NCLEX: Psychosocial Integrity: Behavioral/Mental Health Care Throughout the Life Span

Psychosocial Integrity: Behavioral/Mental Health Care Throughout the Life Span: Sleep Disturbance

Focus topic: Psychosocial Integrity: Behavioral/Mental Health Care Throughout the Life Span

I. TYPES OF SLEEP:

Focus topic: Psychosocial Integrity: Behavioral/Mental Health Care Throughout the Life Span

A. Rapid-eye-movement (REM) sleep: colorful, dramatic, emotional, implausible dreams.
B. Non-REM sleep—stages:

  • Stage 1: lasts 30 seconds to 7 minutes—falls asleep, drowsy; easily awakened; fleeting thoughts.
  • Stage 2: more relaxed; no eye movements, clearly asleep but readily awakens; 45% of total sleep time spent in this stage.
  • Stage 3 (delta sleep): deep muscle relaxation; decreased temperature, pulse, respiration.
  • Stage 4 (delta sleep): very relaxed; rarely moves.

C. Sleep cycle—common progression of sleep stages:

  • Stages 1, 2, 3, 4, 3, 2, REM, 2, 3, 4, etc.
  • Delta sleep most common during first third of night, with REM sleep periods increasing in duration during night from 1 to 2 minutes at start to 20 to 30 minutes by early morning.
  • REM sleep varies.
    a. Adolescents spend 30% of total sleep time in REM sleep.
    b. Adults spend 15% of total sleep time in REM sleep.

II. SLEEP DEPRIVATION (DYSSOMNIAS):

Focus topic: Psychosocial Integrity: Behavioral/Mental Health Care Throughout the Life Span

A. Assessment:

  • Non-REM sleep loss: physical fatigue due to less time spent in normal deep sleep.
  • REM sleep loss: psychological effects—irritability, confusion, anxiety, short-term memory loss, paranoia, hallucinations.
  • Desynchronized sleep: occurs when sleep shifts more than 2 hours from normal sleep period. Irritability, anoxia, decreased stress tolerance.

B. Analysis/nursing diagnosis: sleep pattern disturbance may be related to:

  • Interrupted sleep cycles before 90-minute sleep cycle is completed.
  • Unfamiliar sleeping environment.
  • Alterations in normal sleep/activity cycles (e.g., jet lag).
  • Preexisting sleep deficits before hospital admission.
  • Medications (e.g., alcohol withdrawal or abruptly discontinuing the use of hypnotic or antidepressant medications).
  • Pain.

C. Nursing care plan/implementation:

  • Obtain sleep history as part of nursing assessment. Determine normal sleep hours, bedtime rituals, factors that promote or interrupt sleep.
  • Duplicate normal bedtime rituals when possible.
  • Make environment conducive to sleep: lighting, noise, temperature.
    a. Close door, dim lights, turn off unneeded machinery.
    b. Encourage staff to muffle conversation at night.
  • Encourage daytime exercise periods.
  • Allow uninterrupted periods of 90 minutes of sleep. Group nighttime treatments and observations that require touching the client.
  • Minimize use of hypnotic medications.
    a. Substitute back rubs, warm milk, relaxation exercises.
    b. Encourage physician to consider prescribing hypnotics that minimize sleep disruption (e.g., chloral hydrate and flurazepam HCl [Dalmane]).
    c. Taper off hypnotics rather than abruptly discontinuing.
  • Observe client while asleep.
    a. Evaluate quality of sleep.
    b. It may be sleep apnea if client is extremely restless and snoring heavily.
  • Health teaching: avoid caffeine and hyperstimulation at bedtime; teach how to promote sleep-inducing environment, relaxation techniques.

D. EVALUATION/OUTCOME CRITERIA: verbalizes satisfaction with amount, quality of sleep.

Psychosocial Integrity: Behavioral/Mental Health Care Throughout the Life Span: Eating Disorders

Focus topic: Psychosocial Integrity: Behavioral/Mental Health Care Throughout the Life Span

Psychosocial Integrity: Behavioral/Mental Health Care Throughout the Life Span: Anorexia Nervosa/Bulimia Nervosa

Focus topic: Psychosocial Integrity: Behavioral/Mental Health Care Throughout the Life Span

Anorexia nervosa is an illness of starvation related to a severe disturbance of body image and a morbid fear of obesity; it is an eating disorder, usually seen in adolescence, when a person is underweight and emaciated and refuses to eat. It can result in death due to irreversible metabolic processes.

Bulimia nervosa is another type of eating disorder (bingepurge syndrome) also encountered primarily in late adolescence or early adulthood. It is characterized by at least two binge-eating episodes of large quantities of high-calorie food over a couple of hours followed by disparaging self-criticism and depression. Self-induced vomiting, abuse of laxatives, and abuse of diuretics are commonly associated because they decrease physical pain of abdominal distention, may reduce postbinge anguish, and may provide a method of self-control. Bulimic episodes may occur as part of anorexia nervosa, but these clients rarely become emaciated, and not all have a body image disturbance (Comparison: Anorexia and Bulimia).

I. CONCEPTS AND PRINCIPLES RELATED TO ANOREXIA NERVOSA:

Focus topic: Psychosocial Integrity: Behavioral/Mental Health Care Throughout the Life Span

  • Not due to lack of appetite or problem with appetite center in hypothalamus.
  • Normal stomach hunger is repressed, denied, depersonalized; no conscious awareness of hunger sensation.

II. ASSESSMENT OF ANOREXIA NERVOSA:

Focus topic: Psychosocial Integrity: Behavioral/Mental Health Care Throughout the Life Span

A. Body image disturbance—delusional, obsessive (e.g., does not see self as thin and is bewildered by others’ concern).
B. Usually preoccupied with food, yet dreads gaining too much weight. Ambivalence: avoids food, hoards food.
C. Feels ineffectual, with low sex drive. Repudiation of sexuality.
D. Pregnancy fears, including misconceptions of oral impregnation through food.
E. Self-punitive behavior leading to starvation; suppression of anger.
F. Physical signs and symptoms:

  • Weight loss (20% of previous “normal” body weight).
  • Amenorrhea and secondary sex organ atrophy.
  • Hyperactivity; compulsiveness; excessive gum chewing.
  • Constipation.
  • Hypotension, bradycardia, hypothermia.
  • Skin: hyperkeratosis, poor turgor, dry.
  • Blood: leukopenia, anemia, hypoglycemia, hypoproteinemia, hypocholesteremia, hypokalemia, hyponatremia, decreased magnesium, decreased chloride, increased BUN; ECG: T-wave inversion.

Psychosocial Integrity: Behavioral/Mental Health Care Throughout the Life Span

 

III. ANALYSIS/NURSING DIAGNOSIS:

Focus topic: Psychosocial Integrity: Behavioral/Mental Health Care Throughout the Life Span

  • Imbalanced nutrition, less than body requirements, and fluid volume deficit related to attempts to vomit food after eating, overuse of laxatives/ diuretics, and refusal to eat, related to need to demonstrate control.
  • Risk for altered physical regulation processes/risk for or actual fluid volume deficit: amenorrhea related to starvation; hypotension, bradycardia; metabolic alkalosis.
  • Risk for self-inflicted injury related to starvation from refusal to eat or ambivalence about food.
  • Altered eating related to altered thought processes: binge-purge syndrome.
  • Body-image disturbance/chronic low self-esteem related to anxiety over assuming an adult role and concern with sexual identity; unmet dependency needs, personal vulnerability; perceived loss of control in some aspect of life; dysfunctional family system.
  • Compulsive behaviors related to need to maintain control of self, represented by losing weight.

IV. NURSING CARE PLAN/IMPLEMENTATION:

Focus topic: Psychosocial Integrity: Behavioral/Mental Health Care Throughout the Life Span

A. Help reestablish connections between body sensations (hunger) and responses (eating). Use stimulus response conditioning methods to set up eating regimen.

  • Weigh regularly, at same time and with same amount of clothing, with back to scale.
  • Make sure water drinking is avoided before weighing.
  • Give one-to-one supervision during and 30 minutes after mealtimes to prevent attempts to vomit food.
  • Monitor exercise program and set limits on physical activity.

B. Monitor physiological signs and symptoms (amenorrhea, constipation, hypoproteinemia, hypoglycemia, anemia, eroded tooth enamel,
inflamed buccal cavity, brittle nails, dull hair, secondary sexual organ atrophy, hypothermia, hypotension, leg cramps and other signs of hypokalemia).

C. Health teaching:

  • Explain normal sexual growth and development to improve knowledge deficit and confront sexual fears.
  • Use behavior modification to reestablish awareness of hunger sensation and to relate it to the clock and regular mealtimes.
  • Teach parents skills in communication related to dependence/independence needs of adolescent; allow client to assume control in areas other than dieting, weight loss (e.g., management of daily activities, work, leisure choices).

V. EVALUATION/OUTCOME CRITERIA:

Focus topic: Psychosocial Integrity: Behavioral/Mental Health Care Throughout the Life Span

  • Attains and maintains minimal normal weight for age and height.
  • Eats regular meal (standard nutritional diet).
  • No incidence of self-induced vomiting, bulimia, or compulsive physical activity.
  • Acts on increased internal emotional awareness and recognition of body sensation of hunger (i.e., talks about being hungry and feeling hunger pangs).
  • Relates increased sense of effectiveness with less need to control food intake.

Psychosocial Integrity: Behavioral/Mental Health Care Throughout the Life Span: Sensory Disturbance

Focus topic: Psychosocial Integrity: Behavioral/Mental Health Care Throughout the Life Span

I. TYPES OF SENSORY DISTURBANCE:

Focus topic: Psychosocial Integrity: Behavioral/Mental Health Care Throughout the Life Span

  • Sensory deprivation—amount of stimuli less than required, such as isolation in bed or room, deafness, victim of stroke (brain attack).
  • Sensory overload—receives more stimuli than can be tolerated (e.g., bright lights, noise, strange machinery, barrage of visitors).
  • Sensory deficit—impairment in functioning of sensory or perceptual processes (e.g., blindness, changes in tactile perceptions).

II. ASSESSMENT—based on awareness of behavioral changes:

  • Sensory deprivation—boredom, daydreaming, increasing sleep, thought slowness, inactivity, thought disorganization, hallucinations.
  • Sensory overload—same as sensory deprivation, plus restlessness and agitation, confusion.
  • Sensory deficit—may not be able to distinguish sounds, odors, and tastes or differentiate tactile sensations.

III. ANALYSIS/NURSING DIAGNOSIS: problems related to sensory disturbance:

  • Altered thought processes.
  • Confusion (acute vs. chronic).
  • Anger, aggression.
  • Body-image disturbance.
  • Sleep pattern disturbance.

A. Management of existing sensory disturbances in:

  • Acute sensory deprivation:
    a. Increase interaction with staff.
    b. Use TV.
    c. Provide touch.
    d. Help clients choose menus that have aromas, varied tastes, temperatures, colors, textures.
    e. Use light cologne or aftershave lotion, bath powder.
  • Sensory overload:
    a. Restrict number of visitors and length of stay.
    b. Reduce noise and lights.
    c. Reduce newness by establishing and following routine.
    d. Organize care to provide for extended rest periods with minimal input.
  • Sensory deficits:
    a. Report observations about hearing, vision.
    b. May imply need for new glasses, medical diagnosis, or therapy.

B. Health teaching: prevention of sensory disturbance involves education of parents during child’s growth and development regarding tactile, auditory, and visual stimulation.

  • Hold, talk, and play with infant when awake.
  • Provide bright toys with different designs for children to hold.
  • Change environment.
  • Provide music and auditory stimuli.
  • Give foods with variety of textures, tastes, colors.

V. EVALUATION/OUTCOME CRITERIA:

Focus topic: Psychosocial Integrity: Behavioral/Mental Health Care Throughout the Life Span

  • Client is oriented to time, place, person.
  • Little or no evidence of mood or sleep disturbance.

Psychosocial Integrity: Behavioral/Mental Health Care Throughout the Life Span: Delirium, Dementia, and Amnestic and Other Cognitive Disorders

Focus topic: Psychosocial Integrity: Behavioral/Mental Health Care Throughout the Life Span

These disorders include etiology associated with (1) the aging process (dementias arising in the senium or presenium, including primary degenerative dementia of the Alzheimer type and multi-infarct dementia); (2) substance-related disorders (e.g., alcohol, barbiturates, opioids, cocaine, amphetamines, PCP, hallucinogens, cannabis, nicotine, and caffeine); and (3) general medical conditions.

I. CONCEPTS, PRINCIPLES, AND SUBTYPES:

Focus topic: Psychosocial Integrity: Behavioral/Mental Health Care Throughout the Life Span

A. Course may be progressive, with steady deterioration.

B. Alternative pathways and compensatory mechanisms may develop to show a clinical picture of remissions and exacerbations.

C. Delirium is characterized by a disturbance of consciousness with reduced ability to focus, sustain, or shift attention; and a change in cognition (e.g., memory deficit, disorientation [time and place], language disturbance); or development of perceptual disturbance (e.g., illusions, hallucinations) that develops over a short time (hours or days) and fluctuates during the course of the day. Etiology: a direct physiological consequence of a general medical condition, substance intoxication or withdrawal, use of a medication, or toxin exposure. Diagnostic feature: cannot repeat sequential string of information (e.g., digit span).

D. Dementia is characterized by persistent multiple cognitive deficits (e.g., aphasia, apraxia, agnosia, disturbance in executive functioning) accompanied by memory impairment and mood and sleep disturbances. Possible etiology: vascular dementia, HIV infection, head trauma, Parkinson’s disease, Pick’s disease, Alzheimer’s disease, Huntington’s disease, substance induced, toxin exposure, medication, infections, nutritional deficiencies (hypoglycemia), endocrine conditions (hypothyroidism), brain tumors, seizure disorders, hepatic and renal failure; cardiopulmonary insufficiencies; fluid and electrolyte imbalances. Diagnostic features: cannot learn (register) new information (e.g., a list of words), or retain, recall, or recognize information.

  • Alzheimer’s disease: progressive; irreversible loss of cerebral function due to cortical atrophy; exists in 2% to 4% of people over age 65 years; may have a genetic component; may begin at ages 40 to 65; may lead to death within 2 years. Average duration from onset of symptoms to death: 8 to 10 years.
    a. Progressive decline in intellectual capacity (recent and remote memory, judgment), affect, and motor coordination (apraxia); loss of social sense; apathy or restlessness.
    b. Problems with speech (aphasia), recognition of familiar objects (agnosia), disorientation to self (even parts of own body).
    c. Summaries of stages:
  • Pick’s disease: unknown cause; may have genetic component. Onset: middle age; women affected more than men. Pathology: atrophy in frontal and temporal lobes of brain. Clinical picture similar to Alzheimer’s disease.
  • Creutzfeldt-Jakob disease: uncommon, extremely rapid neurodegeneration caused by transmissible “slow” virus (prion); genetic component in 5% to 15%. Clinical picture: typical dementia, with muscle rigidity, ataxia, involuntary movements. Occurrence: ages 40 to 60 years. Death within 1 year.
  • Amnestic disorder is characterized by severe memory impairment without other significant impairments of cognitive functioning (i.e., without aphasia, apraxia, or agnosia). Diagnostic features: memory impairment is always manifested by impairment in the ability to learn new information and sometimes problems remembering previously learned information or past events. May result in disorientation to place and time, but rarely to self. Appears bewildered or befuddled.                                                                              1. Etiology: due to direct physiological effects of a general medical condition (e.g., physical trauma or vitamin deficiency) or due to persisting effects of a substance (e.g., drug of abuse, a medication, or toxin exposure).
    2. Memory disturbance: sufficiently severe to cause marked impairment in social or occupational functioning and represents a significant decline from a previous level of functioning. May require supervised living situation to ensure appropriate feeding and care.
    3. Lacks insight into own memory deficit and may explicitly deny the presence of severe memory impairment despite evidence to the contrary.
    4. Altered personality function: apathy, lack of initiative, emotional blandness, shallow range of expression.

II. ASSESSMENT:

Focus topic: Psychosocial Integrity: Behavioral/Mental Health Care Throughout the Life Span

A. Most common areas of difficulty can be grouped under the mnemonic term JOCAM: J—judgment, O—orientation, C—confabulation, A—affect, and M—memory.

  • Judgment: impaired, resulting in socially inappropriate behavior (such as hypersexuality toward inappropriate objects) and inability to carry out activities of daily living.
  • Orientation: confused, disoriented; perceptual disturbances (e.g., illusions, misidentification of other persons and objects; misperception to make unfamiliar more familiar; visual, tactile, and auditory hallucinations may appear as images and voices or disorganized light and sound patterns). Paranoid delusions of persecution.
  • Confabulation: common use of this defense mechanism to fill in memory gaps with invented stories.
  • Affect: mood changes and unstable emotions; quarrelsome, with outbursts of morbid anger (as in cerebral arteriosclerosis); tearful; withdrawn from social contact; depression is a frequent reaction to loss of physical and social function.
  • Memory: impaired, especially for names and recent events; may compensate by confabulating and by using circumstantiality and tangential speaking patterns.

B. Other areas of difficulty:

  • Seizures (e.g., in Alzheimer’s disease and cerebral arteriosclerosis).
  • Intellectual capacities diminished.
    a. Difficulty with abstract thought.
    b. Compensatory mechanism is to stay with familiar topics; repetition.
    c. Short concentration periods.
  • Personality changes.
    a. Loss of ego flexibility; adoption of more rigid attitudes.
    b. Ritualism in daily activities.
    c. Hoarding.
    d. Somatic preoccupations (hypochondriases).
    e. Restlessness, wandering away.
    f. Impaired impulse control.
    g. Aphasia (in severe dementia).
    h. Apraxia (inability to carry out motor activities).

C. Diagnostic tests:

  • Neurological examination: perform maneuvers or answer questions that are aimed at eliciting information about condition of specific parts of brain or peripheral nerves.
    a. Assessment of mental status and alertness.
    b. Muscle strength and reflexes.
    c. Sensory-perceptual.
    d. Language skills.
    e. Coordination.
  • Laboratory tests:
    a. Blood, urine to test for: infections, hepatic and renal dysfunction, diabetes, electrolyte imbalances, metabolic/endocrine disorders,
    nutritional deficiencies, and presence of toxic substances (e.g., drugs).
    b. Electroencephalography (EEG) to check brain’s electrical activity.
    c. Computed tomography (CT) scan—image of brain size and shape.
    d. Positron emission tomography (PET)— reveals metabolic activity of brain (important for diagnosis of Alzheimer’s disease).
    e. Magnetic resonance imaging (MRI)— computerized image of soft tissue, with sharply detailed picture of brain tissues.

III. ANALYSIS/NURSING DIAGNOSIS:

Focus topic: Psychosocial Integrity: Behavioral/Mental Health Care Throughout the Life Span

  • Risk for trauma related to cognitive deficits (inability to recognize/identify danger in the environment;confusion; impaired judgment) and altered motor behavior (restlessness, hyperactivity, muscular incoordination).
  • Disturbed thought processes (altered abstract thinking and altered knowledge processes [agnosia]) related to destruction of cerebral tissue, inability to use information to make judgments and transmit messages, and memory deficits.
  • Sensory/perceptual alterations: visual, auditory, kinesthetic, gustatory, tactile, olfactory related to neurological deficit.
  • Sleep pattern disturbance resulting in disorientation at night, related to confusion; increased aimless wandering (day/night reversal).
  • Self-care deficit (feeding, bathing/hygiene, dressing, toileting) related to physical impairments (poor vision, uncoordination, forgetfulness), disorientation, and confusion.
  • Imbalanced nutrition, more or less than body requirements, related to confusion.
  • Total incontinence related to sensory/perceptual alterations.
  • Altered attention and memory related to progressive neurological losses.
  • Altered conduct/impulse processes (irritability and aggressiveness) related to neurological impairment.
  • Impaired communication related to poverty of speech and withdrawal behavior, progressive neurological losses, and cerebral impairment.
  • Caregiver role strain related to long-term illness and complexity of home care needs.
  • Relocation stress syndrome related to separation from support systems, physical deterioration, and changes in daily routine.

IV. NURSING CARE PLAN/IMPLEMENTATION

Focus topic: Psychosocial Integrity: Behavioral/Mental Health Care Throughout the Life Span

  • Long-term goal: minimize regression related to memory impairment.
  • Short-term goal: provide structure and consistency to increase security.
  • Make brief, frequent contacts, because attention span is short.
  • Allow clients time to talk and to complete projects.
  • Stimulate associative patterns to improve recall (by repeating, summarizing, and focusing).
  • Allow clients to review their lives and focus on the past.
  • Use concrete questions in interviewing.
  • Reinforce reality-oriented comments.
  • Keep environment structured the same as much as possible (e.g., same room and placement of furniture); routine is important to diminish stress.
  • Recognize the importance of compensatory mechanisms (e.g., confabulation) to increase self-esteem; build psychological reserve.
  • Give recognition for each accomplishment.
  • Use recreational and physical therapy.
  • Health teaching: give specific instructions for diet, medication (e.g., tacrine [Cognex], donepezil [Aricept] for improving cognition), and treatment; how to use many sensory approaches to learn new information; how to use existing knowledge, old learning, and habitual approaches to deal with new situations.

V. EVALUATION/OUTCOME CRITERIA:

Focus topic: Psychosocial Integrity: Behavioral/Mental Health Care Throughout the Life Span

  • Symptoms occur less frequently and are less severe in areas of: emotional lability and appropriateness; false perceptions; self-care ability; disorientation, memory, and judgment; and decision making.
  • Client is able to preserve optimum level of functioning and independence while allowing basic needs to be met.
  • Stays relatively calm and noncombative when upset or fearful.
  • Accepts own irritability and frustrations as part of illness.
  • Asks for assistance with self-care activities.
  • Knows and adheres to daily routine; knows own nurse, location of room, bathroom, clocks, calendars.
  • Uses supportive community services.

Psychosocial Integrity: Behavioral/Mental Health Care Throughout the Life Span: Substance-Related Disorders

Focus topic: Psychosocial Integrity: Behavioral/Mental Health Care Throughout the Life Span

I. DEFINITION: ingesting in any manner a chemical that has an effect on the body.

II. GENERAL ASSESSMENT:

Focus topic: Psychosocial Integrity: Behavioral/Mental Health Care Throughout the Life Span

A. Behavioral changes exist while under the influence of substance.

B. Engages in regular use of substance.

  • Substance abuse:
    a. Pattern of pathological use (i.e., day-long intoxication; inability to stop use, even when contraindicated by serious physical disorder; overpowering need or desire to take the drug despite legal, social, or medical problems); daily need of substance for functioning; repeated medical complications from use.
    b. Interference with social, occupational functioning.
    c. Willingness to obtain substance by any means, including illegal.
    d. Pathological use for more than 1 month.
  • Substance dependence:
    a. More severe than substance abuse; body requires substance to continue functioning.
    b. Physiological dependence (i.e., either develops a tolerance—must increase dose to obtain desired effect—or has physical withdrawal symptoms when substance intake is reduced or stopped).
    c. Person feels it is impossible to get along without drug.

C. Effects of substance on central nervous system (CNS).

III. GENERAL ANALYSIS: only in recent years has substance abuse been viewed as an illness rather than moral delinquency or criminal behavior. The disorders are very complex and little understood. There are physiological, psychological, and social aspects to their causality, dynamics, symptoms, and treatment, where personality disorder has a major part.

A. Physiological aspects—current unproven theories include “allergic” reaction to alcohol, disturbance in metabolism, genetic susceptibility to dependency, and hypofunction of adrenal cortex. There are organic effects of chronic excessive use.

B. Psychological aspects—disrupted parent-child relationship and family dynamics; deleterious effect on ego function.

C. Social and cultural aspects—local customs and attitudes vary about what is excessive.

D. Maladaptive behavior related to:

  • Low self-esteem.
  • Anger.
  • Denial.
  • Rationalization.
  • Social isolation.
  • A rigid pattern of coping.
  • Poorly defined philosophy of life, values, mores.

E. Nursing diagnosis in acute phase of abuse, intoxication:

  • Risk for ineffective breathing patterns related to pneumonia caused by aspiration, malnutrition; depressed immune system; or overdose.
  • Risk for decreased cardiac output related to effect of substances on cardiac muscle; electrolyte imbalance.
  • Risk for injury related to impaired coordination, disorientation, and altered judgment (worse at night).
  • Risk for violence: self-directed or directed at others, related to misinterpretation of stimuli and feelings of suspicion or distrust of others.
  • Sensory/perceptual alterations: visual, kinesthetic, tactile, related to intake of mind-altering substances.
  • Altered nutrition, less than body requirements.
  • Altered thought processes (delusions, incoherence) related to misinterpretation of stimuli due to severe panic and fear.
  • Sleep pattern disturbance related to mindaltering substance.
  • Ineffective individual coping related to inability to tolerate frustration and to meet basic needs or role expectations, resulting in unpredictable behaviors.
  • Noncompliance with abstinence and supportive therapy, related to inability to stop using substance because of dependence and refusal to alter lifestyle.
  • Impaired communication related to mental confusion or CNS depression due to substance use.
  • Impaired health maintenance management related to failure to recognize that a problem exists and inability to take responsibility for health needs.

Psychosocial Integrity: Behavioral/Mental Health Care Throughout the Life Span: Alcohol Use Disorders: Alcohol Abuse and Dependence

Focus topic: Psychosocial Integrity: Behavioral/Mental Health Care Throughout the Life Span

I. DEFINITIONS:

Focus topic: Psychosocial Integrity: Behavioral/Mental Health Care Throughout the Life Span

A. Alcohol dependence is a primary and chronic disorder that is progressive and often fatal, in which the individual is unable, for physical or psychological reasons or both, to refrain from frequent consumption of alcohol in quantities that produce intoxication and disrupt health and ability to perform daily functions.

B. Alcohol abuse is a separate diagnosis, and is defined as a maladaptive pattern of use with one or more of the following over a 1-year period:

  • Repeated alcohol consumption that results in an inability to fulfill obligations at home, school, or work.
  • Repeated alcohol consumption when it could be physically dangerous (e.g., driving a car).
  • Repeated alcohol-related legal problems (e.g., arrests).
  • Continued drinking despite interpersonal or social problems caused or made worse by drinking.

II. CONCEPTS AND PRINCIPLES RELATED TO ALCOHOL ABUSE AND DEPENDENCE:

Focus topic: Psychosocial Integrity: Behavioral/Mental Health Care Throughout the Life Span

A. Alcohol affects cerebral cortical functions:

  • Memory.
  • Judgment.
  • Reasoning.

B. Alcohol is a depressant:

  • Relaxes the individual.
  • Lessens use of repression of unconscious conflict.
  • Releases inhibitions, hostility, and primitive drives.

C. Drinking represents a tension-reducing device and a relief from feelings of insecurity. Strength of drinking habit equals degree of anxiety and frustration intolerance.

D. Alcohol dependence is not a symptom but rather a disease in itself.

E. Underlying fear and anxiety, associated with inner conflict, motivate the person who is alcoholic to drink.

F. People with alcohol use disorder can never be cured to drink normally; cure is to be a “sober alcoholic,” with total abstinence.

G. The spouse of the person with alcohol use disorder often unconsciously contributes to the drinking behavior because of own emotional needs (co-alcoholic or codependent).

H. Intoxication occurs with a blood-alcohol level of 0.08% or above. Signs of intoxication are:

  • Incoordination.
  • Slurred speech.
  • Dulled perception.

I. Tolerance occurs with alcohol dependence. Increasing amounts of alcohol must be consumed to obtain the desired effect.

III. ASSESSMENT:

Focus topic: Psychosocial Integrity: Behavioral/Mental Health Care Throughout the Life Span

A. Vicious cycle—(a) low tolerance for coping with frustration; tension, guilt and shame, resentment; (b) uses alcohol for relief; (c) new problems created by drinking; (d) new anxieties; and (e) more drinking.

B. Coping mechanisms used: denial, rationalization, projection.

C. Complications of abuse and dependence.

  • Alcohol withdrawal delirium (delirium tremens [DTs]) (Symptoms associated with alcohol withdrawal)—result of nutritional
    deficiencies and toxins; requires sedation and constant watchfulness against unintentional suicide and convulsions.
    a. Impending signs relate to CNS—marked nervousness and restlessness, increased irritability; gross tremors of hands, face, lips; weakness; also cardiovascular—increased blood pressure, tachycardia, diaphoresis, dysrhythmias; depression; gastrointestinal—nausea, vomiting, anorexia.
    b. Actual—serious symptoms of mental confusion, convulsions, hallucinations (visual, olfactory, auditory, tactile). Without treatment, 15% to 25% may die due to cardiac dysrhythmias, respiratory arrest, severe dehydration, massive infection.
  • Wernicke’s syndrome—a neurological disturbance manifested by confusion, ataxia, eye movement abnormalities, and memory
    impairment. Other problems include:
    a. Disturbed vision (diplopia).
    b. Wandering mind.
    c. Stupor and coma.
  • Alcohol amnestic syndrome (Korsakoff ’s syndrome)—degenerative neuritis due to thiamine deficiency.
    a. Impaired thoughts.
    b. Confusion, loss of sense of time and place.
    c. Use of confabulation to fill in severe recent memory loss.
    d. Follows episode of Wernicke’s encephalopathy.
  • Polyneuropathy—weak, irregular, rapid peripheral pulses; sensory and motor nerve endings are involved, causing pain, itching, and loss of limb control.
  • Related concerns—chronic heart failure (generalized tissue edema), gastritis, esophageal varices, cirrhosis, pancreatitis, diabetes, pneumonia, REM sleep deprivation, malnutrition, cancer of mouth, pharynx, and larynx.

D. Diagnostic tests:

  • Blood tests:
    a. Complete blood count (CBC): decreased hemoglobin/hematocrit (Hgb/Hct) to detect iron-deficiency anemia or acute/chronic GI
    bleeding; increased white blood cell (WBC) count (infection); decreased WBC count (if immunosuppressed).
    b. Glucose: hyperglycemia/hypoglycemia may be present (pancreatitis, malnutrition, or depletion of liver glycogen stores).
    c. Electrolytes: decreased potassium and magnesium.
    d. Liver function tests are classic toxic markers that alcohol use leaves on body: increased creatine phosphokinase (CPK), lactate dehydrogenase (LDH), aspartate aminotransferase (AST), alanine aminotransferase (ALT), and amylase (liver or pancreatic problem).

e. Nutritional tests: decreased albumin and total protein; decreased vitamins A, C, D, E, K, and B (malnutrition/malabsorption).

  • Urinalysis: infection; ketones due to breakdown of fatty acids in malnutrition (pseudodiabetic condition).
  • Chest x-ray: rule out right lower lobe pneumonia (related to malnutrition, depressed immune system, aspiration).
  • ECG: dysrhythmias, cardiomyopathies, or ischemia due to direct effect of alcohol on the cardiac muscle or conduction system, as well as effects of electrolyte imbalance.
  • Other screening studies (e.g., hepatitis, HIV, tuberculosis [TB]): dependent on general condition, individual risk factors, and care setting.

IV. ANALYSIS/NURSING DIAGNOSIS:

Focus topic: Psychosocial Integrity: Behavioral/Mental Health Care Throughout the Life Span

  • Risk for injury (self-directed violence): tendency for self-destructive acts related to intake of mind altering substances and chronic low self-esteem.
  • Altered nutrition, less than body requirements, related to a lack of interest in food, interference with absorption/metabolism of nutrients and amino acids.
  • Ineffective individual coping: denial/defensive coping related to tendency to be domineering and critical, with difficulties in interpersonal relationships.
  • Conflict with social order related to extreme dependence coupled with resentment of authority.
  • Spiritual distress or general dissatisfaction with life related to feelings of powerlessness, low frustration tolerance, and demand for immediate need satisfaction.
  • Dysfunctional behaviors/sexual dysfunction related to tendency for excess in work, sex, recreation, marked narcissistic behavior.
  • Social isolation related to use of coping mechanisms that are primarily escapist.
  • Knowledge deficit (learning need) regarding condition, prognosis, treatment, self-care, discharge needs.
[sociallocker]

V. NURSING CARE PLAN/IMPLEMENTATION:

Focus topic: Psychosocial Integrity: Behavioral/Mental Health Care Throughout the Life Span

A. Detoxification phase—maintain physiological stability.

  • Administer adequate sedation to control anxiety, insomnia, agitation, tremors.
  • Administer anticonvulsants to prevent withdrawal seizures (diazepam [Valium], chlordiazepoxide [Librium], phenobarbital, magnesium sulfate).
  • Control nausea and vomiting to avoid massive GI bleeding or rupture of esophageal varices (antiemetics, antacids).
  • Assess for hypertension, tachycardia, increased temperature, Kussmaul’s respirations.
  • Assess fluid and electrolyte balance for dehydration (may need IV fluids) or over hydration (may need a diuretic).
  • Reestablish proper nutrition: high protein (as long as no severe liver damage), carbohydrate, thiamine, vitamins B complex and C.
  • Promote client safety—provide quiet, calm, safe environment: bed rest with rails, and head of bed elevated; well-lit room to reduce illusions; constant supervision and reassurance about fears and hallucinations; assess depression for suicide potential.

B. Recovery-rehabilitation phase: encourage participation in group activities; avoid sympathy when client tends to rationalize behavior and seeks special privileges— use acceptance and a nonjudgmental, consistent, firm, but kind approach; avoid: scorn, contempt, and moralizing or punitive and rejecting behaviors; do not reinforce feelings of worthlessness, self-contempt, hopelessness, or low self-esteem.

C. Problem behaviors:

  • Manipulative—be firm and consistent; avoid “bid for sympathy.”
  • Demanding—set limits.
  • Acting out—set limits, enforce rules and regulations, strengthen impulse control and ability to delay gratification.
  • Dependency—place responsibility on client; avoid giving advice.
  • Superficiality—help client make realistic self-appraisals and expectations in lieu of grandiose promises and trite verbalizations; encourage formation of lasting interpersonal relationships.

D. Common reactions among staff:

  • Disappointment—instead, set realistic goals, take one step at a time.
  • Moral judgment—instead, support each other.
  • Hostility—instead, offer support to each other when feeling frustrated from lack of results.

E. Refer client from hospital to community resources for follow-up treatment with social, economic, and psychological problems, as well as to self-help groups, to reduce “revolving door” situation in which client comes in, is treated, goes out, and comes in again the next night.

  • Alcoholics Anonymous (AA)—a self-help group of addicted drinkers who confront, instruct, and support fellow drinkers in their efforts to stay sober 1 day at a time through fellowship and acceptance.
  • Al-Anon—support group for families of clients with alcohol use disorder. Alateen—support group for teenagers when parent is alcoholic.
  • Aversion therapy—client is subjected to revulsion producing or pain-inducing stimuli at the same time he or she takes a drink, to establish alcohol rejection behavior. Most common is disulfiram (Antabuse), a drug that works by blocking an enzyme that helps metabolize alcohol. It produces intense headache, severe flushing, extreme nausea, vomiting, palpitations, hypotension, dyspnea, and blurred vision when alcohol is consumed while person is taking this drug.
  • Other drug therapy—naltrexone (ReVia) is a drug that works by blocking endorphin receptors and interfering in alcohol-induced brain reward circuitry that is involved in good feelings people get from drinking.
    a. Benefit: reduces alcohol relapse and decreases total amount of drinking per day.
    b. Dose: 50 mg PO/day.
    c. Common side effects: transitory dizziness, diarrhea, nausea. Does not have extreme side effects of Antabuse.
  • Group psychotherapy—the goals of group psychotherapy are for the client to give up alcohol as a tension reliever, identify cause of stress, build different means for coping with stress, and accept drinking as a serious symptom.

F. Health teaching: teach improved coping patterns to tolerate increased stress; teach substitute tension reducing strategies; prepare in advance for difficult, painful events; teach how to reduce irritating or frustrating environmental stress; teach (in simple terms) the physiological effects of alcohol abuse on the body.

VI. EVALUATION/OUTCOME CRITERIA: complications prevented, resolved; everyday living patterns are restructured for a satisfactory life without alcohol; demonstrates feelings of increased self-worth, confidence, and reliance.

[/sociallocker]

FURTHER READING/STUDY:

Resources:

 

 

 

 

 

 

 

 

 

 

 

 

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