Exam 3: Stress, crisis, anxiety, and panic disorders

Question 1

Stress

Answer 1

a natural part of life!
-one of the most complex concepts in health and nursing, often thought of in a negative way but can also be a positive experience that helps us grow.

we arent trying to avoid stress- it is how we COPE THAT MATTERS! chronic stress is when this becomes a problem

Question 2

acute vs. chronic stress

Answer 2

acute: an intense biopsychosocial reaction to a threatening event, time limited, typically less than one month, can occur repeatedly, can have negative impact on health
-fight or flight response
-amygdala and hippocampus play roles
-hormones secreted: adrenaline, cortisol, epinephrine
-VS: increased BP, HR, blood glucose

chronic: ongoing physiologic reaction to events resulting in wear and tear on the body- linked to negative health outcomes
-HTN, weight gain, borderline diabetic- think about the hormones being released over time

Question 3

physiologic stress response

Answer 3

homeostasis and fight or flight
-chronic stress alters hypothalamus-pituitary-adrenal axis increased exposure to cortisol
-allostatic load: consequence of wear and tear on the body and brain leads to ill health
-cumulative changes of the biologic regulatory systems are indicated by abnormal lab values and may increase risk of disease and illness
-the greater the allostatic load, the more negative changes in health
-may present as being on edge, unnerved, or constantly in fight or flight

Question 4

social networks and support for stress

Answer 4

-the larger the network, the more support available
-social networks provide opportunity to give and take- reciprocity
-vital to distinguish the difference between social networking and social media- who is in the patients’ day to day life that can help in times of crisis??

social support= positive interpersonal connections- a person can have a large, complex social network, but little social support.
-ideal network is dense and interconnected, as they are more likely to provide support to someone in times of distress
-social support enhances health outcomes and reduces mortality by helping members make needed behavior changes and buffering stressful life events.

Question 5

emotional stress response

Answer 5

-emotions more likely to be positive if situation is viewed as a challenge
-emotions more likely to be negative if situation is viewed as threatening or harmful
-EMOTIONS OFTEN PROVOKE IMPULSIVE BEHAVIOR- stress may lead people to do what they would not do otherwise!
-stress response includes simultaneous physiologic and emotional responses- basic needs must be met first BEFORE PSYCHOSOCIAL!

Question 6

adaptation and coping

Answer 6

adaptation: a person’s capacity to survive and flourish. being resilient effects health, psychological well being, and social functioning

coping: deliberate, planned, and psychological activity to manage stressful demands. this process may inhibit or override the innate urge to act. capacity to address/adapt the problem. GOAL IS TO ESTABLISH POSITIVE COPING MECHANISMS.
-positive coping can lead to adaptation- characterized by a balance between health and illness, a sense of well-being, and maximum social functioning
-assess effectiveness of treatment by seeing how well a patient is coping and able to function. life will always be stressful, but it is how patients deal with it that matters!

Question 7

two types of coping

Answer 7

1- problem focused= changes the person-environment relationship. person addresses the source of stress and solves the problem by eliminating it or changing its effects.
2-emotion focused= changes the meaning of the situation. person reduces stress by reinterpreting the situation to change its meaning.

-different coping strategies will be needed for different situations. over time, strategies become automatic and develop into patterns for each person.
-as part of the coping process, reappraisal is important because of the changing nature of the stressful situation.

reappraisal: same as appraisal except that it happens after coping strategies are implemented, provides feedback about the outcomes and allows for continual adjustment and actions to new information.

Question 8

nursing management for person experiencing stress

Answer 8

overall goals: resolve stressful person-environment situations, reduce stress response, develop positive coping skills
goals for those at high risk for stress: recognize potential for stressful situations; strengthen positive coping skills through education and practice
-some coping strategies increase risk for mortality and morbidity; the person feels temporarily better but at an increased risk for illness. learning new behaviors of those whose behaviors exacerbate their illness is important.

Question 9

physical functioning during stress response (important for assessment)

Answer 9

-sleep disturbance
-appetite either increases or decreases
-body weight fluctuates
-sexual activity changes
-physical appearance may be uncharacteristically disheveled, projecting the person’s feelings
-body language: muscle tension, conveying anxiety
-assess amount of physical activity, tolerance for exercise, usual exercise patterns.- also helps with reasonable interventions.

Question 10

psychosocial nursing management for stress

Answer 10

-assess coping strategies, how the patient reacts (problem or emotion focused?)
-what is the patient’s perception of the situation?
interventions: appropriate problem-solving strategies, encourage patient to discuss the person-environment situation and develop alternative coping strategies, encourage patient to discuss the person-environment situation and develop alternative coping strategies “lets talk about what you have been feeling”- identifying person’s emotions can be helpful in assessing intensity of the stress being experienced

-assess recent life changes or things considered intense life changes, social network: size and extent of network, function that the network serves, degree of reciprocity, degree of interconnectedness
-facilitate family functioning, assistance in expanding social network, support of family unity functioning, parent education, family therapy

Question 11

crisis

Answer 11

occurs when there is a perceived challenge or threat that overwhelms the capacity to COPE EFFECTIVELY with the event
-time-limited event triggering adaptive or nonadaptive responses to maturation, situational, or traumatic experiences
-outcomes may be positive or negative.

Question 12

phases of crisis

Answer 12

1- problem arises that contributes to increase in anxiety levels. anxiety initiates usual problem-solving techniques of the person
2- usual problem-solving techniques are ineffective. anxiety levels continue to rise.trial and error attempts are made to restore balance.
3- trial and error attempts fail. the anxiety escalates to severe or panic levels. the person adopts automatic relief behaviors.
4- when these measures do not reduce anxiety, anxiety can overwhelm the person and lead to serious personality disorganization, which signals the person is in crisis.

Question 13

types of crises

Answer 13

developmental/maturational crisis: normal part of growth and development, such as leaving home for the first time
-erik erikson formulating ideas and development, proposed that developmental crisis continues to be used to describe significant maturational events.

situational crisis: specific stressful event, such as starting a new job
-specific stressful event threatens a person’s physical and psychosocial integrity and results in some degree of psychological disequilibrium. may be internal such as a disease process. may lack adequate coping skills entering a new situation.

traumatic crisis: unexpected, unusual events, such as riots, violent crimes, environmental disasters.
-initiated by an unexpected, unusual event, that can affect an individual or a multitude of people.

Question 14

after crisis nursing interventions

Answer 14

-providing first aid
-mitigate risk associated with possible homicidal and suicidal ideation
-arranging food and shelter
-after safety needs are met: mobilize social supports, reestablishing self-care routines

GOAL: RETURN TO PRE-CRISIS LEVEL OF FUNCTIONING!!!!
-assess for: level of effectiveness of coping capabilities, suicidal or homicidal risk, evidence of self-mutilation activities, client perception of problem and availability support mechanisms.

Question 15

physical health for stress

Answer 15

assessment: changes in health practices, biologic function such as sleeping and eating patterns, changes in body function- tachycardia, tachypnea, profuse perspiration, nausea, vomiting, dilated pupils, extreme shakiness

interventions: treat life-threatening injuries, do not give realistic or false reassurances of positive outcomes, anticipate pharmacologic interventions to help reduce emotional intensity.

Question 16

mental health and stress

Answer 16

assessment: emotions and coping strategies, behaviors indicating a depressed state, presence of confusion, uncontrolled weeping or screaming, disorientation, aggression, loss of feelings and well-being and safety, possible panic, anxiety, fear, ability to solve problems may be impaired.

interventions: SAFETY, prevention of suicide or homicide, arranging for food and shelter if needed, mobilizing social support, psychosocial aspects such as encouraging report of any depression, anxiety, or interpersonal difficulties, counseling.

socially: determine extent of disruption of usual activities, explore social network, develop new network if needed, telephone hotlines, residential crisis services.

Question 17

grief

Answer 17

intense, emotional reaction to the loss of a loved one, biopsychosocial response that often includes spontaneous expression of pain, sadness, and desolation.

Question 18

bereavement

Answer 18

process of mourning and coping with the loss of a loved one beginning immediately after the loss, but possibly lasting months or years.

Question 19

stages of bereavement

Answer 19

-shock and disbelief
-awareness of loss: separation anxiety, intense physical, emotional, social, and cognitive response
-conservation-withdrawal: social withdrawal, feels one has little strength, may feel despair, helplessness, overtime a turning point occurs
-healing: acceptance of the loss of both intellectually and emotionally; self-perception of having experienced and survived the loss
-renewal: increase in self-esteem, has now learned to live again

Question 20

complicated bereavement

Answer 20

NOT normal
-person is frozen or stuck in a state of chronic mourning- beyond 6 months past lost
-trouble accepting, inability to trust others, feeling that life is meaningless without the deceased person
-increased risk in sudden, unexpected loss, death after chronic illness, those with limited social support

Question 21

types of grief

Answer 21

uncomplicated grief: experienced by most
- painful and disruptive, but there is always movement
-also applied to other situations in which loss occurs, not always a death- divorce, death of a pet, empty nest syndrome
-most bereaved persons do not need clinical interventions are able to find new meaning and purpose in their lives- eventually accept the loss and are able to move on

traumatic grief: more difficult and prolonged grief
-suddenness and lack of anticipation
-violence, mutilation, destruction
-degree of preventability or randomness
-multiple deaths
-mourner’s personal encounter with death

complicated grief: frozen in chronic mourning; intense longing for the deceased for longer than 6 months; may feel bitterness about the loss
-also known as PGD (prolonged grief disorder)
-no movement in the thought processes in how the bereaved view and experience their loss
-person may feel bitter over the loss and wish their life could revert to the time they were together
-intense longing and yearning for the person who died, lasting longer than 6 months

Question 22

anxiety

Answer 22

an unavoidable human condition that takes many forms and serves different purposes. may be positive or negative, can motivate one to act, or produce paralyzing fear causing inaction; constant worry; fear of loss of control.
-during a perceived threat, rising anxiety levels cause physical and emotional changes in all individuals. a normal emotional response to anxiety consists of three parts:
1- physiologic arousal: fight or flight response; signals an individual is facing a threat
2- cognitive processes: decipher situation and decide whether the perceived threat should be approached or avoided
3-coping strategies: used to resolve threat

-uncomfortable feeling of apprehension or dread in response to internal or external stimuli
-physical, emotional, cognitive, and behavioral symptoms
-factors that determine whether anxiety is a symptom of mental disorder: intensity or anxiety relative to the situation, trigger for anxiety, symptom clusters that are manifested.

Question 23

defense mechanisms

Answer 23

used to reduce anxiety by preventing or diminishing unwanted thoughts and feelings. may be helpful, but problematic if overused.
-identify use of particular mechanism
-determine whether use is healthy or unhealthy
-what is healthy for one, may be unhealthy for another!!!
examples: repression or sublimation

Question 24

anxiety disorders

Answer 24

primary symptoms are FEAR AND ANXIETY
-most common of the psychiatric illnesses; chronic and persistent
-women experience more than men
-association with other mental or physical co-morbidities such as depression, heart disease, and respiratory disease
-most common condition of adolescents
-prevalence decreases with age

Question 25

anxiety disorders in children and adolescents

Answer 25

prompt identification, diagnosis, and treatment may be difficult for special populations -most common conditions of children and adolescents -if let untreated, symptoms persist and gradually worsen and can lead to: separation anxiety disorder, mutism, suicidal ideation and suicide attempts, early parenthood, drug and alcohol dependence, educational underachievement later in life.

Question 26

anxiety disorders in older adults

Answer 26

-rates of anxiety disorders are as high as mood disorders -combination of depressive and anxiety symptoms leads to decrease in social functioning, increase in somatic symptoms, and increase in depressive symptoms -due to risk of suicide, special assessment of anxiety symptoms is essential

Question 27

panic disorder

Answer 27

constant worry= GAD, peak episode=panic disorder extreme, overwhelming form of anxiety often experienced when an individual is placed in a real or perceived life-threatening situation- sudden and with significant amount of symptoms. -panic is normal during periods of threat, abnormal when continuously experienced in situations of no real physical or psychological threat. -panic attacks= sudden, discrete periods of intense fear or discomfort accompanied by significant physical and cognitive symptoms. usually peak n about 10 minutes but can last as long as 30 minutes before returning to normal functioning.

Question 28

panic: clinical course

Answer 28

-onset between 20-24 years old -physical symptoms: palpitations, chest discomfort, rapid pulse, nausea, dizziness, sweating, paresthesia (burning, tickling, pricking of skin with no apparent reason), trembling or shaking, and a feeling of suffocation or shortness of breath. -cognitive symptoms include disorganized thinking, irrational fears, depersonalization, and poor communication. -feelings of impending doom or death, losing control, and desperation ensue, feel as if the walls are closing in.

Question 29

panic attacks

Answer 29

characteristic of panic disorder -sudden, discrete period of intense fear or discomfort -usually reaches peak in several minutes and is accompanied with cognitive distress and physical discomfort -palpitations, chest discomfort, sweating, dizziness, pricking of skin without cause -s/sx mimic those of a heart attach. individuals often seek emergency medical care because they feel as if they are dying, but most have negative cardiac workup results. people may also believe attacks stem from underlying major medical illness. even with medical testing and assurance of no underlying disease, they often remain unconvinced. -depersonalization- being detached from oneself -feeling of impending doom

Question 30

diagnostic criteria for panic disorder

Answer 30

recurrent and unexpected panic attacks and 1 month or more after an attack of one of the following: -persistent concern about having another attack -worry about implications of attack or consequences -significant changes in behavior because of fear of the attacks -with or without agoraphobia= the fear of open spaces

Question 30

etiology of panic disorder

Answer 30

genetic factors: familiar predisposition biochemical theories: serotonin and norephinephrine are both implicated. norepinephrine effects act on those systems most affected by a panic attack- the CV, respiratory, and GI systems. serotonergic neurons are distributed in central autonomic and emotional motor control systems regulating anxiety states and anxiety-related physiologic and behavioral responses. GABA is most abundant inhibitory neurotransmitter in the brain. receptor stimulation causes several effects, including neurocognitive effects, reduction of anxiety, and sedation. stimulation also results in increased seizure threshold. -HPA axis- stress hormones are activated and increase anxiety. tress hormones are activated, anxiety increases, and panic attack may occur. psychological and social theories: anxiety response to separation and loss potentially. classic conditioning theory suggests that one learns a fear response by linking an adverse or fear-provoking event with a previously neutral event. phobic avoidance is not always developed secondary to an adverse event. cognitive behavioral theories: fear response may be learned. controlled exposure to anxiety-provoking situations and cognitive countering techniques has proven successful in reducing the symptoms of panic.

Question 31

treatment for panic disorder

Answer 31

-panic control treatment: intentional exposure ot panic-invoking sensations -systematic desensitization: exposure to hierarchy of feared situations. exposure method used to desensitize patients, exposes them to a hierarchy of feared situations that the patient has rated from least to most feared. the patient is taught to use muscle relaxation as levels of anxiety increase through multi-situational exposure. planning and implementing exposure therapy require special training. -implosive therapy: presenting highly anxiety provoking imagery -exposure therapy: repeated exposure to feared stimuli/phobias: controlled exposure to anxiety provoking situations and cognitive countering techniques has proven successful in reducing the symptoms of panic. -CBT: helps correct anxiety-provoking thoughts, often used with medication. highly effective for treating individuals. considered a first-line treatment for those with panic and anxiety disorders and is often used with meds (like SSRIs). goals include helping manage anxiety, correcting anxiety-provoking thoughts through interventions, with cognitive structuring, breathing training, and psychoeducation. pharm: SSRIs best for long term treatment and #1 choice, benzodiazepines used for acute anxiety-not a long term solution!

Question 32

panic disorder nursing care

Answer 32

assessment: RULE OUT POSSIBLE LIFE-THREATENING MEDICAL CAUSES- symptom evaluation- thyroid problems?? -substance use -sleep patterns -physical activity -medications interventions: -breathing control to avoid hyperventilation -nutritional planning: regular, balanced eating habits -relaxation techniques such as monitoring own tension -increased physical activity-can reduce occurrent of panic attacks -psychopharmacology- SSRIs, SNRIs, TCA, benzodiazepines

Question 33

SSRIs and panic disorder

Answer 33

-recommended as first drug option int he treatment of patients with panic disorder -they have best safety profile -antidepressant therapy is recommended for long-term treatment of the disorder and antianxiety as adjunctive treatment -initial increase in serotonergic activity with SSRIs may cause temporary increases in panic symptoms and even panic attacks. after 4-6 weeks of treatment, anxiety subsides, and antianxiety effect of medication begins.

Question 34

psychosocial nursing management of panic disorder

Answer 34

assessment: self-report scales, mental status exam, cognitive thought patterns interventions: assist patient to focus on other stimuli, distraction techniques, reframing, positive self-talk, psychoeducation and teaching patient and family about disorder, cultural competence- many cultures do not have a word for anxiety or anxious and may use words suggesting physical complaints. watch OTCH herbal remedies for substances inducing panic through increased HR, BMR, BP, and sweating.

Question 35

emergency care for panic disorder

Answer 35

symptoms are similar to cardiac emergencies! -stay with patient -reassure patient you wont leave -give clear, concise directions -assist patient to an environment with minimal stimulation -walk or pace with patient -administer prn anxiolytic medications -afterward, allow patient to vent feelings

Question 36

generalized anxiety disorder

Answer 36

feelings of frustration, disgust with life, demoralization, and hopelessness. sense of ill-being and uneasiness and fear of imminent disaster. -many patients complain of being chronic worriers -impacts all ages- adults often worry about matters such as jobs, household finances, health of family. intensity of the worry fluctuates, and stress tends to intensify the worry and anxiety symptoms.

Question 37

clinical course of GAD

Answer 37

-affects all ages -patients may exhibit depressive symptoms, such as dysphoria -often have somatic symptoms- muscle aches, soreness, GI problems- IBS -often experience poor sleep habits, irritability, poor concentration diagnostic criteria: excessive worry and anxiety for at least 6 months; anxiety related to number of real-life activities or events; patient with little or no control over the worry; at least three of the following alongside excessive worry: sleep disturbance, easy fatiguability, restlessness, poor concentration, irritability, and muscle tension -significant impairment in daily personal or social life nursing care: similar to person with panic disorder- help person target specific areas of anxiety and reduce the impact of anxiety

Question 38

agoraphobia

Answer 38

persistent fear of clearly discernible, circumscribed objects or situations leading to avoidance behavior. -fear of anxiety triggered by about two or more situations such as using public transport, open spaces, enclosed planes, standing in life, crowds, being outside of home alone. -individual believes something terrible might happen in these times and escape may be difficult. may experience panic like symptoms or other embarrassing symptoms (NVD) -leads to avoidance behaviors!

Question 39

specific phobia

Answer 39

-anxiolytics for short-term relief of anxiety -exposure therapy is treatment of choice -social phobia: persistent fear of social or performance situation in which embarrassment may occur. SSRIs to reduce social anxiety or phobic avoidance -people with social anxiety disorder appear to be highly sensitive to disapproval or criticism, tend to value themselves negatively, and have poor self-esteem and a distorted view of personal strengths and weaknesses. they may magnify personal flaws, underrate talents, believe others would act with more assertiveness in a given social situation. they replay social encounters in their mind after it has occurred, analyzing their actions, what they said, being very critical.

Question 40

antianxiety medications: benzodiazepines

Answer 40

-alprazolam, lorazepam, diazepam, chlordiazepoxide, oxazepam -side effects: drowsiness, intellectual impairment, memory impairment, ataxia, reduced motor coordination, sedation, "hangover" effects, tolerance or psychological dependence- increased CNS depression with alcohol!

Question 41

antianxiety medications: nonbenzodiazepine

Answer 41

buspirone -effective for treating anxiety without the CNS depressant effects or the potential for abuse and withdrawal symptoms -side effects: dizziness, drowsiness, nausea, excitement, headache -symptom relief occurs after 2-4 weeks of continual use

Question 42

sedative-hypnotics

Answer 42

sedatives reduce activity, nervousness, irritability and excitability without causing sleep at usual doses. hypnotics cause drowsiness and facilitate onset and maintenance of sleep: GABA enhancers, antihistamines, melatonergic hypnotics -benzodiazepines: duration of action is short, intermediate, or long acting -barbiturates: duration is ultra-short, short, long-acting -miscellaneous agent: zaleplon, zolpidem