Substance Abuse: Nursing Care

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In assessing the client, what must the nurse do first?
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Examine feelings about working which pt who abuses substances
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In assessing the client, the nurse
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Must be able to separate the client from the behavior and accept the individual
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Within admission, the nurse initially
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Screen for withdrawal with 1. CIWA-Ar 2. Michigan Alcoholism Screen Test 3. CAGE a. Cut down? b. Annoyed? c. Guilty? d. Eye-opener (drink in the morning?)
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Assessment guidelines include (in order)
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1. Clarify signs 2. Assess for withdrawal 3. Assess overdose 4. Assess self-harm potential 5. Evaluate physiological response 6. Explore interest in taking action 7. Assess knowledge of community resources
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What are the 4 C’s of addiction?
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1. Compulsive behavior 2. Cravings 3. Chronic, relapsing brain disorder 4. Cognitive impairment
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What are the nursing diagnosis for substance abuse?
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1. Risk for injury 2. Risk for infection 3. Risk for suicide 4. Imbalanced Nutrition: less than body requirements/deficient fluid volume 5. Deficient knowledge 6. Chronic low self-esteem 7. Ineffective coping 8. Ineffective denial
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Successful outcomes when patient
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1. has not experienced physical injury 2. has not caused harm to self or others 3. accepts responsibility for own behavior 4. acknowledges association between personal problems and use of substances 5. demonstrates more adaptive coping mechanisms 6. shows no signs/symptoms of infection or malnutrition 7. exhibits evidence of self-worth by trying new projects without failure and is less defensive 8. verbalizes importance of obtaining from substance
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Implementation includes
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Detoxification Intermediate care Rehabilitation
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Implementation begins with
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Detoxification by 1. providing a safe and supportive environment 2. administering substitution therapy
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Intermediate care addresses
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1. Explanations of physical symptoms 2. Promote understanding/identify the cause of substance addiction 3. Education/assistance in course of treatment to client/family
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Rehabilitation intervention includes
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Encouragement of continued participation Promote participation in outpatient support (AA) Assist to find alternative sources of satisfaction Provide support for health promotion and maintaince

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