NCM 212: PHARMACOLOGY

BSN-N22(UNIT 4)
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MUSCLE RELAXANTS & ANTI-PARKINSONIAN AGENTS _ NURSING PROCESS _
- A muscle relaxant is a drug that affects skeletal muscle ASSESSMENT _
function and decreases the muscle tone. It may be used ● Pre-administration Assessment:
to alleviate symptoms such as muscle spasms, pain, and - Obtain patient’s history: Summary of the
hyperreflexia. The term "muscle relaxant" is used to refer disorder, including onset, symptoms, and current
to two major therapeutic groups: neuromuscular blockers treatment or therapy
and spasmolytics. - Examine affected joints in the extremities for
SKELETAL MUSCLE RELAXANTS _ appearance of the skin over the joint, evidence
Uses and Adverse Reactions of joint deformity, and mobility of the affected
● Uses: Various acute, painful musculoskeletal conditions joint if the patient has Arthritis
● Adverse Reactions: ● Ongoing Assessment:
- Drowsiness: Most common reaction - Inspect the joints involved every 1 to 2 hours to
- Diazepam: Drowsiness, sedation, sleepiness, identify immediately a response or nonresponse
lethargy, constipation or diarrhea, bradycardia or to therapy
tachycardia, and rash - Question the patients regarding relief of pain,
adverse drug reactions
- Closely observe the patients for the
development of adverse reactions
Nursing Diagnoses:
● Readiness for Enhanced Fluid Balance related to need
for increased fluid intake to promote excretion of urate
crystals
● Impaired Comfort: Gastric Distress related to irritation
of gastric lining from medication administration
● Risk for Injury related to medication-induced
drowsiness and associated risk for imbalance and falls
● Risk for Allergy Response related to response to
substance trigger (drug allergy)

PLANNING_____________________
● The Expected Outcome includes:
- Optimal response to therapy
- Support of patient needs related to the
management of adverse reactions
- Understanding of and compliance with the
prescribed therapeutic regimen
● Expected Outcome: Depends on reason for the drug
therapy
CONTRAINDICATIONS _ IMPLEMENTATION__________________
Contraindications #1: ● Promoting an Optimal Response to therapy:
● In patients with known hypersensitivity to the drugs - Be alert to reactions such as skin rash, fever,
● Baclofen: Contraindicated in skeletal muscle spams cough, or easy bruising
caused by rheumatic disorders - Be attentive to specific patient complaints
● Carisoprodol: Contraindicated in patients with known such as visual changes, Tinnitus, or hearing
hypersensitivity to meprobamate loss
Contraindications #2: - Evaluate any complaint or comment made by
● Cyclobenzaprine: Contraindicated in patients with a the patient and report it to the primary health
recent Myocardial Infarction (MI), Cardiac Conduction care provider.
Disorders, and Hyperthyroidism - Observe closely for development of adverse
● Oral Dantrolene: Contraindicated during lactation and in reactions, such as Thrombocytopenia and
patients with Active Hepatic Disease and muscle spasms Leukopenia
cause by Rheumatic Disorders - Immediately bring all adverse reactions or
PRECAUTIONS _ suspected adverse reactions to the attention
● Precautions: Used with caution in patients with a history of the primary health care provider.
of Cerebrovascular Accident, Cerebral Palsy,
Parkinsonism, or Seizure Disorders and during pregnancy ● Monitoring and Managing Patient needs:
and lactation - Readiness for Enhanced Fluid Balance:
● Carisoprodol: Used with caution in patients with Severe ✔ Encourage a liberal fluid intake and
Liver or Kidney Disease and during pregnancy and measure the intake and output
lactation - Impaired Comfort: Gastric Distress
● Cyclobenzaprine: Used cautiously in patients with ✔ Administer the drug with 6 to 8 oz of
Cardiovascular Disease and during pregnancy and water while the patient is in an
lactation upright position
● Dantrolene: A Pregnancy Category C Drug–used with - Impaired Comfort: Gastric Distress (cont.)
caution during pregnancy ✔ Check the dosage and frequency
INTERACTIONS _ carefully to prevent drug
administration errors
✔ Administer DMARDs, uric acid
inhibitors, and skeletal muscle
relaxants with or immediately after
meals to minimize gastric distress
- Risk for Injury:

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 ✔ Evaluate the patient carefully before
allowing the patient to ambulate
alone
✔ Notify the primary health care
provider before the next dose is due
if drowsiness is severe
✔ Assist with the ambulatory activities
if drowsiness does occur

● Educating the Patient and Family:

- Develop an effective teaching plan for the
patient and family
- Explain that treatment for the disorder
includes drug therapy, as well as other
medical management
- Emphasize the importance of not taking any
nonprescription drugs unless their use has
been approved by the primary health care
provider
EVALUATION__________________
● The therapeutic drug effect is achieved
● Adverse reactions are identified, reported to the primary
health care provider, and managed using appropriate
nursing interventions
● The patient verbalizes the importance of complying with ADVERSE REACTIONS, CONTRAINDICATIONS, AND _
the prescribed therapeutic regimen PRECAUTIONS
● The patient and family demonstrate an understanding of ● Dry mouth, difficulty swallowing, anorexia, nausea,
the drug regimen. vomiting, abdominal pain, constipation, increased hand
ANTI-PARKINSONIAN DRUGS_____________ tremor, headache, dizziness
Definitions: ● Adverse reactions seen with Levodopa: Choreiform
● Parkinsonism: Referring to a cluster of symptoms movements, dystonic movements
associated with Parkinson Disease (i.e., fine tremors, ● Contraindications:
slowing of voluntary movements, muscular weakness) - Dopaminergic Drugs: Patients with known
● Parkinson Disease: Degenerative disorder caused by an hypersensitivity to the drugs
imbalance of dopamine and acetylcholine in the CNS - Levodopa: Patients with Narrow-angle
DOPAMINERGIC DRUGS _ Glaucoma, those receiving MAOI
ACTIONS _ antidepressants
● Symptoms of Parkinsonism are caused by depletion of ● Precautions:
dopamine in CNS - Levodopa is used cautiously in patients with
● Amantadine: Makes more dopamine available at receptor Cardiovascular or Pulmonary Diseases; Peptic
site; Selegiline and Rasagiline: inhibit monoamine Ulcer Disease; Renal or Hepatic Disease; and
oxidase type B, again making more dopamine available Psychosis
● Combining Levodopa with another drug allows more - Dopamine Agonist Selegiline should not be used
Levodopa to reach brain, hence provide better with opioid Meperidine due to antimetabolite
pharmacologic effect in patients with Parkinson Disease conversion
USES________________________ INTERACTIONS____________________
● Parkinson Disease
● Parkinson-like symptoms as a result of injury, drug
therapy, or Encephalitis
● Restless leg syndrome
● Viral infections

DOPAMINE RECEPTOR AGONISTS _

Actions and Uses
● Actions: Acts directly on Postsynaptic Dopamine
Receptors of nerve cells in brain, mimicking effects of
dopamine in brain
● Uses: Used in treatment of signs and symptoms of
Parkinson Disease and Restless Leg Syndrome
Adverse Reactions, Contraindications, and Precautions
● Nausea; dizziness; vomiting; somnolence; hallucinations;
confusion; visual disturbances; postural hypotension;
abnormal involuntary movements; headache
● Contraindications: Patients with known hypersensitivity to
drugs
● Precautions: Used with caution in patients with
dyskinesia; orthostatic hypotension; hepatic or renal
impairment; history of hallucinations or psychosis;
cardiovascular disease renal impairment

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 NURSING PROCESS _
Interactions ASSESSMENT _
● Pre-administration assessment:
- Obtain health history from family member
- Perform physical assessment of patient to provide baseline data
for future evaluations of drug therapy.
● Ongoing assessment:
- Evaluate patient’s response to drug therapy by observing patients
for various neuromuscular signs and compare these observations
with data obtained during initial physical assessment
NURSING DIAGNOSES ___________
COMT(catechol-O-methyltransferase) INHIBITORs _ ● Imbalanced Nutrition: Less Than Body Requirements
Actions and Uses related to nausea, dry mouth
● Actions: ● Constipation related to neurologic changes in the
- Prolong the effect of Levodopa by blocking an bowel
enzyme, catechol-O-methyltransferase, which ● Risk for Injury related to dizziness, lightheadedness,
eliminates dopamine orthostatic hypotension, loss of balance
- With Levodopa: Increased plasma concentration ● Impaired Physical Mobility related to alterations in
and duration of action of Levodopa balance, unsteady gait, dizziness
● COMT inhibitors are used as adjuncts to ● Disturbed Sleep Pattern related to involuntary
Levodopa/Carbidopa in treating Parkinson Disease
Adverse Reactions, Contraindications, and Precautions PLANNING_____________________
● Dizziness, dyskinesias, hyperkinesias, akathisia, nausea, ● Expected Outcomes for Patient may include:
anorexia, diarrhea, orthostatic hypotension, sleep - Optimal response to drug therapy
disorders, excessive dreaming, somnolence, muscle - Support of patient needs related to management
cramps of adverse reactions
● Contraindicated: Patients with hypersensitivity to drugs, - Absence of injury
including pregnancy and lactation - Understanding of and compliance with
● Caution: Patients with hypertension; hypotension; prescribed therapeutic regimen
decreased hepatic or renal function IMPLEMENTATION____________________
Interactions
● Promoting an Optimal Response to therapy:
- Carefully monitor drug therapy; provide
psychological support; emphasize patient and
family teaching
- Requires titration of doses based on patient
activities
- Withhold next dose of drug and immediately
CHOLINERGIC BLOCKING DRUGS/ANTICHOLINERGICS _ notify primary health care provider if sudden
Actions behavioral changes are noted
● Drugs with cholinergic blocking activity: Blocks Ach in
CNS, enhancing dopamine transmission
● Antihistamines, such as Diphenhydramine, are used in ● Monitoring and Managing Patient needs:
elderly patients as they produce fewer adverse effects - Imbalanced Nutrition: Less Than Body Requirements
Uses and Adverse Reactions ○ Help patient relieve dry mouth by offering
● Uses: Used as adjunctive therapy in all forms of frequent sips of water, ice chips, or hard
parkinsonism and in control of drug-induced candy (not for diabetic pts)
extrapyramidal disorders ○ Create calm environment; serve small.
● Adverse Reactions: Dry mouth; blurred vision; dizziness; Frequent meals; serve foods patients prefer to
mild nausea; nervousness; skin rash; urticaria; urinary help improve nutrition
retention; dysuria; tachycardia; muscle weakness; ○ Monitor patient’s weight daily
disorientation; confusion - Constipation:
Contraindications and Precautions ○ Observe patient with parkinsonism for
● Contraindicated in Patients: With hypersensitivity to outward changes that may indicate one or
anticholinergic drugs; Glaucoma; pyloric or duodenal more adverse reactions
obstruction; peptic ulcers; prostatic hypertrophy; ○ Stress need for diet high in fiber and
achalasia; myasthenia gravis; megacolon increasing fluids in diet
● Used with caution in Patients with: Tachycardia; cardiac - Risk for Injury
arrythmias; hypertension; hypotension; tendency toward ○ Carefully evaluate any sudden changes in
urinary retention; decreased liver or kidney function; patient’s behavior or activity and report them
obstructive disease of urinary system or gastrointestinal to primary health care provider
tract ○ Assist patient in getting out of bed or a chair,
Interactions walking, and other self-care activities
- Impaired Physical Mobility
○ Is the symptoms occur, primary health care
provider may order a drug holiday that
includes complete withdrawal of Levodopa for
5 to 14 days, followed by gradually restarting
drug therapy at lower dose

● Educating the Patient and Family

- Evaluate patient’s ability to understand
therapeutic drug regimen; ability to perform
self-care in the home environment; ability to
comply with prescribed drug therapy

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 ANTI SEIZURES/ANTIEPILEPSY _
- Encourage family to create a home
ANTI-EPILEPTICS _
environment that is least likely to result in
Drugs Used for Managing Seizure Disorders
accidents or falls
● The drug categories used as Anti-Epileptics are the
EVALUATION) ) ))))))))))))))))))))) Hydantoins, Carboxylic Acid Derivatives, Succinimides,
● Therapeutic effect is achieved and the symptoms of Oxazolidinediones, Benzodiazepines, and Non-specified
parkinsonism are controlled drugs
● Adverse reactions are identified, reported, and managed ACTIONS _
successfully through appropriate nursing interventions Actions #1
● No evidence of injury is seen ● Hydantoins stabilize the hyperexcitability postsynaptically
● Patients verbalizes an understanding of treatment in the motor cortex of the brain
modalities, adverse reactions, and importance of ● Carboxylic Acid Derivatives increase levels of Gamma
continued follow-up care (y)-Aminobutyric Acid (GABA), which stabilizes cell
● Patient and family demonstrate an understanding of drug membranes
regimen ● Succinimides depress the motor cortex, creating a higher
threshold before nerves react to the convulsive stimuli
Actions #2
● Oxazolidinediones decrease repetitive synaptic
transmissions of nerve impulses
● Benzodiazepines elevate the seizure threshold by
decreasing postsynaptic excitation
● Non-specified drugs have differing properties; for
example, gabapentin is a GABA agonist, and topiramate
blocks the seizure activity rather than raising the
threshold
USES _
● Used prophylactically to prevent seizures following
trauma, neurosurgery, or tumor
● Used in treatment of:
- Seizures of all types; neuropathic pain; bipolar
disorders; anxiety disorders

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 INTERACTIONS _
Interactions #1

Interactions #2

NURSING PROCESS _
ASSESSMENT _
ADVERSE REACTIONS _
● Pre-administration Assessment:
● CNS Reactions: Drowsiness; weakness; dizziness;
- Obtain vital signs at the time of the initial
headache; somnolence; nystagmus; ataxia; slurred
assessment to provide baseline data
speech
- Thorough patient history is necessary to identify
● GI Reactions: Nausea; vomiting; anorexia; constipation;
type of seizure disorder
diarrhea; gingival hyperplasia; acute liver failure with
- Primary health care provider may order
felbamate
laboratory and diagnostic tests
● Other: Skin rashes; pruritus; urticaria; urinary frequency;
● Ongoing Assessment:
serious skin reactions; hematologic changes
- Carefully document each seizure with regard to
CONTRAINDICATIONS_ ____
time of occurrence; duration of seizure; psychic
Contraindications #1
or motor activity occurring before, during after
● Contraindicated in patients hypersensitive to the drugs
seizure
- Phenytoin is contraindicated in patients with
- Dosage adjustments are based on patient’s
sinus bradycardia; with sinoatrial block; with
response to therapy, as well as occurrence of
Adams-Stokes syndrome; with second-and
adverse reactions
third-degree atrioventricular (AV) block; during
- Serum plasma levels of anticonvulsant are
pregnancy and lactation
measured regularly to monitor for toxicity
- Ethotoin (Peganone) is contraindicated in
NURSING DIAGNOSES ___________
patients with hepatic abnormalities
● Risk for Injury related to seizure disorder, drowsiness,
Contraindications #2
ataxia, and vision disturbances
● Succinimides are contraindicated in patients with bone
● Risk for Impaired Skin Integrity related to adverse
marrow depression or hepatic or renal impairment
reactions (rash)
● Carbamazepine is contraindicated in patients with bone
● Risk for Infection related to immunosuppression
marrow depression or hepatic or renal impairment and
secondary to drug therapy
during pregnancy
● Impaired Oral Mucous Membranes related to gum
● Valproic Acid (Depakote) is not administered to patients
overgrowth secondary to hydantoins
with renal impairment or during pregnancy
● Oxcarbazepine may exacerbate dementia PLANNING________________ _____
PRECAUTIONS _ ● Expected outcomes for patient depend on the type and
Precautions #1 severity of the seizure but may include:
● Used cautiously in patients with liver or kidney disease - Optimal response to therapy
and neurologic disorders - Support of patient needs related to management
- The newer medications such as Elicarbazepine of adverse reactions
and Oxcarbazepine can cause hyponatremia - Understanding of and compliance with
- Benzodiazepines are used cautiously during prescribed therapeutic regimen
pregnancy and in patients with psychoses; IMPLEMENTATION____________________
patients with acute narrow-angle glaucoma;
elderly or debilitated patients ● Promoting an optimal response to therapy:
Precautions #2 - Make notation on the care plan and inform all
● Phenytoin is used cautiously in patients with hypotension; health care team members of the importance
severe myocardial insufficiency; hepatic impairment of the drug
● Trimethadione is used with caution in patients with eye ● Barbiturates:
disorders - Monitor patient carefully during administration
● Miscellaneous Anti-Epileptics are used cautiously in of barbiturate, taking blood pressure and
patients with glaucoma or increased intraocular pressure; observing respirations frequently
a history of cardias, renal, or liver dysfunction; and Benzodiazepines:
psychiatric disorders ○ Dosage of Benzodiazepines is highly individualized;
increase the dosage cautiously to avoid adverse
reactions, particularly in elderly and debilitated patients
○ Do not mix Diazepam with other drugs

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Hydantoins: ○ Determine protective measures when exposed to
○ Monitor serum concentrations of drug on regular basis ultraviolet light, sunlight
to detect signs of toxicity ○ Notify primary health care provider if following
Oxazolidinediones: reactions occur: Visual disturbances; excessive
○ Used when less toxic drugs are not effective in drowsiness; dizziness; sore throat; fever; skin rash;
controlling seizure disorder pregnancy; malaise; easy bruising; epistaxis; bleeding
Succinimides: tendencies
○ Effective in controlling partial seizures; these drugs are
EVALUATION___________________
given with food to prevent GI upset
● Therapeutic effect is achieved and convulsions are
Miscellaneous Anti-epileptics:
controlled
○ Drug is absorbed rapidly when taken orally, should not
● No injury is evident
be chewed but swallowed whole
● Adverse reactions are identified, reported, and managed
successfully through appropriate nursing interventions
● Monitoring and Managing Patient needs:
● Patient verbalizes the importance of complying with the
- Risk for Injury:
prescribed treatment regimen
○ Assist the patient with all ambulatory activities
● Patients verbalizes an understanding of treatment
○ Use caution when giving oral preparation as aspiration
modalities and the importance of continued follow-up care
of tablet, capsule, or liquid may occur if patient
● Patient and family demonstrate an understanding of the
experiences drowsiness
drug regimen.
○ Test swallowing ability of patient by offering small sips
of water before giving drug
- Risk for Impaired Skin Integrity:
○ Carefully examine all affected areas and provide an
accurate description
○ Be alert for signs of Pancytopenia, such as sore throat,
fever, general malaise, bleeding of the mucous
membranes, epistaxis, easy bruising
○ Routine laboratory tests, such as complete blood
counts and differentia; counts, should be performed
periodically
- Impaired Oral Mucous Membranes:
○ Periodically inspect mouth, teeth, gums of patients in a
hospital or long-term clinical setting

● Educating the Patient and Family:

- When patient receives diagnosis of Epilepsy,
nurse must assist patient and family to adjust
to diagnosis
- Instruct family members in care of patient
before, during, and after seizures
- Explain importance of restricting some
activities until seizures are controlled by drugs
- Assist patient to look for other modes of
transportation in order to continue typical
activities or employment
- Review adverse drug reactions associated
with the prescribed anticonvulsant with the
patient and family members
Hydantoins:
○ Inform dentist and other primary health care providers
of use of this drug
○ Brush and floss teeth after each meal and make
periodic dental appointments for oral examination and
care
- Take medication with food to reduce GI upset
- Thoroughly shake Phenytoin suspension
immediately before use
- Do not take capsules that are discolored
- Notify primary health care provider if any of
the following occurs: Skin rash; bleeding;
swollen or tender gums; yellowish
discoloration of the skin or eyes; unexplained
fever; sore throat; unusual bleeding or
bruising; persistent headache; malaise; or
pregnancy.
Succinimides:
○ If GI upset occurs, take drug with food or milk
○ Notify primary health care provider if any of the
following occurs: Skin rash; joint pain; unexplained
fever; sore throat; usual bleeding or bruising;
drowsiness; dizziness; blurred vision; or pregnancy
Oxazolidinediones:

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