NURS 133 Valproic acid and Lorazepam

jasmine's version from 2016-04-30 22:31

Section 1

Question Answer
Valproic acid (Depakene) Monotherapy and adjunctive therapy for simple and complex absence seizures; Monotherapy and adjunctive therapy for complex partial seizures; Adjunctive therapy for patients with multiple seizure types, including absence seizures; Sometimes used together with other seizure medications; Also used to treat manic episodes related to bipolar disorder, and to prevent migraine headaches
Valproic acid actions Increase levels of GABA, an inhibitory neurotransmitter in the CNS
Valproic acid therapeutic uses Suppression of seizure activity; Decreased manic episodes; Decreased frequency of migraine headaches
Elimination/Excretion of Valproic acid Mostly metabolized by the liver; minimal amounts excreted unchanged in urine
Adverse/Side Effects of Valproic acid Suicidal thoughts, agitation, dizziness, headache, insomnia, sedation; Visual disturbances; Hepatotoxicity, pancreatitis, abdominal pain, anorexia, diarrhea, indigestion, nausea, vomiting; Hyperammonemia; Hypothermia, tremor
Contraindications of Valproic acid Hypersensitivity; hepatic impairment; Genetic implication Known/suspected urea cycle disorders (may result in fatal hyper-ammonemic encephalopathy); Mitochondrial disorders caused by mutations in mitochondrial DNA polymerase gamma (increase risk for potentially fatal hepatotoxicity); Pedi: Children <2 years of age with suspected mitochondrial disorder caused by mutations in mitochondrial DNA polymerase gamma (increase risk for potentially fatal hepatotoxicity); OB: Pregnancy (for migraines only)-linked to congenital anomalies, neural tube defects, clotting abnormalities, and hepatic dysfunction in the neonate as well as impaired cognitive development as the child matures; Lactation: Passes into breast milk; Geri: Increase risk of adverse effects; All patients: Increase risk of suicidal thoughts/behaviors
Drug/Food interactions of Valporic acid Increase risk of bleeding with warfarin; Blood levels and toxicity may be increase by aspirin, carbamazepine, chlorpromazine, cimetidine, erythromycin, or felbamate; Increase CNS depression with other CNS depressants, including alcohol, anti-histamines, anti-depressants, opioid analgesics, MAO inhibitors, and sedative/hypnotics; MAO inhibitors and other anti-depressants may decrease seizure threshold and effectiveness of valproate; carbamazepine, meropenem, phenobarbital, phenytoin, or rifampin may decrease valproate blood levels; Valproate may increase toxicity of carbamazepine, diazepam, amitriptyline, nortriptyline, ethosuximide, lamotrigine, phenobarbital, phenytoin, topiramate, or zidovudine; Concurrent use with topiramate may increase risk of hypothermia and hyperammonemia with or without encephalopathy; Ertapenem, imipenem, or meropenem may decrease valproate blood levels
Medication administration of Valproic acid PO; IV; Rect
Nursing interventions of Valproic acid Seizures: Assess location, duration, and characteristics of seizure activity; Bipolar disorder: Assess mood, ideation, and behavior frequently; Migraine Prophylaxis: Monitor frequency and intensity of migraine headaches; Geri: Assess geriatric patients for excessive somnolence; Assess for suicidal tendencies, especially during early therapy. Restrict amount of drug available to patient. Risk may be increased in children, adolescents, and adults less than and equal to 24 years of age; Lab test considerations: Monitor CBC, platelet count, and bleeding time prior to and periodically during therapy-may cause leukopenia and thrombocytopenia; Monitor hepatic function (LDH, AST, ALT, and bilirubin) and serum ammonia concentrations prior to and periodically during therapy. May cause hepatotoxicity-monitor closely, especially during initial 6 months of therapy-fatalities have occurred. Therapy should be discontinued if hyperammonemia occurs; Note: single doses usually administered prior to sleep due to sedation effect
Client education of Valproic acid Instruct patient to take medication as directed; Caution patient to avoid driving or other activities requiring alertness until effects of medication are known; Caution patient to avoid alcohol during therapy; Advise patient and family to notify health care professional if thoughts about suicide or dying, attempts to commit suicide; new or worse depression; new or worse anxiety; feeling very agitated or restless, panic attacks, trouble sleeping; new or worse irritability; acting aggressive; being angry or violent; acing on dangerous impulses; an extreme increase in activity and talking, other unusual changes in behavior or mood occur; Advise patient to notify health care professional if anorexia, abdominal pain, severe nausea and vomiting, yellow skin or eyes, fever, sore throat, malaise, weakness, facial edema, lethargy, unusual bleeding or bruising, pregnancy, or loss of seizure control occurs. Children <2 years of age are especially at risk for fatal hepatotoxicity; Instruct female patients to notify health care professional immediately if pregnancy is planned or suspected-may cause teratogenic effects-or if breast feeding. Advise pregnant patients taking valproates to enroll in the NAAED Pregnancy Registry by calling 1-888-233-2334 or to register at; Advise patient to carry identification at all times describing medication regimen; Emphasize the importance of routine exams to monitor progress
Evaluation/Desired outcomes of Valporic acid Decreased seizure activity; Decreased incidence of manic episodes in patients with bipolar disorders; Decreased frequency of migraine headaches
Potential nursing diagnoses of Valproic acid Risk for injury (indications)

Section 2

Question Answer
Lorazepam (Ativan) Belongs to a group of drugs called benzodiazepines; Anxiety disorder (oral); Pre-operative sedation (injection); Decreases pre-operative anxiety and provides amnesia
Lorazepam actions Depresses the CNS, probably by potentiating GABA, an inhibitory neurotransmitter
Lorazepam therapeutic uses Sedation; Decreased anxiety; Decreased seizures
Elimination/Excretion of Lorazepam Highly metabolized by the liver
Adverse/Side Effects of Lorazepam Dizziness, drowsiness, lethargy; Rapid IV use only: Apnea, cardiac arrest
Contraindications of Lorazepam Hypersensitivity; Cross-sensitivity with other benzodiazepines may exist; comatose patients or those with pre-existing CNS depression; Uncontrolled severe pain; Angle-closure glaucoma; Severe hypotension; Sleep apnea; OB, Lactation: Use in pregnancy and lactation may cause CNS depression, flaccidity, feeding difficulties, hypothermia, seizures, and respiratory problems in the neonate-discontinue drug or bottle-feed; Pedi: Use cautiously in children under 12 years of age; Geri: Lower doses recommended
Drug/Food interactions of Lorazepam Additive CNS depression with other CNS depressants including alcohol, anti-histamines, anti-depressants, opioid analgesics, clozapine, and other sedative/hypnotics including other benzodiazepines; May decrease the efficacy of levodopa; Smoking may increase metabolism and decrease effectiveness; Oral contraceptives may decrease levels; concomitant use of kava-kava, valerian, or chamomile can increase CNS depression
Medication administration of Lorazepam PO; SL (sublingual); IM; IV
Nursing interventions of Lorazepam Assessment of continued need for treatment; Pedi: Assess neonates for prolonged CNS depression related to inability to metabolize lorazepam; Geri: Assess geriatric patients carefully for CNS reactions, as they are more sensitive to these effects-Assess for fall risks; Anxiety: Assess degree and manifestations of anxiety and mental status (orientation, mood, behavior) prior to and periodically throughout therapy; Restrict amount of drug available to patient, as prolonged high-dose therapy may lead to psychological or physical dependence; Status Epilepticus: Assess location, duration, characteristics, and frequency of seizures; Lab test considerations: Patients on high-dose therapy should receive routine evaluation of renal, hepatic, and hematologic function; Following parenteral administration, keep patient supine for at least 8 hours and observe closely
Client education of Lorazepam Instruct patient to take medication exactly as directed and not to double up on doses-inform patient if medication is less effective after a few weeks to notify health care professional; Advise patient lorazepam is usually prescribed for short-term use and does not cure underlying problem; Advise patient to decrease lorazepam dose gradually to minimize withdrawal symptoms-abrupt withdrawal may cause tremors, nausea, vomiting, and abdominal and muscle cramps; Teach other methods to decrease anxiety, such as increased exercise, support groups, relaxation techniques. Emphasize psychotherapy is beneficial in addressing source of anxiety and improving coping skills; Advise patient to avoid driving or other activities requiring alertness until response to medication is known; Caution patient to avoid taking alcohol or other CNS depressants concurrently; Instruct patient to contact health care professional immediately if pregnancy is planned or suspected; Emphasize the importance of follow up exams to determine effectiveness of the medication
Evaluation/Desired outcomes of Lorazepam Increase in sense of well-being; Decrease in subjective feelings of anxiety without excessive sedation; Reduction of pre-operative anxiety; Post-operative anxiety; Post-operative amnesia; Improvement in sleep patterns
Potential nursing diagnoses of Lorazepam Anxiety (indications); Risk for injury (indication, side effects)