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Mental Health Exam 3

Terms in this set (75)

Abuse
Use of illegal drugs or misuse of illegal drugs
Dependence
Includes pbx w/ tolerance, withdrawal, unsuccessful attempts to stop
Addiction
Out-of-control, compulsive drug or alcohol use despite negative consequences
Substance Use Disorder Criteria
1. Failure to fulfill major role obligations at work, school or home
2. Recurrent use in physically hazardous situations
3. Continued use despite having recurrent social or interpersonal problems
4. Tolerance, increased amounts or diminished effects
5. Withdrawal or use of a similar substance to avoid withdrawal
6. Substances often taken in larger amounts over a longer period than intended
7. Persistent desire or unsuccessful efforts to cut down or control substance use
8. A great deal of time spent obtaining, using, or recovering from the substance
9. Craving
10. Important activities are given up or reduced because of substance use
11. Continued use despite knowledge of having a recurrent physical or psychological problem caused or exacerbated by the substance
Substance Use Disorder Severity Scale
- 0 or 1 criterion- no diagnosis
- 2-3= mild substance use disorder
- 4-5= moderate substance use disorder
- 6 or more= severe substance use disorder
Substance intoxication
- Reversible substance specific syndrome
- Recent ingestion
- Behavioral changes
- Psychological changes
- Effects CNS
Withdrawal
Substance-specific signs and symptoms precipitated by the abrupt cessation or reduction of a substance that produces tolerance and dependence after prolonged use
- Ex: depression (cocaine), seizures (alcohol)
- "Do you ever feel sick when you try to stop or cut down on your use?"
Tolerance
Pharmacologic property of some abused substances in which increased amounts over time are required to achieve similar results as in earlier use
"Do you need more to get the same effect?"
Controlled Substance Schedule 1
No accepted medical use, High potential for abuse
Ex: Heroin, LSD, Marijuana, Ecstasy
Controlled Substance Schedule 2
High potential for abuse which may lead to severe psychological or physical dependence
Ex: Dilaudid, morphine, codeine, oxycodone, fentanyl, morphine, hydrocdone Amphetamine (Adderall), methylphenidate (Ritalin)
Controlled Substance Schedule 3
Abuse may lead to moderate or low physical dependence or high psychological dependence
-Ex: Tylenol with codeine, Suboxone
Ketamine, anabolic steroids
Controlled Substance Schedule 4
Low potential for abuse relative to schedule III
Ex: Xanax, Klonopin, Valium, Ativan, Versed, Restoril, Soma
Controlled Substance Schedule 5
Low potential for abuse relative to schedule IV; contain limited quantities of certain narcotics
Ex: Robitussin AC, Phenergan with Codeine
Synergistc effects
refers to intensification or prolongation of drugs taken together
Ex: Alcohol and Valium (CNS depressants)
Antagonistic Effects
refers to inhibiting effects of one drug by using another
Ex: alcohol and caffeine (stimulant)
Is substance use a clinical syndrome (axis 1) Disorder?
Yes
Are all chemical substances the same in physical and psychological dependence?
False
Disease Concept
Recognizes substance use disorder as a complex biological and psychosocial disorder that is:
- Chronic
- Progressive
- Potentially fatal
It has a predictable course.
Etiology (Disease concept)
Genetic, biological, psychological and social factors
Etiology: genetic factors
- Increased vulnerability to addiction when family history is present- doesn't guarantee addiction but increases risk, children of alcoholics 4x more likely than other children to become alcoholics
- Genetic factors account for about half the likelihood that someone will develop addiction
Alcohol dehydrogenase
- some people lack, get really sick if drink alcohol; less likely to become addiction to alcohol
Biologic theories
- Dopamine and the brain "Reward Pathway"
- Imbalances in a neurotransmitter systems.
- Changes in the brain that perpetuate illness.
- Person self-medicating
- Incentive salience: cue sensitive when exposed to substance. Reason for first year relapses. (trigger)
Psychological and Personality factors
- "Dis-ease with feelings"
- Maladaptive Coping
- Risk-taking propensity
- Novelty-seeking- seek new things
- Low self-esteem
- Lack of success
- Lack of meaningful relationships
- The first love concept
Social and Environmental Influences
- Peers
- Cultures (religion, genetic traits)
- Beliefs about the substance (ie, alcohol isn't a drug)
- Availability
- Cost
Family Theory
- Children more likely to use substances if parents model use.
- Dysfunctional family system-Codependent behaviors (maladaptive coping), p. 420
- Enabling
- Lack of nurturing, poor role modeling
- Lack of coping skills
- Do not talk, trust, feel
- Boundaries
- Enmeshed, disengaged, conflictual
Denial
- Integral part of addiction
- Minimizes or disconnects from reality of negative impact of chemical use
- Client may insist there are no problems
- Expressions of concern are viewed as unwelcome meddling
- Defense mechanism
According to the AA
- Addiction is a spiritual disease
- Fear, resentment, self-centeredness
Most used and abused substance in all age groups?
Alcohol
Binge drinking
Five or more drinks on the same occasion in the past month
Heavy drinking
Five or more drinks on the same occasion on each of five or more days in the past month
Alcohol Intoxication
- Slurred speech
- Incoordination, unsteady gait
- Impaired attention and memory
- Stupor/coma
- Nystagmus: involuntary movements of eyes
- Symptoms not due to another medical or psychological condition
Alcohol equivalents
1 drink=
- 1 oz 86 proof spirits
- 5 oz glass of wine
- 12 oz can/bottle of beer
Blood Alcohol Levels
legal limit is .08
What if someone has a BAL of .15 and is not intoxicated?
- Developed a tolerance
What if BAL is .4 and can still walk around?
- Severe chronic alcoholism
Psychiatric comorbidity
- 5 out of 10 people affected by substance-use disorder also affected by mental health disorder
- Depression, anxiety, learning & memory problems (ie, dementia)
Medical comorbidity
- alcohol-related medical problems are the co-morbidities most commonly seen in medical settings
Medical comorbidity examples
- High blood pressure
- Heart disease
- Stroke
- Liver disease (cirrhosis, hepatitis)
- Digestive problems.
- Cancer of the breast, mouth, throat, esophagus, liver, and colon.
Physical complications due to alcohol
- GI system affected first
- Malabsorption of folic acid (B12). Alcoholics are nutritionally deprived
- Part of medication management includes a MVI, folic acid, and Thiamine (to prevent Wernicke-Korsakoff syndrome
- Pancreatitis
- Esophagitis
- Cardiac myopathy
- Endocrine=increase estrogen, decrease testosterone (hormonal imbalances)
- Respiratory problems
Neurological complications due to alcohol
- Painful calves (Thiamine deficiency)
- Imbalance in gait, coordination
- Sleep disturbance
- Cerebral atrophy
- Black outs- look like they're functioning normally, but no recall
- Alcohol- related dementia
- memory Impacted: will utilize confabulation (unconscious defense) to fill in memory gaps
Wernicke- Korsakoff syndrome
- Neurological syndrome
- Result of Thiamine deficiency
- Ocular disturbance
- Imbalance gait, walking
- Occurs after excessive prolonged drinking
- Can progress to severe, chronic disease that requires custoidial care
Facts about alcohol
- Increase estrogen in alcoholics (red face, palms)
- Some may develop alcoholism after operation or menopause (hormones affected)
- Women have a faster progression (15 years earlier than men) of the disease of alcoholism due to hormones, metabolism, and decrease muscle mass
Fetal Alcohol Syndrome
- Occurs when mother has consumed ETOH first trimester
- Exact quantity of ETOH is unknown
- Symptoms: mental retardation, grown lag, small head, facial features (flat), think upper lip, learning disorders, behavioral problems, low IQ, and psychiatric disorders
Fetal Alcohol syndrome Image
ETOH withdrawal
- 6-8 hours- the shakes
- Anxiety, tremor, insomnia, hyper-alert, N/V, elevated BP, pulse psychomotor agitation, increased hand tremors
- Withdrawal does not necessarily mean that someone will experience hallucinations
- Peak 24-48 hours
- Cessation of ETOH use has been heavy or prolonged
DT's- alcohol withdrawal delirium
- 48-72 hourse after cessation
- can last up to 3 days
- life-threatening
- 10% mortality rate
- autonomic hyperactivity
- seizures
- perceptual disturbances
- fluctuating LOC
- delusions
- fever
- agitation
Medications for ETOH withdrawal
- check BP 4-8 hours
- Librum (chlordiazepoxide) or Valium (diazepam), Ativan (lorazepam)
- Benzodiazepine (alcohol in a pill)- prevent seizures CNS depression
- Vitamins B vitamins
- Unit detox protocol
Interventions- ETOH medicaitons
- Acamprosate (Campral) - suppresses alcohol cravings
- Trexan (Naltrexone): reduces alcohol cravings.
- And relapse
- Vivitrol (Naltrexone) extended release IM used to prevent alcohol relapse
Antabuse (disulfiram): Aversion therapy
- Inhibits drinking
- Unpleasant symptoms
- demonstrate sobriety
- begins 5-10 minutes
- lasts 30-120 min
- avoid hidden alcohol
What if exposed to ETOH while on antabuse?
- facial flushing
- tachycardia
- throbbing face/neck
- N/V
- H/A
- HTN
- blurred vision
- vertigo
- confusion
- shock
- need full knowledge and consent of client
- think of hidden sources of ETOH
Assessment guidelines for chemically impaired
- assess for withdrawal syndrome, overdose that warrants medical attention, suicidal thoughts or other self- destructive behaviors
- Evaluate for physical complications related to drug abuse
- assess pt and family for knowledge of community resources
- explore interests in doing something about drug or alcohol problem
Defenses
- Denial
- Blaming
- Rationalizing
- Avoidance
- Impulsive
- Projection
- Manipulation
- Grandiosity
General assessment
2 questions: in the last year have you ever drank or used drugs more than you meant to? have you felt you wanted or needed to cut down on your drinking/drug use in the last year
Drug details include
- route
- quantity
- time of last use
- usual pattern of use
CAGE assessment tool
C- cut down
A- annoyed by criticizing
G- guilty
E- eye opener
Assessment tools
- Michigan Alcohol Screening Test
- AUDIT (Alcohol Use Disorders Identification Test)
- Drug Alcohol Screening Test
- Overall Assessment Guide (Page 418-419)
- Self assessment (DO NOT FORGET)
Nursing diagnosis for substance use disorder
- think maslow- safety first (suicidal ideation, CNS depression, risk for injury, ineffective coping)
- get pt through detox
- prioritize nursing dx
Potential nursing diagnoses for substance use disorder
Imbalanced nutrition: less than body requirements
Disturbed thought processes
Disturbed sleep patterns
Ineffective health maintenance
Hopelessness
Risk for suicide
Risk for other-directed violence
Ineffective airway clearance
Ineffective breathing pattern
Outcomes Identification
- Withdrawal
- Fluid balance
- Neurological status: consciousness
- Distorted thought self-control
- Initial and active drug treatment
- Risk control - alcohol use
- Risk control - drug use
- Substance addiction consequences
- Health maintenance
- Knowledge: substance abuse control
- Family coping
- Abstinence
- Expression of feelings
- even if unpleasant
- accept responsibility for behavior
- alternative coping skills
- aftercare plan
Interventions
-Medications
-Group therapy
-12 step meetings-AA, sponsor for guidance
-Family treatment
-Multi-disciplinary treatment approach
-Be aware of manipulation, set limits
-Psychoeducation
-Urine and blood screen when return from pass/ TLOA (therapeutic leave of absence)
-Check clothes
-Address self-medication issues
-Coordinate inpatient to outpatient care
-Individual therapy
Intervention strategies
- relapse prevention
- self-help groups for pt and family
- 12 step programs
- residential programs- like outpatient
- intensive outpatient programs
- outpatient drug free programs and employee assistance programs
- lab reports
- mandatory outpatient treatment- MOT (some people are mandated, nurses to keep license)
AA says
- AA most effective form of treatment for alcoholic/addict
- Alcoholism is a disease if an alcoholic continues to use the outcome will be jail, institutions, and death
- many of those that are dependent are cross addicted
Evaluation
- increased time in abstinence
- decreased denial
- acceptable occupational functioning
- improved family relationships
- ability to relate comfortably to other indiviuals
Nursing process
- plan and set up goals to evaluate and revise to maintain sobriety
- is an addict cured?/ relapse?
- most relapses occur 2 years after treatment
Stimulants
- amphetamines- speed
- cocaine
- crack
- methamphetamine- "speed"
- cocaine in coke, made illegal in 1914
Cocaine intoxication symptoms
- euphoria
- hyperactivity
- insomnia
- anorexia
- wt loss
- tachycardia
- seizures
- death
- stimulate violent or sexual behavior
- heart attacks
- paranoid
- psychotic
- deterioration nasal septum- from snorting
Cocaine withdrawal symptoms
- opposite of intoxication
- fatigue
- dysphoria
- depressed
- the crash
- craving
- lethargy
- apathy
- sleepy
- disoriented
- agitated
- suicidal ideation
Methamphetamine "speed"
- made with household products
- very toxic
- depletes brain of dopamine
- vasoconstrictor, acne, skin loses elasticity, grind teeth
Treatments for stimulants
- Antidepressants (SNRI)- prozac
- atypical antipsychotics if hallucinations, paranoic, and delusions present while intoxicated- Zyprexa
Opiates, Heroin, Narcotics
- health professionals may become addicted to this category due to availability, injury, chronic pain
- can be snorted, smoked (quickest action), injected (second quickest action), swallowed
- Heroin has high abuse potential because it readily passes the blood-brain barrier, becomes trapped in brain- sustained euphoric affect
- Respiratory depression major cause of death
Heroin: intoxication
- feeling of warmth and well-being, sleepy /relaxed
- decreased pain response
- respiratory depression- biggest risk
- constricted pupils
- euphoria
- slow digestion
- slow CNS
- judgement impaired
- apathetic
- coma
- death
- high risk of HIV/ hepatitis
- cross- addicted
Early and late stages of Heroin withdrawal
- early- insomnia, runny nose, chills, yawning, uncomfortable
- later- N/V, fever, elevated, temp, sweating, panic, cramps
Heroin: Withdrawal
- intense physically and psychologically but seldom fatal
- peaks at 48-72 hours, can last for 7-10 days
- craving may persist for months after withdrawal
- will not let medically unstable patients or pregnant women go through withdrawal. These pts. Will be given Methadone.
- "worst flu ever"
Will pt experience withdrawal if they abruptly stop taking methadone?
yes
Opiates, Heroin, Narcotics Treatments
- Methadone (Dolphine) maintenance (mild onset of action)- used in treatment of withdrawal
- Suboxone (buprenorphine HCL)
- blocks craving for and euphoric effects of heroin
- not used alone, in conjunction with counseling and other treatment modalities
- can gradually taper
- LAAM- used like Methadone but effective for 72 hours so pt comes to clinic less frequently- not used as often
- Trexan- blocks euphoric effects of opiates as well as alcohol
- Vivitrol- ER IM used to prevent relapse alcohol
- Clonidine- high BP med but useful in conjunction with Trexan and suppresses opiate withdrawal sx
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