CHAPTER 66: NEUROLOGICAL MEDICATIONS PYRAMID POINTS CHAPTER 66: NEUROLOGICAL MEDICATIONS

PYRAMID POINTS I. Antimyasthenic Medications Description Side effects Relieve muscle weakness by blocking acetylcholine breakdown at neuromuscular junction Side effects Sign of cholinergic crisis Interventions Assess neuromuscular status and medication effectiveness Instruct client about the importance of taking medication on time Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.

PYRAMID POINTS continued … Tensilon test Diagnosis of myasthenia gravis shows significant improvement in muscle tone 30 to 60 seconds after injection of Tensilon; muscle improvement lasts 4 to 5 minutes In cholinergic crisis, muscle tone does not improve after injection of Tensilon Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.

PYRAMID POINTS II. Antiparkinsonian Medications Description Restore the balance of acetylcholine and dopamine in the central nervous system (CNS) Dopamine medications Levodopa taken with monoamine oxidase (MAO) inhibitor can cause hypertensive crisis Side effects include urinary retention Interventions Assess for risk of injury Instruct client to take medication with food Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.

PYRAMID POINTS continued … Assess for signs and symptoms of parkinsonism Monitor for signs of dyskinesia When administering, instruct client to avoid excessive vitamin B6 intake Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.

PYRAMID POINTS II. Antiparkinsonian Medications (continued) Anticholinergic medications Description Block the cholinergic reception in the CNS, thereby suppressing the acetylcholine activity Contraindicated in clients with glaucoma Side effects include urinary retention Interventions Assess for risk of injury Assess client’s bowel and urinary function Instruct client to have routine eye examinations Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.

PYRAMID POINTS III. Anticonvulsant Medications Description Depress abnormal neuronal discharges Should be used with caution in clients taking anticoagulants, aspirin, sulfonamides, cimetidine (Tagamet), antipsychotic drugs Interventions Monitor liver and renal function tests and medication blood serum levels Client education Instruct about the importance of taking medication exactly as prescribed Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.

PYRAMID POINTS continued … Hydantoins Phenytoin (Dilantin) also used to treat dysrhythmias Side effects Gingival hyperplasia Interventions When administering IV, dilute in normal saline When administering IV, infuse no faster than 25 to 50 mg/min Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.

PYRAMID POINTS III. Anticonvulsant Medications (continued) Barbiturates Side effects include sedation, ataxia, dizziness Benzodiazepines Succinimides Oxazolidinediones Side effects include headache Valproates Iminostilbenes Used to treat trigeminal neuralgia Side effects Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.

PYRAMID POINTS IV. Central Nervous System Stimulants Description Used to treat narcolepsy, attention-deficit/hyperactivity disorder (ADHD) Side effects include insomnia Interventions Assess height, weight, growth of child If given to child, instruct parents to notify school nurse Monitor for calming effects within 3 to 4 weeks in children with ADHD Monitor growth in child on long-term therapy with methylphenidate hydrochloride (Ritalin) Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.

PYRAMID POINTS V. Nonopioid Analgesics Nonsteroidal anti-inflammatory drugs (NSAIDs) Contraindicated in clients with hypersensitivity, liver, renal disease Children with flu symptoms should not take aspirin Clients taking anticoagulants should not take aspirin, NSAIDs Interventions Assess for allergies Monitor serum salicylate (aspirin) level when taking high doses of aspirin Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.

PYRAMID POINTS continued … Monitor for signs of bleeding Instruct client to take with water, milk, food Advise client to inform other health care professionals if taking high dose of aspirin Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.

PYRAMID POINTS V. Nonopioid Analgesics (continued) Acetaminophen (Tylenol) Contraindicated in clients with hepatic, renal diseases, alcoholism, hypersensitivity Side effects include hepatotoxicity Interventions Assess for history of liver, renal dysfunction, alcoholism, malnutrition Monitor for hepatic damage Antidote is acetylcysteine (Mucomyst) Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.

PYRAMID POINTS VI. Opioid Analgesics Description Medications Suppress pain impulses Can produce euphoria, sedation, and physical dependence Medications Codeine sulfate Can cause constipation Meperidine hydrochloride (Demerol) Used for acute pain, preoperative medication; can cause urinary retention Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.

PYRAMID POINTS continued … Morphine sulfate Can cause respiratory depression, orthostatic hypotension, constipation Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.

PYRAMID POINTS VI. Opioid Analgesics (continued) Medications (continued) Oxycodone with aspirin (Percodan) Should not be taken by client with allergy to aspirin Propoxyphene hydrochloride (Darvon), propoxyphene napsylate (Darvon-N) Methadone hydrochloride (Dolophine) Hydrocodone (Hycodan) Frequently used for cough suppression Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.

PYRAMID POINTS VI. Opioid Analgesics (continued) Interventions for opioid analgesics Morphine sulfate Side effects include respiratory depression Withhold if respiratory rate less than 12 breaths/min Meperidine hydrochloride Side effects include urinary retention Contraindicated in clients with head injuries, increased intracranial pressure Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.

PYRAMID POINTS VII. Opioid Antagonists Used to treat respiratory depression from opioid overdose Interventions Monitor blood pressure, pulse, and respirations frequently Do not leave client unattended Have resuscitation equipment available Monitor for recurrent opioid overdose once effect of antagonist wears off Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.

PYRAMID POINTS VIII. Osmotic Diuretics Description Side effects Inhibit reabsorption of water and electrolytes Used for oliguria, to decrease intracranial pressure, and to decrease intraocular pressure Side effects Fluid and electrolyte imbalance Cardiac dysrythmias Interventions Monitor vital signs Monitor for signs of fluid and electrolyte imbalances Monitor heart and lung sounds Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.

1. Break the capsules so that they are easier to swallow. The nurse is assisting in the care of a client being discharged on phenytoin (Dilantin), 100 mg, three times daily, for seizure control. When teaching the client about this medication, the nurse should be sure to include which of the following points? 1. Break the capsules so that they are easier to swallow. 2. Use a soft toothbrush while taking this medication. 3. If a dose is missed, just wait until the next one is due. 4. Sore throat is a common effect of the medication and is nothing to worry about. Answer: 2 Rationale: Phenytoin is an anticonvulsant that can cause gingival hyperplasia, as well as bleeding, swelling, and tenderness of the gums. The client should use good oral hygiene, gum massage, and have regular dental checkups. The client should not skip medication doses, because this could precipitate a seizure. The client should report a sore throat, fever, glandular swelling, or any skin reaction, because this indicates hematological toxicity. Capsules should not be chewed or broken, and they must be swallowed. Test-Taking Strategy: Use the process of elimination. Eliminate option 3, because the client should be encouraged to take medications on time. Choose among the remaining options, recalling that phenytoin can cause gingival hyperplasia. Review the side effects related to phenytoin if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Pharmacology Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 930). Philadelphia: W.B. Saunders. Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.