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Drugs used in nervous system

Slides are prepared as per INC Syllabus Unit IX Drugs used in nervous system and it is most benefited for B sc Nursing students and faculty of the subject

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Drugs used in nervous system

  1. 1. Unit IX – Drugs used in Nervous System Mr. Dipti Sorte
  2. 2. Syllabus • Basic and applied pharmacology of commonly used: 1. Analgesics & Anesthetics. A. Analgesics. Non steroidal anti-inflammatory (NSAIDs) drugs A. Antipyretics. B. Hypnotics & Sedatives Opioids. Non opioids. Tranquilizers. General & Local Anesthetics Gases: O2, Nitrous oxide, Carbon-di- oxide, 2. Cholinergics & Anticholinergics: Muscle Relaxants, Tranquilizers, Anti- psychotic drugs. Antidepressants. Anticonvalscent. Adrenergic. Nor adrenergic. Mood stabilizers. Acetylcholine. CNS Stimulants. Composition, action, Indication, Contraindications, Dosage, Routes, Drug interactions, Side effects, Adverse effects, Toxicity, Role of nurse.
  3. 3. Nervous System CNS PNS SomaticAutonomic ParasympatheticSympathetic
  4. 4. Controls skeletal muscle Controls cardiac muscle & glands Peripheral Nervous System Somatic Nervous System Autonomic Nervous System One Neuron Efferent Limb Two Neuron Efferent LimbPostganglionic Preganglionic smooth &
  5. 5. Parasympathetic Nervous System (Craniosacral Outflow) Genitalia Bladder Large Intestines Kidney Bile Ducts Gallbladder Small Intestines Stomach Bronchi/Bronchial Glands SA & AV Node Sphincter Muscle of Iris Ciliary Muscle Lacrimal Gland Submaxillary & Sublingual Glands Parotid Gland
  6. 6. Radial Muscle of Iris Ciliary Muscle SA & AV Nodes His-Purkinje System Myocardium Bronchi/Bronchial Glands Stomach Kidneys Intestines Bladder//Genitalia Sublingual/Submaxillary & Parotid Gland Pilomotor Muscles Sweat Glands Blood Vessels Sympathetic Nervous System (Thoracolumbar Outflow) Paravertebral Ganglia Prevertebral Ganglia
  7. 7. Analgesics, Antipyretics, Anti- inflammatory (NSAIDs) •Analgesics is an agent which relieves pain. •Antipyrutics which reduce temperature. •Anti-inflammatory which reduce inflammation.
  8. 8. Classification • Analgesics are divided into two: 1. Narcotic Analgesics (Opioid Analgesics) Its primary main action on central pain mechanism and on have narcosis as side effects. 2. Non-narcotic Analgesics (Opioid Analgesics) Its primary main action on peripheral pain mechanism and does not have narcosis as side effects.
  9. 9. Non opioid/Non Narcotic Analgesics (NSAIDS)
  10. 10. Non opioid/Non Narcotic Analgesics (NSAIDS) •These include non steroidal anti- inflammatory drugs (NSAIDs). •They are effective for mild to moderate headache and pain of musculoskeletal origin, also they lower body temperature.
  11. 11. Mechanism of action - NSAIDs •They inhibits prostaglandin formation in inflamed tissues by two actions: 1. Inhibiting stimulation of pain receptors. 2. Inhibiting prostaglandins synthesis with CNS and stimulating peripheral vasodilation to reliever fever (Antipyretic action)
  12. 12. Drug Examples and dosages S. no. Drugs Doses 1 Salicylates - Aspirin 75-325mg orally. 2 Paracetamol 500-1000mg orally & not exceed 4mg/day 3 Diclofenac sodium 50 – 100mg daily. 4 Acelclofenac 100 – 200mg daily 5 Ibuprofen 200 – 1600mg daily 6 Ketoprofen 75 – 300mg daily 7 Mefeanic acid 500mg orally 8hrly 8 Naproxen 250-1000mg daily 9 Nimuslide 100 – 200mg daily
  13. 13. contd S. no. Drugs Doses 10 Indomethacin 25-75mg orally. 11 Ketorolac 30-120mg daily 12 Piroxicam 20mg orally daily. Selective COX inhibitors 1 Celecoxib 50 – 400mg daily 2 Etoricoxib 30-120mg daily
  14. 14. Indications / Uses • Pain (Acetaminophen, ibuprofen, naproxen). • Arthritis and osteoarthritis. • In pyrexia. • To treat inflammatory conditions. • Prevention of transient ischemic attacks & MI (Aspirin) • Dysmenorrhoea. (mefenamic acid, ibuprofen). • Its use can cause early closure of patent ductus arteriosus & delay of labour due to inhibition of prostaglandin synthesis.
  15. 15. Contraindications/ Precautions •Contraindicated in pregnancy except acetaminophen. •Contraindicated in Aspirin hypersensitivity. •Aspirin is Contraindicated in bleeding disorders and GI ulcers. •Used with caution in patients with asthma or nasal polyps. •Aspirin should not given to children unless under the supervision of the prescriber because of increased risk of Reye’s syndrome.
  16. 16. Adverse Effects • GI pain, upset. • Peptic Ulcer. • Diarrhoea. • Nausea / vomiting. • Heart burn. • Tinnitus. • Headache. • Laryngeal edema (Acetaminophen, hypersensitivity). • Aspirin hypersensitivity can produce such signs and symptoms as rash, bronchospasm, rhinitis and shock. • Hepatic or renal failure.
  17. 17. Drug interactions •Prolonged use of acetaminophen with NSAISs increases the risk of renal toxicity or failure. •NSAIDs aggravate the GI adverse effects of alcohol. • Concurrent use of NSAIDs with anticoagulants may prolong bleeding time and increases anticoagulant effect. •Simultaneously use of aspirin with NSAIDs or corticosteroids may aggravate the GI adverse effect of aspirin and may reduce aspirin effects.
  18. 18. Nursing Responsibilities • Instruct the patient to take oral NSAIDs drugs with food to minimize GI irritation. • Obtain a complete health history including allergies, drug history and possible drug interactions. • Administer liquid aspirin immediately after mixing because it breaks down rapidly. Advise patient not to take ibuprofen and naproxen concurrently. • Instruct client to report bleeding, abdominal pain, anorexia, heart burn, jaundice. • Monitor the signs of GI bleeding and hepatotoxicity. • Instruct client to immediately report change in urination, flank pain or pitting edema. • Monitor for hypersensitivity reaction.
  19. 19. Opioid/Narcotic Analgesics “ Narcotic analgesics in an old term for opioid analgesics. They are pharmacologically similar to morphine which is obtained from opium (Poppy plant) and they act on opioid receptor”.
  20. 20. Mechanism of Action •Opioids agonists bind to opiate receptors in the CNS to alter the perceptions of an emotional response to pain. They produce analgesia by: 1. Elevating pain perception threshold. 2. Changing the pain reaction. (i.e. even in the presence of pain patient does not bother about pain). 3. Production or induction of sleep.
  21. 21. Drug Examples and dosages S. no. Drugs Doses Natural Alkaloids 1 Morphine 15-30mg orally/2.5-5mg injected 2 Codeine 15-30mg orally SOS Synthetic compounds 3 Pethidine 25-100mg/IM/SC SOS 4 Methadone 2.5-10mg orally/SC/IM 6hrly 5 Pentazocine 30-60mg IM/IV/SC 6 Fentanyl 25mcg patch
  22. 22. continued S. no. Drugs Doses Semi synthetic morphine derivatives 7 Heroin (Diamorphine) 100mg injection IV Other opioid Analgesics 8 Butorphenol 1-4mg IM/IV 9 Tramadol hydrochloride 50-100mg TDS orally/IM/IV 10 Naloxone 0.4-2mgIM/IV/SC
  23. 23. Indications/Uses •To treat pain that is unresponsive to non opioid analgesics. •Adjuncts to anesthesia. •Used to relieve cough. •MI pain. •In the treatment of diarrhea.
  24. 24. Contraindications / precautions •Use cautiously in patients with head injury, hepatic or renal disease. •Cautiously in CNS depression and in pregnant and breast feeding women. •Use cautiously in elderly or debilitated patients who may need decreased dosage.
  25. 25. Adverse effects • Sedation. • Constipation. • Hallucination. • Respiratory Depression. • Dizziness. • Dysphonia. • Orthostatic hypotension. • Physical dependence. • Psychological Dependence.
  26. 26. Drug interactions •Simultaneously use with alcohol, antihistamines, hypnotics or sedatives causes additive CNS Depression. •Concurrently use with non opioid analgesics may enhance pain relief.
  27. 27. Nursing Responsibilities •Nurse should assess the patients blood pressure, pulse and respiratory status before administering the drug and periodically throughout analgesic therapy. •To prevent withdrawal symptoms, discontinue opioids analgesics gradually after long term use. •Instruct the patient to take oral analgesic with food to minimize GI irritation.
  28. 28. Sedative - Hypnotics
  29. 29. • Sedative: A drug that reduces excitement and calm the subject without inducing sleep. It may cause drowsiness. • Hypnotics: A drug that induces or maintains sleep, similar to normal arousable sleep. • Tranquilizer: A drug that relieves tension and anxiety without affecting consciousness and without producing drowsiness or sleep. Both sedation and hypnosis may be considered as different grade of CNS Depression.
  30. 30. Sedative – hypnotics: Classification Sedative-hypnotics Barbiturates 1-Long acting (12-24 hr) Ex. Phenobarbital 2-Intermediate acting (8-12hr) Ex. Amobarbital 3-Short acting (4-8 hr) Ex. Pentobarbital 4-Ultrashort acting (0.5-1hr) Ex. Thiopental Non-barbiturates Benzodiazepines Non- benzodiazepine
  31. 31. Classification 1. Benzodiazepines: Long acting: a) Diazepam. b) Chlordiazepoxide. c) Clonazepam. Short acting: a) Lorazepam. b) Alprazolam. c) Nitrazepam. d) Oxazepam. Ultra short acting: a) Midazolam. b) Triazolam. 1. Barbiturates: Phenobarbitone. (Long acting) Thiopentone. (Long acting) Hexobarbitone. (Short acting) Phenobarbitone. (Intermediate acting)
  32. 32. Benzodiazepam: Benzodiazepines are the most commonly used medications in psychiatry. In addition to there effects as antianxiety medications. They are also used as sedatives. They are used as anticonvalscent medications. They have muscle relaxant property as well.
  33. 33. Mechanism of Action • Benzodiazepines work by binding to a receptor which is located or neurons in the brain called GABA receptors. And GABA is neurotransmitter in the brain. It is actually one of the most prevalent inhibitory neurotransmitter in the brain. • Pharmacological Action: 1. Sedation and hypnosis. 2. Muscle relaxation. 3. Anticonvalscent effects 4. CNS depressants. 5. Amnesia. 6. Anesthetic. 7. Anti-anxiety.
  34. 34. Drug Examples and dosages S. no. Drugs Doses Long acting (24-48hrs) 1 Diazepam 5-10mg 2to4 times in a day 2 Chlordiazepoxide 15-30mg orally SOS 3 Clonazepam 1.5mg TDS Ultra short acting (<6hrs) 4 Midazolam Loading dose of 0.1-0.35 mg per kg body weight. 5 Triazolam 0.25mg HS
  35. 35. Drug Examples and dosages S. no. Drugs Doses Short acting (12-24 hrs) 1 Lorazepam 2-10mg daily 2 Alprazolam 0.25-1mg per day 3 Nitrazepam 5-10mg orally HS. 4 Oxazepam 30-60mg daily
  36. 36. Indication & Uses • As sedative. • In treatment of status epileptics. • Insomnia. • Muscle relaxants • General Anesthesia. • As hypnotic • As pre-anaesthetic medication. • Anti – convalescents. • During alcohol withdrawal
  37. 37. Contraindication/Precautions • Hypersensitivity to Benzodiazepines. • Shock. • Coma. • Pregnancy. • Lactation. • Inguinal hernia. • Acute alcohol intoxication. • Use cautiously with elderly and debilitated patients. • Impaired liver or kidney functions.
  38. 38. Adverse Effect • Tolerance and physical dependence. • Confusion. • Lethargy. • Headache. • Impaired motor co-ordination. • Incontinence. • Drowsiness • Amnesia • Weakness • Blurred vision. • Ataxia • Urinary retension.
  39. 39. Drug interactions •Antacids may decrease absorption of benzodiazepines. •Carbamazepine decrease benzodiazepine level. •Cigarette smoking decrease the effect of benzodiazepine. •Hormonal contraceptives, cimetidine, erythromycin and some antidepressants may increase the plasma level of benzodiazepines.
  40. 40. Nursing Responsibilities •Take this drug exactly as prescribed. Do not stop taking this drug (Long term therapy) without consulting health care provider. •Tell about side effects to the patient. •Carefully monitor BP, Respiration, during I/V administration. •Maintain patients I/O chart receiving parenteral benzodiazepines in bed for 5hrs, do not permit ambulatory patients to drive vehicle following an injection. •Monitor liver kidney function, CBC during long term therapy.
  41. 41. BARBITURATES •These drugs are derivative of barbituric acid. They are general depressant but now a days they are not preferred as sedative and hypnotics.
  42. 42. Mechanism of action •Exact mechanism is not known. They somehow depress the cerebral cortical activity.
  43. 43. Drug Examples and dosages S. no. Drugs Doses Barbiturates 1 Phenobarbitone (Long acting) 30-120mg daily TDS 2 Thiopentone 3-5mg / kg body weight 3 Hexobarbitone (Short acting) - 4 Pentobarbitone (Intermediate acting) 30-100mg daily
  44. 44. Pharmacological Action •They are powerful cerebral depressants. •They depress cardiac activity and in higher doses cause fall in B.P. •They produces urine flow. •Depress respiratory center in brain.
  45. 45. Indication /uses: •As sedative. •Anticonvalscent. •Anesthesia. •Kernicterus. (increase conjugation of bilirubin increase clearance of bilirubin.)
  46. 46. Contraindications •Liver, kidney and pulmonary diseases.
  47. 47. Adverse Effect •Drowsiness in next morning. •Respiratory Depression. •Physical as well as psychological dependence. •Hypersensitivity reaction may occur. •Drug tolerance.
  48. 48. Drug interactions •They increases metabolism and decreased effectiveness of many concurrently used drug including hormonal contraceptives and warfarin.
  49. 49. Nursing Responsibilities • Administer IV dose slowly. • Monitor pulse, B.P. respiration carefully during IV administration. • Advice to patient the avoid alcohol, sleep inducing OTC drugs, these could cause dangerous effects. • Advise that avoid becoming pregnant while you are taking these drugs. Use other methods of contraception's in place of oral contraceptives which may lose there effect with this drugs. • Take this drugs longer than 2 weeks (for insomnia)
  50. 50. HISTAMIN/ANTIHISTAMIN •Histamine is responsible for symptoms of allergy and anaphylactic shock in some following conditions histamine is released. •Tissue injury. •Cold & chemical injury. •Allergic conditions – Antigen, antibody reactions.
  51. 51. Types • H1 Receptors: By stimulating H1 receptors it causes: 1. Histamine dilate the small blood vessels. 2. It increases bronchial secretion with contraction of bronchial smooth muscle (Bronchoconstriction). 3. They stimulate peripheral sensory nerves (itching & pain). • H2 Receptors: By stimulating H2 receptor it causes: 1. Increased secretion of acid and pepsin from stomach. 2. Secretion of all exocrine glands – pancreatic, bronchial, salivar and lacrimal are increased. • H3 Receptors.
  52. 52. Anti-histamines •Antihistamines are the drugs used in the treatment of allergic disorders and some other conditions. Theses drug blocks the effect of histamine and receptors. •There are three types of antihistamine drugs: •H1 Blockers •H2 Blockers •H3 Blockers Mechanism of action: These drugs block the effect of histamine and its receptors. There three types of antihistamine drugs.
  53. 53. Drugs example and doses: Sr. No. Drugs Doses Highly Sedatives 1 Diphenhydramine 25-50mg 2 Promethazine 25-50mg 3 Hydroxyzine 25-50mg Moderate Sedatives 4 Medizine 25-50mg 5 Buclizine 25-50mg 6 Phenivamine 25-50mg 7 Cyproheptadine 4mg Mild Sedatives 8 Chlorpheniramine 2-4mg 9 Cyclizine 50mg 10 Triprolidine 2.5-5mg Non Sedatives 11 Astemizole 10mg 12 Cetrizine 10mg 13 Lovatadine 10mg
  54. 54. Indication/Uses. • No therapeutic uses. • Only experimental use.
  55. 55. Antihistamine •Antihistamines are the drugs used in the treatment of allergic disorders and some other conditions these drugs block the effect of histamine and its receptors. There are three types of antihistamines drugs.
  56. 56. S. No Drugs Doses Highly sedatives 1. Diphenhydramine 25-50 mg 2. promethazine 25-50 mg 3. Hydroxyzine 25-50 mg Moderate sedatives 4. Medizine 25-50 mg 5. Buclizine 25-50 mg 6. Phenivamine 25-50 mg 7. Cyproheniramine 4 mg Mild sedatives 8. Chlorpheniramine 2-4 mg 9. Cyclizine 50 mg 10. Tripolidine 2.5-5 mg Non-sedatives 11. Astemizole 10 mg 12. Cetrizine 10 mg 13. Lovatadine 10 mg 14. Fexofenadine 120-180 mg
  57. 57. Indications/Uses • Allergic reactions [hay fever, vasomotor rhinitis, urticaria, asthma, anaphylaxis]. • Because of their anticholinergic actions they are used as antimetics and useful in motion sickness. • As hypnotics ,mild sedatives/anxiolytics • Parkinsonism • Insect bites and stings • Emergency treatment of any phylaxis
  58. 58. Adverse Effects • Drowsiness in common • Dryness of mouth • Blurring of vision ------ Due to anticholinergic • Urinary retention • Constipation • Delirium • Convulsions • Severe toxically may cause death due to cardiac and respiratory failure.
  59. 59. Contraindications/Precautions • Hypersensitivity. • Neonates. • Lactations. • Special precautions in acute asthma and pregnancy, elderly, epilepsy. • Coma. • Hypokalemia.
  60. 60. Nursing Responsibilities • Anti – histamines are best given in the evening since all anti-histamin cause drowsiness. • Advise to patient not to drive vehicle or do not operate machinery. • Advise to patient to avoid sedatives such as alcohol or sedatives – hypnotics.
  61. 61. CNS stimulants •These drugs increased the excitability of nervous tissue this group includes amphetamine, caffeine, analeptics monamine oxidase inhibitors and tricyclic antidepressants.
  62. 62. Mechanism of action •They increase neurotransmitter levels in the CNS either by increasing neuronal discharge or by blocking in an inhibitory neurotransmitter.
  63. 63. Drug example & Doses S. No. Drugs Doses 1 Amphetamine 2.5-5mg orally daily 2 Dextroamphetamine 10mg/day 3 Doxapram 1-4 mg /min IV slowly 4 Methylphenidate 5-10 mg BD orally 5 Caffeine 20-100 mg 6 Pentoxiphyllin 400mg TDS
  64. 64. Indication/ Uses • To treat hypractivity. • To increase mental alertness and respiratory rate. • Doxapram is used to treat respiratory failure, sedative, hypnotiv poisoning. • Mental Retardation and Attention Deficit disorder in children. • Senile Dementia. • Memory Disturbances. • Piracetam and Pentoxiphyllin are used in peripheral vascular diseases.
  65. 65. Contraindication & Precaution • Severe cardiovascular disorders. • Glaucoma. • Use with caution in patients with psychosis and in pregnant and breast feeding mothers.
  66. 66. Adverse Effects • Restlessness. • Irritability. • Hypotension. • CV Collapse. • Fatigue. • Growth suppression in children. • Tremor. • Insomnia. • Angina. • Weight loss. • Irritability.
  67. 67. Nursing Responsibilities • Assess the patients behavior to determine drug effectiveness. • Monitor growth in such children who is receiving long term therapy. • During Doxapram administration assess the patients respiratory status (Including lung sound, rate and depth of respiration). • Instruct patient to take last daily dose 6hrs before bed time to present insomnia.
  68. 68. Skeletal muscle relaxants •Muscle relaxants are the drugs which affects skeletal muscle function and decreases the muscle tone. They may be used to alleviate symproms such as muscle spasm, hyper- reflexia, and pain.
  69. 69. Mechanism of action •They work directly by acting on the neuromuscular function or indirectly by acting on the CNS and interfere with calcium release in muscle fiber, interfering with muscle contraction at the neuromuscular function.
  70. 70. Drug example and doses S. No. Drugs Doses 1 Chlorzoxazone 250-750 mg orally 3to4 time a day. 2 Dantrolene 25mg, 50mg, 100mg orally TDS. 3 Methocarbamol 1500mg QID max. dose 8mg/day for severe symptoms. 4 Diazepam 2-10mg 3to4time in a day orally 5-10mg IV. 5 Baclofen 5-10mg orally TDS.
  71. 71. Indication/uses •Useful in painful spacity associated with cord disease. •In acute and painful musculoskeletal conditions. •Muscle spasm.
  72. 72. Indications/Uses •Dry mouth. •Constipation. •Light headedness. •Drowsiness. •Fatigue. •Blurred vision. •Dizziness. •Ataxia.
  73. 73. Contraindications/precautions • Contraindicated in patients who have hypersensitivity to this drugs. • Contraindication in: 1. Arrhythmias. 2. Heart block. 3. Heart failure. 4. Use with caution in patients with breast feeding mothers who have hepatic disorders.
  74. 74. Drug interactions •Simultaneously use with other CNS depressant, or alcohol causes additive CNS depression. • Simultaneously use Baclofen with antidepressants (MAO inhibitors) may cause hypertensive crisis, seizures and death.
  75. 75. Nursing responsibilities • Nurse should advise the patient to take muscle relaxants with meals or milk to prevent GI upset. • Assess affected joints for pain and immobility. • Nurse should teach the patient to avoid alcohol and CNS depressant. • Keep emergency equipment nearby to treat respiratory infections.
  76. 76. Antidepressants •Antidepressants are a type of medication used to treat or prevent depression.
  77. 77. Mechanism of action • Tricyclic antidepressants increase the amount of serotonin, Nor epinephrine, through reuptake inhibition, thus normalizing the hyposensitive receptor site associated with depression. • SSRI ( Selective serotine reuptake inhibitors) block the reuptake of the serotonin into the presynaptic cells, there by increasing serotine levels at the synapse. • Biogenic amines such as 5- hydroxytrptamine, noradrenaline and dopamine are inactivated by the enzyme monoamine oxidase (MAO) MAOI inhibit enzyme MAO that leads to accumulation of these amines in the brain thus produces antidepressant effects.
  78. 78. Drug example and doses S. No. Drugs Doses 1 Imipramine 75-300mg orally/IM 2 Nortryptaline 25mg 3-4time orally 3 Desipramine 100-200mg daily 4 Amitryptyline 25-100mg 3-4time orally 5 Doxepine 25-150mg per day orally 6 Trimipramine 50-150mg per day orally 7 Phenylzine 15mg 3time orally 8 Fluoxetine 20mg-80mg per day orally 9 Fluoxamine 50-100mg OD orally 10 Sartraline 25-100mg Daily orally
  79. 79. Indications/uses • Used in endogenous depression. • Depression associated with other diseases. • Used in phobic anxiety states like school phobia and compulsive phobic states. • Enuresis. • Obsessive compulsive disorder. • Bulimia nervosa. • Smoking cessation. • Premenstrual dysphoric disorders.
  80. 80. Contraindication / precautions •Concurrent use of fluoxetine and MAO inhibitors is contraindicated. •Contraindicated in active liver diseases. •Precautiously used in elderly patients and in hepatic and renal patients.
  81. 81. Adverse effects • TCA may cause orthostatic hypotension, tachycardia, blurred vision, constipation, seizures, dry mouth. • It may exacerbate heart failure. • May cause testicular swelling and gynecomastia in males. • Insomnia, Nausea, and anticholinergic effects. • Overdose can cause CNS stimulation, even hallucination and convulsions.
  82. 82. Drug interactions • They alter the actions produced by the drugs acting on sympathetic nervous system when administered simultaneously. • It may reduce the effectiveness of antihypertensives. • Simultaneously used with alcohol, antihistamines and other CNS depressants cause additive CNS depression. • Antidepressants with MAO inhibitors may cause hypertensive crisis and seizures.
  83. 83. Nursing Responsibilities • Nurse should know that these drugs should be discontinue gradually. • Nurse should instruct the patient about importance of complying with therapy these drugs may take several weeks to produce desired effects. • Nurse should warn the patient to avoid alcohol and other non prescribed drugs to prevent adverse drugs reactions. • Nurse should know that a persistent headache is often a warning of rising B.P. in a patient on MAO inhibitors. • Nurse should tell the patient not to crush controlled release tablets but swallow them whole
  84. 84. Anti-manics (Lithium) •Mania is the condition which characterized with elevated mood with increased emotional liability, excessive talking, increased psychomotor activity with marked euphoria, when mania occur with depression, this condition is known as manic depressive psychosis. •Lithium is the drug used in the treatment of mania.
  85. 85. Mechanism of action •Its anti-manic effects may result from increases in norepinephrine reuptake and serotonin sensitivity. •Lithium probably interact with the Ca+, Na+, Mg+ ions in the body.
  86. 86. Drug example and doses S. No. Drug Doses 1. Lithium Carbonate 0.25 – 2gm orally daily. 2 Valporate 750 mg per day in acute mania.
  87. 87. Indications/uses •Mania. •Bipolar affective disorder. •Manic depressive psychosis.
  88. 88. Contraindication / precautions •Contraindicated in severe renal and cardiovascular disorders and during pregnancy. •Breast feeding. •Severe dehydration. •Use cautiously with elderly patients and those with thyroid disease.
  89. 89. Adverse effects At therapeutic level, nausea, vomiting, fatigue, muscular weakness, polyuria Above therapeutic level - Severe nausea/vomiting - convulsions - Circulator failure - coma Most common adverse reactions are hand tremors, transient, muscle weakness, hypertoniya, bloating, diarrhoea, anorexia, abdominal pain, anorexia etc Antimanics may cause hypothyroidism.
  90. 90. Drug interactions Diuretics, tetracycline's and indomethacin with lithium may increase plasma level of lithium and increase risk of toxicity. Lithium interfere with the effects of haloperidol, succinylcholine non adrenaline. Acetazolamide, aminophylline, sodium bicarbonate, and an increased sodium intake may increase renal excretion of lithium, reducing its effectiveness.
  91. 91. Nursing Responsibilities • Assess therapeutic blood level (0.6 to 1.2 mEq/litre) during course of therapy. • Nurse should teach the patient and family to observe for signs of lithium toxicity (diarrhea, vomiting, drowsiness, ataxia, convulsions and confusion) • Nurse should assess for suicidal tendencies and institute suicide precautions as necessary. • Administer the drug with food to minimize GI irritation. • Nurse should instruct the patient to consult the physician or pharmacist before talking non prescription drugs to prevent adverse drug interaction.
  92. 92. contd •Nurse should teach patient to: 1. Drink 2to3 litres of fluid daily. 2. Maintain adequate salt intake 3. Avoid excessive amounts of coffee, tea, cola, and activities that causes excess sodium loss. 4. Avoid driving and other hazardous activities.
  93. 93. Antipsychotics Antipsychotics are drugs that are mainly used for the treatment of major psychosis like schizophrenia or mania caused by sipolar disorder they are also called as major tranquillizers. There are two main types of antipsychotics atypical antipsychotics and older antipsychotics
  94. 94. Mechanism of action •They block the neurotransmitter dopamine in the limbic system inhibiting transmition of neural impulse (Antipsychotic action).
  95. 95. Drug example and doses S. No. Drugs Doses Phenothiazine 1 Chlorpromazine 25 to 100 mg. 2 Fluphenazine 0.5 to 10 mg/ per day orally divided 6hrly. 3 Mesoridazine 50 mg TDS Butyrophenones 4 Haloperidol 1 to 5 mg once or twice daily till 10 mg daily. 5 Droperidol 1.25 to 5 mg per day. Atypical Antipsychotics 6 Clozapine 12.5 mg once or twice daily 7 Riseperidone Starting dose 0.25 to 1mg per day up to 12mg per day. 8 Olanzapine 5 to 10 mg once daily 9 Loxapine 10 mg orally twice a day.
  96. 96. Indications/uses • Psychosis. • Schizophrenia. • Depression with psychotic features. • Psychotic symptom associated with organic brain syndrome. • Butyrophenones are used to treat nausea, vomiting during surgery and diagnostic procedures. • Haloperidol as an adjunct to anesthesia. • Haloperidol is used to treat psychosis, behavioral problems in children with expulsive hyper excitability, hyperactivity, in hyperactive children. • Atypical antipsychotics are used to treat obsessive compulsive disorders and risk of suicidal behavior.
  97. 97. Contraindication / precautions • CNS Depression. • Risk of suicide. • Pregnancy (First trimester) • Angle closure glaucoma. • Cautiously used in elder patients and in those in acute myocardial infarction, heart disease, respiratory distress.
  98. 98. Drug interactions •Antacids decrease absorption of antipsychotics. •These drugs potentiate alcohol and CNS depressants. •Concurrent use of antipsychotics with anticholinergic including antihistamines and antiparkisonian and antidepressants may increase anticholinergic side effects.
  99. 99. Nursing Responsibilities • Nurse should tell the patient to avoid driving or other hazardous activities until CNS effects of drug are known. • Advise patient to avoid alcohol and other CNS depressants during therapy. • Nurse should tell the patient that phenothiazine may discolor the urine pink or red brown. • Nurse should monitor for extrapyramidal system and other adverse reaction. • Nurse should know that patient taking long term antipsychotic treatment which should undergo regular evaluation of red and white blood cell counts.
  100. 100. contd • Do not give antacid within one hour of giving these drugs to avoid drug interaction. Nurse should assess the patients mental status. • If given parenteral doses monitor the patient for orthostatic hypotension. • Nurse should advise the patient to use sunscreen and use protective clothing to prevent photosensitivity reaction.
  101. 101. Anticonvalscents •Anticonvalscents are drugs that prevents or reduce the severity and frequency of seizures in various type of epilepsy.
  102. 102. Mechanism of action •Two mechanism that appear to be important in anticonvulsants drugs are: 1. Enhancement of GABA action 2. Inhibition of sodium channel activity. (Thus it decreased spread of abnormal electrical discharge.)
  103. 103. Drug example and doses S. No. Drugs Doses 1 Phenytoin 100 mg BD or TDS, 10-15mg / kg slow IV 2 Phenobarbitone 50-100mg orally 2-3 times daily. 3 Primidone 250-300 mg PO per day. 4 Mephobarbitone 400-600 mg PO per day 5 Carbamazepine Initially 20mg/per day up to 1200 mg per day. 6 Clonazepam 1.5 mg per day. 7 Diazepam 5-10mg IV slowly 8 Lorazepam 4mgIV slowly. 9 Valporic Acid. Initially 600mg/per day can be increased up to 3-6gm per day in divided doses. 10 Acetazolamide. 10-30 mg / kg / day.
  104. 104. Indications/uses •Phenytoin can be used in all epilepsies (except patit mal epilepsy) including grand mal epilepsy, psychomotor epilepsy, focal seizures, status epilepticus. •Phenobarbitone can be used to control: - Tonic-clonic (grand mal) epilepsy. - Simple partial seizures - Febrile convulsions - Drug withdrawal sizures - Status epilepticus
  105. 105. contd • Benzodiazedepines [ clonazepam,lorazepam,diazepam] are useful in status epilepticus. • Valporic acid is specially useful in absence [petit mal] and akinetic sizures . • Carbamazapine is useful to control psychomotor epilepsy, grand mal epilepsy, and mixed seizures.It is also useful in trigeminal and glossopharyngeal neuralgies. • Acetazolamide use in combination with other anticonvulsant drugs in petit mal seizures and focal seizures
  106. 106. Contraindication / precautions Contraindicated in patients who have hypersensitive to drug. Phenytoin is contraindicated in patients with sinus bradycardia, second and third degree heart blocked. Barbiturates [ Phenobarbitone ] contraindicated in patients who are sensitive to barbiturates and in pregnant and breast feeding mothers. They are also contraindicated in patient with hepatic impairment and severe respiratory disease. Contraindicated in patients with bone marrow suppression and within 14 days of MAO inhibitor therapy.
  107. 107. Adverse effect • Sedation. • Drowsiness. • Drug Dependence. • Dizziness. • Slurred speech. • Nausea / vomiting (Phenytoin). • Carbamazepine prolonged use may cause bone marrow suppression. • Photophobia. • Ataxia. • Respiratory & Cardiovascular depression. • Blood Dyscariasis. • Gum hypertrophy. (Phenytoin)
  108. 108. Drug interactions • Alcohol, Dioxides, Influenza vaccines, rifampicin, folic acid may decrease phenytoin activity and decrease the drug effectiveness. • Amidarone, and antihistamine, chloramphenicol, cimetidine, diazepam, Disulfiram, oral anticoagulants, Salicylates, Valproate may increase phenytoin activity and may leads to phenytoin toxicity. • Alcohol may cause addictive CNS effects and death. • Benzodiazepines may increase digoxin level and digoxin toxicity if it given together. • Hormonal contraceptive decrease the metabolism of Benzodiazepines.
  109. 109. Nursing Responsibilities • Nurse should monitor for sign and symptoms of toxicity, sign of Anticonvalscents toxicity one ataxia, nystagmus, dysarthria, hypotension, coma. • Teach the patient about the importance of good oral hygiene and regular dental examination to prevent gingival hyperplasia. • Nurse should teach the patient to avoid alcohol and self medication with over the counter drugs. • Also teach about compliance with therapy, avoidance of abrupt deconditions and consistent use of same drug preparation because changing drug brands may differ bioavailability among brands. • Assess respiratory status before and during this therapy. • Nurse shouls also monitor the patient for withdrawal symptoms ( Anxiety, muscle twitching, hand and figure tremors, dizziness, nausea, vomiting, convulsions)
  110. 110. Contd. • Do not mix IV Diazepam with other drugs in same syringe. • Give diazepam by direct IV push only do not give as an infusion. • Know that psychological dependence may develop with the use of clonazepam or diazepam.
  111. 111. Antianxiety Drugs (Minor tranquilizers) •It is a group of mild CNS depressants which are used to control the symptoms of anxiety. They produce a calming effect in anxiety states .
  112. 112. Mechanism of action They cause generalized CNS depression mimicking or enhancement the effects of GABA by antagonizing a protein that inhibits GABA binding to its receptors.
  113. 113. Drug example and doses S. No. Drug Doses Benzodiazepine 1 Alprazolam 0.25 mg 2 Clonazepam 0.25 mg orally twice daily 3 Diazepam 2-5 mg twice daily 4 Nitrazepam 5-10 mg orally 5 Zolpidem 10mg at bed time 6 Chlorodiazepoxide 10-40 mg per day 7 Lorazepam 1 mg orally 2-3 times a day. Azapirones 8 Buspirone 10-30 mg daily in divided dose.
  114. 114. Indications/uses Benzodiazepines are commonly use antianxiety drugs , the have anxiolytic hypnotic, muscle relaxant and anticonvulsant actions also. These drugs are used to treat anxiety. Diazepam is used to produce skeletal muscle relaxation. Used to treat insomnia. Used to preoperatively to induce sedation and amnesia.
  115. 115. Contraindication / precautions Pregnancy. Pre-existing CNS depression. Cautiously used in elderly patients who may require a decreased dosage and in patients with renal and hepatic impairment.
  116. 116. Adverse effects Drowsiness. Ataxia. Temporary memory impairments. Excitement. Respiratory.
  117. 117. Drug interactions Antacids may decrease absorption of benzodiazepines. Erythromycin, Cimetidine, Antidepressants may increase the plasma level of benzodiazepines. Cigarette smoking decrease the effectiveness of benzodiazepines.
  118. 118. Nursing Responsibilities • Nurse should administer IV dose slowly. • Nurse should advise the patient not to increase dosage unless instructed by physician, • Instruct to patient for avoid hazardous activity like driving swimming etc.
  119. 119. Anesthetics •An anesthetic is a drug or agent that produce a complete or partial loss of feeling. There are three types of anesthetics: •General: •Regional: •Local:
  120. 120. General Anesthetics •General anesthetics are used to produce loss of consciousness before and during surgery. •General anesthetics are usually given by inhalation or by injection into a vein.
  121. 121. Mechanism of action •They stabilize neuronal membranes to produce progressive, reversible CNS depression.
  122. 122. Drug example and doses S. No. Drugs Doses Intravenous Anesthetics 1 Midazolam hydrochloride 10-20mg one times orally/1to2.5 mg I/V 2 Thiopental sodium 3-5mg /kg body wt. 3 Methohexital 50-120mg I/V 1% solution 4 Ketamine 2mg/kg body wt. I/V 5 Diazepam 5-10mg/kg in 5% solution 6 Fentanyl 25-150μg/kg Inhalational anesthetics 7 Nitrous oxide Gas 8 Halothane Gas 9 Ether Gas 10 Cyclopropane Gas
  123. 123. Indications/uses •To induce and anesthesia. •To prolong anesthesia when use with anesthetics. •As muscle relaxants. •To produce loss of consciousness.
  124. 124. Contraindication / precautions •Use cautiously in patients with cardiovascular and respiratory instability. •Cautiously in elderly or debilitated patients because they are predispose to an exaggerated response to the drug.
  125. 125. Adverse effect •Respiratory depression. •Muscle twitching. •Apnea. •Tachycardia. •Memory loss. •Depression. •Hypertension. •Confusion. •Arrythmias. •Nausea/ vomiting.
  126. 126. Drug interactions •Concurrent with other CNS depressants increases CNS and respiratory depression and hypertension. •Increases hypotensive effect if it given with labetalol.
  127. 127. Nursing Responsibilities 1. Nurse should assess if patient has allergic before the surgery. 2. Should assess CV, respiratory and renal condition and level of consciousness before and after surgery. 3. Nurses should always keep atropine available to reserve bradycardia. 4. Nurse should advise the patient not to it or drink anything for at least 8hrs before surgery to prevent aspiration and gastric content into the respiratory passage during anesthesia. 5. Nurse should know that shivering is normal during recovery, if shivering occurs, keep the patient warm with extra blanket or heat. 6. Maintain side lying position to prevent aspiration after any procedure in general anesthesia and also oral intake until ability to swallow reflex has returned.
  128. 128. Local Anesthetics •An Anesthetic agent that affect a restricted or specific area of body.
  129. 129. Mechanism of action •They block the conduction of nerve impulses thus provide analgesic relief.
  130. 130. Drug example and doses S. No Drugs Doses 1 Benzocaine 20% topically 2 Lidocaine HCL/ (Xylocaine HCL) 2% viscus solution (Max, 300mg) 3 Chloroprocaine Hydrochloride 11mg / kg inj. (Max 800mg) 4 Procaine hydrochloride 1% inj with 0.9% NaCl.
  131. 131. Indications/uses •To relieve pain from surgery, disease or injury. •To use on the skin or mucus membranes to provide anesthesia for itching, burning or short procedure. •For severe pain unrelieved by topical anesthetics or analgesics.
  132. 132. Contraindication / precautions •Drug hypersensitivity. •Impaired cardiac conduction. •Cautiously used in patient with hepatic disorders, heart block, hypotension, and other endocrinal disorders. •Myasthenia gravis.
  133. 133. Adverse effects •Restlessness. •Hypotension. •Miosis. •Hypersensitivity reaction. •Anxiety. •Bradycardia. •Tinnitus.
  134. 134. Drug interactions •They may increase CNS Depression when it use with other CNS Depressants. •May prolong Anesthetic effect if used with epinephrine.
  135. 135. Nursing Responsibilities •Nurse should ensure the gag reflex has return before feeding a patient who’s throat has be anesthetized. •During post – operative phase nurse should assess for return of motor function and sensation.
  136. 136. Topical Anesthetics •A Topical anesthetics is a local anesthetic which is used to numb the surface of body part.
  137. 137. Mechanism of action •They work by blocking nerve impulses transmission, they accumulated in the nerve cell membrane and cause it to expand and loss its ability to depolarize.
  138. 138. Drug example and doses S. No. Drug Doses 1 Benzocaine 20% mucus spray/gel 2 Benzyl oxide 2.75% to 10% topically. 3 Lidocaine 2% gel. topically 4 Menthol 2% gel topically 5 Tetracaine Topically applied
  139. 139. Indications/uses •Use as topical anesthesia typically either relieves existing pain from a body surface or prevents pain during medical examination or procedure. •To anesthetized an area before an injection is given. •To numb mucosal surface before a tube or catheter is insert.
  140. 140. Contraindication / precautions •Drug hypersensitivity. •Lidocaine should be used cautiously in elderly patients and patient with large area of broken skin or mucus membrane.
  141. 141. Adverse effects •Hypersensitivity reaction (Including rash, pruritus, dyspnea)
  142. 142. Drug interactions •Lidocaine may increase the risk of the lidocaine toxicity so should not be used with ꞵ - Blocker or cimetidine (H₂ Blocker).
  143. 143. Nursing Responsibilities •Nurse should assess the site were topical anesthetic applied before, during and after drug administration. •Discontinue the drug if rash develops.
  144. 144. ꞵ Adrenergic Blocker •Mechanism of Action: ꞵ Adrenergic receptors causes vasoconstriction in blood vessels. Thus, these drugs prevents stimulation of ꞵ adrenergic receptors of sympathetic nervous system, there by decreasing cardiac output.
  145. 145. Drug Examples and doses S. No. Drugs Doses 1 Atenolol 50-100 mg BD orally 2 Timolol. 10-20 mg orally twice a day 3 Propranolol. 20-80mg orally 4 Betaxolol. 10 mg orally BD 5 Metoprolol 50 mg every 4-6 hrly.
  146. 146. Indications/uses: •To treat the mild hypertension. •Angina pectoris.
  147. 147. Contraindications/precautions •Contraindicated in patients with asthma, sinus bradycardia, cardiogenic shock, second and third degree heart block. •Use these drugs cautiously in pregnant and breast feeding women and in those with impaired hepatic functions.
  148. 148. Adverse effects: •Orthostatic Hypertension. •Fatigue. •Bradycardia. •Nausea, Vomiting.
  149. 149. Drug interaction •These drugs caused additive action on hypotension when used concurrently with alcohol and antihypertensives or calcium channel blockers.
  150. 150. Nursing Responsibilities •Do not discontinue drug abruptly. •Administer propranolol, Constituently with food, Food may increase absorption.
  151. 151. Anticholinergics •They causes the bronchodilation by blocking the action of acetylcholine. Acetylcholine causes the bronchoconstriction.
  152. 152. Mechanism of Action: •These agents inhibit the action of acetylcholine neurotransmitter or blocks the neurotransmitter acetylcholine in central and the peripheral nervous system. •They stop transmission of para sympathetic nerve impulses therefore they lesson the spasm of smooth muscles such as G.I. Respiratory Tract & Bladder.
  153. 153. Drug Examples & Doses: S. No. Drugs Doses. 1 Ipratropium Bromide 40-80mg by aerosol 2 Atropine 0.4 to 1mg I/V one time (may repeated 2hrly) 2mg max. in case of brady-arrhythmia. 3 Benztropine 0.5 to 2mg orally I/M, I/V once a day. 4 Diphenhydramine 25-50 mg.
  154. 154. Indication / uses • To reduce salivation and gastric a secretion. • To induce mydriasis • To treat parkinsonian disease. • Motion sickness. • GI Spasm. • Brady-arrhythimias, arrhythmias (Atropine). • Extra-pyradamidal reaction, dyskinesia (Benztropine). • To decrease saliva and bronchial secretion before surgery.
  155. 155. Contraindications/ precautions •Urinary and GI tract obstruction. •Hypersensitivity. •Severe ulcerative colitis. •Angle closure glaucoma. •Acute or severe hemorrhage.
  156. 156. Adverse effects •Blurred vision. •Dryness of mouth. •Urine retention. •Conjunctivitis. •Constipation.
  157. 157. Drug Interaction •Tricyclic antidepressants (TCA) may increase these drugs adverse effects.
  158. 158. Nursing Responsibilities •Nurse should monitor adverse reactions. •Nurse should instruct to patient to administer 30 minutes before meals and at bed time when used to reduce GI motility. •Teach the patient to reduce dry mouth by using ice chips, hard candy or gum and to reduce constipation by exercising and increasing fiber and fluid intake. •Nurse should monitor intake and output and watch for sign and symptoms of urine retention.
  159. 159. References 1. Dr. P.K. Panwar, Essentials of pharmacology for nurses, AITBS pub. 2017, India, Pg no. 90 – 117. 2. Dr. Suresh k sharma, Textbook of pharmacology, pathology & genetics for nurses, Jaypee pub. 2016 India Pg no 256 – 360. 3. Tara v. Shanbhag, Smita shenoy, Pharmacology preparation manual for undergraduate, Elsevier pub. 2014. Pg no. 164 – 233. 4. Marilyn Herbert – Ashton, Nancy Clarkson, Pharmacology, Jones & Barllet pub 2010 India, Pg no 101 – 180. 5. Govind s. mittal, Pharmacology at a glance, Paras medical book pub. 2009 India 1 – 12. 6. Madhuri Inamdar, Pharmacology in nursing, Vora medical pub. 2006 India 1st edition, Pg no 120 – 152.

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