Exam 2 Flashcards
Addiction
- is a complex neurobiologic condition characterized by aberrant behaviors arising from a drive to obtain and take substances for reasons other than the prescribed therapeutic value
- Tolerance and physical dependence are not indicators of addiction
Hallmarks of addiction
Compulsive use
Loss of control of use
Continued use despite risk of harm
How do you determine if the patient uses substances in a way that places them at risk or if a SUD is present?
TheScreening, Brief Intervention, and Referral to Treatment (SBIRT)approach can be used (Fig. 10-3). SBIRT consists of three components: (1) screeningor assessing for substance use problems using standardized screening tools, (2) brief intervention or teaching patients about the consequences of substance use and abuse, and (3) referring those who screen positive for further treatment.13
-The first step of SBIRT is using screening tools to identify those who may have problems with substance use. As a baseline, ask every patient about the use of all substances, including prescribed medications, OTC drugs, caffeine, tobacco, and recreational drugs. Use simple one- or two-question screening tests to detect alcohol, tobacco, and/or other substance use problems (Table 10-12). If a patient has a positive screen, follow up with a detailed assessment to identify specific problems.
Acute Alcohol Toxicity indications
Health History: injuries, disease, hypoglycemia
Supportive Care: ABC’s until alcohol metabolizes
Vitals and Level of Consciousness
IV Fluids for Alcohol Induced Hypotension
Hypoglycemia: Glucose IV solutions
Vitamins: IV thiamine before or with IV Glucose to prevent Wernicke-Korsakoff Syndrome (seizures and brain damage)
Magnesium & Malnutrition: Vitamin IV bag (with thiamine = “banana bag” or thiamine, magnesium sulfate and folate (in separate bags)
Potassium: Hypokalemia
Agitation & Anxiety: stay at bedside as much as possible, assess for potential violence, protect from injury
Alcohol withdrawal syndrome
AWS can develop in a hospitalized patient when the use of alcohol abruptly stops. The onset of AWS is variable depending on the quantity, frequency, pattern, and duration of alcohol use. The early signs usually develop within a few hours after the last drink. They peak after 24 to 48 hours and then disappear unless the withdrawal progresses to alcohol withdrawal delirium.
Alcohol withdrawal deliriumis a serious complication that can occur from 2 to 3 days after the last drink and last 2 to 3 days. The greater the patient’s dependence on alcohol, the greater the risk of alcohol withdrawal delirium. Death may result from hyperthermia, sepsis, aspiration pneumonia, or peripheral vascular collapse.8
Management begins with identifying at-risk people. Use a symptom assessment tool, such as the Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar), to determine treatment8(Table 10-8).Table 10-9presents the clinical manifestations and suggested treatment for alcohol withdrawal. A nursing care plan (eNursing Care Plan 10-1) for a patient with AWS is available on the website athttp://evolve.elsevier.com/Lewis/medsurg.
Delirium Tremors
DTs may not start for a day or two after alcohol leaves the bloodstream, and it can occur without warning. It is primarily for this reason that alcohol withdrawal should be closely supervised by a medical professional who can continually monitor vital symptoms and ensure the individual’s safety during detox. Stopping drinking “cold turkey”is never recommended without medical supervision. Alcohol withdrawal can be fatal, as the brain and central nervous system experience a rebound after being suppressed by alcohol repetitively for an extended period of time. Sudden removal of the central nervous system depressant can be life-threatening.
Clinical Institute Withdrawal Assessment
It is a 10-item questionnaire tool to evaluate, monitor, and treat alcohol withdrawal. It includes symptoms of withdrawal such as anxiety, nausea, and sweating, among others. A score of 8 points or lower corresponds to mild withdrawal, while a score of 9 to 15 corresponds to moderate withdrawal, and a score of 15 or greater corresponds to severe withdrawal symptoms, being at risk for seizures and DT.
CIWA-Ar categories, with the range of scores in each category, are as follows:
Agitation 0-7 Anxiety 0-7 Auditory disturbances 0-7 Headache 0-7 Clouding of sensorium 0-4 Paroxysmal sweats 0-7 Tactile disturbances 0-7 Tremor 0-7 Visual disturbances 0-7
The most serious form of alcohol withdrawal isdelirium tremens (DTs), which occurs in 3-5 percent of individuals in alcohol withdrawal
Treatment
During detox, the first step is usually to monitor and control the physical symptoms and reach a stable point.This is often accomplished via medical detox, which may use medications to treat symptoms like nausea, dehydration, seizures, and insomnia. Benzodiazepines are commonly used during alcohol detox to reduce some of the potential over-activity the central nervous system may undergo as it attempts to restore its natural order. Blood pressure, heart rate, respiration, and body temperature should all be closely monitored in a medical detox center, and steps can be taken to ensure that they remain at safe levels.
At times, alcohol usage may be slowly reduced over a period of time through a detailed tapering schedule that should be set up and supervised by a medical professional. In this way, alcohol can be weaned out of the system in a controlled manner in order to avoid more dangerous withdrawal side effects. Someone dependent on alcohol may also suffer from malnutrition. Supplements and the implementation of a healthy diet and regular sleep schedule may improve withdrawal side effects and help the body heal faster.
Managing Symptoms in a Detox Center
After the physical symptoms have been controlled, mental health professionals can help reduce some of the more powerful emotional side effects of withdrawal.
Anxiety, depression, and potential suicidal ideation can be managed by medications coupled with therapy and counseling sessions. Preventing relapse is an important part of any alcohol detox center, and 12-step groups and individual therapy can offer continued support through detox and beyond. Alcohol detox centers use three medications, which are approved by theU.S. Food and Drug Administration(FDA), to help with alcohol-related cravings in the treatment of alcohol withdrawal and dependency: disulfiram, naltrexone, and acamprosate. These medications work to manage withdrawal symptoms and discourage individuals from drinking again. Naltrexone blocks opioid receptors in the brain, thereby reducing cravings and the potential rewards that may come from drinking, while acamprosate is believed to work on long-term withdrawal symptoms. Disulfiram can make people sick if they drink, thereby making drinking undesirable. A fourth medication, topiramate, also shows promise for the treatment of alcohol use disorders by also potentially interfering with the way alcohol “rewards” drinkers, as reported in the journalAddiction Science and Clinical Practice. Alcohol withdrawal should not be attempted without the professional help of a detox center, as symptoms can pop up and magnify very quickly. Even after the physical effects of alcohol withdrawal are under control, protracted withdrawal, or the continuation of emotional symptoms and cravings, can continue and may lead to relapse without the right level of support and treatment.
Stages of Change
Pre-Contemplation
At this stage, the person does not intend to change in the foreseeable future. The person is often unaware of any problem. Resistance to recognizing or modifying a problem is the hallmark of pre-contemplation.
Contemplation
At this stage, the individual is aware that a problem exists and is seriously thinking about overcoming it but has not yet made a commitment to take action. The nurse can encourage the individual to weigh the pros and cons of both the problem and the solution to the problem.
Preparation
Preparation was originally referred to asdecision making.At this stage, the individual is prepared for action and may reduce the problem behavior but has not yet taken effective action (e.g., reduces amount of smoking but does not abstain).
Action
At this stage, the individual modifies the behavior, experiences, or environment to overcome the problem. The action requires considerable time and energy. Modification of the target behavior to an acceptable criterion and significant overt efforts to change are the hallmarks of action.
Maintenance
In this stage, the individual works to prevent relapse and consolidate the gains attained during action. Stabilizing behavior change and avoiding relapse are the hallmarks of maintenance.
Prevention
Primary Prevention:
Harm reduction approach = health promotion and disease prevention
Healthy lifestyles and resiliency factors
Responsibility, identify talents, dedicate lives to helping society, encourage cooperative solutions rather than competitive or aggressive ones.
Education about drugs and guidelines for their use
Community-Based Activities on Substance Abuse Prevention
Secondary Prevention:
Screening : AUDIT, FAST, M SASQ
Testing: Post accident or random; breath alcohol or blood
Tertiary Prevention: addict and family
Detox – days to weeks, – benzodiazepines are the drug of choice (lorazepam, diazepam, Librium)
Addiction Treatment - focus is on the addiction process not management of negative health consequences
Support Groups
Summary and Key points of Substance Abuse
- Harm reduction is an approach to ATOD problems that deals with substance abuse primarily as a health problem rather than as a criminal problem.
- All persons have ideas, opinions, and attitudes about the use of drugs that influence their actions.
- Social conditions such as a fast-paced life, excessive stress, and the availability of drugs and alcohol influence the incidence of substance use disorders.
- Nurses can help develop community prevention programs.
- Substance Use Disorders often a family, not merely an individual, problem.
Types of Abuse
Emotional abuse Psychological abuse Sexual abuse Physical Abuse Strangulation is one of the best predictors for the subsequent homicide of victims of domestic violence, “the odds of becoming an attempted homicide increased by about seven-fold for women who had been strangled by their partner” (Journal of Emergency Medicine, 2008). Economic or financial abuse
Intimate Partner Sexual Violence
Less likely to seek agency, medical, or police help than other groups of rape survivors
May not be viewed as serious if assaulted by an intimate partner
Victim may not view it as rape due to sexual assault myths “stranger rape is
real rape”
IPSV happens in relationships that may not otherwise be violent
Purpose of Screening / Realistic Expectations:
SCREEN, VALIDATE, DOCUMENT, REFER
Provide a safe environment (use interpreter if necessary)
Should ALWAYS be done alone
Right to medical care / refuse medical care
Resources / danger assessment / safety planning
WI is NOT a mandatory reporting state for DV
Women who spoke with a health care provider about abuse were:
4 x more likely to use an intervention AND 2.6 x more likely to exit the abusive relationship.
