Week 3 Lecture Notes - Medications for Pain Relief, Anesthesia, & More

2023-09-25 TOPICS TO COVER • CH 11 - Analgesics CENTRAL NERVOUS SYSTEM • CH 12 - Anesthetics MEDICATIONS THAT STIMULATE, INHIBIT, ALTER OR SUPPRESS • • • • 1 • CH 13 - CNS depressants and Muscle relaxants • CH 14 - Central Nervous System Stimulants and Related Drugs • • Opioids • Adjuvan...

2023-09-25 TOPICS TO COVER • CH 11 - Analgesics CENTRAL NERVOUS SYSTEM • CH 12 - Anesthetics MEDICATIONS THAT STIMULATE, INHIBIT, ALTER OR SUPPRESS • • • • 1 • CH 13 - CNS depressants and Muscle relaxants • CH 14 - Central Nervous System Stimulants and Related Drugs • • Opioids • Adjuvants Sedatives & Hypnotics • CH 17 – Psychotherapeutics General Regional • Anxiolytic drugs • • • Mood-stabilizing drugs • Local Neuromuscular Blockers Primarily benzodiazepines Antidepressant drugs Antipsychotic drugs 2 Nervous System CNS MODULE LEARNING OUTCOMES 3 • • • • Differentiate between different types of pain • • Identify CNS stimulant drugs • For each medication, recognize and articulate the different phases of the nursing process, including patient teaching, that ensures safe and effective nursing practice. Brain Identify the different classes and uses of opioid drugs and other drugs to treat pain Spinal cord Peripheral nervous system Motor Neurons Somatic Nervous system Define anesthesia and the mechanism of its affect Differentiate between sedative and hypnotic drugs and specific drugs within these categories Autonomic Nervous system Sympathetic division For each class of medication, explain the mechanism of action, indications, contraindications, and therapeutic and adverse effects, including any related toxicities. Adrenergic receptors Alpha Sensory neurons Parasympathetic division Cholinergic receptors Beta 4 1 2023-09-25 ANALGESICS • Medications that relieve pain without causing loss of consciousness • “Pain killers” • Opioids • Adjuvants ANALGESIC DRUGS CHAPTER 11 • I.e. NSAIDs, Antidepressants, Anticonvulsants, Corticosteroids, etc. 5 6 PAIN IS… CLASSIFICATION OF PAIN • Whatever the patient says it is • Whenever the patient says it exists it does • Unpleasant sensory and/or emotional experience • Associated with actual or potential tissue damage 7 Vascular Referred Neuropathic Phantom • vascular or perivascular tissues • Thought to account for vast majority of migraine headaches • visceral nerve fibres synapse at the spinal cord close to fibres from tissues in the body • damage to nerve fibres • Occurs in body part that has been removed Cancer Central • caused from pressure of tumours against nerves, organs, or tissues • tumours, trauma, inflammation or disease affecting CNS tissues 8 2 2023-09-25 ONSET AND DURATION OF PAIN • Acute • • Sudden Usually subsides once treated or less then 3 months • Persistent/Chronic • • • Persistent or recurring Lasts 3-6 months or longer Often difficult to treat 9 • Acute examples • • • Persistent/Chronic examples • • 10 PAIN TRANSMISSION GATE THEORY 1. WHAT IS THE GATE THEORY? • Transduction • • 2. Gate Control Theory of Pain, Animation: https://youtu.be/MrL8XdHo6Q If no impulses are transmitted to higher centers in the brain, there is no pain perception. subjective phenomenon of pain – “How it is felt” Complex behavioural, psychological, and emotional factors Modulation • • 11 Pain impulses move along pain fibres to activate pain receptors up the spinal cord to brain Perception • • 4. Nociceptors detect depth/impact of harmful stimulus. Release of pain-medicating chemicals. Transmission • • 3. the transformation of stimuli into electrochemical energy Neural activity that controls pain transmission to neurons, both in CNS and PNS descending nerve fibres release endogenous neurotransmitters to fight pain 12 3 2023-09-25 • Pain Threshold PAIN INTERPRETED TREATMENT OF PAIN IN SPECIAL SITUATIONS • Patient-controlled analgesia (PCA) • Patient comfort versus fear of drug addiction • Opioid tolerance • Use of placebos • Recognizing patients who are opioid tolerant • Breakthrough pain • Level of stimulus needed to produce the perception of pain • Measure of the physiological response of the nervous system • Pain Tolerance • Amount of Pain a patient can endure without its interfering with normal function • Varies with each individual • Subjective response • Point beyond which pain becomes unbearable 13 • Synergistic effects 14 OPIOID ANALGESICS: MECHANISM OF ACTION • Opioid analgesics act by depressing pain impulse transmission at the spinal cord level by interacting with opioid receptors MECHANISM OF ACTION CONT’D 2. Agonist-Antagonist = binds to receptor causing a weaker pain response than full agonist • Also called partial agonists or mixed agonists • i.e., Suboxone – buprenorphine with naloxone to enhance • Three classifications based on their ‘actions’ 1. Agonist = binds to a pain receptor in brain & produces analgesia (a reduction of pain sensation) • Mild agonist – I.e., codeine, hydrocodone • antagonist effect 3. Antagonist = non-analgesics that bind to pain receptors but do not reduce pain signals • Reverses the effects of these drugs on pain receptors • Also known as competitive antagonists • I.e., Naloxone More commonly used as an antitussive drug • Strong agonist – I.e., morphine, hydromorphone, fentanyl, methadone • Hydromorphone: very potent opioid analgesic • 1 mg of intravenous (IV) or intramuscular (IM) hydromorphone = 7 mg of morphine. 15 16 4 2023-09-25 OPIOID ANALGESICS: INDICATIONS OPIOID ANALGESICS: CONTRAINDICATIONS • Mainly used to alleviate moderate to severe pain • Often first line analgesic in immediate post operative setting • Often given with adjuvant analgesic drugs to assist primary drugs with • Known drug allergy • Often patient had side effect not true allergy eg. nausea • Severe asthma • Use with extreme caution in patients with the following: pain relief • Respiratory insufficiency • Elevated intracranial pressure • Morbid obesity or sleep apnea • Paralytic ileus • Pregnancy • Opioids are also used for: • Cough centre suppression - codeine • Treatment of diarrhea 17 17 18 OPIOID ANALGESICS: ADVERSE EFFECTS OPIATE TOLERANCE DEPENDENCE TO OPIATES • Common physiological result of Physical Adaption of the body to the presence of an opioid This is expected with long-term opioid treatment Psychological A pattern of compulsive drug use characterized by a continued craving for an opioid and the need to use the opioid for effect other than pain relief • GI symptoms (most common) • Nausea, vomiting, constipation, and cramps • Central nervous system (CNS) depression • • chronic opioid treatment • State of adaptation • Once tolerance occurs, larger Leads to respiratory depression = Most serious adverse effect Sedation • Urinary retention • Hypotension • Itching, rash • Pinpoint pupils indicating a possible overdose 19 18 dose of opioids is required to maintain same level of analgesia 19 20 5 2023-09-25 OPIOID ANALGESICS: OPIOID CEILING EFFECT Assess for • #1 - Respiratory dysfunction – resp depression, • Drug reaches a maximum analgesic effect. • Notify prescriber if respirations are 12/min • Analgesia does not improve, even with higher doses. • CNS changes – dizziness, drowsiness, hallucinations, LOC, pupil reaction • Allergic reaction • I&O – watch for urinary retention, constipation • Need for pain medication; reassess pain on pain scale * Tolerance and physical dependence should not be confused with psychological dependence (addiction)* Evaluate • Therapeutic response: decrease in pain • Monitor for adverse effects 21 22 OPIOID ANALGESICS: TEACH PT/FAMILY ADJUVANT THERAPY • Report any symptoms of CNS changes or respiratory changes • Avoid alcohol and other CNS depressants • Constipation is a common side effect • NSAIDs • Acetaminophen • Antidepressants • Anticonvulsants • Corticosteroids • Increase fibre intake and adequate fluid • Urinary retention • Physical dependency may result if used for extended period • Withdrawal symptoms may occur – nausea, vomiting, cramps, faintness • Goal is to wean patient off medications slowly 23 24 6 2023-09-25 NSAIDS ACETAMINOPHEN • Anti-inflammatory • Antipyretic • Analgesic • Analgesic and antipyretic effects • Little to no anti-inflammatory effect • OTC • Component of many combination products • COX inhibitors • Adverse effects – Peptic ulcer, GI bleed, acute kidney injury (AKI) • Max dose __g/24hr • Consider all OTCs that may contain acetaminophen 25 26 ACETAMINOPHEN: ACETAMINOPHEN: Mechanism of Action Contraindications • Blocks pain impulses peripherally by inhibiting prostaglandin synthesis • Lowers febrile body temperature by acting on hypothalamus • Should not be taken in the presence of following: • Drug allergy • _____ dysfunction • Possible _____ failure Indications • Mild to moderate pain • Fever • Inability to take aspirin products • Aspirin can cause bleeding, GI irritation, and Reyes syndrome in children Interactions • Dangerous interactions may occur if taken with alcohol or other drugs that are hepatotoxic. • Recommended antidote: acetylcysteine regimen with flu symptoms 27 28 28 7 2023-09-25 ACETAMINOPHEN: B is a 14 year old who presents to the emergency room with abdominal pain. Upon examination, her liver function tests are all elevated. When asking the patient more about their health history, they disclose that they took “a lot of some white pill yesterday” Assessment • Health history – discuss alcohol consumption • Assess for contraindications • Complete pain assessment • Give pain medications before pain becomes severe What medication could they have taken? What medication should be given as an antidote? Acetylcysteine Evaluation • Decrease in pain • Decreased body temperature for pts with fever 29 30 A patient who has metastasized bone cancer and has been on transdermal fentanyl patches for pain management for 3 months has been hospitalized for tests and has told the nurse that the pain is becoming “unbearable.” The nurse is reluctant to administer the ordered pain medication because the nurse does not want the patient to become addicted to the medication. The nurse’s actions reflect which of the following: A pt is able to go home after their appendectomy and has been given a prescription for hydromorphone to take at home for the pain. The prescription will last them 7 days and after the doctor recommends that they supplement with OTC analgesic medications A. Appropriate concern for the patient’s best welfare B. Appropriate caution for a patient who is already on a long-term opioid C. An uncaring attitude toward the patient D. Failure to manage the patient’s pain properly 31 What OTC’s would you suggest? What will you include in your patient teaching about these pain medications? 32 8 2023-09-25 ANESTHETICS • Drugs that depress the CNS • Consciousness • Loss of responsiveness • Muscle relaxation • Pain relief GENERAL AND LOCAL ANESTHETICS Two Types: CHAPTER 12 1. General anesthesia – produce unconsciousness and muscle relaxation 2. Local anesthesia – reduce pain sensation in the specific tissue area • i.e., Freezing a wound to suture 33 34 1. GENERAL ANESTHESIA GENERAL ANESTHESIA • Drugs that induce a state in which the CNS is altered to produce varying degrees of: • Pain relief • Depression of consciousness • Skeletal muscle relaxation • Reflex reduction • Overall effects: • Orderly and systematic reduction of sensory and motor CNS functions Mechanism of Action • Indications • Overton-Meyer theory • Produce unconsciousness (surgery, • Lipid-soluble anesthetic drugs are stronger because they can more easily cross the blood- procedures, longer sedation) • Relaxation of skeletal muscles and brain barrier visceral smooth muscle relaxation • potency varies directly with lipid solubility. • Rapid onset; quickly metabolized Routes of administration • Inhaled • Injected How does anesthesia work? *video to watch independently • Progressive depression of cerebral and spinal cord functions 35 36 9 2023-09-25 GENERAL ANESTHESIA • Assessment • • • • • • TOXICITY AND MANAGEMENT OF OVERDOSE • Contraindications • In large doses, anesthetics are potentially life threatening. • Cardiac and respiratory arrest are ultimate causes of death in cases • Drug allergy Past history, surgeries, response to anesthesia Allergies and medications Alcohol or illicit drug use of overdose. • Adverse effects Vital signs ABC’s Oxygen saturation • After procedure • Reorient pt to surroundings • Monitor vitals, cardiovascular status, respiratory depression • Administered in a controlled environment • Vary according to dosage and drug used • Can affect heart, peripheral Interactions circulation, liver, kidneys, and respiratory tract • Antihypertensives: increased hypotensive effects • β-Blockers: increased myocardial depression • Pulmonary aspiration • Malignant hyperthermia 37 38 ADJUNCT TO ANESTHESIA: NEUROMUSCULAR BLOCKING DRUGS (NMBD) GENERAL ANESTHESIA - EXAMPLES • Nitrous oxide – inhaled “laughing gas” • Ketamine • • • • Can be used for procedural sedation Rapid onset given IV Also binds to opioid receptors Can cause hallucinations (dissociative) • Propofol • Prevent nerve transmission in skeletal and smooth muscle, resulting in paralysis • Used with anaesthetics during surgery • Artificial mechanical ventilation is required. We Finally Know How Anesthesia Works https://youtu.be/ZSsYj QeK0qg?si=PanyztatPMc91Zk • These drugs paralyze respiratory and skeletal muscles. • • • • Induction and maintenance of sedation • No analgesic properties • Vasoactive - Decreases BP and cardiac output • Main uses: • facilitating controlled ventilation during surgical procedures • To reduce muscle contraction in an area that needs surgery • Limit muscle involvement when undergoing targeted temperature therapy protocol (shivering) • Dexmedetomidine (Precedex) • Sedation, decreased anxiety, and analgesia without resp depression 39 Patient cannot breathe on his or her own. Do not cause sedation or pain relief. Patient may be paralyzed yet conscious. • *MUST give after sedation 40 10 2023-09-25 ANOTHER TYPE OF ANESTHESIA: PROCEDURAL SEDATION 2. LOCAL ANESTHESIA • Does not cause complete loss of consciousness • Combination of an IV benzodiazepine (e.g., midazolam) or propofol and an • “Regional” anaesthetics • No paralysis of respiratory opiate analgesic (e.g., fentanyl or morphine) • Anxiety and sensitivity to pain are reduced, and the patient cannot recall the Topical • Skin or mucous membrane Parenteral • IV or into CNS (various spinal techniques) function procedure (amnesia) • No loss of consciousness • Elimination of pain sensation • Preserves the patient’s ability to maintain own airway and to respond to verbal commands Central • Spinal or intraspinal (epidural/intrathecal) Peripheral • Nerve block, topical, infiltration in specific tissues • Used for diagnostic procedures and minor surgical procedures • Rapid recovery time and safer than general anaesthesia 41 42 LOCAL ANESTHETICS ANAESTHETIC Mechanism of Action • Interferes with nerve transmission in specific area Indications • Spinal – epidural during childbirth • Nerve block – surgical, dental, persistent pain • Infiltration – used for minor procedures Assessments • Sensation to area During surgery, the anaesthetist notes that the patient’s heart rate is gradually increasing and becoming more irregular, the patient’s blood pressure is becoming unstable, and the patient is starting to sweat profusely. What other assessment should the anaesthetist note immediately? Examples • Lidocaine • Most commonly used local anesthetic • Available as cream or EMLA patch • May have epinephrine – causes vasoconstriction • Tetracaine • Topical • Ophthalmic A. Pupillary reactions B. Respiratory effort C. Temperature D. Urinary output 44 43 44 11 2023-09-25 Your patient L is admitted for a GI bleed, the patient has started to have increased bleeding and their BP has dropped to 80/40. You call a code 99 and the team is preparing to intubate your patient, which of the following medications would you expect to be asked to grab from the medication room? Why would we need to depress our CNS? What is a recreationally used CNS depressant? Ketamine CNS DEPRESSANTS AND MUSCLE RELAXANTS Propofol CHP 13 Select all that apply a. b. c. d. Succinylcholine Nitrous oxide e. Lidocaine CNS Depressants and Stimulants 45 46 CNS DEPRESSANTS • • • • • • 1. BENZODIAZEPINES Sedatives Inhibitory effect on CNS (calms CNS) Reduce nervousness, excitability, irritability (dose dependent) Can become a hypnotic if given in large enough dosage Classified into three main groups: 1. Benzodiazepines 2. Barbiturates 3. Miscellaneous drugs • Formerly the most frequently prescribed of the sedative-hypnotics • Calming effects on the CNS • Useful in controlling agitation and anxiety • Classified as either: • • • Hypnotics • • Cause sleep Have much more potent effect on CNS than sedatives have Sedative-hypnotic Anxiolytic (medication that relieves anxiety) Can be either short acting or long acting A sedative can become a hypnotic if given in large enough doses 47 48 12 2023-09-25 BENZODIAZEPINES: BENZODIAZEPINES EXAMPLES SEDATIVE-HYPNOTIC TYPES • Long-acting • Clonazepam • Diazepam Mechanism of Action Indications • Benzodiazepines depress CNS • • • • • • activity • Affect hypothalamic, thalamic, and limbic systems of the brain • Intermediate-acting • Lorazepam • Do not suppress REM sleep as much as barbiturates do Sedation Relief of anxiety or agitation Sleep induction Treatment of acute seizure disorders Treatment of alcohol withdrawal (ETOH protocols) Short-term therapy for insomnia • Do not increase metabolism of • Short-acting • Midazolam hydrochloride – other drugs • Contraindications: normally given IV for sedation • • 49 Drug allergy Pregnancy 50 BENZODIAZEPINE: NURSING IMPLICATIONS BENZODIAZEPINES: ADVERSE EFFECTS Assessment: • Mild symptoms: • • • • • • • • • • Headache Drowsiness Cognitive impairment Lethargy Somnolence Confusion Coma Evaluation: Diminished reflexes • Increased ability to sleep at night • Fewer awakenings • Few adverse effects eg. Hangover effect Fall hazard for older adults “Hangover” effect or daytime sleepiness Antidote treatment • Teaching pt and family Treatment symptomatic and supportive • • Avoid alcohol and other CNS depressants Flumazenil as an antidote • 51 • Allergies, medications, medical history • Monitor safety especially in older adults • Bed alarms and in low position • Assist with ambulation • Keep call light within reach Toxicity or Overdose: It is a competitive antagonist 52 13 2023-09-25 NONBENZODIAZEPINE HYPNOTIC DRUGS AKA SLEEP AID 2. BARBITURATES • Zopiclone (Imovane) • Short-acting benzodiazepine- like drug • Advantage is short half-life • Short-term treatment of insomnia • zolpidem (e.g., Ambien®) • • Habit forming with many side effects; low therapeutic index (what does this mean again?) • Only a few commonly used today partly because of the safety and efficacy of benzodiazepines All barbiturates have the same sedative–hypnotic effects but differ in their potency, time to onset of action, and duration of action. Indications They are primarily indicated for the short-term (4-week) treatment of insomnia. • • Used as a sedative Anticonvulsants • Anaesthesia for surgical procedures • most common use (phenobarbital) 53 Contraindications • Include: known drug allergy, pregnancy, significant respiratory difficulties, and severe kidney or liver disease. • Must be used with caution in older adults due to the drugs’ sedative properties and increased fall risk. 54 EXAMPLE PHENOBARBITAL • most commonly prescribed barbiturate, either alone or in combination with other drugs • considered the prototypical barbiturate and is classified as a long-acting drug. • used for the prevention of generalized tonic–clonic seizures and fever-induced convulsions. 55 56 14 2023-09-25 BARBITURATES OVER-THE-COUNTER HYPNOTICS/MISCELLANEOUS TOXICITY AND OVERDOSE INTERACTIONS • Overdose frequently leads to • Additive effects • • • • • • Symptomatic and supportive Maintain adequate airway Assisted ventilation or oxygen therapy Fluids Alkalization Activated charcoal which have a CNS-depressant effect. • Alcohol, antihistamines, respiratory depression • Overdose produces CNS depression • Treatment of overdose (no antidote) • Nonprescription sleep aids often contain antihistamines (see Chapter 37), benzodiazepines, opioids, tranquilizers • Inhibited metabolism Muscle Relaxants • MAOIs prolong the effects of • group of compounds that act predominantly within the CNS to relieve pain barbiturates. associated with skeletal muscle spasms • Increased metabolism • Most muscle relaxants are known as centrally acting skeletal muscle relaxants • Reduces anticoagulant response, leading to possible clot formation because their site of action is the CNS • These compounds are similar in structure and action to other CNS depressants such as diazepam. 57 58 MULTIPLE CHOICE Kay comes to the clinic requesting a prescription for Ativan (lorazepam) to help them sleep at night. While discussing the patient’s health history and request, what information can you provide to the patient about this medication? When providing education to the patient on the use of a benzodiazepine medication, the nurse will include which information? A. 59 These medications have little effect on the normal sleep cycle. B. Using this medication may cause drowsiness the next day. C. It is safe to drive while taking this medication. D. These drugs are safe to use with alcohol. Kay is given a prescription for Ativan and presents to the ER the following week stating that she can’t sleep so she took a bunch of her medications. She is drowsy and can’t provide much information. What are your nursing priorities? 60 15 2023-09-25 CENTRAL NERVOUS SYSTEM STIMULANTS • Drugs that stimulate a specific area of the brain or spinal cord • Neurons contain receptors for excitatory neurotransmitters CHAPTER 14 • including dopamine (dopaminergic drugs), norepinephrine (adrenergic drugs), and serotonin (serotonergic drugs). CENTRAL NERVOUS SYSTEM STIMULANTS AND RELATED DRUGS 61 • Sympathomimetic drugs 62 Mechanism of Action CLASSIFICATION • • Classified according to: • Site of therapeutic action in the central nervous system (CNS) Drug Effects • Major therapeutic uses: • • • • • 63 Amphetamines • Stimulate areas of the brain associated with mental alertness • CNS effects • Mood elevation or euphoria • Increased mental alertness and capacity for work • Decreased fatigue and drowsiness • Prolonged wakefulness • Respiratory effects • Relaxation of bronchial smooth muscle • Increased respiration • Dilation of pulmonary arteries anti–attention-deficit/hyperactivity disorder (for ADHD) Anti-narcoleptic (for narcolepsy) Anorexiant (for obesity) Antimigraine (for migraines) Analeptic drugs (for CNS stimulation) 64 16 2023-09-25 EXAMPLES AMPHETAMINES OR AMPHETAMINE SALTS (MAS) COMMON ADVERSE EFFECTS • Lisdexamfetamine (Vyvanse) • dextroamphetamine saccharate • amphetamine sulphate • amphetamine aspartate (Adderall®): one of the most commonly prescribed • Wide range; dose related • Tend to “speed up” body systems • Think increased metabolism • Fight or flight response drugs for ADHD • Common adverse effects include: • dextroamphetamine sulphate (Dexedrine®) • Palpitations, tachycardia, hypertension, angina, anxiety, insomnia, headache, tremor, nausea, vomiting, diarrhea, dry mouth, increased metabolic rate, others 65 *Don’t need to memorize 66 EXAMPLE ANALEPTICS EXAMPLE METHYLPHENIDATE HYDROCHLORIDE (RITALIN®) • Caffeine • Found in: • First prescription drug indicated for • Over-the-counter drugs • Combination prescription drugs: Fiorinal-C 1/2® For migraines • Foods and beverages • Use with caution in patients with a history of: • Peptic ulcer • Recent myocardial infarction • Dysrhythmias Available in oral form ADHD • Also used for narcolepsy • Extended-release dosage forms: • Ritalin SR® • Concerta® • Biphentin® 67 68 17 2023-09-25 NURSING IMPLICATIONS ADVERSE EFFECTS • Assess for • Vagal • • • • • Stimulation of gastric secretions, diarrhea, and reflex tachycardia • Vasomotor • Flushing, sweating • Respiratory • • Elevated respiratory rate • Muscular tension and tremors • 69 Potential interactions, including with herbal therapies Conditions such as abnormal cardiac rhythms, seizures, palpitations, liver problems For children, baseline height and weight Monitor for therapeutic responses. • • • • • Musculoskeletal Potential contraindications ADHD: decreased hyperactivity, increased attention span and concentration Anorexiant: appetite control and weight loss Narcolepsy: decrease in sleepiness Serotonin agonist: decrease in frequency, duration, and severity of migraines Monitor for adverse effects. 70 A patient is prescribed an anorexiant. Which statement will the nurse include in patient teaching? 71 A. “Take the medication with your evening meal.” B. “You will need to take this drug for at least 2 years.” C. “If you develop a dry mouth, stop taking the drug immediately.” D. “Avoid caffeine.” PSYCHOTHERAPEUTIC DRUGS CHP 17 72 18 2023-09-25 PSYCHOTHERAPEUTIC DRUGS TYPES OF PSYCHOTHERAPEUTIC DRUGS • Used in the treatment of emotional and mental disorders 1. Anxiolytic drugs • Anxiety • An unpleasant state of mind characterized by a sense of dread and fear • • Changes in mood from mania to depression Some patients may have episodes of both (bipolar) • Primarily benzodiazepines • Affective disorders (Mood disorders) 2. Antidepressant drugs 3. Mood-stabilizing drugs • Psychotic disorders • Severe emotional disorder that impairs the mental function of the affected individual to the point that the individual cannot participate in activities of daily living 4. Antipsychotic drugs • Schizophrenia 73 74 FIRST GENERATION A) TRICYCLIC ANTIDEPRESSANTS - TCAS 2. ANTIDEPRESSANTS TYPES Mechanism of Action • First Generation A. Tricyclics B. MAOIs C. Tetracyclics • Block reuptake of neurotransmitters serotonin and norepinephrine, causing accumulation at the nerve endings • Second-generation antidepressants D. Selective serotonin reuptake Adverse Effects inhibitors (SSRIs) • Largely replaced by SSRIs • Example: E. Serotonin-norepinephrine reuptake inhibitors (SNRIs) F. Miscellaneous 75 Indications: • Neuropathic pain • Insomnia • OCDs • Amitriptyline (Elavil) • Sedation • Impotence • Orthostatic hypotension 76 19 2023-09-25 B) MONOAMINE OXIDASE INHIBITORS (MAOIS) TRICYCLIC ANTIDEPRESSANTS: OVERDOSE • Lethal; 70 to 80% die before reaching the hospital. • CNS and cardiovascular systems are mainly affected. • Death results from seizures or dysrhythmias. • No specific antidote • Effective, but now rarely used for depression due to several dietary restrictions, side effects, and safety concerns Disadvantage • Ingestion of foods or drinks with tyramine leads to hypertensive crisis, • Decrease drug absorption with activated charcoal. which may lead to cerebral hemorrhage, stroke, coma, or death • Patients must avoid foods that contain tyramine! 77 77 78 SECOND-GENERATION ANTIDEPRESSANTS • • Mechanism of Action: Indications Adverse effects C) SSRIs • Depression primarily • Bipolar disorder (BPD), obesity, • Insomnia • Weight gain • • 79 Inhibit serotonin reuptake to increase serotonin in the synaptic cleft D) SNRIs • • SECOND-GENERATION ANTIDEPRESSANTS eating disorders, OCD, PTSD, panic attacks Inhibit both serotonin and norepinephrine The full therapeutic effect may take several weeks 80 20 2023-09-25 SECOND-GENERATION ANTIDEPRESSANTS SECOND-GENERATION ANTIDEPRESSANTS Assessments • Monitor to suicidal ideation especially prior to medications have therapeutic effect • • • • Mental status exam • Bupropion (Wellbutrin®) – also used as an aid in smoking cessation • SSRIs Teaching • 4-6 week time frame for effectiveness • Educate on food and drug interactions • fluoxetine (Prozac®) • sertraline (Zoloft®) • paroxetine (Paxil®) • citalopram (Celexa®) • escitalopram oxalate (Cipralex®) especially MAOIs with food • Avoid abrupt withdrawal Assess sleeping habits Nutritional intake Should not be taken with herbal medication St John’s Wart • Monitor for orthostatic hypotension 82 81 82 3. MOOD STABILIZERS 4. ANTIPSYCHOTICS • These drugs can help reduce mood swings and prevent manic and depressive • Drugs used to treat serious mental illness (i.e., schizophrenia) • Not to cure psychoses but to control symptoms of illness episodes. • Work by decreasing abnormal activity in the brain, on GABA neurotransmitters • Can take up to several weeks to reach their full effect • Mechanism of Action Examples: • • Lithium (severe toxicity effects = Narrow therapeutic range) • Carbamazepine (Carbatrol, Epitol, Equetro, Tegretol) • Divalproex sodium (Depakote) • Lamotrigine (Lamictal) • Valproic acid (Depakene) 83 • • Block dopamine receptors in the brain areas associated with emotion, cognitive function, motor function Dopamine levels in the CNS are decreased. Result: tranquilizing effect in psychotic patients • Atypical antipsychotics • • Block specific dopamine receptors Block specific serotonin receptors – this is responsible for improved efficacy 84 21 2023-09-25 ANTIPSYCHOTICS ANTIPSYCHOTICS - EXAMPLES Indications • Psychotic illness • Anxiety and mood • Conventional • Phenothiazines • Phenylbutylpiperidines • • • Chlorpromazine Prochlorperazine – also used as an antiemetic disorder • Antiemetics Haloperidol Adverse effects • Atypical antipsychotics - Tend to have less severe adverse effects • • • • • CNS effects Clozapine Olanzapine Quetiapine (Seroquel) Risperidone • Drowsiness • Tardive dyskinesia • Extrapyramidal symptoms • 85 Involuntary muscle symptoms 86 CASE STUDY ANTIPSYCHOTICS – NURSING IMPLICATIONS Teaching • Pts to wear sunscreen because of photosensitivity • Avoid antacids within 1 hour of dose • Avoid alcohol and other CNS depressants The patient was admitted to the hospital for observation after taking a couple “depression pills at a time because they weren’t working. Which information will the nurse include in patient teaching about SSRIs? Assessment and Evaluation • Monitor alertness, cognition, daily living activities A. It usually takes 4 to 6 weeks for the patient to experience benefits from the medication. • Improved mood and affect • Decreased hallucinations • Alleviation of psychotic symptoms and B. The patient must avoid foods that contain tyramine. episodes C. If the patient develops an upset stomach when taking this medication, it should be discontinued. D. The patient should take the medication at bedtime to enhance sleep. 87 88 88 22 2023-09-25 CASE STUDY SUMMARY Several months later, the patient returns to the health care provider’s office for followup regarding use of the SSRI. The patient tells the nurse that he is feeling better, stopped taking the SSRI the previous day, and does not plan to taking the medication again. When talking with the patient, which knowledge should guide the nurse’s response? 89 A. Drug dependency will develop, so it is appropriate to stop therapy after a few months. B. To avoid serotonin syndrome, drug therapy must be stopped as soon as the patient feels better. C. The patient is the best person to determine when the drug therapy should end. D. A 1- to 2-month taper period is indicated to prevent adverse effects of abrupt drug discontinuation. • Analgesics • Anesthesia • CNS depressants • CNS stimulants • Psychotherapeutics Concept lab Study note for homework check Discussion board #2 opens after class 89 90 23