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Chemical and Other Dependencies

by Diana Shenefield, PhD
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    00:02 Hi, my name is Diana Shenefield.

    00:04 and we are gonna talk about the topic in Psychosocial Integrity that encompasses Chemical and Other Dependencies.

    00:11 Then we are gonna talk about alcohol withdrawal, illegal drug withdrawal and get us thinking about what these patients are gonna look like when the come in to our facilities.

    00:20 But also what kind of signs and symptoms as I am gonna pick up on as they are in our facilities.

    00:26 So again this falls under Psychosocial Integrity in the NCLEX review.

    00:31 Again knowing what's substances and what kinds of signs and symptoms I need to be watching for.

    00:36 I am gonna assess my patients. They have drug/alcohol related dependencies.

    00:42 Again a lot of times patients aren't gonna tell you that when they walk in the door. That they are addicted to something and so being able to catch signs and symptoms.

    00:50 Being able to pick up on subtleties and their assessment so that I can be prepared in the back of my mind. In case they do go through withdrawal.

    00:57 And then to be able to evaluate the treatment plan and revise as needed.

    01:01 Again if i don't know my patient is addicted to say alcohol and they start going through withdrawal.

    01:07 Not only as I going to change my care plan because of the withdrawal. But may be because of the treatment for the other disease process that brought them into the facility.

    01:16 So again can I pickup on those assessments and reevaluate and reassess to make sure that my patient is taking care of to the best of my ability.

    01:26 So let's start with the question that you might see on NCLEX.

    01:29 Which nursing assessment should indicate to a nurse that a newly admitted patient is in amphetamine withdrawal? Again most of the times your patients aren't going to tell you upfront that they have been using amphetamine or narcotics.

    01:44 And so what kinds of signs and symptoms should you be watching for? Would it be A. Apprehension, tremors and psychosis-deliriums? B. Insomnia, anxiety, and loss of appetite? C. Vomiting, tremors, and diaphoresis? Or D. Depression, lack of energy and somnolence? So again thinking back to our patients when they take amphetamines.

    02:10 If they were withdrawing which of these answers would you pick? And the correct answer is D. Dependence or depression, lack of energy and somnolence.

    02:22 So let's start talking by alcohol abuse.

    02:25 Again a lot of times people will tell you that they are social drinkers.

    02:29 Or they may say that they drink occasionally.

    02:32 Those aren't necessary the patients that are going to go into withdrawal.

    02:36 The patients that are gonna go into withdrawal with the ones that need to have their alcohol every single day.

    02:41 So kind of assessment of alcohol withdrawn delirium am I gonna be watching for? And one of the top assessment findings is gonna be nervousness.

    02:52 Nervousness we see that a lot with people that are smokers.

    02:55 When it comes time for cigarette they get very nervous and a lot of times may be they haven't told us that they are smokers. It also happens with alcohol abuse.

    03:04 Once the body starts realizing that it's getting short on the alcohol the patient becomes very nervous.

    03:11 May be kinda of that a paranoid kind of nervousness.

    03:14 Looking at the doors. Trying to figure out how they can get the next drink.

    03:18 They then become restless.

    03:20 They are not gonna wanna lay on bed. They are not gonna want to just lay there and watch TV or sleep; because, of constantly thinking and the body is craving that alcohol.

    03:30 They start having tremors of their hands, face, and lips. Again watching those signs and symptoms and are you picking up on that as a nurse. Or you so focuses on the disease process that brought them in that you miss those subtle signs and symptoms.

    03:45 Increase BP and HR: You know a lot of things can cause increase blood pressure and heart rate. Things like anxiety which you were seeing here pain, or may be the disease process.

    03:57 But trending those and trying to figure out. Is it getting worse scenario interventions making any difference? Diaphoresis: Again excessive sweating.

    04:06 Dysrhythmias: This is when we start getting into being very dangerous.

    04:10 Again if my patients not on a telemetry unit, will I pickup if they are having dysrhthmias or will I not pickup to its too late.

    04:19 Hopefully you started seeing some of these signs and symptoms.

    04:22 May be started getting a little bit concerned to where you go and put them on telemetry.

    04:28 Again are they becoming depressed? You know are they getting to the point where they know that they are not gonna be able to get the alcohol.

    04:36 They can have some nausea and vomiting.

    04:38 They can have some mental confusion.

    04:40 Again depending on what they are there for in the hospital for we may attribute some of these things to that disease process.

    04:48 But being able to see if something else is going on. Or being able to talk to our patient and find out that they are alcoholics and they are going to alcohol withdrawal.

    04:58 We can then start doing something about these signs and symptoms.

    05:03 Convulsions: Obviously we hope that we can catch this before they go into convulsions.

    05:08 But knowing that once they start having seizures. Do you have them seizures precautions? And what kind of medications are you going to to be giving to stop those seizures.

    05:18 Hallucinations: Any kind of withdrawal can lead to hallucinations.

    05:23 Because of the disorientation. Because of the nervousness.

    05:26 So again if your patient starts complaining of hallucinations whether auditory or visually. Being able to pickup and know that may be it's not the medications that you are giving. Being able to ask the right questions.

    05:40 So then there is another type of alcohol withdrawal besides the delirium there is Wernicke's syndrome. A lot of times these are kind of the same diagnosis just kind of effects are little bit different.

    05:52 And with Wernicke's syndrome we gonna see confusion.

    05:55 We gonna see Ataxia.

    05:57 So when I start thinking about confusion and ataxia, I really start worrying about fall risk.

    06:02 So being able to make sure that my patients not at risk of fall.

    06:06 So what kind of prevention am I going to do? Eye movement abnormalities: When you are talking to the patient keeping good eye contact and being able to pickup on any abnormalities on their eye movement.

    06:18 Memory impairment: Again if you have asked them questions or they have asked you questions and there seems to be some impairment. Being able to pickup on that and is that normal for that patient or not.

    06:31 Diplopia: Again are they complaining of seeing double vision? Do they see two of you? When you try to hand them a pill, are they trying to grab the two separate pills? All are those signs and symptoms that I should be able to pickup on as a nurse.

    06:46 Wondering mind: Again trying to have a conversation with this patient.

    06:51 They may be all over the place when they are talking to you, can't stay on a subject for period of time.

    06:57 Again picking up on that and asking the right questions.

    07:02 Stupor and coma: Obviously we don't wanna get to this point.

    07:05 As nurses we are always helping that we catch these signs and symptoms before they get to either the convulsions or the coma.

    07:15 And then another time of alcohol withdrawal is Amnestic Syndrome which is also called Korsakoff's.

    07:21 That has an impaired thoughts.

    07:24 Again whether it's hallucinations, whether its delirium they do have impaired thoughts.

    07:30 They do have confusion. So again I am really worried about my fall risks.

    07:35 Loss of sense of time and place: That disorientation and constantly trying to keep them oriented to where they are to keep them safe.

    07:44 The become weak, irregular, rapid and peripheral pulses.

    07:48 Now we are looking at more avishock situation. Again the body is shutting down and it's not getting that alcohol that it needs.

    07:57 Chronic heart failure: Again if your patient has a normal heart and they come in and they are seeing the signs and symptoms. Would you be able to attribute that too an alcohol withdrawal and asking the right questions? And assessing all the other things that are going along.

    08:14 And then Gastritis, a lot of time these patients will come in with vomiting and may be some blood in the vomit varices, esophageal varices. Again picking up on these are signs and symptoms of alcohol abuse.

    08:29 Can the esophageal varices picking up on it? They are vomiting or if they are coughing up blood where that blood is coming from.

    08:36 Cirrhosis at the liver. Are you palpating and do you feel that the liver is enlarged and hardened? And also knowing that this is going to effect your metabolism of all your other medications as well.

    08:49 Pancreatitis which can cause a patient to go into shock looking at your lab values.

    08:56 Picking up on your increased amylase and lipase looking at your liver profile and being able to try to figure out why those would be going up.

    09:06 Diabetes: Anytime we have pancreatitis, we also have the risk for diabetes.

    09:11 Plus most alcohols do have sugar so this patient could be diabetic and not know it.

    09:17 And so all the things that go along with undiagnosed diabetes.

    09:21 Malnutrition: Again are they getting the nutrients that they need. A lot of times when people are suffering from [inaudible 0:09:27.720] alcohol is the only thing they think about.

    09:31 And so they are not getting the vitamins and the minerals that they need. And they become very malnourished.

    09:36 But this then also lead to a lot of chronic debilities.

    09:40 May be they have wounds that aren't healing because of malnutrition and because of diabetes.

    09:46 So this patient is a full chronic patient and may be it all leads back to alcoholism.

    09:53 Caner of the mouth has been shown to be a visible in patients that are alcoholic. So we are looking at the mouth.

    10:00 Looking for those stores those stomatitis.

    10:03 Is the bleeding from the mouth Or it is from esophageal varices? So this patient comes in may be they haven't told you that they are alcoholic or may be that they have.

    10:14 Being able to do a thorough assessment from head to toe and understanding what the signs and symptom are of alcoholic withdrawal and then what we do after that. We move into our interventions.

    10:26 We have our Detox phase.

    10:28 We are making sure that we are giving adequate sedation.

    10:32 Making sure that we are keeping them from having seizures.

    10:36 Making sure that we are keeping them safe and keeping them calm and helping them get the rest that they need.

    10:44 Administering anticonvulsants for the possible seizure activity.

    10:48 Controlling the nausea and vomiting. Assessing for hypertension.

    10:52 and giving hypertensive medications in case the pressure is out of control. Or we can get it down just by taking care of their anxiety.

    11:01 Assessing fluid and electrolytes: A lot of times because of malnutrition because of dehydration fluid and electrolytes are all out of whack which we know that potassium causes dysrhythmias.

    11:13 So again looking at potassium levels.

    11:15 Looking at your sodium levels. Is the delusions and the delirium from electrolyte of sodium being off? Or is it because of the alcohol? Making sure they have good nutrition. A lot of times we will be starting on TPN to make sure that they have good nutrition. That we get the body build back up and again promoting safety. If they have ataxia or they having delusions. Safety is a big concern.

    11:42 Then in the recovery phase.

    11:44 We will do a lot of things. But we wanna make sure that we get them the health that they need.

    11:48 Group activities work for a lot of people.

    11:50 We wanna make sure that we are avoiding giving sympathy.

    11:54 So as you are looking at questions on NCLEX. Look at the proper ways, the therapeutic ways, to talk to people when they are going to recover. We don't wanna sympathize with them.

    12:05 But we wanna help them through the process.

    12:07 And then use nonjudgmental attitudes with them.

    12:11 So as you are reading through questions you don't wanna make them feel incompetent.

    12:15 You don't wanna make them feel like you are accusing them.

    12:18 You wanna look for ways that's gonna help the patient take responsibility and then take care of themselves.

    12:25 So now drug abuse (narcotics).

    12:27 Whether the patient is abusing narcotics or whether it's narcotics that we have giving them for the pain that they are abusing.

    12:33 We are gonna come in with the same kind of narcotics.

    12:35 And one of the first thing we are gonna look for is Pupil dilation.

    12:40 Muscle tremors and pain: And a lot of times people get confuse with the pain.

    12:45 Because if they get their abusing or narcotics wouldn't their pain be deadened.

    12:49 We know that narcotics will build up a tolerance.

    12:53 So if they are abusing narcotics and they still have pain we need to look at where is your original source of pain and what kind of narcotics have they been taking.

    13:03 Lacrimation - when their eyes are watering.

    13:06 Rhinorrhea - running nose.

    13:08 Again they may attribute that to seasonal allergies and you may too as a nurse. But being able to assess those things and put them those with all the others assessment bindings.

    13:18 Diaphoresis, chills, vomiting. And don't forget with narcotic withdrawal you have vomiting and abdominal distress. Those with that.

    13:29 Dehydration not only because of not eating and drinking properly but because of the vomiting.

    13:35 Rapid weight loss A lot of times when people are addicted to narcotics they are not eating so they are losing weight. So do they have an unexplained weight loss? Sleep disturbances: Is it because they are constantly thinking about the narcotics? Or is it because that their sleep cycles have been messed up? So besides narcotics we also know that people will withdrawal from barbiturates. Again when the patient come in and say, "I just want you to know I have taken all these drugs", probably not.

    14:05 But if I understand the signs and symptoms of withdrawal from these different medications I can may be pin point down the interventions.

    14:13 So barbiturates, what we are gonna see with them is postural hypotension.

    14:17 that right there tells me they are at risk for falls.

    14:21 So if they are standing up and they are being dizzy. They can't stand up. They complaining of their head spinning for whatever reason. I really need to look at risk for falls.

    14:30 They gonna have techycarida. They gonna have fever.

    14:33 They gonna have insomnia, tremors, agitation, restlessness.

    14:38 Now if I think about, alcohol withdrawal. A lot of these things go along with alcohol withdrawal.

    14:43 Again when my patient is in front of me a lot of the symptoms may be the same. But I would do the same kind of things. I gotta keep my patients safe and I gotta take care of my ABCs.

    14:55 So again I may not find out later.

    14:57 What is it that they are withdrawing from? But I still do a good assessment and I still intervene accordingly.

    15:04 Now if I been on barbiturates and I have a abrupt withdrawal which a lot times happen if I may get brought into the hospital and all of the sudden my medication or my drug abuse has been stopped abruptly.

    15:17 Some medication will be just a gradual withdrawal. But some have different consequences.

    15:22 But barbiturates is one of those and if you abruptly withdrawal you gonna see apprehension. They are gonna be very paranoid.

    15:29 They are gonna have muscle weakness.

    15:31 Again which can lead to falls.

    15:33 They are gonna have tremors. They are gonna have the postural hypotension.

    15:36 They are gonna have twitching, anorexia seizures, again. So watching for seizure activity.

    15:42 Making sure in seizure precautions, making sure you are keeping your patient safe.

    15:46 And then a psychosis and delirium.

    15:49 So again you can look down this list and think mentally to yourself "If that patient sitting in front of me how am I going to treat this patient?". And we are gonna treat them the same.

    15:59 We wanna watch the risk for falls and we are gonna do our ABCs.

    16:03 Amphetamine withdrawal: Remember back to the original question when you talking about amphetamines. How do I know if somebody is withdrawing from amphetamines? They have depression lack of energy and somnolence.

    16:15 So you may say to yourself "Well, that could be any patient" and that's true.

    16:19 But with depression, making sure that they don't harm themselves or others.

    16:23 Lack of energy: Do they have the ability to take care of themselves.

    16:27 Are they getting the proper nutrition? And then somnolence. Are they able to get up and around? Or is their chance of pressure ulcers and those kinds of things.

    16:36 So again it really doesn't matter at the time what the patient is withdrawing from.

    16:41 As long as a nurse I am taking care of them and keeping them safe.

    16:45 Marijuana withdrawal: Now the marijuana is becoming legal in a lot of states.

    16:50 You may say, "They take that legally" but withdrawal is withdrawal and so the same kind of symptoms we need to be watching for.

    16:57 Are they craving the high? Do they have an irritability? And those two kinda go together. Again when you come into the hospital facility. All of the sudden whatever you are addicted to has been taken away.

    17:09 And so you are going to have an irritability, a restlessness, a nervousness.

    17:13 Insomnia: You will notice that they has been with each one of these withdrawals.

    17:18 So if you notice that in your patient, watching them and try to figure our what's happening.

    17:23 Anxiety: Again a paranoid (anxiety), am I going to be able to get that drug.

    17:28 And then loss of appetite of marijuana.

    17:32 So what do we do for interventions? Again we need to keep that patients safe. We need to support their vital signs then nutrition and then hydration.

    17:42 We need to watch our seizure precautions.

    17:45 So think through your mind "How you take care of a patient that is having a seizure or what do you do to prevent seizures?".

    17:52 Assist with medical treatment depending on the patient.

    17:55 A lot of hospitals have protocols for alcohol withdrawal.

    17:59 Know those protocols. Know how to take care of a patient that has nausea and vomiting, That has abdominal pain That has deliriums. What kind of interventions are you going to put into place to take care of that individual patient? And again, education, education, education.

    18:16 We need to keep educating our patients and our families on signs and symptoms of drug abuse, alcohol abuse and what to look for withdrawal.

    18:27 And then referrals. There is lots of agencies available all over the United States for referrals.

    18:33 Again if you don't know personally, know who can make those referrals where you can hook your patient up.

    18:41 So that they can get the help that they need and don't forget about their families.

    18:45 And then counseling goes along with that. And family support.

    18:49 Don't forget it's not just your patient; but, it effect the whole family.

    18:54 Many evaluation of treatment plan, once they leave you, How you are going to evaluate their treatment plan? As a nurse in the hospital, you may not be able to.

    19:04 But you can referral them to people who can keep an eye on and be in constant evaluation of your plan.

    19:10 But if you are in the hospital you know "Are you evaluating?". "Did you prevent seizures?". "Did you prevent falls?".

    19:16 "And what did you do right to take care of that patient?" Those are all constant evaluations that you are going to be documenting.

    19:25 So what nursing diagnosis for these patients? Were you at risk for altered physical regulation process? I mean there is something going on with the body and you are always gonna have risk of altered physical.

    19:36 Risk for injury should always be at the top of your list.

    19:39 Altered impulse processes: You know why is this person addicted in the first place? Altered social interaction. Altered feeling states. Are they always happy? Are they always sad? Is that's what striding them for their abuse? Again sometimes we get hooked on our nursing diagnosis, our top physical ones.

    19:59 But when you are talking about patients that are have addictions.

    20:04 It's not just the physical but it's also the psychosoical that goes along with that. So don't forget about those diagnosis as well.

    20:11 So in closing, remember, anytime we put anything into our body that isn't naturally occuring we are gonna have effects.

    20:19 Again knowing your patients being able to pick up on signs and symptoms of abuse and being able to intervene when they are not safe.

    20:29 Or when they have physical abnormalities is gonna keep your patient safe. Until you can figure our may be what they are addicted to.

    20:37 So as you are answering your NCLEX questions remember Maslow, remember you ABCs and always keep your patient safe.

    20:45 Good Luck!


    About the Lecture

    The lecture Chemical and Other Dependencies by Diana Shenefield, PhD is from the course Psychosocial Integrity. It contains the following chapters:

    • Chemical and Other Dependiencies
    • Alcohol Abuse
    • Assessment of Alcohol Amnestic syndrome
    • Drug Abuse
    • Interventions for Drug Abuse

    Author of lecture Chemical and Other Dependencies

     Diana Shenefield, PhD

    Diana Shenefield, PhD


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