6. Describe relevant outcome criteria for evaluating nursing care of clients with substance-use

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1 BAPTIST HEALTH SCHOOL OF NURSING NSG 3037: PSYCHIATRIC-MENTAL HEALTH NURSING THERAPEUTIC INTERVENTION AND RESOURCE MANAGEMENT: SUBSTANCE ABUSE, CODEPENDENCY, AND IMPAIRED NURSE Sheryl F. Banak, MSN, RN 2007 Q1 LECTURE OBJECTIVES: 1. Define abuse, dependence, intoxication, and withdrawal. 2. Discuss the predisposing factors implicated in the etiology of substance-related disorders. 3. Identify symtomatology and use the information in assessment of clients with various substanceuse disorders and substance-induced disorders. 4. Identify nursing diagnoses common to clients with substance-use disorders and substance-induced disorders, and select appropriate nursing interventions for each. 5. Identify topics for client and family teaching relevant to substance-use disorders and substanceinduced disorders. 6. Describe relevant outcome criteria for evaluating nursing care of clients with substance-use disorders and substance-induced disorders. 7. Discuss the issue of substance-related disorders within the profession of nursing. 8. Define codependency and identify behavioral characteristics associated with the disorder. 9. Discuss treatment of codependency. 10. Describe various modalities relevant to treatment of individuals with substance-use disorders and substance-induced disorders. READING ASSIGNMENT: STUDY TIPS: 1. Townsend, chapter Townsend Pocket Guide, Chapter 4 1. COMPLETE ALL of the READING ASSIGNMENTS. 2. USE the OBJECTIVES as study questions. 3. REALIZE that, when you are studying, you are studying for: a. THIS TEST b. HESI c. N-CLEX d. EXCELLENCE in YOUR NURSING PRACTICE 4. Study REVIEW QUESTIONS at the end of the CHAPTER. 5. NOTE: TEST QUESTIONS are derived from READING ASSIGNMENTS AND LECTURE. 6. Study related material from NCLEX-RN Exam Review Book 7. DEFINE words in VOCABULARY LIST at beginning of chapter; most are in the glossary.

2 Q2 LECTURE OUTLINE: I. Introduction A. Two groups 1. Substance-use disorders a. Abuse b Dependence 2. Substance-induced disorders a. Intoxication b. Withdrawal c. Delirium d. Dementia e. Amnesia f. Psychosis g. Mood disorder h. Anxiety disorder i. Sexual dysfunction j. Sleep disorders B. Some illegal substances accepted in various degrees by subcultures in society II. Substance-use disorders A. Substance abuse. DSM-IV-TR criteria for substance abuse: 1. Recurrent substance use resulting in failure to fulfill major role obligations at work, school, home 2. Recurrent substance use in physically hazardous situations 3. Recurrent substance-related legal problems 4. Continued substance use despite persistent/recurrent social/interpersonal problems caused/exacerbated by effects of a substance B. Substance dependence 1. Physical dependence is manifested by a. The need for increasing amounts of substance t produce desired effects b. Syndrome of withdrawal with cessation of substance 2. Psychological dependence: Overwhelming desire to repeat use of a particular drug to: a. Produce pleasure, or b. Avoid discomfort 3. DSM-IV-TR criteria a. Evidence of tolerance, defined by either (1) Markedly increased amounts of substance to achieve intoxication or desired effects, or (2) Markedly diminished effect with continued use of same amount of substance b. Evidence of withdrawal symptoms, as manifested by either (1) The characteristic withdrawal syndrome for the substance, or (2) The same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms. c. The substance is often taken (1) In larger amounts than intended (2) Over a longer period than was intended d. Persistent desire/unsuccessful efforts to decrease/eliminate substance use e. Much time is spent in activities to (1) Obtain substance (2) Use substance, or (3) Recover from substance s effects

3 f. Substance use results in reduced or elimination of important (1) Social activities (2) Occupational activities (3) Recreational activities g. Substance use is continued despite the person s knowledge that the substance has most likely caused/exacerbated a (1) Persistent or recurrent physical problem, or a (2) Persistent or recurrent psychological problem Q3 III. IV. Substance-Induced disorders A. Substance intoxication DSM-IV-TR: 1. The development of a reversible substance-specific syndrome caused by recent ingestion of (or exposure to) a substance. 2. Clinically significant maladaptive behavior or psychological changes due to effect of a substance on the CNS and develop during or shortly after use of the substance. 3. The symptoms a. are not due to a general medical condition, and, b. are not better accounted for by another mental disorder. B. Substance withdrawal DSM-IV-TR criteria: 1. The development of a substance-specific syndrome caused by the cessation of (or reduction in) heavy and prolonged substance use. 2. The substance-specific syndrome causes a. clinically significant distress, or b. impairment in social, occupational, or other important areas of functioning. 3. The symptoms a. are not due to a general medical condition, and, b. are not better accounted for by another mental disorder. Classes of Psychoactive Substances A. Alcohol B. Amphetamines and related substances C. Caffeine D. Cannabis E. Cocaine F. Hallucinogens G. Inhalants H. Nicotine I. Opioids J. Phencyclidine and related substances K. Sedatives, hypnotics, anxiolytics V. Predisposing factors A. Biological 1. Genetics. Apparent hereditary factor, esp with alcoholism. 2. Biochemical. Alcohol may produce morphine-like substances in the brain; responsible for alcohol addiction. B. Psychological 1. Developmental influences. Focus is on a. a punitive superego, and b. fixation at the oral stage of psychsocial development. 2. Personality factors. a. Personality traits suggested to play a part in tendency toward addictive behavior 1) Low self-esteem 2) Frequent depression

4 Q4 3) Passivity 4) Inability to delay or defer gratification 5) Inability to communicate effectively C. Sociocultural 1. Social learning. a. Increased child and adolescent use w/parents who use; modeling. b. Substance use promoted in peer groups. 2. Conditioning. Pleasurable effects from substance use act as positive reinforcement for continued use. 3. Cultural and ethnic influences. Some cultures more prone to substance use than others. VI. The Dynamics of Substance-related Disorders A. Alcohol abuse and dependence 1. A profile of the substance. 2. Historical aspects. 3. Patterns of use/abuse: a. Phase I. Prealcoholic phase. b. Phase II. Early alcoholic phase. c. Phase III. Crucial phase. d. Phase IV. Chronic phase. 4. Effects on body: a. Peripheral neuropathy b. Alcoholic myopathy c. Wernicke s encephalopathy d. Korsakoff s psychosis e. Alcoholic cardiomyopathy f. Esophagitis g. Gastritis h. Pancreatitis i. Alcoholic hepatitis j. Cirrhosis of the liver: 1) Portal hypertension 2) Ascites 3) Esophageal varices 4) Hepatic encephalopathy k. Leukopenia l. Thrombocytopenia m. Sexual dysfunction B. Alcohol intoxication 1. Occurs with blood levels of mg/dL C. Alcohol withdrawal 1. Occurs within 4-12 hours of cessation of (or reduction in) heavy and prolonged alcohol use. D. Sedative, hypnotic, or anxiolytic abuse and dependence 1. A profile of the substance: a. Barbiturates b. Nonbarbiturate hypnotics c. Antianxiety agents 2. Historical aspects 3. Patterns of use/abuse

5 4. Effects on body: a. Effects on sleep and dreaming b. Respiratory depression c. Cardiovascular effects d. Renal function e. Hepatic effects f. Body temperature g. Sexual functioning E. Sedative, hypnotic, or anxiolytic intoxication 1. Intoxication with these CNS depressants ranges from a. disinhibition and aggressiveness, to b. coma and death (with increasing amounts of drug) F. Sedative, hypnotic, or anxiolytic withdrawal 1. Onset of symptoms depends on half-life of the drug from which withdrawing. 2. Severe withdrawal from CNS depressants can be life-threatening. G. CNS stimulant abuse and dependence 1. A profile of the substance. a. Amphetamines b. Nonamphetamine stimulants c. Cocaine d. Caffeine e. Nicotine 2. Historical aspects 3. Patterns of use/abuse 4. Effects on body: a. CNS effects b. Cardiovascular/pulmonary effects c. Gastrointestinal and renal effects d. Sexual functioning H. CNS stimulant intoxication 1. Amphetamine and cocaine intoxication causes: a. Euphoria b. Impaired judgment c. Anxiety d. Changes in vital signs e. Nausea and vomiting f. Psychomotor agitation g. Muscular weakness h. Respiratory depression i. Cardiac arrhythmias j. Confusion k. Seizures l. Dyskinesias m. Dystonias n. Coma 2. Caffeine intoxication usually occurs after consumption of 250mg a. Most common symptoms: 1) Restlessness 2) Insomnia Q5

6 Q6 I. CNS stimulant withdrawal 1. Amphetamines and cocaine a. Dysphoria b. Fatigue c. Sleep disturbances d. Increased appetite 2. Caffeine a. Headache b. Fatigue c. Anxiety d. Irritability e. Nausea and vomiting 3. Nicotine a. Dysphoria b. Anxiety c. Irritability d. Difficulty with concentration e. Restlessness f. Increased appetite J. Inhalant abuse and dependence 1. A profile of the substance a. Aliphatic and aromatic hydrocarbons b. Examples 1) Gasoline 2) Varnish remover 3) Lighter fluid 4) Airplane glue 5) Rubber cement 6) Cleaning fluid 7) Spray paint 8) Shoe conditioner 9) Typewriter ribbon correction fluid 2. Patterns of use/abuse 3. Effects on the body a. CNS effects b. Respiratory effects c. GI effects d. Renal system effects K. Inhalant intoxication 1. DSM-IV-TR definition: Clinically significant maladaptive behavioral or psychological changes that developed during, or shortly after, use of or exposure to volatile inhalants. 2. Symptoms include a. Dizziness b. Nystagmus c. Incoordination d. Slurred speech e. Unsteady gait f. Lethargy g. Depressed reflexes h. Psychomotor retardation i. Tremor j. Generalized muscle weakness k. Blurred vision or diplopia l. Stupor or coma m..euphoria

7 Q7 L. Opioid abuse and dependence 1. A profile of the substance a. Opioids of natural origin b. Opioid derivatives c. Synthetic opioid-like drugs 2. Historical aspects 3. Patterns of use/abuse 4. Effects on the body a. CNS b. GI c. CV d. Sexual M. Opioid intoxication 1. Symptoms are consistent with the half-life of most opioid drugs and usually last several hours. 2. Severe opioid intoxication can lead to respiratory depression, coma, and death. N. Opioid withdrawal 1. Symptoms a. Occur within 6 to 12 hrs after last dose; b. Peak with 1 to 3 days, and, c. Gradually subside over a period of 5 to 12 days, depending on half-life. d. Include 1) Dysphoric mood 2) Nausea, vomiting 3) Muscle aches 4) Lacrimation 5) Rhinorrhea 6) Dilatation of pupils 7) Piloerection 8) Sweating 9) Abdominal cramping 10) Diarrhea 11) Yawning 12) Fever 13) Insomnia O. Hallucinogen abuse and dependence 1. A profile of the substance a. Naturally occurring hallucinogens 1) Mescaline 2) Psilocybin and psilocyn 3) Ololiugui b. Synthetic compounds 1) LSD 2) Dimethyltryptamine 3) STP 4) Phencyclidine 5) Designer drugs 2. Historical aspects 3. Patterns of use/abuse 4. Effects on the body

8 Q8 VII. P. Hallucinogen intoxication 1. Occurs within minutes to a few hours after using drug 2. Symptoms a. Perceptual alteration b. Depersonalization c. Derealization d. Tachycardia e. Palpitations f. Symptoms of PCP intoxication also include 1) Belligerence 2) Combativeness 3) May proceed to seizures or coma Q. Cannabis abuse and dependence 1. A profile of the substance a. Marijuana b. Hashish 2. Historical aspects 3. Patterns of use/abuse 4. Effects on the body a. CV b. Respiratory c. Reproductive d. CNS e. Sexual functioning R. Cannabis intoxication 1. Symptoms include a. Impaired motor coordination b. Euphoria c. Anxiety d. A sensation of slowed time e. Impaired judgment 2. Impairment of motor skills lasts for 8-12 hours Application of Nursing Process A. Nurse must begin relationship development with a substance abuser by examining own attitudes and personal experiences with substances. B. Assessment tools for determining extent of problem pt has include 1. Michigan Alcoholism Screening Test (MAST) 2. CAGE Questionnaire C. Dual diagnosis: 1. Coexisting substance disorder and mental illness. 2. Patient assigned to special program, targeting both. D. Nursing diagnoses are formulated from data gathered during assessment phase: Outcome criteria established for each. E. Nursing intervention for client with substance use disorder is aimed at: 1. Acceptance of use of substances as a problem 2. Acceptance of personal responsibility for use of substances 3. Identification of more adaptive coping strategies, and 4. Restoration of nutritional status. 5. Care is provided in three phases: a. Detoxification b. Intermediated care c. Rehabilitation

9 F. Client/family education G. Evaluation of care is based on achievement of outcome criteria. Q9 VIII. IX. The Impaired Nurse A. Estimate that 10-20% of nurses suffer from disease of chemical dependency B. Alcohol is most widely abused drug; narcotics follow close behind. C. Clues that may identify an impaired nurse: 1. High absenteeism (if substance source outside of work area) 2. Rarely misses work (if substance source is at work) 3. Problems with relationships 4. Irritability 5. Tendency to isolate 6. Elaborate excuses for behavior 7. Unkempt appearance 8. Impaired motor coordination 9. Frequent trips to the bathroom 10. Patient complaints of inadequate pain control 11. Discrepancies in documentation. D. Peer assistance program developed by American Nurses Association in To assist impaired nurses to recognize their impairments. 2. To obtain necessary treatment. 3. To regain accountability within their profession. 4. Contract is drawn up: a. To detail method of treatment. b. To establish guidelines for monitoring course of treatment. 5. Usually lasts for period of 2 years. Codependency A. Definition: emotional, psychological, and behavioral condition that develops as a result of an individual s prolonged exposure to (and practice of) a set of oppressive rules rules that prevent the open expression of feeling as well as direct discussion of personal and interpersonal problems. B. Derives self-worth from others C. Feels responsible for happiness of others D. Denial that problems exist is common E. Feelings are kept in control; Anxiety may be released in the form of stress-related illnesses, or compulsive behaviors such as a. eating, b. spending, c. working, or d. use of substances F. The codependent nurse 1. Characteristics of some nurses who often have a tendency to fulfill everyone s needs but their own: a. Caretaking. Meeting needs of others to the point of neglecting their own. b. Perfectionism Low self-esteem and fear of failure drive codependent nurses to strive for an unrealistic level of achievement. c. Denial Refusal to acknowledge that any personal problems or painful issues exist. d. Poor communication Rarely express their true feelings.

10 Q10 G. Treating codependence 1. Stage I: Survival Stage. Letting go of the denial that a problems exist. 2. Stage II: Reidentification Stage. Taking responsibility for own dysfunctional behavior. 3. Stage III: Core Issues Stage. Facing the fact that relationships cannot be managed by force of will. 4. Stage IV: Reintegration Stage. Accepting self and willingness to change. X. Treatment Modalities for Substance-Related Disorders A. Alcoholics Anonymous (AA) B. Various support groups patterned after AA for persons with other substance-related problems C. Pharmacotherapy D. Counseling E. Group therapy F. Psychopharmacology for substance intoxication and substance withdrawal XI. XII. Summary (pp in text) Critical Thinking Exercise Source: Townsend, M.C. (2003). Instructor s guide for psychiatric mental health nursing: Concepts of care,(4th ed), Philadelphia: F.A.Davis. January,07/SFBanakkMSN,RN