NURS 6630 Assessing and Treating Patients With Anxiety Disorders

Sample Answer for NURS 6630 Assessing and Treating Patients With Anxiety Disorders Included After Question

The Assignment: 5 pages

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.

In the case study, a 46-year-old man was referred for psychiatric evaluation by his PCP after going to the ER due to concerns about getting a heart attack. He reported experiencing heart attack symptoms like chest tightness, dyspnea, and a sensation of impending doom. The patient’s medical history is positive for mild hypertension, which he manages with a low-sodium diet and he is overweight. Heart attack was ruled out after having a normal EKG during the ER visit and his physical exam findings were unremarkable.  The patient reports that he gets episodes of anxiety attacks characterized by chest tightness, dyspnea, impending doom, and a feeling of wanting to escape. The examiner administers the patient the HAM-A questionnaire, which he scores 26. His mental status exam (MSE) findings are unremarkable apart from a self-reported mood of nervousness and blunted affect. He is diagnosed with generalized anxiety disorder (GAD).

            Various patient factors influence decisions when prescribing medications to clients with anxiety disorders. A patient’s age greatly influences treatment decisions since some medications are not indicated for some age groups (Mangolini et al., 2019).  Another factor is a patient’s clinical condition including the presenting signs and symptoms and co-morbid conditions. The patient has pre-existing hypertension and is overweight. Therefore, the clinician will be required to prescribe medications that are not associated with elevating blood pressure, affecting metabolism, or causing weight gain. The purpose of this assignment is to discuss treatment interventions for the patient in the case scenario including ethical and legal considerations.

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.

Note: Support your rationale with a minimum of five academic resources. While you may use the course text to support your rationale, it will not count toward the resource requirement. You should be utilizing the primary and secondary literature.

A Sample Answer For the Assignment: NURS 6630 Assessing and Treating Patients With Anxiety Disorders

Titles: NURS 6630 Assessing and Treating Patients With Anxiety Disorders

The case highlights a 46-year-old white male presenting with chest tightness, shortness of breath and feeling of impending doom. The patient has a history of mild hypertension and tonsillectomy, which has been accompanied by unremarkable medical history. The patient cites occasional shortness of breath, chest tightness, feelings of impending doom and the need to ‘escape’ or ‘run’ from one place. He confesses using ETOH to combat worries about work since the management at his place of work is harsh, and he fears for his job. The patient’s symptoms are characteristic of generalized anxiety disorder.

Anxiety can be a normal part of life, with concerns such as health, family challenges and money temporarily dominating individual experiences. Post-Traumatic Stress Disorder (PTSD) is an anxiety disorder characterized by nightmares, flashbacks, and intrusive thinking related to catastrophic events in an individual’s life (Ostacher & Cifu, 2019). Exposure to traumatic and terrifying events triggers PTSD. It is a potentially debilitating condition that affects direct victims or witnesses of traumatic events such as accidents, natural disasters, loss of loved ones, violent assaults like rape, war and other life-threatening events. The events can trigger an obsessive, recurrent and repetitive behavior that increases the feeling of fear, worry, helplessness, and hopelessness (Ostacher & Cifu, 2019). Nightmares, intrusive memories and flashbacks are common in individuals with past traumatic experiences increasing the risk of panic disorders.

Generalized anxiety disorders are common in adults with PTSD manifestations evident several months after the exposure to the traumatic and terrifying event. The symptoms of the anxiety disorders can be detrimental, although they subside, reducing the struggle with coping and self-care. According to Holmes (2022), anxiety disorders are mental conditions that deteriorate the quality of life by altering the action of neurotransmitters. Individuals with anxiety disorders have elevated worry and fear.

Psychopharmacological therapy targets relieving symptoms rather than curing the disorders. The recommended medications in the management of anxiety disorders include selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), antipsychotics, beta and adrenergic medications, antihistamines and GABAergic medications (Garakani et al., 2020). The treatment decisions will reflect the drug pharmacokinetics, pharmacodynamics, and ethical considerations in using the pharmacotherapeutic approach. The paper highlights three decisions on Generalized Anxiety Disorders.

Decision One,

Which Decision did you Select?

The first-line treatment for the patient will be the first-line SSRI, oral paroxetine 10 mg daily.

Why did you select this Decision?

Anxiety disorders are managed using different pharmacological regimens. The approaches focus on alleviating the symptoms and restoring social, mental and physical wellbeing. However, SSRIs and SNRIs are recommended for the treatment of PTSD, although sertraline and paroxetine are FDA-Approved as the first-line medication for PTSD management. According to Ostacher and Cifu (2019), benzodiazepines are contraindicated in PTSD. Paxil is FDA-approved for treating anxiety disorders and PTSD and is considered the first-line pharmacotherapeutic option for anxiety disorders.

Paxil is an SSRI that potentiates the serotonin action influencing the serotonergic neurotransmission (Davidson 2016). The medication restores serotonin balance, regulates mood changes, and reduces anxiety, fear, and panic attacks. Paxil has minimal anticholinergic and sedative effects and has a low cardiovascular impact. Its therapeutic window can range from 4-6 weeks and is significant in managing generalized anxiety disorder. It has less anticholinergic, adrenergic and antihistamine activity than tricyclic antidepressants.

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Why did you not select the other two options provided in the exercise?

Paxil is safer and tolerable in diverse patients than other medications such as Buspirone and Imipramine, which have adverse reactions such as increased drowsiness, blurry vision, and dizziness. Besides, they are not approved for first-line treatment of anxiety and PTSD hence my choice of Paxil for anxiety treatment.

What were you hoping to achieve with this Decision?

Paxil is slowly absorbed with its half-life ranging between 11 to 20 hours and attains its peak concentration within 4 to 10 hours. It works by elevating the serotonin levels, which establish a mental balance. According to Strawn (2018), Paxil can elicit minimal adverse reactions and alleviate symptoms such as fear, worry, helplessness, chest tightness, and shortness of breath. In light, I targeted alleviating the anxiety symptoms by elevating the serotonin levels.

Explain how ethical considerations may impact your treatment plan and communication with patients

Paxil has minimal adverse effects that undermine individual ethical values and treatment models. Patient safety is at the center of the pharmacological therapeutic approaches hence a key consideration in medical ethics. However, the patient is not incapacitated and capable of making individual decisions; thus, the psychiatrist needs to highlight the psychotherapeutic and pharmacotherapeutic models available and educate the patient appropriately before consenting to the treatment.

Decision Two

The first-line medication for the treatment of anxiety and PTSD is the most likely option for managing the patient. However, I would opt to retain Paxil as my second decision rather than change the medications. However, I will increase the dose from 10mg to 20mg daily to enhance the therapeutic effect.

Why did you select this decision?

The reaction response to Paxil may take long to manifest. To boost the HAM-A score, I would opt for a higher dose. Paxil is well-tolerated in the body and elicits minimum side effects (Strawn, 2018). Although the drug’s reaction is slow, it attains its therapeutic effect after a significantly more longer period. Therefore, increasing the dose can immediately impact mood and anxiety symptoms. According to Slee (2022), using a higher SSRIs dose can elevate serotonin levels in the brain and enhance the treatment outcome. The client’s compliance with the treatment can HAM-A score and attain best results.

NURS 6630 Assessing and Treating Patients With Anxiety Disorders
NURS 6630 Assessing and Treating Patients With Anxiety Disorders

Why did you not select other options in this exercise?

The anxiety medications exhibit diverse adverse effects. However, Paxil is well tolerated, with minimal side effects reported. In light, rather than changing to another first-line SSRIs with a similar pharmacokinetic and therapeutic effects, I would rather increase the dose. Besides, it is recommended as the best first-line treatment for anxiety disorders and PTSD. According to Javed and Fountoulakis (2018), Paxil significantly reduces the symptoms more than other medications such as imipramine. Therefore, I did not see the need to change the medication rather than maintain the patient on a higher dose of Paxil.

What were you hoping to achieve by making this decision?

Although the medication might take time for the client to realize a significant decline in the clinical manifestations, the main objective of the decision was to lower the HAM-A score further and stabilize mood and anxiety symptoms.

Explain how ethical considerations may impact your treatment plan and communication with patients

The major ethical concerns in medication include patient consent and safety. The medication should align with the major ethical principles that advocate for the patient’s autonomy, beneficence, and nonmaleficence. Paxil dose is well tolerated; therefore, increasing the dose implies that the medication is likely to be well tolerated. Furthermore, patient education should be advocated to allow the patient to make informed consent.

Decision Three

The third decision will be to shift to an SSRI alternative. However, the drug withdrawal process might be lengthy; hence I would opt for 10 mg of oral buspirone. Buspirone will also need close monitoring to assess the need to alter the treatment plan.

Why did you select this decision?

Buspirone is well tolerated in the body, although it is used in the short-term management of anxiety symptoms. It is also FDA-Approved for the management of Generalized Anxiety Disorder. In light, change from SSRI to Azapirone can attain a higher therapeutic effect than non-responsive paroxetine. The drug is well tolerated in the body, although it might exhibit some adverse effects.

Why did you not select the other two options provided in this exercise?

The rationale for the choice of the medications was entirely based on the efficacy and tolerability of the drugs. Buspirone is well-tolerated, exhibits minimal adverse effects, and is FDA approved for treating anxiety disorders. Therefore, I opted for drug safety and FDA recognition in the decision for combination therapy.

What are you hoping for by making this decision?

Adopting a combined therapy aimed to improve the patient’s experiences by lowering the anxiety symptoms. Buspirone regulates neurotransmitters’ actions, reducing anxiety symptoms (Javed & Fountoulakis, 2018). Changing the medications from non-responsive or slow-responding SSRIs to Azapirones can significantly reduce the HAM-A score alleviating the clinical manifestations of anxiety disorder.

Explain how ethical considerations may impact your treatment plan and communication with patients

The ethical concerns in the medical field are crucial, especially in managing mental health disorders. Patient autonomy may be impaired due to the involvement of the family members in the treatment process. However, the psychiatrist can establish the patient’s competence and compliance to determine the best approach for intervention. According to Javed and Fountoulakis (2018), buspirone elicits side effects such as chest pain, drowsiness, nausea, and increased sweating. However, some severe side effects such as blurred vision, uncontrollable shaking, agitation, hallucinations, confusion, irregular heartbeat and seizures can be reported. Clear communication should be established to allow the patient to make informed consent to the medication.

Conclusion

The management plan involved a shift from Paxil 10 mg to 20 mg once per day and further to Azapirone therapy of 10 mg buspirone twice a day. The selection of Paxil and buspirone was based on the recommendation and approval by the FDA in treating anxiety disorders and PTSD. However, due to the low response and impact on the HAM-A score, increasing the dose increased serotonin concentration, low anxiety, and regulated mood. The third decision opted against change from SSRIs to azapirone. Buspirone has partial agonist properties on serotonin and can improve serotonin levels and reduce the HAM-A score.

References

Davidson, J. (2016). Pharmacotherapy of post-traumatic stress disorder: going beyond the guidelines. BJPsych Open, 2(6), e16-e18. http://bjpo.rcpsych.org/content/2/6/e16

Garakani, A., Murrough, J. W., Freire, R. C., Thom, R. P., Larkin, K., Buono, F. D., & Iosifescu, D. V. (2020). Pharmacotherapy of anxiety disorders: current and emerging treatment options. Frontiers in psychiatry, 1412. https://doi.org/10.3389/fpsyt.2020.595584

Holmes, L. (2022). The 4 Major Classes of Anxiety Medications. Verywell Mind. Retrieved 2 July 2022, from https://www.verywellmind.com/mental-health-medications-for-anxiety-2337705.

Javed, A., & Fountoulakis, K. N. (Eds.). (2018). Advances in psychiatry. Springer.

Ostacher, M. J., & Cifu, A. S. (2019). Management of post-traumatic stress disorder. JAMA321(2), 200-201. https://doi.org/10.1001/jama.2018.19290

Slee, A. (2022). Generalized Anxiety Disorder: Incidence and Drug Treatment (Doctoral dissertation, UCL (University College London)). https://discovery.ucl.ac.uk/id/eprint/10146430

Strawn, J. R., Geracioti, L., Rajdev, N., Clemenza, K., & Levine, A. (2018). Pharmacotherapy for generalized anxiety disorder in adult and pediatric patients: an evidence-based treatment review. Expert opinion on pharmacotherapy19(10), 1057-1070. https://doi.org/10.1080%2F14656566.2018.1491966

A Sample Answer For the Assignment: NURS 6630 Assessing and Treating Patients With Anxiety Disorders

Title: NURS 6630 Assessing and Treating Patients With Anxiety Disorders

Anxiety disorders make the patients constantly worry and persistently anxious. The patients with the condition present with various symptoms which complicate their daily lives. Some of the symptoms include nervousness, muscle trembling, chest tightness, and shortness of breath. Therefore, there is a need for patients with anxiety disorders to seek medical attention from psychiatric mental health specialists. Various approaches have been used to treat and manage the condition, including pharmacological and psychotherapy approaches (Horenstein & Heimberg, 2020). The implication is that the prescriber should use medications that can be monitored for dose adjustments and potential stoppage or change in case there are adverse reactions. Therefore, the purpose of this assignment is to summarize a case study of a patient with anxiety disorder and explore various decision points upon the administration of appropriate medication.

The Case Summary

The case is of a forty-six-year-old white male patient who presented to the facility after a referral because he felt he was having a heart attack. The patient experiences a feeling of impending doom, breath shortness, and chest tightness. The patient also has mild hypertension and is overweight. The ER ruled out myocardial infarction, and he also had a normal EKG. While in the office, the patient indicated that he consumes alcohol occasionally to help him deal with his worries at work. The patient is single but currently takes care of his aging parent. He indicates that he fears for his job since the management at his workplace is harsh. The patient scored 26 upon administration of HAM-A, hence diagnosed with anxiety disorder.

Decision 1

The Selected Decision

            The first decision made was to begin Paxil 10 mg PO daily

Why the Decision Was Selected

            The decision was made since Paxil has been approved and widely used as a first-line drug to treat anxiety disorder (Kowalska et al., 2021). While it has similar efficacy as tricyclic antidepressants, Paxil has fewer side effects hence a good choice. In addition, it has a better safety record and a higher response rate compared to other classes of drugs.

Why the Other Options Were Not Selected

            The other two options included beginning Buspirone 10 mg Po BID or Begin Imipramine 25 mg Po BID. Buspirone was not chosen since it is recommended for use among patients with anxiety disorder only if the first line of treatment is not effective or presents safety concerns (Wilson & Trip, 2021). Therefore, it should be used as a second line of treatment (Garakani et al., 2020). This medication also has more side effects in comparison to Paxil, and patients also tend to abuse it after use. Imipramine, also an antidepressant, is only considered a second line of treatment for anxiety disorder. In addition, it has various undesirable side effects, such as urinary hesitancy, sedation, and weight gain (Chang et al., 2021). Therefore, it is not a good option since the patient also already has mild hypertension.

What I was Hoping to Achieve by Making the Decision

            One of the goals I was hoping to achieve by making the decision was to help the patient have reduced anxiety symptoms and lead a normal life. The medication is expected to act within four weeks. Hence the patient should have fewer worries and experience reduced heart attack-like symptoms (Kowalska et al., 2021). I also expected the HAM-A scores to substantially reduce.

How Ethical Consideration May Impact the Treatment Pan and Communication

            One of the ethical considerations at this stage is to offer the patient education regarding the potential side effects of Paxil in addition to informing the patient regarding other available treatment options, such as psychotherapy (Haddad & Geiger, 2020). The patient’s autonomy has to be upheld and be allowed to choose the best option without influence. The patient also needs to be informed of risks connected to not treating the conditions.

Decision 2

The Selected Decision

The second decision made is to increase the dose to 20 mg PO daily

Why the Decision Was Selected

After the first medication dose, the patient came back to the facility, indicating that his symptoms had improved. For example, he no longer experiences breath shortness, chest tightness, and decreased worries. Besides, the HAM-A scores substantially reduced to 18, indicating a partial response implying that the medication is effective; hence an appropriate titration should be done for optimum results. Therefore, a gradual increase from 10 mg to 20 mg should be the choice (Melaragno, 2021). It is also important to note that the patient has not experienced any adverse side effects, indicating that he is tolerating the medication well.

Why the Other Options Were Not Selected

The other two options include increasing the dose to 40 mg PO daily or no change to the drug or dose. It is worth noting that the patient’s improvement was partial; hence maintaining the dosage at 10 mg would give no further improvements or positive changes. In addition, increasing the dosage to 40 mg per day without gradually titrating the medication can lead to various side effects, such as delayed ejaculation, vomiting, nausea, and headaches (Garakani et al., 2020). A normal titration recommendation is usually 10 mg; hence increasing it to 40 mg would present a 30 mg increase which is way too high.

What I was Hoping to Achieve by Making the Decision

I was hoping to achieve increased positive results by increasing the dosage to 20 mg. I was also hoping that the patient gets treated and not only relieves symptoms (Garakani et al., 2020). In addition, I was also hoping that the patient’s score on the HAM-A scale would reduce by at least half.

How Ethical Consideration May Impact the Treatment Pan and Communication

The improvements observed by the patients may lead to excitement, and the patient may even request that he stops taking the medication. However, it is important to advise the patient on the need to continue with the treatment at the end to prevent a potential recurrence of anxiety symptoms. The patient’s autonomy should also be respected, and his input should be considered in further plans.

Decision 3

The Selected Decision

The third decision selected was to maintain the current dose

Why the Decision Was Selected

Upon increasing the dosage to 20 mg, the patient returned to the clinic and indicated that the symptoms had reduced even further. In addition, the patient also had a reduction of the HAM-A scores to 10 (Rabinowitz et al., 2023). There has been a sixty-one percent reduction in the symptoms. Therefore, it will be prudent to maintain the current medication dose as part of the maintenance therapy.

Why the Other Options Were Not Selected

The other two options included increasing the Paxil dosage to 30 mg PO daily or adding an augmentation agent like BuSpar. Increasing the dosage to 30 mg PO daily would further reduce anxiety symptoms. However, there is a high risk of increased side effects (Garakani et al., 2020). The patient data is also not showing any need for augmenting agents like BuSpar. Hence, this choice was also ignored.

What I was Hoping to Achieve by Making the Decision

The decision made was to maintain the dosage. Therefore, I was hoping for all the anxiety symptoms experienced by the patient clear out. I am also hoping that the patient will not suffer any consequences due to ignoring the other two options. I was also hoping that the patient should have improved feelings and not experience any heart attack-like symptoms.

How Ethical Consideration May Impact the Treatment Pan and Communication

There are also ethical considerations that may impact the treatment and communication. One of them is that the patient needs to be educated on the potential risks and threats of increasing the dosage to more than 20 mg in case the patient requests it. The decision should also be made to ensure that the patient does not face any harm but ensure that the patient continues to experience improved symptoms.

Conclusion

The patient in this case study was diagnosed with anxiety disorder; hence medication treatment decision points were taken. The patient presented with various symptoms, such as chest tightness, the feeling of impending doom, and shortness of breath. Therefore, there was a need for the patient with anxiety disorders to seek medical attention from a psychiatric mental health specialist. Various approaches have been used to treat and manage the condition, including pharmacological and psychotherapy approaches. In the case of this patient, the treatment used was 10 mg of Paxil initially. This decision was made while two other decisions were left out, such as beginning Buspirone 10 mg Po BID or Begin Imipramine 25 mg Po BID.

The two choices were majorly ignored since both are considered a second line of treatment (Garakani et al., 2020). Therefore, they are only used when the first line of treatment, in this case, Paxil, is not effective or is presenting safety concerns for the patient. The dosage was increased to 20 mg after the patient initially showed improvement. Besides, two other choices were ignored to ensure that the patient goes on in his path to recovery. This dosage was to be maintained to help balance the risk factors and the expected benefits.

References

Chang, G. R., Hou, P. H., Wang, C. M., Lin, J. W., Lin, W. L., Lin, T. C., … & Wang, Y. C. (2021). Imipramine accelerates nonalcoholic fatty liver disease, renal impairment, diabetic retinopathy, insulin resistance, and urinary chromium loss in obese mice. Veterinary Sciences8(9), 189. https://doi.org/10.3390/vetsci8090189

Garakani, A., Murrough, J. W., Freire, R. C., Thom, R. P., Larkin, K., Buono, F. D., & Iosifescu, D. V. (2020). Pharmacotherapy of anxiety disorders: Current and emerging treatment options. Frontiers in Psychiatry11https://doi.org/10.3389/fpsyt.2020.595584

Haddad, L. M., & Geiger, R. A. (2020, September 1). Nursing ethical considerations – StatPearls – NCBI bookshelf. National Center for Biotechnology Information. https://www.ncbi.nlm.nih.gov/books/NBK526054/

Horenstein, A., & Heimberg, R. G. (2020). Anxiety disorders and healthcare utilization: A systematic review. Clinical Psychology Review81, 101894. https://doi.org/10.1016/j.cpr.2020.101894

Kowalska, M., Nowaczyk, J., Fijałkowski, Ł., & Nowaczyk, A. (2021). Paroxetine—overview of the molecular mechanisms of action. International Journal of Molecular Sciences22(4), 1662. https://doi.org/10.3390/ijms22041662

Melaragno, A. J. (2021). Pharmacotherapy for anxiety disorders: from first-line options to treatment resistance. Focus19(2), 145-160. https://doi.org/10.1176/appi.focus.20200048

Rabinowitz, J., Williams, J. B., Hefting, N., Anderson, A., Brown, B., Fu, D. J., …& Schooler, N. R. (2023). Consistency checks to improve measurement with the Hamilton Rating Scale for Anxiety (HAM-A). Journal of Affective Disorders325, 429–436. https://doi.org/10.1016/j.jad.2023.01.029

Wilson, T. K., & Tripp, J. (2021, August 12). Buspirone – StatPearls – NCBI bookshelf. National Center for Biotechnology Information. https://www.ncbi.nlm.nih.gov/books/NBK531477/