Chapter 18

Depressants

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 Stages of Sleep
 Types and stages of sleep
 Rapid eye movement (REM)
 Nonrapid eye movement (NREM)

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 Sleep Disorders
 Insomnia
 More common in female patients
 Treatment: sedative-hypnotics
 Nonpharmacologic management
 Arise at specific hour in morning
 Limit daytime naps
 Avoid caffeine, alcohol, and nicotine 6 hr before bedtime
 Avoid heavy meals, large amounts of fluids, loud noise,
and strenuous exercise before bedtime
 Take warm bath, read, listen to quiet music, or drink
warm milk before bedtime

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 Sedative-Hypnotics
 Sedatives
 Treat sleep disorders
 Sedative-hypnotics
 Barbiturates
 Benzodiazepines
 Nonbenzodiazepines

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 Sedative-Hypnotics (Cont.)
 General side effects
 Residual drowsiness (hangover)
 Vivid dreams, nightmares
 Drug dependence
 Drug tolerance
 Excessive depression
 Respiratory depression
 Hypersensitivity

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 Barbiturates
 Barbiturates
 Long-intermediate-short-ultrashort-acting
 Restrict to short-term use because of side effects,
including drug tolerance
• Limit use to 2 weeks or less
 Interactions
• Alcohol, opioids, other sedative-hypnotics
• Decreases effects of oral anticoagulants, glucocorticoids,
tricyclic antidepressants, quinidine

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 Benzodiazepines
 Benzodiazepines as hypnotics
 Flurazepam, alprazolam
 Temazepam, triazolam
 Estazolam, quazepam
 For sleep disorders and anxiety
 Lorazepam and diazepam
 Action
 Interacts with neurotransmitter GABA to reduce neuron
excitability
 Use
 Reduce anxiety, treat insomnia

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Nursing Process: Benzodiazepines
 Assessment
 Determine whether the patient has a history of
insomnia or anxiety disorders.
 Nursing diagnosis
 Sleep deprivation related to adverse effect of
insomnia
 Planning
 Patient will receive adequate sleep when taking
benzodiazepines.

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 Nursing Process: Benzodiazepines
(Cont.)
 Nursing interventions
 Observe the patient for adverse reactions, especially
an older or debilitated patient.
 Teach patient to use nonpharmacologic methods to
induce sleep.
 Advise patients to report adverse reactions.
 Teach patient that benzodiazepines should be
gradually withdrawn.
 Evaluation

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 Benzodiazepines
 Nonbenzodiazepines as hypnotics
 Zolpidem
 Action
• Neurotransmitter inhibition
• Duration of action is 6 to 8 hours
 Use
• Treat short-term (less than 10 days) insomnia

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Sedatives and Hypnotics for Older
Adults
 Sedatives and hypnotics for older adults
 Use nonpharmacologic methods first
 Short- to intermediate-acting benzodiazepines such
as estazolam, temazepam, and triazolam
• Are considered safer for older adults
 Avoid benzodiazepines such as flurazepam,
quazepam, and diazepam
• Or use four times/week or less

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 Melotonin Agonists
 Melotonin agonists
 Ramelteon
 First FDA-approved hypnotic not classified as a
controlled substance
 Selectively targets melatonin receptors to regulate
circadian rhythm to treat insomnia
 Not been shown to decrease REM sleep
 Adverse effects
• Drowsiness, dizziness, fatigue, headache, nausea, and
suicidal ideation

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 Nursing Process: Sedative-
Hypnotics (Non-Benzodiazepines)
 Assessment
 Ascertain the patient’s problem with sleep
disturbance.
 Nursing diagnosis
 Sleep deprivation related to anxiety
 Fatigue related to anxiety
 Planning
 Patient will remain asleep for 6 to 8 hours.

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 Nursing Process: Sedative-
Hypnotics (Non-Benzodiazepines)
(Cont.)
 Nursing interventions
 Observe patient for side effects of
nonbenzodiazepines such as hangover, dizziness, or
confusion.
 Encourage patients to avoid alcohol, antidepressants,
antipsychotics, and opioids while taking
nonbenzodiazepines.
 Evaluation

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 Anesthetics
 Types
 General
• Depresses the CNS
• Alleviates pain
• Causes a loss of consciousness
 Local
• Pain relief in limited area

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 Anesthetics (Cont.)
 Routes
 Inhalation
 IV
 Topical
 Local
 Spinal

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 Balanced Anesthesia
 Balanced anesthesia may include
 A hypnotic given the night before
 Premedication
• With an opioid analgesic or benzodiazepine
 Example: midazolam
• With an anticholinergic
 Example: atropine given about 1 hour before surgery to decrease
secretions
 A short-acting barbiturate
• Example: propofol
 An inhaled gas
• Often a combination of nitrous oxide and oxygen
 A muscle relaxant given as needed

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 Stages of General Anesthesia
 Stage 1: Analgesia
 Stage 2: Excitement or delirium
 Stage 3: Surgical
 Stage 4: Medullary paralysis

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 Inhalation Anesthetics
 Inhalation anesthetics
 Halothane, methoxyflurane, enflurane
 Isoflurane, desflurane, sevoflurane
 Provides smooth induction
 Usually combined with
 A nonbarbiturate such as propofol
 A strong analgesic such as morphine
 A muscle relaxant such as pancuronium
 Adverse effects
 Respiratory depression, hypotension, dysrhythmias, and hepatic
dysfunction, malignant hyperthermia
 Consciousness usually reoccurs minutes to an hour upon
discontinuation

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 Intravenous Anesthetics
 Intravenous anesthetics
 Droperidol, etomidate, ketamine
• Rapid onsets and short durations of action
 Midazolam and propofol
• Induction and maintenance of anesthesia or conscious
sedation for minor surgery or procedures (mechanical
ventilation or intubation)
• Patients are sedated and relaxed but responsive to
commands
 Adverse effects
• Respiratory and cardiovascular depression, infection

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 Topical Anesthetics
 Topical anesthetics
 Use
• Mucous membranes, broken or unbroken skin surfaces, and
burns
 Forms
• Solution, liquid spray, ointment, cream, gel, and powder
 Decreases the sensitivity of nerve endings of the
affected area

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 Local Anesthetics
 Local anesthetics
 Block pain at the site where the drug is given
 Consciousness is maintained.
 Use
• Dental procedures, suturing skin lacerations
• Short-term (minor) surgery at a localized area
• Blocking nerve impulses (nerve block) below the insertion of
a spinal anesthetic
• Diagnostic procedures such as lumbar puncture and
thoracentesis
• Regional blocks

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 Local Anesthetics (Cont.)
 Two groups
 Esters
 Amides
 Amides have a very low incidence of allergic
reaction.
 Procaine hydrochloride
 Lidocaine hydrochloride
 Rapid onset, longer duration of action
 Causes fewer hypersensitivity reactions than procaine

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 Spinal Anesthesia
 Spinal anesthesia
 Local anesthetic injected in the subarachnoid space
• Adults—below first lumbar space
• Children—below third lumbar space
 Side effects/adverse reactions
• Respiratory distress
• Headache
• Hypotension

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 Spinal Column Nerve Blocks
 Spinal block
 Penetration of the anesthetic into the subarachnoid
membrane between the pia mater and arachnoid membrane
 Epidural block
 Placement of the local anesthetic in the epidural space
posterior to the spinal cord or dura mater
 Caudal block
 Placed through the sacral hiatus
 Saddle block
 Placed at the lower end of the spinal column to block the
perineal area

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 Nursing Process: Anesthetics
 Assessment
 Obtain a drug and health history, noting drugs that
affect the cardiopulmonary system
 Nursing diagnosis
 Pain, acute related to injury
 Breathing pattern, ineffective related to CNS
depression
 Planning
 Patient will participate in preoperative preparation and
will understand postoperative care.

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 Nursing Process: Anesthetics (Cont.)
 Nursing interventions
 Monitor the postoperative state of sensorium.
 Observe preoperative and postoperative urine output.
 Monitor vital signs following general and local
anesthesia for hypotension and respiratory
depression.
 Administer an analgesic with caution until the patient
fully recovers from the anesthetic.
 Evaluation

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 Practice Question #1
Which nursing intervention would be most
appropriate for a patient taking temazepam?

A. Monitor for fever.

B. Give drug intravenously only.
C. Monitor daily weights.
D. Tell patient to ask for help before standing.

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 Practice Question #2
What would indicate to the nurse that a patient
taking a sedative-hypnotic requires more
teaching?

A. The patient wants to listen to music on the radio.

B. The patient has saved her urine to be measured.
C. The patient says she has taken 1800 mL of fluid today.
D. The patient requests a cup of kava kava tea to help her
get to sleep faster.

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 Practice Question #3
An older adult complains of insomnia. Which
suggestion would be most appropriate for the
nurse to provide as an initial method to deal with
this issue?

A. “Take Benadryl pills each evening before bedtime.”

B. “Drink warm milk or chamomile tea before bedtime.”
C. “Develop an exercise regimen for the evening hours.”
D. “Take naps during the day whenever you feel drowsy.”

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 Practice Question #4
A patient is taking a hypnotic nightly to enhance
sleep. The patient experiences vivid dreams and
nightmares. This may be associated with

A. hangover.
B. tolerance.
C. hypersensitivity.
D. REM rebound.

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 Practice Question #5
The most serious adverse effect of spinal
anesthesia is

A. hypotension.
B. headache.
C. respiratory distress.
D. tachycardia.

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 Practice Question #6
Which drug is commonly used for conscious
sedation?

A. Midazolam
B. Halothane
C. Isoflurane
D. Lidocaine

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