Chapter 12 - Caring for Substance Patients PDF

Chapter 12 - Caring for Patients With Mental Illness and Substance Use Disorders in General Practice Settings Introduction: ○ Historically, clients with mental illness have been misunderstood, misdiagnosed, & mistreated ○ Variety of influences in the etiology...

Chapter 12 - Caring for Patients With Mental Illness and Substance Use Disorders in General Practice Settings Introduction: ○ Historically, clients with mental illness have been misunderstood, misdiagnosed, & mistreated ○ Variety of influences in the etiology of mental illness ○ Clinical illness vs. normal range of emotions ○ Without clear education and understanding of psychiatric symptoms: Clients will continue to remain at risk for lack of treatment/mistreatment ○ Need for educating health-care professionals and the public The need for education of health-care providers [pg. 249]: Clients with significant mental illness die approx. 25 years earlier KNOW Diagnostic overshadowing: a person's physical symptoms are attributed to their mental illness. Clients with mental illness going ot general health-care settings are: ○ At risk for lack of treatment/appropriate referral Every nurse needs education about recognition of mental illnesses in any nursing role Nurses in any non-psychiatric setting must have: ○ Knowledge of the impact of depressive disorder in treating other physical illnesses ○ Depression affects 1 in 5 women and 1 in 10 men during their lifetime ○ Depression is a risk factor for numerous health conditions Screenings [pg. 250]: purpose, impact ○ Two-tem nursing screen for suicide risk in any medical setting ○ The screen asked the pt two questions: “In the past month, have you had thoughts about suicide?” “Have you ever made a suicide attempt?” ○ KNOW A YES answer to either question prompted a third question: “Are you having thoughts of suicide right now?” Interventions if they say “yes”: assign them a sitter to keep them safe ○ Nursing managers have an integral role in equipping their staff nurses with screening tools that are valid, reliable, time-efficient, and user-friendly ○ Many screening tools are free to use and widely accessible, while others are copyrighted, proprietary, and associated with a fee for use ○ High-risk priorities for screening in all patients: Trauma [physical, sexual, emotional abuses] Suicide risk Substance use disorders Trauma [pg. 252]: ○ Well-accepted as an essential psychosocial issue that should be conducted with patients when they first enter a health-care setting ○ Violence and trauma are linked to high risk for injury, unhealthy coping mechanisms, and other illnesses ○ Trauma in childhood is linked to significant cognitive, social, psychological, and neurobiological changes ○ Many people with childhood trauma are reluctant to share critical information [may feel guilty or scared if they share info] ○ Important to assess for history of trauma ○ Trauma-informed care:  Care that assesses for, and demonstrates sensitivity to, the impact of trauma hx on current behavior and relationships Recognize the risk for retraumatizing Important not to re-traumatize them Retraumatization: a triggering of feelings associated with previous trauma Risk for suicide: ○ National attention to suicide rates within specific groups has raised awareness of the need for: Screening/intervention among both laypeople and health-care providers ○ Specific screening is especially important for groups who may not be forthcoming with their thoughts of suicide: Examples: military personnel with post-traumatic stress disorder [PTSD], older adults with depression, trauma victims ○ A brief screening is not enough to prevent suicide in some individuals Defensive medicine: doing the minimum number of interventions needed to “meet the letter of the law” ○ Depression, substance abuse issues, and/or chronic pain are risk factors for suicide in patients in primary care settings ○ Establishing trust, a collaborative relationship, and a willingness to discuss issues from various vantage points are all essential in identifying the needed level of care or referral ○ Nonsuicidal self-injuring behavior (NSSIB) pg. 253 Typically a nonlethal, repetitive act used to reduce distress rather than end one’s life NSSIB is often associated with “cutting” (cutting oneself with a sharp object), but any other nonlethal method of self-injury, such as burning, self-hitting, or head banging, is also classified as NSSIB. ○ Patients with psychiatric comorbidities should be referred to specialized mental-health-care services ○ Those who exhibit NSSIB in response to command hallucinations need immediate medical attention Substance use disorders, pg. 253: ○ Rates of opioid abuse have reached epidemic levels Opioid addiction can lead to overdose ○ Methamphetamine use has also increased Methamphetamine withdrawal is associated with an increased risk for suicide ○ Numerous physical and psychological consequences of long-term alcohol use are well documented ○ A lot of poly-drug use is seen [ex. Meth + benzos] ○ Many patients may deny using substances, because they fear legal consequences Substance use during pregnancy may have legal consequences, which can deter prenatal care ○ Screening, brief intervention, and referral to treatment (SBIRT) pg. 253: This is an evidence-based approach that can be used in emergency departments, trauma centers, primary care, and other community settings Screening quickly assesses the severity of substance use and identifies the appropriate level of treatment Brief intervention focuses on increasing insight and awareness regarding substance use and motivation toward behavioral change  Referral to treatment provides those identified as needing more extensive treatment with access to specialty care Referral: ○ Although structured screening has been established as a critical first step to improving care, controversy arises over the following: How much care can be provided in nonpsychiatric settings? When is it appropriate to refer a patient to a specialist for treatment? ○ If nurses lack clarity about their roles and responsibilities, referring the patient to needed services is unlikely to happen Patient-centered care: ○ Patient-centered care is an approach to care provision that intends to: Identify, respect, and care about patients’ differences, values, preferences, and expressed needs Listen to, clearly inform, communicate with, and educate patients Share decision making and management Continuously advocate for disease prevention, wellness, and promotion of healthy lifestyles ○ The process of referral involves collaboration with the patient ○ Patients who are at high risk of hurting themselves or are unaware they have significant symptoms of mental illness need to be referred to a restrictive environment (even against their own will) Stigma [pg. 256]: ○ Stigmatization: Attitude of devaluing a person because of a particular characteristic or illness Creates a barrier to effective mental illness treatment in any setting Knowledge gaps, clinical skills, and stigma need to be addressed in nonpsychiatric settings ○ Social distancing: An aspect of stigma that refers to the tendency of health-care workers and others to avoid people with mental illness or addiction ○ Hallucinations, neglect of self-care, and agitation can be challenging symptoms for clinicians to manage The Role of the Nurse [pg. 258]: ○ The nurse’s role in caring for clients with psychiatric and substance use disorders in nonpsychiatric settings includes the following: Examine one’s personal beliefs and attitudes about clients with mental illness and substance use disorders Develop awareness of the negative impact of stigmatization ○ Identify patients with potentially high-prevalence, high-risk mental health issues. ○ Utilize evidence-based screening tools to identify patients needing further evaluation or referral. ○ Provide for patient safety, up to and including continuous monitoring, while determinations are being made about referral needs. ○ Establish a working knowledge of available mental health services for referral and collaborate with the health-care team to identify the most appropriate resources. ○ Engage the patient throughout the assessment and referral process using a patient-centered approach. Clicker question 1:  A nursing instructor is teaching a class about SBIRT. Which of the following terms should be excluded? ○ Screening ○ Brief intervention ○ Referral to treatment ○ Transferal Clicker question 2: Which describes the tendency of health-care workers to avoid people with mental illness or addiction? ○ Referral ○ Social distancing ○ SBIRT