CNS Stimulants and Depressants Flashcards
1
Q
3 Psychological States Affected by Anxiolytic and Hypnotic Drugs
A
⭐ Anxiety: Feeling of tension, nervousness, apprehension, or fear involving unpleasant reactions to a stimulus
⭐ Sedation: Loss of awareness and reaction to environmental stimuli
⭐ Hypnosis: Extreme sedation resulting in further CNS depression and sleep
2
Q
Lifespan Considerations for Anxiolytic and Hypnotic Drugs
In Children
A
- Response is unpredictable
- Good sleep hygiene is preferred for insomnia
- Monitor closely for CNS depression and excitability
- Antihistamines commonly used
3
Q
Lifespan Considerations for Anxiolytic and Hypnotic Drugs
In Adults
A
- Short term use ONLY for insomnia; good sleep hygiene is preferred
- With anxiolytics, may need referral for counseling
- Monitor liver during therapy
- Contraindicated in pregnancy and lactation
4
Q
Lifespan Considerations for Anxiolytic and Hypnotic Drugs
In Older Adults
A
- More susceptible to adverse effects
- Dosage should be reduced
- Monitor closely for toxic effects
- Provide safety measures
- Liver and renal function tests should be monitored
- Use non-drug measures to reduce anxiety and induce sleep whenever possible
5
Q
Benzodiazepines
Drug Names
A
“-pam” or “-lam”
Alprazolam
Clonazepam
Diazepam
Lorazepam
Midazolam
Temazepam
6
Q
Benzodiazepines
Mechanism of Action
A
- Act in the limbic system and the RAS
- Make GABA more effective
- Cause interference with neurons firing
- Exact mechanism not clearly understood
7
Q
Benzodiazepines
Indications
A
- Lower doses: anxiety
- Higher doses: sedation and hypnosis
- Anxiety Disorder, alcohol withdrawal, panic disorders, restless leg syndrome, seizure disorders, insomnia
8
Q
Benzodiazepines
Contraindications
A
Absolute:
* Allergy
* Psychosis
* Acute narrow angle glaucoma
* Shock
* Coma
* Acute alcohol intoxication
* Pregnancy and lactation
Cautions:
* Older adults/debilitated patients
* Renal or hepatic dysfunction
Black Box Warning:
Concomitant use with opiods can result in profound sedation, respiratory depression, coma, or death
9
Q
Benzodiazepines
Adverse Effects
A
🤢 GI: Dry mouth, nausea, vomiting
💓 CV: Hypotension
🧠 CNS: sedation, drowsiness, depression, lethargy, blurred vision, confusion
🟡 GU: Urinary retention
🩸 Blood dyscrasias: anemia
😳 Altered sexual funtion
🚫 If stopped abruptly: Can lead to withdrawal symptoms (N/V, headache, seizures)
10
Q
Benzodiazepines
Drug Interactions
A
- Alcohol or other CNS depressants (⬆️ CNS depression)
- Cimetidine, oral contraceptives, disulfiram (⬆️ in effect)
- Theophylline (⬇️ in effect)
11
Q
Benzodiazepines
Assessment
A
History:
* Check for allergy, pregnancy, lactation, psychosis, glaucoma, acute alcohol intoxication, shock, coma
Physical:
* Temperature and weight
* Skin color and lesions
* Affect, orientation, reflexes, vision
* Pulse, BP, perfusion
* Respiratory rate, lung sounds, check for COPD
* Bowel sounds
Labs:
* Renal and liver function tests
* CBC
12
Q
Benzodiazepines
Implementation/Patient Teaching
A
- Have emergency med. available: Flumazenil (Competitive agonist @GABA receptor)
- DO NOT administer intra-arterially: can cause arterial spasm and gangrene
- Toxic to veins: Give IV drugs SLOWLY; do NOT mix with any other drugs
- Give parenteral forms ONLY when oral forms are not feasible or available; switch to oral forms ASAP
- Reduce the dose of opioid and monitor closely
- Patients need to stay in bed for 3 hours after parenteral administration
- No operation of motor vehicles
- Monitor hepatic and renal levels; and CBC
- Taper dose gradually after long term use; especially in epileptic patients
- Report: memory problems, blurred vision, confusion, muscle weakness
13
Q
Benzodiazepines
Nursing Diagnoses/Conclusions
A
- Altered thought processes and disturbed sensory perception (r/t CNS effects)
- Injury risk (r/t CNS effects)
- Altered sleep pattern (r/t CNS effects)
- Knowledge Deficit
14
Q
Barbituates
Drug Names
A
“-barbital”
Pentobarbital
Phenobarbital
Secobarbital
15
Q
Barbituates
Mechanism of Action
A
- Inhibits neuronal impulse conduction in the ascending RAS
- Depresses the cerebral cortex
- Depresses motor output
- Causes: sedation, hypnosis, anesthesia, and coma
16
Q
Barbituates
Indication
A
- Relief of the signs and symptoms of anxiety
- Sedation
- Insomnia
- Preanesthesia
- Seizures
17
Q
Barbituates
Contraindications
A
Absolute:
* Allergy to any barbituate
* Previous history of addiction to sedative-hypnotic drugs
* Latent or manifest porphyria (build up of the chemicals needed to make hemoglobin)
* Marked hepatic impairment
* Nephritis
* Respiratory distress or severe respiratory dysfunction
* Pregnancy and lactation
18
Q
Barbituates
Adverse Effects
A
- 🧠 CNS Depression: Ataxia, vertigo, somnolence, drowsiness, lethargy, syncope
- 🫁 Serious hypoventilation
- 🤢 Nausea, vomiting, constipation
- 💓 CV effects
- Paradoxical excitement, anxiety, or hallucinations
- Physical dependency
19
Q
Barbituates
Drug Interactions
A
- Alcohol, antihistamines, other tranquilizers: Increased CNS depression
- Phenytoin: altered response to phenytoin, seizures may increase
- MAOI: increase serum levels and effect
- Will decrease effectiveness of: anticoagulants, digoxin, TCAs, corticosteroids, oral contraceptives
20
Q
Barbituates
Assessment
A
History:
* Check for allergy or any other contraindication
Physical:
* Temperature and weight
* Blood pressure and pulse, perfusion
* Skin color and lesions
* Affect, orientation, reflexes
* Respiratory rate, lung sounds
* Bowel sounds
21
Q
Barbituates
Nursing Diagnoses/Conclusions
A
- Altered thought process (r/t CNS effects)
- Injury risk (r/t CNS effects)
- Altered gas exchange (r/t respiratory depression)
- Knowledge deficit
22
Q
Barbituates
Implementation/Patient Teaching
A
- DO NOT administer intra-arterially: Serious risk of gangrene
- Do not mix IV drugs in a solution with any other drugs
- Give parental forms only when oral forms are not feasible or available; switch to oral ASAP
- Give IV medications slowly
- Provide standby life support facilities
- Taper dose gradually after long-term therapy, especially in pts with epilepsy
- Avoid driving
23
Q
Other Anxiolytic and Hypnotic Drugs
A
- Antihistamines (promethazine, diphenhydramine): Preoperative and postoperative to decrease need for opioids
- Buspirone: reduces the signs and symptoms of anxiety without serious CNS effects; No sedative effect; takes 1-4 weeks to take effect
- Eszopiclone: Insomnia; works on GABA receptors; take before bed and allow 8 hours to sleep (risk of sleep driving)
- Ramelteon: Insomnia - difficulty with sleep onset; melatonin receptor agonist
- Suvorexant: Insomnia; suppresses drive to wake up
- Zaleplon and zolpidem: Short term treatment of insomnia; sedating (risk of sleep driving)
24
Q
What is a muscle spasm?
A
Problem IN the muscles
* Often results from injury to the musculoskeletal system
* Caused by the flood of sensory impulses coming to the spinal cord from the injured area
25
What is **muscle spasticity**?
**Problem is in the neurons**
* Result of damage to neurons in the CNS
* May result from an increase in excitatory influences or a decrease in inhibitory influences within the CNS
26
Lifespan consideration for Muscle Relaxants
**In Children**
* Safety and effectiveness of some drugs have not been established
* Dosage based on weight
* Monitor for CNS and GI toxicity
27
Lifespan consideration for Muscle Relaxants
**In Adults**
* Safety precautions
* Use non-drug therapies for muscle pain or injury
* Contraindicated in pregnancy and lactation
* Females >35 have increased risk of hepatotoxicty with dantrolene
28
Lifespan consideration for Muscle Relaxants
**In Older Adults**
* More likely to experience adverse effects
* Lower doses may be needed
* Monitor closely for toxicity
* Older women using hormone replacement at same increased risk for hepatotoxicity as premenopausal women
29
**Centrally Acting Skeletal Muscle Relaxants**
Drug Names
**Baclofen**
**Carisoprodol**
**Cyclobenzaprine**
**Metaxalone**
**Methocarbamol**
**Tizanidine**
30
**Centrally Acting Skeletal Muscle Relaxants**
Mechanism of Action
* Works on GABA receptors in upper levels of CNS to interfere with reflexes causing muscle spasm
* Lyse or destroy spasm *(spasmolytics)*
* Exact mechanism unknown, thought to involve action in upper or spinal interneurons
31
**Centrally Acting Skeletal Muscle Relaxants**
Indications
* Relief of discomfort associated with acute, painful musculoskeletal conditions
* Adjunct to rest, physical and occupational therapy, and other measures
32
**Centrally Acting Skeletal Muscle Relaxants**
Contraindications
**Absolute:**
* Allergy
* Rheumatic disorder
**Cautions:**
* Epilepsy *(lowers seizure threshold)*
* Cardiac dysfunction *(worsens)*
* Conditions marked by muscle weakness *(ex. Myasthenia Gravis)*
* Hepatic or Renal Impairment
* Pregnancy or lactation
33
**Centrally Acting Skeletal Muscle Relaxants**
Adverse Effects
* 🧠 **CNS:** Drowsiness, fatigue, weakness, confusion, headache
* 🤢 **GI:** Nausea, dry mouth
* 💓 **CV:** Hypotension
* 😳 **GU:** Urinary frequency
34
**Centrally Acting Skeletal Muscle Relaxants**
Drug Interactions
* CNS Depressants
* Alcohol
35
**Centrally Acting Skeletal Muscle Relaxants**
Assessment
**History:**
* Check for allergy, rheumatic disorders, epilepsy, cardiac dysfunction, pregnancy, lactation, renal or hepatic impairment, or muscle weakness conditions
**Physical:**
* Temperature
* Skin color and lesions
* Orientation, affect, reflexes, bilateral grip strength, spasticity
* Bowel sounds
* Urinary output
**Labs:**
* Liver and renal function tests
36
**Centrally Acting Skeletal Muscle Relaxants**
Nursing Diagnoses/Conclusions
* Impaired Comfort *(r/t GI and CNS effects)*
* Altered thought processes *(r/t CNS effects)*
* Injury Risk *(r/t CNS effects)*
* Knowledge deficit
37
**Centrally Acting Skeletal Muscle Relaxants**
Implementation
* Provide additional measures to relieve discomfort *(heat/ice)*
* Discontinue drug at any sign of hypersensitivity reaction or liver dysfunction
* Baclofen: Taper drug slowly over 1-2 weeks
* Baclofen delivered through a pump - teach patient how to use it
* Monitor respiratory status
* Report: Excessive drowsiness, rash, blurry vision
38
**Direct-Acting Skeletal Muscle Relaxants**
Drug Names
* **Dantrolene**
* Inco**botulinumtoxin**A
* Ona**botulinumtoxin**A
* Rima**botulinumtoxin**B
39
**Direct-Acting Skeletal Muscle Relaxants**
Mechanism of Action
* Enters the muscle to directly prevent muscle contraction *(inhibits calcium release)*
40
**Direct-Acting Skeletal Muscle Relaxants**
Indications
* Treatment of spasticity directly affecting peripheral muscle contraction
* Management of spasticity associated with neuromuscular diseases
* **Dantrolene:** Muscle spasticity in patients with multiple sclerosis or cerebral palsy, malignant hyperthermia
* **IncobotulinumtoxinA:** cervical dystonia, blepharospasm, and chronic sialorrhea *(excessive drooling)*
* **OnabotulinumtoxinA:** chronic migraines, muscle spasms, excessive sweating, overactive bladder, and is the botox used for wrinkles
* **RimabotulinumtoxinB:** treats pain associated with cervical dystonia, treats chronic sialorrhea
41
**Direct-Acting Skeletal Muscle Relaxants**
Contraindications
**Absolute:**
* Allergy
* Pregnancy and lactation
* Spasticity that contributes to locomotion, upright position, or increased function
* Hepatic disease
**Cautions:**
* Women
* All patients older than 35
* Liver disease (even mild)
* Cardiac disease
* Respiratory depression
42
**Direct-Acting Skeletal Muscle Relaxants**
Adverse Effects
* Fatigue, weakness, confusion
* GI irritation
* Enuresis *(night time bedwetting)*
43
**Direct-Acting Skeletal Muscle Relaxants**
Drug Interactions
* Estrogen *(can cause severe liver toxicity)*
* Neuromuscular junction blockers and others that interfere with neuromuscular transmission *(increase in severe muscle weakness)*
44
**Direct-Acting Skeletal Muscle Relaxants**
Assessment
**History:**
* Check for all contraindications and cautions
**Physical:**
* temperature
* skin color and lesions
* orientation, affect, reflexes, bilateral grip strength, spasticity
* Respiration rate and lung sounds
* Pulse and cardiac output
* ECG
* Bowel sounds
* Urinary output
**Labs:**
* Renal and liver function tests
45
**Direct-Acting Skeletal Muscle Relaxants**
Nursing Diagnoses/Conclusions
* Impaired comfort *(r/t GI and CNS effects)*
* Altered thought processes *(r/t CNS effects)*
* Injury Risk *(r/t CNS effects)*
* Knowledge Deficit
46
**Direct-Acting Skeletal Muscle Relaxants**
Implementation/Patient Teaching
* Discontinue drug at any sign of liver dysfunction
* Do not administer botulinumtoxins into any area with active infection
* Monitor IV sites of dantrolene for potential extravasation *(leakage of fluid/drug into surrounding tissues)*
* Institute other supportive measures *(ventilation, anticonvulsants, cooling blankets)* for treatment of malignant hyperthermia
* Periodically discontinue dantrolene for 2 to 4 days to monitor therapeutic effectiveness
* Establish a therapeutic goal before beginning oral dantrolene therapy
* Discontinue dantrolene if diarrhea becomes too severe
47
**Central Nervous System Stimulants**
Drug names
* Amphetamine
* Dextroamphetamine
* Lisdexamfetamine
* Atomoxetine
* Dexmethylphenidate
* Methylphenidate
* Armodafinil
* Modafinil
48
**Central Nervous System Stimulants**
Mechanism of Action
* Increase the release of catecholamines from presynaptic neurons leading to an increase in stimulation of the postsynaptic neurons
* Amphetamine stimulants block reuptake of norepinephrine and dopamine and increase more of their release
49
**Central Nervous System Stimulants**
Indications
* ADHD
* Narcolepsy and various sleep disorders
50
What is **Narcolepsy**?
* Daytime sleepiness and sudden periods of loss of wakefulness
Causes:
* May reflect problems with REM sleep regulation
* High rate of HLA subtype DQB1-0602
* Hypocretin 1 and 2 may be deficient
* May be related to an autoimmune process
51
What is **ADHD**?
* Persistent behaviors demonstrating inattention, hyperactivity, and/or impulsivity
* Can persist into adulthood
Causes:
* Exact pathophysiology unknown
* Evidence of genetic and environmental influences that cause alterations in dopaminergic, serotonergic, and glutamatergic neurotransmitter systems
* May be an inflammatory component
52
**Central Nervous System Stimulants**
Contraindications
**Absolute:**
* Allergy
* Marked anxiety, agitation, or tension
* Severe fatigue
* Glaucoma
* Cardiac Disease
**Cautions:**
* History of seizures
* History of drug or alcohol dependence
* Hypertension
53
**Central Nervous System Stimulants**
Adverse Effects
* **CNS:** nervousness, insomnia, dizziness, headach, blurred vision
* **GI:** anorexia, nausea, weight loss
**Black Box Warning:** controlled substance
54
**Central Nervous System Stimulants**
Drug Interactions
* MAOIs/TCAs
* Some OTC cold medications
* Caffeine
55
**Central Nervous System Stimulants**
Assessment
**History:**
* Check for allergy, anxiety, glaucoma, cardiac disease, pregnancy, lactation, history of seizures, drug or alcohol dependence, and hypertension
**Physical:**
* Temperature and weight
* Skin color and lesions
* Orientation, affect, reflexes
* Ophthalmic exam
* Bowel sounds and output
* Urinary output
* Pulse and BP
* Orthostatic BPs
* Respiration rate and lung sounds
**Labs:**
* CBC
56
**Central Nervous System Stimulants**
Nursing Diagnoses/Conclusions
* Altered thought processes *(r/t CNS effects)*
* Altered vital signs *(r/t CV effects)*
* Injury risk *(r/t CNS and visual effects)*
* Knowledge Deficit
57
**Central Nervous System Stimulants**
Implementation
* Ensure proper diagnosis
* Arrange for overall treatment plan that includes cognitive-behavioral therapy
* Interrupt the drug periodically in children receiving them for behavioral syndromes
* Dispense the least amount of drug possible
* Adminsiter drug **before 6pm**
* Consult with school nurse/counselor
* Report: unexplained weight loss, severe N/V, mood changes, signs of infection, tingling or numbness, difficulty urinating, tremors
