okay, welcome back. this week we are going to be talking about anxiety and anxiety disorders. when we discuss anxiety, it should be a review for us as you may remember in our very first class that we had together we talked about stress and the stages of stress and then crisis. so if in a general review here we'll just discuss stress again. stress is that real
or perceived threat to one's balance. and there are three stages. the alarm stage, the stage of resistance, and the stage of exhaustion. so if we have stressors during the alarm stage, this is where we are going to be getting that flight or fight response to that stressor. as the stress continues, we move on into the stage of resistance. at this stage,
people are trying that trial and error, they're trying different coping mechanisms to see if they can alleviate some of that stress and anxiety. okay? and the final stage was the stage of exhaustion and that's when the stress goes on for so long that the body starts to be stressed out. we can't have that adrenaline running in our body all the time because it will wear out all of our
organs. so that's just a little bit of review on stress and stress on the body. if you want more information you can go back to our first learning plan and look through that powerpoint and listen to that lecture again just for a good review. so as we know, we all experience stressors and therefore we all experience anxiety. so if we wanted to define anxiety,
it's an apprehension or an uneasy feeling, uncertainty or dread from a real or a perceived threat. now anxiety and stress is different than fear. fear is that it is actually a reaction to a specific danger. so fear would be if we had a bear running down the road after us. okay? that would be fear. but there is a connection between fear and anxiety because fear precipitates
anxiety. okay? anxiety is one of the most common psychiatric illnesses that we are aware of and it's estimated that 80% of the population has experienced anxiety. only 20% of the population however go on to form a chronic anxiety disorder. again, it is associated with other mental health illnesses such as depression. approximately one half of people who
have an anxiety disorder also have depression and it's estimated that 20% also have a substance abuse issue. so anxiety is our emotional response to fear and it can be real or it can be perceived. that means, you know, well i think you understand what perceived means. so fear is actually a healthy reaction for us way back to the cave man
times. it was our survival instinct. okay? what happens is it releases that adrenaline and affects multi-organs such as the lungs, the heart, the liver, and gi motility. okay? so if you look at this slide, there's different levels of anxiety. just like there were different levels of stress, there's different levels of the anxiety cascade. mild anxiety actually helps us. so to give you
an example of mild anxiety, that would be like if you know that you have a test coming up and so you study really hard for it. the mild anxiety actually sharpens our perceptions and our thought processes and helps us problem solve. as you go along the arrow to the moderate, as we go along in severity our abilities to perceive
and problem solve decrease at each level. so if you look at the severe or the plus three anxiety level, at this level our perceptions are greatly reduced and our problem solving ability is very poor. the final and last step on this cascade would be panic and panic is determined by disturbance in behavior, loss of touch with reality. they may have some hallucinations or act very erractically.
they're very impulsive and they often feel like they're going crazy or they're going to die. so again, what causes this? genetics, they believe there is a genetic component. research has shown that anxiety disorders do tend to cluster in families, especially when we're talking about panic disorder and obsessive compulsive disorder.
but however there hasn't been a specific gene that they've found that predetermines if a person is going to have an issue with anxiety or not. there's also that biologic or neurochemical imbalance or change that is thought to be part of the problem. so the epinephrine and norepinephine the dopamine, serotonin, and gabba. there is some problem or somethings
not functioning there. and if you look at the pictures that i've put on this slide. so if you look at the normal brain and then you look at a person. this happens to obsessive compulsive but if you look at a person who has an anxiety disorder, that frontal lobe is where we're getting all this extra activity. so you can think the frontal lobe is responsible, is primarily
responsible for producing dopamine, serotonin, and the gabba. so probably gonna have a decreased amount of gabba because we have excitability going on and we probably have an excess amount of dopamine and perhaps an excess of serotonin going on there. so you can probably anticipate the medications that we are going to
be using on these people to try and off set these neurotransmitter imbalances. so researchers have found that over time these neuro- pathways actually change when we have anxiety for a long period of time or chronically. so you can think of neuro- pathway changes kinda like when you learn to tie your shoes, right? at first
it takes up a lot of concentration and a lot of mental energy to learn how to tie your shoes but after over time, after we have tied our shoes plenty of times, we can do this automatically. it's because the neuro-pathways in the brain have actually changed and they've made that connection. same thing happens with anxiety. so if we continually have stress
in the body and the brain is constantly stressed out, these neuro-pathways are going to change and they're going to make direct connection. so that's how we jump to fear to anxiety because remember anxiety is a perceived threat so these neuro-pathways have changed and now it doesn't take anything for us to jump to that anxiety reaction if we have a
perceived threat. i hope that makes sense to you guys. so psychodynamic or your behavioral cognitive theorists believe that there is some disorder in the emotions and how people process the emotions or perhaps they feel that anxiety is a learned behavior that was modeled to them perhaps by parent who had an anxiety disorder.
either way, it's probably a combination of all of these factors put together. okay? so talk briefly about defense mechanisms. we've talked plenty about defense mechanisms and we know that there are fifteen of them. defense mechanisms can be adaptive, meaning that they're short lived and they work to alleviate the anxiety. or a defense mechanism
can be palliative in which it's a temporary relief but the anxiety still is there. so palliative would be maybe nail biting or hair pulling or twisting or chewing. things like that. maladaptive use of defense mechanisms actually causes a disorder. it causes a dysfunction in a way that the
person lives. okay? so the primary gain of these defense mechanisms for people is to lower their anxiety level, to protect their sense of self. a secondary gain is that they may use these defense mechanisms to attract attention or support or be released from any responsibility. okay? all of these defense mechanisms
can cause a distortion in the way the person perceives reality or perceives themself. so how does this apply to the nursing process? well again we're going to be wanting to do our assessment, a good history and physical. we're going to be checking vital signs. we're going to assess and maintain for safety and that would include asking questions about
suicide, substance abuse, if they are experiencing any depression, past medical history again is going to be important as we do find that there is a family connection. we can try and use assessment tools so that all of our information isn't subjective but we have something objective to base our assessment on. and then one other thing
that i wanted to mention is we have to think about the cultural aspects of anxiety. and we have to explore and ask questions about that. so in a general term, you can ask your patient what they think is going on so you can get their perception. ask them what was occurring prior to their symptoms, what was happening before. have they tried anything in the past that
has helped them and what do they think that needs to be done or what kind of treatment? so many, there are many cultural things to think about. so native americans and hispanics and asians have a strong belief in herbals. so that may be a choice that they will go to for treatment is herbals. or trying to get equilibrium between hot and cold. they believe that
there is an imbalance between hot and cold in their body. so that would be an example of a cultural implication. okay? so the hamilton reading scale i did put on blackboard for you so you can review that. it's a pretty simple tool. diagnostics as another area that i just wanted to mention is that we always can't jump to the conclusion that the person has
anxiety or is having anxiety or an anxiety disorder. there are many medical problems that can mimic anxiety and so we would want to be testing and determining symptoms, based on symptoms. so if a person complains of shortness of breath, we'd want to be getting an x-ray. if they're complaining of chest tightness
we might be looking to do cardiac enzymes or get an ekg on them. hyperthyroidism is another condition that often can mimic anxiety so we may be wanting to try and get a tsh level on these people. electrolyte imbalances can be a cause. oxygen and co2 imbalance typically seen in copd can cause anxiety also. so we want to make sure we are ruling out
all medical, other medical problems that could be causing the symptoms. so as far as nursing diagnoses you can see the list here. there are many. i'm sure there are many more. as far as short term goal setting, really what your goal is is to decrease that anxiety level. decrease it or eliminate it completely prior to discharge. a short term goal might be that you want those vital
signs to come back within normal parameters. you might want your patient to be able to maintain concentration and demonstrate accurate thought process. you might want them to demonstrate the ability to make a decision. you may, such as with our obsessive compulsive disorder, we may want a short term goal would be for a decrease in the ritualistic behavior that they exhibit.
long terms goals would be more things like the patient is taught and can demonstrate relaxation techniques that they can use to cope. maybe that they will attend a behavioral cognitive counseling. maybe that they won't have any panic attacks over the next three months. those would be more long term goals that you'd want for your patient.
so nursing interventions that we can use for our patients who are exhibiting anxiety. that milieu therapy, right? making sure that they feel safe and secure is very important. we want to stay with the patient until they have calmed down. we want to establish that trusting nurse-patient relationship. we're going to use therapeutic touch very limitedly or not at all. we are looking to
use short, simple instructions and if irrational thoughts are present we're going to offer the client information. we are not going to confront, argue, or debate with them. this is pretty similar to a lot of the interventions that we've been hearing throughout our learning plans here with different disorders. so this should not be new
news for you. we want to keep that calm environment. decrease the stimulation because they are already over stimulated. allow them to express their thoughts and fears and allow them to pace or cry or do whatever they need to do to release that tension that is built up in their body. again, we can use silence. we can use open-
ended questioning, restating, reflecting. all of those good therapeutic communication techniques that we've learned so far. and we want to be promoting self care. so getting the person to eat. getting them to drink. getting them to be able to sleep through the night. things of that nature. as far as medications, what we're looking for here is that we are going
to be giving those benzodiazepines to try and elicit that gabba and calm those neurotransmitters down and try and relax these people. okay? now remember the benzos are only given on a short term basis. so you know if we need a long term solution for this person, usually we're gonna be looking to the select serotonin, reuptake inhibitors. the
select serotonin or epi-inhibitors. tricyclics aren't used as much. they're not as effective and if all else fails we would go to a mao inhibitor but again those drugs are usually a last ditch effort to try and solve the person's problems. cause if you remember with our maois we have a great risk because of the tyramine threat with the body that
can cause the hypertensive crisis. so we try and stay away from the maois. the anti-psychotics we may have to use if the person is experiencing hallucinations. they have also found that anticonvulsants have been very effective in helping to calm down those neuro-pathways in the brain. so again, we might be looking at tegretol or depakote. some hypertensives such as
inderal or catapres or the beta blockers have also been found to be therapeutic treatments for anxiety. the mechanism there i'm not really sure of but i do know that they do prescribe hypertensives for anxiety. there is one medication that acts like a benzo but it's really not a benzo and that is called buspar. now buspar is going to have that calming effect and increase
that gabba response. however, it's not given an a prn so you want to remember because this is a very common drug. buspar is typically given as scheduled and it's typically given two doses a day, so twice a day. and again it acts like a benzodiazepines but it's not in that class. and finally teaching. so what are we gonna want to be teaching these people? again,
we never want to be using alcohol when we're using these mental health medications so we want to be advising people not to use alcohol because it does potentiate those medications and it can also lead to renal and liver dysfunction. especially in the hispanic and asian population it can cause these problems. we're gonna want to be teaching them about their
disease, what causes it, how to recognize their symptoms, what the treatments are, teaching them those relaxation techniques such as deep breathing or progressive muscle relaxation. perhaps massage or music or art. we even go so far as to use animal therapy, meditation. anything that is going to work for that individual and it may take some trial
and error to find what relaxation technique is useful for that person. we want to teach them about positive self talk. often times they have poor self-esteem, they have poor self-confidence, and so to teach them not to say 'oh i can't do that' or 'that's impossible'. to make positive statements you know such as you know 'if i study for my exam each
day a little bit i will be able to pass this exam'. so to turn things around instead of negative to be positive. okay? we want to be teaching them about community resources, counseling, support groups, hotlines, things like that and again you know making that referral for cognitive behavioral counseling because in the long term that's what's really going to help them. teach them
mechanisms of disorder, correct any misconceptions they have, and continue to teach them adaptive techniques. one other thing that i did want to note for you was that when we're talking about the elderly population. certainly the elderly can experience depression and anxiety just like any other age group but what's important to know about the
elderly is that they tend to be more sensitive to the side effects of the medication that we give. so typically they're going to need a lower dose of medication than say our middle aged person we're treating for anxiety. and what they have found is that there are two drugs that work really well for the elderly population to address
anxiety and those are tamazepam and wellbutrin. they seem to have less side effects for the elderly population. so i'm going to stop here. that's basics about anxiety. the next part of the lecture we're actually going to go in and start discussing anxiety disorders.
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