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Message 1Central Nervous System (CNS) StimulantsPathophysiologyThe prefrontal cortex (PFC) is located in the frontal lobe of the brain. The PFC is responsible for executive functions and does not fully develop until age 25.Attention deficit hyperactivity disorder (ADHD) is a neurological disorder characterized by inattention, distractibility, and/or hyperactivity. ADHD involves structural and functional abnormalities in the PFC, which negatively affect attention span, organization, and impulse control. ● ADHD may also be caused by a dysregulation in neuronal pathways that regulate the neurotransmitters dopamine, norepinephrine, and serotonin. ● Dopamine and norepinephrine play critical roles in regulating attention, motivation, reward pathways, and impulse control ○ Dopamine is the "feel good" neurotransmitter responsible for pleasure and can influence behavior, mood, learning, and memory ○ Norepinephrine stimulates beta-adrenergic receptors, which increases the heart rate and blood pressure, and enhances mental alertness ● Management of ADHD may include a stimulant or nonstimulant drug to reduce hyperactivity and inattentionIndicationsADHD is treated by correcting neurotransmitter imbalances, resulting in symptom improvement of hyperactivity and inattention. Stimulants are considered the first-line treatment for ADHD and help increase levels of neurotransmitters dopamine and norepinephrine. Stimulants may also be used to treat narcolepsy.Stimulants Nonstimulants y First-line treatment y Increased risk for cardiovascular events y Risk for dependency, tolerance y Therapeutic effects are immediate, lasting a few hours to all day y Second-line treatment y Better safety profile y Minimal potential for misuse y Takes several weeks to reach therapeutic effects

2CNS Stimulantsamphetamine-like because, although they have a different chemical structure, they cause the same adverse effects and have the same mechanism of action as amphetamines.Amphetamine stimulants Nonamphetamine stimulants y Amphetamine mixed salts y Methamphetamine y Dextroamphetamine y Lisdexamfetamine y Methylphenidate y DexmethylphenidateMechanism of ActionStimulants increase the levels of certain neurotransmitters (eg, dopamine, norepinephrine) in the brain by promoting their release and inhibiting their reuptake. This increases the synaptic availability of dopamine and norepinephrine. In clients with ADHD, stimulants are used to: ● Increase focus ● Sustain attention ● Help organize daily tasks and routines ● Decrease impulsive behaviors ● Reduce hyperactivityAdverse EffectsAdverse effects of stimulants include: ● Irritability, anxiety, restlessness, and insomnia  ● Due to vasoconstriction  ● Stimulants affect the cardiac conduction system, increasing the risk for potentially lethal cardiac dysrhythmias ● A history of dysrhythmias may be a contraindication to stimulant therapy

3 ● Increased circulating dopamine and norepinephrine suppress hunger ● May lead to nutritional deficiencies Adequate nutritional intake and adequate sleep are crucial for children's growth, development, and learning. These medications can lead to anorexia and insomnia, placing pediatric clients at risk for growth suppression.  ● Due to euphoria and elation, increased energy, improved alertness, and quicker mental responsiveness ● Over time, clients may develop tolerance to stimulants, requiring higher doses to achieve the same effectivenessStimulant IntoxicationAmphetamines are controlled substances with the potential for tolerance, psychological dependence, and misuse, which increase the risk for stimulant intoxication. Adverse effects of stimulants (eg, irritability, hypertension, tachycardia) are amplified in stimulant intoxication.To remember the manifestations AAIR y Anxiety y Agitation y Insomnia y Restlessness y Hallucinations y Hyperthermia y Diaphoresis y Seizures

4Stimulant WithdrawalAbrupt discontinuation of stimulants can lead to stimulant withdrawal, also known as "the stimulant crash." Because of this risk, dosages of these medications should always be tapered. Abrupt withdrawal leads to a rapid change in the levels of neurotransmitters, causing: ● Decreased concentration ● Slowed mental and physical movements ● Increased appetite, cravings, and weight gain ● Increased fatigue or drowsiness ○ Disrupted sleeping patterns ○ Vivid dreams ○  ● Depression ○ Withdrawal can cause thoughts of self-harm or suicide ○ Requires immediate attention and safety interventions (eg, one-to-one observation)Client TeachingMonitor for misuse and tolerance y Do not take more than the prescribed dose y If a dose is missed, avoid taking extra doses y Store medications in a secure area, away from pets and childrenAvoid concurrent use with caffeine, over-the-counter decongestants, nicotine y Concurrent use with other stimulants may increase adverse effects such as hypertension and irritabilityTake medication with meals and in the morning y Take extended-release medication in the morning to reduce insomnia ○ Avoid taking short-acting medications in the late afternoon or evening y Taking with or after meals encourages adequate caloric intakeGrowth suppression y Monitor for growth suppression and nutritional imbalances in childrenReport cardiac symptoms y Clients should immediately report signs of cardiac dysrhythmias (eg, palpitations, racing heart rate, shortness of breath) to the health care providerAvoid abrupt discontinuation of stimulants y Can lead to stimulant withdrawal

5The nurse is caring for a client with attention deficit hyperactivity disorder who is receiving methylphenidate. The nurse should recognize that the medication is administered toa) inhibit the release of oxytocinb) block the serotonin receptors in the brainc) stimulate the adrenal cortex to release epinephrined) increase synaptic availability of dopamine and norepinephrineThe nurse is caring for a client with attention deficit hyperactivity disorder who is receiving dextroamphetamine. The nurse should recognize that the client is at risk for which of the following adverse effects? Select all that apply.a) addictionb) insomniac) tolerance d) weight gaine) hypertensionThe nurse is teaching a client with attention deficit hyperactivity disorder who is receiving methamphetamine. Which of the following information should the nurse include?a) "This medication should be taken at bedtime."b) "Weight gain may occur while taking this medication."c) "This medication is used to reduce impulsive behaviors."d) "Take an extra tablet with the next dose if the previous dose is missed."1) d2) a,b,c,e3) c