ATI RN Pharmacology for Nursing (8th edition) Chapter 7 Anxiety and Trauma-Related Disorders PDF

07/24/15 April 19, 2019 9:51 AM rm_rn_2019_pharm_chp7 CHAPTER 7 UNIT 2 MEDICATIONS AFFECTING THE NERVOUS SYSTEM CHAPTER 7 Anxiety and Trauma- and Stressor-Related...

07/24/15 April 19, 2019 9:51 AM rm_rn_2019_pharm_chp7 CHAPTER 7 UNIT 2 MEDICATIONS AFFECTING THE NERVOUS SYSTEM CHAPTER 7 Anxiety and Trauma- and Stressor-Related 7.1 Medications at a glance Disorders Major medications used to treat anxiety disorders Benzodiazepine sedative hypnotic anxiolytics, such as lorazepam, alprazolam, diazepam, and clonazepam Anxiety disorders include generalized anxiety Atypical anxiolytic/nonbarbiturate anxiolytics, such as buspirone disorder, panic disorder, obsessive-compulsive SELECTED ANTIDEPRESSANTS disorder, social anxiety disorder, and Selective serotonin reuptake inhibitors (SSRIs): paroxetine, sertraline, fluoxetine, posttraumatic stress disorder. Persistent citalopram, escitalopram, and fluvoxamine anxiety can become disabling and can require Serotonin-norepinephrine reuptake inhibitors (SNRIs): venlafaxine, duloxetine, and desvenlafaxine intervention with therapy, biofeedback, relaxation OTHER ANTIDEPRESSANTS: Tricyclic antidepressants (TCAs): amitriptyline, imipramine, clomipramine techniques, and the use of medications. Other medications used less frequently Psychological manifestations of anxiety Monoamine oxidase inhibitor (MAOI): phenelzine disorders can include fear and apprehension. Mirtazapine Trazodone Physical manifestations can include palpitations, Antihistamines, such as hydroxyzine pamoate and hydroxyzine hydrochloride tachycardia, and shortness of breath. Beta blockers, such as propranolol Alpha blockers, such as prazosin Sedative hypnotic anxiolytics: Centrally-acting alpha2 agonist, such as clonidine Anticonvulsants, such as gabapentin and pregabalin Benzodiazepines Antipsychotics, such as quetiapine SELECT PROTOTYPE MEDICATION: Alprazolam In addition to anxiety disorders, some of these medications are used to treat adjustment disorders, OTHER MEDICATIONS dissociative disorders, and depressive disorders. Diazepam Lorazepam Chlordiazepoxide Clorazepate Oxazepam Clonazepam PURPOSE COMPLICATIONS CNS depression EXPECTED PHARMACOLOGICAL ACTION Sedation, lightheadedness, ataxia, decreased Benzodiazepines enhance the inhibitory effects of cognitive function gamma-aminobutyric acid (GABA) in the CNS. Relief from anxiety occurs rapidly following administration. Short- CLIENT EDUCATION term use recommended due to potential for dependence. Observe for CNS depression. Notify the provider if effects occur. THERAPEUTIC USES Avoid activities that require alertness (driving, operating heavy equipment/machinery). Generalized anxiety disorder (GAD) and panic disorder Avoid alcohol and other antianxiety medications OTHER USES FOR BENZODIAZEPINES due to potentiated depressant effects such as severe Trauma- and stressor-related disorders: Acute stress respiratory depression. disorder (ASD) and posttraumatic stress disorder (PTSD) Hyperarousal manifestations of dissociative disorders Anterograde amnesia Seizure disorders Difficulty recalling events that occur after dosing Insomnia Muscle spasm CLIENT EDUCATION: Observe for manifestations. Notify Alcohol withdrawal (for prevention and treatment of the provider if effects occur. acute manifestations) Induction of anesthesia Amnesic prior to surgery or procedures RN PHARMACOLOGY FOR NURSING CHAPTER 7 ANXIETY AND TRAUMA- AND STRESSOR-RELATED DISORDERS 51 07/24/15 April 19, 2019 9:51 AM rm_rn_2019_pharm_chp7 07/24 Toxicity INTERACTIONS Acute toxicity CNS depressants (alcohol, barbiturates, opioids) can result in respiratory depression. Anticonvulsants and Oral toxicity: drowsiness, lethargy, confusion antihistamines can cause increased CNS depression. IV toxicity: can lead to respiratory depression, severe CLIENT EDUCATION hypotension, or cardiac/respiratory arrest Avoid alcohol and other substances that cause Benzodiazepines for IV use include: CNS depression. Diazepam Avoid activities that require alertness (driving, operating Lorazepam heavy equipment/machinery). NURSING ACTIONS Grapefruit juice can reduce metabolism. For oral toxicity, gastric lavage is used, followed by the CLIENT EDUCATION: Avoid the use of grapefruit juice. administration of activated charcoal or saline cathartics. High-fat meals can reduce absorption. Administer flumazenil for benzodiazepine toxicity to CLIENT EDUCATION: Do not take with fatty foods. counteract sedation and reverse adverse effects. Monitor vital signs, maintain patent airway, and provide fluids to maintain blood pressure. Have resuscitation equipment available. NURSING ADMINISTRATION Administer the medication with meals or snacks if CLIENT EDUCATION: Watch for manifestations. Notify the gastrointestinal upset occurs. provider if these occur. Administer the medication at bedtime if possible due to sedation. Paradoxical response Advise clients to swallow sustained-release tablets and Insomnia, excitation, euphoria, anxiety, rage to avoid chewing or crushing the tablets. CLIENT EDUCATION: Watch for manifestations. Notify the provider if these occur. CLIENT EDUCATION Do not take benzodiazepines in larger amounts or more Withdrawal effects often than prescribed without consulting the provider. Include anxiety, insomnia, diaphoresis, tremors, Dependency can develop during or after treatment. lightheadedness, delirium, hypertension, muscle Notify the provider if indications of withdrawal occur. twitching, and seizures Store benzodiazepines in a secure place to prevent misuse by others. CLIENT EDUCATION Swallow sustained-release tablets and do not crush or Withdrawal effects are not common with short-term use. chew them. If taking benzodiazepines regularly and in high doses, taper the dose over several weeks. Atypical anxiolytic/ CONTRAINDICATIONS/PRECAUTIONS nonbarbiturate anxiolytic Benzodiazepines are Pregnancy Risk Category D SELECT PROTOTYPE MEDICATION: Buspirone medications that can cause fetal harm, and harm to infants due to transmission through human milk. These PURPOSE medications are avoided in clients who are pregnant EXPECTED PHARMACOLOGICAL ACTION or breastfeeding. The exact antianxiety mechanism of this medication Benzodiazepines are classified under Schedule IV of the is unknown. This medication binds to serotonin and Controlled Substances Act. dopamine receptors. Dependency is much less likely Benzodiazepines are contraindicated in clients who have than with other anxiolytics, and use of buspirone does sleep apnea, respiratory depression, or glaucoma. not result in sedation or potentiate the effects of other Use benzodiazepines cautiously in older adult clients CNS depressants. It carries no risk of misuse. and those who have liver disease or a history of The major disadvantage is that antianxiety effects substance use disorder. develop slowly. Initial responses take a week, and at Benzodiazepines are generally used short-term due to least 2 to 4 weeks for it to reach its full effects. As a the risk for dependence. result of this pharmacological action, buspirone is taken on a scheduled basis, and is not suitable for PRN usage. THERAPEUTIC USES Panic disorder Social anxiety disorder Obsessive-compulsive and related disorders Trauma- and stressor-related disorders, PTSD Generalized anxiety disorder (GAD) 52 CHAPTER 7 ANXIETY AND TRAUMA- AND STRESSOR-RELATED DISORDERS CONTENT MASTERY SERIES 07/24/15 April 19, 2019 9:51 AM rm_rn_2019_pharm_chp7 COMPLICATIONS Selective serotonin Dizziness, nausea, headache, lightheadedness, agitation reuptake inhibitors (SSRI antidepressants) CLIENT EDUCATION Take with food to decrease nausea. Avoid activities that require alertness until effects SELECT PROTOTYPE MEDICATION: Paroxetine are known. Most adverse effects are self-limiting. OTHER MEDICATIONS Sertraline Constipation Citalopram CLIENT EDUCATION: Increase fiber and fluid. Escitalopram Suicidal ideation Fluoxetine NURSING ACTIONS: Monitor and report manifestations of Fluvoxamine depression and thoughts of suicide. PURPOSE CONTRAINDICATIONS/PRECAUTIONS EXPECTED PHARMACOLOGICAL ACTION Buspirone is Pregnancy Risk Category B. Paroxetine selectively inhibits serotonin reuptake, Buspirone is not recommended for use by clients who allowing more serotonin to stay at the junction of are pregnant or breastfeeding. the neurons. Use buspirone cautiously in older adult clients and It does not block uptake of dopamine or norepinephrine. clients who have liver and/or renal dysfunction. The medication has a long effective half-life. A time Buspirone is contraindicated for concurrent use with frame of up to 4 weeks is necessary to produce MAOI antidepressants or for 14 days after MAOIs are therapeutic medication levels. discontinued. Hypertensive crisis can result. THERAPEUTIC USES Paroxetine INTERACTIONS Generalized anxiety disorder (GAD) Erythromycin, ketoconazole, St. John’s wort, and Panic disorder: Decreases both the frequency and grapefruit juice can increase the effects of buspirone. intensity of panic attacks and also prevents anticipatory CLIENT EDUCATION anxiety about attacks Avoid the use of these antimicrobial agents. Obsessive-compulsive disorder (OCD): Reduces Avoid herbal preparations containing St. John’s wort. manifestations by increasing serotonin Avoid drinking grapefruit juice. Social anxiety disorder Trauma- and stressor-related disorders Dissociative disorders NURSING ADMINISTRATION Depressive disorders Adjustment disorders Labeled for short-term treatment of anxiety, but has shown therapeutic benefit for as long as a year Sertraline: indicated for panic disorder, OCD, social anxiety disorder, and PTSD. CLIENT EDUCATION Escitalopram: indicated for GAD and OCD. Take the medication with meals to prevent Fluoxetine: used for panic disorder, OCD, and PTSD. gastric irritation. Fluvoxamine: used for OCD and social anxiety disorder. Effects do not occur immediately. It can take a week to notice the first therapeutic effects and 2 to 4 weeks for the full benefit. Take on a regular basis and not PRN. Tolerance, dependence, or withdrawal effects are not an COMPLICATIONS issue with this medication. Early adverse effects First few days/weeks: Nausea, diaphoresis, tremor, fatigue, drowsiness CLIENT EDUCATION Report adverse effects to the provider. Take the medication as prescribed. These effects should soon subside. RN PHARMACOLOGY FOR NURSING CHAPTER 7 ANXIETY AND TRAUMA- AND STRESSOR-RELATED DISORDERS 53 07/24/15 April 19, 2019 9:51 AM rm_rn_2019_pharm_chp7 07/24 Later adverse effects Withdrawal syndrome After 5 to 6 weeks of therapy: Insomnia, headache, and Nausea, sensory disturbances, anxiety, tremor, sexual dysfunction (impotence, delayed or absent orgasm, malaise, unease delayed or absent ejaculation, decreased sexual interest) NURSING ACTIONS: Minimized by tapering the CLIENT EDUCATION: Report problems with sexual medication slowly function (managed with dose reduction, medication CLIENT EDUCATION: Do not discontinue use abruptly holiday, changing medications). but slowly taper the dose of medication before stopping, especially with long-term use. Weight changes Occurrence of weight loss early in therapy that can be Postural hypotension followed by weight gain with long-term treatment NURSING ACTIONS: Monitor for hypotension and advise NURSING ACTIONS: Monitor the client’s weight. client to change positions slowly. CLIENT EDUCATION: Follow a well-balanced diet and Suicidal ideation exercise regularly. NURSING ACTIONS: Monitor and report manifestations of GI bleeding depression and thoughts of suicide. NURSING ACTIONS: Use caution in clients who have a history of GI bleed or ulcers and in clients taking other medications that affect blood coagulation. CONTRAINDICATIONS/PRECAUTIONS Paroxetine is a Pregnancy Risk Category D medication. CLIENT EDUCATION: Report indications of bleeding Paroxetine is contraindicated in clients taking (dark stool, coffee-ground emesis). MAOIs or a TCA. Clients taking paroxetine should avoid alcohol. Hyponatremia Use paroxetine cautiously in clients who have liver and More likely in older adult clients taking diuretics renal dysfunction, seizure disorders, or a history of GI bleeding. NURSING ACTIONS: Obtain baseline blood sodium level, and monitor level periodically throughout treatment. Serotonin syndrome INTERACTIONS Use of St. John’s wort, MAOI antidepressants, or TCAs Agitation, confusion, disorientation, difficulty can cause serotonin syndrome. concentrating, anxiety, hallucinations, myoclonus (spastic, NURSING ACTIONS: Educate the client about this jerky muscle contractions), hyperreflexia, incoordination, combination. Avoid concurrent use. tremors, fever, diaphoresis, hostility, delirium, seizures, tachycardia, labile blood pressure, nausea, vomiting, Antiplatelet medications and anticoagulants can increase diarrhea, abdominal pain, coma leading to apnea, and risk for bleeding death in severe cases NURSING ACTIONS: Monitor for bleeding. Avoid concurrent use. NURSING ACTIONS Serotonin syndrome usually begins 2 to 72 hr after initiation of treatment. This resolves when the medication is discontinued. NURSING ADMINISTRATION Watch for and advise clients to withhold the medication Administer with food. and report any of these manifestations, which could indicate a lethal problem. CLIENT EDUCATION Bruxism It can take up to 4 weeks to achieve therapeutic effects. Taking the medication at the same time daily promotes Grinding and clenching of teeth, usually during sleep therapeutic levels. NURSING ACTIONS Taking the medication in the morning can prevent sleep Report bruxism to the provider, who might switch the disturbances. client to another class of medication. Treat bruxism with low-dose buspirone. CLIENT EDUCATION: Use a mouth guard during sleep. 54 CHAPTER 7 ANXIETY AND TRAUMA- AND STRESSOR-RELATED DISORDERS CONTENT MASTERY SERIES 07/24/15 April 19, 2019 9:51 AM rm_rn_2019_pharm_chp7 For all medication classifications in this chapter NURSING EVALUATION OF MEDICATION EFFECTIVENESS Active Learning Scenario Depending on therapeutic intent, effectiveness is A nurse is assessing a client 4 hr after receiving an initial evidenced by the following. dose of fluoxetine. The nurse is concerned that the client Verbalizing feeling less anxious and more relaxed is developing serotonin syndrome. Use the ATI Active Description of improved mood Learning Template: System Disorder and the Mental Improved memory retrieval Health Nursing Review Module to complete this item. Maintaining regular sleep pattern Greater ability to participate in social and occupational ALTERATIONS IN HEALTH (DIAGNOSIS) interactions EXPECTED FINDINGS: Identify at least six. Improved ability to cope with manifestations and RISK FACTORS: Describe at least one risk factor. identified stressors Application Exercises 1. A nurse working in an emergency department is 4. A nurse is teaching a client who has caring for a client who has benzodiazepine toxicity. obsessive-compulsive disorder and has a new Which of the following actions is the nurse’s priority? prescription for paroxetine. Which of the following A. Administer flumazenil. instructions should the nurse include? B. Identify the client’s level of orientation. A. “It can take several weeks before you feel like the medication is helping.” C. Infuse IV fluids. B. “Take the medication just before D. Prepare the client for gastric lavage. bedtime to promote sleep.” C. “You should take the medication when 2. A nurse is teaching a client who has a new prescription needed for obsessive urges.” for escitalopram for treatment of generalized anxiety D. “Monitor for weight gain while disorder. Which of the following statements by the taking this medication.” client indicates understanding of the teaching? A. “I should take the medication on an empty stomach.” 5. A nurse is caring for a client who takes paroxetine to treat posttraumatic stress disorder and reports that B. “I will follow a low-sodium diet while they grind their teeth during the night. The nurse taking this medication.” should identify which of the following interventions C. “I need to discontinue this medication slowly.” to manage bruxism? (Select all that apply.) D. “I should not crush this medication A. Concurrent administration of buspirone before swallowing.” B. Administration of a different SSRI C. Use of a mouth guard 3. A nurse is providing teaching to a client who has a new D. Changing to a different class of prescription for buspirone to treat anxiety. Which of antidepressant medication the following information should the nurse include? E. Increasing the dose of paroxetine A. “Take this medication on an empty stomach.” B. “Expect optimal therapeutic effects within 24 hr.” C. “Take this medication when needed for anxiety.” D. “This medication has a low risk for dependency.” RN PHARMACOLOGY FOR NURSING CHAPTER 7 ANXIETY AND TRAUMA- AND STRESSOR-RELATED DISORDERS 55 07/24/15 April 19, 2019 9:51 AM rm_rn_2019_pharm_chp7 Application Exercises Key Active Learning Scenario Key 1. A. Prepare to administer flumazenil to reverse Using the ATI Active Learning Template: System Disorder the benzodiazepine toxicity. However, there and Mental Health Nursing Review Module is another action to take first. ALTERATION IN HEALTH (DIAGNOSIS): Serotonin syndrome B. CORRECT: The first action to take when using the is a potentially lethal complication that usually begins nursing process is to assess the client. Identifying the 2 to 72 hr after initiation of treatment with an SSRI. The client’s level of orientation is the priority action. syndrome resolves when the medication is discontinued. C. Prepare to infuse IV fluids to support the client’s blood pressure. However, there is another action to take first. EXPECTED FINDINGS D. Prepare to administer a gastric lavage to Agitation reverse the benzodiazepine toxicity. However, Confusion there is another action to take first. Disorientation NCLEX® Connection: Pharmacological and Parenteral Therapies, Difficulty concentrating Adverse Effects/Contraindications/Side Effects/Interactions Anxiety Hallucinations Hyperreflexia 2. A. The client can take this medication with food for GI distress or without food. Incoordination B. The client is at risk for hyponatremia Tremors while taking escitalopram. Fever C. CORRECT: When discontinuing escitalopram, Diaphoresis the client should taper the medication slowly Hostility according to a prescribed tapered dosing schedule Delirium to reduce the risk of withdrawal syndrome. Seizures D. The client can crush escitalopram before swallowing. Tachycardia NCLEX® Connection: Pharmacological and Parenteral Therapies, Labile blood pressure Medication Administration Nausea Vomiting 3. A. The client can take this medication with Diarrhea food to reduce GI distress. Abdominal pain B. Buspirone can take up to 3 to 6 weeks to Coma leading to apnea obtain optimal therapeutic effects. Death C. The client should take buspirone on a regular, not PRN, basis because therapeutic effects occur slowly. RISK FACTORS D. CORRECT: Buspirone has a low risk for physical or Onset of treatment with an SSRI within the last 2 to 72 hr psychological dependence or tolerance. Concurrent use of an SSRI with an MAOI NCLEX® Connection: Pharmacological and Parenteral Therapies, Concurrent use of an SSRI with a TCA Medication Administration NCLEX® Connection: Pharmacological and Parenteral Therapies, Adverse Effects/Contraindications/Side Effects/Interactions 4. A. CORRECT: Paroxetine can take 1 to 4 weeks before the client reaches full therapeutic benefit. B. Take paroxetine in the morning to prevent insomnia. C. Take paroxetine on a regular basis rather than an as-needed basis. D. Paroxetine can cause decreased appetite and weight loss. NCLEX® Connection: Pharmacological and Parenteral Therapies, Expected Actions/Outcomes 5. A. CORRECT: Concurrent administration of a low dose of buspirone is an effective measure to manage the adverse effects of paroxetine. B. Other SSRIs also will have bruxism as an adverse effect. This is not an effective measure. C. CORRECT: Using a mouth guard during sleep can decrease the risk for oral damage resulting from bruxism. D. CORRECT: Changing to a different class of antidepressant medication that does not have the adverse effect of bruxism is an effective measure. E. Increasing the dose of paroxetine can cause the adverse effect of bruxism to worsen. This is not an effective measure. NCLEX® Connection: Pharmacological and Parenteral Therapies, Adverse Effects/Contraindications/Side Effects/Interactions 56 CHAPTER 7 ANXIETY AND TRAUMA- AND STRESSOR-RELATED DISORDERS CONTENT MASTERY SERIES