Exam 2 (module 5-9)

When is anxiety considered an anxiety disorder? Explain the biological considerations of anxiety.

• When anxiety interferes with function its considered an anxiety disorder

  • Inappropriate level and times

• Fight or flight is turned on when there is a perception of threat to increase suvivability

• Catecholamine hormones/ neurotransmitters: Epinephrine (adrenline): increases heart rate and acts on almost all body tissues, improving oxygen intake, norepinephrine (noradrenline); acts more as a vasoconstrictor, significantly increasing blood pressure

• Acute anxiety increases cognitive demand and alters neurotransmitters, including dopamine, which helps signal reward and consequence to support rapid decision-making

  • Long term this leads to mental exertion of metal/cognitive resources

• The biochemical process is same in both parts of brain an GI during anxiety

What is the cycle of anxiety?

• There is a external or internal trigger → Anxious thoughts → Fellings/ emotions → Physiological response (how the body responds automatic body processes like increased hr, diaphoresis etc) → Behavioral response (how you respond to physiological response like avoidence, coping, pacing etc)

  • Thoughts go first, emotions follows & then physiological response)

  • Angor animi: an overwhelming, intense sense that a catastrophe, severe injury, or death is imminent despite no immediate, apparent danger, caused by catecholmine surge and jack up of the amygdala

What are the medical links with anxiety

• PE, asthma, emphysema

• stroke, MI

• Cancer

• Sepsis

• Chronic pain, IBS

• Delirium

What are the risk factors of anxiety?

• Brain chemicals, lifestyle, family history, genetics

What are the chain of events that lead to physiological response of anxiety?

Stressor occurs → anxiety= one of many response to stress → physiological response; fight or flight, adrenaline increase, dry mouth, sweating

What are the manifestations of anxiety?

• Feeling apprehensive or nervous

• Restlessness

• Irritability

• Anticipating the worst result

• Watching for what causes anxiety

• Avoidance of cause

• Increased heart rate and respiratory rate

• Sweating

• Fatigue or exhaustion

• Difficulty concentrating

• GI disturbances

• Sleep disruptions

What are some specific types of anxiety?

• Separation

• Phobias

• Social

• Panic Attacks

• Agoraphobia

How is anxiety connected to OCD?

• OCD is precipitatd by anxiety

• There is a veriety of obsessions and compulsions

• Often diagnosed alongside anxiety disorder, its anxiety driven

Obsessions v Compulsions (list some examples)

• Obsessions are thought based → “Should I stick my finger in outlet?”

  • Thoughts about being harmed or harming someone else

  • Fears of safety

  • Concern for cleanliness or germs

  • Fear that they are offending a higher power or deity

  • Fear of forgetting something important

  • Worry about how tidy or neatly arranged items are

• Compulsion are action based (physical action; hoarding)→ “Can’t step on cracks in sidewalk”, having to lock room multiple times

  • Checking and rechecking that a door is locked

  • Ritualistic order for handwashing

  • Repeating specific words of phrases

  • Hurting self, such as hair pulling

  • Counting objects, items, or actions

  • Repeating an activity a specific number of times

What is the nature of OCD?

• Cyclic, persistant, recurrent, intrusive, not engaging= anxiety

What are some co-diagnoses of anxiety?

• Panic disorders

• Trauma and stressor-related disorder

• Depressive disorders

• Substance use

• Somatic manifestations

• Sleep-wake disorders

• Eating disorders

What are some other OCD manifesations?

• Hoarding: Collecting stuff and not throwing anything away

• Trichotillomania: Pulling out hair

What are the manifesations of body dysmorphic disorder?

• Persistent preoccupation with perceived defects or flaws in one’s appearance.

• Mirror checking

• Excessive grooming

• Skin picking

• Seeking reassurance about looks

• Possible eating disorder

What are excoriation disorder?

• Pattern of behavior defined by recurrent picking at one’s skin, resulting in lesions

• Physical manifestations commonly found on hands, face, arms, or multiple body sites

• May pick pimples, scabs, or previously picked areas of skin

• Extensive time daily is spent picking

• Often the client attempts to cover affected areas with clothing or makeup

What are some non pharm treatments of Anxiety and OCD?

• Psychotherapy

• CBT- Cognitive behavioral therapy

• Cognitive Therapy

• Exposure Therapy

• Support groups

• Lifestyle management

• Complimentary- integrative approaches

What are some pharm treatments of Anxiety and OCD?

• Anxiolytics: often benzos

• SSRI/SNRI

  • Prozac/fluoxetine

• Other antidepresants

  • Alprazolam

  • Paroxetine

  • Venlafaxine

What are the nursing considerations of anxiety/OCD and nursing judgment to keep in mind?

• Time-consuming

  • Make time for ritulistic behavior

  • Plan accordingly

  • Do not force to not do behavior

• Aggravation/frustration

• Patience

• Mindfulness

• Assess manifesations

• What alleviates or aggravates the manifestations

• Underlying causes

  • Thyroid

  • Blood glucose

  • Echocardiography

  • Toxicology

What are the safety considerations to keep in mind with OCD/anxiety?

• Assess for suicidality

• Assess obsessive thoughts and compulsive behaviors

• Skin assessment

• Client readiness

What is the pharm treatment for anxiety/ OCD?

• Benzos

  • Alprazolam (Xanax)

    • Fast/Intermediate acting

    • Used for short term use

    • Dont want to use long term bc dependence can result

    • Half-life: 12-15 hours Good for: PRN anxiety

  • Lorazepam (Ativan)

    • Onset: Intermediate

    • Short half life - used for pre surgery anxiety less consitent b/c don’t want them on it long term

    • Half-life: 10-20 hours

    • Uses: PRN anxiety, ETOH detox

  • Diazepam (Valium)

    • Onset: Fast

    • Half-life: 20-50 hours

    • Good for: ETOH detox, seizures (suppository)

    • Like to use for seizures bc it lasts & acts fast - immediate relief, status epilepticus, but can shield detox s/s

  • Clonazepam (Klonopin)

    • Onset: Slow

    • Half-life: 18-50 hours

    • Uses: Daily anxiety

    • Usally used long term but its easy to abuse

  • Don’t operate heavy machinery

  • Don’t mix with ETOH

• Non- benzos

  • SSRIs – long term

    • Prozac- fluoxetine(OCD)

  • Propranolol – Watch HR/BP as it slows it down; to manage panic symptoms

Define schizoprenia

• Thpught disorder

• Disortion of reality

• Adding things, taking away things

• Poor health outcomes

• Positive and Negative Symptoms

• Anosognosia (insight): can you rationalize psychotic symptoms or not this drive

What are the manifesations of schizophrenia?

• Asocial

• Isolative

• Psychotic

• Impoverished

• Poor relationships

What is schizoaffective disorder?

• Thought disorder w/ emotional components (ex. depression)

What are positive symptoms of schizophrenia?

• Positive (+), like addition

• Adding something to the person’s reality

• Hallucinations

  • Audiovisual

  • Gustatory → taste

  • Olfactory → smell

  • Tactile → touch

  • Command → voices telling you to do smth

• Delusions

  • Paranoid

  • Religious → “I belive I am an archangel etc.”

  • Persecutory → belief that the FBI is after them

  • Referential Delusion → Beliving things that do not apply apply

What are negative of schizophrenia?

• Negative (-), like subtraction

• Subtracting something from the persons reality

• Alogia- poverty of speech

  • Thought block

• Anhedonia- lack of pleasure

• Avoltion- loss of motivation

  • can explain homlessness, lack of job etc.

• Asociality- social isolation, lack of socialization

• Attention deficit

• Flat, blunted affect

How should patient with schizoprenia be assessed?

• Safety is the top priority

  • Command audiovisual hallucinations

  • Audiovisual hallucinations

  • Suicidal ideation, Homicidal ideation

• Medication complience

• Side effects

• Thought content

• Positive and negative symptoms

• Recurrent psychotic breaks/degeneration of mental status

• Presentation changes with recurrent psychotic break

What are the nursing actions to do for schizoprenia?

• Assess for thought content and command

• Rapport and trust building

• Validation or feelings

• Medication complience and encoragement

• Advocacy

• Disposition planning

• If someone is at risk are mandated report due may be due to paranoia

What should not be done with schizoprenia?

• “Feeding in” to delusions and hallucinations

• Challenging thoughts and feelings

• Forcing language

• Disciplining negative behaviors

• Forcing socialization

What is the process for assessment observation with schizoprenia?

• Mood

• Affect

• Actions

• Pacing

• Interactions

• Self-dialoguing

• Responding to internal stimuli

• Isolation

How is safety ensured in schizoprenic patients?

• Frequent observation

• Be “resonable”

• 1:1 Constant observation if needed

• Offer support

• Encorage medication complience

• Build rapport and trust

How does patient insight affect care and define?

• Varying degrees of insight

• Awarness of diagnosis

• Spectrum of awarness

• Theraputic communication techniques change depending on insight

How is theraputic environment created with thought disorders??

• Wecoming milieu

  • Having someone in milieu tends to prevent escalation from happening

• Group therapy

• “Normal” energy level

• Risk reduction

  • Violence

  • Agitation

  • Outbursts

How should boundaries and limits be set in thought disorders??

• Establishment of rules

• Adherence to policies and procedure

• Redirection if needed

• Identifying unsafe behaviors for the client and others

• Reducing risk

• Impulse control

• Set firm boundries, dont say anything, you can’t follow through, don’t threaten

How are outcomes evaluated in thought disorders?

• Improvment in thought process and content

• Medication adherance

• Elimination or reduction of safety concerns

  • Do we feel confident enough that they will be ok

  • Improvment in both positive and negative symptoms

• Appropriate disposition planning

• Prevention of re-admssion

• Want to return to baseline; historical info & collateral to figure out baseline

Explain how to manage schizoprenia in patient

• Always evaluate for safety

  • Risk to self or others (SI, HI)

  • Command auditory

• Assess both positive and negative symptoms

• Utilize therapeutic communication techniques

• Maintain a therapeutic environment

• Establish limits and boundaries as needed

• Ensure medication plan adherence

• Always consider client rights

  • Right to a phone, speedy trial, mail etc.

What is the psychopharm for thought disorders?

• Antipsychotic

  • First gen

    • Haldol

      • Good for psychosis, terminal delirium. agitation, restraint

        • Used agitation resulting from delierium

      • PO, IM, Has long acting injectable varient

      • Usally start at 5ml but for restraint

    • Chlorpromazine/ Throazine

      • First gen

      • Good for sedation

      • Used particulaly for positive symptoms

      • Glass ampule (use filter needle)

      • Also good for bipolar, ADHD, N/V, hiccups

        • Think: dopamine antagonist

        • another interesting fact is that it stops hallucinogenic trip

      • Admin: PO or IM (common restraint drug)

  • Second gen

    • Clozapine

      • Second gen

      • Agranulocytosis: low WBC ( specifacally neutrophils)

      • Higher risk for infection

        • Signs of infection

    • Risperdal

      • Second gen

      • Comes in every form

    • Zyprexa (olanzapine) & Quetiapine (Seroquel)

      • higher risk of metabolic side effects (such as weight gain or lipid changes) but more risk with Zyprexa]

    • Risperdal & Seroquel can increase prolactin

      • High prolactin can lead to side effects such as gynecomastia (breast growth in men), galactorrhea (breast milk production), menstrual changes, and sexual dysfunction.

• Okay to have PRNs as well

• Anxiolytics

  • PRN

  • sedating

• Anticholinergics

  • Help with extrapyramidal symptoms of antipsychotics

  • Also help with dystonia of antipsychotics which also happens with EPS

  • also slighty sedating

What are the major side effects of antipsychotics?

• Extrapyramidal

  • Caused by dopamine blockade in the nigrostriatal pathway.

  • Acute Dystonia: Painful muscle spasms

    • muscle spasm, stiff muscles, twitching

  • Akathisia: Subjective "inner restlessness.”→ fidgiting, pacing, kinetic= movement

  • Pseudoparkinsonism: tremors, ridgidity, slow movements, shuffling gait

  • The med given for this is usally anticholinergic

• Tardive Dyskinesia

  • Usually irreversible, involuntary

  • Lip-smacking

  • Tongue-thrusting

  • Unusual facial movements

  • May or may not go away

• Neruogenic Malignent Syndrome

  • Clinical emergency

  • High fever

  • “stovepipe rigidity”

  • AMS- altered mental status

  • Dysautonomia

  • What to do?: Stay with pt, discontinue the med, initiate hydration (kidneys & rhabdo), cool pt, moniter closely, notify the provider

  • Acheive medical stability

Define mood disorders

• Disorders that impact mood

Bipolar I (higher highs)- define mania

• Features mania; psychotic component

  • High mood with psychosis

What are the considerations with mania?

• Finger foods

• High caloric density

• Safety considerations

• Social interactions

• Limit setting

• Check feet if pacing a lot

• Offer PRNs

  • Benzos(?)

  • Antipsychotics (?)

    • Haldol (haloperidol)

Bipolar II (lower lows)

• More prominent depression

  • no psychosis, deper depression → fluctuate between hypomania (a mild form of mania, marked by elation and hyperactivity.) and depression

Major Depressive Disorder (focus on nursing implications and list meds)

• Everything is down

• Depressed low mood and energy that impacts ability do do ADLs usally have deceased serotonin

• Main thing is to Moniter for SI

  • Ask about plan and intent

  • Assess if they have access to resources (weapons etc.)

• Meds

  • MAOI's Nardil (phenelzine): Oldest, eliminate intake of tyramine (Aged foods, Cured meats, Certain (aged) cheeses, Wine)

    • Tyramine will lead to hypertensive crisis

• Tricyclics: risk for orthostatic hypotension

  • Amitriptyline (Also good for nerve pain)

  • Amoxapine

  • Doxepin

• SSRI/SNRI: Risk for Seratonin Syndrome (takes 4-6 weeks for full effect)

  • Prozac (fluoxetine)

  • Celexa (citalopram): Good starter med

  • Zoloft (sertraline)

  • Lexapro (escitalopram): Good starter med

What is Seratonin syndrome? (Causes, S/S etc)

• Triggered by increase in serotonin

• Causes

  • Sudden changes in antidepressant dose

  • Taking multiple antidepressant

  • Taking antidepressant w/ St. John's Wort

• Can be deadly

• S/S

  • Restlessness

  • Increased VS, primarily HR and BP

  • Muscle Rigidity

What are the meds to keep in mind with psychopharm and the lab values to know?

• Lithium (Therapeutic range 0.6-1.2 mEq/L)

  • Will fry kidneys

  • Maintain salt intake

  • Monitor for toxicity sx

    • Tremors

    • N/V/D

    • Bloating

    • Seizures

    • coma

    • death

  • Restart regimen if stopped for a while

• Depakote (Therapeutic range 50-100 mcg/mL)

  • Weight gain

  • Sexual dysfunction

• Tegretol (Therapeutic range 4-12 mg/L)

  • SJS- Steven johnsons syndrome

  • Kills liver and babies

  • Lamictal

  • Good for depression

  • Lots of skin problems