Professional Documents
Culture Documents
The middle of 20th century identifies a pivotal period in the treatment of persons with
mental illness. It was during this time that the phenothiazines were introduced into the
United States. Before that time they had been used in France as preoperative medications.
As Dr.Henry Laborit of the hospital Bouicaut in Paris stated “it was our aim to decrease
the anxiety of the patient’s to prepare them in advance for their postoperative recovery.
With these new drugs, Phenothiazines, we were seeing a profound psychic physical
relaxation. a real in difference to the environment and to the upcoming operation .It seem
to me these drugs must have an application in psychiatry.( Sage, 1984)
Indeed they have had a significant application in psychiatry. Not only have they given
many individuals a chance, without which they would have been unable to function, but
also they have provided researchers and clinicians with information to study the origins
and etiologies of mental illness. Knowledge gained from learning how these drugs work
has promoted advancement in understanding how behavioral disorders
develop.Dr.Arnold Scheibel,director of the UCLA brain research institute stated “When
these drugs came out there was a sense of disbelief that we could actually do something
substantive for the patients…see them for the first time as sick individuals and not as
something bizarre that we could literally talk to (Sage 1984)
HISTORICAL PERSPECTIVES
Historically, reaction to and treatment of persons with mental illness ranged from benign
involvement to intervention some would consider in human. Individuals with mental
illness were feared because of common belief associating them with demons or the
supernatural. They were looked upon as loathsome and often were mistreated.
Beginning in the late 18th century, a type of “moral reforms” in the treatment of persons
with mental illness considered a break through in the humanization of care, these
instutions, however, well intentioned, fostered the concept of custodial care. Clients were
ensured the provision of food and shelter but received little or no hope of exchange for
the future .As they became increasingly dependent on the institution to fill their need, the
likelihood of their return to the family or community diminished.
The early part of the 20th century saw the advent of the somatic therapies in psychiatry.
Individuals with mental illness were treated with insulin shock therapy, wet sheets packs,
ice baths, electroconvulsive therapy, and psycho-surgery. Prior to 1950, sedatives and
amphetamines were the only significant psychotropic medications available. Even these
had limited use because of there toxicity & addicting effects. Since the 1950s the
development of Psychopharmacology has expanded to include wide spread use of
antipsychotic, antidepressant and antianxiety medications, research into how these drugs
work has provided an understanding of the etiology of many psychiatric disorders.
Psychotropic medications are not intended to “cure” the mental illness. Most physicians
who prescribe these medications for their clients use them as an adjunct to individual or
group psychotherapy. Although their contribution to psychiatric care cannot be
minimizes, it must be emphasized that psychotropic medications relieve physical and
behavioral symptoms. They don’t resolve emotional problems.
Nurse must understand the legal implication associated with the administration of
psychotropic medications. Loss differ from state to state, but most adhere to the clients
rights to refuse treatment .Exceptions exist in emergency situation when it has been
determined that clients are likely to harm themselves or others.
3.Drug administration:
No One on the health care team has a greater daily impact on the patient’s experiences
with psychopharmacological agents than the nurse. Nurse administers the medication
dose, works out a dosing schedule based on the drug requirements and the patient’s need
and preferences and is continually alert for and treats drug effects. This role defines the
nurse as a key professional in maximizing therapeutic effects of drug treatment and
minimizing side effects in such a way that the patient is a true collaborator in managing
the medication regimen.
5.Medication education:
The nurse is a pivotal position to educate the patient and family about medications. This
includes teaching complex information to the patient so that it can be understood,
discussed and accepted. Patients should be informed about each drug prescribed for them.
They should be well educated about the expected benefits and potential risks, understand
Additional potential risks for their condition, and know what to do and whom to contact
if a question or problem arises.
7. Prescriptive authority:
Legislation has been passed in almost every state in US authorizing Advanced Practice
Registered Nurses (APRN) to have atleast some degree of authority to prescribe
medications and in some states APRNs have full autonomy in this role. Psychiatric
mental health nurse practitioners and in some states includes clinical nurse specialists
,who are qualified under their state nurse practices acts are thus able to prescribe
pharmacological agents to treat the symptoms and improve the functional status of
patients with psychiatric disorders. Thus the role of nurses in Psychopharmacological
treatments has been expanded to encompass medication prescription authority in order to
capitalize on the expertise of APRNs and to increase patient access to quality and cost
effective health care.
Pharmacological Principles
Pharmacokinetics:
It is the study of how the body affects a drug. it answers the question. How does the body
get drugs to and from their intended target? Body functions such as absorption (how the
drug is moved into the blood stream from the site of administration), distribution (how
much the drug is moved into the various body tissues) and metabolism (how the drug is
altered, usually by liver enzymes into its active and inactive parts), and elimination (how
much of the drug is removed from the body in a specific amount of time are
pharmacokinetics properties.
Bioavailability (how much of the drug reaches systemic circulation unchanged) is an
estimate used to compare various drug preparations, particularly if the same generic drug
is made by several different manufacturers.
A half life is the name it takes for the dose amount of the drug in the body to decrease by
50%.e.g. Benzodiazipines alprazolam has a half life of approximately 11 hours ,it takes
about 2.5 days for nearly all traces of drugs to be eliminated from the body after taking a
single dose.
Half life determines how long it will take the body to achieve a steady state. Steady state
means that the plasma drug concentration remains relatively constant between the doses
because the amount of drug excreted equals the amount ingested and this equilibrium
occurs in approximately five half-lives of any given drug. Until steady state is reached
the drug level in the body continues to fluctuate accounting for some acute side effects
and preventing determination of the optimum dose for a particular patient.
Pharmacodynamics:
It is the study of the effects of the drugs on the body and in a particular, the interaction of
a drug on the receptor that is its targeted site of action.Pharmacodynamics answers the
questions: What does a drug do once it gets where it’s going? The time course and
intensity of the drug effects on the body can be determined, drug interactions can be
better understood and safety profiles can be developed that affect clinical decision
making by using pharmacologic models.
Receptor mechanisms:
Receptors are channels sitting on the cells that are gatekeepers of communication. They
recognize and respond to molecules (messengers) that affect their biological function thus
receptors are targets for drugs acting as messengers, which modify the biological activity
of receptors, bringing a dysfunctional system back towards normal.
A drug modifies a receptor by attaching (binding) to one (like a key in a single lock) or
many (like a master key for many locks) subtypes of receptors in several ways: a drug
can stimulate the receptor to fully(in which case the drug is an agonist) or partially(partial
agonist) open its channels :it can block(antagonist) another chemical agonist from
stimulating the receptor to open its channels :or can directly close the receptor
channels.e.g benzodiazepines are a agonists for the GABA system (they enhance the
activity of GABA ,an inhibitory neurotransmitter).
Anxiety is a generalized mood condition that occurs without an identifiable triggering stimulus. As
such, it is distinguished from fear, which occurs in the presence of an observed threat.
Additionally, fear is related to the specific behaviors of escape and avoidance, whereas anxiety is
the result of threats that are perceived to be uncontrollable or unavoidable.[2]
Another view is that anxiety is "a future-oriented mood state in which one is ready or prepared to
attempt to cope with upcoming negative events"[3] suggesting that it is a distinction between future
vs. present dangers that divides anxiety and fear.
Anxiety is considered to be a normal reaction to stress. It may help a person to deal with a difficult
situation, for example at work or at school, by prompting one to cope with it. When anxiety
becomes excessive, it may fall under the classification of an anxiety disorder.[4]
Anxiety can be accompanied by physical effects such as heart palpitations, fatigue, nausea, chest
pain, shortness of breath, stomach aches, orheadaches. Physically, the body prepares the
organism to deal with a threat. Blood pressure and heart rate are increased, sweating is
increased, bloodflow to the major muscle groups is increased, and immune and digestive system
functions are inhibited (the fight or flight response). External signs of anxiety may include pale
skin, sweating, trembling, and pupillary dilation. Someone suffering from anxiety might also
experience it as a sense of dread or panic. Although panic attacks are not experienced by every
anxiety sufferer, they are a common symptom. Panic attacks usually come without warning, and
although the fear is generally irrational, the perception of danger is very real. A person
experiencing a panic attack will often feel as if he or she is about to die or pass out. Panic attacks
may be confused with heart attacks.
Anxiety does not only consist of physical symptoms. There are many emotional symptoms
involved as well. Some of them include: "Feelings of apprehension or dread, trouble
concentrating, feeling tense or jumpy, anticipating the worst, irritability, restlessness, watching
(and waiting) for signs (and occurrences) or danger, and, feeling like your mind's gone
blank." [5] There's also, "nightmares/bad dreams, obsessions about sensations, deja vu, a trapped
in your mind feeling, and feeling like everything is scary." [6]
One of the most common symptoms of anxiety is fear, which includes the fear of dying. "You
may...fear that the chest pains [a physical symptom of anxiety] are a deadly heart attack or that
the shooting pains in your head [another physical symptom of anxiety] are the result of a tumor or
aneurysm. You feel an intense fear when you think of dying, or you may think of it more often
than normal, or can’t get it out of your mind." [7]
ANTIANXIETY DRUGS
Antianxiety drugs are medicines that calm and relax people with excessive anxiety,
nervousness, or tension, or for short-term control of social phobia disorder or specific
phobia disorder. Antianxiety drugs are among the most widely prescribed today. A wide
variety of drugs from different classification has been used in the treatment of anxiety.
The family of drugs labeled as barbiturates were the primary biological treatment for
anxiety disorders before the 1950’s. These anti anxiety medications were used in low
doses to calm people and help them to sleep and were referred to as sedative-
hypnoticdrugs. However, barbiturates were found to cause relatively serious problems
with people making them drowsy, were found to be deadly in high doses, and eventually
would lead to a physical dependence upon them.
In the late 1940’s, a pharmacologist by the name of Frank Berger who was trying to make
a more effective antibiotic medicine developed a compound called meprobamate that
relaxed muscles and reduced anxiety. It was later released in the 1950’s as a new
sedative- hypnotic medication under the brand name of Milltown. While this new anti
anxiety medication still continued to cause great drowsiness, it was much less dangerous
and less addictive than barbiturates.
Then in the late 1950’s, a researcher by the name of Lowell Randall found that
chlordiazepoxide, a member of the drug family calledbenzodiazepines, was able to
tranquilize animals without making them extremely tired. This drug was actually
discovered in the 1930’s but was set aside because it was believed to be relatively
useless. After Randall’s discovery however, this anti anxiety medication was then
marketed as a sedative- hypnotic drug under the brand name Librium. Several years later
another benzodiazepine medication was developed and marketed under the name of
diazepam or Valium. Most doctors and patients considered these medications to be very
safe for use as sedative hypnotics and soon became the most widely prescribed
medications in the United States.
However, it was actually many years later that investigators came to understand the
reasons for the effectiveness of these anti anxiety medications. Researchers began to
recognize that there were specific neurons (nerve cells) in the brain that were affected by
benzodiazepines and that these same receptor sites also were able to receive and be
affected by the neurotransmitter GABA. Apparently, when benzodiazepines were
received by certain neurons in the brain (GABA-A receptors), they actually increased the
ability of GABA to bind to them which would then improve GABA’s ability to stop the
firing of neurons which would then slow bodily arousal and reduce anxiety.
ASSESSMENT
Indications:
Anti anxiety drugs are also called anxiolytics and minor tranquillers.They are used in the
treatment of:
• Generalized anxiety disorders
• Panic disorders
• Phobias
• Obsessive Compulsive disorder
• Acute alcohol withdrawal syndrome
• Skeletal muscle spasms
• Convulsive disorders
• Status epileptics
• Preoperative sedation
Their use and efficacy for periods greater than 4 months have not been evaluated.
Antianxiety Drugs
Chemical class Generic (trade)name Half Daily Available
life adult forms(mg)
dosage
Antihistamines Hydsroxyzine 3 hrs 100- Tab:10,25,50,100
(Atarax) 400mg Syrups:10/5ml
Mechanism of action:
Antianxiety drugs depress the sub- cortical levels of the CNS, particularly the limbic
system and reticular formation. Benzodiazepines mediate the actions of amino acid
GABA, the major inhibitory neurotransmitter in the brain. Because GABA receptor
channels selectively admit the anions chloride into the neurons, the activation of GABA
receptors hyperpolarizes neurons, thus is inhibitory benzodiazepines produce their effects
by binding to a specific site on the GABA receptor.Buspirone is believed to expert its
effect by acting as a partial agonist at serotonin receptors, which decreases serotonin
turnover.
Precautions
Precautions and warnings apply to the use of antianxiety agents for use over long periods
of time. They are unlikely to occur in patients who have only received a single dose prior
to surgery. Benzodiazepines should not be used in patients with psychosis, acute narrow-
angle glaucoma, or liver disease. The drugs can act as respiratory depressants and should
be avoided in patients with respiratory conditions. Benzodiazepines are potentially
addictive and should not be administered to patients with substance abuse disorders.
Because benzodiazepines are sedatives, they should be avoided in patients who must
remain alert. Their use for periods over four months has not been documented. These
drugs should not be used during the second and third trimester of pregnancy, although
use during the first trimester appears to be safe. They should not be taken while
breastfeeding. Specialized references for use in children should be consulted.
Buspirone is metabolized by the liver and excreted by the kidney, and should be used
with care in patients with hepatic or renal disease. The drug is classified as schedule B
during pregnancy, but should not be taken during breastfeeding. Its use in children under
the age of 18 years has not been studied.
Interactions
DIAGNOSIS
The following nursing diagnosis may be considered for the clients receiving therapy with
antianxiety agents:
1.Risk for injury related to seizures ,panic anxiety abrupt withdrawal after long term
use,effects of intoxication or overdose.
2.Risk for activity intolerance related to side effects of sedation and lethargy.
3.Risk for acute condition related to action of the medication on the CNS.
PLANNING / IMPLEMENTATION
The plan of care should include monitoring for the following side effects from
antianxiety agents.
2.Tolerance :physical and psychological dependence: Instruct the client on long term
therapy to quit taking the drug abruptly. Abrupt withdrawal can be life threatening.
Symptoms include depression, insomnia,increased anxiety, abdominal and muscle
cramps,tremors,vomiting,sweating,convulsions and delirium.
3. Ability to potentiate the effects of other CNS depressants: Instruct the client not to
drink alcohol take other medications the CNS while taking this medications.
5. Orthostatic hypotension: Monitor lying, & standing blood pressure & pulse every shift.
Instruct the client to arise slowly from a lying or sitting position.
7. Dry mouth: Have the client take frequent sips of water, suck on ice chips or hard
candy, or chew sugarless gum.
8. Nausea and vomiting: Have the client take the drug with food or milk.
9. Blood dyscrasias: Symptom of sore throat, fever,malaise,easy bruising ,unusual
bleeding should be reported to the physician immediately.
10.Delayed onset(Buspirone): ensure that the client understands there is a long time of 10
days to 2 weeks between onset of therapy with buspirone and subsiding of anxiety
symptoms. Client should continue to take the medication during this time.
OUTCOME CRITERIA/EVALUATION
The folleoing critera may be used for evaluating the effectiveness of therapy with
antianxiety agents .The Client:
Bibliography:
Submitted to:
Miss Amarjit Kaur Submitted by:
Professor(Vice-Principal) Manu
Dr.SLT CON,Moga M.Sc(N) 1st year