UNIT THREE CH.14-17 Sedative-Hypnotics Sleep/sleep pattern

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UNIT THREE CH.14-17

• Sedative-Hypnotics

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Sleep/sleep pattern disturbance

• Sleep is a state of unconsciousness from which a
  pt can be aroused by appropriate stimulus
• Adequate sleep that progresses thru the normal
  stages is important to maintainbody function such
  as psychiatric equilibrium and strengthening of
  the immune system.
• Natural sleep is a rhythmic progression, provides
  physical/mental rest
• Sleep based on brain wave activity, muscle
  activity and eye movement.

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NREM/REM

• Sleep divided into 2 stages.
• NREM-non-rapid eye movement
• REM-rapid eye movement
• NREM has 4 stages-each stage characterized by
  specific set of brain wave activities.
• STAGE Itransition phase between wakefulness and
  sleep-last only a few minutes. 2-5 of sleep is
  in this stage.

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• STAGE II------50 of sleep time
• Experience drifting or floating sensationlight
  sleep-pt is easy to arouse.
• STAGE III----transition from the lighter to
  deeper sleep stage of stage IV.
• STAGE IV----sleep is dreamless, very restful,
  associated with 10 to 30 of decrease in BP, RR,
  and basal metabolic rate.
• Also referred to as delta sleep
• As we age sleep diminishes, people over than 75
  years do not demonstrate and stage IV sleep
  patterns

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Normal sleep

• Person cycles from wakefulness thru stages I, II,
  III, IV, then back to stage III, stage II and
  then to REM over about 90 minutes.
• Early episodes of REM last only a few minutes,
  but as sleep progresses REM sleep increases,
  becoming longer and more intense around 5am. This
  sleep represents 20-25 of sleep time and
  characterized by REM (dreaming, increased HR,
  irregular breathing, some muscle activity.
• REM important time for our subconscious minds to
  release anxiety/tension reestablish a
  psychiatric equilibrium.

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• INSOMNIA ---most common sleep disorder known95
  of adults experience insomnia _at_ least once during
  their lives
• Insomina is defined as the inability to sleep
• Symptom of physical/mental stress--- not a
  disease
• Common causes are lifestyle/environment changes.

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• 3 types of insomnia-
• Initialinability to fall asleep when desired.
• Intermittentinability to stay asleep
• Terminalearly awakening-cant go back to sleep.
• Insomnia is classified according to duration
• Transientlast only a few nights
• Short-termlast more than 3 weeks (usually
  associated with travel across time zones, illness
  or anxiety
• Chronic at least one month of sleep disturbances
  to be dx. As a sleep disorder

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• Women twice a likely to effected than men.
• Higher incidence among-elderly, unemployed, lower
  socioeconomic, recently separated or widowed.
• 40 of pts with chronic insomnia suffer from a
  psychiatric disorder
• Fatigue/drowsiness develops from chronic
  insomnia-interferes with daytime functioning.

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SEDATIVE-HYPNOTIC THERAPY

• Hypnotic-a drug that produces sleep
• Sedative quiets the pt and gives a feeling of
  relaxation/restnot necessarily accompanied by
  sleep
• Sedatives used to produce relaxation/rest
  hypnotics-used to produce sleep , are not always
  different drugs.effects depend on dosage and
  condition of pt.. A small dose may act as a
  sedative, whereas larger dose of the same drug
  may act as a hypnotic and produce sleep

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• USES primary uses of sedative-hypnotics are to
  improve sleep patterns for the temporary tx of
  insomnia and to decrease the level of anxiety and
  increase relaxation and/or sleep prior to
  diagnostic/operative procedures.
• NURSING PROCESS
• Assessment- 1) identify LOC/ability to perform
  motor functions 2)VS 3) sleep patterns what is
  usual sleep pattern, problems going to
  sleep/staying asleep, etc.

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• Ask how many hours a night do you sleep. What
  time do you go to bed?
• What medications are you taking?-
• Some medications that induce or aggravate
  insomnia are theophylline, caffeine,
  pseudoephedrine, nicotine, levodopa, some
  antidepressants.
• Does the pt take naps?
• Bedtime rituals?
• Anxiety level---does the pt. really need a
  sedative/hypnotic or does the pt. need the ear
  of a caring and compassionate nurse, like
  yourself.
• Ask what is stressing the pt. _at_ work or home?

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• Also assess your pt.s sleep environment
• Alcohol intake
• Exercise patterns
• Respiratory status

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Drug class barbiturates

• First on market in 1903
• ACTIONS can depress the CNS from mild to deep
  coma to death.
• Used as a hypnotic suppresses REM and stage III
  IV sleep.
• Long half-life-residual side effect is daytime
  sedation.
• USESrarely used for sedation-hypnosis, but when
  used therapy should be limited to 2 weeks due to
  tolerance

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• NURSING PROCESS
• Implementationrapid discontinuing of drugs after
  long-term use may result in s/s similar to
  alcohol withdrawal (s/s can be anything from
  weakness to delirium to grand mal seizures-
• Must be gradual withdrawal over 2-4 weeks
• SIDE EFFECTS TO EXPECT
• Hangover, sedation, lethargypt education should
  include orthostatic hypotension, do not perform
  any activity which requires mental alertness
  while taking medication.
• SIDE EFFECTS TO REPORTexcessive use/abuse

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Drug class BENZODIAZEPINES

• Most commonly used sedative/hypnotic.
• Therapeutic outcomes
• 1) to produce mild sedation
• 2)short-term use to produce sleep
• 3)preoperative sedation with amnesia
• NURSING PROCESS
• Side effects to reportconfusion, agitation,
  hallucinations, amnesia, excessive use/abuse
  blood dyscrasias(do routine labsCBC monitor
  for sore throat, fever, purpura-bleeding disorder
  characterized by hemorrhage into the tissues-,
  jaundice, weakness

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• HEPATOTOXICITYreport s/s of anorexia, NV,
  jaundice, hepatomegaly, splenomegaly, abnormal
  labs (LFTs)
• DRUG INTERACTIONS
• Antihistamines, alcohol, analgesics, narcotics,
  anesthetics can increase toxic effects
• Smoking enhances the metabolism of benzos

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Drug class nonbarbiturate, nonbenzodiazepine
sedative-hypnotic

• Represents a variety of chemical classes, which
  all cause CNS depression
• USESantihistamines have sedative properties that
  may be used short term-tolerance develops after
  only a few nights of use(increasing doses can
  cause a more restless and irregular sleep pattern
• NURSING PROCESS
• EVALUATION OF SIDE EFFECTSgeneral adverse
  effects of drowsiness, lethargy, HA, muscle/joint
  pain mental depression

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• SIDE EFFECTS TO EXPECT
• Hangover/sedation/lethargy-
• Pt education/teaching-
• RESTLESSNESS/ANXIETY
• Elderly pt and those in severe pain may repsond
  paradoxically with excitement, euphoria,
  restlessness and confusionsafety measures such
  as maintenance of bed rest, side rails and
  observation should be used during this period.

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Chapter 15drugs used in Parkinsons disease

• Parkinsons disease is a chronic progressive
  disorder of the CNS2nd most common
  neurodegerative disease with Alzheimers disease.
• Two types of Parkinsonism 1) primary or
  idiopathic is caused by reduction in
  dopamine-producing cells in the basal ganglia. 2)
  secondary-caused by head trauma, intracranial
  infections, tumors drug exposure
• Medicines that deplete dopamine, case secondary
  parkinsonism.

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Drug therapy for Parkinsons

• Goal of treatment is minimizing the symptoms,
  there is no cure.
• NURSING PROCESS
• Assessment-UPDRS
• Planning
• Implementation

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Drugs

• Drug Class Dopamine Agonists
• Agonist is a drug that has a specific cellular
  affinity (measure of binding strength) that
  produces a predictable response.
• (1) Symmetrel-(exact mechanism is
  unknown-originally used to tx viral infections
• 1/2 of pts who benefited from amantadine
  therapy noticed a reduction in benefit after 2-3
  months. Dosage increase or temporary
  discontinuation followed by reinitiation of
  therapy after several week may restore
  therapeutic benefits.
• NURSING PROCESS

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• (2) apomorhine
• Apokyn---thought to stimulate dopamine receptors
  in the brain.
• NURSING PROCESS
• Planning subcutaneously injector pen
• Implementation dosage DO NOT ADMINISTER IV..
• Evaluation
• Side effects to Expect/Report
• Sudden sleep eventssleep attacks or episodes
  including daytime sleep. Pt. education on
  possibility of sleep attacks

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• (3) bromocriptine meslyate
• Parlodel-- stimulates dopamine receptors in
  basal ganglia of brain.
• NURSING PROCESS
• Drug interactions-parlodel and levodopa have
  additive neurologic effects. May be advantageous
  because if often allows a reduction in the dose
  of levodopa.

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• (4) SIMEMET
• (5) Levodopa
• Action-when dopamine is given orally, does not
  enter the brain. Levodopa does cross into the
  brain, is metabolized to dopamine, and replaces
  the dopamine deficiency in the basal ganglia.
  Dopamine stimlutes D1, D2, D3 dopamine receptors
• NURSING PROCESS
• Side effects to report
• 1) NV, Anorexia-reduce by giving with
  food/antacid, dividing doses, increase dosage
  slowly
• 2) orthostatic hypotension

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• Drug interactionVitamin B6 in oral doses of 5-10
  mg reverses the therapeutic/toxic effects of
  levodopa. Must consider ingredients of multiple
  vitamins
• (6) Comtan
• A potent COMT inhibitor that reduces the
  destruction of dopamine in the peripheral
  tissues, allows more dopamine to reach brain to
  eliminate the symptoms of parkinsonism
• (7) Anticholinergic agents-reduce to severity of
  the tremor and drooling. More useful for pt with
  minimal symptoms and no cognitive impairment