CNS Stimulants and Depressants Flashcards
3 Psychological States Affected by Anxiolytic and Hypnotic Drugs
⭐ 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
Lifespan Considerations for Anxiolytic and Hypnotic Drugs
In Children
- Response is unpredictable
- Good sleep hygiene is preferred for insomnia
- Monitor closely for CNS depression and excitability
- Antihistamines commonly used
Lifespan Considerations for Anxiolytic and Hypnotic Drugs
In Adults
- 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
Lifespan Considerations for Anxiolytic and Hypnotic Drugs
In Older Adults
- 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
Benzodiazepines
Drug Names
“-pam” or “-lam”
Alprazolam
Clonazepam
Diazepam
Lorazepam
Midazolam
Temazepam
Benzodiazepines
Mechanism of Action
- Act in the limbic system and the RAS
- Make GABA more effective
- Cause interference with neurons firing
- Exact mechanism not clearly understood
Benzodiazepines
Indications
- Lower doses: anxiety
- Higher doses: sedation and hypnosis
- Anxiety Disorder, alcohol withdrawal, panic disorders, restless leg syndrome, seizure disorders, insomnia
Benzodiazepines
Contraindications
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
Benzodiazepines
Adverse Effects
🤢 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)
Benzodiazepines
Drug Interactions
- Alcohol or other CNS depressants (⬆️ CNS depression)
- Cimetidine, oral contraceptives, disulfiram (⬆️ in effect)
- Theophylline (⬇️ in effect)
Benzodiazepines
Assessment
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
Benzodiazepines
Implementation/Patient Teaching
- 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
Benzodiazepines
Nursing Diagnoses/Conclusions
- 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
Barbituates
Drug Names
“-barbital”
Pentobarbital
Phenobarbital
Secobarbital
Barbituates
Mechanism of Action
- Inhibits neuronal impulse conduction in the ascending RAS
- Depresses the cerebral cortex
- Depresses motor output
- Causes: sedation, hypnosis, anesthesia, and coma
Barbituates
Indication
- Relief of the signs and symptoms of anxiety
- Sedation
- Insomnia
- Preanesthesia
- Seizures
Barbituates
Contraindications
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
Barbituates
Adverse Effects
- 🧠 CNS Depression: Ataxia, vertigo, somnolence, drowsiness, lethargy, syncope
- 🫁 Serious hypoventilation
- 🤢 Nausea, vomiting, constipation
- 💓 CV effects
- Paradoxical excitement, anxiety, or hallucinations
- Physical dependency
Barbituates
Drug Interactions
- 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
Barbituates
Assessment
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
Barbituates
Nursing Diagnoses/Conclusions
- Altered thought process (r/t CNS effects)
- Injury risk (r/t CNS effects)
- Altered gas exchange (r/t respiratory depression)
- Knowledge deficit
Barbituates
Implementation/Patient Teaching
- 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
Other Anxiolytic and Hypnotic Drugs
- 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)
What is a muscle spasm?
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
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
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
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
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
Centrally Acting Skeletal Muscle Relaxants
Drug Names
Baclofen
Carisoprodol
Cyclobenzaprine
Metaxalone
Methocarbamol
Tizanidine
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
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
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
Centrally Acting Skeletal Muscle Relaxants
Adverse Effects
- 🧠 CNS: Drowsiness, fatigue, weakness, confusion, headache
- 🤢 GI: Nausea, dry mouth
- 💓 CV: Hypotension
- 😳 GU: Urinary frequency
Centrally Acting Skeletal Muscle Relaxants
Drug Interactions
- CNS Depressants
- Alcohol
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
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
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
Direct-Acting Skeletal Muscle Relaxants
Drug Names
- Dantrolene
- IncobotulinumtoxinA
- OnabotulinumtoxinA
- RimabotulinumtoxinB
Direct-Acting Skeletal Muscle Relaxants
Mechanism of Action
- Enters the muscle to directly prevent muscle contraction (inhibits calcium release)
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
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
Direct-Acting Skeletal Muscle Relaxants
Adverse Effects
- Fatigue, weakness, confusion
- GI irritation
- Enuresis (night time bedwetting)
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)
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
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
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
Central Nervous System Stimulants
Drug names
- Amphetamine
- Dextroamphetamine
- Lisdexamfetamine
- Atomoxetine
- Dexmethylphenidate
- Methylphenidate
- Armodafinil
- Modafinil
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
Central Nervous System Stimulants
Indications
- ADHD
- Narcolepsy and various sleep disorders
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
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
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
Central Nervous System Stimulants
Adverse Effects
- CNS: nervousness, insomnia, dizziness, headach, blurred vision
- GI: anorexia, nausea, weight loss
Black Box Warning: controlled substance
Central Nervous System Stimulants
Drug Interactions
- MAOIs/TCAs
- Some OTC cold medications
- Caffeine
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
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
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
