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Chapter 19-The Nervous System
-responsible for controlling the functions
of the human body
-analyzes incoming stimuli
-integrating internal & external stimuli
2 components of the Nervous System
 CNS (Central, Brain and Spinal
cord)
 PNS (Peripheral, motor nerves
and receptors)
Neurons
>the structural unit of the Nervous
system
>conducts action potentials to send
messages to the control center (Brain) to
respond to internal and external stimuli
Components of neurons:
>soma (cell body)
-cell nucleus
-cytoplasm
>dendrites (short, branch-like
structures)
>axon hillock (base of axon)
>axons (Nervous
pathways/transmitters)
Contains 2 fiber tracts:
1. Afferent fibers (from receptors
to CNS)
2. Efferent fibers (from CNS to
periphery for stimulation of
muscles & glands)
>Ganglia
 group of nerve bodies responsible
for regeneration of damaged axon
or dendrites
NOTE:
STIMULATION OF A NEURON IS
DEPOLARIZATION, AND CANNOT
BE STIMULATED AGAIN UNTIL IT
HAS REPOLARIZED.
(DEPOL=Na+ channels open, K-
lessens inside the cell)
(REPOL=Na+ channels close,
electrolyte imbalance balances)
Nerves require energy (oxygen &
glucose)
Has a myelin sheath
Myelin sheath
>speeds up electrical conduction and
prevents fatigue of the nerve
Myelinated nerves have Schwann cells.
Nodes of Ranvier
-unexposed areas that allows electric
impulses to skip from one node to the
next which generates an action potential.
Because of the firing potential of the
Nodes of Ranvier, speed of conduction is
much faster, and the nerve is protected
from fatigue.
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Node-to-Node interaction: SALTATORY

or LEAPING CONDUCTION.

NERVE SYNAPSES
-nerve to nerve communication
-the electrical impulse comes to a
halt, and transmission of
information turns to a chemical
reaction.
-the nerve axon releases a
chemical called a
neurotransmitter.

Neurotransmitters
-inhibits or excites postsynaptic cells
Selected neurotransmitters:
• Acetylcholine
• Norepinephrine/epinephrine
• Dopamine
• Gamma-aminobutyric acid
(GABA)
• Serotonin

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Chapter 20-Anxiolytic & Hypnotic Commonly used Benzodiazepines

Agents as Anxiolytics/Hypnotics w/
Indications
1. Alprazolam (Xanax)
Anxiolytics  Anxiety, panic attacks
➢ prevent feelings of tension or  SpC: Taper after long-term
fear therapy

➢ sedatives 2. Chlordiazepoxide (Librium)

 Anxiety
- can calm patients and make  Alcohol withdrawal
them unaware of their  Preoperative anxiolytic
environment  SpC: Monitor Injection
Sites

Hypnotics 3. Clorazepate (Tranxene)

> can cause sleep
➢ minor tranquilizers can produce
a state of tranquility in anxious
patients.
BENZODIAZEPINES
 A class of psychoactive drugs.
 Used to block excess activity of
nerves in the brain and other
areas of the CNS.
 Commonly used to alter patterns
of withdrawal and “cravings” within
the brain.
 Anxiety, alcohol
withdrawal,partial seizures
 SpC: Taper dosage
4. Diazepam (Valium)
 PROTOTYPE
 SpC: Taper after long-term
therapy, monitor injection
sites (When given as IM or
IV)
5. Estazolam (ProSom)
 Hypnotic
 Treatment for Insomnia
 SpC: Monitor hepatic and
renal function; Test CBC in
long-term use
6. Flurazepam (Dalmane)
 Hypnotic
 Treatment of Insomnia
 SpC: Monitor hepatic and
renal function; Test CBC in
long-term use

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7. Lorazepam (Ativan)
 Anxiety
 Preanesthesia anxiolytic
 SpC: Monitor injection sites
(Given in IM or IV); reduce
dosage of narcotics when
given with this drug
8. Oxazepam (Serax)
 Anxiety
 Alcohol Withdrawal
 SpC: Best with elderly
9. Quazepam (Doral)
 Hypnotic
 Treatment of Insomnia
 SpC: Monitor hepatic and renal
function; Test CBC in long-
term use; Taper after long-
term therapy
10. Temazepam (Restoril)
 Hypnotic
 Treatment of Insomnia
 SpC: Taper after long-term
therapy
11. Triazolam (Halcion)
 Hypnotic
 Treatment of Insomnia
 SpC: Monitor hepatic and
renal function; Test CBC in
long-term use; Taper after
long-term therapy
NOTE:
BARBITURATES AND
BENZODAIZEPINES HAVE THE SAME
MECHANISM OF ACTION
Pharmacokinetics
 Benzodiazepines are usually well
absorbed in the GI Tract
 Peak levels are achieved usually
in 30mins to 2 hrs.
 Lipid soluble and well distributed
throughout the body
 Crosses placenta and enters
breast milk
 Metabolized extensively in the
liver
 Excretion is primarily through
urine
Contraindications & Cautions:
 Allergy to benzodiazepines
 Psychosis
(delusions/hallucinations)
 Acute narrow-angle glaucoma
 Shock
 Coma
 Acute alcoholic intoxication (may
exacerbate depressant effects of
drug)
 Pregnancy
 Lactation
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 Should not be taken with alcohol  Perform lab tests (Renal and
or other CNS depressants
Hepatic)
 Cimetidine, Oral contraceptives
 Theophylline or ranitidine  Function tests and Complete
Blood Count (CBC)

Adverse Effects:  SHOULD NOT BE

Half-life of Medications
 Half-life refers to time required
until medication reaches peak
effectiveness
Medications:
1. Alprazolam (6-12hrs)
BARBITURATES
2. Chlordiazepoxide (5-30hrs)
3. Clonazepam (18-50hrs)
4. Diazepam (20-100hrs)
5. Lorazepam (10-20hrs)
6. Oxazepam (4-15hrs)
7. Temazepam (8-22hrs)
8. Triazolam (2hrs)
ADMINISTERED INTRA-
ARTERIALLY
 IV MEDS SHOULD NOT BE
MIXED IN SOLUTION OR ANY
OTHER DRUGS
 Ambulatory patients given
benzodiazepines should not be
permitted to operate a motor
vehicle (due to behavioral effects)
 Taper dose gradually
 If overdosed, give FLUMAZENIL
(Romazicon) as antidote.
 AKA Downers due to hypnotic
effects
 Long up to 2hrs) and short lasting
(5-30mins) effectiveness
 May be injected but usually taken
as pills
 Due to potency, risk of addiction
and dependence is greater

Nursing Considerations: Therapeutic Actions:

 Inhibits neuronal impulse in
 Assess for contraindications and ascending Reticular
cautions Activating System
(responsible for
 Assess baseline status consciousness level, attention
span, pain perception,
changes in mood, anxiety and

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aggression) causing CNS
depression
Barbiturates used as Anxiolytics-
Hypnotics w/ Indications
1. Amobarbital (Amytal sodium)
 Sedative-Hypnotic
 Used for convulsions
 Manic reactions
 SpC: Monitor if in IV
administration
2. Butabarbital (Butisol)
 Short-term sedative-
hypnotic
 SpC: Taper gradually after
long-term use; caution
when administered to
children; may produce
aggressiveness,
excitability
3. Mephobarbital (Mebaral)
 Anxiolytic and antiepileptic
 SpC: Taper gradually after
long-term use; caution
when administered to
children; may produce
aggressiveness,
excitability
4. Pentobarbital (Nembutal)
 Sedative-Hypnotic;
preanesthetic
 SpC: Taper gradually; Give
IV slowly; Monitor injection
sites
5. Phenobarbital (Luminal)
 PROTOTYPE
 Sedative-Hypnotic
 Control of seizures
 SpC: Taper gradually after
long-term use; Give IV
slowly; monitor injection
sites
6. Secobarbital (Seconal)
 Preanesthetic sedative
 Used for convulsive
seizures of tetanus
 SpC: Taper gradually after
long-term use
Pharmacokinetics:
 Absorbed well orally and is
distributed throughout the
body
 Redistribute in the body from
brain to skeletal muscle, then
to adipose tissue
 Readily cross placenta and
can depress fetus
 Metabolized in the liver
 Excreted through urine
Adverse Effects:
 Pain
 Allergic skin lesions
 Drowsiness
 Hangover effect
 Overexcitement
 Nightmares and Night terrors
 Weakness
 Lethargy
Clinically Important Drug–Drug
Interactions:
➢ altered response to phenytoin
if it is combined with barbiturates
➢ MAOI’s - increased serum
levels and effects occur
➢ oral anticoagulants, digoxin,
tricyclic antidepressants,
corticosteroids, oral
contraceptives,
➢ estrogens, acetaminophen,
metronidazole, carbamazepine,
beta-blockers, griseofulvin,
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phenylbutazones, theophyllines, Chapter 21: Antidepressants

quinidine, and doxycycline
DEPRESSION
➢ Feeling of sadness that are
Other Anxiolytics/Hypnotics much more severe and long
lasting than the precipitating
➢ Antihistamines (promethazine
event.
[Phenergan], diphenhydramine
[Benadryl]) Biogenic Amine Theory of
Depression
➢ Buspirone (BuSpar)
 Theory that states
➢ Dexmedetomidine (Precedex) depression is a result from a
deficiency of biogenic
➢ Eszopiclone (Lunesta)
amines in key areas of the
➢ Meprobamate (Miltown) brain

➢ Ramelteon (Rozerem), Biogenic Amines:

1. Norepinephrine
➢ Zaleplon (Sonata)
2. Dopamine
➢ Zolpidem (Ambien)
3. Serotonin
Antidepressants
 Drugs used to relieve or
prevent psychic depression
 Works by altering the way
neurotransmitters work in our
brains (Depression causes
some neurotransmitter
systems to not work
properly)
 Increases the effects of the
biogenic amines in the brain

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Types of Antidepressants:
1. Tricyclic Antidepressants
 Reduces/Inhibits reuptake of
serotonin (5HT)
norepinephrine (NE) into
nerves
 Indicated for relief
symptoms of depression
2. Selective Serotonin Reuptake
Inhibitors (SSRIs)
 Newest group
antidepressant drugs
 Specifically blocks reuptake
of Serotonin
 Less adverse effects
compared to TCAs and
MAOIs
3. Monoamine Oxidase Inhibitors
(MAOI)
 Irreversibly inhibits MAO, and
enzyme found in nerves and
tissues to break down
norepinephrine, dopamine,
and serotonin to relieve
depression
 USED AS A LAST RESORT
DUE TO TOXICITY
4. Atypical Antidepressants
 Unique medication that does
not work like typical
antidepressants
 Most common: Wellbutrin
Tricyclic Antidepressants
PROTOTYPE: Imipramine
Indications: Relief of symptoms of
and
depression; enuresis in children older
than 6 years
of Pharmacokinetics
➢ well absorbed from the gastrointestinal
(GI) tract, reaching peak levels in 2 to 4
of hours.
➢ highly bound to plasma proteins and
are lipid soluble
➢ metabolized in the liver and excreted
in the urine, with relatively long half-lives,
ranging from 8 to 46 hours.
➢ TCAs cross the placenta and enter
breast milk
Contraindications and Cautions
 Allergy
 Recent myocardial infarction
(cardiac arrest)
 Myelography (lab test with dye)
 Concurrent use of MAOI (toxic
reaction)
 Any existing cardiovascular
disorders
 Angle-closure glaucoma
 Urinary retention
 Prostate hypertrophy
 Post-op GI or Genitourinary (GU)
surgery
Adverse Reactions:
 Sedation
 Dry mouth
 Visual disturbances
 Dry eyes
 Urinary retention
 Constipation
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 Photosensitivity  PROTOTYPE: PHENELZINE

Therapeutic Action of MAOI:

Clinically Important Drug–Drug > Blocks the breakdown of the
Interactions: biogenic amines NE, dopamine and
5HT allows these amines to
➢ given with cimetidine, fluoxetine, or accumulate in the synaptic cleft and
ranitidine, an increase in TCA levels in neuronal storage vesicles, causing
results. increased stimulation of the post
synaptic receptors.
➢ Oral anticoagulants

➢ Clonidine – increase risk of arrythmias

and Hypertension Contraindications and Cautions

➢ MAOI’s- risk of severe hyperpyretic  Contraindicated in elderly

crisis with severe convulsions, patients
hypertensive episodes and death.  Hypersensitivity to drugs
 Pheochromocytoma
 Liver, kidney or
Nursing Care: cerebrovascular disease
 Hypertension
1. Monitor glucose levels as it may  Hx of headaches
alter blood sugar due to intake of
 Congestive heart failure
TCAs.
 Intake of cheese, wine, yogurt
2. Give patient ice chips, hard candy,
or sugarless gum to relieve dry  Caution is advised with Pts w/
mouth. impaired lover function, Hx of
3. Carefully monitor blood pressure seizures, parkinsonian
before, during and after therapy. symptoms, diabetes,
4. Tell patient to avoid exposure to hyperthyroidism, risk of
direct sunlight or artificial UV light suicidal ideation or behavior.
5. Monitor intake- overdose is lethal.

Clinically Important Drug–Food

Monoamine Oxidase Inhibitors Interactions
(MAOIs) > Tyramine and other pressor
amines that are found in food
 A class of powerful
antidepressant drugs, particularly > tyramine causes the release of
effective in treating atypical stored NE from nerve terminals,
depression, panic disorders, which further contributes to high
social phobia blood pressure and hypertensive
 A LAST RESORT when other crisis
classes of antidepressant drugs
have failed.

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MAOI Drug Interactions:
 CNS depressants (Meperidine),
alcohol, and anesthetic agents
SHOULD NOT be used with
MAOIs
 SSRIs and SNRIs are
contraindicated in patients on
MAOIs to avoid serotonin
syndrome
Selective Serotonin Reuptake
Inhibitor (SSRIs)
 A class of antidepressants most
prescribed to patients with
depression and anxiety disorders
 Increases extracellular level of
neurotransmitter serotonin by
inhibiting its reuptake into the
presynaptic cell
 PROTOTYPE: FLUOXETINE
LIST OF SSRIs
– citalopram (Celexa)
– escitalopram (Lexapro)
– fluoxetine (Prozac, Sarafem)
– fluvoxamine (Luvox)
– paroxetine (Paxil);
– sertraline (Zoloft)
– vilazodone (Viibryd)
Pharmacokinetics:
Absorption: Well absorbed orally
and peaks between 3-8hrs. May be
slightly increased by food intake.
Distribution: Difference in
plasma protein binding percentages, with
Fluoxetine & Paroxetine most highly
bound to site, and Escitalopram least
bound to site.
Metabolism: metabolized in liver
Wide Therapeutic Index
 Concentration of medication
is not affected by other drugs,
but may affect metabolism of
other drugs.
Contraindications and Cautions
 Caution in patients with
cardiac hx
 Diabetes
 SHOULD NOT BE GIVEN
UNTIL 2 WEEKS HAVE
PASSED FROM STOPPING
MAOIs INTAKE.
 Caution with hepatic/renal
impairment
 Monitor closely for Serotonin
Syndrome during first 2
weeks of therapy or increased
dosage.
Drug to Drug Interactions:
1. Combination with MAOIs should
be avoided.
2. At least 2 to 4 weeks should be
allowed between change of drugs.
Immediate change risks
serotonin syndrome.
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Nursing Considerations: Therapeutic Actions and Indications

 Medication should be tapered,  Typical Antipsychotic Drugs
not stopped immediately – block dopamine receptors,
 Takes 2 weeks for effectiveness preventing the stimulation of the
 Monitor for Serotonin Syndrome post-synaptic neurons by
(Occurs usually 72 hours after dopamine
starting drug) 2. Atypical Antipsychotic
 Monitor for suicidal ideation Drugs
- block both dopamine and
Chapter 22-Psychotherapeutic Agents serotonin receptors

Mental Disorder and Classification INDICATED FOR:

1. Schizophrenia  Schizophrenia
 Common type of psychosis  Hyperactivity
 Hallucinations  Combative
 Delusions Behavior/Aggression
 Agitation for elderly
 Speech Abnormality
 Affective Problems
2. Mania
 Typical Antipsychotic
 Characterized by periods of
Prototype:
extreme overactivity and
excitement CHLORPROMAZINE
(Thorazine)
 Bipolar Illness
3. Narcolepsy Indications:
 Characterized by sudden
periods of loss of Management of
wakefulness. manifestations of psychotic
4. Attention Deficit Disorders disorders; relief of
preoperative restlessness;
 Inability to concentrate on
adjunctive treatment of
one activity for longer than a
tetanus; acute intermittent
few minutes.
porphyria; severe behavioral
problems in children; control of
hiccups, nausea, and vomiting.
 Atypical Antipsychotic
Prototype: CLOZAPINE
(Clozaril)
Indications:
Management of severely ill
patients with schizophrenia
who are unresponsive to
standard drugs; reduction of
risk of recurrent suicidal

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behavior in patients with Drug-Drug Interaction

schizophrenia or
schizoaffective disorder. 1.Beta Blockers – increased effect
on both drugs
Pharmacokinetics
2.Alcohol – increased risk of CNS
 Is erratically absorbed in the GI depression
tract
 IM dosage is 4 to 5 times the
active dose as oral dosage Adverse Effects:
 Medication is stored in the tissues,
1. Extrapyramidal Symptoms ( EPS )
released for up to 6 months after
- Serious neurological symptoms
discontinued intake
associated with antipsychotic
 Crosses placenta and breast milk
medications.
Includes:
A. Acute Dystonia
Contraindications and Cautions a. Torticollis – twisted
 CNS depression, circulatory head and neck
collapse (failure of circulation, b. Opisthotonus –
falling in of the walls of a part or tightness in the entire
organ) body with the head back
 Coronary disease, bone marrow and an arched neck
suppression c. Oculogyric Crisis – eyes
 Severe hypotension rolled back in a locked
position
 Alcoholism
B. Pseudoparkinsonism
 Myelography within the last 24 hrs
– often referred to by the
generic label of EPS.
- symptoms include:
Depot Injections a. Stiff, stooped
 A type of injection formulation that posture
releases slowly over time to permit b. Masklike facies
less frequent administration of a c. Decreased arm
medication swing
d. Shuffling gait
Available form in Depot Injections: e. Pill rolling
movements of the
1. Prolixin (decanoate fluphenazine)
thumb
- Duration of 7 to 28 days.
C. Akathisia - continuous
2. Haldol ( decanoate haloperidol ) restlessness, inability to sit
still, and lack of
- Duration of 4 weeks. spontaneous gesture
* Stabilization of clients condition with 3. Tardive Dyskinesia
oral doses, administration of depot
injections is required every 2 to 4 weeks - a syndrome of permanent,
involuntary movements.

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- Pathophysiology is still not
understood. -no effective
treatment is available.
Major Symptoms: Involuntary
movements of the tongue, facial
and neck muscles, upper and
lower extremities, and truncal
musculature.
4. Respiratory effects such as
laryngospasm, dyspnea, and
bronchospasm.
5. May turn urine pink to reddish-
brown.
NOTE:
PATIENTS W/ SCHIZOPHRENIA
SHOULD BE ADVISED TO AVOID
EVENING PRIMROSE. (ASSOCIATED
W/ INCREASED SYMPTOMS AND
CNS HYPEREXCITABILITY)
Nursing Care and Responsibilities:
 DO NOT ALLOW PATIENT TO
CRUSH OR CHEW
SUSTAINED-RELEASE
CAPSULES. This is due to it
being metabolized orally, and
may cause toxicity due to high
dose.
 Monitor CBC
 Provide Positioning of
extremities. Regulates blood
flow and proper circulation.
 Provide sugarless candies and
ice chips for dry mouth/cotton
mouth.
 If parenteral form is
administered, put patient in
recumbent position.
Anti- Manic Drugs
Major Signs of Mania
• Heightened, grandiose, or
agitated mood.
• Exaggerated self-esteem
• Sleeplessness
• Pressured Speech
• Flight of Ideas
• Reduced ability to filter out
extraneous stimuli
• Increased number of activities
with increased activity
• Multiple, grandiose high-risk
activities using poor judgment with
severe consequences.
Drug of Choice:
Lithium Salts (Lithane, Lithotabs )
- taken orally for the
management of manic
episodes and prevention of
future episodes.
- serum therapeutic effect
0.6 to 1.2 mEq/L. - > 2.5
mEq/L complex multi-
organ failure
Therapeutic Actions and Indications
- alters sodium transport in nerve and
muscle cells.
-Inhibits the release of norepinephrine
and dopamine, but not serotonin.
- increases the intraneuronal stores of
norepinephrine and dopamine slightly.
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PHARMACOKINETICS DRUG TO DRUG INTERACTIONS

• Reaches peak levels in 30 mins to 3 •Lithium-haloperidol combination
hours
encephalopathic syndrome
• Slowly crosses the blood brain barrier (weakness, lethargy,confusion,
tremors,irreversible brain
• In periods of dehydration, kidney damage)
absorbs more lithium in the serum
• w/ carbamazepine
- increased CNS toxicity
CONTRAINDICATIONS & CAUTIONS
• Lithium-iodide salt
• Cardiac disease
- increased incidence of
• Sodium depletion; dehydration hypothyroidism
• Diarrhea Nursing Care:
• Excessive sweating  Administer drug with food or
• Infection with fever milk. Allows for effective
metabolism and delayed release.
• Pregnant patient  Arrange to decrease dose afte
acute panic attacks. Allows for
hyperactivity of brain to settle and
ADVERSE EFFECT prevent toxic effects of drug.
 Provide safety measures.
After performing serum blood tests, the
Provision of siderails, panic
following are its projected effects:
relaxation techniques, and the like
 Serum levels of <1.5 mEq/L: can help calm patient. DO NOT
CNS problems (Lethargy, slurred PANIC WITH THE PATIENT.
speech, muscle weakness, fine
CNS Stimulants
motor tremor)
 Serum levels of 1.5 to 2 mEq/L:  Treats attention deficit and
Intensifies all foregoing reactions narcolepsy
w/ ECG changes.  Paradoxically, these drugs calm
 Serum levels of 2 to 2.5 mEq/L: hyperkinetic children and help
Possible progression of CNS them to focus on one activity for a
effects longer period. They also redirect
 Serum levels > 2.5 mEq/L: and excite the arousal stimuli from
Complex multiorgan toxicity, with the RAS.
a significant risk of death.

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LIST OF CNS STIMULANTS & ITS IMPLEMENTATION

INDICATIONS
• Administer the drug before 6
• Methylphenidate (Ritalin) – ADHD pm. Metabolism of drug may
prototype impede sleep and change diurnal
rhythm.
• Dexmethylphenidate (Focalin)
• Arrange to dispense the least
• Dextroamphetamine (Dexedrine) amount of drug possible.
• Modafinil ( Provigil ) – tx narcolepsy Overdose of drug may lead to
death.
• Monitor weight, CBC and ECG.
Action
•Act as cortical and RAS stimulants, by
increasing the release of cathecolamines
from presynaptic neurons, leading to an
increase in stimulation of the
postsynaptic neuron

Pharmacokinetics
 Peaks at around 2 to 4
hours.
 Usual half life is 2 to 15
hours.

Drug to Drug interactions

• MAOIs
• Guanethidine- decrease in
antihypertensive affects
• TCAs or phenytoin- increased
drug levels

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