Lecture 2 – Alcoholism & Addictions

Alcoholism and Psychological Problems

The primary psychological issue related to abuse (e.g., alcoholism, child abuse, gambling, drug abuse, spousal or elder abuse) is denial.
How should you respond to denial? Confront the patient by highlighting the discrepancy between their words and actions. This approach is not aggressive—it’s important to avoid attacking the patient.
Example: “You say you’re not an alcoholic, but it’s 10 a.m., and you’ve already consumed a six-pack.”
A good response uses “I” statements, while a bad response tends to use “You” statements.
Exception: Denial is acceptable when dealing with loss and grief, as it is part of the normal grieving process (the stages of grief: Denial, Anger, Bargaining, Depression, Acceptance—DABDA).
- When the patient is in denial, determine whether it’s due to loss or abuse:
  - Loss → Offer support.
  - Abuse → Confront the behavior.

Dependency vs. Codependency

The second common psychological issue is dependency and codependency.
Dependency: Occurs when a person (the abuser) relies on a significant other to make decisions or complete tasks for them.
- In this relationship, the abuser is the dependent party.
Codependency: Happens when the significant other gains self-esteem and a sense of purpose by taking care of the abuser or making decisions on their behalf.
- The significant other is the codependent.
Dependency and codependency form a mutual but unhealthy dynamic:
- The dependent person takes advantage of the codependent’s actions.
- The codependent derives self-worth from “helping” the dependent person.

Treatment for Dependency/Codependency:

Dependent (abuser): Confront their behavior to encourage responsibility and autonomy.
Codependent: Address their self-esteem issues by teaching them to set clear boundaries and enforce them.
- Agree ahead of time on what requests are acceptable and ensure those boundaries are maintained.
- Teach the significant other how to say “no” when necessary.
- Focus on building the codependent person’s self-esteem and independence.

Manipulation

Manipulation: Occurs when the abuser persuades the significant other to do things or make decisions that are not in the best interest of the significant other.
- The act requested is typically harmful or dangerous to the significant other.

How is Manipulation Similar to Dependency?

In both cases, the abuser relies on the significant other to act on their behalf.
If the request involves something inherently dangerous or harmful to the significant other, it is considered manipulation.

Treatment for Manipulation: Set firm boundaries and ensure they are strictly enforced.

Wernicke (Korsakoff) Syndrome

Although Wernicke’s encephalopathy and Korsakoff’s psychosis are typically two distinct conditions, the NCLEX treats them as a single syndrome.
- Wernicke’s refers to encephalopathy (brain damage).
- Korsakoff’s refers to psychosis (a mental health disorder).
- These two conditions often occur together.
This syndrome is caused by a vitamin B1 (thiamine) deficiency, which leads to psychosis.
The deficiency causes the patient to lose touch with reality.

Primary Signs and Symptoms:

Amnesia: Memory loss.
Confabulation: The patient fabricates stories, but to them, these made-up stories feel as real as reality.

Characteristics of Wernicke and Korsakoff Syndrome

Preventable: Taking vitamin B1 (thiamine) can prevent the development of the syndrome.
Arrestable: Progression can be stopped by taking vitamin B1, preventing further brain damage.
Irreversible: In about 70% of cases, the condition is irreversible, resulting in permanent brain cell damage.

Antabuse (Disulfiram)

Antabuse (Disulfiram) is an alcohol deterrent used to prevent relapse in individuals with alcohol dependency.
It works as part of aversion therapy, a behavior therapy designed to create a strong aversion (dislike) to alcohol by associating its consumption with unpleasant effects, such as nausea and vomiting.
- This therapy is generally more effective in controlled environments than in everyday life.
Onset and Duration:
- The effects of Antabuse or Revia take 2 weeks to start working and last for 2 weeks.
- For example, if a patient plans to attend an event and drink alcohol, they must stop taking Antabuse/Revia at least 2 weeks prior.

Patient Teaching:

Instruct patients to avoid all forms of alcohol, as even small amounts can cause severe symptoms like nausea, vomiting, and, in rare cases, death.
Patients should avoid alcohol-containing products such as:
- Mouthwash, cologne, perfume, aftershave, elixirs, most OTC liquid medications, insect repellents, hand sanitizers, and vanilla extract (unbaked icing can also pose a risk).
On the NCLEX exam: Avoid selecting Red Wine Vinaigrette as a risky option—it does not contain alcohol.

Overdose and Withdrawal

1. Key question to ask in an overdose scenario: Is the substance an upper or a downer?

This distinction is crucial because all drugs of abuse are classified as either uppers or downers.
Exception: Laxative abuse, particularly in the elderly, does not fit into either the upper or downer category.

Upper	Downer
For the NCLEX, memorize the following five uppers: – CaLeine – Cocaine – PCP/LSD (psychedelics/hallucinogens) – Methamphetamines – Adderall	– There are over 135 drugs classified as downers. – A simple rule for the NCLEX: If it’s not an upper, it’s a downer.
Signs and symptoms – With uppers, everything goes up. – Common signs and symptoms include: Euphoria, Seizures, Restlessness, Irritability, Hyperreflexia (increased reflexes, 3+ or 4+), Tachycardia (fast heart rate), Increased bowel activity (borborygmi),and Diarrhea	Signs and symptoms _ With downers, everything goes down. _ Common signs and symptoms include: Lethargy, Respiratory depression or respiratory arrest, Constipation, Decreased reflexes, and Bradycardia (slow heart rate)

Key nursing priorities based on the type of drug:

Upper: The highest priority is suctioning to manage the risk of seizures.
Downer: The highest priority is intubation/ventilation to address the risk of respiratory arrest.

2. After identifying whether the substance is an upper or a downer, the next step is to determine if the patient is experiencing an overdose or withdrawal:

Overdose and withdrawal produce opposite effects.

	Upper (+)	Downer (-)
Overdose (+)	TOO MUCH (+)	TOO LITTLE (-)
Withdrawal (-)	TOO LITTLE (-)	TOO MUCH (+)

NCLEX Tips:

Apply the rule of multiplication: If the signs are the same, the result is positive; if the signs are different, the result is negative.

Drug Abuse in the Newborn

Always assume intoxication in a newborn within the first 24 hours after birth.
After 24 hours, assume the newborn is experiencing withdrawal.

Alcohol Withdrawal Syndrome (AWS) vs. Delirium Tremens (DT)

Alcohol Withdrawal Syndrome (AWS) and Delirium Tremens (DT) are two distinct conditions.
Every alcoholic experiences AWS around 24 hours after stopping alcohol consumption.
However, less than 20% of those with AWS will progress to DT.
Delirium Tremens (DT) typically occurs around 72 hours after stopping alcohol.
AWS always occurs before DT, but not all cases of AWS lead to DT.

AWS (withdrawal of downer = too much)	DT (withdrawal of downer = too much)
– Occurs 24 hours after the last drink. – It is non-life-threatening to the patient and others.	– Occurs 72 hours after the last drink. – It is life-threatening to the patient and others.
Nursing Care Plan for AWS: – Diet: Regular diet. – Room: Semi-private room, can be located anywhere on the unit. – Activity: Patient is up ad lib (free to move around as desired). – Restraints: No restraints are required.	Nursing Care Plan for DT: – Diet: NPO or clear liquids (due to seizure risk). – Room: Private room near the nursing station for close monitoring. – Activity: Restricted bed rest (patient is not allowed to move around freely, no bathroom privileges). – Restraints: Use of vest or 2-point locked leather restraints to ensure safety.

NOTE:

2-point locked leather restraints: These restraints involve securing one upper extremity and the opposite lower extremity.
- When rotating restraints, release and secure the upper arm first, then release and secure the opposite foot.
- Switch extremities every 2 hours to prevent injury and promote circulation.
For both Alcohol Withdrawal Syndrome (AWS) and Delirium Tremens (DT), administer the following:
- Antihypertensive medications (to manage elevated blood pressure).
- Tranquilizers (to help calm agitation).
- Multivitamin with Vitamin B1 (to prevent or slow the onset of Wernicke’s encephalopathy, which can occur due to vitamin B1 deficiency).
- Alcohol withdrawal (removal of a downer) causes overstimulation, leading to elevated blood pressure and heightened mood, which can lead to complications like Wernicke’s encephalopathy.

Aminoglycosides (Top 5 Most Tested Drugs)

What are Aminoglycosides?

Aminoglycosides are considered the “big guns” of antibiotics—reserved for when nothing else works.
However, due to their potential toxicity, safety is a key concern. Aminoglycosides are one of the top 5 most frequently tested drugs on the NCLEX.
- Top 5 drugs: Psychiatric meds, insulin, anticoagulants, digitalis, and aminoglycosides.
- Other commonly tested drugs: Steroids, beta-blockers (BB), calcium channel blockers (CCB), pain meds, OB meds.
A helpful mnemonic is “A Mean Old Mysin” = Aminoglycosides.
- Aminoglycosides are used to treat serious, resistant, life-threatening gram-negative infections. Think of “A mean old mycin” for a mean old infection.
- Examples: TB, septic peritonitis, fulminating pyelonephritis, septic shock, infections from third-degree burns covering >80% of the body.
- Not used for milder infections such as sinusitis, otitis media, bladder infections, viral pharyngitis, or strep throat.
Aminoglycosides typically end with “-mycin”:
- Examples: Gentamicin, vancomycin, clindamycin, streptomycin, Cleomycin, tobramycin.
- Exception: Exclude drugs ending in “-thromycin” from aminoglycosides (e.g., azithromycin, clarithromycin, erythromycin).

Toxic Effects:

Think of a mouse’s ear shape to remember the toxic effects (ear and kidneys).
- Ear: Ototoxicity (affecting hearing, balance, and causing tinnitus). Toxic to cranial nerve 8 (CN VIII).
- Kidneys: Nephrotoxicity (monitor creatinine levels closely).

NCLEX Tips:

When asked about creatinine levels, always prioritize the 24-hour creatinine clearance test over serum creatinine in NCLEX questions. This provides a more accurate assessment of kidney function.

Route of Aminoglycosides

Aminoglycosides are NEVER given orally (PO) because they are not absorbed in the GI tract and, therefore, would not have systemic effects.
Exceptions: There are two specific cases where aminoglycosides are given PO:
1. Hepatic encephalopathy (hepatic coma): When ammonia levels are too high (e.g., E. coli, a major producer of ammonia), leading to encephalopathy.
2. Pre-op bowel surgery: Aminoglycosides are used to sterilize the bowel.
In these cases, aminoglycosides stay in the gut (since they are not absorbed) and sterilize the bowel without causing systemic toxicity.
Mnemonic: “Who can sterilize my bowel? NEO KAN!”
- Neomycin and kanamycin are the aminoglycosides given PO for bowel sterilization.
In all other situations, aminoglycosides are given IM or IV because they are excreted in feces and not absorbed in the GI tract.

Troughs and Peaks

What are Troughs and Peaks?

Troughs: The lowest concentration of a drug in the patient’s blood.
Peaks: The highest concentration of a drug in the patient’s blood.
Trough and peak levels are measured when administering drugs with a narrow therapeutic window/index, meaning the difference between a therapeutic dose and a toxic dose is small, requiring close monitoring.
Use the acronym “TAP”:
- Trough → Draw before administering the medication.
- Administer → Give the drug.
- Peak → Draw after administration to check the highest drug level.
Narrow therapeutic window/index drugs require this monitoring to ensure safety, as the difference between an effective dose and a toxic dose is minimal.
Common drugs requiring TAP monitoring:
- Aminoglycosides
- Digoxin

When Do You Draw a Trough and a Peak?

Trough: Always draw 30 minutes before the next dose, regardless of the medication or route.
Peak: Timing depends on the route of administration (not the medication):
- Sublingual (SL): Draw 5-10 minutes after the drug has dissolved.
- Intravenous (IV): Draw 15-30 minutes after the drug infusion is complete (when the bag is empty).
- Intramuscular (IM): Draw 30-60 minutes after administration.
- Subcutaneous (SQ): Timing depends on insulin (refer to the diabetes section).
- Oral (PO): Not typically necessary and not tested on the NCLEX.