Med/Surg Nursing2013

Drug-substance that activates the pleasure center of the brain*

Used as a response to stress, low self-esteem, 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; ASI-determines 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 theoriesPhysical 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, co-existing 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 depressedMay use drugs to ease the pain or commit

suicideMay 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 cause1. Use to feel better, the drugs temporarily

relieves the feelings of low self-worth and stress2. 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 usedDenialRationalizationProjection

Management of Dependency1. Recognition2. Intervention3. Treatment-must be STRUCTURED!!4. 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 FacilityCHALLENGINGMust confirm the drug used by laboratory

testsMonitor LOC!!Obtain a thorough historyDetermine when alcohol or drug was last

usedDocument 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 long-term 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 medical work up Lab 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 withdrawal-most 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 carefullyThis may include dextrose IV solutions,

tube-feeding 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 depressantslurred speechunsteady gaitbehavioral changesconfusionChronic 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 Wernicke-Korsakoff 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/AmytalSecobarbital/Seconal

BenzodiazepinesAlprazolam/Xanax*Chlordiazepoxide/LibriumDiazepam/ValiumLorazepam/Ativan

Others

Delirium Depression Slurred speech Amnesia, irreversible dementia Respiratory depression

WITHDRAWALSEIZURESANTIDOTE FOR OD-flumazenil/Romazicon

Date-rape drug Sx of abuse

Labile IncontinentComaseizures

WithdrawalSimilar to DT’s but vitals are often normal or

only slightly elevated

Made from hemp plant and used as hallucinogens

SX of abuseDreamy state, characterized by euphoriaPerception of space and time may be

distortedCan 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 opiatesOriginally 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 drugDo 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

TweakingMeth user who has not slept for days and

is in acute withdrawal

Use cocaine to feel better* Symptoms of abuse:

Sexual dysfunctionSleep disordersDelirium and mood and anxiety disordersHallucinations

Withdrawalintensive 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 MushroomAuditory hallucinations and intense visual

hallucinationsObjects may appear larger-macropsia or

smaller-micropsiaPhencyclidine Hydrochloride

hallucinogens developed as an animal anesthetic

Volatile substances are CNS depressants that when inhaled produce altered states of consciousness and varied degrees of intoxicationBoppers, gluey, locker room, moon gas,

poppers and is very dangerousCauses addictionDeath 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 stimulantDoes 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