Pharm exam 4 - Psych drugs part 2

What are the Sedatives & Hypnotics Drugs?

• Benzodiazepines

• Benzodiazepine-like drugs

• Barbiturates

What do Sedatives & Hypnotics cause?

some level of CNS depression

Main use is control of anxiety
• “Anxiolytics” for anxiety
• “Hypnotics” for insomnia

Benzodiazepines prototype:

Diazepam (Valium)

Diazepam (Valium) MOA:

potentiate the effects of GABA, an inhibitory neurotransmitter

Diazepam (Valium) uses:

Anxiety, insomnia, muscle spasms, seizures, ETOH withdrawal, anesthesia induction

Diazepam (Valium) pharmacokinetics:

• PO, IM, & IV, well absorbed
• Highly lipid soluble (cross BBB)
• Metabolized by liver
• Time course is different for each drug

Benzodiazepines common drugs to recognize:

• Alprazolam (Xanax)
• Clonazepam (Klonopin)
• Lorazepam (Ativan)

Benzodiazepines interactions:

CNS depressants

Benzodiazepines tolerance / dependence:

• Tolerance can develop
• Significant tolerance to anti-seizure effect
• Cross-tolerance for those who have tolerance to barbiturates, alcohol, and opioids
• Potential for abuse (Schedule IV)
• Withdrawal likely in long-term use

Benzodiazepines Expected → Adverse effects:

CNS depression
• Reduce anxiety
• Promote sleep
• Muscle relaxation
Cardiac
• PO no effect
• IV hypotension → cardiac arrest
Respiratory
• Mild in general
• Can be significant for COPD, OSA

What are the signs of benzodiazepine overdose?

• Oral overdose (usually not severe):

  • Drowsiness

  • Lethargy

  • Confusion

• Cardiovascular (CV) and respiratory depression are uncommon unless combined with other CNS depressants

• IV overdose: Can cause profound hypotension, respiratory arrest, and cardiac arrest (life-threatening)

What is the nursing care for acute benzodiazepine toxicity?

• Maintain airway

• Monitor respiratory rate

• Give IV fluids to maintain blood pressure

• Provide supportive care and monitor closely for worsening respiratory status

What is flumazenil (Romazicon)?

• Antidote for benzodiazepine overdose

• Competitive benzodiazepine receptor antagonist

• Given rapid IV over 15 seconds

• Short half-life → may require repeat doses

• Reverses sedation, NOT respiratory depression

• Risk: Can trigger seizures, especially in patients with epilepsy or benzodiazepine dependence

benzodiazepine - Nursing Considerations

• Fall risk!
• Monitor VS
• Evaluate memory and watch for a paradoxical reaction
• Educate not to increase the dosage or stop abruptly without consulting the prescriber
• Educate about good sleep interventions
• Warn about residual sedation
• Avoid mixing with other CNS depressants
• Teratogenic

What factors increase the risk of benzodiazepine toxicity?

• Concurrent opioid or alcohol use

• Liver disease → prolonged sedation

• Long half-life/active metabolites → drug accumulation

• Older adults → increased confusion and fall risk

When should a nurse suspect benzodiazepine oversedation instead of expected sedation?

• Decreased level of consciousness

• Respiratory rate ↓

• Blood pressure ↓

• Difficult to arouse

• Airway or patient safety is threatened

What are the priority nursing actions for suspected benzodiazepine toxicity?

• Hold the medication

• Assess airway, respirations, SpO₂, and vital signs

• Ask about alcohol or opioid use

• Notify the provider

• Prepare flumazenil if ordered

• Continue fall precautions

What patient teaching is most important for benzodiazepines?

• Do not drink alcohol or take other CNS depressants.

• Do not stop the medication abruptly—taper slowly.

• Avoid driving until you know how it affects you.

• Rise slowly and use fall precautions.

What is the prototype for Benzodiazepine-like Drug?

zolpidem

zolpidem MOA:

potentiate the effects of GABA, an inhibitory neurotransmitter

zolpidem uses:

Insomnia (not anxiety)

zolpidem adverse effects:

• Daytime drowsiness
• Dizziness
• Sleep-related behaviors (sleepwalking, sleep driving)
• No resp depression, but don’t combine with CNS depressants
• Long-term use → tolerance & dependence (Schedule IV)

What teaching should nurses provide for patients taking zolpidem?

• Take immediately before bed

• Allow 7–8 hours for sleep

• Use short-term only (≤2 weeks)

• Avoid alcohol and other CNS depressants

• Practice good sleep hygiene (dark room, no screens, avoid caffeine)

When should a nurse notify the provider about zolpidem?

• Sleepwalking or sleep driving

• Confusion or memory problems

• Unsteady gait or repeated falls

• Suspected misuse or long-term dependence

How is zolpidem different from benzodiazepines?

• Acts on GABA receptors but is not a benzodiazepine

• Used only for insomnia (not anxiety)

• Does not usually cause respiratory depression alone

• Respiratory depression risk increases when combined with alcohol or other CNS depressants

What is Barbiturates prototype?

phenobarbital

phenobarbital MOA:

Enhances and mimics the action of GABA

phenobarbital Expected → adverse effects:

• CNS depression
• Cardiac: hypotension & bradycardia
• CYP P450 enzymes (inducer)
• Tolerance / Dependence
• Drug tolerance, but not to resp depression
• Dependence & Cross-tolerance to other CNS depressants

Teratogenic

phenobarbital toxicity s/s:

• respiratory depression
• coma
• pinpoint pupils
• hypotension
• hypothermia (no specific antidote)

profound CNS depression

What are the priority nursing actions for phenobarbital toxicity?

• Hold the medication

• Maintain airway, breathing, circulation (ABCs)

• Continuous cardiorespiratory monitoring

• IV fluids for hypotension

• Prepare for mechanical ventilation if respiratory failure develops

• No specific antidote—treatment is supportive

What important safety teaching should patients taking phenobarbital receive?

• Never mix with alcohol, opioids, or benzodiazepines

• Do not stop abruptly—withdrawal can cause seizures and may be fatal

• Take exactly as prescribed

• Report excessive drowsiness or breathing problems

What is bipolar disorder?

• Chronic biologic illness
• Problem with altered brain physiology with neuronal atrophy of the prefrontal cortex (emotions)
• Requires life-long treatment
• Alternating episodes:
Depression Dysphoria Normal mood Hypomania Mania
• Untreated = longer episodes, less “normalcy”

Drug therapy of bipolar disorder:

Mood stabilizer → Antipsychotics → Antidepressant

Non drug therapy of bipolar disorder:

Psychotherapy ECT

What is the mood stabilizer prototype:

lithium carbonate

lithium carbonate MOA:

unclear, likely involves alteration of ions, neurotransmitters, etc

lithium carbonate uses:

Acute mania and long-term prevention of mania in BPD

lithium carbonate pharmacokinetics:

• PO, well absorbed
• Short T ½ , requires dosing 2-4 times a day
• Excreted by kidneys, affected by Na levels
• NTI 0.4 – 1.0 mEq/L, toxicity at > 1.5 mEq/L

lithium carbonate interactions:

• Thiazide & loop diuretics (hyponatremia)
• NSAIDS (suppresses prostaglandins, increasing renal absorption of lithium)
• Anticholinergics (urine hesitancy with polyuria = discomfort)
• Teratogenic
• Thyroid hormone secretion

Lithium toxicity <1.5

N/V/D
Weakness
Fine hand tremor
Polydipsia/polyuria
Slurred speech

Lithium toxicity 1.5-2

Worse GI upset
Coarse hand tremors
Sedation
Confusion
Incoordination
ECG changes

Lithium toxicity 2-2.5

Ataxia
Polyuria (dilute urine)
ECG changes (severe)
Clonic movements
Seizures
Stupor/coma
Hypotension

Lithium toxicity >2.5

Seizures
Oliguria
Death

Nursing Considerations lithium carbonate:

• Give with food to lessen GI effects
• Monitor drug levels! Therapeutic range is 0.4 – 1.0
• Monitor labs --> Na, BUN, Creatinine, GFR, thyroid levels, HCG
• Monitor fluid intake and output
• Monitor for signs of hypothyroidism
• Educate on s/s of toxicity so patient can hold med & call provider
• Educate to maintain hydration (polyuria)
• Educate to report N/V/D - can lower Na levels → toxicity
• Educate no NSAIDS, no anticholinergics

What increases the risk of lithium toxicity?

• Dehydration

• Low sodium (hyponatremia)

• Kidney disease or decreased kidney function

• NSAIDs

• Thiazide or loop diuretics

What should a nurse do if lithium toxicity is suspected?

• Hold the lithium dose

• Notify the provider

• Check lithium level

• Monitor sodium and kidney function

• Assess for vomiting, diarrhea, confusion, tremors, and decreased urine output

What patient teaching is most important for lithium?

• Drink plenty of water every day

• Maintain consistent sodium intake

• Take with food to decrease GI upset

• Report vomiting, diarrhea, or dehydration

• Avoid NSAIDs and diuretics unless approved by the provider

Which assessment findings suggest lithium toxicity rather than expected side effects?

Expected:

• Mild nausea

• Fine hand tremor

• Thirst

• Mild fatigue

Toxicity:

• Confusion

• Unsteady gait (ataxia)

• Coarse tremor

• Slurred speech

• Decreased urine output

• Seizures (severe)