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Drugs for Anxiety and Insomnia

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Title: Drugs for Anxiety and Insomnia


1
Drugs for Anxiety and Insomnia
Chapter 14
2
OVERVIEW Neuro System
escitalopram (Lexapro)
Tri-Cyclic Antidepressant
Antidepressant / Anxiolytic
MAOIs
Benzodiazepines
lorazepam (Ativan) diazepam (Valium)
GABA Antagonist
zolpidem (Ambien)
A
phenytoin (Dilantin) valproic acid (Depakote)
Phenytoin-Like Drugs
Succinimides
ethosuximide (Zarontin)
Barbiturates
phenobarbital (Luminal)
Phenothiazines
chlorpromazine (Thorazine)
Non-Phenothiazines
halperidol (Haldol)
Opioids
morphine (Infumorph)
Atypical Antipsychotics
risperidone (Risperdal)
aspirin (ASA)
Salicylates
ibuprofen (Motrin)
NSAIDs
acetaminophen (Tylenol)
Non-Opioid
tramadol (Ultram)
Central Acting
ergotamine (Cafergot) Sumatriptan (Imitrex)
Anti-Migraine
Opioid Antagonists
naloxone (Narcan)
3
Major Types of Anxiety Disorders
  • Situational anxiety
  • Generalized anxiety disorder (GAD)
  • Panic disorder
  • Phobias
  • Social anxiety
  • Obsessive-compulsive disorder
  • Post-traumatic stress disorder

4
Pharmacotherapy Illustrated
5
Common Causes of Anxiety
  • Phobias
  • Post-traumatic stress
  • Generalized anxiety
  • Obsessive-compulsive feelings
  • Panic

6
Nonpharmacologic Therapies to Cope with Anxiety
  • Cognitive behavioral therapy
  • Counseling
  • Biofeedback techniques
  • Meditation

7
Anxiolytics
  • Drugs having the ability to relieve anxiety
  • Quite effective
  • Used when anxiety begins to significantly affect
    daily activities

8
Classes of Medications Used to Treat Anxiety and
Sleep Disorders
  • Antidepressants
  • Benzodiazepines
  • Barbiturates
  • Nonbenzodiazepine/nonbarbiturate CNS depressants

9
Treating Anxiety and Insomniawith CNS Agents
  • Antidepressants frequently used to treat anxiety
  • Two major classes
  • Benzodiazepines
  • Barbiturates
  • CNS depression - a continuum ranging from
    relaxation, to sedation, to the induction of
    sleep and anesthesia

10
Sedatives and Hypnotics
  • CNS depressants called
  • sedatives due to ability to sedate or relax a
    patient, or
  • hypnotics because of their ability to induce
    sleep
  • sedativehypnotic calming effect at lower doses
    and sleep at higher doses
  • Most CNS depressants can cause physical and
    psychological dependence

11
Monitor Clients Condition and Provide Education
  • Obtain vital signs, medical and drug history
  • Discuss lifestyle and dietary habits
  • What precipitated the feelings of anxiety?

12
Assess Clients Need for Antianxiety or Insomnia
Drugs
  • Assess intensity and duration of symptoms
  • Identify precipitating factors
  • Identify coping mechanisms
  • Assess for sleep disorder

13
Obtain Drug History
  • Hypersensitivity
  • Use of alcohol and other CNS depressants
  • Drug abuse and dependence

14
Use Cautiously for Certain Clients
  • Those who are elderly
  • Those with suicidal potential
  • Those with impaired renal or liver function

15
Insomnia
  • Acts of sleeping and waking synchronized to many
    different bodily functions
  • Insomnia sometimes associated with anxiety
  • Short-term or behavioral insomnia sometimes
    attributed to stress
  • Food or beverages with stimulants may disturb
    sleep
  • Long-term insomnia often caused by depression,
    manic disorders, chronic pain
  • Nonpharmacologic means should be attempted prior
    to drug therapy
  • Rebound insomnia caused by discontinuation of
    long-used sedative drug
  • Older patients more likely to experience
    medication-related sleep problems

16
Antidepressants
  • Treat major depression and a range of anxiety
    conditions
  • Primary medications to reduce symptoms of panic
    and anxiety TCAs, MAOIs, and SSRIs
  • Atypical antidepressants do not fall conveniently
    into the other categories
  • Adverse reactions make antidepressants unusable
    for some patients

17
Antidepressants (cont'd)
  • Prototype drug Escitalopram oxalate (Lexapro)
  • Mechanism of action increases availability of
    serotonin at specific postsynaptic receptor sites
    located within the CNS
  • Primary use generalized anxiety and depression
  • Adverse effects dizziness, nausea, insomnia,
    somnolennce, confusion, seizures

18
Prototype Drug Escitalopram oxalate (Lexapro)
19
Escitalopram Oxalate Animation
  • Click here to view an animation on the topic of
    escitalopram oxalate.

20
Antidepressant Class Information
  • TCAs (partial list information/conditions)
  • Not for use for patients with heart attack, heart
    block, or arrhythmia
  • Potential side effects dry mouth, blurred
    vision, urine retention, and hypertension
  • concurrent use with alcohol or other CNS
    depressants should be avoided

21
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22
Antidepressant Class Information (cont'd)
  • SSRIs (partial list information/conditions)
  • Safer than other classes
  • Less common sympathomimetic effects (increased
    heart rate and hypertension)
  • Fewer anticholinergic effects
  • can cause weight gain and sexual dysfunction

23
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24
Antidepressant Class Information (cont'd)
  • SNRIs (partial list information/conditions)
  • Many possible side effects
  • abnormal dreams, sweating,
  • constipation, dry mouth, loss of appetite, weight
    loss,
  • tremor, abnormal vision, headaches, nausea and
  • vomiting, dizziness, and loss of sexual desire

25
Antidepressant Class Information (cont'd)
  • MAOIs (partial list information/conditions)
  • avoid foods containing tyramine
  • potentiate the effects of insulin and other
    diabetic drugs
  • common adverse effects include orthostatic
    hypotension, headache, and diarrhea

26
Benzodiazepines
  • Prototype drug lorazepam (Ativan)
  • Mechanism of action binds to GABA
    receptor-chloride channel molecule, which
    intensifies GABA effects
  • Primary use for anxiety disorders and insomnia
  • Adverse effects drowsiness, dizziness,
    respiratory depression

27
Prototype Drug Lorazepam (Ativan)
28
Benzodiazepines
  • Some treat short-term insomnia
  • Others treat various anxiety disorders
  • Most benzodiazepines given orally
  • Drugs of choice for short-term treatment of
    insomnia caused by anxiety greater margin of
    safety

29
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30
Benzodiazepines Bind To GABA Receptor-Chloride
Channel Molecule
  • Intensify effects of GABA
  • Examples Xanax, Librium, Tranxene

31
Benzodiazepines
  • Have a number of other important indications
  • Seizure disorders
  • Alcohol withdrawal
  • Central muscle relaxation
  • Induction agents in anesthesia

32
Benzos
  • Prototype drug diazepam (Valium)
  • Mechanism of action
  • Binds with GABA receptor-chloride channel
    molecules, intensifying effects of GABA
  • Inhibits brain impulses from passing through
    limbic and reticular activating systems
  • Primary use as sedative and hypnotic
  • Adverse effects tolerance, respiratory
    depression, psychological and physical dependence

33
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34
Nonbenzodiazepines, Nonbarbiturate CNS
depressants
  • Chemically unrelated to either benzodiazepines or
    barbiturates
  • Used mainly for treatment of social anxiety
    symptoms
  • Prototype zolpidem (Ambien)
  • Mechanism of action binds to GABA receptors
  • Primary use as hypnotic
  • Adverse effects mild nausea, dizziness,
    diarrhea, daytime drowsiness, amnesia,
    sleepwalking, ingesting carbohydrates while
    sleepwalking

35
Nonbenzodiazepines, Nonbarbiturate CNS
depressants (cont'd)
  • Mechanism of action binds to GABA receptor
  • Preserves sleep stages III and IV
  • Offers minor effects of REM sleep
  • Other Nonbarbiturate CNS Depressants
  • Buspar, Noctec, Placidyl

36
Prototype Drug Zolpidem (Ambien)
37
Zolpidem Animation
  • Click here to view an animation on the topic of
    zolpidem.

38
Nonbenzodiazepine, NonbarbiturateCNS
Depressants (cont'd)
  • Assess for common side effects of CNS depression
  • Assess neurological status, level of
    consciousness
  • Monitor vital signs, observe respiratory patterns
    particularly during sleep
  • Monitor patients intake of stimulants, such as
    caffeine and nicotine
  • Monitor affect and emotional status

39
NCLEX-RN ReviewQuestion 1
  • The nurse should assess a patient who is taking
    lorazepam (Ativan) for the development of which
    of these adverse effects?
  1. Tachypnea
  2. Astigmatism
  3. Ataxia
  4. Euphoria

40
NCLEX-RN ReviewQuestion 1 Answer
  1. Tachypnea
  2. Astigmatism
  3. Ataxia
  4. Euphoria

41
NCLEX-RN ReviewQuestion 1 Rationale
  • Rationale CNS side effects for lorazepam
    (Ativan) include amnesia, weakness,
    disorientation, ataxia, blurred vision, diplopia,
    nausea, and vomiting.

42
NCLEX-RN ReviewQuestion 2
  • A patient is receiving temazepam (Restoril).
    Which of these responses should a nurse expect
    the patient to have if the medication is
    achieving the desired affect?
  1. The patient sleeps in 3-hour intervals, awakes
    for a short time, and then falls back to sleep.
  2. The patient reports feeling less anxiety during
    activities of daily living.
  3. The patient reports having fewer episodes of
    panic attacks when stressed.
  4. The patient reports sleeping 7 hours without
    awakening.

43
NCLEX-RN ReviewQuestion 2 Answer
  1. The patient sleeps in 3-hour intervals, awakes
    for a short time, and then falls back to sleep.
  2. The patient reports feeling less anxiety during
    activities of daily living.
  3. The patient reports having fewer episodes of
    panic attacks when stressed.
  4. The patient reports sleeping 7 hours without
    awakening.

44
NCLEX-RN ReviewQuestion 2 Rationale
  • Rationale The nurse should recognize that this
    medication is ordered for insomnia. Therefore,
    the patient should be experiencing relief from
    insomnia and reporting feeling rested when
    awakening.

45
NCLEX-RN ReviewQuestion 3
  • A 32-year-old female patient has been taking
    lorazepam (Ativan) for her anxiety and is brought
    into the emergency department after taking 30
    days worth at one time. The antagonist used in
    some cases of benzodiazepine overdosage is
  1. Epinephrine
  2. Atropine
  3. Flumazenil
  4. Naloxone

46
NCLEX-RN ReviewQuestion 3 Answer
  1. Epinephrine
  2. Atropine
  3. Flumazenil
  4. Naloxone

47
NCLEX-RN ReviewQuestion 3 Rationale
  • Rationale Flumazenil (Romazicon) is a
    benzodiazepine-receptor blocker which may be used
    to reverse CNS depressant effects. Naloxone
    (Narcan) is an opioid antagonist.

48
NCLEX-RN ReviewQuestion 4
  • A patient has been given instructions about the
    newly prescribed medication alprazolam (Xanax).
    Which of these statements, if made by the
    patient, would indicate that the patient needs
    further instruction?
  1. I will stop smoking by undergoing hypnosis.
  2. I will not drive immediately after I take this
    medication.
  3. I will stop the medication when I feel less
    anxious.
  4. I will take my medication with food if my
    stomach feels upset.

49
NCLEX-RN ReviewQuestion 4 Answer
  1. I will stop smoking by undergoing hypnosis.
  2. I will not drive immediately after I take this
    medication.
  3. I will stop the medication when I feel less
    anxious.
  4. I will take my medication with food if my
    stomach feels upset.

50
NCLEX-RN ReviewQuestion 4 Rationale
  • Rationale Benzodiazepines should not be stopped
    abruptly. The health care provider should decide
    when and how to discontinue the medication.

51
NCLEX-RN ReviewQuestion 5
  • A patient has been taking diazepam (Valium) for 3
    months. Which of these statements by the patient
    would indicate that the outcome of medication
    therapy has been successful?
  1. I will need to take this medication for the rest
    of my life.
  2. I feel like I am able to cope with routine
    stress at my job.
  3. I like this medication. I know that I needed it
    to treat my anxiety, which is now better, but I
    think it just makes me feel good, so I am
    planning to stay on it for quite a while.
  4. I thought this medication would make me think
    clearly, but I dont feel any change in my
    feelings.

52
NCLEX-RN ReviewQuestion 5 Answer
  1. I will need to take this medication for the rest
    of my life.
  2. I feel like I am able to cope with routine
    stress at my job.
  3. I like this medication. I know that I needed it
    to treat my anxiety, which is now better, but I
    think it just makes me feel good, so I am
    planning to stay on it for quite a while.
  4. I thought this medication would make me think
    clearly, but I dont feel any change in my
    feelings.

53
NCLEX-RN ReviewQuestion 5 Rationale
  • Rationale The statement by the patient needs to
    show clearly that the expected benefit of the
    medication therapy has been experienced by the
    patient.

54
NCLEX-RN ReviewQuestion 6
  • Education given to patients about the use of
    benzodiazepines should include an emphasis on
    what important issue?
  1. They will be required lifelong to achieve lasting
    effects.
  2. They require frequent blood counts to avoid
    adverse effects.
  3. If the drug is not effective within the first 2
    months, it will be stopped immediately.
  4. The use of counseling or behavioral techniques in
    addition to the drug will assist in addressing
    the underlying disorder.

55
NCLEX-RN ReviewQuestion 6 Answer
  1. They will be required lifelong to achieve lasting
    effects.
  2. They require frequent blood counts to avoid
    adverse effects.
  3. If the drug is not effective within the first 2
    months, it will be stopped immediately.
  4. The use of counseling or behavioral techniques in
    addition to the drug will assist in addressing
    the underlying disorder.

56
NCLEX-RN ReviewQuestion 6 Rationale
  • Rationale Counseling or behavioral techniques
    such as stress reduction will assist in
    addressing the underlying problem and help ensure
    the drug is not taken longer than necessary.
    Benzodizepines are not stopped abruptly or
    rebound anxiety or cardiovascular effects may
    occur.

57
Nursing Process
58
Drugs for Anxiety and Insomnia
  • Assessment
  • Potential nursing diagnoses
  • Reason for drug
  • Monitoring vital signs
  • Cautions and contraindications
  • Possible drug interactions
  • Completing health history
  • Drug history
  • Evaluation of lab reports

59
Drugs for Anxiety and Insomnia(cont'd)
  • Nursing Diagnosis
  • Risk for injury
  • Knowledge deficient, related to drug therapy
  • Ineffective individual coping

60
Drugs for Anxiety and Insomnia (cont'd)
  • Planning client will
  • Experience therapeutic effects depending on drug
  • Be free of adverse effects
  • Demonstrate an understanding of the drugs
    activity
  • Accurately describe drug side effects and
    precautions
  • Demonstrate proper self-administration technique

61
Drugs for Anxiety and Insomnia (cont'd)
  • Implementation
  • Interventions and rationales
  • Administration of drug
  • Observing for adverse effects
  • Client education and discharge planning

62
Drugs for Anxiety and Insomnia (cont'd)
  • Evaluation
  • Effectiveness of drug therapy
  • Evaluate the achievement of goals and expected
    outcomes

63
Nursing Process Focus Patients Receiving Drugs
for Anxiety Disorders
64
Nursing Process Focus Patients Receiving Drugs
for Anxiety Disorders
65
Nursing Process Focus Patients Receiving Drugs
for Anxiety Disorders
66
Nursing Process Focus Patients Receiving Drugs
for Anxiety Disorders
67
Nursing Process Focus Patients Receiving Drugs
for Anxiety Disorders
68
Receptors The Autonomic Nervous System
69
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Beta 1 Receptors
71
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