NURS 1950Nancy Pares, RN, MSN

Metro Community College

http://www.cafeoflifepikespeak.com/Videos/Licensed%20To%20Pill.swf

Four groups (also called anxiolytics/tranquilizers)◦ Antidepressants (Chap 16)◦ Benzodiazepines◦ Barbiturates◦ Nonbenzodiazepines/nonbarbiturate CNS

depressants

Baseline data◦ Cause of anxiety◦ Vitals◦ Blood dyscrasias, liver disease, pregnancy or

breastfeeding

WHY?

Prototype: Phenobarbital (Luminal) Action: enhances the action of the

neurotransmitter GABA-which suppresses abnormal neuronal discharges

Rarely used today due to significant side effects—high chem dependency & overdose

New studies show◦ No effect on anxiety—too much CNS depression

Overdoses are common; increase enzyme activity…which causes_resp depression

Advantages

End in ‘pam’◦ Diazapam (Valium),oxazepam (Serax), lorazapam

(Ativan)**

Drugs of choice for anxiety and insomnia Action:

◦ bind to the GABA receptor (what is this? And what does it do?

Uses:◦ Acute anxiety, medical illness, ETOH w/drawal

Adverse effects:◦ Hypotension, confusion, syncope

Interactions:◦ ETOH, anesthetics, MAO inhibitors,

antihistamines, TCA’s, narcotics, barbiturates◦ Caffeine and smoking interfere with desired effect◦ Overdose:

Flumazenil (Romazicon)

Nursing Implications◦ Tolerance develops◦ Can cause physical and psychological

dependence◦ No abrupt w/drawal of meds◦ Drug doses vary---check for appropriate dosing◦ Interacts with phenytoin and coumadin

Buspirone (BuSpar)◦ Unrelated to benzo or barbiturates chemically

Action: not well known; may be related to dopamine receptors

Advantages:◦ Less potential for abuse; lower sedative

properties Adverse effects:

◦ Dizziness, HA, drowsiness; may take 3-4 wks for optimal effects

Buspar◦ Schedule regular assessments for slurred speech,

dizziness, CNS disturbances; give at regular intervals (not PRN); do not use with MAO Inhibitors or ETOH

Diphenhydramine (Benedryl) and Hydroxyzine (Vistaril)

Uses: sedative and antiemetic properties; anticholinergic effects are least with these agents; preop sedation, pruititis

Side effects:◦ Blurred vision, constipation, dry mucosa,

sedation; drowsiness will decrease with use

Before giving an antianxiety, what would you assess?

After giving an antianxiety, what would you assess?

What are some common nursing diagnosis for clients taking anxiolytics?

Classifications◦ Tricyclics◦ MAO inhibitors (monoamine oxidase)◦ SSRI◦ Atypical Antidepressants

Action is on serotonin and catecholamines Therapy requires 2-3 wks for mood change Overdoses do occur common side effects:

◦ Sedation, anticholinergic activity, tachycardia, orthostatic hypotension, confusion, tremors

TCA◦ Action: inhibits reuptake of norepinephrine and

seratonin into presynaptic nerve terminals◦ Uses: depression, Manic-depressive

(bipolar)disorder, panic disorders◦ Desired effects: mood elevation, increase activity,

improve appetite, normalize sleep patterns….. What s/s of depression make these desirable effects?

◦ Takes 1-2 months for maximal effect

Adverse effects:◦ Tremor, numbness, tingling, Parkinsonian

symptoms, orthostatic hypotension, anticholinergic effects (which are?)

◦ Cardiac arrhythmias, suicidal actions

Do not use with MAOI..why? Sympathomimetics increase effects of

anticholinergic effects Avoid OTC antihistamines Prototype: imipramine (Tofranil)

Sertraline (Zoloft)◦ Action: inhibits reuptake of serotonin◦ Use: depression, anxiety, OCD and panic disorder◦ Adverse effects: agitation, HA , dizziness and

fatigue; sexual dysfunction; weight gain; ◦ Contraindications: antabuse should be avoided;

no MAOI ; use precaution with St. John Wart

• May take wks to get effect; effects last 2-3 months after d/c

• Give in am or pm• Note eating disorders hx• Exercise and caloric restriction• Monitor labs for pro-bound drugs…ex:

coumadin• May need increase of dilantin due to

interactions

• Phenelzine (Nardil)• Action:intensifies effects of norepinephrine

in adrenergic synapses• Use: depression not responsive to other

drugs• Common S/E: constipation, dry mouth,

orthostatic hypertension; severe hypertension with foods containing tyramine (see pg 195)

• Contraindications: cardiac disease, renal/hepatic impairment

Refrain from foods that contain tyramine Assess cardiac status Assess lab values (why?) No OTC or herbal meds Avoid caffeine Observe for s/s of stroke or MI

General anesthesia, diuretics, antihypertensives: potentiate the hypotensive effects

Insulin and oral hypoglycemics: additive effects

Meperidine and MAOI= severe reactions

What assessments need to be made before antidepressant medications?

What are the nursing diagnosis you would write for clients with antidepressant meds.?

Hypertensive Crisis◦ Ingestion of foods with tyramine (this substance

promotes release of norepinephrine)◦ Avocados, soybeans, figs, bananas, aged meat,

smoked meat, bologna, pepperoni, salami, cheese, caffeine

Lithium carbonate (Eskalith)◦ Action: stabalizes the neuronal membrane,

reduces release of norepinephrine◦ Uses: reduces euphoria of mania without

sedation; may take a week to develop desired effects; begin with low doses and increase q 3-5 days.

◦ Common S/E: n/v, anorexia, abd cramps, excessive thirst and urination

Adverse effects: persistant vomiting; progressive wt gain, fatigue, nephrotoxicity

Serum levels need to be below 1.5mEq/L >1.5: n/v, diarrhea, thirst, polyuria, slurred

speech 1.5-2.0: GI upset, confusion 2.0-2.5: ataxia. Blurred vision, coma 2.5 and >: convulsion, oliguria, death

normal blood level: Nutrition needs: Desired effects in 5-7 days; full effect in 21

days Give with food or milk

Phenothiazines Non phenothiazine Atypical anti psychotics

Chlorpromazine (Thorazine) Action:

◦ Prevent dopamine and serotonin from occupying their receptor sites and block the excitement symptoms

Use: ◦ Schizophrenia, bipolar (manic state), depression,

antiemetic

Adverse effects: (see page 213 table)◦ Extrapyramidal effects

Acute dystonia, spasms of tongue, opisthostonos Treat: anticholinergics

◦ Parkinsonism (why?)◦ Akathesia◦ Tardive dyskinesia

May be irreversible◦ Other common: sedation, sexual dysfunction,

breast growth, galactorrhea

Nursing Interventions◦ Increases effect with anticholinergics◦ ETOH and CNS depressants intensify depressant

effect◦ NOTE: most phenothiazines end in ‘zine’ ; ex:

fluphenzine, prochorperazine, promazine, thiroidazine

◦ Careful monitoring of client condition; report EPS symptoms to MD..may need to d/c med

◦ Life threatening adverse effect: neuroleptic malignant syndrome (NMS)

Haloperidol (Haldol) Action/Use: chemically a butyrphenone;

primary use is psychotic disorder—has less sedation than phenothiazine, but greater EPS

Nursing Interventions:◦ Same as pheno—monitor carefully, esp. elderly

Clozapine (Clozaril) Action/Use:

◦ Largely unknown—block several receptor sites; broader spectrum of action, fewer EPS symptoms

Nursing Interventions:◦ Basically same as pheno..give wkly supply to

assure lab values get drawn

New drug aripiprazole (Abilify)◦ Dopamine stabilizer with fewer EPS

◦ Adverse effects: HA, N/V, fevers constipation, anxiety

◦ Nursing implications As all other categories