Selected Neurotransmitters Acetycholine communicates between nerve and muscle.

uscle. Norepinephrine/epinephrine found in limbic system; involved in arousal Dopamine involved in coordination of impulses and responses (motor and intellectual) GABA inhibits nerve activity and impt in preventing overexcitability or stimulation such as seizure Serotonin found in limbic system, impt for arousal and sleep; prevent depression and promote motivation.

Contraindication: allergy psychosis acute narrow-angle glaucoma Adverse Reaction: headache drowsiness nervousness palpitation dry mouth

- acute alcohol intoxication - pregnancy - shock - dizziness - cognitive impairment - lethargy - nausea - vomiting

ANTIANXIETY A void abrupt discontinuation after prolonged use N ot give if increase BP, renal/hepatic dysfunction or history of drug abuse X anax, Ativa, Serax - a few examples I ncrease in 3 Ds- drowsiness, dizziness, decrease E nhances action of GABA T each to rise slowly from supine Y es, alcohol should be avoided Anxiolytic and Hypnotic agents Anxiolytics prevents feelings of tension or fear Sedatives - calm patients and make them unaware of the environment Hypnotics - cause sleep Minor tranquilizers causes state of tranquility in anxious patients STATES AFFECTED BY ANXIOLYTIC AND HYPNOTIC DRUGS 1. Anxiety - feeling of tension, nervousness, apprehension, or fear that usually involves unpleasant reactions to a stimulus , whether actual or unknown 2. 3. Sedation - loss of awareness and reaction to environmental stimuli a. For patients who are restless, nervous, irritable or overreacting to stimuli Hypnosis extreme sedation results in further CNS depression and sleep a. Act on RAS Overdose: hypotension and respiratory depression somnolence, confusion, coma, diminished reflexes only if taken with CNS depressants such as alcohol and barbiturates nursing intervention: do not give syrup of ipecac (this is contraindicated if pt has ingested a medication that can cause sedation) o gastric lavage Flumazenil treat benzodiazepines overdose reverse sedation caused by benzodiazepines that are used as adjunct anesthesia reverse sedation produced for diagnostic tests and other medical procedures 1. diazepam (Valium) prototype anxiety, alcohol withdrawal, muscle relaxant, antiepileptic, antitetanus, pre-op anxiolytic monitor injection sites 2. estazolam (Prosam) hypnotic, txt of insomia give with food to minimize GI upset 3. flurazepam (Dalmane) - give 15 30 mins before bedtime - causes less REM rebound than any other benzodiazepines 4. halazapam (Paxipam) 5. lorazepam (Ativan) - prototype 6. temazepam (Restoril) - induces sleep within 20 40 mins - give 20 30 mins before bedtime 7. clonazepam (Klonapin) - seizure, panic attacks, neuralgia 8. clorazepate (Tranxene) - anxiety, alcohol withdrawal, adjunct therapy for Partial seizure 9. chlordiazepoxide (Librium) first benzodiazepene BARBITURATES 1st introduced in 1903 standard drug for tx of insomia and producing sedation Page 1 of 15

BP

BENZODIAZEPINES most frequently uses anxiolytic drug prevents anxiety without much sedation act on limbic system and RAS to make GABA more effective peak 30 mins lipid soluble cross the placenta/ enters the milk Schedule IV Indication: anxiety disorders, alcohol withdrawal, hyperexcitability and agitation pre-op relief of anxiety and tension to aid in balanced anesthesia

Major P. Salipot, RN St. Marys College

habit forming; low therapeutic index Category D

6. 7.

do not administer these drugs intra-arterially do not mix IV drugs in solution with other drugs

Mechanism of Action acts on reticular formation reduces nerve impulse traveling to the cortex potentiate GABA raises seizure threshold enzyme- inducer (stimulates enzyme responsible for metabolism breakdown in the liver of many drugs causing quick biotransformation Contraindicaiton: drug allergy, respiratory difficulty, liver disease Adverse reaction: drowsiness, lethargy, dizziness, excitement

and

OTHER ANXIOLYTIC AND HYPNOTIC DRUGS 1. chloral hydrate (Aquachloral) a. Oldest non-barbiturate sedative-hypnotic b. Frequently used to produce nocturnal sedation c. Can cause tachyphylaxis (rapid appearance of a progressive decrease in response to a pharmacologically or physiologically active substance after its repetitive administration) 2. antihistamine (promethazine [Phenergan], diphenhydramine [Benadryl]) a. used to decrease need for narcotics b. monitor for thickened respiratory secretion 3. buspirone (Buspar) a. No sedative, anti-convulsant or muscle relaxant properties ANTIDEPRESSANTS OR MOOD ELEVATORS used to treat depressive disorders caused by emotional or environmental stressors, losses, drugs, disease states such as cerebrovascular accidents or depression that cannot be related to identifiable cause these drugs are classified as: o tricyclic antidepressants (TCAs) o monoamine oxidase inhibitors (MAOI) o selective serotonin reuptake inhibitors (SSRI) TRICYCLIC ANTISEPRESSANTS (TCA) for patients with insomnia, decreased libido, loss of appetite, feelings of worthlessness increases the levels of neurotransmitters serotonin or norepinephrine in the space between nerve endings 1. 2. 3. 4. 5. 6. nortriptyline (Pamelor) amitriptyline (Elavil) clomipramine (Anafranil) desipramine ( Norpramin) imipramine (Tofranil) doxepin ( Sinequan)

Overdose: respiratory depression to respiratory arrest sleep, profound coma, death cold clammy skin fever, areflexia, tachycardia, hypotension TX: symptomatic, supportive o Activated charcoal ( pulls drug from the circulation and eliminating it by GIT o Forced diuresis Drug Interaction: alcohol, antihistamine, benzodiazepines, opioids, tranquilizers MAOI prolonged barbiturate effect Anticoagulant decrease coagulation and possible clot formation Oral contraceptives increase metabolism of contraceptive drug pentobarbital (Nembutal) principally used pre-op to relieve anxiety and provide sedation phenobarbital (Luminal) most commonly prescribed prototype long-acting prevents generalized tonic-clonic seizures for fever-induced convulsions for neonatal hyperbilirubinemia amobarbital (Amytal sodium) sedative/hypnotic; convulsions; manic reactions secobarbital (Seconal) preanesthetic sedation; convulsive seizure of tetanus Nursing interventions: 1. give slow IV. 2. provide standby life support facilities 3. taper dosage gradually 4. provide comfort measures 5. provide thorough patient teachings Major P. Salipot, RN St. Marys College

Nursing responsibilities: 1. Asses the patients level or severity of depression, including the presence of suicidal ideation 2. identify usual coping mechanism 3. Observe for side effects ( dry mouth, blurred vision, tachycardia, urinary retention, constipation) 4. Observe for drug interaction 5. Observe for therapeutic effects of TCAs 2 to 3 weeks after the initial dose therapeutic window (serum plasma level) If no therapeutic response occurs in 4 weeks to 8 weeks, another drug is prescribed. Patient education: 1. Take drug as prescribed. Page 2 of 15

2. 3.

Avoid taking OTC cold remedies or drugs without the physicians knowledge. Antihistamine and narcotic analgesics will increase the effect. Avoid excessive exercise and high temperature because anticholinergic effects of these agents block perspiration.

Medication for overdose: phentolamine (Regitine) for excessive response diazepam ( valium) for excessive agitation Patient Education: 1. take drugs as prescribed. 2. avoid ingestion of tyramine-containing foods 3. report any symptoms indicative of hypertensive crisis, such as headache and palpitations SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRI) became popular because of its advantageous safety profile and its broad spectrum of potential indications depend on neuronal release of serotonin for their action, which is blocking of neuronal uptake of serotonin the inhibition of serotonin reuptake into the nerve terminal by an SSRI increases synaptic transmitter levels to exert a clinically significant antidepressant effect used in treatment of depression alone or in the presence of concurrent disorders such as anxiety, panic attacks, eating disorders, sleep disorders, alcoholism, or schizophrenia Generic name Sertraline Fluoxetine Fluvoxamine Paroxetine cetaprolam Trade name Zoloft Prozac Luvox Paxil Celexa

MONOAMINE OXIDASE INHIBITORS (MAOI) Well known for their multiple drug and food interactions because they inhibit the enzyme that breaks down amino acid tyramine and tryptophan An accumulation of these substances triggers the release of norepinephrine and a HYPERTENSIVE CRISIS can occur Clinical symptoms: i. Elevated Bp ii. Headache iii. Diaphoresis iv. Dilation of pupil v. Rapid heart rate and arrhythmia vi. Intracerebral hemorrhage DIET RESTRICTIONS FOR PATIENTS ON MAOI THERAPY High tyramine content Moderate tyramine (avoid while on MAOI content therapy) (May eat occasionally while on MAOI therapy) Aged cheese (cheddar, Swiss, camembert, blue cheese, parmesan, provolone, Romano, brie) Raisins, fava beans, flat Italian beans, Chinese pea pods Red wines (Chianti, burgundy, sauvignon) Smoked and processed meats (salami. Bologna, pepperoni, summer sausage) Caviar, pickled herring, corned beef, chicken of beef liver Gouda cheese, processed American cheese, mozzarella Yogurt, sour cream Avocados, banana Beer, white wine, coffee, colas, tea, hot chocolate Meat extracts, such as bouillon Chocolate

Low tyramine Content (Limited quantities permissible while on MAOI therapy) Pasteurized cheese 9 cream cheese, cottage cheese, ricotta) Figs Distilled spirits (in moderation)

Client education: 1. Take the dugs as prescribed. Avoid altering the dosage of the medication. Contact the physician before discontinuing use of the drug. 2. Report any unusual symptoms such as tremors, nausea and vomiting, anorexia, weight loss, nervousness, or sexual dysfunction 3. Avoid the use diazepam, alcohol and tryptophan. 4. Inform the physician if taking anticoagulant or theophylline 5. Avoid operating hazardous machinery, including automobile if drowsiness occurs. 6. have the blood pressure and pulse monitored initially and after each dosage change to detect hypotension, hypertension, and irregular heart rates ANTIPSYCHOTICS Action: Blocks dopamine receptor sites in the brain. There is a depression of the limbic system and cerebral cortex that controls aggression. Antiemetic effects by inhibiting the chemoreceptor trigger zone in the medulla. May inhibit anticholinergic, antihistamine and/or sedative effects.

Soy sauce, brewers yeast, meat tenderizer 1. tranylcypromine (Parnate) 2. isocarboxazid (Marplan) 3. phenelzine (Nardil) Maximum therapeutic effect: 2 6 weeks of therapy Major P. Salipot, RN St. Marys College

Page 3 of 15

Indications: Schizophrenic disorders, mania, agitated organic disorders, delusional disorders, antiemetic, intractable hiccups. Preoperative sedation (i.e. Compazine, Phenergan) Warnings: Alcoholism, other CNS depression, hepatic, renal or coronary disease, cerebral insufficiency, severe hypotension, glaucoma, bone marrow depression, blood dyscrasias; young children. Use cautiously in elderly debilitated clients. Undesirable effects: STANCE on the next page will help you remember these effects. Other specific information: Alcohol, CNS depressants may increases CNS and respiratory depression, TCA and MAOI may increase sedation, hypotensive and anticholinergic effects. Decrease levodopa effects. Lithium, antacids, and antidiarrheals may decrease absorption. Interventions: Monitor periodic liver function tests. WBC, serum glucose, VS and psychological testing during therapy. Orthostatic hypotension is likely to occur, rise slowly with assistance and initiate safety measures. Suicidal precautions, if necessary. Do not mix parenteral solutions with other drugs in same syringe. Give deep IM injections. Following parenteral route, remain in supine position for at least 30 minutes/ Liquids should be protected from light and should be diluted with fruit juice before administering. Avoid skin contact with oral suspension solution. Treat extrapyramidal symptoms with anticholinergics (i.e. Cogenin0. Discontinue at least 48 hours prior to surgery. Education: teach that urine may urn pink or reddish brown. Advise that he medication may take 6 weeks or linger to achieve a therapeutic effect. Instruct to give the daily dose 1-2 hours before bedtime. Oral concentrate must be diluted in 2- 3 oz. fluid (water, fruit juice, carbonated drink or milk). Avoid sun exposure, (use sunblock). Caution against driving a car. Explain the importance of reporting sore throat, fever or symptoms of infection. Undesirable effects usually subside approximately 2 weeks of therapy decrease by dose adjustment. Inform other providers when taking these drugs. Advise client to wear an ID bracelet indication medication therapy. Evaluation: The client is able to cope with performance of activities of daily living independently. Drugs: Phenothiazines: chlorpromazine (Thorazine); fluphenazine (Prolixin); mesoridazine (Serentil); Perphenazine (Trifalon); prochlorperazine (Compazine); promazine (Sparine); thioridazine (Mellaril); trifluoperazine (Stelazine); triflupromazine (Vesprin); Non phenothiazine: clozapine (Clorazil); haloperidol ( haldol); loxapine (Loxitane); molindone (Moban); olanzapine (Zyprexa); pimozide (Orap); quetiapine (Seroquel); risperidone ( Risperdal); thiothixene (Navane) S edation unlight T ardive dyskenesia achycardia remors A nticholinergic granulocytosis ddiction N euroleptic malignant syndrome Major P. Salipot, RN St. Marys College

C ardiac arrhythmias (orthostatic hypotension) E xtrapyramidal (Akathesia) ndocrine (change in libido) EPS? Remember PANAT: Psuedoparkinsonism, Akathisia, Neuroleptic Malignant Syndrome (Fever, Encephalopathy, Vital signs unstable, Elevated enzymes esp CPK, Rigidity of muscles), Acute Dystonic Reactions, Tardive Dyskinesia MOOD STABILIZERS given during the manic phase of manic-depressive phase treatment of choice for the manic phase of the bipolar disorder and for longterm prophylaxis of this bipolar disorder level out the activity of neurotransmitter in the area of the brain that controls emotions, thus preventing a decreased activity of nerve impulses, resulting in depression or an increased activity of nerve impulses, resulting in MANIA. Thought to maintain a constant Na concentration in the brain, regulating impulses along the nerve cells as well as mood swings The body does not metabolized Lithium; approximately 80% of a Lithium dose is reabsorbed in the proximal convoluted tubules and excreted by the kidneys Lithium Toxicity: The usual range of therapeutic serum concentrations are: For therapeutic mania: 1.0 to 1.5 mEq/L For maintenance: 0.6 to 1.2 mEq/L Symptoms include: At serum levels of 1.5 to 2.0 mEq/L o Blurred vision, ataxia, tinnitus, persistent nausea and vomiting, severe diarrhea At serum levels of 2.0 to 3.5 mEq/L o Excessive output of diluted urine, increasing tremors, muscular irritability, psychomotor retardation, mental confusion At serum levels above 3.5 mEq/L o Impaired consciousness, nystagmus, seizure, coma, oliguria, anuria, arrhythmia, myocardial infarction, cardiovascular collapse

MOOD STABILIZING AGENTS classification Generic name antimanic Lithium carbonate Lithium citrate Clonazepam Carbamazepine Valproic acid Gabapentin Lamotrigine Topiramate

Trade name Eskalith,Lithane. Eskalith CR

Lithobid,

Anticonvulsants

Cibalith-S Klonopin Tegretol Depakene, Depakote Neurontin Lamictal Topamax Page 4 of 15

Calcium Channel Blockers

verapamil

Calan, isoptin

Give after meal to avoid gastric irritation Cautions: o Heart disease o Sodium restricted diet o Hypotension o Epilepsy o Parkinsonism Lithium level: taken 2x/ week during initiation of therapy and before stability of manic episode o Serum levels taken q 12 hours after dose Drugs that increase effect of lithium : o Diuretics o Anti inflammatory Drugs that decrease effects of lithium o Azetazolamide ( Diamox) o Na bicarbonate o Drugs with theophylline components

CI/Cautions Presence of known allergy Marked agitation, anxiety, tension (exacerbation) Severe fatigue or glaucoma Cardiac dses Pregnancy and lactation Caution: history of drug dependence and hypertension AE Nervousness Insomia Dizziness HA Blurred Vision Difficulty with accommodation Anorexia, nausea, weight loss HTN, arrhythmias, angina Nursing Implications Ensure proper dx of behavioral syndromes and narcolepsy Arrange to interrupt the drug periodically for behavioral syndromes Arrange to dispense the least amount of drug Adm before 6 pm Monitor weight, CBC, ECG Consult with school nurse and counselor for comprehensive care Safety measures Pt teaching (SOP) ANTIEPILEPTIC AGENTS Epilepsy most prevalent of the neurological disorders, is not a single disease, but a collection of different syndromes all of these conditions are characterized by the same feature: sudden discharge of excessive electrical energy from nerve cells located within the brain which leads to a seizure in some cases, this release stimulates motor nerve resulting in convulsions, with tonic-clonic muscle contractions that have potential to cause injury, tics and spasm Antiepileptics these agents are sometimes called as anticonvulsants, but because all types of epilepsy do not involve convulsions, this term is generally not acceptable. Classification of Seizures: 1. generalized seizure begin in one area of the brain and rapidly spread throughout both hemisphere of the brain usually experience a loss of consciousness resulting from massive electrical activity throughout the brain a. tonic-clonic seizure (formerly known as grand mal seizure) Page 5 of 15

L evel - therapeutic (0.6 to 1.2 mEq/L) I ncreased urination T hirst increased H eadache H and tremor I ncrease fluids U nsteady M onitor Salt - adequate intake CNS Stimulants Used to clinically tx attn deficit dos and narcolepsy. Paradoxically, calm hyperkinetic children and keep them focus on one activity for a longer period. methylphenidate (Ritalin, Concerta): tx of attn deficit, other behavioral syndromes assoc with hyperactivity, narcolepsy dexmethylphenidate (Focalin): tx of attn deficit for 6 y/o + dextroamphetamine (Dexedrine): adjunct therapy for exogenous obesity (short term) modafinil (Provigil): tx narcolepsy, improving wakefulness in people with obstructive sleep apnea/hypopneas syndrome MOA/Indication Possibly increase the release of catecholamines from presynaptic neurons, leading to increase in stimulation of the postsynaptic neurons. Paradoxical effect of calming to attn deficit syndrome is believed to be r/t increased stimulation of an immature RAS, which leads to the ability to be more selective in response to incoming stimuli. Major P. Salipot, RN St. Marys College

b.

dramatic tonic-clonic muscle contraction, loss of consciousness, and a recovery period characterized by confusion and exhaustion tonic- prolonged muscular contraction clonic series of alternating contractions and partial relaxation of muscle

a. b. c. d.

phenytoin (Dilantin) for tonic-clonic seizure and status epilepticus as well as in the prevention and treatment of seizure following neurosurgery ethotoin (Peganone) for tonic-clonic seizure and myoclonic seizure fosphenytoin (Cerebyx) For short-term control of status epilepticus and to prevent seizure following neurosurgery Mephenytoin (Mesantoin) For tonic-clonic, myoclonic and partial seizure in patients who do not respond to less toxic antiepileptic agents Has been associated with severe hepatic toxicity, bone marrow suppression and often unacceptable dermatologic reactions

absence seizure (formerly known as petit mal seizure) involved abrupt, brief ( 3-5 seconds) period of loss of consciousness occur commonly in children and frequently disappears at puberty myoclonic seizure involve short, sporadic periods of muscle contractions that last for several minutes. Relatively rare and are often secondary seizure febrile seizure related to very high fever and usually involves convulsions occur in children and are usually self-limiting and do not reappear status epilepticus potentially the most dangerous of seizure conditions, is a state in which seizures rapidly recur again and again without recover of consciousness 3. 2.

c.

d.

BARBITURATES and BARBITURATE-LIKE DRUGS a. Phenobarbital (Luminal) Available in oral and parenteral forms Used for emergency control of status epilepticus and acute seizure associated with eclampsia and tetanus b. Primidone ( Mysoline) Alteranate choice in the treatment of tonic-clonic or partial seizure Have longer half-life than Phenobarbital and is available only in oral form

e.

2.

partial seizure (also called focal seizure) involve one area of the brain and do not spread throughout the entire organ a. simple partial seizure occur in a single area of the brain and may involve a single muscle movement or sensory alteration complex partial seizure involve complex sensory changes such as hallucinations, mental distortion, changes in personality loss of consciousness and social inhibitions motor changes may include involuntary urination, chewing motions, and diarrhea onset usually occurs by late teens

BENZODIAZEPINES

THERAPEUTIC ACTION: In generael, hydrantoins, barbiturate and benzodiazepine all stabilize nerve membranes throughout the CNS to decrease excitability and hyperexcitability to stimulation CONTRAINDICAITON: pregnancy lactation ADVERSE EFFECTS: depression, confusion, drowsiness, lethargy, fatigue, constipation, dry mouth, anorexia, cardiac arrhythmia hydrantoins severe liver toxicity, bone marrow suppression, gingival hyperplasia, and potentially serious dermatologic reactions ( hirsutism, coarsening of facial skin) which are all related to cellular toxicity NURSING RESPONSIBILTIES: 1. discontinue drug at any sign if hyperexcitability reaction or liver dysfunction, or severe skin rash to limit reaction and prevent potentially serious reactions 2. administer drug with food to alleviate GI irritation if GI upset is a problem Page 6 of 15

b.

DRUGS FOR TREATING TONIC-CLONIC SEIZURE 1. HYDANTOINS Stabilize nerve membranes and limit the spread of excitability form the initiating focus Less sedating than many other epileptics, they may be the drug of choice inpatients who are not willing to tolerate sedation and drowsiness

Major P. Salipot, RN St. Marys College

3.

suggest the wearing or a carrying a medic-alert bracelet to alert emergency workers and healthcare providers about the use of epileptic drug

2.

DRUGS FOR TREATING ABSENCE (PETIT MAL) SEIZURE 1. SUCCINIMIDES drugs that modulate the inhibitory neurotransmitter GABA are most frequently used a. b. c. Ethosuximide ( Zarontin) Drug of choice for treating absence seizure Relatively few adverse effects compared to other antiepileptic drug Methsuximide ( celontin) Oral drug, used to treat absence seizures that are resistant to other drugs Associated with bone marrow suppression Phensuximide ( Milontin) Used for treatment of absence seizure that are resistant to other agents

zonisamide ( Zonegram) Inhibits voltage-sensitive sodium and calcium channels, thus stabilizing nerve cell membranes and modulating calciumdependent presynaptic release of excitatory neurotransmitters Patients who take this drug should be very well hydrated; there is a risk of renal calculi development

DRUGS FOR TREATING PARTIAL (Focal) SEIZURE 1. 2. 3. 4. 5. carbamazepine ( Tegetrol, atretol) drug of choice for treating partial seizures gabapentin ( Neurontin) used as adjunct therapy in the treatment of focal seizure Lamotrigine (Lamictal) Tiagabaine (Gabritil) Topiramate ( Topamax) Adjunct therapy for partial seizure in adults

Therapeutic action: suppress the abnormal activity in the brain associated with absence seizure Contraindication: allergy renal or hepatic disease adverse effects: depression,. Drowsiness, fatigue, insomnia, headache, blurred vision nausea, vomiting, anorexia, weight loss, GI pain, constipation or diarrhea bone marrow suppression and dermatologic reactions such as pruritus, urticaria, alopecia, Steven-Johnson syndrome may occur as a result of direct chemical irritation of the skin and bone marrow Nursing Responsibilities: 1. Administer the drug with food to alleviate GI irritation 2. Monitor CBS prior to and periodically during drug therapy to detect bone marrow suppression early and provide appropriate intervention 3. discontinue the drug if skin rash, bone marrow suppression or unusual depression or personality changes occur to prevent the development of serious adverse effects 4. discontinue the drug slowly and never withdraw the drug quickly because rapid withdrawal may precipitate absence seizure OTHER DRUGS FOR TREATING ABSENCE SEIZURES 1. valproic acid ( Depakene) Reduces abnormal electrical activity in the brain and may also increase GABA activity at inhibitory receptors Drug of choice in treating myoclonic seizures Major P. Salipot, RN St. Marys College

Therapeutic actions: stabilize nerve membranes by: o directly by allowing sodium and calcium channels o indirectly by increasing the activity of GABA Contraindications: allergy bone marrow suppression severe hepatic dysfunction ANTIPARKINSONIAN DRUGS PARKINSONS DISEASE a chronic neurologic disorder that affects the extrapyramidal motor tract( which controls posture, balance and locomotion) three major features: rigidity, bradykinesia and tremors postural changes: chest and head thrust forward with knees and hips flexed with shuffling gait and absence of arm swing, with masked fasci. Involuntary movement of head and neck and pill-rolling motion of the hands first described by James Parkinson in 1817 Pathophysiology caused by imbalance of the dopamine and acetylcholine marked by degeneration of the neurons in the substancia nigra and at the basal ganglia there is an unexplained degeneration of the dopaminergic neurons drugs that are used to treat Parkinsons Disease 1. anticholinergics 2. dopaminergics 3. dopamine agonist Page 7 of 15

4. 5.

MAO-B inhibitor COMT inhibitors- inhibits catechol-O-methyltranferase enzyme

4. 5.

Procyclidine (Kemadrin) trihexyphenidyl ( Artane)

ANTICHOLINERGICS drugs that oppose the effects of acetylcholine receptor sites in the substancia nigra and corpus striatum has greater affinity for cholinergic receptors site sin the CNS block the action of acetylcholine in the CNS t help normalize acetylcholinedopamine imbalance reduce rigidity and to a lesser extent, tremor but have minimal effect on bradykinesia are parasymphatolytics first used to treat Parkinsons Disease before levodopa and dopamine agonist were introduced peak in 1 4 hours cross the placenta contraindications: allergy narrow angle glaucoma GI obstruction GU obstruction Prostatic hypertrophy Side effects: dry mouth blurred vision constipation paralytic ileus o rare but potentially very serious side effect. Monitor for abdominal distension, absent bowel sounds, nausea, vomiting, epigastric pain. Report immediately to the physician if these are present. urinary retention tachycardia, decreased sweating, elevated temperature Nursing interventions: 1. arrange to decrease dosage. 2. arrange for a decrease in dosage in hot weather 3. give the drug with meal if GI upset occurs, before meals if dry mouth is a problem 4. monitor bowel function 5. ensure that the patient voids before taking the drug if urinary retention is a problem 6. provide thorough patient teaching anticholinergic drugs: 1. benztropine mesylate ( Cogentin) larger dose at bedtime 2. biperiden ( Akineton) - prototype a. with prolonged use tolerance may occur b. avoid taking with other CNS depressant and alocohol c. start at 2mg/day in 1-4 divided doses 3. ethopropazine ( Parsidol) Major P. Salipot, RN St. Marys College

DOPAMINERGICS increases the amount of dopamine and enhances transmission of dopamine more effective than anticholinergics in treating Parkinsons Disease directly stimulates the dopamine receptors after neurodegeneration has progressed to the extent that the nerves are damaged or gone, these drugs are not effective levodopa is the first drug to be invented in 1961, it is a precursor to dopamine that can cross blood-brain-barrier this increases mobility dopa decarboxylase converts levodopa to dopamine in the brain Side effects: anxiety, nervousness, headache, malaise, fatigue, confusion, mental changes anorexia, nausea, vomiting, dysphagia, constipation Drug-drug interactions: 1. with MAOI increases the risk of hypertensive crisis 2. with Vit B6 and phenytoin may lead to decrease efficacy 1. levodopa (Dopar) a. Prototype b. Can cross the BBB c. Immediate precursor of dopamine\loss of effectiveness after 3-5 years d. Twitching of eyelids is an early sign of dug toxicity e. Common side effects: fatigue, weakness, drowsiness, dizziness, fainting, increased sweating darkening of the urine f. If given with carbidopa ( SINEMET) more effective i. Carbidopa inhibits the enzyme dopa decarboxylase diminishing the metabolism of levodopa 3. 4. 5. 6. amantadine (Symmetrel) a. Antiviral drug that increases levels of dopamine bromocriptine (Parlodel) pergolide (Permax) a. Inhibits prolactin secretion and rise in growth hormone ropinirole (Requip)

Adjunct to levodopa therapy 1. entacapone (Comtan) a. Increase the plasma concentration and duration of action of levodopa b. Inhibits catecholamine O-methyl transferase (COMT) tolcapone (Tasmar) a. Works in similar ways with carbidopa-levodopa b. Blocks COMT Page 8 of 15

2.

3.

Used in later stage of the disease when the effectiveness of cerbidopa-levodopa decreases selegiline (Carbex, Eldepryl) a. Inhibits MAO

c.

Muscle Relaxants Muscle Spasm Often result from injury to musculoskeletal system Violent and painful involuntary muscle contraction Flood of sensory stimuli stimulate intense muscle contraction cut off blood supply increase lactic acid pain Muscle Spasticity Result of injury to CNS rather than at the periphery Permanent Result from increase in excitatory influence or decrease in CNS control Hypertonia excessive stimulation of opposing muscle groups which may cause contractures CENTRAL ACTING MUSCLE RELAXANTS Interfere with the reflexes that causes muscle spasm MOA/Indication Unknown but believed to be involved in action in the upper or spinal interneurons. Relief of discomfort assoc with acute, painful musculoskeletal condition as an adjunct to rest, physical therapy etc. CI/Cautions Presence of known allergy Baclofen shld not be used to treat spasticity that contributes to locomotion or increased function Caution: history of epilepsy, cardiac dysfunction, any condition marked by muscle weakness, hepatic/renal dysfunction, pregnancy/lactation AE CNS Depression: drowsiness, fatigue, weakness, confusion, HA, insomnia GI: nausea, dry mouth, anorexia, constipation Hypotension, arrhythmias Urinary frequency, enuresis, urgency Chlorzoxazone may discolor urine (orange-purple red)

dantrolene (Dantrium) currently available in market in treating spasticity that directly affect peripheral muscle contraction. Used primarily for cerebral palsy, MS, muscular dystrophy, polio, tetanus, quadriplegia, amyotrophic lateral sclerosis (ALS) Not used for tx of muscle spasm assoc with musculoskeletal injury or rheumatic dos

MOA/Indication Dantrolene acts within skeletal muscle fibers, interfering with release of calcium from muscle tubules. Dantrolene is indicated for the control of spasticity resulting from upper motor neuron disorders and prevention of malignant hyperthermia Botulinum toxin type B (Myobloc) approved for the reduction of the severity of abnormal head position and neck pain assoc with cervical dystonia. Botulinum toxin type A (Botox Cosmetic) approved for cervical dystonia, strabismus, blepharospasm and primary maxillary hyperhidrosis CI/Cautions Presence of known allergy Spasticity that contributes to locomotion, upright position or increased function Active hepatic dses Lactation Caution with the use of dantrolene: in women and all patients 35 y/o +, history of liver dse or dysfunction, respi depression, cardiac dse, pregnancy Caution for botulinum toxins: with peripheral neuropathic dse, neuromuscular disorders, pregnancy and lactation AE CNS depression: drowsiness, fatigue, weakness, confusion, HA, insomnia, visual disturbances GI: irritation, diarrhea, constipation, abd cramps Dantrolene: direct hepatocellular damage, urinary frequency, enuresis, urgency, crystalline urine with pain or burning Botulinum: anaphylactic reactions, HA, dizziness, muscle pain, paralysis, redness and edema at injection site.

Nursing Implications Discontinue at signs of liver dysfunction Monitor for possible extravasation Institute for supportive care for malignant hyperthermia (cooling blankets, ventilation, anticonvulsants as needed) Periodically discontinue (2-4 days) to monitor therapeutic effects Discontinue if severe diarrhea NARCOTICS Opioid, derived from opium Opioid Receptors respond to naturally occuring peptins, endorphins, and enkephalin BRAINSTEM: control BP, pupil diameter, GI secretions, chemoreceptor trigger zones (regulates nausea and vomiting, cough and respiration) SPINAL CORD AND THALAMUS: integrate and relate incoming info about pain Page 9 of 15

Nursing Implications Provide additional comfort measures (heat, rest, NSAIDS, positioning) Discontinue if + hypersensitivity reactions or liver dysfunctions Taper baclofen slowly over 1-2 weeks If baclofen is adm by delivery pump: pt should understand the pump, reason for frequent monitoring, how to adjust dose and program. Monitor respiratory status DIRECT-ACTING SKELETAL MUSCLE RELAXANTS Major P. Salipot, RN St. Marys College

PERIPHERAL NERVE SITES: block release of neurotransmitters that are related to pain and inflammation

1. 2.

stimulates certain opioid receptor but block other such receptor less abuse potential than pure narcotic agonist like morphine, causes sedation, respiratory depression, constipation Buprenorphine (Buprenex) Nalbuphine (Nubain) a. For moderate to severe pain, adjunct for general anesthesia b. To relieve pain during labor and delivery c. Should not be given to patients allergic to sulfites Pentazocine ( Talwin) a. Prototype

4 types: 1. mu analgesia, respiratory depression, feeling of euphoria, decrease GI activity, pupil constriction, development of physical dependence 2. kappa analgesia, pupil constriction, sedation 3. beta react with enkephalins to modulate pain transmission 4. Sigma pupil dilation, hallucination Narcotic Agonist react with opioid receptor Indication: analgesia, sedation, and sense of well-being, antitusssives severe acute and chronic pain, pre-op medication, analgesia during anesthesia given IVTT, IM, SC Contraindication: Allergy, pregnancy, labor, lactation diarrhea caused by poisons biliary surgery Adverse reaction: apnea, cardiac arrest, shock orthostatic hypotension nausea and vomiting, constipation and biliary spasm lightheadedness, dizziness, anxiety, fear, hallucinations, pupil constriction, impaired mental processes ureteral spasm, urinary retention, hesitancy, loss of libido Nursing Interventions: 1. provide narcotic antagonist and equipment for assisted ventilation on standby during IV administration. 2. Monitor site for irritation and extravasation 3. Monitor timing of analgesic doses 4. use extreme caution when injecting a narcotic into any body area that is chilled or has poor perfusion Drugs: 1. 2. 3. 4. 5. 6. 7. morphine ( Roxanol) prototype codeine for mild to moderate pain; coughing fentanyl ( Duragesic) hydrocodone ( Hycodan) - relief of cough, for moderate pain meperidine ( Demerol) obstetrical anesthesia opium ( Paregoric) treatment of diarrhea, relief of moderate pain oxycodone ( OxyContin)

3.

Narcotic Antagonist useful in blocking unwanted adverse effects associated with narcotics play a role in treatment of narcotic overdose Adverse effect: Narcotic abstinence Syndrome characterized with nausea, vomiting, sweating, tachycardia, hypertension, feelings of anxiety Drugs: 1. 2. 3. Nalmefene ( Revex) Naloxone ( narcan) used to diagnose suspected narcotic overdose Baltrexone (ReVita) orally for alcohol or narcotic dependence

NON-OPIOID ANALGESIC includes acetaminophen, NSAID, cyclo-oxygenase 2 (COX-2) ACETAMINOPHEN most widely used nonopioid analgesic action similar to salicylate blocks peripheral pain impulses by inhibition of prostaglandin synthesis lowers febrile body temperature for mild to moderate pain and fever Contraindication: allergy glucose-6-phosphate dehydrogenase (G6PD) deficiency Adverse effects: rash, nausea, vomiting can cause hepatotoxicity nephropathy Acetylcysteine - recommended antidote for acetaminophen toxicity prevents the hepatotoxic metabolites of acetaminophen from forming TRAMADOL HYDROCHLORIDE forms weak bond to sigma receptors inhibits re uptake of both norepinephrine and serotonin Page 10 of 15

Narcotic Agonist- Antagonist Major P. Salipot, RN St. Marys College

for moderate to severe pain

D-D -beta-blockers + ergotamine = risk for peripheral ischemia and inc. gangrene Nsg Implementation -avoid prolonged use -use of atropine or phenothiazine if NV is severe -provide comfort measures -assess extremities carefully because of decrease in perfusion especially those with decubitus ulcer or gangrene -provide supportive measure to ensure patient safety if acute OD.

Adverse effects: drowsiness, dizziness, headache, nausea , constipation and respiratory depression Contraindication: allergy acute alcohol intoxication, centrally acting analgesic, opioids can cause seizure to patients taking MAOI, TCA and neuroleptics ANTIMIGRAINE DRUGS Migraine - term used to describe several syndromes usually includes severe, throbbing headaches on one side of the head. Affects personality, GI, CNS, and mood. - types include: Common and Classic - Common migraine is without aura, cause severe unilateral, pulsating pain frequently accompanied by nausea, vomiting, sensitivity to light and sound. - Classic migraine is usually preceded by aura or sensation involving sensory or motor disturbances which usually occurs 10 mins before the pain begins - has two drugs, ergot derivatives and triptans. Ergot Derivatives - cause constriction of the cranial blood vessels and decrease the pulsation of the cranial arteries. Reduces hyperperfusion. - because of many side-effects, has limited use in some patients. - dihydroergotamine(Migranal) is IV or IM form or as nasal spray which provide rapid relief. - ergotamine (generic) prototype which is usually given SL. Cafergot is popular (ergotamine+caffeine) because of rapid absorption at GI tract. MOA/Indication -block alpha-adrenergic and serotonin receptor sites to cause a constriction of cranial blood vessels, a decrease in cranial artery pulsations, and a decrease in the hyperperfusion of basilar artery bed. -for prevention, abortion of migraine or vascular HA. CI -CAD, HTN Peripheral Vascular Dse -impaired liver function -Pregnancy and lactation -Caution: pruritus (exacerbation), malnutrition (cause severe GI reactions) AE -numbness, tingling of extremities, muscle pain -pulselessness, weakness, chest pain arrhythmia, localized edema, itching, MI may occur -GI upset, Nausea, vomiting, diarrhea -Ergotism: syndrome which is manifested by nausea, vomiting, severe thirst, hypoperfusion, chest pain, BP changes, confusion, drug dependency, drug withdrawal Major P. Salipot, RN St. Marys College

Triptans -new drugs cc cause cranial vasoconstriction -not assoc with all vascular and GI effects of ergot -triptan of choice depends on personal experience Sumatriptan (Imitrex) used to tx migraine attacks; PO, SQ, nasal spray; effective against cluster HA; CI for elderly Naratripan (Amerge) - PO; tx of acute migraine; assoc with several birth defects; CI for severe hepatic/renal dysfunction Rizatriptan (Maxalt) PO; tx of migraine with/out aura; have more angina effects so CI for CAD Zolmitriptan (Zomig) PO; tx of migraine with/out aura in adults Almotriptan (Axert) tx of tx of migraine with/out aura Frovatriptan (Frova) has advantage of long-life; PO tx for acute migraine with/out aura; prevents rebound HA Eletriptan (Relpax) PO; tx of migraine with/out aura MOA/Indications - triptans bind to SSR sites to cause vasoconstriction of cranial blood vessels, relieving s/sx of migraine HAs. -used as tx not prevention -sumatriptan injection is also indicated for cluster HA CI -allergy -pregnancy -active CAD -caution: elderly, lactation, renal/hepatic dysfunction

D-D Interaction -triptans + ergot = prolonged vasoaction effect -triptans + MAOI = increase vasoconstriction, must be avoided; more than two weeks not receiving MAOI before use AE -numbness, tingling, burning sensation, feelings of coldness or strangeness, dizziness, weakness, myalgia, vertigo -dysphagia, abd discomfort -BP alterations, tightness or pressure in the chest Page 11 of 15

Nsg Implementation adm to relieve acute migraine arrange safety precautions for CNS or visual changes provide comfort measures such as environmental controls and stress reduction monitor: BP if with history of CAD; D/C if there is sign of angina or prolonged HTN patient teaching

begins with consciousness and ends with loss of consciousness. Speech is difficult, sensation of smell and pain are lost. Dreams and auditory and visual hallucinations may occur. This stage may be called the induction stage.

Stage 2 (Excitement or delirium) produces loss of consciousness caused by depression of the cerebral cortex. Confusion, excitement, or delirium occurs. Short induction time. Stage 3 (Surgical) Surgical procedure is performed during this stage. There are 4 phases. The surgery is usually performed on phase 2 and upper phase 3. As anesthesia deepens, respirations become more shallow and respiratory rate increases. Stage 4 (Medullary paralysis) toxic stage of anesthesia. Respirations are lost and circulatory collapse occurs. Ventilatory assistance is necessary. Induction from beginning until stage 3; danger is in stage 2 because of systemic stimulation Maintenance stage 3 until completion of surgery Recovery from time of D/C of anesthesia until patient regains consciousness

ANESTHETICS -drugs that can cause complete or partial loss of sensation General anesthetics CNS depressants used to achieve the ff goals: Analgesia, unconsciousness and amnesia blocks body reflexes depresses the RAS and cortex lipid soluble metabolized in the liver cross the placenta Contraindication: 1. status asthmaticus 2. absence of suitable veins for intravenous administration Risk Factors: CNS Factors; Presence of underlying neurological disease Cardiovascular factors: CAD, hypotension Respiratory factor: COPD Renal and hepatic factor: conditions that interfere with the metabolism of and excretion of anesthetics Balanced Anesthesia use of combination drugs, each with specific effect, to achieve analgesia, muscle relaxation, unconsciousness and amnesia, rather than the use of single drug involves the ff: 1. 2. 3. 4. 5. Pre-op medication: which may include the use of anticholinergics that decrease secretions to facilitate intubations and prevent bradycardia associated with mental depression sedative/hypnotic to relax patient, facilitate amnesia and decrease sympathetic stimulation Antiemetics to decrease nausea and vomiting associated with GI depression Antihistamine to decrease the chance of allergic reaction and to help dry secretion Narcotics to aid analgesia and sedation

Types of GA 1. Barbiturate Anesthetics are IV drugs used to induce rapid anesthesia which is then maintained by inhaled drugs. b. Thiopental (Pentothal) i. Most widely used of the IV anesthetics ii. Rapid onset and ultra short recovery period iii. Has no analgesic property c. Methotexital ( Brevital) i. Rapid onset and shorter recovery period ii. Cannot come in contact with silicon iii. Lacks analgesic property iv. Causes respiratory depression and apnea 2. Nonbarbiturate Anesthetics given IV a. Midazolam (Versed) i. Prototype ii. Rapid onset with peak effectiveness for 30 to 60 mins. iii. Causes nausea and vomiting b. Droperidol( Inapsime) i. Use cautiously in patients with renal and hepatic failure ii. Causes hypotension, chills, hallucination and drowsiness during recovery period c. Etomidate ( Amidate) i. Sometimes used for sedation of patients on ventilators ii. May experience myoclonic and tonic movements as well as nausea and vomiting iii. Not recommended for children younger than 10 years old Page 12 of 15

Stages of Anesthesia Stage 1 (Analgesia) Major P. Salipot, RN St. Marys College

d. d. Ketamine ( Ketalar) i. Patient appears to be awake but is unconscious and cannot feel pain ii. Causes sympathetic stimulation iii. Crosses the BBB iv. Cause hallucinations, dreams and psychotic episode Propofol (Diprivan) i. Short-acting; rapid onset ii. For short procedures iii. Causes local burning sensation iv. Cause bradycardia, hypotension, edema

Isoflurane ( generic) i. Associated with hypotension, hypercapnia, muscle soreness and bad taste in the mouth ii. Does not cause cardiac arrhythmia or respiratory irritation Methoxyflurane ( Penthrane) i. Can cause renal toxicity, respiratory depression and hypotension ii. Rarely used except during labor and delivery, because it does not relax the uterus Sevoflurane ( Ultane) i. Newest

e.

e.

f. extreme: pulmonary

3. -

Anesthetic gases enter the bronchi and alveoli very high affinity to fats a. Nitrous oxide ( blue cylinder) i. Prototype ii. Potent analgesic iii. Weakest pf the gas anesthetic and least toxic cylopropane ( orange cylinder) i. experience of pain, headache, nausea, vomiting, and delirium during recovery phase Ethylene ( red cylinder) i. Leave patient with headache and unpleasant taste

Nursing responsibilities: 1. must be administered by a trained personnel 2. have equipment standby to maintain airway and provide mechanical ventilation 3. Monitor temperature for prompt detection and treatment of malignant hyperthermia have dantrolene on standby. 4. Monitor VS ECG, cardiac output during administration 5. monitor patient until recovery phase is complete and patient is conscious and able to move and communicate 6. provide comfort measures 7. provide thorough pre-op teachings LOCAL ANESTHETICS cause loss of sensation in limited areas of the body very powerful nerve blockers are either esters and amides esters are broken down by plasma esterases amides are metabolized by the liver temporary interrupt the production and conduction of nerve impulses prevents sodium ions from entering the nerve they stop the nerve from depolarizing used for: infiltration anesthesia, peripheral nerve block, spinal anesthesia , relief of local pain Contraindication: allergy, heart block, shock, decrease plasma esterase Modes of Administration: 1. Topical 2. Infiltration a. Involves injecting the anesthesia directly into the tissues to be treated 3. Field Block a. Injecting the anesthetic all around the area that will be affected by the operation b. Often used for tooth extraction Nerve Block

b.

c. 4. -

Volatile Liquids inhaled anesthetic most are halogenated hydrocarbons a. Halothane (Fluothane) i. Prototype ii. Vomiting, bradycardia and hypotension iii. Increased risk for hepatic failure iv. Recovery syndrome: fever, anorexia, nausea and vomiting eventual hepatitis Desflurane ( Suprane) i. With respiratory reactions: cough, increased secretions, laryngospasm ii. Not recommended for pediatric patients Enflurane ( Ethrane) i. Associated with renal toxicity,cardiac arrhythmia and respiratory depression

b.

c.

4.

Major P. Salipot, RN St. Marys College

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5.

Injecting the anesthetic at some point along the nerve or nerves that run to and from the region to which loss of pain sensation or muscle paralysis is required. b. Could be a peripheral nerve block (Blocks the sensory and motor aspects of a particular nerve for relief of pain or diagnostic procedure) or a central nerve block ( injected through a roots of the nerves in the spinal cord) c. Epidural anesthesia, the drug is injected into the space where the nerve emerge from the spinal cord d. Caudal block, injection into the sacral canal below the epidural area Intravenous Regional Anesthesia a. Carefully draining all the blood from the patients arm or leg, securing a tourniquet to prevent anesthesia from entering the general circulation, and then injecting the anesthesia into the vein of arm or leg.

a.

-occupies muscular cholinergic receptor sites which prevents Ach from reacting with the receptor -effect is more long-lasting - used when muscle paralysis is required. Depolarizing NMJ Blockers: Succinylcholine -attaches to the Ach receptor site of muscle causing stimulation of the muscle and muscle contraction and cant be broken down instantly causing prolonged contraction -hydrophilic thats why not readily cross BBB -rapid onset and short duration bec it is broken down by cholinesterase - indicated for: a. to serve as adjunct therapy for GA during surgery when reflex when reflex muscle movement could interfere with procedure or delivery of gas anesthetics b. to facilitate mechanical intubation by preventing resistance to passing ET and in instances in which patient fight or resist the respirator. c. to facilitate ECT therapy when intense skeletal muscle contractions as a result of electric shock could cause the patient broken bones or other injuries. CI -know allergy -myasthenia gravis -hepatic/renal dses -pregnancy/lactation -caution: History of malignant hyperthermia Pulmonary/CV dysfunction Altered Fluids and Electrolyte imbalances Respiratory condition Fractures Narrow-angle glaucoma SCI, paraplegia -extreme caution: Dse conditions causing low plasma cholinesterase levels such as: Cirrhosis, metabolic dos, carcinoma, thyroid toxicosis, collagen diseases, burns, DHN, hyperpyrexia, exposure to neurotoxic insecticides AE -assoc with muscle paralysis: Apnea Histamine release causes wheezing and bronchospasm Hypotension, cardiac arrhythmias Constipation, vomiting, regurgitation, aspiration Decubitus ulcer Hyperkalemia Muscle pain (aspirin after procedure) Malignant hyperthermia (massive muscle contraction, sharp elevated temp, severe acidosis, death); tx with dantrolene D-D Interaction -DNMJB + halothane = increased effect Page 14 of 15

Adverse reaction: headache, restlessness, anxiety, dizziness tremors, blurred vision, backache nausea and vomiting, peripheral vasodilation, myocardial depression arrhythmia, BP changes Nursing Interventions: 1. Have equipment standby. 2. Ensure drugs for hypotension, cardiac arrest and CNS alteration 3. Ensure patient receiving spinal anesthesia are well hydrated and remain lying down for up to 12 hours. 4. Establish safety precaution 5. Provide comfort measure 6. Provide thorough patient teaching Drugs: Esters: 1. benzocaine (Dermoplast) 2. Procaine ( Novocain) Amides: 1. bupivacaine ( Marcaine) 2. Lidocaine ( Xylocaine) 3. Mepivacaine ( Isocaine)

Neuromuscular Junction Blocking Agents divided into 2: nondepolarizing and depolarizing Nondepolarizing acts as antagonist to Ach while nondepolarizing acts as agonist for Ach Cause paralysis during surgical procedure or facilitation of mechanical ventilation Nondepolarizing NMJ Blockers -curare: first discovered NNMJB which is a poison -destroyed in cooking -clinical usage: tubocurarine Major P. Salipot, RN St. Marys College

-DNMJB + aminoglycoside antibiotics = increased neuromuscular blockage -DNMJB + calcium channel blockers = increased effect -DNMJB + cholinesterase inhibitors = decreased effect -DNMJB + xanthines = reversal effect Nsg Implementation -adm by trained personnel -supplies and equipments, peripheral stimulator, cholinesterase inhibitors are on standby -do not mix with alkaline soln such as barbi -test pt response and recovery periodically -monitor temp -maintain dantrolene for malignant hyperthermia -adm small dose of NNMJB to decrease adverse effect of succinylcholine -provide comfort measures -monitor VS -drug teaching

Major P. Salipot, RN St. Marys College

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