Chapter 13 - Central Nervous System Stimulants and Related Drugs

Preparation for the NCLEX® Examination Questions - Chapter 13 2. A child is prescribed methylphenidate (Ritalin) to treat attention deficit hyperactivity disorder (ADHD). The parent expresses concern about using a controlled substance to treat ADHD and asks the nurse about using a noncontrolled substance. The nurse knows ADHD can be treated with which noncontrolled substance? a. Methylphenidate (Concerta) b. Atomoxetine (Strattera) c. Amphetamine aspartate (Adderall) d. Dextroamphetamine sulfate (Dexedrine)

b Atomoxetine (Strattera) Atomoxetine (Strattera) is not a controlled substance because it lacks drug addictive (psychological dependence) properties, unlike amphetamines and phenidates.

The nurse is teaching a patient how to self-administer triptan injections for migraine headaches. Which statement by the patient indicates that he needs further teaching?

"I will take this medication regularly to prevent a migraine headache from occurring."

CNS stimulant adverse effects

"speed up" body systems: palpitations, tachycardia, hypertension, angina, dysrhythmias, insomnia, and increased urinary frequency

Medications for prophylactic treatment of migraines

- Beta blockers (propanolol) - tricyclic antidepressants - anticonvulsants (divalproex, lamotrigin, gabapentin) - Estrogen therapy if HA associated with menstrual cycle

Uses of Amphetamines

Narcolepsy ADHD (calming effect on 6-17 y/o) Appetite supressant

CNS stimulant categories

amphetamines xanthines sympathomimetics

Black box warning of amphetamines

drug of abuse due to euphoria and addictive properties (CII)

Cluster headache vs Tension headache (definition and treatment)

- Cluster: severe unilateral pain accompanied by lacrimation and nasal congestion. Tx: triptans, ergots, and oxygen via mask 12L/min - Tension: non-trobbing less localized, like a band. Tx: limit tension and caffeine. Responds well to MAPAP or NSAID

Selective Serotonin Receptor Agonist (-triptans)

- Drug of choice for migraine headache - Sumatriptan, rizatriptan - MOA: selective affinity for specific serotonin receptors in cerebral vessels leading to vasoconstriction. Also supressess CGRT and decreases vascular inflammation ADR: tingling of fingers, numbness, dizziness, aggravates ischemia in patients with CAD and possible teratongenic effects - should not be used with nicotine

Ergot Alkaloids

- Ergonovine, ergotamine, methysergide: cause prolonged vasoconstriction and uterine contraction. - Uses: Migraine and obstetrics. - ADR: Can cause physical dependence or ergotism (extensive peripheral vasoconstriction and ischemia of fingers and toes) - Black box:

Antimigraine Drugs (OTC and Rx)

- OTC: NSAIDs and caffeine - Rx: Serotonin receptor agonists (-triptans) vs Ergot alkaloids - Work by stimulating serotonin receptors in brain. Should be used cautiously in patients with severe cardiovascular disease (esp. angina).

The nurse is reviewing the use of central nervous system stimulants. Which of these are indications for this class of drugs? (Select all that apply.)

-Narcolepsy -Neonatal apnea -ADHD -Appetite suppression

A patient is receiving instructions regarding the use of caffeine. The nurse shares that caffeine should be used with caution if which of these conditions is present?

A history of peptic ulcers

What is narcolepsy?

A sleep disorder characterized by uncontrollable sleep attacks. The sufferer may lapse directly into REM sleep, often at inopportune times.

Before a patient receives triptans for the treatment of migraines, the nurse will assess for the presence of which condition, which is a contraindication if present?

CVD

Doxapram (Dopram)

Category: Analeptic IV drug Uses: in cases of respiratory depression that involve anesthetics or drugs of abuse and in COPD associated hypercapnia Monitor VS and heart rhythm

An ergot alkaloid is prescribed for a patient who is having frequent migraine headaches. The nurse provides information to the patient about the medication and tells the patient to contact the prescriber if which problem occurs?

Chest pain

Atomoxetine (Strattera) MOA, use and ADR

Class: selective norepinephrine reuptake inhibitor MOA: selectively inhibits re-uptake of NE Use: control child's impulsive behavior. (lacks addictive properties) ADR: GI upset and stimulation, and weight loss Black box: suicidal thinking and behavior in adolescent patients

Amphetamine drugs include

Dextroamphetamine methylphenidate (ritalin) dextroamphetamine/amphetamine combo (Adderall) Concerta

CRITICAL THINKING AND PRIORITIZATION QUESTIONS Ch.13 p.217 1. The parents of a 10-year-old boy are concerned about the effects of the medication their son is taking for ADHD. They ask, "What should we be looking for when he starts this medicine?" What is the nurse's best response?

During therapy for attention deficit hyperactivity disorder (ADHD), the following need to be monitored: • Nutritional status because these drugs often cause weight loss • Sleep patterns because these drugs may interfere with sleep • Behavior, attention span, and social interactions while at school and at home to determine whether this therapy is effective • Suicidal thoughts because they may occur with drug therapy for ADHD in adolescents. This child is 10 years old, but the concern ought to be mentioned.

Textbook Case Studies Lilley Ch.13 pg. 208 3. At the 2-month checkup, the physician suggests that N.'s mother hold the medication on weekends, giving the drug only during the weekdays while N. is at school. In addition, careful height and weight measurements are taken. What is the reason for this "drug holiday", as described by the physician? What is the purpose of the height and weight measurements?

During therapy, the patient will also be monitored for continued physical growth with specific attention to weight and height. For a school-aged child, the physician may order "medication-free" times on weekends, holidays, or vacations, meaning that the drug may be held periodically so that the need for the medication can be reassessed and sensitivity increased. In addition, these medication-free periods may help to diminish the addictive tendencies of the stimulant drugs.

CNS stimulants MOA

Either increase stimulatory neurotransmitters or decrease inhibitory neurotransmitters, with end result of CNS stimulation. With the most common action is release of NE and dopamine

A 10-year-old patient will be started on methylphenidate hydrochloride (Ritalin) therapy. The nurse will perform which essential baseline assessment before this drug is started?

Height and weight

MOA of amphetamines

Increase release of NE and dopamine

Textbook Case Studies Lilley Ch.13 pg. 208 2. After 3 weeks, N.'s mother calls the physician's office to say that N. has been doing better at school, as reported by her morning teacher, but the band teacher has reported that N. gets restless during after-school rehersals. N.'s mother also reports that N. seems unable to get to sleep at night and has been staying up too late. What should the nurse suggest?

Insomnia may be an adverse effect of drug therapy with methylphenidate. To help decrease the occurrence of insomnia, the last daily dose needs to be taken 4 to 6 hours before bedtime. However, dosing will be individualized and based on the patient's needs at different times during the school day (e.g., an afternoon dose for activities later in the afternoon). Scheduling of these medications and close communication between the school/teachers/school nurse with the family and patient is very important to successful treatment. It is also important to time the dosing of medications—but as ordered—for periods in which symptom control is most needed but without leading to alterations in sleep patterns. The use of once-a-day dosing with extended-release or long-acting preparations avoids the need for dosing during school hours.

Textbook Case Studies Lilley Ch.13 pg. 208 4. When it is time for a refil, N.'s mother calls the pharmacy. However, the pharmacist tells her, "I can't refill this medication by phone. You will need to bring in a new prescription." What is the reason for this?

Methylphenidate is classified as a Schedule II drug under the Controlled Substance Act. Therefore, a written prescription is needed for refills once the original prescription has expired.

What should a nurse monitor for a patient with ADHD/ADD taking CNS stimulant?

Monitor child's growth and weight Monitor sleep patters (insomnia Assess parental drug abuse history or potential

Where do migraine headaches originate from?

Neurovascular origin - Vasodilation - Inflammation of cerebral vessels - Thought to be an imbalance between calcitonin gene-related peptide (CGRP) [which promotes headache and inflammation] and serotonin [which suppresses headache]

CNS stimulant uses

Reverse anesthesia induced CNS and respiratory depression Narcolepsy ADD/ADHD Appetite suppression

A 22-year-old nursing student has been taking NoDoz (caffeine) tablets for the past few weeks to "make it through" the end of the semester and exam week. She is in the university clinic today because she is "exhausted." What nursing diagnosis may be appropriate for her?

Sleep deprivation

How is ADHD/ADD diagnosed?

Specific behavioral problems, present for several months, occuring before age 7. After adolescence age 17 needs to be reassessed for bipolar or OCD

A 6-year-old boy has been started on an extended-release form of methylphenidate hydrochloride (Ritalin) for the treatment of attention deficit hyperactivity disorder (ADHD). During a follow-up visit, his mother tells the nurse that she has been giving the medication at bedtime so that it will be "in his system" when he goes to school the next morning. What is the nurse's appropriate evaluation of the mother's actions?

The medication should be given 4 to 6 hours before bedtime to diminish insomnia.

CRITICAL THINKING AND PRIORITIZATION QUESTIONS Ch.13. p.217 2. A patient calls the headache clinic because she is unhappy about her medication. She says, "I've been taking zolmitriptan (Zomig) to prevent headache, but I am still having them." What is the nurse's priority action at this time?

The priority action is to educate the patient on the purpose of triptans for migraine therapy. These drugs are intended for the relief of migraine headaches, not their prevention. The term abortive therapy means that the medication treats the headache once it has started. It needs to be taken at the first sign (aura) of the headache and repeated as indicated in the instructions. The nurse can also help the patient assess whether she has addressed any possible precipitating factors, such as stress; hypoglycemia; menses; endogenous estrogen (including oral contraceptives); exercise; and intake of alcohol, caffeine, cocaine, nitroglycerin, aspartame, and the food additive MSG.

Textbook Case Studies Lilley Ch.13 pg. 208 N., a 13-year-old girl, has been diagnosed with attention deficit hyperactivity disorder. she is in the seventh grade at a local middle school and plays the clarinet in the school's after-school band. Her parents have noticed that she has had trouble focusing on assignments and music practice for the last year and have discussed her problems with N.'s pediatrician. The physician has prescribed methylphenidate (Ritalin) 5 mg twice a day for 2 weeks, and then increasing the dose to 10 mg twice a day if no improvement is noted. 1. What are the therapeutic effects of methylphenidate?

Therapeutic responses to drugs used in the management of attention deficit and related disorders include decreased hyperactivity, increased attention span and concentration, and improved behavior and/or academic achievement.

NCLEX EXAMINATION REVIEW QUESTIONS Lilley Ch.13 pg. 217 5. The nurse is reviewing the history of a patient who will be starting the triptan sumatriptan (Imitrex) as part of a treatment for migraine headaches. Which condition, if present, may be a contraindication to triptan therapy? a. Cardiovascular disease b. Chronic bronchitis c. History of renal calculi d. Diabetes mellitus type 2

a

Preparation for the NCLEX® Examination Questions - Chapter 13 8. A patient with narcolepsy is prescribed methylphenidate (Ritalin). Which adverse effects should the nurse include in the teaching of this drug? (Select all that apply.) a. Insomnia b. Headache c. Weight Loss d. Decreased blood pressure e. Increased appetite

a,b,c Insomnia, Headache, Weight Loss The adverse effects of methylphenidate on the cardiovascular system include increased heart rate and blood pressure. Other adverse effects include angina, anxiety, insomnia, headache, tremor, blurred vision, increased metabolic rate, GI distress, dry mouth, and worsening of or new onset of psychiatric disorders (including mania, psychoses, or aggression).

NCLEX EXAMINATION REVIEW QUESTIONS Lilley Ch.13 pg. 217 1. A patient with narcolepsy will begin treatment with a CNS stimulant. The nurse expects to see within adverse effect? a. Bradycardia b. Nervousness c. Mental clouding d. Drowsiness at night

b

NCLEX EXAMINATION REVIEW QUESTIONS Lilley Ch.13 pg. 217 4. A patient has a new prescription for sumatriptan (Imitrex). The nurse providing patient teaching on self-administration will include which information? a. Correct technique for intramuscular injections b. Take the medication before a headache worsens. c. Allow at least 30 minutes between injections d. Take no more than 4 doses in a 24-hour period

b

Preparation for the NCLEX® Examination Questions - Chapter 13 7. A nurse working with patients who are diagnosed with ADHD is aware that such patients often take CNS stimulant drugs. These medications are potent with a high potential for abuse and dependence. Based on this potential, how are these medications classified? a. Schedule IV b. Schedule II c. Schedule I d. Schedule III

b Schedule II CNS stimulants are the first-line drugs of choice for both ADHD and narcolepsy. They are potent drugs with a strong potential for tolerance and psychological dependence and are therefore classified as Schedule II drugs under the Controlled Substances Act.

CNS stimulant: Xanthine

methylxanthine = caffeine MOA: stimulates adenosine recepts causing: CV stimulation, bronchodilation, and diuresis Use: in preterm infants to reduce apneic periods. can cause abortion in pregnancy Contraindicated in those with peptic ulcers or cardiac dysrhythmias

Modafinial (Provigil)

CIV drug Use: helps improve wakefulness in patients with excessive daytime sleepiness associated with narcolepsy or shift work sleep disorder

NCLEX EXAMINATION REVIEW QUESTIONS Lilley Ch.13 pg. 217 7. The medication order reads: "atomoxetine (Strattera) 1.2 mg/kg/day inn 2 divided doses." The child weighs 66 lbs. How much will be given with each dose?

18 mg/dose

NCLEX EXAMINATION REVIEW QUESTIONS Lilley Ch.13 pg. 217 6. The nurse is reviewing medication therapy with the parents of an adolescent with ADHD. Which statement is correct? (Select all that apply.) a. "Be sure to have your child blow his nose before administering the nasal spray." b. "This medication is used only when symptoms of ADHD are severe." c. "The last dose should be taken 4 to 6 hours before bedtime to avoid interference with sleep." d. "Be sure to contact the physician right away if you notice the expression of suicidal thoughts." e. "We will need to check your child's height and weight periodically to monitor physical growth." f. "If adverse effects become severe, stop the medication for 3 to 4 days."

c,d,e

NCLEX EXAMINATION REVIEW QUESTIONS Lilley Ch.13 pg. 217 2. A patient at a weight management clinic who was given a prescription for orlistat (Xenical) calls the clinic hotline complaining of a "terrible side effect." The nurse suspects that the patient is referring to which problem? a. Nausea b. Sexual dysfunction c. Urinary incontinence d. Fecal incontinence

d

Preparation for the NCLEX® Examination Questions - Chapter 13 4. The nurse explains to a patient that using caffeine may exacerbate which health condition? a. Cardiac dysrhythmias b. Constipation c. Heart block d. Myelin degeneration

a Cardiac dysrhythmias Caffeine is a CNS stimulant. It should be used with caution in patients with a history of peptic ulcers, cardiac dysrhythmia, or recent myocardial infarction.

NCLEX EXAMINATION REVIEW QUESTIONS Lilley Ch.13 pg. 217 8. A patient with narcolepsy is having problems with excessive daytime sleepiness. The nurse expects which drug to be prescribed to improve the patient's wakefulness? a. Phentermine (Ionamin) b. almotriptan (Axert) c. Modafinil (Provigil) d. Methyphenidate (Ritalin)

c

Preparation for the NCLEX® Examination Questions - Chapter 13 3. A patient diagnosed with narcolepsy is prescribed a central nervous system (CNS) stimulant. Which statement best describes the action of CNS stimulants? a. CNS stimulants activate cyclic adenosine monophosphate. b. CNS stimulants block or reduce the activity of inhibitory neurons. c. CNS stimulants increase release of and block reuptake of neurotransmitters. d. CNS stimulants decrease the production of excitatory neurotransmitters.

c CNS stimulants increase release of and block reuptake of neurotransmitters. CNS stimulation occurs when the amount of neurotransmitters being released and the duration of action of excitatory neurotransmitters are increased.

Preparation for the NCLEX® Examination Questions - Chapter 13 6. Ergot alkaloids exert their therapeutic effect by which action? a. Simulation of the alpha receptors. b. Vasodilation. c. Vasoconstriction. d. Blockade of the beta2 receptors.

c Vasoconstriction Ergot alkaloids narrow or constrict blood vessels in the brain. They are useful in the treatment of migraine headache caused by vasodilation of vessels in the brain. Ergot alkaloids were the mainstay of treatment of migraine headaches but have been replaced by the triptans for first-line therapy.

NCLEX EXAMINATION REVIEW QUESTIONS Lilley Ch.13 pg. 217 3. The nurse is developing a plan of care for a patient receiving an anorexiant. Which nursing diagnosis is most appropriate? a. Deficient fluid volume b. Sleep deprivation c. Impaired memory d. Imbalanced nutrition, less than body requirements

d