1. CNS Depressants and Muscle Relaxants

2. CNS D EPRESSANTS AND M USCLE R ELAXANTS 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 D EPRESSANTS S LEEP 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 D EPRESSANTS S LEEP C YCLE Stage I Transition from wakefulness to sleep; 2%-5% of sleep time Stage IIExperienced as drifting, floating; 50% of sleep time Stage IIITransition from lighter to deeper sleep Stage IVDelta sleep—deep, dreamless, restful; 10%-15% of sleep time in healthy young adults

5. CNS D EPRESSANTS REM S LEEP 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 D EPRESSANTS REM S LEEP 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 D EPRESSANTS I NSOMNIA 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 D EPRESSANTS I NSOMNIA Three types of insomnia Initial: difficulty falling asleep Intermittent: difficulty staying asleep Terminal: waking and an inability to fall back to sleep

9. CNS D EPRESSANTS S EDATIVES / H YPNOTICS 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 D EPRESSANTS S EDATIVES / H YPNOTICS 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 D EPRESSANTS S EDATIVES / H YPNOTICS Uses Temporary treatment of insomnia Decrease anxiety and increase relaxation and/or sleep before diagnostic or operative procedures Anticonvulsive agents

12. CNS D EPRESSANTS N URSING P ROCESS 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 D EPRESSANTS N URSING P ROCESS 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 D EPRESSANTS N URSING P ROCESS 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 D EPRESSANTS N URSING P ROCESS 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 D EPRESSANTS B ARBITURATES 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 D EPRESSANTS B ARBITURATES 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 D EPRESSANTS B ARBITURATES Uses Anticonvulsant General anesthetic (ultrashort acting) Sedation before a diagnostic procedure (short acting) Sedative and hypnotic effect (rare use)

19. CNS D EPRESSANTS B ARBITURATES 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 D EPRESSANTS B ARBITURATES 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 D EPRESSANTS B ENZODIAZEPINES 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 D EPRESSANTS B ENZODIAZEPINES 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

25. CNS D EPRESSANTS N URSING P ROCESS 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

26. CNS D EPRESSANTS 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 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

27. CNS D EPRESSANTS 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

29. CNS M USCLE R ELAXANTS 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

30. CNS M USCLE R ELAXANTS 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

31. CNS M USCLE R ELAXANTS dantrolene (Dantrium) Works directly on skeletal muscle Uses: Malignant hyperthermia crisis & Spasticity

32. CNS M USCLE R ELAXANTS baclofen (Lioresal) cyclobenzaprine (Flexeril) dantrolene (Dantrium) metaxalone (Skelaxin)

33. CNS M USCLE R ELAXANTS N URSING P ROCESS 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

34. CNS D EPRESSANTS & M USCLE R ELAXANTS As individuals age, their sleep becomes: a. more fragmented. b. more sound. c. characterized by fewer nocturnal awakenings d. both a & b

35. CNS D EPRESSANTS AND M USCLE R ELAXANTS 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.

36. CNS D EPRESSANTS & M USCLE R ELAXANTS 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 __________.

37. CNS D EPRESSANTS & M USCLE R ELAXANTS 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 hypnotic and 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) barbiturate drug. 5. Zolpidem (Ambien) is classified as a(n) non-benzodizapine drug. 6. The only skeletal muscle relaxant that acts directly on skeletal muscle is dantrolene (Dantrium).