Lecture 2 Abuse (Psych and Med-Surge)

LECTURE 2 ABUSE (Psych and Med-Surge) Psychological Aspect/Psycho-Dynamics • # 1 psychological problem is the same in any/all abusive situations = DENIAL! - abusers have an infinite capacity for denial so that ! they can continue the behavior w/o answering for it • can use the alcoholism rules for any abuse! - ex. # 1 psych problem in child abuse, gambling or ! cocaine abuse is denial • why is denial the problem? HOW CAN YOU TREAT SOMEONE WHO DENIES/DOESN’T RECOGNIZE THEY HAVE A PROBLEM • denial = refusal to accept the reality of a problem • treat denial by CONFRONTING the problem (it’s not the same as aggression which attacks the person, not the problem) = they DENY you CONFRONT! - pointing out to the person the difference between ! what they say and what they do! - Hint: never pick answers that attack the person! -> ex. bad answers have bad pronouns - “you”! -> ex. good answers have good pronouns - “I”, “we”! -> ex. “you wrote the order wrong” vs. “I’m having ! difficulty interpreting what you want” • loss and grief -> for this denial you must SUPPORT it! - DABDA = denial, anger, bargaining, depression, acceptance • Hint: for questions about denial, you must look to see if it is LOSS or ABUSE! - loss/grief = support! - abuse = confront • #2 psychological problem in abuse = DEPENDENCY, CO-DEPENDENCY! - dependency = when the abuser gets significant other ! to do things for them or make decisions for them! -> the dependent = abuser! - co-dependency = when the significant other derives ! positive self-esteem from making decisions for or ! doing things for the abuser! -> the abuser gets a life w/o responsibilities! -> the sig. other gets positive self-esteem (which is ! why they can’t get out of the relationship) • how do you treat it?! - set limits and enforce them! -> start teaching sig. other to say NO (and they ! have to keep doing it)! - must also work on the self-esteem of the co-dependent ! (ex. I’m a good person because I’m saying “no”) • manipulation = when the abuser gets the sig. other to do things for them that are not in the best interest of the sig. other! - the nature of the act is dangerous/harmful! - how is manipulation like dependency?! -> in both the abuser is getting the other person to ! do something for them! - how do you tell the difference between manipulation ! & dependency?! -> NEUTRAL vs. NEGATIVE (look at what they’re ! being asked to do)! -> if the sig. other is being asked to do something ! neutral (no harm) its dependency/co-dependency! -> if the sig. other is being asked to do something ! that will harm them or is dangerous to them they ! are manipulated • how do you treat manipulation?! - set limits and enforce them -> “NO”! - easier to treat than dependency/co-dependency ! because no one likes to be manipulated (no positive ! self-esteem issue going on) • ex. how many PT’s do you have w/ denial? = 1! ex. how many PT’s do you have w/ dependency/co-! dependency = 2! ex. how many PT’s do you have w/ manipulation = 1 Alcoholism! Wernicke’s & Korsakoff’s! - typically separate BUT boards lumps them together! - wernicke’s = encephalopathy! - korsakoff’s = psychosis (lose touch with reality)! -> tend to go together, find them in the same PT • Wernicke Korsakoff’s syndrome:! a) psychosis induced by Vit. B1 (Thiamine) deficiency! - lose touch w/ reality, go insane because of no B1! b) primary symptom -> amnesia w/ confabulation! - significant memory loss w/ making up stories! - they believe their stories • How do you deal w/ these PT’s?! - bad way = confrontation (because they believe what ! they are saying and can’t see reality)! - good way = redirection (take what the PT can’t do ! and channel it into something they can do) • Characteristics of Wenicke Korsakoff’s:! a) it’s preventable = take Vit. B1 (co-enzyme needed ! for the metabolism of alcohol which keeps alcohol ! from accumulating and destroying brain cells)! * PT doesn’t have to stop drinking! b) it’s arrestable = can stop it from getting worse by ! taking Vit. B1! * also not necessary to stop drinking! c) it’s irreversible (70% of cases) -> Hint: On boards, ! answer w/ the majority (ex. if something is majority ! of the time fatal, you say it’s fatal even if 5% of the ! time it’s not) • Drugs for Alcoholism:! DISULFIRAM (Antabuse)! = aversion therapy -> want PT’s to develop a gut ! hatred for alcohol! -> interacts w/ alcohol in the blood to make you very ill! -> works in theory better than in reality! -> onset & duration: 2 weeks (so if you want to ! drink again, wait 2 weeks)! - PT teaching = avoid ALL forms of alcohol to avoid ! nausea, vomiting & possibly death! -> including mouthwash, aftershaves/colognes/perfumes ! (topical stuff will make them nauseous), insect ! repellants, any OTC that ends with “-elixer”, alcohol-! based hand sanitizers, uncooked (no-bake) icings ! which have vanilla extract, red wine vinaigrette! • Overdoses & Withdrawals:! - every abused drug is either an UPPER or DOWNER! -> the other drugs don’t do anything! -> #1 abused class of drug that is not an upper or ! downer = laxatives in the elderly! a) first establish if the drug is an upper or downer! - uppers (5) = caffeine, cocaine, PCP/LSD (psychedelic ! hallucinogens), methamphetamines, adderol (ADD drug)! • Alcohol Withdrawal Syndrome vs. Delirium Tremens! - they are both different! not the same! a) every alcoholic goes through withdrawal 24 hrs. ! after they stop drinking! - only a minority get delirium tremens! - timeframe -> 72 hrs. (alcohol withdrawal comes 1st)! - alcohol withdrawal syndrome ALWAYS precedes ! delirium tremens, BUT delirium tremens does not ! always follow alcohol withdrawal syndrome! b) AWS is not life-threatening; DT’s can kill you! c) PT’s w/ AWS are not a danger to self/others; PT’s ! w/ DT’s are dangerous to self/others! - they are withdrawing from a downer so they will ! be exhibiting upper S&S! - DT’s are dangerous Differences in Care Diet * S&S -> make you go up; euphoria, tachycardia, ! restlessness, irritability, diarrhea, borborygmi, ! hyper-reflexia, spastic, seize (need suction)! - downers = don’t memorize names -> anything that ! is not an upper is a downer! if you don’t know what ! the med is, you have a high chance that it’s a ! downer if it’s not part of the uppers list! Room Ambulation * S&S -> make you go down; lethargy, respiratory ! depression (& arrest)! - ex. The PT is high on cocaine. What is critical to assess?! Restraints -> NOT resps below 12 because they will be high! -> maybe check reflexes! b) are they talking about overdose or withdrawal! - overdose/intoxication = too much! - withdrawal = not enough! - ex. the PT has overdosed on an upper -> pick the ! S&S of too much upper! - ex. the PT has overdosed on a downer -> pick the ! S&S of too much downer! - ex. the PT is withdrawing from an upper -> not ! enough upper makes everything go down! - ex. the PT is withdrawing from a downer -> not ! enough downer makes everything go up -> downer withdrawal so everything is up = exaggerated ! startle, seizing, high pitched/shrill cry DT Regular diet NPO/clear liquids! (because of risk for seizures which can cause risk of aspiration) Private near nurses station (dangerous & unstable) Semi-private anywhere on the unit Up ad lib Restricted bed rest -> no bathroom privileges (use bedpans/urinals) No restraints Restraints (because dangerous)! (because not - not soft wrist or 4 point soft ! dangerous) because they’ll get out! - need to be in vest or 2-pt. locked ! leathers (opposite 1 arm & leg, ! rotate Q2hrs, lock the free ! limbs 1st before releasing the ! locked ones) They both get ANTI-HYPERTENSIVES & TRANQUILIZERS! - because everything is up (downer withdrawal)! They both get MULTIVITAMIN w/ B1 • RN’s can accept but RPN’s can’t (because PT is unstable)! - on med-surge, the RN who takes them must decrease ! their workload (i.e. reduce PT load if they take a DT PT)! -> Hint: on boards, the setting is always perfect ! (i.e. enough staff/time/resources on the unit etc.) • upper overdose looks like = downer withdrawal • downer overdose looks like = upper withdrawal • In what 2 situations would resp. depression & arrest be your highest priority:! - downer overdose! - upper withdrawal • In what 2 situations would seizure be the biggest risk:! - upper overdose! - downer withdrawal! • Drug Abuse in the Newborn:! - always assume intoxication, NOT withdrawal at birth! - after 24 hrs -> withdrawal! - ex. caring for infant of a Quaalude addicted mom 24 ! hrs. after birth, select all that apply:! AWS ! DRUGS! AMINOGLYCOCIDES • powerful class of antibiotics (when nothing else works pull these outs, the big guns)! - don’t use unless anything else works • boards love to test these drugs because they’re dangerous and are a test of safety • think: A MEAN OLD MYCIN ! -> a mean old = they treat serious, life-threatening, ! resistant, Gram-neg bacteria infections (i.e. a mean ! old antibiotic for a mean old infection)! -> mycin = what they end with (all end w/ -mycin) ! ** not all -mycin’s are aminoglycosides BUT most ! are (the 3 that are not are erythromycin, ! azithromycin, clarithromycin = throw it off the list!)! • 2 toxic effects:! i) when you see ‘-mycin’, think mice! - mice -> ears -> otto toxic! - monitor hearing, tinnitus, vertigo/dizziness! ii) the human ear is shaped like a kidney so next ! effect is nephrotoxicity! - monitor creatinine (not BUN, output, daily weight)! * creatinine = the best indicator of kidney/renal ! function (pick 24 hr. creatinine clearance over ! serum creatinine if both available) • #8 (fits nicely in the kidney) reminds you about 2 things about these drugs! - toxic to cranial nerve 8 = ear nerve! - administer Q8 • route:! - IM or IV • do not give PO -> they are not absorbed! - if you give an oral ‘-mycin’ it will go into gut, dissolve, ! go through and come out as expensive stool (won’t ! have any systemic effect)! - EXCEPT in 2 cases = bowel sterilizers:! * hepatic encephalopathy (hepatic coma) = to get ! ammonia down, oral ‘-mycin’s’ will sterilize the ! bowel by killing Gram-neg bacteria (E. coli) to help ! bring down ammonia and won’t harm the ! damaged liver because it doesn’t go through the ! liver (also gives diarrhea, more poop out is good)! * pre-op bowel surgery = it sterilizes the gut by ! killing the E. coli bacteria! - if oral, no otto or nephro toxicity because not absorbed! - these are neomycin & kanamycin ! * Who can sterilize my bowels? NEO KAN • Trough and Peak levels:! - trough = drug at lowest! - peak = drug at highest! ** TAP levels - trough administer peak! -> draw trough levels first ! -> administer your drug! -> draw peak levels after drug administration • Why draw levels? = narrow therapeutic window! - small difference between what works and what kills! - if the drug has a wide range then you wouldn’t ! need to draw TAP levels! * ex. Lasix doses range from 5-80mg thus a wide ! range so you won’t need TAP levels! * ex. Dig doses range from 0.125 - 0.25 so this ! narrow range needs TAPS levels • A MEAN OLD MYCINS = major class that needs TAPs drawn because of narrow window • When do you draw TAPS? ! -> depends on the route (don’t focus on the med)! a) Trough Levels! ** doesn’t matter which route or med, always 30 mins.! - sublingual = 30 mins. before next dose! - IV = 30 mins. before next dose! - IM = 30 mins. before next dose! - Sub-Q = 30 mins. before next dose! - PO = 30 mins. before next dose! b) Peak Levels! ** different but depends on the route (not the med)! - Sublingual = 5-10 mins after drug is dissolved! - IV = 15-30 mins after drugs is finished infusing! * Hint: if you get two values that are correct (i.e. a ! 15 min. answer and a 30 min. one) pick the highest ! without going over so 30 mins.! - IM = 30-60 mins. after administration! - Sub-Q = SEE (see diabetes lecture -> because the ! only Sub-Q peaks are Insulins)! - PO = forget about it, too variable so not tested The BIG 10 Drugs to Know: 1. psych drugs 2. insulins 3. anti-coagulants 4. digitalis 5. aminoglycosides 6. steroids 7. calcium-channel blockers 8. beta-blockers 9. pain meds 10. OB drugs