Care Given to a Patient with Alcohol Addiction - Case Study Example

The Care Given to a Patient They have Care for Swarnambika S Academia Research There are a number of degrees and kinds of alcoholism. Some alcoholics stop drinking without any medical aid because of changes in their life situations or their attitudes toward life. Some stop with assistance such as psychotherapy, somatic therapy, or social and vocational rehabilitation programs. Probably more than half continue to drink throughout their lives, with the occasional treatment of medical problems related to their alcoholism. Generally, however, when we use the term alcoholism, we are referring to the excessive, compulsive, uncontrolled, and self destructive intake of alcohol. It is that person whose dependence upon alcohol has resulted in his physical, emotional and social deterioration that we refer to as the alcoholic. The care and treatment of such a person is similar to that of a alcohol addict. In this paper, we would be discussing about the care given to a patient who was an alcoholic. Introduction Alcohol is a central nervous system depressant. Once alcohol is absorbed into the bloodstream it affects all body tissues but its immediate effects are caused by its action on the brain. At a level of 0.05 percent of alcohol in the blood, inhibitions are diminished and the individual is likely to say and do things that would be unacceptable to him if he were sober (McCoy et al, 1981). Interestingly, there is a societal norm that, to a point, excuses the behavior of an individual who has been drinking on the grounds that he has been drinking. This cyclical thinking is based on the belief that the behavior of a person when drunk is not a reflection of him but rather a manifestation of the alcohol. The reality is that the impulses acted on emanate from the person and the alcohol merely removes the barriers to their implementation. At a level of 0.10 percent of alcohol in the blood, motor and speech activity is impaired. It is for this reason that there has been a recent national campaign against driving a motor vehicle when drinking (McCoy et al, 1981). Literature Review Alcohol dependence may take many forms and has many causes. One individual may be a chronic alcoholic, which means that he drinks excessively and is incapacitated most of the time. Another person may be referred to as a periodic or cyclic alcoholic, which means that he drinks excessively during certain periods of his life but during other periods may not drink at all (Weist et al, 1982). A third type of alcoholism is exhibited by an individual who drinks large quantities of alcohol daily over a period of years. At first he may not seem to be seriously affected by this overindulgence. Slowly and insidiously, physical, mental, and emotional deterioration occurs. Eventually this person may be described as suffering from alcoholic deterioration (Fortin, 1980). No matter what type of alcohol ism is being considered, the problem is thought to have as one of its bases some emotional conflict, frustration, or feeling of inadequacy. Case Study (Courtesy: Malar Hospitals, Chennai, India) David S is a 24-year-old, single man who was admitted to a long term residential alcoholic rehabilitation program, following a 2-week inpatient stay on a detoxification unit for withdrawal from alcohol. David began using alcohol when he was a junior in high school because his 14-year-old girlfriend refused to date him any longer. About the same time, David was sent by his mother, who lived in New York City, to attend high school in a distant southern city because his parents were getting a divorce. According to David, alcohol made him feel excited, stimulated, and happy. Everything seemed more pleasant, and he enjoyed his daydreams He was also sexually stimulated by alcohol. About the same time, he tried taking barbiturates, which made him sleepy. Because he did not enjoy their effect, he did not continue them. Since alcohol did not completely satisfy him either, he was convinced that his willpower would be great enough to allow him to stop using alcohol when he wanted to be free of it. When David consumed alcohol, for the first time in his life he experienced a feeling of deep contentment. He said. "It didn't affect my intellect, only my emotions. I was happy and content." From that time on he took alcohol to assist him in facing any situation that caused him to be tense or anxious. Alcohol helped him feel independent of his mother and reduced his nervousness when he was out with a girl. Although alcohol gave him a feeling of contentment, it lessened his sexual desire and made it impossible for him to reach a sexual climax. After David discovered the contentment alcohol could achieve for him, he became involved in crimes to support his habit. As his need for larger and larger quantities of alcohol grew, making his habit more costly, his crimes became more frequent and more serious. His mother repeatedly intervened to keep him out of jail by paying his fines. He entered several colleges but because of his habit was never able to stay in any of them for more than a semester. Finally David tried to withdraw himself from alcohol. He thought he could achieve this by himself, since he had been withdrawn twice before in treatment centers. He was not able to accomplish his goal and finally at 24 years of age signed himself into a detoxification unit in the hope of stopping alcohol so that he could return to college. He had set for himself the goal of becoming an engineer. Following the 2-week detoxification program, staff members recommended to David that he admit himself to a long-term residential treatment setting, due to the chronic nature of his difficulties and his past inability to remain abstinent when confronted by stressful life events. The residential alcohol rehabilitation program was staffed by a variety of professional and nonprofessional staff, including recovered alcoholics. The staff worked with David to develop a plan of care designed to meet his individual needs and enhance his strengths. On admission to the center, David was alcohol free. He appeared undernourished, but was in no acute physical distress. He initially gave evidence of being highly motivated and tested in the superior range on a standardized intelligence test. During the admission interview, David recounted the following information about his early childhood. He stated that his parents were married when his mother was 16 years old. David was their first child, and he recalled his mother often reminding him that his birth had been traumatic for her. During his formative years his father suffered from tuberculosis and spent many months in a sanitarium. David remembered that when he was 3 and 4 years old his mother fondled his genitals when she bathed him. As he grew older, she allowed him to observe her dressing and bathing but scolded him if he evidenced interest in her body. Nursing Care David's history reveals a number of factors that potentially contributed to his addictive behaviors and his reliance on alcohol for a sense of well-being. He described the feelings of happiness, contentment, relief of anxiety, and independence that he experienced when using alcohol. David's relationship with his mother was a highly ambivalent and conflicted one. From the time he was a child he had been given the message that he was unwanted and unloved. Owing to her own difficulties in adjustment, David's mother was unable to provide him with a healthy environment in which to develop and grow. Her sexually provocative behaviors contributed to David's poor psychosexual adjustment and his anxieties in relation to intimacy with women. David's attempts to separate from his mother were unsuccessful. Her continual interventions on his behalf with the police enabled him to continue his addictive behaviors while maintaining his unhealthy and dependent relationship with her. The absence of a healthy male role model further hindered David's ability to develop effective adaptations to stress. He seemed to rely solely on alcohol for a sense of well-being and autonomy and used alcohol to deal with all anxiety-provoking situations. David failed to develop a healthy sense of self as an autonomous male individual. His dependence on alcohol may have been a substitute for the dependence he experienced in relation to his rejecting and controlling mother. The adaptation was dysfunctional in that his use of alcohol further impeded his ability to negotiate the adolescent tasks of separation and identity development. David appeared undernourished, probably due to his use of funds to purchase alcohol rather than food. His work history was poor, as was his school performance, and he had begun to rely on stealing to purchase alcohol. David's strengths included his superior intelligence, as well as his apparent motivation to remain free of alcohol and to pursue a career. His willingness to commit himself to a long-term rehabilitation center indicated his emerging recognition of the severity of his alcohol dependence and his desire for change. Nursing diagnoses The nursing diagnoses derived from the assessment data were as follows: 1. Malnourishment related to inadequate food and fluid intake Ineffective coping methods related to long-term reliance on alcohol to cope with stressful life events. 2. Inability to develop and maintain healthy relationships with the opposite sex, related to fear of rejection and psychosexual conflicts. Professional Issues Encountered In David's case, he is an individual with problems that are characteristically his own. David uses alcohol in somewhat the same way that psychotic individuals use psychotic symptoms. When David would be deprived of alcohol, he might substitute psychotic symptoms such as withdrawal from reality, depression, or a paranoid reaction. Many alcoholics are described as having oral personalities (Weist et al, 1982). This suggests that they are fixated at an early stage of emotional development. This early stage of emotional development is called the oral-dependent period and is characterized by infantile emotional reactions. Such individuals receive many of their emotional satisfactions from the intake of food and fluids by mouth (Gibson, 1980). In David's case too, this was found true. He found it difficult to function as independent adult and unconsciously wanted to be dependent on a strong person. In general, David, as an alcohol-dependent individual was unhappy, distraught and unable to cope with the stresses of daily living. Whether these factors are causes or effects of his alcoholism was not clear. Short-term, immediate treatment of David was focused on withdrawing him from this substance and assisting him to attain or regain physical health. This was accomplished by symptomatic treatment of the anxiety, tremors, nausea, and diaphoresis that accompany withdrawal. Seizures and delirium tremens are serious, life-threatening conditions that may occur during detoxification. Delirium tremens is an acute reaction to the withdrawal from a heavy and consistent intake of alcohol for a period of several weeks without an adequate intake of food (Gibson, 1980). In an individual who has been a chronic alcoholic for several years, delirium tremens may be precipitated by a head injury or a surgical procedure without the individual's having taken alcohol at the time of its appearance. Delirium tremens consists of confusion, excitement, and delirium. It is usually of relatively short duration and does not cause a profound and permanent change in the personality (Jefferson & Ensor, 1982). The delirium is preceded by loss of appetite, restlessness, and insomnia (Loweree et al, 1984). Slight noise causes the patient to jerk with fear, and moving objects lead to great excitement and agitation. Gradually, consciousness becomes clouded, friends are no longer recognized, and shadows on the wall appear as insects or crawling animals. The person becomes terrified, picks imaginary threads off the bed clothing, feels and sees nonexistent insects on his skin. There is a ceaseless fumbling and picking movement of his fingers and hands. The person's face has an anxious or terrified expression, and his eyes are bloodshot. His skin is moist with perspiration; his tongue and lips are tremorous. His pulse is rapid and weak, and there is always some elevation of temperature. Anticonvulsant and sedative medications, along with high potency vitamins and copious amounts of clear liquids, were employed during this phase of treatment, to both prevent and treat seizures and delirium tremens. Because of the serious physiological disequilibrium David experienced as he went through withdrawal from alcohol, this procedure was carried out in the hospital by staffs that are knowledgeable about the varied problems involved. The drug disulfiram (Antabuse) was used successfully to treat David. If functions something, like the aversion treatment in that the individual who takes a specific amount of disulfiram daily will become nauseated when he takes even a small amount of alcohol. This drug is helpful as long as the individual is under close supervision and takes the drug regularly. Away from supervision some individuals stop taking the drug. The drug is considered to be dangerous in some instances, and a few individuals have suffered adverse reactions from it. The only potentially effective long-term treatment of the alcohol-dependent individual requires that he accept the fact he is an alcoholic. This step is often the most difficult to achieve since the defense mechanism of denial is universally employed by the, alcohol-dependent person. If he is able to acknowledge to himself and others that he cannot cope with his life without the help alcohol provides and that he needs assistance he may be able to be helped by psychotherapy. Planning and implementing care for David The team working with David consisted of a variety of professional and nonprofessional members and included a primary nurse, the team psychiatrist, a psychiatric social worker, and an occupational therapist. The staff members assigned to David was mature individuals experienced in the treatment of clients with substance dependence. They approached David in a hopeful, caring, and supportive fashion, while clearly maintaining boundaries of separateness and setting firm limits. The initial task of treatment was to assist David to recognize and accept his alcohol addiction as a problem, thereby breaking through the massive defense of denial common to alcohol -dependent individuals. Despite David's high motivation to be alcohol free, the treatment team expected that David eventually would express ambivalence in relation to treatment, and they would need to help him remain abstinent at that time. Finally, treatment would focus on assisting David to develop alternative coping methods to handle stressful life events and uncomfortable feelings to prevent a return to reliance on alcohol as a coping style. The treatment approach consisted of a variety of modalities, including group therapy; peer groups; milieu therapy; peer pressure; recreational and expressive-creative therapies; and assistance with developing social and vocational skills. A contract developed by David and the team outlined mutual expectations for treatment participation. In addition, David was expected to do his share of housekeeping and meal preparation as outlined by the community in weekly meetings. David agreed to the plan as written and was given his final copy of the contract. He agreed to remain in the program for 1 year, to remain alcohol free as evidenced by daily urine screens, and to follow the contract as written. David was assigned a primary nurse whose plan was to establish a supportive but firm relationship, to develop a climate of acceptance that allowed for the expression of feelings, and to facilitate David's full participation in the program as outlined. Violation of the treatment plan would constitute grounds for immediate review and potential discharge. Evaluation David's participation and progress were reviewed by all staff members with David present on a biweekly basis. While he made steady progress, his course of treatment was not without difficulty. After 2 months at the center, it was felt that David was ready to handle an all-day pass to visit with his mother. David had verbalized the hope that he could use some of his new knowledge and behaviors, and that the meeting would go well. On David's return, his urine alcohol screen revealed that he had used alcohol while on pass, despite his earlier denial, of alcohol use. He began to challenge staff when confronted and vehemently denied that the action had any meaning. David was confronted by his peers in group therapy the following day and became withdrawn, sullen, and nonverbal for several weeks. He then began to discuss his fears related to a "life without alcohol" with his primary nurse, who encouraged him to discuss and explore these issues in the various groups he attended. David accused the nurse of being rejecting, just like his mother, by her suggesting that he take his problems elsewhere. The nurse remained accepting of these feelings and encouraged David to discuss them. Gradually he began to use groups and peers for increased support and became particularly close to a group of men close to his age. They relied on one another for support and encouragement. Each new anxiety-producing circumstance David confronted led to a desire to return to alcohol consumption. As he began to explore career avenues, his anxiety again increased, as did the desire to rely on alcohol. David feared each new step toward an independent and alcohol -free existence. He often expressed the feeling that others were "forcing" him to quit alcohol and was frequently reminded by peers that he had voluntarily chosen to make a commitment to treatment. David slowly continued to progress toward recovery. He gradually developed an interest in pottery and became quite skilled. He began to expand his support network and develop new relationships. He became particularly helpful with individuals new to the program. In addition, he began to discuss and explore his angry but dependent feelings toward his mother. He began to attend a local university part-time to pursue his interest in engineering and was permitted increased time away from the center in an effort to encourage independent living and to confront stress while support was available. As the time of David's discharge drew near, many separation issues arose. David's fears about living independently emerged in full force. He angrily stated that he felt as if he was being "thrown out." He expressed the wish to remain longer. David was assisted in coping with these feelings by peers and staff. He was encouraged to continue his involvement with support groups in the community, and contracted to volunteer at the center once a week. At the time of discharge, staff members were hopeful that David had made much progress and would continue to make gains with available supports, meetings with his sponsor, and weekly visits to his therapist. He had not made much progress in the area of heterosexual relationships and continued to be quite anxious and fearful when he contemplated dating and intimacy. It was hoped that David would begin to explore this issue in the future with his therapist. References Fortin, Mary L.1980. A community nursing experience in alcoholism, Am. J . Nurs. 80:113-114. Gibson, Deborah E.1980. Reminiscence, self-esteem and self-other satisfaction in adult male alcoholics, J. Psychosoc. Nurs. Ment. Health Serv, 18:7-11. Jefferson, Linda, and Ensor, Barbara. 1982. Help for the helper: confronting a chemically impaired colleague, Am. J. Nurs. 82:574-577. Loweree, F., Freng, S., and Baines, B. 1984. Admitting an intoxicated patient, Am. J. Nurs. 84:616-618. McCoy, S., Rice, M. & McFadden, K. 1981. PCP Intoxication: psychiatric issues of nursing care, J. Psychosoc. Nurs. Ment. Health Serv, 19: 17-23. Weist, J.K., Lindeman, M., and Newton, M.1982. Hospital dialogues, Am. J. Nurs. 82:1874-1877. Read More