substance abuse rf order 5
Post on 17-Dec-2014
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Renee Franquiz MSN, RN
28 million Americans over the age of 12 years used drugs or etoh (13%)
17 million Americans over the age of 12 years abused (7%) – based on DSM-IV criteria
Highest prevalence was among white males, age 18-25, high school only education
Most highly abused substance was alcohol
Source: http://www.oas.samhsa.gov/nsduh.htm (US Dept of Health and Human Services)
In class we touched on some of the reasons illustrated below, and we spoke of social acceptance/indifference, peer pressure, role modeling, taboo makes it tempting, cultural norms, changes in family (supervision of children), access to information (internet), result of Rx treatment
Within the US 14% of adults have had an alcohol dependence or abuse problem at some time in their lives.
3% of individuals older that 12 years need treatment for drug use disorders.
DefinitionTo use in a
wrong or harmful way
DSM-IV Criteria (1 of the following in the past 12 months)Failure to fulfill role
obligationsPhysical hazard/InjuryLegal Issue(s)Behavior continues
despite an awareness that there is a problem
Definition Compulsive chronic
requirement where the need creates distress if unfulfilled
Often involves tolerance – which is an habituation – the increasing need for greater amount or more frequency
DSM-IV Criteria (3 of the following in the past 12 months) Tolerance Withdraw Symptoms A desire to Decrease Unsuccessful attempt
to decrease Increase time spent in
pursuit Sacrifice personal
Involvements Behavior continues
despite an awareness that there is a problem
PhysiologicalBiochemical – Substance combines with neurotransmitters to produce endogenous morphine, which becomes addictive
Biologic – Gene of predisposition Familial tendency, especially for etoh Supported by Twin Studies and
Adoption studies
PsychologicalDevelopmental – Stalled development at one of the stages (Freud, Erikson, Kholberg etc) predisposes to use/abuse
Personality – Individual traits predispose to use/abuse, such as low self-esteem, impulsiveness, inability to delay gratification, antisocial, depressive personality
SocialLearned– Bandura’s Social Learning
Theory. Modeling in the environment (family and peers) results in use/abuse
Operant Conditioning – Skinner, Pavlov Positive reinforcement from the pleasure aspect of use leads to repeat behavior
Cultural – Can fall under “Learned” and relates to etoh – reflected as Values, Norms, Customs and Beliefs of a particular culture
Reasons for use –previously covered
Significance ¼ all ER admits are
substance related 1/3 of all suicides are
substance related ½ of all Homicides
are substance related
PLEASE REVIEW ATI pages 154-157 Intended and Toxic
effects This is material that
will be tested on the exam
First examine and explore yourself How do you feel about drugs, alcohol, and
addiction? This may include reflecting on your own use, or
that of family and friends Negative attitudes about use may lead to disapproval,
intolerance, condemnation Positive attitudes about use may lead to enabling and
boundary issue Maintain Professionalism – your attitude either way
should not factor into the nurse-client relationship Empathy is a must
Anticipate the possibility of manipulation addiction creates a powerful need that if
unfulfilled, lead to significant client distress Pursuit of the substance may trump all
conventional thought
Assessment Review the general mental health history and
physical on pages 142 – 147 in Townsend
History should include Type, Route, Frequency, Amount of Substance
used Patterns of use and have they changed (Shift from
Use to Dependence) Date/Time of last use, abstinence hx (rehab),
withdraw sx Be sure to include
Have you ever used more than you wanted to?Have you wanted to change your use? Cut
down/stop?
Assessment Labs (Acute Evaluation)
Complete Blood Count (CBC) – Concerns for infection, anemia, thrombocytopenia
Complete Metabolic Panel (CMP) – Concerns for Electrolyte Imbalance, Liver Function, Nutritional Deficits
Urine Analysis (U/A) – Concerns for infection, Renal Impairment
Toxicology Screen – Can do as U/A or Blood Blood Alcohol Level (BAL) – Legal Limit 0.08%
(80g/dl)Unable to discharge client until BAL < 100g/dl,
unless they are being transported by someone else
Life Threatening BAL > 350 g/dl – 400g g/dl - All depends on the individuals tolerance
Assessment Tools Please familiarize yourself with these tools
TextbookMAST (Michigan Alcohol Screening Test)CIWA (Clinical Institute Withdraw Assessment)
ATIMAST (As Above)..\MAST.pdfAddiction Severity Index
..\Addiction Severity Index.pdfRecovery Attitude and Treatment Evaluator
(unable to provide d/t copyright – for purchase only)
Drug Abuse Screen Test (DAST)..\DAST.pdfCAGE-AID..\CAGE-AID.pdf
Analysis and Diagnosis Consider any Nursing Dx you have data to
support Due to the breath of impact that substance abuse
has, the list of nursing dx could be quite exhaustive (physical, psychological, social, cognitive)
Key Dx associated with Substance Abuse Ineffective Coping Denial Impaired Nutrition Risk for Injury Disturbed Thought Process Suicide You likely could add at least 10 more!
Analysis Consider that 50% of people with a serious mental
illness have a substance use disorder some time on their lives.
Disorders associated with substance abuse include: Acute and chronic cognitive impairment Attention deficit disorder Anxiety Borderline personalities Depression Eating disorders/compulsivity
Therefore, carefully consider Dual-Diagnosis when assessing a client with Substance Aubse
Plan Physiologic health and safety first – Prioritize
ABCs if applicable. Then move on to Psych/Soc
Aim of psycho-social treatment is self responsibility
Match the types of treatment with client needs: “Fit” between client and resource Type/Severity of addiction Age Physiologic Health Neuropsychological Health Location/ length of program and ability of client to
attend Finances
Implementation
Safety During the Acute Phase of Detoxification Close Observation – 1:1, usually with a UAP (High risk
for seizures, delirium (psychosis), falls, vomit/aspiration)
+/- Restraints - review restraint video in ATI online Frequent VS assessment – rapidly changing condition Safe Environment – Bed low, No objects in the room
that patient could harm themselves with or throw Seizure Precautions – Padded side rails, tongue blade,
Oxygen, Suction, IV access, PRN orders for antiepileptic drugs (usually Benzodiazepines)
Low Sensory Stimulation (Visual, Auditory, Tactile) Provide for foods, fluids, elimination
Self Help Step programs (AA, NA, GA, Al-Anon)
Peer Driven, Faith Based Emphasize Self Responsibility
Counseling Individual
Educate – About addictions, treatment goals Cognitive behavioral therapy Emphasize Self-Responsibility
Family Educate – About addictions, codependency, relapse Support groups
Groups Clients with similar diagnosis meet under the
supervision of a professional to discuss issues Inpatient or Outpatient
Psychopharmacology Alcohol Withdraw
Benzodiazepines – controls agitation and seizures Antiepileptics – Controls seizures Thiamine – Nutritional replacement Ensure IV access at all times
Alcohol Abstinence Antabuse – Inhibits ETOH metabolism,
Acetaldehyde accumulates and causes serious illness
Opioid Reversal Agent – Narcan (Action is immediate); No
concern if given and no narcotic on board Withdraw – Methadone, Buprenorphine (less side
effects than Methadone
Increased time in abstinence Decreased denial Acceptable occupational functioning Improved family relationships Ability to relate to other individuals
10-20% of practicing nurses are chemically dependent in their personal lives
Access to Controlled Substances presents opportunity/temptation
RN license is in jeopardy of suspension or revocation by the Board of Nursing
Signs Physical/Behavioral signs of impairment Work Absenteeism; Frequent breaks from the unit Missing Controlled Substances from the unit Abusers patients report poor pain control (abuser taking
the meds instead of administering) Abuser frequently offers to help other nurses and
medicate their patients (abuser takes the meds instead of administering)
Co-worker’s Responsibilities: Document Report facts to immediate supervisor Confront your co-worker – that’s a good discussion
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