The Royal Marsden Hospital Manual of Clinical Nursing Procedures - Lisa Dougherty [153]
Feeling dizzy, unsteady, light-headed or faint.
De-realization or depersonalization.
Fear of losing control or going crazy.
Fear of dying.
Pins and needles in extremities.
Chills or hot flushes.
(Donohoe and Ricketts 2006)
Panic attacks occur in up to 5% of the population with a sudden onset of symptoms such as dizziness, difficulty in breathing and thoughts of losing control or dying. The more these thoughts intrude, the more extreme the physiological response becomes (Powell 2009). The immediate response for many individuals is to try and leave the situation as soon as possible. This brings immediate relief but increases the likelihood of further apprehension and repeated attack at a later date (Powell 2009).
An indication for many individuals that a panic attack is beginning is a feeling of tightness in the chest or being aware that their breathing is fast. If not managed, this progresses to hyperventilation (Powell 2009).
Evidence-based approaches
Managing acute anxiety (including panic attacks) can help to avoid the development of panic disorder and generalized anxiety disorder. Nurses can support patients to avoid anxiety attacks by taking time to talk issues through. If the anxiety has progressed further and the patient is experiencing the warning signs that they are on the verge of hyperventilation, it is helpful to:
remind them that the symptoms they are feeling are not harmful
help them to actively release tension in the upper body by encouraging them to sit up and drop their shoulders in a sideways widening direction. This makes hyperventilation more difficult since the chest and diaphragm muscles are stretched outwards
breathe slowly … in to a count of 4 and out to a count of 4. Slowing your own breathing down can help the patient
encourage them to concentrate on breathing out and trying to breathe through their nose.
(Adapted from Powell 2009)
A panic or anxiety attack does not necessarily mean that the patient has a pathological disorder. Prompt treatment and management are important to prevent transient anxiety turning into a disorder (NICE 2007).
Preprocedural considerations
Pharmacological support
Panic disorder
Benzodiazepines, antipsychotics and sedating antihistamines are associated with a worse long-term outcome and pharmacological interventions should be either tricyclic or selective serotonin reuptake inhibitor (SSRI) antidepressant medication (see Depression, Pharmacological support).
Generalized anxiety disorder
Again, antidepressant medication should be considered and this should be an SSRI unless otherwise indicated. Other medication has also been shown to be effective: serotonin-norepinephrine reuptake inhibitors (SNRIs) (venlafaxine) and antihistamines/benzodiazepines in short-term use (NICE 2004).
Non-pharmacological support
The rebreathing technique
This involves the patient rebreathing the air they have just breathed out (Box 5.7). This air is high in carbon dioxide so has less oxygen. This means that there will be a lower amount of oxygen in the blood, thus activating the parasympathetic nervous system and promoting relaxation (Blake and Ledger 2007).
Box 5.7 Rebreathing technique instructions for a patient
Make a mask of your hands and put them over your nose and mouth and keep them there (Figure 5.4).
Breathe in and out through your nose once.
Breathe in your own exhaled air through your nose.
Breathe out hard through your mouth.
This should be done slowly without holding your breath. Repeat this four or five times but no more. Remain calm and relaxed while doing it.
(Adapted from Powell 2009)
Figure 5.4 Hand position for rebreathing technique.
After the panic attack, it is important to reflect with the patient about what happened and try to identify any triggers. Explanation and education about physiological responses can help to show the patient the importance of slowing their breathing which will in turn give them a sense of control.
If these panic attacks continue or if the patient has a history of anxiety then the management