McKenna's Pharmacology for Nursing, 2e

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C H A P T E R 2 0 Anxiolytic and hypnotic agents

CRITICAL THINKING SCENARIO Benzodiazepines

THE SITUATION P.P., a 43-year-old mother of three teenage sons, comes to the outpatient department for a routine physical examination. Results are unremarkable except for blood pressure of 145/90, pulse rate of 98 and apparent tension— she is jittery, avoids eye contact and sometimes appears teary-eyed. She says that she is having some problems dealing with “life in general”. Her sons present many stresses and her husband, who is busy with his career, has little time to deal with issues at home. When he is home, he is very demanding. In addition, she thinks she is beginning menopause and is having trouble coping with the idea of menopause as well as with some of the symptoms. Overall, she feels lonely and has no outlet for her anger, tension or stress. A healthcare provider, who reassures P.P. that this problem is common in women of her age, prescribes the benzodiazepine diazepam ( Valium ) to help P.P. deal with her anxiety. CRITICAL THINKING What sort of crisis intervention would be most appropriate for P.P.? What care interventions are helpful at this point? What non-drug interventions might be helpful? What other support systems could be used to help P.P. deal with all that is going on in her life? Think about the overwhelming problems that P.P. has to deal with on a daily basis and how the anxiolytic effects of diazepam might change her approach to these problems. Could the problems actually get worse? Develop a care plan for the long-term care of P.P. DISCUSSION Anxiolytics are useful for controlling the unpleasant signs and symptoms of anxiety. The diazepam prescribed for P.P. may provide some immediate relief, enabling her to survive the “crisis” period and plan changes in her life in general. However, the associated drowsiness and sedation may make coping with the problems in her life even more difficult. She should be taught the adverse effects of diazepam, the warning signs of serious adverse effects and the health problems to report. A follow-up evaluation should be scheduled. Additional meetings with the same healthcare provider are important for the long-term solution to P.P.’s anxiety. Her need for drug therapy should be re-evaluated once she can discover other support systems and develop other ways of coping. Although anxiolytic therapy may be beneficial initially, it will not solve the problems that are

causing anxiety, and in this case, the causes for the anxiety are specific. The anxiolytic should be considered only as a short-term aid. Unlike P.P., many people in severe crisis do not consciously identify the many causes of stress, or stressors. However, P.P. has identified a list of factors that makes her life stressful. This facilitates the development of coping strategies. She may find the following support systems helpful: • Referral to a counsellor and involvement of the entire family in identifying problems and ways to deal with them. • Support groups for women in various stages of life (e.g. entering menopause, mothers of children who are entering the teens). Just having the opportunity to discuss problems and explore ways of dealing with them helps many people.

CARE GUIDE FOR P.P.: DIAZEPAM Assessment: History and examination

Allergies to diazepam, psychoses, acute narrow angle glaucoma, acute alcohol intoxication, impaired liver or kidney function, pregnancy, breastfeeding, concurrent use of alcohol, omeprazole, cimetidine, disulfiram, oral contraceptives, theophylline, ranitidine

CV: blood pressure, pulse, perfusion CNS: orientation, affect, reflexes, vision Skin: colour, lesions, texture

Respiratory: respiration, adventitious sounds GI: abdominal examination, bowel sounds Laboratory tests: hepatic and renal function tests, FBC Implementation Provide comfort and safety measures, small meals, drug with food if GI upset occurs, bowel program as needed; taper dosage after long-term use; reduce dosage if other medications include narcotics; lower dose with renal or hepatic impairment. Provide support and reassurance to deal with drug effects. Provide teaching regarding drug, dosage, adverse effects, safety precautions and unusual symptoms to report. Evaluation Evaluate drug effects: relief of signs and symptoms of anxiety. Monitor for adverse effects, particularly sedation, dizziness, insomnia, blood dyscrasia, GI upset, hepatic or renal dysfunction, cardiovascular effects. Monitor for drug–drug interactions. Evaluate effectiveness of teaching program. Evaluate effectiveness of comfort and safety measures.