Module 14 CNS depressant and CNS stimulant

Question 1

Psychological States Affected by
Anxiolytic and Hypnotic Drugs

Answer 1

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

Question 2

Use of Anxiolytic and Hypnotic
Agents Across the Lifespan

Answer 2

Children
◦ Response is unpredictable
◦ Good sleep hygiene is preferred for insomnia
◦ Monitor closely for CNS depression and
excitability
Adults
◦ Short-term use only for insomnia
◦ Good sleep hygiene is preferred for insomnia
◦ For anxiolytics, may need referral for counseling
◦ Monitor liver during therapy
◦ Contraindicated in pregnancy and lactation
Older Adults
◦ More susceptible to adverse effects
◦ Dosage should be reduced
◦ Monitor closely for toxic effects
◦ Provide safety measures
◦ Liver and renal function should be monitored
◦ Use non-drug measures to reduce anxiety and
induce sleep

Question 3

Benzodiazepines (-pam or -lam)

Answer 3

Alprazolam
Clonazepam
Diazepam
Lorazepam
Midazolam
Temazepam

Question 4

Benzodiazepines: Actions

Actions

Answer 4

◦ Act in the limbic system and the RAS
◦ Make GABA more effective
◦ Causes interference with neurons firing
◦ Lower doses assist with anxiety
◦ Higher doses cause sedation and hypnosis

Question 5

Benzodiazepines indications

Answer 5

Indications: anxiety disorders, alcohol withdrawal, hyperexcitability and agitation, preoperative
relief of anxiety and tension to aid in balanced anesthesia

Question 6

Benzodiazepines
Contraindications/cautions

Answer 6

◦ Allergy to benzodiazepine
◦ Psychosis
◦ Acute narrow angle glaucoma
◦ Shock
◦ Coma
◦ Acute alcohol intoxication
◦ Pregnancy and lactation

Question 7

Benzodiazepines
ADVERSE EFFECTS

Answer 7

◦ Dry mouth, constipation, nausea, vomiting
◦ Hypotension
◦ Urinary retention
◦ Sedation, drowsiness, depression, lethargy,
blurred vision, confusion

Question 8

Benzodiazepines
Drug - drug interaction

Answer 8

DRUG-DRUG INTERACTIONS
◦ Increase CNS depression when taken with
alcohol
◦ Increase in effect when taken with cimetidine,
oral contraceptives, or disulfiram
◦ Decrease in effect if given with theophylline or
ranitidine

Question 9

Nursing Considerations for
Patients Receiving assessment and diagnosis

Answer 9

Assessment
◦ History and physical exam
◦ Allergies; impaired liver or kidney function; any condition exacerbated by the depressant effects;
pregnancy & lactation; use of other CNS depressing drugs
◦ Assess temperature, weight; skin color and lesions; affect, orientation, reflexes, and vision; VS; LS; BS
◦ Monitor appropriate labs
Nursing Diagnoses
◦ Disturbed thought processes and disturbed sensory perception (visual, kinesthetic) related to CNS
effects
◦ Risk for injury related to CNS effects
◦ Disturbed sleep pattern related to CNS effects
◦ Deficient knowledge regarding drug therapy

Question 10

Nursing Considerations for
Patients Receiving
Benzodiazepines
implementation

Answer 10

Implementation
◦ Do not administer intra-arterially
◦ Do not mix IV drugs in solution with any other drugs
◦ Give parenteral forms only if oral forms are not feasible or available and switch to oral forms as soon as
possible
◦ Give IV drugs slowly
◦ Arrange to reduce the dose of narcotic analgesics and monitor closely in patients receiving a benzodiazepine
◦ Maintain patients who receive parenteral benzodiazepines in bed for a period of at least 3 hours. Do not
permit ambulatory patients to operate a motor vehicle
◦ Monitor hepatic and renal function, as well as CBC, during long-term therapy
◦ Taper dose gradually after long-term therapy, especially in epileptic patients
◦ Provide comfort measures to help patients tolerate drug effects
◦ Provide thorough patient teaching

Question 11

Barbiturates (-barbital) drug list

Answer 11

Pentobarbital
Phenobarbital
Secobarbital

Question 12

Barbiturates
ACTIONS

Answer 12

◦ CNS depressants
◦ Inhibit neuronal impulse conduction in the
ascending RAS
◦ Depress cerebral cortex
◦ Depress motor output
◦ Cause: sedation, hypnosis, anesthesia, and coma

Question 13

Barbiturates Indication

Answer 13

INDICATION
◦ Relief of the signs and symptoms of anxiety
◦ Sedation
◦ Insomnia
◦ Preanesthesia
◦ Seizures

Question 14

Barbiturates
CONTRAINDICATIONS / CAUTIONS

Answer 14

◦ Allergy to any barbiturate
◦ Previous history of addiction to sedative–
hypnotic drugs
◦ Latent or manifest porphyria
◦ Marked hepatic impairment or nephritis
◦ Respiratory distress or severe respiratory
dysfunction
◦ Pregnancy

Question 15

Barbiturates
ADVERSE EFFECTS

Answer 15

◦ CNS Depression
◦ Physical Dependency
◦ Drowsiness, somnolence, lethargy
◦ Ataxia, vertigo
◦ Nausea, vomiting, constipation

Question 16

Barbiturates: Drug-Drug
Interactions

Answer 16

Increase CNS depression when given with alcohol, antihistamines, and other tranquilizers
Altered response to phenytoin
MAOI cause increase serum levels and effect
Decrease effectiveness of the following drugs: anticoagulants, digoxin, tricyclic antidepressants,
corticosteroids and oral contraceptives

Question 17

Nursing Considerations for
Patients Receiving Barbiturates
Assessment and diagnosis

Answer 17

Assessment
◦ History and physical exam
◦ Allergies; history of addiction; impaired liver or kidney function; cardiac or respiratory dysfunction;
seizure disorder; pain disorders; pregnancy or lactation
◦ Assess temperature and weight; VS; skin color and lesions; affect, orientation, and reflexes; LS; BS
Nursing Diagnoses
◦ Disturbed thought processes and disturbed sensory perception (visual, auditory, kinesthetic, tactile)
related to CNS effects
◦ Risk for injury related to CNS effects
◦ Impaired gas exchange related to respiratory depression
◦ Deficient knowledge regarding drug therap

Question 18

Nursing Considerations for
Patients Receiving Barbiturates
Implementation

Answer 18

◦ Do not administer these drugs intra-arterially
◦ Do not mix IV drugs in solution with any other drugs
◦ Give parenteral forms only if oral forms are not feasible or available, and switch to oral forms as soon as
possible
◦ Give IV medications slowly
◦ Provide standby life support facilities
◦ Taper dose gradually after long-term therapy, especially in patients with epilepsy
◦ Provide comfort measures to help patients tolerate drug effects
◦ Provide thorough patient teaching

Question 19

Other Anxiolytic and Hypnotic
Drugs

Answer 19

Antihistamines (promethazine, diphenhydramine): Preoperative medications and postoperative
to decrease the need for narcotics
Buspirone: Reduces the signs and symptoms of anxiety without severe CNS and adverse effects
Zaleplon and zolpidem: Short-term treatment of insomnia

Question 20

Antihistamines (promethazine, diphenhydramine):

Answer 20

Preoperative medications and postoperative
to decrease the need for narcotics

Question 21

Buspirone:

Answer 21

Reduces the signs and symptoms of anxiety without severe CNS and adverse effects

Question 22

Zaleplon and zolpidem:

Answer 22

Short-term treatment of insomnia

Question 23

Neuromuscular Abnormalities

Answer 23

Muscle Spasm
◦ Often results from injury to the musculoskeletal system
◦ Caused by the flood of sensory impulses coming to the spinal cord from the injured area

Muscle Spasticity
◦ Result of damage to neurons within the CNS
◦ May result from an increase in excitatory influences or a decrease in inhibitory influences within the CNS

Question 24

Muscle Spasm

Answer 24

◦ Often results from injury to the musculoskeletal system
◦ Caused by the flood of sensory impulses coming to the spinal cord from the injured area

Question 25

Muscle Spasticity

Answer 25

◦ Result of damage to neurons within the CNS
◦ May result from an increase in excitatory influences or a decrease in inhibitory influences within the CNS

Question 26

Use of Muscle Relaxants Across
the Lifespan

Answer 26

Children
◦ Safety and effectiveness has not been
established
◦ Dosage based on weight
◦ Botulism toxins are not approved; associated
with developing botulism
Adults
◦ Safety precautions
◦ Use non-drug measures for muscle injury or pain
◦ Contraindicated in pregnancy and lactation
◦ Females >35 years have increased risk of
hepatoxicity with dantrolene
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 hepatoxicity as
premenopausal women

Question 27

Centrally Acting Skeletal Muscle
Relaxants

Answer 27

Baclofen
Carisoprodol
Cyclobenzaprine
Metaxalone
Methocarbamol
Tizanidine

Question 28

Centrally Acting Skeletal Muscle Relaxants

Answer 28

Baclofen Carisoprodol Cyclobenzaprine Metaxalone Methocarbamol Tizanidine

Question 29

Centrally Acting Skeletal Muscle Relaxants Actions and indications

Answer 29

◦ Work in upper levels of CNS to interfere with reflexes causing muscle spasm ◦ Possible depression anticipated with their use ◦ Lyse or destroy spasm (spasmolytics) ◦ Exact mechanism unknown, thought to involve action in upper or spinal interneurons Indications ◦ Alleviation of signs and symptoms of spasticity; use in spinal cord injuries or diseases

Question 30

Centrally Acting Skeletal Muscle Relaxants Contraindications

Answer 30

◦ Known allergy ◦ Rheumatic disorders Cautions ◦ Epilepsy ◦ Cardiac dysfunction ◦ Conditions marked by muscle weakness ◦ Hepatic or renal impairment ◦ Pregnancy or lactation

Question 31

Centrally Acting Skeletal Muscle Relaxants

Answer 31

Adverse Effects ◦ Drowsiness, fatigue, weakness, confusion, headache ◦ Nausea, dry mouth ◦ Hypotension Drug-Drug Interactions ◦ CNS depressants ◦ Alcohol

Question 32

Nursing Considerations for Centrally-Acting Skeletal Muscle Relaxants Assessment and diagnosis

Answer 32

Assessment ◦ History and Physical Exam ◦ Known allergy, cardiac depression, epilepsy, muscle weakness, or rheumatic disorder ◦ CNS orientation, affect, reflexes, bilateral grip strength, and spasticity, evaluation; bowel sounds and reported output ◦ Monitor appropriate labs Nursing Diagnoses ◦ Acute pain related to GI and CNS effects ◦ Disturbed thought processes related to CNS effects ◦ Risk for injury related to CNS effects ◦ Deficient knowledge regarding drug therapy

Question 33

Nursing Considerations for Centrally-Acting Skeletal Muscle Relaxants Implementation and evaluation

Answer 33

Implementation ◦ Provide additional measures to relieve discomfort ◦ Discontinue drug at any sign of hypersensitivity reaction or liver dysfunction ◦ If using baclofen, taper the drug slowly over 1 to 2 weeks ◦ If patient is receiving baclofen through a delivery pump, the patient should understand the pump, the reason for frequent monitoring, and how to adjust the dose and program the unit ◦ Monitor respiratory status ◦ Provide thorough patient teaching Evaluation ◦ Monitor patient response to the drug (improvement in muscle spasm and relief of pain; improvement in muscle spasticity) ◦ Monitor for adverse effects (CNS changes, GI depression, urinary urgency) ◦ Evaluate the effectiveness of the teaching plan ◦ Monitor the effectiveness of comfort measures and compliance with the regimen

Question 34

Direct-acting Skeletal Muscle Relaxants

Answer 34

Dantrolene IncobotulinumtoxinA OnabotulinumtoxinA RimabotulinumtoxinB

Question 35

Direct-Acting Skeletal Muscle Relaxants action and indications

Answer 35

Actions ◦ Interfering with the release of calcium from the muscle tubules ◦ This prevents the fibers from contracting ◦ Does not interfere with neuromuscular transmission Indications ◦ Treatment of spasticity directly affecting peripheral muscle contraction ◦ Management of spasticity associated with neuromuscular diseases

Question 36

Direct-Acting Skeletal Muscle Relaxants Contraindications Cautions

Answer 36

◦ Known allergy ◦ Spasticity- that contributes to locomotion, upright position, or increased function ◦ Hepatic disease ◦ Lactation Cautions ◦ Women ◦ All patients older than 35 years ◦ Cardiac disease, respiratory depression ◦ Pregnancy Centrally Acting Skeletal Muscle Relaxants Actions ◦ Work in upper levels of CNS to interfere with reflexes causing muscle spasm ◦ Possible depression anticipated with their use ◦ Lyse or destroy spasm (spasmolytics) ◦ Exact mechanism unknown, thought to involve action in upper or spinal interneurons Indications ◦ Alleviation of signs and symptoms of spasticity; use in spinal cord injuries or diseases 27 Centrally Acting Skeletal Muscle Relaxants Contraindications ◦ Known allergy ◦ Rheumatic disorders Cautions ◦ Epilepsy ◦ Cardiac dysfunction ◦ Conditions marked by muscle weakness ◦ Hepatic or renal impairment ◦ Pregnancy or lactation 28 Centrally Acting Skeletal Muscle Relaxants Adverse Effects ◦ Drowsiness, fatigue, weakness, confusion, headache ◦ Nausea, dry mouth ◦ Hypotension Drug-Drug Interactions ◦ CNS depressants ◦ Alcohol 29 Nursing Considerations for Centrally-Acting Skeletal Muscle Relaxants Assessment ◦ History and Physical Exam ◦ Known allergy, cardiac depression, epilepsy, muscle weakness, or rheumatic disorder ◦ CNS orientation, affect, reflexes, bilateral grip strength, and spasticity, evaluation; bowel sounds and reported output ◦ Monitor appropriate labs Nursing Diagnoses ◦ Acute pain related to GI and CNS effects ◦ Disturbed thought processes related to CNS effects ◦ Risk for injury related to CNS effects ◦ Deficient knowledge regarding drug therapy 30 Nursing Considerations for Centrally-Acting Skeletal Muscle Relaxants Implementation ◦ Provide additional measures to relieve discomfort ◦ Discontinue drug at any sign of hypersensitivity reaction or liver dysfunction ◦ If using baclofen, taper the drug slowly over 1 to 2 weeks ◦ If patient is receiving baclofen through a delivery pump, the patient should understand the pump, the reason for frequent monitoring, and how to adjust the dose and program the unit ◦ Monitor respiratory status ◦ Provide thorough patient teaching Evaluation ◦ Monitor patient response to the drug (improvement in muscle spasm and relief of pain; improvement in muscle spasticity) ◦ Monitor for adverse effects (CNS changes, GI depression, urinary urgency) ◦ Evaluate the effectiveness of the teaching plan ◦ Monitor the effectiveness of comfort measures and compliance with the regimen 31 Centrally Acting Skeletal Muscle Relaxants Prototype 32 Direct-acting Skeletal Muscle Relaxants Dantrolene IncobotulinumtoxinA OnabotulinumtoxinA RimabotulinumtoxinB 33 Direct-Acting Skeletal Muscle Relaxants Actions ◦ Interfering with the release of calcium from the muscle tubules ◦ This prevents the fibers from contracting ◦ Does not interfere with neuromuscular transmission Indications ◦ Treatment of spasticity directly affecting peripheral muscle contraction ◦ Management of spasticity associated with neuromuscular diseases 34 Centrally Acting Skeletal Muscle Relaxants Actions ◦ Work in upper levels of CNS to interfere with reflexes causing muscle spasm ◦ Possible depression anticipated with their use ◦ Lyse or destroy spasm (spasmolytics) ◦ Exact mechanism unknown, thought to involve action in upper or spinal interneurons Indications ◦ Alleviation of signs and symptoms of spasticity; use in spinal cord injuries or diseases 27 Centrally Acting Skeletal Muscle Relaxants Contraindications ◦ Known allergy ◦ Rheumatic disorders Cautions ◦ Epilepsy ◦ Cardiac dysfunction ◦ Conditions marked by muscle weakness ◦ Hepatic or renal impairment ◦ Pregnancy or lactation 28 Centrally Acting Skeletal Muscle Relaxants Adverse Effects ◦ Drowsiness, fatigue, weakness, confusion, headache ◦ Nausea, dry mouth ◦ Hypotension Drug-Drug Interactions ◦ CNS depressants ◦ Alcohol 29 Nursing Considerations for Centrally-Acting Skeletal Muscle Relaxants Assessment ◦ History and Physical Exam ◦ Known allergy, cardiac depression, epilepsy, muscle weakness, or rheumatic disorder ◦ CNS orientation, affect, reflexes, bilateral grip strength, and spasticity, evaluation; bowel sounds and reported output ◦ Monitor appropriate labs Nursing Diagnoses ◦ Acute pain related to GI and CNS effects ◦ Disturbed thought processes related to CNS effects ◦ Risk for injury related to CNS effects ◦ Deficient knowledge regarding drug therapy 30 Nursing Considerations for Centrally-Acting Skeletal Muscle Relaxants Implementation ◦ Provide additional measures to relieve discomfort ◦ Discontinue drug at any sign of hypersensitivity reaction or liver dysfunction ◦ If using baclofen, taper the drug slowly over 1 to 2 weeks ◦ If patient is receiving baclofen through a delivery pump, the patient should understand the pump, the reason for frequent monitoring, and how to adjust the dose and program the unit ◦ Monitor respiratory status ◦ Provide thorough patient teaching Evaluation ◦ Monitor patient response to the drug (improvement in muscle spasm and relief of pain; improvement in muscle spasticity) ◦ Monitor for adverse effects (CNS changes, GI depression, urinary urgency) ◦ Evaluate the effectiveness of the teaching plan ◦ Monitor the effectiveness of comfort measures and compliance with the regimen 31 Centrally Acting Skeletal Muscle Relaxants Prototype 32 Direct-acting Skeletal Muscle Relaxants Dantrolene IncobotulinumtoxinA OnabotulinumtoxinA RimabotulinumtoxinB 33 Direct-Acting Skeletal Muscle Relaxants Actions ◦ Interfering with the release of calcium from the muscle tubules ◦ This prevents the fibers from contracting ◦ Does not interfere with neuromuscular transmission Indications ◦ Treatment of spasticity directly affecting peripheral muscle contraction ◦ Management of spasticity associated with neuromuscular diseases

Question 37

Direct-Acting Skeletal Muscle Relaxants Adverse Effects Drug -drug interactions

Answer 37

◦ Fatigue ◦ Weakness ◦ Confusion ◦ GI irritation ◦ Enuresis Drug-Drug Interactions ◦ Estrogen ◦ Neuromuscular junction blockers and others that interfere with neuromuscular transmission

Question 38

Nursing Considerations for Direct-Acting Skeletal Muscle Relaxants Assessment And diagnosis

Answer 38

Assessment ◦ History and Physical Exam ◦ Known allergies; cardiac depression, epilepsy; muscle weakness; respiratory depression; pregnancy or lactation; renal or hepatic dysfunction ◦ Assess orientation, affect, reflexes, bilateral grip strength, and spasticity; VS; LS; ECG; cardiac output; BS; urinary output ◦ Monitor appropriate labs Nursing Diagnoses ◦ Acute pain related to GI and CNS effects ◦ Disturbed thought processes related to CNS effects ◦ Risk for injury related to CNS effects ◦ Deficient knowledge regarding drug therapy

Question 39

Direct-Acting Skeletal Muscle Relaxants Implementation

Answer 39

◦ Discontinue the drug at any sign of liver dysfunction ◦ Do not administer botulinum toxins into any area with an active infection ◦ Monitor intravenous access sites of dantrolene for potential extravasation ◦ Institute other supportive measures (e.g., ventilation, anticonvulsants as needed, cooling blankets) for the treatment of malignant hyperthermia ◦ Periodically discontinue dantrolene for 2 to 4 days to monitor therapeutic effectiveness ◦ Establish a therapeutic goal before beginning oral therapy with dantrolene ◦ Discontinue dantrolene if diarrhea becomes severe ◦ Provide thorough patient teaching

Question 40

Central Nervous System Stimulants

Answer 40

Armodafinil Dexmethylphenidate Dextroamphetamine Methylphenidate Modafinil

Question 41

Central Nervous System Stimulants Actions and Indications

Answer 41

Actions ◦ CNS stimulants act as cortical and RAS, possible by increasing the release of catecholamines from presynaptic neurons leading to an increase in stimulation of the postsynaptic neurons Indications ◦ Treatment attention – deficit syndromes ◦ Narcolepsy

Question 42

Central Nervous System Stimulants Contraindications Adverse Effects Drug-Drug Interactions

Answer 42

◦ Known allergy, marked anxiety, agitation, or tension and severe fatigue or glaucoma, cardiac disease Cautions ◦ History of seizures; history of drug dependence, including alcoholism; hypertension Adverse Effects ◦ Nervousness, insomnia, dizziness, headache, blurred vision, anorexia, nausea, weight loss Drug-Drug Interactions ◦ MAOI ◦ Guanethidine ◦ Tricyclic antidepressants, phenytoin

Question 43

Nursing Considerations for Central Nervous System Stimulants assessment and diagnosis

Answer 43

Assessment ◦ History and Physical Exam ◦ Allergies; glaucoma; anxiety, tension, fatigue, or seizure disorder; cardiac disease and hypertension; pregnancy or lactation; history of leukemia; history of drug dependency, including alcoholism ◦ Assess skin color and lesions; orientation, affect, reflexes; ophthalmic exam; BS; urinary output; VS; LS ◦ Monitor appropriate labs Nursing Diagnoses ◦ Disturbed thought processes related to CNS effects of the drug ◦ Decreased cardiac output related to CV effects of the drug ◦ Risk for injury related to CNS and visual effects of the drug ◦ Deficient knowledge regarding drug therapy

Question 44

Nursing Considerations for Central Nervous System implementation

Answer 44

◦ Ensure proper diagnosis of behavioral syndromes and narcolepsy ◦ Arrange to interrupt the drug periodically in children who are receiving the drug for behavioral syndromes ◦ Arrange to dispense the least amount of drug possible ◦ Administer drug before 6 pm ◦ Monitor weight, CBC, and ECG ◦ Consult with the school nurse or counselor ◦ Provide safety measures if CNS effects occur ◦ Provide thorough patient teaching