COLLEGE OF NURSING

SILLIMAN UNIVERSITY
DUMAGUETE CITY

RESOURCE UNIT ON SUBSTANCE ABUSE

Submitted to:
Mrs. Florenda F. Cabatit
Clinical Instructor

Submitted by:
Noreene Therese L. Libor
Glenly Rose M. Lahoy
NCM103- PSYCH Rotation E1

April 15, 2010


Topic: Substance Abuse
Number of hours: 2 hours
Topic Description: This topic deals with substance abuse. It includes discussion of different psychoactive substances, its effects and different management approaches, with emphasis on nursing
care.
Central Objectives: At the end of 2 hours classroom activities, the learner shall acquire knowledge, develop beginning skills and manifest desirable attitudes in the care of patients with substance
problems.
SPECIFIC OBJECTIVES
At the end of 2 hours of
classroom activities, the
learner shall:
I.Definition of terms
Define the substance
abuse and other related
terms.
COLLEGE OF NURSING
SILLIMAN UNIVERSITY
DUMAGUETE CITY
CONTENT TA T-L ACTIVITY EVALUATION
Prayer
Most gracious, Heavenly Father Lord God, we thank you for this wonderful day
you’ve given us. Thank you for the gift of life, gift of friendship, gift of love, grace
and wisdom. We humbly come to you with open hearts and minds. We thank you
once again for giving us the great opportunity to study and to live our lives to the
fullest. Forgive us O Lord for all the trespasses we have done to our parents,
friends, siblings, teachers and classmates because sometimes, we do not know
what we are doing, whether we make others hurt or happy. Teach us to be like
you and you may bless us, as well as our families especially those who are far
away from us. We lift up everything to you Lord, we believe that we are nothing
without you in our lives. These we ask through your Son Jesus Christ our Lord,
who lives and reigns forever and ever. Amen.
3 mins.
Introduction
Good morning ladies and gentlemen! Good morning ma’am. I am Glenly Rose M.
Lahoy, I am Noreene Therese Libor. Today, we are here in front of you to discuss
about substance abuse. I believe most of us here do have the basics about this
topic. I anticipate that everybody would be able to easily understand our report
and be able to answer our questions later. Let’s begin the discussion with a game.
5 mins.
a. Substance abuse refers to as a non-therapeutic use of psychoactive agents or
the elicit use of prescribed drug on a regular or episodic basis. It is the use of
alcohol or other drugs repeatedly to the extent that functional problems occur.
“Pick a name
b. Drug dependence is the pathologic use of a psychoactive drug over a significant game”
period of time with symptoms of physical and psychological addiction to the Mechanics: The
 drugs, such that it interferes with physical, social, or occupational functioning. names of the
Differentiate players are written
physiological c. Physiological dependence/Psychological dependence is described as a physical in a piece of
dependence from need for the psychoactive substance. The person suffers marked physiological paper and rolled.
psychological symptoms when the drug is withdrawn and the physical need for the drug is These pieces of
dependence. directly related to the drug used or its interaction with other psychoactive paper are placed
substances. in the box. The
facilitators will
d. Addiction is a state of chronic intoxication produced by the repeated consumption pick a piece of it
of drug. and whosever
name written on it
e. Tolerance refers to the body’s need for larger amounts of a psychoactive should answer the
substance to achieve the same effects previously obtainable with less of the questions. Prizes
drug. will be given.

f. Withdrawal is the spontaneous removal of the drug from the body system as
either an unplanned event or a gradual tapering of the drug under medical Lecture
supervision. discussion

II.Screening for Substance Abuse

10 mins.
Describe a. CAGE Questionnaire- the simplest tool that can be used as an initial screening
comprehensively the tool in any health setting to screen for alcoholism.
screening tools. Have you ever felt you ought to Cut down on your drinking?
Have people Annoyed you by criticizing your drinking?
Have you ever felt bad or Guilty about your drinking?
Have you ever had a drink first thing in the morning and steady your
nerves or get rid of a hangover (Eye-opener)?

b. Breathalyzer- the simplest biological measures to obtain is blood and alcohol

content (BAC) by use of breathalyzer. Alcohol in any amount has an effect to
the CNS. The behaviors can be expected from a non- tolerant person at
different concentrations of alcohol in blood. Remember that a person who has
developed tolerance to alcohol would not demonstrate these behaviors and
could have a high BAC without showing any signs of impairment. A level
greater than 0.10% without associated behavioral symptom indicates the
presence of tolerance. The higher the level without the symptoms, the more
severe the tolerance. High tolerance is a sign of physical dependence.

c. Blood and urine - are the body fluids most often tested for drug content,
although saliva, hair, breath, and sweat analysis methods have been
developed and are being refined. Identification and measurement of drug
levels in the blood are useful for treating drug overdoses or complications in
emergency room and other medical settings. Urine drug screening is the
 method of choice because it is non-invasive. Urine drug screening is
sometimes used to test prospective employees and athletes for evidence of
drug use. It is also used by drug treatment personnel to determine whether
patients have used drugs while in treatment. Urine drug screening is often
used in court to validate a person’s drug use related to criminal activity.
Persons who are being tested may alter the sample to hide drug use by
diluting the urine with water from the toilet or substituting a “clean” specimen
donated by a friend for the “dirty” specimen. To prevent these, specimen is
often collected in random days under direct observations of a same-sex staff
member. Another way is to have the person leave jackets, sweater, purses
and so forth outside the stall, place drops of dye in the toilet water to alter its
color, and test the specimen for temperature. Fresh, undiluted urine should be
approximately 37° C. The length of time that drugs can be found in blood and
urine varies according to dosage and the metabolic properties of the drug. All
traces of the drug may disappear within 24 hours may still be detectable after
30 days.

d. B – DAST
The Brief Drug Abuse Screening Test (B-DAST) is the quickest drug
abuse screening tool. Each item has a one-point value. Scores of 6 or more
suggest significant drug abuse problems. Patients who score above Lecture
established cut-off scores are considered to be addicted. discussion

III.Stages of Drug Dependence

a. Relief phase – refers to the relief experienced by using a drug, which allows a
Discuss the stages of 5 mins.
drug dependence. potential addict to escape one or more of the following feelings such as boredom,
loneliness, tension, fatigue, anger, and anxiety.
b. Increased use – involves taking greater quantities of the drug.
c. Preoccupation phase – consists of a contact concern with the substance – that
is taking the drug becomes “normal” behavior.
d. Dependence phase – is synonymous with addiction. In this phase, more of the
drug is sought without regard for the presence of physical symptoms, such as
coughing and/or shortness of breath in cases of cigarette and marijuana addiction,
blackouts from advanced abuse and moderate to severe soreness of nasal
passages and inflammation from snorting cocaine.
e. Withdrawal phase – involves such symptoms as itching, chills, tension,
stomach pain, or depression from the non-use of the addictive drug and/or an Lecture
entire set of psychological concerns mainly involving an insatiable craving for the discussion
drug.

IV.Predictors of Chemical Dependence

25 mins.
 a. Biological
Recognize the different One of the more potent predictors of whether a person will be at risk for
predictors of chemical chemical dependence is a family history of addiction. The risk seems to
dependence. increase if chemical dependence is present in the nuclear family. Many have
suggested that chemical dependence runs in families and that it may be
transmitted across generations. Familial transmission can also be explained
by behavioral factors such as modeling by parents or siblings of drinking and
using drug to escape, avoid, or cope with stress and problems. Familial
transmission is likely a combination of a genetic predisposition, possibly
related to emotional vulnerability or sensitivity, and of modeling by family
members who maybe using to cope with life.

b. Behavioral
There are certain psychological disorders with specific clusters of
symptoms that have a high co-occurrence with substance abuse and
dependence but there is no single personality type for people with addictive
behaviors. Behavioral principles go long ways towards explaining the
addictive process, even though chemically dependent people have varying
personalities.
Positive reinforcement, something pleasurable happening after behavior
occurs that makes repeating behavior more likely, can happen when people
get high or when they feel relaxed and joyful while using substances. A
reinforcement that doesn’t occur regularly is often referred to being on a
variable schedule is more difficult to change than behavior pattern is
reinforced on a regular basis.
Negative reinforcement occurs when an activity removes an aversive event
or consequence, therefore making it more likely that the behavior will be
repeated. This can also occur on a variable or intermittent schedule, meaning
that sometimes the use alleviates the nasty symptoms, but not always.
Addiction can develop as a result of powerful behavior patterns (desiring
pleasure and avoiding discomforts) reinforced in a random and unpredictable
way. Self-medication also can be thought as negative reinforcement when a
person may use the substance to relieve aversive psychiatric or physical
symptoms such as depression, anxiety or chronic pain. More often than not,
the substance use may actually make the symptoms worsen over the long
term. Addiction is also related to a person’s ability to cope with other people
or with environmental stress. People who abuse substances often have
problems with skills in interpersonal situations, during drinking and using
events, in daily living, and in solving problems.

c. Cognitive
Addiction or addictive processes are influenced by patient’s beliefs. A
person’s beliefs about outcomes are often related to future behaviors. With
regards to chemical dependence, what a patient believes about the outcomes
of using, their ability to cope in certain situations, or their ability to change
their behavior may be critical factor in what really does happen next.
 Expectancies can involve beliefs about the positive or negative effects of
using the substance. Positive expectancies make it hard for a person to want
to change their using behavior because of the belief that good things, like
getting high or avoiding worry or improving mood, will occur after using
substances.

d. Emotional
Substantial numbers of people who are chemically dependent have
difficulties identifying and expressing emotions in socially acceptable ways.
Having difficulties with identifying emotions makes perfect sense when
considering that substance abuse tends to blunt emotions because chemically
dependent patients would have difficulty expressing what she or he feels at
the particular moment since feelings may have been avoided for many years.
Chemically dependent patients have the tendency to under express or over
express their emotions or to confuse one emotion with another emotion.
People with chemical dependence often have problems with emotion
deregulations which mean that they are not very skilled in controlling or
expressing emotions. People who feel emotionally vulnerable may be
naturally attracted to emotionally altering properties of drugs and alcohol, as
well as to the escapes that substance use may provide. Common emotions
associated with addictive process include, anger, sadness and grief, shame
and guilt, regret and rumination, and happiness.

e. Environmental
Chemical dependence is usually associated with poverty, stress and
many have reported drinking or using for relaxation or stress reduction. There
are different types of psychological stress that may contribute to substance
abuse, including job stress, unemployment, familial stress, economic stress,
daily hassles or major life changes or crises. Environmentally crowded
conditions, often associated with increased psychological stress, may be
linked to increased substance use, although crowding usually co-occurs with
poverty. Abuse, traumatic events, and oppression may also be linked to
chemical dependence related to environment stressors. Cultural values and
mores also seem to be associated with the prevalence of chemical
dependence in certain societies. Marketing practices has also been linked to Socialized
positive alcohol and smoking expectancies. discussion

V. CNS Stimulants
5 mins.

The brain has built-in “reward centers” that when stimulated electrically or
chemically, result in inherently pleasurable stimuli. A variety of abused drugs
can stimulate the brain reward systems in the process producing a desired
“high”. Pleasurable sensations are actually produced by the brain itself
through a drug to stimulate the neccessary brain centers. Though scattered
Discuss the connection and separated from each other, these pleasure centers appear to share
between psychiatric neural connections of the so called-dopaminergc brain pathways. This means
disorders and drug that the most of these centers are influenced by the neurotransmitter
abuse. dopamine.
The limbic system is the center of the emotional brain and plays a role in
regulating basic functions such as sexual response, hunger, agression,
expression of emotion, and memory. Dopamine receptors are the
neurotransmitters prevalent in the limbic system. The limbic system is
associated with the “reward pathways” of the brain. Drug-induced changes in
this area of the brain play a role in the chronic brain changes that are
associated with addiction. Stimulants act primarily to produce excitation,
increased alertness, aggressiveness, and decreased food intake, through the
dopamine system of the brain.

a. Amphetamines
The amphetamine drugs include amphetamine, methylphenidate (Ritalin),
methamphetamine, dextroamphetamine (Dexedrine) and benzphetamine.
These were developed in 1887. These were originally used as appetite
suppressants for weight loss. Because of their energizing effects, this is also
used by athletes to increase energy and counteract fatigue hoping to improve
their performance; as well as long-distance truck drivers to keep them awake
on long trips. (Kneisl, 2004)
It increases the release of these cathecholamines at the receptors which
causes increased stimulation. It was once believed that amphetamines did
not cause physical dependence, but clear patterns of tolerance and
withdrawal have been described. Tolerance develops rapidly, and chronic
abusers may suffer a toxic psychosis presenting with symptoms of paranoid
schizophrenia (Kneisl, 2004). People take amphetamines because these
make them feel good. CNS effects include wakefulness, alertness,
heightened concentration and energy, improved mood to euphoria, insomnia
and amnesia. The most common side effects of amphetamine use are
restlessness, dizziness, agitation, and insomnia. PNS effects are palpitations,
tachycardia, and hypertension. Respirations also increase because
amphetamines also stimulate the medulla (Keltner, 1999).

b. Cocaine
This is extracted from leaf of a plant called Erythroxylon and is a fine,
white, odorless substance with a bitter taste. Cocaine alkaloid can be broken
up into smaller pieces referred to as “crack”, so named because of the
cracking sound of the substance when heated. Cocaine exerts two main
effects of the body: stimulant and anesthetic. It has different stimulant
properties. It produces euphoria, loss of fatigue, and a sense of well-being,
and freedom from boredom. It also acts as a stimulant for both sexual arousal
and violent behavior. (Carson, 2000). As an anesthetic, it blocks the
conduction of electrical impulses within the nerve cells that are involved in the
sensory transmission, primarily pain transmission. Cocaine produces an
 imbalance of neurotransmitters ( dopamine and epinephrine) that may be
responsible for many of the physical withdrawal symptoms reported by heavy
chronic cocaine users: depression, paranoia, lethargy, anxiety, insomnia,
nausea and vomiting, and sweating and chills- all signs of the body’s
struggling to regain its normal chemical balance.
It acts on the brains reward centers to block the reuptake of
neurotransmitters dopamine and norepinephrine. This results to excess
excitation of these reward centers by these two excitatory neurotransmitters.
This is responsible for cocaine’s strong reinforcing effect. In consequence, the
brain mediates a release of stress hormones including epinephrine.

c. Treatment of cocaine withdrawal

Detoxification for cocaine abusers depends on the client’s symptoms. The
major challenge in treatment is to prevent relapse. Most clients with crack
dependency need inpatient care because of both the intensity of drug
cravings that crack provokes and the severity of the post-intoxication
psychological “crash” that occurs during withdrawal.
The nurse has to assess the patient for depression, as cocaine users
frequently experience depression during recovery.
The nurse must work with a treatment team, helping the client to choose
recovery and then place himself in settings were recovery is possible.
Day hospitalization is another alternative that offers many of the
advantages of inpatient treatment at lower costs. Counseling focuses on
recognizing and avoiding situations that might lead to renewed use. This often
requires changing friends, living situations, and jobs. Cocaine anonymous
programs, self-help groups patterned after AA, are also helpful.
5 mins.
VI. Opioids

a. Heroin
Also known as “H”, Harry, horse, china white.
As with other opioids, heroin is used as both a pain-killer and a
recreational drug. Frequent and regular administration can quickly cause
tolerance and dependence, and as such, heroin has a very high potential for
addiction. If sustained use of heroin for as little as three days is stopped
abruptly, withdrawal symptoms may appear, though other studies have shown
the onset of withdrawals to begin from 7 to 14 days of continuous use.

a.1. Methods of administration: injection, ingestion, inhalation.

a.2. Treatment of withdrawal

Management is similar with treating the alcoholic. There is a broad range
of treatment options for heroin addiction, including medications as well as
behavioral therapies. Methadone treatment is the treatment of choice for
morphine and heroin addicts. Methadone is a synthetic opioid given to addicts
 to suppress withdrawal symptoms. A methadone dose of 20-80 mg/day is
usually sufficient to stabilize a client. Methadone maintenance is continued
until the client can be withdrawn from methadone. Methadone itself is
addicting , but clients can be withdrawn by gradually decreasing the total daily
dose until the client is methadone-free (Fortinash 2004) .

b. Opium
Opioids are natural or synthetic agents which possess morphine- like
properties and are primarily used for analgesia. The seed pops of the poppy
plant are the naturally occurring source of opium. The site of action of all
opioids is the reward centers of the brain. Acting on various receptors of the
cell membrane, a cascade of neurochemical processes occurs, altering the
perception of pain in the brain and spinal cord. Neuronal excitability is
reduced and neurotransmitters (glutamate and substance P) that
communicate pain messages are inhibited. Stimulation of opioid receptors not
only produces analgesia but the commonly seen effects of respiratory
depression, papillary constriction, decreased gastrointestinal motility
(constipation), euphoria, and physical dependence.
Opium and its derivatives are a perfect fit for chemical receptor molecules
in the nervous system, which has complex neurotransmitter system that
regulates pain and activity and is known as endorphin system. Stimulation of
the endorphin (usually called opiate) receptors produces a wide variety of
changes in the nervous system. Perception of pain is diminished, a sense of
comfort or pleasure is established, bodily functions slow down, and the brain
vomiting center is stimulated. They make some users feel contented and free
of worry and depending on the dose and rapidity of administration, may give
users a “rush” of intense pleasure.

c. Methadone
Methadone (Dolophin), although an opioid similar to morphine, is used to
prevent withdrawal symptoms. Methadone is given orally and is poorly
metabolized in the liver. Accordingly, it has a much longer half-life (15-30 Lecture
hours) than morphine (1.5 -2 hours). Because of the long life, once-a-day discussion
dosing is effective and conducive to outpatient care (Keltner, 1999)
7 mins.
VII. Hallucinogens
-these drugs produce behavioral changes that often are multiple and dramatic;
generally produce perceptual distortions, not true hallucinations.

a. LSD ( lysergic acid diethylene) is the most common used hallucinogen that is
Describe the sensory generally swallowed. It is colorless and tasteless and is often added to a drink
psychological effects of or food. Pleasurable effects of this, use include intensification of sensory
LSD.
experiences. It has been found to interfere with the serotonin receptors of the
neurons. The blocking of important neuron receptors frees the neurons and
gives rise to the out of body and intense emotional feelings experienced by
 the user. Sensory perceptions are altered while the individual remains
awareof self and surroundings. There can be an altered sense of time and
self.

b. Ecstasy/MMDA (methylenedioxymethamphetamine). A modification of MDA

but is thought to have more psychedelic and less stimulant activity than its
predecessor. It is also structurally similar to mescaline. This drug has become
known as Ecstacy, XTC, and Adam. The unusual psychological effects it
produces are part of the reason for its popularity. The drug causes euphoria,
increased energy, increased sensitivity to touch, and lowered inhibitions.
Many users claim it intensifies emotional feelings without sensory distortion
and that it increases empathy and awareness both of the user’s body and of
the aesthetics of the surroundings.

c. PCP (phenycyclidine). The use of PCP was very popular in the 1970s, but
today is less common than LSD. It was originally tested as an an anesthetic-
analgesic agent. This was withdrawn from testing on humans because of its
adverse reactions and as a street drug, it may be ingested and frequently
smoked in a mixture with another substance, such as marijuana. At low
doses, the user experiences a euphoric, floating feeling, along with
heightened emotionality and incoordination. At higher doses, PCP use may
precipitate psychotic experience characterized by extreme agitation. People
that are PCP-intoxicated feel little or no pain and may pund their head into a Socialized
wall or strike out violently, causing serious injury to themselves or others. discussion

1 min.
VIII. Marijuana/Cannabis

It is sometimes called hallucinogenic drug but rarely causes hallucinations. It

Describe the behavioral
& physiological effects of
marijuana.
IX. Inhalants
causes sedation, but is not primarily a CNS depressant. Its active ingredient is
tetrahydrocannabinol (THC) that generally produces an altered state of
awareness accompanied by a feeling of relaxation and mild euphoria.
Possible effects: euphoria followed by relaxation, loss of appetite, impaired
memory, concentration, knowledge retention, loss of coordination; more vivid
sense of taste, sight, smell, hearing; strong doses cause fluctuating emotions,
fragmentary thoughts, disoriented, psychosis; may cause irritation to lungs. Socialized
2 mins. discussion

These are commonly abused substances that are readily found in common
household products.Fumes from volatile ssubstances found in fuels, propelants,
solvents, thinners, and nitrites are inhaled via breathing in deeply through the

X. Codependency
Identify appropriate
management strategies
for codependency.
Identify the roles of the
nurse in the different
therapies.
nose or mouth (“huffing”). Through the exact action at the cellular level is not
clear, they appear to the CNS depressants. Intoxication efffects can include
elated mood, slurred speech, slowed reflexes, ataxia, disorientation,
hallucinations, and lethargy. There is evidence of tolerance. Withdrawal is not
common but discontinuation after chronic use can include sleep disturbance,
irritability, nausea, and shakiness.
Inhalant use should be suspected when an individual presents with an odor
of solvents or evidence of perioral or nasal residue. With long-term exposure
there is evidence of brain atrophy and decreased blood flow. Other organ
system also can be affected, including hepatic, renal, cardiac, and pulmonary. Lecture
discussion
Accidents and injury related to driving or engaging in any other task that
requires mental sharpness can occur.
2 mins.
It is a term used to describe the cluster of behaviors exhibited by family
members/significant others (most oftena spouse) of one who is chemically
addicted that serve to enable the alcoholic or addict to continue usingg thhe
substance. Codependent bahaviors serve t satisfy the needs of the family
member to feel loved, important, and needed. Developed in the 1970s to
describe a predictable pattern of behaviors in family members characterized
overfuntioning, lack of objectivity, powerlessness, and need to control another’s
behavior. Those closest to the patient try in every way possible to orchestrate a
relationship that is meaningful. It is often experienced as a hopeless task
accompanied by hypervigilance and feelings of intense loneliness, self-doubt,
resentment and anger, which preoccupy the individual with codependent
behavior and influence his or her behavior. There is a wish to retaliate, generally
with the knowledge that it will have no effect. According to Johnson(1990), the
self- destructive patterns presented by the individual with substance use that
are most likely to stimulate a strong desire to retaliate in the individual with
codependent behavior include the following:
1.) breaking family commitments, both major and
minor
2.) sending more money than planned
3.) driving while intoxicated and getting arrested
4.) making inappropriate statements to friends,
family and coworkers
5.) arguing, fighting, and other antisocial actions
Although the family confronts the patient in anger about these breaches of
contract or expectations, typically the confrontation fails to achieve its desired
purpose of changing the addict’s behavior. Reflex confrontation stemming from
anger and resentment over behaviors suffered while under the influence
increase the individual’s painful feelings of shame and guilt stimulating further 20 mins.
 substance use. Lecture/Socialized
discussion
XI. Therapies

a. Individual therapy is designed as action-oriented, present-focused, structured,

time limited interventions. Although the specific emphasis varies, these models
use solution-focus techniques to help patients resolve core conflicts; the goal is
for the patients to return to their pre-morbid state of functioning in a short period.
Given hypothetical - Strategies are designed to help patients gain insight quickly and take concrete
situations, the learner action to resolve targeted issues. Therapy draws from more than the relationship
shall: between therapies and patient. It can include joint sessions with significant others
and use of time outside the therapy session for homework assignments. Other
strategies incorporate role playing, recognizing and promoting patient’s strengths,
and expecting patients to assume primary roles in their therapy. Therapist often
ask patients to learn more about their problems outside their sessions through
reading assignments and by attending community support groups and classes on
themes such as stress management and assertiveness.

b. Group therapy/Self-help groups is a usual method in which substance abuse

history sharing (talk about their daily efforts to stop drinking and taking drugs) and
feedback are important elements (therapist and members listen closely and give
feedback).Feedback is considered as an honest reaction of people to what the
speaker says.

c. Behavior Modification is a necessary step to recovery from substance

dependence, and learning new strategies and techniques provides a method for
mastering the environment. Behavior therapy can supply the individual with skills
through relaxation training, thought and behavior substitution for self-control, and
assertiveness training, to name a few. Behavioral aversion programs in the form
of electric shocks or medications that produce vomiting upon drug intake have lost
popularity.

d. Halfway houses. Transitional living arrangements provide recovering drug

abusers interim homes and programs between detoxification and the eventual
permanent home. They allow a slow adjustment to the community and ease the
client’s return home, which may have been a source of difficulty before becoming
sober. Family therapy seems to be an essential component of successful
recovery. Family therapy is a critical component in the ongoing recovery of the
person who uses alcohol or drugs, as members attempt to eliminate enabling and
codependent behaviors that perpetuate the problem. Therapy is directed toward
helping the family gain awareness of the negative effects of enabling and
codependent behaviors and developing strategies based on confrontational
approaches.

e. Motivational approaches
  Five (5) Basic Principles used in this Approach:

a.) Express empathy through reflective listening.

b.) Develop discrepancy between patient’s goals or values and their
current behavior.
c.) Avoid argument and direct confrontation.
d.) Roll with resistance.
e.) Support self-efficacy.

 Critical components of effective motivational interventions:

a.) FRAMES is an acronym for the basic elements of motivational counseling:

 Feedback regarding personal risk or impairment is given to the patient
after assessment of substance abuse patterns and related problems.
 Responsibility for change is placed explicitly on the patient, with
respect for the patient’s right to make his /her own choices.
 Advice about changing substance use behavior is given to the patient
clearly and non-judgmentally by the clinician.
 Menus of self directed change options and treatment alternatives are
offered.
 Empathetic counseling – showing warmth, respect, and understanding
– is emphasized.
 Self-efficacy – or optimistic empowerment – is engendered in the
patient to encourage change.

b.) Decisional balance exercises

-Specific ways that the clinician can assist the patient to explore the pros
and cons of old and mew behaviors for the purpose of tipping the scales
towards a decision for positive change.
All of these motivational approaches are designed to help improve patient
participation in the treatment process. They are based on the stages of
change model, which identifies five stages of change: pre-contemplation, 25 mins.
contemplation, preparation, action, and maintenance.

Identify appropriate XII. Application of Nursing Process Socialized

nursing diagnoses and discussion
nursing outcomes. At stressful times in life, anyone may develop a dependence on drug or
alcohol; however, certain people seem to be predisposed to the illness.
One’s expertise in the stages of the nursing process is vital to the care of
clients with substance abuse problems. One’s focus should be helping
clients work toward self-awareness, good health and good interpersonal
relationships so that they can lead to productive, fulfilling, happy lives.

A. Assessment
 This phase begins with education about the nature of addictive
behaviors and a comprehensive personal assessment of past and present
drug use. This includes a history of the drinking or drug abuse pattern,
social functioning, resources, and level of basic skill development.
A complete history of the patient’s drug abuse pattern includes age of
onset, types of substance abused (including alcohol), mode of
administration, usual conditions or situations in which drug-taking behaviors
occur, previous treatment attempts, and medical treatments for secondary
Formulate a symptoms. Employment history, legal status, and family history provide an
comprehensive nursing insight into the level of disruption in the chemically dependent person’s life
care plan. related to substance abuse.
During assessment, open-ended questions are highly suggested to
elicit information from the patient. Estes and Heinemann (1986) recommend
avoiding the terms alcoholic or addict early in the assessment process and
instead suggest the nurse to use phrases such as “problem with drinking” or
“difficulties with drug use” (Keltner,1999).
The patient’s consumption should be evaluated in more detail if the
initial assessment data identify him as being at risk complaint such as
depression or sexual dysfunction (Keltner, 1999).

B. Diagnosis
After completion of the nursing assessment, the nurse synthesizes the
data regarding the patient’s drug use behavior. Nursing diagnoses relevant
to the rehabilitation phase may include:
- Disturbed sensory perception
- Ineffective individual coping
- Social isolation
- Self care deficit
- Self concept disturbance
- Altered family process
- Ineffective family coping
- Knowledge deficit

C. Outcome identification

The expected outcomes of treatment are easy to identify but hard to

implement. For patients with withdrawal from drugs or alcohol include:
a.) The patient will overcome withdrawal safely and with minimum
discomforts

Short term goals may include the following:

a.) The patient will withdraw from dependence on the abused substance.
b.) The patient will be oriented to time, place, person, and situation.
c.) The patient will report symptoms of withdrawal.
d.) The patient will correctly interpret environmental stimuli.
e.) The patient will recognize and talk about hallucinations or delusions.
 For patients dependent on drugs or alcohol include:
a.) The patient will abstain from all mood-altering chemicals

Studies have shown that most people who are dependent on a drug or
alcohol cannot safely return to any level of use of any addictive drug.
Patients often become very anxious at the thought of never again using
the substance to which they are addicted. Therefore it may be helpful to
focus on short term goals. Short term goals related to abstinence may
include the following:
a.) The patient will agree to remain drug and alcohol free for 1 week, with
the agreement to be renewed weekly.
b.) The patient will make a daily commitment to abstain.
c.) The patient will attend at least two support group meetings weekly.
d.) He patient will contact a supportive person if he or she experiences an
urge to use an addictive substance.
Short-term goals consistent with the patient’s nursing diagnoses are
mutually defined so that they are acceptable to the chemically
dependent person and family. This helps promote ownership of
treatment goals and motivation to achieve them. In most instances, goal
achievement requires a total commitment and daily effort. Setting goals
1 day at a time that are action oriented, realistic, and achievable
increase self awareness and self-confidence.

D. Intervention
The nurse providing care for a client who abuses alcohol and other drugs
will consider a plan of care that meets the client’s needs in relation to an
identified stage in the recovery process. The plan includes helping the
client with withdrawal symptoms/ complications of substance abuse,
providing nutritional support as needed, helping the client resolve anger/
potential violence towards self and others (Fortinash, 2007).
Substance abusers often come into contact with the health care system
because of a physiological crisis. It may be related to overdose, withdrawal,
allergy, or toxicity. Physical deterioration caused by the damaging effects of
drugs maybe noted, including conditions such as malnutrition; dehydration;
and various infections. When an acute physical condition is present, it takes
priority over the other health needs of the patient. It is particularly important
to attend the condition that the patient has identified as the problem. The
nurse is then seen as potentially helpful and will have more credibility when
other aspects of the addiction are addressed. Interventions include:

a.) Intervening in withdrawal

b.) Intervening to maintain abstinence
c.) Psychological and social interventions
d.) Preventive interventions
E. Evaluation
The evaluation of substance abuse treatment is based on the
accomplishment of the expected outcomes and short-term goals. The nurse
and patient together should evaluate progress towards these goals on a
regular basis. If progress is not being made, together they should
reevaluate both the goal of the progress to see where the problem lies and
what needs to be done about it. Relapse does not mean failure. Progress
toward a lifelong goal of abstinence from substances of abuse can be
measured in many ways.

The patient who returns to treatment after relapse should be

commended for previous success and for the decision to keep trying. Then
the nurse and patient together can analyze what worked and what did not
work in the patient’s attempts to maintain sobriety. It is also recommended
that several measures of success toward abstinence goals be used, not just
patient self-report. Success toward goals in other areas of living such as
obtaining or keeping a job, improvements in health, and improvements in 5 mins. “Cabbage game”
family relationships are interrelated with abstinence goals and important in
the total recovery process. Mechanics:
Facilitators
F. Open forum provide a
cabbage of
questions made of
paper. The
players would be
passing it while
music is played.
When the music
stops, the person
who is currently
holding the
cabbage
questions will be
the one to
answer.
References:
Stuart, G.W. and Laraia, M. T. (1998). Principles and Practices of Psychiatric Nursing. 7th Ed. Mosby Yearbook Inc. pp. 488-490: USA.
Videbeck, S. (2006). Psychiatric-Mental Health Nursing. 3rd ed. Philadelphia: Lippincott Williams & Wilkins pp. 378-379.
Mohr, Wanda (2006). Psychiatric-Mental Health Nursing. 6th ed. Philadelphia. Lippincott Williams & Wilkins pp.695-699.
Fortinash, K. & Worret P. (2007). Psychiatric Nursing Care Plans. 5th ed.
Keltner, N., Schwecke L., Bostrom, C. (1999) Psychiatric Nursing. 5th ed. St. Louis, MO.
Fortinash, K. & Worret P. (2004). Psychiatric Nursing Care Plans. 2nd ed.
Carson, Verna. (2000). Mental Health Nursing: The Nurse Patient Journey. Philadelphia. W.B. Saunders Co., pp.733-740.