Shelbye's CSON Notes Blog
Anxiety and Stress Related IllnessVidebeck, p. 242-262 (omit Box 13.1 & 13.2)InfoWhat is anxiety?Feeling of dread that you get from either a real or perceived threat. Source of anxiety is usually unknown What is stress?Your reaction to that crap. Happens to all of us. The wear and tear of life that we see with stress What is fear?Reaction to a specific danger. Levels of Anxiety SymptomsMildUsually able to work with them, can usually make someone do better. A little more alert usually. Restless, may tap or shake your leg or whatever, may be impatient and a little irritable. Can usually respond appropriatelyModerateNot quite as aware of what is going on around you, may respond well to guidance, able to problem solve but not quite as well as the mild level. May complain of “butterflies” in your stomach. BP and pulse may increase. Usually pretty tenseSevereNot aware of what’s going on around us, not able to think well, many times people feel like a sense of impending doom for no explainable reason. May hyperventilate while moving into panic mode. Can be tachycardic, very load and inconsolable. Panic Totally unable to focus or concentrate. Be very specific and point out what’s going on, but they still won’t be able to reason with you. Can become very immobile and they are almost catatonic or may walk out in front of a car or some shit. They may hallucinate or have delusions, out of touch with reality.Defense Mechanisms Are used to relieve anxietyBecome maladaptive when used to extremesNeed to be recognized and understood by the nurse so that the nurse assist the patient in learning more adaptive coping skills Anxiety DisordersAgoraphobia with or without panic disorderAnxiety about or avoidance of places or situations from which escape might be difficult or help might be unavailablePanic disorderPanic attacks-key feature – panic attack is the sudden onset of intense apprehensions, fearfulness, or terror associated with feelings of impending doom Symptoms include feelings of terror, losing their mind, having heart attack palpitations, breathing difficulties, choking, hot flashes, chillsTreatment-CBT, medications, decrease stimulation, deep breathing, journalingSpecific phobiaA phobia is an illogical, intense, persistent fear of a specific object or social situation that causes extreme distress and interferes with normal life functioningTreatment-Behavioral therapy, medicationSocial phobiaAnxiety provoked by certain types of social or performance situations, which often leads to avoidance behaviorObsessive–compulsive disorder (OCD)Obsessions-Thoughts, impulses, or images that persist and recur and cannot be dismissed from the mind Compulsions- Ritualistic behaviors that an individual feels driven to perform to reduce anxietyTreatment- CBT and medications, Anfrenil is DOC Generalized anxiety disorderExcessive worry and anxiety that is unwarranted more days than notSymptoms include uneasiness, irritability, muscle tension, fatigue, difficulty thinking, and sleep alterations Seen most often by family physician, must last at least 6 monthsAlways assess for suicideAcute stress disorderOnset within 4 weeks of event lasting 2-4 daysExposure to a traumatic event involving threat of death/injuryFeeling numb/detached/amnesic/fearfulFlashbacksIncreased anxiety, irritability, decreased concentration, sleep disturbances Posttraumatic stress disorderOnset within 6 months of event, lasting more than 3 monthsExperiencing, witnessing a frightening eventRe-experience the trauma/hallucinationsSudden flashbacksIrritability, sleep disturbances, increased anxiety, outbursts of angerOverview of Anxiety DisordersEtiologyAre some genetic predispositionsCultural considerationsDifferent cultures handle anxiety differentlyElder considerationsCan look like dementia or depressionCommunity-Based CareMost of the time anxiety is treated out patient unless they’ve gotten to the point where they can’t function Incidence of Anxiety DisordersMore prevalent in women except for OCD Prevalent in those less than 45 years of age Most common psychiatric disorders in the U.S., affecting 25% of adultsMore common in divorced, separated, and lower socioeconomic statusOnset and clinical course are variableMany co-occur with other psychiatric conditionsRelated DisordersAnxiety disorder due to a general medical conditionSubstance-induced anxiety disorder Separation anxiety disorder Adjustment disorderPrimary / Secondary Gain in Anxiety DisordersPrimary GainIs the relief of anxiety by performing specific anxiety driven behaviorSecondary gainIs the attention received from others as a result of those behaviorsGeneral TreatmentCombination of medication and therapySSRIs,TCAs, benzodiazipines, beta blockers, anti-epilepticsCognitive–behavioral therapy (aka CBT)Combination of these two gives a much better result that one or the other used separately Nursing Interventions for Mild to Moderate Levels of AnxietyHelp patient identify the anxiety.Anticipate anxiety-provoking situations.Use nonverbal language to demonstrate interest.Encourage talk about patients feeling and concerns.Focus on patients concerns.Ask questions to clarify what is being saidHelp patient identify thoughts or feelings before onset of anxiety.Encourage problem solving with the patient.Assist in developing alternative solutions to a problem.Find out what has helped relieve anxiety in the past.Provide outlets for working off excess energyNursing Interventions for Severe to Panic AnxietyMaintain a calm manner.Remain with the person experiencing a severe to panic level of anxiety.Minimize environmental stimuli.Use clear simple statements.Use low-pitched voice. Speak slowly.Reinforce reality if distortions occurListen for themes in communication.Attend to safety and physical needs.Speak in firm authoritative voice. Limit set for safety.Provide opportunities for exercise.Offer high calorie foods.Assess need for medication or seclusionOverview of Anti-Anxiety MedsBenzodiazepinesReminder: high risk for dependence, withdrawal, and tolerance Common side effects: drowsiness, fatigue, decreased coordination, slow reflexesUsed as anxiolytic, hypnotic, muscle relaxant, anticonvulsant, amnesicParadoxical responses possible (Refer to Table 13.2)Benzo TeachingNot for everyday stressorsAvoid driving/operating machineryDo not exceed prescribed doseTaper dose before stoppingAvoid Kava, Valerian, other herbal therapiesAvoid alcohol Buspirone Anti-depressants (SSRIs, TCAs, MAOIs)SSRIsFirst line treatment for anxiety disordersCommon side effects: tremor, akathesia, nausea, headache, insomnia, drowsiness, sexual dysfunctionSerotonin syndromeSSRI TeachingTake with foodAvoid alcoholTake medication as prescribedDo not discontinue abruptlyTakes several weeks to reach therapeutic levelBeta-blockersAntihistaminesAnticonvulsantsReview Videbeck Table 13.3Anti-Anxiety MedsBuspirone (Buspar) – not a benzo, takes 1-6 to be effectivePropanolol (Inderal) – beta-blocker especially useful in treating social anxiety d/o Hydroxzine ( Vistaril) – antihistamine that relieves anxiety Gabapentin (Neurontin) – anticonvulsant with antianxiety propertiesApplication to Nursing ProcessAssessment- physical and psychosocial exam, assess for self-harm or suicide, assess for cultural beliefs and background.Diagnosis- Nanda, signs and symptomsOutcomes Identification- culturally appropriate, reflect patient values, measurable goals within a time frame. Planning- interventions that are appropriate for setting and anxiety levelImplementation- follow Psychiatric-Mental Health nursing standards, identify community resources and support groups, use therapeutic communication, milieu therapy, promote self-care activities, and health teaching and promotion. Evaluation- is anxiety level reduced, can patient assume usual roles and satisfying relationships, are obsessions, compulsions, phobias, worrying decreased, can patient recognize symptoms related to anxiety and use new learned behaviors to manage anxietySelf Awareness issuesNurses must understand what and how anxiety behaviors workNurses are just as vulnerable to stress and anxiety as others Avoid allowing your own feelings and needs to hinder the care of your patients ................
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