C H A P T E R 2 0
Anxiolytic and hypnotic agents
309
CRITICAL THINKING SCENARIO
Benzodiazepines
THE SITUATION
P.P., a 43-year-old mother of three teenage sons, comes
to the outpatient department for a routine physical
examination. Results are unremarkable except for blood
pressure of 145/90, pulse rate of 98 and apparent tension—
she is jittery, avoids eye contact and sometimes appears
teary-eyed. She says that she is having some problems
dealing with “life in general”. Her sons present many stresses
and her husband, who is busy with his career, has little
time to deal with issues at home. When he
is
home, he is
very demanding. In addition, she thinks she is beginning
menopause and is having trouble coping with the idea of
menopause as well as with some of the symptoms. Overall,
she feels lonely and has no outlet for her anger, tension
or stress. A healthcare provider, who reassures P.P. that this
problem is common in women of her age, prescribes the
benzodiazepine diazepam (
Valium
) to help P.P. deal with
her anxiety.
CRITICAL THINKING
What sort of crisis intervention would be most appropriate
for P.P.?
What care interventions are helpful at this point?
What non-drug interventions might be helpful?
What other support systems could be used to help P.P. deal
with all that is going on in her life?
Think about the overwhelming problems that P.P. has to
deal with on a daily basis and how the anxiolytic effects
of diazepam might change her approach to these
problems. Could the problems actually get worse?
Develop a care plan for the long-term care of P.P.
DISCUSSION
Anxiolytics are useful for controlling the unpleasant signs
and symptoms of anxiety. The diazepam prescribed for
P.P. may provide some immediate relief, enabling her to
survive the “crisis” period and plan changes in her life in
general. However, the associated drowsiness and sedation
may make coping with the problems in her life even more
difficult. She should be taught the adverse effects of
diazepam, the warning signs of serious adverse effects and
the health problems to report.
A follow-up evaluation should be scheduled.
Additional meetings with the same healthcare provider
are important for the long-term solution to P.P.’s anxiety.
Her need for drug therapy should be re-evaluated once
she can discover other support systems and develop
other ways of coping. Although anxiolytic therapy may be
beneficial initially, it will not solve the problems that are
causing anxiety, and in this case, the causes for the anxiety
are specific. The anxiolytic should be considered only as a
short-term aid.
Unlike P.P., many people in severe crisis do not
consciously identify the many causes of stress, or stressors.
However, P.P. has identified a list of factors that makes her
life stressful. This facilitates the development of coping
strategies. She may find the following support systems
helpful:
• Referral to a counsellor and involvement of the entire
family in identifying problems and ways to deal with
them.
• Support groups for women in various stages of life
(e.g. entering menopause, mothers of children who are
entering the teens). Just having the opportunity to discuss
problems and explore ways of dealing with them helps
many people.
CARE GUIDE FOR P.P.: DIAZEPAM
Assessment: History and examination
Allergies to diazepam, psychoses, acute narrow angle
glaucoma, acute alcohol intoxication, impaired liver or
kidney function, pregnancy, breastfeeding, concurrent
use of alcohol, omeprazole, cimetidine, disulfiram, oral
contraceptives, theophylline, ranitidine
CV: blood pressure, pulse, perfusion
CNS: orientation, affect, reflexes, vision
Skin: colour, lesions, texture
Respiratory: respiration, adventitious sounds
GI: abdominal examination, bowel sounds
Laboratory tests: hepatic and renal function tests, FBC
Implementation
Provide comfort and safety measures, small meals, drug
with food if GI upset occurs, bowel program as needed;
taper dosage after long-term use; reduce dosage if other
medications include narcotics; lower dose with renal or
hepatic impairment.
Provide support and reassurance to deal with drug effects.
Provide teaching regarding drug, dosage, adverse effects,
safety precautions and unusual symptoms to report.
Evaluation
Evaluate drug effects: relief of signs and symptoms of
anxiety.
Monitor for adverse effects, particularly sedation, dizziness,
insomnia, blood dyscrasia, GI upset, hepatic or renal
dysfunction, cardiovascular effects.
Monitor for drug–drug interactions.
Evaluate effectiveness of teaching program.
Evaluate effectiveness of comfort and safety measures.
