Transcript Chapter_024 and 39 modified 4-12-07

Copyright © 2005 Mosby, Inc. All rights reserved.
Slide 0
Chapter 24
Chemically Mediated
Responses and
Substance-Related
Disorders
Copyright © 2005 Mosby, Inc. All rights reserved.
Slide 1
Copyright © 2005 Mosby, Inc. All rights reserved.
Slide 2
The CAGE Questionnaire
• Have you ever felt you ought to Cut down on your
drinking?
• Have people Annoyed you by criticizing your drinking?
• Have you ever felt bad or Guilty about your drinking?
• Have you ever had a drink first thing in the morning to
steady your nerves or get rid of a hangover (Eyeopener)?
Scoring: Two “yes” answers indicate probable alcohol
abuse and warrant further assessment.
Copyright © 2005 Mosby, Inc. All rights reserved.
Slide 3
Figure 24-5 The Stuart Stress Adaptation Model as related to substance abuse.
Copyright © 2005 Mosby, Inc. All rights reserved.
Slide 4
Primary Nursing Diagnoses Related to
Chemically Mediated Responses
• Acute confusion
• Ineffective coping
• Dysfunctional family processes: alcoholism
• Disturbed sensory perception
Copyright © 2005 Mosby, Inc. All rights reserved.
Slide 5
Primary Medical Diagnoses Related to
Chemically Mediated Responses
• Substance use disorders
Substance dependence
Substance abuse
• Substance-induced disorders
Substance intoxication
Psychotic disorder
Substance withdrawal
Mood disorder
Delirium
Anxiety disorder
Dementia
Sexual dysfunction
Amnestic disorder
Sleep disorder
Copyright © 2005 Mosby, Inc. All rights reserved.
Slide 6
Evidence-Based Treatments for Chemically
Mediated Responses
Disorder: Alcohol use disorder
Treatment:
• Cognitive behavioral treatments help patients shape
and adapt to their life circumstances.
• 12-step treatment may be as effective as cognitive
behavioral treatments.
• Therapist characteristics may have a stronger effect on
outcome than type of treatment.
• Lower intensity treatment for a longer duration may be
an effective treatment strategy.
Copyright © 2005 Mosby, Inc. All rights reserved.
Slide 7
Evidence-Based Treatments for Chemically
Mediated Responses (Cont.)
Alcohol use disorder (cont.)
• There appears to be little difference in outcome
between inpatient and outpatient treatment.
• Naltrexone is effective in preventing full-blown relapses
in alcoholics who have had a “slip” after achieving
abstinence.
Copyright © 2005 Mosby, Inc. All rights reserved.
Slide 8
Evidence-Based Treatments for Chemically
Mediated Responses (Cont.)
Disorder: Substance use disorders
Treatment:
• The nicotine patch and nicotine gum significantly
increase nicotine abstinence.
• Maintenance treatment using methadone for heroin
dependence is effective.
• LAAM, a longer-acting opioid, also is effective.
Copyright © 2005 Mosby, Inc. All rights reserved.
Slide 9
Principles of Alcohol Detoxification
• The long-acting benzodiazepines are the drugs of
choice because they effectively reduce signs and
symptoms of withdrawal, prevent seizures, and have a
better margin of safety than other drugs.
• A symptom-triggered dosing regimen is preferred over
fixed-schedule dosing because it is effective, requires
less medication, and appears to prevent seizures as
well as fixed schemes.
• The use of a withdrawal assessment tool such as the
CIWA-AR is recommended for medication
determinations because it reduces overmedication
caused by patient overreporting of symptoms or fixed
regimes, and undermedication resulting from staff
reluctance to treat.
Copyright © 2005 Mosby, Inc. All rights reserved.
Slide 10
Principles of Alcohol Detoxification (Cont.)
• A fixed schedule, with prn dosing, may be used on a
unit where the staff members have no training in the
use of a withdrawal assessment tool.
• Although neither magnesium nor thiamine reduces
seizures, administration of thiamine is recommended to
prevent Wernicke disease and Wernicke-Korsakoff
syndrome.
Copyright © 2005 Mosby, Inc. All rights reserved.
Slide 11
Principles of Motivational Counseling
• Express empathy through reflective listening.
• Develop discrepancy between the patient’s goals or
values and current behavior.
• Avoid argument and direct confrontation.
• Roll with resistance.
• Support self-efficacy.
Copyright © 2005 Mosby, Inc. All rights reserved.
Slide 12
Decisional Balance Grid
Old Behavior
New Behavior
Pros/Benefits
Like the taste of alcohol
Helps me to relax
Cons/Costs
Costs a lot of money
Led to DWI—costly,
embarrassing, and
inconvenient
Pros/Benefits
Better relationship with
spouse
No more DWIs
Cons/Costs
Will miss my drinking
friends
Don’t know how to have
fun without it
Copyright © 2005 Mosby, Inc. All rights reserved.
Slide 13
Figure 24-7 A model of change in substance use disorders. (Modified from Prochaska J, DiClemente C: Towards a
comprehensive model of change. In Miller W, Heather N, editors: Treating addictive behaviors: process of change, New
York, 1986, Plenum.)
Copyright © 2005 Mosby, Inc. All rights reserved.
Slide 14
Treatment Stages and Interventions for
Dually Diagnosed Patients
• Engagement—Intervene in crises, help with practical
living problems, establish rapport with family members,
demonstrate caring and support, listen actively
• Persuasion—Help to analyze pros and cons of
substance use, educate patient and family, arrange
peer-group discussions, expose patient to doubletrouble self-help groups, adjust medication, persuade
patient to comply with medication regimen
Copyright © 2005 Mosby, Inc. All rights reserved.
Slide 15
Treatment Stages and Interventions for
Dually Diagnosed Patients (Cont.)
• Active treatment—Help to change thinking patterns,
friends, habits, behaviors, and living situations as
necessary to support goals; teach social skills;
encourage patient to develop positive social supports
through double-trouble self-help groups; enlist family
support of changes; monitor urine and breath for
substances; offer medications
• Relapse prevention—Reinforce abstinence,
compliance, and behavioral changes; identify risk
factors and help to practice preventive strategies;
encourage continued involvement in double-trouble
groups; continue lab monitoring
Copyright © 2005 Mosby, Inc. All rights reserved.
Slide 16