ELDER TIP A benzodiazepine with a long half-life tends to accumulate in an older patient’s system and may cause oversedation. Benzodiazepines are sometimes given along with opioids to add to the analgesic effect or as a preanesthetic. Remember, if the elderly psychiatric patient is scheduled for surgery, he may take longer to recover from anesthesia if these combinations are used.
Tricyclic antidepressants or higher doses of short-acting benzodiazepines may relieve severe anxiety and panic attacks. Buspirone, an antianxiety drug, causes the patient less sedation and poses less risk of physical and psychological dependence than the benzodiazepines.
Psychotherapy for generalized anxiety disorder has two goals: helping the patient identify and deal with the cause of the anxiety and eliminating environmental factors that precipitate an anxious reaction. In addition, the patient can learn relaxation techniques, such as deep breathing, progressive muscle relaxation, focused relaxation, and visualization.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Diseases (Eighth Edition), 2005
Major depression:
Treatment
(Professional Guide to Diseases (Eighth Edition))
Depression is difficult to treat, especially in children, adolescents, elderly patients, and those with a history of chronic disease. The primary treatment methods are drug therapy and psychotherapy, particularly cognitive behavioral therapy.
Drug therapy includes tricyclic antidepressants (TCAs) such as amitriptyline, monoamine oxidase (MAO) inhibitors such as isocarboxazid, maprotiline, and trazodone, which has been available for 40 years. A newer class of drugs, the selective serotonin reuptake inhibitors (SSRIs), such as fluoxetine, paroxetine, sertraline, bupropion, venlafaxine, and mirtazapine, are equally effective and have more tolerable adverse effect profiles.
TCAs, the most widely used class of antidepressant drugs, prevent the reuptake of norepinephrine or serotonin (or both) into the presynaptic nerve endings, resulting in increased synaptic concentrations of these neurotransmitters. They also cause a gradual loss in the number of beta-adrenergic receptors.
MAO inhibitors block the enzymatic degradation of norepinephrine and serotonin. These agents commonly are prescribed for patients with atypical depression (for example, depression marked by an increased appetite and need for sleep, rather than anorexia and insomnia) and for some patients who fail to respond to TCAs. MAO inhibitors are associated with a high risk of toxicity; patients treated with one of these drugs must be able to comply with the necessary dietary restrictions.
Maprotiline is a potent blocker of norepinephrine uptake, whereas trazodone is an SSRI. The mechanism of action of bupropion is unknown.
Electroconvulsive therapy (ECT) may be considered in particularly severe or drug-resistant depression. Six to 12 treatments are typically needed, although in many cases improvement is evident after only a few treatments. However, ECT has been associated with later short-term memory loss, heart arrhythmias, and seizure activity. Researchers hypothesize that ECT affects the same receptor sites as antidepressants.
Short-term psychotherapy is also effective in treating major depression. Many psychiatrists believe that the best results are achieved with a combination of individual, family, or group psychotherapy and medication. After resolution of the acute episode, patients with a history of recurrent depression may be maintained on low doses of antidepressants as a preventive measure.
Depression may be experienced differently by members of different cultures. For instance, in some Asian cultures, there are more somatic manifestations of depression than overt psychologic signs or symptoms.
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Source: Professional Guide to Diseases (Eighth Edition), 2005
Fontanel depression:
Emergency interventions
(Professional Guide to Signs & Symptoms (Fifth Edition))
If you detect a markedly depressed fontanel, take vital signs, weigh the infant, and check for signs of shock—tachycardia, tachypnea, and cool, clammy skin. If these signs are present, insert an I.V. line and administer fluids. Have size-appropriate emergency equipment on hand. Anticipate oxygen administration. Monitor urine output by weighing the wet diapers.
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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Seizures, generalized tonic-clonic:
Emergency interventions
(Professional Guide to Signs & Symptoms (Fifth Edition))
If you witness the beginning of the seizure, first check the patient’s airway, breathing, and circulation, and ensure that the cause isn’t asystole or a blocked airway. Stay with the patient and ensure a patent airway. Focus your care on observing the seizure and protecting the patient. Place a towel under his head to prevent injury, loosen his clothing, and move any sharp or hard objects out of his way. Never try to restrain the patient or force a hard object into his mouth; you might chip his teeth or fracture his jaw. Only at the start of the ictal phase can you safely insert a soft object into his mouth.
If possible, turn the patient to one side during the seizure to allow secretions to drain and to prevent aspiration. Otherwise, do this at the end of the clonic phase when respirations return. (If they fail to return, check for airway obstruction and suction the patient if necessary. Cardiopulmonary resuscitation, intubation, and mechanical ventilation may be needed.)
Protect the patient after the seizure by providing a safe area in which he can rest. As he awakens, reassure and reorient him. Check his vital signs and neurologic status. Be sure to carefully record these data and your observations during the seizure.
If the seizure lasts longer than 4 minutes or if a second seizure occurs before full recovery from the first, suspect status epilepticus. Establish an airway, start an I.V. line, give supplemental oxygen, and begin cardiac monitoring. Draw blood for appropriate studies. Turn the patient on his side, with his head in a semi-dependent position, to drain secretions and prevent aspiration. Periodically turn him to the opposite side, check his arterial blood gas levels for hypoxemia, and administer oxygen by mask, increasing the flow rate if necessary. Administer diazepam or lorazepam by slow I.V. push, repeated two or three times at 10- to 20-minute intervals, to stop the seizures. If the patient isn’t known to have epilepsy, an I.V. bolus of dextrose 50% (50 ml) with thiamine (100 mg) may be ordered. Dextrose may stop the seizures if the patient has hypoglycemia. If his thiamine level is low, also give thiamine to guard against further damage.
If the patient is intubated, expect to insert a nasogastric (NG) tube to prevent vomiting and aspiration. Be aware that if the patient hasn’t been intubated, the NG tube itself can trigger the gag reflex and cause vomiting. Be sure to record your observations and the intervals between seizures.
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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Anxiety disorder, generalized:
Treatment
(Handbook of Diseases)
A combination of drug therapy and psychotherapy may help a patient with generalized anxiety disorder. Benzodiazepine anxiolytics relieve mild anxiety and improve the patient’s ability to cope. They should be used cautiously, however, because they can be addictive. Buspirone, a nonbenzodiazepine anxiolytic, is an alternative to the benzodiazepines because it causes less sedation and poses less risk of physical and psychological dependence.
Psychotherapy for generalized anxiety disorder has two goals: helping the patient identify and deal with the underlying emotional and psychological issues and eliminating environmental factors that precipitate an anxious reaction. In addition, the patient can learn relaxation techniques, such as deep breathing, progressive muscle relaxation, focused relaxation, and visualization.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Diseases, 2003
Depression, major:
Treatment
(Handbook of Diseases)
Depression is difficult to treat, especially in children, adolescents, elderly patients, and those with a history of chronic disease. The primary treatment methods are drug therapy, electroconvulsive therapy (ECT), and psychotherapy.
Drug therapy
In depression, drug therapy includes tricyclic antidepressants (TCAs) such as amitriptyline, serotonin reuptake inhibitors such as fluoxetine, and monoamine oxidase (MAO) inhibitors, such as isocarboxazid, maprotiline, and trazodone.
❑ The most widely used class of antidepressant drugs, TCAs prevent the reuptake of norepinephrine or serotonin (or both) into the presynaptic nerve endings, resulting in increased synaptic concentrations of these neurotransmitters. They also cause a gradual loss in the number of beta-adrenergic receptors.
❑ After resolution of the acute episode, patients with a history of recurrent depression may be maintained on low doses of antidepressants as a preventive measure.
❑ Selective serotonin reuptake inhibitors, including fluoxetine, paroxetine, and sertraline, are increasingly becoming the drugs of choice. They are effective and produce fewer adverse effects than the TCAs; however, they’re associated with sleep and GI problems and alterations in sexual desire and function.
❑ MAO inhibitors block the enzymatic degradation of norepinephrine and serotonin. These agents are commonly prescribed for patients with atypical depression (for example, depression marked by an increased appetite and need for sleep, rather than anorexia and insomnia) and for some patients who fail to respond to TCAs.
MAO inhibitors are associated with a high risk of toxicity; patients treated with one of these drugs must be able to comply with the necessary dietary restrictions. Conservative doses of an MAO inhibitor may be combined with a TCA for patients refractory to either drug alone.
Maprotiline is a potent blocker of norepinephrine uptake, whereas trazodone is a selective serotonin uptake blocker. The mechanism of action of bupropion is unknown.
ECT
When a depressed patient is incapacitated, suicidal, or psychotically depressed, or when antidepressants are contraindicated or ineffective, ECT is commonly the treatment of choice. Six to 12 treatments usually are needed, although improvement is usually evident after only a few treatments. Researchers hypothesize that ECT affects the same receptor sites as antidepressants.
Psychotherapy
Short-term psychotherapy is also effective in treating major depression. Many psychiatrists believe that the best results are achieved with a combination of individual, family, or group psychotherapy and medication. Therapeutic interventions focus on identifying the patient’s negative thoughts and interpretations and substituting adaptive responses.
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Source: Handbook of Diseases, 2003
Skin, clammy:
Nursing considerations
(Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)
Take the patient’s vital signs frequently and monitor urine output. If clammy skin occurs with an anxiety reaction or pain, offer the patient emotional support, administer pain medication, and provide a quiet environment.
Patient teaching
If an underlying illness is related to the patient’s clammy skin, provide information on the condition. If the condition is related to an alteration in the patient’s blood glucose level, provide information on management of hypoglycemia and early signs of a falling blood glucose level. Provide information on the importance of nutrition and hydration.
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Source: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, 2007
Seizures, generalized tonic-clonic:
Nursing considerations
(Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)
Closely monitor the patient for recurring seizure activity. Prepare him for a computed tomography scan or magnetic resonance imaging and EEG. Monitor therapeutic drug levels. Provide a safe environment and institute seizure precautions. Continue to monitor the patient’s vital signs and respiratory status. Provide supplemental oxygen, as indicated.
Patient teaching
Advise the patient’s family to observe and record his seizure activity to ensure proper treatment. Emphasize the importance of strict compliance with the drug regimen and warn the patient about its possible adverse effects. Stress the importance of regular follow-up appointments for blood studies. Provide information on alcohol or drug cessation programs if the seizure was related to withdrawal or abuse.
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Source: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, 2007
Agitation:
Patient counseling
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Orient the patient with agitation to the unit and its procedures and routines. Provide reassurance and emotional support. Explain the need to reduce stressors and maintain a quiet environment.
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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Anxiety:
Patient counseling
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Teach the patient relaxation techniques and practice them with him. Encourage the patient to verbalize his anxiety and listen to him attentively. Help the patient identify and explore coping mechanisms that he used in the past. Work with the patient to identify stressors and guide him in effective coping skills.
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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Skin, clammy:
Patient counseling
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Because the patient with cool, clammy skin may be acutely ill, provide emotional support to him and his family. Explain what’s happening using short, simple sentences. Orient them to the intensive care unit, if applicable, explaining the equipment and the unit’s routines.
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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Seizures, generalized tonic-clonic:
Patient counseling
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Advise the patient’s family to observe and record his seizure activity to ensure proper treatment. Emphasize the importance of strict compliance with the drug regimen, and warn the patient about adverse reactions. Also, stress the importance of regular follow-up appointments for blood studies.
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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Agitation:
Nursing considerations
(Nursing: Interpreting Signs and Symptoms)
▪ Because agitation can be an early sign of many different disorders, monitor the patient's vital signs and neurologic status while the cause is being determined.
▪ Eliminate stressors, which can increase agitation.
▪ Provide adequate lighting, maintain a calm environment, and allow the patient ample time to sleep.
▪ Ensure a balanced diet, and provide vitamin supplements and hydration.
▪ Remain calm, nonjudgmental, and nonargumentative.
▪ Avoid using restraints, unless absolutely necessary, because they tend to increase agitation.
▪ If appropriate, prepare the patient for diagnostic tests, such as a computed tomography scan, skull X-rays, magnetic resonance imaging, and blood studies.
Patient teaching
▪ Orient the patient to the unit and its procedures and routines.
▪ Explain stress-reduction measures.
▪ Offer reassurance and emotional support.
▪ Explain all tests and procedures, the underlying cause, and treatment plan.
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Source: Nursing: Interpreting Signs and Symptoms, 2007
Anxiety:
Nursing considerations
(Nursing: Interpreting Signs and Symptoms)
▪ Provide supportive care, as indicated by the patient's signs and symptoms.
▪ Provide a calm, quiet atmosphere.
▪ Administer medications, as ordered, to reduce anxiety.
▪ Treat the underlying cause of the patient's anxiety, if known.
▪ Encourage the patient to express his feelings and concerns.
Patient teaching
▪ Teach the patient anxiety-reducing measures, such as distraction, relaxation techniques, or biofeedback.
▪ Teach the patient coping mechanisms to help control his anxiety.
▪ Explain the underlying causes of his anxiety, if known.
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Source: Nursing: Interpreting Signs and Symptoms, 2007
Skin, clammy:
Nursing considerations
(Nursing: Interpreting Signs and Symptoms)
▪ Take the patient's vital signs frequently.
▪ Monitor the patient's intake and output.
▪ Provide measures to correct the underlying condition. For example, if clammy skin occurs with an anxiety reaction or pain, offer the patient emotional support, administer pain medication, and provide a quiet environment.
Patient teaching
▪ Explain the underlying disorder and its treatment.
▪ Orient the patient to the intensive care unit.
▪ Explain any diagnostic tests or procedures.
» READ BOOK EXCERPT ONLINE »
Source: Nursing: Interpreting Signs and Symptoms, 2007
Fontanel depression:
Nursing considerations
(Nursing: Interpreting Signs and Symptoms)
▪ Monitor the infant's vital signs and level of consciousness.
▪ Monitor intake and output and watch for signs of worsening dehydration.
▪ Obtain serum electrolyte values to check for an increased or decreased sodium, chloride, or potassium level.
▪ If the infant has mild dehydration, provide small amounts of clear fluids frequently or provide an oral rehydration solution.
▪ If the infant can't ingest sufficient fluid, begin I.V. parenteral nutrition.
▪ If the patient has moderate to severe dehydration, provide rapid restoration of extracellular fluid volume to treat or prevent shock.
▪ Continue to administer I.V. solution with sodium bicarbonate added to combat acidosis. As renal function improves, administer I.V. potassium replacements.
▪ When the infant's fluid status stabilizes, begin to replace depleted fat and protein stores through diet.
▪ Obtain urinalysis for specific gravity and, possibly, blood tests to determine blood urea nitrogen and serum creatinine levels, osmolality, and acid-base status.
Patient teaching
▪ Explain all procedures and treatments to the infant's parents.
▪ Provide emotional support.
▪ Explain ways to prevent dehydration.
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Source: Nursing: Interpreting Signs and Symptoms, 2007
Seizures, generalized tonic-clonic:
Nursing considerations
(Nursing: Interpreting Signs and Symptoms)
▪ Institute seizure precautions.
▪ Closely monitor the patient after the seizure for recurring seizure activity.
▪ Prepare him for a computed tomography scan or magnetic resonance imaging and EEG.
▪ Administer anticonvulsants, as ordered, and monitor drug levels.
Patient teaching
▪ Explain the disorder and treatment plan.
▪ Teach the family how to observe and record seizure activity.
▪ Emphasize the importance of compliance with drug therapy and follow-up appointments.
▪ Tell the patient to carry medical identification.
» READ BOOK EXCERPT ONLINE »
Source: Nursing: Interpreting Signs and Symptoms, 2007
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