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= =  Directions: Working within your assigned teams, answer the following questions. Each team member is expected to contribute to the completion of the case study. Please bring your completed work to class with you on 1/27 so that you are able to contribute to the class discussion of this topic.

Scenario: A 24 year old male is brought to the ER via ambulance at 1030 with a complaint of chest pain and tightness; difficulty breathing; dizziness; palpitations; nausea, paresthesia and feeling like he is going to die. He is having difficulty thinking clearly.  The patient tells you “I don’t think I’m going to make it. I must be having a heart attack.” He is diaphoretic and trembling. V/S: B/P 178/98; P 110; R 28 and shallow; T 36.9C. The onset of symptoms was approximately 40 minutes ago during a staff meeting and became progressively worse. The patient has no history of cardiac problems.

1. What is the highest medical priority for this patient? What is your rationale for the answer you have given? The highest priority for this patient is to rule out MI or other serious heart conditions. While it appears clear that this patient is presenting with physical manifestations of stress we can not assume that there is no underlying heart problem until it is ruled out by a physician. i thought that airway was always the first thing to look at.

After a full medical work-up, the patient is stable. His SOB and anxiety are resolved after he received Lorazepam 1mg IV push. The medical workup did not reveal an underlying medical condition and a diagnosis of panic attack is given. After further conversation with the patient, he reports having 5 similar episodes in the past 3 weeks, but they were not as severe as this one.

2. Identify the patient’s presenting symptoms that support a diagnosis of panic attack. Feeling of going to die, inability to think clearly, palpitations, difficulty breathing, elevated pulse, difficulty breathing, chest tightness and chest pain.

3. What additional assessments would be included when assessing a patient for anxiety and panic? I would do blood work and EKG. ask what medications they are on. I would assess whether or not they have suicidal thoughts and or tendancies. I would also assess how irritable the patient is and ask them if they can identify what set off the panic attack in the first place. Also assess any nausea, headaches, pacing, crying, expressions of helplessness, and feelings of inadequacy.

What circumstances were surrounding the previous 5 episodes in the last three weeks? Were these also related to work or were there some other triggers involved? What is his body language like now that he has calmed down, are there any non verbal cues? Does he have any support systems such as family, friends, coworkers? Is there any history of substance abuse? Is there a family history of panic attacks? What are some other factors contributing to this high level of stress? Are there financial problems, family issues, other health concerns?

4. What is the difference between anxiety attack and panic disorder?  Carrie Avallone-Merritt .An anxiety attack and Panic disorder are very different. An anxiety attack is a build up or overload of anxiety causing physical symptoms; tachycardia, hyperventilation, dizziness, nausea, and headaches. Behavioral changes like withdrawal, pacing, amd making threats or demands is common. As the anxiety of a person increases, so does the inability to think clearly. An anxiety attack is commonly accompanied by trembling, muscle tension, increased pulse and pounding heart. Panic attacks, on the other hand are sudden, acute anxiety attacks. Physically and mentally draining behavior such as severe shakiness, sleeplessness, hyperactivity, and a state of terror. During a panic attack a person is unable to problem solve, process their environment, and may become erratic. A person may even experience hallucinations or delusions, and are likely to be out of touch with reality, during the attack. The overwhelming feeling of impending doom or death is common. Panic disorder is unexpected recurrent panic attacks; followed by fear of more attacks, overall sense of impending doom, or death and may cause an overall change in behavior.  5. What medications are used to treat anxiety and panic disorders and/or attacks? What patient teaching will you include related to these medications. the medications used to treat anxiety and panic disorders are benzodiazpines and antidepressant medications. there are many antidepressants the ones for aniety disorders include: Paroxetine which is a selective serotonin reuptake inhibitor (SSRI), Amitriptyline a tricyclic antidepressant (TCA) Phenelzine a monoamine oxidase inhibitor (MAOI) and Venlafaxine a serotonin-norepinephrine reuptake inhibitor (SNRI). The benzodiazepines used for anxiety disorders are Valium, Xanax, Ativan, Librium, Serax and Klonopin. Some other medications used are BuSpar a nonbarbiturate anxiolytic, antihistamines, beta blckers and anticonvulsants. benzodazepines have a quick onset so they are good to use for a quick fix but they are not recommended for long term use as they may lead to dependency. they depress the CNS so people already addicted to certain drugs run the risk for overdosing. BuSpar does not lead to dependency but it takes from 2 to 4 weeks before any theraputic results can be seen. Antihistamines, bete blockers and anticonvulsants are used if other medications are not successful. Of all the antidepressants SSRIs have the quickest onset and the least side effects.

you would need to teach the pt to take meds as directed as taking too much could cause adverse side effects and takin too little might not make the desired effect. do not operate machinery or drive until you know how your body reacts to these medications as some do have a sedative effect. Do not drink or take additonal antianxiety drugs without a perscription from your dr since they may increase the depressant effects. Avoid any form of caffeine they decrease the desired effects of the drugs. Do not become pregnant or breast feed while on these drugs they may cause congenital defects or have adverse effects ont the infant. Take drugs with meals do prevent intentinal problems. Antacids may cause change how medications are absorbed. Do not stop taking these medications abrubtly as that might cause withdrawal symptoms.

6. Write a psychosocial nursing diagnosis for this patient. Stress overload related to workplace environment/demands as evidenced by patient complaints of SOB, tightness in chest and difficulty thinking clearly with onset occurring while at work.

7. Write one short term and one long-term goal related to the diagnosis you have identified. short term: Pt will identify 2 techniques of managing stress. Long Term: pt will identify all known situations that contribute to panic attacks and learn relaxation techniques to alliviate such situations. 8. For each goal, write 5 nursing interventions. short term: 1. encourage pt to exercise to relieve tension and possibly lower anxiety. 2. tell patient to keep keep a journal and right down what exacally triggers his/hers anxiety. 3. Teach relaxation techniques such as guided imagery and meditation. 4. Teach realistic recreational activities to help reduce stress and promote a healthy balance, before discharge. (Carrie) 5. Have pt identify 2 realistic recreational activities to help reduce stress and promote a healthy balance, before discharge. (Carrie)

long term: 1. assist pt in finding community support groups of individuals suffering from similar problem. 2. assist patient in relaxation and deep breathing techniques 3. Have patient identify 3 coping techniques that he feels comfortable using. 4. Educate patient about different types of treatment that may be effective in helping to reduce stress. 5. Help patient to find a new recreational activity that he can do on a regular basis (Carrie)