Unit 6

Unit 6:

Chapters ​27, 28, & 29

Lauren Cumella

Multiple Choice

Parkinsonism refers to a group of symptoms involving motor movement.

• True

• False

Multiple Select

Select ALL key terms that are associated with Parkinson or Parkinson-like disorders

• achalasia

• akathisia

• bradykinesia

• choreiform

• dystonic

Achalasia

failure to relax; usually referring to the smooth muscle fibers of the GI tract, especially failure of the lower esophagus to relax, causing difficulty swallowing and a feeling of fullness

Akathisia

extreme restlessness and increased motor activity

bradykinesia

slow movement

Choreiform Movements

involuntary muscular twitching of the limbs or facial muscles. Usually drug-induced.

Dystonic

muscular spasms most often affecting the tongue, jaw, eyes, and neck. Usually drug-induced.

Extrapyramidal Symptoms (EPS)

group of adverse reactions involving the estrapyramidal portion of the nervous system causing abnormal moscle movements, espeically akathisia and dystonia

akathisia and choreiform movements

https://youtu.be/MF0aewGOU3U ​

 

A client is newly diagnosed with Parkinson disease.

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Currently, they are taking carbidopa/levodopa (Sinemet) 300 mg three times a day.

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The client presents at the clinic for follow-up and has some questions about the disease and medication.

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Case Study

The client knows that the symptoms of parkinsonism are caused by a depletion of dopamine in the central nervous system.

The client wants to know why they cannot just be given dopamine to supplement the deficiency.

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Why can’t the patient be given dopamine to supplement the deficiency? 

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Case Study

Why can’t the patient be given dopamine to supplement the deficiency? 

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• The blood-brain barrier​ blocks oral dopamine.

• ​Levodopa is a chemical formulation that is converted to dopamine by the body​

• MUST be given with carbidopa (allows more levodopa to reach the brain=better effect)​

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Case Study

KNOW: carbidopa/levodpoa

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Adverse reactions: anorexia, N&V, pain, dysphagia, dry mouth, mental changes, headache, dizziness, increased hand tremor, choreiform, or dystonic movements

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Administration: dosages of the combination drugs can be titrated to minimize symptoms​

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Case Study

As this is a follow-up visit for the client, what should the nurse’s ongoing assessment include?​

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Case Study

Ongoing Assessment:

• ​​observing the client for various neuromuscular signs (tremors of the head and hands at rest, muscular rigidity, mask-like facial expression, and ambulation stability)

• comparing these observations with the data obtained during the initial physical assessment.

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Case Study

The client will have to take carbidopa/levodopa for the rest of their life to control the symptoms of Parkinson disease.

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Clients taking carbidopa/levodopa may develop the on-off phenomenon.​

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Case Study

Multiple Choice

What does the "on-off phenomenon" mean?

• Dopamine levels rise and fall on and off again

• What happens when clients stop taking their meds

• When the drug alternates between working and not working

• When adverse reactions appear then suddenly dissappear

What is the "on-off phenomenon"?

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• ​The client suddenly alternates between improved clinical status and loss of therapeutic effect.

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How is it managed?​

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Case Study

How is it managed?​

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• Using low doses of the drug, reserving the drug for severe cases, or using a “drug holiday.”

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Case Study

• Adjunct to levodopa/carbidopa for Parkinson's & drug-induced EPS

• Enhances dopamine transmission by inhibiting the excess ACh produced by these patients

​Cholinergic Blocking

• Adjuncts to levodopa/carbidopa to prolongs the effect​

• LIVER DAMAGE

• Reserved if other treatments aren't working​

​COMT Inhibitors

Other Meds Used for Parkinsons

Multiple Choice

The nurse educates a client diagnosed with Parkinson disease and family about managing the chronic condition and important aspects about the prescribed medications. Which client statement indicates the need for further clarification?

• “I will suck on sugar free candies, ice chips to help keep my mouth moist.”

• “I will take my meds with meals to decrease gastrointestinal symptoms.”

• “I will have my family journal about any facial grimacing, protruding tongue, exaggerated chewing, head movements and report it at the next visit to my health care provider.”

• “I will work on my balance by enrolling into Tai Chi and practice the movements each day, and I will wear shoes with rubber soles when walking to decrease slipping.”

Rationale

The nurse needs to clarify teaching regarding the journaling process. It is alright to record symptoms, and report the symptoms to the primary care provider at the next appointment when the symptoms are not severe adverse reactions.

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• The ones discussed included adverse symptoms requiring immediate holding of the antiparkinson drugs and calling the primary care provider about the reaction for further guidance.

• The client should have a plan to take care of dry mouth, a common side effect of antiparkinson drugs.

• Taking the meds with meals can help decrease gastrointestinal side effects.

• Tai Chi can help the client maintain balance and gain exercise. It is also important to wear rubber-sole nonslipping shoes and not walk bare foot to help prevent falls.

Multiple Select

A nursing instructor is teaching a session on Parkinson disease to a group of students. The instructor determines the teaching was successful when the students correctly choose which factors as potential causes of Parkinsonism?

Select all that apply.

• Drugs

• Stroke

• Myocardial Infarction

• Encephalitis

• Epilepsy

​Rationale

Parkinsonism may result from the use of certain drugs, head injuries, and encephalitis.

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Strokes, myocardial infarctions, and epilepsy are other conditions which may be related to structural or physiologic situations within the body.

Seizure Types

" https://youtu.be/gUzTE_sG2eQ

Chapter 28

Antiepileptics​

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Group Work

​Central Nervous System Reactions

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Drowsiness, weakness, dizziness

Headache, somnolence

Nystagmus (constant, involuntary movement of the eyeball)

Ataxia (loss of control of voluntary movements, especially gait)

Gastrointestinal System

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• Nausea, vomiting

• Anorexia

• Constipation, diarrhea

• Gingival hyperplasia (overgrowth of gum tissue)

• Acute liver failure (with the drug felbamate)

Integumentary System

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• Skin rashes, pruritus, urticaria

• Serious skin reactions, such as Stevens–Johnson syndrome, have been associated with the use of lamotrigine (Lamictal)

Hematological Reactions

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• Pancytopenia (decrease in all the cellular components of the blood), leukopenia, aplastic anemia, and thrombocytopenia

Patient Teaching to Increase Adherence

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• Blood levels must be monitored at regular intervals, even if seizures are well controlled

• Must be tapered

• Contact local branches of agencies, such as Epilepsy Foundation of America

• ​Oral hygiene

• If GI upset, take with food or milk​

Multiple Choice

A nurse is administering lorazepam to a client with status epilepticus. The nurse will be prepared to administer which additional drug to treat the status epilepticus for the next several hours?

• Ethosuximide

• Phenytoin

• Ethotoin

• Zonisamide

​Rationale

• Due to the short effects of lorazepam (Ativan), a longer-acting anticonvulsant, such as phenytoin (Dilantin), is given to continue control of seizure activity.

• Ethotoin (Peganone) is a hydantoin that is used to treat tonic–clonic seizures.

• Ethosuximide (Succinimide) is a succinimide that is used to treat focal seizures.

• Zonisamide (Zonegran) is a nonspecified preparation and used to treat focal seizures as well.​

Multiple Select

A nurse is preparing to administer an antiepileptic to a client. The nurse predicts the seizure threshold will be elevated based on which additionally prescribed drug? Select all that apply.

• Clonazepam

• Valproic acid

• Gabapentin

• Lorazepam

• Trimethadione

​Rationale

• Benzodiazepines (clonazepam and lorazepam) exert their effect by elevating the seizure threshold by decreasing postsynaptic excitation.

• Valproic acid increases the levels of GABA, gabapentin is a GABA agonist

• trimethadione decreases the repetitive synaptic transmission of nerve impulses.​

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A client presents to the emergency department with complaints of a swollen ankle that is painful to the touch

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Chapter 29: Skeletal Muscle, Bone, and Joint Disorder Drugs

​Case Study

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What assessment should the nurse perform before the physician examines the client?

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Chapter 29: Skeletal Muscle, Bone, and Joint Disorder Drugs

​Case Study

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​Case Study

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Pre-Assessment:

• ​​Examination the affected joints (skin, deformity, signs of immobility)

• Change in ADLs?

• Vital Signs

• ​Type and duration of symptoms

• Pain​

• Previous preventive measures​

• Health History​

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​Case Study

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The emergency department physician diagnoses the client with an acute gout attack.

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The physician orders colchicine 0.5 mg IV every 6 hours until the attack is aborted.

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What should the nurse include in the ongoing assessment of the client?​

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​Case Study

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colchiseen (Gloperba)

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Uric Acid Inhibitor:

used for relief of acute attacks or prevention of gout

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Adverse Reactions:

N&V, diarrhea, abdominial pain, bone marrow depression

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Administration:

Prophylaxis: PO daily

Acute attack: PO or IV​

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​Case Study

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Ongoing Assessment / colchicine (Gloperba):

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• Risk of anaphylaxis (resuscitative equipment at bedside)​

• The nurse should inspect the joints involved every 1 to 2 hours to identify immediate response or nonresponse to therapy.

• The nurse should also question the client regarding the relief of pain, as well as adverse drug reactions.

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​Case Study

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The client is feeling better and is sent home to follow up with the primary care physician in a few days.

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​​At the follow-up appointment, the physician gives the client a prescription for allopurinol (Zyloprim) 100 mg every day.

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What should the nurse instruct the client to do while they are taking the allopurinol?

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​Case Study

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Gout and Uric Acid Inhibitor Education:

• Drink at least 10 glasses of water a day

• Take drug with food to minimize GI upset

• If drowsiness occurs, avoid driving, etc...

• Notify provider if pain not relieved

• Notify provider if skin rash occurs​

Rheumatoid vs Osteoarthritis

• Mechanical wear and tear

• ​NSAIDs, corticosteroids (Inj.), Hyaluronic acid (HA) (Inj.)

• Autoimmune disorder, creates inflammation of the joint

• Use 3 classes​: NSAIDs, DMARDs, corticosteroids

​DMARD: Disease Modifying Antirheumatic Drugs

Ex: hydroxychloroquine, methotrexate, sulfasalazine

• May take a long time to see improvement

• client self-esteem​ management

• Serious Adverse Drug reations: skin rashes, decreased CBC​, liver and renal studies q3 mo

• Secondary infections​

• Activity vs. Inactivity (risk of injury!)

​Osteoporosis: Loss of bone mass

​Bisphosphonates

Action:

• inhibit normal and abnormal bone resorption. Results in increased bone mineral density - reverses the progression of osteoporosis.​

​​​Adverse Reactions:

• Nausea & diarrhea

• Bone pain

• Headache

• Dyspepsia, dysphagia​, abdominal pain

​Osteoporosis: Loss of bone mass

​Bisphosphonates

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​Teaching:

• Check serum Ca+​

• Take in morning with water (GI issues)​, remain up 30 min.

• Not w/in 2 hrs food, vit., supplements, or antacids​

• Increase Ca+ and vit. D for better absorption

• Habits for taking meds (some are only 1 per mo​nth)

• Injury risk management​

Muscle Relaxants

​Several Classes of drugs used

• Used for various acute painful musculoskeletal condition

• Usually, short-term use only​

• Drowsiness most common adverse reaction

• NO alcohol or other CNS depressants should be used together

• Injury risk!​

Muscle Relaxants

Examples

• diazepam (Valium): benzodiazepine, PO, IV

• methocarbamol (Robaxin): PO, IM, IV

• baclofen (ozobax): PO

Multiple Choice

The nurse is preparing to administer colchicine to a client who is in the initial phase of gout. Which disorder will the nurse be prepared to monitor the client for?

• stomatitis

• SJS

• bone marrow depression

• Exfoliative dermatitis

​Rationale

• The nurse needs to closely monitor the client for bone marrow depression, an adverse reaction of colchicine.

• Stomatitis, Stevens–Johnson syndrome, and exfoliative dermatitis are not adverse reactions of colchicine.

• Stomatitis is an adverse reaction of immunosuppressive drugs.

• Stevens–Johnson syndrome and exfoliative dermatitis are adverse reactions of allopurinol.​

Multiple Choice

The nurse has administered anakinra (a DMARD) to a client for RA. Which assessment finding should the nurse prioritize?

• Constipation

• Abdominal Pain

• Retinal Changes

• Pancytopenia

​Rationale

• Due to the immunosuppressive properties of DMARD drugs, pancytopenia is an adverse effect of anakinra, a DMARD, and the client should be monitored for it closely.

• Administration of anakinra may also cause headache and irritation at the injection site, but not constipation, abdominal pain, or retinal changes.

• Constipation is a potential adverse reaction to cyclobenzaprine.

• Retinal changes are potential adverse reactions to hydroxychloroquine.

• Pancytopenia is a potential adverse reaction to sulfasalazine, alendronate, ibandronate, risedronate, allopurinol, and colchicine.

Multiple Select

The nurse is prepared to administer a skeletal muscle relaxant cautiously to clients with which disorder(s)?

Select all that apply.

• Cerebrovascular accident

• Diabetes

• Epilepsy

• Pregnancy

• Parkinsonism

​Rationale

• Skeletal muscle relaxants are used with caution in clients with a history of cerebrovascular accident, cerebral palsy, parkinsonism, or epilepsy and during pregnancy and lactation.

• Clients with diabetes should use DMARDs cautiously.

Multiple Select

The nurse is preparing a teaching session for a client who is prescribed alendronate for osteoporosis. Which instruction(s) will the nurse include in this session?

Select all that apply.

• Take the medication in the evening.

• Take the medication with 6–8 ounces of water.

• Remain upright for at least 30 minutes after administration.

• Wait 30 minutes before taking any other food or drink.

• Take a calcium supplement at the same time with the medication.

​Rationale

• A nurse should include the following administration instructions to a client being discharged with a prescription for alendronate:

  • take the medication in the morning (not evening) with 6–8 ounces of water

  • remain upright for at least 30 minutes after administration

  • do not take any other food, drink, medication, or supplement until at least 30 minutes after administration of the medication.