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Parkinsonism Agents
Antiparkinsonism Agents
| Question | Answer |
|---|---|
| Parkinson Disease | A progressive, chronic neurological disorder. No cure |
| Therapy is aimed at? | Management of S & S to provide optimal functioning for as long as possible |
| Parkinson Disease Presents as | Lack of coordination, rhythmic tremors which lead to rigidity or weakness, difficulty maintaining posture, shuffling gate(hallmark condition), mask like expression due to cranial nerves being affected |
| Parkinson Disease Presents as Bradykinesia | Difficulties performing intentional movements and extreme slowness or sluggishness |
| Parkinsonism | A term used to describe the Parkinson disease like extrapyramidal symptoms that are adverse effects ass. with particular drugs or brain injuries. Pt's exhibit tremors and bradykinesia |
| Pathophysiology | Cause is unknown. S & S are related to damaged neurons in the basal ganglia of the brain. |
| Causation Theories | Viral infection, blows to the head, brain infection, Atherosclerosis, exposure to drugs and certain environmental factors |
| Mechanisms (are understood) | Nerve cell bodies within the substantia nigra (dopamine-rich area) begin to degenerate ➡a reduction of impulses sent to the corpus striatum within the basal ganglia (inhibitory via dopamine) |
| Mechanisms (are understood) | The loss of dopamine secreting cells results in a loss of the inhibitory dopamine effect and is thought to be responsible for Parkinsons disease |
| Mechanisms (are understood) | Higher neurons originating in the cerebral cortex secrete ACh to coordinate intentional movements in the body |
| Mechanisms (are understood) | When dopamine ↓the cholinergic (excitatory) cells dominate➞alters function of extrapyramidal cells (provides coordination for unconscious muscle movement➞position and posture) |
| Mechanisms (are understood) | The result of this imbalance in the motor system leads to symptoms of parkinsons such as rigidity and tremors |
| Treatment | Aimed at restoring the balance between dopamine and ACh. Due to the degenerative effects of the disease pt's exp. episodes of depression or emotional upset➜ psychological and physical support is crucial. Drug therapy is primary TX |
| DOPAMINERGIC AGENTS | Drugs that increase the effects of dopamine receptor sites(more effective than anticholinergic) |
| Therapeutic Actions and Indications | Dopamine does not cross the BBB➜ must use other drugs that act like dopamine or indirectly increase dopamine levels. Drugs affective if there are enough neurons within the substantia nigra to respond to ↑ levels of dopamine |
| Contraindications and Cautions | Any known allergy, angle closure glaucoma. Dopaminergics cross the placenta and enter breast milk, pregnancy. Caution: renal/hepatic impairment, ♥ disease, hypertension, asthma, peptic ulcer, Urinary tract obstruction |
| Adverse Effects | Due to stimulation of dopamine receptors (↑♥, BP, ↓GI, urinary retention). |
| Adverse Effects CNS | Anxiety, nervousness, headache, confusion, dysphagia, mental changes, blurred vision, muscle twitching and ataxia. |
| Adverse Effects PNS | Anorexia, nausea, vomiting, dysphagia, constipation, diarrhea, ♥ arrhythmias, hypotension, urinary retention, ↑ sweating |
| Drug to Drug Interactions | Dopaminergics combined with MAOI's ➜ therapeutic effects ↑and a risk of hypertensive crisis exists. MAOI should be stopped 14 days before beginning therapy with a dopaminergic. Avoid O-T-C vitamins as ↓ effectiveness |
| PROTOTYPE LEVODOPA (DOPAR) | The mainstay of TX for Parkinsons and is almost always given in combination with carbidopa as will allow more Levodopa to cross the BBB. Carbidopa ↓ the amount of Levodopa needed to reach a therapeutic level in the brain so ↓ dose which ↓ adverse effects |
| PROTOTYPE LEVODOPA (DOPAR) | Effective for 2-5 years in relieving symptoms. Oral. Metabolized in liver/excreted urine. Can cause skin lesions and has been associated with development of melanoma |
| PROTOTYPE LEVODOPA (DOPAR) | Do not combine with B6 or phenytoin as ↓Levodopa |
| PROTOTYPE | ↑levels of dopamine in the central area of the brain to reduce signs and symptoms. Fatigue, weakness, drowsy, dizzy, fainting, agitation, ↑ sweating, headache, difficulty sleeping, numbness, dry mouth, adventitious movements and hand tremors |
| OTHER DOPAMINERGIC AGENTS AMANTADINE (SYMMETREL) | Oral. Anitviral drug that ↑ the release of dopamine: TX of idiopathic and drug-indused Parkinsonism in adults |
| APOMORPHINE (APOKYN) | Oral. Newer adjuctive therapy for intermittent TX of hypomobility 'off' episodes of advanced Parkinsons. Get an electrocardiogram |
| BROMOCRIPTINE (PARLODEL) | Oral. TX of idiopathic Parkinsons and beneficial in later stages when Levodopa wears off |
| CARBIDOPA-LEVODOPA (SINEMET) | Given in combination with Levodopa as will allow more Levodopa to cross the BBB. Carbidopa ↓ the amount of Levodopa needed to reach a therapeutic level in the brain so ↓ dose which ↓ adverse effects. TX of idiopathic Parkinson disease |
| PRAMIPEXOLE (MIRAPEX) | TX of idiopathic Parkinson disease |
| RASAGILINE (AZILECT) | New dopamine agonist that ↑ dopamine in the nerve synapse esp. in areas of the brain for controlling movement and coordination. Fewer PNS adverse effects. Used as initial monotherapy or as an adjunct to Levodopa. |
| RASAGILINE (AZILECT) | Avoid tyramine-containing food, ST Johns Wort, meperidine, anaglesics to avoid potentially serious reactions |
| ROPINIROLE (REQUIP) | Newer drug that directly stimulates dopamine receptors. Oral. TX of idiopathic Parkinson disease in early stages and in later stages when combined with Levodopa. TX of restless leg syndrome |
| Nursing Considerations Assessment- History and Exam | Any known allergy, GI depression/obstruction, urinary hesitancy/obstruction, BPH, glaucoma, ♥ arrhythmias, hypertension, resp. disease, pregnant/lactation |
| Nursing Considerations Assessment- History and Exam | Perform physical for a baseline status and to determine drug therapy effectiveness and adverse effects. Inspect skin for lesions or HX of melomona (Levodopa). |
| Nursing Considerations Assessment- History and Exam | Assess CNS-level of orientation, neuro status, reflexes, grip strength, gait, tremors, spasticity. Auscultate lungs and resp. status. Monitor P, BP, ♥ output |
| Nursing Considerations Assessment- History and Exam | Auscultate bowel sounds to evaluate GI, urine output, palpate bladder, liver and renal tests, CBC |
| Nursing Diagnosis Related to Drug Therapy | Disturbed Thought processes R/T CNS effects. Risk for urinary retention R/T dopaminergic effects. Constipation R/T dopaminergic effects. Risk for injury R/T CNS effects and orthostatic hypertension. Deficient knowledge RE: drug therapy |
| Implementation with Rationale | ↓dose if therapy has been interrupted to prevent systemic dopaminergic effects. Record progress and S&S. Give drug with meal if GI upset. Monitor bowels, hepatic/renal tests,urinary output & void prior to taking drug. Support, comfort, pt. teaching. |
| Evaluation | Monitor Pt. response, adverse effects (CNS changes, urinary retention, GI depression, tachycardia, ↑sweating, flushing. Evaluate support measures and effectiveness and compliance of regime |
| ANTICHOLINERGIC AGENTS Synthetic Drugs | Drugs that oppose the effects of ACH at receptor sites in the substantia nigra and the corpus striatum, thus helping to restore chemical balance in the area |
| ANTICHOLINERGIC AGENTS Synthetic Drugs Action | Synthetic drugs have a greater affinity for cholinergic sites in the CNS, however they can still block those in the PNS➜thus manifesting as ↓parasympathetic activity |
| ANTICHOLINERGIC AGENTS | Slowed GI motility and secretions, dry mouth , constipation, urinary retention, blurred vision, dilated pupils. NOT AS EFFECTIVE AS LEVODOPA in TX advanced cases but useful if no longer responding to Levodopa |
| Contraindications and Cautions | Allergy, narrow angle glaucoma, GI or GU obstruction, prostatic hypertrophy, myasthenia gravis (blocks ACh sites at neuromuscular junctions) |
| Contraindications and Cautions | Caution: Tachycardia and arrhythmias (blocking parasympathetic➜leads to a dominance of the sympathetic response). Pregnancy/Lactation only if benefit outweighs risk, hot environment. Safety in Kids not established |
| Adverse Effects CNS | Related to blocking ACh receptors. CNS- disorientation, confusion, memory loss, dizzy, agitation, weakness, light headed |
| Adverse Effects PNS | Decreased GI secretion and motility, dry mouth, blurred vision, ↓ sweating, pupil dilation |
| Drug to Drug Interactions | Risk of fatal paralytic ileus if anticholinergic drugs are used with other drugs that have cholinergic properties, including, tricyclic antidepressants and phenothiazines |
| Pharmacokietics | Variably absorbed from the GI tract, metabolized in liver and excreted by cellular pathways. All cross the placenta into breast milk. |
| PROTOTYPE BIPERIDEN (AKINETON) | Adjunctive TX for Parkinsonism disease. Oral, IM, IV. Acts as a cholinergic mainly in the CNS and helps reduce drooling. Disorientation, confusion, memory loss, nervous, liteheaded, depression, dry mouth, ↓sweating |
| BENZTROPINE (COGENTIN) | Oral, IV, IM. Adjunctive TX for Parkinsonism disease. |
| DIPHENHYDRAMINE (BENADRYL) | Oral, IV, IM. Adjunctive agent for TX of Parkinson disease, TX of Parkinsonism, including drug induced disease particularly in the elderly and Pt's at the early stages of the disease. Adult and Pediatric |
| TRIHEXTPHENIDYL (ARTANE) | Oral only. Adjunct to levopoda to TX Parkinsonism |
| Nursing Considerations Assessment and HIstory | Assess for contraindications and cautions, allergy to drug, GI depression or obstruction, urinary hesitancy, BPH, glaucoma, ♥ arrhythmias, hyper/hypo tension, myasthenia gravis, preg/lactation, hepatic dys, hot environment |
| Nursing Considerations Assessment and HIstory | Physical assess. to determine baseline. Assess CNS -level of orientation and neuro status, affect, reflexes, bilateral grip strength, gait, tremors, spasticity |
| Nursing Considerations Assessment and HIstory | Monitor P, BP, ♥ output, auscultate bowel. Assess urine output, palpate bladder. Monitor renal/liver tests |
| Nursing Diagnosis | Impaired oral mucous membranes R/T to anticholinergic effect. Risk for impaired thermoregulation R/T anticholinergic effects. Impaired urinary elim. R/T GU effects. Constipation R/T GI effects. |
| Nursing Diagnosis | Disturbed thought processes R/T CNS effects. Risk for Injury T/T CNS effects. Deficient knowledge regarding drug therapy. |
| Implementation with Rationale | If dry mouth severe and it becomes difficult to swallow arrange to ↓dose. Provide sugarless lozenges. Arrange to decrease dose in hot weather as ↓ ability to sweat. Give drug with meals if GI upset. |
| Implementation with Rationale | Monitor bowel and institute bowel program if severe constipation. Have pt. void prior to taking drug, monitor output and palpate bladder if urinary retention. Safety for CNS effects. Pt. teaching, support |
| Evaluation | Monitor pt. response to drug, Improvements and S&S, adverse effects. Evaluate teaching plan and pt compliance |
| ADJUNCTIVE AGENTS | Used to increase the responsiveness of the cells to dopamine. They act to decrease the breakdown of dopamine, leaving it on the receptor for longer periods of time |
| ADJUNCTIVE AGENTS | Only used in combination with carbidopa-levodopa and are usually reserved for when the pt. stops responding to traditional therapy |
| ENTACAPONE (COMTAN) | 200mg Oral 8 doses max per day taken with levodopa-carbidona. Adjunctive TX of Parkinson disease with Levodopa-carbidona for pt's with 'wearing off' effects. Absorbed GI/metabolized liver/excreted urine/feces. Crosses placenta |
| TOLCAPONE (TASMAR) | Increases levels of levodopa. Associated with fatal liver damage. Reserved for later stages of Parkinson's when carbidona-levodopa is losing effectiveness. Oral/GI absorption/metabolized liver/excreted urine/feces. Crosses placenta |
| SELEGILINE (CARBEX, ELDEPRYL) | Used with carbidopa-levodopa after pt's show signs of deteriorating response to TX. Irreversibly inhibits Monoamine oxidase (MAO) which breaksdown catecholamines and doamine. |
| SELEGILINE (CARBEX, ELDEPRYL) | Oral MAX daily DOSE 10mg and dose of levodopa must be reduced at start. Absorbed from GI/metabolized liver/excreted urine. Unknown if crosses placenta, benefits must outweigh risks. |
| SELEGILINE (CARBEX, ELDEPRYL) | Risk of MAO inhibitor hypertensive effects, severe headache must be reported. |
| Nursing Considerations Are Similar to Dopaminergic Drugs |
Created by:
gretchencox
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