Central nervous system
ADHD
Pathophysiology: Dysregulation of transmitters, Serotonin, norepinephrine, dopamine
Epidemiology: Usually occurs in children before age 7 years, More common in boys
Characteristics: Inattentiveness, inability to concentrate, restlessness, hyperactivity, inability to
complete tasks, impulsivity
Narcolepsy
Characteristics: Recurrent attacks of drowsiness and sleep during daytime, Unable to control sleep,
Falling asleep while, Driving, Talking, Eating, Standing
Methylphenidate (Ritalin)
Action: Modulates serotonergic pathways by affecting changes in dopamine transport
Use: ADHD, narcolepsy, increase attention span
Interactions: Caffeine may increase effects, Increases effects of oral anticoagulants, barbiturates,
anticonvulsants, TCAs, MAOIs, Decreased effects of antihypertensive, May alter insulin effects
Side effects/adverse reactions: Tachycardia, palpitations, hypertension, dysrhythmias, Restlessness,
tremors, irritability, Dizziness, headache, blurred vision, Euphoria, confusion, Anorexia, dry mouth,
diarrhea, constipation, weight loss, Seizures, erectile dysfunction
Nursing interventions: Teach patient to take the drug before meals. Advise patients to avoid foods that
contain caffeine. Report irregular heartbeat. Record height, weight, and growth of children. Avoid
alcohol, caffeine. Use sugarless gum to relieve dry mouth. Do not stop abruptly; taper off to avoid
withdrawal symptoms.
Anorexiants
Action: Cause stimulant effect on hypothalamic and limbic areas of brain to suppress appetite –
Should not be given to children under 12
Side effects: Nervousness, irritability, insomnia, Tachycardia, hypertension, Palpitations, seizures
Medications: • Benzphetamine HCl (Didrex) • Diethylpropion HCl (Tenuate) • Phentermine HCl
(Suprenza) • Phentermine-topiramate (Qsymia) • Phendimetrazine (Bontril) • Lorcaserin (Belviq)
Doxapram (Dopram)
Uses: Respiratory depression caused by overdose, pre- and postanesthetic respiratory depression, and
chronic obstructive pulmonary disease (COPD)
Onset of action: 20 to 40 seconds, peak within 2 minutes
Side effects: Hypertension, tachycardia, trembling, convulsions
Theophylline
Use: stimulate respiration in newborns
Side effects: Restlessness, tremors, twitching, palpitations, insomnia, Diuresis, tinnitus, nausea, diarrhea,
Psychological dependence
Barbiturates
Side effects: Residual drowsiness (hangover) Vivid dreams, nightmares, Drug dependence, Drug
tolerance, Excessive depression, Respiratory depression, Hypersensitivity
Types – Long-acting – Intermediate-acting – Short-acting – Ultrashort-acting
Restricted to short-term use – 2 weeks or less – Because of side effects, including drug tolerance
Interactions: Alcohol, opioids, other sedative-hypnotics, Decreases effects of oral anticoagulants,
glucocorticoids, tricyclic antidepressants, quinidine
Benzodiazepines as hypnotics
Action • Interacts with neurotransmitter GABA to reduce neuron excitability
Use • Reduce anxiety, treat insomnia
Side effects: Residual drowsiness (hangover), Vivid dreams, nightmares, Drug dependence Drug
tolerance, Excessive depression, Respiratory depression, Hypersensitivity
Medications: Flurazepam (Dalmane), Alprazolam (Xanax), Temazepam (Restoril), Triazolam (Halcion),
Estazolam (ProSom), Quazepam (Doral)
Butabarbital
Side effects: slow heart rate, weak or shallow breathing, extreme drowsiness, feeling light-headed, or
fainting, rapid breathing, gasping for breath, confusion, hallucinations, unusual thoughts, nightmares;
or, overactive reflexes, feeling restless or irritable, severe agitation or nervous feeling.
Contraindicated: high amount of ammonium in the blood, Porphyria, Anemia, decreased blood platelets,
low levels of a type of white blood cell called neutrophils, suicidal thoughts, Alcoholism, drug abuse.
Epilepsy
Patho: abnormal electric discharges from cerebral neurons
Characteristics: loss of consciousness, convulsive movements.
Cause: Unknown, secondary to trauma, anoxia, infection, fever, electrolyte or acid imbalances.
Phenobarbital
Action: enhances GABA activity
Use: tonic clonic, partial, myoclonic seizures, status epilepticus
Therapeutic level 20-40 mcg/ml
Risks: sedation and patient tolerance to the drug.
Discontinuance of phenobarbital should be gradual to avoid recurrence of seizures.
Succinimide (Zarontin)
Action: Decreases calcium influx
Use: Absence seizures
Therapeutic serum range of ethosuximide is 40 to 100 mcg/mL.
Adverse effects: include blood dyscrasias, renal and liver impairment, and systemic lupus
erythematosus.
Iminostilbene (Carbamazepine)
Action: Effective in treating refractory seizure disorders that have not responded to other anticonvulsant
therapies
Uses: grand mal and partial seizures, psychiatric disorders (e.g., bipolar disorder),trigeminal neuralgia (as
an analgesic), and alcohol withdrawal
Therapeutic serum range of carbamazepine is 5 to 12 mcg/mL.
An interaction may occur when grapefruit juice is taken with carbamazepine (Tegretol), causing possible
toxicity
Valproate (Valproic acid)
Action: Used to treat petit mal, grand mal, and mixed types of seizures
Safety and efficacy of this drug has not been established for children younger than 2 years of age.
Caution in patients with liver disorders, because hepatotoxicity is one of the possible adverse reactions.
Liver enzymes should be monitored.
Therapeutic serum range is 50 to 150 mcg/mL.
Hydantoins: Phenytoin (Dilantin)
Contraindications Pregnancy (teratogenic)
Therapeutic serum level 10 to 20 mcg/mL
Side effect/adverse reactions Gingival hyperplasia, nystagmus, diplopia Headache, dizziness, slurred
speech, alopecia Purple glove syndrome, ventricular fibrillation Depression, suicidal ideation
Hyperglycemia, GI distress, urine discoloration Thrombocytopenia, leukopenia Stevens-Johnson
syndrome
Drug interactions: Increased effects with cimetidine (Tagamet), INH, sulfonamides, Decreased effects
with folic acid, antacids, calcium, sucralfate, antineoplastics, antipsychotics, primrose, ginkgo, Decreased
effects of anticoagulants, oral contraceptives, antihistamines, dopamine, theophylline
Nursing interventions: Shake suspension well for 5 minutes, Monitor serum drug levels, Safety: Protect
from environmental hazards, driving, Warn female patients taking oral contraceptives to use additional
contraception, Warn patient to avoid certain herbs, alcohol, and other CNS depressants, Warn patient
not to discontinue abruptly, Patient will need frequent oral hygiene and dental check-ups, Diabetics
must monitor glucose level, Tell each patient to take drug at same time every day, Warn of harmless
pinkish red or brown urine, Teach patient to report sore throat, bruising, nosebleeds.
Status epilepticus
Treatment:
Diazepam, Lorazepam, Followed by phenytoin IV, For continued seizures: midazolam, propofol, Slow IV
administration to avoid respiratory depression
Anticonvulsants and Pregnancy
Seizure episodes increase 25% in women with epilepsy who are pregnant.
Hypoxia that may occur during seizures places both the pregnant patient and the fetus at risk.
Many anticonvulsant drugs have teratogenic properties that increase the risk for fetal malformations.
Anticonvulsant drugs tend to act as inhibitors of vitamin K, contributing to hemorrhage in infants shortly
after birth.
Anticonvulsants also increase the loss of folate (folic acid) in pregnant patients.
Anticonvulsants and Febrile Seizures
Seizures associated with fever usually occur in children between the ages of 3 months and 5 years.
Epilepsy develops in approximately 2.5% of children who have had one or more febrile seizures.
Prophylactic anticonvulsant treatment such as phenobarbital or diazepam may be indicated for high-risk
patients.
Valproic acid should not be given to children younger than 2 years because of its possible hepatotoxicity
Anticholinergics Parasympatholytic– Benztropine (Cogentin) Trihexyphenidyl HCl (Artane) Biperiden
(Akineton)
Action: inhibit the release of acetylcholine
Reduce the rigidity and some of the tremors characteristic of parkinsonism, Minimal effect on
bradykinesia, Used to treat drug-induced parkinsonism, or pseudoparkinsonism
Nursing Interventions: Monitor vital signs, Monitor urine output for early detection of urinary retention,
Increase fluid intake, fiber, and exercise to avoid constipation, Observe for involuntary movements,
Advise patient to avoid alcohol, cigarettes, caffeine, and aspirin to decrease gastric acidity, Encourage
patient to relieve dry mouth with ice chips, hard candy, or sugarless chewing gum, Suggest use of
sunglasses for photophobia.
Dopaminergics Carbidopa-levodopa (Sinemet)
Action: converted to dopamine, increases mobility
Side effects: Fatigue, insomnia, Dry mouth, Blurred vision, Orthostatic hypotension, palpitations,
dysrhythmias, urinary retention, Nausea, vomiting, Dyskinesia, psychosis, severe depression
Drug interactions: Decrease levodopa effect with: Anticholinergics, Phenytoin, Tricyclic antidepressants,
MAO inhibitors, Benzodiazepines, Phenothiazines, Vitamin B6
Acetylcholinesterase Inhibitors/Cholinesterase Inhibitors: Tacrine (Cognex), donepezil (Aricept),
rivastigmine (Exelon), galantamine (Razadyne)
Action: Allow more acetylcholine in neuron receptors, Increase cognitive function
Use: Mild to moderate Alzheimer’s disease
Rivastigimine, Tacrine, donepezil
Side effects: Anorexia, nausea, vomiting, diarrhea, constipation, abdominal pain, GI bleeding, dizziness,
depression, peripheral edema, dry mouth, dehydration, restless legs syndrome, nystagmus
Adverse reactions: seizures, bradycardia, orthostatic hypotension, cataracts, myocardial infarction, heart
failure
Myasthenia Gravis
Patho: Autoimmune disorder, Antibodies attach to acetylcholine receptor sites, obstruct binding of
acetylcholine, and destroy receptor sites, Lack of acetylcholine impairs transmission of messages at
neuromuscular junctions
Characteristics: Muscular weakness and fatigue, Respiratory muscle paralysis, ptosis, difficulty chewing
and swallowing
Myasthenic crisis
Patho: Severe muscle weakness, May involve diaphragm and intercostal muscles
Triggers: Inadequate dosing, Infection, Emotional stress, Menses, pregnancy, Surgery, trauma,
Hypokalemia, alcohol intake, Medication interactions
Treatment: edrophonium (tensilon), and neostigmine (prostigmin)
Cholinergic crisis
Patho: Usually occurs within 30 to 60 minutes after taking anticholinergic medications
Triggers: Triggered by overdosing, Severe muscle weakness (Possible paralysis and arrest, Abnormal
purespiratorypil constriction, Excess salivation, Pallor, sweating, vertigo, GI distress Bradycardia,
Fasciculations
Acetylcholinesterase inhibitors (AChE inhibitors)
Neostigmine (Prostigmin): shortacting
Edrophonium (Tensilon): ultrashortacting for diagnosing
Pyridostigmine (Mestinon): intermediate-acting
Ambenonium (Mytelase): long-acting
Action: Transmission of neuromuscular impulses by preventing destruction of Ach
Use: to treat MG
Side effects: GI disturbances (nausea, vomiting, diarrhea, abdominal cramps), Increased salivation,
Tearing, Miosis (constricted pupil of the eye), Blurred vision, Bradycardia, Hypotension
No response to these medication = Prednisone
Nursing Interventions: Administer doses on time. Take drug before meals if possible. Monitor drug
effectiveness. Have antidote available for cholinergic crisis (Atropine). Encourage patient to wear
medical identification.
Multiple Sclerosis
Patho: Autoimmune disorder: Attacks myelin sheath of nerve fibers in brain and spinal cord, Causes
lesions or plaques
Characteristics: Remission and exacerbations, weakness, spasticity in extremities, diplopia
Treatment: Immunomodulators ◦ First-line treatment ◦ Slows disease progression and prevents relapses,
Immunosuppressants, Sphingosine 1-phosphate receptor modulator, Monoclonal antibody,
Corticosteroids (Reduces edema and acute inflammation)
Cyclobenzaprine
Action: Relax skeletal muscles
Use: Relieves muscle spasm
Side effects: Anticholinergic effects (blurred vision, dry mouth, tachycardia, urine retention,
constipation), Drowsiness, dizziness, headache, nervousness GI distress, unpleasant taste, dysrhythmias
Antipsychotics
Treat: Mental illness to improve thought processes and behavior
Action: Block dopamine receptors in brain
When dopamine is blocked, extrapyramidal symptoms (EPS) of parkinsonism occur. • Tremors, masklike
facies, rigidity, shuffling gait may develop.
Typical antipsychotics
• Phenothiazines • Block norepinephrine causing sedative and hypotensive effects early in treatment.
• Nonphenothiazines • Block only the neurotransmitter dopamine
Atypical antipsychotics
• Treats schizophrenia and other psychotic disorders in patients not responding to or intolerant of
typical antipsychotics
• Decreased side effects
• Often used as first-line therapy
Adverse reactions:
• Extrapyramidal syndrome • Stooped posture, masklike facies, rigidity, tremors at rest • Shuffling gait,
pill-rolling motion of hands, bradykinesia • Acute dystonia, akathisia, tardive dyskinesia
• Neuroleptic malignant syndrome • Excess agitation, altered mental status • Exhaustion, dehydration •
Muscle rigidity, hyperthermia, profuse diaphoresis • Blood pressure fluctuations, tachycardia,
dysrhythmias • Seizures, rhabdomyolysis • Respiratory and renal failure, coma
Extrapyramidal symptoms—four types
• Dystonic reactions/acute dystonia
• Pseudoparkinsonism (tremor, muscular rigidity, masklike expression, shuffling gait, loss/weakness of
motor function)
• Akathisia (pacing, rocking, subjective feelings of anxiety and restlessness)
• Tardive dyskinesia (hyperkinetic abnormal movements)
Fluphenazine (typical)
Action: Blocks dopamine receptors in brain
Use: Manages symptoms of schizophrenia and psychosis
Interactions: Increase depression when taken with alcohol or other CNS depressants; kava kava may
increase EPS, Increased effects with MgSO4 , lithium, beta blockers
Side effects: Sedation, dizziness, headache, seizures, Dry mouth, nasal congestion, blurred vision,
photosensitivity, urinary retention, GI distress, peripheral edema, tachycardia, EPS
Haloperidol (typical)
Action: Blocks dopamine receptors
Use: Treats psychoses, schizophrenia, attention deficit/hyperactivity disorder, Tourette’s syndrome
Contraindications: Narrow-angle glaucoma, CNS depression, Severe liver, kidney, and cardiovascular
disease, Blood dyscrasias
Side effects: Drowsiness, headache, insomnia, Dry mouth, blurred vision, photosensitivity, Tachycardia,
orthostatic hypotension, dysrhythmias, Seizures, weight gain, Urinary retention, sexual dysfunction,
Blood dyscrasias, EPS, NMS
Interactions: Increased sedation with alcohol, CNS depressants, Increased toxicity with anticholinergics,
Decreased effects with phenobarbital, carbamazepine, caffeine
Clozapine (atypical)
Use: Severe schizophrenic patients unresponsive to traditional antipsychotics
Side effects: Dizziness, sedation, constipation, tachycardia, orthostatic hypotension, Tremors, occasional
rigidity, Seizures, agranulocytosis, Low possibility of EPS
Risperidone
Use: Manage symptoms of psychosis, Treats positive and negative symptoms of schizophrenia
Side effects: Sedation, headaches, photosensitivity, EPS, seizures, Dry mouth, weight gain, Tachycardia,
orthostatic hypotension, Urinary retention, sexual dysfunction, Low possibility of EPS and tardive
dyskinesia
Anxiolytics
Lorazepam
Action: inhibits GABA neurotransmission by binding to specific benzodiazepam receptors
Use: Anxiolytic, antiseizure, sedative-hypnotic, preoperative drug, substance abuse withdrawal
Side effects: Drowsiness, dizziness, ataxia, restlessness, weakness, Headache, confusion, amnesia,
blurred vision, GI distress, sleep disturbance, hallucinations, Bradycardia, hypotension/hypertension,
Seizures, suicidal ideation, NMS, respiratory depression
Discontinuation: gradually decrease dose over several days
Withdrawal symptoms: Develops slowly, in 2 to 10 days, and may last several weeks • Withdrawal
symptoms • Tremor, agitation, nervousness • Sweating, insomnia • Anorexia, muscle cramps
Buspirone
Action: Binds to serotonin and dopamine receptors, May not be effective until 1 to 2 weeks after
continuous use
Side effects: Drowsiness, dizziness, Headache, excitement, Nausea, nervousness
Interactions: grape juice can lead to toxicity
Tricyclic Antidepressants (TCA)
Action: Blocks uptake of neurotransmitters norepinephrine and serotonin in brain, Elevates mood,
increases interest in ADLs, decreases insomnia, Blocks histamine receptors which leads to sedation,
Blocks cholinergic receptors which leads to anticholinergic effects
Use: Major depression
Side effects: Drowsiness, dizziness, blurred vision, Dry mouth and eyes, GI distress, Urinary retention,
sexual dysfunction, Weight gain, seizures, Sleep-related behaviors, suicidal ideation, Orthostatic
hypotension, dysrhythmias, Blood dyscrasias, cardiotoxicity, EPS, NMS
Interactions: Alcohol and other CNS depressants potentiate CNS depression, MAOIs may lead to toxic
psychosis, cardiotoxicity, Antithyroid drugs may increase dysrhythmias
Selective Serotonin Reuptake Inhibitors (SSRI)
Action: block uptake of neurotransmitter serotonin
Uses: Major depression, Anxiety disorders, Obsessive-compulsive disorder, Panic disorders, Phobias,
Posttraumatic stress disorder, Prevention of migraine headaches, Decrease premenstrual tension
syndrome
Interactions: Increased sedation with alcohol and other CNS depressants, grapefruit juice can lead to
toxicity
Side effects: Headache, nervousness, Blurred vision, insomnia, Dry mouth, GI distress, Sexual
dysfunction, suicidal ideation, side effects often decrease over 1 to 4 weeks
Atypical Antidepressants
Action: Affect one or two of the three neurotransmitters: serotonin, norepinephrine, and dopamine.
Use: Major depression, reactive depression, anxiety
Interaction: Do not take with MAOIs and do not use within 14 days after discontinuing MAOIs,
Trazodone may have a potential drug interaction with ketoconazole, ritonavir, and indinavir that may
lead to increased trazodone levels and adverse effects
Monoamine Oxidase Inhibitors (MAOI’s)
Action: Monoamine oxidase enzyme inactivates norepinephrine, dopamine, epinephrine, and serotonin
Use: Depression not controlled by TCAs and second-generation antidepressants
Interactions: CNS stimulants such as vasoconstrictors and cold medications containing phenylephrine
and pseudoephedrine can cause a hypertensive crisis when taken with an MAOI.
Food interactions: Foods that contain tyramine, Some cheeses, cream, yogurt, coffee, chocolate,
bananas, raisins, Italian green beans, liver, pickled foods, sausage, soy sauce, yeast, beer, and red wines
can cause a hypertensive crisis.
Side effects: Agitation, restlessness, insomnia, Anticholinergic effects, Orthostatic hypotension,
Hypertensive crisis from tyramine interaction
Lithium
Therapeutic serum range: 1.0 to 1.5 mEq/L
Action: Alteration of ion transport in muscle and nerve cells, Increased receptor sensitivity to serotonin
Use: Bipolar disorder manic episodes
Side effects: Headache, drowsiness, dizziness, blurred vision, Restlessness, tremors, memory
impairment, Dry mouth, metallic taste, GI distress ◦ Hypotension, dysrhythmias, Edema of hands and
ankles, dehydration, Increased urination, blood dyscrasias, NMS, Serotonin syndrome, nephrotoxicity
Interactions: Increased lithium level with ◦ Thiazides, methyldopa, haloperidol, NSAIDs, antidepressants,
theophylline, phenothiazines
Decreased lithium with caffeine, loop diuretics
Gastrointestinal system
Antiemetics
Dopamine antagonist: Phenothiazine antiemetics: Chlorpromazine (Thorazine) ◦ Prochlorperazine
edisylate (Compazine) ◦ Promethazine (Phenergan)
Action: Act on CTZ, block dopamine receptors
Use: Postoperative nausea, vomiting, Chemotherapy, radiation sickness
Side effects: moderate sedation, hypotension, EPS, CNS effects, and mild anticholinergic symptoms
Serotonin antagonists: Ondansetron (Zofran), granisetron (Kytril), dolasetron (Anzemet), palonosetron
(Aloxi)
Side effects: headache, diarrhea, dizziness, and fatigue
Action: Block serotonin receptors in CTZ, Block afferent vagal nerve terminals in upper GI tract
Use: Nausea and vomiting from chemotherapy, Postoperative nausea and vomiting
Cannabinoids
Dronabinol (Marinol)
Actions: alleviate nausea and vomiting resulting from cancer treatment
Use: nausea and vomiting from cancer treatment or chemotherapy
Contraindicated: psychiatric disorders
Side effects: mood changes, euphoria, drowsiness, dizziness, headaches, depersonalization, nightmares,
confusion, incoordination, memory lapse, dry mouth, orthostatic hypotension or hypertension, and
tachycardia
Metoclopramide (Reglan)
Action: Suppress impulses to CTZ
Use: in the treatment of postoperative emesis, cancer chemotherapy, and radiation therapy
Side effects: High doses can cause sedation and diarrhea, Occurrence of EPS is more prevalent in
children than in adults, Contraindicated with GI obstruction, hemorrhage, or perforation
Emetics
Ipecac (OTC)
Action: Stimulates CTZ and acts directly on gastric mucosa
Use: Induces vomiting after toxic substance
Caution: Avoid vomiting if substance is caustic or petroleum, If vomiting contraindicated, activated
charcoal or gastric lavage can be used.
Administration: Use ipecac syrup, not ipecac fluid extract, Take with a glass of water, not with milk or
carbonated beverage, Vomiting occurs in 15 to 30 minutes, If vomiting does not occur, give activated
charcoal, Gastric lavage may be needed if vomiting does not occur
Diarrhea
Causes: Spoiled food or excessively spicy foods, bacteria, drug reactions, fecal impactions, laxative
abuse, malabsorption disorders, bowel tumor, inflammatory bowel disease, stress, anxiety
Nonpharmacological measures: Clear liquids, Oral solutions (Gatorade; Pedialyte or Rehydralyte [both
for use in children]), IV electrolyte solutions
Traveler’s diarrhea
Acute diarrhea: Usually caused by E. coli, Fluoroquinolone antibiotics, Loperamide (Imodium)
Preventions: Traveler’s diarrhea can be reduced by drinking bottled water, washing fruit, and eating
cooked vegetables. Meats should be cooked until well done.
Opiates and opiate-related agents: Diphenoxylate with atropine (Lomotil)
Opiates decrease GI motility, Opiates may cause respiratory depression, Especially children and older
adults, May cause physical dependence, Atropine contraindicated in glaucoma.
Adsorbents
Colestipol and cholestyramine (Questran)
Actions: Colestipol is an oral cholesterol-lowering drug that is not absorbed from the intestine into the
body. Rather, it works by binding to bile acids in the intestine and promoting the elimination of bile
acids in the stool.
Used: diarrhea
Side effects: Constipation, stomach/abdominal pain, gas, nausea, and vomiting may occur.
Contraindication: Biliary cirrhosis, biliary obstruction, cholelithiasis, Constipation, dysphagia, GI
obstruction, hemorrhoids, ileus, Hypertriglyceridemia, Coagulopathy, Hypothyroidism, Renal disease,
Phenylketonuria, Pregnancy.
Constipation
Causes: Bowel obstruction, fecal impaction, Chronic laxative use, ignoring urge to defecate, Neurologic
disorders, Side effect of drugs, Lack of exercise, Insufficient consumption of fiber and/or water
Nonpharmacologic treatment: Diet (high fiber), Water, Exercise, Routine bowel habits
Psyllium (Metamucil)
Action: Absorb water into intestines, increase bulk and peristalsis
Results: 8- 12 hours
Side effects: Abdominal cramps, Excess laxative, Nausea, vomiting, gas, diarrhea
Sucralfate (Carafate)
Action: Combines with protein to form thick paste covering ulcer, protects from acid and pepsin
Side effects: Constipation
Nursing interventions: Given 30 minutes before meals and bedtime
Bisacodyl (Dulcolax), senna (Senokot)
Action: Increase peristalsis by irritating sensory nerve endings in intestinal mucosa
Results: orally 6 to 12 hours, rectally 15 to 60 minutes
Side effects: Abdominal cramps, weakness, reddish brown urine, diarrhea
Docusate sodium (Colace)
Action: Lowers surface tension, Promotes water accumulation in intestine, Emulsifies and lubricates
feces for easier passage
Use: Prevent constipation, Reduce straining postsurgery or myocardial infarction
Side effects: Abdominal cramping, nausea, vomiting, diarrhea
Polyethylene glycol, Lactulose (Chronulac)
Action: Hyperosmolar salts pull water into colon and increase water in feces to increase bulk, which
stimulates peristalsis.
Side effects: Fluid and electrolyte imbalances, hypotension, weakness
Peptic ulcers
Symptoms: Gnawing, aching pain after eating
Predisposing factors/risk factors: Helicobacter pylori (H. pylori), Mechanical, Genetic, Environmental,
Drugs, Stress ulcer following a critical situation
GERD
Information on gerd: Inflammation of the esophageal mucosa caused by reflux of gastric acid content
into the esophagus, Main cause is an incompetent lower esophageal sphincter, Smoking tends to
accelerate the disease process, Medical treatment for GERD is similar to the treatment for peptic ulcers.
Nonpharmacologic measures for both Peptic ulcers and GERD: Avoid tobacco, Avoid alcohol, Avoid hot,
spicy, and greasy foods, Take any NSAIDs, including aspirin and oral glucocorticoids, with food or in
decreased dosage, Sit upright, Do not eat before bedtime, Wear loose-fitting clothing.
Antiulcer drugs
Understanding: Tranquilizers Anticholinergic drugs Antacids H2 blockers Proton pump inhibitors Pepsin
inhibitor Prostaglandin E1 analog
Tranquilizers: Chlordiazepoxide (Librium), Clidinium bromide (Quarzan), Reduce vagal stimulation,
decrease anxiety
Anticholinergics: Propantheline (Pro-Banthine), Inhibits release of HCl by blocking acetylcholine and
histamine, Take before meals
Antacids
Sodium bicarbonate (Alka-Seltzer), Calcium carbonate (Tums), Magnesium (Mg) hydroxide/aluminum
hydroxide (Maalox), Aluminum (Al) hydroxide (Amphojel)
Proton pump inhibitors
Omeprazole (Prilosec), Lansoprazole (Prevacid), Rabeprazole (Aciphex), Pantoprazole (Protonix),
Esomeprazole (Nexium), Dexlansoprazole (Dexilant),
Action: Reduce gastric acid by inhibiting hydrogen/potassium ATPase
Side effects: Headache, insomnia, dizziness, dry mouth, flatulence, abdominal pain
Histamine2 blockers:
Cimetidine (Tagamet), ranitidine (Zantac), famotidine (Pepcid), nizatidine (Axid)
Action: Reduce gastric acid by blocking H2 receptors of parietal cells in stomach, Promote healing of
ulcer by eliminating cause
Side effects: Headaches, dizziness, diarrhea, constipation, reversible impotence, gynecomastia
Interactions: Cimetidine interacts with oral anticoagulants, theophylline, caffeine, phenytoin (Dilantin),
diazepam (Valium), propranolol (Inderal), phenobarbital, and calcium channel blockers. Cimetidine can
cause an increase in blood urea nitrogen (BUN), serum creatinine, and serum alkaline phosphatase.
Neither cimetidine nor ranitidine should be taken with antacids.
Inflammation
Nonspecific immunity
First line: Mechanical or chemical barriers, reflexes
Second line: Phagocytosis, inflammation, fever, protective proteins, natural killer cells
Action second line: Leukocytes go to site of infection (Diapedesis, Chemotaxis), they eat cellular debris
and pathogens
Interferons are secreted by cells infected by a virus. Interferons protect other cells from viral replication.
Complement proteins assist WBCs.
Nk cells: A lymphocyte that acts nonspecifically, Effective against many microbes and certain cancer cells
Signs: redness, heat, swelling, pain, fever
Specific immunity
Third line: B and T lymphocytes or B and T cells
T cells: Cell-mediated immunity
B cells: Antibody-mediated immunity
Macrophages: Help activate T and B cells
Action of T cells: Macrophage ingests antigen, Antigen presentation: Clone produced, Killer T cell, Helper
T cells, Suppressor T cells, Memory T cells
Action of B cells: Macrophage ingests antigen, Antigen presentation: B cells and helper T cells activated,
Clone formed (Plasma cells, Memory B cells)
Antigen, antibody, immunoglobulin:
Antigen: Stimulates formation of antibodies
Antibody: Secreted by B cells, also called immunoglobulins
Antigen: antibody interaction agglutination
Types of immunoglobulins: Immunoglobulin G (IgG), Immunoglobulin A (IgA), Immunoglobulin M (IgM),
Immunoglobulin E (IgE)
Chemical Mediators
Released during inflammatory response, Produces vasodilation, Capillaries become leaky, Causes tissue
swelling, Responsible for symptoms of anaphylaxis: itching, pain, edema, vasodilation,
bronchoconstriction
At injury site: Prostaglandins, Histamine, Leukotrienes, Bradykinin, Complement
Cox system
Cyclooxygenase (COX) enzyme: Converts arachidonic acid into prostaglandins
▪ Has two enzyme forms: ▪ COX-1: protects stomach lining and regulates blood platelets ▪ COX-2: triggers
inflammation and pain
Signs of inflammation
Erythema, Swelling, Pain, Heat, Function loss
Non pharmological ways to treat inflammation (RICE)
Rest, Ice, Compression, Elevation
Aspirin
Action: Treats inflammation by inhibiting Cyclooxygenase (COX)
Therapeutic levels: Therapeutic serum salicylate level ▪ 15 to 30 mg/dL
Side effects: Irritates digestive system, May cause bleeding, Anaphylaxis, Poisoning (toxicity), Tinnitus
(hearing loss), dizziness, headache, confusion hepatotoxicity, leukocytosis, thrombocytopenia, Severe:
convulsions, coma, Avoid in Children: Reye’s syndrome!
Interventions: Obtain health history, Monitor VS, Monitor serum levels, Monitor Renal function,
Platelets, coagulation studies, Monitor for abdominal pain, black stools, urine output, tinnitus, Avoid in
children under 19
Celecoxib (Celebrex)
Action: No inhibition of COX-1, does not cause GI bleeding or ulcers
Side effects: Back pain, upset pain, dizziness, headache, Hypertension
Acetaminophen
Action: reduce fever by direct action at level of hypothalamus and, dilation of peripheral blood vessels
enabling sweating and dissipation of heat
Side effects: Liver damage, Allergic reactions (angioedema, dyspnea)
Interventions: Obtain health history, Monitor VS (Temp), Assess Allergy, Monitor Hepatic Function,
LFT’s: ALT, AST, Increase fluid intake, Teach patient to avoid ETOH
Prednisone (Meticorten)
Action: metabolized to an active form of glucocorticoid
Use: to treat inflammation
Side effects: Long-term therapy may result in Cushing syndrome
Interventions: Obtain health history, Monitor VS (BP & HR), Assess Labs (CBC, Glucose, electrolytes),
Daily weight, Monitor signs of infection, osteoporosis, fluid retention/Cushing's, mood changes
Gout
Patho: Inflammatory disease of joints, tendons, and other tissues, Usually occurs in great toe Defect in
purine metabolism leads to uric acid accumulation: Purine-containing foods: organ meats, sardines,
salmon, gravy, herring, liver, meat soups, and alcohol (especially beer)
Colchicine (Colcrys)
Action: Inhibit migration of leukocytes to inflamed site (Acute attacks)
Side effects: GI distress (take with food)
Allopurinol (Zyloprim)
Action: Decreases production of uric acid, Prophylactic to prevent gout attacks
Interventions: Monitor CBC, liver enzymes, renal function, Yearly eye examinations for visual changes,
Avoid alcohol, caffeine, foods high in purines and thiazide diuretics that increase uric acid level, Advise
patient to increase fluid intake to increase uric acid excretion.
Pain
Types of pain: Acute, Chronic, Cancer, Somatic, Superficial, Vascular, Visceral
PCA Pump
Medications used: Morphine most often used for PCA, Also fentanyl, hydromorphone
Loading dose, predetermined safety limits, Lockout mechanism, Near-constant analgesic level
Morphine
Action: Morphine binding to opioid receptors blocks transmission of nociceptive signals, signals painmodulating neurons in the spinal cord, and inhibits primary afferent nociceptors to the dorsal horn
sensory projection cells.
Side effects: Drowsiness, dizziness, euphoria, Confusion, depression, miosis, blurred vision, GI distress,
flatulence, constipation, Orthostatic hypotension, weakness, Urinary retention, Psychological
dependence, Respiratory depression
Assessment: Determine drug history and check for drug allergies. Assess the type of pain, location, and
duration before giving opioids
Nursing diagnoses: Pain, Acute related to surgical tissue injury. Breathing Pattern, Ineffective related to
excess morphine dosage.
Planning: The patient’s pain will be reduced or alleviated.
Nursing interventions: Administer morphine before pain reaches its peak to maximize drug
effectiveness. Monitor vital signs frequently to detect respiratory changes. Check for pupil changes and
reaction. Have naloxone available as an antidote to reverse respiratory depression if morphine overdose
occurs
Hydromorphone
Use: Analgesic effect is approximately six times more potent than morphine
Side effects and adverse reactions: Drowsiness, dizziness, confusion, Weakness, constipation, Miosis,
tolerance, dependence, Respiratory depression, urinary retention, Fewer hypnotic effects and less GI
distress than morphine
Narcan
Use: suspected opioid overdose
Side effects: flushing, dizziness, tiredness, weakness, nervousness, restlessness, irritability, body aches
Migraine
Symptoms: Characteristics Unilateral throbbing pain Nausea, vomiting, photophobia,
Triggers: Cheese, chocolate, red wine, aspartame, fatigue, stress, monosodium glutamate, missed meals,
odors, light, hormone changes, drugs, weather, too much or too little sleep
Cluster headaches
Characteristics: Severe unilateral nonthrobbing pain, Usually located around eye, Occur in a series of
cluster attacks, One or more attacks every day for several weeks, Not associated with an aura, Does not
cause nausea and vomiting, More common in males
Prevention for migraine and headaches
Prevention: Beta-adrenergic blockers: (Propranolol, Atenolol)
Anticonvulsants: (Valproic acid, Gabapentin)
Tricyclic antidepressants: (Amitriptyline, Imipramine)
Management Analgesics: Aspirin with caffeine, acetaminophen, NSAIDs: ibuprofen, naproxen, Opioid
analgesics: Meperidine, butorphanol nasal spray, Ergot alkaloids: Dihydroergotamine mesylate, Selective
serotonin1 receptor agonists: Sumatriptan, zolmitriptan