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.&quot 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?