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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? Pt's pulse rate would be stabilized first because this will allow the blood pressure to be more easily regulated and the SOB to be alleviated.

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. Chest pain, palpitations, paresthesia, difficulty breathing, dizziness, nausea, diaphoretic, trembling, elevated B/P, rapid pulse and respirations.

3. What additional assessments would be included when assessing a patient for anxiety and panic? The Hamilton Rating scale for Anxiety (p.227,228), to determine the current level of anxiety. Perform a psychosocial assessment,

4. What is the difference between anxiety attack and panic disorder? The main feature of an anxiety attack is that you are worrying about something in your LIFE (for example, relationships, work, school, money). The main feature of a panic disorder is that you are worrying about your BODY or your MIND right then and there, rather than worrying about something in your life. Most people with panic attacks have gone to an emergency room at least once to make sure nothing physical was going on.

5. What medications are used to treat anxiety and panic disorders and/or attacks? What patient teaching will you include related to these medications.

TCAs (Tricyclic Antidepressants)-Pts should never suddenly stop taking these medications because acute withdrawal symptoms may occur. Blood checks are recommended because these medications may build-up in the blood stream, if excess amounts of medication are taken or found to be present in your blood it may lead to heart disease and/or death. This medication dose needs to be monitored closely; pts are at elevated risk for overdose. Tell your doctor of any present or prior heart conditions and medications that pt may be taking. These drugs take six or more weeks to be fully effective.

MAOIs (Monoamine Oxiddase Inhibitors)-Pts should never suddenly stop taking these medications because acute withdrawal symptoms may occur. Pts need to avoid ingestion of certain foods while on this medication such as cheese, some beans, and pickled foods because these foods may cause severe high blood pressure. Many OTC medications may be very dangerous while taking MAOIs, be sure to provide your doctor with a full medication list and to also know which medications to avoid (common cold medications or not recommended for example). These medications are known to cause death when overdose occurs. There is a 14-day waiting period after you stop taking MAOIs before any other antidepressants are taken.

Antidepressants- Pts should never suddenly stop taking these medications because acute withdrawal symptoms may occur. Drug may take 4 weeks or longer to be fully effective. Pts should avoid hazardous activities while on these medications. Pts should consume small meals frequently to avoid GI upset. Pts should look into anti-itch medications if rash develops. Female pts needs to inform prescriber of pregnancy or breastfeeding.

SSRIs(Selective Serotonin Re-uptake inhibitors) -Pts should never suddenly stop taking these medications because acute withdrawal symptoms may occur. SSRIs may increase the risk for bleeding in the upper GI tract and should not be taken with NSAIDs because of the increased risk for bleeding. SSRIs are not commonly used to treat Manic Depression or bipolar disorders. SSRIs may increase the risk of bone fracture in pts over 50 years. If liver disease is present or suspected a lower dose of SSRIs should be given when needed.

Benzodiazepines. - Pts should never suddenly stop taking these medications because acute withdrawal symptoms may occur. Pts on these medications are at risk for dependency, these drugs may cause muscle weakness, blurred vision, slurred speech, drowsiness, memory loss or fatigue.

6. Write a psychosocial nursing diagnosis for this patient. Ineffective coping Severe anxiety Stress overload Disturbed thought process r/t difficulty thinking clearly

7. Write one short term and one long-term goal related to the diagnosis you have identified. Short- Term " Pt. anxiety will decrease to moderate by (date) three days " ( p.219) Long-Term- Pt. will gain mastery over panic episodes by (date)"'. (p. 219)

8. For each goal, write 5 nursing interventions. ST- Take client to a quiet area and assure him he is not having a heart attack. Use firm, short, and simple statments. Educate the client about the symptoms of a panic attack. Offer client a drink of water/juice to help with constructive thought process. Express to the client that he appears upset and if he wants to talk about it. Listen calmly and attentivily to clients feelings.

LT- Educate client about anxiety, and how to cope with life events that cause stress. Use communication tools that are helpful in sorting out feelings; use paraphasing, identify problems, and ways to cope with life events that trigger anxiety. Stress positive responses to medical conditions; relaxation techniques, and recreational activities(walking), talking to other people, when feeling anxious. Encourage future verbalization of fears and anxieties, and expression of feelings with freinds and professional staff. Disscuss use of medications as needed.