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Case Study 148 PaperMeghan NaultUniversity of New HampshireThe following case study refers to a 35-year old man named G.G. who was brought to the emergency department (ED) at 1000 hours by ambulance after having difficulty breathing.It is 1000 hours in the emergency department (ED) when the ambulance brings in G.G., a 35-year-old man who is having difficulty breathing. He complains of chest pain and tightness, dizziness, palpitations, nausea, paresthesia, and feelings of impending doom and unreality; he is having trouble thinking clearly. He tells you, “I don’t think I'm going to make it. I must be having a heart attack.” He is diaphoretic and trembling. His vital signs are 184/92, 104, 28, 98.4°F (36.9°C). This episode began at work during a meeting at approximately 0920 and became progressively worse. A co-worker called 911 and stayed with him until medical help arrived. The patient has no history of cardiac problems (Harding, M.,, Snyder, J., Preusser, B., & Winningham, , M., 2013).With G.G. presented with these symptoms in the emergency department there are many initial steps to take. Looking at the signs, it is obvious the patient has high levels of anxiety but many other conditions can present similarly such as a heart attack or pulmonary problem can also present with similar symptoms. To rule out a heart attack, troponin, CK-MB, and serum myoglobin tests should be performed. G.G. should also have an EKG as well. It is also important to listen to lung sounds and see if the patient is having trouble breathing which can present similarly as well (Sommer et al., 2013).If other diagnoses these are ruled out, his anxiety should be further investigated. Panic attacks can occur from an anxiety disorder, but can also be caused by other medical conditions as well. These conditions include hyperthyroidism, hyperparathyroidism, seizure disorders, arrhythmias, and drug or medicine overdoses (DSM-V, 2013). Labs should be run to rule out underlying problem. T3, T4, and TSH labs should be run to rule out hyperthyroidism and serum calcium should be observed for hyperparathyroidism. An EKG should be done to detect an arrhythmia and a holter monitor should be worn if further investigation is needed (DSM-V, 2013). In addition a urinalysis can be performed to test for drugs if deemed appropriate. Many overdoses can cause intense anxiety attacks. Withdrawals from depressants, such as alcohol, can also cause a hyper-anxious state (Sommer et al., 2013).After a full medical work up, it is found that G.G. is stable and his symptoms resolve after he is given Lorazepam (Ativan) 1 mg IV push. All the lab work and EKG results are within normal parameters and there is no evidence of any physical condition. G.G. is diagnosed with having a panic attack. He admits to having three similar episodes in the past 2 weeks that were not nearly as severe or long lasting (Harding, Snyder, Preusser, & Winningham, 2013).According to the Anxiety and Depression Association of America (ADAA), (2016), panic attacks are a very common and treatable condition. About six million people in the United States experience panic disorder every year. Women are twice as likely to be diagnosed and the average age of diagnosis is between the ages of 22-23 (DSM-V, 2013). Many people experiencing a panic attack end up in the hospital, fearing they have a serious disease or claiming they are going to die, just as G.G. did. G.G.’s diagnosis was made based on a number of factors. He has no significant past medical history and is otherwise a relatively healthy 35-year-old man. His labs and EKG were all within normal parameters, indicating no underlying physiological cause. G.G. also had all of signs and symptoms ofof a panic attack based onoutlined in the DSM-V criteria, and his symptoms were resolved with the Lorazepam (Ativan). He has experienced similar episodes in the past as well that all resolved. The patient states that he has had trouble remembering things lately since the onset of his anxiety. With panic disorder, there are numerous symptoms and everyone experiences them different. In G.G’s case, his panic disorder has been causing some trouble with short-term memory, which is a common occurrence. First, G.G. has not been sleeping much, which can cause trouble remembering and also lead to increased amount of anxiety. , which is also a cause. Once a moderate level of anxiety is reached, the perceptual field decreases and the patient may experience selective attention (Sommer et al., 2013). Since G.G was experiencing severe, or panic level anxiety, his symptoms would be further amplified. This distractibility and unawareness of surroundings can be perceived as memory loss. The Ppatients tend to focus on the intrusive thoughts and negative thinking relating to their anxiety and not block out what is going on in their environment. This can lead tocause patients to experiencing e a feeling of “blacking out” or a “memory lapse” while having a panic attack. Also, forgetting some things on a daily basis is only human, people with anxiety;however, however people with anxiety, tend to focus on their forgetfulness more frequently, believing that it stems from a deeper reason or disease (“Anxiety Can Cause Memory Problems,” 2015). There has been evidence supporting the idea that higher levels of stress and anxiety effect both learning and memory. Duration and level of stress or anxiety may affect the brain in different ways.An article by Karim Alkadhi at the University of Houston (2013) found the following:Severe and/or prolonged stress causes over activation and dysregulation of the hypothalamic pituitary adrenal (HPA) axis thus inflicting detrimental changes in the brain structure and function. Therefore, chronic stress is often considered a negative modulator of the cognitive functions including the learning and memory processes. The same article also shared that daily stress, not experienced over a long period of time, also affects short-term memory. The article additionally discovered that stress is highly correlated to other mental illnesses and exacerbations in current diagnoses (Alkadhi, 2013). So G.G., who is experiencing short-term memory problems related to his panic attacks, could experience longer-term problems if the anxiety persists on a daily basis. Stressful situations may also exacerbate his panic disorder, or lead to further complications or comorbidities in the future. Since stressful situation can make his condition worse, the patient is asked about recent life events. He shares that he has been under severe stress at work and at home. He is going through a divorce and also lost a child last summer in a motor vehicle accident. He also shares that his company is downsizing and he will probably be out of a job soon. In addition, G.G. has not been sleeping well the past couple of months and has lost about 20 pounds, which could show that he has not been taking time to eat or care for himself properly (Harding, Snyder, Preusser, & Winningham, 2013). Allostatic load is defined as the wear and tear stress puts on your body over time (McEwen, 2005). If this stress response keeps occurring, and time is not taken to relieve this stress, it can have lasting negative impacts on the human body. The stressful home environment, the divorce, the loss of a child, the unsteady employment, and the lack of sleep are all stressful events that build on this allostatic load and could have triggered his anxiety to build to the point of a panic attack.According to a study published in the Journal of Affective Disorders (2011), not only can stressful life events trigger panic disorder, they can also intensify them. They categorized “stressful life events” such as job loss, health decline of spouse, family argument, being arrested, loss of home, etc. They then monitored the patients with panic disorder over a 12-week spans before and/or after the stressful life event. They found that panic attack symptoms were dramatically worse after the stressful event, not in the time leading up to it (Moitra et al., 2011). This shows how some of G.G.’s problems could have not only triggered his panic attack, but also made the symptoms much more severe, frequent, and longer lasting. With the repeated attacks, a diagnosis of panic disorder is likely. The DSM-V lists criteria to help physicians make the diagnosis and to distinguish panic attacks from panic disorder. According to the updated DSM, a panic attack is not coded and is not a mental disorder because it accompanies other diagnoses (DSM-V, 2013). The DSM-V defines criteria for panic attack as:An abrupt surge of intense fear or intense discomfort that reaches a peak within minutes and during which time four (or more) of the following symptoms occur: 1) palpitations, pounding heart or accelerated heart rate, 2) sweating, 3) trembling or shaking, 4) sensations od shortness or breath or smothering, 5) feelings of choking, 6) chest pain or discomfort, 7) nausea or abdominal distress, 8) feeling dizzy, unsteady, light-headed or faint, 9) chills or heat sensation, 10) paresthesia (numbness or tingling sensations), 11) Derealization (feelings of unreality) or depersonalization (being detached from oneself), 12) feeling of losing control or “going crazy”, 13) fear of dying (DSM-V, 2013). G.G reported many of these symptoms when he presented in the ED. The manual also explains the two types of panic attacks, expected and unexpected. Expected attacks occur when the person is confronted with an obvious trigger, such as a phobia. Unexpected panic attacks occur “out of the blue” and happen from no present or obvious trigger, but can be caused from built up stress (DSM-V, 2013). Based on these definitions, G.G. experienced an unexpected panic attack.The DSM-V also lists criteria for panic disorder as well, which G.G. was diagnosed with since has experienced multiple panic attacks. They also emphasize that the panic attacks should not stem from a drug or medication, or from another medical condition such as hyperthyroidism. The DSM-V define criteria for Panic Disorder as:Recurrent unexpected panic attacks… At least one of the attacks has been followed by 1 month (or more) of one or both of the following: 1) Persistent concern or worry about additional panic attacks or their consequences (e.g., losing control, having a heart attack, “going crazy”). 2) A significant maladaptive change in behavior related to the attacks (e.g., behaviors designed to avoid having panic attacks, such as avoidance of exercise or unfamiliar situations)” (DSM-V, 2013).With G.G’s diagnosis of panic disorder, the ED physician gives him a prescription for a “weeks worth” of Alprazolam (Xanax) and instructs him to see his primary care physician for further treatment and evaluation (Harding, Snyder, Preusser, & Winningham, 2013). Benzodiazepines are a schedule IV drug on the Controlled Substances Act (Sommer et al., 2013). G.G. was only given a weeks worth because this medication can be fatal if overdose occurs, and . pPatients can use this medication to commit suicide in larger quantities. Also, benzodiazepines are typically used for short-term treatment of anxiety disorders due to their high risk forof dependency. Drug overdoses, specifically benzodiazepines, have been increasing recently. This class of medication can be especially dangerous when combined with alcohol. Statistics from the Center for Disease Control and Prevention (CDC) was published in 2014. They found that in the United States there were 408,021 emergency department visits related to benzodiazepine abuse and that 27.2% of these involved alcohol in combination. These overdoses were most common in men ages 45-54. There are other medications to consider in treating panic attacks longer term. However the American Psychiatric Association (2009) released clinical guidelines to treat panic disorder. They recommend the use of selective serotonin reuptake inhibitors (SSRI’s), serotonin-norepinephrine reuptake inhibitors (SNRI’s), and tricyclic anti- depressants (TCA’s). Medications should be combined with cognitive behavioral therapy (CBT) for best results. Although these are first line recommendations, there are other medications available including Buspirone (BuSpar), and Beta-blockers (Sommer et al., 2013). It is important to note inform the patient that that they may not see a difference from taking these medications until after 3-6 weeks, due to length of time necessary for the medications to reach their full therapeutic benefit.se medications reach full therapeutic benefit after 3-6 weeks. All medications may come with side effects and have withdrawal symptoms. As nurses it is important to educate patients on the potential side effects. For example, SSRI’s can cause serotonin syndrome, which is caused when serotonin levels get too high. This condition usually resolves when the medication is stopped. Symptoms can be as mild as shivering and diarrhea, and can progress to seizures, muscle rigidity, and death if not treated (“Serotonin Syndrome”, 2015). Other common generalized side effects of these medications include sexual dysfunction, nausea, headaches, and weight gain (Sommer et al., 2013).As nurses we should also educate the patients on the importance of adhering to their regimen and tapering the doses if they wish to stop taking the medication. This is important because many of the anti-depressants have unpleasant withdrawal effects. It is important to remind the patient that these medications work differently for everyone, and it may take a while before the patient finds the one that works best for them. In addition to pharmacological treatment, G.G., should consider other coping mechanisms as well. Cognitive behavioral therapy (CBT) has been shown to be very effective in the treatment of panic disorder. A study published in the Comprehensive Psychiatry Journal (2014), described the “Effect of cognitive-behavioral group therapy for panic disorder in changing coping strategies.” They found that in just 12 sessions, patients used fewer “confrontation, escape, and avoidance strategies” after the therapy. They changed these maladaptive techniques for healthier techniques including “acceptance of responsibility, problem solving, positive appraisal and self-control.” (Wesner, Gomes, Detzel, Blaya, Manfro, Heldt, 2014). By using CBT with pharmacological treatments, G.G., will be able to lessen anxiety and know howgain valuable coping skills to use if he gets another panic attack. to cope with it if it happens again. In adding to the effectiveness of CBT, other relaxation techniques can also be implemented to lessen G.G.’s anxiety. This includes controlled breathing techniques, participating in progressive muscle relaxation, biofeedback, yoga and meditation. Lifestyle modifications are also important key to reducing G.G.’s anxiety level. This includesing regular exercise, exercisea balanced diet, diet, and limiting the amounthis consumption of nicotine, alcohol, and caffeine( Halter, Varcarolis, 2014) intake. Since we are unaware of G.G.’s habits, it is still important to educate on the importance of abstaining from drugs, alcohol, and nicotine. A study conducted by Bakhshaie J., Zvolensky M., and Goodwin R., (2015), showed the effects cigarette smoking can have on panic attacks infor middle- aged adults. Theirere results findings showed that daily smoking significantly increased the onset and persistence of panic attacks. It also showed that smoking cessation reduced the incidence of panic attacks So Ooverall, panic disorder is a treatable condition. With cognitive behavioral therapy, lifestyle modifications and medication, G.G. had a dramatic reduction in the amount of panic attacks and anxiety he experienced. With this help G.G. made an appointment with his company’s Employee Assistance Program to take advantage of the resources offered for counseling to help him work with his coping strategies. In addition, his primary care physician starts him on an SSRI. After a few months G.G.’s panic attacks have become very rare and he works on preparing a resume to seek new employment before his company has another round of job cuts (Harding, Snyder, Preusser, & Winningham, 2013).According to the Anxiety and Depression Association of America (ADAA) (2016), anxiety disorders affect 40 million adults in the United States yet one-third of this population does not receive treatment. It is important to educate patients about anxiety disorders and the available resources. With such a large percentage of the population suffering with this disorder, there are online, group and individual therapy supports all over the country. With more education and awareness, anxiety disorder will be treated as a serious disease and the amount of people receiving help or treatment will increase. ReferencesAlcohol Involvement in Opioid Pain Reliever and Benzodiazepine Drug Abuse–Related Emergency Department Visits and Drug-Related Deaths — United States, 2010. (2014). Retrieved March 21, 2016, from mmwrhtml/mm6340a1.htmAngeli, E., Wagner, J., Lawrick, E., Moore, K., Anderson, M., Soderlund, L., & Brizee, A. (2010, May 5). General format. Retrieved from Can Cause Memory Problems. (n.d.). Retrieved March 06, 2016, from , J., Zvolensky, M. J., & Goodwin, R. (2015). Cigarette smoking and the onset and persistence of panic attacks during mid-adulthood in the United States: 1994–2005. Drug & Alcohol Dependence, 156e14-e14 1p. doi:10.1016/j.drugalcdep.2015.07.956Diagnostic and statistical manual of mental disorders: DSM-5 (5th ed., DSM). (2013). Washington, D.C.: American Psychiatric Association.Halter, M. J., & Varcarolis, E. M. (2014). Varcarolis' foundations of psychiatric mental health nursing: A clinical approach. St. Louis, MO: Elsevier.Harding, M., Snyder, J. S., Preusser, B. A., & Winningham, M. L. (2013). Winningham's critical thinking cases in nursing: Medical-surgical, pediatric, maternity, and psychiatric (6th ed.). St. Louis, MO: Elsevier/Mosby.McEwen, B. S. (2005). Stressed or stressed out: What is the difference? Retrieved March 22, 2016, from , E., Dyck, I., Beard, C., Bjornsson, A., Sibrava, N., Weisberg, R., & Keller, M. (2011). Impact of stressful life events on the course of panic disorder in adults. Journal Of Affective Disorders, 134(1-3), 373-376 4p.Panic Disorder & Agoraphobia. (2016). Retrieved March 20, 2016, from syndrome. (2015, November). Retrieved March 20, 2016, from , S., Johnson, J., Roberts, K., Redding, S. R., Churchill, L. Henry, N., McMichael, M., (2013). ATI: RN Mental health nursing (9.0th ed., Content Mastery Series). Assessment Technologies Institute, LLC.Sommer, S., Johnson, J., Roberts, K., Redding, S. R., Churchill, L., Ball, B., Henry, N., Leehy, P., Roland, P., (2013). ATI: RN Adult Medical Surgical Nursing (9.0th ed., Content Mastery Series). Assessment Technologies Institute, LLC.Treating Panic Disorder A Quick Reference Guide. (2009). Retrieved March 20, 2016, from ................
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