Fundamental Final
The nurse teaches a patient about bupropion [Wellbutrin]. Which statement by the patient indicates that more teaching is indicated?
"I had a serious head injury 3 years ago"
The nurse instructs a patient about taking orphenadrine [Norflex]. The nurse determines that teaching is successful if the patient makes which statement?
"I should avoid drinking alcohol while taking this medication"
A patient has been taking a medication for 2 months. Which statement, if made by the patient would indicate to the nurse that drug tolerance is occurring?
"The medication does not seem to be working as well" Tolerance is define as a decreased response occurring during the course of prolonged drug use
A patient with depression has been prescribed fluoxetine [Prozac]. Which statement made by the patient indicates an understanding of the medication teaching?
"it may take 3 to 4 weeks before my mood is elevated"
Antidepressant groups
*Tricyclic antidepressants (TCAs) *Selective serotonin reuptake inhibitors (SSRIs) *Serotonin/norepinephrine reuptake inhibitors (SNRIs) *Monoamine Oxidase Inhibitors (MAOIs) *Atypical antidepressants
Baclofen [Lioresal]
*acts in spinal cord *reduces spasticity associated with - multiple sclerosis, spinal cord injury, and cerebral palsy *does NOT cause muscle weakness *NO antidote for OVERDOSE *gradual withdrawal over 1 to 2 weeks - abrupt withdrawal = risk for rhabdomyolysis
Valproic acid [Depakene, Depakote, Depacon]
*all major seizure disorders *bipolar disorder *migraines *hepatotoxicity - fatal liver failure *highly teratogenic (especially when taken in the first trimester)
Venlafaxine [Effexor]
*blocks NE and Serotonin uptake *SERIOUS reactions if combined with MAOIs
Selegiline [Emasam]
*first transdermal treatment for depression *much lower risk of hypertensive crisis with transdermal route *avoid carbamazepine [Tegretol] and oxcarbazepine [Trileptal]
Suicide risk with antidepressants
*may increase suicidal tendencies during early treatment Patients should be observed closely for the following *suicidality *worsening mood *changes in behavior prescriptions should be written for the smallest number of doses consistent with good patient management
TCAs
*most common adverse effects: sedation, orthostatic hypotension, and anticholinergic effects *most dangerous effect: CARDIAC TOXICITY (gastric lavage, ingestion of activated charcoal, intravenous sodium bicarb to treat cardiac dysrhythmias caused by cardiodtoxicity" *usually single daily dose *requires individualization of dosage sympathomimetics anticholinergics CNS depressants
SSRI
*most commonly prescribed antidepressants *as effective as TCAs but do not cause hypotension, sedation, or anticholinergic effects *overdose does NOT cause cardiac toxicity
Fluoxetine [Prozac, Sarafem]
*most widely prescribed SSRI in the world *produce selective inhibition of serotonin reuptake *produce central nervous system excitation *SEROTONIN SYNDROME (begins 2 to 72 hours after treatment) *Withdrawal syndrome *Monoamine Oxidase Inhibitors (serotonin inhibitors) *TCAs and Lithium (can elevate levels of these drugs)
Phenytoin [Dilantin]
*partial and tonic-clonic seizures *selective inhibition of sodium channels *with or without food (CONSISTENCE = KEY) *Therapeutic level 10-20 mcg/mL Gingival hyperplasia: swelling, tenderness, and bleeding of gums *gingivectomy, folic acid (0.5 mg/day), good oral hygiene, dental flossing, gum massage
Carbamazepine [Tegretol]
*partial seizures and tonic-clonic seizures but NOT absence seizures *bipolar disorder *trigeminal and glossopharyngeal neuralgias (can reduce pain in these specific neuralgias, but is not generally effective as an analgesic, and is not indicated in other types of pain) *Hematologic effects - CBCs before treatment and periodically there after *birth defects - spina bifida (should be used only if the benefits outweigh the risks to the seizures) Advise patients to AVOID grapefruit juice
Treatment modalities
*pharmacotherapy *depression-specific psychotherapy *electroconvulsive therapy *Transcranial magnetic stimulation *vagus nerve stimulation *light therapy
Phenobarbital
*reduces seizures without causing sedation *epilepsy *sedation *induction of sleep *dependency - barbiturate *rickets and osteomalacia - vitamin D & K deficiency *drug withdrawal syndrome can occur
Bipolar disorder
*requires lifelong treatment *recurrent fluctuations in mood *episodes of mania and depression persists for months without treatment
MAOIs
*second- or third-choice antidepressants for most patients *as effective as TCAs and SSRIs but more hazardous *hypertensive crisis if patient eats food rich tyramine MAO-A MAO-B CNS stimulation orthostatic hypotension hypertensive crisis for tyramine (sodium nitroprusside, phentolamine, labetalol) ALL administered ORALLY
Antiepileptic drugs MOA
*suppression of sodium influx *suppression of calcium influx *promotion of potassium efflux *antagonism of glutamate *potentiation of gamma-aminobutyric acid (GABA)
Time course of response
*symtoms resolve slowly *initial response develop after 1-3 weeks *maximal responses may not be seen for 12 weeks *continue 4-6 months after symptoms resolve
Antiepileptic drug evaluation
AED trial period - needed to determine effectiveness. during this time there is no guarantee that seizures will be controlled *WARN patients not to participate in driving or other activities that could be hazardous Dosage adjustment - no drug should be considered ineffective until it has been tested in sufficiently high doses and for a reasonable time Seizure frequency chart MAINTENANCE = IMPORTANT *the chart should be kept by the patient or a family member and should contain a complete recored of ALL seizure events. This record will enable the prescriber to determine whether treatment has been effective
Dantrolene
Acts directly on skeletal muscle *antidote for malignant hyperthermia due to succinylcholine and general anesthetics *hepatic toxicity - MOST serious (administer in lowest effective dose and for the shortest time necessary)
The nurse prepares to administer dantrolene [Dantrium] to a patient. Before the administration of the drug, it is most important for the nurse to assess which laboratory value?
Aminotranserases - liver function tests to reduce the risk of liver damage, liver function tests should be performed at baseline and periodically thereafter
A patient is prescribed isocarboxazid [Marplan] for the treatment of depression. Which foods should the patient be taught to avoid?
Bananas, smoked fish, and cheese
The nurse is caring for a patient who is taking phenytoin [Dilantin]. Which medication, if ordered by the physician, should the nurse question?
Cimetidine [Tagamet]
Monoamine hypothesis of depression
Depression is caused by a functional insufficiency of monoamine neurotransmitters
A patient is prescribed doxepin [Sinequan] for the treatment of depression. Which over-the-counter medication should the nurse teach the patient to avoid?
Diphenhydramine [Benadryl]
BPD drug types
Mood stabilizers: lithium, divalproex sodium, and carbamazapine - these drugs are mainstay for BPD treatment Antipsychotics - given duding severe manic episodes to help control symptoms Antidepressants - given during depressive episodes
Seizure treatment options
Neurosurgery (best success rate) Vagal nerve stimulation (used most widely) Ketogenic diet Medication - HIGHLY INDIVIDUALIZED (must try several AEDs before a regimen that is both effective and well tolerated can be established)
Traditional AEDs
Phenytoin, fosphenytoin, carbamazepine, valproic acid, ethosuximate, phenobarbital, and primidone
BPD mood episodes
Pure manic episode (euphoric mania) Hypomanic episodes (hypomania) Major depressive episodes (depression) Mixed episode
SNRIs
Venlafaxine [Effexor] Duloxetine [Cymbalta]
Cyclobenzaprine
acts primarily in the brain stem and results in a reduction of tonic motor activity *relief of muscle spam and associated pain *usually first line drug *not for spasticity *CNS depression *Anticholinergic effects *cardiac rhythm disturbances *serotonin syndrome AVOID alcohol and other CNS depressants
Treatment for spasm
analgesics (acetaminophen & NSAIDs) centrally acting muscle relaxants *CYCLOBENZAPRINE - prototype *WARM compress NOT cold *whirlpool baths *physical therapy
Secondarily generalized seizure
begins as simple or complex partial seizures and then evolve into generalized tonic-clonic seizures. CONSCIOUSNESS IS LOST *persists 1-2 minutes
Complex partial seizure
characterized by impaired consciousness and lack of responsiveness *persists 45-90 seconds
status epilepticus
continuous series of tonic-clonic seizures that lasts 20 to 30 minutes
Bipolar treatment
drugs psychotherapy BPD should be treated with a combination of drugs and psychotherapy - drug therapy alone is NOT optimal
Febrile seizure
fever associated manifest as generalized tonic-clonic convulsions of short duration. NOT at high risk of developing epilepsy later in life *common among children ages 6 months to 5 years
Generalized seizure
focal seizure activity is conducted widely through both hemispheres *tonic-clonic *absence (petit mal) *atonic *myoclonic *status epilepticus
A patient is newly prescribed carbamazepine [Tegretol] for seizure control. It is most important for the nurse to teach the patient to avoid which food?
grapefruit juice
Seizure disorders
group of disorders characterized by excessive excitability of neurons in the central nervous system
Seizure: Generation
initiated by synchronous, high frequency discharge from a group of hyper excitable neurons called a FOCUS *seizure and convulsions are NOT synonymous seizure = all epileptic events convulsion = abnormal motor phenomena
Muscle spasm
involuntary contraction of muscle or muscle group *muscle spasm is often painful and reduces the ability to function
Absence (petit mal) seizure
loss of consciousness for brief time (10-30 seconds) mild symmetric motor activity or none at all *occur primarily in children and usually cease during early teen years
Simple partial seizure
manifest with discrete symptoms that are determined by the brain region involved. NO LOSS OF CONSCIOUSNESS *persists 20-60 seconds
Tonic-clonic seizure
manifests as major convulsions, characterized by a period of muscle rigiditiy followed by muscle jerks, urination, loud cry, impaired consciousness, CNS depression (postical state) *persists 90 seconds or less
Therapeutic considerations
monitor plasma drug levels promote patient adherence withdraw AED SLOW!! 6 weeks - months SUICIDE RISK - report behaviors immediately *topirimate and Lamotrigine
Spasticity
movement disorders of CNS origin
Status epilepticus seizure
persists 15-30 minutes or longer or a series of recurrent seizures during which the patient does no regain consciousness *several types
Antidepressants
primarily used to relieve symptoms of depression *depressed mood and loss of pleasure or interest in all or nearly all one's usual activities and past times *NOT indicated for uncomplicated bereavement (grief)
Antiepileptic drug treatment goal
reduce seizures to a level that allows the patient to live as normal a life as possible *treatment should eliminate seizures entirely, however this may not be possible without causing intolerable side effects
Partial (focal) seizure
seizure activity undergoes a very limited spread to adjacent cortical areas beyond the focus *simple partial *complex partial *secondarily generalized
Mixed seizures: Lennox-Gastaut Syndrome
severe form of epilepsy that usually develops during the preschool years *involves developmental delay and a mixture of partial and generalized seizures *seizures can be VERY difficult to manage
Atonic seizure
sudden loss of muscle tone, head drop (neck muscles) drop attack causing patient to suddenly collapse (limb and trunk muscles) *occur mainly in children
Myoclonic seizures
sudden muscle contraction that lasts for just 1 second. Seizure activity may be limited to one limb (focus myoclonus) or it may involve the entire body (massive myoclonus)
A patient with multiple sclerosis is prescribed baclofen [Lioresal]. Which assessment by the nurse indicates that the medication is exerting its desired effect?
suppression of spasticity suppress spasticity which consists of heightened muscle tone, spasm, and loss of dexterity
Depression
symptoms must be present most of the day, nearly every day for AT LEAST 2 weeks
A patient is prescribed phenytoin [Dilantin] for epileptic seizures. Which of the following is the priority for patient teaching?
teach the patient to avoid the abrupt cessation of treatment abrupt sensation could lead to life-threatening seizure or status epilepticus
A patient is prescribed Metaxalone [Skelaxin]. Which sign or symptom should the nurse teach the patient to report immediately to the healthcare provider?
yellow skin color indicated hepatotoxicity and possible liver failure