Unit II; Alterations in Patterns of Health; Chapter 6; Nursing Care of Clients with Problems of Substance Abuse

Chapter Review
– Substance abuse is the unsanctioned use of any chemical despite adverse effects on the individual’s physical, psychological, interpersonal, or social health.

– Substance dependence occurs when control over the chemical substance is lost and the individual must use increasing amounts to produce the desired effect (tolerance) and must use the substance to avoid or relieve uncomfortable symptoms (withdrawal).

– Combinations of genetic, biologic, psychological, and sociocultural factors contribute to substance abuse or dependence. Addictive behavior has been linked to biochemical changes in dopamine and serotonin brain levels as well as heredity, ethnic differences, and peer pressure. Thorough assessment of individual risk factors is necessary to plan and deliver appropriate nursing interventions.

– Adolescents are particularly influenced by society and peers to use substances; predominantly tobacco, alcohol, and illicit drugs. A positive ethnic identity and family environment act as “protective” deterrents for substance use.

– Substance abusers have common characteristics including risk-taking behavior, low tolerance for frustration or pain, compulsive preoccupation with the substance, anxiety, anger, and low self-esteem. Stress management, anger control, social support, and counseling are helpful strategies to avoid substance abuse and dependence.

– Alcohol is the most commonly used and abused substance; however, polysubstance abuse is frequent in many individuals. Substances such as marijuana, cocaine, and methamphetamine are often used in conjunction with alcohol. Prescription anti-anxiety agents have been abused in the past; and there is a growing trend in prescription narcotic analgesic abuse.

– Nursing care of clients experiencing substance abuse problems includes health promotion efforts to prevent substance abuse: comprehensive physical, spiritual, and psychosocial assessment; and interventions for the human responses of ineffective coping and denial, imbalanced nutrition, low self-esteem, disturbed thought processes, disturbed sensory perception, and risk for injury or violence.

– Nurses are susceptible to substance abuse due to pressures in the workplace and easy access to drugs. Nurses need to assess their response to stress and seek early treatment for depressive symptoms to avoid impaired professional practice.

Alcohol
the most commonly used and abused substance in the United States. Alcohol and other CNS depressants act on other neurotransmitters in the brain such as gamma-aminobutyric acid (GABA)
Caffeine
is a stimulant that increases the heart rate and acts as a diuretic
Cocaine
a sychostimulant, cocaine has a high potential for abuse. Euphoria is the main subjective effect associated with cocaine, leading to addiction
Delirium Tremens (DTs)
a medical emergency usually occurring 3 to 5 days following alcohol withdrawal and lasting 2 to 3 days; characterized by paranoia, disorientation, delusions, visual hallucinations, elevated vital signs, vomiting, diarrhea, and diaphoresis
Dual Diagnosis
the coexistence of substance abuse/dependence and a psychiatric disorder in one individual (used interchangeably with dual disorder and co-occurring disorders)
Hallucinogens
drugs that produces hallucinations
Kindling
long-term changes in brain neurotransmission that occur after repeated detoxifications
Korsakoff’s Psychosis
secondary dementia caused by thiamine (B1) deficiency that may be associated with chronic alcoholism; characterized by progressive cognitive deterioration, confabulation, peripheral neuropathy, and myopathy
Opiates
opiates such as morphine, meperidine, codeine, hydrocodone, and oxycodone are narcotic analgesics
Polysubstance Abuse
the simultaneous use of many substances
Substance Abuse
the use of any chemical in a fashion inconsistent with medical or culturally defined social norms despite physical, psychological, or social adverse effects
Substance Dependence
a severe condition occurring when the use of a chemical substance is no longer under an individual’s control for at least 3 months. Continued use of the substance usually persists despite adverse effects on the person’s physical condition, psychological health, and interpersonal relationships (used interchangeably with addiction)
Tolerance
tolerance is a cumulative state in which a particular dose of the chemical elicits a smaller response than before. With increased tolerance, the individual needs higher and higher doses to obtain the desired effect. State in which a particular dose elicits a smaller response than it formerly did. With increased tolerance the individual needs higher and higher doses to obtain the desired response
Wernicke’s Encephalopathy
caused by thiamine (B1) deficiency, characterized by nystagmus, ptosis, ataxia, confusion, coma, and possible death. Thiamine deficiency is common in chronic alcoholism
Withdrawal
cessation of use of a substance that an individual has become addicted to
Withdrawal Symptoms
constellation of signs and symptoms that occurs in physically dependent individuals when they discontinue drug use
Explain risk factors associated with substance abuse.
Recognize the signs and symptoms of potential substance abuse in coworkers.
Describe common characteristics of substance abusers.
Classify major addictive substances.
Explain the effects of addictive substances on physiologic, cognitive, psychologic, and social well-being.
Support interdisciplinary care for the client with substance abuse problems, including diagnostic tests, emergency care for overdose, and treatment of withdrawal.
Develop a framework for providing individualized nursing care for clients experiencing problems with substance abuse using the nursing process.
The school nurse is teaching a group of high school students about substance abuse. Which of the following people are most likely to develop a substance abuse problem?

a. An Asian woman
b. A Jewish man
c. A Roman Catholic man
d. A Jewish woman

A Roman Catholic man

Rationale:
Various risk factors help explain why one person becomes addicted while another does not. Genetic, biological, psychological, and sociocultural factors shed light on how a person may abuse or become dependent on a substance. # 1 is incorrect because Asian Americans report the lowest prevalence of family history of alcoholism. Also, women drink less alcohol and have fewer alcohol-related problems than men. # 2 is incorrect because people of Jewish faith have the lowest rate of alcoholism. # 3 is correct because Roman Catholics have the highest rate of alcoholism. # 4 is incorrect because the person is Jewish and a woman which puts her in a lower risk bracket.

Nursing Process: Assessment
Client Need: Health Promotion and Maintenance
Cognitive Level: Analysis
Objective: Explain risk factors associated with substance abuse.
Strategy: Examine each answer choice to determine if this person would be more at risk for developing substance abuse.

The nurse is working night shift with another nurse who has been exhibiting some problematic behaviors, such as weight loss, tachypnea, tachycardia, insomnia, memory loss, and paranoia. Abuse of which of the following substances could contribute to this behavior?

a. Caffeine
b. Amphetamines
c. Nicotine
d. Alcohol

Amphetamines

Rationale:
Amphetamines cause arousal and an elevation of mood with a sense of increased strength, mental capacity, self-confidence, and a decreased need for food and sleep. Methamphetamine users in treatment have reported physical symptoms associated with the use of methamphetamine including weight loss, tachycardia, tachypnea, hyperthermia, insomnia, and muscular tremors. The behavioral and psychiatric symptoms reported most often include violent behavior, repetitive activity, memory loss, paranoia, delusions of reference, auditory hallucinations, and confusion or fright.

Nursing Process: Assessment
Client Need: Psychosocial Integrity
Cognitive Level: Application
Objective: Recognize the signs and symptoms of potential substance abuse in co-workers.
Strategy: Examine the symptoms present and determine which substance if abused would be the cause.

A nurse is assessing a group of teens for characteristics of abuse. Which of the following characteristics may be indicative of abuse? Select all that apply.

a. Loss of control over consumption
b. High tolerance for frustration and pain
c. Impaired social and occupational functioning
d. Development of tolerance and dependence
e. Rebellion against social norms
f. Anxiety, anger, and low self-esteem

– Loss of control over consumption
– Impaired social and occupational functioning
– Development of tolerance and dependence
– Rebellion against social norms
– Anxiety, anger, and low self-esteem

Rationale:
No addictive personality type exists. However, many abusers have several characteristics in common. #’s 1, 3, 4, 5, and 6 all are characteristics that abusers have in common. #2 is incorrect because they have a low tolerance for frustration and pain, not a high tolerance.

Nursing Process: Assessment
Client Need: Psychosocial Integrity
Cognitive Level: Analysis
Objective: Describe common characteristics of substance abusers.
Strategy: Look at each characteristic in order to determine if it is a characteristic common to abusers. Multiple answers will be correct due to the wording of the stem.

A nurse is examining a client who has stopped smoking abruptly without the use of any assistive aids in the process. Which statement made by the nurse would demonstrate an understanding of nicotine abuse?

a. “Initially, nicotine decreases respiration, mental alertness, and cognitive ability.”
b. “Tolerance of nicotine can develop to nausea and dizziness, but not to the cardiovascular effects.”
c. “Some withdrawal symptoms of nicotine include decreased appetite, weight loss, impatience, and increased hostility.”
d. “Nicotine acts on the central nervous system as a depressant.”

“Tolerance of nicotine can develop to nausea and dizziness, but not to the cardiovascular effects.”

Rationale:
# 1 is incorrect because nicotine initially increases respiration, mental alertness, and cognitive ability, but eventually depresses these responses. # 3 is incorrect because the appetite would be increased and there would be weight gain. . # 4 is incorrect because nicotine acts on the central nervous system as a stimulant, and not as a depressant.

Nursing Process: Assessment
Client Need: Psychosocial Integrity
Cognitive Level: Analysis
Objective: Classify major addictive substances
Strategy: Read each statement to determine if it correctly depicts nicotine abuse.

The nurse is counseling a young pregnant client about the potential effects of marijuana on her unborn baby. This pregnant woman has a social history of occasional marijuana use. Which of the following effects could marijuana have on the baby?

a. High birth weight
b. Larger head circumference
c. Normal length
d. Fetal death

Fetal death

Rationale:
Birth defects may be associated with marijuana use. Marijuana crosses the placental barrier and is spread to the fetal tissues. When a pregnant woman smokes marijuana she increases the risk of abnormalities in the fetus such as CNS disturbances, low birth weight, decreased length, smaller head circumference, and fetal death. # 1 is incorrect because it should be low, not high birth weight. # 2 is incorrect because the head circumference would be smaller. # 3 is incorrect because the length would be decreased.

Nursing Process: Implementation
Client Need: Health Promotion and Maintenance
Cognitive Level: Application
Objective: Explain the effects of addictive substances on physiological, cognitive, psychological, and social well-being.
Strategy: Determine if each answer choice would result from the use of marijuana in the pregnant client.

The student health nurse at a large university is assessing the client who was just brought in by friends after a night of partying. The friends report no drug use by the client but report unusual behavior for the last couple of hours. Which of the following hallucinogens could be given to the client without knowledge?

a. Ecstasy
b. PCP
c. Ketamine
d. Marijuana

Ecstasy

Rationale:
MDMA, commonly known as Ecstasy, had high use in the 1980’s as a popular recreational “club drug” associated with dance clubs or “raves”. It has reappeared in recent years as a date or rape drug. Parties where there are other drugs or alcohol present may lead to easier access or availability of Ecstasy. This client may have been given Ecstasy without any knowledge or consent.
The client would have to agree to take all of the other drugs.

Nursing Process: Diagnosis
Client Need: Psychosocial Integrity
Cognitive Level: Analysis
Objective: Explain the effects of addictive substances on physiological, cognitive, psychological, and social well-being.
Strategy: Look at each substance and determine how it can be ingested. Pick the answer of the drug that can be unknowingly given to someone without consent.

The nurse admits a client in alcohol withdrawal to the unit. Which type of care will be most important for this client to receive?

a. Medical Care
b. Nursing Care
c. Psychiatric Care
d. Interdisciplinary Care

Interdisciplinary Care

Rationale:
Effective treatment of substance abuse and dependence results from the efforts of an interdisciplinary team specializing in the treatment of psychiatric and substance abuse disorders.

Nursing Process: Planning
Client Need: Psychosocial Integrity
Cognitive Level: Application
Objective: Support interdisciplinary care for the client with substance abuse problems, including diagnostic tests, emergency care for overdose, and treatment of withdrawal.
Strategy: Determine which level of care is best based the concept of interdisciplinary care in the role of substance abuse.

A client is brought into the emergency room after a family friend found the client barely breathing with a half filled bottle of morphine next to the sofa. Which of the following symptoms would be indicative of an overdose?

a. Myocardial Infarction (MI)
b. Stroke
c. Pupil Dilation
d. Ataxia

Pupil Dilation

Rationale:
Signs of a stimulant overdose, such as in crack cocaine usage include MI, stroke, and ataxia. This is why answers 1, 2, and 4 are all incorrect. Morphine is an opiate that has the following signs of overdose: pupil dilation due to anoxia respiratory depression-arrest, coma, shock, convulsions, and death.

Nursing Process: Assessment
Client Need: Psychosocial Integrity
Cognitive Level: Analysis
Objective: Support interdisciplinary care for the client with substance abuse problems, including diagnostic tests, emergency care for overdose, and treatment of withdrawal.
Strategy: Look at each symptom and determine if it is a symptom associated with opiate overdose. Eliminate as appropriate.

The school nurse is coordinating a program for middle school students on substance abuse. The nurse is encouraging the students to employ healthy lifestyles, stress management, and good nutrition. The nurse also covers information on ways to avoid peer pressure. Under which part of the nursing process does this education apply?

a. Assessment
b. Diagnosis
c. Health Promotion
d. Implementation

Health Promotion

Rationale:
Health promotion efforts are aimed at preventing drug use among children and adolescents and reducing risks among adults. Adolescence is the most common phase for the first experience with drugs. Healthy lifestyles, parental support, stress management, good nutrition, and information about ways to steer clear of peer pressure are important topics for the nurse to provide in school programs.

Nursing Process: Implementation
Client Need: Health Promotion and Maintenance
Cognitive Level: Application
Objective: Develop a framework for providing individualized nursing care for clients experiencing problems with substance abuse using the nursing process.
Strategy: Read the interventions planned and decide which part of the nursing process it most closely aligns.

The wealthy family of a client with substance abuse is visiting the client at the inpatient psychiatric facility. The family of the client is pleasant but disengages each time the topic of the treatment plan is broached. Which of the following nursing diagnoses would be most appropriate for the client and the family?

a. Denial, Ineffective
b. Deficient Knowledge
c. Thought Processes, Disturbed
d. Coping, Ineffective

Denial, Ineffective

Rationale:
In this case, there is not a disturbed thought process or knowledge deficit. Rather, it is the denial on the part of the family that is causing a problem in dealing with the substance abuse. Ineffective denial is a better answer than ineffective coping because the realization that a problem exists is still absent. Coping can commence once the problem is acknowledged.

Nursing Process: Planning
Client Need: Health Promotion and Maintenance
Cognitive Level: Application
Objective: Develop a framework for providing individualized nursing care for clients experiencing problems with substance abuse using the nursing process.
Strategy: Apply knowledge of the nursing process and developing a plan of care to determine the best diagnosis for the client and family.

Case Studies – Client with Problems of Substance Abuse
Client’s Name: Mike Harron

Abstract: Mike Harron, age 34, is admitted to the hospital detoxification unit from the emergency room following initial treatment for a fractured femur. Mr. Harron had a blood alcohol level (BAL) on admission of 0.28%.

Objectives:
Support interdisciplinary care for the client with substance abuse problems, including diagnostic tests, emergency care for overdose, and treatment of withdrawal.

Assess for signs of withdrawal and monitor for life-threatening conditions.

Develop a framework for providing individualized nursing care for clients experiencing problems with substance abuse using the nursing process.

Mike Harron, age 34 is brought to the emergency room at 1:00 AM following a motor vehicle accident. The report from the emergency personnel indicates that Mr. Harron was driving at a high rate of speed while under the influence of alcohol and crashed his car into a tree. On admission to the emergency room, his blood alcohol level (BAL) was 0.28%. Mr. Harron is transferred to the detoxification unit following stabilization in the emergency room. The transferring emergency room nurse reports that Mr. Harron was alert and oriented when brought to the hospital by the ambulance crew. Because of his elevated BAL, Mr. Harron will undergo medical detoxification prior to surgical treatment for the fractured femur. The nurse on the detoxification unit establishes that Mr. Harron is still alert and oriented. His fractured leg was splinted in the emergency room and he has intravenous fluids running at 80 ml/hr. Vital signs are: T 99.2 F., P 86, R 34, and BP 142/88. The physician has ordered scheduled and prn decreasing doses of a benzodiazepine to treat withdrawal.

Mrs. Herron arrives during the admission process and is upset and crying. Mr. Harron tells her, “Don’t worry, this is no big deal, I only had a few drinks.” Mrs. Harron ignores her husband and tells the nurse that this is the second car accident her husband has had in the past 6 months and he wasn’t supposed to be driving because his license was suspended from the last accident. She goes on to state that her husband has been missing work lately due to severe hangovers. She verbalizes, “I don’t know how much longer I can tolerate this, I’m considering leaving him.”

What characteristics does the nurse identify in Mr. Harron that is typical for someone with a substance abuse problem?
One of the common characteristics of someone with a substance abuse problem is the tendency for engaging in high-risk behaviors, such as driving while intoxicated. This is the second time in the past 6 months that Mr. Harron has been in an accident that is alcohol related. Mr. Harron is minimizing his use of substances (“I only had a few drinks”), and has also incurred both occupational (job related) and interpersonal (relationship with his wife) problems related to drinking. Mr. Harron is also exhibiting one of the characteristic signs of someone with a substance abuse problem, called tolerance. His BAL was quite elevated (legal limit for classification of being under the influence is between 0.08 and 0.10%), and yet he was alert and oriented. Tolerance is a cumulative state in which a particular dose of the chemical elicits a smaller response than previous.
The on-coming day shift nurse checks Mr. Harron’s vital signs and notes a T of 100.0 F., P 104, R 40 and BP of 180/90. He is diaphoretic and slightly agitated, stating, “I need to get out of here.” How does the nurse analyze these findings and what nursing intervention should be taken?
The nurse analyzes that Mr. Harron is demonstrating symptoms of withdrawal from alcohol. The nurse establishes the nursing diagnosis of: Risk for injury related to increased central nervous system stimulation secondary to withdrawal from alcohol. Mr Harron is manifesting the symptoms of alcohol withdrawal that include: high blood pressure, rapid pulse and respirations, tremors, insomnia, irritability, sweating, and convulsions. Mr. Harron has elevated vital signs when compared to baseline admission signs and he is diaphoretic and irritable. At this point, he does not have tremors or convulsions. The nursing intervention that should be initiated is to medicate Mr. Harron with his prn dose of the prescribed benzodiazepine. The nurse will administer the prn dose in order to prevent progression of withdrawal to the possibility of seizures. The nurse will also ensure client safety by closely monitoring Mr. Harron’s vital signs, maintaining bed side rails up with the HOB elevated. Restraining Mr. Harron should be avoided unless he is actively pulling out his IV or his catheter. Assigning a nursing assistant to maintain a one-to-one observation of Mr. Harron will help ensure safety and prevent the use of restraints.
Mr. Harron has been safely detoxified from alcohol and he continues to tell the nurse that he does not have an alcohol problem and he can stop “any time I want to.” He states, “My wife just over-reacts to everything.” What nursing diagnosis does the nurse establish at this time and what evidence validates this?
The nurse establishes the diagnosis of, Ineffective Denial: related to minimization of problems with alcohol despite objective evidence of job, personal and legal difficulties. Mr. Herron is refusing to acknowledge an alcohol problem despite the fact that he has had 2 motor vehicle accidents related to the use of alcohol. He has exhibited an increased BAL without the expected behavioral signs of an elevated level (indicating tolerance). He is incurring problems at work, calling in sick after a night of drinking, and his wife is considering leaving him. His failure to acknowledge his problem with alcohol and use of denial is typical of someone who is a substance abuser.
What nursing interventions does the nurse utilize with Mr. Harron in dealing with his continued denial of an alcohol abuse problem?
The nurse will be genuine, honest and respectful in the interactions with Mr. Harron in order to promote trust and establish a therapeutic nurse-client relationship. The use of therapeutic confrontation is important in dealing with the defense mechanism of denial and therefore the nurse will describe in a matter of fact manner the problems that Mr. Harron is experiencing related to the use of alcohol. Presenting the facts of his motor vehicle accidents while driving under the influence, his elevated BAL on admission, his difficulties with his wife and his calling in sick from work will help break through the ineffective denial. It is important that the nurse maintain a non-judgmental attitude when doing this because an individual with a substance abuse problem generally has low self-esteem. The nurse can also make use of one of the screening tools for diagnosis of substance, such as the CAGE questionnaire or the Michigan Alcohol Screening Test (MAST). These screening tools provide quick, non-judgmental methods of determining patterns of substance abuse.
Following surgery to repair his fractured femur, Mr. Harron has agreed to be discharged to an in-patient rehabilitation unit for treatment of alcohol abuse. He has not had any prior treatment and nervously asks the nurse, “What are they going to do for me there?” What interventions/teaching about alcohol rehabilitation will the nurse provide?
The nurse will explain that alcohol treatment units are usually based on the alcoholics anonymous (AA) philosophy in which an individual learns to utilize a 12 program designed to refrain from drinking “one day at a time.” As a member of a group, his peers will support Mr. Harron in his efforts to recover from substance abuse. He will learn about the negative effects of substances on the body, both short and long-term effects. The impact of substance abuse on family members will also be part of the learning on the unit. Signs of relapse and the importance of continued participation as an active member of an AA group will be emphasized. Stress management is also an important part of the recovery process and information and practice in this will be included in the treatment program. His wife will be encouraged to participate in one of the support programs for family members, such as Al Anon.
Care Plan #1
Miss James is a single, 21 year old full time college student who started smoking at the age of 16. She smokes 1-1/2 packs per day, and has recently found out she is 12 weeks pregnant. She has been referred to a smoking cessation class, however she states that she is “stressed out” due to the demands of college, and doesn’t think the patch really works.
Assessment and Diagnosis: What immediate information do you obtain? What is the priority nursing diagnosis?
It is important to obtain an accurate history: both subjective and objective data. Assess her coping skills. Her support groups. It is equally important to determine why she has no confidence in the patch what is her knowledge-base around the patch’s effectiveness. and what she has tried in the past to stop smoking.
What is her knowledge-base of the dangers of smoking, especially in terms of it’s effect on her pregnancy. Does she possess a self- motivation for smoking cessation?
Determine if she can reduce her load at school.

Ineffective individual coping related to multiple stressors evidenced by continued substance abuse (nicotine).

Planning and Intervention: What is your goal for Miss James? What interventions will you implement for the achievement of that goal?
Demonstrate the ability to solve problems and participate at usual level in society.
Remains free of destructive behavior towards self.
Discuss how recent life stressors have overwhelmed normal coping mechanisms, and strategies for improved coping.

Establish trusting environment.
Encourage client to verbalize fears, anxiety, and barriers to lifestyle changes.
Use active listening to and acceptance to help client express emotions such as crying, guilt, and anger.
Encourage client to describe previous stressors and the coping mechanisms used.
Be supportive of coping mechanisms; allow client time to relax.
Explore alternate methods of dealing with stressful situations.
Encourage client to make choices and participate in planning of care and scheduled activities.
Provide information on the effects of Nicotine on an unborn fetus/second hand smoke.
Allow client to set realistic goal for smoking cessation.
Encourage use of cognitive behavioral relaxation.
Refer to counseling as needed.

Evaluation: How do you evaluate Miss James progress toward meeting the goal?
Miss James expresses confidence in her ability to stop smoking, and enrolls in a smoking cessation class.
Client verbalizes alternatives to smoking.
Client verbalizes dangers of smoking for herself and her unborn fetus.
Care Plan #2
Kira Jones is a 32-year-old female being admitted for “alcohol withdrawal” according to the primary care provider who saw Ms. Jones in the clinic. Upon admission, Ms. Jones states “I no longer want to waste my life drinking, so I just stopped”. Her hands are shaking and she is slightly agitated when putting the hospital gown on.
Assessment and Diagnosis: What immediate information do you obtain from Ms. Jones? What is the priority nursing diagnosis for Ms. Jones?
Critical information needed on admit includes vital signs, the time of the last drink, and identification of any other substances abused. A thorough history and physical assessment will provide data regarding withdrawal symptoms and the presence of any other diseases or disorders.

Because of the risks of harm with alcohol withdrawal, the priority nursing diagnosis is Risk for Injury.

Planning and Intervention: What is your goal for Ms. Jones? What interventions will you implement for achievement of that goal?
The goal for Ms. Jones is to remain free from injury. Interventions include:

– Assess the client’s level of disorientation to determine specific risks to safety
– Place the client in a quiet, private room to decrease excessive stimuli
– Frequently orient client to reality and the environment, ensuring that potentially harmful objects are stored outside the client’s access
– Monitor vital signs according to client’s level of withdrawal (If experiencing withdrawals, vital signs every 15 minutes are indicated until client is stable)
– Monitor neurological status according to client’s level of withdrawal (clients in withdrawal may experience seizures)
– Administer any prescribed medications for treatment of withdrawals
– Provide the client with supportive, non-judgmental communication

Evaluation: How do you evaluate Ms. Jones’ progress toward meeting the established goal?
Evaluate the client for the presence of injury. Did the client experience delirium tremors, seizures, or other complications? If so, did the client remain free from injury?
]]>