CENTRAL AND PERIPHERAL
NERVOUS SYSTEM DRUGS
Reporters : Guevara, Tayona, Salcedo,Dosado,Basea,Serneo, Baliao, Camit
NERVOUS SYSTEM
 Composed of all nerve tissues: brain, spinal cord, nerves, and
ganglia.
 Purpose is to receive stimuli and transit information to nerve
centers for an appropriate response.
Two types: Central Nervous System and Peripheral Nervous
System.
CENTRAL NERVOUS SYSTEM
 composed of brain and spinal cord.
 regulates body function.
 interprets information sent by impulses from PNS.
 returns the instruction through the PNS for appropriate
cellular actions.
PERIPHERAL NERVOUS SYSTEM
 Consist of two divisions:
-Somatic nervous system (SNS) – voluntary, acts on skeletal muscles
to produce locomotion and respiration
-Autonomic nervous system (ANS) – involuntary, controls and
regulates the functioning of the heart,respiratory system,
gastrointestinal system and glands.
STIMULANTS
MAJOR GROUPS OF CNS STIMULANTS
Amphetamines and caffeine – stimulate the cerebral
cortex of the brain.
Analeptics and caffeine- act on the brainstem and
medulla to stimulate respiration.
Anorexiants (diethylpropion) – thought to suppress
appetite by stimulating the satiety center in the
hypothalamic and limbic areas of the brain.
PATHOPHYSIOLOGY
Attention-deficit/Hyperativity disorder
 might be caused by dysregulation of the transmitter’s serotonin,
norepiphrine, and dopamine.
 occurs primarily in children.
 characteristic behavioRs includes inattentive, inability to concentrate ,
restlessness (fidgety), hyperactivity, (excessive and purposeless activity)
inability to complete tasks, and impulsivity.
 display poor coordination and there may be abnormal
electroencephalograph (EEG) findings.
AMPHETAMINES
 stimulate the release the
release of the neurotransmitter
norepinephrine, and dopamine
from the brain and sympathetic
nervous system
 inhibit the reuptake of these
transmitters.
 cause euphoria and
increased alertness
 can also cause insomnia,
restlessness, tremors,
irritability, and weight loss.
AMPHETAMINE-LIKE DRUGS FOR
ATTENTION DEFICIT HYPER ACTIVITY
DISORDERAND NARCOLEPSY
METHYLPHENIDATE
 amphetamine-like drugs (CNS stimulant).
 given to increase a child’s attention span and cognitive
performance (e.g., memory, reading).
 decrease impulsiveness, hyperactivity and restlessness.
 used to treat narcolepsy.
 classified as a Controlled Substance Schedule (CSS) II drug because
of the potential for abuse .
METHYLPHENIDATE
PHARMACOKINETICS
 well absorbed in GI mucosa.
 administered to children twice a day before breakfast and lunch.
 should be given 30-45 minutes before meals.
 should be given 6 hours or more before sleep because it can cause
insomnia.
 excreted in the urine.
40% of methylphenidate is excreted unchanged.
METHYLPHENIDATE
PHARMACODYNAMICS
 helps to correct ADHD by decreasing hyperactivity and improving attention
span.
 prescribed for also treating narcolepsy
 considered generally more effective in treating ADHD than amphetamines,
which is generally avoided because they have higher potential for abuse.
 potentials the action of CNS stimulants such as caffeine
 inhibits the metabolism of some barbiturates such as phenobarbital which
can lead to increased blood levels and potential toxicity.
METHYLPHENIDATE HYDROCLORIDE
NURSING PROCESS
Assessment
Determine whether the patient has a history of heart disease, hypertension,
hyperthyroidism, parkinsonism, or glaucoma; in such cases, this drug is usually
contraindicated.
Assess vital signs to be used for future comparisons. Closely monitor patients with
cardiac disease because this drug may cause tachycardia , hypertension, and stroke.
Assess patient mental status , such as mood, affect and aggressiveness.
Evaluate height, weight , and growth of children.
Assess complete blood count (CBC), differential white blood cells (WBCs), and platelets
before and during therapy.
METHYLPHENIDATE HYDROCLORIDE
NURSING PROCESS
Nursing Diagnoses
Planning
Health Behavior, Risk Prone that interfere
with peer relationships, learning, and
discipline,
Patient’s hyperactivity will be decrease.
Family Processes, Interrupted related to
dysfunctional behaviour.
Patient’s blood pressure and heart rate will
be within normal limits.
Development, Risk for Delayed
Patient will behave in calm manner.
Knowledge, Deficient related to
inexperience with methylphenidate drug
regimen.
Patient’s attention span will increase.
METHYLPHENIDATE HYDROCLORIDE
NURSING PROCESS
Nursing Intervention
Patient Teaching
Monitor vital signs and report irregularities
 Teach patients to take the drug
before meals.
Evaluate height, weight, and growth of the
children.
Observe patients for withdrawal symptoms
such as nausea, vomiting, weakness and
headache.
Monitor patients for side effects such as
insomnia, restlessness, nervousness, tremors,
irritability, tachycardia, and elevated blood
pressure. Report findings
METHYLPHENIDATE HYDROCLORIDE
NURSING PROCESS
Patient Teaching
Diet
Advise petients to avoid alcohol consumption.
Advise patients to avoid foods that contain
caffeine (e.g., coffee, tea, chocolate, soft drinks,
and energy drinks.)
driving and using hazardous equipment when
experiencing tremors, nervousness, or increased
heart rate.
Teach patients not to abruptly discontinue the
drug; the dose must be tapered to avoid
withdrawal symptoms. Consult care provider
before modifying doses.
Encourage patients to read labels on over-thecounter (OTC) products because many contain
caffeine. A high plasma caffeine level could be
fatal.
Encourage parents to provide children with a
nutritious breakfast because the drug may have
anorexic effect.
METHYLPHENIDATE HYDROCLORIDE
NURSING PROCESS
Side Effects
Evaluation
Teach patients about drug about
drug side effects and the need to
report tachycardia and palpitations
 Evaluate effective of drug therapy, level
of hyperactivity, and presence of adverse
effects.
Monitor children for onset Tourette
syndrome.
Monitor weight, sleep patterns, and
mental status.
Evaluate patient knowledge of
methylphenidate therapy.
ANOREXIANTS AND ANALEPTICS
ANOREXIANTS
ANALEPTICS
 used to suppressed appetite
 are CNS stimulants.
 do not have the serious side
effects associated with
amphetemines.
 mostly affect the brainstem,
spinal cord and cerebral
cortex.
 individuals who take
anorexiants should be under the
care of health care of a health
care provider.
 primary use is to stimulate
respiration.
ANOREXIANTS AND ANALEPTICS
SIDE EFFECTS AND ADVERSE EFFECT
Similar to those from anorexiants:
 Nervousness
Diuresis (increased urination)
Restlessness
Tremors
GI irritation (e.g., nausea,
diarrhea)
Twitching
Tinnitus (ringing in the ear)
Palpitations
Insomnia
DEPRESSANTS
SEDATIVE-HYPNOTICS
 commonly ordered for treatment of sleep disorders.
 mostly used during daytime.
 increasing the drug dose can produce hypnotic effect-not
hypnosis but form of natural sleep.
 were first prescribed to reduce tension and anxiety.
BENZODIAZEPINES
 ordered as sedative-hypnotics for inducing sleep.
 several benzodiazepines marketed as hypnotics include
flurazepam, alpaszolam (Prototype Drug),Temazepam, traizolam,
estazolam, and quazepam.
 classified as schedule IV according to the Controlled Substances
Act.
 increase the action of the inhibitory neurotransmitter gammaaminobutyric acid (GABA) receptors.
BENZPODIAZEPINES
PHARMACOKINETICS
are well absorbed from the gastrointestinal (GI) tract
peak levels achieved in 30 minutes to 2 hours
lipid soluble and well distributed throughout the body,
crossing the placenta and entering breast milk.
metabolized extensively in the liver.
Patients with liver disease must receive a smaller dose and
be monitored closely.
Excretion is primarily through the urine.
BENZPODIAZEPINES
PHARMACODYNAMICS
 used to treat insomnias by inducing and sustaining sleep.
 have rapid onset of action and immediate to long acting
effects.
 normal recommended dose of benzodiazepine maybe too
much for older adult, therefore half the dose is
recommended initially to prevent overdosing.
BENZPODIAZEPINES
NURSING PROCESS
Assessment
 Obtain a drug history of current drugs complementary and alternative therapies
that the patient is taking, especial CNS depressants, which would potentiate
respiratory depression and hypotensive effects.
 Assess base line vital signs for future comparison.
 Determine whether the patient has a story of insomnia or anxiety disorders.
 Assess renal function. Urine output should be 1500 ml/day. Renal impairment
could prolong drug action by increasing the half-life of the drug.
BENZPODIAZEPINES
NURSING PROCESS
Nursing Diagnoses
 Sleep Deprevation related to adverse effect of
insomnia.
 Injury, risk fur breathing pattern ineffective.
 Breathing Patern, ineffective relative to CNS
depression.
 Sexuality Pattern, Ineffective related to
adverse effect of erectile dysfunction.
Nursing Intervention
 Monitor vital signs, especially respiration and blood
pressure.
 Use a bed alarm for older adults and for patient
receiving a hypnotic for the first time .Confusion can
occur, and injury could result.
 Observe the patient for adverse reaction, especially
an older adult or a debilitated patient.
 Examine he patient skin for rashes. Skin eruptions
may occur in patients in patient taking
benzodiazepine.
BENZPODIAZEPINES
NURSING PROCESS
Patient Teaching
 Teach patients to use non-pharmacologic to induce sleep such as taking warm bath, listening to quite
music, drinking warm fluids, and avoiding drinks with caffeine for 6 hours before bedtime.
 Encourage patient to avoid and antidepressant, antipsychotic, and opioid drugs while taking
benzodiazepines. Respiratory depression can occur while these drugs are combined.
 Warm patients that certain complementary and alternative therapy products may interact with
benzodiazepines. These products may need to be discontinued or the prescription drug dose may need to be
modified.
 Advise patient not to drive a motor vehicle or operate machinery when using benzodiazepines. Caution is
always encouraged
 Encourage patient to check with a health care provider about OTC sleeping aids. Drowsiness may result
from taking these drugs, therefore caution while driving is advised.
BENZPODIAZEPINES
NURSING PROCESS
Side effects
 Advise patient to report adverse reactions
such as cognitive changes and paradoxical
reactions to their health care provider.
Drug selection or dosage might need to be
changed.
 Teach patients that benzodiazepines
should be gradually withdrawn, especially
if they have been taken for several weeks.
Abrupt cessation may result in withdrawal
symptoms such as tremors and muscles
twitching.
Evaluation
 Assess the effectiveness of
benzodiazepines.
 Evaluate respiratory status to ensure that
respiratory depression has not occurred.
ANESTHETICS
 classified as general and local
 general anesthetics depress the CNS, alleviate pain, and
cause a loss consciousness
 first anesthetics, is nitrous oxide (laughing gas) was used
for surgery in the early 1800’s. It is still anesthetic and is
frequently used in dental procedure and surgery.
BALANCED ANESTHESIA
a combination of drugs frequently used in general anesthesia.
 include the following:
◦ A hypnotic given the night before
◦ Premedication with an opioid analgesic or benzodiazepines (e.g., midazolam) plus an
anticholinergic ( e.g., atropine) given about 1 hour before surgery to decrease secretion
◦ a short-acting nonbartirurate such as protofol
◦ an inhaled gas, often a combination of an inhalation anesthetic, nitrous oxide, and oxygen
◦ a muscles relaxant given as needed.
BALANCED ANESTHESIA
minimizes cardiovascular problems.
 decreases the general anesthetic needed
 reduces possible postanesthasia nausea and vomiting
 minimizes the disturbance of organ function
 decreases pain
INHALATION ANESTHETICS
provide smooth induction.
usually combined with a non-barbiturate, such as propofol,
strong analgesic such as morphine and a muscle relaxant, such
as pancuronium for surgical procedures.
adverse includes respiratory depression,
dysrhythmias and hepatic dysfunction.
hypotension,
INTRAVENOUS ANESTHETICS
used for general anesthesia or for the induction stage of
anesthesia
 propofol, droperidol, etomidate and ketamine hydrochloride
are commonly used to provide total intravenous anesthetics
(TIVA).
 adverse effects include respiratory and cardiovascular
depression
TOPICAL ANESTHESIA
Use of topical anesthesia agents limited to mucous
membrane, broken or unbroken skin surface, and burns
comes in different forms: solution, liquid sprays,
ointment, creams, gel and powers
LOCAL ANESTHETICS
block pain at the site where the drugs is administered by
preventing conduction of nerve impulses.
useful in dental procedures, suturing skin laceration, shortterm (minor) surgery at a localized area, blocking nerve
impulses (nerve block) below the insertion of a spinal
anesthetics, and diagnosis procedure such as lumbar puncture
and thoracentesis.
LOCAL ANESTHETICS
block pain at the site where the drugs is administered by preventing
conduction of nerve impulses.
useful in dental procedures, suturing skin laceration, short-term (minor)
surgery at a localized area, blocking nerve impulses (nerve block) below
the insertion of a spinal anesthetics, and diagnosis procedure such as
lumbar puncture and thoracentesis.
divided into two groups, the esters, and the amides, according to their
basic structures. The amides have a very low incidence of allergic
reaction.
SPINAL ANESTHETICS
requires that local anesthetics be injected into the subarachnoid
space below the first lumbar (L1) in adults are the third lumbar
space (L3) in children.
Various sites of the spinal column can be used for a nerve block
with s local anesthetics.
Spinal blocks results from the penetration of the anesthetics into the
subarachnoid space, which is space between the pia mater membrane and
the arachnoid membrane.
SPINAL ANESTHETICS
Epidural block is a placement of the local anesthetics in the epidural space
just posterior to the spinal cord or the dura mater.
Caudal block side is an epidural block placed by administering a local
anesthetics through the sacral hiatus.
Saddle block is given at the lower end of the spinal column to block the
perineal area.
NURSING PROCESS
Assessment
 Assess baseline vital sign.
Obtain a drug and health history,
noting drugs that effect the
cardiopulmonary system.
Nursing Diagnosis
 Pain, acute related to injury
Breathing pattern, ineffective
related to CNS
NURSING PROCESS
Planning
 Patient will participate in preoperative and will understand
postoperative care.
 Patient vital sign will remain stable following surgery.
NURSING PROCESS
Nursing Intervention
 Monitor the postoperative state of sensorium. Report if a patient remain
excessively nonresponsive or confused.
Observe preoperative urine output. Report deficit of hourly of 8 hour of urine
output.
Monitor vital sign following general and local anesthesia; hypotension and
respiratory depression may result.
Administer an analgesic or a narcotic-analgesic with caution until the patient fully
recovers from the anesthetic. To prevent adverse reaction, the dosage might need
to be adjusted if the patient is under the influence of anesthetics.
NURSING PROCESS
Patient Teaching
Evaluation
 Explain to the patients the
preoperative preparation and
postoperative nursing
assessment and intervention.
 Evaluate the patient’s
response to the anesthetics.
Continue to monitor for
adverse reaction.
ANTISEIZURE DRUGS
ANTISEIZURE DRUGS
Drugs used for epileptic seizure are
called antiseizure drugs, anticonvulsants,
or antiepileptic drugs. (AEDs)
Stabilizes nerve cell membranes.
Suppress the abnormal electric impluses
in the cerebral cortex.
Prevent seizures but do not eliminate
the cause or provide a cure.
Classified as central nervous system (CNS)
depressants.
With the use this drug, seizures are
controlled in approximately 70% of the
patients.
Usually taken throughout the persons
lifetime; however the healthcare provider
might discontinue the medication if no
seizure have occurred after 3 to 5 years in
some cases.
ANTISEIZURE DRUGS
 Used to treat seizures, including the hydantoins (phenytoin), long acting barbiturates phenobarbital,
mephobarbital,primidone), succinimides (ethosuximide), benzodiazepines (diazepam, clonazepam),
carbamazepine, and valproate (valporoic acid).
 Are not indicated for all types of seizures, example is phenytoin.
 Works in three ways:
(1) by suppressing sodium influx through the drug binding to the sodium channel when
activated
(2) by suppressing the calcium influx
(3) by increasing the gamma-aminobutyric acid (GABA)
PHENYTOIN
 effective in treating tonic-clonic and partial seizures
 but not effective in treating absence seizures.
PHENYTOIN
PHARMACOKINETICS
slowly absorbed from the small intestine.
highly protein-bound (90-95%) drug, therefore a decrease in
serum protein or albumin can increase the free phenytoin serum
level
 with a small average drug dose, the half-life of phenytoin is
approximately 24 hours.
range can be from 7 to 42 hours.
metabolized to inactive metabolites
 excreted in the urine.
PHENYTOIN
PHARMACODYNAMICS
onset of action within 30 mins to 2 hours
peak serum concentration in 1.5 to 6 hours
steady state of serum concentration in 7 to 10 days
duration of action dependent on the half-life of up to 45 hours.
most commonly ordered as a sustained- release (SR) capsule.
The peak SR concentration time is 4 to 12 hours.
PHENYTOIN
SIDE EFFECTS
 headache
 diplopia
 nystagmus
 confusion
 dizziness
drowsiness
 insomnias
 fatigue
ataxia
 tremor
 rash
ataxia
 tremor
 rash
 gingival
hyperplasia
 anorexia
 nausea
 vomiting
PHENYTOIN
ADVERSE EFFECT
Leukopenia
Hepatic impairment
Depression
Hyperglycemia
Bradycardia
Peripheral neuropathy
 purple glove syndrome
PHENYTOIN
NURSING PROCESS
ASSESSMENT
 Obtain a health history that includes current drugs and herbs the patient uses.
Report and document any probable drug-drug or herb- drug interactions.
Assess the patient knowledge regarding the medication regimen.
Check urinary output to determine whether it is adequate (.1500 mL/d)
Determine laboratory values related to renal and liver function. If both blood urea
nitrogen (BUN) and creatinine levels are elevated serum level enzymes (alkaline
phosphatase, alanine aminotransferase, gamma-glutamyl transferase, 59nucleotidase) indicate a hepatic disorder.
PHENYTOIN
NURSING PROCESS
NURSING DIAGNOSES
 Injury, risk for
Oral mucous membranes, impaired related to blood dyscrasias
Nutrition, imbalanced: less than body requirements related to
anorexia
Falls risk for
PHENYTOIN
NURSING PROCESS
PLANNING
 Patients seizure frequency will diminish.
Patient will adhere to antiseizure drug therapy
Patients side effects from phenytoin will be minimal.
PHENYTOIN
NURSING PROCESS
NURSING INTERVENTION
Monitor serum drug levels of antiseizure medication to determine therapeutic range (10 to 20
mcg/mL)
Encourage patients compliance with medication
 Monitor patients complete blood count (CBC) levels for early detection of blood dyscarasias.
Use seizure precautions (environmental protection from sharp objects, such as table corners) for
patients at risk seizures.
Determine whether the patient is receiving adequate nutrients; phenytoin may cause anorexia,
nausea, and vomiting.
Advise female patients who are taking oral contraceptives and antiseizure drug to use an additional
contraceptive method.
PHENYTOIN
NURSING PROCESS
PATIENT TEACHING
Teach patients to shake suspension form
medication thoroughly before use to
adequately mix the medication to ensure
accurate dosage.
Advise patients not to drive or perform other
hazardous activities when initiating antiseizure
therapy as drowsiness may occur.
Counsel female patients contemplating
pregnancy to consult with a health care
provider because phenytoin and valproic acid
may have a teratogenic effect.
Monitor serum phenytoin levels closely during
pregnancy because seizures tend to become more
frequent due to increased metabolic rates.
Warn patients to avoid alcohol and other central
nervous system depressants because they can cause
an added depressive effect on the body.
Explain to patients that certain herb can interact
with antiseizure drugs and dose adjustment may be
required.
Encourage patients to obtain a medical alert
identification card, medical alert bracelet, or tag
that indicates their diagnosis and drug regimen.
PHENYTOIN
NURSING PROCESS
PATIENT TEACHING
Teach patients not to abruptly stop drug
therapy but rather to withdraw the prescribed
drug gradually under medical supervision to
prevent seizure rebound (recurrence of
seizures) and status epilepticus.
Teach patients not to self-medicate with over
the counter drugs without first consulting a
health care provider.
Counsel patients about the need for
preventive dental checkups.
Advise patients with diabetes to monitor
serum glucose levels more closely than usual
because phenytoin may inhibit insulin
release, causing an increase in glucose level.
Warn patients to take their prescribed
antiseizure drug, get laboratory tests as
ordered, and keep follow-up visits with health
care providers.
Inform patients of the existence of national,
state, and local associations that provide
resources, current information, and support
for people for people with epilepsy.
PHENYTOIN
NURSING PROCESS
DIET
SIDE EFFECTS
 Tell the patients that urine may be a harmless pinkish
 Coach patients to take
antiseizure drugs at the same time red or reddish brown color.
every day with food or milk.
Advise patients to maintain good oral hygiene and to use
a soft toothebrush to prevent gum irritation and
bleeding.
Teach patients to report symptoms of sorethroat,
bruising, and nosebleeds, which may indicate a blood
dyscrasia.
Encourage patients to inform health care providers of
adverse reactions such as gingivitis, nystagmus, slurred
speech, rash and dizziness. (stevens-johnson syndrome
begins with a rash).
PHENYTOIN
NURSING PROCESS
EVALUATION
 Evaluate effectiveness of drug in controlling seizures.
Monitor serum phenytoin levels to determine whether they are within the
desired range. High serum levels of phenytoin are frequently indicators of
phenytoin toxicity.
Monitor patients for hydantoin overdose. Initial symptom,ms are nystagmus
and ataxia (impaired coordination). Later symptoms are hypotension,
unresponsive pupils, and coma. Respiratory and circulatory support, as well
as, hemodialysis, are usually used in the treatment of phenytoin overdose.
DRUGS FOR PARKINSON’S
DISEASE AND ALZHEIMER
DISEASe
PARKINSON’S DISEASE
a chronic neurologic disorder.
 affects the extrapyramidal motor tract which controls posture,
balance and locomotion.
most common form of the parkinsonism which is considered a
syndrome or a combination of similar symptoms.
major features of parkinsonism includes: rigidity (abnormal
increase muscle tone), bradykinesia (slow movement), gait
disturbances and tremors.
PARKINSON’S DISEASE
Drugs used to treat parkinsonism reduce the symptoms or replace the
dopamine deficit. The drugs fall into five categories:
Anticholinergics – it blocks the cholinergic receptors.
Dopaminergics – converts the dopamine
Dopamine agonist – stimulates the dopamine receptors.
MAO-B Inhibitor – it inhibits the monoamine-oxidase B; the monoamine-oxidase
B enzymes interferes with dopamine.
COMT Inhibitors – it inhibits the catechol-o-methyltransferase enzymes that
inactivates dopamine.
ANTICHOLINERGICS DRUGS
reduces the rigidity and some tremors characteristic of Parkinsonism but have
minimal effect on bradykinesia.
 are parasympatholytics that inhibits the release of acethylcholine.
 still used to treat drug-induced parkinsonism or pseudoparkinsonism, a side effect
of the antipsychotic drug group phenothiazines.
Examples of anticholinergics used for parkinsonism include:
Trihexyphenidyl (artane)
Procyclidine (kemadrin)
Benztropine (congentin)
Ethopropazine (parsidol)
Biperiden (akineton)
Orphenadrine (norflex)
NURSING PROCESS
ASSESSMENT
Obtain a health history. Report any history of glaucoma, gastrointestinal (GI)
dysfunction, urinary retention, angina or myasthenia gravis. All anticholinergics are
contraindicated if a patient has glaucoma.
Obtain drug history. Report if any probable drug-drug interactions such as with
phenothiazines, tricyclic antidepressants (TCAs) and antihistamine which increase the
effect of trihexyphenidyl.
Assess baseline vital signs for future comparison. The pulse rate may increase.
Assess the patient’s knowledge regarding the medication regimen.
Determine usual urinary output as a baseline for comparison. Urinary retention may
occur with continuous use of anticholinergics.
NURSING PROCESS
NURSING DIAGNOSES
Mobility, impaired physical related to muscle rigidity, tremors and
bradykinesia.
Elimination, impaired urinary related to urinary retention
Knowledge deficient related to unfamiliarity with the drug regimen.
NURSING PROCESS
PLANNING
NURSING INTERVENTION
Patient will have decreased
involuntary symptoms
caused by parkinson’s
disease or drug-induced
parkinsonism.
Monitor vital signs, urine output
and bowel sounds. Increased pulse
rate, urinary retention and
constipation are side effects of
anticholinergics.
Observe for involuntary
movements.
NURSING PROCESS
PATIENT TEACHING
Advise patients to avoid alcohol,
cigarettes, caffeine and aspirin to
decrease gastric acidity.
SIDE EFFECTS
Encourage patients to relieve a dry mouth with hard candy, ice
chips, or sugarless chewing gum. Anticholinergics decreased
salivation.
Suggest the patients use sunglasses in direct sunlight because of
possible photophobia.
Advise patients to void before taking the drug to minimize urinary
retention.
Counsel patients who take an anticholinergic for control of
symptoms of parkinson’s disease to have routine eyes examination
because anticholinergics are contraindicated in patients with
glaucoma.
NURSING PROCESS
EVALUATION
 Evaluate the patient’s response to trihexyphenidyl or
benztropine mesylate to determine whether Parkinson’s
disease symptoms are controlled.
DOPAMINERGICS
(CARBIDOPA AND LEVODOPA)
LEVODOPA
first dopaminergic drug.
was introduced in 1961 but no longer
available in the United States.
 was effective in diminishing symptoms of
parkinson’s disease and increasing mobility .
This is because the blood-brain barrier
admits levodopa but not dopamine.
 enzyme dopa decarboxylase converts
levodopa to dopamine in the brain, but this
enzyme can also be found in the peripheral
nervous system and allows 99% levodopa to
be converted to dopamine before it reaches
the brain.
only about 1% of levodopa takes is available to be
converted to dopamine once it reaches the brain and
large doses are needed to achieve a pharmacologic
response.
high doses could cause many side effects including
nausea, vomiting, dyskinesia, orthostatic
hypotension, cardiac dysrhythmias and psychosis.
 Carbidopa was developed to inhibit the enzyme
dopa decarboxylase, by inhibiting the enzyme in the
peripheral nervous system, more levodopa reaches
the brain.
 carbidopa is combined with levodopa in a ratio of 1
part of carbidopa to 10 parts of levodopa.
DOPAMINERGICS
(CARBIDOPA AND LEVODOPA)
Advantages of combining levodopa with carbidopa are the following:
- More dopamine reaches the basal ganglia.
- Smaller doses of levodopa are required to achieve the desired effect.
 Disadvantages of combining levodopa and carbidopa are the following:
- More levodopa available
- More side effects may occur
- Psychotic behaviour
NURSING PROCESS
ASSESSMENT
Obtain vital signs to use for future comparisons.
Assess the patients for signs and symptoms of Parkinson’s disease including
stooped forward posture, shuffling gait, masked facies and resting tremors.
Obtain a patient history that includes glaucoma, heart disease, peptic ulcers,
kidney or liver disease and psychosis.
Obtain a drug history, report if drug-drug interaction is probable. Drugs that
should be avoided or closely monitored are carbidopa-levodopa, bromocriptine
and anticholinergics.
NURSING PROCESS
NURSING DIAGNOSES
NURSING INTERVENTION
Mobility impaired physical
related to dizziness
Monitor vital signs and electrocardiogram.
Orthostatic hypotension may occur during early
use of carbidopa-levodopa and bromocriptine.
Instruct patient to rise slowly to avoid faintness.
Activity intolerance risk for
Falls risk for
Knowledge deficient related
to unfamiliar medications.
Observe for weakness, dizziness, or syncope
which are symptoms of orthostatic hypotension.
Administer carbidopa-levodopa with lowprotein foods. High-protein diets interfere with
drug transport to the central nervous system
(CNS).
NURSING PROCESS
PATIENT TEACHING
EVALUATION
Urge patient no to abruptly discontinue the
medication. Rebound Parkinson's disease
(increase symptoms of Parkinson’s disease)
can occur.
Evaluate effectiveness of drug
therapy in controlling symptoms of
Parkinson’s disease.
Inform the patient that urine may be
discolored and will darken the exposure to air.
Perspiration may also be dark. Explain that
both are harmless but clothes may be stained.
Advise patient to avoid chewing or crushing
extended released tablets.
Determine if there is an absence of
side effects.
Determine if the patient and family
have increased knowledge of the
drug regimen.
ALZHEIMER DISEASE
 an incurable dementia illness characterized by chronic
progressive neurodegenerative conditions with mark cognitive
dysfunction.
 onset usually occurs between 45 and 65 years of age.
are genetic predisposition, virus, infection or inflammation
that attacks brain cells as well as nutritional, environmental
and immunologic factors.
RIVASTIGMINE
 an Acetylcholinesterase (Ache) inhibitor.
 prescribed to improve cognitive function for patients with mild
moderate Alzheimer disease.
 increases the amount of ACh at the cholinergic synapses.
 tends to slow the disease process.
 has fewer drug interactions than donepezil.
RIVASTIGMINE
PHARMACOKINETICS
 absorbed faster through the GI tract without food.
 has relatively short half-life.
 given twice a day
 dose is gradually increased.
 protein power is average.
RIVASTIGMINE
PHARMACODYNAMICS
 has been successful improving memory in mild to moderate
Alzheimer disease
 onset of action is 0.5 to 1.0 hour for topical application.
 peak action is 8 to 16 hour.
 when given orally, peak is 1 hour.
RIVASTIGMINE
SIDE EFFECTS
ADVERSE EFFECT
 Anorexia,
 Depression
Seizures
Life threatening:
 Abdominal pain
Confusion
Bradycardia
 Hepatoxicity
 Nausea
Peripheral edema
Orthostatic
Dysrhythmias
 Vomiting
Dry mouth
Hypotension
Suicidal ideation
 Diarrhea
Dehydration
Cataracts
Constipation
Nystagmus
Myocardial infarction
Stevens Johnson
syndrome
Weight loss
Dizziness
Headache
Heart failure
RIVASTIGMINE
NURSING PROCESS
ASSESSMENT
Assess the patient’s mental and physical abilities. Note limitation of cognitive function and self
care.
Obtain a history that includes any liver or renal disease or dysfunction.
Assess for memory and judgment losses. Elicit from family members a history of behavioral
changes such as memory loss, declining interest in people or home, difficulty in following
through with simple activities and a tendency to wander from home.
Observe for signs of behavioral disturbances such as hyperactivity, hostility and wandering.
Examine the patients for signs of aphasia or difficulty in speech.
Note motor function.
Determine family members ability to cope with the patients mental and physical changes.
RIVASTIGMINE
NURSING PROCESS
NURSING DIAGNOSES
Self-care deficit, feeding related to memory
loss
Family processes, interrupted related to
decreased cognition
Self-care deficit, bathing related to memory
loss
Coping, compromised family related to
overwhelming disruption of lifestyle.
Self-care deficit, toileting related to memory
loss
Nutrition, imbalanced: less than body
requirements related to anorexia, nausea
and vomiting.
Confusion, chronic related to memory loss
RIVASTIGMINE
NURSING PROCESS
PLANNING
NURSING INTERVENTIONS
Patients memory will be improved.
Maintain consistency in care
Patient will maintain self-care of
body functions with assistance.
Assist the patient in ambulation and activity
Monitor for side effects related to continuous
use of acetylcholinesterase inhibitors.
Record vital signs periodically. Note signs of
bradycardia and hypotension.
Observe any patient behavioral changes and
note any improvement or decline.
RIVASTIGMINE
NURSING PROCESS
PATIENT TEACHING
Explain to the patient and family the purpose for the prescribed drug therapy.
Clarify times for drug dosing and schedule for increasing drug dosing to the family
member responsible for the patient’s medication.
Teach family members about safety measures such as removing obstacles in the
patients path to avoid injury when the patient wanders.
Inform family members of available support groups such as the Alzheimer Disease
and Related Disorders Association.
RIVASTIGMINE
NURSING PROCESS
SIDE EFFECTS
DIET
Inform patients and family
member that the patient should
rise slowly to avoid dizziness
and loss of balance.
Inform family members about
foods that may be prepared for
the patient’s consumption and
tolerance.
Monitor routine liver function
tests because hepatotoxicity is
in adverse effects.
RIVASTIGMINE
NURSING PROCESS
EVALUATION
Evaluate effectiveness of the drug regimen by determining whether
the patient’s mental and physical status shows improvement from
drug therapy.
DRUGS FOR NEUROMUSCULAR
DISORDERS AND MUSCLE
SPASMS
MYASTHENIA GRAVIS
 is an acquired autoimmune
 disease that impairs the transmission of
message at the neuromuscular junction,
resulting in fluctuating muscle weakness
that increases with muscle use.
occur in people of any ethnicity and sex
 however peaks in women around the
child bearing years, where peak onset
on men is in between 50 and 70 years.
 causes fatigue and muscular
weakness of the respiratory system,
facial muscles, and extremities.
due to cranial nerve involvement,
ptosis (drooping eyelid) and
difficulty in chewing and swallowing
occur.
symptoms are caused by
autoimmune destruction of
acetylcholine (Ach) sites and a
resultant decrease in neuromuscular
transmission.
PYRIDOSTIGMINE
 used to control and treat myasthenia gravis, for
neuromuscular blockage reversal, and for nerve gas (soman)
exposure prophylaxis mode of action:
-Promotes transmission of neuromuscular impulses
across the myoneural junctions by preventing
destruction of acetylcholine.
PYRIDOSTIGMINE
PHARMACOKINETICS
Poorly absorbed in GI tract.
Metabolized in the liver.
Half of the sustained-released capsule is
absorbed, but the balance is poorly
absorbed.
Excreted in the urine.
Half life of oral pyridostigmine is 3 to 7 hours
and 2 to 3 hours for intravenous (IV)
administration
Because of its short half-life , pyridostigmine
must be administered several times a day.
PYRIDOSTIGMINE
PHARMACODYNAMICS
Increases muscle strength in patients with muscular weakness resulting
from MG.
Onset action is between 30 to 45 minutes
Peak is 1 to 3 hours and duration of 3 to 4 hours.
Overdose of Pyridostigmine can result the signs and symptoms of
cholinergic crisis.
PYRIDOSTIGMINE
NURSING PROCESS
ASSESSMENT
NURSING DIAGNOSES
 Obtain a drug history from the patient that  Breathing Pattern, Ineffective related to
includes all current medications.
weak respiratory muscles.
Observe the patient’s drug profile for
possible drug interactions.
Activity Intolerance related to fatigue.
Anxiety related to possible recurrence of
Patients should avoid atropine, atropine-like myasthenic crisis and dyspnea.
drugs , and muscle relaxants.
Knowledge, Deficient related to unfamiliar
Record baseline vital signs.
medications.
Assess patient for signs an symptoms of
myasthenic crisis, such as muscle weakness
with difficulty breathing and swallowing.
PYRIDOSTIGMINE
NURSING PROCESS
PLANNING
NURSING INTERVENTION
Patient’s symptoms of muscle
weakness and difficulty breathing and
swallowing caused by MG will be
eliminated or reduced in 2 to 3 days.
 Monitor effectiveness of drug therapy (Ache
inhibitor).Muscle strength should be increased. Both depth
and rate of respirations should be assessed and maintained
within normal range.
Administer prescribed acetylcholinerase inhibitor following
dosage recommendations and nursing guidelines.
Observe patient for signs and symptoms of cholinergic
crisis caused by overdosing, Such as respiratory failure,
increased salivation, sweating, and bronchial secretions
along with miosis.
Have an antidote for cholinergic crisis (atropine sulphate)
readily available.
PYRIDOSTIGMINE
NURSING PROCESS
PATIENT TEACHING
SIDE EFFECTS
Teach patients to take drugs as
ordered to avoid recurrence of
symptoms.
 Teach patient about the side effects of
medication and when to notify the health care
provide.
Encourage patients to wear a medical
identification bracelet or necklace
that indicates health problems
Advise patients to report recurrence of
symptoms of MG to the health care provider.
PYRIDOSTIGMINE
NURSING PROCESS
DIET
EVALUATION
Inform patients to take the
drug before meals for best
absorption. If gastric
irritation occurs, take the
drug with food.
 Evaluate effectiveness of the drug therapy
to maintain muscle strength.
Determine the absence of respiratory
distress.
Evaluate the correct use of the drug by the
patient.
MUSCLE RELAXANT
 relieve muscular muscle spasms and pain associated with traumatic
injuries and spasticity from chronic debilitating disorders ( MS, stroke
[CVA], cerebral palsy, head and spinal cord injuries)
Central muscle relaxant- is used in case of spasticity to suppress
hyperactive reflex and for muscle spasms that do not respond to anti
inflammatory agents, physical therapy, or other forms of therapy.
CYCLOBENZAPRINE
Central acting muscle relaxants.
For a short-term treatment of muscle
spasm through a central action, possibly
at the brainstem level.
CYCLOBENZAPRINE
PHARMACOKINETICS
PHARMACODYNAMICS
Well absorbed in GI tract
Alleviates muscle spasms
associated with acute painful
musculoskeletal conditions.
Half-life is moderate
Metabolized in the liver
Excreted in urine
Increased CNS depression
occurs when taken with
alcohol, kavavakerian,
sedative hypnotics,
barbiturates, or tricyclic
antidepressants.
PO: Onset of action 1
hour
Peak concentration time
: 3-8 h
Duration: 12-24 hours
CYCLOBENZAPRINE
SIDE EFFECTS
Anticholenergic effects
(blurred vision,
constipation, dry mouth,
tachycardia, urinary
retention);
arrhythmias
confusion
drowsiness
ADVERSE EFFECTS
dizziness,
headache,
nausea,
 nervousness,
unpleasant taste,
urinary
retention.
Allergic reactions
angioedema,
MI
 seizure
ileus.
CYCLOBENZAPRINE
NURSING PROCESS
NURSING ASSESSMENT
Obtain a medical history. Cyclobenzaprine is contraindicated if the patient has
cardiovascular disorders, hyperthyroidism, or hepatic impairment or is taking occurent
monoamine oxide inhibitors (MAOIs).
Obtain baseline vital signs.
Assess the patient’s health history to identify the cause of muscle spasm and
determine whether it is acute or chronic.
Observe the patient’s history for possible drug interactions.
Note whether the patient has a history of narrow-angle glaucoma or MG.
Cyclobenzaprine or orphenadrine are contraindicated with these health problems.
CYCLOBENZAPRINE
NURSING PROCESS
NURSING DIAGNOSES
PLANNING
Physical Mobility, Impaired related
to dizziness and hyperactive
reflexes
The patient will be free of muscular
pain within 1 week
Activity Intolerance related to
drowsiness and hyperactive
reflexes
CYCLOBENZAPRINE
NURSING PROCESS
NURSING INTERVENTIONS
Monitor serum liver enzyme levels of patients taking tandrolene and
carisoprodol.Report to the health care provider elevated levels of liver enzymes such
as alkaline phosphate (ALP), asparate aminotransferase (AST), alanine
aminotransferase (ALT), and gamma-glutamyl transferase (GGT).
Record vital signs . Report abnormal results.
Observe for CNS side effects (e.g., dizziness)
CYCLOBENZAPRINE
NURSING PROCESS
PATIENT TEACHING
Teach patients that the muscle relexant should
not abruptly stopped. The drug should be
tapered over 1 week to avoid rebound spasms.
Advise patients not to drive, operate dangerous
machinery, or make important life-changing
decisions when taking muscle relaxants. These
drugs have sedative effect and can cause
drowsoiness
Inform patients the most of the centrally acting
muscle relaxants for acute spasms are usually
taken for no longer than 3 weeks.
Teach patients to avoid alcohol and CNS
depressants. If muscle relaxants are taken
with this drugs, CNS depression may be
intensified.
Advise patients that these drugs must be
used cautiously when pregnant or nursing.
Patient should always check with the health
care provider prior to stopping medication.
CYCLOBENZAPRINE
NURSING PROCESS
DIET
EVALUATION
Advise patients to take
muscle relaxants with
food to increase GI upset.
Evaluate the effectiveness of the
muscle relaxant, and determine
whether the patient’s muscular
pain or spasms have decreased or
disappeared.