Assessing and Treating Patients with Anxiety Disorders Essay

Assessing and Treating Patients with Anxiety Disorders Essay

Advanced practice registered nurses assess and treat patients, while registered nurses cannot prescribe patient interventions. The added role demands more skills and knowledge in comprehensive patient assessment and diagnosis for APRNs. Anxiety disorders are associated with excessive, irrational fear and apprehension that affects the patient’s quality of life (Stern et al., 2016). Patients’ presentations help APRNs understand their problems and remedy effective interventions. Healthcare providers also use these clinical presentations to determine the clinical efficacy of interventions and inform clinical decisions. This essay evaluates care interventions for a patient presenting with anxiety symptoms

The client, a 40-year-old male and a welder at a steel factory, was admitted to the ER after perceiving a heart attack while working. He complained of chest tightness, breathlessness, and sensed impending doom. An EKG ruled out a heart attack and myocardial infarction. The patient reports that his symptoms include a desire to flee from the place whenever the episodes occur. His underlying hypertension is well-controlled. The patient admits to using ETOH to manage these symptoms, 3-5 beers per night, and denies taking psychiatric medications. He is not married and takes care of her aging mother. He fears losing his job and reports harsh treatment. His HAM-A test score was 26, showing severe anxiety, but he denies hallucinations, delusions, and suicidal tendencies. He has fair judgment and good insight.

Decision Point One

The assessment data provided by the patient will help make decisions regarding care interventions. The first decision is to begin the patient on Paxil 10mg PO daily. Paxil (paroxetine) is an FDA-approved selective serotonin reuptake inhibitor for managing generalized anxiety and other anxiety disorders. Selective serotonin reuptake inhibitors (SSRIs) and selective serotonin-nor-epinephrine reuptake inhibitors (SSNRIs) are the first-line treatment for anxiety and other mood disorders such as depression. Kowalska et al. (2021) note that paroxetine reduces psychic anxiety symptoms, including fear, a sense of impending doom, and irritability. The medication is well-tolerated and effective, with minimal side effects (Kowalska et al., 2021).

The goals of this decision (to begin Paxil 10mg) are to reduce the psychic symptoms of anxiety (fear, sense of impending doom, and desire to free places). The patient has an excessive, irrational fear, affecting his work ability. Another goal is to reduce the psychological and physical effects such as breathlessness and heart attack feelings. The patient perceives harsh workplace treatment, which causes him stress. He has paranoia, and initiating and maintaining therapy might not be easy. Implementing measures to improve adherence is important, such as using medications with fewer side effects. Another consideration is the high dropout rate hence the need to emphasize the need to adhere to the follow-up interventions recommended.

Imipramine is another available treatment option for this patient. It is a second-line treatment for generalized anxiety disorder and an FDA-approved medication for depression (Fayez & Gupta, 2021). Imipramine is not selected because it is not FDA-approved yet FDA-approved, and first-line interventions are available. In addition, imipramine also has undesirable severe side effects such as tachycardia, poor coordination, weakness, mouth dryness, nausea, and vomiting, which affect medication adherence and overall efficacy (Fayez & Gupta, 2021).

One of the decisions available is buspirone. Buspirone is FDA-approved for only GAD. It has a mechanism of action similar to SSRIs and SSNRIs by reducing serotonin levels in the brain (Munir et al., 2022). The medication reinstates the chemical imbalances caused by anxiety in the brain. However, statistics show that the medication has various undesirable characteristics, such as hypertension, chest pain, nausea, vomiting, and drowsiness, reducing its utilization and use as a first-choice medication for anxiety (Munir et al., 2022). In addition, the medication takes at least 2-4 weeks to produce the desired results. These characteristics reduce the drug’s use as a first-line medication for anxiety.

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Decision Point 2

Initiating Paxil 10mg benefited this patient, and he returned to the facility and reported that his symptoms had ceased. He had no chest tightness or shortness of breath, the HAM-A test result is at 18, and thus the patient has achieved partial remission. The second decision is to increase the dosage of Paxil to 20mg. The goal of the decision is to achieve full remission because the symptoms have decreased and the anxiety HAM-A tests scores have reduced, and increasing the dose increases its effectiveness. In addition, the FDA reports that the therapeutically effective dosage of Paxil is 20mg, and thus increasing the dose to 20mg will achieve optimal therapeutic effects (Kowalska et al., 2021). Dosages in Paxil are titrated, and increasing the dose at once strikes the plasma levels, increases serotonin levels in the blood, and could lead to toxicity and severe side effects (FDA). In addition, the medication has not produced a side effect that would warrant a change, hence the retention of the therapy. According to _, healthcare providers can change the initial medication if there is symptom exacerbation, lack of visible changes in the symptoms, and the emergence of severe side effects.

The option of maintaining the current dose is eliminated because although the dose has achieved some results, the symptoms have not disappeared, and there is a risk for resistance and severe disease relapse. Thus, titrating the Paxil dose from 10mg to 20mg is the choice decision during the second decision point.

SSRIs and SSNRIs medications increase the levels of serotonin in the brain. They thus act as mood stabilizers. However, doses above the therapeutic levels can be catastrophic and exacerbate symptoms. Studies show that increasing the doses of these medications above the minimum licensed doses does not produce significantly different results but exposes the patient to severe medication side effects (Baldwin, 2020). Baldwin (2020) states that when changing the dosages, the US FDA thus requires the care providers to titrate the doses as they observe the patients for therapeutic medication effectiveness and any side effects. Thus, increasing the dose to 20mg from 10 mg is preferred over increasing it from 10mg to 40mg.

There are various ethical and legal considerations for this patient. The goal of the treatment is to produce total remission while observing for any side effects. Reducing the HAM-A score to below ten and eliminating anxiety is the priority. Amidst aggressive treatment, there is a need to ensure goodwill and non-maleficence hence the titration of the doses. As mentioned earlier, Paxil 20mg is the minimum licensed dose in GAD and is clinically effective. Thus, increasing the dose to 20 will produce optimal effects, and monitoring for side effects is thus vital for this patient.

Decision Point #3

The results of the second decision were that the patient had a further decrease in the symptoms, and the HAM-A score was at 10, meaning mild anxiety. The patient has achieved 61% remission of the symptoms, and the decision is to maintain the dose of Paxil at 20mg. The goal of the decision is to retain the therapeutic effectiveness of the medication while reducing the chances of side effects. There is a need to prevent relapse, and SSRIs such as paroxetine help reduce GAD symptoms relapse and lead to sustained clinical effectiveness (Kong et al., 2020). The patient has responded to the medication. At this stage, it is not necessary to change the therapy to avoid risks of symptom exacerbation, and maintaining the dose will enhance clinical effectiveness.

The US FDA shows that medication effectiveness warrants dosage continuation in patients. There are two reasons; increasing the dose does not produce other clinical outcomes, and increasing the dose increases the risks for severe side effects. Buspirone has a similar mechanism of action as Paxil, and adding the drug could produce severe side effects. In addition, they place the patient at risk for precipitate serotonin syndrome caused by the use of two serotonin reuptake inhibitors (Scotton et al., 2019). The two medications increase the risk for precipitate serotonin syndrome when used with concomitant serotonergic drugs such as buspirone. The patient has achieved remission with a HAM-A score of 10, indicating mild anxiety.

Beneficence and non-maleficence are the ethical considerations in this case. The patient has achieved remission, and they are happy about the drug. Changing the medication may also reignite their anxiety, besides the risks for poor health outcomes. The choice decision must achieve the desired effects, which are sustained remission, relapse prevention, decreased psychic and physical symptoms of anxiety, and improved quality o life for the patient.

Conclusion

The 40-year-old patient is affected by GAD, a condition characterized by irrational yet excessive fear that interferes with cognitive, physical, and social functioning. These patients are often brought to the emergency department with physical symptoms that cannot be explained through any diagnostic result. The patient in this case study presents with severe symptoms such as fear, a sense of impending doom, a desire to run, palpitations, and a sense of a heart attack, and most of the symptoms cannot be materialized at the emergency department. Generalized anxiety disorder is non-specific irrational fear and presents with symptoms such as fear and a sense of impending doom.

Initial treatment should be begun with effective, first-line, FDA-approved medications if they are available. Low doses are used and titrated based on the patient’s response. Second-line treatment options and drugs that are not FDA-approved but are clinically effective can be used in the absence of first-line and FDA-approved drugs. The goal is to ensure patients achieve remission, tolerate the drugs well, and observe minimal side effects. Medications with a fast onset are selected when dealing with patients with current symptoms. The fast onset helps relieve the symptoms, helps the patients trust the treatment process, and reduces the dropout rate risk.

Clinical response to the drug warrants an increase in dose to produce the desired effects. Increasing the dosage of paroxetine to the minimum licensed dose helped ensure clinical effectiveness while avoiding drug side effects. Maintaining the dose will help avoid relapse, produce sustained therapeutic effects, and promote better patient outcomes. Monitoring the patient after a while will help the care providers assess the long-term effects of the medications and make decisions to ensure his anxiety is managed for life.

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References

Baldwin, D. S. (2020). Pharmacological Treatment of Generalized Anxiety Disorder (GAD). Generalized Anxiety Disorder and Worrying: A Comprehensive Handbook for Clinicians and Researchers, 297-318. https://doi.org/10.1002/9781119189909.ch14

Fayez, R., & Gupta, V. (2021). Imipramine. In StatPearls [Internet]. StatPearls Publishing.

Kong, W., Deng, H., Wan, J., Zhou, Y., Zhou, Y., Song, B., & Wang, X. (2020). Comparative remission rates and tolerability of drugs for a generalized anxiety disorder: a systematic review and network meta-analysis of double-blind, randomized controlled trials. Frontiers in Pharmacology, 11, 580858. https://doi.org/10.3389/fphar.2020.5808

Kowalska, M., Nowaczyk, J., Fijałkowski, Ł., & Nowaczyk, A. (2021). Paroxetine—Overview of the molecular mechanisms of action. International Journal of Molecular Sciences, 22(4), 1662. https://doi.org/10.1002/9781119189909.ch14

Munir, S., Takov, V., & Coletti, V. A. (2022). Generalized anxiety disorder (nursing). In StatPearls [Internet]. StatPearls Publishing.

Scotton, W. J., Hill, L. J., Williams, A. C., & Barnes, N. M. (2019). Serotonin syndrome: pathophysiology, clinical features, management, and potential future directions. International Journal of Tryptophan Research, 12, 1178646919873925. https://doi.org/10.1177/1178646919873925

Stern, T. A., Favo, M., Wilens, T. E., & Rosenbaum, J. F. (2016). Massachusetts General Hospital psychopharmacology and neurotherapeutics. Elsevier.

Examine Case Study: A Middle-Aged Caucasian Man With Anxiety. You will be asked to make three decisions concerning the medication to prescribe to this patient. Be sure to consider factors that might impact the patient’s pharmacokinetic and pharmacodynamic processes.

At each decision point, you should evaluate all options before selecting your decision and moving throughout the exercise. Before you make your decision, make sure that you have researched each option and that you evaluate the decision that you will select. Be sure to research each option using the primary literature.

Introduction to the case (1 page)

Briefly explain and summarize the case for this Assignment. Be sure to include the specific patient factors that may impact your decision making when prescribing medication for this patient.
Decision #1 (1 page)

Which decision did you select?
Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.

Decision #2 (1 page)

Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.
Decision #3 (1 page)

Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.
Conclusion (1 page)

Summarize your recommendations on the treatment options you selected for this patient. Be sure to justify your recommendations and support your response with clinically relevant and patient-specific resources, including the primary literature