Chapter 14 Pharmacology Drugs used for sleep
Patient Education/Health Promotion
-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
Sleep
State of unconsciousness from which a person can be aroused by appropriate stimulus -Needed to maintain psychiatric equilibrium and strengthen immune system -Two phases: REM and NREM >REM sleep associated with dreaming >NREM sleep divided into four stages
Drug Class: Benzodiazepines
Wide safety margin More than 200 derivatives -Difficult to describe as a class, but include >Anticonvulsants >Antianxiety agents >Sedative-hypnotic agents •Overdoses can be better tolerated and are not fatal. Although there are many derivatives in this class, only a small subset is used clinically
Nursing Interventions for Miscellaneous Sedative-Hypnotic Therapy
-Assess vital signs, especially blood pressure, while the patient is sitting and lying down before administration -Monitor laboratory results for hepatic dysfunction or blood abnormalities -Patient teaching >Take immediately before going to bed >May have hypotension on arising >Safety precautions for driving, operating machinery •The patient must understand that habitual use can lead to physical dependency. •Do not abruptly stop these drugs after long-term use because they can cause symptoms similar to alcohol withdrawal.
Nursing Interventions for Sedative-Hypnotic Therapy (cont.)
-Before administering a sedative-hypnotic, determine the actual need for it -Patients with a history of sleep apnea or respiratory difficulties are at higher risk for respiratory depression if sedative-hypnotics are taken -Older adults may react paradoxically -Sleep patterns change when hypnotics are discontinued •Nonpharmacologic interventions include offering dairy products, dimming the lights, reducing noise level, increasing daytime activity, etc.
Nursing Interventions for Benzodiazepine Therapy
-Check vital signs, especially blood pressure, while the patient is sitting and lying down before administration -Monitor laboratory results for hepatic dysfunction or blood abnormalities -Flumazenil is used as an antidote for benzodiazepine reversal and overdoses
Nursing Responsibilities for Sedative-Hypnotic Therapy
-Perform ongoing monitoring for therapeutic and adverse effects -Document findings -Verify the written standards that provide for safe care -Follow policies and procedures of the organization If the drug is ordered as part of a preoperative or preprocedure medication, it must be given at the correct time to ensure the peak effect will occur when it is needed
Nursing Interventions for Sedative-Hypnotic Therapy
-Take baseline assessments -Note sleep disruption patterns -Determine activities done just before bed -Ask about patient stressors -Assess for sleep environment disturbances -Identify caffeine, alcohol in dietary history -Assess for respiratory disorders, heavy snoring •Assessing CNS function is a key component of patient monitoring before and after any sedative-hypnotic agent is administered. •Baseline level of consciousness and state of arousal should be recorded during assessment and then reevaluated. •Baseline sleep patterns may be difficult to measure in a health care setting because sleep patterns are usually disrupted by noise, interruptions, procedures, etc.
The Sleep Cycle
A 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 -Many sleep disorders can be traced to specific abnormalities in this sleep cycle •If the amount of time in a particular stage is increased or decreased from normal averages, it upsets the overall balance. •A sleep study involves scientific assessment of a person's sleep cycles and determines pattern abnormalities.
The nurse is assessing a patient who is being evaluated in an outpatient clinic for complaints of back pain. The patient reports taking diphenhydramine for insomnia related to job stress. Which statement by the nurse is accurate regarding this medication?
A) This medication should only be taken for 1 week. Explanation: Antihistamines (particularly diphenhydramine and doxylamine) have sedative properties that may be used for short term treatment of mild insomnia. They are common ingredients in over the counter (OTC) sleep aids. Tolerance develops after only a few nights of use; increasing the dose actually causes a more restless and irregular sleep pattern. Diphenhydramine does not cause nausea. There is no restriction on taking diphenhydramine after a high fat meal. Diphenhydramine is not an herbal medication.
The nurse is assessing a patient prior to discharge from same day surgery following an incisional breast biopsy. When assessing the patients central nervous system (CNS) function following sedative hypnotic therapy, what will the nurse include? (Select all that apply.)
A, B, C Explanation: Because sedative hypnotics depress overall CNS function, the nurse should identify the patients level of alertness and orientation and ability to perform motor functions. Blood pressure is a vital sign and falls under cardiovascular assessment. Usual sleep pattern should be obtained for information on sleep pattern disruption, but not for CNS function.
What can occur as a result of rapid withdrawal from long term use of barbiturate therapy? (Select all that apply.)
A, B, C, D Explanation: Anxiety, delirium, weakness, and grand mal seizures can be symptoms of rapid withdrawal from long term use of barbiturate therapy. Severe pain is not a symptom of rapid withdrawal from long term use of barbiturate therapy.
Why are benzodiazepines often preferred over barbiturates?
A, B, C, D Explanation: Benzodiazepines decrease REM sleep to a lesser extent. Intentional and unintentional overdoses of benzodiazepines are often well tolerated and not fatal. There are transient hypotensive episodes with benzodiazepine therapy.
Barbiturates have which common adverse effect(s)?
A, B, D, E Explanation: Headache is a general adverse effect of barbiturates. Blurred vision is an adverse effect associated with the hypnotic dosages of long acting barbiturates. Impaired coordination is an adverse effect of barbiturates. Hyperactivity is not generally an adverse effect of barbiturates unless the patient is experiencing a paradoxical response.
The nurse is teaching a patient with a history of insomnia about sleep pattern disturbance. Which statement by the patient indicates the need for further instruction? A. "Insomnia is an occasional normal occurrence of a healthy life." B. "Common causes of insomnia are changes in lifestyle or environment, pain, illness, and excess caffeine or alcohol." C. "People with chronic insomnia often develop fatigue during the day." D. "People with chronic insomnia may also suffer from psychiatric disorders."
A. "Insomnia is an occasional normal occurrence of a healthy life." Insomnia is defined as the inability to sleep; it is not a disease but a symptom of physical or mental stress. Even though 95% of all adults experience insomnia sometime in their lives, it is not considered a "normal occurrence of a healthy life." Causes of insomnia include all of these factors as well as eating large or "rich" meals shortly before bedtime and physical or mental stress. If a person is unable to sleep well during the night, he or she often develops fatigue or drowsiness that interferes with daytime functioning and employment responsibilities. As much as 40% of people with chronic insomnia may also suffer from psychiatric disorders such as anxiety, depression, or substance abuse.
Which patient is most at risk for a paradoxical response to a barbiturate characterized by excitement, restlessness, and confusion? A. A 76 year old with severe pain B. A 52 year old diabetic man C. A 34 year old recovering alcoholic D. An 18 year old with a seizure disorder
A. A 76 year old with severe pain Paradoxical effects from barbiturates are most likely to occur in older adults and those with severe pain. Diabetes, a history of alcoholism, and seizure disorders have no documented relationship to paradoxical responses to barbiturates. However, barbiturates can alter the effects of phenytoin and result in increased seizure activity.
Which benzodiazepine is long acting and places a patient at greater risk for a morning hangover? A. Flurazepam (Dalmane) B. Triazolam (Halcion) C. Midazolam (Versed) D. Temazepam (Restoril)
A. Flurazepam (Dalmane) Flurazepam is a long acting medication. Triazolam and midazolam are short acting medications. Temazepam is an intermediate acting medication.
Drug Class: Benzodiazepines (cont.)
Actions -Affect type 1 and type 2 GABA receptors; bind to the receptors to stimulate the release of GABA Uses -Preoperative sedative, conscious sedation Common adverse effects -Drowsiness, hangover, sedation, lethargy, decreased level of alertness Serious adverse effects -Confusion, agitation, amnesia, hepatotoxicity •Most commonly used sedative-hypnotics. •Individual drugs in this class are prescribed for different uses, such as sleep and anxiety, based on their site of action within the CNS. When they are stopped, a rebound effect can occur, causing rebound insomnia as well as bizarre dreams.
Drug Class: Barbiturates
Actions >Reversibly depress excitable tissues, suppress REM and stage III/IV sleep patterns when used for hypnosis Uses >Anticonvulsant, general anesthetic (ultra-short-acting), sedation before a diagnostic procedure (short-acting) •Barbiturates are so effective in reducing CNS activity that they are sometimes used to induce a coma-like state in cases of severe brain injury to reduce brain metabolism and preserve function. Common adverse effects >Hangover, blurred vision, transient hypotension on arising, sedation, decreased alertness, lethargy Serious adverse effects >Excessive use or abuse, paradoxical response, hypersensitivity (hives, rash, pruritus), blood dyscrasias •Signs/symptoms of physiologic withdrawal can occur if drugs are stopped.
•A single sedative can produce different effects at different dosages; a small dose acts as sedative, a larger dose acts as hypnotic. •Patient condition, baseline level of consciousness, and age also contribute to overall effects.
Actions >Sedatives produce relaxation and rest >Hypnotics produce sleep Uses >Temporary treatment of insomnia, decrease anxiety and increase relaxation and/or sleep before diagnostic or operative procedures, anticonvulsive agents
Drug Class: Nonbarbiturates, Nonbenzodiazepines
Actions >Variable effects on REM sleep Uses >Sedative and hypnotic effects Common adverse effects >Hangover, sedation, lethargy, decreased level of alertness, transient hypotension on arising, restlessness, anxiety •Most recommended only for short-term use of 7 to 10 days, or for as long as 3 weeks with good evaluation. •All cause CNS depression, but mechanisms of action differ.
A patient asks the nurse why her doctor said she could take her "sleeping pill," which is a benzodiazepine, for no more than 4 weeks. Which information serves as the basis of the nurse's response? A. No rapid eye movement (REM) sleep occurs during therapy with a benzodiazepine, resulting in the risk of psychosis. B. Kidney failure can occur as a result of the effect of prolonged exposure to products of drug metabolism. C. Metabolites of the drug can cross the blood brain barrier and cause seizure activity. D. Long term use results in bizarre dreams and rebound insomnia when the drug is discontinued.
After long term use of benzodiazepines, there is a rebound insomnia. There may also be a rebound increase in REM sleep, during which bizarre dreams occur. With benzodiazepine therapy, initially there is less REM sleep but it gradually increases as tolerance to the drug develops. Hepatotoxicity, not nephrotoxicity, is a risk with benzodiazepine therapy. Seizures are not associated with the metabolites of benzodiazepines entering the brain; they are associated with withdrawal from the drug.
In addition to facilitating sleep, what is another benefit of sedatives?
C) Decreased patient anxiety Explanation: Preoperatively, sedatives will help decrease patient anxiety and facilitate sleep. Sedatives are not long acting enough to affect postoperative pain control. Sedatives do not affect bronchial secretions. Sedatives diminish patient alertness.
A patient has been prescribed lorazepam (Ativan), a benzodiazepine used to treat insomnia. Which action will the nurse take?
B) Assess the patients blood pressure in sitting and lying positions. Explanation: Measuring blood pressure in sitting and lying positions is important to assess for transient hypotension. Ativan does not have to be taken with food. Rapid discontinuance of the medication after long term use may result in symptoms similar to those of alcohol withdrawal. Gradual withdrawal of benzodiazepines is over 2 to 4 weeks. Medications should be taken sitting up.
A patient receiving diazepam (Valium) is complaining of nausea and vomiting and is becoming jaundiced. Which type of blood work will be performed?
B) Liver function tests Explanation: Liver function tests will be performed because nausea, vomiting, and jaundice can be indicative of hepatotoxicity. Abnormal liver function test results (i.e., elevated bilirubin, aspartate transaminase [AST], alanine transaminase [ALT], gamma glutamyl transferase [GGT], and alkaline phosphatase levels, as well as prothrombin time) are indicative of hepatotoxicity. Benzodiazepines do not affect the kidneys, clotting times, and electrolytes.
Which two phases make up normal sleep?
B) Rapid eye movement (REM) and non REM Explanation: Normal sleep can be divided into two phases, REM and non REM. Hypnagogic is the state between waking and sleeping; hypnopompic is the transition between sleeping and waking states. Beta waves are those associated with day to day wakefulness. During periods of relaxation while still awake, our brain waves become slower, increase in amplitude, and become more synchronous. These types of waves are called alpha waves. The first stage of sleep is characterized by theta waves. During a normal nights sleep, a sleeper passes from the theta waves of stages 1 and 2 to the delta waves of stages 3 and 4. Delta waves are the slowest and highest amplitude brain waves.
The nurse is administering Somnote to a patient. When providing medication education to the patient, the nurse will include that Somnote should be:
B) taken with a full glass of water. Explanation: Somnote is available in capsule form and should not be chewed, should be taken with a full glass of water, should be taken after meals, and is usually ordered to be taken three times a day after meals.
The nurse is teaching a patient about how to improve sleep quality. Which information does the nurse include in the teaching plan? A. "Go to bed whenever you feel tired." B. "Avoid heavy meals late in the evening." C. "Have a couple glasses of wine just before bedtime." D. "Exercise just before bedtime."
B. "Avoid heavy meals late in the evening." A heavy meal will tax the digestive system, making a person feel uncomfortable and unable to get soothing sleep. A standard time to go to bed should be encouraged to help the body establish a rhythm and routine. Drinking alcohol before bedtime should be reduced or discontinued because it may negatively affect sleep quality. Exercise will help a person be tired at night, but exercising too close to bedtime may cause "overstimulation," resulting in an inability to sleep.
In order to obtain an adequate amount of sleep and maintain good health, what fraction of a person's adult life would typically be spent sleeping? A. One half B. One third One fourth One fifth
B. One third One third of a person's adult life is typically spent sleeping. A normal sleep duration of 7 to 8 hours per night is thought to be optimal for maintaining good health. One half is an excessive amount of time and could be indicative of a psychiatric (depression) or physiological disorder. One fourth and one fifth are inadequate amounts of time. Individuals who do not get enough sleep have an increased risk of a variety of health problems.
How does the effect of a benzodiazepine used for sedation differ in patients who smoke cigarettes from those who do not smoke? A. Cumulation of the drug is more likely to occur in smokers. B. Smokers may require larger doses to maintain the desired effect. C. Respiratory depression is a significant risk in smokers. D. Smokers are more likely to experience paradoxical responses to the drug.
B. Smokers may require larger doses to maintain the desired effect. Smoking enhances the metabolism of the benzodiazepines, and as a result, smokers may need larger doses to enable the drug to maintain its sedative effect. Smoking does not influence drug cumulation. Respiratory depression is a risk for those with a low respiratory reserve regardless of cause. Smoking does not directly increase the risk of respiratory depression or paradoxical response.
The nurse is explaining the use of medications to a patient with insomnia. Which statement about sedatives is true?
C) Increased relaxation occurs with sedatives. Explanation: A hypnotic is a drug that produces sleep; a sedative quiets the patient and gives a feeling of relaxation and rest, not necessarily accompanied by sleep. Sedatives do not increase the total time in REM sleep. A small dose of a drug may act as a sedative, whereas a larger dose of the same drug may act as a hypnotic and produce sleep.
Which disease is associated with insufficient sleep?
C) Myocardial infarction Explanation: Individuals who sleep less than 5 hours a night have a threefold increased risk of heart attacks. Cancer, glaucoma, and renal failure are not associated with lack of sleep.
An older adult patient received a hypnotic agent at 9:00 PM. At 2:00 AM, the nurse discovers that the patient has removed her gown and is attempting to get out of bed without assistance. What type of medication effect is the patient exhibiting?
C) Paradoxical Explanation: A paradoxical effect may occur in older adult patients. This includes periods of excitement, confusion, restlessness, and euphoria. Allergies to medications tend to manifest in skin or respiratory symptoms. A patient who is hypersensitive to a hypnotic would be difficult to rouse. A therapeutic effect for a hypnotic would be sedation.
The nurse is caring for an older patient recently admitted to an assisted living center who is experiencing insomnia associated with the recent relocation. At bedtime, which nursing action will assist the patient to sleep?
C) Performing back massage Explanation: Providing a back rub will promote relaxation and reduce anxiety associated with a new environment. This would also provide an opportunity for the nurse to encourage the patient to express feelings. The patient should avoid products containing caffeine, such as coffee, tea, soft drinks, and chocolate. A quiet unwinding activity before bedtime is helpful for sleep promotion. Administering an analgesic is not an appropriate action.
For what conditions are benzodiazepines prescribed?
C) Preoperative sedation Explanation: The sedative hypnotic effect of benzodiazepines facilitates surgical sedation. Short acting benzodiazepines are administered intramuscularly for preoperative sedation. They are also given intravenously for conscious sedation before short diagnostic procedures or for the induction of general anesthesia. Benzodiazepines are not recommended for long term use and do not affect amnesia. Benzodiazepines are a poor choice for the treatment of chronic insomnia because of their risk for habituation. Benzodiazepines do not have an antipsychotic effect.
The nurse is instructing a patient about the use of medications to treat insomnia. Which statement by the patient indicates the need for further teaching? A. "There are other types of medications to help me sleep besides the usual sleeping pills." B. "The best sleeping pill for me is one that helps me get to sleep fast, stay asleep, then awake without having a hangover." C. "It is OK to take a sleeping pill every night if I need one." Correct D. "Drinking a glass of warm milk before taking a sleeping pill may help me sleep better."
C. "It is OK to take a sleeping pill every night if I need one." Sleeping pills should be taken only on a short term basis because they can become addicting, may have adverse effects, and may alter the normal sleep cycle. Some other drug categories that are used as sleep aids include antidepressants, antipsychotics, and anticonvulsants. A good sleeping pill should provide its intended action within a short period: restful natural sleep, duration of action that allows a patient to awaken at the usual time, natural awakening with no "hangover" effects, and no danger of habit formation. Drinking a glass of warm milk before going to bed may help decrease insomnia. Dairy products and protein foods contain an amino acid that synthesizes serotonin, which is found to increase sleep time and decrease the time required to fall asleep.
What type of food is prohibited with zolpidem (Ambien) therapy? A. High protein meal B. Glass of milk C. High fat meal D. High carbohydrate meal
C. High fat meal A meal high in fat content will slow the absorption of zolpidem. There is no evidence that a high protein meal affects the actions of zolpidem. Taking a sedative with a glass of milk may improve the release of serotonin, a neurotransmitter that decreases the time it takes to fall asleep and increases the time asleep, and is not prohibited with zolpidem therapy. There is no evidence that a meal high in carbohydrates affects the actions of zolpidem.
What information is included in the teaching plan for a patient for whom a hypnotic medication is ordered for insomnia? A. At bedtime put medication on the bedside table with a glass of water in case a pill is needed. B. Avoid eating high protein foods between supper and bedtime. C. Keep a nightlight on for safety in case you need to get out of BED D Go to bed 30 minutes earlier than usual to allow the hypnotic to work.
C. Keep a nightlight on for safety in case you need to get out of bed Because hypnotics induce drowsiness, patient safety is an important concern. A nightlight should be kept on to help the patient get out of bed safely and navigate the environment. Hypnotics should never be kept at the bedside because patients may awaken, not remember they have taken the prescribed dose, and repeat the dose. Protein foods contain an amino acid that synthesizes serotonin, a neurotransmitter that decreases the time it takes to fall asleep and increases the time asleep. Thus warm milk and crackers make a good bedtime snack. It is not necessary to retire earlier than usual when taking a hypnotic medication. It is important for the patient to retire at the same time each night to allow a sleep pattern to become established.
Which assessment finding in a patient taking a sedative for insomnia concerns the nurse? A. The patient drinks two cups of coffee with breakfast. B. The patient reports a routine time at which he goes to bed. C. The patient has a decreased ability to perform activities of daily living. D. The patient has a regular exercise plan
C. The patient has a decreased ability to perform activities of daily living Sedatives depress the central nervous system; the nurse should be concerned about potential safety problems when this patient is started on a sedative. Caffeine may aggravate insomnia, but the patient drinks coffee only in the morning; this should not be a major concern of the nurse. A regular bedtime should be supported by the nurse because it helps in decreasing insomnia. Regular exercise (unless done right before bedtime) should not negatively affect the patient's insomnia.
Drugs Used for Treatment of Insomnia
Classes of sedative-hypnotics -Barbiturates -Benzodiazepines -Nonbarbiturate, nonbenzodiazepines -Miscellaneous agents
The nurse finds that a patient is extremely agitated, yells frequently, and is attempting to get out of bed without assistance. What is the nurses initial action?
D) Spend uninterrupted time listening to the patient. Explanation: Assessing the patients level of anxiety is important. The patient may only need someone to listen to what stressors he or she is facing. The nurse must assess the patient before medication can be administered.
Which sleep pattern stage diminishes as an effect of aging?
D) Stage IV Explanation: As we age, stage IV sleep diminishes. Many people older than 75 years do not demonstrate any stage IV sleep patterns. Between 2% and 5% of sleep is stage I. Stage II comprises about 50% of normal sleep time. Stage III is a transition between lighter sleep and deeper sleep.
When reviewing a patients history and physical information, the nurse notes that the patient has physicians orders for chloral hydrate and warfarin. During assessment of this patient, the nurse observes areas of petechiae and ecchymosis on the upper and lower extremities. The most appropriate lab work for the nurse to assess next is:
D) prothrombin time. Explanation: Chloral hydrate may enhance the anticoagulant effects of warfarin. The patient should be observed for petechiae, ecchymoses, nosebleeds, bleeding gums, dark tarry stools, and bright red or coffee ground emesis. Prothrombin time should be monitored, and the physician should reduce the dosage of warfarin, if necessary.
Monitoring for changes in hepatic function and blood dyscrasias is an essential part of the care plan for a patient on which medication? A. Buspirone B. Hydroxyzine C. Meprobamate D. Diazepam
D. Diazepam Diazepam is a benzodiazepine. Hepatotoxicity and blood dyscrasias are adverse effects associated with this class of drugs. The risk of these effects is particularly increased with individual drugs such as diazepam, which has active metabolites that prolong duration of action and may accumulate to toxic levels. Blood dyscrasias and hepatotoxicity are not related to the use of buspirone, hydroxyzine, or meprobamate.
Which herbal product has been used for the treatment of jet lag? A. St. John's wort B. Ginger C. Ginseng D. Melatonin
D. Melatonin Melatonin appears to be useful in patients traveling through several times zones and who are suffering from jet lag. St. John's wort is used for the treatment of depression; it has not been shown to be effective in treating jet lag. Ginger can be used for motion sickness that may be experienced when flying, but there is no evidence that it is effective for the treatment of jet lag. Ginseng has not been shown to be effective in treating jet lag.
The nurse is reviewing the medication history of a patient taking butabarbital (Butisol) for treatment of insomnia. The nurse contacts the prescriber after discovering the patient is also taking which medication? A. Digoxin (Lanoxin) B. Nitroglycerin C. Penicillin D. Propranolol (Inderal)
D. Propranolol (Inderal) The barbiturate butabarbital may reduce the effects of beta adrenergic blockers such as propranolol. Digoxin, nitroglycerin, and penicillin do not interact with butabarbital.
Stage 2 of NREM sleep
Experienced as drifting, floating; 50% of sleep time
Stage 4 of NREM
Delta sleep; deep, dreamless, restful; 10% to 15% of sleep time in healthy young adults
Four Stages of NREM Sleep
I—Transition from wakefulness to sleep; 2% to 5% of sleep time II—Experienced as drifting, floating; 50% of sleep time III—Transition from lighter to deeper sleep IV—Delta sleep; deep, dreamless, restful; 10% to 15% of sleep time in healthy young adults •The amount of time people sleep changes as they grow older. The pattern of sleep also changes throughout life. •Typical sleep pattern of a 15-year-old compared with that of an 85-year-old—sleep cycles are longer and total sleep is greater in a 15-year-old.
Insomnia
Most common sleep disorder, usually mild and short-lived -Common causes >Lifestyle or environmental changes >Pain, illness, anxiety >Large amounts of caffeine; large meals before bedtime Three types >Initial—difficulty falling asleep >Intermittent—difficulty staying asleep >Terminal—waking and an inability to fall back to sleep •Up to 35% of adults experience insomnia in any given year. Insomnia is experienced by 95% of adults at some time. •Some remedies people use to counter anxiety and stress—caffeine, alcohol, drugs—can disrupt sleep patterns even more. Not a disease but rather a symptom or physical or mental stress
Nursing Interventions for Barbiturate Therapy
Perform a baseline assessment, including >Vital signs—blood pressure, pulse, respirations and pain rating >Degree of alertness >State of arousal >Motor function •The importance of a good baseline assessment before administering a sedative-hypnotic cannot be emphasized enough. •The nurse can address patient safety concerns about paradoxical responses by providing additional supervision, considering restraining devices, and helping patient channel energy by walking.
Sedative-Hypnotic Agents
Sedative Hypnotic Agents -Hypnotic -Sedative -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 •No single drug can produce all the desired effects of sedation and sleep induction without producing adverse effects. •Most of these agents alter the sleep cycle in some manner and can be habit-forming. •REM sleep restores mental and physiologic balance. If REM dreaming is cut short, balance is not restored, and REM rebound may occur.
Hypnotic drug
These slow the central nervous system to reduce anxiety and produce sleep
Stage 3 of NREM sleep
Transition from lighter to deeper sleep
Stage 1 of NREM sleep
Transition from wakefulness to sleep; 2% to 5% of sleep time
Sedative drug
drug that relaxes a patient but is not necessarily accompanied by sleep
Why are the newer, nonbenzodiazepine medications for insomnia preferred over older medications? A. They interfere less with natural sleep cycles. B. They can be used safely for long-term insomnia. C. They have a longer duration of action. D. They are less expensive.
•Answer: A Rationale: The drugs of choice for short-term insomnia treatment are the newer nonbenzodiazepines (zaleplon, zolpidem, eszopiclone) because of their wide margin of safety. They have less effect on stage III, IV, and REM sleep cycles. They are intended for short-term use of 7 to 10 days and are found to cause less morning drowsiness because of their rapid and shorter action
A patient is experiencing insomnia due to anxiety about an upcoming procedure in the morning. The patient is oriented and cooperative, but restless. The nurse has reassured the patient, explained what the patient can expect the next day, and provided a relaxing backrub. Which medication would be most effective for this patient? A. Sedative B. Hypnotic C. Narcotic D. Muscle relaxant
•Answer: B •Rationale: A hypnotic is a drug that produces sleep, whereas a sedative quiets the patient and gives a feeling of relaxation and rest not necessarily accompanied by sleep. In this situation the patient desires to sleep. A hypnotic, an effective medication for short-term use, would help induce sleep and provide better relaxation for the next day.
The non-rapid eye movement (NREM) phase of sleep is divided into four stages. Which stage accounts for the largest amount of normal sleep time for an adult? A.I B.II C.III D.IV
•Answer: B •Rationale: Stage II comprises about 50% of normal sleep time. Stage I only accounts for 2% to 5% of sleep. Stage III is a transition from the lighter to deeper sleep state of stage IV. Stage IV sleep comprises 10% to 15% of sleep time in young healthy adults but diminishes as a person ages.
How many hours of sleep per night is thought to be optimal for good health? A.5 to 6 B.6 to 7 C.7 to 8 D.8 to 9
•Answer: C •Rationale: A normal sleep duration of 7 to 8 hours per night is thought to be optimal for good health. Studies show that a reduced amount of sleep is associated with overweight and obesity, metabolic syndrome, and cardiovascular disease. Individuals who sleep less than 5 hours a night have a threefold increased risk of heart attacks.
A low-dose sedative-hypnotic agent may be prescribed for a patient with which condition? A. Dizziness B. Combative behavior C. Hallucinations D. Inability to sleep
•Answer: D •Rationale: Short-term sedative-hypnotic medications may be useful for insomnia (inability to sleep), but general nursing measures should always be used first. Patients experiencing more serious symptoms such as combativeness or hallucinations would require more aggressive medication therapy. Dizziness is treated with antinausea or antihistamine drugs.