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10 Cards in this Set
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phenytoin
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Dilantin (antiarrhythmics (group IB) anticonvulsants)
Therapeutic Effect: • Diminished seizure activity • Termination of ventricular arrhythmias Action: • Limits seizure propagation by altering ion transport • May also decrease synaptic transmission • Antiarrhythmic properties as a result of shortening the action potential and decreasing automaticity Common SE: ataxia, diplopia, nystagmus, hypotension (↑ with IV phenytoin) ,gingival hyperplasia, nausea, hypertrichosis, rash RN Considerations: • Monitor closely for notable changes in behavior that could indicate the emergence or worsening of suicidal thoughts or behavior or depression • Assess oral hygiene. Vigorous cleaning beginning within 10 days of initiation of phenytoin therapy may help control gingival hyperplasia » Assess patient for phenytoin hypersensitivity syndrome (fever, skin rash, lymphadenopathy). Rash usually occurs within the first 2 wk of therapy. Hypersensitivity syndrome usually occurs at 3–8 wk but may occur up to 12 wk after initiation of therapy. May lead to renal failure, rhabdomyolysis, or hepatic necrosis; may be fatal » Observe patient for development of rash. Discontinue phenytoin at the first sign of skin reactions. Serious adverse reactions such as exfoliative, purpuric, or bullous rashes or the development of lupus erythematosus, Stevens-Johnson syndrome, or toxic epidermal necrolysis preclude further use of phenytoin or fosphenytoin. Seizures • Assess location, duration, frequency, and characteristics of seizure activity. EEG may be monitored periodically throughout therapy » Monitor blood pressure, ECG, and respiratory function continuously during administration of IV phenytoin and throughout period when peak serum phenytoin levels occur (15–30 min after administration) Arrhythmias • Monitor ECG continuously during treatment of arrhythmias Lab Test Considerations • Monitor CBC, serum calcium, albumin, and hepatic function tests prior to and monthly for the first several months, then periodically during therapy » May cause ↑ serum alkaline phosphatase, GGT, and glucose levels Toxicity and Overdose • Monitor serum phenytoin levels routinely. Therapeutic blood levels are 10–20 mcg/mL » Progressive signs and symptoms of phenytoin toxicity include nystagmus, ataxia, confusion, nausea, slurred speech, and dizziness |
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carbamazepine
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Tegretol, Carbatrol (anticonvulsant, mood stabilizer)
Therapeutic Effect: • Prevention of seizures • Relief of pain in trigeminal neuralgia • Decreased mania Action: Decreases synaptic transmission in the CNS by affecting sodium channels in neurons Common SE: ataxia, drowsiness RN Considerations: • Monitor closely for notable changes in behavior that could indicate the emergence or worsening of suicidal thoughts or behavior or depression • Monitor for changes in skin condition in early therapy. Stevens-Johnson syndrome and toxic epidermal necrolysis are significantly more common in patients with a particular human leukocyte antigen (occurs almost exclusively in patients with Asian ancestry, including South Asian Indians). Seizures • Assess frequency, location, duration, and characteristics of seizure activity Trigeminal Neuralgia • Assess for facial pain (location, intensity, duration). Ask patient to identify stimuli that may precipitate facial pain (hot or cold foods, bedclothes, touching face) Bipolar Disorder • Assess mental status (mood, orientation, behavior) and cognitive abilities before and periodically during therapy Lab Test Considerations • Monitor CBC, including platelet count, reticulocyte count, and serum iron, weekly during the first 2 mo and yearly thereafter. Medication should be discontinued if bone marrow depression occurs » Liver function tests, urinalysis, and BUN should be routinely performed. May cause ↑ AST, ALT, serum alkaline phosphatase, bilirubin, BUN, urine protein, and urine glucose levels » Monitor serum ionized calcium levels every 6 mo or if seizure frequency increases. Thyroid function tests and ionized serum calcium concentrations may be ↓; hypocalcemia ↓ seizure threshold » Monitor ECG and serum electrolytes before and periodically during therapy. May cause hyponatremia » May occasionally cause ↑ serum cholesterol, high-density lipoprotein, and triglyceride concentrations » May cause false-negative pregnancy test results with tests that determine human chorionic gonadotropin Toxicity and Overdose • Serum blood levels should be routinely monitored during therapy. Therapeutic levels range from 4–12 mcg/mL |
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lamotrigine
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Lamictal (anticonvulsant)
Therapeutic Effect: • Decreased incidence of seizures • Delayed time to recurrence of mood episodes Action: Stabilizes neuronal membranes by inhibiting sodium transport Common SE: ataxia, dizziness, nausea, vomiting, photosensitivity, rash (higher incidence in children, patients taking valproic acid, high initial doses, or rapid dose increases) RN Considerations: • Monitor closely for notable changes in behavior that could indicate the emergence or worsening of suicidal thoughts or behavior or depression • Assess patient for skin rash frequently during therapy. Discontinue lamotrigine at first sign of rash; may be life-threatening. Stevens-Johnson syndrome or toxic epidermal necrolysis may develop. Rash usually occurs during the initial 2–8 wk of therapy and is more frequent in patients taking multiple antiepileptic agents, especially valproic acid, and much more frequent in patients <16 yr • Monitor for hypersensitivity reactions (fever, lymphadenopathy with or without rash) If cause cannot be determined, discontinue lamotrigine immediately Seizures • Assess location, duration, and characteristics of seizure activity Bipolar disorders • Assess mood, ideation, and behaviors frequently. Initiate suicide precautions if indicated Lab Test Considerations • Lamotrigine plasma concentrations may be monitored periodically during therapy, especially in patients concurrently taking other anticonvulsants. Therapeutic plasma concentration range has not been established, proposed therapeutic range: 1–5 mcg/mL |
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topiramate
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Topamax (anticonvulsant)
Therapeutic Effect: • Decreased incidence of seizures • Decreased incidence/severity of migraine headache Action: Action may be due to » Blockade of sodium channels in neurons » Enhancement of gamma-aminobutyrate (GABA), an inhibitory neurotransmitter » Prevention of activation of excitatory receptors Common SE: dizziness, drowsiness, fatigue, impaired concentration/memory, nervousness, psychomotor slowing, speech problems, sedation, nausea, weight loss, ataxia, paresthesia RN Considerations: • Monitor closely for notable changes in behavior that could indicate the emergence or worsening of suicidal thoughts or behavior or depression Seizures • Assess location, duration, and characteristics of seizure activity Migraines • Assess pain location, intensity, duration, and associated symptoms (photophobia, phonophobia, nausea, vomiting) during migraine attack. Monitor frequency and intensity of pain on pain scale Bipolar Disorder • Assess mental status (mood, orientation, behavior) and cognitive abilities before and periodically during therapy Lab Test Considerations • Monitor CBC with differential and platelet count before therapy to determine baseline levels and periodically during therapy. Frequently causes anemia » Hepatic function should be monitored periodically throughout therapy. May cause ↑ AST and ALT levels » Evaluate serum bicarbonate prior to and periodically during therapy. If metabolic acidosis occurs, dosing taper or discontinuation may be necessary |
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clonazepam
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Klonopin (antoconvulsant)
Therapeutic Effect: • Prevention of seizures • Decreased manifestations of panic disorder Action: • Anticonvulsant effects may be due to presynaptic inhibition • Produces sedative effects in the CNS, probably by stimulating inhibitory GABA receptors Common SE: behavioral changes, drowsiness, ataxia RN Considerations: • Observe and record intensity, duration, and location of seizure activity • Assess degree and manifestations of anxiety and mental status (orientation, mood, behavior) prior to and periodically during therapy • Assess need for continued treatment regularly • Assess patient for drowsiness, unsteadiness, and clumsiness. These symptoms are dose related and most severe during initial therapy; may decrease in severity or disappear with continued or long-term therapy • Monitor closely for notable changes in behavior that could indicate the emergence or worsening of suicidal thoughts or behavior or depression Lab Test Considerations • Patients on prolonged therapy should have CBC and liver function test results evaluated periodically. May cause an ↑ in serum bilirubin, AST, and ALT » May cause ↓ thyroidal uptake of sodium iodide, 123I, and 131I Toxicity and Overdose • Therapeutic serum concentrations are 20–80 mg/mL. Flumazenil antagonizes clonazepam toxicity or overdose (may induce seizures in patients with history of seizure disorder or who are on tricyclic antidepressants) |
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t-PA (alteplase)
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Activase, t-PA (thrombolytics)
Therapeutic Effect: • Lysis of thrombi in coronary arteries, with improvement of ventricular function, and reduced risk of heart failure or death • Lysis of pulmonary emboli • Lysis of thrombi causing ischemic stroke, reducing risk of neurologic sequelae • Restoration of cannula or catheter function Action: Directly converts plasminogen to plasmin, which then degrades clot-bound fibrin Common SE: (no common listed) Bleeding RN Considerations: • Begin therapy as soon as possible after the onset of symptoms » Monitor vital signs, including temperature. Notify health care professional if systolic BP >180 mm Hg or diastolic BP >110 mm Hg. Thrombolytic therapy should not be given if hypertension is uncontrolled. Hypotension may result from the drug, hemorrhage, or cardiogenic shock » Assess patient carefully for bleeding every 15 min during the 1st hr of therapy, every 15–30 min during the next 8 hr, and at least every 4 hr for the duration of therapy. Frank bleeding may occur from sites of invasive procedures or from body orifices. Internal bleeding may also occur (decreased neurologic status; abdominal pain with coffee-grounds emesis or black, tarry stools; hematuria; joint pain). If uncontrolled bleeding occurs, stop medication and notify health care professional immediately » Assess patient for hypersensitivity reaction (rash, dyspnea, fever, changes in facial color, swelling around the eyes, wheezing). If these occur, inform health care professional promptly. Keep epinephrine, an antihistamine, and resuscitation equipment close by in the event of an anaphylactic reaction » Assess neurologic status throughout therapy. Altered sensorium or neurologic changes may be indicative of intracranial bleeding Myocardial Infarction • Monitor ECG continuously. Notify health care professional if significant arrhythmias occur. » Assess intensity, character, location, and radiation of chest pain. Note presence of associated symptoms (nausea, vomiting, diaphoresis). Administer analgesics as directed. Notify health care professional if chest pain is unrelieved or recurs » Monitor heart sounds and breath sounds frequently. Inform health care professional if signs of CHF occur (rales/crackles, dyspnea, S3 heart sound, jugular venous distention, relieved CVP) Acute Ischemic Stroke • Assess neurologic status. Determine time of onset of stroke symptoms. Alteplase must be administered within 3–4.5 hr of onset (within 3 hrs in patients older than 80 years, those taking oral anticoagulants, or those with both a history of stroke and diabetes) Pulmonary Embolism • Monitor pulse, blood pressure, hemodynamics, and respiratory status (rate, degree of dyspnea, ABGs) Deep Vein Thrombosis/Acute Arterial Occlusion • Observe extremities and palpate pulses of affected extremities every hour. Notify health care professional immediately if circulatory impairment occurs. Cannula/Catheter Occlusion • Monitor ability to aspirate blood as indicator of patency. Ensure that patient exhales and holds breath when connecting and disconnecting IV syringe to prevent air embolism Lab Test Considerations • Hematocrit, hemoglobin, platelet count, fibrin/fibrin degradation product (FDP/fdp) titer, fibrinogen concentration, prothrombin time, thrombin time, and activated partial thromboplastin time may be evaluated before and frequently during therapy. Bleeding time may be assessed before therapy if patient has received platelet aggregation inhibitors » Obtain type and crossmatch and have blood available at all times in case of hemorrhage » Stools should be tested for occult blood loss and urine for hematuria periodically during therapy Toxicity and Overdose • High Alert: If local bleeding occurs, apply pressure to site. If severe or internal bleeding occurs, discontinue infusion. Clotting factors and/or blood volume may be restored through infusions of whole blood, packed RBCs, fresh frozen plasma, or cryoprecipitate. Do not administer dextran; it has antiplatelet activity. Aminocaproic acid (Amicar) may be used as an antidote |
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nimodipine
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No Trade name listed (calcium channel blocker)
Therapeutic Effect: Prevention of vascular spasm after subarachnoid hemorrhage, resulting in decreased neurologic impairment Action: • Inhibits the transport of calcium into vascular smooth muscle cells, resulting in inhibition of excitation-contraction coupling and subsequent contraction • Potent peripheral vasodilator Common SE: (no common listed) ARRYTHMIAS, CHF, STEVENS-JOHNSON SYNDROME RN Considerations: • Assess patient's neurologic status (level of consciousness, movement) prior to and periodically following administration • Monitor blood pressure and pulse prior to therapy and periodically during therapy • Monitor intake and output ratios and daily weight. Assess for signs of CHF (peripheral edema, rales/crackles, dyspnea, weight gain, jugular venous distention) Lab Test Considerations • Total serum calcium concentrations are not affected by calcium channel blockers » Monitor serum potassium periodically. Hypokalemia ↑ risk of arrhythmias; should be corrected » Monitor renal and hepatic functions periodically. Several days of therapy may cause ↑ hepatic enzymes, which return to normal upon discontinuation of therapy » May occasionally cause ↓ platelet count concentration, prothrombin time, thrombin time, and activated partial thromboplastin time may be evaluated before and frequently during therapy. Bleeding time may be assessed before therapy if patient has received platelet aggregation inhibitors » Obtain type and crossmatch and have blood available at all times in case of hemorrhage » Stools should be tested for occult blood loss and urine for hematuria periodically during therapy Toxicity and Overdose • High Alert: If local bleeding occurs, apply pressure to site. If severe or internal bleeding occurs, discontinue infusion. Clotting factors and/or blood volume may be restored through infusions of whole blood, packed RBCs, fresh frozen plasma, or cryoprecipitate. Do not administer dextran; it has antiplatelet activity. Aminocaproic acid (Amicar) may be used as an antidote |
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sumatriptan
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Imitrex (vascular headache suppressants)
Therapeutic Effect: Relief of acute attacks of migraine Action: Acts as a selective agonist of 5-HT1 at specific vascular serotonin receptor sites, causing vasoconstriction in large intracranial arteries Common SE: dizziness, vertigo, tingling, warm sensation, injection site reaction. RN Considerations: • Assess pain location, intensity, duration, and associated symptoms (photophobia, phonophobia, nausea, vomiting) during migraine attack • Give initial subcut dose under observation to patients with potential for coronary artery disease including postmenopausal women, men >40 yr, patients with risk factors for coronary artery disease such as hypertension, hypercholesterolemia, obesity, diabetes, smoking, or family history. Monitor blood pressure before and for 1 hr after initial injection. If angina occurs, monitor ECG for ischemic changes • Monitor for serotonin syndrome in patients taking SSRIs or SNRIs concurrently with sumatriptan |
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ergotamine
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Ergomar, Ergostat (vascular headache suppressants)
Therapeutic Effect: Constriction of dilated carotid artery bed with resolution of vascular headache Action: • Vasoconstriction of dilated blood vessels by stimulating alpha-adrenergic and serotonergic (5-HT) receptors • Larger doses may produce alpha-adrenergic blockade and vasodilation Common SE: hypertension, abdominal pain, nausea, vomiting RN Considerations: • Assess frequency, location, duration, and characteristics (pain, nausea, vomiting, visual disturbances) of chronic headaches. During acute attack, assess type, location, and intensity of pain before and 60 min after administration • Monitor blood pressure and peripheral pulses periodically during therapy. Report any increases in blood pressure • Assess for signs of ergotism (cold, numb fingers and toes; nausea; vomiting; headache; muscle pain; weakness) • Assess for nausea and vomiting. Ergotamine stimulates the chemoreceptor trigger zone. Metoclopramide or a phenothiazine antiemetic may be given orally as prophylaxis 1 hr before administration of dihydroergotamine IV. Oral administration may decrease risk of extrapyramidal and other side effects encountered with IV administration Toxicity and Overdose • Toxicity is manifested by severe ergotism (chest pain, abdominal pain, persistent paresthesia in the extremities) and gangrene. Vasodilators, dextran, or heparin may be ordered to improve circulation |
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From the book: General nursing implications for Seizure control
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*Educate pt on taking the drug exactly as prescribed
*all seizure drugs can cause some degree of sedation, drowsiness, lethargy, warn about operating machinery, do not drink alcohol or other CNS depressants *Do not stop taking abruptly *Check interactions with other drugs, anticoagulants, oral contraceptives, digoxin, aspirin, folic acid are significant *Periodic blood work q 1-3 months *Dosages based on therapeutic blood level of drug *Anticonvulsants have narrow therapeutic range can cause toxicity *All have SE such as fever and leucopenia (phenytoin gingival hyperplasia and rash) *Physical dependence with phenobabrital or primidone d/t conversion to Phenobarbital in the blood stream *Toxic SE ataxia, drowsiness, nausea, sedation, dizziness not uncommon |
