ATI Chapter 21: Medications for Anxiety and Trauma-and Stressor-Related Disorders

What are other medications in the SSRI classification?

Sertraline, Citalopram, Escitalopram, Fluoxetine, and Fluvoxamine.

What is another issue that can result from SNRIs?

Sexual dysfunction. Nurses should educate clients on reporting problems with sexual function (managed with the dose reduction, medication holiday, changing medications).

What are some issues that are contraindicated with benzos?

Sleep apnea, respiratory depression, and/or glaucoma.

What is acute toxicity?

Acute toxicity can happen in Oral and IV routes.

What should you do if GI upsets occur?

Administer the medication with meals or snacks if GI upset occurs.

A nurse is caring for a client who takes paroxetine to treat post traumatic stress disorder. the client states, "I grind my teeth during the night, which causes pain in my mouth." The nurse should identify which of the following interventions as possible measures to manage the client's bruxisim? SATA A. Concurrent administration of buspirone B. Administration of a different SSRI C. use of a mouth guard. D. Changing to a different class of anti-anxiety medication. E. Increasing the dose of paroxetine.

A. Concurrent administration of buspirone (Concurrent administration of a low-dosage of buspirone is an effective measure to manage the adverse effect of paroxetine.) C. Use of a mouth guard D. Changing to a different class of anti-anxiety medication.

What are later adverse effects with atypical anxiolytics?

After 5 to 6 years of therapy, sexual dysfunction (impotence, delayed or absent organsm, delayed or absent ejaculation, decreased sexual interest), weight gain, headache.

What should nurses educate clients about withdrawal syndrome?

After long period of use, taper the medication slowly according to a prescribed tapered dosing schedule to avoid withdrawal effects. Avoid abrupt discontinuation of the medication.

Client education about benzodiazepines

After taking benzodiazepines regularly in high doses, taper the dose over several weeks using a prescribed tapered dosing schedule.

SNRIs can cause CNS depression with what drugs?

Alcohol, opioids, antihistamines, sedative/hypnotics. Avoid concurrent use.

What should clients avoid when taking SSRIs?

Alcohol.

What medications can SSRIs interact with?

Concurrent use of TCAs, MAOIs, or St. John's wort can cause serotonin syndrome.

What other drugs should not be taken concurrently with SSRIs?

Concurrent use with TCAs and lithium can result in increased levels of these medications. Avoid concurrent use.

What is the purpose of atypical anxiolytic/nonbarbiturate anxiolytics?

Although the exact anti-anxiety mechanism is unknown. This medication binds to serotonin and dopamine receptors. There is loss potential for dependency than with other anxiolytics. Use of buspirone does not result in sedation or potentiate the effects of other CNS depressants. It carries no risk of misuse.

What issues can result from taking SNRI's?

Anorexia resulting in weight loss. Nurses should monitor the client's weight and educate the client on following a well-balanced diet and exercise regularly.

When can the effects be noted for atypical anxiolytic medications?

Anti Anxiety effects develop slowly. Initial responses take 1 week, and full effects take up to 4 weeks. As a result of this pharmacological action, buspirone needs to be taken on a scheduled basis, and is not suitable for PRN usage.

What are the withdrawal effects of paradoxical response?

Anxiety, insomnia, diaphoresis, tremors, and lightheadedness, delirium and seizures. Occurs infrequently with short-term use.

What other classification of drugs can be used to treat anxiety disorders?

Atypical anxiolytic/nonbarbiturate anxiolytics: Buspirone.

What should nurses educate patients not to do when taking SNRIs?

Avoid abrupt cessation of the medication. Avoid alcohol while taking SNRIs.

What should you avoid with buspirone?

Avoid the use of erythromycin and ketoconazole. Avoid herbal preparations containing St. John's wort. Avoid drinking grapefruit juice.

A nurse is assessing a client 4 hr after receiving an initial dose of fluoxetine. Which of the following finding should the nurse report to the provider as indications of serotonin syndrome? A. Hypothermia B. Hallucinations. C. Muscular flaccidity D. Diaphoresis E. Agitation.

B. Hallucinations. D. Diaphoresis E. Agitation

A nurse working in an emergency department is caring for a client who has benzodiazepine toxicity. Which of the following actions is the nurse's priority? A. Administer flumanzenil. B. Identify the client's level of orientation. C. Infuse IV fluids. D. Prepare the client for gastric lavage.

B. Identify the client's level of orientation. Althought A is the reversal agent, assessment takes the priority.

What are the major medications to treat anxiety disorders?

Benzodiazepine Sedative Hypnotic Anxiolytics: Lorazepam, alprazolam, clonazepam, diazepam.

Are benzodiazepines long term sue or short term use?

Benzodiazepines are generally used short-tem due to the risk for dependence.

What are the therapeutic uses of benzodiazepines?

Benzodiazepines are used for short-term treatment for generalized anxiety disorder and panic disorder Other Uses -Seizure disorders -Insomnia -Muscle spasm -Alcohol withdrawal (for prevention and treatment of acute manifestations) -Induction of anesthesia -Amnesic prior to surgery or procedures

What are the expected pharmacological actions of benzodiazepine?

Benzodiazepines enhance the inhibitory effects of gamma-aminobutyric acid in the central nervous system. Relief from anxiety occurs rapidly following administration.

What disorder in particular should nurses look out for when administering SSRI's?

Bipolar disorder, due to risk of mania.

What Pregnancy Risk Category is buspirone?

Buspirone is a Pregnancy Risk Category B medication.

What is buspirone contraindicated with?

Buspirone is contraindicated for concurrent use with MAOI antidepressants, or for 14 days after MAOIs are discontinued. Hypertensives crisis can result.

Is it recommended for clients who are breastfeeding?

Buspirone is not recommended for use by clients who are breastfeeding.

What are atypical anxiolytic/nonbarbiturate anxiolytics?

Buspirone is the prototype for this category of drug.

What are the benzodiazepine sedative hypnotic anxiolytics?

Select Prototype Medication: Alprazolam Other Medications -Diazepam -Lorazepam -Chlordiazepoxide -Clorazepate -Oxazepam -Clonazepam

A nurse is caring for a client who is to begin taking fluoxetine for treatment of panic disorder. which of the following statements indicates the client understands the use of the medication? a. "I will take the medication at bedtime." b. "I will follow a low-sodium diet while taking the medicaiton." c. "I will need to discontinue this medication slowly." d. "I will be at risk for weight loss with long-term use of this medicaiton."

C. "I will need to discontinue this medication slowly."

What can benzos interact with?

CNS depressants (alcohol, barbiturates, opioids) can cause respiratory depression.

What are some complications with atypical anxiolytic/nonbarbiturate anxiolytics?

CNS effect such as dizziness, nausea, headache, lightheadedness, agitation.

When can serotonin syndrome occur?

Can begin 2 to 72 hr after starting treatment and can be lethal.

What is the pregnancy risk category for SNRIs?

Category C.

What are some of the complications of benzodiazepines?

Central nervous system (CNS) depression such as sedation, lightheadedness, ataxia, and decreased cognitive function)

What are important client education about benzodiazepines?

Client Education -Observe for manifestations. Notify the provider if effects occur. -Avoid hazardous activities (driving, operating heavy equipment/machinery) -Avoid concurrent use of alcohol and other CNS depression.

What should client avoid with benzos?

Client should avoid abrupt discontinuation of treatment to prevent withdrawal manifestations. Do no change the dosage or frequency without approval of the prescriber.

What should clients be educated on later adverse effects of atypical anxiolytics like buspirone?

Client should report problems with sexual function (managed with dose reduction, medication holiday, changing medications).

What should nurses advised about using SSRIs concurrently with other drugs?

Clients should not take SSRIs concurrently with NSAIDs and anticoagulants because it can further suppress platelet aggregation, thereby increasing the risk of bleeding. Clients should monitor for indications of bleeding (bruising, hematuria) and notify the provider if they occur.

What diseases affect the use of duloxetine?

Clients should use duloxetine in patients with hepatic disease or those who consume large amounts of alcohol.

What are SNRIs contraindicated in clients for?

Clients taking MAOIs

What should nurses advise clients of?

Concurrent use of TCAs or St. John's wort with SSRIs.

A nurse is teaching a client who has a new prescription for alprazolam for generalized anxiety disorder. Which of the following information should the nurse provide? A. Three to six weeks of treatment is required to achieve therapeutic benefits. B. Combining alcohol with alprazolam will produce paradoxical response. C. Alprazolam has a lower risk for dependence than other anti-anxiety medications. D. Report confusion as a potential indication of toxicity.

D. Report confusion as a potential indication of toxicity.

When can dependency develop?

Dependency can develop during and after treatment. Notify the provider if indications of withdrawal occur.

Which benzodiazepines can be used for IV administration?

Diazepam and lorazepam.

What is the anterograde amnesia?

Difficulty recalling events that occur after dosing.

What drug should be discontinued if taking SSRI's?

Discontinue MAOIs 14 days prior to starting an SSRI.

What activities should you avoid on benzodiazipines?

Driving, operating heavy equipment/machinery. Avoid alcohol and other substances that cause CNS depression.

What are signs of oral toxicity?

Drowsiness, lethargy, and confusion.

What are the two SNRIs?

Duloxetine and Desvenlafaxine

What are selected antidepressants?

Selective serotonin reuptake inhibitors (SSRI's): Paroxetine, sertraline, fluoxetine, citalopram, escitalopram, fluvoxamine. Serotonin norepinephrine reuptake inhibitors (SNRIs): Venlafaxine, duloxetine, desvenlafaxine.

What does buspirone interact with?

Erythromycin, ketoconazole, St. John's wort, and grapefruit juice can increase the effects of buspirone.

What are some early adverse effects of atypical anxiolytics?

First few days/weeks: nausea, diaphoresis, tremor, fatigue, drowsiness.

What is the reversal for benzodiazepines ?

Flumazenil is used to counteract sedation and reverse the adverse effects.

What drug should be discontinued 5 weeks before starting an MAOI?

Fluoxetine (SSRI)

What are the nursing actions for oral toxicity?

For oral toxicity, gastric lavage is used, followed by the administration of active charcoal or saline cathartics.

What is Escitalopram indicated for?

GAD, OCD, panic disorder, PTSD, and social anxiety disorder.

What can paroxetine be used for?

Generalized anxiety disorder (GAD), Panic disorder: decreases both the frequency and intensity of panic attacks, and also prevents anticipatory anxiety about attacks. Obsessive compulsive disorder (OCD): reduces manifestations by increasing serotonin. Social anxiety disorder. Post traumatic stress disorder (PTSD), depressive disorders, adjustment disorders, and associated manifestations of dissociative disorders.

What is the therapeutic use of atypicalanxiolytric/nonbarbiturate anxiolytics?

Generalized anxiety disorder.

What is bruxism?

Grinding and clenching of teeth, usually during sleep.

What are complications that clients may face with SNRIs?

Headache, nausea, agitation, anxiety, dry mouth, and sleep disturbances.

What other issues can emerge from SNRIs usage?

Hypertension: Nurses should monitor increases in blood pressure.

What electrolyte deficiency can occur from the use of SSRIs?

Hyponatremia is more likely in older adult clients taking diuretics. Nurses should obtain baseline blood sodium, and monitor level periodically throughout treatment.

What electrolyte imbalance can SNRI's cause?

Hyponatremia, especially in older adult clients taking diuretics. Nurses should obtain baseline blood sodium, and monitor level periodically throughout treatment.

Client education on SSRI's

If any of the manifestations occur for serotonin syndrome, withhold the medication and notify PCP.

What is important to note about benzos and quitting them?

If benzos are taken regularly and in high doses, they should be tapered off before quitting over several weeks using a prescribed rapered dosing schedule.

What are SNRI's used for?

Inhibiting the uptake of serotonin and norepinephrine; minimal inhibition of dopamine.

What are symptoms of paradoxical response?

Insomnia, excitation, euphoria, anxiety, rage.

How long can it take to reach therapeutic levels?

It can take up to 4 weeks to achieve therapeutic effects.

How can a nurse identify serotonin syndrome?

Manifestations of serotonin syndrome including Confusion, agitation, poor concentration, hostility. Disorientation, hallucinations, delirium. Seizures leading to status epilepticus Tachycardia leading to cardiovascular shock Labile blood pressure Diaphoresis Fever leading to hyperpyrexia Incoordination, hyperreflexia Nausea, vomiting, diarrhea, abdominal pain Coma leading to apnea (and eatht in severe cases)

When should atypical anxiolytic medications be administered?

Medications should be administered at the same time everyday.

What are nursing actions about SSRIs concerning weight?

Monitor client's weight. Clients should be educated to follow a well-balanced diet and exercise regularly.

What should nurses monitor clients who are taking warfarin and SSRIs?

Monitor prothrombin time (PT) and INR levels. Nurses should also assess for indications of bleeding and the need for dosage adjustment.

What can further suppress platelet aggregation with concurrent use of SNRIs?

NSAIDS and anticoagulants and thereby increasing the risk of bleeding.

What are symptoms of withdrawal syndrome?

Nausea, sensory disturbances, anxiety, tremor, malaise, unease.

What is an adverse effects of SSRIs that nurses should keep an eye on?

Weight changes. Occurance of weight loss early in therapy that can be followed by weight gain with long-term treatment.

Do SSRI's block reuptake of dopamine or norepinephrine?

No, they do no blcok uptake of dopamine or norepinephrine.

What is the client education necessary for paradoxical response?

Nurse should observe for indications. Notify the provider if paradoxical response occurs.

What diseases should nurses pay special attention to when administering benzos?

Nurses should use benzodiazepines cautiously in clients who have liver disease or a history of a substance use disorder.

What is fluvoxamine indicated for?

OCD< GAD, social anxiety disorder, and PTSD.

What client education should the nurse provide about anterograde amnesia?

Observe for manifestations. Notify the provider and withhold the medication if effects occur.

What population should you assess for fall risk when using benzos?

Older adults who are prescribed benzos.

When should the SSRIs be taken?

On a daily basis to establish therapeutic plasma levels.

What are other classifications that may be used to treat anxiety disorders?

Other antidepressants -Tricyclic antidepressants (TCAs): Amitriptyline, imipramine, clomipramine. -Monoamine Oxidase Inhibitors (MAOI's): Phenelzine -Antihistamines: Hydroxyzine pamoate, hydroxyzine hydrochloride, Mirtazapine, Trazodone. -Beta blockers: Propranolol -Centrally acting alpha-blockers: Prazosin -Anticonvulsants: Gabapentin, Pregabalin

What is setraline indicated for?

Panic disorder , OCD, Social anxiety disorder, and PTSD.

What is Citalopram indicated for?

Panic disorder, OCD, GAD, PTSD< and social anxiety disorder.

What is the prototype for SSRI's?

Paroxetine

What are the effects of paroxetine?

Paroxetine causes CNS stimulation, which can cause insomnia.

What is the Pregnancy Risk Category for SSRIs?

Paroxetine is a PRegnancy Risk Category D medication. OTher SRIs pose less risk during pregnancy.

What should the nurse educate the client about?

Report adverse effect to the provider. Take the medication as prescribed. These effects should soon subside. Avoid driving if these effects occur.

What should the nurse instruct the client to do if they have any of these complications?

Report adverse effects to the provider.

What is the nursing action for bruxism?

Report bruxims to the provider, who may: Switch the client to another class of medication. Treat bruxism low=dose buspirone.

What are symptoms of IV toxicity?

Respiratory depression, severe hypotension, cardiac arrest.

What are the therapeutic uses of SSRI's?

SSRI antidepressants are the first-line treatment for panic disorders and trauma-and stressor-related disorders.

How long does it take to get receive the therapeutic effects of SSRI's?

SSRI's have a long effective half-life, up to 4 weeks are necessary to produce therapeutic medication levels.

What is the indications for Selective serotonin reuptake inhibitors?

SSRI's selectively inhibit serotonin reuptake, allowing more serotonin to stay at the junction of the neurons.

What other medications are SSRI's contraindicated for?

SSRIs are contraindicated in clients takign MAOIs or TCAs.

What should nurses know when administering SSRIs?

SSRIs may be taken with food. Sleep disturbances are minimized by taking the medication in the morning.

Can benzos be crushed?

Swallow sustained-release tablets and avoid chewing or crushing the tablets.

What can cause serotonin syndrome with use of SNRIs?

The concurrent use of MAOIs and St. John's wort. Nurses should advise clients to discontinue MAOIs 14 days prior to starting an SNRI.

What are the major medications to treat trauma-and stressor-related disorders?

The major medications to treat trauma-and stressor-related disorders are selective serotonin reuptake inhibitors: Paroxetine, sertraline, fluoxetine, escitalopram, fluvoxamine. Serotonin norepinephrine reuptake inhibitor: Venlafaxine Tricyclic antidepressants: Amitriptyline, imipramine Monoamine oxidase inhibitor: Phenelzine Noradrenergic and specific serotonergic antidepressant (NaSSA): Mirtazapine. Beta Blockers: Propranolol Centrally Acting Alpha-Blockers: Prazosin Centrally Acting Alpha 2 Agonists: Clonidine

What pregnancy risk category are benzodiazepines?

They are a pregnancy risk category D because they can cause fetal issues. They can transmit the medication through human milk, they should not be taken by clients who are breastfeeding.

What are benzos classified under?

They are classified under Schedule IV of the Controlled Substances Act.

What are the nursing actions for atypical anxiolytic/nonbarbiturate anxiolytics?

This medication does not interfere with activities because it does not cause sedation.

What is not an issue atypical anxiolytics?

Tolerance, dependence, or withdrawal manifestations are not an issue with this medication.

What should nurses do when SSRI's cause gastrointestinal bleeding?

Use cautiously in clients who have a history of gastrointestinal bleed, ulcers, and those taking other medications that affect blood coagulation. Nurses should advise clients to report indications of bleeding (dark stools, emesis that has the appearance of coffee ground).

How can nurses evaluate the medication effectiveness?

Verbalized feeling of less anxiety Description or improved mood Improved memory retrieval Maintenance of normal sleep pattern Greater ability to participate in social and occupational interactions Improved ability to cope with manifestations and identified stressors. Ability to perform activities of daily living Report of increased well-being.

What other drugs should not be taken concurrently with SSRIs?

Warfarin can displace warfarin from bound protein and result in increased warfarin levels.

Should this drug be used cautiously?

Yes, especially for clients who have liver or kidney dysfunction, as well as clients who have liver or renal dysfunction.

What is fluoxetine indicated for?

panic disorder, social anxiety disorder, OCD, and PTSD.

Nurses should educate clients on being cautious when taking SSRIs if....

they have liver and renal dysfunction, seizure disorders, or a history of gastrointestinal bleeding.

What are the therapeutic uses of SNRI's?

used for major depression panic disorders, and generalized anxiety disorder.