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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?

Uses