Transcript Smoking and Withdrawal:

Smoking and Withdrawal:
How to be your patient’s advocate
Megan M. Martin
DeSales University
Nicotine
Used as an insecticide and plant spray when
in liquid form
 Considered a very poisonous alkaloid:
colorless, oily liquid in its pure state
 Amount used in cigarettes is not enough to
cause (immediate, direct) death.
 Nicotine in tobacco can cause indigestion,
increase blood pressure, and dull appetite.
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Action of Nicotine
Nicotine is absorbed through the skin, GI
tract, and respiratory mucous membrane
 Action of drug is dose-related
 Temporarily stimulates both sympathetic
and parasympathetic ganglia; also
stimulates skeletal muscle
 Following stimulant phase, nicotine causes
a depressant phase; relaxes skeletal muscle
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Nicotine in cigarettes: A powerful addiction
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Cigarettes are the primary vector of nicotine
ingestion.
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Others are chew, cigars, and pipe smoking
Cigarettes become addicting after
approximately two weeks of smoking ten
cigarettes per day
Initial rush of nicotine initiates a temporary
feeling of well-being by increasing activity of
dopamine in the brain
Considered as addictive as heroine; same action
Addiction
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The DSM-IV criteria for substance dependence
are shown below:
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Maladaptive pattern of substance use leading to
clinically significant impairment or distress, manifested
by three or more of the following within a 12-month
period:
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Presence of tolerance to the drug; presence of withdrawal symptom
Substance taken in larger amounts/longer period of time than
intended
Unsuccessful or persistent desire to cut down or control use…
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Varcarolis, 1998
Withdrawal
Occurs after a period of continued use
 Stopping or reducing use results in specific
physical and psychological signs and
symptoms
 Occurs approximately four hours after last
cigarette, peaks in 3-5 days, lasts at least
two weeks
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Physical and Mental Side Effects
of Nicotine Withdrawal:
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PHYSICAL
Tingling in hands and feet
Sweating
Intestinal disorders,
primarily constipation
and/or upset stomach
Headache
S/S of colds and
respiratory problems
initially
Weight gain
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MENTAL
Insomnia
Mental confusion
Vagueness
Irritability
Tension, perceived
unbearable
Depression, mimics grief
Anxiety
First two weeks of withdrawal
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Critical in determining failure rate
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If smoker cheats in this period, highly likely to
return to habit within six months
After five days, the smoker is undergoing the
most severe physical effects of withdrawal
Emotional effects are carried for approximately
1-3 months after quitting
Success Rates of Quitting
47 million people in U.S. smoke; 28% of
males, 23% of females
 3,000 young people start smoking every day
 Although about 25% of adults smoke, 70%
of them want to quit
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1/3 will try seriously to quit
Only 6% will be successful within one year
Those who continue to try have 50% success
rate
Reasons smokers relapse; fail to
quit permanently
Depression: Cigarettes relieve minor
depression, fits of anger, enhance sense of
well being, enhance concentration
 Physical effects over long-term seem
abstract; “won’t happen to me; I’ll quit”
 Weight gain: quitting smoking/withdrawal
causes body’s basal metabolic rate to drop
for 3-6 months before return to normal.
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Average weight gain: 10-25 lbs.
Nursing’s relation to the smoking
patient
Patients are ill to begin with; withdrawal
symptoms can exacerbate their sense of
illness
 Be your patient’s advocate!! If you know
you’re patient is a smoker, call the
physician:
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 Request
some form of nicotine replacement unless
contraindicated
 Request an oral replacement/antidepressant, e.g.
Zyban®
Nicotine Replacements
Nicotine Patch: Available in several
dosages: 21mg-7mg Dosages should
gradually be decreased over min. of 6 wks.
 Absorbed transdermally
 Should be worn 24hrs/day
 Adverse SE: pruritus/erythema under patch,
nausea, dizziness, myalgias, coughing,
difficulty sleeping, nightmares
 Recommend that patient change sites daily
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Nicotine Gum
Absorbed through buccal mucosa
 Dosage: 2mg, repeated prn up to 30 pieces
of gum/day.
 Gum not chewed, rather bitten into and held
in the cheek
 Adverse SE: injury to mouth, teeth, dental
work. Rare: irregular heartbeat
 Largest complaint: Gum has peppery taste
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Nicotine Nasal Spray
Administers 1 mg/2 sprays to the nasal
membrane
 Faster onset of action than patch or gum
 Should be used for at least three months, no
longer than six months
 Adverse SE: belching, tachycardia, mild
H/A, increased appetite, increased watering
of mouth, sore mouth or throat
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Nursing Considerations
Instruct client to take exactly as directed
 Instruct the client of the importance of NOT
smoking at all while using nicotine
replacement therapy; could lead to nicotine
toxicity
 Give client information of smoking
cessation support groups relative to their
area
 Instruct family if possible of patient needs
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Nursing Diagnoses
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Anxiety-Nurses teach deep breathing
Self-esteem disturbance-Nurses teach coping mechanisms
Noncompliance-Nurses support patient throughout
withdrawal process
Sleep-pattern disturbance (r/t withdrawal and Zyban/
nicotine replacement)-Nurses teach it is temporary effect;
recommend decrease in caffeine, increase in exercise
Constipation-Nurses teach patient about better diet, high
in fiber, increase in exercise will decrease occurrence
Oral agents; Zyban®
Zyban, also Wellbutrin (bupropion HCl) is
an oral agent used to curb the most severe
side effects of nicotine withdrawal
 Only available through prescription
 Actually an antidepressant, Zyban acts as a
weak serotonin reuptake inhibitor, also acts
on dopamine and norepinephrine centers of
the brain
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Zyban...
When used on people not previously
depressed, has no effect on mood
 Instruct patient that its primary function is
to prevent depression, not an upper
 Dosages for smoking cessation differ from
dosage used for depressive disorders
 Patient usually starts with 150 mg QD X
3days, then 150 mg BID X 7-12 wks.
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Zyban...
Contraindicated in patients with seizure
disorders, MAOI’s, eating disorders
 Adverse SE: Weight loss/weight gain,
agitation, dry mouth, blurred vision,
headache, dizziness, tremor, nausea,
vomiting, constipation, insomnia, vivid
dreams
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SEIZURES with overdose (>450mg/day)
Zyban...
Instruct patient that the full antidepressant
effect of drug may not be realized for up to
4 wks
 Patient is to pick a target date for cessation,
stick to it.
 Patient may continue smoking while taking
Zyban for up to two weeks
 It is recommended that the patient consider
nicotine replacement in conjunction
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Nursing Teaching Points...
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It is important that the patient be READY to quit,
otherwise will be unsuccessful
NEVER push a patient to quit. This will only hurt
your relationship with that patient.
Respect the patient’s wishes. Only instruct about
the effects of smoking, the values of quitting. Be a
support system to your patient.
Remember the effects of Nicotine withdrawal. Be
empathetic with the patient’s needs. Be an
advocate!
Stage-of-Readiness Model for Smoking Cessation
Stage
Description of Stage
PRECONTEMPLATION Client has no desire to
quit smoking
Nursing Strategies
Teach negative effects of
smoking, reassure client
that feelings are part of
addiction process
Provide specific examples
of how smoking is
affecting client; stress
health benefits of quitting
CONTEMPLATION
Client has thought about
smoking cessation but
have taken no action
PREPARATION
Client has taken some
steps to quit smoking
Provide behavioral
reinforcement; help the client
identify cues that lead to
smoking; help identify coping
stategies
ACTION
Client quits smoking
MAINTENANCE
Client has not smoked for
6 months
Provide positive
reinforcement to prevent
relapse
Continue positive
reinforcement
Physical Response to Quitting
Time after last cigarette
20 Minutes
8 hours
24 hours
48 hours
Physical Response
BP and pulse return to normal
CO and O2 levels in blood
normalize
Chance of heart attack decreases
Nerve ending start to regrow; ability
to taste and smell increase; after 72
hrs lung capacity increases
2 wks. -3 mos.
Improved circulation; lung
function increases up to 30%
1-9 months
Decreased incidence of
coughing, sinus infx, fatigue, and
SOB; regrowth of cilia in lungs,
increasing ability to handle
mucus, clean the lungs, reduce
chance of infx, overall energy
level increases.
Nursing Teaching: Diet
Encourage your patient to increase the
amount of fruits, vegetables, whole grains,
and fiber-rich foods.
 Encourage the patient to drink large
amounts of water
 Teach the patient about oral cravings;
encourage healthy snacks such as carrots,
apples, celery. Also recommend sugar-free
gum.
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Exercise
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Quitting may be harder for women than men due
to body image perceptions
Encourage patient to increase levels of activity;
recommend taking walks during times of craving
Remind patient that if weight is gained, it will
most likely come off in time
Teach deep breathing exercises. This helps to
mimic feeling of smoking; induces relaxation
Conclusion
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Smoking is a common addiction
Nurses must be aware of the effects of nicotine both
physically and mentally on their patients
Nurses MUST be patient advocates.
– Encourage patient to quit
– Never push
– Speak to the physician about possibility of smoking
cessation aide
– Continue to have a positive, supportive relationship
with patient. Nothing helps more than understanding
References
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Guthrie, C. (2001). Kick butts now! Online. Available:
http://my.webmd.com/content/article/1689.50430
Ignatavicius, D.D., Workman, M.L., & Mischler, M.A.
(1999). Medical-Surgical nursing across the health care
continuum (3rd ed.). Philadelphia: W.B. Saunders
Company.
McKenry, L.M. & Salerno, E. (1998). Pharmacology in
nursing. (20th ed.). St. Louis: Mosby.
Miller, B.F & Keane, C.B. (1997). Encyclopedia &
dictionary of medicine, nursing, and allied health. (6th ed.).
Philadelphia: W.B. Saunders Company.
References (con’t)
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Varcarolis, E.M. (1998). Foundations of psychiatric mental
health nursing. (3rd Ed). Philadelphia: W.B. Saunders
Company
WebMDHealth. (2001). Smoking. Online. Available:
http://my.webmd.com/content/article/1680.51953.
Wilson, B.A., Shannon, M.T. & Stang, C.L. (2001).
Nursing drug guide 2001. New Jersey: Prentice-Hall, Inc.