ERA COLLEGE OF NURSING, LUCKNOW

ADVANCED NURSING PRACTICE

CASE STUDY ON
“SUBSTANCE ABUSE DISORDER”

SUBMITTED TO: SUBMITTED BY:

MISS. GODHULI GHOSH DEEPIKA SONI
ASST. PROFESSOR M.Sc. NSG. 1ST YEAR
DEPT.- MED. SURG. NSG. DEPT.- MENTAL HEALTH
NSG.
ERA COLLEGE OF NSG. ERA COLLEGE OF NSG
SARFARAZGANJ, LKO. SARFARAZGANJ, LKO.
PIN. 226003 PIN. 226003

DATE OF SUBMISSION: 23-AUG-2021

 HISTORY FORMAT IN PSYCHIATRIC NURSING

I. IDENTIFICATION DATA
Name: Nikhil Kumar
Age: 28 years
Sex: Male
Father: Subhas Chandra Jha
Address: Chinahat, Lucknow
Education: Intermediate
Occupation: works in a private company
Income: 10000 Rs/month
Marital Status: Married
Religion: Hindu
Date of Admission: 09/ 07/2021
Informant: Wife
Information: Adequate
Diagnosis: Substance abuse disorder

II. PRESENTING CHIEF COMPLAINT

In patient own words:
Ye Brown sugar, khaini, gutka, alcohol, whitner sb cheez ka nasah krte the

In Informants’ words:
Saans lene me dikkat ho rahi hai, ankho se paani aa raha hai, naak se paani nikal raha hai.
Nasha chhodne pr aisa baar baar hota hai
Increased urination
Lacrimation
Stuffy nose
Body pain
Restlessness

III. HISTORY OF PRESENT ILLNESS

Duration: Started from age 14

Mode of Onset: Acute
Course: continuous
Intensity: Increased one after one
Precipitating Factors: Substance withdrawal (opioids, brown sugar)

Description of present illness:

 Patient was fine before 12 years (age 16years). After that he tried tobacco, smoke on and off when he
was in school. After his mother’s death he started to consume khaini regularly and alcohol
occasionally but later he started it early in the morning. Then started to consume tadi along with
friends. Initially he used to consume 1 bottle of alcohol with friends but later he started to consume 1
bottle all by himself. Then he started to consume inhalants (whitener solution) regularly for 4
months. Then he started to have marijuana with brown sugar and 2 balls of bhang every night before
sleeping.
Since last 2 days, patient has been experiencing intense body pain, lacrimation, rhinorrhoea due to
inability to get brown sugar. He tried for abstinence but was not successful.
Patient had gone jail around 7 times from 2019-2021 for drink and driving case, also for carrying
substance (Brown sugar).

CURRENT USUAL DOSE MAXIMUM DOSE LAST DOSE

PATTERN
Chewable tobacco 2-3 pouch/day 4 pouch/day Around 2-3 days
(Khaini) before admission
Alcohol 1 bottle shared with 4- 1 full litre bottle 1 year back
(Wine/Bear/Tadi) 5 friends
Brown Sugar Pinch of brown sugar Pinch mixed with 10-15 days back
ganga
Inhalants 1 bottle/ day 2 bottle/ day Around 2016
(Whitener/Eraser
Solution)
Ganja, Bhaang Ganja mixed with Bhaang 2 small balls around last week
(Cannabis) brown sugar every night

ABSTINENCE ATTEMPTS

1. 3-4 MONTHS IN 2009

Reason- Due to family care, could not continue due to withdrawal symptoms like vomiting,
lacrimation, sweating.

2. 2020- tried to leave brown sugar for 6-7 because of same reason but could not continue.

TREATMENT HISTORY
ECT: Absent
Psychotherapy: Absent
Family Therapy: Absent
Rehabilitation: Absent
Patient had Disulphiram therapy before the admission as per his wife by the help of local physician

IV. PAST PSYCHIATRIC AND MENTAL HISTORY: Nothing significant

Details of any precipitating factor: Substance withdrawal (opioids, brown sugar)

MEDICAL HISTORY
History of Cholelithiasis

V. FAMILY HISTORY
S.no Name Age Gender Education Occupation Relation Health
 with history
patient
1. Subhash 40 yrs Male 12 std Business Father Healthy
Chandra
Jha
2. Amravati 30 yrs Female illiterate Housewife Mother Dead
devi (Cardiac
arrest)
3. Nikhil 28 yrs Male B.A Business Patient Unhealthy
Kumar
4. Pooja 26 yrs Female 12 std Housewife Wife Healthy
6. Mehak 05 yrs Female 8 std Student Daughter Healthy

Note: Patient’s father is Chronic substance user, multiple substance consumption

VI. FAMILY TREE

Family key:
Male
Female
Female patient
Dead Female

VII. PERSONAL HISTORY

1. Perinatal History
Antenatal period: No any complication
Intra-natal period: Hospital delivery, NVD
Birth: Term
Birth Cry: Immediate
Birth defect: Absent
2. Childhood History
Primary caregiver: Mother (Step mother after her death)
Feeding: Breastfeeding
Age at weaning: at 6 months
Developmental milestones: Normal
Behaviour and emotional problems: Absent
Illness during childhood: Absent

3. Education History
Age beginning of formal education: At 5 years
Academic performance: He was average in his studies
Extracurricular achievement: do not participate in curriculum activities
Relationships with peers and teachers: Respectful and cooperative
School phobia: Absent
Conduct Disorder: Absent

4. Play History
Game played: Roaming around with friends
Relationship with playmates: have few mates

5. Emotional problems during Adolescence: Absent

6. Puberty
Age at appearance of secondary sexual characteristic: 12
Anxiety related to puberty changes: Absent

7. Sexual and Marital History

Type of marriage: Love marriage
Duration of marriage: 7 years
Interpersonal and sexual relation: denies any history of sexual intercourse
8. Occupational History:
Patient use to work with his uncle in his business but was not taking proper responsibility and
then he went to Mumbai at age of 17 yrs and work in paint company.
9. Premorbid Personality
Interpersonal relationships: Patient had no good relationship with his step mother and father,
however he was close to his uncle.
Family and social relationships: separated multiple times
Use of leisure time: help with uncle and stay with friends
Predominant mood: Energetic and cheerful
Usual reaction to stressful event: takes drugs to relieve anxiety.
Attitude to self and other: Insecure
Attitude to work and responsibility: Do not take proper responsibility
Religious beliefs and moral attitudes: Believe in God
Eating pattern: Normal at regular time
Elimination: Proper elimination of stool and urine
Sleep: Around 6-7 hours a day
Use of drugs, tobacco, alcohol: use all kind of drugs, alcohol, smoke, marijuana etc
 MENTAL STATUS EXAMINATION

A. GENERAL APPEARANCE AND BEHAVIOUR

Appearance: looking one’s age
Facial expression: Anxious
Level of grooming: Normal
Level of cleanliness: Adequate
Level of Consciousness: Conscious
Mode of entry: Willingly
Behavior: Normal (aggressive at the time of withdrawal symptom)
Co-cooperativeness: Normal
Eye-to-eye contact: Maintained
Psychomotor activity: Normal (Increase when withdrawal symptoms occur)
Rapport: spontaneous
Gesturing: Normal
Posturing: Normal posture
Other movements: mild tremors were present at the time of admission
Other catatonic phenomena: Absent
Conversion and dissociative sign: Absent
Hallucinatory behavior: Absent
B. SPEECH
Initiation: Speak when spoken too
Reaction time: Normal
Rate: Normal
Productivity: Elaborated replies
Volume: Normal
Tone: Normal variation
Relevance: Relevant
Stream: Normal
Coherence: Coherence
Sample:
Subjective data: Aap kis kis cheez ka nasha krte the?
Objective data: Madam sb galat kaam kiya h, bhaang, charas, whitner, alcohol, tobacco, cigratte sb.
 C. MOOD AND AFFECT
Subjective data:
Question: Aaj man kaisa hai apka?
Answer: Theek hai, koi dikkat nhi h.
Objective data: Patient seems to be in guilt and respond to all questions properly.
Predominant mood state: Patient is anxious and have feeling of guilt
D. THOUGHT
Stream: Normal
Form: Normal and understandable
Delusion: Absent
Ideas: worthlessness, Helpless and Guilt
Thought alienation phenomena: absent
Obsessional /compulsive phenomena: Absent
Phobias: Absent
Any preoccupation: preoccupied with thought of guilt
E. PERCEPTION
Illusions: Absent
Hallucinations: Absent
Somatic passivity: Absent
Deja vu / jamais vu: Absent
Depersonalization / derealization: Absent

F. COGNITIVE FUNCTION (NEUROPSYCHIATRIC ASSESSMENT)

1. Consciousness: Conscious
2. Orientation
a. Time:
Subjective data: abhi kya time hua hai, din hai ya raat?
Objective data: Subah hai
b. Place:
Subjective data: Abhi aap kahan ho?
Objective data: ERA Hospital me
c. Person:
Subjective data: Ye aapke sath me kon hai?
Objective data: Meri wife hai
Inference: Patient is oriented to time, place and person.
3. Attention
Digit forward: patient was able to repeat and count digits in forward direction
Digit backward: patient was able to repeat and count digits in backward direction but attention gets
interrupted in between
Inference: Patient attention is normally aroused
4. Concentration
Patient was able to perform subtraction exercise of 20-1 and 100-7 till 5 steps.
Patient was also able to call names of months in year and days in weeks in backwards direction.
Inference: Patient’s concentration is normally sustained
5. Memory
a. Subjective data: Abhi aapse kis cheez ka color pucha tha?
Objective data: Blanket ke
b. Subjective data: aaj subah aapne naste me kya khaya tha?
Objective data: dalia, dhoodh
c. Subjective data: Hawa, paani aur pankha….inhe aap thodi der baad mujhe bol kr baiyega
Objective data: Hawa, paani, pankha (he recalled these names after 3 mins)
Inference: His immediate memory is intact
6. Remote
Personal event:
Subjective data: Aapki ki shaadi kb hui thi?
Objective data: 2014
Impersonal events:
Subjective data: Aapki ki mata ji ki death kab hui thi?
Objective data: 2009
Illness- related events:
Subjective data: Aap yaha kis wajah se admitted hue hai?
Objective data: Hum nasha jayada krne lage the, har tarah ka, isliye admit hona pada
Inference: Patients remote memory is intact.
7. Intelligence
Subjective data: India kb azad hua tha?
Objective data: 1947.
Subjective data: 175+25=?
Objective data: 200
Inference: Patient intelligence is adequate at present
8. Abstraction
Subjective Data: Ankho ka tara hona; is muhavre ka kya mtlb hai?
Objective data: Jo bahut pyara ho
Subjective data: Bird or aeroplane me kay difference or similarity hai?
Objective data: Chidiya me jaan hoti hai or plane me jaan nhi hoti vo machine hai, pr dono asmaan me udte
hai.
Inference: Patient has normal abstract ability.
9. Judgement
Personal:
Subjective data: Aap yahan se theek hokr jb ghr jayenge to kya karenge?
Objective data: Theek ho jayenge to kaam dhoondhenge
Social:
Question: Aap samaaj ke liye kuch karna chahte h?
Answer: han chaahte hai ke koi bhi nasha na kare.
Social: patient’s social judgment is intact.
Test
Question: Agar aapke samne kisi ka bike se accident hua h, jo bike chlaa raha tha use gehri chot lagi hai or
aap samne hai, tb aap kya krenge?
Answer: Madat krenge or hospital le jayenge kisi ki help lekar
Inference: Patients test judgment is intact

G. INSIGHT
5. Intellectual insight

PHYSICAL EXAMINATION
Past medical History:
Patient had history of Cholelithiasis
Past surgical History:
History of Cholecystectomy (performed two moths back at KGMU, Lucknow)
General Examination
Body Type- Endomorphic
Posture- Bend
Gait- Can barely walk
Activity- Retarded due to withdrawal symptoms
Vital Signs
Temperature- 98 ̊F
Pulse- 102 bt/min
Respiration- 20 br/min
Blood Pressure- 120/74 mmHg
Height- 159 cm
Weight- 46 kg
Integumentary-
Dry skin integrity
Hair and Scalp-
Patient hair color is black with equal distribution, no any abnormality is found.
Head and Neck-
Normal
Eye-
Watery eyes due to excessive lacrimation as result of withdrawal symptoms
Ear-
Normal hearing acuity
Nose-
Stuffy nose
Mouth-
Patient tongue remains white coated due to improper cleaning, no other abnormality is found.
Heart-
Tachycardia
Respiratory-
Patient have decreased respiratory rate.
Abdomen-
Mild abdomen pain was present due to cholecystectomy, vomiting was present
Musculoskeletal-
Tremors was present, making difficult to walk properly, body pain
 INVESTIGATION DONE

1. Complete hemogram-

S. No Investigation Name Patient value Reference Value

1. Hemoglobin 11.0 12-15g/dl
2. WBC 18 4-10 Thousand/MicroLtr
3. Platelet Count 148 15-450 Thousand/MicroLtr
4. RBC count 4.90 3.8-4.8 Million/MicroL
5. PCV 39.0 36.0-46.0 %
6. MCV 84 83-101fL
7. MCH 26 27-32pg
8. MCHC 32.0 31.5-34.5g/dl
9. RDW CV 14 11.6-14%
10. Neutrophils 79.5 40-80%
11. Lymphocytes 17 20-40%
12. Monocytes 4 2-10%
13. Eosinophils 8 1-6%
14. Basophils 0 0-1%
15. Mean Platelets Volume 13 9.4- 12.3 fL
16. Platelet Distribution Width 22 10.0-17.9%

LIVER FUNCTION TEST

1. Total Bilirubin 1.45 0.3-1.2 mg/dl
2. Direct Bilirubin 0.49 <0.3 mg/d
3. Indirect Bilirubin 1.5 <1 mg/dl
4. ALT/SGPT 36 10-28 U/L
5. AST/SGOT 23 <31 U/L
6. ALP 98 30-90 U/L
7. Total Protein 6.68 6.4-8.3 g/dl
8. Albumin 3.86 3.4-4.8 g/dl
9. Globulin 2.82 2-3.5 g/dl
10. A/G Ration 1.37 1.5-2.5 g/dl
11. FT3 3.65 3.5-6.5 pmol/L
12. FT4 13 11.5-22.7 pmol/L
13. TSH 1.6 0.35-5.5 IU/ml
KIDNEY FUNCTION TEST
1. Serum Urea 20 13-43 mg/dl
2. Creatinine 1.2 0.7-1.3 mg/dl
3. Uric Acid 4.95 3.5-7.2 mg/dl
4. Serum Calcium 8.7 8.6-10mg/dl
5. Phosphorus 3.0 2.7-4.5 mg/dl
6. Sodium 136 135-145meq/l
7. Potassium 4.0 3.5-5 meq/l
8. Chloride 99 98-107 meq/l
 TREATMENT
S.no. DRUG NAME DOSE FREQUENCY
1. Tab. Buperinorphine + Tab Nalaxone 2+ 0.5 mg Stat
Give another dose if
symptoms persist
2. Tab. Trazodone 25 mg HS
3. Tab. Clonazepam 0.5 mg HS
4. Tab. Ketan 10 c 10 mg TDS
5. Tab. Clonidine 0.1 mg BD
On 01/03/2021
6. Tab. Clonidine 0.1 mg BD

Patient’s wife gave him Bhang on 02/07/2021

Drugs were slightly changed on 11/07/2021
S.no. DRUG NAME DOSE FREQUENCY
1. Tab. Buprenorphine + Tab Naloxone 2+ 0.5 mg BD
2. Tab. Trazodone 100 mg HS
3. Tab. Clonazepam 0.5 mg HS
4. Tab. Clonidine 0.5 mg BD
5. Tab. Ketorolac 10 mg TDS
6. Tab. Mirtazapine 15 mg HS
7. Tab. Zolcam 10 mg HS
Tab. Zolcam was stopped
8. Tab. Chlorpromazine 50 mg HS

BOOK PICTURE OF DISEASE CONDITION

ADDICTION:
A primary chronic disease of brain reward, motivation, memory and related circuitry where a dysfunction un
these circuits is connected to an individual pathophysiologic ally pursuing reward and or relief by substance
use and other behavior.
 - American Society of Addiction Medicine
SUBSTANCE ADDICTION:
The Diagnostic and Statistical Manual Of Mental Disorders, Fifth Edition (DSM-5) (American Psychiatric
Association, lists diagnostic criteria for addition to specific substances, including alcohol, Cannabis,
Hallucinogens, Inhalants, Opioids, Sedative – Hypnotics stimulants and tobacco.
Individuals are considered to have substance use disorder when use interferes with ability fulfill role
obligation at work, school or home.
Individual would like to control use of the substance, but attempts to do so fail and use continues to increase.
INTOXICATION
A physical and mental state of exhilaration and emotional frenzy or lethargy and stupor.
SUBSTANCE INTOXICATION
Substance Intoxication is defined as the development of a reversible syndrome of symptoms following
excessive use of a substance.
WITHDRAWAL
The physiological and mental readjustment that accompanies the discontinuation of an addictive substance.
SUBSTANCE WITHDRAWAL
Substance withdrawal occurs upon abrupt reduction or discontinuation of a substance that has been used
regularly over a prolonged period of time.

CLASSES OF PSYCHOACTIVE SUBSTANCE

1. Alcohol
2. Caffeine
3. Cannabis
4. Hallucinogens
5. Inhalants
6. Opioids
7. Sedative, hypnotics anxiolytics
8. Stimulants
9. Tobacco
ICD CLASSIFICATION
F10-F19 Mental and behavior disorders due to psychoactive substance use
F10- Mental and behavioral disorders due to use of alcohol
F11- Mental and behavioral disorders due to use of opioids
F12- Mental and behavioral disorders due to use of cannabinoids
F13- Mental and behavioral disorders due to use of sedative and hypnotics
F14 Mental and behavioral disorders due to use of Cocaine
F15- Mental and behavioral disorders due to use of hallucinogens.
CRITERIA
 Substance use disorders span a wide variety of problems arising from substance use, and cover 11
different criteria. The 11 DSM-5 criteria for a substance use disorder include:
1. Took more extensive amounts/extended time. Using the substance in larger amounts or for longer
than it’s meant to be.
2. Repeated efforts to control use or quit. Wanting to cut down or stop using the substance but not
succeeding.
3. Full time spent using. Consuming a lot of time getting, using, or recovering from use of the
substance.
4. Craving. Desires and urges to use the substance.
5. Disregarded major roles. Not accomplishing what is need to be done at work, home, or school
because of substance use.
6. Social or interpersonal dilemmas. Resuming to use even when it causes problems in relationships.
7. Missed activities. Giving up significant social, occupational, or recreational activities because of
substance use.
8. Hazardous use. Using substances again and again even when it places the person in danger.
9. Physical or psychological problems. Extending the use even if physical or psychological problems
arise.
10. Tolerance. Requiring more of the substance to get the effect the person desires.
11. Withdrawal. Development of withdrawal symptoms, which can be alleviated by taking more of the
substance.
In order to be diagnosed with a substance use disorder, the person must meet two or more of these criteria
within a 12-month period. A person with a mild substance use disorder possesses two or three of the criteria.
Four to five is considered moderate, and if the person has six or more criteria, he or she has a severe
substance use disorder.

THE DYNAMIC OF SUBSTANCE RELATED DISODER

ALCOHOL USE DISORDER

Alcohol is a natural substance formed by the reaction of fermenting sugar with yeast spores, cientifically
known as Ethyl Alcohol and chemically known as C2H5OH.
Alcohol is a clear coloured liquid with a strong burning taste. The rate of absorption of alcohol into the
bloodstream is more rapid than its elimination. Absorption of Alcohol into the bloodstream is slower when
food is present in the stomach A small amount is excreted through urine and a small amount is exhaled.

80-100 mg of alcohol per 100 mL of blood is considered Intoxication

200-250 mg per 100mLwill be toxic, sleepy and confused.
300/100 mL will cause loss of consciousness.
500 mg/100mL is fatal
Jellinek (1952) outlined four phases through which the alcoholic's pattern of drinking progresses. Some
variability among individuals is to be expected within this model of progression.
PHASE I. THE PRE-ALCOHOLIC PHASE
This phase is characterized by the use of alcohol to relieve the everyday stress and tensions of life. As a
child, the individual may have observed parents or other adults drinking alcohol and enjoying the effects.
The child learns that use of alcohol is an acceptable method of coping with stress. Tolerance develops, and
the amount required to achieve the desired effect steadily increases.

PHASE II. THE EARLY ALCOHOLIC PHASE

This phase begins with blackouts-brief periods of amnesia that occur during or immediately following a
period of drinking. Now the alcohol is no longer a source of pleasure or relief for the individual but rather a
drug that is required by the individual. Com mon behaviors include sneaking drinks or secret drinking,
preoccupation with drinking and maintaining the supply of alcohol, rapid gulping of drinks, and further
blackouts. The individual feels enormous guilt and becomes very defensive about his or her drinking.
Excessive use of denial and rationalization is evident.

PHASE III. THE CRUCIAL PHASE

In this phase, the individual has lost control of his or her use, and physiological addiction is clearly evident.
This loss of control has been described as the inability to choose whether or not to drink. Binge drinking,
lasting from a few hours to several weeks, is common. These episodes are characterized by sickness, loss of
consciousness, squalor, and degradation. In this phase, the individual is extremely ill. Anger and aggression
are common manifestations. Drinking is the total focus, and he or she is willing to risk losing everything that
was once important in an effort to maintain the addiction. By this phase of the illness, it is not uncommon
for the individual to have experienced the loss of job, marriage, family, friends, and most especially, self-
respect.

PHASE IV. THE CHRONIC PHASE

This phase is characterized by emotional and physical disintegration. The individual is usually intoxicated
more often than he or she is sober. Emotional disintegration is evidenced by profound helplessness and self-
pity. Impairment in reality testing may result in psychosis. Life-threatening physical manifestations may be
evident in virtually every system of the body. Unmanaged withdrawal from alcohol results in a terrifying
syndrome of symptoms that include hallucinations, tremors, convulsions, severe agitation and panic.
Depression and suicidal ideation are not uncommon. For long-term heavy drinkers, abrupt withdrawal of
alcohol can be fatal.

SEDATIVE, HYPNOTICS, ANXIOLYTIC INTOXICATION

They are compound of drugs of diverse chemical structures that are capable of inducing varying degrees of
CNS depression, from tranquilizing relief of anxiety to anesthesia, coma and even death.
Continuum of CNS depression with increasing doses of sedative, hypnotic or anxiolytic.

RELIEF FROM
NORMAL DISINHIBITION SEDATION
ANXIETY
 INCREASING DOSAGE OF DRUG

HYPNOSIS
GENERAL
(SLEEP)
DEATH COMA ANETHESIA

STIMULANTS USE DISORDER

CNS stimulants are identified by the behavioral stimulation and psychomotor agitation they induce. They
differ widely in molecular structures and mechanisms of action.
The amount of CNS stimulation caused by a certain drug depends on both the areas in the brain or spinal
cord that is affected by the drug and the cellular mechanism fundamental to the increase excitability.
INHALANTS USE DISORDER
It is induced by inhaling the aliphatic and aromatic hydrocarbons found in substances such as fuel, solvents,
adhesive, aerosol propellants and paint thinners.
Other examples include Gasoline, varnish remover, lighter fluid, airplane glue, rubber cement, cleaning
fluid, spray paint, shoe conditioner and typewriter correction fluid.
Toluene is a common ingredient in many inhaled substances.

OPIOID USE DISORDER

A group of compounds that include opium, opium derivatives and synthetic substitute.
It exerts both a sedative and an analgesic effect and their major medical uses are pain relief, treatment of
diarrhea and relief coughing.
HALLUCINOGEN USE DISORDER
Substance that can distort an individual ‘s perception of reality, alter sensory perception and induce
hallucinations. They sometimes referred as Min- expanding drug.

CANNABIS
It is derived from Hemp plant, Cannabis sativa. The dried leaves and flowering top are often referred to as
ganja or marijuana.
The resin of the plant is referred to as hashish. Bhang is a drink made from cannabis. Cannabis is either
smoked or taken in liquid from.
 ETIOLOGY

BOOK PICTURE PATIENT PICTURE

1. BIOLOGICAL FACTOR
GENETIC
 Children of alcoholics are four times more Patient’s Father was severe alcoholic
likely than other children to become
alcoholics.
 Twin studies have demonstrated that -
monozygotic twins have a higher rate for
concordance of alcoholism than dizygotic
 Biological offspring of alcoholic parents
have a significantly greater incidence of -
alcoholism than offspring of non-alcoholic
parents whether the child was reared by the
biological parents or by non-alcoholic
adoptive parents
 Genetics account for 40-60 % of a person’s
vulnerability -

BIOCHEMISTRY
 Change in brain structure and brain -
neurochemistry
 Neurotransmitter like opioid, catecholamine -
and Gamma- aminobutyric acid
 Brain Reward circuitry. -

2. PSYCHOLOGICAL FACTORS -
DEVELOPMENTAL INFUENCE
A punitive superego and fixation at the oral stage of
psychosexual development.
PERSONALITY FACTORS -
Low self-esteem, frequent depression, passivity,
antisocial personality traits, inability to relax or to
gratification and the ability to communicate
effectively are in common in individuals who abuse
substances.
COGNITIVE FACTORS
Irrational thinking pattern Present Patient use to stay with his friends and
Addictive thinking drink alcohol as a pleasure-seeking substance
Pleasure seeking

3. SOCIOCULTURAL FACTORS Patient use to see his father drinking alcohol

SOCIAL LEARNING
Modelling, Imitation and Identification on
behaviour can be observed from early childhood
onward
CONTIONING
A learned response that occurs after repeated Present
exposure to a stimulus.
CULTUTAL AND ETHINIC INFLUENCE
Factors within an individual’s culture help establish -
pattern of substance use by molding attitudes,
influencing patterns of consumption based on
cultural acceptance and determining the availability
of the substance.
OCCUPATION
like chef, barmen, salesman ect.y Patient use to do business of selling Alcohol in Less
rate
4. COMORBID MEDICAL DISORDER -
In chronic pain

WITHDRAWAL SYMPTOMS
BOOKS PICTURE PATIENT PICTURE
ALCOHOL
(Begins within 4-6 hrs after last drink)
1. Coarse tremors of hands, tongue, eyelids Present
2. Nausea or Vomiting Present
3. Malaise or Weakness Present
4. Tachycardia Present
5. Sweating Present
6. Transitional Hallucination/ illusion Absent
7. Elevate Blood Pressure Absent
8. Anxiety Present
9. Decreased Mood or Irritability Present
10. Headache Insomnia Absent
11. Alcohol delirium syndrome Absent
SEDATIVES/ HYPNOTICS/ ANXIOLYTICS
Short acting Sedative hypnotics (Alprazolam,
lorazepam)- starts from 12 -24 hrs after last dose,
peak between 24-72 hours, subside in 5 to 10 days
1. Sweating Present
 2. Pulse rate more than 100 bts/min Present
3. Increased hand tremors Present
4. Insomnia Present
5. Nausea/ Vomiting Present
6. Hallucination/ illusion
7. Psychomotor agitation Present
8. Anxiety Present
9. Grandmal seizure
STIMULANTS (Nicotine)
Symptoms begins within 24 hours after last
consumption and may include:
1. Depressed mood Present
2. Insomnia Present
3. Irritability Present
4. Frustration Present
5. Anger/ anxiety Present
6. Difficulty concentrating Present
7. Restlessness Present
8. Decrease heart rate
9. Increased appetite or weight gain

INHALANTS
Intoxication occurs within 5 minutes of inhalation.
Symptoms last 60-90 minutes.
1. Body pain. Present
2. Cravings. Present
3. Depression. Present
4. Hallucinations. Present
5. Headaches. Present
6. Insomnia.
7. Nervousness.
8. Panic attacks.
9. Psychosis. Present
10. Sweating. Present
11. Tremors.

OPIOID
Withdrawal symptoms appears within 6-8 hours
after last dose, reach a peak in second or third day
and subside in 5-10 days
1. Dysphoric mood
2. Nausea or vomiting Present
3. Muscle aches Present
4. Lacrimation Present
5. Rhinorrhoea Present
6. Pupillary dilation
7. Piloerection
8. Sweating Present
9. Diarrhoea Present
10. Yawning
11. Fever Present
12. Insomnia Present

CANNABIS
Intoxication occurs immediately and lasts about 3
hours
1. Irritability, anger or aggression Present
2. Nervousness, restlessness or anxiety Present
3. Sleep difficulty Present
4. Decreased appetite or weight loss Present
5. Depressed mood Present
6. Physical symptoms such as abdominal pain, Present
tremors, sweating, fever, chills or headache

INVESTIGATION
BOOK PICTURE PATIENT PICTURE
History collection Done
Physical Examination Done
Mental Status Examination Done
Blood Investigations (Vitamin deficiency, Uraemia, Done
Thyrotoxicosis, Electrolyte imbalance,
agranulocytosis)

TREATMENT
BOOK PICTURE PATIENT PICTURE
ALCOHOL -
1. Benzodiazepines
2. Chlordiazepoxide
3. Oxazepam
4. Lorazepam
5. Diazepam
ANTICONVULSANT MEDICATION
1. Carbamazepine
2. Valproic Acid
3. Gabapentin
MULTIVITAMIN THERAPY
Oral administration of Thiamine

OPIODS
1. Naloxone
2. Naltrexone
3. Nalmefene
Withdrawal Therapy
1. Methadone Tab Buprenorphine + Naloxone (2+0.5mg) BD
2. Buprenorphine + Naloxone combination Tab. Clonidine (0.5 mg) HS
3. Clonidine
DEPRESSANT -
Benzodiazepine
STIMULANTS -
Minor tranquilizers such as Chlordiazepoxide
HALLUCINOGENS -
Benzodiazepines (Diazepam or Chlordiazepoxide)

PSYCHOTHERAPY
BOOK PICTURE PATIENT PICTURE
Combined Behavioural Intervention Patient had given a paper to write about his past
history of drinking experience`
Family Intervention Involve family members, enhance communication
between them, conflict resolution skills with in the
family.
Motivational Interviewing -
Group Therapy Involve patient with other patients to observe their
own problems mirrored in others and to work out
better ways of coping with them
Aversion Therapy -
Relapse Prevention Technique Educated patient to identify high risk relapse factor
and develop strategies to deal with them.
Que Exposure Technique -

NURSING MANAGEMENT
Assessment of a client with substance abuse disorder include:
 History Client with a parent or other family members with substance abuse problems may report a
chaotic family life, although this is not always the case.
 Thought process and content During the assessment of thought process and content, clients are
likely to minimize their substance abuse, blame others for their problems, and rationalize their
behaviour.
 Sensorium and intellectual process Clients generally are oriented and alert unless they are
experiencing lingering effects of withdrawal.
 General appearance and motor behaviour Assessment of general appearance and behaviour
usually reveals appearance and speech to be normal.
 Self-concept Clients generally have low self-esteem, which they may express directly or cover with
grandiose behaviour.

NURSING DIAGNOSIS
1. Ineffective individual coping related to personal vulnerability as evidenced by his verbalization of
asking for help
2. Low self-esteem related to social stigma as evidenced by patient’s expression of guilt and shame
3. Nutritional imbalance related to insufficient dietary intake as evidence by various physical
symptoms.
4. Risk of Injury related to physical agitation as evidence by marks of self-harms in forearm
5. Altered family process related to addictive personality as evidence by emotional isolation and
disturbed close communication with family

NURSING CARE PLAN

HEALTH EDUCATION
GENERAL NURSING INTERVEN TIONS FOR A PATIENT WITH ACUTE DRUG INTOXICATION
 Care for a substance-abuse patient starts with an assessment to determine which substance he is
abusing. Signs and symptoms vary with the substance and dosage
 During the acute phase of drug intoxication and detoxification, care focuses on main training the
patient's vital functions, ensuring his safety, and easing discomfort
 During rehabilitation, caregivers help the patient acknowledge his substance abuse problem and find
alternative ways to cope with stress. Healthcare professionals can play an importance role in helping
patients achieve recovery and stay drug-free
 These general nursing interventions are appropriate for patients during and after acute intoxication
with most types of psychoactive drugs.
DURING AN ACUTE EPISODE
 Continuously monitor the patient's vital signs and urine output; watch for complications of overdose
and withdrawal, such as cardiopulmonary arrest, seizures, and aspiration
 Maintain a quiet, safe environment
 Take appropriate measures to prevent suicide attempts and assaults, according Pl to facility policy;
remove harmful objects from the room, and use restraints only if you suspect the patient might harm
himself or others.
 Approach the patient in a non-threatening way; limit sustained eye contact, which he may perceive as
threatening.
 Institute seizure precautions
 Administer IV fluids to increase circulatory volume
 Give medications as ordered; monitor and record their effectiveness

DURING DRUG WITHDRAWAL

Administer medications, as ordered, to decrease withdrawal symptoms; monitor and record their
effectiveness
Maintain a quiet, safe environment because excessive noise may agitate the patient

WHEN THE ACUTE EPISODE HAS RESOLVED

 Carefully monitor and promote adequate nutrition
  Administer drugs carefully to prevent hoarding; check the patient's mouth to ensure that he has
swallowed oral medication, and closely monitor visitors who might supply him with drugs.
 Refer the patient for rehabilitation as appropriate; give him a list of available resources
 Encourage family members to seek help regardless of whether the abuser seeks it; suggest private
therapy or community mental health clinics
 Use the episode to develop personal self-awareness and an understanding and positive attitude
toward the patient; control reactions to his undesirable behaviors; commonly, psychological
dependence, manipulation, anger, frustration, and alienation
 Set limits when dealing with demanding, manipulative behavior

PREVENTION OF SUBSTANCE USE DISORDER

PRIMARY PREVENTION
• Reduction of over prescribing by doctors (especially with benzodiazepines and other anxiolytic drugs).
• Identification and treatment of family members who may be contributing to the drug abuse.
• Introduction of social changes is likely to affect drinking patterns in the population as a whole. This is
made possible by:
- Putting up the price of alcohol and alcoholic beverages
- Controlling or abolishing the advertising of alcoholic drinks Controls on sales (by limiting hours or
banning sales in supermarkets)
- Restricting availability and lessening social deprivation (Governmental measures)
Other approaches are to strengthen the individual's personal and social skills to increase self-esteem and
resistance to peer pressure.
Health education to college students and the youth about the dangers of drug abuse through the curriculum
and mass media. Health education should also include certain specific groups where a substance like alcohol
may be culturally accepted. For instance, certain tribal communities such as the Lambani group manufacture
arrack, and its intake is considered normal.
Some communities use it in the postnatal period, as alcohol is believed to strengthen the pelvic muscles and
also speed up retroversion of the uterus. Such attitudes should be addressed and corrected. An overall
improvement in the socio-economic condition of the population.

SECONDARY PREVENTION
- Early detection and counseling.
- Brief intervention in primary care (simple advice by a general practitioner plus an educational
leaflet).
- Motivational interviewing which involves providing feedback to the patient on the personal risks that
alcohol poses, together with a number of options for change.
- A full assessment including an appraisal of current medical, psychological and social problems.
Assessment also includes ascertaining whether alcoholism is the primary or secondary problem. For
example, a patient with diabetic neuropathy may be using alcohol to numb pain. Alcohol is also used
by some to relieve asthmatic symptoms. In such instances, treatment of the medical problem can help
to control alcoholism. Detoxification with benzodiazepines (diazepam, chlordiazepoxide)
TERTIARY PREVENTION
Specific measures include:
 Alcohol deterrent therapy (Disulfiram or Antabuse).
 Other therapies include assertiveness training (to prevent yielding to peer pressure), teaching coping
skills (some take drugs to combat stress), behavior counseling, supportive psychotherapy and
individual psychotherapy.
 Agencies concerned with alcohol-related problems: Alcoholics Anonymous (AA), Al-Anon, Al-
Ateen, etc.
 Some practical issues under relapse prevention include:

- Motivation enhancement, including education about health consequences of alcohol use

- Identifying high-risk situations and developing strategies to deal with them (craving management)
- Drink refusal skills (assertiveness training)
- Dealing with faulty cognitions
- Handling negative mood states Time management
- Anger control
- Financial management
- Developing the work habit
- Stress management
- Sleep hygiene
- Recreation and spirituality
- Family counseling, to reduce interpersonal conflicts, which may otherwise trigger relapse

REHABILITATION

The aim of rehabilitation of an in-azdividual de addicted from the effects of alcohol/drugs, is to enable him
to leave the drug sub-culture and to develop new social contacts, in this, patients first engage in work and
social activities in sheltered surroundings and then take greater responsibilities for themselves in conditions
increasingly like those of everyday life. Continuing social support is usually required when the person
makes the transition to normal work and living.

FOLLOW UP AND HOME CARE

Some patients with drug problems complete treatment the first time and remain sober, while other patients
have to repeat treatment several times. Some patients do not succeed in staying sober. Nurses remain
hopeful and appropriately supportive but realistic when treating patients.

PATIENT AND FAMILY TEACHING

 Teach the patient/family about the physical, psychological and social complications of drug and
alcohol use.
 Inform the patient/family that psychoactive substances may alter a person's mood, perceptions,
consciousness or behavior.
 Explain to the family that the patient may use lies, denial or manipulation to continue drug or alcohol
use and to avoid treatment.
  Teach the patient/family that drug overdose or withdrawal can result in a medical emergency and
even death, give the family emergency resources for help.
 Caution the patient that sharing dirty or used needles can result in a life-threatening disease such as
AIDS, hepatitis B.
 Teach the family to establish trust with the patient and to use firm limit setting, when necessary to
help the patient confront drug abuse issues.
 Provide the patient with a full range of treatment during hospitalization such as medication,
individual therapy, group therapy, 12-step program (AA) and behavior modification to strengthen the
recovery process.
 Teach the patient/family how to recognize psychosocial stressors that may exacerbate substance
abuse problem and how to avoid or prevent them.
 Emphasize to the patient the importance of changing lifestyle, friendships, and habits that promote
drug use to remain sober.
 Teach the patient/family about the availability of local self-help programs (AA, AL Anon) to
strengthen the patient's recovery and support the family's assistance.
 May 31st of every year is observed as World No-Tobacco Day.

PROGNOSIS
Prognosis of patient is based on following factors:
My Patients Prognosis
Day 1: Patient was so anxious and feeling guilty, but ready to interact
Day 2: Patient was participating in various activity planned for him
Day 3: Patient was seeming to be restless, asking help in order to interact with his uncle
Day 4: It has been found that his wife was giving him Bhaang during the hospital stay only due to patient
demand
Day 5: Patient condition was deteriorated again, his doses of medicine was increased, patient seems to be
restless, agitated, and wants to die

SUMMARY
In this case presentation, I discussed about condition Substance Use Disorder, Patient’s history, mental
status examination, physical examination, Investigation, COW scale which I applied to my patient,
Treatment, about disease condition, its historical perspective, definition, incident, classification, type,
aetiology, clinical manifestation, Investigation, treatment of my patient in comparison to book picture,
Nursing management and nursing care plan after formulating nursing diagnosis as per priority, health
education and prognosis.

CONCLUSION
With this case study am able to find that people with substance use suffers a lot. Drug use
and addiction cause a lot of disease and disability in the world. Recent advances in neuroscience may help
improve policies to reduce the harm that the use of tobacco, alcohol, and other psychoactive drugs impose
on society. And primary prevention should be taken from childhood also, education should be provided to
adolescence regarding consumption and harmful effects of drug use.
BIBLIOGRAPHY
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2. Chambers Mary, Psychiatric Mental Health Nursing The craft of Caring, 3rd Edition, published by
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3. Stuart. W Gail, Principles and Practice of Psychiatric Nursing, 10 editions, published by Elsevier, page
no: 440-446
4. Evans Katie, Nizette Debra, Breen Anthony, Psychiatric and Mental Health Nursing, 4th Edition, Elsevier
Publisher, Page no:446- 489
5. Sreevani R, A Guide to Mental Health and Psychiatric Nursing, 4 Edition, published by Jaypee Brothers,
page no: 240-259
6. Townsend C Mary, Morgan I Karyn, Psychiatric Mental Health Nursing, Concepts of care in Evidence
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