Drug used in nervous system

1. MS.ANCHAL SONI
Drugs used in
Nervous System
BSC NURSING FOURTH YEAR

2. Syllabus
• Basic and applied pharmacology of
commonly used:
1. Analgesics & Anesthetics.
A. Analgesics.
Non steroidal anti-inflammatory
(NSAIDs) drugs
A. Antipyretics.
B. Hypnotics & Sedatives
Opioids.
Non opioids.
Tranquilizers.
General & Local Anesthetics
Gases: O2, Nitrous oxide, Carbon-di-
oxide,
2. Cholinergics & Anticholinergics:
Muscle Relaxants, Tranquilizers, Anti-
psychotic drugs.
Antidepressants.
Anticonvalscent.
Adrenergic.
Nor adrenergic.
Mood stabilizers.
Acetylcholine.
CNS Stimulants.
Composition, action, Indication,
Contraindications, Dosage, Routes,
Drug interactions, Side effects,
Adverse effects, Toxicity, Role of
nurse.

3. Nervous System
CNS PNS
Somatic
Autonomic
Parasympathetic
Sympathetic

4. Controls
skeletal
muscle
Controls
cardiac
muscle &
glands
Peripheral Nervous System
Somatic
Nervous
System
Autonomic
Nervous
System
One
Neuron
Efferent
Limb
Two
Neuron
Efferent
Limb
Postganglionic
Preganglionic
smooth &

5. Parasympathetic Nervous System (Craniosacral Outflow)
Genitalia
Bladder
Large Intestines
Kidney
Bile Ducts
Gallbladder
Small Intestines
Stomach
Bronchi/Bronchial
Glands
SA & AV Node
Sphincter Muscle of Iris
Ciliary Muscle
Lacrimal Gland
Submaxillary &
Sublingual
Glands
Parotid Gland

6. Radial Muscle of Iris
Ciliary Muscle
SA & AV Nodes
His-Purkinje System
Myocardium
Bronchi/Bronchial
Glands
Stomach
Kidneys
Intestines
Bladder//Genitalia
Sublingual/Submaxillary
& Parotid Gland
Pilomotor Muscles
Sweat Glands
Blood Vessels
Sympathetic Nervous System
(Thoracolumbar Outflow)
Paravertebral Ganglia
Prevertebral Ganglia

7. Analgesics, Antipyretics, Anti-
inflammatory (NSAIDs)
•Analgesics is an agent which relieves
pain.
•Antipyrutics which reduce temperature.
•Anti-inflammatory which reduce
inflammation.

8. Classification
• Analgesics are divided into two:
1. Narcotic Analgesics (Opioid Analgesics)
Its primary main action on central pain
mechanism and on have narcosis as side
effects.
2. Non-narcotic Analgesics (Opioid
Analgesics) Its primary main action on
peripheral pain mechanism and does not
have narcosis as side effects.

9. Non opioid/Non Narcotic Analgesics
(NSAIDS)

10. Non opioid/Non Narcotic Analgesics
(NSAIDS)
•These include non steroidal anti-
inflammatory drugs (NSAIDs).
•They are effective for mild to moderate
headache and pain of musculoskeletal
origin, also they lower body
temperature.

11. Mechanism of action - NSAIDs
•They inhibits prostaglandin formation in
inflamed tissues by two actions:
1. Inhibiting stimulation of pain receptors.
2. Inhibiting prostaglandins synthesis with
CNS and stimulating peripheral
vasodilation to reliever fever (Antipyretic
action)

12. Drug Examples and dosages
S.
no.
Drugs Doses
1 Salicylates - Aspirin 75-325mg orally.
2 Paracetamol 500-1000mg orally & not exceed
4mg/day
3 Diclofenac sodium 50 – 100mg daily.
4 Acelclofenac 100 – 200mg daily
5 Ibuprofen 200 – 1600mg daily
6 Ketoprofen 75 – 300mg daily
7 Mefeanic acid 500mg orally 8hrly
8 Naproxen 250-1000mg daily
9 Nimuslide 100 – 200mg daily

13. contd
S.
no.
Drugs Doses
10 Indomethacin 25-75mg orally.
11 Ketorolac 30-120mg daily
12 Piroxicam 20mg orally daily.
Selective COX inhibitors
1 Celecoxib 50 – 400mg daily
2 Etoricoxib 30-120mg daily

14. Indications / Uses
• Pain (Acetaminophen, ibuprofen, naproxen).
• Arthritis and osteoarthritis.
• In pyrexia.
• To treat inflammatory conditions.
• Prevention of transient ischemic attacks & MI
(Aspirin)
• Dysmenorrhoea. (mefenamic acid, ibuprofen).
• Its use can cause early closure of patent ductus
arteriosus & delay of labour due to inhibition of
prostaglandin synthesis.

15. Contraindications/ Precautions
•Contraindicated in pregnancy except acetaminophen.
•Contraindicated in Aspirin hypersensitivity.
•Aspirin is Contraindicated in bleeding disorders and
GI ulcers.
•Used with caution in patients with asthma or nasal
polyps.
•Aspirin should not given to children unless under the
supervision of the prescriber because of increased
risk of Reye’s syndrome.

16. Adverse Effects
• GI pain, upset.
• Peptic Ulcer.
• Diarrhoea.
• Nausea / vomiting.
• Heart burn.
• Tinnitus.
• Headache.
• Laryngeal edema (Acetaminophen, hypersensitivity).
• Aspirin hypersensitivity can produce such signs and symptoms as rash,
bronchospasm, rhinitis and shock.
• Hepatic or renal failure.

17. Drug interactions
•Prolonged use of acetaminophen with NSAISs
increases the risk of renal toxicity or failure.
•NSAIDs aggravate the GI adverse effects of alcohol.
• Concurrent use of NSAIDs with anticoagulants may
prolong bleeding time and increases anticoagulant
effect.
•Simultaneously use of aspirin with NSAIDs or
corticosteroids may aggravate the GI adverse effect
of aspirin and may reduce aspirin effects.

18. Nursing Responsibilities
• Instruct the patient to take oral NSAIDs drugs with food to minimize GI
irritation.
• Obtain a complete health history including allergies, drug history and
possible drug interactions.
• Administer liquid aspirin immediately after mixing because it breaks down
rapidly. Advise patient not to take ibuprofen and naproxen concurrently.
• Instruct client to report bleeding, abdominal pain, anorexia, heart burn,
jaundice.
• Monitor the signs of GI bleeding and hepatotoxicity.
• Instruct client to immediately report change in urination, flank pain or pitting
edema.
• Monitor for hypersensitivity reaction.

19. Opioid/Narcotic Analgesics
“ Narcotic analgesics in an old term for
opioid analgesics. They are
pharmacologically similar to morphine
which is obtained from opium (Poppy
plant) and they act on opioid receptor”.

20. Mechanism of Action
•Opioids agonists bind to opiate receptors in the
CNS to alter the perceptions of an emotional
response to pain. They produce analgesia by:
1. Elevating pain perception threshold.
2. Changing the pain reaction. (i.e. even in the
presence of pain patient does not bother about
pain).
3. Production or induction of sleep.

21. Drug Examples and dosages
S.
no.
Drugs Doses
Natural Alkaloids
1 Morphine 15-30mg orally/2.5-5mg injected
2 Codeine 15-30mg orally SOS
Synthetic compounds
3 Pethidine 25-100mg/IM/SC SOS
4 Methadone 2.5-10mg orally/SC/IM 6hrly
5 Pentazocine 30-60mg IM/IV/SC
6 Fentanyl 25mcg patch

22. continued
S.
no.
Drugs Doses
Semi synthetic morphine derivatives
7 Heroin (Diamorphine) 100mg injection IV
Other opioid Analgesics
8 Butorphenol 1-4mg IM/IV
9 Tramadol hydrochloride 50-100mg TDS orally/IM/IV
10 Naloxone 0.4-2mgIM/IV/SC

23. Indications/Uses
•To treat pain that is unresponsive to non opioid
analgesics.
•Adjuncts to anesthesia.
•Used to relieve cough.
•MI pain.
•In the treatment of diarrhea.

24. Contraindications / precautions
•Use cautiously in patients with head injury,
hepatic or renal disease.
•Cautiously in CNS depression and in
pregnant and breast feeding women.
•Use cautiously in elderly or debilitated
patients who may need decreased dosage.

25. Adverse effects
• Sedation.
• Constipation.
• Hallucination.
• Respiratory Depression.
• Dizziness.
• Dysphonia.
• Orthostatic hypotension.
• Physical dependence.
• Psychological Dependence.

26. Drug interactions
•Simultaneously use with alcohol,
antihistamines, hypnotics or sedatives
causes additive CNS Depression.
•Concurrently use with non opioid
analgesics may enhance pain relief.

27. Nursing Responsibilities
•Nurse should assess the patients blood pressure,
pulse and respiratory status before administering
the drug and periodically throughout analgesic
therapy.
•To prevent withdrawal symptoms, discontinue
opioids analgesics gradually after long term use.
•Instruct the patient to take oral analgesic with
food to minimize GI irritation.

28. Sedative - Hypnotics

29. • Sedative: A drug that reduces excitement and calm the
subject without inducing sleep. It may cause
drowsiness.
• Hypnotics: A drug that induces or maintains sleep,
similar to normal arousable sleep.
• Tranquilizer: A drug that relieves tension and anxiety
without affecting consciousness and without producing
drowsiness or sleep.
Both sedation and hypnosis may be considered as
different grade of CNS Depression.

30. Sedative – hypnotics: Classification
Sedative-hypnotics
Barbiturates
1-Long acting (12-24 hr)
Ex. Phenobarbital
2-Intermediate acting (8-12hr)
Ex. Amobarbital
3-Short acting (4-8 hr)
Ex. Pentobarbital
4-Ultrashort acting (0.5-1hr)
Ex. Thiopental
Non-barbiturates
Benzodiazepines Non- benzodiazepine

31. Classification
1. Benzodiazepines:
Long acting:
a) Diazepam.
b) Chlordiazepoxide.
c) Clonazepam.
Short acting:
a) Lorazepam.
b) Alprazolam.
c) Nitrazepam.
d) Oxazepam.
Ultra short acting:
a) Midazolam.
b) Triazolam.
1. Barbiturates:
Phenobarbitone. (Long acting)
Thiopentone. (Long acting)
Hexobarbitone. (Short acting)
Phenobarbitone. (Intermediate acting)

32. Benzodiazepam:
Benzodiazepines are the most commonly
used medications in psychiatry. In addition to
there effects as antianxiety medications.
They are also used as sedatives.
They are used as anticonvalscent
medications.
They have muscle relaxant property as well.

33. Mechanism of Action
• Benzodiazepines work by binding to a receptor which is located or
neurons in the brain called GABA receptors. And GABA is
neurotransmitter in the brain. It is actually one of the most prevalent
inhibitory neurotransmitter in the brain.
• Pharmacological Action:
1. Sedation and hypnosis.
2. Muscle relaxation.
3. Anticonvalscent effects
4. CNS depressants.
5. Amnesia.
6. Anesthetic.
7. Anti-anxiety.

34. Drug Examples and dosages
S.
no.
Drugs Doses
Long acting (24-48hrs)
1 Diazepam 5-10mg 2to4 times in a day
2 Chlordiazepoxide 15-30mg orally SOS
3 Clonazepam 1.5mg TDS
Ultra short acting (<6hrs)
4 Midazolam Loading dose of 0.1-0.35 mg per kg
body weight.
5 Triazolam 0.25mg HS

35. Drug Examples and dosages
S.
no.
Drugs Doses
Short acting (12-24 hrs)
1 Lorazepam 2-10mg daily
2 Alprazolam 0.25-1mg per day
3 Nitrazepam 5-10mg orally HS.
4 Oxazepam 30-60mg daily

36. Indication & Uses
• As sedative.
• In treatment of status epileptics.
• Insomnia.
• Muscle relaxants
• General Anesthesia.
• As hypnotic
• As pre-anaesthetic medication.
• Anti – convalescents.
• During alcohol withdrawal

37. Contraindication/Precautions
• Hypersensitivity to
Benzodiazepines.
• Shock.
• Coma.
• Pregnancy.
• Lactation.
• Inguinal hernia.
• Acute alcohol intoxication.
• Use cautiously with elderly and
debilitated patients.
• Impaired liver or kidney
functions.

38. Adverse Effect
• Tolerance and physical
dependence.
• Confusion.
• Lethargy.
• Headache.
• Impaired motor co-ordination.
• Incontinence.
• Drowsiness
• Amnesia
• Weakness
• Blurred vision.
• Ataxia
• Urinary retension.

39. Drug interactions
•Antacids may decrease absorption of
benzodiazepines.
•Carbamazepine decrease benzodiazepine level.
•Cigarette smoking decrease the effect of
benzodiazepine.
•Hormonal contraceptives, cimetidine,
erythromycin and some antidepressants may
increase the plasma level of benzodiazepines.

40. Nursing Responsibilities
•Take this drug exactly as prescribed. Do not stop taking this
drug (Long term therapy) without consulting health care
provider.
•Tell about side effects to the patient.
•Carefully monitor BP, Respiration, during I/V
administration.
•Maintain patients I/O chart receiving parenteral
benzodiazepines in bed for 5hrs, do not permit ambulatory
patients to drive vehicle following an injection.
•Monitor liver kidney function, CBC during long term
therapy.

41. BARBITURATES
•These drugs are derivative of
barbituric acid. They are general
depressant but now a days they are
not preferred as sedative and
hypnotics.

42. Mechanism of action
•Exact mechanism is not known.
They somehow depress the
cerebral cortical activity.

43. Drug Examples and dosages
S.
no.
Drugs Doses
Barbiturates
1 Phenobarbitone (Long acting) 30-120mg daily TDS
2 Thiopentone 3-5mg / kg body weight
3 Hexobarbitone (Short acting) -
4 Pentobarbitone (Intermediate
acting)
30-100mg daily

44. Pharmacological Action
•They are powerful cerebral depressants.
•They depress cardiac activity and in higher
doses cause fall in B.P.
•They produces urine flow.
•Depress respiratory center in brain.

45. Indication /uses:
•As sedative.
•Anticonvalscent.
•Anesthesia.
•Kernicterus. (increase conjugation of
bilirubin increase clearance of
bilirubin.)

46. Contraindications
•Liver, kidney and pulmonary diseases.

47. Adverse Effect
•Drowsiness in next morning.
•Respiratory Depression.
•Physical as well as psychological dependence.
•Hypersensitivity reaction may occur.
•Drug tolerance.

48. Drug interactions
•They increases metabolism and
decreased effectiveness of many
concurrently used drug including
hormonal contraceptives and
warfarin.

49. Nursing Responsibilities
• Administer IV dose slowly.
• Monitor pulse, B.P. respiration carefully during IV administration.
• Advice to patient the avoid alcohol, sleep inducing OTC drugs, these
could cause dangerous effects.
• Advise that avoid becoming pregnant while you are taking these
drugs. Use other methods of contraception's in place of oral
contraceptives which may lose there effect with this drugs.
• Take this drugs longer than 2 weeks (for insomnia)

50. HISTAMIN/ANTIHISTAMIN
•Histamine is responsible for symptoms of allergy
and anaphylactic shock in some following
conditions histamine is released.
•Tissue injury.
•Cold & chemical injury.
•Allergic conditions – Antigen, antibody reactions.

51. Types
• H1 Receptors: By stimulating H1 receptors it causes:
1. Histamine dilate the small blood vessels.
2. It increases bronchial secretion with contraction of bronchial smooth
muscle (Bronchoconstriction).
3. They stimulate peripheral sensory nerves (itching & pain).
• H2 Receptors: By stimulating H2 receptor it causes:
1. Increased secretion of acid and pepsin from stomach.
2. Secretion of all exocrine glands – pancreatic, bronchial, salivar and
lacrimal are increased.
• H3 Receptors.

52. Anti-histamines
•Antihistamines are the drugs used in the treatment of
allergic disorders and some other conditions. Theses drug
blocks the effect of histamine and receptors.
•There are three types of antihistamine drugs:
•H1 Blockers
•H2 Blockers
•H3 Blockers
Mechanism of action: These drugs block the effect of
histamine and its receptors. There three types of
antihistamine drugs.

53. Drugs
example
and doses:
Sr. No. Drugs Doses
Highly Sedatives
1 Diphenhydramine 25-50mg
2 Promethazine 25-50mg
3 Hydroxyzine 25-50mg
Moderate Sedatives
4 Medizine 25-50mg
5 Buclizine 25-50mg
6 Phenivamine 25-50mg
7 Cyproheptadine 4mg
Mild Sedatives
8 Chlorpheniramine 2-4mg
9 Cyclizine 50mg
10 Triprolidine 2.5-5mg
Non Sedatives
11 Astemizole 10mg
12 Cetrizine 10mg
13 Lovatadine 10mg

54. Indication/Uses.
• No therapeutic uses.
• Only experimental use.

55. Antihistamine
•Antihistamines are the drugs used in
the treatment of allergic disorders
and some other conditions these
drugs block the effect of histamine
and its receptors. There are three
types of antihistamines drugs.

56. S. No Drugs Doses
Highly sedatives
1. Diphenhydramine 25-50 mg
2. promethazine 25-50 mg
3. Hydroxyzine 25-50 mg
Moderate sedatives
4. Medizine 25-50 mg
5. Buclizine 25-50 mg
6. Phenivamine 25-50 mg
7. Cyproheniramine 4 mg
Mild sedatives
8. Chlorpheniramine 2-4 mg
9. Cyclizine 50 mg
10. Tripolidine 2.5-5 mg
Non-sedatives
11. Astemizole 10 mg
12. Cetrizine 10 mg
13. Lovatadine 10 mg
14. Fexofenadine 120-180 mg

57. Indications/Uses
• Allergic reactions [hay fever, vasomotor rhinitis, urticaria, asthma,
anaphylaxis].
• Because of their anticholinergic actions they are used as antimetics
and useful in motion sickness.
• As hypnotics ,mild sedatives/anxiolytics
• Parkinsonism
• Insect bites and stings
• Emergency treatment of any phylaxis

58. Adverse Effects
• Drowsiness in common
• Dryness of mouth
• Blurring of vision ------ Due to anticholinergic
• Urinary retention
• Constipation
• Delirium
• Convulsions
• Severe toxically may cause death due to cardiac and respiratory
failure.

59. Contraindications/Precautions
• Hypersensitivity.
• Neonates.
• Lactations.
• Special precautions in acute asthma and pregnancy, elderly, epilepsy.
• Coma.
• Hypokalemia.

60. Nursing Responsibilities
• Anti – histamines are best given in the evening since all anti-histamin
cause drowsiness.
• Advise to patient not to drive vehicle or do not operate machinery.
• Advise to patient to avoid sedatives such as alcohol or sedatives –
hypnotics.

61. CNS stimulants
•These drugs increased the excitability of nervous
tissue this group includes amphetamine,
caffeine, analeptics monamine oxidase inhibitors
and tricyclic antidepressants.

62. Mechanism of action
•They increase neurotransmitter levels in the
CNS either by increasing neuronal discharge
or by blocking in an inhibitory
neurotransmitter.

63. Drug example & Doses
S.
No.
Drugs Doses
1 Amphetamine 2.5-5mg orally daily
2 Dextroamphetamine 10mg/day
3 Doxapram 1-4 mg /min IV slowly
4 Methylphenidate 5-10 mg BD orally
5 Caffeine 20-100 mg
6 Pentoxiphyllin 400mg TDS

64. Indication/ Uses
• To treat hypractivity.
• To increase mental alertness and respiratory rate.
• Doxapram is used to treat respiratory failure, sedative, hypnotiv
poisoning.
• Mental Retardation and Attention Deficit disorder in children.
• Senile Dementia.
• Memory Disturbances.
• Piracetam and Pentoxiphyllin are used in peripheral vascular diseases.

65. Contraindication & Precaution
• Severe cardiovascular disorders.
• Glaucoma.
• Use with caution in patients with psychosis and in pregnant and breast
feeding mothers.

66. Adverse Effects
• Restlessness.
• Irritability.
• Hypotension.
• CV Collapse.
• Fatigue.
• Growth suppression in children.
• Tremor.
• Insomnia.
• Angina.
• Weight loss.
• Irritability.

67. Nursing Responsibilities
• Assess the patients behavior to determine drug effectiveness.
• Monitor growth in such children who is receiving long term therapy.
• During Doxapram administration assess the patients respiratory status
(Including lung sound, rate and depth of respiration).
• Instruct patient to take last daily dose 6hrs before bed time to present
insomnia.

68. Skeletal muscle relaxants
•Muscle relaxants are the drugs which affects
skeletal muscle function and decreases the
muscle tone. They may be used to alleviate
symproms such as muscle spasm, hyper-
reflexia, and pain.

69. Mechanism of action
•They work directly by acting on the
neuromuscular function or indirectly by
acting on the CNS and interfere with
calcium release in muscle fiber, interfering
with muscle contraction at the
neuromuscular function.

70. Drug example and doses
S. No. Drugs Doses
1 Chlorzoxazone 250-750 mg orally 3to4 time a day.
2 Dantrolene 25mg, 50mg, 100mg orally TDS.
3 Methocarbamol 1500mg QID max. dose 8mg/day for severe
symptoms.
4 Diazepam 2-10mg 3to4time in a day orally 5-10mg IV.
5 Baclofen 5-10mg orally TDS.

71. Indication/uses
•Useful in painful spacity associated with cord
disease.
•In acute and painful musculoskeletal conditions.
•Muscle spasm.

72. Indications/Uses
•Dry mouth.
•Constipation.
•Light headedness.
•Drowsiness.
•Fatigue.
•Blurred vision.
•Dizziness.
•Ataxia.

73. Contraindications/precautions
• Contraindicated in patients who have hypersensitivity to this
drugs.
• Contraindication in:
1. Arrhythmias.
2. Heart block.
3. Heart failure.
4. Use with caution in patients with breast feeding mothers
who have hepatic disorders.

74. Drug interactions
•Simultaneously use with other CNS
depressant, or alcohol causes additive CNS
depression.
• Simultaneously use Baclofen with
antidepressants (MAO inhibitors) may cause
hypertensive crisis, seizures and death.

75. Nursing responsibilities
• Nurse should advise the patient to take muscle relaxants with
meals or milk to prevent GI upset.
• Assess affected joints for pain and immobility.
• Nurse should teach the patient to avoid alcohol and CNS
depressant.
• Keep emergency equipment nearby to treat respiratory
infections.

76. Antidepressants
•Antidepressants are a type of
medication used to treat or prevent
depression.

77. Mechanism of action
• Tricyclic antidepressants increase the amount of serotonin, Nor
epinephrine, through reuptake inhibition, thus normalizing the
hyposensitive receptor site associated with depression.
• SSRI ( Selective serotine reuptake inhibitors) block the reuptake
of the serotonin into the presynaptic cells, there by increasing
serotine levels at the synapse.
• Biogenic amines such as 5- hydroxytrptamine, noradrenaline and
dopamine are inactivated by the enzyme monoamine oxidase
(MAO) MAOI inhibit enzyme MAO that leads to accumulation
of these amines in the brain thus produces antidepressant effects.

78. Drug example and doses
S. No. Drugs Doses
1 Imipramine 75-300mg orally/IM
2 Nortryptaline 25mg 3-4time orally
3 Desipramine 100-200mg daily
4 Amitryptyline 25-100mg 3-4time orally
5 Doxepine 25-150mg per day orally
6 Trimipramine 50-150mg per day orally
7 Phenylzine 15mg 3time orally
8 Fluoxetine 20mg-80mg per day orally
9 Fluoxamine 50-100mg OD orally
10 Sartraline 25-100mg Daily orally

79. Indications/uses
• Used in endogenous depression.
• Depression associated with other diseases.
• Used in phobic anxiety states like school phobia and compulsive
phobic states.
• Enuresis.
• Obsessive compulsive disorder.
• Bulimia nervosa.
• Smoking cessation.
• Premenstrual dysphoric disorders.

80. Contraindication / precautions
•Concurrent use of fluoxetine and MAO inhibitors
is contraindicated.
•Contraindicated in active liver diseases.
•Precautiously used in elderly patients and in
hepatic and renal patients.

81. Adverse effects
• TCA may cause orthostatic hypotension, tachycardia, blurred
vision, constipation, seizures, dry mouth.
• It may exacerbate heart failure.
• May cause testicular swelling and gynecomastia in males.
• Insomnia, Nausea, and anticholinergic effects.
• Overdose can cause CNS stimulation, even hallucination and
convulsions.

82. Drug interactions
• They alter the actions produced by the drugs acting on
sympathetic nervous system when administered
simultaneously.
• It may reduce the effectiveness of antihypertensives.
• Simultaneously used with alcohol, antihistamines and other
CNS depressants cause additive CNS depression.
• Antidepressants with MAO inhibitors may cause
hypertensive crisis and seizures.

83. Nursing Responsibilities
• Nurse should know that these drugs should be discontinue
gradually.
• Nurse should instruct the patient about importance of complying
with therapy these drugs may take several weeks to produce
desired effects.
• Nurse should warn the patient to avoid alcohol and other non
prescribed drugs to prevent adverse drugs reactions.
• Nurse should know that a persistent headache is often a warning of
rising B.P. in a patient on MAO inhibitors.
• Nurse should tell the patient not to crush controlled release tablets
but swallow them whole

84. Anti-manics (Lithium)
•Mania is the condition which characterized
with elevated mood with increased
emotional liability, excessive talking,
increased psychomotor activity with
marked euphoria, when mania occur with
depression, this condition is known as
manic depressive psychosis.
•Lithium is the drug used in the treatment
of mania.

85. Mechanism of action
•Its anti-manic effects may result from
increases in norepinephrine reuptake
and serotonin sensitivity.
•Lithium probably interact with the Ca+,
Na+, Mg+ ions in the body.

86. Drug example and doses
S.
No.
Drug Doses
1. Lithium Carbonate 0.25 – 2gm orally daily.
2 Valporate 750 mg per day in acute mania.

87. Indications/uses
•Mania.
•Bipolar affective disorder.
•Manic depressive psychosis.

88. Contraindication / precautions
•Contraindicated in severe renal and
cardiovascular disorders and during
pregnancy.
•Breast feeding.
•Severe dehydration.
•Use cautiously with elderly patients and
those with thyroid disease.

89. Adverse effects
At therapeutic level, nausea, vomiting, fatigue, muscular weakness,
polyuria
Above therapeutic level
- Severe nausea/vomiting - convulsions
- Circulator failure - coma
Most common adverse reactions are hand tremors, transient, muscle
weakness, hypertoniya, bloating, diarrhoea, anorexia, abdominal pain,
anorexia etc
Antimanics may cause hypothyroidism.

90. Drug interactions
Diuretics, tetracycline's and indomethacin with lithium may
increase plasma level of lithium and increase risk of toxicity.
Lithium interfere with the effects of haloperidol,
succinylcholine non adrenaline.
Acetazolamide, aminophylline, sodium bicarbonate, and an
increased sodium intake may increase renal excretion of
lithium, reducing its effectiveness.

91. Nursing Responsibilities
• Assess therapeutic blood level (0.6 to 1.2 mEq/litre) during course of
therapy.
• Nurse should teach the patient and family to observe for signs of
lithium toxicity (diarrhea, vomiting, drowsiness, ataxia, convulsions
and confusion)
• Nurse should assess for suicidal tendencies and institute suicide
precautions as necessary.
• Administer the drug with food to minimize GI irritation.
• Nurse should instruct the patient to consult the physician or pharmacist
before talking non prescription drugs to prevent adverse drug
interaction.

92. contd
•Nurse should teach patient to:
1. Drink 2to3 litres of fluid daily.
2. Maintain adequate salt intake
3. Avoid excessive amounts of coffee, tea, cola,
and activities that causes excess sodium loss.
4. Avoid driving and other hazardous activities.

93. Antipsychotics
Antipsychotics are drugs that are mainly used
for the treatment of major psychosis like
schizophrenia or mania caused by sipolar
disorder they are also called as major
tranquillizers.
There are two main types of antipsychotics
atypical antipsychotics and older antipsychotics

94. Mechanism of action
•They block the neurotransmitter
dopamine in the limbic system inhibiting
transmition of neural impulse
(Antipsychotic action).

95. Drug example and doses
S. No. Drugs Doses
Phenothiazine
1 Chlorpromazine 25 to 100 mg.
2 Fluphenazine 0.5 to 10 mg/ per day orally divided 6hrly.
3 Mesoridazine 50 mg TDS
Butyrophenones
4 Haloperidol 1 to 5 mg once or twice daily till 10 mg daily.
5 Droperidol 1.25 to 5 mg per day.
Atypical Antipsychotics
6 Clozapine 12.5 mg once or twice daily
7 Riseperidone Starting dose 0.25 to 1mg per day up to 12mg per day.
8 Olanzapine 5 to 10 mg once daily
9 Loxapine 10 mg orally twice a day.

96. Indications/uses
• Psychosis.
• Schizophrenia.
• Depression with psychotic features.
• Psychotic symptom associated with organic brain syndrome.
• Butyrophenones are used to treat nausea, vomiting during surgery and
diagnostic procedures.
• Haloperidol as an adjunct to anesthesia.
• Haloperidol is used to treat psychosis, behavioral problems in children
with expulsive hyper excitability, hyperactivity, in hyperactive
children.
• Atypical antipsychotics are used to treat obsessive compulsive
disorders and risk of suicidal behavior.

97. Contraindication / precautions
• CNS Depression.
• Risk of suicide.
• Pregnancy (First trimester)
• Angle closure glaucoma.
• Cautiously used in elder patients and in those in acute
myocardial infarction, heart disease, respiratory
distress.

98. Drug interactions
•Antacids decrease absorption of antipsychotics.
•These drugs potentiate alcohol and CNS
depressants.
•Concurrent use of antipsychotics with
anticholinergic including antihistamines and
antiparkisonian and antidepressants may
increase anticholinergic side effects.

99. Nursing Responsibilities
• Nurse should tell the patient to avoid driving or other hazardous
activities until CNS effects of drug are known.
• Advise patient to avoid alcohol and other CNS depressants during
therapy.
• Nurse should tell the patient that phenothiazine may discolor the urine
pink or red brown.
• Nurse should monitor for extrapyramidal system and other adverse
reaction.
• Nurse should know that patient taking long term antipsychotic
treatment which should undergo regular evaluation of red and white
blood cell counts.

100. contd
• Do not give antacid within one hour of giving these drugs to
avoid drug interaction. Nurse should assess the patients
mental status.
• If given parenteral doses monitor the patient for orthostatic
hypotension.
• Nurse should advise the patient to use sunscreen and use
protective clothing to prevent photosensitivity reaction.

101. Anticonvalscents
•Anticonvalscents are drugs that
prevents or reduce the severity and
frequency of seizures in various
type of epilepsy.

102. Mechanism of action
•Two mechanism that appear to be important
in anticonvulsants drugs are:
1. Enhancement of GABA action
2. Inhibition of sodium channel activity.
(Thus it decreased spread of abnormal
electrical discharge.)

103. Drug example and doses
S. No. Drugs Doses
1 Phenytoin 100 mg BD or TDS, 10-15mg / kg slow IV
2 Phenobarbitone 50-100mg orally 2-3 times daily.
3 Primidone 250-300 mg PO per day.
4 Mephobarbitone 400-600 mg PO per day
5 Carbamazepine Initially 20mg/per day up to 1200 mg per day.
6 Clonazepam 1.5 mg per day.
7 Diazepam 5-10mg IV slowly
8 Lorazepam 4mgIV slowly.
9 Valporic Acid. Initially 600mg/per day can be increased up to 3-6gm per
day in divided doses.
10 Acetazolamide. 10-30 mg / kg / day.

104. Indications/uses
•Phenytoin can be used in all epilepsies (except patit mal
epilepsy) including grand mal epilepsy, psychomotor
epilepsy, focal seizures, status epilepticus.
•Phenobarbitone can be used to control:
- Tonic-clonic (grand mal) epilepsy.
- Simple partial seizures
- Febrile convulsions
- Drug withdrawal sizures
- Status epilepticus

105. contd
• Benzodiazedepines [ clonazepam,lorazepam,diazepam] are useful
in status epilepticus.
• Valporic acid is specially useful in absence [petit mal] and akinetic
sizures .
• Carbamazapine is useful to control psychomotor epilepsy, grand
mal epilepsy, and mixed seizures.It is also useful in trigeminal and
glossopharyngeal neuralgies.
• Acetazolamide use in combination with other anticonvulsant drugs
in petit mal seizures and focal seizures

106. Contraindication / precautions
Contraindicated in patients who have hypersensitive to drug.
Phenytoin is contraindicated in patients with sinus bradycardia,
second and third degree heart blocked.
Barbiturates [ Phenobarbitone ] contraindicated in patients who are
sensitive to barbiturates and in pregnant and breast feeding mothers.
They are also contraindicated in patient with hepatic impairment and
severe respiratory disease.
Contraindicated in patients with bone marrow suppression and within
14 days of MAO inhibitor therapy.

107. Adverse effect
• Sedation.
• Drowsiness.
• Drug Dependence.
• Dizziness.
• Slurred speech.
• Nausea / vomiting (Phenytoin).
• Carbamazepine prolonged use
may cause bone marrow
suppression.
• Photophobia.
• Ataxia.
• Respiratory & Cardiovascular
depression.
• Blood Dyscariasis.
• Gum hypertrophy. (Phenytoin)

108. Drug interactions
• Alcohol, Dioxides, Influenza vaccines, rifampicin, folic acid may
decrease phenytoin activity and decrease the drug effectiveness.
• Amidarone, and antihistamine, chloramphenicol, cimetidine,
diazepam, Disulfiram, oral anticoagulants, Salicylates, Valproate may
increase phenytoin activity and may leads to phenytoin toxicity.
• Alcohol may cause addictive CNS effects and death.
• Benzodiazepines may increase digoxin level and digoxin toxicity if it
given together.
• Hormonal contraceptive decrease the metabolism of Benzodiazepines.

109. Nursing Responsibilities
• Nurse should monitor for sign and symptoms of toxicity, sign of
Anticonvalscents toxicity one ataxia, nystagmus, dysarthria,
hypotension, coma.
• Teach the patient about the importance of good oral hygiene and
regular dental examination to prevent gingival hyperplasia.
• Nurse should teach the patient to avoid alcohol and self medication
with over the counter drugs.
• Also teach about compliance with therapy, avoidance of abrupt
deconditions and consistent use of same drug preparation because
changing drug brands may differ bioavailability among brands.
• Assess respiratory status before and during this therapy.
• Nurse shouls also monitor the patient for withdrawal symptoms (
Anxiety, muscle twitching, hand and figure tremors, dizziness, nausea,
vomiting, convulsions)

110. Contd.
• Do not mix IV Diazepam with other drugs in same syringe.
• Give diazepam by direct IV push only do not give as an infusion.
• Know that psychological dependence may develop with the use of
clonazepam or diazepam.

111. Antianxiety Drugs (Minor tranquilizers)
•It is a group of mild CNS
depressants which are used to
control the symptoms of anxiety.
They produce a calming effect in
anxiety states .

112. Mechanism of action
They cause generalized CNS depression mimicking or enhancement the
effects of GABA by antagonizing a protein that inhibits GABA binding
to its receptors.

113. Drug example and doses
S. No. Drug Doses
Benzodiazepine
1 Alprazolam 0.25 mg
2 Clonazepam 0.25 mg orally twice daily
3 Diazepam 2-5 mg twice daily
4 Nitrazepam 5-10 mg orally
5 Zolpidem 10mg at bed time
6 Chlorodiazepoxide 10-40 mg per day
7 Lorazepam 1 mg orally 2-3 times a day.
Azapirones
8 Buspirone 10-30 mg daily in divided dose.

114. Indications/uses
Benzodiazepines are commonly use antianxiety drugs , the have
anxiolytic hypnotic, muscle relaxant and anticonvulsant actions also.
These drugs are used to treat anxiety.
Diazepam is used to produce skeletal muscle relaxation.
Used to treat insomnia.
Used to preoperatively to induce sedation and amnesia.

115. Contraindication / precautions
Pregnancy.
Pre-existing CNS depression.
Cautiously used in elderly patients who may require a decreased
dosage and in patients with renal and hepatic impairment.

116. Adverse effects
Drowsiness.
Ataxia.
Temporary memory impairments.
Excitement.
Respiratory.

117. Drug interactions
Antacids may decrease absorption of
benzodiazepines.
Erythromycin, Cimetidine, Antidepressants may
increase the plasma level of benzodiazepines.
Cigarette smoking decrease the effectiveness of
benzodiazepines.

118. Nursing Responsibilities
• Nurse should administer IV dose slowly.
• Nurse should advise the patient not to increase dosage unless
instructed by physician,
• Instruct to patient for avoid hazardous activity like driving swimming
etc.

119. Anesthetics
•An anesthetic is a drug or agent that
produce a complete or partial loss of
feeling. There are three types of
anesthetics:
•General:
•Regional:
•Local:

120. General Anesthetics
•General anesthetics are used to
produce loss of consciousness
before and during surgery.
•General anesthetics are usually
given by inhalation or by injection
into a vein.

121. Mechanism of action
•They stabilize neuronal
membranes to produce
progressive, reversible CNS
depression.

122. Drug example and doses
S. No. Drugs Doses
Intravenous Anesthetics
1 Midazolam hydrochloride 10-20mg one times orally/1to2.5 mg I/V
2 Thiopental sodium 3-5mg /kg body wt.
3 Methohexital 50-120mg I/V 1% solution
4 Ketamine 2mg/kg body wt. I/V
5 Diazepam 5-10mg/kg in 5% solution
6 Fentanyl 25-150μg/kg
Inhalational anesthetics
7 Nitrous oxide Gas
8 Halothane Gas
9 Ether Gas
10 Cyclopropane Gas

123. Indications/uses
•To induce and anesthesia.
•To prolong anesthesia when use with
anesthetics.
•As muscle relaxants.
•To produce loss of consciousness.

124. Contraindication / precautions
•Use cautiously in patients with
cardiovascular and respiratory instability.
•Cautiously in elderly or debilitated
patients because they are predispose to
an exaggerated response to the drug.

125. Adverse effect
•Respiratory
depression.
•Muscle twitching.
•Apnea.
•Tachycardia.
•Memory loss.
•Depression.
•Hypertension.
•Confusion.
•Arrythmias.
•Nausea/ vomiting.

126. Drug interactions
•Concurrent with other CNS
depressants increases CNS and
respiratory depression and
hypertension.
•Increases hypotensive effect if it
given with labetalol.

127. Nursing Responsibilities
1. Nurse should assess if patient has allergic before the surgery.
2. Should assess CV, respiratory and renal condition and level of
consciousness before and after surgery.
3. Nurses should always keep atropine available to reserve bradycardia.
4. Nurse should advise the patient not to it or drink anything for at least
8hrs before surgery to prevent aspiration and gastric content into the
respiratory passage during anesthesia.
5. Nurse should know that shivering is normal during recovery, if
shivering occurs, keep the patient warm with extra blanket or heat.
6. Maintain side lying position to prevent aspiration after any procedure
in general anesthesia and also oral intake until ability to swallow
reflex has returned.

128. Local Anesthetics
•An Anesthetic agent that
affect a restricted or specific
area of body.

129. Mechanism of action
•They block the conduction of
nerve impulses thus provide
analgesic relief.

130. Drug example and doses
S. No Drugs Doses
1 Benzocaine 20% topically
2 Lidocaine HCL/
(Xylocaine HCL)
2% viscus solution (Max,
300mg)
3 Chloroprocaine
Hydrochloride
11mg / kg inj. (Max 800mg)
4 Procaine hydrochloride 1% inj with 0.9% NaCl.

131. Indications/uses
•To relieve pain from surgery, disease or
injury.
•To use on the skin or mucus membranes to
provide anesthesia for itching, burning or
short procedure.
•For severe pain unrelieved by topical
anesthetics or analgesics.

132. Contraindication / precautions
•Drug hypersensitivity.
•Impaired cardiac conduction.
•Cautiously used in patient with hepatic
disorders, heart block, hypotension, and
other endocrinal disorders.
•Myasthenia gravis.

133. Adverse effects
•Restlessness.
•Hypotension.
•Miosis.
•Hypersensitivity reaction.
•Anxiety.
•Bradycardia.
•Tinnitus.

134. Drug interactions
•They may increase CNS Depression
when it use with other CNS
Depressants.
•May prolong Anesthetic effect if
used with epinephrine.

135. Nursing Responsibilities
•Nurse should ensure the gag reflex has
return before feeding a patient who’s throat
has be anesthetized.
•During post – operative phase nurse should
assess for return of motor function and
sensation.

136. Topical Anesthetics
•A Topical anesthetics is a
local anesthetic which is
used to numb the surface
of body part.

137. Mechanism of action
•They work by blocking nerve
impulses transmission, they
accumulated in the nerve cell
membrane and cause it to expand
and loss its ability to depolarize.

138. Drug example and doses
S. No. Drug Doses
1 Benzocaine 20% mucus spray/gel
2 Benzyl oxide 2.75% to 10% topically.
3 Lidocaine 2% gel. topically
4 Menthol 2% gel topically
5 Tetracaine Topically applied

139. Indications/uses
•Use as topical anesthesia typically either relieves
existing pain from a body surface or prevents
pain during medical examination or procedure.
•To anesthetized an area before an injection is
given.
•To numb mucosal surface before a tube or
catheter is insert.

140. Contraindication / precautions
•Drug hypersensitivity.
•Lidocaine should be used cautiously
in elderly patients and patient with
large area of broken skin or mucus
membrane.

141. Adverse effects
•Hypersensitivity reaction
(Including rash, pruritus,
dyspnea)

142. Drug interactions
•Lidocaine may increase the risk
of the lidocaine toxicity so
should not be used with ꞵ -
Blocker or cimetidine (H₂
Blocker).

143. Nursing Responsibilities
•Nurse should assess the site were
topical anesthetic applied before,
during and after drug
administration.
•Discontinue the drug if rash
develops.

144. ꞵ Adrenergic Blocker
•Mechanism of Action:
ꞵ Adrenergic receptors causes vasoconstriction in
blood vessels. Thus, these drugs prevents
stimulation of ꞵ adrenergic receptors of
sympathetic nervous system, there by decreasing
cardiac output.

145. Drug Examples and doses
S. No. Drugs Doses
1 Atenolol 50-100 mg BD orally
2 Timolol. 10-20 mg orally twice a day
3 Propranolol. 20-80mg orally
4 Betaxolol. 10 mg orally BD
5 Metoprolol 50 mg every 4-6 hrly.

146. Indications/uses:
•To treat the mild
hypertension.
•Angina pectoris.

147. Contraindications/precautions
•Contraindicated in patients with asthma,
sinus bradycardia, cardiogenic shock, second
and third degree heart block.
•Use these drugs cautiously in pregnant and
breast feeding women and in those with
impaired hepatic functions.

148. Adverse effects:
•Orthostatic Hypertension.
•Fatigue.
•Bradycardia.
•Nausea, Vomiting.

149. Drug interaction
•These drugs caused additive action
on hypotension when used
concurrently with alcohol and
antihypertensives or calcium
channel blockers.

150. Nursing Responsibilities
•Do not discontinue drug abruptly.
•Administer propranolol, Constituently
with food, Food may increase
absorption.

151. Anticholinergics
•They causes the bronchodilation by
blocking the action of acetylcholine.
Acetylcholine causes the
bronchoconstriction.

152. Mechanism of Action:
•These agents inhibit the action of acetylcholine
neurotransmitter or blocks the neurotransmitter
acetylcholine in central and the peripheral
nervous system.
•They stop transmission of para sympathetic
nerve impulses therefore they lesson the spasm
of smooth muscles such as G.I. Respiratory Tract
& Bladder.

153. Drug Examples & Doses:
S. No. Drugs Doses.
1 Ipratropium Bromide 40-80mg by aerosol
2 Atropine 0.4 to 1mg I/V one time (may
repeated 2hrly) 2mg max. in case of
brady-arrhythmia.
3 Benztropine 0.5 to 2mg orally I/M, I/V once a day.
4 Diphenhydramine 25-50 mg.

154. Indication / uses
• To reduce salivation and gastric a secretion.
• To induce mydriasis
• To treat parkinsonian disease.
• Motion sickness.
• GI Spasm.
• Brady-arrhythimias, arrhythmias (Atropine).
• Extra-pyradamidal reaction, dyskinesia (Benztropine).
• To decrease saliva and bronchial secretion before
surgery.

155. Contraindications/ precautions
•Urinary and GI tract obstruction.
•Hypersensitivity.
•Severe ulcerative colitis.
•Angle closure glaucoma.
•Acute or severe hemorrhage.

156. Adverse effects
•Blurred vision.
•Dryness of mouth.
•Urine retention.
•Conjunctivitis.
•Constipation.

157. Drug Interaction
•Tricyclic antidepressants
(TCA) may increase these
drugs adverse effects.

158. Nursing Responsibilities
•Nurse should monitor adverse reactions.
•Nurse should instruct to patient to administer 30
minutes before meals and at bed time when used to
reduce GI motility.
•Teach the patient to reduce dry mouth by using ice
chips, hard candy or gum and to reduce constipation by
exercising and increasing fiber and fluid intake.
•Nurse should monitor intake and output and watch for
sign and symptoms of urine retention.

159. References
1. Dr. P.K. Panwar, Essentials of pharmacology for nurses, AITBS pub. 2017,
India, Pg no. 90 – 117.
2. Dr. Suresh k sharma, Textbook of pharmacology, pathology & genetics for
nurses, Jaypee pub. 2016 India Pg no 256 – 360.
3. Tara v. Shanbhag, Smita shenoy, Pharmacology preparation manual for
undergraduate, Elsevier pub. 2014. Pg no. 164 – 233.
4. Marilyn Herbert – Ashton, Nancy Clarkson, Pharmacology, Jones & Barllet
pub 2010 India, Pg no 101 – 180.
5. Govind s. mittal, Pharmacology at a glance, Paras medical book pub. 2009
India 1 – 12.
6. Madhuri Inamdar, Pharmacology in nursing, Vora medical pub. 2006 India
1st edition, Pg no 120 – 152.