journal entry psych

NO PLAGERISM

Compare and contrast the serious medical and social
consequences of alcohol abuse to drug abuse. Which
abuse do you think is more detrimental to a client’s
quality of life? Why? Which abuse do you think is more
detrimental to a client’s family? Explain your answers.

I believe alcohol use is more detrimental, utilize the powerpoint to complete this, the setting of the clinical rotation is Newark Beth Israel Medical Center, Newark, NJ 

go into detail and complete the following questions by answering the questions below. assignment must be 3 pages:

Assignment:

In your entry, briefly review the content, idea, issue, or event you are reacting to,
but go beyond an impersonal description of it. Comment on the significance of the
event, and explain what meaning it has for you. You may discuss how relevant the
idea is for you academically, professionally, or personally. Demonstrate that you
have thought about the issue in some way that is not superficial, hopefully by
relating it to class concepts. Then consider the implications of what you have
discussed, speculate on how the meanings or insights you’ve gained can be used
for improvement or growth

My initial thoughts/feelings on the topic were:

Input from readings and the class have altered my perception in the following
ways: 

Please substantiate this section with 3 scholarly references to the literature. Be
specific in this section.

Three implications for nursing practice are:
In this section make the implications relevant specifically to the topic at hand and
not nursing in general.
1.
2.
3

Describe a significant situation or event which occurred in your clinical day.
Explain why the event was important to you, as related to developing
understanding of the nursing care of a client who has (a) mental health
condition(s). Note that “significant event” differs from “critical incident;” i.e.,
the event or situation about which you write your journal entry should
reflect your specific personal learning/development of insight, as opposed to
an evaluation of the event/situation as “minor” or “major” to clinical practice
in general.

• Discuss how this event might have been perceived by others involved (e.g.,
the client, staff, classmates) and those external to the event. For example,
pretend you are someone else (a client, staff nurse, teacher, classmate, etc.)
and react to something you did today in your clinical practice; i.e., if you
attempted to communicate with a client who had aphasia today, write about
the situation from the perspective of the client, etc. Explore alternative ways
of interpreting and responding to the event, including an evaluation of the
feasibility and acceptance of each of these alternatives.

• Identify the specific learning has occurred for you in reflecting about this
event. What specific thing(s) did you learn today and how will you apply that
learning in your practice as a nurse? Identify some differences in what you
learned today from what you learned previously. How will you apply this
learning in your practice as a nurse? As appropriate, you may wish to re-
read a journal entry from a previous week, and write a reaction to what you
wrote, in relation to new learning that has occurred over time.

Note: State that seeing many young children attempting to end their lives made it difficult to try and not relate it to my younger siblings and keep everything neutral – the experience was an eye opener

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SUBSTANCE ABUSE DISORDERS

LEARNING OBJECTIVES

Explain the disease concept of alcoholism and the following theories of addiction: biologic, genetic, behavioral and learning, sociocultural, psychodynamic, and the disease concept of alcoholism

Differentiate the following terms: substance use, addiction, psychological dependence, tolerance, and physiologic dependence

Discuss the dynamics of enabling and codependency

Articulate the difference between alcohol dependence and alcohol abuse

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LEARNING OBJECTIVES (CONT’D)

Recognize the more common physiologic effects of alcoholism

Identify the common medical problems associated with illicit abuse of substances (drugs)

Describe the rationale for the use of substance abuse screening tools during the initial assessment of a client with a substance-related disorder

Evaluate the treatment measures, including nursing interventions, for a client with a substance-related disorder

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LEARNING OBJECTIVES (CONT’D)

Formulate a list of nursing interventions for a client with clinical symptoms of acute substance intoxication

Develop a list of services available to clients who abuse substances

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Perspectives on Substance-Related Disorders:

An Overview

Five Main Categories of Substances

Depressants – Result in behavioral sedation (i.e., alcohol, barbiturates, benzodiazepines, GHB)
Hallucinogens – Alter sensory perception (i.e., LSD, PCP, Mescaline (Peyote)
Opiates – Primarily produce analgesia and depressant (i.e., heroin, morphine derivates, narcotics)
Stimulants – Increase alertness and elevate mood (i.e., amphetamines, caffeine, cocaine, ecstasy, and nicotine)
Other drugs of abuse – Include inhalants, anabolic steroids, medications

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Polysubstance abusing individual

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ALCOHOL (cont.)

Alcohol has greater costs to society than any other drug

Has the most serious effects on fetal development during the brain growth spurt period, which occurs during the last trimester of pregnancy and for several years after birth

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DSM-IV Criteria for Diagnosing Substance Abuse
One or more of the following occurs during a 12-month period:

Failure to fulfill important obligations at work, home, school as a result of use

Repeated use of the substance in physically hazardous situations

(i.e., driving a car)

Continued use of the substance despite social, interpersonal or legal problems as a result of use

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Abuse vs dependency

Abuse: utilizing the substance that interferes with functioning

Dependence: is a more extreme form of abuse with an increasing number of negative consequences

Dopamine is implicated for these individuals

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DSM-IV Criteria for Diagnosing Substance Dependence

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DSM-IV Criteria for Diagnosing Substance Dependence (cont.)
b) Withdrawal, physiological, behavioural, cognitive, and affective symptoms that occur after reduction or discontinuance of a drug that has been used heavily over a long period of time
Withdrawal is also a result of the altered DA system. Withdrawal and abstinence deprive the brain of the only source of DA that produces a sense of pleasure. Without the drug, life seems not worth living.

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DSM-IV Criteria for Diagnosing Substance Dependence (cont.)

Substance often taken in larger amounts

or over a longer period

Persistent desire or unsuccessful efforts

to cut down or control use

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DSM-IV Criteria for Diagnosing Substance Dependence (cont.)

A great deal of time is spent

Obtaining the substance
Using the substance
Recovering from the effects

Social, occupational, recreational activities given up or decreased

Type of drinkers:

Binge Drinkers

Definition:

Consumes large amounts of alcohol in a short period, usually on weekends or during specific periods.

Some may binge only on weekends, while others may drink during the week and abstain on weekends.

Psychological Aspect:

Uses Freud’s Ego Defense Mechanisms to justify their drinking behavior.

Rationalization: They minimize or justify their drinking (e.g., “I only drink on weekends, so it’s fine.”).

Alcohol Withdrawal:

Onset:

Symptoms typically begin 6 to 8 hours after the last drink.

Peak severity occurs 24 to 72 hours after cessation but can last for days to weeks, depending on the severity.

Withdrawal Symptoms:

Ataxia:

Loss of coordination, clumsy movements, and difficulty walking.

Vital Sign Fluctuations:

Blood pressure, heart rate, and respiratory rate may fluctuate due to the body adjusting to the absence of alcohol.

Hypertension:

Elevated blood pressure due to increased sympathetic nervous system activity.

Vomiting:

Nausea and vomiting as the body attempts to rid itself of toxins.

Headache:

Resulting from dehydration and changes in blood flow to the brain.

More Serious Symptoms of Alcohol Withdrawal:

Delirium Tremens (DTs):

A severe and life-threatening form of alcohol withdrawal.

Can cause seizures, hallucinations, confusion, heart attack, agitation

Onset: Usually occurs 48 to 72 hours after the last drink but can take up to 2 weeks in some cases.

Confabulation:

Filling in gaps in memory with false information, often seen in people with chronic alcohol abuse.

Happens due to damage in memory areas of the brain.

Wernicke’s Encephalopathy and Korsakoff Syndrome:

Both are conditions caused by thiamine (vitamin B1) deficiency, common in chronic alcoholics.

Wernicke’s Encephalopathy: Acute and reversible condition causing confusion, lack of coordination, and eye movement abnormalities.

Korsakoff Syndrome: Chronic and often irreversible condition marked by severe memory loss and confabulation.

Brain Effects:

Disturbance of Glutamate:

Alcohol suppresses glutamate, a neurotransmitter that stimulates brain activity.

During withdrawal, glutamate levels spike, leading to over-excitation of the brain, which causes seizures, agitation, and hallucinations seen in DTs.

Detox protocol: Librium (benzodiazepines) – low potency longer acting because we want to avoid 1 addiction substituting another addiction, Thiamine, Folic acid, Vitamin B12, B1
Detox: 3-4 days (typical)
Day 4: Librium q 4hr, Day 3 q 3 hrs, Day 2, q 2 hours – the drug is tapered throughout the 4 day period
Slow with medication management: because pt can go into resp depression

What is their history?

Detox Protocol for Alcohol Withdrawal:

1. Medications Used:

Librium (Chlordiazepoxide)

Class: Benzodiazepine

Why Librium?

Low potency and long-acting → Preferred for alcohol withdrawal to prevent severe symptoms (seizures, DTs).

Goal: Avoid substituting one addiction (alcohol) with another (short-acting benzodiazepines like Xanax or Ativan).

Tapering Protocol:

Day 1: Administered every 4 hours

Day 2: Administered every 3 hours

Day 3: Administered every 2 hours

Taper Duration: Usually over 3-4 days to gradually reduce the dosage and prevent withdrawal complications.

Antipsychotics may be given as well because the patient may be having illusions, pt must be observed

2. Essential Vitamins and Supplements:

Thiamine (Vitamin B1):

Prevents Wernicke’s Encephalopathy and Korsakoff Syndrome.

Given to replace deficiencies caused by chronic alcohol use.

Folic Acid (Folate):

Helps with red blood cell production and prevents anemia caused by poor nutrition in alcoholics.

Vitamin B12:

Supports nerve function and helps prevent further neurological damage.

3. Duration of Detox:

Typical Length:

3 to 4 days depending on the severity of withdrawal and patient response.

4. Tapering Librium Schedule (Example):

Day 1: Librium every 6-8 hours 50 mg

Day 2: Librium every 6-8 hours 25 mg

Day 3: Librium every 6-8 hours 15 mg

Day 4: Gradual tapering and discontinuation

Librium may not be necessary if mild withdrawals or when the pt is about to be discharged

5. Why Slow Medication Tapering is Important:

Risk of Respiratory Depression:

Benzodiazepines (like Librium) depress the central nervous system.

Rapid administration or high doses may cause respiratory depression, sedation, and coma.

Goal: Use the minimum effective dose and taper gradually to avoid complications.

✅ Key Points:

Librium is used for safe withdrawal and to prevent seizures/DTs.

Vitamin replacement prevents long-term neurological damage.

Slow tapering minimizes the risk of respiratory depression.

Flushed red, puffy appearance, ascites (perfusion of abdomen), ulcer bleeding, Liver becomes affected.

History of patient: what is the cause of the alcoholism? Could be genetics

As a younger child the individual may have had to take over the parent role to their younger siblings – this could effect the future and have the person result to substance abuse

Features of family members:

Enabler: utilizing Freuds coping mechanism, justifying and rationalizing things, keeping alcohol and saving some for later but hiding the alcohol throughout the day

– Dependency: Allowing individual to stay at home and allowing them to drink
Alcoholics should stay away from other alcoholics: example gf alcoholic is very educated about alcohol but she is an alcoholic as well, she is an enabler

Treatment: Rehab 30 days, individual is 2x likely to resort back to alcohol
90 day rehab is preferred because the rehab digs into what is the route cause of the problem – “why have they suppressed repressed their problems”
Rehab is voluntary, programs are to follow once rehab is complete, after rehab is over the problem doesn’t end because its easy for the individual to go back to old ways

Alcoholics may guilt trip someone to help them get their fix – Families can be referred to support groups as well to figure out how to deal with the alcoholic

Family members would often fight about the individual as one could believe that they are doing what’s best vs what the other person believe what is best

12 Steps of AA:

Denial → Admission of Powerlessness

“We admitted we were powerless over alcohol—that our lives had become unmanageable.”

Hope → Belief in a Higher Power

“Came to believe that a Power greater than ourselves could restore us to sanity.”

Surrender → Turning Life Over to Higher Power

“Made a decision to turn our will and our lives over to the care of God as we understood Him.”

Self-Reflection → Moral Inventory

“Made a searching and fearless moral inventory of ourselves.”

Confession → Admitting Wrongs

“Admitted to God, to ourselves, and to another human being the exact nature of our wrongs.”

Readiness → Prepared for Change

“Were entirely ready to have God remove all these defects of character.”

Humility → Asking for Help

“Humbly asked Him to remove our shortcomings.”

Accountability → List of Those Harmed

“Made a list of all persons we had harmed and became willing to make amends to them all.”

Making Amends → Taking Responsibility

“Made direct amends to such people wherever possible, except when to do so would injure them or others.”

Continuous Reflection → Ongoing Self-Assessment

“Continued to take personal inventory, and when we were wrong, promptly admitted it.”

Spiritual Growth → Prayer and Meditation

“Sought through prayer and meditation to improve our conscious contact with God, as we understood Him, praying only for knowledge of His will for us and the power to carry that out.”

Service to Others → Spreading the Message

“Having had a spiritual awakening as the result of these steps, we tried to carry this message to alcoholics and to practice these principles in all our affairs.”

Substance abuse: relapse may happen, rehabs tell them to keep it pushing but don’t look at it like a failure
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Alcohol Dependence
Three patterns of use varies from person to person
Drinking large amounts every day
Binge drinking for weeks followed by abstinence
Binge drinking every weekend
People with ETOH dependence can drink with control and at other times, they cannot control drinking behaviour. As the course of alcoholism continues, there may be behaviours such as starting the day off with a drink, sneaking drinks through the day, gulping alcoholic drinks, shifting from one alcoholic beverage to another, and hiding bottles at work and at home.

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Effects of Alcohol

Central Nervous System (CNS) depressant

Stimulates GABA system; increases serotonin & dopamine; inhibits glutamate in both ways, the outcome is depression of the CNS
Short-term
Blood Alcohol Content (BAC)
0.02 = Pleasant feeling, well-being
0.05 = Giddiness, lowered inhibitions & impaired judgment
0.08-0.10 = Legal limit of intoxication; incoordination, speech problems, visual & thought impairment
0.20 = Brain motor area depression causes staggering, easily angered, shouting
0.30 = Confusion, stupor
0.40 = Pass out (lose consciousness), coma
0.50 = Death

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Effects of Alcohol (cont.)

Short-Term Effects
Happy, lose inhibitions
Poor judgment, poor concentration
Impaired sexual functioning

Long-Term Effects
Preoccupied with drinking; secretive
Anxiety, perhaps hallucinations
Blackouts, amnesia for events that occurred during or immediately following the drinking period
Destroys brain cells, poor nutrition
Cirrhosis (1:10 excessive drinkers)

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Physiological Complications

of Alcohol Dependence

Low-grade hypertension

Liver cirrhosis

Vitamin deficiencies

Fetal Alcohol Syndrome (FAS or FAE)

Wernicke’s encephalopathy

Korsakoff’s psychosis

Alcohol-induced dementia

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Alcohol Intoxication

Accidents or falls that may cause contusions, sprains, fractures, and facial or head trauma

Disorientation

Irritability

Labile emotions

Lack of coordination

Lack of inhibition

Loud and frequent talking

Nausea

Poor judgment

Short attention span

Slurred speech

Staggering

Violent behaviors

Vomiting

Unconsciousness, coma, respiratory depression, and death

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Alcohol Withdrawal Syndrome (AWS)

Typically begins 6-8 hours after last drink

Anxiety
Autonomic hyperactivity: sweating, increased heart rate,…
Insomnia
Irritability
Nausea
Sweating
Tremor
Can even lead to grand mal seizures (6-48 hours) (controlled with benzodiazepines)
Intermittent auditory, tactile or visual hallucinations, and/or illusions (12-48 hours) (misinterpretation of external stimuli; i.e., looking at a cord on the floor and thinking you are seeing a snake)

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Alcohol Withdrawal Delirium (cont.)

Psychoses associated with alcoholism

Alcohol Withdrawal Delirium (DTs)- usually occurs on days 2 & 3 (48-96 hours) but may appear as late as 14 days after last drink
Agitation
Acute fear
Confusion
Diaphoresis
Disorientation for time and place
Extreme suggestibility
Hypertension
Perspiration, fever, rapid & weak
heartbeat
Tachycardia
Tremors of hands, tongue, & lips
Vivid hallucinations
Coated tongue, foul breath
Death may result from collapse

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Alcohol Withdrawal Delirium (cont.)

Alcohol Dementia

Characterized by impaired abstract thinking and judgment, personality changes, and impaired memory. This is often seen in chronically heavy drinkers.

Wernicke’s Encephalopathy

Characterized by ataxia (lack of coordination), abnormal eye movements, and confusion. These symptoms results from thiamine deficiency.

Korsakoff’s Psychosis

Caused by toxic effects of alcohol on glutamate transmission necessary for memory storage
Inability to retrieve long-term memory of events or retain new information
Confabulation- as they try to fill in gaps of memory

Wernicke’s Encephalopathy

Characterized by ataxia (lack of coordination), abnormal eye movements, and confusion. These symptoms results from thiamine deficiency.

Korsakoff’s Psychosis

Caused by toxic effects of alcohol on glutamate transmission necessary for memory storage

Inability to retrieve long-term memory of events or retain new information

Confabulation- as they try to fill in gaps of memory

Wernicke’s Encephalopathy: movement, if it gets worse then youll get korsakoffs, ataxia (staggering gate)

Korsakoff’s Psychosis:

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Treatment & Outcome (cont.)

Biological approaches

Detoxification
Benzodiazepines
Are the medications of choice as they decrease withdrawal symptoms by preventing CNS hyperexcitability and prevent seizures (i.e., Librium)
Thiamine (Vitamin B1)
Are given during alcohol withdrawal to decrease the rebound effect of the nervous system (prevents or treats Wernicke’s and Korsakoff’s syndrome) as it adapts to the absence of alcohol
Vitamin B12 and folic acid for nutritional deficiencies
Rehabilitation
Antabuse (Disulfiram)
Antabuse inhibits aldehyde dehydrogenase (ALDH) and leads to an accumulation of acetaldehyde if alcohol is ingested. Reaction occurs within 5 to 10 minutes and may last from 30 minutes to several hours.
Symptoms include: flushing, nausea and copious vomiting, thirst, diaphoresis, dyspnea, hyperventilation, throbbing headache, palpitations, hypotension, weakness

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Avoid anything with alcohol: mouthwash, cough medicine, hand sanitizer – if it touches the skin the pt will have a bad reaction
– More on next slide

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Treatment & Outcome (cont.)
Medication Teaching of Antabuse (Disulfiram): avoid all exposure to alcohol and substances containing alcohol, including food, liquids, and substances applied to the skin (i.e., ETOH swabs, mouthwash, cough syrups, shaving lotion, nail polish remover, and cologne)
Naltrexone (ReVia) and Acamprosate (Campral)
Decrease craving for alcohol and narcotics and lower the relapse rate

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Opiates

Addictive: Concerns led to the Harrison Narcotic Act in 1914 to control use

Administration routes: IV (“mainlining”), snorted or smoked

Low doses – Euphoria, drowsiness, and slow breathing
High doses can be fatal
Withdrawal symptoms can be lasting and severe

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What effects is the client trying to achieve?
What are they trying to escape? Theyre underlying emotions and reliality
Once the medication wears off they go back to reality and feel worse whoch then creates dependency because they will take more

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Opiate Intoxication

When injected IV levels rise rapidly giving a brief, intense sensation called a rush or thrill

This is followed by a longer-lasting period called euphoria (a high, sense of calmness)

Continued use decreases the body’s production of endorphin & enkephalin, resulting in a very low tolerance of pain and discomfort during withdrawal

Can be snorted and injected
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Opiate Intoxication (cont.)

Opioids depress respiration and decrease GI motility

To treat overdose give IV narcan (narcotic antagonist, 0.4-2mg) to reverse respiratory depression & coma

Even more dangerous if used in combination with other substances

People who use cocaine use heroin in combination because cocaine loses its effects of euphoria quickly and heroin maintains it

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Family members may bring in the substance as they are enablers

Overdose treatment: Narcan

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Opiate Withdrawal

Withdrawal from short-acting drugs vs. long-acting drugs

Short-acting drugs (i.e., heroin) occur within 6-12 hours after the last dose, peak within 1-3 days, and gradually subside over a period of 5-7 days
Longer-acting drugs (i.e., methadone) withdrawal symptoms begin within 1-3 days after the last dose and are complete in 10-14 days
Aches, agitation, anxiety
Runny nose, teary eyes, perspiration
Chills vs. sweats, vomiting, diarrhea, cramps
Back pain, severe headache, tremors
Dehydration, can lose weight
Methadone as a treatment of choice for heroin

Withdrawal: flu like symptoms – Aches, agitation, anxiety, Runny nose, teary eyes, perspiration, Chills vs. sweats, vomiting, diarrhea, cramps, Back pain, severe headache, tremors, Dehydration, can lose weight

Methadone – nurse needs to confirm with clinic that pt is getting their methadone from then dr will prescribe methadone
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Complications

Poisoning because heroin is often “cut” with substances that may contain impurities to increase the quantity for sale

Addicts may use unsanitary needles

High risk for hepatitis
HIV infection
AIDS
Liver problems
Kidney failure

Suboxone: opioid antagonist – only used for opiates
Helping cover the cravings the opiates give

Review veins – cellulitis could happen

Needle exchange programs: because substance abuse users will get their drug anyway, curve HIV/AIDs by providing clear needles
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Causal factors in opiate abuse

NO SINGLE PATTERN!
Pleasure is a common reason given (81%)
Addiction associated with pain relief
Addiction associated with psychopathology

Treatment & Outcome

Detoxification
Methadone
Purpose of methadone is to reduce the craving to ward off withdrawal symptoms. Provides a longer-acting narcotic that is a substitute for heroin.
Buprenorphine
Under-the-tongue lozenge acts like extra-mild methadone at low doses

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Sedative, Hypnotic, or Anxiolytic Substance Use Disorders:

An Overview

The Nature of Drugs in This Class

Sedatives – Calming (i.e., barbiturates = Amytal, Phenobarbital, Seconal)
Hypnotic – Sleep inducing (i.e., Ambien, Lunesta, Restoril)
Anxiolytic – Anxiety reducing (i.e., benzodiazepines = Ativan, Valium, Xanax)

Effects Are Similar to Large Doses of Alcohol

Combining such drugs with alcohol is synergistic. Cause significant CNS depression (decreased BP, HR)

All Influence the GABA Neurotransmitter System causing significant CNS depression

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Alcohol and pills are typically abused together

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Sedatives
Barbiturates & Benzodiazepines
Powerful CNS depressant
Medical uses = calming, induce sleep
After short time, feel relaxed then drowsy
Excessive dose is lethal
Physically addictive
Effect: depression, drowsiness, euphoria, labile emotions, irritability, impaired attention and working memory loss, impaired comprehension, mood swings, motor incoordination, sluggish, slow speech, thinking is “fuzzy”
Brain damage may occur if prolonged use
Associated with more overdoses & suicides than any other drug
Cold clammy skin
Weak & rapid pulse
Shallow respirations
Coma & death (increases when combined with ETOH)

Main take away:
The more that is used the higher the tolerance
Withdrawls – these meds cannot be stopped abruptly because they can die from seizures – pt needs to be in a controlled enviorment to deal with the withdrawal effects
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Causal factors in barbiturate dependence
Many experiment, most don’t become dependent
“Silent abusers”
Combining with alcohol can be deadly
The drugs potentiate one another
Treatment & Outcome
Withdrawal symptoms more dangerous than for opiates (6 to 8 hours of last dose to greater than a week)
Altered perceptions, delirium, hallucinations
Agitation, anxious, apprehensive, insomnia
Coarse tremors in hands, face
Weakness, nausea/vomiting, lose weight
Rapid heart rate, high blood pressure
Possible convulsions
If individuals have been taking high doses for a long period of time, WD process should be medically supervised
Abrupt cessation can lead to seizures thus carefully titrate downward until withdrawal process is complete

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Stimulants:

Cocaine Use Disorders (cont.)

Cocaine
Causes vasoconstriction when snorting through the mucous membranes may cause ulceration of the nasal mucous membranes and may lead to perforation of the septum and loss of the sense of smell
Short half-life: Wears off quickly
Makes it less efficient than if smoked as crack
Stimulates cortex inducing excitement & sleeplessness
Initial rush of euphoria lasts 10-20 min., feeling confident & content
May hallucinate with chronic use (some tolerance)
Use can be fatal
Crack (looks like small “rocks”)
Immediate high & intense addiction
freebase cocaine, purified, 6-7 sec. for the drug to reach the brain, high lasts only 2-5 min., and the crash is more severe

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Cocaine: fast acting and doesn’t last that long in system, typically combined with heroin
Who would abuse cocaine: people in the entertainment industry
Appetite: suppresses
Increases confidence
Cocaine can be very expensive

Snorting is common route – crosses the blood brain barrier quicker – watch for cardiac

As a nurse you would observe the nose passageways, bloody noses, irritation

Eyes:

Pin point pupils

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Stimulants:

Cocaine Use Disorders (cont.)

Cocaine: Comorbid with alcohol abuse
Drug Addiction Unit of the Montreal General Hospital: 29% of patients were abusing cocaine & alcohol

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Stimulants:

Cocaine Use Disorders (cont.)

Intoxication

Anger
Combativeness
Euphoria, mental alertness
Rapid heartbeat
Dilation of pupils
Changes in blood pressure, pulse, respiration
Increased energy
Feelings of self-confidence
Tension, fatigue, shyness disappears and the person becomes more talkative and playful (lasts 10-20 min.) Large doses can lead to paranoia & violent behaviour
Seizures, respiratory depression, and cardiac arrhythmias

People with low self esteem may take this, more energy, agitates the patient more
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Cocaine Withdrawal

Following cocaine use, the intense pleasure is replaced by equally unpleasant feelings. Referred to as a rebound dysphoria or “crash.” Negative reinforcement occurs when person experienced crash takes more cocaine to overcome dysphoria.

Fatigue

Vivid dreams

Insomnia or hypersomnia

Increased appetite

Psychomotor agitation or retardation

Treatment is dependent on what the patient is experiencing
Insomnia: benzo may be prescribed
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Cocaine Withdrawal (cont.)

Some try speedballing, in which cocaine is mixed with heroin and injected IV. High reached in seconds. Appeal of speedballing is that heroin decreases the unpleasant jitteriness and crash from cocaine.

Treatment of withdrawal

Lidocaine or propranolol IV for ventricular dysrhythmias
Seizure medications

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Stimulants:

Amphetamine Use Disorders

Effects of Amphetamines

Produce elation, vigor, reduce fatigue
Effects are followed by extreme fatigue and depression

Ecstasy and Ice

Produces effects similar to speed, but no “comedown”
2% of college students report using Ecstasy
Both drugs can result in dependence

Amphetamines stimulate CNS by

Enhancing release of norepinephrine and dopamine
Reuptake is subsequently blocked

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Substance induced dementia could happen, blackouts, confabulation
Brain damage could be irreversible
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Abusing drugs, could:

Age the person
Some substance could be acidic: burns the face

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Some substances could erode the teeth
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Treatment & Outcome for Amphetamine Abuse
Withdrawal usually painless
Enhanced appetite, exhaustion, excessive need for sleep, fatigue, unpleasant dreams,
Cold turkey withdrawal can cause cramping, nausea, diarrhea, convulsions if use was chronic

Treatment: supportive treatment, suppresses the appetite: now they may have an increased appetite
Hypertensive? Beta blockers or another hypertensive med may be given
Seizure risk: smalla mount of seizure med may be given if pt is at risk
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Stimulants:

Nicotine Use Disorders

Effects of Nicotine

Stimulates nicotinic acetylcholine receptors
Stimulant that has direct reinforcing effects on DA in the nucleus accumbens, the reward center of the brain
Results in sensations of relaxation, wellness, pleasure
Nicotine is highly addictive
Relapse rates equal those for alcohol and heroin users

DSM-IV-TR Criteria for Nicotine Withdrawal Only

Psychological symptoms
Physiological symptoms

Cessation causes withdrawal symptoms (i.e., anxiety, headaches, inability to concentrate, insomnia, irritability, overeating, and restlessness)

TX: nicotine patches

Nicotine patches could be given to assist in weening off

Physiological complication: lung cancer, esophageal cancer, oral cancer, second hand smoking, stains teeth (yellow)
Cigarettes aren’t cheap
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Nicotine

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The first dose of nicotine in the morning brings the most pleasure: because you were sleeping you were off the nicotine for a long time, dopamine goes down when you sleep, dopamine will go up once you smoke the cigarette bc it brings the indivisual the most joy

dependency

C – Cut down

“Have you ever felt you should cut down on your drinking?”

A – Annoyed

“Have people annoyed you by criticizing your drinking?”

G – Guilty

“Have you ever felt guilty about your drinking?”

E – Eye-opener

“Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover (eye-opener)?”

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Stimulants:

Caffeine Use Disorders

Effects of Caffeine – The “Gentle” Stimulant

Found in tea, coffee, cola drinks, and cocoa products
Blocks the reuptake of the neurotransmitter adenosine resulting in mental alertness
Small doses elevate mood and reduce fatigue
Used by over 90% of Americans
Regular use can result in tolerance and dependence
Intoxication from caffeine usually occurs following consumption in excess of 250 mg
Complications- increased anxiety, jittery, or shaky, insomnia, dependency and withdrawal can occur

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Can experience dependency
Can be costly

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Hallucinogens:

An Overview

Nature of Hallucinogens

Examples include LSD, PCP, Mescaline (Peyote)
Heighten visual perception, produce delusions, paranoia
Popular in nightclubs, raves, or large social gatherings

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Young age group

These make the pt super psychotic
These substances are very dangerous: delusions, flashback
Safety is very important for these pts
Restraints may be necessary

Drug screen only tells if positive or negative doesn’t give how much
Nurses shouldn’t go into these pts room by themselves esp if giving IM – after giving IM nurse turned her back and the pt pushed her down and was about to rape her

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Hallucinogens:

An Overview (cont.)

One of the dangers is a “bad trip”: during which the person is in a psychotic state and terrified by perceptual changes, hallucinates, severe anxiety, paranoia, loss of control, or insane

The 2nd type of reaction is the “flashback” previous hallucinogenic experiences that occur in the absence of the substance

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Hallucinogens
LSD & PCP (most potent hallucinogen)
8 hours of altered sensory perception, labile emotion, depersonalization, derealization
Effect peaks within minutes to a few hours
Sensory-perceptual distortion
Belligerence, assaultiveness, impulsiveness, unpredictability, psychomotor agitation
Fear of losing one’s mind
Illusions
Insomnia
Paranoia
Psychotic delusions & hallucinations
tremors
Vivid visual images
VS increased
Tolerance tends to be rapid
Withdrawal symptoms are uncommon

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Pt is very assaultive, unpredictable,

Whether their intoxicated or withdrawing

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Cannabis

Marijuana & hashish: smoked or taken orally

THC (tetrahydrocannabinol): active ingredient of cannabis. Acts on cardiovascular and CNS

Most commonly used illegal drug

60 million people have tried it
Effects
Mild euphoria, relaxation, drifting sensation
Time distortion, moderate increase in heart rate
Slowed reaction time, redness of the eyes, contraction of pupils
Dry mouth, increased appetite

Produces a greater amount of “tar” than its equivalent tobacco

Cannabis smoke contains more carcinogens

Withdrawal effects are dose related

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Gateway drug

Pts may self medicate with pain management
Cancer pts: can increase appetite

Has benefits with medical supervision

Marijuana can make people psychotic
Can cause dementia
Eyes: redness
Euphoric
Relaxed

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Cannabis (cont.)

Medical uses: Patients undergoing chemotherapy, suffering from AIDS, glaucoma, MS…

Several states have approved marijuana for medical purposes. It appears to be a more potent antimetic drug.

Gateway drug?

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Other Drugs of Abuse:

Anabolic Steroids

Nature of Anabolic-Androgenic Steroids

Steroids are derived or synthesized from testosterone
Used medicinally or to increase body mass and improve physical appearance
Users may engage in cycling or stacking (i.e., begins with low doses and slowly increases the doses and then slowly decreasing the doses
Steroids do not produce a high
Long-term mood disturbances and physical problems known as roid rage, with dramatic mood swings, manic-like episodes and a tendency toward aggressive behavior and violence.
Women using anabolic steroids may increase muscle mass, develop a deeper voice, absent menses

Athletes typically abuse this
People trying to bulk up may take this
Use of marijuana and anabolic steroids : referred to an endochronoligist because it can effect their hormones

If abusing for a long time – this needs to be tapers down

Long-term mood disturbances and physical problems known as roid rage, with dramatic mood swings, manic-like episodes and a tendency toward aggressive behavior and violence.
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Other Drugs of Abuse: Inhalants

Nature of Inhalants (CNS depressants)

Abusers: boys between 10-15 years old (also multidrug users)
Found in volatile solvents
Examples include air fresheners, dry cleaning fluid, spray paint, hair spray, paint thinner, gasoline, nitrous oxide
Breathed into the lungs directly. Fumes are inhaled directly from an open container or from a surface upon which the substance has been applied (sniffing), from a plastic bag (snorting) or from inhalant-soaked rag next to the mouth or nose (huffing), or substance is placed in a paper or plastic bag and inhaled (bagging)
Such drugs are rapidly absorbed

Children
Inhalant: glue, paint, spray, aerosols, white out
Going across the blood brain barrier, nose bleeds and serizers can be of concern
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Other Drugs of Abuse:

Inhalants (cont.)

Effects

Euphoria, giddiness, impaired judgment, lethargy, lightheadness, loss of contact with reality, slurred speech, tingling, unsteady gait

Produce tolerance

No known withdrawal symptoms

Complications

Nose bleeds
Can cause respiratory tract irritations, CNS damage, hepatitis, liver damage,…
Sudden sniffing death: Arrhythmia or apoxia
Multiple organ damage: CV and pulmonary death

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Characteristics of Substance Abusers

Denial
Rationalization
Justification
Intecultaion
– Freud

First step is admistting you have a problem
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Effects on the Family

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Effects on the Family (cont.)

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Nursing Process
Assessment

Assess for each substance

Age begun

Method of use

Amount and frequency of use

Most recent use

Withdrawal symptoms in the past

Setting and circumstances of use

Benefits of use

Proportion of income or savings spent on drugs

Financial consequences of drug use

Relationship, vocational, social problems associated with use

Things cant be sugar coated with these patients

How much is being consumed?
What type?
How many a day?
When are you drinking?
Where are you drinking?
Are you drinking while driving? Have you ever had a DUI
What problem have you had while drinking?
Any problems they have?
What does this substance do for you?
Whats the feeling?
Have you had any serizers or black outs?
Tremors or shakes?
Are you doing it in front of other individuals?
Where are you getting the money for it?
Are you getting in trouble with the law?
How much of your check are you spending on the substance?

Depending on the substance

Have you ever had nose bleeds

All of these questions would be shown to pt to get them passed this denial

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Nursing Process (cont.)

Physical Assessment

Skin and scalp

Ecchymosis, lacerations, scars, bruises, dermatitis, spider angiomas, edema

Head

Facial edema or a “puffy face” with flushed cheeks and nose

Eyes

Icterus in the sclera from hepatitis or cirrhosis

Ears

Infection

Mouth

Lip peeling or fissures due to vitamin B deficiency, gum disease

Neck

Cardiomypoathy and CHF causing increased venous pressure, which results in distended juglar veins

Chest

TB, pneumonia

Abdomen

Fluid retention and tense glistening skin resulting from ascites, hepatitis, hemorrhoids, esophageal varices

Physical Assessment for alcholics example:
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Concomitant Disorders/

Dual Diagnosis of Mentally Ill

Chemical Abuser

Clients must be assessed for dual diagnosis, the presence of substance abuse with a concurrent psychiatric disorder

A dual diagnosis indicates one of three things:

Two independent disorders occur together
Substance abuse caused the other mental disorder
The person with the mental disorder uses substances in an effort to self-medicate and feel better

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Nurse wants to find out when they started using

Abusing while young?
Mental health issues?
If patient says no – primary substance abuse problem

Treatment? Rehab? NA? AA?

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Nursing Diagnosis

Ineffective denial related to weak, underdeveloped ego

Ineffective coping related to inadequate coping skills and weak ego

Imbalanced nutrition less than body requirements/fluid volume deficit related to drinking or taking drugs instead of eating

Risk for infection related to malnutrition and altered immune condition

Low self-esteem related to weak ego, lack of positive feedback

Deficient knowledge (effects of substance abuse on the body) related to denial of problems with substances evidenced by abuse of substances

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Nursing Outcomes

The client will:

Abstain from alcohol/drugs
Express feelings openly and directly
Accept responsibility for own behavior
Practice nonchemical alternatives to deal with stress or difficult situations
Establish an effective after-care plan

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Nursing Outcomes

Short-term Goals

Identifying and initiating treatment for patients at risk
Encouraging abstinence
Promoting attendance at meetings or other counseling programs
Involving family, community, and employment resources

Long-term Goals

Restoration of self-esteem
Resolution of substance-related social problems
Improvement in physical health issues
Long-term sobriety

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Nursing Process (cont.)

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EKG

Tylenol or aspirin levels will be checked if suspected overdose

Cardiac will be reviewed: Troponin

Marijuana stays in the the body for up to 45 days
Blood alcohol levels: could determine how long the client will stay in the hospital
Blood alcohol should be repeated and have it be less than 10 or 0
25 – 30 points an hour depends on BMI
What are the blood alcohol levels:

Vital signs: keep pt in low stimulating environment

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Psychosocial Treatment of Substance-Related Disorders

Inpatient vs. Outpatient Care

Inpatient treatment occurs in the ED and on acute care inpatient units
Hospitalization is appropriate for those (1) at risk for severe withdrawal syndromes, (2) those who are psychiatrically disabled, (3) those who are a danger to themselves or others, and (4) those who have not responded to less intensive treatment efforts
Residential treatment usually lasts 7-21 days and offers a safe and structured environment for those who lack social and vocational skills and drug-free social supports to be abstinent in a less restricted setting

What is the best program for the patient?

Substance abuse is mostly voluntary unless a judge admits them (danger to self or others)
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Psychosocial Treatment of Substance-Related Disorders (cont.)

Drug rehabilitation

Is the recovery of optimal health. It views chemical dependence as a chronic, progressive, and often fatal disease. The responsibility is on the clients, and any attempt to shift responsibility to others, such as family, is confronted directly. Recovery is considered a lifelong, day-to-day process and is accomplished with the support from peers with the same addiction
i.e., 12-step program (AA and/or NA)

Behavioral interventions

Cognitive therapy

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AA and/or NA: lifelong

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Psychosocial Treatment of Substance-Related Disorders (cont.)

Family therapy and education

Nature of the illness
Effects of substances on the body
Ways in which use of substance affects life
Management of the illness
Support services

Group therapy and early recovery

Clients learn to accept themselves as recovering individuals and help themselves while helping others

Individual therapy

Psychoeducation groups

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Psychosocial Treatment of Substance-Related Disorders (cont.)

Complete Abstinence vs. Sobriety as Treatment Goals

Abstinence is merely stopping the intake of the drug; it does not imply that any other behaviors have changed
Sobriety implies that not only have these individuals stopped using the drug, but they have also achieved a centered or balanced state. Sobriety is the overall goals of drug rehabilitation.

Community Support Programs

Alcoholics Anonymous and related groups
Seem helpful and are strongly encouraged

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Motivation for Change

Key predictor of whether an individual will change his/her substance abuse

Clients must overcome denial and recognize the significance of the substance dependence on his or her life
Involves recognizing problem, correlating problems with substance abuse, and searching for a way to change and then changing

Motivational interviewing seeks to elicit self-motivational statement from patients, supports behavioral change and creates a discrepancy between the patient’s goals and continued alcohol and other drug use

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Patient would most likely relapse

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Transtheortical Model of Change
Precontemplation
Contemplation
Determination
Action
Maintenance
Relapse
Permanent exit

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Reality Confrontation

Therapeutic strategy that promotes the person’s experience of the natural consequences of one’s behavior

Learning from previous behavior

Guidelines for establishing interactions

More assertive in communication – which will upset the pt but the pt needs to understand their actions
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Evaluation

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