Albany Medical College Musculoskeletal Medications Questions I have uploaded powerpoint slides for refernce but not suppose to copy exactly from there. So

Albany Medical College Musculoskeletal Medications Questions I have uploaded powerpoint slides for refernce but not suppose to copy exactly from there. So you can search if don’t want to use powerpoints. Musculoskeletal Medications
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Answer in 25 words or less if possible.
Use your own words only.
1) Explain the difference between non-depolarizing and depolarizing neuromuscular blocking agents.
2) Give an example of a non-depolarizing medication and the specific nursing care you would provide.
3) Give an example of a depolarizing medication and the specific nursing care you would provide.
4) How does calcium work in the body? What is one contraindication of its use?
5) What foods would you recommend to your patient to increase calcium intake?
6) What is rheumatoid arthritis and how does it affect the musculoskeletal system?
7) Name one therapeutic effect that an anti-rheumatoid medication provides.
8) What nursing assessment should be done for patients taking skeletal muscle relaxers?
9) What is the mechanism of action for skeletal muscle relaxers?
10) What is Botox, its use and how it works in the musculoskeletal system?
11) What is a serious contraindication of Botox?
12) What is the mechanism of action of benzodiazepines?
13) Give two examples of a benzodiazepine.
14) What is a contraindication for an elderly patient taking a benzodiazepine? Name one nursing diagnosis and an
associated nursing intervention for elderly patients taking benzodiazepines.
15) What is TNF’s mechanism of action and one contraindication?
16) What patient should you use caution with when administering TNF?
17) What patient education do you provide for patients taking Enbrel?
18) Describe the mechanism of action for colchicine.
19) Describe osteoporosis and how it affects the body.
20) Name one nursing diagnosis and nursing intervention related to osteoporosis.
Describe each medication using the tables below:
Gengraf
Classification
Generic Name
Indications
Action
Therapeutic Effect
Most frequent side
effect
Nursing intervention
Descriptions
Miacalcin
Classification
Generic Name
Indications
Action
Therapeutic Effect
Most frequent side
effect
Nursing intervention
Descriptions
Flexeril
Classification
Generic Name
Indications
Action
Therapeutic Effect
Most frequent side
effect
Nursing intervention
Descriptions
Elitek
Classification
Generic Name
Indications
Action
Therapeutic Effect
Most frequent side
effect
Nursing intervention
Descriptions
Fosamax
Classification
Generic Name
Indications
Action
Therapeutic Effect
Most frequent side
effect
Nursing intervention
Descriptions
Managing musculoskeletal
conditions
MODULE 4A
Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.
MEDICATION CLASSIFICATION: CALCIUM
SUPPLEMENTS
Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.
Medication Classification: Calcium
Supplements
Prototype Medication: calcium citrate (Citracal)
 Other Medications:
 Calcium carbonate (Tums, Rolaids)
 Calcium acetate (PhosLo)
 For IV administration:
 Calcium chloride
 Calcium gluconate
Purpose
 Maintenance of normal musculoskeletal, neurological, and cardiovascular
function.
Therapeutic Uses
Oral calcium supplements are used for clients with hypocalcemia, or deficiencies of
parathyroid hormone, vitamin D, or dietary calcium.
 Oral dietary supplements are used for adolescents, older adults, and women who
are postmenopausal, pregnant or breastfeeding.
 Intravenous medications are used for clients with critically low levels of calcium.
Calcium Supplements
Side/Adverse Effects
Nursing Interventions/Client Education
Hypercalcemia (Calcium level greater than
10.5 mg/dL)
• Findings include tachycardia and elevated
blood pressure leading to bradycardia and
hypotension, muscle weakness and hypotonia,
constipation, nausea, vomiting
and abdominal pain, lethargy, and confusion.
• Instruct clients to monitor for symptoms
and report to the provider.
• Monitor serum calcium levels to maintain
between 9.0 to 10.5 mg/dL.
Contraindications/Precautions
Calcium supplements are contraindicated in clients who have
hypercalcemia, bone tumors, and hyperparathyroidism.
Use cautiously in clients with kidney disease or a decrease in GI
function.


Medication/Food Interactions
Interventions/Client Education
Concurrent use of glucocorticoids
reduces absorption of calcium
Concurrent use of calcium decreases
absorption of tetracyclines and thyroid
hormone
Concurrent administration of thiazide
diuretics increases risk of
hypercalcemia.
Spinach, rhubarb, bran, and whole
grains may decrease calcium
absorption.
Give medications at least 1 hr apart
IV calcium precipitates with
phosphates, carbonates, sulfates, and
tartrates
Concurrent use of digoxin and
parenteral
Ensure 1 hr between administration of
medications
Assess clients for hypercalcemia.
• Avoid concurrent use.
Do not administer calcium with foods that
decrease absorption.
• Instruct clients to avoid consuming these
foods at the same time as taking calcium
Do not mix parenteral calcium with
compounds that cause precipitation
IV injection of calcium must be given
slowly
Nursing Administration
 Instruct clients to take a calcium supplement at least 1 hr apart
from glucocorticoids, tetracyclines, and/or thyroid hormone.
 Chewable tablets provide more consistent bioavailability
 Recommended doses of oral calcium vary widely depending on
the specific calcium preparation. Instruct client to follow provider
prescription.
 Prior to administration, warm IV infusions of calcium to body
temperature.
 Administer IV injections at 0.5 to 2 mL/min.
 Nursing Evaluation of Medication Effectiveness
 Depending on therapeutic intent, effectiveness may be evidenced
by: Serum calcium level within expected reference range: 9.0 to 10.5
mg/dL.
MEDICATION CLASSIFICATION: SELECTIVE
ESTROGEN RECEPTOR MODULATORS/SERM S
Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.
Select Prototype Medication: raloxifene (Evista)
 Purpose
 Works as endogenous estrogen in bone, lipid
metabolism, and blood coagulation
 Decreases bone resorption(osteoclasts break down
bone), which results in slowing down of bone loss
and preservation of bone mineral density
 Works as an antagonist to estrogen on breast and
endometrial tissue
 Can decrease plasma levels of cholesterol
Therapeutic Uses
 Used in female clients to prevent and treat
postmenopausal osteoporosis and to prevent spinal
fractures
 Used to protect against breast cancer
Complications
Increases the risk for pulmonary embolism and
deep vein thrombosis (DVT)
Hot flashes

Medication should be stopped prior to scheduled
immobilization such as surgery.
• Medication can be resumed when the client is
fully mobile.
• Discourage long periods of sitting and inactivity.
Inform clients that the medication may
exacerbate, rather than reduce, hot
flashes.
Contraindications/Precautions
●Raloxifene is Pregnancy Risk Category X.
●This medication is contraindicated in clients with a history of venous thrombosis.
The medication should be stopped three days before periods in which risk of DVT is
high (such as before surgical procedures).
Interactions
●No significant interactions
Nursing Administration
 For maximum benefit of the medication, encourage clients to consume adequate amounts
of calcium (such as from dairy products) and vitamin D (such as from egg
yolks). Inadequate amounts of dietary calcium and vitamin D cause release of parathyroid
hormone, which stimulates calcium release from the bone.
 Medication may be taken with or without food once a day.
 Monitor the client’s bone density; clients should undergo a bone density scan every 12 to
18 months.
 Monitor the client’s serum calcium. Expected reference range is 9.0 to 10.5 mg/dL.
 Monitor liver function tests. Raloxifene levels may be increased in clients with hepatic
impairment.
 Encourage clients to perform weight-bearing exercises daily, such as walking 30 to 40 min
each day.
Nursing Evaluation of Medication Effectiveness
 Depending on therapeutic intent, effectiveness may be evidenced by:
 Increase in bone density
 No fractures
NEUROMUSCULAR
BLOCKING AGENTS
Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.
Neuromuscular blocking agents
 Neuromuscular-blocking drugs block neuromuscular





transmission at the neuromuscular junction,causing
paralysis of the affected skeletal muscles.
Neuromuscular blocking agents are used as adjuncts to
general anesthesia to promote muscle relaxation
These agents are used to control spontaneous respiratory
movements in clients receiving mechanical ventilation
These agents are used as seizure control during
electroconvulsive therapy
Used during endotracheal intubation and endoscopy
Reduce intensity of muscle contractions in tetany, botulism,
and electroconvulsive therapy
Neuromuscular blocking agents
1.
Types: non-depolarizing and depolarizing
Non-Depolarizing
a.
action: competes with acetylcholine (ACh) at cholinergic receptor
sites to block nerve impulse transmission; histamine releasing
properties
b.
examples – see Epocrates Online for greater detail
i.
tubocurarine chloride
ii.
atracurium besylate (Tracrium) loading dose 0.3-0.5 mg/kg IV
followed by continuous infusion 0.25-0.35 mg/kg IV
iii.
Vecuronium , Pancuronuim
Drug
Uses
Tubocurarine Chloride
Neuromuscular blocking
agents
Non-depolarizing blocking
agent
– muscle relaxant
– long lasting
-competitive antagonists
-reversible

Tubocurarine (also
known as D-tubocurare
or DTC), used adjunctively
in anesthesia to provide
skeletal muscle relaxation
during surgery or
mechanical ventilation.
Overdose
Management:Treatment:
Overdosage chiefly treated
by artificial respiration,
although neostigmine,
atropine, and
edrophonium chloride
should also be on hand
How Supplied:Injection: 3
mg/mL
Dosage
IV, IMAdjunct to surgical
anesthesia.
Adults, IM, IV, initial


Adjunct to
mechanical
ventilation
Muscle relaxation
during general
anesthesia
Reduce intensity of
muscle contractions
in tetany, botulism,
and
electroconvulsive
therapy(ECT
Adverse Reactions
Contraindications
Nurse Care
Adverse effects: life-threatening

Histamine release:
bronchospasm-paralyzed
muscles causing
difficulty breathing

hypotension, excessive
secretions

Malignant hyperthermia
is a rare life-threatening
condition that is usually
triggered by exposure to
certain drugs used for
general anesthesia and
neuro –blocking drugs
which overwhelms the
body’s capacity to supply
oxygen, remove carbon
dioxide, and regulate body
temperature, eventually
leading to circulatory
collapse and death if not
treated quickly.
Tubocurarine (Cl) is
contraindicated in
conditions like
1.Hypovolaemia-labs
indicate – is a state of
decreased blood volume;
more specifically, decrease
in volume of blood plasma
2. 2.Myasthenia gravis,
3.Renal failure, 4.Malignant
hyperthermia.



cardiopulmonary arrest
hyperkalemia



Special Concerns:Use with
caution during pregnancy
and lactation and in
children. If repeated doses
are used before delivery,
the newborn may manifest
decreased skeletal muscle
activity. Children up to 1
month of age may be more
sensitive to the effects of
tubocurarine. Use with
extreme caution in clients
with renal dysfunction, liver
disease, or obstructive
states


Observe RN
establish baseline
data monitor assessment
Monitor
electrolytes, renal
function tests, V/S,
EKG, SaO2
Muscle function
usually restored
within 90 minutes
after therapy
Promptly report
any muscle
weakness(retained
in the body long
after the effects
have worn off)
RN must
implement client
teaching plan.
Report immediately
any muscle
weakness.
Drug
Uses
Atracurium(tracrium)
Neuromuscular blocking
agents
Loading dose 0.3-0.5
mg/kg IV followed by
continuous infusion 0.250.35 mg/kg IV
Antagonizes
acetylcholine
receptors at the
motor end
plate, producing
paralysis
Immediate acting
-Non depolarizer
-Competitive
Atracurium (Tracrium)
– Onset: 3-5 min (dose
dependent)
– Duration: 20-35 min
Safer than Tubocurarine
Same as Tubocurarine but
safer and used more
commonly than
Tubocurarine
Adverse Reactions
Contraindications
-histamine

release (hypoTN, •
tachycardia,
bronchoconstrict

ion)
-laudanosine
may cause CNS
excitation or
seizure in pts w/
liver failure

Acidosis, renal
dysfunction
When histamine
release is a
hazard
Hyperthermia,
electrolyte
imbalances
Nurse Care



Cardio
pulmonary
arrest
Monitor electrolytes,
renal function tests,
V/S, EKG, SaO2
Muscle function
usually restored
within 90 minutes
after therapy
Promptly report any
muscle
weakness(retained in
the body long after
the effects have worn
off)
Hypovolaemia-labs

Reversal agent
Neostigmine
Depolarizing
a. Action: competes with acetylcholine (ACh) for ACh-receptor sites
resulting in muscle cell depolarization, initial contraction, and flaccid
paralysis; ultra-short acting
b.
example: Succinylcholine (Anectine) – dosage should be individualized
(see Epocrates Online for greater detail)
c. uses
i.
muscle relaxation during surgery
ii.
adjunct to mechanical ventilation
iii.
facilitate intubation, electroconvulsive therapy
iv.
postoperative shivering when meperidine chloride is contraindicated
and myocardial oxygen consumption must be minimized
Side Adverse
Succinylcholine
Low pseudocholinesterase
activity can lead to prolonged
apnea
Reversal Agent:
Pseudocholinesteras
e
Test continuous cardiac and respiratory
monitoring
Have equipment ready for resuscitation and
mechanical ventilation
Monitor clients for return of respiratory
function when medication is discontinued.
Monitor the clients vital signs
Signs of malignant hyperthemia
include muscle rigidity
accompanied by increased
temperature , reaching levels as
high as 43c (109.4f)
Stop succinylcholine and other anesthetics
Ice or infusion of iced saline can be used to cool
the clients
Administer dantrolene to decrease metabolic
activity of skeletal muscle
After 12 to 24 hr postoperative
clients may experience muscle
pain in the upper body and back
Hyperkalemia
Advise clients that this response is not unusual
and eventually will subside
Notify the provider to consider short-term use of
muscle relaxant
Monitor potassium levels
Nursing care
i. Establish baseline data and continually monitor vital signs,
EKG, airway, ventilation, and SaO2
ii. Establish baseline data and monitor neuromuscular response
to stimuli, fasciculations, serum electrolytes
iii. Remain at bedside during infusion
•keep emergency equipment and drugs at the bedside
•maintain oxygenation and ventilation while client is
being treated
iv. Administer sedation and analgesia to clients while being
treated – client is conscious and alert without sedation
v.Fasciculations subside rapidly after initial administration
Depolarizing
Client Teaching

etiology of muscle pain

reassurance about drug-induced, temporary
paralysis
Contraindications
i.History or family history of malignant hyperthermia
ii.After reversal of competitive blockade with
neostigmine
Skeletal Muscle Relaxants
Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.
Skeletal Muscle Relaxants
 A muscle relaxant is a drug which affects skeletal
muscle function and decreases the muscle tone.
 It may be used to alleviate symptoms such as muscle
spasms, pain, and hyperreflexia. The term “muscle
relaxant” is used to refer to two major therapeutic
groups: neuromuscular blockers and spasmolytics.
 Act to relieve pain associated with skeletal muscle spasms
 Majority are central-acting
 CNS is the site of action
 Similar in structure and action to other CNS depressants
 Direct-acting
 Act directly on skeletal muscle
Common Muscle Relaxants






baclofen (Lioresal)
cyclobenzaprine (Flexeril)
dantrolene (Dantrium)
metaxalone (Skelaxin)
tizanidine (Zanaflex)
Others
Skeletal Muscle Relaxants
 These drugs act directly on the neuromuscular
junction or indirectly on the CNS.
 Centrally acting muscle relaxants depress neuron
activity in the spinal cord or brain.
 Peripherally acting muscle relaxants act directly on
skeletal muscle.
 They are used to prevent or relieve muscle spasms, to
treat spasticity associated with spinal cord disease or
lesions, for painful musculoskeletal conditions, and
for chronic debilitating disorders (e.g., multiple
sclerosis, cerebral palsy).
Skeletal Muscle Relaxants
 Skeletal muscle relaxants should not be taken with CNS depressants







(e.g., barbiturates, opioids, alcohol, sedatives, hypnotics, or tricyclic
antidepressants).
Side effects include dizziness and hypotension, drowsiness, dry mouth,
GI upset, photosensitivity, and hepatic toxicity.
Safety is a priority; assess the client for his or her risk of injury.
Assess involved joints and muscles for pain and mobility.
Monitor liver function parameters; hepatotoxicity may occur.
Instruct the client to take the medication with food to help prevent GI
upset.
Instruct the client to avoid activities requiring alertness, because
drowsiness may occur.
Instruct the client to implement measures to alleviate photosensitivity
if it occurs (e.g., by wearing sunglasses).
Skeletal muscle relaxing agents
1. Type: cyclobenzaprine
a.
centrally acting
i.
action: acts on CNS at the brain stem to relieve muscle spasm
without loss of function; similar in structure to tricyclic
antidepressant
ii.
examples – see Epocrates Online for greater detail

cyclobenzaprine (Flexeril) 10-20 mg by mouth 3 times daily

carisoprodol (Soma) 350 mg by mouth 3 times daily

OTHER – Baclofen , Metaxalone, Tizanidine, Diazepam
Cyclobenzaprine •
is used with rest,
physical therapy,

and other
measures to relax
muscles and
relieve pain and

discomfort caused
by strains, sprains,
and other muscle
injuries.
Cyclobenzaprine:
2
subtypes(central
ly acting and
direct acting
Cyclobenzaprine
(Flexeril): 10-20
mg po TID
Carisoprodol(So
ma): 350 mg po
TID
Short term
therapy
Painful
musculoskelet
al conditions,
tetanus
Spasticity
associated
with nerve
compression
or irritation,
and
degenerative
neuromuscula
r disease(MS)
Serious Reactions

seizures

cardiac
conduction
disturbances




Hyperthyroidism
Hepatic or renal
dysfunction
Spasticity due to
rheumatic conditions
Acute MI, dysrhythmias,
heart block, heart
failure
elderly pts





arrhythmias

MI

stroke

hepatic impairment

heat stroke

MI, acute recovery

anaphylaxis


psychosis
cardiac conduction
disturbances



hepatitis

arrhythmias

Common Reactions

heart block

CHF

hyperthyroidism

drowsiness

dry mouth

dizziness

fatigue

headache

constipation

caution in elderly pts

nausea


dyspepsia
caution if hepatic
impairment

taste changes

caution if urinary
retention

blurred vision
Caution.

avoid abrupt
withdrawal (long-term
use)


Monitor heart rate, airway, EKG,
lovel of consciousness, liver and
renal tests, muscle strength, pain
level, bowel pattern
Provide frequent oral care
Withhold drug for rash, pruritis
Carefully administer opioid
analgesia with concurrent use of
muscle relaxants
Collaborate with PT for adjunct
therapy to decrease need for
muscle relaxers
Change positions slowly
Avoid alcohol or other CNS
depressants
Establish regular bowel habits
including fluids, fiber, and
activity
Avoid dangerous activity
centrally acting
Metaxalone , Tizanidine
Relief of muscle spasm related to muscle injury
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