NR293 exam 3, Latest 2022.

NR293 exam 3, Latest 2022. airway, breathing, and circulation ** requires frequent and close observation of the patient at all times What is the priority of general, moderate, and local anesthetics? No. Only general and moderate cause amnesia.  Do local anesthetics cause amnesia?  They paralyze the muscles. They DO NOT provide sedation/analgesia.  What do neuromuscular blocking drugs do?  1. Barbiturates 2. Benzodiazepines 3. Miscellaneous drugs  ** muscle relaxants are also CNS depressants  What are the 3 main groups of CNS depressants?  it is a drug that causes sleep What is a hypnotic drug?  High doses calm the CNS to the point of causing sleep. Low doses calm the CNS without causing sleep.  Do high doses of sedative-hypnotics cause sleep? How about low doses?  Benzodiazepines  "zepam" and "zolam" Examples: - midazolam (Versed) - alprazolam (Xanax) - diazepam (Valium) - lorazepam (Ativan)  MOA: reduces neural excitability  Indications: - relief of anxiety, agitation, and insomnia - treatment of alcohol withdrawal and acute seizure disorders (seizures that won't stop) - balanced anesthesia Contraindications: - allergy - pregnancy - narrow angled glaucoma - sleep apnea - respiratory depression Caution:  - older adults - substance use disroder - mental illness - liver disease  Adverse effects: - CNS depression -- sedation, drowsiness, lethargy, cognitive impairment, amnesia, headache, dizziness, and vertigo  - “hangover” effect (daytime sleepiness) - fall hazard in elderly - withdrawal effects Antidote: flumazenil (Romazicon) Nursing implications: - withdrawal effects can occur if stopped abruptly (taper down on medication)  - addicting; can cause dependency  - don't take with alcohol or other CNS depressants  BBW: benzos + opioids = profound sedation Barbiturates  Example: - phenobarbital (Ancalixir)  MOA: reduce nerve impulses to the cerebral cortex (depress the activity of the CNS); cause memory and judgment impairment Indications: - sedation - seizures  Contraindications:  - respiratory difficulty - severe kidney/liver disease - pregnancy  Adverse effects: - drowsiness, lethargy, dizziness, paradoxical effects, hangover, REM rebound  - increased risk of falls in elderly  Interactions: - enzyme inducer -- drugs metabolize faster - lunesta (Eszopicolone) - zolpidem / zolpidem CR (Ambien) - ramelteon (Rozerem)  What are the 3 miscellaneous drugs for insomnia in the CNS depressant category?  lunesta (eszopiclone) MOA: hypnotic  Caution:  - must allow 8 hours of sleep time - older adults Interactions:  - alcohol  - other CNS depressants  zolpidem (Ambien) MOA: short acting non-benzodiazepine hypnotic  Caution: - controlled release (CR): approved for long term use but can cause somnambulation (sleep walking)  - allow 8 hours of sleep  Adverse effect: fall risk in older adults Interactions: - alcohol  - other CNS depressants  ramelteon (Rozerem) MOA:  - similar to melatonin  - no dependency risk  Caution: - take 30 minutes before bed  - contraindicated in severe liver dysfunction  Adverse effects: - hormonal -- amenorrhea, decreased libido, infertility, and galactorrhea (nipple discharge)  Interactions: - high fat meals delay absorption -- so take on an empty stomach  Muscle Relaxants Examples:  - cyclobenzaprine (Flexeril) - baclofen (Lioresal) MOA:  - work within CNS  - muscle relaxant effects r/t CNS depressant activity  - work best when used along with physical therapy Indications: - muscle spasm r/t muscle injury - management of spasticity in chronic disorders (MS and cerebral palsy) - malignant hyperthermia  Contraindication: severe renal impairment  Adverse effects: - extension of effects on CNS and skeletal muscles -- euphoria, lightheadedness, dizziness, drowsiness, fatigue, muscle weakness, nausea, constipation, and urinary retention - serious: seizures (from baclofen)  Interactions: - other CNS depressants (alcohol and benzos) can cause confusion, anxiety, tremors, and additive hypoglycemia  to decrease pain when paired with therapy  What is the goal of muscle relaxant drugs?  ADHD and Narcolepsy drugs * stimulants * Examples: - methylphenidate (Ritalin) -- ADHD - amphetamine aspartate (Adderall) -- ADHD - modafinil (Provigil) -- narcolepsy  MOA: stimulates areas of the brain associated with mental alertness; may induce euphoria  Adverse effects: "speed up" - increased CV effects (increased HR and BP, dysrhythmias, angina) - decreased appetite -- weight loss and growth suppression - GI distress - physical tolerance and withdrawal reaction; potential for abuse - psychotic manifestations - toxicity  Interactions: - if methyphenidate is taken with MAOIs, a hypertensive crisis can occur - methyphenidate can increase the effects of anticoagulants  Nursing implications: - continuous and cautious patient assessment REQUIRED  - children -- monitor for continued physical growth (height and weight)  - adults -- cardiac assessment (BP, HR, heart sounds, hx of angina/palpitations, and medications) - assess sleep habits/patterns -- last daily dose given at least 4-6 hours before bed to prevent insomnia  - take on empty stomach 30-45 minutes before meals (but can be taken with food to reduce GI upset)  - drug "holidays" may be ordered  atomoxetine (Strattera) - ADHD drug that is a NONamphetamine aka non-addictive - no CNS stimulant effects - BBW: suicidal ideation Anorexiants Example: - phentermine (Lonamin) MOA:  - increases body's basal metabolic rate - suppresses appetite control centers in the brain Indications: treatment of obesity Contraindications: - severe CV disease or uncontrolled HTN - hyperthyroidism - glaucoma - mental agitation - drug abuse/eating disorder Adverse effects: - CV: palpitations, dysrhythmias, increased BP - CNS: anxiety, agitation, dizziness, HA  Antimigraine Drugs: Selective Serotonin Receptor Agonists (SSRAs) "triptans"  Examples: - sumatriptan (Imitrex) - zolmitriptan (Zomig)  MOA:  - rapid vasoconstriction which reduces HA symptoms  - decreased production of inflammatory neuropeptides Administration: - multiple routes; use as directed - TREATMENT; not to be used for prevention - take as soon as HA begins (abortive therapy) - DO NOT administer more than 2 doses in 24 hours Contraindications: - serious CV disease (stroke, TIA, angina, MI, PVD) Adverse effects: - CV vasoconstriction effects  - tingling, flushing, congested feeling - overuse -- rebound headaches Antiepileptic drugs (AEDs) Examples: - benzodiazepines  - phenytoin (Dilantin) - carbamazepine (Tegretol) - divalproex sodium (Depakote) - gabapentin (Neurotin)  MOA:  - alter movement of Na, K, Ca, and Mg ions resulting in increased stabilized, less excitable cell membranes  Indications: - long term maintenance therapy for chronic, recurring seizures (epilepsy) - benzodiazepines: diazepam (Valium) or lorazepam (Ativan) are used to treat status epilepticus  Contraindications:  - allergy - pregnancy Adverse effects: - numerous; vary per drug - adverse effects often necessitate a change in medication  BBW: suicidal thoughts and behavior - control or prevent seizures while maintaining a reasonably quality of life - minimize adverse effects and drug induced toxicity  What are the goals of antiepileptic drug therapy?  narrow -- monitoring is required  Is the therapeutic index for antiepileptic drugs wide or narrow?  Hydantoins Example: - phenytoin (Dilantin) -- protypical drug for epilepsy  Indications: - first line therapy for seizures  Contraindications: - bradycardic heart conditions  - pregnancy BBW: CV risk for rapid infusion - slow IV infusion -- do not exceed 50 mg/min - only diluted in NS; filter must be used - large gauge (16 or 18) IV needed - saline flush after injection/infusion of dose Adverse effects:  - gingival hyperplasia  - dilantin facies (facial changes) - hirsutism - lethargy - abnormal movements - confusion - cognitive changes  Toxicity:  - nystagmus - ataxia - slurred speech - blurred vision - encephalopathy  - hepatitis - steven johnson (skin sloughs off)  Notes: - therapeutic level: 10-20 mcg/ml  - DO NOT stop abruptly or at risk for a seizure  - avoid IV in hands because "purple" glove can happen -- put into large vein  Iminostilbenes Example: - carbamazepine (Tegretol) Indications: - seizures - some psych disorders Contraindications: - pregnancy (cat. d) - absence and myoclonic seizures - bone marrow suppression (BMS) Adverse effects: - BBW: bone marrow suppression; skin hypersensitivity reaction  - autoinduction (causes liver to create more enzymes, which metabolizes the drug quicker)  - CNS: nystagmus, double vision, vertigo, ataxia  - skin disorders: rash or steven johnson  Interactions: - grapefruit - many others  Valproic acid and derivatives  Example: - divalproex sodium (Depakote) Indications: - seizures - bipolar disorder Administration: - PO (liquid, sprinkles) - IV Contraindications: - allergy - liver impairment - pregnancy  Adverse effects: - drowsiness - N/V - weight gain - tremor  - hepatotoxicity - pancreatitis - BMS  Interactions: - highly protein bound -- interacts with many meds  gabapentin (Neurontin) Indications: - seizures - neuropathic pain  Adverse effects: - GI: nausea - CNS: dizziness, drowsiness, visual/speech changes Nursing implications: - reduce dose in renal impairment  Suicidal thoughts and behavior  What is the black box warning for all antiepileptic drugs?  they trick the brain into thinking they're getting alcohol  How do benzodiazepines treat alcohol withdrawal? Respiratory depression. Lunesta is a CNS depressant and cannot be combined with another one.