Chapter 14 Sedative-Hypnotics Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Chapter 14 Lesson 14.1 Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Objectives Differentiate among the terms sedative and hypnotic; initial, intermittent, and terminal insomnia; and rebound sleep and paradoxical excitement Identify alterations found in the sleep pattern when hypnotics are discontinued Cite nursing interventions that can be implemented as an alternative to administering a sedative-hypnotic Compare the effects of barbiturates and benzodiazepines on the central nervous system Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Sleep State of unconsciousness from which a person can be aroused by appropriate stimulus Needed to maintain psychiatric equilibrium and strengthen immune system Two phases: REM and NREM REM sleep associated with dreaming NREM sleep divided into four stages Factors contributing to patterns of inadequate sleep: stress, anxiety, illness, change of environment, longer working hours, longer commute times, two-career families, alcohol and drug abuse, medication use, and caffeine. Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Four Stages of NREM Sleep I Transition from wakefulness to sleep; 2% to 5% of sleep time II Experienced as drifting, floating; 50% of sleep time III Transition from lighter to deeper sleep IV Delta sleep – deep, dreamless, restful; 10% to 15% of sleep time in healthy young adults The amount of time people sleep changes as they grow older. The pattern of sleep also changes throughout life. Typical sleep pattern of a 15-year-old compared with that of an 85-year-old – sleep cycles are longer and total sleep is greater in a 15-year-old. Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

The Sleep Cycle A healthy young adult cycles through NREM and REM in a 90-minute period Stage I → Stage II → Stage III → Stage IV → Stage III → Stage II → REM Many sleep disorders can be traced to specific abnormalities in this sleep cycle. If the amount of time in a particular stage is increased or decreased from normal averages, it upsets the overall balance. A sleep study involves scientific assessment of a person’s sleep cycles and determines pattern abnormalities. Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Insomnia Most common sleep disorder, usually mild and short lived Common causes Lifestyle or environmental changes Pain, illness, anxiety Large amounts of caffeine; large meals before bedtime Three types Initial – difficulty falling asleep Intermittent – difficulty staying asleep Terminal – waking and an inability to fall back to sleep Up to 35% of adults experience insomnia in any given year. Insomnia is experienced by 95% of adults at some time. Some remedies people use to counter anxiety and stress – caffeine, alcohol, drugs – can disrupt sleep patterns even more. Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Sedative-Hypnotic Agents Hypnotic – drug that produces sleep Sedative – drug that relaxes a patient but is not necessarily accompanied by sleep Increase total sleeping time, mainly in stages II and IV Decrease number of REM cycles and amount of REM sleep May cause REM rebound when drug use is stopped No single drug can produce all the desired effects of sedation and sleep induction without producing adverse effects. Most of these agents alter the sleep cycle in some manner and can be habit-forming. REM sleep restores mental and physiologic balance. If REM dreaming is cut short, balance is not restored, and REM rebound may occur. Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Sedative-Hypnotic Agents (cont’d) Actions Sedatives produce relaxation and rest Hypnotics produce sleep Uses Temporary treatment of insomnia, decrease anxiety and increase relaxation and/or sleep before diagnostic or operative procedures, anticonvulsive agents A single sedative can produce different effects at different dosages; a small dose acts as sedative, a larger dose acts as hypnotic. Patient condition, baseline level of consciousness, and age also contribute to overall effects. Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing Interventions for Sedative-Hypnotic Therapy Take baseline assessments Note sleep disruption patterns Determine activities done just before bed Ask about patient stressors Identify caffeine sources in dietary history Assessing CNS function is a key component of patient monitoring before and after any sedative-hypnotic agent is administered. Baseline level of consciousness and state of arousal should be recorded during assessment and then re-evaluated. Baseline sleep patterns may be difficult to measure in a health care setting because sleep patterns are usually disrupted by noise, interruptions, procedures, etc. Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing Interventions for Sedative-Hypnotic Therapy (cont’d) Before administering a sedative-hypnotic, determine the actual need for it Patients with a history of sleep apnea or respiratory difficulties are at higher risk for respiratory depression if sedative-hypnotics are taken Older adults may react paradoxically Sleep patterns change when hypnotics are discontinued Nonpharmacologic interventions include offering dairy products, dimming the lights, reducing noise level, increasing daytime activity, etc. Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing Responsibilities for Sedative-Hypnotic Therapy Perform ongoing monitoring for therapeutic and adverse effects Document findings Verify the written standards that provide for safe care Follow policies and procedures of the organization If the drug is ordered as part of a preoperative or pre procedure medication, it must be given at the correct time to ensure the peak effect will occur when it is needed. Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Chapter 14 Lesson 14.2 Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Objectives Explain the major benefits of administering benzodiazepines rather than barbiturates Identify the antidote drug used in the management of benzodiazepine overdose Identify laboratory tests that should be monitored when benzodiazepines or barbiturates are administered over an extended period Develop a plan for patient education for a patient receiving a hypnotic Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Drugs Used for Treatment of Insomnia Classes of sedative-hypnotics Barbiturates Benzodiazepines Nonbarbiturate, nonbenzodiazepines Miscellaneous agents Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Drug Class: Barbiturates Actions Reversibly depress excitable tissues, suppress REM and stage III/IV sleep patterns when used for hypnosis Uses Anticonvulsant, general anesthetic (ultra short acting), sedation before a diagnostic procedure (short acting) For specific drug information, see Table 14-1. Barbiturates are so effective in reducing CNS activity that they are sometimes used to induce a coma-like state in cases of severe brain injury to reduce brain metabolism and preserve function. Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Drug Class: Barbiturates (cont’d) Common adverse effects Hangover, blurred vision, transient hypotension on arising, sedation, decreased alertness, lethargy Serious adverse effects Excessive use or abuse, paradoxical response, hypersensitivity (hives, rash, pruritus), blood dyscrasias Signs/symptoms of physiologic withdrawal can occur if drugs are stopped. Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing Interventions for Barbiturate Therapy Perform a baseline assessment, including: Vital signs – blood pressure, pulse, respirations and pain rating Degree of alertness State of arousal Motor function The importance of a good baseline assessment before administering a sedative-hypnotic cannot be emphasized enough. The nurse can address patient safety concerns about paradoxical responses by providing additional supervision; considering restraining devices; helping patient channel energy by walking. Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Drug Class: Benzodiazepines Wide safety margin More than 200 derivatives Difficult to describe as a class, but include: Anticonvulsants Antianxiety agents Sedative-hypnotic agents Overdoses can be better tolerated and are not fatal. Although there are many derivatives in this class, only a small subset is used clinically. Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Drug Class: Benzodiazepines (cont’d) Actions Affect type 1 and type 2 GABA receptors; bind to the receptors to stimulate the release of GABA Uses Preoperative sedative, conscious sedation Common adverse effects Drowsiness, hangover, sedation, lethargy, decreased level of alertness Serious adverse effects Confusion, agitation, amnesia, hepatotoxicity For specific drug information, see Table 14-2. Most commonly used sedative-hypnotics. Individual drugs in this class are prescribed for different uses, such as sleep and anxiety, based on their site of action within the CNS. When they are stopped, a rebound effect can occur, causing rebound insomnia as well as bizarre dreams. Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing Interventions for Benzodiazepine Therapy Check vital signs, especially blood pressure, while the patient is sitting and lying down before administration Monitor laboratory results for hepatic dysfunction or blood abnormalities Flumazenil is used as an antidote for benzodiazepine reversal and overdoses Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Drug Class: Nonbarbiturates, Nonbenzodiazepines Actions Variable effects on REM sleep Uses Sedative and hypnotic effects Common adverse effects: Hangover, sedation, lethargy, decreased level of alertness, transient hypotension on arising, restlessness, anxiety For specific drug information, see Table 14-3. Most recommended only for short-term use of 7 to 10 days, or for as long as 3 weeks with good evaluation. All cause CNS depression, but mechanisms of action differ. Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing Interventions for Miscellaneous Sedative-Hypnotic Therapy Assess vital signs, especially blood pressure, while the patient is sitting and lying down before administration Monitor laboratory results for hepatic dysfunction or blood abnormalities Patient teaching The patient must understand that habitual use can lead to physical dependency. Do not abruptly stop these drugs after long-term use because they can cause symptoms similar to alcohol withdrawal. Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Patient Education/Health Promotion Encourage standard bedtime Avoid late, heavy meals Limit caffeine and alcohol intake Control sleep environment Promote stress-reducing techniques Discuss benefits of medication compliance and nonpharmacologic interventions Encourage patient use of self-assessment form Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.