Care and management of clients with substance abuse | CHAPTER 4 | Psychiatric nursing

Care and management of clients with substance abuse– This book covers the entire syllabus of “Psychiatric Nursing” prescribed by the Universities of Bangladesh- for Basic and diploma nursing students. We tried to accommodate the latest information and topics. This book is an examination-friendly setup according to the teachers’ lectures and examination questions.

At the end of the book previous university questions are given. We hope in touch with the book students’ knowledge will be upgraded and flourish. The unique way of presentation may make your reading of the book a pleasurable experience.

Care and management of clients with substance abuse

When substance use is harmful to the health of the individual as well as the health of others.

Or

Substance abuse is the use of any substance that threatens a person’s health or impairs his or her socials or economic functioning.

Or

Substance abuse refers to the harmful or hazardous use of psychoactive substances, including alcohol and illicit drugs. Psychoactive substance use can lead todependence syndrome a cluster of behavioural, cognitive, and physiological phenomena that develop after repeated substance use and that typically include a strongdesire to take the drug, difficulties in controlling its use, persisting in its use despite harmful consequences, a higher priority given to drug use than to other activities andobligations, increased tolerance, and sometimes a physical withdrawal state-(WHO).

Common causes of substance abuse:

1. The search for euphoria (a sense of wellbeing) 2. Relief of psychological pain of diverse origins

3. Wanting to feel better than they do

4. To avoid withdrawal symptoms.

[Ref: S Nambi/2/167)

Routes of substance abuse:

Substances can be taken into the body in several ways:

1. Oral ingestion

2. Inhalation or smoking

3. Injection into the veins (shooting up)

4. Depositing onto the mucosa of the mouth, or nose (snorting)

Ref: Rashid, Khabir, Hyder/1781

Classification of abused substances according to ICD 10:

1. Alcohol

2. Opioids

3. Cannabinoids

4. Sedatives or hypnotics

5. Cocaine

6. Other stimulants – including caffeine

7. Hallucinogens

8. Tobacco

9. Volatile solvents

10. Multiple drug use and use of other psychoactive substances.

(Ref: WHO/ICD-101)

Common drugs abused in Bangladesh:

1. Tobacco

2. Alcohol

3. Opioids

4. Cannabis

5. Multiple drug use

6. Cocaine

7. Sedative hypnotics

Causes/contributing factors of substance abuse:

1. Genetic predisposition to addiction or abuse

2. History of mental illness

3. Neglect or other childhood trauma

4. Poor social skills or lack of social support structure

5. Peer pressure or the belief that drug abuse is not a bad thing

6. Family history of mental illness

7. Experiencing a traumatic event, such as childhood trauma, early loss of a parent, or neglect

8. Brain injury or defects, or severe physical illness that affects the brain

9. Environmental toxins or poor nutrition that hinders brain development

10. Poor ability to relate to others

11. Cultural expectations or a desire to fit in

12. Unstable home environment, often due to drug abuse or mental illness of the parent

13. A poor relationship with parents

14. Use of drugs by friends / peers

15. Permissive attitude towards their own drug use and the drug use of the adolescent

16. Behavioral problems combined with poor parenting

17. Poor achievement in school

18. Apparent ambivalence or approval of drug use in the school, peer group or community

19. Availability of drugs from friends. [Ref-Basic concepts of community health Nursing/1. Clement/2nd edition)

Criteria of substance abuse disorder (SAD):

According to DSM-5 the criteria of substance use disorder (SAD) are –

Impaired control:

Impaired control may be evidenced in several different ways:

1. Using for longer periods of time than intended, or using larger amounts than intended;

2. Wanting to reduce use, yet being unsuccessful doing so;

3. Spending excessive time getting/using/recovering from the drug use;

4. Cravings that are so intense it is difficult to think about ariything else.

Social impairment:

5. People may continue to use despite problems with work, school or family/social obligations. This might include repeated work absences, poor school performance, neglect of children, or failure to meet household responsibilities.

6. Addiction may also be indicated when someone continues substance use despite having interpersonal problems because of the substance use. This could includearguments with family members about the substance use; or, losing important friendships because of continued use.

7. Important and meaningful social and recreational activities may be given up or reduced because of substance use. A person may spend less time with their family, or they may stop playing golf with their friends.
Risky Use:

8. Addiction may be indicated when someone repeatedly uses substances in physically dangerous situations. For instance, using alcohol or other drugs while operatingmachinery or driving a car.

9. Some people continue to use addictive substances even though they are aware it is causing or worsening physical and psychological problems. An example is the person who continues to smoke cigarettes despite having a respiratory disorder such as asthma or COPD. Pharmacological indicators: Tolerance and Withdrawal:

10. Tolerance occurs when people need to increase the amount of a substance to achieve the same desired effect. Stated differently, it is when someone experiences less of an effect using the same amount. The “desired effect” might be the desire to avoid withdrawal symptoms.

11. Withdrawal is the body’s response to the abrupt cessation of a drug, once the body has developed a tolerance to it.

Or

Criteria for Substance Use Disorders:

Substance use disorders span a wide variety of problems arising from substance use, and cover 11 different criteria:

1. Taking the substance in larger amounts or for longer than you’re meant to.

2. Wanting to cut down or stop using the substance but not managing to.

3. Spending a lot of time getting, using, or recovering from use of the substance,

4. Cravings and urges to use the substance.

5. Not managing to do what you should at work, home, or school because of substance use.

6. Continuing to use, even when it causes problems in relationships.

7. Giving up important social, occupational, or recreational activities because of substance use.

8. Using substances again and again, even when it puts you in danger.

9. Continuing to use, even when you know you have a physical or psychological problem that could have been caused or made worse by the substance.

10. Needing more of the substance to get the effect you want (tolerance).

11. Development of withdrawal symptoms, which can be relieved by taking more of the substance.

Common substance related psychiatric disorder:

1. Drug addiction

2. Alcoholism

3. Ganja psychosis

4. Withdrawal symptoms

Physical symptoms:

Substance abuse can be recognized by following symptoms.

• Bloodshot or glazed eyes.
• Dilated or constricted pupils.
• Abrupt weight changes.
• Bruises, infections, or other physical signs at the drug’s entrance site on the body.

Behavioral Symptoms:

• Increased aggression or irritability.
• Changes in attitude/personality.
• Lethargy,
• Depression.
• Sudden changes in a social network.
• Dramatic changes in habits and/or priorities.
• Financial problems.
• Involvement in criminal activity.

Nursing intervention of substance abuse/ prevention of substance abuse:

The role of the nurses in Primary Prevention:

Primary Prevention for substance abuse will:

1. Increase-involvement and pride in school activities.

2. Organize student assistance Programs

3. Organized students against drunk driving.

4. Mobilize parent awareness and action groups. 5. Increase availability of recreation facilities.

6. Encourage parental commitment to non- drinking parties.

7. Encourage involvement of religious institutions in conveying nonuse messages and providing activities associated with nonuse.

8. Curtail media messages that glamorize drug and alcohol use.

9. Support and reinforce anti-drug use peer pressure skills.

10. Provide general health screening, including for ATOD use.

11. Collaboration among community leaders to solve problems related to crime, housing, jobs and access to health care.

The role of the nurse in secondary prevention:

• To identify substance abuse and plan appropriate interventions.
• Nurses must assess each client individually.
• When drug abuse dependence or addiction is identified, nurses must assist clients to understand the connection between their drug use patterns and the negative consequences on their health, their families, and the community.

The role of the nurses in tertiary prevention:

Nurses with their knowledge of community resources can help addicts and their families and also find ways to improve the quality of care clients receive. Nurses can offer guidance to the most effective treatment, including brief interventions as well as long-term treatment. Six element commonly included in brief interventions using the acronym

FRAMES:

1. F- Feedback: Provide the client direct feedback about the potential or actual personal risk impairment related to drug

2. R- Responsibility: Emphasize personal responsibility for change

3. A- Advice: Provide clear advice to change risky behaviour.

4. M- Menu: Provide a menu of option or choices for changing behavior.

5. E- Empathy: Provide a warm, reflective, empathy and understanding approach.

6. S- Self-efficacy: Provide encouragement and belief in the client’s ability to change.

[Lesson plan volume/2/170,171]

Abuse and addiction

Abuse

Maladaptive patterns of substance uses that impair health in a broad sense.

Addiction

Addiction is defined as a chronic, relapsing brain disease that is characterized by compulsive drug seeking and use, despite harmful consequences. Addiction is the compulsive need to use a substance. Stopping use would cause user to suffer mental, physical, and emotional distress.

[Ref: Rashid, Khabir, Hyder/5/376]

Tolerance:

When a person uses drug for first time, even for a small dose, drug is very effective, whereas on repeated use increasing doses are required as the individual lost his sensitivity to a particular drug.

[Ref: KP Neeraja/I/Vol-2/604)

Drug Abuse

Taking a drug for other than medical reasons, and increased frequency, dose or manner that damages the physical or mental functioning.

[Ref: KP Neeraja/1/Vol-2/604]

Or

Drug abuse is defined as persistent or sporadic drug use inconsistent with, or unrelated to acceptable medical practice.

[Ref: S Nambi/24/96]

Signs/Symptoms of drug abuse:

1. Physical signs

• Needle tracks,
• Vein thrombosis especially in the anti-cubital fossa,
• Wearing garments with long sleeves in hot weather also, scars.

2. Behavioural manifestations

• Absence from school or work
• Occupational decline
• Neglect in personal appearance
• Loneliness
• Minor criminal offenses.

3. Medical presentation

• Drug addicts will declare different types like
• Some may present that they are dependent on drugs
• Some may conceal their dependency and ask for drugs to control or for relief of pain, e.g. Renal colic or dysmenorrhoea
• Some may present with drug related complications like cellulites, pneumonia, serum hepatitis, accidents.

[Ref: KP Neeraja/T/Vol-2/606]

Factors involved in drug abuse:

1. The drug is seen as a re-inforcer.

2. Tolerance.

3. Physical dependence.

4. The abuser

• The personality degree of stability and attitude of the individual.

5. The environment

• Isolation
• Stress
• Peer group influence.

6. The motivating factors

• Initiation by company
• Curiosity
• Acceptance by the group.
• Pleasure

[Ref: S Nambi/2/107]

Prevention of drug dependence:

A. Development of public policy: Considering the enormous effects of drug abuse on individual health and economy, every country must develop its own discouragement policy. Public method to prevent drug dependence in various parts of the world include-

• Laws to prohibit or control manufacture, transport, sale or use of drugs.
• Eradication, replacement, diversification of crop producing dependence substances
• Combating smuggling of drugs.
• Harsh penalties for offenders.
• More strict control of imported drugs with medical values as well as dependence properties.
• Prescribing and dispensing restrictions on drugs like morphine, pethidine, barbiturates and benzodiazepines.
• Warning labels on dependence producing drugs and cigarettes.

B. Alerting population at risk: Periodical meetings of parents of a group of adolescents who socialize together so as to collectively set curfew rules and other guidelines for the children

• Encouraging working parents to give more attention and time to their children so that children may not think themselves neglected.
• Motivating social organizations to arrange meetings, seminars, and rallies on anti-drug theme, and provide facilities for games and recreation.

C. Education and information dissemination: Educational efforts may ensure learning about health and social consequences of drug abuse. School curricula should be designed not only to impart specific information concerning various drug uses, but also to cover more basic topics like attitudes, values, behaviours, self-control, self- care and improving self-respect.

D. Avoidance of risky prescription: Prevention of drug dependence should include the avoidance of prescribing dependence inducing drugs in cases where their use may cause more harm than good.

E. Early detection of cases: Detection of cases at an early stage is necessary for drug intervention which will keep the disease from becoming fully developed. The various techniques used for screening of drug dependence include testing motorist for breath of alcohol, and assaying blood of comatose patients for barbiturates and heroin detection.

[Ref: Rashid, Khabir, Hyder/5/379-380]

Drug abuse:

Compulsive, excessive, and self-damaging use of habit forming drugs or substances, leading to addiction or dependence, serious physiological injury (such as damage to kidneys, liver, heart) and/or psychological harm (such as dysfunctional behavior patterns, hallucinations, memory loss), or death. Also called substance abuse.

Drug Dependence/Substance Dependence

Drug dependency:

A maladaptive pattern of substance use leading to significant impairment or distress.

[Ref: S Nambi/24/96]

Or

‘Drug dependence is a detrimental factor for individual and society, due to tolerance, compulsion to take the drug in increase doses’.

[Ref: KP Neeraja/P/Vol-2/604)

Manifestations of drug dependence:

1. Tolerance

A need for markedly increased amounts of the substance in order to achieve intoxication or desired effect.

2. Characteristic withdrawal symptoms

If the abused drug is stopped or reduced in quantity, the person develops physical and/or psychological disturbances.

3. Frequent preoccupation with seeking or taking the substance.

4. Often takes the substance in larger amounts or over a longer period than was intended.

5. Often takes the substance to relieve or avoid withdrawal symptoms.

6. There are unsuccessful efforts to cut down or control substance use.

7. Much time is spent in search of, or to obtain, the drug. 8. Important social, occupational or recreational activities are given up or reduced because of substance use.

9. Intoxicated by substance when expected to attend to his duties (e.g. does not go to work because of hangover; goes to work high; drives when drunk).

10. Continuation of substance use despite a significant occupational, social or legal problem or a physical disorder.

[Ref: S Nambi/24/96-971

Social impacts of drug dependence:

1. Home and marital problems: Breakdown of many relationships, single parent homes, lower their standard of living, domestic violence,

2. Effect on education: Absenteeism, poor grades, stealing from classmates, introducing classmates to dependence Crimes: Stealing, mugging and fraud to collect money, sex offence

3. Employment: Low performance and depleted personal hygiene lead to loss of job, absenteeism

4. Financial concern: Financial constraints

5. Health issues: increased proneness to accidents, suicide, unwanted pregnancy, increase STD

6. Burden

[Ref: Rashid, Khabir, Hyder/5/379]

Nursing care of a drug dependent patient:

1. Knowledge of the patient’s level of functioning is necessary to form an appropriate plan of care.

2. Obtain drug history to determine:

a. Type of substance used (drug).

b. Time of last abuse and amount consumed.

c. Duration and frequency of consumption,

d. Amount consumed on a daily basis.

3. History from relatives and friends and laboratory investigator to assist drug abuse is essential. Often patient himself may not tell the facts required.

4. Place the patient in a quiet room as excessive stimulation increases patient’s agitation.

5. Safety precautions:

a. Avoid getting drugs from outside sources.

b. Prevent deliberate self-harm (attempted suicide). Patient’s safety is a nursing priority.

6. Medication as instructed by the doctor.

[Ref: S Nambi/2/109-1101]

Common causes of drug dependency in Bangladesh:

I. Hopelessness

2. Frustration

3. Rejection by loved ones

4. Environment

5. Failure in education.

6. Unsatisfied married life.

7. Family problem

8. Social deprivation

9. Lack of religiosity

10. Unemployment

Drug Addiction

It is ‘a state of periodic or chronic intoxication produced by the repeated consumption of a drug’.

Criteria of drug addiction:

1. An overpowering desire or need (compulsion) to continue taking the drug and to obtain it by any means

2. A tendency to increase the dose

3. A psychic and physical dependence on the effects of the drug

4. A detrimental effect both on the individual and on the society-

[Ref: KP Neeraja/1/Vol-2/604-605]

Causes of drug addiction:

1. To gain acceptance in a group to belong

2. Peer group pressure or influence of bad company

3. Too much pocket money/loose availability of money

4. Escape from social, economic pressures

5. Defiant gesture against authority

6. Broken families, unhappy home conditions

7. Lack of parental control

8. Homelessness

9. Industrialization

10. Unemployment

11. Low socio-economic conditions

12. To get relief from strenuous activities

13. Relaxed legal systems

14. Social prestige

15. Social pressures, insisting on consumption of drugs to achieve status vinn

16. Low religiosity

17. Social deprivations

18. Problems within the family

19. Lack of recreational facilities

20. Easy availability of drugs.

(Ref: KP Neeraja/1/Vol-2/605)

clinical features of drug addiction:

1. Emotional manifestations

• Euphoria (A sense of well-being)
• Deterioration in mental and ethical sense
• Moodiness
• Dull
• Physiological depression
• Irritability
• Withdrawal from family activities otent ant et lovievni ed ut ani plime
• Lethargy
• Lack of motivation, curiosity, enthusiasm, energy and vitality
• Stealing money and valuable items
• Erratic behavior, confused thoughts

2. Physical Symptoms

• Reddening of eyes
• Glazed dull eyes
• Pin-point pupils
• Puffiness under the eyes
• Slurring of speech
• Ataxic gait
• Anorexia
• Presence of pricks and injection marks all over the b
• Sleep disturbances

(Ref: KP Neeraja/1/Vol-2/603-6061)

Preventive measures of drug addiction:

1. Primary Prevention

➤ Provide healthy and happy family environment

➤ Loving, tender-care, establish healthy child-parent relationship

➤Give mutual respect for the child

➤ Taking timeout for fun

➤Openly talk to the child and communicate love

➤Show interest in child’s activities

➤ Share problems of child, talk to the child and teach how to solve the problems and handle the situations

➤ Counselling, inform career options and motivate the child to set goals in life

➤ Parents should not be sarcastic, accusatory or blaming of the child for his behaviour

➤ Avoid influencing factors like companion which promotes the child for bad habits

2. Secondary Prevention:

➤ Observe closely change in the behaviour of the individual and avail medical assistance as early as possible

➤ Establish de-addiction centres, after-care centres, day-care centres which will assist the individual and their family members in over-coming the problem of drug addition

➤ Early identification of the drug abusers

➤ Treat promptly by specified therapies to prevent the complications of disease.

3. Tertiary Prevention:

➤ Includes the treatment in the state of severe dependence

➤ Identify the social agencies which will assist in rehabilitative activities

➤ Rehabilitation measures has to be planned based on severity of the problem

➤ Family has to be involved in the restorative and rehabilitative activities,

4. Preventive measures related to drug:

➤ Limit the availability of drugsundim

➤ Legislation measures to be formulated to control the production, supply, sale, possession and export of drugs

➤ Physicians should be careful, not to prescribe drugs of powerful action and if needed they have to advice to take drugs on prescription

➤ Drug should be made available for genuine use and safeguard to prevent illicit use.

[Ref: KP Neeraja/1/Vol-2/607-608]

Identification of an addict:

It is possible to identify the early signs and symptoms of addiction. They are:

1. Lack of interest in studies and poor academic performance

2. Loss of interest in hobbies games and sports

3. Withdrawal from the family

4. Social isolation, preferring to be aloof

5. Blank expression and irresponsible and aggressive behavior

6. Irregular eating and sleeping habits

7. Long hours in the bathroom

8. Persistent lying and stealing

9. Lack of energy and motivation

10. Low productivity

11. Impaired judgment

[Ref: S Nambi/2/107-1081]

Alcoholism

“Chronic dependence of alcohol characterized by excessive and compulsive drinking that produces disturbance in mental or cognitive level of functioning, which interferes with social and economic functioning.

[Ref: KP Neeraja/1/Vel-2/593]

Or

“The use of alcoholic beverages to the point of causing damage to the individual, society or both.”

(Ref: Alphanse Jacob)

Or

“It is a chronic disease manifested by repeated drinking that produces injuring to the drinker’s health or to his social or economic functioning.”

[Ref: S Nambi/2/991]

Development of alcoholism:

Alcoholism is the excessive consumption of alcohol and become addicted to it. It starts with

1. Experimental

2. Due to peer pressure and curiosity individuals starts to consume alcohol

3. Recreationalch live anemiye ladinals to mes

4. Gradually the frequency of alcohol consumption will increase during cultural meets as an enjoyment.

5. Relaxational

6. During weekends or on holidays individuals stat enjoying and continue it. If consumed small quantities may not cause problem. It may work out to release the tension, relaxes the mind and sedates the brain from painful emotions and promotes a sense of well-being and pleasure.

7. Compulsive

8. Once used to drinking, tendency to develop as compulsive and becomes as an addicts to overcome the discomfort of withdrawal symptoms.

[Ref: KP Neeraja/1″/Vol-2/593-594)

Pathogenesis of alcoholism:

1. Pre-alcoholic symptomatic phase

➤In conventional social situations an individual starts drinking alcohol but soon experiences tension relief, gradually tolerance for tension decreases such as extent he resorts to alcohol almost daily,

2. Prodromal phase

➤ Sudden onset blackouts, signs of intoxication, loss of memory or events.

3. Crucial phase

➤ Loss of control over drinking, increased isolation, decrease in sexual drive, centering the behaviour on alcohol.

4. Chronic phase

➤ Marked impairment in thinking process leading to alcoholic psychosis, delirium tremens occurs.

➤ Develops rationalization and amenable to treatment.

Causes of alcohol abuse:

1. To forget miseries and problems of life

2. Physical exhaustion

3. Hard physical labour

4. Certain occupations such as heavy vehicle drivers, laborers, manual workers

5. Unhealthy environment

6. Ignorance

7. Sudden loss in property or close ones

8. New ethics: Suddenly if a person become rich, consumes alcohol to show the status

9. Chronic stage: Even for small amounts of alcohol a person will start begging, borrowing, stealing. Alcohol takes priority over family or job o

10. Common in cyclothymic personalities

11. Disorders like depression, anxiety, phobia are prone to consume as an escape

12. Biochemical factors: Role of dopamine and nor epinephrine affects neurotransmitter mechanism

13. Psychological factors: E.g. injustice, inferiority, low self-esteem, poor impulse control. Poor stress management skills, loneliness, desire to escape from reality, a sense of adventure, pleasure seeking etc.

14. Sexual immaturity

15. Social factors like over-crowding, influence of bad company, cinemas, literature, peer pressure, urbanization, religious reasons, unemployment, poor social support, fashion-a sign of modernity, social inadequacy, isolation

[Ref: KP Neeraja/1/Vol-2/594)

Acute intoxication features of alcohol:

During or shortly after alcohol ingestion characterized by –

A. Psychological features:

1. Maladaptive behaviour,

2. Aggressive behaviour,

3. Inappropriate sexual behaviour,

4. Mood lability,

5. Poor judgement,

6. Slurred Speech,

7. Unsteady gait, and nystagmus.

B. Medical related problem:

1. Respiratory depression

2. Vomiting

3. Hypoglycemia

[Ref: KP Neeraja/1/Vol-2/596/

Medical consequences of alcohol misuse:

[Ref: KP Neeraja/1″/Vol-2]

Psychiatric consequences of alcohol misuse:

Pathological intoxication: Maladaptive behavioral effects, such as

1. Fighting

2. Impaired judgment,

3. Physiological signs such as –

4. Slurred speech,

5. Incoordination, and unsteady gait

6. Psychological changes such as –

7. Mood changes,

8. Irritability,

9. Impaired attention withdrawal phenomenon:

10. The general withdrawal symptoms are-

11. Tremor,

12. Nausea and vomiting

13. Malaise

14. Tachycardia

15. Elevated blood pressure,

16. Anorexia,

17. Insomnia,

18. Fits

[Ref: S Nambi/2/101]

Cerebral consequences of alcohol misuse:

1. Confusion,

2. Numbness of hands, feet,

3. Disordered thinking

4. Depression, depresses vital centres of the brain

5. Peripheral Neuropathy

6. Dementia.

7. Epilepsy

8. Head injury

9. Cerebellar degeneration

10. Wernick’s encephalopathy,

11. Coma

[Ref: KP Neeraja/1/Vol-2/595)

Withdrawal state:

It is defined as a group of symptoms occurring when a drug is withdrawal or limited from use and persists for a brief period of time.

Sign-symptoms of acute alcohol withdrawal:

1. Simple Withdrawal Syndrome

➤ Mild tremors

➤ Nausea and vomiting

➤ Weakness

➤ Irritability

➤ Insomnia

➤ Anxiety

➤ Tachycardia

➤ Hypertension

➤ Impaired attention.

2. Delirium Tremens:

➤ The term derived from Latin means ‘trembling madness. It occurs within 24 days of complete or significant abstinence from heavy alcohol drinking.

[Ref: KP Neeruja/1/Vol-2/597]

Treatment of alcohol withdrawal syndrome:

1. Detoxification

2. It is the process by which an alcohol dependent person recovers from the intoxication effects in a supervised manner.

3. Benzodiazepines-Chlordiazep oxide 80-200 mg/day.

4. Diazepam 40-80 mg/day to control anxiety, insomnia, agitation and tremors.h

5. Thiamine 100 mg intramuscular for 3-5 days followed by vitamin-B administration 100 mg OD for atleast 6 months.

6. If necessary anti-convulsants,

7. Close observation for 5 days,

8. Maintenance of intake and output chart:

9. Strict monitoring of vital signs, observation of level of consciousness and orientation, assess fluid and electrolyte balance, if necessary administer I.V fluids

10. High protein diet (if the liver is not damaged)

11. Provision of calm and safe environment.

Alcohol Deterrent Therapy:

1. Deterrent agents like disulfiram are given to desensitize the individual from alcohol effects and to maintain abstinence.

[Ref: KP Neeraja/1/Vol-2/599-600)

Nursing care of acute alcoholism:

1. Patient to be kept in a quiet environment

2. Excessive stimuli increase the patient’s agitation’ Well lighted rooms help reduce fears and illusions

3. Safety precautions-careful observation of the patient’s behavior 4. Observe for any sign of eveloping Delirium tremens (DT)

5. Be sure that the side-rails are up when the patient is in bed

6. Physical restraint may be necessary if patient is highly disturbed or hyperactive

7. Keep potentially harmful objects away from the room since the chance of deliberate self-harm is there Keep the bed clean, dry and warm since some patients maybe incontinent

8. Monitor vital signs every 15 minutes initially

9. Frequently orient the patient to reality and surroundings.

10. Medication:

➤Follow medication as advised by the doctor

➤ Antianxiety drugs like chlordiazepoxide (Librium) and drazepam, if necessary parenterally given

➤ Plenty of vitamins, especially injection B1, B6 and B12 and tablet B complex and vitamin C

➤ Antacids to relieve gastritis

11. Correct fluid and electrolyte imbalance by IV fluids.

12. Nutrition:

• Take care of the nutrition of the patient
• Document intake, output and calorie content
• Weigh daily
• Ensure that the patient receives small frequent feedings rather than large meals
• Ask family members to bring food that the patient enjoys.

[Ref: S Nambi/2/104-105]

Nursing care of late stage of alcoholism:

To understand the alcoholic, it is important to look beyond the symptoms and learn about the person These persons are in need of physical as well as social rehabilitation

1. Attention to their rest diet personal hygiene and appearance is important

2. During the recovery and rehabilitation period, the acceptance of the patient by the nurse is essential. The nurse’s acceptance may encourage the patient to socialize and participate in planned ward activities

3. The alcoholic patients have inferior feelings and low self-esteem, If the nurse accepts him as an individual and cordially talks to him, these feelings will be reduced

4. The nurse should be empathetic with the person, but should not be over sympathetic and be sure that they do not become dependent on her

5. The nurse has an important role in the care and rehabilitation of alcoholic I patients and theirfamilies. The wives should always be included in the psychological therapy

6. It is important for the nurse to anticipate improvement instead of incomplete cure

7. I Expression of kindness and being nonjudgmental, accepting him, being consistent and understanding in approach, all induces a favorable relationship, which will help the recovery process.

[Ref: S Nambi/24/105-106)

Role of nurses to prevent alcoholism:

1. Primary prevention: Aim to avoid the appearance of new cases of alcohol abuse by reducing the consumption of alcohol through health promotion, especially health education.

2. Secondary prevention: Attempt to detect cases early, and to treat them before serious complications cause disability.

3. Tertiary prevention: Aim to avoid further disabilities and to reintegrate individuals into society who have been harmed by severe alcohol-related problems.

4. The nurse will be involved in all of these levels.

[Ref: S Nambi/24/106/]

Management of alcoholism:

1. Assessment of the patient

a. His drinking pattern

b. Work spot

c. Family

d. Environment.

2. Physical methods

a. Detoxification.

b. Disulfiram therapy.

3. Psychological methods:

a. Counseling

b. Individual and group psychotherapy

c. Military and family therapy

d. Behavioral modification (aversion therapy)

e. Relapse prevention therapy.

f. Rehabilitation

g. Alcoholic anonymous.

4. Detoxification; Detoxification is the process by which an alcohol dependent person recovers from the intoxicating effects of alcohol in a supervised way.

It includes:

• Administration of minor tranquilisers (antianxiety drugs like chlordiazepoxide or diazepam) to control anxiety, insomnia agitation and tremors.
• Assess fluid and electrolyte balance for dehydration-IV fluids are essential.
• Re-establish proper nutrition by giving a diet high in protein (when there is no liver damage), carbohydrate, vitamins C and B-complex (especially vitamin 81, B6 and B12)
• preparation parenterally. Provide calm, safe environment control nausea and vomiting, and administer anticonvulsants if there is withdrawal seizure (rumfit)
• Disulfiram (Antabuse) therapy: This drug produces intense headaches, severe flushing & extreme nause4 vomiting, palpitations, hypotension, dyspnea and blurred vision, when alcohol is consumed by the person.
• Aversion therapy: Patient is subjected to pain-inducing stimuli at the time of drinking to establish alcohol-rejection behavior.
• Alcoholics Anonymous (AA): A self-group of ex-addicts who confront, instruct and support fellow-drinkers in their efforts to stay sober one day at a time, through fellowship and acceptance.

[Ref: S Nambi/2/103)

Goals of management of alcoholism:

1. Improving social relationships and supports. 2. Developing confidence and ability to change.

3. Identifying reasons to change.

4. Developing alternative activities.

5. Learning to prevent relapse.

[Ref: S Nambi/2/104)

Psychotherapy for alcoholism:

1. Motivational interviewing:

• Explaining the complications and personal risks of consuming the alcohol
• Availability of treatment options to change their behaviour related to alcohol consumption.

2. Individual psychotherapy:

• Educate each affected individual the detrimental effects of alcohol consumptions and the coping strategies to overcome the habit;

3. Group therapy:

• Observe the problems of alcoholic, provide an opportunity to observe others problems and discuss with each other and explain them to workout in better ways of with these problems.

4. Counselling:

• The therapist has to counsel the client to find out the problem and shows the ways to solve the same.

5. Aversive conditioning:

• It is based on the principle of classical conditioning.
• The therapist has to explain the behavior patterns which are pleasurable, pros and cons of alcoholism, maladaptive behaviour, show the clients who are with the complications of alcoholism, and their family problems.

6. Cognitive therapy:

• Help the client to identify the maladaptive thinking patterns, evil effects of alcoholism and guide the individual to slowly reduce the dose of alcohol intake and by understanding the evil effects of alcohol.

7. Relapse prevention technique:

• Cue Exposure Technique

8. Supportive Psychotherapy:

• Symptomatic treatment along with educating the individual about preventive measures against complications.

9. Behaviour Modification Techniques:

• Systematic desensitization, relaxation techniques, operant-conditioning techniques can be used.

10. Family Therapy:

• If the head of the family develops alcoholism the total members of the family will be affected with economic crisis, maladjustment, children are prone to develop this bad habit thus family disorganization occurs hence it is necessary and responsibility of health personnel to educate the social evil effects of alcoholism, care of the clients and preventive measures to adopt.

[Ref: KP Neeraja/T/Vol-2/599)

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