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  • Ataxia=loss of muscle coordination

    1. 1. Psychotherapeutic Agents Sedative-Hypnotic Drugs Antidepressants Mood Stabilizers 1
    2. 2. Psychotherapeutic Agents1. What does it mean when a drug has a sedative effect?2. What is the difference between sedation and hypnosis?3. What are the level of anxiety? 2
    3. 3. States Affected by Sedative- Hypnotics 1. Anxiety – Feeling of tension, nervousness or apprehension – Manifested associated with SYMPATHETIC NS • Sweating, fast heart rate, rapid breathing and elevated BP – Mild • Lowest level, source of positive motivation in certain situation – Moderate – High • Overwhelming, can cause interference with activities of daily living 3
    4. 4. States Affected by Sedative-Hypnotics2. Sedation – loss of awareness and reaction to environmental stimuli – Diminished physical & mental response – Drugs can be administered to sedate client • Irritable and restless 4
    5. 5. States Affected by Sedative-Hypnotics3. Hypnosis – Extreme state of sedation in which the person no longer sense or reacts to incoming stimuli – Effective hypnotics act on the RAS and block the brain’s response to incoming stimuli 5
    6. 6. Sedative-Hypnotic Drugs Benzodiazepines Barbiturates 6
    7. 7. Benzodiazepines• Alprazolam• Clonazepam (Klonopin)• Diazepam (Valium)• Lorazepam (Ativan)• Chlordiazepoxide (Librium) 7
    8. 8. BenzodiazepinesAction:• Act on limbic system and RAS to enhance the action of gamma- aminobutyric acid (GABA)• GABA = inhibitory neurotransmitter – depress neuronal function at multiple sites in the CNS – Also promote sleep by affecting cortical areas and sleep-wakefulness cycle – Muscle relaxation thru effects on supraspinal motor areas =cerebellum 8
    9. 9. BenzodiazepinesIndications:• Drug of choice for anxiety and insomnia• Anxiety disorders• Alcohol withdrawal• Hyperexcitability & agitation• Short-acting are administered through IM – Preop to sedate the client – Before short diagnostic procedures – For induction of general anesthesia 9
    10. 10. BenzodiazepinesPharmacokinetics:• GI peak of 30min-2h• Readily cross blood-brain barrier to reach intended sites• Metabolized by liver• Excreted in urine 10
    11. 11. BenzodiazepinesContraindications:• Psychosis = can exacerbate sedation,• Acute narrow glaucoma• Shock• Coma• Acute alcoholic intoxication• Pregnancy cause – cleft palate, – inguinal hernia, – cardiac defects, – microcephaly, – pyloric stenosis during 1st trim 11
    12. 12. BenzodiazepinesCaution:• Elderly & debilitated clients = renal/liver dysfunction 12
    13. 13. BenzodiazepinesAdverse Effects:• CNS depression – Drowsiness – Lightheadedness – Incoordination and difficulty concentrating• Anterograde amnesia (impaired recall of recent events)• Paradoxical (opposite) responses: – Insomnia – Excitation – Euphoria – rage 13
    14. 14. BenzodiazepinesAdverse Effects• Severe respiratory depression with IV useNote: Substantial respiratory depression can result from combining oral benzodiazepine + other CNS depressants Prolong use=physical dependence Withdrawal symptoms: panic, delirium, HPN, muscle twitches & convulsion 14
    15. 15. Barbiturates• Amobarbital (Amytal)• Butabarbital sodium (Butisol)• Pentobarbital (Barbilixir, Luminal sodium)• Secobarbital (Seconal) 15
    16. 16. BarbituratesActions:• Bind with GABA receptors to enhance inhibitory functions• Are general CNS depressants that inhibit neuronal impulse conduction in ascending RAS• Depress cerebral cortex• Alter cerebellar function and depress motor output 16
    17. 17. BarbituratesIndications:• LONG ACTING (phenobarbital & mephobarbital) – Control seizures in epilepsy• INTERMEDIATE ACTING (amobarbital, aprobarbital) – Use in maintaining long periods of sleep• SHORT-ACTING (thiopental sodium) – Used as general anesthetic 17
    18. 18. BarbituratesPharmacokinetics:• Absorption : well in 20-60mins• Metabolism: liver• Distribution: lipid-soluble, readily cross placenta & enter breastmilk• Elimination: kidney 18
    19. 19. BarbituratesContraindications:• +allergy to any barbiturate• Previous hx of addiction to sedative-hypnotic drugs• Hepatic impairement• Respiratory distress• Pregnancy 19
    20. 20. BarbituratesAdverse Effects:• With increasing dosage, responses range from sedation – sleep – general anesthesia• Can ↓BP & HR; toxic dose lead to shock• They stimulate hepatic enzymes that can accelerate their own metabolism and that of other drugs• Prolonged used=physical dependence 20
    21. 21. Sedative-Hypnotic DrugsGeneral Nursing Considerations:• Do not administer intra-arterially – Serious arteriospasm and gangrene can occur• Do not mix IV drugs in solution with other drugs – To avoid drug-drug interxn• Parenteral forms should be the last resort, only if oral forms are not available – Oral less likely cause AE• Give IV medications slowly – Rapid administration can cause cardiac problems 21
    22. 22. Sedative-Hypnotic DrugsGeneral Nursing Considerations:• Maintain client who receive parenteral benzodiazepines in bed for a period of 3 hrs• Monitor hepatic & renal functions, CBC during long therapy• Taper dosage gradually after long-term therapy, esp in epileptic client – Abrupt withdrawal could trigger seizures 22
    23. 23. Sedative-Hypnotic DrugsGeneral Nursing Considerations:• Prepare emergency life support facilities in case of severe respiratory depression• Provide comfort measures to help client tolerate drug effects – Small, frequent meal – Consume drug with food 23
    24. 24. Anti-Depressant Agents 24
    25. 25. Major Depression Disorder• Characterized by: – Low mood – Low self-esteem – Loss of interest or pleasure in normally enjoyable activities• Commit suicide 25
    26. 26. Biogenic Amine Theory of Depression• Depression results from a deficiency in biogenic amines: – norepinephrine, dopamine and serotonin• Norepinephrine – Alertness & energy, anxiety, attention and interest in life• Serotonin – Anxiety, obsession and compulsion• Dopamine – Attention, motivation, pleasure and reward and interest in life 26
    27. 27. Biogenic Amine Theory of Depression• Deficiency of these neurotransmitter may be caused by: – Breakdown by monoamine oxidase to be recycled or restored in neuron – Rapid or sudden abnormal electrical discharges from the brain – Increase in # or sensitivity of postsynaptic receptors 27
    28. 28. Anti-Depressant Drugs• Given with major depression• Works: balance the neurotransmitters• Purpose: – Improve sleeping pattern• Onset/effective: – 2-3wks after – Given with anti-psychotic to minimize bizarre behavior – On 3rd week: • Very watchful and vigilant • Pt can commit suicide – Have enough energy 28
    29. 29. Classification ofAnti-Depressants TCA MAOI SSRI Atypical 29
    30. 30. 1. Tricyclic Anti-Depressants (TCA) • TCAs inhibit uptake at presynaptic junction of the norepinephrine and serotonin • results in the accumulation of these neurotransmitter in the synaptic cleft and increased stimulation of postsynaptic receptors. • asserts that depression stems from a deficiency in monoamine- mediated transmission. • Elevate mood, increase alertness, improve appetite and normalize sleep patterns. 30
    31. 31. 1. Tricyclic Anti-Depressants (TCA)• Preferred drug for major depression.• Therapeutic effect: 1-3 wks• Full relief of symptoms: 1-2mos• Tx of enuresis in children >6yo due to its anticholinergic effects 31
    32. 32. 1. Tricyclic Anti-Depressants (TCA)• Amitriptyline HCl• Desipramine HCl• Imipramine HCl (Tofranil) 32
    33. 33. 1. Tricyclic Anti-Depressants (TCA)Contraindications:• Recent MI – Reinfarction can occur• Undergone myelography within prev 24h or in the next 24h• Should not be taken with MAOI – Severe HYPERPYRETIC CRISIS with severe convulsion – Elevated BP and death 33
    34. 34. 1. Tricyclic Anti-Depressants (TCA)Caution:• With cardiovascular disorders• Hx of seizures – Seizure threshold may decreased• Renal and liver disease 34
    35. 35. Adverse Effects:• ORTHOSTATIC HYPOTENSION = most serious• Anticholinergic effects – Dry mouth – blurred vision – Photophobia – constipation – urinary hesitancy – Tachycardia• Sedation• Dysrhythmias = slows heart conduction• Lowers seizure threshold 35
    36. 36. 1. Tricyclic Anti-Depressants (TCA) Note: NO MILK/MILK PRODUCTSContain tryptophan = precursor of serotonin 36
    37. 37. Examples of TCAs (3 SISTERS): PAM ELLOR ELA VIL T OFRA NIL 37
    38. 38. 2. Monoamine Oxidase Inhibitors• MAO is an enzyme found in liver, intestinal wall and terminals of monoamine-containing neurons• Function: – convert norepinephrine, serotonin and dopamine into inactive products – In intestine, MAO serves to inactivate tyramine and other biogenic amines in food 38
    39. 39. 2. Monoamine Oxidase Inhibitors• Isocarboxazid (Marplan)• Phenelzine (Nardil)• Tranylcypromine (Pamate) 39
    40. 40. 2. Monoamine Oxidase InhibitorsAction:• Irreversibly inhibit MAO• Preventing the inactivation of neurotransmitters.• Allows accumulation of such chemicals in postsynaptic receptors 40
    41. 41. 2. Monoamine Oxidase InhibitorsIndications:• Depression• Bulimia• Obsessive-Compulsive disorders 41
    42. 42. 2. Monoamine Oxidase InhibitorsContraindications:• + allergy to MAOI• Pheochromocytoma – Tumor of adrenal gland – Sudden ↑norepinephrine = HYPERTENSIVE CRISIS • 1st sign: pounding occipital headache • Give REGITINE (antidote)• Cardiovascular dse• Scheduled for myelography w/in past 24h to next 48h = reaction to dye 42
    43. 43. 2. Monoamine Oxidase InhibitorsCaution:• Psyche pt = lead to overstimulation/manic phase• Seizure disorders & hyperthyroidism = exacerbate stimulation of drug 43
    44. 44. 2. Monoamine Oxidase InhibitorsAdverse Effect• In contrast to TCA, MAOI cause direct CNS stimulation – Excessive stimulation produce: • anxiety • Agitation • Hypo/hypermania• Orthostatic hypotension 44
    45. 45. MAOI + TYRAMINE not compatible Cause HYPERTENSIVE CRISISSpecial Nursing Consideration:• NO TYRAMINE RICH FOOD – Processed foods – Fermented foods – Preserved foods – Ex. Use of yeast, cheese, f.sausage, aged fish and meat – Give WHITE wine & cheese (cottage) 45
    46. 46. Examples of MAOI: PA RNATE MA RPLAN NA RDIL 46
    47. 47. 3. Selective Serotonin Reuptake Inhibitors (SSRI)• Block the reuptake of serotonin into the nerve terminal of the CNS• Enhancing its transmission at the serotonergic synapse 47
    48. 48. 3. Selective Serotonin Reuptake Inhibitors (SSRI)Indications:• Major depression• Anxiety disorders: – Obsessive-compulsive – Panic – Phobias – Posttraumatic stress disorders 48
    49. 49. 3. Selective Serotonin Reuptake Inhibitors (SSRI)• Fluoxetin (Prozac, Sarafem)• Paroxetine (Paxil)• Sertraline (Zoloft) 49
    50. 50. 3. Selective Serotonin Reuptake Inhibitors (SSRI)Contraindications:• + allergy to drugs• Pregnancy and lactationCaution:• Impaired renal/liver functions 50
    51. 51. Adverse Effects:• ↑ Serotonin levels – Headache – Drowsiness – Insomnia – Tremors – Agitation – Seizures• GU – Painful menstruation – Cystitis – SEXUAL DYSFUNCTION – IMPOTENCE 51
    52. 52. If pt wants to get pregnant To change drug:Gradual ↓dosage of SSRI to MAOI Examples of SSRI: Z OLOFT PA IL PRO AC 52
    53. 53. 4. Atypical Antidepressants• Also called second-generation antidepressants• Affect 1 or 2 of the 3 neurotransmitters (serotonin, dopamine& norepinephrine)• Used in treating depression who do not respond to other antidepressants• Examples: – bupropion (Wellbutrin) – amoxapine (Asendin) – nefazodone (Serzone) 53
    54. 54. Anti-DepressantsGeneral Nursing Considerations:• Maintain initial dosage for 4-8wks to achieve full therapeutic effect.• Maintain suicide precaution for severely depressed clients• Monitor BP and PR on regular schedule; q4• Instruct to avoid sudden change in position – to prevent orthostatic hypotension• Advise to avoid hazardous activities if sedation is prominent 54
    55. 55. Anti-DepressantsGeneral Nursing Considerations:• Encourage to undergo ECG prior and during tx• Instruct not to abruptly stop taking the drug. Dosage should be gradually decreased• Encourage client who wants to get pregnant to consult HCP about possible teratogenic effects of the drug on fetus. 55
    56. 56. Anti-DepressantsGeneral Nursing Considerations:• Take drug with food if GI upset occurs.• Advise that antidepressants may be taken at bedtime to decrease the dangers from the sedative effect 56
    57. 57. Mood Stabilizers (ANTI-MANIA) Tx for Bipolar disorder(Manic-Depressive Disorders) Lithium Valproic acid Carbamazepine 57
    58. 58. 1. LithiumActions:• Alters sodium transmission in nerve and muscle cells• Inhibit release of norepinephrine and dopamine but not serotonin• In manic client, lithium reduces euphoria & hyperactivity• Antimanic effect begins at 5-7days after onset of tx• Full benefit: 2-3 wks 58
    59. 59. 1. Lithium• Lithium – Carbolith – Duralith – Eskalith – Lithonate 59
    60. 60. 1. LithiumIndications:• Controlling acute manic episodes in Bipolar disorder• Long-term prophylaxis against recurrence of mania and depression 60
    61. 61. 1. LithiumPharmacokinetics• Absorption: oral• Distribution: all tissues & body fluids• Elimination: kidney• Short half-life due to rapid renal excretion. 61
    62. 62. 1. Lithium• Renal excretion is affected by blood levels of sodium.• Lithium excretion is reduced when blood levels of sodium are low.• Thus, toxicity happens when there is not enough sodium in the blood• Dehydration will cause lithium to remain in kidneys, accumulation can lead to toxicity 62
    63. 63. 1. Lithium• Therapeutic level: – 0.8-1.4 mEq/L• >1.4mEq/L = toxic 63
    64. 64. 1. LithiumContraindications:• + hypersensitivity• Pregnancy and lactation• Renal/cardiac disease• Hx of leukemia• Metabolic disorders (Na++ depletion, dehydration and diuretic use) 64
    65. 65. 1. LithiumCautions:• Any condition that could alter Na++ level – Diarrhea – Excessive sweating – Infection with fever 65
    66. 66. 1. LithiumAdverse Effects:<1.5mEq/L:• Lethargy• Slurred speech• Muscle weakness• Fine tremor• Polyuria – renal toxicity1.5-2.0mEq/L• Increased intensity s/sx• ECG changes 66
    67. 67. 1. LithiumAdverse Effects:2.0-2.5 mEq/L• Ataxia• Clonic movements• Hyperreflexia• Seizure• Cardio effects: severe ECG changes & hypotension• Large output of diluted urine secondary to renal toxicity• Fatalities = pulmo toxicity 67
    68. 68. 1. LithiumAdverse Effect:>2.5 mEq/L• Complex multi-organ toxicity = death 68
    69. 69. 1. LithiumSpecial Nursing Considerations:1. Draw samples immediately before the next dose (8-12hrs after previous dose)2. Advise to maintain adequate fluid intake – 2-3L/day initially – 1-2L/day maintenance3. advise to maintain adequate Na++ intake and to avoid crash diets that affect physical and mental health 69
    70. 70. 1. LithiumSpecial Nursing Considerations:4. Can be taken with meals – to decrease gastric irritation5. Therapeutic effect will be observed after 1-2 weeks6. Advice client who are planning to conceive to consult with HCP about possible teratogenic effects on fetus 70
    71. 71. 2. Valproic AcidAction:• Control symptoms in acute manic episodes• Can provide prophylaxis against recurrent episodes of mania and depression• Has higher therapeutic index than lithium and more desirable side effects 71
    72. 72. 2. Valproic AcidAction:• Increases levels of GABA in brain, resulting to decreased seizure activity• Starting dosage in adult: – 250mg, tid• Maintenance 1000-2500mg/day 72
    73. 73. 2. Valproic Acid• Depakene-syrup• Depacon-injection 73
    74. 74. 2. Valproic AcidAdverse Effects:• GI – N&V – Diarrhea – Dyspepsia – Indigestion – Depakote = to minimize these effects• Blood dyscrasia: – Thrombocytopenia – Leucopenia• Hepatotoxicity 74
    75. 75. 2. Valproic AcidSpecial Nursing Consideration:• Monitor for dev’t: – Sore throat – Fever – Purpura – Jaundice – Excessive and progressive weakness 75
    76. 76. 3. Carbamazepine• Like lithium, reduces symptoms of manic and depressive episodes• Preferred for – with mixed mania/rapid-cycling bipolar disorder• For tx of acute manic episodes, dosage increases• Maximum dosage: 1600-2000mg/day 76
    77. 77. 3. Carbamazepine• Carbatrol• Tegretol• Epitol 77
    78. 78. • Hematologic effects: – Leucopenia – Anemia – Thrombocytopenia – Aplastic anemia 78
    79. 79. Case AnalysisM.H, 38 years old, was started on oral lorazepam for her anxiety attacks. Four days after, she calls the clinic complaining that the dose must not be high enough because she reports that her symptoms of anxiety have been increased. She feels euphoric and excited for no reason and she has difficulty falling asleep.a. What is the therapeutic action of lorazepam?b. What is your assessment of the client’s problem?c. What will be your nursing interventions at this time? 79