Chapter 14 Substance-Related and Addictive Disorders

21. A nursing instructor is teaching nursing students about cirrhosis of the liver. Which of the following statements about the complications of hepatic encephalopathy should indicate to the nursing instructor that further student teaching is needed? (Select all that apply.) 1. A diet rich in protein will promote hepatic healing. 2. This condition results from a rise in serum ammonia, leading to impaired mental functioning. 3. In this condition, an excessive amount of serous fluid accumulates in the abdominal cavity. 4. Neomycin and lactulose are used in the treatment of this condition. 5. This condition is caused by the inability of the liver to convert ammonia to urea.

1. A diet rich in protein will promote hepatic healing. Rationale: The nursing instructor should understand that further teaching is needed if the nursing student states that a diet rich in protein will promote hepatic healing. The treatment of hepatic encephalopathy requires abstention from alcohol and temporary elimination of protein from the diet.

24. A nursing supervisor is offering an impaired staff member information regarding employee assistance programs. Which of the following facts should the supervisor include? (Select all that apply.) 1. A hotline number will be available in order to call for peer assistance. 2. A verbal contract detailing the method of treatment will be initiated prior to the program. 3. Peer support is provided through regular contact with the impaired nurse. 4. Contact to provide peer support will last for one year. 5. One of the program goals is to intervene early in order to reduce hazards to clients.

1. A hotline number will be available in order to call for peer assistance. 3. Peer support is provided through regular contact with the impaired nurse. 5. One of the program goals is to intervene early in order to reduce hazards to clients. Rationale: The peer assistance programs strive to intervene early, to reduce hazards to clients, and increase prospects for the nurses recovery. Most states provide either a hotline number that the impaired nurse may call or phone numbers of peer assistance committee members, which are made available for the same purpose. Typically, a written, not verbal, contract is drawn up, detailing the method of treatment, which may be obtained from various sources, such as employee assistance programs, Alcoholics Anonymous, Narcotics Anonymous, private counseling, or outpatient clinics. Peer support is provided through regular contact with the impaired nurse, usually for a period of two years, not one year.

7. A client diagnosed with chronic alcohol addiction is being discharged from an inpatient treatment facility after detoxification. Which client outcome, related to AA, would be most appropriate for a nurse to discuss with the client during discharge teaching? 1. After discharge, the client will immediately attend 90 AA meetings in 90 days. 2. After discharge, the client will rely on an AA sponsor to help control alcohol cravings. 3. After discharge, the client will incorporate family in AA attendance. 4. After discharge, the client will seek appropriate deterrent medications through AA.

1. After discharge, the client will immediately attend 90 AA meetings in 90 days. Rationale: The most appropriate client outcome for the nurse to discuss during discharge teaching is attending 90 AA meetings in 90 days after discharge. AA is a major self-help organization for the treatment of alcohol addiction. It accepts alcohol addiction as an illness and promotes total abstinence as the only cure.

20. Which of the following nursing statements exemplify the cognitive process that must be completed by a nurse prior to caring for clients diagnosed with a substance-related disorder? (Select all that apply.) 1. I am easily manipulated and need to work on this prior to caring for these clients. 2. Because of my fathers alcoholism, I need to examine my attitude toward these clients. 3. I need to review the side effects of the medications used in the withdrawal process. 4. Ill need to set boundaries to maintain a therapeutic relationship. 5. I need to take charge when dealing with clients diagnosed with substance disorders.

1. I am easily manipulated and need to work on this prior to caring for these clients. 2. Because of my fathers alcoholism, I need to examine my attitude toward these clients. 4. Ill need to set boundaries to maintain a therapeutic relationship. Rationale: The nurse should complete a cognitive process prior to caring for clients diagnosed with substance-abuse disorders. It is important for nurses to identify potential areas of need within their own cognitions that may affect their relationships with clients diagnosed with this problem.

18. A nurse is assessing a pathological gambler. What would differentiate this clients behaviors from the behaviors of a non-pathological gambler? 1. Pathological gamblers have abnormal levels of neurotransmitters, whereas non-pathological gamblers do not. 2. Pathological gambling occurs more commonly among women, whereas non-pathological gambling occurs more commonly among men. 3. Pathological gambling generally runs an acute course, whereas non-pathological gambling runs a chronic course. 4. Pathological gambling is not related to stress relief, whereas non-pathological gambling is related to stress relief.

1. Pathological gamblers have abnormal levels of neurotransmitters, whereas non-pathological gamblers do not. Rationale: There is a correlation between pathological gambling and abnormalities in the serotonergic, noradrenergic, and dopaminergic neurotransmitter systems. This is not the case with non-pathological gambling. For a pathological gambler, the preoccupation with and impulse to gamble intensifies when the individual is under stress. This is not the case with non- pathological gambling. Pathological gambling occurs more commonly among men not women and generally runs a chronic not acute course.

5. A lonely, depressed divorce has been self-medicating with small amounts of cocaine for the past year. Which term should a nurse use to best describe this individuals situation? 1. Psychological addiction 2. Physical addiction 3. Substance induced disorder 4. Social induced disorder

1. Psychological addiction Rationale: The nurse should use the term psychological addiction to best describe the clients situation. A client is considered to be psychologically addicted to a substance when there is an overwhelming desire to use a drug in order to produce pleasure or avoid discomfort

1. What should be the priority nursing diagnosis for a client experiencing alcohol withdrawal? 1. Risk for injury R/T central nervous system stimulation 2. Disturbed thought processes R/T tactile hallucinations 3. Ineffective coping R/T powerlessness over alcohol use 4. Ineffective denial R/T continued alcohol use despite negative consequences

1. Risk for injury R/T central nervous system stimulation Rationale: The priority nursing diagnosis for a client experiencing alcohol withdrawal should be risk for injury R/T central nervous system stimulation. Alcohol withdrawal may include the following symptoms: course tremors of hands, tongue, or eyelids; nausea or vomiting; malaise or weakness; tachycardia; sweating; elevated blood pressure; anxiety; depressed mood; hallucinations; headache; and insomnia.

16. A client diagnosed with major depressive episode and substance use disorder has an altered sleep pattern and demands that a psychiatrist prescribe a sedative. Which rationale explains why a nurse should encourage the client to first try nonpharmacological interventions? 1. Sedative-hypnotics are potentially addictive, and their effectiveness will be compromised owing to tolerance. 2. Sedative-hypnotics are expensive and have numerous side effects. 3. Sedative-hypnotics interfere with necessary REM (rapid eye movement) sleep. 4. Sedative-hypnotics are known not to be as effective in promoting sleep as antidepressant medications.

1. Sedative-hypnotics are potentially addictive, and their effectiveness will be compromised owing to tolerance. Rationale: The nurse should recommend nonpharmacological interventions to this client because sedative-hypnotics are potentially addictive, and their effectiveness will be compromised owing to tolerance. The effects of central nervous system depressants are additive with one another, capable of producing physiological and psychological addiction.

22. A clinic nurse is about to meet with a client diagnosed with a gambling disorder. Which of the following symptoms and/or behaviors is the nurse likely to assess? (Select all that apply.) 1. Stressful situations precipitate gambling behaviors. 2. Anxiety and restlessness can only be relieved by placing a bet. 3. Winning brings about feelings of sexual satisfaction. 4. Gambling is used as a coping strategy. 5. Losing at gambling meets the clients need for self-punishment.

1. Stressful situations precipitate gambling behaviors. 2. Anxiety and restlessness can only be relieved by placing a bet. 4. Gambling is used as a coping strategy. 5. Losing at gambling meets the clients need for self-punishment. Rationale: In gambling disorder, the preoccupation with and impulse to gamble intensifies when the individual is under stress. Many impulsive gamblers describe a physical sensation of restlessness and anticipation that can only be relieved by placing a bet. Winning brings feelings of special status, power, and omnipotence, not sexual satisfaction. The gambler increasingly depends on this activity to cope with disappointments, problems, and negative emotional states.

25. A nursing counselor is about to meet with a client suffering from codependency. Which of the following data would further support the assessment of this dysfunctional behavior? (Select all that apply.) 1. The client has a long history of focusing thoughts and behaviors on other people. 2. The client, as a child, experienced overindulgent and overprotective parents. 3. The client is a people pleaser and does almost anything to gain approval. 4. The client exhibits helpless behaviors but actually feels very competent. 5. The client can achieve a sense of control only through fulfilling the needs of others.

1. The client has a long history of focusing thoughts and behaviors on other people. 3. The client is a people pleaser and does almost anything to gain approval. 5. The client can achieve a sense of control only through fulfilling the needs of others. Rationale: The codependent person has a long history of focusing thoughts and behavior on other people and is able to achieve a sense of control only through fulfilling the needs of others. Codependant clients are people pleasers and will do almost anything to get the approval of others. They usually have experienced abuse or emotional neglect as a child. They outwardly appear very competent, but actually feel quite needy, helpless, or perhaps nothing at all.

15. A nurse is reviewing the stat laboratory data of a client in the emergency department. At what minimum blood alcohol level should a nurse expect intoxication to occur? 1. 50 mg/dL 2. 100 mg/dL 3. 250 mg/dL 4. 300 mg/dL

2. 100 mg/dL Rationale: The nurse should expect that 100 mg/dL is the minimum blood alcohol level at which intoxication occurs. Intoxication usually occurs between 100 and 200 mg/dL. Death has been reported at levels ranging from 400 to 700 mg/dL

19. A nursing instructor is teaching about the impaired nurse and the consequences of this impairment. Which statement by a student indicates that further instruction is needed? 1. The state board of nursing must be notified with factual documentation of impairment. 2. All state boards of nursing have passed laws that, under any circumstances, do not allow impaired nurses to practice. 3. Many state boards of nursing require an impaired nurse to successfully complete counseling treatment programs prior to a return to work. 4. After a return to practice, a recovering nurse may be closely monitored for several years.

2. All state boards of nursing have passed laws that, under any circumstances, do not allow impaired nurses to practice. Rationale: Several state boards of nursing have passed diversionary laws that allow impaired nurses to avoid disciplinary action by agreeing to seek treatment. This may require successful completion of inpatient, outpatient, group, or individual counseling treatment program(s); evidence of regular attendance at nurse support groups or 12-step program; random negative drug screens; and employment or volunteer activities during the suspension period. When a nurse is deemed safe to return to practice, he or she may be closely monitored for several years and required to undergo random drug screenings.

8. A client with a history of heavy alcohol use is brought to an emergency department (ED) by family members who state that the client has had nothing to drink in the last 48 hours. When the nurse reports to the ED physician, which client symptom should be the nurses first priority? 1. Hearing and visual impairment 2. Blood pressure of 180/100 mm Hg 3. Mood rating of 2/10 on numeric scale 4. Dehydration

2. Blood pressure of 180/100 mm Hg Rationale: The nurse should recognize that high blood pressure is a symptom of alcohol withdrawal syndrome and should promptly report this finding to the physician. Complications associated with alcohol withdrawal syndrome may progress to alcohol withdrawal delirium in about the second or third day following cessation of prolonged alcohol use.

2. A nurse evaluates a clients patient-controlled analgesia (PCA) pump and notices 100 attempts within a 30-minute period. Which is the best rationale for assessing this client for substance addiction? 1. Narcotic pain medication is contraindicated for all clients with active substance use disorders. 2. Clients who are addicted to alcohol or benzodiazepines may develop cross-tolerance to analgesics and require increased doses to achieve effective pain control. 3. There is no need to assess the client for substance addiction. There is an obvious PCA malfunction, because these clients have a higher pain tolerance. 4. The client is experiencing alcohol withdrawal symptoms and needs accurate assessment.

2. Clients who are addicted to alcohol or benzodiazepines may develop cross-tolerance to analgesics and require increased doses to achieve effective pain control. Rationale: The nurse should assess the client for substance addiction, because clients who are addicted to alcohol or benzodiazepines may have developed cross-tolerance to analgesics and require increased doses to achieve effective pain control. Cross-tolerance is exhibited when one drug results in a lessened response to another drug.

23. A nursing supervisor is about to meet with a staff nurse suspected of diverting client medications. Which of the following assessment data would lead the supervisor to suspect that the staff nurse is impaired? (Select all that apply.) 1. The staff nurse is frequently absent from work. 2. The staff nurse experiences mood swings. 3. The staff nurse makes elaborate excuses for behavior. 4. The staff nurse frequently uses the restroom. 5. The staff nurse has a flushed face.

2. The staff nurse experiences mood swings. 3. The staff nurse makes elaborate excuses for behavior. 4. The staff nurse frequently uses the restroom. 5. The staff nurse has a flushed face. Rationale: A number of clues for recognizing substance impairment in nurses have been identified. They are not easy to detect and will vary according to the substance being used. There may be high absenteeism if the persons source is outside the work area, or the individual may rarely miss work if the substance source is at work. Some other possible signs are irritability, mood swings, tendency to isolate, elaborate excuses for behavior, unkempt appearance, impaired motor coordination, slurred speech, flushed face, inconsistent job performance, and frequent use of the restroom.

3. On the first day of a clients alcohol detoxification, which nursing intervention should take priority? 1. Strongly encourage the client to attend 90 Alcoholics Anonymous (AA) meetings in 90 days. 2. Educate the client about the biopsychosocial consequences of alcohol abuse. 3. Administer ordered chlordiazepoxide (Librium) in a dosage according to protocol. 4. Administer vitamin B1 to prevent Wernicke-Korsakoff syndrome.

3. Administer ordered chlordiazepoxide (Librium) in a dosage according to protocol. Rationale: The priority nursing intervention for this client should be to administer ordered chlordiazepoxide in a dosage according to protocol. Chlordiazepoxide is a benzodiazepine and is often used for substitution therapy in alcohol withdrawal to reduce life-threatening complications.

11. A client presents with symptoms of alcohol withdrawal and states, I havent eaten in three days. A nurses assessment reveals BP 170/100 mm Hg, P 110, R 28, and T 97F (36C) with dry mucous membranes and poor skin turgor. What should be the priority nursing diagnosis? 1. Knowledge deficit 2. Fluid volume excess 3. Imbalanced nutrition: less than body requirements 4. Ineffective individual coping

3. Imbalanced nutrition: less than body requirements Rationale: The nurse should assess that the priority nursing diagnosis is imbalanced nutrition: less than body requirements. The client is exhibiting signs and symptoms of malnutrition as well as alcohol withdrawal. The nurse should consult a dietitian, restrict sodium intake to minimize fluid retention, and provide small, frequent feedings of nonirritating foods.

17. A client diagnosed with a gambling disorder asks the nurse about medications that may be ordered by the clients physician to treat this disorder. The nurse would give the client information on which medications? 1. Escitalopram (Lexapro) and clozapine (Clozaril) 2. Citalopram (Celexa) and olanzapine (Zyprexa) 3. Lithium carbonate (Lithobid) and sertraline (Zoloft) 4. Naltrexone (ReVia) and ziprasidone (Geodon)

3. Lithium carbonate (Lithobid) and sertraline (Zoloft) Rationale: The SSRIs and clomipramine have been used successfully in the treatment of pathological gambling as a form of obsessive-compulsive disorder. Lithium, carbamazepine, and naltrexone have also been shown to be effective. The antipsychotic medications clozapine, olanzapine, and ziprasidone are not treatments of choice for this disorder.

12. A clients wife has been making excuses for her alcoholic husbands work absences. In family therapy, she states, His problems at work are my fault. Which is the appropriate nursing response? 1. Why do you assume responsibility for his behaviors? 2. I think you should start to confront his behavior. 3. Your husband needs to deal with the consequences of his drinking. 4. Do you understand what the term enabler means?

3. Your husband needs to deal with the consequences of his drinkin Rationale: The appropriate nursing response is to use confrontation with caring. The nurse should understand that the clients wife may be in denial and enabling the husbands behavior. Codependency is a typical behavior of spouses of alcoholics. Partners of clients with substance addiction must come to realize that the only behavior they can control is their own.

13. Which medication orders should a nurse anticipate for a client who has a history of benzodiazepine withdrawal delirium? 1. Haloperidol (Haldol) and fluoxetine (Prozac) 2. Carbamazepine (Tegretol) and donepezil (Aricept) 3. Disulfiram (Antabuse) and lorazepan (Ativan) 4. Chlordiazepoxide (Librium) and phenytoin (Dilantin)

4. Chlordiazepoxide (Librium) and phenytoin (Dilantin) Rationale: The nurse should anticipate that a physician would order chlordiazepoxide and phenytoin for a client who has a history of benzodiazepine withdrawal delirium. It is common for long-lasting benzodiazepines to be prescribed for substitution therapy. Phenytoin is an anticonvulsant used to prevent seizures.

4. Which client statement indicates a knowledge deficit related to a substance use disorder? 1. Although its legal, alcohol is one of the most widely abused drugs in our society. 2. Tolerance to heroin develops quickly. 3. Flashbacks from LSD use may reoccur spontaneously. 4. Marijuana is like smoking cigarettes. Everyone does it. Its essentially harmless.

4. Marijuana is like smoking cigarettes. Everyone does it. Its essentially harmless. Rationale: The nurse should determine that the client has a knowledge deficit related to substance use disorders when the client compares marijuana to smoking cigarettes and claims it to be harmless. Cannabis is the second most widely abused drug in the United States.

6. Which term should a nurse use to describe the administration of a central nervous system (CNS) depressant during the substance induced disorder of alcohol withdrawal? 1. Antagonist therapy 2. Deterrent therapy 3. Codependency therapy 4. Substitution therapy

4. Substitution therapy Rationale: Various medications have been used to decrease the intensity of symptoms in an individual who is withdrawing from, or who is experiencing the effects of excessive use of, alcohol and other drugs. This is called substitution therapy and may be required to reduce the life-threatening effects of alcohol withdrawal.

9. Which client statement demonstrates positive progress toward recovery from a substance use disorder? 1. I have completed detox and therefore am in control of my drug use. 2. I will faithfully attend Narcotic Anonymous (NA) when I cant control my cravings. 3. As a church deacon, my focus will now be on spiritual renewal. 4. Taking those pills got out of control. It cost me my job, marriage, and children.

4. Taking those pills got out of control. It cost me my job, marriage, and children. Rationale: A client who takes responsibility for the consequences of substance use disorder or substance addiction is making positive progress toward recovery. This would indicate completion of the first step of a 12-step program.

14. A nurse is interviewing a client in an outpatient addiction clinic. To promote success in the recovery process, which outcome should the nurse expect the client to initially accomplish? 1. The client will identify one person to turn to for support. 2. The client will give up all old drinking buddies. 3. The client will be able to verbalize the effects of alcohol on the body. 4. The client will correlate life problems with alcohol use.

4. The client will correlate life problems with alcohol use. Rationale: The nurse should expect that the client would initially correlate life problems with alcohol addiction. Acceptance of the problem is the first part of the recovery process.

10. A nurse holds the hand of a client who is withdrawing from alcohol. What is the nurses rationale for this intervention? 1. To assess for emotional strength 2. To assess for Wernicke-Korsakoff syndrome 3. To assess for tachycardia 4. To assess for fine tremors

4. To assess for fine tremors Rationale: The nurse is most likely assessing the client for fine tremors secondary to alcohol withdrawal. Withdrawal from alcohol can also cause headache, insomnia, transient hallucinations, depression, irritability, anxiety, elevated blood pressure, sweating, tachycardia, malaise, and coarse tremors.

Alcoholics Anonymous

A major self-help organization for the treatment of alcoholism Based on the concept of: • Peer support • Acceptance • Understanding from others who have experienced the same problem The 12 steps that embody the philosophy of A A provide specific guidelines on how to attain and maintain sobriety. Total abstinence is promoted as the only cure; the person can never safely return to social drinking.

1. Which of the following has been implicated in the predisposition to substance abuse? A. Hereditary factor B. Fixation in the adolescent stage of psychosexual development C. Punitive ego D. Narcissistic and dependent personality traits

A. Hereditary factor Research has indicated that an apparent hereditary factor is involved in the development of substance-use disorders. This is especially evident with alcoholism.

Classes of Psychoactive Substances

Alcohol Caffeine Cannabis Hallucinogens Inhalants Opioids Sedatives/hypnotics Stimulants Tobacco

Alcohol Intoxication and Withdrawal

Alcohol intoxication: Occurs at blood alcohol levels between 100 and 200 milligrams per deciliter Alcohol withdrawal: Occurs within 4 to 12 hours of cessation of or reduction in heavy and prolonged alcohol use

Fetal Alcohol Syndrome

Alcohol use during pregnancy can result in fetal alcohol spectrum disorders (F A S D's). • Fetal alcohol syndrome (F A S): Problems with learning, memory, attention span, communication, vision, and hearing • Alcohol-related neurodevelopmental disorder • Alcohol-related birth defects

Treatment Modalities for Gambling Disorder

Behavior therapy Cognitive therapy Motivational interviewing Psychopharmacology • S S R I's • Clomipramine • Lithium • Carbamazepine • Naltrexone Gamblers Anonymous • Organization modeled after A A • Only requirement for membership is an expressed desire to stop gambling • Reformed gamblers help others resist the urge to gamble.

Predisposing Factors for substance disorders

Biological factors Genetics: Apparent hereditary factor, particularly with alcoholism Biochemical: Alcohol may produce morphine-like substances in the brain that are responsible for alcohol addiction. Psychological factors Developmental influences• Punitive superego• Fixation in the oral stage of psychosexual development Personality factors: Certain personality traits are thought to increase a tendency toward addictive behavior. Cognitive factors: Irrational thinking patterns have long been identified as a problem that is central in addictions. Sociocultural factors Social learning: Children and adolescents are more likely to use substances with parents who provide a model for substance use. Use of substances may also be promoted within a peer group. Conditioning: Pleasurable effects from substance use act as a positive reinforcement for continued use of the substance. Cultural and ethnic influences: Some cultures are more prone to substance abuse than are others.

Predisposing Factors to Gambling Disorder

Biological influences • Genetic: Increased incidence among family members • Physiological: Abnormalities in neurotransmitter systems Psychosocial influences • Loss of a parent before age 15 • Inappropriate parental discipline • Exposure to gambling activities as an adolescent • Family emphasis on material and financial symbols • Lack of family emphasis on saving, planning, and budgeting

3. A client diagnosed with chronic alcoholism says to the nurse, "I'm tired of using and I want to stop. Is there a medication that can help me maintain sobriety?" About which medication would the nurse provide information? A. Carbamazepine (Tegretol) B. Clonidine (Catapres) C. Disulfiram (Antabuse) D. Folic acid (Folvite)

C. Disulfiram (Antabuse) Disulfiram is used as a deterrent to drinking. Ingestion of alcohol while disulfiram is in the body results in a syndrome of symptoms that can cause varying degrees of discomfort. It can even result in death if blood alcohol levels are high. It is important that the client understands that all alcohol, oral or topical, and medications that contain alcohol, are strictly prohibited when taking this drug.

The Codependent Nurse

Classic characteristics • Caretaking • Perfectionism • Denial • Poor communication

Dual Diagnosis

Clients with a coexisting substance disorder and mental disorder may be assigned to a special program that targets the dual diagnosis. Program combines special therapies that target both problems.

2. A client is brought to the emergency department. The client is aggressive, has slurred speech, and impaired motor coordination. Blood alcohol level is 347 milligrams per deciliter. Among the physician's orders is thiamine. Which is the rationale for this intervention? A. To prevent nutritional deficits B. To prevent pancreatitis C. To prevent alcoholic hepatitis D. To prevent Wernicke's encephalopathy

D. To prevent Wernicke's encephalopathy Wernicke's encephalopathy is the most serious form of thiamine deficiency in clients diagnosed with alcoholism. If thiamine replacement therapy is not undertaken quickly, death will ensue.

Codependency

Defined by dysfunctional behaviors that are evident among members of the family of a chemically dependent person, or among family members who harbor secrets of physical or emotional abuse, other cruelties, or pathological conditions Codependent people sacrifice their own needs for the fulfillment of others to achieve a sense of control. Derives self-worth from others Feels responsible for the happiness of others Commonly denies that problems exist Keeps feelings in control, and often releases anxiety in the form of stress-related illnesses, or compulsive behaviors such as eating, spending, working, or use of substances

Pharmacotherapy for Alcoholism

Disulfiram (Antabuse) Alcohol withdrawal • Benzodiazepines • Anticonvulsants • Multivitamin therapy • Thiamine

Nursing Process: Evaluation

Evaluation involves reassessment to determine whether the nursing interventions have been effective in achieving the intended goals of care.

C A G E Questionnaire

Have you ever felt you should Cut down on your drinking? Have people Annoyed you by criticizing your drinking? Have you ever felt bad or Guilty about your drinking? Have you ever had a drink first thing in the morning to steady your nerves (Eye-opener)?

Nursing Diagnosis/Outcome Identification

Ineffective Denial related to weak, underdeveloped ego Outcome: Client will demonstrate acceptance of responsibility for own behavior and acknowledge association between personal problems and use of substance(s). Ineffective Coping related to inadequate coping skills and weak ego Outcome: Client will be able to demonstrate more adaptive coping mechanisms that can be used in stressful situations (instead of taking substances). Imbalanced nutrition less than body requirements. / Fluid volume deficit related to drinking or taking drugs instead of eating. Outcome: Client will be free from signs or symptoms of malnutrition/dehydration. Risk for infection related to malnutrition and altered immune condition Outcome: Shows no signs or symptoms of infection. Chronic low self-esteem related to weak ego, lack of positive feedback Outcome: Exhibits evidence of increased self-worth by attempting new projects without fear of failure and by demonstrating less defensive behavior toward others. Deficient knowledge (effects of substance abuse on the body) related to denial of problems with substances evidenced by abuse of substances Outcome: Verbalizes importance of abstaining from use of substances to maintain optimal wellness. For the client withdrawing from C N S depressants • Risk for Injury related to C N S agitation For the client withdrawing from C N S stimulants • Risk for suicide related to intense feelings of lassitude and depression, "crashing," suicidal ideation

Stimulant-Induced Disorders

Intoxication Amphetamine and cocaine intoxication produce euphoria, impaired judgment, confusion, and changes in vital signs (even coma or death, depending on amount consumed). Caffeine intoxication usually occurs following consumption in excess of 250 milligrams. Restlessness and insomnia are the most common symptoms. Withdrawal Amphetamine and cocaine withdrawal may result in dysphoria, fatigue, sleep disturbances, and increased appetite. Withdrawal from caffeine may include headache, fatigue, drowsiness, irritability, muscle pain and stiffness, and nausea and vomiting. Withdrawal from nicotine may include dysphoria, anxiety, difficulty concentrating, irritability, restlessness, and increased appetite.

Cannabis-Induced Disorder

Intoxication Symptoms include impaired motor coordination, euphoria, anxiety, sensation of slowed time, and impaired judgment. Physical symptoms include conjunctival injection, increased appetite, dry mouth, and tachycardia. Impairment of motor skills lasts for 8 to 12 hours. Withdrawal Occurs upon cessation of cannabis use that has been heavy and prolonged Symptoms occur within a week following cessation of use. Symptoms include irritability, anger, aggression, anxiety, sleep disturbances, decreased appetite, depressed mood, stomach pain, tremors, sweating, fever, chills, or headache.

Hallucinogen-Induced Disorder

Intoxication • Occurs during or shortly after using the drug • Symptoms include perceptual alteration, depersonalization, derealization, tachycardia, and palpitations .Symptoms • Belligerence and assaultiveness, and may proceed to seizures or coma

Sedative/Hypnotic-Induced Disorder

Intoxication • With these central nervous system (C N S) depressants, effects can range from disinhibition and aggressiveness to coma and death (with increasing dosages of the drug). Withdrawal • Onset of symptoms depends on the half-life of the drug from which the person is withdrawing. • Severe withdrawal from C N S depressants can be life-threatening.

The Chemically Impaired Nurse

It is estimated that 10% to 15% of nurses suffer from the disease of chemical dependency. Alcohol is the most widely abused drug, followed closely by narcotics. High absenteeism may be present if the person's source is outside the work area. Or, the person may rarely miss work if the substance source is at work. Increase in "wasting" of drugs, higher incidences of incorrect narcotic counts, and a higher record of signing out drugs for other nurses may be present. Poor concentration, difficulty meeting deadlines, inappropriate responses, and poor memory or recall Problems with relationships Irritability, tendency to isolate, elaborate excuses for behavior Unkempt appearance, impaired motor coordination, slurred speech, flushed face Patient complaints of inadequate pain control, discrepancies in documentation State board response May deny, suspend, or revoke a license based on a report of chemical abuse by a nurse Diversionary laws allow impaired nurses to avoid disciplinary action by agreeing to seek treatment. During the suspension period Successful completion of an inpatient, outpatient, group, or individual counseling treatment program Evidence of regular attendance at nurse support groups or 12-step program Random negative drug screens Employment or volunteer activities Peer assistance programs serve to assist impaired nurses to: • Recognize their impairment • Obtain necessary treatment • Regain accountability within the profession

Characteristics of F A S

Learning difficulties Speech and language delays Intellectual disability Poor reasoning skills Sleep and sucking problems as a baby Vision or hearing problems Problems with the heart, kidneys, or bones Abnormal facial features Small head size Shorter-than-average height Low body weight Poor coordination Hyperactive behavior Difficulty paying attention Poor memory Difficulty in school

Client/Family Education

Nature of the illness Effects of (substance) on the body • Alcohol • Other C N S depressants • Hallucinogens • Inhalants • Opioids • Cannabinols Ways in which use of substance affects life Management of the illness Activities to substitute for (substance) in times of stress Relaxation techniques • Progressive relaxation, tense and relax, deep breathing, autogenics Problem-solving skills Essentials of good nutrition Support services Financial assistance Legal assistance Alcoholics Anonymous (or other support group specific to another substance) One-to-one support person

Application of the Nursing Process: substance

Nurses must begin relationship development with a substance abuser by examining own attitudes and personal experiences with substances. Motivational interviewing

Psychopharmacology for Substance Intoxication and Substance Withdrawal

Other medications • Naltrexone (ReVia) • Nalmefene (Revex) • Selective serotonin reuptake inhibitors (S S R I's) • Acamprosate (Campral) Opioids • Narcotic antagonists ‒ Naloxone (Narcan) ‒ Naltrexone (ReVia) ‒ Nalmefene (Revex) • Buprenorphine • Methadone • Clonidine Depressants • Phenobarbital (Luminal) • Long-acting benzodiazepines Stimulants• Minor tranquilizers • Major tranquilizers • Anticonvulsants • Antidepressants Hallucinogens and cannabinols • Benzodiazepines • Antipsychotics

Effects of Alcohol on the Body

Peripheral neuropathy, characterized by: • Peripheral nerve damage • Pain • Burning • Tingling • Prickly sensations of the extremities Alcoholic myopathy: Thought to result from same B vitamin deficiency that contributes to peripheral neuropathy • Acute: Sudden onset of muscle pain, swelling, and weakness; reddish tinge to the urine; rapid rise in muscle enzymes in the blood • Chronic: Gradual wasting and weakness in skeletal muscles Wernicke's encephalopathy: Most serious form of thiamine deficiency in alcoholic patients Korsakoff's psychosis: Syndrome of confusion, loss of recent memory, and confabulation in alcoholic patients Alcoholic cardiomyopathy: Effect of alcohol on the heart is an accumulation of lipids in the myocardial cells, resulting in enlargement and a weakened condition. Esophagitis: Inflammation and pain in the esophagus Gastritis: Effects of alcohol on the stomach include inflammation of the stomach lining characterized by epigastric distress, nausea, vomiting, and distention Pancreatitis • Acute: Usually occurs 1 or 2 days after a binge of excessive alcohol consumption. Symptoms include constant, severe epigastric pain; nausea and vomiting; and abdominal distention. • Chronic: Leads to pancreatic insufficiency resulting in steatorrhea, malnutrition, weight loss, and diabetes mellitus Alcoholic hepatitis • Caused by long-term heavy alcohol use • Symptoms: Enlarged, tender liver; nausea and vomiting; lethargy; anorexia; elevated white blood cell count; fever; and jaundice. Also ascites and weight loss in severe cases. Cirrhosis of the liver• Cirrhosis is the end-stage of alcoholic liver disease and is believed to be caused by chronic heavy alcohol use. There is widespread destruction of liver cells, which are replaced by fibrous (scar) tissue. Leukopenia: Impaired production, function, and movement of white blood cells Thrombocytopenia: Platelet production and survival are impaired as a result of the toxic effects of alcohol. Sexual dysfunction • In the short term, enhanced libido and failure of erection are common. • Long-term effects include gynecomastia, sterility, impotence, and decreased libido.

Gambling Disorder

Persistent and recurrent problematic gambling behavior that intensifies when the individual is under stress. As the need to gamble increases, the individual may use any means required to obtain money to continue the addiction. Gambling behavior usually begins in adolescence, although compulsive behaviors rarely occur before young adulthood. The disorder usually runs a chronic course, with periods of waxing and waning. The disorder interferes with interpersonal relationships, social, academic, or occupational functioning.

Alcohol Use Disorder: Patterns of Use

Phase I. Prealcoholic phase: Characterized by use of alcohol to relieve everyday stress and tensions of life Phase II. Early alcoholic phase: Begins with blackouts—brief periods of amnesia that occur during or immediately following a period of drinking; alcohol is now required by the person. Phase III. The crucial phase: Person has lost control; physiological dependence is clearly evident. Phase IV. The chronic phase: Characterized by emotional and physical disintegration. The person is usually intoxicated more often than sober.

Hallucinogens: Effects on the Body

Physiological• Nausea/vomiting• Chills• Pupil dilation• Increased blood pressure, pulse• Loss of appetite• Insomnia• Elevated blood sugar• Decreased respirations Psychological• Heightened response to color, sounds• Distorted vision• Sense of slowed time• Magnified feelings• Paranoia, panic• Euphoria, peace• Depersonalization• Derealization• Increased libido

Inhalant Use Disorder

Profile of the substance • Aliphatic and aromatic hydrocarbons are found in substances such as fuels, solvents, adhesives, aerosol propellants, and paint thinners. Patterns of use/abuse Effects on the body • C N S effects • Respiratory effects • Gastrointestinal effects • Renal system effects Intoxication• Develops during or shortly after use of or exposure to volatile inhalants• Symptoms include:‒ Dizziness, ataxia, muscle weakness‒ Euphoria, excitation, disinhibition, slurred speech‒ Nystagmus, blurred or double vision‒ Psychomotor retardation, hypoactive reflexes‒ Stupor or coma

Stimulant Use Disorder

Profile of the substance • Amphetamines • Synthetic stimulants • Non-amphetamine stimulants • Cocaine • Caffeine • Nicotine Patterns of use Effects on the body • C N S effects • Cardiovascular effects • Pulmonary effects • Gastrointestinal and renal effects • Sexual functioning

Sedative/Hypnotic Use Disorder

Profile of the substance • Barbiturates • Nonbarbiturate hypnotics • Antianxiety agents Patterns of use Effects on the body • Effects on sleep and dreaming • Respiratory depression • Cardiovascular effects • Hepatic effects • Body temperature • Sexual functioning

Hallucinogen Use Disorder

Profile of the substance • Naturally occurring hallucinogens • Synthetic compounds Patterns of use • Use is usually episodic

Opioid Use Disorder

Profile of the substance • Opioids of natural origin • Opioid derivatives • Synthetic opiate-like drugs Patterns of use/abuse Effects on the body • C N S effects • Gastrointestinal effects • Cardiovascular effects • Sexual functioningIntoxication Symptoms are consistent with the half-life of most opioid drugs and usually last for several hours. Symptoms include initial euphoria followed by apathy, dysphoria, psychomotor agitation or retardation, and impaired judgment. Severe opioid intoxication can lead to respiratory depression, coma, and death. Symptoms of opioid withdrawal • Dysphoria, muscle aches, nausea/vomiting, lacrimation or rhinorrhea, pupillary dilation, piloerection, sweating, abdominal cramping, diarrhea, yawning, fever, and insomnia

Cannabis Use Disorder

Profile of the substance Marijuana Hashish Patterns of use Effects on the body • Cardiovascular • Respiratory • Reproductive • C N S • Sexual functioning

Treating Codependence

Recovery process • Survival stage • Re-identification stage • Core issues stage • Reintegration stage

Planning/Implementation

Risk for injury • Provide safe and supportive environment.• Administer substitution therapy. Denial • Develop trust. • Identify maladaptive behaviors or situations Ineffective coping • Establish trust. • Set limits. • Explore options. Dysfunctional family processes • Review history. • Provide information. • Involve the family.

Substance-Induced Disorders

Substance intoxication Development of a reversible syndrome of symptoms following excessive use of a substance Direct effect on the central nervous system Disruption in physical and psychological functioning Judgment is disturbed and social and occupational functioning is impaired. Substance withdrawal Development of symptoms that occurs upon abrupt reduction or discontinuation of a substance that has been used Symptoms are specific to the substance that has been used. Disruption in physical and psychological functioning

Substance Use Disorder

Use of the substance interferes with the ability to fulfill role obligations Attempts to cut down or control use fail Intense craving for the substance Excessive amount of time spent trying to procure the substance or recover from its use Use of the substance causes the person difficulty with interpersonal relationships or to become socially isolated Engages in hazardous activities when impaired by the substance Tolerance develops and the amount required to achieve the desired effect increases Substance-specific symptoms occur upon discontinuation of use

Nursing Process: Assessment

Various assessment tools are available for determining the extent of the problem a client has with substances. • Drug history and assessment • Clinical Institute Withdrawal Assessment of Alcohol Scale • Michigan Alcoholism Screening Test (M A S T) • C A G E Questionnaire C A G E Questionnaire Have you ever felt you should Cut down on your drinking? Have people Annoyed you by criticizing your drinking? Have you ever felt bad or Guilty about your drinking? Have you ever had a drink first thing in the morning to steady your nerves (Eye-opener)?

Treatment Modalities for Substance-Related Disorders

Various support groups patterned after A A, but for individuals with problems with other substances Counseling Group therapy

Opioid-Induced Disorders: Withdrawal

Withdrawal From short-acting drugs (for example, heroin) • Symptoms occur within 6 to 8 hours, peak within 1 to 3 days, and gradually subside in 5 to 10 days. From long-acting drugs (for example, methadone) • Symptoms occur within 1 to 3 days, peak between days 4 and 6, subside in 14 to 21 days. From ultra-short-acting meperidine • Symptoms begin quickly, peak in 8 to 12 hours, and subside in 4 to 5 days Symptoms of opioid withdrawal • Dysphoria, muscle aches, nausea/vomiting, lacrimation or rhinorrhea, pupillary dilation, piloerection, sweating, abdominal cramping, diarrhea, yawning, fever, and insomnia

Ascites

abnormal accumulation of fluid in the abdomen

Barbiturates

drugs that depress the activity of the central nervous system, reducing anxiety but impairing memory and judgment

Hepatic encephalopathy

impaired ammonia metabolism causes cerebral edema. s/s: change in LOC, memory loss, asterixis (flapping tremor) impaired handwriting, hyperventilation w/ resp alkalosis. Rx: lactulose, low protein, safety, rest

Esophageal varices

swollen, varicose veins at the lower end of the esophagus

Portal hypertension

the elevation of blood pressure within the portal venous system

Complications of cirrhosis of the liver can include

• Portal hypertension • Ascites • Esophageal varices • Hepatic encephalopathy