1. Unit 11: Drugs that affect the CNS Nancy Pares, RN, MSN NURS 1950 Metropolitan Community College

2. Obj. 1: Describe the general cause of seizures and the two major clinical findings associated with seizures.  Seizures ◦ Abnormal or uncontrolled neuronal discharges in the brain ◦ affect  Consciousness  Motor activity  Sensation ◦ Symptom of an underlying disorder-not a disease itself

3. Obj 2: Factors that precipitate seizures  Infectious diseases  Trauma  Metabolic disorders  Vascular diseases  Pediatric disorders  Neoplastic diseases

4. Drugs as cause of seizures  High dose of local anesthetics  Drug abuse  Withdrawal from alcohol  Withdrawal from sedative-hypnotics

5. Convulsion  Involuntary violent spasm of large muscles of the face, neck, arms and legs  Not synonymous with seizure

6. Obj. 3: Name and describe major types of epileptic seizures  Signs and symptoms ◦ Related to the area of the brain with abnormal activity  Types-based on International Classification ◦ Partial (focal) ◦ Generalized ◦ Special epileptic syndromes

7. Simple partial (focal) seizures  Occur in limited portion of brain  Point of origin: abnormal focus or foci  Clients experience ◦ Feeling that is vague ◦ Hallucinations with all senses ◦ Extreme emotions ◦ Twitching of arms, legs or face

8. Complex partial (focal) seizures  Altered levels of consciousness  Involve sensory, motor, autonomic symptoms  Aura commonly precedes seizure  No memory of seizure

9. Generalized seizures  Travel throughout the entire brain  Subcatagories ◦ Absence ◦ Atonic ◦ Tonic-clonic

10. Absence seizures  Common in children  Subtle symptoms ◦ Staring ◦ Transient loss of consciousness ◦ Eyelid fluttering ◦ Myclonic jerks

11. Atonic seizures  Usually last only a few seconds  Characterized by stumbling or falling

12. Tonic clonic  Most common  Usually preceded by aura  Tonic phase ◦ Intense muscle contractions ◦ Hoarse cry at onset ◦ Loss of bowel/bladder control ◦ Shallow breathing

13. Tonic clonic, cont  Clonic phase ◦ Alternating contraction and relaxation of muscles  Postictal state (post seizure) ◦ Drowsiness, disorientation, deep sleep

14. Special epileptic syndromes  Febrile seizures  Myoclonic seizures  Status epilepticus

15. Febrile seizures  Last one –two minutes  Tonic clonic motor activity  Common in 3-5 year olds  Occur with rapid rise in body temperature  Affect 5% of all children

16. Myoclonic seizures  Large jerking body movements  Quick contraction of major muscles  Stumbling and falling  Similar to normal infantile Moro reflex

17. Status epilepticus  Medical emergency  Continuously repeating seizure  Common with generalized tonic-clonic  Continuous muscle contractions ◦ May compromise airway ◦ May cause hypoglycemia, hypothermia, acidosis ◦ May produce lactic acid

18. Obj. 4, 5, 6,and 7 (inclusive)  The choice of drug depends upon ◦ Type of seizure ◦ Client history and diagnostic studies ◦ Pathologic process causing seizures

19. Barbiturates and GABA Agents  GABA= gamma aminobutyric acid ◦ Primary neuro transmitter of brain.  Drugs that potentiate GABA action ◦ Barbiturates ◦ Benzodiazepines ◦ Misc. agents

20. Barbiturates  Prototype: phenobarbital (Luminal) ◦ Mechanism of action  Changing the action of GABA ◦ Primary use  Controlling seizures ◦ Adverse effects  Dependence, drowsiness, vitamin deficiencies, laryngeospasm

21. Benzodiazepines  Prototype: diazepam (Valium) ◦ Mechanism of action  Similar to barbiturates, but safer ◦ Primary use  Short term seizure control ◦ Adverse effects  Drowsiness and dizziness

22. Miscellaneous GABA Agents  Prototype: valproic acid (Depakene)  Mechanism of action: ◦ similar to benzo’s and barbiturates  Primary use ◦ Adjunct therapy  Adverse effects: ◦ Sedation, drowsiness, GI upset, prolonged bleeding time

23. Hydantoins  Prototype: phenytoin (Dilantin)  Mechanism of action: ◦ Desensitize sodium channel blockers  Primary use ◦ Treatment of all types of seizures, except absence seizures  Adverse effects: ◦ CNS depression, gingival hyperplasia, skin rash, cardiact dysrhythmias, and hypotension

24. Phenytoin-like Drugs  Prototype drug: valproic acid (Depakene)  Mechanism of action: ◦ Desensitize sodium channels  Primary use: ◦ Absence seizures  Adverse effects: ◦ Limited CNS depression, visual disturbances, ataxia, vertigo, HA, GI, hepatotoxicity, pancreatitis

25. Succinimides  Prototype: ethosuximide (Zarontin)  Mechanism of action ◦ Suppress calcium influx  Primary use ◦ Absence seizures  Adverse effects: ◦ Rare, but include drowsiness, dizziness, lethargy ◦ Rare, but serious: lupus, leukopenia, aplastic anemia, Stevens-Johnson syndrome

26. Nurse’s role in pharmacological management  Barbiturates: ◦ Monitor for liver and kidney function ◦ Category D in pregnancy ◦ Depletion of nutrients ◦ Alcohol and ginko biloba interactions ◦ Client teaching  Use reliable contraception  Immediately report pregnancy  Report excessive bleeding,drowsiness, bone pain  Avoid alcohol and gingko biloba

27. Benzodiazepines-schedule IV drug  Monitor for drug abuse potential  Pregnancy risk (category D)  Contraindicated in narrow angle glaucoma  Liver and kidney function monitored  Respiratory depression  In event of overdose ◦ Give flumazenil (Romazicon)

28. Status epilepticus  Give IV valium and ativan  Do not mix with other drugs in IV line  Client teaching ◦ Avoid ETOH, OTC drugs, herbal preps, nicotine, driving and hazardous activities ◦ Rebound seizures if d/c abruptly ◦ Take with food ◦ These drugs most often used illegally

29. Hydantoin and Phenytoin-like drugs  Monitor serum drug levels, liver and kidney function  Monitor for bleeding disorders  Fatal hepatotoxicity can occur  Contraindicated ◦ Hx of heart block or seizures due to low BS  Client teaching ◦ Routine labs; report s/s of toxicity, bleeding, pregnancy, hypoglycemia

30. Succinimides  Monitor for liver and kidney function  Pregnancy category C  Adverse reactions: ◦ Drowsiness, HA, euphoria, n/v, weight loss, abd. Pain  Life threatening reactions: ◦ Mental depression with suicide intent ◦ Blood dyscrasias and Stevens-Johnson syndrome

31. Succinimides  Symptoms of overdose ◦ CNS depression, stupor, ataxia, coma  Client teaching ◦ Report mood changes or suicidal thoughts ◦ Avoid driving and hazardous activities ◦ Take with food ◦ Do not stop abruptly ◦ Report weight loss and anorexia

32. General client teachings for epilepsy  Start with smallest dose of med  Add additional drugs, if needed  Monitor serum drug levels  Withdrawal of meds ◦ Seizure free for three years ◦ Done gradually ◦ Resume meds if seizures return ◦ Knowledge of rebound seizures

33. Nursing diagnosis for epilepsy  Disturbed sensory perception RT seizure activity  Risk for injury RT seizure activity  Deficient knowledge RT disease/drugs  Noncompliance RT drug regime  Noncompliance RT serum lab testing

34. Goals in epilepsy treatment  Absence/reduction in number of seizures  No injury during seizure  Understanding of disease  Understanding of drug regimen  Compliance with lab testing

35. Obj. 13: define sedative and hypnotic  Sedative: ◦ An agent that calms nervousness, irritability and excitement  Hypnotic ◦ An agent that induces sleep

36. Obj. 16: Name the conditions that may cause muscle spasticity.  Results from damage to the motor area of the cerebral cortex  Conditions: ◦ Cerebral palsy ◦ severe head injury, spinal cord injury or lesions ◦ stroke ◦ dystonia

37. Obj. 17: Goals of drug therapy for muscle spasms  Goals of muscle relaxants ◦ Minimize discomfort ◦ Increase ROM ◦ Improve ability to function independently

38. Obj. 18: Name the musculoskeletal relaxants  Centrally acting muscle relaxants ◦ Prototype: cyclobenzaprine (Flexeril) ◦ Mechanism of action  Inhibits upper motor neuron activity  Alters simple spinal reflexes, causes CNS depression ◦ Primary Use  Treat localized spasms ◦ Adverse effects  CNS depression, hepatic toxicity, physical dependence, anticholinergic effects

39. Obj. 18: cont  Direct acting antispasmodics ◦ Prototype: dantrolene (Danantrium) ◦ Mechanism of action  Interferes with release of calcium ions in skeletal muscle ◦ Primary use  Relieve dystonias and leg cramps ◦ Adverse effects  Hepatic toxicity, muscle weakness, drowsiness, diarrhea

40. Obj. 19 Nursing process for CNS drugs  Assessment ◦ Monitor pain, LOC, vital signs ◦ Monitor muscle tone, ROM, degree of spasms ◦ Monitor labs  Nursing Dx ◦ Pain ◦ Impaired physical mobility ◦ Risk for injury ◦ Deficient knowledge

41. Obj. 19 cont  Goals ◦ Decrease pain ◦ Increase range of motion (ROM) ◦ Reduce muscle spasms ◦ No adverse effects of drugs ◦ Knowledge of drug regimen