CNS DEPRESSANTS

Barbiturates
Phenobarbital is an example of a barbiturate primarily used as a sedative and to treat seizure disorders. In high
doses it can be used to induce anesthesia, and overdosage can cause death.
In the 1960s and 1970s, barbiturates were used to treat anxiety and insomnia, but are no longer used for these
purposes due to their serious adverse effects.
The abuse of barbiturates continues to occur with street use as a “downer” to counteract the effect of cocaine and
methamphetamine.
Mechanism of Action: Barbiturates produce sedation and drowsiness by altering cerebellar function and depressing
the actions of the brain and sensory cortex.
Indications: Barbiturates are primarily used for sedation and seizures.
Nursing Considerations:
Do not use for children less than 1 month of age. Barbiturates may harm the fetus during pregnancy.
Avoid use in geriatric clients.
Phenobarbital serum levels should be monitored to ensure adequate therapeutic concentrations for anticonvulsant
activity, with a therapeutic range of 15-40 mcg/mL.
Health Teaching & Health Promotion:
The client should be advised to take the prescribed medication as directed. Clients who undergo prolonged therapy
should not discontinue treatment abruptly as this may cause onset of seizure activity.
These medications may cause drowsiness and should not be taken with alcohol or other CNS depressants. Female
clients using oral contraceptives should also use nonhormonal-based contraceptives during therapy.
Phenobarbital

Prototype/
Class/Subclass Nursing Considerations Therapeutic Effects Side/Adverse Effects
Generic

May be administered orally, IM, or IV CNS depression;

Phenobarbital levels should be monitored to overdosage can cause
Primarily used as an
assess for toxicity death
anticonvulsant
High abuse potential May cause suicidal
Barbiturates phenobarbital Also used as a sedative and may
Should not be combined with other CNS thoughts or behavior
also be used as a preanesthetic
depressants Respiratory depression
agent
When therapy is discontinued, the dose GI: Nausea and
should be tapered and not stopped abruptly vomiting

Benzodiazepines

Lorazepam, a benzodiazepine with antianxiety, sedative, and anticonvulsant effects, is available for oral,
intramuscular, or intravenous routes of administration.
Indications: Benzodiazepines are used for sedation, antianxiety, and anticonvulsant effects.
Lorazepam injection is indicated for the treatment of status epilepticus.
It may also be used in adult clients for preanesthetic medication to produce sedation (sleepiness or drowsiness),
relieve anxiety, and decrease the ability to recall events related to the day of surgery.
Oral lorazepam is used to treat anxiety disorders.
Nursing Considerations:
Benzodiazepines may cause fetal harm when administered to pregnant women.
Children and the elderly are more likely to experience paradoxical reactions to benzodiazepines such as tremors,
agitation, or visual hallucinations.
Elderly or debilitated clients may be more susceptible to the sedative and respiratory depressive effects of
lorazepam. Therefore, these clients should be monitored frequently and have their dosage adjusted carefully
according to client response; the initial dosage should not exceed 2 mg.
Dosages for clients with severe hepatic insufficiency should be adjusted carefully according to client response.
Side Effects/Adverse Effects:
The most important risk associated with the intravenous use of lorazepam injection is respiratory depression.
Accordingly, airway patency must be assured, and respiration monitored closely. Ventilatory support should be
given as required.
The additive central nervous system effects of other drugs, such as phenothiazines, narcotic analgesics, barbiturates,
antidepressants, scopolamine, and monoamine-oxidase inhibitors should be considered when these other drugs are
used concomitantly with, or during the period of recovery from, lorazepam injection.
Sedation, drowsiness, respiratory depression (dose dependent), hypotension, and unsteadiness may occur with oral
dosages as well.
Health Teaching & Health Promotion: Clients who receive lorazepam should be cautioned that driving a motor
vehicle, operating machinery, or engaging in hazardous or other activities requiring attention and coordination
should be delayed for 24 to 48 hours following administration or until the effects of the drug, such as drowsiness,
have subsided.
Clients should be advised that getting out of bed unassisted may result in falling and potential injury if undertaken
within 8 hours of receiving lorazepam.
Alcoholic beverages should not be consumed for at least 24 to 48 hours after receiving lorazepam injectable due to
the additive effects on central nervous system depression seen with benzodiazepines in general.
Elderly clients should be instructed that lorazepam injection may make them very sleepy for a period longer than 6
to 8 hours following surgery.
Lorazepam

Prototype/ Side/Adverse
Class/Subclass Nursing Considerations Therapeutic Effects
Generic Effects

Benzodiazepines lorazepam
Boxed Warning: Concomitant use of To relieve anxiety, reduce Oversedation and
benzodiazepines and opioids may result in profound seizure activity, or as a drowsiness
sedation, respiratory depression, coma, and death preanesthetic Respiratory
May cause fetal harm in pregnant women depression
May cause paradoxical effect in children Unsteadiness and
Use cautiously in elderly and with those with liver fall risk
dysfunction Overdosage can
cause coma and
 Prototype/ Side/Adverse
Class/Subclass Nursing Considerations Therapeutic Effects
Generic Effects

death
Flumazenil used for
overdose

CNS STIMULANTS

Methylphenidate
Methylphenidate is an example of a CNS stimulant that is often used to treat ADHD.
Indications: Methylphenidate is used for ADHD.
Nursing Considerations: Methylphenidate is typically prescribed to clients over the age of 6. It should be avoided
in clients with known structural cardiac abnormalities, cardiomyopathy, serious heart rhythm arrhythmias, or
coronary artery disease. Blood pressure and heart rate should be monitored in all clients.
CNS stimulants have been associated with weight loss and slowing of growth rate in pediatric clients. It increases
the risk of peripheral vasculopathy, such as Raynaud’s phenomenon, with signs and symptoms of fingers or toes
feeling numb, cool, painful, and/or changing color from pale, to blue, to red.
Methylphenidate is contraindicated in clients using a monoamine oxidase inhibitor (MAOI), or use of an MAOI
within the preceding 14 days. If paradoxical worsening of symptoms or other adverse reactions occur, the dosage
should be reduced, or if necessary, discontinued.
Administer methylphenidate hydrochloride extended-release capsules orally once daily in the morning. Extended-
release capsules should not be crushed, chewed, or divided. Monitor for signs of abuse and dependence while on
therapy.
Side Effects/Adverse Effects:
Sudden death, stroke, and myocardial infarction have been reported in adults with CNS-stimulant treatment at
recommended doses.
Methylphenidate may cause increased blood pressure and increased heart rate.
The most common adverse reactions (greater than 5% incidence) were headache, insomnia, upper abdominal pain,
decreased appetite, and anorexia.
Alcohol should be avoided because it may cause a rapid release of the drug in extended-release formulations.
Controlled Substance Status/High Potential for Abuse and Dependence: Advise clients that methylphenidate is
a controlled substance, and it can be abused and lead to dependence. Instruct clients that they should not give
methylphenidate to anyone else. Advise clients to store methylphenidate in a safe place, preferably locked, to
prevent abuse.
Serious Cardiovascular Risks: Advise clients that there is a potential serious cardiovascular risk, including sudden
death, myocardial infarction, stroke, and hypertension.
Instruct clients to contact a health care provider immediately if they develop symptoms such as exertional chest pain
or unexplained syncope.
Blood Pressure and Heart Rate Increases: Instruct clients that methylphenidate hydrochloride extended-release
capsules can cause elevations of their blood pressure and pulse rate.
Teach clients, especially those with a history of hypertension, to avoid OTC cold and allergy products containing
phenylephrine and pseudoephedrine.
Psychiatric Risks: Advise clients that methylphenidate can cause psychotic or manic symptoms, even in clients
without prior history of psychotic symptoms or mania.
Circulation Problems in Fingers and Toes: Instruct clients beginning treatment with methylphenidate about the
risk of peripheral vasculopathy and associated signs and symptoms: fingers or toes may feel numb, cool, painful,
and/or may change color from pale, to blue, to red. Instruct clients to report to their provider any new numbness,
pain, skin color change, or sensitivity to temperature in fingers or toes or any signs of unexplained wounds
appearing on fingers or toes.
Suppression of Growth: Advise parents that methylphenidate may cause slowing of growth and weight loss.
Alcohol Effect: Advise clients to avoid alcohol while taking extended-release capsules.
Methylphenidate

Prototype/
Class/Subclass Nursing Considerations Therapeutic Effects Side/Adverse Effects
Generic

CNS methylphenidate Boxed Warning: High abuse potential Increases mental focus Immediately report signs and
Stimulant Clients should avoid alcohol and attention in clients symptoms of abuse, cardiac or
Monitor BP and HR with ADHD peripheral vascular complications, and
Monitor growth and weight in priapism
children Report mania or psychotic episodes
Monitor for signs of abuse Common side effects: Headache,
Contraindicated with MAOIs or use of insomnia, upper abdominal pain,
an MAOI within the preceding 14 decreased appetite, and anorexia
days Gynecomastia

ANTIDEPRESSANTS

Antidepressants are used to treat depression and other mental health disorders, as well as other medical conditions
such as migraine headaches, chronic pain, and premenstrual syndrome.
Antidepressants increase levels of neurotransmitters in the CNS, including serotonin (5-HT), dopamine, and
norepinephrine.
Treatment is based on the belief that alterations in the levels of these neurotransmitters are responsible for causing
depression.
TCAs and MAOIs are referred to as first-generation antidepressants because they were first marketed in the 1950s.
SSRIs, SNRIs, and other miscellaneous medications such as bupropion are called second-generation antidepressants
and are popular because of fewer side effects like sedation, hypotension, anticholinergic effects, or cardiotoxicity.
Tricyclic Antidepressants
Tricyclic antidepressants (TCAs) were one of the original first-generation antidepressants. Due to the popularity of
SSRIs and SNRIs, TCAs are now more commonly used to treat neuropathic pain and insomnia.
Indications: TCAs are used to treat depression, neuropathic pain, and insomnia.
Nursing Considerations: TCAs are often administered at bedtime due to sedating effects and are contraindicated
with MAOIs.
Geriatric clients are particularly sensitive to the anticholinergic side effects of tricyclic antidepressants.
Peripheral anticholinergic effects include tachycardia, urinary retention, constipation, dry mouth, blurred vision, and
exacerbation of narrow-angle glaucoma.
Central nervous system anticholinergic effects include cognitive impairment, psychomotor slowing, confusion,
sedation, and delirium.
Elderly clients taking amitriptyline may be at increased risk for falls. Elderly clients should be started on low doses
of amitriptyline and observed closely.
After prolonged administration, abrupt cessation of treatment may produce nausea, headache, and malaise. The dose
should be gradually tapered, but transient symptoms may still occur.
Side Effects/Adverse Effects: Adverse effects of TCAs are a result of their blockade effects on various receptors,
often resulting in anticholinergic adverse effects such as constipation, urinary retention, and drowsiness.
Blockage of adrenergic and dopaminergic receptors can cause cardiac conduction disturbances and hypotension.
Histaminergic blockage can cause sedation, and serotonergic blockade can alter the seizure threshold and cause
sexual dysfunction.
Death may occur from overdosage with this class of drugs. Multiple drug ingestion (including alcohol) is common
in deliberate tricyclic antidepressant overdose.
Health Teaching & Health Promotion: Due to the increased risk of suicidality with antidepressants, clients and
their family members or caregivers should be instructed to immediately report any sudden changes in mood,
behaviors, thoughts, or feelings.
Amitriptyline

Prototype/
Class/Subclass Nursing Considerations Therapeutic Effects Side/Adverse Effects
Generic

Tricyclic amitriptyline Boxed Warning: Increased risk of Based on indication: Decrease Immediately report signs or
suicidality feelings of depression, chronic symptoms of suicidality
Taper dose when discontinuing; do not pain, or insomnia Anticholinergic effects
stop abruptly Hypotension
Monitor orthostatic blood pressures and May lengthen QT interval;
consider fall risk precautions risk for arrhythmias
Sedation
Sexual dysfunction
Altered seizure threshold

Selective Serotonin Reuptake Inhibitor (SSRI)

Selective serotonin reuptake inhibitors (SSRIs) are a second-generation antidepressant and have fewer side effects
than TCAs and MAOIs. Fluoxetine and citalopram are commonly used SSRIs.
Indications: SSRIs are primarily used to treat depression, but are also used to treat obsessive compulsive disorder,
bulimia, panic disorder, post-traumatic stress disorder, other forms of anxiety, premenstrual syndrome, and
migraines.
Nursing Considerations: The onset of fluoxetine’s antidepressant effect develops slowly for up to 12 weeks.
Use with caution in clients who are taking other CNS medications or who have liver dysfunction. This drug is
contraindicated with MAOIs.
Monitor for increased suicide ideation in all populations, as well as for the development of serotonin syndrome.
Side Effects/Adverse Effects: Side effects include rash; mania; seizures; decreased appetite and weight; increased
bleeding associated with the concomitant use of fluoxetine and NSAIDs, aspirin, warfarin, or other drugs that affect
coagulation; hyponatremia; anxiety; and insomnia.
The development of a potentially life-threatening serotonin syndrome or neuroleptic malignant syndrome (NMS)-
like reactions has been reported with SNRIs and SSRIs, particularly with concomitant use of serotonergic drugs,
drugs that impair metabolism of serotonin (including MAOIs), or with antipsychotics or other dopamine antagonists.
Symptoms of serotonin syndrome may include mental status changes (e.g., agitation, hallucinations, coma),
autonomic instability (e.g., tachycardia, labile blood pressure, hyperthermia), neuromuscular aberrations (e.g.,
hyperreflexia, incoordination), and/or gastrointestinal symptoms (e.g., nausea, vomiting, diarrhea).
Serotonin syndrome, in its most severe form, can resemble neuroleptic malignant syndrome (NMS), which
includes hyperthermia, muscle rigidity, autonomic instability with possible rapid fluctuation of vital signs, and
mental status changes. Clients should be monitored for the emergence of serotonin syndrome or NMS-like signs and
symptoms.
Abrupt discontinuation may cause several adverse effects, so a gradual reduction in the dose rather than abrupt
cessation is recommended whenever possible.
Health Teaching & Health Promotion: Clients should be careful to take medications as directed. Abrupt
discontinuation may cause anxiety, insomnia, and increased nervousness. Additionally, orthostatic blood pressure
changes are common during medication therapy. Clients may also be increasingly drowsy or exhibit some
confusion. Use of SSRI medications with alcohol or other CNS depressant drugs should be avoided.
Clients should be monitored carefully by family members and caregivers for suicidal thoughts. Other side effects
include possible decreased libido, urinary retention, constipation, and increased photosensitivity.
Fluoxetine and Citalopram

Prototype/
Class/Subclass Nursing Considerations Therapeutic Effects Side/Adverse Effects
Generic

Boxed Warning: Monitor for

increased risk of suicidality
Do not stop abruptly; taper dose
when discontinuing
fluoxetine
SSRI Contraindicated with MAOIs
citalopram
Use caution with liver
dysfunction
May take up to 12 weeks before
achieve therapeutic effect
Immediately report signs/symptoms of
increased suicidality or serotonin
Based on indication:
syndrome
Primarily decreases
Rash, mania, seizures, decreased appetite
feelings of depression
and weight, increased bleeding,
hyponatremia, anxiety, and insomnia

Serotonin Norepinephrine Reuptake Inhibitor (SNRI)

Venlafaxine is an example of a serotonin norepinephrine reuptake inhibitor (SNRI).
Indications: SNRIs are indicated for treatment of a major depressive disorder.
Nursing Considerations: SNRIs are contraindicated with MAOIs or within 14 days of use of an MAOI. Dosage
adjustment is required for use in clients with renal and/or liver disease. Elderly clients are at greater risk for
developing hyponatremia. Use with caution with other serotonin medications.
Side Effects/Adverse Effects: SNRI medication may cause sustained increase in blood pressure. Other side effects
include serotonin syndrome, insomnia, anxiety, decreased appetite, weight loss, mania, hyponatremia, increased
bleeding (especially with the concomitant use of fluoxetine and NSAIDs, aspirin, warfarin, or other drugs that affect
coagulation), elevated serum cholesterol, somnolence, and nausea.
Health Teaching & Health Promotion: Clients should be careful to take medications as directed. The dose should
be tapered prior to discontinuation. Clients may also be increasingly drowsy or dizzy. Use of SNRI medications with
alcohol or other CNS depressant drugs should be avoided. Clients should be monitored carefully by family members
and caregivers for suicidality.
Venlafaxine

Prototype/
Class/Subclass Nursing Considerations Therapeutic Effects Side/Adverse Effects
Generic

Increased suicidality
Serotonin syndrome
Elevated BP
Anxiety
Boxed Warning: Monitor for increased
Insomnia
risk of suicidality
Decreased appetite
Monitor BP May take up to 8 weeks before
Weight loss
SNRI venlafaxine Gradually reduce dose when therapeutic effect is recognized
Mania
discontinuing when possible Decrease feelings of depression
Hyponatremia
Use with caution with clients with liver
Increased bleeding
or renal disease
Elevated cholesterol
Somnolence
GI: Nausea and
constipation

Monoamine Oxidase inhibitors (MAOI)

Monoamine oxidase inhibitors (MAOIs) are a first-generation antidepressant. Tranylcypromine is an example of an
MAOI. A significant disadvantage to MAOIs is their potential to cause a hypertensive crisis when taken with
stimulant medications or foods containing tyramine.
Indications: Tranylcypromine is indicated for the treatment of major depressive disorder in adult clients who have
not responded adequately to other antidepressants. The drug may also be used to treat Parkinson’s disease.
Nursing Considerations: Serious interactions with several medications, as well as foods and beverages containing
tyramine, have been reported; check drug labelling before administering. Safety has not been established with the
pediatric population. The elderly population is at increased risk for postural hypotension and serious adverse effects.
Abuse and dependence have been reported. Withdrawal effects can continue for several weeks after discontinuation.
Side Effects/Adverse Effects: Use with caution due to the risks of hypertensive crisis, serotonin syndrome, and
increased suicidality.
Hypertensive crisis is defined by severe hypertension (blood pressure greater than 180/120 mm Hg) with evidence
of organ dysfunction. Symptoms may include occipital headache (which may radiate frontally), palpitations, neck
stiffness or soreness, nausea or vomiting, sweating, dilated pupils, photophobia, shortness of breath, or confusion.
Either tachycardia or bradycardia may be present and may be associated with constricting chest pain. Seizures may
also occur. Intracranial bleeding, sometimes fatal, has been reported in association with the increase in blood
pressure.
Other potential side effects include mania, orthostatic hypotension, hepatotoxicity, seizures, hypoglycemia in
diabetic clients, decreased appetite and weight loss, dizziness, headache, drowsiness, and restlessness. Clients should
be advised it may impair their ability to operate machinery or drive. MAOIs should be discontinued if hepatotoxicity
occurs.
Health Teaching & Health Promotion: Clients should be careful to take medications as directed. They should
avoid abrupt cessation of therapy to avoid withdrawal symptoms. Clients should avoid alcohol, other CNS
depressants, and tyramine-containing products for two weeks after therapy is discontinued. Clients should be
advised regarding the signs of hypertensive crisis and to immediately report headache, chest or throat tightness, and
palpitations to the provider.
Tranylcypromine

Class/Subclass Prototype/ Nursing Considerations Therapeutic Effects Side/Adverse Effects

Generic

Increased suicidality
Hypertensive crisis
Serotonin syndrome
Mania
Boxed Warning: Monitor for Orthostatic hypotension
hypertensive crisis and increased Hepatotoxicity
suicide ideation Seizures
Avoid foods containing tyramine Based on indication: Decreased Hypoglycemia in clients
MAOI tranylcypromine Many drug interactions feelings of depression or decreased with diabetes
Monitor BP symptoms of Parkinson’s disease Decreased appetite and
Do not stop abruptly; taper dose when weight loss
discontinuing CNS: Dizziness,
Discontinue if hepatotoxicity headache, drowsiness, and
restlessness
May impair ability to
operate machinery or
drive

ANTIMANIAS

Mood stabilizers are used to treat bipolar affective disorder. Lithium was the first medication used to treat this
disorder and is sometimes referred to as an antimania drug because it can help control the mania that occurs in
bipolar disorder. Lithium must be closely monitored with a narrow therapeutic range.

Lithium
Mechanism of Action: Lithium alters sodium transport in nerve and muscle cells and affects a shift toward
intraneuronal metabolism of catecholamines, but the specific biochemical mechanism of lithium action in mania is
unknown.
Indications: Lithium is indicated in the treatment of manic episodes of bipolar disorder and as a maintenance
treatment for individuals with a diagnosis of bipolar disorder.
Nursing Considerations: Lithium must be closely monitored with a narrow therapeutic serum range of 0.8 to 1.2
mEq/L. Serum sodium levels should also be monitored for potential hyponatremia.
The drug is contraindicated in renal or cardiovascular disease, severe dehydration or sodium depletion, and to clients
receiving diuretics because the risk of lithium toxicity is very high.
Lithium can cause fetal harm in pregnant women. Safety has not been established for children under 12 and is not
recommended.
When given to a client experiencing a manic episode, lithium may produce a normalization of symptomatology
within 1 to 3 weeks.
Side Effects/Adverse Effects: Fine hand tremor, polyuria, and mild thirst may persist throughout treatment.
Signs of early lithium toxicity include diarrhea, vomiting, drowsiness, muscular weakness, and lack of coordination.
At higher levels, giddiness, ataxia, blurred vision, tinnitus, and a large output of dilute urine may be seen. No
specific antidote for lithium poisoning is known; treatment focuses on the elimination of the medication.
Health Teaching & Health Promotion: Clients should be taught to take medication as directed, get labs drawn as
scheduled, and maintain a consistent salt intake. Clients should also be advised that antimanic drugs may increase
dizziness and drowsiness and weight gain may occur. Additionally, if individuals have low sodium levels, it may
predispose the client to lithium toxicity.
Lithium

Prototype/ Side/Adverse
Class/Subclass Nursing Considerations Therapeutic Effects
Generic Effects

Antimanic lithium Boxed Warning: Monitor for signs of When given during a manic episode, Lithium toxicity
lithium toxicity symptoms may resolve in 1-3 weeks Hyponatremia
Monitor serum lithium and sodium levels When given for maintenance therapy, it Tremor
Contraindicated in renal and should reduce the frequency and intensity of Cardiac
cardiovascular disease and in manic episodes arrhythmia
dehydration Polyuria
Thirst

ANTIPSYCHOTICS

Antipsychotic drugs are used to treat drug-induced psychosis, schizophrenia, extreme mania, depression that is
resistant to other therapy, and other CNS conditions. Antipsychotics are sometimes referred to as tranquilizers
because they produce a state of tranquility.
Selection of antipsychotic medication is based on the client’s ability to tolerate the adverse effects.
First-generation antipsychotics, also called “typical” antipsychotics, have similar mechanisms of action and several
potential adverse effects. An example of a first-generation antipsychotic is haloperidol.
Second-generation antipsychotics, also referred to as “atypical” antipsychotics, have fewer adverse effects. An
example of an atypical antipsychotic is risperidone.
Both typical and atypical antipsychotics have a Boxed Warning indicating that elderly clients with dementia-related
psychosis treated with antipsychotic drugs are at an increased risk of death.
Mechanism of Action: All antipsychotics block dopamine receptors in the brain. However, the precise mechanism
of action has not been clearly established.
First-generation antipsychotics, such as haloperidol, block dopamine receptors in certain areas of the CNS, such as
the limbic system and the basal ganglia. These areas are associated with emotions, cognitive function, and motor
function, so dopamine blockage thus produces a tranquilizing effect in clients experiencing psychosis. However,
several adverse effects are also caused by this dopamine blockade.
Second-generation, or atypical, antipsychotics block specific dopamine 2 receptors and specific serotonin 2
receptors, thus causing fewer adverse effects.
Indications: Haloperidol is primarily indicated for schizophrenia and Tourette’s disorder.
Risperidone is primarily indicated for schizophrenia but is also used for acute manic episodes and for irritability
caused by autism.
Some atypical antipsychotics are also used as adjunct therapy for depression.
Nursing Considerations: Elderly clients with dementia-related psychosis treated with antipsychotic drugs should
be closely monitored for signs and symptoms of cardiovascular events or infections such as pneumonia.
Haloperidol is contraindicated in clients with Parkinson’s disease or dementia with Lewy body.
Clients who are concurrently taking lithium and antipsychotics should be monitored closely for neurotoxicity
(weakness, lethargy, fever, tremulousness, confusion, and extrapyramidal symptoms), and symptoms should be
immediately reported.
Side Effects/Adverse Effects: Elderly clients with dementia-related psychosis treated with antipsychotic drugs are
at an increased risk of death due to cardiovascular or infection-related causes.
First-generation and second-generation antipsychotics can cause agranulocytosis.
First-generation antipsychotic medications have increased risk for several potential serious adverse effects such
as tardive dyskinesia, neuroleptic malignant syndrome (NMS), and extrapyramidal symptoms. These adverse
effects are due to the blockage of alpha-adrenergic, dopamine, endocrine, histamine, and muscarinic receptors.
Clients should be warned to not consume alcohol and that their ability to operate machinery or drive may be
impaired.
Potential Adverse Effects of Antipsychotic

Adverse Effect Definition

Involuntary contraction of the oral and facial muscles (such as tongue thrusting) and wavelike movements of the
Tardive Dyskinesia
extremities.

Neuroleptic Malignant
Potentially life-threatening adverse effect that includes high fever, unstable blood pressure, and myoglobinemia.
Syndrome (NMS)

Extrapyramidal Involuntary motor symptoms similar to those associated with Parkinson’s disease. Includes symptoms such
Symptoms as akathisia (distressing motor restlessness) and acute dystonia (painful muscle spasms.) Often treated with
Adverse Effect Definition

anticholinergic medications such as benztropine and trihexyphenidyl.

Second-generation, or atypical, antipsychotics are less likely to cause adverse effects, but have a potential to do so.
Atypical antipsychotics may also cause metabolic changes such as hyperglycemia, hyperlipidemia, and weight gain,
which can cause clients to stop treatment.
Health Teaching & Health Promotion: Advise clients to take medication as directed. Medication doses should be
evenly spaced throughout the day. It may require several weeks to obtain desired effects. Clients should be advised
regarding the possibility of extrapyramidal symptoms and that abrupt withdrawal may cause dizziness; nausea and
vomiting; and/or uncontrolled movements of mouth, tongue, or jaw. Additionally, the client should be careful to
avoid alcohol or other CNS depressants while using the medication.
Haloperidol and Risperidone

Prototype/
Class/Subclass Nursing Considerations Therapeutic Effects Side/Adverse Effects
Generic

haloperidol Boxed Warning: Monitor elderly clients Life-threatening

risperidone with dementia closely for symptoms of cardiovascular events or
cardiovascular events or infection infections
Advise clients to avoid alcohol, operate Agranulocytosis
machinery, or drive Tardive dyskinesia
1st-Generation Neuroleptic malignant
(Typical) syndrome
Decrease symptoms of
Antipsychotics Extrapyramidal symptoms
psychosis, hallucinations,
2nd-Generation 2nd generation:
delusions, and delirium
(Atypical) Hyperglycemia,
Antipsychotics hyperlipidemia, and weight
gain
Hypersensitivity reactions
Falls related to sedation,
motor instability, and
postural hypotension

ANTICONVULSANTS

Medications used for seizures are called anticonvulsants or anti-seizure drugs.

Anti-seizure drugs stabilize cell membranes and suppress the abnormal electric impulses in the cerebral cortex.
These drugs prevent seizures but do not provide a cure.
Anti-seizure drugs are classified as CNS depressants. There are many types of medications used to treat seizures
such as phenytoin, phenobarbital, benzodiazepine, carbamazepine, valproate, and levetiracetam.
There are three main pharmacological effects of anti-seizure medications.
First, they increase the threshold of activity in the motor cortex, thus making it more difficult for a nerve to become
excited.
Second, they limit the spread of a seizure discharge from its origin by suppressing the transmission of impulses from
one nerve to the next.
Third, they decrease the speed of the nerve impulse conduction within a given neuron.
Some drugs work by enhancing the effects of the inhibitory neurotransmitter gamma-aminobutyric acid (GABA),
which plays a role in regulating neuron excitability in the brain.
Gabapentin, although structurally similar to GABA and classified as an anticonvulsant, is commonly used to control
chronic neuropathic pain. Neuropathic pain is defined as “pain caused by a lesion or disease of the somatosensory
nervous system.”
An example of neuropathic pain is tingling or burning in the lower extremities that often occurs in clients with
diabetes.

Phenytoin
Phenytoin, which was discovered in 1938, was the first anti-seizure medication and is still being used to control
seizures.
Indications: Phenytoin is indicated for the treatment of tonic-clonic (grand mal) and psychomotor (temporal lobe)
seizures and for the prevention and treatment of seizures occurring during or following neurosurgery.
Nursing Considerations: Phenytoin should not be administered to pregnant women because it will cause harm to
the fetus. Careful cardiac monitoring is needed during and after administering intravenous phenytoin.
Phenytoin has a narrow therapeutic drug level, usually between 10-20 mcg/mL, so serum drug monitoring is
required. Serum levels of phenytoin sustained above the therapeutic range may produce confusional states referred
to as delirium, psychosis, or encephalopathy. Accordingly, at the first sign of acute toxicity, serum levels should be
immediately checked.
Abrupt discontinuation can cause status epilepticus, so in the event of an allergic or hypersensitivity reaction, rapid
substitution of alternative therapy may be necessary.
Use with caution in clients with renal or hepatic impairment. Elderly clients may require dosage adjustment.
Side Effects/Adverse Effects: Serious and sometimes fatal dermatologic reactions, including toxic epidermal
necrolysis (TEN) and Stevens-Johnson syndrome (SJS), have been reported with phenytoin treatment. The onset of
symptoms is usually within 28 days but can occur later. Phenytoin should be discontinued at the first sign of a rash.
Health Teaching & Health Promotion: Clients should be advised to take medications as directed and that doses
should be evenly spaced throughout the day. It may take several weeks to obtain the desired medication effect.
Abrupt withdrawal of medication may cause status epilepticus. Clients should avoid alcohol and other CNS
depressants while taking anticonvulsant drug therapy. Additionally, clients with diabetes should monitor their blood
glucose levels carefully.
Phenytoin

Prototype/ Therapeutic
Class/Subclass Nursing Considerations Side/Adverse Effects
Generic Effects

Anticonvulsan phenytoin Careful cardiac monitoring is needed during and Decrease or Cardiovascular risk associated
t after administering intravenous phenytoin prevent seizure with rapid IV infusion
For IV infusions, an in-line filter (0.22 to 0.55 activity Discontinue and notify the
microns) should be used. Cannot be given with provider if a rash occurs
D5W due to precipitate formation and no faster Notify the provider immediately if
 Prototype/ Therapeutic
Class/Subclass Nursing Considerations Side/Adverse Effects
Generic Effects

than 50 mg/minute in adults fever, rash, lymphadenopathy,

Monitor serum drug levels and/or facial swelling occur
Contraindicated for clients with heart block Cardiovascular: Arrhythmia and
Use cautiously in clients with hepatic or renal hypotension
impairment CNS: Nystagmus, ataxia, slurred
Taper dose; do not stop abruptly speech, decreased coordination,
somnolence, and mental confusion
GI: Constipation, gingival
hyperplasia, and hepatotoxicity
Hematology: Thrombocytopenia,
pancytopenia, and agranulocytosis

Levetiracetam
Levetiracetam is indicated as adjunctive therapy in the treatment of partial onset seizures in clients 12 years of age
and older with epilepsy. It is generally well-tolerated.
Indications: Levetiracetam is used for partial onset seizures in clients with epilepsy.
Nursing Considerations: Plasma levels can gradually decrease during pregnancy and should be monitored closely.
Safety and effectiveness in pediatric clients ages 12 years and older have been established.
Levetiracetam immediate release and levetiracetam solution can be used in clients as young as 1 month.
Levetiracetam should not be stopped abruptly, or withdrawal seizures may occur. Use with caution in clients with
renal impairment.
Side Effects/Adverse Effects: Behavioral abnormalities, including psychotic symptoms, suicidal ideation,
irritability, and aggressive behavior, have been observed; monitor clients for psychiatric signs and symptoms.
The most common adverse reactions are somnolence and irritability. Advise clients not to drive or operate
machinery until they have gained sufficient experience on levetiracetam.
This drug can cause anaphylaxis or angioedema after the first dose or at any time during treatment. Serious
dermatological reactions, including Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN), have
been reported, as well as coordination difficulties and hematologic abnormalities.
Health Teaching & Health Promotion: Medications should be taken as directed and may cause increased dizziness
and somnolence. Clients should be monitored carefully for suicidality during medication therapy.
Levetiracetam

Prototype/ Therapeutic
Class/Subclass Nursing Considerations Side/Adverse Effects
Generic Effects

Anticonvulsan levetiracetam Taper dose; do not stop abruptly or Decrease seizure Behavioral/mood changes (psychotic symptoms,
t seizures may occur activity suicidal ideation, irritability, and aggressive
Monitor plasma levels for pregnant behavior)
women Anaphylaxis or angioedema
 Prototype/ Therapeutic
Class/Subclass Nursing Considerations Side/Adverse Effects
Generic Effects

Use cautiously if renal impairment Somnolence, fatigue, and irritability

Serious skin conditions
Coordination difficulties
Hematopoietic abnormalities

Gabapentin
Gabapentin is indicated as an adjunct treatment for partial seizures but is most commonly used to treat neuropathic
pain. It is also used to treat substance withdrawal.
Indications: Gabapentin is used for partial seizures and neuropathic pain.
Nursing Considerations: This drug can cause harm to the fetus of pregnant women.
Gabapentin use in pediatric clients with epilepsy 3 to 12 years of age is associated with the occurrence of central
nervous system related adverse events.
The most significant of these can be classified into the following categories:
1) emotional lability (primarily behavioral problems);
2) hostility, including aggressive behaviors;
3) thought disorder, including concentration problems and change in school performance; and
4) hyperkinesia (primarily restlessness and hyperactivity).
In elderly clients, peripheral edema and ataxia tended to increase in incidence with age. Fall precautions should be
considered.
Antiepileptic drugs should not be abruptly discontinued because of the possibility of increasing seizure frequency.
Side Effects/Adverse Effects: Antiepileptic drugs, including gabapentin, increase the risk of suicidal thoughts or
behavior in clients taking these drugs for any indication. Clients should be monitored for the emergence or
worsening of depression, suicidal thoughts or behavior, and/or any unusual changes in mood or behavior.
Gabapentin may cause dizziness, somnolence, and other symptoms and signs of CNS depression. Clients should be
advised neither to drive a car nor to operate other complex machinery until they have gained sufficient experience
on gabapentin to gauge whether or not it affects their mental and/or motor performance adversely.

Gabapentin
 Prototype/ Therapeutic
Class/Subclass Nursing Considerations Side/Adverse Effects
Generic Effects

Anticonvulsan gabapentin Administer first dose at bedtime to decrease Decreased Increased suicidal ideation
t dizziness and drowsiness neuropathic pain or Immediately report fever,
Monitor for worsening depression, suicidal seizures rash, and/or lymphadenopathy
thoughts or behavior, and/or any unusual changes CNS depression: Dizziness,
in mood or behavior somnolence, and ataxia
Taper dose; do not stop abruptly

ANTI-PARKINSON’S MEDICATIONS

Parkinson’s disease is believed to be related to an imbalance of dopamine and acetylcholine and a deficiency of
dopamine in certain areas of the brain, so drug therapies are aimed at increasing levels of dopamine and/or
antagonizing the effects of acetylcholine.
Drug therapy does not cure the disease but is used to slow the progression of symptoms. Common medications used
to treat Parkinson’s disease are carbidopa/levodopa, selegiline, and amantadine.

Carbidopa/Levodopa
Carbidopa/levodopa is the most common drug used to treat Parkinson’s disease and is usually started as soon as the
client becomes functionally impaired.
Indications: Carbidopa/levodopa is indicated for Parkinson’s disease. It is also used to treat restless leg syndrome.
Side Effects/Adverse Effects: Hallucinations and psychotic-like behavior have been reported with dopaminergic
medications. Clients taking dopaminergic medications may experience intense gambling urges, increased sexual
urges, intense urges to spend money, binge eating, and/or other intense urges, and the inability to control these
urges. These urges stopped when the dosage was decreased or the medication discontinued.
A higher risk for melanoma has been reported. Occasionally, dark red, brown, or black color may appear in saliva,
urine, or sweat after ingestion of carbidopa and levodopa. Although the color appears to be clinically insignificant,
garments may become discolored.
Health Teaching & Health Promotion: Clients should take their medications at regular intervals as directed. If
gastric irritation is experienced, clients may eat food shortly after taking medications, but high-protein foods may
impair drug action. Medications may cause increased drowsiness, dizziness, and orthostatic changes. Clients should
carefully assess their skin to monitor for new lesions, and any abnormality should be reported to the health care
provider.

Carbidopa-Levodopa
 Class/Subclass Prototype/Generic Nursing Considerations Therapeutic Effects Side/Adverse Effects

Depression, suicidal ideation,

Avoid high-protein diets due to
decreased absorption
Anti- Monitor for sudden somnolence
Parkinson’s carbidopa/levodopa and increased depression
Agent Contraindicated with MAOIs
Periodically monitor hepatic,
renal, and hematopoietic functions
Slow progression of symptoms
of Parkinson’s disease (tremors,
rigidity, and mobility issues)
hallucinations, and intense urges
with inability to control them
Somnolence and fatigue
NMS symptoms with dose
reductions or when discontinued
Dyskinesia
Discolored body fluids
Hypomobility with long-term use

Selegiline
Selegiline is often used conjunction with carbidopa-levodopa when clients demonstrate a deteriorating response to
this treatment. It is helpful to control symptom fluctuations.
Indications: Selegiline capsules are indicated as an adjunct in the management of Parkinsonian clients being treated
with levodopa/carbidopa who exhibit deterioration in the quality of their response to this therapy. There is no
evidence from controlled studies that selegiline has any beneficial effect in the absence of concurrent levodopa
therapy.
Nursing Considerations: Large doses of selegiline may inhibit MAO-A that promotes metabolism of tyramine in
the GI tract, which can cause a hypertensive crisis.
Health Teaching & Health Promotion: Clients should be advised to avoid foods high in tyramine. Additionally,
medications may cause increased drowsiness, dizziness, and orthostatic changes. If clients experience abnormal
behaviors such as hallucinations, sexual urges, gambling, etc., this should be reported promptly to the health care
provider.
Selegiline

Prototype/
Class/Subclass Nursing Considerations Therapeutic Effects Side/Adverse Effects
Generic

Minimize progression of
Anti-Parkinson’s Agent, Avoid food with tyramine if on a Higher doses increase risk
selegiline Parkinson’s disease
MAO Type B Inhibitor large dose (above 10mg/day) for hypertensive crisis
symptoms

Amantadine
Amantadine is used in early stages of Parkinson’s disease but can be effective in moderate or advanced stages in
reducing tremor and muscle rigidity.
Indications: Amantadine is used for Parkinson’s disease, medication-induced extrapyramidal symptoms, and
influenza A.
Side Effects/Adverse Effects: Suicide ideation, congestive heart failure, and peripheral edema can occur. This drug
can cause intense gambling urges, increased sexual urges, intense urges to spend money uncontrollably, and other
intense urges with an inability to control them. There is an increased risk of melanoma.
Adverse reactions reported most frequently are nausea, dizziness (light-headedness), and insomnia. This drug can
also cause anticholinergic side effects, impaired thinking, and orthostatic hypotension.
Health Teaching & Health Promotion: Clients should take medications as directed and ensure they do not skip or
double doses. Medications may cause drowsiness, dizziness, and orthostatic blood pressure changes. Clients should
avoid using this medication with OTC cold medications or alcoholic beverages. If clients, family, or caregivers note
worsening depression or suicidality, this should be reported immediately to the health care provider.
Amantadine

Prototype/ Nursing Consideration Therapeutic

Class/Subclass Side/Adverse Effects
Generic s Effects

Anti-Parkinson amantadine Monitor renal function Improve Increased suicidal ideation

Agent, Antiviral Monitor mental state Parkinson’s and urges
Assess blood pressure disease symptoms Congestive heart failure
and peripheral edema
Neuroleptic malignant
syndrome (NMS) when
dosage decreased
Orthostatic hypotension
Nausea, dizziness, and
insomnia
Anticholinergic side effects