alcoholism

ALCOHOLISMPresented by-

Jasleen Kaur Brar

INTRODUCTION Alcoholism is a chronic relapsing disease

characterized by denial and inability to discontinue its use despite knowing its adverse consequences.

A person is considered to suffer from chronic alcoholism if his use of alcohol is upto such extent that it interferes with successful physical and social functioning.

DEFINITION The National Council on alcohol and drug

dependency and The American Society of Addiction Medicine define alcoholism as "a primary, chronic disease characterized by impaired control over drinking, preoccupation with the drug alcohol, use of alcohol despite adverse consequences, and distortions in thinking."

The DSM-IV defines alcohol abuse as repeated use despite recurrent adverse consequences.

It further defines alcohol dependence as alcohol abuse combined with tolerance, withdrawal, and an uncontrollable drive to drink.

Use refers to simple use of a substance. An individual who drinks any alcoholic beverage is using alcohol

Moderate Use is defined as no more than two alcoholic beverages per day for men and no more than one alcoholic beverage per day for women.

Abuse is often used to refer to the illegal use of any substance, use of prescription medications in excess of the prescribed dosage or use of a prescription drug without a prescription, and sometimes refers to use that results in long-term health problems.

CAUSES/RISK FACTORS Genetic factors – It runs in

families, children of alcoholics consume 4 times more than the children of non alcoholic.(Neumann, 2005). So if father is alcoholic, children are having greater risk

Psychological – Poor stress management skills,

loneliness, desire to escape from reality, a sense of adventure, pleasure seeking.

Emotionally immature, need for praise and appreciation.

Low frustration tolerance , feelings of inadequacy.

Psychological trauma during childhood as disturbed parent child relationship.

Inferiority, low self esteem, poor impulse control.

Disorders like depression, anxiety, phobia are prone to consume as an escape.

Personality disorders – persons who have harsh super ego and who are self puncture turn to alcoholics to diminish their stress.

Childhood history of antisocial personality disorder.

Common in cyclothemic personalities.

Social factors – over crowding, influence of bad company, cinemas, literature.

Peer pressure, urbanization, religious reasons, unemployment.

Poor social support, fashion- a sign of modernity, social inadequacy, isolation.

Some settings as colleges and military settings where alcohol is considered as a status symbol.

To forget miseries and problems of life.Unhealthy environment, sudden loss in

property or closed ones.Parental disharmony.

Occupational – heavy vehicle drivers, labourers, manual workers, Physical exhaustion or hard physical labour.

Economic causes : Poverty Unemployment Professions like poets, painters, waiters, journalists,

commercial, musicians, reporters are at greater risk.

Others : Marital disharmony Easy availability Free time and boredom Loneliness.

PATHOGENESIS IN ALCOHOLISMPre-alcoholic symptomatic phase : In conventional social situations, an

individual starts drinking alcohol but soon experiences tension relief. Gradually tolerance for tension decreases to such an extent that he resorts to alcohol almost daily.

Prodromal phase: Sudden onset of black outs, signs of

intoxication, loss of memory or events. Seek occasions to drink, unknown to others

with the fear that they will misjudge them.

Worrying about whether there will be enough to drink at a social gathering or not.

Swallow the first two drinks very quickly. Guilt feelings about drinking behaviour.

Crucial phase: Loss of control over drinking, increased

isolation, decrease in sexual drive, centering the behaviour around alcohol.

Improper nutrition, increased hostility towards spouse, increased jealousy feelings, suspicious nature.

Chronic phase : marked impairment in thinking process leading to alcoholic psychosis, delirium tremors occurs, develops rationalization and amenable to treatment.

- Casual to habitual drinker

ELLIOT and MERRILL has described five stages through which a person has to pass till he became complete disorganized personality-

1. Morning drinking- Person starts drinking alcohol in morning and he feels it is necessary to push him throughout the day.

2. Escape drinking- It starts, when a person is not able to face reality of problems without the help of alcohol.

3. Increasing consumption : Consumption of alcohol increases in amount leading to personal disorganization and decreased social value and feels that he cannot survive without alcohol.

4. Drinking and social functions: Drinking becomes absolute necessity in social gathering.

5. Extreme behaviour : drinks excessively and behave indiscriminately, eg. Fighting, abusing, throwing away things, beating wife and children, absurd and dangerous behaviour etc.

TYPES OF DRINKERS MODERATE : Moderately consuming

alcohol and does not cause much problem.

PROBLEM : Drinking will impair health, affects peace of mind, family disruption, loss of reputation and drinking becomes the routine.

PROCESS OF ALCOHOLISM EXPERIMENTAL: Due to peer pressure and

curiousity, individual starts consuming alcohol. RECREATIONAL : Gradually the frequency of

alcohol consumption will increase as an enjoyment.

RELAXATIONAL : During weekends or on holiday, it may work out to release the tension ,relax mind and to sedate the brain from painful emotions and promotes a sense of well being and pleasure.

COMPULSIVE: Person becomes addict to overcome the discomfort of withdrawal symptoms.

IDENTIFYING THE ALCOHOLICS Red palms and red nose Improper gait Decreased sensation and

weakness in legs and feet. Disorientation Ring like opacity of cornea

CLINICAL FEATURES PHYSICAL SIGNS : Indigestion- anorexia Sweating Unsteady gait Malaise and tremors Weakness in feet and legs Pain in upper abdomen

PSYCHOLOGICAL SIGNS : Blackouts- amnesia of events Loss of self control Outburst of aggressive behaviour Insomnia

COMPLICATIONSA .Medical :a.Gastro-intestinal Tract Gastritis Dyspepsia Vomiting Peptic ulcer Cancer

Reflex esophagitis Carcinoma of stomach and oesophagus, larynx,

liver, colon Fatty degeneration of the liver, interferes with

absorption of vitamin B-complex Cirrhosis of liver Hepatitis, Jaundice Liver cell carcinoma Acute and chronic pancreatitis

b. Cardiovascular System : Cardiomyopathy Hypertension Heart failure or stroke High risk for myocardial infarction.c. Blood : Folic acid deficiency anaemia Decreased WBC production causes infections

d. Nervous System : Confusion, numbness of hands, feet,

disordered thinking Depression, depresses vital centers of the brain Peripheral Neuropathy, Dementia Epilepsy Head injury Cerebellar degeneration Wernicke’s encephalopathy coma

e. Hormonal : Hypoglycemiaf. Muscle : Peripheral muscle weakness Wasting of musclesg. Bones : Interferes with the production of bones Thinning of bones, osteoporosis Fractures

I. Reproductive System : Sexual dysfunction in male Failure of ovulation in female Interruption in menstruationj. Nutritional Deficiency Diseases : PEM B complex deficiency-Pellagra, Beriberi

k. Pregnancy : Fetal abnormalities Developmental disabilities- Mental

retardation, Growth retardation Low birth weight Still birth Birth defects Foetal alcohol syndrome

Social Complications : Domestic abuse, divorce, poor performance in

school and at work. Prone for motor vehicle accidents, susceptible for

accidental injuries, violence acts,e.g. murder, reduced productivity.

WITHDRAWAL SYNDROMES

Any rapid decrease in the amount of alcohol content in the blood will produce withdrawal symptoms.

1 Simple Withdrawal Syndrome : Mild tremors Nausea and vomiting Weakness Irritability Insomnia

Insomnia Anxiety Tachycardia Hypertension Impaired attention

2 Delirium Tremors : The term means ‘trembling madness’. It

occurs within 2-4 days of complete or significant abstinence from heavy alcohol drinking.

Definiton. ‘A severe form of withdrawal that involves

sudden and severe mental or neurological changes.

Manifestations : Mental status changes: Mood changes,

confusion, disorientation in the time and place, psychomotor agitation, restlessness, excitement, decreased attention span, irritability,

Disorderly behaviour, clouding of consciousness, altered sensorium.

3.ALCOHOLIC PARANOID : It occurs in chronic alcoholics, characterized by suspicious nature, decreased sexual potency and other paranoid features.

Treatment is symptomatic.

4.ALCOHOLIC HALLUCINATIONS It develops after an attack of delerium tremors, auditory and visual hallucinations, delusions of persecutory and reference are common.

Capacity for social adjustment is retained.

Full recovery takes place in 3-4 weeks.

5. DEMENTIA : It develops slowly. Signs include tremors, indistinct speech, mild

euphoria etc. No specific treatment is recommended. Usually it

resolves by itself.

6.Wernicke encephalopathy : It is a syndrome characterised by ataxia, ophthalmoplegia, confusion, and impairment of short-term memory.

Treatment begins with IV or IM injection of thiamine, followed by assessment of central nervous system and metabolic conditions.

7.Korsakoff's syndrome: (amnesic-confabulatory syndrome)is a brain disorder caused by the lack of thiamine (vitamin B1) in the brain

There are six major symptoms of it: Anterograde amnesia Retrograde amnesia, severe memory loss Confabulation, that is, invented memories

which are then taken as true due to gaps in memory

Unrelevant content in conversation Lack of insight Apathy - the patients lose interest in things

quickly and generally appear indifferent to change.

TREATMENT Treatment involves the replacement or

supplementation of thiamine by IV or IM injection, together with proper nutrition and hydration. However, the amnesia and brain damage caused by the disease does not always respond to thiamine replacement therapy. So in some cases, drug therapy is recommended

SCREENING AND DIAGNOSIS CAGE questionnaire : named for its four

questions, is used to screen patients. Two "yes" responses indicate that the respondent

should be investigated further. The questionnaire asks the following questions:

Have you ever felt you needed to Cut down on your drinking?

Have people Annoyed you by criticizing your drinking?

Have you ever felt Guilty about drinking? Have you ever felt you needed a drink first

thing in the morning (Eye-opener) to steady your nerves or to get rid of a hangover?

OTHER SCREENING TEST AVAILABLE : Alcohol Dependence Data Questionnaire Michigan Alcohol Screening Test Alcohol Use Disorders Identification Test

(AUDIT) Paddington Alcohol Test (PAT)

According to the DSM-IV, an alcohol dependence diagnosis is:

Maladaptive alcohol use with clinically significant impairment as manifested by at least three of the following within any one-year period:

Tolerance Withdrawal Taken in greater amounts or over longer time

course than intended

Desire or unsuccessful attempts to cut down or control use.

Great deal of time spent obtaining, using, or recovering from use.

Social, occupational, or recreational activities given up or reduced; continued use despite knowledge of physical or psychological sequeale.

Urine and blood tests : One common test being that of blood alcohol

content (BAC).

MANAGEMENT Detoxification : Alcohol detoxification or 'detox' for alcoholics

is an abrupt stop of alcohol drinking coupled with the substitution of drugs that have similar effects to prevent alcohol withdrawal.

It treats the physical effects of prolonged use of alcohol, but does not actually treat alcoholism. After detox is complete, relapse is likely without further treatment.

Drugs used for this are : Benzodiazepines – chlordiazep 80-

200mg/day. Diazepam 40-80 mg/day Thiamine 100 mg IM for 3-5 days followed

by vitamin b administration 100 mg OD for atleast 6 months.

Anticonvulsants can be given if necessary.

DISULFRAM THERAPY Used for over 30 years. Works on principle of classical

conditioning. 300-600 mg of drug mixed in

alcohol is given to the client for 6-8 times in a week.

Soon after the ingestion of drug, adverse reaction starts appearing and may last for 30-120 minutes. Reaction consists of :

Facial flushing Sweating Throbbing headache Neck pain Tachycardia

Respiratory distress Potentially serious drop in B.P. Nausea and vomiting. In severe disulfram reaction,

diphenhydramine hydrochloride 50 mg IM or IV is given.

CLIENT EDUCATION It must be taken daily atleast for 6-8 days,

period can last for upto 2 weeks. Alcohol containing substances (hidden

alcohol) can trigger the side effects, so these should be avoided. These are :

Foods as soups, apple ciders, anything made with wine vinegar as pickles, flavour extracts used in cooking.

Medicines include cold and cough syrups, mouth washes, vitamin and mineral tonics.

Skin preparations include alcohol rubs, after shave lotions, transdermal patches.

Avoid inhaling fumes, substances that contain alcohol as paints.

NALTRAXONE THERAPY It is an opoid antagonist which is now approved for

treatment of alcoholism. Unlike disulfram, it decreases the pleasant and reinforcing effects of alcohol without making the user ill.

THERAPEUTC MODALITESMOTIVATIONAL INTERVIEWING : Explaining the complications and personal

risks of consuming alcohol Availability of treatment options to change

their behaviour related to alcohol consumption.

INDIVIDUAL PSYCHOTHERAPY : Educate about the effects of alcohol

consumption and the coping strategies to overcome the habit.

Precautionary measures, diversional activities.

Methods to prevent occurrence of complications.

GROUP THERAPY : Observe the problems of alcoholic Provide oppurtunities to observe

other problems and discuss with each other.

Explain them the better ways of coping with problems.

COUNSELLING : To find out the problems and to solve them. To guide about various methods to relax mind

and engaging themselves in productive activities.

AVERSIVE COUNSELLING : Based on principle of classical conditioning. Explain the behaviour pattern which are

pleasurable, pros and cons of alcoholism, maladaptive behaviour.

Explain about the complications of alcoholism and family complications.

Client is exposed to adverse effects of excessive alcohol consumption like chemical induced vomiting, shock etc. thereby develops aversion towards the evil habbits.

COGNITIVE THERAPY : Help the client to identify the maladaptive

thinking patterns; evil effects of alcoholism. To guide the individual to slowly reduce the

dose of alcohol intake and by understanding the evil effects of alcohol.

RELAPSE PREVENTION TECHNIQUE : It helps the client : Identify high risk relapse factors and develop

strategies to deal with them. Learn the methods to cope up with cognitive

distortions.

CUE EXPOSURE TECHNIQUE : Repeated exposures to desensitise the clients to the

effects of alcohol and thus improve their ability to remain abstinent.

SUPPORTIVE PSYCHOTHERAPY : Symtomatic treatment along with educating

the individual about preventive measures against complications.

BEHAVIOUR MODIFICATION TECHNIQUES: Systematic desensitization Relaxation techniques Operant conditioning

FAMILY THERAPY : If the head of family develops

alcoholism, family will be affected with economic crisis,maladjustment. Thus the family need to be educated about various cpoing strategies, evil effects of alcoholism to ahildren and preventive measures to adopt.

AL-ANON/ALATEEN Al-Anon and Alateen are international

organizations jointly known as Al-Anon Family Groups with a membership of over half a million men, women and teens, providing a twelve-step program of recovery for friends and family members of alcoholics.

Al-Anon is for adults within the program whereas Alateen is for young people (ages 12 to 20).

NURSING MANAGEMENT

Nursing Assessment History Collect brief history of the client Developemental aspects-milestones

pattern, educational status ,scholastic environment and any problems associated with it .

Employment history and details about stressors in working environment , work load

Marital history: Marital life pattern ,any history of conflicts between life partners/couple, deprivation ,disparities

Sexual history : Satisfactory pattern/dissatisfactory life/difficulties in sexual life

Transitional periods in life- any life events influencing alcoholism or drug abuse

Any positive family history-history of alcoholics or drug addicts among parents and relatives

Social history : social environment-peer group influence , influence of western culture, social gathering, broken family, deprivation of love, school environment, life style pattern.

Psychological factors, e.g.feeling of aloofness, isolation, exposed to extreme stress in life, e.g.death of loved one; separation /divorce, failure in life.

Forensic history: Previuos court cases, any imprisonment, or pending court case.

Physical Examination Inspection or observation: General

appearance, behaviour pattern, evidence of malnutrition,tremors , etc.

Percussion:Tenderness-epigastric region Palpation:Hepatomegaly, splenomegaly,

cardiomegaly Auscultation: Look for cardiac murmurs, respiratory sounds.

Mental status Examination General appearance and behaviour Psychomotor activity Thought, content, mood ,perception Cognitive function : orientation ,memory,

intelligence, abstractility, jugdement insight. General information

Psychosocial Assessment Family: Environment, Interaction and

relationship. pattern ,bondage, healthy/unhealthy living pattern

Work environment: Regularity in job, performance ,responsibilities, workload,change of job, relationship with superior and colleagues.

Social environment-peer group, social relationship, social functions, accidents, friends and relatives influence

Crime:History of committing criminal acts and violence

Religion , caste,cultural functions, social gatherings, motivating or stimulating factors.

1.Nursing Diagnosis Alteration in sleep pattern r/t post drinking agitation

evidenced by improper sleep. Goal: To enhance adequate sleeping pattern.

Interventions and rationale : Provide a calm and quiet environment, will

help the client to sleep better.

Advice the family members to stay along with the client to promote comfort and security.

Never leave the client alone as leaving the client alone will divert his mind, and it also promote the sense of being cared and loved.

Observe the sleeping pattern, to check for the factors that hinders good sleep for the client.

Ask the client to cultivate the habit of taking bath before going to bed, will promote the sleep.

Provide dim light ,soft music, if the client is having the habit of reading books, allow him to do so.

Administer the medications as per doctors prescription.

2.Nursing Diagnosis Potential for self injury and injury to others

r/t alcohol withdrawal, seizures etc. as evidenced by confusion and agitated behaviour.

Goal : To protect the client from self injury and injury to others.

Interventions and rationale : Provide safe environment, if the client exhibits

violent or withdrawal behaviour, to prevent self and injury to others.

Administer medications as per prescriptions, helps in improving physical and mental stability.

Assist for self care activities and ambulation, will provide diversion and improves confidence.

Observe and document ,if the client is having seizures, to maintain records.

Observe the gait and assist ,to give help to the client.

Assess the emotions of the client, e.g.: depression, violence; counsel the client ,utilize behavior modification techniques, cognitive, assertiveness techniques, will help in early recovery.

3.Alteration in physical health r/t adverse efftects of alcoholism as evidenced by poor health

Goal :To promote and maintain good physical health.

Interventions and rationale : Observe and record vital signs, physical

complaints, will provide baseline data to intervene.

Provide symptomatic care and needed assistance ,to cope with the existing problems.

Provide care to the client during and after seizures,if any. This will help to prevent injury to the client.

If the client is too calm during withdrawal period ,observe or check for any possession of alcohol, to asess the remission at earliest.

4.Negligence in meeting physical needs related to depression, insecurity as evidenced by poor personal hygiene.

Goal : To calm-up the mind and maintain good personal hygiene.

Interventions and rationale : Promote a sense of well-being to the

client ,helps in motivation towards good hygiene habbits.

Motivate the client to be self sufficient and independent, helps in improving confidence.

Make the client to understand about importance of maintenance of good personal hygiene and insist on hygienic habits and maintaining it, will help in improving the hygiene of client.

Assist the client for self care activities, if the client is in depressive mood, will help in gaining trust and mutual confidence.

5.Knowledge deficit related to adverse effects of alcoholism and methods to overcome the problems.

Goal : To make the client to adopt the normal life without alcohol, slowly and gain knowledge over the adverse effects of alcoholism.

Interventions and rationale : Educate the client on adverse effects of

alcoholism; show the case, who are suffering with complications of alcoholism, how their families are affected due to this problem ,will help the client to understand complications and adverse effects in a better way.

Counsel the client to utilize behavior modification techniques to get aversion towards alcoholism.

Motivate the client to have change in life style, social group gathering pattern to improve socialization and to promote self confidence.

6.Altered sensory perception related to disturbances like hallucinations &altered consciousness as evidenced by fear, psychomotor retardation etc.

Goal : Reduction in fear, anxiety, hallucinations and depression.

Intervention Maintain good emotional status and improved

sensory perception pattern to promote a sense of well being.

Assess the level of consciousness and behavioral responses to have baseline data to intervene.

Accept the client’s emotions pattern and altered levels to promote emotional support and comfort of client.

Note onset and pattern of hallucination and document it to check the efficacy of the treatment modalities.

Provide emotional/moral support; counsel the client, explore the stressors and teach the strategies to overcome the problems

Provide calm and quiet environment to promote comfort to the client.

Be non judgemental; observe the client’s behaviour, helps in gaining trust and improving confidence.

Motivate the client to talk about his feelings openly without any inhibitions , will help to ventilate.

Never leave the client alone, always motivate someone who is close to him will improve the sense of being loved.

Provide stress free environment to promote physical and emotional comfort.

Protect the client from self-injury as agitated clients may harm themselves.

Explain to the relatives, not to show their emotional disturbances to the client, on bedside to prevent further demotivation.

PREVENTION Parents : Provide the child with a secure, stable home

environment (lack of love is a cause of taking alcohol)

Keep the child occupied .Provide opportunities for sports, hobbies and other useful activities that could stand him away from evil outlets.

Keep the children informed about hazards of alcohol addiction and how to stay away from people and places that can influence him.

Promote a well knit family feeling of inter dependence .It will lead to feeling of being wanted and loved.

Parents should build a relationship of mutual truth and understanding. A healthy loving parent child relationship can be a great help to avoid alcohol addiction.

Individualisation :to establish mutual respect, parents should began respecting the child as human being in his own right.

Taking time for recreation: Parents should spend time with children in regard to their hobbies and interests.

Encouragement: Family and friends need to know the child’s strength and help him to accept his weakness in order to cope with the realities of life

Communicating love :Children should be dealt with love, sympathy, security and sense of well being.

Encountering alcohol abuse: Family should not over react when they come to know about the chemical dependence of the person .

They should keep all lines of communication open. Family should speak to his friends ,inform his teacher and should consult for professional evaluation.

Accepting the fact: The professionals should let the person recognize his alcohol depending and that he is suffering with a disease and needs to be controlled .Recognizing their reality means half their battle won.

Confrontation: If the person does not accept the disease ,then confront him. Family should talk honestly and without anger, should describe their anger only when the person can understand it and should be specific while talking to the client.