Substance Abuse and Addiction

Substance Abuse

• Substance-induced disorders are temporary and reversible and can include depression, anxiety, and psychosis.
• Substance use disorders involve the continued, frequent use of a substance, leading to abuse and dependence.
• Behavioral addictions are behaviors that produce a reward response; gambling is the only one classified in the DSM-5.
• Examples of other behavioral addictions: internet, gaming, food, sex.
• Risk factors for substance abuse: burnout, family history, homelessness, and mood disorders/stress.
• The most commonly abused substances are alcohol and tobacco.
• The most common illicit substances are cannabis and prescription pain medications.

Alcohol Abuse and Withdrawal

• Alcohol screening involves NIAAA quantity and frequency questions, and CAGE questions.
• Emergency management includes addressing opiate overdose, acute alcohol withdrawal syndrome (delirium tremens), and Wernicke-Korsakoff syndrome.
• Non-emergency management includes substance abuse recovery, motivational interviewing, and pharmacotherapy.
• Binge drinking/heavy drinking can lead to alcohol abuse/withdrawal.
• Reducing or quitting alcohol suddenly (cold turkey) after chronic use is a cause of alcohol withdrawal.
• Symptoms of alcohol withdrawal: tremors, anxiety, tachycardia, increased BP, and diaphoresis, typically beginning 6-8 hours after cessation.
• Withdrawal seizures occur 12-24 hours after cessation.
• Assess CIWA score before and 30-60 minutes after medication administration.
• Wernicke-Korsakoff syndrome is due to thiamine deficiency.

Bipolar Disorder

• Bipolar 1: one manic episode with major depression.
• Bipolar 2: hypomanic episodes alternating with depression.
• Cyclothymic disorder lasts for 2 years, with hypomanic symptoms and minor depression.
• Assess mania through Altman's self-rating mania scale.
• Mania symptoms: inability to stop eating or resting, grandiose self-view, impulsivity, and manipulativeness.
• Depression symptoms: low mood, fatigue, loss of interest, suicidal ideation, and changes in sleep/appetite.

Suicide

• Suicide assessment utilizes the SAFE-T (Suicide Assessment Five-Step Evaluation and Triage) and C-SSRS (Columbia-Suicide Severity Rating Scale).
• Watch for signs such as a sudden brightening of mood, increased energy, giving away belongings, writing letters, or organizing financial affairs.
• Constant supervision is needed, including removing hazards, limiting visitors, creating a safety plan, keeping the client in sight, and documenting accountability.
• If a patient states they no longer feel suicidal during an assessment, continue the assessment.
• Place patients showing suicidal tendencies with a sitter or at the nurses' station.

Depression

• Major depressive disorder is characterized by a single or recurrent episode of unipolar depression, resulting in significant changes in normal functioning.
• Hallucinations or delusions can occur in major depressive disorder.
• Postpartum depression is a depressive episode within 4 weeks of childbirth.
• Assessment involves PHQ-9 questionnaire, and interventions focus on ensuring safety.

Schizophrenia

• Schizophrenia symptoms include hallucinations, delusions, disorganized speech or thoughts, catatonic behavior, and negative symptoms (diminished emotional expression).
• Positive symptoms include hallucinations, delusions, and disorganized speech.
• Negative symptoms include alogia (limited speech), anergia (lack of energy), and anhedonia (lack of pleasure).
• The prodromal phase occurs before psychotic symptoms begin and can last months/years.
• The active phase involves active hallucinations and delusions.
• In the residual phase, symptoms lessen but are not fully resolved.

Child Abuse/Elder Abuse/IPV

• Child abuse most commonly involves neglect, followed by sexual and physical abuse.
• Child abuse is deliberate and intentional; girls are more likely to be abused.
• Risk factors for child abuse: children under 4, those perceived as different (autism), unwanted pregnancy, and interference with emotional bonding.
• Assess for injuries, bruises, burns, and a caregiver's lack of concern or unexplained delays in seeking care.
• Results of child abuse: PTSD, depression, developmental issues, psychiatric distress, and involvement in prostitution.
• IPV (intimate partner violence) involves physical/sexual violence, stalking, and psychological aggression by a current or former partner

Intimate Partner Violence

• IPV is Preventable
• Cycles of IPV include tension building, acute battering, and a honeymoon phase.
• Risk factors for IPV: male dominance, pathological jealousy, alcohol/substance abuse, and pregnancy.

Older Adult Abuse

• Risk factors: poor mental/physical health, dependency needs, being female, age over 75, living with a relative.
• Educate on the escalation of violence and strategies for getting out of dangerous situations.

Acid-Base Balance

• Normal pH: 7.35-7.45
• Normal PaCO2: 35-45
• Normal HCO3: 22-26
• Acids release H ions, while bases receive H ions.
• Respiratory (CO2) and metabolic (HCO3) systems maintain acid-base balance.

Respiratory Acidosis

• Retention of CO2.
• Kidneys conserve HCO3 and secrete H into urine to compensate.
• Causes: COPD, asthma, anesthesia, overdose.
• Signs/symptoms: vasodilation, dyspnea, muscle weakness, drowsiness, dysrhythmias.

Respiratory Alkalosis

• Excess loss of CO2.
• Renal compensation if chronic.
• Causes: hyperventilation, hypoxia, pain, anxiety.
• Signs/symptoms: numbness in fingers/toes, breathlessness, fatigue.

Metabolic Acidosis

• Accumulation of too much acid.
• Causes: vomiting, blood transfusions, opioid use, NG suctioning.
• Signs/symptoms: hypokalemia, weakness, muscle cramping, confusion.

Metabolic Alkalosis

• Accumulation of too much base.
• Causes: diabetes, ketoacidosis, impaired kidney function.
• Signs/symptoms: coma, abdominal discomfort, lethargy, headache.

Arterial Blood Gas Levels

• Respiratory Acidosis: pH less than 7.35, PaCO2 greater than 45, HCO3, 22-26
• Respiratory Alkalosis: pH greater than 7.45, PaCO2 less than 35, HCO3, 22-26
• Metabolic Acidosis: pH less than 7.35, PaCO2, 35-45, HCO3 less than 22
• Metabolic Alkalosis: pH greater than 7.45, PaCO2, 35-45, HCO3 greater than 25
• ROME: Respiratory Opposite Metabolic Equal

Glucose Regulation

• DKA (Diabetic Ketoacidosis), diabetic retinopathy, and gestational diabetes.
• DKA typically occurs in type 1 diabetes with uncontrolled hyperglycemia >250 mg/dl.
• Breakdown of body fat for energy leads to ketone production. Results in Hyperglycemia, Ketosis and Metabolic Acidosis
• DKA Clinical Manifestations include polyuria, polydipsia, polyphagia, weight loss, orthostatic hypotension, fruity/acetone breath, Kussmaul respirations, and altered A&O.
• DKA can lead to seizures, coma, or death.
• Interventions for DKA: ABC's, O2 via NC or nonrebreather mask, establishing IV access and providing isotonic fluids (Normal saline and Lactated ringers).

Diabetic Retinopathy

• Microvascular damage to the retina caused by chronic hyperglycemia, nephropathy, and hypertension.
• Symptoms: blurred vision, reduced visual acuity, floaters/dark spots, photopsia.(flashes of light)
• Proliferative retinopathy is severe, characterized by seeing black or red spots/lines.

Gestational Diabetes

• Form of diabetes during pregnancy in the 2nd or 3rd trimester.
• Screening occurs between 24-48 weeks.

Perfusion

• PAD (Peripheral Artery Disease)/CVI (Chronic Venous Insufficiency)
• PAD involves the thickening of artery walls due to atherosclerosis (plaque buildup).
• Risk factors for PAD: tobacco use, diabetes, HTN, high cholesterol, age >60.
• Intermittent claudication is ischemic muscle pain caused by PAD.
• PAD symptoms: paresthesia in toes/feet, pallor/shiny skin, loss of hair, arterial ulcers, decreased/absent pulses, severe rest pain, and critical limb ischemia.
• Assess PAD through bilateral pulse checks, color, sensation, and temperature assessment.

Chronic Venous Insufficiency

• CVI occurs when the venous system cannot carry blood back to the heart, leading to blood pooling.
• Risk factors for CVI: family history, female gender, pregnancy, obesity, prolonged sitting/standing, leg injury, and advanced age.
• Symptoms of CVI: warm, thick, hardened, brownish skin, edema, venous ulcers, normal/thick nails, and present pulses.

Sickle Cell Anemia

• RBC shape is sickled and crescent-shaped.
• Caused by autosomal recessive gene (both parents must carry) or genetic mutation.
• Symptoms: decreased perfusion, pain, fatigue, jaundice, increased HR, SOB.
• Interventions: hydration, O2, pain control, bed rest, transfusion therapy.

Nutrition

• IDA (Iron Deficiency Anemia)
• Causes: blood loss, inadequate dietary intake, malabsorption, hemolysis.
• Risk factors: infants/children (picky eaters), poor diet, women in reproductive years (menstrual cycle).
• Symptoms: decreased O2 levels, low BP, fatigue, lethargy, pallor.
• Treatment: iron supplements, and diet changes.

Pernicious Anemia

• Causes: absence of intrinsic factor.
• Risk factors: gastric surgeries, autoimmune diseases, long-term smoking.
• Symptoms: sore/red beefy tongue, fatigue, abd pain, paresthesia, confusion.
• Treatment: cyanocobalamin/ B12 injections.

Fluid and Electrolytes

• First spacing: normal fluid distribution within compartments.
• Second spacing: abnormal accumulation of interstitial fluid (edema).
• Third spacing: excess fluid collects in non-functional areas (body cavities).

Fluid Volume Deficit/Dehydration

• Isotonic dehydration: GI losses, hemorrhage. Initiate oral rehydration followed by isotonic fluids (NS & LR).
• Hypertonic dehydration: excessive Na intake, end-stage renal disease, diabetes insipidus (DI= dry/ release too much fluid). Treat with hypotonic fluids and isotonic fluids (NS & LR)
• Hypotonic dehydration: prolonged vomiting/diarrhea, burns (third spacing), end-stage renal disease. Treat with oral rehydration followed by isotonic and hypertonic fluids. Symptoms include; tachycardia, tachypnea, flat neck veins, cold and clammy skin, weight loss, dry mucous membranes, seizures.

Fluid Volume Excess

• Symptoms: changes in LOC, increased BP and HR, S3 sounds, pulmonary congestion/edema, weight gain.
• SIADH: "swollen" due to too much antidiuretic hormone.

Electrolyte Imbalance

• Normal Sodium: 135-145
• Hyponatremia: Causes: diuretics, NG, kidney disease, SIADH. Symptoms: weak thready pulse, muscle cramps, hyperreflexia, edema.
• Hypernatremia: Causes: excess Na intake, diabetes insipidus, kidney failure, crushing syndrome. Symptoms: flushed skin, edema, polydipsia (thirsty), swollen dry tongue, increased muscle tone.
• Normal Potassium: 3.5-5
• Hypokalemia (LOW and SLOW): Causes: Symptoms: flat T waves, prominent U wave, increased DTR, muscle cramps, paralytic ileus.
• Hyperkalemia (TIGHT and CONTRACTED): Causes: potassium-sparing diuretics. Symptoms: peaked T waves, bradycardia, V fib, cardiac standstill, profound muscle weakness, increased DTR.
• Normal Calcium: 8.5-10.5
• Hypocalcemia: too much blood in transfusion, thyroidectomy, elevated serum, decreased mag, acute pancreatitis. Symptoms: trousseaus and chvosteks sign, circumoral tingling.
• Hypercalcemia: constipation, bone pain, stones (renal calculi), decreased DTR.
• Normal Phosphorus: 3.0 - 4.5
• Hypophosphorous: (SWOLLEN AND SLOW): alcoholism, low vitamin D intake, and hyperparathyroidism. Symptoms include constipation, decreased DTR, and severe muscle weakness.
• Hyperphosphorous: Symptoms include trousseaus and chvosteks sign (cheek and BP), and weak B's (bone, blood, beats).
• Magnesium = 1.3 -2.1
• Hypomagnesium (BUCK WILD)- torsades de pointes, v fib, hyperreflexia, nystagmus, diarrhea
• Hypermagnesium (CALM AND QUIET) - renal insufficiency, OTC antacids, Mag supplements, heart block, prolonged PR intervals, hyporeflexia, depressed respirations

Infection

• Hepatitis A and E: fecal/oral route (food and water).
• Risk factors for Hepatitis A and E: poor hygiene, contaminated food/water, close contact with infected individuals, traveling.
• Symptoms of Hepatitis A and E: N/V, abdominal pain, loss of appetite, fatigue, fever, dark urine, clay-colored stool, joint pain.
• Hepatitis B/C: blood and bodily fluids.
• Risk factors for Hepatitis B/C: unprotected sex, perinatal transmission, IV drug use, healthcare exposure, lack of vaccinations, hemodialysis.
• Symptoms of Hepatitis B/C: flu-like symptoms, jaundice, dark urine, pale stools, joint/muscle aches, cirrhosis.
• Hepatitis D: blood and bodily fluids.
• Hepatitis D can only occur with Hepatitis B.
• Symptoms of Hepatitis D: more severe jaundice, dark urine, clay-colored stools, ascites, increased risk for liver failure/cancer.

Inflammation

• Cholecystitis is inflammation usually from an obstruction.
• Risk factors: Women >40, multiparous women, estrogen replacement therapy, oral contraceptives, Native Americans.
• Symptoms in cholecystitis; feeling of fullness, jaundice, N/V, anorexia, fat intolerance, abdominal distension.
• Pancreatitis is inflammation of the pancreas // pancreatic spillage = autodigestion and severe pain.
• Acute pancreatitis symptoms: LUQ pain, sudden onset, radiates to back, worsened by eating, vomiting doesn't provide relief, Cullen's sign, Gray Turner's sign.
• Chronic pancreatitis: can result from excessive alcohol use, gallstones, tumor, pseudocyst, or trauma.
• Symptoms of chronic pancreatitis: acute episodes of gnawing pain, food/antacids don't provide relief, constipation, dark urine, steatorrhea, bile duct obstruction.

IBD (Inflammatory Bowel Disease)

• Crohn's disease symptoms: RLQ pain, anorexia, weight loss, 5 loose stools with mucus or pus, abdominal distension/pain, steatorrhea.
• Ulcerative colitis: LLQ pain, anorexia, weight loss, 15-20 loose stools/day with mucus/pus/blood, rectal bleeding.
• Goals of treatment: bowel rest (NG), control inflammation, combat infection, correct malnutrition.
• There is no current cure for IBD.