Extreme anxiety

Hospice Nurse LPN, BSN, RN · Jun 21, 2011

This is so hard to watch, and for the family too. Some LTC facilities are very opposed to controlling it because of the sedative effect the meds can have. I almost think I'd rather have physical pain!
Patient is on ativan 1mg Q4, valium 2.5 TID, no relief so far. Have you had a patient like this? What helped? Resperidal? Haldol? Add Xanax to the already antianxiety meds on board???
We are using soothing music, volunteers to come hold her hand etc...

Is the pt on anything else? Do you think he/she is in pain? Pain can also cause anxiety and unless the pain is addressed, the anxiety will continue. You mentioned the pt is in LTC...is the ativan scheduled or PRN? Many times we have to get antianxiety and pain meds scheduled for our LTC pts and make more frequent visits until the situation is resolved. I'm racking my brain right now and I'm not fully awake. NEED MORE COFFEE! If I think of anything else during the day, I'll let you know. Hopefully, some others will have more ideas. Good luck.

tewdles, RN · Jun 21, 2011

Consider that if this patient is quite elderly she may be having a paradoxical response to the benzo's and may respond better to another approach. I recommend you discuss this possibility with your PharmD and Medical Director.

leslie :-D · Jun 21, 2011

i agree that pain or any other discomfort, needs to be ruled out.

is pt constipated?

i ask, because constipation is the culprit, more often than not.

tewdles is right about benzo's, so something to keep in mind.

i'd hesitate in adding something else, until it is known if in pain or not.

you don't want to mask anything going on with her.

if she has hx of dementia, we'd add/increase haldol.

keep us updated?

leslie

Whispera, MSN, RN · Jun 21, 2011

I agree with the others. Consider pain, constipation, breathing difficulty, psychosis, and medicate as appropriate. Don't add another benzo to the 2 the patient is already getting. Instead consider switching one of them to another or increasing dosage or decreasing time between doses. Make sure the meds are scheduled rather than prn. Sometimes prns don't get given.

And, sad to say, sometimes terminal restlessness is at play. Sometimes meds don't help....

Vtachy1 · Jun 21, 2011

She does have some pain, which we increased the fentanyl patch from 25 to 50mcg and she is on hydrocodone QID scheduled and the ativan is also q 4 hours scheduled along with the valium also scheduled.

Having good BMs daily is on miralax and

The APN from her docs office visited and ordered UA and chem, thyroid panel, CBC. Nothing showed up so far, all labs normal.

Patient wants to die and is obsesses with dying, obsesses about her bowels/bladder etc. She has some confusion but yet knows enough to unhook her bed alarms LOL before she gets out of bed, she knows all the staff members' names etc. But yet sometimes thinks her deceased husband is "not off work yet".

I'm scheduled to see her tomorrow, will update you then.

MissIt · Jun 22, 2011

Also maybe do a bladder scan. Sometimes Versed is used, as well. It is sedating, but we've had people on a Versed pump who were able to wake up and talk with their family, answer if they were in pain, etc.

tewdles, RN · Jun 22, 2011

Seroquel?

Whispera, MSN, RN · Jun 22, 2011

Haldol is cheaper and works fast.

Dublin37 · Jun 23, 2011

Seroquel helped with two of mine :redpinkhe

Long Term Care Columnist / Guide · Jun 23, 2011

Ahhhh, terminal agitation.........that can be sooooo hard to work with sometimes.

I'm not a hospice nurse, but I work extensively with, and am a strong advocate of hospice, and I've seen this phenomenon over and over again. However, benzos seem to be useless more often than not in my experience, and I've had better luck with aggressive management of pain plus scheduled Haldol or Seroquel........PRN doesn't really cut it for psychotropics IMHO. It also helps to play CDs with music the patient knows and loves, or have someone s/he trusts at the bedside to hold a hand or just be there in the room with them. Impending death can be terrifying, especially to those who don't feel "ready to go", and that coupled with the physical discomforts can really make their EOL journey rough.

Nonick9700 · Jun 23, 2011

Our medical director was just telling us last week that new research is showing (proving?) Ativan/benzo's are either not effective or actually increasing the anxiety. I haven't seen this research yet, but the alternative we were told would be risperdal or seroquel.