CNS DEPRESSANTS
ex: secobarbital & pentobarbital
SLEEP
- state of unconsciousness from which a pt.
can be aroused by appropriate stimulus.
- to maintain body function such as:
> equilibrium
> strengthening immune system
Reasons for insomnia:
- anxiety, sleeping pattern, environment,
respiratory disorders
- diet: coffee, exercise, alcohol (causes
sedation & disrupts sleep pattern)
- medications: corticosteroids , selective
serotonin re-uptake inhibitor (SSRI),
antidepressants, theophylline,
pseudoephedrine, ephedrine
CNS DEPRESSANTS
- depress overall CNS functions: alertness,
orientation, ability to perform motor function
• Anxiolytics – prevent feelings of tension or
fear
• Sedatives – calms pt. & make them
unaware of their environment
• Hypnotics – can cause sleep and extreme
sedation
• Minor tranquilizers – can produce a state
of tranquility in anxious pt.
Goal for use:
- to improve sleep patterns for temporary
insomnia
- to ↓ level of anxiety
- to ↑ relaxation before diagnostic procedure
or operation
BARBITURATES
• absorbed well reaching peak levels in 20-
60 min.
• known to induce liver enzyme systems.
Classification of Barbiturates:
1. Long-acting - used to control seizures in
epilepsy
ex: phenobarbital & mephobarbital
2. Intermediate-acting - useful as sleep
sustainers, to maintain long periods of sleep, it
takes an hour for the onset of sleep (not
prescribed for those who have trouble getting
to sleep)
ex: amobarbital, aprobarbital, &
butabarbital (among naka apron & boots)
3. Short-acting - used to induce sleep (with
difficulty falling asleep); it may cause the
person to be awaken early in the morning.,
take effect within 15 – 30 min (do not mix
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with other medications, given in deep IM
4. Ultra short-acting - used as general
anesthesia / adjunct
ex: thiopental sodium
BARBITURATES - “barbi”
- for short term use only (2 wks or less)
- class II controlled substance in US
- if with fluid deficit may potentiate hypotensive
effects
- when used as hypnotics, it suppress REM,
stage 3 & 4 sleep pattern → hangover
- long half-life →daytime residual sedation.
- ↓ therapeutic effect of phenytoin
(anticonvulsant)
Side Effects:
1. Hangover – residual drowsiness, with
distortion of mood & impaired coordination
2. REM rebound
3. Dependence – results from chronic use
withdrawal symptoms:
muscular twitching, tremors, dizziness,
orthostatic hypotension, delusion,
hallucinations, delirium, & seizures
- It starts within 24 hours and last for
several days.
4. Tolerance – results when there is a need
to increase the dosage over time to obtain
the desired effect.
5. Excessive Depression – results from long
term use (lethargy, sleeplessness, lack of
concentration, confusion, psychologic
depression
6. Respiratory depression
7. Hypersensitivity – rashes & urticaria
BENZODIAZEPINES – “zepam” “zolam”
- a minor tranquilizer or anxiolytics
- wide safety margin between therapeutic &
lethal;
- overdose well tolerated & not fatal
- Schedule IV
- lipid soluble ; readily absorbed from GI
- half-life is 25 – 50 hours
- cumulative effects may result
- traces of its metabolites present in urine for
weeks / months after the person has stopped
taking the drug
diazepam (Valium), alprazolam (Xanax),
lorazepam (Ativan), flurazepam (Dalmane),
triazolam (Halcion), estrazolam (Prosam)
Indication:
anxiety, alcohol withdrawal, hyper-excitability &
agitation; pre-op anxiety & tension; aids in
balance anesthesia
Side effects:
- long term use can cause tolerance within
weeks
- REM rebound/ compensatory REM sleep
- dizziness, drowsiness, N & V, unsteadiness
- if with slurred speech, vision changes – report
3-4 days.
- transient hypotension
Adverse effects:
Nervous System: lethargy, depression,
blurred vision, headaches, apathy, & confusion
1st week of therapy: mild paradoxical excitatory
reactions (nervousness & insomnia)
GI conditions: dry mouth, constipation, N/V,
increased liver enzymes
CV: ↑↓ BP, arrythmias, palpitation & respiratory
difficulties
Hematologic conditions: blood dyscracias &
anemia
GU: urinary retention, ↓libido, changes in
sexual functioning, hepatotoxicity – anorexia,
N/V, jaundice, hepatomegaly, spleenomegaly,
abnormal liver test (↑AST, ↑ALT, ↑prothrombin
time)
Drug Interactions:
cimetidine - ↓ metabolism of flurazepam
barbiturates - ↓ effectiveness of
flurazepam by ↑metabolism of
benzodiazepam
Antidote: flumazenil (Romazicon)
Caution :
– Psychosis , Acute narrow angle
glaucoma, coma, shock
– Acute alcohol intoxication
– Pregnancy – cleft lip and palate,
inguinal hernia, pyloric stenosis,
cardiac defects, microcephaly
– Theophyline and ranitidine - ↓
effect of benzodiazepines
CHLORAL HYDATE
- used as sedative for diagnostic procedures
- induce sleep & decrease nocturnal
awakening
- less occurrence of S/E
- effective for older adults & with mild liver
dysfunction
- does not depress respiration & cough reflex
- gastric irritation is common – take with full
glass of water
OTHER SEDATIVE-HYPNOTICS
- all have effects of rebound REM sleep,
insomnia & tolerance
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paraldehyde (Paral) - old drug ; bitter tasting
with foul smell breath (pt. unaware);
– delirium tremens and extreme excitement
– do not administer or dispense in plastic
containers
diphenhydramine (Benadryl)
hydroxyzine HCl ( Atarax, Vistaril)
- used in pre-op & as post-op to ↓narcotic
- for short term relief of anxiety
- can cause drowsiness & have sedative
effect
- do not cause tolerance
- used temporarily when other anti-anxiety
have been abused
- monitor for thickened respiratory secretions
buspirone (BuSpar)
- has lower sedative properties
- no S/E like benzodiazepine
- no anticonvulsant or muscle relaxant
property
- no physical dependence
- effective only after 1 – 2 wks of continued
use
meprobamate (Equanil, Miltown)
- used to treat anxiety before
benzodiazepine was made
- for short-term relief of anxiety
- used for its muscle relaxant properties in
OR
NARCOTIC ANALGESIC
• also known as narcotic agonists
• for moderate to severe pain
• not only suppress pain impulses but can
suppress respiration & cough centers in the
medulla
Strong Agonist
morphine (Morphine Sulfate)
- an extract form opium
- very potent
CI: severe respiratory disorder
↑ ICP
severe renal disease
- monitor VS esp. RR, UO, bowel
sound, pupilary changes and reaction
(pinpoint pupils – indicates overdose)
antidote : naloxone (Narcan)
meperidine (Demerol)
- 1st synthetic narcotic
- Schedule II
- shorter duration than morphine
- no antitussive property
- can be given during pregnancy
 - major side effect : - narcotic antagonist (naloxone(Narcan)
hypotension is added to a narcotic agonist to↓narcotic
abuse
Side effects of narcotics
1. repiratory depression Ex: pentazocine (Talwin) – needs to be
2. orthostatic hypotension mixed
3. tachycardia butorphanol (Stadol)
4. drowsiness & mental confusion nalbuphine (Nubain
5. constipation
6. urinary retention Narcotic Antagonists
7. pupilary constriction (sign of toxicity) - antidotes for overdoses of narcotics
8. tolerance - higher affinity to the narcotic receptor
9. psychologic & physical dependence site than the narcotics
Withdrawal symptoms (Abstinence - blocks the receptor & displaces any
syndrome) narcotic that would be at the receptor
- occurs 24-48 hours after the site
last narcotic dose Ex: naloxone (Narcan)
- most unpleasant but not as naltrexone HCl (Trexan)
severe or life-threatening as – per orem
those that accompany nalmefene (Revex)
withdrawal from sedative –
hypnotics (a process that may Methadone treatment program
lead to convulsion) - It helps to withdraw narcotic addicted
person from heroin or similar narcotics
Sx: irritability, diaphoresis, without causing withdrawal symptoms
restlessness, muscle twitching, ↑PR & BP - It causes less dependency

CI of Narcotics: 2 Types of Methadone Program:

 Clients with head injuries (narcotics 1. Weaning program
↓resp., thus causing an accumulation of 2. Maintenance program
CO2. With ↑CO2 retention, blood
vessels dilate, esp. cerebral vessels →
↑ICP) ANESTHETICS
 Respiratory disorders (in asthmatic,
narcotics ↓resp. drive while Overton Meyer Theory
simultaneously increasing airway  the greater solubility in fat the greater
resistance) the effect
 Shock with very low BP  medulla centers are depressed last

Adverse Effects and Nursing Care : ANESTHETIC AGENTS

respiratory depression with apnea &
cardiac arrest
orthostatic hypotension, light
headedness, dizziness, psychoses
N/V, constipation , biliary spasm
GU effects – spasms, retention and ↓
libido
Moderate Agonist
codeine
- has about ½ the analgesic potency of
morphine (used for milder pain)
- very useful as cough suppressant
- produces less sedation or respiratory
depression and fewer GI effects
- addiction and withdrawal is less
severe
Opiate Partial Agonists
 interfere with nerve conduction
 diminish pain and sensation
 have affinity for nervous tissue
 action is reversible upon elimination of
drug from cells
Stages of Anesthesia
1. Analgesia
– induction state, ends with loss of
consciousness, IV anesthetics
2. Excitement or delirium
– loss of consciousness, short,
dangerous due to systemic stimulation
3. Surgical anesthesia
– operation is performed, inhalation or
gas anesthetics are given as maintenance
4. Medullary paralysis
– toxic stage, very deep CNS
depression (death may occur)
Recovery – discontinuation of anesthetics until
consciousness regained

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Balanced anesthesia
- Combination of drugs each with a specific
effect to achieve analgesia, muscle relaxation,
unconsciousness, amnesia.
Balanced Anesthesia
• Preoperative medications
– Anti-cholinergics to decrease
secretions and facilitate
intubation
• Sedative/hypnotics
– Relax the patient, facilitate
amnesia
• Antiemetics
– Decrease N/V associated with
GI depression
• Antihistamines
– Dry secretion and decrease
chance of allergic response
• Narcotics
– Aid analgesia and sedation
Purpose of balanced anesthesia :
1. Minimizes CV problems
2. ↓ the amount of general anesthesia
3. Reduces possible post-anesthetic N/V
4. ↑ recovery from anesthesia
5. Fewer S/E of general anesthesia
Classifications of Anesthesia
A. General Anesthesia
1. Inhalation anesthesia
Intravenous anesthesia
a. Anesthetic gases
a. barbiturates
b. Volatile liquids
b. non-barbiturates
B. Regional Anesthesia
1. topical 4. nerve
block
2. infiltration 5.
regional anesthesia
3. field block
General Anesthesia
- used to produce loss of pain sensation
& consciousness
- blocks body’s reflexes (heart,
respiration, GI & immune status
- provide controllable anesthesia
- allegic reactions are uncommon
Malignant hyperthermia may
occur --- muscle rigidity
hyperthermia
Tx: dantrolene (Dantrium)
• Dantrolene is associated with
potentially fatal cellular damage. Any
patient on dantrolene should
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• monitored for signs of liver damage and
have liver function tests done regularly
Chloroform – no longer used due to liver
toxicity
General Anesthesia per inhalation
Nursing Considerations:
1. Monitor temperature & BP
2. Assess client for any pain
3. Avoid sudden change in position
4. Provide warmth
General anesthesia
1. Inhalation anesthesia
a. Anesthetic Gases
 Nitrous Oxide (laughing gas)
(blue cylinder) – a potent
analgesic
- weakest of the gas
anesthetic & least toxic
- 1st anesthetic used
- used in dental surgery
 Cyclopropane (orange
cylinder)phase
- rapid onset, rapid recovery
- not a good analgesic, may
experience pain, headache,
N/V, delirium during
recovery
- Highly flammable (no
longer being used)
 Ethylene (red cylinder)
- less toxic
- can have headache
- with unpleasant taste
b. Volatile liquids
- unstable at room temperature
- releases gas (halogenated
hydrocarbons)
 Halothane (Fluothane)
- non-flammable anesthetic
IV - has rapid induction time
- has rapid recovery
- has a bronchodilator effect
- metabolized in the liver to
toxic hyrocarbons & bromide
- halothane hepatitis – fever,
anorexia, N/V & hepatitis
 Desflurane (Suprane)
- associated with resp.
and reaction – cough, ↑
secretions & laryngospasm
- not for pediatric clients
 Enflurane (Ethrane) - renal
toxicity and cardiac arrhythmias
 Isoflurane – can cause muscle
relaxation
  Methoxyflurane (Penthrane) – 2. Infiltration – injecting anesthetic agent
rarely used except during labor & directly into the tissues to be treated.
delivery. 3. Field block – injecting anesthetic all
- around the area that will be affected by
doe the operation.
s 4. Nerve block – injecting anesthetic at
not some point along the nerve in which
rela loss of pain sensation or muscle
x paralysis is desired.
the - spinal anesthesia
ute - caudal block
rus - epidural anesthesia
2. Intravenous anesthesia - saddle block
- used for induction & maintenance of
general anesthesia per inhalation 5. IV Regional Anesthesia
- rapid onset & short duration of action  Blood is drained from leg or arm,
- it decrease the amount of inhalation tourniquet is applied & anesthetic is
anesthesia required injected into the vein of the arm or leg.

a. Barbiturates – IV drugs as adjunct Overall Assessment:

with inhaled anesthesia  Hypotension
 thiopental (Pentothal) –  Rapid PR
most widely used, but no  GI upset
analgesic property  Dysuria
 methohexital (Brevital) –  Injury to the nerves
cannot come in contact with  Pain, heat or redness over a vein
silicon.  Extreme anxiety or other behavioral
changes
b. Non-barbiturates  Changes in skin temp. / color
midazolam (Versed). droperidol
(Inapsins), ethomidate (Amidate)

ketamine (Ketalar) – appears to

be awake but is unconscious & cannot feel the
pain.
- Avoid
premature awakening
Propofol (Diprivan) – can cause
local burning upon injection
• Cautions:
– Status Asthmaticus
– Absence of suitable veins for
intravenous administration
• Adverse Effects
– Depressive effects – CNS, CV
and Respiratory
– Malignant Hyperthermia –– Tx.
Dantrolene
– Risk for skin breakdown
– Nephrotoxicity

Regional Anesthesia
- blocks pain at the site where the drug
is administered, allowing consciousness to be
maintained.
- for dental procedures, suturing, minor
surgery, spinal anesthesia & diagnostic
procedures
- temporary conduction of the nerve
impulses are interrupted,preventing Na+ ions
from sia
1. Topical

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