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action of acetylcholine PHARMACOKINETICS  Absorption: Varies widely; rarely administered intramuscularly (I.M.) or intravenously (I.V) because they would be subject to immediate breakdown by cholinesterases; usually given orally or subcutaneously (S.C.)  Distribution: Widely distributed, binding primarily to muscarinic and nicotinic receptor sites, in the plasma, and in liver.  Excretion: Excreted in the urine DRUG EXAMPLES  Bethanechol chloride(Duvoid,Myotonachol),pilocarpine(Isoptocarpine,Pilocar) INDICATIONS  Cholinergic agonists are used to treat glaucoma and to stimulate bladder and intestinal function  Bethabechol is used to treat non-obstructive urine retention and neurogenic bladder  Pilocarpine is used to treat glaucoma CONTRAINDICATIONS AND PRECAUTIONS  Prostate enlargement, possible urinary or GI obstruction, hyperthyroidism, bradycardia or atrioventicular (AV) conduction defects, asthma, and pregnancy ADVERSE REACTIONS  Hypotension, headache, flushing, sweating, increased salivation, abdominal cramps, nausea, vomiting, diarrhea, blurred vision, bronchial constriction INTERACTIONS  Inhibits parasympathomimetic action when used with atropine-like drugs (antimuscarinics) and sympathomimetics  Acetycholinesterase inhibitors and cholinergic agonists potentiate each other  Causes additive effects when parasympatholytics are used with other anticholinergic  Quinidine and procainamide may antagonize effects bethanedchol chloride NURSING RESPONSIBILITIES When administering bethanechol chloride: - Base patient evaluation on increased bladder tone and function - Assess the patient’s urinary status - Never give bethanechol chloride I.V. or I.M. (only give by mouth P.O. or S.C.) - Observe the patient for 20 to 60 minutes after S. C. administration

- Monitor the patient for signs and symptoms of drug toxicity, such as urinary urgency, excessive secretions, respiratory depression or spasm, bradycardia, abdominal cramping, and involuntary defecation - Administer atropine as the antidote for toxicity, as prescribed When administering pilocarpine: - base patient evaluation on decreased intraocular pressure - teach the patient how to instill the eyedrops PARASYMPATHOMIMETICS ACETYCHOLINESTERASE INHIBITORS MECHANISM OF ACTION  Inhibit acetycholinesteras, the enzyme that inactivates acetylcholine, thereby stimulating cholinergic receptors and producing prolonged activation of the parasympathetic nervous system PHARMACOKINETICS  Absorption. Absorbed readily in the GI tract, subcutaneous tissues, and mucous membranes, except for neostigmine, which is absorbed poorly if given orally  Distribution: Only physostigmine readily penetrates the blood-brain barrier  Metabolism: Most are metabolized by the plasma esterases  Excretion: Excreted in the urine; half-life (of neostigmine)- oral,40 to 60 minutes; injection, 50 to 90 minutes DRUG EXAMPLES  Ambenonium (mytelase), edrophonium (Enlon, Reversol, Tensilon), neostigmine, (Prostigmin), physostigmine (antilirium), pyridostigmine (Mestinon,regonol) INDICATIONS  Acetycholinesterase inhibitors are used to treat myasthenia gravis and glaucoma and to prevent or treat postoperative paralytic ileus  Edrophonium and neostigmine, are used to diagnose myasthenia gravis  Ambenonium, neostigmine, and pyridostigmine promote muscle construction and are used to treat myasthenia gravis  Neostigmine is used to prevent or treat postoperative ileus, prevent or treat postoperative distention, and treat non-obstructive urine retention  Physostigmine is used to treat anticholinergic poisoning (including tricyclic antidepressant overdose)  Edrophonium, neostigmine, and pyridostigmine are used to reverse the effects of nondepolarizing neuromuscular blockers CONTRAINDICATIONS AND PRECAUTIONS  Possible urinary or GI obstruction ADVERSE REACTIONS  Parasympathomimetic, or muscarinic adverse effects are common and include nausea, vomiting, diarrhea, increased salivation, bradycardia, hypotension, dyspnea, diaphoresis, blurred vision, and miosis  Nicotinic adverse effects include muscle cramps, fatigue, weakness, paralysis, hypertension, and respiratory depression

INTERACTIONS  Use of edrophonium, neostigmine, and pyridostigmine, with nondepolarizing neuromuscular blocker(for example, tubocurarine) antagonizes the effect of the neuromuscular blocker, decreasing the drug’s therapeutic effectiveness  Neostigmine and pyridostigmine potentiate depolarizing muscle relaxants (for example, succinylcholine),prolonging muscle paralysis  Use with cholinergic agonists(such as pilocarpine, bethanechol, and carbachol) will increase the effect of acetylcholine  Use with anticholinergics (such as atropine and scopolamine) decreases the effect of the anticholinesterase and could mask signs of a cholinergic crisis NURSING RESPONSIBILITIES  Asses the patient’s neuromuscular status, including gait, muscle strength, reflexes, and heart rate, before and during therapy  Monitor the patient for signs and symptoms of toxicity, such as generalized weakness, dysphagia, and respiratory weakness, administer atropine as the antidote for toxicity, as prescribed  Monitor the patient’s vital signs and auscultate for breath sounds at least once every 4 hours  Take seizure precautions

PARASYMPATHOLYTICS: CHOLINERGIC BLOCKERS (ANTICHOLINERGICS) MECHANISM OF ACTION  Block the action of acetycholine at muscarinic receptors in the parasympathetic nervous system PHARMACOKINETICS  Absorption: Absorbed in the GI tract, mucous membranes, skin, and eyes  Distribution: Belladonna alkaloids are distributed widely and readily cross the blood-brain barrier; the other drugs aren’t.  Metabolism: Alkaloids are metabolized in the liver; the other drugs are hydrolyzed in the GI tract and the liver  Excretion: Excreted in the feces and the urine DRUG EXAMPLES  Atropine, belladonna, benztropine (Cogentin),gycopyrrolate (Robinul) propantheline (Pro-banthine),scopolamine (Scop, Transderm Scop), trihexyphenidyl hydropchloride(Artane) INDICATIONS  Parasympatholytics are used to reduce salivation and gastric secretions, to reverse heart block, to induce mydriasis, and to treat Parkinson’s disease, GI spasms, motion sickness and enuresis  Atropine and gycopyrrolate are used to treat bradyarrhythmias, arrhythmias, and sinus arrest

hard candy.feeding women ADVERSE REACTIONS  Ophthalmic adverse effects with topical application of atropine include blurred vision. and glycopyrrolate are used to decrease saliva and bronchial secretions before surgery CONTRAINDICATIONS AND PRECAUTIONS  Contraindicated in angle-closure glaucoma. or dopamine receptors activated by dopamine PHARMACOKINETICS  Absorption: Varies widely with each drug  Distribution: Varies widely with each drug  Metabolism: Varies widely with each drug . such as urinary frequency with voiding of minimal amounts ADRENERGIC AGONISTS (SYMPATHOMIMETICS) MECHANISM OF ACTION  Mimic sympathetic activity by activating or inhibiting alpha and beta receptors that normally are activated by the neurotransmitter norepinephrine. uncontrolled tachycardia. acute or severe hemorrhage. Benztropine and trihexyphenidyl are used to treat dyskinesia. myasthenia gravis. conjunctivitis. extrapyramidal reactions. severe ulcerative colitis. and photophobia  Systematic adverse effects include tachycardia. scopolamine. constipation. or gum and to reduce constipation by exercising and increasing fiber and fluid intake  Instruct the patient to consult a physician or pharmacist before taking nonprescription drugs to prevent adverse drug interactions  Administer a cholinergic blocker 30 minutes before meals and at bedtime when used to reduce GI motility  Monitor the patient’s intake and output. hypersensitivity. and watch fro signs and symptoms of urine retention. tachycardia caused by cardiac insufficiency or thyrotoxicosis. urinary or GI tract obstruction. or unstable cardiovascular status  Also contraindicated in children and breast. and urinary hesitancy or urine retention INTERACTIONS  Use with various drugs (such as tricyclic antidepressants) may increase anticholinergic adverse effects  Antacids decrease absorption of parasympatholytics NURSING RESPONSIBILITIES  Assess the patient for relief of symptoms  Monitor the patient fro adverse reactions  Teach the patient to reduce dry mouth by using ice chips. dry mouth. and parkinsonism  Propantheline and glycopyrrolate are used to treat peptic ulcer and bowel spasms  Scopolamine is used to prevent nausea and vomiting resulting from motion sickness  Atropine also is used to induce mydriasis  Atropine.

Bricanyl ) INDICATIONS  Alpha –adrenergic agonist. Excretion: Varies widely with each drug DRUG EXAMPLES  Albuterol (Proventil. Suldafed). it’s also used to stimulate alpha. cardiac stimulation in cardiac arrest. restlessness. dopamine (In tropin). which dilate renal arteries in low does. are used to treat heart failure  Beta2. myocardial contractility. when combined with local anesthetics. susphrine). angina. noropinephedrine (Levophed).adrenergic agonist. are used to treat hypotension  Beta1. epinephrine (Adrenalin. isoproterenol (isuprel). metaproteronol sulfate (Alupent).  Isoproterenol is used for cardiac stimulation and bronchodilation through stimulation of beta1 and beta2 receptors  Norepinephrine is used to stimulate the heart in cardiac arrest and to increase blood pressure through vasoconstriction in acute hypotension and shock  Dopamine is used in higher doses for increased blood pressure and cardiac output through positive inotropic action and in lower doses for increased renal and mesenteric blood flow through its action on alpha – adrenergic and beta1-adrenergic receptors  Dobutamine is used for increased myocardial force and cardiac output through stimulation of beta1. terburtaline ( Brethine. pseudoephedrine (Novafed. overuse of nasal decongestants may result in rebound stuffiness . and heart rate and accelerate AV conduction. dobutamine (Dobutrex). which increase blood pressure.adrenergic receptors for patients with acute congestive heart failure and those undergoing cardiopulmonary bypass  Albuterol and metaproterenol are used for bronchodilation  Terbutaline is used for brochodilation and to delay delivery in preterm labor  Psuedoephrine and phylephrine are used for nasal decongestion  Phenylephrine is given I. tachycardia. which cause peripheral vasodilatation and bronchodilation. which increase cardiac output. are used to treat mild renal failure caused by decreased cardiac output  Epinephrine is used for bronchodilation in asthma or allergic reactions. thereby decreasing blood flow to the site and prolonging anesthetic action. and mydriasis. phenylephrine (Neosynephrine).adrenergic agonist. beta1. are used to treat asthma and allergy  Dopamine agonist.V. to produce local vasoconstriction . Ventolin). to treat severe hypotension or shock CONTRAINDICATIONS AND PRECAUTIONS  Epinephrine is contraindicated in angle-closure glaucoma  Dopamine and isoproterenol are contraindicated in patients with tachyarrhythmias ADVERSE REACTIONS  Arrhythmias.and beta2 receptors and . urinary urgency or incontinence.

and hemodynamics or on relief of bronchospasms without serious adverse effects ADRENERGETIC BLOCKERS (SYMPATHOLYTICS) ALPHA – ADRENERGETIC BLOCKERS MECHANISM OF ACTION  Inhibition sympathetic activity by activating or inhibiting alpha-and betareceptors that normally are activated by norepinephrine . isoproterenol.muscle relaxants and vasodilators. phentolamine (Regitine) INDICATIONS  As smooth. phenoxybenzamine (Dibenzyline).  Teach the patient how to administer the prescribed inhalation drug. if extravasation occurs during infusion of dopamine or norepinepherine. or other evidence of coronary artery disease. Raynaud’s disease. and urine output to prevent the adverse effects listed above  Monitor the electrocardiogram and hemodynamic parameters for undesirable changes  Correct hypovolemia before infusing dopamine or norepinephrine to ensure the drug’s effectiveness  Administer drugs through a large vein to prevent extravasations. breath sounds. ergotamine tartrate (Ergostat). urine output. or dopamine receptors that are activated by dopamine PHARMACOKINETICS  Absorption: Absorption is erratic when administered orally. pregnant women .INTERACTIONS  Antagonize the effects of beta blockers ( epinephrine. and adrenergic excess (for example. used to treat peripheral vascular disorders. ergotamine tartrate with caffeine (Cafergot). and norepinephrine) NURSING RESPONSIBILITIES  Explain to the patient the purpose of the drug  Assess the patient’s vital signs. more rapidly and completely absorbed when administered sublingually  Distribution: unknown  Metabolism: Metabolized by the liver  Excretion: Excreted in the feces with only traces in the urine DRUGS EXAMPLE  Doxazosin mesylate (Cardura). vascular headaches. as appropriate  Base patient evaluation on improved vital signs. coronary insufficiency. pheochromocytoma)  Phenoxybenzamine is used to treat Raynaud’s disease  Phentolamine is used to diagnose and treat hypertension secondary to pheochromocytoma and treat extravasation of vasopressors  Ergotamine is used to treat vascular headache CONTRAINDICATIONS AND PRECAUTIONS  Patients who have had a myocardial infraction (MI). as ordered. infiltrate the skin with phentolamine (Regitine) and normal saline solution.

which may result in bronchospasm in individuals with asthma or obstructive lung disease PHARMACOKINETICS  Absorption: Usually absorbed rapidly and well from the GI tract and some drugs are absorbed more completely than others. characterized by numbness. dizziness. and miosis  Ergotamine may cause ergotism (chronic poisoning from excessive ergot use). quiet room. and blindness INTERACTIONS  Use with antihypertensives (phenoxybenzamine) potentiates hypotensive effects  Use of adrenergic agonists with other adrenergic causes additive effects  Use with epinephrine or ephedrine will antagonize their vasoconstricting and hypertensive effects  Use of ergotamine tartrate and caffeine suppository with potent CYP3 A4 inhibitors (such as macrolides and protease inhibitors) can cause ergot toxicity (vasospasms. tingling of fingers and toes. as appropriate BETA.ADRENERGIC BLOCKERS MECHANISM OF ACTION  Reduce or block myocardial stimulation and cause vasodilatation.  Inform the patient that the intended effects of phenoxybenzamine may take 1 week to appear  Instruct the patient with vascular headache and then lie down in a dark. arrhythmias. and cerebral ischemia) NURSING RESPONSIBILITIES  When administering phenoxybenzamine or phentolamine. ischemic extremities. or weakness in extremities  Administer with milk or food to minimize gastric irritation  If the patient experiences a shocklike state. such as numbness. monitor blood pressure for signs of orthostatic hypotension  If a phentolamine test is scheduled. food may enhance absorption . as ordered.ADVERSE REACTIONS  Phenoxybenzamine and phentolamine may cause nasal congestion. and explain the test to the patient  Instruct the patient to change positions slowly to minimize orthostatic hypotension. reducing glycogenolysis and bronchodilator effects  Selective beta block beta1 and beta2 receptors. tachycardia. place the patient in resuscitation. withhold all antihypertensives. tingling. GI irritation. orthostatic hypotension. weakness.  Monitor the patient receiving ergotamine for signs and symptoms of vascular insufficiency due to ergotism. found predominantly in the heart  Nonselective beta blockers block both beta1 and beta2 receptors.

bradycardia.carteolol. propranolol. increased sensitivity to cold INTERACTIONS  Use with drugs having similar effects(such as antiarrhythmics and calcium channel blockers) may cause additive myocardial depression and bradycardia  Use with insulin or hypoglycemics increases the risk of hypoglycemia.glaucoma. Metipranolol (OptiPranolol). and propranolol are used to treat angina  Acebutolol. liver . Timolol (Blocarden) INDICATIONS  Beta Blockers are used to treat hypertension. sotalol and propranolol are used to treat tachyarrhythmias  Carvedilol is used to treat mild to severe heart failure and left ventricular dysfunction after MI  Metoprolol. withhold the drug and notify the physician if the rate is below 50 beats/minute (or according to hospital policy)  After administering eyedrops.Propranolol (Inderal). vomiting. and breast milk DRUGS EXAMPLES Acebutolol (Sectral). and timolol are used to treat glaucoma CONTRAINDICATIONS AND PRECAUTIONS Bradyarrhythmias. usually metabolized in the liver  Excretion: Excreted in feces. Kerlone). and tachyarrhythmias and to prevent migraine headache.atenolol. Carvedilol (Coreg). brochospasm. heart block ADVERSE REACTIONS  Arrhythmias. levobunolol (Betagan). and timolol are used to prevent MI  Propranolol is used to prevent vascular headache  Betaxolol. pindolol. nadolol.bound. urine. Pindolol (Visken). nausea. Labetalol (Ormodyne). Metoprolol (Lopressor). apply pressure to the inner canthus of the eye for 1 minute to minimize systemic absorption  Teach the patient to monitor pulse and blood pressure for adverse changes (for specific teaching tips(teaching about beta-adrenergic . lungs. propranolol. metipranolol. Carteolol (Artrol). diarrhea. and timolol are used to treat hypertension  Atenolol. distributed widely in the body tissues. may alter insulin requirements. and may mask signs and symptoms of hypoglycemia (such as tachycardia and sweating) NURSING RESPONSIBILITIES  Assess the patient’s pulse rate. Nadolol (Corgard). Penutolol (Levatol). Distribution: Somewhat protein. MI. penbutolol. esmolol (Brevibloc). nadolol.carvedilol.labetalol. Sotalol (Betapace). Trandate). esmolol. metoprolol. and saliva  Metabolism: Except for nadolol and atenolol.metaprolol. angina. Atenolol (Tenormin).betaxolol. with highest concentrations in the heart. and acute anxiety reaction  Acebutolol. bronchospasm. betaxolol (Betopti. lovobunolol.

encourage the patient to comply with other recommended antihypertensive interventions(such as weight reduction. therefore. dietary sodium restriction. hypotension. bronchospasms.)  If appropriate. pancuronium bromide. regular exercise and stress management  Instruct the patient to carry identification describing the disease and drug regimen  Advise the patient who is receiving long-term therapy not to discontinue the drug suddenly because this may precipitate an IM or arrhythmias NEUROMUSCULAR BLOCKERS NONDEPOLARIZING DRUGS(COMPETITIVE OR STABILIZING DRUGS) Mechanism of action  Comparison with acetycholine at the cholinergic receptor sites of the skeletal muscle membrane.vecuronium bromide (Norcuron) Indications  For prolonged or intermediate muscle relaxation during surgery or facilitation of endotracheal(ET) intubation  For paralysis in patients who are insufficiently ventilated or who fight with the ET tube or ventilator Contraindications and precautions  Contraindicated in patients hypersensitive to drug and in neonates because these drugs contain benzyl alcohol  Use cautiously in pregnant and breast-feeding women Adverse reactions  Apnea.smoking cessation.such as antibiotics and reactions. that interact with a nondepolarizing blocker will have an additive effect .blockers –make sure to include the ff topics in your teaching plan for the patient receiving a beta-adrenergic blocker. moderation of alcohol consumption.cisatracurium besylate(Nimbex).excessive bronchial or salivary excretions Interactions  Most drugs.thereby blocking acetylcholine transmitter action and preventing muscle membranes from depolarizing Pharmacokinetics  Absorption:Absorb parenterally because they are poorly absorbed after oral administration  Distribution: Distributed rapidly throughout the body but don’t cross bloodbrain barrier.doxacurium chloride(Nuromax).they don’t alter consciousness or pain perception  Metabolism:Partially metabolized in the liver  Excretion:Most are excreted unchanged in the urine Drugs examples  Atracurium besylate (Tacrium).

head lift. or penetrating eye injuries . during drug therapy  Have oxygen and ET and suction equipment available at all times in case respiratory support is needed  Monitor respirations frequently until the patient is fully recovered from the neuromuscular blockade.V. levels.pyridostigmine. I.Quelicin) Indications  For short-term muscle relaxation as an adjunct to general anesthesia to facilitate ET intubation  To induce skeletal muscle relaxation during surgery or mechanical ventilation Contraindications and precautions  Contraindicated in patients with a known hypersensitivity to the drug or its components. a genetic disorder of plasma pseudocholinesterase. myopathies associated with elevated creatine phosphokinase. especially apnea or bronchospasm. personal or family history of malignant hyperthermia. administration is the preferred route  Distribution:Unknown  Metabolism:hydrolyzed in the liver and plasma by pseudocholinesterase  Excretion: Excreted in the urine:about 10% is excreted unchanged Drugs  Succinylcholine chloride (Anectine.The second phase is seen only in high doses Pharmacokinetics  Absorption:Absorbed poorly in the GI tract. Anticholinesterases(neostigmine.First phase : These drugs compete with acethycholine at the cholinergic receptors of the skeletal muscle membrane and depolarize that postsynaptic membrane of the muscle: NOT counteracted by antichonesterase causing persistent depolarization followed by muscle fasciculations and paralysis or flaccidity . never turn off the ventilator alarm DEPOLARIZING DRUGS Mechanics of action  Produce a biphasic effect at the skeletal muscle . acute angle-closure glaucoma. as evidenced by increased muscle strength (peripheral nerve stimulation. and edrophonium) antagonistic and are used as antidotes to nondepolarizing blockers are Nursing responsibilities  Monitor the patient for any adverse reactions. and ability to cough)  Keep drugs refrigerated to maintain their potency  Suction the patient as needed because the drug will suppress the cough reflex and increase respiratory secretions  Frequently check the mechanical ventilator settings and functions to ensure that it’s working properly. hand grip.

pemoline (Cylert.hepatic. dextroamphetamine(Dexedrine). and a return of previous levels of muscle strength on hand-grip and head-lift tests CNS STIMULANTS Mechanism of action  Increase neurotransmitter levels in the CNS. Use cautiously in pregnant or breast-feeding women.doxapram (Dopram). either by increasing neuronal discharge or by blocking an inhibitory neurotransmitter. heightened mental alertness.methylphenidate. methylphenidate hydrochloride (Concerta. Metadate. and patients with cardiovascular.pulmonary. Methylin. signs of recovery include a renewed ability to cough. and a diminished sense of fatigue Pharmacokinetics  Absorption: Absorbed in the GI tract after oral administration  Distribution: Varies with each drug  Metabolism: Usually metabolized by the liver  Excretion: Excreted in the urine Drug examples  Dexmethyphenidate hydrochloride (Focalin). possible muscle pain and increased intraocular pressure Interactions  Anticholinesterases increase succinylcholine blockade  Check the patient’s respiratory rate and pattern every 5 minutes during drug infusion Nursing Responsibilities  Maintain a patent airway for the patient at all times  Check the patient’s respiratory rate & pattern every 5 minutes during drug infusion  Monitor the patient closely until recovery from the neuromuscular blockade is complete. increased motor activity.Ritalin).causing CNS and respiratory stimulation. or renal disorders Adverse reactions  Prolonged apnea and cardiovascular effects.metabolic. pupil dilation.and pemoline are used to treat narcolepsy and ADHD  Doxapram is used to treat respiratory stimulation after anesthesia .PemADD) Indications  To increase mental alertness and respiratory rate  To treat hyperactivity in children  Dexmethylphenidate hydrochloride effectively manages symptoms of attention deficit hyperactivity disorder(ADHD) at half the dose of Ritalin  Dextroamphetamine.children. brighter spirits.

tremor. fatigue.decreased hyperactivity.Urine acidification enhances renal excretion of the drug . and growth suppression (in children) Interactions  Concurrent use with similar-acting drugs causes additive sympathomimetic effects  Altered urine Ph may alter the effectiveness of CNS stimulants . and brighter spirits . irritability. arrhythmias.base evaluation on improved respiratory status and ABG measurements ANTICONVULSANTS HYDANTOINS Mechanism of action  Inhibit seizure activity by promoting sodium outflow from the neurons.thereby depressing abnormal neuronal stimulation and discharge Pharmacokinetics .Contraindications and precautions  Contraindicated in patients with glaucoma and severe cardiovascular (CV)disease  Use with caution in patients with psychosis and in pregnant and breastfeeding women Adverse reactions  Acute adverse effects (toxicity) include restlessness. depression.Urine alkalinization enhances renal absorption of the drug Nursing responsibilities  Assess the patient’s behavior to determine drug effectiveness  Monitor growth in a child who is receiving long-term therapy  When administering the patient receiving doxapram to treat respiratory depression after anesthesia. and a prolonged attention span(these effects usually appear in 3 to 4 weeks) . the patient with the patient with narcolepsy. and CV collapse  Chronic adverse effects include marked weight loss. assess the patient’s respiratory status(including lung sounds and rate and depth of respirations) and arterial blood gas(ABG) measurement for changes  Keep in mind that most CNS stimulants are controlled substances and that amphetamines may cause dependence and abuse  Instruct the patient to take the last daily dose at least 6 hours before bedtime to prevent insomnia  Instruct the patient to avoid beverages containing caffeine to prevent added stimulation  Base patient evaluation on the reason for using the drug . angina.diminished fatigue. base evaluation on increased calmness. base evaluation on increased activity and alertness. insomnia. hypotension.

oral anticoagulants.mephenytoin(Mesantoin). second-and third.distributed in breast milk  Metabolism: Metabolized in the liver  Excretion: Excreted in the urine. leading to phenytoin toxicity  Oral tube feedings may interfere with absorption of oral phenytoin. nystagmus. fosyphenytoin sodium (Cerebyx). bioavailability varies among products.). treatment for toxicity is nonspecific  Monitor therapeutic hydantoin. chloramphenicol.V). such as trigeminal neuralgia Contraindications and precautions  Contraindicated in patients hypersensitive to drug or its components  Phenytoin is contraindicated in patients with sinus bradycardia. phenytoin(Dilantin. and folic acid may decrease phenytoin activity and diminish the drug’s effectiveness  Amiodarone. diminishing the drug’s effectiveness. coma. ataxia. feedings should be scheduled at least 1 hour before or 2 hours after phenytoin dose  Phenytoin is incompatible with dextrose and any dextrose containing solutions Nursing responsibilities  Monitor the patient for signs and symptoms of toxicity(ataxia. Phenytek) Indications  To treat tonic-clonic (grand mal) seizures. slurred speech. and complex partial seizures  Phenytoin also is used to treat arrhythmias and painful conditions. diazoxide. sulfamethizole and valproate may increase phenytoin. infuse no faster that 50 mg/minute  Teach the patient about the importance of good oral hygiene and regular dental examinations to prevent gingival hyperplasia  If GI upset occurs. or Adam-Stokes Syndrome Adverse Reactions  Gingival hyperplasia. status epilepticus (I. may give drug with food . or unresponsive pupils. activity. hypotension.nausea and vomiting Interactions  Alcohol (long-term use). salicylates. diazepam. diplopia. half-life varies and is dose-dependent Drug examples  Ethotoin (Peganone). Absorption: Usually slowly absorbed in the small intestines after oral administration. dilute in normal saline solution (dextrose solutions cause a precipitate).V.disulfiram. drowsiness. and dysarthria). sinoatrial block. and liver enzyme levels to avoid or detect toxicity  When administering phenytoin intravenously (I. cycloserine. antihistamines.cimetidine. tremors. phenylbutazone. rifampin. heart block. rare blood dyscrasias. isoniazid. complete blood count.influenza vaccine.  Distribution: Protein-bound .

causing drowsiness. and insomnia  As adjuncts to anesthesia. Instruct the patient to consult the physician or pharmacist before changing drug brands because bioavailability may differ among brands (for specific teaching tips) BARBITURATES AND DEOXYBARTITURATES Mechanism of action  Depress the sensory cortex and motor activity and alter cerebellar function. hypotension. blood dyscrasias Interactions  Alcohol may cause additive CNS effects & death  Phenobarbital toxicity can occur if primidone is given with Phenobarbital (primidone is metabolized in the liver to Phenobarbital)  Barbiturates reduce the effectiveness of hormonal contraqceptives Nursing Responsibilities  Assess patient’s respiratory status before & during drug therapy  Discourage alcohol use during drug therapy  Know that barbiturate3s maybe habit-forming. and hypnosis.sedation. respiratory depression (with high doses). especially following prolonged use at high dose . drowsiness. primidone is also excreted in breast milk Drug examples  Mephobarbital(Mebaral). tolerance & psychological & physical dependence may occur. may be used as an emergency control for acute convulsive episodes Contraindications & Precautions * Barbiturates are contraindicated in patients who are sensitive to barbituarates & in pregnant & breast feeding women * Also contraindicated in patients with hepatic impairment or severe respiratory disease & in those who have had a previous addiction to a sedative or hypnotic * Intra-arterial & subcutaneous (SC) administrations are contraindicated Adverse Reactions  Dizziness. in high doses. rate of absorption increases if given on an empty stomach  Distribution: Protein-bound and well distributed in body tissues  Metabolism: Metabolized by the liver  Excretion: Excreted in the urine. barbiturates may induce anesthesia Pharmacokinetics  Absorption: Absorbed slowly in the GI tract.Phenobarbital(Luminal).primidone (mysoline) Indications  To treat tonic-clonic (grand mal)seizures. partial seizures.

drowsiness. sore throat. blood dyscrasias. Monitor the patient for withdrawal symptoms  Minor symptoms may appear 8 to 12 hours after the last dose &include anxiety. bleeding. give the drug with food or milk  Monitor for adverse reactions  Notify prescriber if rashes. dizziness. hematuria Drug examples  Ethosuximide (Milonitn) (Zarontin). Phensuximide Key nursing actions  Don’t withdraw the drug abruptly  If GI upset occurs. drowsiness. dizziness. bruising.  Metabolized in the liver  Excreted in the urine When to use succinimides  Absence of seizures When not to use succinimides  Hypersensitivity Adverse reaction to watch for  Anorexia. ataxia. under the skin during drug therapy. unexplained fever. vomiting. SUCCINIMIDES Mechanisms of Action  Reduce epileptic attacks by suppressing paroxysmal three cycle per second spike and wave activity. depressing the motor cortex. hand & finger tremors. joint pain. muscle twitching. unusual bleeding or bruising. or blurred vision develops  Tell patient to avoid alcohol during therapy OXAZOLIDINEDIONES Mechanisms of actions  Affect the brain and nervous system to change seizure patterns . or tiny broken blood vessels. Methosuximide (Celontin). dizziness. mouth sores. nausea. sore throat. and elevating the threshold of the CNS to convulsive stimuli. & nausea & vomiting  Severe symptoms include convulsions & delirium within 16 hours of last dose & may last after 5 days after abrupt cessation of these drugs  Notify doctor immediately if patient develops fever. weakness.

fatigue. or visual disturbances develop. ataxia. anorexia Drug examples  Zonisamide (Zonegran) Key nursing actions  Monitor adverse reactions . or drowsiness. agitation.When to use  Absence seizures When not to use  Hypersensitivity  Pregnancy  Breast-feeding  Liver disease  Renal disease  Diseases affecting the bone marrow  Optic or retinal diseases Adverse Reaction  Dangerous levels of sedation. SULFONAMIDES Mechanism of action  Raise the threshold for generalized seizures in rats  Increase dopaminergic and serotonergic neurotransmission  Block sodium channels  Stabilize neuronal membranes  Suppress neuronal hypersynchronization When to use  Partial seizure related to epilepsy When not to use  Hypersensitivity  Renal failure Adverse reaction to watch for  Somnolence. dizziness. headache. photosensitivity reaction Drug Example  Trimethadione (Tridione) Key Nursing Reaction  Give drug with food if patient complains of GI upset  Advise patient that extreme drowsiness and sedation may occur  Notify prescriber immediately if ataxia. fever. sore throat. rash easy bruising. dizziness.

tiagabine (gabitril). topiramate (topamax). If rash or seizure worsen. or oral ulcers MISCELLANEOUS ANTI CONVULSANT Mechanism of action  Action largely unknown. refractory absence seizure. gabapentin (neurontin). Key nursing actions  Assess seizure characteristics  Implement seizure precautions as indicated  Watch for signs and symptoms of anticonvulsive toxicity  Instruct the patient not to discontinue the drug without consulting the prescriber  Warn the patient not to consume alcohol during anticonvulsant therapy . easy bruising. felabmate (felbatol). valproate sodium (Depakene). may reduce polysynaptic responses and block posttetanic potentiation by blocking voltage-sensitive sodium channels  Metabolize in the liver  Excreted in the urine When to use  Tonic-clonic seizures  Simple and complex partial seizures  Trigeminal neuralgia  Neurogenic pain  Absence seizure  Postherpetic neuralgia When not to use  Hypersensitivity  Bone marrow suppression  Within 14 days of MAO inhibitor therapy  Pregnancy  Breast-feeding Adverse reaction to watch for  Sedation. contact prescriber if the patient develops fever. divalproex sodium (depakote). levetiracetam (Keppra). lamotrigine (lamictal). oxcarbazepine (Trileptal). blood dyscrasias Drug examples  Carbamazepine (Tegretol). drowsiness. photophobia. sore throat.

confusion. thereby . sore throat. or fatigue develops. altered tastes. periphery. agitation. bromocriptine [dopar]). ANTIPARKINSONIAN DOPAMINERGIC AGONIST Mechanism of Action  Restore natural balance of acetycholine and dopamine in the CNS  Decrease signs and symptoms of Parkinson’s disease  Metabolized in the brain. Instruct the patient to carry identification describing the disorder and drug regimen  Notify prescriber if fever. tremors. hallucinations Drug examples  Amantidine(symmetrel). orthostatic hypotension. dry mouth. mood changes. and in the liver  Excreted in the urine When to use  Parkinson’s disease  Influenza A  Hyperprolactinemia  Cocaine abuser When not use  Angle-closure glaucoma Adverse reaction  Dizziness. vomiting. insomia. nausea. oral ulcers. levodopa-carbidopa (sinemet) (parlodel). involuntary movements. ANTICHOLINERGICS (CHOLINERGIC BLOCKERS) Mechanism of Action  Block muscarinic acetylcholine receptors suppressing acetylcholine activity  Metabolism and excretion unknown When to use  Parkinson’s disease  Idiopathic parkinson’s disease in the CNS. levodopa (L-dopa Key nursing actions  Assess for signs and symptoms of parkinsonism  Base patient evaluation on improvement in signs and symptoms of Parkinsonism without severe adverse effects. easy bruising or bleeding.

vomiting. diphenhydramide hydrochloride (Benadryl) Key nursing action  Assess bowel and urinary function for evidence of adverse effects  Instruct patient to consult health care provider or pharmacist before taking nonprescription drugs  If GI upset occurs. Postencephalitic parkinson’s disease  Acute dystonic reaction  Drug-induced extrapyramidal reactions When not to use  Angle-closure glaucoma  Pyloric and duodenal obstruction  Myasthenia gravis  Stenosing peptic ulcer  Achalasia  Megacolon  Prostatic hypertrophy  Bladder neck obstructions Adverse reactions  Blurred vision  Constipation  Dry mouth  Urine retention Drug examples  Benztropine mesylate (Cogentin). miosis. administer drug with foods CHOLINERGICS (ANTIMYASTHENICS) Mechanism of Action  Relieve muscle weakness associated with myasthenia gravis by blocking acetylcholine breakdown at the neuromuscular junction  Undergoes hydrolysis by cholinesterase or metabolize by the liver  Excreted in the urine When to use  Myasthenia gravis  Myasthenic crisis When not to use  Hypersensitivity  Bromide allergy Adverse reaction  Abdominal pain. increased salivation. increased bronchial secretions. nausea. diarrhea. difficulty breathing . sweating. biperiden (Akineton).

headache.  Metabolized in the liver  Excreted in the urine. bronchospasm. diarrhea. pyridostigmine Key nursing actions  assess neuromuscular status  monitor patient for signs and symptoms of drug overdose or underdose  urge patient to carry identification describing the disease and drug regimen  base patient evaluation on improvement of neuromuscular symptoms or strength without cholinergic signs or symptoms NONOPIOID ANALGESIC Mechanisms of action  Act peripherally to prevent prostaglandin formation in inflamed tissues by two actions: 1) inhibits stimulation for pain receptors. neostigmine (prostigmine). breast milk. nausea. and shock Drug examples  Salicylate analgesics. dizziness. mucosal lesions. vomiting. and kidneys When to use  Pain  arthritis and osteoarthritis  fever reduction  inflammation reaction  prevention of transient ischemic attacks and MI  dysmenorrheal When not to use  aspirin hypersensitivity  bleeding disorders  children  GI ulcers  pregnancy Adverse reactions  GI pain and upset.Drug examples  Edrophonium (mestinon) (tensilon). rash. tinnitus.A) Key nursing action  administer the drug before meals for a rapid effect and with meals for GI irritation reductions .S. laryngeal edema. aspirin (A. fever. angioneurotic edema. 2) inhibits prostaglandin synthesis in the CNS and stimulate peripheral vasodilation to reduce fever. heartburn. rhinitis.

or viral illness OPIOID ANTAGONIST Mechanisms of action  completely blocks the effect of opioid without producing analgesic effects  may cause withdrawal symptoms in patient with physical dependence on opioid  metabolized in the liver  excreted in the urine When to use  opioid overdose  adjunct to therapy in treating drug abuse Adverse reaction  nausea. varicella. reversible CNS depression  Metabolized hepatically  Renal or hepatic excretion Indications fro rapid-acting hypnotics  Anesthesia induction and maintenance  Anesthesia extension .propofol Keys facts about rapid-acting hypnotics  Stabilize neuronal membranes to produce progressive. advise the patient that the CCD warns against giving salicylates to children or adolescents with influenza. blood pressure. vomiting. arrhythmias. hypotension. hyperventilation and tremors Drug examples  nalmefene (Revex). hypertension. tachycardia. RAPID-ACTING HYPNOTICS Mechanics of action  Stabilize neuronal membranes to produce progressive. reversible CNS depression Drug examples  Methohexital (brevital).thiopental sodium (Pentothal) hydrochloride(versed).midazolam (diprivan). naloxone (Narcan) Key nursing actions  assess respiratory status. pulse and level of consciousness until the opioid wears off  opioid dosage should be adjusted according to the patient’s pain level  give only the amount required to reverse respiratory depression or increase mental alertness.

enflurane (ethrane)halothane Adverse reactions  Exaggerated response to the normal dose(most common). INJECTABLE ANALGESIC ANESTHETICS Mechanics of action  Depress the CNS  Metabolized by liver  Excreted in feces When to use injectable analgesic anesthetics  Rapid anesthesia or conscious sedation induction  Pain Drug examples  Alfentanil (Alfenta).Adverse reactions  Respiratory depression. to compensate for the increased oxygen demand. tachycardia. and renal status and level of consciousness before and after surgery INHALATION ANESTHETICS Mechanics of action  Depress the CNS  Metabolized in lungs and liver  Excreted in urine When to use inhalation and anesthetics  Promotion of loss of consciousness. hypotension. and muscle relaxation  Anesthesia maintenance Drug examples  Desflurane (suprane). fentanyl (sublimaze) . loss of responsiveness to sensory stimulation including pain. respiratory. arrhythmias.agitation. hypotension. confusion. nausea and vomiting.memory loss Key nursing actions  Keep atropine available at all times to reverse possible bradycardia  Monitor the patient’s temperature frequently  Shivering is normal during recovery. as prescribed . apnea. tachycardia. tissue necrosis with extravasation Key nursing actions  Determine if patient has allergies before the surgery.postanesthesia nausea and vomiting. if shivering occurs.  Assess CV. etomidate. keep the patient warm with extra blankets or heat and administer oxygen. muscle twitching.

bradycardia. brochospasms. and shivering Key nursing reactions  Continually assess respiratory status  Only those experienced in endotracheal intubation should use these drugs NUEROLEPTANESTHETICS Mechanics of action  Droperidol and ketamine produce dissociation from the environment during induction of anesthesia  Droperidol-fentanyl produces pain relief and sedation by directly blocking subcortical receptors  Metabolized in liver  Excreted in feces When to use neuroleptanesthetics  Analgesia induction When NOT to use neuroleptanesthetics  Hypertension  Cardiac decompensation  History of cerebrovascular accidents  Surgery of the pharynx. and torsade de pointes Key nursing actions  In droperidol-fentanyl. seizures. extrapyramidal signs and symptoms. arrhythmias. excessive salivation. asystole. seizures. dry mouth. cough. respiratory depression. all dose of analgesics and other CNS depressants must be reduces by one-third to one-half during recovery from anesthesia LOCAL ANESTHETICS Mechanics of action  Provide analgesic relief by blocking the conduction of nerve impulses at the point of contract  Metabolism varies  Excreted in the urine . QT interval prolongation. laryngospasm.When NOT to use injectable analgesic anesthetics  Hypersensitivity Adverse reactions  Respiratory depression. disturbing dreams or hallucinations. muscles rigidity. shivering. larynx. urine retention. hypotension. skeletal and thoracic muscle rigidity. or brochial tree Adverse reaction  Arrhythmias.

chills.tinnitus. bradycardia. including spinal and epidural when not to use  drug hypersensitivity  myasthenia gravis  severe shock  impaired cardiac conduction adverse reactions  possible anxiety. during and after application  Don’t apply a refrigerated topical anesthetic to broken skin or mucous membranes . arrhythmias. bupivacaine hydrochloride (Marcaine) key nursing action  Assess for return of motor function and sensation postoperatively  Ensure that the gag reflex has returned before feeding a patient whose throat has been anesthesized. mioisis.When to use  Pain  anesthesia. restlessness. hypersensitivity reactions drug example  benzocaine (dermoplast). TOPICAL ANESTHETIC Mechanism of action  block nerve impulse transmission  stimulate the nerve endings and interfere with pain perception  stimulate the cold sensation receptors and block the nerve endings in the frozen area  metabolized in the blood and liver  excreted in urine When to use topical anesthetics  pain  anesthesia  surface numbing When NOT to use topical anesthetics  Drug hypersensitivity Adverse reactions  Hypersensitivity Key nursing actions  Assess the area where topical anesthetic is to be applied before. hypotension.

V.chlordiazepoxide hydrochloride (Librium).clonazepam(Klonopin). doses slowly  Know that many sedative-hypnotics are controlled substances  Limit amount of medication available to patient  Know that long-term use of these drugs may cause physical and psychological dependence  Monitor patient’s respiratory status.diazepam When to use benzodiazepines  Anxiety  Alcohol withdrawal  Preoperative sedation amnesia  Insomnia  Seizures . clorazepate (Tranxene). BENZODIAZEPINES Mechanism of action  Cause generalized CNS depression by mimicking or enhancing the effects of GABA  Metabolized by the liver  Excreted in the urine Drug examples  Alprazolam(Xanax.BARBITURATES Mechanism of action  The exact mechanism of action of barbiturates is unknown  The drugs are believed to cause generalized CNS depression by mimicking or enhancing the effects of GABA in the brain Drug examples  Rapid-acting barbiturates include thiopental sodium  Short-acting barbiturates include pentobarbital When to use barbiturates  Anesthesia  Insomnia  Seizures When NOT to use Barbiturates  Pregnancy  Uncontrolled pain  History of acute intermittent porphyria and CNS depression Adverse reactions to watch for  Hangover feeling.XanaxXR).speechm paradoxical excitement Key nursing reactions  Assess patient’s sleep patterns  Administer I.slurred.

doses slowly. reactions of rage.or hostility Key nursing action  Administer I.V.  Advise patient not to increase dosage unless instructed by physician NONBARBITURATES SEDATIVE-HYPNOTICS AND ANXIOLYTICS Mechanism of action  Cause generalized CNS depression  Metabolized by the liver  Excreted in the feces Drug examples  Buspirone(BuSpar). Skeletal muscle relaxation When NOT to use benzodiazepines  Pregnancy  Uncontrolled pain  Preexisting CNS depression  Acute angle-closure glaucoma Adverse reactions  Drowsiness. ataxia. temporary memory impairments. excitement.diphenhydramine When to use nonbarbiturates sedative-hypnotics and anxiolytics  Anxiety  Insomnia  Preoperative sedation  As adjuncts to opioid analgesics  General anesthesia When NOT to use nonbarbiturates sedative-hypnotics and anxiolytics  Pregnancy  Uncontrolled pain  Preexisting CNS depression Adverse Reactions  Drownsiness  Respiratory depression Key nursing actions  Use z-track method of injection(hydroxyzine)  Administer after meals(Chloral hydrate) .  Instruct patient to notify physician if dose becomes ineffective after a few weeks.Chloral hydrate(Noctec).

schizophrenia.tardive dyskinesia. dry mouth. sedation. depression with psychotic features.psychotic symptoms associated with organic brain symptoms associated with organic brain syndrome  Nausea and vomiting When NOT to use phenothiazines  Angle-closure glaucoma  CNS depression  Pregnancy (first trimester)  Coma  Risk of suicide Adverse reactions  Extrapyramidal symptoms. blood dyscrasias. sunburn.PHENOTHIAZINES Mechanism of action  Block the neurotransmitter dopamine in the limbic system.neuroleptic malignant syndrome.schizoaffective disorder.mesoriadazine When to use phenothiazines  Psychosis. inhibiting transmission of neural impulses  Inhibit the chemoreceptor trigger zone in the medulla of the brain  Metabolized in the liver  Excreted mostly in the urine Drug examples  Chlorpromazine(thorazine). blurred vision. fluphenazine(prolixin). haloperidol(Haldol) . constipation. heat intolerance Key nursing actions  Tell patient that phenothiazines may discolor urine to pink or redbrown  Instruct patient to call physician before taking over-the-counter or herbal preparations  Monitor QT interval in patient taking thioridazine BUTYROPHENONES Mechanism of action  These drugs block the neurotransmitter in the limbic system.inhibiting transmission of neural impulses(antipsychotic action)  These drugs also inhibit the chemoreceptor trigger zone in the medulla of the brain  Metabolized in the liver  Excreted mostly in the urine Drug examples  Droperidol(Inapsine). photosensitivity reaction.

neuroleptic malignant syndrome. sedation. constipation. blood dyscrasias. Tourette syndrome. blood dyscrasias. sunburn. heat intolerance Drug example  Clomipramine (anafranil).When to use butyrophenones  Nausea and vomiting during surgery and diagnostic procedures  As adjunct to anesthesia  Psychosis.nueroleptic malignant syndrome. sunburn. photosensitivity reaction.blurred vision.heat intolerance Key nursing action  Tell patient to avoid driving or other hazardous activities until CNS effects of drug are known  Advise patient to avoid alcohol and other CNS depressants during therapy ATYPICAL ANTIPSYCHOTICS Mechanism of actions  Block the neurotransmitter dopamine in the limbic system. inhibiting the transmission of the neural impulses. blurred vision. photosensitivity reaction. behavioral problems in children with explosive hyperexcitability.  Inhibit the chemoreceptor trigger zone in the medulla of the brain  Metabolize by the liver  Excreted in the urine When to use  Psychotic disorders such as schizophrenia and schizoaffective disorders  Obsessive-compulsive disorder  Bipolar disorder  Risk of suicidal behavior When not to use  Angle-closure glaucoma  CNS depression Adverse reaction  Extrapyramidal symptoms. tardive dyskinesia. clozapine (clorazil) Key nursing action  assess the patient’s mental status . sedation. dry mouth. tardive dyskinesia. hyperactivity in hyperactive children When NOT to use butyrophenones  Angle-closure glaucoma  CNS depression Adverse reaction  Extrapyramidal symptoms. dry mouth. constipation.

tachycardia. thus normalizing the receptor site associated with depression  SSRI’s block the reuptake of serotonin into the presynactic cells. AND MISCELLANEOUS ANTIDEPRESSANTS AND SSRI’s Mechanism of Action  tricyclic and second-generation antidepressants increase the amount of norepinephrine. monitor patient for extrapyramidal symptoms and other adverse reaction  if the patient is recovering from anesthesia with droperidol or fentanyl. thus increasing serotonin levels at the synapse  Metabolized by the liver  Tricyclic antidepressants excretion mostly in the urine as metabolites When to use  Endogenous depression. SECOND-GENERATION.avoid driving and hazardous activities until CNS effects of drug are known . exacerbation of heart failure or bundlebranch block  Insomia. blurred vision. clomipramine(anafranil). drowsiness.avoid alcohol and other CNS depressant . rash. or both through reuptake inhibition. anticholinergic effects  Somnolence. Adverse reaction  Orthostatic hypotension. monitor patient for orthostatic hypotension  know that the patient receiving long term antipstchotic therapy should undergo regular evaluation of red and white blood counts  don’t give antacids within 1 hour of administering these drugs  know that the drug should be discontinued gradually  teach the patient to: . serotonin.use sunscreen and wear protective clothing ANTIDEPRESSANTS TRICYCLIC. amoxapine (asendin). fatigue. nausea. asthenia. sexual disturbances . decrease opioid analgesic dosages to one-quarter to one third of normal  after parenteral doses. seizures. dry mouth. imipramine (tofranil).comply with therapy . tremor. constipation. episodes of major depression  Enuresis  Anxiety  Neurogenic pain (unlabeled use)  Generalized anxiety disorder  Obsessive-compulsive disorder  Depression  Bulimia nervosa  Smoking cessation  Premenstrual dysphoric disorder When not to use  MAO inhibitor therapy  Active liver disease Drug example  Tricyclic antidepressant include amitriptyline hydrochloride (Endep).

but to swallow them whole MONOAMINE OXIDASE (MAO) INHIBITORS Mechanism of action  Impair inactivation of norepinephrine . liver disease or abnormal liver function test results. antihypertensives. caffeine. orthostatic hypotension. constipation. anorexia. nausea. anesthetics.Key nursing action  Know that these drug should be discontinued gradually  Know that these drug may take several weeks to produce desired effects  Teach patient to : o Avoid alcohol and nonprescription drugs o Avoid driving and other hazardous activities until CNS effects of drug are known o Take daily dose of tricylic antidepressants at bedtime o Take fluoxetine or paroxetine early in day o Not crush controlled-release tablets. and vomiting  Hypertensive crisis Key nursing action  Don’t administer these drugs in the evening  Assess patient’s mental status for mood changes and suicidal tendencies  Know that it may take several weeks for these drugs to produce desired effects  Be alert for suicide attempts when depression begins to lift and energy improves .serotonin.drowsiness. peripheral edema.headache. thus prolonging their presence in CNS synapses and increasing their concentrations in the body  Metabolized in the liver  Excreteed mainly in the feces and partly in the urine When to use MAO inhibitors  Depression  Bulimia(Unlabeled use)  Panic disorder with associated agoraphobia and globus hystericus syndrome (unlabeled use) When NOT to use MAO Inhibitors  Hypersensitivity to MAO inhibitors or their components  Pheochromocytomas.insomnia. dizziness.history of headaches  With other MAO inhibitors. CNS depressants. renal impairment.heart failure. blurred vision.cheeses or other foods high in tyramine Adverse reaction  Restlessness. confirmed or suspected cerebrovascular disease.tricyclic antidepressants. hypertension. or both. dry mouth.

hypertonia. avoid excessive amounts of coffee. Monitor patient for signs and symptoms of hypertensive crisis  Teach patient to: o Avoid alcohol and foods containing tyramine o Carry identification describing disorder and drug regimen ANTIMANICS(LITHIUM) Mechanism of action  Alters the sodium transport in nerve and muscle cells  Affect synthesis. slurred speech. maintain adequate salt intake.nephrogenic diabetes insipidus Key nursing actions  Know that tolerance for lithium is high in acute phase of mania and decreases as mania subsides  Assess for suicidal tendencies and institute suicide precautions.abdominal pains. as necessary  Assess patient for signs and symptoms of lithium toxicity. diarrhea.  Teach patient to: o Drink 2 to 3 L of fluid daily.transient muscle weakness. decreased coordination. bloating. vomiting. nausea. muscle and cola. polyuria. and avoid activities that cause excess sodium loss o Avoid driving and other hazardous activities until CNS effects of drug are known .polydipsia. drowsiness. release and reuptake of central monoamine neurotransmitters  Antimanic effects may result from increases in norepinephrine reuptake and serotonin sensitivity  Excreted mostly in the urine Drug example  Lithium carbonate. and twitching. diarrhea. including vomiting.lithium citrate When to use lithium  Mania  Bipolar affective disorders When Not to use lithium  Renal or cardiovascular disease  Breast-feeding  Severe dehydration  Severe sodium depletion  Severe debilitation Adverse reactions  Hand tremors. tea. mild thirst. anorexia.

o Consult physician before taking nonprescription drugs .