Download SUBSTANCE ABUSE

SUBSTANCE ABUSE
Cost to Business & Industry
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100 million annually
Alcohol= 500 million lost work days
40% industrial fatalities
47% workplace injuries
50% of motor vehicle fatalities(2005)
Effects on society
National health problem
 More deaths,illness,accidents,disabilities than any
other health problem
 15 million dependent on alcohol
 500,000 between ages 9-12
 7 million persons between 12-20
binge drink
(Narconon,2005)
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Effects on the family
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# of babies born with physiologic & emotional
consequences of crack & alcohol ---Increasing
at an alarming rate
43% of US families exposed to alcoholism
50% persons who seek tx have at least one
parent w/ alcoholism hx.
Culture and Substance abuse
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Attitudes vary in cultures
Muslims – no alcohol consumption
Jewish – use wine for religious rites
Native Americans – use payote (religious
ceremonies)
Genetic traits found – predispose or protect
Flushing reaction – Asians
Genetics & substance abuse
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Variations is structure & activity levels of enzymes
involved in metabolism of ETOH
Variations among Asians, Africian Americans and
whites
Japanese – enzyme produces faster elimination of
alcohol
Native Americans- etoh use –one of five leading
causes of death(75% accidents)
Japan – ETOH consumption quadrupled since 1960
Effects of addiction
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Abuse
Tolerence
Physical dependence - addiction
Psychologic dependence –mind-body
connection
Alcoholism – chronic progressive potentially
fatal
Blackouts
Alcohol and other drugs are
associated with:
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Up to 50% spousal abuse
50% traffic accidents
49% murders
68% manslaughter charges
69% drownings
38% child abuse
52% rapes
62% assaults
20-35% suicides
(Johnson-1997)
Similarities & Differences
Alcohol
Intended effect
Alcohol- CNS
Depressant/relaxation, loss of
inhibition
Intoxication
Slurred
speech;loss of
coordination;
ataxia; decreased
coordination,
attention/concentration, memory
judgment
W/d – detox
4-12n hrs. p last
drink
Course hand
tremor,sweating
 T, P,B/P, R
Insomnia, anxiety,
N/V –
If no tx.= DT’s
Sedatives /Hypnotics
Anxiolytics
Induced effect
Benzodiazapines
& Barbituates
Use: to produce
Drowsiness,
 anxiety
Intox-OD
Benzo’s rarely
fatal when taken
alone; sx’s =
Lethergy,
Confusion;
Barb’s –fatal in
OD-coma,resp –
cardiac arrest
W/d –detox
Ativan-10 hrs
W/d sx’s-6-8 hrs
p last dose
Valium –w/d up
to 1 wk
W/d= v/s
Need to taper off
drug
Stimulants
amphetamines/cocaine
Intended effect
Excite – CNS
Limited clinical
use – high abuse
potential
Cocaine-highly
addictive
Intox- OD
High-euphoric
feeling;hyperactivity/vigilance
Talkativeness,
grandiosity,hallucin
ations, anxiety
Repetitive
behaviors, anger ,
fighting
W/d – detox
Occurs-few hrsdays
C/b marked
dysphoria;
fatigue; vivid &
unpleasant
dreams; hyper or
insomnia;
psychomotor act.
Opioids: morphine,
heroin,meperidine,codeine,hydromorphone,
Induced effect
Popular for
abuse –
desensitize user
to both
physio/psych
pain-induce
euphoria, wellbeing
Intox – OD
Intox- develops
quickly c/b apathy,
lethergy,listlessness,
judgment, psychomotor retardation or
agiation, constricted
pupils,slurred speech
Severe o d coma,
Resp. arrest/death
W/d detox
Drug intake ceases
or  markedly; c/b
anxiety/restless.,
aching back,legs,
craving for opioids
Heroin –w/d
6-24 hr;
peak 2-3 days;
Ends=5-7 days
Hallucinogens
Intended
effect
Distort users
perception of
reality
Intoxification/OD
Intox= (Psychologic)
anxiety,depression,
Paranoid delusions,
hallucinations
(Physio)  B/P,T,P
dilated pupils,sweating,
blurred vision,tremors,
decreased coordination
Withdrawal/Detox
No withdrawal
symptoms known
-may crave drug
Produce flashbacks
May continue up to
5 years after use.
Pharmacologic treatment
substance abuse
Disulfiram(antabuse)-maintain abstinence
from alcohol
 Teach client to read all labels – avoid any
product containing alcohol
 Lorazepam(ativan) – for w/d fro etoh
Monitor V/S/client safety/assess effectiveness
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Pharmacologic treatment
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Clonidine(catapres) –suppresses opiate
withdrawal symptoms –check B/P prior to
administration – withhold if hypotensive
Thiamine(vitamin B1) Folic acid (folate), B12
= tx nutritional deficiencies – teach re: proper
nutrition; darkened urine may result w/folate.
Nursing Dx.:Risk for Injury(etoh withdrawal)
r/t environment & individual defenses
Place client close to nursing station
(safety a priority)
 Seizure precautions(seizures can occur during
w/d-prevents injury)
 Reorient x4 as necessary(provides reality
orientation)
 Speak in simple direct concrete language(clients
ability to deal with complex or abstract ideas is
limited)
 Reassure client that bugs,snakes etc. are not
real(provides reality orientation – decreases
anxiety)
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Ineffective Health maintenance r/t inability to
identify/manage/seek help
Monitor health status,V/S parameters,
& behavioral changes, administer meds per protocol
(B/P , P,presence or absence of tongue tremorsdetermine need for medication- use predetermined
parameters)
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Offer fluids freq –esp.juices,malts, no caffeinated
beverages(caffeine increases tremors,malts,juices
offer nutrients & fluids)
Ineffective health maintenance(cont’d)
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Monitor fluid/electrolytes,IV therapy-indicated in
severe alcohol withdrawal(clients with ETOH abuse
are high risk for fluid/lyte imbalance)
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Provide food and nourishing fluids as soon as client
can tolerate eating(clients who abuse alcohol often
have gastritis or anorexia – important to reestablish
nutritional intake)
continued
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Assist with physical care as necessary(client needs
should be met with permitting as much
independence as possible for client)
Educate –Alcoholism is a disease that requires
long term tx and f/u(detox. deals w physical w/d
but not address primary disease of alcoholism)
Administer meds to minimize progression of w/d,
complications, & to facilitate sleep(client will be
fatigued,requires rest)
Dual diagnosis
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50% of persons with substance abuse also
have mental disorder (2005)
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Need to be treated in special units designated
for tx. of dual diagnosis – tx. must focus on
both the mental disorder and the substance
abuse to be effective.
Dual Diagnosis CARE PLAN Noncompliance
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Discuss patterns of drug/alcohol use in nonjudgmental way(non-judgmental manner increases
chance of obtaining data)
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Help client to correlate increased use of chemicals
with increased psychiatric symptoms(these effects
may not be apparent to client)
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Educate (factual info –sound basis for problem
solving)
Dual diagnosis – Ineffective coping
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Encourage open expression of feelings(initial step towards
dealing constructively with those feelings)
Validate client’s frustrations or anger re dual
problem(expression of feelings – may relieve stress &
anxiety)
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Give positive feedback for abstinence(positive feedback
reinforces abstinence behaviors)
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Encourage client to record activities,feelings thoughts in a
journal(provides a focus for client to yield information that
is useful in future planning)
Review questions
The nurse would recognize the following as signs
of alcohol withdrawal:
A.
coma, disorientation, hyper vigilance
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B
tremors, sweating,elevated b/p
C.
increased temperature, lethargy,hypothermia
D.
talkativeness, hyperactivity, blackouts
Which of the following foods would the nurse
eliminate from the diet of a client with alcohol
withdrawal?
A. Ice cream
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B. Milk
C. Orange juice
D. Regular coffee
The nurse includes the following intervention in a
plan of care for a client with severe alcohol
withdrawal:
A.
Continuous use of restraints
B.
Informing the client about alcohol treatment
programs
C.
Remaining with the client when he/she is
confused
D.
Touching the client before saying anything
ALCOHOLISM & SUBSTANCE ABUSE
IN THE OLDER ADULT
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Onset after 50 not uncommon
30 –60 % of elders in treatment programs
began drinking abusively after age 60
Risk factors – elder substance
abuse
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Chronic illness-pain (long term use of Rx. narcotics
etc.)
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Life stress
Loss
Social isolation
Grief
Depression
Abundance of free time
Money
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(Atkinson, 2004)
Drinking problems fall into two distinct
patterns in the older adult
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2/3rds early onset alcoholism
1/3rd late onset alcoholism
(Menniger, 2002)
Use screening tool AUDIT(Alcohol Use Disorder
Identification Test) for early identification of
alcoholism problem in older adults.
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Psychosocial issues & physiologic changes
associates with substance abuse in elderly
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Increase risk for falls/injuries
Increase risk –suicide (especially older
male,single,caucasian,>65 w/health problems)
Increase vulnerability to infection( r/t
decreased immune system from alcohol abuse)
Age related problems include:
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Difficulty seeking help
Exacerbation of Cardiovascular and GI
problems
Increased risk for withdrawal & S/E’s of
ETOH & drugs r/t more fragile homeostasis
Ignored by health care system & society
Few age related programs exist
Little research published
SUBSTANCE ABUSE IN HEALTH
PROFESSIONALS
Higher rates of dependence on controlled
substances (Jaffe & Anthony 2005)
Problems with Reporting colleagues:
 Sensitive issue
 Want to avoid conflict
 Fear of falsely accusing colleague
 Feel guilty
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Legal /ethical responsibility
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Ethical responsibility –report suspicious
behaviors to supervisor!
Legal obligation –defends State Nurse Practice
Act!
DO NOT try to handle situation alone!
Warning signs of abuse
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Poor work performance
Frequent absenteeism
Unusual behaviors
Slurred speech
Isolates self from colleagues
Specific signs& symptoms of
substance abuse
Nurse should watch for:
 Incorrect drug counts
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Controlled substances listed as
wasted/contaminated(occurring more frequently)
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Client reports of ineffective pain relief
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Damages/torn packages of controlled substances
Nurse should watch for:
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Increased reports of pharmacy errors
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Frequently offers trips to pharmacy to obtain
controlled substances
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Trips to bathroom after contact with controlled
substances
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Consistently arrives early or departs late from
work – no apparent reason
CA BRN Diversion Program
Rehab -based program
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Provides early intervention
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Board determines candidacy for program
BRN criteria for admission into
program:
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CA license & residence
No hx. of previous discipline
Has not failed to complete a previous diversion
program
No harm to clients has been determined
Problems r/t chemical dependency or mental illness
Willingness to comply with practice restrictions
Not a sex offender
Additional program eligibility:
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Must voluntarily request admission
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Agree to undergo reasonable Psychiatric/medical
examination
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Cooperate – provide medical info., authorizations,
release liability
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Agree in writing to comply to all elements
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Not have diverted controlled substances for sale
Clients with eating disorders
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Underlying emotional conflicts – dealt with by
destructive food related behavior
Nursing Dx.:Imbalanced nutrition <body
requirements r/t intake of nutrients insufficient to
meet body needs
Assessment characteristics:
 Wt loss
 Body wt 15% + under ideal body wt.
 Denial or loss of appetite,difficulty swallowing
 Inability to perceive accurately & respond to internal
stimuli r/t hunger or nutritional needs
 Epigastric distress,vomiting,
 Laxative abuse
 Concealing wt’s on body to wt .measurement
Anorexia characteristics continued:
Denial of illness or resistance of treatment
 Denial of being too thin
 Excessive exercise
 Multiple related physical problems
Interventions must be specific to client physical
and emotional problems and degree /severity
of wt loss and anorexia
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Examples of interventions:
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If critically malnourished:
Parenteral nutrition through a central catheter may be
indicated(adequate nutrition,electrolytes etc. can be
provides parenterally,client cannot vomit this type of
nutrition)
Tube feedings may be used alone or with oral
parenteral nutrition(fortified liquid diets can be
provided through tube feedings)
Severe anorexia interventions:
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Supervise client for specified time(90 minutes –
decrease to 30 minutes after tube feeding or remove
NG tube after feeding(supervision decreased clients
opportunity to vomit or siphon feedings)
Offer client opportunity to eat food orally-use tube
feeding if amount consumed is insufficient(client may
prefer to eat food orally- however, physical health is
priority)
Severe malnourishment
If N/G tube is used – be matter-of fact re:
insertion/use –DO NOT use as a threat!
DO NOT permit client to bargain!(limits &
consistency essential in avoiding power
struggles and decreasing manipulative
behaviors)
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Interventions for the non- critically
malnourished client
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Initially do not allow client to eat with ither
clients or visitors(other clients may repeat
family patterns by urging client to eat or
providing attention to client for not eating)
Provide structure to mealtime-state limits
matter-of-factly (clear limits lets client know
what is expected)
Interventions continued
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Do not bribe,coax,threaten or focus on eating
at all!
Withdraw attention if client refuses to eat.
When meal is over remove food without
discussion(minimizes client’s secondary gains
from not eating- does not reinforce issues of
control which are central to client)
Interventions continued
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Encourage client to seek out staff members after
eating to talk about feelings of anxiety or guilt or
if urge to vomit exists.(speaking to staff promotes
focus on emotional issues rather than food)
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Supervise during & after meals start with 90
minutes gradually reduce to 30 minutes.Do not
permit use of bathroom until at least 30 minutes
after each meal (client may spill,hide or discard
food-may use BR to vomit or dispose of concealed
food)
Interventions continued
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Gradually permit client increased choices regarding
food, mealtime etc.(develops independence in
eating habits)
Monitor I&O in an unobtrusive and matter-of fact
manner(minimizes direct attention to eating and
removes emotional issues)
Weigh client daily,after client has voided and before
morning meal; client should wear only hospital
gown(consistency is necessary for accurate
comparison of wt.over time)
Observe/record client overt/covert physical
activity(client may exercise to excess to control wt.)
Review questions:
Eating disorders
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The nurse should include which of the following
interventions in the plan of care for a client with
bulimia? (select all that apply)
A. Encourage the client to avoid eating except at mealtime.
B. Promote a weight gain of 3 to 5 pounds per week.
C. Observe the client for one hour after meals.
D. Encourage the client to identify foods that trigger a
binge.
E. Instruct the client to keep laxatives and diuretics in a
locked area.
F. Inform the client that there are no “forbidden” foods.
Review questions
The nurse is caring for a client with anorexia
nervosa. Even though client has been eating all
her meals and snacks her weight is unchanged
for one week. Which intervention would be
indicated:
A. Close Obs.x’s2 hrs. p meals/snacks
B.  caloric intake from 1500 –2000 calories
C. fluid intake
D. Request Rx for antianxiety med from MD
An intoxicated client is admitted to the hospital for
alcohol withdrawal. Which of the following
actions would the nurse do to assist the client to
become sober?
A.
Give client black coffee to drink
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B.
Have the client take a cold shower
C.
Provide client with a quiet room to sleep
D.
Walk around the unit with the client
The nurse is evaluating the progress of a client with
bulimia.Which behavior indicates the client is
making progress?
A. The client identifies calorie content for each
meal
B. The client identifies healthy ways of coping
with anxiety
C. The client spends time resting in her room
after meals
D. The client verbalizes knowledge of former
eating patterns
A client diagnosed with bulimia tells the nurse she
eats excessively when she is upset then vomits so she
won’t gain weight. The most appropriate nursing
diagnosis for this client is:
A. Anxiety
B. Disabled family coping
C. Imbalanced nutrition:more than body
requirements
D. Ineffective coping
When teaching a group of adolescents about
anorexia, the nurse would describe this disorder as
being characterized by which of the following:
a)
b)
c)
d)
Excessive fear of becoming obese, near-normal
weight, and self-critical body image
Extreme concern about dieting, calorie
counting,and an unrealistic body image
Intense fear of becoming obese,emaciation, and a
disturbed body image
Obsession with the weight of others,chronic dieting,
and an altered body image.
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A.
B.
C.
D.
E.
F.
Which of the following nursing interventions should
the nurse include in the plan of care for a client with
anorexia nervosa in the outpatient setting?
(select all that apply)
Set minimum weight limits in which the client may
continue treatment in the outpatient setting.
Avoid discussing the client’s irrational thoughts
about food and weight with the client’s family.
Encourage the client to be weighed dailyat the same
time of day.
Instruct the client to avoid preparing one’s own meal.
Instruct the client to keep a food diary.
Assist the client with meal planning.
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A.
B.
C.
D.
E.
F.
The nurse should assess a client suspected of having
bulimia for which of the following clinical
manifestations: (select all that apply)
Constipation
A 20% loss of normal body weight
Dental erosion
Languo
A serum potassium of 3.0mEq/L
Depression
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Which of the following nursing interventions should the nurse
include in the plan of care for a client with
anorexia nervosa in the outpatient setting? (select all that
apply)
A. Set minimum weight limits in which the client may continue
treatment in the outpatient setting.
B. Avoid discussing the client’s irrational thoughts about food
and weight with the client’s family.
C. Encourage the client to be weighed dailyat the same time of
day.
D. Instruct the client to avoid preparing one’s own meal.
E. Instruct the client to keep a food diary.
F. Assist the client with meal planning.
Review questions :
Adolescent disorders
An effective nursing intervention for for the
impulsive and aggressive behaviors that accompany
conduct disorders is:
A. Assertiveness training
B. Consistent limiting setting
C. Negotiation of rules
D. Open expression of feelings
The nurse would expect to see all of the following
behaviors in a child with Attention deficit
hyperactivity disorder(AD/HD) except:
A. Easily distracted and forgetful
B. Excessive running,climbing,fidgeting
C. Moody,sullen, pouting behavior
D.Interrupts others and cannot take turns
A 9 year old client with AD/HD tells the nurse “no
one in my class likes me because they think I’m
stupid !” The nurse would apply the following
nursing diagnosis to this child:
A. Anxiety
B. Impaired socialization
C. Ineffective coping
D. Low Self-Esteem
The nurse would identify which of the following
children as being most at risk for an adjustment
disorder?
A. A 10 year old boy who has never liked school an
has a few friends
B. A 16 year old boy who has been struggling in
school, getting only C’s and D’s
C. A 13 year old girl who is upset about not being
selected for a cheerleading squad
D. A 16 year old girl who recently moved to a new
school after her parents’ divorce