anticholinergics
This mnemonic describes anticholinergic side effects: dry as a bone, blind as a bat, red as a beet, hot as a hare, and ___ as a hatter.
Mad (confused/altered mental status). The full mnemonic covers: dry mouth, blurred vision, flushing, hyperthermia, confusion, and urinary retention.
The mnemonic SLUDGE describes cholinergic overdose effects. What does it stand for?
Salivation, Lacrimation, Urination, Defecation, GI distress, Emesis. Also includes bradycardia, bronchospasm, and miosis.
Before administering an opioid analgesic, these are the two most critical assessments the nurse must perform.
Respiratory rate (hold if less than 12/min) and level of consciousness/sedation level. Also assess pain score and blood pressure.
Levodopa/carbidopa (Sinemet) is the gold standard for Parkinson's. What is carbidopa's specific role in this combination drug?
Carbidopa is a peripheral decarboxylase inhibitor — it prevents levodopa from being converted to dopamine in the bloodstream, allowing more levodopa to cross the blood-brain barrier. Reduces peripheral side effects and required dose.
This antihypertensive class ends in '-sartan,' blocks the angiotensin II receptor, is NOT associated with cough, and is contraindicated in pregnancy.
ARBs (angiotensin II receptor blockers) — e.g., losartan, valsartan. Contraindicated in pregnancy (fetal renal toxicity). Monitor for hyperkalemia and renal function, especially with concurrent diuretics.
A patient receiving atropine pre-operatively asks why their mouth is so dry. What is the nurse's best explanation?
Atropine blocks muscarinic receptors, inhibiting salivary gland secretion. This is an expected, temporary side effect.
Bethanechol (Urecholine) is ordered post-operatively. What is the expected therapeutic effect?
Stimulates bladder contraction (muscarinic agonist), promoting urination in post-op urinary retention. Assess urinary output within 30-60 minutes.
A patient on morphine develops a respiratory rate of 8, pinpoint pupils, and unresponsiveness. What is the priority intervention?
Administer naloxone (Narcan) IV/IM/intranasal per order, maintain airway, apply oxygen, and call Rapid Response
A patient on levodopa/carbidopa reports that their medication 'stops working' before their next dose is due. What is this phenomenon called?
The 'wearing-off' effect (end-of-dose deterioration). Managed by adjusting dosing intervals, adding a COMT inhibitor (entacapone), or adding a dopamine agonist.
A patient on amlodipine (a calcium channel blocker) develops peripheral edema and flushing. Are these side effects expected, and should the medication be held?
Yes, expected — calcium channel blockers cause peripheral vasodilation leading to dependent edema and flushing. Do not hold unless BP is critically low or edema is severe.
This anticholinergic drug is the first-line antidote for organophosphate (nerve agent) poisoning.
Atropine — given in large doses to competitively block excess acetylcholine at muscarinic receptors.
A patient receives neostigmine to reverse neuromuscular blockade after surgery. What class is this and how does it work?
Cholinesterase inhibitor (indirect-acting cholinergic). It prevents acetylcholinesterase from breaking down acetylcholine, increasing ACh levels at the neuromuscular junction.
This non-opioid analgesic is the most common cause of liver failure in the US due to overdose, and the maximum safe daily dose for a healthy adult is ___.
Acetaminophen (Tylenol). Maximum 4,000 mg/day in healthy adults; 2,000 mg/day in patients with liver disease or alcohol use. Monitor LFTs.
This class of anti-Parkinson's drug works by blocking dopamine breakdown and includes selegiline and rasagiline. What dietary interaction must patients avoid?
MAO-B inhibitors. Patients must avoid tyramine-rich foods (aged cheese, cured meats, wine) to prevent hypertensive crisis — though risk is lower with selective MAO-B inhibitors vs. nonselective MAOIs.
A patient's blood pressure is 90/58 after their first dose of an antihypertensive. They feel dizzy when standing. What is this phenomenon and what is the priority nursing intervention?
Orthostatic (postural) hypotension — most common after first dose, especially with alpha-blockers. Have patient sit or lie down, take BP lying and standing, hold further doses, notify provider, and teach fall precautions
A patient with COPD is prescribed ipratropium (Atrovent). What class is this, and what is its primary mechanism?
Anticholinergic bronchodilator. It blocks muscarinic receptors in bronchial smooth muscle, causing bronchodilation. Used for maintenance, not acute rescue.
Pilocarpine eye drops are used to treat this condition by constricting the pupil and opening the trabecular meshwork.
Open-angle glaucoma (also used in angle-closure glaucoma). Miosis opens the canal of Schlemm, improving aqueous humor drainage.
NSAIDs like ibuprofen are contraindicated in this patient population and with this co-medication due to risk of GI bleeding and renal impairment.
Contraindicated in: patients with renal insufficiency, active GI ulcers, heart failure, and patients on anticoagulants. Use with caution in elderly patients.
A patient with Parkinson's disease is admitted for surgery. The nurse knows levodopa/carbidopa should never be abruptly stopped because of this life-threatening complication.
Neuroleptic malignant syndrome (NMS) or Parkinson's-hyperpyrexia syndrome — characterized by hyperthermia, rigidity, altered consciousness, and autonomic instability. Doses must continue through hospitalization.
Amiodarone (Cordarone) is a powerful Class III antiarrhythmic. Name three major organ toxicities that require ongoing monitoring.
Pulmonary toxicity (interstitial pneumonitis — monitor for cough and dyspnea), hepatotoxicity (monitor LFTs), thyroid dysfunction (both hypo- and hyperthyroidism — monitor TSH), and corneal microdeposits/photosensitivity.
An elderly patient on oxybutynin for overactive bladder develops acute confusion. What is the most likely cause and priority nursing action?
Anticholinergic toxicity — oxybutynin crosses the blood-brain barrier. Stop the medication, notify the provider, monitor vitals and mental status. Physostigmine may be ordered as antidote.
A patient with myasthenia gravis is on pyridostigmine. What assessment finding would indicate a cholinergic crisis vs. a myasthenic crisis?
Both cause muscle weakness — the key differentiator is cholinergic signs: SLUDGE symptoms (salivation, lacrimation, etc.) indicate cholinergic crisis. The Tensilon (edrophonium) test can help differentiate.
A patient on a PCA pump reports their pain is uncontrolled. The nurse notes they have received 90% of allowed doses. What is the priority action — and what should the nurse NOT do?
Reassess pain, notify provider to adjust PCA settings or add a basal rate. Do NOT press the PCA button for the patient — this bypasses the safety mechanism and constitutes a medication error.
Amantadine is used in Parkinson's disease. What is a unique nursing consideration for this drug's side effects compared to levodopa?
Amantadine causes livedo reticularis (mottled purplish skin discoloration), ankle edema, and CNS effects (confusion, hallucinations). Unlike levodopa, it also has antiviral properties. Assess mental status regularly, especially in elderly.
Before administering digoxin, the nurse must assess this for a full minute and hold the drug if it falls below this value
Apical pulse — hold if less than 60 bpm. Also assess for signs of toxicity: nausea, visual disturbances (yellow-green halos), bradycardia. Therapeutic serum level: 0.5-2 ng/mL.