Hi, my name is Diana Shenefield.
and we are gonna talk about the
topic in Psychosocial Integrity
that encompasses Chemical
and Other Dependencies.
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.
But also what kind of signs and
symptoms as I am gonna pick up on
as they are in our facilities.
So again this falls under Psychosocial
Integrity in the NCLEX review.
Again knowing what's substances and what kinds
of signs and symptoms I need to be watching for.
I am gonna assess my patients. They have
drug/alcohol related dependencies.
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.
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.
And then to be able to evaluate the
treatment plan and revise as needed.
Again if i don't know my patient is addicted
to say alcohol and they start going through withdrawal.
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.
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.
So let's start with the question
that you might see on NCLEX.
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.
And so what kinds of signs and
symptoms should you be watching for?
Would it be A. Apprehension, tremors
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.
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.
So let's start talking
by alcohol abuse.
Again a lot of times people will tell
you that they are social drinkers.
Or they may say that
they drink occasionally.
Those aren't necessary the patients
that are going to go into withdrawal.
The patients that are gonna go into
withdrawal with the ones that need
to have their alcohol every single day.
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.
Nervousness we see that a lot
with people that are smokers.
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.
Once the body starts realizing that
it's getting short on the alcohol
the patient becomes very nervous.
May be kinda of that a
paranoid kind of nervousness.
Looking at the doors. Trying to figure
out how they can get the next drink.
They then become restless.
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.
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.
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.
But trending those and trying to
figure out. Is it getting worse
making any difference?
Diaphoresis: Again excessive sweating.
Dysrhythmias: This is when we start
getting into being very dangerous.
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.
Hopefully you started seeing some
of these signs and symptoms.
May be started getting a little bit concerned
to where you go and put them on telemetry.
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.
They can have some nausea and vomiting.
They can have some mental confusion.
Again depending on what they are
there for in the hospital
for we may attribute some of these
things to that disease process.
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.
We can then start doing something
about these signs and symptoms.
Convulsions: Obviously we hope that we
can catch this before they go into convulsions.
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.
kind of withdrawal
can lead to hallucinations.
Because of the disorientation.
Because of the nervousness.
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.
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.
And with Wernicke's syndrome
we gonna see confusion.
We gonna see Ataxia.
So when I start thinking about confusion
and ataxia, I really start worrying about fall risk.
So being able to make sure that
my patients not at risk of fall.
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.
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.
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.
Wondering mind: Again trying to have
a conversation with this patient.
They may be all over the place
when they are talking to you,
can't stay on a subject
for period of time.
Again picking up on that and
asking the right questions.
Stupor and coma: Obviously we
don't wanna get to this point.
As nurses we are always helping that we catch
these signs and symptoms before they get to
either the convulsions or the coma.
And then another time
of alcohol withdrawal
is Amnestic Syndrome which
is also called Korsakoff's.
That has an impaired thoughts.
Again whether it's hallucinations, whether its delirium
they do have impaired thoughts.
They do have confusion. So again I
am really worried about my fall risks.
Loss of sense of time and place:
That disorientation and
constantly trying to keep
them oriented to where they
are to keep them safe.
The become weak, irregular,
rapid and peripheral pulses.
Now we are looking
at more avishock
situation. Again the
body is shutting down
and it's not getting that
alcohol that it needs.
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.
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.
Can the esophageal varices picking up on it?
They are vomiting or if they are coughing up
blood where that blood
is coming from.
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.
Pancreatitis which can cause
a patient to go into shock
looking at your lab values.
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.
Diabetes: Anytime we have pancreatitis,
we also have the risk for diabetes.
Plus most alcohols do have sugar
so this patient could be
diabetic and not know it.
And so all the things that go
along with undiagnosed diabetes.
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.
And so they are not getting the vitamins and the
minerals that they need. And they become very malnourished.
But this then also lead to
a lot of chronic debilities.
May be they have wounds
that aren't healing
because of malnutrition
and because of diabetes.
So this patient is a
full chronic patient
and may be it all leads
back to alcoholism.
Caner of the mouth has been shown
to be a visible in patients that are
alcoholic. So we are looking at the mouth.
Looking for those stores
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.
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.
We have our Detox phase.
We are making sure that we
are giving adequate sedation.
Making sure that we are keeping
them from having seizures.
Making sure that we are keeping
them safe and keeping them
calm and helping them get
the rest that they need.
Administering anticonvulsants for
the possible seizure activity.
Controlling the nausea and vomiting.
Assessing for hypertension.
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.
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.
So again looking at potassium levels.
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.
Then in the recovery phase.
We will do a lot of things. But we wanna make
sure that we get them the health that they need.
Group activities work for a lot of people.
We wanna make sure that we
are avoiding giving sympathy.
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.
But we wanna help them
through the process.
And then use nonjudgmental
attitudes with them.
So as you are reading through questions you
don't wanna make them feel incompetent.
You don't wanna make them feel
like you are accusing them.
You wanna look for ways
that's gonna help the patient
take responsibility and then
take care of themselves.
So now drug abuse (narcotics).
Whether the patient is abusing narcotics
or whether it's narcotics that we have
giving them for the pain that they are abusing.
We are gonna come in with
the same kind of narcotics.
And one of the first thing we are
gonna look for is Pupil dilation.
Muscle tremors and pain:
And a lot of times people
get confuse with the pain.
Because if they get their abusing or
narcotics wouldn't their pain be deadened.
We know that narcotics
will build up a tolerance.
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.
Lacrimation - when their
eyes are watering.
Rhinorrhea - running nose.
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.
vomiting. And don't forget with
narcotic withdrawal you have vomiting
and abdominal distress.
Those with that.
Dehydration not only because of not
eating and drinking properly
but because of the vomiting.
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.
But if I understand the signs and symptoms
of withdrawal from these different medications
I can may be pin point
down the interventions.
So barbiturates, what we are gonna see
with them is postural hypotension.
that right there tells me
they are at risk for falls.
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.
They gonna have techycarida.
They gonna have fever.
They gonna have insomnia, tremors,
Now if I think about, alcohol
withdrawal. A lot of these
things go along with alcohol withdrawal.
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.
So again I may not find
What is it that they are
withdrawing from? But I
still do a good assessment and
I still intervene accordingly.
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.
Some medication will be just
a gradual withdrawal. But some
have different consequences.
But barbiturates is one of those
and if you abruptly withdrawal
you gonna see apprehension.
They are gonna be very paranoid.
They are gonna have muscle weakness.
Again which can lead to falls.
They are gonna have tremors. They are
gonna have the postural hypotension.
They are gonna have twitching, anorexia
seizures, again. So watching
for seizure activity.
Making sure in seizure precautions, making
sure you are keeping your patient safe.
And then a psychosis and delirium.
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.
We wanna watch the risk for falls and
we are gonna do our ABCs.
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.
So you may say to yourself "Well, that could
be any patient" and that's true.
But with depression, making sure that they
don't harm themselves or others.
Lack of energy: Do they have the
ability to take care of themselves.
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.
So again it really
doesn't matter at the time
what the patient is withdrawing from.
As long as a nurse I am taking
care of them and keeping them safe.
Now the marijuana is becoming
legal in a lot of states.
You may say, "They take that legally"
but withdrawal is withdrawal and so the
same kind of symptoms we need to be watching for.
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.
And so you are going to have an irritability,
a restlessness, a nervousness.
Insomnia: You will notice that they has
been with each one of these withdrawals.
So if you notice that in your patient, watching
them and try to figure our what's happening.
Anxiety: Again a paranoid (anxiety), am
I going to be able to get that drug.
And then loss of appetite of marijuana.
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.
We need to watch our seizure precautions.
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?".
Assist with medical treatment
depending on the patient.
A lot of hospitals have
protocols for alcohol withdrawal.
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.
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.
And then referrals. There is lots
of agencies available all over
the United States for referrals.
Again if you don't
know personally, know who
can make those referrals where
you can hook your patient up.
So that they can get the help that they
need and don't forget about their families.
And then counseling goes along
with that. And family support.
Don't forget it's not just your patient; but,
it effect the whole family.
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.
But you can referral them to people
who can keep an eye on and
be in constant evaluation of your plan.
But if you are in the hospital you know
"Are you evaluating?". "Did you prevent
seizures?". "Did you prevent falls?".
"And what did you do right
to take care of that patient?"
Those are all constant evaluations
that you are going to be documenting.
So what nursing diagnosis for
these patients? Were you at risk
for altered physical
I mean there is something going on
with the body and you are always
gonna have risk of altered physical.
Risk for injury should always
be at the top of your list.
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.
But when you are talking about
patients that are have addictions.
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.
So in closing, remember, anytime
we put anything into our body
that isn't naturally occuring
we are gonna have effects.
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.
Or when they have physical abnormalities
is gonna keep your patient safe. Until you
can figure our may be what they are addicted to.
So as you are answering
your NCLEX questions
remember Maslow, remember you ABCs
and always keep your patient safe.