NR 293 - Review questions

Barbiturates: Drug Interactions

**Additive effects - Alcohol, antihistamines, benzodiazepines, opioids, tranquilizers **Inhibited metabolism - MAOIs prolong the effects of barbiturates. **Increased metabolism - Reduces anticoagulant response, leading to possible clot formation

Muscle Relaxants adverse effects..

- Euphoria - Lightheaded/dizzy - Drowsy - Muscle weakness

Muscle Relaxants: Adverse Effects

- Euphoria - Lightheadedness - Dizziness - Drowsiness - Fatigue - Muscle weakness, others

Nursing implications with hypnotics

- Give hypnotics 30 to 60 minutes before bedtime for maximum effectiveness in inducing sleep (depends on drug's onset). - Most benzodiazepines cause REM rebound and a tired feeling the next day; use with caution in older adults. Instruct patients to avoid alcohol and other CNS depressants. - Rebound insomnia may occur for a few nights after a 3- to 4-week regimen has been discontinued.

Temazepam (Restoril)

- Intermediate-acting benzodiazepine - Normally induces sleep within 20 to 40 minutes - Long onset of action, so it is recommended that patients take it about 1 hour prior to going to bed

Barbiturates: Drug Effects

- Low doses: sedative effects - High doses: hypnotic effects (also lower respiratory rate) - Notorious enzyme inducers Stimulate liver enzymes that cause metabolism or breakdown of many drugs - Result in shortened duration of action

Barbiturates: Toxicity and Overdose

- Overdose frequently leads to respiratory depression and subsequent respiratory arrest - Overdose produces CNS depression (sleep to coma and death) - Can be therapeutic - Anesthesia induction - Uncontrollable seizures: "phenobarbital coma"

Common Barbiturates

- Pentobarbital (Nembutol) - Phenobarbital

Pentobarbital (Nembutal)

- Prototypical barbiturate - Long-acting drug - Uses: prevention of generalized tonic-clonic seizures and fever-induced convulsions, as well as treatment of hyperbilirubinemia in neonates - Rarely used today as a sedative and is no longer recommended to be used as a hypnotic drug

Barbiturates: Indications

- Sedatives - Anticonvulsants - Anesthesia for surgical procedures

Zolpidem (Ambien) Nonbenzodiazepine

- Short-acting nonbenzodiazepine hypnotic - Lower incidence of daytime sleepiness compared with benzodiazepine hypnotics - Ambien CR is a longer acting form with two separate drug reservoirs - Somnambulation

Zaleplon (Sonata) Nonbenzodiazepine

- Short-acting nonbenzodiazepine hypnotic - Unique advantage of this drug stems from its very short half-life - Patients whose sleep difficulties include early awakenings can take a dose in the middle of the night as long as it is at least 4 hours before they must arise.

Barbiturates: Mechanism of Action

- Site of action: brainstem (reticular formation) - By potentiating the action of GABA, nerve impulses traveling in the cerebral cortex are inhibited.

Toxicity/Overdose Effects of Benzodiazepines..

- Somnolence (sleepiness) - Confusion - Coma - Diminished reflexes

Ramelteon (Rozerem) Nonbenzodiazepine

- Structurally similar to the hormone melatonin: works as an agonist at melatonin receptors in the CNS - Technically, it is not a CNS depressant; used as hypnotic - Indicated for patients who have difficulty with sleep onset rather than sleep maintenance

Barbiturates: Treatment of overdose

- Symptomatic and supportive - Maintain adequate airway - Assisted ventilation or oxygen therapy - Fluids - Pressor support - Activated charcoal

Herbal Products: Valerian

- Used to relieve anxiety, restlessness, and sleep disorders - May cause CNS depression, hepatotoxicity, nausea, vomiting, anorexia, restlessness, insomnia - Many interactions, including with CNS depressants, MAOIs, phenytoin, warfarin, and alcohol - Contraindicated in cardiac and liver disease - Patient should not operate heavy machinery during use.

Herbal Products: Kava

- Used to relieve anxiety, stress, and restlessness and to promote sleep - May cause temporary yellow skin discoloration (extended, continued intake) and visual disturbances - Potential interactions with alcohol, barbiturates, and psychoactive drugs - Contraindicated in liver disease, alcoholism, other conditions - Patient should not operate heavy machinery during use.

What is the antidote for barbiturate overdose?

Activated Charcoal

The patient tells the nurse that his friend has been taking valerian for a long period of time and that he isn't feeling so well. The patient asks the nurse what the adverse effects of valerian are. The best response by the nurse is that adverse effects of valerian include 1. insomnia. 2. yellow skin. 3. bruising. 4. increased appetite.

Correct answer: 1 Rationale: Adverse effects of valerian include CNS depression, hepatotoxicity, nausea, vomiting, anorexia, headache, restlessness, and insomnia.

The patient asks, "Is there anything I have to worry about when taking Kava?" The best response by the nurse is: 1. "Kava is a natural product which has no side effects." 2. "You need a prescription to take Kava." 3. "No worries, Kava is recommended for patients with depression." 4. "It is best to inform you health care provider of any additional medication or supplements you plan to take to check for interactions that may be harmful."

Correct answer: 4 Rationale: Even natural products have side effects. Side effects of Kava include skin discoloration, possible accommodative disturbances and pupillary enlargement, and scaly skin (with long-term use). Kava and other supplements are available without a prescription. Kava is contraindicated in patients with Parkinson's disease, liver disease, depression, or alcoholism; in those operating heavy machinery; and in pregnant and breastfeeding women. As with all medications and supplements, it is best to inform the health care provider to evaluate possible interactions among drugs and supplements taken.

Which statement regarding muscle relaxants does the nurse identify as being accurate? A. Baclofen (Lioresal) is available as an injectable form for use with an implantable pump device. B. Cyclobenzaprine (Flexeril) produces little sedation. C. Patients taking muscle relaxants are at high risk of developing hypertension. D. Patients taking muscle relaxants should be told to stop taking the medication if they feel sleepy.

Correct answer: A Rationale: Baclofen (Lioresal) is sometimes used in an injectable form. Cyclobenzaprine (Flexeril) often results in deep sedation and sleepiness. Patients taking muscle relaxants are at risk to develop hypotension; therefore, they should be taught safety measures to prevent falls. Sedation and sleepiness are common side effects of muscle relaxants; however, a patient should not abruptly discontinue use of the medication. Safety procedures should be followed to prevent accidents and falls.

Which statement regarding muscle relaxants does the nurse identify as being accurate? Baclofen (Lioresal) is available as an injectable form for use with an implantable pump device. Cyclobenzaprine (Flexeril) produces little sedation. Patients taking muscle relaxants are at high risk of developing hypertension. Patients taking muscle relaxants should be told to stop taking the medication if they feel sleepy.

Correct answer: A Rationale: Baclofen (Lioresal) is sometimes used in an injectable form. Cyclobenzaprine (Flexeril) often results in deep sedation and sleepiness. Patients taking muscle relaxants are at risk to develop hypotension; therefore, they should be taught safety measures to prevent falls. Sedation and sleepiness are common side effects of muscle relaxants; however, a patient should not abruptly discontinue use of the medication. Safety procedures should be followed to prevent accidents and falls.

An older adult patient taking multiple medications has a barbiturate added to his medication regimen. When administering a barbiturate to an older adult, the nurse should expect A. a decrease in dosages of the other medications. B. the patient will experience increased amounts of REM sleep. C. to administer half of the usual dose of the barbiturate. D. total relief of anxiety

Correct answer: C Rationale: Barbiturates are associated with an increased incidence of falls when used in older adults; therefore, the usual dose is reduced by half whenever possible. Because barbiturates stimulate the action of enzymes in the liver, drugs are usually broken down more quickly, sometimes requiring the dose to be increased. Patients taking barbiturates have decreased amounts of REM sleep and often experience paradoxical restlessness or excitement

Eszopiclone (Lunesta) Nonbenzodiazepine

Designed to provide a full 8 hours of sleep Considered a short- to intermediate-acting agent Patients should allot 8 hours of sleep time and should avoid taking hypnotics when they must awaken in less than 6 to 8 hours.

Benzodiazepines antidote is..

Flumazenil

Does taking excess benzodiazepines cause hypotension and respiratory depression?

No these are "Benz" like Mercedes "Benz". They go fast-- therefor they are excreted out of your body fast. They only cause hypotension and respiratory depression if used with other CNS depressants at the same time such as alcohol and opiods.

Hypnotics cause..

SLEEP. A sedative can come hypnotic if given in large doses

CNS depressants, concurrent use of alcohol

can cause respiratory depression or arrest.

Sedatives are..

drugs that have an inhibitory effect on the CNS and reduce: - nervousness - excitability - irritability

Barbiturates have a low therapeutic index. This means: low doses are not therapeutic. the toxic range is narrow. they are habit forming. the effective, safe dosage range is narrow.

the effective, safe dosage range is narrow. Rationale: Drugs with a low therapeutic index have only a narrow dosage range within which the drug is effective; above that range, they are rapidly toxic. Barbiturates are habit forming, but this is not related to the therapeutic index.