Chronic Neurological Disorders UNIT 2 chapter 13 MEDICATIONS AFFECTING THE NERVOUS SYSTEM Chapter 13 Chronic Neurological Disorders Overview в—Џв—Џ в—Џв—Џ Use medications for chronic neurologic disorders to manage symptoms and improve quality of life. Chronic neurologic disorders include myasthenia gravis, ParkinsonвЂ™s disease, and seizure disorder. MEDICATION CLASSIFICATION: CHOLINESTERASE INHIBITORS в—Џв—Џ Select Prototype Medication вЂ“ Neostigmine (Prostigmin) в—Џв—Џ Other Medications: в—Їв—Ї Ambenonium (Mytelase) в—Їв—Ї Pyridostigmine (Mestinon) в—Їв—Ї Edrophonium (Tensilon) Purpose в—Џв—Џ Expected Pharmacological Action в—Їв—Ї в—Џв—Џ Cholinesterase inhibitors prevent the enzyme cholinesterase (ChE) from inactivating acetylcholine (ACh), thereby increasing the amount of ACh available at receptor sites. Transmission of nerve impulses is improved at all sites responding to ACh as a transmitter. Therapeutic Uses Treatment of myasthenia gravis NEOSTIGMINE AMBENOMIUM PYRIDOSTIGMINE X X X Diagnosis of myasthenia gravis Reversal of nondepolarizing neuromuscular blocking agents EDROPHONIUM X X PN PHARMACOLOGY FOR NURSING X X 159 Chronic Neurological Disorders Complications SIDE/ADVERSE EFFECTS NURSING INTERVENTIONS/CLIENT EDUCATION Excessive muscarinic stimulation as evidenced by increased gastrointestinal (GI) motility, increased GI secretions, bradycardia, and urinary urgency вЂў Advise clients of potential side effects. If effects become intolerable, instruct clients to notify the provider. вЂў Treat side effects with atropine. Cholinergic crisis (excessive muscarinic stimulation and respiratory depression from neuromuscular blockade) вЂў Monitor clients receiving atropine for muscarinic effects. вЂў Assist with emergency respiratory care. Contraindications/Precautions в—Џв—Џ в—Џв—Џ Cholinesterase inhibitors are Pregnancy Risk Category C. These medications are contraindicated in clients with obstruction of GI and genitourinary (GU) system, peptic ulcer disease, asthma, and coronary insufficiency. Interactions MEDICATION/FOOD INTERACTIONS NURSING INTERVENTIONS/CLIENT EDUCATION Atropine counteracts the effects of neostigmine. вЂў Atropine is used to treat neostigmine toxicity. Neostigmine reverses neuromuscular blockade caused by neuromuscular blocking agents after surgical procedures and overdose. вЂў Monitor clients for return of respiratory function. Support respiratory function as necessary. If used to treat overdose, provide mechanical ventilation until clients have regained full muscle function. Succinylcholine increases neuromuscular blockade. вЂў Avoid concurrent use. Nursing Administration в—Џв—Џ Neostigmine may be given PO, IM, IV, or subcutaneously. в—Џв—Џ Instruct clients to take medications as prescribed. в—Џв—Џ в—Џв—Џ Advise clients that dosage is very individualized, starts at very low doses, and is titrated until desired muscle function is achieved. Encourage clients to participate in self-dosage adjustments. Have clients: в—Їв—Ї в—Їв—Ї в—Їв—Ї в—Џв—Џ 160 Keep records of medication administration and effects. Recognize signs of inadequate dosing, such as difficulty swallowing, and signs of overmedication, such as urinary urgency. Modify dosage based on response. Advise clients to wear a medical alert bracelet. PN PHARMACOLOGY FOR NURSING Chronic Neurological Disorders Nursing Evaluation of Medication Effectiveness в—Џв—Џ Depending on therapeutic intent, effectiveness may be evidenced by: в—Їв—Ї в—Їв—Ї Fewer episodes of fatigue Improvement in strength as demonstrated by improved ability to chew, swallow, and perform activities of daily living (ADLs) such as bathing, walking, eating, and dressing MEDICATION CLASSIFICATION: ANTI-PARKINSONвЂ™S MEDICATIONS в—Џв—Џ в—Џв—Џ Select Prototype Medications: в—Їв—Ї Dopaminergics вЂ“ Levodopa (Dopar, Larodopa) or levodopa plus carbidopa (Sinemet) в—Їв—Ї Dopamine agonists вЂ“ Pramipexole (Mirapex) в—Їв—Ї Centrally acting anticholinergics вЂ“ Benztropine (Cogentin) в—Їв—Ї Dopamine releaser (Antiviral) вЂ“ Amantadine (Symmetrel) Other Medications: в—Їв—Ї Dopamine agonists вЂ“ Ropinirole (Requip), bromocriptine (Parlodel) в—Їв—Ї Centrally acting anticholinergics вЂ“ Trihexyphenidyl (Artane) Purpose в—Џв—Џ Expected Pharmacological Action в—Їв—Ї These medications do not halt the progression of ParkinsonвЂ™s disease (PD). However, they do offer symptomatic relief from dyskinesias (bradykinesia, resting tremors, and muscle rigidity) and an increase in the ability to perform ADLs by maintaining the balance between dopamine and ACh in the extrapyramidal nervous system. CLASSIFICATIONS EXPECTED PHARMACOLOGICAL ACTION Dopaminergics вЂў Levodopa crosses the blood-brain barrier and is taken up by dopaminergic nerve terminals and converted to dopamine (DA). This newly synthesized DA is released into the synaptic space and causes stimulation of DA receptors. вЂў Use carbidopa to augment levodopa by decreasing the amount of levodopa that is converted to DA in the intestine and periphery. This results in greater amounts of levodopa reaching the CNS. Dopamine agonists вЂў These agents act directly on DA receptors. Centrally acting anticholinergics вЂў These agents block ACh at muscarinic receptors, which assists in maintaining balance between dopamine and ACh in the brain. Antiviral вЂў Antivirals stimulate DA release, prevent dopamine reuptake, and may block cholinergic and glutamate receptors. PN PHARMACOLOGY FOR NURSING 161 Chronic Neurological Disorders в—Џв—Џ Therapeutic Uses в—Їв—Ї в—Їв—Ї Use levodopa as a first-line medication for PD treatment. Use pramipexole as monotherapy in early-stage PD and use in conjunction with levodopa in late-stage PD. It is used more often in younger clients who are better able to tolerate daytime drowsiness and orthostatic hypotension. Complications SIDE/ADVERSE EFFECTS NURSING INTERVENTIONS/CLIENT EDUCATION Dopaminergics: levodopa (Usually dose dependent) Nausea and vomiting, drowsiness вЂў Administer with food in small doses, and at the start of treatment. Dyskinesias (head bobbing, tics, grimacing, tremors) вЂў Administer a decreased dosage. The decrease may result in resumption of PD symptoms. Orthostatic hypotension вЂў Monitor the clientвЂ™s blood pressure. вЂў Instruct clients about signs of orthostatic hypotension (lightheadedness, dizziness). Instruct clients to change positions slowly and to sit or lie down if symptoms occur. Cardiovascular effects from beta1 stimulation (tachycardia, palpitations, irregular heartbeat) вЂў вЂў вЂў вЂў Psychosis (visual hallucinations, nightmares) вЂў Administer antipsychotic medications as prescribed. Discoloration of sweat and urine вЂў Advise clients that this is a harmless side effect. Activation of malignant melanoma вЂў Avoid use of medication in clients who have skin lesions that have not been diagnosed. Monitor the clientвЂ™s vital signs. Monitor ECG. Notify the provider if symptoms occur. Use cautiously in clients who have cardiovascular disorders. Dopamine agonists: pramipexole Sudden inability to stay awake вЂў Advise clients to notify the provider immediately if this occurs. Daytime sleepiness вЂў Advise clients of the potential for drowsiness and to avoid hazardous activities. вЂў Advise clients to avoid other CNS depressants such as alcohol. Orthostatic hypotension вЂў Instruct clients about the signs of orthostatic hypotension (lightheadedness, dizziness). Instruct clients to change positions slowly and to sit or lie down if symptoms occur. Psychosis (visual hallucinations, nightmares) вЂў Administer an atypical antipsychotic medication if symptoms occur. Dyskinesias (head bobbing, tics, grimacing, tremors) вЂў Decrease dosage of medication. Nausea вЂў Advise clients to take medication with food. 162 PN PHARMACOLOGY FOR NURSING Chronic Neurological Disorders SIDE/ADVERSE EFFECTS NURSING INTERVENTIONS/CLIENT EDUCATION Centrally acting anticholinergics: benztropine Nausea, vomiting вЂў Advise clients to take medication with food but to avoid highprotein snacks. Anticholinergic effects (dry mouth, blurred vision, mydriasis, urinary hesitancy or retention, constipation) вЂў Advise clients to observe for symptoms and notify the provider if they occur. вЂў Monitor I&O and check clients for urinary retention. вЂў Advise clients to chew sugarless gum, eat foods high in fiber, and increase fluid intake to 2 to 3 L/day from beverage and food sources. Antihistamine effects (sedation, drowsiness) вЂў Advise clients to avoid hazardous activities while taking the medication. Antiviral: amantadine CNS effects (confusion, dizziness, restlessness) вЂў Advise clients to avoid hazardous activities while taking the medication. Anticholinergic effects (dry mouth, blurred vision, mydriasis, urinary hesitancy or retention, constipation) вЂў Advise clients to observe for symptoms and notify the provider. вЂў Monitor I&O and check clients for hesitancy or urinary retention. вЂў Advise clients to chew sugarless gum, eat high-fiber foods, and increase fluid intake to 2 to 3 L/day from beverage and food. Discoloration of skin, also called livido reticularis вЂў Advise clients that discoloration of the skin will subside when the medication is discontinued. Levodopa plus carbidopa Abnormal movements, psychiatric disorders вЂў Advise clients of potential side effects and to notify the provider if they occur. Contraindications/Precautions в—Їв—Ї Levodopa в– в– This medication is Pregnancy Risk Category C. в– в– Contraindicated in clients with malignant melanoma. в– в– Do not use within 2 weeks of MAOI use. в– в– в—Їв—Ї Use cautiously in clients who have heart disease, clients who have psychiatric disorders, and older adult clients. Pramipexole в– в– This medication is Pregnancy Risk Category C. в– в– Use cautiously in clients with liver and kidney impairment. PN PHARMACOLOGY FOR NURSING 163 Chronic Neurological Disorders в—Їв—Ї Benztropine в– в– в– в– Contraindicated in clients with narrow-angle glaucoma, myasthenia gravis, and obstruction of the GI or GU system. Use cautiously in older adults, debilitated clients, clients who have enlarged prostate glands, hypertension, and renal and liver disease. Interactions MEDICATION/FOOD INTERACTIONS NURSING INTERVENTIONS/CLIENT EDUCATION Dopaminergics: levodopa Proteins interfere with levodopa absorption and transport across the blood-brain barrier. Highprotein meals decrease therapeutic effects. вЂў Proteins trigger an вЂњoff episode.вЂќ вЂў Advise clients to avoid high-protein meals and snacks. Conventional-antipsychotic agents (chlorpromazine [Compazine], haloperidol [Haldol]) decrease therapeutic effects. вЂў Avoid concurrent use. вЂў If clients experience levodopa-induced psychosis, administer an atypical antipsychotic agent. Pyridoxine (vitamin B6) decreases therapeutic effects. вЂў Advise clients to avoid vitamin preparations that contain pyridoxine. Concurrent use of MAOIs may result in hypertensive crisis. вЂў Avoid concurrent use. вЂў Use these medications concurrently to Carbidopa, dopamine agonists, anticholinergics, increase the beneficial effects of levodopa, Catechol O-methyltransferase (COMT) inhibitors, but this increases the risk of adverse effects and dopamine releasers increase therapeutic effects. such as psychosis. Dopamine agonists: pramipexole Use with levodopa can decrease motor control fluctuations and allow for lower dosage of levodopa. Concurrent use can also increase the risk of orthostatic hypotension and dyskinesias. вЂў Monitor clients for these interactions. Levodopa plus carbidopa Beneficial interactions include allowing for lower dosage of levodopa, reduced cardiovascular responses to dopamine in the periphery, and decreased nausea. вЂў Monitor clients for therapeutic effects. Nursing Administration в—Џв—Џ в—Џв—Џ в—Џв—Џ 164 Instruct family members to assist clients with the medication at home. Instruct clients about the possible sudden loss of the effects of medication and to notify the provider if symptoms occur. Inform clients that effects may not be noticeable for several weeks to several months. PN PHARMACOLOGY FOR NURSING Chronic Neurological Disorders в—Џв—Џ в—Џв—Џ Instruct clients that a medication вЂњholidayвЂќ may be prescribed, but will take place in an inpatient setting. Advise clients to avoid high-protein meals and snacks. Nursing Evaluation of Medication Effectiveness в—Џв—Џ Depending on therapeutic intent, effectiveness may be evidenced by: в—Їв—Ї в—Їв—Ї Improvement of symptoms as demonstrated by absence of tremors, and reduction of irritability and stiffness. Increase in ability to perform ADLs. MEDICATION CLASSIFICATION: ANTIEPILEPTICS (AEDs) в—Џв—Џ Select Prototype Medications: в—Їв—Ї в– в– Phenobarbital (Luminal) в– в– Primidone (Mysoline) в—Їв—Ї Phenytoin (Dilantin) в—Їв—Ї Carbamazepine (Tegretol) в—Їв—Ї Ethosuximide (Zarontin) в—Їв—Ї Valproic acid (Depakote) в—Їв—Ї Gabapentin (Neurontin) в—Їв—Ї в—Џв—Џ Barbiturates: Benzodiazepines: в– в– Diazepam (Valium) в– в– Lorazepam (Ativan) Other Medications: в—Їв—Ї Lamotrigine (Lamictal) в—Їв—Ї Oxcarbazepine (Trileptal) Purpose в—Џв—Џ Expected Pharmacological Action в—Їв—Ї AEDs control seizure disorders by various mechanisms, which include: в– в– в– в– в– в– Slowing the entrance of sodium and calcium back into the neuron and, thus extending the time it takes for the nerve to return to its active state. Suppressing neuronal firing, which decreases seizure activity and prevents propagation of seizure activity into other areas of the brain. Decreasing seizure activity by enhancing the inhibitory effects of gamma butyric acid (GABA). PN PHARMACOLOGY FOR NURSING 165 Chronic Neurological Disorders в—Џв—Џ Therapeutic Uses MEDICATION THERAPEUTIC USES Phenobarbital вЂў Use for partial seizures and generalized tonic-clonic seizures. вЂў This medication is not effective against absence seizures. Phenytoin вЂў Use for all major forms of epilepsy except absence seizures. вЂў Use IV route for status epilepticus. вЂў Use for dysrhythmias with QT prolongation. Carbamazepine вЂў Use for the treatment of partial (simple and complex) seizures, tonic-clonic seizures, bipolar disorder, and trigeminal and glossopharyngeal neuralgias. Ethosuximide вЂў Use only for absence seizures. Valproic acid вЂў Use for partial, generalized, and absence seizures; bipolar disorder; and migraine headaches. Gabapentin вЂў Use as a single agent for control of partial seizures. вЂў This medication is also used for neuropathic pain and the prevention of migraine headaches. Diazepam or lorazepam вЂў Use IV route for status epilepticus. Complications SIDE/ADVERSE EFFECTS NURSING INTERVENTIONS/CLIENT EDUCATION Barbiturates: phenobarbital CNS effects in adults manifest as drowsiness, вЂў Advise clients to observe for symptoms and sedation, confusion, and anxiety. In children, CNS to notify the provider if they occur. effects manifest as irritability and hyperactivity. вЂў Advise clients to avoid hazardous activities, such as driving. Toxicity (nystagmus, ataxia, respiratory depression, coma, pinpoint pupils, hypotension, death) 166 вЂў Stop medication. Administer oxygen and assist with emergency care. вЂў Monitor the clientвЂ™s vital signs. PN PHARMACOLOGY FOR NURSING Chronic Neurological Disorders SIDE/ADVERSE EFFECTS NURSING INTERVENTIONS/CLIENT EDUCATION Hydantoins: phenytoin CNS effects (nystagmus, sedation, ataxia, cognitive impairment, double vision) вЂў Monitor for symptoms and notify the provider if symptoms occur. Gingival hyperplasia (softening and overgrowth of gum tissue, tenderness, and bleeding gums) вЂў Advise clients to maintain good oral hygiene (dental flossing, massaging gums). Skin rash вЂў Instruct clients to stop the medication and notify the provider. Teratogenic (cleft palate, heart defects) вЂў Avoid use in pregnancy. Cardiovascular effects (dysrhythmias, hypotension) вЂў Monitor clients receiving IV therapy for adverse CV effects. Endocrine and other effects (coarsening of facial features, hirsutism, and interference with vitamin D metabolism) вЂў Instruct clients to report changes. вЂў Encourage clients to consume adequate amounts of calcium and vitamin D. Carbamazepine Cognitive function is minimally affected, but CNS effects (nystagmus, double vision, vertigo, staggering gait, headache) can occur. вЂў Administer in low doses initially and then gradually increase dosage. вЂў Instruct clients to administer the dose at bedtime. Blood dyscrasias (leukopenia, anemia, thrombocytopenia) вЂў Obtain the clientвЂ™s baseline and perform ongoing monitoring of CBC and platelet count. вЂў Observe clients for signs of bruising and bleeding of gums. Hypo-osmolarity (Carbamazepine promotes secretion of ADH, which inhibits water excretion by the kidneys and places clients who have heart failure at risk for fluid overload. вЂў Monitor serum sodium periodically. вЂў Monitor clients for edema, decrease in urine output, and hypertension. Skin disorders (dermatitis, rash, Stevens-Johnson syndrome) вЂў Treat mild reactions with anti-inflammatory or antihistamine medications. вЂў Instruct clients to notify the provider of severe reaction. The medication should be discontinued. Ethosuximide GI effects (nausea, vomiting) вЂў Administer with food. CNS effects (sleepiness, lightheadedness, fatigue) вЂў Administer low initial dosage. вЂў Advise clients to avoid hazardous activities, such as driving. PN PHARMACOLOGY FOR NURSING 167 Chronic Neurological Disorders SIDE/ADVERSE EFFECTS NURSING INTERVENTIONS/CLIENT EDUCATION Valproic acid GI effects (nausea, vomiting, indigestion) вЂў Advise clients to take medication with food. Enteric-coated formulation can decrease symptoms. Hepatotoxicity (anorexia, abdominal pain, jaundice) вЂў Check baseline liver function and monitor liver function periodically. вЂў Advise clients to observe for signs (anorexia, nausea, vomiting, abdominal pain, jaundice), and notify the provider if symptoms occur. вЂў Administer in lowest effective dose. Pancreatitis as evidenced by nausea, vomiting, and abdominal pain вЂў Advise clients to observe for symptoms and to notify the provider immediately if these symptoms occur. вЂў Monitor amylase levels. вЂў Medication should be discontinued if pancreatitis develops. Thrombocytopenia вЂў Advise clients to observe for symptoms such as bruising, and to notify the provider if these occur. вЂў Monitor the clientвЂ™s platelet counts. Gabapentin CNS effects (drowsiness, nystagmus) вЂў Administer low initial dosage. вЂў Advise clients to avoid hazardous activities, such as driving. Diazepam Respiratory depression вЂў Monitor the clientвЂ™s vital signs. вЂў Have resuscitation equipment ready. вЂў Administer oxygen. Anterograde amnesia вЂў Monitor clients for memory loss. вЂў Notify the provider if symptoms occur. Contraindications/Precautions в—Џв—Џ Phenobarbital, phenytoin, carbamazepine and valproic acid are Pregnancy Risk Category D. в—Џв—Џ Barbiturates are contraindicated in clients with intermittent porphyria. в—Џв—Џ 168 Phenytoin is contraindicated in clients with sinus bradycardia, sinoatrial blocks, secondand third-degree AV block, or Stokes-Adams syndrome. PN PHARMACOLOGY FOR NURSING Chronic Neurological Disorders в—Џв—Џ в—Џв—Џ Carbamazepine is contraindicated in clients with bone marrow suppression or bleeding disorders. Valproic acid is contraindicated in clients with liver disorders and children less than 3В yr of age. Interactions MEDICATION/FOOD INTERACTIONS NURSING INTERVENTIONS/CLIENT EDUCATION Phenytoin Phenytoin causes a decrease in the effects of oral contraceptives, warfarin (Coumadin), and glucocorticoids because of the stimulation of hepatic drug-metabolizing enzymes. вЂў Inform clients of interaction, and provider may need to adjust the dosage of oral contraceptives. Suggest use of an alternative form of birth control. вЂў Monitor for therapeutic effects of warfarin with PT and INR. Provider may adjust dosage. Alcohol, diazepam (Valium), cimetidine (Tagamet), and valproic acid decrease phenytoin levels. вЂў Advise clients to avoid alcohol use. вЂў Monitor phenytoin serum levels. Carbamazepine (Tegretol), phenobarbital, and chronic alcohol use increase phenytoin levels. вЂў Encourage clients to avoid use of alcohol. Additive CNS depressant effects can occur with concurrent use of CNS depressants (barbiturates, alcohol). вЂў Advise clients to avoid concurrent use of alcohol and other CNS depressants. Carbamazepine Carbamazepine causes a decrease in the effects of oral contraceptives and warfarin (Coumadin) because of the stimulation of hepatic drugmetabolizing enzymes. вЂў Inform clients of interaction and provider may need to adjust the dosage of oral contraceptives. Suggest use of an alternative form of birth control. вЂў Monitor for therapeutic effects of warfarin with PT and INR. вЂў Provider may adjust dosage. Grapefruit juice inhibits metabolism, and thus increases carbamazepine levels. вЂў Advise clients to avoid intake of grapefruit juice. Phenytoin and phenobarbital decrease the effects of carbamazepine. вЂў Avoid concurrent use. Valproic acid Concurrent use with valproic acid increases the levels of phenytoin and phenobarbital. PN PHARMACOLOGY FOR NURSING вЂў Monitor phenytoin and phenobarbital levels. вЂў Adjust dosage of medications as prescribed. 169 Chronic Neurological Disorders Nursing Administration в—Џв—Џ в—Џв—Џ в—Џв—Џ в—Џв—Џ в—Џв—Џ в—Џв—Џ в—Џв—Џ в—Џв—Џ Monitor therapeutic serum levels. Be aware of therapeutic levels for medications prescribed. Notify the provider of results. Advise clients taking antiepileptic medications that treatment provides for control of seizures, not cure of disorder. Encourage clients to keep a seizure frequency diary to monitor effectiveness of therapy. Advise clients to take medications as prescribed and not to stop medications without consulting the provider. Sudden cessation of medication may trigger seizures. Advise clients to avoid hazardous activities (driving, operating heavy machinery) until seizures are fully controlled. Advise clients who are traveling to carry extra medication to avoid interruption of treatment in locations where their medication is not available. Advise clients of childbearing age to avoid pregnancy, because medications may cause birth defects and congenital abnormalities. Advise clients that phenytoin has a narrow therapeutic range, and strict adherence to the medication regimen is imperative to prevent toxicity or therapeutic failure. Nursing Evaluation of Medication Effectiveness в—Џв—Џ 170 Depending on therapeutic intent, effectiveness may be evidenced by: в—Їв—Ї Absence or decreased occurrence of seizures в—Їв—Ї Ability to perform ADLs в—Їв—Ї Absence of injury PN PHARMACOLOGY FOR NURSING Chronic Neurological Disorders APPLICATION EXERCISES 1. Clients who take phenytoin must perform good oral hygiene. Why is oral hygiene important for these clients? 2. A client has been diagnosed with absence seizures. The nurse should recognize that which of the following medications are used to treat this type of seizure? (Select all that apply.) Phenytoin (Dilantin) Ethosuximide (Zarontin) Gabapentin (Neurontin) Carbamazepine (Tegretol) Valproic acid (Depakote) 3. A nurse is caring for a client who is taking valproic acid (Depakote) to prevent seizures. What laboratory values should the nurse plan to monitor for this client? 4. A client who has ParkinsonвЂ™s disease is prescribed levodopa/carbidopa (Sinemet) and pramipexole (Mirapex). For which of the following should the nurse monitor this client? A. Urinary hesitancy B. Watery diarrhea C. Weight gain D. Orthostatic hypotension 5. A client with ParkinsonвЂ™s disease has a new prescription for levodopa (Dopar). Which of the following findings should the nurse watch for in this client? (Select all that apply.) Hallucinations Memory loss Mania Paranoid ideas Nightmares PN PHARMACOLOGY FOR NURSING 171 Chronic Neurological Disorders APPLICATION EXERCISES ANSWER KEY 1. Clients who take phenytoin must perform good oral hygiene. Why is oral hygiene important for these clients? Gingival hyperplasia, an overgrowth of gum tissue, may occur in clients who take phenytoin. Bleeding gums, and swelling and tenderness of tissue, may result. The client should brush well, floss between teeth, and perform gum massage to minimize this adverse reaction. NCLEXВ® Connection: Pharmacological Therapies, Adverse Effects/Contraindications/Side Effects/Interactions 2. A client has been diagnosed with absence seizures. The nurse should recognize that which of the following medications are used to treat this type of seizure? (Select all that apply.) Phenytoin (Dilantin) X Ethosuximide (Zarontin) Gabapentin (Neurontin) Carbamazepine (Tegretol) X Valproic acid (Depakote) Use ethosuximide and valproic acid to treat absence seizures. Phenytoin is effective against all major forms of seizures except absence seizures. Use gabapentin as a single agent for control of partial seizures. Use carbamazepine for the treatment of partial (simple and complex) seizures, tonic-clonic seizures, bipolar disorder, and trigeminal and glossopharyngeal neuralgias. NCLEXВ® Connection: Pharmacological Therapies, Expected Actions/Outcomes 3. A nurse is caring for a client who is taking valproic acid (Depakote) to prevent seizures. What laboratory values should the nurse plan to monitor for this client? Severe hepatotoxicity and pancreatitis may occur in the client taking valproic acid. The nurse should plan to monitor periodic liver function tests and amylase values. The nurse should also reinforce teaching about manifestations of hepatotoxicity (nausea, anorexia, abdominal pain, and jaundice) and pancreatitis (abdominal pain, nausea, vomiting, and weight loss) for the client to report to the provider. NCLEXВ® Connection: Pharmacological Therapies, Adverse Effects/Contraindications/Side Effects/Interactions 172 PN PHARMACOLOGY FOR NURSING Chronic Neurological Disorders 4. A client who has ParkinsonвЂ™s disease is prescribed levodopa/carbidopa (Sinemet) and pramipexole (Mirapex). For which of the following should the nurse monitor this client? A. Urinary hesitancy B. Watery diarrhea C. Weight gain D. Orthostatic hypotension Orthostatic hypotension is an adverse effect of both levodopa/carbidopa and pramipexole. When both medications are prescribed, the incidence of orthostatic hypotension is very high. Memory loss, diarrhea, and weight gain are not adverse effects of either medication. NCLEXВ® Connection: Pharmacological Therapies, Adverse Effects/Contraindications/Side Effects/Interactions 5. A client with ParkinsonвЂ™s disease has a new prescription for levodopa (Dopar). Which of the following findings should the nurse watch for in this client? (Select all that apply.) X Hallucinations Memory loss Mania X Paranoid ideas X Nightmares Psychotic behaviors which may occur in clients taking levodopa include visual hallucinations, paranoid ideas, and vivid dreams or nightmares. Memory loss and mania are not manifestations seen in clients taking this medication. NCLEXВ® Connection: Pharmacological Therapies, Adverse Effects/Contraindications/Side Effects/Interactions PN PHARMACOLOGY FOR NURSING 173