Anxiety and Traumatic Stress-Related Disorders Flashcards
Medications affecting nervous system
Benzodiazepines Medications
Alprazolam (prototype) Diazepam Lorazepam Chlorodiazepoxide Clorazepate Oxazepam Clonazepam
Expected Pharmacologic Actions: Benzodiazepines
Benzodiazepines enhance the inhibitory effects of gamma-aminobutyric acid (GABA) in the CNS. Relief from anxiety occurs rapidly following adminstration
Therapeutic Uses: Benzodiazepines
Generalized anxiety disorder (GAD) and Panic Disorder
Other Uses:
- trauma and stressor-related disorders: Acute stress disorder (ASD) and post-traumatic stress disorder (PTSD)
- hyperarousal manifestations of dissociative disorders
- seizure disorders
- insomnia
- muscle spasm
- alcohol withdrawal (for prevention and treatment of acute manifestations
- induction of anesthesia
- amnesic prior to surgery or procedure
Complications: Benzodiazepines
- CNS Depression: sedation, lightheadedness, ataxia, decreased cognitive function
- Anterograde amnesia: difficulty recalling events that occur after dosing.
- Toxicity: drowsiness, lethargy, confusion, respiratory depression, severe hypotension, or cardiac/respiratory arrest
- Paradoxical Response: insomnia, excitation, euphoria, anxiety, rage
- Withdraw Effects: anxiety, insomnia, diaphoresis, tremors, lightheadedness, delirium, HTN, muscle twitching, and seizures
Contraindications /Precautions: Benzodiazepines
- Pregnancy Risk Category D
- classified under schedule 4 of the Controlled Substances Act
- Contraindicated: in clients who have sleep apnea, respiratory depression, or glaucoma
- Caution: older clients and those who have liver disease of history of mental illness or a substance abuse disorder
- generally used short term due to the risk of dependence
Interactions: Benzodiazepines
CNS DEPRESSANTS:
- can result in respiratory depression.
- Anticonvulsants and antihistamines can cause increased CNS depression.
- advise clients to avoid alcohol and other substances that cause CNS depression
- advise clients to avoid activities that require alertness (driving, operating heavy equipment/machinery)
GRAPE FRUIT JUICE REDUCE METABOLISM
- avoid use of grapefruit juice
- HIGH FAT MEALS REDUCE ABSORPTION
- do not take with fatty foods
RN Administration: Benzodiazepines
- take the medication as prescribed and to avoid abrupt discontinuation of treatment to prevent withdrawal manifestations. Do not change the dose or frequency without prior approval of provider
- when discontinuing benzodiazepines that have been taken regularly for long periods and in higher doses, taper the dose over several weeks
- administer the medication with meals to snacks if GI upset occurs
- advise clients to swallow sustained release tablets and to avoid chewing or crushing the tablets
- inform clients about the possible development of dependency during and after treatment and to notify the provider if indications of withdrawal occur.
- advise clients to keep benzodiazepines in a secure place due to they abuse potential
Atypical Anxiolytic/Nonbarbiturate Anxiolytic
Buspirone
Action: Atypical Anxiolytic
Action:
- exact mechanism of this medication is unknown. Binds to serotonin and dopamine receptors. Dependency is much less likely than with other anxiolytics, and the use of buspirone does not result in sedation or potentiate the effects of other CNS depressants
- major disadvantage is the anti anxiety effects develop slowly. Initial response take a week, and at least 206 weeks for it to reach its full effects. As a result of this pharmacological action, buspirone is taken on a schedule basis, and is. mot suitable for
Therapeutic Uses: Atypical Anxiolytic
Therapeutic Uses:
- panic disorder
- social anxiety disorder
- OCD and related disorder
- trauma - and stressor-related disorder, PTSD
Complications: Atypical Anxiolytic
Dizziness, nausea, headache, lightheadedness, agitation.
- advise the client to take with food to decrease nausea
- avoid activities that require alertness until effects are known
- instruct the client that most adverse effects are self-limiting
Constipation
- advise client to increase fiber and fluid
Suicidal Ideation
- monitor and report manifestations of depression and thoughts of suicide.
Contraindications: Atypical Anxiolytic
- Pregnancy Risk Category B
- No recommended for use by women who are breastfeeding
- contraindicated for concurrent use with MAOI or for 14 days after MAOIs are discontinued. Hypertensive crisis can result
Cautions: Atypical Anxiolytic
- older clients
- clients with liver and/or renal dysfunction
Interactions: Atypical Anxiolytic
Erythromycin, Ketaconazole, St. John’s wort, and grapefruit juice can increase the effects of buspirone
- advise clients to avoid the use of these antimicrobial agents
- advise clients to avoid herbal preparations containing St. John’s wort.
- advise clients to avoid drinking grapefruit juice
Increased risk for Serotonin syndrome with SSRI’s
- monitor for serotonin syndrome: fever, diarrhea, and delirium. Avoid concurrent use.
RN Administration: Atypical Anxiolytics
- advise clients to take the medication with meals to prevent gastric irritation
- advise clients that effects do no occur immediately. It can take a week to notice the first therapeutic effects and 2-6 weeks for the full benefit. Take on a regular basis and not PRN
- instruct clients that tolerance, dependence, or withdrawal effects are not an issue with this medication
- labeled for short term treatment of anxiety, but has shown therapeutic benefit for as long as a year
SSRI (Selective Serotonin Reuptake Inhibitors)
Paroxetine* Sertraline Citalopram Escitalopram Fluoxetine Fluvoxamine
Action: SSRI
- Paroxetine selectively inhibits serotonin reuptake, allowing more serotonin to stay at the junction of the neurons
- it does not block reuptake of dopamine or norepinephrine
- produces CNS stimulation, which can cause insomnia
- the medication has a long effective half-life. A time frame of up to 4 weeks is necessary to produce therapeutic medication levels
Therapeutic Uses: SSRI
Paroxetine
- GAD
- Panic Disorder: decrease both the frequency and intensity of panic attacks and also prevents anticipatory anxiety about attacks
- OCD: reduces manifestations by increasing serotonin
- Social anxiety disorder
- trauma- and stresor- related disorder
- dissociative disorder
- depressive disorder
- adjustment disorder
Sertraline: panic disorder, OCD, social anxiety disorder, and PTSD
Escitalopram: GAD, OCD
Fluoxetine: panic disorder, OCD, PTSD
Fluvoxamine: OCD, and social anxiety disorder
Complications: SSRI: Early effects
First few days/weeks: nausea, diaphoresis, tremor, fatigue, drowsiness
- instruct client to report adverse effects to the provider
- instruct clients to take the medication as prescribed
- advise clients that theses effects should soon subside
Complications: SSRI: Later affects
After 5-6 weeks of therapy: sexual dysfunction (impotence, delays or absent orgasm, delated or absent ejaculation, decreased sexual interest)
- instruct clients to report problems with sexual dysfunction ( managed with dose reduction, medication holiday, changing medications)
Complications: SSRI: Weight gain
advise clients to follow a well balanced diet
Complications: SRRI: GI bleeding
- use caution in clients who have a history of GI bleed or ulcers and in clients taking other medications that affect blood coagulation
- advise clients to report indications of bleeding such as dark stool or coffee ground emesis
Complications: SSRI: Hyponatremia
More likely in older adult clients taking diuretics
- obtain baseline serum sodium, and monitor level periodically throughout treatment
Complications: SSRI: Serotonin Syndrome
Agitation, confusion, disorientation, difficulty concentrating, anxiety, hallucinations, myoclonus ( spastic, jerky muscle contractions), hyperreflexia, incoordination, tremors, fever, diaphoresis.
- usually begins 2-72 hours after initiation of treatment
- resolves when the medication is discontinued
- watch for and advise clients to report any of these manifestations, which could indicate a lethal problem.
Complications: SSRI: Bruxism
Grinding and clenching of teeth, usually during sleep
- report to the provider, who might switch the client to another class of medication
- treat with low dose buspirone
- advise the clients to use a mouth guard during sleep
Complications: SSRI: Withdrawal Syndrome
Nausea, sensory disturbances, anxiety, tremor, malaise, and unease
- minimized by tapering the medication slowly
- advise clients that, after a long periods of use, the medication is tapered slowly to avoid withdrawal syndrome
- advise clients to discontinue use abruptly
Complications: SSRI: postural hypotension
monitor for hypotension and advise client to change position slowly.
Complications: SSRI: suicidal ideation
monitor and report manifestations of depression and thoughts of suicide
Contraindications: SSRI
- Pregnancy Risk Category D
- Contraindicated in clients taking MAOIs and TCS
- avoid alcohol
Cautions: SSRI
- in those with liver and renal dysfunction, seizure disorder, or a history of GI bleeding
Interactions: SSRI
Use of MAOI or TCAs can cause serotonin syndrome
- educate the client about this combination. Avoid concurrent use.
Antiplatelet medications and anticoagulats can increase risk of bleeding
- monitor for bleeding. Avoid concurrent use.
Nursing Administration: SSRI
- advise clients that medications can be taken with food. Sleep disturbances are minimized by taking medication in the morning
- instruct clients to take the medication on a daily basis to establish therapeutic plasma levels
- Assist with medication regimen adherence by informing clients that it can take up to 4 weeks to achieve therapeutic effects from an SSRI
RN Evaluation of Medication Effectiveness: Anxiety and Trauma- and Stressor- Related Disorders
Depending on therapeutic intent, effectiveness is evidence by the following
- verbalization of feeling less anxious and more relaxed
- description of improved mood
- improved memory retrieval
- maintaining regular sleep pattern
- greater ability to participation in social and occupational interaction
- improved ability to cope with manifestations and identified stressors
