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: 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 toinformation (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.
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
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
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
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
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
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
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 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
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 Clientswith 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