NURSING CARE OF CLIENTS WITH CNS AND

PSYCHOTHERAPEUTIC DRUGS 3. Brain stem

- Beneath the cerebrum and in front of
REVIEW OF THE CNS: the cerebellum
Central Nervous System - Connects the brain with spinal cord
○ Responsible for sending, receiving and - Controls a number of autonomic
interpreting information from all parts of the functions including: respiration and
body blood pressure.
○ Responds to external stimuli
○ Monitors and coordinates the functions of Composed of:
internal organs 1. Brain
2. Pons
Composed of: 3. Medulla oblongata
1. Brain
2. Spinal cord
- Both are enclosed in protective layers called Spinal Cord
meninges: - Extends from the medulla oblongata
■ Dura mater - outer layer and down the back
■ Arachnoid mater - middle layer - Protected by and located in the
■ Pia mater - inner layer vertebral column
- A hollow tube that contains the
Subarachnoid Space cerebrospinal fluid
- Between the pia mater and arachnoid mater - 31 pairs of spinal nerves arise from
- Filled with cerebrospinal fluid the spinal cord: These nerves
transmit information from body
BRAIN organs to the brain and from the
- Located in the cranium of the skull brain to the organs.

3 Parts:
1. Cerebrum
- Largest part of the brain
- Divided into left & right hemispheres
- Each is composed of a frontal,
temporal, parietal and occipital lobe

Corpus Callosum
- A nerve tract that connects the 2
hemispheres

● Learning
● Memory
● Interpretation
● Personality

2. Cerebellum
- Located in the back of the brain just
below the cerebrum.

● Balance
● Movement
● Coordination
REVIEW OF THE PNS: 2 DIVISIONS:
Peripheral Nervous System 1. Voluntary Responses / Reflexes
➢ 31 pairs of nerves branching from the spinal - Consciously controlled
cord (spinal nerves) 2. Involuntary Responses / Reflexes
➢ 12 pairs that emerge from the brain (cranial - Unconsciously controlled
nerves)
➢ 43 nerve pairs = separate from the brain and S​omatic Nervous System
spinal cord ○ PNS division that controls voluntary
responses
○ Forms the basis of the peripheral nervous ○ Responsible for relaying sensory and motor
system information between the outside
environment and the CNS
2 TYPES OF NEURONS: ○ Innervate outer sections of the body (skin
1. Sensory (afferent) and skeletal muscles)
2. Motor (efferent) ○ Any muscle movement or voluntary motor
output uses the somatic nervous system
Sensory Neurons
- Detects various sensations such as pain and
heat Autonomic Nervous System
- Transmit messages ​towards the CNS to be - PNS division that handles involuntary
interpreted by either the spinal cord or the movement in the body
brain ○ Innervates our internal organs
○ Controls vital functions that keep us alive
Motor neurons ● Heart rate
- Transmit messages​ away​ from the the CNS ● Respiration and breathing
- Stimulate effectors (skin, sense organs, ● Digestion
muscles. etc. ) to perform a function or
reflex.
AUTONOMIC NERVOUS SYSTEM
*All 43 segments of nerves in the PNS perform
sensory, motor or mixed (both) functions. Perform opposite functions to maintain internal balance

The reflex arc SYMPATHETIC PARASYMPATHETIC

● Sensory detection Fight or flight response Rest and digest response
● Interpretation of sensory input system system
● Motor output
Causes general alertness Restores the body to a
Ganglia and excitement calm or restful state
- Collections of sensory neuron soma
Body’s way of responding
to a perceived threat
CNS Part 1:
Nervous System
○ Composed of all nerve tissues:
● Brain
● Spinal cord
● Nerves
● Ganglia
○ Receives stimuli and transmits information to
nerve centers for an appropriate response
*Evident 7 times more in boys than in girls
2 types: ​CNS ​and ​PNS
Central Nervous System (CNS)
○ Composed of ​brain ​and ​spinal cord
○ Regulates body functions
○ Interprets information sent by impulses from
the PNS and returns the instruction through
the PNS for appropriate cellular action
○ Stimulation of the CNS may ​either ​increase
the neuron activity or ​block nerve cell
activity
Peripheral Nervous System (PNS)
Consists of 2 divisions:
➢ Somatic Nervous System (SNS)
- Voluntary (a person could control it)
- For locomotion and respiration
➢ Autonomic Nervous System (ANS)
- Involuntary (cannot be controlled by
a person)
- For function of the heart, respiratory
system, gastrointestinal system and
glands
GROUP OF MEDICATIONS:
Stimulants
➢ Numerous drugs can stimulate the CNS,
which involves the brain and spinal cord,
and regulates body functions. Medically
approved use of CNS stimulants is limited to
the ​treatment of these ​indications​:
● Attention-Deficit/ Hyperactivity Disorder in
children (ADHD)
● Narcolepsy
● Reversal of Respiratory Distress
➢ Attention-Deficit/Hyperactivity Disorder
(ADHD)
○ This is also called as Minimal Brain
Dysfunction, Hyperactivity in
children, Hyperkinesis, and
Hyperkinetic Syndrome with Learning
Disorder
● May be caused by dysregulation of the
transmitter’s serotonin, norepinephrine and
dopamine
● May occur before 7 years of age and may
continue through teenage years
● Characteristics​: inattentiveness, inability to
concentrate, restlessness, hyperactivity
(fidgety, excessive and purposeless activity),
inability to complete tasks, and impulsivity.
➢ Narcolepsy
○ Characterized by: falling asleep
during normal waking activities
(driving a car, talking with someone)
○ Sleep paralysis usually accompanies
narcolepsy and affects the voluntary
muscles (person will be unable to
move and may collapse)
➢ Respiratory Distress
○ Refers to a condition in which the
person is having trouble breathing
which often show signs of that they
are having to work harder to breathe
or are not getting enough oxygen
○ This condition prevents the body
organs from getting the oxygen they
need to function
Major Groups of CNS Stimulants: ● Dry mouth
● Anorexia
1. Amphetamines and caffeine
● Weight loss
- Stimulates the cerebral cortex of the
● Diarrhea
brain
● Constipation
2. Anorexiants
● Seizure
- Suppress appetite by stimulating the
● Tremors
satiety center of the hypothalamic
● Erectile dysfunction
and limbic areas of the brain
3. Analeptics and caffeine
- Act in the brainstem and medulla to
Amphetamine-like Drugs
stimulate the respiration
Examples:
● Methylphenidate
1. Amphetamines
hydrochloride
Examples:
● Modafinil
● Amphetamine sulfate
● Dexmethylphenidate
● Dextroamphetamine sulfate
hydrochloride
● Lisdexamfetamine dimeslytate
● Armodafinil
These medications stimulate the release of
○ Used for ​ADHD​ and ​narcolepsy
norepinephrine and dopamine from the brain and
○ More ​effective in treating ADHD than
the sympathetic nervous system and inhibit the
amphetamines
reuptake of these transmitters.
○ Methylphenidate and
Dexmethylphenidate are given to
○ Causes ​euphoria and increased alertness
increase a child’s attention span and
as well as ​insomnia, restlessness, tremors,
cognitive performance and to
irritability, and weight loss
decrease impulsiveness,
○ Increased heart rate, palpitations, cardiac
hyperactivity, and restlessness
dysrhythmia, and increased blood pressure
○ Methylphenidate is most frequently
can also result from cardiac stimulation and
prescribed drug in the ​treatment of
vasoconstriction with continuous use of
ADHD
amphetamines (excessive use may lead to
○ Modafinil increases wakefulness in
psychosis)
patients with sleep disorders such as
○ Have a half-life of 9-13 hours
narcolepsy
○ Amphetamine and dextroamphetamine are
○ Classified as Controlled
prescribed for narcolepsy and ADHD when
Substance Schedule (CSS) II drug
amphetamine-like drugs are ineffective
(cannot be purchased using ordinary
○ Amphetamine and amphetamine-like drugs
prescriptions; the physicians who can
should not be administered in the evening of
only prescribe are those with CSS II
before bedtime because insomnia may
licenses)
result
○ Well absorbed for the GI mucosa
○ Usually administered to children
✓ Side effects and adverse reactions:
twice a day before breakfast and
● Dizziness
lunch
● Headache
○ Food affects absorption rate → ​given
● Euphoria
30-45 minutes before meals
● Blurred vision
○ Should be given at least ​6 hours
● Restlessness
before slee​p (causes insomnia)
● Insomnia
○ Transdermal patch may be worn for
● Tachycardia
9 hours
● Hypertension
● Palpitations
● Dysrhythmia
 Assessment:
➢ Determine for history of heart disease,
hypertension, hyperthyroidism, parkinsonism
or glaucoma (in such cases this drug is
usually contraindicated)
➢ Assess vital signs (to be used for further
comparisons; closely monitor patients with
cardiac disease because these drugs may
cause tachycardia, hypertension, and
stroke)
➢ Assess mental status (mood, affect,
aggressiveness)
Amphetamine-like Drug: ➢ Evaluate height, weight, and growth of
Methylphenidate HCl children
○ Monoamine Oxidase Inhibitors (MAOIs) + ➢ Assess complete blood count or cbc,
methylphenidate → ​hypertensive crisis differential white blood count or wbcs and
○ Potentiates the action of the CNS stimulants platelets before and during drug therapy
(ex. caffeine)
○ Inhibits the metabolism of some barbiturates Nursing diagnosis examples:
(ex. phenobarbital) ➢ Risk for health behavior that interfere with
peer relationships
✓ Side effects: ➢ Interrupted family process related to
● Anorexia dysfunctional behavior
● Dry mouth
● Nausea Planning:
● Vomiting ➢ Patient’s hyperactivity will be decreased
● Dizziness ➢ Patient’s attention span will increase
● Insomnia *related to ADHD
● Irritability
● Tremors Nursing Interventions:
● Euphoria ➢ Monitor vital signs and report irregularities
● Blurred vision ➢ Evaluate height, weight and growth of
● Headache children (especially that 1 of the adverse
● Abdominal pain effects of methylphenidate HCl is growth
● Anemia suppression)
➢ Observe withdrawal symptoms and side
✓ Adverse reaction: effects
● Tachycardia
● Hypertension Patient Teachings:
● Growth suppression ➢ Teach patient to take drug before meals
● Palpitations ➢ Advise patient to avoid alcohol consumption
● Seizure ➢ Use sugarless gum to relieve dry mouth
● Transient weight loss in children ➢ Monitor weight 2x a week and report weight
● Exfoliative dermatitis loss
● Stroke ➢ Avoid driving and using hazardous
● Thrombocytopenia equipment when experiencing tremors,
● Hepatotoxicity nervousness, or increased heart rate
➢ Do not discontinue abruptly to avoid
Applying nursing process in the care of clients withdrawal symptoms
who are taking ​methylphenidate HCl: ➢ Read labels of over-the-counter products
(may contain caffeine, can be fatal)
 ➢ Teaching nursing mothers to avoid taking all
CNS stimulants. These drugs are excreted ○ Reliance and appetite suppressants should
in breast milk and can cause hyperactivity or be discouraged
restlessness in infants ○ Children younger than 12 years old should
➢ Direct families to seek counseling for not be given with this medication
children with ADHD (drug therapy alone is ○ Long term use results to nervousness,
not an appropriate therapy program) restlessness, irritability, insomnia,
➢ Notify school nurse of drug therapy regimen palpitation, and hypertension
➢ Explain to patients and family that long-term
use may lead to drug abuse 3. Analeptics
➢ Avoid foods that contain caffeine (coffee, Examples:
tea, chocolate, soft drinks, and energy ● Caffeine citrate
drinks) ● Theophylline
➢ Encourage parents to provide children with a ● Doxapram
nutritious breakfast because a drug may
have anorexic effects ○ Used to ​stimulate respiration
➢ Teach patients about drug side effects ○ One subgroup is the xanthines
➢ To report tachycardia and palpitations (methylxanthines) of which caffeine and
➢ Monitor for onset of ​Tourette syndrome theophylline are the main drugs
- Neurological disorder ​characterized ○ Caffeine stimulates CNS
by repetitive, stereotyped, involuntary ○ Large dose of caffeine will stimulate
movements and vocalizations called respiration
ticks ○ Theophylline is mostly used to relax
bronchioles and to increase respiration in
Evaluation: newborns
➢ Evaluate effectiveness of drug therapy, level
of hyperactivity, and presence of adverse ✓ Side Effects of Caffeine:
effects ● Nervousness
➢ Monitor weight, sleep pattern and mental ● Restlessness
status for any changes ● Tremors
● Twitching
Amphetamine-like drug: ● Palpitation
Modafinil ● Insomnia
○ Increases wakefulness in patients with sleep ● Diuresis
disorders such as narcolepsy ● GI irritation
● Tinnitus (rare)
2. Anorexiants
Examples:
● Benzphetamine
● Diethylpropion
● HCl
● Phentermine HCl
● Phentermine topiramate
● Phendimetrazine
● Liraglutide
● Naltrexone HCl
● Bupropion HCl

These medications cause a stimulant effect on the

hypothalamic and limbic regions of the brain to
suppress appetite​. These medications do not have
serious side effects associated with amphetamines.
 ● Nursing indication​: the medication must be
Depressants tapered (should not be stopped abruptly;
○ Drugs that are CNS depressants cause reducing medication gradually)
varying degree of depression or reduction in ● General rule​: the lowest dose should be
the functional activity within the CNS. The taken to achieve sleep
degree of depression depends primarily on ● Patients with severe respiratory disorders
the drug and the amount of drug taken, the should avoid hypnotics which could cause
broad classification of CNS depressants an increase in respiratory depression
include: ● Hypnotics are contraindicated during
● Sedative-hypnotics pregnancy
● General anesthetics ● Ramelteon is the only major
● Analgesics (opioid and non-opioid) sedative-hypnotic approved for long term
● Anticonvulsants use. This drug may be used to treat chronic
● AntipsychoticAntidepressant insomnia

Non-pharmacologic ways to promote sleep: (to Types of Sedative-hypnotics

avoid drug dependence​ and ​drug tolerance​) 1. Barbiturates
○ Useful as sleep sustainers for
1. Arise at specific hour in the morning maintaining long periods of sleep
2. Take a few or no daytime naps
3. Avoid drinks that contain caffeine and Classifications:
alcohol 6 hours before bedtime 1. Long-acting: ​PHENOBARBITAL and
4. Avoid heavy meals or strenuous exercise MEPHOBARBITAL
before bedtime 2. Intermediate-acting:
5. Take warm bath, listen to quiet music, or BUTABARBITAL
perform other soothing activities before 3. Short-acting: ​SECOBARBITAL
bedtime
6. Decrease exposure to loud noises ○ Must be short term use only (2 weeks or
7. Avoid drinking copious amount of fluids less) cause of numerous side effects
before sleep ○ Pentobarbital and psychobarbital are used
8. Drink warm milk before bedtime primarily to treat insomnia; the onset of
action of pentobarbital is slower when
Sedative-hypnotics administered IM than when administered
○ Commonly ordered for sleep disorders PO; for pentobarbital this medication
Examples: increases hepatic enzyme action causing an
● Secobarbital sodium increased metabolism and decreased effect
● Butabarbital sodium of drugs such as anticoagulants,
● Phenobarbital glucocorticoids, tricyclic antidepressants,
● Mephobarbital and kinetin
○ Pentobarbital may cause hepatotoxicity if
○ Sedation is a mildest form of CNS taken with large doses of acetaminophen
depression
○ Hypnotic effect is a form of natural sleep ✓ Side effects and Adverse reactions:
○ Hypnotic drug therapy should be short term ● Hangover
(to prevent drug dependence and tolerance) ● Rapid Eye Movement (REM)
○ Interrupting hypnotic therapy can decrease rebound
drug tolerance ● Dependence
○ Abrupt discontinuation of a high dose of ● Tolerance
hypnotic medication → ​withdrawal ● Excessive (CNS) depression
symptoms ● Respiratory depression
● Hypersensitivity
2. Benzodiazepines ✓ Alprazolam Adverse Reactions:
○ Used to induce sleeping ● Depression
○ Increase the action of the ● Tolerance
gamma-aminobutyric acid or GABA to the ● Dependence
GABA receptors, which in turn reduce the ● Withdrawal
neuron excitability ● Hypotension
● Tachycardia
Examples: ● Seizure
● Alprazolam
● Estazolam Nursing Process when administering
● Lorazepam Benzodiazepines:
● Temazepam
● Triazolam Assessment:
● Quazepam ➢ Obtain a drug history of current drugs and
● Diazepam complementary and alternative therapies
that a patient is taking especially CNS
○ Antagonist: Flumazenil (antidote for over depressants, which would potentiate
dosage of the above medications) respiratory depression and hypotensive
effects
Increased anxiety can be the cause of insomnia for ➢ Assess baseline vital signs for future
some patient, and so the medications lorazepam comparisons; determine if the patient has a
and diazepam can be used to elevate the anxiety so history of insomnia or anxiety disorder
that the person can have a better sleep. ➢ Assess renal function​; urine output should
be 1500mL per day; renal impairment could
○ Effective for sleep disorders for several prolong drug action by increasing the
weeks longer than other sedative hypnotics half-life of the drug
○ Must not be used for longer than 3-4 weeks
(prevent REM rebound) Nursing Diagnosis:
○ Adverse reaction: anterograde amnesia – ➢ Sleep deprivation related to adverse effect of
impaired ability to recall events after dosing insomnia
➢ Ineffective breathing pattern related to CNS
Sleep related behaviors associated with depression
anterograde amnesia:
● Preparing and eating meals *nursing diagnosis presented are just 2 parts:
● Sleep driving problem statement/diagnostic statement and
● Engaging in sex etiology; no specific sign presented
● Making phone call during sleep without any
memory of the event Planning:
➢ Patient will receive adequate sleep when
Alcohol and CNS depressants increase the risk of taking benzodiazepine
sleep related behaviors
Nursing Interventions:
✓ Alprazolam Side Effects: ➢ Monitor vital signs especially respirations
● Lethargy and blood pressure must be performed by
● Drowsiness the nurse
● Dizziness ➢ Use bed alarm especially for adults and for
● Headache patients receiving hypnotic for the first time;
● Constipation confusion can occur and injury could result
● Anterograde amnesia ➢ Observe the patient for adverse reactions
especially an older adult or a debilitated
patient
 ➢ Examine for skin rashes as skin eruptions Nursing Process when administering
may occur in patients taking Nonbenzodiazepines:
benzodiazepines
Assessment:
Patient Teaching: ➢ Vital signs and laboratory tests (aspartate
➢ Avoid alcohol, antidepressants, aminotransferase, alanine aminotransferase,
antipsychotic and opioid drugs while taking bilirubin) (check for the liver function)
benzodiazepines (respiratory depression ➢ Obtain a drug history
can occur when these drugs are combined)
➢ Do not drive motor vehicle or operate Nursing Diagnosis:
machinery when using benzodiazepines ➢ Sleep deprivation related to anxiety
➢ Benzodiazepines should be gradually ➢ Fatigue related to insomnia
withdrawn
Planning:
Evaluation: ➢ Patient will remain asleep for 6-8 hours
➢ Assess the effectiveness of benzodiazepine (achieve a better sleep)
(assess whether the patient has achieved
better sleep or not) Nursing Interventions:
➢ Evaluate respiratory status ➢ Monitor vital signs and check for signs of
respiratory depression like slow irregular
breathing patterns
3. Nonbenzodiazepines ➢ Use bed alarm for older adults or patient
○ Almost entirely the same as benzodiazepine receiving nonbenzodiazepines for the first
drugs and therefore employ similar benefits, time; confusion may occur and injury may
side effects, and risks. However, result
nonbenzodiazepines have dissimilar or ➢ Observe patient for side effects of
entirely different chemical structures and are nonbezodiazepines such as:
therefore unrelated to benzodiazepines on a hangover/residual sedation,
molecular level. lightheadedness, dizziness, or confusion)

Examples: Patient teaching:

● Zolpidem tartrate – used for short term ➢ Teach non-pharmacologic methods to
treatment of insomnia specifically less than induce sleep (taking a warm bath, listening
10 days; has a half-life of 1.4-6.73 hours; to music, drinking warm fluids such as milk,
metabolized in the liver and excreted in the and avoiding drinks with caffeine after
bile, urine, and feces; dose should be dinner)
decreased if prescribed for adults ➢ Avoid alcohol, antidepressants,
● Eszopiclone antipsychotics, and narcotic drugs (severe
● Zaleplon respiratory depression may occur when
these drugs are combined)
✓ Side effects: ➢ Take the medication before bedtime
● Drowsiness (alprazolam takes effect within 15-30mins)
● Lethargy ➢ Suggest that patient urinate before taking
● Headache nonbenzodiazepine to prevent sleep
● Hot flashes disruption
● Hangover ➢ Encourage patients to check with the health
care provider about over-the-counter
✓ Adverse reactions: sleeping aids
● Tolerance ➢ Warn the patients to caution while driving as
● Psychological or physical drowsiness may occur
dependence ➢ Advise patients to report adverse reactions
● Withdrawal such as hangover to a health care provider
 ➢ Drug selection or dosage may need to be
changed if hangover occurs
Evaluation:
➢ Evaluate effectiveness of sedative-hypnotics
in promoting sleep (assess the duration of
sleep of the patient as well as the quality of
the sleep of the patient)
➢ Determine for development of side effects
4.Melatonin Agonist
➢ Ramelteon is the newest category of
sedative hypnotics:
○ The first hypnotic approved by the
USFDA that is not classified as a
controlled substance
○ This drug acts by selectively
targeting melatonin receptors to
regulate circadian rhythm in the
treatment of insomnia
○ Has not been shown to decrease
rapid eye movement sleep
○ Has a half-life of 1-2.6 hours
✓ Adverse Reactions:
● Drowsiness
● Dizziness
● Fatigue
● Headache
● Nausea
● Suicidal ideation
CNS PART 2:
ANESTHETICS
○ Are substances that induces insensitivity to
pain
Classified as:
● General
● Local
○ Monitor vital signs following general and
local anesthesia because hypotension and
respiratory depression may result
Balanced anesthesia
- Combination of several drugs each with a
specific effect to achieve analgesia, muscle
relaxation, unconsciousness and amnesia
rather than one drug
- Used to minimize cardiovascular problems,
decreases the amount of general anesthetic
used, reduces possible post-anesthesia
nausea and vomiting, and minimizes the
disturbance of organ function and decreases
pain
May include the following:
1. a hypnotic drug given the night before the
operation
2. premedication with an opioid analgesic or
benzodiazepine plus an anticholinergic given
about 1 hour before surgery to decrease
secretions
3. a short-acting nonbarbiturate such as
propofol
4. an inhaled gas, often a combination of an
inhalation anesthetic, nitrous oxide and
oxygen
5. a muscle relaxant given as needed
Stages of Anesthesia
1. Analgesia
○ begins with consciousness and ends with
loss of consciousness. Speech is difficult,
sensations of smell and pain are lost,
dreams and auditory and visual
hallucinations may occur
○ this stage may be called the induction stage
2. Excitement or delirium
○ produces a loss of consciousness caused by
depression of the cerebral cortex, confusion,
excitement or delirium occur and induction
time is short
 3. Surgical
○ surgical procedure is performed during this
stage
○ there are 4 phases, surgery is usually
performed in phase 2 and upper phase 3 as
anesthesia deepens, respirations become
shallower and the respiratory rate is
increased
4. Medullary paralysis
○ toxic stage of anesthesia
○ respirations are lost and circulatory collapse
occurs, ventilatory assistance is necessary
Example​: propofol, droperidol, etomidate and
ketamine hydrochloride
○ also commonly used to provide a total
intravenous anesthesia or TIVA – these
anesthetics have rapid onset and short
duration of action.
○ propofol supports microbial growth and may
increase the risk of bacterial infection thus
discarding open vials within six hours is a
necessary precaution in the prevention of
sepsis

The patient’s response to anesthesia may differ Topical Anesthetics

according to variables related to health status of the ○ Used to decrease sensitivity of nerve
individual. These variables include age, current endings in the affected area
health disorder, pregnancy, history of heavy ○ These can be in different forms:
smoking, and frequent use of alcohol and drugs. ● Solution
These problems may be identified before surgery ● Liquid sprays
because the type and amount of anesthetic required ● Ointments
may need to be adjusted ● Creams
● Gels and powders
Anesthetic agents can be administered through:
● Inhalation Local Anesthetics
● Intravenous ○ Used to block the pain at the site where the
● Topical drug are administered by preventing the
● Local infiltration conduction of nerve impulses
● Spinal route ○ Useful in dental procedures, suturing skin
lacerations, short-term surgery at a localized
Inhalation anesthetics area, block nerve impulses below the
○ Gas or volatile liquids administered as gas insertion of spinal anesthetic and diagnostic
are used to deliver general anesthesia procedures such as lumbar puncture and
thoracentesis
Example of volatile liquids​: Halothane,
Methoxyflurane, Enflurane, Isoflurane, Desflurane, Example:
Sevoflurane ● Chloroprocaine, HCl
Example of gas​: nitrous oxide ● Procaine HCl
Adverse reactions​: respiratory depression, ● Lidocaine HCl – rapid onset, long duration of
hypotension, dysrhythmia, and hepatic dysfunction action; more stable in solution form; cause
○ these drugs can trigger malignant fewer hypersensitivity reactions than
hyperthermia – is a type of severe reaction procaine
that occurs in response to a particular ● Mepivacaine HCl
medication used during general anesthesia ● Prilocaine, HCl
among those who are susceptible. ● Bupivacaine, HCl
Symptoms include​: muscle rigidity, high fever and ● Dibucaine, HCl
a fast heart rate ● Etidocaine, HCl
Complications can include​: muscle breakdown, ● Tetracaine, HCl
high blood potassium
Spinal Anesthesia
Intravenous anesthetics ○ Requires that a local anesthetic be injected
● May be used for general anesthesia or for into the subarachnoid space:
the induction stage of anesthesia
 ○ Below the first lumbar space (L1) in
adults
○ The 3rd lumbar space (L3) in
children
○ Postdural-puncture headache might result
following spinal anesthesia possible
because of a decrease of cerebrospinal fluid
pressure caused by the leak of fluid at the
needle insertion point
Nursing intervention​: encourage the patient to
remain flat following surgery and increased fluid
intake usually decreases the likelihood of leaking
spinal fluid
○ Various sides of the spinal column can be
used for a nerve block with a local
anesthetic
○ Spinal block – results from the penetration of
an anesthetic into the subarachnoid space –
the space between the pia mater membrane
and the arachnoid membrane
○ Epidural block – placement of the local
anesthetic in the epidural space just
posterior to the spinal cord or the dura
mater. The epidural space is located
between the posterior longitudinal ligament
on the anterior side and the ligament of
flavum posteriorly
○ Caudal block – epidural block placed by
administering a local anesthetic through the
sacral hiatus
○ Saddle block – given at the lower end of the
spinal column to block the perineal area
● blood pressure should be monitored during
administration of these types of anesthesia
because a decrease in blood pressure
resulting from the drug and procedure might
occur
Antiseizure drugs
- These medications are used for epileptic
seizures
- Also called ​anti-convulsants or
anti-epileptic drugs
- The medication acts by stabilizing nerve cell
membrane and suppress abnormal electrical
impulses in the cerebral cortex
- The type of medications prevent seizures
but do not eliminate the cause or provide a
cure. Dosage of the medication usually
starts low and gradually increases over a
period of weeks until the serum drug level is
within therapeutic range or the seizure
ceases.
- The medication is usually taken throughout
the lifetime but it may be discontinued if
seizure has not occurred in 3 to 5 years
Anti-seizure drugs act in 3 ways:
1. By suppressing sodium influx
→ through the drug binding to the sodium
channel when it is inactivated, this prolongs the
channel inactivation and thereby prevents neuro
firing
Example: phenytoin, fosphenytion, carbamazepine,
oxcarbazepine, valproic acid, superamate (?),
zonisamide and lamotrigine
2. Suppressing calcium influx
→ which prevents the electric current
generated by the calcium ions to the t-type calcium
channel
Example: valproic acid and ethosuximide
3. Increasing the action of Gamma
Aminobutyric Acid (GABA)
→ which inhibits neurotransmitters
throughout the brain
Example: barbiturates, benzodiazepines and
tiagabine
Anti-seizure drugs
1. Hydantoins
2. Barbiturates
3. Succinimides
4. Benzodiazepines
5. Iminostilbenes
6. Valproate
Hydantoins
- Acts by inhibiting sodium influx, stabilizing
cell membranes, reduces repetitive neuronal
firing and limit seizures
- by increasing electrical stimulation threshold
in the cardiac tissue, it also acts as an
anti-dysrhythmic, it has a slight effect on
general sedation and it is non-addicting
- the first anti-seizure drug used to treat
seizures was phenytoin – a hydantoin
► it was discovered in 1938 and still commonly
used for controlling seizures as of today
 - hydantoins should not be used during
pregnancy because it can have teratogenic
effect on the fetus – it may cause birth
defects or congenital anomalies
Phenytoin ​– used for the treatment of tonic-clonic
seizure, partial seizures and status epilepticus
→ these medication is slowly absorbed from
the small intestine
→ half-life of 24 hours, but it can range 7-42
hours
→ the drug is metabolized and excreted
through the urine
!! has a narrow therapeutic range: 10-20mcg/mL –
generally considered as 1-1.2mcg/mL unbound or
free phenytoin
Nursing application​: monitor the therapeutic
serum level/drug range of phenytoin.
− If the medication will exceed the 20mcg/mL it may
cause toxic effects
− If the medication is below 10mcg/mL the
medication will not render a desired effect or the
patient will not feel the desired effect of medication
- Onset of action of PO route is 30 minutes to
2 hours. With a peak of 1.5 to 6 hours a
steady state of serum concentration at 7 to
10 days and a duration of action dependent
on the half-life which could be up to 45 hours
- IV infusion must be administered through a
large vein by a central line or peripherally
inserted central catheter. The IV line should
always be flushed with saline solution,
before and after use to reduce venous
irritation
!! may be diluted in saline solution and dextrose
should be avoided because of drug precipitation
→ IV Phenytoin 500 milligrams or a fraction
thereof must be administered over 1 minute for
adults and a rate of 25 milligram per minute for
older adults
→ infusion rates more than 50 milligrams
per minutes may cause severe hypotension or
cardiac dysrhythmia especially for adults and
debilitated patients
!! must not be administered through IM route
because the absorption is erratic
irritate the tissues which may cause damage
- Cimetidine and sulfonamides can increase
the action of hydantoins by inhibiting liver
metabolism which is necessary for drug
excretion
Nursing implication​: monitor the serum level of
Phenytoin as if it will not be excreted by the body,
the serum level might exceed the 20mcg/mL – the
patient may experience toxic effects of the
medication
- Antacids, calcium preparations, sucralfate
and antineoplastic drugs decrease the
absorption of hydantoins
Nursing implication: monitor serum level of
phenytoin because the danger of decreased
absorption of the medication is that the therapeutic
range which is 10-20mcg/mL might not be achieved
and the seizure activity will not be controlled
Adverse reactions of Hydantoins
● Depression
● Suicidal ideation
● Steven-Johnson’s syndrome
→ rare serious disorder of the skin and
mucous membranes, its usually a reaxtion of
medications that start with flu-like symptoms,
followed by a painful rash that spreads and blisters,
then the top layer of the affected skin dies, sheds
and begins to heal after several days
● Ventricular fibrillation
● Blood dyscrasias
● Purple glove syndrome
→ in an uncommon but dreaded
complication of intravenous phenytoin
administration characterized by pain, edema and
purple-blue discoloration of the limb distal to the
injection site
Hyperglycemia
→ results after hydantoin usage but this only
happens after a long period of hydantoin use
→ this happens because there is an
increase blood glucose due to the inhibition of drug
on the release if insulin
Less severe side effects of hydantoin
● Nausea and vomiting
● Gingival hyperplasia
● over growth of gum tissue
● Constipation
 ● Drowsiness
● Headaches
● Slurred speech
● Confusion
● Alopecia
● Hirsutism
→ a condition in women that results in
excessive growth of dark or coarse hair in a
male-like pattern. Usually very evident on the face,
chest and back
● Nystagmus
→ vision condition in which the eyes make
repetitive uncontrolled movements, these
movements often result in reduced vision and depth
perception. Can affect balance and coordination
Patient teachings:
Before we administer Phenytoin to our patients:
Assessment:
➢ Obtain a health history
➢ current drugs and herbs the patients uses
➢ report & document any probable drug to
drug, or herb to drug interaction
➢ check the patient’s knowledge regarding the
medication regimen
➢ Check urinary output (1500mL/day)
➢ to determine whether it is adequate
Determine liver and kidney function
➢ determine laboratory values related to renal
and liver function if both BUN or blood urea
nitrogen and creatinine levels are elevated,
a renal disorder should be suspected
➢ elevated liver serum enzymes indicate a
hepatic disorder
Nursing diagnosis: (patient who had been taking
Phenytoin)
➢ Risk for injury
➢ Risk for fall
→ considering that Phenytoin has an
adverse effect of suicidal ideation and a side effect
of drowsiness
Planning:
➢ Patient’s seizure frequency will diminish
➢ Patient will adhere to anti-seizure drug
therapy
Nursing interventions:
➢ Monitor serum drug level to determine the
therapeutic range
➢ Encourage compliance with medication
regimen
➢ monitor patient’s complete blood count
(CBC) levels for early detection of blood
dyscrasias
➢ Use seizure precautions or environmental
protection from sharp objects such as table
corners for patients at risk for seizures
➢ Determine whether the patient is receiving
adequate nutrients because Phenytoin may
cause anorexia, nausea and vomiting
➢ Advise patient who are receiving oral
contraceptives to use an additional
contraceptive method
➢ Teach patient to shake suspension form of
medication before using to adequately mix
the medication to ensure adequate dosage
➢ Advise patient not to drive or perform other
hazardous activities
► when initiating anti-seizure therapy as
drowsiness may occur
➢ Counsel female patient contemplating of
pregnancy to consult with a health care
provider
► because Phenytoin and valproic acid may
have a teratogenic effect
► monitor serum Phenytoin levels closely
during pregnancy, because seizures tend to
become more frequent due to increased
metabolic rates
➢ Avoid alcohol and other CNS depressants
► because they can cause an added
depressive effect on the body
➢ Teach patients not to abruptly stop drug
therapy
► but rather to withdraw the prescribed drug
gradually under medical supervision this is
to prevent seizure rebound or the recurrence
of seizures and status epilepticus
➢ Advise patients with diabetes mellitus to
monitor serum glucose levels
► more closely than usual because
Pheyntoin may inhibit insulin release
causing an increase in glucose level
➢ Coach patients to take anti-seizure drugs
with food and milk at the same time
everyday
➢ Tell patients that urine may be a harmless
pinkish red or reddish brown in color
➢ Advise patients to maintain good oral ➢ - Diazepam is administered through IV
hygiene and use a soft-bristled toothbrush to to treat status epilepticus; has short term
prevent gum irritation and bleeding effect phenytoin or phenobarbital must be
► report symptoms of sore throat, bruising given during or immediately after
and nose bleeds which may indicate a blood administration of diazepam
discretion ➢
➢ Iminostilbenes
Evaluation: ➢ - Example: Carbamazepine
➢ Evaluate effectiveness of drugs in controlling ➢ - ↑ Is used to control tonic-clonic and
seizures partial seizures; also used for psychiatric
➢ Monitor serum phenytoin levels disorders – trigeminal neuralgia and alcohol
➢ Monitor patients for hydantoin overdose withdrawal
➢ - Therapeutic range is 4-12mcg/mL
➢ Barbiturates ➢ - A potentially toxic interaction can
- Phenobarbital (an ex. of baribiturate) occur when grapefruit juice is taken with
is prescribed to treat tonic-clonic, carbamazepine and drug concentrations
partial and myoclonic seizures as must be carefully monitored
well as status epilepticus or the rapid ➢
succession of epileptic seizures ➢ Valproate
- Reduces seizures by enhancing the ➢ - Or valproic acid
activity of the gamma-aminobutyric ➢ - Is prescribed for tonic-clonic,
acid which is an inhibitory absence and mixed type of seizure
neurotransmitter ➢ - Safety and efficacy of these drug has
- Therapeutic range is 20-40mcg/mL not been established for children younger
- Also a sedative hepnotic than 2 years old. Care should be taken when
giving these drug to the very young children
➢ Succinimide ➢ - and to patients with liver disorders
Example: Ethosuximide because hepatotoxicity is one of the adverse
↑ Is used to treat absence seizures this reactions; liver enzymes should be
medication acts by decreasing calciul influx monitored
through t-type calcium channel ➢ - Therapeutic serum range is
- Therapeutic range is 40-100mcg/mL 50-100mcg/mL
➢ - Anti-seizure drug dosages usually
➢ Adverse effects of Succinimide: start low and gradually increase over a
➢ Blood dyscrasias period of weeks until the serum drug level is
➢ Renal and liver impairment within the therapeutic range or seizure
➢ Systemic Lupus Erythematosus ceases
➢ → SLE is an autoimmune disorder in which ➢ - Serum anti-seizure drug levels
the immune system of the body mistakenly should be closely monitored to prevent
attacks healthy tissues toxicity
➢ ➢
➢ Benzodiazepines ➢
➢ - Examples that have anti-seizure ➢ antiseizure drugs & pregnancy
effects ➢ - During pregnancy, seizures episodes
➢ Clonazepam, clorazepate increase 25% in women with epilepsy
dipotassium, lorazepam and diazepam ➢ - Hypoxia may occur during seizure
➢ - Clonazepam is effective for absence ➢ - Phenytoin and carbamazepine are
and myoclonic seizures but tolerance may linked to fetal anomalies
occur 6 months after drug therapy starts ➢ - Valproic acid causes major
➢ - Clorazepate dipotassium is for partial malformations
seizures is administered for treating partial ➢ - Anti-seizure drugs tend to act as
seizures inhibitors of vitamin k
 ➢ - Pregnant women are given oral
vitamin k supplement during the last week or Seizures
10 days of the pregnancy or vitamin k is - happen as a result of a sudden surge in the brains
administered to the infant soon after birth electrical activities
➢ - Anti-seizure drug can also increase
the loss of folate in pregnant women thus Symptoms
pregnant women should take daily folate
supplements; folate is very important during ● loss of awareness
pregnancy as it will prevent neural tube ● unusual behavior/sensations uncontrollable
defects movements
● loss of consciousness
➢ antiseizure drugs & fibrile seizures
➢ Seizures associated to fever occur in Brain
children between 3 months to 5 years of age - is a complex network of billions of neurons
➢ Prophylactic anti-seizure drug treatment
such as phenobarbital or diazepam may be Neurons
indicated for high risk patients - can be​ Excitatory​ or ​Inhibitory
➢ Valproic acid should not be given to children
younger than 2 years old Excitatory neuron
➢ antiseizure drugs & status epilepticus - stimulate others to fire action potentials and
transmit electrical messages
Status epilepticus – is a continuous seizure
state which is considered as a medical Inhibitory neuron
emergency - suppress this process preventing an
➢ If treatment is not started immediately, death excessive firing
could result
➢ Drug of choice: diazepam or lorazepam via “A balance between excitation and inhibition is
IV followed by phenytoin via IV essential for normal brain functions.”
➢ For continued seizures, midazolam or
propofol and then high-dose barbiturates are “If this abnormal electrical surge happens within a
used; these drugs must be administered limited area of the brain, causes ​partial or focal
slowly to avoid respiratory depression seizures”

“If the entire brain is involved , ​generalized

seizures ​will result “

Partial Seizures
- sub divide further to:

1. Simple Partial
- depending on the affected brain area
patients may have unusual feelings , strange
sensations or uncontrollable jerky
movements but remain conscious and aware
Epilepsy of the surroundings.
Epilepsy
- is a group of neurological diseases 2. Complex Partial Seizure
characterized by recurrent seizures. - on the other hand involves a loss or changes in
- there is enough regulation of excitation and consciousness , awareness and responsiveness.
or down regulation of inhibition causing lots
of neurons to fire synchronously at the same Generalized Seizure
time. - sub divide further to

1. Absence seizures
- this type often occurs in children
- is characterized by very brief loss of
awareness commonly manifested as
a blank stare with or without subtle
body movements such as high
blinking or lip smacking.
“ people with absence seizures may not be aware
that something is wrong for years”
2. Tonic Seizures
- are associated with stiffening of
muscles and may cause a person to
fall.
3. Atonic Seizures
- also known as drop attacks
- are characterized by a sudden loss
of muscle tone which may cause the
person to collapse or drop down.
4. Clonic seizures
- are associated with rhythmic jerking
muscle movements.
- are rare
5. Myoclonic Seizures
- brief jerks or twitches of a muscle or
a group of muscles
- there can be one or many
non-rhythmic twitches occurring
within a couple of seconds.
6. Tonic-clonic Seizures
- the most common and also most
dramatic.
- also known as convulsive seizures
- are combinations of muscle stiffening
and jerky
- this type most people relate to when
they think of a seizure
- it also involves sudden loss of
consciousness and sometimes loss
of bladder control
“A Tonic Clonic Seizure that lasts
longer than five minutes requires
immediate medical treatment”
Causes
Acquired :
1. Injury
2. tumor stroke
3. infection
4. birth defect.
“Generalized seizures that start in childhood
are likely to involve ​genetic factors​”
Genetics :
1. Single gene mutation is rare
(Single Mutation <2%)
2. Interaction of multiple genes and the
environmental factors is responsible”
( multiple genes + environment )
3. Hundreds of genes have been
implicated
(200 genes: GABA receptor ion
channels,...)
4. Genetic disorders ( Down, Dravet,
Angelman…) cause brain
abnormalities or metabolic conditions
and epilepsy primary symptoms.
Diagnosis
- is based on observation of:
● Symptoms
● Medical History
● Electroencephalogram or EEG
- to look for abnormal brain waves
- may also help in differentiating
between ​partial and generalized
seizures
● Genetic Testing
- helpful when genetic factors
are suspected
“There is no cure for epilepsy but various
treatments are available to control seizures”
Treatments:
1. Medications: target sodium channels,
GABA receptors
( Medication successfully controls
seizures for about 70% of cases.
Many Antiepileptic Drugs are
available which target sodium
channels GABA receptors and other
components involved in neuron
 communication. Different medicines
help with different types of seizures
patients may need to try several
drugs to find the most suitable)
2. Dietary therapy: ketogenic diet.
(has been shown to reduce or
prevent seizures in many children
whose seizures could not be
controlled with medication)
Ketogenic Diet
- Is a special high-fat, low carbohydrate diet
that must be prescribed followed strictly.
- With this diet, the body uses fat as the major
source of energy instead of carbohydrates.
- The reason why this helps control epilepsy is
unclear.
3. Nerve stimulation: Vagus Nerve
- In which a device placed under the skin is
programmed to stimulate the vagus nerve at
a certain rate .
- The device acts as a pacemaker for the
brain.
- The underlying mechanism is poorly
understood but it has been shown to reduce
seizure significantly.
4. Surgery
- May be performed to remove part of the
brain that causes seizure.
- This is usually done when tests show that
seizures originate from a small area that
does not have any vital function.
Parkinson’s Disease
- Is the second most common
neurodegenerative disease after Alzheimer’s
- The most visible features of this disease are
slowness of movement, muscle rigidity and
tremors at rest.
- Affects many areas of the nervous system
and different types of neurons. However ,
much focuses has been placed on neurons
in the brain regions associated with the overt
motor symptoms, notably a region of the
membrane called ​“SUBSTANTIA NIGRA
PARS COMPACTA”
SUBSTANTIA NIGRA PARS COMPACTA
- This region forms part of a
major pathway in the brain
that’s critical for facilitating
movements.
Dopaminergic Neurons
- in the substantia nigra gradually die,
leading to the malfunction of this
pathway and the characteristic motor
problems.
Drugs that replace or mimic dopamine
- Are often used to treat these modes of
deficits but they grow less effective over
time.
Deep brain stimulation
- May also be used to treat symptoms,
however, no current treatment slows the
neurodegeneration.
A distinctive pathology in most cases of Parkinson’s
- Clumps of misfolded proteins within
neurons.
Lewy Bodies
- Are the most common type.
Characteristic Components
● Misfolded protein called ​alpha synuclein
These molecules can form small
repeated units called ​oligomers or
longer fibrils.
- Mounting Evidence indicates that
these are toxic to neurons and play a
key role in driving Parkinson’s.
Unwanted Proteins
- Are normally cleared by the cell’s different
types of protein degrading machinery.
● Proteasome
● Autophagosome
Parkinson’s
- Has also been linked to problems with
mitochondria.
- Provides cells with the energy to
perform vital functions.
- They are highly dynamic and fuse
together or break up into smaller
versions in response to cell’s energy
demands.
- Can also be transported to areas of a
cell that need them the most.
 However, in Parkinson’s these processes
can be impared and mitochondria are unable
to sustain proper neuronal function.
As they become old or damaged,
mitochondria are removed and are replaced.
Again this recycling is thought to be
disrupted in Parkinson’s lading to the
accumulation of damaged or worn out
mitochondria.
Glial
- Surrounding neurons may play a role
in Parkinson’s.
As dopamine neurons are lost one particular
type of glial cell, called Microglia, is thought to take
up the resulting cellular debris, triggering an
immune response. Once activated they release
inflammatory cytokines which activate neighbouring
microglia and another type of glial cell called
astrocytes.
Chemical released by activated microglia and
astrocytes have been shown to injure neurons.
It remains unclear which mechanisms drive the
disease process in Parkinson’s. What is clar is that
with time, more areas of the nervous system
develop pathology. And one emerging idea is that
this happens through the transmission of misfolded
alpga synuclein. ​While a multifactorial nature of
Parkinson’s disease progression might make it hard
to fully understand, it does provide a potential
therapeutic target for slowing or even halting the
neurodegeneration.
Example:
Enhancing the clearance of abnormal proteins and
blocking their transmission, improving the function
of mitochondria, and targeting neuroinflammation
are all currently active areas of research.
Acetylcholinesterase
Inhibitors
- patients with myasthenia gravis experience
a decrease stability of muscle movement
Neurological component of this disease and what
we can do about it:
N​ervous System
- is a group of neurons with gaps in between
electrical signals passing between these
gaps from one neuron to the next with the
help of neurotransmitters.
Acetylcholine
- is the neurotransmitter when this binds to
the receptor, it opens the receptor and
around sodium to enter.
this is silly when sodium enters the neuron it's ionic
charge allows the electrical signal to move from the
last neuron to the next neuron
with ​Acetylcholine bound to the Receptor, the
electrical signal fires until it reaches the muscle
this is us ​Acetylcholine Esterase this is an ​enzyme
that breaks down acetylcholine
breaking down acetylcholine will stop it from
being able to open the receptor
if the ​receptor ​stays closed ​then sodium cannot
enter and the electrical signal cannot be relayed to
the next nerver
Acetylcholinesterase Inhibitors were bind to
acetylcholinesterase and keep them from breaking
down acetylcholine
since Acetylcholine is not broken down it can
bind to the receptor and allow sodium to enter
this allows the electrical signal to continue to the
next neuron
with the nerve impulse continuing to its
destination the muscles can contract and relax
Parkinson’s disease
- a chronic, progressive, neurologic disorder
that affects the ​extrapyramidal motor tract
which controls ​posture​, ​balance​, and
locomotion
The most common form of Parkinsonism, which
is considered a syndrome, a recombination of
similar symptoms because of its major features
like:
· Rigidity ​(abnormal increased muscle tone;
​
increases with movement)
·​ Bradykinesia​ (slow movement)
​
*postural changes caused by rigidity and
bradykinesia included chest and head thrust
forward with the knees and hips flexed, a
shuffling gait, and the absence of arm swing;
other characteristics symptoms are masked
facies or no facial expression, involuntary
tremors of the head and neck, and pill rolling
motions of the hands. The tremors may be
more prevalent at rest
·​ Gait disturbances
​
·​ Tremors
​
Neurotransmitters
Dopamine
- An inhibitory neurotransmitter
- ​Released from dopaminergic neurons
- Maintains control of ACh and inhibits its
excitatory response
- Plays a part in controlling the
movements a person makes as well as
their emotional responses
- Right balance of dopamine is vital for
both physical and mental well-being
- ​Vital brain functions that affect mood,
sleep, memory, learning, concentration,
and motor control are influenced by the
levels of dopamine in a person’s body
- Has a control in the locomotion or in the
movement of a person
Acetylcholine (Ach)
- An excitatory neurotransmitter
- Released from cholinergic neurons
- Achieved neurotransmitter of the
parasympathetic nervous system that
contracts smooth muscles, dilates blood
vessels, increases bodily secretions, and
slows heart rate
- ​Essential for muscles to contract;
without it muscles cannot contract
*these 2 neurotransmitters need to work
hand-in-hand in order to create balance; if one
is elevated, there will be a chaos within the
body system
How Parkinson’s Diseases Develops
● · ​There are approximately 86 billion of
neurons in the brain
● · ​Parkinson’s disease is caused by an
imbalance of the neurotransmitters,
dopamine and acetylcholine
● · ​Marked by the degeneration of
neurons of the extrapyramidal motor
tract in the substantia nigra of the
midbrain, reason is unknown
● · ​Dopamine is produced by the
dopaminergic neurons
● · ​With degeneration of dopaminergic
neurons, less dopamine is produced in
which the excitatory response exceeds
the inhibitory response of the dopamine,
this is because the level of the
acetylcholine is beyond what the
dopamine could handle or inhibit
● · ​Only the dopamine production is
affected but the production of the ACh
continues, thus there is more ACh than
dopamine and ACh is an excitatory
neurotransmitter
● · ​Excessive amount of ACh stimulates
neurons that produce GABA which
inhibits activity of neuron
● · ​GABA or gamma-aminobutyric acid is
considered an inhibitory neurotransmitter
because it blocks or inhibits certain brain
signals and decreases activity in your
nervous system
 ● · ​When certain brain signals are 5. Catechol-​O​-methyltransferase (COMT)
inhibited in the nervous system, inhibitors
symptomatic movement disorders of
Parkinson’s disease occurs like rigidity, Anticholinergics
tremors, gait disturbance, and
·​ Inhibit the release of acetylcholine
​
bradykinesia
● · ​By the time early symptoms of ·​ Examples:
​
Parkinson’s disease appear, 80% of the
striatal dopamine has been depleted 1) Benztropine mesylate
● · ​Aside from the movements disorders 2) Trihexyphenidyl
mentioned above, other characteristics hydrochloride
like masked facies or no facial
·​ Glaucoma is contraindicated
​
expression, involuntary tremors of the
head and the neck, which are more
This medication can actually induce glaucoma
prevalent at rest as well as pill rolling and so if the patient is already a glaucoma,
motions of the hands are also then the possibility is that the glaucoma of that
manifested
person will worsen
Nonpharmacologic Measures for
·​ Side effects:
​
Parkinson’s disease
● ​ Dry mouth
Patient teaching
● ​Dry secretions

● ​Urinary retention
Exercise​ – improve mobility and flexibility
​
● ​Constipation

The patient with Parkinson’s disease should ● ​Blurred vision

enroll in a therapeutic exercise program, ● ​Increase in heart rate

tailored to this disorder.

Assessment:
Nutrition
​
Obtain a health history
​

A balanced diet with fiber and fluids helps

prevent constipation and weight loss Report any history of glaucoma, GI dysfunction,
urinary retention, angina, or myasthenia gravis
Good sport
​
Obtain a drug history
Patients with Parkinson’s disease and their
family should be encouraged to attend a Report any probable drug-to-drug interaction,
such as with phenothiazine, tricyclic
support group, to help cope and understand
this disorder antidepressants, and antihistamine. These
medications can increase effect of
Drugs for Parkinson’s Disease trihexyphenidyl hydrochloride

1. Anticholinergics Assess baseline vital signs for future

comparisons
2. Dopamine replacements (dopaminergics)
Patient’s pulse rate may increase
3. Dopamine Agonists
Assess the patient’s knowledge regarding
4. Monoamine Oxidase B (MAO-B) inhibitors the medication regimen
Assess usual urinary output
Urinary retention may occur with continuous
use of anticholinergics
​Nursing Diagnoses:
·​ Impaired mobility related to muscle rigidity
​ -
· Impaired urinary elimination related to
​
Parkinson’s disease – a chronic,
progressive, neurologic disorder that affects
the ​extrapyramidal motor tract which
controls ​posture​, ​balance​, and ​locomotion
The most common form of Parkinsonism, which
is considered a syndrome, a recombination of
similar symptoms because of its major features
like:
· Rigidity (abnormal increased muscle tone;
​ -
increases with movement)
·​ ​ ​Bradykinesia ​(slow movement)
*postural changes caused by rigidity and
bradykinesia included chest and head thrust
forward with the knees and hips flexed, a
shuffling gait, and the absence of arm swing;
other characteristics symptoms are masked
facies or no facial expression, involuntary
tremors of the head and neck, and pill rolling
motions of the hands. The tremors may be
more prevalent at rest
​​ Gait disturbances
Tremors
Neurotransmitters
Dopamine
- An inhibitory neurotransmitter
- Released from dopaminergic neurons
- ​Maintains control of ACh and inhibits its
excitatory response
- Plays a part in controlling the
movements a person makes as well as
their emotional response
- ​ Right balance of dopamine is vital for
both physical and mental well-being
- Vital brain functions that affect mood,
sleep, memory, learning, concentration,
and motor control are influenced by the
levels of dopamine in a person’s body
​Has a control in the locomotion or in the
movement of a person
Acetylcholine (Ach)
- An excitatory neurotransmitter
Released from cholinergic neurons
- Achieved neurotransmitter of the
parasympathetic nervous system that
contracts smooth muscles, dilates blood
vessels, increases bodily secretions, and
slows heart rate
- Essential for muscles to contract; without
it muscles cannot contract
*these 2 neurotransmitters need to work
hand-in-hand in order to create balance; if one
is elevated, there will be a chaos within the
body system
How Parkinson’s Diseases Develops
- There are approximately 86 billion of
​
neurons in the brain
- ​Parkinson’s disease is caused by an
imbalance of the neurotransmitters,
dopamine and acetylcholine
- ​Marked by the degeneration of neurons
of the extrapyramidal motor tract in the
substantia nigra of the midbrain, reason
is unknown HI
- Dopamine is produced by the
dopaminergic neurons
- ​With degeneration of dopaminergic
neurons, less dopamine is produced in
which the excitatory response exceeds
 the inhibitory response of the dopamine,
this is because the level of the
acetylcholine is beyond what the
dopamine could handle or inhibit
A balanced diet with fiber and fluids helps
prevent constipation and weight loss
Good sport
​

- Only the dopamine production is affected

Patients with Parkinson’s disease and their
but the production of the ACh continues,
family should be encouraged to attend a
thus there is more ACh than dopamine
support group, to help cope and understand
and ACh is an excitatory
this disorder
neurotransmitter
- ​Excessive amount of ACh stimulates

neurons that produce GABA which

inhibits activity of neuron

- GABA or gamma-aminobutyric acid is Drugs for Parkinson’s Disease

considered an inhibitory neurotransmitter
because it blocks or inhibits certain brain 1. Anticholinergics
signals and decreases activity in your 2. Dopamine replacements (dopaminergics)
nervous system
- ​When certain brain signals are inhibited 3. Dopamine Agonists
in the nervous system, symptomatic
movement disorders of Parkinson’s 4. Monoamine Oxidase B (MAO-B) inhibitors
disease occurs like rigidity, tremors, gait
5. Catechol-​O​-methyltransferase (COMT)
disturbance, and bradykinesia
inhibitors
- By the time early symptoms of
Parkinson’s disease appear, 80% of the Anticholinergics
striatal dopamine has been depleted
- ​Aside from the movements disorders - Inhibit the release of acetylcholine
mentioned above, other characteristics
like masked facies or no facial Examples:
​

expression, involuntary tremors of the

head and the neck, which are more
prevalent at rest as well as pill rolling
motions of the hands are also
manifested
Benzotropine mesylate
​
Trihexyphenidyl hydrochloride
Glaucoma​ is contraindicated

Nonpharmacologic Measures for This medication can actually induce glaucoma

Parkinson’s disease and so if the patient is already a glaucoma,
then the possibility is that the glaucoma of that
Patient teaching person will worsen

​​ Exercise​ – improve mobility and flexibility Side effects:

​

The patient with Parkinson’s disease should ■ ​Dry mouth

enroll in a therapeutic exercise program, ■ ​Dry secretions
tailored to this disorder. ■ ​Urinary retention

■ Constipation
Nutrition
​
■ ​Blurred vision
 ■ Increase in heart rate
​ ·​ Observe for involuntary movements
​

Assessment:

·​ Obtain a health history

​

Report any history of glaucoma, GI dysfunction,

urinary retention, angina, or myasthenia gravis

·​ Obtain a drug history

​

Report any probable drug-to-drug interaction,

such as with phenothiazine, tricyclic
antidepressants, and antihistamine. These
·​ ​ ​Patient teachings:
medications can increase effect of
trihexyphenidyl hydrochloride ● Avoid alcohol, cigarette, caffeine and
aspirin (to decrease gastric acidity)
· Assess baseline vital signs for future
​
● Encourage patients to relieve dry mouth
comparisons
with hard candy, ice chips and sugarless
Patient’s pulse rate may increase chewing gum (anticholinergics can
decrease salivation)
· ​Assess the patient’s knowledge regarding ● Suggest that patient uses sunglasses in
the medication regimen direct sunlight (possible photophobia)
● Advise patient to void before taking the
·​ ​​Assess usual urinary output drug (to minimize urinary retention)
● Counsel patients who take an
Urinary retention may occur with continuous
anticholinergic for control of symptoms of
use of anticholinergics
Parkinson’s disease to have routine eye
examination because anticholinergics
are contraindicated in patients with
Nursing Diagnoses: glaucoma
● Encourage patients to ingest foods high
·​ Impaired mobility related to muscle rigidity
​
in fiber and increase fluid intake to
· Impaired urinary elimination related to
​
prevent constipation
urinary retention Evaluation:
Planning: · ​Evaluate the patient’s response to the
· Patient will have decreased involuntary
​
medication (trihexyphenidyl or the
benztropine mesylate) and determine
symptoms caused by Parkinson’s disease
whether symptoms of Parkinson’s disease
or drug-induced parkinsonism
are controlled
Nursing Interventions:
Dopaminergics
· Monitor vital signs, urine output and bowel
​
·​ Examples
​
sounds

Increased pulse rate, urinary retention, and Levodopa

​

constipation are side effects of anticholinergics

o ​1st​ dopaminergic drug, which was introduced
in 1961, but no longer available in the U.S.
o ​Was effective in diminishing symptoms of
Parkinson’s disease and increasing mobility
because the blood brain barrier admits
levodopa but not dopamine.
o ​The enzyme ​dopa decarboxylase ​converts
levodopa to dopamine in the brain, but is
also found in the PNS and allows 99% of
levodopa to be converted to dopamine
before it reaches the brain. Therefore only
1% of levodopa taken in is available to be
converted to dopamine once it reaches the
brain
● Psychotic behavior
The peripheral side effects of levodopa are not
as prevalent, however angioedema,
palpitations, and orthostatic hypotension may
occur.
GI disturbances is very common for patients
taking carbidopa-levodopa because ​dopamine
stimulates the ​chemoreceptor trigger zone or
CTZ in the medulla​, which then stimulates the
vomiting center. Taking the drug with food can
decrease nausea and vomiting, but foods slows
the absorption rate of the medication
Assessments:

o Large doses are needed to achieve a

​
·​ Obtain vital signs (for future comparison)
​

pharmacologic response, theses high doses

· ​Assess for signs and symptoms of Parkinson’s
could cause many side effects including
disease (stoop forward posture, shuffling
nausea, vomiting, dyskinesia, orthostatic
gait, masked facies, resting tremors)
hypotension, cardiac dysrhythmia, and
psychosis. · ​Obtain a patient history and contraindications
(glaucoma, heart disease, peptic ulcer,
o ​Because of its side effects and the fact that
kidney/liver disease, psychosis; because
so much levodopa is metabolized before it
severe cardiac renal or psychiatric health
reaches the brain and alternative drug
problems are contraindications for
carbidopa ​was developed.
levodopa)
Carbidopa
​
· Obtain a drug history (esp. if patient is taking
​

- To developed the enzyme dopa monoamine oxidase inhibitor or MAOI)

decarboxylase. By inhibiting the enzyme
Carbidopa-levodopa + MAOI antidepressants
in the PNS, more levodopa reaches the
→ ​hypertensive crisis – a severe increase in
brain.
the blood pressure that may lead to stroke
·​ 1 part carbidopa: 10 parts levodopa
​
Nursing Diagnoses:
Advantage: more dopamine reaches the basal
·​ I​ mpaired physical mobility related to dizziness
ganglia, and smaller doses of levodopa are
required to achieve the desired effect ·​ Risk for fall
​

Disadvantage: more available levodopa, more Planning:

side effects may occur which includes:
· ​Patient’s symptoms of Parkinson’s disease
● Nausea
​ will be decreased or absent after 1-4 weeks
● ​Vomiting of drug therapy
● Dystonic movement
(involuntary abnormal Nursing Interventions:
movement)
· Monitor vital signs and ECG (orthostatic
​ Amantadine
hypotension may occur during early use of
carbidopa-levodopa; instruct patient to rise o ​an antiviral drug that affects the dopamine
slowly to avoid faintness) receptors

· ​Observe for symptoms of syncope (weakness, o ​Can be taken alone or in combination with
dizziness; symptoms of orthostatic carbidopa-levodopa or anticholinergic.
hypotension)
o ​Produces improvement in symptoms but drug
· ​Administer levodopa-carbidopa with tolerance develops.
low-protein foods (high protein diets
o Can also be used for drug-induced
​
interfere with drug transport to the CNS)
parkinsonism.
·​ ​Observe for symptoms of Parkinson’s disease
o​Side effects:
Patient teaching:
​
-​ Orthostatic Hypotension
​

● Urge patient not to abruptly discontinue

-​ Confusion
​
the medication (rebound parkinson’s
disease may occur) -​ Urinary retention
​
● Advise patient to avoid crushing or
chewing extended release tablets -​ Constipation
​

● Encourage patient to report side effects

and symptoms of dyskinesia, explain
that it may take weeks or months before
Bromocriptine Mesylate
symptoms are controlled
● Suggest to patient that taking o More effective than amantadine and
​

carbidopa-levodopa with food may anticholinergics

decrease GI upset but will slow the rate
of drug absorption o ​Not as effective as carbidopa-levodopa in
alleviating the symptoms

o Patients
​ who cannot tolerate
​Evaluation: carbidopa-levodopa are given with this
medication
· Evaluate effectiveness of drug therapy in
​

controlling symptoms of parkinson’s disease o​ S

​ ide effects:

· Determine if there is an absence of side

​ -​ Nausea
​

effects
-​ Orthostatic Hypotension
​

· Determine if the patient and family have

​

increased knowledge of drug regimen -​ Palpitation

​

Dopamine Agonist -​ Chest Pain

​

·​ Also called dopaminergics

​ -​ Lower Extremity Edema
​

·​ Stimulate dopamine receptors

​ -​ Nightmares
​

·​ Examples:
​ -​ Delusion
​
 -​ Confusion
​ dopamine will not be catabolized by the
MAO-B.
Nursing Interventions: ● MAO-A is an enzyme that promotes the
metabolism of Tyramine in the GI tract. If
·​ ​ ​Patient teaching:
tyramine is not metabolized, it can cause
● Report any signs of skin hypertensive crisis – a severe increase
lesions, seizures, or in the blood pressure that may lead to
depression stroke
● Advise patients taking ● In cases where large dose of selegiline
bromocriptine to report is administered the MAO-B will be
symptoms of inhibited by the selegiline, thus the
lightheadedness when dopamine will not be catabolized by the
changing positions, a MAO-B, but this time MAO-A will also be
symptom of orthostatic inhibited by the selegiline. Therefore,
hypotension tyramine won’t be metabolized by the
● Warn patients to avoid MAO-A. So patient may experience
alcohol when taking hypertensive crisis.
bromocriptine
Nursing Interventions:
● Teach patients to check
their heart rate and report ​​Patient teaching:
rate changes or irregularity
● Counsel patients not to - Urge patients who take high doses of
abruptly stop the drug selegiline to avoid foods high in tyramine
without first notifying such as aged cheese, red wine, cream,
yoghurt, chocolate, bananas, and raisins
Pramipexole
​
to prevent hypertensive crisis
- Severe drug interaction may occur
Ropinirole HCl
between selegiline and various TCAs or
Monoamine Oxidase B Inhibitor or MAO-B Selective Serotonin Reuptake Inhibitors
Inhibitor (SSRIs)

● Inhibit MAO-B→ prolongs the action of Catechol-​O​-Methyltransferase (COMT)

levodopa Inhibitors
● ​The enzyme MAO-B causes catabolism
·​ Examples:
​
or breakdown of dopamine
Entacapone
Examples:
​

o​ D
​ oes not affect liver function
Rasagline
​

o Combination of carbidopa, levodopa, and

​
Selegiline HCl
​
entacapone provides greater dosing
● Can delay the use of flexibility and individualization to the patient
carbidopa-levodopa by 1 year
o Urine can
​ have brownish orange
● ​The enzyme MAO-B causes catabolism
discoloration
of dopamine, thereby further depleting or
decreasing the number of dopamine. Tolcapone
Selegiline works by inhibiting the MAO-B
thus preserving the dopamine or the
o​ ​1st​​ COMT inhibitor given with levodopa 4. Monoamine Oxidase B (MAO-B) inhibitors –
inhibit the enzyme MAO-B
o​ C
​ an affect liver function

5. Catechol-​O​-methyltransferase (COMT)
Nursing action: check for the liver enzymes in inhibitors – inhibit COMT enzymes
order to determine the liver function of the
patient

o May cause liver damage (pts w/ liver

​

dysfunction should not take this drug)

· Patient will have decreased involuntary
​

o​ S
​ ide effects: (harmless) symptoms caused by Parkinson’s disease
or drug-induced parkinsonism
-​ Dark discoloration of urine
​

Nursing Interventions:
- Perspiration may also be
​

dark · Monitor vital signs, urine output and bowel

​

sounds
COMT inactivates dopamine
​

Increased pulse rate, urinary retention, and

· COMT inhibitors stops COMT from
​
constipation are side effects of anticholinergics
inactivating dopamine
·​ Observe for involuntary movements
​
· ​COMT inhibitors + levodopa → increases
the amount of levodopa concentration in the ·​ Patient teachings:
​

brain
- Avoid alcohol, cigarette, caffeine and
The use of Tolcapone and Entacapone: aspirin (to decrease gastric acidity)
- Encourage patients to relieve dry mouth
·​ Can intensify the actions of levodopa
​
with hard candy, ice chips and sugarless
chewing gum (anticholinergics can
· ​May lead to intense, uncontrollable urges
decrease salivation)
(sex, gambling, spending money) in addition
- Suggest that patient uses sunglasses in
to suddenly falling asleep
direct sunlight (possible photophobia)
· Warn patient to avoid driving and other
​ - Advise patient to void before taking the
potentially dangerous activities drug (to minimize urinary retention)
- Counsel patients who take an
anticholinergic for control of symptoms of
Parkinson’s disease to have routine eye
Drugs for Parkinson’s Disease
examination because anticholinergics
are contraindicated in patients with
1. Anticholinergics – block the cholinergic
receptors glaucoma
- Encourage patients to ingest foods high
2. in fiber and increase fluid intake to
prevent constipation
Stimulate dopamine receptors

Dopamine replacements (dopaminergics) Evaluation:

3. Dopamine Agonists
 1. ​Evaluate the patient’s response to the in the PNS, more levodopa reaches the
medication (trihexyphenidyl or the brain.
benztropine mesylate) and determine
whether symptoms of Parkinson’s ·​ 1
​ part carbidopa: 10 parts levodopa

disease are controlled

Ø Advantage: more dopamine
​

reaches the basal ganglia, and

smaller doses of levodopa are
required to achieve the
desired effect
Dopaminergics
Disadvantage: more available levodopa, more
​
·​ Examples
​
side effects may occur which includes:

Ø​ ​Levodopa -​ Nausea
​

o ​1st​ dopaminergic drug, which was introduced -​ Vomiting

​
in 1961, but no longer available in the U.S.
- ​Dystonic movement
o ​Was effective in diminishing symptoms of (involuntary abnormal
Parkinson’s disease and increasing mobility movement)
because the blood brain barrier admits
levodopa but not dopamine. -​ Psychotic behavior
​

o ​The enzyme ​dopa decarboxylase ​converts
levodopa to dopamine in the brain, but is
also found in the PNS and allows 99% of
levodopa to be converted to dopamine
before it reaches the brain. Therefore only
1% of levodopa taken in is available to be
converted to dopamine once it reaches the
brain
o Large doses are needed to achieve a
​ vomiting center. Taking the drug with food can
pharmacologic response, theses high doses
could cause many side effects including
nausea, vomiting, dyskinesia, orthostatic
hypotension, cardiac dysrhythmia, and
psychosis.
The peripheral side effects of levodopa are not
as prevalent, however angioedema,
palpitations, and orthostatic hypotension may
occur.
GI disturbances is very common for patients
taking carbidopa-levodopa because ​dopamine
stimulates the ​chemoreceptor trigger zone or
CTZ in the medulla​, which then stimulates the
decrease nausea and vomiting, but foods slows
the absorption rate of the medication
Assessments:
·​ Obtain vital signs (for future comparison)
​

o ​Because of its side effects and the fact that

· ​Assess for signs and symptoms of
so much levodopa is metabolized before it
Parkinson’s disease (stoop forward posture,
reaches the brain and alternative drug
shuffling gait, masked facies, resting
carbidopa ​was developed.
tremors)
Carbidopa
​
· ​Obtain a patient history and
- To developed the enzyme dopa contraindications (glaucoma, heart disease,
decarboxylase. By inhibiting the enzyme peptic ulcer, kidney/liver disease, psychosis;
because severe cardiac renal or psychiatric
 health problems are contraindications for Ø Advise patient to avoid
​

levodopa) crushing or chewing extended

release tablets
· Obtain a drug history (esp. if patient is taking
​

monoamine oxidase inhibitor or MAOI) Ø ​Encourage patient to report

side effects and symptoms of
Carbidopa-levodopa + MAOI antidepressants dyskinesia, explain that it may
→ ​hypertensive crisis – a severe increase in take weeks or months before
the blood pressure that may lead to stroke symptoms are controlled

Nursing Diagnoses:

· Impaired physical mobility related to

​

dizziness

·​ Risk for fall

​

Ø ​Suggest to patient that taking

Planning: carbidopa-levodopa with food
may decrease GI upset but will
· ​Patient’s symptoms of Parkinson’s disease
slow the rate of drug
will be decreased or absent after 1-4 weeks
absorption
of drug therapy

Nursing Interventions:
Evaluation:
· Monitor vital signs and ECG (orthostatic
​

hypotension may occur during early use of · Evaluate effectiveness of drug therapy in
​
carbidopa-levodopa; instruct patient to rise controlling symptoms of parkinson’s disease
slowly to avoid faintness)
· Determine if there is an absence of side
​
· Observe for symptoms of syncope
​
effects
(weakness, dizziness; symptoms of
orthostatic hypotension) · Determine if the patient and family have
​

increased knowledge of drug regimen

· Administer levodopa-carbidopa with
​

low-protein foods (high protein diets Dopamine Agonist

interfere with drug transport to the CNS)
·​ Also called dopaminergics
​

· Observe for symptoms of Parkinson’s

​

disease ·​ Stimulate dopamine receptors

​

·​ Examples:
​

​ ​Patient teaching: Ø​ ​Amantadine

Ø ​Urge patient not to abruptly
discontinue the medication
(rebound parkinson’s disease
may occur)
o ​an antiviral drug that affects the dopamine
receptors
o ​Can be taken alone or in combination with
carbidopa-levodopa or anticholinergic.
o ​Produces improvement in symptoms but drug ● Advise patients taking
tolerance develops. bromocriptine to report
symptoms of
o Can also be used for drug-induced
​
lightheadedness when
parkinsonism. changing positions, a
symptom of orthostatic
o​ S
​ ide effects:
hypotension
-​ Orthostatic Hypotension
​ ● Warn patients to avoid
alcohol when taking
-​ Confusion
​ bromocriptine
● Teach patients to check
-​ Urinary retention
​
their heart rate and report
-​ Constipation
​
rate changes or irregularity
● Counsel patients not to
Ø​ ​Bromocriptine Mesylate abruptly stop the drug
without first notifying
o More effective than amantadine and
​ ● Pramipexole
anticholinergics ● Ropinirole HCl
●
o ​Not as effective as carbidopa-levodopa in
alleviating the symptoms Monoamine Oxidase B Inhibitor or MAO-B
Inhibitor
o Patients
​ who cannot tolerate
carbidopa-levodopa are given with this · Inhibit MAO-B→ prolongs the action of
​
medication levodopa

Side effects:
​ · The enzyme MAO-B causes catabolism or
​

breakdown of dopamine
-​ Nausea
​

·​ Examples:
​
-​ Orthostatic Hypotension
​

Rasagline
​
-​ Palpitation
​

Selegiline HCl
​
-​ Chest Pain
​

o ​Can delay the use of carbidopa-levodopa by

-​ Lower Extremity Edema
​
1 year
-​ Nightmares
​
o ​The enzyme MAO-B causes catabolism of
-​ Delusion
​
dopamine, thereby further depleting or
decreasing the number of dopamine.
-​ Confusion
​ Selegiline works by inhibiting the MAO-B
thus preserving the dopamine or the
Nursing Interventions: dopamine will not be catabolized by the
MAO-B.
·​ Patient teaching:
​

o MAO-A is an enzyme that promotes the

​
● Report any signs of skin
metabolism of Tyramine in the GI tract. If
lesions, seizures, or
tyramine is not metabolized, it can cause
depression
 hypertensive crisis – a severe increase in
the blood pressure that may lead to stroke
o ​In cases where large dose of selegiline is
administered the MAO-B will be inhibited by
the selegiline, thus the dopamine will not be
catabolized by the MAO-B, but this time
MAO-A will also be inhibited by the
selegiline. Therefore, tyramine won’t be
metabolized by the MAO-A. So patient may
experience hypertensive crisis.
Nursing Interventions:
·​ ​ ​Patient teaching:
- Urge patients who take
high doses of selegiline to
avoid foods high
tyramine such as aged
cheese, red wine, cream,
yoghurt, chocolate,
bananas, and raisins to
prevent hypertensive crisis
- Severe drug interaction
may occur between
selegiline and various
TCAs or Selective
Serotonin Reuptake
Inhibitors (SSRIs)
Catechol-​O​-Methyltransferase (COMT)
Inhibitors
·​ Examples:
​
Entacapone
​
- Does not affect liver function
- Combination of carbidopa, levodopa,
and entacapone provides greater dosing
flexibility and individualization to the
patient
- Urine can have brownish orange
discoloration
Tolcapone
​
- 1​st​ COMT inhibitor given with levodopa
- Can affect liver function
Nursing action​: check for the liver enzymes in
order to determine the liver function of the
patient
- May cause liver damage (pts w/ liver
dysfunction should not take this drug)
Side effects: (harmless)
​
-​ Dark discoloration of urine
​
- Perspiration may also be
​
dark
in ·​ ​COMT inactivates dopamine
· ​COMT inhibitors stops COMT from inactivating
dopamine
·COMT inhibitors + levodopa → increases the
amount of levodopa concentration in the
brain
The use of Tolcapone and Entacapone:
● Can intensify the actions of levodopa
​
● ​May lead to intense, uncontrollable
urges (sex, gambling, spending money)
in addition to suddenly falling asleep
● Warn patient to avoid driving and other
potentially dangerous activities
Drugs for Parkinson’s Disease
1. Anticholinergics – block the cholinergic
receptors
2.
Stimulate dopamine receptors
Dopamine replacements (dopaminergics)
3. Dopamine Agonists

4. Monoamine Oxidase B (MAO-B) inhibitors –

inhibit the enzyme MAO-B

5. Catechol-​O​-methyltransferase (COMT)
inhibitors – inhibit COMT enzyme

Drugs for Alzheimer’s disease

- Is an incurable dementia illness
- Characterized by chronic, progressive
neurodegenerative conditions with marked
cognitive dysfunction
- Onset is between 45-65 years of age

Acetylcholinesterase / Cholinesterase
Theories related to the changes that cause inhibitor
Alzheimer’s disease: ★ Is a classification of medication that can be
● Degeneration of the cholinergic neuron and administered to a patient with Alzheimer’s
deficiency in acetylcholine disease
● Neuritic plaques that form mainly outside of ★ An enzyme called acetylcholinesterase or
the neurons and in the cerebral cortex cholinesterase breaks down acetylcholine if
● Apolipoprotein E4 that promotes formations this will happen the level of acetylcholine will
of plaques, which binds beta amyloid in the further deplete to prevent such from the
plaques happening the medications –
● Beta-amyloid lipoprotein accumulation in Acetylcholinesterase or Cholinesterase
high levels that may contribute to neuronal inhibitor will be administered which will then
injury inhibit the cholinesterase and preserve the
● Presence of neurofibrillary tangles with acetylcholine
twists inside the neurons ★ Examples: donepezil, memantine,
galantamine, rivastigmine

Rivastigmine
● Increases the amount Ach at the cholinergic
synapses
● Acetylcholinesterase inhibitors increase
cognitive function with mild to moderate
Alzheimer’s disease
● This medication is through the GI tract
without food
● Rivastigmine has a short half-life and is
given twice a day and the dose is gradually
increased
● Contraindicated to patients with liver
disease because hepatotoxicity may occur
● Cumulative drug effect is likely to occur in
older adults and patients with renal and liver
dysfunction
Assessment:
 ● Assess the patient’s mental and
physical abilities; note limitation of
cognitive function and self-care
● Obtain a history that includes any
liver or renal disease or dysfunction
● Assess for memory and judgement
loss – elicit from family members a
history of behavioral changes such
as memory loss, declining interest in
people or home, difficulty in following
through with simple activities and a
tendency to wander from home
● Observe for signs of behavioral
disturbances – such as hyperactivity,
hostility and wandering
ü Examine patient for signs of aphasia or
difficulty in speech
ü Note motor function
ü Determine family member’s ability to
cope with patient’s mental and physical
changes
Nursing diagnoses:
1. Self-care deficit related to memory
loss
2. Chronic confusion related to
memory loss
Planning:
1. Patient’s memory will be improved
2. Patient will maintain self-care of body
functions with assistance
Nursing interventions:
1. Maintain consistency in care
2. Assist the patient in ambulation and
activity
3. Monitor for side effects related to
continuous use of
acetylcholinesterase inhibitors
4. Record vital signs periodically; note
signs of bradycardia and hypotension
5. Observe any patient behavioral
changes; note any improvement or
decline
ü ​Patient teaching:
● Teach family members about safety
measures – removing obstacles in
the patient’s path to avoid injury
when the patient wanders
● Inform family members of available
support groups such as Alzheimer’s
disease and related disorders
association
● Patient should rise slowly to avoid
dizziness and loss of balance
● Monitor routine liver function tests
because hepatotoxicity is an adverse
effect
● Inform family members about foods
that may be prepared for the
patient’s consumption and tolerance
Evaluation:
- Evaluate the effectiveness of drug regimen –
look into the manifestations of patients with
Alzheimer’s disease if the manifestations
have improved
Drugs for myasthenia gravis
§ Is a chronic autoimmune neuromuscular
disease
§ Affects approximately 20 in every 100,000
people
antibodies attack the ACh receptor sites then this
receptors sites will be obstructed and eventually
destroyed; the acetylcholine is prevented from
binding to the receptors and the simulation of
normal neuromuscular transmission is inhibited
thereby, there is ineffective muscular contraction
and weakness
► acetylcholine is very important neurotransmitter
in order for your muscles to contract. So if there is a
problem with the transmission later on there will
also be a problem in relation to muscle contraction
Manifestations:
❖ Ptosis
❖ Diplopia
❖ Dysphagia
❖ Dysarthria
❖ Respiratory muscle weakness
§ Acetylcholine may be depleted because of
the enzyme Acetylcholinesterase (AChE) /
cholinesterase (responsible for the
breakdown of acetylcholine) to stop that
acetylcholinesterase or cholinesterase
 inhibitor will be administered in order to temperature extremes and
inhibit the action of the AChE and prevent alcohol intake
the breakdown of acetylcholine – more - Can also occur 3-4 hours
ACh is available to activate the cholinergic after taking certain medications
receptors and promote muscle contraction like aminoglycosides,
§ Examples: Neostigmine & pyridostigmine phenytoin, macrolides,
fluoroquinolones, quinine,
quinidine, lidocaine, magnesium
salt, psychotropic medications,
and neuromuscular blocking
agents

​Cholinergic crisis
- over dosage of the acetylcholinesterase
inhibitor
Neostigmine
- accurate (?) exacerbation of symptoms
- Is the first drug used to manage myasthenia
- usually occurs within 30-60 minutes after
gravis
taking anticholinergic drugs
- Short-acting, with half-life of 0.5-1 hour
- due to continuous depolarization of
- Must be given on time to prevent muscle
post-synaptic membranes that creates a
weakness
neuromuscular blockage
- patient with cholinergic crisis often has
severe muscle weakness that can lead to
respiratory paralysis and arrest
- accompanying symptoms include ​miosis or
Pyridostigmine abnormal pupil constriction, sweating,
● Is poorly absorbed by the GI tract vertigo, excessive salivation, nausea,
● Has a short half-life that’s why it must be vomiting, abdominal cramping, diarrhea,
administered several time a day bradycardia and fasciculations or involuntary
● Half-life of oral pyridostigmine is 3-7 hours muscle twitching
and is 2-3 hours for IV
● Give every 4-6 hours ► because these two crisis have similar major
● Increases muscle strength symptom which is severe muscle weakness
● Overdosing or under-dosing of Edrophonium ​which is an ultra-short acting
acetylcholinesterase inhibitors has an effect: cholinesterase inhibitor may be used to distinguish
Myasthenic crisis the myasthenic crisis from the cholinergic crisis.
- under dosage of the
acetylcholinesterase inhibitor
- A severe complication
►After edrophonium as administered
manifested as generalized
muscle weakness that may
​if the symptoms are elevated because of an
involve the muscles of
increase in acetylcholine the cause is
respiration
myasthenic crisis
- May also be triggered by
infection, emotional stress, If the muscle weakness becomes more severe the
menses, pregnancy, surgery, cause is cholinergic crisis due to drug
trauma, hypokalemia, overdosing
 Nursing diagnoses:

►Edrophonium may be used to diagnose ● Ineffective breathing pattern related to weak

myasthenia gravis its ultra-short duration of 5-30 respiratory muscle
minutes increases muscle strength immediately. If ● Activity intolerance related to fatigue
ptosis is immediately corrected after administration
of this drug the diagnoses is most likely myasthenia
gravis.
Planning:

● Patient’s symptoms of muscle weakness,

If unresponsive to AChE inhibitors: difficulty in swallowing caused by MG will be
- May require additional drug treatment eliminated or reduced in 2-3 days
§ Prednisone
→ drug of choice
→ like other immunosuppressants it
Intervention:
reduces the presence of antibodies
→ corticosteroids do not produce - Monitor effectiveness of drug
permanent remission and the long-term therapy, muscle strength should be
side effects are significant increased both depth and rate of
§ Plasma exchange respirations should be assessed and
§ IV immune globulin maintained within range
§ Immunosuppressive drugs - Administer prescribed AChE inhibitor
following dosage recommendations
and nursing guidelines
- Observe for s/s pf cholinergic crisis
Side effects and adverse reactions of AChE
- Have antidote for cholinergic crisis
inhibitors:
ready: ​ATROPINE SULFATE
● Nausea
● Vomiting
● Diarrhea
ü ​Patient teaching
● Abdominal cramps
❏ Teach patients to take drug
● Increased salivation
as ordered to avoid
● Tearing
recurrence of symptoms
● Miosis
❏ Encourage patients to wear a
● Blurred vision
medical ID or necklace that
● Tachycardia
indicates health problem
● Hypotension
❏ Teach patients about side
effects of medication and
when to notify the health care
Assessment: provider. Advise patients to
report recurrence of
- Obtain a drug history. Include all current symptoms or myasthenia
medications gravis to the health care
- Observe the patient’s drug profile for provider
possible drug interactions. Patients should ❏ Inform patients to take the
avoid atropine, atropine like drugs and drug before meals for best
muscle relaxants absorption. If gastric irritation
- Record baseline vital signs. occur take the drug with food
- Assess for s/s of myasthenic crisis
Evaluation:
● Evaluate effectiveness of drug therapy
● Determine the absence of respiratory
distress
● Evaluate the correct use of the drug by the
patient
Drugs for multiple sclerosis
- Is an autoimmune disorder that attacks
the myelin sheath of the nerve fibers in the
brain and the spinal cord, which results in
the lesions called plaques
- It is thought that the disease develops in
a genetically susceptible as a result of
environmental exposure like an infection
- The onset of multiple sclerosis is usually
slow
- It is a condition in which there are
remissions and exacerbations of multiple
symptoms
- Common manifestations of multiple
sclerosis are
· Motor
· Sensory
· Neurologic
· Cerebellar
· Emotional
Immunomodulators
- Are disease modifying drugs also called
as disease modifying therapies
- First line of treatment for patients with
multiple sclerosis
- Disease modifying drugs can slow the
progression of the disease and prevent
relapses
- Examples:
Ø beta interferon
►interferon beta-1a
►interferon beta 1b
Ø glatiramer acetate
Ø teriflunomide
other medications prescribed for MS
​Alemtuzumab
- A monoclonal antibody
► monoclonal antibody are
laboratory-produced molecules
engineered to serve as substitute
antibodies that can restore, enhace or
mimic the immune system’s attack on
cancer cells
►they are designed to bind to antigens
that are generally more numerous in the
surface of cancer cells than healthy cells
Corticosteroids
- Classification of medication that
lowers inflammation in the body
- Can also reduce immune system
activity
Beta-1b & Glatiramer Acetate
- Administered subcutaneously either once
dailt or 3x a week depending on the health
care provider’s order
Teriflunomide
- Is an oral drug
- Administered daily
Alemtuzumab
- Requires a daily IV dose of 12 mg for 5
consecutive days and in 12 months an
additional 12 mg dose for 3 consecutive
days
Corticosteroids
- Used to manage exacerbation of multiple
sclerosis
Exacerbation – the condition has worsened or
there is an increase in the severity of a disease
or its signs and symptoms