1. Chapter 14 Sedative-Hypnotics
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2. Chapter 14
Lesson 14.1
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3. 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
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4. 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.
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5. 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.
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6. 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.
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7. 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.
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8. 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.
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9. 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.
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10. 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.
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11. 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.
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12. 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.
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13. Chapter 14
Lesson 14.2
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14. 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
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15. Drugs Used for Treatment of Insomnia
Classes of sedative-hypnotics
Barbiturates
Benzodiazepines
Nonbarbiturate, nonbenzodiazepines
Miscellaneous agents
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16. 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.
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17. 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.
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18. 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.
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19. 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.
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20. 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.
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21. 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
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22. 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.
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23. 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.
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24. 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
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