Module 5
CNS Stimulants
(crack & cocaine, methamphetamines, caffeine, and nicotine) -Dilation of pupils, dryness of oral nasal cavity, excessive motor activity, euphoria, insomnia, increased energy TX: antipyschotics, for convulsions > diazepam Nicotine: highly toxic, highly addictive. Can be a stimulant, depressant, tranquilizer. Dependence/abstinence syndrome (difficulty to quit)
4 C's of addiction
-Compulsive behavior: finding & taking substance despite harmful consequences -Cravings are MOTIVATION to drug seeking behavior Chronic, relapsing brain disorder Cognitive impairment: difficulty planning, working, inhibition, memory & decision making
Assess client situations for the potential for violence (suicide, homicide, self-destructive behavior, etc.) and use safety precautions
-Determine is there is a need for safety interventions bc of suicidal or homicidal ideations or gesture FIRST -THEN assure patients has a feeling of safety and security while minimizing anxiety -THEN assess the patients perception of the event, the patients available supports, and the patients usual coping skills.
Use crisis intervention techniques to assist the client in coping
-Identify needed coping skills such as problem solving, relaxation or job training to minimize effects -Assess for suicidal/homicidal thoughts or plans -Make patient feel safe and lower anxiety -Use active listening and therapeutic techniques -Assess patient supports systems and rally existing systems if patient is overwhelmed -Identify and mobilize needed social supports -Collaborate with the patient to plan interventions and ensure follow-up.
Collaborate with the health care team to identify the initial needs of people facing an adventitious crisis/mass disaster
-Initial needs during a disaster include rescue, evacuation, food/shelter, medical attention, and physical safety. -After immediate needs are met, people need help reconstructing their lives by means of: housing assistance, job assistance, and trauma counseling.
Plan client-centered care for a person who has experienced an adventitious crisis/mass disaster and identify the potential cognitive and emotional states likely to be present
-Patients involved in a mass disaster commonly experience cognitive impairment such as confusion, difficulty making decisions, and intrusive memories. -behavioral changes like substance use, difficulty with ADLs and sleep disturbances. emotional issues like fluctuating emotions, relationship strain, fear, or withdrawal. -PTSD, depression, and anxiety are common issues plaguing victims of mass disaster.
Differentiate between the long-term prognosis of anorexia nervosa, bulimia nervosa, and binge eating disorder
-Self-worth and interpersonal functioning eventually become issues that are useful to target. Long-term outpatient treatment helps patients: -Maintain healthy weight -With individual, family, group therapy, psychopharmacology, and nutrition counseling -Address depression, substance abuse, and/or personality disorders that interfere with quality of life
BAL
0.08% legal level of intoxication in most states. Clumsiness in voluntary motor activity.
Discuss the teamwork and collaboration needed to effectively treat eating disorders
3 MAIN GOALS: -Restore the patient's nutritional state. -Modify the patient's distorted eating behaviors. -Help change distorted and erroneous beliefs about weight loss and body image. Teamwork and Collaboration needed: Nurse Psychiatrist and psychopharmacologically, Licensed Mental Health Counselor (LMHC), Registered dietician, Internist and pediatrician Psychologist, Social services, Mental Health Technician, Family Social network, Support groups
other info on crisis
4 phases of crisis: -External event -Perception of threat, increase in anxiety, cope/resolution -Failure of coping, disorganization, physical symptoms, relationship probs -Mobilization of internal and external resources, return client to pre-crisis functioning Types of crisis - Maturational- developmental stages/changes like marriage and birth -Situational- arise externally and consist of upsetting life event like death of a loved one -Adventitious- crisis of disaster that is unplanned or accidental like tornado or fire Suicidal patients! -Have feelings of worthlessness, guilt, hopelessness and feel that they are unable to go on. -Always consider possibility of suicide -Does the client have a plan, what is the plan, do they have the means to carry out the plan?
Describe two aspects of enabling behaviors that you have witnessed in friends, family, or others and explain how these behaviors can impact one's recovery process
A persons substance use or addiction affects everybody, family, friends, coworkers, and others and may leave them to adopt codependent behaviors to cope by minimizing the behaviors of the abuser and enabling a responsibility and continued drug use.
Compare and contrast the clinical picture of an individual in alcohol withdrawal with that of an individual experiencing alcohol delirium. Consider signs and symptoms, diagnostic data, risk factors, etc..
ALCOHOL WITHDRAWAL: -Early signs within a few hours (24-48hrs) -Peaks within 24 to 48 hours -Rapidly and dramatically disappears unless it progresses to delirium -Irritability and "shaking inside" -Grand mal seizures possible in 7 to 48 hours after cessation -illusions MINOR SX: ax, tremor, insomnia, HA, palpitations, GI disturbance, diaphoresis, Ox3 (person, place, time). MOD to SEVERE: mild sx & diaphoresis, increased sys BP, tachypnea, tachycardia, mild hyperthermia, hallucinations (tactile and/or auditory), & illusions although pt remain Ox3 DT (delirium tremens): moderate sx & disorientation to time, person, place, impaired attention, agitation, hallucinations (visual, tactile, auditory)., potential seizures ALCOHOL WITHDRAWAL DELIRIUM: -Medical emergency, possible death -Peaks 2 to 3 days after cessation and reduction -Autonomic hyperactivity, sensorial and perceptual disturbances, fluctuating loss of consciousness (LOC), delusions (paranoid), agitated behaviors & body temperature 100° F or higher NURSING CARE/PHARMOCOLOGICAL TX: Alcohol withdraw delirium: **Sedatives/Benzos: chlordiazepoxide (Librium) > provide safe withdrawal and has anti-convulsant affects. diazepam (Valium) > has anti-convulsant qualities ***not metabolized in the liver. Both are cross-addicting **Seizure control: carbamazepine (tegretol, valporic acid (Depakote), MG sulfate, thiamine (vit B1) > helps reduce withdrawal symptoms and the risk of seizures, increase effectiveness of vitamin B1 and helps reduce post withdrawal seizures, vitamin B1 given intramuscularly or IV before glucose loading to prevent Wernick's encephalopathy. **Alleviation of autonomic NS sx: beta blocker (propanolol) or alpha blockers clonidine > may help reduce A&S hyper activity such as trimmer, tachycardia, elevated blood pressure, diaphoresis, but should only be used with benzo, most effective in short time. MG sulfate, thiamine (vit B1), multi-vit, and folic acid > banana bag > may be given all together via IV
Compare and contrast the clinical picture of anorexia nervosa and bulimia nervosa. Consider signs and symptoms, diagnostic results/values, typical coping methods, therapeutic milieu, etc..
Anorexia Nervosa Assessment: -cachectic (severely underweight w/ muscle wasting), lanugo, malnourished, dehydrated, BMI <19, may have prominent parotid glands & largest of the salivary gland located in each cheek in front of the ears (with binging/purging), mottled, cool skin on extremities, LOW BP, HR, TEMP. Electrolyte imbalance d/t purging. -Judges self-worth by weight self induced vomiting; use of laxatives and diuretics. -Terror of gaining weight, preoccupation w/thoughts of food, view self as fat even when emaciated, peculiar handling of food: cutting foods into small bits, pushing plate around. Possible development of rigorous exercise regimen, cognition is so disturbed that individual judges self-worth by his or her way, and controls what he or she is to feel powerful to overcome feelings of helplessness. -Typical coping methods: techniques such as assisting the patient with a daily meal plan, reviewing a journal of meals and dietary intake, and providing for weekly Wayne ideally two or three times a week or essential in order to reach medically stable weight. -Therapy milieu: highly structured milieu includes precise meal times, adherence to the selected menu, observation during and after meals, and regularly scheduled weigh-ins. Close supervision of patient includes monitoring of all trips to the bathroom after eating to ensure that there is no self inducing vomiting. Bulimia Nervosa Assessment: -close to ideal body weight, enlarged parotid glands, dental erosion/caries, increased levels of anxiety, & compulsivity, binge eating, self-induced vomiting, laxative and diuretic abuse, depressive s/sx. Problems w/ interpersonal relationships, self-concept, & impulsive behaviors. Possible chemical dependency, possible impulsive stealing, Controls/undoes weight after binging, which is motivated by feelings of emptiness. -Coping methods: restructuring faulty perceptions and helping individuals develop accepting attitudes towards themselves and their bodies as a primary focus of therapy. -Therapeutic milieu: highly structured milieu of an inpatient unit has as it's primary goal the interruption of binge/purge cycle and the prevention of the disordered eating behaviors. Interventions such as observation during and after meals to prevent purging, normalization of eating patterns, and maintenance of appropriate amount of exercise are integral elements of treatment.
Assess clients for the evidence of an eating disorder to include the potential for self-destructive behaviors, family dynamics, and psychosocial and spiritual factors
Anorexia Nervosa Behaviors -exercises excessively for several hours daily (anxious if misses workout). Obsesses about food constant talks about food or eating habits, hides food peculiar handling of food eats in private, abuses laxatives or diuretics Bulimia Nervosa Behaviors: compensatory mechanisms struggle with impulsivity or compulsivity, family life may reveal chaos or instability, troubled interpersonal relationships, possible chemical dependency, possible impulsive stealing. -Fairly common in women but among the most lethal of all psychiatric diseases. Anorexia nervosa has the highest mortality rate of any mental illness. Reason for death include: starvation, substance abuse, and suicide. Results of family, twin, and adoption studies of individuals with anorexia nervosa, bulimia nervosa shown that genetic factors contribute to the risk of developing an eating disorder. •Sociocultural models look both at our present societal ideal of being thin and at the ideal feminine role model, eating disorders are now appearing in populations which had been rare. The dynamics—the stress of acculturation vs identification with the new culture are being examined
Identify examples of therapeutic interventions that are appropriate for the acute phase and those that are appropriate for the long-term phase of treatment when planning patient-centered care for a patient with anorexia nervosa and a patient with bulimia nervosa
Anorexia nervosa acute phase: A multi-disciplinary treatment approach incorporating consideration of nutritional, medical and psychological aspects, family-based therapies in younger patients and specialist therapist-led manual-based psychological therapy with long-term follow up. A harm minimization approach should be used, the approach to diagnosis and treatment should be culturally informed. Intensive care unit (ICU), critical care unit (CCU), EDs Unit (crisis state). **Establishment of trust, Monitoring of weight and eating. Countering distorted ideas. Milieu therapy, counseling, health teaching, and medications. Patient privileges linked to treatment plan compliance Anorexia nervosa long term tx: chronic illness that waxes and wanes. Recovery is evaluated as a stage in the process rather than a fixed event. Combination of individual, group, couples, and family therapy provides the anorectic patient with the greatest chance for successful outcome. Chronic illness Possible long-term treatment: Periodic brief hospital stays, outpatient psychotherapy, and medications. Greatest success with a combination of individual, group, family, and couples therapy. -Olanzapine second-generation antipsychotic, is increasingly being reported in the literature to positively affect weight gain and improve cognition and body image. Bulimia nervosa acute phase: CBT to treat eating disorders to interrupt the cycle of binge eating and purging. The goal is to normalize eating habits. Therapy is used to determine underlying conflicts and distorted perceptions. Eating disorder must occur after substance dependence (if applicable) is treated. Long term tx focuses on therapy aimed at addressing any coexisting depression, substance abuse, and or personality disorders. Fluoxetine "Gold standard" works best with concurrent CBT. **Potential for increased risk for Suicidal ideation.
Recognize life-threatening conditions that may occur in clients with anorexia nervosa and bulimia nervosa, and provide appropriate nursing interventions
Anorexia nervosa: bradycardia, orthostatic changes, cardiac murmur, sudden cardiac arrest, prolonged Q interval on electrocardiogram, acrocyanosis, symptomatic hypotension, leukopenia, lymphocytosis, carotenemia, hypokalemic alkalosis, elevated serum bicarb, electrolyte imbalance, osteoporosis, fatty degeneration of the liver, elevated cholesterol levels, amenorrhea, abnormal thyroid functioning, hematuria, proteinuria, hypoalbuminemia > causes peripheral edema. -Nursing interventions: acknowledge the emotional and physical difficulty pt is experiencing (FIRST PRIORITY ESTABLISH A THERAPEUTIC ALLIANCE) , assess for suicidal thoughts/self-injuries behaviors, weigh patient wearing only bra and underwear (SAME TIME OF DAY AFTER VOIDING & BEFORE DRINKING/EATING), monitor pt. during and after meals, recognize the patients distorted image/overvalued ideas of body shape & size, educate the pt. about the ill effects of low weight & resultant impaired health, work with patients to identify strengths. Bulimia Nervosa: cardiomyopathy, cardiac dysrhythmias, sinus brady, sudden cardiac arrest d/t electrolyte imbalance, orthostatic changes in pulse and BP, cardiac murmur, elevated serum bicarb, hypochloremia, hypokalemia, dehydration, severe attrition and erosion, loss of dental arch, diminished chewing ability, parotid gland enlargement, esophageal tears, severe ABD pain, Russell's sign. -Nursing interventions: Assess mood and presence of suicidal thoughts, monitor physiological parameters (VS, electrolytes as needed), monitor the patient's weight, explore dysfunctional thoughts that maintain the binge/purge cycle, educate the pt. that fasting can lead to continuation of bingeing and the binge/purge cycle, monitor pt. during and after meals, acknowledge the patient's overvalued ideas of body shape and size without minimizing or challenging the pt.'s perception, encourage patient to keep a journal of thoughts and feelings
Assess clients for drug/alcohol dependency, withdrawal, or toxicities and provide interventions as appropriate: include pharmacotherapy used in various treatment stages for drug/alcohol disorders
CNS depressants (alcohol, benzos, & barbiturates): these are cross-tolerant to one another. Multiple drug and alcohol dependency is can result in the simultaneous withdrawal syndrome and present a bizarre clinical picture and may pose problems for safe withdraw. Abrubt withdrawal can be fatal; with suspected OD administer activated charcoal to help absorption of drug. intoxication: slurred speech, incoordination, unsteady gait, drowsiness, decrease blood pressure, disinhibition of sexual or aggressive drives, impaired judgment, impaired social or occupational function, impaired attention or memory, and irritability. OD effects: CV/RESP depression/arrest, coma, shock, convulsions, & death. TX: if awake, keep awake. induce vomiting, give activated charcoal to aid w/ drug absorption; coma > clear airway, insert ET tube, IV fluids, gastric lavage w/ AC, freq VS checks, initiate seizure precautions Withdrawal: N/V, tachycardia, diaphoresis, ax/irritability, tremors (hands, fingers, eyelids), marked insomnia, gran mal seizures, delirium (after 5-15 yr of heavy use). PYSCHOPHARMACOLOGY USED TO MAINTAN SOBRIETY: **disulfiram (Antabuse): helps prevent relapse of alcohol abuse. Ingested in combination with alcohol, it will cost nausea, vomiting, headache, and flushing. Must be alcohol free for at least 14 days. LFT monitoring. Advantages: useful for patients who have maintain sobriety but who have a history of relapse, current motivation, and a witness ingestion. Risks: metallic aftertaste, dermatitis, severe reaction or death could result from alcohol ingestion **naltrexone (ReVia): diminishes alcohol cravings (must be alcohol/opioid free), possibly by reducing the reinforcing affects of alcohol. ALSO used to block the facts of opioids. Advantages: very useful in the acute recovery phase of alcohol dependence, first 12 weeks. Risks: nausea, abdominal pain, constipation, dizziness, headache, anxiety, fatigue vivitrol (naltrexone for ER, injectable substance): used for alcohol abuse only, should not be used if patient has opioid dependence. UDS, LFT before. Maybe easier for patients recovering from alcohol dependency to use consistently. Should not be used in patients who is also using opioids such as heroin.
Discuss the cognitive deficits that occur in all individuals with substance use disorders
Changes in their brain circuits that may persist long after detoxification. ▫Changes are evidenced in core executive functioning. ▫All SA's have difficulty with planning, working memory, inhibition, and decision making. Alterations in select attention, episodic memory, and difficulties with emotional processing. Brain doesn't fully develop until early adulthood (early to mid 20's). Therefore youth and teenagers are at risk for "long-term impact on those whose brains are still busy building new connections and maturing in other ways" during this stage of development.
Discuss what is meant by a crisis and identify at least six principles of crisis intervention
Crises: s a turning point at which a crucial and decisive decision must be made ◦A struggle for equilibrium and adjustment when problems seem unsolvable ◦**Acute, time-limited occurrence experienced as an overwhelming emotional reaction Crisis intervention: INITIAL GOAL > pt safety & anxiety reduction - plan & conduct crisis assessment, establish rapport & rapidly establish relationship, identify major problems (including the "last straw" or crisis precipitants), deal w/ feelings & emotions (including active listening & validation), generate & explore alternatives, develop & formulate and action plan, & follow-up plan & agreement. -Assess for suicidal and homicidal ideation or plans .-Make the patient feel safe, and lower the anxiety -Listen carefully -Maintain directive and creative approaches. -Assess the patient's support systems. -Identify the needed social supports and rally them. -Identify the needed coping skills. -Plan acceptable interventions (to patient and nurse). -schedule regular FU to assess progress 6 principles of crisis intervention (Box20-1) -Crisis is self-limiting and usually resolves in 4-6 weeks -Goal of crisis intervention is to return the individual to the pre-crisis level of functioning. -How crises are resolved are unique to specific crises, as well as how individuals respond to them -During a crisis people are more open to outside help --Person in a crisis is assumed to be mentally healthy and to have functioned well in the past -Crisis intervention deals with the persons present problem and resolution of the immediate crisis only
Discuss the rationale for inclusion of motivation and spirituality for planning care and how that may affect your patient's progress toward sobriety
Enhance person motivation for ABSTINENCE (strongly r/t good work adjustment, positive health status, comfortable interpersonal relationships, & general social stability). Spirituality: important aspect of recovery in AA & a host of other recovery modalities. Spirituality levels & spiritual practices are related to improved outcomes; strong body of evidence that spiritual & religious beliefs could impact the use & abuse of substances. Higher spiritual levels correlate w/ sense of purpose, gratitude, and forgiveness which are all aspects of spirituality. Motivational incentives: much like token therapy, positive reinforcements (such as privileges) are provided when pt participates in counseling sessions, maintains a therapeutic drug regimen, or remains drug-free for example. Motivational interviewing: provides strategies to evoke rapid & internally motivated change to stop drug use & facilitate tx. Motivational strategies help resolve ambivalence (having mixed feelings/contradictory ideas about someone/something) by asking evocative questions that elicit change in thinking & behavior. Guided by 4 principle evoking change: a) expressing empathy, b) developing discrepancies, c) rolling with resistance, & d) supporting self-efficacy (the set of beliefs we hold about our ability to complete a particular task)
Plan care and provide teaching for clients experiencing substance-related withdrawal or toxicity; incorporate the client's cultural practices and beliefs, as well as psychosocial and spiritual factors
Goals ▫Remaining free from injury while withdrawing from the substance ▫Attending programs for treatment and maintenance of sobriety ▫Attending a relapse prevention program during the active course of treatment ▫Verbalizing cues or situations that pose increased risk of drug use ▫Having a stable group of drug-free friends and socializing with them at least three times a week by {date} ▫ Demonstrating 1 new skill in dealing with troubling Planning: Unique because must consider: socioeconomic situation, ethnic background, gender, age, substance abuse history, and current condition ▫Best option: ABSTINENCE from abusing drug ▫Must address psychologic, social, and medical problems along with issue of substance abuse. ocial status and social relations often suffer due to addiction ▫Essential to include FAMLY whenever possible. Job loss>no income>unable to meet basic needs ▫Marriage and relationships fail = social isolation mplementation ▫Aim of treatment is SELF-RESPONSIBILITY, not compliance ▫There is no "one size fits all" treatment for addiction ▫Treatment may be covered by insurance ▫Remember there are often long-term effects even once the addict is in recovery ▫What is the role of the nurse here? Recognizing sx of substance abuse in both pt/family & being familiar with the community resources in their area.
Explain the mental health safety needs that people may face if they do not obtain support during or after a crisis period
If individuals are not assisted early on they are left vulnerable to stress-related disorders and chronic impairment.
Identify factors that may cause a crisis for a client
Major factors that may cause a crisis include: overwhelming presence of other stressful life events, mental illness, substance abuse, history of poor coping skills, diminished cognitive abilities, pre-existing physical health problems, limited social support network, and developmental or physical challenges
Opiate intoxication/withdrawal
Narcotics (morphine, heroin, codeine, fentanyl, methadone) Intoxication sx: constricted(pinpoint) pupils, decrease RR, decreases BP, slurred speech, drowsiness, psychomotor retardation, initial > euphoria, later > dysphoria, impaired concentration, judgement, and memory . Withdrawal: yawning, insomnia, irritability, rhinorrhea, panic, diaphoresis, cramps, N/V, muscle aches, chills/fever, lacrimation, diarrhea. **naloxone (Narcan): FIRST choice to tx opioid toxicity/OD. Disadvantage > short-acting **methadone: tapering & can be used for maintenance therapy. Detox tool; SYNTHETIC opiate that reduces severe withdrawal effects and blocks craving for & effects of heroin. Long-acting **naltrexone (ReVia, Vivitrol): antagonist that blocks EUPHORIC affects of opioid. **clonindine (Catapres): E-R/injectable suspension over a month period. Is an effective somatic treatment when COMBINED with naltrexone
Provide care and support for clients with non-substance related dependencies, such as gambling, sexual addiction, etc
Self-help groups & 12step program.
Compare and contrast the difference between substance abuse and substance dependence, as well as the symptoms of tolerance and withdrawal
Substance Abuse: •Habitual use of a substance occurs outside of a medical necessity. •Abuse of a substance occurs outside of social acceptance. •Purpose is to alter one's mood or emotional state of consciousness •Results in adverse effects to the abuser or to others Substance Addiction/dependence •Habitual psychological and physiological dependence on a substance or practice beyond one's voluntary control •Tolerance occurs when a person has to take more of the drug to "stay normal" and/or to prevent withdrawal. •Control over substance is lost. •Can be fatal. Tolerance: ▫The need for increasing amounts of the substance to reproduce the effects originally produced by smaller doses ▫Person has to take increasing amounts of the drug to "stay normal" •Withdrawal ▫Occurs after a long period of continued use, so that stopping or reducing use results in specific s/s specific to the substance
Provide an overview of Critical Incident Stress Debriefing (CISD), including its purpose and process
The CISD is a tertiary intervention directed toward a group that has experience a crisis like a school shooting or natural disaster. It is a 7 phase program that gives people the opportunity to share thoughts and feelings in a safe environment. -Intro phase- purpose of debriefing is presented, confidentiality is assured, members are identified, and questions are answered -Fact phase- participants are assisted in discussing the incident from their perspective -Thought phase- discuss initial thoughts -Reaction phase- discussing most painful parts of incident -Symptom Phase- describe cognitive, emotional, behavioral, experiences -Teaching phase- feelings are affirmed and stress management techniques are discussed. -Reentry phase- any new topics discussed, members provide encouragement and resources for help, experience is summarized
Describe how reporting an impaired colleague to the proper authorities would protect the safety of clients.
The patient is always the nurses first responsibility. When nurses observed signs of impairment in healthcare colleague, documentation of reporting are imperative using the guidelines set out by your state & facility. Patient safety comes first, but ensure effective treatment for a colleague through a program that will allow for return to work when here she is sober.
a-motivational syndrome
There's been a great concern over chronic use of cannabis and the possibility that heavy use can produce persistent cognitive defects and or in amotivational syndrome. And amotivational syndrome is characterized by apathy, loss of achievement motivation, decrease in productivity, difficulty with learning and memory, impaired concentration, lack of personal hygiene, and preoccupation with the drug