Sedatives and Hypnotics Chap. 21

sedative

drug producing a relaxing, calming effect

hypnotic

drug that induces sleep

ataxia

unsteady gait; muscular incoordination

paradoxical reaction

when a drug or treatment has the opposite effect of the usual intent

Key Points

Sedatives produce a relaxing and calming effect. Hypnotic drugs produce sleep. These drugs work by depressing the CNS. Barbiturate use is lessening because of both dependency and harsh adverse reactions. The nonbarbiturates include both benzodiazepines and nonbenzodiazepines. Insomnia affects nearly 70 million people in the United States. Although it is often treated in the outpatient setting, many hospitalized patients suffer from insomnia, too. These drugs are meant to treat insomnia for only a short period of time, such as 2 weeks. If continued longer dependency can occur. Patients should always be asked about sleep aids they have tried before, because both herbal and OTC products are abundant. Patients should be cautioned about activities requiring concentration and focus, such as driving, and be aware that blood pressure can drop, leading to dizziness and potential for injury. Doses should not be increased without consulting the primary health care provider. Sedatives and hypnotics can also cause respiratory depression. Other CNS depressants, such as alcohol, should not be used with these drugs.

pentobarbital pen-toe-bar'-bih-tall Barbiturates

Trade Name:Nembutal Uses: Sedative, hypnotic, preoperative sedation Adverse Reactions: Respiratory and CNS depression, nausea, vomiting, constipation, diarrhea, bradycardia, hypotension, syncope, hypersensitivity reactions, headache Dosages: Available only in parenteral form: 100 mg deep IM or IV, may titrate up to 200-500 mg

Differentiate between a sedative and a hypnotic.

A hypnotic is a drug that induces drowsiness or sleep, meaning it allows the patient to fall asleep and stay asleep. Hypnotics are given at night or bedtime. A sedative is a drug that produces a relaxing, calming effect. Sedatives are usually given during daytime hours, and although they may make the patient drowsy, they usually do not produce sleep.

Discuss the uses, general drug actions, adverse reactions, contraindications, precautions, and interactions of sedatives and hypnotics.

Actions Barbiturates All barbiturates have essentially the same mode of action. These drugs are capable of producing central nervous system (CNS) depression and mood alterations ranging from mild excitation to mild sedation, hypnosis (sleep), and deep coma. These drugs also are respiratory depressants; the degree of depression usually depends on the dose taken. Benzodiazepines and Nonbenzodiazepines Nonbarbiturate sedatives and hypnotics have essentially the same mode of action as the barbiturates—that is, they depress the CNS. The benzodiazepine effect on gamma (γ)-aminobutyric acid (GABA) to potentiate neural inhibition is discussed in Chapter 20. However, these drugs have a lesser effect on the respiratory rate—another reason they are chosen over barbiturates for insomnia. The nonbenzodiazepine effects diminish after approximately 2 weeks. Persons taking these drugs for longer than 2 weeks may have a tendency to increase the dose to produce the desired effects (e.g., sleep, sedation). Physical tolerance and psychological dependence may occur, especially after prolonged use of high doses. However, their addictive potential appears to be less than that of the barbiturates. Discontinuing use of a sedative or hypnotic after prolonged use may result in mild to severe withdrawal symptoms. Uses The sedative and hypnotic drugs are used in the treatment of: Insomnia Convulsions or seizures They are also used as adjuncts for anesthesia and for: Preoperative sedation Conscious sedation Adverse Reactions Nervous system reactions include dizziness, drowsiness, and headache. A common gastrointestinal reaction is nausea. Contraindications These drugs are contraindicated in patients with known hypersensitivity to sedatives or hypnotics. Do not administer these drugs to comatose patients, those with severe respiratory problems, those with a history of drug and alcohol habitual use, or pregnant or lactating women. Due to a specific enzyme reaction, grapefruit or its juice should not be taken if the patient is on triazolam or zaleplon. The barbiturates are classified as pregnancy category D drugs. Benzodiazepines (e.g., estazolam, quazepam, temazepam, triazolam) used for sedation are classified as pregnancy category X drugs. Most nonbenzodiazepines are pregnancy category B or C drugs. Precautions Sedatives and hypnotics should be used cautiously in lactating patients and in patients with hepatic or renal impairment, habitual alcohol use, and mental health problems. Interactions antidepressants Management of depression Increased sedative effect opioid analgesics antihistamines Pain relief, relief of allergy symptoms (runny nose and itching) Increased sedative effect phenothiazines (e.g., Thorazine) Management of agitation and psychotic symptoms Increased sedative effect cimetidine Management of gastric upset Increased sedative effect alcohol Relaxation and enjoyment in social situations Increased sedative effect

Drug Classes

Barbiturates Nonbarbiturates Benzodiazepines Nonbenzodiazepines

Discuss important preadministration and ongoing assessment activities the nurse should perform with the patient taking a sedative or hypnotic.

Preadministration Assessment Before administering a sedative or hypnotic, document the patient's blood pressure, pulse, and respiratory rate. Changes in vital signs (especially hypotension) may occur after drug administration, so having baseline values is important for comparison. In addition to the vital signs, assess the patient's status by asking the following questions: Hypnotic Drug Administration (for Sleep Disturbances) Is the patient uncomfortable? If the reason for discomfort is pain, an analgesic, rather than a hypnotic, may be required. A hypnotic may not be necessary because an analgesic can also induce drowsiness and sleep. When is the drug scheduled for administration? Is it too early for the patient to receive the drug—will they awaken early in the morning? Are there disturbances in the environment that may keep the patient awake and decrease the effectiveness of the drug? Sedative Drug Administration (for Relaxing and Calming) Is the sedative for a surgical procedure, and is its administration correctly timed? Has a consent form for the procedure been signed before the medication is given? Informed consent cannot be established if the patient has medication in his or her system. If the patient is receiving one of these drugs for daytime sedation, assess the patient's general mental state and level of consciousness. If the patient appears sedated and difficult to awaken, you should withhold the drug and contact the primary health care provider as soon as possible. Ongoing Assessment Before administering the drug, perform an assessment that includes the patient's vital signs (temperature, pulse, respiration, and blood pressure) and level of consciousness (e.g., alert, confused, or lethargic). Ask the patient about the circumstances causing insomnia and whether other factors such as pain, lights, or disruptive activity are bothersome. After assessing the patient, make a decision regarding administration of the drug or if other interventions are more appropriate to try first. Ask if the drug helped the patient sleep on previous nights. If not, a different drug or dose may be needed; consult the primary health care provider regarding the drug's ineffectiveness. Usually, at least 2 hours should elapse between administration of a hypnotic and any other CNS depressant, but this interval may vary, depending on factors such as the patient's age and diagnosis.

Discuss ways to promote an optimal response to therapy, how to manage common adverse reactions, and important points to keep in mind when educating patients about the use of sedatives or hypnotics.

Promoting an Optimal Response to Therapy You should provide supportive care to promote the effects of the sedative or hypnotic drug. This includes interventions such as back rubs, night lights or a darkened room, and a quiet atmosphere. The patient is discouraged from drinking beverages containing caffeine, such as coffee, cola, or energy drinks, which can contribute to wakefulness. Never leave hypnotics and sedatives at the patient's bedside to be taken at a later hour; hypnotics and sedatives are controlled substances (see Chapter 1). In addition, never leave these drugs unattended in the nurses' station, hallway, or other areas to which patients, visitors, or hospital personnel have direct access. Educating the Patient and Family The primary health care provider usually prescribes these drugs for short-term use only. If the drug appears to be ineffective, contact the primary health care provider. Do not increase the dose unless advised to do so by the primary health care provider. Notify the primary health care provider if any adverse drug reactions occur. Do not drink any alcoholic beverage 2 hours before, with, or 8 hours after taking the drug. When taking the drug as a sedative, be aware that the drug can impair the mental and physical abilities required for performing potentially dangerous tasks, such as driving a car or operating machinery. After taking a drug to sleep, observe caution when getting out of bed at night. Keep the room dimly lit and remove any obstacles that may result in injury when getting out of bed. Never attempt to drive or perform any hazardous task after taking a drug intended to produce sleep. Do not use these drugs if you are pregnant, considering becoming pregnant, or breastfeeding. Do not use OTC cold, cough, or allergy drugs while taking this drug unless their use has been approved by the primary health care provider. Some of these products contain antihistamines or other drugs that also may cause mild to extreme drowsiness. Others may contain an adrenergic drug, which is a mild stimulant, and therefore will defeat the purpose of the sedative or hypnotic. Do not take zolpidem with food. A high-fat meal or snack can interfere with the absorption of the following drugs: eszopiclone, ramelteon, or zaleplon.

List nursing diagnoses particular to a patient taking a sedative or hypnotic.

Risk for Injury related to drowsiness or impaired memory Ineffective Breathing Pattern related to respiratory depression Ineffective Individual Coping related to excessive use of medication