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Substance abuse rf order 5


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Mental Health Fall '12

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Substance abuse rf order 5

  1. 1. Renee Franquiz MSN, RN
  2. 2.  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 alcoholSource: Dept of Health and Human Services)
  3. 3. 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 toinformation (internet), result of Rx treatment
  4. 4.  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.
  5. 5.  Definition  DSM-IV Criteria (1 of the  Touse in a following in the past 12 wrong or months) harmful way  Failure to fulfill role obligations  Physical hazard/Injury  Legal Issue(s)  Behavior continues despite an awareness that there is a problem
  6. 6.  Definition  DSM-IV Criteria (3 of  Compulsive chronic the following in the requirement where the past 12 months) need creates distress if  Tolerance unfulfilled  Withdraw Symptoms  A desire to Decrease  Often involves  Unsuccessful attempt to tolerance – which is an habituation – the decrease increasing need for  Increase time spent in greater amount or more pursuit frequency  Sacrifice personal Involvements  Behavior continues despite an awareness that there is a problem
  7. 7.  Physiological Biochemical– 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
  8. 8.  Psychological Developmental – 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
  9. 9.  Social  Learned– 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
  10. 10.  Reasons for use –  PLEASE REVIEW previously covered  ATI pages 154-157  Intended and Toxic effects Significance  This is material that ¼ all ER admits are will be tested on the substance related exam  1/3 of all suicides are substance related  ½ of all Homicides are substance related
  11. 11.  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
  12. 12.  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?
  13. 13.  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
  14. 14.  Assessment Tools  Please familiarize yourself with these tools  Textbook  MAST (Michigan Alcohol Screening Test)  CIWA (Clinical Institute Withdraw Assessment)  ATI  MAST (As Above)..MAST.pdf  Addiction Severity Index ..Addiction Severity Index.pdf  Recovery Attitude and Treatment Evaluator (unable to provide d/t copyright – for purchase only)  Drug Abuse Screen Test (DAST)..DAST.pdf  CAGE-AID..CAGE-AID.pdf
  15. 15.  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!
  16. 16.  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
  17. 17.  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
  18. 18.  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
  19. 19.  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  Clientswith similar diagnosis meet under the supervision of a professional to discuss issues  Inpatient or Outpatient
  20. 20.  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
  21. 21.  Increased time in abstinence Decreased denial Acceptable occupational functioning Improved family relationships Ability to relate to other individuals
  22. 22.  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