NCP Alcohol Related Disorders

Alcohol is a CNS depressant drug that is used socially in our society for many reasons (e.g., to enhance the flavor of food, to encourage relaxation and conviviality, for feelings of celebration, and as a sacred ritual in some religious ceremonies). Therapeutically, it is the major ingredient in many OTC/prescription medications. It can be harmless, enjoyable, and sometimes beneficial when used responsibly and in moderation. Like other mind-altering drugs, however, it has the potential for abuse and, in fact, is the most widely abused drug in the United States (research suggests 5% to 10% of the adult population) and is potentially fatal. Frequently, the client in a residential care setting has been using alcohol in conjunction with other drugs. It is believed that alcohol is often used by clients who have other mental illnesses to assuage the pain they feel. The term “dual diagnosis” is used to mean an association between the use/abuse of drugs (including alcohol) and other psychiatric diagnoses. It may be difficult to determine cause and effect in any given situation to determine an accurate diagnosis. However, it is important to recognize when both conditions are present so that the often-overwhelming problems of treatment are instituted for both conditions.

This plan of care addresses acute intoxication/withdrawal and is to be used in conjunction with CP: Substance Dependence/Abuse Rehabilitation.

ETIOLOGICAL THEORIES

Psychodynamics

The individual remains fixed in a lower level of development, with retarded ego and weak superego. The person retains a highly dependent nature, with characteristics of poor impulse control, low frustration tolerance, and low self-esteem.

Biological

Enzymes, genes, brain chemistry, and hormones create and contribute to an individual’s response to alcohol. The two types of alcohol-related disorders are (1) familial, which is largely inherited, and (2) acquired. A childhood history of attention-deficit disorder or conduct disorder also increases a child’s risk of becoming alcoholic. Certain physiological changes also may cause addiction to alcohol, or alcoholism.

Family Dynamics

One in 12–15 persons has serious problems from drinking. In a dysfunctional family system, alcohol may be viewed as the primary method of relieving stress. Children of alcoholics are 4 times more likely to develop alcoholism than children of nonalcoholics. The child has negative role models and learns to respond to stressful situations in like manner. The use of alcohol is cultural, and many factors influence one’s decision to drink, how much, and how often. Denial of the illness can be a major barrier to identification and treatment of alcoholism and alcohol abuse.

CLIENT ASSESSMENT DATA BASE

Data depend on the duration/extent of alcohol use, concurrent use of other drugs, degree of organ involvement, and presence of other psychiatric conditions.

Activity/Rest

Difficulty sleeping, not feeling well rested

Circulation

Peripheral pulses weak, irregular, or rapid

Hypertension common in early withdrawal stage but may become labile/progress to hypotension

Tachycardia common during acute withdrawal

Ego Integrity

Feelings of guilt/shame; defensiveness about drinking

Denial, rationalization

Reports of multiple stressors; problems with relationships

Multiple stressors/losses (relationships, employment, financial)

Use of substances to deal with life stressors, boredom, etc.

Elimination

Diarrhea

Bowel sounds varied (may reflect gastric complications [e.g., gastric hemorrhage])

Food/Fluid

Nausea/vomiting, food tolerance

Muscle wasting, dry/dull hair, swollen salivary glands, inflamed buccal cavity, capillary fragility (malnutrition)

Generalized tissue edema may be noted (protein deficiencies)

Gastric distension; ascites, liver enlargement (seen in cirrhosis)

Neurosensory

“Internal shakes”

Headache, dizziness, blurred vision, “blackouts”

Psychopathology such as paranoid schizophrenia, major depression (may indicate dual diagnosis)

Level of Consciousness/Orientation: Confusion, stupor, hyperactivity, distorted thought processes, slurred/incoherent speech

Memory loss/confabulation

Affect/Mood/Behavior: May be fearful, anxious, easily startled, inappropriate, silly, euphoric, irritable, physically/verbally abusive, depressed, and/or paranoid

Hallucinations: Visual, tactile, olfactory, and auditory (e.g., picking items out of air or responding verbally to unseen person/voices)

Nystagmus (associated with cranial nerve palsy)

Pupil constriction (may indicate CNS depression)

Arcus senilis, a ringlike opacity of the cornea (normal in aging populations, suggests alcohol-related changes in younger clients)

Fine motor tremors of face, tongue, and hands; seizure activity (commonly grand mal)

Gait unsteady/ataxia (may be due to thiamine deficiency or cerebellar degeneration [Wernicke’s encephalopathy])

Pain/Discomfort

May report constant upper abdominal pain and tenderness radiating to the back (pancreatic inflammation)

Respiration

History of tobacco use, recurrent/chronic respiratory problems

Tachypnea (hyperactive state of alcohol withdrawal)

Cheyne-Stokes respirations or respiratory depression

Breath Sounds: Diminished/adventitious sounds (suggests pulmonary complications [e.g., respiratory depression, pneumonia])

Safety

History of recurrent accidents, such as falls, fractures, lacerations, burns, blackouts, or automobile accidents

Skin: Flushed face/palms of hands, scars, ecchymotic areas, cigarette burns on fingers, spider nevi (impaired portal circulation); fissures at corners of mouth (vitamin deficiency)

Fractures, healed or new (signs of recent/recurrent trauma)

Temperature elevation (dehydration and sympathetic stimulation); flushing/diaphoresis (suggests presence of infection)

Suicidal ideation/attempts (some research suggests alcoholic suicide attempts are 30% higher than national average for general population)

Social Interactions

Frequent sick days off work/school, fighting with others, arrests (disorderly conduct, motor vehicle violations [DUIs])

Denial that alcohol intake has any significant effect on the present condition/situation

Dysfunctional family system of origin; problems in current relationships

Mood changes affecting interactions with others

Teaching/Learning

History of alcohol and/or other drug use/abuse (including tobacco)

Ignorance and/or denial of addiction to alcohol or inability to cut down or stop drinking despite repeated efforts

Large amount of alcohol consumed in last 24–48 hours, previous periods of abstinence/withdrawal

Previous hospitalizations for alcoholism/alcohol-related diseases (e.g., cirrhosis, esophageal varices)

Family history of alcoholism/substance use

DIAGNOSTIC STUDIES

Blood Alcohol/Drug Levels: Alcohol level may/may not be severely elevated depending on amount consumed and length of time between consumption and testing. In addition to alcohol, numerous controlled/illicit substances may be identified in a polydrug screen (e.g., amphetamine, cocaine, morphine, Percodan, Quaalude).

CBC: Decreased (Hb/Hct) may reflect such problems as iron-deficiency anemia or acute/chronic GI bleeding. White blood cell count may be increased with infection or decreased, if immunosuppressed.

Glucose: Hyperglycemia/hypoglycemia may be present, related to pancreatitis, malnutrition, or depletion of liver glycogen stores.

Electrolytes: Hypokalemia and hypomagnesemia are common.

Liver Function Tests: CPK, LDH, AST, ALT, and amylase may be elevated, reflecting liver or pancreatic damage.

Nutritional Tests: Albumin is low and total protein decreased. Vitamin deficiencies are usually present, reflecting malnutrition/malabsorption.

Other Screening Studies (e.g., Hepatitis, HIV, TB): Dependent on general condition, individual risk factors, and care setting.

Urinalysis: Infection may be identified; ketones may be present related to breakdown of fatty acids in malnutrition (pseudodiabetic condition).

Chest X-Ray: May reveal right lower lobe pneumonia (malnutrition, depressed immune system, aspiration) or chronic lung disorders associated with tobacco use.

ECG: Dysrhythmias, cardiomyopathies, and/or ischemia may be present owing to direct effect of alcohol on the cardiac muscle and/or conduction system, as well as effects of electrolyte imbalance.

Addiction Severity Index (ASI): An assessment tool that produces a “problem severity profile” of the client, including chemical, medical, psychological, legal, family/social, and employment/support aspects, indicating areas of treatment needs.

NURSING PRIORITIES

1. Maintain physiological stability during withdrawal phase.
2. Promote client safety.
3. Provide appropriate referral and follow-up.
4. Encourage/support SO involvement in Intervention (confrontation) process.

DISCHARGE GOALS

1. Homeostasis achieved.
2. Complications prevented/resolved.
3. Sobriety being maintained on a day-to-day basis.
4. Ongoing participation in a rehabilitation program/attendance at group therapy (e.g., Alcoholics Anonymous).
5. Plan in place to meet needs after discharge.

This plan of care is to be used in conjunction with CP: Substance Dependence/Abuse Rehabilitation.