Clinical Pharmacology: Exam 4 Review (CNS, Analgesic, & Musculoskeletal)

Depression is most effective when treated with: A. Medications B. Psychotherapies C. Combination of the two therapies

C. Combination of the two therapies

What medications are used to treat ADHD?

CNS Stimulatants such as: •Methylphenidate (Methylin, Ritalin) •Amphetamine mixtures (Adderall)

Major element in neuron is __________________

Communication

A patient who has developed opioid tolerance will experience which effect?

Decreased analgesic effect

Symptoms of serotonin syndrome

Diaphoresis, agitation, tachycardia, autonomic instability, hypertension, diarrhea & hyperactive bowel sounds, mydriasis, hyperreflexia, clonus, tremor

What three major neurotransmitters in the body do psychiatric medications effect?

Dopamine, serotonin, and norepinephrine

What are the signs and symptoms of over sedation?

Drowsy, lethargy, respiratory rate <8 breath per minute, low blood pressure

Do anticonvulsants cure seizures?

No. They prevent seizures, but don't provide a cure.

_______ ___________ are prescribed for moderate and severe pain.

Opioid analgesics

What is neuroleptic malignant syndrome?

Potentially life-threatening adverse effect that includes high fever, unstable blood pressure, muscle rigidity, and myoglobinemia.

What serious pathological condition causes swelling of the liver and brain and is associated with the use of aspirin in children?

Reye's Syndrome

What medications cause serotonin syndrome?

SSRI's, SNRI's

____________ is a chemical your body produces that's needed for your nerve cells and brain to function.

Serotonin

____________ _______________ occurs when high levels of serotonin accumulate in the body.

Serotonin syndrome

What kind of medication is Cyclobenzaprine (Flexeril)?

Skeletal muscle relaxant

When it comes to disorders of the CNS system, does the nursing process rely on subjective or objective data?

Subjective

How does a patient controlled analgesia (PCA) device work?

To receive the opioid using a PCA device, the patient pushes a button, which releases a specific dose but also has a lockout mechanism to prevent an overdose.

True or false: Antiseizure drugs are classified as CNS depressants.

True

Examples of benzodiazepines include

lorazepam (Ativan), diazepam (Valium), Alprazolam(Xanax) Class: benzodiazepines (-pam,-lam) Pam takes lorazepam for her anxiety. She doesn't drive her benz anymore because benzos cause sedation.

tranylcypromine (Parnate), phenelzine (Nardil,) isocarboxazid (Marplan) Class: _________ ____________ _______________ (____)

monoamine oxidase inhibitors (MAOIs)

Lithium (Lithobid) Class: _____ ________, _______-_______

mood stabilizer, anti-mania

Severe serotonin syndrome can lead to _________ _____________ ________________.

neuroleptic malignant syndrome

Your brain communications with electrical impulses that signal a release of _________________, which then binds to the target cell.

neurotransmitter

When it comes to depression, there is no "____ ______ ______ ______" treatment.

one size fits all

What are some examples of anti-convulsants? (Used for seizures)

phenobarbital (Luminal) phenytoin (Dilantin) levetiracetam (Keppra) gabapentin (Neurontin) lorazepam (Ativan)

What are some examples of anticonvulsants?

phenobarbital (Luminal) phenytoin (Dilantin) levetiracetam (Keppra) gabapentin (Neurontin) lorazepam (Ativan)

An abnormal electrical signal in the brain being fired from neurons is called a ____________. (Can be general or focal)

seizure

paroxetine (Paxil), sertraline (Zoloft), fluoxentine (Prozac) class: __________ ___________ _________ _________

selective serotonin reuptake inhibitors (SSRI)

venlafaxine (Effexor), duloxetine (Cymbalta) Class: _________ __________ __________ ________ (____)

serotonin norepinephrine reuptake inhibitor (SNRI)

You would use _______ _________ to gather subjective data. An example would be, "Tell me more about how you are feeling today."

therapeutic communication

While taking lithium, it is important to maintain an adequate intake of sodium and fluids to counteract __________ ___________.

kidney damage.

What is the therapeutic serum range for lithium?

0.8-1.2mEq/L

What if you have a pediatric patient on a PCA pump?

Be sure to instruct parents not to active device when their child is sleeping. This can apply to an adult patient as well.

What disorder is: •marked by serious mood swings •patients experience extreme highs (called mania or hypomania alternating with extreme lows (depression) •People feel normal in the periods between the highs and lows •Cycles occur so rapidly that they hardly ever feel a sense of control over their mood swings

Bipolar

How long can it take for anxiety medications to be fully effective?

3-4 weeks

Lithium toxicity can occur at what level?

>1.5mEq/L

_____________ is characterized by hyperactivity, lack of impulse control, and/or lack of attention that interferes with how a person functions.

ADHD

Examples of non-opioid analgesics

Acetaminophen (Tylenol) Nonsteroidal Anti-inflammatory drugs (NSAIDS)

Signs and symptoms of anxiety

Aches, pain, stomach aches, headaches, heart racing or pounding, trembling, sweating, difficulty concentrating, increased agitation, crying, sleep problems

What effects/actions do NSAIDs have?

Analgesic, antipyretic, anti-inflammatory

Tricyclic antidepressants (TCAs) Selective serotonin reuptake inhibitors (SSRI) Serotonin norepinephrine reuptake inhibitors (SNRIs) Monoamine oxidase inhibitors (MAOIs) are all examples of:

Antidepressants

What additional effect does aspirin have?

Antiplatelet As a result of the inhibition of COX1 by an NSAID, there is decreased protection of the stomach lining and gastric irritation and bleeding may occur.

Disorders of the CNS system

Anxiety, depression, bipolar, schizophrenia, ADHD, seizures, Parkinson's

What does ADHD stand for?

Attention Deficit Hyperactive Disorder

What are two examples of medications called anti-psychotics that are used to treat schizophrenia?

Haloperidol (Haldol) Risperidone (Perseris)

Signs and symptoms of pain:

Increased HR Increased BP Increased RR

tardive dyskinesia

Involuntary contraction of the oral and facial muscles (such as tongue thrusting) and wavelike movements of the extremities.

Extrapyramidal Symptoms

Involuntary motor symptoms similar to those associated with Parkinson's disease. Includes symptoms such as akathisia (distressing motor restlessness) and acute dystonia (painful muscle spasms.) Often treated with anticholinergic medications such as benztropine and trihexyphenidyl

Morphine Class: analgesic opioid agonists

Uses: •Moderate to severe pain Mechanism of Action: •Morphine binds to opioid receptors in the CNS and alters the perception of and response to painful stimuli while producing generalized CNS depression Adverse/Side Effects •respiratory depression (primary risk), hypotension, light-headedness, dizziness, sedation, constipation, nausea, vomiting, and sweating •Black Box Warning: risk of serious adverse reactions, including slowed or difficulty breathing and death, have been reported with the combined effects of morphine with other CNS depressants. Teaching/Education: •Do not drink or drive while on this medication •Morphine is a scheduled II controlled substance, risk of misuse, abuse, & diversion. •Morphine is safe for all ages Antidote/Reversal •Naloxone

High risk for committing suicide if a patient:

can identify a concrete plan and has the means to carry out a plan. •May need to be hospitalized for closer monitoring (psychiatric hold 5150)

Higher levels of lithium toxicity signs and symptoms:

coarse tremors, confusion, hypotension, seizures, tinnitus

Early signs and symptoms of lithium toxicity:

diarrhea, vomiting, drowsiness, muscular weakness, and lack of coordination

Lithium is contraindicated with _______________.

diuretics

Severe hypertension with evidence of organ dysfunction is known as _____________ ___________.

hypertensive crisis

If a patient is taking lithium, serum sodium levels should be monitored for potential ____________________.

hyponatremia

Lithium and sodium have an ____________ relationship.

inverse (As lithium levels rise, sodium levels fall.)

Methylphenidate (Methylin, Ritalin) Adderall Class: stimulants

• •Uses: Methylphenidate is an example of a CNS stimulant that is often used to treat ADHD. CNS stimulants are Schedule II controlled substances and have a high potential for abuse and dependence. •Mode of Action •Methylphenidate stimulates the brain and acts similar to amphetamines. Methylphenidate is thought to block the reuptake of norepinephrine and dopamine into the presynaptic neuron •Adverse/Side Effects •Immediately report signs and symptoms of abuse, cardiac or peripheral vascular complications, and priapism •Report mania or psychotic episodes •Common side effects: headache, insomnia, upper abdominal pain, decreased appetite, and anorexia •Gynecomastia •Teaching/Education •Black Box Warning: High abuse potential •Patients should avoid alcohol •Monitor BP and HR; can increase BP •Monitor growth and weight in children; causes growth suppression •Monitor for signs of abuse •Contraindicated with MAOIs or use of an MAOI within the preceding 14 days

tranylcypromine (Parnate), phenelzine (Nardil,) isocarboxazid (Marplan) Class: monoamine oxidase inhibitors (MAOIs)

•1st generation antidepressant and can be used in Parkinson's disease. •Significant disadvantage of MAOIs is their potential to cause a hypertensive crisis when taken with stimulating medications or foods containing tyramine. •Mode of Action •MAO is an enzyme that inactivates norepinephrine, dopamine, epinephrine, and serotonin. By inhibiting MAO, the levels of these transmitters rise. •Adverse/Side Effect •Black Box Warning: monitor for hypertensive crisis & increased suicidal ideation •S/E: dizziness, drowsiness, weakness/fatigue, loss of appetite, N/V, irritability/nervousness •Administration •Do NOT stop abruptly; take medication as prescribed. •Interact with MANY other medications. •Teaching •Limit intake of tyramine-rich foods (cheese, alcohol, banana, avocados, red wine, salami/pepperoni, & chocolate), tyramine can lead to a hypertensive crisis for up to 2 weeks after therapy. •Discontinue at the 1st sign of hepatic function (jaundice) •Discontinue 2 weeks before starting any other meds.

Schizophrenia

•Affects people from all walks of life & usually appears between the ages of 15 and 30. Not everyone will experience the same symptoms, but many symptoms are common such as withdrawing, hearing voices, talking to oneself, seeing things that are not there, neglecting personal hygiene, and showing low energy •Positive symptoms: include altered perceptions (e.g., changes in vision, hearing, smell, touch, and taste), abnormal thinking, and odd behaviors. •Negative symptoms: include loss of motivation, disinterest or lack of enjoyment in daily activities, social withdrawal, difficulty showing emotions, and difficulty functioning normally. •Cognitive symptoms include problems in attention, concentration, and memory.

Aspirin

•Contraindicated if the patient has a bleeding disorder such as hemophilia or a recent history of bleeding in the stomach or intestine. •Black Box Warning: •Children or teenagers should not take aspirin to treat chickenpox or flu-like symptoms because of the risk of Reye's Syndrome. •Teaching/Education •Patients should avoid concurrent use of alcohol while taking medication to avoid gastric irritation. •Report tinnitus, unusual bleeding, or fever lasting greater than 3 days to the healthcare provider (toxic effect of aspirin). •Take with a full glass of water and sit upright for 15-30 minutes after administration •Take with food if the patient reports that aspirin upsets their stomach •Do not crush, chew, break, or open an enteric-coated or delayed-release pill; it should be swallowed whole •The chewable tablet form must be chewed before swallowing •Should be stopped 7 days prior to surgery due to the risk of postoperative bleeding

Symptoms of hypertensive crisis

•Severe hypertension with evidence of organ dysfunction •Blood pressure >180/120 •Palpitations •Neck stiffness or soreness •Nausea/vomiting •Sweating •Dilated pupils •Photophobia •SOB •Confusion •Tachycardia or bradycardia •Seizures •Intracranial bleeding (due to elevated BP)

What are the signs and symptoms of ADHD?

•Hyperactivity •Inability to concentrate •Difficulty with self-control •Lack of emotional control

Nursing Process for Pain Management- Evaluation

•It is important to always evaluate the patient's response to the medication. •With analgesic medications, the nurse should assess for the decrease in pain 30 minutes after IV administration and 60 minutes after oral medication. •If the patient's pain level is not acceptable, the nurse should investigate alternate treatment modalities. •The nurse is a patients' advocate, the healthcare provider may have to be informed if the patient's pain is not being controlled by analgesics. •One of the adverse effects of opioid analgesics is respiratory depression. The nurse should evaluate the respiratory rate, pulse oximetry, and blood pressure after administration of the medication. •Other common side effects of opioid analgesic medications are constipation or nausea.

How is bipolar treated?

•Medications, psychotherapy, or a combination of the two. (antidepressants, and pscychotherapies such as talk therapy) •Electroconvulsive therapy (ECT)

Parkinson's Disease

•Parkinson's disease is a progressive disease of the nervous system that impairs one's ability to move. •The typical onset for Parkinson's disease is middle to later stages of life. •Parkinson's disease is believed to be related to an imbalance of dopamine and acetylcholine and a deficiency of dopamine in certain areas of the brain, so drug therapies are aimed at restoring the balance of dopamine and/or acetylcholine. •Drug therapy does not cure the disease, but is used to slow the progression of symptoms. •Common medications used to treat Parkinson's disease are carbidopa/levodopa, selegiline, and amantadine.

Classes of seizures:

•Partial seizures have focal onset on one side of the brain. •They are further classified into simple, complex, or secondarily generalized: simple partial, complex partial, and tonic-clonic seizures. •Generalized seizures have bilateral onset on both sides of the brain and are typified by petit mal seizures. •Status epilepticus is a state of repeated or continuous seizures. •It is often defined operationally as a single seizure lasting more than 20 minutes or repeated seizures without recovery of consciousness. •Prolonged status epilepticus leads to irreversible brain injury and has a very high rate of mortality.

Nursing Process for Pain Management- Implementation

•Perform the five rights (right patient, medication, dose, route, and time) and to check for allergies prior to administration. •Prior to administration, it is important to consider the best route of administration for this patient at this particular time. •For example, if the patient is nauseated and vomiting, then an oral route may not be effective. An antiemetic may have to be administered prior to pain medication. •When administering opioid medications, it is important to remember that these medications are controlled substances with special regulations regarding storage, auditing counts, and disposal or wasting of medication •A general rule of thumb when administering analgesics is to use the least invasive medication that is anticipated to treat the level of pain reported by the patient.

Signs and symptoms of depression

•Persistent sad, anxious, or "empty" mood •Feeling of hopelessness, or pessimism •Irritability •Feelings of guilt, worthlessness, or helplessness •Loss of interest or pleasure in hobbies, & activities •Decreased energy or fatigue •Moving or talking more slowly •Feeling restless or having trouble sitting still •Difficulty concentrating, remembering, or making decisions •Difficulty sleeping, early-morning awakening, or oversleeping •Appetite and/or weight changes •Thoughts of death or suicide, or suicide attempts •Aches or pains, headaches, cramps, or digestive problems

Signs and symptoms of a bipolar manic episode

•Rapid speech •Hyperactivity •Reduced need for sleep •Flight of ideas •Grandiosity •Poor judgement •Aggression/hostility •Risky sexual behavior •Neglect basic self-care •Decreased impulse control

haloperidol (Haldol) Class: anti-psychotic, 1st generation (conventional)

•Used to treat drug-induced psychosis, schizophrenia, extreme mania, depression that is resistant to other therapy, and other CNS conditions. Mainly control the positive symptoms. •Haloperidol is primarily indicated for schizophrenia and Tourette's disorder. •Mode of Action: •Blocks dopamine receptors in certain areas of the CNS, such as the limbic system and the basal ganglia. These areas are associated with emotions, cognitive function, and motor function, and blockage thus produces a tranquilizing effect in psychotic patients. •Adverse/Side Effects: •Life-threatening cardiovascular events or infections (pneumonia) •Tardive dyskinesia •Neuroleptic malignant syndrome •Extrapyramidal symptoms (EPS) •Hypersensitivity reactions •Falls related to sedation, motor •Instability, & postural hypotension •Black Box Warning: monitor elderly patients with dementia closely for symptoms of cardiovascular events or infection •Contraindicated in pts with Parkinson's disease or dementia with Lewy bodies •Teaching/education: •Take medication as directed, dose should be evenly spaced throughout the day. •May require several weeks to obtain desired effects •Advise about the possibility of extrapyramidal symptoms & abrupt withdrawal may cause dizziness, nausea, and vomiting, uncontrolled movements of mouth, tongue, or jaw.

paroxetine (Paxil), sertraline (Zoloft), fluoxentine (Prozac) Class: selective serotonin reuptake inhibitors (SSRI)

•Uses •Anxiety, depression, obsessive compulsive disorders (OCD), bulimia, post-traumatic stress disorder (PTSD) •Mode of Action •Increases level of serotonin in the brain. Serotonin is a neurotransmitter that carries signals between brain nerve cells (neurons). SSRI block the reabsorption (reuptake) of serotonin into neurons, therefore increasing the amt of serotonin available to improve transmission of messages between neurons. •Adverse/Side Effects •Sexual dysfunction, seizures, mania, hyponatremia, & insomnia •Serotonin syndrome •Black Box Warning: increased risk of suicidality •Administration •Do NOT abruptly stop; taper dose when discontinuing •Contraindicated with MAOIs due to the risk of serotonin syndrome •May take up to 12 weeks to achieve therapeutic effect •Teaching •Take as directed •Abrupt discontinuation may cause anxiety, insomnia, & increased nervousness •Do not take with alcohol or other CNS depressants •Do not take with St. John's wort

buspirone (Buspar) Class: antianxiety, non-benzodiazepine

•Uses •Anxiety, obsessive compulsive disorder (OCD), & post-traumatic stress disorder (PTSD) •Mode of Action •Affects neurotransmitters in the brain such as serotonin & dopamine. It is a serotonin & dopamine agonist, meaning it increases at both serotonin & dopamine receptors in the brain, which in turn help to alleviate anxiety & anxiety symptoms. •Side Effects •Dizziness, nausea, and headache. •Administration •Long term medication for anxiety •Will take several weeks before patients feels the effects •Do not discontinue early •Teaching •Take meds with food or always take without food to prevent a change in how buspirone is absorbed in the body •Do not take with grapefruit juice because it is contraindicated with this med

lorazepam (Ativan), diazepam (Valium), Alprazolam(Xanax) Class: benzodiazepines (-pam,-lam)

•Uses •Anxiety, seizures, muscle spasms, alcohol withdrawal and the induction & maintenance of anesthesia. •CNS depressant; 1st medication used for break through seizures (IV, IM) •Mode of Action •"benzos" enhance the effect of the neurotransmitter gamma-aminobutyric acid (GABA) at the GABAA receptor, resulting in sedative, hypnotic (sleep-inducing), anxiolytic (anti-anxiety), anticonvulsant, & muscle relaxant properties. •Side Effects •Sedation, respiratory depression, amnesia, dependency, and withdrawal •Black box warning: use with opioids may result in profound sedation, resp. depression, coma & death •Administration •Not intended for long term use, only for a short period of time. •Do NOT abruptly discontinue, withdrawal symptoms (anxiety, increased HR, fever, sweating, nausea, muscle cramps, & insomnia) •Used IV/IM to stop a seizure; status epilepticus; break through seizures because of their rapid onset of action •Avoid operating machinery or driving because of sedation effect. •Antidote •flumazenil (Romazicon)

venlafaxine (Effexor), duloxetine (Cymbalta) Class: serotonin norepinephrine reuptake inhibitor (SNRI)

•Uses •Major depressive disorder, anxiety, and neuropathic pain •Mode of Action •Inhibit the reuptake of serotonin and norepinephrine, with weak inhibition of dopamine reuptake •Adverse/Side Effect •Black Box Warning: monitor for increased risk of suicidality •Serotonin syndrome SS: agitation, hallucinations, fever, diaphoresis, tremors •Increased bleeding when used with NSAIDs, warfarin, & aspirin •Elevated serum cholesterol •GI upset, decreased libido •Administration •Gradually reduce dose when discontinuing when possible •Use with caution in patients with liver or renal disease •Teaching •Make take up to 8 weeks before therapeutic effect; taper dose when discontinuing •May increase drowsy or dizziness. •Avoid using alcohol or other CNS depressants •Family should monitor for suicidal ideation

Lithium (Lithobid) Class: mood stabilizer, anti-mania

•Uses •Treatment of bipolar disorder •Mode of Action •Works by influencing the reuptake of neurotransmitters. Specific biochemical mechanism of lithium action in mania is unknown. •Adverse/Side Effect •Black Box Warning: lithium toxicity ( >= 1.5 mEq/L), monitor serum lithium levels & sodium •Lithium can cause abnormal ECG (heart rhythm) findings & risk of sudden death •Administration •Contraindicated in renal and cardiovascular disease & in dehydration •When given during a manic episode, symptoms may resolve in 1-3 weeks •When given for maintenance therapy, it should reduce frequency & intensity of manic episodes •Teaching •Take medication as directed •May increase dizziness & drowsiness, If patient has low sodium levels, may predispose pt to toxicity •Weight gain may occur •Can cause mild nausea, abdominal bloating

Allopurinol Class: hyperuricemia

•Uses •Used for the prevention & treatment of gouty arthritis and neuropathy and for the treatment of secondary hyperuricemia •Mode of Action: •Allopurinol blocks the production of uric acid by inhibiting the action of xanthine oxidase •Adverse/Side Effects •hypotension, flushing, hypertension, drowsiness, nausea and vomiting, diarrhea, hepatitis, renal failure, or a drug rash with eosinophilia and systemic symptoms (DRESS) syndrome or drug hypersensitivity syndrome •Teaching/Education: •Can take months to work •Take as directed. •Alkaline diet & increase fluids to prevent kidney stone formation. •Not for pain •May cause dizziness or drowsiness •Patient who consume large amounts of alcohol may increase uric acid level & decrease effectiveness of the medication •If the patients develop a rash or blood in the urine, this should be reported promptly to their provider

Cyclobenzaprine (Flexeril) Class: skeletal muscle relaxant

•Uses: •Acute muscle spasms •Safe for patients 15 years & older •Mode of Action: •Reduces tonic somatic muscle activity at the level of the brainstem. It is structurally similar to tricyclic antidepressants •Adverse/Side Effects: •Dizziness, blurred vision, drowsiness, dry mouth, urinary retention, constipation, and serotonin syndrome with antidepressant use, or increased sedation with other CNS depressants •Teaching/Education •Take medication as directed and abrupt withdrawal should be avoided. •Change positions slowly b/c of potential orthostatic changes; dizziness or drowsiness •Avoid alcohol or other CNS depressants. •May cause constipation; increase fluids •Serotonin Syndrome •Life-threatening syndrome can occur when taking SSRI, SNRI, TCA, or MAOIs. The concomitant use of cyclobenzaprine hydrochloride with MAO inhibitors is contraindicated

Naloxone (Narcan) Class: opioid reversal agent - opioid antagonist

•Uses: •Complete or partial reversal of opioid depression, including respiratory depression induced by natural & synthetic opioids •IV/IM & inhaled •Mode of Action: •Naloxone reverses analgesia and the CNS and respiratory depression caused by opioid agonists. It competes with opioid receptor sites in the brain and, thereby, prevents binding with receptors or displaces opioids already occupying receptor sites. •Adverse/Side Effects •tremors, drowsiness, sweating, decreased respirations, hypertension, nausea, and vomiting •Opioid dependence patient-may precipitate an acute withdrawal syndrome, which may include, but not limited to, the following signs and symptoms: body aches, fever, sweating, runny nose, sneezing, piloerection, yawning, weakness, shivering or trembling, nervousness, restlessness or irritability, diarrhea, nausea or vomiting, abdominal cramps, increased blood pressure, and tachycardia. •In the neonate, opioid withdrawal may also include convulsions, excessive crying, and hyperactive reflexes •Naloxone has a shorter duration of action than opioids, and repeated doses are usually necessary. Half life is 1-2 hours.

Acetaminophen (Tylenol) (Ofirmev)

•Uses: Acetaminophen is used to treat mild pain and fever (antipyretic); however, it does not have anti-inflammatory properties. •Mode of Action: •Acetaminophen inhibits the synthesis of prostaglandins that may serve as mediators of pain and fever primarily in the CNS •Adverse/Side Effects •skin reddening, blisters, rash, and hepatotoxicity (monitor liver function) (Jaundice) •Administration •Safe for all ages and can be orally, rectally, and IV •Assess pain prior to and after administration •Administer with a full glass of water •Maximum dose over 24-hour period: •-4000 mg for adults, •-3200 mg for geriatric patients •-2000 mg for patients with chronic alcoholism •Teaching/Education: •Take medication as directed •Do not take greater than 10 days and avoid drinking alcohol •Antidote: administer acetylcysteine

Phenytoin Class: hydantoins, anticonvulsant

•Uses: tonic-clonic (grand mal) or focal seizures •Mode of Action •Phenytoin improves evidence of seizures by interfering with sodium channels in the brain, resulting in a reduction of sustained high-frequency neuronal discharges. •Adverse/Side Effects •Gums (gingival hyperplasia): enlarged & bleed •Bone marrow suppression (watch platelets & WBCs) •Monitor for Rash (SJS) •Should not be administered to pregnant women •Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) •Teaching/education •Patient needs good oral hygiene; report signs of rash •Do not give with milk or antacids •Therapeutic levels are 10-20 mcg/ml •Abrupt withdrawal of medication may cause status epilepticus. •Careful cardiac monitoring is needed during and after administering intravenous phenytoin

Aspirin Class: Platelet aggregation inhibitor

•Uses: Aspirin is used for the treatment of mild pain and fever. Once daily dosages are also used to reduce the risk of heart attack and stroke. •Mode of Action: •Aspirin produces analgesia and reduces inflammation and fever by inhibiting the production of prostaglandins. It also decreases platelet aggregation. •Adverse/Side Effects: •Allergy alert: hives, facial swelling, shock, asthma (wheezing) •Stomach bleeding warning: The chance for bleeding is higher if a patient: •takes a higher dose or takes it for a longer time than directed •takes other drugs containing prescription or nonprescription NSAIDs (aspirin, ibuprofen, naproxen, or others) •has had stomach ulcers or bleeding problems •takes a blood-thinning (anticoagulant) or steroid drug •is age 60 or older •has 3 or more alcoholic drinks every day while using this product

Ibuprofen Class: NSAID

•Uses: to treat mild to moderate pain and fever, inflammatory disorders including rheumatoid arthritis and osteoarthritis, and pain associated with dysmenorrhea. •Mode of Action: •Ibuprofen inhibits prostaglandin synthesis. •Nursing considerations: •Ibuprofen is safe for infants >=6 months or older. •Do not to use ibuprofen during the last 3 months of pregnancy unless directed to do so by a doctor because it may cause complications during delivery or in the unborn child. •Adverse/Side Effects •headache, GI bleed, constipation, dyspepsia, nausea, vomiting, Steven-Johnson syndrome, and renal failure. •Allergy alert •Stomach bleeding warning: The chance for bleeding is higher if the patient: •is age 60 or older •has had stomach ulcers or bleeding problems •takes a blood thinning (anticoagulant) or steroid drug •takes other drugs containing prescription or nonprescription NSAIDs (aspirin, ibuprofen, naproxen, or others) •has 3 or more alcoholic drinks every day while using this product •takes more or for a longer time than directed