NCM 106:

ANXIOLYTICS and ANTI-

DEPRESSANTS
Ma. Concepcion A. Maico-Bacus, EdD, MAN, RN
Clinical Instructor
ANXIOLYTIC-HYPNOTICS
Introduction
• Anxiolytic-hypnotic agents are used to alter an individual’s responses
to environmental stimuli. These agents are referred to as anxiolytics
(prevent feelings of tension or fear), sedatives (help patient feel calm
and unaware of their environment), and hypnotics (help patients
sleep).
Common
Anxiolytic-
Hypnotics
Anxiety
• Anxiety is described as a feeling of tension, nervousness, and
apprehension which typically involves unpleasant reactions to a
stimulus both real and imaginary. It is accompanied by
sympathetic nervous system reactions like fast heartbeat, rapid
breathing, flushing, and sweating. Anxiety can be mild, moderate, or
severe.
Sedation
• Sedation is the loss of awareness and reaction to environmental
stimuli. However, this may be desirable for restless and irritable
patients. This is also beneficial for patients who are about to
undergo surgery.
Hypnosis
• Hypnosis is the further depression and sleep of the central nervous
system (CNS) which usually results from extreme sedation. In this
state, the person no longer senses or reacts to incoming stimuli.
Benzodiazepines Used as
Anxiolytic-Hypnotics
Benzodiazepines Used as Anxiolytic-
Hypnotics
• This is the most frequently used anxiolytic drug because it can lyse or
break the feeling of anxiety without causing much sedation and are
less likely to make patients physically dependent.
• Indicated for the treatment of the following conditions: anxiety
disorders, alcohol withdrawal, hyperexcitability and agitation, and
preoperative relief of anxiety and tension to aid in
balanced anesthesia.
Benzodiazepines Used as Anxiolytic-
Hypnotics
CHILDREN
• Response of children to these agents is unpredictable so indication of
this drug to the younger population remains to be a challenge.
• Children may be inappropriately aggressive, tearful, and irritable.
• Only clonazepam, clorazepate, and diazepam have
established pediatric dosage. Possible dried secretions and their
effect on breathing must always be assessed carefully.
Benzodiazepines Used as Anxiolytic-
Hypnotics
ADULTS
• If drug is indicated for insomnia, they should be cautioned that drug is
for short-term use only. Other methods to help induce sleep such as
strict implementation of set bedtime, warm bath, and a back rub
must be encouraged before prescribing this drug.
• It should be advised that activities such as driving, sports, and making
legal decisions should be avoided when taking this drug.
• Liver function should be evaluated before and during therapy.
• Use of this drug in pregnant and lactating women is contraindicated.
Benzodiazepines Used as Anxiolytic-
Hypnotics
OLDER ADULTS
• Older adults are more susceptible to drug adverse effects like
hallucinations and sedation.
• Dosage should be reduced and careful monitoring for toxicity is
instituted.
• Like adults, liver and renal function should be monitored closely.
• Non-drug measures to reduce anxiety should be encouraged.
Contraindications and Cautions
• Allergy to benzodiazepines. Prevent severe hypersensitivity reactions.
• Psychosis. Can be exacerbated by sedation
• Acute narrow-angle glaucoma, shock, coma, acute alcoholic
intoxication. Can be exacerbated by the depressant effects of these drugs.
• Pregnancy. Associated with development of cleft lip or palate,
inguinal hernia, cardiac defects, microcephaly, and pyloric stenosis when
taken in the first trimester of pregnancy. Neonatal withdrawal syndrome
may also result.
• Lactation. Potential adverse effects to the neonate (e.g. sedation)
• Elderly, debilitated. Possibility of unpredictable reactions
• Renal or hepatic dysfunction. May alter metabolism and excretion of drugs
resulting in direct toxicity.
Adverse Effects
• CNS: sedation, drowsiness, depression, lethargy, blurred vision, headache,
apathy, light-headedness, amnesia, confusion, mild paradoxical excitatory
reactions in the first two weeks of therapy
• CV: hypotension, hypertension, arrhythmias, palpitations
• GI: dry mouth, constipation, nausea, vomiting, elevated liver enzymes
• GU: urinary retention and hesitancy, loss of libido, changes in sexual
functioning
• Hematological: blood dyscrasias, anemia
• Local injection sites can develop phlebitis, local reactions, and thrombosis.
• Withdrawal syndrome caused by abrupt cessation of drugs is characterized
by nausea, headache, vertigo, malaise, and nightmares.
Interactions
• Alcohol, other CNS depressants: increased risk of CNS depression
• Cimetidine, oral contraceptives, disulfiram: increased effects of
benzodiazepines
• Theophylline, ranitidine: decreased therapeutic effects of
benzodiazepines
• Flumazenil is the antidote of benzodiazepine.
Nursing Considerations
Nursing Assessment
• Assess for the mentioned cautions and contraindications (e.g. drug
allergies, hepatorenal diseases, psychosis, glaucoma, etc.) to prevent any
untoward complications.
• Perform a thorough physical assessment to establish baseline data before
drug therapy begins, to determine effectiveness of therapy, and to evaluate
for occurrence of any adverse effects associated with drug therapy.
• Monitor results of laboratory tests (e.g. renal and liver functions tests,
complete blood count (CBC), etc.) to monitor effectiveness of the therapy
and provide prompt treatment to developing complications.
Nursing Considerations
NURSING IMPLEMENTATION
• Administer intravenous diuretics slowly to prevent severe changes in fluid
and electrolytes.
• Do not mix intravenous drugs in solution with any other drugs to avoid
potential drug-drug interactions.
• Maintain patients who receive parenteral benzodiazepines in bed for at
least 3 hours to ensure patient safety.
• Monitor patient response to drugs through vital signs, weight, serum
electrolytes and hydration to evaluate effectiveness of drug therapy.
Nursing Considerations
NURSING IMPLEMENTATION
• Monitor hepatic and renal function and CBC for long-term therapies to
detect dysfunction and to arrange to taper and discontinue drug if
dysfunction occurs.
• Provide safety measures (e.g. adequate lighting, raised side rails, etc.) to
prevent injuries.
• Educate client on drug therapy to promote compliance.
Nursing Considerations
EVALUATION
• Monitor patient response to therapy (e.g. controlled anxiety, sleep, etc).
• Monitor for adverse effects (e.g. hypotension, blood dyscrasias,
hepatorenal dysfunction, etc).
• Evaluate patient understanding on drug therapy by asking patient to name
the drug, its indication, and adverse effects to watch for.
• Monitor patient compliance to drug therapy.
Barbiturates Used as Anxiolytic-
Hypnotics
Indications
• Generally indicated for anxiety, sedation, insomnia, paresthesia, and
seizures.
• Parenteral forms may be used for treatment of acute manic reactions.
Indications
CHILDREN
• Barbiturates have established pediatric dosage but must be used with
caution because children often have unexpected responses.
• Children may be inappropriately aggressive, tearful, and irritable.
• Possible dried secretions and their effect on breathing must always be
assessed carefully.
Indications
ADULTS
• If drug is indicated for insomnia, they should be cautioned that drug is
for short-term use only.
• Other methods to help induce sleep such as strict implementation of
set bedtime, warm bath, and a back rub must be encouraged before
prescribing this drug.
• It should be advised that activities such as driving, sports, and making
legal decisions should be avoided when taking this drug.
• Liver function should be evaluated before and during therapy.
• Use of this drug in pregnant and lactating women is contraindicated.
Indications
OLDER ADULTS
• Older adults are more susceptible to drug adverse effects like
hallucinations and sedation.
• Dosage should be reduced and careful monitoring for toxicity is
instituted.
• Like adults, liver and renal function should be monitored closely.
• Non-drug measures to reduce anxiety should be encouraged.
Contraindications and Cautions
• Allergy to barbiturates. Prevent severe hypersensitivity reactions.
• History of addiction to sedative-hypnotic drugs: barbiturates are more
addicting than most other anxiolytics
• Latent or manifest euphoria. May be exacerbated by drug effects
• Marked hepatic impairment or nephritis. May alter the metabolism
and excretion of drugs
• Respiratory distress and dysfunction. Exacerbated by CNS depression
caused by drugs.
Contraindications and Cautions
• Pregnancy. Associated with congenital abnormalities
• Lactation. Has potential for adverse effects on the infant.
• Acute or chronic pain. Can cause paradoxical excitement which can
mask other symptoms
• Seizure disorder. Abrupt withdrawal of barbiturates can precipitate
status epilepticus
• Chronic hepatic, cardiac, and respiratory diseases. Can be
exacerbated by the depressive effects of these drugs.
Adverse Effects
• CNS: drowsiness, somnolence, lethargy, ataxia, vertigo, “hangover”
feeling, thinking abnormalities, paradoxical excitement, anxiety,
hallucinations
• CV: bradycardia, hypotension, syncope
• Respiratory: serious hypoventilation, respiratory depression
• Hypersensitivity reactions: rash, serum sickness, Steven-Johnson
syndrome
• Development of physical tolerance and psychological dependence
Interactions
• Alcohol, other CNS depressants (e.g. antihistamines, tranquilizers,
etc.): increased risk of CNS depression
• Phenytoin: altered response to phenytoin
• Monoamine oxidase (MAO) inhibitors: increased serum levels of
barbiturates
• Oral anticoagulants, digoxin, corticosteroids, tricyclic
antidepressants (TCAs), oral contraceptives,
acetaminophen, metronidazole, carbamazepine: reduced effectivity
of these drugs because of enzyme induction effect of barbiturates
•
Nursing Considerations
NURSING ASSESSMENT
• Assess for the mentioned cautions and contraindications (e.g. drug
allergies, hepatorenal diseases, seizure disorders, etc.) to prevent any
untoward complications.
• Perform a thorough physical assessment to establish baseline data
before drug therapy begins, to determine effectiveness of therapy,
and to evaluate for occurrence of any adverse effects associated with
drug therapy.
Nursing Considerations
IMPLEMENTATION
• Administer intravenous diuretics slowly because rapid administration may
cause cardiac problems.
• Do not mix intravenous drugs in solution with any other drugs to avoid
potential drug-drug interactions.
• Taper dose as ordered because abrupt withdrawal can
precipitate seizure attacks.
• Provide comfort measures (e.g. small, frequent meals, access to bathroom
facilities, orientation, etc.) to help patient tolerate drug effects
• Provide safety measures (e.g. adequate lighting, raised side rails, etc.) to
prevent injuries.
• Educate client on drug therapy to promote compliance.
Nursing Considerations
EVALUATION
• Monitor patient response to therapy (e.g. controlled anxiety, sleep,
etc).
• Monitor for adverse effects (e.g. hypotension, dependence,
hepatorenal dysfunction, etc).
• Evaluate patient understanding on drug therapy by asking patient to
name the drug, its indication, and adverse effects to watch for.
• Monitor patient compliance to drug therapy.
ANTIDEPRESSANTS