Drug Class
Drug Sample
Pharmacodynamics
Potentiates the effects
of GABA, depresses
the CNS, and
suppresses the spread
of seizure activity.
 Anxiety
 Acute alcohol withdrawal
 Before endoscopic
procedures
 Muscle spasm Preoperative
sedation
 Adjunctive treatment for
seizure disorders
 Status epilepticus, severe
recurrent seizures
 Patients on stable regimens
of antiepileptic drugs who
need diazepam intermittently
to control bouts of increased
seizure activity
 Tetanus
 Acute treatment of
intermittent, stereotypic
episodes of frequent seizure
activity (i.e., seizure clusters,
acute repetitive seizures) that
are distinct from usual
seizure pattern in patients
with epilepsy
Potentiates the effects
of GABA, depresses
the CNS, and
suppresses the spread
of seizure activity.
 Anxiety
 Insomnia from anxiety or
transient situational stress
 Preoperative sedation
 Status epilepticus
Diazepam
Benzodiazepines
Lorazepam
CENTRAL NERVOUS SYSTEM (CNS) DRUGS
ANTIEPILEPTIC ( ANTICONVULSANTS )
Indications
Side Effects
CNS: drowsiness, dysarthria,
slurred speech, tremor,
transient amnesia, fatigue,
ataxia, headache, insomnia,
paradoxical anxiety,
hallucinations, minor changes
in EEG patterns, pain, vertigo,
confusion, depression.
CV: CV collapse, bradycardia,
hypotension.
EENT: diplopia, blurred vision,
nystagmus; with nasal form:
nasal discomfort, nasal
congestion, epistaxis.
GI: nausea, constipation,
diarrhea with rectal form, dry
mouth, dysgeusia (nasal form).
GU: incontinence, urine
retention.
Hematologic: neutropenia.
Hepatic: jaundice.
Respiratory: respiratory
depression, apnea, hiccups.
Skin: rash, phlebitis at injection
site.
Other: altered libido, physical
or psychological dependence.
CNS: drowsiness, sedation,
amnesia, insomnia, agitation,
dizziness, weakness,
unsteadiness, disorientation,
depression, headache,
somnolence.
CV: hypotension.
EENT: visual disturbances,
nasal congestion.
GI: abdominal discomfort,
nausea, change in appetite.
Respiratory: respiratory failure,
respiratory depression.
Other: pain at injection site.
Nursing Considerations
• Periodically monitor LFTs, CBC, and renal function
in patients receiving repeated or prolonged therapy.
• Monitor HR, BP, and mental status changes.
Patients are at an increased risk for falls.
Alert: Use of drug may lead to abuse, misuse, and
addiction, which can lead to overdose or death.
Abuse and misuse of benzodiazepines frequently
involves concomitant use of other medications,
alcohol, or illicit substances, which increase frequency
of serious adverse outcomes. Assess each patient’s
risk of abuse, misuse, and addiction before
prescribing and throughout treatment.
• Look alike–sound alike: Don’t confuse diazepam
with diazoxide or Ditropan. Don’t confuse Valium with
Valcyte.
• Monitor hepatic, renal, and hematopoietic function
periodically in patients receiving repeated or
prolonged therapy.
To reduce risk of withdrawal reactions, gradually taper
drug to discontinue or reduce dosage.
• Look alike–sound alike: Don’t confuse lorazepam
with alprazolam, clonazepam, or Lovaza. Don’t
confuse Ativan with Atgam.
Benzodiazepines
Barbiturates
Unknown. Probably
acts by facilitating the
effects of the inhibitory
neurotransmitter
GABA.
 Lennox-Gastaut syndrome,
atypical absence seizures,
akinetic and myoclonic
seizures
 Panic disorder
Produces all levels of
CNS depression.
Depresses the sensory
cortex, decreases
motor activity, and
alters cerebellar
function. Inhibits
transmission in the
nervous system and
 Treatment of all types of
seizures except absence
seizures
 Anticonvulsant in tonic-clonic
(grand mal), partial, and
febrile seizures in children
 Preoperative sedative and in
other situations in which
sedation may be required
Clonazepam
Phenobarbital
CNS: amnesia, aphonia,
choreiform movements, coma,
confusion, depression,
dysarthria, dysdiadochokinesis,
hallucinations, headache,
hemiparesis, hypotonia,
hysteria, increased libido,
insomnia, psychosis, slurred
speech, tremor, vertigo,
paradoxical reactions
CV: palpitations.
EENT: abnormal eye
movements, diplopia,
nystagmus, blurred vision,
pharyngitis, rhinitis, sinusitis.
GI: anorexia, coated tongue,
constipation, diarrhea, dry
mouth, encopresis, gastritis,
nausea, sore gums
GU: dysuria, enuresis, nocturia,
urine retention, colpitis,
dysmenorrhea, delayed
ejaculation, erectile
dysfunction, urinary frequency
Hematologic: anemia,
eosinophilia, leukopenia,
thrombocytopenia.
Hepatic: hepatomegaly,
transient elevations of serum
transaminases and ALP.
Respiratory: chest congestion,
hypersecretion in upper
respiratory tract passages,
respiratory depression,
rhinorrhea, shortness of breath,
bronchitis, URI, cough.
Skin: hair loss, hirsutism, rash.
CNS: hangover, delirium,
depression, drowsiness,
excitation, lethargy, vertigo.
Respiratory: respiratory
depression
CV: hypotension.
GI: constipation, diarrhea,
nausea, vomiting.
Skin: photosensitivity, rashes,
Alert: Closely monitor all patients for changes in
behavior that may indicate worsening of suicidal
thoughts or behavior or depression.
• Don’t stop drug abruptly because this may worsen
seizures. Notify prescriber at once if adverse
reactions develop.
• Closely assess response of older adults, who are
more sensitive to drug’s CNS effects.
• Monitor patient for oversedation.
• Monitor CBC and LFTs.
• Withdrawal symptoms are similar to those of
barbiturates.
• To reduce inconvenience of somnolence when drug
is used for panic disorder, giving one dose at bedtime
may be desirable.
• Look alike–sound alike: Don’t confuse clonazepam
with clonidine, clozapine, or lorazepam. Don’t confuse
Klonopin with clonidine.
 Monitor phenobarbital concentrations, CNS status,
and CBC with differential
 Monitor signs of hypersensitivity reactions. Notify
physician immediately because these symptoms
may indicate serious reactions.
 Assess symptoms of bronchospasm and
laryngospasm. Perform pulmonary function tests to
document suspected changes in ventilation and
respiratory function.
Secobarbital
Phenytoin
Hydantoin
(Dilantin)
raises the seizure
threshold. Capable of
inducing (speeding up)
enzymes in the liver
that metabolize drugs,
bilirubin, and other
compounds.
 Hypnotic (short-term)
urticaria.
MS: arthralgia, myalgia,
neuralgia.
Others: hypersensitivity
reactions, physical
dependence, psychological
dependence.
Produces CNS
depression through
gammaaminobutyric
acid (GABA)–like
effects. Therapeutic
Effects: Induction of
sleep, sedation, or
anesthesia.
 Short-term treatment of
insomnia
 Adjunctive agent for
anesthesia
May stabilize neuronal
membranes and limit
seizure activity either
by increasing efflux or
decreasing influx of
sodium ions across cell
membranes in the
motor cortex during
generation of
nerve impulses.
 To control tonic-clonic (grand
mal) and psychomotor
(temporal lobe) seizures
 To control tonic-clonic (grand
mal) and psychomotor
(temporal lobe) seizures in
patients
 requiring a loading dose
 Generalized tonic-clonic
status epilepticus; prevention
and treatment of seizures
during
 neurosurgery
CNS: abnormal thinking,
behavior changes, delirium,
excess sedation, excitation,
hallucinations, mental
depression, vertigo, sleep
disorders, sleep—driving,
neuralgia, "hangover" effect
Respiratory: respiratory
depression.
GI: nausea, vomiting,
constipation
Skin: photosensitivity, rashes,
urticaria
MS: arthralgia, myalgia.
Others: physical dependence,
psychologic dependence.
CNS: ataxia, decreased
coordination, mental confusion,
slurred speech, dizziness,
headache, insomnia,
nervousness, twitching,
peripheral neuropathy, vertigo.
CV: bradycardia, periarteritis
nodosa, hypotension, CV shock
EENT: diplopia, nystagmus,
blurred vision, thickening of
facial features.
GI: gingival hyperplasia,
nausea, vomiting, constipation.
Hematologic:
agranulocytosis, leukopenia, ,
thrombocytopenia,
macrocythemia, megaloblastic
anemia, pancytopenia
Hepatic: toxic hepatitis.
Metabolic: hyperglycemia.
Musculoskeletal:
osteomalacia.
 Monitor daytime drowsiness and ―hangover‖
symptoms
 Assess seizures
 Be alert for depression, delirium, excitation, or other
alterations in mood or behavior.
 Assess BP after IV administration and compare to
normal values. Report hypotension, especially if
patient experiences dizziness or syncope.
 Assess symptoms of respiratory depression. Monitor
pulse oximetry and perform pulmonary function tests
to quantify suspected changes in ventilation and
respiratory function.
 Monitor daytime drowsiness.
 Assess dizziness and vertigo that might affect gait,
balance, and other functional activities
 Report any personality and behavioral changes,
including excitation, hallucinations, mental
depression, delirium, or expression of abnormal
thoughts.
 Assess any muscle, joint, or nerve pain to rule out
musculoskeletal pathology; that is, try to determine if
pain is drug induced rather than caused by
biomechanical or neurophysiologic problems.
• If rash appears, stop drug. If rash is scarlatiniform or
morbilliform, resume drug after rash clears. If rash
reappears, stop therapy. If rash is exfoliative,
purpuric, or bullous, don’t resume drug.
• Don’t stop drug suddenly because this may worsen
seizures. Call prescriber immediately if adverse
reactions develop.
• Monitor drug level. Therapeutic level of total
phenytoin is 10 to 20 mcg/mL in adults and children
and 8 to 15 mcg/mL in neonates. Therapeutic range
of free phenytoin is 1 to 2 mcg/mL.
• Long-term use may decrease bone mineral density.
Vitamin D and calcium supplements may be needed.
• Because of the risks of cardiac and local toxicity with
parenteral phenytoin, use oral form when possible.
• Monitor CBC and calcium level every 6 months, and
periodically monitor hepatic function. If megaloblastic
anemia is evident, prescriber may order folic acid and
vitamin B12
• Maintain seizure precautions, as needed.
Alert: Closely monitor all patients for changes in
behavior that may indicate worsening of suicidal
Skin: SJS, toxic epidermal
necrolysis, bullous or purpuric
dermatitis, exfoliative
dermatitis, hypertrichosis,
inflammation at injection site,
necrosis, pain, photosensitivity
reactions, scarlatiniform or
morbilliform rash.
Elevates the seizure
threshold. Suppresses
abnormal wave and
spike activity
associated with
absence (petit mal)
seizures.
 Absence seizures (petit mal)
Hasn't been
established. Activity in
epilepsy is thought to
be related to increased
brain concentrations of
GABA.
 Simple and complex
absence seizures, mixed
seizure types (including
absence seizures)
 Complex partial seizures
 Mania
 To prevent migraine
headache
Ethosuximide
Valproic Acid
CNS: increased frequency of
tonic-clonic seizures, dizziness,
ataxia, drowsiness, euphoria,
fatigue, headache,
hyperactivity, irritability,
psychiatric disturbances.
EENT: myopia.
GI: abdominal pain, anorexia,
cramping, diarrhea, nausea,
vomiting, weight loss, hiccups.
GU: pink/brown discoloration of
urine, vaginal bleeding.
Skin: Stevens-Johnson
syndrome, hirsutism, rashes,
urticaria.
Hematologic: agranulocytosis,
eosinophilia, leukopenia,
pancytopenia.
Other: systemic lupus
erythematosus.
CNS: asthenia, dizziness,
headache, insomnia,
paresthesia, tardive dyskinesia,
nervousness, somnolence,
vertigo, tremor, agitation,
abnormal gait, dysarthria,
hallucinations, hypertonia,
amnesia, ataxia, depression,
speech disorder.
CV: chest pain, edema, HTN,
hypotension, vasodilation,
tachycardia, palpitations.
EENT: blurred vision, diplopia,
conjunctivitis, eye pain,
thoughts or behavior or depression.
• Watch for gingival hyperplasia, especially in
children.
Alert: Doubling the dose doesn’t double the level but
may cause toxicity. Consult pharmacist for specific
dosing recommendations.
• If seizure control is established with divided doses,
once-daily dosing may be considered.
• Look alike–sound alike: Don’t confuse phenytoin
with mephenytoin, fosphenytoin, phenelzine,
phentermine, or phenobarbital. Don’t confuse Dilantin
with Dilaudid, diltiazem, or Dipentum.
 Document the number, duration, and severity of
seizures to help determine if this drug is effective in
reducing seizure activity.
 Monitor skin reactions such as rash, itching/burning
skin, hives, exfoliation, and dermatitis.
 Be alert for signs of agranulocytosis and leukopenia,
eosinophilia, or fatigue and poor health that might
be due to other blood dyscrasias.
 Assess dizziness or ataxia that might affect gait,
balance, and other functional activities.
 Monitor daytime drowsiness, euphoria, irritability, or
other psychiatric disturbances.
 Monitor signs of drug-induced lupus syndrome.
 Periodically assess body weight and other
anthropometric measures.
• When converting adults and children age 10 and
older with seizures from Depakote to Depakote ER,
make sure the extended-release dose is 8% to 20%
higher than the regular dose taken previously.
• Never withdraw drug suddenly because sudden
withdrawal may worsen seizures.
• Notify prescriber if tremors occur
• Monitor drug level.
• When converting patients from a brand-name drug
to a generic drug, use caution because breakthrough
seizures may occur.
Alert: Sometimes fatal, hyperammonemic
encephalopathy may occur when starting valproate
therapy in patients with UCD.
Carbamazepine
Thought to stabilize
neuronal membranes
and limit seizure
activity by either
increasing efflux or
decreasing influx of
sodium ions across cell
membranes in the
motor cortex during
generation of nerve
impulses.
 Generalized tonic-clonic and
complex partial seizures,
mixed seizure patterns
 Acute manic and mixed
episodes associated with
bipolar I disorder
 Trigeminal neuralgia
nystagmus, deafness, ear pain,
pharyngitis, periodontal
abscess, rhinitis, tinnitus.
GI: abdominal pain, anorexia,
diarrhea, fecal incontinence,
flatulence, gastroenteritis,
glossitis, stomatitis, dyspepsia,
hematemesis, eructation,
pancreatitis, constipation
GU: vaginitis, dysmenorrhea,
dysuria, cystitis, urinary
frequency
Hematologic: hemorrhage,
thrombocytopenia
Musculoskeletal: back and
neck pain, arthralgia, leg
cramps, twitching,
myasthenia.
Respiratory: bronchitis,
dyspnea
Skin: alopecia, ecchymosis,
petechiae, discoid lupus
erythematosus, furunculosis,
seborrhea, rash, pruritus
CNS: ataxia, dizziness,
drowsiness, somnolence,
vertigo, worsening of seizures,
confusion, fatigue, fever,
headache, syncope, pain,
depression, speech disorder.
CV: arrhythmias, AV block, HF,
HTN, hypotension.
GI: nausea, vomiting,
abdominal pain, anorexia,
diarrhea, dry mouth, dyspepsia,
glossitis, stomatitis.
Hematologic: agranulocytosis,
aplastic anemia, leucocytosis,
thrombocytopenia, eosinophilia,
Respiratory: pulmonary
hypersensitivity.
Skin: erythema multiforme,
SJS, toxic epidermal necrolysis,
excessive diaphoresis, rash,
urticaria, pruritus.
Alert: Closely monitor all patients taking or starting
antiepileptic drugs for changes in behavior indicating
worsening of suicidal thoughts or behavior or
depression.
Alert: Dose-related thrombocytopenia can occur.
Monitor CBC, platelet count, PT, and INR
before starting therapy and at frequent intervals.
Alert: Monitor patients and immediately report
symptoms of DRESS syndrome
• Look alike–sound alike: Don't confuse Depakote
with Depakote ER.
• Watch for worsening of seizures, especially in
patients with mixed seizure disorders, including
atypical absence seizures.
Alert: Closely monitor all patients taking or starting
AEDs for changes in behavior indicating worsening of
suicidal thoughts or behavior or depression.
• Obtain baseline determinations of urinalysis, renal
function, iron levels, electrolyte levels, liver function,
CBC, and platelet and reticulocyte counts.
• Never stop drug suddenly when treating seizures.
• Adverse reactions may be minimized by increasing
dosages gradually.
• Monitor level and effects closely. Ask patient when
last dose was taken to better evaluate drug level.
Alert: Watch for signs of anorexia or subtle appetite
changes, which may indicate excessive drug level.
• Look alike–sound alike: Don’t confuse
carbamazepine with oxcarbazepine. Don’t confuse
Tegretol or Tegretol-XR with Topamax, Toprol-XL, or
Toradol. Don’t confuse Carbatrol with carvedilol.
CENTRAL NERVOUS SYSTEM (CNS) DRUGS
Drug Class
Drug Sample
Pharmacodynamics
Thought to be linked to
drug’s inhibition of
CNS neuronal uptake
of serotonin.






Fluoxetine


Selective
Serotonin
Reuptake
Inhibitors
(SSRI)
Thought to be linked to
drug’s inhibition of
CNS neuronal uptake
of serotonin.





Paroxetine



ANTIDEPRESSANTS
Indications
Side Effects
CNS: nervousness,
Depression, OCD
somnolence, anxiety, insomnia,
Maintenance therapy for
headache, drowsiness, tremor,
depression in patients who
dizziness, asthenia, abnormal
are stabilized (not for newly
thinking, fatigue, fever,
diagnosed depression)
emotional lability.
Short-term and long-term
treatment of bulimia nervosa CV: palpitations, hot flashes,
Short-term treatment of panic prolonged QT interval.
EENT: nasal congestion,
disorder with or without
pharyngitis, sinusitis.
agoraphobia
GI: nausea, diarrhea, dry
Depressive episodes
mouth, anorexia, dyspepsia,
associated with bipolar I
constipation, abdominal pain,
disorder (with olanzapine)
vomiting, flatulence, increased
Premenstrual dysphoric
appetite, taste perversion.
disorder
GU: sexual dysfunction,
Treatment-resistant
decreased libido, micturition
depression
disorder.
Metabolic: weight loss,
hyponatremia.
Musculoskeletal: muscle pain.
Respiratory: URI, cough.
Skin: rash, pruritus,
diaphoresis
Other: flulike syndrome, chills
CNS: asthenia, dizziness,
Major depressive disorder
headache, insomnia,
(excluding Brisdelle)
OCD (Paxil and Pexeva only) somnolence, tremor,
nervousness, anxiety,
Panic disorder (excluding
paresthesia, confusion,
Brisdelle)
Social anxiety disorder (Paxil agitation, dysgeusia.
CV: palpitations, vasodilation,
and Paxil CR only)
Generalized anxiety disorder HTN, tachycardia, chest pain.
EENT: blurred vision, tinnitus,
(Paxil and Pexeva only)
lump or tightness in throat,
PTSD (Paxil only)
pharyngitis, rhinitis, sinusitis.
Premenstrual dysphoric
GI: dry mouth, nausea,
disorder (PMDD) (Paxil CR
constipation, diarrhea,
only)
flatulence, vomiting, dyspepsia,
Moderate to severe
decreased appetite, abdominal
vasomotor symptoms
pain.
associated with menopause
GU: ejaculatory disturbances,
(Brisdelle only)
sexual dysfunction, decreased
Nursing Considerations
Alert: If linezolid or methylene blue must be given,
fluoxetine must be stopped and patient monitored for
serotonin toxicity for 5 weeks or until 24 hours after
final dose of linezolid or methylene blue, whichever
comes first.
• Use antihistamines or topical corticosteroids to treat
rashes or pruritus.
• Watch for weight change during therapy.
• Record mood changes. Watch for suicidal
tendencies.
• Monitor patient for serotonin syndrome.
• Monitor blood glucose level, liver and renal function.
• Obtain ECG and monitor periodically in patients with
risk factors for QT-interval prolongation and
ventricular arrhythmia.
• Monitor mental status for depression, suicidal
ideation, anxiety, social functioning, mania, or panic
attacks.
• Observe for signs or symptoms of serotonin
syndrome, akathisia, or sleep disturbances.
• When discontinuing drug, taper dosage over 2
weeks to 1 month to avoid withdrawal syndrome.
• Look alike–sound alike: Don’t confuse fluoxetine
with fluvoxamine or fluvastatin. Don’t confuse Prozac
with Proscar or Prilosec.
• Patients taking Paxil CR for PMDD should be
periodically reassessed to determine the need for
continued treatment.
• If signs or symptoms of psychosis occur or increase,
expect prescriber to reduce dosage. Record mood
changes. Monitor patient for suicidal tendencies.
• Monitor patient for complaints of sexual dysfunction.
Alert: Don’t stop drug abruptly.
Alert: Combining triptans with an SSRI or an SSNRI
may cause serotonin syndrome or NMS like reactions.
Alert: If linezolid or methylene blue must be given,
stop paroxetine and monitor patient for serotonin
toxicity for 2 weeks or until 24 hrs after the last dose
of methylene blue or linezolid, whichever comes first.
• Look alike–sound alike: Don’t confuse paroxetine
with fluoxetine or paclitaxel. Don’t confuse Paxil with
Doxil, paclitaxel, Plavix, or Taxol.
Thought to be linked to
drug’s inhibition of
CNS neuronal
reuptake of serotonin.





Probably linked to
potentiation of
serotonergic activity in
the CNS resulting from
inhibition of neuronal
reuptake of serotonin.
 Depression
Depression
OCD
Panic disorder
PTSD
Premenstrual dysphoric
disorder
 Social anxiety disorder
 Generalized anxiety disorder
Sertraline
Citalopram
libido, urinary frequency, other
urinary disorders,
dysmenorrhea, female genital
tract disease.
Metabolic: weight gain.
Musculoskeletal: myopathy,
myalgia, myasthenia, back
pain.
Respiratory: dyspnea.
Skin: diaphoresis, rash,
pruritus
CNS: fatigue, headache,
tremor, dizziness, insomnia,
somnolence, anxiety, agitation,
hyperkinesia, aggression.
CV: palpitations.
EENT: visual disturbances,
blurred vision, mydriasis, dry
mouth, epistaxis.
GI: nausea, diarrhea,
dyspepsia, vomiting,
constipation, thirst, flatulence,
anorexia, abdominal pain,
decreased appetite.
GU: male sexual dysfunction,
decreased libido (both
genders), urinary incontinence.
Metabolic: weight loss.
Musculoskeletal: myalgia,
arthralgia.
Skin: rash, pruritus, purpura
diaphoresis, alopecia
CNS: somnolence, insomnia,
suicide attempt, anxiety,
agitation, dizziness,
paresthesia, migraine, impaired
concentration, amnesia,
depression, apathy, tremor,
confusion, fatigue, fever.
CV: tachycardia, orthostatic
hypotension, hypotension,
prolonged QT interval.
EENT: rhinitis, sinusitis,
abnormal accommodation.
GI: dry mouth, nausea,
diarrhea, anorexia, dyspepsia,
• Record mood changes. Monitor patient for suicidal
tendencies, and allow only a minimum supply of drug.
• Assess patients for sexual dysfunction at baseline
and periodically during treatment. SSRIs may cause
signs and symptoms of sexual dysfunction and
patients may not spontaneously report changes in
sexual function.
Alert: If linezolid or methylene blue must be given,
stop sertraline and monitor patient for serotonin
toxicity for 2 weeks or until 24 hrs after the last dose
of methylene blue or linezolid, whichever comes first.
Alert: Combining triptans with an SSRI or an SSNRI
may cause serotonin syndrome or NMS-like reactions
• Gradual dosage reduction is recommended when
stopping treatment. Monitor patient for
discontinuation syndrome
• Look alike–sound alike: Don’t confuse sertraline with
cetirizine or Soriatane.
• Correct electrolyte disturbances before starting drug;
monitor patients at high risk for electrolyte
disturbances periodically during therapy.
• Although drug hasn’t been shown to impair
psychomotor performance, any psychoactive drug
has the potential to impair judgment, thinking, or
motor skills.
• Reduce risk of overdose by limiting amount of drug
available per refill.
• At least 14 days should elapse between MAO
inhibitor therapy and citalopram therapy.
Alert: Combining triptans with an SSRI or an SSNRI
may cause serotonin syndrome or NMS-like reactions
Alert: If linezolid or methylene blue must be given,
Unknown. May
increase amount of
norepinephrine,
serotonin, or both in
the CNS by blocking
their reuptake by the
presynaptic neurons.
Tricyclic
Antidepressants
(TCA)
Amitriptyline
vomiting, abdominal pain, taste
perversion, increased saliva,
flatulence, increased appetite.
GU: dysmenorrhea,
amenorrhea, ejaculation
disorder, erectile dysfunction,
anorgasmia, polyuria,
decreased libido.
Metabolic: decreased or
increased weight.
Musculoskeletal: arthralgia,
myalgia.
Respiratory: URI, coughing.
Skin: rash, pruritus.
Other: increased sweating,
yawning, decreased libido.
CNS: stroke, seizures, coma,
 Depression (outpatients)
 Depression (patients who are ataxia, tremor, peripheral
neuropathy, anxiety, insomnia,
hospitalized)
restlessness, drowsiness,
dizziness, weakness, fatigue,
headache, extrapyramidal
reactions, hallucinations,
delusions, disorientation.
CV: orthostatic hypotension,
tachycardia, heart block,
arrhythmias, MI, ECG changes,
HTN, edema, palpitations,
syncope.
EENT: blurred vision,
mydriasis, increased IOP,
tinnitus.
GI: dry mouth, nausea,
vomiting, anorexia, epigastric
pain, diarrhea, constipation,
paralytic ileus.
GU: urine retention, altered
libido, erectile dysfunction.
Hematologic: agranulocytosis,
thrombocytopenia, leukopenia,
eosinophilia.
Metabolic: hypoglycemia,
hyperglycemia.
Skin: rash, urticaria, alopecia,
photosensitivity reactions,
diaphoresis.
stop drug and monitor patient for serotonin toxicity for
2 weeks, or until 24 hours after the last dose of
methylene blue or linezolid, whichever comes first.
• Don’t discontinue drug abruptly because a
discontinuation syndrome can develop
• Look alike–sound alike: Don’t confuse CeleXA with
Zyprexa, CeleBREX, or Cerebyx.
• Amitriptyline has strong anticholinergic effects and is
one of the most sedating TCAs.
Anticholinergic effects have rapid onset even though
therapeutic effect is delayed for weeks.
• Older adults may have an increased sensitivity to
anticholinergic effects of drug; sedating effects of drug
may increase the risk of falls in this population.
• If signs or symptoms of psychosis occur or increase,
expect prescriber to reduce dosage.
Record mood changes. Monitor patient for suicidal
tendencies and allow only minimum supply of drug.
• Because patients using TCAs may suffer
hypertensive episodes and arrhythmias during
surgery, stop drug gradually several days before
surgery.
• Monitor glucose level.
• Watch for nausea, headache, and malaise after
abrupt withdrawal of long-term therapy; these
symptoms don’t indicate addiction.
• Don’t withdraw drug abruptly.
• Look alike–sound alike: Don’t confuse amitriptyline
with nortriptyline or aminophylline. Don’t confuse
Elavil with Eldepryl or enalapril.
Unknown. Increases
norepinephrine,
serotonin, or both in
the CNS by blocking
their reuptake by the
presynaptic neurons.
Mechanism for
enuresis unknown but
thought to be separate
from drug’s
antidepressant
effects.
 Depression
 Childhood enuresis
Inhibits the enzyme
monoamine oxidase,
resulting in an
accumulation of
various
neurotransmitters
(dopamine,
epinephrine,
norepinephrine, and
serotonin) in the body.
 Treatment of major
depressive episode without
melancholia (usually
reserved for patients who do
not tolerate or respond to
other modes of therapy)
Imipramine
Mono Amine
Oxidase
Inhibitors
( MAOI’s)
Tranylcypromine
(Parnate)
CNS: drowsiness, dizziness,
seizures, stroke, excitation,
tremor, confusion,
hallucinations, anxiety, ataxia,
fatigue, peripheral neuropathy,
restlessness, headache,
paresthesia, nervousness,
extrapyramidal reactions,
agitation, sleep disorders,
tiredness.
CV: orthostatic hypotension,
tachycardia, ECG changes, MI,
arrhythmias, heart block, HTN,
precipitation of HF, palpitations.
EENT: blurred vision,
mydriasis, tinnitus.
GI: dry mouth, constipation,
nausea, vomiting, anorexia,
paralytic ileus, abdominal
cramps, black tongue, diarrhea.
GU: urine retention, urinary
frequency.
Hematologic: bone marrow
depression, thrombocytopenia.
Metabolic: hypoglycemia,
hyperglycemia, weight loss,
weight gain.
Skin: rash, urticaria,
photosensitivity reactions,
pruritus, diaphoresis, alopecia.
CNS: seizures, confusion,
dizziness, drowsiness,
headache, insomnia,
restlessness, tremor,
paresthesia, weakness.
EENT: blurred vision, tinnitus.
CV: hypertensive crisis, edema,
orthostatic hypotension,
tachycardia.
GI: abdominal pain, anorexia,
constipation, diarrhea, dry
mouth, hepatitis, nausea.
GU: sexual dysfunction, urinary
retention.
Hematologic: agranulocytosis,
leukopenia, thrombocytopenia.
• Monitor WBC count during therapy, and monitor
patient for fever and sore throat. Discontinue drug if
pathologic neutrophil depression occurs.
• Monitor patient for nausea, headache, and malaise
after abrupt withdrawal of long-term therapy; these
symptoms don’t indicate addiction.
• Safety of long-term use as adjunctive therapy for
nocturnal enuresis in children age 6 or older hasn’t
been established. Consider a drug-free period after
an adequate therapeutic trial with a favorable
response.
• Don’t withdraw drug abruptly.
• Because of hypertensive episodes during surgery in
patients receiving TCAs, stop drug gradually several
days before surgery.
• If signs or symptoms of psychosis occur or increase,
expect prescriber to reduce dosage. Monitor mood
changes. Monitor patient for suicidal tendencies, and
allow only a minimum supply of drug.
• To prevent relapse in children receiving drug for
enuresis, withdraw drug gradually.
• Recommend sugarless hard candy or gum to relieve
dry mouth. Saliva substitutes may be useful.
Alert: Tofranil may contain tartrazine.
• Look alike–sound alike: Don’t confuse imipramine
with desipramine.
 Be alert for new seizures or increased seizure
activity, especially at the onset of drug treatment.
Document the number, duration, and severity of
seizures, and report these findings to the physician
immediately.
 Measure BP periodically & compare to normal
values. Immediately report a large, rapid increase in
BP.
 Watch for signs of agranulocytosis and leukopenia
and thrombocytopenia.
 Be alert for increased depression and suicidal
thoughts and ideology.
 Be alert for restlessness, confusion, or other
alterations in mood and behaviour.
 Assess BP when patient assumes a more upright
position.
Skin: alopecia, rashes.
MS: muscle spasm.
Isocarboxazid
(Marpan)
Phenelzine
(Nardil)
Inhibits the enzyme
monoamine oxidase,
resulting in an
accumulation of
various
neurotransmitters
(dopamine,
epinephrine,
norepinephrine, and
serotonin) in the body.
 Treatment of depression
Inhibits the enzyme
monoamine oxidase,
resulting in an
accumulation of
various
neurotransmitters
(dopamine,
epinephrine,
norepinephrine, and
serotonin) in the body.
 Treatment of neurotic or
(usually reserved for patients
who do not tolerate or
respond to other modes of
therapy)
atypical depression (usually
reserved for patients who do
not tolerate or respond to
other modes of therapy
CNS: seizures, dizziness,
headache, akathisia, anxiety,
ataxia, drowsiness, euphoria,
insomnia, restlessness,
weakness.
EENT: blurred vision.
CV: hypertensive crisis,
orthostatic hypotension.
GI: nausea, black tongue,
constipation, diarrhea, dry
mouth.
GU: dysuria, sexual
dysfunction, urinary
incontinence, urinary retention.
Skin: photosensitivity.
CNS: seizures, dizziness,
drowsiness, fatigue, headache,
hyperreflexia, insomnia, tremor,
twitching, weakness, euphoria,
paresthesia, restlessness.
EENT: blurred vision,
glaucoma, nystagmus.
CV: hypertensive crisis, edema,
orthostatic hypotension.
GI: constipation, dry mouth,
abdominal pain, liver function
test elevation, nausea,
vomiting.
GU: sexual dysfunction, urinary
retention.
Skin: pruritus, rashes.
Endo: weight gain.
 Assess peripheral edema using girth
measurements, volume displacement &
measurement of pitting edema.
 Assess paresthesias, tremor, or muscle spasms.
 Be alert for new seizures or increased seizure
activity. Document the number, duration, and
severity of seizures, and report these findings to the
physician immediately.
 Measure BP periodically & compare to normal
values. Immediately report a large, rapid increase in
BP.
 Assess BP when patient assumes a more upright
position.
 Be alert for increased depression and suicidal
thoughts and ideology.
 Assess dizziness, drowsiness, and ataxia that might
affect gait, balance, and other functional activities.
 Be alert for new seizures or increased seizure
activity, especially at the onset of drug treatment.
Document the number, duration, and severity of
seizures, and report these findings immediately to
the physician.
 Measure BP periodically & compare to normal
values. Immediately report a large, rapid increase in
BP.
 Be alert for increased depression and suicidal
thoughts and ideology.
 Be alert for anxiety, euphoria, severe restlessness,
or other alterations in mental status.
 Assess BP when patient assumes a more upright
position.
 Assess peripheral edema using girth
measurements, volume displacement, and
measurement of pitting edema.
 Assess paresthesias, tremor, or increased reflex
activity.
 Assess dizziness and drowsiness that might affect
gait, balance, and other functional activities.
CENTRAL NERVOUS SYSTEM (CNS) DRUGS
Drug Class
Drug Sample
Pharmacodynamics
Alters the effects of
dopamine in the CNS.
Has significant
anticholinergic/alphaadrenergic blocking
activity.







Chlorpromazine
Antipsychotics
A. Typical
Antipsychotic
A butyrophenone that
probably exerts
antipsychotic effects by
blocking postsynaptic
dopamine receptors in
the brain.
Haloperidol
PSYCHOTHERAPEUTIC DRUGS
Indications
Side Effects
CNS: neuroleptic malignant
Psychosis, mania
syndrome, sedation,
Nausea and vomiting
extrapyramidal reactions,
Acute intermittent porphyria,
tardive dyskinesia
intractable hiccups
EENT: blurred vision, dry eyes,
Tetanus
lens opacities
Behavioral disorders,
CV: hypotension, tachycardia.
hyperactivity
GI: constipation, dry mouth,
Preoperative sedation,
anorexia, hepatitis, ileus,
anxiety
priapism
Second-line treatment for
schizophrenia and psychoses GU: urinary retention
Skin: photosensitivity, pigment
after failure with atypical
changes, rashes
antipsychotics
Endo: galactorrhea,
amenorrhea
Hematologic: agranulocytosis,
leukopenia
Metabolic: hyperthermia
Others: allergic reactions
Schizophrenia
Chronic schizophrenia
requiring prolonged therapy
Nonpsychotic behavior
disorders
Tourette syndrome
CNS: severe extrapyramidal
reactions, dystonia, tardive
dyskinesia, NMS, seizures,
sedation, drowsiness, lethargy,
headache, insomnia,
confusion, vertigo, agitation,
anxiety, depression, euphoria,
restlessness, tonic-clonic
seizures, hallucinations,
parkinsonian-like syndrome.
CV: tachycardia, hypotension,
HTN, prolonged QT interval
and other ECG changes,
torsades de pointes
GI: dry mouth, anorexia,
constipation, diarrhea, nausea,
vomiting, dyspepsia.
Hematologic: leukopenia,
leukocytosis.
Hepatic: jaundice.
Metabolic: hyperglycemia,
hypoglycemia, hyponatremia.
Nursing Considerations
 Monitor and report signs of neuroleptic malignant
syndrome.
 Watch for signs of agranulocytosis and leukopenia.
 Assess motor function, and be alert for
extrapyramidal symptoms.
 Assess BP periodically and compare to normal
values. Report low BP, especially if patient
experiences dizziness or syncope.
 Assess heart rate, ECG, and heart sounds,
especially during exercise. Report a rapid HR or
symptoms of other arrhythmias.
 Monitor signs of allergic reactions.
 If used to control behavioral problems in children,
document any changes in combative or hyperactive
behavior to help determine drug efficacy and
appropriate dosing.
 If used to control vascular headache, monitor the
frequency, severity, and duration of attacks to help
document the effects of drug therapy.
• Monitor patient for tardive dyskinesia, which may
occur after prolonged use.
Alert: Watch for signs and symptoms of NMS, which
is rare but commonly fatal.
Alert: Monitor ECG when drug is given in high doses
or when patient is taking other QT interval–
prolonging drugs because of the increased risk of
QT-interval prolongation and torsades de pointes.
• Don’t withdraw drug abruptly unless required by
severe adverse reactions.
• Complete fall risk assessments at start of
antipsychotic treatment and recurrently for patients
on long-term therapy, especially those at increased
risk for falls.
• Esophageal dysmotility and aspiration can occur.
Use cautiously in patients at risk for aspiration.
• Look alike–sound alike: Don’t confuse Haldol with
Halcion or Halog.
Alters the effects of
dopamine in the CNS.
Has anticholinergic
and alpha-adrenergic
blocking activity.
 Acute and chronic psychotic
disorders
Fluphenazine
Unknown. Binds
 Schizophrenia in patients
selectively to
who are severely ill and
dopaminergic
unresponsive to other
receptors in the CNS
therapies; to reduce risk of
and may interfere with
recurrent suicidal behavior in
adrenergic, cholinergic, schizophrenia or
histaminergic, and
schizoaffective disorder
serotonergic
receptors.
Antipsychotics
B. Atypical
Antipsychotics
Clozapine
CNS: neuroleptic malignant
syndrome, extrapyramidal
reactions, sedation, tardive
dyskinesia.
EENT: blurred vision, dry eyes.
CV: hypertension, hypotension,
tachycardia.
GI: anorexia, constipation,
drug-induced hepatitis, dry
mouth, ileus, nausea, weight
gain.
GU: urinary retention.
Skin: photosensitivity, pigment
changes, rashes.
Endo: galactorrhea.
Hemat: agranulocytosis,
leukopenia, thrombocytopenia.
Misc: allergic reactions.
CNS: drowsiness, sedation,
dizziness, vertigo, headache,
seizures, syncope, tremor,
disturbed sleep or nightmares,
restlessness, hypokinesia or
akinesia, agitation, rigidity,
akathisia, confusion, fatigue,
insomnia, hyperkinesia,
weakness, lethargy, ataxia,
slurred speech, depression,
myoclonus, anxiety, fever.
CV: tachycardia, hypotension,
HTN, chest pain, ECG
changes, orthostatic
hypotension
EENT: visual disturbances
GI: constipation, excessive
salivation, dry mouth, nausea,
vomiting, heartburn, diarrhea.
Hematologic: leukopenia,
neutropenia, eosinophilia.
Metabolic: hyperglycemia,
weight gain,
hypercholesterolemia,
hypertriglyceridemia.
Respiratory: respiratory arrest.
Monitor and report signs of neuroleptic malignant
syndrome.
Monitor signs of agranulocytosis and leukopenia or
thrombocytopenia.
Assess motor function, and be alert for
extrapyramidal symptoms.
Monitor signs of allergic reactions.
Assess BP and compare to normal values.
Assess heart rate, ECG, and heart sounds,
especially during exercise.
Periodically assess body weight and other
anthropometric measures.
Alert: Drug may cause hyperglycemia. Monitor
patients with diabetes regularly.
Alert: Monitor patient for metabolic syndrome.
• Monitor patient for signs and symptoms of
myocarditis and cardiomyopathy.
• Some patients experience transient fever with
temperature higher than 100.4° F (38° C), especially
in the first 3 weeks of therapy. Monitor these patients
closely.
Alert: Fever may be the first sign of neutropenic
infection. Interrupt therapy and obtain ANC level.
• If drug is to be discontinued and patient doesn’t
have moderate to severe neutropenia, reduce dose
gradually over 1 to 2 weeks.
• When discontinuing drug, monitor patients carefully
for recurrence of psychotic symptoms and symptoms
related to cholinergic rebound.
• Drug can cause sedation and impair cognitive and
motor performance. Monitor patient carefully for CNS
changes.
• Complete fall risk assessments when initiating
therapy and recurrently for patients on long-term
therapy.
• Look alike–sound alike: Don’t confuse clozapine
with clonidine, clonazepam, or Klonopin. Don’t
confuse Clozaril with Colazal.
May block dopamine
and 5receptors.
Olanzapine
Risperidone
 Schizophrenia
 Short-term treatment of acute
manic episodes linked to
bipolar I disorder
 Short-term treatment, with
lithium or valproate, of acute
mixed or manic episodes
linked to bipolar I disorder
 Maintenance treatment of
bipolar I disorder
 Agitation caused by
schizophrenia and bipolar I
mania
 Depressive episodes
associated with bipolar I
disorder
 Treatment-resistant
depression
 Preventing chemotherapyassociated acute and
delayed nausea or vomiting
 Chemotherapy-associated
breakthrough nausea or
vomiting
Blocks dopamine, 5 Schizophrenia
,
and
 Parenteral maintenance
adrenergic, and
therapy for schizophrenia or
histaminergic
bipolar I disorder (as
receptors in the
 monotherapy or as
brain.
combination therapy with
lithium or valproate)
 Monotherapy or combination
therapy with lithium or
valproate for 3-week
treatment of acute manic or
mixed episodes from bipolar I
disorder
 Irritability, including
aggression, self-injury, and
temper tantrums, associated
with an autistic disorder
CNS: somnolence, insomnia,
parkinsonism, dizziness, NMS,
suicide attempt, abnormal gait,
asthenia, personality disorder,
auditory hallucinations,
restlessness, fatigue, akathisia,
headache, tremor, articulation
impairment, tardive dyskinesia,
fever, extrapyramidal events
(IM), hypertonia.
CV: prolonged QT interval,
orthostatic hypotension,
tachycardia, chest pain, HTN,
ecchymosis, peripheral edema,
hypotension (IM).
EENT: amblyopia,
conjunctivitis, rhinitis,
pharyngitis.
GU: hematuria, metrorrhagia,
urinary incontinence, UTI,
amenorrhea, vaginitis, vaginal
discharge.
Hematologic: leukopenia.
Metabolic: hyperglycemia,
dyslipidemia, weight gain.
CNS: akathisia, sedation,
somnolence, dystonia,
headache, insomnia, agitation,
pain, parkinsonism, abnormal
gait, ataxia, hallucination,
mania, hypoesthesia, fatigue,
depression
CV: tachycardia, bradycardia,
bundle-branch block, ECG
changes, chest pain,
hypotension, edema,
palpitations, HTN.
GU: urinary incontinence,
increased urination, abnormal
orgasm, decreased libido,
vaginal dryness, amenorrhea,
menstrual disorder, cystitis
Musculoskeletal: arthralgia,
myalgia, muscle rigidity, spasm
Respiratory: cough, dyspnea,
bronchitis, pneumonia, URI.
• ODTs contain phenylalanine.
• Monitor patient for abnormal body temperature
regulation, especially if patient exercises, is exposed
to extreme heat, takes anticholinergics, or is
dehydrated.
• Obtain baseline and periodic LFT results.
• Monitor patient for weight gain.
• Monitor patient for mental status changes,
sedation, coma, or delirium.
• Monitor patient for tardive dyskinesia, which may
occur after prolonged use. It may not appear until
months or years later and may disappear
spontaneously or persist for life, despite stopping
drug.
• Periodically reevaluate the long-term usefulness of
olanzapine.
• Patient who feels dizzy or drowsy after an IM
injection should remain recumbent until assessment
for orthostatic hypotension and bradycardia can be
done. Patient should rest until the feeling passes.
• Taper dosage slowly when discontinuing.
• Look alike–sound alike: Don’t confuse olanzapine
with olsalazine or quetiapine.
Alert: Obtain baseline BP measurements before
starting therapy, and monitor BP regularly. Watch for
orthostatic hypotension.
Alert: Watch for evidence of NMS.
• Life-threatening hyperglycemia may occur in
patients taking atypical antipsychotics. Monitor
patients with diabetes regularly.
Alert: Monitor patient for symptoms of metabolic
syndrome.
• Periodically reevaluate drug’s risks and benefits
• Monitor patient for weight gain.
• Monitor CBC in patients with preexisting low WBC
count or history of drug-induced leukopenia or
neutropenia.
• Complete fall risk assessments when initiating
treatment and recurrently for patients on long term
therapy
• Look alike–sound alike: Don’t confuse risperidone
with reserpine or ropinirole.
Probably alters
 Acute mania in bipolar
chemical transmitters
disorder
in the CNS, possibly by  Long-term control in bipolar
interfering with ionic
disorder
pump mechanisms in
brain cells, and may
compete with or
replace sodium ions.
Antimanic
Lithium
Releases nerve
terminal stores of
norepinephrine,
promoting nerve
impulse transmission.
At high doses, effects
are mediated by
dopamine.
CNS Stimulants
Methylphenidate
 ADHD
 Narcolepsy
CNS: fatigue, lethargy, coma,
seizures, tremors, drowsiness,
headache, restlessness,
dizziness, psychomotor
retardation, blackouts, EEG
changes, impaired speech,
ataxia, incoordination.
CV: arrhythmias, bradycardia,
reversible ECG changes,
severe bradycardia,
hypotension, Brugada
syndrome.
GI: vomiting, anorexia,
diarrhea, thirst, nausea,
metallic taste, dry mouth,
abdominal pain, flatulence,
indigestion.
GU: polyuria, renal toxicity with
long-term use, glycosuria,
decreased CrCl, albuminuria,
erectile dysfunction.
Hematologic: leukocytosis.
Metabolic: transient
hyperglycemia, goiter,
hypothyroidism, hyponatremia.
CNS: nervousness, headache,
insomnia, seizures, tics,
dizziness, akathisia,
dyskinesia, drowsiness, mood
swings, anxiety, irritability,
depression, tremor, vertigo,
confusion, insomnia, sedation,
CV: palpitations, tachycardia,
arrhythmias, HTN.
EENT: blurred vision, eye pain,
pharyngitis, sinusitis, bruxism,
xerostomia, oropharyngeal
pain.
GI: nausea, abdominal pain,
anorexia, decreased appetite,
dry mouth, vomiting,
constipation, dyspepsia,
diarrhea.
GU: decreased libido.
Metabolic: weight loss.
• Monitor patient and discontinue drug for signs and
symptoms of lithium toxicity.
• Monitor baseline ECG, thyroid studies, renal
studies, and electrolyte levels.
• Check fluid intake and output, especially when
surgery is scheduled.
• Weigh patient daily; check for edema or sudden
weight gain.
• Adjust fluid and salt ingestion to compensate if
excessive loss occurs from protracted diaphoresis or
diarrhea.
• Check urine specific gravity and report level below
1.005, which may indicate diabetes insipidus.
• Monitor glucose level closely.
• Perform outpatient follow-up of thyroid and renal
function every 2 to 3 months during 6 months of
treatment, then as clinically indicated. Monitor CBC
and ECG (patients older than age 40) before therapy
and as needed. Monitor lithium level twice weekly, 12
hours after the last oral dose, until patient and levels
are stable, then every 1 to 2 months or as needed.
• Palpate thyroid to check for enlargement. Monitor
weight before and during therapy.
• Look alike–sound alike: Don’t confuse lithium
carbonate with lanthanum carbonate.
• Don’t use drug to prevent fatigue or treat severe
depression.
• Before starting drug, assess for the presence of
cardiac disease by performing a careful history,
family history of sudden death or ventricular
arrhythmia, and physical exam.
• Observe patient for signs of excessive stimulation.
Monitor BP.
• Check CBC, differential, and platelet counts with
long-term use, particularly if patient shows signs or
symptoms of hematologic toxicity.
• Monitor height and weight in children on long-term
therapy.
• Monitor patient for tolerance or psychological
dependence.
• Carefully observe patient for digital changes.
• Monitor patients using patch for chemical
leukoderma. Report skin changes to prescriber.
• Look alike–sound alike: Don’t confuse
methylphenidate with methadone.
CENTRAL NERVOUS SYSTEM (CNS) DRUGS
Drug Class
Drug Sample
PANCURONIUM
Pharmacodynamics
Prevents acetylcholine
from binding to
receptors on the motor
end plate, blocking
neuromuscular
transmission.
ATRACURIUM
Prevents
neuromuscular
transmission by
blocking the effect of
acetylcholine at the
myoneural junction.
NONDEPOLARIZING
NMJ BLOCKERS
Binds with a high
affinity to cholinergic
receptors, prolonging
depolarization of the
motor end plate and
ultimately producing
muscle paralysis.
DEPOLARIZING
NMJ BLOCKERS
SUCCINYLCHOLINE
NEUROMUSCULAR BLOCKERS (NMJ BLOCKERS)
Indications
Side Effects
CV: tachycardia, increased BP,
 Adjunct to anesthesia to
flushing.
relax skeletal muscle,
EENT: excessive salivation.
facilitate intubation, and
Musculoskeletal: residual
assist with mechanical
muscle weakness.
ventilation
Respiratory: prolonged
respiratory insufficiency or
apnea.
Skin: transient rashes.
Other: allergic or idiosyncratic
hypersensitivity reactions.
Respiratory: bronchospasm
 Induction of skeletal muscle
CV: hypotension, tachycardia
paralysis and facilitation of
Skin: flushing, rash
intubation after induction of
Other: allergic reactions
anesthesia in surgical
including anaphylaxis
procedures.
 Facilitation of compliance
during mechanical
ventilation.
 Adjunct to anesthesia to
facilitate tracheal intubation;
to provide skeletal muscle
relaxation during surgery or
mechanical ventilation
CV: arrhythmias, bradycardia,
cardiac arrest, tachycardia,
HTN, hypotension, flushing.
EENT: increased IOP,
excessive salivation.
Metabolic: hyperkalemia.
Musculoskeletal:
postoperative muscle pain,
muscle fasciculation, jaw
rigidity, rhabdomyolysis with
acute renal failure.
Respiratory: apnea,
bronchoconstriction, prolonged
respiratory depression.
Skin: rash.
Other: allergic or idiosyncratic
hypersensitivity reactions,
anaphylaxis, malignant
hyperthermia.
Nursing Considerations
• Allow succinylcholine effects to subside before
giving this drug.
• Monitor baseline electrolyte determinations and VS.
• Measure fluid intake and output.
• Monitor respirations closely until patient recovers
fully from neuromuscular blockade, as indicated by
tests of muscle strength.
• After spontaneous recovery starts, neuromuscular
blockade may be reversed with an anticholinesterase.
• Give analgesics for pain.
Alert: Careful dosage calculation is essential.
 Assess respiratory status continuously.
 Monitor neuromuscular response with a peripheral
nerve stimulator intraoperatively.
 Monitor ECG, heart rate, and BP throughout
administration.
 Observe the patient for residual muscle weakness
and respiratory distress during the recovery period.
 Monitor infusion site frequently. If signs of tissue
irritation or extravasation occur, discontinue and
restart in another vein.
• Dosage depends on anesthetic used, individual
needs, and response. Recommended dosages must
be individually adjusted.
• Monitor baseline electrolyte determinations and vital
signs. Check respirations every 5 to 10 minutes
during infusion.
• Monitor respirations closely until tests of muscle
strength.
Alert: Don’t use reversing drugs.
• Repeated or continuous infusions aren’t advisable;
they may cause reduced response or prolonged
muscle relaxation and apnea.
• Give analgesics for pain.
• Keep airway clear. Have emergency respiratory
support equipment immediately available.
Alert: Careful dosage calculation is essential. Always
verify dosage with another health care professional.
CENTRAL NERVOUS SYSTEM (CNS) DRUGS
Drug Class
Drug Sample
PANCURONIUM
Pharmacodynamics
Prevents acetylcholine
from binding to
receptors on the motor
end plate, blocking
neuromuscular
transmission.
ATRACURIUM
Prevents
neuromuscular
transmission by
blocking the effect of
acetylcholine at the
myoneural junction.
CENTRALLY
ACTING
MUSCLE
RELAXANTS
DIRECT
ACTING
MUSCLE
RELAXANTS
DANTROLENE
Acts directly on
skeletal muscle,
causing relaxation by
decreasing calcium
release from
sarcoplasmic reticulum
in muscle cells.
Prevents intense
catabolic process
associated with
malignant
hyperthermia.
MUSCLE RELAXANTS
Indications
Side Effects
CV: tachycardia, increased BP,
 Adjunct to anesthesia to
flushing.
relax skeletal muscle,
EENT: excessive salivation.
facilitate intubation, and
Musculoskeletal: residual
assist with mechanical
muscle weakness.
ventilation
Respiratory: prolonged
respiratory insufficiency or
apnea.
Skin: transient rashes.
Other: allergic or idiosyncratic
hypersensitivity reactions.
Respiratory: bronchospasm
 Induction of skeletal muscle
CV: hypotension, tachycardia
paralysis and facilitation of
Skin: flushing, rash
intubation after induction of
Other: allergic reactions
anesthesia in surgical
including anaphylaxis
procedures.
 Facilitation of compliance
during mechanical
ventilation.
 Spasticity and sequelae from
severe chronic disorders,
such as MS, cerebral palsy,
spinal cord injury, and stroke
 To manage malignant
hyperthermic crisis
 To prevent or attenuate
malignant hyperthermic crisis
in susceptible patients who
need surgery
 To prevent recurrence of
malignant hyperthermic crisis
CNS: drowsiness, muscle
weakness, confusion,
dizziness, headache, insomnia,
malaise, nervousness.
EENT: excessive lacrimation,
visual disturbances.
Respiratory: pleural effusions.
CV: changes in blood pressure,
tachycardia.
GI: hepatotoxicity, diarrhea,
anorexia, cramps, dysphagia,
GI bleeding, vomiting.
GU: crystalluria, dysuria,
frequency, erectile dysfunction,
incontinence, nocturia.
Skin: pruritus, sweating,
urticaria.
Hematologic: eosinophilia.
Musculoskeletal: myalgia.
Nursing Considerations
• Allow succinylcholine effects to subside before
giving this drug.
• Monitor baseline electrolyte determinations and VS.
• Measure fluid intake and output.
• Monitor respirations closely until patient recovers
fully from neuromuscular blockade, as indicated by
tests of muscle strength.
• After spontaneous recovery starts, neuromuscular
blockade may be reversed with an anticholinesterase.
• Give analgesics for pain.
Alert: Careful dosage calculation is essential.
 Assess respiratory status continuously.
 Monitor neuromuscular response with a peripheral
nerve stimulator intraoperatively.
 Monitor ECG, heart rate, and BP throughout
administration.
 Observe the patient for residual muscle weakness
and respiratory distress during the recovery period.
 Monitor infusion site frequently. If signs of tissue
irritation or extravasation occur, discontinue and
restart in another vein.
Be alert for signs of hepatotoxicity Report these signs
to the physician immediately.
Assess patient's spasticity, ROM, functional ability,
and posture, especially when beginning Dantrium
treatment or during dose adjustments.
Assess dizziness or drowsiness that might affect gait,
balance, and other functional activities.
Monitor symptoms such as confusion, nervousness,
insomnia, or malaise.
Monitor signs of eosinophilia.
Assess BP and compare to normal values.
Assess heart rate, ECG, and heart sounds, especially
during exercise.
Assess any breathing problems or signs of pleural
effusion.
Assess injection site during and after IV
administration, and report signs of phlebitis.
BOTULINIUM
TOXIN A
BOTULINIUM
TOXIN B
Produces partial
chemical denervation
by inhibiting the
release of
acetylcholine. Result is
local decrease in
muscle activity.
 Temporary improvement in
Binds to and cleaves
the synaptic Vesicle
Associated Membrane
Protein, which is a
component of the
protein complex
responsible for docking
and fusion of the
synaptic vesicle to the
presynaptic
membrane, a
necessary step to
neurotransmitter
release.
 Treatment of patients with
the appearance of moderateto-severe glabellar lines
associated with corrugator
and/or procerus muscle
activity in adults ≤65 yr.
cervical dystonia to reduce
the severity of abnormal
head position and neck pain
associated with cervical
dystonia.
CNS: headache.
EENT: temporary eyelid droop.
GI: nausea.
Local: discomfort at injection
sites.
Musculoskeletal: local muscle
weakness.
Other: allergic reactions,
including anaphylaxis (rare).
CV: heart burn
EENT: blurry vision,
accommodation difficulties,
conjunctival irritation, dry nasal
mucosa
GI: indigestion, dry mouth,
severe dry throat associated
with dysphagia, swallowing
difficulties, constipation, head
instability, thrush
Other: reduced sweating
 Monitor signs of allergic reactions and anaphylaxis.
Notify physician immediately if these reactions
occur.
 Be alert for possible systemic effects that might
occur if botulinum toxin spreads beyond the IM
injection site. Report signs of systemic botulism to
the physician immediately.
 Assess spasticity, ROM, and functional ability as the
drug begins to take effect.
 Monitor IM injection site for redness and irritation.
 Assess for mentioned contraindications and
cautions to prevent untoward complications.
 Conduct thorough physical assessment to obtain
baseline data.
 Monitor liver and renal function tests to detect
potential adverse effects.