SUBSTANCE DEPENDENCE/ABUSE REHABILITATION

DSM-IV
ALCOHOL USE DISORDERS 303.90 Alcohol dependence 305.00 Alcohol abuse AMPHETAMINE (OR AMPHETAMINE-LIKE) USE DISORDERS 304.40 Amphetamine dependence 305.70 Amphetamine abuse CANNABIS USE DISORDERS 304.30 Cannabis dependence 305.20 Cannabis abuse COCAINE USE DISORDERS 304.20 Cocaine dependence 305.60 Cocaine abuse HALLUCINOGEN USE DISORDERS 304.60 Hallucinogen dependence 305.30 Hallucinogen abuse INHALANT USE DISORDERS 304.60 Inhalant dependence 305.90 Inhalant abuse NICOTINE USE DISORDERS 305.10 icotine dependence OPIOID USE DISORDERS 304.00 !pioid dependence 305.50 !pioid abuse PHENCYCLIDINE USE DISORDERS 304.90 "henc#clidine dependence 305.90 "henc#clidine abuse SEDATIVE, HYPNOTIC, OR ANXIOLYTIC SUBSTANCE USE DISORDERS 304.10 $edati%e& h#pnotic& o' an(iol#tic dependence 305.40 $edati%e& h#pnotic& o' an(iol#tic abuse POLYSUBSTANCE USE DISORDER 304.)0 "ol#substance dependence *+o' othe' listings& consult DSM-IV manual., -an# d'ugs and %olatile substances a'e sub.ect to abuse *as noted in p'e%ious plans o/ ca'e,. 0his diso'de' is a continuum o/ phases inco'po'ating a cluste' o/ cogniti%e& beha%io'al& and ph#siological s#mptoms that include loss o/ cont'ol o%e' use o/ the substance and a continued use o/ the substance despite ad%e'se conse1uences. A numbe' o/ /acto's ha%e been implicated in the p'edisposition to abuse a substance *e.g.& biological& biochemical& ps#chological 2including de%elopmental3& pe'sonalit#& sociocultu'al and conditioning& and cultu'al and ethnic in/luences,. Ho4e%e'& no single theo'# ade1uatel# e(plains the etiolog# o/ this p'oblem. 0his plan o/ ca'e add'esses issues o/ dependence and is to be used in con.unction 4ith plans o/ ca'e 'elati%e to acute into(i/ication /4ithd'a4al /'om speci/ic substance*s,.

CLIENT ASSESSMENT DATA BASE

5e/e' to app'op'iate acute plan o/ ca'e 'ega'ding in%ol%ed substance*s,.

DIAGNOSTIC STUDIES
Drug (i !"u#i g-$"!%&%") S!r'' ( Identi/ies d'ug*s, being used. A##i!)i% S'*'ri)+ I #', (ASI) Assessment 0ool6 "'oduces a 7p'oblem se%e'it# p'o/ile8 o/ the patient& including chemical& medical& ps#chological& legal& /amil# /social and emplo#ment /suppo't aspects& indicating a'eas o/ t'eatment needs. O)&'r S!r'' i g S)u#i'- ('.g., H'/$)i)i-, HIV, TB)( 9epend on gene'al condition& indi%idual 'is: /acto's& and ca'e setting.

NURSING PRIORITIES
1. 2. 3. 4. 5. 6. "'o%ide suppo't /o' decision to stop substance use. $t'engthen indi%idual coping s:ills. +acilitate lea'ning o/ ne4 4a#s to 'educe an(iet#. "'omote /amil# in%ol%ement in 'ehabilitation p'og'am. +acilitate /amil# g'o4th /de%elopment. "'o%ide in/o'mation about condition& p'ognosis& and t'eatment needs.

DISCHARGE GOALS
1. 2. 3. 4. 5. 5esponsibilit# /o' o4n li/e and beha%io' assumed. "lan to maintain substance;/'ee li/e /o'mulated. +amil# 'elationships /enabling issues being add'essed. 0'eatment p'og'am success/ull# begun. Condition& p'ognosis& and the'apeutic 'egimen unde'stood.

NURSING DIAGNOSIS M$+ B' R'"$)'# )%(

DENIAL i '00'!)i*' "e'sonal %ulne'abilit#< /ea'< di//icult# handling ne4 situation =ea'ned 'esponse patte'ns< cultu'al /acto's& pe'sonal>/amil# %alue s#stems

P%--i1"+ E*i#' !'# 1+(

9ela# in see:ing& o' 'e/usal o/& healthca'e attention to the det'iment o/ health>li/e 9oes not pe'cei%e pe'sonal 'ele%ance o/ s#mptoms o' dange'& o' admit impact o/ condition on li/e patte'n< p'o.ection o/ blame>'esponsibilit# /o' p'oblems ?se o/ manipulation to a%oid 'esponsibilit# /o' sel/

D'-ir'# Ou)!%2'-/E*$"u$)i% C"i' ) 4i""(

Cri)'ri$3

@e'baliAe a4a'eness o/ 'elationship o/ substance abuse to cu''ent situation. Bngage in the'apeutic p'og'am. @e'baliAe acceptance o/ 'esponsibilit# /o' o4n beha%io'.

ACTIONS/INTERVENTIONS I #'/' #' )

Asce'tain b# 4hat name client 4ould li:e to be add'essed.

RATIONALE

$ho4s cou'tes# and 'espect& gi%ing the client a sense o/ o'ientation and cont'ol. "'omotes /eelings o/ dignit# and sel/;

Con%e# attitude o/ acceptance o/ client& sepa'ating 4o'th. indi%idual /'om unacceptable beha%io'. Asce'tain 'eason /o' beginning abstinence& in%ol%ement in the'ap#. client

"'o%ides insight into clientCs 4illingness to commit to long;te'm beha%io'al change and 4hethe' client e%en belie%es that he o' she can change. N%)'( I/ t'eatment is cou't;o'de'ed& ma# .ust be 7doing time8 until case is 'esol%ed

and the'e/o'e ma# not be /ull# committed to the p'og'am. *9enial is one o/ the st'ongest and most 'esistant s#mptoms o/ substance abuse., 5e%ie4 de/inition o/ d'ug dependence and 0his in/o'mation helps client ma:e decisions catego'ies o/ s#mptoms *e.g.& patte'ns o/ use& 'ega'ding acceptance o/ p'oblem and t'eatment impai'ment caused b# use& tole'ance to substance,. choices. Ans4e' 1uestions honestl# and p'o%ide /actual in/o'mation. Deep all p'omises. C'eates t'ust& 4hich is the basis o/ the the'apeutic 'elationship.

"'o%ide in/o'mation about addicti%e use %e'sus "'og'ession o/ use continuum in the addict is /'om e(pe'imental& occasional use< biochemical /genetic e(pe'imental /'ec'eational to addicti%e use. diso'de' theo'# *genetic p'edisposition,< use Comp'ehending this p'ocess is impo'tant in acti%ated b# en%i'onment< pha'macolog# o/ combating denial. Bducation ma# 'elie%e client o/ stimulant< compulsi%e desi'e as a li/elong guilt and blame and ma# help a4a'eness o/ occu''ence. 'ecu''ing addicti%e cha'acte'istics. 9iscuss cu''ent li/e situation and impact o/ to substance use. +i'st step in dec'easing use o/ denial is /o' client see the 'elationship bet4een substance use and pee' g'oup. ?se con/'ontation 4ith ca'ing. pe'sonal p'oblems. Con/'ont and e(amine denial /'ationaliAation in in pee' g'oup. ?se con/'ontation 4ith ca'ing. help conse1uences o/ beha%io's and that d'ug use is a ma.o' Eecause denial is the ma.o' de/ense mechanism addicti%e disease& con/'ontation b# pee's can the client accept the 'ealit# o/ ad%e'se

p'oblem. Ca'ing attitude p'ese'%es sel/;concept and helps dec'ease de/ensi%e 'esponse. "'o%ide in/o'mation 'ega'ding e//ects o/ addiction Indi%iduals o/ten mista:e e//ects o/ addiction on on mood /pe'sonalit#. mood /pe'sonalit# /o' its cause and use this to .usti/# o' e(cuse d'ug use. Con/'ont use o/ ange'& 'ationaliAation& o' p'o.ection. de/ense mechanisms p'olong the stage o/ denial that p'oblems e(ist in clientCs li/e because o/ substance use. 5emain non.udgmental. Ee ale't to changes in beha%io' *e.g.& 'estlessness& inc'eased tension,. "'o%ide positi%e /eedbac: /o' e(p'essing 'ein/o'ce a4a'eness o/ denial in sel/ /othe's. -aintain /i'm e(pectation that client attend to 'eco%e'# suppo't/the'ap# g'oups 'egula'l#. Con/'ontation can lead to inc'eased agitation& 4hich ma# comp'omise sa/et# o/ client /sta//. ecessa'# to enhance sel/;esteem and to insight into beha%io'. Attendance is 'elated to admitting need /o' help& 4o':ing 4ith denial& and /o' maintenance o/ a long;te'm d'ug;/'ee e(istence. Ange' is o/ten a 'esponse o/ de/ensi%eness& and pointing this out to the client can help him o' he' to accept /eelings unde'l#ing ange'. 0hese

Bncou'age and suppo't clientCs ta:ing 9enial can be 'eplaced 4ith 'esponsible action 'esponsibilit# /o' o4n 'eco%e'# *e.g.& de%elopment 4hen client accepts the 'ealit# o/ o4n o/ alte'nati%e beha%io's to d'ug u'ge /use,. Assist 'esponsibilit#. client to lea'n o4n 'esponsibilit# /o' 'eco%e'ing.

NURSING DIAGNOSIS M$+ B' R'"$)'# )%(

COPING, INDIVIDUAL, i '00'!)i*' "e'sonal %ulne'abilit# egati%e 'ole modeling< inade1uate suppo't s#stems "'e%ious ine//ecti%e>inade1uate coping s:ills 4ith substitution o/ d'ug*s,

P%--i1"+ E*i#' !'# 1+(

Alte'ed social patte'ns>pa'ticipation Impai'ed adapti%e beha%io' and p'oblem;sol%ing s:ills 9ec'eased abilit# to handle st'ess o/ illness>hospitaliAation +inancial a//ai's in disa''a#< emplo#ment di//iculties *e.g.& losing time on .ob>not

maintaining stead# emplo#ment& poo' 4o': pe'/o'mance& on;the;.ob in.u'ies, @e'baliAation o/ inabilit# to cope>as: /o' help D'-ir'# Ou)!%2'-/E*$"u$)i% C"i' ) 4i""( Cri)'ri$3 Identi/# ine//ecti%e coping beha%io'> conse1uences& including use o/ substances as a method o/ coping. ?se e//ecti%e coping s:ills>p'oblem;sol%ing. Initiate necessa'# li/est#le changes.

ACTIONS/INTERVENTIONS I #'/' #' )

RATIONALE

5e%ie4 p'og'am 'ules& philosoph#& e(pectations. Ha%ing in/o'mation p'o%ides oppo'tunit# /o' client to coope'ate and /unction as membe' o/ g'oup /milieu& enhancing sense o/ cont'ol and sense o/ success. 9ete'mine unde'standing o/ cu''ent situation and "'o%ides in/o'mation about deg'ee o/ denial< p'e%ious /othe' methods o/ coping 4ith li/eCs acceptance o/ pe'sonal 'esponsibilit# /commitment p'oblems. to change< identi/ies coping s:ills that ma# be used in p'esent situation. $et limits and con/'ont clientCs e//o'ts to get ca'egi%e' to g'ant special p'i%ileges& ma:ing e(cuses /o' not /ollo4ing th'ough on beha%io's ag'eed on and attempting to continue d'ug use. help Client has lea'ned manipulati%e beha%io' th'oughout li/e and needs to lea'n a ne4 4a# o/ getting needs met. +ollo4ing th'ough on conse1uences o/ /ailu'e to maintain limits can the client to change ine//ecti%e beha%io's. Ee a4a'e o/ sta// attitudes& /eelings& and enabling =ac: o/ unde'standing& .udgmental /enabling beha%io's. beha%io's can 'esult in inaccu'ate data collection and nonthe'apeutic app'oaches. Bncou'age %e'baliAation o/ /eelings& /ea's& an(ieties. -a# help client begin to come to te'ms 4ith long; un'esol%ed issues. B(plo'e alte'nati%e coping st'ategies. adapti%e Client ma# ha%e little o' no :no4ledge o/ 'esponses to st'ess and needs to lea'n othe' options /o' managing time& /eelings& and 'elationships 4ithout d'ugs. Assist client to lea'n /encou'age use o/ 'ela(ation Helps client to 'ela(& de%elop ne4 4a#s to deal s:ills& guided image'#& %isualiAations. 4ith st'ess& enhances p'oblem;sol%ing.

$t'uctu'e di%e'sional acti%it# that 'elates to 'eco%e'# 9isco%e'# o/ alte'nati%e methods o/ coping 4ith *e.g.& social acti%it# 4ithin suppo't g'oup,& d'ug hunge' can 'emind client that addiction is a 4he'ein issues o/ being chemicall# /'ee a'e e(amined. li/elong p'ocess and oppo'tunit# /o' changing patte'ns is a%ailable. ?se pee' suppo't to e(amine 4a#s o/ coping 4ith $el/;help g'oups a'e %aluable /o' lea'ning and d'ug hunge'. p'omoting abstinence in each membe'& using unde'standing and suppo't& and pee' p'essu'e. Bncou'age in%ol%ement in the'apeutic 4'iting. Ha%e client begin to 4'ite autobiog'aph#. and clientCs p'og'ess. Autobiog'aphical acti%it# p'o%ides an oppo'tunit# /o' the client to 'emembe' and identi/# se1uence o/ e%ents in his o' he' li/e that 'elate to cu''ent situation. 9iscuss clientCs plans /o' li%ing 4ithout d'ugs. phase o/ beha%io'al change. "'o%ides oppo'tunit# to de%elop /'e/ine plans. 9e%ising a comp'ehensi%e st'ateg# /o' a%oiding 'elapses helps mo%e client into maintenance 0he'apeutic 4'iting can enhance pa'ticipation in t'eatment< se'%ing as a 'elease /o' g'ie/& ange'& st'ess< p'o%ides a use/ul tool /o' monito'ing clientCs sa/et#< and can be used to e%aluate

C%""$1%r$)i*'
Administe' medications as indicated& e.g.6 disul/i'am *Antabuse,< abstinence E# inhibiting alcohol o(idation& the d'ug leads to an accumulation o/ acetaldeh#de 4ith a highl# unpleasant 'eaction i/ alcohol is consumed *o' e%en abso'bed th'ough the s:in %ia colognes o' sha%ing p'epa'ations,. acamp'osate< e(citato'# neu'ot'ansmitte' glutamate. 0his agent ma# become the d'ug o/ choice as it does not ma:e the use' sic: i/ alcohol is consumed< it has no sedati%e& anti;an(iet#& musle 'ela(ant& o' antidep'essant p'ope'ties& and p'oduces no 4ithd'a4al s#mptoms. methadone *9olophine,< 0his d'ug is thought to blunt the c'a%ing /o'/diminish the e//ects o/ opioids and is used to assist in 4ithd'a4al and long;te'm maintenance p'oblems. It can allo4 the indi%idual to maintain Helps to p'e%ent 'elapses in alcoholism b# lo4e'ing the acti%it# o/ 'ecepto's /o' the 0his d'ug can be help/ul in maintaining /'om alcohol 4hile othe' the'ap# is unde'ta:en.

dail# acti%ities and ultimatel# 4ithd'a4 /'om d'ug use. nalt'e(one *5e%ia,& alcohol. Cu''ent 'esea'ch suggests that nalt'e(one supp'esses u'ge to continue d'in:ing b# inte'/e'ing 4ith alcohol;induced 'elease o/ endo'phins. N%)'( alme/ene has /e4e' side e//ects than nalt'e(one. Bncou'age in%ol%ement 4ith sel/;help 'esou'ces "uts client in di'ect contact 4ith suppo't s#stems *e.g.& Alcoholics / a'cotics Anon#mous,. necessa'# /o' managing sob'iet# /d'ug;/'ee li/e as meetings a'e a%ailable at man# di//e'ent times and places in most communities. alme/ene *5e%e(,. ?sed to supp'ess c'a%ing /o' opioids and ma# help p'e%ent 'elapse in the client abusing

NURSING DIAGNOSIS M$+ B' R'"$)'# )%(

PO4ERLESSNESS $ubstance addiction 4ith>4ithout pe'iods o/ abstinence Bpisodic compulsi%e indulgence< attempts at 'eco%e'# =i/est#le o/ helplessness

P%--i1"+ E*i#' !'# 1+(

Ine//ecti%e 'eco%e'# attempts< statements o/ inabilit# to stop beha%io'>'e1uests /o' help Continuous>constant thin:ing about d'ug and>o' obtaining d'ug Alte'ation in pe'sonal& occupational& and social li/e

D'-ir'# Ou)!%2'-/E*$"u$)i% C"i' ) 4i""(

Cri)'ri$3

Admit inabilit# to cont'ol d'ug habit& 'ecogniAe po4e'lessness o%e' addiction. @e'baliAe acceptance o/ need /o' t'eatment and a4a'eness that 4illpo4e' alone cannot cont'ol abstinence. Bngage in pee' suppo't. 9emonst'ate acti%e pa'ticipation in p'og'am. 5egain and maintain health# state 4ith a d'ug; /'ee li/est#le.

ACTIONS/INTERVENTIONS I #'/' #' )

?se c'isis inte'%ention techni1ues to initiate /o' beha%io'al changes6 Assist client to 'ecogniAe p'oblem e(ists< discuss in a ca'ing& non.udgmental manne' ho4 d'ug has inte'/e'ed 4ith li/e. use In%ol%e client in de%elopment o/ t'eatment plan 'ealiAes using p'oblem;sol%ing p'ocess in 4hich client in identi/ies goals /o' change and ag'ees to desi'ed outcomes outcomes. 9iscuss alte'nati%e solutions. 9u'ing

RATIONALE

Client is mo'e amenable to acceptance o/ need t'eatment at this time. In the precontemplation phase & the client has not #et identi/ied that d'ug use is p'oblematic. Fhile client is hu'ting& it is easie' to admit substance has c'eated negati%e conse1uences. 9u'ing the contemplation phase & the client a p'oblem e(ists and is thin:ing about a change beha%io'. 0he client is committed to the 4hen the decision;ma:ing p'ocess in%ol%es solutions that a'e p'omulgated b# the indi%idual. E'ainsto'ming helps c'eati%el# identi/# possibilities and p'o%ides sense o/ cont'ol. the preparation phase & mino' action ma# be

ta:en as indi%idual o'ganiAes 'esou'ces /o' de/initi%e change. Assist in selecting most app'op'iate alte'nati%e. As possibilities a'e discussed& the most use/ul solution becomes clea'. $uppo't decision and implementation o/ selected Helps the client to pe'se%e'e in p'ocess o/ change. solutions. 9u'ing the action phase & the client engages in a sustained e//o't to maintain sob'iet#& and mechanisms a'e put in place to suppo't abstinence. B(plo'e suppo't in pee' g'oup. Bncou'age sha'ing Client ma# need assistance in e(p'essing sel/& about d'ug hunge'& situations that inc'ease the spea:ing about po4e'lessness& and admitting desi'e to indulge& 4a#s that substance has need /o' help& to /ace up to p'oblem and begin in/luenced li/e. 'esolution. Assist client to lea'n 4a#s to enhance health and =ea'ning to empo4e' sel/ in const'ucti%e st'uctu'e health# di%e'sion /'om d'ug use *e.g.& a'eas can st'engthen abilit# to maintain maintaining a balanced diet< getting ade1uate 'est< 'eco%e'#. 0hese acti%ities help 'esto'e natu'al e(e'cising 2e.g.& 4al:ing& .ogging& long;distance biochemical balance& aid deto(i/ication& and 'unning3< and acupunctu'e& bio/eedbac:& deep manage st'ess& an(iet#& use o/ /'ee time& meditati%e techni1ues,. inc'easing sel/;con/idence and the'eb# imp'o%ing sel/;esteem. N%)'( B(e'cise p'omotes 'elease o/ endo'phins& c'eating a /eeling o/ 4ell;being.

"'o%ide in/o'mation 'ega'ding unde'standing o/ ?nde'standing these concepts can help the client human beha%io' and inte'actions 4ith othe's *e.g.& begin to deal 4ith past p'oblems /losses and t'ansactional anal#sis,. p'e%ent 'epeating ine//ecti%e coping beha%io's and sel/;/ulling p'ophecies. Assist client in sel/;e(amination o/ spi'itualit#& /aith. Although not necessa'# to 'eco%e'#& su''ende'ing to and /aith in a po4e' g'eate' than onesel/ has been /ound to be e//ecti%e /o' man# indi%iduals in substance 'eco%e'#< ma# dec'ease sense o/ po4e'lessness. Inst'uct in and 'ole;pla# asse'ti%e communicationB//ecti%e in assisting in abilit# to 'e/use use& to stop s:ills. 'elationships 4ith use's and deale's& to build health# 'elationships& and 'egain cont'ol o/ o4n li/e. "'o%ide t'eatment in/o'mation on an ongoing basis. Helps client :no4 4hat to e(pect and c'eates oppo'tunit# /o' client to be a pa't o/ 4hat is happening and ma:e in/o'med choices about pa'ticipation /outcomes.

C%""$1%r$)i*'
5e/e' to/assist 4ith ma:ing contact 4ith p'og'ams positi%e /o' ongoing t'eatment needs *e.g.& pa'tial hospitaliA; once ation d'ug t'eatment p'og'ams& a'cotics /Alcoholics Anon#mous& pee' suppo't g'oup,. Continuing t'eatment is essential to outcome. +ollo4;th'ough ma# be easie' initial contact has been made.

NURSING DIAGNOSIS M$+ B' R'"$)'# )%(

NUTRITION( $")'r'#, "'-- )&$ r'5uir'2' )-

1%#+

Insu//icient dieta'# inta:e to meet metabolic needs /o' ps#chological& ph#siological& o' economic 'easons Feight loss< 4eight belo4 no'm /o' height>bod# build< dec'eased subcutaneous /at>muscle mass 5epo'ted alte'ed taste sensation< lac: o/ inte'est in /ood "oo' muscle tone $o'e& in/lamed buccal ca%it# =abo'ato'# e%idence o/ p'otein>%itamin de/iciencies

P%--i1"+ E*i#' !'# 1+(

D'-ir'# Ou)!%2'-/E*$"u$)i%

Cri)'ri$3

9emonst'ate p'og'essi%e 4eight gain to4a'd

C"i' ) 4i""(

goal& 4ith no'maliAation o/ labo'ato'# %alues and /'ee o/ signs o/ malnut'ition. @e'baliAe unde'standing o/ e//ects o/ substance abuse and 'educed dieta'# inta:e on nut'itional status. 9emonst'ate beha%io's& li/est#le changes to 'egain and maintain app'op'iate 4eight.

ACTIONS/INTERVENTIONS I #'/' #' )

RATIONALE

Assess height& 4eight& age& bod# build& st'ength& "'o%ides in/o'mation about indi%idual on 4hich to acti%it# le%el. ote condition o/ o'al ca%it#. base calo'ic needs /dieta'# plan. 0#pe o/ diet//oods ma# be a//ected b# condition o/ mucous memb'anes and teeth. !btain anth'opomet'ic measu'ements *e.g.& t'iceps Calculates subcutaneous /at and muscle mass to s:in/old,. aid in dete'mining dieta'# needs. ote total dail# calo'ie inta:e< maintain a dia'# o/In/o'mation about clientCs dieta'# patte'n 4ill help inta:e& as 4ell as times and patte'ns o/ eating. identi/# nut'itional needs /de/iciencies. B%aluate ene'g# e(penditu'e *e.g.& pacing o' Acti%it# le%el a//ects nut'itional needs. B(e'cise sedenta'#,& and establish an indi%idualiAed e(e'cise enhances muscle tone& ma# stimulate appetite. p'og'am. "'o%ide oppo'tunit# to choose /oods /snac:s to meet Bnhances pa'ticipation /sense o/ cont'ol& ma# dieta'# plan. p'omote 'esolution o/ nut'itional de/iciencies& and helps e%aluate client lea'ning o/ dieta'# teaching. 5ecommend monito'ing 4eight 4ee:l#. "'o%ides in/o'mation 'ega'ding e//ecti%eness o/ dieta'# plan.

C%""$1%r$)i*'
Consult 4ith dietitian. ?se/ul in establishing indi%idual dieta'# needs /plan and p'o%ides additional 'esou'ce /o' lea'ning.

5e%ie4 labo'ato'# studies& as indicated *e.g.& glucose& Identi/ies anemias& elect'ol#te imbalances& othe' se'um albumin /p'ealbumin& elect'ol#tes,. abno'malities that ma# be p'esent& 'e1ui'ing speci/ic the'ap#.

5e/e' /o' dental consultation as necessa'#. this

0eeth a'e essential to good nut'itional inta:e and dental h#giene /ca'e is o/ten a neglected a'ea in population.

NURSING DIAGNOSIS M$+ B' R'"$)'# )%(

SEL6 ESTEEM, !&r% i! "%7 $ocial stigma attached to substance abuse& e(pectation that one cont'ol beha%io' egati%e 'ole models< abuse>neglect& d#s/unctional /amil# s#stem =i/e choices pe'petuating /ailu'e< situational c'isis 4ith loss o/ cont'ol o%e' li/e e%ents Eiochemical bod# change *e.g.& 4ithd'a4al /'om alcohol>othe' d'ugs,

P%--i1"+ E*i#' !'# 1+(

$el/;negating %e'baliAation& e(p'essions o/ shame>guilt B%aluation o/ sel/ as unable to deal 4ith e%ents< con/usion about sel/& pu'pose o' di'ection in li/e 5ationaliAing a4a#>'e.ecting positi%e /eedbac:& e(agge'ating negati%e /eedbac: about sel/

D'-ir'# Ou)!%2'-/E*$"u$)i% C"i' ) 4i""(

Cri)'ri$3

Identi/# /eelings and unde'l#ing d#namics /o' negati%e pe'ception o/ sel/. @e'baliAe acceptance o/ sel/ as is and an inc'eased sense o/ sel/;4o'th. $et goals and pa'ticipate in 'ealistic planning /o' li/est#le changes necessa'# to li%e 4ithout d'ugs.

ACTIONS/INTERVENTIONS I #'/' #' )

"'o%ide oppo'tunit# /o' and encou'age %e'baliAation /discussion o/ indi%idual situation.

RATIONALE

Client o/ten has di//icult# e(p'essing sel/ and has e%en mo'e di//icult# accepting the deg'ee o/ impo'tance substance has assumed in li/e and its 'elationship to p'esent situation.

Assess mental status. ote p'esence o/ othe' ps#chiat'ic diso'de's *dual diagnosis,. substance

-an# clients use substances in an attempt to obtain 'elie/ /'om dep'ession o' an(iet#& 4hich ma# p'edate use and /o' be the 'esult o/ use. App'o(imatel# 60G o/ substance;dependent

clients ha%e unde'l#ing ps#chological p'oblems& and t'eatment /o' both is impe'ati%e to maintain abstinence. $pend time 4ith client. 9iscuss clientCs beha%io' /use 0he nu'seCs p'esence con%e#s acceptance o/ the o/ substance non.udgmentall#. client as a 4o'th4hile pe'son. 9iscussion p'o%ides oppo'tunit# /o' insight into the p'oblems substance abuse has c'eated /o' the client. "'o%ide in/o'mation /o' positi%e actions and p'oblems encou'age client to accept this input. as +ailu'e and lac: o/ sel/;esteem ha%e been /o' this client& 4ho needs to lea'n to accept sel/ an indi%idual 4ith positi%e att'ibutes. !bse'%e /amil# inte'actions /$! d#namics and le%el $ubstance abuse is a /amil# p'oblem& and ho4 the o/ suppo't. membe's act and 'eact to the clientCs beha%io' a//ects the cou'se o/ the disease and ho4 the client sees sel/. -an# unconsciousl# become 7enable's&8 helping the indi%idual to co%e' up the conse1uences o/ the abuse. *5e/e' to 96 +amil# "'ocess& alte'ed6 alcoholism., Bncou'age e(p'ession o/ /eelings o/ guilt& shame& 0he client o/ten has lost sel/;'espect and belie%es and ange'. that the situation is hopeless. B(p'ession o/ these /eelings helps the client begin to accept 'esponsibilit# /o' sel/ and ta:e steps to ma:e changes. Help the client ac:no4ledge that substance use is Fhen d'ugs can no longe' be blamed /o' the the p'oblem and that p'oblems can be dealt 4ith p'oblems that e(ist& the client can begin to deal 4ithout the use o/ d'ugs. Con/'ont the use o/ 4ith the p'oblems and li%e 4ithout substance use. de/enses *e.g.& denial& p'o.ection& 'ationaliAation,. Con/'ontation helps the client accept the 'ealit# o/ the p'oblems as the# e(ist. As: the client to list and 'e%ie4 past accomplish; 0he'e a'e things in e%e'#oneCs li/e that ha%e been ments and positi%e happenings. success/ul. !/ten 4hen sel/;concept is lo4& it is di//icult to 'emembe' these successes o' to %ie4 them as successes. ?se techni1ues o/ 'ole 'ehea'sal. Assists client to p'actice de%eloping s:ills to cope 4ith ne4 'ole as a pe'son 4ho no longe' uses o' needs d'ugs to handle li/eCs p'oblems.

C%""$1%r$)i*'

In%ol%e client in g'oup the'ap#. clientCs

H'oup sha'ing helps encou'age %e'baliAation& as othe' membe's o/ g'oup a'e in %a'ious stages o/ abstinence /'om d'ugs and can add'ess the conce'ns /denial. 0he client can gain ne4 s:ills& hope& and a sense o/ /amil# /communit# /'om g'oup pa'ticipation.

+o'mulate plan to t'eat othe' mental illness Clients 4ho see: 'elie/ /o' othe' mental health p'oblems. *5e/e' to app'op'iate C" as indicated., p'oblems th'ough d'ugs 4ill continue to do so once discha'ged. 0he substance use and mental health p'oblems need to be t'eated togethe' to ma(imiAe abstinence potential. Administe' antips#chotic medications as necessa'#. "'olonged /p'o/ound ps#chosis /ollo4ing =$9 o' "C" use can be t'eated 4ith these d'ugs& as this condition ma# be the 'esult o/ an unde'l#ing /unctional ps#chosis that has no4 eme'ged. N%)'( A%oid the use o/ phenothiaAines& as the# ma# dec'ease seiAu'e th'eshold and cause h#potension in the p'esence o/ =$9/"C".

NURSING DIAGNOSIS M$+ B' R'"$)'# )%(

6AMILY PROCESS, $")'r'#( $"!%&%"i-2 8-u1-)$ !' $1u-'9 Abuse o/ substance*s,< 'esistance to t'eatment +amil# histo'# o/ substance abuse Addicti%e pe'sonalit# Inade1uate coping s:ills& lac: o/ p'oblem;sol%ing s:ills

P%--i1"+ E*i#' !'# 1+(

An(iet#& ange'>supp'essed 'age< shame and emba''assment Bmotional isolation>loneliness< %ulne'abilit#< 'ep'essed emotions 9istu'bed /amil# d#namics< closed communication s#stems& ine//ecti%e spousal communication and ma'ital p'oblems Alte'ed 'ole /unction>dis'uption o/ /amil# 'oles -anipulation< dependenc#< c'iticiAing< 'ationaliAation>denial o/ p'oblems Bnabling to maintain d'in:ing *substance abuse,< 'e/usal to get help>inabilit# to accept and 'ecei%e help app'op'iatel#

D'-ir'# Ou)!%2'-/E*$"u$)i% 6$2i"+ 4i""(

Cri)'ri$3

@e'baliAe unde'standing o/ d#namics o/ enabling beha%io's. "a'ticipate in indi%idual /amil# p'og'ams. Identi/# ine//ecti%e coping beha%io's and conse1uences. Initiate and plan /o' necessa'# li/est#le changes. 0a:e action to change sel/;dest'ucti%e beha%io's>alte' beha%io's that cont'ibute to pa'tne'Cs>$!Cs addiction.

ACTIONS/INTERVENTIONS I #'/' #' )

5e%ie4 /amil# histo'#< e(plo'e 'oles o/ /amil# membe's& ci'cumstances in%ol%ing d'ug use& st'engths& a'eas o/ g'o4th.

RATIONALE

9ete'mines a'eas /o' /ocus& potential /o' change.

B(plo'e ho4 the $! has coped 4ith the clientCs 0he pe'son 4ho enables also su//e's /'om the same habit *e.g.& denial& 'ep'ession& 'ationaliAation& hu't& /eelings as the client and uses ine//ecti%e methods loneliness& p'o.ection,. /o' dealing 4ith the situation& necessitating help in lea'ning ne4/e//ecti%e coping s:ills. 9ete'mine unde'standing o/ cu''ent situation and "'o%ides in/o'mation on 4hich to base p'esent p'e%ious methods o/ coping 4ith li/eCs p'oblems. plan o/ ca'e. Assess cu''ent le%el o/ /unctioning o/ /amil# membe's. situation. A//ects indi%idualCs abilit# to cope 4ith

9ete'mine e(tent o/ enabling beha%io's being Bnabling is doing /o' the client 4hat he o' she e%idenced b# /amil# membe's< e(plo'e 4ith each needs to do /o' sel/ *'escuing,. "eople 4ant to be indi%idual and client. help/ul and do not 4ant to /eel po4e'less to help thei' lo%ed one to stop substance use and change the beha%io' that is so dest'ucti%e. Ho4e%e'& the substance abuse' o/ten 'elies on othe's to co%e' up o4n inabilit# to cope 4ith dail# 'esponsibilities. "'o%ide in/o'mation about enabling beha%io'& A4a'eness and :no4ledge o/ beha%io's *e.g.& addicti%e disease cha'acte'istics /o' both the use' a%oiding and shielding& ta:ing o%e' and nonuse'. 'esponsibilities& 'ationaliAing& and subse'%ing, p'o%ide oppo'tunit# /o' indi%iduals to begin the p'ocess o/ change. Identi/# and discuss sabotage beha%io's o/ /amil#B%en though /amil# membe'*s, ma# %e'baliAe a membe's. desi'e /o' the indi%idual to become substance; /'ee&

the 'ealit# o/ inte'acti%e d#namics is that the# ma# unconsciousl# not 4ant the indi%idual to 'eco%e'& as this 4ould a//ect the /amil# membe'sC o4n 'ole in the 'elationship. Additionall#& the# ma# 'ecei%e s#mpath# /attention /'om othe's *seconda'# gain,. Bncou'age pa'ticipation in the'apeutic 4'iting& e.g.& $e'%es as a 'elease /o' /eelings *e.g.& ange'& g'ie/& .ou'naling *na''ati%e,& guided o' /ocused. st'ess,< helps mo%e indi%idual*s, /o'4a'd in t'eatment p'ocess. "'o%ide /actual in/o'mation to client and /amil# -an# clients/$!s a'e una4a'e o/ the natu'e o/ about the e//ects o/ addicti%e beha%io's on the /amil# addiction. I/ client is using legall# obtained d'ugs& and 4hat to e(pect a/te' discha'ge. he o' she ma# belie%e this does not constitute abuse. Bncou'age /amil# membe's to be a4a'e o/ thei' o4n Fhen the enabling /amil# membe's become a4a'e /eelings& loo: at the situation 4ith pe'specti%e and o/ thei' o4n actions that pe'petuate the addictCs ob.ecti%it#. 0he# can as: themsel%es6 7Am I being p'oblems& the# need to decide to change connedI Am I acting out o/ /ea'& shame& guilt& themsel%es. I/ the# change& the client can then /ace o' ange'I 9o I ha%e a need to cont'olI8 the conse1uences o/ o4n actions and ma# choose to get 4ell. "'o%ide suppo't /o' enabling pa'tne'*s,. Bncou'age +amilies /$!s need suppo't as much as the pe'son g'oup 4o':. 4ho is addicted to p'oduce change. Assist the clientCs pa'tne' to become a4a'e that clientCs "a'tne's need to lea'n that use'Cs habit ma# o' abstinence and d'ug use a'e not the pa'tne'Cs ma# not change despite pa'tne'Cs in%ol%ement in 'esponsibilit#. t'eatment.

Help the 'eco%e'ing */o'me' use', pa'tne' 4ho is Bnabling beha%io' can be pa'tne'Cs attempts at enabling to distinguish bet4een dest'ucti%e aspects pe'sonal su'%i%al. o/ beha%io' and genuine moti%ation to aid the use'. ote ho4 pa'tne' 'elates to the t'eatment team /sta//. 9ete'mines enabling st#le. A pa'allel e(ists bet4een ho4 pa'tne' 'elates to use' and to sta//& based on pa'tne'Cs /eelings about sel/ and situation. B(plo'e con/licting /eelings the enabling pa'tne' ?se/ul in establishing the need /o' the'ap# /o' the ma# ha%e about t'eatment *e.g.& /eelings simila' to pa'tne'. 0his indi%idualCs o4n identit# ma# ha%e

those o/ substance abuse' 2blend o/ ange'& guilt& /ea'& been lostJshe o' he ma# /ea' sel/; disclosu'e to e(haustion& emba''assment& loneliness& dist'ust& sta// and ma# ha%e di//icult# gi%ing up the g'ie/& and possibl# 'elie/3,. dependent 'elationship. In%ol%e /amil# in discha'ge 'e/e''al plans. /amil# substance abuse beha%io'& /amil# membe's need help ad.usting to the ne4 beha%io' o/ sob'iet#/abstinence. Incidence o/ 'eco%e'# is almost doubled 4hen the /amil# is t'eated along 4ith the client. Ee a4a'e o/ sta//Cs enabling beha%io's and /eelings =ac: o/ unde'standing o/ enabling and about client and enabling pa'tne'*s,. codependence can 'esult in nonthe'apeutic app'oaches to clients and thei' /amilies. 9'ug abuse is a /amil# illness. Eecause the has been so in%ol%ed in dealing 4ith the

C%""$1%r$)i*'
Bncou'age in%ol%ement 4ith sel/;help associations "uts client//amil# in di'ect contact 4ith suppo't such as Alcoholics / a'cotics Anon#mous& Al;Anon& s#stems necessa'# /o' continued sob'iet# and Alateen& and p'o/essional /amil# the'ap#. assists 4ith p'oblem 'esolution.

NURSING DIAGNOSIS M$+ B' R'"$)'# )%(

SEXUAL #+-0u !)i% Alte'ed bod# /unction6 neu'ological damage and debilitating e//ects o/ d'ug use *pa'ticula'l# alcohol and opiates, "'og'essi%e inte'/e'ence 4ith se(ual /unctioning In men6 A signi/icant deg'ee o/ testicula' at'oph# is noted *testes a'e smalle' and so/te' than no'mal,& g#necomastia *b'east enla'gement,& impotence>dec'eased spe'm counts In 4omen6 =oss o/ bod# hai'< thin& so/t s:in& and spide' angioma *ele%ated est'ogen,< ameno''hea>inc'ease in misca''iages

P%--i1i"i)+ E*i#' !'# 1+(

D'-ir'# Ou)!%2'-/E*$"u$)i% C"i' ) 4i""(

Cri)'ri$3

@e'ball# ac:no4ledge e//ects o/ d'ug use on se(ual /unctioning>'ep'oduction. Identi/# inte'%entions to co''ect>o%e'come indi%idual situation.

ACTIONS/INTERVENTIONS

RATIONALE

I #'/' #' )
Asce'tain clientCs belie/s and e(pectations. Ha%e 9ete'mines le%el o/ :no4ledge< identi/ies client desc'ibe p'oblem in o4n 4o'ds. mispe'ceptions& lea'ning needs. Bncou'age and accept indi%idual e(p'essions o/ -ost people /ind it di//icult to tal: about this conce'n. sensiti%e sub.ect and ma# not as: di'ectl# /o' in/o'mation. "'o%ide education oppo'tunit# *e.g.& pamphlets& -uch o/ denial and hesitanc# to see: t'eatment consultation /'om app'op'iate pe'sons, /o' client to ma# be dec'eased 4ith su//icient and app'op'iate lea'n e//ects o/ d'ug on se(ual /unctioning. in/o'mation. "'o%ide in/o'mation about indi%idualCs condition. $e(ual /unctioning ma# ha%e been a//ected b# d'ug *alcohol, inta:e o' ph#siological and /o' ps#chological /acto's *such as st'ess,. In/o'mation 4ill assist client to unde'stand o4n situation and identi/# actions to be ta:en. "'o%ide in/o'mation about e//ects o/ substance use A4a'eness o/ the negati%e e//ects o/ alcohol /othe' on the 'ep'oducti%e s#stem//etus *e.g.& inc'eased d'ugs on 'ep'oduction ma# moti%ate client to stop 'is: o/ p'ematu'e bi'th& b'ain damage& and /etal using d'ug*s,. Fhen client is p'egnant& mal/o'mation,. Assess d'in:ing /d'ug histo'# o/ identi/ication o/ potential p'oblems aids in p'egnant client. planning /o' /utu'e /etal needs /conce'ns. 9iscuss p'ognosis /o' se(ual d#s/unction *e.g.& 4ith impotence /lo4 se(ual desi'e,. In about 50G o/ cases& impotence is 'e%e'sed abstinence /'om d'ug*s,< in 25G& the 'etu'n to no'mal /unctioning is dela#ed< in app'o(imatel# 25G impotence 'emains.

C%""$1%r$)i*'
5e/e' /o' se(ual counseling& i/ indicated. 'esol%e ha%e di//icult ad.usting& i/ d'ug has imp'o%ed se(ual e(pe'ience *he'oin dec'eases d#spa'eunia in 4omen /p'ematu'e e.aculation in men,. +u'the'mo'e& the client ma# ha%e engaged en.o#abl# in biAa''e& e'otic se(ual beha%io' 4hile unde' the in/luence o/ stimulant d'ug*s,< client ma# ha%e /ound no substitute /o' the d'ug& ma# ha%e d'i%en a pa'tne' a4a#& and ma# ha%e no moti%ation to ad.ust to se(ual e(pe'ience 4ithout d'ugs. 5e%ie4 'esults o/ sonog'am& i/ client is p'egnant. Assesses /etal g'o4th and de%elopment to identi/# possibilit# o/ /etal alcohol s#nd'ome *+A$, and /utu'e needs. Couple ma# need additional assistance to mo'e se%e'e p'oblems /situations. Client ma#

NURSING DIAGNOSIS

KNO4LEDGE #'0i!i) 8LEARNING NEED9 r'g$r#i g !% #i)i% , /r%g %-i-, )r'$)2' ), -'"0 !$r' $ # #i-!&$rg' ''#=ac: o/ in/o'mation< in/o'mation misinte'p'etation Cogniti%e limitations>inte'/e'ence 4ith lea'ning *othe' mental illness p'oblems>o'ganic b'ain s#nd'ome,< lac: o/ 'ecall

M$+ B' R'"$)'# )%(

P%--i1"+ E*i#' !'# 1+(

$tatements o/ conce'n< 1uestions>misconceptions Inaccu'ate /ollo4;th'ough o/ inst'uctions>de%elopment o/ p'e%entable complications Continued use in spite o/ complications>8bad t'ips8

D'-ir'# Ou)!%2'-/E*$"u$)i% C"i' ) 4i""(

Cri)'ri$3

@e'baliAe unde'standing o/ o4n condition>disease p'ocess& p'ognosis& and t'eatment plan. Identi/#>initiate necessa'# li/est#le changes to 'emain d'ug;/'ee. "a'ticipate in t'eatment p'og'am.

ACTIONS/INTERVENTIONS I #'/' #' )

Ee a4a'e o/ and deal 4ith an(iet# o/ client and /amil# membe's. "'o%ide an acti%e 'ole /o' the client /$! in the lea'ning p'ocess *e.g.& discussions& g'oup pa'ticipation& 'ole;pla#ing,.

RATIONALE

An(iet# can inte'/e'e 4ith abilit# to hea' and assimilate in/o'mation. =ea'ning is enhanced 4hen pe'sons a'e acti%el# in%ol%ed.

"'o%ide 4'itten and %e'bal in/o'mation as indicated. Helps client/$! ma:e in/o'med choices about Include list o/ a'ticles and boo:s 'elated to client / /utu'e. Eibliothe'ap# can be a use/ul addition to /amil# needs and encou'age 'eading and discussing othe' the'apeutic app'oaches. 4hat the# lea'n. Assess clientCs :no4ledge o/ o4n situation *e.g.& Assists in planning /o' long;'ange changes disease& complications& and needed changes in necessa'# /o' maintaining sob'iet# /d'ug;/'ee li/est#le,. status. Client ma# ha%e st'eet :no4ledge o/ the d'ug but be igno'ant o/ medical /acts. 0ime acti%ities to indi%idual needs. 'eadil# +acilitates lea'ning& as in/o'mation is mo'e assimilated 4hen pacing is conside'ed.

5e%ie4 condition and p'ognosis //utu'e e(pectations. "'o%ides :no4ledge base on 4hich client can ma:e in/o'med choices. 9iscuss 'elationship o/ d'ug use to cu''ent situation. !/ten client has mispe'ception *denial, o/ 'eal 'eason /o' admission to the ps#chiat'ic *medical, setting. 9iscuss e//ects o/ d'ug*s, used& e.g.& "C" is deposited In/o'mation 4ill help client unde'stand possible in bod# /at and ma# 'eacti%ate */lashbac:s, e%en long;te'm e//ects o/ d'ug use. a/te' long inte'%al o/ abstinence< alcohol use ma# 'esult in mental dete'io'ation& li%e' in%ol%ement / damage< cocaine can damage postcapilla'# %essels& inc'ease platelet agg'egation& p'omote th'omboses and in/a'ction o/ s:in /inte'nal o'gans& cause localiAed at'ophie blanche o/ scle'ode'matous lesions. 9iscuss potential /o' 'eeme'gence o/ 4ithd'a4al B%en though s#mptoms o/ into(ication ma# ha%e s#mptoms /'om stimulant abuse as ea'l# as 3 months passed& client ma# mani/est denial& d'ug hunge'& o' as late as 9K12 months a/te' discontinuing d'ug and pe'iods o/ 7/la'e;up&8 in 4hich a dela#ed use. 'ecu''ence o/ 4ithd'a4al s#mptoms occu's *e.g.& an(iet#& dep'ession& i''itabilit#& sleep distu'bance& compulsi%eness 4ith /ood 2especiall# suga's3,. In/o'm client o/ e//ects o/ disul/i'am *Antabuse, in Inte'action o/ alcohol and Antabuse 'esults in combination 4ith alcohol inta:e and impo'tance o/ nausea and h#potension& 4hich ma# p'oduce /atal a%oiding use o/ alcohol;containing p'oducts *e.g.& shoc:. Clients ta:ing Antabuse a'e sensiti%e to /oods /cand#& cough s#'ups& mouth4ash& a/te'sha%e / alcohol on a continuum& 4ith some being able to cologne,. d'in: 4hile ta:ing the d'ug and othe's ha%ing a 'eaction 4ith onl# slight e(posu'e to alcohol. 5eactions also appea' to be dose;'elated. 5e%ie4 speci/ic a/te'ca'e needs *e.g.& "C" use' "'omotes indi%idualiAed ca'e 'elated to speci/ic should d'in: c'anbe''# .uice and continue use o/ situation. C'anbe''# .uice and asco'bic acid asco'bic acid,< alcohol abuse' 4ith li%e' damage enhance clea'ance o/ "C" /'om the s#stem. should 'e/'ain /'om d'ugs /anesthetics o' use o/ $ubstances that ha%e the potential /o' li%e' household cleaning p'oducts deto(i/ied in the li%e'. damage a'e mo'e dange'ous in the client 4ith impai'ed li%e' /unction. 9iscuss %a'iet# o/ help/ul o'ganiAations and =ong;te'm suppo't is necessa'# to maintain p'og'ams that a'e a%ailable /o' assistance /'e/e''al. optimal 'eco%e'#. "s#chosocial needs& as 4ell as othe' issues& ma# 'e1ui'e add'essing.