Medical-Surgical Nursing: An Integrated Approach, 2E

Chapter 34

NURSING CARE OF THE CLIENT: SUBSTANCE ABUSE

Substance: Defined as:

A drug, legal or illegal, that may cause physical or mental impairment.

Substance Disorders

In the U.S., substance disorders affect males and females, all ethnic groups, and persons of all levels of education and income. From the newborn to the elderly, all ages can be affected.

Classifications of Substance Disorders Intoxication (The reversible effect on the CNS

soon after the use of a substance). Abuse (The misuse, excessive, or improper

use of a substance, the abstinence of which does not cause withdrawal symptoms).

Dependence (addiction) (The reliance on a substance to such a degree that abstinence causes functional impairment, physical withdrawal symptoms,and/or a psychological craving for the substance).

Factors Related to Substance Abuse

Individual factors (e.g. genetic factors; personality traits).

Family patterns. Lifestyle. Environmental factors. Developmental factors.

Detoxification: Defined as:

The elimination of the substance from the body.

Alcohol

Low doses of alcohol depress areas of the brain that are inhibitory, causing diminished self-control and impaired judgment.

Continued alcohol ingestion may cause unconsciousness and even death.

Alcohol and the Liver

Chronic alcohol abuse causes three distinct diseases of the liver: Fatty liver (an accumulation of

triglycerides in the liver). Alcoholic hepatitis. Cirrhosis.

Alcohol and Gastrointestinal Disturbances

Alcohol damages the lining of the stomach and esophagus by irritating the mucosa and causing inflammation or ulcer formation.

Gastric pain, vomiting, and diarrhea are common in alcohol abuse.

Pancreatitis

An alcoholic has a higher risk of developing pancreatitis than an abstainer.

Severe pancreatitis can result in death.

Wernicke’s Encephalopathy

An inflammatory hemorrhagic and degenerative condition of the brain caused by a thiamine deficiency resulting from alcoholism.

Characterized by delirium, memory loss, unsteady gait, a sense of apprehension, and an altered level of consciousness.

Korsakoff’s Psychosis

Thiamine and B12 deficiencies contribute to the degeneration of the brain and peripheral nervous system.

Disorientation, amnesia, insomnia, hallucinations, and peripheral neuropathologies characterize this psychosis.

Alcohol and Cardiovascular Disturbances

Moderate amounts of alcohol causes cutaneous vasodilation (flushed skin). This causes rapid heat loss and core temperature may drop to a dangerous level.

Blood pressure decreases with intoxicating doses of alcohol.

Irregularities in cardiac rhythm may result.

Fetal Alcohol Syndrome

Excessive use of alcohol in pregnancy may result in this syndrome in the newborn, with growth retardation, CNS involvement, and craniofacial abnormalities.

Women who are pregnant or are trying to get pregnant should abstain from alcohol consumption.

Withdrawal Refers to the symptoms produced when a

substance on which an individual has dependence is no longer used by that individual.

Alcohol withdrawal occurs in 3 stages: Stage 1/Minor (anxiety, sleep problems, tremors, etc.); Stage 2/Major (stage 1 signs plus hallucinations, whole-body tremors, vomiting, etc.); Stage 3/Delirium tremens (fever, disorientation, inability to recognize familiar people and objects. This is a medical emergency with a 2% to 5% mortality rate).

Johnsonian Intervention: Defined as:

A confrontational approach to a client with a substance problem that lessens the chance of denial and encourages treatment before the client “hits bottom.”

Self-Help Groups

Alcoholics Anonymous (AA), AL-ANON (for adults); AL-ATEEN (for teenagers) and AL-ATOT (for younger children in family of alcoholic) are holistic approaches that have been very successful.

Drug Intervention for Alcoholics

Disulfiram (Antabuse) may be given to some alcohol abusers as a deterrent to drinking. It inhibits the enzyme needed to metabolize alcohol.

Drinking alcohol with disulfiram in the body causes flushing, blurred vision, nausea, vertigo, anxiety, etc.

Benzodiazepines and Other Sedative-Hypnotics Examples include Valium, Seconal, Paral,

with street names like roofies, tranks, ludes, barbs.

Low doses produce drowsiness or sedation; larger doses produce sleep.

Potential for addiction is high. Withdrawal symptoms include anxiety,

insomnia, anorexia, delirums, tremors, and seizures.

Cannabis Marijuana is most common type of

cannabis used. Hash or hashish is a potent concentrate of the resin from the flowers. Street names are grass, pot, reefer, smoke, weed, and Mary Jane.

Short-term effects include memory and learning problems; distorted perception; loss of coordination; panic attacks.

Potential for psychologic addiction is moderate.

Cocaine Extracted from leaves of the coca plant. It may be heated and fumes inhaled. This is

termed free-basing. As a white powder, it may be snorted by inhaling

through the nose. It may also be heated to a liquid state and injected intravenously.

Crack is a crystallized form of cocaine that is melted in a water pipe and smoked. Sreet names include coke, crack, flake, rocks, snow, “C,” and blow.

Amphetamines Also called uppers, speed, bennies, they

include Dexedrine, Amphetamine, and Desoxyn.

Enhances psychomotor performance, induces a temporary state of well-being, and gives an instantaneous euphoria. Followed by a crash.

High doses may cause insomnia, tachycardia, headache, arrhythmias, hypertension, followed by hypotension, nausea, vomiting, cramping, diarrhea, convulsions, and death.

Caffeine

Probably the best known and most frequently used and abused CNS stimulant.

Found in coffee, tea, chocolate, cocoa, cola beverages, and some nonprescription drugs.

Potential for addiction is moderate. Withdrawal produces headache, irritability, and tremulousness.

Nicotine

Tobacco kills more than 430,000 U.S. citizens every year. More than alcohol, cocaine, heroine, homicide, suicide, car accidents, fire, and AIDS combined.

Potential for addiction is high. Causes respiratory and cardiovascular

disease, cancer.

Other Substances Hallucinogens (Psilocybin and psilocin, DMT,

DET, Ecstasy). LSD (Lysergic Acid Diethylamide). Phencyclidine (PCP). Opiods (Morphine, Heroin, Demerol, Percodan). Inhalants (glues, kerosene, acetone, naptha,

fluorcarbons, nitrous oxide). Anabolic Steroids.

Codependency: Defined as:

A learned pattern of feeling and behaving. Codependence occurs when people feel good about themselves only when they fulfill the expectations of others.

Characteristics of the Codependent Person

Caretaking (“I always give to others. No one gives to me”).

Obsession (“I can’t stop worrying about ___problems”).

Denial (“I pretend I don’t have problems”). Poor communication (“No one trusts me”). Lack of trust (“I don’t trust myself”). Anger (“I resent feeling controlled and

manipulated”).

The Impaired Nurse

Most states now have peer assistance programs to help nurses impaired by either alcohol or other substances.

Substance abuse and dependence are greater problems among nurses than among the general population because nurses have access to many controlled substances.