Alcohol Abuse and Alcohol Disorders - Case Study Example

Design a management plan for a client with a habitual alcohol intake who is admitted for a surgical procedure that will require a hospital stay of several days. Introduction: Alcohol abuse and alcohol related disorders are very common in clinical practice. Recent years have witnessed a blossoming of clinically relevant research regarding alcohol abuse and dependence, including information on specific genetic influences, the clinical course of these conditions, and the development of new and helpful treatments (Stevenson, 2005, 245-280). However, when the patient is cared for some other reason in the practice area, such as, surgery, the issues are slightly different, since the secondary effects of alcohol abuse become prominent, and if due to the reason for management, the hospitalized patient needs to abstain from alcohol, the dependence on alcohol and issues with withdrawal becomes prominent (Hudetz et al., 2007, 423-430). Consequently, the nursing care would need to be tailored as appropriate to help the client in such situations. In this assignment, the case scenario of a patient who has been admitted to the surgical area for a cholecystectomy for gallbladder stones will be discussed in that light. This patient is a 45-year-old male with cholelithiasis and cholecystolithiasis with mild hyperbilirubinaemia due to partial obstruction of the common bile duct due to stone. This patient is a known alcoholic, and the idea of admitting him to the hospital is to control his bilirubin levels and sustain his abstinence from alcohol in the hospital ward so the surgery becomes uneventful. Therefore, the nursing management plan will have to be designed which would take care of his problems during the course of his hospital management. The most important health issues during this preparatory phase of the management will be the nutritional care of the patient who has already been compromised from the nutritional point of view. Literature has delineated the nutritional problems in alcoholics that arise from alcoholic hepatitis and pancreatitis. Moreover, alcohol per se leads to deficiency of vitamins due to poor nutritional intake and compromise in the fat digestion due to abnormal fat metabolism due to pancreatitis. Surgery is a stress situation (Breslow et al., 2006, 359-366). Therefore, for the upcoming surgery, this patient needs to be prepared nutritionally to be able to tolerate this stress. This problem has been compounded by the hyperbilirubinaemia on presentation that tends to aggravate these problems further. Alcoholic hepatic dysfunction and fatty liver both add to the gravity of the problem. From that perspective, one of the core issues would be nursing nutritional management of this patient. The second core issue is related to his habitual alcohol intake that is continuing over years. A sudden stop or abstinence forced or otherwise, would point to the issues related to dependence and problems related to withdrawal symptoms. These symptoms or syndrome, if they appear in the acute form may be potentially problematic, and consequently, the nursing care plan must evolve around this core issue also (Banks et al., 2000, 1249-1254). Care Plan and Related Evidence: Dependence and Withdrawal: Alcohol or ethanol is a sedative anesthetic found in various proportions in liquor, wine, and beer. Alcohol produces a sedative effect by depressing the central nervous system (CNS). This effect causes the individual to experience relaxed inhibitions, heightened emotions, mood swings that can range from bouts of gaiety to angry outbursts, and cognitive impairments such as reduced concentration or attention span, and impaired judgment and memory (Porjesz and Rangaswamy, 2007, 131-141). Depending on the amount of alcohol ingested, the effects can range from feelings of mild sedation and relaxation, to confusion and serious impairment of motor functions and speech, to severe intoxication that can result in coma, respiratory failure, and death. Excessive or long-term abuse of alcohol can adversely affect all body systems, and the effects can be serious and permanent. People who abuse alcohol can exhibit various patterns of use. Some engage in heavy drinking on a regular or daily basis; others may abstain from drinking during the week and engage in heavy drinking on the weekends; still others can experience longer periods of sobriety interspersed with bouts of binge drinking with several days of intoxication (Poster Session PB3 , 2007, 162-165). Thus, all patients should be screened not only for alcohol use disorders, but also for drinking patterns or behaviors that may place them at increased risk for experiencing adverse health effects or alcoholism (Berman, 2001, 4). Alcohol makes the neuronal membranes more permeable to potassium (K+) and chloride (Cl-) and closes sodium (Na+) and calcium (Ca++) channels. This increased permeability depresses the CNS, and adrenergic activity raises blood pressure and heart rate. Alcohol is metabolized in the liver as a carbohydrate into carbon dioxide and water. The breakdown process of the compound ethanol (CH3CH2OH) is: ethanol->acetaldehyde->water->acetic acid->carbon dioxide->water. Acetaldehyde is toxic and is usually broken down by acetaldehyde dehydrogenase. Rapid alcohol intake can cause an accumulation of acetaldehyde, which then combines with the neurotransmitters dopamine and serotonin to produce tetrahydroisoquinolines and beta-carbolines. Physical dependence on alcohol becomes a problem when central nervous system cells require alcohol to function normally. People who have abused alcohol for long periods of time often experience alcohol tolerance, a phenomenon producing a more rapid metabolism of alcohol and decreased response to sedating, motor, and anxiolytic effects (Bradford and Rusyn, 2005, 13-17). Alcohol withdrawal syndrome, which occurs after alcohol consumption is reduced or when abstaining from alcohol after prolonged use, causes changes in vital signs, diaphoresis, and gastrointestinal and CNS adverse effects. The severity of withdrawal symptoms ranges from mild to severe, depending on the length and amount of alcohol use. Symptoms include increased heart rate and blood pressure, diaphoresis, mild anxiety, restlessness, and hand tremors. In patients with alcoholism or in chronic drinkers, the alcohol withdrawal syndrome usually begins within 12 hours after abrupt discontinuation or attempt to decrease consumption. Only 5% of individuals with alcohol dependence ever experience severe complications of withdrawal, such as delirium tremens or grand mal or tonic-clonic seizures (Barclay et al., 2008, 139-151). Alcohol abuse continues to require nursing assessment and interventions in all settings. Patients who abuse alcohol for long periods of time are at high risk for delirium tremens. Observing for signs of seizure activity is a priority nursing intervention. Clients generally experience clinical symptoms of alcohol withdrawal within several hours to a few days after the cessation or reduction of heavy and prolonged alcohol consumption. The client may experience symptoms such as autonomic hyperactivity; increased hand tremor; sleep disturbances, insomnia, or nightmares; nausea or vomiting; transient visual, tactile, or auditory hallucinations or illusions; psychomotor agitation; anxiety; and grand mal seizures. Elevated temperatures in excess of 100 Fahrenheit (37.3 Celsius) and pulse in excess of 100 beats per minute may indicate impending alcohol withdrawal delirium.Alcohol withdrawal delirium, also referred to as delirium tremens, may occur from 24 to 72 hours after the client's last drink. Elevation of vital signs accompanies restlessness, tremulousness, agitation, and hyperalertness. Any noises or quick movements are perceived as greatly exaggerated, shadows are misinterpreted, and illusions and hallucinations frequently occur. The client's speech is incoherent. Serious medical complications may occur if the client is left untreated (O'Connor & Schottenfeld, 1998, 592-602). Nutritional Issues: The major adverse effects of alcohol use are related to liver damage. Alcohol use, even as short as week-long episodes of increased drinking, can result in an accumulation of fats and proteins, which produce the appearance of a fatty liver, sometimes found on physical examination as an enlarged liver. The association between fatty infiltration of the liver and serious liver damage remains unclear. Alcohol use, however, is associated with the development of alcoholic hepatitis and hepatic cirrhosis. Alcohol abuse also appears to inhibit the intestine's capacity to absorb various nutrients, such as vitamins and amino acids. This effect, coupled with the often poor dietary habits of those with alcohol-related disorders, can cause serious vitamin deficiencies, particularly of the B vitamins (Hvas and Nexo, 2006, 1506-1512). Along side the usual medical management directed towards improvement of nutritional status of the patient prior to surgery, the nursing intervention must consider nutritional management in this patient. Poor nutrition and vitamin deficiencies are often symptoms of alcohol dependence. Multivitamins and adequate nutrition are essential for patients who are severely malnourished, but other vitamin replacement may be necessary for certain individuals. Thiamine may be needed when a patient is in withdrawal, to decrease ataxia and other symptoms of deficiency. It is usually given orally, 100 mg four times daily, but can be given intramuscularly or by intravenous infusion with glucose. Glucose intake must be increased in this patient not only due to these alcohol-induced nutritional disorders, but also due to hepatic dysfunction indicated by hyperbilirubinaemia. Folic acid deficiency is corrected with administration of 1.0 mg orally, four times daily. Magnesium deficiency also is found in those with long-term alcohol dependence. Magnesium sulfate, which enhances the body's response to thiamine and reduces seizures, is given prophylactically for patients with histories of withdrawal seizures. The usual dose is 1.0 g intramuscularly, four times daily for 2 days (Schuckit, 2005, 1168). The Nursing Process: Data collection is the necessary first step in addressing the quality of the health of the client. The data collection process must be continual, systematic, accurate, and comprehensive to enable the addictions nurse and other members of the treatment team to reach sound conclusions, plan and implement interventions, and evaluate care. During the assessment process, the questions were directed toward identifying his frequency and quantity of drinking and duration of use. Information regarding any prior treatment for a substance-related disorder also is important. The assessment of a client who abuses alcohol can be frustrating as well as challenging for several reasons. The client may use defense mechanisms of denial, rationalization, and projection when confronted about his or her drinking behavior. Family members or significant others may also be in denial of the client's drinking problem. Furthermore, they may be enablers who perpetuate the person's dependence on alcohol who share the client's addiction to alcohol (Henderson-Martin, 2000, 27-32). The nurse uses the interview process to obtain data from the client, including the client's interpretation of the drinking problem and attitude toward control of the problem. Data regarding the client's level of sensorium, mood and affect, ability to communicate needs and follow instructions, ability to meet basic needs, and general physical condition are collected. It is also needed to document whether the client is inebriated, undergoing withdrawal, dehydrated, malnourished, in any physical distress, or at risk for injury due to an unsteady gait or the presence of tremors. Also information is obtained regarding available support systems at this time. The client's behaviour is observed, documenting whether the client is withdrawn, argumentative, hostile, disruptive, combative, or exhibiting any behavioral symptoms due to the presence of hallucinations, illusions, or delusions. Also whether the client has exhibited any suicidal or homicidal thoughts or behaviors in the past is to be noted. Finally, the client is asked about any history of driving while under the influence or any other legal charges related to the use of alcohol. Several screening tools are frequently used during the assessment process. They include the Michigan Alcohol Screening Test (MAST) and the CAGE Screening Test for Alcoholism (Ewing, 1984, 1905-1907). The Alcohol Use Disorders Identification Test (AUDIT) also may be used. The AUDIT contains 10 questions about quantity and frequency of drinking, bingeing, and drinking consequences. Because of its emphasis on drinking within the past year, this self-administered screening tool may not identify clients with previous drinking problems. Experts caution that brief screening tests may be less effective in some populations. These implications could have a significant importance, given the number of individuals who abuse alcohol (Graham, 2000, 37-38). In addition to using the assessment format described for the client who abuses alcohol, the nurse must be able to recognize symptoms of alcohol drug withdrawal during the collection of data. Alcohol withdrawal is identified in part by physical and behavioral manifestations. Therefore, focus assessment measures on obtaining baseline data and monitoring vital signs; observing for signs of CNS depression, such as irregular respirations or hypotension; recognizing signs of impending seizures or coma. Other assessment parameters include assessing general nutritional status; determining the client's level of sensorium; and listening to physiologic complaints. Monitoring behaviour is a very important aspect of the assessment, focusing on the client's history of suicidal ideation or attempts; withdrawal symptoms, including hallucinations, confusion, tremors, seizures, and the like; longest alcohol-free period; and desire for treatment. Diagnostic laboratory tests include liver function tests and mean corpuscular volume, which when elevated are indicators of heavy alcohol use. Other tests, such as blood alcohol level or urine screen for alcohol, may be ordered depending on the physical condition of the client or complaints verbalized during the assessment process (Selwyn & Merino, 1997, 597-619). There are wide cultural variations in attitudes toward substance consumption, patterns of use, accessibility of substances, physiologic reactions to substances, and prevalence of substance-related disorders. For example, Asians have a genetic intolerance to alcohol even when consumed in small amounts. Some cultures forbid the use of alcohol or drugs, whereas other cultures include alcoholic beverages with their meals and accept the use of various substances to achieve mood-altering effects (Ballesteros et al, 2004, 3-4). Clients who use or abuse alcohol may have poor general health and inadequate nutrition like this patient. They are more susceptible to infections and medical complications. Sensory or perceptual alterations may occur, and there is a potential for injury due to impaired memory or cognition. Communication and social interaction may be impaired. Family dynamics may be dysfunctional (Bale, 1993, 117-144). The outcomes must be identified. Outcomes focus on providing a safe environment to prevent injury; stabilizing existing medical complications secondary to alcohol use or abuse; improving impaired cognition and communication; establishing nutritious eating patterns; establishing a balance of rest, sleep, and activity; establishing alternative coping skills; and resolving any personal or family issues related to the client's disorder (Giesbrecht, 2007, 1345-1349). The nursing plan of care documents the human response patterns that will be addressed by nursing interventions; guides each nurse to intervene in a manner congruent with client needs and goals; and provides outcome criteria for measurement of client progress. Upon the basis of this plan, nurses can contribute effectively to formulation of the multidisciplinary treatment plan and collaborative therapeutic interventions. Experts have described stages of change that clients experience during treatment. These stages include precontemplation, contemplation, preparation, determination, action, maintenance, and relapse. Addictions nursing addresses an area of concern extending over the entire health-care continuum. Addictions nursing interventions consist of all those nursing actions that are directed toward fostering adaptive human responses to actual or potential health problems stemming from patterns of abuse or addiction. Attitudes of nursing personnel can influence the quality of care given to clients who abuse substances. Nurses may exhibit disapproval, intolerance, moralistic condemnation, anger, or disinterest. Displaying an accepting, nonjudgmental attitude or assisting clients with their activities of daily living as they exhibit manipulative, noncompliant, aggressive, or hostile behavior is difficult (Thurston, 1997, 653-694). Various approaches can be used to provide effective care. These include maintaining one-to-one contact, orienting the client to reality, speaking slowly and clearly in a low voice, avoiding either negative or positive judgments, and offering support if the client is willing to verbalize feelings about his or her situation. Clients with the diagnosis of a substance-related disorder often require placement in a safe environment as the nursing staff provides assistance in meeting the client's basic needs; monitors the client's medical condition; uses interventions to stabilize the client's medical condition and behavioral problems; and assists with medication management, intervention strategies, interactive therapies, and client education (Babor and Higgins-Biddle, 2001, 1-34). Client safety is a priority because the client may exhibit clinical symptoms of overdose, intoxication, or withdrawal. The client also may react to substance-induced internal stimuli such as hallucinations or delusions, placing him or her at risk for injury to self or others. It may be necessary to place the hospitalized client in a room near the nurses' station or where the staff can observe the client closely. Stimuli should be reduced by placing the client in a partially lighted room. Seizures can occur during withdrawal from various substances. Therefore, seizure precautions must be instituted to minimize chances of injury. Intravenous barbiturates may be required to control extreme agitation. Nursing interventions focus on providing adequate hydration and nutrition and assisting the client with personal hygiene and activities of daily living. Promoting a balance of sleep, rest, and activity and monitoring the client's elimination patterns also are important. Nursing interventions include promoting adequate nutrition and hydration because the client is at risk for fluid and electrolyte imbalance due to severe dehydration or malnourishment. The client's intake and output must be monitored. If the client is vomiting, IV therapy may be necessary (Dawson et al., 2005, 139-150). The vital signs need to be assessed frequently for changes, and the client needs to observed for signs of impending or current delirium tremens. Laboratory tests may need to be repeated because of abnormal values. A computed tomography (CT) scan and electroencephalography (EEG) may be ordered to rule out metabolic encephalopathy or coexisting neurologic disorders. The bahaviour must be stabilized since the clients are often manipulative and prone to staff-splitting. They may continue to exhibit alcohol-seeking behavior despite placement in a secure, controlled environment. Clients have been known to have peers bring alcoholic beverages or drugs to them during treatment, and the nurses must keep an watchful eye to that. Other psychiatric intervention strategies must include interactive therapies, individual psychotherapies, and family therapy (O'Farrell, 1999, 125-129). Client education can be provided by the nurse in several ways depending on the client's level of motivation, reading ability, educational background, willingness to participate in group discussions, and availability of a family support system (Apodaca and Miller, 2003, 289-304). Conclusion: In short, an intervention, a term used to describe an organized, deliberate confrontation of a client who uses or abuses substances, may also be planned and then implemented. Generally it is used as an intervention to encourage a person to enter treatment but can be used once a person has entered treatment. In this case, it will help the patient to abstain from alcohol while in care. The nursing process is a dynamic activity that incorporates alternative strategies at every stage of the process, based on ongoing and systematic evaluation of client assessment data. The nurse evaluates the response of the client to the interventions and revises the nursing diagnoses, interventions, and treatment plan accordingly. Data are obtained from multiple sources, such as the staff, documentation, the client, and his or her family or significant others. The ultimate outcome is complete freedom from alcohol use and abuse, and in this case, this would lead to a successful outcome from his surgery without complications. Reference List Apodaca, T. and Miller, W. (2003) A meta-analysis of the effectiveness of bibliotherapy for alcohol problems. Journal of Clinical Psychology 59, 289-304. Babor, T. F. and Higgins-Biddle, J. C. (2001) Brief Intervention for Hazardous and Harmful Drinking. A Manual for Use in Primary Care. World Health Organization, Geneva, 1-34. Bale, R. (1993). 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