Unit 10- Central Nervous System

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1

sedatives

depress the central nervous system (CNS).

induces relaxation and ¯ anxiety (anxiolytic), sedation at higher doses

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hypnotics

a. Upper end of sedation

b. Induces sleep, coma

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precautions/contraindications for hypnotics and sedatives

1. level of consciousness (LOC)

2. Respiratory insufficiency

3. Risk for injury

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general nursing actions

assess for therapeutic and side effects

monitor LOC, respiratory function, blood pressure; ensure safety

patient education: drug information, drug levels

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potential issues with sedatives/hypnotics

physical and psychological dependence

withdrawal symptoms

psychological disturbances – anxiety, insomnia

fever, tachycardia, ­ or ¯ blood pressure

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barbiturates therapeutic effects/indications

Potent CNS depressant, → nerve transmission, ­ seizure threshold

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dose dependent actions of barbituates

low: antianxiety, drowsy / sedation

moderate: antiseizure

high: anesthesia, induced coma

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barbituates side effects

no longer recommended for sleep induction, deprives REM sleep

i. respiratory rate, blood pressure, lethargy

ii. enzyme inducer = ­ metabolism of certain drugs by liver

iii. shortens duration of action of certain meds

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9

barbiturates nursing actions

narrow therapeutic range – side effects, drug levels

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barbiturates prototypes

phenobarbital

no alcohol! can increase sedative effects

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phenobarbital drug range

Therapeutic drug level: 10 – 40 mcg / ml

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benzodiazepines therapeutic effects/indications

CNS depressants

drugs of choice: anxiety, sedation, insomnia, skeletal muscle relaxation

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benzodiazepine side effects

headache, drowsy, hangover effect no alcohol

paradoxical excitement / nervousness

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benzodiazepine nursing actions

appropriate use

patient education, patient safety

drugs effect sleep cycle, can have daytime sleepiness

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benzodiazepine reversal agent

flumazenil

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benzodiazepine prototypes

lorazepam- panic attacks, anxiety and seizures

clonazepam

temazepam

midazolam- amnesiac effect/outpatient procedure

alprazolam

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non-benzodiazepines therapeutic effects

does not disrupt sleep as much, lack sedative dependency potential

anxiolytic – decreases anxiety

induces sleep – treats insomnia

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non-benzo side effects

Ambien (zolpidem) – sleep walking, eating, driving

BuSpar (buspirone) – grapefruit juice ­ drug concentration

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non-benzo nursing actions

safety with Ambien; dietary guidelines with BuSpar

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non-benzo prototypes

zolpidem- sleep induction

buspirone- decreases anxiety with less sleepiness

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skeletal muscle relaxants therapeutic effects

Used to treat muscle spasms – involuntary contractions of muscles

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skeletal muscle relaxants indications- centrally acting

excessive muscle use

injury; stress

rigidity with Parkinson’s

musculoskeletal symptoms – multiple sclerosis, cerebral palsy, etc.

side effects of antipsychotic drugs

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skeletal muscle relaxants indications- direct acting

spasticity related to malignant hyperthermia

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skeletal muscle relaxant precautions/contraindications

care with concurrent use of other drugs causing sedation

increases sedative effects

renal insufficiency with some agents

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skeletal muscle relaxant side effects

Dizziness, lightheadedness, sedation

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skeletal muscle relaxant nursing actions

assess for therapeutic and side effects

ensure safety

patient education: drug information, safety issues

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skeletal muscle relaxant prototypes

Central acting:

cyclobenzaprine

baclofen

carisoprodol

Direct acting:

dantrolene

used in malignant HTN, caused by GA use, propofol

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ADHD

encompasses, decreases attention span, behavioral issues, hyperactivity

cause essentially unknown

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ADHD potential influences

lead levels in children; maternal exposure to alcohol, drugs

dopamine / norepinephrine / serotonin levels in brain

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ADHD drugs therapeutic effects

central nervous system (CNS) stimulants stimulate areas in the brain which increases mental alertness, improve mood, decreases fatigue and drowsiness

wakefulness and attention

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ADHD medication indications

ADHD

Narcolepsy

Obesity

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ADHD precautions/contraindications

marked anxiety, glaucoma

tic disorders (Tourette’s syndrome)

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ADHD drug side effects

heart rate, blood pressure, metabolic rate

gastrointestinal distress, dry mouth

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ADHD drug nursing actions

assessment of therapeutic effects and side effects

appropriate use / dosing of drugs

patient education: drug info, facilitate counseling, behavior modification, drug holiday (diminish addictive tendencies, go 1 day/week without medication

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ADHD drug prototypes

methylphenidate extended release

methylphenidate

atomoxetine

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36

seizure disorders

does not mean convulsions

abnormal electrical activity in the brain’s nerve cells

affects LOC, motor activity, sensation

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seizure disorder acute causes

fever

infection, trauma

vascular, cancer

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convulsion

involuntary, spastic contractions of voluntary muscles

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epilepsy

recurrent pattern of seizures

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partial seizure

focal seizure

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generalized seizure

grand mal, alternation between relaxation and spastic

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simple seizure

petite mal, sudden loss of awareness with no LOC- blank stare

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complex seizure

LOC reduced but not lost

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secondary generalization seizure

grand mal/ tonic clonic

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status epilepticus

multiple seizures occurring with no recovery between them.

can cause hypotension, hypoxia, first line of treatment: benzodiazepines

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antiepileptic drugs therapeutic effects

seizure threshold, decreased transmission between and within a neuron

control / minimize seizure activity

maintain quality of life

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antiepileptic drug indications

prevention or control of seizures

acute and long-term maintenance

status epilepticus

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antiepileptics drugs precautions/contraindicated

drugs must be tapered

concurrent use with some antidepressant can precipitate seizures

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antiepileptic drug side effects

numerous, drug dependent

general: bone marrow suppression, dizzy, drowsy, GI upset, skin issues

black box: suicidal thoughts and behaviors

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antiepileptic nursing actions

assessment of therapeutic effects and side effects

knowledge of drug levels, specific side effects; Black Box

drugs must be tapered, not stopped abruptly

patient education: drug info, compliance, safety issues, emergency treatment

alternative therapy: ketogenic diet

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antiepileptic prototypes

phenytoin

levetiracetam

phenobarbital

pregabalin

gabapentin

carbamazepine

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phenytoin side effects

possible thrombocytopenia

bone marros suppression

ataxia

gingival hyperplasia

lethargy

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phenytoin therapeutic drug level

10-20 mcg/ml

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phenobarbital therapeutic drug level

10-40 mcg/ml

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carbamazepine therapeutic drug level

4-12 mcg/ml

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depression description

alteration in brain chemistry; response to situation

low serotonin

response from health care providers, society

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criteria for depression diagnosis

sleep disturbances

changes in eating patterns

↓ energy, fatigue

↓ interest in activities

↓ concentration; suicidal ideation

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therapeutic effects for depression rx

relief of symptoms in approximately 6 – 8 weeks of therapy

no harm to self

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indications for depression rx

major depression; seasonal affective disorder (SAD)

generalized anxiety disorder (GAD); obsessive compulsive disorder (OCD)

adjunct for pain management, smoking cessation

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precautions/contraindications for depression rx

concurrent use of varied classes of antidepressants, St. John’s Wort

cardiac / seizure history

drugs must be tapered

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nursing actions for depression rx

assess for therapeutic and side effects, serotonin syndrome ensure reason for use of agent

patient education – disorder, drug information, facilitate counseling

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depression rx classes

tricyclic antidepressants (TCA)

selective serotonin (and/or nonrepinephrine) reuptake inhibitors (SSRI/SNRI)

monoamine oxidase inhibitors (MAO-I)

atypical agents

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tricyclic antidepressant indications

major depression, obsessive compulsive disorder (OCD)

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tricyclic antidepressant side effects

orthostatic hypotension (due to a1 blockade) s

sedation, anticholinergic effects

alcohol increase likelihood of overdose

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tricyclic antidepressant prototypes

amitryptoline

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SSRI/SNRSI indications

major depression, generalized anxiety disorder (GAD), OCD

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SSRI/SNRSI side effects

sexual dysfunction

headache, insomnia or sedation

contraindicated in allergy or use of MOAI within 14 days

asses for suicidal tendencies

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SSRI/SNRI protypes

escitalopram

paroxetine

fluoxetine

sertraline

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atypical agent indications

depression and may be used for specific actions

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atypical agents side effects

seizure, nervousness, insomnia / sedation

headache, dry mouth

weight changes

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atypical agents

trazodone- given for depression, insomnia and chronic pain

bupropion- smoking cessation

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bipolar disorder description

stages of mania cycled with depression, variable times diagnosis can be delayed depending on severity of symptoms

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bipolar disorder rx therapeutic effect

decreased cycles of mania/depression

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bipolar disorder rx indications

bipolar disorder

depression

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bipolar disorder rx precautions/contraindications

Many drug interactions

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bipolar disorder rx side effects

Lithium: headache, GI upset, confusion, tremor, seizure, cardiac dysrhythmias

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bipolar disorder rx nursing interventions

assessment of therapeutic effects and side effects

follow therapeutic drug level, fluid volume status

recognition of stages or poles, triggers

patient education: disorder, management of triggers, facilitate counseling

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bipolar disorder rx prototypes

lithium

carbamezapine

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lithium therapeutic drug level

0.5-1.5 mEq/L

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carbamazepine drug level

4-12 mcg/mL

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Parkinson’s disease description

degenerative CNS disease; death of neurons which produce dopamine

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Parkinson’s disease symptoms

usually: > age 50; men > women

tremors, muscle rigidity, bradykinesia, postural instability

anxiety, depression, dementia

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Parkinson’s disease therapeutic effects

↑­ dopamine (dopaminergic) and / or ↓ acetylcholine (anticholinergic)

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Parkinson’s disease indications

Parkinson’s disease

restless leg syndrome

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Parkinson’s disease precautions/contraindications

closed angle glaucoma

drug effect with phenytoin, haloperidol, Vitamin B6

can increase IOP

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Parkinson’s disease side effects

syncope, rhinorrhea, abdominal pain

uncontrolled body movement

nausea, vomiting, constipation, ↑ HR (anticholinergics)

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Parkinson’s disease nursing actions

assess for therapeutic and side effects

physical and mental assessment

ensure safety – fall risk, swallow

must taper drugs – possible rebound

patient education – drug information, psychological effect, support groups

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dopaminergic (dopamine replacement) prototypes

levodopa – carbidopa

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dopamine agonist prototype

ropinirole

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anticholinergic prototype

benztropine

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Parkinson’s disease medication classes

dopaminergic (dopamine replacement)

dopamine agonist

anticholinergic

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Alzheimers disease

progressive mental deterioration

confusion, memory loss

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Alzhemeir’s Rx therapeutic effects

cholinergic drugs, ↑ anticholinesterase activity ↑ acetylcholine in brain

NMDA – receptor antagonist

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precautions/contrainidications

cardiac dysrhythmias; hyperthyroidism

renal / hepatic impairment; seizure disorders

Parkinson’s disease

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Alzhemeir’s Rx side effects

Cholinergic effects: ↓ HR, ↓ BP, nausea / vomiting, ­ secretion

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Alzhemeir’s rx nursing actions

assess for therapeutic and side effects

avoid anticholinergic agents whenever possible – reverses drug effect

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Alzhemeir’s rx prototypes

donepezil

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psychotic states description

severe disorder that impairs mental function, unable to perform ADLs

hallmark: lose contact with reality

schizophrenia, induced psychoses (drugs, depression)

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psychotic state rx therapeutic effects

block dopamine receptors, ↓ dopamine concentration in CNS areas of emotion, cognitive function, motor function- tranquilizing effect

chemical control of symptoms

selection of agent of choice based on condition and least side effect

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psychotic state rx indications

Schizophrenia

induced psychoses; autism

extreme manic phase of bipolar disorder

disorders of movement (Tourette’s, Parkinson’s)

select medical conditions (intractable hiccups)

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