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Med/Surg Nursing 2013 Drug-substance that activates the pleasure center of the brain* Used as a response to stress, low selfesteem, obsessed with food, work, sex, gambling Addictions know no racial, religious, age, gender or socioeconomic barriers Nursing care requires PATIENCE APA definition-“maladaptive pattern of substance use leading to clinically significant impairment or distress” with one or more of the following in a 12 month period: Failure to fulfill role obligations Use that presents danger to self or others Recurrent use-related legal problems* Continued use Drugs that are abused include: alcohol, marijuana, cocaine, methamphetamines, MD prescribed medications, etc. Chemical Dependency (substance dependence) as defined by the APA as those listed above including at least 3 of the following in a 12 month period:. 1. Tolerance-need more of the drug to produce desired effect 2. Withdrawal-occurs when they stop using, must take the drug or alcohol to avoid these symptoms 3. Use larger amounts of the drug 4. Would like to cut down or quit but can’t 5. Spend time, energy and money to obtain the drug 6. Give up their former “important things” in life in order to use the drug 7. Continued use of the drug regardless of its effect on the body (spiritually, mentally, interpersonal relationships) Chemical dependencies are often combined with other behaviors such as gambling Dx Tools: DIS-specific for alcohol; ASIdetermines degree of addiction to any drug Chemical dependency can lead to mental disorders, sexual dysfunction, cirrhosis of the liver, organic brain damage, and pancreatitis Causes: Several theories Physical Factors Theory: excessive consumption is the most immediate cause of addiction Use substances to escape from life or to feel better Genetic Theory: could possibly be based on direct biologic transmission or as a learned childhood behavior Emotional and Psychological Theory: use to escape from stress, or d/t low self-esteem, dissatisfaction with life, low tolerance for frustration, self-destructive tendencies, coexisting mental illness Need the drug to feel good about life Dual Disorders: Mental illness combined with chemical dependency (MI/CD) Mentally ill clients are usually depressed May use drugs to ease the pain or commit suicide May experience auditory hallucinations (hear voices) and use chemicals to make the “voices” go away What the client don’t realize is that alcohol, sedatives, and narcotics are depressants and this accelerates the already depressed client’s mood Progressive Nature: psychological cause 1. Use to feel better, the drugs temporarily relieves the feelings of low self-worth and stress 2. Use to keep from feeling bad, need increased amounts to stop feeling sick or depressed, the body needs the drug 3. Lose control-small amounts of the chemical causes illness or severe intoxication Blackouts occur with excessive use Need medical attention to save their life! **Defense Mechanisms-most commonly used Denial Rationalization Projection Management 1. 2. 3. 4. of Dependency Recognition Intervention Treatment-must be STRUCTURED!! Recovery Nursing care can be on an outpatient basis, ECF, special treatment centers and clinics, and hospitals Insurance companies may not reimburse for a substance abuse Dx so the client may be listed under another Dx (medical) Use defense mechanisms regularly Be aware of withdrawal sx: tremors, anxiety, agitation Interview Process-see questions to ask on pg. 1633 Dealing With an Intoxicated Person in the Healthcare Facility CHALLENGING Must confirm the drug used by laboratory tests Monitor LOC!! Obtain a thorough history Determine when alcohol or drug was last used Document ALL information Dx test ordered by Md: blood alcohol test (do not prep site with alcohol) and urine toxicity (U-tox) which will determine the drugs used If a visitor is intoxicated-do not allow them into the room, notify the charge nurse, supervisor or security Detoxification-process of removing a drug and its physiologic effects from the person’s body May take days depending on the drug used, amount, level of dependence, liver and kidney function Provide comfort and SAFETY during withdrawal Use sedation and emotional support to allow rest and recuperation Detoxification must occur before longterm CD treatment can occur Person wants to stop Don’t want to rely on the drug Want to cut down on the drug but it is not possible-must stop! May be court ordered and they will be angry because they may not want to stop Need strong peer pressure to stop Usually escorted by the police Under medical supervision while in the center Need supportive care and referral to continuing therapy after detox. Isolated from the substance-oriented environment Recovering abusers usually organize the program; group therapy May be gender specific and focus on male or female problems Goals-address physical and emotional problems and understand the cycle of dependence, then they begin the “true” recovery Complete Lab medical work up work Blood chemistry levels to determine vitamin deficiencies, lipid levels, uric acid levels U-tox Determine withdrawal behavior-may still ask for the drug even though they don’t have symptoms Must experience withdrawal symptoms-n/v, tremors, diaphoresis, agitation, anxiety, hallucinations, h/a, confusion for drugs to be initiated May have medical problems such as esophageal varices, brain damage, CHF, dyspnea Reassess the client at a minimum of q. 1 hour Body is denied access to the drug Withdrawal occurs-mild to severe Depends on the drug, how much was used and for how long Present with psychological and medical problems **An injury can precipitate withdrawal Alcohol withdrawalmost dangerous Often combined with other drugs Detox begins within 72 hours of last ingestion Suicide risk increases TREMORS!! Agitation, anxiety Diaphoresis Delusions HTN, tachycardia, hyperthermia N/V, anorexia Seizures Hypoglycemia Dilated pupils Confusion Blackouts Cardiac arrest May cause FAS in pregnant women CD clients are usually malnourished Baseline weight May need nutritional supplements Refeeding Syndrome CHO’s must be given very carefully This may include dextrose IV solutions, tubefeeding mixtures and liquid dietary supplements! Substance abuser, alcoholic dependent, chemically dependent or polysubstance abuser, most people are codependent (live with others that abuse) **Active interventions must occur or addiction continues! 12-steps-NA or AA; teach that the disease is incurable and is considered to be in remission The goal is what “Linehan” calls the wise mind, a midway point between being totally rational and totally emotional They will need intensive counseling Will need to provide support, not encourage the behavior Family recovery can begin even if use continues* Chemically dependent person needs detox or intensive CD treatment AA and other groups must continue for at least 2 years Public health problem Contributes to over 100,000 deaths/year MADD DARE FAS If you drink to often/to much, there are negative consequences** S/S: Chronic alcoholics are at risk for suicide Blood alcohol levels are important to detox programs Chronic alcoholism can lead to dementia, amnesia, sleep disorders and psychotic symptoms including delusions and hallucinations* Legal level varies state to state Generally between 0.08-0.10 g/dl At 0.3 g/dl-person vomits, and may become aggressive or be in a stupor At 0.4 g/dl-coma can occur At 0.5 g/dl-severe respiratory distress and death can occur It takes 3-5 glasses of 4 oz wine/hour to reach a BAC level of 0.08 g/dl(depending on food consumption) Nurses may draw blood alcohol levels-DON’T USE ALCOHOL TO CLEAN SITE!! S/S: CNS depressant slurred speech unsteady gait behavioral changes confusion Chronic abusers have may have swollen nose, spidery veins and thickened and reddened palms AST, ALT, LDH, ALP AND THE GGTP/SCCT may be used to evaluate liver function The GGTP/SGGT is elevated in 75% of chronic alcoholics Thiamine and folate levels are low \ RBC’s are often low Lipids and uric acid levels may be increased Dietary Deficiencies-vitamin B1, B9 Untreated thiamine deficiencies may lead to severe neurologic disorder called WernickeKorsakoff syndrome. S/S: dementia, ataxia, somnolence, diplopia, horizontal nystagmus, mortality rate from this disease is high Cirrhosis of the liver and Hepatitis Client has malnutrition and decreased intestinal ability to absorb medications* Laennec’s cirrhosis r/t chronic alcohol abuse Hepatits C is a result from chronic alcohol abuse Esophageal varices Gastritis Gastric ulcers kidney disorders CAD Sexual impotence-decreased desire/ability to perform during sex* FAS Detox and f/u, must have support program Autonomic hyperactivity Tachy over 100 Nervous TREMORS! insomnia, vivid nightmares diaphoresis flushed face anorexia/nausea Neuronal excitement Sensory-perceptual disturbances Severe toxic state is DT’s S/s include delusions and vivid auditory, visual and tactile hallucinations called alcohol hallucinosis which may last from a few days to several weeks Vomiting may be present Position on side! Family disease the alcoholic family have these characteristics: control perfectionism mistrust of others Tension Members may have low self esteem! overuse defense mechanisms Codependent is often the person the alcoholic blames for the entire problem! Must understand that alcoholics have a bad disease but are not bad people* Antabuse-used for aversion therapy when the alcoholic is unable to maintain sobriety *Loading dose is 500 mg/day for 2 weeks followed by a daily maintenance dose of about 250 mg *If the person drinks while taking Antabuse, they become ill d/t the buildup of acetaldehyde; s/s: flushing, h/a, dyspnea, hypotension, nausea, tremors, thirst Do NOT give Antabuse within 12 hours of alcohol ingestion Naltrexone-Blocking agent used to treat opioid abuse and as adjunct treatment for alcoholism Decreases subjective effects of alcohol, which results in the person drinking less Don’t use this drug if the client has hepatitis or liver failure Must be completely detoxified from coexisting opioids before beginning treatment Includes barbiturates and antianxiety drugs such as benzo’s Barbiturates Amobarbital/Amytal Secobarbital/Seconal Benzodiazepines Alprazolam/Xanax* Chlordiazepoxide/Librium Diazepam/Valium Lorazepam/Ativan Others Delirium Depression Slurred speech Amnesia, irreversible dementia Respiratory depression WITHDRAWAL SEIZURES ANTIDOTE FOR OD-flumazenil/Romazicon Date-rape drug Sx of abuse Labile Incontinent Coma seizures Withdrawal Similar to DT’s but vitals are often normal or only slightly elevated Made from hemp plant and used as hallucinogens SX of abuse Dreamy state, characterized by euphoria Perception of space and time may be distorted Can induce psychological and physical dependence! Withdrawal Diarrhea, ptsosis, rhinorrhea heroin morphine meperidine HCL (Demerol) hydromorphone (Dilaudid) Symptoms of Abuse/narcotic intoxication s/s: drowsiness/coma, slurred speech, bradypnea, depression, suicide risk Withdrawal: sore throat, rhinorrhea, insomnia, diaphoresis, dilated pupils; more severe: Gi discomfort, joint and muscle pains Naloxone/Narcan is the antidote for narcotic overdose** Naltrexone-before use, the client must go through detox from opiates Originally developed as a treatment for narcotic addiction Must wait 7 days prior to administration If addicted to methadone-must wait 10 days prior to tx. Methadone-opiate analgesic used for the tx of heroin-dependent individuals, used as a substitute for heroin-does not produce a “high” Powder is mixed in at least 120 ml of OJ to mask the taste and dosage of drug Do well on therapy as long as they don’t continue to use other drugs Can precipitate withdrawal even if client not completely detoxified* Mood elevators and appetite depressants and they combat drowsiness and simple fatigu Street names “ecstasy”, “crystal meth” S/S of abuse: euphoria, confusion, anger, poor judgement Withdrawal: depression, paranoid psychosis, nightmares, increased appetite Tweaking Meth user who has not slept for days and is in acute withdrawal Use cocaine to feel better* Symptoms of abuse: Sexual dysfunction Sleep disorders Delirium and mood and anxiety disorders Hallucinations Withdrawal intensive care or 1:1 staffing! Stimulant Abuse Euphoric and stimulant effects Appear emotionally unstable Induces psychosis, including hallucinations and a feeling of being liberated from space and time Withdrawal Drowsy Hallucinations Lethargy Mild depression Not believed to cause actual or physical dependence, but produce psychological dependence and mild tolerance LSD/Mescaline and Mushroom Auditory hallucinations and intense visual hallucinations Objects may appear larger-macropsia or smallermicropsia Phencyclidine Hydrochloride hallucinogens developed as an animal anesthetic Volatile substances are CNS depressants that when inhaled produce altered states of consciousness and varied degrees of intoxication Boppers, gluey, locker room, moon gas, poppers and is very dangerous Causes addiction Death can result from sudden cardiac arrest, suffocation, burns or aspiration of vomitus Derive from testosterone Promote growth of muscle and increase lean body mass Take steroids intermittently Side effects: liver damage, cancer, edema, fatigue and insomnia May experience mood lability and paranoia Death can occur Found in cigarettes and snuff Smokers have a higher than normal risk of cancer of the stomach, kidney, pancreas, bladder, or skin Nicotine also contributes to heart and blood vessel disorders Cigarette smoke binds with hemoglobin to diminish the bloods oxygen carrying capacity reducing tissue oxygenation Verenicline tartrate/Chantix is a nicotine receptor antagonist Found in coffee, tea, chocolate, soft drinks CNS stimulant Does not reverse alcohols intoxicating or depressant effects and may actually add to depression* Heart rate increases and may become irregular Aggravation of cystic breast disease Available without a RX Can be abused if taken in large doses and more frequently than normal Pregnant Women: drugs, alcohol, caffeine and nicotine can complicate pregnancy Babies are preterm, subject to physical and or mental disorders Adolescents: Peer pressure and low self-esteem are problems, cigarette smoking and alcohol are on the rise Older Adults: Seniors may “double dose”, attempt suicide with medications and may overuse antacids Nurses: Drugs are available in healthcare facilities, 50% more likely to become chemically dependent than the general population