Naloxone Classification: Antidotes, Detoxifying Agents & Drugs Used in Substance Dependence Mechanism of Action: While the mechanism

of action of naloxone is not fully understood, the preponderance of evidence suggests that naloxone antagonizes the opioid effects by competing for the same receptor sites, especially the opioid mu receptor. Recently, naloxone has been shown to bind all three opioid receptors (mu, kappa and gamma) but the strongest binding is to the mu receptor. Naloxone is an opiate antagonist and prevents or reverses the effects of opioids including respiratory depression, sedation and hypotension. Also, it can reverse the psychotomimetic and dysphoric effects of agonist-antagonists such as pentazocine. Naloxone is an essentially pure narcotic antagonist, i.e., it does not possess the "agonistic" or morphine-like properties characteristic of other narcotic antagonists; naloxone does not produce respiratory depression, psychotomimetic effects or pupillary constriction. In the absence of narcotics or agonistic effects of other narcotic antagonists, it exhibits essentially no pharmacologic activity. Indications: For the complete or partial reversal of narcotic depression, including respiratory depression, induced by opioids including natural and synthetic narcotics, propoxyphene, methadone and the narcotic-antagonist analgesics: nalbuphine, pentazocine and butorphanol. For diagnosis of suspected or known acute opioid overdosage. Contraindications: Hypersensitivity to drug class / component Caution if cardiovascular disease Caution if opioid addiction Caution if hepatic impairment Caution if renal impairment Caution if w/ cardiotoxic drugs Side Effects: Chest pain or fast or irregular heartbeats Feeling light-headed, fainting Seizure (convulsions) Difficulty breathing Dizziness, weakness, tired feeling Nausea, vomiting, or diarrhea Feeling nervous, restless, or excited Sweating Runny nose Trembling Nursing Responsibilities: Assessment History: Allergy to narcotic antagonists; narcotic addiction; CV disorders; lactation Physical: Sweating; reflexes, pupil size; P, BP; R, adventitious sounds

Interventions Monitor patient continuously after use of naloxone; repeat doses may be necessary, depending on duration of narcotic and time of last dose. Maintain open airway and provide artificial ventilation, cardiac massage, vasopressor agents if needed to counteract acute narcotic overdose. Teaching points Report sweating, feelings of tremulousness.

Hydrobromide Classification: Antidepressant; SSRI Mechanism of Action: Potentiates serotonergic activity in the CNS by inhibiting neuronal reuptake of serotonin, resulting in antidepressant effect, with little effect on norepinephrine or dopamine reuptake. Indications: Treatment of depression, particularly effective in major depressive disorders Unlabeled uses: Obsessive-compulsive disorders, panic disorder, premenstrual dysphoric disorder (PMDD), social phobia, trichotillomania, post-traumatic stress disorder Contraindications: Contraindicated with MAOI use; allergy to drug or any component of the drug or other SSRIs; concomitant use of pimozide. Use cautiously with renal or hepatic impairment, pregnancy, lactation, and in patients who are elderly or suicidal. Side Effects: Nausea Dry mouth Somnolence Increased sweating Insomnia Dizziness Diarrhea Fatigue Tremor Aorexia Ejaculation disorder Nursing Responsibilities: Assessment History: MAOI use; allergy to drug or any component of the drug; renal or hepatic impairment, elderly, pregnancy, lactation, suicidal tendencies Physical: Orientation, reflexes; P, BP, perfusion; bowel sounds, normal output; urinary output; liver evaluation; liver and renal function tests

Interventions Administer once a day, in the morning; may be taken with food if desired. Encourage patient to continue use for 46 wk, as directed, to ensure adequate levels to affect depression. Limit amount of drug given in prescription to potentially suicidal patients. Establish appropriate safety precautions if patient experiences adverse CNS effects. Institute appropriate therapy for patient suffering from depression. Teaching points Take this drug exactly as directed, and as long as directed; it may take a few weeks to realize the benefits of the drug. The drug may be taken with food if desired. This drug should not be taken during pregnancy or when nursing a baby; using barrier contraceptives is suggested. You may experience these side effects: Drowsiness, dizziness, tremor (use caution and avoid driving a car or performing other tasks that require alertness if you experience daytime drowsiness); GI upset (eat frequent small meals; perform frequent mouth care); alterations in sexual function (it may help to know that this is a drug effect, and will pass when drug therapy is ended). Report severe nausea, vomiting; palpitations; blurred vision; excessive sweating.

Flumazenil Classification: Benzodiazepine antagonist; Antidotes, Detoxifying Agents & Drugs Used in Substance Dependence Mechanism of Action: Flumazenil, an imidazobenzodiazepine derivative, antagonizes the actions of benzodiazepines on the central nervous system. Flumazenil competitively inhibits the activity at the benzodiazepine recognition site on the GABA/benzodiazepine receptor complex. Flumazenil is a weak partial agonist in some animal models of activity, but has little or no agonist activity in man. Indications: For the complete or partial reversal of the sedative effects of benzodiazepines in cases where general anesthesia has been induced and/or maintained with benzodiazepines, where sedation has been produced with benzodiazepines for diagnostic and therapeutic procedures, and for the management of benzodiazepine overdose. Contraindications: Contraindicated in patients with a known hypersensitivity to flumazenil or

benzodiazepines. Contraindicated in patients who have been given a benzodiazepine for control of a potentially life- threatening condition (eg, control of intracranial pressure or status epilepticus). Contraindicated in patients who are showing signs of serious cyclic antidepressant overdose.

Side Effects: Headache Sweating Irritation at the injection site Blurred vision Flushing Nausea Vomiting Dizziness Rapid heart rate Skin rash Mood changes Irritability Anxiety Mental confusion Nervousness Tremor Abnormal / jerky muscle movements Depression Nursing Responsibilities: Assessment History: Allergy Interventions Ensure that patient has a patent airway before administration of flumazenil Observe IV site frequently for redness or irritation. Administer through a free-flowing IV infusion into a large vein to minimize pain at the injection site Optimal emergence should be undertaken slowly to decrease undesirable effects including confusion, agitation, emotional lability, and perceptual distortion Institute seizure precautions. Seizures are more likely to occur in patients who are experiencing sedative/hypnotic withdrawal, patients who have recently received repeated doses of benzodiazepines, or those who have a previous history of seizure activity. Seizures may be treated with benzodiazepines, barbiturates, or phenytoin. Larger than normal doses of benzodiazepines may be required Suspected Benzodiazepine Overdose: If no effects are seen after administration of flumazenil, consider other causes of decreased level of consciousness (alcohol, barbiturates, opioid analgesics) IV Adminstration: Direct IV: Diluent: May be administered undiluted or diluted in syringe with D5W, 0.9% NaCl, or LR. Diluted solution should be discarded after 24 hr; Concentration: Up to 0.1 mg/mL; Rate: Administer each dose over 1530 sec into free-flowing IV in a large vein. Do not exceed 0.2 mg/min in children or 0.5 mg/min in adults Teaching points Flumazenil does not consistently reverse the amnestic effects of benzodiazepines. Provide patient and family with written instructions for postprocedure care. Inform family that patient may appear alert at the time of discharge but the sedative effects of the benzodiazepine may recur. Instruct patient to avoid driving or other activities requiring alertness for at least 24 hr after discharge Instruct patient not to take any alcohol or nonprescription drugs for at least 1824 hr after discharge

 Resumption of usual activities should occur only when no residual effects of the benzodiazepine remain

Reference: http://www.drugbank.ca/drugs/DB01183 https://online.epocrates.com/u/103324/naloxone/Contraindications+Cautions http://web.squ.edu.om/med-Lib/MED_CD/E_CDs/Psychiatric%20Nursing%20Care %20Plans/monographs/naloxone %20hydrochloride.htm#N240181▪NursingconsiderationsAssessment http://www.depression-guide.com/citalopram.htm http://www.nursing-nurse.com/drug-study-citalopram-hydrobromide-celexa-157/ http://web.squ.edu.om/med-Lib/MED_CD/E_CDs/Nursing%20Drug %20Guide/mg/citalopram_hydrobromide.htm http://www.medicinenet.com/flumazenil-injection/article.htm http://www.druglib.com/activeingredient/flumazenil/