Mental Health Fall '12

1. Renee Franquiz MSN, RN

2.  28 million Americans
over the age of 12 years
used drugs or etoh (13%)
 17 million Americans
over the age of 12 years
abused (7%) – based on
DSM-IV criteria
 Highest prevalence was
among white males, age
18-25, high school only
education
 Most highly abused
substance was alcohol
Source: http://www.oas.samhsa.gov/nsduh.htm
(US Dept of Health and Human Services)

3. In class we touched on some of the reasons illustrated below,
and we spoke of social acceptance/indifference, peer pressure,
role modeling, taboo makes it tempting, cultural norms,
changes in family (supervision of children), access to
information (internet), result of Rx treatment

4.  Within the US 14% of adults have had an
alcohol dependence or abuse problem at
some time in their lives.
 3% of individuals older that 12 years need
treatment for drug use disorders.

5.  Definition  DSM-IV Criteria (1 of the
 Touse in a following in the past 12
wrong or months)
harmful way  Failure to fulfill role
obligations
 Physical hazard/Injury
 Legal Issue(s)
 Behavior continues despite
an awareness that there is
a problem

6.  Definition  DSM-IV Criteria (3 of
 Compulsive chronic the following in the
requirement where the past 12 months)
need creates distress if  Tolerance
unfulfilled
 Withdraw Symptoms
 A desire to Decrease
 Often involves
 Unsuccessful attempt to
tolerance – which is an
habituation – the decrease
increasing need for  Increase time spent in
greater amount or more pursuit
frequency  Sacrifice personal
Involvements
 Behavior continues
despite an awareness
that there is a problem

7.  Physiological
Biochemical– Substance combines with
neurotransmitters to produce
endogenous morphine, which becomes
addictive
Biologic – Gene of predisposition
 Familial tendency, especially for etoh
 Supported by Twin Studies and Adoption
studies

8.  Psychological
Developmental – Stalled development
at one of the stages (Freud, Erikson,
Kholberg etc) predisposes to use/abuse
Personality – Individual traits
predispose to use/abuse, such as low
self-esteem, impulsiveness, inability to
delay gratification, antisocial,
depressive personality

9.  Social
 Learned– Bandura’s Social Learning Theory.
Modeling in the environment (family and peers)
results in use/abuse
 Operant Conditioning – Skinner, Pavlov Positive
reinforcement from the pleasure aspect of use
leads to repeat behavior
 Cultural– Can fall under “Learned” and relates
to etoh – reflected as Values, Norms, Customs
and Beliefs of a particular culture

10.  Reasons for use –  PLEASE REVIEW
previously covered  ATI pages 154-157
 Intended and Toxic
effects
 Significance  This is material that
¼ all ER admits are will be tested on the
substance related exam
 1/3 of all suicides are
substance related
 ½ of all Homicides are
substance related

11.  First examine and explore yourself
 How do you feel about drugs, alcohol, and addiction?
 This may include reflecting on your own use, or that of
family and friends
 Negative attitudes about use may lead to disapproval,
intolerance, condemnation
 Positive attitudes about use may lead to enabling and boundary
issue
 Maintain Professionalism – your attitude either way should not
factor into the nurse-client relationship
 Empathy is a must
 Anticipate the possibility of manipulation
 addiction creates a powerful need that if unfulfilled,
lead to significant client distress
 Pursuit of the substance may trump all conventional
thought

12.  Assessment
 Review the general mental health history and
physical on pages 142 – 147 in Townsend
 History should include
 Type, Route, Frequency, Amount of Substance used
 Patterns of use and have they changed (Shift from Use
to Dependence)
 Date/Time of last use, abstinence hx (rehab),
withdraw sx
 Be sure to include
 Have you ever used more than you wanted to?
 Have you wanted to change your use? Cut
down/stop?

13.  Assessment
 Labs (Acute Evaluation)
 Complete Blood Count (CBC) – Concerns for infection,
anemia, thrombocytopenia
 Complete Metabolic Panel (CMP) – Concerns for
Electrolyte Imbalance, Liver Function, Nutritional
Deficits
 Urine Analysis (U/A) – Concerns for infection, Renal
Impairment
 Toxicology Screen – Can do as U/A or Blood
 Blood Alcohol Level (BAL) – Legal Limit 0.08% (80g/dl)
 Unable to discharge client until BAL < 100g/dl,
unless they are being transported by someone else
 Life Threatening BAL > 350 g/dl – 400g g/dl - All
depends on the individuals tolerance

14.  Assessment Tools
 Please familiarize yourself with these tools
 Textbook
 MAST (Michigan Alcohol Screening Test)
 CIWA (Clinical Institute Withdraw Assessment)
 ATI
 MAST (As Above)..MAST.pdf
 Addiction Severity Index
..Addiction Severity Index.pdf
 Recovery Attitude and Treatment Evaluator (unable
to provide d/t copyright – for purchase only)
 Drug Abuse Screen Test (DAST)..DAST.pdf
 CAGE-AID..CAGE-AID.pdf

15.  Analysis and Diagnosis
 Consider any Nursing Dx you have data to support
 Due to the breath of impact that substance abuse has,
the list of nursing dx could be quite exhaustive
(physical, psychological, social, cognitive)
 Key Dx associated with Substance Abuse
 Ineffective Coping
 Denial
 Impaired Nutrition
 Risk for Injury
 Disturbed Thought Process
 Suicide
 You likely could add at least 10 more!

16.  Analysis
 Consider that 50% of people with a serious mental illness
have a substance use disorder some time on their lives.
 Disorders associated with substance abuse include:
 Acute and chronic cognitive impairment
 Attention deficit disorder
 Anxiety
 Borderline personalities
 Depression
 Eating disorders/compulsivity
 Therefore, carefully consider Dual-Diagnosis when
assessing a client with Substance Aubse

17.  Plan
 Physiologic health and safety first – Prioritize
ABCs if applicable. Then move on to Psych/Soc
 Aim of psycho-social treatment is self
responsibility
 Match the types of treatment with client needs:
 “Fit” between client and resource
 Type/Severity of addiction
 Age
 Physiologic Health
 Neuropsychological Health
 Location/ length of program and ability of client to
attend
 Finances

18.  Implementation
 Safety During the Acute Phase of Detoxification
 Close Observation – 1:1, usually with a UAP (High risk
for seizures, delirium (psychosis), falls,
vomit/aspiration)
 +/- Restraints - review restraint video in ATI online
 Frequent VS assessment – rapidly changing condition
 Safe Environment – Bed low, No objects in the room
that patient could harm themselves with or throw
 Seizure Precautions – Padded side rails, tongue blade,
Oxygen, Suction, IV access, PRN orders for
antiepileptic drugs (usually Benzodiazepines)
 Low Sensory Stimulation (Visual, Auditory, Tactile)
 Provide for foods, fluids, elimination

19.  Self Help
 Step programs (AA, NA, GA, Al-Anon)
 Peer Driven, Faith Based
 Emphasize Self Responsibility
 Counseling
 Individual
 Educate – About addictions, treatment goals
 Cognitive behavioral therapy
 Emphasize Self-Responsibility
 Family
 Educate – About addictions, codependency, relapse
 Support groups
 Groups
 Clientswith similar diagnosis meet under the
supervision of a professional to discuss issues
 Inpatient or Outpatient

20.  Psychopharmacology
 Alcohol Withdraw
 Benzodiazepines – controls agitation and seizures
 Antiepileptics – Controls seizures
 Thiamine – Nutritional replacement
 Ensure IV access at all times
 Alcohol Abstinence
 Antabuse – Inhibits ETOH metabolism, Acetaldehyde
accumulates and causes serious illness
 Opioid
 Reversal Agent – Narcan (Action is immediate); No
concern if given and no narcotic on board
 Withdraw – Methadone, Buprenorphine (less side effects
than Methadone

21.  Increased time in abstinence
 Decreased denial
 Acceptable occupational functioning
 Improved family relationships
 Ability to relate to other individuals

22.  10-20% of practicing nurses are chemically dependent in
their personal lives
 Access to Controlled Substances presents
opportunity/temptation
 RN license is in jeopardy of suspension or revocation by
the Board of Nursing
 Signs
 Physical/Behavioral signs of impairment
 Work Absenteeism; Frequent breaks from the unit
 Missing Controlled Substances from the unit
 Abusers patients report poor pain control (abuser taking the
meds instead of administering)
 Abuser frequently offers to help other nurses and medicate
their patients (abuser takes the meds instead of administering)
 Co-worker’s Responsibilities:
 Document
 Report facts to immediate supervisor
 Confront your co-worker – that’s a good discussion