Transcript Chapter One

Chapter 27
Care of the Chemically Impaired
Elsevier items and derived items © 2006 by Elsevier Inc. All rights reserved.
Prevalence (United States)
• 14% of adults have had an alcohol
dependence or abuse problem at some time
in their lives.
• 3% of individuals older than 12 years need
treatment for drug use disorders.
Elsevier items and derived items © 2006 by Elsevier Inc. All rights reserved.
Psychiatric Comorbidity
• 50% of people with a serious mental illness have a substance
use disorder some time in their lives.
• Psychiatric disorders associated with substance abuse include:
– Acute and chronic cognitive impairment disorders
– Attention deficit disorder
– Borderline and antisocial personality disorders
– Anxiety disorders
– Depression
• High risk for suicide
– Eating disorders
– Compulsive behavior
• Rate of suicide three to four times higher in
substance abusers
Elsevier items and derived items © 2006 by Elsevier Inc. All rights reserved.
Medical Comorbidity
• CNS
– Wernicke's encephalopathy
– Korsakoff's psychosis
• Gastrointestinal system
– Esophagitis
– Gastritis
– Pancreatitis
– Alcoholic hepatitis
– Cirrhosis of the liver
• Tuberculosis
Elsevier items and derived items © 2006 by Elsevier Inc. All rights reserved.
Medical Comorbidity
• Accidents
• Homicide
• Fetal Alcohol Syndrome
Elsevier items and derived items © 2006 by Elsevier Inc. All rights reserved.
Medical Comorbidity
• Cocaine abusers
–
–
–
–
Extreme weight loss
Malnutrition
Myocardial infarction
Stroke
• Intravenous drug users
– Infections and sclerosing of veins
• Intranasal users
– Sinusitis, perforated nasal septum
• Smoking a substance
– Respiratory problems
Elsevier items and derived items © 2006 by Elsevier Inc. All rights reserved.
Theories of Addictions
Biological
• Specific effects on opioid, catecholamines (dopamine),
& GABA neurotransmitters
• Substance use problems run in families.
Psychological
• Defense against anxious impulses
• Oral regression (dependency)
• Self-medication for depression
Behavioral
• Positive reinforcement effects of drug-seeking behavior
Sociocultural
• Social and cultural norms
–
High rates alcohol use among Native Americans and
Alaska Natives
• Socioeconomic stress
Elsevier items and derived items © 2006 by Elsevier Inc. All rights reserved.
Substance Abuse vs.
Substance Dependence
Substance Abuse
• Inability to fulfill role expectations
• Participation in hazardous activities
while impaired
• Recurring legal or interpersonal
problems
• Continued use despite problems
Elsevier items and derived items © 2006 by Elsevier Inc. All rights reserved.
Substance Abuse vs.
Substance Dependence
Substance Dependence
• Tolerance to drug
• Withdrawal syndrome
• Substance taken in increasingly larger
amounts for longer periods of time
• Desire to cut down
• More and more time spent getting and using
substance
• Reduction in important social, occupational, &
recreational activities
• Continued use in spite of recurring problems
Elsevier items and derived items © 2006 by Elsevier Inc. All rights reserved.
Tolerance vs. Withdrawal
Tolerance
• The need for higher and higher doses to
achieve the desired effect
Withdrawal
• After a long period of continued use,
stopping or reducing drug results in specific
physical and psychological signs and
symptoms
Elsevier items and derived items © 2006 by Elsevier Inc. All rights reserved.
Assessment: Interview Guidelines
• Two questions of importance
1. In the last year have you ever drunk or used
drugs more than you meant to?
2. Have you felt you wanted or needed to cut down
on your drinking or drug use in the last year?
• Details include:
– Drugs used
• Route
• Quantity
• Time of last use
• Usual pattern of use
Elsevier items and derived items © 2006 by Elsevier Inc. All rights reserved.
Other Problems With Substance
Abuse
• Flashbacks
• Synergistic effects
– When drugs are taken together and result in
intensified or prolonged effects of either or both
drugs
– Can result in unintentional death
• Antagonistic effects
– When drugs are taken together to weaken or
inhibit the effect of one of the drugs
• Cocaine with heroin to reduce withdrawal from cocaine
Elsevier items and derived items © 2006 by Elsevier Inc. All rights reserved.
Other Problems Associated With
Substance Abuse
• Codependence
– Overresponsible behavior exhibited by individuals
involved with someone abusing substances
– A constellation of maladaptive thoughts, feelings,
behaviors, and attitudes that prevent the person
from living a full and satisfying life
Elsevier items and derived items © 2006 by Elsevier Inc. All rights reserved.
Assessment: Overall Guidelines
• History of client's past substance use
• Medical history
• Psychiatric history
• Psychosocial issues
Elsevier items and derived items © 2006 by Elsevier Inc. All rights reserved.
Assessment: Psychological Changes
• Characteristics associated with
substance abuse:
– Denial
– Depression
– Anxiety
– Dependency
– Hopelessness
– Low self-esteem
Elsevier items and derived items © 2006 by Elsevier Inc. All rights reserved.
Central Nervous System
Depressants
• Alcohol
• Benzodiazepines
• Barbiturates
• Withdrawal associated with severe morbidity
and mortality, unlike withdrawal from other
drugs.
Elsevier items and derived items © 2006 by Elsevier Inc. All rights reserved.
Blood Alcohol Level (BAL)
BAL (mg %)
Effect in Nontolerant Drinker
0.05
Change in mood, behavior, and
impaired judgment
0.20
Staggering, ataxia, emotional lability
0.40
Coma
0.50
Death from respiratory depression
• BAL can be used to assess level of intoxication and
level of tolerance.
• As tolerance develops, a discrepancy is seen
between BAL and expected behavior.
Elsevier items and derived items © 2006 by Elsevier Inc. All rights reserved.
Alcohol Withdrawal
Withdrawal
• Early signs a few hours after decreasing alcohol
• Signs peak after 24 to 48 hours then rapidly disappear
• Signs and symptoms
–
–
–
–
–
Hyperalertness
Jerky movements
Irritability
Easily startled
"Shaking inside"
• To reduce client's anxiety
– Orient to time and place
– Clarify illusions to reduce client's terror
Elsevier items and derived items © 2006 by Elsevier Inc. All rights reserved.
Alcohol Withdrawal Delirium
• Withdrawal delirium
• A medical emergency that can result in death
• Delirium peaks at 2 to 3 days after cessation
of alcohol and lasts 2 to 3 days
• Signs and symptoms:
– Tachycardia, diaphoresis, elevated blood pressure
– Disorientation and clouding of consciousness
– Visual or tactile hallucinations
– Hyperexcitability to lethargy
– Paranoid delusions, agitation
– Fever (100° F to 103° F)
Elsevier items and derived items © 2006 by Elsevier Inc. All rights reserved.
Central Nervous System Stimulants:
Cocaine, Crack, Amphetamines
Common signs of stimulant abuse:
• Dilation of the pupils
• Dryness of the oronasal cavity
• Excessive motor activity
Elsevier items and derived items © 2006 by Elsevier Inc. All rights reserved.
Cocaine and Crack
• Extracted from leaf of coca bush
• When smoked takes effect in 4 to 6 seconds; a
5- to 7-minute high follows, then a deep depression
• Two main effects on body
– Anesthetic
– Stimulant
• Produces imbalance in dopamine and
norepinephrine
• Withdrawal symptoms include:
– Depression, paranoia, lethargy, anxiety, insomnia, nausea,
vomiting, sweating, chills
Elsevier items and derived items © 2006 by Elsevier Inc. All rights reserved.
Marijuana (Cannabis sativa)
• Indian hemp plant
• Tetrahydrocannabinol (THC) is active ingredient in
flowering tops and leaves
• Depressant and hallucinogenic properties
• Usually smoked
• Desired effects: euphoria, detachment, relaxation
• Other effects: talkativeness, slowed perception of
time, inappropriate hilarity, heightened sensitivity
to external stimuli, anxiety, and paranoia
• Long-term effects: lethargy, anhedonia, difficulty
concentrating, loss of memory
Elsevier items and derived items © 2006 by Elsevier Inc. All rights reserved.
Hallucinogens
• Lysergic acid diethylamide (LSD or acid)
• Mescaline (peyote)
• Psilocybin (magic mushroom)
• Phencyclidine piperidine (PCP, angel dust,
horse tranquilizer, peace pill)
– Generalized anesthesia
– Intoxication can produce acute anxiety or
psychosis
– Assess for suicide risk
Elsevier items and derived items © 2006 by Elsevier Inc. All rights reserved.
Inhalants
• Volatile solvents
– Spray paint
– Glue
– Cigarette lighter fluid
– Propellant gases used in aerosols
• Used by ~19% of adolescents
• May be an early marker of serious
substance abuse
Elsevier items and derived items © 2006 by Elsevier Inc. All rights reserved.
Rave and Techno Drugs/Club Drugs
• Common drugs
– Ecstasy (3,4-methylenedioxymethamphetamine), also called
MDMA, Adam, yaba, XTC
– MDA (methylenedioxyamphetamine) or "love"
– MDE (3,4-methylenedioxyethylamphetamine) or "Eve"
• Side effects
– Euphoria, increased energy
– Increased self-confidence
– Increased sociability
– Feeling of closeness to others
• Adverse effects
– Hyperthermia, heart failure, kidney failure, acute dehydration
Elsevier items and derived items © 2006 by Elsevier Inc. All rights reserved.
Date Rape Drugs
• Flunitrazepam (Rohypnol or "roofies")
• γ-Hydroxybutyric acid (GHB)
• Rapidly produces:
– Unconsciousness
– Disinhibition
– Relaxation of voluntary muscles
– Anterograde amnesia
• Unable to remember what has occurred
Elsevier items and derived items © 2006 by Elsevier Inc. All rights reserved.
Self-Assessment by the Nurse
• Examine your own attitudes, feelings, and beliefs
about addicts and addiction. This may include
examining your own use, use by your family
members, or friends' use of addictive substances.
• Avoid disapproval, intolerance, condemnation, or
lack of emotional reaction to client.
• Develop empathy and the ability to manage the
manipulative behaviors and avoid power struggles
with the clients.
Elsevier items and derived items © 2006 by Elsevier Inc. All rights reserved.
Chemically Impaired Nurse
• The wrong choice: doing nothing.
• Without intervention or treatment the potential for client
harm increases.
• 10% to 20% of practicing nurses are chemically
dependent.
• Co-worker's responsibilities:
– Clear documentation (dates, times, events, consequences)
– Report facts to nurse manager
– Nurse manager then takes facts to nursing administration
• If no action is taken by nurse manager and co-worker's
behavior continues, take facts to the next level in the
chain of command.
Elsevier items and derived items © 2006 by Elsevier Inc. All rights reserved.
Enabling Behaviors
• Excused or ignored behaviors of coworker
• Never told supervisor
• Accepted responsibility for co-workers unfinished
work
• Believed that nurses do not use drugs or alcohol
• Liked to use drugs or alcohol also
• Exonerated a co-worker's irresponsible behavior
by covering for him or her
• Defended a co-worker when suspicious behavior
was questioned
Elsevier items and derived items © 2006 by Elsevier Inc. All rights reserved.
Assessment of Chemically
Impaired Clients
• Suicidal or homicidal thoughts or plans
• Overdose needing immediate medical
attention
• Withdrawal symptoms
• Physical complications
• Client's interest in treating addiction
• Client's and family's knowledge of
community resources
Elsevier items and derived items © 2006 by Elsevier Inc. All rights reserved.
Relevant Nursing Diagnoses
In order of priority:
• Risk for suicide
• Risk for self-directed or other-directed violence
• Ineffective airway clearance
• Ineffective breathing pattern
• Decreased cardiac output
• Deficient fluid volume
• Disturbed thought processes
• Risk for infection
• Imbalanced nutrition: less than body requirements
Elsevier items and derived items © 2006 by Elsevier Inc. All rights reserved.
Outcome Criteria
• Client's blood pressure will not be compromised.
• Client will have no seizure activity.
• Client will consistently demonstrate a commitment
to alcohol use control strategies.
• Client will consistently demonstrate
acknowledgement of personal consequences
associated with drug misuse.
• Client will describe actions to prevent and manage
relapses in substance use.
Elsevier items and derived items © 2006 by Elsevier Inc. All rights reserved.
Intervention
• Aim of treatment: self-responsibility not compliance
• Challenge: matching clients with types of treatment
considering various needs
– Type of addiction
– Age
– Physical health
– Neuropsychological health
– Financial situation
– Location of program
– Length of time of program
– Family needs
Elsevier items and derived items © 2006 by Elsevier Inc. All rights reserved.
Communication Guidelines
• Behaviors to be addressed:
– Dysfunctional anger
– Manipulation
– Impulsiveness
– Grandiosity
• Make abstinence and sobriety worthwhile
for client.
• Communicate in culturally appropriate ways.
– See “Culturally Speaking” on page 563.
Elsevier items and derived items © 2006 by Elsevier Inc. All rights reserved.
Intervention Strategies
• Primary prevention: health teaching
FRAMES
– Feedback of personal risk
– Responsibility of the patient
– Advice to change
– Menu of ways to reduce substance use
– Empathetic counseling
– Self-efficacy or optimism of the patient
Elsevier items and derived items © 2006 by Elsevier Inc. All rights reserved.
Intervention Strategies
• Dual-diagnosis principles (p.564)
• Psychotherapy
• Relapse prevention (p.564-565)
• Self-help groups for client and family
• 12-Step programs
• Residential programs
• Intensive outpatient programs
• Outpatient drug-free programs
• Employee assistance programs
Elsevier items and derived items © 2006 by Elsevier Inc. All rights reserved.
Psychopharmacology:
Treatment of Alcoholism
• Trexan, Revia (naltrexone)
– Blocks opiate receptors
– Interferes with mechanism of reinforcement
– Reduces or eliminates alcohol craving
• Campral (acamprosate)
– Helps client abstain from alcohol
– Mechanism not well understood
• Antabuse (disulfiram)
– Works on classical conditioning principle
– Alcohol-disulfiram reaction causes unpleasant physical effects
Elsevier items and derived items © 2006 by Elsevier Inc. All rights reserved.
Psychopharmacology:
Treatment of Opioid Addiction
• Dolophine (methadone)
– Synthetic opiate blocks craving for and effects of heroin
– Highly addictive
• LAAM (L-α-acetylmethadol)
– An alternative to methadone
– Effective up to 3 days
• Naltrexone (Trexan, Revia)
– Antagonist that blocks euphoric effects of opioids
• Clonidine (Catapres)
– Nonopioid suppressor of opioid withdrawal symptoms
– Effective somatic treatment when combined with naltrexone
Elsevier items and derived items © 2006 by Elsevier Inc. All rights reserved.
Evaluation
• Increased time in abstinence
• Decreased denial
• Acceptable occupational functioning
• Improved family relationships
• Ability to relate comfortably to other
individuals
Elsevier items and derived items © 2006 by Elsevier Inc. All rights reserved.