Drugs Affecting the Nervous System
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Transcript of Drugs Affecting the Nervous System
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Drugs Affecting the
Nervous System
Jane Bordner, Rn BSN
Instructor of Nursing
HACC Central Pennsylvania’s
Community College
Nursing 102Fall 2012
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Nervous System Review
• 2 Major divisions–CNS–PNS
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The Central and Autonomic Nervous Systems
• Central nervous system (CNS)– Made up of brain and spinal cord– Receives signals from sensory
receptors (vision, pressure, pain, cold, warmth, touch, smell)
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The Central and Autonomic Nervous Systems
• PNS• 2 Divisions
– Somatic- voluntary-conscious control– Autonomic- involuntary-unconscious control
• Sympathetic- fight or flight epinephrine/norepinephrine
• Parasympathetic- rest or digest• acteylocholine
• 2 Types of Nerves– Afferent – to the brain– Efferent-from sensory organs
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The Central and Autonomic Nervous Systems (cont’d)
• Peripheral nervous system– Afferent nerves—transmit signals to
the spinal cord and brain– Efferent nerves—carry impulses from
CNS to other parts of body.
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Autonomic Nervous System (ANS)
• 2 systems often have opposing functions
• Stimulate or inhibit
• Most organ are innervated by both
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Autonomic Nervous System
• Sympathetic - Adrenergic
• “Fight or Flight”
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Sympathetic Nervous System
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Autonomic Nervous System• Parasympathetic - Cholinergic• “Rest and Digest”
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ParasympatheticNervous System
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Synapses
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Neurotransmitters
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1. Message travels along nerve; when it approaches nerve ending a neurotransmitter is released 2. Neurotransmitter is received by next cell 3. Some of neurotransmitter gets reabsorbed 4. When enough neurotransmitter is received by
next nerve cell message moves forward
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Biochemical Response
Messenger Molecule(hormone, neurotransmitter, or drug)
Cell surface Cell surface
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Sympathetic
• Major Neurotransmitters (Catecholamines) – Epinephrine– Norepinephrine– Dopamine
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Effects of Sympathetic System
• Increase heart rate• Relax bronchial smooth muscles • Pupil dilation• Increased metabolism• Decreased GI motility• Peripheral vasoconstriction
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Neuroreceptors
• Alpha 1: vasoconstriction of arterioles, relax bladder, eyes, liver
• Alpha 2: skeletal blood vessels, pancreas• Beta 1: AV and SA node stimulation =
increased heart rate and contraction strength
• Beta 2: relaxes smooth muscle of bronchi and uterus
• Dopaminergic
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Sympathetic Neurotransmitters
• Act on alpha, beta, or dopaminergic receptor sites
• Example:– Alpha 1 receptors are found in
peripheral blood vessels, when stimulated they cause peripheral vasoconstriction which leads to increased BP
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Parasympathetic Activity
• Major Neurotransmitter (Cholinergic) –Acetylcholine
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Parasympathetic Neuroreceptors
• Cholinergic receptors– Muscarinic
• Both excitation and inhibition–Salivation –Lacrimation –Gastric acid secretion
• Slow onset– Nicotinic
• Excitation• Fast onset• Short duration
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Parasympathetic Effects
• Decrease heart rate• Constrict bronchial smooth
muscle• Pupil constriction• Increased GI motility• Increased secretions• Increased bladder tone
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Alpha Beta
1 2 1 2
Muscarinic Nicotinic
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Drug Effects
• Drug effect depends on:– Specific receptor it
interacts with– Number of receptors– Type of receptors– Drug specificity
• Antagonist = Block • Agonist = Stimulate
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Drug Effects
• Imitate neurotransmitters’ action• Block neurotransmitters’ action• Enhance or inhibit
– synthesis – storage – release – breakdown
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Drug Categories
• ANS drugs are categorized by– Site of action– Effect– Receptor
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Drug Categories
• Sympathomimetics– Adrenergics
• Sympatholytics– Adrenergic blockers
• Parasympathomimetics– Cholinergics
• Parasympatholytics– Cholinergic blockers
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SYMPATHOMIMETICS AKAADRENERGIC AGENTS
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Sympathomimetics/ Adrenergic Agents
• Catecholamines• Noncatecholamines• Primary Actions
– Increase heart rate– Increase BP– Relax bronchial smooth muscle– Relax GI tract– Coronary artery vasodilation– Peripheral vascular vasoconstriction
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Catecholamines
• Stimulate alpha and beta receptors• Mimic action of epinephrine,
norepinephrine, and dopamine• Examples:
– dobutamine HCL (Dobutrex, Intropin, Dopastat )
– Epinephrine (Adrenalin, EpiPen )– Norepinephrine (Levophed)– isoproterenol HCL (Isuprel)
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Catecholamines
• Uses– Severe hypotensive crisis– Cardiac arrest– Anaphylactic shock
• Special considerations– Destroyed by digestive enzymes
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“Cat”echolamines
• Side Effects–Severe throbbing headache–Dizziness–Anxiety–Fear–Palpitations–Hypertension
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Noncatecholamines
• Similar responses• More receptor selective• Slower acting• Longer lasting• Can be given PO• Usually given SC or by
inhaler
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Noncatecholamines• Examples
– albuterol (Proventil)– metaproterenol sulfate (Alupent)– terbutaline (Brethine)– phenylephrine HCL (Neo-
Synephrine)• Uses
– Bronchospasm (Asthma/Emphysema)
– Nasal congestion– Preterm labor
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Bronchoconstriction
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Noncatecholamines
• Side Effects– Tachycardia– Palpitations– Tremors – Hypertension– Headache– Anxiety
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Adrenergic Agents
• Nursing Measures– Monitor VS frequently– Monitor breath sounds– Monitor blood glucose in Diabetic
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SYMPATHOLYTICSAKAADRENERGIC BLOCKERS
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Adrenergic Blocking Agents
• AKA– Sympatholytics– Antiadrenergics
• Antagonistic effect• Classified by site of action
– Alpha Adrenergic Blockers– Beta Adrenergic Blockers
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Alpha Adrenergic Blocking Agents
• Action– Relax smooth muscle – Peripheral vasodilation
• Uses– Antihypertensives– Vascular H/A– Raynaud’s Disease– Buerger’s Disease
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Alpha Adrenergic Blocking Agents• Side Effects
– Hypotension– Tachycardia– Dizziness– H/A
• Nursing Actions– Postural BP– Teach to avoid caffeine
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Alpha Adrenergic Blocking Agents
• Examples– ergotamine tartrate (Ergostat)
• Inhaler, PO or SL• Treat migraine H/A
– phenoxybenzamine HCL (Dibenzyline)• Antihypertensive• Treat Raynaud’s Disease
– doxazosin mesylate (Cardura)– prazosin HCL (Minipress)– terazosin (Hytrin)
• Arteriole and venous vasodilation lower BP
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Beta Adrenergic Blocking Agents
• AKA– Beta Blockers
• Most widely used group• Beta 1 receptors = heart• Beta 2 receptors = bronchi and blood
vessels• Mixed = Nonselective blocking agents
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Beta Adrenergic Blocking Agents
• Effect– Lower HR– Decrease BP– Constrict pupil– Decrease
production of aqueous humor
• Uses– Cardiac
Arrhythmias– HTN– Angina– Glaucoma
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Beta Adrenergic Blocking Agents• Mixed
– *labetalol (Normodyne)
• Selective Beta-1– esmolol (Brevibloc)– *metoprolol
(Lopressor/Toprol XL/Betaloc )
– acebutolol (Sectral)– betaxolol (Kerlone)– bisoprolol (Zebeta)– *atenolol (Tenormin)
• Non-selective Beta-1 and Beta-2– *propranolol
(Inderal)– *nadolol (Corgard)– pindolol (Visken)– carteolol (Cartrol )– *sotalol (Betapace)– Timolol
(Blocadren/Timoptic )
– penbutolol (Levatol)* Most commonly used
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Beta Adrenergic Blocking Agents
• Treatment of Glaucoma– Decrease IOP by decreasing
production of aqueous humor• betaxolol (Betoptic)• timolol maleate (Timoptic)• levobunolol HCL (Betagan)
– Can cause systemic side effects
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Beta Adrenergic Blocking Agents
• Side Effects– Hypotension– Bradycardia– Dizziness– Insomnia– Wheezing and Bronchospasm
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Beta Adrenergic Blocking Agents
• Nursing Measures– Never give with antacid– Check apical pulse for one
minute before administering– Closely monitor blood glucose
in diabetic pt.– Teach pt. to not discontinue
abruptly
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PARASYMPATHOMIMETICSAKACHOLINERGICS
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Cholinergic Agents• AKA
– Parasympathomimetic
• Promotes/mimics– function of acetylcholine
• Stimulate cholinergic receptors– nicotinic and muscarinic
• Imitate parasympathetic effects
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Cholinergic Agents
• Uses– Glaucoma– Paralytic ileus– Urinary retention– Diagnosis and treatment of Myasthenia Gravis
(MG)– Antidote for tricyclic antidepressant overdose– Antidote for neuromuscular blocking agent
overdose
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Cholinergic Agents
• Examples– pilocarpine HCL - treatment of glaucoma– bethanechol (Urecholine) – treatment of
urinary retention and neurogenic bladder– neostigmine (Prostigmin), pyridostigmine
(Mestinon) – diagnosis and treatment of MG
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Cholinergic Agents
• Side Effects– N/V/D– Bradycardia– Hypotension– Increased salivation and sweating– Bronchoconstriction = wheezing and
SOA
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Cholinergic Agents
• Nursing Measures– Never given IM or IV– Antidote = Atropine sulfate
(Cholinergic Blocker)
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PARASYMPATHOLYTICSAKACHOLINERGIC BLOCKERS
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Cholinergic Blocking Agents
• AKA:– Anticholinergics – Parasympatholytics
• Actions– Compete with acetycholine at
muscarinic receptor sites– antagonists
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Cholinergic Blocking Agents
• Effects– Decreased GI motility– Decreased secretions – Relax bladder muscle– Increased heart rate
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Cholinergic Blocking Agents
• Uses– Parkinson’s Disease– Preanesthesia Agents– Cardiac Arrhythmias– Spastic conditions of bowel and
bladder
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Cholinergic Blocking Agents• Examples
– Atropine sulfate • Preanesthesic • Emergency treatment of brady
arrythmias – glycopyrrolate (Robinul)
• Preanesthesic– dicyclomine HCL (Bentyl)
• Irritable bowel syndrome
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Cholinergic Blocking Agents• Examples
– oxybutynin (Ditropan)• Bladder spasms
– propantheline (Pro-Banthine)• Peptic ulcer disease
– benztropine mesylate (Cogentin)• Extrapyramidal symptoms of
Parkinson’s
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Cholinergic Blocking Agents
• Side Effects– Mild
• Dry mouth• Decreased sweating• Decreased bronchial secretions
– Moderate• Decreased accommodation
– Severe• Urinary retention• Severe constipation• Ileus
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Cholinergic Blocking Agents
• Overdose– Restlessness– Disorientation– Hallucinations– Unconsciousness– Death
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Cholinergic Blocking Agents
• Nursing Measures– Dose range is very small– Infants, children and elderly are more
prone to side effects– Heatstroke is potential complication– NEVER give to patient with glaucoma– Used to decrease GI motility, give 30
minutes before meals – Watch for urinary retention
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NEUROMUSCULAR BLOCKING AGENTS
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Neuromuscular Blocking Agents
• Relax skeletal muscles– Disrupt transmission of nerve impulses
at neuromuscular junction• Clinical Uses
– Relax muscles during surgery– Decrease muscle spasms during ECT– Manage ventilator patients
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Neuromuscular Blocking Agents
• Examples– pancuronium bromide (Pavulon)– doxacurium Cl (Nuromax)– succinylcholine Cl (Anectine)– vecuronium bromide (Norcuron)
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Neuromuscular Blocking Agents
• Side Effects– Excessive salivation– Excessive bronchial
secretions– Bronchospasm– Apnea– Hypotension
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Neuromuscular Blocking Agents
• Nursing Measures– O2 – Suction equipment – Artificial ventilation
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AntiParkinson’s Medications
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Parkinson’s Disease
• Neurotransmitters– Dopamine ( inhibitory)– Acetylcholine (excitatory)
• Types of parkinsoinsm– Primary (idiopathic)– Secondary (induced by head
trauma, infection, tumors, or drug exposure
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Parkinson’s Disease
• Goal of treatment is minimization of symptoms
• Individualized combination therapy
• Therapy begins when symptoms interfere with the ability to function in daily life
• All symptoms cannot be eliminated because of side effects involved
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Parkinson’s Disease• Signs
– Facial appearance– Psychological involvement
• Symptoms– Motor function
• Tremor• Dyskinesia, propulsive, uncontrolled
movement• Bradykinesia, akinesia• Excessive salivation
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Parkinson’s Disease
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Parkinson’s Disease
• Dopamine agonists– Amantide hydrochloride– Bromocriptine mesylate– Carbidopa– Pergolide mesylate– Pramipexole– Ropinirole
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Parkinson’s Disease
• Anticholinergic Agents– Cogentin ( Benztropine mesylate)– Akineton ( Biperiden hydrochloride)– Benadryl (diphenhydramine
hydrochloride)– Banflex, Norflex (Orphenadrine
citrate)
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ANTICONVULSANT MEDICATIONS
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Types of seizures
• Generalized– Tonic-Clonic (grand mal)– Myoclonic– Absence (petite mal)
• Partial (localized)– Partial simple– Partial complex
• Status Epilepticus
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Anticonvulsant Therapy (cont’d)
• Nurses may play an important role in diagnosis and treatment– Learn to take histories, describe
seizures, record postictal behavior– Identify a care plan, have proper
supplies, discuss with patient and family
– Learn to assist patient during seizures, observe and record, discuss lifestyle and feelings with patient
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Anticonvulsant Medications• Agents
– Barbiturates– Benzodiazepines– Succinimides– Hydantoins– Miscellaneous Agents
• Action– Increase seizure threshold– Regulate firing by inhibiting excitation or
enhancing brains ability to inhibit its own excitation
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Barbiturates
• phenobarbital (Luminal)–Action
• Increase seizure threshold• Prevent spread of electrical activity
–Uses• Partial seizures• Generalized clonic tonic seizures
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Barbiturates
• Side Effects– Sedation– Nausea– Lethargy
• Nursing Measures– Monitor therapeutic blood levels– Monitor effectiveness– Monitor degree of sedation
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Benzodiazepines
• Action– Enhance inhibitory effect– It is thought that they enhance the inhibitory
effects of GABA in postsynaptic clefts between nerve cells
• Drugs and Uses– diazepam (Valium) – acute status
epilepticus ;IV– lorazepam (Ativan) – status epilepticus– clonazepam (Klonopin) – absence and
myoclonic seizures– clorazepate (Tranxene) – adjunct treatment of
partial seizures
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Benzodiazepines
• Side Effects– Drowsiness– Confusion– Weakness– Dizziness
• Adverse Effects– Blood dyscrasias– Hepatotoxicity
• Nursing Measures– Monitor CBC and
LFT’s
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Succinimides
• Action– unknown
• Uses– Absence seizures– Petit mal
• Drugs– ethosuximide
(Zarontin)– Methsuximide
(Celontin)• Side Effects
– GI upset – Sedation
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Hydantoins
• Action – Stabilizes nerve cells against hyperexcitability – Inhibits spread of seizure activity
• Uses– Partial and generalized seizures
• Drugs– phenytion (Dilantin)– fosphenytion (Cerebyx) – CAUTION: phenytoin (and diazepam) must be
administered slowly, and not mixed with other medications in the same syringe
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Hydantoins
• Side Effects– GI upset– Sedation– Confusion– Gingival Hyperplasia
• Adverse Effects– Hyperglycemia– Blood Dyscrasias– Hepatotoxicity– Rashes and pruritus
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Hydantoins
• Toxicity– Nausea– Sedation– Lethargy– Nystagmus
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Hydantoins• Nursing Measures
– Monitor CBC, LFT’s, Blood Glucose and Therapeutic Blood Levels
– Good oral hygiene– Monitor effectiveness– Monitor for excessive sedation– Give with food– Give at same time each day
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MISCELLANEOUS AGENTS
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carbamzepine (Tegretol)– Action – Blocks up the reuptake of norepinephrine– Decreases release of norepinephrine and rate of
dopamine and GABA turnover– Mechanisms of action as anticonvulsant are
unknown• unknown
– Uses• Generalized tonic-clonic seizures• Partial and mixed seizures• Often used with other agents
– Side Effects• GI upset• Sedation• Edema
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carbamazepine (Tegretol)
• Adverse Effects– Orthostatic hypotension– Hypertension– Dyspnea– Edema– Hepatotoxicity– Blood Dyscrasias– Rashes and pruritus
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carbamazepine (Tegretol )• Nursing Measures
– Monitor CBC, LFT’s and therapeutic blood level
– Monitor BP– Give with food– Monitor seizure activity– Monitor for excessive sedation
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valproic acid (Depakote, Depakene
–Action• May increase concentrations of GABA
–Uses• Absence seizures• Combination seizures
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valproic acid (Depakote, Depakene)
• Side Effects• Abdominal pain• Diarrhea• Dizziness• Drowsiness• Unusual bleeding
• Nursing Measures– CBC and platelet count before and 2 wks
after start of therapy– LFT’s before and every 6 months– Can cause birth defects
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gabapentin (Neurotin)
• Uses– Partial seizures– In combination with other agents
• Side Effects– Sedation– Confusion
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Other Miscellaneous Agents
• lamotrigine (Lamictal)• levetiracetam (Keppra)• primidone (Mysoine)• tiagabine (Gabatril)• oxcarbazepine (Trileptal)• topiramate (Topamax)• zonisamide (Zonegran)
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Anticonvulsant Medications
• General Nursing Considerations– NEVER suddenly stop anticonvulsant
therapy– SEDATION is MOST common reason for
non-compliance with drug therapy– Driving
• Must be seizure free for 6 months• Physicians required to report seizures to
DOT
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Alternative Therapy
• Ketogenic Diet– Most successful in children– Used for intractable epilepsy– High fat, low CHO, low protein– Limited fluids– Mechanism of action unknown– Nutritional supplementation of Ca+ and vitamins– Monitor ketones with every void– May not see response for 10 wks– May gradually wean from diet after seizures
controlled
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Research• GABA
– Discovered in 1950• Chemical that maintains balance in brain’s delivery
system• Nerve cells communicate by releasing
neurotransmitters• GABA halts messages• Without GABA, system becomes overloaded and
seizures occur• New drug vigabatrin (Sabril ) has chemical structure
similar to GABA, ensuring GABA stays at level necessary to keep message delivery system functioning properly