PHARM ATI ch 7 Anxiety disorders

what medications are classified as sedative hypnotic anxiolytic-benzodiazepine?
-alprazolam (xanax)
-diazepam (valium)
-lorazepam (ativan)
-chlordiazepoxide (librium)
-clorazepate (tranxene)
-oxazepam (serax)
– clonazepam (klonopin)

what are the pharmalogical action of Diazepam?
enhances the inhibitory effects of gamma-aminobutyric acid in the CNS. Relief from anxiety occurs rapidly following administration

what are the therapeutic uses of benzodiazepines?
-Generalized anxiety disorder and panic disorder
-seizures disorders
-insomnia
-muscle spasm
-alcohol withdrawal
-induction of anesthesia
-amnesic prior to surgery or procedures

the following are nursing interventions for which type of benzodiazepines adverse effect?
-advise clients to observe for CNS depression, instruct the client to notify the provider if effects occur
-advise clients to avoid hazardous activities (driving, operating heavy equipment/machinery)
CNS depression, (sedation, lightheadedness, ataxia, decreased cognitive function)

the following are nursing interventions for which type of benzodiazepines adverse effect?
-advise clients to observe for manifestations. instruct clients to notify the provider if effects occur
anterograde amnesia (difficulty recalling events that occur after dosing)

the following are nursing interventions for which type of benzodiazepines adverse effect?
-for oral toxicity, gastric lavage can be used, followed by the administration of activated charcoal or saline cathartics
-for IV toxicity, administer flumazenil (Romazicon) to counteract sedation and reverse adverse effect
-monitor the clients vital signs, maintain patent airway, and provide fluids to maintain blood pressure
-have resuscitation equipment available
-acute toxicity
-oral toxicity (drowsiness, lethargy, confusion)
-iv toxicity (may lead to respiratory depression, severe hypotension, or cardiac/ respiratory arrest)

Benzodiazepines for IV use include?
– Diazepam (Valium)
-Lorazepam (ativan)

the following are nursing interventions for which type of benzodiazepines adverse effect?
-advise clients to watch for manifestations. notify the provider if these occur
-paradoxical response (insomnia, excitation, euphoria, anxiety, rage)

the following are nursing interventions for which type of benzodiazepines adverse effect?
-advise clients that withdrawal effects are not common with short term
-advise clients who have been taking diazepam regularly and in high doses to taper the dose over several weeks
manifestations of withdrawal include anxiety, insomnia, diaphoresis, tremors, light-headedness

what are contraindications/precautions for the use of benzodiazepines?
-classified under schedule IV of the controlled substances Act
-short term due to risk for dependence
Diazepam:
– cautiously with clients who have liver disease or mental illness or substance use disorder
-contraindicated in clients who have sleep apnea, respiratory depression, and or glaucoma
-pregnancy risk category D medication

interaction of benzodiazepines and CNS depressants results in
respiratory depression; therefore clients should avoid hazardous activities

benzodiazepines nursing administration
-take as prescribed avoid abrupt discontinuation to prevent withdrawal manifestation
-when discontinuing benzodiazepines that have been taken regularly for long periods and in higher doses, taper the dose over several weeks
-administer with meals and snacks if GI upset occurs
-swallow sustained-released and to avoid chewing or crushing the tablets
-dependency during and after treatment and to notify provider if indications of withdrawal occur

what kind of medications are Atypical anziolytic/nonbarbiturate anxiolytic
buspirone (Buspar)

what is the pharmacological action of buspirone (Buspar)?
it is unknown, binds to serotonin and dopamine receptors, dependency is much less likely than with other anxiolytics and use of buspirone does not result in sedation or potentiate the effects of other CNS depressants.

what are the therapeutic use of Buspirone (Buspar)
-panic disorder
-social anxiety disorder
-obsessive- compulsive and related disorders
-trauma- and stressor- related disorders, such as post-traumatic stress disorder (PTSD)

what are buspirone (Buspar) adverse effects?
dizziness, nausea, headache, lightheadedness, agitation

what are nursing intervention for buspirone’s adverse effects?
-advise clients to take with food to decrease nausea
– instruct client that most adverse effects are self-limiting

what are contraindications/precautions for buspirone’s?
-pregnancy risk category B
-not recommended for use by women who are breastfeeding
-cautiously in older adult clients and clients who have liver and/ or renal dysfunction
-contraindicated for concurrent use with MAOI antidepressants or for 14 days after MAOIs are discontinued. Hypertensive crisis may result

what increased the effects of buspirone?
interaction with
-erythromycin
-ketoconazole
– St. John’s wort
-grapefuit juice

how do you administer buspirone?
– advise clients to take medication with meals to prevent gastric irritation
-effects do not occur immediately may take a week to notice the first therapeutic effects and 3 to 6 weeks for the full benefit.
-medication should be taken on a regular basis and not PRN
– instruct clients that tolerance, dependence, or withdrawal effects are not an issue with this medication

what medication is a selective serotonin reuptake inhibitors (SSRI antidepressants)
-paroxetine (paxil)
-sertraline (zoloft)
-escitalopram (lexapro)
-fluoxetine (prozac)
-fluvoxamine (luvox)

what is the pharmalogical action of Paroxetine (Paxil)?
-inhibits serotonin reuptake, allowing more serotonin to stay at the junction of the neurons
-does not block uptake of dopamine or norepinephrine
-produces CNS stimulation, which can cause insomnia
-medication has a long effective half-life. a time frame of up to 4 weeks to necessary to produce therapeutic medication levels

Therapeutic uses of Paroxetine?
-GAD
-panic disorders (decreases both the frequency and intensity of panic attacks and also prevents anticipatory anxiety about attacks
-obsessive- compulsive disorder (OCD) Reduces manifestations by increasing serotonin
-social anxiety disorder
-trauma- and stressor-related disorders
-depressive disorders

what is sertraline used for?
panic disorder, OCD, social anxiety disorder, and PTSD

What is escitalopram used for?
GAD and OCD

What is fluoxetine used for?
panic disorder and OCD

what is fluvoxamine used for?
OCD and social anxiety disorder

what are adverse effects of SSRI antidepressants for the first few days/weeks?
-nausea
-diaphoresis
-tremor
-fatigue
-drowsiness

what are late adverse effects of SSRI antidepressants? after 5-6 weeks
-sexual dysfunction
-impotence
-delayed or absent orgasm
-delayed or absent ejaculation
-decreased sexual interest

what are adverse effects of SSRI antidepressants?
-GI bleeding
-hyponatremia (on older adults)
-agitation, confusion, disorientation, difficulty
-bruxism: grinding and clenching of teeth, usually during sleep
-withdrawal syndrome

what are contraindications/precautions of paroxetine?
-is a pregnancy risk category D medication
-contraindicated in clients taking MAOIs or a TCA
-avoid alcohol
-cautiously in clients who have liver and renal dysfunction, seizure disorders or a history of GI bleeding

interaction of paroxetine and MAOI antidepressants or TCA can cause?
serotonin syndrome
-agitation, confusion, disorientation, difficulty concentration, anxiety, hallucinations, hyperreflexia, incoordination, tremors, fever, diaphoresis

nursing administration of SSRI?
-advise clients that medications may 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 may take up to 4 weeks to achieve therapeutic effects from an SSRI

effectiveness of SSRI?
-maintaining normal sleep pattern
-verbalizing feeling less anxious and more relaxed
-greater ability to participate in social and occupational interactions

Chapter 27: Anxiety-Related, Obsessive-Compulsive, Trauma- and Stressor-Related, Somatic, and Dissociative Disorders Practice questions

Which intervention should the nurse use first when caring for a patient experiencing anxiety?
a. Assist the patient to problem solve.
b. Provide support and understanding.
c. Reorient the patient.
d. Provide privacy.
b. Provide support and understanding.

Patients with anxiety disorders experience discomfort from the anxiety. The patient must feel safe, acknowledged, and cared for before problem solving can begin. The nurse’s first priority is to provide support and understanding. Allowing the patient to remain alone fosters social withdrawal and may allow anxiety to increase. Patients with anxiety seldom lose contact with reality.

A patient diagnosed with obsessive-compulsive disorder (OCD) experiences improvement after beginning treatment with a selective serotonin reuptake inhibitor (SSRI). This phenomenon supports the theory that OCD is associated with:
a. norepinephrine deficiency.
b. serotonin dysregulation.
c. dopamine excess.
d. GABA deficiency.
b. serotonin dysregulation.

Serotonin dysregulation is hypothesized to play a part in OCD. Relief associated with SSRIs supports this hypothesis. The other theories are nonrelated.

A patient says, “I have the same continuous and intrusive thoughts that my house is contaminated with lethal bacteria. I spend hours cleaning the walls, floors, and furniture.” These symptoms are most consistent with which diagnosis?
a. Social phobia
b. Panic disorder
c. Somatoform disorder
d. OCD
d. OCD

The patient’s persistent intrusive thoughts are obsessions, and the need to continually clean is a compulsion. Hence, the patient’s disorder can be identified as OCD. The symptoms are not consistent with any of the other options.

A patient’s family member died in the 9/11 World Trade Center explosion. The patient says, “I can’t go into tall buildings because I get sweaty, my heart races, and I can’t breathe. I get terrifying feelings the building will explode.” These symptoms suggest which diagnosis?
a. OCD
b. Generalized anxiety disorder
c. Acute stress disorder
d. Specific phobia
d. Specific phobia

The patient has a severe and persistent fear of entering tall buildings. The extreme physical and emotional reactions are consistent with panic-level anxiety. The scenario does not suggest any of the other options as diagnoses.

When working with a patient diagnosed with dissociative amnesia, the nurse should begin by:
a. setting mutual goals for behavioral changes.
b. instituting measures to prevent identity diffusion.
c. identifying and supporting the patient’s strengths.
d. helping the patient develop a realistic self-concept.
c. identifying and supporting the patient’s strengths.

Strengths serve as the foundation for later therapeutic work to promote more adaptive coping, so identifying and supporting strengths is a fundamental initial intervention. The other options are useful but are not fundamental.

A patient diagnosed with OCD paces up and down the corridor counting every tile. Select the nurse’s best action.
a. Offer to play cards with the patient in the dayroom.
b. Ask the patient, “Why are you pacing and counting?”
c. Take the patient’s arm and escort the patient to a quiet area.
d. Permit the patient to pace and count until feeling more comfortable.
d. Permit the patient to pace and count until feeling more comfortable.

The performance of the pacing-counting ritual is decreasing the patient’s anxiety. Stopping her will increase anxiety. Rituals should be restricted only when they physically endanger the patient. The other options will not promote anxiety reduction

A driver was trapped in a car for several hours after an earthquake caused a bridge to collapse. A year later this person still has nightmares and reexperiences feelings of fear associated with being trapped in the car. The assessment findings are consistent with symptoms of:
a. agoraphobia.
b. panic attacks.
c. generalized anxiety disorder.
d. posttraumatic stress disorder (PTSD).
d. posttraumatic stress disorder (PTSD).

PTSD follows exposure to a traumatic event. Symptoms include those described in the scenario, as well as persistent symptoms of arousal and avoidance of stimuli associated with the traumatic event. The symptoms presented are inconsistent with the other options.

A patient is hospitalized with blindness of sudden onset. According to the spouse, the patient entered a room and found the spouse in a romantic embrace with a neighbor. The patient is unconcerned about the blindness and says, “I’m sure things will turn out all right.” Which term best describes this reaction?
a. La belle indifference
b. Agoraphobia
c. Dissociation
d. Fugue
a. La belle indifference

La belle indifference refers to an attitude of unconcern or indifference about a symptom when the symptom is unconsciously used to lower anxiety. The other options do not characterize the symptoms described.

Which principle best applies to care of a patient diagnosed with conversion disorder?
a. Structure care to provide time for rituals.
b. Facilitate progressive review of the trauma.
c. Give attention to the patient, not the symptom.
d. Permit dependence while the symptoms are acute.
c. Give attention to the patient, not the symptom.

Often, patients with conversion disorder think that their symptom makes them interesting and that they are not interesting as persons. The nurse should matter-of-factly accept the symptom without focusing on it and direct attention to the person as an individual. Two distracters refer to care of a patient with OCD and care of a patient with PTSD.

A patient with panic attacks awakens from sleep complaining of chest pain. The patient is diaphoretic and breathlessly says, “I feel like I’m going to die.” Select the nurse’s priority action.
a. Have the patient lie flat and relax.
b. Bring the crash cart to the patient’s room.
c. Shake the patient and shout, “Are you okay?”
d. Instruct the patient to breathe into a paper bag.
d. Instruct the patient to breathe into a paper bag.

Hyperventilation should be addressed immediately by having the patient breathe using a paper bag. Bringing breathing under control will help diminish the other symptoms. The calm presence of the nurse is vital to symptom reduction. The other interventions would not be effective in relieving the hyperventilation.

What is the nurse’s initial action when working with a patient with PTSD?
a. Develop trust.
b. Promote problem solving.
c. Encourage verbalization of anger.
d. Have the patient evaluate past behaviors.
a. Develop trust.

Patients with PTSD are often withdrawn and feel suspicious, detached, or estranged from others. Developing a trusting relationship might be difficult for them; however, the development of trust is fundamental to the therapeutic nurse-patient relationship. The other interventions will not be possible until a trusting relationship exists.

Which statement by an individual with PTSD best indicates that treatment was effective?
a. “I’m drinking less now that I’ve faced my problems.”
b. “I feel like the accident happened to someone else.”
c. “I sleep for 3 to 4 hours a night without nightmares.”
d. “My artwork distracts me and eases my anxiety.”
d. “My artwork distracts me and eases my anxiety.”

Treatment has been successful when an individual can use coping mechanisms to move forward and find meaning in the traumatic event. Continued use of drugs and alcohol is maladaptive. Continued sleep disturbances and insomnia as well as dissociation or depersonalization do not indicate that treatment was effective.

After a mass transit disaster many injured patients are expected at the emergency room. The nurse expects victims to have which assessment findings?
a. Dissociative symptoms, numbing, detachment, and derealization
b. Auditory hallucinations and other perceptual distortions
c. Physical symptoms that mimic neurologic disorders
d. Exaggerated mood (either depression or elation)
a. Dissociative symptoms, numbing, detachment, and derealization

Acute stress reactions are marked by dissociative symptoms such as numbing of emotional responsiveness, feelings of detachment, and decreased awareness of surroundings. The other options list behaviors that are atypical of acute stress reactions.

Which statement by a patient diagnosed with somatic symptom disorder indicates that goals for treatment are being achieved?
a. “I need to be very careful about what I eat.”
b. “I can focus on things other than my symptoms.”
c. “I understand that my doctor is not an expert in everything.”
d. “I try to figure out my diagnosis by reading articles on the Internet.”
b. “I can focus on things other than my symptoms.”

This statement suggests that the patient’s preoccupation with physical symptoms has decreased. The other options suggest ongoing concern with his or her physical state.

The nurse would expect which comment from a patient diagnosed with depersonalization disorder?
a. “I feel like I’m outside my body, watching what’s happening.”
b. “I feel as though someone is reading thoughts in my mind.”
c. “I know I have cancer, but the doctors can’t find it.”
d. “When I woke up, my legs were paralyzed.”
a. “I feel like I’m outside my body, watching what’s happening.”

In depersonalization, individuals feel detached from parts of their body or their mental processes. The distracters reflect somatization disorder, conversion disorder, and schizophrenia.

Which symptom would the nurse expect in a patient diagnosed with dissociative fugue?
a. Worry about having a serious disease
b. A feeling of detachment from one’s body
c. Belief that part of the body is ugly or disproportionate
d. Travel away from home and assumption of a new identity
d. Travel away from home and assumption of a new identity

Dissociative fugue involves unplanned travel away from one’s usual home and either confusion about identity or assumption of a new identity. The person does not seem to be wandering but behaves purposefully. The other options relate to body dysmorphic disorder, depersonalization disorder, and hypochondriasis.

A priority focus of milieu management for a patient diagnosed with dissociative identity disorder (DID) should be:
a. ensuring safety.
b. stimulating memory return.
c. insight-oriented group therapy.
d. gathering data about family relationships.
a. ensuring safety.

Patients with DID have a host personality and one or more alternates. It is not unusual for one of the alternate personalities to be depressed and wish to commit suicide or for a personality to wish to harm the others. Safety is the priority concern in care.

Select the most important assessment question to ask a patient suspected of having a dissociative disorder.
a. “Do any members of your family have problems with drugs or alcohol?”
b. “Do you ever find yourself in places with no idea how you got there?”
c. “How would you describe your current level of anxiety?”
d. “How do you think we can be of help to you?”
b. “Do you ever find yourself in places with no idea how you got there?”

The correct response would provide information relevant to dissociative amnesia, dissociative fugue, or dissociative identity disorder, making it a good assessment question. The other questions are of no particular relevance.

Which term describes the final stage in the normal process of anxiety?
a. Panic
b. Crisis
c. Disorganization
d. Coping
d. Coping

The individual moves from experiencing the symptoms of anxiety to the use of coping behaviors to alleviate these symptoms. Panic is a level of anxiety. Crisis involves disorganization, which is not always the end product of anxiety. Disorganization is not always experienced as the product of anxiety.

The effects of stress can be seen by measurement of clinical changes of the body. This statement is a tenet of which theorist?
a. Freud
b. Selye
c. Peplau
d. Sullivan
b. Selye

Selye found that the effects of stress can be seen by objective measurement of structural and clinical changes in the body. Roy’s nursing theory uses this foundation. None of the other options deal with stress.

If a patient’s threshold set point for anxiety is lowered, the nurse can expect subsequent stressors to:
a. have a lesser effect.
b. easily reactivate the anxiety response.
c. produce marked personality disorganization.
d. be easily managed using familiar coping strategies.
b. easily reactivate the anxiety response.

Lowering the threshold set point for anxiety will result in the patient becoming anxious more easily. Thus, lesser effect and ease of handling are incorrect options. Marked personality disorganization would not necessarily occur.

An anxious patient has distorted perceptions and ineffective reasoning. On an anxiety rating scale, the nurse would expect to record the patient’s level of anxiety as:
a. mild, +1.
b. moderate, +2.
c. severe, +3.
d. panic, +4.
c. severe, +3.

Cognitive symptoms of severe anxiety include distorted perceptions, difficulty focusing, and ineffective reasoning. Other symptom constellations relate to the other levels.

A patient is demonstrating severe (+3) anxiety. Nursing interventions will center around:
a. encouraging ventilation and refocusing attention.
b. discussing possible sources of anxiety.
c. taking control to guide the patient.
d. decreasing stimuli and pressure.
d. decreasing stimuli and pressure.

Severe anxiety requires intervention to relieve the heightened tension and discomfort that the patient is experiencing. Perceptions are often distorted, focusing is difficult, and problem solving is impossible, even with help. Environmental simplification and kind, firm directions are approaches to decreasing stimuli and pressure. The other options will not be as effective.

A nurse is assigned to care for a patient diagnosed with moderate (+2) anxiety. Which assessment findings are most likely?
a. Distorted perceptions, disorientation, and defensiveness.
b. Poor concentration, narrow perceptions, and irritability.
c. Irrational reasoning and loss of contact with reality.
d. Alertness, attentiveness, and accurate perceptions.
b. Poor concentration, narrow perceptions, and irritability.

In moderate anxiety states, the body is preparing for protective action. Cognitive symptoms include difficulty concentrating, distractibility, narrowed perceptions, short attention span, tangentiality or circumstantiality, and decreased problem-solving ability. Alertness is associated with mild anxiety. Distorted perceptions are associated with severe anxiety. Irrational reasoning is associated with panic.

The nurse is assigned to care for a patient with moderate anxiety (+2). The most effective nursing intervention will be:
a. use of time-out.
b. initiation of problem solving.
c. providing firm guidance and control.
d. administering a parenteral antianxiety drug.
b. initiation of problem solving.

Using problem solving is an appropriate goal for a patient experiencing moderate anxiety, because these patients are capable of problem solving with assistance. Use of time-out, providing firm guidance and control, and giving parenteral medication are interventions more often used for severe and panic-level anxiety.

A patient diagnosed with PTSD has frequent flashbacks and persistent hyperarousal symptoms. Which nursing interventions should be planned? Select all that apply.
a. Offer empathy and support.
b. Encourage relaxation activities.
c. Encourage verbalization of anger.
d. Set limits when the patient begins to tell of the story of the traumatic incident.
e. Help the patient associate current feelings and behaviors with trauma experience.
a. Offer empathy and support.
b. Encourage relaxation activities.
c. Encourage verbalization of anger.
e. Help the patient associate current feelings and behaviors with trauma experience.

These measures are designed to help reduce PTSD symptoms. Anger should be expressed and accepted. Patients with PTSD should learn that their feelings are commonly experienced by others with the same disorder. Recounting the traumatic event helps patients integrate the feelings of distress, so limiting such behavior is not therapeutic.

General Anesthesia, Neuromuscular Blockers, Parkinson’s Disease; Anxiety and Insomia

General Anesthesia (GA)
– Not just one medication
– Block flow of sodium into neurons or enhance GABA receptors
– Delay nerve impulses and reduce neural activity
– Exact mechanism not known, but likely that GABA receptors in brain are deactivated
– Produce unconsciousness
– Produce lack of responsiveness to painful stimuli
– Inhalation agents or intravenous agents
– Pt will need cardiopulmonary
– Stages of general anesthesia
– Inhalation agents: gaseous agents (nitrous oxide) or volatile liquids

GA – Block flow of sodium into neurons or enhance GABA receptors
Some anesthetics work through both pathways

GA – Exact mechanism not known, but likely that GABA receptors in brain are deactivated
– GABA: main inhibitors neurotransmitter in brain
– Increases chloride influx and decreases sodium

GA Combo of several medications for a BALANCED ANESTHESIA
– Med that sedates pt
– Med that paralyzes pt
* Doesn’t cause loss of pain
* Normally just used at beginning of anesthesia because they will be unconscious from sedative meds
– Analgesics (opiates)
* Prevent feeling of pain

GA – Inhalation agents or intravenous agents
Usually start through inhalation and maintain with IV

GA – Stages of general anesthesia
Stage I (induction): loss of pain; pt starts to become sedated
Stage II: excitement and hyperactivity
Stage III: surgical anesthesia
Stage IV: paralysis of medulla

GA – Stage I
Induction
– loss pain
– pt starts to become sedated

GA – Stage II
Excitement and hyperactivity
– Want to transition quickly into Stage III
– Some prolong this stage – Ketamine (Special K)
* Used because it doesn’t affect BP as much as other anesthetics

GA – Stage III
Surgical anesthesia
* Want to keep pt here
* Achieve balanced anesthesia

GA – Stage IV
Paralysis of Medulla
* Pt needs cardiovascular support
* Overdose – give pt NARCA or something else to reverse opioids/anesthetics
* Incident report required if pt enters Stage IV

GA Inhalation Agents (IA) – kinds
– Gaseous agents (Nitrous oxide)
– Volatile liquids

GA Inhalation Agents (IA) – characteristics
– Don’t always need to be on cardiovascular support – may still maintain ability to breathe (nitrous oxide)
– Prevent flow of sodium into neurons in CNS, delay nerve impulses, produce reduction in neural activity
– Primary Use: with IV agents to maintain loss of consciousness; used alone for dental procedures/short procedures
– Opiates, sedatives, sometimes hypnotics
– Gaseous agents

GA – Gaseous Agents
– Nitrous oxide

GA – Nitrous Oxide
– Fairly safe, minimal side effects
* does not lead to severe hypertension
– Risk for abuse, especially by health care providers
– Causes pt to relax enough for procedure – for short surgical procedures
– Side effects

GA Side effects of Nitrous Oxides
– Fairly safe, minimal side effects
* does not lead to severe hypertension
– Dizziness, drowsiness
– Vomiting, nausea
– Euphoria – part of excitatory period
– Malignant hyperthermia
* Rare – ICE Pt
– Apnea – Slowed RR
* Must count respirations
– Cyanosis:Hypoxemia
– Liver Damage

GA Volatile liquid
– vaporized upon inhalation

GA Contradictions of Nitrous oxide
– Impaired LOC
– Head injuries
– Inability to comply with instructions
– Abdominal pain
– Bowel obstruction
– COPD
– Chest trauma with pneumothorax

GA Drug to Drug interactions Nitrous oxide
-Sympathomimetics and phosphodiesterase inhibitors may exacerbate dysrhythmias

GA Herbal Tx for Nitrous oxide
Milk-taken before or after NO to lower liver damage
-Ginger- therapeutic benefits

GA Overdoes of Nitrous Oxide Treatment
Metoclopramide- help reduce the symptoms of nausea and vomiting associated w/ inhalation of nitrous oxide

GA – Intravenous Agents
– Opioids (very high does acts as general anesthesia)
– Benzodiazepines (GABA enhancing drug), and miscellaneous agents
– Used in combination with inhalation agents
* provide greater anesthesia and muscle relaxation
* Balanced anesthesia – decreases side effects
– Used alone for procedures that take 15 minutes or less
– Miscellaneous IV general anesthetics
* GABA enhancers
* Good for patients in shock
* Need to be ready to assist during intubation – intubation kit must be at bedside in case pt needs it
* causes CNS depression
* Types (all given via IV)

GA Intravenous Agents
– Etomidate (Amidate)
– Propofol

GA Etomidate (Amidate)
-Intravenous Agent
-Give IV push
-Cause GABA enhancement (Sedation)
-Depending on dose, pt may need Cardio Support- maintain air way
-Normally pt is intubated in case pt vomits
-Doesn’t affect BP -pt hypovolemic shock benefit

GA Problem with Etomidate (Amidate)
– if pt is addisonian crisis (acute adrenal insufficiency); can cause pt to go into shock b/c cortisol deficiency

GA Propofol (Diprivan)
– Very painful – lipid based
* many pt receive a small amount of lidocaine or analgesic in vein prior to giving propofol
– Works by GABA enhancement and blocking Na channels – powerful sedative
– Can be used to both induce and maintain anesthesia
– Recommended for short-term use

GA Why can nurse give Propofol via IV push?
– out of scope of nursing practice
– can only be IV pushed (bulus) by anesthesiologist or CRNA (Certified registered nurse anesthesiologist): that would be giving an anesthetic.

GA Propofol Side effect
– Severe hypotension * causes vasodilatation
– Drowsiness
– Respiratory depression

GA Propofol Infusion Syndrome
– Toxic buildup of medication in body
* Hepatotoxicity – Rabdomyolisis
* Acidosis
* Death

GA Adverse Effect of IV Agent for General Anesthesia
– Allergic reactions, dysrhythmias, respiratory depression
* CNS depression, shivering, headache
* Nausea and vomiting, vital-sign changes
– During postoperative period: hallucinations, confusion, excitability
– Most anesthetics can give you arrhythmias/CNS depression and excitability

Neuromuscular blockers NB
– Depolarizing muscle paralyzers
– Intravenous agents
– Nondepolarizing muscle paralyzer

(NB) Depolarizing muscle paralyzers – Name the drug
– Succinylcholine (Anectine)
– Binds with acetylcholine receptors at neuromuscular joints
– Action potential goes through (depolarization occurs) but it prevents repolarization – muscle contracts until it can’t anymore and then slowly relaxes (doesn’t contract again)
– Has short half life **
– Given with anesthesia
– Do not decrease pain or anxiety
– Main side effect of prolonged contraction is malignant hyperthermia
– Along with muscle paralyzer, ppt needs sedative med and an analgesic

Anectine
Succinylcholine

(NB) Main side effects of prolonged contraction
Malignant hyperthermia
– It happens often with succunylcholine (Anectine)
* black box
– Genetically linked – check family history
– Causes extremely high fever and muscle rigidity
– Causes rapid breakdown of muscle (rabdomyolysis)
– Metabolic acidosis
– Pt. needs to be intubated and mechanically ventilated
– Reversal agent is dantrolene (muscle relaxer)

NB – side effect: causes rapid breakdown of muscle
Rabdomyolysis

NB – reversal agent
Dantrolene

(NB) Nondepolarizing muscle paralyzer – name the drug
– Mivacurium (Mivacron)
– Prevents depolarization/contraction of muscle **
– Compete with acelylchololine for cholinergic receptors at neuromuscular junctions
– Benefit is that there is less chance of pt developing malignant hyperthermia
* No prolonged contraction
– Need to intubate pt
– Doesn’t work as fast
– Used as drug of choice – safer profile than succinylcholine (Anectine)
– Main side effect is paralysis

NB Mivacurium (Mivacron)
(NB) Nondepolarizing muscle paralyzer

PD Parkinson’s Disease
– Causes by lack of dopamine
– Progressive condition characterized by
– Rapids swings in response to levodopa occur (“on-off phenomenon”)
– “Wearing-off phenomenon”/”on-and-off phenomenon”
– Patients with Parkinson’s needs to receive meds at SAME TIME EVERY DAY
-Treatment

PD Rapids swings in response to levodopa occur (“on-off phenomenon”)
– PD worsens when too little dopamine is present
– Dyskinesia (abnormal voluntary movement) occurs when too much dopamine is present

PD “Wearing-off phenomenon”/”on-and-off phenomenon”
– Able to move and all of the

PD Patients with Parkinson’s needs to receive meds at SAME TIME EVERY DAY
– Will go into “on and off phenomenon”
* Many meds just dissolved under tongue so pt doesn’t need to drink water with it

PD Parkinson’s Disease characteristics
– Tremors
– Bradykinesia
– Rigidity
– Postural Instability: Shuffle gate:leaning forward and walking without lifting legs

PD treatment goal
To increase dopamine or decrease acetylcholine

PD treatment
– Dopamine:slows down/controls movement
– Acetylcholine: increase/speeds up movement
– Need a balance between dopamine/acetylcholine
– Anticholinergics (decrease acetylcholine)
– Dopaminergics (increase dopamine)
– Dopamine replacement drugs

PD Dopamine for PD
slows down/ controls movement

PD Acetylcholine
increase/ speeds up movement

PD Anticholinergics
-Decrease acetylcholine
-Block Effects Ach
-Used to treat muscle tremors and muscle rigidity associated with PD
– DOES NOT relieve bradykenesia (extremely slow movement)

PD Symptoms causing PD tremors
these two symptoms are caused by excessive cholinergic activity

PD Benztropine Mesylate (Cogentin)
Treat extrapyramidal side effects caused by use of antipsychotic and other drugs

PD Extrapyramidal Side Effects
normally happen as result of depletion of dopamine; symptoms look like PD.

PD Diphenhydramine (Benadryl)
used for extrapyramidal s/e
-Antihistamine with anti-cholinergic side effect
-Can be used for pts with PD or extrapyramidal symptoms

PD Dopaminergics
– Increase dopamine
– Levodopa therapy
– Dopamine replacement drugs

PD Levodopa therapy
– Levodopa: precursor of dopamine
– Blood brain barrier doesn’t allow exogenously supplied dopamine to enter, but does allow Levopoda
– Levodopa is taken up by dopaminergic terminal, converted to dopamine and released as-needed; as a result neurotransmitter imbalance is controlled in pts with early PD who still have functioning nerve terminals
– Levodopa is broken down quickly
– As PD progresses, it becomes difficult to control with Levodopa (not a cure)

PD Dopamine replacement drugs
– Carbidopa is given with Levodopa
Carbidopa/Levodopa (Sinemet)
– Carbidopa does not cross blood-brain barrier and prevents Levodopa breakdown in periphery
* More Levodopa crosses blood-brain barrier,where it is converted to dopamine

PD Sinemet
Carbidopa/Levodopa

(ANS) Anxiety, Insomnia and Seizure Pharmacology

(ANS) Anxiety – short term
– Short Term Anxiety is usually resolved
* meditation, listening to music, deep breathing, massage : non-pharmacological
* sometimes requires pharmacological action

(ANS) Anxiety -long term
– Chronic Anxiety is not easy to change
* altered level of neurotransmitter needs pharmacological intervention

(ANS) CNS depression
a continuum ranging from relaxation, to sedation, to induction of sleep and anesthesia

(ANS) Limbic System
– located in the middle of the brain
– responsible for emotional responses, learning, and memory
– Signals pass to hypothalamus

(ANS) Hypothalamus
– responsible for unconscious responses
– connects with reticular formation (group of neurons that branch into brainstem)

(ANS) Reticular formation
– network of neurons along length of brainstem
– stimulation causes heightened awareness and arousal
– inhibition causes general drowsiness and sleep (affects sleep cycles)

(ANS) Anxiolytics
– drugs that can relieve anxiety
– used for short term anxiety
– quite effective
– used when anxiety begins to significantly affect daily activities
– most common is benzodiazepines
– many antidepressants used for anxiety: SSRIs, SNRI’s

(ANS) Benzodiazepines
– short term anxiety and sleep inducers
* addictive/habit forming
– formerly most common prescribed sedative-hynotic drug
– GABA enhancers
– “pam” and “lam” endings
– Meant for short-periods – highly addictive
– May affect REM – some data from studies shows this: REM (Rapid Eye Movement)

(ANS) SSRI’s
– classification of antidepressants
– first line of anxiety
– maintenance of anxiety
– increase serotonin in brain
– selective serotonin reuptake inhibitor

(ANS) SNRI’s
– selective serotonin norepinephrine reuptake inhibitor
– anti-depression and anxiety

(ANS) Classes of Medications Used to Treat Anxiety and Sleep Disorders
– ALL ARE GABA ENHANCERS; GABA=main inhibitory neurotransmitter in brain
– Antidepressants
– Benzodiazephines
– Barbiturates (older)
– Nonbenzodiazepines/nonbarbiturate CNS depressants

(ANS) Barbiturates
– similar to benzodiazepines
– enhance GABA
– Definitely affect REM in negative way (lose REM) – mess up sleep cycle
– used less than benzodiazepines
– used for anxiety and insomnia

(ANS) Treating anxiety/insomnia with CNS agents
– Used when patient can’t get out of cycle of anxiety and insomnia
– Antidepressants frequently used to treat anxiety (SSRI’s,SNRIs)
– Major classes of CNS agents : Benzodiazepines
Barbiturates
SSRi’s
SNRI’s

(ANS) Sedatives and Hypnotics
– used for anxiety
– CNS depressant are called:
* Sedatives due to ability to sedate or relax pt
* Hypnotics for their ability to induce sleep
*Sedative- hypnotic: calming effect (sedative) at lower doses and sleep (hypnotic) at higher doses
– category depends on dosage
– most CNS depressants can cause physical and psychological dependence

(ANS) Sleep
– normal sleep cycle is cyclic and repetitive
– sleeping person is unaware of sensory stimuli within immediate environment
– sleep architecture
– sleep stages
– need both REM and non-REM sleep cycles for memorization and storage of information

(ANS) Non-REM sleep
rest and restore

(ANS) REM sleep
dreaming; associated with memory, learning and adaptation

(ANS) Sleep Stages
3 stages (5-15 minutes each)
– stage 1: easy to wake up;awarae
– stage 2: longest stage: light sleep; body gets ready for deep sleep
– stage 4: deep sleep (relaxation); harder to wake up; body repairs tissues, builds bone/muscle, and strengthens immune system (HR SLOWS AND BODY TEMP DROPS)
– wide and deep waves of sleep

(ANS) Sleep Stages (REM sleep) 4th stage
– usually happens 90 minutes after you fall sleep
– first period usually last 10 minutes, and each later stage lasts longer
– HR AND BREATHING QUICKENS
– dreams occur (brain more active)
– without REM cycle: no deep sleep, final outcome is you don’t dream, sleep debt, day dreaming occurs
– without REM cycle: unable to memorize, not able to store information in long term files

(ANS) Sleep Architecture
– Non-REM sleep
* Happens first
– Rapid Eye Movement (REM) sleep – 4th Stage
* Happens 900 minutes after you fall sleep
– REM Interference: barbiturals
– REM rebound: REM cycle length and frequency increase after sleep deprivation; also takes shorter time to reach REM cycle

(ANS) Insomnia
– short term insomnia: usually caused by stress
– long term insomnia: medical condition: depressioin, chronic pain, chronic anxiety (lack ability to sleep)
– rebound insomnia: due to abrupt discontinuation of a sedative medication
– diagnostics:
* 1st pharmacological
* EEG: monitors brainwave activity; looks at NREM and REM cycles
* REM: dreaming; associated with memory, learning and adaptation
* NREM: rest and restore
– pt may develop daytime drowsiness – can cause safety hazard

(ANS) CNS depressants: Benzodiazepines
– short term anxiety/insomnia
* addictive/habit forming
– formerly most common prescribed sedative-hypnotic drug
Nonbenzodiazepines (long term problems) currently more frequently prescribed
– favorable drug effect profiles, efficacy, and safety
– classified as either:
* sedative – hypnotic
* Anxiolytic (medication that relieves anxiety)
– long acting

Benzodiazepines name the drugs
– Long acting
* Diazepan (Valium)
– Intermediate Acting
* Alprazolam (Xanax) – oral form, Lorazapam (Ativan), Temazepam (Restoril)
* Short Acting – most end in “pam”
– Used for insommia, anxiety, antidepresants, seizures, many clinical problems
– pam and lam endings “BARS on the streets”

Benzodiazepines- mechanism of action

What is Social Anxiety Disorder

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Social Anxiety Disorder is described as “the fear of being judged and evaluated negatively by others, leading to feelings of inferiority, embarrassment, humiliation, and depression.” Someone coping with Social Anxiety Disorder feel very nervous and uncomfortable in social situations such as:

  • Being introduced to other people
  • Being teased or criticized
  • Being the center of attention
  • Being watched while doing something
  • Meeting people in authority (“important people”)Most social encounters, especially with strangers
  • Going around the room (or table) in a circle and having to say something
  • Interpersonal relationships, whether friendships or romantic

Those with social anxiety disorder often feel as if they’ll do or say something wrong. When faced with certain social situations, someone with a social anxiety disorder may experience a panic attack, or feel some physical signs of anxiety. Stomach Ache, Blushing, Sweating, Shaking, Muscle tension, Irritability, Feeling detached from one’s body (derealization).

Social Anxiety Disorder can have a very strong impact on one’s quality of life. Some may steer clear of certain careers and/or fields of study, avoid spending time with their friends, and end up skipping many days of school.

  • School refusal
  • Avoiding participating in new activities or going places
  • Asking a parent to be present or available
  • Declining invitations to social events
  • Not answering in class
  • Crying or tantruming
  • Refusing to go on a ‘playdate’ without a parent
  • Mumbling or poor eye contact
  • Staying home on weekends rather than hanging out with friends

Types

Those suffering from Social Anxiety Disorder usually experience ‘specific’ or ‘generalized’ variations of the condition.

These are largely self explanatory; a specific social anxiety would be a fear of presenting to a class (and only that), and those experiencing generalized social anxiety are anxious, nervous, and overall uncomfortable in almost all social situations.

Most commonly people will experience generalized social anxiety as opposed to specific social anxiety, as most feelings of worry can be applied to a multitude of different social interactions.

Causes

Some possible causes of Social Anxiety Disorder are as follows;

Inherited traits: It has been observed that anxiety disorders tend to run in families. However, it isn’t completely clear just how much of this is due to genetics, and how much is due to learned behavior.

Brain structure: The structure in the brain we’re all now familiar with called the amygdala plays a role in controlling fear responses. People who have a hyperactive amygdala could have a more intense fear response, causing anxiety in a variety of social situations.

Environment: Social Anxiety Disorder can be a learned behavior; some people could develop the condition because of an unpleasant or embarrassing social situation. There could also be a connection between a child’s Social Anxiety Disorder and their parents who either express anxious behavior or are more controlling or overprotective of their children; causing the child to have less self confidence as well as less exercise in social intelligence.

Video by Anxiety BC https://www.youtube.com/watch?v=ypHzXOcUQwE Prevention While predicting what experiences or situations will cause someone to develop an anxiety disorder is extremely difficult, there are steps you can take to reduce the impact of some symptoms if you’re feeling anxious. Keeping a journal is a great way to keep track of your personal life, and it can help you convey to your doctor or therapist what is causing you stress, and what seems to help you feel better. Always remember to try to find help early. Very much like other mental health conditions, Social Anxiety Disorder can become more difficult to treat the longer you wait.