Alcohol Use Disorder Care Plan PDF

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NURS 2021 Weekly Nursing Care Plan PT Initials: R.A Significant Medical Diagnoses: Alcohol Abuse & risk of self-harm Safety Considerations: Excessive use of alcohol & self-harm Activity level and restrictions: Exercises occasionally Activities of Daily Living: mobility is good

Data/Information

Analysis/Rationale (where applicable)

(1) Provide the etiology and pathophysiology (the primary disease or condition the patient is admitted with) Defining Characteristics

Alcohol Use Disorder • A pattern of alcohol abuse use that involves problems with control over the amount of alcohol consumed, continuing to consume alcohol after it causes problems, having to increase alcohol consumption in order to get the same effect, may experience withdrawal symptoms may occur if alcohol consumption is decreased or stopped immediately. Etiology Biochemical factors: the reverse of tolerance with an enhanced neural response upon repeated exposure can lead to substance abuse Genetic Factors: alcoholism is associated with a family history of

alcoholism. Genetic variation in regulation results in low serotonin which can possibly be associated with the development of alcoholism. Psychosocial factors: An individual may consume alcohol for certain life situations, the induvial may long for the effects that alcohol gives. The individual may have excessive consumption due to trying to fit in with social groups. Symptoms to look out for • Unable to limit the amount of alcohol consumed • Being unsuccessful in cutting down the amount of alcohol consumed • Continuing consuming alcohol with knowledge that it is causing interpersonal, physical, and social issues. • Developing a tolerance to alcohol resulting in consumption being increased • Experiencing withdrawal symptoms; nausea, sweating & shaking

(2) Assessment data: Baseline assessments from text and other resources (from health history/interview, vital signs and physical examination). Provide your analysis after you collect the data.

Pathophysiology • Toxic to most organ systems of two or more drinks are consumed daily. • Dopamine is a neurotransmitter in the CNS that is involved with stimulation of physiological responses. Alcohol increases dopamine levels which creates a strong association with physiological effects and behavior. • Lower levels of serotonin due to genetic factors could be a cause for a development of alcoholism. • Alcohol could be used to suppress feelings of anxiety and depression. • Get the chief complaint

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Obtain patients medical history

The patient is a 20year-old female who has been admitted due to a sprained wrist and alcohol abuse. The patient also expresses suicidal ideation. • The patient has a history of alcohol abuse and anxiety. The patient has suffered a sprained right wrist due to a MVA, and had an

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Assess the patient’s mental status

Assess the patient’s Vital Signs • BP:112/75 • HR: 87 • RR: 14 • Temp: 37 • Sp02: 100%

alcohol level of 0.2%. The patient reported being allergic to peanuts. • The patient suffers from moderate anxiety and stress due to her circumstances and that this anxious feeling is gradually increasing. The patient is stable and has no disordered behaviors. It is clear that the patient has suicidal ideations, as they state they do not care if they live or die. The patient does not display any evidence of delusions or hallucinations, or false sensory perceptions.

BP: Normotensive HR: Normal RR: Normal Temp: Normothermic • Sp02: Normal

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(3) One priority physiological and One priority psychosocial nursing diagnosis (must be NANDA approved). Related Factors ( R/T) Provide the rationale for why you determined as priority.

Assess the patient’s General Appearance • Eye contact • Clothing • Posture • Grooming Physiological • Risk of self-harm

Indirect eye contact Clean clothing Tension and rigidity • Appropriate level of grooming • By excessive alcohol consumption this can lead to the patient becoming very intoxicated and not being aware of their surroundings and being at risk of self-harm. The patient in this simulation was intoxicated and had drove their car and ended up crashing and sprained their wrist. If the patient is to do this again they can be at an even greater risk of self-harm as a sprain wrist could be a very minimal injury to the patient and they might not even think about it twice before getting in a car again while intoxicated. Excessive alcohol consumption results in a high risk of self-harm. • • •

Psychosocial • Risk of Obesity

(4) Planning: create in collaboration with the patient/family two SMART goals for each nursing diagnosis (one short, one long-term) Provide the rationale for each goal.

Short-term Goal • Get the patient to agree to taking Naltrexone, this will help reduce alcohol assumption.

The patient could be at risk of obesity because of her alcohol consumption and not caring much for what they eat. The patient is currently about 5 feet and 110lbs, which is a normal weight. If the patient continues on this path and gaining more weight, they could potentially become obese due to excessive alcohol consumption. • Having the patient agree to talking Naltrexone by the end of the shift will be beneficial to the patient because this medication will reduce the patients desire to consume alcohol. This medication works by, suppressing the euphory and pleasurable sensations from alcohol. This means the patient will no longer get that good feeling from drinking and lessens their need to want or need to drink. This medication gets absorbed by the liver and can •

potentially cause damage if used in high dosages, so it is important to educate the patient on this medication.

Long-term Goal • Get the patient to agree and enroll in cognitive behavior therapy and carry out therapy for as long as the treatment lasts; usually 16 weeks. Encourage the patient to enroll in therapy after CBT is done.

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Getting the patient to agree to enrolling themselves in Cognitive Behavioural therapy would be beneficial to the patient’s mental health because of the stressors in their life. CBT would help with the patient’s alcohol use disorder, as it is a therapy that can help with addictions. This form of therapy will also help the patient with their anxiety, as it can focus on this as well. After the patients CBT treatment is over, it would be in the patients best interest to start therapy with a therapist who specializes in addictions and anxiety, it would be very beneficial to this patients mental health as

(5) Three to four nursing interventions to implement (must relate to the primary nursing diagnoses and determined goals).

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Maintain a therapeutic relationship with the patient.

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Discover the reason for beginning of substance use

Provide the rationale for each nursing intervention.

they are very young. • Maintaining a therapeutic relationship with the patient will allow them to open up and be more comfortable when being interviewed. The patient in this simulation was not 100% comfortable talking about a few things when being interviewed, like when asked about her relationship with her mother. • The patient started to drink excessively due to the stressors in their life. The patient feels overwhelmed by school and does not have a good support system. The patient reported that she drinks four to five times a week and she usually has about 5 drinks or more. The patient believes that drinking like this eases her stress and anxiety due to school, her parent’s relationship deteriorating, and the being anxious. • When talking with the patient, I had

(6) Evaluation/result of the intervention (can be expected results if longterm)

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Encourage the patient to attend AA meetings

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The intended result with the short-term goal is that the patient will take Naltrexone and take it as directed before discharge and agree to take it after being discharged to control their alcohol consumption. It is expected the patient follows through with this short term goal if they agree to this plan as they were not keen on seeking treatment during the interview, but if the patient is educated it can potentially change their mind. The intended result for the long-term goal is that the patient will agree to CBT and therapy after CBT treatment is over.

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educated her on AA meetings and that they may be helpful to her due to getting a DUI and her excessive drinking. When interviewing the patient, I also suggested therapy to the patient as she was not too keen on AA meetings.

This should be recommended to the patient and they should be thoroughly educated on the benefits of therapy for addiction because they were not willing to seek treatment during the interview. As a college student, who lives a very stressful life, it would be beneficial for the patient to do therapy. During the interview the patient had stated that they wished they had someone to talk to, so this may encourage the patient to go through with CBT and therapy, If the patient goes through with this long-term goal, it could potentially help the patient become sober and stay sober, which is the expected result. (7) Medications (use drug card template) *have drug card for two (2) new medications prepared each week – unless you are giving meds that shift, then you must know all of them.

Indications/Therapeutic Effects Dosage range Routes of Administration Pharmacokinetics Nursing Implications/Assessments Adverse Effects Contraindications Client Teaching Other

Attached Below

(8) Relevant laboratory and diagnostic tests (why is the test being done, what are the findings, are there any special considerations needed before/during/after the test?)

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Complete blood count

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B12 Test

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Complete metabolic panel

*research one if non- applicable to patient

The purpose of this test is to evaluate the patient’s overall health and detect if there is suspicion of anemia, infection, and leukemia. This test also measures the amount of red blood cells in the body, white blood cells, hemoglobin, hematocrit, and platelets. The patients CBC results indicated that all tests were in normal range and there were no abnormalities. • The purpose of the B-12 test is to measure the amount of the vitamin B12 in the body. The patients B12 level was in the normal range of 200-900 picograms per milliliter; they had 250 picograms per milliliter. • The purpose of the CMP is to measure the glucose levels, electrolytes and fluid balance, kidney function, and liver function. the main concern was their liver functioning All these measures for the patient came back normal. •

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Urinalysis

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Iron test

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Ethanol test

The purpose of the Urinalysis is to measure a wide range of disorders including kidney disease and diabetes. It also involves checking the appearance, concentration, and content of the urine. The urinalysis came back normal and no abnormalities, indicating no disease or illness in the patient. • The purpose of the iron test is assessed for the amount of iron circulating in the blood, total capacity of the blood to transport iron, as well the amount of iron stored in the body. This test can also detect of the patient has anemia. The test results for the patient came back normal and no abnormalities. • The purpose of the Ethanol test is to determine the level of ethanol in the blood so the health care provider can treat the intoxicated patients’ symptoms effectively. The patients result •

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(9) Relational Practice (what techniques have you explored and practiced?). Provide specific examples.

CAGE Screening

Making Observation • Making observations while interviewing the patient is important because as a nurse it helps us determine any underlying factors, such as the patient being stressed or anxious, we can figure this out by

indicated that their ethanol level was 100mg/dL, which is very high, a normal range is 50mg/dL. This result indicates that the patient has a high level of alcohol in their blood and they will have to be treated according to this level of ethanol. • The CAGE measurement is a screening questionnaire that aids in id-ing potential problems with alcohol. For females, only one yes is needed for the test to be positive. The patient’s test result was positive, there for they had to be educated about this addiction and there was recommended interventions stated above.

watching for nonverbal cues. Nonverbal cues include fidgeting with their hands or clothes, picking at their nails or skin, biting their lip, feeling overly hot etc. As well observing the patient’s appearance is important because this can play a huge role in the patient’s mental health. The patient that I did interview had clean clothes but for someone who may be depressed they could have dirty clothes indicating that they have not groomed themselves in awhile due to their mental illness. Active listening • Making nonverbal cues such as nodding of the head and encouraging the patient by saying “I see” or “I understand”, This would be done if the interview was in person. During the interview in the simulation I let the patient know I am listening by saying “I understand”

(10) Ethical considerations (what ethical situations/ dilemmas developed as part of providing care). Provide specific examples.

during certain conversations in the interview, the patients appreciate this acknowledgement. Focusing • Focusing on the patient’s diagnosis is important because it shows that you as nurse care about the patient and making sure the patient gets the care they need. Consent • It is important to get the patients consent; verbal and written. This is important as the patients nurse because it is needed to record the interview with the patient and ensures that you have the patients consent if you have to inform another health care provider or family member of their choosing, information about the interview. Confidentiality • The nurse or health care provider should get ensure the patient that all information that they share with their health care

provider is confidential unless they give consent for their information to be released to another medical center or family/spouse.

Ibuprofen Anti-Inflammatory

Indications/ Therapeutic Effects:

Dosage Range: Routes of Administration:

Pharmacokinetics:

Nursing Implications/ Assessments:

Side/ Adverse Effects:

Contraindications:

Client Teaching:

Other:

I: treatment for mild to moderate pain, fever, treatment for inflammatory disorders TE: Decreases pain, inflammation, and reduces fever 400-800mg 4 times daily Orally (PO) Absorption: Oral formulation is 80% absorbed from the GI Tract Distribution: does not enter breast milk, is distributed in significant amounts Protein binding: 99% Metabolism & excretion: mostly metabolized by the liver, small amounts are excreted by kidneys. Half-life: 2-4hrs I: don’t confuse Motrin with Neurontin, higher doses does not provide increased pain tolerance, patients should be hydrated when taking ibuprofen, should be administered 30 minutes before or two hours after meal, can be taken with food, milk or antiacids. Tablets can be crushed and mixed w/ fluids or food. A: patients with asthma, aspirin-induced allergy, & nasal polyps are at risk for developing hypersensitivity rx’n’s, assess the pt for asthma, urticaria, rhinitis. Assess the pt for S&S of GI bleeding, renal dysfunction. Assess the patient for skin rash, assess the patient’s pain, assess ROM, monitor fever CNS: headache, dizziness, drowsiness, intraventricular hemorrhage EENT: amblyopia, blurred vision, tinnitus CV: arrhythmias, edema, hypertension GI: GI bleeding, Hepatitis, constipation, dyspepsia, nausea, vomitting, abdo discomfort GU: cystitis, hematuria, renal failure DERM: Exfoliative Dermatitis, Stevens-Johnson syndrome, Toxic Epidermal, Necrolysis, rashes HEMAT: anemia, blood dyscrasias, prolonged bleeding time MISC: allergic reactions; Anaphylaxis Hypersensitivity, Active GI bleeding or ulcer disease, the chewable tablets contain aspartame and patients with phenylketonuria should not take it, or for pain from coronary artery bypass Advise patients to take ibuprofen w/ a full glass of water Instruct pt to take medication as directed Avoid alcohol consumption, aspirin, acetaminophen, and other OTC Advise pt to not take more than 10 days Inform pt to notify HCP if rash occurs after taking ibuprofen If pregnant or planning pregnancy tell pt to notify HCP

Ortho Tri-Cyclen Lo – Et hinyl Estradiol/Norgestimate Ethinyl Oral contraceptive

Indications/ Therapeutic Effects:

Prevent pregnancy, treats acne in females of the age of about 15 who have started menstruating

Dosage Range:

21 pills and 7 placebo pills

Routes of Administration:

Orally (PO)

Pharmacokinetics:

Nursing Implications/ Assessments:

Side/ Adverse Effects:

Contraindications:

Client Teaching:

Other:

Absorption: 100% absorbed Distribution: N/A Protein Binding: 97-98% Metabolism & Excretion: extensive first pass hepatic metabolism Half-life: 6-20hrs I: Do not confuse Ortho Tri-Cyclen Lo with Ortho Tri-Clyclen, administer with or right after food A: Assess BP before and during therapy, exclude possibility of pregnancy, assess acne before and during therapy, assess menopausal symptoms Nausea, Vomiting, headache, bloating, breast tenderness, weight change, spotting Can cause blood clots, dizziness, fainting, SOB, unusual headaches; migraines, depression, abdominal pain. Hypertension Advise patient to check BP regularly and notify HCP if its high Does not protect against HIV or other STI’s Discontinue use of hx of blood clots, diabetes, severe hypertension etc. Do not use if pregnant Have had cancer or breast cancer Inform HCP if irregular periods, depression, diabetes, high BP, seizures, and migraines

Inspiring Nursing as if EVERY PPerson erson matters…

Ativan (LORazepam) Sedative

Indications/ Therapeutic Effects:

I: decreases anxiety TE: sedation and decreased anxiety

Dosage Range:

1-3mg, 203 times daily

Routes of Administration:

Orally (PO)

Pharmacokinetics:

Absorption: Absorbed follow oral administration Distribution: widely distributed, crosses the BBB, crosses the placenta, and enters breast milk Metabolism & Excretion: Metabolized by the liver Half-life: 10-16 hours

Nursing Implications/ Assessments:

Side/ Adverse Effects:

Contraindications:

Client Teaching:

Other:

I: Do not confuse Ativan with Atarax, Take as directed A: assess degree of anxiety and mental status before and during therapy CNS: Dizziness, drowsiness, lethargy, headache, confusion, depression, slurred speech EENT: blurred vision RESP: respiratory depression GI: constipation, diarrhea, nausea, vomiting, weight gain DERM: rashes MISC: physical dependence psychological dependence, tolerance Hypersensitivity; with other benzodiazepines Educate the patient on the importance of taking the medication exactly as directed Advise patient that this medication is for short term use Educate the patient that the medication dose should be decreased gradually to avoid withdrawal symptoms Educate patient on other ways to decrease anxiety Instruct patient that the medication may cause dizziness an...