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1. PRSENTATION ON
“ DRUGS USED IN NEUROLOGICAL
DISORDER”
ADVISOR:
DR. ( MRS) DAISY THOMAS
ASSISTANT PROFESSOR
PRESENTER:
MR.RAKESH KUMAR
M.Sc NURSING, 2nd year)

2. INTRODUCTION The features of the human nervous system, including the
complexities of the human brain, sometimes make it difficult to
predict the exact reaction of a particular patient to a given
drug. When a drug is used to affect the nervous system, the
occurrence of many systemic effects is always a possibility
because the nervous system affects the entire body. The
below content address the individual classes of drugs used to
treat disorders of the nervous system, including their adverse
effects. An understanding of the actions of specific drugs
makes it easier to anticipate what therapeutic and adverse
effects might occur. In addition, nurses should consider all of
the learned, cultural, and emotional aspects of the patient’s
situation in an attempt to provide optimal therapeutic benefit
and minimal adverse effects.

3. Drugs
Any chemical that affects the processes of
living organism.
Pharmacology
The study or science of drugs

4. Pharmacologic Principles
1) Pharmaceutics
2) Pharmacokinetics
3) Pharmacodynamics
4) Pharmacotherapeutics
5) Pharmacognosy

5. CLASSIFICATIONOF NEUROLOGICAL
DRUGS
1. Analgesics and antagonists---
2. Anesthetics
3. Anti-anxiety sedative-hypnotics & Tranquilizers
4. Anti-seizure / anti-convulsants-----
5. Cholinergics & Anticholinergics
6. CNS stimulators----
7. Osmotic Diuretics---
8. Antimyasthenic Medications
9. Multiple Sclerosis Medications
10. Antiparkinsonian Medications

6. Opioids Analgesics
(Narcotics/ Morphine like
Analgesics )
Non Opioids
Analgesics (NSAIDs/ Non
Narcotic , Aspirin like
analgesics)
CLASSIFICATION
1. ANALGESICS AND ANTAGONISTS

7. Algesia (pain) is an ill-defined, unpleasant bodily
sensation, usually evoked by an external or internal noxious
stimulus.
Analgesic A drug that selectively relieves pain
by acting in the CNS or on peripheral pain
mechanisms, without significantly altering consciousness.

8. OPIOID ANALGESICS
DESCRIPTION:
Opioid analgesics suppress pain impulses but can suppress
respiration and coughing by acting on the respiratory and
cough center in the medulla of the brainstem.
They can produce euphoria and sedation and can cause
physical dependence.
Used for relief of mild, moderate, or severe pain

9. MEDICATIONS
▪ Acetaminophen/ hydrocodone
▪ Buprenorphine
▪ Butorphanol tartrate
▪ Codeine
▪ Fentanyl
▪ Hydrocodone
▪ Hydromorphone
▪ Levorphanol
▪ Meperidine
▪ Methadone
▪ Morphine
▪ Nalbuphine
▪ Oxycodone
▪ Oxycodone; acetaminophen
▪ Oxycodone; aspirin
▪ Oxymorphone 10
▪ Pentazocine
▪ Remifentanil
▪ Sufentanil
▪ Tramadol

10. INDICATION MECHANISM OF ACTION
 Pain relief
 Acute pulmonary edema
 Pre-surgical medication
 Intraoperative adjunct medication
 A primary component of anesthetic
drug regimens when used in high
doses
 Opioids are most commonly used in
cardiovascular surgery and other types
of high-risk surgery where a primary
goal is to minimize cardiovascular
depression;
Opioids act both presynaptically and
postsynaptically to produce an analgesic
effect. Presynaptically, opioids block calcium
channels on nociceptive afferent nerves to
inhibit the release of neurotransmitters
such as substance P and glutamate, which
contribute to nociception.
Postsynaptically, Opioids open potassium
channels, which hyperpolarize cell
membranes, increasing the required action
potential to generate nociceptive
transmission

11. MEDICATION AND DESCRIPTION SIDE AND ADVERSE EFFECTS INTERVENTIONS
1. Codeine:
 Codeine also is an effective cough
suppresantat low doses.
It can cause constipation.
2. Hydromorphone:
 Hydromorphone can decrease
respirations.
3. Meperidine:
May be used for acute pain and as a
preoperative medication.
Contraindicated in clients with head injuries
and increased ICP, respiratory disorders,
hypotension, shock, and severe hepatic and
renal disease and in clients taking monoamine
oxidase inhibitors.
Should not be taken with alcohol or a sedative-
hypnotic because it may increase the CNS
depression.
Should be used cautiously in children and
adults with a seizure disorder or a history of
seizures because it decreases the seizure
threshold
Respiratory depression
Hypotension and dizziness
Tachycardia
Drowsiness and confusion
Constipation
Urinary retention
Nausea and vomiting
Seizures
Tremors
Monitor vital signs.
Monitor for respiratory
depression and hypotension.
Have naloxone available for
overdose.
Monitor for urinary retention.
Monitor bowel sounds and for
constipation.
To administer meperidine
intravenously, dilute in at least
5 mL of sterile water or normal
saline (per agency procedure)
for injection and administer
the dose over 4 to 5 minutes.

12. MEDICATION AND DESCRIPTION SIDE AND ADVERSE EFFECTS INTERVENTIONS
Morphine:
Used for acute pain caused by
myocardial infarction or cancer, for
dyspnea caused by pulmonary
edema, for surgery, and as a
preoperative medication.
Is contraindicated in clients with
severe respiratory disorders; head
injuries; increased ICP; severe
renal, hepatic, or pulmonary
disease; or seizure activity.
Morphine is used with caution in
clients with blood loss or shock.
Respiratory depression
Orthostatic hypotension
Urinary retention
Nausea and vomiting
Constipation
Sedation, confusion,
and hallucinations
Reduction in pupillary
size
Miosis
 Have naloxone available for overdose.
 Assess vital signs and level of consciousness.
 Compare rate and depth of respirations to baseline.
 Withhold the medication if the respiratory rate is
less than 12 breaths/minute; respirations of less
than 10 breaths/minute can indicate respiratory
distress.
 Monitor urinary output, which should be at least 30
mL / hour.
 Monitor bowel sounds for decreased peristalsis
because constipatiMon can occur.
 Monitor for pupil changes because pinpoint pupils
can indicate morphine overdose.
 Avoid alcohol or CNS depressants because they can
cause respiratory depression.
 Instruct the client to report dizziness or difficulty
breathing.
 If taking sustained-release morphine, the client may
need short-acting opioid doses for breakthrough
pain.
 To administer morphine intravenously, dilute in at
least 5 mL of sterile water (per agency procedure)
for injection and administer slowly over 4 to 5
minutes.
 Explain to the client and family about
administration and the side and adverse effect.

13. RESPIRATORY
DEPRESSION IS THE
PRIORITY CONCERN WITH
MORPHINE.
ALERT

14. MEDICATION AND DESCRIPTION INTERVENTIONS
OXYCODONE WITH
ACETYLSALICYLIC ACID
Oxycodone with acetylsalicylic acid should
not be taken by a client allergic to
acetylsalicylic acid.
Can cause gastric irritation and should be
taken with food or plenty of liquids
NALBUPHINEis preferable for
treating the pain of a myocardial infarction
because it reduces the oxygen needs of the
heart without reducing blood pressure.
Methadone
Dilute doses of oral concentrate with at
least 90 mL of water.
Dilute dispersible tablets in at least120 mL
of water, orange juice, or acidic fruit
beverage.
Methadone is used as a replacement
medication for opiate dependence and to
facilitate withdrawal.
Hydrocodone/ homatropine
frequently is used for cough suppression.
Monitor vital signs.
Assess the client thoroughly before administering pain medication.
Initiate nursing measures such as massage, distraction, deep breathing and relaxation
exercises, the application of heat or cold as prescribed, and providing care and
comfort along with administering the opioid analgesic.
Administer medications 30 to 60 minutes before painful activities.
Monitor respiratory rate and, if the rate is less than 12 breaths/minute in an adult,
withhold the medication unless ventilatory support is being provided or the client has
terminal disease (as prescribed).
Monitor pulse and, if bradycardia develops, withhold the dose and notify the HCP.
Monitor blood pressure for hypotension.
Auscultate breath sounds because opioid analgesics suppress the cough reflex.
Encourage activities such as turning, deep breathing, and incentive spirometry to
prevent atelectasis and pneumonia.
Monitor level of consciousness.
Initiate safety precautions such as a night light and supervised ambulation.
Monitor intake and output.
Assess for urinary retention.
Instruct the client to take oral doses with milk or a snack to reduce gastric irritation.
Instruct the client to avoid alcohol.
Instruct the client to avoid activities that require alertness.

15. NON OPIOIDANALGESICS
(Nonsteroidal antiinflammatory drugs (NSAIDs)
DESCRIPTION:
 Inhibit the synthesis of prostaglandins.
 Act as an analgesic and an anticoagulant
 Relieve inflammation and pain and to treat rheumatoid arthritis, bursitis, tendinitis,
osteoarthritis, and acute gout.
NSAIDs are contraindicated in clients with hypersensitivity or liver or renal disease.
Clients taking anticoagulants should not take acetylsalicylic acid or NSAIDs.
Acetylsalicylic acid and an NSAID should not be taken together because aspirin
decreases the blood level and effectiveness of the NSAID and can increase the risk of
bleeding.
 Increase the effects of warfarin, sulfonamides, cephalosporins, and phenytoin.
Hypoglycemia can result if ibuprofen is taken with insulin.
 High risk of toxicity

16. NON OPIODS ANALGESICS MEDICATIONS
A. Acetaminophen
▪ Acetaminophen
B. Aspirin
▪ Aspirin (acetylsalicylic acid; ASA)
▪ Aspirin (acetylsalicylic acid), buffered
C. Nonsteroidal Antiinflammatory Drugs
▪ Ibuprofen
▪ Naproxen
D. Cyclooxygenase-2 (COX-2) Inhibitor
▪ Celecoxib

17. NON OPIODS ANALGESICS MEDICATIONS
E. Other Nonsteroidal Antiinflammatory
Drugs
▪ Diclofenac
▪ Diflunisal
▪ Etodolac
▪ Indomethacin
▪ Ketoprofen
▪ Ketorolac
▪ Meclofenamate
▪ Mefenamic acid
▪ Meloxicam
▪ Piroxicam
▪ Sulindac
▪ Tolmetin

18. SIDE AND ADVERSE EFFECTS INTERVENTIONS
Acetylsalicylic acid
▪ Allergic reactions (anaphylaxis, laryngeal edema)
▪ Bleeding (anemia, hemolysis, increased bleeding
time)
▪ Dizziness, Drowsiness
▪ Flushing
▪ Gastrointestinal symptoms (distress, heartburn,
nausea, vomiting)
▪ Headaches, Decreased renal function
▪ Tinnitus, Visual changes
Nonsteroidal Antiinflammatory
Drugs
▪ Dysrhythmias, Blood dyscrasias
▪ Cardiovascular thrombotic events
▪ Dizziness, Gastric irritation
▪ Hepatotoxicity, Hypotension, Pruritus
▪ Decreased renal function
▪ Sodium and water retention
▪ Tinnitus
Assess client for allergies.
Obtain a medication history on the client.
Assess for history of gastric upset or bleeding or liver or renal
disease.
Assess the client for gastrointestinal upset during medication
administration.
Monitor for edema.
Monitor the serum salicylate (acetylsalicylic acid) level when the
client is taking high doses.
Monitor for signs of bleeding such as tarry stools, bleeding gums,
petechiae, ecchymosis, and purpura.
Instruct the client to take the medication with milk, or food.
An enteric-coated or buffered form of acetylsalicylic acid can be
taken to decrease gastric distress.
Instruct the client that enteric-coated tablets cannot be crushed or
broken.
Clients taking acetylsalicylic acid should sit upright for 20 to 30
minutes after taking the dose.
Advise the client to inform other health care professionals if they are
taking high doses of acetylsalicylic acid.
Note that acetylsalicylic acid should be discontinued 3 to 7 days
before surgery as prescribed to reduce the risk of bleeding.
Instruct the client to avoid alcoholic beverages

19. MEDICATION AND DESCRIPTION SIDE AND ADVERSE EFFECTS INTERVENTIONS
Acetaminophen:
Acetaminophen inhibits
prostaglandin synthesis.
Used to decrease pain and
fever.
Should not be taken if
liver dysfunction exists
Anorexia, nausea,
vomiting
Rash
Hypoglycemia
Oliguria
Hepatotoxicity
Monitor vital signs.
Assess client for history of liver
and renal dysfunction,
alcoholism, and malnutrition.
Monitor for hepatic damage,
which includes nausea, vomiting,
diarrhoea, and abdominal pain.
Monitor liver enzyme test
results.
Instruct the client that self-
medication should not be used
longer than 10 days for an adult
and 5 days for a child.
Note that the antidote for
acetaminophen is acetylcysteine.
Evaluate for the effectiveness of
the medication.

20. Acetaminophen is
contraindicated in
clients with
hepatic or renal
disease,
alcoholism, and/or
hypersensitivity.
ALERT
Adolescents and
children with flu
symptoms, viral
illnesses, and
varicella should not
take acetylsalicylic
acid because of the
risk of Reye’s
syndrome.

21. OPIOID ANtagonists

22. Medication of Opioid Antagonists
▪ Alvimopan
▪ Methylnaltrexone
▪ Naloxone
▪ Naltrexone
▪ Naloxegol
Intervention
 Monitor blood pressure, pulse, and
respiratory rate every 5 minutes initially,
tapering to every 15 minutes, and then
every 30 minutes until the client is stable.
 Place the client on a cardiac monitor and
monitor cardiac rhythm.
 Auscultate breath sounds.
 Have resuscitation equipment available.
 Do not leave the client unattended.
 Monitor the client closely for several hours
because when the effects of the antagonist
wear off, the client may again display signs
of opioid overdose.

23. 2. ANAESTHETICS
General anaesthetics (GAs) are drugs which produce reversible loss of all sensation and
consciousness. The cardinal features of general anaesthesia are:
• Loss of all sensation, especially pain
• Sleep (unconsciousness) and amnesia
• Immobility and muscle relaxation
• Abolition of somatic and autonomic reflexes.

24. Techniques Of Inhalation Of Anaesthetics
1) Open drop Method
2) Through anaesthetic machines
 Open system
 Closed System
 Semi closed System

25. A) For the Patient:
 Pleasant, non irritating, should not cause nausea or vomiting.
 Induction and recovery should be fast with no after effects.
B) For the Surgeon:
 It should provide adequate analgesia, immobility and muscle relaxation.
 It should be non inflammable and non explosive.
PROPERTIES OF AN IDEAL ANAESTHETIC:

26. C). For the anaesthetist Its administration should be easy,
controllable and versatile.
• Margin of safety should be wide—no fall in BP.
• Heart, liver and other organs should not be affected.
• It should be potent so that low concentrations are needed and oxygenation of
the patient does not suffer.
• Rapid adjustments in depth of anaesthesia should be possible.
• It should be cheap, stable and easily stored.
• It should not react with rubber tubing or soda lime.

27. CLASSIFICATION
Inhalational Intravenous
 Gas Volatile liquids
 Nitrous oxide Ether
 Halothane
 Isoflurane
 Desflurane
 Sevoflurane
Fast acting drugs Slower acting
drugs
 Thiopentone sodium
 Methohexitone sod
 Propofol
 Etomidate
Benzodiazepines
 Diazepam
 Midazolam
Dissociative anaesthesia
 Ketamine
Opioid analgesia
 Fentanyl

28. Complications Of
General
anaesthesia

29. During anaesthesia After anaesthesia
1. Respiratory depression and hypercarbia.
2. Salivation, respiratory secretions. This is less
problematic now as non irritant anaesthetics are
mostly used.
3. Cardiac arrhythmias, asystole.
4. Fall in BP.
5. Aspiration of gastric contents: acid pneumonitis.
6. Laryngospasm and asphyxia.
7. Awareness: dreadful perception and recall of
events during surgery. This may occur due to use
of light anaesthesia + analgesics and muscle
relaxants.
8. Delirium, convulsions and other excitatory
effects are generally seen with i.v. anaesthetics;
especially if phenothiazines or hyoscine have
been given in premedication. These are
suppressed by opioids.
9. Fire and explosion.
1. Nausea and vomiting.
2. Persisting sedation: impaired psychomotor
function.
3. Pneumonia, atelectasis.
4. Organ toxicities: liver, kidney damage.
5. Nerve palsies—due to faulty positioning.
6. Emergence delirium.
7. Cognitive defects

30. Drug Interactions
1. Patients on antihypertensives given general anaesthetics—BP may fall
markedly.
2. Neuroleptics, opioids, clonidine and monoamine oxidase inhibitors
potentiate anaesthetics.
3. Halothane sensitizes the heart to Adr.
4. If a patient on corticosteroids is to be anaesthetized, give 100 mg
hydrocortisone intra-operatively because anaesthesia is a stressful state—
can precipitate adrenal insufficiency and cardiovascular collapse.
5. Insulin need of a diabetic is increased during GA: switch over to plain insulin
even if the patient is on oral hypoglycaemic.

31. 3. ANTIANXIETY, SEDATION - HYPNOTICS &
TRANSQUILIZER
Antianxiety Drugs
Description:
These are an ill-defined group of drugs, mostly mild CNS depressants, which are aimed to control the
symptoms of anxiety, produce a restful state of mind without interfering with normal mental or physical
functions. The anxiolytic-sedative drugs differ markedly from antipsychotics, and more closely resemble
sedative-hypnotics. They:
1. Have no therapeutic effect to control thought disorder of schizophrenia.
2. Do not produce extrapyramidal side effects.
3. Have anticonvulsant property.
4. Produce physical dependence and carry abuse liability.
5. Do not selectively block conditioned avoidance response in animals.

32. CLASSIFICATION
Benzodiazepines Azapirones Sedative/
antihistaminic
Β Beta blocker
Diazepam
Chlordiazepoxide
Oxazepam
Lorazepam,
Alprazolam
Buspirone,
Gepirone,
Ispapirone
Hydroxyzine Propranolol

33. MECHANISM OF ACTION
Antidepressants reduce anxiety by increasing the concentration of chemicals
(neurotransmitters) that the brain uses to communicate. These neurotransmitters
include serotonin, norepinephrine, and dopamine.
Buspirone may reduce anxiety by stimulating serotonin and dopamine receptors on
nerves, thereby altering the chemical messages that nerves receive.
Benzodiazepines reduce symptoms of anxiety by increasing the action of a brain
chemical called gamma-aminobutyric acid (GABA). GABA is a chemical that nerve cells
use to communicate with each other and it reduces brain activity. It is believed that
excessive activity in the brain may lead to anxiety or other psychiatric disorders.
Pregabalin is an anticonvulsant. Like benzodiazepines, Pregabalin also increases the
action of GABA, and this may be its main mechanism for reducing anxiety.

34. 1) Benzodiazepines
Description:
• have little effect on other body systems
• have lower dependence producing liability
than barbiturates and other sedatives;
withdrawal syndrome is milder and delayed
due to their long half lives
• are relatively safe even in gross overdosage,
They are presently one of the widely used
class of drugs. Potent BZDs like lorazepam and
clonazepam injected i.m. have adjuvant role in
the management of acutely psychotic and
manic patients.
Side effects:
That occur in their use to relieve anxiety are—
 Sedation
 Light-headedness
 Psychomotor and cognitive impairment,
 Confusional state (especially in the elderly),
 Increased appetite
 Weight gain,
 Alterations in sexual function.
 Rashes are uncommon.
 Some women fail to ovulate while on
regular use of bzds.
 The major constraint in their long-term use
for anxiety disorders is their potential to
impair mental functions and to produce
dependence.

35. Chlordiazepoxide Diazepam Oxazepam
It was the first BZD to be used
clinically.
Oral absorption is slow.
A smooth long lasting effect is
produced.
It is preferred in chronic anxiety
states.
Chlordiazepoxide is often
combined with other drugs in
psychosomatic disorders, and
has been the commonest BZD
used to cover alcohol
withdrawal.
Daily dose: 25–100 mg
Example: LIBRIUM 10, 25 mg tabs;
EQUILIBRIUM 10 mg tab.
It is quickly absorbed
Produces a brief initial phase of
strong action followed by
prolonged milder effect due to a
two phase plasma concentration
decay curve.
It is preferred in acute panic
states and anxiety associated
with organic disease.
Daily dose: 5–30 mg
Example: VALIUM, PLACIDOX 2, 5,
10 mg tabs; CALMPOSE 5, 10 mg
tab, 2 mg/5 ml Syr.
 It is slowly absorbed;
 Its penetration in brain is also slow.
 It is metabolized only by glucuronide
conjugation, therefore no active
metabolite is produced.
 Duration of action is relatively
shorter making it preferable for the
elderly and in those with liver
disease. It has been used mainly in
short lasting anxiety states.
Daily dose: 30–60 mg in 2–3 divided
portions
Example: SEREPAX 15, 30 mg tab.

36. Lorazepam Alprazolam
Has slow oral absorption.
Being less lipid-soluble than diazepam, its rate
of entry in brain is slower.
No active metabolite is produced, since it is
directly conjugated with glucuronic acid, and
is suitable for older patients.
However, it is quite sedative and capable of
producing marked amnesia when injected i.v.
Injection site complications are minor.
Therefore, it is the only BZD recommended
for i.m. use.
It has been preferred for short lasting anxiety
states, panic, OCD and tension syndromes, as
well as for psychosomatic diseases and for i.v.
use in status epilepticus.
Daily dose: 1–6 mg; LARPOSE, ATIVAN 1, 2 mg
tab.
Example: CALMESE 1, 2 mg tabs, 4 mg/2 ml inj.
 A high potency anxiolytic BZD which in addition has some mood
elevating action in mild depression.
 It is particularly useful in anxiety associated with depression.
 Good response has been obtained in panic disorders with severe
anxiety and autonomic symptoms.
 Alprazolam is also used as hypnotic. When administered daily as
anxiolytic,
 Some patients experience anxiety in between doses, which may
be obviated by employing sustained release tablet.
 Withdrawal symptoms may be more marked on discontinuation
than with other BZDs.
Dose: 0.25–1.0 mg TDS; upto 6 mg/day in panic disorder;
Example:
ALPRAX 0.25, 0.5, 1.0 mg tabs., 0.5, 1.0, 1.5 mg SR tabs;
ALZOLAM 0.25, 0.5, 1.0 mg tabs; 1.5 mg SR tab,
ALPROCONTIN 0.5, 1.0, 1.5 mg CR tabs. RESTYL 0.25, 0.5,
mg tabs, RESTYL-SR 0.5, 1.0, 1.5 mg SR tabs.

37. 2) AZAPIRONES
Buspirone:
It is the first azapirone, a
new class of antianxiety
drugs, distinctly
different from BZDs.
Description:
• Does not produce significant sedation or cognitive/functional
impairment.
• Does not interact with BZD receptor or modify GABAergic
transmission.
• Does not produce tolerance or physical dependence.
• Does not suppress BZD or barbiturate withdrawal syndrome.
• Has no muscle relaxant or anticonvulsant activity.
Buspirone relieves mild-to-moderate generalized anxiety, but is
ineffective in severe cases,
Dose: 5–15 mg OD–TDS:
Example: ANXIPAR, BUSPIN, BUSCALM 5, 10 mg tab.

38. 3) Sedative/ Antihistamine
Hydroxyzine:
 An H1 antihistaminic with sedative, antiemetic, antimuscarinic and
spasmolytic properties.
 It is claimed to have selective anxiolytic action, but the accompanying
sedation is quite marked.
 Hydroxyzine may be used in reactive anxiety or that associated with
marked autonomic symptoms.
 Due to antihistaminic and sedative property, it is
useful in pruritus and urticaria.
Daily dose : 50–200 mg;
Example: ATARAX 10, 25 mg tab, 10 mg/5 ml syr, 25 mg/2 ml inj.

39. 4) β Blockers
Propranolol and other nonselective β blockers help anxious
patients troubled by these symptoms, by cutting the vicious
cycle and provide symptomatic relief.
They do not affect the psychological symptoms such as worry,
tension and fear, but are valuable in acutely stressful situations.
They may be used for performance/situational anxiety or as
adjuvant to BZDs.
The role of β blockers in anxiety disorders is
quite limited.

40. Sedative: A drug that subdues excitement and calms the subject without inducing
sleep, though drowsiness may be produced. Sedation refers to decreased responsiveness
to any level of stimulation; is associated with some decrease in motor activity and
ideation.
Hypnotic: A drug that induces and/or maintains sleep, similar to normal arousable
sleep. This is not to be confused with ‘hypnosis’ meaning a trans-like state in which the
subject becomes passive and highly suggestible.

41. CLASSIFICATION
1. Barbiturates:
Long acting Short acting Ultra-short
acting
Phenobarbitone Butobarbitone
Pentobarbitone
Thiopentone
Methohexitone

42. Hypnotic Antianxiety Anticonvulsant
Diazepam
Flurazepam
Nitrazepam
Alprazolam
Temazepam
Triazolam
Diazepam
Chlordiazepoxide
Oxazepam
Lorazepam
Alprazolam
Diazepam
Lorazepam
Clonazepam
Clobazam
2. Benzodiazepines:
3. Newer nonbenzodiazepine hypnotics
Zopiclone
Zolpidem
Zaleplon

43. Pharmacological Actions Uses Doses
Barbiturates are general
depressants for all excitable cells,
the CNS is most sensitive where
the effect is almost global, but
certain areas are
more susceptible.
1. CNS Barbiturates produce dose-
dependent effects:
sedation →sleep
→anaesthesia
→coma.
Except for
phenobarbitone in
epilepsy and thiopentone
in anaesthesia no other
barbiturate is used now.
As hypnotic and anxiolytic
they have been
superseded by BZDs. They
are occasionally employed
as adjuvants in
psychosomatic disorders.
Phenobarbitone :
30–60 mg oral OD–TDS; 100–200 mg i.m./i.v.
GARDENAL :
30, 60 mg tab, 20 mg/5 ml syr; LUMINAL 30
mg tab;
PHENOBARBITONE SOD :
200 mg /ml inj
Barbiturates

44. 4) Antiseizure / Anti Convulsants:
Antiseizure Medications
Description:
Antiseizure medications are used to depress abnormal neuronal discharges
and prevent the spread of seizures to adjacent neurons.
These should be used with caution in clients taking anticoagulants,
acetylsalicylic acid, sulfonamides, cimetidine, and antipsychotic
medications.
Absorption is decreased with the use of antacids, calcium preparations,
and antineoplastic medications.

45. Antiseizure Medications
Medication Therapeutic Serum Range
Carbamazepine 3-14 mcg/mL (13-59 mcmol/L)
Clonazepam 20-80 ng/mL (0.02-0.08 mcg/L)
Divalproex 50-100 mcg/mL (347-693 mcmol/L)
Ethosuximide 40-100 mcg/mL (283-708 mcmol/L)
Lorazepam 50-240 ng/mL (156-746 nmol/ L)
Phenobarbital 15-40 mcg/mL (65-172 mcmol/L)
Phenytoin 10-20 mcg/mL (40-79 mcmol/L)

46. MECHANISM OF ACTION
Antiseizure drugs affect the generation and spread of epileptic
hyperexcitability.
They have actions on voltage-gated sodium, calcium and potassium ion
channels.
Also affect excitatory and inhibitory neurotransmission and
neurotransmitter release.

47. MEDICATION AND DESCRIPTION SIDE AND ADVERSE EFFECTS INTERVENTIONS
Hydantoins:
Fosphenytoin,
phenytoin:
Hydantoins are used to
treat partial and
generalized tonic-clonic
seizures.
Phenytoin is also used
to treat dysrhythmias.
Gingival hyperplasia
(reddened gums that bleed
easily)
Slurred speech
Confusion
Sedation and drowsiness
Nausea and vomiting
Blurred vision and
nystagmus
Headaches
Blood dyscrasias: Decreased
platelet count and
decreased white blood cell
count
Elevated blood glucose level
Alopecia or hirsutism
Rash or pruritus
 Tube feedings may interfere with the
absorption of the enteral form of phenytoin
and diminish the effectiveness of the
medication; therefore, feedings should be
scheduled as far as possible away from the
time of phenytoin administration.
 Monitor therapeutic serum levels to assess
for toxicity.
 Monitor for signs of toxicity.
 When administering phenytoin intravenously,
dilute in normal saline because dextrose
causes the medication to precipitate.
 When administering phenytoin intravenously,
infuse with an inline filter and no faster than
25 to 50 mg/minute; otherwise, a decrease in
blood pressure and cardiac dysrhythmias
could occur.
 Assess for ataxia (staggering gait).
 Instruct the client to consult with the HCP
before taking other medications to ensure
compatibility with anticonvulsants.

48. ALERT
Phenytoin must be given slowly to
prevent hypotension and cardiac
dysrythmias. Also, it may decrease the
effectiveness of some birth control pills
and may cause teratogenic effects, if
taken during pregnancy.

49. MEDICATION AND DESCRIPTION SIDE AND ADVERSE EFFECTS
Barbiturates: Amobarbital, mephobarbital,
phenobarbital:
 Barbiturates are used for tonic-clonic seizures and acute
episodes of seizures caused by status epilepticus.
 Barbiturates also may be used as adjuncts to anesthesia.
Benzodiazepines:
 Clonazepam, clorazepate, diazepam,lorazepam
 Benzodiazepines are used to treat absence seizures.
 Diazepam and lorazepam are used to treat status
epilepticus, anxiety, and skeletal muscle spasms.
 Clorazepate is used as adjunctive therapy for partial
seizures
 Sedation, ataxia, and dizziness during
initial treatment
 Mood changes
 Hypotension
 Respiratory depression
 Tolerance to the medication
 Sedation, drowsiness, dizziness, blurred
vision
 For intravenous injection, administer
slowly to prevent bradycardia.
 Medication tolerance and dependency
 Blood dyscrasias
 Hepatotoxicity.

50. MEDICATION AND DESCRIPTION SIDE AND ADVERSE EFFECTS
Succinimides: Ethosuximide, methsuximide
Succinimides are used to treat absence seizures.
Valproates: Valproic acid, divalproex sodium
Valproates are used to treat tonic-clonic,
partial, and myoclonic seizures.
Iminostilbenes:
 Iminostilbenes are used to treat seizure disorders
that have not responded to other anticonvulsants.
 Iminostilbenes are also used to treat trigeminal
neuralgia.
 Anorexia, nausea, vomiting
 Blood dyscrasias
 Transient nausea, vomiting, and indigestion
 Sedation, drowsiness, and dizziness
 Pancreatitis
 Blood dyscrasias: Decreased platelet count and
decreased white blood cell count
 Hepatotoxicity
 Drowsiness
 Dizziness
 Nausea and vomiting, dry mouth
 Constipation or diarrhea
 Rash
 Visual abnormalities
 Blood dycrasias, agranulocytosis
 Headache

51. Interventions For Clients On Antiseizure Medications
Initiate seizure precautions.
Monitor urinary output.
Monitor liver and renal function tests and medication blood serum levels
Monitor for signs of medication toxicity, which would include CNS
depression, ataxia, nausea, vomiting, drowsiness, dizziness, restlessness,
and visual disturbances.
If a seizure occurs, assess seizure activity, including location and duration
Protect the client from hazards in the environment during a seizure.

52. Client Education: Antiseizure Medications
 Take the prescribed medication in the prescribed dose and frequency.
 Take with food to decrease gastrointestinal irritation, but avoid milk and antacids, which impair
absorption.
 If taking liquid medication, shake well before ingesting.
 Do not discontinue the medications.
 Avoid alcohol.
 Avoid over-the-counter medications.
 Wear a MedicAlert bracelet.
 Use caution when performing activities that require alertness.
 Maintain good oral hygiene and use a soft toothbrush.
 Maintain preventive dental checkups.
 Maintain follow-up health care visits with periodic blood studies related to determining toxicity.
 Monitor serum glucose levels (diabetes mellitus).
 Urine may be a harmless pink-red or red-brown color.
 Report symptoms of sore throat, bruising, and nosebleeds, which may indicate a blood dyscrasia. Inform
the health care provider if side and adverse effects occur, such as bleeding gums, nausea, vomiting,
blurred vision, slurred speech, rash, or dizziness.

53. Description:
These are drugs which produce
actions similar to that of ACh,
either by directly interacting with
cholinergic receptors (cholinergic
agonists) or by increasing
availability of ACh at these sites
(anticholinesterases).
Dose: 10–40 mg oral, 2.5–5 mg
s.c.;
Example: UROTONIN, BETHACOL
25 mg tab
Uses:
Choline esters are rarely, if ever,
clinically used. ACh is not used because
of evanescent and nonselective action.
Methacholine was occasionally used to
terminate paroxysmal supraventricular
tachycardia but is obsolete now.
Bethanechol has been used in
postoperative/ postpartum
nonobstructive urinary retention,
neurogenic bladder to promote
urination. It can afford symptomatic
relief in congenital megacolon and
gastroesophageal reflux, but is rarely
used for these
Side effects are prominent:
Belching,
Colic
Involuntary
urination/defecation,
Flushing,
Sweating,
Hypotension,
Bronchospasm.
5) Cholinergesics and Anticholingesics
Cholinergesics drugs

54. Description:
 Anticholinergic medications block
the cholinergic receptors in the
CNS, thereby suppressing
acetylcholine activity.
 They reduce the tremors and
drooling but have a minimal effect
on the bradykinesia, rigidity, and
balance abnormalities.
 They are contraindicated in clients
with glaucoma.
 The client with chronic obstructive
lung disease can develop dry, thick
mucous secretions.
Side and adverse effects:
Blurred vision
Dryness of the nose,
mouth, throat, and
respiratory secretions
Increased pulse rate,
palpitations, and
Dysrhythmias
Constipation
Urinary retention
Restlessness, confusion,
depression, and
hallucinations
Photophobia
Interventions:
Monitor vital signs.
Assess for risk of injury.
Monitor the client for improvement in signs and
symptoms.
 Assess the client’s bowel and urinary function and
monitor for urinary retention, constipation, and
paralytic ileus.
Monitor for involuntary movements.
Encourage the client to avoid alcohol, smoking,
caffeine, and acetylsalicylic acid to decrease gastric
acidity.
Instruct the client to consult with a health care
provider (HCP) before taking any non prescription
medications.
Instruct the client to minimize dry mouth by
increasing fluid intake and using ice chips, hard
candy, or gum.
Instruct the client to prevent constipation by
increasing fluids and fiber in the diet.
Instruct the client to use sunglasses in direct
sunlight because of possible photophobia.
Instruct the client to have routine eye examinations
to assess intraocular pressure.
Anti Cholinergesics drugs

55. ALERT
If an anticholinergic medication is
discontinued abruptly, the signs and
symptoms of parkinsonism, such as rigidity,
tremors, akinesia, bradykinesia, stooped
forward posture, shuffling gait, and masked
facies, may be intensified.

56. 6) Central Nervous System Stimulants
Amphetamines: Anorexiants:
Amphetamine sulfate ▪ Benzphetamine hydrochloride
Amphetamine/dextroamphetamine ▪ Diethylpropion
Atomoxetine ▪ Orlistat
Dextroamphetamine sulfate ▪ Phendimetrazine
Dexmethylphenidate ▪ Phentermine hydrochloride
Lisdexamfetamine ▪ Phentermine/ topiramate
Methylphenidate hydrochloride

57. MEDICATION AND MOA SIDE AND ADVERSE EFFECTS INTERVENTIONS
Amphetamines and caffeine
stimulate the cerebral cortex of
the brain
Amphetamines have a high
potential for abuse.
Analeptics and caffeine act on
the brainstem and medulla to
stimulate respiration.
Anorexiants act on the cerebral
cortex and hypothalamus to
suppress appetite.
CNS stimulants are used to treat
narcolepsy and attention
deficit/hyperactivity disorders and
are used as adjunctive therapy for
exogenous obesity.
1. Irritability
2. Restlessness
3. Tremors
4. Insomnia
5. Heart palpitations
6. Tachycardia and dysrhythmias
7. Hypertension
8. Dry mouth
9. Anorexia and weight loss
10. Abdominal cramping
11. Diarrhea or constipation
12. Hepatic failure
13. Psychoses
14. Impotence
15. Dependence and tolerance
 Monitor vital signs.
 Assess mental status.
 Document the degree of inattention, impulsivity, hyperactivity, and
periods of sleepiness.
 Assess height, weight, and growth of the child.
 Monitor complete blood count and white blood cell and platelet
counts before and during therapy.
 Monitor for side and adverse effects.
 Monitor sleep patterns.
 Monitor for withdrawal symptoms such as nausea, vomiting,
weakness, and headache.
 Instruct the client to take the medication before meals.
 Instruct the client to avoid foods and beverages containing caffeine to
prevent additional stimulation.
 Instruct the client not to chew or crush long acting forms of the
medications.
 Instruct the client to read labels on over-the counter products
because they many contain caffeine.
 Instruct the client to avoid alcohol.
 Instruct the client not to discontinue the medication abruptly (can
produce extreme fatigue and depression).
 Instruct the client to take the last daily dose of the CNS stimulant at
least 6 hours before bedtime to prevent insomnia.
 Monitor for medication dependence and abuse with amphetamines.
 If a child is taking a CNS stimulant, instruct the parents to notify the
school nurse.
 Monitor for calming effects of CNS stimulants within 3 to 4 weeks on
children with attention deficit/ hyperactivity disorder.
 Monitor growth in the child on long-term therapy with
methylphenidate or other medications to treat attention-
deficit/hyperactivity disorder

58. 7) Osmotic Diuretics

59. Desciption Side and Adverse effect Intervention
Osmotic diuretics increase
osmotic pressure of the
glomerular filtrate, inhibiting
reabsorption of water and
electrolytes.
They are used for oliguria
and to prevent kidney
failure, decrease ICP, and
decrease intraocular
pressure in clients with
narrow-angle glaucoma.
Mannitol is used with
chemotherapy to induce
diuresis.
Fluid and electrolyte
imbalances
Pulmonary edema from
the rapid shifts of fluid
Nausea and vomiting
Headache
Tachycardia from the rapid
fluid loss
Hyponatremia and
dehydration
 Monitor vital signs.
 Monitor weight.
 Monitor urine output.
 Monitor electrolyte levels.
 Monitor lungs and heart sounds for signs of
pulmonary edema.
 Monitor for signs of dehydration.
 Monitor neurological status.
 Monitor for increased intraocular pressure.
 Assess for signs of decreasing ICP if
appropriate.
 Change the client’s position slowly to
prevent orthostatic hypotension.
 Monitor for crystallization in the vial of
mannitol before administering the
medication; if crystallization is noted, do not
administer the medication from that vial.

60. 8) Antimyasthenic Medications
Medications:
Ambenonium chloride
Edrophonium chloride
Neostigmine bromide
Pyridostigmine
Cyclosporine
Methotreate

61. USES SIDE AND ADVERSE EFFECTS INTERVENTIONS
Antimyasthenic medications, also
called anticholinesterase
medications, relieve muscle
weakness associated with
myasthenia gravis by blocking
acetylcholine breakdown at the
neuromuscular junction.
These are used to treat or diagnose
myasthenia gravis or to distinguish
cholinergic crisis from myasthenic
crisis.
 Neostigmine bromide,
pyridostigmine, and ambenonium
chloride are used to control
myasthenic symptoms.
Edrophonium is used to diagnose
myasthenia gravis and to distinguish
cholinergic crisis from myasthenic
crisis.
Cholinergic crisis
Abdominal cramps
Nausea, vomiting, and
diarrhea
Pupillary miosis
Hypotension and dizziness
Increased bronchial
secretions
Increased tearing and
salivation
Increased perspiration
Bronchospasm, wheezing,
and bradycardia
 Assess neuromuscular status, including reflexes,
muscle strength, and gait.
 Monitor the client for signs and symptoms of
medication overdose (cholinergic crisis) and
under dose (myasthenic crisis).
 Instruct the client to take medications on time to
maintain therapeutic blood level, thus preventing
weakness, because weakness can impair the
client’s ability to breathe and swallow.
 Instruct the client to take the medication with a
small amount of food to prevent gastrointestinal
symptoms.
 Instruct the client to eat ameal 45 to 60 minutes
after taking medications to decrease the risk for
aspiration.
 Instruct the client to wear a MedicAlert bracelet.
 Note that antimyasthenic therapy is lifelong
therapy.
 Evaluate for medication effectiveness, which is
based on the improvement of neuromuscular
symptoms or strength without cholinergic signs
and symptoms.
 When administering edrophonium, have
emergency resuscitation equipment on hand and
atropine sulfate available for cholinergic crisis.

62. Edrophonium test
 Edrophonium is injected intravenously.
 The edrophonium test can cause bronchospasm, laryngospasm, hypotension, bradycardia,
and cardiac arrest.
 Atropine sulfate is the antidote for overdose.
Diagnosis of myasthenia gravis:
 Most myasthenic clients will show a significant improvement in muscle tone within 30 to 60
seconds after injection, and the muscle improvement lasts 4 to 5 minutes.
 The edrophonium test is also used to diagnose cholinergic crisis (overdose with
anticholinesterase) or myasthenic crisis (under medication).
 In cholinergic crisis, muscle tone does not improve after the administration of
edrophonium, and muscle twitching may be noted around the eyes and face.
 An edrophonium injection temporarily worsens the condition when a client is in cholinergic
crisis (negative edrophonium test).
 An edrophonium injection temporarily improves the condition when the client is in
myasthenic crisis (positive edrophonium test).

64. 9) Multiple Sclerosis Medications
Medications commonly used to Treat Symptoms of
Multiple Sclerosis:
Bladder And Bowel Dysfunction: Psyllium, Docusate
Fatigue: Amantadine, Modafinil
Depression: Fluoxetine, Sertraline
Sexual Dysfunction: Sildenafil, Vardenafil
Neuropathic Pain: Gabapentin,carbamazepine
Mechanism of Action:
Immunomodulators (interferon-
beta and glatiramer acetate), which
shift the immune balance toward
an anti-inflammatory response, are
at the frontline of treatments for
MS. Immunomodulators have
targeted actions on the immune
system, but affect a greater number
of immunopathogenic processes
than monoclonal antibodies.

65. Medication for Multiple
Sclerosis DESCRIPTION SIDE AND ADVERSE EFFECTS
Immunomodulators
Interferons (beta-1a, 1b,
peginterferon beta-1a)
Glatiramer acetate
Fingolimod
Teriflunomide
Dimethyl fumarate
Immunosuppressant
Mitoxantrone
Monoclonal antibodies
Natalizumab
Alemtuzumab
Potassium channel blockers
Dalfampridine (used to improve
walking)
 Medication therapy is aimed at
modifying the disease, treating
acute episodes or relapses, and
treating symptoms.
 Disease-modifying medications
decrease the frequency and
severity of relapses, reduce brain
lesions, increase future functional
capability, and increase overall
quality of life.
 The 2 main groups of disease-
modifying medications are
immunomodulators and
immunosuppressants
Immunomodulators: Flu-like
reactions, hepatotoxicity,
myelosuppression, injection site
reactions,depression, and
neutralizing antibodies.
Immunosuppressants:
Myelosuppression,
cardiotoxicity, fetal harm,
reversible hair loss, injury to the
gastrointestinalmucosa, nausea
and vomiting, and menstrual
irregularities.

66. 10) Antiparkinsonian Medications
Definition:
Antiparkinson drugs are medicines that relieve the symptoms of Parkinson's disease and
other forms of parkinsonism.
Purpose:
Treat symptoms of parkinsonism,
 Other forms of the disorder may result from viral infections,
 environmental toxins,
carbon monoxide poisoning,
 Effects of treatment with antipsychotic drugs.

67. ( CAPABLE LOS ) Medications to Treat Parkinson’s Disease
▪ Carbidopa- ▪Bromocriptine
▪ Amantadine ▪ levodopa , Rasagiline
▪ Pramipexole ▪ Ropinirole
▪ Apomorphine ▪ Selegiline hydrochloride
Anticholinergics
 Orphanadrine
 Benztropine mesylate
▪ Trihexyphenidyl hydrochloride
Catechol-O-Methyltransferase (COMT) Inhibitors
▪ Carbidopa/ levodopa/entacapone Tolcapone
▪ Entacapone

68. DESCRIPTION AND MOA SIDE AND ADVERSE EFFECTS INTERVENTIONS
 Antiparkinsonian medications
restore the balance of the
neurotransmitters acetylcholine
and dopamine in the central
nervous system (CNS),
decreasing the signs and
symptoms of Parkinson’s
disease to maximize the client’s
functional abilities.
 These medications include the
dopaminergics, which
stimulate the dopamine
receptors; the anticholinergics,
which block the cholinergic
receptors; and the catechol-O-
methyltransferase inhibitors,
which inhibit the metabolism
of dopamine in the periphery.
Dyskinesia
Involuntary body
movements
Chest pain
Nausea and vomiting
Urinary retention
Constipation
Sleep disturbances,
insomnia, or periods of
sedation
Orthostatic hypotension
and dizziness Confusion
Mood changes, especially
depression
Hallucinations
Dry mouth
 Assess vital signs.
 Assess for risk of injury.
 Instruct the client to take the medication with food if
nausea or vomiting occurs.
 Assess for signs and symptoms of parkinsonism such as
rigidity, tremors, akinesia, bradykinesia, a stooped
forward posture, shuffling gait, and masked facies.
 Monitor for signs of dyskinesia.
 Instruct the client to report side and adverse effects and
symptoms of dyskinesia.
 Monitor the client for improvement in signs and
symptoms of parkinsonism.
 Instruct the client to change positions slowly to minimize
orthostatic hypotension.
 Instruct the client not to discontinue the medication
abruptly.
 Instruct the client to avoid alcohol.
 Inform the client that urine or perspiration may be
discolored and that this is harmless, but may stain the
clothing.
 Advise the client with diabetes mellitus that glucose
testing should not be done by urine testing because the
results will not be reliable.
 Instruct the client taking carbidopa-levodopa to divide
the total daily prescribed protein intake among all meals
of the day; high-protein diets interfere with medication
availability to the CNS.
 When administering carbidopa-levodopa, instruct the
client to avoid excessive vitamin B6 intake to prevent

69. ALERT
Carbidopa-levodopa taken with a
monoamine oxidase inhibitor
antidepressant can cause a
hypertensive crisis.

70. Summary & Conclusion
A neurotransmitter must be produced by a nerve it must be released into the
synapse when the nerve is stimulated; it must react with a very specific
receptor site to cause a reaction; and it must be immediately broken down or
removed from the synapse so that the cell can be ready to be stimulated
again.Much of the drug therapy in the nervous system involves receptor sites
and the release or reuptake and breakdown of neurotransmitters. An
understanding of the actions of specific drugs makes it easier to anticipate
what therapeutic and adverse effects might occur. Respiratory depression is
the priority concern with morphine. Continuous monitoring is very essential
after injecting opiods drugs.