Pharm Chapter 12 Muscle Relaxants

cyclobenzaprine (Flexeril) Side Effects

*dizziness*, *drowsiness*, confusion, fatigue, headache, *dry mouth*, blurred vision, -assess pt. for *Serotonin Syndrome* as this is a rare side effect that can cause mood disturbances in a pt. *stop immediately*

What is are the adverse effects/potentially dangerous effects of centrally acting muscle relaxants?

-Generalized CNS Depression -Hepatic Toxicity -Physical Dependence -its important to draw slowly & taper off dosage/no sudden stoppage

The nurse notes that a patient has taken an excessive dose of baclofen. Which action does the nurse implement immediately? 1. Comfort measures 2. Seizure precautions 3. Airway maintenance 4. Antidote preparation

3 An overdose of baclofen can cause respiratory depression as a result of excessive central nervous system depression, so the nurse has to maintain an open airway with the use of oxygen and a bag for ventilation. General supportive therapy and seizure therapy, including cardiac monitoring, gastric lavage, and fluid therapy, are then instituted to maintain vital functions until the depressant effects of baclofen wear off. Although comfort measures are usually appropriate, the nurse's priority is the maintenance of vital functions. An antidote to baclofen does not exist.

A Feedback: Baclofen is used for treatment of muscle spasticity associated with neuromuscular diseases such as multiple sclerosis. Cyclobenzaprine, metaxalone, and orphenadrine are used for relief of discomfort associated with painful, acute musculoskeletal conditions.

A 20-year-old female patient has been diagnosed with multiple sclerosis. What drug will most likely be prescribed? A) Baclofen (Lioresal) B) Cyclobenzaprine (Flexeril) C) Metaxalone (Skelaxin) D) Orphenadrine (Banflex)

A Feedback: Taking cyclobenzaprine with alcohol can cause an increase in central nervous system depression. The nurse should stress that this combination should be avoided due to possible injury or severe body system depression that could lead to coma or death. No significant concerns exist with the use of antiemetics, antihistamines, or antibiotics with this drug.

A nurse is providing discharge teaching for a patient who will be going home on cyclobenzaprine (Flexeril) prescribed for his acute musculoskeletal pain. The nurse will stress that the patient should avoid what? A) Drinking alcohol B) Taking antiemetics C) Taking antihistamines D) Taking antibiotics

A Feedback: Baclofen is available in oral and intrathecal forms and can be administered via a delivery pump for the treatment of central spasticity. Flexeril, dantrolene, and Soma are not administered intrathecally

A patient is admitted to the unit with central spasticity after a terrible motor vehicle accident. The doctor places an intrathecal delivery pump. What medication can be administered via this route to treat the central spasticity? A) Baclofen (Lioresal) B) Cyclobenzaprine (Flexeril) C) Dantrolene (Dantrium) D) Carisoprodol (Soma)

A nurse is caring for a patient receiving intrathecal baclofen [Lioresal]. The patient is unresponsive. After asking a coworker to contact the provider, the nurse anticipates performing which intervention? a.Preparing to support respirations b.Administering an antidote to baclofen c.Administering diazepam to prevent seizures d.Obtaining an electrocardiogram

ANS: A An overdose of baclofen can produce coma and respiratory depression, so the nurse would be correct to suspect overdose in this patient. Respiratory support is essential to prevent a fatal outcome. There is no antidote for baclofen overdose. Diazepam would not be indicated, because seizures are not a result of baclofen overdose and may further depress respirations. An electrocardiogram is not indicated for this patient.

A patient with cerebral palsy has severe muscle spasticity and muscle weakness. The patient is unable to take anything by mouth. The nurse is correct to anticipate that which medication will be ordered for home therapy? a.Baclofen [Lioresal] b.Dantrolene [Dantrium] c.Diazepam [Valium] d.Metaxalone [Skelaxin]

ANS: A Baclofen is used to treat muscle spasticity associated with multiple sclerosis, spinal cord injury, and cerebral palsy. It does not reduce muscle strength, so it will not exacerbate this patient's muscle weakness. It can be given intrathecally, via an implantable pump, and therefore is a good choice for patients who cannot take medications by mouth. Dantrolene must be given by mouth or intravenously and so would not be a good option for this patient. It also causes muscle weakness. Diazepam is not the first-line drug of choice. Alternative routes to PO administration are IM, IV, or by rectum. Metaxalone is used to treat localized muscle spasms caused by injury and is not used for cerebral palsy.

A patient with multiple sclerosis needs pharmacologic treatment for spasticity to begin strengthening exercises to improve walking ability. The nurse anticipates that which medication will be ordered for spasticity? a.Baclofen [Lioresal] b.Dantrolene [Dantrium] c.Diazepam [Valium] d.Metaxalone [Skelaxin]

ANS: A Baclofen is used to treat spasms associated with multiple sclerosis. It has no direct muscle relaxant effects, so it does not reduce muscle strength. Dantrolene works well to reduce spasms, but it also has significant effects on muscle strength. Diazepam is not the first-line drug of choice, but it could be used because it does not reduce muscle strength. Metaxalone is not indicated to treat spasms caused by multiple sclerosis.

Which drugs are used to treat spasticity? (Select all that apply.) a.Baclofen [Lioresal] b.Dantrolene [Dantrium] c.Diazepam [Valium] d.Metaxalone [Skelaxin] e.Tizanidine [Flexeril]

ANS: A, B, C Three drugs—baclofen, dantrolene, and diazepam—are used to treat spasticity. Baclofen and diazepam act in the CNS, whereas dantrolene acts directly on skeletal muscles. With the exception of diazepam, drugs used for muscle spasm, such as metaxalone and tizanidine, are not effective for treating spasticity.

A nurse is admitting a patient to the hospital. The patient reports taking oral baclofen [Lioresal] but stopped taking the drug the day before admission. The nurse would be correct to anticipate which adverse effects? a.Weakness and dizziness b.Fatigue and drowsiness c.Seizures and hallucinations d.Respiratory depression and coma

ANS: C Abrupt discontinuation of baclofen is associated with visual hallucinations, paranoid ideation, and seizures. Central nervous system effects of baclofen include weakness, dizziness, fatigue, and drowsiness. Respiratory depression is a result of overdose of baclofen.

A patient who has a lower back injury exhibits muscle spasms. The provider orders cyclobenzaprine [Flexeril] 10 mg three times a day. What will the nurse include when teaching this patient about this drug? a."This drug carries some risk of developing hallucinations and psychotic symptoms." b."This medication may cause your urine to turn brown, black, or dark green." c."You may experience blurred vision, dry mouth, or constipation." d."You will need to have liver function tests performed while taking this medication."

ANS: C Cyclobenzaprine has significant anticholinergic effects and patients should be warned about dry mouth, blurred vision, and constipation. Tizanidine can cause hallucinations and psychotic symptoms. Methocarbamol may turn urine brown, black, or green, which is a harmless side effect. Tizanidine and metaxalone can cause liver toxicity and require monitoring.

A patient with cerebral palsy who has been receiving baclofen [Lioresal] via gastrostomy tube for 3 months is admitted to the hospital for evaluation of new-onset seizures. What may the nurse suspect to be the cause of these seizures? a.Baclofen toxicity b.Common adverse effect of baclofen c.Idiopathic causes related to disease process d.Missed doses of baclofen

ANS: D Baclofen does not appear to cause physical dependence, but abrupt discontinuation has been associated with adverse reactions. Abrupt withdrawal of oral baclofen can cause visual hallucinations, paranoid ideation, and seizures and should be considered when a patient develops these symptoms. Seizures are not a symptom of baclofen toxicity.

A nurse is teaching the parent of a child with spastic quadriplegia about intrathecal baclofen [Lioresal]. Which statement by the parent indicates a need for further teaching? a."I can expect my child to be more drowsy when receiving this medication." b."I should not notice any change in my child's muscle strength." c."I will contact the provider if my child is constipated or cannot urinate." d."If my child has a seizure, I should stop giving the medication immediately."

ANS: D Seizures may occur if oral baclofen is withdrawn abruptly; seizures are not an adverse effect of baclofen. If intrathecal baclofen is stopped abruptly, patients can experience lifethreatening effects, so parents should be advised not to stop the drug abruptly. The central nervous system effects of baclofen include drowsiness and lethargy, so these effects are expected. Baclofen does not reduce muscle strength. It can cause constipation and urinary retention, and patients should be advised to contact their provider so that these conditions can be treated.

A Feedback: Other measures in addition to drugs should be used to alleviate muscle spasm and pain. The nurse can independently encourage rest of the affected muscle and provide heat applications to increase blood flow to the area to remove the pain-causing chemicals.

After administering a centrally acting skeletal muscle relaxant, what other independent nursing measures might the nurse implement to relieve pain and reduce spasm? A) Rest of the affected muscle B) Application of cold C) Physical therapy D) Order of a nonsteroidal anti-inflammatory drug

Indirect acting Muscle Relaxants

Baclofen (Lioresal)- used for chronic spastic conditions. Adverse effects: euphoria, weakness, fatigue. Cyclobenzaprine (Flexeril)- used for spasms d/t injury. Adverse effects: drowsiness, weakness, dry mouth.

B, C, D Feedback: Adverse effects include transient drowsiness, dizziness, weakness, fatigue, constipation, headache, insomnia, hypotension, nausea, and urinary frequency. Bone marrow suppression and coronary artery disease are not associated with therapy involving these drugs.

Baclofen is a prototype drug for the centrally acting skeletal muscle relaxants. What adverse effects do drugs in this class have? (Select all that apply.) A) Coronary artery disease B) Hypotension C) Urinary frequency D) Dizziness E) Bone marrow suppression

Baclofen is a _____ that _____?

Baclofin (lioresal) is a *antispasticity agent & centrally acting skeletal muscle relaxant* that *acts on the spinal cord and suppresses hyperactive reflexes.*

A patient has received an excessive dose of baclofen (Lioresal). Which action does the nurse implement next? A. Comfort measures B. Seizure precautions C. Airway maintenance D. Antidote preparation

C. Airway maintenance An overdose of baclofen can cause respiratory depression as a result of excessive central nervous system depression, so the nurse prepares to maintain the patient's airway and breathing with the use of an airway, oxygen, and a bag for ventilation. General supportive therapy, including cardiac monitoring, gastric lavage, and fluid therapy, is instituted to maintain vital functions until the depressant effects of baclofen wear off. An antidote to baclofen does not exist. Although comfort measures are usually appropriate, the nurse's priority is the maintenance of vital functions.

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 todevelop 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.

The nurse prepares to administer cyclobenzaprine (Flexeril) to a patient who has been in a motor vehicle accident (MVA). Which piece of preadministration assessment data is the nurse's priority in the evaluation of adverse effects of therapy? A. Amount of bleeding B. Indicators of infection C. Spasms of the muscles D. Level of consciousness

D. Level of consciousness The nurse compares the patient's level of consciousness after the administration of cyclobenzaprine to the findings of the preadministration neurologic assessment to evaluate the adverse effects of the drug, which can cause significant sedation. However, because the patient was in an MVA, a significant reduction in the level of consciousness or unresponsiveness in the patient warrants further investigation by the nurse to rule out increased intracranial pressure. The nurse assesses muscle spasms to evaluate the effectiveness of therapy, as less muscle spasticity is expected after the administration of cyclobenzaprine. Cyclobenzaprine should have no effect on infection; as long as the spastic muscles are not bleeding, it should have no direct effect on bleeding.

Cyclobenzaprine (Flexeril)

Drug class: Central acting muscle relaxer Indications: Muscular pain: spasticity from spinal cord injury, stroke, or other neuromuscular condition reduce spasms following musculoskeletal injuries Contraindications: CNS depression Common adverse effects: sedation, nausea Therapeutic effect: reduction in pain; reduction in spasticity Nurse considerations: avoid activities requiring alertness

cyclobenzaprine (Flexeril) is a _____ that promotes_____?

Flexeril (cyclobenzaprine) is a *centrally acting skeletal muscle relaxant* that promotes *reduction in muscle spasm & hyperactivity without loss of function*.

Types of Muscle relaxants

Most are centrally acting CNS depressants. This means they have a sedative property, and do not act directly on muscle + calcium. Examples- Baclofen (Lioresal), Cyclobenzaprine (Flexeril).

D Feedback: The priority to monitor is respiratory status. One of the primary adverse effects of this drug is central nervous system (CNS) depression. If the patient receives too much medication, or reaches toxic levels, respiratory rate will decline as the result of excessive CNS depression and the drug dosage will either be adjusted downward or the drug may be held until the patients respirations improve. Monitoring other vital signs including blood pressure and pulse is indicated but is not the priority.

The nurse is caring for a patient receiving intrathecal baclofen via pump while participating in rigorous rehabilitation therapy. What is the nurses priority to monitor related to adverse effects of this drug? A) Blood pressure B) Pulse pressure C) Spasticity D) Respiratory status

C Feedback: If using baclofen, taper drug slowly over 1 to 2 weeks to prevent the development of psychoses and hallucinations. Giving both drugs at once would risk toxicity and serious adverse effects and would never be done.

The nurse is caring for a patient who is being discharged home from the rehabilitation unit. Baclofen will be discontinued and the patient will begin taking carisoprodol as an outpatient. What is the nurses primary consideration about discontinuing administration of baclofen? A) Taper drug over 72 hours to reduce dependence on the drug. B) Alternate doses of baclofen and soma over 10 days to prevent drug withdrawal. C) Taper drug slowly over 1 to 2 weeks to prevent psychoses and hallucinations. D) Start carisoprodol immediately while continuing baclofen at full dose to establish carisoprodol level.

A, B, D Feedback: Acute pain related to GI effects of drug, risk for injury related to CNS effects, and disturbed thought processes related to CNS effects all apply to both patients. Disturbed body image may apply to the patient having the pump placed, but this is not related to muscle pain. Only the patient having the pump placed would need information related to the procedure.

The nurse is caring for a patient who is having a pump placed to deliver intrathecal baclofen and another patient who will receive dantrolene as a muscle relaxant. What nursing diagnosis would be appropriate for both care plans? (Select all that apply.) A) Acute pain related to GI effects of drug B) Risk for injury related to central nervous system (CNS) effects C) Disturbed body image related to muscle pain D) Disturbed thought processes related to CNS effects E) Deficient knowledge related to procedure

A, B, C Feedback: Muscle spasms often result from injury to the musculoskeletal system (e.g., overstretching a muscle, wrenching a joint, tearing a tendon or ligament). These injuries can cause violent and painful involuntary muscle contractions. Breaking a bone or exercising would not cause muscle spasms unless one of the other options was involved.

The patient presents to the emergency department with muscle spasms in the back. What types of injury would the nurse recognize can result in muscle spasm? (Select all that apply.) A) Overstretching a muscle B) Wrenching a joint C) Tearing a tendon or ligament D) Breaking a bone E) Exercising too vigorously.

Baclofen Uses & Side Effects

Uses: MS, Spinal Cord Injury, Cerebral Palsy Side Effects: dizziness, drowsiness, fatigue, weakness, nausea, constipation -Baclofen is a CNS Depressant (so avoid other CNS depressants) -abrupt withdrawal risks *rhabdomylosis* (intrathecally if it went into sub q or im space) -high fever, LOC, rebound spasticity. -must taper doses, there is no antidote for overdose!

B Feedback: The spinal reflexes are the simplest nerve pathways that monitor movement and posture. Arc reflexes and afferent nerve reflexes are distracters for this question. Spindle gamma loops respond to stretch receptors

What are the simplest nerve pathways in the body? A) Arc reflexes B) Spinal reflexes C) Afferent nerve reflexes D) Spindle gamma loop

D Feedback: The normal daily dosage of cyclobenzaprine is 10 mg taken orally t.i.d., and it can be increased to a maximum of 60 mg per day.

What is the maximum daily dose of cyclobenzaprine (Flexeril) the nurse can administer? A) 20 mg B) 30 mg C) 40 mg D) 60 mg

A Feedback: Other spinal reflexes may involve synapses with interneurons within the spinal cord, which adjust movement and response based on information from higher brain centers to coordinate movement and position. Spinal reflexes do not adjust response and recovery, adjust the body to the upright position, or coordinate balance.

When spinal reflexes involve synapses with interneurons within the spinal cord, what physiological adjustments are made? A) Coordinate movement and position B) Adjust response and recovery C) Adjust to upright position D) Coordinate balance

Mr. P., is recovering from an automobile accident and has received a prescription for cyclobenzaprine for painful muscle spasms. a.- What patient teaching will he need about this medication? b.- What other measures should be included in addition to this drug therapy?

a.- Patient teaching should include information about the potential side effects and potential drug interactions. In addition, safety measures to prevent injury stemming from decreased sensorium must be emphasized b.- These medications are most effective when used in conjunction with rest and physical therapy.

A patient with back muscles spasms is being treated with a skeletal muscle relaxant. To ensure that these drugs are most effective, the nurse will make sure what other treatment is ordered? a.-Benzodiazepines b.-Moist heat c.-Physical therapy d.-Aspirin

c.-Physical therapy

Baclofen (Lioresal)

more commonly used for "spasticity"is used for chronic spastic muscular conditions Drug class: Central acting muscle relaxer Indications: Muscular pain: spasticity from spinal cord injury, stroke, or other neuromuscular condition Contraindications: CNS depression Common adverse effects: sedation, nausea Therapeutic effect: reduction in pain; reduction in spasticity Nurse considerations: avoid activities requiring alertness