Welcome to Nursing 2.

Welcome to Nursing 2

Mental Health a.k.a. Psychiatric Nursing (chapter 93)
By Debi Campbell, RN, MSN Objectives include: Define the most important terms and acronyms relating to the mental health and its deviations Explain the role of normal defense mechanisms. Describe results when defense mechanisms are overused. Differentiate between functional and organic mental illnesses. List at least five organic causes of mental illness. Describe the role of neuropsychological and neurodiagnostic testing in diagnosis mental illness. List at least five general symptoms of mental disorder. Describe the diagnostic criteria for a mood disorder. Explain the differences between a major depressive disorder and dysthymia. Describe the behavioral characteristics of the person with bipolar disorder. List and describe at least four personality disorders. Describe in detail common behaviors of people with borderline personality disorder. Describe psychosis and list its most common symptoms. List and describe the relationship between substance abuse and mental illness. Identify the key members of the mental healthcare team and describe their roles. Describe the outpatient services commonly available for people with mental illnesses. Identify three types of structures living available to clients with mental disorders. Discuss the legal categories of admission to the acute mental health-care setting. Discuss therapies available to client with mental illness. Describe electroconvulsive therapy, indications for its use, and associated nursing implication. Identify the most commonly used classifications of medicines in psychiatry. Give at least three examples of each classification. Describe the undesirable side effects of neuroleptic therapy. Discuss the legal rights of clients with mental illness. Target approaches for dealing with aggressive or assaultive persons. State the people most likely to attempt suicide and describe precautions in the acute mental healthcare settings. Discuss nursing responsibilities when working with each of the following: overactive, withdrawn, depressed, hypomanic, regressive, or self-injuring clients.

Terminology Affect Agoraphobic Akathisia Echolalia Anhedonia
Anxiety Assaultive Athetoid Benzodiazepine Bipolar disorder Catalepsy Cognwheeling movement Commitment Compulsion Cyclothermic Decanoate Defense mechanism Delusion Dual diagnosis Dyskinesia Dysthymia Dystonia Echolalia Echopraxia Entitlement Euthymia Extrapyramidal side effects Forensic Functional disorder Grandiosity Hallucination Hypersomnia Hypervigilance Hypomania Intrusive Lability Malingering Mania Milieu therapy Any of these are game for tests. How many do you know????

More Terminology Mood Mutism Neuroleptic
Neuroleptic malignant syndrome Obsession Oculogyric crisis Opisthotonos Organic disorder Orthostatic hypotension Paranoia Perservate Phobia Polydipsic Psychiatrist Psychometric Psychosis Psychotropic Rapport Regression Sally port Schizophrenia Self-esteem Tardive dyskinesia Vulnerable adult Zydis Any of these are game for tests. How many do you know????

Acronyms SA SI SIB SIRS SIW SP SSRI TA TAT TCA TCD TD TDK T-Hold TR
U-Tox VH vol W/D ABR AER AH AIMS ALC AMSIT ANAD A&O X3 AOB AP APA APE AWOL B-52 BDI BPRS CHI CHTCIC CMHC CPMI DCH DISCUS DSM-IV ECR ECT EP EPR EPSE ETOH, EtOH FAI FOI GP HDRS HI HID KELS LOR LSR MAOI MDD MI/CD MI&D MI/MR MMPI MMSE NOS NSAID OCD OD PADS PCA PO PTSD Ψ REBT RT 72 hr/72˚ Any of these are game for tests. How many do you know????

Suppression Repression Reaction-formation Rationalization Displacement
Explain the role of normal defense mechanisms. Describe results when defense mechanisms are overused. Suppression Repression Reaction-formation Rationalization Displacement Denial Projection Sublimation Intellectualization Suppression is consciously inhibiting an unacceptable impulse or emotion. Repression is an unconsciously inhibiting an unacceptable impulse or emotion Reaction-formation is displaying a behavior, attitude, or feeling opposite to that which one would normally exhibit in the situation. Rationalization is trying logically to justify irrational or unacceptable behaviors or feelings Displacement is unconsciously transferring feelings onto another person or object Denial is disavowing the existence of unpleasant realities Projection is attributing to another person one’s unacceptable thoughts or feelings Sublimation is diverting unacceptable urges into personally and socially acceptable channels Intellectualization is unconsciously transferring emotions into the realm of intellect; using reasoning as a means of avoiding confrontation with objectionable impulses

Organic is from a physical disorder such as
Differentiate between functional and organic mental illnesses and list at least five causes of organic mental illness. Organic is from a physical disorder such as endocrine disorder such as the thyroid, Infection Hypoglycemia Overdose Psychoactive drug or alcohol abuse Cerebrovascular disease Brain lesion Conditions such as Huntington’s, AIDS, Alzheimer’s Closed head injury such as from an MVA. Functional mental illness No specific cause is located If organic etiology is found, then it is treated. “Getting lost in Memories. If the person with Alzheimer’s mistakes someone for a person from the past or thinks he is in a different place entirely, allow him the leisure and liberty to take you where he wants you to go. Not all memories are pleasant ones, of course. If, for example, the patient starts crying because she sees a parent in the mirror, acknowledge the issue “”its making you unhappy to see your mother right now, I understand” distract the patient “how about a cookie” and remove the trigger of unhappiness (get rid of the mirror). Happy or not, though, getting lost in memories may indicate that the patient needs to discuss the past – perhaps not at that moment however” (Butler, R. 114).

Psychometric tests Neurologic tests Also called neuropsychiatric
Describe the role of neuropsychological and neurodiagnostic testing in diagnosis mental illness. Psychometric tests Also called neuropsychiatric Include interview such as the brief psychiatric rating scale and the mini mental status exam Neurologic tests Used to rule out organic cause Tests include CT, PET, MRI, TCD, cerebral angiogram, EEG, LP, etc. Psychometric tests -- Often results address mood, senses, intelligence, thought process, as well as orientation to time, person, and place -- Also include personality testing, ink blot tests, memory tests, word association and thermatic apperception -- Minnesota Multiphasic Personality is an example -- Client’s living condition is evaluated as well as the client’s ability to meet their own ADLs such as the Kohlman’s Evaluation of living skills (KELS). -- r/o malingering (faking symptoms to get into or stay in the hospital as well as obtaining medication, or get attention. Neurologic tests

List at least five general symptoms of mental disorder.
Noticeable behavioral changes sudden lack of concern about physical appearance, inability to perform basic ADL less of contact with reality cognitive confusion morbid fascination with death Total immobility or suddenly becoming mute Symptoms include: -- Noticeable behavior changes such as exaggerated feelings, inappropriate responses, unexplained depression or inappropriate elation -- sudden lack of concern about physical appearance, inability to perform basic ADL -- not eating, binge eating, excess fluid intake -- not sleeping or sleeping all the time -- physical symptoms without apparent medical cause -- overuse of defense mechanisms -- less of contact with reality – alerted perception and sensory changes such as watchfulness (hypervigilance), hallucinations, misperception, distorted thinking, difficulty in filtering out irrelevant stimuli, paranoia, delusional thinking -- cognitive confusion – disorientation, thought blocking, loose association, poor abstract thinking, illogical thinking, inability to problem solve, inability to cope with stress, preoccupation, poor concentration, poor memory and speech latency -- morbid fascination with death -- Total immobility or suddenly becoming mute

Describe the diagnostic criteria for a mood disorder.
Major Depressive Episode mood includes five or more present in a 2 week period At least one symptoms must be A: depressed mood most of the day B: anhedonia Four or more additional signs and symptoms must be present Group of clinical conditions characterized by mood (internal, subjective emotional state), along with a loss of control and a subjective feeling or distress. Euthymia means normal mood Anhedonia diminished or loss of interest or pleasure in all, or most activities Four or more additional signs and symptoms must be present from the following list: weight or appetite change Sleep disturbances Psychomotor retardation Fatigue Feelings of worthlessness Diminished ability to think/concentrate Recurrent thoughts of death or suicidal ideation, with or without a plan. Situational depression is cause by a specific event in life such as physical disorders, chronic illness, pain, fear of death, feelings of being overwhelmed Becoming more common in the elderly. Major Depressive Episode mood includes five or more present in a 2 week period and must represent a change from previous functional levels At least one symptoms must be A: depressed mood most of the day B: diminished or loss of interest or pleasure in all, or most activities (anhedonia)

Dysthymia Major Depression
Explain the differences between a major depressive disorder and dysthymia. Dysthymia Must occur at least 2 years Symptoms Major Depression During a 2 week period Symptoms Symptoms of dysthymia Sleep disturbances Appetite changes Decreased energy Low self-esteem Poor concentration Feelings of hopelessness Major Depression During a 2 week period Symptoms appetite changes Loss of energy Diminished ability to think/concentrate Recurrent thoughts of death

Describe the behavioral characteristics of the person with bipolar disorder.
Mood swings from manic to major depression are symptoms which characterized Bipolar. Mania symptoms: Mixed episode of BPD results when symptoms of both a manic and a major depressive episode occur simultaneously for one week. Mood swings from manic to major depression are symptoms which characterized Bipolar. Mania symptoms: Agitation, elation, hyperactivity, and hyperexcitability. Accelerated thinking and speaking Grandiosity (feeling of invincibility and self-importance), distractibility (inability to concentrate), and excessive involvement in pleasurable activities that have a high potential for painful or undesirable consequences. Must be present for at least one week Alternate with depression. Mixed episode of BPD results when symptoms of both a manic and a major depressive episode occur simultaneously for one week.

Paranoid personality disorders. Schizoid personality disorder.
List and describe at least four personality disorders. Describe in detail common behaviors of people with borderline personality disorder. Personality may be of several types and may show more than one at any given time. These range from slight deviations from normal to highly acceptable behaviors. Paranoid personality disorders. Schizoid personality disorder. Schizotypal personality disorders. Histrionic personality disorder Narcissistic personality disorder Avoidant personality disorder Dependent personality disorder When a personality trait becomes dysfunctional, it is described as personality (Axis II) disorder. Must follow a patter of inner experience and outward behavior that deviates markedly from the expectations of the person’s culture. Manifests itself in two or more of the following ways: Cognitive Affectivity (affect is the outward manifestation of subjective emotions) Interpersonal functioning (relationships with others). Poor impulse control; intrusive (interfering) behavior; bizarre behavior Personality may be of several types and may show more than one at any given time. These range from slight deviations from normal to highly acceptable behaviors. Paranoid personality disorders: pervasive distrust and suspiciousness of others; marked hyperviligilance. Schizoid personality disorder: Pattern of detachment from social relathionships and restricted range of emotions in interpersonal settings. Schizotypal personality disorders: pattern of social and interpersonal deficits, marked by acute discomfort with and reduce capacity for close relationships; also includes cognitive or perceptual distortions and behavioral eccentricities Antisocial personality disorder: patterns of disregard for and violation of the rights of others, with no remorse for actions. Borderline personality disorder: pervasive pattern of instability in interpersonal relationships and affect; low self-image; includes marked impulsivity, with displays of self-destructive behavior or self-injurious behavior, self-inflicted wounds, and suicidal gestures. These people often have a history of sexual abuse, are most often female, and are frequently lesbian. They may have frequent hospitalizations and complain of many physical symptoms. Obesity is often present in severely ill people. Histrionic personality disorder pattern excessive emotionality and attention seeking behavior Narcissistic personality disorder pattern of grandiosity, need for admiration, lack of empathy, and sense of entitlement Avoidant personality disorder pattern of social inhibition, feelings of inadequacy, hypersensitivity to negative evaluation; inability to be with others Dependent personality disorder a pervasive and excessive need to be taken care of, leading to submissive, clingy behavior and fear of separation. These people are often difficult and/or frustrating to work with. One reason is many do not see their behaviors and make more stress for others than themselves. Clients response may be defensive.

Borderline personality disorder
pervasive pattern of instability in interpersonal relationships and affect; low self-image; includes marked impulsivity, with displays of self-destructive behavior or self-injurious behavior, self-inflicted wounds, and suicidal gestures. Note: These people often have a history of sexual abuse, are most often female, and are frequently lesbian. They may have frequent hospitalizations and complain of many physical symptoms. Obesity is often present in severely ill people.

Anxiety disorders. Several disorders have panic type symptoms with them. These include: Panic attacks Phobias Agoraphobia Obsessive-compulsive disorder Post traumatic stress disorder Give examples

Describe psychosis and list its most common symptoms.
Marked by definite deviations from normal acceptable behavior. interferes with ability to recognize and deal with reality Interferes with interpersonal communication May include Hallucinations Delusions impaired reality, Can be organic or functional Severely disturbed are said to be acutely psychotic Medical Conditions can also cause psychotic disturbances. Causes may include high fever, infections, neoplasms of the brain, head trauma, AIDS, dementia, tertiary syphilis, pre-existing dementia or electrolyte imbalances. Give real life examples.

List and describe the relationship between substance abuse and mental illness.
Substance induced psychosis has characteristics which may include hallucinations, delusions or other schizophrenic symptoms during drug use or within a month of intoxication or withdrawal. Dual diagnosis is also seen as it is a combination of drug addiction with some form of mental illness. “The degree of psychotic behavior associated with crack use is staggering even to experienced staff members. Severe paranoia is ever-present, magical ideas of mind reading, thought insertion, and grandiosity commonplace, along with violent mood swings and zero impulse control” (Brown, M. 115). Alcohol is a depressant and can make depression work as well as affecting mood swings. Polysubstance are abusers of more than one drug Chemical abuse exacerbates mental illness Alcohol can cause reactions with antipsychotics and other meds. People with mental illnesses can be more sensitive to drugs and sometimes self medicate, not realizing that a mental illness is the cause. Clients are often vulnerable and are easy targets by those who traffic drugs Some faiths, cultures and after care do not believe in medications and thus prohibit well being of those in need of medications which would give them a better quality of life.

Psychiatric techs/certified nurses assistants
Identify the key members of the mental healthcare team and describe their roles. Psychiatrists Nurse Psychiatric techs/certified nurses assistants Human service or mental health workers Psychometrists Recreational therapists Social workers Physicians Cardiologists Volunteers Medical/surgical specialists Interpreters Diabetic or stoma specialists Dieticians Pharmacists Respiratory therapists Laboratory specialists Occupational therapists Speech therapists Pet therapists Give real life examples

Outpatient mental health clinics Psychiatric home care
Describe the outpatient services commonly available for people with mental illnesses. Identify three types of structures living available to clients with mental disorders. Outpatient mental health clinics Psychiatric home care Community outreach programs Telephone services Internet based groups Drop in centers such as the Monarch House Community Based Living Facilities Board and care, licensed group homes and nursing homes The halfway house Sheltered workshops and vocational workshops Mary Ellen Copeland WRAP program. is for teens. The Mission Ashby House Several houses in town.

Admission status Voluntary admit Emergency hold Transportation hold
Discuss the legal categories of admission to the acute mental health-care setting. Admission status Voluntary admit Emergency hold Transportation hold District court hold Assessment hold Court commitment Mentally ill/chemically dependent Mentally ill and dangerous Partial program are for voluntary. Normally outpatient Inpatient Admission status Voluntary admit – person comes voluntarily Emergency hold – place by a physician or psychiatrist for 72 hours which does not include weekend and holidays Transportation hold – placed by police to bring person into the hospital District court hold – placed by a judge before commitment hearing Assessment hold – placed by the person doing the assessment to determine if competent Court commitment – usually to a state, veterans administration, county hospital, or chemical dependency treatment center. Mentally ill/chemically dependent – dual diagnosis both needing treatment Mentally ill and dangerous – commitment to a security hospital

Discuss therapies available to client with mental illness.
Psychotherapy Individual therapy Group therapy verbal and other therapies Behavior modification Remotivation Reality therapy Rational emotive therapy Transactional therapy One to one therapy verbal or other therapies Psychodrama Occupational therapy Recreational therapy/therapeutic therapy Music therapy Pet therapy Play therapy Hydrotherapy ECT Medication therapy

Used for severe depression After medications have been tried and fail
Describe electroconvulsive therapy, indications for its use, and associated nursing implication. Used for severe depression After medications have been tried and fail Consultation done with medical doctor and clearance gotten Commonly used in middle age or older adults (out of those who get this treatment) disadvantages are short term memory loss and anxiety prior to each session

Mood stabilizers, include: Antipsychotics
Identify the most commonly used classifications of medicines in psychiatry. Give at least three examples of each classification. Describe the undesirable side effects of neuroleptic therapy. Psychotropic drugs Mood stabilizers, include: Antipsychotics Anti-anxiety (CNS depressants) Mood stablizers Antidepressants 20% of people on antipsychotics result in TD or tardive dyskinesia. (1587) EPSE (extra-pyramidal side effects) can feel life threatening to the patient, often the dosage is lowered. Symptoms can include (parkinson type movements, restlessness and akathisia, dykinesia, opisthotonos, oculogyric crisis, orthostatic hypertension, dystonica, cognwheeling movements, and tardive dyskinesia) Neuroleptic malignant syndrome is a rare complication (20 -25% mortality rate) treat symptoms early. Page Common cause of death is respiratory or renal failure as well as pulmonary embolism). Psychotropic drugs Mood stabilizers, include: antipsychotics, also known as neuroleptics such as haldol, thorazine, prolixin, trilafon, Used for positive symptoms such as hallucinations, paranoia, delusions, severe agitation, combativeness and feelings of unreality. Work the brains postsynaptic dopamine receptors Antipsychotics treating negative symptoms such as apathy, social and emotional withdrawal and poor hygiene and lack of insight and judgment utilize zyprexa, clozaril, and risperdal Side effects include agranulocytosis, EPSE, and Tardive Dyskinesia Anti-anxiety (CNS depressants) such as benzodiazepines, barbituates, and buspar for example. Disadvantage is they cause depression or worse depressive symptoms Mood stablizers such as Lithium, anticonvulsants used as mood stabilizers such as tegretol and depakote Antidepressants, such as SSRI and MAOI, tricyclics, and other non-MAOI. SSRI and non-MAOI are the most common.

Discuss the legal rights of clients with mental illness.
Civil rights -- equal rights for everyone, can refuse tx, unless by a court order Vulnerable adult legislation – to protect those who cannot protect themselves such as the mentally and intellectually impaired Advocacy – employ counselors or advocates (ombudspersons) who advise people about their rights Prevention of dehumanization – all members must follow the same rules, maintain their individuality, treated with dignity, encourage participation to achieve quality of life and best outcomes

Target approaches for dealing with aggressive or assaultive persons.
Security needed to protect the patients from harming themselves and others (including other patients and personnel) Injuries such as self-mutilation, scratching, cutting, biting, burning or beating, suicide attempts, throwing objects, using environmental or medical equipment as weapons Restraints and client safety devices Emergency chemical restraints (B-52 aka Texas cockteil, etc.) Emergency restraints -- wrists, poseys, leather, four post cuffs Tabs alerts Mattress alerts Activity vests Seclusion Locked down room, some have straps for the walls, others only a mattress type covering for walls and floors Use examples of real life.

Depressed, especially those who become well extremely fast
State the people most likely to attempt suicide and describe precautions in the acute mental healthcare settings. Depressed, especially those who become well extremely fast Teenagers and seniors have the highest risks Women attempt more than men but men are more violent in their attempts A person who has tried to complete a suicide before Other mental illnesses with depression such as a psychosis Poor support system Physical illness – chronic and noncurable Personality disorder patients related to high risk activity and high risk rescue Give examples.

Self-injuring patients
Discuss nursing responsibilities when working with each of the following: overactive, withdrawn, depressed, hypomanic, regressive, or self-injuring clients. Overactive Withdrawn Depressed Hypomanic Regressive Self-injuring patients Overactive – limit stimulation, calm, soft voice, avoid long discussions, avoid forcing issues, set consistent limits and boundaries and prevent from harm, may use working out or physical activity as well as prn RX to assist with calming Withdrawn – monitor closely, check on patient for safety, encourage meals, provide cheerful atmosphere, encourage participation, include one to one person, give two choices only to avoid confusion Depressed – same as withdrawn Hypomanic – minimize stimulation, offer adequate food and water, encourage good moth and skin care, do not force groups Regressive – reteach basic social skills, stimulate interest in current events, encourage self-respect, be alert for violent outburst and suicide attempt Self-injuring patients, monitor carefully, ask if patient has a plan to harm or for suicide, consider every threat, document, constant supervision and undemanding emotional support

Substance Abuse Chapter 94

Chemical Abuse and Dependency
Abuse definition from the APA includes patterns and time frame Dependence also called substance dependence has signs and symptoms of abuse plus more during the same time frame. Declared as disease in the 1950s Causes include: Physical Genetic Emotional and psychological Dual disorder Definition of substance abuse is “a maladaptive pattern of substance use leading to clinically significant impairment or distress” with one or more of the following in a 12-month period (direct from text page 1610). Failure to fulfill role obligations (work, school, home) Use that presents a danger (while driving or use of heavy machinery for example) Recurrent use causing or resulting in legal problems (DWI, disorderly conduct) Continued use despite related interpersonal problems. Chemical dependence occurs within a 12 month frame Tolerance – needs more of the drug for the same effect Withdrawal – symptoms occur when the substance is stopped. The person takes more than planned or for longer than planned Unable to cut back or stop but wants to Spends energy to get the drugs (including illegal activity) The person gives up formerly important activities such as family, entertainment, etc for drug use The person continues to use even though he/she is aware of the difficulties with the drug Often has difficulties with impulsive activities such as gambling, Chemical dependence is classified as (and will worsen, becoming fatal if uncontrolled) Active In remission In therapy with blocking / agonist In a controlled environment Causes: Physical factors – caused by larger doses, possibly dietary factor (being looked at in alcoholism), endocrine (such as that in diabetes) is present, or an allergic response (it affects them differently), to feel better, or to escape Genetic factors. – may be more learned than genetic, although with examples such as alcoholism there may be a link. This is still being addressed. Emotional and psychological – could be associated with low self-esteem, difficulties with relationships, dis-satisfaction with life, low tolerance for frustration, tendency towards excessiveness or self-destructive acts, co-existing mental disorder. Unclear if it is a result or cause of the drug use. Dual disorders – this is a mental disorder plus a substance abuse issue.

Chemical dependence Nature Management
Progressive (see page 1611 figure ). Defense mechanism Management Recognition Intervention Treatment Recovery Progressive has three steps Allows person to feel better about him/herself, used to escape Keeps a person from feeling bad, but at this point it does not make them feel good anymore The person finds that the substances causes illness or intoxication. Blackouts occur. Can be life threatening. Need to take actions at this point. Defense mechanism Denial “not me, don’t do that, who said that, just imagining it” Rationalization “I still work daily, It is only on weekends, I can control it” Projection “I wouldn’t drink if it were not for (job, person, situation) Management Recognize it. Usually someone else sees it Intervention – need to actively intervenes or it will get worse Treatment is needed, sometimes something may cause the person to see what is happening and they stop on their own, but support is needed. Treatment for health, social and relationships are usually needed. Recovery can lead to a successful or productive life. 12 steps is an example.

Nursing Care Measures Identify the person
Assessment (p.1613 for nursing process 94-1) Dealing with a person under the influence in the healthcare facility Detoxification Motivation for CD treatment The detox center The therapeutic community Intermediate treatment for CD Withdrawal sxs (see Table 94-1) 45% of patients receiving general medical care have a substance abuse problem, majority is alcohol 33% + of emergency dept. admits can be traced or related to substance/alcohol abuse 20% of acute hospitalizations are also related. Many people are admitted under different dx since some insurances won’t cover it MVA, depression, pancreatitis, cirrhosis and liver disorders, GI problems, HA, Cardio difficulties Identify the chemically dependent person. Do not stereotype. \ Assessment includes talking to the patient and family. Be weary of sudden symptoms. Day surgery, ED, L&D, as well as others may have withdrawal sxs. Report important information to the person doing the nursing care plans. Remember questions must include alcohol intake, frequency, last drank, how often, how much, what type. Use open ended questions “tell me about your drinking?” Ask about coping mechanisms… how do you cope with stress? Pain? Do you combine alcohol or drugs with your medication? How much does it cost? When did you use last? What is your drug of choice? Ever had problems with withdrawal? Seizures? Do you/have you ever inhaled, shot up, smoked drugs? Dealing with a person under the influence in the healthcare facility This can be a challenge - Anticipate any and all behaviors - Thorough history required - Last use and every had withdrawal sxs Doctor may order blood and/or urine tests for legal, OTC, and illegal. Detox and recovery Detox is removing the drug and the effects from the body Manage comfort and safety Treatment depends on the substance Detox must occur before long term treatment Motivation What is the reason? Family, finances, court ordered, license, health, freedom. Abstinence is the only sure method Often angry if sent by court. Desire may not be there. Peer pressure is a factor. Detox center Often transported by the police Desire to quit may be weak Done under medical supervision Therapeutic community They are isolated substance-oriented community Lifestyle changes are hard for some Recovery has various organizations (AA, NA, Inpatient and outpatient setting) Clients assigned reading to help them Sometimes group therapy Some are gender specific, smoking vs non-smoking Goal is to address physical and emotional problems associated with this When they have completed their goals, they may then be ready for recovery Intermediate tx for CD Blood work looks at body functions such as liver, kidney, and thyroid Looks for vitamin deficiency, lipids, uric acid and enzyme levels Urine toxicology may show what drugs are in the system Some are med seeking and ask for meds to treat sxs they do not have. The sxs may include n/v, tremors, diaphoresis, anxiety, agitation, hallucinations, HA, confusion Pts with brain damage, CHF, dyspneic, elderly, have varices (enlarged blood vessels in esophagus) Reassess them more frequently when detoxing. Withdrawal sxs Occurs once substance is not entering the body Severity depends on what was used, how much, how long used, previous withdrawal, health and nutritional status Detoxing can be fatal Nutrition and general health Look at if patient is malnourished Liver function test to see if damage has occurred GI eval to r/o ulcers, diverticulitits, esophageal varices, or colon cancer Monitor weight if indicated Vitamin supplements may be ordered Refeeding syndrome If severely malnourished, rehydrate slowly Watch carefully and do not overload with carbs r/t sugars can cause sudden increase in insulin and other which could further damage the electrolyte imbalance. See care guidelines on page 1620. See pages 1617 – 1619

Nursing Care Measures Long-Term Follow-Up and Treatment
Inpatient or outpatient After-Care Extreme discomfort caused by the withdrawal process may motivate the patient to continue with treatment. There could be more than one substance (polysubstance dependence) In or out patient Client’s attitude, family support, insurance coverage, and client’s work and personal situation often dictate which type of treatment will work or can be done. 12 steps – such as AA is outpatient. Rationale recovery – albert ellis rationale emotive behavioral therapy is based on the belief that the person’s values and belief system controls behavior Family counseling can be helpful because individual may not be enough. The environment may be needed to be altered in order to maintain a drug free living. Person needs encouragement and support Family needs to know how to help support Characteristics of the alcohol family may include Control – the alcoholic controls the family Perfection or rigidity – everyone trying too hard Mistrust of others Tension or overly cheerful and social behavior that seemed forced. Constant cover for real feelings Overuse of mechanisms, such as projection, rationalization, and denial Young people raised in these families have problems with self-esteem, feelings of failure, and a sense of responsibility to care for everyone else. Some people think they are responsible for their parents actions. Adult children of alcoholics are often depressed or suicidal. Codependent or enabler is the one who lets someone elses behavior affect him/her. The spouse of an alcoholic will try to keep the family together, is the one who drives off those to defend the drunk, lies for him and denies the problem. After care – plan for follow up is very important. Continuing in AA or NA groups well after sobriety is achieved is an important step to maintaining the corrected lifestyle.

Alcohol Abuse and Dependence
SXS Specific disorders caused by alcohol abuse Dietary deficiency Wernicke-Korsakoff syndrome Cirrhosis of the liver and hepatitis Other disorders Treatment Stages of withdrawal Family considerations Medication therapy Alcohol = ETOH or EtOH, which contributes is a major public health issue. 100,000 deaths (5% of all deaths) are alcohol related, often from MVA MADD DARE SXS CNS depressant Sxs include slurred speech, unsteady gait, confusion, behavioral changes Chronic abuser may have a swollen nose, prominent or spidery veins and thickened reddened palms Chronic use can lead to dementia, amnesia, sleep disorders, and psychotic sxs including delusions and hallucinations They are also at “major risk” for suicide BAL = 0.08 to 0.10 grams per deciliter is max legal limit in most states May need breathalizer and/or blood alcohol test in order to determine the levels. 0.3 g/dL usually cause vomiting, incoherant, aggressiveness, or stupor 0.4 g/dL may result in a coma 0.5 g/dL may cause severe respiratory depression and death Routine blood work looks at liver enzymes AST (1622) aspartate transaminase ALT (alanine transaminase) LDH (lactice dehyrogenase) ALP (alkaline phosphatase) GGTP/SGGT Ÿ-glutamyl-tanspeptidase/serum Ÿ-glutamyl-transferase GGPT/SGGT is elevated in 75% of chronic alcoholics Thiamine and folic acid levels are usually low RBC is often low as well Hypoglycemia is seen usally Malnutrition may be evident Specific disorders Dietary deficiency -- primary absorption of alcohol is in the small intestine therefore absorption of other nutrients may be impaired. Vitamin B1 or thiamine and B2 (folic acid, folate) Untreated thiamine deficiency causes a severe neurological disorder – Wernicke-Korsakoff syndrome (WKS) symptoms include dementia, hallucination, diplopia (double vision), ataxia, somnolence (extreme sleepiness), stupor, and horizontal nystagmus (rapid eye movement, in this case side to side). Ocular sxs may be reversed but often dementia and ataxia are irreversible. Mortality rate in WKS is as high as 15%. Cirrhosis of the liver and hepatitis – cirrhosis is chronic interstitial inflammation associated with chronic alcholism (Laennec’s cirrhosis). Acute alcoholic hepatitis with fever and dehydration sometimes referred to as ARLD (alcohol related liver disease) Liver is crucial to the person’s existence, so restoring it to its maximum health is imperative. Other disorders Esophageal varices and bleeding, cancer of the mouth and esophagus, gastritis, gastric ulcers, and other GI disturbances: kidney disorders, and heart disorders, included CAD. Sexual impotence is common Newborns of alcohol abusing mothers often born with FAS Treatment Treatment is complex. Medications may be given to assist the patient and maintain sobriety. Antabuse can not be mixed with alcohol. It has three distinct stages Stages include Autonomic hyperactivity – elevated pulse (>100), nervousness, restlessness, and psychomotor agitation (see page 1623). Anxiety, sleep disturbances, irritability, diaphoresis, flushed face, anorexia, and nausea (also copious vomiting followed by dry heaves). Tremors, hand are the first. Stage one often occurs within hours after the last drink. Neuronal excitement is the second stage. It includes severe tremors, panic, insomnia, and increased agitation. May include severe transient hallucinations such as “drowning while drunk” or auditory hallucinations. Paranoia may occur. High risk for suicide. This stage often occurs within hours after the last drink. Sensory-perception disturbances is the third stage. Sxs include vivid visual hallucinations. Generalized tonic-clonic seizures, severe agitation, panic which lead to confusion and coma. “Death may occur during a seizure or due to exhaustion”, . This state is a medical emergency with a mortality rate of 25%. Often occurs within 3-4 days after the person’s last drink. DTs include vivid and terrifying auditory, visual and tactile hallucinations. It is called alcohol hallucinosis (bugs crawling on the skin). May last for a few days to a few weeks. Tachycardia ( ), fever ( ) and seizures may be present. Death may occur during these. Uncomplicated withdrawal may take 3-7 days. Medication therapy Antabuse – disulfiram, cronetal is sometimes used as aversion therapy or adverse conditioning unable to remain sobriety. Oral does 500mg daily for two weeks followed by 250mg daily (see page 1624). Antabuse causes building of acetaldehyde by blocking the oxidation of alcohol. Causes flushing, throbbing headache, nausea, hypotension or fluxtuating blood pressure, violent vomiting, diasphoresis, thrist , anxiety dizziness, weakness, and confusion. Severe reaction – resp. depression, cardiovascular collapse, heart attack, seizures, coma and death can result. There are disease which contraindicate the use (page 1624) Naltrexone – trexan, ReVia Blocking agent used to treat opioid abuse. Reduces subjective effects of alcohol so they don’t enjoy it. Not to be used with those with hepatitis.

Abuse other than alcohol
Sedatives Hypnotics Anxiolytic drugs GHB Cannabis related Narcotics CNS Stimulants Anabolic steroids Caffeine OTC Therapies Agonist and drug replacement therapy Marijuana and cocaine are more common than heroin. Heroin is on the rise. Sedatives Barbituates – amobarbital (Amytal), butabarbital (Butalan), mephobarbital (Mebaral), Nembutal (pentobarbital), Luminal (phenobatbital), Seconal or “reds” (secobarbital), etc. Benzodiazepines – xanax, librium, valium, ativan, serax Other abused drugs – chloral hydrate, ambien, atarax, vistaril, GHB, meprobamate (Miltown, Equanil), These drugs are broken down in the liver. Can make liver damage worse. Can cause physical depression, nystagmus, coma, stupor, and memory damage. The psychological side effects can include delirium, amnesia, hallucination, mood or anxiety disorders or permanent dementia. Overdose is a danger of these r/t resp. depression. Potential of physical and psychological dependence. Withdrawal of these drugs must be done gradually. Overdose and sudden withdrawal may be cause for hospitalization. Antidote for overdose is flumazenil (Romazicon). Hypnotics Anxiolytic drugs GHB (gamma hydroxybutyrate) Newer street drug, known as date rape drug “G” is liquid ecstasy, not the same as ecstasy Is colorless and odorless and tasteless Is in some dietary supplements Active ingredient is furanone or lactone Decreases inhibitions, often causing amnesia Death may occur even with first time use GBL and 1,4 BD, made before GHB are sold as cleaners on the internet. Sale, possession and use is illegal Symptoms of abuse include lability, from combativeness from somnolence, facial tics, nystagmus, snoring, hypothermia, urinary/fecal incontinence, bradycardia, n/v, seizure activity and death. Withdrawal may look like DTs with alcohol withdrawal but vital signs are often normal or only slightly elevated. Withdrawal begins 2-5 hours after the last dose. Early withdrawal may include anxiety, diaphoresis, tachycardia, hypervigilance, hypertension, paranoia, and severe insomnia. They may progress to severe withdrawal with extreme agitation and combativeness, hallucinations, paranoia and delirium. Coma and somnolence may also occur. Wakening from coma can cause an emergence delirium. Withdrawal symptoms may last 7-12 days and may be fatal. Cannabis related Active ingredient is THC or tetrahydrocannabinol From the hemp plant and classified as hallucinogens Preparations include bhang, ganja, marijuana (Mary Jane), pot or week and hashish Usually dried and smoked Hashish is more potent and is smoked or chewed usually Marijuana cigarettes dipped in formaldehyde “wets” often cause permanent brain damage Side effects include “dreamy state”, altered perception of space and time, poor motor coordination, hunger, nausea and dry mouth Intoxication include delirium, delusions, hallucinations, anxiety or panic Although not proven to cause the use of harder drugs, many people who use harder drugs use marijuana previously Can cause physical and psychological addiction Withdrawal sxs may start as soon as 12 hours from last use but more often 1 week after last use and may include diarrhea, “wet dog” shakes, excessive salivation and yawning, drooping eyelids, restlessness, irritability, insomnia, runny nose, hiccups, anorexia, hot flashes and mild flu like symptoms. Not usually life threatening. Is used as a tx for cancer treatment in the form of Marinol, but may make schizophrenia, bipolar, HTN, and cardiovascular disease worse. Dronabinal (Marinol) usually is locked up and refrigerated. Narcotics highly addictive substances Intoxication include drowsiness and coma, slurred speech, decreased memory and attention span, decreased respiration, dysphora, and depression. Persons using this are at risk for suicide. Withdrawal sxs are less dangerous than barbiturate or alcohol withdrawal and resemble that of cold or allergy. Narcan is given for overdoses of narcotics. These include: heroin, opium, methadone, stadol, dilaudid, talwin, and codeine. Opiates -- Trexan – blocks the brain’s opiate receptors, may cause liver damage. Re-addiction is possible. Methadone – treatment for opiate addiction, suppressed opiate symptoms for hours, Orlaam – long acting synthetic opioid against, taken 3x weekly. Oral liquid only 10mg/mL. not used at home, but at state approved facilities only. It is diluted before administration. SE include palpitation, fainting, abdominal pain, diaphoresis, nervousness, sexual dysfunction and cough. Effects build over time. Can be fatal in overdose. CNS Stimulants Include amphetamines, cocaine, and hallucinogens Amphetamines are mood elevators and appetite depressants, combat drowsiness and simple fatigue. Abuse sxs include confusion, anger, poor judgment, irritability and blunted affect or euphoria. Withdrawal usually causes depression, paranoid psychoses and requires hospitalization. Hypervigilence, paranoia, insomnia or hypersomnia, increased appetite and psychomotor changes. These abusers have been known to alternate them with sedatives. Cocaine and related drugs come from the coca plant. Derivatives include crack, crank, and rock. If snorted can cause a perforated nasal septum. Can cause fetal damage during pregnancy. It is an expensive habit. Violent crimes are related to the use of cocaine. Withdrawal may need ICU or special duty nurse. Hallucinogens – are not known to cause actual physical dependence, but produce psychological dependence. Three types: traditional psychedelics such as LSD or PCP, sodium pentothal, an anesthetic Amphetamine like drugs like DOM, MDA;MDMA; GBA Anticholinergics such as belladonna, methantheline bromide, and scopolamine Volatile substances are CNS depressants that when inhaled caused altered states of consciousness and various degrees of intoxication, such as those caused by huffing vapors from helium balloons or aerosol cans. Anabolic steroids Derived from male hormone, testosterone Promote growth of skeletal muscles and increase lean muscle mass Abused primarily by athletes Used intermittently (cycling) Liver damage and cancer can be results of usage as well as endocrine and sexual dysfunction The can become emotionally volatile with paranoia and mood lability. Some of these are withdrawal sxs. Death can occur due to endocrine imbalances, MI or stroke. Relapse is common. Nicotine Is a substance cigarettes and in chewing and other tobaccos. One of the most addictive drugs available. Nicotine contributes to or cause cancer, heart, and blood vessels disorders and congenital disorders, as well as other physical disorders. The Surgeon general’s warning is on the side of cigarettes packages. Withdrawal causes dysphoria and depression, as well as insomnia, irritability, restlessness, and anxiety. HR decreases and the person often feels hungry and gain weights. Free or low-cost local and national self-hellp programs. Caffeine Found not only in coffee, but also in tea, some alcoholic beverages, soft drinks (colas, diet colas, root beer, and surge, mello yellow, and mountain dew), and chocolate. Caffeine is also a component of many OTC and prescription analgesic preps such as excedrin, fiorinal, anacin, norgesic, vanquish, and cope. Ergotamine and caffeine are combined as Ercaf or Caffergot for migraines. Caffeine is also sold OTC as NoDoz and Vivarin. Sometimes it is medically as a CNS stimulant and to treat newborn apnea. (see page 1630 for caffeine amounts in common substances). It acts directly on the blood vessels and dilates them. Is a mild stimulant and diuretic. 200 to 300 mg of caffeine partially sets off fatigue. It increases attention and helps with boredom. Overuse includes restlessness, nervousness, agitation, insomnia, flushed face and GI discomfort. Does not reverse alcohol intoxication or depression effects and may add to depression. At 500mg or higher, heart rate increases, and can become irregular. A small amt can make a person fall asleep and interfere with normal sleeping patterns. Research is ongoing to evaluate potential adverse effects. Dependence is a physical reality. Notable withdrawal sxs are tiredness, severe headache, and irratibility. OTC Medications and herbal preparations can be purchased. Self-medication can be dangerous Adequate nutrition and attention to proper rest, sleep and activity are usually enough to maintain health and prevent discomfort.

Special abusers Pregnant women Adolescents Older adults Nurses
Pregnant women – drug, nicotine or alcohol use greatly complicates pregnancy, labor and delivery with profound on both mother and baby. Babies born to drug or alcohol abusing mothers are often low birth weight, with related problems. Preterm labor is common. Heroin withdrawal sxs in a new born occurs hours after delivery; most show sxs within 24 hours. Cocaine and crack addicted babies continue to increase. Adolescents -- is a serious problem among adolescents and school age children. Peer pressure and low self-esteem are common problems in these age groups. Potent forces contribute to chemical abuse. Cigarette smoking alcohol use are also on the increase among adolescents. Older adults Many older adults take large amts of prescription and OTC rx. The senior may accidentally take a double dose of rx. May seniors also overdose on meds such as cathartics and antacids. No unusual for pts to change their own meds without telling their doctor. May take meds to get away from loneliness depression, health problems feelings of loss or hopeless or financial difficulties. Suicide attempts with meds and/or alcohol are not uncommon. Alcohol abuse is very common. Dangerous when mixing with meds. Interactions with meds need to be taught and accurate are data collection is very important. Nurses Nurses are at risk for substance abuse. 50% are more likely to become chemically dependent that the rest of the population Bound by law, nursing code of ethics, and pledge taken on entering nursing to report any suspect of abusing drugs or alcohol. Reporting is necessary to assist others to get help and to protect clients with whom abuser might come in contact. The safe care of all clients rests in the nurse’s hands.

References Rosdahl, C. B., (2003). Textbook of basic nursing, 8th edition. Lippincott, Williams, & Wilkins. Butler, R. N., (2003). Learning to speak Alzheimer’s: A groundbreaking approach for everyone dealing with the disease. First Mariner Books 2004. Brown, M. (1992). Nurses, the human touch. Random House.

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