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. Slide 2 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. Slide 3 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 Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 4 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 Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 5 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. Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 6 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 Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 7 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 Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 8 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 Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 9 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 Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 10 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 Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 11 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 Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 12 Chapter 14 Lesson 14.2 Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 13 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. Slide 14 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. Slide 15 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) Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 16 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 Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 17 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 Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 18 Drug Class: Benzodiazepines • Wide safety margin • More than 200 derivatives • Difficult to describe as a class, but include: Anticonvulsants Antianxiety agents Sedative-hypnotic agents Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 19 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 Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 20 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. Slide 21 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 Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 22 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 Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 23 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. Slide 24