2012-Nursing Management of Client WSubstance Related

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Nursing Care Plan for

Client with SubstanceRelated Disorder

Dian Wahyuni

Mental Health Nursing II

Binawan Institute of Health Science



Objectives

Discuss the Biologic, Psychologic, and

Sociocultural Context of Care

Understand the symptoms patterns

Develop nursing care plan for clients with

substance use

Understand treatment modalities



Psychological Context

Depressed mood

Unmet dependency meet

Impulsive style Inability to contend with life stress

Unmet needs of power/attention

Low self-concept/self-esteem Inability to tolerate failure



Sociocultural Context

Peer influence/pressure

Detrimental environment

Deteriorating neighborhood Alienating issues

Illegal behaviors

Drug trafficking

Dysfunctional family system



Terms

Substance Dependence / addiction Continued to use despite substance-related problems, asevidence by physiologic, cognitive, and behavioral symptoms.

Tolerance: The need for greater amount of the substance toproduced the desire effect or when the same amount of thesubstance is used overtime the effect is decreased

Withdrawal : The physiologic, cognitive, and behavioralsymptoms (specific to the substance) that occur when heavy useof the substance for over long period is stopped and thedecrease level of the substance in blood/tissues.

Compulsive use pattern: the use pattern is longer than intendedand larger is needed, the individuals want to stop the habit but

always fail, more time devoted to gain, use and recovering fromthe drugs, the use of substance continues despite the physical,legal, occupational problems.



Substance Abuse Failure to complete obligations in home, work or school

Continued use of substance despite danger

Legal problems related to substance use

Recurrent social or interpersonal problems

Substance intoxication A reversible substance-specific syndrome that occurs following

intake or exposure to the substance

Comorbidity / Dual Diagnosis Substance-related disorders that occur in association with other

Axis I mental disorders in DSM-IV-TR Other coexisting mental disorders with substance disorders are:

anxiety disorders, mood disorders, major depression, bipolardisorders, personality disorders.

Terms



Klasifikasi Zat

1. Depresan SSP Alkohol

BArbiturat

Sedatif/ Hipnotik NonBarbiturat

Ansiolitik Inhalan

Opioid (analgesik narkotik )

Sintetis

2.Stimulan SSP Amfetamin Stimulan Non Amfetamin

Nikotin

Kafein

3. Halusinogen

•Fenisiklidin (PCP)

•Psilosisbin (dalam jamur psilocybe)

•Meskalin (dalam kaktus peyote)

• Asam lisergis

4. Kanabioid

•Kanabis (Mariyuana)

•Hasish (hash)

•Dronabinol (Marionol)



Depresan SSP

Efek muncul karena neurotransmitor inhibitordistimulasi (GABA) atau mengubahneurotransmiter eksitasi (dopamin danepineprin)

Penggunaan kronis dapat mengurangi produksidan suplai neurotransmitor inhibitor

Neuro eksitasi terjadi bila konsumsi dihentikan

tiba-tiba. Stimulasi Norepineprin dan dopaminyang terjadi setelah penghentian menyebabkangejala putus zat.



Stimulan SSP

Meningkatkan pelepasan norepineprin dari saraf

prasinaps dan mencegah pengambilannya

kembali

Blokade prasinaps menyebabkan deplesikatekolamin dan menyebabkan peningkatan

kebutuhan akan zat yang menstimulasi.

Bila dihentikan secara tiba-tiba, neurotransmiter

eksitasi akan sangat deplesi dan menyebabkan

depresi serta disforia yang parah



Opioid

Adalah depresan SSP dan analgesik yang

sangat kuat

Menghambat pelepasan zat p dan

menempel pada reseptor endorfin untuk

meredakan nyeri

Bila dihentikan mendadak, akan terjadi

pelepasan norepineprin yang sangat

banyak



Halusionogen

Menstimulasi reseptor prasinaps danmenyebabkan gangguan penglihatan danpersepsi

PCP melepaskan dopamin, norepineprin,serotonin dan menghambat GABA

Penghentian mendadak menyebabkan

ketidakseimbangan neurotransmiter danmenyebabkan kecemasan, insomnia danpanik



Kanabioid

Mirip dengan halusinogen dan depresan

SSP

Menyebabkan sulit konsentrasi, euforia,

hilangnya memori jangka pendek

Penghentian yang tiba-tiba membuat efek

stimulasi berlebihan karena sifat depresan

dihentika



Inhalan

Bekerja sebagai depresan SSP, dapat

menembus sawar darah otak

Dosisnya tidak dapat dikendalikan, sangat

berbahaya

Bila dihentikan tiba-tiba, tidak

menimbulkan gejala



Assessment

Multiaxial Assessment (DSM IV TR)

Axis I: Clinical dysfunction

Axis II: Personality Disorders and Mental

Retardation

Axis III: Psychosocial and Environmental

Problems

Axis IV: Global Assessment of Functioning(GAF)



Assessment

Autoanamnesis (client) and aloanamnesis(parents, caregiver or any significant person)

Physical Assessment

Psychiatric Assessment Laboratory Assessment

Fluoroscopy Assessment

Electrophysiology assessment

Psychology test

Social evaluation



Autoanamnesis

Firstly build trust relationship with client then ask

client related to substance use

If trust relationship has not been established:

Identify areas where client needs professional help(problem at school, problems with parents, problems

in client working place, etc)

How long the problem has existed?

What efforts have been done?

Demographic data



Ask client related to what, when, why and how the client use

the substance. Ask client related to medical complication related to drug use

Ask client related to other complication such as: insomnia,lack of concentration, agitated, lost of appetite, etc.

Ask client related to mental disturbance: hallucination,

delusion, panic, depression Why the client want to stop using right now? Why now?

How client use his/her leisure time?

Are there any problems with client psychosocial relationship?

How is client education, marriage and work history?

Is client have been admitted to hospital or rehabilitationcenter?



Aloanamnesis

Client growth and development history

Educational, marriage, and work history

Typical behavior of client before the substance

consumption What are behaviors changes occurred?

Are tools used for substance use found inclient’s room? Or family found the substance in

client’s property? Was family members often lost their valuables?



Physical examination

(not only limited to these signs and symptoms)

Examination Sign and Symptoms Details

Consciousness Somnolent

Stupor-coma

Delirium

Opioid intoxication, sedatif-hipnotic, alcohol,

inhalant. Amphetamines and cocaine

withdrawal.

Any substance overdose

Sedatif – hipnotik or alcohol withdrawl,

amphetamine or PCP intoxicationPulse Rapid

Slow

LSD or amphetamine intoxication,

opioid withdrawal

Opioid; sedatif-hipnotik; alcohol;

inhalant intoxication

Body temperatureHigh

Low

LSD intoxication; amphetamineintoxication. Alcohol, sedatif-hipnotic,

opioid withdrawal, infection disease

Opioid intoxication




Respiratory rate Slow

Fast and shallow

Sedatif-hipnotic, alcohol, or

opioid use

High dose sedatif hipnotic

intoxication

Blood pressure High

Low

Amphetamin, cocaine, LSD

and Canabis use

Alcohol withdrawl. Opioid

withdrwl (BP usually high at

the beginning)




Eye Palpebra is half closed

Conjunctiva :

Red

Pale

Sclera icteric

Pupil:

Pin pointDilatation and reactive

Dilatation and nonreactive

Eye movement:

Lateral nistagmus

Vertical or horizontalnistagmus

Lacrimation

Diplopia

Increase blinking reflect

Opioid intoxication

Canabis intoxicationLong consumption of

amphetamine and cocain

Substance use induced hepatic

disease

Opioid intoxication

Amphetamine and LSDintoxication

Anticolinergic drugs

Sedatif-hipnotic intoxication,

canabis intoxication

PCP intoxication

Opioid withdrawl

Sedatif-hipnotik intoxication

Sedatif-hipnotik withdrawl




Nose Rinore (wet)

Ulcus or Nasal Septum

perforation

Opioid withdrawl

Inhalant cocain use

Mouth Bad breath/ dry chemical

substance

Frequent yawning

Inhalant use

Amphetamine, cocaine or hallucinogen

intoxication, opioid withdrawl

Lung Bronchitis

Tuberculosis

Fibrosis

Cancer

Tobaco and canabis use

Heavy psychoactive drug user

Psychoactive drug user (parenteral

use)

Tobacco smoker




Heart Tachycardia

Arrhythmia

Amphetamin, cocain,

hallucinogen intoxication;

opioid, sedative-hypnotic,

alcohol withdrawal

Inhalant intoxication;

sedative-hipnotic withdrawl

Stomach Gastritis Alcohol use

Liver Cirrhosis hepatic

Fatty liver

B/C hepatitis

Heavy alcohol use

Overdose alcohol use

Parenteral/intravena opioid

use




Stomach wall Spasme Opioid or sedatif-hipnotic

withdrawlSkin Blushing

Sianosis

Over perspiration

Gooseflesh

Pruritus

Dry

Needle trackPopping scar

Paronikia, tinea, skabies, pedikulosis

Alcohol, amphetamine,

hallucinogen, and opioid use

Opioid, amphetamine,

cocaine and hallucinogen use

Amphetamine intoxication,

cocaine and opioidwithdrawal

Opioid withdrawl

Opioid use

Colinergic drug use

Intravena route of opioid,

amphetamine or barbiturate

Swallowing injection site,

usually because of opioid use

Psychotic user who doesn’t

pay attention in their self care




Nervi Craniales Diplopia, dismetria, dan disartri Sedatif-hipnotik, alcohol, opioid

and inhalant intoxication.

Motor nerve Ataxia

Light tremor

Major tremor

Sedatif-hipnotik, alcohol,

inhalant, opioid intoxication. Amfetamin, cocain, hallucinogen,

opioid withdrawl.

Sedatif-hipnotic withdrawl

Reflects Hyperreflexion

Hypo-/a-reflection

Amphetamin, cocaine, LSD use

Sedative –hypnotic, alcohol or

inhalant heavy intoxication



Psychiatric Assessment Comorbidity/dual diagnosis

Anxiety, depression, dissocial personality disorders, hyperactivity are some mental disordersthat could lead to substance abuse

Substance abuse lead to several mental disorders: panic (cannabis user), psychosis (amphetamine or cocaine users), dementia (alcohol), depression (amphetamine and cocainewithdrawal) delirium (alcohol or sedative-hypnotic withdrawal)

Emotional disorders: Agitative: amphetamine, cocaine, cafeine, PCP intoxication

Aggressive: amphetamine, cocaine, PCP intoxication

Depression: Amphetamine, cocain, segdative-hypnotic, alcoholwithdrawal

Disforia/: cocaine or opioid beginners

Euforia: All psychoactive drugs intoxication

Nervous: Amphetamine, cocaine, hallucinogen, cafeine, PCP, cannabisuse. Opioid, sedative hipnotic, alcohol and nicotiine withdrawal

Impulsive: PCP intoxication Irritabel : Alcohol intoxication, sedatif-hypnotic, inhalant intoxication.

Alcohol, sedative hypnotic, nicotine withdrawal

Labil : Sedative-hypnotic, alcohol, PCP intoxication.



Communication disorders:

Lots of talking: alcohol intoxication

Thought disorders: Delusions: Amphetamine, cocaine, hallucinogen, cannabis intoxication;

alcohol withdrawal

Depersonalization: Hallucinogen, PCP intoxication

Perception disorders: Hallucination: amphetamine, hallucinogen intoxication; alcohol

withdrawal

Illusion: hallucinogen intoxication

Sinestesi: Hallucinogen intoxication

Memory and Attention disturbance

Amnesia: alcohol, sedative-hypnotic withdrawal Dementia: long time use of alcohol



Tingkah laku klien pengguna zat sedatif hipnotik

a. Menurunnya sifat menahan dirib. Jalan tidak stabil, koordinasi motorik kurang

c. Bicara cadel, bertele-tele

d. Sering datang ke dokter untuk minta resep

e. Kurang perhatianf. Sangat gembira, berdiam, (depresi), dan kadang

bersikap bermusuhan

g. Gangguan dalam daya pertimbangan

h. Dalam keadaan yang over dosis, kesadaran menurun,

koma dan dapat menimbulkan kematian.i. Meningkatkan rasa percaya diri



Observasi perilaku pasien

Mekanisme pertahanan diri yang biasa digunakan:

denial dari masalah

proyeksi merupakan tingkah laku untuk melepaskan diri dari tanggung jawab

Disosiasi merupakan proses dari penggunaan zat adiktif

Data khusus jumlah dan kemurnian zat yang digunakan

Sering menggunakan

Metode penggunaan (dirokok, intravena, Oral)

Dosis terakhir digunakan

Cara memperoleh zat (dokter, mencuri, dll)

Dampak bila tidak menggunakan Jika over dosis, berapa beratnya

Stressor dalam hidupnya

Sistem dukungan (keluarga, social, finansial)

tingkat harga diri klien, persepsi klien terhadap zat adiktif

Tingkah laku manipulatif



Tingkah laku klien pengguna opioda :

a. Terkantuk-kantuk

b. Bicara cadel

c. Koordinasi motorik terganggud. Acuh terhadap lingkungan, kurang perhatian

e. Perilaku manipulatif, untuk mendapatkan zat adiktif

f. Kontrol diri kurang

Tingkah laku klien pengguna kokain :

a. Hiperaktif

b. Euphoria, agitasi, dan sampai agitasi

c. Iritabilitas

d. Halusinasi dan wahame. Kewaspadaan yang berlebihan

f. Sangat tegang

g. Gelisah, insomnia

h. Tampak membesar – besarkan sesuatu

i. Dalam keadaan over dosis: kejang, delirium, dan paranoid



Observasi perilaku pasien

Mekanisme pertahanan diri yang biasa digunakan:

denial dari masalah

proyeksi merupakan tingkah laku untuk melepaskan diri dari tanggung jawab

Disosiasi merupakan proses dari penggunaan zat adiktif

Data khusus jumlah dan kemurnian zat yang digunakan

Sering menggunakan

Metode penggunaan (dirokok, intravena, Oral)

Dosis terakhir digunakan

Cara memperoleh zat (dokter, mencuri, dll)

Dampak bila tidak menggunakan Jika over dosis, berapa beratnya

Stressor dalam hidupnya

Sistem dukungan (keluarga, social, finansial)

tingkat harga diri klien, persepsi klien terhadap zat adiktif

Tingkah laku manipulatif



The Treatment

Detoxification:

Medical treatment to overcome overdose

Opioid Withdrawal:

Abrupt withdrawal

Symptomatic treatment withdrawal

Gradual withdrawal

Non Opioid substitute (clonididne)

Rapid detoxification



Long Term Medical Management

Disulfiram (Antabuse alcohol)

Naltrexon (opioid antagonis)

Methadone maintenance program (forheroin user)

Buprenorfin maintenance program (opioid

user)



Therapeutic Community

Same with Milieu therapy The leader is an ex user

The professionals act as consultant or advisor

Four principles:

• Democratization• Permissive behaviors

• Communality

• Reality confrontation

Phase I: orientation

Phase II: therapy (everyday therapy or seminars)

Phase III: Community relationship

Phase IV: TC in once a week

Graduation



Treatment modalities Abstinence VS Controlled use

Behavioral, cognitive, Traditional psychotherapy

Self-help group

Alcoholic Anonymous (AA)

• 12 steps of AA Al-Anon; Naranon; Cocanon

Narcotics Anonymous (NA)

Cocaine Anonymous CA)



1. Ancaman kehidupan

a. Gangguan keseimbangan cairan: mual, muntah berhubungandengan pemutusan zat opioda

b. Resiko terhadap amuk berhubungan dengan intoksikasisedatif hipnotik

c. Resiko cidera diri berhubungan dengan intoksikasi aklkohol,sedatif, hipnotik

d. Panik berhubungan dengan putus zat alkohol

2. Intoksikasia. Cemas berhubungan dengan intoksikasi ganja

b. Kerusakan komunikasi verbal berhubungan denganintoksikasi sedatif hipnotik, alcohol, opioda

DIAGNOSA KEPERAWATAN



Resiko tinggi terhadap cedera: jatuh berhubungan dengan kesulitan

keseimbangan

Perubahan nutrisi: kurang dari kebutuhan tubuh berhubungan

dengan asupan makanan yang kurang

Gangguan pola tidur berhubungan dengan sensori sistem sarafpusat

pola tidur berhubungan dengan hipersensitifitas

Kerusakan pertukaran gas: pola nafas tidak efektif berhubungan

dengan penurunan ekspansi paru.

Diagnosa keperawatan lain yang mungkin muncul



Nursing Diagnosis

Growth and development, altered

Infection, risk for Injury, risk for

Nutrition, altered

Self-care deficit

Sensory/Perceptual Alteration

Sexual dysfunction

Sleep pattern disturbance

Knowledge deficit Management therapeutic regimen, individuals or families: ineffective

Noncompliance

Anxiety

Communication, impaired verbal

Family process, altered

Social isolation Self-esteem disturbance

Violence, risk for

Powerlessness

Spiritual distress



RENCANA KEPERAWATAN

1. Kondisi overdosis

Tujuan : Klien tidak mengalami ancaman kehidupan

Rencana tindakan:

- Oservasi tanda – tanda vital, kesadaran pada 15 menit pada 3 jam pertama, 30 menit pada 3 jam kedua tiap 1 jam pada 24 jamberikutnya

- Bekerja sama dengan dokter untuk pemberian obat

- Observasi keseimbangan cairan

- Menjaga keselamatan diri klien

- Menemani klien- Fiksasi bila perlu



3. Kondisi withdrawl

a. Observasi tanda- tanda kejang

b. Berikan kompres hangat bila terdapat kejang pada perut

c. Memberikan perawatan pada klien waham, halusinasi: terutama

untuk menuunkan perasaa yang disebabkan masalah ini: takut,curiga, cemas, gembira berlebihan, benarkan persepsi yang salah

d. Bekerja sama dengan dokter dalam memberikan obat anti nyeri

4. Kondisi detoksikasi

a. Melatih konsentrasi: mengadakan kelompok diskusi pagi

b. Memberikan konseling untuk merubah moral dan spiritual klienselama ini yang menyimpang, ditujukan agar klien menjadi manusiayang bertanggung jawab, sehat mental, rasa bersyukur, dan optimis

c. Mempersiapkan klien untuk kembali ke masyarakat, dengan bekerjasama dengan pekerja social, psikolog.

RENCANA KEPERAWATAN



INTERVENSI KEPERAWATAN

Dx: Resiko tinggi terhadap cedera: jatuh berhubungan dengan kesulitankeseimbangan

Kriteria hasil:

- mendemonstrasikan hilangnya efek-efek penarikan diri yang memburuk

- tidak mengalami cedera fisik

Intervensi:

Mandiri

1.Identifikasi tingkat gejala putus alkohol, misalnya tahap I diasosiasikandengan tanda/gejala hiperaktivitas (misalnya tremor, tidak dapatberistirahat, mual/muntah, diaforesis, takhikardi, hipertensi); tahap IIdimanifestasikan dengan peningkatan hiperaktivitas ditambah denganhalusinogen; tingkat III gejala meliputi DTs dan hiperaktifitas autonomikyang berlebihan dengan kekacauan mental berat, ansietas, insomnia,demam.

2.Pantau aktivitas kejang. Pertahankan ketepatan aliran udara. Berikankeamanan lingkungan misalnya bantalan pada pagar tempat tidur.

3.Periksa refleks tenton dalam. Kaji cara berjalan, jika memungkinkan

4.Bantu dengan ambulasi dan aktivitas perawatan diri sesuai kebutuhan



Kolaborasi

5. Berikan cairan IV/PO dengan hati-hati sesuai petunjuk

6. Berikan obat-obat sesuai petunjuk: benzodiazepin, oksazepam,fenobarbital, magnesium sulfat.

Rasional:

1. Pengenalan dan intervensi yang tepat dapat menghalangi terjadinyagejala-gejala dan mempercepat kesembuhan. Selain itu perkembangangejala mengindikasikan perlunya perubahan pada terapi obat-obatanyang lebih intensif untuk mencegah kematian.

2. Kejang grand mal paling umum terjadi dan dihubungkan denganpenurunana kadar Mg, hipoglikemia, peningkatan alkohol darah atauriwayat kejang.

3. Refleksi tertekan, hilang, atau hiperaktif. Nauropati perifer umumterjadi terutama pada pasien neuropati

4. mencegah jatuh dengan cedera

5. mungkin dibutuhkan pada waktu ekuilibrium, terjadinya masalahkoordinasi tangan/mata.

6. Penggantian yang berhati-hati akan memperbaiki dehidrasi danmeningkatkan pembersihan renal dari toksin sambil mengurangi resikokelebihan hidrasi.



PERAN PERAWAT

Perawat harus mengetahui masalah yangberkaitan dengan penggunaan NAPZA agardapat memberikan perawatan kepada kliensecara efektif.

Perawat harus memahami perasaan seseorangtentang alkohol sehingga perawat dapat bekerjasecara efektif. Perawat jiwa juga membantudalam mendampingi klien NAPZA dan keluarga

dalam melaksanakan terapi. Serta memberikanpendidikan kesehatan agar klien bisaberkomunikasi efektif dan berpersepsi positif



Laboratory Assessment

Urine analysis

Should be done before 48 hours after the

last use



Ineffective individual coping

Expected outcomes: The patient will abstain from using all mood-altering chemicals

Short-term goals: The patient will substitute healthy coping responses for

substance abusing behaviors

The patient will assume responsibility for behaviors The patient will identify and use social support system

Intervention: Build trust relationship with the patient

Help the patient to identify the substance abuse problem

Involve the patient in describing situations that lead tosubstance-abusing behaviors

Consistently offer support and the expectation hat the patienthas the strength to overcome the problem

I t ti (C t )



Intervention (Cont.)

Encourage the patient to participate in a treatment

program Develop with the patient a written contract for behavioral

changes that is signed by the nurse and patient

Help the patient to identify and adopt healthier copingresponses.

Identify and assess social support systems that areavailable to the patients

Provide support to significant others

Educate the patient and significant others about thesubstance abuse problem and available resources

Refer the patient to appropriate resource and providesupport until the patient is involved in the program

M ti ti l h



Motivational approaches

(Stuart&Laraia, 2001, p.513)

Principles Express emphaty trough reflective listening

Develop discrepancy between patients’ goal or values and their currentbehaviors

Avoid arguments and direct confortation

Roll with resistance

Support self-efficacy

FRAMES approach

Feedback

Responsibility for change

Advice; nonjudgmental Menus of self-directed change

Emphatic Counseling

Self-efficacy; optimistic empowerment

Decisional balance grid



The Treatment

Detoxification:

Medical treatment to overcome overdose

Opioid Withdrawal:

Abrupt withdrawal

Symptomatic treatment withdrawal

Gradual withdrawal

Non Opioid substitute (clonididne)

Rapid detoxification



Long Term Medical Management

Disulfiram (Antabuse alcohol)

Naltrexon (opioid antagonis)

Methadone maintenance program (for

heroin user)

Buprenorfin maintenance program (opioid

user)



Therapeutic Community

Same with Milieu therapy The leader is an ex user

The professionals act as consultant or advisor

Four principles:• Democratization

• Permissive behaviors

• Communality

• Reality confrontation

Phase I: orientation

Phase II: therapy (everyday therapy or seminars)

Phase III: Community relationship

Phase IV: TC in once a week

Graduation



Treatment modalities Abstinence VS Controlled use

Behavioral, cognitive, Traditional psychotherapy

Self-help group

Alcoholic Anonymous (AA)

• 12 steps of AA Al-Anon; Naranon; Cocanon

Narcotics Anonymous (NA)

Cocaine Anonymous CA)

2012-Nursing Management of Client WSubstance Related

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