MH- Chapter 22, 23

Alcohol withdrawal stages

Stage 1: mild- anxious, insomnia, abdominal pain: begins 8 hours after last drink Stage 2: moderate withdrawal symptoms: BP increase, temperature and HR increase, confusion: 24-72 hours after last drink Stage 3: severe withdrawal- alcohol withdrawal delirium, delirium tremors, happens 2-3 days after last drink, MED EMERGENCY!, seizure, disoriented, severe HTN, dysrythmias, lead to delirium and potentially death

Stages of AD

Stage1: no memory problems 2: short term memory loss/will forget/will feel ashamed and anxious 3: problems with memory and concentration 4: early stages AD: personality changes, more withdrawn, close relationships will notice patients memory loss 5: mid stage- disorientation and confusion of time and place/inability to recall important events such as addresses or numbers 6: moderate-severe continued worsened memory loss, tendency of having hallucinations/compulsive behavior/wander around/need assistance with ADL/violent tendencies/incontinence 7: end- late stage:loss of ability to respond to environment/ loss of ability to speak/cant control movements/inability to eat/impaired swallowing/coma/death

Risk factors delirium

always due to underlying condition that usually multifactorial predisposing factors include: age lower education level sensory impairment decrease functional status comorbid medical conditions malnutrition depression

intoxication of hallucinogens

anxiety depression paranoia impaired judgment/social function pupil dilation tachycardia diaphoresis (sweating) palpitations blurred vision tremor incoordination panic attacks

dementia assessment

aphasia: loss of language apraxia loss of purposeful movement/ putting on pants a shirt for ex agnosia: loss of sensory ability agraphia: loss of writing ability hyperorality: everything they see- they will put it in their mouth hypermetamorphis: everything they see they will touch -use positive regard with dementia

NCLEX: mrs smith dies at age 82, in 2 months following her death, her husband aged 84 and in good health begins to pay less attention to hygiene, seems less alert, difficulty concentrating, lack of sleep and energy, his family reminds has to remind him to take a shower, take his meds and eat which he then does, which response is most appropriate?

arrange for an appointment with a therapist for evaluation and treatment of suspected depression

NCLEX: when interviewing with a patient who is intoxicated from alcohol it is useful to first:

ask what drugs other than alcohol the patient has recently used

Cannabis- marijuana

more potent: hashish can be smoked or orally ingested causes euphoria, sedation, sometimes hallucination

CNS stimulants

morphine heroin hydromorphone (dialudid) euphoria, withdrawal symptoms after last drug. Not life threatening but suicidal ideations may occur - use clonidine for withdrawal symptoms

Bath salts

sold as tablets, capsules or powder in sealed envelopes. they can be purchased at convenience stores -there are 3 ingredients that are hallucinogenic in them they are similar to: cocaine, meth, ecstasy, LSD

NCLEX: the nurse is conducting a daily nursing assessment on a client gambling with alcohol addictions who is in the OP addiction program. Which client statement reflects need for more teaching

"i am going to have a night out with a friend at an area night club"

Types of nuerocognitive disorders

Alzheimers disease- most common traumatic brain injury parkinsons disease

severe opiate overdose results in

Opiate overdose results in lower BP and RR increased HR

Disulfuram

- if they decide to abstain from alcohol, the drug that helps is disulfuram. - aversion therapy- negative reaction like a shock. -it is an oral medication taken every day, behavioral type of method, if used with alcohol it can lead to respiratory depression- cannot use with alcohol Sedo high: persists for 2 weeks, N/V, sweating, hypotension - do not take any products that contain alcohol with this, cough syrup has alcohol!

Common meds to treat dimentia

- there is no cure for AD 3 meds are used for early stages of AD Donepezil (aricept) Rivastigmine (exelon) Galantomine (razadyne) used for late stages of AD: Memantine (nemenda)

what is the alcohol intoxication level in california

.08% believe this would affect motor function and reaction times

Reasons why AD happens

1)nueropathological changes amyloid is a protein that produces normally, supposed to be broken down and eliminated in the body, but with AD it is accumulated and becomes plaque 2)

NCLEX: A booth at a health fair assesses safe driving. The nurse booth explains that coordination and mental alertness are affected at a blood alcohol level of .04, even though states may have legal limit of .08. When asked how many drinks per hour the average person needs to be close to the .08 intoxication level, the nurse would make which reply?

3-5, four ounce glasses of wine, depending on how recently food was consumed.

drugs to treat AD

Acetylcholinesterase inhibitor Memory deficit is thought to be related to a lack of acetylcholine at the synaptic level. drugs prevent the chemical that destroys acetylcholine from acting, thus leaving more available acetylcholine.

NCLEX: the nurse instructs the client about addiction. The nurse determines that the client understands the information given when the client makes which statement? Select all that apply

Addiction is a mental illness addiction is a behavioral habit addiction is an emotional attachment

What is the problem with benzodiazepines

Addiction- if they have problems with alcohol addiction, there will be addiction to benzo so you have to adjunct medication will be given

NCLEX: During a meeting on an inpatient addictions unit, a newly admitted client asks what defines drug abuse. The best response by the nurse is

An excessive drug use consistent with accepted medical purposes

risk factors for AD

Brain injury and trauma are associated with a greater risk of developing Alzheimer's disease and other dementias. People who suffer repeated head traumasuch as boxers and football players, may be at greater risk.

Drugs to stop tobacco use

Buproprion (zyban) nicotine gum nictoine patch- take off before MRI nicorette nicotine nasal spray (each spray is 1 cigarette) avoid eating or drinking when chewing nicotine gum

Cage screening for alcohol

C: "have you ever felt that you should CUT down on your drinking?" A: Do people ANNOY you when they tell you to cut down on drinking?- criticize G: "have you felt bad or GUILTY about your drinking" E: have you ever had a drink first thing to steady nerves or get rid of your hangover? - excessive use

sedative and hypnotics

CNS depressants, like benzodiazepines: decreases anxiety and keeps sedated - problems are respiratory depression and decreased LOC - the antidote to these is Flumazenil (Romazicon)

Amephetamines

CNS stimulant orally, IV injection increased energy, euphoria- similar to cocaine makes a person awake for a long period of time, moving constantly wanting to do everything after effects- person becomes tired and sleeps for about 18 or more hours * acute cardiovascular effects: tachycardia, elevated BP

Alzheimers late stages symptoms

First is denial- family will also use denial. Refusal to accept changes and loss of memory 2) confabulation: making up stores because they cannot remember and want to protect ego from embarrassment and decrease own anxiety 3) perservation: avoiding answering questions because want to protect ego from shame/anxiety. conscious attempt to preserve self-esteem 4) total avoidance of questions

behaviors that lead in addictive disorders: non substance related disorders

Gambling sexual activity shopping/spending internet use, social media use gaming Denail!

Care for someone in alcohol withdrawal

Hydrate them at the ER and give major benzodiazepines! benzo's are good for withdrawal symptoms "the pam's, and librium" - benzo's lower HR, BP and maintain vitals within normal limits: prevents seizure activity

hallucinogens

LSD, PSP- can be injested or smoked heightened sense of self and can alter perceptions colors more vivid- feels like one can touch images or colors

substance abuse

Need to be involved with repeated use for at least 12 month period - not disorders of choice - craving, seeking and using REGARDLESS of consequences

Withdrawal safety measures

Seizure precaution: pad side rails, suction at bedside, vital signs q2h, benzo's around the clock and PRN's

Medications guidelines for AD

TCA: increase anticholinergic effects- be careful with elderly, they can be detrimental thorazine: do not use with older patients-strong alpha blockage give smaller doses of FGA antipsychotics do not use atypicals to control agitation dont use continued benzo- can increase fall risk

nursing interventions for substance abuse

all about safety! provide intervention for withdrawal symptoms adequate nutrition/hydration remove them from high stimuli to low stimuli environment individual psychotherapy to cognitive behavioral therapy develop motivation and commitment for abstinence and recovery

When preparing someone for a surgical procedure, the most important thing to ask the patient is

When was the last date of substance abuse- it will interfere with the anesthesia

NCLEX: The mental health nurse explains to clients who are learning about cross addiction that there is a synergistic or addictive effect from using various kinds of chemicals together. The nurse illustrates this as

Wine and taking benzodiazepines

NCLEX: 86 year old diagnosed with AD, for discharge education, which interventions would be beneficial to teach the family? select all that apply

a b c e f a. recommend switching to hospital type gowns to facilitate bathing etc b. discourage wandering by installing complex locks c. for situations in which the patient becomes upset, teach loved ones to listen briefly provide support and change topic e. encourage caregivers to care for themselves, as well as patient, via support resources such as adult day care or respite care f. if patient prone to wandering away, encourage family and notify police and neighbors of the patient condition, behavior and description

Delirium

acute cognitive impairment REVERSIBLE! caused by a medical condition: common in hospitalized and older patients numerous symptoms: disorientation- often to time and place anxiety poor memory agitation delusions hallucinations vivid dreams, fantasies inability to sleep will often feel fear

NCLEX: the provision of optimal care for patients withdrawing from substances of abuse is facilitated by the nurses understanding that severe morbidity and mortality are often associated with withdrawal from

alcohol and CNS depressants (like benzo's, barbituates -phenoarbital) * Hyperpyrexia and convulsions are dangerous symptoms seen in central nervous system stimulant overdose.

substance abuse used by teens

alcohol, marijuana, tobacco, prescription drugs, hallucinogens

Etiology- nuerobiological

homozygous 11 genotype of Dopamine D1 receptor is associated with increased risk of abuse - remember dopamine

NCLEX: intervention (s) appropriate for patients experiencing delirium include which of the following? select all that apply

b. ensuring a clock and a sign indiciating the day and date are displayed where a patient can see easily c. being prepared for possible hostile responses to effort e. speaking with patient frequently for short periods for reassurance, assisting the patient in remaining oriented, and ensuring safety f. anticipating the patient may try to leave if agitated and providing for continuous direct observation to prevent wandering

Signs/Symptoms of alcohol intoxication

body weight, gender, concentration of drinks, absorption rate, tolerance level, how much has been drunk.

adjunct meds for benzodiazepines treating withdrawal

carbamazepine: not sedating, low potential for abuse, anti epileptic, mood stabilizer clonadine (catapress), and propranolol: beta blockers, lower HR and BP quickly Propranolol: decreases the affects of craving alcohol

dementia

cognitive impairment in judgment, insight, language, tasks, cant plan or organize memory impairment altered judgment will alter affect sundowners syndrome: more confused/agitated at night predisposition to delirium PTSD at a higher risk of developing dementia *with dementia or AD: it will deteriorate cognitive function and executive function (add, plan, decisions)

NCLEX: you are caring for mick, a 32 year old patient with chemical addiction who will soon be preparing for discharge. a principle counseling intervention that should be observed when caring for a patient with chemical addiction is to

communicate that relapses are always possible

NCLEX: the nurse asks the client the following "what does it mean, dont cry over spilled milk?" what is the nurse assessing

concrete thoughts

Most common symptom for adults when they have UTI

delirium- confusion

delirium vs dementia

delirium: reversible, acute and rapid, fluctuated levels, unstable vital signs, medical emergency! dementia: irreversible, no hallucination, sun-downing syndrome, unchanged levels, stable vital signs

Alzehimers mimics

depression To differentiate between depression and AD: depressed clients witll have more changes with their ADL's and decreased socialization and activities and more likely to have family history--> mostly, depression will COMPLAIN about memory loss while dementia will cover or HIDE it.

care continuum for substance abuse

detox unit- then go to rehab for 1-3 months after rehab- halfway houses sometimes doctors will have them go to partial hospitilization

planning/implementation

ensure you keep consistent daily routine- same caregiver- provide safety decrease stimuli address by name. support memory and orientation - mark room and bathroom address by name promote sleep-nightlight if sundowning, place near window- help with time orientation no new learning consistent environment one instruction at a time fall prevention promote self esteem explain procedures limit choices when dressing or eating avoid confrontation

Withdrawal

feeling of discomfort, distress and intense craving for a substance when the substance activity or use stops

Risk factors of substance abuse

genetics lowered self esteem lowered tolerance for pain frustration few meaningful relationships few life successes risk taking tendencies sociocultural theories - native Americans have a high percentage of numbers who have alcoholic substance abuse

withdrawal hallucinogens

hallucinogen persisting perception disorder visual disturbances or flashbacks hallucinations can occur intermittently for years!

NCLEX: which statement about dementia is correct?

hypertension, diminished activity levels and head injury increase the risk of dementia

cocaine

injected, smoked, inhaled or snorted causes euphoria, pleasure, increased energy, hallucinations

nuerocognitive disorder

looking at deliriums reduction of cognitive function in one or more areas of the brain care needs to be compassionate can include attention, short/long term memory, cognition

addiction

loss of control due to addictive behavior - primary chronic disease of brain reward, motivation, memory and related circuitry - a disease of dis-regulation in pleasure seeking-hedonic or reward pathway of the brain - tendency to relapse back to addictive behavior

kortstokoff syndrome

memory syndrome caused by severe deficiency of thiamine, most common cause is alcohol abuse

conditions leading to delirum " I watch Death"

most common in older adults from taking multiple meds at the same time, and also ICU patients I-infectious W: withdrawal A: acute metabolic: acidosis, alkalosis etc T: trauma C: cns abnormality: ICP pressure, hemmorhage H: hypoxia D: defeciences E: endocrinopathies: adrenal disorder, thyroid problems A: acute vascular: shock T: toxins/drugs H: heavy metals

Basic medical work-up

need to check this if the person has alzheimers to find out if there is a physiological reason first things like chest and skull xray, ECG, urinalysis, liver function test etc.

Inhalants

nitrous oxide euphoria no withdrawal symptoms for inhalants but there is intoxication

Assessment for substance abuse

open ended questions Look for pattern, frequency, amount, age onset, look for withdrawal manifestation, last date of substance abuse!

NCLEX: as you evaluate a patients progress, which treatment outcome would indicate a poor general prognosis for long term recovery substance abuse

patient demonstrates positive expectations for ongoing drug use

Tobacco/nictone

tobacco- cns stimulant, relaxes, decreases anxiety, - it can be inhaled smoked or chewed

NCLEX: you are caring for leah a 26 year old patient who has been abusing CNS stimulants. Which statement provides a basis for planning care for a patient who abuses cns stimulants

postwithdrawal symptoms include fatigue and depression

Alzheimers Disease

progressive deterioration of cognitive function early stages: may be able to compensate for loss of memory, can be subtle

comorbidity

psychiatric: adolescents w/ mood and anxiety disorders, antisocial behaviors, and histories of conduct are more likely to abuse substances medical- hep C, diabetes, Cardiovascular, HIV and pulmonary disorders more likely to abuse

Naltraxone

pure opiod antagonist, suppresses craving and pleasurable affects of alcohol - take at night

S/S of alcohol withdrawal

restlessness irritability lack of appetite- anorexia tremor insomnia impaired cognitive functions mild perceptual changes -possible seizures

screenings for substance abuse

screening: health care staff assesses patient using standardized screening tools brief intervention: discuss risks of abuse behaviors with the patient, and provide feedback referral: suggest referral for brief therapy or treatment for patients who screen positively

mini mental status exam

short version of MSE used for geriatric population- scores up to 30 25-30 mild cognitive impairment

NCLEX: the nurse reports a strange experience, she was riding carpool with her partner after her second double shift in a row and did not recognize her hands as her own what is she experiencing

the long hours of work with little recovery time led her to have a transient episode of depersonalization

NCLEX: a 73 year old woman with pnuemonia becomes agitated after being admitted to the ICU. Her vitals are erratic, thinking disorganized, during her first 24 hours in the ICU, the pt varies from somnolent to agitated and from laughing to angry shouting. Her daughter reports the patient was never like this at home. what is the most likely explanation?

the patient is experiencing delirium secondary to the pneumonia

Dopamine - how drug tolerance happens

the reward pathway - the brain responds to different stimuli. All indicate that you are being rewarded for example: hug, praise, food. The nuerotransmitter is produced and goes to different parts of the brain- the hippocampus focuses on reward and goes to the prefrontal cortex which makes you want more - dopamine is released with a stimuli and travels through pathway and tells the body "this is good lets do it again" natural response of the reward system - can lead to craving, drug tolerance.

what is substance abuse? At least 2 of the following they need to have in order to be diagnosed 2-3 is mild substance abuse disorder 4-5 is severe substance abuse

use substance in larger amounts for longer time than intended - continued desire or unsuccessful attempt to control substance abuse -spends a considerable amount of time obtaining, using or recovering from effects of substance -continues to use regardless of social of interpersonal problems related -reduces or quits participation in social occupational or recreational activities - uses in physically hazardous situations like drunk driving -tolerance develops, needs more of substance to reach effect -withdrawal -strong urge to use

Acamprosate (campral)

will reduce craving of alcohol