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Learning Outcomes
• 1. Discuss factors contributing to anxiety and explain some
nonpharmacologic therapies used to cope with this disorder.
• 2. Identify the three classes of medications used to treat anxiety and
sleep disorders.
• 3. Explain the pharmacological management of anxiety and insomnia.
• 4. Describe the nurse’s role in the pharmacologic management of anxiety
and insomnia.
• 5. Categorize drugs used for anxiety and insomnia based on their
classification and mechanism of action.
• 6. Use the nursing process to care for patients receiving drug therapy for
anxiety and insomnia.
OVERVIEW:
Neuro System
Drugs
Tri-Cyclic
Antidepressant
Antidepressant /
Anxiolytic
MAOIs
lorazepam (Ativan)
diazepam (Valium)
Benzodiazepines
GABAA
zolpidem (Ambien)
Antagonist
Phenytoin-Like
Drugs
phenytoin (Dilantin)
valproic acid (Depakote)
Succinimides
ethosuximide (Zarontin)
Barbiturates
phenobarbital (Luminal)
Phenothiazines
Non-Phenothiazines
Opioids
Salicylates
NSAIDs
Non-Opioid
morphine (Infumorph)
Atypical
Antipsychotics
aspirin (ASA)
ibuprofen (Motrin)
acetaminophen (Tylenol)
Central Acting
tramadol (Ultram)
Anti-Migraine
ergotamine (Cafergot)
Sumatriptan (Imitrex)
escitalopram (Lexapro)
Opioid Antagonists
naloxone (Narcan)
chlorpromazine (Thorazine)
halperidol (Haldol)
risperidone (Risperdal)
Major Types of Anxiety Disorders
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Situational anxiety
Generalized anxiety disorder (GAD)
Panic disorder
Phobias
Social anxiety
Obsessive-compulsive disorder
Post-traumatic stress disorder
Pharmacotherapy Illustrated
Common Causes of Anxiety
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Phobias
Post-traumatic stress
Generalized anxiety
Obsessive-compulsive feelings
Panic
Roseman University of Health Sciences
Nonpharmacologic Therapies to Cope
with Anxiety
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Cognitive behavioral therapy
Counseling
Biofeedback techniques
Meditation
‘Anxiolytics’
• Drugs having the ability to relieve anxiety
• Quite effective
• Used when anxiety begins to significantly affect daily activities
Classes of Medications Used to Treat Anxiety
and Sleep Disorders
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Antidepressants
Benzodiazepines
Barbiturates
Non-benzodiazepine / nonbarbiturate CNS depressants
Treating Anxiety and Insomnia
with 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
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
• sedative–hypnotic: calming effect at lower doses and sleep at
higher doses
• Most CNS depressants can cause physical and psychological
dependence
Monitor Client’s Condition and Provide
Education
• Obtain vital signs, medical and drug history
• Discuss lifestyle and dietary habits
• What precipitated the feelings of anxiety?
Assess Client’s Need for Antianxiety
or Insomnia Drugs
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Assess intensity and duration of symptoms
Identify precipitating factors
Identify coping mechanisms
Assess for sleep disorder
Obtain Drug History
• Hypersensitivity
• Use of alcohol and other CNS depressants
• Drug abuse and dependence
Use Cautiously for Certain Clients
• Those who are elderly
• Those with suicidal potential
• Those with impaired renal or liver function
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
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
Antidepressants (cont'd)
• Prototype drug: Escitalopram
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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
Prototype Drug: Escitalopram oxalate (Lexapro)
Escitalopram Oxalate Animation
Click here to view an animation on the topic of escitalopram oxalate.
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
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
Antidepressant Class
Information (cont'd)
• SNRIs (partial list information/conditions):
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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
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
Benzodiazepines
lorazepam (Ativan)
Mechanism of action: binds to GABA receptorchloride channel molecule, which intensifies
GABA effects
Primary use: for anxiety disorders and insomnia
Adverse effects: drowsiness, dizziness, respiratory
depression
• Prototype drug:
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Prototype Drug: Lorazepam (Ativan)
Benzodiazepines
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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
Benzodiazepines Bind To GABA
Receptor-Chloride Channel Molecule
• Intensify effects of GABA
• Examples: Xanax, Librium, Tranxene
Benzodiazepines
• Have a number of other important indications
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Seizure disorders
Alcohol withdrawal
Central muscle relaxation
Induction agents in anesthesia
Benzo’s
• 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
as sedative and hypnotic
Adverse effects: tolerance, respiratory depression,
psychological and physical dependence
• Primary use:
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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
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
Prototype Drug: Zolpidem (Ambien)
Zolpidem Animation
Click here to view an animation on the topic of zolpidem.
Nonbenzodiazepine,
Nonbarbiturate
CNS 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 patient’s intake of stimulants, such as caffeine and
nicotine
• Monitor affect and emotional status
NCLEX-RN Review
Question 1
The nurse should assess a patient who is taking lorazepam
(Ativan) for the development of which of these adverse effects?
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4.
Tachypnea
Astigmatism
Ataxia
Euphoria
NCLEX-RN Review
Question 1 – Answer
1.
2.
3.
4.
Tachypnea
Astigmatism
Ataxia
Euphoria
NCLEX-RN Review
Question 1 – Rationale
Rationale: CNS side effects for lorazepam (Ativan)
include amnesia, weakness, disorientation, ataxia,
blurred vision, diplopia, nausea, and vomiting.
NCLEX-RN Review
Question 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?
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4.
The patient sleeps in 3-hour intervals, awakes for
a short time, and then falls back to sleep.
The patient reports feeling less anxiety during
activities of daily living.
The patient reports having fewer episodes of
panic attacks when stressed.
The patient reports sleeping 7 hours without
awakening.
NCLEX-RN Review
Question 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.
NCLEX-RN Review
Question 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.
NCLEX-RN Review
Question 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:
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4.
Epinephrine
Atropine
Flumazenil
Naloxone
NCLEX-RN Review
Question 3 – Answer
1.
2.
3.
4.
Epinephrine
Atropine
Flumazenil
Naloxone
NCLEX-RN Review
Question 3 – Rationale
Rationale: Flumazenil (Romazicon) is a benzodiazepinereceptor blocker which may be used to reverse CNS
depressant effects. Naloxone (Narcan) is an opioid
antagonist.
NCLEX-RN Review
Question 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?
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“I will stop smoking by undergoing hypnosis.”
“I will not drive immediately after I take this
medication.”
“I will stop the medication when I feel less
anxious.”
“I will take my medication with food if my
stomach feels upset.”
NCLEX-RN Review
Question 4 – Answer
1.
2.
3.
4.
“I will stop smoking by undergoing hypnosis.”
“I will not drive immediately after I take this
medication.”
“I will stop the medication when I feel less
anxious.”
“I will take my medication with food if my stomach
feels upset.”
NCLEX-RN Review
Question 4 – Rationale
Rationale: Benzodiazepines should not be stopped
abruptly. The health care provider should decide when
and how to discontinue the medication.
NCLEX-RN Review
Question 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?
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“I will need to take this medication for the rest of
my life.”
“I feel like I am able to cope with routine stress at
my job.”
“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.”
“I thought this medication would make me think
clearly, but I don’t feel any change in my feelings.”
NCLEX-RN Review
Question 5 – Answer
1.
2.
3.
4.
“I will need to take this medication for the rest of my
life.”
“I feel like I am able to cope with routine stress at
my job.”
“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.”
“I thought this medication would make me think clearly,
but I don’t feel any change in my feelings.”
NCLEX-RN Review
Question 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.
NCLEX-RN Review
Question 6
Education given to patients about the use of benzodiazepines
should include an emphasis on what important issue?
1.
2.
3.
4.
They will be required lifelong to achieve lasting
effects.
They require frequent blood counts to avoid
adverse effects.
If the drug is not effective within the first 2 months,
it will be stopped immediately.
The use of counseling or behavioral techniques in
addition to the drug will assist in addressing the
underlying disorder.
NCLEX-RN Review
Question 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.
NCLEX-RN Review
Question 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.
Drugs for Anxiety and Insomnia
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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
Drugs for Anxiety and Insomnia
(cont'd)
• Nursing Diagnosis
• Risk for injury
• Knowledge deficient, related to drug therapy
• Ineffective individual coping
Drugs for Anxiety and
Insomnia (cont'd)
• Planning: client will
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Experience therapeutic effects depending on drug
Be free of adverse effects
Demonstrate an understanding of the drug’s activity
Accurately describe drug side effects and precautions
Demonstrate proper self-administration technique
Drugs for Anxiety and Insomnia
(cont'd)
• Implementation
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Interventions and rationales
Administration of drug
Observing for adverse effects
Client education and discharge planning
Drugs for Anxiety and Insomnia
(cont'd)
• Evaluation
• Effectiveness of drug therapy
• Evaluate the achievement of goals and expected outcomes
Nursing Process Focus: Patients Receiving Drugs for Anxiety Disorders
Nursing Process Focus: Patients Receiving Drugs for Anxiety Disorders
Nursing Process Focus: Patients Receiving Drugs for Anxiety Disorders
Nursing Process Focus: Patients Receiving Drugs for Anxiety Disorders
Nursing Process Focus: Patients Receiving Drugs for Anxiety Disorders
Review
RECEPTORS
“Receptors”
& The Autonomic Nervous System
Beta 1 Receptors