Mental health nursing

1. ERA COLLEGE OF NURSING
LESSON PLAN
0N
ANXIOLYTICS
SUBJECT – MENTLHEALTH NURSING
SUBMITTED TO- SUBMITTEDBY-
MR. LIBIN SHIVENDRADIXIT
SR. NURSING TUTOR MSC. NURSING
ERA COLLEGE OF NURSING 1ST
YEAR

2. LESSON PLAN
NAME OF THE STUDENT TEACHER : SHIVENDRA DIXIT
SUBJECT : MENTAL HEALTH NURSING
TIME : 45 MINS
TOPIC : ANXIOLYTICS
LANGUAGE USED : ENGLISH, HINDI
GROUP : B.SC. 3RD YEAR
METHOD OF TEACHING : LECTURE CUM DISCUSSION
AV AIDS USED : PROJECTOR, HANDOUT, PAMPHLET
PREVIOUS KNOWLEDGE : STUDENT IS HAVING LITTLE KNOWLEDGE REGARDING THE
TOPIC ANXIOLYTICS
GENERAL OBJECTIVE : AT THE END OF THE SESSION CLASS STUDENT WILL BE
ABLE TO GAIN IN DEPTH KNOWLEDGE REGARDING
ANXIOLYTICS
SPECIFIC OBJECTIVE : AT THE END OF THE CLASS STUDENTS WILL BE ABLE TO-
 INTRODUCE THE TOPIC
 INDICATION
 MECHANISM OF ACTION
 CLASSIFICATION
 INDICATIONS OF BENZODIAZIPINE
 MECHANISM OF ACTION
 SIDE EFFECTS
 POSSIBLE NURSING DIAGNOSIS
 NURSES RESPONSIBILITY
 CLIENT AND FAMILY EDUCATION
 BIBLIOGRAPHY

3. S.R.NO. DURATION SPECIFIC
OBJECTIVE
CONTENT TEACHING LEARNING
ACTIVITY
AV AIDS EVALUATION
TEACHER
ACTIVITY
LEARNER
ACTIVITY
1 2mins Introduce the topic INTRODUCTION
There has been exponential increase
in the number of medications
demonstrated to be effective for the
treatment of anxiety and anxiety
disorders. Beginning in the late 19 the
century, there was a progression from
alcohol, bromides and opiates to
barbiturates developed in the early
20th century.
Alcohol is the oldest drug used to
reduce anxiety. In more recent times,
other drugs have been developed to
alleviate anxiety. The first drug
specific to treat anxiety was
meprobamate, developed in
1955. Barbiturates were effective in
decreasing anxiety, but they were
addictive in and lethal in
overdose. There was continued
advancement in the development of
anxiolytics like meprobamate and the
antihistamine hydroxyzine. The major
advancement in the field of
anxiolytics in the 1960 s was the
development and approval
of benzodiazepines.
Lecture cum
discussion
Listening
and writing
PPT
What are
anxiolytics?

4. 2 2mins Tell the indications for
anxiolytics
INDICATIONS
Anti anxiety drugs are also called
anxiolytics and minor tranquilizers. They
are used in the treatment of anxiety
disorders, anxiety symptom, acute alcohol
withdrawal, skeletal muscle spasms,
convulsive disorders, status epileptics and
preoperative sedation. Their use and
efficacy for periods greater than 4 months
have not been evaluated.
Lecture cum
discussion
Listening
and writing
PPT
What are the
indications for
anxiolytics?
3 2mins Explain the mechanism of
action of anxiolytics
MECHANISM OF ACTION-
Anti anxiety drugs depress the sub cortical
levels of CNS, particularly the limbic
system and reticular formation. They may
potentiate the effect of powerful inhibitory
neurotransmitter GABA in the brain
thereby producing a calming effect. All
levels of CNS depression can be affected,
from mildsedation to hypnosis to coma.
EXCEPTION-
Buspirone does not depress the CNS
.Although its action is unknown; the drug is
believed to produce the desired effects
through interactions with serotonin,
dopamine, and other neurotransmitter
receptors.
Lecture cum
discussion
Listening
and writing
PPT
What is the
exception for
anxiolytics in its
mechanism of
action?
4 5min Explain the classification
of anxiolytics
CLASSIFICATION
 Barbiturate - Barbiturates can
be divided into 4 main groups.
1. Long acting- Duration of action is
more than 8 hours. Eg.
Phenobarbital.

5. 2. Intermediate acting- duration of
action is 5-8 hours. Eg;
amobarbital and pentobarbital.
3. Short acting- duration of action is
1-5 hours. Eg; secobarbital .
4. Ultra short acting- duration of
action is less than 1 hour. eg:
thiopentone and methohexital.
The barbiturates are no longer used
commonly as anti-anxiety agents. They
produce multiple side effects like excessive
sedation, respiratory and circulatory
depression, hepatic enzyme induction,
dependence, withdrawal symptoms,
rebound increase in REM sleep on
withdrawal, and potential for use in
suicide.
 Non-barbiturate, non
benzodiazepine anti anxiety
agents-
These can be further divided into
following categories.
1. Carbamates-not used commonly
because of potentials of abuse and
dependence.
2. Piperidinediones- this too
use not used now due to
dependence potential.
3. Alcohols- these drugs are highly
dependence producing.
4. Quinazoline derivatives- eg;
methaqualone. It had become a
street drug or drug of abuse. So it
was discontinued as an ant anxiety
agent and a hypnotic.
5. Anti-Histaminics-eg;
diphenhydramine, hydroxycine,
and promethazine.
Diphenhydramine is usually

6. combined with methaqualone or
diazepam.
They may be used as hypnotic-sedative,
but their use as antianxiety agent is
minimal and probably not effective.
6. Cyclic ethers- Not used commonly
as it is very effective and is
dependency producing.
7. Others- antipsychotic (eg;
thioridazine) and antidepressants
(eg: doxepine) are sometimes used
for treatment of severe
intractable anxiety. However they
are not the drugs of first choice
and should be used with
discretion, when all other rugs
have failed to benefit.
8. Beta blockers- eg:
propanolol. This is
particularly effective in treatment
of peripheral somatic
manifestations of anxiety. It is also
used as the drug of first choice of
anticipatory anxiety and
situational anxiety.
Propanolol can be used either alone or
along with benzidiazepines. The role of
this in the treatment of psychic
manifestations of anxiety is still in
research. It is contraindicated in patients
of bronchial asthma and cardiac
conditions.

7. 5 5mins Explain the
benzodiazepines
 Benzodiazepines-
 Since the discovery of
chlordiazeopoxide in 1957 by
Sternbach, benzodiazepines have
replaced other anti-anxiety
drugs. Presently benzodiazepines
are the drugs of first choice in
treatment of anxiety and for the
treatment of insomnia
 The benzodiazepines are thought
to reduce anxiety because they are
powerful potentiators (receptor
agonists) of the inhibitory
neurotransmitter GABA. A post
synaptic receptor site specific for
the benzodiazepine molecule is
located next to GABA
receptor. The BZ molecule and
GABA bind to each other at the
GABA receptor site. The result is
an enhancement of the actions of
GABA, resulting in an inhibition of
neurotransmission (a decrease in
the firing rate of neurons),
resulting in a clinical decrease in
the person’s level of anxiety.
 The benzodiazepines are classified
according to their elimination half
lives.
Lecture cum
discussion
Listening
and writing
PPT
What are
benzodiazepines?

8. 6 2mins Explain the indications
of benzodiazepines
INDICATIONS
The indications for the use of
benzodiazepines are as follows.
1. Generalized anxiety disorder,
adjustment disorder with anxious
mood.
2. Panic disorder, agoraphobia, and
school phobia (particularly
alprazolam and clonazepam)
3. Agitated depression, (added to
antidepressants for first 1-2 week);
alprazolam probably has an
antidepressant effect.
4. Insomnia
5. Stage 4 NREM sleep disorders like
enuresis, somnambulism,
(diazepam reduces duration of
stage 4 NREM sleep).
6. Nightmares (diazepam also
reduces REM sleep duration)
7. Premedication in anaesthesia
(intravenous lorazepam,
midazolam or diazepam).
8. Anticonvulsant use (drugs of
choice for status epilepticus,
myoclonic seizures, and certain
infantile spasms)
Lecture cum
discussion
Listening
and writing
PPT
What are the
indications for
benzodiazepine
s?

9. 9. To produce skeletal muscle
relaxation ( eg: in tetanus, cerebral
palsy)
10. Treatment of alcohol and other
drug withdrawal syndromes.
11. For minor surgical, endoscopic or
obstetric procedures.
12. Acute mania (clonazepam, either
alone or with lithium)
13. Antipsychotic induced akathisia
14. Emergency management of acute
psychoses ( iv lorazepam , along
with parenteral antipsychotics)
15. Narcoanalysis or abreaction (IV
diazepam)
7 5mins Explain the mechanism
of action of
benzodiazepines
MECHANISM OF ACTION
Exact mechanism of action of
benzodiazepines is not clear. The recent
discovery (1977) of benzodiazepine
Lecture cum
discussion
Listening
and writing
PPT
What is the
action of
mechanism of
benzodiazepine
s?

10. receptors has shed some light on the mode
of action.
There are presently 2 known
benzodiazepine receptors.
1. BDZ receptor 1, which is linked with
GABA ( Gamma –Amino Butyric – Acid)
2. BDZ receptor 2, which is alone and is
probably involved in cognition and motor
control.
Thus benzodiazepines probably act by
enhancing GABA transmission in brain.
Benzodiazepine receptor antagonists
(eg: flumazenil) are anxiety provoking
agents. The benzodiazepines have no
significant clinical advantage over each
other, although differences in half life can
be clinically useful. For e.g.; patients with
persistent high level of anxiety should take
a drug with a long half life. Patients with
fluctuating anxiety might do better with
either a short acting drug or drug with
a sustained release formulation
(alprazolam, chlorazepate, diazepam and
adinazolam). Sustained release BZP, blunt
the peaks of toxicity and the troughs of
symptom breakthrough and are becoming
a popular alternative to the original
formulations.
In addition the lipid solubility of each
BBZP determines the rapidity of onset and
the intensity of effect, and this should be
considered when selecting a BZP. FOR eg;

11. the diazepam is more lipid soluble than
lorazepam , thus is more readily move into
and out of the central nervous system
(CNS) .and is more extensively distributed
toperipheral sites particularly to fat cells.
The rate of absorption of different BZP
from the gastrointestinal tract varies
considerably, thus affecting this rapidity
and intensity of onset of their acute effects.
Antacids and food in the stomach slow
down this process when these drugs are
taken by mouth.
The injectable BZP (lorazepam, and
midazolam) have been proven reliable
when administered in the deltoid muscle.
Diazepam results in predictable and rapid
rises in the blood level when used
intravenously. Concentrations of BZP in
the blood have not been firmly correlated
to clinical effects, so blood level
measurements are not clinically helpful.
Some patients need to take anti anxiety
drugs for extended periods. Because of the
potential disadvantage of BZP, they should
be always used along with
nonpharmacological treatments for the
patient with chronic anxiety or insomnia.
Psychotherapy, behavioural technique,
environmental changes, stress
management, sleep hygiene, and an
ongoing therapeutic relationship continue
to be important in the treatment of anxiety
disorders and insomnia.

12. In general the treatment of BZP should be
brief and used during a time of specific
stress or for a specific indication. The
patient should be observed frequently
during the early days of treatment to
assess target symptom response and
monitor side effects so that the dose can be
adjusted as needed. Some patients, such as
those with [panic disorder, may require
daily dosing and long term BZP treatment.
8 2mins Explain the
pharmacological effect
of benzodiazepines
PHARMACOLOGIC EFFECTS
Benzodiazepines have generally depressing
effect on the CNS, including the limbic
system, the thalamus, the hypothalamus,
RAS. Benzodiazepines have five major
effects (Aston 2000) that are used
therapeutically to,
- Reduce anxiety
- Promote Sleep
- Prevent seizures
- Relax Muscles
- Produce amnesia
These drugs can cause several levels of CNS
depression, from sedation to anesthesia.
Benzodiazepines accomplish this by
sedating the patient and depressing the
inhibitory neuron that affect arousal.
Distribution results in feeling of euphoria
Lecture cum
discussion
Listening
and writing
PPT
What is the
pharmacologica
l effect of
benzodiazepine
s?

13. and excitement that in turn, can lead to
poor judgment. The natural restraint that
minimizes the social blunders in depressed.
9 2mins Elplain the drug
intreraction
DRUG INTERACTIONS
Benzodiazepines, like other sedative
anxiolytics, potentiate the effects of alcohol
and drug that depress the CNS. Significant
respiratory depression has been reported in
some patients receiving combined
treatment with benzodiazepines &
clozapine.
Lecture cum
discussion
Listening
and writing
PPT
What is the
drug interaction
of
benzodiazepine
s?
10 3mins Tel the side effects of
benzodiazepines
SIDE EFFECTS
The side effects are common, dose related,
usually short term and almost always
harmless. It include nausea, vomiting ,
weakness , epigastric pain , diarrhoea,
vertigo, blurring of vision , body aches ,
urinary incontinence( rare), impotence.,
lassitude, sedation, increased reaction time
,ataxia ( in high doses ) , dry mouth
retrograde amnesia ( rare) , impairment of
driving skills , severe effects when
administered with alcohol, irritability (
particularly with flurazepam and
chlordiazepoxide) , disinhibited behaviour (
particularly with diazepam ) .
Lecture cum
discussion
Listening
and writing
PPT
What are the
side effects of
benzodiazepine
s?

14. Tolerance: can develop to the sedative
effect of BZP which in some ways is an
advantage, but is unclear whether tolerance
also develops to induced sleep or
antianxiety effects. These drugs should be
tapered to minimize withdrawal symptoms
and rebound symptoms of insomnia and
antianxiety. If these symptoms occur the
dose should be raised until symptoms are
gone and then tapering is resumed at a
slower rate.
Withdrawal syndromes: include agitation,
anorexia, anxiety, autonomic arousal,
dizziness, generalized seizures,
hallucinations, headache, hyperactivity,
insomnia, irritability, nausea and vomiting,
sensitivity to light and sounds, tinnitus and
tremulousness.
Elderly patients are more vulnerable to
side effects because the aging brain is more
sensitive to sedatives, Dosing ranges from
one-half to one-third of the usual daily dose
used for adults. The BZP with no active
metabolites are less affected by liver
disease, the age of the patient, or drug
interactions.
BZP are more successfully used in
children to treat sleep waking ,in single
dose to allay anticipatory anxiety , and
to treat panic , generalized anxiety disorder
, and avoidant personality disorder but in
general they can increase anxiety and

15. produce or aggravate behaviour disorders
,especially ADHD.
BZP during pregnancy have been
associated rarely with palate
malformations and intrauterine growth
retardations especially when used during
the first trimester. When used in late
trimester or during breast feeding, these
drugs are associated with floppy infant
syndrome, neonatal withdrawal symptoms
and poor sucking reflex. Hence they are not
recommended.
11 5mins Introduce some of
selected
benzodiazepines
SELECTED BENZODIAZEPINES
Alprazolam
Alprazolam is particularly useful for
generalized anxiety, adjustment disorders
panic disorders and anxiety associated with
depression. Alprazolam has been criticized
for its potentials to cause addiction and
dependence and there have been reports of
alprazolam – induced violent or aggressive
behavior (Gold, 1992; Shelton,
1993) Dose is 0.25 -0.5 mg. 2-3 times
daily. Available as oral tablets from (0.25
mg, 0.5 mg & 1 mg)
Lecture cum
discussion
Listening
and writing
PPT
What is
clonazepam?

16. Chlordiazepoxide
Chlordiazepoxide (Librium) is prescribed
for anxiety disorders, the relief of the
symptoms of anxiety and acute alcohol
withdrawal. Cholordiazepoxide is absorbed
well orally. Indicated for fear anxiety &
tension. Dosage 20-40 mg daily, elderly
10mg daily. Available as 10 mg & 20 mg
tablet form. Parenteral chlordiazepoxide is
used as an antipanic agent.
Clonazepam
Clonazepam is used most often as an
anticonvulsant, but also has clinical use in
the treatment of panic disorder. Patients
taking clonazepam over the long term
should be slowly tapered off this drug,
because evidence suggests that abrupt
withdrawal can precipitate status
epileptics. Dose 0.5-10 mg in daily divided
dozes. Available as oral tablet firm.
Diazepam
Diazepam (Valium) is an often prescribed
anti anxiety agent that has multiple uses
related to its CNS- depressing effects. In
addition to treating anxiety disorders and
providing short term relief from symptoms
of anxiety, diazepam is used pre-
operatively to relieve pre surgery jitters for
skeletal muscle spam, as a drug of choice
for status epileptics. Dose for anxiety 2-
10mg 2-3 times daily. As pre medication 5-

17. 30 mg before operation. Available as both
in oral and IV preparation. Oral tablets of 5
mg and 10 mg. IV form 2 ml (10mg)
injection
Lorazepam
Lorazepam is used to treat anxiety
disorders and also can be used as an anti
tremor agents, antipanic agent,
anticonvulsant (parental only) and
antiemetic for cancer patients undergoing
chemotherapy. Dosage is 1-4 mg daily.
Severe anxiety up to 10 mg daily in divided
doses. Available forms 0.5 mg, 1mg & 2 mg
tablets and injection form 2mg/1ml
(2ml/Amp)
4. NEWER DRUGS
A) Buspirone
Buspirone is a new anti-anxiety drug which
is not a BZP. It is an azaspirodecane –Dione
(azaspirone) derivative and is 5 HT partial
agonist and is a selective DA autoreceptor
antagonist. It also inhibits the spontaneous
firing of 5HT neurons. It does not seem to
act upon BZPreceptors. It is anxioselective
with no sedative action, no anticonvulsant
or muscle relaxant properties.
It is administered in a dose of 15-30
mg/day, in a thrice a daily schedule due to
short half life. As it has a slower and more
gradual onset of action, it usually takes
about 2 weeks before the anti-anxiety
effects of buspirone are evident .It is not

18. useful in the treatment of panic disorder.
The side effect includes dizziness,
headache, light headedness and diarrhoea.
As it is anxioselective, and lack any risk of
dependence, it may replace the BZP as the
drug of choice in GAD.
B) Zopiclone
Zopiclone belongs to a new class of BZP
drugs, the cyclopyrrolones. Cyclopyrrolone
derivatives also act on the GABA receptors,
but at a site distinct from that of BZP.
Zopiclone has a short duration of action as
well as shorter onset. After oral
administration it is observed rapidly, with
peak plasma concentration occurring in
about 60 minute. The elimination half life is
4-6 hours.
The usual dose of zopiclone is 3.75-7.5 mg
at bedtime (lower dose in elderly and in
patients with severe hepatic failure). The
side effects include bitter taste, dry mouth,
drowsiness, nausea and headache. Its safety
in pregnancy, lactation and in children is
not proven. It is clinically superior to BZP in
subjective awakening quality, well being
and attention span in the morning.
C) Zolpidem
It is an imidazopyridine derivative which I
being marketed as a hypnotic. It is
administered in a dose of 5-10 mg for
hypnotic use. It has a half lifeof 2-3 hours;

19. therefore it is useful in the treatment of
difficulty in initiation of sleep.
The side effects include drowsiness,
dizziness, headache, depression, nausea,
dry mouth and myalgia. It should not be
used for more than 2 weeks at one time.
Its safety in pregnancy, lactation and
children is not proven.
D) Zalpelon
Zalpelon is an pyrazylo-pyramidine
derivative which is being marketed as a
hypnotic. Although a non BZP drug it acts
on the omega -1 BZP receptor located on
the alpha sub unit of the GABA –A receptor
complex ( causing sedation ) , with very
little effect on omega 2 and omega 3
receptors.
Side effects include headache, drowsiness,
dizziness nausea and myalgia . It should
not be used for more than 1 week at a time
.Its safety in pregnancy, children and
lactation are not proven.

20. 12 2mis Mention some possible
nursing diagnosis
POSSIBLE NURSING DIAGNOSIS
1. Risk forinjury related to seizures;
panic anxiety, abrupt withdrawal after
long term use, effectsof intoxication
and overdose.
2. Risk foractivity intolerance
related to side effectsof sedation and
lethargy.
3. Risk foracute confusionrelated to
action of the medication on CNS.
Lecture cum
discussion
Listening
and
writing
PPT
What are the
possible nursing
diagnosis?
13 2mins Explain the nurses
responsibilities
NURSE’S RESPONSIBILITY
- Monitor lying and standing BP and
pulse every shift( Orthostatic
hypotenion)
- Instruct the client not to drink
alcohol or take other medications that
depress the CNS while taking this
medication.
- Have the client take frequent sips
of water, suck ice chips or hard candy,
or chew sugarless gum.
- Have the client take the drug with
foodor milk to avoidnausea and
vomiting.
- Symptoms of sore throat, fever,
malaise easy bruising or unusual
bleeding should be reported to the
physician immediately.
- Instruct the client to arise slowly
from a lying or siting position.
- Ensure that the client understands
there is a lag time of 10 days to 2 weeks
between onset of therapy with
Lecture cum
discussion
Listening
and
writing
PPT
What are the
nurses
responsibility?

21. buspirone and subsiding of anxiety
symptoms.
- Instruct the client not to drive or
operate dangerous machinery. While
taking the medication.
14 2mins Explain the client
and family education
CLIENT AND FAMILYEDUCATION
· The Client should be aware of
possible side effects.The client should
refer to written materials furnished by
health care providers regarding the
current method of self administration.
· Client and family should be
educated about symptoms like sore
throat, malaise, fevereasy bruising and
unusual bleeding or motor restlessness
and to report immediately.
· Educate the client not to take non
prescription medication without
approval from physician.
· Advise the client not to stop taking
the drug abruptly.
Lecture cum
discussion
Listening
and
writing
PPT
What education
will b given to
client and family?
15 1min Provide the
bibliography of the
content
BIBLIOGRAPHY
1. Gail W Stuart, Michele T Laraia.
Principles and practice of Psychiatric
Nursing .8th edn. Missouri. Mosby
publications. 2005.
2. Kaplan I Harold, Sadock .J. Benjamin
(1998)‘ Synopsis of Psychiatry ‘, 8th
edition , BI Wawerly Pvt limited
, NewDelhi ,Pp 932 - 1110
3. Mary C Townsend. Psychiatric Mental
Health Nursing. 5th edn. Philadelphia. FA
Davis company.
Lecture cum
discussion
Listening
and
writing
PPT

22. 4. Gelder Michel, Harrison Paul , Cowen
Philip (2006) Shorter Oxford Text book of
Psychiatry , Fifth edition, Oxford university
press, New Delhi, Pp 518 – 565
5. Cacelia Monat Taylor. Essentials of
Psychiatric Nursing .5th edn. Missouri.
Mosby publications . 2002
6. Niraj Ahuja. A Short Textbook of
Psychiatry.5th edn. New Delhi.Jaypee
publications .2002.
7. Deborah Antai Otong.Psychiatric
Nursing. Biological and Behavioural
Concepts.U.S. North Texas Health Care
System. 2003.
Journals
1. Paul PD. Trends in the Pharmacologic
Management of Insomnia. J Clin Psychiatry
2006; 67: suppl 13: 5-8.
2. Milton KE. Influence of
Pharmacokinetic profiles on safety and
efficacy of Hypnotic medications.J of Clin
Psychiatry. 2006; 67: suppl 13: 9-12.