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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 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 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 CNS DEPRESSANTS SLEEP 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 CNS DEPRESSANTS REM 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 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 CNS DEPRESSANTS INSOMNIA 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 CNS DEPRESSANTS INSOMNIA Three types of insomnia Initial: difficulty falling asleep Intermittent: difficulty staying asleep Terminal: waking and an inability to fall back to sleep CNS DEPRESSANTS SEDATIVES / 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 CNS DEPRESSANTS SEDATIVES / 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 CNS DEPRESSANTS SEDATIVES / HYPNOTICS Uses Temporary treatment of insomnia Decrease anxiety and increase relaxation and/or sleep before diagnostic or operative procedures Anticonvulsive agents CNS DEPRESSANTS NURSING PROCESS Take baseline assessments Note sleep disruption patterns Determine activities done just before bed Ask about patient stressors Identify caffeine sources in dietary history CNS DEPRESSANTS NURSING 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 CNS DEPRESSANTS NURSING 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 CNS DEPRESSANTS NURSING 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 CNS DEPRESSANTS BARBITURATES 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) CNS DEPRESSANTS BARBITURATES 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 CNS DEPRESSANTS BARBITURATES Uses Anticonvulsant General anesthetic (ultrashort acting) Sedation before a diagnostic procedure (short acting) Sedative and hypnotic effect (rare use) CNS DEPRESSANTS BARBITURATES 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 CNS DEPRESSANTS BARBITURATES 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 CNS DEPRESSANTS BENZODIAZEPINES 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) CNS DEPRESSANTS BENZODIAZEPINES Actions Act on specific CNS sites Decrease Stage III/IV sleep and to a lesser extent, REM Uses E.g., sedative-hypnotics affect type 1 and type 2 GABA receptors; bind to the receptors to stimulate the release of GABA 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 CNS DEPRESSANTS NURSING 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 CNS DEPRESSANTS NON-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 Uses Variable effects on REM sleep Tolerance development Rebound REM sleep Insomnia after discontinuation Sedative and hypnotic effects Therapeutic outcomes To produce mild sedation For short-term use to produce sleep CNS DEPRESSANTS NON-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 CNS MUSCLE RELAXANTS Relieves pain associated with skeletal muscle spasms Majority are central acting Direct acting CNS is the site of action Similar in structure and action to other CNS depressants 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 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 CNS MUSCLE RELAXANTS dantrolene (Dantrium) Works directly on skeletal muscle Uses: Malignant hyperthermia crisis & Spasticity CNS MUSCLE RELAXANTS baclofen (Lioresal) cyclobenzaprine (Flexeril) dantrolene (Dantrium) metaxalone (Skelaxin) CNS MUSCLE RELAXANTS NURSING 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 CNS DEPRESSANTS & MUSCLE RELAXANTS As individuals age, their sleep becomes: a. more fragmented. b. more sound. c. characterized by fewer nocturnal awakenings d. both 2 and 3 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. 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 __________.
