CH18 + 19: Anxiety Disorders Flashcards
What are the symptoms of anxiety disorders?
NEED TO KNOW!!!
- apprehension
- worry, fear
- palpitations
- SOB
- heartburn
- dry mouth
- excess sweating
What can high levels of anxiety/ “panic attack” can be misconstrued as?
NEED TO KNOW!!!
often can be miscontrued as heart attack
- always rule out MI first (diagnostic tests & ECG)
- obtain hx of recent events that might trigger anxiety or that might indicate drug abuse
Anxiety disorders - how do you ensure an accurate diagnosis?
NEED TO KNOW!!!
nurse needs to take complete hx:
- medications that may worsen/cause anxiety symptoms
- medical conditions that may be associated with anxiety
- consider nonpharmacological interventions that reduce environmental, physical, and emotional stressors prior to pharmacological intervention
Benzodiazepines - what are they ?
- drugs of choice for generalized anxiety disorder and short-term therapy of insomnia
- off-label use: seizures, alcohol withdrawal, status epilepticus
- metabolized in liver, excreted in kidneys
- tolerance develops
- potential for dependence
- OD with alcohol may be fatal
- “-azepam”
Benzodiazepines - what are the cautions with them?
NEED TO KNOW!!!
- change dose gradually - DONT stop abruptly
- watch for suicidal ideation
- may cause mania or psychosis
- watch in use with dysfunctional kidneys, liver, CV, or pulmonary system
- use cautiously with the elderly
what are the 5 “Bs” to be aware of with benzodiazepines?
NEED TO KNOW!!!
- brain: sleepy, make person relaxed, put into dreamy state
- blood - cause blood dyscrasias
- drops BP
- bile (think liver)
- bonkers - more likely for elderly (e.g., gets agitated instead of relaxed)
benzodiazepines - prototype drug?
lorazepam (Ativan)
therapeutic: antianxiety agent, sedative - hypnotic, antiseizure agent
pharmacologic: benzodiazepine, GABA receptor agonist
lorazepam - uses & mechanism of action?
effects & uses:
- routine management of GAD
- reduce anxiety prior to surgery/medical procedure
- reduce anxiety in mechanically ventilataed patients
- off-label use for insomnia, seizures, ethanol withdrawal, status epilepticus
mechanism of action:
- potentiates GABA
- can cause diff levels of CNS depression: relaxation, sleep (higher doses), coma (higher doses)
What are some nursing considerations for lorazepam?
NEED TO KNOW!!!
- aspirate prior to injection (IM) & give slowly
- assess for paradoxical CNS excitement
- advise pt to stop smoking
- watch CBC, liver function & renal function
- teach nonpharmacological methods first, before anti-anxiety drugs
- assess for S/S overdose or abuse
- teach nonpharmacological methods of sleep & relaxation
- assess for suicidal ideation
What are the adverse effects of phenobarbital?
- oversedation
- “hangover” effect, lethary
- hallucinations
- blood dyscrasias
- hypocalcemia
- hepatic disease
- N/V/D/C
- paradoxical excitation in children or older adults
Barbituates - what are they and what are they for?
therapeutic: sedative-hypnotics & anti-epileptic drug
pharmacologic: barbituate, GABA receptor agonist
prototype drug: phenobarbital (Luminal)
- for status epilepticus (IV route) and ST management of insomnia
- dependence high, overdose / withdrawal severe
what are the serious AEs of phenobarbital?
KNOW THIS!!!!
- coma
- SJS
- angioedema
- periorbital edema
- ** thrombophlebitis**
Phenobarbital - any nursing considerations?
NEED TO KNOW!!!
- monitor for resp depression
- assess pt given IV barbituates q15 min
- monitor for s/s blood dyscrasias
- aspirate prior to injection
- monitor therapeutic serum concentrations of drug (like dig, dilantin, lithium)
- teach nonpharmacologic methods of relaxation/sleep
- assess baseline hepatic + renal function and monitor during therapy
- if pt develops fever, angioedema, and body rash - hold med & call MD
What are the causes of depression? does it coexist with other conditions?
NEED TO KNOW!!!
causes:
- environmental
- situational
- hereditary
- no longer thought to be related to parenting or unresolved childhood
often does coexist with other conditoins
- anxiety disorders
- substance abuse
- HTN or arthritis
Depression - what is it?
NEED TO KNOW!!!
a mood disorder
- persistant disturbance in emotion that impairs ability to effectively deal with ADLs
- 2 primary types of mood disorders = depression & bipolar disorder
Assessment of Depression - how long does it take for mood to improve?
NEED TO KNOW!!!
- 3 or more weeks of antidepressant therapy may be required before pt’s mood begins to improve
- 6-8 weeks to reach maximal benefit
- risk of attempted suicide highest in month before pharmacotherapy
- majority of persons who commit suicide have been diagnosed with major depression
Assessment of Depression - what is the nurse’s role?
NEED TO KNOW!!!
- careful monitoring of talk of suicide
- weekly or daily patient contact
- careful monitoring of medications
tricyclic antidepressants - what are they used for? and how?
- once mainstay treatment of depression, but have many AEs
- block reuptake transport of norepinephrine and serotonin @ synapses
Tricyclic antidepressants - what are the disadvantages?
NEED TO KNOW!!!
many side effects
- anticholinergenic effects/ sympathomimetic effects
- orthostatic hypotension
- sedation (worsened w/ concurrent use of other CNS depressants)
- relatively high incidence of sexual dysfunction (often cause of cessation)
- withdrawal symptoms if not tapered - don’t stop suddenly
- may take 3 weeks to see effects & 6 weeks to see optimum benefits
tricyclic antidepressants - prototype drug?
imipramine (Tofranil)
- therapeutic = tricyclic antidepressant
- pharmacologic = norepinephrine reuptake inhibitor
- for major depressive disorder
off-label uses:
- adjuvant tx of ca / neuropathic pain
- overactive bladder; ADHD; bulimia nervosa
- social anxiety disorder
- panic disorder
imipramine - any contraindications?
NEED TO KNOW!!!
- MI, heart block, dysrhythmias
- asthma, GI disorders, alcoholism, schizophrenia, bipolar disorder
- avoid use w/ alcohol
- seizure disorders
imipramine - any precautions?
NEED TO KNOW!!!
d/t sympathomimetic effect
- suicidal tendencies
- urinary retention
- prostatic hyperplasia
- cardiac/hepatic disease
- increased intraocular pressure
- hyperthyroidism
- parkinson disease
what are selective serontin reuptake inhibitors?
- drugs of choice for treating depression d/t low incidence of serious AEs
- fewer sympathomimetic & anticholinergic effects
- for variety of MH disorders: social anxiety, PTSD, GAD, panic disorder, OCD
imipramine - any considerations?
NEED TO KNOW!!!
- monitor for suicidal ideation
- be sure pt swallows each dose
- encourage compliance
- monitor for urinary retention / constipation
- treat for dry mouth
SSRIs - prototype drug? what is it used for?
fluoxetine (Prozac, Sarafem)
therapeutic: anti-depressant, anti-anxiety
pharmacologic: SSRI
uses:
- depression
- bulimia
- pediatric depression
- panic attacks
mechanism of action:
- blocks uptake of serotonin @ neuronal presynaptic membrane
- enhances action of serotonin
what is serotonin syndrome?
SSRIs
NEED TO KNOW!!!
- when pt takes multiple medications (or overdose) that cause serotonin to accumulate in neurons in CNS
- confusion, restlessness, tremors, lack of muscle control
- conservative treatment to discontinue all serotonergic drugs
Fluoxetine - AEs?
- pediatric patients - personality disorder or hyperkinesia**
- N/V/D/C
- anorexia
- cramping/flatulence
- fluctuations in weight
- sexual dysfunction
- seizures
- poor concentration
- nightmares
- hot flashes
- palpitations
- nervousness
- serotonin syndrome
fluoxetine - contraindications / precautions
- bipolar disorder
- cardiac dysfunction
- diabetes
- seizure disorders
- carefully observe peds pts for hyperkinesia and personality changes/disorders
- late pregnancy
Monoaime Oxidase Inhibitors - what are they for?
- effective antidepressants but rarely used d/t potentially serious AEs
- off-label use for OCD, panic disorder, social anxiety disorder, migraine prophylaxis
- potentiates effects of insulin, diabetic drugs
NEED TO KNOW!!!
MAOIs - what to avoid?
to avoid incidence of AEs
- avoid foods containing tyramine (MAO in food) - foods that have been aged or fermented
- cheese, alcohol, condiments, certain aged meats, wine (think charcuterie board)
- avoid L-tyrosine (a.a) - tyramine a component of tyrosine (found in some aged foods - fermented foods, e.g., sausages)
- avoid caffeine
Fluoxetine - drug interactions
- increased extrapyramidal side effects (EPS) with certain antipsychotics
- incr risk of toxicity with phenytoin, digoxin, carbamazepine
- excessive sedation with other CNS depressants
- incr risk of bleeding with warfarin, aspirin, NSAIDs
what are the AEs of MAOIs?
- dizziness/orthostatic hypotension
- drowsiness/headache
- sexual dysfunction
- anorexia/ diarrhea
what are the serious AEs of MAOIs?
- hypertensive crisis (foods with tyramine)
- dysrhythmias
- SIADH- like symptoms (h2o retention)
NEED TO KNOW!!!
what is the difficulty with MAOIs?
high incidence of AEs & high level of NON-compliance
What considerations are there for MAOIs?
- assess for suicidal ideation
- encourage compliance
- **avoid foods containing tyramine (MAO in food) - aged / fermented
- avoid L-tyrosine (a.a.) - tyramine a component of tyrosine**
- avoid caffeine
NEED TO KNOW!!!
what precautions are there for MAOIs?
- epilepsy
- severe, frequent headaches
- HTN
- dysrhythmias
- suicidal tendencies
