Pain + CNS

Name 2 examples for sedative & anxiety medications

lorazepam (ativan) and alprazolam (xanax)

What drug class do lorazepam and alprazolam belongs to?

benzodiazepines

What do benzodiazepines do?

enhances GABA, a main inhibitory transmitter in brain

slows brain activity, reduces anxiety and agitation

CNS depression

What are the major risks with lorazepam (Ativan)?

respiratory depression, oversedation

What should you assess before giving lorazepam?

RR and depth; LOC; if patient is on any other sedating meds (opioids, antihistamines, alcohol)

When should you hold lorazepam

if RR is < 12 or if patient is drowsy

Taking lorazepam together with other sedating meds can increase the risk of?

respiratory arrest

How do older adults react to benzos/ lorazepam?

very sensitive to benzodiazepines

Using benzodiazepines/lorazepam in older adutls can increase what risk?

delirium, confusion, falls, paradoxical agitation even at small doses

What should the nurse make sure when administering lorazepam to older adults?

use smallest effective dose + ensure fall precautions

What are the risk of lorazepam if use regularly or stop abruptly?

risk of physical dependence & withdrawal symptoms

What are the withdrawal symptoms if lorazepam is stopped abruptly?

rebound anxiety, tremors, insomnia, seizures

What should be done to avoid lorazepam withdrawal symptoms?

tapered gradually under supervision

What are the key teaching points for lorazepam?

- take as prescribed

- short term only

- avoid alcohol & other sedatives

- avoid driving or operating machinery

- report unusual agitation, behavior change, breathing problems

What are the indications for lorazepam?

acute anxiety, agitation, seizure control, pre-op sedation

What are the indications for alprazolam?

anxiety & panic attacks

How long is the onset of alprazolam?

fast, works quickly

Because of its fast onset, alprazolam increases risk of?

addiction, misuse, and abuse risk

What are the nursing assessments that must be done when giving alprazolam?

- check RR, O2, LOC before dose

- screen for substance use disorder

- evaluate for signs of developing dependence (early refill requests/ increase dose frequents)

What are the risks of taking alprazolam with other sedatives (opioids, alcohol, sleep meds, antihistamines)?

CNS & respiratory depression

Is alprazolam for short or long term use?

short-term symptom relief only, not a "daily forever" meds

What are the withdrawal symptoms of stopping alprazolam abruptly?

rebound anxiety, insomnia, tremor, palpitation, seizures

Like lorazepam, how should we stop alprazolam to prevent withdrawal risks?

taper slowly

What are the key teaching points for alprazolam?

- take only as prescribed

- no double doses if missed

- avoid driving

- report worsening anxiety, mood change, or thoughts of self-harm

What type of medication is Zolpidem?

sleep meds

What class does zolpidem belong to?

non-benzodiazepine hypnotics

What is the indication for zolpidem?

short-term treatment of insomnia

What is the action of the drug zolpidem?

promotes sleep via GABA receptors

What are some major safety issues with zolpidem?

sleepwalking, sleep-driving, eating without memory

What are the nursing assessments that must be done when giving zolpidem?

- ask about sleep history/ apnea/ walking

- check baseline mental status & fall risks esp in adults

What are the adverse effects for older adults taking zolpidem?

confusion, delirium, falls

What can we do to minimize adverse effects for older adults taking zolpidem?

use lower doses & try non-drug sleep strategies first

When should patient take zolpidem?

right before bed when they can dedicate 7-8 hours to sleep

What are some key teaching points for zolpidem?

- not to take extra dose in middle of night

- avoid alcohol & other sedatives

- groggy might be expected next morning

- avoid driving

Name an example of an opioid agonist

morphine

What is the indication for morphine?

moderate to severe pain, post-op pain, cancer pain, certain cardiac conditions (MI/PE)

What should the nurse asses PRIOR to giving morphine?

- RR (hold if <12)

- sedation & LOC (RASS or similar)

- BP (risk for hypotension)

- opioid history

- bowel function (risk for constipation)

What are some major risks of morphine?

respiratory depression, hypotension, bradycardia, constipation, urinary retention

How often should the nurse reasses pain after giving morphine?

within 30-60 mins

What should the nurse monitor for after giving morphine?

RR, breath depth, O2, oversedation (drowsiness before respiratory depression)

Patient on morphine is often on what other meds for their constipation?

bowel regimen (stool softener + stimulant)

What are the key teaching points for morphine?

- no alcohol

- increase fluid and fiber intake (constipation)

- report severe drowsiness or breathing difficulty

- no driving or operating machinery

Name an example for opioid antagonist/ reversal for opioid OD

naloxone (narcan)

What is the action of naloxone?

restores breathing by knocking opioids off receptor sites

What is the onset for naloxone?

fast onset & short duration

What is the half-life of naloxone?

short (30-90mins)

What are the assessment priorities for naloxone?

check responsiveness, breathing, pulse -> if apnea: call ER + begin rescue breathing -> administer naloxone as ordered

What are the routes for naloxone?

subQ, intranasal, IV, IM

Why do we often need repeating doses of naloxone?

because of its short half life compares to longer half life of many opioids -> breathing might stop again

What happens after naloxone is given?

sudden awakening and withdrawal symptoms may occur

What are the withdrawal symptoms that can happen when naloxone is given?

agitation, sweating, N/S, tachycardia, pain return

What are the nursing responsibilities when giving naloxone?

monitor respirations continuously, prepare for recurrent respiratory depression, provide emotional support (withdrawals)

What are the key teaching points for naloxone?

how to administer intranasal naloxone + call 911 since naloxone is temporary

Name an example drug of an SSRI class

fluoxetine

The subclass SSRI is under what type of drug class?

antidepressants

What is the action of fluoxetine?

increase serotonin levels in the brain

What are the indications of fluoxetine?

first line for depression, anxiety, OCD, PTSD, PMDD

What is the onset for fluoxetine?

4-6 weeks for full effect (not immediately)

What should the nurse assess when giving fluoxetine?

mood, energy, sleep, appetite, ability to perform daily activities, and suicidal thoughts

Fluoxetine is under what drug warning and why?

black box warning because it increases suicidal thoughts in young people when just started or doses are changed

What is the biggest risk of SSRI?

serotonin syndrome (emergency)

What is serotonin syndrome?

too much serotonin esp when combining with MAOIs, other SSRIs/SNRIs, linezoid, triptans, St. John's wort

What are the symptoms of serotonin syndrome?

agitation, confusion, sweating, fever, tachycardia, tremor, hyperreflexia, diarrhea

What should you do if suspected serotonin syndrome?

stop drug, notify provider, support airway, monitor vitals

What are the key teaching points for fluoxetine?

- take daily even if feeling better

- not addictive but shouldn't be stopped abruptly (withdrawal symptoms)

- open communication so med can be adjusted if needed

What are the possible side effects for fluoxetine?

GI upset, headache, insomnia, sexual dysfunction

Name an example drug for the tricyclic antidepressant class

amitriptyline

The subclass tricyclic antidepressant (TCA) is under which type of drug class?

antidepressants (older ver)

What are the indications for amitriptyline?

chronic pain, migraines, insomnia

Why is amitriptyline not being used as often now?

due to strong sedation and anticholinergic (side) effects

What is the action of amitriptyline?

increases serotonin and NE level but also blocks other receptors (muscurinic, histamine, alpha1)

What are the side effects of amitriptyline?

anticholinergic effects (can't see can't pee can't shit can't spit)

TCA are highly lethal in OD because?

can lead to arrythmia and cardiotoxicity (must assess patient at risk for self-harm)

Besides anticholinergic effects, what other risk does amitriptyline carry?

orthostatic hypotension & sedation

What are the key teaching points for amitriptyline?

- take @ bed time

- taper slowly when withdrawing to avoid withdrawal symptoms

- report chest pain, palpitations, fainting, or severe constipation/ urinary retention

Name an example of a monoamine oxidase inhibitor (MAOI) class

phenelzine

The subclass MAOIs belong to which type of drug class?

antidepressants

What is the action of phenelzine?

blocks the enzyme that breaks down NE, serotonin, and dopamine -> increasing their levels

What is the indication of phenelzine?

for patients who haven't responded to safer antidepressants (SSRI/ SNRI)

What is the biggest safety issue/ risk for phenelzine?

hypertensive crisis

Why would phenelzine potentially cause hypertensive crisis?

monoamine oxidase breaks down tyramine (in aged cheese, cured meats, fermented foods, red wine, beers) -> MAO is inhibited -> tyramine builds up -> massive release of NE

What are the symptoms in hypertensive crisis?

severe HTN, headache, stroke, N/S, palpitation, chest pain, sweating, confusion

What should be done if suspected hypertensive crisis?

stop med, treat as emergency, notify provider

What drug should NOT be combined with phenelzine to prevent interactions?

SSRI, SNRI, TCA, certain pain meds (meperidine), cold meds, decongestants

What are the key teaching points for phenelzine?

- teach what food is safe and what to avoid

- even a single tyramine-high meal can be dangerous

- report severe headache and chest pain asap

Name an example of a mood stabilizer

lithium

The subclass mood stabilizer belongs to which drug class?

antidepressants

What is an indication for lithium?

bipolar disorder, manic episodes

What is the narrow therapeutic range for lithium?

0.6-1.2 mEq/L

What electrolyte is lithium similar to?

sodium

What should the nurse advise patient taking lithium to do?

stay hydrated and keep salt instake consistent

What are the early signs of lithium toxicity?

N/S, diarrhea, fine tremor, polyuria, confusion

What are the worsening signs of lithium toxicity?

coarse tremor, GI upset, confusion, ataxia, slurred speech

What are the severe signs of lithium toxicity?

seizures, coma, arrhythmia

What should be monitored after taking lithium?

lithium serum level (12 hrs after last dose), kidney function (nephrotoxicity), thyroid function (hypothyroidism)

What are the key teaching points for lithium?

- take it consistently and at same time everyday

- avoid drastic change in salt intake or use of diuretics

- notify if N/S, diarrhea, fever, sweating a lot

- never double dose if missed

Name an example of first gen (typical) antipsychotics

haloperidol

What is the action of haloperidol?

blocks dopamine receptors

What is the indication of haloperidol?

treating positive symptoms of schizophrenia & acute agitation & aggression

What are the risks for haloperidol?

extrapyrimidal symptoms (EPS) and neuroleptic malignant syndrome (NMS)