Module 14 CNS depressant and CNS stimulant Flashcards
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
Use of Anxiolytic and Hypnotic
Agents Across the Lifespan
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
Benzodiazepines (-pam or -lam)
Alprazolam
Clonazepam
Diazepam
Lorazepam
Midazolam
Temazepam
Benzodiazepines: Actions
Actions
◦ 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
Benzodiazepines indications
Indications: anxiety disorders, alcohol withdrawal, hyperexcitability and agitation, preoperative
relief of anxiety and tension to aid in balanced anesthesia
Benzodiazepines
Contraindications/cautions
◦ Allergy to benzodiazepine
◦ Psychosis
◦ Acute narrow angle glaucoma
◦ Shock
◦ Coma
◦ Acute alcohol intoxication
◦ Pregnancy and lactation
Benzodiazepines
ADVERSE EFFECTS
◦ Dry mouth, constipation, nausea, vomiting
◦ Hypotension
◦ Urinary retention
◦ Sedation, drowsiness, depression, lethargy,
blurred vision, confusion
Benzodiazepines
Drug - drug interaction
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
Nursing Considerations for
Patients Receiving assessment and diagnosis
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
Nursing Considerations for
Patients Receiving
Benzodiazepines
implementation
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
Barbiturates (-barbital) drug list
Pentobarbital
Phenobarbital
Secobarbital
Barbiturates
ACTIONS
◦ CNS depressants
◦ Inhibit neuronal impulse conduction in the
ascending RAS
◦ Depress cerebral cortex
◦ Depress motor output
◦ Cause: sedation, hypnosis, anesthesia, and coma
Barbiturates Indication
INDICATION
◦ Relief of the signs and symptoms of anxiety
◦ Sedation
◦ Insomnia
◦ Preanesthesia
◦ Seizures
Barbiturates
CONTRAINDICATIONS / CAUTIONS
◦ 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
Barbiturates
ADVERSE EFFECTS
◦ CNS Depression
◦ Physical Dependency
◦ Drowsiness, somnolence, lethargy
◦ Ataxia, vertigo
◦ Nausea, vomiting, constipation
Barbiturates: Drug-Drug
Interactions
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
Nursing Considerations for
Patients Receiving Barbiturates
Assessment and diagnosis
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
Nursing Considerations for
Patients Receiving Barbiturates
Implementation
◦ 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
Other Anxiolytic and Hypnotic
Drugs
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
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
Neuromuscular Abnormalities
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
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
Use of Muscle Relaxants Across
the Lifespan
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
Centrally Acting Skeletal Muscle
Relaxants
Baclofen
Carisoprodol
Cyclobenzaprine
Metaxalone
Methocarbamol
Tizanidine
Centrally Acting Skeletal Muscle Relaxants
Baclofen Carisoprodol Cyclobenzaprine Metaxalone Methocarbamol Tizanidine
Centrally Acting Skeletal Muscle Relaxants Actions and indications
◦ 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
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
Centrally Acting Skeletal Muscle Relaxants
Adverse Effects ◦ Drowsiness, fatigue, weakness, confusion, headache ◦ Nausea, dry mouth ◦ Hypotension Drug-Drug Interactions ◦ CNS depressants ◦ Alcohol
Nursing Considerations for Centrally-Acting Skeletal Muscle Relaxants Assessment and diagnosis
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
Nursing Considerations for Centrally-Acting Skeletal Muscle Relaxants Implementation and evaluation
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
Direct-acting Skeletal Muscle Relaxants
Dantrolene IncobotulinumtoxinA OnabotulinumtoxinA RimabotulinumtoxinB
Direct-Acting Skeletal Muscle Relaxants action and indications
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
Direct-Acting Skeletal Muscle Relaxants Contraindications Cautions
◦ 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
Direct-Acting Skeletal Muscle Relaxants Adverse Effects Drug -drug interactions
◦ Fatigue ◦ Weakness ◦ Confusion ◦ GI irritation ◦ Enuresis Drug-Drug Interactions ◦ Estrogen ◦ Neuromuscular junction blockers and others that interfere with neuromuscular transmission
Nursing Considerations for Direct-Acting Skeletal Muscle Relaxants Assessment And diagnosis
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
Direct-Acting Skeletal Muscle Relaxants Implementation
◦ 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
Central Nervous System Stimulants
Armodafinil Dexmethylphenidate Dextroamphetamine Methylphenidate Modafinil
Central Nervous System Stimulants Actions and Indications
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
Central Nervous System Stimulants Contraindications Adverse Effects Drug-Drug Interactions
◦ 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
Nursing Considerations for Central Nervous System Stimulants assessment and diagnosis
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
Nursing Considerations for Central Nervous System implementation
◦ 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
