Psych - PPCC nursing - Substance Abuse Disorder PDF

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Summary

Substance abuse personality disorders and diagnoses. Assessment techniques and identification of the disorder. Medications and treatments for the illnesses as well as the type of substance being abused....

Description

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Substance Abuse Disorder: What is it?

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A maladaptive pattern Manifested by recurrent and significant adverse consequences related to repeated use of substances Must have occurred repeatedly during 12 month period Repeated failure to fulfill role obligations Social/interpersonal problems\

Substance dependence:  

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3 or greater criteria over 12 month period May or may not have physiological dependence, which depends on whether there is tolerance or withdrawal present o Tolerance – need for greatly increased amounts to achieve intoxification or desired effect or, less effect with continued use of same amount o Withdrawal – the physiological and mental (mal)adaption that occurs when addictive substance is discontinued Pattern of compulsive use o Takes larger amounts over longer period of time o Expressed desire and/or failure to cut down or control use o May spend increased time obtaining, using or recovering from effects of substance o Important activities are given up due to substance use o Despite recognized problem, the person continues to use

Intoxification:  

Reversible substance specific syndrome due to recent ingestion Maladaptive behavioral or psychological changes due to the substances acting on the CNS o Perceptual o Wakefulness o Thinking o Judgement o Psychomotor o Interpersonal

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Cross tolerance – tolerance developed with one substance transfers so that one would have tolerance in a similar substance even if never used before Synergistic effects – when 2 drugs used together there may be intensification and/or prolongation of intoxication.

Substances: 

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Depressants – o ETOH, sedative-hypnotics  Barbiturates, benzos, non-barb Stimulants – o Amphetamines, cocaine, crack, nicotine, caffeine Psychedelics/Hallucinogens o LSD, mescaline Dissociative Drugs o PCP, MDMA (ecstasy) Narcotic/analgesics o Opiates, pain meds

Effects – CNS Depressants:       

In lower doses there is a more selective depressant action in the brain (affecting arousal), nerves, muscles Sleep – barbiturates decrease dream time Respiratory depression by inhib of RAS; additive effects with other CNS depressants Cardiovascular – HypoTN with large doses Renal – high anesthetic doses, barb may suppress urine function Hepatic Stimulation – production of liver enzymes; jaundice Sexual – biphasic-initial increase, disinhibition, then decrease ability to maintain erection

Progression of Drug’s Effect 

ETOH (Barbs and Benzos similar): o Thought process/mood changes –  decrease inhibition  Increase in confidence/socialability  Decrease attention  Altered attention

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Physical –  Slurred speech  Decreased coordination/unsteady gait  Vasodilation  Nystagmus  Anesthesia  Respiratory depression

Opiods: o Initial rush = orgasmic like feeling  Flushing, voice deepen followed by euphoria then lethargy or “nod”, when eyes roll back  Decreased response and finally with awakening/arousal = drug seeking

Effects – Hallucinogens/dissociative Drugs 

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Effects – Stimulants: 

CNS stimulants can excite entire nervous system; responses vary with dose and potency o CNS –  Elation, subjective feelins of greater power  Increased alertness  Tremor  Restlessness  Anorexia  Insomnia  Agitation  May lead to paranoia o Cardio Pulmonary –  Amphetamines have sympathomimetic effects  Vasoconstriction  Increase BP/HR  Angina  Hyperthermia possibly leading to HTN crisis  MI, STROKE, AND VENTRICULAR DYSRHYTHMIAS o Nasal rhinitis, pulmonary hemorrhage o Chronic bronchitis/pneumonia with inhaled form o Sexual – aphrodisiacs; dysfunction for men

A distortion of perception o Causes depersonalization or hallucinations o Heightened response to color, texture, sounds o Distorted vision o Magnified feelings (intense) o Dreamlike state For PCP toxicity/od o n/v o Chills o Pupil dilations o Increased temp, BP, Pulse o Decreased respirations o Loss of appetite o Insomnia o Sweating o ELEVATED BLOOD SUGAR o There is rare intoxication that can cause seizures or coma o Behaviorally PCP users may experience severe psychosis and be combative or suicidal o Very dangerous behavior requires restraints

Biological Markers:  

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Breath analysis for ETOH Urine toxicology – depends on metabolites and how long they last o In urine = 1-3 days o False positives from poppy seeds for opiates o Marijuana in systems for 3-4 weeks Serum testing – shortest window of detection o Most drugs clear in less than 12 hours Hair sample – show long term use from 90 days prior Sweat patch/saliva testing

Blood Alcohol Level:  

Corresponds to ETOH level in brain and predicts CNS effects Chronic drinkers o Exhibit tolerance to lower doses

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Vulnerable to respiratory depressive effects Levels are 0.40-0.52

Application of the Nursing Process

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Ineffective coping (chemical use and behavioral – stealing, lying) Chronic low self-esteem (prior to addiction and comes out with tx) Imbalanced nutrition (potential with all substances)

Medical Complications with substance abuse: 

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Assessment o Screening  CAGE – short 4 questions to ID addiction illness  C – cut back  A – Annoying  G – guilt  E -Etoh to wake up  CIWA – pt admitted already, withdrawal s/x o Family assessment  Codependence  Enabling o Self-assessment Interview o What and how do you use? o When and frequency of use? o How much do you use? o Have others commented? o Defenses : denial, rationalize, project Physical o VS/Neuro: pupils, nystagmus, alertness, speech, coordination, tremors, mood, impulsivity, psychosis o Respiratory and cardiac o Integumentary – needles, skin picking, cellulitis, nasal/oral o GI – pancreatitis, hepatitis CODEPENDANCE o Children of alcoholics – parents decrease in nurturing, child plays role rather than individuate at developmental level o Spouse behaviors – identify with caretaking, feel they have no choice

Diagnoses r/t substance use d/o:   

Risk for injury (substance dependant) Risk for suicide (cocaine w/d) Ineffective denial (all substances)

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Cellulitis from infected needles Cariac valvular infection HIV, hep C Nasal septum erosion Ischemic brain lesions Dental erosion Lung cancer, emphysema Seizures

Outcomes: 

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SHORT TERM o Priority outcome depends on substance intox or detox and what pts symptoms are o Example:  Pt will remain safe without injury as demonstrated by stable gait, VS WNL, neuro status intact, verbalization of safety precautions and symptoms indicating need for assistance VERY LIMITED PATIENT: o Pt will verbally commit to and demonstrate safe behavior with staff (stay in bed, hydrate and eat when offered etc). patient will respond positively to staff directions/redirections as needed q 1 hour (verbal) and ongoing (behavioral) LONGER TERM: o PT WILL VERBALIZE INSIGHT INTO OWN ADDICTION BY DISCUSSING THEIR PROGRESSION INTO SUBSTANCE USE, IDENTIFYING THEIR SPECIFIC TRIGGERS and naming specific ways to maintain sobriety to prevent using.

Interventions: 

RN will perform substance specific assessment to include:

Neuro assessment (PERRLA, grips, gait, coordination, speech, judgement, perception o VS, respiratory assessment o Cardiac o Mood/cognition o GI o Integumentary Rn will after assessment, enact pt specific precautions and communicate with MD need for specific orders to maintain pt safety, including medications for pt symptoms RN will discuss/teach plan for safe detox with pt at onset of shift and prn pt need for reorientation. o

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Complications with Chronic alcoholism: 

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NEUROLOGICAL – thiamine deficit o Wernicke’s encephalopathy –  Ataxia (loss of muscle coordination, mental status changes, paralysis of extraocular eye movement; possibly reversible with THIAMIE (vitamin B1) o Korsakoff’s syndrome – chronic amnesia, dementia, psychosis, confabulation, polyneuropathy Pancreatitis Cancer (GI tract, liver) higher in men Cardiomyopathy; myopathy; HTN Esophagitis/ Gastritis Liver: fatty>hep>cirrhosis of liver portal HTN, ascites, esophageal varices, encephalopathy>increased ammonia levels Fetal alcohol spectrum disorders (FASD) range from mild neurobehavioral sx to FAS – facial malformations, microcephaly.

Withdrawal Symptoms: 

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Alcohol Withdrawal: 

Withdrawal sx: o Tremulousness, the shakes o Anorexia o Insomnia o Tachycardia o HTN o Fever

o Diaphoresis o Agitation o N/V o Loss of appetite Acute hallucinations o May occur after tremors, usually visual hallucinations o Agitation Delirium tremens o Onset 24-72 hours after last drink; disorientation o Visual/tactile halluc o Severe agitation o Fever o Perspiration o Tachy o Seizures (usually with liver disease)

Sedative/hypnotic: o Anxiety, intolerance to extreme brightness or loudness, muscle twitch, possible seizure o High doses of barbs can cause delirium, hallucinations, repeated seizures Opioid: o (Not dangerous but very uncomfortable) severe muscle cramps/spasm, yawning, bone pain, rhinorrhea, diarrhea, piloerection, temperature fluctuation, craving, pupil dilation, dysphoria Amphetamine/Cocaine: o “crash” fatigue, severe depression, vivid bad dreams, psychomotor and sleep disturbance, increased appetite

Detoxification (withdrawal therapy) 

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ETOH – o To prevent severe w/d administer CNS depressand over 3-5 days, decreasing dose each day prn  Benzos are 1st line for detox (Librium, valium, Ativan) Sedative/hypnotic -

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o gradual reduction of dose may require weeks o may use tegretol or phenobarbital to prevent seizures cocaine/ Amphetamines o no physiological intervention o they have depression hallucinogens/PCP – o w/d not ussue but tx to aid safe detox o keep environmental stimuli low o monitor safety o benzos rarely effective for labile or violent behavior o neuroleptics not implicated o acidify urine o gastric lavage Opioids – o Methadone (synthetic opioid) o Buprenorphine (suboxone) a partial opioid agonist o Both are for detox and maintenance therapy for opiate addicts Naloxone (Narcan) blocks receptors fully, for OD (not for w/d or maintenance)

Sobriety Maintenance: 

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Acamprosite (Camprel) after detox to MAINTAIN abstinence o Decreases craving for ETOH o Maintenance only Naltrexone (ReVia) after detox o Initially only for opiate users o Antagonist that blocks receptors and prevents euphoria associated with OPIOIDS AND ETOH o IM only o MAINTAINS abstinence by decreasing craving Disulfuram (Antabuse) o Uses classical conditioning to deter ETOH o Watch for hidden etoh in food o Maintenance only Methadone o Blocks craving of opiods

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o Is addictive (w/d and maintenance) Buprenorphine o Partial opioid agonist o Decreases craving o For w/d and maintenance Length of use, safety r/t use of each of these...