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CNS

CNS. Depressants and Muscle Relaxants. CNS Depressants and Muscle Relaxants. Discuss the action and uses of the classes of drugs used as sedatives and hypnotics Describe the nursing process related to patients receiving sedation

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CNS

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  1. CNS Depressants and Muscle Relaxants

  2. CNS Depressants and Muscle Relaxants • Discuss the action and uses of the classes of drugs used as sedatives and hypnotics • Describe the nursing process related to patients receiving sedation • Compare and contrast the uses of barbiturates and related nursing care • Describe the steps in caring for patients with acute depressant drug overdose • Discuss the action and uses of direct skeletal muscle relaxants

  3. CNS Depressants Sleep • State of unconsciousness from which a patient can be aroused by appropriate stimulus • Needed to maintain psychiatric equilibrium and physical well-being • Divided into two phases: REM and NREM • REM sleep associated with dreaming • NREM sleep divided into four stages

  4. CNS DepressantsSleep Cycle • Stage I Transition from wakefulness to sleep; 2%-5% of sleep time • Stage II Experienced as drifting, floating; 50% of sleep time • Stage III Transition from lighter to deeper sleep • Stage IV Delta sleep—deep, dreamless, restful; 10%-15% of sleep time in healthy young adults

  5. CNS DepressantsREM Sleep • Accounts for 20% to 25% of normal sleep • Amount of REM peaks around 5:00 AM • Characterized by: • Rapid eye movements, increased heart rate, irregular breathing • Secretion of stomach acids, muscular activity, dreaming • Important for re-establishment of psychological equilibrium & Memory

  6. CNS Depressants REM Sleep • The healthy young adult cycles through NREM and REM in a 90-minute period • Stage I → Stage II → Stage III → Stage IV → Stage III → Stage II → REM

  7. CNS DepressantsInsomnia • Most common sleep disorder • Experienced by 95% of adults at some time • Usually mild and short lived • Common causes • Lifestyle or environmental changes • Pain, illness, anxiety • Large amounts of caffeine; large meals before bedtime

  8. CNS DepressantsInsomnia • Three types of insomnia • Initial: difficulty falling asleep • Intermittent: difficulty staying asleep • Terminal: waking and an inability to fall back to sleep

  9. CNS DepressantsSedatives / Hypnotics • Hypnotic—drug that produces sleep • Sedative—drug that relaxes the patient, but is not necessarily accompanied by sleep • Actions: • Increase total sleeping time, mainly in Stages II and IV • Decrease number of REM cycles and amount of REM sleep • May cause REM rebound when drug use is stopped

  10. CNS DepressantsSedatives / Hypnotics • Actions • Sedatives produce relaxation and rest; hypnotics produce sleep • Same drug may serve both functions • Classes of sedative-hypnotics • Barbiturates • Benzodiazepines • Nonbarbiturate, nonbenzodiazepines • Miscellaneous agents

  11. CNS DepressantsSedatives / Hypnotics • Uses • Temporary treatment of insomnia • Decrease anxiety and increase relaxation and/or sleep before diagnostic or operative procedures • Anticonvulsive agents

  12. CNS DepressantsNursing Process • Take baseline assessments • Note sleep disruption patterns • Determine activities done just before bed • Ask about patient stressors • Identify caffeine sources in dietary history

  13. CNS DepressantsNursing Process • Before administering a sedative-hypnotic, determine the actual need for it • Patients with history of sleep apnea or respiratory difficulties -higher risk for respiratory depression • Older adults may react paradoxically

  14. CNS DepressantsNursing Process • Encourage standard bedtime • Avoid late, heavy meals • Limit caffeine and alcohol intake • Control sleep environment • Promote stress-reducing techniques • Discuss benefits of medication compliance and nonpharmacologic interventions • Encourage patient use of self-assessment form

  15. CNS DepressantsNursing Process • Perform ongoing monitoring for therapeutic and adverse effects • There should be written standards that specify minimum monitoring criteria for providing safe care • Always follow the policies and procedures of the organization and document the monitored findings

  16. CNS DepressantsBarbiturates • First introduced in 1903 • Mainstay of therapy until 1960 • Use has declined in favor of benzodiazepines • Common barbiturates: • butabarbital (Butisol) • pentobarbital (Nembutol) • phenobarbital (Luminal) • secobarbital (Seconal)

  17. CNS DepressantsBarbiturates • Actions • Reversibly depress excitable tissues • Effect depends on dose, tolerance, route of administration, patient’s condition • Suppress REM and Stage III/IV sleep patterns when used for hypnosis • Long half-lives; residual sedation common

  18. CNS DepressantsBarbiturates • Uses • Anticonvulsant • General anesthetic (ultrashort acting) • Sedation before a diagnostic procedure (short acting) • Sedative and hypnotic effect (rare use)

  19. CNS DepressantsBarbiturates • Baseline assessment should include • Respiratory rate and depth • Level of consciousness • State of arousal • Behavior • Motor function • Side effects to report • Habitual use—can result in physical dependence • Hypersensitivity—infrequent; hives, rash, pruritus • Blood dyscrasias—rare; schedule routine lab studies

  20. CNS DepressantsBarbiturates • Patient Education: Side effects to expect • Morning “hangover” • Blurred vision • Transient hypotension on arising • Impaired coordination • Lethargy • Drug interactions • Alcohol, antihistamines, tranquilizers, and analgesics increase effects of barbiturates • Patients taking phenytoin and barbiturates for seizure control should have drug levels monitored to ensure adequate dosages • Reduced effectiveness of other medicines

  21. CNS DepressantsBenzodiazepines • Wide safety margin • More than 200 derivatives • Difficult to describe as a class, but include: • Anticonvulsants • Antianxiety agents • Sedative-hypnotic agents Hypnotic Drugs: • Long acting • estazolam (Prosom), flurazepam (Dalmane), others • Short acting • temazepam (Restoril),triazolam (Halcion)

  22. CNS DepressantsBenzodiazepines • Actions • Act on specific CNS sites • E.g., sedative-hypnotics affect type 1 and type 2 GABA receptors; bind to the receptors to stimulate the release of GABA • Decrease Stage III/IV sleep and to a lesser extent, REM • Uses • Most commonly used sedative-hypnotics • Preoperative sedative • Conscious sedation • Agitation • Depression • Balanced anesthesia • Therapeutic outcomes • To produce mild sedation • For short-term use to produce sleep • Preoperative sedation with amnesia

  23. CNS DepressantsNursing Process • Assessment • Vital signs, especially blood pressure, should be assessed while the patient is sitting and lying down before administering benzodiazepines • Give15 to 30 minutes before bedtime for maximum effectiveness in inducing sleep • Most benzodiazepines cause REM rebound and a tired feeling the next day; use with caution in the elderly • Check liver function tests • Side effects to report • Physical dependence can result from chronic use • Blood dyscrasias; hepatotoxicity • Patient Education • Side effects to expect: Morning “hangover,” blurred vision, transient hypotension on arising • Toxic effects - increased if used with alcohol, tranquilizers, antihistamines, analgesics, and anesthetics • Smoking increases the metabolism of benzodiazepines

  24. CNS Depressantsnon-barbiturates / non-benzodiazepines • All cause CNS depression, but mechanisms of action differ zalepion (Sonata), zolpidem (Ambien), and eszoplicone (Lunesta) • Share many characteristics of benzodiazepines • Used to treat insomnia • Actions • Variable effects on REM sleep • Tolerance development • Rebound REM sleep • Insomnia after discontinuation • Uses • Sedative and hypnotic effects • Therapeutic outcomes • To produce mild sedation • For short-term use to produce sleep

  25. CNS Depressantsnon-barbiturates/non-benzodiazepines • Nursing Process: • Vital signs, especially blood pressure, should be assessed while the patient is sitting and lying down before administering • Laboratory results should be monitored for hepatic dysfunction or blood abnormalities • Patient Education: • Side effects to expect: • Morning “hangover” • Blurred vision • Transient hypotension on arising • Restlessness, anxiety

  26. CNS Muscle Relaxants • Relieves pain associated with skeletal muscle spasms • Majority are central acting • CNS is the site of action • Similar in structure and action to other CNS depressants • Direct acting • Acts directly on skeletal muscle • Closely resembles GABA • Relief of painful musculoskeletal conditions • Muscle spasms • Management of spasticity of severe chronic disorders • Multiple sclerosis, cerebral palsy • Work best when used along with physical therapy

  27. CNS Muscle Relaxants • Adverse Effects • Usually seen in 0.2% of patients treated for more than 60 days – to be used only for short term • Extension of effects on CNS and skeletal muscles • Euphoria • Lightheadedness • Dizziness • Drowsiness • Fatigue • Muscle weakness, others • Toxicity • Overdose involves CNS – airway, IV fluids, cardiac monitor

  28. CNS Muscle Relaxants • dantrolene (Dantrium) • Works directly on skeletal muscle • Uses: Malignant hyperthermia crisis & Spasticity

  29. CNS Muscle Relaxants • baclofen (Lioresal) • cyclobenzaprine (Flexeril) • dantrolene (Dantrium) • metaxalone (Skelaxin)

  30. CNS Muscle RelaxantsNursing Process • Patient Assessment • Determine allergies, mental status, • Sleep diary & review sleep habits • Renal and hepatic function testing • Patient Education • Intended for short term use • Same precautions as with benzodiazepines • Avoid alcohol and benzodiazepines • Caution to avoid overdose

  31. CNS Depressants & Muscle Relaxants • As individuals age, their sleep becomes: • a. more fragmented. • b. more sound. • c. characterized by fewer nocturnal awakenings • d. both a & b

  32. CNS Depressants and Muscle Relaxants • Long term administration of benzodiazepines may result in: • a. nephrotoxicity. • b. withdrawal symptoms if withdrawn rapidly. • c. a rush of morning energy with repeated usage. • d. seizures during the time it is being administered.

  33. CNS Depressants & Muscle Relaxants 1. Benzodiazepines work by ________________. An example of a benzodiazepine is _______________. 2. Restoril is used as a ________________and has the adverse effects of ___________. 3. Larger dosages of sedative-hypnotics result in a _____________ effect. Smaller doses have a _______________ effect. 4. Phenobarbital is a(n) ____________________ drug. 5. Zolpidem is classified as a(n) _______________drug. 6. The only skeletal muscle relaxant that acts directly on skeletal muscle is __________.

  34. CNS Depressants & Muscle Relaxants 1. Benzodiazepines work by: Anticonvulsants; Antianxiety agents; Sedative-hypnotic agents – on select CNS sites An example of a benzodiazepine Long acting: estazolam (Prosom), flurazepam (Dalmane), Short acting: temazepam (Restoril),triazolam (Halcion) 2. Restoril is used as a hypnoticand has the adverse effects of Morning “hangover,” blurred vision, transient hypotension on arising. 3. Larger dosages of sedative-hypnotics result in a hypnotic effect. Smaller doses have a sedative effect. 4. Phenobarbital is a(n) barbituratedrug. 5. Zolpidem (Ambien) is classified as a(n) non-benzodizapinedrug. 6. The only skeletal muscle relaxant that acts directly on skeletal muscle is dantrolene (Dantrium).

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