Nursing Pharmacology- Neuro Meds

What is Myasthenia Gravis?
Myasthenia gravis is a chronic condition that causes muscles to tire and weaken easily. For example, a patient with myasthenia gravis may notice that during a meal, their jaw muscles become tired and weak. After they have rested for a little while, the muscles may become strong again allowing them to resume eating.

What is the key neurotransmitter involved with myasthenia gravis?

Causes include insufficient secretion of acetylcholine, excessive secretion of cholinesterase and unresponsiveness of the muscle fibers to acetylcholine

What are the goals of myasthenia gravis medications?
Goal is to increase the amount of acetylcholine available to help relieve muscle weakness associated with myasthenia gravis
Anticholinesterase medications increase the amount of acetylcholine available by blocking ACH breakdown at the neuromuscular junction
Antimyasthenic medications are also used to distinguish between a cholinergic crisis from a myasthenic crisis (more on this a little later)

Examples of antimyasthenic medications
Ambenonium chloride (Mytelase)
Edrophonium chloride (Tensilon)
Neostigmine bromide (Prostigmin)
Pyridostigmine (Mestinon)

When preforming a Tensilon test to distinguish between a myasthenic crisis and a cholinergic crisis, what medication should be readily available in case of an overdose of edrophonium chloride (Tensilon)?
Atropine sulfate

Name 4 nursing interventions when administering antimyasthenic medications?
-Assess neuromuscular status (reflexes, muscle strength and gait)
-Monitor for signs and symptoms of medication overdose (cholinergic crisis) and underdose (myasthenic crisis).
-Instruct client to take medications on time to maintain therapeutic level, thus preventing weakness. Weakness can impair the client’s ability to breathe and swallow.
-Take with small amount of food to prevent GI symptoms
-Instruct the client to eat 45 to 60 minutes after taking medications to decrease risk for aspiration
-Instruct to wear a Medic-Alert bracelet.
-Instruct patient that therapy for myasthenia gravis is lifelong.
-Evaluate for medication effectiveness, which is based on improvement of neuromuscular symptoms or strength without cholinergic signs and symptoms.
-When administering edrophonium chloride (Tensilon), have emergency resuscitations equipment on hand and atropine sulfate available for a cholinergic crisis

If the patient’s condition temporarily improves after administering Tensilon, what kind of crisis were they in (cholinergic or myasthenic)?
Myasthenic crisis

What is the major neurotransmitter involved with Parkinson’s Disease?

-Parkinson’s disease is a degenerative disease caused by depletion of dopamine, which interferes with the inhibition of excitatory impulses, resulting in a dysfunction of the extrapyramidal system.
-It is a slow, progressive disease that results in a crippling disability.
-The debilitation can result in falls, self-care deficits, failure of body systems, and depression.

Name some symptoms of Parkinson’s Disease
-Bradykinesia (abnormal slowness of movement and sluggishness of physical and mental responses)
-Akinesia (loss or impairment of voluntary activity)
-Monotonous Speech
-Handwriting that becomes progressively smaller
-Tremors in hands and fingers at rest
-Rigidity with jerky movements
-Restlessness and pacing
-Blank facial expression
-Difficulty swallowing and speaking
-Loss of coordination and balance
-Shuffling steps, stooped position and propulsive gait

What is the main goal of antiparkinsonian medications?
-Antiparkinsonian Medications restore the balance of the neurotransmitters ACH and dopamine in the CNS, decreasing the signs and symptoms of Parkinson’s disease to maximize the client’s functional abilities.

How do anticholinergic medications help alleviate some of the symptoms of Parkinson’s Disease?
Anticholinergics inhibit the action of ACH. Anticholinergic medications reduce the tremors and drooling associated with Parkinson’s disease but have a minimal effect on bradykinesia, rigidity and balance abnormalities.

Examples of anticholinergic drugs
Benztropine (Cogentin)
Biperiden hydrochloride (Akineton)
Procyclidine hydrochloride (Kemadrin)
Trihexyphenidyl hydrochloride

Anticholinergic medications are contraindicated in patients who have what eye disorder?

What are the side effects of anticholinergic drugs?
-Can’t see, can’t spit, can’t pee, can’t shit (Blurred vision, dry secretions, urinary retention, constipation)
-Increases heart rate, palpitations and dysrhythmias
-Restlessness, confusion, depression and hallucinations
-Photophobia (eye discomfort in bright light)

How do dopaminergic medications help alleviate some of the symptoms of Parkinson’s Disease?
These medications stimulate the dopamine receptors and increase the amount of dopamine available in the CNS or enhance neurotransmission of dopamine

Examples of dopaminergic medications
Amantadine (Symmetrel)
Bromocriptine (Parlodel)
Carbidopa and levodopa (Sinemet)
Levodopa (Larodopa, Dopar)
Pramipexole (Mirapex)
Ropinirole (Requip)
Selegiline hydrochloride (Carbex, Eldepryl)

Levodopa should not be taken with which B vitamin because it decreases the effectiveness of levodopa?
Vitamin B6

What do COMT inhibitors do?
-Adjunct treatment for Parkinson’s Disease to carbidopa-levodopa in the patient who experiences “wearing off” at the end of the dosing interval
-Slowly taper off of these meds

Examples of COMT inhibitors
Tolcapone (Tasmar)
Entacapone (Comtan)

What are some side effects of COMT inhibitors?
-Brown-orange urine discoloration (entacapone)
-Life threatening reactions to COMT inhibitors: Acute liver failure

What are some side effects of phenytoin (Dilantin)?
-Gingival hyperplasia
(Reddened gums that bleed easily)
-Slurred speech
-Sedation and drowsiness
-Rash or pruritis
-Elevated blood glucose level
-Blood dyscrasias: decreased platelet count and decreased WBC count

What is the therapeutic serum range for phenytoin (Dilantin)? What are signs of phenytoin toxicity?
Monitor the patient’s blood levels; the therapeutic level for phenytoin is 10 to 20 mcg/mL. Signs of toxicity include fever, coma, confusion, nystagmus, lethargy, low BP, ataxia, tremor, uncoordinated movements, slurred speech.

Nursing interventions for phenytoin (Dilantin)
-Oral tube feedings may interfere with the absorption of orally administered phenytoin and diminish the effectiveness of the drug. Stop feedings for 2 hours before and after phenytoin administration.
-When administering phenytoin IV, infuse no faster than 25-50 mg/min. Hypotension and cardiac dysrhythmias may occur if given any faster.
-Monitor the patient’s blood levels; the therapeutic level for phenytoin is 10 to 20 mcg/mL. Signs of toxicity include fever, coma, confusion, nystagmus, lethargy, low BP, ataxia, tremor, uncoordinated movements, slurred speech.
-Monitor CBC every 6 months.
-Don’t mix phenytoin with dextrose 5% in water because it will cause phenytoin to precipitate. Give with normal saline and infuse over 30-60 minutes with an in-line filter.
-Avoid giving phenytoin by IV push into veins on the back of the hand to avoid discoloration known as purple glove syndrome. Inject into larger veins or a central venous catheter, if available.
Instruct to not abruptly stop the medication and to take with food to reduce GI upset.
-Advise patient that phenytoin (Dilantin) decreases the effectiveness of some birth control pills.

When giving phenobarbital by IV, what should the RN have at the bedside?
Resuscitation equipment
-Laryngospasm, respiratory depression and hypotension when given IV
When giving phenobarbital by IV, monitor the patients respirations, don’t give more than 60 mg/min and have resuscitation equipment readily available

Examples of benzodiazepines
Clonazepam (Klonopin)–>long-term treatment of epilepsy
Clorazepate (Tranxene)–>adjunct therapy for partial seizures
Diazepam (Valium)–> treats status epilepticus
Lorazepam (Ativan) –> treats status epilepticus

*Benzos also used to treat anxiety and as sedatives and muscle relaxants

Nursing implications when administering benodiazepines
-Give with food to reduce GI irritation.
-If giving the IV form of diazepam, administer no more than 5 mg/min. have emergency resuscitation equipment at bedside.
-Don’t store IV diazepam solutions in plastic syringes.
-Monitor CBC and liver function tests (hepatotoxic)

What are some nursing considerations when administering valproic acid?
-Valproic acid can causes deadly liver toxicity. Contraindicated in patients with a history of liver disease and patients younger than 2. Also, monitor liver function.
-Monitor level of the drug in the blood (therapeutic level is 50-100 mcg/mL).

What is the root word for 5-HT agonists (antimigraine medications)?

What patient teaching should you give to a patient who is taking a 5-HT agonist?
-For most antimigraine medications, teach the patient to take the medication at the first indication of a migraine and if possible, lay in a darkened room for several hours.

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