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Module 9 Pharm

Terms in this set (27)

-Examples of benzodiazepines include flurazepam, diazepam, clonazepam, alprazolam, temazepam, triazolam, and estazolam.
-Notice the benzodiazepines all have the last name of "pam" and "lam". I remember that they are useful for sleep because you count sheep (lams) to fall asleep. And they are good for anxiety because everybody knows a "crazy pam" (not really but it makes it where I can remember these drugs, if your name is Pam, I am sure you are no crazier than me.)

-MOA: Depress activity in the CNS, thought to stimulate GABA receptors in the brain (main inhibitory neurotransmitter of the brain)

-Indications: anxiety, seizures, muscle spasms, anesthesia and status epilepticus

-Contraindications: allergy, pregnancy and narrow-angle glaucoma

-Side effects: drowsiness, dizziness, cognitive impairment, amnesia, confusion, and "hang over".
-All of these are similar to someone who is drunk.

-Toxicity: not likely to occur unless taking other CNS depressants, such as alcohol, opioids, or barbiturates; or with intentional overdose.
-The management of toxicity is symptomatic and supportive- meaning we treat the symptoms and support the patient as needed. We may need to provide airway and breathing for the patient. We may need to use vasopressors to raise the blood pressure.
-The antidote is flumazenil, however, it is not commonly used for overdoses because of the risk of seizures. It is more likely to be used for anesthesia reversal.

-Interactions: Other CNS depressants cause increased sedation. Herbal products valerian and kava kava increase sedation level. Grapefruit will prolong the effects of the benzodiazepines.
Assessment should include:
-Obtain drug history (look for use of alcohol, kava kava, valerian, and any other CNS depressant, assess use of grapefruit/grapefruit juice)
-Assess VS (can lower blood pressure, heart rate and RR, although not likely alone; more apt to occur with use of other CNS depressants)
-Assess renal function as renal impairment can prolong drug action
-Assess past medical history (look for appropriate use for the benzodiazepine in the patient's history; assess for pregnancy and narrow angle glaucoma)
-Assess for suicidal thoughts (Suicidal ideation)

Diagnosis (depends on why the patient is on benzo):
-Sleep deprivation
-Risk for injury (True for every patient on a benzo or non-benzo)

Planning (this will depend on why the patient is taking the Benzo):
-Patient will receive 6-8 hours of sleep per night while taking the benzo or non-benzo
-Patient will remain free from injury while on benzo or non-benzo
-Patient will experience less anxiety. (benzo)Implementation
-Use bed alarm on older adults and patients receiving benzo/nonbenzodiazepine for first time.
-Monitor vital signs
-Monitor renal function throughout therapy (urine output, creatinine level)
-Administer when the patient is ready to fall asleep and ready to stay in bed.
-For sleep, benzo's are recommended for no longer than 3-4 weeks, due to tolerance and addiction.

Patient teaching:
-*Avoid alcohol and antidepressants, antipsychotics, and opioid drugs while on benzo or nonbenzo. These increase the risk of sedation and respiratory suppression which means severe reactions can occur that could lead to death.
-Teach nonpharmacologic methods to help with sleep and rest
-Warn patient to avoid Kava kava and valerian as they increase sedative effect
-Advise not to drive while on benzo (but since it causes amnesia and impaired cognitive abilities, they might drive anyway)
-Teach to gradually withdraw benzo, do not abruptly stop (can cause withdrawal symptoms)

Evaluation:
-Will depend on what the medication was used for. Less anxious if for anxiety. Better rest if used for rest.
Assessment•:
-Obtain drug history (look for use of alcohol, kava kava, valerian, and any other CNS depressants)
-Assess VS (can lower blood pressure, heart rate and RR)
-Assess renal function as renal impairment can prolong drug action
-Assess past medical history (look for appropriate use for the barbiturate)

Diagnosis (depends on why the patient is on barbiturate):
-Sleep deprivation
-Risk for injury (True for every patient on a barbiturate

Planning (this will depend on why the patient is taking the Barbiturate):
-Patient will receive 7-8 hours of sleep per night while on barbiturate.
-Patient will remain free from injury while on barbiturate
-Patient will experience less seizure activity.

Implementation:
-Use bed alarm on older adults and patients receiving barbiturate for first time.
-Monitor vital signs
-Monitor renal function throughout therapy (urine output, creatinine level)
-Administer when the patient is ready to fall asleep and ready to stay in bed.
-For sleep, barbiturates are recommended for no longer than 2 weeks, due to tolerance and addiction.Patient teaching
-*Avoid alcohol and antidepressants, antipsychotics, and opioid drugs while on barbiturates because of increased risk of sedation and respiratory suppression. The combination can cause severe reactions that can even lead to death.
-Teach nonpharmacologic methods to help with sleep and rest
-Warn patient to avoid kava kava and valerian as they increase sedative effect
-Advise not to drive while on barbiturate (but since it causes amnesia and impaired cognitive abilities, they might drive anyway)
Assessments should include: ​
-Assess past medical history: Heart disease, Hypertension, Hyperthyroid, parkinsonism, glaucoma​
-Assess VS (Elevated heart rate, elevated blood pressure)​
-Mental status (Aggressive, affect, mood)​

Diagnosis:​
-Risk-prone behaviour​
-Risk for injury​
-Interrupted family processes​

Planning:
-The patient will be more focused and alert during therapy.

Implementation
-Monitor for SE-nervousness, insomnia, restlessness, tachycardia, elevated BP​
-At follow up appointments, measure child's growth and weight. Make sure growth suppression isn't occurring.

TEACHING: ​
-Take before meals (breakfast and lunch, last dose 6 hours before sleep if possible, no later than 6 PM) If transdermal patch, put on before school and remove right after school. Should be on around 9 hours, want the patch to be off for 6 hours before bed if possible. ​
-Avoid alcohol (if adult patient, if pediatric, I hope this teaching isn't necessary).​
-Dry mouth, sugar free gum or candy​
-Monitor weight 2x/week and report weight loss (anorexia can occur for both pediatric and adult patients and growth suppression can occur in pediatric patients)
-DO NOT STOP ABRUPTLY-withdrawal can occur, taper off. Many times, children will have a "summer break" from the drugs for ADHD. They will be tapered off their dose at the end of the school year. When they start back on their medication, they will do a "taper on", meaning they start with low doses and work up. Want to give the lowest dose possible.​
-Read labels on OTC products because many contain caffeine (a CNS stimulant).​
-DIET: avoid foods that contain caffeine​
-Make sure to give nutritious breakfast- because the patient might only have anorexia for lunch.​
-Teach to report tachycardia and palpitations (most dangerous)​

Evaluation​
-Increased focus, increased attention span, better grades, less trouble at school
Assessments should include:​
-Therapeutic level of prescribed anticonvulsant drug(be sure you know the ranges and what happens if it is above or below the therapeutic level)​
-Assess type of seizure, last seizure, duration of seizure​
-Assess for hepatic disease (Valproic acid is contraindicated or used with caution)​
-Assess pregnancy (many of these drugs can cause birth defects or complications after delivery)​
-Assess past medical history and drug history (look at each drug interaction for each anticonvulsant drug discussed, look at contraindications for each type of antiepileptic drug)​
-Assess age (younger than 2, should not take valproic acid)​

Diagnosis​:
-Risk for injury​

Planning​:
-Patient will be free from injury​
-Patient will be seizure free​

Implementation​:
-If administering IV phenytoin- mix only with NS. When administering by IV push, the infusion should be slow, not above 50 mg/minute for adult patients. The line must be flushed with NS after the IV push is administered. It is not administered IM because the absorption is too irregular. ​
-Pad the side rails, keep the bed in low position, ensure oxygen flow-meter is in room (safety)​
-Monitor for side effects​
-Monitor therapeutic levels periodically throughout therapy​ (be sure you know each drug's therapeutic range)

Patient Teaching​
-Oral care (brushing and flossing) at least 2 times per day for phenytoin. See dentist twice per year (helps prevent gingival hyperplasia)​
-Take drug as close to the same time per day as possible. Minor time changes are ok (one hour late, or one hour early)​
-Oral contraceptives do not work as well with phenytoin, use back up birth-control (condoms)​
-Barbiturates cause sedation and patient will be prone to tolerance. Drug dose will be raised periodically based on therapeutic range and patient response.​
-If a patient plans on becoming pregnant, the instruction that we provide is to speak with their health care provider before conceiving. This way, the best type of anticonvulsant for pregnancy can be tried (however, sometimes, the patient will remain on a drug that can cause birth defects if it controls the seizures for the mother, and frequent monitoring of the fetus will be done during pregnancy).​
-Avoid grapefruit juice with carbamazepine​

Evaluation​
-Patient remains safe and free from injury​
-Patient has no seizures and no side effects.