CNS

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CNS

• Depressants and Muscle Relaxants

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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

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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

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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 sleepdeep, dreamless, restful
  10-15 of sleep time in healthy young adults

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CNS DepressantsREM Sleep

• Accounts for 20 to 25 of normal sleep
• Amount of REM peaks around 500 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

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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

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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

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CNS DepressantsInsomnia

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

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CNS DepressantsSedatives / Hypnotics

• Hypnoticdrug that produces sleep
• Sedativedrug 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

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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

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CNS DepressantsSedatives / Hypnotics

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

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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

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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

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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

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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

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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)

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CNS DepressantsBarbiturates

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

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CNS DepressantsBarbiturates

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

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CNS DepressantsBarbiturates

• Baseline assessment should include
• Respiratory rate and depth
• Level of consciousness
• State of arousal
• Behavior
• Motor function
• Side effects to report
• Habitual usecan result in physical dependence
• Hypersensitivityinfrequent hives, rash,
  pruritus
• Blood dyscrasiasrare schedule routine lab
  studies

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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

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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)

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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

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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

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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

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CNS Depressantsnon-barbiturates/non-benzodiazepin
es

• 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

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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

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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

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CNS Muscle Relaxants

• dantrolene (Dantrium)
• Works directly on skeletal muscle
• Uses Malignant hyperthermia crisis Spasticity

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CNS Muscle Relaxants

• baclofen (Lioresal)
• cyclobenzaprine (Flexeril)
• dantrolene (Dantrium)
• metaxalone (Skelaxin)

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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

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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

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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.

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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 __________.