mobility/inflammation learning guide and self assessment questions
typical peak release: Anterior Pituitary releases ACTH
0600-0900
What is the typical time limit on the use of bisphosphonates in low-risk women and risk for long-term use?
3-5 years Femoral shaft fractures.
The nurse, caring for a client experiencing stress, knows that activation of the stress reaction will initially cause the release of what? ACTH oxytocin glucose aldosterone
ACTH Activation of the stress reaction through the sympathetic nervous system bypasses the usual diurnal rhythm and causes release of ACTH and secretion of the adrenocortical hormones—an important aspect of the stress ("fight-or-flight") response. Glucose will eventually be released to supply energy, but first ACTH and adrenocortical hormones must stimulate this response. Aldosterone can be released without ACTH stimulation when the blood surrounding the adrenal gland is high in potassium.
Describe why each of these circumstances may in a decrease in bone matrix and mass, from less calcium and phosphorus being deposited in the bone: a. Advancing age b. Menopause: c. Malnutrition: d. Lack of physical stress on the bones
Advancing age: endocrine system slowing down and stimulation to build bone decreases Menopause: loss of estrogen decreases calcium depositing Malnutrition: lack of vitamin C and protein essential for bone production Lack of physical stress on the bones (lack of weight-bearing): promotes calcium removal and osteoclast activity not stimulated
What are the 3 types of corticosteroids, and describe what androgens are/do
Androgens, glucocorticoids, mineralocortoids what do androgens do? growth and development of male sex organs and maintenance of 2ndary characteristics
Anticholinergics and contraindications
Anticholinergics are contraindicated in anyone who the "drying effects would be harmful, such as those with narrow-angle glaucoma, GI or GU obstruction and prostatic hypertrophy. Additionally, anticholinergics are contraindicated for those with myasthenia gravis, because it would be exacerbated by the blocking of acetylcholine receptor sites at neuromuscular synapses.
The nurse is explaining the therapeutic effects of levodopa to a client with Parkinson's disease. What characteristics of levodopa and dopamine should the nurse describe? Select all that apply. a) Dopamine reverts levodopa for metabolism. b) Levodopa crosses the blood-brain barrier. c) Levodopa is a precursor of dopamine. d) Levodopa is converted to dopamine. e) Levodopa stimulates the brain to synthesize dopamine.
B, C, D
Why should bisphosphonates not be used in the presence of hypocalcemia?
Because they lower calcium levels.
Group the adverse effects of dopaminergics based on the location of the dopamine receptors
CNS: Stimulation of dopamine receptors causes confusion, mental changes, blurred vision, ataxia. GI: Anorexia, N/V Heart: Dopamine stimulation would increase HR, chance for arrythmias, prolonged QT (apomorphine) Urinary: Renal disease impacts excretion so levels remain elevated
What are some signs/symptoms of adrenal insufficiency, such as in Addison's Disease, with surgical removal of the glands, or when steroids are discontinued after prolonged use?
Confusion, disoriented, HTN, arrythmia, hyperpigmentation, hair loss, blue-black oral mucosa, hypoNa, hyperK, hypoBG, lethargy, weakness, dehydration, poor response to stress and infection.
An older adult client was diagnosed with Parkinson's disease 2 years ago, and the client's symptoms have gradually worsened. What nursing diagnoses are likely to apply to this client? Select all that apply. a) Risk for autonomic dysreflexia related to CNS disruptions b) Disturbed thought processes related to low dopamine levels c) Impaired physical mobility related to extrapyramidal symptoms d) Self-care deficit: dressing/grooming related to ataxia e) Acute pain related to nociceptor stimulation
D. Parkinson's disease causes ataxia, which can impair physical mobility and create a self-care deficit. Thought processes are not normally affected, and the disease does not cause acute pain. Autonomic dysreflexia is related to spinal cord injury, not Parkinson's disease.
A client with advanced Parkinson's disease has undergone diagnostic testing and diagnostic imaging. What are the results most likely to reveal? Decreased enzyme dopa decarboxylase levels Bain infarcts Increased gamma-aminobutyric acid (GABA) Degeneration of dopamine-producing nerve cells
Degeneration of dopamine-producing nerve cells. Dopa decarboxylase levels are affected by the administration of carbidopa.
what is bradykinesia
Difficulty performing intentional movements and extreme slowness or sluggishness. "slow movement"
goal of drug therapy in parkinson
Drug therapy in treating Parkinson's disease is aimed at achieving a balance between the stimulating cholinergic effects and the inhibitory effects of dopamine in the basal ganglia. Type 1 drugs affect dopamine and are inhibitory. Type 2 drugs block cholinergic effects, preventing stimulation. When they say "inhibitory", they mean the drugs are inhibitory of the basal ganglia, which is what dopamine normally does. When they say Type 2 "block stimulation", that means that in PD there is too much cholinergic effects stimulating the basal ganglia, so the goal with these drugs is to block the cholinergic effects.
The adverse effects of anticholinergics are often referred to as 'drying effects'. What are the adverse effects?
Dry mouth, constipation, urinary retention, blurred vision, dilated pupils.
Why should corticosteroids be taken immediately upon awakening in the morning?
Due to ACTH, CRH domino effect. Adrenal cortex responds to ACTH which responds to CRH released in a diurnal rhythm. So ACTH is high in the morning around 6-9 and CRH is suppressed and cortisol is at peak. Corticosteroids mimic cortisol so you want them peaking in the morning and dropping throughout the day with normal day-shift folks.
Alendronate and risedronate are often dosed once per week. Looking at the pharmacokinetics, why can they be dosed so infrequently?
Duration of action is days to weeks and they are not metabolized.
What are the side effects of the anticholinergics that occur because of the blocking of the peripheral cholinergic receptors?
GI motility slows, dry mouth, constipation, urinary retention, blurred vision, dilated pupils.
Block the activities of the inflammatory and immune systems has what detrimental effects under periods of extreme or prolonged stress?
Healing blocked due to lack of protein production, infection can occur with depressed immune system and inflammation (fever, WBCs, etc) depressed.
What precautions need to be taken with children and topical steroids?
Implications for growth and development, due to large BSA, topical absorption can too large (related to weight).
The nurse is caring for a client diagnosed with Parkinson's disease who has been prescribed an anticholinergic drug. What factormost likely prompted the primary care provider to prescribe this drug? a) Levodopa has not caused a sufficient therapeutic response b) The client's disease has been deemed incurable c) The client has exhibited adverse effects of medications d) The client has developed psychological dependence on dopaminergics
Levodopa has not caused a sufficient therapeutic response. Although anticholinergics are not as effective as levodopa in the treatment of advancing cases of the disease, they may be useful as adjunctive therapies and for clients who no longer respond to levodopa.
interaction of carbidopa and levodopa
Levodopa is almost always given in conjunction with carbidopa or other adjunctive agents. These adjunctive agents diminish the metabolism of levodopa in the gastrointestinal (GI) tract and in peripheral tissues, thereby leading to higher levels crossing the blood-brain barrier. With less levodopa needed to get to a therapeutic level in the brain, lower doses of levodopa can be administered resulting in fewer adverse side effects.
1. What class of drugs must not be taken at the same time as dopaminergics, because of its effects on dopamine and other neurotransmitters?
MAOIs. Stop 14 days before. B6 decreases levodopa SJW, analgesics, meperidine with rasagiline=serious but not specific in text
What are some signs/symptoms an individual can have if they are exposed to too much corticosteroids, as in the case of Cushing disease or taking too much steroid medication?
Moon face, central obesity, HTN, protein breakdown, osteoporosis, hirsutism.
what is the goal of Parkinson therapy?
NO treatment for neuron degeneration but therapy aimed to restore balance between declining levels of dopamine and cholinergic neurons.
what is Parkinson
Parkinson's disease is a progressive neurologic disorder, where nerve cell bodies in a dopamine-rich area, the substantia-nigra (brain), begin to disintegrate. This results in a decrease in the number of impulses sent to the corpus striatum in the basal ganglia (area of brain for muscle tone).
Blocking the activities of the inflammatory and immune systems has what benefit during an acute crisis?
Preserves energy (hormones released during crisis do this, increase rate of protein breakdown) at the same time as increasing blood volume, release of glucose, slowing protein production.
Under what circumstances is aldosterone released without ACTH stimulation, and what does it do?
Released in hyperkalemia to make kidneys absorb sodium, causing K to be excreted.
The nurse is teaching a client newly diagnosed with Parkinson's disease about the appropriate use of levodopa-carbidopa. What should the nurse teach the client? a) Take the daily dose at bedtime to minimize sedative effects b) Use a moisturizing cream if a rash develops after beginning the medication c) Remain seated upright for 30 minutes after taking the medication, if possible d) Take the drug three times each day, at the times specified
Take the drug three times each day, at the times specified
What action do glucocorticoids have on protein and fat?
They increase the rate of protein breakdown and decrease the rate of protein formation. cause lipogenesis - fat to be stored for fuel.
Adrenal cortex releases cortisol
This is a good time for corticosteroids to be taken to mimic cortisol
The nurse is caring for an older adult client who has been diagnosed with Parkinson's disease and who will soon begin drug therapy. What nursing action will best promote safe and effective drug therapy? a) Reassurance that many of the client's symptoms may be normal age-related changes rather than pathologic changes b) Detailed education about the need for outpatient blood pressure monitoring c) Teaching the family to best match medication doses to the daily severity of the client's symptoms d) Thorough client and family teaching, supplemented with written materials
Thorough and individualized client education is necessary to ensure safe and effective treatment. There is not normally a need for frequent blood pressure monitoring for most clients, and drug doses are not changed to address short-term symptoms. The symptoms of Parkinson's disease are not attributable to normal age-related physiologic changes.
Many other types of drugs have anticholinergic properties, and must be used with caution in combination with anticholinergics. Name the 2 classes the books gives:
Tricyclic antidepressants and phenothiazines
True/False: Adrenocortical agents should be sued short-term to relieve inflammation during acute stages of illness, or for replacement therapy to maintain hormone levels when the adrenals do not properly function
True
True/False: Some steroids have both glucocorticoid and mineralcorticoid effects.
True (hydrocortisone, cortisone, prednisone)
Which is more effective for Parkinson's: drugs that increase the effects of dopamine at receptor sites, or anticholinergics?
Well, since the goal is to achieve balance between inhibitory (up dopamine) and stimulation (blocking), and Parkinson disease is a lack of dopamine, it would seem logical that inhibitory drugs are more effective.
Under what circumstances is the stress response activated (cellular injury or need for flight/fight) and will the body do so at a time when the hormones are typically low?
When stress response is activated, diurnal rhythm is bypassed and cortisol (adrenocortical hormones) released. Hormone level would depend on time of day that stress response occurred. Additionally, aldosterone is released in times unrelated to stress, in hyperkalemia.
What time of day, and under what conditions should alendronate be administered and what is risk in noncompliance?
When the patient is going to be active and upright for at least 30 minutes due to the risk of esophageal erosion; in the morning for dayshift folks. Esophageal erosion.
What are some signs of osteoporosis in inactive, elderly, postmenopausal women:
a. Wrist and hip fractures b. Shrinking (height) c. Spine curvature
Where are corticosteroids produced?
adrenal cortex
List 3 non-pharmacological ways that osteoporosis can be prevented, and circle the lease desirable method
aerobic walking, proper diet, HRT (least desirable)
why are Mineralocorticoids are contraindicated
also used with caution with HTN, HF, or cardiac disease because of increased BP.
Taking bisphosphonates on an empty stomach a full 30 minutes before food or other medications helps to reduce the risk of the following drug-drug interactions (4):
antacids, calcium products, iron, multiple vitamins.
drugs that stimulate SNS
benztropine, diphenhydramine (Benadryl), trihexyphenidyl
The nurse is caring for an African American client who received a kidney transplant and receives methylprednisolone for immunosuppression. What is the nurse's priority assessment specific to this client? Assessing: blood glucose cardiac rhythm RBC count cap refill time
blood glucose (risk of DM)
The nurse is providing discharge teaching for a client prescribed prednisone to be taken on alternate days. The client asks why he cannot just take half a pill every day. What rationale should the nurse describe? decrease adrenal suppression To eliminate adverse side effects To prevent steroid tolerance To prolong therapeutic effects
decrease adrenal suppression
A 10-year-old boy has been prescribed an antiparkinsonian drug due to changes in movement. Which treatment should the nurse expect as the first choice for this child?
diphenhydramine
T/F: Adrenocortical agents are used to cure inflammatory disorders
false
What are the most common adverse effects with bisphosphonates?
headaches, nausea, diarrhea
Aldosterone is a mineralocorticoid, and how does it work?
holds sodium, and with it water, in the body and causes the excretion of potassium by acting on the renal tubule. Aldosterone IS NO LONGER available for pharmacological use.
At what point are dopaminergic agents no longer effective?
if disease has progressed to the point that neurons no longer intact in substantia nigra
What action do glucocorticoids have on glucose?
increase production
drugs that increase dopamine
levodopa, rasagiline; (release) amantadine; (stimulate receptors) apomorphine, bromocriptine, pramipexole, ropinirole.
typical time of release Hypothalamus releases CRH
midnight
The nurse is teaching a new client with Parkinson's disease about levodopa (L-dopa). What should the nurse instruct the client to avoid using concurrently with L-dopa? Over-the-counter calcium carbonate tablets Topical corticosteroid ointments Multivitamin-mineral preparations Foods that are high in tyramines
multivitamins (due to B6)
Define bone resorption (use any reliable source):
osteoclasts break down tissue in bones and release the minerals (calcium) from bone tissue to blood.
Anticholinergics are helpful to minimize EPS symptoms that occur with some drugs, such as
phenothiazines, and antipsychotics.
what glucocorticoid is limited to oral
prednisone
The bisphosphonates act to
slow or block bone reabsorption by doing this, they help to lower serum calcium levels, but they do not inhibit normal bone formation and mineralization.
A 66-year-old client is on long-term oral glucocorticoid therapy to treat chronic obstructive pulmonary disease. When providing drug teaching, the nurse will inform this client that there is a particularly high risk for what? spontaneous fractures respiratory depression hyponatremia ineffective temperature regulation
spontaneous fractures
Anticholinergics are drugs that oppose
the effects of acetylcholine at receptor sites in the substantia nigra and the corpus striatum, thus helping to restore chemical balance in the area.
Adverse effects with mineralocorticoids are related to
the increased fluid volume seen with sodium and water retention and include: headache, edema, HTN, HF, arrythmia, hypokalemia, weakness.
hypokalemia is an adverse effect of mineralocorticoids because of
the loss of K+ at the cellular level in the kidneys?
A home health nurse is visiting an older adult client with Parkinson's disease. What should the nurse assess this man for related to common adverse effects? Increased dopamine activity Skin lesions Urinary retention Jaundice
urinary retention (due to increased SNS response)
A client is newly diagnosed with Parkinson's disease, and levodopa has been prescribed. What health education should the nurse provide? Identifying foods and supplements high in vitamin B6 The need for weekly laboratory blood work for the first 6 weeks Matching doses to the daily severity of symptoms The fact that adverse effects will subside when the body adjusts to the drug
vitamin B6. Vitamin B6 speeds the conversion of levodopa to dopamine before it can cross the blood-brain barrier. This leads to Parkinson's symptoms. (also education on orthostatic hypotension)
How do we prevent adrenal insufficiency secondary to prolonged steroid use?
wean slowly
