CNS Medications
Kristall Fears
Created on February 8, 2024
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Transcript
Central Nervous System Medications
Start
Index
The Nervous System
Cholinergic Meds
Anticholinergic Meds
Adrenergic Meds
Alpha Adrenergic Blockers
01
The Nervous System
Parasympathetic (Cholinergic):
- “Rest and Digest”
- Cholinergic Response
- Dominant controller of nervous system
- Maintains periods of rest
- Due to acetylcholine
Autonomic Nervous System
Sympathetic (Adrenergic):
- “Fight or Flight”
- Adrenergic Response
- Bronchioles dilate
- Arteries to heart dilate
- Heart pumps stronger
- Pupils dilate
- Liver releases glucose
- Due to norepinephrine
When the receptor is stimulated, these effects occur:
Parasympathetic vs Sympathetic:
Prototype meds:
- epinephrine (sympathomimetic/adrenergic)
- doxazosin (alpha-adrenergic blocker)
- metoproplol (beta blocker): will discuss with cardiac meds
Prototype meds:
- Donepezil (cholinesterase inhibitor)
- Bethanechol (cholinergic)
- Atropine (anti-cholinergic)
02
Cholinergic Meds:Cholinesterase inhibitors and Para-sympathomimetics (Cholinergics)
Cholinergic Agonists
- Also known as cholinergic drugs
- Stimulate the parasympathetic nervous system
- Acetylcholine is the neurotransmitter responsible for transmission of nerve impulses to effector cells in the PNS.
- Cholinergic receptors bind to acetylcholine and allow it to act; cholinergic drugs are those that mimic effects of acetylcholine
Cholinergic Agonists
- Nicotinic: located at the ganglia (nerve cell bodies) of the PNS and SNS. Can be stimulated by nicotine
- Muscarinic: located postsynaptically in smooth muscle, cardiac muscle, and glands. Stimulated by muscarine.
Cholinergic Agonists
Toxicity or cholinergic crisis, think SLUDGE:
- Salivation
- Lacrimation
- Urinary incontinence
- Diarrhea
- GI cramps
- Emesis
Patient Teaching
Nursing Considerations
Drug Interactions
Pharmacokinetics
Uses
Contraindications
Adverse Effects
Prototype Drug: donepezil (Aricept)
Cholinesterase Inhibitors
Donepezil
Patient Teaching
Nursing Considerations
Drug Interactions
Pharmacokinetics
Uses
Contraindications
Adverse Effects
Prototype Drug: bethanechol (Urecholine)
Para-sympathomimetic (Cholinergic):
Bethanechol
03
Anticholinergic Meds:Atropine
Anticholinergic Meds
- These meds block or inhibit the actions of acetylcholine in the parasympathetic nervous system.
- Acetylcholine that is released from a stimulated nerve fiber cannot bind to the receptor site and does not produce a cholinergic effect.
Anticholinergic Meds
Major sites of action for anticholinergic meds:
- Heart
- Respiratory tract
- GI tract and Urinary bladder
- Eye
- Exocrine glands (salivary and sweat glands)
Anticholinergic Effects on the Body
Anticholinergic Effects on the Body
Patient Teaching
Nursing Considerations
Drug Interactions
Pharmacokinetics
Uses
Contraindications
Adverse Effects
Prototype Drug: atropine
Anticholinergic Meds
Atropine
04
Adrenergic (sympathomimetic) Drugs : Epinephrine
Adrenergic Meds
- Drugs that mimic the effects of SNS neurotransmitters like norepinephrine, epinephrine, and dopamine
- These neurotransmitters are also known as catecholamines.
- When given, these drugs go to the synaptic cleft, the area between the nerve and the effector cell, and induce a response
Patient Teaching
Nursing Considerations
Drug Interactions
Pharmacokinetics
Uses
Contraindications
Adverse Effects
Prototype Drug: epinephrine (Adrenalin)
Adrenergic Meds
Epinephrine
Text for this section (link is for tamsulosin, but the mechanism of action is similar):
05
Alpha Adrenergic Blockers: Doxazosin
Patient Teaching
Nursing Considerations
Drug Interactions
Pharmacokinetics
Uses
Contraindications
Adverse Effects
Prototype Drug: doxazosin (Cardura)
Alpha-Adrenergic Blockers
Doxazosin
- GI upset
- Headache
- Seizure
- Hypotension
- Asthma attacks
Adverse Effects
- Take with meals to decrease GI upset
- Notify provider if side effects persist.
- Change positions slowly to avoid dizziness and fainting with orthostatic hypotension
Patient Teaching
- Anti-cholinergic meds (ex. Atropine): counteract effects of donepezil
- NSAIDs (ex. Ibuprofen): increase risk of GI bleed
Drug Interactions
- Route: PO
- Onset: 30-90 minutes
- Peak plasma concentration: less than 30 minutes
- Half-life: unknown
- Duration of action: 1-6 hours
Pharmacokinetics
- Route: IV
- Onset: Immediate
- Peak plasma concentration: 2-4 minutes
- Half-life: 2.5 hours
- Duration of action: 4-6 hours
Pharmacokinetics
- Can take 6 weeks for drug to become effective. Keeping a journal may be helpful to determine if there is improvement or side effects.
- Take as with meals to decrease GI upset
- Notify provider if side effects persist.
- Change positions slowly to avoid dizziness and fainting with orthostatic hypotension.
Patient/Family Teaching
- Assess vital signs and EKG/telemetry
- Monitor I&O
- Assess for bowel sounds and abdominal distension
Nursing Considerations
- Route: PO
- Onset: 3 weeks
- Peak plasma concentration: 3-4 hours
- Half-life: 70 hours
- Duration of action: 2 Weeks
Pharmacokinetics
Donepezil is used to treat mild to moderate Alzheimer’s Disease
- This is a neuro disease in which the patient has decreased acetylcholine
- Works to increase acetylcholine by inhibiting/decreasing cholinesterase
- Limited efficacy, but patients can show improvement in mental status
- Does not cure the disease! Simply slows progression in the best-case scenario.
Uses
- Causes increased heart rate, so it is used to treat bradycardia and heart block
- Given pre-op or to the dying to decrease salivation and GI secretions.
- Bronchospasm (given IM as an auto-injector)
- Treat insecticide or mushroom poisoning
Uses
- Angle-closure glaucoma
- Advanced liver and kidney dysfunction
- Hiatal hernia
- Obstructive GI and GU conditions
- Severe ulcerative colitis
Contraindications
- Acetylcholinesterase inhibitors (donepezil) increase the adverse effects of bethanechol
Drug Interactions
- known drug allergy
- hyperthyroidism
- peptic ulcer
- bronchial asthma
- cardiac disease
- epilepsy
- parkinsonism
- urinary obstruction
Contraindications
Adverse effects are typically mild and resolve on their own:
- GI upset
- Drowsiness
- Dizziness
- Insomnia
- Muscle cramps
- Bradycardia, syncope, hypotension, hypertension
Adverse Effects
- Direct-acting cholinergic med
- Bethanechol is used to treat acute postoperative and postpartum nonobstructive urinary retention.
- Also used to treat chronic urinary retention associated with neurogenic atony (lack of normal muscle tone) of the bladder.
Uses
- Allergy to donepezil
Contraindications
Patient Teaching
- Oral hygiene to assist with dry mouth
- Can cause fever in peds patients
- Men with BPH may experience increased urinary retention
- Drugs that have anticholinergic side effects ex. antihistamines, tricyclic antidepressants—increase in anticholinergic effects
- Can increase the effects of digoxin when taken together.
Drug Interactions
Indirect-acting cholinergic drug
- Indirect-acting drugs increase acetylcholine at the receptor sites, which stimulates the effector cells
- Acetylcholine is a transmitter substance within the neuropathway – think of pavement on a road vs gravel – it makes travel much easier
- Never give if the patient has an obstruction
- Thorough assessment, medication, and medical history
- Vital signs
- SLUDGE
Nursing Considerations
- Dysrhythmias
- Restlessness, irritability, delirium (especially older adults)
- Drowsiness, confusion
- Dilated pupils, increased intraocular pressure
- Decreased salivation, gastric secretions, motility (constipation)
- Urinary retention
- Decreased sweating
- Decreased bronchial secretions
- Can cause delirium in the elderly
Adverse Effects
- Head to toe assessment with vitals
- Thorough medical and medication history
- Patient’s neuro status and memory
- Presence or absence of family support
- SLUDGE
Nursing Considerations
- Known drug allergy
- Hepatic and renal disease
- CAD
- Peptic ulcer
- Sepsis
Contraindications
- Antihypertensive meds can negate effects
- MAOIs can cause hypertensive crisis
- Antihistamines and thyroid meds can increase the effects of the drug
Drug Interactions
- Headache
- Restlessness
- Chest pain, palpitations
- Dysrhythmias
- Hypertension
- Toxicity: Seizures and intracranial bleeding
Adverse Effects
- Monitor BP and pulse
- Monitor I&O, daily weights
- For BPH: assess symptom improvement, decrease in hesitancy, dribbling, incomplete bladder emptying, impairment of urinary stream
Nursing Considerations
- Route: SQ
- Onset: 5-10 minutes
- Peak plasma concentration: 20 minutes
- Half-life: variable
- Duration of action: unknown
- Route: IV
- Onset: less than 2 minutes
- Peak plasma concentration: rapid
- Half-life: less than 5 minutes
- Duration of action: 5-30 minutes
Pharmacokinetics
- Monitor vital signs and EKG
- Assess IV site for infiltration
- SQ/IM Epi pen: assess respiratory status
Nursing Considerations
Uses
- Endogenous catecholamine—it is found in the body and is made synthetically
- Direct acting—it binds directly to the receptor
- Used primarily as a bronchodilator (more on that later) or as a cardiovascular medication
- Most common uses are in the form of an epi pen to treat anaphylactic shock and as a vasoconstrictor to raise blood pressure.
- Main vasoactive medication in ACLS (advanced cardiac life support)
- Med error risk—different dosages for SQ, IM, and IV preparations
- Route: PO
- Onset: 1-2 hours
- Peak plasma concentration: 2-6 hours
- Half-life: 22 hours
- Duration of action: 24 hours
Pharmacokinetics
- First-dose phenomenon—severe drop in BP after taking the first dose. Can cause syncope. Monitor BP for 2-6 hours after first dose and with dose changes.
- Orthostatic hypotension, edema, tachycardia
- Dizziness, fatigue, weakness
- Headache
- N/V, diarrhea, constipation
- Incontinence, dry mouth
Adverse Effects
- Erectile dysfunction drugs (sildenafil) and antihypertensives increase the risk of hypotension
- Alcohol, NSAIDS, adrenergic meds (epinephrine), and estrogens can decrease the antihypertensive effects
Drug Interactions
- Epi Pen: use as directed, reinforce usage using teach back method
- Seek medical attention ASAP after using epi pen.
- Teach children how to manage allergies and use epi pen
Patient Teaching
- Take meds even if feeling well
- Take at the same time each day
- Change positions slowly due to orthostatic hypotension
- Monitor BP
Patient Teaching
- Allergy to the epinephrine and extreme hypertension
Contraindications
- Blocks the effects of alpha-adrenergic receptors of the SNS
- Causes arterial and venous dilation, which reduces peripheral vascular resistance
- Lowers BP
- Decreases symptoms of benign prostatic hyperplasia (BPH), increases urine flow
- Important to note WHY your patient is taking this med—HTN or BPH or both?