Chapter 17 Psychiatric Mental Health Nursing Abuse Chemical Substances PDF

Chapter 17 The Client Who Abuses Chemical Substances Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.  Student Learning Outcomes List types of substances subject to misuse & abuse Define/differentiate between tolerance, withdrawal, dependence, craving, addi...

Chapter 17 The Client Who Abuses Chemical Substances Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.  Student Learning Outcomes List types of substances subject to misuse & abuse Define/differentiate between tolerance, withdrawal, dependence, craving, addiction Identify effects, withdrawal symptoms, patterns of abuse, means of treatment for nicotine, alcohol, cocaine, opiate abuse Nursing & medical management for client with substance addiction Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.  Guam Statistics Data reveals that smoking among Guam adults remains unchanged from 2001. 1in 3 adults smokes. In addition, smoking among adults on Guam is significantly higher than the nation (57% higher). Heavy drinking: Guam 7.5% vs. nationwide 5.2% Methamphetamine- Guam 5.7% vs. nationwide 4.4% Marijuana- Guam 23.3% vs. nationwide 19.7% Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. National Statistics: Death from Overdose 1999: 16,849 people died from OD 2017: 70, 237 deaths from OD Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.  Definitions Drug use – Taking a drug Substance abuse – Drug used in situations of real or potential harms; harmful use of drugs causing physical or mental damage ‘Drug Addiction’ Tolerance – Acquired resistance to drug’s effects; ie need more and more of the drug to get that ‘high’ (continued) Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.  Definitions Withdrawal – Stopping drug use results in drug-specific set of symptoms; prolonged heavy use of the substance declines Drug dependence- Box 17-1 p. 407 – Inability to control drug use (continued) Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.  Definitions Craving – Strong, overpowering urge for drug Addiction – Inability to abstain from drug use Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.  Data Collection Type of substance Frequency of substance use Amount used Age at onset of substance abuse Previous withdrawal symptoms Date of last substance use Experience of stressful situation Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.  Abused Substances Stimulant drugs – Produce excitation, increased alertness, aggressiveness, and decreased food intake – Amphetamines, cocaine, crack, PCP, nicotine, caffeine Hallucinogens- LSD, mescaline, MDMA (ecstacy) – Produce perceptual and sensory alterations Central nervous system (CNS) depressants – Decrease CNS functions; alcohol, opium, morphine, heroin, barbituates, inhalants Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Client found unresponsive on park bench bought to ER. Vital signs are HR 112 and irregular, BP 89/62mmHg, RR 6/min, shallow and uneven. The client has pinpoint and is unarousable. Which prescription does the nurse implement first? 1. Deliver oxygen via nasal cannula 5/Lmin 2. Administer naloxone 0.4mg 3. Draw an arterial blood gas (ABG) 4. Contact the client’s family Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.  2 Administering Narcan is safe, effective nursing action Others can wait. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.  RISK FACTORS Genetics: family Hx 50-75% addiction have some genetic component Starting using addictive substances at young age = risk for addiction Sociocultural theories: Native Americans = high % with alcohol dependence, Asian groups = low % with alcohol dependence d Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.  Psychological Risk Factors Stress Impuslivitiy Depression Anxiety Eating Disorders Physical/Sexual/Emotional Abuse Peers Access to addictive substances Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.  Most Utilized Substances in the U.S. Caffeine Nicotine Alcohol Marijuana Volatile inhalants Cocaine LSD Prescription (opiods) Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.  Substance Control Efforts Substances continue to be abused Illegal drugs continue to inc. in potency = the risk for onset of mental illness & major medical problems Chronic use of some drugs can lead to both short & long term changes in brain = mental illness: paranoia, depression, anxiety, aggression, hallucinations Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.  Signs of Abuse Low tolerance Need immediate gratification…got to get that ‘hit’ now…. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Nicotine Causes physiological dependency Causes relaxation and excitement Withdrawal causes variety of symptoms Difficult to quit Relapse rate high Nurses involved in all levels of prevention Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Alcohol Causes physiological dependency Chronic, Progressive, often FATAL disease Impedes motor & cognitive function Tolerance develops Develop distorted thinking & denial Tolerance towards sedatives So often need higher doses of Sedatives!! Delirium tremens (DTs) – Withdrawal Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.  Alcoholism: Alcohol Craving When abused leads to: BLACKOUTS!! – Work problems = loss of job – Hazardous practices – Legal difficulties = problems with the Law – Physical problems – Social problems = relationship probles – Phases of Drinking behavior- table 17-3 p. 416 Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.  BLACKOUTS!! Form of Amnesia of actions & events that take place when a person is drinking!! DENIAL: major barrier to recovery from Alcoholism Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.  Support Groups AA Support group for recovering Alcoholics Al-Anon support group specifically for family members of Alcoholics Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Abrupt Withdrawal of Alcohol Leads to Severe Withdrawal symptoms Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.  Nursing Care Use open-ended questions “When was your last drink” Focus on SAFETY in acute stage Safe environment, prevent falls, implement seizure precautions as necc. Adequate nutrition & fluid balance Low-stimulating environment Monitor for covert substance abuse during detox Emotional support, self-help groups Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.  Treatment Detoxification- withdrawal or Delirium Tremens (DTs)- sweating, rapid pulse, tremor, sleep disorder, n/v, agitation- p. 414 Counseling & Group support Alcoholics Anonymous (AA)-12 steps Box17-4 p.417 Medications- benzodiazepines first (Valium & Ativan), Librium, Tegretol Alcohol abstinence (help prevent relapse: Naltrexone (ReVia), Antabuse Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.  Cocaine ‘Cardiac’ CNS Stimulant (central nervous system) Causes dependence and tolerance Lab rats choose cocaine over food Crystallized cocaine called crack – Most addictive Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.  Cocaine Abuse Tachycardia ‘Cardiac Issues’ Elevated BP Inc Resp Rate Irritability Insomnia Agitation Hyperactivity OD = Seizures, MI, Stroke Perforated Nasal Septum Why? Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.  Cocaine Potent Stimulant Is INJECTED, SMOKED or SNORTED Inhaled ‘snorting’ via nose: absorbed into bloodstream through nasal tissues Snorting leads to: ulcerate, erode, perforate nasal mucosa & septum, runny nose SE: irregular rapid HR, Cardiac Arrthymias, Chest Pain HTN, insomnia, anorexia (lack of desire to eat) Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Nasal Damage: Cocaine Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.  Treatment Relapse common Withdrawal – 1-2 week withdrawal period Symptoms = opposite of stimulation = fatigue, vivid/unpleasant dreams, sleeping ++, irritability, agitation, watch for suicidal tendencies Seizure Precautions & Airway protection LOC Calm, Quiet Environment Personal motivation important predictor of success g Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.  Methamphetamine Easily created in home-made labs Produces longer-lasting effects similar to cocaine Results in “meth mouth” and behavioral and cognitive changes - chronic dry mouth and poor oral hygiene; impulsive sexual behavior Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.  Treatment Similar to treatment for cocaine dependence Cognitive therapies also may be appropriate Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.  Opiates Produced by the poppy seed pods as they ripen; relieves pain and apprehension Stimulate endorphins Abused for euphoric properties Create intense pleasure (continued) Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.  Opiates Chemically interact with opioid receptors in nerve cells Generally safe short term but produce euphoria in addition to pain relief = misused = lead to independence/addiction Cause dependence, tolerance, and withdrawal Used illegally IV = risk of Human Immunodeficiency Virus (HIV) transmission Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.  Treatment May include detoxification May include methadone or buprenorphine – More acceptable; long-acting oral medication indefinitely suppress both the symptoms of withdrawal and craving for fast acting IV Psychotherapy Twelve-step group: meetings, share experiences, support each other, positive mental health, better long term outcomes. Face the problem, self awareness, Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.  Buprenorphine Latches onto natural receptors in brain (same ones heroin etc bind to) Naloxone blocks effects of opioids, added to prevent abuse of buprenorphine Both meds stave off withdrawal symptoms, dec. physical cravings, recognized by WHO, effective in dec. deaths, overdoses Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.  Hallucinogens LSD, mescaline ecstacy Cause disturbances of perception – Hallucinations Dependence rare Use increases risk of physical injury Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Substance STREET NAMES RISK FACTORS ACTION FENTANYL Apache, China White, Potency increases risk Bind opioid receptors Dance Fever, Friend, of addiction to brain to relieve pain, Jackpot, TNT, 50-100x more potent inc. release of Goodfella, Tango, than morphine dopamine stimulates Cash pleasure reward system Prescription Oxycontin - Oxy, Anyone prescribed as above OPOIDS hillbilly, heroin, long-term can become kickers, OC addicted Methadone = Fizzies, chocolate chip cookies, Morphine = Roxinol, Miss Emma, M, white stuff, monkey Heroin H, smack, junk, Horse, Not all users become Injected, snorted, dope, brown sugar, addicted smoked thunder, hell dust Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Substance Signs Symptoms of Signs of Overdose Treatment Use FENTANYL Extreme happiness, Bradypena, pinpoint Narcan, often drowsiness, nausea, pupils, Resp. Arrest, multiple doses are confusion, hypoxia, brain death needed. constipation, Possibly CPR is sedation, resp. needed depression, resp. arrest Prescription Tolerance, Bradypnea, Resp. Narcan OPOIDS dependence, arrest, hypoxia = Possible CPR constipation, N&V, death dry mouth, sleepiness, confusion, depression, itching, sweating, low testosterone levels Heroin Surge of euphoria, Bradypnea, Resp. Narcan dry mouth, warm arrest, hypoxia = Possible CPR flushing of skin, death heavy feeling in arms,©severe Copyright itching 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.  Heroin Overdose Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Substance Signs Symptoms of Timing of Withdrawl Withdrawl FENTANYL Insominia, diarrhea, Begins 12-30 hrs after last vomiting, severe cravings, dose. Peaks 3-5 days, can last uncontrollable leg 2 weeks movements, tachycardia, HTN, dilated pupils Prescription OPOIDS Watery eyes, runny nose, Begins 12-30 hrs after last sweating, anxiety, irritability, dose. insomnia, muscle Lasts between 4-10 days pain/cramping, diarrhea, vomiting, tachycardia, HTN, restlessness, dilated pupils, chills Heroin Watery eyes, runny nose, Begins 6-12 hrs after the last sweating, anxiety irritability, dose, peaks 1-3 days, insomnia, muscle duration 5-7 days pain/cramping, diarrhea, vomiting, tachycardia, HTN, restlessness, dilated pupils, chills Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. SUBSTANCEx Immediate Withdrwal Timing of Withdrawl Treament FENTANYL Supportive care Meds: Methadone, Clonidine, Naltrexone Prescription OPOIDS Supportive Meds: Methadone, Clonidine, Naltrexone Heroin Supportive Meds: Methadone, Clonidine, Naltrexone Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. SUBSTANCEx Immediate Withdrwal Long Term Treatment Treament FENTANYL Supportive care Meds: Methadone, Clonidine, Naltrexone, clonidine, probuphine Counselling Prescription OPOIDS Supportive for symptoms Meds: Methadone, Clonidine, Naltrexone, probuphine, buprenorphine Counselling Heroin Supportive for symptoms Meds: Methadone, Clonidine, Naltrexone Buprenorphine, probuphine Counselling Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. SUBSTANCE Nursing Management FENTANYL Cardiac & Resp monitoring Prescription Opioids Cardiac & Resp monitoring Heroin Cardiac & Resp monitoring Cocaine Cardiac monitoring Benzodiazepines Cardiac & Resp monitoring Alcohol Cardiac monitoring, Liver function tests, Assess for GI Bleeding, Fluid & Electrolyte status, Nutritional status, monitor for DTs Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. SUBSTANCE STREET NAMES RISK FACTORS ACTIONS COCAINE Coke, flake, snow, Not all users become CNS stimulant. blow, loot, base, big addicted. Crack Inhibits reuptake of rush, pearl, candy, Cocaine very Serotonin, baseball, stash, C. addictive norepinephrine, bump, nose candy dopamine Benzodiazepines Benzos, chill pills, May have been CNS depressant, blues, candy, French prescribed at first, used to sedate, fries, downers, but tolerance can induce sleep, prevent sleeping pills, Z bars build seizures, dec. anxiety ALCOHOL Booze, giggle juice, Tolerance can build CNS depressant joy juice, sauce Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. SUBSTANCE Signs Symptoms of Signs Symptoms of Treatment Use Overdose COCAINE Pinpoint pupils, Chest pain, HTN, Benzoidiazepins, extreme insomnia, nausea, tachycardia, lidocaine, O2, anorexia, dysthythmias, overconfidence, confusion, chills, paranoia, mood tremors, pinpoint swings pupils, seizures, coma, death Benzodiazepines Sedation, confusion, Slurred speck, lack Flumazeni (reverse memory loss, of muscle symptom) CPR dizziness, coordination, weak hypotension, rapid pulse, shallow bradypnea resps, dilated pupils, stupor, coma ALCOHOL Slurred speech, Alcohol poisioning: Supportive care, IV slow clumsy confusion, fluids, movements, vomiting, seizures Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Substance Signs Symptoms of Timing of Withdrawal Withdrawal COCAINE Lack of energy/motivation, Begins within 24 hrs, hunger, irritability, anxiety, some symptoms my last extreme depression, trouble up to 10 weeks, concentrating, paranoia depression can last 6 cravings months Benzodiazepines Anorexia, insomnia, Begins 24-48 hrs anxiety, flushing, sweating, Benzos are tapered down NV, headache, psychosis ALCOHOL Disorientation, hand Begins as early as 2hrs tremors, seizures, from last drink, usually insomnia, HTN, 24-48 hrs = DTs hallucinations (tactile, visual, auditory) hyperpyrexia, excessive sweating, delirium tremens (DTs) Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Substance Immediate Withdrawal Long Term Treatment Treatment COCAINE Supportive for symptoms Antidepressants, as needed Counselling Benzodiazepines Supportive for symptoms Taper down Counselling ALCOHOL Supportive for symptoms Naltrexone, acamprosate, disulfiram, topiramate Counselling Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.  Inhalants Produce behavioral & psychological changes Can cause permanent neurological damage May cause death Most often used by adolescents Dependence uncommon Paint, “rush”, markers Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.  Cannabis (Marijuana) Also known as hemp, pot, or weed Effects include euphoria and mental impairments Psychological dependence not uncommon Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.  Side effects of Marijuana Red Eyes (inflammation of eyes) almost always present after smoking marijuana!!! Rapid pulse Euphoria, drowsiness, light-headedness, hunger Chronic Users: disinterested in school, work,. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.  Chronic Uses of M. Affects memory Affects ability to learn Dec. Sperm production Can dec. ova production in women Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.  Pharmacological Therapy Alcohol Withdrawal (WD): Diazepam, Lorazepam, Librium, Tegretol, Clonidine Alcohol Abstinence: Antabuse, Re Via Opioid WD: Clonidine, Subutex Nicotine WD: Wellbutrin, Nicotine gum & patch Monitor vital signs, neuro status, safety, seizure precautions Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.  Drug Abuse and Families Impact goes beyond abuser Affects families Codependence – Enables addict to continue abusing substances Encourage self-help for families Families to remove prescription meds in home not being used Emotional support for families Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.  Nursing and Psychological Theory Interpersonal nursing theory guides the nurse to see the addict as an individual Addiction – Complex – Difficult to establish relationship but recovery is dependent on client’s ability to bond with others Attempt to understand client Plan interventions Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.  Assessment Client history Pattern of abuse- how much do they use in a week? Withdrawal symptoms Treat underlying issues Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.  Outcome Identification Client chooses recovery Establishes lifestyle without substances Safe withdrawal Remain free of substance Family provides support for recovery Client verbalizes coping strategies to use in times of stress Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.  Planning/Interventions Establish relationship with client Establish trust, Fair, Firm, Consistent Monitor vital signs & neuro status Seizure precautions, safety Challenge denial Assist with necessary life changes Support Groups, AA/ 12-step programs may increase success Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.  Interventions Focus = safety & safe environment Provide close observation for withdrawal symptoms Maintain adequate nutrition, fluids Low stimulation environment Administer withdrawal medications Reinforce teaching with pt. how to recognize signs/symptoms of relapse Drug Monitoring: Urine drug tests Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.  Evaluation Based on expected outcomes May require more than one attempt Be ready to assist when client is ready Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.  The nurse completes the post-op assessment for a client after an ORIF of a # R radius following a fall. The nurse notes a Hx of 4 alcoholic drinks each night during the week and 6-8 per night on weekends. Which action is priority? 1. Monitor for paranoia 2. Assess for bradypnea 3. Monitor for hand tremors 4. Assess for hypothermia Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.  3 Paranoia not ass. with alcohol withdrawal More likely Tachycardia Hand tremors yes …..Dts, withdrawl Hypo thermia: no (hyperthermia yes) Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.