CH19 ANTISEIZURE DRUGS

Drug interactions
EPILEPSY > Increased effects with cimetidine, isoniazid,
Seizure disorder chloramphenicol, sulfonamides
> Abnormal electric discharges from cerebral > Decreased effects with folic acid, antacids,
neurons calcium, sucralfate, antineoplastics, antipsychotics,
Characteristics primrose, ginkgo, borage
1. Loss of consciousness > Decreased effects of anticoagulants, oral
2. Involuntary, uncontrolled movements contraceptives, antihistamines, corticosteroids,
Cause theophylline, dopamine, cyclosporine, quinidine,
1. Unknown rifampin
2. Secondary to brain trauma or anoxia, infection,
stroke Nursing Process: Phenytoin
3. Isolated seizures due to fever, electrolyte, or Assessment
acid–base imbalance, alcohol, or drugs -Obtain a current health history including drugs and
herbs used.
International Classification of Seizures -Determine renal and hepatic function lab values.
Common generalized seizure types Nursing diagnosis
1. Tonic–clonic (grand mal) -Injury, risk for Falls, risk for
-Most common Planning
-Generalized alternating muscle spasms and -Patient’s seizure frequency will diminish.
jerkiness Nursing interventions
2. Absence (petit mal) -Monitor serum drug levels of antiseizure drug to
-Brief loss of consciousness (10 seconds or less) determine therapeutic range.
-Usually occurs in children -Warn female patients taking oral contraceptives
Common partial seizure type and antiseizure drugs to use additional
Psychomotor contraceptive method.
1. Repetitive behavior -Use seizure precautions for patients at risk for
- Chewing or swallowing motion seizures.
2. Behavioral changes -Advise patients not to drive or perform other
3. Motor seizures hazardous activities when initiating drug therapy.
Evaluation
Antiseizure drugs
> Stabilize nerve cell membranes Barbiturates
> Suppress abnormal electric impulses in cerebral Phenobarbital
cortex Action
Specific types of action Enhances GABA activity
> Suppress sodium influx Use
> Suppress calcium influx Tonic–clonic, partial, myoclonic seizures, status
> Enhance action of GABA epilepticus
> Promote GABA release Therapeutic serum range
20 to 40 mcg/Ml
Hydantoin Side effects
Phenytoin Sedation, tolerance
Contraindications Discontinuation
Pregnancy (teratogenic) Should be gradual
Therapeutic serum level
10 to 20 mcg/mL Succinimide
Side effect/adverse reactions Ethosuximide
-Gingival hyperplasia, nystagmus, diplopia Action
-Headache, dizziness, slurred speech, alopecia Decreases calcium influx
-Purple glove syndrome, ventricular fibrillation Use
-Depression, suicidal ideation Absence seizures
-Hyperglycemia, GI distress, urine discoloration Therapeutic serum range
-Thrombocytopenia, leukopenia 40 to 100 mcg/mL
-Stevens-Johnson syndrome Adverse effects
Blood dyscrasias, renal and liver impairment  Pregnant females need daily folate
Systemic lupus erythematosus. supplements
* Monitor serum phenytoin levels closely during
Benzodiazepines pregnancy because seizures tend to become more
Clonazepam frequent due to increased metabolic rates.
Treats absence and myoclonic seizures
Tolerance may occur in 6 months
Antiseizure Drugs and Febrile Seizures
Clorazepate dipotassium
> Seizures associated with fever
Treats partial seizures
 Usually occur in children between the ages
Diazepam
Treats status epilepticus of 3 months and 5 years
Must be administered IV for status epilepticus > Epilepsy develops in approximately 2.5% of
Short-term effect children who have had one or more febrile
seizures.
 Other antiseizure drugs must be given
> Prophylactic treatment for high-risk patients
during or immediately after administration of
 Phenobarbital or diazepam
diazepam

Iminostilbene Antiseizure Drugs and Status Epilepticus

Carbamazepine Status epilepticus
Use > Medical emergency
Tonic–clonic, partial seizures > Treatment must begin immediately
Also used for psychiatric disorders (e.g., bipolar Treatment
disorder), trigeminal neuralgia, and alcohol > Diazepam
withdrawal > Lorazepam
Therapeutic serum range > Followed by phenytoin IVF or continued seizures:
4 to 12 mcg/mL midazolam, propofol
Side effects, adverse reactions > Slow IV administration to avoid respiratory
Dizziness, drowsiness, headache, blurred vision depression
GI distress, ataxia, weakness, anemia
Agranulocytosis, Stevens-Johnson syndrome 1. What is the highest priority nursing diagnosis for
Possible interaction with grapefruit juice a patient taking phenytoin?
Anxiety
Valproate Risk for falls
Valproic acid Risk for constipation
Use—tonic–clonic, absence, and mixed seizures Deficient fluid volume
Therapeutic serum range *The nursing diagnosis “Risk for falls” has the
50 to 100 mcg/mL highest priority for a patient taking phenytoin
Side effects, adverse reactions because it may lead to side effects of dizziness,
Dizziness, drowsiness decreased coordination, and ataxia. Anxiety,
Insomnia, diplopia constipation, and efficient fluid volume are not side
Weakness, GI distress effects of phenytoin, but depression and
Suicidal ideation
discoloration of urine are.
Thrombocytopenia

Antiseizure Drugs and Pregnancy 2. Before administering a daily dose of phenytoin, it

> Seizure episodes increase 25% in women with is most important for the nurse to
epilepsy who are pregnant maintain the patient on bed rest.
> Many antiseizure drugs are teratogenic check phenytoin levels.
> Antiseizure drugs tend to inhibit vitamin K monitor intake and output.
monitor renal function tests.
 Contributes to infant hemorrhage soon after
*Checking the phenytoin level is most important
birth
because of the narrow therapeutic range of 10 to
 Vitamin K may be given during last few days
20 mcg/mL. Maintaining bed rest and monitoring
of pregnancy or given to infant soon after
I&O and renal function tests are not necessary.
birth
> Antiseizure drugs increase loss of folate (folic
acid) in pregnant patients
3. A patient was discharged 3 days ago on CH20 Drugs for Parkinson Disease and
phenytoin therapy for seizure disorder. The patient Alzheimer Disease
comes to the emergency department experiencing
seizures. What will be of most value to determine
the etiology of the returned seizures? Parkinson Disease
A CT scan Pathophysiology of Parkinson disease
An EEG > Chronic neurologic disorder
Serum phenytoin levels > Imbalance of neurotransmitters dopamine and
Serum electrolytes acetylcholine
*For dilantin therapy to be effective, a therapeutic > Degeneration of dopaminergic neurons leading to
serum range of 10 to 20 mcg/mL must be a lack of dopamine
maintained. Subtherapeutic serum levels are a Pseudoparkinsonism
> Frequently occurs as an adverse reaction to
frequent cause of seizures for patients on dilantin
various drugs, carbon monoxide, manganese, or
therapy. disorders (encephalitis, stroke, trauma)
4. When assessing a patient taking hydantoin *Dopamine: an inhibitory neurotransmitter
therapy for seizure disorder, which indicates an Acetylcholine: an excitatory neurotransmitter
adverse reaction to this therapy? Dopamine normally maintains control of
Thrombocytopenia acetylcholine and inhibits its excitatory response.
Leukocytosis In Parkinson disease, there is an unexplained
Gingival atrophy degeneration of dopaminergic neurons, and an
Hypoglycemia imbalance between dopamine and acetylcholine
*Severe side effects of hydantoins include occurs.
thrombocytopenia, leukopenia, gingival With less dopamine production, acetylcholine is
hyperplasia, and hyperglycemia. unopposed, causing excitation and stimulation of
neurons that release gamma-aminobutyric acid
5. A patient is experiencing status epilepticus. The (GABA).
nurse anticipates immediate administration of which With increased stimulation of GABA, symptomatic
drug? movement disorders occur.
Phenobarbital
Phenytoin Characteristics
Valproic acid > Involuntary tremors of limbs
Diazepam > Rigidity of muscles
*Diazepam (Valium) is the drug of choice for status > Bradykinesia (slow movement)
epilepticus administered IV or lorazepam (Ativan), > Postural changes
followed by IV administration of phenytoin > Head and chest thrown forward
> Shuffling walk
(Dilantin). For continued seizures, midazolam
> Lack of facial expression
(Versed) or propofol (Diprivan) is used followed by > Pill-rolling motion of hands
high-dose barbiturates.
Parkinson's Disease Treatment
Treatment regimen
> Anticholinergics
Block cholinergic receptors
> Dopamine replacements
Stimulate dopamine receptors
> Dopamine agonists
Stimulate dopamine receptors
> MAO-B inhibitors
Inhibit MAO-B enzyme that interferes with
dopamine
> COMT inhibitors
Inhibit COMT enzyme that inactivates dopamine
Antiparkinson Drugs
Anticholinergics
Action
Inhibit release of acetylcholine
Reduces rigidity and some of the tremors
Minimal effect on bradykinesia
Side effects
Dizziness, drowsiness, anxiety, headache
Insomnia, paresthesia, restlessness
Blurred vision, ocular hypertension
Weakness, dry mouth, GI distress
Anhidrosis, urinary retention

Nursing Process: Antiparkinson:

Anticholinergic Agent
Assessment A, When levodopa is used alone, only 1% reaches
-Obtain a health history especially glaucoma, GI the brain because 99% converts to dopamine while
dysfunction, urinary retention, angina, or in the peripheral nervous system. B, By combining
myasthenia gravis. carbidopa with levodopa, carbidopa can inhibit the
-Obtain a drug history. enzyme decarboxylase in the periphery, thereby
Nursing diagnosis allowing more levodopa to reach the brain.
-Mobility, impaired physical related to muscle
rigidity, tremors, and bradykinesia. Dopamine Agonists
Planning Amantadine
-Patient will have decreased involuntary symptoms Also antiviral drug for influenza A
caused by Parkinson disease. Action
Nursing interventions Stimulates dopamine receptors
> Counsel patients who take an anticholinergic to Taken alone or in combination with levodopa or
have routine eye exams because anticholinergics anticholinergic
are contraindicated in patients with glaucoma. Side effects
> Encourage patients to relieve a dry mouth with Dizziness, drowsiness, headache, confusion
hard candy, ice chips, or sugarless gum. Nightmares, insomnia, anxiety, irritability
> Monitor urine output for early detection of urinary Nausea, orthostatic hypotension
retention. Peripheral edema
> Increase fluid intake, fiber, and exercise to avoid
constipation. Monoamine Oxidase B Inhibitors
Evaluation Selegiline
Action
Antiparkinson Drugs Inhibit MAO-B enzyme that interferes with
Dopaminergics dopamine
Carbidopa–levodopa Side effects
Action Dizziness, headache, nausea, dry mouth
Converts to dopamine and increases mobility Orthostatic hypotension, hypertension
Side effects Impulse control disorder, suicidal ideation
Fatigue, insomnia, dry mouth, blurred vision Interaction
Orthostatic hypotension, palpitations, dysrhythmias Foods high in tyramine can cause hypertensive
GI distress, urinary retention crisis
Dyskinesia, psychosis, severe depression
Function Catechol-O-Methyltransferase Inhibitors
Advantages Tolcapone
Action
Inhibit COMT enzyme that inactivates dopamine
Side effects
Dizziness, drowsiness, headache
GI distress, excess dreams
Insomnia, sudden sleep onset
Orthostatic hypotension
Impulse control disorder Stevens-Johnson syndrome
Hepatic dysfunction
Nursing Process: Rivastigmine
Alzheimer Disease Assessment
> Incurable dementia illness > Assess patient’s mental and physical abilities.
> Chronic, progressive neurodegenerative disorder > Obtain a history especially hepatic or renal
> Marked cognitive dysfunction dysfunction.
> Onset usually between ages 45 and 65 > Assess for memory and judgment losses.
Pathophysiology Nursing diagnosis
> Cholinergic neuron degeneration and > Self-care deficit, toileting related to memory loss
acetylcholine deficiency > Confusion, chronic related to memory loss
> Neuritic plaques form Planning
> Neurofibrillary tangles are in neurons > Patient’s memory will be improved.
> Histologic changes > Patient will maintain self-care with assistance.
Nursing interventions
> Maintain consistency in care.
> Record vital signs.
> Observe any patient behavioral changes and
note any improvement or decline.
> Teach family members about safety measures to
avoid injury when the patient wanders.
> Inform family members of available support
groups.
Evaluation

*Safety when wandering: remove obstacles from

patient’s path so that patient can avoid injury.
Histologic changes in Alzheimer’s disease. A,
1. A patient has been diagnosed with Alzheimer
Healthy neuron. B, Neuron affected by Alzheimer’s
disease. The patient’s daughter asks the nurse
disease showing characteristic neuritic plaques and
what the cause of Alzheimer disease is. The best
cellular neurofibrillary tangles.
response by the nurse is “The cause of Alzheimer
disease is
Symptoms
A. a virus.”
> Memory loss, confusion
B. a cancer.”
> Inability to communicate
C. unknown.”
> Aggressive behavior, depression, psychoses
D. normal aging.”
> Progression leads to
2. The nurse should teach the patient’s family to
 Loss of memory, logical thinking, and
judgment administer the rivastigmine
 Time disorientation A. without food.
 Personality changes B. with meals.
 Hyperactivity; tendency to wander C. at 3:00 am and 3:00 pm.
D. when the patient is acting most confused.
 Inability to express oneself
*Food decreases absorption rate of Exelon, so it is
 Later hostility, paranoia best administered without food.
3. Which comment to the nurse indicates more
Acetylcholinesterase/Cholinesterase Inhibitors
Rivastigmine teaching is needed for a patient taking
Action carbidopa/levodopa?
Allow more acetylcholine in neuron receptors A. “I know I need to take this drug once a
Increase cognitive function, slows disease process day.”
Side effects B. “I know I shouldn’t stop taking this drug
Dizziness, headache, confusion, depression abruptly.”
Dry mouth, GI distress, dehydration, weight loss C. “I understand my urine may become dark
Bradycardia, orthostatic hypotension, dysrhythmia and discolored.”
Hepatotoxicity, suicidal ideation
 D. “I know it may take a few weeks or months 7. A nurse at an adult day care center notes that
to control my symptoms.” many patients are on rivastigmine. The nurse
*A statement from the patient such as “I know I knows that the function of this medication is to
need to take this drug once a day” indicates that A. increase physical mobility.
more teaching is needed because B. cure Alzheimer disease.
carbidopa/levodopa has a short half-life and must C. slow the progression of symptoms of
be taken three or four times per day. The other Alzheimer disease.
answers are true. D. restore full memory to the patients.
*Rivastigmine tends to slow the disease process.
4. Which side effect/adverse effect of
There is no known cure for Alzheimer disease.
carbidopa/levodopa does the nurse realize is most
important to monitor?
A. Dysphagia
B. Increased libido
C. Agranulocytosis
D. Urinary retention
*It is most important for the nurse to monitor the
patient taking carbidopa/levodopa for
agranulocytosis (decreased white blood cells),
which is life-threatening. Dysphagia, increased
libido, and urinary retention are not life-threatening.
5. Before administering carbidopa–levodopa for the
treatment of Parkinson’s disease, it is most
important for the nurse to assess the patient for a
history of
A. pulmonary disease.
B. diabetes mellitus.
C. allergy to penicillin.
D. glaucoma.
*Contraindications to therapy include narrow-angle
glaucoma; severe cardiac, renal, hepatic disease;
and suspicious skin lesions (activates malignant
melanoma).
6. A patient with Parkinson’s disease is being
treated with carbidopa–levodopa. The daughter
asks the nurse why he needs both agents. The
nurse responds,
A. “The two medicines together are doubly
effective.”
B. “This combination has fewer side effects.”
C. “You’ll tolerate this better than a single-
agent medication.”
D. “The carbidopa helps the levodopa reach
the brain.”
*Because of the side effects of levodopa and the
fact that so much levodopa is metabolized before
reaching the brain, an alternative drug, carbidopa,
was developed to inhibit the enzyme dopa
decarboxylase. By inhibiting the enzyme in the
peripheral nervous system, levodopa reaches the
brain. The carbidopa is combined with levodopa in
a ratio of 1 part carbidopa to 10 parts levodopa.
CH21 Drugs for Neuromuscular Disorders and Symptoms
Muscle Spasms > Severe muscle weakness
> Possible respiratory paralysis and arrest
Myasthenia Gravis > Abnormal pupil constriction
Pathophysiology > Pallor, sweating, vertigo
> Autoimmune disorder > Excess salivation, GI distress
> Antibodies attach to acetylcholine receptor sites, > Bradycardia, fasciculations
obstruct binding of acetylcholine, and destroy Worsens after edrophonium
receptor sites *Cholinergic crisis is caused by continuous
> Lack of acetylcholine impairs transmission of depolarization of postsynaptic membranes that
messages at neuromuscular junctions create neuromuscular blockade.
 Leads to ineffective muscle contraction and Fasciculations: involuntary muscle twitching
muscle weakness
 Leads to weakness of respiratory, facial, Acetylcholinesterase Inhibitors
and extremity muscles Overdosing and underdosing
> Similar symptoms
*Myasthenia gravis is an autoimmune disease > Muscle weakness, dyspnea, bradycardia
> Drooling, dysphagia, abdominal cramping
resulting from a loss of acetylcholine (ACh). > Tearing, sweating
Antibodies attach to ACh receptor (AChR) sites, Myasthenia crisis
obstructing the binding of acetylcholine and Caused by underdosing
eventually destroying receptor sites. When AChR Cholinergic crisis
sites are reduced, Ach molecules are prevented Caused by overdosing
from binding to receptors and stimulating normal
neuromuscular transmission. This results in *After administering edrophonium in a crisis:
ineffective muscle contraction and muscle • If signs and symptoms are alleviated, the
cause is myasthenic crisis
weakness.
• If signs and symptoms become worsened,
the cause is cholinergic crisis
Characteristics Cholinesterase inhibitors inhibit the action of the
> Skeletal muscle weakness enzyme, resulting in more acetylcholine being
> Fatigue, ptosis available to activate the cholinergic receptors and
> Dysphagia, dysarthria promote muscle contraction.
> Respiratory muscle weakness, paralysis, and
arrest Acetylcholinesterase inhibitors
Myasthenic crisis > Edrophonium—ultrashort-acting for diagnosing
> Severe generalized muscle weakness • Differentiates between
 Involves diaphragm and intercostal muscles myasthenic and cholinergic
> Triggers crisis
 Inadequate dosing > Neostigmine—short-acting
 Emotional stress, menses, pregnancy > Pyridostigmine—intermediate-acting
 Infection, surgery, trauma > Ambenonium—long-acting
 Hypokalemia, alcohol intake Action
 Temperature extremes Increases muscle strength in patients with
 Medication interactions myasthenia gravis
> Treat with neostigmine
If untreated, it may cause death from paralysis of Acetylcholinesterase inhibitor: neostigmine
respiratory muscles.
Myasthenic crisis may occur 3 to 4 hours after Side effects
taking certain medications: aminoglycoside > Increased salivation and tearing
antibiotics, calcium channel blockers, phenytoin, > Miosis, blurred vision
psychotropics. > Bradycardia, hypotension
Cholinergic crisis > GI distress
> Usually occurs within 30 to 60 minutes after  Nausea, vomiting, diarrhea, abdominal
taking anticholinergic medications cramps
> Triggered by overdosing
Patients Unresponsive to Acetylcholinesterase Diagnosis
Inhibitors  No specific diagnostic test
> Prednisone  Indicators of diagnosis
 Drug of choice  Medical history
> Plasma exchange  Neurologic exam
> Intravenous immune globulin  Multiple lesions observable through MRI
> Immunosuppressive drugs  Visual evoked potential
 Azathioprine  Elevated immunoglobulin G in the
o Need to monitor for leukopenia and cerebrospinal fluid
hepatoxicity Classifications
 Relapsing remitting
Nursing Process: Acetylcholinesterase  Relapse with full recovery and residual
Inhibitors deficit
Assessment  Primary progressive
> Assess for signs and symptoms of myasthenic  Slowly worsening neurologic function
crisis, such as muscle weakness with difficulty with relapses or remissions
breathing and swallowing.  Secondary progressive
Nursing diagnosis  Initial course is relapsing remitting, then
> Breathing pattern, ineffective related to weak progression with or without occasional
respiratory muscles relapses, minor remissions, and
Planning plateaus
> The patient’s symptoms of muscle weakness will  Progressive relapsing
be eliminated or reduced in 2 to 3 days.  Progressive from onset with acute
Nursing interventions relapses with or without full recovery
> Administer doses on time.
> Take drug before meals if possible. Multiple Sclerosis Drug Treat
> Monitor drug effectiveness.  Immunomodulators
> Have antidote available for cholinergic crisis. o First-line treatment
 Atropine o Slows disease progression and prevents
> Encourage patient to wear medical identification. relapses
Evaluation  Immunosuppressants
 Sphingosine 1-phosphate receptor modulator
*Cholinesterase inhibitors ([AChE] inhibitors) are
 Monoclonal antibody
absorbed best if taken before meals.
Refer to Prototype Drug Chart 21-1:  Corticosteroids
Pyridostigmine. o Reduces edema and acute inflammation
Refer to Nursing Process: Drug Treatment for
Myasthenia Gravis: Pyridostigmine (Mestinon).

Multiple Sclerosis
Pathophysiology 1. A patient with myasthenia gravis comes to the
 Autoimmune disorder emergency department in respiratory distress.
He has been diagnosed with myasthenic crisis.
 Attacks myelin sheath of nerve fibers in brain
The nurse anticipates administration of which
and spinal cord
drug?
 Causes lesions (plaques)
A. Diazepam
Characteristics
B. Baclofen
 Remissions and exacerbations C. Edrophonium
 Weakness or paralysis of extremities, fatigue D. Neostigmine
 Muscle spasticity, paresthesia *Neostigmine is a short-acting acetylcholinesterase
 Dysarthria, dysphagia, ataxia inhibitor which can relieve myasthenic crisis.
 Diplopia, blurred vision, vertigo, tinnitus
Edrophonium (Tensilon) is most commonly used to
Usually Caucasian females of 20–40 years of age differentiate between myasthenic crisis and
May affect bladder, bowel, sexual, and cognitive cholinergic crisis; diazepam is an anxiolytic, and
dysfunction baclofen is a muscle relaxant.
No known cure
2. The patient is admitted to the emergency A. induce sleep and rest.
department with cholinergic crisis. The nurse B. increase appetite.
anticipates administration of C. reduce muscle spasticity.
D. increase bowel function.
A. atropine.
*Muscle relaxants are used to decrease a patient’s
B. baclofen.
C. edrophonium. muscular pain and spasticity.
D. neostigmine.
*Atropine sulfate is an antidote for cholinergic crisis.

3. A patient with myasthenia gravis comes to the

emergency department in respiratory distress.
To determine if the patient is in myasthenic
crisis or cholinergic crisis, the nurse anticipates
administration of which drug?
A. Diazepam
B. Baclofen
C. Edrophonium
D. Neostigmine
*Edrophonium is ultrashort-acting and most
commonly used to differentiate between
myasthenic crisis and cholinergic crisis.
Neostigmine is a short-acting acetylcholinesterase
inhibitor; diazepam is an anxiolytic, and baclofen is
a muscle relaxant.

4. A patient with myasthenia gravis is prescribed

neostigmine. The nurse identifies that the
medication is effective when the patient
experiences
A. increased muscle strength.
B. decrease in sweating and salivation.
C. change in vital signs to within normal limits.
D. a decrease in generalized pain.
*Improved muscle strength indicates that
neostigmine bromide (Prostigmin) therapy is
exerting a therapeutic effect.

5. A patient with multiple sclerosis is being treated

with large doses of corticosteroids. Which
nursing diagnosis would be the priority at this
time?
A. Alteration in nutrition: less than body
requirements
B. Risk for infection
C. Ineffective individual coping
D. Fatigue
*Suppression of the immune system and risk for
infection are two of the many side effects
associated with high-dose corticosteroid therapy.

6. A child with cerebral palsy is ordered to receive

baclofen. The nurse is aware that this
medication is prescribed to
CH22  Advise patient not to drive a motor vehicle or
Anxiety operate dangerous equipment when taking
Types anxiolytics because sedation is a common side
 Primary effect.
o It is not caused by a medical condition or  Warn patient not to consume alcohol or CNS
drug use. depressant while taking an anxiolytic.
o It is managed with short-term anxiolytics. Evaluation
 Secondary
o It is related to selected drug use, medical, or
psychiatric conditions.
o Medications are not usually given for 1. The nurse realizes more medication teaching is
secondary anxiety. necessary when the 30-year-old patient taking
lorazepam states
Lorazepam A. “I must stop drinking coffee and colas.”
Action B. “I can stop this drug after 3 weeks if I
 Inhibits GABA neurotransmission by binding to feel better.”
specific benzodiazepine receptors C. “I must stop drinking alcoholic beverages.”
Use D. “I should not become pregnant while taking
 Anxiolytic, antiseizure, sedative-hypnotic, this drug.”
*Lorazepam should not be discontinued abruptly,
preoperative drug, substance abuse withdrawal
Side effects but gradually, over a period of several days.
 Drowsiness, dizziness, ataxia, restlessness, Caffeine and alcohol should be avoided when
weakness taking lorazepam, a benzodiazepine. This drug
 Headache, confusion, amnesia, blurred vision should not be taken during pregnancy because of
 GI distress, sleep disturbance, hallucinations possible teratogenic effects.
 Bradycardia, hypotension/hypertension
 Seizures, suicidal ideation, NMS, respiratory 2. A young woman is being treated for psychosis
depression with fluphenazine. Which sign would indicate
Discontinuation the need to add an anticholinergic to the
 Gradually decrease dose over several days patient’s medication regimen?
Withdrawal symptoms A. A decrease in pulse and respiratory rate
 Develops slowly, in 2 to 10 days, and may last B. Facial grimacing and tongue spasms
several weeks C. An increase in hallucinations
 Withdrawal symptoms D. A decrease in the patient’s level of
o Tremor, agitation, nervousness orientation
o Sweating, insomnia *Pseudoparkinsonism, which resembles symptoms
o Anorexia, muscle cramps of Parkinson’s disease, is a major side effect of
typical antipsychotic drugs such as fluphenazine
Nursing Process: Benzodiazepines (Prolixin). Anticholinergic medications may be used
Assessment to control this side effect.
 Assess for suicidal ideation.
 Obtain a history of patient’s anxiety reaction. 3. A patient on risperidone may be at increased
 Determine patient’s support system. risk for injury due to
Nursing diagnosis A. increased potential for aspiration due to
 Anxiety related to situational crisis sedation.
 Noncompliance related to adverse effects of B. increased risk for falls due to orthostatic
medications. hypotension.
Planning C. increased risk for infection due to
 Patient’s anxiety and stress will be reduced. neutropenia.
Nursing interventions D. increased risk for suicide due to changes in
 Observe patient for side effects of anxiolytics. thought processes.
 Monitor vital signs. *Orthostatic hypotension is the most common
 Encourage family to be supportive of patient. adverse reaction seen in patients treated with
risperidone (Risperdal).
 D. Lorazepam
4. Assessment findings for a patient with *Treatment of NMS involves immediate withdrawal
neuroleptic malignant syndrome (NMS) include of antipsychotics, adequate hydration, hypothermic
A. bradycardia. blankets, and administration of antipyretics,
B. hypothermia. benzodiazepines, and muscle relaxants such as
C. muscle weakness. dantrolene (Dantrium). Tetrabenazine (Xenazine),
D. rhabdomyolysis. used to improve symptoms of Huntington’s disease,
*NMS symptoms include muscle rigidity, sudden seems to be effective in treating tardive dyskinesia.
high fever, altered mental status, blood pressure Propanolol (Inderal) has been found to be effective
fluctuations, tachycardia, dysrhythmias, seizures, in the treatment of akathisia. Acute dystonia may
rhabdomyolysis, acute renal failure, respiratory be treated with lorazepam (Ativan).
failure, and coma.

5. Which statement by a patient indicates that 1. A patient with major depression has been
more teaching on phenothiazine therapy for the prescribed fluoxetine. What nursing diagnosis
treatment of psychosis is needed? would be most appropriate?
A. “It might take 6 weeks or more for the drug A. Social Isolation
to take effect.” B. Mobility, Impaired Physical
B. “I will get up slowly from a seated position.” C. Urinary Elimination, Impaired
C. “When I start to feel better, I will cut the D. Sensory Perception, Disturbed
dose of my medication in half.”
D. “I will avoid exposure to direct sunlight.” 2. A patient with reactive depression is ordered to
*The drug should be taken exactly as ordered. receive fluoxetine. Which information will the
Antipsychotics do not cure the mental illness but do nurse include when teaching this patient?
alleviate symptoms. Compliance with drug regimen A. The medication takes effect in 1 to 2 days.
is extremely important. B. The medication increases libido.
C. The medication should be taken with
6. A nurse caring for a patient in an outpatient grapefruit juice.
setting notes that the patient is currently taking D. The medication may cause headaches and
lorazepam for anxiety and her breath smells of insomnia.
alcohol. The nurse reports this to the health *Side effects include headache, nervousness,
care provider because restlessness, insomnia, blurred vision, tremors, GI
A. taking alcohol with Ativan can be fatal. distress, and sexual dysfunction. The drug takes
B. taking alcohol with Ativan may increase about 2 to 4 weeks for onset, decreases libido, and
sedative effects. has no interaction with grapefruit juice.
C. all patients using alcohol should be referred
for assistance. 3. Before administering an monoamine oxidase
D. Ativan and alcohol antagonize one another. inhibitor, it is most important for the nurse to
*Alcohol and other CNS depressants should not be assess the patient’s
taken with benzodiazepines because respiratory A. sexual history.
depression could result. B. socioeconomic status.
C. dietary intake.
7. A patient has been diagnosed with neuroleptic D. hydration status.
malignant syndrome. The nurse anticipates *Certain drug and food interactions with MAO
administration of which medication to treat this inhibitors can be fatal. Foods that contain tyramine
patient? have sympathomimetic-like effects and can cause a
A. Dantrolene hypertensive crisis. These types of food must be
B. Tetrabenazine avoided by MAOI users.
C. Propranolol
4. Which laboratory test is most important for the *When discontinuing TCAs such as amitriptyline
nurse to monitor when a patient is receiving (Elavil), the drug should be gradually decreased to
lithium? avoid withdrawal symptoms such as nausea,
A. Urinalysis vomiting, anxiety, and akathisia. TCAs are given at
B. Serum glucose night to minimize problems caused by their
C. Serum electrolytes sedative action. The onset of the antidepressant
D. Complete blood count effect of amitriptyline is 1 to 4 weeks. Orthostatic
*Serum sodium levels need to be monitored in hypotension is a common side effect of amitriptyline
patients taking lithium. Lithium tends to deplete (Elavil).
sodium. Lithium must be used with caution, if at all,
by patients taking diuretics.

5. When providing dietary teaching for a patient

taking monoamine oxidase inhibitors, the nurse
should teach the patient to avoid which food?
A. Yogurt
B. Avocado
C. Grapefruit
D. Potato chips
*When taking monoamine oxidase inhibitors
(MAOIs), patients should avoid cheese, red wine,
beer, liver, bananas, yogurt, and sausage.

6. Which advice will the nurse include when

teaching the patient about lithium therapy?
A. Take the drug on an empty stomach.
B. Eliminate all sodium from your diet.
C. Stop taking the lithium when you feel better.
D. It may take 1 to 2 weeks before you have
any benefits from taking the medication.
*The effectiveness of lithium may not be evident
until 1 to 2 weeks after the start of therapy. The
patient should be taught to maintain adequate
sodium intake and to avoid crash diets that affect
physical and mental health. Lithium levels are
maintained by taking the drug on a daily basis. The
patient should be taught to take lithium with meals
to decrease gastric irritation.

7. Which statement about amitriptyline does the

nurse identify as being true?
A. The drug is administered first thing in the
morning.
B. The drug should be discontinued slowly.
C. The onset of antidepressant effect is 48
hours.
D. Hypertension is a frequent side effect of this
drug.
CH24 ANTIINFLAMMATORIES o Salicylates
Inflammation o Parachlorobenzoic acid derivatives
Pathophysiology o Phenylacetic acids
 Protective response to tissue injury and o Propionic acid derivatives
infection o Fenamates
 A vascular reaction occurs causing fluid, blood o Oxicams
elements, leukocytes, and chemical mediators
 Second-generation NSAIDs
(prostaglandins) to accumulate at the injured
o Selective COX-2 inhibitors
site
Inflammatory phases
Salicylates
1. Vascular phase
Aspirin (acetylsalicylic acid) (ASA)
o Occurs 10 to 15 minutes after injury
Action
o Associated with vasodilation and increased
 Antiinflammatory, antiplatelet, antipyretic
capillary permeability
effects
o Fluid and blood substances move to injured
Therapeutic serum salicylate level
site
 15 to 30 mg/dL
2. Delayed phase
Toxic serum salicylate level
o Leukocytes infiltrate inflamed tissue
 Mild toxicity—Greater than 30 mg/dL
Cyclooxygenase (COX) enzyme
 Severe toxicity—Greater than 50 mg/dL
o Converts arachidonic acid into
Drug-lab-food interactions
prostaglandins
 Drugs
o Has two enzyme forms:
 Increased bleeding with
 COX-1: protects stomach lining and
anticoagulants and other NSAIDs
regulates blood platelets
 Risk for hypoglycemia with oral
 COX-2: triggers inflammation and
antidiabetics
pain
 Increased gastric ulcer risk with
Cardinal signs of inflammation
glucocorticoids
o Redness
 Decreased effects of ACE inhibitors,
o Swelling loop diuretics, probenecid
o Heat  Salicylate effects are decreased by
o Pain corticosteroids
o Loss of function  Lab
Antiinflammatory drug groups  Increase PT, bleeding time, INR, uric
o Nonsteroidal antiinflammatory drugs acid
(NSAIDs)  Decrease cholesterol, T3 and T4
o Corticosteroids levels
o Disease-modifying antirheumatic drugs  Foods containing salicylates
o Antigout drugs  Prunes, raisins, licorice
Action of NSAIDs  Certain spices such as curry and
o Inhibit biosynthesis of prostaglandins paprika
o Analgesic effect Aspirin
o Antipyretic effect Caution
o Inhibit platelet aggregation  Do not take with other NSAIDs
o Mimic effects of corticosteroids  Avoid during the last trimester of pregnancy
o Inhibit COX enzyme  Do not give to children with flu or virus
symptoms as it may lead to Reye syndrome
Side effects/adverse reactions
NSAIDs
 Dizziness, drowsiness, headache
 First-generation NSAIDs
  Tinnitus, hearing loss Ketorolac
 GI distress, bleeding, ulceration  Is recommended for short-term management of
 Thrombocytopenia, leukopenia, pain
agranulocytosis, hemolytic anemia
 Hepatotoxicity, Reye syndrome Propionic Acid Derivatives
 Hypersensitivity: Tinnitus, dizziness, Ibuprofen
bronchospasm  Most widely used NSAID
Action
Nursing Process  Inhibits prostaglandin synthesis
Assessment Use
 Determine patient’s medical history  Pain, osteoarthritis, rheumatoid arthritis
 Obtain a drug history Side effects
Nursing diagnosis  Drowsiness, dizziness, headache, confusion
 Injury, Risk for  Insomnia, dreams, blurred vision, edema
 Pain, Chronic related to tissue swelling from  Gastric distress and bleeding
injury  Tinnitus, dysrhythmias, nephrotoxicity
Planning Drug interactions
 The patient’s inflammation will be reduced  Increased bleeding with warfarin
within 1 week.  Increased effects with phenytoin, sulfonamides,
Nursing interventions warfarin, cephalosporins
 Monitor serum salicylate level.  Decreased effect with aspirin
 Observe the patient for evidence of bleeding.
 Advise patient not to take aspirin with alcohol or Nursing Process: Ibuprofen
warfarin to prevent increased bleeding. Assessment
 Instruct patient to discontinue aspirin  Obtain a drug and herbal history, and report
approximately 7 days before surgery to reduce any possible drug-drug or herb-drug
risk of bleeding. interactions.
 Warn parents not to give aspirin for virus or flu  Assess for GI distress and peripheral edema,
symptoms to children to avoid risk of Reye which are common side effects of NSAIDs.
syndrome. Nursing diagnoses
 Educate parents to call the poison control  Injury, Risk for
center immediately if a child has taken a large Planning
or unknown amount of aspirin.  The patient’s inflammatory process will subside
 Inform patient that aspirin tablets can cause GI in 1 to 3 weeks.
distress. Nursing interventions
Evaluation  Observe the patient for bleeding gums,
petechiae, ecchymoses, or black tarry stools.
Phenylacetic Acid Derivatives  Report if patient has GI discomfort.
Action  Advise patient to avoid alcohol when taking
 Inhibits prostaglandin synthesis NSAIDs.
Use  Alert patient that many complementary and
 Rheumatoid arthritis, osteoarthritis, ankylosing alternative therapies may interact with NSAIDs
spondylitis, and pain and could cause bleeding.
 No antipyretic effect Evaluation
Side effects/adverse effects
 Dizziness, drowsiness, headache Fenamates
 GI distress, GI bleeding/perforation Action
 Weakness, stroke  Inhibits prostaglandin synthesis
Use  Not the drug of choice for arthritis because of
 Osteoarthritis, rheumatoid arthritis their numerous side effects
 Pain, dysmenorrhea Discontinuation
 Taper off over 5-10 days
Side effects/adverse effects
 Dizziness, headache, tinnitus, pruritus, edema
 GI distress/bleeding, renal dysfunction Disease-Modifying Antirheumatic Drugs
 Elevated hepatic enzymes, stroke Types
Caution  Immunosuppressive agents
 Avoid if a history of peptic ulcer  Immunomodulators
 Antimalarials
Use
Oxicams
 Alleviate symptoms of rheumatoid arthritis when
Action other treatments fail
 Inhibits prostaglandin synthesis  Osteoarthritis, ankylosing spondylitis
Use  Psoriatic arthritis, severe psoriasis
 Osteoarthritis, rheumatoid arthritis  Crohn disease, ulcerative colitis
Side effects/adverse effects Side effects/adverse effects
 Dizziness, headache, insomnia, edema  Headache, fever, chills, insomnia, fatigue
 Oral ulcerations, nasopharyngitis, infection
 GI distress/bleeding, renal dysfunction
 GI distress, elevated hepatic enzymes
 Angioedema, elevated hepatic enzymes, stroke  Peripheral edema, hypotension/hypertension
 Well-tolerated  Weakness, hypercholesterolemia
 Aplastic anemia, leukopenia, neutropenia,
Selective COX-2 inhibitors thrombocytopenia
Action  Injection site reaction
 Selectively inhibits COX-2 enzyme without
inhibition of COX-1
Immunosuppressive Agents
Use Action
 Osteoarthritis, rheumatoid arthritis, ankylosing  Suppress inflammatory process
spondylitis, pain, dysmenorrhea Use
Similar agents  Refractory rheumatoid arthritis unresponsive to
 Nabumetone anti-inflammatory drugs
Side effects
 Dizziness, headache, sinusitis
Immunomodulators
 GI distress/ulceration, hypertension Classifications
 Peripheral edema, renal dysfunction  Interleukin 1 (IL-1) receptor antagonists
NSAIDs in older adults  Tumor necrosis factor (TNF)
 Drug interactions more common due to number Action
of drugs taken  Disrupt inflammatory process
 Delay disease progression
 Greater incidence of GI distress, ulceration
 Neutralize TNF
 Reduced dose decreases risk of side effects Use
 Increase fluid intake for adequate hydration  Rheumatoid arthritis, psoriatic arthritis,
psoriasis, spondylitis, ulcerative colitis, Crohn
Corticosteroids disease
Action
 Control inflammation by suppressing or Antimalarials
preventing many of the components of the Action
inflammatory process at the injured site  Unclear
Use  Effect may take 4 to 12 weeks to become
 Arthritic flare-ups apparent
Use
 Rheumatoid arthritis when other methods of Evaluation
treatment fail
Gout Uricosurics
Gout pathophysiology Action
 Inflammatory disease of joints, tendons, and  Blocks reabsorption of uric acid which promotes
other tissues its excretion
 Usually occurs in great toe Side effects
 Defect in purine metabolism leads to uric acid  Flushed skin, headache, sore gums
accumulation  GI distress, kidney stones
o Purine-containing foods: organ meats,  Severe blood dyscrasias (rare)
sardines, salmon, gravy, herring, liver, meat
soups, and alcohol (especially beer)
1. A 35-year-old woman diagnosed with rheumatoid
Antigout Drugs arthritis has been prescribed infliximab. The nurse
Colchicine identifies infliximab as which type of medication?
Action A. Immunosuppressive
 Inhibits migration of leukocytes to inflamed site B. Immunomodulator
 Alleviates gout symptoms C. Antimalarial
Side effects D. Steroid
 GI distress 2. The nurse identifies Infliximab as useful in the
 Taken with food to avoid GI distress treatment of rheumatoid arthritis as well as
Contraindications A. Crohn disease.
 Severe renal, cardiac, or GI problems B. asthma.
C. peptic ulcer disease.
D. multiple sclerosis.
Uric acid inhibitors 3. The patient asks the nurse how the infliximab
Action will be administered. The nurse should respond
that this medication is administered
 Decreases uric acid synthesis
A. orally.
 Prevents gout attacks
B. subcutaneously.
Side effects
C. intramuscularly.
 Dizziness, headache, dry mouth, GI distress D. intravenously.
 Arthralgia, pruritus, erectile dysfunction * Infliximab (Remicade) is administered
 Bradycardia, hyperglycemia intravenously (IV) over at least 2 hours;
 Blood dyscrasias, Steven-Johnson syndrome
adalimumab is administered subcutaneously, and
leflunomide is administered orally.
Nursing Process: Allopurinol 4. A patient has been advised to take ibuprofen.
Assessment When teaching the patient about ibuprofen, which
 Assess serum uric acid value for future instruction should the nurse include? (Select all
comparisons that apply.)
Nursing diagnoses A. Avoid taking aspirin with ibuprofen.
 Tissue integrity, Impaired related to B. Take with food to reduce GI upset.
inflammation of the great toe C. Monitor for bleeding gums, nosebleeds,
 Pain, Acute related to tissue swelling black tarry stools.
D. Take herbs, ginkgo and garlic, with
Planning
ibuprofen.
 Patient’s pain will be controlled without side
E. Take NSAIDs 2 days before menstruation to
effects.
decrease discomfort.
Nursing interventions
* One should avoid aspirin with NSAIDs. Food may
 Record urine output.
be taken with NSAIDs to reduce GI upset. Patients
 Monitor lab tests for renal and hepatic function.
 Instruct patient to increase fluid intake to should be taught to monitor for bruising and
increase drug and uric acid excretion. bleeding. Many herbs, such as ginkgo, garlic, and
 Advise patient to have a yearly eye exam as ginger, should be avoided because bleeding may
visual changes can result from prolonged use of increase. Female patients should avoid NSAIDs for
allopurinol.
1 to 2 days before menses to prevent excessive
bleeding.
5. An older adult patient takes tolmetin for arthritis CH25 ANALGESICS
pain. Which statement made by the patient is of Pain Terminology
most concern to the nurse? 1. Fifth vital sign
A. “I feel like I am coming down with a cold.” 2. Pain threshold
B. “My stomach aches and burns.” 3. Pain tolerance
C. “I have a bad headache.” 4. Analgesics
D. “I feel dizzy when I get up fast.”  Opioid
* Older adults frequently use NSAIDs to treat pain  Nonopioid
associated with inflammation caused by 5. Nociceptors
osteoarthritis, rheumatoid arthritis, and 6. Neuropathic pain
neuromuscular-skeletal disorders. With use of * Pain threshold: reflects level of stimulus needed
NSAIDs, gastrointestinal distress (including to create a painful sensation
ulceration) is four times more common in older Pain tolerance: the amount of pain one can endure
adults; hospitalization is often necessary. without having it interfere with normal functioning
6. A 65-year-old man has been diagnosed with
Pain Pathophysiology
chronic gout. The nurse anticipates that the patient
 Gate control theory
will be treated with
 Types of pain
A. allopurinol. o Acute
B. colchicine. o Chronic
C. adalimumab. o Cancer
D. infliximab. o Somatic
* Allopurinol (Zyloprim) inhibits the final steps of o Superficial
uric acid biosynthesis and therefore lowers serum o Vascular
uric acid levels, preventing the precipitation of an o Visceral
attack. This drug is frequently used in the treatment
of chronic gout as a prophylactic to prevent Undertreatment of Pain
reoccurrences. Colchicine is effective in alleviating  Up to 75% of patients have unrelieved pain.
acute symptoms of gout. Infliximab (Remicade) and  Reasons for under-treatment
 Effects of unrelieved pain
adalimumab (Humira) are immunomodulators used
to treat moderate to severe rheumatoid arthritis by Nonopioid Analgesics
disrupting the inflammatory process and delaying Less potent than opioid analgesics
the disease progression. Use
 Mild to moderate pain
Effective for dull, throbbing pain of:
 Headaches, dysmenorrhea, minor abrasions
 Inflammation, muscular aches, pain
 Mild to moderate arthritis
Action site
 Peripheral nervous system at pain receptor
sites

NSAIDs
 Aspirin
 Ibuprofen
 Naproxen
Action
 Analgesic
 Antipyretic
 Antiinflammatory effects  Muscular aches and pain, fever
Maximum dose
 4 g/day
Aspirin—Nonopioid Analgesic  If taken frequently 2 g/day
Action Side effects
 Inhibits biosynthesis of prostaglandins  Rash, headache, insomnia
 Inhibits COX-2 decreases inflammation and  Low incidence of GI distress
pain Toxic effects/excess dosing
 Inhibits COX-1 decreases protection of the  Hepatotoxicity, renal failure
stomach lining  Thrombocytopenia
Use  Hemolytic anemia
 Drug of choice for pain and arthritic  Agranulocytosis
inflammation  Leukopenia, neutropenia
 Analgesic, antipyretic, antiinflammatory
 Decreases platelet aggregation Nursing Process: Acetaminophen
Nursing interventions
 Check liver enzyme tests for abnormalities.
COX-1 and COX-2 Inhibitors  Teach patient to keep acetaminophen out of
children’s reach.
 Teach patient to avoid alcohol ingestion while
taking acetaminophen.
 Encourage patient to report side effects.
 Check serum acetaminophen level if toxicity is
suspected.

Opioid Analgesics
Use
 Moderate and severe pain
 Many opioids possess antidiarrheal effects.
Action site
 Act on CNS
 Suppress pain impulses
 Suppress respiration and coughing by acting on
respiratory and cough centers in the medulla
Contraindication
 Head injury
Morphine: side effects/adverse reactions
 Drowsiness, dizziness, euphoria
 Confusion, depression, miosis, blurred vision
 GI distress, flatulence, constipation
Aspirin
 Orthostatic hypotension, weakness
Side effects/adverse reactions
 Urinary retention
 Tinnitus, vertigo
 Psychological dependence
 GI distress
 Respiratory depression
 Excess bleeding
 Metabolic acidosis, hyperventilation Nursing interventions
 Anaphylaxis, bronchospasm, dyspnea, urticaria  Administer morphine before pain reaches its
 Reye syndrome peak to maximize drug effectiveness.
 Monitor vital signs frequently to detect
respiratory changes.
Acetaminophen—Nonopioid Analgesic
 Check for pupil changes and reaction.
Acetaminophen is not an NSAID
 Have naloxone available as an antidote to
Action
reverse respiratory depression if morphine
 Inhibits prostaglandin synthesis
overdose occurs.
Uses
  Used along with a nonopioid and opioid
Meperidine Adjuvant analgesics
Use  Anticonvulsants
 Primarily effective in GI procedures  Antidepressants
 Preferred to morphine during pregnancy  Corticosteroids
Caution with large doses in older adults and  Antidysrhythmics
patients with advanced cancer  Local anesthetics
 Neurotoxicity
 Nervousness, agitation, irritability, tremors, Opioid Agonist-Antagonists
seizures  Not given for cancer pain
Side effects  Safe for use during labor
 Less constipation and urinary retention than  Safety during early pregnancy has not been
morphine established
Hydromorphone Nursing Process: Nalbuphine hydrochloride
Use Nursing interventions
 Analgesic effect is approximately six times  Monitor vital signs.
more potent than morphine  Check bowel sounds and the date of last bowel
Side effects and adverse reactions movement to identify constipation.
 Drowsiness, dizziness, confusion  Determine urine output.
 Weakness, constipation  Warn patient not to use alcohol or CNS
 Miosis, tolerance, dependence depressants while taking nalbuphine.
 Respiratory depression, urinary retention  Advise patient to report side effects.
 Fewer hypnotic effects and less GI distress
than morphine Opioid Antagonists
Action
Patient-Controlled Analgesia (PCA)  Blocks receptor and displaces opioid
 Medications used Use
 Morphine most often used for PCA  Antidote for opiate overdoses
 Also fentanyl, hydromorphone  Reverse effects of opiates including respiratory
 Loading dose depression, sedation, hypotension
 Predetermined safety limits  Respiratory depression
 Lockout mechanism Side effects/adverse effects
 Near-constant analgesic level  Sweating, flushing, agitation, dyspnea
 Hypo/hypertension, tachycardia
Transdermal Opioid Analgesics  Nausea, vomiting
Transdermal route  Elevated PTT, bleeding
 Provide continuous pain control  Reversal of analgesia
 Helpful for chronic pain Nursing interventions
 Fentanyl more potent than morphine  Monitor vital signs and bleeding continuously.
 Available in various strengths
Migraine Headaches
Analgesics in Special Populations Characteristics
 Children  Unilateral throbbing pain
 Older adults  Nausea, vomiting, photophobia
 Cognitively impaired individuals Triggers
 Oncology patients  Cheese, chocolate, red wine, aspartame,
 Individuals with substance abuse history fatigue, stress, monosodium glutamate, missed
meals, odors, light, hormone changes, drugs,
Addiction: psychologic and physical dependence weather, too much or too little sleep
on a substance beyond normal voluntary control; Pathophysiology theory
usually occurs after prolonged use of a substance  Due to neurovascular events in cerebral cortex

Adjuvant therapy *Last for hours or days

Usually affects women in their 20s and 30s A. Hydromorphone must be administered
intravenously.
Cluster Headaches B. Hypertension is a common side effect.
Characteristics C. Physical dependence does not occur with
 Severe unilateral nonthrobbing pain hydromorphone therapy.
 Usually located around eye D. Hydromorphone is more potent than
 Occur in a series of cluster attacks morphine.
o One or more attacks every day for *Hydromorphone (Dilaudid) is a semisynthetic
several weeks opioid similar to morphine. The analgesic effect is
 Not associated with an aura approximately six times more potent than
 Do not cause nausea and vomiting morphine.
 More common in males 2. The nurse assesses a patient receiving morphine
via a PCA pump. The patient has a respiratory rate
Migraine and Cluster Headaches of 6 breaths/min. The nurse anticipates
Prevention administration of which of the following drugs?
 Beta-adrenergic blockers A. Naloxone
o Propranolol B. Sumatriptan
o Atenolol C. Nalbuphine
 Anticonvulsants D. Hydromorphone
o Valproic acid *Naloxone is a opiate antagonist and an antidote
o Gabapentin for opioid analgesic overdoses. Sumatriptan
 Tricyclic antidepressants (Imitrex) is used for the treatment of migraine
o Amitriptyline headaches; nalbuphine HCl (Nubain) and
o Imipramine hydromorphone are opiates.
3. The nurse identifies which of the following as a
Management common side effect/adverse effect of morphine
 Analgesics therapy?
 Aspirin with caffeine, acetaminophen A. Diarrhea
 NSAIDs: ibuprofen, naproxen B. Hypertension
 Opioid analgesics C. Urinary retention
 Meperidine, butorphanol nasal spray D. Tachypnea
 Ergot alkaloids *Urinary retention, constipation, hypotension, and
 Dihydroergotamine mesylate bradypnea are common side effects of morphine.
 Selective serotonin1 receptor agonists Diarrhea, hypertension, and tachypnea are not
 Sumatriptan, zolmitriptan common side effects.
4. A patient received morphine sulfate for severe
Sumatripan pain. The nurse assesses the patient 20 minutes
Action later. What is the best indication that the medication
 Causes vasoconstriction of cranial arteries has been effective?
Use A. Patient verbalizes pain relief.
 Treats migraine and cluster headaches B. Patient has an increase in heart rate.
Side effects C. Patient is resting.
 Dizziness, drowsiness, flushing, fatigue D. Patient has an increase in blood pressure.
 Dysgeusia, nausea, vomiting *The best source for evaluation of pain is the
 Paresthesia, seizures patient.
 Dysrhythmias, thromboembolism, heart attack,
stroke, suicidal ideation

1. The next day, the patient’s pain medication is

changed from morphine sulfate to hydromorphone.
Which statement regarding hydromorphone does
the nurse identify as being true?