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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 medial priority is difficulty breathing. ( according to the ABC's - Airway, Breathing and Circulation.)

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. Objective Symptoms: Respirations elevated 28 & shallow, B/P Elevated 178/98, Pulse 110 elevated. Diaphoretic. subjective: pt stated having difficulty thinking clearly. Complaining of chest pains. Patients states “I don’t think I’m going to make it. I must be having a heart attack.” 3. What additional assessments would be included when assessing a patient for anxiety and panic? How often were the previous attacks, causes, behavior. Feeling of choking, chills, hot flashes. What triggers pt's anxiety. What did pt do to get himself through past panic attacks and what coping mechanism did he use in the past.

4. What is the difference between anxiety attack and panic disorder? anxiety attack has a slower onset and is less severe. Anxiety also can be mild, moderate or severe which is situational bound (i.e.. social situation) Panic disorder hits suddenly without warning, has a rapid onset, and is more severe. Also panic disorders (attacks) usually precipatate feelings of a medical emergency (DSM 4. Panic attacks usually last only a few minutes.

5. What medications are used to treat anxiety and panic disorders and/or attacks? What patient teaching will you include related to these medications. Ativan, benzodiazepines, xanax, alprazolam, diazepam, clonazepam, lorazepam, SSRIs, desyel, trazodone.BuSpar-long term treatment that does not cause dependence but take a few weeks to take full effects. Instruct pt to take med exactly as directed. Advise pt to avoid driving or other activities that require alertness until response to med is known. Avoid taking alcohol/ other CNS depressants currently with these meds as it could reduce desired effects of medications. Make position changes slowly. Do not stop drug abruptly. Instruct the pt in the appropriate use of anti anxiety meds. Some meds may have an addiction/dependancy risk.Antacids may delay absorption rate.

6. Write a psychosocial nursing diagnosis for this patient. Ineffective coping Anxiety a/e/b increased pulse and respiration, shortness of breath, and chest pain.

7. Write one short term and one long-term goal related to the diagnosis you have identified.

ST Goal: Patient's anxiety will decrease/diminish for remainder of hospital stay. LT Goal: Patient will be able to identify 5 means of self control.

ST: pt's anxiety will decrease to moderate by the end of the shift. LT: Pt's will gain mastery over panic episodes by discharge.

8. For each goal, write 5 nursing interventions.

1) Teach patient abdominal breathing techniques and instruct patient to use when anxiety is detected. 2) Provide a calm environment for the patient. 3) Encourage patient to be involved with his care and decision making.    4) Establish a trusting relationship with patient 5) Reassure pt that he is safe.

Orient pt to the new environment and new experiences/ people as needed to produce comfort and reduce the anxiety. LT: 1) Patient will be able to use positive self talk. 2) Patient will be able to identify stress factors in his life and what can be done to alleviate these stressors. 3) Patient will plan coping mechanisms for future stressful situations. 4) Patient will maintain a sleep diary. 5) Patient will seek information/receive information about panic attacks and ways to reduce anxiety . Assist pt in developing problem-solving abilities. Emphasize the logical strategies pt can use when experiencing anxious feelings. Assist pt in developing anxiety-reducing skills to enhance pt's sense personal of mastery and confidence.