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85 Cards in this Set
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What are the common co-morbidities of an Anxiety Disorder?
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80% of pts with anxiety disorder develop a depressive disorder
58% of its with depressive disorder are dx'd with anxiety 20% of its with anxiety d/o have co-morbid substance abuse 20-43% of its with schizophrenia experience panic attacks |
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What are the physiologic manifestations of anxiety?
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Adrenergic responses (flight or fight response)
Increased HR Increase BP Diaphoresis GI problems Sleep disturbances Appetite changes |
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What are the emotional manifestations of anxiety?
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Irritability
Anger Crying Withdrawal Fear and dread |
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What are the cognitive manifestations of anxiety?
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Forgetfulness
Preoccupation Accident/mistake prone Decreased concentration |
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What are the clinical signs of anxiety?
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Demanding, talkative
Repetitive questioning Fearful, needy Irritable, suspicious, drug seeking Sleep deprived Hostile, attention seeking Pacing, restless |
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What are the four parts to the "Anxiety Continuum"? (What are the four levels of anxiety?)
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1. Mild
2. Moderate 3. Severe 4. Panic |
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What are the characteristics of mild anxiety?
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Increased alertness
Broadened perceptual field Can process information well > motivation Good time to teach Best time to start psychotherapy |
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What a ret he characteristics of moderate anxiety?
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Perceptual field is narrowed
Information should be short/simple Basic learning opportunities Reinforce teaching by writing down information Unable to think clearly Tension, pounding heart, increased pulse and respirations, preparation, mild GI discomfort, urinary urgency, shaking |
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What are the nursing interventions for mild - moderate anxiety?
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Use specific communication to help problem-solve
Be calm, steady, relaxed Use short, simple sentences with confidence Active listening Explore behaviors that have helped in the past |
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What are the characteristics of severe anxiety?
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Perceptual field is greatly reduced
Person can focus on few small details Anxiety must be reduced before teaching or therapy Increased somatic symptoms - nausea, headache, dizziness, trembling, pounding heart, sense of impending doom |
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What are the characteristics of Panic?
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Perceptual field is completely distorted
Pt is experiencing terror Pt cannot process information, loses touch with reality Flight or flight response |
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What are the nursing interventions for severe -panic level anxiety?
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Maintain a calm manner and stay with the pt
Minimize environmental stimuli Use clear, simple directives with repetition Reinforce reality if distortions occur Attend to physical and safety needs Assess need for medication |
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What are some of the etiological theories surrounding anxiety? (Possible causes)
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1. Behavioral - anxiety is a conditioned response (anxiety-provoking stimulus paired with neutral stimulus can make neutral stimulus a trigger)
2. Social - anxiety results from identification and role modeling (i.e.: children learn from parents) 3. Cognitive - faulty thinking, overestimation of danger 4. Biological - Overstimulation of the Amygdala (fear center), Damage of the Hippocampus (processes emotions and memories) 5. Genetic - those with a genetic linkage are more susceptible (twin studies show linkage) |
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What neurotransmitters play a role in anxiety? (3)
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Norepinephrine (regulates stress response - dysregulation and higher levels associated with anxiety)
Serotonin (regulates mood, pain, appetite - lower levels associated with anxiety) GABA (has inhibitory effect on NTs, plays role in amygdala-centered fear circuits) |
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What life circumstances are predisposing to anxiety disorders?
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Childhood trauma
Anxious parenting Abuse/neglect Maternal loss |
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Is anxiety more common in men or women? Why?
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Women:
- Women have higher incidence of depression - Girls and women are more likely to be victims of mental and physical abuse - High prevalence of panic disorder, social and specific phobias, PTSD and mood disorders in women |
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What is the most common mental health disorder in older adults?
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Anxiety
(11% of people over 55 suffer from an anxiety d/o) |
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What are substance induced anxiety disorders?
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Anxiety symptoms develop with use of a substance or within a month of discontinuing use of a substance
Common substances: EtOH, caffeine, nicotine, cocaine, benzos, stimulants |
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What is an acute distress d/o? How long does it last?
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Occurs w/in a month (sometimes more) of a highly traumatic event
Person exhibits at least 3 dissociative s/sx during the trauma (numbing, detachment, absence of emotional response, reduction in awareness, amnesia) Usually resolves in 4 weeks |
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What is Generalized Anxiety D/O (GAD)?
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Persistent, excessive worry about several things
Worrying everyday for at least 6 mo Difficulty controlling worries - causes distress or impairment Dx: Must have 3 of the following (irritability, insomnia, poor concentration, tense, restless, muscle tension, fatigue) |
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What are the pharmacological interventions for anxiety and panic?
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Beta-blockers - for performance anxiety (not for panic)
Clonidine HCl (Catapres) - for GAD and panic d/o Buspirone (BuSpar) - for GAD and panic d/o Benzos Atypical antipsychotics in low doses (poor SE/benefit ratio for most pts) |
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What are the non-pharmacologic interventions for anxiety and panic?
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CBT
Exposure therapy for phobias EMDR Biofeedback/relaxation Hypnosis |
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Describe a Panic Attack. How long does a panic attack last?
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Sudden terror of fear that something catastrophic is going to happen
Sweating, palpations, SOB, chest pain, smothering sensation, feeling of dissociation Fear of "going crazy" or losing control or dying Trigger may be specific or it may occur spontaneously Lasts 1-10 mins |
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How does panic develop?
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1. Person becomes aware of a thought of bodily sensation
2. Person focuses on this thought and it gets stronger 3. Sensation is misinterpreted and the person believes something catastrophic will happen 4. Anxiety turns to panic |
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What is panic disorder?
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Recurrent, unexpected panic attacks
DVSM-IV-TR - Period of intense fear in which 4 or more sx are present: 1. Cardiopulmonary sx 2. Neurological sx 3. Psychiatric sx 4. Autonomic sx 5. GI sx |
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How do you treat Panic D/O?
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1. CBT
2. SSRIs 3. Anxiolytics |
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What is panic d/o with agoraphobia?
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anxiety/fear about being in a situation from which escape is difficult
ie: driving over bridge, being alone outside, flying, elevators |
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Nursing interventions for panic d/o:
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1. Deep breathing with pt
2. Keep expectations simple 3. Help relate feelings to onset/triggers 4. Explain physical s/sx of anxiety 5. Teach positive self-talk 6. Teach about meds and SE |
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Specific Phobias - what are:
Agoraphobia Acrophobia Claustrophobia Hydrophobia Arachnophobia Pathophobia |
Agoraphobia: fear of being in a public place
Acrophobia: fear of heights Claustrophobia: fear of enclosed spaces Hydrophobia: fear of water Arachnophobia: fear of spiders Pathophobia: fear of disease |
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What is social anxiety d/o?
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Extreme uneasiness, self-consciousness, fear of embarrassment, avoidance of social gatherings
Attending social gathering may trigger panic attack Rarely starts after age 25, more common in women |
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How do you treat social anxiety d/o?
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SSRIs
SNRIs Anxiolytics (benzos) Beta blockers Buspirone CBT |
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What is OCD? What are common Obsessions and Compulsions?
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Persistent, involuntary thoughts/worries/urges that are recognized as obsessive > causes distress > engages in repetitive behavior to neutralize thoughts
Common obsessions: contamination, neglecting to do something, objects needing to be in a particular order Common compulsions: hand washing, checking, cleaning, counting, repeating words |
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How is OCD treated?
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CBT
Clomipraine (Anafranil) Luvox (SSRI) Exposure therapy?? |
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What is PTSD? What are the symptoms?
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Three categories of PTSD symptoms: 1. Re-experiencing (Intrusive memories, nightmares, flashbacks, physiological distress) 2. Avoidance (lack of interest, detachment from others) 3. Arousal (sleep disturbance, irritability, trouble concentrating)
Chronic PTSD: s/sx evident for more than 3 mo Acute PTSD: s/sx last 1-3 mo after trauma Delayed onset PTSD: at least 6 mo pass before s/sx |
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What are risk factors for PTSD?
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Experiencing panic and terror at time of exposure is called peritraumatic panic - this is the strongest predictor.
Dissociation at time of traumatic event Psychological isolation when returning home from combat |
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How is PTSD treated?
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Emotional and behavioral stabilization
Trauma psychoeducation Stress management Resolution/detachment/termination CBT SSRIs (usually Zoloft and Paxil) |
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When working with a client with PTSD who
has frequent flashbacks and persistent symptoms of arousal, the LEAST effective nursing intervention would be to: |
Encourage client to repress memories
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What are the four main properties of Benzodiazepenes?
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1. Muscle relaxant
2. Anticonvulsant 3. Sedation 4. Anxiolytic **Do so by potentiating the effects of GABA (inhibitory NT) |
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What are the SE of Benzodiazepenes?
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Memory impairment
Psychomotor slowing Coordination difficulties Ataxia Behavioral disinhibition Addictive & tolerance develops quickly |
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Name 5 types of benzos:
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1. Alprazolam (Xanax)
2. Lorazepam (Ativan) 3. Clonazepam (Klonopin) 4. Diazepam (Valium) Chlordiazepoxide HCl (Librium) |
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What is the DSM-IV-TR criteria for substance abuse?
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maladaptive pattern of substance use manifested by recurrent and significant adverse consequences related to repeated use of the substance
Impairment in 1 or more of the following in 12 mo: 1. Failure to fulfill major role obligations (work, home, school) 2. Recurrent substance use in situations that are physically hazardous 3. Recurrent substance-related legal problems 4. Continued use despite persistent relational problems |
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What is incentive salience?
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Activation of dopamine transmission causes "cue sensitivity" (overwhelming urge to use the drug when presented with the stimulus)
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What are the four stages of Jellinek's Model of Alcohol Progression?
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Stage I: Prealcoholic phase (relief of everyday stress, tolerance develops)
Stage II: Early alcoholic phase (begins with blackouts, alcohol is now required, denial and rationalization are used) Stage III: Crucial phase (loss of control with physiological dependence) Stage IV: Chronic phase (emotional and physical disintegration, psychosis) |
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What are some physiological complications seen in alcoholics?
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Generalized depression of CNS
Peripheral neuropathy (pain, burning, tingling of extremities) Alcoholic myopathy (sudden onset of muscle pain, rapid rise in musc. enzymes) Alcoholic cardiomyopathy (weakening of cadiac muscle, CHF, arrhythmia) Gastritis Pancreatitis Cirrhosis Leukopenia Thrombocytopenia Sexual dysfunctions |
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What is Wernicke's Encephalopathy?
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Most serious form of thiamine deficiency
Death will occur w/o thiamine replacement Characterized by diplopia, ataxia, somnolence, stupor, paralysis of ocular muscles |
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What is Korsakoff's Psychosis?
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-Frequently encountered in clients recovering from Wernickie's encephalopathy
-Syndrome of confusion -Loss of frequent memory |
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When do symptoms of alcohol withdrawal begin?
What are the symptoms? |
4-12 hours after cessation of alcohol
-coarse tremors of hands/tongue/eyelid -nausea, vomiting -tachycardia -diaphoresis -elevated BP -headache -insomnia -anxiety, irritability, hallucinations |
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What is Delirium Tremens (DTs)?
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Complicated alcohol withdrawal syndrome
Onset on 2nd or 3rd day following cessation Ultimate level of CNS irritability Extreme motor agitation Proverbial "Pink Elephants" Seizures can occur |
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What is the main nursing assessment tool for Alcohol Withdrawal?
What is the main nursing assessment tool for Alcohol Use/Abuse? |
CIWA - used to see if benzos need to be used during withdrawal
CAGE - "yes" answers indicate a problem with alcohol |
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What is Disulfiram (Antabuse)? What are the contraindications?
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Acts as a deterrent to drinking by producing symptoms of discomfort when taken with alcohol.
Taken daily. Contraindicated in its with cardiac, renal or hepatic disease |
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What is Naltrexone (ReVia, Trexan)?
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Decreases cravings for alcohol and heroine
Does not create a "narcotic high" Blocks opiate receptors Injectable forms = Vivitrex, Vivitrol |
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What is Acamprosate (Campral)?
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Treatment for alcoholism
Restores balance of neuronal excitation and inhibition Used in clients that are abstinent from alcohol |
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What is Topiramate (Topamax)?
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Treatment for alcoholism
Decrease in alcohol cravings |
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What is the main class of drugs used to treat alcohol? What are the four brand/trade names that are most commonly used in alcohol withdrawal?
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Benzodiazepenes
1. Chlordiazepoxide (Librium) 2. Diazepam (Valium) 3. Lorazepam (Ativan) 4. Oxazepam (Serax) |
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What are the three anticonvulsants used in alcohol withdrawal?
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Tegretol
Depakote Neurontin |
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What are signs of stimulant intoxication?
What can the intoxication (not w/d) be treated with? |
Amphetamine/cocaine: euphoria, affective blunting, changes in social behavior, dilated pupils, diaphoresis, chills, n/v, respiratory depression, tremors, seizures
Can be treated with Librium and Haldol |
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When do stimulant withdrawal symptoms appear?
What are the symptoms? How are the withdrawal symptoms treated? |
Develops within a few hours to several days after cessation of heavy prolonged use
Dysphoria, fatigue, insomnia or hypersomnia, increased appetite, agitation Treated by reducing craving and managing depression. Drug used for cocaine w/d: Desipramine |
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What are some types of opiates that are commonly abused?
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Opium
Heroin Morphine Codeine Fentanyl Methadone Dilaudid Oxycotin Vicodin |
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What effects to opiates have on the body?
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largely depressive on CNS
euphoria mood lability drowsiness dec pain respiratory depression dec peristalsis in GI - constipation hypotension (in lg doses) pupils constrict |
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When do heroin w/d symptoms occur?
When do methadone w/d symptoms occur? What are the s/sx of opiate w/d? |
Heroin: occur 6-12 hrs after last dose, peak 1-3 days, subside over 5-7 days
Methadone: occur 1-3 days after last dose, subside after 10-14 days Dysphoric mood, cravings, n/v, pupillary dilation, muscle pain, rhinorrhea, lacrimation, diaphoresis, abdominal cramping, diarrhea, fever, insomnia, piloerection |
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What drug is used for methadone w/d?
What drug is used for narcotic w/d? |
Clonidine - for methadone w/d
Buprenophine (Suboxone) - decreases cravings, does not cause high, relieves w/d sx, contains naloxone |
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What effects do hallucinogens have on the body?
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Pupil dilation
n/v tremors loss of appetite diaphoresis insomnia heightened response to color, texture, sounds derealization, depersonalization increased libido hallucinations! anxiety, maladaptive responses paranoia |
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How is hallucinogen intoxication treated?
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With Valium and Haldol
(PCP intoxication occurs w/in an hour of use, but delirium can occur 24 hours - 1 week following use) |
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How long can these drugs be detected in the urine and blood?
1. Heroin 2. Methadone 3. Xanax 4. Cocaine 5. Cannabis |
1. U= 1-2d B= 3d
2. U= 1-7d B= 1-7d 3. U= 24-36h B=7d 4. U=2-3d B= 2-3d 5. U= 7-30d B= 15wks |
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What is Bipolar I?
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At least one episode of mania alternates with major depression, psychosis may be present
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What is Bipolar II?
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Hypomanic episodes alternate with major depression
No psychosis Hypomania may increase functioning, resembles euphoria Depression equated with high suicide risk |
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What is cyclothymia?
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Hypomanic episodes alternate with minor depressive episodes
Irritability At least 2 yrs in duration |
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What is mixed bipolar d/o?
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Rapidly alternating moods accompanied by symptoms r/t mania and depression
Can exhibit psychotic features |
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What is rapid cycling?
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4 or more episodes occur in a 12-mo period
More severe sx poor global functioning, high recurrence rates, resistance to conventional tx |
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What is mania?
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change in mood expressed by feelings of elation
inflated self-esteem grandiosity hyperactivity accelerated thinking |
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What is depression?
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diagnostic profile related to bipolar disorder is similar to that of MDD
except in bipolar d/o pt must have had one or more manic episodes |
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What is Stage I Mania, Stage II Mania, Stage III Mania?
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I: Hypomania - does not cause marked impairment, mood is cheerful and expansive
II: Acute Mania - marked impairment in social/occupational functioning, euphoria with mood variation, fragmented/rapid thinking, flight of ideas, pressured speech III: Delirious Mania - clouding of consciousness, confusion, disorientation (rare form) |
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In the etiology of bipolar d/o, what are the biological, neurobiological and neuroendocrine factors?
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Biological - 80-90% hereditary, 5-10 times higher risk for those who have relatives with bipolar, irregularities on chromosomes 13 and 15
Neurobiological - NT imbalances, receptor site insensitivity, dysregulation of neuro-circuits in prefrontal cortex Neuroendocrine - hypothyroidism associated with depressed mood and rapid cycling, hypothalamic-pituitary-thyroid-adrenal axis disrupted |
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What are the diagnostic criteria for hypomania and mania?
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Period of elevated, expansive or irritable mood for at least: 4 days (hypomania) or 1 week (mania)
Must have 3 or more of the following present: 1. inflated self-esteem or grandiosity 2. decreased need for sleep 3. more talkative, pressured speech 4. flight of ideas, racing thoughts 5. distractability 6. inc in goal directed activity or psychomotor activities 7. excessive involvement in pleasurable activities |
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What are some nursing diagnoses for mania?
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Risk for injury
Risk for other-directed violence Risk for self-directed violence Risk for suicide Impaired social interaction Imbalanced nutrition: less than body requirements Deficient fluid volume Self-care deficit (bathing, dressing, feeding, toileting) Disturbed sleep pattern Ineffective coping Defensive coping Disturbed thought processes Interrupted family processes Caregiver role strain Impaired verbal communication |
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What are the nursing outcomes for bipolar d/o in the acute phase, continuation phase and maintenance phase?
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Acute - focus on injury prevention, client will be: well hydrated, maintain stable cardiac status, maintain tissue integrity, get sufficient sleep, make no attempt at self harm, demonstrate impulse control
Continuation (4-9 mo) - relapse prevention, knowledge of illness and meds, consequences of substance addiction, knowledge of s/s of relapse, attendance at support groups Maintenance - prevention of relapse, supportive therapies and skills training |
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What are the first line treatments in bipolar d/o?
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Lithium
Depakote Lamictal Note: Atypical antipsychotics can be used for psychotic features (Seroquel) |
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What types of bipolar d/o is Lithium most effective? least effective?
How long does it take to reach therapeutic levels? |
Most - Bipolar I, recurrent manic and depressive episodes
Least - mixed mania, rapid cycling, those w/ atypical features Therapeutic levels in 7-14 days Lithium inhibits 80% of acute manic/hypomanic episodes in 10-21 days |
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What are the trade names of Lithium?
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Lithane
Eskalith Lithonate |
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What are therapeutic levels of Lithium?
What are the expected SE at this level? How often are serum levels measured? |
0.6 - 1.2 mEq/L
Sx: fine hand tremor, mild thirst, mild nausea, weight gain Measured every 5 days until therapeutic level reached, then every 3 months until 6-12mo of stability reached (measured more frequently in older adults) |
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What serum levels indicate early toxicity of Lithium?
What are the signs of early toxicity? |
1.5 mEq/L
Sx: n/v/d, thirst, polyuria, lethargy, slurred speech, muscle weakness To-do: Withhold med, take bld levels and address dehydration |
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What serum levels indicate advanced toxicity of Lithium?What are the signs of advanced toxicity?
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1.5 - 2.6 mEq/L
Sx: coarse hand tremor, persistent GI upset, confusion, muscle hyperirritability, EEG changes, incoordiantion, sedation To-do: stop med, hospitalize, rehydrate |
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What serum levels indicate severe toxicity of Lithium?What are the signs of severe toxicity?
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>2.6 mEq/L (over 3.5 causes death)
Sx: ataxia, delirium, lg amt of dilute urine, EEG changes, blurred vision, seizures, severe hypotension, coma |
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What drugs are used in controlling bipolar d/o other than Lithium?
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Anticonvulsant drugs (AEDs):
Depakote (for Lithium non responders in acute mania) Tegretol (for rapid cycling, paranoia, hostility) Lamictal (for bipolar depression) Atypical antipsychotics: Abilify (mania maintenance) Zyprexa (mania) Seroquel (depression and mania) Risperdal (severe mania) Geodon (mania) |
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What are non-pharmacologic interventions for bipolar d/o?
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ECT (effectively subdues mania, rapid cycling, depressive episodes, acutely suicidal pts)
Milieu management (reduce stimuli, safety) |
