Exam 4 question Pharmacology
The nurse prepares to administer lithium to a patient. Which laboratory result should first be assessed?
Urinary creatinine clearance
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
The nurse is caring for a patient who is receiving pramipexole [Mirapex]. The nurse is most concerned if the patient makes which statement?
"Sometimes I just fall asleep without warning."
The nurse teaches a 16-year-old female patient about methylphenidate (Ritalin). Which statement by the patient indicates that more teaching is needed?
"I can have an unlimited number of noncola soft drinks."
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 provides teaching for a patient with obsessive-compulsive disorder who has been prescribed Sertraline [Zoloft]. Which statement by the patient indicates that more teaching is necessary?
"I will feel better in 3 weeks."
Cabergoline Occasionally used for PD
"Possibly effective" for improving "off" times during levodopa therapy Hyperprolactinemia
The nurse teaches a patient about eszopiclone [Lunesta]. Which statement by the patient indicates that the teaching has been effective?
"The drug may leave a bitter taste in my mouth."
A nurse instructs a parent about the administration schedule for Adderall XR (amphetamine/dextroamphetamine mixture) to treat the child's ADHD. The nurse determines that teaching is successful if the parent makes which statement?
"The drug should be given in the morning, before school."
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."
The nurse instructs a young adult patient about triazolam [Halcion] for the short-term management of insomnia. Which statement, if made by the patient, indicates an understanding of the instructions?
"The medication will not affect my breathing."
The nurse receives a phone call from a patient who has been taking a CNS drug for 3 days. The patient tells the nurse that the medication causes nausea. Which response by the nurse is best?
"The nausea will most likely decrease over time."
A patient is prescribed the dopamine agonist pramipexole [Mirapex]. Which statement made by the patient indicates a need for further teaching?
"This drug will stop the progression of Parkinson's disease."
A patient is prescribed venlafaxine [Effexor XR] and requests information about the medication. Which response by the nurse is most appropriate?
"Venlafaxine [Effexor XR] is used to treat anxiety and depression."
Parkinson's disease (PD) is a neurodegenerative disorder of the extrapyramidal system associated with the disruption of neurotransmission in the striatum
-Characterized by dyskinesias and akinesia -Proper function of the striatum requires a balance between the neurotransmitters dopamine and acetylcholine (ACh) -Imbalance between dopamine and ACh results from the degeneration of the neurons that supply dopamine to the striatum -Symptoms generally appear during middle age and progress -No cure for motor symptoms
Adaptation of the CNS to Prolonged Drug Exposure
-Depends on the length of time medication is taken will determine effect. -Psychiatry (such as antipsychotics or antidepressants) must be taken for several weeks before full therapeutic effects develop -Full therapeutic effects are not seen until the CNS has had time to modify itself in response to prolonged drug exposure -Decreased side effects: When CNS drugs are taken chronically, the intensity of the side effects may decrease, but the therapeutic effects remain undiminished -Tolerance: Decreased response occurring during the course of prolonged drug use Physical dependence State in which abrupt discontinuation of drug use will precipitate a withdrawal syndrome
Parkinson's disease Therapeutic goals
-Ideal treatment that reverses neuronal degeneration or prevents further degeneration does not exist -The goal is to improve the patient's ability to carry out the activities of daily life -Drug selection and dosages are determined by the extent to which PD interferes with work, dressing, eating, bathing, and other activities of daily living
Levodopa
-Only given in combination with carbidopa or carbidopa/entacapone -Highly effective, but benefits diminish over time Orally administered;rapidly absorbed from small intestine Food delays absorption Neutral amino acids compete with levodopa for intestinal absorption and for transport across blood-brain barrier High-protein foods reduce therapeutic effects
Galantamine [Razadyne, Reminyl] Reversible cholinesterase inhibitor indicated for mild to moderate AD
Adverse effects Nausea, vomiting, diarrhea, weight loss, and anorexia Bradycardia, fainting, falls, and fall-related fractures Can cause bronchoconstriction
Apomorphine [Apokyn] (Nonergot Dopamine Agonists)
Acute treatment of hypomobility during "off" episodes in patients with advanced PD Not given by mouth Not indicated for routine PD management Derivative of morphine but devoid of typical opioid effects (for example, analgesia, euphoria, respiratory depression) Adverse effects
Rasagiline (Azilect) MAO-B Inhibitors
Adverse effects Monotherapy: Insomnia Orthostatic hypotension Irritation of buccal mucosa Hypertensive crisis Drug interactions Levodopa Meperidine Selective serotonin reuptake inhibitors
Rivastigmine [Exelon] Irreversible inhibition of cholinesterase
Adverse effects Nausea, vomiting, diarrhea, abdominal pain, and anorexia Significant weight loss Intensify symptoms in patients with peptic ulcer disease, bradycardia, sick sinus syndrome, urinary obstruction, and lung disease, bradycardia, fainting, falls, and fall-related fractures
The nurse prepares to administer a cholinesterase inhibitor to a patient with AD. Which medication, if ordered by the health care provider, should the nurse question?
Amitriptyline [Elavil]
Dimethyl Fumarate [Tedfidera]
Approved for the management of relapsing MS Management of psoriasis Mechanism Immunomodulator Promotes apoptosis (self-destruction) of activated T lymphocytes Inhibits migration of lymphocytes into the CNS Activation of the Nrf2 antioxidant response pathway Protects cells from oxidative stress and provides anti-inflammatory effects
An older patient with skin cancer and hypertension is prescribed levodopa/carbidopa [Sinemet] to treat Parkinson's disease. Which action by the nurse is best?
Ask the patient about the type of skin cancer.
The nurse is caring for a patient with social anxiety disorder. The patient is currently experiencing intense anxiety. The nurse should prepare to administer which medication for the immediate relief of anxiety?
Clonazepam [Klonopin]
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 prepares to administer memantine [Namenda] to a patient with severe AD. The nurse should assess what before administering of the medication?
Blood urea nitrogen and serum creatinine
CNS drugs act by
Brain and Spinal cord Medical uses: Relief of pain; Suppression of seizures; Production of anesthesia Treatment of psychiatric disorders Nonmedical uses: Stimulant, depressant, euphoriant, and other "mind- altering" abilities
Bromocriptine and Cabergoline (Ergot Derivatives)
Bromocriptine is approved for PD; cabergoline is not These drugs are poorly tolerated, so their use is limited Bromocriptine [Parlodel] Derivative of ergot Direct-acting dopamine agonist Beneficial effects derive from activating dopamine receptors in the striatum Used alone for early PD and in combination with levodopa for advanced PD
Amantadine [Symmetrel] Adverse effects MAO-B Inhibitors
CNS effects: Confusion, lightheadedness, and anxiety Peripheral effects: Blurred vision, urinary retention, dry mouth, and constipation Livedo reticularis: A condition characterized by mottled discoloration of the skin
Dimethyl Fumarate [Tedfidera] Drug interactions
Can decrease the body's response to vaccines Patients should not receive live vaccines when taking this drug Vaccine-related infection could occur Avoid other immunosuppressants
Alzheimer's disease Adverse effects Cholinesterase inhibitors
Cholinergic side effects Gastrointestinal effects Dizziness Headache Bronchoconstriction
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]
A patient is diagnosed with type 2 diabetes mellitus and schizophrenia. The nurse will closely monitor the blood sugar if the patient receives which medication for the treatment of schizophrenia?
Clozapine [Clozaril]
Before administering ramelteon [Rozerem] to a patient on the medical unit, which action by the nurse is best?
Consult the prescriber if the patient has chronic hepatitis.
Overactivity of gamma-aminobutyric acid neurons contributes to the motor symptoms of PD
Correct
Secondary progressive MS Interferon beta (Mitoxantrone)
Decreases clinical attack rate Reduces development of new brain lesions Slows progression of disability Cardiotoxicity
Alzheimer's disease Pathophysiology
Degeneration of neurons Early in hippocampus/Later in cerebral cortex Reduced cholinergic transmission Levels of Ach 90% below normal Important neurotransmitter Critical to forming memories Loss of cholinergic function
Amantadine [Symmetrel] MAO-B Inhibitors
Developed as an antiviral agent Later found effective for PD Inhibition of dopamine uptake, stimulation of dopamine release, blockade of cholinergic receptors, and blockade of glutamate receptors Responses within 2 to 3 days Much less profound than with levodopa or the dopamine agonists Responses may begin to diminish within 3 to 6 months Not considered a first-line agent May be helpful for dyskinesias caused by levodopa
MS Six immunomodulators currently available
Dimethyl fumarate [Tedfidera] Glatiramer acetate [Copaxone] Natalizumab [Tysabri] Fingolimod [Gilenya] Teriflunomide [Aubagio] Interferon beta [Avonex, Rebif, Betaseron, Extavia]
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]
Interferon Beta Preparation, dosage, and administration
Dispensed as single-use syringes and vials
Parkinson's disease drug therapy
Drug therapy can maintain functional mobility for years (i.e., prolongs/improves quality of life)
Entacapone [Comtan] Adverse effects
Dyskinesias Orthostatic hypotension Nausea Hallucinations Sleep disturbances Impulse control disorders Managed by decreasing levodopa dosage Entacapone can cause vomiting, diarrhea, constipation, and yellow-orange discoloration of the urine
Cardinal symptoms of PD
Dyskinesias: tremor at rest; rigidity; postural instability; bradykinesia (slowed movement); tremor In addition to motor symptoms: Autonomic disturbances Depression Psychosis and dementia
Memantine [Namenda, Namenda XR]
First drug in a new class, the N-methyl-d-aspartate receptor antagonists Indicated for moderate to severe AD Better tolerated than cholinesterase inhibitors Adverse effects Dizziness Headache Confusion Constipation
Levodopa drug interactions
First-generation antipsychotic drugs (for example, chlorpromazine, haloperidol) block receptors for dopamine in the striatum and decrease therapeutic effects of levodopa MAO inhibitors: Levodopa can cause a hypertensive crisis if administered to an individual taking a nonselective MAO inhibitor Anticholinergic drugs: Excessive stimulation of cholinergic receptors contributes to the dyskinesias of PD; by blocking these receptors, anticholinergic agents can enhance responses to levodopa Pyridoxine (vitamin B6) Stimulates decarboxylase activity Acceleration of decarboxylation of levodopa in the periphery; pyridoxine can decrease the amount of levodopa available to reach the CNS Therapeutic effects of levodopa can be reduced Because levodopa is now always combined with carbidopa, a drug that suppresses decarboxylase activity, this potential interaction is no longer a clinical concern
Levodopa/Carbidopa/Entacapone
Fixed-dose combinations sold as Stalevo More convenient than taking separate doses Disadvantages Available only in immediate-release tablets Available in only three strengths
Interferon Beta Adverse effects and drug interactions
Flu-like reactions Hepatotoxicity Myelosuppression Injection-site reactions Depression Suicidal thoughts Neutralizing antibodies Drug interactions
A patient is brought to the emergency department for the treatment of an overdose of alprazolam [Xanax]. Which medication should the nurse prepare to administer to this patient?
Flumazenil [Romazicon]
Dimethyl Fumarate [Tedfidera] Adverse effects
Flushing Gastrointestinal discomfort Lymphopenia Rash Alteration in laboratory analysis
Glatiramer Acetate [Copaxone] Therapeutic use
For long-term therapy of relapsing-remitting MS
Alzheimer's disease drugs
Four drugs are approved for the treatment of Alzheimer's dementia: Cholinesterase inhibitors: Donepezil, galantamine, and Rivastigmine Memantine: Blocks neuronal receptors for N- methyl-d-aspartate
The nurse cares for a patient who is receiving lithium. Which medication, if prescribed by the healthcare provider, should the nurse question?
Furosemide [Lasix]
Ropinirole [Requip] (Nonergot Dopamine Agonists)
Highly selective for D2 and D3 receptors; both drugs share the same indications: PD and restless legs syndrome PD: Ropinirole can be used as monotherapy for early PD and as an adjunct to levodopa for advanced PD Most common effects are nausea, dizziness, somnolence, and hallucinations Rarely sleep attacks will occur When ropinirole is combined with levodopa, the most important side effects are dyskinesias, hallucinations, and postural hypotension Compulsive gambling, shopping, eating, and hypersexuality Drug should not be used during pregnancy
A patient with BPD is prescribed lithium. Which statement, if made by the patient, indicates the need for further teaching?
I will reduce my salt intake while taking this medication."
The nurse cares for a patient with depression who has been prescribed an antidepressant. When would the nurse expect the medication to reach its full therapeutic effect?
In 2 to 3 weeks
Entacapone [Comtan] Drug interactions
Increases levels of drugs metabolized by COMT, including levodopa as well as the following: Methyldopa (an antihypertensive agent) Dobutamine (an adrenergic agonist) Isoproterenol (a beta-adrenergic agonist)
Donepezil [Aricept, Aricept ODT]
Indicated for mild, moderate, or severe AD Causes reversible inhibition of cholinesterase Adverse effects Nausea and diarrhea Bradycardia Fainting Falls Fall-related fractures
COMT Inhibitors
Inhibit metabolism of levodopa in the periphery No direct therapeutic effects of their own Two COMT inhibitors available Entacapone (safer and more effective) Tolcapone
A patient taking levodopa/carbidopa [Sinemet] for Parkinson's disease experiences frequent "on-off" episodes (i.e., the abrupt loss of effect). Which action by the nurse is best?
Instruct the patient to avoid high-protein foods.
Levodopa Use in PD
Introduced during the 1960s Most effective drug for PD Diagnosis of PD questioned if levodopa fails Several months of treatment needed for full therapeutic response Symptoms well controlled for first 2 years Return to pretreatment state at end of 5 years
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."
Rotigotine [Neupro] (Nonergot Dopamine Agonists)
Management of PD from early to advanced stages Management of moderate to severe primary restless legs syndrome Most common adverse effects: CNS and neuromuscular system effects, sleeping disorders, dizziness, headache, dose-related hallucinations, and dose-related dyskinesia Orthostatic hypotension and peripheral edema may occur Nausea and vomiting, skin reactions at the site of application, and hyperhidrosis (excessive perspiration)
Alzheimer's disease symptoms
Memory loss Confusion Feeling disoriented Impaired judgment Personality changes Difficulty with self-care Behavior problems (for example, wandering, pacing, agitation, and screaming) "Sundowning" Inability to recognize family members Inability to communicate
Drug Selection: Initial Treatment
Mild symptoms: Monoamine oxidase-B (MAO-B) inhibitor Selegiline or rasagiline More severe symptoms: Levodopa (combined with carbidopa) or a dopamine agonist Levodopa is more effective than dopamine agonists, but long-term use carries a higher risk for disabling dyskinesias Management of motor fluctuations: "Off" times can be reduced with dopamine agonists, catechol-O- methyltransferase (COMT) inhibitors, and MAO-B inhibitors Drug-induced dyskinesias
Selegiline (Eldepryl, Zelapar) MAO-B Inhibitors
Monotherapy or used with levodopa Modest improvement in motor function Causes selective and irreversible inhibition of MAO-B Can suppress the destruction of dopamine derived from levodopa and prolong the effects of levodopa Benefits decline dramatically within 12 to 24 months
Bromocriptine adverse effects
Nausea Psychological reactions (for example, confusion, nightmares, agitation, hallucinations, paranoid delusions) Retroperitoneal fibrosis, pulmonary infiltrates, a Raynaud-like phenomenon, erythromelalgia, and valvular heart disease
Levodopa Adverse effects
Nausea and vomiting Activation of dopamine receptors in the chemoreceptor trigger zone of the medulla Low initial doses and administration with food can reduce therapeutic effects by decreasing levodopa absorption Giving additional carbidopa (without levodopa) can help reduce nausea and vomiting The reason that carbidopa helps is unknown Adverse effects: Cardiovascular Postural hypotension Increase intake of salt and water Alpha-adrenergic agonist Psychosis Visual hallucinations Vivid dreams or nightmares Paranoid ideation Caused by activation of dopamine receptors Symptoms can be reduced by lowering levodopa dosage This will reduce beneficial effects as well Central nervous system (CNS) effects Anxiety and agitation Memory and cognitive impairment Insomnia and nightmares are common Problems with impulse control Behavioral changes associated with promiscuity, gambling, binge eating, and alcohol abuse Dyskinesias given to alleviate movement disorders, but it actually causes movement disorders in many patients Develop just before or soon after optimal levodopa dosage has been achieved Managed in three ways: Reduce dosage of levodopa Amantadine Surgery and electrical stimulation Darkens sweat and urine Activates malignant melanoma: Important to perform a careful skin assessment of patients who are prescribed levodopa
Morphine is taken to control pain
Nausea is a common side effect early on Treatment continues, nausea diminishes, and analgesic effects persist
Alzheimer's disease drug therapy
Neuronal receptor blocker Memantine Cholinesterase inhibitors Donepezil Galantamine Rivastigmine
Do you have Neuroprotection with PD?
No drug has yet been proven to provide neuroprotective effects for people with PD
A patient is concerned about developing AD. What should the nurse include in the teaching plan?
No solid evidence supports the use of drugs to prevent AD.
MS s/sx
Paresthesias: Numbness, tingling, and pins and needles sensations Muscle or motor problems: Weakness, clumsiness, ataxia, spasms, spasticity, tremors, and cramps Visual impairment: Blurred vision, double vision, and blindness Bladder and bowel symptoms: Incontinence, urinary urgency, urinary hesitancy, and constipation Sexual dysfunction Disabling fatigue Emotional lability, depression, and cognitive impairment Slurred speech and dysphagia Dizziness and vertigo Neuropathic pain
Transmitters of CNS
Peripheral NS: Acetylcholine, norepinephrine, and epinephrine CNS: At least 21 compounds Evidence supports a neurotransmitter role for dopamine, NE, serotonin, and enkephalins
A patient who is diagnosed with BPD is prescribed lithium. To monitor for lithium toxicity, the nurse should observe the patient for which signs and symptoms?
Polydipsia, slurred speech, and fine hand tremors
Primary Progressive MS
Possible benefit from immunosuppressants: Methotrexate Azathioprine Cyclophosphamide
How CNS Drugs Produce Therapeutic Effects
Precise mechanism vs. plausible hypotheses Although we cannot state with certainty how CNS drugs act, we do have sufficient data to permit the formulation of plausible hypotheses
Glatiramer Acetate [Copaxone] Description and mechanism
Protects myelin by inhibiting immune response to myelin basic protein
Centrally Acting Anticholinergic Drugs: Benztropine [Cogentin] and Trihexyphenidyl [Artane]
Reduce tremor and possibly rigidity No reduction of bradykinesia Less effective than levodopa or the dopamine agonists but better tolerated Used as second-line therapy for tremor Most appropriate for younger patients with mild symptoms Avoided in the elderly, who are intolerant of CNS side effects (for example, sedation, confusion, delusions, hallucinations)
Secondary progressive MS Interferon beta
Reduces severity and frequency of attacks Reduces development of brain lesions detectable by magnetic resonance imaging
Levodopa Mechanism of action
Reduces symptoms by increasing dopamine synthesis in the striatum Enters the brain via an active transport system that carries it across the blood-brain barrier In the brain: Uptake into the remaining dopaminergic nerve terminals that remain in the striatum Levodopa, which has no direct effects of its own, is converted to dopamine, its active form Levodopa helps to restore a proper balance between dopamine and ACh The activity of decarboxylases is enhanced by pyridoxine (vitamin B6)
Interferon Beta Therapeutic use
Reduces the frequency and severity of attacks Reduces the number and size of lesions detectable with magnetic resonance imaging Delays progression of disability
A child with ADHD has been prescribed Daytrana (a transdermal methylphenidate patch). When teaching the child's caregiver how to administer the medication, which instruction should the nurse include in the teaching?
Remove the patch within 9 hours of application
Alzheimer's disease Drugs for neuropsychiatric symptoms
Risperidone [Risperdal] Olanzapine [Zyprexa] Modest benefits Slightly increase mortality, mainly from cardiovascular events and infection Cholinesterase inhibitors may offer modest help Little or no evidence of benefit from conventional antipsychotics (for example, haloperidol or chlorpromazine), mood stabilizers (for example, valproate, carbamazepine, or lithium), antidepressants, or memantine
Entacapone [Comtan]
Selective and reversible inhibitor of COMT Indicated for use with levodopa Inhibits metabolism of levodopa in the intestines and the peripheral tissues Prolongs time that levodopa is available to the brain Increases levodopa availability by inhibiting COMT, which decreases the production of levodopa metabolites that compete with levodopa for transport
Alzheimer's Disease
Sixth leading cause of death in the United States
Drug Therapy for Parkinson's Disease
Two major categories Dopaminergic agents By far the most commonly used drugs for PD Promote activation of dopamine receptors Levodopa [Dopar] Anticholinergic agents Prevent activation of cholinergic receptors Benztropine [Cogentin]
Alzheimer's disease Progressive Symptoms
Symptoms typically begin after the age of 65 years but may appear as early as the age of 40 years Life expectancy from symptom onset may be 20 years or more but is usually 4 to 8 years
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.
A patient with mild symptoms of AD is prescribed donepezil [Aricept]. Which statement made by the patient indicates the need for further teaching?
The drug will stop damage to the neurons in my brain."
The nurse prepares to administer the first dose of an antipsychotic agent to a patient. One hour after administration, it is most important for the nurse to assess what?
The orthostatic blood pressure measurements
Which manifestations does the nurse associate with tardive dyskinesia?
Twisting, worm-like movements of the tongue and face
Pramipexole [Mirapex] (Nonergot Dopamine Agonists)
Used alone in early PD and with levodopa in advancing PD Maximal benefits take several weeks to develop Adverse effects Monotherapy: Nausea, dizziness, daytime somnolence, insomnia, constipation, weakness, and hallucinations Combined: Orthostatic hypotension, dyskinesias, and increase in hallucinations Rare instances of pathologic gambling and other compulsive self-rewarding behaviors
Tolcapone [Tasmar]
Used only in conjunction with levodopa Benefits derived from inhibiting levodopa metabolism in the periphery, which prolongs levodopa availability Improves motor function and may allow for a reduction in levodopa dosage Reduces the "wearing-off" effect that can occur with levodopa, thereby extending levodopa "on" times by as much as 2.9 hours a day Deaths from liver failure have occurred Treatment should be limited to 3 weeks in the absence of a beneficial response
A child takes Adderall XR (amphetamine/dextroamphetamine mixture) for ADHD. The nurse should assess the child for which adverse effects?
Weight loss, restlessness, and chest pain
Bromocriptine (Advantages)
When combined with levodopa, bromocriptine can prolong therapeutic responses and reduce motor fluctuations Bromocriptine allows the dosage of levodopa to be reduced The incidence of levodopa-induced dyskinesias may be reduced
Drug Therapy for MS
immunomodulators Interferon beta-1a [Avonex] Interferon beta-1a [Rebif] Interferon beta-1b [Betaseron, Extavia] Glatiramer acetate [Copaxone] Natalizumab [Tysabri] Fingolimod [Gilenya] Teriflunomide [Aubagio] Dimethyl fumarate [Tedfidera]
Interferon is a
naturally occurring glycoprotein with antiviral, antiproliferative, and immunomodulatory actions
