadyne):
- prevents breakdown of acetylcholine
- used to treat mild-moderate symptoms of AD
Assisting With the Nursing Process
for Razadyne:
ASSESSMENT: measure vital signs and weight, observe
cognitive functions
PLANNING: oral dose forms: 4, 8, 12mg tablets and 16, 24mg
extended release capsules
IMPLEMENTATION: initial dose: 4mg 2x/daily, after 4 weeks
dose increased to 8mg 2x/day, after another 4 weeks dose
increased to 12mg 2x/day. Drug given with food.
EVALUATION: report and record:
-nausea, vomiting, diarrhea, weight loss
Drugs Used for Alzheimer’s Disease (AD) cont…
rivastigmine (Exelon):
- prevents breakdown of acetylcholine
- used to treat mild-moderate AD symptoms
Assisting With the Nursing Process
for Exelon:
ASSESSMENT: measure vital signs and weight, observe cognitive
functions and for muscle weakness
PLANNING: oral dose forms: 1.5, 3, 4.5, 6mg capsules
transdermal patch: 4.6mg/24 hours or 9.5mg/24 hours
IMPLEMENTATION: initial dose is for 4 weeks:
oral: 1.5mg 2x/day with food
patch: 4.6mg once/day (after 4 weeks 9.5mg patch once/day)
after 4 weeks oral dose is increased by 1.5mg 2x/day every 2
weeks. Usual maintenance dose is 3-6mg 2x/day
EVALUATION: report and record:
-nausea, vomiting, weight loss, GI upset, muscle weakness