Unit 10- Central Nervous System

sedatives

depress the central nervous system (CNS).

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

hypnotics

a. Upper end of sedation

b. Induces sleep, coma

precautions/contraindications for hypnotics and sedatives

1\. level of consciousness (LOC)

2\. Respiratory insufficiency

3\. Risk for injury

general nursing actions

assess for therapeutic and side effects

monitor LOC, respiratory function, blood pressure; ensure safety

patient education: drug information, drug levels

potential issues with sedatives/hypnotics

physical and psychological dependence

withdrawal symptoms

psychological disturbances – anxiety, insomnia

fever, tachycardia, ­ or ¯ blood pressure

barbiturates therapeutic effects/indications

Potent CNS depressant, → nerve transmission, ­ seizure threshold

dose dependent actions of barbituates

low: antianxiety, drowsy / sedation

moderate: antiseizure

high: anesthesia, induced coma

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

barbiturates nursing actions

narrow therapeutic range – side effects, drug levels

barbiturates prototypes

phenobarbital

*no alcohol!* can increase sedative effects

phenobarbital drug range

Therapeutic drug level: 10 – 40 mcg / ml

benzodiazepines therapeutic effects/indications

CNS depressants

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

benzodiazepine side effects

headache, drowsy, hangover effect *no alcohol*

paradoxical excitement / nervousness

benzodiazepine nursing actions

appropriate use

patient education, patient safety

drugs effect sleep cycle, can have daytime sleepiness

benzodiazepine reversal agent

flumazenil

benzodiazepine prototypes

lorazepam- panic attacks, anxiety and seizures

clonazepam

temazepam

midazolam- amnesiac effect/outpatient procedure

alprazolam

non-benzodiazepines therapeutic effects

*does not disrupt sleep as much, lack sedative dependency potential*

anxiolytic – decreases anxiety

induces sleep – treats insomnia

non-benzo side effects

Ambien (zolpidem) – sleep walking, eating, driving

BuSpar (buspirone) – grapefruit juice ­ drug concentration

non-benzo nursing actions

safety with Ambien; dietary guidelines with BuSpar

non-benzo prototypes

zolpidem- sleep induction

buspirone- decreases anxiety with less sleepiness

skeletal muscle relaxants therapeutic effects

Used to treat muscle spasms – involuntary contractions of muscles

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

skeletal muscle relaxants indications- direct acting

spasticity related to malignant hyperthermia

skeletal muscle relaxant precautions/contraindications

care with concurrent use of other drugs causing sedation

*increases sedative effects*

renal insufficiency with some agents

skeletal muscle relaxant side effects

Dizziness, lightheadedness, sedation

skeletal muscle relaxant nursing actions

assess for therapeutic and side effects

ensure safety

patient education: drug information, safety issues

skeletal muscle relaxant prototypes

Central acting:

cyclobenzaprine

baclofen

carisoprodol

Direct acting:

dantrolene

**used in malignant HTN, caused by GA use, propofol**

ADHD

encompasses, decreases attention span, behavioral issues, hyperactivity

cause essentially unknown

ADHD potential influences

lead levels in children; maternal exposure to alcohol, drugs

dopamine / norepinephrine / serotonin levels in brain

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

ADHD medication indications

ADHD

Narcolepsy

Obesity

ADHD precautions/contraindications

marked anxiety, glaucoma

tic disorders (Tourette’s syndrome)

ADHD drug side effects

heart rate, blood pressure, metabolic rate

gastrointestinal distress, dry mouth

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

ADHD drug prototypes

methylphenidate extended release

methylphenidate

atomoxetine

seizure disorders

*does not mean convulsions*

abnormal electrical activity in the brain’s nerve cells

affects LOC, motor activity, sensation

seizure disorder acute causes

fever

infection, trauma

vascular, cancer

convulsion

involuntary, spastic contractions of voluntary muscles

epilepsy

recurrent pattern of seizures

partial seizure

focal seizure

generalized seizure

grand mal, alternation between relaxation and spastic

simple seizure

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

complex seizure

LOC reduced but not lost

secondary generalization seizure

grand mal/ tonic clonic

status epilepticus

multiple seizures occurring with no recovery between them.

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

antiepileptic drugs therapeutic effects

seizure threshold, decreased transmission between and within a neuron

control / minimize seizure activity

maintain quality of life

antiepileptic drug indications

prevention or control of seizures

acute and long-term maintenance

status epilepticus

antiepileptics drugs precautions/contraindicated

drugs must be tapered

concurrent use with some antidepressant can precipitate seizures

antiepileptic drug side effects

numerous, drug dependent

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

black box: suicidal thoughts and behaviors

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

antiepileptic prototypes

phenytoin

levetiracetam

phenobarbital

pregabalin

gabapentin

carbamazepine

phenytoin side effects

possible thrombocytopenia

bone marros suppression

ataxia

gingival hyperplasia

lethargy

phenytoin therapeutic drug level

10-20 mcg/ml

phenobarbital therapeutic drug level

10-40 mcg/ml

carbamazepine therapeutic drug level

4-12 mcg/ml

depression description

alteration in brain chemistry; response to situation

low serotonin

response from health care providers, society

criteria for depression diagnosis

sleep disturbances

changes in eating patterns

↓ energy, fatigue

↓ interest in activities

↓ concentration; suicidal ideation

therapeutic effects for depression rx

relief of symptoms in approximately 6 – 8 weeks of therapy

no harm to self

indications for depression rx

major depression; seasonal affective disorder (SAD)

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

adjunct for pain management, smoking cessation

precautions/contraindications for depression rx

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

cardiac / seizure history

drugs must be tapered

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

depression rx classes

tricyclic antidepressants (TCA)

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

monoamine oxidase inhibitors (MAO-I)

atypical agents

tricyclic antidepressant indications

major depression, obsessive compulsive disorder (OCD)

tricyclic antidepressant side effects

orthostatic hypotension (due to a1 blockade) s

sedation, anticholinergic effects

alcohol increase likelihood of overdose

tricyclic antidepressant prototypes

amitryptoline

SSRI/SNRSI indications

major depression, generalized anxiety disorder (GAD), OCD

SSRI/SNRSI side effects

sexual dysfunction

headache, insomnia or sedation

contraindicated in allergy or use of MOAI within 14 days

asses for suicidal tendencies

SSRI/SNRI protypes

escitalopram

paroxetine

fluoxetine

sertraline

atypical agent indications

depression and may be used for specific actions

atypical agents side effects

seizure, nervousness, insomnia / sedation

headache, dry mouth

weight changes

atypical agents

trazodone- given for depression, insomnia and chronic pain

bupropion- smoking cessation

bipolar disorder description

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

bipolar disorder rx therapeutic effect

decreased cycles of mania/depression

bipolar disorder rx indications

bipolar disorder

depression

bipolar disorder rx precautions/contraindications

Many drug interactions

bipolar disorder rx side effects

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

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

bipolar disorder rx prototypes

lithium

carbamezapine

lithium therapeutic drug level

0\.5-1.5 mEq/L

carbamazepine drug level

4-12 mcg/mL

Parkinson’s disease description

degenerative CNS disease; death of neurons which produce dopamine

Parkinson’s disease symptoms

usually: > age 50; men > women

tremors, muscle rigidity, bradykinesia, postural instability

anxiety, depression, dementia

Parkinson’s disease therapeutic effects

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

Parkinson’s disease indications

Parkinson’s disease

restless leg syndrome

Parkinson’s disease precautions/contraindications

closed angle glaucoma

drug effect with phenytoin, haloperidol, Vitamin B6

can increase IOP

Parkinson’s disease side effects

syncope, rhinorrhea, abdominal pain

uncontrolled body movement

nausea, vomiting, constipation, ↑ HR (anticholinergics)

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

dopaminergic (dopamine replacement) prototypes

levodopa – carbidopa

dopamine agonist prototype

ropinirole

anticholinergic prototype

benztropine

Parkinson’s disease medication classes

dopaminergic (dopamine replacement)

dopamine agonist

anticholinergic

Alzheimers disease

progressive mental deterioration

confusion, memory loss

Alzhemeir’s Rx therapeutic effects

cholinergic drugs, ↑ anticholinesterase activity ↑ acetylcholine in brain

NMDA – receptor antagonist

precautions/contrainidications

cardiac dysrhythmias; hyperthyroidism

renal / hepatic impairment; seizure disorders

Parkinson’s disease

Alzhemeir’s Rx side effects

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

Alzhemeir’s rx nursing actions

assess for therapeutic and side effects

avoid anticholinergic agents whenever possible – reverses drug effect

Alzhemeir’s rx prototypes

donepezil

psychotic states description

severe disorder that impairs mental function, unable to perform ADLs

hallmark: lose contact with reality

schizophrenia, induced psychoses (drugs, depression)

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

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)