DRUG PRESENTATION ON

DRUGS ACTING ON NERVOUS

SYSTEM

SUBMITTED TO- MS SARITA NADIYA MADAM

SUBMITTED BY- MS MANISHA
SUBMITTED ON-07/10/17
 Classification of CNS
drugs
Neurological:

• Sedative-hypnotics

• Antiepileptic and anticonvulsive drugs

• Drugs for Parkinson’s disease

• Analgesics and anesthetics

• Central stimulants

Psychological:

• Antipsychotic drugs

• Antidepressant

• Antimanic drugs
 SEDATIVE HYPNOTIC DRUGS

1. Benzodiazepines- Diazepam ,Oxazepam ,Triazolam.

2. Barbiturates-Pentobarbital, phenobarbital ,thiopental

3. Others- Buspirone,Zolpidem.

1. Benzodiazepines:

Classification according to action duration

Short-acting: triazolam, laorazepam, oxazepam, etc

Medium and long-acting: -diazepam, nitrazepam, chlordiazepoxide, flurazepam etc

ACTIONS:

1. Reduction of anxiety: at small doses, used as anxiolytics (not work on schizophrenia)

2. Sedative-hypnotic effects
-- used for insomnia and preanesthetic medication
3. Antiepileptic and anticonvulsant effects

-- inhibit epileptiform activity

-- used for seizures, status epilepticus , convulsion

4 .Centrally acting muscle relaxant effect

-- relaxing the spasticity of skeletal muscle, probably by increasing presynaptic inhibition in the spinal
cord.

-- used for the treatment of skeletal muscle spasms caused by central or peripheral diseases.

Contraindications
Myasthenia gravis
Infants < 6 months
Pregnant and lactation mothers
Elderly with heart/lung/liver/kidney dysfunction
Workers requiring mental alertness and fine motor coordination

Adverse effects
1. Central depression
Most common: drowsiness and confusion ataxia; cognitive
impairment (hangover effect)

Additive with other CNS depressant drugs

Antagonized by BZ receptor antagonist flumazenil

1. Others
Respiratory and CVS reactions ,Teratogenic effects.
 2.BARBITURATES

1.Pharmacological effects and clinical uses

1.Sedative-hypnotic effects - REM decrease
2.Antiepileptic and anticonvulsant effects
3.Preanesthetic medication

2. . Adverse effects

(1) Central depression: after (hangover) effect

(2) Tolerance and dependence: repetitive use, long- term use, REM rebound
(3) Porphyria (enhances porphyrin synthesis): anemia, photosensitive skin injury
4) Acute poisoning
--supporting therapies: oxygen inhalation, unblocked respiratory tract (tracheotomy), central
stimulants.
---alkalizing urine
---hemodialysis

ANTICONVULSANT DRUGS

1. PHENYTOIN
2. DIAZEPAM
3. PHENOBARBITAL
4. CARBAMAZEPINE

DIAZEPAM
 ACTION :Psychotherapeutic agent related to chlordiazepoxide; reportedly superior in antianxiety and
anticonvulsant activity, with somewhat shorter duration of action. Like chlordiazepoxide, it appears to act
at both limbic and subcortical levels of CNS

THERAPEUTIC EFFECTS

Shortens REM and stage 4 sleep but increases total sleep time. Antianxiety and anticonvulsant agent.

USES

Drug of choice for status epilepticus. Management of anxiety disorders, for short-term relief of anxiety
symptoms, to allay anxiety and tension prior to surgery, cardioversion and endoscopic procedures, as an
amnesic, and treatment for restless legs. Also used to alleviate acute withdrawal symptoms of alcoholism,
voiding problems in older adults, and adjunctively for relief of skeletal muscle spasm associated with
cerebral palsy, paraplegia, athetosis, stiff-man syndrome, tetanus.

CONTRAINDICATIONS

Injectable form: Shock, coma, acute alcohol intoxication, depressed vital signs, obstetrical patients, infants
<30 d of age. Tablet form: Infants <6 mo of age, acute narrow-angle glaucoma, untreated open-angle
glaucoma; during or within 14 d of MAO inhibitor therapy. Safe use during pregnancy (category D) and
lactation is not established. Store in tight, light-resistant containers at 15°–30° C (59°–86° F), unless
otherwise specified by manufacturer. Store Dizac emulsion at 2°–8° C (36°–46° F). Do not freeze.

SIDE EFFECTS:

 signs of an allergic reaction, like rash; hives; itching; red, swollen, blistered, or peeling
skin with or without fever; wheezing; tightness in the chest or throat; trouble breathing
or talking; unusual hoarseness; or swelling of the mouth, face, lips, tongue, or throat.
 Signs of low mood (depression), thoughts of killing yourself, nervousness, emotional ups
and downs, thinking that is not normal, anxiety, or lack of interest in life.
 Shortness of breath.
 Change in balance.
 Feeling confused.
 Hallucinations (seeing or hearing things that are not there).
 Memory problems or loss.
 Very bad dizziness or passing out.
 Feeling very tired or weak.
 If seizures are worse or not the same after starting this medicine.
 Muscle spasm.
 Twitching.
 Not able to sleep.
  Change in eyesight.

NURSING CONSIDERATIONS:

 Monitor for adverse reactions. Most are dose related. Physician will rely on accurate observation and
reports of patient response to the drug to determine lowest effective maintenance dose.
 Monitor for therapeutic effectiveness. Maximum effect may require 1–2 wk; patient tolerance to
therapeutic effects may develop after 4 wk of treatment.
 Observe necessary preventive precautions for suicidal tendencies that may be present in anxiety states
accompanied by depression.
 Observe patient closely and monitor vital signs when diazepam is given parenterally; hypotension, muscular
weakness, tachycardia, and respiratory depression may occur.
 Lab tests: Periodic CBC and liver function tests during prolonged therapy.
 Supervise ambulation. Adverse reactions such as drowsiness and ataxia are more likely to occur in older
adults and debilitated or those receiving larger doses. Dosage adjustment may be necessary.
 Monitor I&O ratio, including urinary and bowel elimination.
 Note: Smoking increases metabolism of diazepam; lowering clinical effectiveness. Heavy smokers may need
a higher dose than the nonsmoker.
 Note: Psychic and physical dependence may occur in patients on long-term high dosage therapy, in those
with histories of alcohol or drug addiction, or in those who self-medicate.

Patient & Family Education

 Avoid alcohol and other CNS depressants during therapy unless otherwise advised by physician.
Concomitant use of these agents can cause severe drowsiness, respiratory depression, and apnea.
 Do not drive or engage in other potentially hazardous activities or those requiring mental precision until
reaction to drug is known.
 Tell physician if you become or intend to become pregnant during therapy; drug may need to be
discontinued.
 Take drug as prescribed; do not change dose or dose intervals.
 Check with physician before taking any OTC drugs.
 Do not breast feed while taking this drug without consulting physician.

ANTIPARKINSON DRUGS

 Levodopa (L-dopa)

 Carbidopa

 Amantadine
 LEVODOPA:

The combination of levodopa and carbidopa is used to treat the symptoms of Parkinson's disease and
Parkinson's-like symptoms that may develop after encephalitis (swelling of the brain) or injury to the
nervous system caused by carbon monoxide poisoning or manganese poisoning. Parkinson's
symptoms, including tremors (shaking), stiffness, and slowness of movement, are caused by a lack of
dopamine, a natural substance usually found in the brain. Levodopa is in a class of medications called
central nervous system agents. It works by being converted to dopamine in the brain. Carbidopa is in
a class of medications called decarboxylase inhibitors. It works by preventing levodopa from being
broken down before it reaches the brain. This allows for a lower dose of levodopa, which causes less
nausea and vomiting.

ACTION:

When levodopa is given alone, large doses must be administered. Carbidopa prevents peripheral metabolism
(decarboxylation) of levodopa and thereby makes more levodopa available for transport to the brain. Carbidopa
does not cross blood-brain barrier and therefore does not affect metabolism of levodopa within the brain.
Carbidopa also prevents the inhibitory effect of pyridoxine (vitamin B6) on levodopa.

ROUTE AND DOSAGE:

Parkinson's Disease in Patients Not Currently Receiving Levodopa

Adult: PO 1 tablet containing 10 mg carbidopa/100 mg levodopa or 25 mg carbidopa/100 mg
levodopa t.i.d., increased by 1 tablet q.d. or q.o.d. up to 6 tablets/d

Patients Receiving Levodopa

Adult: PO 1 tablet of the 25/250 mixture t.i.d. or q.i.d., adjusted by ½–1 tablet as needed up to
8 tablets/d (start at 20–25% of initial dose of levodopa)

CONTRAINDICATIONS:

Hypersensitivity to carbidopa or levodopa; narrow-angle glaucoma; history of or suspected melanoma. Safe use in
women of childbearing potential, during pregnancy (category C), in lactation, and in children <18 y not established.

SIDE EFFECTS:

1. dizziness

2. loss of appetite

3. diarrhea
 4. dry mouth

5. mouth and throat pain

6. constipation

7. change in sense of taste

8. forgetfulness or confusion

9. nervousness

10. nightmares

11. difficulty falling asleep or staying asleep

12. headache

13. weakness

NURSING CONSIDERATIONS:

Assessment & Drug Effects

 Make accurate observations and report promptly adverse reactions and therapeutic effects. Rate of
dosage increase is determined primarily by patient's tolerance and response to levodopa.
 Monitor vital signs, particularly during period of dosage adjustment. Report alterations in BP, pulse,
and respiratory rate and rhythm.
 Monitor all patients closely for behavior changes. Patients in depression should be closely observed
for suicidal tendencies.
 Monitor for changes in intraocular pressure in patients with chronic wide-angle glaucoma.
 Monitor patients with diabetes carefully for alterations in diabetes control. Frequent monitoring of
blood sugar is advised.
 Lab tests: Periodic blood glucose, hepatic and renal function tests, CBC with differential, Hgb and
Hct.
 Report promptly abnormal involuntary movement such as facial grimacing, exaggerated chewing,
protrusion of tongue, rhythmic opening and closing of mouth, bobbing of head, jerky arm and leg
movements, and exaggerated respiration.
 Assess for "on-off" phenomenon: sudden, unpredictable loss of drug effectiveness ("off" effect),
which lasts 1 min–1 h. This is followed by an equally abrupt return of function ("on" effect).
Sometimes symptoms can be controlled by increasing number of doses per day.
 Monitor therapeutic effects. Some patients manifest increase in bradykinesia ("leg freezing" or slow
body movement). The patient is unable to start walking and frequently falls. Reduction of dosage
may be indicated in these patients.
 Patients who require more frequent drug administration are most likely to manifest gradual return of
parkinsonian symptoms toward the end of a dose period.
Patient & Family Education

 Follow physician's directions regarding continuation or discontinuation of levodopa. Both adverse

reactions and therapeutic effects occur more rapidly with carbidopa-levodopa combination than with
levodopa alone.
 Make positional changes slowly and in stages, particularly from recumbent to upright position,
dangle your legs a few minutes before standing, and walk in place before ambulating, as some
patients experience weakness, dizziness, and faintness. Tolerance to this effect usually develops
within a few months of therapy. Support stockings may help. Consult physician.
 Report muscle twitching and spasmodic winking promptly, as these may be early signs of
overdosage.
 You may notice elevation of mood and sense of well-being before any objective improvement.
Resume activities gradually and observe safety precautions to avoid injury.
 Maintain your prescribed drug regimen. Abrupt withdrawal can lead to parkinsonian crisis with
return of marked muscle rigidity, akinesia, tremor, hyperpyrexia, mental changes.
 Avoid driving or other hazardous activities until reaction to drug is determined.
 Levodopa may cause urine to darken on standing and may also cause sweat to be dark-colored. This
effect is not clinically significant.
 Wear medical identification. Inform all health care providers that you are taking carbidopa-levodopa.
 Do not breast feed while taking this drug.

 ANAESTHETIC DRUGS
 Classification:

Inhalation I.V.

VOLATI 1.Ultra short barbiturates

GA LE
SES LIQUID 2- Non Barbiturate:
Nitrous 1- Halothane - Benzodiazepines
Oxide 2- Enflurane - Propofol
3- Isoflurane - Propanidid
4- Desflurane - Neurolept analgesia
5- Methoxyflurane - Etomidate
 6- Trichloro-ethylene - Ketamine

PROPOFOL:

ACTION-

Sedative-hypnotic used in the induction and maintenance of anesthesia or sedation.

USES:

Induction or maintenance of anesthesia as part of a balanced anesthesia technique; conscious sedation in

mechanically ventilated patients.

CONTRAINDICATIONS:

Hypersensitivity to propofol or propofol emulsion, which contain soybean oil and egg phosphatide; obstetrical
procedures; patients with increased intracranial pressure or impaired cerebral circulation; pregnancy (category B),
lactation. Do not use for conscious sedation in children <3 y.

ROUTE AND DOSAGE:

Induction of Anesthesia
Adult: IV 2–2.5 mg/kg q10sec until induction onset
Geriatric: IV 1–1.5 mg/kg q10sec until induction onset
Child: IV 3 y, 2.5–3.5 mg/kg over 20–30 sec

Maintenance of Anesthesia
Adult: IV 100–200 mcg/kg/min
Geriatric: IV 50–100 mcg/kg/min
Child: IV 3 y, 125–300 mcg/kg/min

Conscious Sedation
Adult: IV 5 mcg/kg/min for at least 5 min, may increase by 5–10 mcg/kg/min q5–10 min until desired level
of sedation is achieved (may need maintenance rate of 5–50 mcg/kg/min)

ADVERSE EFFECTS:

CNS: Headache, dizziness, twitching, bucking, jerking, thrashing, clonic/myoclonic movements. Special
Senses: Decreased intraocular pressure. CV: Hypotension, ventricular asystole (rare). GI: Vomiting, abdominal
cramping. Respiratory: Cough, hiccups, apnea. Other: Pain at injection site.

NURSING IMPLICATIONS:

Assessment & Drug Effects

  Monitor hemodynamic status and assess for dose-related hypotension.
 Take seizure precautions. Tonic-clonic seizures have occurred following general anesthesia with
propafol.
 Be alert to the potential for drug induced excitation (e.g., twitching, tremor, hyperclonus) and take
appropriate safety measures.
 Provide comfort measures; pain at the injection site is quite common especially when small veins are
used.

ANALGESIC DRUGS

CLASSIFICATION:

1. NSAIDs
2. Opioids
3. Combinations
4. Alcohol
5. Psychotropic agents
NSAIDs CLASSIFICATION:

Acetic acids
 Diclofenac
 Etodolac
 Indomethacin
 Ketorolac
 Nabumetone
 Sulindac
 Tolmetin
COX-2 inhibitors
 Celecoxib
Fenamates
 Meclofenamate
 Mefenamic acid
Oxicam derivatives
 Meloxicam
 Piroxicam

 DICLOFENAC SODIUM

ACTION:

Although its exact mechanism of action has not been fully elucidated, it appears to be a potent inhibitor of
cyclooxygenase, thereby decreasing the synthesis of prostaglandins.

USES

Analgesic and antipyretic effects in symptomatic treatment of rheumatoid arthritis, osteoarthritis, and ankylosing
spondylitis. Also acute gout; juvenile rheumatoid arthritis; various rheumatic conditions including bursitis, myalgia,
sciatica, and tendinitis; acute soft tissue injuries including sprains and strains; dysmenorrhea; headache, migraine,
and dental, minor surgical, and postpartum pain; and renal or biliary colic. Ophthalmic: Cataract surgery;
photophobia associated with refractive surgery. Topical: Treatment of actinic keratosis.

CONTRAINDICATIONS:

Hypersensitivity to diclofenac, patients in whom asthma, urticaria, angioedema, bronchospasm, severe rhinitis,
shock, or other sensitivity reaction is precipitated by aspirin or other NSAIDS, pregnancy (category B), lactation.

ROUTE AND DOSAGE:

Rheumatoid Arthritis
Adult: PO 150–200 mg/d in 3–4 divided doses
Child: PO 25 mg b.i.d. or t.i.d.

Osteoarthritis
Adult: PO 100–150 mg/d in 3–4 divided doses 100 mg sustained release q.d.

Ankylosing Spondylitis
Adult: PO 25 mg q.i.d. and 25 mg h.s.

Cataract Surgery
Adult: Ophthalmic 1 drop of 0.1% solution in affected eye q.i.d. beginning 24 h after surgery and
continuing for 2 wk

Actinic Keratosis
Adult: Topical Apply to affected area b.i.d. for 60–90 d

ADVERSE EFFECTS:

CNS: Dizziness, headache, drowsiness. Special Senses: Tinnitus. Skin: Rash, pruritus. GI: Dyspepsia, nausea,
vomiting, abdominal pain, cramps, constipation, diarrhea, indigestion, abdominal distension, flatulence, peptic ulcer;
liver enzymes, transaminases increased, liver test abnormalities. CV: Fluid retention, hypertension,
CHF. Respiratory: Asthma. Body as a Whole: Back, leg, or joint
pain. Endocrine: Hyperglycemia. Hematologic: Prolonged bleeding time; inhibits platelet aggregation.

NURSING IMPLICATIONS:

Assessment & Drug Effects

 Monitor for therapeutic effectiveness. Up to 3 wks may be needed for beneficial effects with
rheumatoid arthritis or osteoarthritis.
 Lab tests: Periodic liver function, serum uric acid concentrations Hct, PT/INR, and blood glucose.
 Observe and report signs of bleeding (e.g., petechiae, ecchymoses, bleeding gums, bloody or black
stools, cloudy or bloody urine).
 Monitor BP for hypertension and blood sugar for hyperglycemia.
 Monitor diabetics closely for loss of diabetic control.
 Monitor for increased serum sodium and potassium in patients receiving potassium-sparing diuretics.
 Monitor weight and report gains greater than 1 kg (2 lb)/24 h.
 Monitor for signs and symptoms of GI irritation and ulceration.

Patient & Family Education

Oral Form

 Do not lie down for 15–30 min after taking medicine to decrease esophageal irritation.
  Discontinue use with onset of ringing or buzzing in the ears, impaired hearing, dizziness, GI
discomfort, or bleeding and notify physician.
 Do not take aspirin or other OTC analgesics without permission of the physician.
 Avoid alcohol or other CNS depressants.
 Do not drive or engage in other potentially hazardous activities until reaction to drug is known.
 Note: Diabetics need to monitor blood glucose carefully for loss of glycemic control.

CENTRAL STIMULANTS

AMPHETAMINE SULPHATE:

ACTION:

Indirect-acting synthetic sympathomimetic amine with peripheral alpha- and beta-adrenergic activity. Marked
stimulant effect on CNS thought to be due to action on cerebral cortex and possibly the Reticular Activating System.
Acts indirectly on adrenergic receptors by increasing synaptic release of norepinephrine and dopamine in brain and
by blocking reuptake at presynaptic membranes.
USES:

Narcolepsy, attention deficit disorder in children and adults (hyperkinetic behavioral syndrome, minimal brain
dysfunction). Use as short-term adjunct to control exogenous obesity not generally recommended because of its
potential for abuse.

CONTRAINDICATIONS:

Hypersensitivity to sympathomimetic amines; history of drug abuse; severe agitation; hyperthyroidism; diabetes
mellitus; moderate to severe hypertension, advanced arteriosclerosis, angina pectoris or other cardiovascular
disorders; Gilles de la Tourette disorder; glaucoma; during or within 14 d after treatment with MAOIs. Safety during
pregnancy (category C) or lactation is not established.

ROUTE AND DOSAGE:

Narcolepsy
Adult: PO 5–60 mg/d divided q4–6h in 2–3 doses
Child: PO >12 y, 10 mg/d, may increase by 10 mg at weekly intervals; 6–12 y, 5 mg/d, may
increase by 5 mg at weekly intervals

Attention Deficit Disorder

Adult/Adolescent: PO 10 mg extended release once daily in a.m.; may increase by 5–10 mg at
weekly intervals if needed to max 30 mg/d.
Child: PO 6 y, 5 mg 1–2 times/d, may increase by 5 mg at weekly intervals (max: 40 mg/d); 3–5
y, 2.5 mg 1–2 times/d, may increase by 2.5 mg at weekly intervals; 10 mg extended release
once daily in a.m.; may increase by 5–10 mg at weekly intervals if needed to max of 30 mg/d.

ADVERSE EFFECTS:

Body as a Whole: Allergy, urticaria, sudden death (reported in children with structural cardiac
abnormalities). CNS: Irritability, psychosis, restlessness, nervousness, headache, insomnia,
weakness, euphoria, dysphoria, drowsiness, trembling, hyperactive reflexes. CV: Palpitation, elevated BP;
tachycardia, vasculitis. Urogenital: Impotence & change in libido with high doses. GI: Dry mouth, anorexia, unusual
weight loss, nausea, vomiting, diarrhea, or constipation.

NURSING IMPLICATIONS:

Assessment & Drug Effects

 Monitor for therapeutic effectiveness. Tolerance to the mood-elevating effects commonly occurs
within a few weeks. Drug is usually discontinued when tolerance develops. Generally, tolerance
does not occur when used for attention deficit disorder or narcolepsy.
 Monitor for S&S of toxicity in children. Response to this drug is more variable in children than
adults; acute toxicity has occurred over a wide range of dosage.
  Monitor for S&S of insomnia or anorexia. Report complaints to physician. Dosage reduction may be
required.
 Monitor diabetics closely for loss of glycemic control.
 Monitor growth in children; drug may be discontinued periodically to allow for normal growth.
 Note: Drug's excitatory and euphoric effects are associated with a high abuse potential.

Patient & Family Education

 Keep physician informed of clinical response and persistent or bothersome adverse effects. This drug
exerts a stimulating effect that masks fatigue; after exhilaration disappears, fatigue and depression
are usually greater than before, and a longer period of rest is needed.
 Report insomnia or undesired weight loss.
 Do not drive or engage in potentially hazardous tasks until response to drug is known.
 Rinse mouth frequently with clear water, especially after eating, to relieve mouth dryness; increase
fluid intake, if allowed; chew sugarless gum or sourballs.
 Note: Meticulous oral hygiene is required because decreased saliva encourages demineralization of
tooth surfaces and mucosal erosion. Use of a commercially available oral lubricant, such as Moi-Stir
or Xero-Lube, can relieve soft tissue problems and reduce the potential of tooth decay.
 Note: Appetite suppression usually lessens within a few weeks and appetite increases; dose increase
is not indicated.
 Avoid caffeine-containing beverages because caffeine increases amphetamine effects.
 Note that drug is usually tapered gradually following prolonged administration of high doses. Abrupt
withdrawal may result in lethargy, profound depression, or other psychotic manifestations that may
persist for several weeks.
 Do not breast feed while taking this drug without consulting physician.

ANTI PSYCHOTIC DRUGS

HALOPERIDOL

ACTION:

Potent, long-acting butyrophenone derivative with pharmacologic actions similar to those of piperazine
phenothiazines but with higher incidence of extrapyramidal effects and less hypotensive and relatively low sedative
activity

USES:

Management of manifestations of psychotic disorders and for control of tics and vocal utterances of Gilles de la
Tourette's syndrome; for treatment of agitated states in acute and chronic psychoses. Used for short-term
treatment of hyperactive children and for severe behavior problems in children of combative, explosive
hyperexcitability.

CONTRAINDICATIONS:

Parkinson's disease, parkinsonism, seizure disorders, coma; alcoholism; severe mental depression, CNS depression;
thyrotoxicosis. Safe use during pregnancy (category C), lactation, or in children <3 y is not established

ROUTE AND DOSAGE:

Psychosis
Adult: PO 0.2–5 mg b.i.d. or t.i.d. IM 2–5 mg repeated q4h prn; Decanoate: 50–100 mg q4wk
Child: PO 0.5 mg/d in 2–3 divided doses, may be increased by 0.5 mg q5–7d to 0.05–0.15
mg/kg/d
Severe Psychosis
Adult: PO 3–5 mg b.i.d. or t.i.d., may need up to 100 mg/d IM 2–5 mg, may repeat q.h. prn;
Decanoate: 50–100 mg q4wk
Child: PO 0.05–0.15 mg/kg/d in 2–3 divided doses

Dementia
Geriatric: PO 0.25–0.5 mg 1–2 times daily, may increase every 4–7 d (max: 4 mg/d in 2–3
divided doses)

SIDE EFFECTS:

NS: Extrapyramidal reactions: Parkinsonian symptoms, dystonia, akathisia, tardive dyskinesia (after long-term use);
insomnia, restlessness, anxiety, euphoria, agitation, drowsiness, mental depression, lethargy, fatigue, weakness,
tremor, ataxia, headache, confusion, vertigo; neuroleptic malignant syndrome, hyperthermia, grand mal seizures,
exacerbation of psychotic symptoms. CV: Tachycardia, ECG changes, hypotension, hypertension (with
overdosage). Endocrine: Menstrual irregularities, galactorrhea, lactation, gynecomastia, impotence, increased
libido, hyponatremia, hyperglycemia, hypoglycemia. Special Senses: Blurred vision. Hematologic: Mild
transient leukopenia, agranulocytosis (rare). GI: Dry mouth, anorexia, nausea, vomiting, constipation, diarrhea,
hypersalivation. Urogenital: Urinary retention, priapism. Respiratory: Laryngospasm, bronchospasm, increased
depth of respiration, bronchopneumonia, respiratory depression. Skin: Diaphoresis, maculopapular and acneiform
rash, photosensitivity. Other: Cholestatic jaundice, variations in liver function tests, decreased serum cholesterol.

NURSING IMPLICATIONS:

Assessment & Drug Effects

 Monitor for therapeutic effectiveness. Because of long half-life, therapeutic effects are slow to
develop in early therapy or when established dosing regimen is changed. "Therapeutic window"
effect (point at which increased dose or concentration actually decreases therapeutic response) may
occur after long period of high doses. Close observation is imperative when doses are changed.
 Target symptoms expected to decrease with successful haloperidol treatment include hallucinations,
insomnia, hostility, agitation, and delusions.
 Monitor patient's mental status daily.
 Monitor for neuroleptic malignant syndrome (NMS) (see Appendix F), especially in those with
hypertension or taking lithium. Symptoms of NMS can appear suddenly after initiation of therapy or
after months or years of taking neuroleptic (antipsychotic) medication. Immediately discontinue drug
if NMS suspected.
 Monitor for parkinsonism and tardive dyskinesia (see Appendix F). Risk of tardive dyskinesia
appears to be greater in women receiving high doses and in older adults. It can occur after long-term
therapy and even after therapy is discontinued.
 Monitor for extrapyramidal (neuromuscular) reactions that occur frequently during first few days of
treatment. Symptoms are usually dose related and are controlled by dosage reduction or concomitant
administration of antiparkinson drugs.
 Be alert for behavioral changes in patients who are concurrently receiving antiparkinson drugs.
  Monitor for exacerbation of seizure activity.
 Observe patients closely for rapid mood shift to depression when haloperidol is used to control
mania or cyclic disorders. Depression may represent a drug adverse effect or reversion from a manic
state.
 Lab tests: Monitor WBC count with differential and liver function in patients on prolonged therapy.

Patient & Family Education

 Avoid use of alcohol during therapy.

 Do not drive or engage in other potentially hazardous activities until response to drug is known.
 Discuss oral hygiene with health care provider; dry mouth may promote dental problems. Drink
adequate fluids.
 Avoid overexposure to sun or sunlamp and use a sunscreen; drug can cause a photosensitivity
reaction.
 Do not breast feed while taking this drug without consulting physician.

ANTI MANIC DRUGS

1. Lithium carbonate
2. Valproic acid
3. Anti psychotics
4. Combinations.

 LITHIUM CARBONATE

ACTION:

The lithium ion behaves in the body much like the sodium ion; but its exact mechanism of action is unclear.
Competes with various physiologically important cations: Na+, K+, Ca++, Mg++; therefore, it affects cell membranes,
body water, and neurotransmitters. At the synapse, it accelerates catecholamine destruction, inhibits the release of
neurotransmitters and decreases sensitivity of postsynaptic receptors.

USES:

control and prophylaxis of acute mania and the acute manic phase of mixed bipolar disorder.

CONTRAINDICATIONS:
Significant cardiovascular or kidney disease, brain damage, severe debilitation, dehydration or sodium depletion;
patients on low-salt diet or receiving diuretics; pregnancy, especially first trimester (category D), lactation, children
<12 y.

ROUTE AND DOSAGE:

Mania
Adult: PO Loading Dose 600 mg t.i.d. or 900 mg sustained-release b.i.d. or 30 mL (48 mEq) of solution
t.i.d. PO Maintenance Dose 300 mg t.i.d. or q.i.d. or 15–20 mL (24–32 mEq) solution in 2–4 divided doses
(max: 2.4 g/d)
Child: PO 15–60 mg/kg/d in divided doses

ADVERSE EFFECTS:

CNS: Dizziness, headache, lethargy, drowsiness, fatigue, slurred speech, psychomotor retardation, giddiness,
incontinence, restlessness, seizures, confusion, blackout spells, disorientation, recent memory loss, stupor, coma,
EEG changes. CV: Arrhythmias, hypotension, vasculitis, peripheral circulatory collapse, ECG changes. Special
Senses: Impaired vision, transient scotomas, tinnitus. Endocrine: Diffuse thyroid enlargement,
hypothyroidism, nephrogenic diabetes insipidus, transient hyperglycemia, glycosuria, hyponatremia. GI: Nausea,
vomiting, anorexia, abdominal pain, diarrhea, dry mouth, metallic taste. Musculoskeletal: Fine hand
tremors, coarse tremors, choreoathetotic movements; fasciculations, clonic movements, incoordination including
ataxia, muscle weakness, hyperreflexia, encephalopathic syndrome (weakness, lethargy, fever, tremors, confusion,
extrapyramidal symptoms). Skin: Thought to be toxicity rather than allergy: Pruritus, maculopapular rash,
hyperkeratosis, chronic folliculitis, transient acneiform papules (face, neck, intertriginous areas), anesthesia of skin,
cutaneous ulcers, drying and thinning of hair, allergic vasculitis. Hematologic: Reversible leukocytosis (14,000 to
18,000/mm3). Urogenital: Albuminuria, oliguria, urinary incontinence, polyuria, polydipsia, increased uric acid
excretion. Body as a Whole: Edema, weight gain (common) or loss, exacerbation of psoriasis; flu-like symptoms.

NURSING IMPLICATIONS

Assessment & Drug Effects

 Monitor response to drug. Usual lag of 1–2 wk precedes response to lithium therapy. Keep physician
informed of progress.
 Lab test: Periodic lithium levels (draw blood sample prior to next dose or 8–12 h after last dose);
periodic thyroid function tests.
 Monitor for S&S of lithium toxicity (e.g., vomiting, diarrhea, lack of coordination, drowsiness,
muscular weakness, slurred speech when level is 1.5–2.0 mEq/L; ataxia, blurred vision, giddiness,
tinnitus, muscle twitching, coarse tremors, polyuria when >2.0 mEq/L). Withhold one dose and call
physician. Drug should not be stopped abruptly.
 Monitor older adults carefully to prevent toxicity, which may occur at serum levels ordinarily
tolerated by other patients.
 Be alert to and report symptoms of hypothyroidism (see Appendix F).
 Weigh patient daily; check ankles, tibiae, and wrists for edema. Report changes in I&O ratio, sudden
weight gain, or edema.
 Report early signs of extrapyramidal reactions promptly to physician.
Patient & Family Education

 Be alert to increased output of dilute urine and persistent thirst. Dose reduction may be indicated.
 Contact physician if diarrhea or fever develops. Avoid practices that may encourage dehydration: hot
environment, excessive caffeine beverages (diuresis).
 Drink plenty of liquids (2–3 L/d) during stabilization period and at least 1–1½ L/d during ongoing
therapy.
 Avoid self-prescribed low-salt regimen, self-dosing with antacids containing sodium, and high-
sodium foods (e.g., prepared meats and diet soda).
 Do not drive or engage in other potentially hazardous activities until response to drug is known.
Lithium may impair both physical and mental ability.
 Use effective contraceptive measures during lithium therapy. If therapy is continued during
pregnancy, serum lithium levels must be closely monitored to prevent toxicity.
 Do not breast feed while taking this drug.

ANTI DEPRESSANT DRUGS

 FLUOXENTINE
 ACTION:

Oral antidepressant chemically unrelated to tricyclic, tetracyclic, MAOI, or other available

antidepressants. Antidepressant effect is presumed to be linked to its inhibition of CNS neuronal uptake
of serotonin, a neurotransmitter. Known as a selective serotonin reuptake inhibitor (SSRI).

USES:

Depression, geriatric depression, obsessive-compulsive disorder (OCD), bulimia nervosa, premenstrual

dysphoric disorder.

CONTRAINDICATIONS:

Hypersensitivity to fluoxetine or other SSRI drugs; concurrent administration with MAOIs, or thioridazine;
pregnancy (category C), children <7 y for OCD, children <8 y for depression.

ROUTE AND DOSAGE:

Depression, Obsessive-Compulsive Disorder

Adult: PO 20 mg/d in a.m., may increase by 20 mg/d at weekly intervals (max: 80 mg/d); 20 mg/d in
a.m.; when stable may switch to 90 mg sustained-release capsule qwk (max: 90 mg/wk)
Child: PO > 7 y 10–20 mg/d in a.m. (max: 60 mg/d for OCD)
Geriatric: PO Start with 10 mg/d

ADVERSE EFFECTS:

CNS: Headache, nervousness, anxiety, insomnia, drowsiness, fatigue, tremor, dizziness. CV: Palpitations, hot
flushes, chest pain. GI: Nausea, diarrhea, anorexia, dyspepsia, increased appetite, dry mouth. Skin: Rash,
pruritus, sweating, hypersensitivity reactions. Special Senses: Blurred vision. Body as a Whole: Myalgias,
arthralgias, flu-like syndrome, hyponatremia. Urogenital: Sexual dysfunction, menstrual irregularities.

NURSING IMPLICATIONS:

Assessment & Drug Effects

 Use with caution in the older adult patient or patient with impaired renal or hepatic function (may
need lower dose).
 Use with caution in anorexic patient, since weight loss is a possible side effect.
 Monitor for S&S of anaphylactoid reaction (see Appendix F).
 Lab tests: Periodic serum electrolytes; monitor closely plasma glucose in diabetes.
 Monitor serum sodium level for development of hyponatremia, especially in patients who are taking
diuretics or are otherwise hypovolemic.
 Monitor diabetics for loss of glycemic control; hypoglycemia has occurred during initiation of
therapy, and hyperglycemia during drug withdrawal.
  Monitor for S&S of improved affect. Requires approximately 2–3 wk for therapeutic effects to be
felt.
 Weigh weekly to monitor weight loss, particularly in the older adult or nutritionally compromised
patient. Report significant weight loss to physician.
 Observe for and promptly report rash or urticaria and S&S of fever, leukocytosis, arthralgias, carpal
tunnel syndrome, edema, respiratory distress, and proteinuria. Drug may have to be discontinued or
adjunctive therapy instituted with steroids or antihistamines.
 Observe for dizziness and drowsiness and employ safety measures (up with assistance, side rails,
etc.) as indicated.
 Monitor for and report increased anxiety, nervousness, or insomnia; may need modification of drug
dose.
 Monitor for seizures in patients with a history of seizures. Use appropriate safety precautions.
 Supervise patients closely who are high suicide risks; especially during initial therapy.
 Monitor patients with hepatic or renal impairment carefully for S&S of toxicity (e.g., agitation,
restlessness, nausea, vomiting, seizures).

Patient & Family Education

 Notify physician of intent to become pregnant.

 Notify physician of any rash; possible sign of a serious group of adverse effects.
 Do not drive or engage in potentially hazardous activities until response to drug is known; especially
if dizziness noted.
 Monitor blood glucose for loss of glycemic control if diabetic.
 Note: Drug may increase seizure activity in those with history of seizure.
 Do not breast feed while taking this drug without consulting physician.
 DRUGS THAT ACT ON PERIPHERAL
NERVOUS SYSTEM
SKELETAL MUSCLE RELAXANTS

PERIPHERALLY ACTING
CENTRALLY ACTING

NEUROMUSCULAR DIRECTLY ACTING

BLOCKING AGENT AGENT 1.MEPHENESIN CONGENERS
2.BENZODIAZEPINES
3.GABA MIMETICS
Nondepolarizing blockers Depolarizing blockers 4.CENTRAL ALFA-2 AGONISTS

1.Long acting Succinyl choline

2.Intermediate acting
3.Short acting

SUCCINYL CHOLINE
ACTION:
Synthetic, ultrashort-acting depolarizing neuromuscular blocking agent with high affinity for acetylcholine (ACh)
receptor sites

USES:
To produce skeletal muscle relaxation as adjunct to anesthesia; to facilitate intubation and endoscopy, to increase
pulmonary compliance in assisted or controlled respiration, and to reduce intensity of muscle contractions in
pharmacologically induced or electroshock convulsions.

ROUTE AND DOSAGE:

Surgical and Anesthetic Procedures

Adult: IV 0.3–1.1 mg/kg administered over 10–30 sec, may give additional doses prn IM 2.5–4 mg/kg up to
150 mg
Child: IV 1–2 mg/kg administered over 10–30 sec, may give additional doses prn IM 2.5–4 mg/kg up to
150 mg

Prolonged Muscle Relaxation

Adult: IV 0.5–10 mg/min by continuous infusion
ADVERSE EFFECTS:
CNS: Muscle fasciculations, profound and prolonged muscle relaxation, muscle pain. CV: Bradycardia, tachycardia,
hypotension, hypertension, arrhythmias, sinus arrest. Respiratory: Respiratory depression, bronchospasm,
hypoxia, apnea. Body as a Whole: Malignant hyperthermia, increased IOP, excessive salivation, enlarged salivary
glands. Metabolic: Myoglobinemia, hyperkalemia. GI: Decreased tone and motility of GI tract (large doses).

NURSING IMPLICATIONS:

Assessment & Drug Effects

 Lab tests: Obtain baseline serum electrolytes. Electrolyte imbalance (particularly potassium,
calcium, magnesium) can potentiate effects of neuromuscular blocking agents.
 Be aware that transient apnea usually occurs at time of maximal drug effect (1–2 min); spontaneous
respiration should return in a few seconds or, at most, 3 or 4 min.
 Have immediately available: Facilities for emergency endotracheal intubation, artificial respiration,
and assisted or controlled respiration with oxygen.
 Monitor vital signs and keep airway clear of secretions.

Patient & Family Education

 Patient may experience postprocedural muscle stiffness and pain (caused by initial fasciculations
following injection) for as long as 24–30 h.
 Be aware that hoarseness and sore throat are common even when pharyngeal airway has not been
used.
 Report residual muscle weakness to physician.
 DRUGS ACTING ON
AUTONOMIC NERVOUS SYSTEM
CLASSIFICATION:

CHOLINERGIC DRUGS

They are also called Parasympathomimetic drugs because their effect mimics the effect of parasympathetic nerve
stimulation.

 TACRINE (ACETYLCHOLINE)

ACTION:

Cholinesterase inhibitor, presumably elevates acetylcholine in the cerebral cortex by slowing degradation of
acetylcholine release by the remaining intact neurons. Balance pathologic changes in neurons that result in
deficiency of acetylcholine in early stages of Alzheimer's disease.
USES:

Improvement of memory in mild to moderate Alzheimer's dementia.

ROUTE AND DOSAGE

Alzheimer's Disease
Adult: PO 10 mg q.i.d. (taken between meals if tolerated), increase in 40 mg/d increments not sooner than
q6wk (max: 160 mg/d)

Hepatic Impairment
Dose-related hepatotoxic effects have been observed, use with caution or not at all in patients with history of
past or current liver disease

ADVERSE EFFECTS:

CNS: Agitation, dizziness and confusion, ataxia, insomnia, somnolence,

hallucinations. GI: Nausea, vomiting, belching, diarrhea, abdominal discomfort,
anorexia, hepatotoxicity. Skin: Purpura. Urogenital: Excessive micturition and incontinence with UTI
infections. Body as a Whole: Diaphoresis

NURSING IMPLICATIONS:

Assessment & Drug Effects

 Monitor for clinical improvement (defined as a 4-point improvement in Alzheimer's Disease

Assessment Scale/Cognitive Subscale). Improvement has been observed after 1–4 wk; may take 6
mo for maximum benefit.
 Lab tests: Monitor serum transaminase (ALT) levels according to following schedule: Every 2 wk
for first 16 wk, then monthly for 2 mo, then every 3 mo thereafter; resume weekly monitoring for 6
wk with each dose increase; continue weekly monitoring if ALT remains more than 2 times normal;
if therapy is interrupted more than 4 wk then restarted, resume full ALT monitoring schedule.
 Monitor I&O because tacrine may cause bladder outflow obstruction.
 Monitor for seizure activity and take appropriate precautions.
 Monitor patients with history of angle-closure glaucoma for a worsening of this condition.
 Monitor for GI distress and bleeding, especially in patients with a history of peptic ulcer disease or
on concurrent NSAID therapy.
 Supervise ambulation because dizziness occurs in more than 10% of patients.
 Monitor cardiovascular status including periodic ECG monitoring. Assess for fluid retention and
worsening of CHF.
 Monitor periodically for development of drug-induced diabetes.

Patient & Family Education

  Be aware of adverse effects related to initiation of therapy or dosage increases (e.g., nausea,
vomiting, diarrhea) as well as delayed effects (e.g., rash, GI bleeding, jaundice). Report adverse
effects to the physician.
 Do not discontinue or reduce dosage of 80 mg/d or more abruptly because it may precipitate acute
deterioration of cognitive function.
 Make sure to have regular follow-up and liver function tests.
 Tacrine may induce seizures, vertigo, and syncope. Use appropriate precautions.
 Understand that tacrine therapy is not a cure and will become ineffective at some point as the disease
progresses.

ANTI CHOLINERGIC DRUGS

ATROPINE SULFATE:

ACTION:
Acts by selectively blocking all muscarinic responses to acetylcholine (ACh), whether excitatory or inhibitory.
Selective depression of CNS relieves rigidity and tremor of Parkinson's syndrome. Antisecretory action (vagolytic
effect) suppresses sweating, lacrimation, salivation, and secretions from nose, mouth, pharynx, and bronchi. Blocks
vagal impulses to heart with resulting decrease in AV conduction time, increase in heart rate and cardiac output, and
shortened PR interval.
USES:

Adjunct in symptomatic treatment of GI disorders (e.g., peptic ulcer, pylorospasm, GI hypermotility,

irritable bowel syndrome) and spastic disorders of biliary tract. Relaxes upper GI tract and colon during
hypotonic radiography. Ophthalmic Use: To produce mydriasis and cycloplegia before refraction and for
treatment of anterior uveitis and iritis. Preoperative Use: To suppress salivation, perspiration, and
respiratory tract secretions; to reduce incidence of laryngospasm, reflex bradycardia arrhythmia, and
hypotension during general anesthesia. Cardiac Uses: For sinus bradycardia or asystole during CPR or that
is induced by drugs or toxic substances (e.g., pilocarpine, beta-adrenergic blockers, organophosphate
pesticides, and Amanita mushroom poisoning); for management of selected patients with symptomatic sinus
bradycardia and associated hypotension and ventricular irritability; for diagnosis of sinus node dysfunction
and in evaluation of coronary artery disease during atrial pacing; for management of chronic symptomatic
sinus node dysfunction. Other Uses: Oral inhalation for short-term treatment and prevention of
bronchospasms associated with asthma, bronchitis, and COPD and as drying agent in upper respiratory
infection. Adjunctive therapy for hypermotility of GI tract.

CONTRAINDICATIONS:

Hypersensitivity to belladonna alkaloids; synechiae; angle-closure glaucoma; parotitis; obstructive uropathy,

e.g., bladder neck obstruction caused by prostatic hypertrophy; intestinal atony, paralytic ileus, obstructive
diseases of GI tract, severe ulcerative colitis, toxic megacolon; tachycardia secondary to cardiac
insufficiency or thyrotoxicosis; acute hemorrhage; myasthenia gravis. Safety during pregnancy (category C)
or lactation is not established.

ROUTE AND DOSAGE:

Preanesthesia
Adult: IV/IM/SC 0.2–1 mg 30–60 min before surgery
Child: IV/IM/SC <5 kg, 0.02 mg/kg; >5 kg, 0.01–0.02 mg/kg 30–60 min before surgery

Arrhythmias
Adult: IV/IM 0.5–1 mg q1–2h prn (max: 2 mg)
Child: IV/IM 0.01–0.03 mg/kg for 1–2 doses

Organophosphate Antidote
Adult: IV/IM 1–2 mg q5–60min until muscarinic signs and symptoms subside (may need up to 50 mg)
Child: IV/IM 0.05 mg/kg q10–30 min until muscarinic signs and symptoms subside

COPD
Adult: Inhalation 0.025 mg/kg diluted with 3–5 mL saline, via nebulizer 3–4 times daily (max: 2.5 mg/d)
Child: Inhalation 0.03–0.05 mg/kg diluted with 3–5 mL saline, via nebulizer 3–4 times daily

ADVERSE EFFECTS:

CNS: Headache, ataxia, dizziness, excitement, irritability, convulsions, drowsiness, fatigue, weakness;
mental depression, confusion, disorientation, hallucinations. CV: Hypertension or hypotension, ventricular
tachycardia, palpitation, paradoxical bradycardia, AV dissociation, atrial or ventricular fibrillation. GI: Dry
mouth with thirst, dysphagia, loss of taste; nausea, vomiting, constipation, delayed gastric emptying, antral
stasis, paralytic ileus. Urogenital: Urinary hesitancy and retention, dysuria, impotence. Skin: Flushed, dry
skin; anhidrosis, rash, urticaria, contact dermatitis, allergic conjunctivitis, fixed-drug eruption. Special
Senses: Mydriasis, blurred vision, photophobia, increased intraocular pressure, cycloplegia, eye dryness,
local redness.

NURSING IMPLICATIONS:

Assessment & Drug Effects

 Monitor vital signs. HR is a sensitive indicator of patient's response to atropine. Be alert to changes
in quality, rate, and rhythm of HR and respiration and to changes in BP and temperature.
 Initial paradoxical bradycardia following IV atropine usually lasts only 1–2 min; it most likely
occurs when IV is administered slowly (more than 1 min) or when small doses (less than 0.5 mg) are
used. Postural hypotension occurs when patient ambulates too soon after parenteral administration.
 Note: Frequent and continued use of eye preparations, as well as overdosage, can have systemic
effects. Some atropine deaths have resulted from systemic absorption following ocular
administration in infants and children.
  Monitor I&O, especially in older adults and patients who have had surgery (drug may contribute to
urinary retention). Palpate lower abdomen for distention. Have patient void before giving atropine.
 Monitor CNS status. Older adults and debilitated patients sometimes manifest drowsiness or CNS
stimulation (excitement, agitation, confusion) with usual doses of drug or other belladonna alkaloids.
In addition to dosage adjustment, side rails and supervision of ambulation may be indicated.
 Monitor infants, small children, and older adults for "atropine fever" (hyperpyrexia due to
suppression of perspiration and heat loss), which increases the risk of heatstroke.
 Note: Intraocular tension and depth of anterior chamber should be determined before and during
therapy with ophthalmic preparations to avoid glaucoma attacks (ophthalmic solutions and ointments
are available in various strengths).
 Patients receiving atropine via inhalation sometimes manifest mild CNS stimulation with doses in
excess of 5 mg and mental depression and other mental disturbances with larger doses.

Patient & Family Education

 Follow measures to relieve dry mouth: adequate hydration; small, frequent mouth rinses with tepid
water; meticulous mouth and dental hygiene; gum chewing or sucking sugarless sourballs.
 Note: Drug causes drowsiness, sensitivity to light, blurring of near vision, and temporarily impairs
ability to judge distance. Avoid driving and other activities requiring visual acuity and mental
alertness.
 Discontinue ophthalmic preparations and notify physician if eye pain, conjunctivitis, palpitation,
rapid pulse, or dizziness occurs.
 Do not breast feed while taking this drug without consulting physician.

BIBLIOGRAPHY

 Tripathi KD ,Pharmacological classification of drugs,5th edition,Jaypee publishers,pg no-1,60 and

64.
 Mosby’s,Drug consult for nurses,2006 edition,Elsevier publisher,pg no-632-940.
 http://www.robholland.com/Nursing/Drug_Guide/
 https://en.wikipedia.org/wiki/CNS_Drugs_(journal)
 https://www.tcd.ie/medicine/physiology/assets/docs/lecturenotes/AG/JS/2_CNS_Sys_Pharmacology
.pdf