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Propranolol (INN) is a sympatholytic non-selective beta blocker. Sympatholytics are used to treat hypertension, anxiety and panic.

It was the first successful beta blocker developed. Propranolol is available in generic form as propranolol hydrochloride, as well as an AstraZeneca and Wyeth product under the brand names Inderal, Inderal LA, Avlocardyl (also available in prolonged absorption form named "Avlocardyl Retard"), Deralin, Dociton, Inderalici, InnoPran XL, Sumial, Anaprilinum (depending on marketplace and release rate), Bedranol SR (Sandoz). Propranolol is one of the banned substances in the Olympics, presumably for its use in controlling social anxiety (stage fright) and tremors. Propranolol is contraindicated in patients with:[22]

Reversible airways disease, particularly asthma or chronic obstructive pulmonary Bradycardia (<60 beats/minute) Sick sinus syndrome Atrioventricular block (second or third degree) Shock Severe hypotension Cocaine toxicity [per American Heart Association guidelines, 2005]

disease (COPD)

Mechanism of action Propranolol is a non-selective beta blocker, that is, it blocks the action of epinephrine and norepinephrine on both 1- and 2-adrenergic receptors. It has little intrinsic sympathomimetic activity (ISA) but has strong membrane stabilizing activity (only at high blood concentrations, e.g. overdosage). Research has also shown that propranolol has inhibitory effects on the norepinephrine transporter and/or stimulates norepinephrine release (present experiments have shown that the concentration of norepinephrine is increased in the synapse but do not have the ability to discern which effect is taking place).[23] Since propranolol blocks -adrenoceptors, the increase in synaptic norepinephrine only results in -adrenergic activation, with the 1-adrenoceptor being particularly important for effects observed in animal models. Therefore, some have suggested that it be looked upon as an indirect 1 agonist as well as a antagonist. Probably owing to the effect at the 1adrenoceptor, the racemate and the individual enantiomers of propranolol have been shown to substitute for cocaine in rats, with the most potent enantiomer being S-()-propranolol. In addition, some evidence suggests that propranolol may function as a partial agonist at one or more serotonin receptors (possibly 5-HT1B). Both enantiomers of the drug have a local anesthetic (topical) effect, which is normally mediated by blockade of voltage-gated sodium channels. Few studies have demonstrated propranolol's ability to block cardiac, neuronal, and skeletal voltage-gated sodium channels, accounting for its known membrane stabilizing effect and anti-arrhythmic and other central nervous system effects.[24] [25] [26] Dosage The usual maintenance dose ranges for oral propranolol therapy vary by indication:

Hypertension, angina, essential tremor o 120-320 mg daily in divided doses o Sustained-release formulations are available in some markets. Migraine Prophylaxis o The initial dose is 80 mg Inderal daily in divided doses. The usual effective dose range is 160 mg to 240 mg per day. The dosage may be increased gradually to achieve optimum migraine prophylaxis. If a satisfactory response is not obtained within four to six weeks after reaching the maximum dose, Inderal therapy should be discontinued. Tachyarrhythmia, anxiety (GAD), hyperthyroidism o 10-40 mg 3-4 times daily

Performance anxiety o 5-10 mg 30min or 1.5hrs before and after performance, optionally 5-10 mg night before. Up to 40 mg if necessary, but side-effects may present.

Intravenous (IV) propranolol may be used in acute arrhythmia or thyrotoxic crisis. Terbutaline (trade names Brethine, Bricanyl, Brethaire, or Terbulin) is a 2-adrenergic receptor agonist. Terbutaline is currently on the World Anti-Doping Agency's list of prohibited drugs for Olympic athletes, except when administered by inhalation and a Therapeutic Use Exemption (TUE) has been obtained in advance. Terbutaline is currently used to delay preterm labor for 48 hours to allow for fetal lung maturity through steroid injections. It should not be used to prevent preterm labor or delay labor past 48-72 hours. In February 2011, the Food and Drug Administration has ordered to put a boxed warning on the drug's label. Pregnant women should not be given injections of the drug terbutaline for the prevention of preterm labor or for long-term (beyond 48-72 hours) management of preterm labor, and should not be given oral terbutaline for any type of prevention or treatment of preterm labor "due to of the potential for serious internal heart problems and death."[1][2] The American College of Obstetricians and Gynecologists also discourages the use of terbutaline for preventing preterm labor.[3] Uses Terbutaline is used as a fast-acting bronchodilator (often used as a short-term asthma treatment) and as a tocolytic[4] to delay premature labor. The inhaled form of terbutaline starts working within 15 minutes and can last up to 6 hours. Terbutaline as a treatment for premature labor is an off-label use not approved by the FDA. It is a pregnancy category 'B' medication and is routinely prescribed to stop contractions. After successful intravenous tocolysis, little evidence exists that oral terbutaline is effective.[5] However, following uterine inversion in the third stage of pregnancy, Terbutaline (or either Halothane or magnesium sulfate) can be utilized to relax the uterus if necessary prior to uterine replacement. Levetiracetam (INN) ( /lvtrstm/) is an anticonvulsant medication used to treat epilepsy.[1] It is the S-enantiomer of etiracetam, structurally similar to the prototypical nootropic drug piracetam. Levetiracetam is marketed under the trade name Keppra. Keppra is manufactured by UCB Pharmaceuticals Inc. Since November of 2008 the drug has been available as a generic brand in the United States. Medical uses Levetiracetam has been approved in the European Union as a monotherapy treatment for epilepsy in the case of partial seizures, or as an adjunctive therapy for partial, myoclonic and tonic-clonic seizures.[2] It is also used in veterinary medicine for similar purposes. Levetiracetam has potential benefits for other psychiatric and neurologic conditions such as Tourette syndrome, autism, bipolar disorder and anxiety disorder, but its most serious adverse effects are behavioral and its benefit-risk ratio in these conditions is not well understood.[3] Along with other anticonvulsants like gabapentin, it is also sometimes used to treat neuropathic pain. It has not been found to be useful for essential tremors.[4] Mechanism of action The exact mechanism by which levetiracetam acts to treat epilepsy is unknown. However, the drug binds to a synaptic vesicle protein, SV2A,[7] which is believed to impede nerve conduction across synapses.

Sleep Pattern Disturbance (_)Actual (_) Potential Related To: [Check those that apply] (_) Impaired oxygen transport (_) Impaired elimination (_) Impaired metabolism (_) Immobility (_) Medication (_) Hospitalization (_) Lack of exercise (_) Anxiety response (_) Life-style disruptions (_) Other:____________________________ _ __________________________________ __ __________________________________ __ As evidenced by: [Check those that apply] Major: (Must be present) Minor: (May be present) (_) Fatigue on awakening or during the day (_) Dozing during the day (_) Agitation (_) Mood alterations Date Achieve d: (_) Difficulty falling or remaining asleep

Date & Sign.

Plan and Outcome [Check those that apply]

Target Date:

Nursing Interventions [Check those that apply]

The patient will: (_) Demonstrate an optimal balance of rest and activity A.E.B. ___ hours of uninterrupted sleep at night. (_) Remain awake during the day. (_) Other:

(_) Explore with patient potential contributing factors. (_) Maintain bedtime routine per patient preference. Likes to go to bed @ ___ pm. Prefers quiet Darkness Night light Music

(_) Takes sleeping pill as ordered by a physician @ ____ pm. (_) Provide comfort measures to induce sleep: Back rub

Herbal tea-warm milk Pillows for support Bedtime snack when appropriate. Pain medication if needed. Other:

(_) Limit nighttime fluids to:________ (_) Void before retiring. (_) Coordinate treatment/meds to limit interruptions during sleep period. (_) Limit the amount and length of daytime sleeping:____________ (_) Increase daytime activity:______ ________________________