Kalena-Lanuza-NURU 641-Signature Assignment

Transcript

00:01

Xanax (alprazolam)

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Signature Assignment NURU 641 Kalena Lanuza, DNP, FNP-C,CLC Dr. Haidy Willis

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- Medication overview

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- Case study: Appropriate use

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- Case study: Inappropriate use

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Class: Benzodiazepine (anxiolytic)

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(Stahl, 2020b)

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FDA Approved

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- Generalized Anxiety Disorder

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- Panic Disorder

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- Off-label uses

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Additional 'off-label' uses

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'Other' anxiety disorders

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Anxiety assc. w/ depression

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PMDD

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IBS

00:55

Insomnia

00:57

Catatonia

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ADJUNCT

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Acute Psychosis

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Acute Mania

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Mechanism of Action

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Binds to receptors @ GABA-A

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chloride conduction through GABA channels

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inhibitory effects of GABA

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ANXIETY

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(Stahl, 2020a)

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Rapid onset

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Less sedating than others in class

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XR formula available

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STahl, 2020b

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May lead to abuse

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Avoid w/ hx of substance/ etoh abuse

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Overdose & fatalities

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(Stahl, 2020b)

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Side effects

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sedation - fatigue - depression dizziness - weakness - slurred speech forgetting - confusion dry mouth or too much saliva HALLUCINATING (rare) HYPOTENSION (rare)

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Respiratory depression Liver - kidney dysfunction Blood dyscrasias

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Opioids & alcohol

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Certain 'azole' antifungals

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Angle- closure glaucoma

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Pregnancy & breastfeeding

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Avoid use.....

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Use CAUTION in....

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Children - Adolescents - Elderly

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Case study 1: Good candidate for Xanax

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New patient referred by PCP for increased anxiety & worry.

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Summary

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Identifying data

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Background

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Demographics

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Asian-American female; 45 y.o.

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Source & reliability

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Referral note; client report

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Difficulty sleeping, focusing at work, increased irritability with partner and feeling on edge.

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Feeling, "on edge" started approximately 1 year ago w/ onset of pandemic and has progressively worsened. Now having 'issues' concentrating at work and in relationship with partner and children. Sleeping 4-6 hrs per day and constantly feels fatigued. Denies thoughts of harm to self or others.

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"I feel like I'm completely loosing it- like it's all coming undone & I can't stop worrying."

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Current meds/ NKDA:

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Multi-vitamin daily Tylenol PRN H/A

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CC:

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HPI:

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Completed graduate school, works as systems analyst x 8 years Married x 15 years; 1 child (age 11) Strong involvement w/in Asian American community PTA president for child's school

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Developmental & Social Hx:

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Adopted

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Family Hx:

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None

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Medical Hx:

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0

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Denies alcohol or any drugs/ herbals expect as listed in med section.

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CAGE-AID:

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Zoloft 50 mg PO qd x appx. 1 yr after pregancy (2001)

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Substance use/ abuse:

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Past Psyche meds:

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Psychiatric Hx:

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Postpartum anxiety

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GAD-7: 11/21- mild anxiety PHQ-2: 2/6- negative

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Non-contributory

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Physical exam:

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Strong family/ social support Good mental health insurance coverage

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Assets & liabilities:

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Well groomed, A & O x 3 Sl. anxious but cooperative Good insight/ judgment Denies thoughts of harm or plan

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Mental Status Exam:

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Diagnostic tests:

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TSH: 1.25 mIU/L CBC/CMP/Lipids: WNL

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Vitamin D: 20 ng/mL

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Case Formulation

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Diff. Dx:

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Anxiety disorder due to a medical condition Substance/ med induced anxiety disorder PTSD & Adjustment disorder Depressive/ bipolar/ psychotic disorders

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Vitamin D deficiency, unspecified: E55.9

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Medical Dx:

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Generalized Anxiety Disorder: F41.1

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Psychiatric Dx:

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(American Psychiatric Association [APA], 2013)

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Short term- bridge treatment until sertraline starts to work: <12 weeks

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Vitamin D3 800 IU PO daily

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Alprazalom IR 0.25mg tab PO in 3 divided doses.

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Sertraline 25 mg tab PO q HS x 1 week then 50 mg tab PO q HS

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Pharmacology:

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Treatment Plan

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(Stahl, 2020b)

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Diagnostic/labs:

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Confer w/ PCP for routine lab frequency Vit D level

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Non-pharm Interventions/ referrals:

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Support group Mindfulness/ Relaxation techniques Behavioral therapy

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Treatment Plan

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(Sadock et al., 2015))

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Patient Education

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Review all common and dangerous S/E with patient. SSRI may take 4-8 weeks to really start to make a chance in how you feel Xanax is for short term use and may be habit forming (addictive) Do NOT drink or use opioids while on these medications Close follow up is necessary. Return to the office in 2 weeks or sooner to re-assess.

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(Stahl, 2020b; Sadock et al., 2015)

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DSM V: Has all criteria in A-F AND >3 in criteria C

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(APA, 2013; Budhwani, 2019)

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Case study 2: Poor candidate for Xanax

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Identifying Data

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Client report; questionable

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Source & reliability

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Latinx female; 72 y.o.

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Demographics

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Has been at home for last year w/ limited social contacts r/t pandemic. Trouble concentrating, feels she is constantly worrying about everything.

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Background

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New patient; referral from gerontologist for increase in worrying, irritability

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Summary

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CC:

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HPI:

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Current meds:

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"Well, my doctor thinks I'm anxious so I'm here to see you for help."

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Increased irritability over last 6 months. Watching news channels and states she is , 'now worried about everything, especially my kids and grandkids.' C/o being restless and having more difficulty sleeping than she used to. Just feels 'down' most of the time.

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pilocarpine 2% ophthalmic solution; 2 gtts to OU q 6 hrs lisinopril 10 mg po qd Vit D3 800 IU po qd Calcium carbonate 500 mg po qd

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None

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Widowed x 3 years Adult children live out of state Decreased social activity r/t pandemic Very active with friends prior

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Father: deceased age 74: CVD Mother: deceased age 87: 'natural causes' Step-children; non-contributory

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Medical Hx:

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Substance use/ abuse:

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Developmental & Social Hx:

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Family Hx:

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Psychiatric Hx:

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Hypertension, osteopenia, glaucoma

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0

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1 glasses of red wine 5 x/wk; denies other substance use, no herbals.

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None

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Past Psychiatric meds:

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CAGE-AID:

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Aware that she needs help Enjoys nightly wine Social isolation Hx: glaucoma

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Well groomed, A & O x 3 Cooperative, good insight/ judgment Appears anxious about constantly worrying No thoughts of harm or plan

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MoCA: 28/30 PHQ-9: 5/21 GAD-7: 5/21

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CBC/ Lipids/ Vit D: WNL CMP: WNL- GFR 61 TSH- 2.02mIU/L

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Diagnostic tests/labs:

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Physical exam:

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No substantial findings

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Assets & liabilities

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Mental Status Exam:

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Anxiety disorder due to a medical condition Substance/ med induced anxiety disorder Depressive/ bipolar/ psychotic disorders

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Diff. Dx:

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Case Formulation

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Psychiatric Dx:

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Major Depressive Disorder, single episode, mild w/ anxious distress: F32.0

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Hypertension: I10 Osteopenia: M85.80 Unspecified open- angle glaucoma: H40.10

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Medical Dx:

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APA, 2013)

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(APA, 2013)

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Cont. current meds, no new psychotropic additions at this time

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Treatment Plan

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Pharmacology:

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Non-pharm Interventions/ referrals:

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CBT Social Support Group Relaxation techniques

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Diagnostics/labs:

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Defer to PCP

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(Melillo & Houde, 2011)

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Patient Education

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Discussion of depression/ anxiety/ causes and all treatment options Review of possible medications to treat and why they are contraindicated as first line treatment at this time Discuss how CBT works Review relaxation techniques Offer referrals with follow-up to promote closed-loop system for care

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Treatment Plan

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(Sadock et al., 2015)

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Educate family if pt. agrees Written and electronic resources for disorder and social support networks Follow-up in 1-2 weeks to re- assess.

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(Budhwani,2019)

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(Budhwani,2019)

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A good social & medical history is a MUST before rx'ing benzodiazepines!!

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Use with elderly has significant increased risk so knowledge of non-pharmacologic treatment options for common psychiatric disorders is KEY

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Cultural considerations r/t racial discord and long-term pandemic effects are becoming common place- need to consider

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Thank you!