Behavior 5B-NUR 211 PDF

Behavior Unit 5: Module 5 B Part One Cassey Epley BSN, RN Learning Outcomes: ● Describe the neurobiological brain changes that occur with addiction ● Compare risk factors associated with addiction, nicotine use, alcohol abuse, and substance abuse ● Identify evidence-...

Behavior Unit 5: Module 5 B Part One Cassey Epley BSN, RN Learning Outcomes: ● Describe the neurobiological brain changes that occur with addiction ● Compare risk factors associated with addiction, nicotine use, alcohol abuse, and substance abuse ● Identify evidence-based practice interventions that facilitate safe and effective care for individuals with addiction, nicotine use, alcohol abuse, and substance abuse. ● Describe components of interprofessional teamwork and collaboration that facilitate the short-term and long-term treatment of individuals with addiction, nicotine use, alcohol abuse and substance abuse ● Apply the nursing process in the care of individuals across the lifespan with assaultive behaviors ● Discuss pharmacological and nonpharmacological therapies used in the care of individuals with addiction, nicotine use, alcohol abuse, substance abuse and assaultive behaviors Learning Resources ● Halter, M.J. (2022) Chapter 22 & 27 ● ATI RN Mental Health Nursing 11.0- Chapters 18 & 31 Substance Use Disorders ● Pathological use of a substance that leads to a disorder of use ● Complex diseases of the brain ● Characterized by: ○ Craving ○ Seeking ○ Using regardless of consequence ● Symptoms groups: ○ Impaired control ○ Social impairment ○ Risky Use ○ Physical Effects Substances That Lead to Use Disorders ● Alcohol ● Caffeine ● Cannabis ● Hallucinogen ● Inhalant ● Opioid ● Sedative-Hypnotic ● Stimulant ● Tobacco ● Process Addictions ○ Gambling ○ Shopping ○ Internet/ Texting ○ Sex ○ Food Concepts Central to Addictive Use Disorder ● Addiction ○ Chronic medical condition ● Intoxication ○ Process of using a substance in excess ● Tolerance ○ Takes higher dose to achieve the initial level of response ● Withdrawal ○ Physiological symptoms ○ Occur when person stops using substance ○ Specific to substance being used DEA Classes ● Schedule 1 ○ High potential for abuse ○ No acceptable medical use ● Schedule 2 ○ High potential for abuse ○ Dangerous ○ Only available via prescription ● Schedule 3 ○ Low to moderate potential for abuse ○ Available only by prescription ● Schedule 4 ○ Low risk drugs ○ Available by prescription ● Schedule 5 ○ Contain limited number of narcotics ○ Available OTC Epidemiology ● Estimated 165 million people (60%) used substances within last month ● Estimated 20.3 million people with substance abuse disorder ● Alcohol ○ 15 million people addicted ● Marijuana ○ 4.5 million people addicted ● Opioids ○ 2.0 million people addicted Comorbidity ● Psychiatric Comorbidity ○ Any combination of two or more substance use disorders and mental disorders Risk Factors ● Neurobiological ○ Neurotransmitters Caffeine Caffeine ● Most widely used psychoactive substance ● Can cause ○ Intoxication ○ Overdose ■ Children & adolescents very vulnerable ■ Breastfeeding babies at risk when mothers ingest excessive amounts ○ Withdrawal ● Intoxication is common at high doses ○ Usually more than 250 mg ● Stimulatory effects ○ 15 minutes to 6 hours Caffeine Intoxication vs Withdrawal Intoxication: ● Restlessness ● Nervousness ● Excitement ● Agitation ● Rambling speech ● Inexhaustibility ● Flushed face ● Diuresis ● Gastrointestinal disturbance ● Muscle twitching ● Tachycardia ● Cardiac arrhythmias Withdrawal: ● Not associated with serious medical problems ● Headache ● Drowsiness ● Irritability ● Poor concentration ● Flu-like symptoms ● Nausea/Vomiting ● Muscle aches ● Symptoms: ○ Occur within 12-24 hrs after last dose ○ Peak in 24-48 hrs ○ Resolve within 1 week Caffeine Overdose ● Rare from coffee/tea ● Common with: ○ Energy drinks ○ Diet aids ○ Decongestants ○ Bronchodilators ○ Stay awake preparations ● Treatment: ○ Oral/IV rehydration ○ Gastric lavage/activated charcoal ○ Beta-Blockers (tachycardia) ○ Vasopressors (maintain BP) ● Clinical Manifestations: ○ Fever ○ Tachycardia or Bradycardia ○ Hypertension (initially) followed by hypotension ○ Grand mal seizures (high doses) ○ Respiratory failure (high doses) ○ Pupillary mydriasis (dilation) ○ Muscular rigidity ○ Hyperreflexia ○ Nausea/Vomiting Cannabis (Marijuana) Cannabis ● 3rd most common psychoactive drugs ● THC= mind altering effects ● Some medicinal use (in synthetic form) ○ Nausea relief/ appetite boost ○ Epilepsy ● Schedule 1 per DEA ● Increased potency makes more dangerous; more likely to result in addiction ● Can cause ○ Intoxication ○ Withdrawal Cannabis Intoxication ● Heightened senses ○ Brighter colors ○ New details in common stimuli ○ Time seems to go slower ● Depersonalization ● Derealization ● Motor skills impacted for 8-12 hours ● Hallucinations ● Physical Symptoms (must have 2 of the following): ○ Conjunctival irritation (red eyes) ○ Increased appetite ○ Dry mouth ○ Tachycardia Cannabis Withdrawal ● Can be late onset ○ Within 1 week of cessation ● Irritability ● Anger ● Aggression ● Anxiety ● Restlessness ● Depression ● Insomnia/Disturbing Dreams ● Decreased appetite/ weight loss ● Must include at least one physical symptom: ○ Abdominal pain ○ Shakiness ○ Sweating ○ Fever ○ Chills ○ Headache Treatment: ● Abstinence from use ● Support ○ Hospitalization ○ Outpatient Care ○ Therapy ■ Individual ■ Family ■ Group ○ Anti-Anxiety Medication ■ Short-term relief of withdrawal symptoms Hallucinogen Hallucinogen ● “Intoxicants” ● Profound disturbance in reality ● Associated with ○ Flashbacks ○ Panic Attacks ○ Psychosis ○ Delirium ○ Mood & Anxiety Disorders ● Schedule 1 Medications ● Natural & Synthetic Substances ● Found in plants/mushrooms or synthetic ● 2 categories: ○ Classic Hallucinogens: ■ LSD ○ Dissociative Drugs: ■ PCP ■ Ketamine Classic Hallucinogen Intoxication ● Clinically significant psychological and behavioral changes ○ Paranoia ○ Impaired Judgment ○ Intensification of perceptions ○ Hallucinations ○ Synesthesia ● Physical Symptoms: ○ Pupillary Dilation/ Blurred vision ○ Tachycardia/ Palpitations ○ Sweating ○ Tremors ○ Incoordination Treatment: ● Maintain patient and provider SAFETY ○ Restraints ● Talking the patient down ○ Reassurance ○ Symptoms caused by drug and will reside ● Antipsychotic medication ○ Haldol ● Benzodiazepines ○ Valium ○ Ativan PCP Intoxication ● Medical Emergency!! ● Can have dangerous/violent side effects ○ Belligerent ○ Assaultive ○ Impulsive ○ Unpredictable ● Physical: ○ Nystagmus ○ Hypertension ○ Tachycardia ○ Diminished response to pain ○ Ataxia ○ Dysarthria ○ Muscle rigidity ○ Seizures ○ Coma ○ Hyperacusis ○ Hyperthermia ● Treatment ○ Cannot be talked down ○ May require restraints ○ May need mechanical cooling! Hallucinogen Withdrawal ● No official diagnosis ● Hallucinogen persisting perception disorder ○ Occurs in 4% ○ Experienced when sober ○ Re-experience symptoms of intoxication ○ Distressing ○ Impair normal functioning ■ Weeks ■ Months ■ Years Inhalants Inhalants ● Toxic gases ● Common household products ○ Solvents ○ Propellants ○ Thinners ○ Fuels ● “Sudden sniffing death” ○ Death from cardiac arrhythmias ○ Common with: ■ Butane ■ Propane ● More common in youth Inhalant Intoxication Small Doses: ● Disinhibition ● Euphoria ● Apathy ● Diminished social functioning ● Impaired judgment ● Impulsive/ Aggressive Behavior ● Nausea ● Anorexia ● Nystagmus ● Depressed reflexes ● Diplopia Large Doses/ Lengthy Exposure: ● Fearfulness ● Illusions ● Auditory & Visual Hallucinations ● Distorted Body Image ● Stupor ● Unconsciousness ● Amnesia ● Delirium ● Dementia ● Psychosis Opioids Opioids ● Chronic relapsing disorder ● Cravings result in larger amounts ○ Increasing tolerance ● Significant impairment ○ Life roles ○ Interpersonal conflict ○ Physically hazardous situations Opioid Intoxication ● Psychomotor retardation ● Drowsiness ● Slurred speech ● Altered Mood ○ Withdrawn ○ Elated ● Impaired memory/attention ● Physical symptoms: ○ Miosis (pinpoint pupils) ○ Decreased bowel sounds ○ Reduced respiratory rate ○ Reduced BP and pulse rate ○ Skin disruptions (track marks) Opioid Overdose ● Key Symptoms: 1) Coma 2) Pinpoint Pupils 3) Respiratory depression ● Treatment: ○ Airway ■ OPA/NPA ○ Breathing ■ BVM ■ Mechanical ventilation ○ Narcan ■ Quickly increases RR ■ May need repeat administration Opioid Overdose Opioid Withdrawal ● Occurs after reduction/cessation of heavy usage ● Occurs after Narcan administration ● Symptoms: ○ Mood dysphoria ○ Nausea/vomiting ○ Diarrhea ○ Muscle aches ○ Fever ○ Insomnia ○ Lacrimation (watery eyes) ○ Rhinorrhea (runny nose) ○ Pupillary dilation ○ Yawning ○ Piloerection (bristling of hairs) ○ Sweating/ spontaneous ejaculation (in males) Opioid Withdrawal Opioid Withdrawal Treatment: ● Methadone ○ Decreases painful withdrawal symptoms ○ Only dispensed through opioid treatment program ○ Once a day dose ● Clonidine ○ Alpha agonist hypertensive ○ Symptom reduction ● Lofexidine (lucemyra) ○ Costly medication ○ Mitigate symptoms in abrupt cessation ● Buprenorphine ○ After 12-24 hrs ○ Side effects ○ Subutex/ Suboxone Opioid Maintenance Therapy ● Abstinence ● Buprenorphine/Naloxone/Methadone ● Naltrexone ○ Prevents intoxication ● Vivitrol ○ Injectable long-acting form of naltrexone ● Psychological Treatment ○ Therapy ■ Individual ■ Behavioral ■ Group ■ Family ○ Social Skills Training ○ Support groups ■ Narcotics Anonymous (NA) Sedative, Hypnotic and Anti-Anxiety Medication Usage Sedative, Hypnotic and Anti-Anxiety Medication Usage ● Craving ● Significant tolerance/withdrawal can develop ● Benzodiazepines ● Benzodiazepine-like drugs ○ Zolpidem (Ambien) ○ Zaleplon ● Carbamates ● Barbiturates ● Barbiturate-like hypnotics ● All prescription sleeping medications ● Almost all prescription anti-anxiety medications Intoxication (Sedative, Hypnotic & Anti-anxiety) ● Slurred speech ● Incoordination ● Unsteady gait ● Nystagmus ● Impaired thinking ● Coma ● Inappropriate aggression ● Inappropriate sexual behavior ● Mood fluctuation ● Impaired judgment Overdose Treatment ● Airway Patency ○ OPA/NPA ○ BVM ○ ET Tube ● Keep patient awake ○ Prevent loss of consciousness ● IV access ● Careful vital sign monitoring ● Poison Control ● Activated charcoal ● Gastric lavage Withdrawal- Sedative, Hypnotic & Anti-anxiety ● Repeated depression of CNS results in rebound hyperactivity with removal of substance ○ Autonomic hyperactivity ● Tremors ● Insomnia ● Psychomotor agitation ● Anxiety ● Grand mal seizures ● Degree/timing of withdrawal syndrome depends on substance Stimulants Stimulant Usage ● Amphetamine type ● Cocaine ● Produces euphoric feelings ● High energy Stimulant Intoxication ● Superhuman feelings ● Elated ● Euphoric ● Sociable ● Hypervigilant ● Sensitive ● Anxious ● Tense ● Angry ● Physical Symptoms (2 or more) ○ Chest pain ○ Cardiac arrhythmia ○ High or low BP ○ Tachycardia ○ Bradycardia ○ Respiratory depression ○ Dilated pupils ○ Perspiration ○ Chills ○ Nausea/vomiting ○ Weight loss ○ Psychomotor agitation or retardation ○ Weakness ○ Confusion ○ Seizures ○ Coma Stimulant Withdrawal ● Amphetamines ○ In-patient setting ○ Short-term medications ■ Valium ● Hyperactivity ● Agitation ■ Wellbutrin ● Depression Tobacco Tobacco ● Cravings ● Persistent and recurrent usage ● Dependence happens quickly Tobacco Withdrawal ● At least 4 symptoms: ○ Irritability ○ Anxiousness ○ Depression ○ Difficulty concentrating ○ Restlessness ○ Insomnia ● Within days after stopping smoking, HR decreases by 5-12 beats/min ● Within first year- weight increases average of 4-7 pounds Tobacco Withdrawal Treatment ● Behavioral Therapy ● Hypnosis ● Nicotine replacement therapy ● Medications: ○ Bupropion (Zyban) ■ Reduces cravings for nicotine ■ Reduces withdrawal symptoms ○ Varenicline (Chantix) ■ Nicotinic receptor partial agonist ■ Mimics effects of nicotine ■ Partially blocks nicotine receptors ■ Blunts effect of nicotine if smoking resumed Alcohol Alcohol ● Sedative ● Initial feeling of euphoria ● Decreased inhibitions ● Severity based on number of symptoms ● DSM- 5 criteria for alcohol use disorder ○ Page 417; Halter textbook ● 10.1 % young adults 18-25 estimated to have disorder ● Rates higher in adult men ● Comorbidity ● Reduced immune response ● Medication interactions Alcohol Alcohol Intoxication ● Legal Definition ○ Blood concentration 80-100 mg/dL ● Based on how quickly alcohol is consumed ○ Quick ingestion equals higher levels of blood alcohol ● Many factors ○ Age ○ Gender ○ Metabolism Alcohol Withdrawal ● Tremulousness ○ “Shakes or jitters” ■ 6-8 hrs ● Mild to moderate symptoms ○ Agitation ○ Lack of appetite ○ Nausea/vomiting ○ Insomnia ○ Impaired cognition ○ Mild perceptual changes ○ Increased BP ○ HR and temp increase ● Librium Alcohol Withdrawal Alcohol Withdrawal Delirium (DT’s) ● Medical Emergency!! ● Death in 20% untreated pts ● Autonomic Hyperactivity ● Delusion ● Visual/tactile hallucinations ● Unpredictable behaviors ● Medications: ○ Valium ○ Librium ○ Ativan Alcohol Withdrawal Delirium (DT’s) Alcohol Withdrawal Alcohol Blackouts ● Excessive consumption followed by amnesia ● Person actively engages in behaviors ● Can perform complicated tasks ● Appears normal but has no memory ● Blocked consolidation of new memories Wernicke-Korsakoff Syndrom ● Wernicke’s (alcoholic) encephalopathy ○ Acute ○ Reversible ○ Responds rapidly to large doses of IV thiamine 2-3 times daily for 1-2 weeks ○ Altered gait ○ Vestibular dysfunction ○ Confusion ○ Several ocular motility abnormalities (bilateral but not necessarily symmetrical) ■ Horizontal nystagmus ■ Lateral orbital palsy ■ Gaze palsy ■ Sluggish reaction to light ■ Anisocoria (unequal pupil size) ● Korsakoff ’s Syndrome ○ Chronic condition ○ More severe and permenaent ○ Thiamine for 3-12 months ○ Recovery rate of 20% ○ Most patients never fully recover ■ Cognitive improvement may occur with thiamine and nutrition support Fetal-Alcohol Syndrome ● Common cause of intellectual disability ● Alcohol in pregnancy ○ Intrauterine growth problems ○ Postnatal development issues ■ Microcephaly ■ Craniofacial malformations ■ Limb and heart defects ■ Shorter statue as adult Systemic Effects of Alcohol Usage ● Peripheral Neuropathy ○ “Pins and Needles” ○ Caused by thiamine deficiency ● Alcoholic myopathy ○ Muscle weakness/damage ○ Caused by binge drinking ● Alcoholic cardiomyopathy ○ Enlarged heart ○ Caused by weakening/thinning of heart muscle due to toxins ● Esophagitis ○ Inflammation of esophagus ○ Toxic effects on the esophageal mucosa ○ Esophageal varices Systemic Effects of Alcohol Usage ● Gastritis ○ Irritation/erosion of mucosa of stomach lining ○ Ulcers and bleeding ● Pancreatitis ○ Pancreatic damage ○ Abdominal pain, N/V ● Leukopenia ○ Low WBC ○ Vitamin deficiency and low protein intake ● Thrombocytopenia ○ Low platelet count ● Cancer Systemic Effects of Alcohol Usage ● Alcoholic Hepatitis ○ Diseased and inflamed liver ○ Occurs in heavy users ○ Symptoms: ■ Appetite changes ■ Dry mouth ■ Weight loss ■ Nausea & Vomiting ■ Pain or swelling in the abdomen ■ Jaundice ■ Fever ■ Confusion ■ Fatigue ● Cirrhosis of the liver ○ Slowly progressing disease ○ Scar tissue ○ Slowed processing of nutrients, hormones, drugs and toxins ○ Symptoms ■ Easy bleeding/brusing ■ Pruritus ■ Jaundice ■ Ascites ■ Leg edema ■ Weight loss ■ Confusion ■ Petechiae (spider like blood vessels) ■ Testicular atrophy Assessment ● Pattern of substance use ● Mental health symptoms ● Family history of substance use ● Physical symptoms ● Is the client ready for help? Alcohol Treatment ● Cognitive behavioral therapy ● Motivational interviewing ● Care continuum ○ Halfway House ○ Rehab programs ○ Alcoholics Anonymous (AA) ● Detox ○ Medically managed inpatient program ■ Used during acute withdrawal phase ● Partial hospitilization program ● Intensive outpatient programs ● Outpatient treatment Generic (Brand Name) Uses Implications for Therapeutic Process Disulfiram (Antabuse) Maintenance, relapse prevention, aversion therapy Physical effects when alcohol is used; Intense N/V, headache, diaphoresis, flushed skin, dyspnea and confusion. Avoid all alcohol containing substances Naltrexone (Vivitrol, Depade) Withdrawal, relapse prevention, decrease pleasurable feelings and cravings Oral or long acting (once a month) injectable form. Nausea usually goes away after first month; headache, sedation. Pt needs to be opiate free for 10 days before initiation of medication. Acamprosate calcium (Campral) Relapse prevention Begin taking on 5th day of abstinence from alcohol. Tablets taken TID. Contraindicated in pts with renal impairment. Benzodiazepines Withdrawal Sedation, decreased anxiety, and BP. Use CIWA-AR scale to assess dose according to agency policies. Assess for seizures that could lead to delirium tremens (DTs) Anticonvulsants Barbiturates Withdrawal Older treatments, still used today. Other treatments have proven more effective/safer. Watch for seizures. Clonidine (Catapres) Mild to moderate withdrawal Alpha-agonist hypertensive agent. Give q 4-6 hr PRN Process Disorders Gambling ● Compulsive activity ● Economic problems ● Disturbances in functioning ○ Personal ○ Occupational ○ Social ● Preoccupation ● Predisposition to lying to conceal behavior ● Financial problems ● Treatment: ○ Gamblers Anonymous (GA) ○ Hospitalization ○ Individual, group or family therapy Clinical Judgment Recognize Cues ● Assessment: ○ Self assessment ○ Family assessment (codependence) ○ Physical assessment Analyze Clues & Prioritize Hypothesis ● Risk for Injury ● Overdose ● Withdrawal ● Impaired Sleep ● Impaired Coping ● Risk for suicide ● Hopelessness ● Denial ● Dysfunctional Family Process Generate Solutions & Take Action ● Promote safety and sleep ● Reintroduce good nutrition and hygiene ● Support for self-care ● Explore harmful thoughts and spiritual distress ● Health teaching and promotion ○ Prevention against genetic vulnerability ○ Public classes Evaluate Outcomes ● Remains free of injury ● Assess effectiveness of treatment plan ● Use objective data to evaluate if actions addressed patients symptoms ● Measure changes in patients behaviors for progress toward stated goal ● Reassessment ● Documentation! Ticket to Class/ Case Study ● Case Study- Ticket to Class Questions 1) Download case study on Open LMS 2) Read case study 3) Answer the following questions a) What is the priority diagnosis b) What outcome do we want to see for this patient? c) List 1 short term goal, 1 intervention, 1 rationale for intervention and 1 way we can evaluate outcome (when will we know that the goal is met?) 4) Turn in paper (can be written or typed) at the beginning of class.