A AND R PHARM ASSIGNMENT 3

1.What is true of hypnotics? a.Mechanisms of action include suppression of the reticular activating system that controls wakefulness in our brains. b.Nursing implications include warning against an adverse effect of zolpidem in which some patients sleep-walk and perform activities that are not remembered the next morning. c.The effect of benzodiazepines in the motor cortex helps to relax muscles, thus helping with sleep. d.All the above. 2.The phrase “start low, go slow” can apply to , because . tion of pain medications for the elderly : the diminished function of liver and kidneys increase risk of drug toxicity. uctions for patients weaning off of chronic opioid use : if they try to stop cold turkey it will be immediately life-threatening. Withdrawal from opioids is very distressing and often painful, but not life-threatening. (On the other hand, withdrawal from alcohol can be indeed life-threatening, resulting in seizures and death if not managed correctly, usually with use of a benzo like lorazepam). tic abuse definition : it shows that even if you slowly begin opioid use, it can cause your life to become “low” because of high risk of addiction. of adjuvant medications : they should only be used by themselves and not with any other analgesic. This is the opposite from what “adjuvant” means. Examples of adjuvant drugs are, say, use of non-pain-med-related drugs in addition to pain meds… A person with chronic neuropathic pain often benefits from use of an opioid med PLUS an extra medication like an antidepressant. The antidepressant would in this context be called the adjuvant med. 3.A patient has been admitted after overdosing on acetaminophen (Tylenol), with a total ingested dose of 14 g over a period of 1 hour. The patient’s nurse will expect results showing a high serum creatinine level, indicating renal failure. Much more likely to see S&S of liver failure, not renal failure… see answer D. pain and hyperuricemia, indicating rapid onset of gout. Joint pain and hyperuricemia are S&S of gout, but have no relevance to what the question is asking. tion and anxiety, since this drug blocks reuptake of adrenergic neurotransmitters from neural synapses. Not the mechanism of action for acetaminophen. results showing high liver enzyme levels, indicating hepatic failure. Acetaminophen is notorious for causing liver problems when taken in large amounts either over a long period of time or in one lump amount, as in this case. We really don’t want people taking more than 4gms a day, preferably much less. Labs that measure liver enzymes in the blood, such as AST and ALT are checked, and if the enzymes are high, that means hepatocyte destruction is occurring & releasing enzymes into the blood. 4.The patient in the previous question will likely receive as an antidote one (Narcan) since it blocks the acetaminophen molecules from attaching to opioid receptor sites. Naloxone is important in blocking opioid receptors in the body, thus used when there is opioid overdose (know the name of this drug well, not only for a test, but for the future when you are giving opioids to your patients and may need to give a reversal.) lcysteine (Mucomyst) since it increases glutathione, a substance which enhances the ability of the liver cells to metabolize acetaminophen molecules. zenil (Romazicon) since it increases GABA, a substance which is important in CYP450 enzymatic function. flumazenil is the reversal agent for benzodiazepine overdose… important drug to know, like naloxone, but it doesn’t apply to this question. Also, GABA’s calming effect is enhanced by benzos, not by benzo-blocker like flumazenil. ozam (Versed), a benzodiazepine which will decrease the patient’s agitation and allow the liver to clear the acetaminophen molecules more quickly. Does this sentence make sense to you, based on your readings? Hopefully not. An example of needing to read an answer really closely and realizing that even though it may sound kind of credible, the statement has no factual basis. 5.An RN is speaking to an addiction-cessation group about ways to decrease or stop their addictive substance. Which instructions by the nurse are correct? a.The best way to use a nicotine patch is a step-wise progression of increasing dosage. No —the progression is in decreasing dosages. Often someone with an addiction is encouraged to cut down a little at a time. For instance, if I wanted to lessen my ice cream addiction, I would maybe decrease it by one scoop a day.  b. Chewing nicotine gum will rapidly, temporarily relieve a craving for a tobacco product. The dose goes straight to the blood stream via the highly vascular mucous membranes, just like when a person takes a sublingual medication like nitroglycerin. c.Disulfiram (Antabuse) creates acetaldehyde syndrome and is the best first-line drug for treating DT’s (delirium tremens) in an alcoholic. Disulfiram will create an unpleasant reaction when drinking alcohol, thus it is a preventive. The treatment for DTs would be something that will stop the risk of seizure, so a benzodiazepine such as Ativan is first- line. d.The opioid agonist naltrexone (Revia) is a good treatment for alcohol craving. Revia is a good alcohol-craving treatment for some patients, but it is not an opioid agonist—it is an opioid antagonist. Read answers closely. 6.Massage therapy is ordered as adjunct treatment for a patient with musculoskeletal pain. The patient asks the nurse how “rubbing my muscles” will help the pain go away. The nurse’s response is based on the knowledge that massaging muscles ases the inflammatory response that initiates the painful stimuli. Massage won’t actually decrease inflammation. ates large sensory nerve fibers (A fibers) that send signals to the spinal cord to close the gate, thus blocking painful stimuli from reaching the brain. The gate theory of pain transmission is explained in your book in a simplified fashion, and we’ll keep it simple! Very simplistically, we are going to associate A fibers with inhibition of pain. when stimulated, as in massage, they help to alleviate pain (6th edition: see page 156, 3rd paragraph. 7th edition: pg 144 first paragraph ) ates small sensory nerve fibers (C fibers) that send signals to the spinal cord to open the gate and allow endorphins to reach the muscles and relieve the pain. C fibers = sensing of pain, so they are associated with being able to assess and feel pain. This is an important part of the protective aspect of pain, but not a good thing when it comes to wanting pain relief. The functioning of these fibers is more often associated with chronic pain issues, whereas A fibers are associated with “normal,” short-lived, acute pain. ces the effect of Substance P, which is an endogenous pain-relieving biochemical modulator. Always associate Substance P with PAIN. It is a neurotransmitter whose presence is associated with feeling pain, not pain-relief. (See articles cited in RRD). 7.Joe Hardy, RN, is about to give a dose of hydromorphone (Dilaudid) to his patient, Ms Umbridge. What does this entail? a.Understanding that as a powerful hypnotic, this drug blocks GABA sites in the brain and thus can cause hallucinations. Hypnotics are benzos, so they enhance GABA effect (GABA = calm). Hydromorphone isn’t a benzo. b.Asking Ms. Umbridge about various aspects of her pain, such as onset, palliation factors, describing the quality of the pain, and its quantification. Always try to assess FIRST. c.Understanding the Margo McCaffery maxim that pain should always be carefully described and documented exactly as seen by the healthcare provider. Nope—pain is what the patient says it is, not what the observer “sees.” d.Knowing that with any SSRI antidepressant like this one, one has to be aware of the black box warning against increased suicidal tendencies. Very true that many antidepressants have a blackbox warning about increased suicidal tendencies but remember to pay attention to the stem of the question—it is asking about a med that is NOT an SSRI. (The reason that so many antidepressants can increase risk of suicide is that when a person is suicidally depressed, they often don’t actually have the energy to think of a plan and go through with it. Sometimes, after being on an antidepressant for a little while, their thought processes clear up and energy comes back, and then before the actual depression can lift them out of suicidal thoughts, they go ahead and commit the act.) 8.Ms Umbridge is in the hospital for several days receiving regular doses of hydromorphone. Which is true? a.She will need a daily laxative, because hydromorphone activates opioid receptors in the bowel, causing “calming” of peristalsis and subsequent constipation. b.Constipation is likely because opioids have anticholinergic side effects, which include slowing of parasympathetic stimulation of the GI tract. c.If the patient is switched to an oral pain reliever such as oxycodone, a fairly large dose will initially be needed, since oxycodone is considerably weaker than hydromorphone. d.All the above. 9.You notice that a patient begins having some muscle stiffness, slight tongue-rolling motions and drooling, and mild lip smacking. a.You believe she is having a side effect of too much benzodiazepine and may progress to having respiratory problems. Benzodiazepines don’t cause this problem. b.You are concerned that too much dopamine suppression has occurred from the phenothiazine medication she is taking, and the patient is now having EPS symptoms. A question and answer like this needs step-by-step critical thinking. Students often get confused about the link between oversuppression of dopamine (a risk when a person is on a phenothiazine drug like Thorazine)and S&S of EPS (that is, the same kind of S&S that people with Parkinson’s have). 1.First, what does dopamine do? (See ADDENDUM) It fine-tunes motor movement. Also it modulates elements of behavior and cognition, motivation and reward, mood, attention, and learning. 2.Secondly, what we know about the mechanism of psychoses, and especially schizophrenia (a type of psychosis), is that it is thought to be partly a problem of too much dopamine or overactive dopamine in certain areas of the brain, causing those elements mentioned above to be skewed, resulting in a reality- breach. Delusions, hallucinations, and socially unacceptable behaviors can result. 3.Drugs like chlorpromazine—Thorazine-- (in the phenothiazine class) suppress that overactivity, so that in essence things become “real” again. 4.The problem is, if you suppress dopamine too much, the person starts having disorders of movement (remember, dopamine is important in motor fine-tuning) such as tremors and also the ability to control fine-movements like facial expressions. The result can be either strange repetitive movements of the face (like in the video I directed you to) or someone who resembles a Parkinson’s patient—having no movement at all in their face—a very flat affect; and very jerky movements of the body These are known as extrapyramidal, or EPS, S&S. See pic in this site: 5.So the tongue rolling and lip-smacking is part of this picture of EPS S&S, caused by not enough dopamine from the over-effect (too much) of chlorpromazine (Thorazine). c.Your biggest priority is to halt the progression of tardive dyskinesia, brought on by too much dopamine being released by the patient’s anti-psychotic medications. If not noticed and no intervention takes place, the tongue-rolling and lip-smacking can become an irreversible syndrome called tardive dyskinesia. But this answer is wrong because tardive dyskinesia is brought on by suppression of dopamine, not “too much” dopamine. It is likely that the patient is not receiving enough chlorpromazine and must have her dosage incr