SUBSTANCE ABUSESUBSTANCE ABUSE

Cost to Business & IndustryCost to Business & Industry 100 million annually100 million annually Alcohol= 500 million lost work daysAlcohol= 500 million lost work days 40% industrial fatalities40% industrial fatalities 47% workplace injuries47% workplace injuries 50% of motor vehicle fatalities(2005)50% of motor vehicle fatalities(2005)

Effects on societyEffects on society National health problemNational health problem More deaths,illness,accidents,disabilities than any More deaths,illness,accidents,disabilities than any

other health problemother health problem 15 million dependent on alcohol15 million dependent on alcohol 500,000 between ages 9-12500,000 between ages 9-12 7 million persons between 12-207 million persons between 12-20

binge drinkbinge drink

(Narconon,2005)(Narconon,2005)

Effects on the familyEffects on the family # of babies born with physiologic & emotional # of babies born with physiologic & emotional

consequences of crack & alcohol ---Increasing consequences of crack & alcohol ---Increasing at an alarming rate at an alarming rate

43% of US families exposed to alcoholism43% of US families exposed to alcoholism 50% persons who seek tx have at least one 50% persons who seek tx have at least one

parent w/ alcoholism hx.parent w/ alcoholism hx.

Culture and Substance abuseCulture and Substance abuse

Attitudes vary in culturesAttitudes vary in cultures Muslims – no alcohol consumptionMuslims – no alcohol consumption Jewish – use wine for religious ritesJewish – use wine for religious rites Native Americans – use payote (religious Native Americans – use payote (religious

ceremonies)ceremonies) Genetic traits found – predispose or protectGenetic traits found – predispose or protect Flushing reaction – AsiansFlushing reaction – Asians

Genetics & substance abuseGenetics & substance abuse Variations is structure & activity levels of enzymes Variations is structure & activity levels of enzymes

involved in metabolism of ETOHinvolved in metabolism of ETOH Variations among Asians, Africian Americans and Variations among Asians, Africian Americans and

whiteswhites Japanese – enzyme produces faster elimination of Japanese – enzyme produces faster elimination of

alcoholalcohol Native Americans- etoh use –one of five leading Native Americans- etoh use –one of five leading

causes of death(75% accidents)causes of death(75% accidents) Japan – ETOH consumption quadrupled since 1960Japan – ETOH consumption quadrupled since 1960

Effects of addiction Effects of addiction AbuseAbuse TolerenceTolerence Physical dependence - addictionPhysical dependence - addiction Psychologic dependence –mind-body Psychologic dependence –mind-body

connectionconnection Alcoholism – chronic progressive potentially Alcoholism – chronic progressive potentially

fatalfatal BlackoutsBlackouts

Alcohol and other drugs are Alcohol and other drugs are associated with:associated with:

Up to 50% spousal abuseUp to 50% spousal abuse 50% traffic accidents50% traffic accidents 49% murders49% murders 68% manslaughter charges68% manslaughter charges 69% drownings69% drownings 38% child abuse38% child abuse 52% rapes52% rapes 62% assaults62% assaults 20-35% suicides20-35% suicides

(Johnson-1997)(Johnson-1997)

Similarities & DifferencesSimilarities & DifferencesAlcoholAlcohol

Intended effectIntended effect

Alcohol- CNSAlcohol- CNS

Depressant/relax-Depressant/relax-

ation, loss of ation, loss of inhibitioninhibition

IntoxicationIntoxication

Slurred Slurred speech;loss of speech;loss of coordination;coordination;

ataxia; decreased ataxia; decreased coordination, coordination, attention/concen-attention/concen-tration, memorytration, memory

judgmentjudgment

W/d – detoxW/d – detox

4-12n hrs. p last 4-12n hrs. p last drinkdrink

Course handCourse hand

tremor,sweatingtremor,sweating

T, T, P,B/P, RP,B/P, R

Insomnia, anxiety, Insomnia, anxiety, N/V –N/V –

If no tx.= DT’sIf no tx.= DT’s

Sedatives /Hypnotics Sedatives /Hypnotics AnxiolyticsAnxiolytics

Induced effectInduced effect

BenzodiazapinesBenzodiazapines& Barbituates& Barbituates

Use: to produceUse: to produce

Drowsiness,Drowsiness,

anxietyanxiety

Intox-ODIntox-OD

Benzo’s rarely Benzo’s rarely fatal when taken fatal when taken alone; sx’s =alone; sx’s =

Lethergy,Lethergy,

Confusion;Confusion;

Barb’s –fatal in Barb’s –fatal in OD-coma,resp –OD-coma,resp –cardiac arrestcardiac arrest

W/d –detoxW/d –detox

Ativan-10 hrsAtivan-10 hrs

W/d sx’s-6-8 hrs W/d sx’s-6-8 hrs p last dosep last dose

Valium –w/d up Valium –w/d up to 1 wkto 1 wk

W/d=W/d= v/s v/s

Need to taper off Need to taper off drugdrug

Stimulants Stimulants amphetamines/cocaineamphetamines/cocaine

Intended effectIntended effect

Excite – CNSExcite – CNS

Limited clinical Limited clinical use – high abuse use – high abuse potential potential

Cocaine-highly Cocaine-highly addictiveaddictive

Intox- ODIntox- OD

High-euphoric High-euphoric feeling;hyper-feeling;hyper-activity/vigilanceactivity/vigilance

Talkativeness, Talkativeness, grandiosity,hallucingrandiosity,hallucinations, anxietyations, anxiety

Repetitive Repetitive behaviors, anger , behaviors, anger , fighting fighting

W/d – detoxW/d – detox

Occurs-few hrs- Occurs-few hrs- daysdays

C/b marked C/b marked dysphoria;dysphoria;

fatigue; vivid & fatigue; vivid & unpleasant unpleasant dreams; hyper or dreams; hyper or insomnia;insomnia; psychomotor act.psychomotor act.

Opioids: Opioids: morphine,morphine,heroin,meperidine,codeine,hydromorphone,heroin,meperidine,codeine,hydromorphone,

Induced effectInduced effect

Popular for Popular for abuse – abuse – desensitize user desensitize user to both to both physio/psych physio/psych pain-induce pain-induce euphoria, well-euphoria, well-being being

Intox – ODIntox – OD

Intox- develops Intox- develops quickly c/b apathy, quickly c/b apathy, lethergy,listlessness,lethergy,listlessness,judgment, psycho-judgment, psycho-motor retardation or motor retardation or agiation, constricted agiation, constricted pupils,slurred speechpupils,slurred speech

Severe o d Severe o d coma,coma,

Resp. arrest/deathResp. arrest/death

W/d detoxW/d detox

Drug intake ceases Drug intake ceases or or markedly; c/b markedly; c/b

anxiety/restless., anxiety/restless., aching back,legs,aching back,legs,

craving for opioidscraving for opioids

Heroin –w/dHeroin –w/d

6-246-24hr;hr;

peak 2-3 days;peak 2-3 days;

Ends=5-7 daysEnds=5-7 days

HallucinogensHallucinogens

Intended Intended effecteffect

Distort users Distort users perception of perception of realityreality

Intoxification/ODIntoxification/OD

Intox= (Psychologic) Intox= (Psychologic) anxiety,depression,anxiety,depression,

Paranoid delusions, Paranoid delusions, hallucinations hallucinations

(Physio) (Physio) B/P,T,P B/P,T,P

dilated pupils,sweating, dilated pupils,sweating, blurred vision,tremors,blurred vision,tremors,

decreased coordinationdecreased coordination

Withdrawal/DetoxWithdrawal/Detox

No withdrawal No withdrawal symptoms knownsymptoms known

-may crave drug-may crave drug

Produce flashbacksProduce flashbacks

May continue up to May continue up to 5 years after use.5 years after use.

PharmacologicPharmacologic treatment treatment substance abusesubstance abuse

Disulfiram(antabuse)-maintain abstinence Disulfiram(antabuse)-maintain abstinence from alcoholfrom alcohol

Teach client to read all labels – avoid any Teach client to read all labels – avoid any product containing alcoholproduct containing alcohol

Lorazepam(ativan) – for w/d fro etohLorazepam(ativan) – for w/d fro etoh

Monitor V/S/client safety/assess effectivenessMonitor V/S/client safety/assess effectiveness

Pharmacologic treatmentPharmacologic treatment Clonidine(catapres) –suppresses opiate Clonidine(catapres) –suppresses opiate

withdrawal symptoms –check B/P prior to withdrawal symptoms –check B/P prior to administration – withhold if hypotensiveadministration – withhold if hypotensive

Thiamine(vitamin B1) Folic acid (folate), B12 Thiamine(vitamin B1) Folic acid (folate), B12 = tx nutritional deficiencies – teach re: proper = tx nutritional deficiencies – teach re: proper nutrition; darkened urine may result w/folate.nutrition; darkened urine may result w/folate.

Nursing Dx.:Risk for Injury(etoh Nursing Dx.:Risk for Injury(etoh withdrawal) r/t environment & individual withdrawal) r/t environment & individual

defensesdefenses Place client close to nursing stationPlace client close to nursing station((safety a priority)safety a priority) Seizure precautionsSeizure precautions(seizures can occur during w/d-(seizures can occur during w/d-

prevents injury)prevents injury) Reorient x4 as necessary(Reorient x4 as necessary(provides reality orientation)provides reality orientation) Speak in simple direct concrete language(Speak in simple direct concrete language(clients ability clients ability

to deal with complex or abstract ideas is limited)to deal with complex or abstract ideas is limited) Reassure client that bugs,snakes etc. are not Reassure client that bugs,snakes etc. are not

real(real(provides reality orientation – decreases anxiety)provides reality orientation – decreases anxiety)

Ineffective Health maintenance r/t inability to Ineffective Health maintenance r/t inability to identify/manage/seek helpidentify/manage/seek help

Monitor health status,V/S parameters,Monitor health status,V/S parameters,& behavioral changes, administer meds per protocol & behavioral changes, administer meds per protocol

((B/P , P,presence or absence of tongue tremors-B/P , P,presence or absence of tongue tremors-determine need for medication- use predetermined determine need for medication- use predetermined parameters)parameters)

Offer fluids freq –esp.juices,malts, no caffeinated Offer fluids freq –esp.juices,malts, no caffeinated beverages(beverages(caffeine increases tremors,malts,juices caffeine increases tremors,malts,juices offer nutrients & fluids)offer nutrients & fluids)

Ineffective health maintenance(cont’d)Ineffective health maintenance(cont’d) Monitor fluid/electrolytes,IV therapy-indicated in Monitor fluid/electrolytes,IV therapy-indicated in

severe alcohol withdrawal(severe alcohol withdrawal(clients with ETOH abuse clients with ETOH abuse are high risk for fluid/lyte imbalance)are high risk for fluid/lyte imbalance)

Provide food and nourishing fluids as soon as client Provide food and nourishing fluids as soon as client can tolerate eatingcan tolerate eating(clients who abuse alcohol often (clients who abuse alcohol often have gastritis or anorexia – important to reestablish have gastritis or anorexia – important to reestablish nutritional intake)nutritional intake)

continuedcontinued Assist with physical care as necessary(client Assist with physical care as necessary(client needs needs

should be met with permitting as much independence as should be met with permitting as much independence as possible for client)possible for client)

Educate –Educate –Alcoholism is a disease that requires long Alcoholism is a disease that requires long term tx and f/uterm tx and f/u(detox. deals w physical w/d but not (detox. deals w physical w/d but not address primary disease of alcoholism)address primary disease of alcoholism)

Administer meds to minimize progression of w/d, Administer meds to minimize progression of w/d, complications, & to facilitate sleepcomplications, & to facilitate sleep(client will be (client will be fatigued,requires rest)fatigued,requires rest)

Dual diagnosisDual diagnosis 50% of persons with substance abuse also 50% of persons with substance abuse also

have mental disorder (2005)have mental disorder (2005)

Need to be treated in special units designated Need to be treated in special units designated for tx. of dual diagnosis – tx. must focus on for tx. of dual diagnosis – tx. must focus on both the mental disorder and the substance both the mental disorder and the substance abuse to be effective.abuse to be effective.

Dual Diagnosis CARE PLAN - Dual Diagnosis CARE PLAN - NoncomplianceNoncompliance

Discuss patterns of drug/alcohol use in non-Discuss patterns of drug/alcohol use in non-judgmental way(judgmental way(non-judgmental manner non-judgmental manner increases chance of obtaining data)increases chance of obtaining data)

Help client to correlate increased use of chemicals Help client to correlate increased use of chemicals with increased psychiatric symptoms(with increased psychiatric symptoms(these effects these effects may not be apparent to client)may not be apparent to client)

Educate (Educate (factual info –sound basis for problem factual info –sound basis for problem solving)solving)

Dual diagnosis – Ineffective copingDual diagnosis – Ineffective coping

Encourage open expression of feelings(Encourage open expression of feelings(initial step towards initial step towards dealing constructively with those feelings)dealing constructively with those feelings)

Validate client’s frustrations or anger re dual Validate client’s frustrations or anger re dual problem(problem(expression of feelings – may relieve stress & anxiety)expression of feelings – may relieve stress & anxiety)

Give positive feedback for abstinenceGive positive feedback for abstinence(positive feedback (positive feedback reinforces abstinence behaviors)reinforces abstinence behaviors)

Encourage client to record activities,feelings thoughts in a Encourage client to record activities,feelings thoughts in a journal(journal(provides a focus for client to yield information that is provides a focus for client to yield information that is useful in future planning)useful in future planning)

Review questionsReview questions

The nurse would recognize the following as signs The nurse would recognize the following as signs of alcohol withdrawal:of alcohol withdrawal:

A.A. coma, disorientation, hyper vigilance coma, disorientation, hyper vigilance

BB tremors, sweating,elevated b/p tremors, sweating,elevated b/p

C.C. increased temperature, lethargy,hypothermia increased temperature, lethargy,hypothermia

D.D. talkativeness, hyperactivity, blackoutstalkativeness, hyperactivity, blackouts

Which of the followingWhich of the following foods would the nurse foods would the nurse eliminate from the diet of a client with alcohol eliminate from the diet of a client with alcohol withdrawal?withdrawal?

A.A. Ice creamIce cream

B.B. MilkMilk

C.C. Orange juiceOrange juice

D.D. Regular coffeeRegular coffee

The nurse includes the following intervention in a plan of care The nurse includes the following intervention in a plan of care for a client with severe alcohol withdrawal:for a client with severe alcohol withdrawal:

A.A. Continuous use of restraintsContinuous use of restraints

B.B. Informing the client about alcohol treatment Informing the client about alcohol treatment programsprograms

C.C. Remaining with the client when he/she is Remaining with the client when he/she is confusedconfused

D.D. Touching the client before saying anythingTouching the client before saying anything

ALCOHOLISM & SUBSTANCE ABUSE ALCOHOLISM & SUBSTANCE ABUSE IN THE OLDER ADULT IN THE OLDER ADULT

Onset after 50 not uncommonOnset after 50 not uncommon

30 –60 % of elders in treatment programs 30 –60 % of elders in treatment programs began drinking abusively after age 60began drinking abusively after age 60

Risk factors – elder substance Risk factors – elder substance abuseabuse

Chronic illness-pain (long term use of Rx. narcotics Chronic illness-pain (long term use of Rx. narcotics etc.)etc.)

Life stressLife stress LossLoss Social isolationSocial isolation GriefGrief DepressionDepression Abundance of free timeAbundance of free time MoneyMoney (Atkinson, 2004)(Atkinson, 2004)

Drinking problems fall into two distinct Drinking problems fall into two distinct patterns in the older adultpatterns in the older adult

2/3rds early onset alcoholism2/3rds early onset alcoholism

1/31/3rdrd late onset alcoholism late onset alcoholism(Menniger, 2002)(Menniger, 2002)

Use screening tool AUDIT(Alcohol Use Disorder Use screening tool AUDIT(Alcohol Use Disorder Identification Test) for early identification of Identification Test) for early identification of alcoholism problem in older adults.alcoholism problem in older adults.

Psychosocial issues & physiologic changes Psychosocial issues & physiologic changes associates with substance abuse in elderlyassociates with substance abuse in elderly

Increase risk for falls/injuriesIncrease risk for falls/injuries Increase risk –suicide (especially older Increase risk –suicide (especially older

male,single,caucasian,>65 w/health problems)male,single,caucasian,>65 w/health problems) Increase vulnerability to infection( r/t Increase vulnerability to infection( r/t

decreased immune system from alcohol abuse)decreased immune system from alcohol abuse)

Age related problems include:Age related problems include: Difficulty seeking helpDifficulty seeking help Exacerbation of Cardiovascular and GI Exacerbation of Cardiovascular and GI

problemsproblems Increased risk for withdrawal & S/E’s of Increased risk for withdrawal & S/E’s of

ETOH & drugs r/t more fragile homeostasisETOH & drugs r/t more fragile homeostasis Ignored by health care system & societyIgnored by health care system & society Few age related programs existFew age related programs exist Little research publishedLittle research published

SUBSTANCE ABUSE IN HEALTH SUBSTANCE ABUSE IN HEALTH PROFESSIONALSPROFESSIONALS

Higher rates of dependence on controlled Higher rates of dependence on controlled substances (Jaffe & Anthony 2005)substances (Jaffe & Anthony 2005)

Problems with Reporting colleaguesProblems with Reporting colleagues:: Sensitive issueSensitive issue Want to avoid conflictWant to avoid conflict Fear of falsely accusing colleagueFear of falsely accusing colleague Feel guiltyFeel guilty

Legal /ethical responsibilityLegal /ethical responsibility

Ethical responsibility –report suspicious Ethical responsibility –report suspicious behaviors to supervisor!behaviors to supervisor!

Legal obligation –defends State Nurse Practice Legal obligation –defends State Nurse Practice Act!Act!

DO NOT try to handle situation alone!DO NOT try to handle situation alone!

Warning signs of abuseWarning signs of abuse

Poor work performancePoor work performance Frequent absenteeismFrequent absenteeism Unusual behaviorsUnusual behaviors Slurred speechSlurred speech Isolates self from colleaguesIsolates self from colleagues

Specific signs& symptoms ofSpecific signs& symptoms of substance abuse substance abuse

Nurse should watch for:Nurse should watch for: Incorrect drug countsIncorrect drug counts

Controlled substances listed as Controlled substances listed as wasted/contaminated(occurring more frequently)wasted/contaminated(occurring more frequently)

Client reports of ineffective pain reliefClient reports of ineffective pain relief

Damages/torn packages of controlled substancesDamages/torn packages of controlled substances

Nurse should watch for:Nurse should watch for:

Increased reports of pharmacy errorsIncreased reports of pharmacy errors

Frequently offers trips to pharmacy to obtain Frequently offers trips to pharmacy to obtain controlled substancescontrolled substances

Trips to bathroom after contact with controlled Trips to bathroom after contact with controlled substancessubstances

Consistently arrives early or departs late from work – Consistently arrives early or departs late from work – no apparent reasonno apparent reason

CA BRN Diversion ProgramCA BRN Diversion Program

Rehab -based programRehab -based program

Provides early interventionProvides early intervention

Board determines candidacy for programBoard determines candidacy for program

BRN criteria for admission into BRN criteria for admission into program:program:

CA license & residenceCA license & residence No hx. of previous disciplineNo hx. of previous discipline Has not failed to complete a previous diversion Has not failed to complete a previous diversion

programprogram No harm to clients has been determinedNo harm to clients has been determined Problems r/t chemical dependency or mental illnessProblems r/t chemical dependency or mental illness Willingness to comply with practice restrictionsWillingness to comply with practice restrictions Not a sex offenderNot a sex offender

Additional program eligibility:Additional program eligibility: Must voluntarily request admissionMust voluntarily request admission

Agree to undergo reasonable Psychiatric/medical Agree to undergo reasonable Psychiatric/medical examination examination

Cooperate – provide medical info., authorizations, Cooperate – provide medical info., authorizations, release liabilityrelease liability

Agree in writing to comply to all elementsAgree in writing to comply to all elements

Not have diverted controlled substances for saleNot have diverted controlled substances for sale

Clients with eating disordersClients with eating disorders

Underlying emotional conflicts – dealt with by Underlying emotional conflicts – dealt with by destructive food related behaviordestructive food related behavior

Nursing Dx.:Imbalanced nutrition <body Nursing Dx.:Imbalanced nutrition <body requirements r/t intake of nutrients insufficient to requirements r/t intake of nutrients insufficient to meet body needsmeet body needs

Assessment characteristics: Assessment characteristics: Wt lossWt loss Body wt 15% + under ideal body wt.Body wt 15% + under ideal body wt. Denial or loss of appetite,difficulty swallowingDenial or loss of appetite,difficulty swallowing Inability to perceive accurately & respond to internal Inability to perceive accurately & respond to internal

stimuli r/t hunger or nutritional needs stimuli r/t hunger or nutritional needs Epigastric distress,vomiting,Epigastric distress,vomiting, Laxative abuseLaxative abuse Concealing wt’s on body to Concealing wt’s on body to wt .measurementwt .measurement

Anorexia characteristics continuedAnorexia characteristics continued::

Denial of illness or resistance of treatmentDenial of illness or resistance of treatment Denial of being too thinDenial of being too thin Excessive exerciseExcessive exercise Multiple related physical problemsMultiple related physical problems

Interventions must be specific to client physical Interventions must be specific to client physical and emotional problems and degree /severity and emotional problems and degree /severity of wt loss and anorexiaof wt loss and anorexia

Examples of interventions:Examples of interventions:

If critically malnourished:If critically malnourished: Parenteral nutrition through a central catheter may be Parenteral nutrition through a central catheter may be

indicated(indicated(adequate nutrition,electrolytes etc. can be adequate nutrition,electrolytes etc. can be provides parenterally,client cannot vomit this type of provides parenterally,client cannot vomit this type of nutrition)nutrition)

Tube feedings may be used alone or with oral Tube feedings may be used alone or with oral parenteralparenteral nutrition(nutrition(fortified liquid diets can be fortified liquid diets can be provided through tube feedings)provided through tube feedings)

Severe anorexia interventions:Severe anorexia interventions:

Supervise client for specified time(90 minutes – Supervise client for specified time(90 minutes – decrease to 30 minutes after tube feeding or remove decrease to 30 minutes after tube feeding or remove NG tube after feeding(NG tube after feeding(supervision decreased clients supervision decreased clients opportunity to vomit or siphon feedings)opportunity to vomit or siphon feedings)

Offer client opportunity to eat food orally-use tube Offer client opportunity to eat food orally-use tube feeding if amount consumed is insufficient(feeding if amount consumed is insufficient(client may client may prefer to eat food orally- however, physical health is prefer to eat food orally- however, physical health is priority)priority)

Severe malnourishmentSevere malnourishment

If N/G tube is used – be matter-of fact re: If N/G tube is used – be matter-of fact re: insertion/use –DO NOT use as a threat!insertion/use –DO NOT use as a threat!

DO NOT permit client to bargain!DO NOT permit client to bargain!(limits & (limits & consistency essential in avoiding power consistency essential in avoiding power struggles and decreasing manipulative struggles and decreasing manipulative behaviors)behaviors)

Interventions for the Interventions for the non- criticallynon- critically malnourished clientmalnourished client

Initially do not allow client to eat with ither Initially do not allow client to eat with ither clients or visitors(clients or visitors(other clients may repeat other clients may repeat family patterns by urging client to eat or family patterns by urging client to eat or providing attention to client for not eating)providing attention to client for not eating)

Provide structure to mealtime-state limits Provide structure to mealtime-state limits matter-of-factly (matter-of-factly (clear limits lets client know clear limits lets client know what is expected)what is expected)

Interventions continuedInterventions continued

Do not bribe,coax,threaten or focus on eating Do not bribe,coax,threaten or focus on eating at all!at all!

Withdraw attention if client refuses to eat.Withdraw attention if client refuses to eat. When meal is over remove food without When meal is over remove food without

discussion(discussion(minimizes client’s secondary gains minimizes client’s secondary gains from not eating- does not reinforce issues of from not eating- does not reinforce issues of control which are central to client)control which are central to client)

Interventions continuedInterventions continued

Encourage client to seek out staff members after Encourage client to seek out staff members after eating to talk about feelings of anxiety or guilt or if eating to talk about feelings of anxiety or guilt or if urge to vomit existsurge to vomit exists.(speaking to staff promotes .(speaking to staff promotes focus on emotional issues rather than food)focus on emotional issues rather than food)

Supervise during & after meals start with 90 minutes Supervise during & after meals start with 90 minutes gradually reduce to 30 minutes.Do not permit use of gradually reduce to 30 minutes.Do not permit use of bathroom until at least 30 minutes after each meal bathroom until at least 30 minutes after each meal ((client may spill,hide or discard food-may use BR to client may spill,hide or discard food-may use BR to vomit or dispose of concealed food)vomit or dispose of concealed food)

Interventions continuedInterventions continued

Gradually permit client increased choices regarding Gradually permit client increased choices regarding food, mealtime etc.(food, mealtime etc.(develops independence in eating develops independence in eating habits)habits)

Monitor I&O in an unobtrusive and matter-of fact Monitor I&O in an unobtrusive and matter-of fact mannermanner(minimizes direct attention to eating and (minimizes direct attention to eating and removes emotional issues)removes emotional issues)

Weigh client daily,after client has voided and before Weigh client daily,after client has voided and before morning meal; client should wear only hospital morning meal; client should wear only hospital gown(gown(consistency is necessary for accurate comparison consistency is necessary for accurate comparison of wt.over time)of wt.over time)

Observe/record client overt/covert physical Observe/record client overt/covert physical activity(activity(client may exercise to excess to control wt.)client may exercise to excess to control wt.)

Review questions:Review questions:Eating disordersEating disorders

The nurse should include which of the following The nurse should include which of the following interventions in the plan of care for a client with interventions in the plan of care for a client with bulimia? (bulimia? (select all that apply)select all that apply)

A.A. Encourage the client to avoid eating except at mealtime.Encourage the client to avoid eating except at mealtime.B. B. Promote a weight gain of 3 to 5 pounds per week.Promote a weight gain of 3 to 5 pounds per week.C. C. Observe the client for one hour after meals.Observe the client for one hour after meals.D. Encourage the client to identify foods that trigger a D. Encourage the client to identify foods that trigger a

binge.binge.E.E. Instruct the client to keep laxatives and diuretics in a Instruct the client to keep laxatives and diuretics in a

locked area.locked area.F.F. Inform the client that there are no “forbidden” foods.Inform the client that there are no “forbidden” foods.

Review questionsReview questionsThe nurse is caring for a client with anorexia The nurse is caring for a client with anorexia

nervosa. Even though client has been eating all nervosa. Even though client has been eating all her meals and snacks her weight is unchanged her meals and snacks her weight is unchanged for one week. Which intervention would be for one week. Which intervention would be indicated:indicated:

A.A. Close Obs.x’s2 hrs. p meals/snacksClose Obs.x’s2 hrs. p meals/snacksB.B. caloric intake from 1500 –2000 calories caloric intake from 1500 –2000 caloriesC.C. fluid intakefluid intakeD.D. Request Rx for antianxiety med from MDRequest Rx for antianxiety med from MD

An intoxicated client is admitted to the hospital for An intoxicated client is admitted to the hospital for alcohol withdrawal. Which of the following alcohol withdrawal. Which of the following actions would the nurse do to assist the client to actions would the nurse do to assist the client to become sober?become sober?

A.A. Give client black coffee to drinkGive client black coffee to drink

B.B. Have the client take a cold showerHave the client take a cold shower

C.C. Provide client with a quiet room to sleepProvide client with a quiet room to sleep

D.D. Walk around the unit with the clientWalk around the unit with the client

The nurse is evaluating the progress of a client with The nurse is evaluating the progress of a client with bulimia.Which behavior indicates the client is bulimia.Which behavior indicates the client is making progress?making progress?

A.A. The client identifies calorie content for each The client identifies calorie content for each mealmeal

B.B. The client identifies healthy ways of coping The client identifies healthy ways of coping with anxietywith anxiety

C.C. The client spends time resting in her room The client spends time resting in her room after mealsafter meals

D.D. The client verbalizes knowledge of former The client verbalizes knowledge of former eating patternseating patterns

A client diagnosed with bulimia tells the nurse she A client diagnosed with bulimia tells the nurse she eats excessively when she is upset then vomits so she eats excessively when she is upset then vomits so she won’t gain weight. The most appropriate nursing won’t gain weight. The most appropriate nursing diagnosis for this client is:diagnosis for this client is:

A.A. AnxietyAnxiety

B.B. Disabled family copingDisabled family coping

C.C. Imbalanced nutrition:more than body Imbalanced nutrition:more than body requirementsrequirements

D.D. Ineffective copingIneffective coping

When teaching a group of adolescents about When teaching a group of adolescents about anorexia, the nurse would describe this disorder as anorexia, the nurse would describe this disorder as being characterized by which of the following:being characterized by which of the following:

a)a) Excessive fear of becoming obese, near-normal Excessive fear of becoming obese, near-normal weight, and self-critical body imageweight, and self-critical body image

b)b) Extreme concern about dieting, calorie Extreme concern about dieting, calorie counting,and an unrealistic body imagecounting,and an unrealistic body image

c)c) Intense fear of becoming obese,emaciation, and a Intense fear of becoming obese,emaciation, and a disturbed body imagedisturbed body image

d)d) Obsession with the weight of others,chronic dieting, Obsession with the weight of others,chronic dieting, and an altered body image.and an altered body image.

Which of the following nursing interventions should the Which of the following nursing interventions should the nurse include in the plan of care for a client with anorexia nurse include in the plan of care for a client with anorexia nervosa in the outpatient setting? nervosa in the outpatient setting? ((select all that apply)select all that apply)

A.A. Set minimum weight limits in which the client Set minimum weight limits in which the client may may continue treatment in the outpatient setting.continue treatment in the outpatient setting.

B.B. Avoid discussing the client’s irrational thoughts Avoid discussing the client’s irrational thoughts about about food and weight with the client’s family.food and weight with the client’s family.

C.C. Encourage the client to be weighed dailyat the Encourage the client to be weighed dailyat the same same time of day.time of day.

D.D. Instruct the client to avoid preparing one’s own meal.Instruct the client to avoid preparing one’s own meal.E.E. Instruct the client to keep a food diary.Instruct the client to keep a food diary.F.F. Assist the client with meal planning.Assist the client with meal planning.

The nurse should assess a client suspected of having The nurse should assess a client suspected of having bulimia for which of the following clinical bulimia for which of the following clinical

manifestations: ( manifestations: (select all that apply)select all that apply)

A.A. ConstipationConstipation

B.B. A 20% loss of normal body weight A 20% loss of normal body weight

C.C. Dental erosionDental erosion

D.D. LanguoLanguo

E.E. A serum potassium of 3.0mEq/LA serum potassium of 3.0mEq/L

F.F. DepressionDepression

Which of the following nursing interventions should the nurse Which of the following nursing interventions should the nurse include in the plan of care for a client with include in the plan of care for a client with anorexia nervosa in the outpatient setting? (anorexia nervosa in the outpatient setting? (select all that apply)select all that apply)

A.A. Set minimum weight limits in which the client may continue Set minimum weight limits in which the client may continue treatment in the outpatient setting.treatment in the outpatient setting.

B.B. Avoid discussing the client’s irrational thoughts about food and Avoid discussing the client’s irrational thoughts about food and weight with the client’s family.weight with the client’s family.

C.C. Encourage the client to be weighed dailyat the same time of Encourage the client to be weighed dailyat the same time of day.day.

D.D. Instruct the client to avoid preparing one’s own meal.Instruct the client to avoid preparing one’s own meal.E.E. Instruct the client to keep a food diary.Instruct the client to keep a food diary.F.F. Assist the client with meal planning.Assist the client with meal planning.

Review questions :Review questions :Adolescent disordersAdolescent disorders

An effective nursing intervention for for the An effective nursing intervention for for the impulsive and aggressive behaviors that accompany impulsive and aggressive behaviors that accompany conduct disorders is:conduct disorders is:

A.A. Assertiveness trainingAssertiveness training

B.B. Consistent limiting settingConsistent limiting setting

C.C. Negotiation of rulesNegotiation of rules

D.D. Open expression of feelingsOpen expression of feelings

The nurse would expect to see all of the following The nurse would expect to see all of the following behaviors in a child with Attention deficit behaviors in a child with Attention deficit hyperactivity disorder(AD/HD) except:hyperactivity disorder(AD/HD) except:

A.A. Easily distracted and forgetfulEasily distracted and forgetful

B.B. Excessive running,climbing,fidgetingExcessive running,climbing,fidgeting

C.C. Moody,sullen, pouting behaviorMoody,sullen, pouting behavior

D.Interrupts others and cannot take turnsD.Interrupts others and cannot take turns

A 9 year old client with AD/HD tells the nurse A 9 year old client with AD/HD tells the nurse “no one in my class likes me because they think “no one in my class likes me because they think I’m stupid !” The nurse would apply the I’m stupid !” The nurse would apply the following nursing diagnosis to this child:following nursing diagnosis to this child:

A.A. AnxietyAnxiety

B.B. Impaired socializationImpaired socialization

C.C. Ineffective copingIneffective coping

D.D. Low Self-EsteemLow Self-Esteem

The nurse would identify which of the following The nurse would identify which of the following children as being most at risk for an adjustment children as being most at risk for an adjustment disorder?disorder?

A.A. A 10 year old boy who has never liked school an A 10 year old boy who has never liked school an has a few friendshas a few friends

B.B. A 16 year old boy who has been struggling in A 16 year old boy who has been struggling in school, getting only C’s and D’sschool, getting only C’s and D’s

C.C. A 13 year old girl who is upset about not being A 13 year old girl who is upset about not being selected for a cheerleading squadselected for a cheerleading squad

D.D. A 16 year old girl who recently moved to a new A 16 year old girl who recently moved to a new school after her parents’ divorceschool after her parents’ divorce