PHARM EXAM 3 - MODULE 10
Remember the normal parasympathetic responses we talked about with the cholinergic agonists? Remember that the parasympathetic nervous system is often referred to as "____ and ______".
"rest and digest". Now we are trying to block, or inhibit, those responses.
The family of a client diagnosed with Alzheimer's disease asks how the newly prescribed donepezil works. What is the best response by the nurse? A. "It prevents the breakdown of the neurotransmitter responsible for memory recall." B. "It stimulates the receptor sites in the brain responsible for memory recall." C. "By allowing more acetylcholine in the brain, this medication cures Alzheimer's disease." D. "It blocks the cholinergic receptor sites in the brain which allows for memory recall."
A. "It prevents the breakdown of the neurotransmitter responsible for memory recall." Donepezil is a cholinesterase inhibitor- it blocks the breakdown of acetylcholine in the central nervous system. By preventing the breakdown of the acetylcholine, it is thought to aid in memory recall. No medications currently available today can cure Alzheimer's disease.
A client is to have a major in-patient surgery and the nurse administered scopolamine transdermal patch behind the ear. The client asks, "What is that for? Why do I need a band aid behind my ear?" What is the best response by the nurse? A. "This medication is used to help dry up secretions to prevent aspiration during surgery." B. "The patch behind your ear will help decrease motion sickness on your ride home." C. "This medication helps with pain control after your surgery is completed." D. "The patch behind your ear will help prevent complications of glaucoma."
A. "This medication is used to help dry up secretions to prevent aspiration during surgery." Scopolamine is an anticholinergic medication used to prevent motion sickness, to dry up secretions during surgery to help prevent aspiration, and to help treat "death rattle" in hospice patients at end of life. Since the nurse is administering this medication pre-operatively, the reason is to prevent aspiration during surgery.
You are caring for a client post-operatively. The indwelling urinary catheter was removed in the post-anesthesia care unit per the surgeon's orders. The client is unable to urinate, and a bladder scan reveals 500 mL in in the bladder. What prescribed medication should you administer? A. Bethanechol B. Metoclopramide C. Atropine D. Tolterodine
A. Bethanechol When a patient has urinary retention post-operatively, one method of correcting this problem is to administer bethanechol. Bethanechol is a cholinergic medication used to stimulate the bladder contract, which will help with post-operative urinary retention. Tolterodine is an anticholinergic used to treat overactive bladder. Atropine is an anticholinergic medication and is known to cause urinary retention. Metoclopramide is a cholinergic medication that stimulated peristalsis in the gastrointestinal tract and is used for post-operative nausea and vomiting.
A client is prescribed an anticholinergic medication. What information in the past medical history would be of most concern to the nurse? A. Glaucoma B. Asthma C. Diabetes D. Bradycardia
A. Glaucoma Anticholinergics are blocking the responses of the parasympathetic nervous system. By blocking the response, the patient would have pupil dilation, increased heart rate, bronchodilation, urinary retention and constipation (to name a few). The most concerning thing in the patient's history is Glaucoma because of the risk of increased intraocular pressure which could cause blindness in narrow-angle or closed-angle glaucoma.
A client is prescribed a cholinergic medication. What assessment finding would be of most concern to the nurse? A. Heart rate of 50 beats per minute B. Urinary frequency C. Increased tear production D. Blood pressure 104/64
A. Heart rate of 50 beats per minute Cholinergic medications stimulate the parasympathetic nervous system response. Think "Rest and Digest". Remember that this will cause lowering of the heart rate and the blood pressure. While the blood pressure is a little low, it is not considered low enough to be the priority in this situation. A heart rate of 50 is low and the nurse should worry the patient may be going into a heart block, which is a serious adverse effect of cholinergic medications. While urinary frequency and increased tear production are adverse effects of cholinergic medications, they are not life-threatening.
A patient with myasthenia gravis is prescribed pyridostigmine. The nurse identifies that the medication is effective when the patient experiences? A. Increased muscle strength B. Decrease in sweating and salivation C. Changes in vital signs to within normal limits D. Decrease in generalized pain
A. Increased muscle strength. Ways to know it's working: Breathing deeply, better ability to swallow and chew their food, handgrips are stronger and equal, may be able to get up and walk to the bathroom. We can see that pyridostigmine is working by increased muscle strength. Some of the side effects of pyridostigmine are sweating and salivation because it's a cholinergic medication. So we will probably see some increase in sweating and salivation as a side effect. Pyridostigmine, being a cholinergic medication will probably cause some bradycardia and some orthostatic hypotension, so it will change the vital signs, probably will lower them below the normal limits. Pyridostigmine does not help with pain
What is the antidote used to treat anticholinergic toxicity? A. Physostigmine B. Edrophonium C. Atropine D. Pyridostigmine
A. Physostigmine Treatment normally is supportive care, for example hydration. The anticholinergic drug is stopped, and the body will return to normal with some time. If the patient has severe issues (hallucinations, coma, cardiac dysrhythmias) the patient may be administered physostigmine (a cholinergic drug). It is not routine to give this antidote because of the potential for severe side effects.
A client is prescribed carbidopa-levodopa and the nurse is providing education on this new medication. What information should the nurse provide to help prevent injury? A. Rise slowly, in stages B. Drink 3 liters of fluid each day C. Increase intake of foods high in protein D. Decrease intake of dietary fiber
A. Rise slowly, in stages Carbidopa-levodopa is known to cause syncope and orthostatic hypotension, which can result in the patient falling and causing harm. Rising in stages will help prevent orthostatic hypotension and falls. While increasing fluid is important to help prevent constipation, it will not help prevent injury. Increasing fiber intake would be important to help prevent constipation as well. High protein foods can decrease absorption of the carbidopa-levodopa.
A patient with myasthenia gracis is admitted to the emergency department with cholinergic crisis. Which medication should be administered per protocol? A. atropine sulfate B. baclofen C. edrophonium D. neostigmine
A. atropine sulfate Whenever a patient is experiencing cholinergic crisis the best treatment is an anticholinergic medication. The drug of choice, the anticholinergic of choice is atropine sulfate. The symptoms of myasthenia gravis is profound muscle weakness and in cholinergic crisis the patient is having some muscle weakness as well. Baclofen is a muscle relaxer, so if we administer baclofen it will make the muscle weakness worse and could exacerbate the cholinergic crisis. Edrophonium and neostigmine are cholinergic medications, if a patient is already diagnosed with cholinergic crisis, if we administer cholinergic medications it will only make the cholinergic crisis worse.
Indirect-acting Cholinergic Drugs: Donepezil and rivastigmine are cholinesterase inhibitors used to treat ___________ _______.
Alzheimer's disease. By allowing more acetylcholine in the CNS, it helps with memory recall. This does not cure Alzheimer's, however it does slow the progression of the disease.
Cholinergic drugs continued: Interactions Antagonistic effects: (3) Additive effects: (1)
Antagonistic effects: • anticholinergics (such as atropine) • antihistamines (because they have anticholinergic properties) • adrenergic agonists (epinephrine for example) Additive effects: • other cholinergic drugs
What is a common contraindication of cholinergic drugs? A. Increased salivation B. Asthma/COPD C. Myasthenia Gravis D. Glaucoma
B. Asthma/COPD Lungs: you have some bronchial constriction and increased secretions It would cause severe broncho constriction and increase secretion this would be bad for someone who has COPD and asthma.
What is the therapeutic effect of tolterodine? A. Increased heart rate B. Decreased frequency of urination C. Increased blood pressure D. Decreased bowel movement
B. Decreased frequency of urination Tolterodine is used to treat overactive bladder.
What is a way to prevent constipation related to anticholinergic effects? A. Decrease fiber intake B. Increase fluid intake C. Increase resting time D. Take a cholinergic drug
B. Increase fluid intake -We would want to increase fiber -Ambulation, exercise -Taking a cholinergic drug would help with constipation but would also make the anticholinergic drug not effect (they would cancel each other out)
A nurse has just administered atropine to a patient. It is most important for the nurse to assess the patient for the development of which effect? A. Nausea B. Tachycardia C. Rales D. Hypotension
B. Tachycardia We do know that it does raise the heartrate. Tachycardia is the most important thing to assess for. Atropine is used to treat bradycardia and if we are administering this to a patient we need to be looking at how it affects the cardiovascular system. If we are treating bradycardia most of the time the patients blood pressure will elevate. So the patient will not likely experience hypotension with atropine, if atropine is working effectively. Rales is fluid in the lungs, when you listen, you'll hear core sounds in the lung and this will be drying up secretion. Rales will probably not be happening with atropine because it dries up secretions that includes gastrointestinal secretions and that can actually help and be beneficial as treatment for nausea.
A client is receiving bethanechol, this is used to treat what condition? A. Glaucoma B. Urinary Retention C. Delayed Gastric emptying D. Gastroesophageal reflux disease
B. Urinary Retention Bethanechol is used for post-operative urinary retention, post partum urinary retention and urinary retention related to neurogenic atony of the bladder. Contraindications include: • bradycardia • hypotension • asthma • COPD • peptic ulcer • parkinsonism.
A patient received atropine as a preoperative medication 30 minutes ago. The nurse evaluates the medication as effective if the patient states, A. "I feel llike I need to throw up" B. "I need to urinate." C. "My mouth feels dry." D. "I have a headache."
C. "My mouth feels dry." It means that it's working to dry up oral and lung secretions to prevent aspiration during surgery Dry mouth, dry skin (dry as a bone)
What is the antidote used to treat cholinergic crisis? A. Physostigmine B. Tolterodine C. Atropine D. Diphenhydramine
C. Atropine Atropine is used for symptomatic bradycardia (the heart rate is slow, the patient is pale, diaphoretic, blood pressure low, perhaps they have passed out because their heart rate is so low); atropine can also be used preoperatively to decrease the secretions and decrease risk of aspiration in surgery.
What can happen if a patient has an active peptic (GI) ulcer and receives a cholinergic medication? A. The ulcer will heal more rapidly B. The patient will have increased constipation C. The ulcer may get worse and could start bleeding D. The patient will have increased urinary retention
C. The ulcer may get worse and could start bleeding We need to think about cholinergic medications and parasympathetic. A cholinergic medication stimulates the parasympathetic response. Remember that the parasympathetic nervous system is often referred to as "rest and digest". The gastric acid production will increase. If a patient has a GI ulcer and we increase the amount of gastric acid that is being produced that ulcer is probably going to get worse and it could start bleeding bc of increase gastric acid production
Cholinergic antagonists inhibit the parasympathetic nervous system response. An overview of the parasympathetic nervous system response is provided in the cholinergic drugs content. Cholinergic antagonists are commonly called anticholinergics. Remember the Poem:
Can't See, Can't Pee, Can't Spit, Can't Poop? We are now talking about the drugs that cause those side effects.
A client has been diagnosed with myasthenia gravis and is placed on pyridostigmine. Thirty minutes after taking the first dose of medication, the nurse suspects cholinergic crisis. What clinical manifestations would the nurse identify as being potential symptoms of cholinergic crisis? SELECT ALL THAT APPLY Confusion Miosis Diaphoresis Mydriasis Excessive salivation Lacrimation
Confusion ✓ Miosis ✓ Diaphoresis Mydriasis ✓ Excessive salivation ✓ Lacrimation When a patient is experiencing cholinergic crisis, the mnemonic to remember is "DUMBELLS": Diarrhea, urination, miosis (pupil constriction), bradycardia, emesis, lethargy, lacrimation, and salivation.
Anti-Parkinson's Drugs Dopamine receptor agonists: carbidopa/levodopa is the cornerstone of therapy for Parkinson's disease. Levodopa crosses the blood brain barrier and converts to dopamine. If given alone, the majority of the levodopa (around 90%) is broken down in the peripheral nervous system and only 10% will make it to the brain. Carbidopa decreases the amount of levodopa broken down in the peripheral nervous system, which will decrease the amount of levodopa required. High doses of levodopa can cause severe hypotension and cardiovascular collapse. Generally, within 5-10 years of starting levodopa therapy, the medication is no longer effective, and the person is debilitated. Contraindication: (2) Side effects: (8) Interactions: (2)
Contraindications: • angle-closure glaucoma • use in caution in open-angle glaucoma Side effects: • cardiac dysrhythmias • orthostatic hypotension • involuntary movements • dyskinesia • depression • nausea • vomiting • constipation Interactions: • pyridoxine (vitamin B6) • high protein in diet can slow or prevent absorption
Bethanechol Bethanechol is used for post-operative urinary retention, post partum urinary retention and urinary retention related to neurogenic atony of the bladder. Contraindications: (5) Side Effects: (11)
Contraindications: • bradycardia • hypotension • asthma, COPD • peptic ulcer • parkinsonism Side Effects: • blurred vision • miosis • hypotension • bradycardia • sweating • increased salivation and gastric acid • nausea • vomiting • diarrhea • abdominal cramps • bronchoconstriction
How long after eating protein should a patient wait to take their dose of carbidopa-levodopa? A. 15 minutes B. 2 hours C. 5 minutes D. 1 hour
D. 1 hour Lower protein diet, spread protein throughout the day. Avoid it around the meal that has protein. Do not take carbidopa-levodopa with a high protein meal as this delays absorption of the medication. Take either half an hour before or an hour after. Split protein across all meals of the day.
What condition is benztropine used to treat? A. Paralytic ileus B. Motion Sickness C. Urinary Retention D. Parkinsonism
D. Parkinsonism It blocks the effects of acetylcholine in the brain, as well as the rest of the body, which helps reduce the tremors and muscle rigidity associated with Parkinsonism. Remember side effects of anticholinergics? Dilated pupils (mydriasis), blurred vision, urinary retention, constipation, and dry mouth? Remember the toxic effects? Mad as a hatter, hot as hare, red as a beet, dry as a bone, blind as a bat and full as a flask. Also, remember that cholinergic drugs would have an antagonistic effect against the anticholinergic drugs, therefore, a cholinergic medication would be contraindicated in Parkinson's disease.
Nursing Process: Anticholinergic Drugs Diagnosis: (1) Planning: (3)
Diagnosis: Constipation related to adverse effects of anticholinergic drugs. Planning: Outcome Identification: • Heart rate will increase to 60-80 beats per minute after administration of atropine • Patient empties bladder every 3-5 hours (tolterodine) • The patient experiences less motion sickness while traveling (scopolamine).
Nursing Process: Anti-Parkinson's Drugs Diagnosis: (2) Planning: (1)
Diagnosis: • Urinary retention related to anticholinergic drug therapy and pathophysiologic changes related to Parkinson's disease • Constipation related to changes in GI peristalsis related to Parkinson's disease and anticholinergic effects of medications. Planning: • Patient has less muscle rigidity and tremors.
Nursing Process: Cholinergic Drugs Diagnosis: (2) Planning: (2)
Diagnosis: • Urinary retention related to surgical anesthesia administration (bethanechol) • Risk for falls related to weak muscles (pyridostigmine) Planning: • Patient will have increased bladder tone as evidenced by voiding of 250 mL or more every 3-5 hours. • Patient will have increased muscle tone as evidenced by respirations deep, unlabored at a rate of 12-20 breaths per minute.
Anticholinergic Drugs Examples: (6) Mechanism of action: (1)
Examples: • atropine • diphenhydramine • benztropine • tolterodine • ipratropium • scolpamine Mechanism of action: • block the neurotransmitter acetylcholine at the muscarinic receptors
True or False: COPD and Asthma are common contraindications to anticholinergic medications.
False. COPD and Asthma are common contraindications to cholinergic medications. Anticholinergic drugs would cause broncho dilation. Anticholinergic drugs are bad for glaucoma patients.
Indirect-acting Cholinergic Drugs: Donepezil; Pyridostigmine; Edrophonium (Tensilon test) Cholinesterase is an enzyme responsible for breaking down acetylcholine. Indirect -acting cholinergic drugs inhibit cholinesterase. Inhibiting cholinesterase stops the break down of acetylcholine, leading to more available acetylcholine. The drug itself is not stimulating the cholinergic receptors, it is just allowing for more acetylcholine to be available to stimulate the cholinergic receptors. Functions: (2) Desired therapeutic effect: (2) Contraindications: (2) Side effects: (5)
Functions: • break down cholinesterase enzyme into choline and acetic acid • allow Acetylcholine to active muscarinic and nicotinic cholinergic receptors Desired therapeutic effect: • stimulate skeletal muscles, increase tone • increased memory in Alzheimer's disease Contraindications: • intestinal and urinary obstruction • use caution in: patients with bradycardia, asthma, peptic ulcers Side effects: • greater GI motility • bradycardia • miosis • bronchial constriction • promote urination
If too much of a cholinergic drug caused the crisis, what kind of drug can fix the crisis?
How about the opposite type of drug, a cholinergic antagonist, or anticholinergic drug? In this case, the drug is atropine.
Anticholinergic Drugs Indications: (5) Contraindications: (2)
Indications: • Parkinson's disease • drug-induced extrapyramidal symptoms • symptomatic bradycardia • peptic ulcers • overactive bladder Contraindications: • glaucoma because dilated pupils increase the intraocular pressure and can cause blindness in patients with narrow-angle or closed-angle glaucoma • myasthenia gravis gravis is treated with cholinergic agonists, a cholinergic antagonists (anticholinergic) would cause the disease to be uncontrolled. This leads to muscle weakness, and if severe, it could paralyze the diaphragm, causing the patient to stop breathing.
What do you think is a contraindication of cholinergic drugs?
Look at what happens in the lungs. Think about disease that cause bronchoconstriction-Asthma/COPD. If we give those patients a cholinergic drug-it would cause severe bronchoconstriction and could cause their airway to close altogether. Look at cardiovascular effects. Which patients would you not want to take a cholinergic drug because of the cholinergic effects? Patient's with hypotension and bradycardia.
Nursing Process: Anti-Parkinson's Drugs Patient Teaching: (5) Evaluation: (1)
Patient education: • Teach the patient to rise slowly, in stages to prevent orthostatic hypotension (amantadine and carbidopa-levodopa) • Do not take carbidopa-levodopa with a high protein meal as this delays absorption of the medication. Take either half an hour before or an hour after. Split protein across all meals of the day. • Drink 3 L of fluid per day to help prevent constipation • Increase fiber intake to prevent constipation • With MAO-B inhibitors, may need to limit intake of tyramine foods (aged cheese, wine, beer, etc) Evaluation: • The patient is able to participate in activities of daily living (less tremors and rigidity).
Nursing Process: Anticholinergic Drugs Patient Teaching: (6) Evaluation: (1)
Patient teaching: • Avoid heat and physical exertion, remember that there is decrease perspiration. This decreases the ability to cool body temperatures. • Teach patient with MG and glaucoma to avoid atropine and atropine like drugs • Wear sunglasses (Have you ever had your pupil's dilated at the optometrist? They always provide sunglass afterwards because the sunlight will cause pain when you walk outside) The patient will have photophobia because of the pupil dilation. It will hurt their eyes. • Teach side effects • Teach about how to help with dry mouth: Ice chips, hard candy, sugarless gum, and frequent oral care. • Increase fluids, fiber and ambulation for constipation Evaluation: • It would depend on the anticholinergic drug we are administering: For example, decreased motion sickness after the administration of scopolamine. Make sure you know why the anticholinergic drugs would be administered, so that you can evaluate if the desired therapeutic response was achieved, or not.
Nursing Process: Cholinergic Drugs Patient teaching: (3) Evaluation: (2)
Patient teaching: • Teach to rise slowly in stages to prevent orthostatic hypotension • Report difficulty breathing • Report signs of GI bleeding-epigastric pain, coffee grounds emesis and dark tarry stools Evaluation: • Patient able to empty bladder • Patient able to breath deeply, walk, and chew and swallow food (Increased muscle strength).
Direct-Acting Cholinergic Drugs Selective to muscarinic receptors: Metoclopramide: Pilocarpine: Bethanechol chloride:
Selective to muscarinic receptors: • Located in smooth muscles- heart, GI, GU, glands Metoclopramide: • Increases gastric emptying Pilocarpine: • Constricts pupils Bethanechol chloride: • Contracts the bladder
Anti-Parkinson's Drugs Anticholinergic Drugs: Benztropine It blocks the effects of acetylcholine in the brain, as well as the rest of the body, which helps reduce the tremors and muscle rigidity associated with Parkinsonism. Side effects: (5) Antihistamines also have anticholinergic properties: (1)
Side effects: • dilated pupils (mydriasis) • blurred vision • urinary retention • constipation • dry mouth Remember the toxic effects? Mad as a hatter, hot as hare, red as a beet, dry as a bone, blind as a bat and full as a flask. Antihistamines also have anticholinergic properties: • diphenhydramine can be used to control symptoms
Anticholinergic Drugs Side effects: (10) Interactions: (2)
Side effects: • tachycardia • palpitations • nasal congestion • flushing • photophobia • blurred vision • dry mouth and skin • abdominal distention • urinary retention • impotence Anytime a drug has anticholinergic properties, we need to remember our poem. There is potential for pupil dilation (can't see), urinary retention (can't pee), dry mouth and skin (can't spit) and decreased GI motility that can lead to constipation (can't poop). Interactions: • additive effects with other anticholinergic • increased effects with digoxin
True or False: Carbidopa-levodopa is combined in order to ensure more dopamine makes it to the CNS.
True Carbidopa-levodopa is combined in order to ensure more dopamine makes it to the CNS. If given alone, the majority of the levodopa (around 90%) is broken down in the peripheral nervous system and only 10% will make it to the brain. Carbidopa decreases the amount of levodopa broken down in the peripheral nervous system, which will decrease the amount of levodopa required. High doses of levodopa can cause severe hypotension and cardiovascular collapse. Generally, within 5-10 years of starting levodopa therapy, the medication is no longer effective, and the person is debilitated.
True or False: Ropinerole can cause sleep attacks and drowsiness.
True Ropinerole can cause sleep attacks and drowsiness. What does a sleep attack mean? An attack happens suddenly; suddenly fall asleep. Ropinirole is a dopamine receptor agonists, meaning it causes direct stimulation of the presynaptic and/or postsynaptic dopamine receptors in the brain. It can be used at various stages of Parkinson's Disease and can also be used for treatment of Restless Leg Syndrome. Side effects include: • ataxia • dizziness • orthostatic hypotension • headache • drowsiness • depression • GI upset
True or False: Selegeline is a MAO-B inhibitor.
True Selegeline is a MAO-B inhibitor. Monoamine oxidase is an enzyme that breaks down dopamine, norepinephrine, and serotonin. By inhibiting the break down of dopamine, this allows for more dopamine to be available in the Central Nervous system, controlling some of the symptoms of Parkinson's Disease. They can be used alone, or in combination with levodopa. Note the food interactions. This is normally not a problem with selegiline, however, in doses greater than 10 mg/day, the patient would need to be careful with tyramine containing foods.
Cholinergic drugs stimulate the parasympathetic nervous system response. The main neurotransmitter is _____________ .
acetylcholine
When learning about the anti-Parkinson Drugs, it is important to understand the pathophysiology of Parkinson's Disease. The issue is that there is not enough ________ to inhibit the _____________.
dopamine; acetylcholine Therefore, in order to treat Parkinson's disease, we must either replace dopamine or inhibit acetylcholine
Anticholinergic Drugs Scopolamine:
is a small patch placed behind the ear. It can be used to treat severe motion sickness. It can also be used preoperative to help prevent aspiration of secretions during surgery. I have also seen it used in hospice because it dries up the secretions at the back of the throat, therefore, helping decrease "death rattle" , the sound that is made when a dying person is breathing through the secretions at the back of their throat that they cannot expectorate.
Anticholinergic Drugs Atropine:
is used for symptomatic bradycardia (the heart rate is slow, the patient is pale, diaphoretic, blood pressure low, perhaps they have passed out because their heart rate is so low); atropine can also be used preoperatively to decrease the secretions and decrease risk of aspiration in surgery.
Anticholinergic Drugs Benztropine:
is used to treat Parkinson's disease (decreases the tremors and rigidity), it can also be used to treat drug-induced EPS (Keep this in the back of your mind and we will talk more about that with the antipsychotic medications)
Anticholinergic Drugs Ipratropium:
is used to treat asthma and COPD. It is a bronchodilator that has slower onset of action and prolonged duration of action when compared to albuterol.
Anticholinergic Drugs Tolterodine:
is used to treat overactive bladder.
Indirect-acting Cholinergic Drugs: Pyridostigmine is a cholinesterase inhibitor that is used for treatment of ___________ ______.
myasthenia gravis. It helps simulates skeletal muscles and increase tone. This treats the profound weakness in myasthenia gravis patients. In order to diagnose myasthenia gravis, edrophonium is used (it is ultra short acting). A patient with myasthenia gravis normally presents with a drooping eye (ptosis).
Atropine Overdose: Treatment normally is:
supportive care, for example hydration. The anticholinergic drug is stopped, and the body will return to normal with some time. If the patient has severe issues (hallucinations, coma, cardiac dysrhythmias) the patient may be administered physostigmine (a cholinergic drug). It is not routine to give this antidote because of the potential for severe side effects.
Indirect-acting Cholinergic Drugs: Edrophonium (Tensilon test) The edrophonium is administered and...
the eye gets better (positive Tensilon test) which means the patient has myasthenia gravis. If the drooping doesn't get better (negative Tensilon test), this means the drooping eye is caused by something other than myasthenia gravis, which means they do not have myasthenia gravis.
Nursing Process: Cholinergic Drugs Assessment: (3)
• Baseline vitals- heart rate being low is contraindication, low blood pressure would be concerning. • Urine output • Obtain history: look for contraindications- asthma/COPD, peptic ulcer, Parkinson's disease, and urinary obstruction
Atropine Overdose: The symptoms of overdose can be seen in:
• Confusion (mad as a hatter) • Flushing of the skin (red as a beet) • Mildly elevated temperature (hot as a hare) • Dry mouth, dry skin (dry as a bone) • Pupil dilation, blurred vision (blind as a bat) • Urinary retention, so you can think "Full as a flask".
Signs of Cholinergic Crisis: Toxicity and Management of Overdose Overdose of cholinergic drugs is called cholinergic crisis. This can be life-threatening. So when you think about cholinergic crisis, I want you to think "DUMBELLS"
• Diarrhea (and Diaphoresis) and abdominal cramping. • Urination • Miosis (pinpoint pupils) • Bradycardia (muscarinic) or Tachycardia (nicotinic) • Emesis (nausea and vomiting) • Lacrimation • Legarthy • Salivation Early signs will be abdominal cramps, salivation, flushing of the skin, nausea and vomiting. As the crisis continues, the heart will slow and may even have a complete heart block (the atria and the ventricle are asynchronously beating); airway will become compromised and blood pressure will decrease (orthostatic hypotension especially).
Cholinergic agonists or Parasympathomimetic • Eye: • Lungs: • Cardiovascular: • GI: • GU: • Glands • CNS:
• Eye: Pupils will dilate (mydriasis) and have decreased accommodations, which leads to blurred vision (Can't see) • Lungs: bronchodilation and decreased secretions (useful in treating asthma/COPD) • Cardiovascular: large doses will increase the heart rate • GI: Relaxes smooth muscle tone, decrease motility and peristalsis, and cause decrease secretions. This can lead to constipation (Can't poop). Because of the decreased secretions, anticholinergics can be used to help treat gastric ulcers • GU: relaxes the detrusor muscle and increase the sphincter constriction, leading the urinary retention (Can't pee) • Glands: Decrease in saliva production. This leads to dry mouth (Can't spit). Decrease perspiration can lead to heat intolerance. The patient is at risk for heat stroke because perspiration helps with cooling the body temperature. • CNS: decreases tremors and rigidity, which makes this useful to treat Parkinson's disease.
Cholinergic agonists or Parasympathomimetic • Eye: • Lungs: • Cardiovascular: • GI: • GU: • Glands • Striated muscle:
• Eye: pupils will constrict, increase accommodation • Lungs: some bronchial constriction and increased secretions • Cardiovascular: the heart rate slows, blood pressure decreases because of decreased cardiac output and vasodilation • GI: increase tone and motility, increase peristalsis, relax sphincter muscles • GU: increase ureter tone, contract bladder (which allows for emptying of the bladder) and relax sphincter muscles • Glands: increase salivation, perspiration, and tears • Striated muscle: increase neuromuscular transmission, maintain muscle strength and tone
Nursing Process: Anti-Parkinson's Drugs Implementation: (2)
• Monitor blood pressure throughout therapy, especially looking at positional blood pressure changes • Selegiline can be administered oral or transdermal. If using a patch, clean the area of application, allow to dry, apply the patch and hold pressure for 30 seconds to help patch remain intact. Patch should be on patient for 24 hours. Only 1 selegiline patch should be on patient at a time. Rotate sites. Apply to torso, upper arm and upper thigh.
Nursing Process: Cholinergic Drugs Implementation: (6)
• Monitor vital signs, BP and pulse may decrease • Record I&O • Observe for side effects such as orthostatic hypotension, gastric pain, cramping, diarrhea, bradycardia, increased salivation • Assess lung sounds for rales, crackling sounds from fluid congestion • Have IV atropine available as antidote for cholinergic crisis • Monitor for cholinergic crisis (Overdose) DUMBELLS and muscle weakness.
Nursing Process: Anticholinergic Drugs Implementation: (6)
• Monitor vital signs, looking for tachycardia • Monitor I&O. Encourage to void prior to taking medication • Assess Bowel function- can cause decrease peristalsis leading to constipation and paralytic ileus. • Use a bed alarm because of the potential for confusion • Provide frequent oral care for dry mouth • Observe for signs and symptoms of anticholinergic toxicity
Nursing Process: Anticholinergic Drugs Assessment: (3)
• Obtain vitals: Especially looking at heart rate and blood pressure • Assess urine output as urinary retention may occur • Obtain medical history: narrow-angle glaucoma, myasthenia gravis (both are contraindications of the drug)
Anti-Parkinson's Drugs: Selegiline is a Monoamine Oxidase Type B Inhibitors. Food interactions:
• Tyramine containing foods (aged cheese, sausages, red wine, and beer) -results in severe hypotension This is normally not a problem with selegiline, however, in doses greater than 10 mg/day, the patient would need to be careful with tyramine containing foods. The food interaction is also known as the "cheese effect." Be sure to look at the list of foods high in tyramine in your Davis's Drug Guide for Nurses.
Nursing Process: Anti-Parkinson's Drugs Assessments should include: (4)
• Vital signs (blood pressure, heart rate); all the anti-Parkinson's Drugs cause orthostatic hypotension • Depression and suicidal ideation (this is a depressing disease with poor long-term prognosis and suicide can be a risk and many of the drugs increase the chance of depression) • Past medical history (glaucoma-contraindication for anticholinergic medications; hypertension-potential side effect with MAO-B inhibitors) • Current prescribed medications: look at each anti-Parkinson's Drug and know which drugs or foods interact with each one.
Anti-Parkinson's Drugs Dopamine receptor agonists: Ropinirole Is a dopamine receptor agonists, meaning it causes direct stimulation of the presynaptic and/or postsynaptic dopamine receptors in the brain. It can be used at various stages of Parkinson's Disease and can also be used for treatment of Restless Leg Syndrome. Side effects: (7)
• ataxia • dizziness • orthostatic hypotension • headache • drowsiness • depression • GI upset
A client was brought into the emergency department with symptomatic bradycardia and has received multiple doses of atropine. What clinical manifestations would the nurse identify as being potential symptoms of atropine toxicity? SELECT ALL THAT APPLY Confusion Flushing of the face and neck Diaphoresis Miosis Excessive salivation Urinary frequency
✓ Confusion ✓ Flushing of the face and neck Diaphoresis Miosis Excessive salivation Urinary frequency When a patient has symptoms of atropine toxicity, the clinical manifestations can be remembered by using the mnemonic "Mad as hatter, hot as a hair, red as a beet, dry as a bone, and blind as a bat." Confusion, flushed skin, dry skin and mouth, elevated temperature and blurred vision(related to pupil dilation) are the symptoms to look for. Miosis is pupil constriction, mydriasis is pupil dilation.
What is a symptom of atropine overdose? SATA o Flushing o Miosis o Delirium o Dry mouth
✓ Flushing ✓ Delirium ✓ Dry mouth The symptoms of overdose can be seen in this visual representation: • Confusion (mad as a hatter) • Flushing of the skin (red as a beet) • Mildly elevated temperature (hot as a hare) • Dry mouth, dry skin (dry as a bone) • Pupil dilation, blurred vision (blind as a bat) • While not on the picture, remember that anticholinergics cause urinary retention, so you can think "Full as a flask".
What symptoms does the nurse associate with cholinergic crisis? Select All That Apply o Heart rate of 58 o Drooling o Constipation o Skin hot to touch
✓ Heart rate of 58 ✓ Drooling We need to think about the parasympathetic system and overstimulating that parasympathetic system. "DUMBELLS" DUMBELLS: • Diarrhea (and Diaphoresis) and abdominal cramping. • Urination • Miosis (pupil contriction/pinpoint pupils) • Bradycardia (muscarinic) or Tachycardia (nicotinic) • Emesis (nausea and vomiting) • Lacrimation • Legarthy • Salivation
A client has been placed on high-dose therapy of selegiline. What foods should the nurse educate the client to avoid or limit while on this treatment regimen? SELECT ALL THAT APPLY Sharp cheddar cheese Summer sausage Red wine Hamburger and french fries Fish and chips
✓ Sharp cheddar cheese ✓ Summer sausage ✓ Red wine Hamburger and french fries Fish and chips MAO-B inhibitors are normally well tolerated and may not require the patient to avoid the tyramine- containing foods; however, in high doses, tyramine foods should be limited or avoided in order to prevent hypertensive crisis.
A client is prescribed scopolamine transdermal patch to help with motion sickness while on a cruise. What education should the nurse provide the client to alleviate the common side effects of the medication? SELECT ALL THAT APPLY Wear sunglasses when going outside Chew sugar free gum Increase fluid and fiber Urinary incontinence may occur, use caution Avoid exercise to avoid fatigue
✓ Wear sunglasses when going outside ✓ Chew sugar free gum ✓ Increase fluid and fiber Urinary incontinence may occur, use caution Avoid exercise to avoid fatigue Side adverse effects of anticholinergic medications are as follows: • pupil dilation - wear sunglasses to help prevent photophobia • Dry mouth- chew sugar free gum, suck on sugar free hard candy, suck on ice chips, perform frequent oral care- to help alleviate dry mouth • constipation-increase fluid, fiber, and ambulation to help prevent constipation • urinary retention- scheduled voiding will help prevent urinary retention
